San Antonio Medicine January 2016 by Traveling Blender

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SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL

VOLUME 69 NO. 1

Dr. Jayesh Shah 2016 BCMS President

SAN ANTONIO, TX PERMIT 1001

PAID

NON PROFIT ORG US POSTAGE

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

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MEDICINE

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SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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WWW.BCMS.ORG

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$4.00

Bexar History

Part 1: Frontier Medicine ........................14 Part 2: Notable Physicians of the

Part 3: organized Medicine in the

19th Century...........................................24

SUBSCRIPTION RATES: $30 per year or $4 per individual issue

By J. J. Waller Jr., MD

BCMS President’s Message ...........................................................................................................8 BCMS News..................................................................................................................................10 Book Review: Women in Prison by Fred H. Olin, MD ..............................................................................28 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................30 Financial Mistakes Made by Doctors by Jim Rice, CPA..........................................................................32 Business of Medicine: Healthcare Mergers by Dana A. Forgione, Ph.D., CPA, CMA, CFE ...................34 BCMS Circle of Friends Services Directory .............................................................................................37 In the Driver’s Seat...................................................................................................................................43 Auto Review: 2016 Mustang GT, By Steve Schutz, MD...........................................................................44

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4 San Antonio Medicine • January 2016

Janis Maxymof janismaxymof@gmail.com

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BUSINESS MANAGER: Vicki Schroder

VOLUME 69 NO. 1

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

Bibliography.............................................26

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

19th Century...........................................19

PUBLISHED BY:

JANUARY 2016

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.

NINEtEENth CENtury MEdICINE IN BEXAr CouNty

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

For more information on advertising in San Antonio Medicine, Call SmithPrint, Inc. at 210.690.8338 SmithPrint, Inc. is a family owned and operated San Antonio based printing and publishing company that has been in business since 1995. We are specialists in turn-key operations and offer our clients a wide variety of capabilities to ensure their projects are printed and delivered on schedule while consistently exceeding their quaility expectations. We bring this work ethic and committment to customers along with our personal service and attention to our clients’ printing and marketing needs to San Antonio Medicine magazine with each issue.

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BOARD OF DIRECTORS

OFFICERS Jayesh B. Shah, MD, President Sheldon Gross, MD, Vice President Leah Jacobson, MD, President-elect James L. Humphreys, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary Adam V. Ratner, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Jorge Miguel Cavazos, MD, Member Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John W. Hinchey, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Jennifer Lewis, BCMS Alliance President Roberto Trevino Jr., MD, Board of Censors Chair Jesse Moss Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director Alice Sutton, Controller

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Fred H. Olin, MD, Member Esmeralda Perez, Community Member David Schulz, Member J.J. Waller Jr., MD, Member

6 San Antonio Medicine â&#x20AC;˘ January 2016

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PRESIDENT’S MESSAGE

An optimistic greeting from the new BCMS President By Dr. Jayesh Shah, 2016 BCMS President

Dear Friends, It is my privilege and honor to be your president and represent more than 4,700 Bexar County physicians, residents and fellows that make up the 8th largest county medical society in the United States. It is a very proud moment for me to represent you as your first president from our new home (at 4334 N. Loop 1604 West) reflecting our 162 years of glorious tradition and history. I take on this role as the BCMS President at a time when physicians are facing unprecedented challenges. But these challenges also bring opportunities for us as physicians to shape the best health care for our patients. Physician leadership is a must as our nation’s health care continues to evolve in the new century. Our patients expect us to take a leadership role and they want us to be in charge. A recent survey by American Medical Association showed that 75 percent of patients wants to see their personal physicians, even if they have to wait longer. A recent survey of 8,000 patients by the University of Chicago showed that 97 percent of patients wanted their doctor to discuss the treatment options with them and two-thirds of them wanted their doctor to make decisions for them. Polls consistently show that patients trust their physicians. We cannot let our patients down. I recently got invited to speak at the Optimistic Club’s international meeting in San Antonio. I was very impressed by their message on optimism which I would like to share with you as we start our New Year 2016.

The Optimist Creed Promise Yourself To be so strong that nothing can disturb your peace of mind. To talk health, happiness and prosperity to every person you meet. To make all your friends feel that there is something in them. To look at the sunny side of everything and make your optimism come true. To think only of the best, to work only for the best, and to expect only the best. To be just as enthusiastic about the success of others as you are about your own. To forget the mistakes of the past and press on to the greater achievements of the future. To wear a cheerful countenance at all times and give every living creature you meet a smile. To give so much time to the improvement of yourself that you have no time to criticize others. To be too large for worry, too noble for anger, too strong for fear, and too happy to permit the presence of trouble.

After I reflected back on my presentation, after meeting some extraordinary optimistic people at the Club, and after reading the book “Adversity to Success” by Ron Graves and Ron Palermo, I felt that if all physicians combined this positive worldview with determination, persistence and a strong work ethic, then we can overcome all adversities in practicing medicine and we can work together to “achieve the extraordinary.” Let us work together to change the tides and create the best physician-led health care system in the United States. I wish you all a Happy Holiday Season. Warm Regards, Dr. Jayesh Shah

8 San Antonio Medicine • January 2016

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BCMS NEWS

In Memoriam Estrella de Forster, MD, died on Nov. 20, 2015 at age 86. She was a BCMS member and past president of the Texas Medical Association 50-Year Club. William Pilcher Fitch III, MD, died on Nov. 29, 2015 at age 72. He was a BCMS Life Member. Michael J. Gagnon, MD, died on Nov. 18, 2015 at age 47.

BCMS and BCVI are moving! The Bexar County Medical Society and Bexar Credentials Verification Inc. will be moving into the new office building this month. The new office is located at 4334 N. Loop 1604 West, just inside the loop between Lockhill Selma and N.W. Military Drive, about two miles east of Interstate 10. All phone numbers and email addresses will remain the same. Beginning on Jan. 6, the old office at 6243 IH 10 West, Suite 600, will be packed up with the major portion of the move taking place on Jan. 8-9. BCMS and BCVI will be open for business at the new office on Jan. 11. BCMS will be located on the second floor of the 20,000 square foot building. There is also 10,000 square feet of rentable space available on the first floor.

Attention physicians with STRAC ID Badges that are about to expire or have expired. STRAC is working on a new security feature for the Version 3 badges. Until that is complete your STRAC ID badge will continue to work. BCMS will let you know in advance when they will be ready to issue new ones.

BCMS supporter of 8th Annual Healthy Futures of Texas Luncheon Healthy Futures of Texas held its 8th Annual Luncheon with the Stars on November 6 at the beautiful Tobin Center for the Performing Arts. Healthy Futures of Texas provides educational programs with evidence-based curricula for teens and parents in schools and agencies. Janet Realini, MD, president of Healthy Futures (standing) paused for a photo with guests at the BCMS table (l-r): Tyia Clark, Deanna Kitchen, Alie Cole and Gilda Digman, (all secondyear medical students); Mary Nava; Maria Tiamson Beato, MD and Jun Beato, MD. For local discussion on this and other advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at 210-301-4395.

10 San Antonio Medicine â&#x20AC;˘ January 2016

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BEXAR HISTORY

NINETEENTH CENTURY MEDICINE

IN BEXAR COUNTY This presentation on the history of medicine in Bexar County during the 19th century is divided into three parts: FRONTIER MEDICINE. NOTABLE PHYSICIANS OF THE 19TH CENTURY. ORGANIZED MEDICINE IN THE 19TH CENTURY.

There are many books and references in the literature concerning this period and they have furnished the information to compile these articles. There is a complete bibliography at the end of Part 3. By J.J. Waller Jr., MD

During the first 20 years of the 1800s, Texas was a province of the

abandoned as a mission and was converted into a hospital by the

Spanish government, administered from Mexico City. From 1821

Spanish government. The areaâ&#x20AC;&#x2122;s only physician, a civil employee,

to 1836 it was a state in the Republic of Mexico, and from 1836 to

treated all the residents of the county, including military, civilian set-

1845 it was the Republic of Texas. Thereafter it became a state in

tlers, and Indians residing in the various other missions. During the

the United States except during the Civil War when it was a member

Spanish rule of Texas, excellent records were maintained of the var-

of the Confederacy.

ious military and civilian medical problems encountered in the

While under Spanish rule, the physician at San Antonio de Bexar

province of Texas. These included extensive medical records, which

was appointed by the viceroy in Mexico City. From 1821 on, the

were then transmitted to the viceroy in Mexico and then onto the

physicians in Bexar County were independent practitioners or were

Spanish government in Madrid. From 1821 to 1836, during the pe-

part of the military units assigned to the San Antonio area.

riod of revolution of Mexico from Spain, the records decreased in

In 1805, the Mission San Antonio de Valero (the Alamo) was

14 San Antonio Medicine â&#x20AC;˘ January 2016

frequency and from 1836 to 1845, during the Republic, records were

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BEXAR HISTORY almost non-existent. Information from the Bexar county archives (translated from the

pox and malaria, the latter being treated with extract of cinchona bark (quinine).

Spanish documents) transmitted back to Spain indicated that the

Pneumonia, with varieties consisting of catarrhal, croupous and

prevalent diseases at the time consisted of smallpox, pneumonia, in-

interstitial, was treated with quinine, Dover’s powders, morphine,

flammatory influenza, malaria, extensive gonorrhea and syphilis in

and Veratrum, a local herb consisting of “Indian poke (Indian helle-

the military, and measles throughout the community. The various

bore)” and also the use of antipyrine (phenazone) for high fever. A

treatments recommended were suggested isolation, rest, fresh air,

quote from a doctor of the time was, “The disease abates only when

light diet, plenty of “rye water”, frequent bathing, cream of tartar

there has been time for repairs through the agency of nature and oc-

orally, and olive oil or butter externally applied.

casionally the art of man.”

