Roshan George, Raudel Guerra and Joshua Kuehne

from San Antonio Medicine September 2021

By Alice K. Gong, MD

Changing Life Trajectories with Positive Intelligence

By Charles Campbell, Jessica Glossop, Roshan George, Raudel Guerra and Joshua Kuehne

The effects of the COVID-19 pandemic restrictions impacted more than just the capacity of Bexar County health systems and the local economy. For our most vulnerable and at-risk adolescent populations, the restrictions amplified pre-existing social inequalities and led to increased incidences of distress, anxiety and depression as a result of the mandated internal displacement and social isolation imposed on our youth.1 Without question, the psychological and mental health impacts of the COVID-19 pandemic will have lasting effects on Bexar County youth with regard to educational and career goals. To mitigate these negative effects, an ambitious team of medical students at the UIW School of Osteopathic Medicine (UIWSOM) partnered with Southwest Independent School District (SWISD) through a community engagement partnership (CEP) project and developed an educational video series to provide high school juniors and seniors positive intelligence and mindfulness training. Dr. Leticia Vargas, the team’s lead advisor, made it clear that "if something isn't done to change the life trajectory of these high school students, their ability to take advantage of opportunities for meaningful careers will be limited. Teaching them the value of positive intelligence is one way to help alter their trajectory and bring them closer to their educational and career goals." The Positive Intelligence (PQ) training is based on the book Positive Intelligence by Shirzad Chamine. It is the science and practice of developing mastery over your own mind so you can reach your full potential for both happiness and success. PQ is based around an understanding of saboteurs, the agents of self-sabotage, that represent your brain's automatic habits used to handle life’s challenges. There are ten saboteurs (harmful, innate stress-coping mechanisms) that include the Judge, Controller, Avoider, Victim, Stickler, Pleaser, Hyper-Achiever, Hyper-Vigilant, Restless and Hyper-Rational. Through weakening of the saboteurs and development of one’s sages (beneficial positive emotions) - activate, explore, innovate, navigate and empathy - a person can increase their positive intelligence score, which can lead to increased success and happiness.2 The PQ series’ adaptability for a younger audience was the primary reason it was selected as the model for the CEP.

The CEP targeted underserved and disadvantaged high school juniors and seniors in SWISD. The majority of the student body are Hispanic with 74.6% of students coming from economically disadvantaged backgrounds.3 In addition, the majority of students at this school are classified as “at risk” for dropping out of school based upon criteria established at the state level. When it comes to college readiness, the students are achieving SAT and ACT scores that are below the statewide average.

The COVID-19 mandated restrictions caused students to struggle with learning, impacting their ability to reach their academic achievement goals. This project sought to teach students skills to foster a mindset that promotes greater achievement while learning to address mindsets that may limit their growth. Without intervention, it was hypothesized that some students may continue down a path that would prevent them from achieving their full potential. Therefore, the project was developed with the intentions of challenging the student’s mindset, along with their habits, so they can achieve their highest potential and continue to grow.

Valerie Gutierrez, the SWISD Health Science Department Lead, aided the team in targeting a population of approximately 90 students, all of whom are dually enrolled in the school’s medical assistant certification program. These students were able to complete the mindfulness training during specified time periods in class with technology platforms available through the school. An understanding of the student population

and technology access allowed the team to select the appropriate media to ensure the best results.

For the purposes of training and education, a series of twelve videos consisted of ten training modules and two summary and follow-up/assessment modules. Each of the ten training videos discussed one of the saboteurs outlined in the PQ book. The videos introduced a character, similar to a pop culture icon, that the students could easily identify with. The character was described as embodying one of the saboteurs to aid students in understanding how the saboteur could negatively impact their life and how they could properly identify it. The video would end with an explanation of how to activate the sages and utilize mindfulness techniques to overcome the saboteur and increase the students’ PQ. The students were given PowerPoint slides from the videos to track and take notes as they watched them. Along with the link to the PQ “Self-Assessment” website, they could choose to take a free self-assessment to determine where their emotional strengths and weaknesses resided on the scaled continuum. The training was initiated and completed over a course of six weeks during the 2021 spring semester.

