San Antonio Medicine Novermber 2014

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VOLUME 67 NO. 11

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.

LETTING OFF STEAM

Krav maga: “Stuff” that works

By Robert G. Johnson, MD .........................................12

The great balancing act: Music, theater help mind and spirit

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

By Teri Hospers, MD ...................................................14

Diseases and conditions of the healthcare systems

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

By Adam V. Ratner, MD .................................................16

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BCMS President’s Message ........................................................................................................8 Opinion: Shamelot by Robert G. Johnson, MD ..........................................................................18 BCMS News ................................................................................................................................20

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Nonprofit: San Antonio Food Bank’s new Pharm2Farm program ................................................26 Business of Medicine: Understanding economic dynamics to survive and thrive in healthcare markets by Lee W. Bewley, PhD, FACHE............................................................28 Nonprofit: FAQs: The Rape Crisis Center by Deana Buril ....................................................................30 UTHSCSA Dean’s Message by Francisco González-Scarano, MD ......................................................32 BCMS Circle of Friends Services Directory ..........................................................................................35 Book Review: “Spillover: Animal Infections and the Next Human Pandemic,” written by David Quammen, Reviewed by Fred H. Olin, MD ..................................................40 In the Driver’s Seat ................................................................................................................................42 Auto Review: Audi A3 Sedan by Steve Schutz, MD ..............................................................................44

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San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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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

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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 • November 2014

PRESIDENT’S MESSAGE

A salute to women physicians, A call to end gender disparities

By K. Ashok Kumar, MD, FRCS, FAAFP 2014 BCMS President Each November, our Bexar County Medical Society celebrates Women in Medicine Month. I take this opportunity to salute all my women physician colleagues in San Antonio, Bexar County and South Texas for their contributions to improving the health of the communities in which they live. Women physicians, like their male counterparts, care for patients in San Antonio and throughout South Texas, teach medical students and residents, and serve in the military. Many female physicians are leaders in medical education, research and organized medicine.

This year the American Medical Association selected Women in Medicine Month’s theme as "Innovators and Leaders Changing Healthcare." This theme reaffirms our commitment to increase the influence of women physicians and recognize their advocating for women's health issues.

Many women physicians have made significant contributions to medicine and society. Since Dr. Elizabeth Blackwell, the first woman awarded a medical degree in the United States, graduated from the Medical College of Pennsylvania in 1849, we have had many shining examples of women serving in high positions in the field of medicine. Three of the past five U.S. Surgeon Generals are women: Dr. Antonia C. Novello, the first woman and first Hispanic appointed as the U.S. Surgeon General (1990-1993), followed by Dr. Joycelyn Elders (1993-1994), and Dr. Regina Benjamin (2009-2013). Texas’ own Dr. Nancy Dickey was the first woman elected as the president of the American Medical Association in 1998. In Bexar County, Dr. Rajam Ramamurthy was the first woman elected as president of the Bexar County Medical Society (2004), followed by Dr. Diana M. Burns-Banks (2006).

Women’s participation in the medical profession was limited by law until the 19th century. When women routinely were barred from medical schools, they formed their own schools. The Women’s Medical College of Pennsylvania was founded in 1850, and London School of Medicine for Women was founded in1874. The number of women graduating from medical schools gradually gained momentum and accelerated during the latter part of 20th century. The proportion of women in medical school increased from 5 percent in 1952 to 48 percent in 2011.1 Unfortunately, even today, gender disparities persist in the percentage of practicing women physicians, the number of women who own their practices, and the number of women who practice part-time. In 2010, women comprised 34 percent of practicing physicians and surgeons in the United States.2, 3 Women physicians are less likely to have ownership in the practices where they work. In 2004, 41 percent of women owned at least part of their practice, compared to 59 percent of men.3 A 2006 survey of physicians under 50 found that 24 percent of women physicians and 2 percent of men reported working parttime at some point in their career.4 Disparities also exist in the representation of women physicians in higher-paying specialties. Women are over-represented in traditionally lower-paying specialties such as pediatrics, family medicine and psychiatry. Pediatrics, for example, is the only specialty in which women 8 San Antonio Medicine • November 2014

are the majority (56 percent in 2011).5 Women have the lowest representation in surgery. In 2005, women composed less than 6 percent of orthopaedic, thoracic, urological and neurological surgeons.3 Gender segregation among specialties remains constant even as more women become physicians. A pay gap also exists between women physicians and their male colleagues. Women physicians and surgeons earn 79 percent of their male colleagues’ income. This income disparity between genders exists even within the higher-paying specialties after controlling for age, specialty and hours worked.4 Academic medicine and research are not immune to gender disparities in rank and income. The percentage of women medical school faculty increased from 26 percent in 1997 to 37 percent in 2012.4 However, women make up only 20 percent of full professors.6 Even among physician researchers awarded prestigious National Institutes of Health grants, women receive lower salaries than men. This inequality persists when studies control for specialty, institutional characteristics, productivity, academic rank, work hours and other factors.7 The reasons for these disparities are multifactorial. Some of these disparities might correct themselves with time as more women physician graduates become experienced and advance to higher positions in private practice, and academic and research fields. We can accelerate the elimination of these disparities by mentoring more women physicians to become leaders in their practices and/or in their academic and research institutions. We also must encourage women physicians who are in higher positions to mentor their junior colleagues. We need to identify women physicians with leadership and management skills earlier in their career and encourage them to attend leadership development programs. One such program is the Executive Leadership in Academic Medicine Program for Women that is offered by the Association of American Medical Colleges.

It is time we, the medical community as a whole, correct these disparities between men and women physicians, and do our duty to ensure equality within our profession.

REFERENCES 1.

2.

3.

4.

5.

6.

7.

American Association of Medical Colleges (AAMC). 2010. Table 1: Medical Students, Selected Years, 1965-2010. https://www.aamc.org/download/170248/data/2010_table1.pdf.

Bureau of Labor Statistics, U.S. Dept of Labor. 2012. “Table 11. Employed persons by detailed occupation, sex, race, and Hispanic or Latino ethnicity.” Household Data Annual Averages. http://www.bls.gov/cps/cpsaat11.htm.

Stacy J. Williams, Laura Pecenco, and Mary Blair-Loy. 2013. “Medical Professions: The Status of Women and Men.” Center for Research on Gender in the Professions, UC San Diego. http://crgp.ucsd.edu.

Langston, E. 2008. Report 19 of the Board of Trustees: Gender Disparities in Physician Income and Advancement. American Medical Association. http://www.aap.org/en-us/about-the-aap/departments-and-divisions/departmentof-education/Documents/women_med_demographics.pdf#search=women%20demographics AAMC. 2012. Table 3: Distribution of Full-Time Faculty by Department, Rank, and Gender, 2012. https://www.aamc.org/download/305522/data/2012_table3.pdf.

Jagsi, Reshma et al. 2012. “Gender Differences in the Salaries of Physician Researchers.” JAMA 307 (22): 2410-2417

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LETTING OFF STEAM

KRAV MAGA: “Stuff” that works

By Robert G. Johnson, MD

Dr. Robert Johnson pummels away the day’s frustration. Courtesy photos

As brutal as an ultimate fighting championship (UFC) fight appears on television to the casual observer, those guys are holding back. Believe it or not, full-contact mixed martial arts (MMA) has rules; there are certain moves and strikes that are verboten, even in the apparent no-holds-barred-free-for-all that it seems to represent. Ironically, the forbidden techniques are the precise ones most effective in defending ourselves on the street. MMA fighters cannot strike to the groin, eye-gouge, head butt or attack the throat, just to list the major no-no’s. (Did I mention biting?)

Most traditional martial arts have restrictions inherent to each sport. Boxers cannot hit below the belt or kick; wrestlers can’t punch; karate and tae-kwon-do do not teach ground fighting. In medicine, this would be tantamount to disallowing vancomycin for the ID doc, taking EKGs from the cardiologist, or — God forbid — pedicle screws from the spine surgeon. “Just do the best you can with half the assets.”

This was this realization that struck a Czechoslovakian Jew named Imrich “Imi” Lichtenfeld in the 1930s. The Nazis were disarming civilians, and roving gangs of thugs dispensed their own brand of justice, on Jews in particular. Imi was a trained boxer and wrestler, but soon discovered that his skills were no match for the unregulated violence of his street foes. So, he developed krav maga (Hebrew for “contact combat”). Imi took the last boat out of Europe in 1940 and moved to Palestine where he helped in the struggle to create the State of Israel in 1948. Refined over the years, krav is the official training and self-defense program for the 12 San Antonio Medicine • November 2014

Israeli Defense Force, and has been adopted by police and many military units (including Navy Seals) around the world.

