San Antonio Medicine September 2014

MEDICINE SAN ANTONIO

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OCCUPATIONAL

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MEDICINE SAN ANTONIO

TA B L E O F CO N T E N T S

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SEPTEMBER 2014

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VOLUME 67 NO. 9

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

All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement

by BCMS.

Occupational Health

Are alcoholism and addiction occupational diseases for physicians?

By Neal H. Gray, MD ...................................................12

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Email: editor@bcms.org

Strategies for hearing loss prevention

By Jose E. Barrera, MD, FACS ....................................14

Hand-washing until it hurts

By E. Chad Schmidgal, MS4, and Robert Gilson, MD..16

MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org

Impairment isn’t disability

By Fred H. Olin, MD ......................................................18 COVER: Photograph courtesy E. Chad Schmidgal and Dr. Robert Gilson

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Physician as Patient Part 6: Recovery by Jay Ellis, MD ..............................................................20

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BCMS News ................................................................................................................................22

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BCMS News: A New Home for Bexar County Medical Society ..................................................10

Lifestyle: Performing Arts by Beth Bond ....................................................................................24 BCMS News ................................................................................................................................26 In the News: Health Collaborative by Dennis P. Gonzales, PhD ................................................28 HASA: The benefits of HIE accreditaion by Gijs van Oort, PhD ..........................................................30 Business of Medicine by Joseph P. Gonzales, MHA, FACHE, PMP ......................................................32 BCMS Circle of Friends Services Directory ..........................................................................................35 Book Review: “The Book Thief,” written by Markus Zusak, reviewed by Fred H. Olin, MD ........40 In the Drivers’ Seat ................................................................................................................................43 Auto Review: Nissan Versa Note by Steve Schutz, MD ........................................................................44

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BOARD OF DIRECTORS

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

DIRECTORS Josie Ann Cigarroa, MD, Member Chelsea I. Clinton, MD, Member John Robert Holcomb, MD, Member Luci Katherine Leykum, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Adam V. Ratner, 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 Luke Carroll, Medical Student Representative Cindy Comfort, BCMS Alliance President Nora Olvera Garza, MD, Board of Censors Chair Rajaram Bala, MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom

DIRECTOR OF COMMUNICATIONS Susan A. Merkner

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Diana H. Henderson, MD, Member Jeffrey J. Meffert, MD, Member Sumeru “Sam” Mehta, MD, Member Rajam S. Ramamurthy, MD, Member John C. Sparks Sr., MD, Member Chittamuru V. Surendranath, MD, Member J.J. Waller Jr., MD, Member Jason Ming Zhao, MD, Member

6 San Antonio Medicine • September 2014

BCMS NEWS

A new home for the

Bexar County Medical Society

By Benard T. Swift Jr., DO, MPH Diplomat, ABPM in Occupational Medicine N

If you’ve been a member of the BCMS for a decade or more, you’ll remember attending meetings at the old West French Place office building. Approximately 10 years ago that building was sold, the proceeds invested, and a temporary home for the society was established in the space we now occupy at the First National Bank office building on I-10.

The lease to that space will expire soon, and the proceeds from the French Place sale can’t be used for anything other than a real estate investment. So it seems that the time is right to find a permanent home.

CONSTRUCTION OF A NEW BUILDING After much research and time spent looking at raw land and existing office buildings, your board has approved a plan to enter into an earnest money contract to purchase an undeveloped 1.71-acre tract of land on Loop 1604 just to the west of Northwest Military Drive (see accompanying map) to construct what will be a 20,000-squarefoot, two-story Class A office building. The top floor (10,000 square feet) will be occupied by the medical society, and the bottom will be leased out to prospective office and/or medical tenants.

This will allow us to (1) utilize the funds sitting in a reserve account for that purpose; (2) create a permanent “home” for the society with its own identity -- we will have outside building signage; and (3) make an investment that will reap the long-term reward of eventually reducing our occupancy costs. Some of you may recall the Texas Medical Association having the foresight to undertake this very same kind of project many years ago in Austin.

10 San Antonio Medicine • September 2014

The total cost of the project is estimated to be in the $4.5 million range, though firm numbers have yet to be established. As of this writing (end of July), the 120-day due diligence period on the land has just begun, and we will firm those numbers up before fully committing to close on the land.

FINANCING Financing for the project will come from three sources: (1) cash on hand; (2) bank financing; and (3) fundraising.

In order to fulfill the last of these three components, and before starting any fundraising with our many friends in the community, your board believed it important that each member initially participate in the fundraising effort. They have, therefore, approved a $150 assessment from each member, payable in two annual installments of $75 each, the first of which will be payable with your dues statement for 2015 (the statement will go out in October 2014). The second installment of $75 will be due next year at the same time. Of course, additional sums are welcome, and we are in the process of creating a tiered system that will permanently recognize those who make significant contributions toward this important effort. More about that in the future as we develop the entire campaign.

The BCMS staff, board and executive committee have worked hard and had many discussions to allow us to get to this point. The membership’s financial and moral support are of paramount importance for us to undertake this project, and to create an identity for the society that is a symbol of our commitment to our patients and community.

OCCUPATIONAL HEALTH

Are alcoholism and addiction occupational diseases for physicians?

By Neal H. Gray, MD

The headline poses a good question. There are many overlaps that muddy the process of answering this simple question. Scientific studies in addiction are hampered by sampling errors and bias. Most of the subjects lie, and populations and incidence analysis frequently have an unknown denominator. In spite of that disclaimer, let’s look at a few examples in an attempt to understand some of the issues.

Do at-risk students preferably choose medicine? Obviously some with previous drug usage do, thinking that it would really be cool. Others make the decision to enter nursing or medicine so that they might then be able to help the crazy, unpredictable alcoholics and addicts in their dysfunctional families.

BUBBLE UP THROUGH THE SYSTEM Drinking and drugging usually begins before medical school.

A student council president at a North Side high school in San Antonio told me that probably 30 percent of students were high before first period. Some of these will bubble up through the system and become physicians in spite of their continued abuse.

Physicians probably do not have an incidence of these diseases more often than other professionals such as lawyers or politicians.

They do differ in the drugs they use, namely legal medicines from around the office or hospital, stealing from patients, forging Rx pads of partners or spouse, and thinking all the time that they are doing a good job of practicing without detection.

No specialty is immune. Family practice and internal medicine seem to have recently become the most affected probably because they often can function solo and work undetected. A physician can drink alcoholically for 10 years before being detected or the bottom falls out, but the anesthesiologist using fentanyl will come to light in about three months, if he survives. We see psychiatrists on massive doses of Valium, surgeons taking their kid’s Ritalin, OBs doing hydrocodone, or others taking their narcotic long after a surgical recovery. All of them deny their addiction, assume that 12 San Antonio Medicine • September 2014

they have control, and are too smart and good to need help. They are a danger to themselves and others.

Can they recover? Absolutely. They will need to be treated and they can return to practice better than ever. But continued aftercare, monitoring, follow-up visits, 12-step support, and family and practice encouragement are necessary. Do they need to change their specialty? No, if they are well monitored and motivated.

We all have heard people say that if you had his/her spouse, job, patients, kids or something else, you would take dope or drink like he does. Occasionally this person, recognizing a need for change, will take a spouse cure, practice cure, location cure, giving up important aspects of his life instead of treating the addiction. It never helps. We always take ourselves wherever we go.

There is a little sticker that one can put on the bathroom mirror that states, “You are looking at the problem.” It’s not the job.

Neal H. Gray, MD, is a member and past chairman of the BCMS Physician Health and Rehabilitation Committee. The 1992 president of BCMS, Dr. Gray is a retired anesthesiologist.

EDITOR’S NOTE: The BCMS Physician Health and Rehabilitation (PH&R) Committee's goal is to advocate and aid in recovery success of the impaired physician. Committee members are a confidential advocacy group of physicians that identify and facilitate recovery success for other physicians with substance use disorders (alcohol and/or drugs) and depression, through support and monitoring, using a series of meetings, discussions and other activities. Inquiries, participation, discussions, meeting information and help with related issues can be submitted to: Oliver Johnson Jr., MD, PH&R Committee Chair, at 210-313-3378 or the BCMS office at 210-301-4391.

OCCUPATIONAL HEALTH

STRATEGIES FOR HEARING LOSS PREVENTION:

Prevalence and prevention of otitis media

By Jose E. Barrera, MD, FACS Otitis media is a major cause of acquired hearing impairment worldwide, especially in developing countries. Most approaches to prevention are either unsatisfactory or very expensive and difficult. For example, microdebridement of cerumen requires specialized equipment and trained personnel. Also, the use of systemic aminoglycoside antibiotics for chronic suppurative otitis media (CSOM) Figure 1. Regional Burden of CSOM and Hearing Impairment requires long hospitalization and is pocoid material for greater than 6 weeks to 3 months. The term tentially ototoxic. Aural toilet including wicking the ear and chronic otitis media is not well defined. It may involve all types ototopical quinolones offer high effectiveness in these high-risk of otitis media that fail to resolve after an acute episode such as populations. With today’s conservative healthcare environment, persistent or recurrent middle ear effusion, otherwise classified as surgery may be impractical due to cost and lack of trained perOME. It may involve perforations that are dry (from trauma or sonnel. Cost-effective prevention is necessary. pressure changes) or those with persistent otorrhea or CSOM. Regional estimates of hearing impairment are estimated by the REGIONAL ESTIMATES World Health Organization (WHO). The Western Pacific has CSOM is commonplace in the developing world. It is the result the highest burden of hearing impairment due to CSOM with of an initial episode of AOM and is characterized by persistent Europe having the smallest (Figure 1). In total, 164 million cases discharge from the middle ear through a tympanic perforation. It of hearing impairment may be due to CSOM with 90 percent of is a cause of preventable hearing loss, but does account for 28,000 these coming from developing countries. Country prevalences deaths worldwide. were grouped based on WHO regional classification as categoEar wax is the leading cause of reversible hearing loss, followed rized during the WHO/CIBA workshop of otitis media experts

by CSOM. CSOM frequently leads to mastoiditis, brain abscess, in 1996. CSOM prevalence rates of 1 percent to 2 percent are facial nerve palsy, meningitis in high-risk populations. Large numconsidered low and 3 percent to 6 percent high (Figure 2). bers of mastoiditis complicated by brain abscess have been rePopulation-based estimates in developing nations range from ported in Bangladesh and Nepal.

