San Antonio Medicine December 2019

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2019 Medical Year in Review

Border Health Issues By Luis M. Benavides, MD....10 The Study of Health Disparities

By Vincent P. Fonseca, MD, MPH, FACPM............14 AI – Detecting and Analyzing Breast Cancer Cells

By Hakima Ibaroudene ........................................16 Younger Physicians – Why They Choose an Employed Health Care Setting

By Nora Vasquez, MD & Veronica Vasquez, MD ....18 A Brief History of Physician Payment

By Ezequiel Silva, III, MD ......................................20 Diversifying the Physician Workforce

By Chiquita Collins, PhD, MA ...............................22 Cannabinoids: A Modern Doctor’s Dilemma By J.J. Seidenfeld, MD .................................................26 The Vaping Crisis: What We Know About Lung Injury By John R. Holcomb, MD ..............................30

BCMS President’s Message ........................................................................................................................8 New Initiative Seeks to Turn Tide on Opioid Use Disorder

By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio ........32 BCMS Officer’s Installation Save the Date ..................................................................................................33 BCMS Legislative News ............................................................................................................................34 BCMS Circle of Friends Physicians Purchasing Directory............................................................................36 Recommended Auto Dealers......................................................................................................................43 Auto Review: 2020 Ford F-150 Turbo By Steve Schutz, MD ......................................................................44 PUBLISHED BY: SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net BUSINESS MANAGER: Vicki Schroder

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San Antonio Medicine • December 2019

DECEMBER 2019

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VOLUME 72 NO. 12

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Adam V. Ratner, MD, President Rodolfo “Rudy’’ Molina, MD, Vice President John W. Hinchey, MD, Treasurer John J. Nava, MD, Secretary Gerald Q. Greenfield Jr., MD, PA, President-elect Sheldon G. Gross, MD, Immediate Past President

Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robert Richard Leverence, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Brent W. Sanderlin, DO,

DIRECTORS Michael A. Battista, MD, Member

Medical School Representative Alice Kim Gong, MD, Board of Ethics Chair

PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Carmen Garza, MD, Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member John Seidenfeld, MD, Member

John D. Edwards, MD, Member Vincent Paul Fonseca, MD, MPH, Member

BCMS SENIOR STAFF

J.J. Waller Jr., MD, Member

Michael Joseph Guirl, MD, Member

Stephen C. Fitzer, CEO/Executive Director

David Anthony Hnatow, MD, Member

Melody Newsom, Chief Operating Officer

Teresa Samson, OMS-II, Member

Gerardo Ortega, MD, Member

Yvonne Nino, Controller

Manuel M. Quinones Jr., MD, Member

August Trevino, Development Director

David M. Siegel, MD, JD, Member

Mary Nava, Chief Government Affairs Officer

Rajeev Suri, MD, Member

Phil Hornbeak, Auto Program Director

Danielle Henkes, Alliance Representative

Mary Jo Quinn, BCVI Director

George Rick Evans, Legal Counsel

Brissa Vela, Membership Director

Col. Charles Gregory Mahakian, MD,

Al Ortiz, Chief Information Officer

Military Representative

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San Antonio Medicine • December 2019

Sneha Aidasani, MD, Member Stephen C. Fitzer, Editor

PRESIDENT’S MESSAGE

I’m Serious.

Have Fun!

By Adam Ratner, MD, 2019 BCMS President As a medical student completing my first research fellowship,

the program sponsor, Stanley J. Sarnoff, MD, asked me one of the

most important questions ever asked of me in my life, “Adam, did

row, I know I need to change something.”

The good news is that if we’re not happy, we as physicians have

far more power than most to change our lives, but it’s not easy

you have fun?”

and not without tradeoffs. Many of us are pretty good at optimiz-

to me that fun should be a serious consideration in the life of a

to optimizing long-term happiness (and fun). If you’re not as

cine was the most serious of professions. After I contemplated

intellectual firepower to examine your life and adjust your priori-

I was dumbfounded. No one had ever pointed out so explicitly

medical researcher or physician. I had always thought that medithis unexpected question for several seconds, I finally replied,

“Yes, I had a blast!” This made him smile.

I had always known that my father, Irving A. Ratner, MD, was

dedicated to his patients and worked long hours as a pediatric sur-

geon. It wasn’t until many years later, after I’d been in private prac-

ing our short-term revenue but have never given enough thought

happy as you’d like to be, consider refocusing your considerable

ties to optimize meaning and fun. Steve Jobs also said, “Have the

courage to follow your heart and intuition. They somehow know

what you truly want to become.”

As this is my last BCMS presidential message, I want to take

this opportunity to thank so many who have contributed to the

tice for several years and he had been practicing for several

success of the BCMS this year: You, the members, the committee

world. I love what I do, and they actually pay me to do it. I’d do it

ganization would be nothing; our energetic and passionate staff

decades, that Dad told me explicitly, “I have the best job in the for nothing if I had to.”

We have invested an enormous amount of time, energy, and

money while deferring gratification, to become the best physicians

we can be. We deserve to be happy and have fun while we perform our important and meaningful work.

Yet, too many of us are unhappy. Each of us have our own

chairs, co-chairs, directors, and officers, without whom this or-

led by our most capable executive director, Steve Fitzer; Danielle

Henkes and the passionate leaders of the BCMS Alliance; our sup-

porters from the Circle of Friends. I must also thank my amazing

and beautiful wife, Varda, for her forbearance and considerable

support during this year. You have all helped make this year at

BCMS more fun and meaningful for me and I hope I’ve, at least

challenges to our happiness. For many, misery comes from the

in some small way, made it more fun and meaningful for you.

dens of the health care bureaucracy; and for others, the need for

UIW School of Osteopathic Medicine and UT Health San Antonio

anized practices.

stantly remind me that the future of Medicine is very, very bright.

lack of autonomy in our practices; for others, the relentless bur-

fresh and exciting challenges beyond our reach in dreary, mechSteve Jobs once said, “For the past 33 years, I have looked in

the mirror every morning and asked myself: ‘If today were the last

day of my life, would I want to do what I am about to do today?’

And whenever the answer has been ‘No’ for too many days in a

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San Antonio Medicine • December 2019

Finally, I want to thank the students and residents at both the

who reinvigorate my soul with their energy and passion and conDr. Adam Ratner is President of the Bexar County Medical Society and

serves as Professor and Assistant Dean of the University of the Incarnate

Word School of Osteopathic Medicine and Chair of The Patient Institute.

MEDICAL YEAR IN REVIEW

BORDER HEALTH ISSUES

2019

By Luis M. Benavides, MD

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San Antonio Medicine • December 2019

MEDICAL YEAR IN REVIEW 2019, the southern US border issues were in the headlines of every national and local news service. Besides reporting on the large crowds of immigrants from primarily Central America and Mexico, the issues of health and safety were examined in the public press not only for the immigrants themselves but for the residents of the United States. Texas was at the center of all of this fury with reports of immigrant camps, visiting politicians, and yes, the healthcare community trying to get access to and relieve suffering. This is part of living in a border state. The impacts of that reality as it affects healthcare are the subjects of this article.

Physician leaders along the border from El Paso to Corpus Christi as well as San Antonio united in 2001 to establish the Border Health Caucus (BHC). Their mission: to ensure lawmakers in Austin and Washington, D.C., understand the unique health challenges facing the border region and improve access to care for its more than three million residents. The Border Health Caucus works closely with the Texas Medical Association, advising on health issues, policy and working to improve the delivery of healthcare in border areas.

Perspective – The Demographics The Texas-Mexico border stretches 1,254 miles and borders four Mexican states and two tribal nations (the Kickapoo Traditional Tribe of Texas near Eagle Pass and Ysleta del Sur Pueblo in El Paso). The population along the border totals 3 million people, 88.4 % of which are Hispanic, 29.3% are below the poverty level, 31.7% do not speak English well and much of the population over 25 years of age (32.8%) do not have even a high school diploma. Median family incomes there range from $27,000-$34,500, which is about 50% of the comparable median in-

come in Texas or in the entire United States. Unemployment for this area ranges from 12-17%, several times the US National average for Hispanic residents.

Homes for many of these residents along the border are in “colonias”, which are informal settlements with mostly substandard housing and poor infrastructure.

Those who live in this area and are between the ages of 18 and 64, have less than a 50% chance of having health insurance.

The numbers of physicians and health care providers are proportionately lower in Texas than they are nationally, a situation that is magnified in border areas. The vast majority of the border region is designated as both a Health Professional Shortage Area and a Medically Underserved Area. With recent changes at the Federal level, many rural hospitals have been closed (over half of these hospital closings have been in Texas), some of which were on the border and were primary access points for patients.

Public Health The health of the general population is as important as the individual care received by an individual patient. Research is being done across the border to better understand the general population problems, which we know are going to travel with immigrants.

Dr. Joseph McCormick, Regional Dean, University of Texas HSC Houston School of Public Health-Brownsville and Dr. Maria Jose Reyes Fentanes, Infectious Disease Specialist, Centro Medico ABC in Queretaro, Mexico, discussed some of the research and issues that they are investigating.

This research includes not only obesity and diabetes, but also the disproportionally high rates of non-alcohol-related cirrhosis and hepatic carcinomas, STD’s, cervical cancer and other chronic physical and behavioral health issues.

Cross Border Health Care Ten years ago, the people that were crossing the border were mostly men from Mexcontinued on page 12

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MEDICAL YEAR IN REVIEW continued from page 11

ico or Central America looking for work.

