San Antonio Medicine February 2015

MEDICINE SAN ANTONIO

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VOLUME 68 NO. 02

‘Why I Create...’

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MEDICINE SAN ANTONIO

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Why I paint

By Alfred L. Laborde, MD ..........................................10

By Oliver Johnson, MD...............................................14

Why I create pottery

Why I dance

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By Rajam Ramamurthy, MD .......................................21 COVER: Sunflower.

Copyright Oliver Johnson, MD

BCMS News ................................................................................................................................25 UTHSCSA Dean’s Message by Francisco González-Scarano, MD ......................................................26

by Joseph B. Topinka, JD, MBA, MHA, and Dana A. Forgione, PhD ................................................30 BCMS Circle of Friends Services Directory ..........................................................................................33 Book Review: ‘The Happiness Project” by Gretchen Rubin, reviewed by Rajam Ramamurthy, MD ................................................................................................37 In the Driver’s Seat ................................................................................................................................39 Auto Review: BMW 435i by Steve Schutz, MD ......................................................................................40

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VOLUME 68 NO. 02

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Why I’m a photographer

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FEBRUARY 2015

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS).

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Creativity

BCMS President’s Message ..............................................8

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BOARD OF DIRECTORS

OFFICERS James L. Humphreys, MD, President Leah Hanselka Jacobson, MD, Vice President Maria M. Tiamson-Beato, MD, Treasurer Adam V. Ratner, MD, Secretary Jayesh B. Shah, MD, President-elect K. Ashok Kumar, MD, Immediate Past President

DIRECTORS Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Bonnie Harriet Hartstein, MD, Military Representative Rebecca Christopherson, BCMS Alliance President Gerald Q. Greenfield Jr., MD, PA, Board of Censors Chair Donald L. Hilton Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., Legal Counsel

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CHIEF OPERATING OFFICER Melody Newsom

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COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Jeffrey J. Meffert, MD, Member Rajam S. Ramamurthy, MD, Member J.J. Waller Jr., MD, Member

6 San Antonio Medicine • February 2015

PRESIDENT’S MESSAGE

It’s time to take a seat at the table

By James L. Humphreys, MD 2015 BCMS President Our new state legislature has spent the last month memorizing the location of their offices and other important Capitol landmarks such as conference rooms and the nearest restrooms. The first month of every legislative session gets off the ground a little slowly as the new guys learn the system and legislators get a feel for their committee assignments and committee chairmen and women. With so much change in the legislature after the November elections, this feeling-out process has taken even longer than usual.

This month is when things start to heat up and get serious.

Bill filings pick up and committees start to have more frequent meetings. Advocacy activity at both the TMA and BCMS never actually stops, but there is a definite uptick in activity starting in February. The annual collection of First Tuesdays advocacy visits to the Capitol jointly operated by TMA and the TMA Alliance run from February through May. If you have not participated in a First Tuesdays visit to Austin, I highly recommend attending at least one to see how your state and local advocacy teams take issues affecting your practice straight to the legislators.

In the 84th Legislative Session we face the usual list of issues: attempts to undo or weaken tort reform, expansion of non-physician scope of practice, inadequate Medicaid pay-

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ment for services and the numerous bureaucratic obstacles of the Medicaid program, and lack of sufficient funded residency slots to take advantage of the newly graduated medical students and maintain a sufficient physician workforce in the state. Additionally we have to attempt to restore the lost Medicare/Medicaid dual eligible patient funding that hit doctors hard all across the state and particularly in the Rio Grande Valley. Lastly, the issue of price transparency in medical care has been pressed to the fore by a media blitz over the past two years and is sure to be an issue with bill filings this session.

Take advantage of the opportunity to learn our current hotbutton issues at the state house and what new legislation is in the pipeline that affects them. Every new legislative session is your chance to be a part of the process directly and take a shot at shaping new laws (or fixing broken old ones). BCMS will again be very active in legislative advocacy this session, and we invite you to join us in these efforts. Feel free to contact either myself or Mary Nava if you have any questions about how to help us help ourselves and our colleagues. Remember, if you aren’t at the table, you are on the menu.

James L. Humphreys, MD, is the 2015 president of BCMS. He is a pathologist with Precision Pathology in San Antonio.

CREATIVITY

Why I paint

By Alfred L. Laborde, MD

Untitled. Copyright Alfred L. Laborde, MD

I have always loved to draw. That love was probably born out of countless hours watching my grandfather entertain my siblings and me as he drew for us on his kitchen table. These were wonderful drawings of houses, horses, landscapes or whatever we shouted out. These drawings were in lieu of watching television; they did not own one until much later. That was our entertainment for the evening on the Saturday nights we would spend with my grandparents. These evenings were loose, carefree and without any strict rules. My grandfather was not an artist but he was an excellent craftsman who paid very close attention to detail. With no formal education past the eighth grade, he began waiting tables at a popular downtown San Antonio restaurant. He eventually retired at the age of 50 as coowner of the establishment.

After passing the age when I was entertained by “horse drawings,” my grandfather began buying paint-by-number art sets, 10 San Antonio Medicine • February 2015

and without fail, Sunday afternoons were spent carefully opening the thumb-size containers of oil paints. Not wanting to conform to the “rules” of paint by numbers, I often begged my grandfather to allow me to blend colors to give the painting a more personal and realistic look. With the last piece I can remember painting with my grandfather, he finally conceded defeat, and I did the painting my way. To this day, I don’t know whether it was out of frustration with my whining or out of curiosity. The end result was priceless. By no means was it a work of art, but the look on my grandfather’s face, and without saying a word, reflected approval.

STRUCTURE, DISCIPLINE With the rigors of college work, part-time jobs and medical school, I did not have much time for drawing or painting. The structure and discipline required to advance through various lev-

CREATIVITY

Untitled. Copyright Alfred L. Laborde, MD

els of education and training superseded any desire to enrich the whimsical, artistic side of the brain -- the same side I would later learn complemented my career perfectly.

After graduating from medical school at Texas Tech University, I accepted a surgical residency in Chicago. I soon learned that decision-making in the medical profession does not allow a lot of room for error. Pursuing a surgical specialty and later a vascular sub-specialty drove that point home over and over. My surgical residency taught me precision, and I learned the skill to visualize actions, two or three steps ahead. The attention to detail brought back memories of my grandfather’s early art lessons.

A true appreciation for the craftsmanship in a surgical career was brought to light.

Needless to say, the leisure time usually allotted for painting was rarely available. After completing a surgical residency in Chicago, followed by a vascular fellowship at the University of

Iowa, I accepted a position with my current partners at Peripheral Vascular Associates and returned to my hometown. My daughter, Veronica, was born in Iowa one month before our move back to San Antonio. My son, A.J., was born the following year.

The inspiration to resume my artistic side didn’t occur until my children were at an age when their artistic curiosity was peeking through. Weekend mornings were transformed into a mix of pancake making and art sessions. I was eager to explore my children’s unabashed artistic side. My true fascination was with how 4- and 5-year-olds would convert a blank piece of paper into a “work of art.” On one hand, my perfectionist daughter spent more time with the eraser than with the freedom the blank piece of paper could afford her. My son, on the other hand, could spend the entire time drawing, coloring and painting without any regard to artistic rules or regulations. His sesContinued on page 12 visit us at www.bcms.org

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CREATIVITY Continued from page 11

Autumn on the Banks of Sister Creek. Copyright Alfred L. Laborde, MD

sions were relaxed and carefree.

At those innocuous moments I began to see the contrasts in my own life. My surgical career was exact and unforgiving, and I severely missed the relaxed and carefree side. I certainly felt that my creative, relaxed side could compliment my surgeon’s personality.

