San Antonio Medicine September 2018 by Traveling Blender

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SEPTEMBER 2018

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VOLUME 71 NO. 9

MEDICINE SAN ANTONIO

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

Architecture & Design

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SEPTEMBER 2018

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VOLUME 71 NO. 9

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Editor: Mike W. Thomas Email: Mike.Thomas@bcms.org

The State and The Art in Healthcare

By Carlos N. Moreno, AIA ..............................................12

Art and Architecture

By Furkan Torlak, MBS ..................................................16

Innovations in Healthcare Design

Keeping up with the Jetsons? Get Smart!

MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org

BCMS President’s Message........................................................................................................................8

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BCMS Legislative News ............................................................................................................................10 BCMS News ............................................................................................................................................11 Feature: Polio: Once the Scourge of Summer By Marvin Forland, MD, MACP ...........................................26 Feature: The Swarm, Part 1 of 4, By Allen Cosnow, DVM..........................................................................30 Practice Groups: Urology San Antonio, P.A., By Mike W. Thomas .............................................................32 Business: Managing Operating Room Distractions By Kirsten Baze, RPLU, ARM......................................34 BCMS Circle of Friends Directory ..............................................................................................................36 In the Driver’s Seat ....................................................................................................................................42 Auto Review: 2018 Volvo S90 By Steve Schutz, MD ...............................................................................44

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San Antonio Medicine • September 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&#x20AC;˘ September 2018

PRESIDENT’S MESSAGE

EFFECTIVE COMMUNICATION BETWEEN PATIENTS AND PHYSICIANS IS ESSENTIAL TODAY By Sheldon Gross, MD, 2018 BCMS President

Dear Colleagues,

For this month’s issue of San Antonio Medicine, I would like to discuss the importance of physician communication in medicine. This is one of those statements that sounds obvious. One does not require an M.D. to understand the importance of physicians effectively communicating with each other. As medical students, most of us were taught rules regarding when not to communicate. Certainly, one does not discuss relevant patient information on an elevator when others cannot help but listen to what is being said. Physician discussions have to occur privately and in settings in which patient confidentiality can be protected. We have all learned that it is crucial to know who we are allowed to communicate with. This is especially true in pediatrics. Communicating a patient’s personal health information to someone who does not have legal custody or legal permission can be not only inappropriate but possibly illegal. Physicians can be placed in a very precarious medical legal position if they release information to the wrong person. Having discussed who not to communicate with, it is probably more important to discuss how physicians need to communicate. I am familiar with multiple malpractice lawsuits that could have all been avoided by either physicians communicating with each other more effectively or communicating with the patient or the patient’s family. We now have access to text messaging, emails, and any number of other means of communicating electronically. I would suggest that in certain instances, none of this takes the place of a phone call and person to person discussions. In my practice, I have made a point as a consultant to personally contact by telephone a referring doctor if there is a major development with one of their patients. Should an MRI scan reveal a brain tumor or should someone require hospitalization, I do not rely on text messaging or having my secretary call their secretary. I have also found that when referring doctors receive this type of direct phone call from me they are not irritated by an interruption in their busy schedule. In fact, they are typically very grateful that I would take the time to call them and notify them of serious developments. I am very concerned that too many physicians, particularly younger physicians, feel that a text message or email is the equivalent of a live discussion between two people on the telephone or in person. It is not the same. I do not always have my cellphone with me. There is sometimes a delay in checking my emails. Despite how far we have come from a technology standpoint, live discussion is still the gold standard. Regretfully, getting someone on the telephone is not as easy as it used to be. We are typically met with telephone recordings with a various menu of different options. I have had the unpleasant experience of being forced to leave a message on a recording when I desperately needed to speak with a physician at that moment. I would state that it is the responsibility of all physicians to be certain that they can be reached by other physicians in emergency situations. It is a physician’s responsibility to ensure that another physician is not required to leave a message on a recording or have his secretary contact someone else’s secretary. This is not only bad medicine but is potentially liti8

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gious medicine. We spend so much time as physicians learning how to effectively communicate with our patients. After 35 years of private practice, I am still learning how to effectively communicate with my patients. I would like to ask how much time do physicians spend learning how to effectively communicate with other physicians? The answer is amazingly little time, and I think this could be at times as important or even more important than communicating with individual patients. It seems that part of a physician’s formal training should include how to communicate with other doctors. When is a note in the chart adequate and when is a telephone call required? None of us like to be interrupted by telephone calls while we are seeing patients or otherwise involved in our practice. However, when a secretary states that Dr. Smith is on the phone and it is an emergency, all of us should be willing to drop what we are doing and speak with Dr. Smith. Our patients depend on us and assume that we will communicate effectively with the appropriate physicians involved. That is as much a part of our responsibility as prescribing the correct dosage of any drug or ordering the appropriate imaging study. This means communicating with physicians that we like and work with routinely. It also means communicating with physicians that we may not know or possibly even dislike with the same degree of responsibility and urgency. There have been books, studies, and models of healthcare tried for years in an attempt to save money and have more efficient and quality healthcare. Something very basic has been overlooked. I have no doubt that enhanced physician communication would provide better and less expensive care without the need for new technology or new models of healthcare. In my case as a child neurologist, it is not unusual for one of my patients to arrive in an outlying emergency room with breakthrough seizures. Many of these patients will be immediately sent for imaging studies. These patients may have already had multiple imaging studies in the past which have all been normal. A phone call to my office would clarify that and obviate the need for many expensive procedures. I am sure that this is true in every specialty. I would invite any reader who knows of a specific example of how enhanced physician communication can improve healthcare and lessen cost to please put that in writing and send it to the Bexar County Medical Society. A telephone call depends on technology that has been around for many years. I would stress the importance of physicians trying to develop ways of increasing healthcare efficiency. If we abdicate that responsibility, it is inevitable that health plans and insurance companies will only take more draconian roles in making decisions for us. As always, I welcome any response from those who agree or disagree with my comments. I wish to welcome those physicians new to San Antonio, whether in training or in practice. Bexar County Medical Society would like to invite you to become active participants and offer any suggestions to enhance our relevance to membership. Sincerely, SHELDON GROSS, MD President, Bexar County Medical Society

