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MEDICAL YEAR IN REVIEW Expectation vs. Reality: A Brief Look at My First Two Months as a Vascular Surgeon By Celso F. Uribe II, MD.......................................................12 Telehealth: The Silver Lining of the Pandemic By Ivelisse Velázquez Negrón, MD.......................................14 Medical Students Reflect on Education During the COVID-19 Pandemic By Niva Shrestha, Sabrina Heath, Rachel Fray, Fatima Raza and Komal Sharma .....................16 COVID-19 Generation of Residents By Alexis Ramos, MD..........................................................17 Street Medicine: San Antonio Inaugural Review By Amy Moore, PA-C, DScPAS, Patrick Muehlberger, MD, Hans Bruntmyer, DO, MPH ..................................................18 Update on the Bexar County Medical Society’s Physician Health and Rehabilitation Program By Neal Gray, MD and Danielle Moody ................................22 Skin of Color Dermatology: Exploring Skin Cancer Disparities in Ethnic Populations By Marie Vu, Alexandra Montgomery and Tue “Felix” Nguyen ....................24 The Potential Implications of Maternal Incarceration on Childbirth Outcomes: The State of Women in the American Prison System By Philip Whalen MS, OMS III, Chinazaekpele Nweke, OMS III, Charley Meadows, MS, OMS III, Josephine Sinamano, MS, OMS III, Valentina Bustamante, OMS III ......................................26 BCMS President’s Message .................................................................................................................................................8 BCMS Alliance President’s Message ..................................................................................................................................10 In Memoriam: Everett Bratcher, MD....................................................................................................................................11 Pandemic and Pedagogy: COVID-19 and Medical Education – A Review of “Life on the Line: Young Doctors Come of Age in a Pandemic” By David Alex Schulz, CHP........................................................................................................30 Patient-Centered Transitional Care Management By Ramon S. Cancino, MD, MBA, MS, FAAFP.......................................32 Artistic Expression in Medicine By Oliver H. Johnson, MD ..................................................................................................34 BCMS 35th Annual Auto Show ..........................................................................................................................................35 Physicians Purchasing Directory.........................................................................................................................................36 Auto Review: 2021 John Cooper Works Mini By Stephen Schutz, MD ...............................................................................40 Recommended Auto Dealers .............................................................................................................................................42

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SAN ANTONIO MEDICINE • December 2021

DECEMBER 2021

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VOLUME 74 NO.12

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS. EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

For advertising rates and information Call (210) 410-0014 Email: louis@travelingblender.com SAN ANTONIO MEDICINE is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, its members, or its staff. SAN ANTONIO MEDICINE the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

Rodolfo “Rudy” Molina, MD, President John Joseph Nava, MD, Vice President Brent W. Sanderlin, DO, Treasurer Gerardo Ortega, MD, Secretary Rajeev Suri, MD, President-elect Gerald Q. Greenfield, Jr., MD, Immediate Past President

DIRECTORS

Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member David Anthony Hnatow, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member John Shepherd, MD, Member Ezequiel “Zeke” Silva III, MD, Member Amar Sunkari, MD, Member Col. Tim Switaj, MD, Military Representative Manuel M. Quinones Jr., MD, Board of Ethics Chair George F. “Rick” Evans, General Counsel Jayesh B. Shah, MD, TMA Board of Trustees Melody Newsom, CEO/Executive Director Nichole Eckmann, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative

SAN ANTONIO MEDICINE • December 2021

Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Katelyn Jane Franck, Student Alexis Lorio, Student

BCMS SENIOR STAFF

Melody Newsom, CEO/Executive Director Monica Jones, Chief Operating Officer Yvonne Nino, Controller August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Betty Fernandez, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member David Schulz, Community Member Chinwe Anyanwu, Student Member Winona Gbedey, Student Member Cara J. Schachter, Student Member Niva Shrestha, Student Member Taylor Sullivan, DO, Member Faraz Yousefian, DO, Member Neal Meritz, MD, Member Jaime Pankowsky, MD, Member Danielle Moody, Editor

PRESIDENT’S MESSAGE

2021 A Year in Review: Reflections, Regrets and Restoration By Rodolfo “Rudy” Molina, MD, MACR, FACP, 2021 BCMS President

Reflections: As I thought about what to write as my last message as President, I decided to first review what my two most recent predecessors wrote as their last message. I loved rereading them. Dr. Ratner’s “I’m Serious. Have Fun!” (2019) and Dr. Greenfield’s “A Year of Tumult” (2020), offered good advice and were insightful as usual. With those articles in mind, I thought of writing a three-part article that summarizes my thoughts as we go forward into 2022. I could reflect on the political landscape and discuss the laws recently passed; however, Mary Nava did a superb job reviewing the legislative activities of 2021 in her article published in August’s magazine. Great work Mary! I could also discuss the incredible work our immediate past CEO, Steve Fitzer, accomplished (you would be impressed; I know I am). I could also discuss the very impressive hard work and accomplishments our new CEO, Melody Newsom, has already done and is doing, but it would take more words than I am allotted. There is also Brissa Vela, who I would consider our ambassador to the community. She makes us all proud with her undertakings and accomplishments. That being stated, I want to express a deep gratitude to the entire staff at BCMS. They are dedicated, informed and their intuitive help did not go unnoticed or underappreciated. Regrets: When I speak of a regret, I don’t see it as a destination where one’s journey ends and we are destined to forever mull over the incident. I instead see it as a process, a passage if you will, where the journey teaches us something about ourselves and we are left with an opportunity to improve and prepare for the next similar episode in our lives. A regret is an opportunity to make changes when necessary and possible. My biggest regret about this year is that we didn’t have live in-person meetings. Live meetings lend themselves to

SAN ANTONIO MEDICINE • December 2021

lively discussions. Zoom meetings have a restrictive aura for me. I’m not able to read body language (not that I’m very good at it), I’m not able see all the participants and I’m not able to independently meet in person with the participants before or after the meeting. Therefore, I don’t feel I was able to have a full discussion on particular topics. As our conversation progressed from topic to topic during our Zoom meetings, I couldn’t help but think we sometimes gave a thumbs up on a car to take us on a drive without looking under the hood. Restoration: In the biblical sense, restoration refers to making something better than it was before. Whereas, I have felt the title of President really refers to my duties as being a good steward of the organization, restoration has played a big part in the motives and agenda during my term. I also believe the incoming leadership and those who are on our Board or who serve on the various committees all want to make our Society a better organization. Restoration is in the hearts of all who serve. I want to thank them for all that they do for our Society and our community. I would encourage all of you to seek opportunities to serve on one of our committees and grow as a person. I cannot honestly say that I’ve made this Society a better place, but I can humbly state that serving the Society has made be a better person. And for that I’m eternally grateful. My thanks and my very BEST to ALL. Respectfully signing off on my last Presidential message, Rodolfo “Rudy” Molina MD, MACR, FACP 2021 President, Bexar County Medical Society

BCMS ALLIANCE

Year in Review By Nichole Eckmann

The BCMS Alliance continues to move forward in 2021 and beyond with great momentum and unity as an organization. This year has brought challenges, but has also proven to all of us that we can adapt to uncertainty and change and remain united. We achieved this through virtual events, including a presentation from Dairy Maxx on nutrition and wellness, to the slow start of in-person events, including a Body and Mental Health Pilates event at In Balance Studios, and a fun get together at Board and Brush where physician spouses and their partners came together to unleash their creative side. We continue to engage in community outreach, with our blood drive in celebration of Doctor’s Day hosted in April, to our Afghan Refugee Center drive, where we collected hundreds of supplies for incoming Afghan refugees. In September, we participated in the YMCA sponsored Siclovia outdoor event where we fitted bicycle helmets on kids to promote TMAA’s Hard Hats for Little Heads campaign to protect children from head injuries. Lastly, the end of October marked an opportunity to meet with the Institute of Surgical Research Burn Center located at Brooke Army Medical Center to explore possible partnerships and volunteer opportunities for the Bexar County Medical Society Alliance. This is a quick year in review for our organization, and we are excited for 2022 as we continue to work together to make Bexar County STRONG in the wake of much change. Nichole Eckmann is the 2021 President of the BCMS Alliance.

SAN ANTONIO MEDICINE • December 2021

IN MEMORIAM

Everett Bratcher, MD Everett Bratcher, MD was a general surgeon and a member of the Bexar County Medical Society for 57 years, joining on January 4, 1964. He attended The Ohio State University, graduating from the School of Medicine and specializing in surgery. Dr. Bratcher joined the United States Air Force after graduation and served as a flight surgeon, later achieving the rank of Captain while stationed in San Antonio. He practiced medicine for the next fifty years in San Antonio and became Chief of Staff at Methodist Hospital. Dr. Bratcher retired from practice in 2012. He was married to his wife, June Bratcher, for whom TEXPAC established the June Bratcher Award for Political Action, for 67 years. Their family includes Beth Clegg, Kim Kuykendall, Daniel Bratcher, David and (spouse) Monica Bratcher, seven grandchildren and 13 great-grandchildren. Dr. Bratcher led a fulfilling life that revolved around family, travel, gardening, woodworking, the Arts and a continuous quest for knowledge. In lieu of flowers, Dr. Bratcher’s family requests that contributions be made in his memory to St. Jude Children's Research Hospital (https://www.stjude.org). The Bexar County Medical Society extends sympathy to the family and friends of Dr. Bratcher.