Dates were set up in May to allow for a virtual discussion and follow-up between the team and the students. This discussion would address the subjects, ideas, concepts and lessons learned during the mindfulness training program and answer questions. Ms. Gutierrez was able to provide the team with her personal impression of the outcomes of the training, “Through the collaboration with the UIWSOM,” she explained, “we were able to bring awareness to students, by highlighting some of the tools and techniques that could lead to achieving their full potential under less-than-ideal situations. I believe, wholeheartedly, the more students that are made aware and educated early, the better prepared they can be in their personal and professional lives.”

Ultimately, by improving mental health advocacy and strengthening the bonds between the medical learners at UIWSOM and the community, the team hopes to spark interest in our Bexar County adolescent population to pursue a career in medicine. Dr. Vargas stressed, "having experiential moments where high schoolers can interact with medical learners and having that human connection allows them to see themselves in each and every one of us and realize that they too are capable of achieving a medical career. Every kid needs a champion."

References: 1. Loades, M. E., Chatburn, E., Higson-

Sweeney, N., Reynolds, S., Shafran, R.,

Brigden, A., . . . Crawley, E. (2020). Rapid

Systematic Review: The Impact of Social

Isolation and Loneliness on the Mental

Health of Children and Adolescents in the Context of COVID-19. Journal of the American Academy of Child & Adolescent Psychiatry,59(11). doi:10.1016 /j.jaac.2020.05.009 2. Chamine, Shirzad. Positive Intelligence (PQ), Greenleaf Books Group Press (2012). https://www.positiveintelligence.com. Positive Intelligence training is focused on improving a person’s “mental fitness,” using neuroscience, cognitive and positive psychology, and performance science. 3. The Texas Tribune. (2018). Southwest

High School. https://schools.texastribune.org/districts/southwest-isd/southwest-high-school/

Charles Campbell, Jessica Glossop, Roshan George, Raudel Guerra and Joshua Kuehne are all students at the UIW School of Osteopathic Medicine and members of the CEP Team.

An Analysis of

“Quackery: A Brief History of the Worst Ways to Cure Everything”

By David Alex Schulz, CHP

When authors Lydia Kang and Nate Pedersen approached the “Worst Ways to Cure Everything,” they faced a challenge of balance: much of this history is morbidly humorous while equally serious: fraud in health care is not only still with us, but as prevalent as ever. To recount history’s phony, ineffective or poisonous attempts at healing calls for an approach that neither forces the book into a tour of Ripley’s Hall of Horrors or a Rube Goldberg’s Sunday Funnies, the truth is far more ambiguous.

As Kang and Pederson explore the history of false and fraudulent health care therapies, we learn that with many substances and forces, a little can go a long way to good effect; but a lot, on the other hand, might only go about six feet … vertically.

Take the Russian Electric Shower, a perfect example of excess. When electricity was harnessed by Alessandro Volta and Luigi Galvani, they discovered the muscles of a dead frog’s leg twitched when struck by an electric spark. If electricity brings motion to the dead, it must certainly benefit the living! (One can see Mary Shelley lurking in the literary background.)

Early medical uses of electricity shocked patients suffering from rheumatism, malignant fever and the plague. Electric baths were advertised to help with a variety of chronic conditions such as gout and sciatica, the justification for the Russian Electrical Shower. By the end of the 19th century, electric hairbrushes, corsets, belts and a device to cure erectile dysfunction were marketed for the DIY electro-therapy enthusiast. Ironically, this coincides with the incorporation of electricity for “humane” execution.

Even today, products are pulled off the shelf for electrocuting in the name of health. In 1996, the Executive Briefcase, a top-of-the line Electronic Muscle Stimulator (EMS) machine, was yanked by the FDA for causing cardiac arrhythmias. More recently, the FDA has received reports of shocks, burns, bruising, skin irritation and pain associated with the use of some of these devices. There have been a few recent reports of interference with implanted devices such as pacemakers and defibrillators. Some injuries required hospital treatment.

We also know, of course, that carefully controlled application of electricity is extraordinarily beneficial to patients, from pacemakers and defibrillators to instrumentation like the EKG and EEG.

This is the key to making “Quackery” such an enjoyable read. The authors end each topic with a reflection of our current use of some previously, terribly abused chemical, organic material, instrument, animals (think leeches), or “mysterious power” like electricity, light and radionics.

They begin with the manifold and bizarre medical uses of mercury. This silvery, unique liquid metal was assumed to have great powers, and it did: the power to purge. Marketed under the name Calomel, Mercurous Chloride was the “go to” laxative for many decades. For example, Lewis and Clark were given 1,300 of “Dr. Benjamin Rush’s Famous THUNDERCLAPPERS.” It proved so effective an evacuant that the expedition’s progress can be traced by remnants of mercury in the soil a “latrine’s length” from their trail.