EARLY BEDTIMES In addition to those relaxed Saturday mornings, I took advantage of my kids’ early bedtimes to begin drawing and painting at night. I began to look forward to these late-night painting sessions because I could feel a better sense of balance returning to my life. I soon realized that my love of watercolors truly represented that sense of balance. In the operating room, being in complete control of the situation often meant the difference between life and death. With watercolors, losing control of the medium was the difference between a beautiful outcome verses 12 San Antonio Medicine • February 2015

a rigid, confined painting totally lacking creativity.

In surgery, planning is everything. Picturing the end result gives you the best results. With art, my best work has been by accident. The work that has received the most compliments was never planned. I have always said that a masterpiece is never planned in advance.

For several years, I used art at a therapeutic tool, never realizing that anyone would be interested in what I produced.

Thanks to my family, I have had more than 10 art shows with the sale of more than 300 pieces. The majority of the proceeds have gone to educational scholarships.

I consider myself extremely lucky to find this balance in my life which has benefited both my professional career as well as my artistic side.

Alfred L. Laborde, MD, is a vascular surgeon at Peripheral Vascular Associates and a BCMS member.

CREATIVITY

Why I’m a photographer

Castle Grotti Sunrise. Copyright Oliver Johnson, MD

By Oliver Johnson, MD

As an anesthesiologist in San Antonio for the past 25 years, I have lived my life mostly in my left brain. My father (another very left-brainer) told me that photographs are only for recording a moment in time — nothing more. It wasn’t until 10 years ago that I came to see the photograph as an opportunity to make a statement, to convey an idea or emotion visually. I began with the question, “Why don’t my photographs look anything like the ones in magazines,” and I started a search for what was lacking in my photos.

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A simple Google search uncovers a wealth of information, some of it free, regarding how good photographers create their finished images. A new world was beginning to open for me, as I was attracted to the creative side of photography. I began learning the craft on my own with Internet resources. There is a plethora of tutorials, written and video, authored by some of the great photographers if we have the interest, patience and most especially time to devote to learning a new craft.

CREATIVITY Palouse Fields. Copyright Oliver Johnson, MD

Dune. Copyright Oliver Johnson, MD

Continued on page 16 visit us at www.bcms.org

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CREATIVITY Continued from page 15 Cars Night Stars. Copyright Oliver Johnson, MD

But to really learn a complex subject, one must have mentor(s) to learn effectively, people with long-term, intimate knowledge and experience of photography who can directly teach the nuances and give feedback in real time. I bought a Canon 40-D camera and associated lenses and began to learn how to manipulate an image to make it say something to the viewer. I signed up my wife and myself for a 10-day photographic workshop. Jim Chamberlain is a well-known European landscape photographer, and we went for an adventure in travel and learning in Italy. We travelled all over Tuscany, Florence, Rome, Venice and the islands of Murano and Burano. When I first asked, “What do you take pictures of,” the answer was, “What do you want to say with your image?”

CONVEY EMOTION The answer requires a complete turn-around in thinking. Instead of taking a picture and hoping for a lucky shot as most am16 San Antonio Medicine • February 2015

ateurs do, one must consider the message or emotional impact one is trying to convey. Only then can one decide how to get that feeling into an image which will impact another person who views it.

I had to become a right-brain person where photography was concerned.

It continues to be an evolving process, and as my skills have progressed, so my work has improved, as has my equipment. Today I shoot with a Canon 5D Mark III and some very good lenses. Since that time, my wife and I have done photo-shoots in France, Sicily, Dallas, and I have been to Death Valley and the Palouse in eastern Washington state with Scott Stulberg, another professional photographer. I’ve been told by several pros that I’ve got “the eye” of a photographer. My images will have to speak for themselves.

My future plans include another 12-day trip to Italy with my wife next spring where we also will be driving one of the vehicles on a workshop with Jim Chamberlain and his wife for 12 people.

CREATIVITY

I have been asked to help scout locations in northern France with Jim in the fall, just the two of us. This is high praise for me.

My website is under construction. I print my own images in my office at home up to 24 inches by 36 inches. I have a framer who works with clients on proper matting and framing of each image according to their budget and tastes. My wife also has a great eye and helps clients pick images and sizes to compliment the walls of their office or home. My “real” job prevents me from dedicating as much time to photography as I would like. Perhaps some day I’ll be able to concentrate only on the images.

Oliver Johnson, MD, (left) is an anesthesiologist at Star Anesthesia and a BCMS member.

visit us at www.bcms.org

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CREATIVITY

Why I create pottery

By Dudley Harris, MD

What will I do with myself while my 12year-old son takes his first pottery class?

Well, dang! I’ll just take the class with him!

That was more than 30 years ago. I’m still making pottery. Who knew?

There’s work time, and there’s free time.

What do we do with our free time? We seek entertainment -- travel, movies, television, etc. Making stuff is entertainment. It just so happened that it was making pottery that chose to entertain me.

Pottery is a beautiful thing for an introvert with a touch of the obsessive. Hours of solitude working on the potter’s wheel making the same thing over and over and striving only for just a bit more refinement … a bit more beauty … with each thousand pots.

Above: Pottery bowls are readied for an open house sale, with proceeds benefiting local charities. Photos courtesy Dr. Dudley Harris Below: A mixing bowl with a Shino glaze was created by Dr. Harris.

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KINSHIP, CONNECTION There is nostalgia surrounding pottery.

It’s a feeling of being connected ... to early man around his campfire working clay, to the Japanese tea master and to all the unknown craftsmen through the centuries.

This is not something I think about all the time, but when I sit down at my wheel and slap down a ball of clay on the wheel head, I do feel a kinship with all the potters who have made exactly that same maneuver and stared at exactly that same potential.

Making pottery on the potter’s wheel is not easy. It requires a single-mindedness that might seem excruciatingly boring. But that spinning wheel with its lump of clay has an allure that drives me today and has driven me for decades. I don’t even bother asking why.

Turning a ball of clay into a mixing bowl

CREATIVITY Dr. Harris holds a wooden rib he makes and sells from his workshop.

in two minutes is a beautiful thing. It’s pleasurable to do, and it’s mesmerizing to watch.

(See link at end of article.)

The potter’s tools are very simple. The more skilled the potter, the fewer tools he needs. But one tool that every potter uses is a “rib.” These are made of wood or stiff plastic. Old credit cards make good ribs. Ribs are held in one hand to scrape or shape the clay while the other hand pushes against the clay. Ribs used by American potters are usually quite thin, but Japanese potters prefer thicker ones. It occurred to me that I could make a thick rib by shaping a piece of hardwood on the wood-turning lathe. I tried many shapes and many woods before settling on a wood called Padauk. It’s easy to turn, takes a nice finish and has a beautiful red color. These round, thick ribs became popular, and I started a little business from my wood shop.

Continued on page 20

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CREATIVITY Continued from page 19

I do have to ask myself, “What am I going to do with all the pots?” You can’t store pots like you can memories. I use about 300 pounds of clay per week. That’s 8 tons a year. That makes for a lot of pottery. I have a pottery sale each December and give the proceeds to assorted charities.

This clears out enough space in my studio so that I can start over again in the spring.

For more information, visit www.dudleyharris.com and www. the-beautiful-bowl.com.

To watch a video of Dr. Harris throwing a pot, visit http://youtube/ mZcMk9FFt1A. Dudley Harris, MD, (left) is an ophthalmologist at San Antonio Eye Center and a BCMS member.