Images: Daisy Charters & Shuttles

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MEDICAL YEAR IN REVIEW

Expectation vs. Reality: A Brief Look at My First Two Months as a Vascular Surgeon By Celso F. Uribe II, MD

gave my son a kiss and hug after we sang happy birthday. It was cold, but not for the lack of affection. His first birthday was on February 16, 2021, and we were at the tail end of one of the worst winter storms in San Antonio history. My father-inlaw’s house had been without power for three days and the water had just sputtered out. With our luck, we had decided months ago to move our family and belongings to Texas in what would end up being the worst possible weeks we could have chosen. Our entire household was on a truck stuck on a frozen road in Louisiana, and the precious week I had taken off during fellowship to make this move now seemed

SAN ANTONIO MEDICINE • December 2021

wasted. Again, as it happens so often in life, my expectations were upended by reality. I chose vascular surgery because I wanted to be the guy other doctors called for help. Whether it's an emergency in the operating room or a routine outpatient referral, I love helping my fellow partners in the medical community just as much as I love helping patients. Colloquially known as the “firefighters” of the hospital, vascular surgeons could be needed at a moment's notice, on any floor, in an array of urgent scenarios. Although this may not foster the best lifestyle, I knew it was for me early on in my general surgery training. Since 2015, my goal of becoming a vascular

MEDICAL YEAR IN REVIEW

surgeon in private practice was born, and has been built up with hours of daydreaming and high expectations over the past seven years. Now I’m finally here, albeit with just two months under my belt. So, what is it like? Well, I’ll do my best to explain. As a trainee, I had been accustomed to working at one single hospital at a time, yet I suddenly found myself seeing patients at nearly every community hospital in Northwest San Antonio. My first couple of weeks on the job were dizzying. Four different badges, four different EMRs, seven different hospitals and staff to get acquainted with (in addition to our own offices and staff ). Oh, and not to mention, my first job as a full-fledged attending practicing vascular surgery. In all honesty though, that has been the easy part. Everything else, however, has been quite an adjustment. But, before I knew it, I was able to quickly jump from hospital to hospital, navigating an impossible network of different computer systems, caring for the most patients over the biggest area that I’d ever had. Still, there were more things that were very different from before. At the University of Virginia, where I received my surgical training, the pandemic was rough, but I’ve come to the stark realization that things were probably much worse here. In my first month, I saw several cases of COVID-19 related lower extremity ischemia that I had not been exposed to previously. More troubling was that some of its effects on circulation became clinically evident well after the initial infection. With the exception of acute thromboembolism to named vessels, I’ve seen multiple cases of COVID-19 related ischemic events that were isolated to the microvasculature of the feet. Unfortunately, this is where our specialty has the least number of surgical options for treatment. Cases like these, and the patients and families impacted by these circumstances, have affected me the most in this transition. Luckily, help has been close by, thanks not only to the board-certified, highly-specialized surgeons who make up my team at Peripheral Vascular Associates (PVA), but also to the broader medical community of Northwest San Antonio. The level of camaraderie and support I’ve encountered has been crucial in

getting my bearings and handling some of these difficult cases. Similarly, love for this city’s culture and diversity has boosted my morale. Being born and raised on the border in Laredo, the rich Hispanic culture of San Antonio always made it feel like a second home to me. Now back to speaking Spanish on a regular basis, consults sometimes feel more like happy visits with my “tios” and “tias.” The Big Red and Hot Cheetos in the physician’s lounges are a nice touch, too.

So, from moving across the country, to starting my first job outside of training, I think it's safe to say that I’m starting to get the hang of it. Getting lost in the hallways at Main Methodist only happens once a week now, so progress is being made. Yes, I thought the transition would’ve been easier in my previous daydreaming, but expectations rarely match up with reality. With every challenge, whether it be surviving a freak blizzard in Texas, or trying to figure out computerized picture archiving systems, we inevitably grow and add to our experience. Fortunately, I’ve had a great support system from my family, my colleagues and our network of partners. I’ve quickly become captivated with the San Antonio health care community and the patients that are a part of it, and hope they will allow me to make them a permanent fixture of my life. Celso F. Uribe II, MD is a vascular and endovascular surgeon at Peripheral Vascular Associates (PVA). He is a member of the Bexar County Medical Society.

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MEDICAL YEAR IN REVIEW

Telehealth:

The Silver Lining of the Pandemic By Ivelisse Velázquez Negrón, MD

t the beginning of the COVID-19 pandemic, adjusting to virtual interactions was one of the most frustrating limitations that many of us encountered. This frustration was shared among most of my peers, that after months of being confined to our houses and finishing medical school through virtual didactics, were craving a more personal connection. However, safety has always been the number one priority. Within time, we all adapted to this new form of practicing medicine. We learned and made it work for us and for our patients. More than a transitional period, this was going to be a new era, and medicine was going to change before and after COVID-19. Telehealth was here to stay. In the blink of an eye, I was starting my second year of psychiatric residency. I was at Geriatrics printing out my schedule and to my surprise, had a fair share of virtual visits. The average age of the clinic was 76 years old, so I mistakenly thought that my patients would not be “on board” with doing virtual visits. As I reviewed their charts, I noted that most of them were vaccinated, so I wondered why they preferred a “MyChart video visit” rather than coming to the clinic they had been coming to for years. I was determined to find out the reason behind this. Certainly, during my intern year I experienced all the struggles you can imagine with technology. One example was not knowing how a

SAN ANTONIO MEDICINE • December 2021

COW (computer on wheels – it took me a while to figure that one out too) connects to the internet; I admit that I was not fond of technology, especially in an acute psychiatric setting. However, it seems that the experience was different for most of my patients, and surprisingly, even more so for the elderly. “Good morning, I’m Dr. Velazquez, can you hear me?” Audio is connecting. “Hi, Dr. Velazquez, can you hear us?” “Yes, I can, can you see me?” I asked. “Yes, I can, can you see us?” they asked me. I started my first assessment with a new patient. She told me that she had not seen a doctor for a while since she lived in a town 90 miles away from San Antonio, and at least 60 minutes away from the nearest medical facility. Her family lived on a ranch, and they had not been out for a long time since their adult daughter had a severe neurodevelopmental disorder and was almost fully dependent on her. She confided that it was a lot of work and said she appreciated the fact that she was able to get care through a video call. A similar story was told by another patient who was relieved that Medicaid was covering video visits since she did not drive anymore. She explained to me that her husband was physically unable to drive her to San Antonio for her medical appointments. At the end of the day, I realized that what started as a solution for a Public Health Emer-

MEDICAL YEAR IN REVIEW

gency was a feasible solution to ease the burden of care for so many patients. We needed it to stay. Our patients can safely access needed mental health services during the COVID-19 pandemic through telehealth. Congress and the Administration acted to lift many of Medicare's telehealth restrictions, but at the end of the Public Health Emergency, Medicare will require that individuals seeking mental health treatment need to meet in person with a clinician within six months of the first telehealth visit. This restriction could impede access to care for patients seeking mental health services, especially elderly patients that depend on Medicare to be able to afford health care. Our geriatric population is approximately 16.5% of the American population and is expected to reach 22% by 2050. As per a CDC telehealth and telemedicine publication, “Telehealth is a promising public health tool because of its 1) potentially significant impact on medically underserved populations through increased access, 2) increasing prevalence as a recognized standard of care, 3) influence on the provider-patient relationship, and 4) potential to save billions of dollars in healthcare expenditures.”

Similar access restrictions are not required for patients seeking services for substance use disorders or co-occurring mental health conditions. The Tele-Mental Health Care Access Act (S.2061) could remove the six month in-person barrier to accessing mental health treatment for Medicare patients. This bill could potentially help patients access mental health care, avoid worse outcomes and likely avoid higher-level crisis interventions that are more expensive to our state, our patients and Medicare. In my opinion, although telehealth visits will never be superior to in-person visits, this could be a superior solution to no visits at all. All of us have a privileged position where our voices can be heard, and it only takes a couple of minutes to help our elderly and/or incapacitated population. Ivelisse Velázquez Negrón, MD is a resident in the Department of Psychiatry at the UT Health Long School of Medicine. She is a resident member of the Bexar County Medical Society.

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MEDICAL YEAR IN REVIEW

Medical Students Reflect on Education During the COVID-19 Pandemic By Niva Shrestha, Sabrina Heath, Rachel Fray, Fatima Raza and Komal Sharma

he past two years and future have been shaped and forever changed by the COVID-19 pandemic. In March 2020—in a haze of confusion and fear—everything from schools to airports started closing. Closures included the nation’s 192 medical schools. Here, medical students from the University of the Incarnate Word School of Osteopathic Medicine (UIWSOM) reflect on the educational, social, emotional, mental and professional consequences of the pandemic. “Even before the first day of class, the pandemic drastically affected my medical education. With everything online, it made establishing relationships with classmates a relatively unnatural process. I met most peers through meetings and breakout rooms on Zoom. Besides weekly clinical skills and anatomy workshops in the spring of 2021, my entire first year was virtual. Safety concerns prohibited students from accessing the clinical skills and cadaver labs on campus, inhibiting development of practical medical knowledge. Despite this, our class acquired a unique resiliency and developed telemedicine skills that will serve us well in the future.” –Sabrina Heath, MS2 “The pandemic took a mental and physical toll on everyone. I look back on my first year with fondness but also sadness for all the missed opportunities. Resuming weekly, in-person labs in January 2021 was exciting. While these initial handson experiences were incredibly helpful, I know many still feel behind from our year of virtual medical school. While nothing can change the past, my hope is that as time continues, future classes and professors alike will extend the same kindness, warmth and encouragement to each other now as they did before the pandemic. As future physicians, we owe it to our patients, peers and ourselves to prioritize our mental health and maintain our humanity and humility. We will not let the past hinder the care of our patients and medical community.” –Rachel Fray, MS2 “The pandemic began six months into my first year of medical school when I finally felt comfortable with my learning style and study habits. My class most acutely felt the total loss of normalcy. The stress of school was compounded by the added challenge of navigating a new learning medium. I learned the vitality of simple human interaction and found myself missing small daily exchanges. While no one can know what the future entails, I hope the past few years have made us more empathetic and appreciative of each other and the profession we are embarking on.” –Fatima Raza, MS3 16

