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JUNE 2019

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VOLUME 72 NO. 6

MEDICINE SAN ANTONIO

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

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Art & Medicine

To Help Each Other So Art and Defamilarization in Medical Education By Mark A. Clark, PhD ...................................12 Art in Medicine at UIW By Anna Rogalska .........................................14 Art & Medicine — Medical School Students: Anna Rogalska, Scott Cho, Samantha Studvick, Alyson Randall, Andrew Franks, Kathleen Francis, Ashley Rhae Lopez, Jennifer GaertnerOtt, Rachel Amuzu, Cassandra A. Jones, Connie Cheng, Roshni Grace Ray ............16-27

BCMS President’s Message ........................................................................................................................8 BCMS Legislative News ............................................................................................................................10 Healthcare: New Primary Care Training in Bexar County By Thomas Mohr, MS, DO, FACOI, FAODME ......28 Feature: Lung Story Short By Douglas Jenkins, MD....................................................................................30 BCMS News ..............................................................................................................................................31 Business: How to Prepare for Homebuying If You Run a Practice By Jon Tober ........................................32 BCMS Circle of Friends Directory ..............................................................................................................34 In the Driver’s Seat ....................................................................................................................................39 Auto Review: 2019 BMW X7 By Steve Schutz, MD ..................................................................................40

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San Antonio Medicine • June 2019

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JUNE 2019

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VOLUME 72 NO. 6

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

San Antonio Medicine • June 2019

PRESIDENT’S MESSAGE

Art & Medicine: SHARPENING THE EYES AND MINDS, STRENGTHENING THE TEAMS, AND NOURSHING THE SOULS By Adam Ratner, MD, 2019 BCMS President

Over the past several years, physician leaders at top medical institutions have come to realize that studying the fine

arts can improve the effectiveness and satisfaction of physicians and other healthcare professionals.

UT Health San Antonio (UTHSA) was one of the first institutions in the country to offer such an experience to its

students more than a decade ago. Under the auspices of the Center for Medical Humanities and Ethics, dr. Craig Klugman, a bioethicist who at the time was at UTHSA, created one of the first “Art Rounds” courses in the country.

The Art Rounds course has grown from dr. Klugman’s founding vision at UTHSA (see San Antonio Medicine May

2017) and a similar activity is now offered at the University of the Incarnate Word School of Osteopathic Medicine

(UIWSOM). The UIWSOM experience includes medical, graduate nursing, and pharmacy students who work together

as peers. It is an interactive, interprofessional program that takes students to the McNay Art Museum where they study

selected works from the impressive collection housed there. led collaboratively by faculties from the respective pro-

fessional schools and the professional educators at the McNay, participants view, observe, interpret and discuss selected works of art.

Not only do participants improve visual observation and interpretation skills, they develop and improve interprofes-

sional communication skills and practice team-based problem solving. Students learn to gain comfort with ambiguity

and uncertainty as well as gain empathy and humanity as clinicians. What’s more, it’s fun!

Share your creative talent …

When I returned to academia a decade ago, I soon learned that many medical students, staff and faculty colleagues

had amazing artistic talents beyond their nominal medical roles. At UTHSA, some of these works are collected into an annual publication called Connective Tissue. Connective Tissue is typically curated by senior medical students and con-

tains prose, poetry, photography and other pictorial arts submitted from students, staff and faculty at UTHSA and

UHS. It’s truly amazing.

At UIWSOM, dr. Mark Clark, associate professor of medical humanities, and Ania Rogalska, a second-year medical

student and leader of the Art & Medicine student program, encourage students to create works of art both within the curriculum and through extracurricular projects.

I’m proud to say that in this month’s San Antonio Medicine you will see examples of creative works from contributors

from both UIWSOM and UTHSA. I know that many other bCMS and Alliance members have artistic talents. In future

editions of San Antonio Medicine, I would like to see works of art created by you.

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.

San Antonio Medicine • June 2019

BCMS LEGISLATIVE NEWS

86TH SESSION FIRST TUESDAYS NOW COMPLETE Many thanks to all the bCMS members, Alliance members and medical students who attended the May First Tuesdays visit to the Capitol on May 7. Attendees included: Physicians – John Green, Md, who was serving as doctor of the day at the Capitol; leah Jacobson, Md; Alex Kenton, Md; Sanjiv Kumar, Md; lubna Naeem, Md; John Nava, Md; John Shepherd, Md and Ezequiel “Zeke” Silva, Md. Alliance members in attendance, were: Carol Growney, Jennifer lewis 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 – Jacob Canfield; Trevor dickey; Karan Goenka; lessly Hernandez; Sid Pradeep; luke verlinsky; Ryan Wealther and from UIWSOM – Marc Ghosn. At the time of this writing, there are just 17 days left in the 140-day legislative session. Many of medicine’s bills are still moving through the process and a number of topics were covered during the First Tuesdays visits, including: Medicaid, state budget; mental health; scope of practice; surprise billing; health plan directories; prior authorizations; utilization reviews; maternal health; end of life 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.

Top: bCMS physician members, Alliance members and medical students visit with Rep. lyle larson, district 122 (right) in the halls of the Capitol during the May 7 First Tuesdays.

Middle: bCMS physicians and medical students pause for a photo with Rep. barbara Gervin-Hawkins, district 120 (back row) on May 7 during the final First Tuesdays visit to the Capitol.

bottom: Rep. Ray lopez, district 125 speaks with bCMS physicians and medical students about medicine issues during the May 7 First Tuesdays visit to the Capitol.