0.24 percent (Thailand), 1.8 percent (Africa), 10.4 percent AOM often begins in childhood. CSOM is diagnosed in pa(South Korea). Cholesteatoma varies among regions (60 percent tients with tympanic perforations that continue to discharge mu14 San Antonio Medicine • September 2014

OCCUPATIONAL HEALTH

in South Korea, 66 percent in South Africa, 0 percent among Navajo children, 0.08 percent in Saudi Arabian children). Mastoid abscess is the most common extracranial cause of death, followed by labyrinthine fistula. Other less-frequent extracranial complications include facial weakness and profound deafness which occurred in 14.3 percent of reported cases. Meningitis is the most common intracranial cause usually presenting as fever, headache and meningeal signs.

Among patients with intracranial complications, 18.6 percent died and 28 percent had permanent facial paralysis, deafness, diplopia, epilepsy, or hemiparesis.

There is no consensus among general and specialist physicians with regard to the medical management of CSOM. However, it is generally agreed that aural toilet is a necessary part of treating CSOM. Cleaning mucoid discharge reduces infection and could facilitate middle ear penetration of ototopicals.

From the Cochrane review, aural toilet combined with antimicrobial therapy is more effective than aural toilet alone. A trial comparing clindamycin with aural toilet alone found resolution rates of 93 percent and 29 percent, respectively. Some oral antibiotics are as good as others. Similar rates of otorrhea resolution were found between cefotiam, amoxycillin-clavulanic acid, and cefuroxime. All had otorrhea resolution rates between 61 percent and 70 percent.

Figure 2. CSOM Prevalence

INCREASING GLOBAL BURDEN

polymyxin. Combined topical and systemic antibiotics are no better than topical antibiotics alone. The rates of resolution were 50 percent and 53 percent, respectively.

The increasing global burden of otitis media and hearing loss coupled with declining health services and inadequate health infrastructure make the prevention of hearing loss a difficult problem. Mobile ear clinics may provide surgical services to communities that have neither physical access nor financial capability and logistic support. Technical proficiency among primary care and ENT specialists in developing countries will contribute to the overall success in eradicating CSOM. Finally, the national health system of a particular nation must make ear care and prevention a priority.

Cochrane review found ototopicals to be more effective in resolving otorrhea and eradicating middle ear bacteria. The addition of ototopicals to aural toilet was associated with a 57 percent rate of otorrhea resolution compared to 27 percent with aural toilet alone. Topical quinolones are better than topical nonquinolones. Specifically, topical oflaxacin or ciprofloxacin were more effective than gentamycin, tobramycin, and neomycin-

Jose E. Barrera, MD, FACS, is a diplomate of the American Boards of Otolaryngology – Head and Neck Surgery, Sleep Medicine, and Facial Plastic and Reconstructive Surgery. For information on his San Antonio practice, Texas Facial Plastic Surgery and ENT, visit www.drjosebarrera.com.

References 1. WHO: Prevention of hearing impairment from chronic otitis media, report of a WHO/CIBA Foundation Workshop, London, 12-21 November 1996, WHO/PDH/98.4.

2. Eason R, Harding F, Nicholson R. Chronic supparative otitis media in Soloman Islands: a prospective microbiological, audiometric and therapeutic survey. NZ Med J, 1986;99:812-815 3. Cannoni M, Bonfils P, Sednaoui P, et al. Cefotiam hexetil versus amoxicillin/clavulanic acid for the treatment of chronic otitis media in adults.

Medicine et Mal Infect 1997;27:915-921 4. Dellamonica P, Choutet P, Lejeune JM, et al. Efficacy and safety of cefo-

tiam hexetil in the treatment of chronic otitis media. Medicine et Mal Infect 1995;25:733-739 5. Esposito S, D’Errico G, Montanaro C. Topical and oral treatment of chronic otitis media with ciprofloxacin. Arch Oto Head Neck Surg, 1990;116:557-559 6. Frandis M,Brodsky A, Ben-David J, et al. Chronic otitis media treated topically with ciprofloxacin and tobramycin. Arch Oto Head Neck Surg, 1997;123:1057-1060 7. Smith AW, Hatcher J, Mackenzie IJ, et al. Randomized control of chronic suppurative otitis media in Kenyan schoolchildren. Lancet, 1996;348:1128-1133. visit us at www.bcms.org

15

OCCUPATIONAL HEALTH

Hand-washing until it hurts!

By E. Chad Schmidgal, MS4, and Robert Gilson, MD

INTRODUCTION

PREVENTION

As healthcare providers, most of us have experienced dry, itchy and cracking skin due to frequent hand washing and sanitizing.

Hand eczema or irritant contact dermatitis (ICD) is common in occupations that involve repeated hand washing or repeated exposure of the skin to water, food materials, soaps and other irritants. High-risk occupations include cleaning, food preparation, hairdressing and nail salons, and healthcare employees. In healthcare settings requiring frequent hand washing, such as ICUs, the incidence of ICD may be as high as 55.6 percent. ICD has a significant impact on an individual’s ability to work; one study of 62 workers with hand eczema reported one-third had a greater than 10 percent drop in productivity, 35 percent had missed time at work, and 28 percent had to change jobs or were not working due to hand eczema.

Complete avoidance or greatly reducing the number of exposures to cutaneous irritants is the best method for treating and preventing irritant contact dermatitis. Decreasing the number of wet-to-dry cycles by reducing the number of times one washes their hands also will reduce the likelihood of developing ICD. Wash hands with warm, not hot, water using mild soaps such as Dove Sensitive or Cetaphil and avoiding harsh soaps such as Ivory or soaps with added fragrances.

For healthcare workers, utilizing waterless hand sanitizers is also key to preventing ICD. Ethanol-based hand sanitizers are the most practical for healthcare workers to use on a daily basis. They are cost-effective and have a low incidence of developing resistance to bacteria. One study at a French hospital comparing 16 different sanitizers concluded that Purell was the most favorable among the study participants. Whatever brand you choose, there may still be slight drying effects of ethanol on skin though they are generally less problematic than other alternatives for those with tendencies for hand eczema. Avoid allergens whenever possible; the most common hand allergens detected by patch testing as reported by the North American Contact Dermatitis Group included preservatives, metals, fragrances, topical antibiotics, and rubber additives. Due to the rising incidence of rubber or latex allergy, non-latex vinyl or nitrile gloves are better alternates. For physicians and dentists and other occupations requiring better manual dexterity, nitrile gloves are more form fitting.

PRESENTATION The typical presentation of irritant contact dermatitis is skin with erythema, scaling, thickening (lichenification), or fissuring.

The skin may have a glazed or scalded appearance. Irritant contact dermatitis is caused by skin injury, direct cytotoxic effects, or cutaneous inflammation from contact with an irritant. Symptoms can include severe itching, pain from open fissures, and may be functionally limiting or require time away from work.

ICD symptoms can occur immediately but may persist if the irritant is unrecognized and exposure continues. The effects of ICD may also be more pronounced in colder, less humid environments (“winter itch”).

FURTHER CONSIDERATIONS Allergic contact dermatitis (ACD) may present similarly to irritant contact dermatitis. Allergic contact dermatitis is a delayedtype hypersensitivity requiring previous exposure and sensitization to the allergen, whereas irritant dermatitis can occur in anyone’s skin with sufficient exposure and provocation. A dermatologist can perform patch testing when an allergen is suspected for hand dermatitis not responding to the usual measures.

16 San Antonio Medicine • September 2014

TREATMENT To treat ICD, frequent application of a bland emollient such as Vaseline or Aquaphor to irritated skin is imperative for restoring the epidermal barrier in workers with irritant contact dermatitis.

For more severe cases, a dermatologist can prescribe moderatestrength topical steroids. The most severe cases may even need a course of oral steroids. Patch testing for the refractory cases can identify potential allergens for those with allergen contact dermatitis. Identifying the irritants and/or allergens, and preventing the repeated exposure, remains the penultimate treatment.

OCCUPATIONAL HEALTH COMPLICATIONS Pruritus and scratching already compromised skin can further damage the skin barrier and predispose to staphylococcal infection. The skin may then exhibit signs of infection such as crusting, weeping and purulence. Though crusting and weeping may be related to the underlying inflammation itself, antibiotic treatment may be indicated for secondarily impetiginized dermatitis. With compromise of our skin barrier, herpetic infections (herpetic whitlow) can also occur more frequently, especially in healthcare workers. Tinea manus should also be included in the differential diagnosis of scaly eczematous hands.

Hand Eczema — Fast Facts: • Wash hands when necessary with warm, not hot, water and gentle cleansers.

• Utilize waterless hand sanitizers to decrease hand washing frequency.

• Use gloves to avoid contact with irritants and known allergens.

• Treat damaged skin with emollients (Vaseline® or Aquaphor®).

• Visit your dermatologist if hand eczema persists.

CONCLUSION In summary, protect your hands as much as you can from the elements they contact daily. Your hands remain your tools to heal, and they must be kept healthy to continue to do good works in your profession as physicians.

E. Chad Schmidgal is a fourth-year medical student at the University of Texas Health Science Center San Antonio. He is pursuing a career as a U.S. Navy dermatologist and began his training as a transitional intern at the Navy Medical Center San Diego in July.

Robert Gilson, MD, is a board-certified dermatologist and associate professor at the University of Texas Health Science Center San Antonio. Dr. Gilson is a BCMS member. visit us at www.bcms.org

17

OCCUPATIONAL HEALTH

Impairment isn’t disability

By Fred H. Olin, MD

Any physician who takes care of people who are injured or

Here in Texas we are obligated by legislative action to use the

made ill by workplace events or in accidents may be asked to

4th edition of the Guides, which was first published in 1993,

express an opinion about the patient’s “disability” as a result of

to determine impairment. Since then there have been two more

whatever occurred. As in those recent TV truck commercials

editions produced, each of which has had significant changes

telling you what to do if asked for a down payment, DON’T

in methodology. In my opinion, each new edition has im-

DO IT! Here’s why:

proved on the process of arriving at an appropriate level of impairment to submit to whatever authority has requested the

DESIGNATED DOCTOR

evaluation. But, the Texas Legislature and Department of In-

As the headline here states, “impairment” is not “disability.”

Some years ago I took a course to become a Texas “Designated

surance being what they are, I wouldn’t expect them to allow us to update any time soon.