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“When the pandemic struck, I was moving back home to Austin and beginning my dedicated board prep. The stress of boards was already colossal and social distancing requirements led the testing center to cancel and postpone exam dates upwards of six weeks. My clinical rotations began the day after I completed my delayed exams. Fortunately, I only missed two weeks of my pediatrics rotation—a fate many of my peers did not experience. Many students had multiple canceled rotations, forcing them to make up rotations in their fourth year—a year busy with residency applications and interviews. This unavoidable restructuring caused anxiety and hindered our learning. We even struggled with our Zoom weekly didactic sessions. Being present for class was difficult and lack of interaction with peers was isolating. While I learned how to handle a new virus, I lost crucial aspects of my clinical experience.” –Komal Sharma, MS4 In retrospect, the advancements in virtual education made didactic learning challenging, but possible. The pandemic cost current students 18 months of clinical and practical knowledge. COVID-19 stretched students, educational institutions and hospitals to the limit, while also forcing medicine to be more accessible to future generations through virtual (cost-friendly) interviews. With telemedicine, hopefully health care will become accessible for many patients too. The pandemic also inspired and energized a new generation of physicians such that—according to the American Association of Medical Colleges (AAMC)— applications to medical school increased over 18% during the 2020 cycle. Applications grew around 3% per year over the last decade. The collective experiences of the past few years have spotlighted physician and student mental health, underscored the importance of human connection and created a stronger, more resilient future of doctors. Niva Shrestha (MS2), Sabrina Heath (MS2), Rachel Fray (MS2), Fatima Raza (MS3) and Komal Sharma (MS4) are medical students at UIWSOM.

MEDICAL YEAR IN REVIEW

COVID-19 Generation of Residents By Alexis Ramos, MD

oday is my first day of residency, the day all medical students dream about. I imagined waltzing into the obstetrical wards for my first rotation, donning a long white coat and a new pager. My patients would ask me medical questions, and I would shake their hands and greet them with a smile, responding with confidence. Times are vastly different. Instead of a white coat, I wear scrubs, which are easier to wash off the day. Instead of healing and rebuilding, we are living in a declared health emergency. Entering the wards for the first time was not exactly how I envisioned. I am greeted by nurses asking for my signature to prescribe medications. The upper-level residents are busy in deliveries, and four of my patients need discharge orders in the computer system. The sense of urgency and stress are entangled in the air. I breathe in the large expectation to retain knowledge quickly and perform efficiently, which is even more pressing in the COVID-19 generation of residents. We can’t escape the vast differences of social distancing COVID-19 has created, even at work. We are constantly reminded by the screening nurses that take our temperature before each shift, by the increasingly high patient volume with masks and personal protective equipment (PPE) and by the code blues that ring throughout the hospital. All of this sets the stage as I start work in the obstetrical emergency room. Two patients in active labor burst through the double doors. The experienced resident tends to one and I am assigned the other. I freeze. I clumsily flip through a few stacks of paper that outline the crucial steps and common orders to place: Normal saline, UA, CBC and a COVID screen. The nurse and I quickly initiate a digital exam. The patient is dilated to 8 cm. She is visibly scared. I cannot tell whether her emotion is moving through me or if I am transferring my emotion onto her. I sit on the edge of the bed and express as much understanding as possible with two thirds of my face covered by a mask. We cycle through some deep breathing exercises. I also attempt to distract her with small talk about her husband at home and their two children. I

know they all cannot be present for the birth because she is only allowed one visitor. I assure her we have great doctors here who perform routine deliveries around the clock, but that does not seem to ease her fear. I exit the room and place quick admission orders. She is whisked away to a labor room. The day continues and when I look up, it is past my time to leave. I leave, feeling that I am bringing the unknown to my family and unsuspecting cat. I shower as soon as I get home, using Lysol on my shoes and book bag. I have just enough time to eat dinner and prepare my patients’ notes for the next day in order to get a solid six hours of sleep. I remind myself it is okay to grieve the loss of normalcy. The uncertainty in duration is what truly unsettles me. How long will the state of emergency last? The notion of taking each 24 hours as they come has become my mantra. I open the remote-access charting system to begin looking at the postpartum patients for tomorrow. My mind wanders back to the kind lady who came through the obstetrical emergency room. I notice a red flag next to her lab values; positive for COVID-19. Alexis Ramos, MD is a second-year family and community medicine resident at UT Health San Antonio. She is a resident member of the Bexar County Medical Society.

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MEDICAL YEAR IN REVIEW

Street Medicine San Antonio Inaugural Review By Amy Moore, PA-C, DScPAS; Patrick Muehlberger, MD; Hans Bruntmyer, DO, MPH

Background Dr. Hans Bruntmyer, a retired military emergency medicine physician, had a career that largely revolved around being comfortable with the uncomfortable and was no stranger to practicing medicine in austere environments. When he and his family relocated to San Antonio following his military retirement, he was moved by the obvious need for improved access to medical care for the most vulnerable in our society — those who lack shelter, transportation, basic safety and support. He was already familiar with the Street Medicine movement, originally founded by Dr. Jim Withers of Pittsburgh, and began networking with Dr. Withers and other Street Medicine program directors in 2015. During the next few years, Dr. Bruntmyer began to see the reality of creating a Street Medicine — San Antonio program (SMSA) and, in January of 2019, Dr. Bruntmyer began leading “backpack medicine” teams onto the streets of San Antonio to care for unsheltered individuals. Since those first “Street Rounds,” the organization has grown in size and scope, beginning with a single physician and student volunteers to now including three emergency medicine physicians, advanced practice clinician-led teams, nursing teams and a behavioral health component – Street Smart, in addition to countless volunteers of varying levels of training and across a range of professions. Despite his experience to that point, Dr. Bruntmyer could not have imagined the relationships formed or personal and professional growth that would be experienced by himself and all of the volunteers. Over two years have elapsed since the first backpack medicine mission by SMSA. The organization intends to publish regular research to support the development of future Street Medicine programs, educate the medical community on care for the homeless, and to help this program evolve in order to

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make a greater impact on its patients, San Antonio street sleepers, present and future. The authors believe that the first step in that process should be a 100% indepth patient chart review to systematically understand patient and organizational needs over SMSA’s first two years of service. Protocol approval was obtained from the University of the Incarnate Word Institutional Review Board on February 15, 2021 (FWA00009201). This study is an outcome evaluation design of Street Medicine — San Antonio from January 1, 2019 to December 31, 2020. In preparation for the review, a Google Scholar search was conducted between December 1, 2020 and December 31, 2020 to identify Street Medicine program evaluations. Key terms included Street Medicine, Street Medicine review, Street Medicine program evaluation, Street Healthcare and Street Healthcare program. The literature review resulted in three distinct Street Medicine program capstone projects and/or publications1-3 and one case series obtained from the annual Street Medicine Symposium.4 Additionally, eight articles obtained provided additional research related to Street Medicine Programs, such as resident and patient experiences, and in-depth looks at current data and issues that are unique to providing health care for the homeless, both locally and nationwide.5-12 The authors are grateful to contribute to the limited existing field of Street Medicine literature. Results Paper charts were pulled for each patient seen during this timeframe and a single investigator scrubbed each chart for basic demographics (Figure 1), major ailments treated (Figure 2) and supplies utilized (Figure 3). Referrals to SMSA from local social work organizations including Centro San Antonio, Chris-

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FIGURE 1

FIGURE 2

FIGURE 3

FIGURE 4

FIGURE 5

tian Assistance Ministries and SAMMinistries were also tracked, in addition to referrals Street Medicine made to the above social work organizations for assistance (Figure 4). Finally, the authors tracked SMSA provider referrals for follow-on medical care (Figure 5).

Discussion During its first two years of operations, SMSA provided care to 220 patients over 419 encounters. 71 percent were male. The majority of patients, 163, had one encounter with SMSA. Four patients were treated over 10 visits. The maximum number of visits continued on page 20 Visit us at www.bcms.org

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for a single patient was 45. Ages of patients ranged from 21 through 82 years. Ages were estimated by decade for 24 patients. 35 charts did not have ages or approximations. The two most common ailments treated were infections/acute wounds and musculoskeletal pain, together making up 56% of total acute conditions. Osteopathic manipulation was performed by Dr. Bruntmyer, the sole DO physician, whenever possible. NSAIDS, Tylenol and triple antibiotic ointment were the most common medications administered. Wound care supplies were provided for 69 patients; three of these had incision and drainage performed. 19 patients received orthopedic supplies, including splints and braces. Local social work organizations referred 46 patients to SMSA for acute medical conditions. SMSA referred 17 patients to local social work organizations for assistance, including ID card retrieval, housing and detox programs. Housing was achieved for nine patients during this two-year timeframe. 69 patients were evaluated at a local shelter, with all others being evaluated on the street. Upon recommendation of SMSA providers, 10 patients went to the ER following a street encounter. Of these, four were escorted by SMSA providers or EMS, and three resulted in subsequent hospitalization and/or surgery. 11 patients refused ER evaluation. Specialty referrals included general surgery, dental, podiatry and ophthalmology. All evaluations, treatments and operations were provided pro-bono. PCM referral included pre-established PCMs at the community hospital and VA, in addition to public and church-run clinics. Conclusion and the way ahead SMSA has grown in size and scope over the past two years. This evaluation will be utilized to develop further training and build needed inventory. Future goals include wellness fairs for street sleepers which will focus on health education and preventive medicine. Additionally, SMSA plans to conduct training seminars for the medical community and potential SMSA volunteers to discuss lessons learned about how to best connect with and care for this unique