San Antonio Medicine • June 2019

BCMS LEGISLATIVE NEWS

Above: bCMS physicians and medical students visit with Mia balderas (center), communications director in the office of Rep. diego bernal, district 123, during the May 7 First Tuesdays visit to the Capitol.

At left from the Top: Rep. leo Pacheco, district 118 (left) listens as bCMS physicians and medical students discuss bills of importance to medicine during the May 7 First Tuesdays visit to the Capitol.

bCMS physicians, Alliance members and medical students provide updates on bills of importance to medicine to Christina Haas, legislative aide in the office of Sen. Judith Zaffirini, district 21. during the May 7 First Tuesdays visit to the Capitol, bCMS physicians and medical students discussed issues of importance to medicine with Maria Jaimes, legislative aide in the office of Rep. Roland Gutierrez, district 119.

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ART & MEDICINE

To Help Each Other So: Art and Defamiliarization in Medical Education Mark A. Clark, PhD

Proponents of incorporating experiences of the arts in medical education often tout the fact that the slow, careful examinations of artistic representations promote crucial observational skills called for in clinical practice. I agree with this claim, but I would also assert that the point deserves some elaboration. It’s not simply that, in looking at works of art, we pay attention to physical details and therefore develop skills that will help us read X-rays more carefully or become more astute in picking up diagnostic clues related to the structure and function of a patient’s body. Artistic representations are infused with an emotional dynamism such that the devoted observer beholds—and develops important observational skills in beholding—an integration of mind-body-spirit and a wholeness of personhood that medical imaging and representation tends to undo. To make this point with my students, I engage them in visual Thinking Strategies with respect to (a) the photograph, as one might find in a medical text, of a woman with scoliosis; (b) a medical illustration/drawing of a woman with scoliosis; (c) an X-ray of a woman with scoliosis; and (d) a selection of self-portraits by artist laura Ferguson, who has suffered from severe scoliosis all her life. In each case, students are invited to respond to the visual Thinking Strategy questions, “What do you see? What do you see that makes you think that? What more do you see?” And what becomes clear, of course, is that the nature of the observation and the nature of understanding that flows from it are quite different when it comes to the Ferguson representations. Ferguson’s pieces feature the sensual, nude body of a woman rendered transparent to reveal the spine contorted by the condition. In the arabesque of that spine, one beholds and shares in some approximate feeling of persistent, agonizing, debilitating tension. but almost impossibly, it seems, one is simultaneously drawn into an experience of calm, exquisite beauty and gracefulness—as if the body itself had captured and held forever before our eyes, in a kind of transfiguration, the movement and spirit of dance. The arabesque of the spine dances in perfect

San Antonio Medicine • June 2019

congruence and harmony with the nude body, even as some tortuous tension prostrates that body in debilitating pain. The observational skills one acquires by means of an absorption in the Ferguson representations are crucial to one’s development as a clinician, though the understanding they afford is qualitatively different than those promoted by much of medical education. Much of medical education and practice is aimed at seeking explicit knowledge that can be told, recorded as a collection of facts, repeated, and described. It tends to conceive of the patient in the third person—as an other about whom medical professionals may make factual statements based on measurements, scans, and evidence—and is inclined, indeed, to regard the patient as a biological puzzle in need of solving. A clinician, on the other hand, is, by virtue of the physician-patient relationship, called to develop knowledge through second person, I-Thou experience, which is interpersonal, engages the integrated mind-body-spirit, and yields tacit understanding of another person, where, as Polanyi would say, “we know more than we can tell” or put in words explicitly. It’s more than knowing a collection of facts about the structure and function of this body: it’s knowing you. And such knowledge is crucial to understanding suffering and offering care that is truly compassionate. It is this kind of knowledge and understanding that engagements with art can offer. Such engagements serve as experiences of epistemic defamiliarization in medical education. Promoting the tacit knowledge they do, this is to say, they disrupt the habits of knowing that pervade medicine and that would conceive of persons as biological puzzles of structure and function. They bring to consciousness the habits of thinking that would otherwise remain unacknowledged and mindlessly adopted. Consider, for example, the cases of Problem-based learning and Case-based learning programs in medical schools. The cases are stories by means of which medical educators promote in students’ habits of thought. The “characters” of patients in these sto-

ART & MEDICINE

ries, however, are often unwittingly de-humanized in the sense that they are depicted as lacking the socioeconomic complexity and agency of persons situated in the cultural milieu of the world. The unintended message of this representation—which is provided by us educators—is that the patient-person to be regarded as a biological puzzle to be solved through tests and scans whose results may be discussed and acted upon by medical professionals. One story after another—all the cases of medical school, provided by us medical educators—promote habits of understanding that patients are to be regarded as utterly passive biological puzzles that we, with some considerable satisfaction, can solve. The unrecognized habits of our teaching promote a hidden curriculum we do not intend. While we desire to teach our students to regard patients as persons and to treat them with compassion, our stories instill habits of regarding patients as otherwise. And these habits get reinforced through systems of practice whereby patient identity is constructed by means of codes in an EMR, test measurements, and an array of scans. Such habits have serious consequences, and not only for the patients who—in spite of the clearly positive benefits that can arise through systemic efficiency—feel treated like objects of study. The de-humanization of the Other in a relationship leads to the de-humanization of both; and for those who came to medicine motivated by a profound yearning to share in compassionate, altruistic relationships of healing, such de-humanization spells the utter destruction of the raison d’etre and the foundational aspiration of students: the calling to pursue the vocation of healer. True, absolute, literal de-moralization ensues, manifest in symptoms of burnout, depression, and suicide. In the vacuity of meaning, where one loses sight of the purpose of human being, despair establishes its empire. Often, the medical humanities and engagements with the arts are regarded as a kind of intellectual recess—a break, at best, a disruption, at worst—from the rigors of studying scientific medicine. This tragically mistaken assessment and the curricular decisions that arise