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Why I dance

CREATIVITY

By Rajam Ramamurthy, MD

Dr. Rajam Ramamurthy of the Arathi School of Indian Dance performs in August 1998 at the San Antonio Folklife Festival. Photo courtesy University of Texas at San Antonio Institute of Texan Cultures

Why do you like dance? That is a more difficult question to answer than why you like to entertain with dance. I have to dance. My parents and grandparents used to say that I was dancing at age 2. I do remember dancing as a 4year-old every night when my mom’s six brothers and two sisters gathered after dinner in her parents’ home in Kollam (Quilon) Kerala when we went for long vacations.

In my family there has never been a dancer, trained or natural. Also at the time I was growing up, the most popular dance form in south India, “Bharathanatyam,” was taboo for us young girls as it was denigrated and stifled during the British occupation of India and was practiced mostly by the community of courtesans. However, by the time I was in school, the art had been Continued on page 22

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CREATIVITY Continued from page 21

revived as part of the nationalistic movement; it just had not reached the small gold-mining town where I was growing up. My formal training in dance began in San Antonio with my 5-year-old daughter, four other women and their daughters. The Arathi School of Indian Dance, founded in 1981, is the first Indian dance school in San Antonio.

Why do humans like to dance? Are there animals who like to dance? In an elegant scientific research paper published in 2006, neuroscientist Dr. Anirudh Patel found that a species of cockatoo could move to a beat, whereas our closest genetic relative, the chimpanzee, does not move to music. Other animals that have evolved with humans for millions of years and that live closely with us, such as dogs and cats, do not move to musical beats. Patel concludes, “Dance may have evolved as a byproduct of our ability to mimic sounds -- a rare ability shared by humans, cockatoos and parrots.” It is not known why humans have this innate ability. However, it is well known that babies as young as five months sway to a beat.

Dance is in each one of us. Dancing was a way for our prehistoric ancestors to communicate, and those who were thus bonded had an evolutionary advantage. Another study found that dancers shared two genes associated with a predisposition for being good social communicators. The degree to which you take to dance could be an evo-

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lutionary process influenced by social, religious and economic factors that thwart our natural tendency. Famous dancer Agnes de Mille said, “The truest expression of a people is in its dance and in its music. Bodies never lie.”

Music invokes pleasure and reward areas like the orbitofrontal cortex, located directly behind one's eyes, and stimulates a midbrain region called the ventral striatum. The degree of activation matches with how much we enjoy some particular music.

I have taught dance every Friday evening for the past 33 years. The students range from age 5 to adults. The moment I start teaching, the rest of the world is tuned off. My mind is empty of everything but movement. It is my meditation, my mantra.

When young moms observe a class in which I teach their 5- or 6year-old, they tell me, “You are something else, aunty.” In the Indian community, you are respectfully addressed as aunty or uncle. In Bharathanatyam, you stamp the feet to create various rhythmic beats.

My calloused soles are an enigma for the pedicurist who will meekly ask,”What do you do?” The main posture in Bharathanatyam is a half sitting stance called “Araimandi,” meaning half-bent knee. And it does take a toll on your knees if you don’t exercise. Dancers are phenomenal athletes with a unique variety of health-related issues.

CREATIVITY

Caregivers require a strong knowledge and appreciation of their craft.

They are performing at the highest levels of human performance.

One scientific study asked the question, what is the toughest, most difficult to master, most challenging sport? Researchers looked at 60 sports and rated them based on more than 20 performance criteria, including physical, intellectual and environmental. The conclusion was that ballet was the most exacting physical endeavor. I am sure that is true of Bharathanatyam and other dance forms, too.

Another group of researchers sought to examine if dancers' beliefs correlate with actual use of provider services when they are injured.

Dancers perceived dance teachers to be first-line treatment providers (47.5 percent), followed by physical therapists (30 percent). Physicians were ranked third (12.5 percent) and only marginally higher than a dance colleague (10 percent). The dancers expressed a strong preference for nonsurgical rather than surgical physicians (87.5 percent versus 5 percent), and among physicians, the majority of dancers preferred subspecialists (60 percent), namely nonsurgical sports medicine doctors and physiatrists.

I have found it very difficult to convey the technical aspect of the dance form to orthopaedic, sports or rehabilitation practitioners. The science has advanced much more for ballet and other Western forms of dance. In 1990, the International Association for Dance Medicine

and Science was formed by an international group of dance medicine practitioners, dance educators, dance scientists and dancers. Membership began with 48 participants and has grown to more than 900 members in 35 countries today.

The question, why you like to entertain with dance, is answered in a poem in the ancient treatise on dance, “Natya Shastra:” Yatho Hastas Thato Dhrishti: Where the hand goes there should your eyes follow.

Yatho Dhristi Thato Manaha: Where your eyes follow there should be your mind.

Yatho Manaha Thatho Bhavaha: Where your mind is there should be your emotions.

Yatho Bhavaha Thatho Rasaha: Where your emotions are it elicits a response in the Other, meaning the audience or “Rasika.”

I dance to convey to you the joy I feel.

Rajam Ramamurthy, MD, is an adjunct professor of pediatrics at the University of Texas Medical School in San Antonio and senior guru at Arathi School of Indian Dance. She was BCMS president in 2004 and is a member of the BCMS Communications/Publications Committee.

visit us at www.bcms.org

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BCMS NEWS

Legislature begins new session in Austin

By Mary E. Nava, MBA BCMS Chief Governmental and Community Relations Officer The Texas Legislature convened Jan. 13 for the 84th Legislative Session in Austin.

One again, as your lobbyist and representative in Austin, I will attend the legislative session daily to keep you informed on the work of the House and Senate as we prepare to participate in First Tuesdays and also work with the Texas Medical Association on legislative bills and meetings with our elected officials and their staffs.BCMS President James Humphreys, MD, encourages members to sign up and attend at least one First Tuesdays visit to the Capitol during the coming session. Sessions are

scheduled for Feb. 3, March 3, April 7 and May 5.

"We need all our physicians to get involved in our discussions with our elected officials," Dr. Humphreys said.

To register for a First Tuesdays visit, visit www.texmed.org.

For regular updates during the legislative session, read The Weekly Dose, the BCMS electronic newsletter.

For local discussion on this and other advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at Mary.Nava@bcms.org.

SAVE THE DATE March 11: BCMS General Membership Meeting 6:30 p.m. Watch The Weekly Dose for details.

March 13: Medicine at the Crossroads Noon, University of Texas Health Science Center at San Antonio. Special guest speaker will be Richard Gunderman, MD, PhD, (right) Alpha Omega Alpha Visiting Professor at the School of Medicine. Dr. Gunderman is the Chancellor’s Professor of Radiology, Pediatrics, Medical Education Philosophy, Liberal Arts, Philanthropy and Medical Humanities and Health Studies at Indiana University. Free and open to the public. Sponsored by BCMS, The Patient Institute and UTHSCSA.

In Memoriam David K. Jameson, MD, age 84, died Dec. 11, 2014. A family practitioner, Dr. Jameson was a BCMS life member.

Robert Travis Jensen, MD, died Dec. 5, 2014. Dr. Jensen, 88, was an internal medicine and preventive medicine specialist and a BCMS life member.

Reginald Brian Furness Smith, MD, died Dec. 22, 2014, at age 83. Dr. Smith was an anesthesiologist and a BCMS retired member.

Michael Grant Zeigler, MD, age 80, died Dec. 26, 2014. Dr. Zeigler was a general surgeon and BCMS member.

Honoring our past ‌ Building our future BCMS is purchasing land to build its new headquarters.