BCMS LEGISLATIVE NEWS

Blue Cross HMO Emergency Payment Review Policy Begins By Steve Levine, TMA Vice President – Communications Blue Cross Blue and Shield of Texas (BCBSTX) will require some members to pay 100 percent of their medical bills if they go to an out-of-network emergency room for certain non-life-threatening conditions, company officials have confirmed. BCBSTX announced the policy for its fully insured group and retail HMO members in April, drawing criticism from numerous medical organizations, including the Texas Medical Association (TMA), as well as the Texas Department of Insurance (TDI). “We are disappointed that Blue Cross is moving ahead with this policy,” said TMA President Douglas Curran, MD. “Unfortunately, even the announcement of this plan has already planted a seed in patients’ minds that they’ll be left with a big bill if they go to the emergency room for the ‘wrong reason.’ We encourage TDI to join us in monitoring this closely to make sure no patients are denied necessary care.” Dr. Curran asks TMA member physicians to report any specific cases to the TMA Hassle Factor Log. Robert Morrow, MD, BCBSTX Southeast Texas market president, told Texas Medicine Today the new policy is a response to “a continual escalation of emergency room costs due to multiple factors including billing for services that were not performed or not medically necessary, inaccurate billings, inappropriate ER use, excessive and unconscionable charges for routine services, and the proliferation of out-of-network freestanding emergency rooms.” Therefore, Dr. Morrow said, the company feels “a need to verify the accuracy and legitimacy of the services that our members receive and are potentially billed for by emergency facilities.” In a mid-May letter, TMA and 18 state specialty societies asked Insurance Commissioner Kent Sullivan whether the BCBSTX policy runs afoul of the state’s “prudent layperson standard,” which shields patients from having to self-diagnose emergencies. Dr. Morrow said BCBSTX will “review each medical record so that we’re taking into account the symptoms that caused the need for the visit.” He said the company will “pend — not deny” a claim

while it is under review. BCBSTX’s decision coincides with a related lawsuit the Texas Association of Health Plans (TAHP) filed against TDI. The suit challenges TDI rules that require HMOs and EPOs to hold their enrollees harmless for out-of-network emergency care and require insurers to pay, at a minimum, the “usual or customary charge” for emergency care to physicians and providers who are out of network in a patient’s PPO health plan. "This lawsuit is another health plan tactic to avoid paying for the out-of-network emergency coverage that our patients bought" with their policies, Dr. Curran said. "Rather than filing a suit that seeks to undermine critical TDI patient protection rules, we encourage all of the plans to develop adequate emergency care networks and to pay for non-emergent after-hours care, including via telemedicine, from patients’ primary care physicians.” BCBSTX originally planned to implement the HMO policy June 4, but delayed the start to today to answer questions posed by state insurance regulators “while continuing to educate our members on the importance of appropriately using emergency services.” In late May, TDI Associate Commissioner for Consumer Protection Melissa Hield asked for answers to six questions about the new policy, why it was proposed, how it will work, and patients’, physicians’, and providers’ appeal rights. According to BCBSTX’s response to TDI and Dr. Morrow, emergency room claims reviews will be done by a licensed physician. In addition: • Any claims denials would come only after a review of medical records by a BCBSTX medical director; • When the medical director is contemplating a denial, the physician or provider will be offered a peer-to-peer conversation; • Consumers will be able to appeal if the claim is denied as not medically necessary. This would include an appeal to an independent review organization.

For local discussion on this and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

San Antonio Medicine • September 2018

BCMS NEWS

WE NEED YOUR HELP

TO ENSURE A HEALTHY FUTURE FOR CHILDREN IN TEXAS The state of Texas has participated in the Federal Vaccines for Children Program (VFC) since its inception in 1994. Our version of this program is called Texas Vaccines for Children Program (TVFC). The program was initiated by the passage of the Omnibus Budget Reconciliation Act of 1993. This legislation guaranteed that vaccines would be available at no cost to providers in order to immunize eligible children (birth – 18 years of age). Texas leads the nation in the number of uninsured and underinsured children. We also have more than three million Texas children on Medicaid (Federal Fiscal Year 2018 data). Many of these children are not receiving the complete series of immunizations required to protect them from vaccine-preventable diseases. Today, more than 9,000 Texas providers in more than 3,000 clinics are enrolled in TVFC. We invite you to join them by enrolling. By enrolling in TVFC, you can provide innumerable benefits to families in your practice and to the people of Texas. One of the most important benefits is removing barriers to immunizations; for example, you will no longer have to refer an uninsured child to a public health clinic for immunizations. TVFC removes the burden of the financial cost of vaccines, thereby eliminating the need to refer clients. Children are then kept in their “medical home,” which is beneficial to the provider and client. Families who are currently paying for vaccinations may be TVFC eligible. Vaccines are supplied to enrolled clinics at no cost. A TVFC-enrolled clinic may not charge for the vaccine, but is permitted to charge an administration fee. An additional benefit of joining the TVFC program is the ability to bill clients for an administration fee for non-Medicaid/non-CHIP patients. Staff at a TVFC-enrolled site also receive free training and education and have access to an automated vaccine ordering and reporting system. They also receive support from the Texas Department of State Health Services (DSHS) Immunization Unit staff and the City of San Antonio Health Department. Providers continue to serve the same populations they have always served. Except now, through enrollment in the TVFC, more children will be receiving their complete series of immunizations. This benefits everyone by maintaining a higher level of immunity in our community. TVFC automatically covers all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Centers for Disease Control and Prevention (CDC). A fully immunized society is necessary to reach optimum eradication of vaccinepreventable infectious diseases. With your help we can reach these goals, leading to a healthier Texas.

If you are not enrolled in TVFC, please consider doing so. The process is simple: • complete online policy and practice training • receive free technical assistance • fill out a Provider Agreement • agree to screen for eligibility • agree to maintain screening records, and agree to maintain vaccine safety and inventory. Under TVFC, children (birth – 18 years of age) in these groups should receive free vaccines: • Medicaid eligible • Does not have health insurance • Is American Indian or Alaskan native • Enrolled in the Children’s Health Insurance Program (CHIP) and the provider bills CHIP for the services • Is underinsured: has commercial (private) health insurance, but does not cover vaccines; health insurance only covers select vaccines (TVFC eligible for noncovered vaccines only) Questions? To contact DSHS: (800) 252-9152 or email TVFCenrollment@dshs.texas.gov

To contact San Antonio Metropolitan Health District: TVFC Program (210) 207-3965 Every Dose Matters. With your help, we can eradicate vaccine-preventable diseases. Enroll now. Call (800) 252-9152 TVFCenrollment@dshs.texas.gov Resources • TVFC information for providers: http://dshs.texas.gov/immunize/tvfc/info-for-providers.aspx Includes a TVFC Provider Manual which can be found by clicking on the “Forms & Publications” link in the left menu. • TVFC website: dshs.texas.gov/immunize/tvfc • Immunization forms and literature: https://secure.ImmunizeTexasOrderForm.com • Immunization website: ImmunizeTexas.com • ImmTrac2, the Texas Immunization Registry: ImmTrac.com Consolidates patients’ immunization records in one centralized electronic system and provides online access to patients’ immunization histories. visit us at www.bcms.org