SELF-DEFENSE SYSTEM Krav maga has borrowed the best from other disciplines — boxing, wrestling, jiu jitsu, muay thai, karate — but maintains its own signature. It is a system for self-defense against unarmed foes as well as guns, knives and blunt objects. Imi Lichtenfeld (19101998) and those to follow have created a comprehensive and detailed discipline to counter any assault, from any angle or direction, with any body part or weapon. It teaches its user how to defend, counter attack, and end a fight ASAP, and follows a tiered progression of training from level 1 (yellow belt) up to level 6 (black belt). No actual belts are worn nor are there uniforms or gis, just comfortable workout gear and a krav T-shirt. In the early levels (1-3), the student learns basic kicks, strikes and combatives: punches (straight, hook, hammer fist), kicks (front, side, back), elbows and knees. It includes practical stuff — how to defend against chokes, hair grabs, bear hugs (unwanted ones), how to fall (fall breaks), then continue fighting once you hit the ground.

Upper levels (4-6) learn advanced combatives in addition to weapon defenses. What would you do if a bad guy shoves a gun in your face? In the movies people panic, throw up their arms, stare at the gun barrel for what seems like endless minutes. Krav will teach you how to turn the tables a few seconds; the same with knives, baseball bats, axes, etc.

LETTING OFF STEAM

Sounds very uncivilized and pugilistic, right? Here’s how I see it. Disease is uncivilized and pugilistic. It usually strikes without warning and with a vengeance; its unswerving intent is to cripple, maim and kill — no-holds-barred, no rules. And as doctors we fight back with no mercy or restrictions (FDA a qualified exception). We don’t “wait and see” if that sarcoma is going to spread, or if the “touch of pneumonia” might be just passing through, or the cauda equina syndrome will go away on its own. We strike and strike hard: with knives, and chemo, and antibiotics; we intubate, start IVs, infuse, drain, debride, amputate — with every weapon in the arsenal. Street violence is a disease. Bad guys strike without warning, swiftly, and with unmetered violence: joggers are stabbed in parks, vehicles carjacked, homes invaded.

We should stock our self-defense pharmacy — today.

STAYING FIT ALSO HELPS Still not your cup of tea? Then consider just staying fit. Enter a room with a hunA krav maga instructor (left) works with Dr. Robert Johnson on a defense against a knife attack. dred 120-pound bags waiting to be seminars. Krav has an impressive safety record; there’s the usual punched, kicked, pounded into submission (and they don’t hit bumps and bruises of any work-out, but few serious injuries. While back), taking with it the day’s stress and anxiety. Krav breaks away fitness is a goal, one does not have to be in top shape to start krav. from traditional fitness gyms; you won’t find endless rows of weight It was designed for the average person to learn; its techniques are machines and treadmills. You will use kettle bells (great resistancenot complex (no spinning aerial kicks with a half-twist), and utilize aerobic workout), battle ropes (best shoulder-chest-back exercise, the body’s natural protective movements. For those who have limited bar none), rings (use your body weight to tone up). Want to train workout time, want the most bang for their buck, and get to the like a UFC fighter without ever entering the octagon? Take a fit-toreal thing ASAP, krav maga is the “stuff ” that works. fight or advanced heavy bag class with non-stop combatives, ropes, There are two krav gyms in San Antonio: 100 Crossroads Blvd. spinning, running, medicine ball, burpies, crunches — and that’s (near the Medical Center, 210-348-6127) and 18450 Blanco Road only the warm-up. (at Loop 1604, 210- 545-3900).

I’ve been working out at krav for 10 years, going slowly on the self-defense (I’m only at level four) but I try to make three of the cardio bag and advanced bag classes a week. My 16-year-old often accompanies me and has become a self-defense machine. We attend many of the numerous seminars on defense against all manner of weapons, how to handle an active shooter scenario, parking lot assaults. Members of my office staff have taken women’s self-defense

Robert G. Johnson, MD, is an orthopaedic spine surgeon with Neurosurgical Associates of San Antonio. A frequent contributor to San Antonio Medicine, he has been a BCMS member since 1989. The author has no financial interests in krav maga, nor received anything of value for this article. visit us at www.bcms.org

13

LETTING OFF STEAM

THE GREAT BALANCING ACT: Music, theater help mind and spirit

By Teri Hospers, MD

I still had the acceptance letter to medical school at the University of Texas Health Science Center in my back pocket when I went to a Longhorn Singers (LHS) party at an apartment complex in Austin. My future was bright, and I had no intention of meeting anyone, much less the person I would spend the rest of my life with.

I was in my last year of pre-med studies at the University of Texas at Austin and had a lab that interfered with the show choir’s class period. I made time to attend the social events since I had spent three years of my time in college singing, traveling and partying with these great people. Making music with this fun-loving group of people from all different areas of study at UT was a great way to balance the many hours in the lab or studying biochemisty.

Lee Cusenbary and wife Dr. Teri Hospers enjoy performing live as a break from their busy personal and proOne of my friends at the party said I needed fessional lives. Courtesy photos to meet Lee, the newest LHS member who had just auditioned weeks before. I had no for a band of rocker lawyers. Lee pulled out his guitar again and idea that Lee was a he, not a she. I also didn’t know that we would started singing with a group of lawyers who were all having their talk for three hours on the couch at the party and laugh more than own renaissance of sorts.

I recall laughing my entire time in college. We saw each other almost The reason I think we gravitated back toward having music in our every day after that meeting. Lee was a “he,” and we have been marlives is it provides a balance of mind and spirit. When it comes to ried for 26 years, with three very tall and musical children. living happily as a busy family, balance is key. I don’t know that I would have had any music to go back to if my parents hadn’t given NO TIME FOR MUSIC me piano lessons as a child. For that, I’m very grateful.

When Lee went to law school and I was a pediatric resident, there As our interest in music has grown, we’ve returned to the thewas no time for music. There was time for work, diapers, washing ater, becoming involved with different productions and have enclothes, reading to the kids and maybe a minute to myself. We didn’t joyed the feeling of live performance again. Lee writes and directs make music a priority and it was not a part of our lives. a show to raise money for charity each year called Ethics Follies As happens with many people, we had more time when our chilat the Charline McCombs Empire Theatre. We both have perdren got older, started to drive and had their own interests. I started formed in the Follies for nine years. Lee also has chaired the playing the piano and singing again, and was even a “back-up chick”

14 San Antonio Medicine • November 2014

LETTING OFF STEAM

board of trustees at The Playhouse San Antonio for two years and still sits on that board. Lee will direct Fiddler on the Roof in November for The Playhouse as well.

FIND BALANCE IN LIFE We have thoroughly enjoyed attending local theater productions and have met so many people who have similar stories of rediscovering music and theater again after a break due to busy lives.

Consider finding some balance in your lives by coming to The Playhouse to have a cocktail before the show with friends and then see a well-produced show that rivals touring companies at a fraction of the price. The production quality of local theater in San Antonio is so much better than it was even five years ago; you will be pleasantly surprised. You can learn more about The Playhouse and the new season of shows at ThePlayhouseSA.org.

Teri Hospers is a pediatric cardiologist at Pediatric Cardiology Associates and a BCMS member. She is married to C. Lee Cusenbary Jr., general counsel at Mission Pharmacal Co.

visit us at www.bcms.org

15

LETTING OFF STEAM

DISEASES AND CONDITIONS of the Healthcare Systems

By Adam V. Ratner, MD Over the years, scientists and physicians have developed various methods of identifying, classifying and organizing the diseases and conditions that affect all life forms. In the day-to-day practical healthcare system of the United States, we generally employ a system called ICD-9 and will sooner or later be adopting ICD-10 and/or ICD-11. Whether we like them or not, they represent generally accepted organizational schemes for identifying and classifying diseases and conditions affecting humans. Having such a scheme makes it easier to identify, study, understand and ultimately treat the diseases. The ICD-X systems represent a common, albeit imperfect, system of communicating human diagnoses.

No similar scheme exists for identifying and classifying problems encountered in our immensely complex healthcare systems.

Those of us who practice medicine are all too aware of the shortcomings of the healthcare systems in which we work. Depending on the individual characteristics of our respective practices, we see from our own unique perspective what works and what doesn’t.

The amazing fragmentation of our healthcare systems makes it difficult to identify, understand and heal those acute and chronic conditions that impair healthcare delivery and adversely affect our patients, our practices, our institutions, our payors and ourselves.

