COVID-19 and Pre-Clinical UME at UIW School of Osteopathic Medicine

By Adam V. Ratner, MD, FACR

Medical school has surely changed since I was a student way back in the last millennium. Back then, in the first two years of medical school, we spent hours every weekday sitting in lectures while trying not to daydream. At night and on weekends we crammed and binged, trying to memorize the material that we would purge onto the next test and shortly thereafter, forget.

At the University of the Incarnate Word School of Osteopathic Medicine (UIWSOM), our case-based, team-oriented, student-directed learning curriculum is built on active engagement and interaction between medical students and faculty facilitators. Every Monday through Friday morning, first and second-year medical students work in small groups and larger teams with faculty facilitators to learn, discuss, and critically think through clinical situations, their basic science and socioeconomic underpinnings, and humanistic consequences.

This curriculum requires the presence and active engagement of students at a far higher level than just sitting in a classroom or watching a video screen. That said, since the inception of the school we had debated the merits of allowing students who were unable to attend a session for personal reasons or mild illness to be able to join sessions remotely. The founding leaders of UIWSOM had made the investments in the appropriate IT infrastructure to allow the use of technologies to support remote learning.

In early 2020, the leadership at UIWSOM began discussing the potential effects of a possible epidemic on our medical school. When it became apparent that the COVID-19 pandemic had reached San Antonio by the second week of March, we were prepared. Our office of Medical and Interprofessional Education trained the faculty, staff, and students in the art of Zoom teleconferencing. We converted our highly interactive live curriculum into a virtual one, literally over a single weekend.

I remember I was most concerned about adequate bandwidth and power of the Zoom servers, but my fears were unfounded. All things considered, the transition has been astoundingly successful but, of course, not perfect.

The lack of in-person interaction has created a myriad of challenges. Without in-person guidance and oversight it’s not possible to convey the nuances of performing ideal history and physical examinations or osteopathic manipulative techniques. The good news is that students are learning practical telemedicine skills much earlier now than in the past.

Just as importantly, the lack of real person-to-person interaction adds to loneliness and isolation among medical students. Most medical students (and faculty) are able to develop strong camaraderie with colleagues. This camaraderie just isn’t quite the same on Zoom teleconferences.

From its inception, UIWSOM has always emphasized the humanism required to be a caring and effective physician. One way we support physician humanism is this through addressing the behavioral health needs of medical students and faculty. We have increased our behavioral health resources and created new programs to address these mental health challenges in the COVID-19 learning environment.

As of the time I write this (late October 2020), we are developing a thoughtful and controlled plan to bring our pre-clinical medical students back on campus for the hands-on clinical skills training they have missed in the past few months. We will continue to seek the best possible balance to continue our mission of creating the next generation of sorely needed, primary care physicians while seeing the resurgence of COVID-19 cases across the country and the world.

Stay tuned.

Adam V. Ratner, MD, FACR is Professor of Radiology, Health Policy, and Medical Humanities and Assistant Dean of Strategic Initiatives at UIWSOM. He is also Chairman of The Patient Institute and 2019 President of the Bexar County Medical Society

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ASSETT WEALTH MANAGEMENT

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MEDICAL PHYSICS

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PRACTICE SUPPORT SERVICES

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PROFESSIONAL ORGANIZATIONS

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BURNOUT: Symptom of Moral Injury at the Workplace or Something More? A Thought Analysis

By Rodolfo (Rudy) Molina MD MACR FACP

The word and concept of “burnout” is becoming better known and now more often written about in medicine. What is it? The Oxford Dictionary notes the first use of burnt out was in 1837 describing elder nobleman. In 1926, the term burnt out was used to describe a young woman’s demeanor. So, I did a PubMed search using the terms burn out or burn-out from 1926 through 2020. There were no references to burn out up until the early 1970s. From 1970 through 1979, there were a total of sixty-five articles published that mentioned burn out. Thereafter, a steady increase in the number of articles mentioning burnout appear in our literature. A sampling of the number of articles published each in the following years gives us a sense of the continual increase and interest in this subject.

In 1980, 32 articles were published dealing with burnout; in 1990, 161 articles; in the year 2000, 329 articles were published; and in 2019, 1,644 articles were published. The concept of burnout has become so prominent, the World Health Organization (WHO) designated burnout with the ICD10 code of Z73.0. This code defines burnout as circumstances which influence the patients’ health status, but not a current illness or injury and one that is unacceptable as a principal diagnosis. The ICD -11 code, QD85, more clearly defines and characterizes burnout as a chronic workplace stress that has not been successfully managed. It refers specifically to this phenomenon in the occupational context and states it should not be applied to other experiences in other areas of life. It goes further by describing three characteristics:

1. Feeling of energy depletion or exhaustion, 2. Increased mental distance from one’s job or feeling of negativism or cynicism related to ones’ occupation, and 3. Reduced professional efficacy.