Mercury had been applied to treat syphilis from the 15th century through recent times. “Niccolò Paganini, one of the most famous violinists in history, likely suffered from mercury toxicity after he was diagnosed with syphilis … shaking uncontrollably, contributing to his withdrawal from the stage in 1834,” write the authors.

Mercury’s toxicity is well-accepted but still makes its presence in health care, symbolically at least. The god’s symbol, the caduceus of two entwined snakes on a winged rod, is often mistaken for the proper symbol of physicians: the Rod of Asclepius, a single snake on a simple rod.

For shocks and giggles: a Russian Electric Shower.

Arsenic’s deadliness made it an early favorite for homicide-by-poison – odorless, often tasteless and easily concealed. It has also been used since antiquity as a medicinal. “It’s an escharotic, which means it causes the skin surface to die and slough off … And like many medicinals in history, arsenic was used for a hell of a lot that didn’t make sense: fevers, stomach pain, heartburn, rheumatism, and as a general tonic. From Aiken’s Tonic Pills to Compound Sulphur Lozenges to Gross’s Neuralgia Pills, the quackery-laden patent medicine trade was loving arsenic in the eighteenth century,” say the authors.

Despite frequent accidental or malicious deaths by arsenic, it maintains a legitimate place in pharmacopeia. “Salvarsan, neosalvarsan, and bismarsen are all arsenical compounds that finally brought syphilis to a stop after centuries without a cure. Eventually, penicillin usurped their place,” Kang and Pederson write, but “white arsenic has been used to treat acute promyelocytic leukemia, and is curing many patients today.”

“Quackery” details “nature’s gifts” to health care: opiates, strychnine, tobacco, cocaine, alcohol and Earth, the eating of dirt. The history of opiates continues to resonate today. It begins with poppies producing raw opium and its power to anaesthetize and addict. This led 15th century celebrity physician Paracelsus to invent a “safer” refinement of opium: laudanum.

Opium devastated China, but America found its weakness in laudanum, a tincture containing 10-percent powdered opium. “The addition of alcohol only intensified the euphoric and mind-altering effects. The products were touted by most physicians and obtainable without a prescription, used in the comfort of the home—no opium den required.”

But addiction remained: laudanum or other opium elixirs and nostrums never found acceptance by physicians. In answer, a young chemist created a new extraction from the poppy pod in 1803. He named it after the Greek god of dreams, Morpheus. Say hello to morphine.

Its adoption by physicians was in time for the Civil War, when huge quantities of morphine and opium healed and hurt in equal measure. And then came a new instrument to introduce it to the body: the hypodermic syringe. “By the 1880s, (the) invention brought on new creations: morphinomania and morphinism, terms for morphine addiction. The syringe was a miracle for medicine, but unfortunately a vehicle for a dark disease.” Back to the drawing board.

In 1874, a London pharmacist searched for a version of morphine without the addictive qualities. His new formulation, diacetylmorphine, was potent but wouldn’t be adopted until a Bayer Laboratories chemist wanted a product stronger than the aspirin they ‘reinvented.’ Bayer’s chemist experimented with the pharmacist’s diacetylmorphine, and after testing on rabbits and frogs, tried it on Bayer employees.

“They loved it. Some said it made them feel mighty, or heroicsh (heroic, German).” They called it heroin. Bayer immediately touted heroin as a cure for morphine addiction.

“Quackery” also covers surgical instruments. An Antidotes Hall of Shame: bloodletting, lobotomy, cautery, enemas and clysters, leeches, cannibalism and corpse medicine and therapies which defy modern imagination.

“Quackery” would be an interesting read at any time, but our times give it particular pertinence. We follow a year in which significant discussion was given to internally introducing UV light. A year in which people accidentally ingested chloroquine phosphate, a poisonous fishbowl cleaner, mistaking it for an anti-malarial drug. There has been no better time to read Kang and Pedersen’s review of medicine’s steps and missteps, and reconsider current events in light of history’s vagaries.

Calomel remained in British pharmacopoeia until the 1950s.

David Alex Schulz, CHP is a community member of the BCMS Publications Committee.