Seeing the need to identify and organize healthcare system problems, The Patient Institute, a 501(c)(3) nonprofit organization serving our community, has initiated a new project called the Diseases and Conditions of Healthcare Systems (DCHS). The DCHS will be open and available freely on the Internet via The Patient Institute’s website, patientinstitute.org.

While many of the conditions and diseases have what appear to be ironic or amusing names (and are written in “medicalese” demonstrating medical jargonosis), they are all serious conditions that affect the well-being of patients and other stakeholders in the healthcare system. By its nature this compendium will always be a work-in-progress and is always subject to expansion and modification.

We invite contributions to the DCHS via info@patientinsti-

16 San Antonio Medicine • November 2014

tute.org. If you truly have a passion for this new enterprise and are interested in becoming a DCHS curator/editor, please contact The Patient Institute at the same email address.

Below is a sample of some of the categories and listings in the newly formed DCHS:

HEALTHCARE SYSTEMIC SYNDROMES BUREAUCROSIS: The required production of large quantities of non-clinical/administrative work, often in an inefficient manner, which distracts healthcare providers and staff from delivering care to individual patients. Extremely common in health/medical record systems and as part of the third-party payor, benefit management and accreditation/compliance/regulatory processes.

HYPERMETRICOSIS: The collection of large quantities of metrics/data, often in an inefficient manner, which distracts healthcare providers and staff from delivering care to individual patients. Extremely common in electronic health/medical record systems and as part of the third-party payor, benefit management and accreditation/compliance/regulatory processes. A variant of bureaucrosis.

MALIGNANT DISSOCIATIVE HYPERMETRICOSIS: A variant of hypermetricosis where the data collection process not only does not yield meaningful and useful data but also impairs, sometimes dangerously, the delivery of care to individual patients.

MALIGNANT HYPERBUREAUCROSIS: A variant of bureaucrosis where the non-clinical/administrative workload not only does not yield meaningful and useful results but also impairs, sometimes dangerously, the delivery of care to individual patients.

PATIENT/PAYOR/(PHYSICIAN-PROVIDER) INCENTIVE MALALIGNMENT SYNDROME (PPPIMS): A fundamental condition of healthcare systems where the interests of

LETTING OFF STEAM

patients, healthcare providers and those who pay for services are not in alignment. It is argued that PPPIMS in the root cause of most of the problems extant in healthcare systems today.

JARGONOSIS SYNDROMES MEDICAL JARGONOSIS (“MEDICALESE"): Use of terms and acronyms by physicians and other healthcare providers to aid in the efficiency of communication among such providers. Medical jargon, not well understood by patients, impedes communication and understanding between providers and their patients.

Medical jargonosis exacerbates the nearly ubiquitous health illiteracy among patients at all socioeconomic and educational levels.

HEALTHCARE SYSTEM JARGONOSIS: Use of terms and acronyms by healthcare system administrators and regulators which aid in the efficiency of communication among such individuals. Healthcare system jargon is not well understood by most physicians and other providers or their patients. Healthcare system jargonosis impedes communication and understanding among all healthcare stakeholders and exacerbates bureaucrosis syndromes.

HYPOPYROSIS SYNDROMES IATRIC HYPOPYROSIS: PHYSICIAN BURNOUT. Physicians lose their sense of purpose and humanity. Often caused and exacerbated by healthcare systemic syndromes and working with others who also suffer from hypopyrosis syndromes.

PROVIDER HYPOPYROSIS: Non-physician provider burnout. Often caused and exacerbated by healthcare systemic syndromes and constantly dealing with behavioral issues caused by physicians and other providers who also suffer from hypopyrosis syndromes themselves.

Adam V. Ratner, MD, FACR, is chairman of The Patient Institute and clinical professor and deputy chair for strategic development and socioeconomics of the Department of Radiology at the University of Texas Health Science Center at San Antonio. He also advises individual physicians and medical practices to more successfully navigate changing healthcare environments.

visit us at www.bcms.org

17

OPINION

Shamelot

… a medi-evil tale of the Plights of the Round Stable

By Robert G. Johnson, MD

A short time to go in a land near away, in the country of CitrUS, there was a young boy/girl who had a clever idea. Now the land of CitrUS was green and verdant, a land of hopes and dreams, flowing with milk and fruit trees. The child opened up a lemonade stand, round in shape, as all were equal in CitrUS. They also dispensed limes and oranges and other fruits, and their business thrived.

But the government of the Grand Duchy of CitrUS also expanded along with the fattening economy. Before long, the Council of Elders passed an edict enabling seniors free access to orange-lemonaid, with Medipear Insurance, cutting reimbursements for the health-giving beverages in half (much to the boy/girl’s des-pear). At first it seemed like the right thing to do — helping the elderly with access to delicious nectars, but soon, every customer had some low-bid HMO insurance (Help yourself to My Orange).

Before long, several regular clients came down with bird flu, and the lemonade stand was served its first lawsuit. Vitamin C was supposed to guarantee perfect health, and birds did build nests in fruit trees — the correlation was obvious. Following on the heels of the plaintiffs’ attorneys arrived the Fruit and Drug Agency. “We’ll need proof,” said the FDA, ”in the form of double-blinded, controlled, prospective stud-

18 San Antonio Medicine • November 2014

ies with 10-year follow-ups, that your lemonade won’t cause Lime Disease in its current dosages.” The now-struggling small business was slapped with a Don’t-Squeeze-and-Desist order.

The People’s Republic of CitrUS continued its meander into bigger and bigger government. HIPA (HypochondrIacal Potability Act) disallowed the use of client names, lists, spoken greetings, etc., and customers were assigned IDs: “Good morning, Unit 24601. Would you like your usual beverage? Oh no, I see you’ve had a recent birthday — 70 — the law states you’ll have go home and die of thirst.”

JCCO (Joint Commission for Citrus Oversight ) spot inspections became more frequent and demanding. Clothed in black capes and riding boots, and armed with pruning shears, they appeared unannounced and snooped about the stand and surrounding orchards. This elite force wielded the power to cut Medipear payments to the lemonade stand on a whim. The graying boy/girl, unfortunately having become dependent on business from the elderly, was forced to hire seers and extra scribes to deal with the expanding paperwork. High guard towers were erected around the stand, with lookouts, to warn of impending raids by inspectors.

OHSA (Orange you Happy Someone gives A— ) required breakrooms for the staph (no coffee), cov-

ered stables, disabled-friendly outhouses, ramps, foam-infoam-out protocols, and a-peeling work environment. The list went on: ACO, UnACcountable DisOrganization; CMS, Citrus Manglement DiSservice; STARK, Stop Thinking About Referring Kinfolk; IRB, Irresponsible Research with Bananas …

By this time, with the fruit stand gasping to keep its head above the juice line, the United Socialist Feudal Kingdom of CitrUS introduced a deadline for EMR (Electronic Mandarin Recording). No more fruit-tree-killing paper — go green! Each and every citizen’s consumption habits was recorded in the National Juicers Data Bank, located in the nation’s capital city of Washemandhangemoutodry. (One tiny bit of good news: The latest and most popular flavor, Melon Entitle-mint (it’s all about ME), was becoming a huge hit.) All were equal in CitrUS, but some, it seemed, more equal than others.

The lemonade stand owner, now bent and feeble, was forced to sell out and move to Florida. As their time grew near, they returned for one last glimpse of where it all had started. They hardly recognized the place, with electrified fences, chimneys billowing lemon-lime scented smoke, rows of computerized self-check-in counters, voice recognition robots, conveyor belts delivering hermetically sealed and sterilized containers of FDAapproved, government-inspected Citrus Flavored Beverage.

Wheeling into a handicapped space, they stared wide-eyed.

In the midst of this futuristic city, roped off with yellow biohazard tape, stood the now decrepit, original, round wooden lemonade stand. A long forgotten poem stirred: “Don’t let it be forgot, that once there was a spot …”

A child walked up to the dying owner.

“Gee,” he said with wonder in his voice. “I’d like to have my own lemonade stand some day.”

The feeble occupant of the wheelchair stirred. “Can you write, child?”

The child produced a pen and paper (the last remaining on the planet).

“Now listen carefully, and record everything I tell you.”

The child nodded, his eyes huge.