To donate and learn more, visit http://bcms.org/building.html.

visit us at www.bcms.org

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UTHSCSA DEAN’S MESSAGE

Advancing the standard of care in neurosurgery

By Francisco González-Scarano, MD The Department of Neurosurgery at the School of Medicine is expanding in size and scope, and also in its reach, changing the landscape of adult and pediatric patient care in innovative ways.

With a focus on minimally invasive approaches, the department, chaired by Dr. David Jimenez, now has one of the largest neurosurgery residency programs and is playing an expanding role in advancing the standard of care for a host of conditions.

Our neurosurgeons operate at University Hospital, at St. Luke’s and North Central Baptist hospitals, and at the Veterans Administration Hospital. They also care for patients at the Cancer Therapy & Research Center (CTRC). Many patients find out about our expertise because they are admitted to one of these hospitals, but others seek out Dr. Jimenez and his team, especially for the treatment of craniosynostosis. In fact, treatment of craniosynostosis is one of the areas in which our department has become the destination for patients from around the world. The department’s philosophy is to deliver maximum benefit with the minimum possible disruption to the lives of the patients and their families. This is how the neurosurgery team approaches all cases, and it has a profound impact in children with this condition.

mations: one causes a triangular shape, another an oblong shape, and yet another causes one side of the face/head to grow much larger and at a different angle than the other side. Multiple fusions create other distortions and issues.

Dr. Jimenez began developing a minimally invasive technique 17 years ago – including the design of special instruments – with his partner and wife, Dr. Constance Barone, who is a plastic surgeon. They have been perfecting their approach ever since.

Known as an “endoscopic strip craniectomy,” this procedure has totally transformed the standard of care for children with craniosynostosis.

The traditional approach is one of the few surgeries where blood transfusions are always necessary as part of the preoperative process. Because of the complexity of the standard surgery, the child must be at least 6 months old, a time when the skull has already thickened and will bleed profusely. Coupled with long surgical times (four to eight hours), it is common to replace the child’s entire blood volume during a regular procedure; sometimes it is replaced twice.

ZIG-ZAG INCISIONS PREMATURE FUSION Craniosynostosis is the result of the premature fusion of one or more of the sutures of the skull. The National Institutes of Health report that it occurs in about 4/10,000 births. Because the brain grows so rapidly during the first few years of life, the skull must have open, expandable sutures. If these sutures are prematurely fused, the growing brain will create deformations in the skull.

This condition results in a myriad of other complications that often include learning and other development delays as well as problems with vision, respiration, hearing and other neurological functions.

Parents seek out Dr. Jimenez and bring their children from all over the United States as well as from China, Japan, Germany, Russia and the Middle East. As this article was being prepared, Dr. Jimenez received a CT scan of a newborn in Bogota, Colombia. This child, only a few weeks old, had a very distinct protrusion of one side of the forehead, causing asymmetry of the eye sockets. Fusion of different skull sutures causes different defor26 San Antonio Medicine • February 2015

The key approach in the traditional surgery is to make large zig-zag incisions in the scalp from ear to ear across the top of the head. The skull is then removed and put back together in a more “normal” shape and must then be fixed back together with wires, screws and other hardware. It is an extensive, complex operation that commonly results in a hospital stay of three to five days, with the first two or three in the ICU. There is a great deal of postoperative swelling and pain. Typically there are multiple followup procedures as well, in order to adjust, repair and reconfigure the skull. Children treated in the later stages (at 9 to 12 months of age) often have a lifetime uncorrectable disfigurement.

In contrast, the endoscopic procedure developed by Dr. Jimenez averages 57 minutes of operating time. There are no screws, wires or other appliances used on the skull, and because it takes so little time, children as young as one or two days old can be operated on. Unlike the traditional method, the scalp is not peeled back, only a small incision is made, and the fused suture of the skull is removed relatively quickly -- leaving large spaces for the skull to

UTHSCSA DEAN’S MESSAGE Case 1: Pre-op

Case 1: 2.5 years post

grow in. Skull growth is then guided by custom-fitted helmets that are worn 23 hours a day over the next 10 – 12 months. Children routinely go home the next day, with an average hospital stay of one night.

Besides involving less time under anesthesia, less blood loss, and a shorter hospital stay, Dr. Jimenez also has seen a large decrease in developmental delays with the new procedure. With the traditional approach, some surgeons report as many as 60 percent of patients with delayed development.

The level of developmental delays in Dr. Jimenez’ patients seems to be significantly less clinically, and is currently being quantified formally.

Dr. Jimenez attributes developmental delays after the traditional approach to two key factors: first, the lengthy time before surgery leads to effects on the underlying brain tissue, and second, the extensive nature of the traditional procedure, especially the hours of anesthesia and routine replacement of 100 percent or more of the patient’s blood. He notes that systemic hypotension, with concomitant brain hypoperfusion, can certainly lead to brain dysfunction and developmental problems with these very young brains.

The transfusion rate for the endoscopic procedure is anywhere from zero to 6 percent, depending on which suture is fused. More than 600 children have had this transformative procedure, and the team has performed as many as six operations in one day. The youngest patient was a baby born 11 weeks premature and had the surgery on his due date.

They have had zero reoperations.

BARRIERS TO ADOPTION Surgeons have come from all around the United States and the world to learn the technique, but the traditional method is still done in the majority of cases. That the procedure also requires training on new instruments, including endoscopes, is one of the barriers to widespread adoption. Like many new approaches, this one has seen a slow, but steady growth curve. The department is now doing a study with a neuropsyCase 2: Pre-op

Case 2: 4.5 years post

Photos courtesy of the School of Medicine at the University of Texas Health Science Center San Antonio

Continued on page 28 visit us at www.bcms.org

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UTHSCSA DEAN’S MESSAGE Continued from page 27

chologist to compare the developmental impacts of the endoscopic and traditional surgeries. Besides the previous research published on the procedure, Dr. Jimenez believes the new data will be the final point firmly establishing the endoscopic method’s superiority.

It is easy to see why the department holds their craniosynostosis procedure up as the epitome of their philosophy of providing a maximum benefit with minimal disruption. They also carry this philosophy over to all aspects of neurosurgery. When a minimally invasive procedure is an option the team has the expertise to provide this service for spinal, cranial and peripheral nerve operations. The department offers comprehensive expertise in functional neurosurgery/movement disorders, especially ones such as Parkinson’s disease that have not responded to treatment; general and complex spinal surgery, neuroendovascular (minimally invasive) procedures to treat complex vascular lesions in the head, neck and spine; neurosurgical oncology for tumors of the brain, spinal cord, spine and skull base; neurosurgical trauma and critical care, peripheral nerve surgery/carpal tunnel release, with an emphasis on minimally invasive techniques; skull base/cranial base surgery with specialization in removal of tumors at the base of the skull where many neurological and vascular structures are densely concentrated; and vascu-

28 San Antonio Medicine • February 2015

lar neurosurgery, to repair damaged or abnormal blood vessels in the brain.

A recent patient had chronic pain relieved through an endoscopic procedure to repair the vertebral artery that had shifted near the brain stem and was putting pressure on the glossopharyngeal nerve with every pulsation. After four years of medical treatment for pain – with no results – Dr. Jimenez and his team were able to identify the issue and bring total relief to the woman through a hole in the skull the size of a dime, with an instrument the size of a pencil lead.

Another minimally invasive procedure offered is an endoscopic trans-sphenoidal approach to pituitary tumors, an area where Dr. John Floyd has excelled. Dr. Floyd is a neurosurgical oncologist.