Doctor” so that I could do impairment examinations. The in-

Even if you aren’t a “Designated Doctor” for the state, it is

structor used an example something like this: “Pretend that you

possible that you could be asked to come up with a numerical

are two people: one of you is a professional basketball player;

impairment rating by an attorney or an insurance company. It’s

the other you is a receptionist who hardly ever has to get out

not hard: what you need is a copy of the 4th edition of the

of her chair while working. Both of your avatars sustain a se-

Guides, the ability to read, and a copy machine. The copier is

rious fracture around the ankle that results in a fusion of the

particularly useful in the musculoskeletal section, which makes

ankle and subtalar joint, so you have essentially no motion

up about half of the book, as there are forms there that, if filled

below the knee. Both of you would have the same percentage

out carefully, will essentially automate the rating process.

of impairment according to the AMA Guides to the Evaluation of Permanent Impairment (hereafter “the Guides”), but he

APPROPRIATE RATING

would be 100 percent disabled from his job, while she would

Writing the report is essentially doing what we were all taught

have minimal or no disability in relation to her job.” Another

in medical school: document a history of the current problem,

point made in the Guides is that impairment is “… an alter-

the patient’s current complaints, and the findings of a careful,

ation of an individual’s health status,” and that disability is “…

appropriately limited physical examination. Then, referring to

an alteration of an individual’s capacity to meet personal, social,

the Guides, come up with an appropriate rating. When you

or occupational demands … because of an impairment.” An-

do this, you become responsible to several individuals and en-

other sort of shorthand way to look at the difference is that im-

tities.

pairment

is

a

medical

term

administrative/legal term.

18 San Antonio Medicine • September 2014

and

disability

is

an

First and foremost, you are responsible to the patient who, assuming that there are residual problems from the incident in

OCCUPATIONAL HEALTH

question, deserves an accurate evaluation.

states for a company that services claims adjusters who question

Secondly, you are obligated to the requesting authority to

the validity of an impairment rating. While many of these re-

give them an impairment rating that neither overstates nor un-

ports are well done, I never cease to be amazed and appalled by

derstates the problem. Overestimating the impairment can cost

the lack of attention to detail combined with arrogance of some

an insurance company money that they shouldn't have to pay

examiners. You can’t just snatch a number out of the air because

out, or induce an attorney to take action not truly in his client’s

you like or dislike the patient.

best interests. Underestimating has the obvious risk of possibly

It’s really not hard to write a report that will treat all parties

preventing the injured party from receiving appropriate com-

fairly. It requires a bit of study, and perhaps taking a course on

pensation, as well as perhaps causing unnecessary repeated re-

the subject that deals with whatever edition of the Guides you’re

quests for re-evaluation.

using. Then you’ll be ready to do an efficient job.

Next, there is an obligation to the potential payors to detect malingering and the potential for fraud. A gentle suggestion

Fred H. Olin, MD, is a semi-retired or-

in the report that further observation of the patient in non-

thopaedic surgeon who was one of the physician

clinical settings might have value gets the message across. Of

reviewers of the AMA Guides to the Evaluation

course, use of such terms as “fraudulent” or “malingering” could

of Permanent Impairment , 6th edition. He is

open you up to problems.

chairman of the BCMS Communications/Publi-

I have a side gig examining impairment reports from several

cations Committee.

visit us at www.bcms.org

19

PHYSICIAN AS PATIENT

Physician as Patient

EDITOR’S NOTE: This is the sixth in a series of articles written by San Antonio anesthesiologist Jay Ellis, MD, a member of the BCMS Communications/Publications Committee. The series, published monthly in San Antonio Medicine, examines the physical, emotional, financial and spiritual burden of lifethreatening illness

Recovery

By Jay Ellis, MD

After I left the hospital, I returned home a feeble, debilitated man. For the first time in my life I had to face the possibility that I might be permanently impaired.

I also worried that I might not be strong enough to tolerate any more chemotherapy. I had already missed one session, and Dr. Greg Guzley told me it would be at least a week before he would even think about letting me attempt another treatment. I could not climb a flight of stairs. I could barely make it around the backyard.

Greg gave me specific instructions before I left the hospital.

I would do nothing more strenuous than walk a mile on Dr. Greg Guzley discusses my treatment plan. I credit him with saving my life. level ground at no more than a 15-minute-mile pace. At that moment, 15-minute miles seemed the equivalent of running a pound dumbbells which in my impaired condition felt like the marathon. I would have to stay home. If I were to go out in a Olympic weightlifter workout. That would take me to lunch crowd and get the flu, I would not survive the event. time, and I had the rest of the day to kill. It was so boring. It My life assumed a very dull existence. I would get up in the truly was house arrest without the ankle bracelet. morning and read three newspapers. I would go and try to take On my first attempt at walking away from the house Merrill my walk hoping to see signs of improvement. Greg also allowed needed to run some errands, and I went on my own. She gave me to lift with light weights, and I used my wife Merrill's 12me strict instructions to be careful, but I decided I would get 20 San Antonio Medicine • September 2014

PHYSICIAN AS PATIENT

out there and push it. After all, no pain, no gain, right? I took my pulse oximeter with me and found that if I walked a steady, measured pace I could keep my saturation above 90 percent, but just barely. I made it six-tenths of a mile and turned to go up a slight hill that I had run hundreds of times before. After about 10 yards, my oxygen saturation hit 85 percent, my heart rate was 120, and I was feeling very lightheaded. I quickly bent over and put my head between my legs. I have no idea what the traffic passing by thought of this strange posture, but after a few minutes I rallied enough energy to turn for home. I walked 1.2 miles, it took me over 30 minutes, and I was exhausted. Merrill returned home to see me collapsed on the couch. She didn’t say a word, but she never let me walk alone again.

CATCHING MY BREATH These are just a few of the nurses from Cancer Care Centers of South Texas who guided me It was humbling to walk with Merrill. through my chemotherapy.

She has always been an avid walker, moving at a brisk pace that challenges I went out to clean the pool and when I came in I realized that most people. In my recovering state I could not keep up with my wedding band fell off my skinny, emaciated finger. I her. I would put my pulse oximeter on and watch as I struggled searched the pool, the yard and the filter equipment without to keep my heart rate under 120 and my saturation greater than success. I was heartsick, but Merrill told me to stop fretting.

90 percent. If we walked up any sort of incline, I would have The monotony of my existence was broken by good friends. to stop and catch my breath – or just pass out, which did not Ed Rashid came by and brought me some books and movies to seem as appealing. I let her borrow the pulse oximeter for a watch, as well as a delicious cake. Friends sent notes, email and while just to check her heart rate and oxygen saturation. The called. Merrill stood guard at the front door and anyone with normality of her readings was a stark contrast to my physiologic the appearance of illness was given a polite shove toward the infirmity. It only reaffirmed how impaired the pneumocystis street. I made vain attempts to escape. I told her I thought I pneumonia left me. might go to the gym and she responded, “How many sick peoDespite a difficult start, I did see signs of progress. We monple use that exercise equipment?” I thought we might go to itored our pace with a free app on my iPhone, and my pace per church and sit off by ourselves, and she reminded me how mile went from over 20 minutes a mile to under 18 minutes. I many people we heard cough when we watched services online. was hoping this would be enough to let me resume my She was an effective and diplomatic warden. chemotherapy. When I saw Greg for my next appointment, he I decided I would use my month of enforced confinement as concurred that I could start treatment again. It was a great rean opportunity for self-improvement and did some online lief, at least until the next day. In my debilitated state the CME. I continued to read three newspapers every day, and I chemotherapy hit even harder. I couldn't even go for a walk. I considered myself the world's expert on current events for the did rally, and Merrill and I continued our daily walks. I tried month of January 2014. Each day seemed to get a little better. to do light chores around the house to make myself feel useful.

Continued on page 22 visit us at www.bcms.org

21

PHYSICIAN AS PATIENT Continued from page 21 My ability to lift weights improved, and I was even able to start doing push-ups again. I would take great pride in my little victories. I began to have some hope that I would recover from this near-life-ending event.

Just before my fifth chemotherapy, I went for my fourth CT scan. After the study Dr. Michael Lane was again good enough to review the results with me. My lungs were dramatically improved, but even more heartening was the effect of chemotherapy. The abdominal mass, the lymphadenopathy, even the splenic changes were undetectable. The results of the chemotherapy after just four treatments were dramatic. I was euphoric.

IMPROVEMENT WAS POSSIBLE Merrill and I began to push my daily walks even farther. By the end of January, we were able to walk 3 1/2 miles at just under 16 minutes a mile. I felt like Roger Bannister breaking the fourminute mile. I was certainly exhausted after I performed this otherwise mundane feat, but it gave me hope that greater improvement was possible.

I returned for my fifth chemotherapy and got even better news.

My hemoglobin, which had been under nine for most of the course of my illness, was now over 11. No wonder I felt better. Greg allowed me to return to work half-time. It was great to be back in the office and working, even on a reduced schedule. I was able to start going to Spurs games again and to go out to dinner. Prior to this Merrill and my mother were my primary connections to the outside world. It was great to feel part of society again.

I finished my sixth chemotherapy and began counting the days until the ultimate test, my PET scan. I received a list of preoperative instructions for the PET scan. It rivaled the user's manual for your car. No heavy exercise 24-48 hours, no sweeteners or artificial sweeteners for 24 hours, high-protein, low-carb meal the night before. No eating for eight hours prior to the procedure. I showed up on the day of the procedure and received my injection from the steel container containing the radionuclide, while sitting inside the metal-walled room. I felt like a toxic fund cleanup site. The scan takes 20 to 30 minutes, but by this time I was so used to the CT scanner that I fell asleep during the procedure. I was hoping to be able to review the results as I had with previous studies, but didn't get the opportunity this time. I promptly went home and pulled the results up on my computer. Me reading a PET scan is second only to me trying to read Sanskrit. I did know that bright activity outside my kidneys was not good. There was only one tiny spot outside my kidneys that lit up, and it was in my lung. I was confident that this was nothing more than residual effects of my pneumonia, and it was just a matter of time until Greg called me 22 San Antonio Medicine • September 2014

Race day, May 19, 2014. To be so close to death and disability just four months ago and to feel so well today feels like a miracle. Courtesy photos

to tell me that I was in remission. It seemed miraculous.

Unfortunately, when Greg called it wasn't quite what I expected.

He did confirm that there was a spot in my lung. However, there would be no way to determine whether this was lymphoma or residual pneumonia without a biopsy. I would need CT scan number six and a needle-directed biopsy to answer the question. OK, I can do this. I believed it to be merely a formality, but if it would save me from more chemotherapy I would let them stick a needle between my eyes. Dr. Beatriz Escobar did my biopsy, and it went smoothly. I began waiting for the results. I would log into the Meditech system and check my results each day waiting to see the report. It took days, but it seemed like eternity. Greg allowed me to go back to work full time since I felt so well. I was even beginning to run again, though anyone watching me would have a hard time calling it running, considering my pace was hardly better than 12 minutes a mile.

Finally, at the end of a Wednesday, just as I finished my cases, Greg called. The results were in. There was no lymphoma on the biopsy, and I was in remission. As Greg would say later, I wasn't cured, but I had made the first cut. I immediately called Merrill and my Mom to share the news. I tried to stand up, but I couldn't.

