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Where to From Here?
COVID-19 S A N A N TO N I O
MEDICINE SAN ANTONIO
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COVID-19 Where to From Here?
Lessons Learned about COVID-19 By Alan Preston, MHA, ScD ..........................................................12 Adapting to the Needs of the COVID-19 Pandemic By Carlos E. Moreno, MD, MBA ....................................................16 Do We Learn From History? By Wendy B. Kang, MD, JD ..........................................................18 Bexar County Medical Society and COVID-19 By Melody Newsom ......................................................................20 Medical Education: Meta Reflection in the Midst of a Pandemic By Samantha Bailey, OMS1 and John Seidenfeld, MD ..................22 Discovering the Healer’s Art By Medical Students at the UT Long School of Medicine.............................24 Have You Ever Been Asked to Pray for Patients? By George S. Best, MD.............................................26 More Quality Time By Sheldon Gross, MD.................................................................................................27 COVID-19 Causing PTSD Among Dual Healthcare Worker Households By Erika Gonzalez, MD.........28 COVID-19 Testing: A Local Lab’s Experience By Kelly Elterman, MD and Steven Goodman, MD ...........29 Sleep By Avie Grunspan, MD ......................................................................................................................30 The Healing Process: A Lesson Learned from Your Blood By Teresa Samson .....................................32 SARS-CoV 2 Clinical Presentation By Anisha Guda, Kavina Patel, Aleena Vargas, Tracey Vuong; peer reviewed by Dr. Philip Ponce ..............................................................................................................33 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10 Reducing Physician Burnout: The Role Health Plans Can Play By P. Nelson Le, MD, MBA .....................................34 The Business of Medicine: Exiting Your Practice By Tom Jordan ............................................................................36 BCMS Circle of Friends Physicians Purchasing Directory........................................................................................38 Where Vehicle Production is Headed Post COVID-19 By Stephen Schutz ..............................................................42 Recommended Auto Dealers .................................................................................................................................44 PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com
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JULY 2020
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VOLUME 73 NO. 7
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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Gerald Q. Greenfield, Jr., MD, PA, President Rajeev Suri, MD, Vice President Rodolfo “Rudy” Molina, MD, President-elect John Joseph Nava, MD, Treasurer Brent W. Sanderlin, DO, Secretary Adam V. Ratner, MD, Immediate Past President
DIRECTORS Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member Danielle Hilliard Henkes, Alliance Representative David Anthony Hnatow, MD, Member Lyssa N. Ochoa, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones, Jr., MD, Member John Milton Shepherd, MD, Member Richard Edward Hannigan, MD, Board of Ethics Co-chair Nora Lee Walker, MD, Board of Ethics Co-chair Charles Gregory Mahakian, MD, Military Representative George Rick Evans, Legal Counsel Jayesh B. Shah, MD, TMA Trustee
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Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Stephen C. Fitzer, CEO/Executive Director (ex-officio)
BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Yvonne Nino, Controller August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer
PUBLICATIONS COMMITTEE Kristy Yvonne Kosub, MD, Chair John Joseph Seidenfeld, MD, Vice Chair Louis Doucette, Consultant Charles Hirose Hyman, MD, Member Tzy-Shiuan B. Kuo, MD, Member Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member David Schulz, Community Member Alexis A. Wiesenthal, MD, Member Tyler Adams, Student Member Chinwe Anyanwu, Student Member Darren M. Donahue, Student Member Donald Bryan Egan, Student Member Christopher Hsu, Student Member Aishwarya Devesh Kothare, Student Member Anirudh Madabhushi, Student Member Anjali Surya Prasad, Student Member Teresa Samson, Student Member Cara Jillian Schachter, Student Member Stephen C. Fitzer, Editor
PRESIDENT’S MESSAGE
The COVID-19 Pandemic – Are We Really All In This Together? By Gerald Q. Greenfield Jr., MD, 2020 BCMS President
While current national and local monikers state that we are all in this together, the use or not of masks would suggest otherwise. The wearing of masks is recommended for all who are outside of their home, not in an automobile or who are in a confined space (such as their home). The political and medical leadership of this country were both initially unsure and unclear about the wearing of facemasks during this pandemic. Even Dr. Anthony Fauci initially stated that there was little value in the use of facemasks. However, as scientists have learned more and more about the virus and its effects, the use of facemasks or face-coverings by all members of society has been recommended; even children are shown to gain a protective advantage. The ability of political leaders to provide direction in a public health crisis is only as good as the value of the medical recommendations they receive. As I mentioned, the use of masks was not initially recommended, but it has now been proven to be efficacious in prevention of disease transmission. Leadership, both political and medical, must recognize errors, correct the errors, and provide guidance in a timely manner. They must provide explanations of changes and then chart new direction. Instead, the use of masks and of certain medications has become part of partisan politics. This points out the weaknesses of our political leaders on both sides. Political leaders must be able to accept and adjust both guidance and support based on the effectiveness of prior acts and treatments, and based upon future expectations, which may continually change. The current patchwork and interpretation of medical recommendations regarding this virus is due to the lack of political unity and leadership. Medical guidance changes cannot be instituted without leadership support. Both medical and political leaders need to be consistent in reevaluating the changing situation, adjusting guidance and regulations, and finally, providing non-partisan support of evidence-based medicine. In addition, political leadership is from the top, and top leaders must lead by example. The newest medical information indicates that masks protect wearers to a small degree, and mostly protect other members of the society from a potentially infected person. Although an infected person may be asymptomatic, it is still possible to pass the disease 8
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on to other people, leading to a widening of the pandemic. Public health statements now emanate from all levels of government and medicine, causing recommendations to differ in some respects and consequently to be politicized. As a result, both physicians and politicians are being accused by some members of the society of infringement on their freedom. This leads to the question of whose freedom is being limited? Is the freedom of the asymptomatic infected person who can possibly infect others and widen the pandemic limited? Is it their freedom to have the ability to expose others in society to unnecessary risk? Who then will care for those newly infected patients? Are first responders and medical providers obligated to assume extra risk for themselves and their families due to irresponsible behavior by members of the society? Do first responders and other members of the medical team have freedom? Can they choose not to participate as care providers in order to protect themselves and their families from unnecessary risks? When a person insists upon their rights without acknowledging their responsibilities, that is not freedom; it is adolescence. Adults behaving as pedantic children, focusing on the details of their rights only, must be treated based on their actions. Just as children need evidence and leadership to act responsibly, so do adults. Guidance, at times, must be stern and potentially supported by punitive measures. When an explanation of the basis for guidance is not adequate to change behavior, other measures become necessary. Members of the medical care team are by nature concerned about the greater good, willing to take risks to protect public health and well-being. They cannot, however, be expected to embark on suicide missions willingly and repeatedly. In summary, wearing a mask is more to help others than to help oneself. Medical and political leadership all agree it is important to control the spread of the virus. If we truly are all in this together, then wearing a mask to help limit the spread of the virus is a small price to pay. It protects the rights of all people. This is of paramount importance when the contrary, not wearing a mask, puts the lives of medical professional along with their families at risk of death. Gerald Greenfield, MD, is an Orthopedic Surgeon in Bexar County and is the 2020 President of the Bexar County Medical Society.
BCMS ALLIANCE
Tell us a little about your background.
I am originally from a small farm town in the middle of Illinois but was educated at Indiana University. I hold a master’s degree in Audiology and practiced in both private pediatric settings and military hospitals. I met my husband John, also a Midwesterner, on the first day of internship for both of us at Beaumont Army Medical Center when we were stuck in a broken elevator together. I got off the elevator and declared, “That’s the man I’m going to marry.” We celebrate 32 years this summer. What prompted you to return to school? Why public health?
My role at Texas Medical Association Alliance as Vice President of Legislative Affairs has allowed me to become involved with, and understand, how important advocacy and policy formation is for medicine and public health. I found that with each new issue that TMA tackled I wanted to take a look at the issues more in depth; eventually I decided to head back to school for a Master’s in Public Health at UT Health School of Public Health. I really feel called to give back to our community and public health is an area where I think can make a huge impact. Has your master’s program changed since COVID-19 hit?
The School of Public Health at UT is an interesting program: while it is based out of UT Health Science Center at Houston, it operates satellite campuses around the state in most major cities. They offer on-site teaching, ITV from other campuses and online work. Since COVID-19 hit everything transitioned to online. While I prefer more interaction, it is pretty nice to get up for an 8 am lecture and still be in my pajamas! What exactly is COVID-19 tracing?
Through the school I’ve had an opportunity to volunteer with San Antonio Metro Health as a COVID-19 contact tracer. It’s not only interesting and a valuable experience but a great way to help San Antonio! Contact tracing has been used in public health for decades as a way to control the outbreak of communicable diseases. It’s a little like being a detective. You search for clues to find all contacts of a confirmed case in order to help stop the spread of disease. Could you run us through a case?
When a positive test result is received the health department is notified and then a tracer attempts to contact the patient. Every pa10
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tient is asked the same information in an attempt to gain information about the disease itself (symptoms) as well as the places visited and people the patient may have been in contact with while potentially infectious. We try to gain information from 2 days before the symptoms began to 10 days after diagnosis. While every call is different, I was really lucky to have people very willing to help and really rack their brains to come up with information on where they might have been. Sometimes it’s a tough task. Before shelter in place went into effect, I’m not sure I could tell you all the places I’d been and people I’d encountered! Did most people realize they were sick before they self-quarantined?
Before COVID-19 was the hot topic on everyone’s mind, I don’t think most people immediately jumped to the conclusion they were sick. Spring allergies were the most common thought. Of course, that’s where the danger lies: in someone not realizing they’re sick and continuing with their daily life, unfortunately spreading the disease. I think that’s something really important to keep in mind as we begin resuming our life in our new normal. Common questions you’re asked?
Most people want to know how to keep other people safe! To me that’s really heartening given the huge political divide we have going on in our country right now over…well, everything, but in particular how to deal with the virus, whether to wear a mask, is the virus serious…the list goes on. Any funny or poignant stories you can share?