There has been a major shift in that demographic. Now, the people crossing into the US are mostly women and children, either as families, women alone or as unaccompanied children. The influx is no longer primarily from Mexican origin; now it is a mix of people from Mexico, Central America, Venezuela, other parts of South America, Africa (including the Congo), Syria, China, and Cuba.

The respective health departments on both sides of the US border are tasked with ensuring no potentially communicable or high consequence infectious diseases are present in these migrant people. Hector Gonzalez, MD, MPH from the Laredo Health Department, has an excellent relationship with his counterpart, Dr. Oscar Gerardo Gonzalez Arrambide, in Nuevo Laredo. Together they stressed the regional binational network for disease surveillance and detection. Webb County, for example, has a rate of tuberculosis three times higher than the state of Texas and up to five times higher than the US national rate.

An important area that is stressed is the need for all healthcare providers, from physicians to first responders to school nurses, to report infectious diseases. Some of this reporting is already mandated by law, but needs to be significantly improved. Only by this prompt reporting can detection and prevention of the spread of disease be stopped as early as possible. Suggestions for improvement in reporting include: • Establishing a program through the State Health Department to re-educate all who are involved in health care as to reporting requirements. Only through enhanced, real-time, around-the-clock reporting can we stop a disease from moving beyond an outbreak.

• Working individually and as groups with community programs such as Catholic 12

San Antonio Medicine • December 2019

Social Services and Methodist Healthcare Ministries, who have established programs for food, shelter and assistance.

• Continuing to work bi-nationally on common solutions to all health care issues, with special emphasis on those of the persons coming across the border.

The Border Health Caucus Improving Access to Care Following tort reform in 2003, as in the rest of Texas, the number of border physicians increased. More recently, medical schools have opened along the border that are training physicians that will, if appropriately developed and integrated with residency programs, help alleviate the border’s physician shortage. Other healthcare practitioner training programs are also being developed to complement the physician workforce, including nurses and therapists of all types, as well as community healthcare workers or “promotoras” that are being successfully used in multiple counties of the border region.

The Border Health Caucus in trying to assist with increasing the number of physicians in the border areas by: • Advocating for 1.1 Graduate Medical Education slots per graduating medical student from Texas-based medical schools entering the first year of residency.

• Advocating for increases in direct medical education and incentivize primary care training at teaching hospitals.

• Addressing the significant imbalance in the Medicare GME funding base rate for not only Texas, but for many other states.

• Facilitating the development of new teaching hospitals by allowing hospitals in underserved communities to have more flexibility in the Medicare GME cap-setting schedule.

• Advocating for evaluation of Texas Medicaid’s physician payment rates compared with commercial payers.

• Continuing to work in an effort to reinstate the 20% deduction on the Medicare/Medicaid payment system. All Part B services require the patient to pay

Border Health Caucus physicians aim to improve access to care for their patients and raise awareness of health care disparities along the binational border.

MEDICAL YEAR IN REVIEW

a 20% co-payment. The Medicare Physician Fee Schedule (MPFS) does not deduct the co-payment amount. Therefore, the actual payment by Medicare is 20% less than shown in the fee schedule.

This situation has existed for far too long and has unfairly been a financial burden to the physicians willing to take care of this very vulnerable patient population.

An important component of access to care is the education of patients. They must be taught healthcare maintenance at preentry levels, such as classes early in school, social media, and other public programs.

This needs to be coupled with education at all entry levels to the healthcare system whether a family planning appointment, an emergency room visit or participation in appropriate postpartum prevention programs for one year after birth.

The Border Conference The Border Health Conference had over 125 participants learning about programs on both sides of the border. Hidalgo County has the program “Eating Smart Being Active”, administered by Eddie Olivares, Chief Administrative Officer, Hidalgo County Health and Human Services. Another is the outreach “Tu Salud Si Cuenta” (Your Heath Does Matter) from our Mexico counterparts. From the City of El Paso Health Department Director, Roberto Resendes, we were told first-hand how they dealt with the recent shooting there along with the lessons learned. Ideas for further improvements in this area included: • Medical schools, public health departments, government and community advocated health programs and private physicians must all cooperate in order to better understand and participate in the solution of these issues.

• A consortium should be established to allow collaboration on all the research projects currently being undertaken so they may be compiled and cross-referenced so anyone can access them, without cost. Perhaps this can be accomplished through the US Mexico Border Health Commission, establishing a permanent community for research.

• Continue to support the establishment of partnerships with community health organizations and workers, including “promotoras”.

• Establish a mechanism for educating our communities and employers about the need for healthcare promotion. The current cost of lost productivity due to health issues is annually more than $3 billion. It is an incentive for promotion of healthcare in the workplaces.

• Consider a mechanism for suspending HIPAA regulations during a catastrophic situation such as the one that occurred in El Paso, in combination with estab-

lishment of a centralized communication system to assist with such situations.

The health care issues along the border are more numerous than can be enumerated in such a short article. TMA President, Dr. David Fleeger and TMA Past President, Dr. Doug Curran both pointed out: There are answers; we just need to work together energetically to find solutions to issues that are under our control, advocate for and implement them at the appropriate governmental or societal levels.

I thank all who participated in the conference to make it successful. I invite all to come to the Border Health Caucus meetings we have at TexMed and at the Fall and Winter Conferences. I especially invite all to the 15th Annual Border Health Conference in El Paso next Fall.

Luis M. Benavides, MD is the Chair of the Border Health Caucus.

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MEDICAL YEAR IN REVIEW

The Study of

Health Disparities

By Vincent P. Fonseca, MD, MPH, FACPM

If we are to improve the health of all Texans, that is, support population health improvement at the state level, we must address health disparities.

Health disparities are preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health that are experienced by certain populations. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health.

To address health disparities, we must go upstream and address the real causes of the disparities (e.g., disparities in diabetes outcomes related to differences in lifestyle).

Even more upstream of the real causes of the disparities are the root causes of dispar14

San Antonio Medicine • December 2019

ities, the social determinants of health (SDOH).

We find health disparities are almost everywhere we have data to examine. We often see disparities by race/ethnicity since that is often captured in health-related data systems. Unfortunately, in Texas and the rest of the country, race/ethnicity isn't the real cause of the disparity but is a proxy for the root causes: food insecurity, housing instability, transportation problems, poverty, low educational attainment, unemployment or unsafe jobs, or unsafe neighborhoods (violence or pollution), poor access to affordable, high quality health services, and others. These are called the social determinants of health. The social determinants of health are the conditions in which people

are born, grow, live, work, and age.

For example, one of the most basic concepts in health is self-perceived health status. Self-perceived health status can be categorized as excellent, very good, good, fair, or poor. In the 2014 Texas BRFSS (Behavioral Risk Factor Surveillance System), 15% of non-Hispanic Whites had fair/poor health compared to 25% of Hispanics. Hispanics' rate of fair/poor health was 67% higher than Whites.

Here’s an example of the complex interactions of SDOH. Neighborhoods with concentrated poverty and concentrated low educational attainment, 2 of the root causes of health disparities (SDOH), are also neighborhoods with loose dogs. They also are neighborhoods with schools that are

MEDICAL YEAR IN REVIEW

low performing schools, and also neighborhoods where segregation and health disparities exist. In a sense, if providers don't understand the profound impact of the social determinants of health, they may be surprised that loose dogs are somehow related to poor glucose control.

Primary care providers see the impact everyday in patients with chronic conditions. Chronic condition self-management is the key to improved outcomes individually and at the population level. However, it is more difficult to effectively self-manage, whether it's eating healthier, getting more physical activity, or adhering to medication when patients are also struggling with food insecurity, housing insecurity, keeping the utilities on, or unsafe neighborhoods.

The local health information exchange (HIE) in Bexar County, HASA, did an evaluation in categorizing glucose control in patients with diabetes by zip codes with concentrated poverty and concentrated low educational attainment (high SDOH risk).

They found that the proportion of patients with poor control (>=9%) was higher in zip codes that had high SDOH risk.

While providers may be aware of their individual patient's struggles, they probably haven't had aggregated patient outcomes stratified by factors such as SDOH risk.

Most of the quality measurement systems either don't address SDOH at all and just have one standard for recognition set of clinical quality criteria (e.g., MIPS), whether your patients are mainly high income or mainly low income. However, the MIPS bonus or penalties may adversely impact providers who care for patients with high SDOH risk.

Therefore, it may be useful for providers to review the information available at assessment.communitycommons.org/Footprint/ to view their area's census tracts with high social determinant risk, known as "vul-

nerable populations." Then review the CDC's 500 Cities project at www.cdc.gov/500cities/ that has estimates down to the census tract level for the largest 500 cities in the US based on the BRFSS. This means that only adults are covered but there still are many topics: 13 health outcomes, 9 prevention, and 5 unhealthy behavior topics. Texas has 47 cities available, from Houston to Missouri City. Knowing which census tracts are in greatest need for certain topics will help providers and communities overall meet those needs.

While difficult and new, there are some national efforts to try to connect specific patients and households to specific community-based social service support. The American Academy of Pediatrics has an effort to screen for food insecurity and then

coordinate community services for those families. CMS has an Accountable Health Communities pilot project to screen for 5 social determinants and coordinate community services where they are providing funding to help providers do this extra work. Until we work together with community-based organizations providing services to address the social determinants of health, we will not make the desired improvements in population health.