My entire body went limp. I believed I was handling all this pres-

PHYSICIAN AS PATIENT sure so well. I then realized that once I had the definite answer, a wave of relief swept over me, and I was free from the stress of not knowing. The subconscious burden had sapped my energy, and I was now exhausted. I sat in the doctor's lounge at MSTH for 15 minutes surprisingly all alone, until I was finally able to move. I went home and hugged Merrill.

RUNNING A RELAY I met with Greg a week later, and we discussed my new plan.

There was a new protocol that might increase my chances of survival by 50 percent. I would start on rituximab every other month for two years. If there was no recurrence, I would be done. This seemed like a piece of cake. Get one drug every other month instead of five drugs every three weeks? I can do that standing on my head.

My hemoglobin was now over 12, and I felt better than I had in months. My running partner Bob Johnson and I decided to see if I could run 3 miles. If I could, I would run an entire leg of the Beach to Bay Relay, an annual event I did with five of my friends each year for the past 18 years. I had signed us up in October, but didn’t know if I would be alive on race day and had little hope that

I would be running. If things went well, I hoped I could come to the race and cheer. I started running with Bob, but it did not begin well. I would run for 100 paces, walk for 100 paces, gasping for breath. Slowly but surely we were able to improve the pace. OK, we improved my pace. Bob, as ex-triathlete, wasn’t even winded.

On May 19, 2014, 136 days after I left the hospital and supplemental oxygen and 89 days after my last chemotherapy, Bob stood next to me as I lined up for the start of the race. It was an unbelievably cool day for this race. It wasn't over 70 degrees, and I can't remember better race day weather. If there was ever a day when I was going to be able to make it, this would be the day. All I wanted to do was finish without walking. Despite the cool weather, there was a 30-mile-per-hour head wind blowing sand in my face. Actually, it was a blessing. It kept me from thinking about how much my legs hurt. I finished my leg, 3.5 miles, in just over 37 minutes.

It seemed like a miracle. After being so sick I was back running again, albeit slowly. In January, I thought I would never run again.

In October and again in December, I wasn’t sure that I was going to live. Now I was doing both.

NEXT: What I learned.

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23

LIFESTYLE

Performing Arts in San Antonio

By Beth Bond

TOBIN CENTER FOR THE PERFORMING ARTS This performance space has been several years and $203 million in the making, and it’s finally opening! On Sept. 4, for the first time ever, Ballet San Antonio, Opera San Antonio and members of the San Antonio Symphony will perform together on the HE-B Performance Hall stage as the resident companies of the Tobin Center for the Performing Arts.

Don’t miss guitar great Carlos Santana on Sept. 30. Then get ready for two Beatles in one month! Paul McCartney will perform a benefit concert Oct. 1, topping off a monthlong grand-opening celebration for the new performing arts center in the heart of downtown. In his first San Antonio appearance since 1993, McCartney and his band will perform as a fundraising event for the new venue. Ringo Starr With His All Starr Band will perform favorites on Oct. 7. The Tobin Center hosts An Intimate Evening With Art Garfunkel, an acoustic performance with songs, anecdotes, prose and a unique audience Q&A session, on Oct. 9.

24 San Antonio Medicine • September 2014

The next few months promise spectacular dance, musical and theatrical performances in San Antonio.

Get your tickets now for the 2014-15 season!

BALLET SAN ANTONIO Ballet San Antonio’s 2014-15 season begins Oct. 16-19 with the critically acclaimed Dracula, artistic director Gabriel Zertuche’s take on the legendary count’s nocturnal escapades. The Nutcracker, featuring local children and live music by the San Antonio Symphony, kicks off the holidays Nov. 28-Dec. 7.

Award-winning choreographer Ben Stevenson returns to San Antonio to stage Romeo and Juliet in time for Valentine’s Day weekend, Feb. 12-15. The Shakespearean tale of forbidden love will feature sets and costumes from Houston Ballet and Prokofiev’s famed score performed live by the San Antonio Symphony.

The company will round out its season March 27-29 with Balanchine, an evening of contemporary works that spotlights Donizetti Variations by famed choreographer George Balanchine.

Season tickets for all four Ballet San Antonio performances at the Tobin are available through Oct. 1. Prices start at $99. Call 210-223-8624 or tickets@tobincenter.org.

For more detailed information about the performances, visit balletsanantonio.org.

SAN ANTONIO SYMPHONY Not only will this be the San Antonio Symphony’s first season in the new Tobin Center, it’s also the symphony’s 75th anniversary season, and part of the celebration involves the work of composers from Germany, France, Mexico and beyond.

“For each one of our classic concerts, we have commissioned a composer to write a short, three- to four-minute prelude to announce the opening of the Tobin Center and the 75th anniversary,” said president David Gross.

Kicking off the celebratory season on Sept. 20 is a gala evening with soprano Renée Fleming, who sang for many years with the Metropolitan Opera. She also sang the national anthem at this year’s Super Bowl.

“The game-changer with the Tobin Center is that the performance hall was built with considerations so that the orchestra is presented in the best acoustical environ-

LIFESTYLE

Above: Tobin Center for the Performing Arts, river view at night. Left: Soprano Renée Fleming will kick off the celebratory season of the San Antonio Symphony.

Courtesy photos

ment,” Gross said. “The Tobin Center is built on the site of the old Municipal Auditorium. They left the facade, scooped out the interior and rebuilt the whole thing.

The space was excavated down to the river so that people can have dinner on the River Walk, then take a river taxi from the restaurants.”

Celebrate the holidays with associate conductor Akiko Fujimoto for Holiday Pops (Dec. 19-21), a magical celebration of the season complete with a singalong, special guests and a program featuring traditional and popular music.

Experience the music and excitement of one of the world’s most popular and best-selling ABBA show bands, Arrival from Sweden, with The Music Of ABBA, March 6-8.

The annual Fiesta Pops concert (April 17-19) features the music, dance and culture of San Antonio and South Texas.

Enjoy the beautiful sounds of Campanas de America and a colorful corps of dancers with the Guadalupe Dance Company. The program is sure to get guests into the Fiesta spirit.

The symphony’s former home was the Majestic Theatre, which will continue to host the symphony for a series called Symphony Goes to the Movies, in which films will be accompanied by live soundtrack performances. Check out Star Trek Into Darkness on Oct. 17-18 and Bugs Bunny Goes to the Symphony on April 3-4.

MAJESTIC THEATER The historic Art Deco movie house converted to a live performance space will host classic Broadway and blockbuster hits this season. The 2014-15 season of North Park Lexus Broadway in San Antonio features six show-stopping productions, two market debuts and three season options.

The season opens with passionate romance and an electric stage adaption of Dirty Dancing (Nov. 4-9), followed by an extended run of Disney's phenomenal production of The Lion King (Dec. 10-Jan. 4).

Then Chicago (Jan. 27-Feb. 1) kicks off the new year with everything that makes Broadway great: a universal tale of fame, fortune and all that jazz. Winner of eight

Tony Awards including best musical, Once will captivate audiences March 3-8 with its powerful music and an enchanting tale of a Dublin street musician. Leapin’ lizards!

Broadway’s best-loved musical Annie returns to town April 14-19, followed May 12-17 by the smash hit, crowd-pleasing musical from Disney, Newsies, winner of the 2012 Tony Awards for best score and best choreography.

Three season options give Broadway fans more choices than ever before. Subscribers can add these shows to their season package.

The eye-popping spectacle Disney’s Beauty and the Beast (Sept. 30-Oct. 5), presented

by NETworks, features unforgettable characters and dazzling production numbers.

Blue Man Group, best known for their wildly popular theatrical shows and concerts, returns March 24-29 to combine comedy, music and technology to produce a totally unique form of entertainment.

Then, have the time of your life at Mamma Mia! (June 9-14), the ultimate feel-good show that has audiences returning again and again to hear ABBA's greatest hits. visit us at www.bcms.org

25

BCMS NEWS

Dr. Jayesh Shah wraps up year as

AAPI president

The American Association of Physicians of Indian Origin (AAPI) held its 32nd annual convention in San Antonio June 25-29. Dr. Jayesh Shah concluded his year as president by orchestrating a plan to bring the national AAPI convention to San Antonio for the first time. The convention was filled with numerous speakers, entertainers and celebrities from the United States and India. Among the notables attending the convention was India's Hon. Minister of Health and Family Welfare, Dr. Harsh Vardhan, who delivered a presentation of the work he and other leaders are doing in collaboDr. Vijay Koli (second from left) was thanked for his work as AAPI convention chairman June 28 by AAPI President Dr. Jayesh Shah, Himalchal Pradesh Health Minister Kaul Singh, and Medical Council of India Chairwoman Dr. Jayshree Mehta.

ration with 24 countries to improve the healthcare climate and access to care in India.

The convention included the organization's inaugural "Be Fit. Be Cool" walk, with the focus of combating obesity. On hand for the opening ceremony and walk were the 2014 Miss America, Nina Davuluri, the first Indian American to be chosen as Miss America, and Sendhil Ramamurthy, an American actor known for his roles in Heroes and Covert Affairs; he is the son of Drs. Somayaji and Rajam Ramamurthy.

For the first time in its history, AAPI, through a philanthropic endowment created by San Antonio plastic surgeon Dr. Rajaram Bala, announced the newly established Dr. Rajaram Bala Endow-

India's Hon. Minister of Health and Family Welfare Dr. Harsh Vardhan (center) is presented a plaque June 28 for his leadership in working to improve access to care in India.

ment Award for Research. The four winners, who were chosen during the 2014 Global Healthcare Summit’s first-ever research and poster contest held in India in January, were announced during the San Antonio convention.

"I want to thank the Bexar County Medical Society and its members for their strong support in hosting the AAPI national convention in San Antonio,” said Dr. Shah. “I appreciate the hard work and commitment by all my colleagues who helped plan and execute a successful convention culminating my year as president of AAPI. Also, I want to thank the BCMS Alliance for their support and participation in the AAPI inaugural ‘Be Fit. Be Cool’ walk."

The 2014 reigning Miss America Nina Davuluri speaks about her personal journey with diabetes during the inaugural ‘Be Fit. Be Cool’ walk June 28.

26 San Antonio Medicine • September 2014

For

more

information,

mary.nava@bcms.org.

contact

Mary

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BCMS NEWS

Lecture planned on ancient health: Financial aid sought Dr. Alain Touwaide will present a lecture on “The Archaeology of Health in the Ancient Mediterranean World� at 7:30 p.m. Oct. 20 in Chapman Hall at Trinity University. The event is free and open to the public.