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population. In the summer of 2021, SMSA was approved for Americares Medical Outreach medication distribution program, which will greatly affect the ability of the organization to provide a broad spectrum of prescription medication to its patients. The review has also highlighted the importance of streamlining documentation. Beginning in February of 2021, SMSA has transitioned to an EMR. This has already aided in building patient trust and ensuring continuity of care when seen by multiple providers. Furthermore, as a result of this review, SMSA intends to track more specific and consistent demographic information, diagnoses, past medical history, social work needs and referral status. Last, but not least, SMSA intends to keep its close relationships with community partners to both accept and refer those in need. The ultimate goal of the SMSA, to care for San Antonio’s most vulnerable, has not changed. References 1. Edwards, A. L. (2017). Street medicine: A program evaluation. Georgia State University. https://scholarworks.gsu.edu/iph_capstone47 2. Waara, A., Abraham, K., & Mason, W. (2017). Street medicine Detroit annual report. https://static1.squarespace.com/static/509c2caae4b0c7861e4 b4512/t/5ad93db9562fa7843a6cc941/15241865 80889/Street+Medicine+Detroit+Annual+Report+2017.pdf 3. Hemba, K. E., Simon, R., & Weinstein, L. D. (2013). JFMA street outreach: A resident-run street medicine program. A retrospective chart review examining the needs of a vulnerable population and services provided. Department of Family & Community Medicine Presentations and Grand Rounds. Thomas Jefferson University. https://jdc.jefferson.edu/fmlectures/16 4. Howe, E. C., Buck, D. S., & Withers J. (2009, October). Delivering health care on the streets: challenges and opportunities for quality management. Qual Manag Health Care, 18(4), 239-46. https://doi:10.1097/QMH.0b013e3181bee2d9 5. South Alamo Regional Alliance for the Homeless (SARAH). (2020). 2020 Point in time count report: San Antonio and Bexar County.

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http://www.sarahomeless.org/wp-content/uploads/2021/03/PIT2020-OnePager-Updated03.05.2021.pdf 6. Doohan, N. & Mishori, R. (2020). Street medicine: Creating a "classroom without walls" for teaching population health. Med. Sci. Educ., 30, 513-521. https://doi.org/10.1007/s40670-019-00849-4 7. Maness, D. L. & Khan M. (2014, April 15). Care of the homeless: an overview. Am Fam Physician, 89(8), 634-40. PMID: 24784122. 8. DeVoe, J. E., Likumahuwa-Ackman, S., Shannon, J. & Steiner Hayward, E. (2017, April). Creating 21stcentury laboratories and classrooms for improving population health: A call to action for academic medical centers. Acad. Med., 92(4), 475-482. https://doi:10.1097/ACM.0000000000001385 9. Christensen, A. (2015). Patient satisfaction & knowledge of services: An evaluation of a street medicine program. Georgia State University. https://scholarworks.gsu.edu/iph_theses/423 10. Capelli, K. (2020). Is street medicine effective in improving access to healthcare? Student Research Poster Presentations 2020. Misericordia University. https://digitalcommons.misericordia.edu/research_posters2020/43 11. Smith-Graham, S. (2017). Understanding the role street medicine programs play in the career trajectories of student volunteers who choose to work with underserved populations. Georgia State University. https://scholarwords.gsu.edu/iph_theses/503 12. Arndell, C., Proffitt B., Disco M. & Clithero A. (2014, January-April). Street outreach and shelter care elective for senior health professional students: An interprofessional educational model for addressing the needs of vulnerable populations. Educ Health, 27, 99-102. https://doi:10.4103/1357-6283.134361

Amy Moore, PA-C, DScPAS is an active duty Army emergency medicine physician assistant and faculty member of the Army-Baylor Emergency Medicine Physician Assistant degree/residency at Brooke Army Medical Center. She joined SMSA in January of 2020. Patrick Muehlberger, MD, an emergency medicine physician, is an Assistant Clinical Professor at the University of the Incarnate Word-School of Osteopathic Medicine and faculty of the Uniformed Services Health Education Consortium Emergency Medicine Residency. He was one of the first team leads for SMSA and serves as one of the two Assistant Medical Directors and Emergency Department Liaisons within the organization. Dr. Muehlberger is retired from the U.S. Air Force. Hans Bruntmyer, DO, MPH is an emergency medicine physician and is the founder and Medical Director of SMSA. SMSA is the flagship project of Imago Dei Ministries, of which Dr. Bruntmyer is a founding member and acting Secretary. He also serves as Assistant Clinical Professor and Director of Outreach Medicine at the University of the Incarnate Word-School of Osteopathic Medicine. Dr. Bruntmyer is retired from the U.S. Air Force and is a member of the Bexar County Medical Society.

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Update on the Bexar County Medical Society’s Physician Health and Rehabilitation Program By Neal Gray, MD and Danielle Moody

The Physician Health and Rehabilitation Program (PH&R) started in the 1970s. In the beginning, the program would occasionally interview a physician accused of being intoxicated, but there were few resolutions. In 1982, Dr. Neal Gray recognized the need and went to a number of courses at the American Medical Association, partnering with other doctors around the country to create a program for physicians. The goal was to return physicians to the safe practice of medicine and to the active privileges at their respective hospitals. In 1983, Dr. Gray volunteered himself to join the Impaired Physicians Committee and shortly after became Chairman. He worked with staff from across the country to devise a contract for the program. It was found that another physician could intervene in the disease progression, and treatment could be offered to physicians for assistance. The program was a new concept for the state board. The team was seeing an average of five to ten patients a month. Dr. Gray explained that one out of eight physicians struggle with alcoholism. Doctors in the program struggle with the misuse of alcohol, drugs and opiates. The physicians who get started on opiates get sick very fast and, in some cases, have died. The program continued and changed very little since the early days. It gained enough success that the cities of Austin, Dallas and Houston started creating similar programs. The state of Texas eventually took the program and made it into their Texas Physician Health Program. Dr. Gray mentioned that most of the PH&R program’s patients have come from Bexar County, but they have also taken patients from all over South Texas, including Austin. The program has never turned anyone away, nor has it ever charged a fee. The process begins with a referral from a family member or hospital staff to stage an intervention for the physician. Two or three members from the committee meet with the physician and explain the program to them in order to help them get sober. The PH&R program has been very successful in doing this, now hundreds of times. The Bexar County Medical Society (BCMS) hosts PH&R meetings every month, with members from a wide variety of specialties. The BCMS patient’s coordinator often receives a phone call from somebody that needs help and then they are referred to the program. The BCMS provides the meeting space for the committee and a meeting space for Caduceus which is an organization composed of recovering physicians. 22

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Relapse is common among physicians, but can be prevented by following the actions outlined in the program’s contract. The five-year contract was derived to focus on relapse prevention with the objective of making sick doctors well, not bad doctors good. It was also created to make sure doctors could have access to rehab and be able to get back to work. It gives a progress report on the physician, discussing whether or not they are in compliance with the contract. Many cases need letters of compliance to hospitals written regularly, which BCMS staff assists with. Each physician signs the contract along with the PH&R committee under these guidelines: 1. No usage of alcohol or drugs of issue, 2. Have a primary physician who understands their situation, 3. Attend AA meetings, 4. Have urine, blood or drug testing frequently, 5. Work with hospitals and clinics to satisfy working mandates, 6. Align with the Texas Physician Health Program. The PH&R program has been successful in providing assistance to the physicians in need, and the future of the program is bright. Dr. Gray explained that the program will continue to do the same thing they have been doing for several decades. Physicians can come to the PH&R Committee; they will respect their confidentiality and will do their very best to return the physicians to their families and to the active and safe practice of medicine. Neal Gray, MD is a retired board-certified Anesthesiologist and Addictionologist. Dr. Gray was the 1992 President of the Bexar County Medical Society and received the Golden Aesculapius Award in 2018. He is a life member of the Bexar County Medical Society. Danielle Moody is the Editor of San Antonio Medicine.

