San Antonio Medicine, November 2025

MEDICINE

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SAN ANTONIO MEDICINE is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, 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 origin, or an intention to make such preference limitation or discrimination.

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HEALTH INSURANCE OPEN ENROLLMENT 2026

The Right Coverage—and Support—Starts Here

From Eligibility to Enrollment and Beyond:

How We Help Owners and Independents

For practice owners with group coverage, we help manage costs while offering your employees a combination of PPO and HMO plans.

If your staff is covered elsewhere (such as through a spouse’s plan), you might still qualify for group PPO coverage for yourself and your family.

If you own a business with your spouse as the sole employee, you may be eligible for group coverage, without partnership documentation.

Partners with no W-2 employees may qualify for individual group coverage by providing basic partnership documentation and your company’s SS4 or recent K-1 (Form 1065).

For physicians opening a new practice, we simplify the process of starting your group plan, right from the beginning.

We assist with high-deductible health plans, allowing you to open a Health Savings Account (HSA) and take advantage of tax-saving benefits.

We continue to provide support after enrollment, handling administrative tasks such as issuing ID cards, making updates, and managing plan changes.

This Open Enrollment season, we’re here to help.

Whether you practice independently, with a partner, or lead a team, you may still qualify for group PPO coverage— even just for yourself and your family. With us, you’ll have access to clear, physician-focused guidance, allowing you to make informed decisions with confidence.

Our commitment doesn’t end when your coverage begins.

At TMA Insurance Trust, coverage comes with care, not just at enrollment, but throughout the year. There are no inflated costs, hidden fees, or sales pressure, just practical help, ongoing plan management, and reinvestment in vital resources that support you and your fellow physicians.

Make the most of Open Enrollment 2026. Connect with a TMA Insurance Trust advisor at 1-800-880-8181, Monday through Friday from 8:00 AM to 5:00 PM CST or visit tmait.org.

SCAN TO CALL

BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

John Shepherd, MD, President

Lyssa Ochoa, MD, Vice President

Jennifer R. Rushton, MD, President-Elect

Lubna Naeem, MD, Treasurer

Lauren Tarbox, MD, Secretary

Ezequiel “Zeke” Silva, III, MD, Immediate Past President

DIRECTORS

Woodson “Scott” Jones, Member

John Lim, MD, Member

Sumeru “Sam” G. Mehta, MD, Member

M. “Hamed” Reza Mizani, MD, Member

Priti Mody-Bailey, MD, Member

Dan Powell, MD, Member

Saqib Z. Syed, MD, Member

Nancy Vacca, MD, Member

Luis O. Rohena, MD, Military Representative

Jayesh Shah, MD, TMA President

John Pham, DO, UIW Medical School Representative

Robert Leverence, MD, UT Health Medical School Representative

Cynthia Cantu, DO, UT Health Medical School Representative

Lori Kels, MD, UIW Medical School Representative

Ronald Rodriguez, MD, UT Health Medical School Representative

Alice Gong, MD, Board of Ethics Representative

Melody Newsom, BCMS CEO/Executive Director

George F. “Rick” Evans, Jr., General Counsel

BCMS SENIOR STAFF

Melody Newsom, CEO/Executive Director

Brissa Vela, Chief Membership & Development Officer

Yvonne Nino, Controller

Betty Fernandez, BCVI Director of Operations

Phil Hornbeak, Auto Program Director

Al Ortiz, Chief Information Officer

Jacob Hernandez, Advocacy and Public Health Specialist

PUBLICATIONS COMMITTEE

Jennifer C. Seger MD, Chair

Timothy C. Hlavinka, MD, Member

John Robert Holcomb, MD, Member

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George-Thomas Martin Pugh, MD, Member

Adam Ratner, MD, Member

Rajam Ramamurthy, MD, Member

Patrick Reeves, MD, Member

John Joseph Seidenfeld, MD, Member

Amith Skandhan, MD, Member

Francis Vu Tran, MD, Member

Subhashini Valavalkar, MD, Member

Louis Doucette, Consultant

Brissa Vela, Staff Liaison

Gabriella Bradberry, Staff Liaison

Trisha Doucette, Editor

Ayomide Akinsooto, Student

Gabrielle Holliefield, Student

Rita Espinoza, DrPH, Volunteer

Melissa Rosales, Volunteer

Ramaswamy Sharma, MS, PhD, Volunteer

Andrea Wazir, Volunteer

Fast Imaging. Faster Answers.

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Gratitude

By John Shepherd, MD, President, Bexar County Medical Society

At 18, I packed my bags for the University of Wisconsin and set off on my quest to go from awkward, science-loving, nerdy kid to Dr. Shepherd, pediatric anesthesiologist. And then, in the very first month, my tuition check from my parents bounced. Suddenly the dream I had carried for years felt like it might slip away. I scrambled for money, patched things together, and kept moving forward. But it took me much longer to learn the real lesson in that moment: gratitude.

Gratitude has never been just about saying thank you. It’s about learning to embrace the detours, the challenges and even the failures. Those are the places where character grows — quietly, sometimes pain fully, but always with purpose. Medicine is the same way. The road is rarely smooth, but there is always something worth being grateful for.

In the rush of rounds, difficult patients or middle-of-the-night phone calls, it’s easy to lose sight of the privilege of being in a posi tion to care for others. Every patient brings not only their illness, but also their stories, their hopes and their trust. When we walk into a room, we’re often stepping into some of the hardest days of someone else’s life. That’s no small thing. For me, gratitude is about more than being thankful for my education or training — it’s about recognizing what an honor it is to be allowed into people’s lives at such vulnerable moments. Healing, whether through a simple conversation or a com plex procedure, is a reminder that each day in medicine is a chance to give, to learn and to grow.

As I’ve aged, I’ve learned that gratitude doesn’t only live in the extraordinary moments but it also shows up in the quiet, everyday parts of the job. The way a patient’s shoulders relax when you really listen and they realize they’re being heard. The subtle nod between colleagues after a tough case. The steady rhythm of teamwork during a surgery when everyone moves in sync. These aren’t the moments that make headlines or fill awards banquets, but they are the heartbeat of what we do.

I’m also deeply grateful for my colleagues — the ones standing shoulder to shoulder with me every day, and all of you who are part of the Bexar County Medical Society. Medicine is not a solo act. The best outcomes come when a team brings its collective knowledge and heart to the work. From the seasoned physician who shares hard-earned wisdom, to the medical student just beginning the journey, I’ve found the strength of our profession in mutual respect and shared commitment. Camaraderie in medicine is priceless; it makes me a better doctor and, truthfully, a better human being.

Of course, like many of you, I couldn’t do what I do without the support of friends and family — the ones who have cheered the highs and steadied me in the lows. I’m especially grateful for my family’s sacrifices, because it hasn’t always been easy to be married to medicine. Long days spent caring for others mean they are often the ones carrying the weight at home. And yet, my spouse has always understood what this calling demands. They know what it means when the phone rings at 2:00 a.m., or when birthdays and anniversaries are shifted around

keep me focused on what makes this calling worth it.

Gratitude, at its core, is not a passive emotion. It’s an active practice and a way of choosing to see the good alongside the hard. It’s what allows us to hold on to our sense of purpose when things get tough.

As we enter this season of Thanksgiving and the holidays ahead, it feels especially important to pause and remember what we do have: the chance to serve, the colleagues who stand beside us and the families who give us the grace to do this work. My hope is that each of us can carry that spirit of gratitude with us not just this season, but throughout the year so that we continue to find meaning and fulfillment in the journey of healing.

Because in the end, it’s not the paperwork or the sleepless nights that define us. It’s the moments of connection, the trust of our patients, the strength of our teams and the love of those who support us. And that, more than anything, is something worth being grateful for.

John Shepherd, MD, 2025 President of the Bexar County Medical Society and TEXPAC Chair, has been an active advocate for the Family of Medicine at the Texas State Capitol and has held several “Party of Medicine” events, introducing physicians on how to get involved with legislation that affects medical issues. He has been Chief of Surgery at Christus Santa Rosa Children’s Hospital and a past member of the Board of Directors of Tejas Anesthesia. Dr. Shepherd is currently a Pediatric Anesthesiologist with University Medical Associates, and serves on the BCMS Legislative Committee and the Bexar Delegation to TMA.

A u t u m n

FESTIVAL

J o i n u s i n c e l e b r a t i n g t h e s e a s o n a n d

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T r u n k - O r - T r e a t i n g

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F a m i l y F u n

A n d M o r e !

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C A S A D O M A I N E C U S T O M H O M E S

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S C A N Q R T O R S V P

Empowering Medical Families, Enriching Community Health, and Shaping the Future of Medicine in Bexar County

By Jenny Shepherd

The Bexar County Medical Society Alliance (BCMSA) is a vibrant community of physician spouses and physicians dedicated to supporting medicine, medical families and the health of our community. We are a social, philanthropic and advocacy-driven group with a long tradition of making a meaningful impact in Bexar County.

Each year, the Alliance provides thousands of dollars in scholarships to medical students, nursing students and allied health students. By investing in the next generation of health professionals, we help ensure that the future of medicine remains strong, compassionate and accessible.

Our community outreach projects bring health and wellness directly to families. Through BookShare, we place books in the hands of children who might otherwise go without. With Hard Hats for Little Heads, we distribute free bicycle helmets to protect kids from head injuries. We assist with health fairs and partner with local organizations to make our neighborhoods healthier and safer.

Advocacy is another cornerstone of our mission. The Alliance works alongside physicians to build relationships with legislators, standing up for patients and for the practice of medicine in Texas. We are proud to be a voice for both the needs of families and the future of healthcare.

Of course, we also believe in taking care of each other. The Alliance hosts social gatherings and events that bring physician families together for connection, friendship and support. At its heart, BCMSA is about community — because when medical families are supported, the whole community thrives.

Jenny Shepherd is the Immediate Past President of the TMA Alliance, Chair of First Tuesdays at The Capitol and acting BCMSA President with a legacy of supporting physicians, their families and the broader health of the community.

Miraflores Garden Tour

Miraflores Garden Tour

Community Outreach-Bike Safety and Nutrition

Connect over Coffee

COMMUNICATING WITH CONFIANZA — A HEALTH LITERACY ECHO

TOGETHER, WE CAN IMPROVE COMMUNICATION AND HEALTH LITERACY SKILLS

Join us for a free online learning series designed to empower health professionals with health literacy education, resources and knowledge-sharing tools. The series is presented by Health Confianza, an award-winning health literacy nonprofit funded by Bexar County and housed at The University of Texas Health Science Center at San Antonio.

Who is this for? Health professionals, including physicians, nurses, community health workers, social workers and pharmacists.

Join our expert team the first and third Friday of each month TOPICS:

• Acknowledging perspectives

• Shame/stigma; Creating a shame-free environment

• Plain language

• Shared decision-making

• Teach Back

WHAT: Free, six-part series

DATE/TIME: Sept. 5th - Nov. 21, 1st and 3rd Fridays of the month, 12:00-1:00 p.m.

REGISTER:

bit.ly/Communicatingwith Confianza CE credits are available

Multidisciplinary Care and Advances in Lung Cancer Diagnosis and Treatment

By Oluwatobi "Tobi" Afolayan, MD, and Gustavo E. Guajardo Salinas, MD

Lung cancer care has rapidly changed in the past few years, enabling earlier diagnosis and better patient outcomes. Minimally invasive procedures mean faster diagnosis and treatment, and multidisciplinary care teams can screen patients who are then treated by surgery, chemotherapy and radiation therapy according to their stage, medical conditions and preferences to suit their lifestyle, goals and personal health history.

Screening for lung cancer is critical to catch the disease in early stages. In the United States, only 27.4% of diagnoses are in early stages, with a 5-year survival rate of 64%, while 43% are late stage, with a drastically lower 5-year survival rate of 9%.1 Unfortunately, only 18% of eligible individuals nationally get screened, and only 10.6% in Texas.2,3

Patients with significant risk factors — including cigarette smoking or second-hand smoke exposure, radon exposure, occupational exposure to hazardous substances (arsenic, asbestos, beryllium, cadmium, chromium, silica, soot and uranium), chronic obstructive pulmonary disease or pulmonary fibrosis or a family history of lung cancer in first degree relatives — should undergo assessment for consideration of screening with annual low dose CT of the chest without contrast.4

Patients with symptoms like a persistent cough, blood in mucus or sputum, unintentional weight loss, trouble breathing, chest pain or pain when swallowing, or new onset severe fatigue should see their physicians for appropriate workup. Following screening, the thoracic surgery team can support all stages of the cancer journey — diagnosis, biopsy, treatment, metastasis and survivorship.

Thoracic Expertise and Collaboration

Thoracic surgeons play a key role in determining (1) if biopsy is required before surgery, depending on a pre-test probability assessment, and (2) whether a patient is an ideal candidate for surgery based on age, comorbidities and size and location of nodules and tumors. Since biopsies can add time, cost and risk without altering treatment decisions, early surgical consultation can reduce unnecessary procedures.4

Depending on the patient and their unique needs, we work closely with pulmonologists, cardiologists, radiation oncologists, medical oncologists and other specialists in the San Antonio community to provide comprehensive, leading-edge care for each patient. For example, by combining surgery with identification of molecular markers, we offer targeted treatments that are more convenient and less disruptive.

For patients with early-stage non-small cell lung cancer, thoracic surgery is the first line of treatment.5 Many patients undergo a resection or removal of part of their lung, formerly considered major inpatient surgery. We can now operate quickly with fewer complications, quicker discharge and improved outcomes.6

Patients often ambulate within hours and can be discharged after 24-48 hours, experiencing minimal pain from surgery. Through shared decision-making, we help patients maintain quality of life. While full recovery can take several weeks to months, some patients see almost no change to their lives and even return quickly to physical activity.

Robotics Revolution

Much of the progress made in reducing operative trauma, post-surgical pain and complications is due to advancements in robotic surgical devices, leading to faster, earlier diagnosis and less disruptive treatment.5 By allowing for full visualization of the operating field, precise fine movements and better range of motion, robotic surgery benefits both patients and physicians.

For example, in treating non-small cell lung cancer (the most common form of lung cancer), we use a single-incision, uniportal approach, rather than three to four incisions. Patients prefer this option for quicker recovery, and surgeons can do more complex operations, including advanced pulmonary resections (e.g., segmentectomies, sleeve lobectomies) with an ergonomic and comfortable set up. During screening procedures, robotic bronchoscopes can facilitate making diagnoses in nodules that traditionally would not have been reachable. We can also perform diagnosis and treatment in one session, meaning patients only need to undergo anesthesia once, further reducing the risk of complications.

