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VOLUME 71 NO. 8

MEDICINE SAN ANTONIO

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

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The Problem with Sleep: Research in Military City USA Addresses a High Priority in Military Medicine By Alan L. Peterson, PhD, ABPP ...................................12

The Pentagram of Overt Indicators of Concussion By Jonathan Lifschiz, PhD, and Joshua A. Beitchmen, MBS ...........................................18

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Camp Neuro: A Unique Insight for High Schoolers into the Brain and Mind By Patricia S. Machado, Medical Student ......................20

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AUGUST 2018

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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Sheldon G. Gross, MD, President Gerald Q. Greenfield Jr., MD, PA, Vice President Adam V. Ratner, MD, President-elect Leah H. Jacobson, MD, Immediate Past President Kristi G. Clark, MD, Secretary John Robert Holcomb, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Jenny Shepherd, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Charles Mahakian, MD, Military Representative Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Manuel Quinones, MD, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member

BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Pavela Bambekova, Medical Student Darren Donahue, Medical Student Carmen Garza, MD, Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member Austin Sweat, Medical Student J.J. Waller Jr., MD, Member

San Antonio Medicine â€˘ August 2018

PRESIDENT’S MESSAGE

A lifelong fascination with neurology By Sheldon Gross, MD, 2018 BCMS President

Dear Colleagues,

This month’s issue of San Antonio Medicine is dedicated to the field of neurology. As a child neurologist, I am delighted that neurology is receiving this attention. I remember when the first CAT scan images were being reviewed during my residency. Back then, it seemed like nothing short of magic to be able to image the brain in this fashion. Looking back on some of those images from the 1970’s, I wonder how any types of diagnosis could be made. By today’s standards, those images would have been interpreted as artifact and would simply have been repeated. It has been fascinating to watch the evolution of neuroimaging and our ability to diagnose conditions so much more quickly. With CAT scans, MRI scans, PET scans, and a vast array of other technologies available, it seems that there are no boundaries with regards to our ability to diagnose and treat neurological patients. Neurology takes on a special significance when looking at the demographics of our nation. As the average age in this country gets higher and higher, we are seeing that a huge percentage of Medicare expenditures are going towards patients with chronic neurological conditions. If one simply considers three conditions including dementia, stroke, and Parkinson’s disease, this accounts for billions of dollars and a huge amount of resources to care for these individuals and to help families deal with this type of chronic burden. In response, the NIH has allocated a very large amount of resources for research regarding these areas. We are looking at these chronic neurodegenerative conditions not only from a treatment standpoint but also from a prevention standpoint. However, we should not lose sight of the fact that along with new and dazzling progress in research, we already know that there are specific risk factors for stroke. We know that chronic untreated hypertension, diabetes, and obesity all increase the likelihood of stroke. These are public health issues that need to be approached from a public 8

San Antonio Medicine • August 2018

health standpoint. We know that staying active physically and mentally can help delay and slow down the progression of dementia. I have always considered myself fortunate to have a career in neurology. From my perspective, there is nothing more fascinating than brain function and the interface between mind and body. Neurology together with psychiatry remain two of the most captivating specialties in medicine. Along with the progress being made, new challenges and ethical dilemmas require address. Child neurology now has the dubious honor of having two of the most expensive treatments for neurological disease. We can effectively treat spinal muscular atrophy as well as Duchenne muscular dystrophy from a genetic standpoint. The cost of these treatments is in the hundreds of thousands of dollars. I have no doubt that with time we will see more and more neurological disease as well as other chronic conditions becoming amenable to genetic manipulation and treatment. How do we finance these extremely expensive treatments? We are rapidly approaching an era in medical ethics when we have to decide how our resources will be directed. We are quickly reaching, or perhaps have already reached, a stage where we can no longer afford to do the things that are possible. We will have to address these and many other issues as a nation. I could spend the next 20 pages documenting progress in the areas of migraine, epilepsy, perinatal asphyxia, and hypoxic encephalopathy. Suffice it to say that neurology is one of the most dynamic and rapidly changing specialties in the country. I may be biased. In fact, I am most certainly biased. I hope you will find this issue of interest. Enjoy the rest of the summer. Sincerely, SHELDON GROSS, MD President, Bexar County Medical Society

BCMS LEGISLATIVE NEWS

CMS PROPOSES BIG MEDICARE CHANGES FOR 2019 The Centers for Medicare & Medicaid Services (CMS) last week proposed what the agency called “historic changes” in the Medicare program. TMA is already digging deep into the proposal to make sure the changes are good for Texas physicians and your patients. “Today’s proposals deliver on the pledge to put patients over paperwork,” said CMS Administrator Seema Verma. “The proposed changes to the Physician Fee Schedule and Quality Payment Program (QPP) address those problems head-on, by streamlining documentation requirements to focus on patient care and by modernizing payment policies so seniors and others covered by Medicare can take advantage of the latest technologies to get the quality care they need.” Texas Medical Association President Douglas Curran, MD, said the association welcomes that approach. “Physicians are among the most regulated professionals in the country,” Dr. Curran said. “The paperwork burdens and administrative hassles come between doctors and our patients, and are significant causes of the epidemic of physician burnout. That's why TMA has repeatedly petitioned CMS to remove the yoke of unnecessary regulation.” U.S. Rep. Michael Burgess, MD (R-Lewisville), chair of the House Energy and Commerce Subcommittee on Health, agreed. "These proposed changes seek to strengthen the critically important doctor-patient relationship by reducing unnecessary reporting burdens,” Representative Burgess said.

San Antonio Medicine • August 2018

TMA staff experts have begun a detailed analysis of the proposed rule and will offer written comments by the Sept. 10 deadline. As always, staff will work with TMA’s various councils and committees as the comments are drafted, but if you have something specific you would like to say, please pass it on by emailing HIT@texmed.org. The Physician Fee Schedule establishes payment for physicians and other clinicians who treat Medicare patients. CMS created the QPP under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The program uses a framework of integrated policies for the two Medicare payment tracks required by MACRA: the Merit-based Incentive Payment System (MIPS) and advanced alternative payment models. The Physician Fee Schedule and QPP are updated annually to create, update, or change program and payment policies, payment rates, and other provisions that govern them. Over the past two years, CMS published two separate rules for the Physician Fee Schedule and QPP, but this year it rolled both sets into one massive 1,473-page proposed rule. For more information visit www.texmed.org. To learn how you can get involved in this and other legislative activities contact Mary Nava, chief government affairs officer, at mary.nava@bcms.org.

BCMS NEWS

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NEUROLOGY & SLEEP DISORDERS

The Problem with Research in Military City USA Addresses a High Priority in Military Medicine By Alan L. Peterson, PhD, ABPP

leep is a biological requirement that is crucial for maintaining physical and psychological health and resiliency (Young-McCaughan et al., 2011). Sleep deprivation is a major factor related to occupational injuries and transportation accidents (Uehli et al., 2014). The Sleep Research Society and American Academy of Sleep Medicine task force (Zee et al., 2014) highlighted the health burden caused by chronic sleep disorders and the potential for sleep-focused therapy to reduce morbidity, mortality, and healthcare costs and improve quality of life and public safety. When people think of sleep problems, they typically think of insomnia, which is one of the most common sleep problems seen in most health care settings. The prevalence of insomnia has been estimated at about 30 percent in the general population (Roth, 2007). It is even higher in certain populations such as those with chronic health conditions (e.g., chronic pain, obesity) and in military personnel and veterans who have deployed in support of military operations (Peterson et al., 2008; Pruiksma & Peterson, 2018; Pruiksma, Taylor, & Peterson, 2015; Taylor et al., 2016). In fact, it is the most commonly reported problem among our troops returning from deployment. Insomnia is generally defined as difficulty falling asleep or staying asleep or nonrestorative sleep. These sleep problems persist despite having an adequate opportunity and circumstance to sleep. Insomnia is associated with daytime impairment or distress, it occurs at least three times per week, and it has been a problem for at least one month. Although a number of medications are effective for the treatment

San Antonio Medicine â€˘ August 2018

of insomnia, most have been developed to treat acute insomnia, and their long-term efficacy is limited. An additional problem is that sleep medications can cause side effects such as grogginess, slowed cognitive processing, and slowed reaction time, which are dangerous for military personnel, particularly in deployed settings. A number of studies have been conducted to evaluate the individual and combined efficacy of pharmacological and cognitivebehavioral treatment for insomnia (CBT-I). CBT-I is designed to treat the underlying causes of insomnia by helping individuals identify thoughts and behaviors that cause or contribute to sleep problems and replace them with practices that promote sound sleep. Results have generally shown that both medications and CBT-I treatments are equally effective over the short term. However, CBT-I has been found to result in better long-term improvements in sleep for those with chronic insomnia (Beaulieu-Bonneau, Ivers, Guay, & Morin, 2017). Much of my professional career as a clinical health psychologist has focused on sleep disorders. My earliest work in this area was in the late 1980s while I was a resident and fellow in clinical health psychology at Wilford Hall Medical Center in San Antonio. After several permanent-change-of-station assignments with the Air Force, I returned to Wilford Hall in 1997 to serve as the director of the Clinical Health Psychology postdoctoral fellowship program. Because of the significant psychological factors related to sleep disorders, the Sleep Medicine and Clinical Health Psychology programs at Wilford Hall established a close collaborative clinical, teaching, and research partnership. One of our first studies at Wilford Hall focused on delivering