Because of the use of the endoscope, this procedure is a major advancement from the traditional pituitary surgery, since there is less painful swelling of the very sensitive facial tissues and the improved operation reduces bleeding, recovery time and, of course, length of stay in the hospital. Dr. Floyd works closely with colleagues and neuro-oncology team at the CTRC where the team of oncologists and radiation specialists address all manner of brain, spine and tumors of the central nervous system.

UTHSCSA DEAN’S MESSAGE NEUROSURGERY’S FUTURE Neuromodulation for relief of epilepsy, Parkinson’s and intractable chronic pain symptoms is another area where the department has been participating in the leading edge of care. Informally known as a “pacemaker for the brain,” the treatment involves a stimulation device (typically implanted in the same location as a pacemaker) that has electrical leads going into the spine/nerves, or has leads in the brain for deep brain stimulation (DBS) or vagal nerve stimulation (VNS).

Department of Neurosurgery faculty also are actively involved in the care of epilepsy patients who come to the Level 4-designated Epilepsy Center in partnership with the Department of Neurology and the University Health System. This is the highest accreditation from the National Association of Epilepsy Centers. Using VNS and other interventions, patients can receive surgical treatment that can dramatically reduce the occurrence of seizures associated with the condition.

Additionally, there are a number of psychiatric disorders where DBS or VNS may offer some relief, and Drs. Jean-Louis Caron, professor, and Alexander Papanastassiou, assistant professor, both in the Department of Neurosurgery, have begun promising research that involves DBS for post-traumatic stress disorder (PTSD). They are collaborating with Bradley Dengler, MD, a current neurosurgery resident who

graduated from the Uniformed Services University of Health Sciences and has an interest in PTSD. Using rodent models, they have preliminary results that suggest that this approach will be useful in humans.

The department also conducts research focused on brain and spine trauma, as well as many aspects of stroke treatment.

Endovascular neurosurgery has been a game-changer in the treatment of many conditions and diseases, and our department, along with its extensive residency program, is at the forefront of this movement, as well as advancing the standard of more traditional methods.

Offering specialization in all aspects of adult and pediatric care – and leading the world in the treatment of craniosynostosis – we are very fortunate to have Dr. Jimenez and his team at the School of Medicine.

To read more about our neurosurgery programs and people, visit http://neurosurgery.uthscsa.edu. To discuss a case with Dr. Jimenez, please call him directly at 210-567-5625.

Francisco González-Scarano, MD, is dean of the School of Medicine, vice president for medical affairs, professor of neurology, and the John P. Howe III, MD, Distinguished Chair in Health Policy at the University of Texas Health Science Center at San Antonio. His email address is scarano@uthscsa.edu.

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BUSINESS OF MEDICINE

A legal perspective on public health

By Joseph B. Topinka, JD, MBA, MHA, and Dana A. Forgione, PhD

In light of recent events surrounding the Ebola virus outbreak, our communities need to have a candid discussion about infectious diseases, public health emergencies, and how our system of laws addresses these important issues. Physicians, clinicians, allied health professionals, health system leaders, business leaders, community leaders and, yes, even lawyers have an important voice in this discussion. Hopefully, we will learn from the past, and be better prepared for a future of unexpected public health challenges.

U.S. CONSTITUTION There is no mention of public health in the U.S. Constitution.

As a result, public health has normally been the primary responsibility of the state and local governments. Despite that responsibility, the federal government has often asserted its authority over public health-related activities through its interstate commerce, taxation and spending powers under Article I, Section 8, of the U.S. Constitution.

The U.S. Constitution is the source of all legal authority for the federal government and our state governments. Yet, each state, such as Texas, has its own constitution and often, subordinate levels of government have their own legal sources of governance, such as charters or statutes. Since they all differ, their style of governance may be different, yet they all still fall under the U.S. Constitution.

The U.S. Constitution is the supreme law of the land, except that the 10th Amendment specifies, “The powers not delegated to the United Sates by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

That is, if the U.S. Constitution does not contain a provision dealing with a certain matter, that matter is reserved to the states, and ultimately to the people. Those powers are often referred to as state police powers. They explain such policies as tobacco taxes and na-

30 San Antonio Medicine • February 2015

tional speed limits — local-looking matters controlled or influenced by the federal government. This also has been a source of tension under the concept of federalism.

THE MIX OF FEDERALISM Statutes and regulations are outgrowths of the U.S. Constitution and the respective state constitutions, such as in Texas with the Communicable Disease Prevention and Control Act, and Chapter 121 of the Texas Health and Safety Code. The several constitutions in the United States give the U.S. Congress and the various state legislatures the power to pass laws in the form of statutes. Then federal and state agencies write regulations to implement the statutes. These statutes can impact public health at the federal, state and local levels.

For example, Congress passed statutes that created the U.S. Public Health Services with its authorities and powers. It also created regulatory agencies like the Food and Drug Administration (FDA) or the Occupational Safety and Health Administration (OSHA), and non-regulatory agencies like the Centers for Disease Control and Prevention (CDC). The Texas Legislature passed the aforementioned Communicable Disease Prevention and Control Act which created powers to respond to disease outbreaks. Like other states, Texas further delegated those powers between the Commissioner of Health in the Texas Department of State Health Services (DSHS) and the local health authorities (HAs). As an example, the director of public health for the City of San Antonio also serves as the chief executive officer of the Metropolitan Health District and the Health Authority for Bexar County. Thus, there is a mix of federal, state and local laws and regulations.

Law in our system is based on English Common Law, which by its nature is historical in terms of relying on past precedents as the basis for current and future judicial rulings. Local, state and

BUSINESS OF MEDICINE

federal courts determine the guilt of accused criminals, resolve private law disputes between individuals, and review actions of agencies enforcing civil laws — like public health laws. In general, the lower courts follow the decisions of higher courts, and state courts review the state’s laws to determine if they violate the state or federal constitutions. Federal courts review the constitutionality of state and federal laws, and the U.S. Supreme Court’s decisions bind all state and federal courts.

EMERGENCY SCENARIO The federal courts and most of the state courts use common law precedent — which is critical, especially when it comes to decisions that impact public health matters. That precedent established by some decision will then bind us in terms of what we can, or cannot, do in a public health emergency scenario. Probably the most important public health legal opinion was in the case of Jacobson vs. Massachusetts, 197 U.S. 11 (1905). This 1905 U.S. Supreme Court case (http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=US&vol=197&invol=11), concerned an order based on state statute compelling vaccinations of residents against small pox after a recent outbreak in Massachusetts. The Cambridge Board of Health ordered the vaccinations, and Henning Jacobson refused the vaccination and refused to pay the $5 fine.

The U.S. Supreme Court decided that “Upon the principle of self-defense, of paramount necessity, a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.”

With its decision in support of the law, the U.S. Supreme Court began our modern constitutional approach to disease control law, which includes the: • Use of police powers for public health concerns; • Delegation of certain authorities to health agencies and other government subdivisions; and • Use of actions limiting liberty for well-established public health interventions.

More importantly, the Jacobson case addressed the balancing of public good vs. individual rights — a concept that physicians and healthcare leaders must address as we face future public health matters.