Smallpox, initially introduced into Mexico by Hernando Cortez,

The treatment of tetanus had utilized many modalities, but it was

was rather widespread. In response to the pleas for assistance from

found that the hypodermic injection of oil of tobacco in a few drops

San Antonio de Bexar to Madrid, the king of Spain by royal decree

in water was successful in controlling severe spasms, but not the final

directed his royal physician to act. In 1805, a ship with a large num-

outcome of the disease. There were many ways of treating whooping

ber of children and a physician set sail for the Americas. Initially,

cough including cocaine, hyoscyamine, cannabis, and others. Most

two of the children had been vaccinated with the recent “Jenner dis-

successful was the use of bromide as a sedative to reduce the severity

covery”. The cowpox vaccine was given to two children. From this,

of the symptoms; however, this wasn’t a cure. Quinine was also uti-

two more children were inoculated every week from the prior two

lized in the treatment of whooping cough.

children who had been vaccinated. In this way, the vaccine was kept

Typhlitis (inflammation of the cecum, now known as appendicitis)

current until the ship reached Mexico. The process was then contin-

was diagnosed only when it had reached the advanced stage of peri-

ued throughout the province and eventually reached San Antonio

tonitis. Treatment consisted of sedatives to make the patient more

de Bexar. The population was convinced by the local physician of

comfortable, along with hot or cold packs to the abdomen, and ir-

the necessity and safety of the process, and the smallpox was on its

rigation of the colon when there was a possibility of obstruction. If

way to eventually being eradicated.

there was formation of an abscess in the abdomen that was palpable,

During the 1820s and 1830s, colonization of Texas by groups from the United States began, the first being that of the Stephen F.

then it would be drained. The mortality was very high, approaching 90 percent in children and about 30 percent in adults.

Austin colony. Among the people flowing to Texas were occasional

In the summertime, there were bilious disorders present, which

physicians: these physicians of the 19th century were engaged in the

were treated with calomel, quinine, and tartar emetic. Bloodletting

general practice of medicine. They depended largely on their five

was popular during the early period. In 1825 and 1830, there were

senses, their experiences, and their judgment in making a diagnosis

epidemics of “fevers of various types,” possibly including typhoid.

and treatment. Much of the medical treatment was similar to that

In 1832, an epidemic of cholera in Gonzales was controlled by es-

which existed in colonial America. The motto of the times was

tablishing a quarantine of the city from other areas of the state.

“bleed, puke, or purge.”

The treatment for extensive gunshot wounds consisted of boiled

Malarial fever was a great killer that existed in almost every com-

light oak bark (very strong) mixed with pounded char wood and

munity. Other diseases included yellow fever, tuberculosis, small-

Indian meal made into a poultice and placed around the gunshot

pox, diptheria, whooping cough, and various diarrheal conditions.

wound of an extremity or compound fracture for five days, after

An additional responsibility on the early doctor was the necessity

which the mortified parts fell off and the extremity then occasion-

to prepare and dispense his own medicine. Generally, these tasted

ally healed.

bad and consisted of medication such as quinine, turpentine, cas-

In 1857, it was reported that the treatment of yellow fever con-

tor oil, and bichloride of mercury (calomel), and included local

sisted of the use of lobelia and quinine, as against the early treatment

botanical preparations.

with bleeding or purging. Treatment of diphtheria was with potas-

In the 19th century there were two preventable diseases: small-

sium chlorate as well as steam inhalations of sodium chloride, carContinued on page 16 visit us at www.bcms.org

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BEXAR HISTORY Continued from page 15

bolic acid, or other antiseptics. Turpentine or lime were also added

Diagnoses and treatment were enhanced by the introduction of

to the inhalation formula at times. Secretions were regulated by the

the stethoscope (from England) in 1853, and the hypodermic syringe

use of the occasional dose of calomel.

was in general use by 1875. The latter part of the century saw the

Surgical treatment for internal conditions were almost unheard of in the first half of the century. Surgery was used mainly for the treat-

introduction of the germ theory of disease, broadly increasing a physician’s understanding of many infectious diseases.

ment of fractures, dislocations or external conditions. It was not until

Payment of the physician in the early days was primarily in goods

the latter 19th century that physicians attempted to utilize surgery

or services, rather than in hard cash. Money was in very short supply

for the problems within the body cavities. The latter half of the 19th

and his payment frequently was in the form of agricultural products,

century saw the introduction of numerous medical advances. Anes-

horses, cows, donkeys, etc. Frequently, there was barely enough to

thesia in the form of ether and then chloroform was made available.

cover the office expense and supplies.

Also, the use of Lister’s principle of antiseptic surgery was more widely accepted. Before the Civil War, the practitioner was frequently required

If we look at a page of a doctor’s journal dated 1853, we find the following:

to travel great distances to treat his patients, and as a result most of his time was required in house calls, either on foot, by horse-

January 2 – Note to W. G. Gray, MD, for account (past)

back, or buggy. With the increase of population, more roads and

by W. R. Lacey in amount of $9.28.

railroads, and the establishment of community in small towns, the

Interest 10% per year, $0.92.

physician’s ability was increased to see more patients in his office

Prescription and treatment that day and eye water-$1.30

for longer periods each day. These offices were generally located

January 29 – Prescription treatment and medicine, $2.50.

in his home, in his barn, in a local store, upstairs of a pharmacy,

March 3 – One cake of shaving soap, $0.20.

or outside in the open.

April 4 – Treatment and prescription, $1.00.

Practicing in the frontier was frequently a dangerous activity. In-

Total on the books: $15.40.

dian attacks continued up until the 1880s. There was also the threat of desperados waylaying the local physician out on a house call far from town. A doctor was trained to wield a six-shooter and fre-

In 1860, the annual income of physicians ranged from $300 to

quently was forced to utilize it. A certain Dr. Webb was making a

$600. By the 1890s, the average income was $1,000 to $2,000 per

trip from San Antonio to El Paso. His carriage or wagon was a “New

year with the latter considered a rather large income.

York rockaway” which was fit for sleeping. It was so armed that it

During these years, there were many places without regular

could be called an armory. It was a large vehicle with closed sides

physicians, but there were many ‘quacks.’ These individuals easily

and windows, and it contained the following armament: suspended

duped the public by advertising locally and promoting their tonics

from the top was a double-barreled gun, to one of the uprights on

and patented medicine. There were advertisements in local news-

each side was attached a sharp repeating rifle (6 shot), and a heavy

papers about various treatments also. Quacks and quackery pro-

revolver Colt six-shooter was strapped to each door. Dr. Webb and

ceeded uncontrolled, but in 1853 at a meeting of the newly

the driver carried a pair of Colt five-shooters and a pair of Derringers.

organized State Medical Association of Texas the problem of quack-

This enabled them to fire a round of 37 shots without having to re-

ery was presented by Dr. George Cupples of San Antonio for con-

load in case of an attack. On the frontier, circumstances were such

sideration by the group. In spite of such efforts, restrictions on

that whenever a doctor came into a community he had to become

irregular medicine did not occur until the latter part of the 19th

physician, surgeon, apothecary, nurse, sanitarian, friend, veterinarian,

century and actually was not solved until the passing of the Pure

counselor, civic leader, educator, and even a statesman.

Food and Drug Act in 1906.

16 San Antonio Medicine • January 2016

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BEXAR HISTORY

The following are some notices that appeared in the newspapers about various treatments: COUGH

DROPS

—

Take

tincture

blood-root, a syrup of pocacuanchia, syrup of squils, tincture of balsam tolu, and paregoric, and each of one ounce mix. Use in severe coughs from colds; it is a valuable mixture. Half of one drachm whenever the cough is severe. This appeared in the San Antonio Ledger of May 27, 1852. Another notice in the newspaper to cure hoarseness: CURE HOARSENESS — Take the white of two eggs and beat them with two teaspoons of white sugar, grate in a little nutmeg, then add a pint of lukewarm water. Stir well and drink often. Repeat the prescription as necessary and it will cure the most obstinate case of hoarseness. This appeared in the San Antonio Daily Herald of July 23, 1853. Another notice is the treatment of asthma: REMEDY FOR ASTHMA — An individual who has suffered from asthma and who has vain sought relief should give concern to the following remedy: “Procure common blotting paper, and thoroughly saturate it in a solution of nitre, (saltpeter,) and let it be carefully dried by the fire, or by exposure to the rays of the sun. On retiring at night, ignite it, and deposit it, burning, on a plate or square sheet of zinc or iron in your bedroom. This appeared in the San Antonio Daily Herald, January 28, 1858.

For most of the century, doctors who came to Texas were trained

of Health in Texas was formed near Houston. However, the next

elsewhere, since Texas was behind many states in the establishment

year the second Board of Health, much more productive, was

of medical schools. Graduates of medical schools had to compete

formed in San Antonio.

with the graduates of diploma schools that would give anyone with

The physicians of the 19th century faced many hardships and

$50 to spare a diploma. The New York Medical College of San

tribulations, and they practiced medicine to the best of their

Antonio was an embarrassment to all physicians. They awarded a

ability. Despite obstructions, they made great progress in the

diploma when the teaching staff consisted of a doctor, his wife,

last few decades of the century. Literature is brimming with in-

and his 6-year-old child who were listed as the faculty. The Galve-

formation about our early practitioners, their lives, and their

ston Medical College was established in 1865 and eventually be-

accomplishments. Presented here is only the briefest glimpse

came the University of Texas Medical School.

into that rugged era.

During the days of the Republic, Dr. Anson Jones, as president, instituted legislation for the control of physicians. It was finally passed the second time on Dec. 14, 1837, establishing a Board of

J.J.Waller Jr., MD, is a member of the

Medical Censors and outlining requirements for the licensing of

BCMS Communications/Publications Committee.

physicians, including a fee of $20 by the applicant. The first Board

visit us at www.bcms.org

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BEXAR HISTORY Charcoal drawing by Kathleen Waller Stewart, M.D.