The ancient voice was weak, but clear. “A short time to go in a land near away …”

Robert G. Johnson, MD, is an orthopaedic spine surgeon with Neurosurgical Associates of San Antonio. A frequent contributor to San Antonio Medicine, he has been a BCMS member since 1989. visit us at www.bcms.org

19

BCMS NEWS

Bexar County recognizes BCMS Women in Medicine

Bexar County Commissioners Court recognized BCMS and its Women in Medicine Committee with a proclamation issued Oct 7. “The progress of women in medicine is a long and continuing journey,” the proclamation stated. “There are many pioneering women physicians to thank and many accomplishments to celebrate.”

Attending (from left) were Commissioner Tommy Adkisson, Precinct 4; August Treviño, BCMS development director; Commissioner Sergio “Chico” Rodriguez, Precinct 1; Brissa G. Vela, BCMS director of membership; Commissioner Paul Elizondo, Precinct 2; Dr. Janet F. Williams; County Judge Nelson Wolff; Dr. K. Ashok Kumar, BCMS President; Dr. Lan-Anh Ngo; Commissioner Kevin Wolff, Precinct 3; Dr. Leah Jacobson; and Melody Newsom, BCMS COO. The 22nd annual BCMS Women in Medicine annual recognition event will be held Nov. 1 at the Omni San Antonio Hotel with the theme, “Good Health is Always in Fashion – Nurture Your Soul.”

TMA stands firm in opposition to audiologists' scope proposed legislation

By Mary E. Nava, MBA Chief Governmental and Community Relations Officer Recently, TMA joined with more than 110 national organizations, along with state and local medical associations and specialty societies, to address Congress in a letter vehemently opposing H.R. 5304, the Audiology Patient Choice Act of 2014, which would provide audiologists with unlimited, direct access to Medicare patients without a physician referral.

Equally troubling is that the proposed legislation also would amend Title XVIII of the Social Security Act to include audiologists in the definition of "physician."

To read the letter to Speaker John Boehner and Leader Nancy Pelosi, visit www.texmed.org.

Among those attending the BCMS fishing tournament Oct. 3 were Judy and Dr. Lorence Trick (from left), guide/captain Danny Adams, and Dr. Fred and Sondra Olin. Special thanks to Dr. and Mrs. Delbert Chumley for happy hour at their bayside retreat, and to sponsor Stefen Brooks, Gateway Mortgage Group LLC. Photo by Kris King

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

David Clay Wolfe, MD, died Sept. 8, 2014, at age 82.

Dr. Wolfe, a BCMS member, was an orthopaedic surgeon in the U.S. Air Force and in private practice in San Antonio and Seguin.

20 San Antonio Medicine • November 2014

IN MEMORIAM

BCMS NEWS

NOTEWORTHY Michael Arambula, MD, has been named chair of the Texas Medical Board. The board protects and enhances the public’s health, safety and welfare by establishing and maintaining standards of excellence used in regulating the practice of medicine and ensuring quality healthcare for Texas. Dr. Arambula is a psychiatrist in private practice, an adjunct associate professor in the Department of Psychiatry at the University of Texas Health Science Center at San Antonio, and a BCMS member. The length of his TMB appointment as chair is determined by the governor.

community health, medical education, and his service as president of the UTHSCSA and chancellor of the UT System.

Ernesto Guerra, MD, was honored Sept. 20 at the Holy Cross of San Antonio third annual President’s Blue and Gold Gala with the 2014 Lifetime Achievement Award. Dr. Guerra, of San Antonio Gastroenterology Associates, is a BCMS member. He was recognized for his support of Catholic education. Holy Cross is an independent Catholic co-educational college preparatory middle and high school.

Francisco G. Cigarroa, MD, received the BioMed SA 2014 Julio Palmaz Award for Innovation in Healthcare and the Biosciences on Sept. 18.

BioMed SA is a nonprofit corporation focused on growing and promoting San Antonio’s healthcare and bioscience sector. The ninth annual award, named after Palmaz Stent inventor Julio Palmaz, MD, honors individuals for significant contributions to advance the fields of healthcare and bioscience. Dr. Cigarroa, a pediatric transplant surgeon and BCMS member, was honored for his roles in medicine,

Basil A. Pruitt Jr., MD, FACS, was named science committee chair of the National Trauma Institute, a nonprofit organization that advocates for increased federal funding for trauma research and research infrastructure to reduce death and disability. Dr. Pruitt is a clinical professor of surgery, the Betty and Bob Kelso Distinguished Chair in Burn and Trauma Surgery, and the Dr. Ferdinand P. Herff Chair in Surgery at the University of Texas Health Science Center at San Antonio and a BCMS member.

visit us at www.bcms.org

21

BCMS NEWS

22 San Antonio Medicine • November 2014

BCMS NEWS

Unsung Hero honored Mary Casiano, automation engineer at Urology San Antonio PA, was named the BCMS Unsung Hero for September.

The Unsung Hero program allows BCMS members to recognize their office managers/administrators for their dedication and hard work in assisting physicians in delivering the best attention and care to patients.

Casiano was nominated by Dr. Clayton H. Hudnall, who wrote: “Mary is one of those quiet individuals who excels based on an inner drive, who brings insight to every project, and whose exemplary ethics and strong values guide her life and her interactions with others.”

Casiano joined the practice in 2006 as an administrative assistant, and graduated from the University of the Incarnate Word in December 2013 with a degree in engineering management. Casiano has reworked staff scheduling, developed internal systems for accounting and budgeting, and currently oversees a major update in the practice’s information technology.

“She is selfless in her desire to help others, claiming, ‘Look what we did,’ when the work was exclusively hers,” Dr. Hudnall said.

“Whether it is integrating complex spreadsheets or redesigning clinical workflows, she completes tasks efficiently, on time and below budget. We call her our ‘Automation Engineer’ but her real title should be miracle worker.”

Physician members: Please remember to recognize your "Unsung Hero." Monthly deadlines and additional information are at www.bcms.org.

(Front row, from left) Elizabeth Martinez, human resources liaison; Abbey Forney, communications director; Unsung Hero Mary Casiano, automation engineer; and Gloria Clark, chief operations officer.

(Back row, from left) Alan Winkler, executive director; Dr. Clayton Hudnall, board president; Dr. William Harmon, board vice president; and Steve Flageol, director of finance. Photo courtesy Urology San Antonio

visit us at www.bcms.org

23

BCMS NEWS

TMA president visits San Antonio twice in two weeks UTHSCSA medical student Gilda Digman (left), BCMS President Dr. K. Ashok Kumar and TMA President Dr. Austin King visit informally at the BCMS General Membership Meeting Sept. 24 at the Hilton San Antonio Airport.

Participants at the BCMS General Membership Meeting Sept. 24 listen as TMA President Dr. Austin King presents a legislative update and shares personal anecdotes about his involvement in organized medicine. Dr. King urged those in attendance to become active in BCMS and in TMA to advocate on behalf of their profession.

BCMS President Dr. K. Ashok Kumar (left) listens to a presentation by TMA President Dr. Austin King Oct. 6 at the UTHSCSA medical school. Approximately 150 students attended the luncheon program.

Dr. King encouraged them to become involved in organized medicine, and discussed specific programs and opportunities for student involvement, such as the First Tuesday visits to the Legislature in Austin. Medical students receive free membership in BCMS and TMA. Photos by Susan A. Merkner

24 San Antonio Medicine • November 2014

BCMS NEWS

Events recognize links between BCMS, UTHSCSA

MEMBERSHIP UPDATE ACTIVE Adebukola Adedeji, MD, General Surgery Julio Gutierrez, MD, Hepatology Parmish Kohlo, MD, Nephrology Sarah Lopez-Llado, MD, Internal Medicine Bacel Nseir, MD, Infectious Diseases Vasudha Panday, MD, Ophthalmology

BCMS President Dr. K. Ashok Kumar (center) visits with students at a reception in honor of UTHSCSA medical students July 24. Students were encouraged to participate in BCMS and to play an active role in their profession. BCMS representatives also attended the event to answer questions from the students about opportunities for involvement in BCMS activities and committees.