from it undermine the important role that the humanities and arts should play in medical education. Engagements with art and the humanities promote uses of the mind that challenge the habits of knowing that de-humanize us: they involve us in an epistemic defamiliarization through which we remember how to understand others and ourselves as persons. In his famous dramatic monologue “Fra lippo lippi,” Robert browning gives us the humorous, endearing portrait of the very flawed painter-monk, who in spite of all he says that we might distrust, does speak a testimony to the role of artists that is surely one of the most moving and true accounts. What we, in medicine, have passed by “a hundred times nor cared to see” are our patients, in their humanity. Artists can remind us of how to see—can call us back to the vision we hoped to have all along:

For, don’t you mark? we’re made so that we love

First when we see them painted, things we have passed Perhaps a hundred times nor cared to see;

And so they are better, painted—better to us,

Which is the same thing. Art was given for that; God uses us [artists] to help each other so . . .

Art helps us to see and treasure what we’ve forgotten to look for. Mark Clark is an Associate Professor of Medical Humanities at the University of the Incarnate Word School of Osteopathic Medicine. His PhD in English literature has led to a career trajectory of using his expertise in narrative and rhetorical theory, the humanities, and the arts to examine medical practice and to optimize the processes of Professional Identity Formation in medical education.

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ART & MEDICINE

Art in Medicine at UIW By Anna Rogalska

In order to become a physician, medical students frequently draw into the notion that their lives should fully and whole-heartedly become immersed in “science”. Steering clear from the arts and humanities however will not develop the physicians we need for tomorrow. Certainly, medical students need to master the pathologies of the zebras they may never see and understand the transporters of all the possible luminal interfaces. However, at the end of their medical school journey, students will be faced with patients who are individuals. These patients will have their own narratives and they won’t be a textbook. In order to be able to assess these patients and develop the skills needed to think critically, medical students may have to look beyond standard approaches. Students who engage in artistic analysis and development may be able to see their patients from a different perspective and benefit from their outcomes. For example, when looking at a painted portrait, if you take an extra moment to look at the hues chosen by the artist or the brushstrokes, will you come to learn more about the person under observation? learning to analyze these details takes practice, creative thinking and active conversation. At UIWSOM, the Art in Medicine organization seeks to build well-rounded physicians who are nurtured through creativity. From a hands-on approach, our students do charcoal drawing classes of the human anatomy with models. At the same time, they go to the McNay Art Museum where they look at art work and push the boundaries by asking questions. What is the diagnosis of the patient in the painting? What was the artist thinking? Why is there an object that doesn’t belong in the composition? With subsequent exposures to this type of critical thinking the brain learns to approach problems in our daily lives differently. The way medical students analyze art can positively influence the patients of these future physicians. They will have refined observation, explorative thinking and individualized attention. As we strive to build medical professionals with these qualities, we should remember to welcome the arts and humanities as they have much to offer for the betterment of the medical profession.

San Antonio Medicine • June 2019

ART & MEDICINE

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Art in Medicine ART & MEDICINE

By Anna Rogalska

Above: Rx This art piece bring to light the entrapment patients may feel from the medication they take or the disease they live with. do we become someone else while on the medications we take? do the side effects outweigh the benefits? How do we prevent our diagnosis from defining who we are? Right: Just Listen This art piece is a digital water color of the human ear anatomy. Anna Rogalska is a third year medical student at The University of the Incarnate Word. She is from Chicago where she completed her undergraduate education in Biology, Studio Arts and Bioethics at Loyola University.

San Antonio Medicine • June 2019

intramorph ART & MEDICINE

This story in verse explores the evolution of a scientist through his experiences with depression. By Anna Dar, Medical Student at University of the Incarnate Word School of Osteopathic Medicine in the family politic there exists a code of treatment for your every “problem”– exogenous until proven otherwise. when asked what is “the problem” my words are broken, estranged from my mind. at the start there were numbers put more numbers in my hand, fed me and my home and did you know that numbers necrose? number. num(b)er. like any other life, industry disintegrates. I have learned more than I can say yet my limbs run from my brain met with faces that beg, react, react! I remain inert, immovable. science, first nature spills freely from me, but its warmth is gone. the light of God is gone if it was ever there. God is the end of the vector from my eyes into the sky—

San Antonio Medicine • June 2019

life now orthogonal to life before. numbers bleed in to memories blister under eyes— there are so many eyes that I feel even when I am alone the eyes speak, “Everything inside and out under waves and on slides in human eyes is alright.

no energy left from cells to soul, struggling in my silence I am told I am the source of my own suffering and the eyes are left to stare. in my years on this Earth We made more eyes and hands to behold:

What then is the problem?”

numbers of eyes that feed me back

all of these eyes know how I have fallen know not what I feel— they only see skin.

now stare back in a gaze of glass like fruit looking down on rotting roots.

they have exhausted every visible route of tracing the root of this pain.

but the hunger for light resides in us all,

from where does pain project when it is not formed within the body?

desensitized to probing eyes, I myself looked for listeners.

the snaking feeling of spasms from my gut to my throat robs me of words— the sensations mocked by devices that peer inside me to view a true bleed. diagnosis is a recurring plaguing dream that failed to find why food is now a forgotten idea that effaces my core.

and the light did return.

in my search I found both silenced pain and silenced hands— I wonder, is the greater shame emotion or psychiatry? a mass unfolding awoke: from folds of my brain out tumbled feeling, the energy core of memories—

the strain on my bones and bowels loosed my fingers once caught in a tangle of wringing refolded into strength, softness. my hands free to build life as I began again anew. I organified: the fluidity of my body unearthed to reveal I am my own faith.