18 San Antonio Medicine â&#x20AC;˘ January 2016

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BEXAR HISTORY

By J.J. Waller Jr., MD Many physicians practiced in the San Antonio Bexar County area during the 1800s, and the majority provided the best care possible under the frontier conditions. All should be remembered for their dedication and tenacity, but there were a few that contributed greatly to medicine and society for one reason or another. Dr. Frederico Zervan was the first physician mentioned in the archives of Spanish documents for Bexar County. He accompanied a bishop in 1805 on his travels through the province, and at the government’s request he remained in San Antonio de Bexar and was assigned to the new hospital in the Alamo. An incident occurred during this period in which the Attorney General of the province, made a complaint to the governor that Dr. Zervan was inefficient and inattentive to the patients, neglecting them, and was a quack and requested that the doctor be replaced. After an investigation by the governor, it was determined that the doctor’s practice was greatly appreciated by both the military and the people, and the complaint had no grounds whatsoever. Therefore, the governor exonerated the doctor, raised his pay to 30 pesos a month, and dismissed the attorney from the position as Attorney General. (Obviously, an early inkling of tort reform in Texas.) In 1808, Dr. Zervan retired and a new physician, a Dr. Munive, was appointed as the surgeon of the military hospital. He remained for two years and left, so there was no physician in the area, according to the archives, until 1819. In the archives, it is stated that in 1806 the government granted a Dr. Latigue permission to practice as a “master of surgery in the class of dentist.” In the archives there is no further mention of this individual, but he probably was the first dentist in San Antonio and possibly in the state of Texas. The first battle of the Texas Revolution was fought at Gonzales on Oct. 2, 1835, after which the Army of Texas under the direction of Stephen F. Austin and Ben Milam moved on to attack San Antonio. After a two-month battle, General Martin Perfecto de Cos, commander of the Mexican garrison and brother-in-law to Santa Anna, surrendered his 600-man garrison to the 250-man Texas Army. Several of the physicians with the Army in San Antonio at that time re-

mained in the Army to eventually fight and die in the Battle of the Alamo in 1836. One of those remaining in San Antonio was a Dr. Amos Pollard. He graduated from the Middlebury College and Vermont Academy of Medicine in 1824. He joined the Stephen F. Austin colony in 1834 and joined the Texas Army in 1835. Dr. Pollard was a part of the action in taking San Antonio, and he remained in the Alamo and was assigned as the Chief Medical Officer of the forces stationed there. He directed several urgent dispatches from the Alamo to Sam Houston and Gov. Henry Smith beginning several weeks before the siege by Santa Ana. He was urgently requesting either money or medical supplies and additional instruments that would be needed to care for any wounded that would occur in the forthcoming battle. Such assistance was not forthcoming, as were neither additional forces for the Alamo. He and two other physicians were among the gallant defenders who were overrun and annihilated on March 6, 1836. Certain it is that at the age of 33 he, along with the other two physicians, achieved for the medical profession a portion of the glory of the Alamo. His portrait hangs on the walls of the Alamo. Of particular interest at this time was the plight of two physicians who were assigned to Fannin’s command at Goliad and were spared from the massacre of the defenders on March 27, 1836. Eventually these two physicians, Dr. John Shackelford and Dr. Joseph Bernard, were under guard and escorted back to San Antonio to provide medical care for Mexican soldiers wounded in the siege of the Alamo. They remained there treating the wounded Mexicans and also some of the civil population for several months following the Battle of San Jacinto on April 21, 1836, which essentially ended hostilities with Mexico. Dr. Bernard remained in the Texas Army for another year and then opened a practice nearby. It should be noted that at the Battle of San Jacinto there was a San Antonio physician who was the only casualty of the action, Dr. William Motley, who was only 24 years old. Dr. Edward Weidermann was a physician practicing in Bexar County during the time of the Republic. He was a military surgeon, a Russian scholar and naturalist. He was highly cultivated and was considered an excellent physician and surgeon. On the night of Continued on page 20 visit us at www.bcms.org

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BEXAR HISTORY Continued from page 19

March 19, 1840, there was an Indian raid on San Antonio and Dr. Weidermann took an active part in the fight and killed two Indian warriors. He approached a friend’s house to borrow a cart to take the two bodies home. He explained that he needed actual skeletons to continue his studies and research. That night at his home he stewed the bodies in a soap boiler, and when the flesh was completely separated he emptied the pot into the acequia. This stream furnished the freshwater supply to the community for drinking, whereas the San Antonio River was used primarily for washing and bathing. There was a city ordinance to the effect that the acequia should not be contaminated under any circumstances and if violated would be coupled with a heavy fine. Dr. Weidermann now had his skeletons to study, but this was not considered appropriate by the townspeople; they were horrified to learn of the event, believing that the water of the acequia had been defiled by the doctor, and they were drinking particles of Indian in the fluid. In great indignation, a mob formed and had the doctor arrested, and he was brought to trial. He assured the judge and jury that the rapid-flowing acequia would have washed all the particles during the night into the river and people were not drinking “Indian soup.” Convinced for the most part, the court let the doctor off with a heavy fine, assuring him that if it were not for his previous good record he would have been run out of town at gunpoint! Dr. George Cupples was born in Scotland in 1815 and took his medical training at the University of Paris. He was persuaded to move to Texas after meeting Dr. Ashbel Smith, who was representing the Republic of Texas in the French court at that time. Dr. Cupples arrived in the San Antonio area in 1846 and opened a practice in Castroville. He moved to San Antonio in 1850, at which time the population of San Antonio was 1,000, of which 90 percent were of Mexican descent. When he opened his practice, he was either the second or third physician in San Antonio. During the Mexican war in 1846, he served as surgeon with the Texas Rangers. During the Civil War, he served as a surgeon to the 7th Texas Cavalry. Dr. Cupples helped to establish the Bexar Medical Society and was its first president in 1853. He was also instrumental in establishing the Texas State Medical Association at its organizational meeting in 1853 and he became its president in 1853. He returned to San Antonio after the Civil War to resume his surgical practice. This was a time of notable advances and changes in medicine and surgery, and Dr. Cupples participated in many of these events. He was the first surgeon in Texas to use a general anesthetic and this was in a case of an amputation of a leg. He was noted for performing several proce20 San Antonio Medicine • January 2016

dures for the first time in Texas. In addition to using ether and chloroform for the first time, he was the first in America to resect the tongue for cancer. He performed the first resection of an ovarian tumor in a child Dr. George Cupples, first BCMS President in 1853. age 6. He was the first surgeon in Texas to employ the Freund’s procedure for removal of the uterus and ovaries, and he was the first to amputate an extremity at the hip joint and also at a knee joint successfully. It is notable that these various procedures were performed without the benefit of a hospital being available. Also of note is that antiseptic surgery was not practiced in America until the end of the 19th century. However, Dr. Cupples describes scrubbing and cleansing of the operative sites during the above procedures. He helped establish a committee on surgery of the Texas Medical Association in 1885. He was chairman of the six-man committee that sent out 6,000 questionnaires to the physicians of Texas asking for information on the surgeries that had been performed with extensive detail and information about the patient and the procedure. Multiple aspects of the surgeries performed were requested and 138 surgeons responded. Dr. Cupples’ summary, a 74-page report, covers 4,293 operations, and the report was exhibited at the meeting of the Association in 1886. Included was the type of operation, mortality, anesthetics, vital statistics, and if antiseptics were employed and their effects and consequences. Most of the operations were not performed in hospitals but in the office, the patient’s home, or out in the open for better light. Chloroform was chosen over ether 35 to 1. Carbolic acid was practically the only antiseptic. Mortality was from 10 percent to 100 percent depending on the type of surgery. For all the major operations (2,080), the overall mortality was 16 percent. A review of the report was noted in the Journal of the AMA and in the British Medical Journal. It should be noted that in the report is the following quote by Dr. Cupples: “If the whole truth must be told, the writer of this report remembers to have read in the London Lancet some years ago, ‘What good (professionally, that is) can come

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BEXAR HISTORY out of Texas?â&#x20AC;&#x2122;, and it has very much at heart to answer this sneer of the great London Journal by proving from a survey of our work that

caring for military combat injuries. During his time in Germany, there was considerable unrest politi-

the surgeons of Texas, country doctors though they be, though no

cally and many professionals turned their interest to immigration to Texas. In 1847, Dr. Herff led a group of German immigrants who

long string of academic honors illustrate their names, are second to those of no country in the variety, the boldness, the success of their operations, in practice, skill, in fertility of resources, and in that selfreliance founded on knowledge without which no man can be a successful surgeon.â&#x20AC;? Dr. Cupples was a master of his profession and was extremely careful in his practices, keeping meticulous records of his cases. He received many accolades from both the state and the Bexar County Medical Society. Dr. Cupples died in 1895 at the age of 79. His funeral, by many accounts, was the largest ever held in San Antonio, with numerous eulogies by physicians and leading citizens of the town. Ferdinand Herff, MD, was born in 1820 in Germany. His father was an influential politician and statesman. He attended university and was active in the student military corps and fought many duels throughout his training. He was interested in botany but saw no future in this and so studied medicine, graduating in March 1843. After graduation, he entered the Prussian Army as a military surgeon and over the next two years had considerable experience as a surgeon

came to Texas to establish a colony on the Llano River. This was eventually unsuccessful for various reasons, and Dr. Herff returned to Germany to marry. In 1849, he and his wife returned to Texas and established a practice in New Braunfels. However, in 1850 they moved to San Antonio, which was a much more prosperous town, and he established a surgical practice. At this time, San Antonio appeared as an old Mexican pueblo. However, it was the principal trading point to Mexico, Santa Fe, El Paso, New Orleans, and areas north. In 1855, in addition to his practice, Dr. Herff served as city physician for a salary of $10 per month. He served in the Confederate Army as a brigade surgeon, but in the latter portion of the Civil War and the instability in the country he returned to Germany briefly to serve again in the Prussian Army. He then returned to Texas in December 1867. In 1854, he had performed an operation on a Texas Ranger in which he performed a lithotomy and removed a very large bladder stone. The procedure was a success, and after this his popularity as a surgeon increased tremendously and he became extremely Continued on page 22

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BEXAR HISTORY Continued from page 21 Below - Dr. Frank Paschal, 1893. At right, Dr. Ferdinand Herff with graduates of the Santa Rosa Infirmary Training School in 1903.