TEXAS PERSPECTIVE Every state does things in its own unique way regarding public health law, especially as the law relates to public health emergencies. While you don’t need to be a scholar in Texas public health law, having a basic idea of available Texas resources is critical. One of our favorite resources is the Community Preparedness section of the Texas Department of State Health Services (www.dshs.state.tx.us/commprep). This site is very user friendly and contains a tremendous amount of source material and background publications. Another great source is the University of Houston Law Center’s Health Law and Policy Institute’s bench book designed for judges, entitled Control Measures and Public Health Emergencies (www.law.uh.edu/healthlaw/#). This book provides a comprehensive summary and simplifies public health law, federalism, executive branch authority in Texas, and judicial authority in Texas, regarding public health emergencies. Finally, all physicians should be familiar with the City of San Antonio’s Metropolitan Health District website, and specifically its link at www.sanantonio.gov/Health/EmergencyManagement.aspx, which has important contact information for reporting public health emergencies. We hope these resources will be a help to you when facing an everyday, or unusually daunting, public health challenge.

Joseph B. Topinka, JD, MBA, MHA, LLM, FACHE, FHFMA is a recently retired military attorney whose focus is on health law. He previously was an assistant professor in the Army-Baylor Graduate Program in Health and Business Administration, and has taught as an adjunct professor at several local universities.

Dana A. Forgione, PhD, CPA, CMA, CFE is the Janey S. Briscoe Endowed Chair in the Business of Health at the University of Texas at San Antonio.

He is also an adjunct professor in the School of Medicine, Department of Cardiothoracic Surgery, the Department of Pediatrics, and in the School of Public Health, all at the University of Texas.

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.

ACCOUNTING FIRMS Anderson, Johns & Yao CPAs (HH Silver Sponsor) Ann Yao, CPA/PFS 210-696-9400 yao@ajycpa.com www.ajycpa.com Padgett Stratemann & Co. LLP (HH Silver Sponsor) Vicky Martin, CPA 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com Sol Schwartz & Associates P.C. (HH Silver Sponsor) Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com

ATTORNEYS Pulman, Cappuccio, Pullen, Benson & Jones LLP (H Bronze Sponsor) Eric Pullen 210-222-9494 EPullen@pulmanlaw.com

BBVA Compass (HHH Gold Sponsor) Zaida Saliba, Commercial Relationship Manager 210-370-6012 Zaida.Saliba@BBVACompass.com Mary Mahlie, Global Wealth Management 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com

Broadway Bank (HHH Gold Sponsor) Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com

Frost (HHH Gold Sponsor) Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com

BANKING

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BB&T (HHH Gold Sponsor) Ed L. White Jr. 210-247-2985 ewhite@bbandT.com www.bbandt.com

The Bank of San Antonio (HHH Gold Sponsor) Brandi Vitier 210-807-5581 brandi.vitier@thebankofsa.com Baptist Credit Union (HH Silver Sponsor) Sarah Chatham 210-525-0100, ext. 201 memberservices@baptistcu.org www.baptistcu.org Cadence Bank (HH Silver Sponsor) Margarita Ortiz 210-764-5500 maggie.ortiz@cadencebank.com Steve Edlund, 210-764-5573 steve.edlund@cadencebank.com http://cadencebank.com

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Huffman Developments (HHH Gold Sponsor) Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com

St. Joseph's Credit Union (HH Silver Sponsor) Armando Rodriguez 210-225-6126 arodriguez@sjcusatx.net www.sjcusatx.com

San Antonio Retail Builders (HH Silver Sponsor) H.B. Newman 210-446-4793 brett@texaspremiercapital.com

Jefferson Bank (H Bronze Sponsor) Ashley Schneider 210-734-7848, ext. 7848 aschneider@jeffersonbank.com www.jeffersonbank.com

CUSTOM HOME BUILDERS

Security Service Federal Credit Union (H Bronze Sponsor) Luis Rosales 210-845-8159 lrosales@ssfcu.org Texas Farm Credit (H Bronze Sponsor) Tiffany Nelson 210-798-6280 www.texasfcs.com

Diamante Custom Homes (HHH Gold Sponsor) Keith Norman 210-341-6430 knorman@diamantehomes.com www.diamantehomes.com

EDUCATION Alpha Bilingual Preschool (H Bronze Sponsor) Tania Lopez de Pelsmaeker 210-348-8523 tldp@hotmail.com

CATERING Corporate Caterers (H Bronze Sponsor) Ricardo Flores 210-789-9009 rflores@corpcatererstex.com Heavenly Gourmet Catering (H Bronze Sponsor) 210-496-9090 www.heavenlyg.com

ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES

Med MT, Inc. (H Bronze Sponsor) Ray Branson 512-331-4669 branson@medmt.com www.medmt.com

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 33 ELECTRONIC MEDICAL RECORDS

Greenway Health (HHH Gold Sponsor) Jason Siegel 512-657-1259 jason.siegel@greenwayhealth.com www.greenwayhealth.com

FINANCIAL SERVICES

Northwestern Mutual Wealth Management Co. (HHHH Platinum Sponsor) Eric Kala CFP, CLU, ChFC, Wealth Management Advisor 210-446-5752 eric.kala@nm.com www.erickala.com

Aspect Wealth Management (HHH Gold Sponsor) Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com Bob Davidson — New York Life (HH Silver Sponsor) Bob Davidson, 210-321-1445 rdavidson02@Q.newyorklife.com www.linkedin.com/in/bobdavidsonnyl Platinum Wealth Solutions of Texas LLC (HH Silver Sponsor) Tom Valenti 210-998-5023 tvalenti@jhnetwork.com Eric Gonzalez 210-998-5032 ericgonzalez@jhnetwork.com www.platinumwealthsolutionsoftexas.com Retirement Solutions (HH Silver Sponsor) Robert C. Cadena 210-342-2900 robert@retirementsolutions.ws www.retirementsolutions.ws

34 San Antonio Medicine • February 2015

Bold Wealth Management (H Bronze Sponsor) Richard A. Poligala 210-998-5787 richard.poligala@natplan.com www.boldfinancialgroup.com

Elite Care 24 Hour Emergency Center (HH Silver Sponsor) Rosie Clark 210-771-0141 rclark@elitecaremarketing.com www.elitecareemergency.com

GOLF

Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/

TPC San Antonio (H Bronze Sponsor) Matt Flory 210-491-5816 www.tpcsanantonio.com

HOSPITALS/ HEALTHCARE SERVICES

First Choice Emergency Room (HHH Gold Sponsor) Hardy Oak Boulevard 24-hour 210-451-8340 Nacogdoches Road 24-hour 210-447-7560 Tezel Road 24-hour 210-437-1180 www.fcer.com

Seasons Hospice and Palliative Care (HH Silver Sponsor) Deb Houser-Bruchmiller 210-471-2300 dhouser@seasons.org www.seasons.org Southwest General Hospital (HH Silver Sponsor) Craig Desmond 210-921-3521 Elizabeth Luna 210-921-3521 www.swgeneralhospital.com

HUMAN RESOURCES

Select Rehabilitation of San Antonio (HHH Gold Sponsor) Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com

South Texas Sinus Institute (HHH Gold Sponsor) Sue Musgrove 210-225-5666 stsisue@gmail.com www.southtexassinusinstitute.com

Warm Springs Medical Center Warm Springs Thousand Oaks Warm Springs Westover Hills (HHH Gold Sponsor) Central referral line: 210-592-5350

Employer Flexible (HHH Gold Sponsor) John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com

INFORMATION TECHNOLOGY

Dahill (HHH Gold Sponsor) Stephanie Stephens 210-332-4924 sstephens@dahill.com www.dahill.com PitCrew IT Services (H Bronze Sponsor) Eric Murcia 210-547-0305 eric@pitcrewit.com

INSURANCE

Blue Cross Blue Shield of Texas (HHH Gold Sponsor) Edna Pérez-Vega 210-558-5162 Edna_Perez-Vega@bcbstx.com www.bcbstx.com