I think the funniest thing has been how some people really were just so happy to talk to someone new! For extroverts or people who live alone, quarantine can be tough! The most poignant things...The saddest is the fear some people express of being alone in the face of all this. It makes me ever so grateful for my friends and my family. On the opposite end of the spectrum there are tales of friends, neighbors and strangers coming to the rescue in ways people could never have imagined. It makes me thankful to live in a community where there are such great people. When Jenny Shepard is not being a public health detective, studying for her 2nd graduate degree, advising the Alliance President or in Austin or DC advocating for medicine, Jenny Shepherd busts sod with husband John (pediatric anesthesiology) on their Stockdale ranch.
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WHERE TO FROM HERE
Lessons Learned about COVID-19 By Alan Preston, MHA, ScD
There is always much to learn about how to manage a pandemic. They have things in common, but are all a bit different. I have been watching how this deadly pandemic has been characterized, including that health officials recommend everyone, both healthy and sick, stay at home to stop the spread of the disease. This is a change from how history has managed pandemics in the past. What I mean is, normally the quarantine (stay-at-home) focus is only on the sick. This pandemic is being strategically approached in new ways that we have never witnessed. And like all disasters, there are intended and unintended consequences with every policy decision made. The benefit of time will usually provide us with tremendous insight as to what worked and what didn’t. I was fortunate to share a podcast with some of the leading experts on the subject and have kept in close contact with them since the airing of the podcast. What struck me during the interviews was how all of us independently came to similar conclusions as to how federal, state, and local governments are "managing" this crisis. Let's recall what has taken place so far, how we got where we are today and what we have learned. It appears that in Wuhan, China, somehow a virus (with perhaps multiple strains) was transmitted to the local population leading to the beginning of what we call COVID19. The exact timing is not precisely known; however, many speculate that it showed up in the general public around late November or early December 2019. (i.e., thus the 19 in the name COVID-19). On January 3rd, China notified the World Health Organization (WHO) of the outbreak. The USA announced the first case in Washington State on January 21st, 2020. Five days after Washington State, cases were confirmed in Chicago, Los Angeles, Arizona, and Orange County. On January 30th, the U.S. issued a Level-4 travel advisory, which is a NO TRAVEL ban to China. On February 29th, the U.S. had its first reported death as a result of COVID-19. The President then imposed more travel restrictions to other infected countries that day. The imposition of travel restrictions by the Federal Government so early on during the pandemic created an avalanche of criticism. 12
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LESSONs LEARNED: 1. Travel restrictions in the early stages of an outbreak serve to mitigate the spread of unknown diseases, as was the case with the COVID-19 pandemic. 2. Travel restrictions will be met with criticism from the media for both commercial and political reasons. In the early stages of the pandemic, there were numerous models predicting the nature, spread and effects of the virus. Medical experts and the Centers for Disease Control (CDC) familiar with epidemics and pandemics were drawn upon by the federal government to provide guidance, strategies and tactics. At the time, when little was known about the virus, the people of the United States were told not to worry about the virus. People were also advised that masks were not necessary, presumably because the virus was not yet prevalent enough (or because testing had not yet caught-up to establish its prevalence). Once the virus spread was established, the need for masks became a key part of the strategy to limit the spread, along with hand-washing and social-distancing. Masks are recommended to mitigate any droplets from a sneeze,
COVID-19
WHERE TO FROM HERE cough or forceful speech, because the transmission is spread through consequential droplets. From the chart on the previous page listing possible mask materials, we see that a surgical mask is 89% effective against COVID-19 particles. Masks made from other materials are less effective, but better than not wearing a mask. If you touch the mask after touching a surface that has the virus, none of the mask materials may be as effective as you think. On March 13th, the NY Times reported that up to 2.2 million deaths could occur from the U.S. pandemic. This prediction of 2.2 million deaths was based upon the Imperial College of London COVID-19 Response Team. It is amazing how computer models, interpretations and actual progress of the pandemic changed the outlook and strategy for dealing with the pandemic in just 30 days! Think of a disease pandemic as a puzzle. If I had a 1,000-piece jigsaw puzzle and gave 20 people around the room ten different pieces each, and then asked everyone to tell me what the picture is based upon their ten pieces, they would all get it wrong. This pandemic is like a jigsaw puzzle, everyone has a few pieces here and there, and no one has a full picture. It is the responsibility of those managing the response to such diseases to interpret data and ground them in science. That is not an easy job! LESSONs LEARNED: 1. The lesson here is to be measured in comments when empirical data is insufficient to come to proper, exact conclusions. Policymakers, as well as the public, rely on these conclusions; therefore, extreme caution is necessary when there is not enough data to come to exact conclusions.
dividuals. I suspect the CFR is even lower due to the fact there are people infected, pre-symptomatic, who have not been tested. I would estimate that the CFR is closer to .2% to .5% given that the unknown prevalence of COVID-19 is probably at least 10 to 20 times greater than we know. The CDC has new scenarios that suggest it is closer to .26%. The flu is about .1%, and about 50% of the population gets a vaccination for the flu. Context is important! LESSONs LEARNED: 1. The lesson here is that when calculating CFR, do not base it on incidence rates, base it on prevalence rates; that will take some time to estimate as testing becomes more widespread. Currently, for every 100 people that get tested, about 11% test positive. This may suggest why the prevalence could be at least ten times more than the stated number of cases. Another reason the COVID-19 infected rate of citizens (i.e., the prevalence rate) may be higher than advertised has to do with the calculation of excess deaths. Why do we calculate “excess deaths,” and what is the implication of such? The mortality rate of “observed” over “expected” deaths tells us the relative risk of death of a particular disease. A rate of over 1.00 is considered "excessive" deaths for a specific illness. It is important to understand whether or not deaths are the result of a specific disease, such as COVID19, vs. merely a catalyst of a death that would have occurred anyway. The CDC calculates two sets of excessive deaths for this pandemic. One measurement of deaths is due to COVID-19, and then they compare it to all-causes of deaths when COVID-19 is not the cause,
The CDC now reports (as of the end of the second week in June) total deaths as 115,729. This number may not be exactly accurate for a variety of reasons. According to the CDC, the definition of a COVID19 death “may not be confirmed”, or it “may be presumed”. Therefore, it is quite possible there are H1N1 flu deaths comingled into the COVID-19 deaths. “COVID-19 deaths are identified using a new ICD– 10 code. When COVID-19 is reported as a cause of death — or when it is listed as a “probable” or “presumed” cause — the death is coded as U07.1. This can include cases with or without laboratory confirmation.” The Case Fatality Rate (CFR) drops with widespread testing. Let me explain. As of the first week in June, the CDC reported that 20,384,850 people were tested for COVID-19, and the number of individuals infected (i.e., tested positive) was 2,296,561 with 112,078 deaths. That suggests a CFR of 4.8% of infected incontinued on page 14
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but is present. As we can see from the graph, the observed, over-the-expected deaths in ages over 65 years, is cause for concern. On the other hand, if coders listed COVID-19 as the “cause” of death without confirmation and were motivated due to the incentives to call the diagnosis a COVID-19, that might explain some of the excessive death due to COVID-19. The other issue in reporting is due to the unnecessary deaths in nursing homes, that have accounted for over 40% of all COVID-19 deaths. If the data were normalized, the excessive deaths might be closer to a factor of 1.00. Regardless of the reason for the excess deaths, the vulnerable population is greater than age 65, and that has implications concerning the rest of the population younger than age 65. LESSONs LEARNED: 1. Co-mingling data points into one category is confusing. If flu deaths and non-casual COVID-19 deaths are included in the reporting, and policymakers then rely on the data, their decisions on how to treat the disease (i.e., the cure) may not indicate the correct strategy forward. Why was shutting down swaths of the economy part of the strategy? The thinking in mid-March was that COVID-19 would overwhelm the hospital system. To mitigate the spread of COVID-19 and not overwhelm the hospitals, a “stay-at-home” recommendation was initiated by the CDC and mandated by governors and mayors across the USA. The stay-at-home orders were initially for a 30-day period, then extended. We were told we needed to “mitigate the burden of disease,” and “flatten the curve”. As a corollary to ensuring capacity at the hospitals, non-essential medical procedures were ordered stopped. This greatly impacted non-hospital medical practices. It was an unfortunate trade-off that the stay-at-home order led to over 40-million people becoming unemployed, and record deficit spending to soften the blow to those out of work. One could say that the strategies was so successful, that not only were hospital systems not overwhelmed, they were underwhelmed. So much so, that many hospitals furloughed staff. There are over 6,000 hospitals in the USA. Even with significant excess capacity, 14
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there was worry hospitals would be overwhelmed. In the “hotspot,” New York City, the federal government responded with the New York National Guard and the U.S. Army Corps of Engineers ultimately building an additional 2,900 beds at the Javits Convention Center. The USNS Comfort was sent to New York on March 30th to help mitigate the demand of patients with COVID-19 from going to the local hospitals. In New York, the governor mandated (via Executive Order) that anyone who tested positive but did not need a ventilator or ICU bed, be transferred to a nursing home facility. Other states followed the “wisdom” of Governor Cuomo. That move proved to be disastrous, as consequently over 40% of COVID-19 deaths occurred in nursing homes. LESSONs LEARNED: 1. Shutting down the economy seems to have flattened the curve as intended (i.e. it slowed the increase in the rate of new infections). 2. Wholesale shutdown of certain businesses and stopping non-essential medical procedures had serious consequences, including: a. Delaying the health needs for millions of Americans. b. The unemployment of 40-million people. 3. The wholesale-mandate of a one-size-fits-all policy does not work. 4. Policy makers should listen to those that run the businesses; in this case, nursing home administrators pushed back on the Executive Order, but to no avail. 5. New York, like many states, has a Certificate of Need demon-