Withering love

ART & MEDICINE

By Scott Cho, Medical Student at University of the Incarnate Word School of Osteopathic Medicine Coming to the conclusion of empathy Sympathy ran out of steam, so much as to care for her own well-being. A promise to herself to never love again Or rather trust that people are good. Offering help was no substitute for Her feelings of emptiness. It grew and grew. It drooped and drooped. It loved and loved, or at least it tried. It wrote beautiful poems out of misery, Then saw that it was all misery. It resented beauty and everything good. It waited for time to pass, but it never came. Time betrayed. beauty deceived and hurt. Skepticism became a shield of comfort. When the sun rose, she only saw shades.

Scott Cho, the author of Withering Love: I am originally from Queens, New York and a first year medical student at UIWSOM. After graduating from college, I did full-time volunteer work at clinics in resource-poor settings and hope to work in a similar setting in the future as a clinician.

On Cells, Molecules, and Compassion By Samantha Studvick (Edited and approved by Courtney Chason) One cell. Two cells Four cells. Eight. To enter this world there can be no mistakes.

low hemoglobin, hematocrit, platelets, oh my! You’ve got to look at the smear to figure out the why.

Genomic instability. Angiogenesis. Invasion, Metastasis. Resisting Cell death. Remember the hallmarks of cancer’s breadth

Mitosis. Meiosis. No anaphase lag. Nondisjunction? Wouldn’t that be a drag?

Is the stress of this all making you dizzy? Fatigued? Remove the spleen! Can I get an iron panel, STAT please?

In the midst of all the anemia and lab tests, don’t forget the cranial nerves, HEENT, upper extremity, and breast.

No drinking, drugs, or saunas for mom block that FGF8, and your limb growth is done.

One Cell. Two cells. Four cells. Eight. The same process that bore you is now the mistake.

Cancer seems bad. but the opposite is aging. Mitochondria dysfunction. Reactive Oxygen species raging.

Yet here you are. Alive and well. blood coursing. Too slow? dvT. Stuck in the spleen? Sickle cell.

Cancer. Those ingenious cells. Hijacking normal processes to make you unwell.

Starve yourself. Eliminate your stress. What difference will it make? To live an extra day or two? Just eat your chocolate cake.

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deal

ART & MEDICINE

By Alyson Randall, Medical Student at University of Incarnate Word School of Osteopathic Medicine While deployed I e-mailed with a family friend. “I’m in a place filled with sun and sand,” I said; he laughed. While I was fighting a war, he was fighting cancer. “If you promise to stay safe,” he said, “I’ll promise to continue fighting. deal?” Our last exchange. He fought valiantly for four more years. Alyson Randall, UIWSOM class of 2021, is an Army Veteran, active-duty Army wife and mother to 2 children. She is a native of Pennsylvania and currently resides in San Antonio.

Silhouette at Twilight

By Andrew Franks, Medical Student at University of Incarnate Word School of Osteopathic Medicine Andrew Franks is a first year medical student at The University of the Incarnate Word School of Osteopathic Medicine. Upon finishing high school in Tomball, Texas he received his bachelor of Science and Arts at The University of Texas at Austin and his Master of Science at the University of North Texas Health Science Center. Andrew has a strong fascination with science and medicine with a peaked interest in radiology, pathology and family medicine.

San Antonio Medicine • June 2019

To Find Health

ART & MEDICINE

By Kathleen Francis, Medical Student at University of Incarnate Word School of Osteopathic Medicine Kathleen Francis is a second-year medical student at the University of the Incarnate Word School of Osteopathic Medicine, inaugural class of 2021. during her free time in between studying for boards, she enjoys running with a local running group located at brooks City base with her German Shepherd dog and watching matinee movies. Kathleen's future plans are to apply for Emergency or Internal Medicine residencies while continuing to develop her osteopathic manipulative skills.

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Spectrum ART & MEDICINE

By Ashley Rhae Lopez and Jennifer Gaertner-Ott, Medical Students at University of Incarnate Word School of Osteopathic Medicine Spectrum illuminates how people express varying degrees of pain, whether that be physical, emotional, or psychological, and how the experience of pain, in of itself, is individualized. These individuals removed the varnish—lifted their painted veil—and gave an honest portrayal of their personalized experience of pain, on their scale of 0 to 10.

San Antonio Medicine • June 2019

You Kept it From Me

ART & MEDICINE

By Rachel Amuzu, 3rd year Medical Student at University of Incarnate Word School of Osteopathic Medicine I believe family values and interactions are crucial in medical care and sought to creatively interpret an interaction between a mother and her daughter in regards to a potential cancer diagnosis, which is loosely based on my own experience.

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Heart of Gold ART & MEDICINE

By Cassandra A. Jones, UT Health San Antonio, Long School of Medicine, Class of 2020

San Antonio Medicine â€¢ June 2019

ART & MEDICINE

Heading Out to See By Connie Cheng, UT Health San Antonio, Long School of Medicine, Class of 2020 What do you see? A profile facing the water? Just some rocks, grass, and a puddle? Perhaps four friends frolicking on the beach (did you spot the two furry, four-legged ones in the surf ?) What you see depends on how and how closely you choose to look. Perspective starts from observation, but the intention of the observer is what creates nuance and draws meaning from the details.