ARCHITECTURE & DESIGN

Highlighting the Practice of Design within the Practice of Medicine By Carlos N. Moreno, AIA

Health and the Built Environment: Bringing Delight into Design

Vitruvius, the 1st Century Roman Architect, taught that all architecture must inhabit the following three attributes: Comfort, Commodity and Delight. How simple, yet how challenging. 30 years ago, my introduction to healthcare architecture began. It remains an exciting and evolving experience. In the beginning, though, it involved climbing the steep curve on issues relating to infection control, the application of healthcare regulations and building codes, while also addressing the needs of my client’s objectives for efficient space programming, medical equipment, operational and financial goals. Amazingly, the notion, or presence of “design”, was rarely a driving force within the conversations with my clients. “Where was Vitruvius?” “When do we move from Commodity to Comfort and Delight?!” As an architect, the topic of design is always part of the equation. However, it became quickly apparent that it was not an integral part of my client’s formula for a successful and holistic project. Why was 12

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this the case? How could the process be further navigated to see the trifecta become complete? It turned out the answer was always present: not all consumers are patients, but everyone is certainly a consumer of design.

Evidence of improved Health via Design : Aesthetics and impact on Health

Through the eyes of patients I met during a POE (Post-Occupancy Evaluation) on a med-surge floor, it was readily apparent that the newly designed environment was more than a byproduct of a strong operational space program and a code compliant assembly of materials. It was a tangible and experiential environment that became part of the patient’s daily routine and ultimately became part of what they found to be helpful in the overall improvement of their health. This med-surge floor became an extension of who they were, in addition to what their families recognized as a “transitional home” for their loved-ones. With this experience and all others since then, the following man-

ARCHITECTURE & DESIGN

Emergency Department Expansion / Metropolitan Methodist Hospital/ San Antonio, Texas (THW Design San Antonio)

date was established: Within the economy of the built-environment for healthcare, all of us (Physicians and Designers) are called to show how well we understand the requirement for commodity, in addition to uplifting the basic human need for both comfort and delight. Such an application of principles is no less required on the interior than it is on the exterior of our facilities. If done well and with sensitivity to the patient and visitor, the “optics” stemming from the experience should evoke a deep measure of confidence in the level of care to be received. And, size has little to do with this success factor. It is all about the “physical, visual and

Emergency Department Expansion / Reception / Interior Metropolitan Methodist Hospital/ San Antonio, Texas (THW Design San Antonio)

mental contact” introduced via the mind, the body and the spirit of place. Worthy of note, this also applies to technology.

continued on page 14

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ARCHITECTURE & DESIGN continued from page 13

Rural Health Clinic Expansion / Medina Regional Health System / San Antonio, Texas (THW Design San Antonio)

Access to holistic design via the art of medical technology

From medical equipment to security, the technology is constantly evolving. The “art of engineering” has taken hold in the technology being installed within today’s healthcare facilities. It has even become a sculptural expression. This trend needs to continue. The elements of design aesthetics are part of our daily lives. Within healthcare, these elements become objects of focus. Whether a medical gas column or the backbone to a cardiovascular telemetry system, these objects are essential to the art and science of medicine. They are the perfect opportunity for the expression of ART in the engineering of medical technology as a further means to enhance the experience. A simple example of this is when each of us has been to an appointment with our PCP (Primary Care Physician). While in the exam room, think about what you recall viewing and studying: exam room cabinetry, sink, implements, sharps container, stool, exam table. All these items are the tools of healthcare. The question to be asked is: what is their application to the appreciation for design within this very personal environment? If it did not meet the element of “delight,” it could have. In another example, in the design of a new Interventional Radiology Lab, virtually every aspect of the patient experience is considered via the enhancement of visual display platforms, lighting, temperature and almost “Star Trek-like” features in every system to be installed. 14

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Interventional Radiology Lab / Metropolitan Methodist Hospital / San Antonio, Texas (THW Design San Antonio)

The driving common denominator in this is that the designer can make every effort to employ sensitivity to the varied levels of experience to be had by the patient, the family member and the physician. Such a deliberate and intentional act of practice is no longer an option. It can be done. It must be done. I believe Vitruvius would agree. Carlos N. Moreno, AIA is Healthcare Divison Leader and Managing Director of THW Design San Antonio.

Art Architecture ARCHITECTURE & DESIGN

University Hospital’s Innovative Approach to Art, Healing and Sustainability By Furkan Torlak, MBS The 10 story Sky Tower of University Hospital opened its doors to patients and families alike in April of 2014. Designed by the coordinated efforts of three architectural firms, University Hospital is a testament to modern architecture and its role in human health. From an architectural standpoint, the University Hospital Sky Tower expansion is a textbook piece of modern architectural design. The designers of the building were clearly inspired by the ever-growing number of modernist buildings around the world, whose initial inspiration all comes from the Bauhaus school in Germany. Architects like Walter Gropius and Frank UHS Sky Tower at dusk. Photo courtesy of Zachary Construction Corp, one of the firms that helped Lloyd Wright pioneered the modernist archibuild the new hospital addition. tectural movement, and now the combination But what happens when the patient of steel, glass, and concrete has become symbolic of professionwalks inside? alism, industry, and the power of human development over the Interior design is an ever-growing discipline that’s meant to appeal chaos of nature. University Hospital’s sleek, steel exterior instills to the eye and navigate it around to prevent a sense of boredom patients with the confidence that they will be receiving the best with a space. Nothing is more important than the feeling you get quality of care. when you enter the hospital lobby for the first time. At Sky Tower, Human society revolves around the ability to make impulse judgeyou immediately notice the bright white of the flooring that reflects ments. Perhaps this stems from an evolutionary need to evade danthe sun’s rays that shine through the all glass exterior of the building. ger, but has given birth to modern-day marketing. We are constantly The high ceilings and scaling artwork by Ed Carpenter, known as comparing, constantly assessing and constantly making decisions. Foxglove, creates a wonderful feeling of tons of open space. The Although some of these are conscious processes, many of our inillusion of open space can sometimes be even more powerful than stinctual decisions fly under the radar in our subconscious thought. the actual reality of it as the space creates a question with which We have been geared to like the clean and the new. one desires an answer. It captivates. Aside from the feelings of space The modernist take on architecture creates a refined, geometric and brightness, a hospital needs to provide areas that stimulate reexterior so pleasing to the human psyche that the building markets flection and serenity. itself. It does not tickle the eye with free-flowing forms or medieval Maintaining mental health and psychological wellbeing also respires. After all, a hospital is no place for whimsy or nonsense, it is quires areas for relaxation and indulging the imagination. For this, a place for the serious business of human healing. The ideals for a patients can experience the one-acre green space expansion known good hospital need to be summed up and sold to the patient before as the “Jardin,” or one of two rooftop gardens. Patients also have they make it through the door. For our local University Hospital, the opportunity to explore all of the amazing art showcased around the new building has been a powerful investment into the brand the new hospital expansion. that is University Health System. 16

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ARCHITECTURE & DESIGN Studies have shown that visual art in hospitals provides major benefits to the wellbeing and improvement of care for both patients and employees. Unbeknownst to most, the University Hospital expansion houses over 1,200 pieces of artwork from over 275 artists representing eight countries. The hospital expansion is part of University Health System’s Design Enhancement and Public Art Program: the largest in the city of San Antonio with a budget of $6 million. One would not often expect a hospital on the cutting edge of healthcare to also be a storehouse for such a large collection of art work.