Vincent P. Fonseca, MD, MPH, FACPM, is an Associate Professor, Preventive Medicine and Director, Patient Safety and Quality Improvement, at the University of the Incarnate Word School of Osteopathic Medicine. Dr. Fonseca is a member of the Bexar County Medial Society.

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MEDICAL YEAR IN REVIEW Artificial intelligence (AI) and medical

imaging are merging to create more precise diagnostic tools for pathologists and better

treatment options for cancer patients. Using

a type of AI known as machine learning, we

DETECTING AND ANALYZING BREAST CANCER CELLS

By Hakima Ibaroudene

program computer systems to “learn” or simulate human processes, such as visual

perception and decision making. The systems form a neural network of

algorithms that calculate the best solutions

for a wide range of problems. Recently, our team of engineers at Southwest Research

Institute (SwRI) used AI to enhance cancer

diagnostics. In collaboration with UT Health San Antonio pathologists, we trained a computer algorithm to quickly and

accurately detect and analyze breast cancer

tumor cells. The team envisions developing

this algorithm further, eventually using it to detect other forms of cancer and to collect valuable, life-saving data from cancer cells, such as DNA structure and mutation analysis information.

The Cancer Cellularity Challenge The journey to developing a cancer-detecting algorithm began with an international competition, the BreastPathQ: Cancer Cellularity Challenge conducted by the American Association of Physicists in Medicine, the National Cancer Institute and SPIE, the international society for optics and photonics. The challenge presented the task of determining cancer cellularity from pathology hematoxylin and eosin (H&E) slide patches of breast cancer 16

San Antonio Medicine • December 2019

tumors. Our SwRI engineers sought the expertise of the UT Health pathologists who condensed years of training into a short course on pathology and imaging. Armed with new knowledge on the appearance and structure of breast cancer tumor cells, our team set out to train the algorithm to analyze cell images and look for defining characteristics that distinguish cancerous cells from normal ones.

Challenge organizers provided two collections of images: one to train the algorithm,

the other to test it. Once our team was satisfied with the algorithm, we analyzed the images from breast cancer patients and assigned a score based on the number of invasive cancer cells in each image. The algorithm sorted through the images and matched the findings of human pathologists at the highest rate, making it the top-performing algorithm out of 100 competing submissions.

In January 2019, we learned we won the international competition. Our success on

MEDICAL YEAR IN REVIEW

a global stage launched a new era in machine learning applications at SwRI. While we have developed machine learning algorithms for other biomedical and health applications, such as markerless biomechanics in sports medicine and gait analysis to detect indications of cognitive decline, this was our first time using machine learning for cancer diagnostics.

A Promising Future Pathologists track tumor response to therapy by determining the percentage of tumor cells in a particular area. Currently, this task is performed manually and relies on experts to interpret complex tissue structures. A dependable automated method, like an algorithm, produces faster results and more consistent data, while avoiding human error.

Artificial intelligence and machine learning approaches to medical imaging provide a powerful tool to rapidly identify and quantify cancer cells and guide treatment.

While our algorithm holds promise for all types of cancer, for now, we are continuing to focus on breast cancer. As of 2016, breast cancer is the most commonly diagnosed form of cancer in females, with over 200,000 new cases annually since 2006, according to the Centers for Disease Control and prevention.1 High diagnostic rates result in high numbers of tests performed and profiles collected. This testing surplus, combined with a predicted downturn in practicing pathologists, could “negatively impact… health care providers’ abilities to deliver more effective health care to their patient populations.”2 These factors create a significant need for improved digital pathology tools to assist and automate parts of the traditional pathologist workload.

We are planning new research to expand the algorithm’s capabilities to benefit both pathologists and breast cancer patients. Our goal is to use computer vision coupled with deep neural networks to determine not only

breast cancer cellularity, but also hormone receptor status of the cancerous cells. Breast cancer is typically diagnosed using hematoxylin and eosin (H&E) stain and assessed visually for morphology, classification of the type and growth pattern of a tumor. Once morphology is assessed, tissues are stained with immunohistochemistry (IHC) to look for predictive biomarkers. Visual diagnostics naturally introduce human error. We are aiming to research the feasibility of using our existing neural network expertise to classify breast cancer into different groups based on hormone receptor status.

Hormone receptor status is an important prognostic and predictive tool for breast cancer patients, particularly in terms of therapeutic response. As part of routine pathology testing, breast cancer tissue is stained with IHC to observe certain biomarkers, specifically estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor-2 (HER2). The combination of these biomarkers informs diagnosis, therapeutic decisions and risk of reoccurrence. Diagnoses range from triple positive (positive to all three receptors) to triple negative. While these classifications are crucial to choosing the proper treatment path, they are susceptible to observer variability. Classifying breast cancer by hormone receptor status with an algorithm would result in a more definitive diagnosis and therefore, more tailored treatment options for individual patients. Breast cancer is our starting point, but patients with all forms of cancer could potentially benefit from this capability.

Along with research to expand the algorithm’s capabilities, plans are underway to make this new diagnostic tool a reality in pathology labs very soon. It could look something like this – pathologists would gaze at a monitor attached to a camera over a microscope. The pathologist would select an image to study more closely and the al-

gorithm would go to work, gathering precise data and information about that very specific patch of cells. That detailed information would mean faster patient diagnosis and better treatment options to potentially save more lives.

AI Making a Difference Artificial intelligence has become a part of modern life. Most of us interact with a form of AI every day through streaming services, social media and in-home connected devices. At SwRI, we have applied machine learning to automotive, robotics and defense technology. However, the BreastPathQ Challenge presented a problem that we had not previously tackled with artificial intelligence. Now that we know what’s possible, we will continue to grow this capability. Our method continues to garner enthusiasm and support from the pathology community. As we explore the potential for machine learning in cancer diagnostics, we expect more opportunities to emerge to provide new health care tools, and most importantly, improve patient outcomes.

Hakima Ibaroudene is Group Leader of R&D at the Southwest Research Institute.

Citations [1] “USCS Data Visualizations - CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, https://gis.cdc.gov/Cancer/USCS/DataVi z.html.

[2] Robboy, Stanley J, et al. “Pathologist Workforce in the United States I. Development of a Predictive Model to Examine Factors Influencing Supply.” Archives of Pathology, 5 June 2013, www.archivesofpathology.org/doi/pdf/10.5858/arpa.20130200-OA.

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MEDICAL YEAR IN REVIEW

YOUNGER PHYSICIANS – Why They Choose an Employed Health Care Setting

By Nora Vasquez, MD and Veronica Vasquez, MD

One of the most notable trends nationwide is the increasing number of employed physicians. The term “employed” is generally defined as those who work in a setting where they do not have ownership or have decision-making authority in their practice.

According to a 2019 survey by the American Medical Association, approximately 47% of physicians nationwide are now employed.

This major shift of physicians choosing an employed health care setting is also being seen in Texas. According to a Texas Medical Association (TMA) Survey, from 2014 to 2018 there has been a 12% decrease in Texas physicians who own their practice.

Currently, 38% of Texas physicians are now employees. Interestingly, the increase in employed physicians appears to be most notable in physicians who are less than 45 years of age or within 8 years of residency or fellowship training.

Dr. Renee DeLaTorre is a recent Family Medicine graduate from Corpus Christi, Texas. She was drawn to an employed position because it felt like a natural extension of residency. In addition, she wanted to have a patient panel that was already established with ample support staff to start in her new clinic. She decided to devote her 18

San Antonio Medicine • December 2019

primary focus on patient care rather than managing a medical practice. Dr. DeLaTorre’s decision to be employed was common among her peers.

According to the Texas Medical Board, 75% of newly licensed physicians are graduates of medical schools outside of Texas.

The passage of Tort Reform in 2003 likely contributed to this trend. As more physicians move to Texas, they may lack established connections to the local community.

This may influence their decision to obtain employment with larger academic or government entities, or even as an employee of larger medical practices rather than go into private practice as an owner or partner.

Dr. Erin Moody, a Vascular and Interventional Radiologist who practices in Corpus Christi, Texas has experience in an employed practice. After Dr. Moody completed her fellowship in California, she joined an employed setting, as it offered her work-life balance and a stable salary. She was not alone. A survey from Merritt Hawkins revealed that 43% of the 2019 graduating residents preferred to be employed by a hospital. This is reasonable given that most medical training occurs in an employed setting at an academic or gov-

ernment institution, such as the Veteran Affairs system. Furthermore, medical students and residents have limited exposure to private practice groups or other models of health care settings such as rural medicine, locums, telemedicine, direct primary care or concierge medicine. In addition, they are not exposed to the intricacies involved in managing a medical practice. Therefore, it is not surprising that many younger physicians want to focus on patient care rather than worry about the financial and legal challenges of running a medical business.

Some of the immediate benefits that attract doctors to employed positions include: • • • • • • • • • • •

Work-life balance Guaranteed salary Loan forgiveness Health insurance Retirement benefits More clinical support staff Malpractice Insurance Call coverage Continuing Medical Education funds Paid vacation Disability Insurance

Despite these incentives, many employed physicians realize these benefits come at a great cost. The leading causes of dissatis-

MEDICAL YEAR IN REVIEW faction are the loss of autonomy and limited decision-making abilities that come with an employed-physician status. Many physicians feel the pressure of having to see more patients in shorter time periods. This is troubling as many doctors derive their greatest joy from the relationships they develop with their patients. In addition, physicians are frustrated with the increasing number of hours required for charting and increased productivity and quality metric demands. As physicians find they have less autonomy, their overall morale declines. According to the Physicians Foundation Survey, Texas physicians rank 50th in the nation for positive professional morale. Unfortunately, there is also an increasing rate of overall frustration with the current medical system leading many to pursue part-time work, seek alternative models of healthcare practice or retire early.