Frost Insurance (HHH Gold Sponsor) Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com

Humana (HHH Gold Sponsor) Donnie Hromadka 512-338-6151 dhromadka@humana.com www.humana.com

Texas Medical Association Insurance Trust (HHH Gold Sponsor) James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org Catto & Catto (HH Silver Sponsor) Crystal Metzger James L. Hayne Jr. 210-222-2161 www.catto.com Texas Drug Card (H Bronze Sponsor) Todd Walker 512-569-5547 twalker@texasdrugcard.com http://texasdrugcard.com/index. php

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH Platinum Sponsor)

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org

Medical Protective Medical Malpractice Insurance (HHH Gold Sponsor) Thomas Mohler 512-213-7714 thomas.mohler@medpro.com www.medpro.com

The Bank of San Antonio Insurance Group Inc. (HHH Gold Sponsor) Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com ProAssurance (HH Silver Sponsor) Paul Schneider 800-282-6242 pschneider@proassurance.com Mark Keeney 512-314-4347, ext. 7347 mkeeney@api-proassurance.com www.proassurance.com The Doctors Company Medical malpractice insurance (HH Silver Sponsor) Kirsten Baze 512-275-1874 KBaze@thedoctors.com www.TheDoctors.com

INTERNET/ TELECOMMUNICATIONS

Time Warner Cable Business Class (HHH Gold Sponsor) Rick Garza 210-582-9597 Rick.garza@twcable.com

MARKETING SERVICES Know Your Doctor SA (HH Silver Sponsor) Lorraine Williams, RN 210-884-7505 LWilliams@KnowYourDoctorSA.com www.KnowYourDoctorSA.com

Phiskal LLC Marketing and Promotion (H Bronze Sponsor) Sundeep Sadheura 210-865-4520 Sunnys@phiskal.com http://Phiskal.com

MEDICAL BILLING AND COLLECTIONS SERVICES

DataMED (HHH Gold Sponsor) Anita Allen 210-892-2333 aallen@datamedbpo.com www.datamedbpo.com Commercial & Medical Credit Services (H Bronze Sponsor) Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com PriMedicus Consulting Inc. (H Bronze Sponsor) Sally Combest, MD 877-634-5666 s.combest@primedicusconsulting.com www.primedicusconsulting.com

MEDICAL TRAINING

LINRON速 Bioskills Training Institute (HHH Gold Sponsor) Yolanda S. Garza, RN 210-572-2434 yolanda.garza@linrontraining.com www.linrontraining.com

MENTAL HEALTH/ EDUCATION

The Ecumenical Center (HHH Gold Sponsor) Mary Beth Fisk 210-616-0885, ext. 215 mbfisk@ecrh.org www.ecrh.org

ORGANIZATIONS Fundacion Teleton USA (HH Silver Sponsor) Ricardo Guzman Hefferan guzman@teletonusa.org www.teletonusa.org

PAYMENT SYSTEMS/ CARD PROCESSING

Urgent Care Billing Solutions LLC (H Bronze Sponsor) Ann DeGrassi, CMIS 210-878-4052 adegrassi@ucbillingsolutions.com www.urgentcarebillingsolutions.net

Heartland Payment Systems (HH Silver Sponsor) Tanner Wollard 979-219-9636 Tanner.Wollard@e-HPS.com http://www.heartlandpaymentsystems.com

MEDICAL SUPPLIES/ EQUIPMENT

PUBLICATION MANAGEMENT

Henry Schein Medical (HHHH Platinum Sponsor) Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com/medical McKesson Medical-Surgical (H Bronze Sponsor) Karan Cook 210-573-2117 karan.cook@mckesson.com

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PRINTING SERVICES SmithPrint (H Bronze Sponsor) Robert Upton 210-846-5268 Robert@smithprint.net http://www.smithprint.net

REAL ESTATE/ COMMERCIAL Cano and Company Commercial Real Estate

(HH Silver Sponsor) Dennis Cano, Agent 210-731-6613 Dennis@canoandcompany.com www.canoandcompany.com Stream Realty Partners (H Bronze Sponsor) Carolyn Hinchey Shaw 210-930-3700 cshaw@streamrealty.com www.streamrealty.com

REAL ESTATE/RESIDENTIAL Kuper Sotheby's International Realty (HH Silver Sponsor) Joe Salinas III 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com Becky Aranibar Realty Group Keller Williams (H Bronze Sponsor) Carlo G. Aranibar, MBA 210-862-4022 BARgrouptx@gmail.com www.beckyaranibar.com

REAL ESTATE INVESTMENTS Texas Premier Capital (HH Silver Sponsor) H.B. Newman 210-446-4793 brett@texaspremiercapital.com Rick Carter 210-367-7909 rick@texaspremiercapital.com www.texaspremiercapital.com

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Favorite Healthcare Staffing (HHHH Platinum Sponsor) Brian Cleary 210-301-4362 BCleary@FavoriteStaffing.com http://www.favoritestaffing.com/ public/medicalsocieties/bexar_c ounty/bexarcounty_index.aspx

As of Jan. 13, 2015

For more information, call 210-301-4366, email ugust.Trevino@bcms.org, or visit www.bcms.org.

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35

Matin Tabbakh is well known for his “Make it Happen” attitude. He has been actively involved in the Real Estate industry for over a decade. Having experience in both Luxury Residential and Commercial properties, Matin has a proven record of Excellence! He has earned a Broker’s Real Estate License which is the highest professional licensing in the state of Texas and an Accredited Luxury Home Specialist (ALHS) designation; he is an active member of the CCIM Institute (Certified Commercial Investment Member) as well. Matin’s real estate education, business academics and experience are exceptional; his success comes from his unsurpassed need of excelling at what he does!

Matin’s expertise in the Luxury and Commercial market makes his knowledge priceless! If you want to achieve outstanding results, call Matin for a private consultation.

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(210) 722-7777

BOOK REVIEW

‘The Happiness Project’ Written by Gretchen Rubin Reviewed by Rajam Ramamurthy, MD

Author Gretchen Rubin quotes writer Robert Louis Stevenson as saying, “There is no duty we so much underrate as the duty of being happy.” In her book “The Happiness Project,” Rubin writes about her efforts to bring happiness to her life.

The author is married to Jamie, a tall, dark and handsome man who is the love of her life. Rubin has two delightful daughters. She is highly educated, a lawyer who gives up a lucrative law practice to write, and she becomes a successful author with two bestsellers to her credit. Bring happiness to her life?

You have got to be kidding, lady, I thought as I picked up the book in the Atlanta airport and read the reviews, a little about the author and the opening pages. I bought the book and raced to the gate to sit and read.

What grabbed me were the next few sentences: “… Often I sniped at my husband or the cable guy. I felt dejected after even a minor professional setback. I drifted out of touch with old friends … listlessness, free-floating guilt.”

Rubin’s book fell into the category of books I stole time to read when I should have been doing more urgent things such as answering e-mails.

“The Happiness Project” resonated with me, and I think many who read San Antonio Medicine will feel the same. In launching her happiness project, Rubin took up a phase of it every month. Some activities, such as clearing clutter or changing shopping habits will probably grab us women, as these tasks by default do fall on us, employed or not. But the book is filled with well-researched and referenced statements to which everyone can relate.

Her July project was to buy some happiness. She writes: “In particular, I kept seeing the argument money can’t buy happiness, but it seemed that people appeared fairly well convinced about the significance of money to their happiness.” A 2006 Pew Research Center study in the United States found the percentage of reported happiness increased as income rose, from 24 percent for those earning less than $30,000 per year to 49 percent for those earning $100,000. Could it be possible that there is some reverse correlation: Happy people become rich faster because they’re more appealing to other people and their happiness helps them to succeed? This chapter was particularly informative. A sense of growth is so important to happiness that it’s often preferable to be progressing to the summit rather than to be at the summit. Rubin’s argument for growth in the happiness project is thought-provoking.