References

Pearson, Brita. A Prescription for Art: Healing at the new Sky Tower at University Hospital

https://perkinswill.com/news/prescription-art-healingnew-sky-tower-university-hospital Photos: Top — Main lobby with a view of artist Ed Carpenter’s Foxglove which is an scaling, abstract representation of Digitalis the heart medication. Bottom — Lobby view from the opposite side with a view of the wall piece titled Hippocrates.

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ARCHITECTURE & DESIGN

Innovations

In Healthcare Design

Architecture Keeping Pace with Medicine By David Alex Schulz, CHP Healthcare delivery sites are challenged to evolve as quickly as the applied science they host. From the time Joseph Lister’s sterile surgery inspired the Johnson Brothers to invent aseptic surgical equipment, medicine enjoyed a century and a half of constant change based on research. Has the architecture and design of healthcare delivery kept pace with accelerated changes in science? We spoke with two noted San Antonio healthcare architects: Jason Puchot, Principal at RVK Architects and current President of the American Institute of Architects San Antonio Chapter, and whose practice has a focus exclusively on healthcare design; and Tiffany Robinson Long, Associate Partner at Marmon Mok Architecture serving healthcare clients and the chair of AIA’s Healthcare Knowledge Community. “Health and wellness architecture definitely plays by a strict set of rules,” began Long. “You have to consider daily life-or-death scenarios, the constant need to have impenetrable and sterilized surfaces, or the endless rotation of patients with varying medical conditions.” As a result, hospitals often have the reputation of 18

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being uncomfortable, confusing, or scary as durability and practicality have traditionally eclipsed comfort. Now, the time has come for health and wellness design to exist in harmony with functionality, efficiency, and aesthetics; when they do, remarkable results occur. Take the Mays Cancer Treatment Center at UT Health San Antonio, one of Long’s projects. Twenty years ago, infusion centers were essentially large, open rooms with recliners all lined up so the staff could observe. Instead, “We took a family-centered approach, providing patients more space and flexibility to turn their treatment chairs to look out the floor-to-ceiling windows and enjoy the nature and city that surrounds them. There are also comfortable accommodations for family and friends to be with the patients to keep them company during treatments and engage in the recovery process.” With the Center’s maxim, “We're here for you long after treatment ends,” the design features a second floor with a teaching kitchen, living room space, resource library, and a very inviting

ARCHITECTURE & DESIGN environment for Gentle Yoga, Tai Chi, and ways to build a support system. Family members are also welcome to join and learn, Long notes. Research and experiential evidence is key to modern design, as is observation: “Research has shown that patients respond better to natural environments. In response, we designed a space where furniture could rotate to look outside. In our focus groups, when the staff set them up, they were all facing the middle of the room, and the patients inevitably rotated to look outside. “Incorporating the notion of biophilia into design is proven to also lower stress levels and promote healing. So much is needed to combat stress and promote comfort and convenience. Now we’re at the point where sufficient research and data have accumulated to prove that design helps patients feel better and heal better,” says Long.

“Just as important, well-designed environments also help the doctors and nurses deal with stressful situations and help them feel comfortable in the space they’re essentially living in.” Adopting Biophilic features in healthcare architecture, reconnecting patients with nature and the world outdoors, has evidence-proven impact at practices large and small. RVK’s design for Heying Orthodontics incorporated these principles; by client request, “They wanted the site’s natural setting to be preserved as much as possible, so the architecture had to respond to the existing trees and site, as well as include a playground, as most of the patients are children.”

continued on page 20 visit us at www.bcms.org

ARCHITECTURE & DESIGN continued from page 19

The design achieves a minimal footprint, respects the existing vegetation and characteristics, and incorporates an assembly of natural materials. As with the Mays Center, openness is a design imperative. “Large windows in the lobby and operatory areas afforded parents the ability to watch their kids from the inside lobby, as well as offer beautiful views for the patient and staff during treatment,” says Puchot. Despite the greater investment, private healthcare providers actively seek innovative approaches to delivery design, assures Puchot: “With fee for service going away, consumer driven healthcare requires improving the quality of healthcare delivery.” Rapid changes in technology are having their own impact. “Technology certainly keeps healthcare on its toes, especially when it comes to design,” continues Puchot, “the technology footprint always needs to be accommodated into the infrastructure.” The challenge is not to lose the human being in the midst of tech-centric medicine. “Wireless handhelds and touchpads are now allowing more face-to-face interaction with the patient, rather than a patient talking while the caregiver types away on a computer on the wall.” 20

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“A recent project RVK completed, the Gonzaba Medical Group Northwest Clinic, integrated wall-mounted touchscreens so that caregivers could pull up charts and anatomy photos to help explain a diagnosis,” says Puchot. Understanding the impact of design on therapy keeps architects in a mode of lifelong learning. In the design of the new Veterans Affairs Polytrauma Healthcare/Rehabilitation Center, “We had to learn a lot about traumatic brain injuries, how they mani-

ARCHITECTURE & DESIGN

fest,” says Long of Marmon Mok. “For example, lighting can trigger headaches, and must be considered. Many of the patients watch their feet when they walk, so we have striping on the floor next to the patient rooms for wayfinding.” Designed for Wounded Warriors with multiple traumatic injuries, this facility includes a new 84,000 GSF, three-story, state-of-the-art rehab facility with inpatient rooms, multipurpose rehab space, physical medicine, rehabilitation service, and prosthetic service. Says Long, “It’s one of perhaps five in the country; it’s a project in which we all take great pride … designing in San Antonio, we are always aware of our military community, and it’s a privilege and honor to serve men and women from all over the country.” Dynamic dialog between stakeholders and designers is the key to building not only for today, but for many tomorrows as well. Puchot described a recently completed project, the new Methodist Healthcare Ministries Dixon Clinic on the southeast side. “The objective was to bring the healthcare services to the people they serve,” says Puchot. “The stakeholders implemented

a true collaborative-care model which contributed to the final design. This collaboration resulted in each exam room designed to provide an entry on one side for the patients and an entry on the opposite wall for the caregiver, entering from a shared workspace where all caregivers can act as a team. “This is a change from the standard three-exam-room and one-physician-office layout that we are accustomed to. This new layout leads to efficiencies allowing patients to stay in one room and get treated by multiple caregivers during the same appointment. It was also designed for flexibility, the larger patient rooms allowing for examination, treatment or counseling, depending on the patient’s needs,” concludes Puchot. David Schulz, community member of the BCMS Communication Committee, writes about accelerated technological change and its implications on how we live, work, and navigate a complex world. A Certified HIPAA and Information Privacy Professional, he’d like to remind everyone to lock their phones and change passwords regularly. visit us at www.bcms.org

ARCHITECTURE & DESIGN

Keeping up with the Jetsons?