The future of medicine requires that all doctors obtain the support and leadership training needed to better advocate within their employed setting. The TMA and the Bexar County Medical Society (BCMS) recognize these challenges and want to help.

Both organizations offer training in leadership and management. In fact, TMA held its first Ad-Hoc Committee on Employed Physicians at the 2019 TMA Winter Conference. This committee was established to identify and develop support for employed physicians.

If you would like more information or have suggestions, please contact the TMA Knowledge Center at 800-880-7955 and visit www.texmed.org/employedphysicians/, or email knowledge@texmed.org. Likewise, you may contact Brissa Vela at BCMS at 210301-4371 or explore membership support offered on the website www.bcms.org.

Dr. Nora Vasquez is a BoardCertified Internal Medicine physician who was awarded the BCMS 2019 Women in Medicine Leadership Rising Award. Dr. Nora Vasquez serves on the TMA Ad-Hoc Committee for Employed Physicians. She was chosen to participate in the 2020 TMA Leadership College and the 2019 BCMS Leadership Course.

Dr. Veronica Vasquez is a BoardCertified Family Medicine physician who serves on the Physician Advisory Counsel for UMA, and was selected for the 2020 TMA Leadership College and the 2019 BCMS Leadership Course.

References (1) AMA Employed Physicians Now Exceed those who own their practices (May 2019).

(2) The Physicians Foundation: A survey of America’s physicians: Practice Patterns and Perspectives (September 2018).

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A Brief History of Physician Payment

By Ezequiel Silva, III, MD The next time you visit with an octogenarian physician, ask how physicians were paid during the 1970s. Most likely, the response will be, “We were paid what we billed.” Ask that same question of an early-career physician today, and the answer will be quite different. You may hear they are paid based on national fee schedules, adjusted for quality performance and mandating financial downside risk. What a difference 50 years makes!

How did we get here? To answer this question, a brief history of physician payment under Medicare may provide insight.

Medicare was signed into law in 1965. In its early years, physician payment was based on usual and customary charges. In other words, physicians could charge whatever they could justify, and that amount was paid. The system came to be known as fee-for service (FFS). Perhaps predictably, this arrangement resulted in sizable regional variation in payments and associated growth in overall federal spending. To address this growth, the federal government created a national fee schedule. Based on studies of physician work from the Harvard School of Public Health, a new system was born: The Resource-Based Relative Value Scale (RBRVS).

I wrote about the RBRVS in San Antonio Medicine last July1. In that column, I described how payments within the Medicare Physician Fee Schedule (MPFS) are based on the RBRVS. Physician services are described by CPT codes, and each code is assigned a valuation based on the required resources to provide the services. For instance, the physician work of a surgical procedure is determined by the time, technical skill, physical effort and psychological stress of the procedure. Practice expense and malpractice are also included in the resultant payment amount. Payments are based on relativity across all physician services, that is, the more resources required, 20

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the higher the relative payment. During the history of the RBRVS, the federal government has continued to experience increases in expenditures within the MPFS. Moreover, policymakers perceive shortcomings in quality, or at least a relative lack of accountability for quality.

To achieve greater accountability for quality, in the mid to late 2000s the federal government created several quality-based programs, referred to as Pay for Performance (P4P). Such initiatives as the Physician Quality Reporting Initiative (PQRI) and Meaningful Use emerged. This move toward quality accelerated in 2010 with the passage of the Affordable Care Act (ACA). As a result, the PQRI became permanent, updating its name to the Physician Quality Reporting System (PQRS); and the Value-Based Modifier and codified accountable care organizations, (shared savings models), were created. In addition, the ACA provided $5B in funding for the CMS Innovation Center to develop and test innovative health care models. Around this time, FFS came to be described as volume-driven care; P4P, value-driven care. A popular catchphrase in policy circles described a move from volume-driven care to value-driven care. This effort culminated in 2015 with the passage of the Medicare Access & CHIP Reauthorization Act (MACRA).

MACRA provided the blueprint for the future of physician payment. First, it is worth pointing out that MACRA replaced the flawed Sustainable Growth Rate (SGR), a widely criticized method to control Medicare spending on physician services. In exchange for SGR relief, MACRA further accelerated the focus on value-based payments. MACRA, which later spawned the Quality Payment Program (QPP) created two payment arms: (1) the Merit-Based Incentive Payment System (MIPS) and (2) advanced Alternative

Payment Models (APMs). MIPS unified the existing P4Ps into one system with one overall performance score. This score adjusted FFS payments depending on performance and determined by four categories: quality, cost (initially, resource use), promoting interoperability (initially, advancing care information) and improvement activities. The second arm, advanced APMs, includes models that are less dependent on FFS architecture, such as Accountable Care Models (ACOs), bundled care initiatives and other innovative models. Advanced APMs must either improve quality or lower cost – or both. And they require that providers assume downside financial risk.

A lot has changed in the past 50 years. We have gone from a system of usual and customary charges to a system of national fee schedules, quality adjustments, emerging alternative payment models mandating the demonstration of value, and downside financial risk. The evolution of the QPP and its emerging APMs will have a direct effect on the future of physician payment. Maintaining appropriate physician payment and supporting independent practice will require not only our knowledge of payment systems but also our full engagement in their maturation.

Dr. Ezequiel “Zeke” Silva III, MD, a member of the Bexar County Medical Society, is with South Texas Radiology Group in San Antonio and was recently elected as an alternate delegate of the Texas Delegation to the AMA. Dr. Silva is a Diagnostic Radiologist, with Vascular and Interventional specialization.

References: 1 - “The RVS Update Committee and its role in Physician Payment” - Ezequiel Silva, III, MD, San Antonio Medicine magazine, July 2019.

MEDICAL YEAR IN REVIEW

the Physician Workforce

By Chiquita Collins, PhD, MA

For several decades, Texas and the nation have been

faced with the possibility of a severe physician shortage.

In a recent report by the Association of American Medical

Colleges (AAMC), it is projected that a shortage of between 46,900 and 121,900 physicians will occur by 2032.

The number of new primary care physicians and other

medical specialists are not keeping pace with the demands of a growing and aging population.

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Source: US. Census Bureau. 2018 www.census.gov/quickfacts/fact/table/TX/PST045216.

The US federal government identifies areas experiencing a shortage of physicians and other health professionals as Health Professional Shortage Areas (HPSAs) in primary care, mental health care and dental care. These shortages may be geographicbased (a shortage of providers for the entire population within a defined geographic area), population-based (a shortage of providers for a specific population group within a defined geographic area – e.g., low income, migrant farmworkers, etc.), or facility-based (correctional facilities, state mental hospitals). HPSAs affect approximately 5.5 million Texans, most of whom represent individuals from diverse racial/ethnic backgrounds. According to the Health Resources and Services Administration, there are 462 HPSAs throughout Texas. Bexar County has a total of 12 HPSAs, half are Federally Qualified Health Centers or community-based health centers that receive direct federal funds to provide primary care services in underserved areas.

Texas is experiencing significant growth.

Approximately 28.7 million persons reside in Texas, which is 14.1% higher than the 25.1 million estimated in 2010. Recent data reveal that more than half of the Texas population, 57.6%, is of a race other than non-Hispanic white, according to the US Census Bureau.3 Texans of color are paving the way for a true melting pot of backgrounds, ideas, and perspectives, yet the number of physicians in the state do not mirror the general population. Texas is con-

sidered a “minority-majority” state whereby a sizable portion of individuals identify themselves as African-American, Hispanic or Latino, and Asian, and make up the majority of the population.

There’s little question Texas needs more physicians; however, the workforce shortage is particularly acute in communities of color. The Lone Star state’s biomedical workforce shortage and maldistribution issues are exacerbated by a mismatch in the diversity of the healthcare workforce and the populations they serve.

The physician workforce in the state of Texas should ideally mirror its population demographics, and even more so within its counties. The North Texas Regional Extension Center in its 2015 report, documented that the number of Hispanic physicians in Texas is about twice that of the national physician workforce, 8.7% in Texas compared to 4.6% nationally. Nevertheless, the number of Hispanic physicians in Texas is not representative of the Hispanic population in the state, nor is the number of black physicians in Texas representative of the black population. Both groups are significantly underrepresented.

Asian physicians, by contrast, are overrepresented relative to the general population of Asians in Texas. About 3,800 Spanish speaking physicians practice in Texas, which is equivalent to approximately 8.1% of the total physician population.4 Miscommunication and misinterpretation due to language barriers can lead to errors in

care and even create life-threatening situations which are largely avoidable.

Much success has been made with diversifying the entering class of medical schools with respect to gender. In 2018, for the first-time ever, women outpaced men in both applying to and enrolling in medical schools. Well-intentioned efforts aimed at increasing diversity in the medical profession are underway at many medical schools, yet the number of Hispanics and AfricanAmericans entering medical school remains lower than whites, and in some instances, has remain unchanged. For African-American males, the number of applicants to medical school is substantially lower than any other group and has remained stagnant for nearly 40 years. The AAMC reports that in 1978, 1,410 Black men applied to US medical schools, yet in 2014, that number was 1,337. In Texas, among the 10 accredited allopathic medical schools, the number of enrolled Hispanic and African-American is slightly comparable and in some instances higher than national rates.