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Skin of Color Dermatology: Exploring Skin Cancer Disparities in Ethnic Populations By Marie Vu, Alexandra Montgomery and Tue “Felix” Nguyen

kin of color (SOC) dermatology is a subset of dermatology which treats skin, hair and nail conditions in individuals of African American, Asian, Hispanic/Latino, Native Indian or Pacific Islander descent. With a diverse ethnic population that continues to grow, demographics in the United States are shifting. These changes underscore the importance of a thorough understanding of SOC dermatology, although attention to addressing these needs has increased in recent years. There are cutaneous diseases that are more prevalent, present differently or are inadequately understood in people of color. More specifically, skin cancer plays an impactful role when assessing disparities within SOC dermatology due to its increased prevalence and malignant potential. The three most common types of skin cancer are basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma. Each of these skin cancers have characteristic features that doctors and patients can look for, but some of these classic signs are often not present when these cancers arise in SOC, which can make early detection more difficult and can negatively impact prognosis. Basal cell carcinoma is the most common skin cancer in Caucasians, Asians and Hispanics, and the second most common in African Americans.1 In fair skin, this cancer typically looks like a flesh-colored or “pearly pink” bump, often with raised edges, visible blood vessels and commonly with an open sore in the center. In SOC, BCC may lack its characteristic pink hue and visible blood vessels, and instead may contain extra melanin, giving the lesion a darker appearance. Squamous cell carcinoma is the most common skin cancer in African Americans, and the second most common in Caucasians, Hispanics 24

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and Asians. The typical appearance of this cancer in fair skin can vary from scaly pink-to-red patches to thickened, crusted plaques or nodules. Like BCC, the appearance of SCC in darker skin is often brown or black rather than pink due to excess pigmentation. In Caucasians, SCC usually appears in areas that have been chronically exposed to the sun, like the face and upper body. However, in patients of color, it can often occur in areas without much sun exposure, such as the lower legs or the genital region, and may be more often related to chronic wounds or additional underlying disease.1 Melanoma is the least common type of skin cancer, but is the most dangerous due to its ability to spread to other organs. It primarily affects Caucasians, however, the diagnosis of melanoma in SOC is often associated with poorer clinical outcomes. Melanomas are often irregularly shaped and may have different shades of pigmentation within a single lesion. The common “warning signs” to detect melanoma include lesions that exhibit asymmetry, irregular borders, color changes, a diameter greater than six millimeters and a spot that has significantly changed over time. An important difference between the development of melanoma in people of color and in Caucasians is location. While melanomas most often present on the trunk in Caucasians, melanomas often develop in unusual locations such as the lower extremities, palms, soles, nails and mucosal surfaces in African American, Hispanic and Asian populations.2 Though SOC individuals are less likely to develop skin cancer, there is increased morbidity and mortality in such populations when compared to Caucasians.3 An epidemiological review showed a 5-year survival rate of 70% for SOC patients while Caucasian patients had a significant in-

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crease of 92%.4,5,6 The cause of this notable disparity is multifactorial. One reason for increased mortality in SOC patients is late detection of skin cancers. As discussed previously, symptoms are not easily visible, as they present differently in people of color. In addition, SOC patients may not fully understand their risk for skin cancer as there is a false belief that darker skin is protected from UV rays.7 While increased melanin and dispersed melanosomes absorb and deflect UV rays more efficiently, it is still possible for people of color to develop skin cancer.8 Another reason for increased mortality is attributed to lack of access to medical care. SOC patients have the least percentage of medical coverage, thus decreasing access to required care and accounting for poorer prognosis. Other factors to consider are the lack of resources available in the past decades of medical training, which provide insight on evaluating skin cancer lesions in SOC individuals. This poses diagnostic challenges, including identifying specific characteristics like variation of color in lesions.9 There has been increasing recognition of the need for more representation of people of color in the field of dermatology. A study found that African American and Hispanic patients are less likely to receive outpatient dermatological treatments compared to Caucasians.10 Potential resources that can help minimize this health disparity and improve visibility include dermatology free-clinics. In San Antonio, two free dermatology clinics that exist are Travis Park Dermatology Clinic and Haven For Hope. Both clinics are student and faculty-led clinics supported by the University of Texas at San Antonio Health Science Center, which provide free dermatologic care to people of all backgrounds — including those who are homeless and uninsured. Many people within these communities are people of color. According to a 2019 Racial Indicator Equity Report in San Antonio, 22.5% of African Americans and 21.3% of Hispanics live in poverty compared to 11.2% of the Caucasian population.11 As a result, free clinics can help not only provide quality skin care to these marginalized communities but also educate patients about how to properly take care of their skin to minimize the occurrence of preventable skin diseases. Additionally, from the provider’s perspective, treating melanated skin further improves education for medical students and residents by exposing them to the morphologic differences of common skin conditions that are often misdiagnosed in people of color. SOC dermatology has become more prevalent in recent years, changing the landscape of how providers practice medicine and address disparities. While there are many unique cutaneous conditions which affect people of color, skin cancer remains an important topic due to its vast prevalence and malignant potential. The increased morbidity and mortality associated with skin cancer in SOC individuals can be attributed to many factors. Public awareness of skin cancer education and prevention, combined with increased accessibility to care and comprehensive medical training for providers, may be the key to a timely diagnosis and treatment.

References 1. Higgins S, Nazemi A, Chow M, Wysong A. Review of Nonmelanoma Skin Cancer in African Americans, Hispanics, and Asians. Dermatologic Surg. 2019;44(7):903-910. doi: 10.1097/DSS.0000000000001547. 2. Higgins S, Nazemi A, Feinstein S, Chow M, Wysong A. Clinical Presentations of Melanoma in African Americans, Hispanics, and Asians. Dermatol Surg. 2019 Jun;45(6):791-801. doi: 10.1097/DSS.0000000000001759. PMID: 30614836. 3. Cancer Facts and Figures 202. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2021/cancer-facts-and-figures-2021.pdf. Accessed October 30, 2021. 4. Merrill SJ, Subramanian M, Godar DE. Worldwide cutaneous malignant melanoma incidences analyzed by sex, age, and skin type over time (19552007): Is HPV infection of androgenic hair follicular melanocytes a risk factor for developing melanoma exclusively in people of European-ancestry? Dermatoendocrinol. 2016 Jul;8(1):e1215391. doi: 10.1080/19381980. 2016.1215391. PMID: 27588159 5. Wu XC, Eide MJ, King J, Saraiya M, Huang Y, Wiggins C, Barnholtz-Sloan JS, Martin N, Cokkinides V, Miller J, Patel P, Ekwueme DU, Kim J. Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999-2006. J Am Acad Dermatol. 2011 Nov;65(5 Suppl 1):S26-37. doi: 10.1016/j.jaad.2011.05.034. PMID: 22018064. 6. Gohara MA. Skin cancer in skins of color. J Drugs Dermatol. 2008 May;7(5):441-5. PMID: 18505135. 7. Jacobsen AA, Galvan A, Lachapelle CC, Wohl CB, Kirsner RS, Strasswimmer J. Defining the Need for Skin Cancer Prevention Education in Uninsured, Minority, and Immigrant Communities. JAMA Dermatol. 2016 Dec;152(12):1342-1347. doi: 10.1001/jamadermatol.2016.3156. PMID: 27626892. 8. Cummins DL, Cummins JM, Pantle H, Silverman MA, Leonard AL, Chanmugam A. Cutaneous malignant melanoma. Mayo Clin Proc. 2006 Apr;81(4):500-7. doi: 10.4065/81.4.500. PMID: 16610570. 9. Agbai ON, Buster K, Sanchez M, Hernandez C, Kundu RV, Chiu M, Roberts WE, Draelos ZD, Bhushan R, Taylor SC, Lim HW. Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am Acad Dermatol. 2014 Apr;70(4):748-762. doi: 10.1016/j.jaad.2013.11.038. PMID: 24485530. 10.Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United States. JAMA Dermatol. 2018;154(11):1286–1291. doi:10.1001/jamadermatol.2018.3114 11.City of San Antonio Office of Equity. 2019 Racial Equity Indicator Report. A Report by City of San Antonio Office of Equity, San Antonio, TX. 2019;16.

Marie Vu, Alexandra Montgomery and Tue “Felix” Nguyen are medical students at UT Health San Antonio who are interested in dermatology. They all serve as officers for the medical school’s Dermatology Interest Group.

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MEDICAL YEAR IN REVIEW

The Potential Implications of Maternal Incarceration on Childbirth Outcomes: The State of Women in the American Prison System By Philip Whalen MS, OMS III; Chinazaekpele Nweke OMS III; Charley Meadows MS, OMS III; Josephine Sinamano MS, OMS III; Valentina Bustamante OMS III

Introduction As of 2016, there were 111,616 incarcerated women in the United States, and an estimated 6-10% were pregnant.1,2 The National Commission on Correctional Health Care (NCCHC) and the American Public Health Association (APHA) defined standards of care for incarcerated pregnant women. However, there is no agency that enforces these standards resulting in women receiving poor nutrition, lack of exercise, unsanitary living space and little or poor prenatal care.3 In this article, we will be examining the effects of maternal incarceration on childbirth outcomes by looking at three determinants of childbirth success, as well as the long-term effect on children’s mental health, to provide evidence for the need for strict regulation of adequate prenatal care for incarcerated women. The outcomes examined include birth weight, the incidence of preterm birth, and the fetal outcomes of infant mortality, miscarriage and abortion. Birth Weight Low birthweight is defined as a newborn weighing less than 5 pounds, 8 ounces or 2,500 grams. The average weight of a newborn child is roughly 8 pounds. While low birth weight may be associated with developmental abnormality, this isn’t necessarily a given as some underweight newborns do not have developmental abnormalities. Few studies concluded that incarceration during the first trimester led to decreased birth weight; however, this effect was minimal. In contrast, no correlation has been found in women initially incarcerated during the second and third trimester. This is exemplified by a two-year-long cross-sectional study of pregnant females incarcerated in Texas state prisons, that reported no children born with low birth weight born by mothers entering prison past 34-week gestation.6 Overall, studies demonstrated that there is no strong correlation between maternal incarceration and low birth weight.4 Kyei-Aboagye, K. et al. concluded that the prison environment, which provided limited access to controlled substances and adequate prenatal care improved fetal and maternal outcomes of expectant mothers. For example, they found that many women who admitted to smoking and/or using recreational drugs prior to going to prison had 26