The WHO recognizes these as symptoms arising from the stress of one’s occupation. We have heard about burnout in other occupations such as policing, fire fighters, as well as field and service workers during the pandemic. The stress of constant re-entry into a hazardous job is considered a factor that leads to burnout.

If burnout is a description of a symptom complex associated with one’s occupation, then the root of the problem would be the stressors of that particular occupation. Jonathan Shay began to talk about combat stress in October 1991, comparing it to what was described in Homer’s Iliad and the soldiers who returned from battle. He then wrote about the Achilles in Vietnam in 1994, discussing severe cases of Post-Traumatic Stress Disorder. These solders were trained to commit legal criminal acts and after they witnessed horrific battle scenes, they then returned to civilian life where they could no longer trust their leaders. Why? They were suffering from what he termed a “moral injury”, defined as “a betrayal of what’s right by someone who holds legitimate authority in a high-stakes situation, so that there can be personality changes and complications in treating the post-trauma injury.” In the case of the Vietnam vets, there were frequent complaints of being issued M-16 rifles that malfunctioned, or being sent out on patrols where they felt like sitting ducks in difficult and unfamiliar terrain by commissioned officers corps. Moral injury has been applied to our medical profession as the root for burnout. As I read through the literature, I thought the idea of moral injury should be expanded to more completely address the issue of burnout. Over my last forty-one years (nine in the military and 32 in private practice) that I’ve been practicing medicine and hearing my colleagues speak of their issues and problems with their practices, I’ve pondered the idea of burnout. This has led me to the following analysis of the problem. I believe there are three areas of activity that we have to be managed successfully to address and prevent burnout. And if any one of these areas fails, burnout is eminent for the other two cannot compensate. The three areas are:

1. Resilience (self-motivation), 2. Life balance, and 3. Control of the workplace.

I’ll discuss each individually. I do want to clarify that this analysis applies to the individual who continues to try working at 100%, despite failing in any one of these three areas.

Resilience is our ability to overcome

hardship. As physicians, or a healthcare provider such as a Nurse Practitioner or Physician Assistant, we have all spent long hours to get our degrees. Completing medical school, internship, residency (and in some cases fellowships) we have endured numerous hardships to get where we are today. So, I would say that most of us have a healthy dose of resilience and self-motivation that empowers our ability to be the physicians and caretakers that we are. However, over time some of us might incur an illness, physical or mental, that could wear on our resilience. Chronic pain or depression can and does impede our ability to continue treating patients successfully. And of course, there is age to consider. With aging comes slower response rates and less energy. Most of us who are older just cut down our hours in clinic or find another job that is less demanding to avoid the frustration of not staying on time with our clinical load. For my younger readers, I hope there are many, many years ahead of you before you can possibly (and never do) relate to what I just wrote about aging. If we lose our resilience, I believe burnout is imminent. As an FYI, our medical society provides a free personal consultation for members who wish to discuss, in confidence, a personal matter with a licensed medical psychologist by linking to LifeBridge on our website.

Life balance speaks to our ability to find other outlets for our mental and physical

well-being. For some, it’s raising a family and enjoying the time going to soccer games, talent shows and other activities. I’m always intrigued, but no longer surprised, to hear about our talented physicians that enjoy painting, playing an instrument, composing music, writing, hiking, bicycling, traveling, etc. The list of activities outside of medicine that my colleagues enjoy is long and, for me, gratifying to hear of their endeavors and adventures. We need that time to replenish and refocus our energies as we return to our demanding profession. Without these outlets we risk the development of burnout. However, having these other activities is not enough to avoid burnout. There is number three of my analysis.