Dr. Touwaide is a science historian who specializes in the history of medicinal plants in the cultures that flourished around the Mediterranean Sea from antiquity to the 17th century CE. His lecture is sponsored by the Southwest Texas Archeological Society (SWTAS), a branch of the Archeological Institute of America.

Financial support is being sought to cover the approximate cost of $2,000 for expenses. Contributions of all sizes are appreciated by the SWTAS, which is a 501(c)(3) organization. Contributions can be sent to AIA SWTAS. The check should be mailed to: Laura Childs, 2858 Burning Log, San Antonio, TX 78247. The check should stipulate Touwaide Lecture.

SAVE THE DATE Sept. 18: BCMS Foundation Golf Tour-

nament, Quarry Golf Club. Register at www.bcms.org.

Dr. Alain Touwaide digitizes information on medicinal plants from ancient herbals.

Courtesy photo

Dr. Wulfsohn Honored Acuity Hospital of South Texas named its board room after anesthesiologist Dr. Norman L. Wulfsohn on July 18. Dr. Wulfsohn, a BCMS life member, was honored for his years of service to the hospital, patients and the South Texas community as a physician, author and educator.

Sept. 24: BCMS Fall General Membership Meeting, Hilton at the Airport.

CME and legislative updates.

Register at www.bcms.org.

Sept. 28: Siclovia, Alamo Plaza. www.siclovia.org.

Oct. 9-10: Texas Health Literacy Conference, La Quinta Inn and Suites Medical Center. www.healthcollaborative.net.

Oct. 16: BCMS Auto Show, BCMS office parking lot. Buffet and cocktails; new model vehicles; family and friends welcome.

(From left) Dr. Francisco Gonzalez-Scarano, Dr. Roberto San Martin, Dr. David Malave, Dr. Norman Wulfsohn, and Kris Karns, CEO Acuity Hospital of South Texas. Courtesy photo

visit us at www.bcms.org

27

IN THE NEWS

2014 Bexar County Community Health Improvement Plan offers opportunity for physicians to get involved

By Dennis P. Gonzales, PhD

the Sisters of Charity in 1866 to even more people. It will help us Measureable goals and strategies to continue improving the health lift up the least among us — those without access to healthcare for status of San Antonio and Bexar County were unveiled recently a variety of reasons — to make healthcare better for all. when the Health Collaborative released the 2014 Bexar County To survive and thrive we must change our focus, transforming Community Health Improvement Plan. our system from “sick care” to prevention and wellness. Physicians The Health Collaborative is a powerful network of citizens, comare key partners in this effort, and munity organizations and busiwe welcome your participation nesses addressing the health needs Community health improvement plan and input. of San Antonio and Bexar County. focus areas and goals are: The Health Collaborative hosted HEALTHY EATING AND ACTIVE LIVING For each area, the community the health improvement plan Goal: Foster systemic and social change to support eqhealth improvement plan provides process, which included a commuuity in healthy eating, active living and wellness health determinants, objectives, nity health assessment and planto enable all community members to make targets, strategies and partners/rening effort conducted over 24 healthy choices and lead healthy lives. sources with time frames. months with 85 agency partners HEALTHY CHILD AND FAMILY DEVELOPMENT and community stakeholders, inGoal: Promote access and utilization of preventive We encourage you to review cluding Metro Health and healthcare across the lifespan to improve healthy the plan at www.healthcollaboraSA2020. child and family development. tive.net. Use it to identify barriThe plan serves as a vision for ers that you and your patients the health of the community and SAFE COMMUNITIES Goal: Develop community-defined safe neighborhoods face, and share it with your cola framework for organizations to by identifying and implementing local and global leagues. But most of all, use it as use in making that vision a reality. best practices through community empowera vehicle to become part of the efFrom my perspective, embracing ment. fort to improve community and advancing the plan is the best health. way we can improve the health staBEHAVIORAL AND MENTAL WELLNESS Goal: Improve and expand a comprehensive, integrated tus of the community in a signifibehavioral health system to provide holistic servDennis P. Gonzacant and measurable way. ices with access for all. les, PhD, is a board As a board member of the member for the Health Collaborative and regional SEXUAL HEALTH Health Collaboravice president for San Antonio’s Goal: Ensure all Bexar County community members of any sexual orientation or gender identification tive and regional oldest faith-based healthcare syshave access to culturally appropriate education vice president, mistem, I believe the community and resources to promote sexual health. sion integration, at CHRISTUS health improvement plan extends Santa Rosa Health System. the healing ministry established by 28 San Antonio Medicine • September 2014

HASA

The benefits of HIE accreditation

By Cijs van Oort, PhD Concerns about patient safety and privacy are nowhere more telling than in the area of exchanging patient information. The public has been clear that it appreciates the convenience of having information available at the doctor’s office at the time of a visit. At the same time, there remains a level of paranoia that this highly personal information can fall into the hands of marketers, insurance companies or “devil of all” – the government.

Organizations which have taken on the task of managing patient information among providers are ultimately aware of those seemingly contrasting interests. Healthcare Access San Antonio (HASA), a regional nonprofit health information exchange, has been tasked to aggregate patient information from hospital EMRs, physician EMRs, labs and pharmacies, and aggregate those disparate data sources into single patient records, for physicians and other providers to use at the time a patient seeks care. As a new organization in a new dynamic of healthcare, HASA has needed to establish itself as a trusted source to providers. Submitting to a rigorous independent assessment was one way to accomplish that. HASA thus became a first participant in the state-endorsed EHNAC certification. As of July 10, HASA now is the first Health Information Exchange or-

30 San Antonio Medicine • September 2014

ganization in Texas – and the fourth in the nation – to have successfully completed that process and be fully accredited.

The intent of an accreditation – identical to the process hospitals, health clinics, and physician clinics are going through – is to ensure that daily practices for exchanging personal health information (PHI) follow national and state guidelines and laws. The accreditation process provides a mandate to objectively evaluate how well an organization operates within those. HASA, as a new entity offering new services, verified several important processes and filled multiple gaps in processes that were incomplete.

While the process covered three months and involved many hours of work, the endpoint is that HASA now can be a trusted utility for providers who need patient information in real time. Given that HASA’s role is an aggregator, complete records cannot be guaranteed, but the way in which this information is stored, indexed and transferred can assure HASA users that federal and state guidelines are adhered to.

Gijs van Oort, PhD, is the executive director of Healthcare Access San Antonio; www.hasatx.org.

visit us at www.bcms.org

31

BUSINESS OF MEDICINE

Physician ownership, conflicts of interest and medical practice: Do they make an impact on patient outcomes?

By Joseph P. Gonzales, MHA, FACHE, PMP

I received the following message from the BCMS Communications/Publications Committee: “Many physicians now own all or part of a profit-making business, such as a pharmacy, lab, imaging center, rehab facility, selling back braces in their office, etc. Many physicians say they can’t make enough income ‘just seeing patients’ and have branched out to these other businesses. Is there research available on how owning these businesses might impact the doctors’ decisionmaking (i.e., do they order more tests at their own facilities?) Is there any evidence of impact on their patients’ outcomes?” My article is an attempt to shed some light on this topic.

INTRODUCTION I hesitated to agree to address this issue because it is sort of like the saying, “Beauty is in the eye of the beholder.” There are studies that address various aspects of this issue, and like many other healthcare issues, if you look hard enough you can find a study that supports your side. My purpose for this article is not to provide a definitive answer, but to give the reader a framework that identifies various aspects related to physician ownership and perceptions that exist. My main references for this article are the Institute of Medicine’s “Conflict of Interest in Medical Research, Education, and Practice,” published by the National Academies Press, Washington, D.C., 2009, and “Physician Ownership in Hospitals and Outpatient Facilities,” Center for Healthcare Research and Transformation, by Nancy Baum and Emily Ehrlich, July 2013.

32 San Antonio Medicine • September 2014

RELATED FACTS There are federal laws that generally prohibit physicians from referring Medicare and Medicaid patients to facilities in which the physicians have financial ownership. There are many similar state laws that restrict referral of privately insured patients, but despite these facts, physician ownership in specialty hospitals and outpatient facilities grew rapidly in the past decade. Today there are more than 235 physician-owned specialty hospitals nationwide, and a 2008 national survey found that one in six physicians owned or leased advanced imaging equipment, and nearly one in seven owned or leased three or more types of medical equipment.

Historically, the attempt to regulate self-referral resulted in the passage of a series of laws beginning in 1989 with the Stark Law. As far as a definition: “When physicians refer patients to facilities in which they have ownership (“self-referral”), the physicians receive payment for their professional services and share in the profits of the facilities they own.” In March 2010 the passage of the Patient Protection and Affordable Care Act (PPACA) curtailed growth in physician ownership by effectively prohibiting both the creation of new and the expansion of existing physician-owned hospitals and outpatient facilities after March 2010. As with most issues there are two sides to this issue: the advocates of physician ownership and the American Medical Association, among others, support efforts to repeal this new ban; and the American Hospital Association and other hospital groups oppose the repeal efforts.

BUSINESS OF MEDICINE THE BASIC QUESTION Many from each side of the political spectrum suggest that ownership arrangements between facilities and physicians and the resulting self-referrals create an inherent conflict of interest since physicians directly benefit financially from the services provided by these facilities. So is there evidence concerning the impact of physician ownership on costs, quality, and access to care? Various studies have examined the direct and indirect effects of physician-owned facilities on use of services, access, patient mix, and quality of services. Most of the research deals with utilization of services, and less is known about the quality of services that are provided.

A LOOK AT COSTS, UTILIZATION Costs are a function of the volume, price and efficiency with which services are provided, regardless of physician ownership.

Studies have found that the volume of services provided is higher in areas with physician-owned specialty hospitals than in areas without such hospitals. One example of this is that a 2007 study

by Mitchell found that rates of complex spinal fusion surgery and epidural procedures for workers with back injuries increased significantly as physician ownership increased from 1999 to 2004.

The same study found that rates of complex spinal fusion surgery were higher for Medicare beneficiaries living in areas with physician-owned hospitals compared to areas without physician ownership. Two other studies in 2006 reported similar growth in utilization in areas after specialty cardiac hospitals opened compared to cardiac programs in general hospitals.

A study by Hollingsworth et al. (2010) analyzed the volume of services provided in ambulatory surgical centers (ASCs) in Florida from 2003 to 2005. This study reported greater use of five common outpatient procedures in physician-owned ambulatory surgical centers compared to non-physician-owned ASCs. This study also reflected that with the accounting for baseline differences in volume, surgeons who acquired ownership in ASCs increased their volume of services compared to before they held ownership.