Finally, the past few years we have shifted from lobectomies (removal of a full lobe of the lung) to segmentectomies (removal of a smaller part) in patients with nodules less than 2 cm, allowing patients to retain more healthy tissue than previously possible.7 This less invasive robotic procedure has been associated with comparable 5-year survival rates while improving recovery, respiratory symptoms, physical functioning, cognitive ability and fatigue.8,9

As the landscape of lung cancer care has evolved, thoracic surgeons have a key role to play on multidisciplinary teams, ensuring that patients receive personalized, efficient and effective care tailored to their unique needs and preferences. We hope the future of lung cancer care promises even greater strides in screening, survival and patient-centered outcomes.

References:

1. Lung Cancer Key Findings. (2024, November 13). Retrieved from American Lung Association: https://www.lung.org/research/state-oflung-cancer/key-findings

2. Potter, A.L., Kothagundla, S., Haridas, C., Chang, A.E., Sequist, L.V., & Yang, C.-F. (2025). Preventive Health Care Use Among Adults Eligible for Lung Cancer Screening in the US. JAMA, 333(18), 1635-1638

3. American Lung Association. (2024). State of Lung Cancer. Texas. American Lung Association

4. National Comprehensive Cancer Network. (2025). Lung Cancer Screening. NCCN Guidelines

5. Mangiameli, G., Cioffi, U., Alloisio, M., & Testori, A. (2022). Chapter 3: The State of the Art in Thoracic Surgery: Treating Lung Cancer

Between Tradition and Innovation. In S. CM (Ed.), Metastasis. Brisbane (AU): Exon Publications

6. Walcott-Sapp, S. (2016, December 8). The History of Pulmonary Lobectomy: Two Phases of Innovation. Retrieved from CTSNET: https://www.ctsnet.org/article/history-pulmonary-lobectomy-two-phases-innovation

7. Kirkendoll, S.M. (2025, March 5). Less Invasive Lung Cancer Surgeries on the Rise, Study Shows. Retrieved from Duke University School of Medicine: https://medschool.duke.edu/news/less-invasive-lungcancer-surgeries-rise-study-shows

8. Jiang, S., Wang, B., Zhang, M., Liu, Z., Xiao, Z., Gong, J., . . . Zhang, Z. (2023). Quality of life after lung cancer surgery: sublobar resection versus lobectomy. BMC Surg, 23, 353

9. Magouliotis, D.E., Cioffi, U., Minervini, F., Lampridis, S., Guttadauro, A., & Scarci, M. (2025). Changes in quality of life of early-stage lung cancer patients undergoing sublobar resection: a systematic review. Front. Surg., 12

Oluwatobi "Tobi" Afolayan, MD, is a board-certified thoracic surgeon practicing at Texas Oncology Medical Center and Westover Hills. Dr. Afolayan is a member of the Bexar County Medical Society.

Gustavo E. Guajardo Salinas, MD, is a board-certified thoracic surgeon practicing at Texas Oncology Medical Center, Stone Oak and New Braunfels. Dr. Guajardo Salinas is a member of the Bexar County Medical Society.

Prostate Cancer Screening: The #1 tool in reducing mortality

By Austin Enenmoh, MD

Prostate cancer remains a major health threat to men, yet screening continues to decline. Prostate cancer is the most diagnosed noncutaneous cancer in American men and the second leading cause of cancer death. In 2025, an estimated 313,780 men will be diagnosed with and 35,770 will die of prostate cancer, which is equivalent to 15.4% of all new cancer cases and 5.8% of all cancer deaths. For a broader view, consider that the lifetime risk of prostate cancer diagnosis is estimated to be one in eight (12.9%), and more than 3.5 million men in the United States are living with a history of prostate cancer.1 The average age for prostate cancer diagnosis is 67, with six out of 10 cases diagnosed over 65 and cases rarely diagnosed in men under 40. The vast majority of prostate cancer (~83%) is diagnosed at a localized or regional stage, for which the 5-year relative survival approaches 100%. However, once prostate cancer becomes metastatic, the 5-year survival markedly declines to ~38%.2 Despite this burden, screening remains underused: population surveys show PSA testing dropped ~46% from 2008 to 2020, with only a partial rebound after 2020.3,8 Some of the decline was attributed to the 2012 USPSTF grade D recommendation, which cited a “moderate to high certainty that harms of PSA screening outweighed the benefits.” However, trends reversed and rates of PSA screening increased after the USPSTF’s draft statement in 2017 and updated recommendations in 2018.4 Nevertheless, these facts underscore why structured, shared decision-making about PSA testing remains essential.

Contemporary American Urological Association/Society of Urologic Oncology (AUA/SUO) guidance centers the purpose of screening on detecting clinically significant disease while limiting overdiagnosis and overtreatment. The guideline recommends PSAbased screening in the context of shared decision-making, starting at age 45 to 50 years for the general population. It’s then recommended that screening continue every two to four years for most patients between the ages of 50 and 69 years. However, clinicians should offer screening earlier beginning at age 40 to 45 years for those with higher baseline risk (e.g., Black ancestry, strong family history or pathogenic germline variants).5 Baseline PSA can help tailor the indicated screening interval thereafter. For patients with newly elevated PSA > 4.0, the PSA should be repeated prior to considering additional testing such as imaging or transrectal prostate biopsy. At this step, a urologist should be involved to assist with management. Clinicians should not use digital rectal examination (DRE) as the sole screening method. The PPV of DRE as a screening method to detect prostate cancer is low. However, DRE has been shown to be of greatest benefit in the setting of elevated PSA and physicians should strongly consider DRE to help establish risk of clinically significant prostate cancer.6

Overall prostate cancer risk is higher in certain populations, including African American men and Caribbean men of African ancestry. Although city-level, race-specific PSA public data are limited, estimates from NCI and CDC do provide county-level PSA screening prevalence for men 55–69, underscoring the feasibility and need to monitor this locally. Closer to home, a South Texas safety-net cohort (majority Hispanic) found only ~27% of men had any PSA test from 2008 to 2010, which is about half the national testing rate at the time. Black men were more likely to be tested than White men, but had more abnormal PSAs, highlighting downstream risk without consistent early detection.7

The path forward requires deliberate action at the practice level. Primary care physicians are uniquely positioned to reverse declining screening trends by making PSA discussions a routine part of care for men ages 45-69 and high-risk patients as young as 40. By using baseline PSA values to personalize screening intervals and emphasizing outreach to Black and Hispanic men who face reduced access and/or elevated risk, we can translate guidelines into real improvements in early detection. The 46% drop in screening rates since 2008 represents tens of thousands of missed opportunities to intercept disease at its most curable stage. Reversing that trend begins with the next annual visit.

References:

1. National Cancer Institute. Cancer Stat Facts: Prostate cancer. SEER website. https://seer.cancer.gov/statfacts/html/prost.html

2. American Cancer Society. Key statistics for prostate cancer. American Cancer Society website. https://www.cancer.org/cancer/types/ prostate-cancer/about/key-statistics.html

3. National Cancer Institute. Prostate-specific antigen (PSA) screening prevalence within the past year—model-based small area estimation (NHIS/BRFSS). https://sae.cancer.gov/nhis-brfss/estimates/psa. html

4. Leapman, M.S., Wang, R., Park, H., et al. Changes in prostate-specific antigen testing relative to the revised US Preventive Services Task Force recommendation on prostate cancer screening. JAMA Oncol. 2022;8(1):41-47. doi:10.1001/jamaoncol.2021.5143

5. Wei, J.T., Barocas, D.A., Carlsson, S., et al. Early detection of prostate cancer: AUA/SUO guideline Part I: Prostate cancer screening. J Urol. 2023;210(1):46-53. doi:10.1097/JU.0000000000003491

6. Wei, J.T., Barocas, D.A., Carlsson, S., et al. Early detection of prostate cancer: AUA/SUO guideline Part II: Considerations for a prostate biopsy. J Urol. 2023;210(1):54-63. doi:10.1097/ JU.0000000000003492

7. Liang, Y., Du, F., Thompson, I.M., Turner, B.J. Limited PSA testing in indigent men in South Texas: an appropriate care or missing a prevention opportunity? Cancer Epidemiol Biomarkers Prev. 2012;21(9):1489-1496. doi:10.1158/1055-9965.EPI-12-0497

8. Merrill, R.M., Gibbons, I.S. Prostate-specific antigen testing in the United States during 2008–2022 in relation to the US Preventive Services Task Force recommendations. Sci Rep. 2024;14(1):31345. doi:10.1038/s41598-024-82821-w

9. Kratzer, T.B., Mazzitelli, N., Star, J., Dahut, W.L., Jemal, A., Siegel, R.L. Prostate cancer statistics, 2025. CA Cancer J Clin. Published online September 2, 2025. doi:10.3322/caac.70028

10. National Cancer Institute. Prostate cancer screening. Cancer Trends Progress Report. https://progressreport.cancer.gov/detection/prostate_cancer kso

Austin Enenmoh, MD, is a practicing urologist with Urology San Antonio, San Antonio’s largest urology practice. He is a general urologist with a particular interest in men’s health and robotic surgery. Dr. Enenmoh is a member of the Bexar County Medical Society.

Kegel Exercises Benefit Men, Too!

By Alexandra De Vita, OMS-II; Madeline Ajero-Mercado, OMS-II; Ashley Acosta, OMS-II; and Ramaswamy Sharma, MS, PhD

Kegel exercises, named after Dr. Arnold Kegel, an American gynecologist, were designed to help women suffering from urinary incontinence after childbirth by strengthening the pelvic floor muscles, i.e., the levator ani and coccygeus muscles. His exercises were not new, as practitioners of the ancient Mula bandha yoga or followers of the physiotherapist, Margaret Morris, who described similar exercises in her books, Maternity and Post-operative Exercises – In Diagrams and Words, and Training for Childbirth from the Mother’s Point of View in 1936 and 1941 respectively, would attest. However, Dr. Kegel’s re-introduction of pelvic floor muscle exercises in 1948 to improve bladder control and treat or prevent vaginal and uterine prolapse gained more recognition, perhaps because he also invented the perineometer to measure pelvic floor muscle strength.

While Kegel exercises are associated with post-partum recovery in women, their importance and benefits in men are often overlooked. The pelvic floor muscles provide stability to the pelvic organs and support the bladder, intestines and also the prostate in men; therefore, they play important roles in preserving urinary and fecal continence as well as erectile function and ejaculation. However, aging, prolonged inactivity, surgery, obesity and other factors can weaken these muscles, leading to complications.

Urinary incontinence is a complication that occurs in about 5-20% of men a year after prostatectomy, resulting in physical issues as well as emotional and social issues that result in a sharp decline in the quality of life. The predisposition of patients to the risk of developing urinary incontinence is multifactorial, associated with either preoperative conditions such as age, body mass index, size of prostate, etc., the surgery itself, or the methods in which incontinence is defined and assessed. Several randomized clinical studies have reported that providing appropriate pre- and post-operative training sessions of Kegel exercises to patients who underwent radical prostatectomies resulted in a significant decrease in incontinence or improved return to continence, as measured by parameters such as significantly lower numbers of incontinence episodes recorded per day, per week or after three to six months, reduced usage of pads, etc., in comparison to control groups. A recent metanalysis also concluded that pelvic floor muscle training before radical prostatectomy significantly reduced the incidence of urinary incontinence postoperatively.

Nocturia or frequent urination at night is a bothersome symptom that affects the quality of life; however, it is commonly mistaken as being a normal consequence of aging and is, therefore, underreported and undertreated. A typical first-choice treatment model for nocturia

involves prescribing alpha-adrenergic antagonists for men and overactive bladder medications for women. A study comparing antimuscarinic medication versus behavioral intervention in men suffering from one or more voids per night reported that participants treated with a multi-component approach consisting of pelvic floor muscle training, delayed voiding and urge suppression techniques experienced a significant reduction in nocturia as compared to drug therapy. Similarly, participants experiencing clinically relevant nocturia (two or more voids per night) at baseline also showed significant improvement with behavioral therapy when compared to the pharmacological treatment group.

Kegel exercises can also enhance sexual health of patients with either erectile dysfunction (ED) or those with increasing refractory period after ejaculation, as may occur with aging. Training the perineal muscles via Kegel exercises also helps maintain the semen ejaculative force that diminishes with age. A randomized controlled trial compared the effect of pelvic floor muscle exercises and biofeedback combined with lifestyle changes (intervention group) on erectile dysfunction as compared to lifestyle modifications alone (control group). The intervention group exhibited significantly higher International Index of Erectile Function (IIEF) scores than the control group at three months post-intervention. Importantly, implementation of pelvic floor muscle exercises by the control group after the three-month assessment resulted in significantly increased IIEF scores that paralleled the IIEF scores of the intervention group at six months. More recently, a systematic review that investigated the efficacy of pelvic floor exercises in treating ED and premature ejaculation (PE) based on 10 trials also concluded that pelvic floor muscle exercises were effective in treatment of ED.

Regular post-operative Kegel exercises have also been shown to decrease fecal incontinence to preoperative levels after fistulotomy by helping recover lost sphincter function; similarly, a recent systematic review found that pelvic floor muscle training helps in preventing and managing low anterior resection syndrome (LARS) among patients with rectal cancer.

While electromagnetic therapy can also be used to strengthen pelvic floor muscles, Kegel exercises are inexpensive and effective as behavioral therapeutic approaches. High quality videos demonstrating Kegel exercises can be found on YouTube. Steps typically include identifying the right muscles by trying to stop urine flow midstream or controlling the urge to pass gas, contracting or squeezing those muscles and holding them for three to five seconds (or up to 10 seconds, as the muscles get stronger), releasing the contraction and relaxing for

three to five seconds, and repeating these steps between eight to 15 times, three times a day. Specialists in pelvic floor rehabilitation may also be approached for guidance. Fast contractions focus on maintaining contraction against increased intra-abdominal pressure, whereas slow contractions focus on muscle strengthening. Kegel exercises can be personalized to fit the patient’s needs.

It is important to track progress with Kegel exercises for remaining motivated and noting improvements over time. Baseline values can be determined by observing the holding time of contraction and the number of repetitions, and then increasing both parameters over time; the corresponding improvement in symptoms or benefits should also be noted. Studies show that push notifications or reminders on mobile phones to perform Kegel exercises enhances adherence to post-operative Kegel instructions.

In summary, Kegel exercises can be beneficial for male patients in addressing complications such as incontinence and erectile dysfunction. With improved patient education, more men can benefit from Kegel exercises, too.