Control of the workplace is a challenge and it starts on the day we see our first pa-

tient. For most of us, we spent almost a decade of training for this moment and our training was all about developing a doctor-patient relationship. Then, on that first day of seeing our patient, we are confronted with numerous barriers between us and the patient. One, insurance companies that restrict testing have limited the resources for the patient including a limited list of providers in their network and, if it’s an HMO, a delay in treatment on the day of the office visit. Two, an EMR (electronic medical record) that will oblige you to become more proficient with its use in order to see the required number of patients needed to pay for your overhead and your salary. Three, regulatory demands for documentation in order to bill an acceptable level. The number of metrics and type of metric are and continue to be a work in progress. The metrics are redundant in their need to be documented at each office visit and all too often arbitrary and superfluous to the actual care needed for that visit. Four, the dreaded priorauthorization (PA) required by the pharmacy benefits managers (PBMs). PBMs are the “unchecked” entities that profit the most from the kick-backs, termed as rebates, they get from the pharmaceutical companies. Based on their rebates, they create a formulary unique and profitable to them and restrictive to our patients. PAs have been shown to delay or deny treatment and increase the administrative time and cost to providers. These four intrusive barriers can be and are a frustration we confront on a daily basis. Herein lies the moral injury, the betrayal by the system that is supposed to allow us to give our patient the best care we can. The care that we have so diligently trained for and so desperately want to administer.

How did we get here? One possible explanation is the increasing regulatory laws that are well meaning but short-sighted. A PubMed search for the number of healthcare laws created over the last few decades revealed a steady increase in their number. In the decade of the 1970s, we have a total of seventy laws passed dealing with healthcare policy. Thereafter, the number of healthcare policy laws increase steadily and exponentially. In this last decade, from 2010 thru 2019, there were 1,271 laws passed. The curve for the number of healthcare policy laws passed matches the curve of the number of articles written about burnout. The control of our work place has been systematically striped from our hands and passed into the hands of administrators, law makers, insurance companies and PBMs. We, who take care of our patients, have lost control and therein lies the consequential burnout for some.

All three of these areas, resilience (self-motivation), life balance, and control of the workplace are equally important and, in my view, require examination if we recognize burnout in one of our colleagues. Regaining control of our doctor-patient relationship is a must and we should all feel obliged to develop a relationship with our policy makers. I hope this “thought analysis” of burnout in our profession will lead to a broader conversation on this very important topic.

Rodolfo (Rudy) Molina MD MACR FACP is a Practicing Rheumatologist and 2021 President-elect of the Bexar County Medical Society.

Consider These Year-end Financial Moves

By Elizabeth Olney

We’re nearing the end of 2020 –and for many of us, it will be a relief to turn the calendar page on this challenging year. However, we’ve still got a few weeks left, which means you have time to make some year-end financial moves that may work in your favor.

Here are a few suggestions: • Add to your IRA. For the 2020 tax year, you can put in up to $6,000 to your traditional or Roth IRA, or up to $7,000 if you’re 50 or older. If you haven’t reached this dollar limit, consider adding some money. You actually have until April 15, 2021, to contribute to your IRA for 2020, but the sooner you put the money in, the quicker it can go to work for you. Plus, if you have to pay taxes in April, you’ll be less likely to contribute to your IRA then.

• Make an extra 401(k) payment. If it’s allowed by your employer, put in a little extra to your 401(k) or similar retirement plan. And if your salary goes up next year, increase your regular contributions.

• See your tax advisor. It’s possible that you could improve your tax situation by making some investment-related moves. For example, if you sold some investments whose value has increased, you could incur capital gains taxes. To offset these gains, you could sell other investments that have lost value, assuming these investments are no longer essential to your financial strategy. Your tax advisor can evaluate this type of move, along with others, to determine those that may be appropriate for your situation.

• Review your investment mix. As you consider your portfolio, think about the events of these past 12 months and how you responded to them. When COVID19 hit early in the year, and the financial markets plunged, did you find yourself worrying constantly about the losses you were taking, even though they were just on “paper” at that point? Did you even sell investments to “cut your losses” without waiting for a market recovery? If so, you might want to consult with a financial professional to determine if your investment mix is still appropriate for your goals and risk tolerance, or if you need to make some changes.

• Evaluate your need for retirement plan withdrawals. If you are 72 or older, you must start taking withdrawals – technically called required minimum distributions, or RMDs – from your traditional IRA and your 401(k) or similar retirement plan. Typically, you must take these RMDs by December 31 every year. However, the Coronavirus Aid, Relief, and Economic Stimulus (CARES) Act suspended, or waived, all RMDs due in 2020. If you’re in this age group, but you don’t need the money, you can let your retirement accounts continue growing on a tax-deferred basis.

• Think about the future. Are you saving enough for your children’s college education? Are you still on track toward the retirement lifestyle you’ve envisioned? Or have your retirement plans changed as a result of the pandemic? All of these issues can affect your investment strategies, so you’ll want to think carefully about what decisions you may need to make.