Get smart! Your career has a trajectory that could be tracked by NASA, but is your home keeping up with your needs?

San Antonio Medicine • September 2018

By Bjorn Dybdahl

The talk of your social circles is the smart home, or what used to be called home automation. It’s revolutionizing our lives by streamlining our lifestyles and lowering our utility costs.

What makes a home “smart?”

Everybody has wiring to the patio, the best television and home theaters, and a high-tech security system, Smart home automation is the next step and can start with a single, easy-to-understand home theater remote control that replaces the usual three or four, one of which is usually lost. Advancing one easy phase beyond your home theater, it can also dim the lighting, lower the shades, and adjust your thermostat’s temperature! Monitor your home from anywhere using your phone or tablet with cameras placed strategically on the front porch, driveway and anywhere

ARCHITECTURE & DESIGN

else you feel that you need to keep a watchful eye inside your home. Close the garage door, lock your doors and set the security system, all at your convenience and location. The ability to monitor lifestyle and health issues is here, easy and affordable. Imagine having your heart rate, blood pressure and calories burned monitored just by pressing a button, and even the ability to contact your doctor or emergency help. How many lives will be saved with smart home features? Itâ&#x20AC;&#x2122;s easy to be the smartest home on the block with Control 4, Harmony Pro, URC, and Josh AI, the top innovative smart home solutions that offer one room to whole house solutions. Connecting to almost all smart home systems and devices, they offer as much or little control as you want and streamline the smart home lifestyle to fit your needs. If youâ&#x20AC;&#x2122;ve considered hiring a butler or full-time help, Josh AI, voice-controlled artificial intelligence smart home system, is just for you. This little multitasker can follow a string of commands, like open the garage door, set the thermostat and turn on Pandora to

continued on page 24 visit us at www.bcms.org

ARCHITECTURE & DESIGN continued from page 23

welcome you to your private oasis from the pressures of daily life. Itâ&#x20AC;&#x2122;s all controlled with advanced speech recognition, and it will even understand your unique accent. The next step in upgrading your home to the smartest house on the block would be to connect with a knowledgeable, experienced and trustworthy provider that offers both home automation and installation so it is a seamless process. Another key aspect to having a smart home is adding a reliable remote management system. A remote management system is a software program that will troubleshoot any problems and monitor your system to ensure there is no down time and costly repairs. Again, a reputable full service company will offer all the products and services to get you started and on the road to peace and relaxation. The lifestyles of Captain Kirk, George Jetson and even the tools of Dr. Spock are at our disposal today. Connect your life with Josh AI, Control 4, Harmony Pro or URC and be the early adopter in your neighborhood! 24

San Antonio Medicine â&#x20AC;˘ September 2018

FEATURE

POLIO: Once the Scourge of Summer By Marvin Forland, MD, MACP

or those of us of a certain age, children of the 1930’s through mid-50’s, the joys of school summer vacations were overcast by a sinister pall. Our parents’ anxieties about the insidious illness that could attack suddenly in the summer were communicated all too well to us. We knew the disease could strike overnight and result in paralysis, and breathing impairment that might require the dreaded “iron lung”. It could even cause death. Prevention meant avoiding the ballpark, public swimming pool or the pre-television treat of a movie matinee. The well-known consequences it had on the life of the nation’s leader through many years of that era, Franklin Delano Roosevelt, were an on-going reminder of the dangers of the disease. Since those fearful childhood summer months, my adult experience with polio now covers over six decades. Fast forward to the past mid- twentieth century when one of my closest college friends was a fellow pre-med student. He was from Brooklyn and, in addition to being an academic stand-out, he had been named an “All New York City” second baseman in his senior year of high school. During the summer before his expected admission to college, polio struck. After a strenuous year of rehabilitation, he entered college using leg braces and crutches, an impairment similar in extent to FDR. He got around campus with an Oldsmobile equipped with hand controls, but his success was propelled by a facile intellect, unswerving focus and an intense desire to become a physician. He was Salutatorian of our class and one of its most widely admired members. We went on to the same medical school and he did not miss a beat, even accomplishing the requisite number of newborn deliveries from a sterilely draped wheel chair. He mused that retractor holding at long surgeries was easier for him than us. Supported by his locked braces, he leaned on the table and avoided getting leg weary. He would later become the “go-to” radiologist in Staten Island for diagnostic dilemmas and a pioneer in invasive radiology. In mid-April, 1955, toward the end of our first year in medical

San Antonio Medicine • September 2018

SALK POLIO VACCINE

school, the two of us returned to our residence hall in the late afternoon, our clothes still redolent with the acrid odor of formaldehyde from our long hours in the dissection laboratory. Passing through the lobby, we saw a mass of students gathered around the lounge television set. A senior student excitedly told us the news. The results of the field trials of the Salk vaccine were just announced in Ann Arbor. Polio would soon become a disease of the past. I looked at my friend and thought how narrowly he missed the benefits of this discovery that would have changed his life. Move forward again to the mid-80’s. I was directing a medical residency program at a time when we found ourselves confronted with a new plague. This was more selective in occurrence, but thought to be transmissible by body fluid exposure. Its cause was unknown and there was no specific therapy. In confronting AIDS, anxiety for personal safety was coupled with a sense of professional impotence. “Why did this occur when I’ve just become a physician?” was a frequent lament I heard from our house officers. I would point out that doctors incurring personal risk were nothing

FEATURE

new. We could look back to the medieval scourge of the plague, or the influenza pandemic of 1918, or tuberculosis. Three of my fellow interns contracted tuberculosis. I remembered that two San Antonio physicians had succumbed to polio in the mid-century epidemics. The anxieties of AIDS lessened with time. The young doctors learned a lesson well known to doctors of the horse and buggy era: that the mediation of a comfortable and dignified death for the patient and support of his loved ones was an important service; one could “heal” even when there was no cure. The