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improvements in their child’s fetal birth weight and overall health.5 As a whole, this indicates that incarceration may actually prevent harmful and addictive behaviors that negatively impact mothers and children. Preterm Birth Preterm birth is defined as the birth of a fetus before 37 weeks gestation. According to the Center for Disease Control and Prevention (CDC), babies born prematurely are more likely to decease or suffer from respiratory problems, feeding issues, developmental sluggishness, vision problems, cerebral palsy or hearing problems.8 It has been speculated that maternal incarceration results in increased risk of preterm births. Shapiro-Mendoza et al.,9 stated that in the United States, preterm birth was the leading cause of death and morbidity of newborns. In 2013, preterm birth was responsible for about 36% of the 8,470 infant deaths. Some conditions seen in children born prematurely include necrotizing enterocolitis, intraventricular hemorrhage, decreased school performance, developmental sluggishness and respiratory distress syndrome. The risk factors found to increase preterm birth are advanced maternal age, low socioeconomic class, recreational drug and tobacco use, high or low Body Mass Index (BMI), multiple gestations, a previous preterm birth, pregnancy complications (placenta abruption, polyhydramnios, oligohydramnios), and maternal medical disorders (thyroid disease, asthma, etc.).9 Sufrin et al.1 conducted a study on pregnant women in prisons and found that out of 753 live births, 6% were preterm. In another study, Sufrin et al1 concluded that out of 224 pregnancies that occurred in jails, 64% resulted in live births, and of them 8% were preterm births.10 According to Shapiro-Mendoza et al., the risk of preterm birth could be minimized by increasing access to preconception care services to women of childbearing age ensuring that they enter pregnancy in peak health. They also highlighted the need for early identification of women who have an increased risk and providing them with additional prenatal care. For example, women with a history of preterm birth should be given 17 alpha-hydroxyprogesterone caproate which helps

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reduce the risk by about 30%. At-risk pregnant women can also be offered antenatal corticosteroids that have been shown to decrease respiratory distress syndrome by 66%, intraventricular hemorrhage by 54%, death by 69% and necrotizing enterocolitis by 46% when compared to non-ANCS therapy.9 Mental Health According to The Sentencing Project, in 2019, the incarceration rate for non-Hispanic black women was 84 per 100,000, twice that of nonHispanic white women, 48 per 100,000, while the rate for Hispanic women was 64 per 100,000.12,13 Reports show that for pregnant women, the mental health effects of being incarcerated can magnify existing problems or create new ones.12 Dumont, D. et al. found that incarceration of either the mother or the father is associated with depression, and other social determinants of health like unemployment and homelessness.11 They also found a strong association between the well-being of the prisoner’s family−his/her children, partners, siblings and parents alike. The experience of incarceration qualifies as an independent contributor to health outcomes and health behaviors.11 Left unanalyzed, the effects of parental incarceration could ultimately perpetuate systemic disadvantages as populations likely affected are those of underserved minorities. We, the authors, postulate that all those effects reported can also negatively affect the mental health of the infant and affect their childhood development. The impact on the behavioral health of the mother or the infant is something worth exploring. Further research would be beneficial to target specific populations that have a strong association with parental incarceration and the perinatal outcomes as it pertains to mental health. This would bring awareness to components that if addressed, would potentially alleviate the process of systemic incarceration. Infant Mortality, Miscarriage, Abortion The CDC defines infant mortality as death of an infant within their first year of life. Due to the fact that jails and prisons only provide postpartum care for three days after delivery, attempts at studying birth outcomes in prison and jail settings have proven difficult.1 Sufrin, C. et al. found that incarcerated women had a much lower rate of infant survivability.1 The low survivability can be attributed to the use of shackles before and during labor, placement of chains on pregnant women's abdomens, placement of pregnant women in solitary confinement, and variability of pre- and post-partum care, including lack of follow up of the children born to incarcerated mothers.1,14 Only 37.7% of prison facilities perform a pregnancy test on intake, therefore measuring miscarriages and abortions is difficult due to the fact that women may not know they are pregnant and may have an early miscarriage without the correctional facility being aware.14 continued on page 28 Visit us at www.bcms.org

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Conclusion Overall, current health and general practices in prisons were not shown to have negative health effects on children born to incarcerated women. Only one outcome was found to be negatively impacted by incarceration: infant mortality, miscarriage and abortion.1 These findings highlight that while incarceration may not have long-term effects on the child's health, it is a determinant of whether the child will be born or not. It is in our opinion that this outcome alone provides sufficient evidence that the care of incarcerated mothers needs to improve. Across all prisons and jails in the country, there are standards set forth to ensure proper infant care, but correctional facilities are not required to abide by them, meaning that perinatal care is varied throughout the country.14 Improvements that could be made include preventing the use of shackles on pregnant women, providing them lower bunk beds, prenatal vitamins, rest time and two mattresses.2 References 1. Sufrin, C., Beal, L., Clarke, J., Jones, R., & Mosher, W. (2019) Pregnancy Outcomes in US Prisons, 2016–2017. American Journal of Public Health. https://www-ncbi-nlm-nih- gov.uiwtx.idm.oclc.org/ pmc/articles/PMC6459671/ 2. Sabol, W. J., West, H. C., & Cooper, M. (2009). Prisoners in 2008. Washington, DC: US Department of Justice, Bureau of Justice Statistics. 3. Ferszt GG, Clarke JG. Health care of pregnant women in U.S. state prisons. J Health Care Poor Underserved. 2012 May;23(2):55769. doi: 10.1353/hpu.2012.0048. PMID: 22643607. 4. Freeborn, D., PhD, Trevino, H., & Burd, I., MD, PhD. (2020). Low Birth Weight. Retrieved December 02, 2020, from https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90 5. Kyei-Aboagye, K., Vragovic, O., & Chong, D. (2000). Birth outcome in incarcerated, high- risk pregnant women. The Journal of reproductive medicine, 45(3), 190–194 6. Howard, D. L., Strobino, D., Sherman, S. G., & Crum, R. M. (2011). Maternal incarceration during pregnancy and infant birthweight. Maternal and child health journal, 15(4), 478–486. https://doiorg.uiwtx.idm.oclc.org/10.1007/s10995-010-0602-y 7. Testa, A., Jackson, D. B., Vaughn, M. G., & Bello, J. K. (2020). Incarceration as a unique social stressor during pregnancy: Implications for maternal and newborn health. Social science & medicine (1982), 246, 112777. https://doiorg.uiwtx.idm.oclc.org/10.1016/ j.socscimed.2019.112777 28

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8. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. (2020). Preterm Birth. Retrieved from https://www.cdc.gov/reproductivehealth/ maternalinfanthealth/pretermbirth.htm 9. Shapiro-Mendoza, C., Barfield, W., Henderson, Z., James, A., Howse, J., Iskander, J., & Thorpe, P. (2016). CDC Grand Rounds: Public Health Strategies to Prevent Preterm Birth. MMWR Morb Mortal Wkly Rep. 10. Sufrin, C., Jones, R. K., Mosher, W. D., & Beal, L. (2020). Pregnancy Prevalence and Outcomes in U.S. Jails. Obstetrics and gynecology, 135(5), 1177–1183. 11. Dumont, D., Wildeman, C., Lee, H., Gjelsvik, A., Valera, P., Clarke, J. (2014) Incarceration, Maternal Hardship, and Perinatal Health Behaviors. Maternal Child Health J. 12. Bronson, J., Sufrin, C. (2019). Pregnant Women in Prison and Jail Don’t Count: Data Gaps on Maternal Health and Incarceration. 13. The Sentencing Project. Fact sheet: incarcerated women and girls. 2020. https://www.sentencingproject.org/wp-content/uploads/ 2016/02/Incarcerated-Women-and-Girls.pdf. Accessed October 5, 2021. 14. Kelsey, C. M., Medel, N., Mullins, C., Dallaire, D., Forestell, C. (2017). An Examination of Care Practices of Pregnant Women Incarcerated in Jail Facilities in the United States. Maternal and Child Health Journal. doi:10.1007/s10995-016-2224-5

Philip Whalen MS, OMS III; Chinazaekpele Nweke OMS III; Charley Meadows MS, OMS III; Josephine Sinamano MS, OMS III and Valentina Bustamante OMS III are medical students at the UIW School of Osteopathic Medicine.

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Pandemic and Pedagogy: COVID-19 and Medical Education A Review of “Life on the Line: Young Doctors Come of Age in a Pandemic” By David Alex Schulz, CHP

Hippocrates’ Greece had two words for time: Chronos for normal time and Kairos for periods of great challenge, accomplishment and risk. Fourth-year medical students unknowingly crossed from one to the other in the spring of 2020, as schools across the country sped up graduation to help hospitals besieged by the novel coronavirus. New York Times reporter Emma Goldberg followed some of those students, speaking with them daily. Now in a book, she details the experiences of six young physicians thrust into the frontlines at Bellevue and Montefiore Health Systems during the earliest days of the COVID-19 pandemic. The stories of newlyminted Drs. Sam, Iris, Gabriela, Jay, Elana and Ben provide fresh insights and perspectives on the enduring crisis. Documenting their sudden entrée to the world of patient care reflects on how the current crisis may alter medical education for years to come. Goldberg’s “Life on the Line: Young Doctors Come of Age in a Pandemic” (Harper Publishing, June 2021) refrains from political or polemical judgments; its examination provides very personal recounting of events from spring through summer, 2020, concluding be-

fore a vaccine was promised or delivered. Goldberg’s journalistic technique brings the stark uncertainty and confusion of those early days back to life. With last names redacted, we are introduced first to Dr. Sam as he finds his world in flux: “The third Friday in March was Match Day. After four years of medical school, Sam and his classmates would be placed into residency programs for the next phase of their

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training. After all the stress of medical school—the late-night cramming, the ungodly early wake-ups, the Step 1 exam, the Step 2 exam, all those endless exams—this was supposed to be a spring of unwinding, before residency started in July.” Instead, NYU offered Sam’s class early graduation if they wanted to work in hospitals overwhelmed by the surge of COVID19 patients. Swearing to the Hippocratic