A study by Baker (2010) shows that the growth in the volume of advanced imaging services is also positively associated with physician ownership. It appeared that once they purchased or leased MRI equipment, they ordered more scans for their patients than they had before they owned or leased the equipment. The same study showed that total Medicare spending per patient increased once physicians owned or leased the equipment. A national random sample of physicians surveyed revealed that non-radiologists with imaging facilities on-site had rates of utilization 1.2-1.7 times as high, depending on specialty, as those without such facilities. Medpac reports in 2005 and 2006 also compared discharge costs for inpatient services delivered to

Medicare beneficiaries in specialty hospitals compared to those in community hospitals. Specialty orthopaedic hospitals had higher costs per discharge than community hospitals.

ACCESS Discussion associated with self-referral is the expectation that referrals for services within a physician’s practice or in another facility in which a physician has ownership may provide patients with convenient, same-day, or one-stop access to services. Studies found that same-day referral was quite low for advanced imaging services. A 2010 study by Sunshine and Bhargavan found that Medicare beneficiaries received same-day service for 74 percent of X-rays but only 15 percent of CTs and MRIs. A 2010 Medpac report found that less than half of advanced imaging services were performed on the same day as office visits for Medicare beneficiaries.

Another aspect of “access” has to do with the availability of emergency room beds. This is particularly of interest given the tendency of individuals (even with insurance) to seek care in the hospital’s emergency department versus seeking care in their physician’s office.

A 2008 report by the Office of the Inspector General of the U.S. Department of Health and Human Services found that just over half of physician-owned specialty hospitals had an emergency department, and more than half of those had only one emergency bed. Most studies support that specialty hospitals were much less likely to have emergency departments than community hospitals (45 percent of specialty hospitals compared to 92 percent of general community hospitals, 2003 GAO report).

PATIENT MIX, COMPETITION, QUALITY A study by Hollingsworth and colleagues noted statistically significantly lower severity in patients treated in physician-owned ASCs in Florida compared to patients treated in facilities not owned by physicians, although absolute differences were small. Another study looked at practices in Arizona, and physician-owners treated proportionately more “minor” surgical cases compared to non-owners, and treated fewer “moderate” or “major” surgical cases. Consistent with other studies, a GAO study found that specialty hospitals treated a lower percentage of patients who were severely ill than did the general hospitals.

A study by Gabel found that physicians who owned ASCs were more likely to refer patients covered by Medicaid to community hospitals, and more likely to refer privately insured patients to the facilities they owned.

It may be assumed that quality of care may be greater in specialty hospitals because of the narrow focus on a limited set of procedures, but few studies assess quality of care in addition to patient mix. One study by Cram and colleagues analyzed claims data to Continued on page 34 visit us at www.bcms.org

33

BUSINESS OF MEDICINE Continued from page 33 evaluate outcomes from major joint replacement surgery in specialty orthopaedic hospitals and in general hospitals. They found that patients in the specialty hospitals had fewer comorbidities (such as diabetes, congestive heart failure, and renal failure) and lived in wealthier areas than those in general hospitals. It would appear that more research is needed to understand the contribution of comorbidities and procedure volumes to patient outcomes to verify claims of higher quality in specialty facilities. A recent Wall Street Journal article noted that approximately half of the top 100 facilities receiving payment bonuses from CMS were physician-owned facilities.

CONCLUSIONS Can one say that physician ownership resulted in profit incentives and do they negatively affect the care patients receive? Not with any certainty. It would appear that much more research is needed to support the claims that specialty hospitals and outpatient services (owned by physicians) actually improve the quality of patient outcomes. There is a large body of research that shows that ownership and self-referral are associated with increased uti-

34 San Antonio Medicine • September 2014

lization and higher costs, low same-day referral, and the diversion of complex patients and Medicaid beneficiaries away from physician-owned facilities.

Society has traditionally granted the medical profession considerable autonomy to regulate itself. They may be willing to continue to do so in the case of conflicts of interest, but will Congress, state legislatures, federal agencies and other organizations that push for stronger measures? Similar to my belief in the need for real healthcare reform, my position is that physicians can play a vital role in designing responsible and reasonable conflict of interest policies and procedures to reduce the risks of bias and to avoid undue burdens or harm. Providers should understand public concerns when it comes to conflicts of interest and take measures to maintain public trust.

Joseph P. Gonzales is a "specialist master" with Deloitte Consulting LLP. An adjunct faculty member with UTSA, he teaches in the MBA program, business of healthcare track. He is a fellow in the American College of Healthcare Executives.

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

• ACCOUNTING Anderson, Johns & Yao CPAs (HH Silver Sponsor) We strive to provide a professional and friendly atmosphere for all your accounting and financial needs Ann Yao, CPA/PFS, 210-696-9400 yao@ajycpa.com www.ajycpa.com San Antonio based CPA firm with 30 plus years of experience Padgett Stratemann & Co. LLP (HH Silver Sponsor) Padgett Stratemann is one of Texas’ largest, locally-owned CPA firms, providing sophisticated accounting, audit, tax, and business consulting services.

Vicky Martin, CPA 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com Offering Service. More Than Expected. On every engagement.

Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets.

Jim Rice, CPA, 210-384-8000, ext 112 jprice@ssacpa.com www.ssacpa.com Dedicated to working with physicians and physician groups

law firms.

Dan G. Webster, III 210-554-5500 dgwebste@coxsmith.com www.coxsmith.com Pulman, Cappuccio, Pullen, Benson & Jones (H Bronze Sponsor) The attorneys at Pulman, Cappuccio, Pullen, Benson & Jones, LLP have over 150 years of combined experience providing exemplary representation for clients.

Eric Pullen, 210-222-9494 EPullen@pulmanlaw.com

• BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with 5 core values; Attention, Accountability, Appreciation, Adaptability & Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett 210-343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com Community Banking Partnership

• ATTORNEYS

Carabin Shaw Law Firm Texas Prompt Pay Lawyers (HHHH Platinum Sponsor) Paul L. Sadler psadler@carabinshaw.com www.carabinshaw.com 210-222-2288

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance. BB&T offers banking services to help you reach your financial goals and plan for a sound financial future Ed L. White, Jr. 210-247-2989 ewhite@bbandT.com www.bbandt.com

Cox Smith Matthews, Inc. (H Bronze Sponsor) The largest Texas law firm headquartered in San Antonio and one of the top 25 largest Texas

BBVA Compass (HHH Gold Sponsor) A multinational banking group

providing financial services in over 30 countries,and to 50 million clients throughout the world.

Commercial Relationship Manager Zaida Saliba, 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com Working for a better future

Broadway Bank (HHH Gold Sponsor) Broadway Bank is a full service personal and commercial bank with a specialized Healthcare banking team committed to supporting our medical community. We offer 40 convenient locations in San Antonio, Austin and surrounding areas.

Ken Herring, 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com We’re here for good.

Crockett National Bank (HHH Gold Sponsor) Crocket National Bank is a leading Texas community bank specializing in mortgage, ranch and commercial real estate lending providing superior customer service and competitive financial products.

Lydia Gonzales, 210-384-9304 lydiagonzales@crockettnationalbank.com www.crockettnationalbank.com Doing what we promise.

Frost (HHH Gold Sponsor) As one the largest Texas-based banks,Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment, insurance

services to individuals and businesses.

Lewis Thorne, 210-220-6513 lewis.thorne@frostbank.com www.frostbank.com Frost@Work provides your employees with free personalized banking services.

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

Our local insurance professionals are one of the few agents in the state that specialize in Medical Malpractice and all lines of insurance for the medical community.

Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com Bank SNB (HH Silver Sponsor) Bank SNB combines the resources of a full-service bank with the expertise of healthcare specialists to deliver services that maximize your revenue and profit.

Sandy Cilone, 210-442-6145 sandycilone@banksnb.com www.banksnb.com The opportunity to work with a team of healthcare advisors to achieve the financial goals of your practice.

Baptist Credit Union (HH Silver Sponsor) It is Baptist Credit Union’s mission to meet our members needs by providing extraordinary service, quality financial products, and personal financial education.

Sarah Chatham 210-525-0100, ext 201 memberservices@baptistcu.org www.baptistcu.org We commend your dedication to the health & wellbeing of our community.

Continued on page 36

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 35

Cadence Bank (HH Silver Sponsor) Margarita Ortiz 210-964-5500 maggie.ortiz@cadencebank.com http://cadencebank.com Citi Commercial Bank (HH Silver Sponsor) Chris McCorkle 210-408-5014 christopher.a.mccorkle@citi.com www.citi.com Firstmark Credit Union (HH Silver Sponsor) Address Your Office Needs.

Upgrading your equipment or technology?

Expanding your office space?

We offer loans to meet your business or personal needs.

Competitive rates, favorable terms, and local decisions.

Gregg Thorne, SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org St. Joseph's Credit Union (HH Silver Sponsor) A Credit Union providing savings, checking, IRA, club, and CD accounts. Plus, Auto, signature, Lines of Credit, MasterCard and Real Estate Loans.

Debra Abernathy, 210-225-6126 lending@sjcusatx.net www.sjcusatx.com Better Rates on Auto loans, Signature loans and Platinum MasterCard Jefferson Bank (H Bronze Sponsor) Full service bank specializing in mortgages, wealth management & trusts.

Ashley Schneider 210-734-7848 ext 7848 aschneider@jeffersonbank.com www.jeffersonbank.com Security Service Federal Credit Union (H Bronze Sponsor) Business financing, specializing in low interest commercial real estate transactions Luis Rosales, 210-845-8159 lrosales@ssfcu.org BCMS members can get up to half a percent off the origination fee

Texas Farm Credit (H Bronze Sponsor) Rural, homestead and acreage lending.

Tiffany Nelson, 210-798-6280 www.texasfcs.com

• BUSINESS CONSULTING/ COACHING The Growth Coach Kay Wakeham (H Bronze Sponsor) k.wakeham@thegrowthcoach.com www.thegrowthcoachsanantonio.com 210-492-2400

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

• CONTRACTOR/ BUILDERS Huffman Developments (HH Silver Sponsor) Steve Huffman, 210-979-2500 Shawn Huffman, 210-979-2500 www.huffmandev.com San Antonio Retail Builders (HH Silver Sponsor) Specializing in remodeling/finish out of medical offices.

H.B. Newman 210-446-4793 brett@texaspremiercapital.com Rick Carter 210-367-7909 rick@texaspremiercapital.com Next 6 months Architectural Space Plan / Rendering No Cost or Obligation

• EDUCATION Alpha Bilingual Preschool (H Bronze Sponsor) Our mission is to provide young children with an integral early education in a Spanish immersion environment.

Tania Lopez de Pelsmaeker 210-348-8523 tldp@hotmail.com Give your children the gift of speaking a second language.