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ART & MEDICINE

Reflections By Roshni Grace Ray, UT Health San Antonio, Long School of Medicine

It felt as though I was playing a convoluted game of dress-up. It was the day before my first day at medical school and I was volunteering in a high school to provide screenings as part of a back to school event. I spent some time standing in front of my bathroom mirror scrutinizing my appearance. My white coat was spotless and stiff, a vivid reminder of my inexperience. On the drive there, I recited the steps to each of the screenings we were providing: always wipe the first drop of blood when taking blood sugar, make sure to palpate and place the cuff over the brachial artery. As I drew near to the school, my first reaction was disbelief. The line of people made a dizzying course through the grass and wound up and down the sidewalks. Children of every age stood in the scalding sun to receive school supplies and health screenings. A sense of panic erupted through me, “I am about to disappoint so many people.” As the day continued, however, my nervousness waned and I found conversation flowed more naturally. “What do you want to be when you grow up?” I asked, while distracting a particularly nervous teenager from the needle stick. “A doctor,” she said sheepishly. before I could say anything, she added, in hushed tone, “but mom says it isn’t realistic—too much money.” As I began to respond, the display on the glucometer flashed. Her blood glucose level was right underneath 300 mg/dl and she had not eaten that day. I swallowed my shock. I wrote down the number on her sheet as her mother came over and the teenager was ushered to the next station. 26

San Antonio Medicine • June 2019

Her mother craned her neck to look at the number. Guilt tore through her face. “I know it’s very high,” she said quietly, “and insurance has been a problem.” What do I say to a mother whose child is ill when she cannot afford to get help? We spoke about diet and exercise and I guided her to the counseling table. later, when the family waved goodbye, I had this unshakable feeling that I wish I was more capable to help. As our group of students left the clinic, a child pointed at our white coats and said, “look, there are the doctors!” I dropped my head. I certainly did not feel like a doctor. In the hospital emergency room, a week later, I found myself standing over a man who had been in a car accident. The cuts on his face needed stitches and I was the extra pair of hands to hold the skin together. A discerning viewer might have noticed how my knees shook or the light sheen on my face. When we paused to get more sutures, I saw the wife waiting in the hallway. She forced a smile, but her knuckles were white. While I waited, I thought of my mother and how she had waited for my father’s surgery after his car crash. She had told me about the direness of the situation and the panic in hearing he had been brought in by helicopter. She talked about the mangled remains of the vehicle and how, with bated breath, she had waited to hear from the surgeons. Would I have wanted my mother to speak to a nervous, unconfident physician? I straightened my posture and tried to command my knees to stay still. I focused on following the fourth year medical student’s instructions and listening to how he spoke with honesty

ART & MEDICINE

and empathy to the patient and his family. After finishing the stitches, I watched him discuss a plan of treatment with the resident. I stared, amazed by their speed. I mentioned to him how it felt like I was wearing a costume and putting on a charade. “I think it’s always like playing dress up,” he said, smiling, “it’s impossible to know everything, but it is always possible to care.” Those words serve as a mantra for me. I think it is relatively easy to sink into a sense of nihilism in medical school. Everyday I go to school excited to learn and come back confused by a new system. I came to medicine, in part, because I loved understanding the science —the why and the how of our bodies. It was a field where the uncommon act of looking within a body and understanding its workings became second nature. That fascination with science becomes difficult to maintain when I am knee deep in a metabolic cycle and every step has a disease and drug associated with it. However, whenever I think “What am I even doing here?” I think of the girl in the high school clinic who is fighting to become a doctor. When I hear the thuds of helicopters as I study, I think of my father. I remember: I came to medical school to become capable. I came to help to relieve suffering. I came to become the physician that comforted my mother on the worst day of her life. Nothing about learning or applying medicine happens overnight. I remind myself of that each time I watch older students and doctors interact with patients. They felt the same way I do, and they fought to get to where they are today. Ultimately, my white coat was not boasting of knowledge, but one promising service. It has been quite some time since that first day at the clinic. With more practice, I am less worried about “the charade” and more patient with myself. Every so often I catch my reflection in a window and pause. My white coat has lost its stiffness and I wear it with less hesitation. More and more, I look like a doctor. In those moments of reflection, I reconnect to the person I was when I started that very first day; standing in front of the mirror, sure of nothing else but my determination to serve. Roshni Grace Ray is a first-year medical student at the Long School of Medicine. She is honored to have received the On Being a Doctor Writing Award for this essay from the Texas Chapter ACP Medical Student Essay Competition in November 2018. visit us at www.bcms.org