NEUROLOGY & SLEEP DISORDERS

group cognitive-behavioral therapy for insomnia. Historically, this treatment had almost always been delivered to patients on an individual basis. However, with the large number of patients being referred for the treatment of insomnia, we developed and evaluated a group CBT-I program including 42 consecutively treated patients in the Wilford Hall Insomnia Program (Hryshko-Mullen et al., 2000). The results indicated that sleep onset latency (time it takes to fall asleep) was improved by 53 percent, wake after sleep onset was decreased by 40 percent, and sleep efficiency (ratio of total time sleeping compared to time in bed) was improved by 22 percent. These results compared favorably with data from previous studies of individual CBT-I. Soon after the publication of our group CBT-I study in 2000, the terrorist attacks on America occurred on September 11, 2001. Before long, I was deployed with the U.S. Air Force in support of Operation Enduring Freedom (OEF). Our deployment was to an undisclosed, classified location that was in the midst of being constructed as we arrived. A few weeks into our deployment, a major aircraft accident almost occurred during the takeoff of a fully fueled KC-135 refueling plane. The subsequent investigation revealed that sleep deprivation in the pilot was a major factor related to the near miss. Consequently, I was asked to assess the overall sleep conditions in our deployed location and to make recommendations for possible improvements. I was able to collect data on the symptoms of sleep disturbance and insomnia in a group of 156 deployed military personnel (Peterson, Goodie, Satterfield, & Brim, 2008). The results indicated that about three quarters of deployed service members (74 percent) rated their quality of sleep as significantly worse in the deployed environment, 40 percent had a sleep efficiency of less than 85 percent, and 42 percent had a sleep onset latency of greater than 30 minutes. Night-shift workers had significantly worse sleep efficiency and more problems getting to sleep and staying asleep as compared to dayshift workers. The results of the study highlighted the need for programs to help deployed military members get more and better sleep. In 2004-2005, I deployed as a military clinical psychologist to Iraq in support of Operation Iraqi Freedom and was assigned to the Air Force Theater Hospital at Balad Air Base, Iraq. It was during this deployment that I saw firsthand the impact of combat-related physical and psychological trauma on the troops deployed to the combat theater. The combat-related stress disorders and sleep problems I observed in Iraq were even more widespread than what I had observed during my OEF deployment. When I reviewed the scientific literature to help guide me in the use of evidence-based treatments for combat-related post-traumatic

stress disorder (PTSD) and sleep disorders in the deployed setting, there was a dearth of dataâ€”in fact, not a single clinical trial had ever been conducted on combat-related PTSD or sleep disorders in military personnel in deployed or non-deployed settings. Nonetheless, I modified evidence-based treatment protocols developed for civilian traumas, collected outcome data, and published the results, which were very promising (Cigrang, Peterson, & Schobitz, 2005). Several deployed service members with severe PTSD symptoms were able to be treated into remission in about four individual prolonged exposure treatment sessions. These individuals were able to return to duty and successfully completed their deployments rather than being aeromedically evacuated out of theater. Upon my return from my deployment to Iraq in 2005, I decided to retire from active duty after having completed 21 years of service. I was greatly impacted both personally and professionally from my deployment to Iraq. I knew that something needed to be done to help develop and evaluate evidenced-based treatments for deployment-related psychological health conditions in active duty military personnel. At the time, I had two projects funded by the National Institutes of Health (NIH) and three by the Department of Defense (DoD) in the areas of behavioral medicine. I interviewed with the chair of the Department of Psychiatry at UT Health San Antonio and was offered a faculty position so I could focus fulltime on my research.

Immediately after arriving at UT Health San Antonio, I began working on NIH, DoD, and private research grant submissions. In 2007, the DoD published a request for applications to fund a Multidisciplinary PTSD Research Consortium. This was just the opportunity I was looking for, and I compiled a comprehensive grant application in collaboration with many of the top PTSD investigacontinued on page 14

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NEUROLOGY & SLEEP DISORDERS continued from page 13

tors across the nation. The grant application was selected for funding, and the STRONG STAR Multidisciplinary PTSD Research Consortium was officially established in September 2008. The South Texas Research Organizational Network Guiding Studies on Trauma And Resilience, or STRONG STAR, initially included 14 linked basic science, epidemiology, genetic, and clinical trial studies targeting combat-PTSD and related conditions in active duty service members and recently discharged veterans. Although the primary focus was PTSD, we included a major focus on sleep disorders because of the common comorbidity of the two disorders. Over the subsequent 10 years, STRONG STAR has expanded to include over 50 DoD, NIH, Department of Veterans Affairs (VA), and privately funded research projects with a combined nationwide budget of over $150 million. In June 2018, STRONG STAR was approved by the UT System as an Organized Research Unit (ORU) at UT Health San Antonio. The infrastructure funding provided for the STRONG STAR ORU will allow us to continue to be highly competitive to secure research funding. In addition to our funding for PTSD research, we have received DoD and private funding to support four military sleep disorder research projects and have two additional projects that are in final negotiation for possible funding. Our research studies have documented that insomnia is highly prevalent in military personnel (Taylor et al., 2016) and that cognitive-behavioral therapy for insomnia is effective in military primary care (Goodie, Isler, Hunter, & Peterson, 2009; Isler, Peterson, & Isler, 2005) and specialty care settings (Taylor et al., 2017, 2018). Our primary care study found that over 80 percent of patients no longer met criteria for insomnia after being treated with three, 30-minute CBT-I sessions (Goodie et al., 2009). We have also found similar results for the treatment of deployment-related insomnia in military specialty care settings using standard face-to-face or Internet-delivered CBT-I (Taylor et al., 2017, 2018).

San Antonio Medicine • August 2018

In addition, we have documented that insomnia is the most common residual symptom after the successful treatment of PTSD (Pruiksma et al., 2016). Among participants who no longer met criteria for PTSD following treatment, 57 percent continued to report insomnia. We have secured additional DoD/VA research funding through the Consortium to Alleviate PTSD, also headquartered at UT Health San Antonio, to investigate the most effective approach to treating comorbid PTSD and insomnia. That study is well underway, and one of its considerations is whether the order of treatment – PTSD first or insomnia first – affects outcomes for both disorders. With the nationwide success of STRONG STAR, I have led a similar nationwide effort for the past three years to try to establish a Military Sleep Disorders Research Consortium headquartered at UT Health San Antonio and including the nationwide collaboration of DoD, VA, and civilian sleep experts. The establishment of the proposed Military Sleep Disorders Research Consortium in San Antonio will help expand our national reputation of excellence in clinical, research, and teaching related to military sleep disorders. Dr. Peterson teaches in the Department of Psychiatry, School of Medicine, University of Texas Health Science Center at San Antonio.

NEUROLOGY & SLEEP DISORDERS

with Alan L. Peterson, PhD, ABPP Interviewed by Melissa Vasquez

What is your title?

Professor and Chief, Division of Behavioral Medicine Department of Psychiatry, School of Medicine University of Texas Health Science Center at San Antonio

What is your area of expertise? What drove you into this specific area?

chologist in terms of maintaining a healthy lifestyle through exercise, healthy eating, and sleep management. As a military veteran, my work is a way for me to “pay it forward” to other service members and veterans.

What makes UT Health a special place to be?

Clinical health psychology and behavioral medicine. I was inspired to specialize in this area because psychological and lifestyle factors are the most significant modifiable factors related to disease and illness. Early in my career, I developed clinical and research expertise in a number of areas of behavioral medicine including sleep disorders, tobacco cessation, weight management, chronic pain management, and chronic tic disorders. After September 11, 2001, I quickly developed additional expertise related to combat-related trauma including post-traumatic stress disorder (PTSD), traumatic brain injury, and suicide. My previous expertise in insomnia and other sleep disorders was very beneficial in helping me adapt to the unique factors of combat-related sleep disorders.

After serving for over 20 years on active duty in the U.S. Air Force working primarily as a clinician, UT Health San Antonio has allowed me to continue my career with a focus primarily on military-relevant research. UT Health has a long history of military collaboration related to clinical teaching and research activities in San Antonio, and it has allowed me to take some of this to a completely new level.

What professional accomplishment are you most proud of? What did it mean to you?

What do you do to relax outside of the office, lab, or clinic?