36 San Antonio Medicine • September 2014

• ELECTRONIC MEDICAL RECORDS

Greenway Health (HHH Gold Sponsor) Greenway Health offers a fully integrated electronic health record (EHR/EMR), practice management (PM) and interoperability solution that helps healthcare providers improve care coordination, quality and satisfaction while functioning at their highest level of efficiency.

Jason Siegel 512-657-1259 jason.siegel@greenwayhealth.com www.greenwayhealth.com

• FINANCIAL SERVICES

Northwestern Mutual Wealth Management Company (HHHH Platinum Sponsor) Comprehensive Financial Planning Insurance and Investment Planning Estate Planning and Trust Services.

Eric Kala CFP, CLU, ChFC, Wealth Management Advisor 210-446-5752 eric.kala@nm.com www.erickala.com

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction,confidence, and freedom to achieve more in life.

Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com Get what you deserve… Maximize your Social Security benefit!

Frost Leasing (HHH Gold Sponsor) As one the largest Texas-based banks, Frost has helped Texans

with their financial needs since 1868, offering award-winning customer service and a range of banking, investment, insurance services to individuals and businesses.

Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com Commercial leasing for a doctor’s business equipment and vehicle.

Platinum Wealth Solutions of Texas LLC (HH Silver Sponsor) Comprehensive financial planning firm who assists medical professionals to protect their income, their wealth, their practice and legacy.

Tom Valenti 210-998-5023 tvalenti@jhnetwork.com Eric Gonzalez: 210-998-5032 ericgonzalez@jhnetwork.com www.platinumwealthsolutionsoftexas.com Understanding the uniqueness in the financial life as a physician.

Retirement Solutions (HH Silver Sponsor) Committed to providing comprehensive, reliable consultation to help you navigate the complex world of retirement planning.

Robert C. Cadena 210-342-2900 robert@retirementsolutions.ws www.retirementsolutions.ws Bold Wealth Management (H Bronze Sponsor) Comprehensive Investment Advisory and Retirement Planning Services for Businesses and Individuals.

Richard A. Poligala, 210-998-5787 richard.poligala@natplan.com www.boldfinancialgroup.com Complimentary no-obligation retirement plan review to BCMS members

• GOLF TPC San Antonio (H Bronze Sponsor) 18-hole championship golf courses designed by two of golf's most innovative architects, Pete Dye and Greg Norman.

Matt Flory, 210-491-5816 www.tpcsanantonio.com

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY • HEALTHCARE CONSULTING TNT Healthcare Consulting LLC (H Bronze Sponsor) We want physicians to concentrate on what they were trained to do, treating patients.

Tom Tidwell, CMPE 210-861-1258 Thomas.tidwell@att.net Let TNT healthcare consultants evaluate your practice and improve efficiency and cost.

• HOSPITALS/ HEALTHCARE SERVICES

Select Rehabilitation of San Antonio (HHH Gold Sponsor) At Select Rehabilitation Hospital of San Antonio, we provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

Miranda Peck, 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com/ Offers patients a higher degree of excellence in medical rehabilitation.

South Texas Sinus Institute (HHH Gold Sponsor) The South Texas Sinus Institute is a state of the art facility dedicated to in-office Balloon Sinuplasty using the unique Painless Sinuplasty Anesthetic Linked Method.

Sue Musgrove, 210-225-5666 stsisue@gmail.com www.southtexassinusinstitute.com.

We will offer convenient same day or lunch appointments to BCMS members.

Warm Springs Medical Center Warm Springs Thousand Oaks Warm Springs Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate,expert care during the rehabilitation process & support recovery through education & research.

Central referral Line 210-592-5350 Joint Commission COE Elite Care 24 Hour Emergency Center (HH Silver Sponsor) We are a fully equipped emergency room open 24 hours a day and 7 days a week, staffed by experienced emergency physicians. We provide the same level of emergency medical care that you would receive in a hospital ER. Clemente Sanchez, 210-269-8028 csanchez@elitercaremarketing.com Rosie Clark, 210-771-0141 rclark@elitecaremarketing.com www.elitecareemergency.com Get seen by an experienced physician within 10 minutes.

Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano, 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.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) Southwest General Hospital is a 327-bed, state-of-the-art hospital located in San Antonio, Texas.

Southwest General offers comprehensive healthcare services.

Craig Desmond, 210-921-3521 Elizabeth Luna, 210-921-3521 www.swgeneralhospital.com

• HUMAN RESOURCES

Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page.

John Seybold, 210-447-6518 jseybold@employerflexible.com www.employerflexible.com BCMS members get a free HR assessment valued at $2,500.

Pinnacle Workforce Corp HR. Services (H Bronze Sponsor)

Dan Cardenas, 210-344-2088 dancardenas@pinnacleworkforce.com

• INFORMATION TECHNOLOGY

Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes.

Stephanie Stephens, 210-332-4924 sstephens@dahill.com www.dahill.com Allison Royce Business Technologies (H Bronze Sponsor) Business Technology Provider, specializing in HIPAA Compliant Managed IT Services and IT Support since 1993.

Jeff Tuttle,210-564-7000 jtuttle@allisonroyce.com www.allisonroyce.com PitCrew IT Services (H Bronze Sponsor) Provides reliability for your business computers or network, enabling you to operate smoothly.

Eric Murcia, 210-547-0305 eric@pitcrewit.com

businesses.

Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com Business and personal insurance tailored to meet your unique needs.

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

Donnie Hromadka 512-338-6151 dhromadka@humana.com www.humana.com Nationwide Insurance Joel Gonzales Agency (H Bronze Sponsor) What matters to you, matters to us!

Joel Gonzales 210-314-7514 gonzj8@nationwide.com www.nationwide.com/jgonzales Texas Drug Card (H Bronze Sponsor) The Texas Drug Card program is a FREE statewide Rx assistance program available to all residents.

Todd Walker 512-569-5547 twalker@texasdrugcard.com http://texasdrugcard.com/index.php

• INSURANCE/MEDICAL MALPRACTICE

• 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) As one the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment, insurance services to individuals and

Texas Medical Liability Trust (HHHH Platinum Sponsor) Texas Medical Liability Trust is a physician-owned health care liability claim trust, providing malpractice insurance products to the physicians of Texas.

Currently, we protect more than 14,000 doctors in all specialties who practice in all areas of the state. TMLT is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, the Dallas, Harris, Tarrant, and Travis County Medical Societies.

Patty Spann, Continued on page 38

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37

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

Medical Protective Medical Malpractice Insurance (HHH Gold Sponsor) Medical Protective, the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Thomas Mohler 512-213-7714 thomas.mohler@medpro.com www.medpro.com

• INTERNET/ TELECOMMUNICATIONS Time Warner Cable Business Class (HH Silver Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterprise-class technology and communications that are highly reliable, flexible and priced specifically for the medical community.

Rick Garza, 210-582-9597 Rick.garza@twcable.com Time Warner Cable Business Class offers custom pricing for BCMS Members.

• MARKETING SERVICES Texas Medical Association Insurance Trust (HHH Gold Sponsor) Created and endorsed by the Texas Medical Association (TMA), the Texas Medical Association Insurance Trust (TMAIT) helps physicians, their families, and their employees get the insurance coverage they need.

James Prescott, 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org We offer BCMS members a free insurance portfolio review.

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

Our local insurance professionals are one of the few agents in the state that specialize in Medical Malpractice and all lines of insurance for the medical community.

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

The Doctors Company Medical malpractice insurance (HH Silver Sponsor) Kirsten Baze 512-275-1874 KBaze@thedoctors.com www.TheDoctors.com

Phiskal LLC Marketing and Promotion (H Bronze Sponsor) A leading edge marketing and development firm using proprietary Artificial Intelligence engines to enhance your presence with websites, apps & database applications.

Sundeep Sadheura 210-865-4520 Sunnys@phiskal.com HTTP://PHISKAL.COM/

• MEDICAL BILLING AND COLLECTIONS SERVICES

DataMED (HHH Gold Sponsor) Providing your practice with the latest compliance solutions, concentrating on healthcare regulations affecting Medical Billing and Coding changes allowing you and your staff to continue delivering excellent Patient Care.

Anita Allen (210) 892-2333 aallen@datamedbpo.com www.datamedbpo.com BCMS members receive a discounted rate for our billing services.

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

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net

38 San Antonio Medicine • September 2014

www.cmcs-sa.com Make us the solution for your account receivables.

PriMedicus Consulting Inc. (H Bronze Sponsor) A physician-founded and built company, dedication to your success.

Sally Combest MD. 877-634-5666 s.combest@primedicusconsulting.com www.primedicusconsulting.com PriMedicus Consulting for the Health of Your Practice.

Urgent Care Billing Solutions, LLC (H Bronze Sponsor) UCBS provides superior practice management services and revenue optimization services to the healthcare community in a virtual office environment.

Ann DeGrassi, CMIS 210-878-4052 adegrassi@ucbillingsolutions.com www.urgentcarebillingsolutions.net

• MEDICAL SUPPLIES & EQUIPMENT

Henry Schein Medical (HHHH Platinum Sponsor) From alcohol pads and band aids to EKG’s and Ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines, and pharmaceuticals serving office based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com/medical BCMS members receive GPO discounts of 15%-50%.

McKesson Medical-Surgical (H Bronze Sponsor) MCKESSON is a leading distributor of Medical Supplies and Equipment.

Karan Cook 210-573-2117 karan.cook@mckesson.com

• PAYMENT SYSTEMS/ CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Tanner Wollard, 979-219-9636 Tanner.Wollard@e-HPS.com www.heartlandpaymentsystems.com

• PUBLICATION MANAGEMENT FIRM Traveling Blender (H Bronze Sponsor) Publication Management Firm Janis Maxymof, 210-413-9731 janismaxymof@gmail.com 10% discount on display advertising in magazine for members.

• PRINTING SERVICES SmithPrint (H Bronze Sponsor) SmithPrint offers custom printing, branding, graphic design, signage and more!

Robert Upton 210-846-5268 Robert@smithprint.net http://www.smithprint.net/ New customers: 10% discount on print materials at SmithPrint.

• REAL ESTATE/ COMMERCIAL Cano and Company Commercial Real Estate (HH Silver Sponsor) Experienced and respected commercial real estate representation.

We specialize in office leasing, property acquisition, and commercial real estate investment.

Dennis Cano, Agent 210-731-6613 www.canoandcompany.com Dennis@canoandcompany.com Effective commercial real estate solutions for your practice and investments.

Newmark Grubb Knight Frank (H Bronze Sponsor) Commercial Real Estate Darian Padua 210-804-4841 Dpadua@ngkf.com Stream Realty Partners (H Bronze Sponsor) Carolyn Hinchey Shaw 210-930-3700 cshaw@streamrealty.com www.streamrealty.com

• REAL ESTATE/ RESIDENTIAL SA Luxury Realty (HH Silver Sponsor) Effective real estate transactions (Buy, Sell, Lease, Syndicate, etc.) within the shortest time possible and for maximum results!