busy. There were no hospitals in San Antonio. Therefore, operations were performed outdoors where there was sufficient light, as well as many spectators. He is noted for being the first surgeon to perform a number of operations not only in Texas, but also in the United States. These include the first hysterectomy, first surgery for Jacksonian epilepsy, perineal lithotomy, a successful appendectomy, the first gastrostomy, and the first cataract operations. These operations were performed between 1847 and 1879. It is noted that with the gastrostomy, which was performed on a teenage girl who had swallowed lye, he did the gastrostomy in order to be able to introduce nutrition through a tube in her stomach. This appeared to be unsuccessful for a few weeks until he added the girl’s saliva to the contents of the food being introduced into the stomach, and thereafter the child thrived tremendously. As mentioned earlier about the TMA’s report in 1885 of the surgical procedures performed in Texas by the 138 surgeons, it is noted that of the 4,293 surgical procedures performed, Dr. George Cupples and Dr. Ferdinand Herff performed 25 percent of the total. In 1891, at the founding of the University of Texas Medical School in Galveston, there was a statewide movement to have Dr. Herff appointed as the first chairman of the Department of Surgery. He declined, preferring to remain in his home in San Antonio and continue his private practice. He became close friends with Dr. Cupples, and they worked tirelessly to maintain ethical behavior for both their businesses and professional dealings. The American Medical Association established a Code of Ethics in 1847 and both these men 22 San Antonio Medicine • January 2016

tried to maintain these principles in San Antonio. Dr. Herff and Dr. Cupples both served as examiners for the Texas State Board of Medical Examiners. In 1853, Dr. Herff helped establish the Texas Medical Association and was one of the 35 charter members of the Bexar County Medical Society and was a charter member of the West Texas Medical Association. He was active in publishing medical information and journals, and he helped establish the West Texas Medical and Surgical Record, which for a number of years was a credit to medical journalism. Dr. Herff was an active member of the Hessian Association of Physicians and Surgeons, and a member of San Antonio’s Casino Club. In addition, he was director of the San Antonio National Bank, which was affiliated with the San Antonio Loan and Trust Company, and was identified with the Lacoste Ice Company, the first to manufacture artificial ice in the United States. In April 1859, the first drugstore where prescriptions could be filled opened in the home of Dr. Herff. Dr. Herff, during his earlier years in South Texas had learned several Indian languages. As a result, he had a number of Native American patients. He had successfully performed bilateral cataract surgery (one of the first in Texas) on an Indian chief, restoring his sight. In 1886, Geronimo, the famous Apache chief, while imprisoned in Fort Sam Houston, requested a visit from Dr. Herff. They conversed in Apache and together recalled many medical stories in which Herff had been involved with the Indians. Later in 1888, the Lipan Apaches were on one of their final raids and they rampaged through

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BEXAR HISTORY the burning area where Dr. Herff had his ranch. The warriors could be heard throughout the night raiding the town and the nearby ranches, farms, and homes. However, the Herff ranch was spared and the next morning at the gate post was found a lone Apache arrow with a white feather. He performed his last surgery, an ectopic pregnancy, at age 87. He died in his home in May 1912 at the age of 91 years and 6 months. A fitting obituary appeared in the bulletin of the Bexar County Medical Society. Frank Paschal, MD was born Oct. 22, 1849, one of the first four white children born in Bexar County. His father and mother were the first American born individuals to be married in Bexar County. His father had come to Texas in 1836 from Georgia. He came to join the Texas Army to avenge the death of several of his friends who had been massacred at Goliad. He later became the first sheriff of Bexar County. Dr. Paschal received his early education in San Antonio and Monterrey, Mexico where his family lived for a short period of time. He began his study of medicine at age 19 in 1868 with Dr. George Cupples as his preceptor. During the next two years, he was privileged to observe and assist Dr. Cupples in many of his “Texas firsts in surgery,” mentioned earlier. He entered Louisville Medical School in 1870, graduating in 1873 with honors, and won a competitive internship at the Louisville Hospital. He returned to San Antonio in 1874 to open a practice. The first few months in San Antonio were not as successful as he had hoped, and he moved south and opened up a practice in Chihuahua, Mexico, which was a major mining center. He spoke fluent Spanish and was highly successful. He traveled to San Antonio frequently and married a San Antonio girl. After a few years in Mexico, he returned to Bexar County to practice for the next 30 years. In 1890, San Antonio was the largest city in Texas, having surpassed Galveston, which at that time was the largest. In 1892, the population of Bexar County was 38,000. In the next 40 years, it would grow to 230,000. The 30 years he spent practicing in Bexar County were highly successful for him and his community. Most of his practice was accomplished by many house calls each day. He was an excellent diagnostician and successful surgeon. He was highly regarded by his colleagues and was known as “Dr. Ethics.” He was elected president of the West Texas Medical Association in 1893. This organization’s charter expired after a few more years. His activities in the Bexar County Medical Society were evidenced by the fact that he was repeatedly charged with being chairman of the Ethics Committee. He was responsible for counseling wayward members, occasionally resorting to reprimands and very occasionally to suspension or expulsion from the society. He was active at the state level

of the TMA and served on multiple committees. He was instrumental in exposing the activity of the New York Medical College in San Antonio (previously mentioned) and its closure. He was the San Antonio Health Officer for four years at a salary of $1200 per year. In 1903, Dr. Paschal was elected president of the newly reorganized Texas Medical Association and the reorganization of the County Medical Societies. Dr. Cupples, Dr. Paschal’s mentor, had been elected president of the TMA in 1853, and his protégé fell into his footsteps in 1903. During his tenure, and secondary to his intense interest in the treatment of tuberculosis, the first state sanitarian was established in Carlsbad, Texas. It had been a 20-year pursuit by Dr. Paschal. The TMA began collecting materials to preserve Texas’s medical heritage. More than a century ago Dr. Paschal told the TMA House of Delegates in his presidential address, “The labors of this Association should always be conserved, and unless steps are taken the past work will be lost forever.” He then established the Committee on Collection and Preservation of records, the forerunner of the present day History of Medicine committee. Dr. Paschal was concerned with organized medicine as a physician involved in the establishment of the Texas Surgical Society and later served as its president. Along with other physicians in Bexar County, he was among the principal organizers of the Physicians’ and Surgeons’ Hospital. It was the precursor of the San Antonio Baptist Hospital System. He continued until his death in 1925 to be active in the Bexar County Medical Society. He generously donated $10,000 to the Bexar County Medical Society to help provide a permanent home for this group. At that time, this was a very princely donation. “Frank Paschal did much more than accept responsibilities for medical care. He became a major public force for good, and as such was able to influence the development of one of the significant urban areas of the United States in ways that he would never himself have conceived. There were many notable physicians in this century in Bexar County. The previous discussions seem to represent some of the finest among many. Remarkable progress was made from the end of the Civil War to the end of the century. Considering the medical knowledge of the day, their accomplishments were noteworthy. They all took their work seriously and met the demands of the frontier with dedication and devotion to their patients. They prepared a foundation upon which success would be obtained by their successors with even greater accomplishments. J.J.Waller Jr., MD, is a member of the BCMS Communications/Publications Committee.

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BEXAR HISTORY On Jan. 17-19, 1853, 35 physicians from the surrounding communities met at the Methodist Church in Austin to found and organize the Texas Medical Association.

By J.J. Waller Jr., MD

In January of 1853, a group of physicians from mainly Austin and San Antonio met to form a medical organization. A constitution and bylaws were proposed and discussed. The first regular meeting of the Texas State Medical Association was held in San Antonio in early September 1853. The constitution and bylaws were accepted and subordinate local organizations were proposed. The first to receive a charter in the state was Bexar County in late September 1853. It was to be known as the Bexar Medical Society and the first president of both the state and Bexar county group was Dr. George Cupples. The original certificate resides in the offices of the Medical Society. During the 1870s through the 1880s and 1890s, the certificate was kept in the offices of Dr. Frank Paschal until the Society finally secured a “home” of its own. In the early 20th century, it was transferred to the Society offices for safekeeping. 24 San Antonio Medicine • January 2016

In 1853, San Antonio was a small village of about 3,000 inhabitants. The surrounding area was wild and uninhabited. Indian raids were frequent and occasionally reached into the center of town. At the start, Medical Society meetings were held once a month. Each man attending carried a sidearm (see previous article). It was recorded that at meetings all sidearms were required to be checked at the door until the meeting was complete. Due to various impediments (including primarily the Civil War), the Texas State Medical Association did not have regular meetings again until 1869. For the next several years after that, meetings were occasionally held in various towns around Texas with as few as seven members attending at a time. There are no surviving records of any meetings of the local society that may have been held by the Bexar Medical Society during this period.

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BEXAR HISTORY The first recorded attempt locally to reestablish a county organization was in 1873 with the formation of the West Texas Medical Association by some of the physicians who had initially been involved in the formation of the Bexar Medical Society (including such notables a George Cupples, Ferdinand Herff, John Herff, Rudolph Menger, and others.) The exact reason behind the formation of a different local organization is not entirely clear. A number of factors may have come into play, including the following: 1. The extended absence of meetings of the state organization. 2. Once meetings of the state were resumed, to attend required long transport by horseback or buggy through still hostile and hazardous country. 3. The adjustments to reconstruction were still progressing slowly. 4. Problems of unavailability of hard currency. 5. The economic panic of 1873 was nationwide, and bankruptcy was common in many commercial ventures, including the large ranchers of South Texas. This may have induced the county physicians to form a different organization over which they had more control. The West Texas Medical Association was chartered by the State of Texas to last 25 years, commencing in 1873. (A copy is in the archives in the P.I. Nixon Library, and the original in the lobby of the Bexar County offices.) According to a summary by Dr. Frank Paschal (located in the archives), about 1900 he stated it had been a very active and well-organized association through the years. It continued with monthly meetings with increasing membership as the town grew (1877 population 19,278 — number of physicians 13; 1890 population 37,173 — number of physicians 41; 1900 population 53,321 — number of physicians 60). It later added clinical discussions of local cases and autopsy reports and discussions of local health problems, fees and ethics. In the beginning, the Association met in the county courthouse, and later meetings were held in various settings throughout the county, including the Pulling’s Hall which after a while the group was asked to move; various doctors’ offices; the Hall of the Brothers of Locomotive Engineers; the Elks Hall; next to a local dance hall (however the noise of the music drowned out the discussions); and in the dance hall of the St. Anthony Hotel until all the chairs were broken and they were requested to move; and then other various places. During the 25 years, the total rent paid amounted to 50 dollars. By 1900, it was obvious that the organization needed a home of its own. This would not occur until 20 years later. More detailed information about the meetings of the Association is not available. From the Bexar County Medical Society archives in the P.I. Nixon

The Charter of the Western Texas Medical Association, signed in 1877.

Library, it appears the West Texas Medical Association continued its contact with the Texas State Medical Association. There were occasional disagreements between the two organizations, but Bexar County hosted the state meetings in 1878 and 1889. In 1903 the American Medical Association reorganized, and the state associations followed suit. The charter of the West Texas Medical Association had expired, and the basis of the system was once again the local societies. The state became the Texas Medical Association and locally, the Bexar County Medical Society. Great strides were to be made in organized medicine during the next century, but the frontier physicians of the 19th century forged the real basis of the county medical organizations. It was orchestrated by a group of honest, intense, talented, dedicated and tough physicians. We should all be proud of this heritage.