One approach that has been identified as effective in addressing these healthcare workforce challenges is the “grow-yourown” strategy. Growing-your-own healthcare workforce means finding ways to recruit, develop, cultivate and retain individuals from the local region to enter healthcare careers that would allow them to serve their local community. This approach recognizes the idea that individuals that are raised within a local community are more continued on page 24

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likely to stay in that local community for their professional careers even if they leave to study in a different location. By recruiting, developing, and cultivating individuals from a community to become part of the healthcare workforce, they are more likely to be retained to serve their home base or areas that are in most need (e.g., medically underserved areas).

Grow-your-own strategies can also address the mismatch in diversity as the recruitment occurs within the local communities where diverse populations reside. This approach does not necessarily provide immediate healthcare workers that can enter the current labor force but is instead a long-term strategy that would enable local communities to more effectively address their longterm healthcare workforce needs.

Diversifying the biomedical workforce is not solely for the sake of change in population dynamics, but there are four significant reasons why diversifying the biomedical workforce is important: (1) to advance cultural competency, (2) increase access to high-quality health care services, (3) strengthen the medical research agenda, and (4) ensure optimal management of the health care system. It has also been widely documented that African-American, Hispanic, and Native American physicians are much more likely than white physicians to practice in medically underserved areas.

All health professions, and specifically medicine, have long been recognized as having a lack of diversity among individuals underrepresented in medicine which include but is not limited to Hispanics or Latinos, African-Americans, first-generation (someone whose parents/guardians did not complete a four-year college degree or a student raised by a single par24

San Antonio Medicine • December 2019

ent/guardian who did not complete a four-year college degree), low-income individuals and women.

It is by no surprise that Bexar County is growing and has become more racially and ethnically diverse than ever.

The number of Hispanic residents has grown from 1,006,958 in 2010 to 1,201,366 residents in 2018, an increase of 19.3 %. Although Hispanics have contributed to the largest growth, African-Americans and Asians have also contributed. Reports show there was a 44.8 % increase among Asian American residents since 2010, from 103,222 to 149,453 in 2018.3.

Meeting the needs of an ever-growing diverse population requires commitment and strategic investments. Recommendations might include expanding college-

level health professions programs, to increase the number of medical students committed to practicing in underserved areas; recruit and train students from underrepresented regions (i.e., rural counties, urban metros) and backgrounds and

MEDICAL YEAR IN REVIEW other under-resourced communities to practice in underserved areas; implement pipeline programs within the primary and secondary educational system that energize underrepresented students to pursue a career in healthcare and equip them with the skills needed to succeed; connect practicing physicians with college-students, including those from community colleges, to serve as mentors; provide scholarships for qualified students who pursue priority health professions and serve in underserved communities; develop and expand medical Spanish curricula and assess proficiency among medical students, and; incentivize out-of-state medical school graduates with meaningful loan repayment programs if they commit to primary care practice in Texas for a predetermined time (i.e., 5 years).

Chiquita A. Collins, PhD is the Chief Diversity Officer, Vice Dean for Inclusion and Diversity Associate Professor, Department of Population and Health Sciences at the UTHSA Joe R. & Teresa Lozano Long School of Medicine in San Antonio Texas.

REFERENCES 1. Association of American Medical Colleges. 2019. “New Findings Confirm Predictions on Physician Shortage.”

Press Release. Washington, DC: Association of American Medical Colleges. Accessed November 1, 2019.

2. Health Resources and Services Administration Shortage Areas https://data.hrsa. gov/tools/shortage-area/hpsa-find. Accessed November 1, 2019.

3. US. Census Bureau. 2018 www.census. gov/quickfacts/fact/table/TX/PST045

216. Accessed November 1, 2019.

4. The North Texas Regional Extension Center. 2015. The Physician Workforce in Texas: An Examination of Physician Distribution, Access, Demographics, Affiliations, and Practice Patterns in Texas’ 254 Counties. Accessed November 1, 2019.

5. Association of American Medical Colleges. 2018. “Women Were Majority of US Medical School Applicants in 2018.”

Press Release. Washington, DC: Association of American Medical Colleges. Accessed November 1, 2019.

6. Laurencin, C. & Murray, M. 2017. “An American Crisis: The Lack of Black Men in Medicine.” J Racial Ethn Health Disparities. Jun; 4(3): 317–321.

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MEDICAL YEAR IN REVIEW

CANNABINOIDS A Modern Doctor’s Dilemma

By J.J. Seidenfeld, MD

Background In 2019, Texas Gov. Greg Abbott signed into law a bill that lets Texas farmers grow hemp – and allows the sale of products such as CBD oil as long as they contain less than .3% of the psychoactive element in marijuana THC. HB 3703 made the following major changes to the 2015 Compassionate Use Act to include additional conditions: HB 3703 amended the Compassionate Use Act by adding conditions that may qualify for treatment with low-THC cannabis.

Now, the following conditions may qualify for treatment: epilepsy, seizure disorder, multiple sclerosis, spasticity, amyotrophic lateral sclerosis, autism, terminal cancer and “incurable neurodegenerative diseases” (INDs).

INDs are diseases designated by rule of the executive commissioner of the Texas Health and Human Services Commission. Also note that HB 3703 changed “intractable epilepsy” to just epilepsy. Now, patients should no longer have to wait until they have been treated unsuccessfully two or more times by “appropriately chosen and maximally titrated 26

San Antonio Medicine • December 2019

antiepileptic drugs” before seeking treatment with low-THC cannabis.

Because HB 3703 expanded the conditions qualifying for treatment with low-THC cannabis, it also, consequently, expanded the specialty physicians qualified to recommend treatment. To recommend treatment, a physician must register with DPS’ Compassionate Use Program, and the physician must: • Be licensed, • Be board certified by a specialty board approved by the American Board of Medical Specialties or the Bureau of Osteopathic Specialties in a medical specialty relevant to the treatment of the patient’s particular medical condition, and • Dedicate a significant portion of his or her practice to the evaluation and treatment of the patient’s particular condition.

Notably, DPS still has discretion to approve or deny the application. That means DPS can decide if the physician’s board-certified specialty is relevant to the treatment

of the patient’s particular medical condition.

DPS also can decide if the physician’s clinical practice is dedicated to evaluating and treating a “significant portion” of patients with the particular condition being treated.

The Dilema While the jury is out on these issues for medical professionals, law makers and enforcement officials, the public already has experience with these substances in large numbers, using it to reduce suffering and make the world a seemingly friendlier place, while there is suffering from abuse in some cases. Cannabis sativa, popularly known as marijuana, is a source of cannabinoids most notably CBD (cannabidiol) and THC (tetrahydrocannabinol). CBD containing products for ingestion such as gummy bears or brownies, vaporized liquids, raw plant material for smoking and skin lotions as well as body products are available at state-sanctioned (NOT in Texas) and licensed dispensaries where laws have legalized such use.

MEDICAL YEAR IN REVIEW There are also “Botanical” stores nationwide and of course internet sales sites. Buds and flowers or the entire marijuana or hemp plants are rendered both physically and by distillation to purify the active chemicals and often sold as an oil or resin as the plants yield terpenes (natural plant oils) and cannabinoids. Legality remains a question in some states. This is a complicated issue in Texas as all compounds containing THC are illegal, but hemp-based CBD is sold without prescription or prosecution, subject to DPS’ Compassionate Use Regulations.

The plant (or “weed” as some know it) has been cultivated and used by humans for recreational and medicinal for centuries and on many continents. More recently, the study of cannabinoids has not been governmentally allowed or supported and its therapeutic value has been scientifically assessed in only a few maladies.

Research on the endocannabinoid system and substances that affect these biochemical reactions and receptors reveal a system with possibly great potential to influence body systems. Presently, it is known that endocannabinoids have a role in the pathophysiology of many disorders. Conditions such as emesis, pain, inflammation, multiple sclerosis, anorexia, epilepsy, glaucoma, schizophrenia, cardiovascular disorders, cancer, obesity, metabolic syndrome related diseases, PTSD, Parkinson's disease, Huntington's disease, Alzheimer's disease and Tourette's syndrome might be treatable by drugs modulating the endocannabinoid system. Presently, cannabinoid receptor agonists like nabilone and dronabinol are used for reducing chemotherapy-induced vomiting. Sativex (cannabidiol and THC combination) has been approved for use in the UK, Spain and New Zealand to treat spasticity due to multiple sclerosis (in the US it is under investigation for cancer pain).