HEALTHCARE

New Primary Care Training in Bexar County By Thomas Mohr, MS, DO, FACOI, FAODME The University of the Incarnate Word School of Osteopathic Medicine (UIWSOM) opened its doors to students in 2017 and will soon begin its third year of training. As a new, privately funded medical school, UIWSOM promotes a mission that emphasizes primary care, and care for underserved populations in South Texas. To meet this mission, the university recognized that new graduate medical education (GME) programs must be created. Since 2013, the Texas Medical Association and the bexar County Medical Society have been instrumental in convincing the Texas legislature to substantially fund new initiatives to develop and maintain new GME programs in the state. Since the inception of the GME Expansion Grant program, the Texas Higher Education Coordinating board has administered this funding to support over 1,200 new training positions.1 Traditionally, residency programs are funded through the Centers for Medicare & Medicaid Services through Medicare payments made to host hospitals. Unfortunately, due to an arcane and outdated 20-year-old statute, any hospital which had any existing residency training programs in 1998 or had allowed any residents from other programs to rotate in their facility since that time are subjected to a federal funding cap. In bexar County, nearly every hospital is ‘capped’ for this funding and therefore cannot afford to host residency programs. This has made it difficult, if not impossible, to create new GME programs. There is a clear lack of primary care training programs in the region. UT Health San Antonio boasts an outstanding Family and Community Medicine Residency program with 15 residents per year and Christus Santa Rosa recently expanded their Family Medicine Residency program to include nine residents per training year. As the seventh largest city in the nation, San Antonio had a total of 72 family medicine trainees in two programs. This stands in stark contrast to the sixth largest city, Philadelphia, which has seven training programs with 156 trainees.2 The University of the Incarnate Word School of Osteopathic Medicine created a GME consortium called the Texas Institute for Graduate Medical Education and Research (TIGMER) as a 501(c)3 nonprofit entity to work towards gathering the resources needed to establish a residency program without relying on federal funding. 28

San Antonio Medicine • June 2019

TIGMER achieved accreditation as an Institutional Sponsor for GME programs through the Accreditation Council for GME as well as programmatic accreditation for a new residency program. TIGMER has received $3.6 million in state funding through the GME Expansion Grant Program. The grant provides funding for approximately half of the expenses of a residency program. In order to make up the difference, TIGMER has received donations from the University of the Incarnate Word, the Center for Health Care Services (CHCS), and CommuniCare Health Centers. Additional funding was later received through veterans Administration grants and from baptist Health System. This residency program is unique as it is truly based on a community health model in partnership with multiple clinical entities. CommuniCare is a Federally Qualified Health Center with 14 clinical locations in and near San Antonio providing full spectrum primary care to those in need. CommuniCare acts as the outpatient cornerstone for this residency and the continuity training clinic is housed at their West Campus on barclay Street. Residents also train in outpatient pediatrics and obstetrics and gynecology at this site. The Center for Health Care Services (CHCS) recognized early on that training in primary care could not be complete without a focus on mental and behavioral healthcare and substance abuse. CHCS is a national leader in integrated mental health care, substance abuse and addiction, and primary care for homeless and underserved populations. Residents rotate with CHCS physicians and staff each year during their training program. Hospital-based rotations such as internal medicine, surgery, obstetrics, and emergency medicine are predominately completed at baptist Health System Hospitals. baptist Health System has been extremely generous in facilitating the development of the inpatient rotations along with physician groups such as Sound Hospitalists, U.S. Acute Care Solutions, The San Antonio Orthopedic Group, South Texas Renal Group, Sports Medicine Associates of San Antonio and dozens of community-based clinicians who have been willing to volunteer their time to work with these residents. The program is accredited for eight residents per year and will matriculate its third class in July 2019, at which time the program will have a full compliment of 24 trainees. The first class will grad-

HEALTHCARE

uate in June 2020 and most of the rising third year residents hope to remain in the area to practice. Program director Michael Mohr, dO, and Associate Program director bridget Thackeray, dO, have worked tirelessly to ensure the success of the program and each individual trainee. The unique structure of the program allows residents to experience clinical practice in a wide variety of underserved venues including FQHCs, Community Mental Health Centers, veterans Administration clinics, and private practices in health professions shortage areas. The faculty look to foster a level of comfort with these practice venues to encourage vocations in underserved medicine. “When residents are looking for a job at the end of residency, they tend to migrate towards the types of practices they have trained in, and we hope that our broad exposure will open their hearts to continue providing medical care to those most in need,” says dr. Mohr. dr. Thackeray has worked for CommuniCare for nearly a decade and notes that “there is a great need for improved access to high quality medical care in our community. We have outstanding trainees who will be ready to make a difference in the lives of our patients when they complete their training.” The CommuniCare Community-based Family Medicine Residency Program at UIWSOM—Texas Institute for GME and Research is a welcome addition to the San Antonio medical community. The program is always in need of continued support to continue to operate. If you are able to assist with resident education with didactic sessions or you can host a resident on clinical rotations, please contact the residency coordinator, Taylor Aoughsten at aoughste@uiwtx.edu. If you are interested in donating financial support for the program, please contact dr. Thomas Mohr at tjmohr@uiwtx.edu or donate online at www.tigmer.com/donate. Thomas Mohr, DO, is the Associate Dean for GME at the University of the Incarnate Word School of Osteopathic Medicine and the Designated Institutional Official for the Texas Institute for Graduate Medical Education and Research. He is a Professor of Internal Medicine and works as a hospitalist in the Baptist Health System. He serves on the Texas Medical Association Council on Higher Education. 1.

Texas Higher Education Coordinating board (http://www.thecb.state.tx.us/index.cfm?objectid=988db3C 0-1E3A-11E8-bC500050560100A9 ) Pennsylvania Academy of Family Physicians (www.pafp.com ) visit us at www.bcms.org

FEATURE

LUNG STORY SHORT By Douglas Jenkins, MD

About ten years ago I received an e-mail from our younger son that he titled “lung Story Short.” He does have a sense of humor. With some abbreviation, his message was that he had connected with a friend from elementary school via social media. She had finished her comments by saying that people that smoke make her sick and “to this day” she thinks about the bag of lungs I brought to school that day many, many, years ago. The memories started coming back. The time was 1981 or 1982. I had become “show and tell” through the years for our two sons as they went through school, particularly as I also volunteered with our local lung Association. I would go to a school class and spend some time talking about lungs, how we defended ourselves from dangers to our lungs from the outside world and, of course, the special dangers of smoking. Indeed, I did have a “bag of lungs.” A wonderful lab Officer had in the far past prepared some lungs that were fixed and dried in the inflated state. The source of the lungs was obscured by time, but I suspect that some came from the Pathology lab and some perhaps from what was then called the “dog lab.” The result of the process is a specimen that looks and feels much like Styrofoam, but it maintains the markings and, more importantly for demonstration purposes, the pigmentation of the lung. I would pass the specimens out and ask the students to treat them carefully as they were fragile and return them when they had looked at them and thought about which specimens might have come from smokers since some of the specimens clearly had more pigmentation. I always got every lung back and some kids would stay a while to ask questions.