References:

1. Alvarez, K., Fillbrunn, M., Green, J.G., Jackson, J.S., Kessler, R.C., 1. Aydın Sayılan, A., & Özbaş, A. (2018). The effect of pelvic floor muscle training on incontinence problems after radical prostatectomy. American Journal of Men’s Health, 12(4), 1007–1015. https:// doi.org/10.1177/1557988318757242

2. Belarmino, A., Walsh, R., Alshak, M., Patel, N., Wu, R., & Hu, J. C. (2019). Feasibility of a mobile health application to monitor recovery and patient-reported outcomes after robot-assisted radical prostatectomy. European Urology Oncology, 2(4), 425–428. https://doi. org/10.1016/j.euo.2018.08.016

3. Brubaker, L. (2025). Pelvic floor muscle exercises: Beyond the basics. In R. L. Barbieri & K. Eckler (Eds.), UpToDate. Retrieved May 28, 2025, from https://www.uptodate.com/contents/pelvic-floor-muscle-exercises-beyond-the-basics

4. Chitre, A., & Kulkarni, J. N. (2022). Effect of early pelvic floor muscle exercises (Kegel’s) after Robotic Prostatectomy in Prostate cancer patients. Journal of Robotic Surgery, 17(3), 1065–1070. https://doi. org/10.1007/s11701-022-01506-6

5. Dorey, G., Speakman, M. J., Feneley, R. C. L., Swinkels, A., & Dunn, C. D. R. (2005). Pelvic floor exercises for erectile dysfunction. BJU International, 96(4), 595–597. https://doi-org.uiwtx.idm.oclc. org/10.1111/j.1464-410X.2005.05690.x

6. Gacci, M., De Nunzio, C., Sakalis, V., Rieken, M., Cornu, J., & Gravas, S. (2023). Latest evidence on Post-Prostatectomy urinary incontinence. Journal of Clinical Medicine, 12(3), 1190. https://doi. org/10.3390/jcm12031190

7. Garg, P., Sohal, A., Yagnik, V., Kaur, B., Menon, G., & Dawka, S. (2022). Incontinence after fistulotomy in low anal fistula: Can Kegel exercises help improve postoperative incontinence? Polish Journal of Surgery, 95(3), 13–20. https://doi.org/10.5604/01.3001.0015.9820

8. Gunay, N. F., Cakmak, S., Gelmis, M., & Dizdaroglu, C. (2025). Bridging the gap in patient guidance: Quality analysis of kegel exercise videos on YouTube. Neurourology and Urodynamics. https:// doi.org/10.1002/nau.70070

9. Hong, M., Yu, W., Gao, Y., Pei, B., Chen, J., & Lou, Y. (2024). Pelvic Floor Muscle Training for the Prevention and Management of Low Anterior Resection Syndrome in Patients with Rectal Cancer: An Evidence-Based Summary. Asia-Pacific Journal of Oncology Nursing, 12, 100620. https://doi.org/10.1016/j.apjon.2024.100620

10. Johnson, T.M., 2nd, Markland, A.D., Goode, P.S., Vaughan, C.P., Colli, J.L., Ouslander, J.G., Redden, D.T., McGwin, G., & Burgio, K.L. (2013). Efficacy of adding behavioural treatment or antimuscarinic drug therapy to α-blocker therapy in men with nocturia. BJU international, 112(1), 100–108. https://doi.org/10.1111/j.1464410X.2012.11736.x

11. Kegel, A.H. (1948). The nonsurgical treatment of genital relaxation; use of the perineometer as an aid in restoring anatomic and functional structure. Annals of Western Medicine and Surgery, 2(5):213-6

12. Meldrum, D.R., Morris, M.A., Gambone, J.C., & Esposito, K. (2019). Aging and erectile function. The Aging Male, 23(5), 1115–1124. https://doi.org/10.1080/13685538.2019.1686756

13. Myers, C., & Smith, M. (2019). Pelvic floor muscle training improves erectile dysfunction and premature ejaculation: a systematic review. Physiotherapy, 105(2), 235–243. https://doi.org/10.1016/j.physio.2019.01.002

14. Puppo, V., & Puppo, G. (2015). Comprehensive review of the anatomy and physiology of male ejaculation: Premature ejaculation is not a disease. Clinical Anatomy, 29(1), 111–119. https://doi. org/10.1002/ca.22655

15. Rangganata, E., & Rahardjo, H.E. (2021). The Effect of Preoperative Pelvic Floor Muscle Training on Incontinence Problems after Radical Prostatectomy: A Meta-Analysis. journals.sbmu.ac.ir. https://doi. org/10.22037/uj.v18i04.6481

16. Scott, K.M., Gosai, E., Bradley, M.H., et al. (2020). Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain. International Urology and Nephrology, 52(4), 655–659. https://doi.org/10.1007/s11255-01902343-7

17. Tienforti, D., Sacco, E., Marangi, F., D'Addessi, A., Racioppi, M., Gulino, G., Pinto, F., Totaro, A., D'Agostino, D., & Bassi, P. (2012). Efficacy of an assisted low-intensity programme of perioperative pelvic floor muscle training in improving the recovery of continence after radical prostatectomy: A randomized controlled trial. BJU International, 110(7), 1004–1010. https://doi.org/10.1111/j.1464410X.2012.10948.x

Alexandra De Vita, OMS-II, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2028. Her interests include Internal Medicine and community engagement in healthcare.

Madeline Ajero-Mercado, OMS-II, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2028. Her interests include Pediatrics, Primary Care and improving health outcomes for underserved communities.

Ashley Acosta, OMS-II, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2028. Her current interests include Psychiatry, Emergency Medicine, Primary Care and promoting access to healthcare to underserved communities.

Ramaswamy Sharma, MS, PhD, is a Professor of Histology and Pathology at the University of the Incarnate Word School of Osteopathic Medicine. He is interested in delineating the multiple molecular and cellular roles of melatonin in maintaining our quality of life. Dr. Sharma serves on the BCMS Publications Committee.

Men’s Health and Modifiable Dementia Risk: A clinical call to action

By Jeffrey M. Benzick, MD

Dementia is often framed as an inevitable consequence of aging. Yet emerging data underscore that many of the risks are modifiable — and that midlife prevention strategies may alter the trajectory of cognitive health in later years. For men in particular, who carry a disproportionate burden of cardiovascular and lifestyle-related risk factors, the implications are substantial.

A recent CDC analysis of the 2019 Behavioral Risk Factor Surveillance System (BRFSS) identified eight modifiable risk factors linked to subjective cognitive decline (SCD): hypertension, physical inactivity, obesity, diabetes, depression, smoking, hearing loss and binge drinking. For physicians of every specialty, the findings provide an opportunity to integrate dementia prevention into the broader conversation about men’s health and well-being.

Hypertension: The Leading Risk Factor

Hypertension was the most prevalent risk factor, reported by nearly 50% of adults surveyed. Among those with high blood pressure, the prevalence of SCD was 13.8%, compared to 8.8% in normotensive individuals.

The message is clear: midlife hypertension is not simply a cardiovascular issue — it is a neurologic one. Long-term vascular injury, impaired cerebral perfusion and small-vessel disease all contribute to accelerated cognitive decline.

Clinical takeaway: Aggressive detection and treatment of hypertension remain critical. Counseling men on the value of dietary modification, exercise and adherence to antihypertensive regimens is as much about preserving cognition as preventing myocardial infarction or stroke. I tend to harp on the 120/80 numbers, and encourage patients to not be satisfied until their blood pressure is consistently in this range.

Physical Inactivity: The Price of Sedentarism

Nearly half of respondents (49.7%) did not meet aerobic activity guidelines. SCD prevalence was 14.5% among inactive individuals versus 8.3% in those meeting activity targets. The specific target is 150 minutes of zone 2 cardio exercise per week.

Regular aerobic activity supports cerebral perfusion, promotes synaptic plasticity, and reduces cardiometabolic risk. Men often neglect exercise due to occupational demands or cultural attitudes that equate activity with “organized sports” rather than daily movement.

Clinical takeaway: Counseling should emphasize accessible, sustainable activity — 150 minutes weekly of brisk walking, cycling or resistance training. Even modest increases in activity can confer neuroprotective benefits. When men ask me what the best exercise is for dementia prevention, I reply, “Whatever you’ll keep doing.” I also counsel men on the precipitous muscle loss that occurs beginning at age 30 (3-5% per year) and accelerating at age 60, and strongly encourage weightlifting or body weight training to counter this.

Obesity: The Metabolic Burden

Obesity affected 35.3% of the cohort. Prevalence of SCD was 12.7% among those with obesity compared to 10.8% among nonobese peers. Obesity accelerates vascular pathology, promotes insulin resistance, and is associated with systemic inflammation — mechanisms implicated in dementia pathophysiology.

Clinical takeaway: Weight management must be framed not only as cardiovascular prevention but as cognitive preservation. Structured nutrition counseling, behavioral interventions and, where appropriate, pharmacotherapy or referral for bariatric surgery should be considered part of dementia-prevention strategies. I have found it helpful, even as a mental health professional, to be well-versed on the GLP-1 agonists and their role in weight control, as so many patients ask about them.

Diabetes: Cognitive Consequences of Hyperglycemia

Diabetes was reported by 18.6% of respondents. Prevalence of SCD was 17.4% among diabetics versus 9.9% in non-diabetics. Hyperglycemia accelerates advanced glycation end-product formation, promotes microvascular injury, and disrupts neuronal energy metabolism. The cumulative effect is increased dementia risk, particularly in men with poor glycemic control.

Clinical takeaway: Optimizing glycemic control remains central to preventing downstream neurologic injury. Integrating endocrinology, nutrition and primary care support can improve both adherence and long-term outcomes.

Depression: A Critical but Underappreciated Risk

Depression was reported by 18.0% of participants, with an SCD prevalence of 28.5% — the highest risk increase among all factors (!). The bidirectional relationship between depression and cognitive decline is well established. Depression may represent prodromal dementia, but

it also independently increases risk via hippocampal atrophy, altered neurochemistry and behavioral consequences such as reduced activity and social withdrawal.

Clinical takeaway: Screening for depression in men should be routine, not optional. Many male patients underreport mood symptoms due to stigma. I find asking about anger and marriage/relationship trouble (The HATAH question, “How are things at home?”) to be helpful, as men often process feelings of loss this way, and data indicate just asking, “Are you depressed?” is an effective way to start the conversation.

Smoking: Cognitive and Vascular Harm

Smoking was reported by 14.9% of respondents. Worldwide, a third of men are active smokers (!!), compared to less than one in 10 women. Smoking accelerates vascular injury, oxidative stress and neuroinflammation. While less prevalent than hypertension or inactivity, its contribution to dementia risk is well documented.

Clinical takeaway: Smoking cessation counseling is one of the few interventions with near-immediate cardiovascular and neurologic benefits. Combining pharmacotherapy with behavioral support remains best practice. Varenicline and bupropion are both inexpensive generics that genuinely increase success in quitting smoking.

Hearing Loss: An Overlooked Contributor

Hearing loss was present in 10.5%, with a SCD prevalence of 24.7% — second only to depression in its impact.

Untreated hearing impairment leads to sensory deprivation, social isolation and increased cognitive load as patients struggle to decode incomplete auditory input. These mechanisms significantly accelerate decline.

Clinical takeaway: Encouraging men to pursue audiologic testing and hearing aids is not simply about quality of life — it is a cognitive health intervention. Given the reluctance many men have toward hearing aids (we can be stubborn!), framing the issue in terms of dementia prevention may improve acceptance.

Binge Drinking: A Subtle but Significant Factor

Binge drinking was reported by 10.3%. Overall, men have higher rates of binge drinking (outside of young adulthood). While the prevalence of SCD was not dramatically higher in binge drinkers compared to the overall average, cumulative heavy alcohol use is clearly associated with structural brain changes and dementia risk.

Clinical takeaway: Routine alcohol-use screening, brief interventions and referral to treatment when indicated should remain part of comprehensive dementia-prevention strategies. Some men can be resistant to the idea that they need to cut down on their weekend drinking. Be supportive but firm!

The Multiplier Effect of Multiple Risk Factors

The most striking finding was cumulative risk. Among those with four or more risk factors, SCD prevalence was 25%, compared to only 3.9% among those with none.

Clinical takeaway: Risk factors are synergistic. The presence of multiple factors should prompt a more aggressive, coordinated prevention strategy. Men with clustering of hypertension, obesity, diabetes and depression, for example, represent a high-risk group requiring intensive intervention.

Implications for Men’s Health Practice

For men, these findings highlight a convergence of risks already familiar to clinicians. Cardiometabolic disorders, mood symptoms, smoking and hearing loss are routinely encountered in practice. What is often missing is framing these issues not only in terms of cardiovascular outcomes but also as dementia-prevention strategies.

Framing may be particularly effective for men, who are often reluctant to engage with preventive care until functional decline is apparent. Positioning interventions as a means of preserving independence, memory, appearance and family roles can make prevention more tangible.

Practical Clinical Strategies

• Integrate dementia risk into routine counseling. Position blood pressure checks, diabetes control and weight management as interventions for both heart and brain.

• Screen proactively for depression and hearing loss. Addressing these less-visible conditions may have disproportionate cognitive benefit.

• Leverage motivational strategies. Men may respond to language emphasizing strength, independence and long-term vitality.

• Address multiple risks simultaneously. Coordinated care — particularly in primary care settings — ensures risk reduction efforts are not fragmented.

Conclusion

Dementia is not an inevitable outcome of aging. The CDC analysis provides strong evidence that many of the risks are modifiable, and that men in particular stand to benefit from early, aggressive preventive strategies.

Hypertension, inactivity, obesity, diabetes, depression, smoking, hearing loss and binge drinking represent actionable targets. Addressing these risks in midlife not only reduces cardiovascular morbidity but also preserves cognitive health — a dual win for patients and for the healthcare system.

For clinicians, the call to action is straightforward: integrate dementia prevention into routine men’s healthcare. Our patients may not always see the connection between blood pressure, mood or hearing aids and their memory. It is our role to make that connection explicit, to counsel clearly, and to intervene decisively.

In doing so, we shift the trajectory — not only adding years to life, but life to years.

Reference:

1. Omura, J.D., McGuire, L.C., Patel, R., Denny, C.H., Goodman, R.A., & Taylor, C.A. (2022). Modifiable risk factors for Alzheimer disease and related dementias among adults aged ≥45 years — United States, 2019. Morbidity and Mortality Weekly Report, 71(20), 680–685. https://doi.org/10.15585/mmwr.mm7120a2

Jeffrey M. Benzick, MD, is a psychiatrist in private practice in San Antonio. After serving in the U.S. Air Force, he has spent nearly 20 years helping patients pursue emotional and physical well-being through a holistic, integrative approach. His practice emphasizes psychotherapy, behavioral change and lifestyle strategies while using medication only when truly needed. Dr. Benzick is a member of the Bexar County Medical Society.