UTHSCSA students enjoy refreshments at a reception July 24 while talking with BCMS President Dr. K. Ashok Kumar, who is a member of the medical school faculty. Medical students, who receive free membership in BCMS and TMA, were encouraged to become active in organized medicine through the professional groups. Photos by Brissa Vela

ACTIVE FIRST YEAR IN PRACTICE Mark Glover, MD, General Surgery

MEDICAL RESIDENTS Brian Griffith, DO, Radiology

MEDICAL STUDENTS Jamie Archambault Anam Azimuddin Vitali Azouz Joshua Barker Jacob Boyd Alexandra Cole Seth Cope Ryan Folsom Mashala Horton Luyang Jin Ellen Johnson Caleb Jones Jade Law Steven Madsen Melissa Meyer Nathanael Phillips Mecklin Ragan

MILITARY The 2014 President’s Gala of the University of Texas Health Science Center at San Antonio was held Sept. 13 at the Grand Hyatt San Antonio. University President Dr. William L. Henrich, MACP, honored Tom and Pat Frost for their support of the Health Science Center and the community. Among those attending were BCMS life member Dr. Charles Rockwood (from left), Jane Rockwood, Missy Rockwood and Dr. Andrew Rockwood, a member of the Hill Country County Medical Society. Photo courtesy UTHSCSA

Alexander Black, MD, Pediatric Cardiology Kelly Joanne Morales, MD, OB/GYN Randall Curtis Zernzach, MD, Pediatrics Behavioral/Developmental

visit us at www.bcms.org

25

NONPROFIT

San Antonio Food Bank’s new Pharm2Farm program: An apple a day keeps the doctor away, but only for those who can afford apples Special to San Antonio Medicine Remember the old adage, “An apple a day keeps the doctor away”? There is a growing body of evidence in the field of nutrition science that this sage advice is in fact true: a daily helping of fruits and vegetables, in combination with a commitment to staying physically active, is proving to be the simple and effective prescription to combat diabetes, obesity and heart disease. But just because the solution is simple doesn’t necessarily mean it is an easy solution for everyone to implement.

Barriers to staying physically active are probably the easiest for most everyone to overcome. For people who have not been active, something as simple as 30 minutes of walking a day will start to produce big benefits in overall health and well-being.

It is in the area of consuming more fruits and vegetables in our diet that many people, particularly low-income families, seem to face more challenging barriers.

26 San Antonio Medicine • November 2014

NONPROFIT Not a week goes by these days when we don’t hear from a doctor or healthcare professional who wants to learn how to get their low-income patients more fruits and vegetables. Their patients could benefit from the rewards of consuming more produce, but because of strapped finances they often skip these items for cheaper foods that won’t perish as quickly and will fill them up faster.

LIMITED CASH FOR GROCERIES To be sure, apples themselves aren’t the most expensive item in the grocery store. But the reality for most lowincome families is that buying perishable fruits and vegetables just doesn’t seem to be the best way to stretch their very limited cash available for groceries. According to the San Antonio Food Bank, after paying basic household, transportation and healthcare expenses, a low-income family does not have enough cash to meet their monthly nutritional needs.

What do families do to cope? Many work multiple jobs; others visit food pantries; some find temporary help from public programs such as SNAP, but nearly all start to skip meals and steer away from the perishable-produce aisles at the grocery store.

The Food Bank recently launched a new initiative aimed at getting low-income individuals the fruits and vegetables they need for a healthier lifestyle.

Pharm2Farm is a unique program in which a physician writes a produce prescription for a low-income patient that can be redeemed at a Food Bank mobile farmer’s market. The dose and duration of the produce prescription will be determined by the doctor, and the Food Bank will raise the money to allow the prescription to be filled for free.

WRAP-AROUND SERVICES Pharm2Farm also will engage low-income patients with critical wrap-around services: meal planning, budget planning and healthy cooking. Getting a weekly dose of produce, in conjunction with learning and implementing new lifestyle behaviors, is a solution that simultaneously improves health and well-being for the patient and reduces healthcare costs.

Hippocrates coined the term “Food is medicine.” Join the Food Bank as a new prescription for health is brought to the San Antonio area, and put the idea of food as medicine into concrete action. The “farmacy” prescription, supported by San Antonio’s world-class medical community and its generous philanthropy community, is ready.

Learn more and get involved at www.safoodbank.org. visit us at www.bcms.org

27

BUSINESS OF MEDICINE

Understanding economic dynamics to survive and thrive in healthcare markets

By Lee W. Bewley, PhD, FACHE The modern healthcare market often seems to be a cooperative battlefield. The interactive, multi-disciplinary nature of the practice of medicine requires that providers, institutions, insurers, and other market players dually coordinate and compete for market share and margins. A prime organizational guiding tenant is that firms seek to remain a “going concern” continuing to generate sufficient value to customers and stakeholders that will provide a resource basis to avoid bankruptcy, liquidation, or some other selection from the marketplace; however, beyond this tendency of organizations to avoid dying, is a larger goal of generating substantial market value yielding competitive advantage within the marketplace. In simplest terms, organizations first seek to survive and then thrive when competing for resources. Economics provides a framework to judge the likelihood of an organization being able to achieve either or both of these prime strategic goals within respective markets.1 28 San Antonio Medicine • November 2014

Efficient or perfectly competitive market conditions serve as a useful tool for healthcare executives to judge potential viability of business models or initiatives. Perhaps an even more valuable application of this economic framework in the strategic market game of “survive and thrive” is possessing a clear understanding of the position of a firm among competitors that will enable development of strategic “shields and swords.” Strategic shields may serve to protect firms from market selection in the face of other firms’ competitive advantages while strategic swords may be employed to seize the initiative and gain market share and resources.

COMPETITIVE MARKETS Economist Alfred Marshall, building upon the work of others in the field, is generally credited with establishing the basis for assessing perfectly competitive markets: many buyers and sellers, homogenous

BUSINESS OF MEDICINE

product/service, zero transaction costs, free entry/exit from the marketplace, and perfect information. When these conditions exist in markets, efficient allocations of resources are expected characterized by a single market clearing price, balance in value experienced between buyers and sellers, and no market power. In practice, a truly perfectly competitive market is extremely rare, but deviations from these conditions are highly prevalent and can yield both opportunities and threats for firms in the healthcare market.2, 3 Applying the requirement of many buyers and sellers to the healthcare market finds efficient market problems on both sides of the transaction. While virtually every person within a market exists as a potential buyer of health services, varying or no insurance coverage and the peculiar nature of third-party payers in our markets inhibits natural participation in market exchanges. Many factors, including the other conditions for efficient markets, impact the number of health services sellers in the market. Healthcare executives must assess the level of competitiveness in their own market for those segments of the healthcare market that they intend to serve. If scarce or no competition exists, then sword-like initiatives such as cutting reimbursement discounts may be in order, but in the face of meaningful competition, developing shields such as community service and loyalty programs may be in order.

The efficient market condition of product or service homogeneity is predicated on making consumer and producer choices simple.

While state licensure requirements and accreditation standards establish a baseline of commonality within the market, varying levels of heterogeneity exist throughout the market in many forms including reputation, levels of technology, or facilities. Heterogeneity in health services creates complexity in the market that can be utilized to positively differentiate from competition to secure resources (revenue, staff, etc.) or disable organizations from demonstrating value.

Transaction costs in markets are those costs that must be borne by a buyer before a normal buyer-seller exchange occurs. For buyers, these costs are often transportation and health services information seeking related. For sellers, contract negotiations, adherence to licensing\accreditation standards, procurement of specialized equipment, and/or recruitment of staff exist as major transaction costs in the healthcare market. Strategic success in this area of perfect market condition is dependent upon understanding the aggregate balance of transaction costs serves to protect or compromise organizational competitive viability relative to other competitors.

The ability of buyers and sellers of health services to enter and exit the marketplace ensures that resources are focused to the opportunity for greatest return (seller) or satisfaction (buyer) across markets. Encumbrances to the ability of health services sellers to enter the market may effectively shield organizations from compe-

tition while ready access to markets provide organizations the opportunity to charge into the field to compete.

KNOWLEDGE ASYMMETRY Finally, the condition of perfect information among buyers and sellers of health services ensures clear understanding of the benefits, costs, prices and effects of services and products. Among all conditions of perfectly competitive competition, knowledge asymmetry is often the most pervasive deficit. Often, this economic problem can be professionally challenging for physicians and other providers trying to serve as “perfect agents” for their patients while also serving the economic interests of the group practice or organization. The healthcare executive must assess where knowledge deficits exist to protect against adverse selection problems and to find where relative knowledge surpluses or the ability to process information more efficiently than competitors facilitates actions leading to thriving activities.

Long ago, Cervantes observed that “all is fair in love and war.”

While most citizens should seek and expect efficiency in our economic markets, those organizations and individuals who have invested resources in markets are often well-served to ensure the survival and potential thriving success of their enterprise by responding appropriately and legally to less-than-perfectly competitive market conditions. Much the same as actual war, healthcare executives and their organizations may be well-served by recognizing conditions that are far removed from being fair and competitive.4

REFERENCES 1.

2.

3.