J.J.Waller Jr., MD, is a member of the BCMS Communications/Publications Committee.

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BEXAR HISTORY

Atkinson, Donald T. Texas Surgeon. An Autobiography, New York: Ives Washburn, Inc., 1958

Nixon, Pat I., M.D., The Medical Story of Early Texas, San Antonio: Mollie Bennet Lupe Memorial Fund, 1946

Brown, Mel, San Antonio in Vintage Picture Card/ Post Card History, Austin, Texas: Texas Medical Association Archives, Austin, Texas: SC Arcadia Publishing, 2000

Nixon, Pat I., M.D., History of the Texas Medical Association, Austin, Texas: University of Texas Press, 1953

Cox, I. Wayne, The Spanish Acequia of San Antonio, San Antonio,Texas: Maverck Publishing Co., 2005 Daniel, F.E., M.D., Daniel’s Texas Medical Journal, Vol. IV, July, 1888 to June, 1889: Edited and Published in Austin, Texas, 1889 Ferris Van Voast, Slyvia and Sellers Hoppe, Eleanor, Scalpels and Sabers, Austin, Texas: Eakin Press, 1985 Garrison, F.H., M.D., Introduction to History of Medicine, Philadelphia: W.B. Saunders Co., 1929 Gray, W.G., M.D., Page From Personal Journal, 1865 (In my possession) Hood, R. Maurice, M.D., Early Texas Physicians, Austin, Texas: Statehouse Press, 1999 Hoyt, Henry F., A Frontier Doctor, Boston: Houghton Mifflin Company, 1929 Jones, Bill M., Health — Seekers in the Southwest 1817-1900, Norman Oklahoma: University of Oklahoma Press, 1967 Nixon, Pat I., M.D., A Century of Medicine in San Antonio, Privately Published by Author, San Antonio, 1936

26 San Antonio Medicine • January 2016

Nofi, Albert A., The Alamo and the War For Texas Independence: Da Capo Press, 1922 Oberste, William H., Texas Irish Empresarios and Their Colonies, Austin, Texas: Von Boeckmann-Jones Company, 1953 Schuman, Henry, Sixty-five Notable Milestones in the History of Medicine in the Bexar County Medical Library, San Antonio, Texas, 1961 Young, J.W. Sr., It All Comes Back, Sweetwater, Texas: Watson Focatt Company, 1962 Texas State Journal of Medicine Centennial Issue, Volume 49, Number 5, May 1953 Bexar County Medical Society Archives, (AR 61 – 51 Boxes) Pat I. Nixon Medical Historical Library in the Dolph Brisco Library of the University of Texas Health Science Center, San Antonio, Texas Transcripts Relating to the Medical History of Texas, Thirty-one Bound Notebooks, Texas Medical Association Archives, Austin, Texas, 1923-1953

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BOOK REVIEW

WOMEN IN PRISON

Two books with little in common By Fred H. Olin, MD

Orange is the New Black: My Year in a Women’s Prison by Piper Kernans and The Execution of Noa P. Singleton by Elizabeth L. Silver have only one thing in common: they each involve an incarcerated woman. Otherwise, they couldn’t be more different. It’s likely that you have heard of Orange is the New Black, as it was the inspiration for a series that has appeared on Netflix. I’ve never seen the TV show, but I’ve been told that it isn’t particularly true to the book. Ms. Kernans is an upper-middle-class Smith College graduate who, after graduation, fell in with an older lesbian woman, Nora, a minor drug runner. One time only, Kernans ferried some money back from the Far East for Nora. She then dropped back into both senses of the straight world; she moved to San Francisco, started dating the man who would ultimately become her husband, and went to work. Many years after she committed the offense, someone (probably Nora) ratted on her and she was arrested, tried and sentenced to 15 months in the women’s prison in Danbury, Connecticut. Her tale from prison combines character studies of her fellow inmates, stories about her interactions with them and discussions of her activities: among other things, she is assigned to the electrical shop where she learns how to be an electrician. She discovers that others who didn’t have access to private counsel and had to depend on public defenders were serving much longer sentences for offenses of even lesser severity than her own. She realizes that she was part of her colleagues’ problems: “[F]or the first time I really understood how my choices made me complicit in their suffering. I was the accomplice to their addiction.” She continues: “A lengthy term of community service working with addicts on the outside would probably have driven the same truth home and been a hell of a lot more productive for the community. … Instead, our system of ‘corrections’ is about arm’s-length revenge and retribution. Then its overseers wonder why people leave prison more broken than when they went in.” The last part of the story is different. She is moved via “ConAir”, the federal government’s prisoner transfer air service, to Oklahoma City, which is sort of a prisoner movement hub, and then to the Chicago federal holding facility to participate in a trial of another of Nora’s accomplices. These two places make Danbury seem pretty good to her. While in Chicago, her sentence ends, with time off for good behavior. She is released onto the street, where her fiancé meets her and takes her home. The above is a really superficial review: the book is beautifully written, full of interesting details and observations, hard to put down 28 San Antonio Medicine • January 2016

and worth your time. Now, on to a totally different sort of story. The Execution of Noa P. Singleton is an intensely moving novel. The first-person narrator of much of the story is Noa, a 35-year-old woman who has been on death row in a Pennsylvania prison for 10 years, living through a series of unsuccessful appeals. She was convicted of killing Sharon Dixon and her unborn child. That child’s father is Noa’s ex-con father, Caleb, a totally worthless sort of guy. No one disagrees that Noa shot Sharon, not even Noa. However, as the book progresses, this reader, for one, began to wonder exactly where the truth lay. There is not one really likable or admirable character here: not Noa, not Sharon, not Caleb, not Sharon’s mother Marlene, a high-powered lawyer, or Marlene’s sidekick, Oliver Stanstead, a young English law graduate. The story starts six months before “X day,” which is what Noa calls the proposed date of her execution, and progresses one month at a time. It is a tale of maternal neglect, maternal dominance, introspection, lack of introspection, memory and amnesia. Oliver’s job is to draw out Noa’s life story, ostensibly to help Marlene get a clemency order from the governor, allowing Noa to serve a life sentence without possibility of parole… but it was Marlene who insisted on the death penalty at the time of Noa’s trial. She says that she’s had a change of heart, but one wonders. Interspersed between chapters of Noa’s narration are letters written by Marlene to her dead daughter, who had been a classmate of Noa’s at the University of Pennsylvania. As the story progresses, the plot weaves back and forth in time, and we learn more about Noa, Caleb and Sharon, and what someone once described as “the real realism of the real reality” becomes more and more obscure… and clearer all at the same time. There’s even a bit of an advantage in the story for those us with medical knowledge: Did the “fatal” shot really kill Sharon? We may never know. The author, Elizabeth Silver is a lawyer and has degrees in creative writing. One of her jobs included working for the Texas Court of Criminal Appeals on death penalty cases. She admits that she always wanted to be a writer, and she has succeeded admirably with this first novel. It was chosen as “Best Book” of the year by several organizations and very definitely deserved the honors. Fred H. Olin, M.D., is a semi-retired orthopaedic surgeon. He has never been either a woman or in prison. Perhaps that’s why he was so taken by these books.

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UTHSCSA DEAN’S MESSAGE

Point-of-Care Ultrasound Changing the Practice of Medicine By Francisco González-Scarano, MD Our School of Medicine is leading the way in an expanding field that promises to revolutionize health care in the next several decades: point-of-care ultrasound. Point-of-care ultrasound is becoming routine in many areas of clinical practice, taking on an increasingly important role in clinical decision making and improving efficiency in patient care. Like many technological devices, ultrasound equipment has become more portable, powerful, and affordable. This point-of-care approach is now widely used in some specialties such as cardiology, obstetrics, emergency, and internal medicine. The expectation is that it will benefit more specialties as they find appropriate uses. However, as with many new technologies, there is still a lag between development and integration into clinical practice. Our recently launched Center — which opened in December 2015 — is helping bridge that lag, and ultrasound training is now built into our curriculum from the first year through residency training. The Center and our faculty’s achievements in this new technology are distinguishing the School as one of the country’s leading training grounds for point-of-care ultrasound. In the traditional model, ultrasound tests are most commonly performed in an imaging facility, acquired by a skilled technician and then interpreted by a radiologist; sometimes the image is obtained at the hospital bedside by technicians and then reviewed. With the new more portable machines, clinicians directly use the instrumentation. While the clinician may not capture all the detail 30 San Antonio Medicine • January 2016

that a radiologist can, in many cases the gains in efficiency and speed save lives. For example, if a patient is at high risk for cardiac arrest because of pericardial effusion and tamponade, the diagnosis can be made quickly. Similarly, abdominal aortic aneurysms can be detected rapidly in patients with abdominal or back pain. In a hypotensive patient, point-of-care ultrasound can quickly establish whether the problem is to due heart failure, or identify collapsed great veins due to hypovolemia. To prepare our students for a future where these technologies are routine, we are investing resources in teaching students and house staff how to acquire the necessary images, along with the knowledge to understand and interpret them. Nilam J. Soni, MD, Associate Professor of Medicine, is co-director of the Ultrasound Curriculum and director of the all new Center for Clinical Ultrasound Education. He is one of the physicians who is helping to integrate ultrasound into medicine on a local, national and international level. Dr. Soni is the chief editor and co-author of the book Point-of-care Ultrasound, a definitive guide to the principles and diverse applications of the technology. The book recently received the prestigious President’s Choice Award at the 2015 British Medical Association’s Medical Book Awards, competing against 630 books in 21 categories. The book, which also earned the designation “Highly Recommended” in the BMA’s internal medicine category, is available in print and also digitally with videos

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UTHSCSA DEAN’S MESSAGE of ultrasound images to allow readers to quickly access images on a tablet or laptop. The book is now available in Chinese and is also being translated into Spanish. Dr. Soni’s interest in ultrasound began in his medical school days, when the focused assessment with sonography for trauma (FAST) exam emerged as one of the main protocols for evaluating patients in the emergency department. He wondered aloud why physicians do not use ultrasound with all patients and became committed to expanding the use of the technology He credits the technology with saving many patients during his years on night shifts at the University of Chicago. In addition to developing proficiency with the tool, he solidified his belief that ultrasound has much more potential in a variety of medical applications. In fact, seeing the potential to teach and train other physicians in the use of ultrasound is one of the reasons Dr. Soni came to us in 2012. In addition to his work with students, Dr. Soni provides CME training locally, nationally and internationally. Together with Dr. Soni, Craig Sisson, MD, RDMS, FACEP, Associate Clinical Professor of Emergency Medicine, is co-director of the School of Medicine’s ultrasound curriculum. Our School is one of only a handful of medical schools around the country that integrates ultrasound into the curriculum of each year of medical school so that even undifferentiated students learn how ultrasound is used in various environments and have the opportunity to choose electives to further explore point-of-care ultrasound. This curriculum will reduce one of the primary limitations of the technology: provider training. Today’s medical students are the next innovators; they will devise new ways to use the technology to decrease patient risk and improve outcomes. That is why our goal is to introduce them to ultrasound as early as possible in their medical training to expose them to the possibilities of the technology. No other medical school in the United States has a center such as the Center for Clinical Ultrasound Education, making our School a national model for the multidisciplinary integration of ultrasound into healthcare education. The facility is a 1,000 square foot laboratory containing eight ultrasound stations, each equipped with cameras and 40-inch plasma screens to share images, along with an adjacent 1,700 square foot lecture hall. This resource gives students valuable hands-on exposure in both using the equipment and interpreting ultrasound images while providing videoconferencing capabilities that enable up to 145 students to simultaneously benefit from the curriculum.