Visceral Truths: Obesity in men

By Rajvi Patel, OMS-II; Ravi Patel, OMS-III; Aidan Haabenicht, OMS-III; and Ramaswamy Sharma, MS, PhD

Obesity can be defined as abnormal or excessive accumulation of body fat resulting in a body mass index (BMI) over 30 kg/ m2. The World Obesity Atlas 2025 estimates that around 725 million women, particularly in low and middle-income countries, and 604 million men are living with obesity. Data from the 2022 Community Health Needs Assessment survey indicated that 63% to 81% of adults in Bexar County were overweight or obese, significantly higher than the national average; results from the 2025 survey will be released later this month.

Amongst several biological, psychosocial, cultural and behavioral factors influencing obesity, sex is known to play a significant and multifaceted role, with sex or gender-based norms or role modeling that vary by society, culture and regions playing a significant role. From a physiology perspective, males tend to accumulate visceral fat in the abdominal area (central obesity) from puberty onwards via hypertrophy of adipocytes, resulting in an “apple shape” body, which is associated with greater health risks such as type 2 diabetes and cardiovascular disease due to elevated levels of metabolically active postprandial insulin, triglycerides and free fatty acids. In contrast, females are initially protected from weight gain due to high levels of estrogen, which promotes energy expenditure by increasing mitochondrial biogenesis and function, termed “browning,” resulting in more brown adipose tissue; over time, females tend to accumulate subcutaneous fat in the hip and thigh areas, resulting in a “pear shape” distribution, which carries less metabolic risk. Visceral fat, compared to subcutaneous fat, undergoes higher rates of lipolysis, leading to excessive fat deposition in the liver that is then converted to glucose. In addition, visceral fat also promotes higher levels of inflammation due to several reasons, primarily attributed to macrophages reacting to the debris left by ruptured hypertrophic adipose cells by releasing pro-inflammatory cytokines. It should be noted, however, that older women exhibit central obesity in addition to obesity in gluteofemoral regions, correlating with decreased estrogen synthesis; similarly, decreased testosterone as well as overall reduced expression of estrogen receptor β in adipose tissue are associated with increased obesity in men. Genome-wide association studies (GWAS) have determined several genes of interest that may play a role in sexspecific fat distribution.

The physiological and sex differences in obesity translate to clinical differences as well. Comorbidities associated with obesity include hypertension, dyslipidemia, depression, pre-diabetes, type 2 diabetes, metabolic dysfunction-associated steatotic liver disease, obstructive sleep apnea, osteoarthritis, chronic kidney diseases and coronary heart

diseases. Men who are obese have a higher risk of developing type 2 diabetes as they are more resistant to insulin than women. Obesity is directly associated with the development of cardiovascular disease as well as cardiovascular disease mortality, particularly in men. Interestingly, obesity increases hypertension more in women than men, which may be related to decreased BMI-associated sympathetic activation and tone in women compared to men.

While obesity-related depression is strongly associated with women, men who are obese are at a higher risk for early onset of cognitive decline. A recent study comprising 34,425 participants found a strong association between reduced grey matter volume and both visceral as well as subcutaneous adipose tissue. Interestingly, a strong association was found in males aged 45 to 74 years whereas it occurred in females a decade later, between the ages of 55 to 74 years. Thus, obesity contributes to significantly more extensive brain atrophy in males and at earlier ages compared to females. These findings suggest that earlier intervention to reduce visceral adipose tissue would be particularly beneficial in men compared to women who would need similar interventions after menopause.

Additionally, men who are obese are more prone to developing colorectal, kidney and esophageal cancers due to higher levels of insulin and insulin-like growth factor-1 while women who are obese are at increased risk for endometrial, ovarian and breast cancers perhaps due to increased estrogen secretion by adipose tissue. Women with a BMI between 30 and 34.9 kg/m2 increase their risk of developing cancer by 18% compared to a 9% increase in cancer risk in men with a similar BMI. The risk increases to 62% in women and 52% in men with a BMI above 40 kg/m2. Overall men have a decreased risk of developing obesity-related cancer as compared to women.

Obesity also decreases male fertility by reducing sperm count and motility, decreasing fertilization and affecting implantation; it may also induce programming of offspring phenotype. For example, offspring of males with obesity are small at birth, demonstrate glucose and insulin tolerance as well as low fertility for up to two generations, exhibit increased adiposity and have impaired white adipose and pancreatic function. Such paternal programming can occur through reactive oxygen species (ROS)-mediated DNA damage, alteration of microRNAs, changes in histone retention and epigenetic modifications at the level of spermatozoa, embryo and offspring.

Several lifestyle interventions have been shown to be effective in reducing visceral adipose tissue. For example, exercising three to five times every week for 12 to 52 weeks reduced visceral adipose tissue

compared to controls. Moderate-intensity exercise comprising of aerobics, three months of walking or maintaining physical activity of 150 minutes per week have all been shown to reduce hepatic and pericardial visceral fat. While caloric restrictions through dietary interventions also reduce visceral adipose tissue, exercise-related interventions appear to be superior. Yet, men often delay treatment for various reasons, are underdiagnosed compared to women, and are less committed to lifestyle changes. While visceral adipose tissue decreases even in the absence of weight loss, men often lose weight faster in the earlier phase of intervention compared to women due to more muscle mass and metabolic differences. Yet, women are more motivated to continue with their weight loss program than men. Pharmacotherapy with drugs such as semaglutide, sibutramine and liraglutide benefits women more than men but also results in higher side effects. Women also undergo more bariatric surgery compared to men, experiencing a higher percentage of excess weight loss than men; however, they tend to have lower satisfaction and psychological outcomes compared to men who have poor physiological outcome and very little improvement in comorbidity. Overall, sex differences in obesity influence clinical presentation as well as prevention and treatment approaches, as hormones, genetics, behavioral differences have to be considered.

References:

1. Bae, J.P., Nelson, D.R., Boye, K.S., & Mather, K.J. (2025). Prevalence of complications and comorbidities associated with obesity: a health insurance claims analysis. BMC Public Health, 25(1). https://doi. org/10.1186/s12889-024-21061-z

2. Jiang, X., Zhao, Y., Yang, Q., Wang, W., Lin, T., & Qiu, Y. (2025). Gender differences in associations between obesity and hypertension, diabetes, dyslipidemia: evidence from electronic health records of 3.5 million Chinese senior population. BMC Public Health, 25(1). https://doi.org/10.1186/s12889-025-21534-9

3. Koceva, A., Herman, R., Janez, A., Rakusa, M., & Jensterle, M. (2024). Sex- and Gender-Related differences in obesity: From pathophysiological mechanisms to clinical implications

4. McPherson, N.O., Fullston, T., Aitken, R.J., & Lane, M. (2014). Paternal obesity, interventions, and mechanistic pathways to impaired health in offspring. Annals of Nutrition and Metabolism, 64(3–4), 231–238. https://doi.org/10.1159/000365026

5. Mody-Bailey, P. and Lutz, E. (2022). Bexar County Community Health Needs Assessment. https://www.healthcollaborativechna. com/2022chnabexar

6. Nowell, J., Gentleman, S., & Edison, P. (2024). Cardiovascular risk and obesity impact loss of grey matter volume earlier in males than females. Journal of Neurology Neurosurgery & Psychiatry, jnnp333675. https://doi.org/10.1136/jnnp-2024-333675

7. Powell-Wiley, T.M., Poirier, P., Burke, L.E., Després, J., Gordon-Larsen, P., Lavie, C.J., Lear, S.A., Ndumele, C.E., Neeland, I.J., Sanders, P., & St-Onge, M. (2021). Obesity and cardiovascular Disease: A scientific statement from the American Heart Association. Circulation, 143(21). https://doi.org/10.1161/cir.0000000000000973

8. Seery, C. (2024, May 21). Men at higher risk of type 2 diabetes due to pronounced insulin resistance of adipose tissue. Diabetes. https:// www.diabetes.co.uk/news/2024/may/men-at-higher-risk-of-type-2diabetes-due-to-pronounced-insulin-resistance-of-adipose-tissue.html

My Big Slap in the Face

By Michael Seger, MD

Most men are like me when it comes to their weight. We feel like we can just flip a switch, hit the gym for a bit and clean up the diet — boom! Problem solved. The last thing we want to do is see someone about it; God forbid take some medication!

This was my M.O. for many years. As a weight loss surgeon, I felt particularly qualified to treat myself as I was the guy others came to see to help them solve this problem. The truth was that as a younger guy, I could usually get away with this methodology but it all caught up to me one day like a big slap in the face. Life had gotten pretty intense, I was super busy at work and we were raising five kids at home. As most doc parents do, I was putting my self-care on the back burner to serve our family and my patients. You see yourself every day and don’t really notice the slow changes. My weight had gotten up over 260.

This all came to a head when I was diagnosed with colon cancer about 12 years ago. I had a resection and went to see my oncologist. His words, I will never forget. “You really need to lose weight, or you will be at higher risk for recurrence and even other de novo cancer.” There it was … the slap in the face. The guy who is supposed to be the expert at solving weight problems has the problem himself.

This time I took a different approach. I had already learned how to become a patient going through the cancer treatment, so I made an appointment, spoke to our dietitians, got on some medications and laid out a plan that included accountability visits, body composition tracking and labs. It took a while but I finally got in a groove and got down to about 210-215. It has not been easy, but it wasn’t even possible until I leaned into the notion that I needed some help.

I love sharing my story as I feel lucky to be on the Earth. That whole pride thing that gets in the way of so many men seeking care … that’s crazy. Getting the help I needed took courage, and the journey has required strength and perseverance. You know — manly stuff.

Rajvi Patel, OMS-II, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2028.

Ravi Patel, OMS-III, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2027.

Aidan Haabenicht, OMS-III, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2027.

Ramaswamy Sharma, MS, PhD, is a Professor of Histology and Pathology at the University of the Incarnate Word School of Osteopathic Medicine. He is interested in delineating the multiple molecular and cellular roles of melatonin in maintaining our quality of life. Dr. Sharma serves on the BCMS Publications Committee. With over 2000 surgeries performed, Michael “Mickey” Seger, MD, has provided expert care to Texans since 2004. He earned a B.A. in Zoology from UT Austin; attended medical school at the University of Texas Health Science Center in San Antonio; completed his surgical residency at the Texas Tech University Health Sciences Center; and completed a fellowship in Advanced Laparoscopic and Bariatric Surgery at the University of Texas Medical School at Houston. Dr. Seger is a member of the Bexar County Medical Society.

Update in Male Hair Loss Treatment: What’s old, new or new again

By Jennifer Krejci, MD, FAAD, ABHRS

Male pattern hair loss (MPHL), a.k.a. androgenetic alopecia, effects 80% of men by age 70. What was once considered an unfortunate fact of life, is now a rising concern at seemingly all dermatology visits and likely across primary care and other specialty offices.

The International Society for Hair Restoration Surgery (ISHRS) biennial practice census report found a 60% increase in hair transplant procedures for men since 2014. This growth is attributed to advancements in technology, greater awareness of treatments for androgenic alopecia, higher rates of hair loss and increased social acceptance for aesthetic procedures.

If you consider the millions of men suffering from thinning hair, it’s no wonder social media is flooded with the latest hair loss miracles. Add a little Zoom Dysmorphia and celebrity/influencer endorsement and you have a cosmetic boon. From supplements, to serums, to stem cells; which trends are effective or is it more snake oil? Here’s a review of the expanding options for balding men.

Rogaine® (minoxidil 5% solution) was released in 1988 and has been available over-the-counter since 1996. It is still considered standard of

care but the latest trend in formulation is in combination with ingredients such as finasteride, dutasteride, tretinoin, corticosteroids, latanaprost and others. Topical finasteride or dutasteride have become popular alternatives for patients unable or unwilling to use oral 5α-Reductase Inhibitors (5αRi). Topical combinations containing minoxidil and 5αRi are frequently promoted and prescribed through telehealth platforms, which may be convenient for patients but follow-up of hair loss through virtual means can be problematic. Fear of side effects from oral medications has driven patients to seek alternative remedies; however, the side effects from compounded topicals is largely unknown since these off-label concoctions are not standardized and not well studied. Blood levels of both finasteride and minoxidil can be measured after topical usage but are dependent on multiple factors, e.g. frequency of application, concentration and absorption enhancing ingredients. In my experience, they can be an effective part of the hair loss treatment regimen. The downside to any topical treatment is the hassle or messiness of daily application and potential for irritant or allergic dermatitis.

On the flipside, after the New York Times article in 2022, “An Old Medicine Remedies Hair Loss for Pennies a Day,” prescriptions

for low dose oral minoxidil skyrocketed. This has been the biggest game-changer in treating hair loss of my career. (Propecia® launched in 1997). Doses are typically between 1.25mg - 5mg daily and generally safe, convenient, effective and inexpensive (90-day supply around $20). Side effects are extrapolated from hypertension data but with low dose, one can expect the side effects to be reduced. Patients should be counseled on the common side effects including dizziness, palpitations, mild hypertrichosis and headaches, some of which tend to be transient. Rare side effects include peripheral or general edema and pericardial effusion. Lowering or stopping the dose usually leads to rapid resolution so extensive work-up is generally not necessary.

Generic finasteride has been available since 2006 and the price dropped dramatically around 2018 (90-day supply approximately. $30) making it an effective and economical treatment. It is the ONLY FDA approved oral medication. The biggest hurdle for prescribing finasteride is addressing the laundry list of alarming side effects, e.g. gynecomastia, infertility, erectile dysfunction, cancer, suicidal ideation, etc. Interestingly, according to the package insert, the rate of sexual dysfunction is around 3%, similar to placebo. In longitudinal studies, the rates of decreased libido were initially higher in the finasteride group but dropped to equivalent rates of placebo after several years. It’s important to note that the nocebo effect has also been documented with finasteride: with over 30% men reporting sexual side effects when specifically counseled on this risk. The prevalence of online forum discussions likely adds to this phenomenon. Finasteride (and dutasteride off-label) are by far the most effective drugs that directly treats the cause of male pattern hair loss: conversion of testosterone to dihydrotestosterone at the level of the hair follicle. Personally, I encourage almost all male hair loss patients to the FDA approved options first, often at lower doses (2-3x weekly) and advise that they avoid preoccupation with internet fodder. As my mentor, Dr. Bob Bernstein, FAAD, of NYC would say, “Don’t go looking for side effects, they’ll find you if they want to.”