I am most proud of my establishment of the STRONG STAR Consortium, the nation's largest research consortium focused on combat posttraumatic stress disorder (PTSD) and related conditions in active duty military personnel and veterans. I consider this to be the most important clinical and research work of my career. My previous military and deployment experience provides me with unique insights into the scientific and military-relevant gaps in these areas. To address these gaps, I have successfully recruited many of the nation’s top scientists to partner with us in San Antonio on collaborative research projects. I am certain we have successfully changed the life trajectories of hundreds of service members and veterans. In some cases, I am certain we have saved lives.

What do you want patients to know about you?

I do my best to practice what I preach as a clinical health psy-

San Antonio Medicine • August 2018

What is unique or surprising about doing research and clinical work in Bexar County?

Bexar County is incredibly supportive of its military and veteran community. This makes my collaborative clinical, research, and teaching even more rewarding.

I enjoy trail running amongst the many dry creek beds throughout Bexar County and surrounding locations. After completing three deployments and retiring from active duty, I started running ultra trail marathons (defined as any distance exceeding 50K) as a way to help me relax and to work through life stressors.

What unique challenges or opportunities do you have as a psychologist in San Antonio?

Working in Military City USA provides me with unique opportunities to have an impact on military medical research and policy at a national level. With Fort Hood located about 150 miles north of San Antonio, we have been able to embed about 40 UT Health faculty and staff at that location to successfully conduct several of the nation’s largest randomized clinical trials related to PTSD and insomnia.

NEUROLOGY & SLEEP DISORDERS

The pentagram of overt indicators of By Jonathan Lifschiz, PhD and Joshua A. Beitchmen, MBS

child receives a hit to the head and falls to the ground. They may not be unconscious, but their arms are held postured in an unnatural position. Why are they reaching upwards or defensively guarding? Observers are aghast, confused, and worried. This event and those like it are indicative of the Fencing Response, which identify moderate traumatic brain injury or concussion. Upon impact, if direct or indirect forces of injury transmit to the brainstem, then an individual’s forearms are held flexed or extended (typically into the air) for a period lasting up to several seconds. One expression of the posture resembles a fencer’s en guarde stance, thereby earning the name Fencing Response. Reports of the Fencing Response include all genders, ages, and activities, including organized sport, domestic violence, non-accidental trauma, automobile accidents, violent assaults, and self-inflicted injury. The Fencing Response originates from motor reflexes in the brainstem. Concussive forces can be transmitted to the vestibular nuclei (lateral vestibular nucleus (LVN); aka Deiter’s nucleus) and mechanically activate primitive reflexes, normally reserved for correcting balance. The motor output arises from vestibular activation of motor nuclei in the anterior column of the spine. The reflex is observed as contraction of the limb extensors and relaxation of flexors – described as the Fencing Response as shown in Figure 1.

FIGURE 1

San Antonio Medicine • August 2018

Schematic illustration of the Fencing Response during a knockout. A. The individual receives a punch or sudden force to the head. B. After the traumatic blow to the head, the unresponsive individual immediately exhibits posturing of the arms. C. During prostration, the rigidity of the extended and flexed arms is retained for several seconds as flaccidity gradually returns. Image reprinted from https://en.wikipedia.org/wiki/Fencing_response. The Fencing Response is used by healthcare professionals and

NEUROLOGY & SLEEP DISORDERS

lay observers as an overt, visual indicator of moderate injury forces applied to the brainstem and midbrain. This aids in real-time concussion identification and classification for individuals of all ages and in all situations. Observing the Fencing Response should initiate immediate medical attention and accepted concussion protocols. If injury forces were sufficient to elicit the Fencing Response, then the likelihood exists for injury to nearby brainstem areas that could impact breathing, cardiovascular function, alertness, and other brainstem functions. Investigation into other brainstem functions that may be affected by concussive forces have yielded additional overt, visual indicators of brain injury. It is hypothesized that these pathophysiological responses originate from forces applied to nuclei in close proximity to the LVN in the brainstem. Evoked pathophysiological responses include responses such as seizing, snoring, crying, and vomiting following injury. These responses may occur in addition to or independent of the Fencing Response and therefore represent additional signs of concussion. By observing the pathophysiological manifestations of concussion, clinicians and lay public can ensure that patients receive appropriate care following head injury. By acting on clear and objective indicators of brain injury, such as the Fencing Response, patients can receive immediate medical care and thereby be positioned for optimal outcomes. The concussed individual may not be aware of the events of their own injury, its severity, or potential neurological consequences. The Fencing Response removes subjectivity from the evaluation. While a positive Fencing Response, even observed by the lay public, represents a concussion requiring medical attention, an impact to the head without eliciting a Fencing Response may be severe enough to require medical attention. All head impacts require an evaluation from individuals with specialized training on the subject. In sum, the Fencing Response is a diagnostic biomarker identified as forearm posturing that indicates a concussion of moderate severity. Furthermore, pathophysiological response such as

seizures, snoring, crying, and vomiting may also be indicative of concussive forces applied to the brainstem. Knowledge of these tools can speed access to care for concussed individuals and ought to be considered in a clinical differential. The clinical and translational research that accompanies the pentad of concussion responses identified here helps to improve access to treatment that may mitigate the acute and chronic effects of concussion for patients of all ages. You can learn more from the Wikipedia page (https://en.wikipedia.org/wiki/Fencing_response) and YouTube videos (https://youtu.be/ZlXjwAlOflA) prepared by BNI@PCH faculty. Jonathan Lifshitz, Ph. D. is Director, Translational Neurotrauma Research Program, BARROW Neurological Institute at Phoenix Childrenâ€™s Hospital and Associate Professor, Department of Child Health, University of Arizona College of Medicine-Phoenix. Joshua A. Beitchman, MBS is a medical student at University of Texas Health San Antonio, Long School of Medicine and a Graduate Research Assistant, Translational Neurotrauma Research Program, BARROW Neurological Institute at Phoenix Childrenâ€™s Hospital. visit us at www.bcms.org

NEUROLOGY & SLEEP DISORDERS

A Unique Insight for High Schoolers into the Brain and the Mind Edit and photos by Patricia S. Machado, Medical Student, University of Texas San Antonio, Long School of Medicine

he second-year medical students of University of Texas Health San Antonio Long School of Medicine had the pleasure to organize and execute Camp Neuro this year on its campus from June 25th-29th. Camp Neuro is a one-week summer camp hosted by cities all over the nation, where medical students teach high-school aged kids about neurology, medicine, and psychology. This is an innovative approach to learning that allows high schoolers to have a valuable hands-on experience at a medical school level. Talented doctors and medical students put together a camp to mentor young students towards healthcare careers and education in healthy living. The camp is composed of hands-on workshops, exercises to promote healthy living, and lectures ranging from neurophysiology, neuroimaging and diagnostics, and pathological diseases. The camp also provides the invaluable opportunity to learn hands on anatomy by assisting students dissect sheep brain and teach suture techniques using pig feet. Joshua Bietchman is a 2nd year medical student and was the primary organizer and host of Camp Neuro this year. As a Texas A&M alumni, he worked with blast traumatic brain injury research, and continued on to pursue a Masters in Biomedical sciences at Midwestern University and researched affective conditions following TBI (traumatic brain injury). After being asked why he got involved with camp neuro he responds: “I got into Camp Neuro due to my continuing desire to help educate and treat children. Being an Eagle Scout, I have worked with children of all ages in Scouting, research and medicine. I have a firm belief to continue to "pay it forward" from all the excellent mentorship that I have received from the physician and scientists that

San Antonio Medicine • August 2018

From left to right we have some of the medical student leaders of Camp Neuro, Patricia Machado, Fayette Adelaja, Zach Burgess, JP Bonansaga, Zach Burgess, Ahnaff, Josh Bietcham, and Dr. Vogul. Dr. Vogul is one of the MS2 module directors for the UT School of Medicine Neurology block “Mind Brain & Behavior” and neuroanatomist in charge of teaching different aspects of the brain anatomy.

have allowed me to be successful in my personal and professional life. I find working with children and specifically the campers this week incredibly rewarding.” JP Bonansiga (MS2) was also an invaluable leader and conducted most of the lectures in Camp Neuro. With his extensive background in the military and interest in neurology he was able to provide his perspective in traumatic brain injury and anatomy. His lectures constituted of demyelinating diseases, ALS, Myasthenia Gravis, Parkinson’s disease and general anatomy overview. Ahnaf Arefin was another MS2 leader of Camp Neuro and at-

NEUROLOGY & SLEEP DISORDERS

The 29 high school students that participated in Camp Neuro 2018 at UT Health San Antonio Long School of Medicine.