4.

Ginter, Peter, Duncan, Jack, Swanye, Linda (2013). Strategic Management of Healthcare Organizations (7th edition).

Jossey-Bass. San Francisco, California.

Marshall, Alfred (1920). Principles of Economics (8th edition).

Cosimo Classics. New York.

Baye, Michael (2006). Managerial Economics and Business Strategy (5th edition). McGraw-Hill. Boston, Massachusetts.

Cervantes Saavedra, Miguel de, and Edith Grossman (2003).

Don Quixote (reprint). Harper Perennial. New York.

Lee W. Bewley, PhD, FACHE, is a retired Army officer, associate professor of healthcare management, and a board-certified healthcare executive. He is a faculty member in the Walker School of Business at Webster University in St. Louis. He has served as the program director of the Army-Baylor University MHA/MBA program and as an adjunct faculty member at the University of Texas at San Antonio, Trinity University and University of the Incarnate Word. visit us at www.bcms.org

29

NONPROFIT

FAQs: The Rape Crisis Center

By Deana Buril, deputy director of client services at the Rape Crisis Center

The mission of the Rape Crisis Center is to provide comprehensive services to victims of sexual assault and their families, and to conduct sexual assault prevention and education programs to youth throughout San Antonio, Bexar County and surrounding areas.

The following information is provided in response to questions frequently asked by physicians and their staffs.

RESOURCES FOR SURVIVORS OF SEXUAL ASSAULT If the sexual assault happened less than 96 hours ago, the following hospitals have certified Sexual Assault Nurse Examiner programs.

Advocates are available 24/7 to provide accompaniment.

For adults and adolescents who have gone through puberty: Methodist Specialty and Transplant Hospital Phone: 210-575-8168 (ER) 8026 Floyd Curl, San Antonio, Texas 78229 For children and adolescents under the age of 17: The Children’s Hospital of San Antonio Phone: 210-704-2190 (ER) 333 N. Santa Rosa, San Antonio, Texas 78207

30 San Antonio Medicine • November 2014

HOTLINE The Rape Crisis Center hotline is available 24/7 at 210-349-7273.

Trained hotline operators provide crisis intervention, resources and information to survivors and their loved ones.

COUNSELING All Rape Crisis Center counseling services are free and open to children, women and men. For more information or to make an appointment, call 210-521-7273.

The Rape Crisis Center is located at 7500 U.S. Highway 90 West, Bldg. 2, Suite 201, San Antonio, Texas 78227; www.rapecrisis.com.

UTHSCSA DEAN’S MESSAGE

GRADUATE MEDICAL EDUCATION: Institute of Medicine suggests how to improve the system

By Francisco González-Scarano, MD We often point out that a medical school grants a degree; a Graduate Medical Education (GME) program is necessary in order to obtain a license to practice. The GME system in the United States is arguably the best in the world, and the thousands of international medical graduates who seek training here – and not just to stay and practice in the United States – are a testament to its success.

However, there are problems with distribution of positions, both geographically and in terms of specialty. Most importantly, the number of residency slots has not kept up with the physician manpower needs of the country. In 2014, 1,800 graduates of U.S. medical schools were unable to match to a residency program in the National Resident Matching Program (NRMP). Subsequent offers reduced this number to closer to 400. The numbers provided by the NRMP are that in 1996 there were 20,563 positions with 24,718 active applicants, including AMGs and IMGs.1 In 2014, there were 26,678 positions for 34,270 applicants.2 The current GME funding system came to be as part of the creation of the Medicare and Medicaid programs in 1965. Put together as part of the Social Security Act, federal money has provided billions of dollars to fund GME, which includes residency and fellowship programs for both osteopathic and allopathic medical education. In 2012, tax dollars contributed more than $15 billion to support residency training, with 90 percent – $10 billion and $4 billion, respectively – coming from Medicare and Medicaid.3 The Veterans Administration is another, much smaller source. These amount to a trivial figure relative to the country’s healthcare bill, which is roughly $2.9 trillion.

INDEPENDENT REVIEW Because of concerns about the responsiveness of the system to the healthcare needs of the country, the Josiah Macy Jr. Foundation asked the Institute of Medicine (IOM) to conduct an independent review of GME and persuaded 12 other organizations to contribute to this effort. Two years in the making, the report was released this past summer. At 256 pages long, it discusses GME Medicare funding (though not other sources) and proposes some potentially controversial changes to what they perceive as problems.

The GME funding system was put in place when hospitaliza32 San Antonio Medicine • November 2014

tions for less-severe illnesses were more common. Despite significant changes since then, in nearly every aspect of healthcare delivery, funding and education, the GME system remains mostly unchanged, although programs themselves shifted to more outpatient training. The following bullet points, taken directly from the summary of the IOM report, crystalize the core issues as they saw them:

There are 3: • • • • •

a mismatch between the health needs of the population and specialty makeup of the physician workforce; persistent geographic maldistribution of physicians; insufficient diversity in the physician population; a gap between new physicians’ knowledge and skills and the competencies required for current medical practice; and a lack of fiscal transparency regarding Medicare/Medicaid financing.

It is nearly impossible to talk about each of these issues separately as they are all interrelated and can be tied back to the funding system, which makes up a majority of the IOM report’s focus.

Although the GME system has been producing more physicians, it has not kept pace with the number of medical school graduates, nor has it produced an increasing proportion of physicians who choose to practice primary care, or to provide care to underserved populations. And it is not just a primary care problem; many other important specialties and subspecialties – such as rheumatology, nephrology and endocrinology – are also in desperate need of more physicians, particularly as the number of older Americans increases.

Following the money was a difficult task for the group, noting in the report that “tracking the flow of GME funds is daunting.”

Further complicating the funding path, most states also support GME through their Medicaid programs; and some states provide other GME support through loan repayment incentives or even direct support. There are also private contributions, difficult to quantify, but including private insurers who support GME by paying higher rates to teaching institutions. Many residencies and fellowships are directly supported by hospitals, universities, physi-

UTHSCSA DEAN’S MESSAGE

cians’ organizations and faculty practice plans as well as private philanthropy and gifts or grants from industry. Of course, much of the resident subsidy is secondary to the need for skilled 24-hour coverage in many specialties, and for maintaining trauma centers, to name one major need5.

Furthermore, the Medicaid portion has been shrinking as some states opt out of providing GME funding.

Since 2000, the United States has added 26 new medical schools and most existing schools have increased class sizes. But budget cuts to Medicare/Medicaid and virtually no increase in GME funding in the last decade has resulted in training fewer physicians relative to the numbers of MDs graduating. This is contrary to the needs of our growing and aging population – which have dramatically changed the need for providers. This is ironic given that the original funding law in 1965 was tied to the care of the elderly.

BALANCED BUDGET ACT Most of the legislation regarding GME funding has involved limiting spending or allowing for slight increases only in certain aspects of the program. In 1997, as part of the “Balanced Budget Act,” residency slots were capped at FY 1996 levels due to Congress’ perception that there was an excess number of physicians.

This had the possibly unintended effect of also freezing geographic distribution (the Northeast has the largest concentration of training slots). In 1999, the cap for rural hospitals was increased by 130 percent of their 1996 levels. The Affordable Care Act created a five-year, $230 million program to increase primary care GME, and attempts to move some GME slots from hospitals with excess capacity to those in need of more physicians in the area (more rural hospitals).

The geographic “freeze” resulting from the 1997 Balanced Budget Act is troubling for states such as Texas, since there is a well-established connection between a physician’s residency training and where he or she will ultimately practice. The graph pub-

lished with the article, which was used in the report, speaks for itself in regards to the geographical funding disparity.

The graph, reprinted by permission above, and a study from a 2013 article in Health Affairs, 4 estimates that nearly 20 percent of all Medicare GME funding goes to the state of New York. For various reasons including the higher preponderance of teaching hospitals, the northeastern states have the most residencies slots, and generally, receive the most dollars/resident.

The IOM report notes there is very little tracking of Medicare funding and how it is spent. The group states that as they attempted to “follow the money,” they found a lack of accountability for the results. As the report says, “The financial underpinnings of the GME enterprise are complex and largely undocumented.

Hospitals are only required to report the data that are needed to calculate hospital GME payments.”6 Almost nothing about the GME programs is tracked or reported.