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WHERE TO FROM HERE stration program that stopped thousands of hospital beds from being built. That caused a “shortage� of beds there and elsewhere. One quite positive consequence of the COVID-19 pandemic is the adoption of telemedicine. The federal government loosened the regulatory grip and allowed many types of telemedicine platforms to exist, which helped patients and physicians alike. Additionally, businesses are now looking at whether or not to have employees come to an office to work when it is possible to work from home remotely. Time will tell how this trend will ultimately play out; however, flexibility in the workplace was an unanticipated consequence of the pandemic. There are many lessons yet to learn, and this is by no means an exhaustive list, given restraints in writing an article; however, I wanted to share these thoughts on some of the significant lessons learned, and surely there will be many more to come. In closing, we need to be careful NOT to create panic and confusion with the American people. We cannot mitigate all deaths or all injuries; people must take responsibility for their own actions, but at the same time must consider how their actions impact other people. We can manage the vulnerable population (i.e., those over 65, especially with comorbidities), and allow others to conduct themselves appropriately (keeping a safe distance, washing hands, exercising, eating healthy). Fargo North Dakota is not the same as New York City, and we should not mandate measures for Fargo as we do for New York City. LESSONs LEARNED: 1. Telemedicine is here to stay and in instances of infectious disease, it is a godsend. 2. While medical providers can treat the afflicted and warn the vulnerable, people need to be responsible for themselves and considerate of how what they do impacts others. 3. Crises lead to sensationalism in the press, in social media and the like. We must learn to differentiate between the real and the sensationalized. That requires time and fact checking. It can mean sickness or health to each of us. Be wise and be well! Alan Preston works in the area of Population Health Management and has a doctorate in Science in Epidemiology and Biostatistics from Tulane University and has spent his entire career in the healthcare space. visit us at www.bcms.org
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Adapting to the Needs of the COVID-19 Pandemic By Carlos E. Moreno, MD, MBA
As we look back four months on the spread of COVID-19 throughout the world, it brings to light how ill-prepared the world’s healthcare systems were for this Pandemic. I am the Chief Clinical Officer at CommuniCare Health Centers, a bedrock institution that has provided primary health services to Bexar county residents for over 48 years. With the onslaught of COVID-19, we all needed to react and adapt quickly to ensure a safe environment for personnel and patients in order to continue to provide healthcare access. That ability to adapt to the everchanging climate was driven by leadership and staff ’s ability to rise to the task. We first started from within our center to stress the need for personal and public hygiene awareness on the frontlines, handwashing for 20 seconds, social distancing and the use of facemasks were just the beginning. We also had to deal with the management and use of scarce Personal Protective Equipment (PPE) which was in short supply at almost all healthcare institutions throughout the city, state, and country. It required that scarce PPE be used solely for those personnel dealing with face-to-face encounters. It was necessary to adapt quickly to providing health care access in a different mode; telemedicine to the rescue. Telemedicine has been a key tool that our clinic has been experimenting with over the past few years. The appearance of COVID-19 drove its utilization overnight with maximum efficiency and buy-in from both patients and providers. COVID-19 accelerated the use of telemedicine by a decade, as the CDC recommended that healthcare facilities utilize alternatives for face-to-face triage to reduce unnecessary visits and prevent the transmission of COVID-19. In our case, face-to-face visits were facilitated for those patients that required them through the sectioning off clinics with specific waiting areas as well as designated exam rooms for these visits. As the pandemic progressed, our clinic began the utilization of a new model of care, via curbside services. This came about as a sug16
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gestion from a clinical director and practice manager. Our parking lots now became a waiting area and a contained environment for patients who were awaiting testing or a telemedicine consult through a tablet we provided for them to use from their car. We next addressed the issue of parents that were concerned for the safety of children needing medical visits or well-child exams in a safe environment. This was solved by converting our clinics, on the weekends, solely for pediatric patient visits providing a sense of safety and assurance for concerned parents. Curbside immunizations were well-accepted as a convenience also. Algorithms helped us screen our patients for potential COVID-19 infection before patients were seen by clinicians and tested. Maximizing the use of clinical staff skills and licensure allowed frontline staff to play a bigger role in the care of our patients. In summary, the staff undertook changes in job duties, the restructuring of departments, and the restructuring of the mode and delivery of services without ever compromising quality of care or safety to all. Adaptation to this pandemic was an all-in effort with the Board of Directors fully supporting all physician and staff efforts. The Board expressed gratitude and praise for the fact that we did not have to shut down our clinics (except for our dental services which was mandated by the state) or furlough staff. The senior leadership staff even undertook pay cuts to save staff jobs. CommuniCare weathered this tremendous unforeseen pandemic with unity and conviction to serve our community and patients with total dedication to our Mission: “To improve the health of those we serve with a commitment to excellence in all we do”. There will be light and hope for all at the end of this pandemic. Carlos E. Moreno, MD, MBA is Vice President and Chief Clinical Officer for CommuniCare Health Centers.
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Do We Learn from History? By Wendy B. Kang, MD, JD
Is it just my imagination or are the bugs becoming deadlier? We could all recite the recent litany of infectious, contagious diseases: H1N1, swine flu, Ebola, SARS. The influenza virus hits us every year. Older people and those with medical co-morbidities die despite receiving annual flu shots. Yet, I cannot recall the level of fear, especially the fear of dying, inspired by these diseases as much as has been expressed about COVID-19. The nightly news, blood red coloring of nations smearing our globe appears as Death stalking our tiny Earth. Would the Black Death or the bubonic plaque have looked like this had newsmen covered it back in the Middle Ages? At least the rats carrying the Yersinia pestis infected fleas can be seen, trapped and neutralized. Modern day patients can be treated with antibiotics. How do we see the deadly spiculated crown coating of the COVID-19 virus as it throngs in deadly hordes within the respiratory droplets of a cough, a sneeze, a song leaping to an innocent victim? A contaminated touch, an embrace, a kiss becomes deadly 18
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as many family members have discovered. From whence cometh our hope? Is a magical vaccine coming soon? In the meantime, healthcare personnel are under attack in the front-line trenches fighting an invisible enemy. Physicians, nurses, medical assistants, even members of the housekeeping staff brave the microscopic deadly bullets daily. What thoughts lie in the minds of ER and Anesthesiology physicians as they literally stare down at vocal cords, gateway to their own potential death, to aim endotracheal tubes to provide a lifeline to patients gasping for clean air? The reflexive need to help patients, the need to be compassionate, the need to do some good, steps forward. Whatever fears of harm to one’s own self are pushed into unexpressed caverns of the mind. Selfless love characterizes a professional. We may term it a fiduciary responsibility, a duty to our patients. But it is really about love for our fellow human beings! Akin to veterans who paid the ultimate sacrifice for the sake of freedom, too many within the healthcare profession have given dearly and left us too soon.
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“Stay safe” is a common admonition nowadays. But sheltering at home and social distancing are not new concepts. Even in the Middle Ages, those who could escape from the crowded, rat-infested large cities fled to the countryside to cloister themselves. The wealthy partied; the poor starved outside their castles. Farmers sickened. The food-chain supply and distribution lines halted. There were no food banks then. The known world economy faltered as traders (and infected rodents) sailed to other ports, thereby smearing the Black Death to outlying countries. The world of Emperor Justinian may have been the initial epicenter in the early 1300s only to explode into the deadliest pandemic by the mid-14th century. An estimated 75 to 200 million Eurasians — rich, poor, mighty, weak, young, old — perished, an unwanted reminder of the frailty of life, the universality of death. Personal protective equipment (PPE) existed then and now. Instead of N-95 masks, physicians wore beaked masks with glassed eyeholes reminiscent of those worn for carnival festivities. Herbs and various aromatics stuffed inside the beaks futilely countered the putrid miasma thought to carry the offending causative agent. The rest of the PPE included a widebrimmed hat, waxed-fabric overcoat and a cane used to examine patients without contact. Towns even employed physicians to look after the health of its folks, a commendable start to the subspecialty of public health had the physicians actually been trained to be medical doctors instead of, say, a fruit seller. Fortunately for the people back then, real physicians and scientists such as Nostradamus, Paracelsus, Ambroise Pare truly served to advance knowledge and supportive treatments. History does instruct. Are the bugs getting deadlier? In terms of human lives lost, the Black Death still trumps our modern world
numbers. Are the incidents of deadly contagions increasing? It certainly feels like it. Or could our ever-growing interconnections of travel, economies, nonstop news broadcasts expose adverse occurrences faster, at deadlier speeds? Our collective spirits sag as we creep towards 100,000 Americans dead because of COVID-19. Our hopes float with news of teams of scientists around the world racing towards promising vaccines. The U.S. stock markets plunged and are crawling back up. People lost their jobs and sources of income for their basic necessities. Some will have work again; others may remain unemployed. Our society, like that of the Middle Ages, has been punched. We are aching all over. At least most of us are still alive — recovered or unexposed. Unfortunately, la danse macabre continues. Death has never taken a holiday. Neither has COVID-19. An eventual vaccine does not hint of lifelong immunity. Perhaps like the influenza vaccine, it will be a best guess annually as to its latest mutated morphology. Meanwhile, we in the profession of medicine continue our tradition to continue to protect our fellow human beings. We can only hope that they return our love for them by following our advice to wash their hands frequently, to stay away from sick people and to wear masks to protect others. In essence, to stay out of the hospitals by not getting infected with COVID-19! As I watch the news and see people sans masks crowding into movie theaters, bars, beaches and amusement parks, their fears of dying receding in the rush to get on with living, I wonder what novel bug is coming and will it be even deadlier… Wendy Kang, MD, JD is board certified in Anesthesiology and in Pain Medicine Anesthesiology and is a member of the Bexar County Medical Society.
visit us at www.bcms.org
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Bexar County Medical Society & COVID-19 By Melody Newsom
As the reality of the Novel Coronavirus 2019 (COVID-19) began to unfold around the world, and a flood of information began to inundate the inboxes and airwaves, it became obvious to the Bexar County Medical Society (BCMS) management team that we needed to create an online, all-inclusive resource page for our members to enable them to find credible information about the pandemic. By the end of the first day following this realization of 20
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need, BCMS had a one-stop-shop webpage that included links to COVID-19 resources from San Antonio Metropolitan Health (Metro Health), Southwest Texas Regional Advisory Council (STRAC), Texas Department of State Health Services (DSHS), Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and the Texas Medical Association (TMA), as well as informative articles from other credible sources.