Dr. Occhialini is a plastic surgeon and head of the Anatomy department, and is charge of teaching anatomy to medical students during preclinical years. She lead the suture clinic during Camp Neuro and taught the students different suturing techniques using pig feet. The consistency and thickness of pig skin is very similar to human skin. She mentions that the students at Camp Neuro have a learning advantage to practice with pig skin because it’s far superior to the chicken skin that medical students tend to practice with during surgical rotations.

tained a Bachelor of Science in Neuroscience at University of Texas at Dallas. He mentions, “I decided to participate in camp neuro because I have a great interest in neurology as well as teaching. I enjoy sharing knowledge that I have learned from my time as a neuroscience major in undergraduate as well as medical school. Camp neuro allowed me to get an opportunity to talk with students about pursuing medical school and discuss neurology on a level that I wish I got in high school.” Zach Burgess discusses his reasons for joining the team, “I got roped into it by Josh, JP, and Ahnaf. I’m joking of course! In reality, I’ve always loved teaching others about things they don’t know, especially in the sciences. I’ve had a lifelong adoration for understanding the universe, especially how our bodies work, so for me having the chance to help others learn about the most complex structure that we know to exist was priceless. It was a rewarding experience to indulge the curiosity of these bright young minds, and I hope that they will continue to explore and

Ahnaf Arefin providing tips and information on how to get into medical school and the career of being a physician.

Dr. Occhialini during her demonstration of suturing techniques on the pig’s foot.

learn about how our most intricate organ operates.” As a volunteer and leader of Camp Neuro myself, I primarily assisted students with the dissection lab during the week. Mentoring in high school is a key opportunity to spark interest for young adults and can be a turning point for many kids for selecting careers. My interest in medicine began during sophomore year high school (Cinco Ranch High School, Houston TX) in a program called “Health Science Technology”. During this program students had a chance to shadow different specialties in our local Memorial Hermann Hospital. Watching a baby being born on my first day simply amazed me and solidified my interest in medicine. This is the reason why I’m adamant about becoming involved in programs focusing on high school mentorship, because it can be a truly life changing experience. The students were very ecstatic at the end of the program, and the medical school is hoping to host Camp Neuro again next year alongside with the sister program “Camp Cardiac” which emphasizes cardiology. visit us at www.bcms.org

NEUROLOGY & SLEEP DISORDERS

Treating a Root Cause of

NASAL AIRWAY OBSTRUCTION:

The evolution of treatment modalities for nasal valve collapse By Jose Barrera, MD

is estimated that more than 20 million Americans suffer from nasal airway obstruction (NAO)1, which limits airflow through the nose with significant quality of life consequences.2 As nasal breathing delivers 70% of the airflow that the lungs receive,3 NAO may significantly reduce the amount of air delivered to the lungs. Symptoms of NAO include nasal congestion, labored nasal breathing, challenges getting enough air through the nose while exercising, and trouble sleeping.4

COLLAPSED VALVE

How Nasal Valve Collapse (NVC) Can Contribute to NAO

NAO can result from even the slightest narrowing of the nasal passage;5,6,7 common conditions that contribute to NAO include septal deviation, turbinate hypertrophy and nasal valve collapse (NVC).8 NVC, which may equal or even exceed septal deviation as the prime cause of NAO, occurs as a result of weak nasal cartilage collapsing inward when a person inhales,8,9 It may be due to previous rhinoplasty, nasal trauma or congenital

San Antonio Medicine â€˘ August 2018

MODIFIED COTTLE MANEUVER

weakness of the nasal cartilage. NVC can be readily diagnosed with the Modified Cottle Maneuver, which is performed using a cerumen loop or curette to gently support the lateral wall cartilage on each side of the nose while the patient breathes. If the patient experiences significant improvement in breathing on inspiration, the Modified Cottle Maneuver is indicative of NVC. In my experience treating individuals with NAO, I have found that many patients often make the mistake of ignoring symptoms because they may become accustomed to their nasal breathing issues, or compensate with mouth breathing. It is also common for patients to misdiagnose their symptoms for chronic allergies or sinusitis, and decide to soldier on with reduced nasal breathing. Treatment of NAO due to NVC has often included vasoconstrictive and/or anti-inflammatory nasal sprays that do not correct NVC, and nasal strips or dilators that are ill-suited for daytime use and may irritate the skin and mucosa. Traditional NVC procedures (grafts) are less than ideal, as continued on page 24

NEUROLOGY & SLEEP DISORDERS continued from page 22

they are highly invasive and often lead to less predictable functional and cosmetic outcomes – leading many ENTs to forgo treating NVC. None of these solutions meet the risk-benefit expectations of either physicians or patients.

An innovative treatment for NVC may provide durable relief from NAO symptoms

A recent innovation has enabled physicians to use a new approach for addressing NAO due to NVC - the LATERA® absorbable nasal implant. This new option has yielded success for both patients and physicians as these implants address the anatomical issue of a collapsed ABSORBABLY nasal wall by providing adNASAL IMPLANT ditional support to nasal wall cartilage and stabilizing its structural integrity. The implant is inserted through a small incision and works to support the upper and lower lateral cartilage by anchoring above the maxilla to provide cantilever support. Correction of the underlying structural defect in the nasal wall reduces NAO symptoms and helps patients breathe better. Importantly, patients have experienced a minimal risk of any adverse cosmetic changes. The implant is designed to be absorbed over a period of approximately 18 months. After implantation, tissue encapsulation promotes acute implant stability and enables localized tissue response during the absorption process. Remodeling occurs once the implant is replaced with fibrous collagen construct to provide ongoing support. Positive data were recently presented at the 2017 Annual Meeting of the American Academy of Facial Plastic and Reconstruction Surgery (AAFPRS). The study was conducted in 30 adult patients with NVC. Patients had severe or extreme symptoms as established by the validated Nasal Obstruction Symptom Evaluation (NOSE) instrument. A total of 56 implants were placed in these 30 patients, 26 of whom received implants on both sides of the nose. Patients were assessed at 1 week and 1, 3, 6, 12, 18 and 24 months post-procedure.

Key findings of the study include:

• Continuing, significant NOSE score reduction at all time points,

San Antonio Medicine • August 2018

averaging 63.4%, 56.2%, 52%, 52.5% and 57.7% at 3, 6, 12, 18 and 24 months, respectively (p<0.001) • No adverse change in cosmetic appearance at 24 months post procedure • Short learning curve for physicians adopting the technology While we need to remember that NAO treatment options will always depend on the cause, it is important to consider anatomical issues, including NVC as a possibility. NVC independently affects the quality of life for NAO patients, and patients fare significantly worse when left untreated. The availability of a safe, intuitive solution to treat NVC patients without altering appearance now enables physicians to administer a durable solution to their condition – and that should help all of us breathe a bit easier. Dr. Jose Barrera, MD practices at the Texas Center for Facial Plastic and Laser Surgery & Endormir Sleep and Sinus Institute in San Antonio where he specializes in sleep and nasal surgery.

References

1. Value calculated based on 2014 US population estimate from US Census and World Bank data in conjunction with incidence numbers cited in Stewart et al. Epidemiology and burden of nasal congestion. Intl J Gen Med 2010; 2010:3 37-45. 2. Rhee et al. Nasal Valve Surgery Improves Disease-Specific Quality of Life. Laryngoscope 115: March 2005. 3. Crawford-Brown, Theoretical and Mathematical Foundations of Human Health Risk Analysis; 1997, Page 103. 4. Stewart M G. et al.Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. OtolaryngolHead Neck Surg 2004;130 (2) 157- 163. 5. Wever, The Nasal Airway: A Critical Review; Facial Plast Surg 2016;32:17–21. 6. Camacho et al, The Effect of Nasal Surgery on Continuous Positive Airway Pressure Device Use and Therapeutic Treatment Pressures: A Systematic Review and Meta-Analysis; SLEEP, Vol. 38, No. 2, 2015. 7. Lin et al, Nasal Aerodynamics. May 14, 2015. 8. Constantian MB, Clardy RB. The Relative Importance of Septal and Nasal Valvular Surgery in Correcting Airway Obstruction in Primary and Secondary Rhinoplasty. Plastic and Reconstructive Surgery. 1996 Jul; 98(1): 47. 9. Ricci, et al. Role of Nasal Valve in the Surgically Corrected Nasal Respiratory Obstruction: Evaluation Through Rhinomanometry. American Journal of Rhinology. September-October 2001, Vol. 15, Nov. 5.

NEUROLOGY & SLEEP DISORDERS

Obstructive Sleep Apnea: An Overview By Major (Dr.) Nicholas Scalzitti

bstructive sleep apnea (OSA) is one of the most

to stabilize the upper airway and maintain patency for airflow.

common sleep disorders diagnosed in our society.