OMT in Practice: An Anecdote from a Third-Year Medical Student

By Travis B. Fenlon

Following my successful outing of seeing patients by myself for an entire day, I strolled into the office with aplomb. Despite my timorous reservations and growing pains of what only amounted to my first week of clinicals, I felt as if I were a health care provider. Was this normal? Was it right to feel this way? It didn’t matter. No time for hesitance; we had 30 patients and I wasn’t going to waste my newfound confidence.

Our first patient was a 69-year-old male following up on lab results for hypertension. His slicked-back hair was reminiscent of that of George Carlin in the later years, but our patient’s posture and muscle atrophy were far from risible. As my preceptor was counseling him on starting low-dose losartan, something called out to him to start palpating the man’s neck and shoulders—boom, trigger points. Delving a little more into his history revealed osteoporosis, a sedentary lifestyle and diffuse musculoskeletal pain. He was barely able to flex his hips for us from a seated position. As my preceptor started explaining that he wanted him to see either a chiropractor or massage therapist, I jumped at the opportunity: “Actually, would you mind if I worked on him?” His head turned, eyebrows rose and he smiled with his eyes before explaining to our patient who I was and what osteopathic manual manipulation could do for him. He consented to treatment; this was my big break!

Within seconds, I had a working osteopathic structural diagnosis: severely restricted active and passive range of motion in the cervical spine in flexion, extension, rotation and side bending with bilateral muscle hypertonicity and referred pain on deep palpation consistent with myofascial trigger points. I didn’t even bother trying to find somatic dysfunctions of his individual vertebrae; I wanted to go right into providing him relief. I eagerly jumped into the "Bilateral Forearm Fulcrum Forward Bending Method" technique. Said another way, I flexed his neck for 90 seconds. (Again, with an homage to Carlin: what's wrong with using honest, direct language?) He sighed with relief, so I figured I’d give the “Single Forearm Fulcrum Forward Bending/Side Bending/Rotation” technique a try on both sides of his neck. Again, more affirming sounds that the treatment was working. After several minutes, I felt his neck again and the environment had completely changed from indomitable stone to a lissome water bed. I had him flip over on his stomach and I proceeded to do “Unilateral Prone Pressure” bilaterally along the length of his cervical and thoracic spine. The aural signs of relief entered the room again. I reevaluated him after about ten minutes of working; his range of motion significantly improved, and the trigger points were gone.

When he got up from the table, I told him that I felt a few of his vertebrae were “out of whack” and I wanted him to seek out an osteopathic physician in San Antonio. “Sir, I want you to try to find anyone who has the initials D.O. after their name, okay? They will be better able to help you out than I can,” I said.

“I can do that, but where is your office? I’d like to schedule an appointment,” he said. It’s fortunate that we were still wearing masks in clinic, because my jaw dropped. I’m just a medical student, one who is only seven days into his first rotation, at that. Just a few short hours later, a 70-year-old man came into the office for a follow up on his labs for hypertension and diabetes. He was on top of things, and even dropping two pounds and an HbA1c level within reference range wasn’t good enough for him. He had been experiencing low back pain after a car accident eight years prior, but was too claustrophobic to receive an MRI, so he wanted clearance to be sedated for his imaging procedure. He told my preceptor and me about shooting pains he was experiencing down his arms, and an inability to perform daily tasks without severe back pain. Before I could even ask this time, I heard, “Well, you’re in for a treat today! Did you check in at the spa up front? Because my medical student here will fix you up. He goes to an osteopathic medical school, and they specialize in a lot of extra techniques that we do not learn in a traditional medical school.” Our patient immediately consented to treatment and started to unbutton his shirt before my preceptor left the room. I evaluated him and had the identical diagnosis of the previous gentleman I had seen earlier.

I was getting into a rhythm at this point, so I remembered to actually talk with my patient this time. It turns out he had a storied history with massage therapists. I frantically asked him if I was doing okay, and he ecstatically responded in the affirmative.

Once I was done, I directed him to lie down on his stomach, but he told me that would be a problem. He had not been able to do this since before his accident. I helped him get into a position he was comfortable

with: planking. I had never tried a prone technique with a patient tensed up like this before, but I figured it was worth a shot. I hoped what I was doing wouldn’t be considered barmy. I worked on him from that planking position for a while, and with each passing minute, I noticed his forearms slipping. With all the sighs he let out, I asked if he was getting tired or in any pain. He responded that the sounds he was making were all good ones, and that he had not felt this way in years. He asked if he could tell me something confidential—something he had yet to even tell my preceptor. Mere minutes of hands-on treatment elicited a relationship so strong, he felt he could tell me things in confidence that he had never been able to tell anyone. Before I knew it, his arms dropped, and he was flat on the table—he hadn’t been able to lie down on his stomach for eight years without pain. “Sir, you have a healing presence in your hands, I want you to know that. You’ve changed my quality of life,” he said.