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WHERE TO FROM HERE Even before 9/11, BCMS has been involved with emergency preparedness in our community and for almost that entire time, I have had the privilege of being the BCMS staff liaison with the BCMS Emergency Preparedness Committee. This included working closely with the STRAC in the development and administration of the Unified ID Badge (post 9/11) and with Metro Health coordinating the physician and medical response to hurricane evacuee sheltering following Hurricanes Katrina/Rita. As a result of this community involvement, I also represent BCMS at the Regional Medical Operations Center (RMOC) located at the Emergency Operations Center (EOC). Once the COVID-19 crisis was identified as a pandemic, I reached out to Metro Health to identify BCMS’ role in the COVID-19 response in San Antonio. I started my days at the EOC/ RMOC and began attending the Metro Health Testing Taskforce meetings. Testing capacity was being ramped up with the first drive through testing site at the Freeman Coliseum. It became evident very quickly that while the testing capacity was there, the sample collection supplies were extremely limited. Metro Health reached out to BCMS about the issue and the Society began asking physician members for their help by donating specimen collecting kits and Viral Transport Medium with synthetic-tip swabs, such as Influenza tests, HSV PCR tests and various STD tests. Dr. Lindsey Irvin heard about the limitation on testing due to the supply shortage, and connected me with the head of Texas Public Radio (TPR). Public service announcements (PSAs) were soon developed and broadcasted to the listeners of TPR asking for donations of the needed specimen kit supplies. Through distributive emails to BCMS physician members and the PSAs, the community physicians stepped up and donated enough of these collection kit items to keep the drive-thru testing station running for the first few weeks of the crisis. In early March, a third-year medical student, Gwendolyn Quintana, reached out to BCMS after seeing the need for personal protective equipment (PPE) first-hand in the medical community. Her family is well connected in the construction industry and she and her family, within two days, organized a PPE donation drive with the construction industry and contractors across the region that included construction grade N95s, gloves, goggles, face shields, etc. being donated and made available to physicians in need within the medical community. But the donation drive didn’t stop there. Miss Quintana reached out to other groups in the community such as the Vietnamese community and some distilleries that stepped up to help the cause with gloves, face shields, face masks and hand sanitizer. Other students also began to volunteer to help with the distribution of the PPE. Miss Quintana
and the other students organized and formed the Students Alliance for Emergency Response, calling it “SAFER Texas”. Because of BCMS’ continuing work with STRAC and Metro Health through the years, BCMS reached out to STRAC and volunteered to be a conduit to get PPE to those physician practices left out of the distribution of PPE from the Strategic National Stockpile (SNS) in Bexar County and in all 23 counties covered by STRAC (Trauma Service Area – P). In this role, BCMS, with the help of and dedication of SAFER Texas, has become the PPE distribution headquarters for PPE distribution to physicians in the region. To help it work, SAFER Texas created a request, tracking and distribution process. They created a PPE request form for physician practices, a tracking system so every piece of PPE donated/received is accounted for, a volunteer scheduling form to manage the local distribution of PPE to physician practices by the student volunteers, and a shipping process to reach physician practices in rural areas and other counties. Besides ensuring PPE for physicians, BCMS leadership and staff participate in a multitude of conference and video calls to closely monitor and report on the activities of various entities who interact and overlap with outside crisis management organizations, including UT Health/University Hospital, STRAC, DSHS, Metro Health, TMA and the BCMS COVID-19 Task Force. The BCMS COVID-19 Task Force was formed by physician leadership comprised of the BCMS Executive, Public Health, and Emergency Preparedness Committees. This task force has monitored, discussed, and identified issues with the handling of the crisis by the city and county. They have communicated with Mayor Ron Nirenberg and Judge Nelson Wolfe on issues deemed important to the community on behalf of the physician members of BCMS. There is so much to be proud of at BCMS! Your Medical Society has stepped up when a need was identified and responded as the COVID-19 crisis has evolved. I am blessed to work with and for such an outstanding and caring group of physicians, staff and community officials! No amount of emergency preparedness training and planning could have fully prepared us for this pandemic, but the relationships that BCMS and its people have fostered through the years gave us a tremendously strong foundation with which to work. Melody Newsom is the Chief Operating Officer for BCMS and the staff liaison to the BCMS Emergency Preparedness Committee. She has been with BCMS since October 1999.
visit us at www.bcms.org
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Medical Education:
Meta Reflection in the Midst of a Pandemic By Samantha Bailey, OMS1 and John Seidenfeld, MD Over 100,000 countrypersons and over two million people worldwide are likely to have died due to the ongoing pandemic. Clinicians and scientists are working as hard as they can to prevent death and reduce suffering. Some governments have tried and failed to protect the populace while others have succeeded, and only history will be able to interpret propriety of actions taken and timing. We have offered prayers of healing and prayers of mourning for the souls of the dead. We have felt pain and sadness, hope and aspiration, anger and frustration, joy and grace, shame and doubt, schadenfreude and malice, and happiness and faith over the past months. The first-year class of osteopathic medical learners from San Antonio were asked to reflect on their experience and thoughts living through the COVID-19 pandemic as their first year of medical education came to an end. Over fifty of their reflections were reviewed in preparation of this meta-reflection which will share no personally identifiable information. These learners are full of hope, as they aspire to join colleagues in earning the trust of those cared for, help to preserve and improve the life of the public they will serve, and contribute to advances in the science and art of medicine. They persevere as learners in a profession that values educational growth, tirelessly works for the needs of the ill, and rises to health challenges brought about by wars, epidemics, pandemics, lifestyles, genetics, and endemic disease. These young students are on a path as laypeople who will become doctors and healers, peaking through the gap between the curtains. How have they felt and what have they witnessed these last four months as their country and world have faced the pandemic of COVID-19? Common themes emerge from members of the class of 2023, of whom many could never have imagined their first year of medical school would end during a global pandemic. Accustomed to study 22
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groups, case reviews, Socratic discussions of basic medical sciences, cadaver labs, learning interview techniques and other tools of the physician’s trade, quite suddenly they came to a hard stop. From living alone or with partners in small apartments, some had to establish new routines and went back to live with parents or partners in different cities. Instead of having classes together, they were faced with the task of learning the last few months of their curriculum via the virtual classroom isolated from their peers and professors. Examining themes expressed in these reflections, we found that most learners commented on the effects of the pandemic on their personal lives, including feelings of isolation, but also thankfulness to be able to spend more time with family. Being away from campus was a new learning experience for many with lack of learner and facilitator collaboration, an aspect of medical school many had looked forward to throughout their day. There was fear of the unknown in these young learners for what not only their future would look like personally and professionally, but the future of their families and neighbors. Some were concerned as caregivers or children of elderly parents that they would be helpless and have no control over losses or deaths. Slipping silently and alone into depression, some were able to reach out for help, but others found resilience in hope and faith. Many learners mentioned the role of telemedicine in the past few months, alluding to the large strides medicine has made in reaching patients outside the face-to-face medical setting but also the necessity at times for in-person contact between a doctor and their patients in establishing trust and aiding in diagnosis. An overarching theme throughout all the essays was the importance of unity and the necessity to work together in this unknown time. This abrupt change in routine has resulted in reflection, hardships,
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WHERE TO FROM HERE new resolutions, questions about the wisdom of those who lead the health care system and government at all levels, new outlooks on their future profession, motivation, and new faith and gratitude for a better world and its inhabitants. As they witness the might of a natural force much greater than man, they develop resolve to gain new knowledge and help in any way they are able as they soon become front line care providers. Many will carefully study the distribution of health services, the multileveled governmental response to the crisis, the economic consequences of the pandemic, whether a nation’s wealth can be protected from the ravages of the virus infection, and the effect on different geographic areas in their locale along with a myriad of other topics related to them personally or distantly. At the forefront of these young learners’ minds was the impact this pandemic would have on themselves and their future patients. They reflected on their personal hardships as mere inconveniences compared to the rest of the population who will continue to suffer from the ramifications of COVID-19 economically, mentally, and medically. Although learning shifted from the classroom, these future physicians learned lessons they will carry in hopes that history will not repeat itself. The need for human interaction, unity, and collaboration has become evident as a necessity to overcoming this time in history and resuming daily life. In the face of this tragedy of epic proportions, we mourn for the
dead and those with permanent health consequences. Many people will be our patients for years to come suffering sequelae of this plague. We have relearned lessons from the Bible which tells of how to avoid transmission of leprosy, the Spanish flu pandemic mentioned by other writers in this journal, and many other previous scourges to wear face coverings, wash hands, not touch our faces, trace contacts, and distance ourselves from others to best avoid contagion. We will be tempted to resist our calling and view these events with cynicism, dark humor, and partisan squabbles searching for those to blame. When faced with such an event, many will find hope, faith, gratitude, grace, positive thinking, mission, and hard work as the answers to aid us in the tasks ahead. To care for those in need, let us each day join hands and voices (if only virtually today) to continue to do what we are able. Thank you for your time and attention. Samantha Bailey is an OMS1 at Midwestern University, Chicago College of Osteopathic Medicine; John J. Seidenfeld, MD is a board-certified specialist in pulmonary diseases and internal medicine, is an Associate Professor of Clinical and Basic Sciences Education at UIW School of Osteopathic Medicine, is currently the Vice Chair of the BCMS Publications Committee, and is a longstanding member of the Bexar County Medical Society and the Texas Medical Association.
visit us at www.bcms.org
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Discovering the Healer’s Art By Medical Students at the UT Long School of Medicine Why do you want to be a doctor? What motivates you to spend years in training and constantly make sacrifices for others? We are students at the Long School of Medicine at UT Health San Antonio (UTHSA). Our time as pre-meds is still sharp in our memories, and much of our energy was spent contemplating these important questions. Most of our peers would agree that we are motivated by the deep desire to alleviate suffering and to serve others with compassion and empathy. Flash forward to present day. We spend our time poring over lecture videos and books, trying to cram every bit of knowledge into our over-caffeinated brains. While the passion for helping patients and serving our 24
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community remains, the grueling reality of medical training can admittedly start to overshadow these ideals. What if there was a way to restore the sense of awe and compassion that first drew us to medicine? What does it truly mean to be a healer? Together with physician mentors, we explored these lofty questions during The Healer’s Art, an enrichment elective offered to first year medical students across the country. Since its arrival at our school in 2018, The Healer’s Art has immersed students in topics of grief, wonder, and service in medicine. Dr. Rachel Naomi Remen of UCSF created the course almost 30 years ago as a way to help students deepen their connections to their
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At Left, Felt Hearts: "Every participant in The Healer's Art Course receives a handmade "feelie heart" as a symbolic object to bring comfort in times of stress or grief, and to remind them to hold their own hearts and the hearts of others tenderly." Opposite Page: "Last class of Healer's Art done through Zoom."