Currently, an increasing number of providers are prescribing au-

adult patients are afflicted by this disorder. OSA is a

through the same mechanism. However, these machines can au-

Some authors have estimated that as many as 1 in 5

condition of recurring collapse of the upper airway during sleep that leads to sleep disruption and repeated episodes of hypoxia

tomatic positive airway pressure (APAP) machines which work

tomatically adjust or titrate pressure within the prescribed range

as needed to prevent apneas and hypopneas. As the machines are

and sympathetic nervous system surges. Patients with OSA and

capable of recognizing these events, they can provide a compli-

witnessed apneas, gasping/choking arousals from sleep, excessive

vice usage and its effectiveness (residual AHI).

their bed partners often report symptoms of snoring, restless sleep, daytime sleepiness, drowsy driving episodes, and poor memory and

cognitive function. The nocturnal symptoms not only disturb the patientâ€™s sleep, but also the sleep of the bed partner.

ance report that offers information regarding the amount of de-

The most important factor limiting the effectiveness of posi-

tive airway pressure is compliance with therapy. Studies have sug-

gested that as many as 50 percent of patients do not tolerate or

The importance of recognizing and diagnosing this disorder is

continue using PAP therapy in the long-term. Due to this, alter-

time sleepiness, as well as negatively impact other systemic ill-

changes in sleep positioning, such as sleeping on the side or with

highlighted by its ability to degrade sleep quality and cause daynesses such as hypertension, arrhythmias, cardiovascular and

cerebrovascular disease, and diabetes mellitus. Given these serious

consequences of untreated OSA, as well as the high prevalence

native treatment options are necessary. For milder cases of OSA, the head elevated, can be helpful. For patients that are overweight

or obese, weight loss can be an adjunctive treatment which both

lowers the AHI and results in subjective improvement in sleep

of disease, medical providers should routinely screen at risk pop-

quality.

to easily stratify patients who warrant a sleep study. Sleep studies,

ment devices (also called

ulations. Simple validated questionnaires (e.g. STOP-BANG) exist

or polysomnography, can be performed either in a sleep laboratory or at home to identify the presence of OSA. The diagnosis

of OSA is made based on the number of apneas (complete cessation of airflow) and hypopneas (partial decreases in airflow)

Dental

devices

called mandibular advanceoral appliances) are effective in treating both snoring

and mild to moderate OSA.

These appliances can be ob-

per hour of sleep, termed the apnea-hypopnea index (AHI).

tained on an over-the-

any patient with moderate or severe OSA, or any patient with

custom-fitted

After the diagnosis is made, treatment should be initiated for

mild OSA who exhibits bothersome symptoms. For over 3

decades, the gold standard of treatment for OSA has been con-

tinuous positive airway pressure (CPAP) therapy. These machines

provide positive pressure through nasal or oral-nasal interfaces

San Antonio Medicine â€˘ August 2018

counter

basis,

and

but

ad-

MANDIBULAR ADVANCEMENT DEVICE (ORAL APPLIANCE)

justable devices made by dental professionals are generally more

effective. As the name suggests, these devices have their effect by bringing the lower jaw (mandible) to a more anterior position

during sleep, which slightly moves the tongue and possibly the

NEUROLOGY & SLEEP DISORDERS

soft palate to relieve obstruction of the airway.

technique, referred to as upper airway stimulation, is accom-

tive, surgical intervention may be warranted. Surgeries can be tar-

the patient has control over with a bedside remote control. This

When these treatment options are not tolerated or not effec-

plished through a fully-implantable nerve stimulator system that

geted at multiple sites of the airway, including the nasal cavity,

therapy is emerging as an alternative to PAP therapy for patients

ture of the mandible and maxilla that house the upper airway.

ments. There is currently one such nerve stimulator available on

tonsils and soft palate, tongue base, epiglottis, and the bony struc-

However, it is important to understand that surgical treatment is not always effective. In selected patients, an obvious source of

obstruction such as tonsil hypertrophy can be effectively elimi-

with moderate or severe OSA who cannot tolerate other treatthe market with approval from the FDA, but others are undergoing development and clinical trial.

Obstructive sleep apnea is an important disorder that affects

nated with surgery. For others, increases in airway caliber and sta-

both sleep quality and general health conditions, most notably

ability to tolerate PAP therapy because a lower treatment pressure

is evident. For the vast majority of cases, the gold standard of

bility can be achieved to provide improvement in AHI or in the

is needed. In other cases, curing OSA with surgery is sometimes

a near impossibility, but these surgical options may be the only viable ones for a given patient. In this circumstance, surgery can

be thought of as a salvage treatment to provide as much relief as

possible to improve sleep quality for the patient and bed partner.

An exciting new therapeutic target in treating OSA is augment-

ing the tone of the muscles that dilate the upper airway. This is

currently done through neurostimulation of the hypoglossal

nerve branches that cause tongue stiffening and protrusion. This

cardiovascular disease. Therefore, the importance of treatment PAP therapy should be attempted first. However, treatment is not

always easy, so tailoring treatment to the individual patient is nec-

essary to achieve the best result.

Dr. Nicholas Scalzitti is the chief of the Sleep Surgery Division of the

Otolaryngology Department at the San Antonio Military Medical Center. He is board certified in both Sleep Medicine and Otolaryngology/Head and

Neck Surgery.

visit us at www.bcms.org

FEATURE

TEXAS LIVER INSTITUTE PROVIDES FOCUSED CARE FOR AN AGE-OLD DISEASE By Mike W. Thomas, BCMS Director of Communications

The Texas Liver Institute’s mission is to find new ways to treat an old disease. Liver ailments such as fatty liver disease have always been around, but new technology and research are making it possible to provide better care and treatment for a condition that effects and estimated 30 percent of the U.S. population. Founded in 2012, the Texas Liver Institute (TLI) is one of the largest diagnostic and treatment centers of its kind in the world and is globally recognized as a leading research facility in the field of liver disease. TLI was founded by Eric Lawitz, MD (at right), who now serves as its medical director and is also a clinical professor of medicine at UT Health San Antonio. Lawitz came to San Antonio after serving in the Army and did his postgraduate training at Brooke Army Medical Center. He is board certified in the area of Gastroenterology/Hepatology. Lawitz said he was inspired to start TLI after surmising what he saw as a paucity of liver care available in San Antonio. Believing that 28

San Antonio Medicine • August 2018

the disease merited its own institute, Lawitz said he was inspired to launch a liver disease-focused practice.

The Three Pillars

Lawitz said TLI is focused on providing excellent clinical care for patients, providing teaching resources and conducting research and development. “Those are the three pillars of our practice,” he said. “We are different from other (medical practices) because we only do liver disease.” TLI has grown steadily since it was founded and is now a place where many researchers come to conduct trials for Phase II and Phase III drugs. The institute has developed a strong reputation and its doctors regularly publish their work in a number of high-impact academic journals. A lot of the top research into liver diseases that is presented at international conferences is conducted in here, Lawitz adds. TLI’s strong reputation has helped it to recruit some of the best doctors in the field, Lawitz notes. This past year, TLI treated more than 800 patients for Hepatitis C, a common liver ailment. Lawitz said his goal is to bring patients to a healthier state with their livers and maintain a family-friendly atmosphere at all of its clinics.

Community support

TLI currently has three locations, one in San Antonio, one in Cedar Park and another in Austin. Most of TLI’s patients are local or regional, but some have trav-

FEATURE eled from around the world to seek specialized treatment. “We try to support the local community whenever we can,” Lawitz said. “We provide a lot of community education by offering free seminars, symposiums, conferences and talks whenever we can. We also conduct free screening services in the community.” Lawitz said he believes that when you do good work, good things will happen. TLI’s philosophy is to try and treat everyone that comes in its doors, he said. “We don’t want to turn anyone away,” he said. “We will accept any insurance and are willing to work with anyone. We try to stay away from politics and just focus on giving care to the whole community.” Lawitz said TLI does not have any immediate plans for further expansion, but he is open to more growth in the future.

Fatty Liver Disease

The current “epidemic of obesity” in the United States is driving much of the problems with NonAlcoholic Fatty Liver Disease (NAFLD), one of the most common and deadly liver ailments, he said. NAFLD is characterized by an accumulation of fat in the liver. It is known as a ‘silent’ condition because most people have no symptoms and are unaware that they have a problem. If left untreated it can progress into more serious ailments resulting in inflammation and scarring of the liver (cirrhosis). NAFLD currently affects up to 30 percent of the U.S. population. “There are currently no treatments for (NAFLD) and a lot of work is being done in this area,” Lawitz said. There are some emerging therapies that have shown promise, but the best route for most people is to try and avoid the disease altogether by altering their lifestyles. “If people would just change their lifestyles then they wouldn’t need these expensive drugs,” Lawitz said. By eliminating risk factors, people can take control of their own health care. “I can tell patients that I lived in their shoes once,” Lawitz said. “I was forced to reduce my weight through changes in my lifestyle, so I can appreciate the struggles that my patients go through.” If you simply burn more calories than you take in, you can avoid a lot of these problems, he adds. But for those who need additional help, Lawitz says there are emerging therapies that have shown a lot of promise. He is optimistic that there will be effective treatments on the market very soon.