San Antonio Medicine • June 2019

I did enjoy the school visits, perhaps because both my Mom and dad were teachers, but it was not until later that I came to appreciate the impact. A lady stopped me in the local grocery store, “dr. Jenkins, thank you so much, my daughter would never touch a cigarette.” A comment from a young man sitting nearby at a restaurant, “You’re doug’s dad aren’t you? You came to class to talk about smoking.” The message from my son that started this piece was almost 30 years after the fact. And about three years ago a young man re-introduced himself, again at a grocery store. The son of a physician, he is now a high school teacher, “dr. Jenkins, every time we reach that module in our class, I tell my students about your presentation back then.” It took me quite a while to realize how fortunate I was to have just the right items for, “show and tell.” Talk about feel good! Albeit miniscule, I offered some assistance as the United States moved from about 50 percent smokers to under 20 percent smokers during my professional lifetime. Is there a general message in what is otherwise a personal story? I think so. In the medical field we all develop special knowledge. Sometimes the use of an example, a parallel, a little careful humor, or something special for “show and tell” can get a thought or concept to “stick.” If we can find a way to effectively translate “medical” to “human,” then we can be better in communication. This can be a critical improvement as we work with and for our patients and others we meet. Dr. Douglas Jenkins is a Life Member of the Bexar County Medical Society. He is now semi-retired and working part-time.

BCMS NEWS

2018-19 BCMS Leadership Series Congratulations to the physician members that attended the first ever bCMS leadership Seminar Series which began in September of 2018 and concluded on May 6, 2019! Attendees received up to 10 hours of professional leadership training enabling them to be better leaders and managers in their practices, in organized medicine and in the community. The course was taught by professors from Trinity Universityâ€™s Masters Program who are experts in teaching physicians the techniques, strategies, and methods of leadership that enable a physician to step up and lead with confidence while knowing how to engage others and rally them to the desired goals. Attendee evaluations of the course were unanimously positive about the quality of the course and how much they learned. Plans are being made to offer another leadership Series beginning in the fall. Watch your email in the next few months for details.

visit us at www.bcms.org

BUSINESS

How to Prepare for Homebuying If You Run a Practice By Jon Tober

Running your own medical practice comes with a unique set of perks, but if you’re ready to purchase a home, it also requires some unique steps in the homebuying process. Typically, self-employed individuals tend to have fluctuating income and debts that could be tied to their business, so lenders will require additional pieces of documentation—even if those aren’t necessarily concerns for you and your practice. don't let this deter you from pursuing the homebuying journey! This article will list the types of documentation you may need, as well as any obstacles that could get in your path so that you can properly prepare. While the actual homebuying process is the same for both selfemployed and employed homebuyers including the application, rate qualification, credit and income requirements, underwriting, etc., the documentation aspect of the process is relatively different. Whereas someone who is employed for a corporation can access their W-2 forms and get proof of employment, self-employed homebuyers will have to provide a few more pieces of information to their lender in order to accurately assess their true financial picture.

In general, all borrowers and co-borrowers, if applicable, are required to submit the following: • • • • • •

A driver's license or government-issued photo identification birth date Social security number bank and liquid asset account statements Address information for the previous two years If a current homeowner, loan information

San Antonio Medicine • June 2019

Tax Returns

You’ll most likely need to submit at least two years' worth of federal tax returns, as opposed to one year for employed applicants.

Profit and Loss Statement

A profit and loss statement, commonly referred to as your P&l, provides a comprehensive snapshot of the revenues, costs, and expenses that your practice incurred over a period of time. Since business owners may typically not receive traditional paychecks to validate income, the P&l provides lenders with the information they need to understand if a business is profitable. This impacts how the lender views the financial standing of you and your practice.

Statements

While bank and financial statements are required from all borrowers, self-employed applicants are required to submit statements from both their personal and business accounts. Again, lenders want to accurately assess your full financial picture, including personal and business debts and liabilities. To help make things as clear and uncomplicated as possible, avoid mingling expenses between the accounts.

Partnership Tax Returns

If more than 25% of your practice is owned by another individual or entity, your lender will require copies of the previous two years' corporate/partnership tax returns.

BUSINESS

Getting a mortgage approval while running a practice will require some diligence and recordkeeping to ensure you can answer any and all questions regarding the health of your practice. like all potential mortgage applicants, one of the first steps to ensuring you're on the right path to homeownership is to seek out a mortgage loan officer that is knowledgeable and available to answer all of your questions. A good loan officer will partner with you from start to finish, ensuring you know exactly what documentation you need and keeping you informed of any potential challenges that you may face along the way. To learn more about the homebuying journey, contact me at 210-317-7421 or jon.tober@swbc.com. Jon Tober is a Senior Loan Officer, NMLS #212945 with SWBC Mortgage Corporation (9311 San Pedro Ave, Ste. 100, San Antonio, TX, 78216). He offers unique product opportunities, professional expertise, and the sound advice needed to deliver results in this challenging and ever-changing lending environment.

visit us at www.bcms.org

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

San Antonio Medicine • June 2019

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

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

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

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 (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity. Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

FINANCIAL ADVISOR

Elizabeth Olney with Edward Jones ( Gold Sponsor)

We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"

MGugliotti@swbc.com Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

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

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!”