peers and become more compassionate physicians. The heart and soul of The Healer’s Art are small group sessions, in which students explore the unique experiences that brought them to medicine in a supportive peer group. We found emotional resilience discussing the hard parts of medicine and identifying traits that make us healers. It is difficult to convey the positive impact of being given the space to regroup and reconnect with the human side of medicine for a few hours each week. Then in March, the world changed. Our bedrooms and living rooms became our new lecture halls. Before COVID-19, we spent our days consulting with faculty in hallways, volunteering at free clinics, and studying with friends in the library. Suddenly, our only ties to medicine became our laptop screens. Those of us in Healer’s Art this spring lost the chance to attend our final class and say good-bye to the small family we had formed. Or so we thought. Despite concern that the intimacy of Healer’s Art’s small group format would be lost to an online format, we decided to hold one last class over Zoom. It was a chance to reconnect in a time of social isolation, to reaffirm our commitment to one another and our profession, and to remind ourselves that we must always look for the meaning in medicine. Our last session focused on service as a way of life, and there was no better time for this discussion than during a pandemic. Our speaker was a physician in the COVID-19 ward at University
Hospital. She told us the story of one of her patients and the meaning she found in her care. We have all felt a little adrift without the anchor of patient care and community in our lives. Her talk, work, and ideal of service revived us. After our small group discussion, we each renewed our commitment to service by contributing to our written version of the Hippocratic Oath. Although we were not able to finish the course in person, we were able to reconnect with one another and consider our shared values as healers during a time when others need us the most. Time at home brings new challenges, but it also provides us with some much-needed time for self-reflection. Thinking back on The Healer’s Art, we are confident that it has important implications for our upcoming generation of future physicians. As medical students, The Healer’s Art gave us an opportunity to return to the heart and soul of medicine and cultivate the healer inside of us before facing the challenges of clinical practice. Our course participants emphatically concurred that they were able to come to terms with their feelings of grief or loss, while nurturing an appreciation for the suffering of others. We are thankful for these lessons learned and remain hopeful that our experience has prepared us to journey into the trenches of clinical rotations and beyond. We are grateful for opportunities such as this to learn how to combat burnout and be better equipped to process the many emotions we will inevitably face. As future physicians, we vow to always seek awe and beauty in medicine and to utilize our innate characteristics and strengths to make us better healers. Glennette Castillo, Yolanda Crous, Victoria Helton, Johnnie McElroy, Chandler Morrow, Amy Nguyen, Muslima Razaqyar, Madison Rigsby, Matthew Smith and Vy Vu are Medical Students at the Long School of Medicine References: http://www.rishiprograms.org/healers-art/ visit us at www.bcms.org
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Have You Ever Been Asked to Pray for Patients? By George S. Best, MD My colleagues in the practice of medicine: Have any of you ever been asked by a patient to pray for them? Have you ever seen or heard one of your doctor friends praying with a patient pre-op or after news of the last CT scan or other diagnosis showing a severe malignancy? In 1977, I finished medical school here in San Antonio at the U.T. Health Science Center and thereafter completed my residency in urology here at Wilford Hall. Throughout my training, I do not recall ever seeing or hearing of another doctor praying with their patient. No doubt the patients often prayed but they did so in private and not in front of their doctor. After losing a son in 2006, a year before he was to start medical school, my faith was tried. In time, and after starting a bible study with some friends, gradually my faith and knowledge of the love of Christ and of my salvation through his death and resurrection is secure in my heart. Over time, I have concluded that if you are a doctor and a believer, you are in a position to show your faith by offering to pray with your patients and their family and friends in your office and at the hospital in the pre-op or waiting area before surgery. This came to me after I had observed one of my Baptist System surgeon friends praying with a humble family before an operation. Several hours later, when I saw my friend's reflection in the mirror in the hold-room, I jokingly asked him if he was having a sĂŠance since everyone was holding hands. He looked at me a little red in the face, then said that they were praying. In response I admitted, somewhat sheepishly, that I knew that to be the case. Then I asked him how he knew what to say in his prayers with his patients. He responded that he had asked some of the hospital pastors and priests for help. He said that this had come about after his late wife had made him promise before she passed away to pray with all of his patients for the rest of his life. My friend remarked that since then, over fifteen (15) years ago, 26
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he has been praying with all of his patients and that they were all very grateful when he did so. He said that on only one occasion had he been asked not to do so. On that occasion, to his surprise and wonder, he was asked to listen while the patient and his family prayed for him. Prayer to God is a source of peace and comfort to many religious peoples, whether they are Jewish, Christian, Islamic, Hindu, Buddhist or other faith. I am Christian. We physicians who, like the Apostle Luke, are followers of Christ, have the opportunity to include in our healing work the love and healing powers of Christ in prayer with our patients in addition to using our God given talents as physicians. To do so has been a blessing to me with my patients over the last few years of my practice, until my recent retirement. Now, prayer with my own physicians is a comfort to me as I have been diagnosed with dementia/Alzheimer's. I write this with love for all of my colleagues, and request for your prayers. Yours in Christ. George S. Best, MD.
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More Quality Time By Sheldon Gross, MD
Physicians in private practice faced a major earthquake in 2020. The COVID-19 virus has affected the private practice of medicine in ways that I have never seen before. Most are very negative. These have been discussed numerous times. However, as with most things, there is also some positive aspect to it. As I reflect on the last two months, I cannot help but realize differences that I would consider in most ways positive. Telemedicine has been available to practitioners for many years. Most physicians practicing in an outpatient setting are now using telemedicine to a much greater degree than ever before. In my experience, I had not used telemedicine at all. I now find it indispensable. It is helpful to both me and my patients. This is something that without question will continue into the future. Most of my colleagues have described a fairly dramatic decrease in patient flow. People have been told by government officials and public announcements to stay at home and not go out. That is exactly what has happened. I think this has decreased the number of patients who have contracted COVID-19, but has also resulted in businesses across the board being hurt, including the private practice of medicine. I find myself valuing each individual patient to a much greater degree. I always valued my patients. However, the difference is I now have a chance to put that into action. A lower patient volume means more available time to delve into various aspects of healthcare or even just talk about people as individuals. I find my patients much happier and appear more satisfied with their visit after they
leave. I am now able to schedule patients within a very short period of time. This results in people being grateful and appreciative as soon as they walk in the door. This automatically sets the stage for a much more positive physician/patient relationship. This whole environment is reminiscent of my first one or two years in private practice. At that time, I was excited about seeing every patient. I was in a building phase without wait times of three, four, or six weeks. The enthusiasm that I felt as a physician in this first or second year of practice appears to have returned. It could in some ways be considered a rejuvenating experience. With extra time, I find myself spending more minutes on the phone discussing cases with referring doctors. They are grateful for this type of feedback. I regret that at some point in my busy practice over the past 30 years I lost sight of how important that is. It is not only about cementing a doctor/patient relationship, it’s also about strengthening a specialist-referring-doctor relationship. I call patients back sooner. I listen more carefully and respond to their questions and concerns more completely. I am hopeful that the present COVID-19 virus pandemic will be over quickly. I am hopeful there will never be another one like this. I am also hopeful that I will continue to enjoy relationships with patients and physicians more and not forget or lose sight of the more positive aspects of my practice as a result. Sheldon Gross, MD is a board-certified specialist in Pediatric Neurology and is past President of the Bexar County Medical Society. visit us at www.bcms.org
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COVID-19 Causing PTSD Among Dual Healthcare Worker Households By Erika Gonzalez, MD
COVID-19 has changed much of daily life in America and worldwide. The children of our nation are being affected in their education, their daily activities and their social capabilities. The children of doctors, however, are facing some eerie parallels to those of active duty military parents. The struggles created when a set of military parents deploy are now being faced during the time of COVID-19 in dual healthcare worker households. As parents and physicians, we face the harsh reality that our community relies on our care in the face of illness and that our children rely on that same care, at the same time. It isn’t a burden to care for our kids, nor is it a burden to care for the community, but it is daunting to know that our children may feel the same as they did when we are out on deployment. Published by Innovations in Clinical Neuroscience, a journal piece entitled “Psychiatric Effects of Military Deployment on Children and Families” noted that “a study of Army spouses with a deployed service member with children aged 5 to 12 years showed one-third of the children were at high risk for psychosocial morbidity.” Similarly, in an article published by Children and Adolescent Psychiatry and Mental Health, we see that “the reduced contact with the deployed parent, concerns about that parent’s safety, and the role confusion brought on by taking on too-early and possibly age-inappropriate family responsibilities can lead to physical and mental overload.” With COVID-19 causing physician burnout and a need for rooms in a home to desterilize, children may feel similar emotions when faced with one or two parents working countless hours. Unlike the military, there aren’t safeguards in place to attempt to keep both parents from ‘deployment’ at the same time. When you’re needed, 28
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you’re needed. In some households, dual-physician households are sending their children off to live with grandparents or other family relatives. When parents – both military – are deployed at the same time, something similar happens. Arrangements are commonly in place to ensure that kids have someone familiar watching over them. Physicians have taken this route during the pandemic due to the daily ‘frontline’ work that occupies their lives and for fear that they could expose their loved ones to the deadly virus. There is no research – that I could find – that supports this theory. However, the research similar to that presented here shows the effects of missing a parent for long periods. To resist these harsh effects on our children, we have to understand them first; we have to address the elephant in the room from the get-go. How do we address the possible psychological effects of this occurrence? Speak up. Sit with your children, explain the need for your extended working hours. Reassure them that they are safe. Answer any questions they have. Work with your employer to request shifts that alternate with your spouse or partner. Use tools like Facetime and Zoom to recreate the family unit through this alternative medium. There is no “one” solution, nor is there just one type of family dynamic. These types of challenges arise when the world around us is changing. Schools and the workplace are among the most notable places with long-term effects, but the truth is, our homes may never be the same either. We have Coronavirus to blame for that. Erika Gonzales-Reyes, MD is board-certified in Allergy and Immunology and Pediatrics, and is a member of the Bexar County Medical Society.