TEXAS LIVER INSTITUTE 607 Camden Street San Antonio, Texas 78215 210-253-3426 www.txliver.com

7 Hepatologists & 9 mid-level Providers Over 100 Staff Members INSURANCE: Accepts Medicare/Medicaid and all insurances. Insured and uninsured patients accepted. Medical liability provider: TMLT visit us at www.bcms.org

FEATURE

Immigrants as Healers: The Role of International Medical Graduates in U.S. Healthcare By Fadi Adel, MD

he candlelight was dancing back and forth on the pages of my book; there was no electricity and the temperature was above 100 degrees Fahrenheit. Every now and then, I would hear the sound of gunfire or an explosion. I would blink and I could still see the candle-lit page. I knew I was still alive and I would resume studying for my exam the next morning. This scenario was the norm as I studied for my twelfth-grade baccalaureate exam on a typical hot and dry June night in Baghdad. It was a rough time to be living in Baghdad and an even harder time to keep dreams alive. Despite the surrounding inconveniences, I did not lose focus on my goals. I survived the war, the heat, and the turmoil of a changing country, and graduated as the top student of my class at The Gifted Students’ School. Then, I was admitted to a competitive six-year medical program at Baghdad College of Medicine. I was thrilled. Finally, I could understand the intricacies of the lub-dub sound I heard when I measured my chronically-hypertensive mother’s blood pressure using my Oncologist father’s old mercury sphygmomanometer (yes, they do still exist in Iraq). However, I was destined to put my future on hold, as my family’s safety was threatened. We had to flee for Damascus, which was safe in 2007, and assume the refugee status.

San Antonio Medicine • August 2018

In Syria, I found myself to be clueless and without a clear path to a bright future. College was expensive. I felt uneasy as I saw my dream fade away. But, soon enough, I picked myself up. I worked as an interpreter for a local tech company, took the SAT and the TOEFL (Test of English as a Second Language), and spent nights at Internet cafés applying for scholarships to come to the U.S. since I didn’t have a personal computer. On a game-changing December night, I was awarded a fully-funded scholarship to study Cell and Molecular Biology at UT-Austin. Now 10 years later, I am a 4thyear medical student at The University of Texas Health San Antonio (UTHSA), headed for residency training in internal medicine, and I cannot be any more thankful for this opportunity. The tortuous path that I took to become a medical student is not uncommon among immigrant physicians who come to this country. They may not all have had to deal with war, but they all had to work extremely hard to become worthy of the privilege of serving the community in the U.S. That work ethic – study hard, work hard, don’t leave a page unturned – is one of the many things immigrant healthcare workers, like myself, and international medical graduates (IMGs) bring to the U.S. health system. “IMGs are diverse. One unifying theme is their strong work ethic,” said Saad Ghumman, MD, a third-year internal medicine resident at UTHSA, heading for

FEATURE

his fellowship in Cardiology at the University of Virginia this summer. “Most of the IMGs are very motivated. They live more than 4,000 miles away from their families, with limited resources. They are tough, and they cherish the opportunity of being here. They are very hard-working and collaborative, which makes them stand out.” Saad is from Lahore, Pakistan, and he completed a 5-year medical program at Shifa College of Medicine in Islamabad. During his last year of medical school, he did four months of clinical electives in the U.S. During that time, Saad discovered how much he liked the U.S. healthcare system, the residents, the way they cared for their patients, and affirmed his passion for clinical research. After graduating from medical school in 2012, Saad spent most of 2013 studying for and taking the USMLE board exams, all while working in his medical school and doing research. At the end of 2013, he took an unpaid research assistant position at Thomas Jefferson College of Medicine in Philadelphia, were he remained until he matched here in March, 2015. Like many immigrants, “I came here to be the best version of myself professionally,” Saad says. Saad cites the immense support in clinical research and superb quality of education to be among the main factors behind wanting to train and practice in the U.S. “The quality of medical education here is excellent. The attendings focus on educating medical students and residents, and they make everyone feel like they’re an integral part of the team.” That opinion is shared by Dr. Jack Badawy, MD, a hospitalist at the University Hospital in San Antonio who also completed his residency training in Internal Medicine at UTHSA. “Medical education and residency training here are well-organized, up-to-date, and residents do feel supported throughout their training.” Born in New York City to an Egyptian-American father and an American mother, Jack left for Egypt at age 7. While there, he would visit the U.S. during the summer. Jack obtained his medical degree at the University of Alexandria-Faculty of Medicine in Alexandria, Egypt, after completing a 6-year in-class medical curriculum and a 1-year inpatient internship in 2011. He then studied for the USMLE board exams while working as a general practitioner for more than a year. Dr. Badawy also did a medical observership in Bethlehem, Pa. Upon finishing his residency training in internal medicine at UTHSA in 2016, he attended a 1-year fellowship in academic medicine at The University of Texas Southwestern (UTSW) Medical Center. In 2017, Dr. Badawy joined the faculty of internists at University Hospital in San Antonio.

Impact on patient care:

Drs. Badawy and Ghumman are examples of IMGs, hard-working physicians who provide excellent patient care and are crucial to the survival of the U.S. healthcare system. In fact, 25 percent of the current U.S. physician workforce is comprised of physicians who completed their medical education overseas. Furthermore, they constitute 35 percent of the primary care physicians, supplying a dire need for such services.1 Additionally, IMGs are more likely than their American Medical Graduates (AMGs) to practice in underserved areas.2 They do that because they believe the opportunity given to them in this country is priceless. According to Norcini et al, an analysis of nearly 250,000 congestive heart failure and acute myocardial infarction hospitalizations revealed an interesting finding: the mortality rate was lower among patients cared for by IMGs and AMGs who were non-U.S. citizens at the time of entering medical school than among patients whose doctors were U.S.-medical school graduates or U.S. citizens who received their degrees overseas.3 This study was not a fluke. Indeed, a more recent observational study published in the British Medical Journal last year found that patients treated by IMGs, despite having more chronic conditions on average, had a lower 30-day mortality rate than patients treated by AMGs.4 Furthermore, Drs. Ghumman and Badawy believe that IMGs contribute in unique ways to patient care. “In addition to contributing to the diversity of the resident body, one other advantage IMGs bring is their open-mindedness and their tolerance of patients of all backgrounds,” says Dr. Badawy. “Also, by practicing medicine in a develcontinued on page 32

visit us at www.bcms.org

FEATURE continued from page 31

oping country, you become very aware of the accessibility to healthcare. When you prescribe a medication, you think about the barriers to the patients and whether he or she will be able to afford it.” Dr. Ghumman also believes that living in different environments “makes you more tolerant of other ways of life and it enhances you as a person.” He adds, “When I was in Pakistan, I saw many patients with Leishmaniasis. That was why I was able to pick it up quickly when I saw one patient here with this disease.”

Impact on medical education:

Furthermore, the unique backgrounds of IMGs allows them to contribute significantly to medical education. Among the U.S. academic physicians, 18 percent were IMGs, and they hold 15 percent of the full-time medicine professorships.5 Dr. Badawy theorizes that studying in a resource-limited educational setting overseas trained him to think of innovative ways to solve problems. During his intern year at UTHSA, Dr. Badawy identified a problem: “In general, interns, including myself, did not feel prepared for a lot of the common things you see in the hospital, such as doing med reconciliations, putting orders in the EMR, or how to make outpatient appointments, especially at the beginning.” Therefore, he cofounded the Helping Interns Train (HIT) Team in order to aid interns in transitioning from being medical students to physicians. The HIT team has, indeed, proven to be a hit among UTHSA in32

San Antonio Medicine • August 2018

ternal medicine interns and it remains an integral part of the residency program here. After obtaining his master’s in medical education, Dr. Badawy ultimately intends to create a medical education platform that can be accessed online worldwide for free; a platform that uses up-to-date materials and cutting-edge learning techniques that would benefit students here and internationally and “help level the playing field” among all medical students. Like Dr. Badawy, Dr. Ghumman has been an active educator during his residency training, giving back to his colleagues and medical students. Dr. Ghumman relishes in teaching, and he dedicates whatever free time he has to teaching medical students who happen to rotate with him, in addition to teaching pre-clinical students how to excel on Step 1. On a regular basis, he participates in the third-year medical student bedside physical exam teaching sessions, one of his many strong suits. “Having trained in Pakistan with limited diagnostic tools, we learned how to maximize the physical exam for diagnostic purposes,” Saad states. Saad’s passion for teaching also prompted him to regularly lead mock megacodes for residents at the Veteran Affairs Hospital in San Antonio. For my part, I cannot imagine myself practicing medicine outside an academic center. Before starting medical school, I tutored individual pre-med students in sciences and for the MCAT. During medical school, I tutored other medical students in physiology, biochemistry, and pharmacology. I also taught medical biochemistry to continued on page 34

FEATURE continued from page 32

a class of pre-med students during the summer of 2015. Being an immigrant allowed me to form a special bond with the refugee patients at the San Antonio Refugee Health Clinic, where I served as one of the medical student leaders. My service there allowed me to notice an improvement in my clinical skills as a pre-clinical medical student. Therefore, I launched a research project to assess the impact of volunteering on medical students. Today, using empirical evidence, I strongly advocate the integration of the Student-Faculty Collaborative Practices (SFCP) into the formal medical curriculum.