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"

continued on page 36

visit us at www.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 35

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.”

HEALTHCARE BANKING

Amegy Bank of Texas ( Gold Sponsor) We believe that any great

San Antonio Medicine • June 2019

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 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

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

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 pro-

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY tect 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 bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

continued on page 38

visit www.bcms.org 37 37 visit usus atatwww.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

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

Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage. We have served the buyers and

San Antonio Medicine • June 2019

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

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

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

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 BMW X7 By Stephen Schutz, MD

San Antonio Medicine â€¢ June 2019

AUTO REVIEW

The full-size luxury SUv market niche, which I define as big

comfort, but that’s not the case here. These are very cushy seats

cushy SUvs with three rows of seats, continues to fill up quickly

that have been created to sooth your posterior, and I enjoyed them

(Wasn’t it just yesterday that it was the Cadillac Escalade, lincoln

Also comfortable and soothing is the X7’s ride, which is very

with offerings from Cadillac, Infiniti, Mercedes, volvo, and others.

Navigator, and nothing else?) This year bMW enters the fray with

the X7, a new alternative that’s nice to look at, made in America,

more every time I sat in the X7.

smooth indeed. The 1970s expression, “like driving on a cloud”

seems fitting here, and given the X7’s mission—carry up to seven

and, maybe, the best of the bunch.

passengers in maximum comfort—I’m not bothered by that in

sprawling plant in Spartanburg, South Carolina. Thanks to that

to task for not making the X7 into a big SUv “Ultimate driving

I’m happy to report that all X7s worldwide are built in bMWs

plant’s huge output of around 450,000 vehicles per year, bMW is

a net exporter of vehicles from this country. Anybody concerned

that U.S. factory workers can’t compete with those from other

countries would do well to tour this gigantic facility. I did just that

about a year and a half ago and was very impressed.

It’s possible that the designers at bMW decided that their

the least. dan Neil of the Wall Street Journal recently took bMW

Machine,” but I don’t see why they should. buyers from tony zip

codes in the US (and increasingly China) are looking for luxury

first and foremost, and the idea that bMW should alienate them

because of an old advertising tag line seems a little silly.

The X7’s curb weight of just over 5,500 pounds means that

good fuel economy is not happening. Two versions of bMW’s

newest SUv needed a grille commensurate with the size of the

biggest vehicle are offered, the X7 xdrive40i powered by a 338HP

than the Great Wall of China, easily visible from the international

that comes with a 456HP twin-turbo 4.4l v8. Their EPA num-

factory that built it, because that grille is big. How big? It’s longer

twin-turbo 3.0 liter in-line six cylinder engine, and the xdrive50i

space station, and each end of the grille is located in a different

bers are 20 MPG city and 25 MPG highway for the six-cylinder

The remainder of the X7’s styling is much more understated,

offered, so there’s no way to goose the numbers to curb the wrath

time zone.

looking very much like the taller and more squared off X5 that it actually is. The best adjective to describe the X7’s design is stately,

although there’s a lot going on styling-wise if you look closely.

X7, and 15 city/21 highway for the v8. No diesel option will be of your Sierra Club member friends. Sorry.

X7 pricing starts at just over $72,000 for a base xdrive40i but

moves up quickly as you add options and option packages. My

Many character lines and bodywork protuberances are used to add

loaded xdrive50i press vehicle listed for $117,000 and change, al-

sculpted than on older bMW SUvs. While the aforementioned

$3,550 M Sport package, and $4,750 dynamic Handling package.

visual interest, and the front- and rear lights are now more

grille is bigger than I’d like, it does get less jarring with time and appears to reflect the future of bMW design.

The interior of the X7 is modern bMW, as you’d expect. As

I’ve noted previously, a few years ago the bavarian automaker

ditched their trademark white-on-black gauges with orange back-

lighting in favor of Audi-esque white lighting with bright red nee-

dles. bMW still uses those black/white/red Audi colors for their

gauges, but now everything’s electronic and located on big screens.

bMW isn’t the first company to do this—Tesla was, actually—

but they have certainly embraced the trend. Which I’m warming

though I could certainly do without the $2,100 Executive package,

(Hey bMW, a handling package on a 2.5 ton SUv? Seriously?)

The new bMW X7 is a large luxury SUv just like its competi-

tors from Germany, the U.S., and Japan. No, it’s not an Ultimate

driving Machine, but it is a fine vehicle that I’m happy to recommend if you need all that space.

As always, call Phil Hornbeak at 210-301-4367 for more infor-

mation and to get your best bCMS deal.

Stephen Schutz, MD, is a board-certified gastroen-

to, by the way. Once I configured the X7’s touchscreens the way

terologist who lived in San Antonio in the 1990s

In addition to a large cabin, the X7’s interior features excep-

He has been writing auto reviews for San Antonio

I wanted them I found them to be helpful and not distracting.

tionally comfortable seats, including in the “way back.” The seats

you’ll find in many smaller bMWs emphasize lateral support over

when he was stationed here in the U.S. Air Force. Medicine since 1995.

visit www.bcms.org 41 41 visit usus atatwww.bcms.org

THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA

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Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of May 27, 2019.

San Antonio Medicine â€˘ June 2019