Bedside ultrasound offers four main application areas: Education. Ultrasound can teach students anatomy and help them understand the structural relationship between different organs in the body.

Diagnostics. Point-of-care ultrasound is vital in emergency medicine, where time is of the essence. In a rural setting, this may be the only real diagnostic imaging that is available quickly. Therapeutics. Point-of-care ultrasound offers applications for procedural guidance, such as vascular access in chronically ill patients. Screening. Ultrasound can quickly and efficiently screen patients for specific conditions such as an abdominal aortic aneurysm. Detected early and easily with point-of-care ultrasound technology, physicians can refer patients to vascular surgeons for appropriate treatment, thereby saving lives. It should be emphasized that point-of-care ultrasound does not replace radiologists. There are certain conditions that can be safely identified with point-of-care ultrasound, while others require more detailed analysis. The in-depth analysis provided by advanced imaging and radiology will continue to be vital and may become increasingly so as ultrasound becomes more widely used. In addition, point-of-care ultrasound may lead to improved communication between physicians and radiologists, fostering the continuum of care between many specialties. Ultrasound will play an increasingly greater role in health care as we move toward more efficient, higher-value patient care. Equipment will become increasingly more affordable and readily available with portable ultrasound equipment apt to become as common as a blood pressure machine in patient care settings. It is quite possible that smaller hand-held devices will become as common as stethoscopes are today. As these advances happen, the School of Medicine will remain focused on training clinicians to explore the diverse applications and tremendous potential point-of-care ultrasound can bring to our providers and their patients. The next workshop on point-of-care testing for providers is Feb. 12-13, 2016. If you would like to enroll or just learn more about point-of-care ultrasound, visit our website at: http://cme.uthscsa.edu/ultrasound.asp

Francisco González-Scarano, MD Dean, School of Medicine Vice President for Medical Affairs Professor of Neurology John P. Howe, III, MD, Distinguished Chair in Health Policy The University of Texas Health Science Center at San Antonio scarano@uthscsa.edu

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FINANCIAL MISTAKES

Five Major Financial Mistakes Made by Doctors By Jim Rice, CPA To become a physician takes exceptional dedication and focus. Doctors acquire a vast quantity of medical knowledge but too little in the business management area. In today’s environment, business issues can dominate the running of a medical practice. It is important for you to be aware of common mistakes that are made in operating a practice, and even more importantly, to address the possibility that you are making some of these mistakes. The mistakes below were gathered from years of experience in assisting physicians in their practices.

# 1 Putting the wrong people in place A medical practice deals with many different insurers with their own codes and rules. Billing and coding errors can quickly be the downfall of a practice. With the government stepping up fraud abuse audits, hiring an expert billing assistant can be crucial. Your spouse, cousin, best friend, etc. may seem like a good way to avoid theft and give you an assurance in dealing with someone you are comfortable with, but does this person know health information technology or accounting so that you get timely and accurate information on how your practice is doing? Placing too much responsibility and reliance on one person can also be a problem. Embezzlement occurs too often in medical practices. Establish internal controls to safeguard cash in and out. You invest much time and cost into your staff. Hire well. 32 San Antonio Medicine • January 2016

# 2 Trying to keep it simple Doctors don’t want more complexity to an ever challenging career. However, complexity can provide great benefits. Separating different locations and services can give asset protection and isolate loss centers. Owning your building in a separate partnership provides many advantages. Moving your unprotected investments into a family limited partnership creates asset protection and allows for future tax planning. The right federal taxable entity for your practice can help avoid payroll taxes. Tracking provider performance and clearly establishing compensation goals can create motivation and reward. With the low interest rates, financing your life insurance premiums and using the arbitrage makes sense. Don’t operate on a handshake; document all agreements with fellow partners and employees.

# 3 Not paying attention to the numbers Accountants prepare financial statements all day long that doctors do not look at or understand. These financial statements, if timely prepared with comparison to similar prior periods, can identify excessive expenses, declining collections, etc. The data can also help the doctors anticipate future income tax payments that are looming and therefore budget for them. Doctors do not have time to learn how to interpret financial data, and they tend to not ask for help. Get your accountant to sit with you and explain what the financial statements mean and how you should use that information. If you have

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FINANCIAL MISTAKES

financial budgets, review them with the actual results. If you don’t have budgets, establish some. If you have to ask your accountant for help, you may need a new accountant.

# 4 Mixing business with pleasure Doctors can forget that their practice is a separate entity. They distribute collections out of the practice for personal matters, pay personal expenses through the practice bank account and invest personally with practice funds. It is important from a tax planning and asset protection perspective that all personal financial activity be kept out of the practice. Doctors have a reputation, right or wrong, for being easy marks and spending too much. A medical practice can be a very successful business that is destroyed by the personal spending habits of the doctor. Determine what your personal spending habits are and how they affect the operations of your practice. Many doctors complain of working harder and having less to show for it. This may be perception only or it could be a sign of the practice and/or the physician not controlling costs or protecting revenues.

# 5 Not planning for the future I don’t just mean for retirement. We have heard many times over

how none of us are adequately putting money away for our retirement. This is more true for doctors who after years of school start their retirement funding later than most. There are also things doctors should be addressing before retirement. Is there an adequate buy sell agreement for your practice? Do you have a succession plan to protect your practice? Are you insuring your most valuable asset – Yourself? Disability insurance may seem expensive until you need it. Apart from retirement funding, do you have readily available reserves in case of a rainy day? Physicians have worked hard to get to where they are. Making the most of their efforts is the goal. Jim Rice, CPA is a shareholder at Sol Schwartz & Associates, P.C. (jprice@ssacpa.com). He has 32 years of experience in public accounting. In addition to providing business consultation, financial planning and various other accounting services, Jim specializes in income tax planning and consultation. He works with a high concentration of physician practices and high net worth individuals. Contact Jim at (210) 384-8000 Ext. 112.

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BUSINESS OF MEDICINE

HEALTHCARE MERGERS By Dana A. Forgione, Ph. D., CPA, CMA, CFE It seems just about everyone in healthcare is either merging, planning to merge, or debating if they should merge. We’ve been through this before. Merging. Unmerging. Re-merging. I suppose it’s to avoid

Second, what information do you need to make a properly informed decision? Too many deals go sour and end up dissolving. Expectations are not met, and adequate information is not obtained in

sub-merging (sorry, couldn’t resist…). Some research shows that the anticipated benefits of mergers often will never be realized. But it’s all about strategic market share and negotiating clout. Of course it doesn’t hurt that the brokers and lawyers earn tidy fees putting the deals together, and taking them apart again later. Why, the latest merger announcement about the Pfizer and Allergan’s $150 billion mega-merger of the century already includes discussion of how they’ll divide the impending biggest drug company in the world into two, before the deal has even obtained its regulatory approval. Physician practices are being acquired by hospitals, and then the hospitals and systems are merging — so the payers are also merging to build counter-clout. We’ll no doubt end-up seeing the market consolidate into an oligopoly of national, fully-integrated healthcare organizations. Maybe that’s a good thing. Maybe it’s not. So what should you consider if a merger or acquisition opportunity presents itself? First and foremost, consider your expectations. For example, why are you interested in merging? What are your greatest issues of concern? What essential issues and risks need to be identified and addressed before starting a merger? What might the new organizational

advance. While not a merger, I did a litigation support engagement once where four surgeons were suing a hospital over alleged fraudulent misrepresentation of the economic prospects for their practices in the region. The issues are relevant. The hospital management had done a health needs assessment for the surrounding community, and determined it needed four more general surgeons. So the hospital actively recruited these four surgeons from across the country, offering them signing bonuses, payment of their relocation expenses, and collection-guarantee loans to help support them as they built up their new practices. Of course the loans would be forgive on a pro-rata basis over four years, as long as the surgeons stayed and continued to serve the community. In compliance with Stark, patient referrals to the hospital were explicitly not required. If the surgeons decided to leave before their four-year term expired, all amounts would become immediately due and payable. As collateral for the loans, the hospital could take their office equipment, and both current and future accounts receivable. There was also a non-compete agreement upon severance. The docs accepted the offers, signed the contracts, moved into town, set up their practices, and bought homes. It’s an old story. Let’s digress here for a minute. Some of you may be old enough to remember Tennessee Ernie Ford singing about 16 Tons:

governance structure be like, and how would it affect your role? What benefits do you anticipate, and what is the prospect of realizing those benefits? Are there other ways to achieve those benefits apart from a merger? For example, I was approached by a young cosmetic surgeon once about wanting to acquire the practice of another cosmetic surgeon who was planning to retire. I asked him what he was expecting to gain from the acquisition. The patient referral base, of course. It takes time to build a referral base, and this would be a way to jump-start that process. We talked about the potential for hidden liabilities, unknown malpractice claims yet to be asserted, patient attrition, and other issues. I suggested that rather than acquire the practice, why not just work with the other surgeon for a year, capitalize on his goodwill, build a reputation and relationships with referral sources, and then carry on with your own practice. Was the cost and risk of an acquisition really necessary or desirable? 34 San Antonio Medicine • January 2016