Impact on Biomedical Research:

IMGs were responsible for 18 percent of all U.S. publications in biomedical research. Twelve percent of NIH-funded grants went to IMGs, and they led 18.5 percent of all clinical trials in the U.S.5 Dr. Badawy studied the variation in recorded respiratory rates in hospitalized adults during his fellowship at UTSW. His published piece of work resulted in important considerations for the clinical assessments of critically-ill patients.6 Dr. Ghumman assessed the contrast-induced acute kidney injury in peripheral angiography patients, which resulted in an important published work.7 Saad plans to continue clinical cardiology research during his fellowship and beyond, a goal I share with him. During my undergraduate years, I discovered my passion for basic research and volunteered in a cell biology lab at UT Austin, where I studied clathrin-mediated endocytosis. After graduating in 2012, I 34

San Antonio Medicine • August 2018

found myself unable to attend medical school since I was not a permanent resident. Therefore, I joined a microbiology lab and worked on a Mycoplasma pneumoniae toxin, a research project that was published, too.8 As I started medical school in 2014, I became involved in a community needs-based assessment for the local LGBT community. Our study findings showed a dire need for compassionate health services, which we were able to translate into the Pride Community Clinic last year, now another SFCP.

Restricting immigration and IMGs:

Dr. Badawy, Dr. Ghumman, and myself are merely individual examples of what immigrants bring to the U.S. healthcare system in patient care, education, and biomedical research. However, under the current political climate, immigrants feel more restricted and their contributions may suffer. “Most of my foreign colleagues would not want to travel back to their home countries to visit their families nowadays. They worked so hard to get here and they wouldn’t want to take any risks,” Saad says, referring to the potential complications of re-entry to the U.S. now. Even if the rhetoric does not translate to actual policies, “it still feels mentally exhausting.” I could not agree more. While it is customary for 4th-year medical students to travel internationally before starting residency, I find myself hesitant to go visit my brother in Australia even though I am a permanent resident of the U.S. “Restricting IMGs may have a negative impact since they fill a large gap of healthcare access in the U.S.,” adds Dr. Badawy. “IMGs also bring their experiences and unique sets of skills that are invaluable to residency programs and the patient populations.” Immigrants come to this country seeking a better life, willing to work their hearts out to succeed. We believe that the U.S. is truly the land of opportunities. For those of us who make it here, we feel extremely fortunate, we cherish the opportunity, and we take nothing for granted. “I feel extremely grateful for being supported throughout my residency and beyond. I’ve learned so much, and I’ve found myself spontaneously engaged in making a positive change whether large or small. They really push you to be the best version of yourself,” says Dr. Badawy. “It is a sacrifice to live away from family, but I am very grateful for this opportunity. This country is unique, and it allows you to maximize your potential,” says Saad jubilantly. He added, “I wouldn’t have become the physician that I am if I didn’t come here. I would do it all over again.” I certainly would, too. Fadi Adel, MD a graduate of the Long School of Medicine at UT Health San Antonio. He began his internal medicine residency in July 2018 at the Mayo Clinic School of Graduate Medical Education in Rochester, Minn.

FEATURE

References:

1. Chen PGC, Nunez-Smith M, Bernheim SM, Berg D, Gozu A, Curry LA. Professional Experiences of International Medical Graduates Practicing Primary Care in the United States. J Gen Intern Med. 2010; 25(9):947â€“53. DOI: 10.1007/s11606-0101401-2. 2. Ranasinghe PD. International Medical Graduates in the US Physician Workforce. J Am Osteopath Assoc. 2015; 115(4):236241. doi:10.7556/jaoa.2015.047.

3. Norcini JJ, Boulet JR, Dauphinee WD, Opalek A, Krantz ID, Anderson ST. Evaluating The Quality Of Care Provided By Graduates Of International Medical Schools. Health Affairs. 2010; 29(8): 1461-1468.

4. Tsugawa Y, Jena AB, Orav J, Jha AK. Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study. BMJ.2017;356:j273 | doi: 10.1136/bmj.j273. 5. Khuller D, Blumenthal DM, Olenski AR, Jena AB. U.S. Immigration Policy and American Medical Research: The Scientific

Contributions of Foreign Medical Graduates. Ann of Internal Med. 2017; 167(8): 584-587.

6. Badawy J, Nguyen OK, Clark C, et al Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults BMJ Qual Saf 2017;26:832-836.

7. Ghumman SS1, Weinerman J1, Khan A1, Cheema MS1, Garcia M1, Levin D1, Suri R2, Prasad A1. Contrast induced-acute kidney injury following peripheral angiography with carbon dioxide versus iodinated contrast media: A meta-analysis and systematic review of current literature. Catheter Cardiovasc Interv. 2017 May 2. PMID: 28463460

8. Somarajan SR, Al-Asadi F, Ramasamy K, Pandranki L, Baseman JB, Kannan TR. Annexin A2 Mediates Mycoplasma pneumoniae Community-Acquired Respiratory Distress Syndrome Toxin Binding to Eukaryotic Cells. mBio. 2014;5(4):e01497-14. doi:10.1128/mBio.01497-14.

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us. ACCOUNTING FIRMS Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ASSET MANAGEMENT

Avid Wealth Partners (HHH Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and well-served by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

San Antonio Medicine • August 2018

ATTORNEYS

Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence. Mark R. Flora Partner and Office Head 512-382-8800 mflora@constangy.com William E. Hammel Partner 214-646-8625 whammel@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice.

Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

210-377-4580 kmoczygemba@thorntonfirm.com https://thorntonfirm.com “Protecting Physicians and Their Practices”

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”

U.S. Trust ( Gold Sponsor) At U.S. Trust, we have a long and rich history of helping clients achieve their own unique objectives. Since 1853, we've been committed to listening, building long-term relationships, and helping individuals and their families realize the opportunities they create for themselves, their children, businesses, communities and future generations. SVP, Private Client Advisor, Certified Wealth Strategist® Christian R. Escamilla 210.865.0287 christian.escamilla@ustrust.com “Life’s better when we’re connected®”

Thornton, Biechlin, Reynolds, & Guerra (HHH Gold Sponsor) Worried about the TMB, government audit, or investigation? From how to avoid TMB complaints to navigating the complex regulations of government agencies like Medicare and Medicaid, we stand ready to guide and protect our clients. Robert R. Biechlin, Jr. Partner (210) 581-0275 rbiechlin@thorntonfirm.com Michael H. Wallis Partner (210) 581-0294 mwallis@thorntonfirm.com Kevin Moczygemba Associate

ASSETS ADVISORS/ PRIVATE BANKING

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”

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Stephanie Dick, Vice PresidentCommercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Mary Mahlie Global Wealth Management 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com “Working for a better future”

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans. Sam Fisher Vice President/Commercial Lender 210-319-3503 samf@ozonabank.com www.ozonabank.com

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the

state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com

RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more. Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org

DIAGNOSTIC IMAGING Touchstone Medical Imaging (HH Silver Sponsor) Touchstone Medical Imaging provides a wide range of imaging services in a comfortable, service oriented outpatient environment while utilizing state of the art equipment, the most qualified radiologists and superior customer service. Patrick Kocurek Area Marketing Manager 210-614-0600 x5047 patrick.kocurek@touchstoneimaging.com www.touchstoneimaging.com/ locations " We provide peace of mind, giving compassionate care to our community with integrity"

EMPLOYEE MANAGEMENT Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals. Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!” First National 1870, a division of Sunflower Bank, N.A. (HH Silver Sponsor) First National 1870 is a regional community bank dedicated to building long-term relationships founded on sound principles and trust. Jamie Gutierrez Business Banking Officer 210-961-7107 (Direct) Jamie.Gutierrez@firstnational1870 .com www.FirstNational1870.com “Creating Possibility For Your Medical Practice”

BUSINESS CONSULTING Alto Vista Enterprises, LLC (HH Silver Sponsor) We specialize in helping physicians grow their business according to the goals and timeline of the practice. Customized business development strategies are executed by an experienced and dedicated team of consultants. Michal Waechter, Owner (210) 913-4871 MichalWaechter@gmail.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

Beyond (HHH Gold Sponsor) Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire employee life cycle. From online onboarding to certification tracking to payroll processing, manage your people anytime, anywhere. Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"

FINANCIAL ADVISOR

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

FINANCIAL SERVICES

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance. Leslie Barnett SWBC Mortgage lbarnett@swbc.com Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Cleo Garza SWBC Mortgage 210-386-0732 cleogarza@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Avid Wealth Partners ( Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's ommitted to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP, CIMA, AEP, CLU, CRPS Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to

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achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Beyond ( Gold Sponsor) Beyond is a financial technology company offering a suite of business tools including payment processing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference. Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"

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

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning). Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org

San Antonio Medicine • August 2018

The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank. Carol Mani Johnston Senior Vice President – Wealth Management Senior Portfolio Manager 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney." Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small businesses and partnered with multiple financial institutions, to assist with financing of building acquisitions, construction projects, and machinery and equipment loans. Cheryl Pyle Business Development Officer – San Antonio & South Texas 830-708-2445 CherylPyle@CapitalCDC.com www.capitalcdc.com “Long-term, fixed-rate financing for owner-occupied commercial real estate.”