I fought to plug the dam that was beginning to give way in my eyes. I told him that was the best compliment I had ever received in my medical career. I reevaluated him, and his tension was gone. I told him we were done for the day, and he asked if he could schedule a follow up appointment with me sometime in the near future. He asked when I was going to open up a practice here in San Antonio, so that he could be my first patient. I was speechless and perhaps that was the way I should have stayed, for everything I was trying to weave together came out as doggerel. I tried to explain to him that I wanted to be a pathologist—a laboratory scientist—and that I was eyeing to move up north for my residency. “Ah, you’ll be back in San Antonio. We need you here,” he said.

I felt deracinated but still somehow genial as I cried on the way back to my apartment. I lamented over the fact that my patient had been suffering for nearly a decade. I pondered how the course of his life might have played out if an additional 20 minutes could have been doled out to him somewhere along the way, by anyone. After all, there was nothing extraordinarily special about the techniques I performed, but to him, the 20 minutes I took to perform them meant everything.

Travis B. Fenlon is a third-year medical student at the UIW School of Osteopathic Medicine.

LETTER TO THE EDITOR

REFLECTIONS ON UGANDA – Kony’s Rock

If you would like to send a letter to the editor of San Antonio Medicine magazine, please email editor@bcms.org.

July 13, 2021

To the editor,

I have enjoyed reading San Antonio Medicine (SAM) since late in the last millennium. The magazine is chock full of articles from the President’s message to the article from the BCMS Alliance through Steve Schutz’s must-read car reviews. SAM features a wide variety of articles of interest written by member physicians, medical students, BCMS staff and supporters. That said, it’s missing something:

Where is the ‘letters to the editor’ section?

I have yet to meet a medical student or physician in San Antonio who doesn’t have at least one and often many opinions on any subject. Would it be possible to institute a ‘letters to the editor’ section in a forthcoming SAM so we all can read what our colleagues are thinking? I know we will have to keep it respectful and pithy, but could we please give it a try?

Thank you for your consideration.

Sincerely,

Adam V. Ratner, MD Adam V. Ratner, MD is a member of the Publications Committee and former President of the Bexar County Medical Society.

By Averi White, MD

Last year, when we arrived in Omoro District, our driver immediately pointed out Joseph Kony’s childhood home, a small hut like all the others we had already seen along the way. I wondered how this little quiet place had given birth to so much evil; how the other members of this community had felt the day Kony banged two rocks together atop a plateau, now called Kony’s rock, declaring himself a god. The homes of the children in this picture were identical to the hut Kony grew up in, back up to Kony’s rock. Their parents described the banging noise and their terror as Kony sat atop his rock, using the Acholi people below as target practice. Eventually, they fled to refugee camps. For years, even after families returned from the refugee camps, people were scared to climb the rock. However, in the last few years, the local people have slowly but surely reclaimed the rock. Today, the rock is a reminder of the endurance and bravery of the Acholi people. In this photograph, a new generation looks out across the beautiful Acholi land from atop the rock.

Children atop Kony’s Rock, Gulu

55 Word Stories:

Learning from our Youngest Patients…Guiding Them and Their Families on the Path of Healing

By Medical Students at the UT Health Long School of Medicine

Medical students at UT Health Long School of Medicine use the writing of 55-word stories to reflect on their clinical experiences.

A Mom’s Goodbye

Child is coming into trauma tonight.

You read a pager.

First time doing CPR and you don't stop until told to.

You imagine a future for him.

You imagine how his smile would look or how his laugh would sound.

You know it doesn't look good.

Mom comes in.

“Baby. My baby. Not my baby.”

Reflection: This was one of the hardest cases I was involved in while on my trauma shift. It was my first time doing CPR on a child, and just seeing him bleeding and intubated was a really hard thing for me. Physicians allowed the mom to see the child in the trauma bay to begin the process of saying goodbye. It reminded me how short life is and how sometimes you can’t help the patient, but remember that you can help the family and comfort them. It reminds me to always put myself in their shoes and try to just be there for the patient and family.