COVID-19 Testing: A Local Lab’s Experience By Kelly Elterman, MD and Steven Goodman, MD Introduction With the arrival of COVID-19, physicians in San Antonio and around the world found themselves suddenly facing circumstances never faced before: a novel virus, a potentially deadly disease course, no definitive treatment, anxious patients and loved ones, and growing uncertainty as stay-at-home orders brought nearly all aspects of daily life to a halt. As the numbers of infections and deaths in the United States began rising, against a backdrop of international public health crises and economic devastation in other parts of the world, many physicians started asking, “How can we help?” Some fled to the frontlines to provide direct patient care, others to legislators to demand proper personal protective equipment for those on the frontlines. For many physician practices, both on the frontlines and not, the risks of COVID-19 and the resultant decrease in clinic visits and surgical procedures necessitated almost immediate practice changes. Many clinic-based physicians adapted by switching to telehealth services. Emergency physicians and anesthesiologists offered to help in intensive care units. Even with these changes in place, physicians across all specialties faced decreased workloads and increased anxiety about the future of their practices. Pathology, as a hospital and laboratory-based specialty, was not immune to these factors driving drastic practice changes. As surgical volume decreased, so too did the volume of surgical specimens requiring a pathologic diagnosis. Some pathology practices panicked. Some of these practices furloughed physicians and staff and in others even permanently reduced their employed physicians, while others sought ways to contribute to the crisis. With the known exception of Italian pathologists recently being asked to manage ventilators in the intensive care unit due to an overwhelming number of patients along with an insufficient number of available intensivists, pathologists are not typically on the frontlines of clinical care. Despite this, as COVID-19 descended upon San Antonio, in a similar manner to the way the clinicians offered to provide care in emergency rooms and intensive care units, we too at Pathology Reference Laboratory (PRL) asked ourselves, “How can we help?” The realization and the process As normal specimen volume slowed, our molecular testing platform, typically used to perform high volume PCR testing for various infectious pathogens of gynecologic specimens, stood empty. This question of how could we help kept spinning in our minds until one day we spoke with the platform vendor, Hologic, who mentioned that they were working to develop SARS-CoV-2 testing. They confirmed
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that our platform could indeed run up to thousands of tests per day. At that time, testing was still very limited in San Antonio so we knew that if we could provide testing on such a scale it would significantly help the patients and fellow physicians in our community. Without hesitation, we unanimously agreed that we needed to do whatever we could to make this a reality. We may not have been able to help in the emergency rooms, but we would do all we could to make accurate testing widely available in San Antonio as soon as possible. It turned out that performing COVID-19 testing meant making significant changes to our lab. We quickly learned that we would need to enlarge our space, buy a new hood, obtain more personal protective equipment for our staff and expand our courier services, all of which would require much time and financial investment. We could not know at the time if we would even be able to obtain enough testing kits to be able to run the tests, but we forged ahead with the changes all the same. The chance of being able to help our community if we succeeded was worth the risk of loss if we failed. We remodeled a conference room into additional lab space and set up two new hoods within a week. We obtained sufficient personal protective equipment for our lab technicians, educated them and restructured our staff to be able to run the tests seven days a week. By mid-April, all we needed was the actual test kits. When the kits arrived in the first week of May, we validated our platform immediately and began testing patients within days. Initially, we ran 20 tests a day. With an increase in the availability of test kits nationally, and the willingness of our technicians to work around the clock, that number has steadily increased to nearly 300 tests daily from over 30 different sites within San Antonio and the surrounding area. Looking forward As physicians, we are all interconnected across our individual specialties. Whether we see patients in a clinic, on a computer screen, in the operating room, or in a laboratory, we all have an obligation to serve our patients to the best of our abilities and to safeguard our community. Unfortunately, it is likely that COVID-19 will be with us at least for the foreseeable future, if not forever, as a regular seasonal guest. As SARS-CoV-2 is highly virulent, frequently asymptomatic, and can have devastating medical consequences, adequate PCR testing is crucial to our success against the spread of this disease. At Pathology Reference Laboratory, we are proud to help our colleagues and our community navigate these challenging times. Kelly Elterman, MD is an anesthesiologist and an independent contractor at Lackland AFB, involved with preop COVID-19 testing; Steven Goodman, MD, a pathologist at Pathology Reference Laboratory, is director of their COVID-19 testing efforts. visit us at www.bcms.org
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WHERE TO FROM HERE
Sleep
By Avie Grunspan, MD
“Sleep is overrated.” This is a not-too-uncommon remark made by physicians trained in the days in which they felt sleep deprivation was a right of passage allowing one to toughen up their preparedness for the rigors of the medical field. The argument of the time was staying up to monitor a patient through a rapidly evolving disease process such as diabetic ketoacidosis, improved understanding of the pathophysiology of a condition and provided valuable teaching opportunities. It was a form of hazing (and pride) to stay up for 24-36 hours straight and believe we had performed our positions dutifully, constructively, safely, and without self-harm. In the last few decades, sleep research has shown otherwise. There is an increasing body of evidence that physician sleep habits, not unlike our own patient's sleep habits, are taking a significant toll on physical and emotional well-being. Our 24/7 society around the world resulted in The American Academy of Sleep Medicine and the Sleep Research Society reaching a consensus recommendation in 2016. Based on review of 5314 articles in the National Library of Medicine MeSH, they concluded adults should sleep more than 7 hours per night to promote optimal health. They based this on increasing evidence that fewer than 7 hours is associated with impaired immune function, increased pain, impaired performance, in30
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creased errors, and a greater risk of accidents. Associated health outcomes from this deficit include weight gain, obesity, diabetes, hypertension, increased risk of heart disease and stroke, depression, and increased risk of death. (Watson, et al, Sleep;2015;38:843-4) Sleep deprivation has also been shown to lead to significant decrements in cognitive function, lapses of attention, vigilance, and speed of psychomotor responses. There is increasing literature over the past few decades regarding the effects of sleep deprivation in medical students and residents in training, though there remains less data regarding attending physicians. Over the past four decades, several iterations of work-hour and on-call restrictions have been implemented after several studies revealed medical and diagnostic errors were more common in residents working over 24 hours consecutively. In 2011, the Joint Commission called on all health care organizations to embark on mitigation efforts to reduce clinician sleep deprivation and fatigue. A recent article from the Journal of Clinical Sleep Medicine highlighted the concern that, “sleep deprivation due to shift work schedules, high workload, long hours, sleep interruptions, and insufficient recovery sleep have been implicated in the genesis of and perpetuation of (physician) burnout” in practicing attending physicians.
COVID-19
WHERE TO FROM HERE Proper sleep requires we adhere to a relatively consistent rhythm, achieve an adequate amount of sleep, and that we treat any underlying sleep disorders adversely affecting the quality of our sleep. Critical to this concept is maintaining one’s 24-hour circadian rhythm. Repeated disruption of this rhythm leads to physiological and emotional dysfunction. If this is combined with sleep deprivation and/or potential primary sleep disorders such as obstructive sleep apnea – a common disorder worsening in mid-life — these critical elements provide a recipe for potential emotional and physical impairment and can lead to early burnout. In the midst of pressures to perform at 100% peak performance, any time of the day or night, how do we achieve this balance? We need to prioritize sleep, and NOT think of it as a disposable commodity we can minimize and hope to catch up on when we “retire.” The benefits of adequate sleep results in better mood, interpersonal interaction, physical well-being, and improved cognition.
benefit, but should be avoided about 6-10 hours prior to anticipated sleep.
4) Daily exercise for 20-30 minutes can improve the quality of sleep but should not be performed with fewer than 3 hours prior to scheduled sleep.
5) When leaving an overnight shift in the AM and planning to sleep in the AM hours, wear sunglasses on the drive home and keep the environment dark until you get into your darkened bedroom. Put a “do not disturb” sign on the door, silence all electronics and wear ear plugs if needed.
6) Set aside some winding-down time just prior to sleep in the form of meditation, word puzzles, relaxing music-- any activity not associated with work to enhance the natural sleep drive. 7) Try to keep bedroom temperature around 68 degrees. 8) Limit alcohol intake, which may be soporific as Bacchus proclaimed, but can lead to cortical arousals 4-6 hours after libation and leads to poor sleep quality.
In summary, physician, heal thyself. You owe it to yourself, your family and your patients to prioritize your sleep so you can maintain your health, remain active, vital, and potentially avoid burnout. References 1. Sleep deprivation and physician performance: Why should I care? Howard, SK, Baylor University Medical Center Proceedings. 2005 Apr; 18 (2): 108-112 2. Fatigue, Sleep Deprivation, and Patient Safety, PSNet, September 2019 3. Deterioration of neurobehavioral performance in resident physicians during repeated exposure to extended duration work shifts. Anderson, et al, Sleep, 2012 Aug 1; 35(8) 1137-1146 4. Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society, Journal of Clinical Sleep Medicine, 2015;11 (6): 591-592 5. Short and long term health consequences of sleep disruption, Nature and Science of Sleep, 2017; 9: 151-161
Achieving sleep balance is possible using the following precepts: 1) Think of the last time you were on vacation and did not have to wake up to a clock or call situation. Count the average hours of sleep to feel “refreshed” in the AM. Set this time as your goal daily amount, even if that seems unrealistic.
Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement, Journal of Clinical Sleep Medicine, Kancherla, et al. 2020, Volume 16, Issue 5: 803-805.
3) Caffeine in moderation has been shown to offer some short-term
Avie Grunspan, MD is a board certified sleep specialist with the Texas Pediatric Specialties and Family Sleep Center and Assistant Clinical Professor in Sleep Medicine at the UIW School of Osteopathic Medicine.
2) Scheduling brief naps of up to 45 minutes may be helpful, especially prior to night shift or overnight call.