Robert B. Green Memorial Hospital where he served as chairman of the medical service. A diagnosis of polio was quickly made and he was placed in an iron lung to assist his failing respiration – but to no avail. He died in the early morning of August 15th. This was a family tragedy compounded. Two weeks earlier his 32-year-old sister and her 4-year-old son had succumbed to polio. The sister’s twin and her son also simultaneously developed polio but recovered. The sisters and their children had spent two weeks in July at a rural summer retreat in Concan, Texas where Dr. Hargis visited

with polio in his Pulitzer Prize winning book, Polio: An American Story, I was motivated to try to unearth the account of those two young doctors. I sequestered myself through a series of afternoons in the Genealogy section of the San Antonio Public Library and scrolled microfilms of issue after issue of the San Antonio Light and San Antonio News of that period, seeking their coverage of polio. My first observations provided local confirmation of how variable and unpredictable the disease was, usually far overshadowed numerically by many other infectious problems. In 1948, San Antonio experienced one polio death, while 194 children succumbed to infantile diarrhea and 292 adults and children to tuberculosis. However, 1949 provided a different experience for San Antonio and the nation. On Aug. 13, 36-year-old Dr. W. Huard Hargis, Jr. experienced a marked resurgence of the malaise and fatigue which had troubled him for several days. He was taken to the

checks of southward bound Americans to control the disease’s spread. A concerned community supported a piano recital to raise funds for the March of Dimes. Movie theatres held collections for victims under the rubric “Texas takes care of its own.” In what was described as the worst American polio epidemic since 1916, San Antonio lost 14 of its 166 reported patients and some 42,000 cases were counted nationally. The 1950 polio season was greeted with optimism. In early May, the San Antonio Department of Health director approved public picnics and the initial case report rate was far behind the previous year. On the morning of April 11th, 35-year-old Dr. J.D. Frederick Matthews became acutely ill in his office. He was taken to near-by Santa Rosa Hospital where a diagnosis of polio was made. Dr. Matthews was later transferred to the Green for iron lung placement, but again to no avail. On May 11th he became the year’s first

causative agent was identified as HIV and increasingly effective therapies continue to be introduced. HIV and AIDS management are now well-integrated into the health care structure in our country, in contrast to its continued rampage through too many of the developing nations. Through the years I often wondered about the two San Antonio physicians who succumbed to polio. I heard stories of the summers when an entire floor of the original county hospital, the Robert B. Green Memorial Hospital, would be filled with patients in iron lungs, cared for by a few dedicated nurses and aides, all under the supervision of volunteer physicians. Reading University of Texas Professor David Oshinsky’s masterful recounting of our country’s experience

for one day. This young physician had all the qualifications for inclusion in what was later to be termed “the Greatest Generation.” A graduate of UT Austin and the Medical Branch at Galveston, he trained in internal medicine at the University of Iowa and the Mayo Foundation. He then served in the U.S. Army Medical Corps for five years in the Pacific Theater, rising to the rank of Lt. Colonel. Upon discharge he opened his practice in internal medicine in San Antonio, an experience limited to less than four years. He was survived by his wife and five children. The number of polio cases mounted rapidly through the summer of 1949. The recently reopened R.B. Green Memorial Hospital reserved 44 beds for polio patients. The Mexican government-initiated border

continued on page 28

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FEATURE continued from page 27

polio death of a San Antonian. His life experience closely parallels Dr. Hargis; he attended the UT Austin and St. Mary’s University and graduated from the Baylor University College of Medicine in Dallas. Dr. Matthews trained at St. Paul’s Hospital in Dallas and the Green. He then served as a major in the U.S. Army Medical Corps in South America and returned to San Antonio to enter private practice. He was survived by his wife and daughter. Subsequently the case reports accelerated through the summer to reach 118 patients. It seems likely these two promising young physicians on the thresholds of their careers were exposed to the disease in the course of their professional duties and service at the newly reopened County Hospital. We know that the virus spreads like wildfire, and for many, the illness is no more than a cold, upset stomach or fever. No doubt they each saw one or more patients carrying the polio virus. Both vividly demonstrate our shared vulnerabilities, but also underline the remarkable contributions of medical progress. The summer outbreaks continued through 1955, when

San Antonio Medicine • September 2018

the Salk vaccine was introduced. New cases of polio were halved the following year and fell progressively as polio immunization became a routine procedure. After 1980, scarcely a dozen cases per year were reported nationally, primarily as a rare consequence of the altered virus used in the oral Sabine vaccine. Consequently in 2000, the Center for Communicable Diseases recommended use of the injected, killed vaccine, effectively eliminating the disease in our country. The San Antonio and American polio narratives have receded to history. Attention to this period was again heightened in 2010 by Philip Roth’s riveting novel, Nemesis, concerning the polio epidemic which swept my birthplace, Newark, New Jersey, in the summer of 1944. Our stories capture the tragedy of unchecked polio in the pre-vaccine era. They recall the heroism and sacrifice of people at the front line. Ultimately the stories are a testament to science prevailing and concluding a chapter in American medicine on a triumphant note.

FEATURE

The Swarm

Part 1 of 4

By Allen Cosnow, DVM

here is a part of the life of honey bees that evokes fear in many people: the swarm. The very word can be frightening to those who aren't familiar with this phenomenon, but for those of us who know the bees, this natural way that their colony reproduces by dividing is a biological marvel, an almost mystical occurrence. Although there is still much that remains not well understood about all the intricacies, I will describe what happens when a colony swarms. During the winter the queen doesn't lay eggs, and the workers don't leave the hive (or the natural cavity if it is a wild colony). Many workers die, and the population decreases, sometimes to a very low level. Then as the days begin to grow longer in late winter, the queen recommences her egg-laying, slowly at first because the workers have only one source of protein--the pollen that remains in the hive from the previous year--to feed to her for egg production and to the new larvae for growth and development. But in late March (in our latitude) the weather becomes a little warmer, giving the workers the opportunity to fly out to gather and bring back the fresh pollen that becomes available from certain species of maples and willows, from crocus in gardens, and from other kinds of early-flowering plants. Now the egg-laying

San Antonio Medicine â&#x20AC;˘ September 2018

can continue at a more rapid rate--and even more rapid in April, when there is a large diversity of spring plants blooming. By May the queen, in a good year, is laying eggs 24 hours a day. Then a new and abundant source of protein-rich pollen appears from fruit trees such as the crabapples that grow all over our suburbs. The hive is already crowded, but the pollen continues to be brought in, and the queen continues her egg-laying at a more and more intensive rate. A thousand, even twelve hundred new worker bees emerge from their cells every day. The hive often becomes crowded to the point that there isn't enough room inside for all of them, so after dark, when none of them are out flying to work on flowers and all are "at home," many have to spend the night gathered on the outside walls of the hive. At this overpopulated stage the colony must divide, and it becomes intent on swarming. To be continuedâ&#x20AC;Ś

Allen Cosnow, D.V.M. is a retired small animal veterinarian who keeps his several bee colonies on a city lot in Glencoe, Il, a lake-shore suburb of Chicago. He is a veterinary school classmate of Fred H. Olin, D.V.M., M.D.