~ Clarissa Meza, Class of 2022, Long School of Medicine, UT Health San Antonio Is he okay? I think so

He held her hand and cried

She looked confused

“What is going on?” she said.

No response.

The team talked in code.

She tried to make eye contact

“Please, is he okay?”

A squeeze, a nod. “We think so.

He’s a fighter. He’s going up now.”

Less blue. A tiny cry.

We didn’t expect this.

Reflection: This experience was from one of the deliveries I observed while on my OB rotation. The mother was searching around the room looking for positive news about her newborn, but no one knew what to say. While the PICU team worked on the infant, the mother was crying and holding her partner’s hand, pleading for answers. The OB team was focused on making sure the mother’s bleeding was controlled. While one team worked on the newborn and the other worked on the mother, I felt that there needed to be more of a human focus on the mother and her son as an interconnected unit. I wish I had known what to do or say in that situation. When the mother looked at me, I felt that I didn’t know enough about what was happening to offer her support or answer her pleas for information. As COVID has limited the amount of human- and thus emotional- support a birthing mother can have, it is extremely important that we continue to prioritize the patient’s emotional needs during an already overwhelming process.

~ Anonymous, Long School of Medicine, UT Health San Antonio

It’s better when you don’t know.

Hospitalized for weeks. Alone.

Technically an adult, but sitting in bed she looks like a child. 19 years old and terrified.

Unexplained infections, painful debridements, fevers.

What could be causing all this in someone so young?

She watches TikTok videos and worries about how swollen her face becomes.

Until we say the dreaded C word.

Reflection: She was only 19 years old and alone in that hospital bed for over a month. We would often find her watching videos on her phone and trying to keep her spirits up. She was really struggling emotionally, even before the cancer diagnosis of an aggressive form of leukemia. This patient really has stuck with me. She is so young and is going up against this horrible cancer. It’s hard to watch people younger than you going through these terminal illnesses and imagining yourself in that situation. I will use this experience to make me a better physician by reminding myself to take time to slow down and have real human conversations with my patients. These are the hardest days of their lives and they have to spend a lot of their time alone. Even though I am providing them medical care, my care should include their emotional and spiritual well-being.

~ Jessica LaRouere, Class of 2022, Long School of Medicine, UT Health San Antonio

Empowering the Health Care Consumer

By M. Reza Mizani, MD

Spiraling out-of-pocket costs and intermediaries have put 1 of 4 Bexar County residents in medical debt. The time has come to restore the direct relationship between provider and patient.

The medical debt crisis in Bexar County

Although every single person reading this article has received a “surprise” medical bill at some point in their life, very few know the magnitude of the medical debt crisis in Bexar County.

According to the Urban Institute’s interactive debt map, as of March 31, 2021, approximately 43% of Bexar County residents – two out of every five people – have medical debt in collections averaging $2,099. As with many aspects of health care, the impacts on underserved and minority communities are even more dire. According to RIP Medical Debt, a national nonprofit that abolishes medical debt for pennies on the dollar, Bexar County has over $100 million dollars of medical debt in collections. Surprise medical debt affects people at all income levels. According to a Lending Tree survey, medical debt has prevented 72% of families from reaching milestones in life such as buying a house or having children.

Surprise bills and medical debt are symptoms, rising costs and care deferment are the epidemic

How did we end up here? We may or may not actually be getting sicker, but the costs of getting better have become much higher. Our health insurance has rapidly put the cost burden on the patient in terms of rising deductibles, premiums and co-pays. How much has the burden shifted? Consider this chart from the Kaiser Family Foundation that demonstrates the inflationary effects since the passage of the Affordable Care Act since 2009. The above statistics show how this rapid cost escalation has pushed the payment burden onto the patient in terms of out-ofpocket expenses. It is also easy to see why so many families default to the “maybe it will get better” approach to health care, which may mean not seeking care at all. According to a Harris Poll in 2019, 54% of Americans will defer seeking health care due to concerns about cost.

The path from there is very linear: the illness either does “get better,” or it turns into a ride to an urgent care or ER. By the time this patient seeks care, it could be time for surgery or a stay in the hospital. This treatment now undoubtedly leads to large follow-on bills for a host of different services and providers which, according to a 2021 Credit Karma survey, over 60% of American families cannot afford to pay immediately. These unpaid bills then become medical debt, which can often lead to bankruptcy. How often? Depending on the annual data above, it is calculated that 67-70% of all consumer bankruptcies are medical debt-related.