RECOMMENDATIONS According to the report, the fundamental question of Medicare/federal dollars as the main funding source was debated at length by the committee. Undergraduate medical education and many other professions also valuable to society receive no similar federal support as their foundation, so why GME? They looked at other scenarios such as an all-payer GME funding sysContinued on page 34 visit us at www.bcms.org

33

UTHSCSA DEAN’S MESSAGE Continued from page 33

tem or a completely new federal GME program. In the end, they recommended continued federal funding through Medicare (as program for the greater public good), noting that its effectiveness depends on secure and predictable funding – which would be less feasible as a private system or a discretionary line item subject to the politics of the federal budget process.

Public funding brings with it a responsibility for strong stewardship of the system, with appropriate supervision and tracking of the results of the investment. The committee’s recommendations get immediately to the difficulty of “rebuilding the plane while in flight” (my quote, not theirs) – and calls for funding the status quo (current amount with increases for inflation) while simultaneously “carving out” the development of a new system with innovative performancebased methodology.

The report also calls for building a graduate medical education policy and financing infrastructure as a GME policy council under the secretary of Health and Human Services. The council would be tasked with establishing a strategic plan and then establishing a department in Medicare and Medicaid Services to oversee and govern the distribution of GME payments. As a sign of the controversial nature of this recommendation, the American Association of Medical Colleges (AAMC) points out the inconsistency of recommending stable funding while taking out a portion of payments for innovative programs, and creating a new bureaucracy for administration. Furthermore, the committee recommended that Medicare support end after 10 years. This would almost immediately jeopardize the longest residencies such as neurosurgery (seven years), since programs would be in funding “limbo” three years into a proposed phase-out period. However, the proposal that some funds be devoted to research in graduate medical education (what works well, how can we develop even better physicians) is sound, and based on a dearth of data in this area.7 Graduate Medical Education funding and distribution is in need of an in-depth analysis and overhaul in order to ensure that it will meet the future needs of our population. The IOM report, which is free online, brings together the main points very clearly.

The other report, on geographic distribution, is much shorter.

Links to the reports are included here, as well as a link to the AAMC site where their thoughts are summarized. I encourage anyone interested in medical education to read them, and consider how you can influence the changes needed to secure our nation’s healthcare needs for the immediate and long-term future.

While the IOM report does not provide the final answer, it is a good start for an important conversation.

34 San Antonio Medicine • November 2014

LINKS Graduate Medical Education That Meets the Nation's Health Needs, Institute of Medicine: 2014 http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx The Geography of Graduate Medical Education: Imbalances Signal Need for New Distribution Policies; Health Affairs, 32, no. 11 (2013):1914-1921 http://content.healthaffairs.org/content/32/11/1914.full.html Medical Experts Say Physician Shortage Goes Beyond Primary Care AAMC Reporter: February 2014 https://www.aamc.org/newsroom/reporter/february2014/370350 /physician-shortage.html Innovation in Medical Education David A. Asch, M.D., and Debra F. Weinstein, M.D.; N Engl J Med 2014; 371:794-795 August 28, 2014 http://www.nejm.org/toc/nejm/371/9/

REFERENCES 1. NRMP Match Report 1996.

2. NRMP Match Report 2014 (Incomplete; as of April 2014).

3. Graduate Medical Education That Meets the Nation's Health Needs; Institute of Medicine: 2014; (Summary).

4. The Geography of Graduate Medical Education: Imbalances Signal Need for New Distribution Policies; Health Affairs, 32, no.11 (2013):1914-1921.

5. Medical Experts Say Physician Shortage Goes Beyond Primary Care; AAMC Reporter: February 2014.

6. Graduate Medical Education That Meets the Nation's Health Needs; Institute of Medicine: 2014; ( Sec. 3, page 1.)

7. Innovation in Medical Education; NEJM; Aug. 2014.

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

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

• ATTORNEYS 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

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. 210-247-2985 ewhite@bbandT.com www.bbandt.com

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 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.

Cadence Bank (HH Silver Sponsor) Cadence Bank is a full-service financial institution serving commercial, consumer, treasury and wealth-management clients in Texas and the Southeast.

Margarita Ortiz, 210-764-5500 maggie.ortiz@cadencebank.com Steve Edlund, 210-764-5573 steve.edlund@cadencebank.com http://cadencebank.com Explore Cadence Bank’s innovative financing options and treasury management solutions.

Citi Commercial Bank (HH Silver Sponsor) Chris McCorkle 210-408-5014 christopher.a.mccorkle@citi.com www.citi.com Continued on page 36

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 35

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

• CATERING Corporate Caterers (H Bronze Sponsor) A locally owned family franchise business serving the San Antonio area.

Ricardo Flores 210-789-9009 rflores@corpcatererstex.com

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

• CUSTOM HOMEBUILDING

Diamante Custom Homes (HHH Gold Sponsor) Experience your new custom homebuilding process through San Antonio’s leading designbuild firm. Over two decades of streamlining the balance between your budget and your dreams. The name you know from the builders you trust!

Keith Norman, 210-341-6430 knorman@diamantehomes.com www.diamantehomes.com Special promotions for all BCMS members – call us today!

• 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 • November 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

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.

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 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)

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

• HOSPITALS/ HEALTHCARE SERVICES

First Choice Emergency Room (HHH Gold Sponsor) The nation's oldest and largest

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY network of independent freestanding emergency rooms. Patients seen almost immediately.

Board-certified physicians and emergency-trained registered nurses. In-house CT scanner, ultrasound, digital X-ray and COLA/CIA accredited on-site lab to handle emergencies 24/7/365.

Nacogdoches Road 24-hour 210-447-7560 Tezel Road 24-hour 210-437-1180 www.fcer.com Check in online – free, easy, fast!

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

• 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 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

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.

Catto & Catto (HH Silver Sponsor) Providing insurance, employee benefits and risk-management products and services to thousands of businesses and individuals in Texas and the United States.

Crystal Metzger James L. Hayne Jr. 210-222-2161 www.catto.com Continued on page 38

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37

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

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, 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

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) We relentlessly defend, protect and reward the practice of good medicine. As the patient safety industry leader, we proudly offer a comprehensive selection of CME opportunity and risk-mitigation resources.

Kirsten Baze, 512-275-1874 KBaze@thedoctors.com www.TheDoctors.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 Know Your Doctor SA (HH Silver Sponsor) Increase your practice’s unique marketing/communications program. Connect with SA community through video, advertising, PR and medical opinion e-news.

Limited to 300 physicians.

Lorraine Williams, RN 210-884-7505 LWilliams@KnowYourDoctorSA.com www.KnowYourDoctorSA.com

38 San Antonio Medicine • November 2014

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 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

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

• PAYMENT SYSTEMS/ CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by 250-plus business associations.

Tanner Wollard, 979-219-9636 Tanner.Wollard@e-HPS.com http://www.heartlandpaymentsystems.com/ Lowered cost for American Express; next-day funding.

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY ing in magazine for Circle of Friends members.

• REAL ESTATE/ RESIDENTIAL

• PRINTING SERVICES

Kuper Sotheby's International Realty (HH Silver Sponsor) Joe Salinas III, 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com My hometown roots are based in Fredericksburg while my home away from home is San Antonio.

Local knowledge, exceptional results. Embrace your new life ... I'll help you become a connoisseur!

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

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.

• 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 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

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 October 13, 2014

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

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health

Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA

Contact BCMS today to join the 100% Membership Program!

South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA Village Oaks Pathology Services/Precision Pathology WellMed Medical Management Inc.

*100% member practice participation as of October 15, 2014. visit us at www.bcms.org

39

BOOK REVIEW

“Spillover: Animal Infections and the Next Human Pandemic” Reviewed by Fred H. Olin, MD My sister called me and strongly recommended “Spillover: Animal Infections and the Next Human Pandemic” by David Quammen.

When I was about three-quarters of the way through it, I called her back and told her that I was glad there wouldn’t be a test on it. It is packed full of information about the epidemiology of zoonotic diseases, virology, viral phylogenetics, zoology, agriculture and so much more it’s hard to remember it all … and I just finished the book this morning.

Quammen’s writing style manages to take difficult, complicated concepts and express them in terms that any educated person should be able to understand. He is a contributing writer for National Geographic, and with their help (and the help of others) traveled all over the world to produce this book. As an example of his style, this comes from the next-to-last chapter: “That’s the salubrious thing about zoonotic diseases: They remind us, as St. Francis did, that we humans are inseparable from the natural world. In fact there is no “natural world,” it’s a bad and artificial phrase.

There is only the world. Humankind is part of that world, as are the ebolaviruses, as are the influenzas and the HIVs, as are Nipah and Hendra and SARS, as are chimpanzees, and bats and palm civets and barheaded geese, as is the next murderous virus — the one we haven’t yet detected.”