Looking back – and ahead – can help you make the moves to end 2020 on a positive note and start 2021 on the right foot.

Elizabeth Olney, is an Edward Jones Financial Advisor and is a member of the BCMS Circle of Friends. Edward Jones, Member SIPC

By Stephen Schutz, MD

In the 1950s and ‘60s sports cars with two doors like MGTDs, Porsche 911s, and muscle cars were all car enthusiasts wanted. Then in the ‘70s and ‘80s sports sedans such as the Mercedes 6.9, BMW M5, and Saab 9000 turbo (remember that?) grabbed our attention. Now it’s SUVs.

And why not? A Porsche Cayenne Turbo S can lap the Nurburgring as quickly as the 1980s supercar Porsche 959, and a Lamborghini Urus SUV can do it even faster. The combination of turbocharging, all-wheel drive, torque vectoring, and traction/suspension management software has resulted in the ability to make SUVs go really really fast.

Enter the 2021 BMW X5M, a hyper-SUV (I just made that up— give me credit if it catches on) which is pretty much an M5 sedan with a higher center of gravity and more space (and weight).

Driving the X5M is surprisingly similar to being behind the wheel of the M5. Explosive acceleration accompanied by a raucous V8 soundtrack is what happens when you hit the gas. And be careful when you do that, not because you’re approaching the X5M’s limits—they’re prodigious and much higher than yours—but because just five or so seconds after you nail the throttle at 60mph you’ll be going 120MPH.

Despite a curb weight of 5425lbs (!), the X5M can handle almost as well as its M5 brother because of the aforementioned tech-enabled advancements. Cornering is neutral at any speed (at least any sane speed), and the big Bimmer is very stable on the highway as well. And thanks to a wide track and lowered suspension, the X5M isn’t “tippy”.

Nevertheless, that tuned suspension combined with bigger diameter wheels and low profile performance tires give the X5M a “sporty” ride, which borders on harsh if the pavement’s not smooth.

On the highway, on the other hand, everything’s wonderful. Not only is the ride comfortable and wind noise subdued, but the gearing is such that the engine is relaxed at any speed. I spent a lot of time between 75 and 90MPH and the X5M was quiet and very much in its element the whole time. And all that power and torque means that passing is a snap. In fact, the ability to pass quickly and effortlessly even at high speeds may be the best reason to buy an X5M (or M5 for that matter).

For the record, the X5M sprints from 0-60MPH in 3.6 seconds, but guzzles premium gasoline at a rate of 13 MPG City/18 Highway.

Naturally, driving the largest and heaviest BMW M-vehicle off road would be stupid. Would you hurt it? Probably not, but, even though it’s an SUV; this beast is about as much of an off-roader as a Ferrari.

It sure doesn’t look like a Ferrari though. Instead it looks like, umm, an X5. That’s either good or bad depending on your point of view. If you want your neighbors to recognize instantly that you spent $120,000 (and possibly more) on your hyper-SUV, then you’re likely to be disappointed. On the other hand, if understatement is your thing, then you’ll like the X5M.

There’s less understatement inside the X5M’s cabin where numerous M-badges and classic M blue and red accents serve as reminders that you own a special machine connected with such automotive icons as the M1 supercar, E30 M3, and wish-I-had-one E34 M5. I could do without the bold X5M badges on the seat backs (which light up at night), but the two tone seating surfaces with diamond stitching certainly look good.

Of course, at this price point there needs to be luxury, and there's plenty of that. The interior materials are first rate, and there’s tech galore easily accessible via the rotary iDrive knob on the center console. Rest assured, BMW makes sure buyers of the X5M will feel special when they drive it.

After close to 20 years of evolution the iDrive system is finally intuitive. Porsche and Audi have switched to touch screens, but they’re no better than this generation of iDrive.

Like all M-vehicles, the X5M can be had as the “base” model or the X5M Competition. For an extra $12,000, choosing the Competition version gets you 17 additional HP (for a total of 617, which is probably closer to 700 since BMW famously understates their power figures), blacked out badging and trim, and other enhancements. Frankly, the standard X5M is all you need (actually the nonM X5 50i is plenty fast), but if you want bragging rights and paying rock bottom prices isn’t that important to you, the X5M Competition is quite satisfactory.

It’s now the ‘20s, and performance SUVs have supplanted sports cars and sports sedans as “the” thing. I personally don’t like that reality much, but I can’t argue with the performance of vehicles like the X5M. It’s an amazing vehicle.

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

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