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Oath by Webex was only the beginning of an altered reality. Regardless of their chosen specialties, these residents would support the internal medicine units. Sam reported for assignment at Bellevue Hospital on April 13. New York State would lose 778 more patients by the time he started his first shift in the morning. For a young gay man in Greenwich Village, comparisons to the HIV crisis were inevitable, particularly when living on blocks where entire populations had vanished in the ’80s. Mindful of this, “Sam would develop an elaborate routine to douse himself in sanitizer and try to prevent any possibility of taking the virus home.” Face masking and hand scrubbing were the new normal in this era. Dr. Gabriela, from Massachusetts, also attended NYU. Her story is emblematic of the heartache of separation from loved ones in the middle of a health crisis, made more poignant by struggling to deal with death on a daily and hourly basis. This newly-minted doctor of Hispanic heritage was determined to become a pediatrician and a role model. Instead, she was propelled into hospice-like situations, where palliative care was the norm. Life in New York quickly became more arduous: just going out to a neighborhood store called for face coverings and gloves like a covert mission. “But this was what the pandemic had done: turned the mundane into some cross between heroism and paranoia,” even before spontaneous cheering sections formed for health care frontline workers coming and going. Dr. Iris attended the Einstein College of Medicine, a research-intensive medical school located in the Bronx, part of the integrated Montefiore Health System. She had left in February for a study-abroad program, completing her rotation at a hospital in Paris. She “didn’t know of reports that would suggest that the first coronavirus patient in France, a coughing fishmonger, had actually turned up in a Paris hospital on December 27.” Dr. Iris portrays the global nature of the epi-

demic, from her second week in the hospital, when a patient showed up wheezing and feverish. “He was whisked away by doctors in full protective gear. Everybody on Iris’s floor started whispering about whether that patient had the novel disease.” In March, travel from Europe to the United States was suspended, and Iris made it back home just under the wire. But she barely believed what she saw on arriving. She left a Paris of hand sanitizers, Clorox wipes and face coverings and landed in a high-risk New York airport. “There were points of possible transmission all around her: hands brushing at baggage claim, children sprawled on the linoleum ground, carts slung from passenger to passenger. She knew she was on the precipice of a historical moment.” Dr. Jay finds a sense of mission and duty in the crisis. Choosing to graduate early, her mentor advised that “it would be a learning opportunity…given the scale of this pandemic, Jay would likely have to care for COVID patients at some point, so it was better to start early.” But families weren’t so sanguine, and her mother emailed concerns to Jay’s friends about her first day in the hospital: “As per an executive order signed by Governor Andrew Cuomo, Jay will graduate early today from medical school and accelerate her entry into the medical workforce due to the COVID-19 crisis. It was supposed to be different. I was supposed to have the incredible honor of hooding her on the stage of Lincoln Center. I was not supposed to feel as if I’m sending her off to war.” Dr. Elana, also graduating Einstein School, found her new role at odds with Orthodox Judaism. She had to fit ancient prayers into new applications to fulfill her duty to God, as well as her patients. Yet she also found resonance: “Later that week was Passover. It was her first time celebrating far from family; she was only comfortable seeing them outside when she dropped off groceries, not indoors for a meal.

But the holiday’s grandiose messages suddenly felt more real. Resilience, survival, sacrifice— none of these was theoretical anymore. Passover had all sorts of obvious parallels to their new reality. They were celebrating liberation in a time of real-life plague.” Through these young eyes, it becomes obvious that in the hasty rush toward their future, preparation for dealing with a “real-life plague” showed both strengths and weaknesses. One student initially wanting ER residency discovered the value of longer-term patient relationships. Another finds his best purpose in the cardiac telemetry unit. But despite a love for the technical aspects of health care, “he sensed there wasn’t anything that could have properly prepared him for the telemetry floor during the pandemic.

“Every morning their hospital was seeing five, six, seven codes. Before the pandemic, they would have seen five or so codes a week; at the COVID peak they hit thirty per day.” It will be a long time before lessons from the pandemic are validated and incorporated into medical schools. Perhaps its effects will be as striking as those following the Flexner Report, emphasizing even greater clinical experience. Regardless, the effect on this particular class of doctors is profound, and Emma Goldberg’s reportage provides a snapshot not only of their preparedness to deal with the crisis, but the raw courage, determination and sense of duty in which today’s students face with unknown travail. Kairotic times, indeed. All quotes from “Life on the Line: Young Doctors Come of Age in a Pandemic” by Emma Goldberg, Harper © 2021. David Alex Schulz, CHP is a community member of the BCMS Publications Committee.

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Patient-Centered Transitional Care Management

By Ramon S. Cancino MD, MBA, MS, FAAFP

A patient’s transition from the hospital setting to his or her next setting is one of the most dangerous times in health care. There are over 35 million hospital discharges in the United States every year, and the process of discharging from a hospital is complex and fraught with challenges.1 Challenges include ensuring patients understand why they were admitted, what medications they should now be taking and not taking, and scheduling a follow-up outpatient appointment with their primary care team. When these or other components of the discharge process do not occur consistently, patients may be readmitted back into the hospital. The cost of unplanned readmissions is $15 to $20 billion annually.2 Hospital readmissions following a COVID-19 admission contribute to the current problem. CDC investigators found, among survivors, 9% of patients were readmitted to the same hospital within two months of discharge and 1.6% were readmitted more than once.3 Hospital readmissions are often a sign of system breakdowns and poor communication between inpatient and outpatient settings. Programs to improve communication and standardized discharge processes have decreased hospital readmission.4,5 The UT Health San Antonio Regional Physician Network (RPN) has developed a patient-centered approach. The RPN developed a data-driven evidence-based approach to transitional care management. A team of Nurse Care Managers is assigned to all RPN accountable care organization practices in the community. This team of nurses receives an electronic notification every time an RPN patient is admitted or discharged from a hospital and every time the patient enters an emergency department. Once 32

notified, the nurse works with the patient’s primary care team to develop a transitional care plan, contacts the patient to review posthospitalization instructions including medications, and schedules the patient for a post-hospitalization transitional care management appointment at their primary care physician’s office. Using this approach, we have seen a significant decrease in our readmission rate. The readmit rate per 1,000 patients dropped from 169 to 152 from 2019 to 2021 after the program was implemented. There are many examples where patients benefit from this approach to transitional care management. Recently, after a patient discharged from a local hospital, a nurse called the patient for a non-face-to-face assessment where she learned the patient had a severely

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elevated blood glucose of 490. The patient had not thought to call her primary care physician’s office and was planning to go to the nearest emergency room. Instead, upon learning this information, the nurse intervened. She called the patient’s primary care physician to explain the situation, and the patient was seen and treated in the office the same day. Rather than going to a crowded emergency room with a long wait time, the patient was able to have their medications adjusted by her primary care team, who she knew and trusted. Per protocol, the nurse care manager followed up with the patient the next day with a phone call to assess the patient’s status. The patient’s blood glucose levels were improving, and the nurse took time to provide advice on diet and exercise.

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In addition to being a more patient-centered approach, this high-value activity is viewed as important by Medicare. In fact, Medicare provides increased reimbursements for these types of transitional care management encounters (CPT codes: 99495 or 99496) when compared to usual office visit E/M codes. The UT Health San Antonio Regional Physician Network understands that, to improve the quality of life of our patient community and to improve the well-being of our health care system, we must all work together during times of care transitions. Especially during this challenging pandemic, we must not allow patients to fall through the cracks and, at the same time, support our physicians with the necessary infrastructure. In doing so, we not only support our patients, we also support physician well-being.

References 1. CDC. Hospital Utilization (in non-Federal short-stay hospitals). Published March 1, 2021. Accessed September 4, 2021. https://www.cdc.gov/nchs/fastats/hospital.htm 2. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi: 10.1056/NEJMsa0803563 3. Kuehn BM. Hospital Readmission Is Common Among COVID-19 Survivors. JAMA. 2020;324(24):2477-2477. doi:10. 1001/jama.2020.23910 4. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to Reduce 30-Day Rehospitalization: A Systematic Review. Ann Intern Med. 2011;155(8): 520-528. doi:10.7326/0003-4819-155-8201110180-00008

5. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, Forsythe SR, O’Donnell JK, PaascheOrlow MK, Manasseh C, Martin S, Culpepper L. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178-187. Ramon S. Cancino, MD, MBA, MS, FAAFP is Senior Medical Director and Medical Management Director of the Primary Care Center of UT Health Physicians. He is a member of the Bexar County Medical Society.

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Artistic Expression in Medicine By Oliver H. Johnson, MD

I started seriously taking photographs 12 years ago when a friend had booked a tenday workshop in Italy with a professional photographer and couldn’t use it. He offered the slot to my wife and me, and it seemed like the perfect learning vacation. There were ten mostly professional photographers and myself as students on the tour. I was able to watch and learn how pros do it in the beautiful landscapes of Tuscany. I learned much on that and many other workshops including ones in France, Sicily, England and Cuba as well as Death Valley, Washington’s Palouse, the Oregon coast and most recently Acadia National Forest in Maine two weeks ago. COVID-19 and retirement in 2020 gave me much time at home to hone my post-processing skills with online tutorials in Photoshop and Lightroom from nationally known tutors. My photographic journey is ongoing, and I now strive to create the 'compelling frame,’ attempting to always capture and convey the feeling I had when observing the scene, more than just a well-exposed, sharp image. Scotland and the northwest coast are my next immediate destinations. I’m constantly striving to see with the photographer’s eye. The Bexar County Medical Society would like to thank Dr. Johnson for his work producing the February and July 2021 magazine cover photos of San Antonio Medicine featuring Dr. Rodolfo “Rudy” Molina, 2021 BCMS President and Melody Newsom, CEO. Displayed are a selection of his most prominent photographs.