When health insurance is no longer insurance

Many will assume that these bankruptcies are being filed by Americans without insurance, currently estimated to be some 31 million people, (pre-COVID numbers). What will shock most is that of those medical debt bankruptcies, 68% of those that filed bankruptcy due to medical debt had health insurance at the time of injury or illness. So how does this happen?

This goes back to the rising costs illustrated above. But with real wages and sav-

ings not keeping pace, there is a growing group of people: the “functionally uninsured.” In short, if a family’s health insurance plan deductible exceeds their available savings, they are functionally uninsured. For most working age adults that are younger and healthy, perhaps this imbalance is never noticed. But should that same family face a catastrophic illness or suffer a major injury – such as a ruptured appendix – they will quickly find themselves incredibly burdened financially, and perhaps become a bankruptcy statistic themselves.

For many years, employer-sponsored health insurance (ESI) had plenty of value and utility. So many Americans with ESI were conditioned to see their health insurance card as a credit card. The first thing the medical receptionist would ask after hello is, “who is your insurance with?”

While much of the focus on solving the issues of surprise billing and medical debt focuses on the patients, you may have a hard time finding physicians that are fans of the current state of insurance-driven health care either. Billing, coding, negotiating, collecting – this is a system that has created billing- and insurance-related (BIR) costs of $0.17 on every dollar spent for private insurance payers. On top of the waste and excess cost, the time this BIR administration takes means less time and attention for actual patient care: the reason most become physicians and health care providers to begin with.

Restoring the direct relationship between the health care consumer and the provider

Prior to World War II, most Americans paid their providers directly out of pocket at the time of service. When they required insurance to assist, it was often with fixed-fee costs. One nurse could support the patients, the front office and perhaps even a couple physicians at one time. Above all else, the relationship between the physician and the patient was direct; there were no intermediaries between illness and care. In other words, before the advent of the health insurance industry, there was price transparency and a direct relationship between the physician and the patient.

Today, the patient has become the consumer, and change is now being driven from the outside where “innovation, not regulation” is the answer. Some innovations are within the insurance industry offerings themselves, such as defined contribution health care plans, which employers large and small are rapidly demanding and embracing. There are also many physicians opening subscription-based “direct primary care” model practices that remove the intermediary.

Price transparency, direct access and convenience are the keys to greater consumer participation, and the biggest advancements for the new health care consumers will come through technology. Our smartphones have irrevocably changed the human existence, and if in an Uber analogy we think of insurance-driven health care as the “old taxi” that everyone complains about, then the solution, represented in apps like LASO, should be similar: a free market platform with upfront pricing, direct access to physicians and convenient booking right from a mobile device at the time and place convenient to you. When we accomplish this, seeking the care you need now will then be as easy as “getting a ride in minutes.” With the participation of innovation-minded partner physicians in this effort, we can make a lasting impact on how retail health care is delivered, and simultaneously end care deferment and the scourge of medical debt. M. Reza Mizani, MD is the founder and CEO of South Texas Renal Care Group. LASO Health is a health technology startup founded in San Antonio by Dr. Mizani, and is currently seeking health and wellness providers of all kinds to join them in their effort. For more information on becoming a LASO provider, visit https://www.lasohealth.com/md-partners/ or call (210) 624-7715.

Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed.

ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions” Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

BANKING

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking (210) 283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com

BB&T (HH Silver Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services — BB&T offers solutions to help you reach your financial goals and plan for a sound financial future Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com www.bbt.com/wealth/start.page "All we see is you"

Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need. Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

BUSINESS CONSULTING

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210.846.9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210.557.9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

FINANCIAL ADVISOR

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community. Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

Elizabeth Olney with Edward Jones (HH Silver 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 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services. Mary P. Mahlie Vice President Wealth Advisor (512)787.2488 Mary.Mahlie@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (210)385.9326 Fred.Kelley@Regions.com www.Regions.com SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Michael Leos Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318 mleos@swbc.com swbc.com

HEALTHCARE BANKING

Amegy Bank of Texas (HH Silver 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 TECHNOLOGY SOLUTIONS SUPPLIER

Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent & treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension & topical wound care. info@NitricOxideInnovations.com (512) 773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options. Laura Kouba Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

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

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

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

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

state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com

ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown - Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

INVESTMENT ADVISORY REAL ESTATE

MEDICAL BILLING AND COLLECTIONS SERVICES

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.”