One statement in the book stuck with me. Happiness, some people think, is not a worthy goal; it’s a trivial American preoccupation, the product of too much money and too much television. They think that being happy shows a lack of values and being unhappy is a sign of depth. It vaguely reminded me of an Indian philosophical statement wherein you strive to reach a state of equanimity where you are neither happy nor unhappy. Will I ever forget the day when Sridevi and I ran to her grandfather to announce that we jumped off the highest level of the spring board in the swimming pool, and all I heard was a grunt from him? We were both 8 years old; a bravo and a pat on the head might have created two Olympic athletes.

It takes energy, generosity and discipline to be unfailingly lighthearted, Rubin says. One fact of human nature is that people have a “negativity bias.” In a marriage, it takes at least five good acts to repair the damage of one critical destructive act. With money, the pain of losing a certain sum is greater than the pleasure of gaining that sum. Distraction is a powerful, mood-altering device. When you feel unhappy, find an area of refuge. These and many more thought-provoking statements push you to keep reading. Happiness is in you.

Rubin has used a method to feel it. Why not seek yours?

Rajam Ramamurthy, MD, is a member of the BCMS Communications/Publications Committee and 2004 BCMS president. visit us at www.bcms.org

37

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38 San Antonio Medicine • February 2015

Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Acura 11911 IH-10 West

* Fernandez Honda 8015 IH-35 South

Ingram Park Auto Center 7000 NW Loop 410

Ingram Park Auto Center 7000 NW Loop 410

Gunn Honda 14610 IH-10 West (@ Loop 1604) Ancira Chrysler 10807 IH-10 West Cavender Audi 15447 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Mercedes-Benz of Boerne 31445 IH-10 W, Boerne * Gunn Infiniti 12150 IH-10 West

Ancira Ram 10807 IH-10 West

Mercedes-Benz of San Antonio 9600 San Pedro Ave.

North Park Subaru 9807 San Pedro Ave.

Ancira Dodge 10807 IH-10 West BMW of San Antonio 8434 Airport Blvd.

Ingram Park Auto Center 7000 NW Loop 410 Ancira Jeep 10807 IH-10 West

* Mini Cooper The BMW Center 8434 Airport Blvd.

Ingram Park Auto Center 7000 NW Loop 410 Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)

Batchelor Cadillac 11001 IH-10 at Huebner Cavendar Cadillac 801 Broadway

* Ancira Volkswagen 5125 Bandera Rd.

Northside Ford 12300 San Pedro Ave.

* North Park Lexus 611 Lockhill Selma

Cavender Toyota 5730 NW Loop 410

Ingram Park Nissan 7000 NW Loop 410 * The Volvo Center 1326 NE Loop 410

Cavender GMC 17811 San Pedro Ave. * North Park Lincoln/ Mercury 9207 San Pedro Ave.

Porsche Center 9455 IH-10 West

visit us at www.bcms.org

39

AUTO REVIEW

BMW 435i New, attractive, athletic and a hall-of-fame engine

By Steve Schutz, MD As many readers know, BMW recently took a page out of Audi's playbook and decided to call what used to be 3-series coupes and convertibles 4-series cars. That clever idea, which Audi first used when they launched the A5 coupe in 2008, allowed them to charge more for a car that, while using the exact same platform as the A4 sedan, was one number "better." Shades of "This is Spinal Tap," I know, but it worked, as robust A5 sales will attest.

For the record, it was actually BMW that had the idea first back in the 1970s when they created a coupe based on the 5-series sedan platform and called that (gorgeous and classic) car the 6-series.

40 San Antonio Medicine • February 2015

FOR BETTER, FOR WORSE Recently, I had the chance to sample a BMW 4-series convertible, and after a week with it I can say that, for better and for worse, it is quite different from the beloved E93 3-series convertible that preceded it.

For starters, the interior is more spacious.

Front foot- and head-room have been increased, and the cabin feels bigger from behind the wheel. Still, despite the expanded passenger space, the rear seats in the 4-series are tight and appropriate only for children and out-of-favor in-laws.

As with the 3-series sedan, the 4-series' interior has been upgraded with nicer materials and a more integrated look. The level of lux-

ury you perceive when you sit behind the wheel is now what it is in the Audi A5, and the iDrive user interface is as good as the class-leading Audi MMI system.

That's two Audi mentions in one sentence, by the way, which should serve as a reminder to BMW (and Mercedes and Lexus) that the status quo in the automotive luxury market can shift rapidly. It was only 10 years ago that Audi was an also-ran in this segment, and now they're the benchmark in many if not most areas.

The designers at BMW obviously spent time ensuring that the 4-series was visually distinct from the 3-series sedan. The wheelbase is the same on both cars, but the profile

AUTO REVIEW And, truth be told, the convertible with the top up lacks the coupe's graceful lines. Naturally, if you love convertibles those disadvantages won't matter much to you.

AUTO PROGRAM BENEFITS

and rear views of the 4 are sleeker and sportier than on its four-door sibling. Overall, the 4-series looks new, attractive and athletic, though it doesn’t quite manage to be as comfortably handsome as the A5.

Driving the 435i is another matter as it leaves the A5 in the dust thanks to superior weight distribution and a much better engine. Yes, the Audi has a nice turbo fourcylinder power plant that moves it along just fine, but that engine is nothing compared with BMW's delicious twin turbo in-line six.

With a lusty 300 HP, 295 ft-lbs of torque, and a to-die-for exhaust note, this is a hallof-fame engine, and I hope it's a long time before this jewel is replaced with a threecylinder diesel hybrid or some other such nonsense. The sound and potency of this engine are quite something to experience, and I'd grab it while you can before fuel economy and emission standards take it away as they have so many normally aspirated V8s.

Despite all that horsepower, the 435i does surprisingly well at the pump, with fuel economy that the EPA estimates at 20 MPG city/30 highway. Those numbers are less than what you'll see with the turbo four-cylinder 428i, but they're still respectable and no reason to resign your Sierra Club membership.

As hinted at above, the 4-series has an almost perfect 50-50 weight distribution which helps handling. No, the 435i isn't quite as sharp as the last-gen 335i convertible that it replaced, but I'd defy anyone to take a 435i on their most challenging back road and not be impressed. Composed, confident and fast were the adjectives that came to mind when I took my test car on a spirited jaunt on a twisty back road near my home.

The 435i convertible uses a folding hardtop rather than one made of canvas, and that's a mixed blessing. A folding hardtop helps keep the cabin quiet when the top is up but takes up a lot of trunk space when the top is down.

As always, the price you pay for a 435i will depend greatly on which option packages and stand-alone features you choose, but a final tab of $55k or so seems about right. Ask Phil Hornbeak (see contact information, below) for your best BCMS price as well as other member benefits before you buy this or any other new or used car.

BMW may be following Audi's lead by changing the name of their 3-series-based coupe to the 4-series, but making that switch still makes sense and should result in more sales, which is the point. It helps that the 435i comes in coupe and convertible versions, both of which sport a delightful in-line six. If your curiosity is piqued, call Phil.

Steve 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 since 1995.

For more information on the BCMS Auto Program, call Phil Hornbeak at 3014367 or visit www.bcms.org.

visit us at www.bcms.org

41

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42 San Antonio Medicine • February 2015