Photo Biomodulation (PBM), a.k.a. Low-Level Laser Therapy, comes in the form of combs, bands, helmets or caps utilizing 630670nm red laser diodes. Red light activates mitochondrial in follicular stem cells, promotes dermal papilla cell proliferation and prolongs anagen phase. A systematic review from 2025 cited 63 studies of PBM in androgenic alopecia or telogen effluvium with positive results, including those combined with topical minoxidil or oral finasteride reporting enhanced efficacy of PBM. Current data is limited by small sample sizes, inconsistent protocols and a lack of long-term data, plus some are sponsored by device manufacturers which poses a conflict of interest. Devices vary greatly in price from $500-$3000 depending on the device and number of diodes but there is no data to support superiority of more expensive models. Most protocols instruct the user to wear the device for short periods on several days per week. They are very safe and easy to use at home.

Platelet-rich-plasma (PRP) has become a mainstay in hair loss therapy over the last decade. There are multiple collection/concentration systems available, with the goal of producing a 3-7x concentration of platelets compared to whole blood. PRP is injected into the dermis of the scalp where contact with collagen causes alpha granules from the platelets to release their biologically active contents such as growth factors and cytokines. This serves as the basis for the use in the treat-

ment of androgenetic alopecia. Recent review articles suggested efficacy of PRP may be considered comparable to topical minoxidil and that overall, PRP is safe and effective in improving hair density, reducing hair loss, and enhancing patient satisfaction. It is imperative to take a thorough patient history identifying any drugs and supplements that may inhibit platelet activity. Unintentional ibuprofen usage or high dose fish oil, for example, can render platelets inactive and negate the effects of PRP. Like all hair loss treatments, PRP does not create new hair de novo. It works by thickening existing miniaturized hair. Personally, I find it works better in younger patients with more native hair. There is minimal downtime but the downside is pain of injections and cost, ranging from $400-$1000 per treatment. Of note, the difference between PRP vs. Platelet Rich Fibrin (PRF) is that PRF creates a fibrin scaffolding, which may be beneficial when treating facial rhytids but is not necessary for hair growth.

Exosomes came onto the scene around 2018 with much excitement, but by December 2019, the FDA released a public statement cautioning the use of exosomes as they are unapproved for human use. Yet, they are still being sold and used widely with no oversight. Mesenchymal stem cell (MSC)-derived exosomes are small extracellular vesicles that contain a variety of bioactive molecules that can potentially stimulate hair follicle regeneration. Sources of mesenchymal exosomes include bone marrow, amniotic fluid, placental and other gestational tissue. In the most recent systematic review, 11 human studies were identified: two RCTs, three retrospective studies, three prospective single-arm studies, one case series and two case reports. The safety profile was favorable and results are promising; however, one must interpret results with caution, e.g. an increase of 11-20% in hair density may be statistically significant but may not translate to adequate scalp coverage in the clinical setting. Furthermore, most studies included microneedling or other stimulatory factors as part of the treatment protocol. Commercially available exosomes vary by product source and concentration and come packaged in vials that are kept frozen until they are reconstituted with saline for immediate injection into the balding scalp. Treatments can range in price from $600-$6000.

Stem Cells is a buzz word in social media feeds; however, there is no single defined “Stem Cell” treatment for hair loss. Advertisers may use the term to describe PRP, MSC-exosomes or other non-FDA approved regenerative treatments. There are also clinics in the U.S. and outside our borders that advertise autologous or donor stem cells harvested from bone marrow for intravenous injections, intraarticular and/or intradermal. It’s no surprise that some clinics are associated with professional athletes or celebrities. These tend to carry VERY high price tags (upwards of $100,000) and have primarily anecdotal evidence to support their use, and patients must beware. Hair treatment in these circumstances is usually a tertiary goal.

AlmaTED is a novel ultrasound-based system that combines proprietary technology (patented tip + Impact DeliveryTM) with a peptide-based serum. The ultrasound is emitted through a special tip that combines forced air to create channels or bubbles in the epidermis that allows for penetration of the serum. The growth factors and other large molecules contained in the serum normally could not pass through our protective epidermis. The treatment is essentially painless, which is a welcomed change for patients experiencing “needle fatigue” of PRP. There are only two white papers of 61 subjects to support safe-

ty and efficacy; increased total hair density, increased terminal/velus hair ratios and high patient satisfaction was found in 30- and 90-day follow-ups after three monthly sessions. In my practice, results have also been favorable with correct patient selection and risks are nearly non-existent other than the high-pitched ringing transmitted by the ultrasound tip.

Folix is the newest device to the hair loss market in 2024. It is a 1565nm non-ablative fractionated laser (NAFL) that delivers a non-adjustable energy setting safe for use in most skin types (currently approved for Fitzpatrick types 1-4). The fractionated laser targets water and generates microscopic thermal injury zones in the dermis. Through this low-grade thermal injury, it increases blood flow, induces expressions of cytokines and growth factors, and stimulates dermal papilla cell growth and/or stem cells. Two small studies are published, both favorable: one retrospective observational study and one randomized trial comparing NAFL to minoxidil 5% solution. The latter demonstrated superiority to topical minoxidil after four monthly sessions. Treatment was very tolerable and safe with minimal downtime. Like PRP and AlmaTED, maintenance treatments are required to maintain efficacy but the precise intervals are yet to be determined.

Hair transplantation can be a “permanent” option for some receding men but this does not address the progressive thinning that will inevitably occur. Gone are the days of unsightly plugs since the invention of Follicular unit grafting developed right here in San Antonio by Dr. Bobby Limmer, MD. However, Turkey has become a popular destination for men seeking a cheaper option, but this comes with obvious risks and lack of recourse should complications occur. There are two methods for harvesting hairs: Follicular Unit Transplant (FUT- “strip method”) and Follicular Unit Excision (FUE- “punch method”), each with pros and cons. Regardless of harvest method, implantation of single or small groups of follicles in a natural pattern, looks and grows just like native hair.

What’s in the pipeline?

It’s been almost 30 years since Propecia gave bald men the hope of overcoming their genetics. Topical PP405 0.5% gel is in Phase II trials showing promising results. When applied once daily, one-third of men at week 8 had a greater than 20% increase in hair density, compared to 0% of patients in the placebo group. PP405 works by inhibiting the mitochondrial pyruvate carrier (MPC) in hair follicle stem cells, which shifts their cellular metabolism toward a regenerative state. Different from both finasteride and minoxidil, PP405 directly targets and reactivates the stem cells at the metabolic level within the follicle itself. While the scintillating headlines have created a buzz online, we likely won’t see the product come to market until 2027.

Hair loss treatments are a $50 million industry and growing. The cost of treatments ranges from pennies to thousands of dollars and paid for almost exclusively out of pocket. We know that more men are seeking treatment for androgenetic alopecia so having more tools in our toolbox for these patients is helpful. This review provides updates on standard therapies and newer technologies and can allow you to understand the risk/benefits of each option. It can also help you and your patients not to be taken in by social media claims that are too good to be true.

References:

1. Lubis, F.F., et al. Randomized controlled trial on the efficacy and safety of the combination therapy of topical 0.1% finasteride - 5% Minoxidil in male androgenetic alopecia. Arch Dermatol Res. 2025 Apr 10;317(1):691

2. Gupta, A.K., et al. Efficacy and safety of low-dose oral minoxidil in the management of androgenetic alopecia. Expert Opin Pharmacother. 2024 Feb;25(2):139-147

3. Mondaini, N., et al. Finasteride 5 mg and sexual side effects: how many of these are related to a nocebo phenomenon? J Sex Med. 2007 Nov;4(6):1708-12

4. Vanaria, R.J., et al. The Use of Light-Based Therapies in the Treatment of Alopecia. J Cosmet Dermatol. 2025 Sep;24(9):e70434

5. Abdin, R., et al. Treatment of Androgenetic Alopecia Using PRP to Target Dysregulated Mechanisms and Pathways. Front Med (Lausanne). 2022 Mar 16;9:843127

6. Abid, A., et al. Comparison of the efficacy of platelet-rich plasma with topical minoxidil in treating patients with androgenetic alopecia: a systematic review of clinical trials. Skin Health Dis. 2025 Jul 23;5(5):311-318

7. Anitua, E., et al. Platelet-Rich Plasma in the Management of Alopecia: A Systematic Review and Meta-Analysis of Clinical Evidence. Dermatol Ther (Heidelb). 2025 Sep 13

8. Al Ameer, M.A. et al. Exosomes and Hair Regeneration: A Systematic Review of Clinical Evidence Across Alopecia Types and Exosome Sources. Clin Cosmet Investig Dermatol. 2025 Sep 10;18:2215-2227

9. Gupta, A.K., Wang, T., Rapaport, J.A. Systematic review of exosome treatment in hair restoration: Preliminary evidence, safety, and future directions. J Cosmet Dermatol. 2023 Sep;22(9):2424-2433

10. Desai, S., A Single-center Study Evaluating Alma TEDTM and a Peptide-based Topical Hair Care Formula for Female and Male Pattern Hair Loss. Duly Health and Care, Naperville, USA

11. Lady, Dy L. A Single-center Study Evaluating Alma TEDTM and a Peptide-based Topical Hair Care Formula for a Variety of Hair Loss Concerns. Dy Dermatology, Glenview, USA

12. Qu, H., et al. Investigator-blinded, controlled, and randomized comparative study on 1565 nm non-ablative fractional laser versus 5% minoxidil for treatment of androgenetic alopecia. J Cosmet Dermatol. 2024 May;23(5):1638-1644

13. Avram, M.R., et al. Improvement in Scalp Hair Appearance Following Treatment with a Non-Ablative Fractional Laser: A Retrospective Observational Study. Lasers Surg Med. 2025 Sep;57(7):590-597

14. Asfour, L., et al. The emotional impact of alopecia and role of psychological interventions in supporting hair loss patients. Clin Exp Dermatol. 2025

Jennifer Krejci, MD, FAAD, ABHRS, is the medical director of the Limmer Hair Transplant Center, clinical faculty for The University of Texas at San Antonio Health Science Center and staff dermatologist for the South Texas Veterans Health Care System. She has numerous publications and is an invited speaker around the world as a specialist in hair loss and hair transplantation. Dr. Krejci is a member of the Bexar County Medical Society.

Supporting Sleep Health: Addressing obstructive sleep apnea in Bexar County

By Patrick Reeves, MD, FAAP, DABOM, and Benjamin Long, MD

Obstructive sleep apnea (OSA) is one of the most common yet underdiagnosed conditions affecting both children and adults in our community. Nationally, pediatric OSA is estimated to affect 1–5% of children, most often between ages 2–8 during peak adenotonsillar growth. In adults, prevalence ranges from 9–38%, with higher rates in men, individuals with obesity and older populations.1 OSA is often underrecognized in women where symptoms such as insomnia and fatigue can be mistaken for other conditions. In Bexar County, where obesity and cardiometabolic disease rates are among the highest in Texas, undetected OSA represents a critical but modifiable driver of morbidity.

As primary care physicians, we are often the first to recognize the subtle signs of OSA. Children may present with snoring, restless sleep, behavioral concerns or growth impairment. Adults may report daytime sleepiness, morning headaches or bed partner observations of loud snoring and witnessed apneas. Left untreated, OSA contributes to hypertension, insulin resistance, arrhythmias, impaired school or work performance, and increased risk of accidents.

Screening for OSA in the Clinic

For adults, we recommend using the STOP-Bang questionnaire due to this tool being a validated and efficient screener for OSA. The STOP-Bang is an 8-item screening tool for obstructive sleep apnea assessing Snoring, Tiredness, Observed apneas, high Pressure (hypertension), plus BMI, Age, Neck circumference, and Gender (male). Each “yes” = 1 point (0–8 total); higher scores mean higher OSA risk (0–2 low, 3–4 intermediate, ≥5 high) and can prompt referral for sleep testing. A score of 3 or more indicates elevated risk and should, at minimum prompt referral for diagnostic testing. Higher scores such as 5 or greater portend much greater risk and likelihood of clinically significant OSA.

In children, routine well-child visits are an opportunity to ask parents about snoring, pauses in breathing or sleep quality. Because pediatric symptoms can mimic ADHD or behavioral disorders, a high index of suspicion is required. Subtle symptoms for children with OSA can include secondary enuresis, daytime hyperactivity and nighttime awakenings.

Diagnostic Evaluation

The gold standard for both children and adults remains overnight polysomnography (sleep study). This measures airflow, oxygen saturation, respiratory effort, sleep stages and arousals, allowing for precise diagnosis and severity grading. Home sleep apnea testing can be considered for adults with high pre-test probability (such as a STOP-Bang score of 5+) and no major comorbidities, but children should undergo in-laboratory studies for accurate assessment.

Defining OSA

• Pediatric OSA: An apnea–hypopnea index (AHI) > 1 event/ hour is considered abnormal. Severity is stratified as mild (1–5), moderate (5–10) and severe (>10).

• Adult OSA: An AHI ≥ 5 events/hour with symptoms, or ≥ 15 events/hour regardless of symptoms, defines OSA. Severity is mild (5–15), moderate (15–30) and severe (>30).

Treatment Approaches

Children

• First-line: Adenotonsillectomy remains the cornerstone for children with adenotonsillar hypertrophy.

• Adjuncts: Weight management, allergy control and nasal corticosteroids may be helpful.

• Persistent cases: Positive airway pressure (PAP) therapy and orthodontic interventions may be needed.

Adults

• Lifestyle interventions: Weight reduction, positional therapy, avoidance of alcohol and sedatives.

• CPAP therapy: Gold standard for moderate to severe disease; improves cardiovascular outcomes and quality of life.

• Alternatives: Oral appliance therapy for mild to moderate OSA, surgical options for select patients and hypoglossal nerve stimulation for refractory cases.

Sleep: The Foundation of Health

Beyond diagnosing and treating OSA, we must also emphasize the critical importance of sufficient sleep. The American Academy of Sleep Medicine recommends:

• Children 6–12 years: 9–12 hours/night

• Teenagers 13–18 years: 8–10 hours/night

• Adults: 7-9 hours/night

Chronic sleep deprivation magnifies the risks of OSA and compounds its impact on cardiometabolic health, cognition and emotional well-being.

As primary care physicians in Bexar County, we are uniquely positioned to identify, screen, and manage patients at risk for OSA. By asking the right questions, utilizing validated screeners, and referring for appropriate testing, we can ensure earlier diagnosis and treatment — ultimately improving long-term health outcomes for our patients and community. Thank you for your commitment to advancing the sleep health of every child, adult, and family in our care.

Reference: 1. Geer, J.H., Hilbert, J. Gender Issues in Obstructive Sleep Apnea. Yale J Biol Med. 2021;94(3):487-496. Published 2021 Sep 30

Patrick Reeves, MD, FAAP, DABOM, is a native Texan and graduate of Texas A&M University (class of 2012) who currently serves as a triple board-certified pediatric gastroenterologist, obesity medicine specialist and general pediatrician in San Antonio, Texas. He works on the liver transplant unit at University Hospital and is active in clinical research focused on clinical action plan implementation. Dr. Reeves is a member of the Bexar County Medical Society.