Another drug, Epidiolex (cannabidiol), is also under investigation in the US for childhood seizures. Rimonabant, CB1 receptor

antagonist, appeared as a promising antiobesity drug during clinical trials but it also was implicated as a cause of suicide. As a result, the US Food and Drug Administration did not approve Rimonabant for use in the US. Its sale was also suspended across the European Union in 2008. Recently, a clinical trial related to fatty acid amide hydroxylase (FAAH) inhibitor, was discontinued due to the occurrence of serious adverse events in the participating subjects. (ref 1-3) Research is being carried out to explore and establish the therapeutic targets for both cannabinoid receptor agonists and antagonists despite some negative effects in clinical trials related to drugs acting on endocannabinoid system. One challenge is to develop drugs that target only cannabinoid receptors in a specific tissue, and another is to invent drugs that act selectively on cannabinoid receptors located outside the blood brain barrier. In addition, development of the suitable dosage forms with maximum efficacy and minimum adverse effects is also warranted. (ref 4) Cannabis sativa is used to alter consciousness. It contains over 500 distinct chemical compounds, but the one of primary interest related to substance abuse is δ-9-tetrahydrocannabinol (THC). In some people, it causes hallucinations which may be debilitating. While some more randomized clinical trials are needed for some medical conditions, other medical disorders like chronic cancer and neuropathic pain as wells as certain symptoms of multiple sclerosis,

have substantial evidence supporting cannabinoid efficacy. While herbal cannabis has not met rigorous FDA standards for medical approval, specific well-characterized cannabinoids have met those standards.

In Texas, where medical cannabis is legal for only certain diagnoses, physicians must consider important patient selection criteria such as failure of standard medical treatment for a debilitating medical disorder.

Medical cannabis patients must be informed about potential adverse effects, such as acute impairment of memory, coordination and judgment, and possible chronic effects, such as cannabis use disorder, cognitive impairment, and chronic bronchitis. In addition, social dysfunction may result at work or school and there is increased possibility of motor vehicle accidents. Novel ways to use the endocannabinoid system are being explored to maximize benefits of cannabinoid therapy and lessen possible harmful effects.

Marijuana has been used widely as an appetite stimulant and antiemetic. Pure THC is the major active ingredient in marijuana, is the most psychoactive and is available by prescription as dronabinol. In doses of 5– 15 mg/m2, oral dronabinol is effective in treating nausea associated with chemotherapy, but it is associated with central nervous system side effects in most patients. Strains continued on page 28

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MEDICAL YEAR IN REVIEW continued from page 27

of medical marijuana with different proportions of various naturally occurring cannabinoids (primarily THC and cannabidiol [CBD]) can be chosen to minimize its psychoactive effects.

Medical marijuana laws appear to have contributed to increased prevalence of illicit cannabis use and cannabis use disorders; state-specific policy changes may also have played a role. While medical marijuana may help, some cannabis-related health consequences associated with changes in state marijuana laws should receive consideration by health care professionals and the public. (ref 5-8) Summary In summary, this is an area where doctors as lifelong learners will continue to see new information but are awaiting evidence-based recommendations. We will likely take a back seat to dispensary “baristas” and our patients’ experiences but should keep eyes on the literature to manage abuse, treat overdosage and use of adulterated products, and recommend new therapies when available.

J.J. Seidenfeld, MD is board certified in Pulmonary Disease and Internal Medicine and is a member of the Bexar County Medical Society.

References 1. J Basic Clin Physiol Pharmacol 2016: 27(3): 181-7. Cannabis- the Israeli Perspective. Mechoulam, R 2. CMAJ. 2019 August 19:191:E907-8 doi 10.1503. Medical Cannabis: strengthening evidence in the face of hype and public pressure. Fitzcharles, MA, Shir, Yoram, Hauser, Winfried 3. Ann Med. 2016;48(3):128-41. doi: 10.3109/07853890.2016.1145794. Epub 2016 Feb 25. Cannabinoids: Medical implications. Schrot RJ1,2, Hubbard JR3,4 4. Curr Clin Pharmacol. 2016;11(2):110-7.

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Therapeutic Target. Kaur R , Ambwani SR, Singh S. Department of Pharmacology, AIIMS, Jodhpur, Rajasthan, India. sidhurimple@yahoo.com. Abstract 5. Epilepsia. 2014; 55(6):791-802. Doi:101111. Cannabidiol. Pharmacology and potential role in epilepsy. Devinsky, O, Cilio MR, Cross, H et al 6. Current Medical Diagnosis and Treatment 2020. Maxine A. Papdakis and Stephen J. McPhee 15-02: Nausea & Vomiting Kenneth R. McQuaid 7. JAMA Psychiatry. 2017;74(6):579-588. doi:10.1001/jamapsychiatry.2017.0724

US Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws 1991-1992 to 2012-2013 Deborah S. Hasin, PhD; Aaron L. Sarvet, MPH; Magdalena Cerdá, DrPH; Katherine M. Keyes, PhD; Malka Stohl, MS; Sandro Galea, MD, DrPH; Melanie M.Wall, PhD Published online April 26, 2017.

8. Cannabis | The Substance Abuse Handbook, 2e | Pedro Ruiz and Eric C. Strain.

Chapter One

MEDICAL YEAR IN REVIEW

WHAT WE KNOW ABOUT LUNG INJURY

By John R. Holcomb, MD

HISTORY The term “vaping” refers to the use of various devices and techniques to produce an inhaled vapor from a liquid (usually oil) which serves as the delivery vehicle for a large variety of substances, commonly nicotine, tetrahydrocannabinol (THC), or other herbs and flavors that can be vaporized.

This activity is mentioned by the Roman statesman Cicero in reference to Herodotus, a Greek writer who used the technique circa 450 B.C. Egyptian hieroglyphics describe the use of hot rocks to vaporize herbs as early as the fifth century B.C., and devices such as shishas and hookahs have been in use in Afghanistan, India, and the Middle East for centuries.

The modern use of vaporizing devices was heralded by Joseph Robinson in 1927, who envisioned a “smokeless tobacco cigarette”, but he never capitalized on his design. In 30

San Antonio Medicine • December 2019

1965, Herbert Gilbert patented an e-cigarette prototype, similar to those in use today. A Chinese pharmaceutical company began manufacturing such a device in 2005, and began marketing it in the United States in 2007.

causative agent in the development of “popcorn lung”, a particularly aggressive form of bronchiolitis obliterans observed in factory workers exposed to high concentrations of diacetyl used as a flavoring in production of microwave popcorn.

USE Generally, currently used devices consist of a battery which heats a liquid-filled cartridge and aerosolizes any of a large variety of solubilized agents, including nicotine, tetrahydrocannabinol (THC), and cherry, cinnamon, mint and menthol flavors. Few analyses of these vapors have been undertaken (the FDA does not regulate these agents), but propylene glycol, liquid glycerin, acrolein, formaldehyde and diacetyl (2,3 butanedione) have been found in commercial brands; this last agent is of particular concern, as it has been identified as the

POTENTIAL BENEFITS There is ongoing controversy regarding the use of e-cigarettes, with proponents arguing that their use is likely to be an important harm-reduction technique in tobacco cessation programs, especially when the vapor includes nicotine. This concept is particularly in favor in Canada, New Zealand, and Great Britain, where hospitalized smokers are allowed to use e-cigarettes in the hospital. A study published in the New England Journal of Medicine (NEJM) in February of this year described a randomized trial of 886 adults assigned to a

MEDICAL YEAR IN REVIEW

smoking cessation program which included nicotine replacement by means of nicotinebased e-cigarettes, versus other means of nicotine replacement. The 1-year abstinence rate was validated biochemically at the last visit; 18% of the e-cigarette group were abstinent, versus 9.9% of those using other nicotine products. Public Health England, an executive agency of Public Health and Social Care of the United Kingdom has posted in the British Medical Journal that “e-cigarettes are 95% safer than smoking”.

E-CIGARETTE/VAPING ASSOCIATED LUNG INJURY (EVALI) In mid-summer of 2019, the Illinois and Wisconsin health authorities initiated a coordinated investigation into an apparent cluster of cases of severe lung injury in young healthy persons who reported recent e-cigarette use, and who presented with dyspnea, cough, pulmonary infiltrates, and for which there was no evidence of infection or other cause for the findings. In collaboration with the CDC, these observations were published in the September 6, 2019 issue of NEJM, which described 53 cases: median age was 19, 83% were male, and all presented with bilateral pulmonary infiltrates, respiratory complaints, and constitutional symptoms. Of these, 94% were hospitalized, 32% required intubation, and one died. A total of 84% reported recent use of THC via vaping.

CDC has since been receiving new reports from 49 states and the District of Columbia, totaling 1604 cases as of October 22, 2019 with 34 deaths, some of whom had used THC products exclusively.

CLINICAL FEATURES Symptoms at presentation have included dyspnea, chest pain, cough, nausea and vomiting, hemoptysis, subjective fever, and

fatigue. Vital signs demonstrated tachycardia, tachypnea, and hypoxemia. Median duration of symptoms prior to admission was 6 days. Laboratory findings included leukocytosis, elevated erythrocyte sedimentation rate, and normal procalcitonin levels. All have had bilateral infiltrates, either on chest radiographs or CT scans. Glucocorticoid therapy was administered in 92% of the cases; 65% were thought to have improved with glucocorticoid therapy. Lung biopsies were available in 17 cases; findings included acute fibrinous pneumonitis, diffuse alveolar damage, and organizing pneumonia, usually with bronchiolitis. Foamy macrophages and pneumocyte vacuolization were present in all. None of the biopsies demonstrated findings of lipoid pneumonia, which previously had been raised as a possibility.

single agent was used (80%), but many cases involved the use of 2 or more agents, such as nicotine and THC together. Since the makeup of many of the commercial liquids is unknown, there may be products in the carrier liquids that need further study.

Declared components in nicotine-based vaping agents include propylene glycol and glycerin as well as nicotine. When commercial vaping products have been analyzed, contaminants identified have included nitrosamines, toxic metals, and aromatic hydrocarbons. The flavoring compounds 2,3 pentanedione and diacetyl are of particular interest (as noted above, diacetyl has been identified as the cause of “popcorn lung”, in which the pathologic findings of bronchiolitis obliterens have been similar to those in the few available biopsies in EVALI patients).