Castle Grotti Sunrise, Tuscany, Italy, 2018

Abbey Sebanc Lavender, South France, 2014

Oliver H. Johnson, MD is the Chair of the Physician Health & Rehabilitation Committee and is a member of the Bexar County Medical Society. Jessup Path, Acadia National Forest, 2021 34

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Thor’s Well Oregon Coast, 2018

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BCMS 35th Annual Auto Show On October 21, 2021, the Bexar County Medical Society held its 35th Annual Auto Show in the Society parking lot on 1604. Guests enjoyed reviewing car and truck models from the BCMS Auto Program dealer members and goodies from the Circle of Friends members. Great food and drink were provided by Chicken N Pickle, Drury Hotels, The Éilan Hotel and Hilton Garden Inn at The Rim. Special thanks to the 2021 Auto Show event sponsors: Arthritis Associates PA, Cano Health and Genesis Cancer Care. The BCMS would like to thank the Rick Cavender Band for the music and the great physician members with their families and staff for attending and celebrating the event.

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PHYSICIANS PURCHASING DIRECTORY Support the BCMS by supporting the following sponsors. Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed. ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness. 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”

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210-270-7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210-270-7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210-270-7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

ASSETT WEALTH MANAGEMENT

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

BANKING

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President

SAN ANTONIO MEDICINE • December 2021

512-547-6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210-253-0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

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

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need. Synergy FCU Member Services 210-750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

BUSINESS CONSULTING

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales,

CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210-846-9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor) Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for health care entities. Betty Fernandez Director of Operations 210-582-6355 Betty.Fernandez@bexarcv.com www.BexarCV.com “Proudly serving the medical community since 1998”

FINANCIAL ADVISORS

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community. Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner” Elizabeth Olney with Edward Jones (HH Silver Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop

an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

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

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

Security benefit!” SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Michael Leos Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318 mleos@swbc.com swbc.com

HEALTHCARE BANKING

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512-547-6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210-253-0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

First Citizens Bank (HHH Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com Danette Castaneda Business Banking Specialist 512-797-5129 Danette.castaneda@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise” Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210-343-4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private Banking 210-343-4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President | Private Banking 210-343-4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210-343-4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER

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

HOSPITALS/ HEALTHCARE FACILITIES

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

INFORMATION AND TECHNOLOGIES

INSURANCE

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

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

INSURANCE/MEDICAL MALPRACTICE

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

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

continued on page 38 Visit us at www.bcms.org

PHYSICIANS PURCHASING DIRECTORY continued from page 37

are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Patrick Flanagan Southwest Regional Business Development Representative 800-282-6242 PatrickFlanagan@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown Regional Vice President of Sales – San Antonio 210-693-8025 clayton.brown@upnfiber.com Aron Sweet – Account Director 210-788-9515 aron.sweet@upnfiber.com Jim Dorman – Account Director 210-428-1206 jim.dorman@upnfiber.com Tammy Carosello – Account Director 210-868-0420 tammy.carosello@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

INVESTMENT ADVISORY REAL ESTATE

MEDICAL BILLING AND COLLECTIONS SERVICES

Medical Financial Group (★★★ Gold Sponsor) Healthcare and Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller and past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210-846-9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.” Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

SAN ANTONIO MEDICINE • December 2021

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

MEDICAL PAYMENT SYSTEMS/CARD PROCESSING

First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com Danette Castaneda Business Banking Specialist 512-797-5129 Danette.castaneda@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

MEDICAL SUPPLIES AND EQUIPMENT

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

of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

MOLECULAR DIAGNOSTICS LABORATORY

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

MORTGAGES

SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Jon Tober Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober

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 Medical Group Management Association (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. Alan Winkler, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates). Jon Wiegand Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405-410-8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate” Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management. Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com

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

RETIREMENT PLANNING

TELEHEALTH TECHNOLOGY

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

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

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

Visit us at www.bcms.org

AUTO REVIEW

SAN ANTONIO MEDICINE • December 2021

AUTO REVIEW

2021 John Cooper Works Mini By Stephen Schutz, MD

In 1994 BMW AG purchased the Rover Group, which included Rover, Land Rover and Mini. Just five years later, BMW mostly exited the British car business by dumping Rover and selling Land Rover to Ford, although they elected to keep Mini. And in 2000 they launched the new Mini, a fun two door hatchback that was a modern (and much larger) reinterpretation of the original Mini, in an attempt to create a brand that would capture desirable customers who couldn’t yet afford BMWs. 20 years later, where are we? The original two door Mini hatchback has been joined by a convertible, four door hatchback and two small crossovers. And Mini has been thoroughly integrated into the BMW family. My week with a 2021 two door John Cooper Works ( JCW) hatchback reminded me that the company has evolved in a good way during their 20 years of BMW ownership. For one thing, all Minis now share a platform with the BMW 1and 2-series cars and X1 and X2 crossovers. Engines, transmissions and most of the electronics are also shared, despite the fact that Minis continue to be manufactured in the UK. The Mini’s exterior design retains its retro vibe from 20 years ago, but it’s become (slightly) more contemporary with time. While the old Mini-ish profile is retained, the headlights are smaller and sleeker, and the taillights, now larger and squarer, feature British flag-esque LED lighting. Inside, many Mini standbys such as big round gauges and numerous toggle switches remain, but otherwise things are much more BMWish than they were in 2001. The gear lever in automatic transmission Minis—most Minis will come equipped with a 7-speed dual clutch automatic, but thankfully a 6-speed manual is still available—looks slightly different from BMW units, but it works just like BMW’s. And as with BMW automatics, pushing the lever forward in manual mode shifts the transmission down a gear, the opposite of what happens with every other manufacturer’s gear levers. One fun touch is the start/stop function. In most vehicles today, you keep a fob in your pocket or purse, touch the door to get in and then push a big “start” button on the dash to start the engine. In Minis, there’s no button on the dash, just a red “start” toggle switch protruding from the center stack. It works the same as a button, but is definitely cooler. The infotainment system is very BMW too, with a central touch screen that accesses and controls all of the usual functions, but which

can also be navigated using a wheel and buttons on the center console—a setup otherwise known as iDrive in BMWs. I have no problem with all of this BMW-ness being present in Minis. BMW makes upscale vehicles that we all like and admire, and if Mini had to develop their own systems from scratch, their cars would cost a lot more. And Minis are indeed affordable—my loaded JCW model stickered for just over $40,000, but a base two door hatchback starts at just over $23,000. Interestingly, JCW versions of all Minis are available. Much as M versions of BMWs are the performance models, so JCWs are the sporty Minis. The JCW two door hatchback makes sense to me—and would be the version I’d get if I were buying one—but a JCW Countryman seems slightly incongruous. It’s not a big crossover by any means, but neither is it a zippy hot hatch like my press car. For the record, the front wheel drive JCW two door Mini is totally a hot hatch. Its potent 228HP turbocharged 4-cylinder engine is “the jam,” as the kids might say, and driving one on my favorite deserted back road was a delight thanks to it and its fantastic suspension tuning. There’s virtually no understeer, and the combination of all that power and handling is really enjoyable. Honestly, there are few cars for sale today as fun as the two door JCW Mini. Of course, all the things that make it fun detract from it being a truly practical car. Its diminutive size means that passenger and luggage space is limited; you’re safer in a big pickup or SUV, and being able to see above or around vehicles in front of you isn’t happening. In addition, those space limitations and a buzzy engine mean that long road trips in the Mini will be less pleasurable than in an F-150. The JCW two door Mini hatchback is a seriously fun hot hatch that will entertain you every time you get behind the wheel. Just don’t expect it to carry lots of people or stuff, or be a great long-distance traveler. But if you want a zippy everyday driver that’s terrific around town or on twisty back roads, this is your car. 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.

Visit us at www.bcms.org

11911 IH 10 West San Antonio, TX 78230

Audi Dominion 21105 West IH 10 San Antonio, TX 78257

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

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX

Coby Allen 210-696-2232

Rick Cavender 210-681-3399

Charles Williams 210-912-5087

William Boyd 210-859-2719

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave. New Braunfels, TX 78130

Northside Ford 12300 San Pedro San Antonio, TX

Northside Honda 9100 San Pedro Ave. San Antonio, TX 78216

14610 IH 10 West San Marcos, TX 78249

Matthew C. Fraser 830-606-3463

Marty Martinez 210-477-3472

Paul Hopkins 210-988-9644

Mark Hennigan 832-428-9507

Kahlig Auto Group

Land Rover San Antonio 13660 IH 10 West San Antonio, TX

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 25131 IH 10 W Dominion San Antonio, TX

North Park Lincoln 9207 San Pedro San Antonio, TX

Cameron Tang 210-561-4900

Tripp Bridges 210-308-8900

James Cole 210-816-6000

Sandy Small 210-341-8841

North Park Mazda 9333 San Pedro San Antonio, TX 78216

Mercedes Benz of Boerne 31445 IH 10 West Boerne, TX

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

9455 IH 10 West San Antonio, TX 78230

John Kahlig 210-253-3300

James Godkin 830-981-6000

Al Cavazos Jr. 210-366-9600

Douglas Cox 210-764-6945

Kahlig Auto Group

North Park Subaru 9807 San Pedro San Antonio, TX 78216

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

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

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

Raymond Rangel 210-308-0200

Phil Larson 877-356-0476

Gary Holdgraf 210-862-9769

Justin Boone 210-635-5000

Kahlig Auto Group

San Antonio Medicine December 2021

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