You load sixteen tons, what do you get? Another day older and deeper in debt Saint Peter don’t you call me ’cause I can’t go I owe my soul to the company store The “company store” is an old economic routine, dressed-up in new clothes. My grandfather was one of them. He was an Italian immigrant who worked in the sand quarries of Long Island in New York. The workers worked long hours and had to buy their food and supplies only from the company store. And on their low wages, the workers all quickly became deeply in debt to the store. Moonlighting was not allowed. So what did he do? He would

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BUSINESS OF MEDICINE

sneak out at night and dig clams on the local beaches (which was illegal). He sold enough of them to eventually buy his way out of debt, and started a one wheel-barrow construction company. Things went well for him until the great depression, but that’s a story for another time. My point? Those four surgeons got themselves locked into the company store. What happened was the hospital had not obtained adequate buyin from the local physicians who were critical as a patient referral base for these four newcomers. When the local docs didn’t refer enough patients, the four surgeons got deeper and deeper into debt to the hospital. They couldn’t leave, because it would trigger immediate repayment of all the loans, and they didn’t have enough money to pay them off. And all their equipment and future receivables would be taken. And they couldn’t stay, because they were not making enough money to support their practices without drawing down even more on the collection guarantee loans. They were economically trapped. “I owe my soul to the company store.” So what did they do? They sued the hospital for alleged fraudulent misrepresentation of the economic prospects for their practices. While there were prob-

lems, the court found that there was not fraud. All four of them were, no doubt, brilliant surgeons. But tragically one of them ended up bankrupt. It didn’t need to end that way. You never have enough information. And you can never eliminate all uncertainty. But take stock of your own expectations, and be sure to do your due diligence and gather all of the salient information you can get. Your future may, rather will, depend on it. Dana A. Forgione, Ph.D., CPA, CMA, CFE is the Janey S. Briscoe Endowed Chair in the Business of Health at the University of Texas at San Antonio. He is also an Adjunct Professor in the School of Medicine, Department of Cardiothoracic Surgery, the Department of Pediatrics, and in the School of Public Health, all at the University of Texas. He previously held a joint appointment in the School of Pharmacy at the University of Maryland, where he taught in the Doctor of Pharmacy program. His research interests are in international comparisons of healthcare payment systems, costs and quality of care, as well as financial management for hospitals and physician practices.

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36 San Antonio Medicine â&#x20AC;˘ January 2016

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

ACCOUNTING FIRMS 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.”

BANKING

BBVA Compass (HHHH 10K Platinum Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Commercial Relationship Manager Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future.”

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great rela-

tionship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett 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. Chris Sherman 210-247-2978 csherman@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

Frost (HHH Gold Sponsor) As one of 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 and insurance services to individuals and businesses.

Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”

IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC BankSan Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area. Markham Benn 210-354-6921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”

Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans. Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com

SSFCU (HHH Gold Sponsor) Founded in 1956, Security Service provides medical professionals with exceptional service and competitive rates on a line of mortgage products including one-time close construction, unimproved lots/land, jumbo and specialized adjustable-rate mortgage loans. Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Bank of America (HH Silver Sponsor) Bank of America provides people, companies and institutional investors the financial products and services they need to help achieve their goals at every stage of their financial lives. Jennifer Dooling 210-270-5226 jennifer.dooling@baml.com Courtney Martinez 210-419-2643 courtney.martinez@baml.com http://about.bankofamerica.com/ en-us/index.html Making financial lives better — one connection at a time 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 Generations Federal Credit Union (HH Silver Sponsor) Generations provides a wide array of innovative products including

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37 loan, deposit and investment solutions for personal and commercial banking needs. Yvonne "Bonnie" M. Aguilar 210-229-1800 bonnie.aguilar@ mygenfcu.org www.mygenfcu.org “For this generation and the next.” RBFCU (HH Silver Sponsor) 210-945-3800 businesslending@rbfcu.org www.rbfcu.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. Armando Rodriguez 210-225-6126 arodriguez@sjcusatx.net www.sjcusatx.com “Better rates on auto loans, signature loans and Platinum MasterCard.”

BIOMEDICAL WASTE DISPOSAL

BioMedical Waste Solutions, LLC (HHH Gold Sponsor) Save costs on your medical waste disposal! BioMedical Waste Solutions provides a compliant, reliable and low-cost service. Wes Sonnier 1-877-974-1300 Wes@BioMed-Disposal.com Joe Loyacano 1-877-974-1300 Joe@BioMed-Disposal.com www.BioMedicalWasteSolutions.com “BCMS members save 10 percent off or one free month! Request a free quote in 10 seconds at www.BioMedicalWasteSolutions.com.”

CONTRACTORS/BUILDERS/ COMMERCIAL

Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer. Our model allows you to own your own office space as opposed to leasing.

38 San Antonio Medicine • January 2016

Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com

RC Page Construction, LLC (HHH Gold Sponsor) Commercial general contractor specializing in ground-up and interior finish-out projects. Services include conceptual and final pricing, design-build and construction management. Single-source management from concept to completion ensures continuity through all phases of the project. Clay Page 210-375-9150 clay@rcpageconstruction.com

ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES

Med MT, Inc. (HHH Gold 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.”

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. Stacy Berry 830-832-0949 Stacy.berry@greenwayhealth.com www.greenwayhealth.com

FINANCIAL SERVICES

Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor) Comprehensive financial planning, insurance and investment planning, estate planning and trust services. Eric Kala, CFP, CLU, ChFC Wealth Management Advisor 210-446-5752 eric.kala@nm.com www.erickala.com

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

Frost Leasing (HHH Gold Sponsor) As one of 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 and 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.” Bob Davidson New York Life (HH Silver Sponsor) Dedicated agent at New York Life helping physicians and medical professionals achieve their financial dreams. Bob Davidson 210-321 1445 rdavidson02@ft.newyorklife.com www.linkedin.com/in/bobdavidsonnyl “Taking care of those who take care of us.”

Retirement Solutions (HH Silver Sponsor) Committed to providing comprehensive, reliable consultation to help you navigate the complex world of retirement planning. Robert C. Cadena 210-342-2900 robert@retirementsolutions.ws www.retirementsolutions.ws

HIPAA COMPLIANCE SERVICES Cyber Risk Associates (HH Silver Sponsor) Cyber Risk Associates provides HIPAA compliance services designed for small practices, offering enterprise-quality privacy and security programs, customized to your needs. David Schulz 210-281-8151 DAS@CyberRiskAssociates.com www.CyberRiskAssociates.com

HIPAA/MANAGED IT/ VOIP/SECURITY

Hill Country Tech Guys (HHH Gold Sponsor) Provides complete technology services to many different industries, specializing in the needs of the financial and medical industries. Since 2006, our goal has always been to deliver relationship-based technology services that exceed expectations. Whit Ehrich, CEO 830-386-4234 whit@hctechguys.com http://hctechguys.com/ “IT problems? Yeah… we can fix that!”

HOSPITALS/ HEALTHCARE SERVICES

Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years. Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery. Business Development Director Blake Pollock

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 210-243-9151 bpollock@iasishealthcare.com www.swgeneralhospital.com "Quality healthcare with you in mind."

Warm Springs •Medical Center •Thousand Oaks •Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Elite Care Emergency (HH Silver Sponsor) 24/7 full-service, no-wait, freestanding ER with board-certified physicians and RNs offering Elite Care advantage for patients. Marketing Liaison Dlorah Martin 509-592-7998 dmartin@elitecareemergency.com Marketing liaison Kylyn Stark 210-978-4110 kstark@elitecareemergency.com www.elitecareemergency.com “When seconds count, Elite Care can make ALL the difference.” Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/ Select Rehabilitation of San Antonio (HH Silver Sponsor) 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 “The highest degree of excellence in medical rehabilitation.”

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.”

INSURANCE

Frost Insurance (HHH Gold Sponsor) As one of 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 and 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. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

SWBC (HHH Gold Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships. VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Professional Employer Organization Bryce Fegley

830-980-1200 BFegley@swbc.com Ad Valorem Tax Advisor Nikki McNish 210.376.2316 nmcnish@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services

Texas Medical Association Insurance Trust (HHH Gold Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org 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. James L. Hayne Jr. 210-222-2161 jhaynejr@catto.com Corey Huffman 210-298-7123 chuffman@catto.com www.catto.com Joel Gonzales Agency Nationwide (HH Silver Sponsor) Joel Gonzales 210-275-3595 www.nationwide.com/jgonzales

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all

areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and 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.”

MedPro Group (HHH Gold Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Thomas Mohler, 512-213-7714 thomas.mohler@medpro.com Kirsten Baze 512-375-3972 Kirsten.Baze@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 some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC, 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best. Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) ProAssurance helps you control your professional risk and navigate today’s changing medical environment with greater ease — that’s only fair. Keith Askew, 512-314-4368 Kaskew@proassurance.com

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 39 Mark Keeney 512-314-4347, ext. 7347 Mkeeney@api-proassurance.com www.proassurance.com “A.M. Best-rated A+ (Superior), ProAssurance treats you fairly.”

INTERNET/ TELECOMMUNICATIONS

Time Warner Cable Business Class (HHH Gold Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterpriseclass 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.”

IT SUPPORT/VOIP/ CLOUD SERVICES

ICS (HHH Gold Sponsor) ICS® is a Texas-based provider of business technology integration solutions, including managed IT support, business telephones, VoIP communications, video conferencing systems, surveillance cameras, and voice/data cabling. Family owned since 1981. Daniel Simons 210-581-9020 daniel.simons@ics-com.net Robert Foehrkolb 210-225-5427 rfoehrkolb@ics-com.net www.ics-com.net “Providing IT, voice and video solutions for business.”

LABORATORY SERVICES

PGX TESTING (HHH Gold Sponsor) PGX Testing is a multi-faceted diagnostics company currently offering pharmacogenomics, urine toxicology, women's health testing, cancer screening, and well-

40 San Antonio Medicine • January 2016

ness testing to the medical profession. Charlie Rodkey Sr. charlie@pgxt.com 210-218-8610 Ryan Rodkey ryan@pgxt.com 210-323-7717 Ron Inselmann ron@pgxt.com 210-382-7761 www.PGXT.com Clinical Pathology Laboratories (HH Silver Sponsor) Mitchell Kern 210-229-2513 mkern@cpllabs.com www.cpllabs.com

MARKETING SERVICES Digital Marketing Sapiens (HH Silver Sponsor) Healthcare marketing professionals with proven experience and solid understanding of compliance issues. We deliver innovative marketing solutions that drive results. Irma Woodruff 210-410-1214 irma@dmsapiens.com Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com 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 210-884-7505 LWilliams@KnowYourDoctorSA.com www.knowyourdoctorsa.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. Betty Aguilar 210-892-2331 baguilar@datastreamllc.net www.datamedbpo.com “BCMS members receive a discounted rate for our billing services.”