Benjamin Long, MD, is an active-duty general pediatrician for the United States Air Force. He is also board certified in sleep medicine.

Rapamycin for Anti-Aging and Longevity

By Rajvi Patel, OMS-II; Gabriel Bietz, MD; and Mark Rosenbloom, MD, MBA

Rapamycin has garnered significant attention for its potential anti-aging and longevity benefits. A recent opinion article in the journal Aging suggests that "not taking Rapamycin may be as dangerous as smoking."1 This assertion highlights the growing interest in pharmacological interventions to promote healthy aging and extend lifespan.

Background and Discovery

Aging is characterized by a multifaceted decline in physiological function and stress resilience, leading to an increased prevalence of various diseases. Research has identified multiple targets for regulating aging and promoting longevity, including drugs and geroprotectors.8 Rapamycin, also known as sirolimus, is a macrolide immunosuppressant initially approved for transplant patients. It was first discovered on Rapa Nui (an Easter Island) near Chile and noted for its antifungal properties.1 Subsequent studies revealed its activity against solid tumors and strong immunosuppressive effects, resulting in its approval in 1999 as an anti-rejection medication. Rapamycin is now recognized as a potent immunomodulator, capable of reducing hyperimmunity and paradoxically can boost a weakened immune system or “rejuvenates immunity.”2 This means that rapamycin acts as an “adaptogen” for immune function.

Research and Lifespan Extension

With over 18,000 published studies, rapamycin stands out as the only drug consistently shown to extend lifespan across all animal species tested, sometimes by more than 30%. Even if the increase in human lifespan were only a fraction of that observed in other species, the health benefits could surpass those gained from quitting smoking. (Notably, rapamycin has demonstrated a 90% reduction in lung cancer proliferation in a mouse model exposed to smoking.)3 Many studies, including the National Institute on Aging Interventions Testing Program, have shown that rapamycin significantly extends life span in mice, with female mice living an average of 249 days longer and male mice 154 days longer.7

Mechanism of Action

Rapamycin inhibits the mechanistic target of rapamycin complex 1 (mTORC1), a key regulator of cellular growth and metabolism. Enhanced mTORC1 activity promotes anabolism, while its inhibition shifts cells toward catabolism. mTORC1 inhibition has emerged as a promising strategy for anti-aging and lifespan extension, supported by thousands of preclinical studies demonstrating rapamycin’s efficacy in improving both lifespan and healthspan, even when treatment begins later in life.5,6

Preclinical Evidence

The anti-aging effects of rapamycin are largely attributed to its inhibition of mTORC1, which encourages cellular rest and recovery, promotes autophagy, reduces cellular senescence, and delays the onset of age-related conditions. Dosing is a critical consideration; intermittent or low-dose regimens (such as 5-7 milligrams weekly) offer a favorable safety profile, selectively inhibiting mTORC1 while minimizing off-target metabolic and immunosuppressive effects associated with mTORC2 inhibition.4 Side effects at these lower doses are rare and reversible, whereas higher doses used for transplant rejection carry more significant risks and potential toxicity.

Safety and Efficacy in Humans

Human studies on rapamycin for longevity are limited but growing. The 48-week randomized, placebo-controlled PEARL trial assessed weekly low doses of rapamycin (5mg or 10mg) in healthy adults. No significant new toxicities were observed compared to placebo; in fact, there was a trend toward more reported side effects in the placebo group. Participants receiving rapamycin noted improvements in lean muscle mass, reduced pain and enhanced well-being.9 Another drug, everolimus, demonstrated benefits for immune aging by increasing the immune response to the flu vaccine in older adults, supporting rapamycin’s potential to preserve or restore immune function with age.7

Advantages of Microdosing

Selective mTORC1 inhibition at lower doses prevents metabolic and immunologic issues associated with mTORC2 inhibition.9

• Low-dose regimens are better tolerated, as indicated by clinical and survey data, with fewer adverse effects.9,10

• Improved healthspan has been observed, including enhancements in physical and emotional health and positive effects on multiple organ systems.6,9

Disadvantages and Uncertainties

• The limited duration of human studies may not reveal delayed adverse effects such as impaired wound healing or increased infection risk.7,9,11

• Rapamycin lacks a standardized regimen for aging biology, unlike its established dosing for transplant patients. More research is needed to determine the optimal dose, frequency and duration for maximizing lifespan benefits while minimizing adverse effects.9,11

• Most evidence comes from mouse models, which may not translate directly to humans.7,12

• Longevity use of rapamycin is not officially approved. Off-label use lacks standardized regulation and uniform guidelines.10

Conclusion

The use of low-dose, intermittent rapamycin to prolong lifespan is supported by robust preclinical and preliminary human evidence. While safety and efficacy appear promising, long-term studies are needed to clarify optimal dosing, duration and long-term risks. Until more conclusive clinical data is available, rapamycin for antiaging should be considered investigational. Proper patient selection, thorough monitoring and comprehensive informed consent are essential for its use. Nevertheless, the potential profound benefits of low-dose, intermittent rapamycin in preventing severe age-related diseases likely greatly outweigh the risks, which have so far been rare, mild and manageable.

References:

1. Blagosklonny, M. Rapamycin for longevity: opinion article. 2019. Aging, Vol. 11, No. 19, 8048-8067

2. Blagosklonny, M. Aging and immortality: quasiprogrammed senescense and its pharmacologic inhibition. 2006. Cell Cycle, 5, 2087-102

3. Granville, C.A., Warfel, N., Tsurutani, J., Hollander, M.C., Robertson, M., Fox, S.D., Veenstra, T.D., Issaq, H.J., Linnoila, R.I., Dennis, P.A. Identification of a highly effective rapamycin schedule that markedly reduces the size, multiplicity, and phenotypic progression of tobacco carcinogen-induced murine lung tumors. 2007. Clin Cancer Res. 13, 2281–89. https://doi.org/10.1158/1078-0432.CCR-062570 [PubMed]

4. Blagosklonny, M. Towards disease-oriented dosing of rapamycin for longevity: does aging exist or only age-related diseases? 2023. Aging, Vol. 15, No. 14, 6632-6640

5. Selvarani, R., Mohammed, S., & Richardson, A. Effect of rapamycin on aging and age-related diseases-past and future. 2021. GeroScience, 43(3), 1135–1158. https://doi.org/10.1007/s11357-02000274-1

6. Zhang, Y., Zhang, J., Wang, S. The Role of Rapamycin in Extending Healthspan by Delaying Organ Aging. Ageing Research Reviews. 2021;70:101376. doi:10.1016/j.arr.2021.101376

7. Kritchevsky, S.B., Cummings, S.R. Geroscience. JAMA. 2025;2837435:. doi:10.1001/jama.2025.11289

8. Fu, W., Wu, G. Targeting mTOR for Anti-Aging and Anti-Cancer Treatments. Molecules (Basel, Switzerland). 2023;28(7):3157. doi:10.3390/molecules28073157

9. Moel, M., Harinath, G., Lee, V., et al. Impact of Rapamycin on Safety and Healthspan Metrics After One Year: Results from the PEARL Trial. Aging. 2025;17(4):908-936. doi:10.18632/aging.206235

10. Kaeberlein, T.L., Green, A.S., Haddad, G., et al. Assessment of Off-Label Rapamycin Use to Enhance Healthspan in 333 Adults. GeroScience. 2023;45(5):2757-2768. doi:10.1007/s11357-02300818-1

11. Konopka, A.R., Lamming, D.W. Paving the Way for Clinical Use of Rapamycin as a Geroprotector. GeroScience. 2023;45(5):2769-2783. doi:10.1007/s11357-023-00935-x

12. Lamming, D.W., Ye, L., Sabatini, D.M., Baur, J.A. Rapalogs and mTOR Inhibitors as Anti-Aging Therapies. The Journal of Clinical Investigation. 2013;123(3):980-9. doi:10.1172/JCI64099

Rajvi Patel, OMS-II, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine, class of 2028. She is interested in pursuing a career in cardiopulmonary health, and is passionate about leading global mission trips to provide medical care in underserved areas.

Gabriel Bietz, MD, is a board-certified vascular surgeon and Chairman of the Board for San Antonio Surgical Center of Excellence. He is a partner at Texas Cardiac and Vascular Institute, serving patients across San Antonio, Seguin and Corpus Christi. He is recognized for his expertise in both open and endovascular procedures, along with his leadership in advancing patient-centered vascular care. In addition to his medical career, Dr. Bietz is a serial entrepreneur with ventures spanning healthcare and private investments, and is a member of the Bexar County Medical Society.

Mark Rosenbloom, MD, MBA, is the Founder and Chief Medical Officer of Lifeforce Medical Institute and a recognized expert in longevity and age management medicine. He is a published author and speaker with a focus on bio-identical hormone therapy, preventive care and healthspan optimization. Dr. Rosenbloom completed his medical training at Northwestern University with additional studies at Stanford and McGill Universities.

Oral Health: A vital component of whole-person care

By

Oral health is an inseparable part of overall well-being, yet it is too often overlooked in preventive medicine. For many families, the primary care physician (PCP) serves as the first point of contact regarding when and why children and adults should see a dentist. This unique position places physicians at the forefront of anticipatory guidance, making it essential to integrate oral health into every stage of patient care. By reinforcing the connection between oral health and systemic conditions — from diabetes to cardiovascular disease — PCPs can reduce preventable oral disease, strengthen interdisciplinary collaboration, and improve long-term outcomes.

Early Childhood: Building Lifelong Habits

The American Dental Association (ADA) recommends that children establish a “dental home” by age 1 or within six months of the first tooth eruption. At this initial visit, the dentist evaluates growth, eruption patterns and early caries risk while counseling parents on critical issues: baby bottle tooth decay, feeding practices, teething, oral hygiene, pacifier use and finger-sucking habits. Preventive exams should occur every six months, with more frequent follow-up for children at higher risk of cavities or developmental concerns. Parents’ attitudes strongly influence a child’s perception of dental care; calm reassurance and positive reinforcement are key to reducing anxiety and fostering lifelong oral health behaviors.

Adolescents and Adults: Oral Health as Preventive Medicine

For older children and adults, semiannual dental examinations remain the standard. These visits provide professional cleaning and early detection of caries, periodontal disease or oral malignancies. Importantly, systemic health influences oral health: diabetes, cardiovascular disease, pregnancy and immunocompromised states all heighten the need for diligent dental care. Physicians must remind patients that the absence of symptoms does not mean the absence of disease. Caries and periodontal inflammation often progress silently, while early oral cancers may be subtle but are most treatable when detected promptly.

The Role of Physicians

Physicians are uniquely positioned to integrate oral health into preventive care visits. During well-child checks and annual physicals, PCPs can reinforce dental visit intervals, counsel families on brushing and flossing, and recommend fluoride exposure when appropriate. For high-risk groups, such as patients with special healthcare needs or chronic illnesses, physicians should emphasize collaboration with dental providers to coordinate individualized care.

The Texas Oral Health Coalition (TxOHC) exemplifies this multidisciplinary approach, serving as a statewide nonprofit that brings together diverse stakeholders to achieve equitable access to oral health across the lifespan. As the primary nonpartisan forum for oral health in Texas, TxOHC leverages shared partnerships to advance awareness, access and equity statewide and nationally.

Oral Health Resources for Physicians

Physicians should familiarize themselves with evidence-based oral health resources to educate patients effectively. The American Dental Association provides comprehensive materials that explain preventive practices, risk factors and the systemic links between oral and overall health.

The Texas Department of State Health Services Oral Health Program offers state-specific tools, patient handouts and referral guidance. Finally, the Texas Dental Association connects providers and patients with community dentists and ongoing advocacy for oral health in Texas.

Top Three Links for Physicians to Educate Patients:

1. American Dental Association Oral Health Topics: https:// www.ada.org/about-the-ada/ada-topics/oral-health

2. Texas Department of State Health Services Oral Health Resources: https://www.dshs.texas.gov/dental-health/ oral-health-resources

3. Texas Dental Association: https://www.tda.org/

Natalie Schiefele Barber, DDS Candidate, Class of 2027 UT Health Dental School

Patrick T. Reeves, MD, FAAP, DABOM, Associate Professor, UT Health Medical School

Empowering Patients in the Dental Chair

Just as physicians encourage patients to ask questions about their medical treatment, they should also empower patients to engage actively with their dentists. Primary care providers can guide patients to ask about:

1. Individual caries risk and preventive strategies (e.g., sealants, fluoride varnish, diet counseling)

2. Periodontal health status and how gum health influences systemic conditions such as diabetes and heart disease

3. Oral cancer screening practices, particularly for patients with high-risk behaviors (tobacco, alcohol use) or comorbidities

Conclusion

Oral health is integral to whole-person care. For children, establishing dental care early prevents cavities and builds positive lifelong habits. For adults, routine dental visits detect hidden disease and reduce risks linked to systemic conditions. Physicians play a crucial role in reinforcing oral health during medical visits, serving as

trusted guides who connect patients to evidence-based resources and dental professionals. With coordinated care, strong partnerships like TxOHC and consistent preventive messaging, we can ensure that oral health becomes a core pillar of overall health equity and well-being for all Texans and beyond.

Natalie Schiefele Barber is a DDS Candidate, Class of 2027, at UT Health Dental School.

Patrick Reeves, MD, FAAP, DABOM, is a native Texan and graduate of Texas A&M University (class of 2012) who currently serves as a triple board-certified pediatric gastroenterologist, obesity medicine specialist and general pediatrician in San Antonio, Texas. He works on the liver transplant unit at University Hospital and is active in clinical research focused on clinical action plan implementation. Dr. Reeves is a member of the Bexar County Medical Society.

High Stakes, High Speed: From the operating room to the racetrack

By Gabriella Bradberry

by Herman Pragt

Stephen Earle, MD’s need for speed developed at an early age, starting with motorcycle racing. Unfortunately, a racing injury put his high school hobby to a sudden stop. As the years passed, with college, medical school, residency and starting a family, Dr. Earle, like many other physicians and working adults, lost sight of his former pastime. It wouldn’t be until years later, after he had established himself as an orthopaedic spinal surgeon, that he would be given a once-in-a-lifetime opportunity. Today, Dr. Earle successfully balances his time between his profession and pastime — the operating room and the racetrack.

Stephen Earle, MD, is the sixth “Dr. Earle” in his family. Spanning across five generations, the first Dr. Earle in his family can be traced back to 1762. Eventually, Dr. Stephen Earle’s paternal grandfather, father, older brother and, ultimately, Dr. Stephen Earle himself, all

followed suit and became physicians. While he is not the first physician in his family, Dr. Stephen Earle has set himself apart by being the first race car driver in his family’s history.