CDC RECOMMENDATIONS FOR CASE IDENTIFICATION Confirmed case: 1. Use of vaping within 90 days before symptoms.

2. Bilateral pulmonary infiltrates.

3. Absence of pulmonary infection (negative viral panel, urine antigen for S. pneumonia and Legionella, negative PCR for influenza, and negative sputum culture or broncholalveolar lavage if done).

4. No underlying condition which is plausible as an etiology (cardiac, rheumatologic, neoplastic).

Probable case: 1. Use of vaping within 90 days before symptoms.

2. Bilateral pulmonary infiltrates.

3. Clinical team finds no plausible alternative diagnosis.

CURRENT CDC RECOMMENDATIONS: 1. As products containing THC, especially when obtained off the street or from family and friends, are linked to a majority of reported EVALI cases; persons should not use e-cigarettes obtained in that manner.

2. Persons should not add any substances to a commercially-purchased e-cigarette.

3. Although only a small percentage of patients with EVALI reported use of only nicotine in their vaping, CDC recommends not using nicotine-containing ecigarettes.

4. CDC recommends that youths, young adults and pregnant women not vape.

POTENTIAL CAUSATIVE AGENTS THC is the most common exposure identified in the available reports when a

John R. Holcomb, MD is board certified in Pulmonary Diseases, Internal Medicine and Critical Care Medicine and is a past President and member of the Bexar County Medical Society.

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UT HEALTH

OPIOID USE DISORDER

NEW INITIATIVE SEEKS TO TURN TIDE ON

By William L. Henrich, MD, MACP

Most of us know someone who has been touched by substance use disorder, if not in our practices, in our families, friends and communities.

Research has shown that substance use disorders are a leading cause of disease and death in the United States and directly cause cancer, overdose death, psychiatric disorders and suicide. In fact, the number of deaths each year from drug-related overdoses in the US has more than tripled since 2000, with opioid overdose as the leading cause of accidental death. And for every substance-related death there are tens of thousands of other people struggling with substance use. It is one of the biggest public health challenges of our time.

The good news is that substance use disorders are treatable with evidence-based treatments. And we, as health care providers, have the opportunity to turn the tide on this issue and save lives.

To do this, we must overcome three barriers. They include access to high-quality, evidence-based care for patients; affordable treatment; and awareness of helpful resources in a society in which substance use disorder is heavily stigmatized.

While the first two barriers are quite formidable, the third barrier may be the most difficult. Substance use concerns are often kept secret until a crisis occurs. Family members, friends and others may not know where to seek help or how to navigate our complex health care system. People struggling with substance use and their families likely fear judgment. These things make early screening and identification of substance use disorder a real problem.

We now have an opportunity to change these barriers into opportunities, and I am seeking your help.

UT Health San Antonio has just received a $7.2 million annual contract from the Health and Human Services’ Texas Targeted Opioid Response to create the Texas Medication for Opioid Use Disorder (TxMOUD) initiative. This initiative will help address the challenge of providing access to high-quality, lifesaving care to Texans regardless of their ability to pay.

Jennifer Sharpe Potter, Ph.D., M.P.H., will lead this effort. She is a professor of psychiatry and behavioral sciences and vice dean for research in the Joe R. and Teresa Lozano Long School of Medicine.

She is a national expert in opioid use disorder research and care, and has been actively involved in local and state efforts.

Within the Bexar County Opioid Task Force, Dr. Potter created and led the San Antonio Substance Use Symposium, a community32

San Antonio Medicine • December 2019

wide forum to discuss solutions to the opioid crisis. After coordinating two annual symposiums on our campus, Dr. Potter has moved the 2020 symposium, to be held May 1-3, to the Henry B. Gonzalez Convention Center to meet growing demand.

When it was learned that there were only 1,500 health providers in Texas qualified to prescribe buprenorphine, Dr. Potter obtained a $1 million state contract to create a streamlined training program to help doctors, nurse practitioners and physician assistants obtain the necessary DEA waiver to prescribe buprenorphine, an FDAapproved medication for opioid use disorder that can be prescribed as an outpatient treatment.

Beginning in fall 2018, her team took the training to communities throughout the state. Just nine months later, more than 450 new providers have received the waiver through her successful GetWaiveredTX program.

The new TxMOUD initiative builds on this success by addressing critical needs. First, it provides training and technical assistance for health care providers who are treating or considering providing opioid use disorder treatment in their practices. Second, the initiative funds treatment and medications (buprenorphine and naltrexone) for underserved citizens in need. Third, TxMOUD serves as a platform for research that will benefit the residents of San Antonio, Bexar County and Texas.

We are proud to have a hand in turning the tide against opioid use disorder and ask that you join this collaborative effort so that TxMOUD will become not only a model for Texas, but also a blueprint for successful treatment throughout the US If you are interested in learning more about TxMOUD, the San Antonio Substance Use Symposium, or becoming more involved with opioid use disorder research through UT Health San Antonio more broadly, please visit www.txmoud.org or call 210-450-5370.

This is truly our opportunity, by working together, to make lives better.

William L. Henrich, MD, MACP, is president of UT Health San Antonio and professor of medicine in the university’s Joe R. and Teresa Lozano Long School of Medicine. With missions of teaching, research, healing and community engagement, UT Health San Antonio is one of the country’s leading health sciences universities. www.UTHealthSA.org.

BCMS LEGISLATIVE NEWS

BCMS IN THE CAPITAL 1. Standing (l-r): State Senator Jose Menendez (District 26) visits with Varda and Adam Ratner, MD, during a reception honoring Sen. Menendez at Club Giraud on Oct. 10 hosted

by Gordon Hartman and Harvey Najim.

2. Standing (l-r): Martha Vijjeswarapu, TMA Alliance president-elect; John Nava, MD; Rep. Philip Cortez (House District 117); and Janet Realini, MD met Oct. 17 at Rep. Cortez’ district office in San Antonio and presented him with a plaque on behalf of the Texas Medical Association for his support of medicine’s issues during the 86th Legislative Session.

3. BCMS physician members, Alliance member, medical student and staff met with Congressman Chip Roy (TX-21) on Oct. 8 in the Congressman's San Antonio district office to discuss the latest happenings in Congress on medicine issues.

Standing (l-r) are: John Shepherd, MD; BCMS Alliance member Jenny Shepherd; Congressman Roy; Mary Nava, BCMS chief government affairs officer; Dan Deane, MD and Marc Ghosn, medical student at the UIW School of Medicine.

4. Alex Kenton, MD (left), pauses for a photo with State Senator Jose Menendez (District 26) on Oct. 10 during a reception hosted by Gordon Hartman and Harvey Najim in honor of Sen. Menendez at Club Giraud.

5. Standing (l-r): Bernard Swift, Jr., MD; John Shepherd, MD; State Senator Donna Campbell (District 25); Jenny Shepherd; David Shulman, MD and John Menchaca, MD visit during a reception held in honor of Sen. Campbell at Club Giraud on Nov. 6.

6. Standing (l-r): Michael Battista, MD; Rep. Trey Martinez Fischer (House District 116); Mary Nava and Jenny Shepherd met Nov. 19 at Rep. Martinez Fischer’s district office in San Antonio and presented him with a plaque on behalf of the Texas Medical Association for his support of medicine’s issues during the 86th Legislative Session.

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BCMS LEGISLATIVE NEWS

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PHYSICIANS PURCHASING DIRECTORY Brought to you by the BCMS Circle of Friends

By supporting these sponsors with your patronage, you are supporting the BCMS. ACCOUNTING FIRMS Sol Schwartz & Associates P.C. (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”

ARCHITECTURE LK Design Group, Inc. (HH Silver Sponsor) LK Design Group has over 24 years of experience designing various medical and hospital buildings. We have experience in both ground up developments and re-design of interior spaces for medical professionals.

Lynn Kuckelman Peters President 210-824-8825 Lynn.p@lkdesigngroup.com Kristin Savage Director of Business Development 210-824-8825 Kristin.s@Lkdesigngroup.com www.lkdesigngroup.com

ATTORNEYS

Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on

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San Antonio Medicine • December 2019

workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence.

Kathleen Barrow Partner 512-382-8796 kbarrow@constangy.com Ashlee Mann Ligarde 512-382-8800 aligarde@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”

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 na-

tional ranking for healthcare law according to US News & World Report and Best Lawyers”

ASSETS ADVISORS/ PRIVATE BANKING

BB&T (HHH Gold Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services — BB&T offers solutions to help you reach your financial goals and plan for a sound financial future.

Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com www.bbt.com/wealth/start.page "All we see is you"

512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future.

Joseph Bieniek Vice President Small Business Specialist 210-247-2985 jbieniek@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability.

We work hard and together with our clients to accomplish great things.

Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle.

Moses D. Luevano Market President

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com Daniel Ganoe Mortgage Loan Originator 210-283-5349 www.broadwaybank.com “We’re here for good.”

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

Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals.

Synergy FCU Member Service (210) 750-8331 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

DIAGNOSTIC IMAGING

Touchstone Medical Imaging (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity.

Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

BUSINESS CONSULTING Waechter Consulting Group (HH Silver Sponsor) Want to grow your practice? Let our experienced team customize a growth strategy just for you.