Matin Tabbakh 210-772-7777

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY matin@saluxuryrealty.com www.saluxuryrealty.com Accredited Luxury Home Specialist. Call us today.

Becky Aranibar Realty Group Keller Williams (H Bronze Sponsor) Offering Real Estate Services to the San Antonio Medical Community.

Carlo G. Aranibar, MBA, 210-862-4022 BARgrouptx@gmail.com www.beckyaranibar.com Offering free comparative market analysis to determine your home's value.

www.texaspremiercapital.com

• REGULATORY COMPLIANCE Hildebrand Regulatory Compliance (H Bronze Sponsor) HEDIS, Accreditation, PCMH, ICD10 Patricia Hildebrand, 432-352-6143 Pati.Hildebrand@HildebrandHealthcare.com www.hildebrandhealthcare.com

• RESEARCH STUDIES/ BIOTECHNOLOGY

• REAL ESTATE/ INVESTMENTS Texas Premier Capital (HH Silver Sponsor) A real estate development company offering and managing real estate investment funds in the South Texas area.

H.B. Newman 210-446-4793 brett@texaspremiercapital.com Rick Carter 210-367-7909 rick@texaspremiercapital.com

ICON Development Solutions (HHHH Platinum Sponsor) We are a respected clinical research organization that has an extensive reputable history in diabetes research. Depending upon the current studies, ICON may establish working relationships with local physicians.

Your expertise may be invaluable

to our efforts to identify subjects Dr. Dennis Ruff 210-283-4572 dennis.ruff@iconplc.com www.iconplc.com Find out how ICON can help your Practice.

• STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 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!

Brian Cleary, 210-301-4362 BCleary@FavoriteStaffing.com www.favoritestaffing.com/public/medicalsocieties/bexar_count y/bexarcounty_index.aspx Favorite Healthcare Staffing

offers preferred pricing for BCMS members.

• TRANSCRIPT SERVICES Med MT, Inc. (H Bronze Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records.

Ray Branson, 512-331-4669 branson@medmt.com www.medmt.com The Med MT solution allows physicians to keep practicing just the way they like.

As of August 11, 2014

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

visit us at www.bcms.org

39

BOOK REVIEW

The Book Thief

“

“

Reviewed by Fred H. Olin, MD “The Book Thief,” by Australian author Markus Zusak, is about love, hate, friendship, captivity, freedom, girls, boys, men, women, a house painter/accordionist and his wife, a Jewish fist fighter, war, life, death, Death, burning books, rescuing books, stealing books, giving books, reading books, listening to books being read, stealing apples, stealing potatoes, capture, escape, more war, and, ultimately, peace … just a few pages of peace, but there it is. It is narrated by Death, who has a really clear vision of reality and the human race, and who is likeable, humane and has a sense of humor. Despite all that, this will be a short review.

I saw this book sitting on a table at the Cody Branch Public Library marked “Express Collection No Renewals No Holds.” I had heard of it, but never thought much about it. I picked it up, read a couple of pages and was hooked. Now, if you go looking for reviews online, you will likely find it called a “Young Adult” novel. I totally disagree. I’m an adult, but if there’s one thing I’m not, it’s young. I think it probably got classified that way because the protagonist is Liesel Meminger, 9 years old at the start of the story. In reality, I believe that this is one of the most adult books I’ve ever read. It moved me in many ways.

Liesel’s parents were Communists … not a good thing to be in

Nazi Germany. It is January 1939. Her father is gone, and she is taken from her mother and lodged with foster parents in a suburb of Munich. They live in a poor area on a street named “Himmel,” which is German for “Heaven.” It isn’t. As the fortunes of Hitler’s armies change over the next few years, the residents of Himmel Street try to live normal lives despite the fear, privations and bombings. Liesl’s adventures and relationship with her foster parents and her best friend, a neighbor boy named Rudy Steiner, form the core of the story. By the end of the book you know these people and a bunch more. Some are admirable, some are pitiful, and some are horrid, just like real life. As I write this I’m beginning to think that I may have to break down and buy a copy. I seldom re-read novels, but this one is calling me. Please consider giving it a look.

Zusak’s view of the human race and humanity (they are different things) was on The New York Times’ best-seller list for 230 weeks. It deserved it.

Fred H. Olin, MD, is a semi-retired orthopaedic surgeon who, if sleep were unnecessary, would read more books on paper, online, on his Kindle, or any other way they were available. He is chair of the BCMS Communications/Publications Committee.

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA

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ENT Clinics of San Antonio, PA

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Gastroenterology Consultants of San Antonio

South Alamo Medical Group

General Surgical Associates

South Texas Radiology Group, PA

Greater San Antonio Emergency Physicians, PA

Tejas Anesthesia, PA

Institute for Women's Health

Texas Partners in Acute Care

Lone Star OB-GYN Associates, PA

The San Antonio Orthopaedic Group

M & S Radiology Associates, PA

Urology San Antonio, PA

MacGregor Medical Center San Antonio

Village Oaks Pathology Services/Precision Pathology

MEDNAX

WellMed Medical Management Inc. Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of August 15, 2014.

40 San Antonio Medicine • September 2014

visit us at www.bcms.org

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42 San Antonio Medicine • September 2014

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

* Fernandez Honda 8015 IH-35 South

* North Park Lincoln/ Mercury 9207 San Pedro Ave.

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Ancira Ram 10807 IH-10 West * Gunn Infiniti 12150 IH-10 West

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Ingram Park Auto Center 7000 NW Loop 410

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

Ingram Park Auto Center 7000 NW Loop 410

Mercedes-Benz of Boerne 31445 IH-10 W, Boerne Ancira Jeep 10807 IH-10 West

Ancira Elite Motorcars 10835 IH-10 West

Mercedes-Benz of San Antonio 9600 San Pedro Ave.

Ingram Park Auto Center 7000 NW Loop 410 Cavender Toyota 5730 NW Loop 410

Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604) Northside Ford 12300 San Pedro Ave.

North Park Subaru 9807 San Pedro Ave.

Ancira Kia 6125 Bandera Road

* Mini Cooper The BMW Center 8434 Airport Blvd.

* Ancira Volkswagen 5125 Bandera Rd.

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

Cavender GMC 17811 San Pedro Ave.

* North Park Lexus 611 Lockhill Selma

Ingram Park Nissan 7000 NW Loop 410

* The Volvo Center 1326 NE Loop 410

visit us at www.bcms.org

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AUTO REVIEW

Nissan Versa Note: Inexpensive, fuel efficient, but not a kick to drive

By Steve Schutz, MD

Recently, I read an article in Automotive News about an upcoming feature from Nissan that seems amazing: self-cleaning paint.

Nissan took the idea which RainX pioneered for windshields more than 30 years ago and made paint that doesn't hold on to dirt but rather lets it slide off. An accompanying video was convincing, and I found myself wondering why it took so long for this great concept to come to fruition. (I'm not a paint engineer, but I'm going to guess that it took so long because it was really difficult.)

Anyway, I was surprised to see that, rather than introducing this exciting new technol44 San Antonio Medicine • September 2014

ogy on a top-shelf Infiniti, Nissan chose to unveil it on their B-class Versa Note hatchback. Is that a signal that the company intends to make their new paint a feature that any customer can have? Nissan's not saying, but I'm hoping that's the case.

STUDENT LOAN HELL? Self-cleaning paint notwithstanding, the Versa Note is a good car. At a price that starts at just under $15,000, it's not likely to make the shopping lists of most BCMS members — let alone our neurosurgeon and orthodontist friends — but it's worth

a look if you're a resident or young physician just beginning a long climb out of student loan hell.

The Versa Note is small — about the same size as the Ford Fiesta — but thanks to its hatchback configuration it makes the most of a (very) diminutive footprint.

Sales figures tell us that hatchbacks don't do well in this country, but I can't for the life of me understand why. In my book, compact hatchbacks make more sense than sedans. Yes, the Versa Note has a sedan sibling, the Versa, but I'd take the hatchback every time because of its extra utility. Gro-

AUTO REVIEW

ceries and packages fit under the hatch easily, and if you fold down the rear seats there's a lot of space — enough for my 29inch mountain bike, actually. And the hatchback looks better to my eyes because of a design that emphasizes the car's utilitarian bent.

Nevertheless, if you prefer a traditional four-door-with-a-trunk design, the Versa sedan gets you the same small car virtues mentioned below in a look that's more khakis and polo shirt than jeans and T-shirt.

Nissan won't release the breakdown, but assuming that the Versa sedan outsells the Versa Note is a good bet.

While at 6-feet, 2-inches I approached my week with the Versa Note with trepidation, in fact I fit into the driver's area easily and comfortably. I had plenty of headroom, and the steering wheel moved to where I needed it without any special effort. Still, the center stack and shifter are closer than I'm used to, and I doubt I'd enjoy sitting in the rear seat behind someone my size very much. Again, this is a small car.

Of course, the biggest benefit of small cars is that they're inexpensive to buy and own, and the Versa Note is certainly that. In addition to the low price tag quoted above, Nissan's pint-size hatchback gets 31 mpg city and 40 mpg highway. That's almost Prius territory.

One of the reasons the Versa Note does so well on gas is its continuously variable transmission (CVT), an automatic gearbox without gears (!) that's the bane of driving enthusiasts everywhere. CVTs work by connecting the engine to the driving wheels — the front ones in this case — via a belt rather than normal gears. That belt along with lots of computer power helps keep the engine in its most efficient rev range at all speeds, resulting in maximal fuel efficiency and minimal emissions. From behind the wheel, CVTs under acceleration feel and sound like an airplane taking off. Despite the fact that

you are indeed accelerating, the engine revs at the same level the whole time until you let off the throttle. I find the whole process to be annoying, but my wife, who's not an enthusiast, neither noticed nor cared, even after I pointed it out to her.

a very reasonable choice for their offspring, and for residents or physicians just starting out. If Nissan were to see fit to offer it with self-cleaning paint, it would appeal to even more customers. Here's to seeing that option on all new cars soon!

FUN FACTOR LIMITED

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.

Not surprisingly given the Versa Note's charge to be inexpensive and fuel efficient, it's not exactly a kick to drive. While the fun factor would certainly increase with a manual transmission, choosing that option would make commuting and errand running more of a headache than they already are.

The Nissan Versa Note is an inexpensive but nice hatchback that's not going to ring a bell for most BCMS members, but would be

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

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46 San Antonio Medicine • September 2014