HEALTHCARE BANKING

Amegy Bank of Texas ( Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith

Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HEALTHCARE CONSULTING

Digital Telehealth Solutions (HHH Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program. Dr. Jorge Arango CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

HEALTHCARE TECHNOLOGY RubiconMD (HH Silver Sponsor) RubiconMD enables primary care providers to quickly and easily discuss their e-Consults with top specialists so they can provide better care - improving the patient experience and reducing costs Shang Wang Business Development (845) 709-2719 shang@rubiconmd.com Cyprian Kibuka VP of Business Development (650) 454-9604 cyprian@rubiconmd.com www.rubiconmd.com “Expert Insights. Better Care."

HOSPITALS/ HEALTHCARE SERVICES

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with

disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

INFORMATION AND TECHNOLOGIES

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

INSURANCE/MEDICAL MALPRACTICE

“Improving Patient outcomes and lower unnecessary 30-day readmissions” The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair. Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET TELECOMMUNICATIONS 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

Digital Telehealth Solutions ( Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program. Dr. Jorge Arango, CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com

LUXURY REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients. Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

MEDICAL BUSINESS CONSULTING

MEDICAL BILLING AND COLLECTIONS SERVICES

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations. Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice." Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”

PHYSICIAN SERVICES

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practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance. Leslie Barnett SWBC Mortgage lbarnett@swbc.com Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Cleo Garza SWBC Mortgage 210-386-0732 cleogarza@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

PRIVATE EQUITY

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation. Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator

San Antonio Medicine • August 2018

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. Tina Turnipseed President Tom Tidwell President-Elect info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

RESIDENTIAL REAL ESTATE

(210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

STAFFING SERVICES

MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"

TOXICOLOGY LABORATORY TESTING Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley, Branch Director 210-301-4362 bwhitley@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.” United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients

Diagnostic Solutions, LLC (HHH Gold Sponsor) Partnering with Diagnostic Solutions allows providers to incorporate the industry’s best practices into drug compliance testing and clinical decision-making with accurate and timely results for UDT quantitation and identification. Jana Raschbaum, MBA, BSN, RN 210-478-6633 janelleraschbaum@gmail.com Donald Nelson, MD 928-529-5110 dhnelson@citilink.net www.trustedtox.com For questions regarding services, Circle of Friends sponsors or Joining our program. Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html

THE BEXAR COUNTY MEDICAL SOCIETY CIRCLE OF FRIENDS PROGRAM Grow your business by supporting our Physicians and the Medical Community. The Circle of Friends (COF) is a program design for companies and organization like yours that would like to reach out to our 5000+ membership and our medical community with your products and services. Through our program, we have helped many businesses grow in our medical community. In addition, your charitable donations made as sponsors in the Circle of Friends program help fund programs and events that are important to our Community's health and the physicians that serve it.

To join or for more information please contact: The director of development August Charles Trevino 210-301-4366

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA

Renal Associates of San Antonio, PA San Antonio Eye Center, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of July 25, 2018.

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

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

We will locate the vehicle at the best price, right down to the color and equipment. We will put you in touch with exactly the right person at the dealership to handle your transaction. We will arrange for a test drive at your home or office. We make the buying process easy! When you go to the dealership, speak only with the representative indicated by BCMS. GUNN AUTO GROUP

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Rudy Solis 210-558-1500

Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX

GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

Bill Boyd 210-859-2719

GUNN AUTO GROUP

GUNN Honda 14610 IH 10 W San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209

Eric Schwartz 210-680-3371

Coby Allen 210-625-4988

Abe Novy 210-496-0806

Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Gary Holdgraf 210-862-9769

Marty Martinez 210-525-9800

William Taylor 210-366-9600

James Godkin 830-981-6000

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX

North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211

Scott Brothers 210-253-3300

North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257

13660 IH-10 West (@UTSA Blvd.) San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Barrett Jaguar 15423 IH-10 West San Antonio, TX

Sandy Small 210-341-8841

James Cole 800-611-0176

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Victor Zapata 210-341-2800

15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org

visit us at www.bcms.org

AUTO REVIEW

2018 Land Rover Discovery By Stephen Schutz, MD After following tradition for 24 years, the 2018 Land Rover Discovery has moved decisively into the SUV mainstream, and for some purists that’s a problem. The biggest change is a switch from the previous Discovery’s steel body-on-frame platform to a unibody structure infused with as much aluminum as possible. While the new structure saves hundreds of pounds, and is shared by the Discovery’s up market cousins, the Range Rover and Range Rover Sport, it diminishes the Discovery’s off-road credibility in some minds. As the Discovery went through its first two generations, it maintained a distinctly utilitarian personality: think driving off-road to your favorite fishing hole, tossing your fish and gear in back when you’re done, and then hosing out the inside once you’re back home. In its third and fourth generations, the Discovery, inexplicably called the LR3 and LR4 in the U.S., became much more of a soccer mom mobile than double-track denizen despite maintaining its prodigious off-road abilities. That trend accelerated with the all new fifth generation Discovery, which really amps up the luxury. (For the record, the newest Discovery maintains its prodigious off-road abilities, though it relies more on software and less on traditional 444

San Antonio Medicine • August 2018

wheel drive tricks like locking hubs, fixed axles, and the aforementioned body-on-frame structure.) Whatever, the Discovery emphasizes on-road comfort over rock crawling because that’s what customers want, and I was impressed by how smoothly the Discovery rides even on rough roads. Historically, Land Rover has maintained separation between Range Rover and non-Range Rover models, and in many important ways they still do, but when it comes to ride quality, there’s not much of a difference. The cabin is also whisper quiet, even with the diesel my test vehicle had. Part of the credit for the Discovery’s quiet interior experience goes to the all-new, and very aerodynamic, exterior design. While the previous four generations of Discoveries looked like the box they came in, the fifth gen model is surprisingly rounded. In fact, it’s not wrong to call it pretty, and for a vehicle with such a “truckish” reputation I wonder if current owners will avoid the newest Discovery because it lacks the visual toughness they expect. Anyway, inside the cabin, the whole luxury SUV thing continues. The materials are first rate, and the sense you get from behind the wheel is of a luxury SUV with a British accent. Which has some

AUTO REVIEW

quirks by the way: The window controls sit at the top of the inner doors rather than lower down, the volume knob for the stereo is on the right side of the center stack, presumably because in the UK cars are right hand drive, and the Discovery retains the (kinda hokey) rotary gearshift knob that rises from the center console when you start the engine. Nevertheless, the inside of the 2018 Land Rover Discovery is a very pleasant place in which to spend time. Jaguar Land Rover’s infotainment has been improved in this its most updated iteration, but I still found it lagging behind the industry benchmark Audi. For example, entering a point of interest into the (touch activated) system is a hit or miss affair, and I found the voice recognition system to be limited and difficult to operate. Things are much better than they were in the LR4, but there’s still work to be done. (That’s true in other areas as well: Land Rover is below average in the most recent JD Power initial quality survey.) As noted above, my test vehicle came with a 3.0 liter V6 turbo diesel engine coupled with an 8-speed automatic transmission, and that is the combination I would recommend. The torquey diesel had no trouble moving the 5,586 lbs Land Rover around with dispatch, even when merging onto the freeway or passing, and there’s the notincidental fact that the diesel gets you 21 MPG city/26 highway. Despite my diesel enthusiasm, most Discoveries will be ordered with the 340 HP supercharged 3.0 liter gasoline powered V6. Predictably, there is a fuel economy penalty with that engine (16 MPG city/21 highway.) Of the three trim levels — SE, HSE, and HSE Luxury — the HSE, which adds tasty features like gorgeous 20-inch wheels, keyless

go, panoramic sunroof, 380-watt Meridian premium audio with 11 speakers, and 12-way adjustable front seats with driver memory settings, will be selected by most buyers. The 7-Seat package, which includes a third row of seats and an electronically controlled air suspension is also likely to be popular. I would select that package for the air suspension alone, which adds significantly to the Discovery’s ride quality. Average transaction prices for Discoveries are likely to be in the mid- to high-$60,000 range, but a fully optioned Discovery can reach $80,000, which is Range Rover territory. Land Rover provides a complimentary two-hour off-road driving course to all buyers of new Discovery models. I took that course two years ago at their Carmel, Calif. location and learned a tremendous amount about Land Rover’s off-road capabilities (as well as how to drive off-road). The 2018 Land Rover Discovery moves decisively into the luxury mainstream with a more aerodynamic (and stylish) body as well as unibody construction. It rides better than it used to and provides a more comfortable driving experience too. Purists may howl in frustration, but given strong sales I don’t see Land Rover turning back. If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 45 45 visit us us at at www.bcms.org

San Antonio Medicine â€˘ August 2018