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 & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL PAYMENT SYSTEMS/CARD PROCESSING

First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com Danette Castaneda Business Banking Specialist 512.797.5129 Danette.castaneda@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

MEDICAL SUPPLIES AND EQUIPMENT

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.

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

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

MORTGAGES

SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Jon Tober

Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober

PRACTICE SUPPORT SERVICES

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

PROFESSIONAL ORGANIZATIONS

The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates). Jon Wiegand Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management. Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease”

The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center. Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

RETIREMENT PLANNING

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. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.” TELEHEALTH TECHNOLOGY

Join our Circle of Friends Program

The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship, please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366

2021 PORSCHE 911

By Stephen Schutz, MD

The Porsche 911 was first introduced at the Frankfurt Auto Show in 1963 and reached series production in 1964. After two generations and 17 years of success, the 911 was scheduled to be phased out, but was famously rescued in 1981 by then CEO Peter Schutz (no relation) before evolving into the automotive icon it is today.

About two years ago, the eighth generation 911, the 992, was launched, and it is turning out to be very popular, maybe the most popular 911 ever.

How popular is it? Porsche San Antonio General Sales Manager Matt Hokenson told me recently that if you order one now, you’ll need to wait more than a year for it to arrive (that will presumably change as the chip crisis currently bedeviling car manufacturers eases).

The exterior design of the new 911 is, no surprise, evolutionarily. The timeless silhouette is instantly recognizable, as are the low front end, front fenders that stretch forward to connect with the round headlights and squatting rear end. But look closer and you’ll notice many retro design elements that look backwards as much as the rest of the styling points to the future. The hood, for example, mimics the classic G-body 911s of the 1970s and ‘80s, as does the full width red light bar that connects the taillights.

Inside the 911, Porsche followed its corporate cousin Audi into the screens-everywhere world, but they did it half-heartedly (thank you Porsche). While Audis give you one big screen right behind the steering wheel where the gauges used to be, Porsche combines a large central analog tachometer with two small screens on either side of it, along with a central touch screen. And while some manufacturers make sure that their screens welcome you with little CGI “movies” when you start the engine, Porsche just turns on what you selected previously. No theater and no drama.

Another nice touch is the steering wheel. Too many manufacturers of sporty cars (and even SUVs) include a thick steering wheel in their vehicles, as if gripping a beefy wheel will reinforce in your mind the idea that whatever extra you paid for, the more athletic package was worth it. Whatever, Porsche doesn’t do thick steering wheels. They give you what they think works best.

When Porsche says “works best” they mean it enhances the driving experience. Porsche used to only make sports cars that drove the way they thought sports cars should. And they built a solid following doing just that. Then they realized that limiting their products to sports cars was a ticket to extinction, so they introduced SUVs and a sedan.

Nothing wrong with that, those non-sports cars saved the company. But the heart of Porsche remains the rear engine, flat six cylinder, twoplus-two-seater 911 sports car. Which still drives really well, almost 60 years after it first saw the light of day way back in 1963.

I drive many new cars every year, and few are genuinely “different.” The 911 is different. You start the engine by turning a “key” located to the left of the steering wheel, and immediately you hear the sound of the flat-six engine, which has a distinctive exhaust note that’s different from every other engine. And, of course, the sound comes from behind you, which is also different.

Then you drive the 911, and it handles uniquely because so much of the mass is at the rear of the car, unlike so many front- or mid-engine sports cars. Over the years Porsche engineers have used software and many other tricks to get rid of the off-throttle oversteer that used to haunt older 911s, and now the latest version corners amazingly well but also in a way that feels different from other sports cars. I recently drove a BMW M3 Competition, which has about the same power as a 911 Carrera S and was struck by how front-heavy the Bimmer felt in comparison. That is not to disparage the M3, but rather an observation that driving a 911 doesn’t feel like driving other performance cars.

Another different “thing” about the 911 is that most customers configure their cars and then order them, rather than picking them off the lot. And since the number of available options is gigantic, almost no two 911s are the same. I invite any doubters to sit down with their iPads and the Porsche configurator and see what I mean.

By the way, I can’t predict what your configuration will look like, but I can guarantee it will be expensive (the 911 starts at around $100,000). 58 years after it was introduced, the Porsche 911 remains the best all-around sports car available. And it’s as desirable as ever because it’s unlike everything else out there, and because it feels just right. If you can afford it, it’s worth every dime.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.