We all know a little about some zoonoses such as rabies, flu and Q fever. Some of these conditions are only transmitted from animals to man, under most circumstances, but others (such as influenza and SARS) adapt, mutate and become epidemic among humans without the animal reservoir being needed for the transmission. That’s the definition of “spillover.” And that brings up a large portion of the book: the search for the “reservoir” for various diseases.

HOST ANIMAL The reservoir is defined as the host animal (mammal or bird) that has lived and evolved with a potentially pathogenic organism for a long, long time. It has reached a mutual non-aggression pact with the virus for the most part, and everyone gets along. But if that virus is accidentally transmitted to a species that doesn’t have the ability to fight it off, and it can be passed on to others, it can become a disease-causing problem. Remember the SARS outbreak in 2003? At first, a creature known as a palm civet, which is a delicacy in South China, was thought to be the reservoir host because people who developed SARS had had contact with civets, and animals tested from local civet farms and markets had evidence of antibodies to the causative coronavirus. So the government ordered the death of all farm and market civets. But wait!

Scientists trapped and sampled a bunch of wild civets, all of whom were found to be free of the virus! But then, where did it come from?

40 San Antonio Medicine • November 2014

And what was the civets’ role?

It turns out that the civets were an “amplifier host.” This is an animal that can harbor the pathogen without too much problem. The virus propagates and lives there, and then can be spread to yet another species for which it is pathogenic. After exploring several dead-ends, zoologists, virologists, veterinarians and others discovered that the reservoir was probably horseshoe bats. Bats, too, are eaten in South China. How did it get into the civets? One of the research groups wrote, “An infectious consignment of bats serendipitously juxtaposed with a susceptible amplifying species could result in a spillover and establishment of a market cycle while susceptible animals are available to maintain infection.” Quammen calls this “infection by association.”

One of the most educational and informational sections of the book is the one titled “Going Viral.” It contains a history of virology, a short course on the difference between DNA and RNA viruses, and a somewhat scary description of why RNA viruses are the really, really bad guys.

Among the diseases explored in this wonderful book are HIV/AIDS, Ebola, Q fever, Marburg virus, and good old influenza. Flu seems to be mostly a bird-borne virus, and pigs are occasionally an amplifier host. African fruit bats probably host Ebola. One strain of malaria is zoonotic: macaques in Southeast Asia host Plasmodium knowlesi. The other malarias appear to be ours alone, as are measles and polio.

If you like adventure books, do not despair. Quammen tells fascinating tales about catching bats in caves in Africa and in nets on a roof in Bangladesh, trekking through West African jungles to collect chimp feces, and exploring goat farms in the Netherlands. In my opinion, the best section of the whole book is chapters 99 to 101, where he tells the hypothetical story of the “real” HIV “Patient Zero.” This is not the unfortunate, massively promiscuous homosexual Canadian airline flight attendant Gaetän Dugas, who died in March 1984, but a lucky hunter in the southeastern part of Cameroon in 1908. He catches a chimpanzee in a trap, kills and butchers it (they still eat chimps there), and starts down river, fetching up in Leopoldville, later Kinshasa, on the Congo River. He is infected by the chimp (who probably got it from a fruit bat) and starts the whole HIV/AIDS ball rolling. You’ll read every word. It’s Huckleberry Finn without Jim, and echoes throughout the world today.

Fred H. Olin, MD, is a semi-retired orthopaedic surgeon, former veterinarian and 2014 chair of the BCMS Communications/Publications Committee.

visit us at www.bcms.org

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

* Fernandez Honda 8015 IH-35 South

Ingram Park Auto Center 7000 NW Loop 410

Ingram Park Auto Center 7000 NW Loop 410

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

Ingram Park Auto Center 7000 NW Loop 410

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

Ancira Ram 10807 IH-10 West

Mercedes-Benz of San Antonio 9600 San Pedro Ave.

North Park Subaru 9807 San Pedro Ave.

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

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

* Mini Cooper The BMW Center 8434 Airport Blvd.

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

Batchelor Cadillac 11001 IH-10 at Huebner

* Ancira Volkswagen 5125 Bandera Rd.

Northside Ford 12300 San Pedro Ave.

* North Park Lexus 611 Lockhill Selma

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

Cavender GMC 17811 San Pedro Ave.

Cavendar Cadillac 801 Broadway

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* North Park Lincoln/ Mercury 9207 San Pedro Ave.

Cavender Toyota 5730 NW Loop 410

Porsche Center 9455 IH-10 West

AUTO REVIEW

Audi A3 sedan: Pleasurable driving, top-shelf interior; hatchback model due out next year

By Steve Schutz, MD I've written about Audi's amazing sales growth a number of times before, but their progress has accelerated, so it's time to talk about it again.

First some data: Audi has posted monthover-month sales gains — that is, one month’s sales this year versus the same month last year — for more than 40 consecutive months. Their sales are double what they were just five years ago. Ten years ago, Audi sold just 77,917 vehicles, compared with 287,917 Lexuses. This year the totals will be about 168,000 for Audi and roughly 276,000 for Lexus. For the first time ever, Audi sold more units in a month than Cadillac. And let's not forget that in the dark days following a sudden acceleration scare in the late 1980s, Audi almost pulled out of the United States after selling just 12,283 cars here in 1991. (They moved 16,867 units just 44 San Antonio Medicine • November 2014

in June 2014.)

There are many reasons for Audi's remarkable surge, but ultimately it boils down to one sine qua non: product. Audi now has excellent products, and customers are responding.

FOUR-DOOR HELPS SALES The new A3 sedan, famously launched with a hilarious Super Bowl ad featuring a Chihuahua-Doberman mix and Sarah McLachlan, is a representative example of an excellent Audi product. After doing just OK with the previous generation A3 hatchback, Audi decided to go with a more conventional four-door sedan. And it's outselling the old A3 almost 10:1 and would be doing even better if dealers could get more cars. Not only is the four-door configuration helping sales, but the A3's good looks and the presence of numerous upscale amenities are also

driving customer interest.

So far large numbers of first-time Audi buyers are purchasing A3s. It's probably worth noting that those new customers will go away if they find that busy Audi dealers don't provide a better owner experience than they received from Ford, Honda or Toyota.

Audi, you are warned.

Driving the A3 is a treat, as a recent topplace finish in a Car and Driver comparison test against the Mercedes CLA and BMW 2series emphasizes. Audi's parent company Volkswagen spent a rumored $2 billion on a modular architecture that is expected to underpin everything from the tiny Euro-only Volkswagen Polo to the upcoming 2016 Audi Q5 SUV. The A3 is the first vehicle for sale here to sit on that MQB platform, and you can feel all that money in the solidity of the driving experience. Despite most of the

AUTO REVIEW

weight of the A3 being forward of the car's center, there's no discernible understeer, even when you're in a hurry. And cruising on the interstate is comfortable without those OMG moments you get in other small cars as you're passing a semi pulling two trailers.

No, the A3 isn't an A8, so there's more noise and less poise than you get with vehicles of that ilk at speed on the highway, but the A3 is still better than it was and better than most of the competition.

While it's a surprise to see Audi equaling Mercedes and BMW in driving dynamics, a top-shelf interior is expected from Volkswagen's luxury arm, and the A3 delivers in that department. Despite it being Audi's entrylevel vehicle, the materials in the A3's cabin look expensive and feel special, and the German brand's typically gorgeous gauges with sharp white numbers and red lighting are

present as they are in every other Audi.

Packaging is a downer, though. For now the Germans have given up on hatchbacks, which means that when it comes to bringing it with you, you're limited by a small trunk.

While the rear seat back can be folded down, no way can the A3 sedan haul as much a similarly sized hatchback can. If that's a problem, you might consider the Lexus CT 200h hatchback. Or if you can wait, a new A3 hatchback is expected here in 2015 (with an available diesel engine).

QUATTRO AIDS HANDLING Audi is following Mercedes' lead with their CLA marketing and has framed the A3 as a $30,000 car. It's not. Average transaction prices are running around $35k as customers find they can't resist upgrades like the bigger engine, upgraded upholstery, and, especially,

Quattro all-wheel drive. Obviously, Texans don't need AWD for snow and sleet, but I wouldn't own an A3 without Quattro because it helps handling in all weather conditions.

Only time will tell how long Audi can continue to march up the sales charts, but as long they keep producing hits like the new A3, it's likely to be a while. The A3 may be small, but it delivers.

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

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

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46 San Antonio Medicine • November 2014