PRACTICE GROUPS

Urology San Antonio, P.A. By Mike W. Thomas

the end of 2018, the care giving teams at Urology San Antonio will have provided almost 200,000 patient visits, analyzed data from over 26,000 patient surveys, and implemented programs which measure not only patient satisfaction but also patient outcomes around more than 40 clinical pathways. Urology San Antonio was founded in 1976 and currently has 28 physicians, eight advanced practice providers, two pelvic floor physical therapists, and over 230 other clinical and non-clinical care givers. The practice is also preparing to add another five physicians in 2018. With nine sites of care including seven geographically-dispersed clinics, a radiation therapy cancer center, an ambulatory surgery center, a catheter division, a pharmacy, and a robust clinical research division, Urology San Antonio addresses the full range of a patientsâ&#x20AC;&#x2122; urological needs.

San Antonio Medicine â&#x20AC;˘ September 2018

At the forefront of urologic health, the group was one of only five groups permitted to launch the revolutionary Rezum Procedure for benign prostatic hyperplasia (BPH) and one of the first in the market with Fusion Biopsy which utilizes multiparametric MRI images overlaying ultrasound images to more precisely diagnose prostate cancer, which permits more informed decisions around active surveillance and/or treatment. While all of the urologists in the group treat general urology patients, many sub-specialize in areas such as robotic prostatectomies, renal cancer / transplants, overactive bladder, BPH, and bladder cancer. With three female urologists on staff, two more having recently joined and another set to join in 2018, Urology San Antonio offers more female urology practicioners than any other group in South Texas and more than most in the whole nation. Urology San Antonio specialists also include radiation oncology, radiology, and

PRACTICE GROUPS pathology with bladder and prostate cancer tissues being read inhouse by a urologic pathologist. Clayton H. Hudnall, MD serves as the group’s president and works with a physician-elected governing board of five physicians and an administrative team to provide inpatient service at all five Baptist, all five Methodist, and the Christus Santa Rosa Westover Hills hospitals. “Delivering excellent patient care and service requires an attention to metric-driven details in the present, a culture of compassion, and a focused vision for the future,” Hudnall said. Urology San Antonio participates in most commercial insurance plans, accepts Medicare patients, treats Medicaid patients from in and around San Antonio, and is part of both capitated and fee-forservice insurance plans inside and outside of the ACO models. Currently, it is transitioning to a new Electronic Health Record platform which provides robust clinical analytics to further integrate nationally-recognized clinical protocols. With 270 employees, the group offers a full range of employee benefits including health, life, disability, and retirement benefits. TMLT remains as its professional liability insurer.

About Urology San Antonio Clayton H. Hudnall, M.D. – President Alan D. Winkler, MHSA, FACMPE – Executive Director (Alan.Winkler@UrologySA.com) Web-Site: www.urologysanantonio.com Referral / Call Center: (210) 614-4544 or info@urologysa.com Administrative Contact: (210) 731-2050

visit us at www.bcms.org

BUSINESS

Managing Operating Room Distractions By Kirsten Baze, RPLU, ARM

an operating room (OR), patient safety can be compromised when surgical team members are distracted. Diligent concentration, vigilance, and clear communication are paramount in completing the intricate and complex tasks required in surgery. However, noise — a significant distraction in the OR — is a given in this setting. Sources of noise in an OR include medical equipment devices (e.g., monitors, clinical alarms, and other alerts), fixed communication devices (e.g., overhead announcements and landline telephones), environmental devices (e.g., HVAC systems and pneumatic tube systems), electronic activities by OR staff (e.g., texting, internet browsing, etc.), and healthcare personnel entering and leaving the room. The most commonly cited distractions in the OR are conversa-

San Antonio Medicine • September 2018

tions unrelated to the surgical procedure, telephone calls, technology use, and music.(1) These noises can lead to ineffective communication; diminished signal and speech intelligibility; poor performance of complex tasks; poor cognitive function and concentration; and stress, fatigue, and anxiety.(2) The concept of the “sterile cockpit,” which mandates elimination of nonessential activities during aircraft takeoffs and landings, can be applied in the OR. Protocols similar to the sterile cockpit can be created to ensure the least amount of noise and distractions occur during critical periods of the surgical procedure.(3) Some examples of critical times during surgery include the induction and emergence of anesthesia, clipping of an intracranial aneurysm, and initiation of cardiopulmonary bypass.

BUSINESS To mitigate the effects that distractions in the OR may cause, this publication offers strategies to keep focused attention on the patient and maintain a safer surgical environment. 1. Use a sound level meter or a dosimeter to determine whether the OR has a noise problem. The Environmental Protection Agency’s recommended level for continuous background noise in hospitals is 45 decibels, which can still interfere with concentration. However, a study measuring noise levels in OR trauma found an average level of almost double the recommended level.(4) 2.

4. 5.

8. 9.

Create a no-interruption zone where nonessential conversation and activities are prohibited during the critical phases of the surgical procedure.

Use fixed communication devices (such as overhead pages and announcements as well as landline telephones) only for essential communication, and ensure that they operate on the lowest volume available. Control/limit the amount of healthcare personnel entering and exiting the OR during surgery to minimize interruptions.

Review and comply with the facility’s guidelines and/or policies regarding the use of personal electronic devices in the OR. If guidelines don’t exist, devise specific policies about technology use in the OR.

Require healthcare staff members to place personal communication and electronic music devices on vibrate or silent mode during surgery. If possible, have them turn off the devices or leave them in another room. If staff do bring mobile communication devices into the OR, have them silence ring tones and forward calls to voicemail. Minimize tones on personal technology devices that sound similar to monitors and alarms in the OR.

Consider limiting OR internet access only to patient-care-related websites to avoid discretionary browsing.

Educate all surgical team members about the sources of noise in the OR and how they affect patient and staff safety.

10. Provide training to enhance OR staff members’ focused attention in the presence of noise — both continuous and intermittent — and other distractions.

11. Consider simulation training to model specific strategies for reducing noise (such as equipment use, communication techniques, and speaking up to reduce noise). 12. Foster a culture of safety in which staff feel empowered and comfortable to speak up and ask for silence.

13. Consider the OR’s physical environment and what can be done

to lessen noise. For example, advise healthcare staff to place metal instruments onto trays as quietly as possible.