Dr. Earle completed his residency in 1984 and joined his father’s private practice as a spinal surgeon. The next several years were dedicated to juggling his career and personal life — a conundrum many physicians are familiar with. Dr. Earle best encapsulated this balancing act by sharing an experience from his wedding. Having gotten married on a Saturday, Dr. Earle’s father said to him before leaving, “Well, I will see you at work on Tuesday.” This moment cemented the expectations placed upon him as a medical professional.

While being a spinal surgeon is still a major defining component of Dr. Earle’s life, his perspective on work-life balance broadened in

Photography

1992 when an old high school friend called and asked if he was interested in racing Camaros with him, as there was an opening on the team. Dr. Earle agreed within a nanosecond and soon found himself at a small track in Hallett, Oklahoma, taking a three-day course to earn his provision license for the Sports Cars Club of America. At the end of the course, all the teammates raced, and the only person who beat Dr. Earle was the instructor. This was a pivotal moment for Dr. Earle, who shared, “Sometimes you’re given talents you don’t know you have until you test them out.” Having started his racing career at the age of 40, the very next year, Dr. Earle was invited alongside his friend to represent San Antonio at the amateur racing series known as the “Ferrari Challenge.”

While it may seem daunting to try to squeeze a new hobby into an already packed schedule, Dr. Earle emphasized the importance of finding an outlet for stress relief and the potential for discovering transferable skills. While at face-value, race car driving and spinal surgery may not seem comparable, both require long periods of intense focus and are very technical. Racing isn’t just about being the bravest racer. Rather, a race car driver has to consider many different elements such as using the correct gear, factoring in the different corners on various tracks, and making note of when the tires start wearing out. Furthermore, both a successful surgery and win at the races can leave you feeling rewarded and confident in a job well done.

However, regardless of whether or not the hobby you discover has similarities to your day job, it should ultimately provide you with some catharsis. Dr. Earle highlighted the importance of finding an outlet, stating, “You have to find time to balance things, because otherwise, you just go crazy.” He encouraged discovering a hobby that allows you to completely ignore and get away from the medical practice, stating that this separation is the only way to cleanse yourself of the stresses the medical field throws at physicians. Having the outlet of racing has had a positive impact on Dr. Earle’s life overall. It allows him to not have work stress weigh on him and gives him an opportunity to bond with patients over his latest race.

This year, Dr. Earle has 17 races scheduled with Ferrari in Europe. If you have the opportunity to tune into one of his races, rest assured that the cameras love to highlight him on the screen and celebrate his feat of competing as the only American, the eldest driver and only doctor on the racetrack. While the outlet you discover may not be racing Ferraris in Europe, it is important to prioritize yourself and find an outlet to get away from the demands and strain that coincide with being a physician. We encourage you to discover a new passion today and learn what talents you may have unknowingly been hiding.

Gabriella Bradberry is the Admin/Communication Specialist for the Bexar County Medical Society.

The Art of Being “Shute”

This past year, we had the opportunity to create a medical mission experience as members of the University of the Incarnate Word School of Osteopathic Medicine’s student chapter of DOCare, an international group that assists students in finding their passion for global healthcare. Serving as president and vice president for our chapter brought us into contact with Dr. Thomas Shima, a family medicine physician who has been traveling to Guatemala for over 20 years. Under his guidance, we planned an experience for students from UIWSOM that we knew would leave a lasting impact.

Months of planning finally came to fruition as our eager group of first- and second-year medical students stood with luggage full of medical supplies, ready to catch the flight. After a long travel day, we finally arrived to Monterrico, a small town on the Pacific coast of Guatemala. That first evening, over dinner, Dr. Shima laid out the vision for the care we prepared to provide in the days ahead. During our discussion, Dr. Juan Carlos encouraged us to “be shute” when interviewing patients. In Guatemalan slang, shute refers to someone who is nosy, always asking questions and getting involved. We all laughed at the term, but the wisdom behind his advice stayed with us. In a clinical setting, being shute is not about being intrusive. It is about being curious, engaged, and committed to understanding the whole picture.

Though still early in his career, Dr. Juan Carlos is already a trusted partner in Dr. Shima’s long-standing mission work. As a native Guatemalan physician, he carries an intimate understanding of the culture, language and needs of the communities we were preparing to serve. To us, he quickly became a mentor. Someone who could model how to combine medical knowledge with cultural insight, and how to earn trust by meeting patients where they are. His simple reminder to “be shute” captured not only a local expression, but also a philosophy of medicine that shaped the way we would approach every encounter on the trip.

We began to see this not only as a strategy for better patient interviews, but also as a mindset that every physician-in-training should cultivate. To be shute is to resist the surface-level explanation. It is a posture of active listening, cultural humility and an eagerness to learn beyond what is immediately obvious. It means asking questions that uncover not just the disease, but the environment in which it takes root. It means recognizing the human story behind the symptoms.

Little did we know that learning to be shute would be one of the most important lessons we learned on our mission trip. That lesson became clear as our bus approached the first clinic site. Conversations

faded into silence as we looked out the window and saw the line of men, women and children wrapped around the schoolhouse courtyard. Their faces carried a mix of fatigue and hope as they realized we were arriving. Some clutched small bags with medical papers, others balanced infants on their hips, and all had come in search of care. As we unloaded the bins of medical equipment, classrooms became exam rooms, procedure spaces and even a working pharmacy. It was clear that efficiency mattered, but we also reminded ourselves that true effectiveness required being shute with the patients we were about to meet.

Each day brought us to a new community, where we set up the daily outreach clinic that provided general medical consultations, wound care, prenatal care, Osteopathic Manipulative Treatment (OMT) and health education. Working with Dr. Shima was wonderful because our group of students got to see a medical mission that was unlike any other. His decades of service to Guatemala have created a rare system of continuity of care in medical missions, where patients are not left behind after the team departs. Continuity is possible because the clinics are not imposed from the outside but organized in collaboration with local community leaders. Each site functions as a complement to the local medical system rather than a replacement for it. Dr. Shima works closely with local physicians and health workers to ensure that patients are connected to the resources in their own communities, creating a bridge between mission care and long-term follow-up.

That continuity allows for a lasting impact, but it also challenges us to stay creative. With limited resources, we often had to think on our feet to find solutions that would best serve our patients. It became clear that being shute did not just apply to patient encounters; it extended to practicing medicine itself. A medical mission trip teaches you lessons no textbook can fully capture: how to adapt, innovate, and approach challenges with curiosity. One student, for example, used a blood pressure cuff in place of an IV pump to help stabilize a patient during transport to a nearby hospital. These kinds of solutions emerged from not having the right equipment, but from asking questions, staying resourceful, and being willing to problem solve. In other words, learning to be shute.

One memorable patient was an elderly woman who came to the clinic with chronic back pain. As we spoke to her, we learned about her daily routine, which included carrying heavy loads for household chores. Recognizing how her environment contributed to her symptoms, we brought her to one of the classrooms designated for OMT. After treating her spine, we asked how she felt. She smiled and replied, “Tranquila,”

By Alexis Mischel, OMS-III, and Keith Vargas Kern, OMS-III

By Alexis Mischel, OMS-III, and Keith Vargas Kern, OMS-III

which translates to calm, at peace. Watching her leave the clinic light on her feet reminded us of the unique tools we have as osteopathic medical students — the ability to use our hands to diagnose and treat, even when other resources are limited. This experience underscored what it means to be shute. It was curiosity that led us to ask about her daily activities, attentiveness that helped us connect the pain to its root cause and creativity that allowed us to apply OMT as a safe, effective intervention in that setting. This lesson was not just about technique, but about mindset. Seeing beyond the symptom to the story, and using whatever tools we have, thoughtfully, to meet the needs of our patients.

What started as a lighthearted conversation about local slang, became a lesson we will carry throughout our medical careers. During the mission, we learned that the most meaningful insights often surfaced only when we allowed ourselves to be a little more shute — more observant, more inquisitive and more open to the people we came to serve.

For us, being shute has become more than just a cultural expression; it is a philosophy of care. It reminds us that medicine is not only about diagnosing disease, but about understanding lives, environments and the stories behind each patient. Whether in a rural Guatemalan village or a clinic in San Antonio, this posture of curiosity and humility helps us bridge gaps, build trust, and uncover what truly matters to our patients.

In the end, to “be shute” is to embrace the essence of good medicine: to listen deeply, to remain curious, and to let our patients teach us how best to heal. Just as Dr. Juan Carlos encouraged us, we encourage every physician and physician-in-training to find their own ways to be a little more shute.

Alexis Mischel, OMS-III, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine. As the former president of DOCare International medical student section at UIWSOM, she led a team in planning a memorable medical mission experience. Alexis had her sights set on taking part in a medical mission before starting medical school and continues to have an interest in global outreach along with rural and women’s health.

Keith Vargas Kern, OMS-III, is a medical student at the University of the Incarnate Word School of Osteopathic Medicine. He holds a master's in biomedical science from UIWSOM and dual bachelor's degrees in biology with a concentration in neuroscience from UIW and in Applied Science and Technology from Thomas Edison State University. A former U.S. Army cardiovascular specialist, Keith brings both clinical experience and a dedication to service into his medical training.

The 1853 Club Luncheon

October 7, 2025

The Bexar County Medical Society hosted its most recent 1853 Club luncheon on October 7, 2025. These luncheons, held on a quarterly basis, serve as an opportunity for retired members to reconnect with colleagues and friends while becoming informed on various topics presented by guest speakers.

This luncheon’s guest speaker was Anne Elise Urrutia, author of Miraflores: San Antonio’s Mexican Garden of Memory. Her book tells the story of her great grandfather, Dr. Aureliana Urru-

tia, a prominent physician who built the Miraflores Garden in San Antonio’s historic Brackenridge Park. Inspired by the guest speaker, members of the BCMS Alliance toured the Miraflores Garden shortly after.

If you are a retired or life BCMS member and are interested in joining the 1853 Club, please reach out to membership@bcms.org or call 210-301-4391. Our 2026 meeting dates and speakers are to be announced.

Physician Wellness Resources

The Bexar County Medical Society is committed to helping our members find personal balance and improve general well-being.

BCMS Physician Wellness Program

Resources and services provided to help BCMS members maintain a healthy and well-balanced lifestyle through confidential counseling, educational resources, local events, webinars and more.

Lifebridge

A BCMS provided resource for physician members who seek counseling from Texas-licensed professionals, discretely and confidentially through BetterHelp. Free 30 days counseling.

Wellness Coaching Webinars & Events

Nora Vasquez, MD, an Internal Medicine Doctor and Advanced Certified Physician Coach, helps physicians and healthcare professionals overcome burnout so that they can lead with joy and confidence while creating a more harmonious work-life balance that is fulfilling!

BCMS Find a Doc

Utilize our free Find a Doc service when looking for a new physician. Our members can be found by the specified tabs provided to narrow down your preferred physician.

Physician Support Line (888) 409-0141

Psychiatrists are available to help physicians and medical students navigate the balance of a personal and professional life. Free, confidential and anonymous. No appointment necessary. Call for any issue, not just a crisis.

Physician Coach Support

Free Confidential Physician-to-Physician support line. A group of volunteer physicians using their own personal development skills and life coaching certifications to support other physicians!

Physician Health & Rehabilitation Program

Confidential advocacy group of BCMS physicians that identify and facilitate recovery success for physicians with substance use disorder (Alcohol and/or Drugs) and depression, through support and monitoring.

Please scan QR code for more information and available resources for BCMS Members

39th Annual BCMS Auto Show

The BCMS Auto Program recently hosted its 39th Annual Auto Show on October 16, 2025. Each year, our members and their families are invited to spend the evening at the Bexar County Medical Society to enjoy stunning auto displays, food, live music and the company of friends and colleagues. This year’s event featured live music performed by Dylan Loza and gourmet foods provided by Ruth's Chris Steakhouse, Fogo de Chão and the Bariatric Counseling Center.

Thank you to our participating dealerships:

Cavender GMC

North Park Lexus

Mercedes Benz San Antonio

Gunn Acura

Gunn Honda

Porsche San Antonio

Northside Chevrolet

Northside Ford

North Park Mazda

Cavender Toyota

Gunn Honda

North Park Subaru

Audi Dominion

If you are interested in any of the feature vehicles from this year’s Annual Auto Show or want to learn more about the BCMS Auto Program, contact our Auto Director, Phil Hornbeak, at phil.hornbeak@ bcms.org or 210-896-4191. Visit our website for a list of participating dealers or to submit a vehicle request: https://bcms.org/auto.html

Shop Businesses Who Support BCMS

BCMS Business Directory

As a BCMS member, you can find exclusive discounts on premium products and services that you and your practice use every day.

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.

Christopher Davis, CPA 210-384-8000, ext. 118 cbd@ssacpa.com www.ssacpa.com

“Dedicated to working with physicians and physician groups.”

CLA - CliftonLarsonAllen LLP (HH Silver Sponsor)

Transform complexity into opportunities. Work with professionals who understand the specific financial, operational, clinical, and strategic needs of physician practices and medical groups. Our team is made up of knowledgeable, accessible, and responsive individuals devoted to the health care industry.

Bryan Garcia

210-298-7924

Bryan.Garcia@CLAconnect.com CLAconnect.com

"We'll get you there."

ASSET WEALTH MANAGEMENT

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.

Michael Clark President 210-268-1520

MClark@aspectwealth.com www.aspectwealth.com

“Your wealth. . .All aspects”

Atlas Retirement Strategies LLC (HHH Gold Sponsor)

Atlas Retirement Strategies LLC is a comprehensive financial planning firm dedicated to serving the unique needs of the medical community. We offer customized strategies in business planning, retirement planning, risk management, wealth preservation, estate planning, and wealth transfer – empowering healthcare professionals to achieve long-term financial security, clarity, and peace of mind.

David M. Webb, Ph.D., MSM, CLF, CLTC, LACP

Founder & Principal

210-281-4400

David@atlas-plans.com www.atlas-plans.com

BANKING

Broadway Bank (HHH Gold Sponsor)

Healthcare banking experts with a private banking team committed to supporting the medical community.

Thomas M. Duran

SVP, Private Banking Team Lead 210-283-6640

TDuran@broadway.bank www.broadwaybank.com

“We’re here for good.”

Texas Partners Banks (HHH Gold Sponsor)

Our private banking team specializes in healthcare banking and will work with you to craft and seamlessly integrate financial solutions for you and your practice, including practice loans, lines of credit and custom local lockbox solutions headquartered in San Antonio.