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COVID-19
WHERE TO FROM HERE
The Healing Process: A Lesson Learned from Your Blood By Teresa Samson There is a lot we can learn from the way our bodies heal. So often when we are experiencing spiritual injury, be it emotional exhaustion, physical fatigue, or unspeakable heartbreak; we seek sources of instant relief. Understandable. It gives us a sense of control to pull ourselves from sadness and take an active part in healing. Healing is, after all, an active process. The part we may be missing, though, is that it also requires an element of stasis — remaining where we are, slowing the constant influx of distractions, and allowing our injuries to become a scaffold for healing. Recall the last time you nicked yourself shaving. You probably grabbed a towel quickly to apply pressure and help stop the bleed before your bathroom looked like a scene out of a horror movie. Action taken. Situation controlled. Right? Maybe, but what about that scab that appeared a day later? Despite your active role in healing, the reason your wound has become a site of new growth has little to do with continuous movement and scrambling for ways to control the tiny bleed. In fact, let’s be reminded that it came about through the headache of a process we call hemostasis, heme= blood; stasis = state of inactivity. We all know how hemostasis works, but allow me to refresh your memory: 1. A blood vessel gets injured, blood escapes. Your shower floor turns bright red. 2. Your blood vessel responds by constricting, narrowing its lumen to slow the flow of blood through the site of injury. 3. Platelets aggregate and bind at the site of injury. 4. Proteins are synthesized to help stabilize the clot. There you have it! What was once a wound is now a scaffold for new tissue growth. While the clotting proteins get all the credit for its final product, your scab, it is the relative stillness surrounding the wound site that is the first and arguably most fundamental step in blood clot formation. Your being and all your cellular components can be stirred to action in an environment conducive to an instantaneous initiation of healing. But first, things must slow. In this despairing season, it is tough to believe that becoming couch potatoes will bring forth healing to society, and it’s cringe32
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worthy to approach this destruction as a foundation for newness. The havoc sparked by the novel coronavir us f o r c e s many of us to slow down, which undoubtedly feels more painful than helpful. Yet, no one can deny that this stagnation of life is the most necessary step to healing (#FlattenTheCurve), and that the ways our lives have changed give us structure to build new and better things for our futures. Is it just me or are phone calls less uncomfortable now? There is nothing passive about the healing of ourselves and our communities, but for it to happen, it requires stillness. I am not necessarily using the process of hemostasis to make a political statement. I am just a medical student in the throes of dedicated board prep, recognizing that there are lessons to be learned on every page of life… and of First Aid. My mind, probably much like yours, is frustrated having been stripped of the foundations it once relied on (e.g. stability and safety in work, availability to friends, freedom to explore, closeness to family). And more than likely, we both feel stuck in this period of stillness. But with what knowledge I have gained through my study of hemostasis, let me remind you of this: The healing, the building, the growth, the newness – it is all happening right now. We need only to tune into ourselves to discover it. Teresa Samson is an OMS-II at UIWSOM, is a member of the BCMS Publications Committee and a member of the Bexar County Medical Society.
COVID-19
WHERE TO FROM HERE
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SAN ANTONIO MEDICINE
Reducing Physician Burnout: The Role Health Plans Can Play By P. Nelson Le, MD, MBA Physician burnout is not a new phenomenon, but the recognition of its prevalence and impact has elevated this topic to national attention. Recent data shows that 44% of physicians demonstrate at least 1 symptom of burnout and have the highest suicide rate of all professions: one physician dies from suicide each day.1,2 Physician burnout does not affect only physicians; patients are also suffering and there is a huge cost to the healthcare system. Physicians who report signs of burnout are twice as likely to have made a medical error.3 The root causes of physician burnout are multifactorial. Two leading causes of burnout are due to the increasing administrative burden and the inability for physicians to practice at top of license. These factors have led to disengagement from the mission that brought these hard-working, highly-capable individuals to this profession: caring for patients. With this complex issue, all stakeholders in the healthcare ecosystem have a role to play in what needs to be a multipronged solution. Here is how payors can play their part. Administrative Burden and Complexity In a survey of 20,000 physicians, the AMA found that 70% spend at least 10 hours per week on administrative tasks with 32% spending 20 or more hours per week.4 Studies show insurance-related transactions are one of the top three tasks that physicians wished were more efficient.5 The backand-forth between physicians, patients, and payors to identify the most clinically-appropriate and cost-effective therapy is a significant contributor to the administrative burden. Recently, the Journal of the American Medical Association published a study by researchers from Humana and the University of Pittsburgh which found that administrative complexity (billing and coding costs, physician and insurance administrative burden) accounted for $265.6 billion of the annual wasteful health care spend in the United States.6 One way forward-leaning health plans can alleviate administrative burden is to simplify the prior authorization process by digitizing the workflow or bundling services under one approval. This decreases the time to complete these forms and ensures that patients have timely access to appropriate care. A second solution is to offer real-time benefit checking to providers at the point-of-care. This is especially relevant when trying to prescribe medications that patients can afford. If physicians had visibility into out-of-pocket costs for patients 34
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at the time of prescribing, this would limit the transactional burden of patients not filling prescriptions due to cost, which is known to be a significant barrier to medication adherence. Improvements like these not only decrease administrative burden, but improve patient care and experience. Value-based Care: Practicing at Top of License With the emphasis of addressing social determinants of health and providing holistic care, many physician practices are struggling to sustain clinical programs and support staff to provide comprehensive services. As a result, physicians often need to be the care coordinator, social worker, pharmacist, health coach and other roles in addition to being the medical doctor. In a fee-for-service environment, these additional responsibilities are not reimbursed, require time, and can create tension since they limit the number of patients that physicians can care for in a day. However, in value-based arrangements, incentives are better aligned between payors and physicians since physicians are paid for quality of care rather than volume of patients. This allows physicians to focus on providing high-quality care to their patients rather than filling time slots. In addition to rewarding quality care and outcomes, payors are incentivized to offer additional resources and services to help physicians in value-based arrangements care for their patients. One key to succeeding at value-based care is the implementation of multidisciplinary care teams to provide support for patients outside of office visits. This team approach can help coordinate care and provide resources to patients for transportation, medication management, in-home assessments, and chronic disease monitoring, for example. By extending the reach of the practice, payors can provide visibility into the patient’s home environment. As a result, physicians can practice at the top of their license. Restoring the Joy of Medicine By creating simplified experiences for physicians and patients, reducing friction in the delivery of care, and supporting physicians on their journey to value-based care, payors can have an impact on administrative burden and enabling physicians to practice at the top of license. Ultimately, this results in positive health outcomes for physicians, patients, and the healthcare ecosystem overall. P. Nelson Le, MD, MBA, Medical Director, Office of the Chief Medical Officer, Humana CITATIONS 1 Mayo Clin Proc. 2019;94(9):1681-1694. 2 Physicians Experience Highest Suicide Rate of Any Profession – Medscape – May 07, 2018. 3 CMAJ. 2018 Oct 9; 190(40): E1216-E1217. 4 Medscape Physician Compensation Report 2018. 5 Deloitte 2018 Survey of US Physicians. 6 JAMA. 2019;322(15):1501-1509.
THE BUSINESS OF MEDICINE
The Business of Medicine: Exiting Your Practice By Tom Jordan
Physicians running a practice are in a constant balancing act of caring for their patients while managing the business aspects of their practice — something that isn’t taught in medical school. Like most business owners, practice owners are focused on caring for their patients and ensuring their employees have the tools and resources they need to be successful, so there’s a good chance that exit planning is not high on your priority list. 36
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THE BUSINESS OF MEDICINE There are a number of things to consider when it comes to the eventual sale of your practice — everything from the tax implications to whether or not you will pass the practice down to a family member or sell outright to a third party. In order to make a sound decision that is best for you, your practice, your patients, and your family, it's important to thoroughly weigh all of your options. There are several indicators that can be used as a good barometer for where your practice stands today. Creating a strategy will prepare you and your practice for the day you leave and will ensure the transaction and transition meet your expectations. To ensure there are no misunderstandings in your current conception of business finance, you can work toward implementing solutions that will ensure your assets and financial future are secure. Have your practice valued by an expert Most practice owners could tell you what their company is worth, but the amount can often be misleading, even to the business owners themselves. The valuation of a medical practice is a multi-faceted figure, and calculating it correctly is a complex task. To know whether or not you can be confident in knowing the current value of your practice, ask yourself the following: • In the past 12 months, have my reimbursements increased? • Do I have control over my career and future earning potential? • If I have capital investments, am I satisfied with the return am I getting from those investments? • Can I predict the stability of my current position or industry? • Do I preform a yearly review of my estate and my practice’s finances? Coordinate personal and practice financial plans Finding the time to coordinate personal and practice financial plans can often get put on the back burner again and again. Ask yourself these questions to get an idea of how up to date you are with your finances: • Do I have a will that is up to date? • Do I have a plan to retain key employees if something happens to me? • Have I had my trust and estate plan reviewed in the past three years? • Are my assets protected from potential litigation? Plan for the unexpected Running a practice is hard work and time consuming. We all inevitably end up putting off planning for our financial futures until the future, but this isn’t always the best strategy. Ask yourself: • Do I know when I want to retire?
• Do I know how much income I will need in retirement? • Do I know how much control in the practice I must maintain to secure my retirement income? • Have I started creating replacement income from other sources? Consider key tax strategies It’s probably not your job to know the in’s and out’s of tax codes, but having the right tax strategy is a crucial step in knowing, understanding, and maximizing the value of your practice. If you’re unsure about whether you are fully taking advantage of the best tax strategies, consider the following: • Have I determined my financial goals? • Am I proactively planning to deal with the changes in tax laws? • Will any sources of my retirement income be tax free? • Am I working with financial experts? Prepare for the unexpected We can’t always predict the turning of the world, and sometimes even the soundest foundations can collapse without much warning. Don’t get caught in the trap of thinking that your company or industry is untouchable, or “that will never happen to me.” To make sure that you’re being realistic about vulnerabilities, ask yourself: • Do I have a formal succession plan prepared and on file? • Does my succession plan have a provision for disability? • Do I have personal disability income insurance coverage? • Do I have contribution protection for my retirement account if I become disabled? Diversify your retirement plans Your practice is very likely a good nest egg for your financial future, but that doesn’t mean that you shouldn’t diversify your retirement plans. If you want to make sure you’re covered from all angles when you decide to retire, consider the following: • Do I have investments other than my practice? • Will my retirement funding come from more than four sources? • Do any of my retirement assets have guaranteed returns? • Have I had my retirement income projected and analyzed to identify shortfalls? Whether you intend to exit your practice soon or expect to continue practicing medicine for years to come, exit planning can bring positive benefits to you, your practice, and your family. Specifically, exit planning works to position you to leave your practice how and when you want, with the money you decide you need, and transferred to whomever you choose. It’s never too soon to start planning for your future and the future of your practice. visit us at www.bcms.org
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PHYSICIANS PURCHASING DIRECTORY Brought to you by the BCMS Circle of Friends
By supporting these sponsors with your patronage, you are supporting the BCMS. ACCOUNTING FIRMS
Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”
ACCOUNTING SOFTWARE
Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”
ARCHITECTURE LK Design Group, Inc. (HH Silver Sponsor) LK Design Group has over 24 years of experience designing various medical and hospital buildings. We have experience in both ground up developments and re-design of interior spaces for medical professionals. Lynn Kuckelman Peters President 210-824-8825 Lynn.p@lkdesigngroup.com Kristin Savage Director of Business Development 210-824-8825 Kristin.s@Lkdesigngroup.com www.lkdesigngroup.com
ATTORNEYS
Kreager Mitchell (HHH Gold Sponsor)
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San Antonio Medicine • July 2020
At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”
Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”
ASSETT WEALTH MANAGEMENT
Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor
210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres
BANKING
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”
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"
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.”