Utilizing marketing and business development tactics, we create a plan tailored to your needs!

Michal Waechter, Owner (210) 913-4871 Michal@WaechterConsulting.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

COMMERCIAL PROPERTY MANAGMENT

Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton.

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com

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

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection.

Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor

210-278-3813 Tiffany_briggs@ml.com Rene Farret Wealth Management Advisor 210-278-3806 rene_farret@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Jon M. Tober SWBC Mortgage—Sr. Loan Officer NMLS #212945 (210) 317-7431 jon.tober@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

specialized products and services to meet the challenging demands of their career and lifestyle.

Moses D. Luevano Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”

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" Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

HEALTHCARE BANKING 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!”

BankMD (HHH Gold Sponsor) We believe Physicians deserve

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

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visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY continued from page 37 Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

HEALTHCARE CONSULTING

recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

INSURANCE

CareAllies (HHHH 10K Platinum Sponsor) CareAllies works side-by-side with health care providers to accelerate the transition to valuebased care, helping improve the quality, value and experience of care for patients and make health care better for everyone.

Sabrina Moreno, Network Operations Senior Manager (713) 437-3088 X 523088 Sabrina.Moreno@careallies.com info@careallies.com https://www.careallies.com/ “For Better Health and Better Business”

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

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TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

Jon Buss: 512-338-6167

Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

OSMA Health (HHH Gold Sponsor) Health Benefits designed by Physicians for Physicians.

Bill Brooks Senior Vice President (214) 329-4584 BBrooks@abadmin.com www.osmahealth.com/ “People you know Coverage you can trust”

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems William J. Trijullo Medical Services Representative 210-800-5500 wtrujillo@acumen.systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a checkup?

Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL FURNITURE

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

MEDICAL PRACTICE

UT Health Physicians (HHH Gold Sponsor) UT Health Physicians, the faculty practice of UT Health San Antonio, features the region's most comprehensive array of specialists & sub-specialists. Now offering free, secure access to your patients’ records. Most health plans accepted.

For referrals or questions, contact: Jose Gamez, Director, Physician Relations (210) 450 8347 GamezJ4@uthscsa.edu www.UTHealthcare.org “Offering daily grand rounds with no-cost CME to local physicians since 1969.”

MEDICAL SUPPLIES AND EQUIPMENT Henry Schein Medical (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.”

MORTGAGE

PrimeLending (HHH Gold Sponsor) Doctor Loans, Construction Loans, VA Loans, Conventional and FHA Loans.

Cleo Garza Sr. Loan Officer NMLS#218858 210-483-4907 cleo.garza@primelending.com

www.lo.primelending.com/cleo.garza Home Loans Made Simple

OFFICE FURNITURE

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

PRACTICE SUPPORT SERVICES

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Debbie Marino SWBC Employee Benefits, SVP Corporate Relations (210) 210-525-1248 DMarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more

efficient and profitable, and aims to accelerate their growth with proven successes and systems William J. Trijullo Medical Services Representative 210-800-5500 wtrujillo@acumen.systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up?

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio.

Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent

210-560-1443 matt.evans@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton.

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

KW Commercial (HHH Gold Sponsor) We specialize in advising Medical Professionals on the viability of buying & selling real estate, medical practices or land for development Marcelino Garcia, CRE Broker Assciate 210-381-3722 Marcelino.kwcommercial@gmail.com Leslie Y. Ayala Business Analyst/ CRE Associate 210-493-3030 x1084 Leslie.kwcommercial@gmail.com www.GAI-Advisors.com “Invaluable Commercial Real Estate Advice for The Healthcare Professional”

RETIREMENT PLANNING

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection.

Mike Bertuzzi Senior Financial Advisor

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PHYSICIANS PURCHASING DIRECTORY continued from page 39 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Ben Taylor Wealth Management Advisor 210-278-3802 ben_taylor@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Donna Bakeman Office Manager 210-301-4362 dbakeman@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELECOMMUNICATIONS ANSWERING SERVICE

TAS United Answering Service ( Gold Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7.

Dan Kilday Account Representative 210-258-5700 dkilday@tasunited.com www.tasunited.com “We are the answer!"

For questions regarding services, Circle of Friends sponsors or joining our program please contact August Trevino, Program Director at 210-301-4366, August.Trevino@bcms.org, bcms.org/COF.html

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San Antonio Medicine • December 2019

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San Antonio Medicine • December 2019

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

We will locate the vehicle at the best price, right down to the color and equipment.

We will put you in touch with exactly the right person at the dealership to handle your transaction.

We will arrange for a test drive at your home or office. We make the buying process easy!

When you go to the dealership, speak only with the representative indicated by BCMS. GUNN AUTO GROUP

GUNN AUTO GROUP

11001 IH 10 W at Huebner San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Esther Luna 210-690-0700

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Ford 12300 San Pedro San Antonio, TX

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Marty Martinez 210-525-9800

Cavender Audi Dominion 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Rick Cavender 210-681-3399

Gary Holdgraf 210-862-9769

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Subaru 9807 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

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

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

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

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

Sandy Small 210-341-8841

James Cole 800-611-0176

Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

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

AUTO REVIEW

2020 Ford F-150 Turbo Diesel

By Stephen Schutz, MD

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San Antonio Medicine • December 2019

AUTO REVIEW This is a strange time for diesel engines in the automotive industry. Passenger cars with diesel engines are being phased out quickly, while at the same time their use is increasing in light trucks. Hmm. Sprinter vans and the like have offered diesel engines for years, and that’s not changing, but in the last few years, Ram, Nissan, GM, and in 2019, industry sales leader Ford have started selling half ton pickups with diesel engines. This was formerly the purview of heavy duty three quarter or one ton pickups only, but now everyday trucks are getting in on the action.

It should be noted that diesel engines are slowly being muscled out of the global marketplace. European and Chinese regulations in particular are very tough on particulates, which diesels emit more than gasoline engines, so it makes sense. Still, while electric powered vehicles clearly represent the future, it’s interesting that diesel pickup trucks are actually increasing in number in this country and seem to be selling well.

If you ignore regulatory pressures, diesel engines are attractive because they provide excellent fuel economy as well as good drivability. A German auto executive I can’t recall summarized, very succinctly, why car buyers like diesels: torque and range.

Pickup trucks that are designed to tow trailers and carry loads are ideally suited for torquey and efficient diesel engines. We’ll see what happens to the diesel engine over time, but in the meantime I’m pleased to see one offered in the popular F-150.

For readers who may not be aware, the current (thirteenth) generation F-150, launched in 2015, differs from its competitors the Chevrolet Silverado, Ram 150, and Toyota Tundra primarily in its construction, which is aluminum intensive. While the weight savings from using aluminum body panels and other components are significant, there may be durability concerns, as Chevy ads have highlighted, where heavy cement blocks are dropped into F-150 beds. Nevertheless, real world usage, during which buyers are likely to put much less damaging items like dog kennels and dirt bikes back there, probably won’t result in any more wear than owners of the competition experience.

I’ve reviewed the current (gasoline powered) F-150 previously, so I won’t repeat what I’ve written before about its interior (nice but not quite as nice as the Ram’s) and exterior (still best-in-class and much better looking than the Silverado’s). Instead I’ll focus on the diesel engine and what makes the oil burning F-150 different from the other ones.

For the record, the 3.0 liter turbo diesel in the F-150 isn’t really

new. In fact, it’s a beefed-up version of an engine that was jointly developed a few years ago for use in Europe and elsewhere by Ford and Peugeot, the company that’s about to merge with FiatChrysler, the makers of the Ram pickup. How’s that for ironic?

Oh by the way, Land Rover uses the same engine manufactured at a plant in England in the Range Rover, Range Rover Sport, and Land Rover Discovery.

Also btw, Ram isn’t offering a diesel engine in its half-ton pickup this year, although I’m told it will reappear in 2020 (assuming Peugeot approves.....)

Anyway, if this were a twitter review, I’d start by typing #torqueandrange because those are the factors that make the diesel stand out from other F-150s. Ok, yes, the 3.5 liter Ecoboost has even more power and torque (375HP and 470lb-ft respectively), but at 17MPG city and 23MPG highway, it can’t compete with the diesel’s fuel economy numbers of 22 city and 30 highway.

The F-150 diesel engine’s output numbers are 250HP and 440lb-ft of torque, and the only available transmission is a 10speed automatic. And, while you get a decent amount of grunt and towing ability from the diesel, it’s not as muscular as the 3.5 Ecoboost.

It should be noted that choosing the diesel option in the F-150 costs an additional $3000 to $4000 depending on which version of the F-150 you select (and it can’t be the XL or XLT, those can only be diesels if you’re a fleet customer).

Now is where I remind potential buyers that diesel engines typ-

ically get better fuel economy than the EPA predicts, while gasoline and (especially) hybrids do worse. Remember that as you calculate how long you’ll need to own a diesel F-150 before the fuel savings overcome the extra cash diesels cost.

Diesel engines may be dying, but they’re experiencing a bit of a renaissance in the half-ton pickup world. I’m a diesel fan, so I’d choose an oil burning F-150 over an EcoBoost any day. But the EcoBoost offers more power for less cost, so I suspect most buyers will go with that engine option.

To get your best deal on a new F-150, call Phil Hornbeak at BCMS 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 US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

visit us at www.bcms.org

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Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of November 19, 2019.

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San Antonio Medicine • December 2019