Maria Breen 210-807-5562

Maria.Breen@texaspartners.bank www.texaspartners.bank

Lone Star National Bank (HHH Gold Sponsor)

Established in 1983, Lone Star National Bank has provided banking services to communities in South Texas for the past 41 years. LSNB is an independent and locally owned bank subsidiary of Lone Star National Bancshares-Texas, Inc with consolidated assets of $3 billion (12/31/23) and 36 full-service banking centers throughout Starr, Hidalgo, Cameron and Bexar counties. Aside from personal and business banking, LSNB offers investments, wealth management & trust along with property and casualty insurance, health insurance and supplemental coverage.

Ivan Corona Molina Assistant VP 210-479-4713

MolinaI@lonestarnationalbank.com www.lonestarnationalbank.com

“We do what the Little Banks can’t, and the Big Banks won’t!”

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.

Robert Lindley

SVP | Private Banking Team Lead 210-343-4526

Robert.Lindley@amegybank.com

Denise Smith

Vice President | Private Banking 210-343-4502

Denise.C.Smith@amegybank.com

Scott Gonzales

Assistant Vice President | Private Banking 210-343-4494

Scott.Gonzales@amegybank.com www.amegybank.com “Community banking partnership”

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!”

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 healthcare 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

Avid Wealth Partners (*** Gold Sponsor)

For over 15 years, Avid Wealth Partners has been the trusted financial partner for local physician specialists and practice owners. We specialize in physician-focused financial advising, offering proactive tax planning, customized investment strategies, and comprehensive risk management solutions. Our approach addresses every aspect of your financial life, protecting your hardearned assets and building lasting wealth. With a team of credentialed specialists, we simplify complexity so you can focus on what you do best— caring for patients

MDWealth@avidwp.com www.avidforphysicians.com 210-864-3333

Elizabeth Olney with Edward Jones (HHH Gold Sponsor)

We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney Financial Advisor

210-858-5880

Elizabeth.Olney@edwardjones.com www.edwardjones.com/elizabeth-olney

FINANCIAL SERVICES

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.

Michael Clark President 210-268-1520

MClark@aspectwealth.com www.aspectwealth.com

“Your wealth. . .All aspects”

Hancock Whitney (HH Silver Sponsor)

Since the late 1800s, Hancock Whitney has embodied core values of Honor & Integrity, Strength & Stability, Commitment to Service, Teamwork and Personal Responsibility. Hancock Whitney offices and financial centers in Mississippi, Alabama, Florida, Louisiana and Texas offer comprehensive financial products and services, including traditional and online banking; commercial, treasury management, and small business banking; private banking; trust; healthcare banking; and mortgage services.

John Riquelme

San Antonio Market President 210-273-0989

John.Riquelme@hancockwhitney.com

Serina Perez

San Antonio Business Banking 210-507-9636

Serina.Perez@hancockwhitney.com

GERIATRICS/PRIMARY CARE

UT Health San Antonio

MD Anderson Cancer Center

(HHH Gold Sponsor)

UT Health provides our region with the most comprehensive care through expert, compassionate providers treating patients in more than 140 medical specialties at locations throughout San Antonio and the Hill Country.

UT Health San Antonio Physicians

Regina Delgado Business Development Manager 210-450-3713

DelgadoR4@uthscsa.edu

UT Health San Antonio

MD Anderson Mays Cancer Center

Laura Kouba Business Development Manager 210-265-7662

NorrisKouba@uthscsa.edu

Appointments: 210-450-1000

UT Health San Antonio

7979 Wurzbach Road San Antonio, TX 78229

HOSPITALS/PRACTICE SERVICES

Golden Billing & Benefits (HHH Gold Sponsor)

Golden Billing is owned and operated for over 20 years in Houston, TX. The owner, Marcus Yi, is focused on creating a partnership with clients. We are dedicated to optimizing the small business doctor’s productivity and maximizing practice cash flow by accurate claims coding and timely processing. Call today for a free consultation. If you don’t want to use us at lease maybe we can help you fine tune your decision.

Marcus Yi 713-263-0054

MYi@goldenbilling.com www.goldenbilling.com

Genuine Health Group (HHH Gold Sponsor)

Genuine Health Group partners with primary care providers to help them successfully adopt value-based payment models and demonstrate better health outcomes. Providers choose us for our proven expertise and consistency both for their patients enrolled in Medicare Advantage plans and for their patients with traditional Medicare who can align with one of ACOs. We have a track record of effectively reducing the cost of care while simultaneously improving care quality.

786-878-5500 info@genuinehealthgroup.com www.genuinehealthgroup.com

Equality Health (HH Silver Sponsor)

Equality Health deploys a wholeperson care model that helps independent practices adopt and deliver value-based care for diverse communities. Our model offers technology, care coordination and hands-on support to optimize practice performance for Medicaid patients in Texas.

Cristian Leos

Network Development Manager 210-608-4205

CLeos@equalityhealth.com www.equalityhealth.com

“Reimagining the New Frontier of Value-Based Care.”

SpeedEz’s (** Silver Sponsor)

For over three decades, SpeedE’z has been Bexar County’s truly local partner for answering service, contact center and courier solutions. R.N. owned and family-led, we combine compassionate care with professional expertise. Our HIPAA Certification, SOC 2 Type II Compliance and Woman-Owned HUB status reflect our commitment to integrity and security. Ranked Top Ten nationally in the ATSI Award of Excellence, our team delivers results that stand out – rooted right here in San Antonio!

Lauren Garza 210-615-0964

Lauren@speedez.com https://speedez.com

DialOPS

(H Bronze Sponsor)

Dialops is a trusted U.S.-based medical answering service and virtual receptionist solution designed specifically for healthcare practices. We provide 24/7 live call handling, HIPAA-compliant messaging, appointment scheduling, and reliable after-hours and overflow support. Our medically trained agents answer every call with professionalism and care— just like your in-office staff—ensuring your patients always feel heard and supported. From solo providers to busy clinics, Dialops helps reduce missed calls, ease front desk overload, and improve the patient experience—all at a fraction of the cost of hiring in-house.

Rachel Caero Rachel@dialops.net

877-2-DIALOPS/210-699-7198 www.dialops.net

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor)

TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you.

Wendell England Director of Member Benefits

512-370-1746

Wendell.England@tmait.org 800-880-8181 www.tmait.org

“We offer BCMS members a free insurance portfolio review.”

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor)

With more than 20,000 healthcare 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 healthcare for patients by educating, protecting and defending physicians.

Patty Spann Director of Sales and Business Development 512-425-5932

Patty-Spann@tmlt.org www.tmlt.org

“Recommended partner of the Bexar County Medical Society”

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, RPLU, ARM AVP Market Manager, SW Division 512-658-0262

Fax: 844-293-6355

Kirsten.Baze@medpro.com www.medpro.com

IT-TELEMEDICINE SERVICES

LASO Health Telemedicine and Rx App (HH Silver Sponsor)

LASO Health is the industry’s only solution that makes healthcare services accessible, cost-transparent and convenient. Its mission is to reinvent “healthcare” in the United States by empowering every individual and employer, insured or uninsured to have easy, timely, predictable, cost-effective care.

LASO combines an intuitive, mobile superapp with a marketplace of virtual and in-person health services to give customers a one-touch, onestop-shop, comprehensive health solution.

Ruby Garza, MBA 210-212-2622

RGarza@texaskidneycare.com www.lasohealth.com

Continued on page 42

BCMS Business Directory

MICROPRACTICE SERVICES

EnviroMerica

(HHHH 10K Platinum Sponsor)

Eliminate all liabilities caused by non-compliance with state and federal regulations and enjoy true peace of mind. Protect your practice by becoming audit proof as a subscriber to our compliance software that’s affordable and guaranteed. We have been protecting physicians for over 27 years and in 2013 were selected as the exclusive vendor of choice for compliance and medical waste by the 2nd largest Medical Association in the nation.

Work with certified experts who understand the specific compliance requirements imposed by OSHA, HHS/OCR (HIPAA), Boards, DOT, EPA, DTSC, CMS & many more. Everything we do, say, or develop for is guaranteed against fines and backed by our insurance policy that covers all our clients for up to $2 Million per occurrence.

This is true peace of mind that is invaluable.

Julian Goduci

Founder/CEO

1-888-323-0583 or 650-655-2045

JulianG@enviromerica.com

Enviromerica.com "Providing True Peace of Mind."

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HH Silver Sponsor)

From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving officebased practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Kelly Emmon

Field Sales Consultant

210-279-6544

Kelly.Emmon@henryschein.com www.henryschein.com

“BCMS members receive GPO discounts of 15 to 50 percent.”

SpeedEz’s

(** Silver Sponsor)

For over three decades, SpeedE’z has been Bexar County’s truly local partner for answering service, contact center and courier solutions.

R.N. owned and family-led, we combine compassionate care with professional expertise. Our HIPAA Certification, SOC 2 Type II Compliance and Woman-Owned HUB status reflect our commitment to integrity and security. Ranked Top Ten nationally in the ATSI Award of Excellence, our team delivers results that stand out – rooted right here in San Antonio!

Lauren Garza

210-615-0964

Lauren@speedez.com https://speedez.com

PHYSICIAN ORGANIZATIONS

Methodist Physician Practices (HH Silver Sponsor)

Methodist Physician Practices is committed to providing exceptional care for patients in greater San Antonio and South Texas. As part of Methodist Healthcare, we are dedicated to raising the standards of performance excellence while advancing the health and well-being of the communities we serve. Our extensive network of highly-skilled primary care physicians, specialists and surgical care providers ensures patients receive comprehensive, coordinated and compassionate care. As part of the Methodist Healthcare System, our physicians are committed to delivering personalized, high-quality services that meet the diverse needs of our patients. At Methodist Physician Practices, we go beyond healthcare — providing hope, healing and unwavering support for each individual we serve.

Erin Fitzgerald

Methodist Healthcare I Methodist Physician Practices

M:281-673-7350 methodistphysicianpractices.com

PROFESSIONAL ORGANIZATIONS

The Health Cell (HH Silver Sponsor)

“Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

Kevin Barber President 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. Jeannine Ruffner

President info4@samgma.org www.samgma.org

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.

San Antonio Office 210-301-4362 www.favoritestaffing.com

“Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

2025 Lexus LX600

By Stephen Schutz, MD

I’ve been writing, “Get ‘em while you can” a lot lately — think my 2024 BMW M3 and Subaru WRX STI reviews — and it seems appropriate to do it again with my discussion of the full size 2025 Lexus LX600 because it’s another anachronistic vehicle that will likely be replaced soon by something less carbon emitting (for the record, a hybrid LX700h version of the LX was introduced earlier this year, so de-carbonization has already begun).

Interestingly, the rest of the world gets to buy Toyota’s latest 300-series “real” Land Cruiser, but we can’t because Toyota elected to give us a re-badged 4Runner as our Land Cruiser, and the only way we can get the “real” one is to buy a new 300-based Lexus LX. Sigh. Anyway, let’s get into the LX’s exterior design, which does look good. Lexus’s signature spindle grille has matured with time — no longer a novelty, it now feels like a visual anchor. The side profile retains the high-beltline borrowed from Land Cruisers of the past, with fender bulges hinting at the body-on-frame off-road toughness beneath. It’s unapologetically upright, unmistakably Lexus and, maybe intentionally, a little intimidating.

Under the hood you’ll find Toyota’s venerable 3.4-liter twin-turbo V6, producing 409 horsepower and 479 lb-ft of torque. Paired with a 10-speed automatic, which, like the engine, is borrowed from

Like previous Lexus LX models, such as the LX470 from the early 2000s or the beefier LX570s from the 2010s and beyond, the LX600 provides a luxurious on-road experience coupled with lots of off-road capability that owners will likely never use but are glad is there.

And make no mistake, the LX remains an off-road master. The LX600 looks fairly ordinary, but it will climb, crawl, and descend with the unfussy competence that comes from decades of Land Cruiser DNA. Multi-Terrain Select, Crawl Control and lots of other modern wizardry — it even includes an underfloor camera view, if you can believe it — turn trail driving into a game of, “let’s do this,” rather than a test of bravado. There may be vehicles that look better on safari, but very few offer superior performance in those circumstances.

Inside the LX600, open-pore wood, hand-stitched leather and metal switchgear greet you not with flash but with craftsmanship. The 2025 refresh brings minor updates to the 12.3-inch central display and 7-inch lower screen combo — still an unusual arrangement, but one you’ll forgive because it’s functional. Every click and tactile response have seemingly been tuned by Japanese engineers who

the Toyota Tundra pickup, the LX600 can accelerate from a stop or even decent highway speeds with vigor.

seemingly obsess over how a door should sound when it closes, what leather seats should smell like and what pushing a button should feel like.

The VIP four-seat Ultra Luxury version is a niche model that no one who’s buying his or her vehicle for him or herself would ever select (it turns what should be an eight-seater into a four-seater).

The rest of the range, particularly the Premium and Luxury models, strike a more livable balance. Meanwhile, the F Sport, with its Torsen limited-slip differential, stiffer damping and bespoke 22-inch alloys, tries to inject sport into the equation, which doesn't work. The LX’s steering is syrupy, its body control limited by a big curb weight, and its braking more deliberate than decisive.

Ultimately, this is a 6,000-pound vehicle tuned for Abu Dhabi dunes, Aspen (or Alamo Heights) driveways and Beverly Hills traffic, and therefore it cruises effortlessly, isolates passengers with world-class NVH suppression, and dispatches long journeys with a composure that even some S-Class drivers would envy. But it’s not sporty.

Fuel economy remains a weak spot — 17 mpg combined is not something to brag about in 2025 — and Lexus hamstrung the LX with a surprisingly small 21-gallon gas tank, so range is limited.

Lexus has wisely resisted the urge to turn the LX into a mobile iPad. There is no gesture control, no hyperactive AI assistant and no Instagram-integrated mood lighting. The tech that’s present, wireless Apple CarPlay/Android Auto, Over-the-Air updates and a battery of driver assists, remain in service of the driver. And that’s perhaps the most Japanese aspect of the LX600’s philosophy: modern luxury, but with restraint.

At $106,000 to start and $130,000 for the Ultra Luxury, which again you don’t want, the LX600 is an expensive vehicle. But it makes sense in the slightly irrational segment that is full-size luxury SUVs because of its off-road bonafides. In a world of poseurs, the LX600 remains authentic in spirit — an honest-to-goodness machine designed by engineers, not influencers.

In the end, the 2025 LX600 is a thoughtful evolution of Lexus’ SUV flagship — luxurious, understated and deeply competent. It won’t out-cool a Land Rover Defender or out-flash a Maybach GLS, but it will probably outlast both. Get ‘em while you can.

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

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