Synergy Federal Credit Union (HHH Gold Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need. Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”
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
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”
COMMERCIAL PROPERTY MANAGMENT
Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"
FINANCIAL SERVICES Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton. Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."
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
Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres
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!”
management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society. Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group and SWBC PEO, SVP Corporate Relations (210) 525-1241 DMarino@swbc.com Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”
HEALTHCARE BANKING 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"
SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth
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
CareAllies (HHHH 10K Platinum Sponsor) CareAllies works side-by-side with health care providers to accelerate the transition to valuebased care, helping improve the quality, value and experience of care for patients and make health care better for everyone. Sabrina Moreno, Network Operations Senior Manager (713) 437-3088 X 523088 Sabrina.Moreno@careallies.com info@careallies.com https://www.careallies.com/ “For Better Health and Better Business”
HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER GHA TECHNOLOGIES, INC (HH Silver Sponsor) Focus on lifelong relationships with Medical IT Professionals as a mission critical, healthcare solutions & technology hardware & software supplier. Access to over 3000 different medical technology & IT vendors. Pedro Ledezma Technical Sales Representative 210-807-9234 pedro.ledezma@gha-associates.com www.gha-associates.com “When Service & Delivery Count!”
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PHYSICIANS PURCHASING DIRECTORY continued from page 39 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”
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.”
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San Antonio Medicine • July 2020
Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com
OSMA Health (HHH Gold Sponsor) Health Benefits designed by Physicians for Physicians. Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”
INSURANCE/MEDICAL MALPRACTICE
Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) 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) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas
INTERNET TELECOMMUNICATIONS
Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown - Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”
MEDICAL BILLING AND COLLECTIONS SERVICES
Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems Christiane Escobar, CMRM
Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up? 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 FURNITURE
CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline. Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com
MEDICAL PRACTICE
IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner. Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.com Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “
For questions regarding services, Circle of Friends sponsors or joining our program please contact August Trevino, Program Director at 210-301-4366, August.Trevino@bcms.org, bcms.org/COF.html
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.”
MOLECULAR DIAGNOSTICS LABORATORY
iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”
MORTGAGE
PrimeLending (HHH Gold Sponsor) Doctor Loans, Construction Loans, VA Loans, Conventional and FHA Loans. Cleo Garza Sr. Loan Officer NMLS#218858 210-483-4907 cleo.garza@primelending.com www.lo.primelending.com/cleo.garza Home Loans Made Simple
OFFICE FURNITURE
CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office
furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline. Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com
PRACTICE SUPPORT SERVICES
Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up?
SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society. Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group and SWBC PEO, SVP Corporate Relations (210) 525-1241 DMarino@swbc.com
PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org
REAL ESTATE SERVICES COMMERCIAL
CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”
Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton. Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA,
Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."
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”
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. Donna Bakeman Office Manager 210-301-4362 dbakeman@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!"
visit us at www.bcms.org
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AUTO REVIEW
Where Vehicle Production Is Headed Post COVID-19
By Stephen Schutz, MD
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San Antonio Medicine • July 2020
AUTO REVIEW The COVID-19 pandemic has made it impossible to get press vehicles to drive, so instead of a car review I will give you my sense of how I think the automotive world will change post-COVID-19. Here are my predictions of winners and losers, in no particular order. Vehicle categories: Pickups and full-size SUVs (winner) The most important change that the COVID-19 pandemic has brought is cheap oil. Inexpensive gasoline makes owning an F-150 or Suburban more affordable, but another factor in their favor is that pickups and full-size SUVs are the most profitable vehicles that Ford, GM, and Fiat-Chrysler make. As those cash-starved companies, like all auto manufacturers, do everything they can to maximize revenues, look for them to produce and sell as many of these money makers as they can. Electric vehicles (loser) For all the reasons pickups and full-size SUVs will thrive, electric vehicles will struggle. Low gas prices will make them less attractive to consumers, and the fact that they are all money losers — even Tesla loses money on every car they sell — will make them less appealing to manufacturers. Supercars (loser) Over the past 20 years, supercar sales have boomed as personal wealth has increased and these very high-end sports cars — think Ferrari, Lamborghini, and the like — have become comfortable and reliable enough to be considered daily drivers. An interesting observation in 2019, that maybe too many cars from too many brands were chasing too few buyers, has become a major problem that threatens all of the players now that there are even fewer buyers. All supercar producers will take a hit, but financially weaker ones such as Aston Martin and McLaren will be particularly threatened. In addition, expect healthy automakers to cut back on the supercar offerings they offer — I can’t imagine the Audi R8 or Acura NSX will be around much past 2021, to give just two examples. Luxury SUVs (winner) While I expect expensive sports cars to take a major hit after COVID-19, luxury SUVs should continue to be popular. They provide all the pampering that you expect from a top shelf luxury sedan but without the flashiness that provokes envy from the throngs of people stuck working from home for 75% of what they used to make. Look for plenty of new BMW X7s, Mercedes GLSs, Audi Q8s, and Cadillac Escalades on South Texas roads over the next few years. Sedans/cars (loser) The vehicles that most of us grew up with become less popular by the day, and the coming age of cheap gas will only accelerate the movement of customers from regular passenger cars to SUVs and crossovers.
Automotive Brands: Jeep (winner) Talk about good timing. Jeep introduced a new pickup, the Gladiator, just last year and has plans to launch a fullsize SUV sometime later this year. Jeep can’t seem to do anything wrong these days. Nissan (loser) The turmoil caused by having their CEO jailed rather than firing him — serious question: why did even one executive at Nissan think that was a good idea? — resulted in falling sales and a tanking stock price before COVID-19. Post-COVID19 they’re toast. Look for them to get absorbed by Toyota. Jaguar/Land Rover (loser) They make compelling vehicles in a market segment that I expect to do well, but woes in China and a wobbly balance sheet are clear signs that they’ll struggle. Still, I hope they survive because I don’t want to think about a world where there are no more Range Rovers. Mercedes/Audi/BMW (winner) Now considered to be accessible luxury brands as opposed to showy status symbols, which BMW and Mercedes certainly were 25 years ago, the German “Big Three” will remain popular with all the right customers (that would include BCMS members) despite the COVID-19 recession. Lexus (loser) Now that the above mentioned German “Big Three” luxury brands provide reliability, strong resale value, and reasonable running costs why buy a Lexus? Especially when visiting a dealership isn’t nearly the event it was back in the ‘90s when they were really trying. Lexus should be surging this year, but I don’t see that happening unless they make significant changes in their operations. Porsche (winner) For all the reasons Mercedes, Audi, and BMW will do well in the post-COVID-19 world, but I think they’ll do even better than their Teutonic brethren. Of course, they’re starting from a much lower baseline, but Porsche’s 20-year-old bet on SUVs will really pay off over the next few years. As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit us at www.bcms.org
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RECOMMENDED AUTO DEALERS • • • •
Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463
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.
11001 IH 10 W at Huebner San Antonio, TX Esther Luna 210-690-0700
Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216
Northside Ford 12300 San Pedro San Antonio, TX
David Espinoza 210-912-5087
Marty Martinez 210-525-9800
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Acura 11911 IH 10 W San Antonio, TX
GUNN Honda 14610 IH 10 W San Antonio, TX
Coby Allen 210-625-4988
Eric Schwartz 210-680-3371
Northside Honda 9100 San Pedro San Antonio, TX 78216
Cavender Audi Dominion 15447 IH 10 W San Antonio, TX 78249
Sean Beardsley 210-988-9644
Rick Cavender 210-681-3399 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 Mazda 9333 San Pedro San Antonio, TX 78216
William Taylor 210-366-9600
James Godkin 830-981-6000
Scott Brothers 210-253-3300
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Subaru 9807 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
Mark Castello 210-308-0200
Tripp Bridges 210-308-8900
Justin Blake 888-341-2182
Stephen Markham 877-356-0476
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
Cavender Toyota 5730 NW Loop 410 San Antonio, TX Gary Holdgraf 210-862-9769
Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.) San Antonio, TX Ed Noriega 210-561-4900
Porsche Center 9455 IH-10 West San Antonio, TX Matt Hokenson 210-764-6945
Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org
THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA
MEDNAX
Dermatology Associates of San Antonio, PA
Peripheral Vascular Associates, PA
Diabetes & Glandular Disease Clinic, PA
San Antonio Eye Center, PA
ENT Clinics of San Antonio, PA
San Antonio Gastroenterology Associates, PA
Gastroenterology Consultants of San Antonio
San Antonio Infectious Diseases Consultants
General Surgical Associates
San Antonio Pediatric Surgery Associates, PA
Greater San Antonio Emergency Physicians, PA
South Alamo Medical Group
Institute for Women's Health
South Texas Radiology Group, PA
Little Spurs Pediatric Urgent Care, PLLC
South Texas Renal Care Group
Lone Star OB-GYN Associates, PA
Star Anesthesia (USAP Texas-South)
M & S Radiology Associates, PA
The San Antonio Orthopaedic Group
MacGregor Medical Center San Antonio
Urology San Antonio, PA
Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of June 24, 2020. 46
San Antonio Medicine • July 2020