14. Avoid loud or distracting music in the OR.

Resources

• Distractions in the Operating Room: An Anesthesia Professional’s Liability? (Anesthesia Patient Safety Foundation) • Minimizing Noise and Distractions in the OR and Procedural Units (The Joint Commission) • Minimizing OR Noise and Distractions (OR Today) • Statement on Distractions in the Operating Room (American College of Surgeons) Ms. Baze is the AVP – Market Manager Southwest Division for MedPro. She can be reached at Office: 512-774-5487, Cell: 512-658-0262, Fax: 844-293-6355, Kirsten.Baze@medpro.com, www.medpro.com, 9600 Escarpment Blvd., Ste 745, PMB 30, Austin, TX 78749 www.bcms.org 35 35 visitvisit us us at at www.bcms.org

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

ACCOUNTING SOFTWARE

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

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 • September 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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visit us at www.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

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"

New York Life Insurance Company (HHH Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace. Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332

San Antonio Medicine • September 2018

rlgarcia@ft.newyorklife.com Efrain Mares Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY sional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology” Y&L Consulting (HH Silver Sponsor) We are an IT Consulting company that specializes in Software Managed Delivery, Business Process Outsourcing Managed Services, IT Staff Augmentation, Digital and Social Media with experience in the Medical industry. David Stich Senior VP of Strategic Partnerships 210-569-3328, David.stich@ylconsulting.com Marisu Frausto Account Executive 210-363-4139, Marisu.frausto@ylconsulting.com www.ylconsulting.com/ “Your success is our success.”

“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

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

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

oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com

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

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

LUXURY REAL ESTATE

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

MEDICAL BUSINESS CONSULTING

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations. Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

MEDICAL BILLING AND COLLECTIONS SERVICES

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

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 to 50 percent.”

PHYSICIAN 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

San Antonio Medicine • September 2018

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 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

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

RESIDENTIAL REAL ESTATE

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley, Branch Director 210-301-4362 bwhitley@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.” United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"

TOXICOLOGY LABORATORY TESTING

RETIREMENT PLANNING

New York Life Insurance Company ( Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace. Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares, Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

Diagnostic Solutions, LLC (HHH Gold Sponsor) Partnering with Diagnostic Solutions allows providers to incorporate the industry’s best practices into drug compliance testing and clinical decision-making with accurate and timely results for UDT quantitation and identification. Jana Raschbaum, MBA, BSN, RN 210-478-6633 janelleraschbaum@gmail.com Donald Nelson, MD 928-529-5110 dhnelson@citilink.net www.trustedtox.com

For questions regarding services, Circle of Friends sponsors or Joining our program. Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html

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

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

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

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 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 Volvo S90 By Stephen Schutz, MD In 2010, Zhejiang Geely Holding Group (better known as Geely Motors) purchased Volvo Cars Inc. from Ford Motor Co. for $1.8 billion. It was the first major automotive purchase by a Chinese company, and it has turned out to be very good for car buyers — the vehicles being turned out by Geely/Volvo are far superior to those produced by Ford/Volvo. And the Swedish carmaker is now solidly profitable. Amusingly, when Geely’s chairman, Li Shufu, first met with Ford’s CFO at the 2008 Detroit auto show, he wasn’t taken seriously as a potential buyer. But as the two talked and Li convinced the Ford executive that he was serious, a deal took shape, and in 2010 Ford sold Volvo to a company very few Americans (or Swedes) had ever heard of. It was a good deal all around. Ford got $1.8 billion for a moneylosing division, and Geely gained a valuable global brand with potential. And wow has Volvo realized its potential. Eight years after Geely paid to both buy Volvo and then finance an expensive reboot of its entire product lineup, the automaker from Gothenburg reported earnings of almost $2 billion in 2017. And Volvo is expected to be even more profitable this year. How did Geely succeed where 44

San Antonio Medicine • September 2018

Ford failed? Instead of sending an army of administrators to Volvo to “help” as Ford did, Geely was hands-off with their new Swedish friends and basically said, “Do your thing, and we’ll pay for it.” A quick cold shower: yes, Geely-financed Volvos are increasingly popular, especially in China, and the XC90, XC60, and XC40 crossovers are selling very well in the U.S. But, at least here in this country, Volvo has been goosing their numbers with a lot of fleet sales to rental car companies. Anyway, I recently drove a new Volvo S90 sedan for a week. It was everything I expected it to be: quiet, luxurious, Scandinavian, and very good. Before I discuss the S90 though, another cold shower: in the first seven months of 2018, Volvo sold about 42,000 XC models (XC40, 60, and 90) compared with just over 6,000 90-series sedans and wagons. Crossovers rule the roost now, and sedans/wagons are likely to continue to fade for the foreseeable future. While the S90 sedan is based on the same platform as the XC90 crossover, it has a lower center of gravity and tuned suspension settings to optimize handling and therefore drives better. Nevertheless,

AUTO REVIEW

piloting the S90 is, not surprisingly, a lot like driving a lower and lighter XC90, which is to say, not as good as driving a Mercedes EClass or Audi A6. Naturally, the design of the S90 is very different from the XC90. Long, low, and wide, the S90 is reminiscent of those classic late 1960s Pontiac Grand Prixs we all remember from print ads. And I appreciate that Volvo designers decided that less is more and stuck with a simple, sleek, and modern sedan shape. The new S90 looks good from any angle. The same goes for the interior, which is very contemporary and undeniably attractive. Most infotainment functions are controlled via an intuitive touch screen, which, unlike other brands actually works well. Volvo left a few redundant buttons and knobs anyway as a time saver, but I found myself rarely needing them as swiping up, down, or sideways usually got me what I wanted. Volvo’s user interface is the closest thing I’ve seen (in a car) to an iPad. After about five years of saying that Audi’s MMI is the best user interface in the world, I’m officially handing the baton to Volvo. They are now the industry standard, in my opinion. (For the record, since they don’t provide press cars I haven’t yet tried Tesla’s touchscreen, but I can’t imagine their system is any better than Volvo’s.) The S80’s seating is also first rate. Chinese executives are generally

driven around by chauffeurs, so I expected the rear seats to be comfortable, and they were. But Volvo made sure the driver and front seat passengers were also well taken care of. Oh, by the way, Volvo seats have been industry benchmarks for decades, and thankfully Geely didn’t mess that up. I loved every minute I spent sitting in the S90’s wonderful seats. Many options and option packages can be had in the S90, as is the case with every luxury vehicle. As always, I recommend calling BCMS’ own Phil Hornbeak before you buy any new or used vehicle. Volvo cars is in a good place right now thanks to their surprisingly successful purchase by Geely Motors. Their product portfolio is better than it’s ever been, and the new S90 is proof. As the Chinese car market continues to expand and mature, I expect more good things from Volvo. 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

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 August 24, 2018. 46

San Antonio Medicine â&#x20AC;˘ September 2018