Kareo (HHH Gold Sponsor) The only cloud-based medical office software and services platform purpose-built for small practices. Our practice management software, medical billing solution, practice marketing tools and free, fully certified EHR has helped 30,000+ medical providers more efficiently manage their practice. Regional Solutions Consultant Lilly Ibarra 210-714-9815 lilly.ibarra@kareo.com www.kareo.com Commercial & Medical Credit Services (HH Silver 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.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHHH 10K Platinum Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide MultiSpecialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products. Physician’s memberships are free. Shari Smith 866-434-9974

shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

MEDICAL TRAINING/ HANDS ON

LINRON® Bioskills Training Institute (HHH Gold Sponsor) LINRON® is dedicated to providing hands-on medical training to healthcare professionals who want to improve their clinical skills and offer their patients the latest in treatment modalities while using state-of-the-art medical equipment and technology. Yolanda S. Garza, RN 210-572-2434 yolanda.garza@linrontraining.com www.linrontraining.com

MENTAL HEALTH EDUCATION AND CONSULTING

The Ecumenical Center (HHH Gold Sponsor) The Ecumenical Center provides faith-based counseling and education for healing, growth and wellness. The center is a catalyst, bringing together community leaders in research, education, ethics, medical and mental health professions. Mary Beth Fisk 210-616-0885, ext. 215 mbfisk@ecrh.org www.ecrh.org

MERCHANT PAYMENT SYSTEMS/CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by over 250 business associations. Tanner Wollard 979-219-9636 tanner.wollard@e-hps.com www.heartlandpaymentsystems.com “Lowered cost for American Express; next day funding.”

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY MORTGAGE

SWBC Mortgage at La Cantera (HHH Gold Sponsor) In a complex lending environment we are committed to providing realistic expectations, simple solutions, and a stress-free buying experience. Exceeding customer expectations is our highest priority Sr. Loan Officer #212945 Jon M. Tober 210-317-7431 jtober@swbc.com

OFFICE EQUIPMENT/ TECHNOLOGIES Dahill (HH Silver 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. Ronel Uys 210-805-8200, ext. 10105 ruys@dahill.com www.dahill.com

REAL ESTATE/ COMMERCIAL

Robbie Casey Commercial Realty ( Gold Sponsor ) Robbie Casey Commercial Realty was founded on the principles of providing thorough market strategies, innovative advertising, superior service, and uncompromising integrity. Robbie is dedicated to each of her clients. She brings enthusiasm and creativity to each project and knows how to get the job done. Robbie Casey 210-872-8453 robbie@robbiecaseyrealty.com http://robbiecaseyrealty.com Endura Advisory Group (HH Silver Sponsor) Endura Advisory Group specializes in representing physicians and clients in the purchase, lease, sale, management or sublease of commercial real estate. Vicki Cade, CCIM 210-366-2222 Mobile 210-827-7640 vcade@endurasa.com Teresa Corbin 210-366-2222 tcorbin@endurasa.com www.endurasa.com

REAL ESTATE/ RESIDENTIAL

PHYSICIANS BUYING GROUP

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide Multi-Specialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products. Physician’s memberships are free. Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

Robbie Casey Realty ( Gold Sponsor ) My extensive experience and expertise in the San Antonio, Alamo Heights and Terrell Hills real estate market will benefit you whether you are looking to buy or sell a home in the area. Realtor, ABS, ILHM, ALMS Roslyn Casey 210-710-3024 Roslyn@roslyncasey.com http://roslyncasey.kwrealty.com “Communication is key” Kuper Sotheby's International Realty (HH Silver Sponsor) My hometown roots are based in Fredericksburg while my home away from home is San Antonio. Local knowledge — exceptional results. Joe Salinas III 830-456-2233

Joe.Salinas@SothebysRealty.com JoeSalinas.com “Embrace your new life ... I'll help you become a connoisseur.”

SENIOR LIVING

As of December 17, 2015 To join the Circle of Friends program or for more information, call 210-301-4366, email August.Trevino@bcms.org, or visit www.bcms.org/COf.html.

Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resort-quality environment. Shane Brown Executive Director 210-305-5713 hello@ legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley, Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TRAVEL CONSULTANTS Alamo Travel Group (HH Silver Sponsor) Locally owned travel agency for over 30 years, offering personalized travel services for your next family vacation, business travel needs or group travel. American Express Travel Network representative. Patricia Pliego Stout 210-593-5500 pstout@alamotravel.com www.amazingjourneysbyalamo.com “See what a difference we can make for you!”

visit us at www.bcms.org

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42 San Antonio Medicine â&#x20AC;˘ January 2016

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Ancira Chrysler 10807 IH-10 West Gunn Acura 11911 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ancira Dodge 10807 IH-10 West Cavender Audi 15447 IH-10 West

* Gunn Infiniti 12150 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

North Park Mazda 9333 San Pedro Ave.

North Park Subaru at Dominion 21415 IH-10 West

Mercedes-Benz of Boerne 31445 IH-10 W, Boerne

Cavender Toyota 5730 NW Loop 410

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

Mercedes-Benz of San Antonio 9600 San Pedro Ave. Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)

Northside Ford 12300 San Pedro Ave.

Cavender GMC 17811 San Pedro Ave. Batchelor Cadillac 11001 IH-10 at Huebner

Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Chevrolet 12602 IH-35 North

North Park Subaru 9807 San Pedro Ave.

* North Park Lexus 611 Lockhill Selma North Park Lexus Dominion 21531 IH-10 West Frontage Road

Ancira Nissan 10835 IH-10 West Ingram Park Nissan 7000 NW Loop 410

North Park Toyota 10703 SW Loop 410

* Ancira Volkswagen 5125 Bandera Rd. North Park VW at Dominion 21315 IH-10 West

Gunn GMC 16440 IH-35 North

* Fernandez Honda 8015 IH-35 South

* North Park Lincoln/ Mercury 9207 San Pedro Ave.

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

Gunn Honda 14610 IH-10 West (@ Loop 1604)

visit us at www.bcms.org

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AUTO REVIEW

2016 Ford Mustang GT By Steve Schutz, MD In past reviews I’ve discussed “One Ford,” former CEO Alan Mullaly’s famous plan to unify the far flung company’s products as much as possible. Why not, the great Mr Mullaly wondered, make one Ford Focus for all markets instead of different ones like Ford always had? Naturally the answer was, “because it’s unbelievably hard,” but thanks to their recently retired CEO, Ford now produces far fewer different car and truck models around the world than they used to, and we’re the better for it. Want a better example than the Focus? How about the Transit, a full-size van that has sold in Europe and other markets for 44 San Antonio Medicine • January 2016

decades, and which just recently replaced the Econoline/E-series vans in the U.S. How’s that radical change been going? In a word, well, with sales that are significantly better than the Econoline could muster before it was replaced. Despite sporting a distinctly Euro design, the Transit is proving to be very popular because it’s a better product than the E-series, offering vastly better packaging and much more efficient drivetrains. OK, you say, One Ford is good. But are there any Fords which couldn’t work in non-North American markets? Two years ago I would have said the Mustang and F150. I still say the F-150, but I no longer

think that about the Mustang. Not coincidentally, the new Mustang was completely re-engineered last year and is now clearly meant for global consumption. Three changes in particular are designed to make Ford’s long time icon more desirable in non-North American markets: replacing the solid rear axle with an independent rear suspension (IRS), cutting weight for improved fuel economy, and upgrading the quality of the interior. Those changes are important because cars in Europe, Asia, and elsewhere are more expensive than they are here. That means that customers expect their cars to be well built with excellent materials and

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AUTO REVIEW

athletic handling. Yet fuel costs and other operating expenses are also higher outside of the U.S., so vehicles have to be economical too. Let’s start our discussion of the new 2016 Mustang with a look at the new rear suspension. A solid rear axle is better than an IRS for only one thing, drag racing. But the IRS is costlier to manufacture, hence the solid axle’s longevity in the Mustang. I’m not an expert-enough test driver to probe the limits of the new ‘Stang, but even I was able to tell that it’s more nimble than its predecessor and noticeably more settled over bumpy roads. The lower weight -100-200 pounds less depending

on options, according to Ford — obviously helps in this area too. A nicer interior won’t help either handling or performance, but it is a welcome change nevertheless. All of the surfaces you touch feel softer than they used to, and all of the places you look at appear nicer. That’s kind of it. Ergonomically the new Mustang isn’t significantly better than the previous model because the older Mustang was fine in that department. And spacewise, I’d call it a wash. Just remember, this is a sports car not a family sedan, so don’t expect to put your in-laws in the rear seats and have them not hate you. The 2016 Mustang is available with three engine options. A 300HP 3.7L V6 (19MPG city/28 highway) is standard on the base Mustang, with the next best engine being the 310HP EcoBoost 2.3L four-cylinder engine (21/32MPG). My tester Mustang GT came with a 435HP 5.0L V8 that provides 16MPG city/25 highway. OK, a word about the V8 Mustang GT: the sound that glorious engine makes when you step on the gas pedal is wonderful. It’s so wonderful, in fact, that when you drive this car it’s hard to stop yourself from accelerating and grinning for no reason. Obviously, that V8 sound becomes normal after a while, but that “normal” is still way, way better than what you hear when you

drive an average car, and that’s the beauty of owning a Mustang GT. So is the exuberant handling and the delicious manual transmission (if you select it). If you care at all about these sorts of things, buy a V8 Mustang now. Electrification and autonomous technology are coming, and it won’t be too long before we’re all riding silent self-driving drone-pods that we don’t even own to work. Just so we can spend even more time on our phones. So get cars with actual personality like the Mustang GT before they’re gone forever. But maybe I’m wrong, and the One Ford plan is serving to show the world that American cars can be fun, full of character, and desirable like so many German cars are. And maybe that essential goodness will turn back the relentless march of the drone-pods. I sure hope so. If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-3014367 and take a look at the Subaru Legacy. 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. visit us at www.bcms.org

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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 Contact BCMS today to join the 100% Membership Program! 46 San Antonio Medicine â&#x20AC;˘ January 2016

Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians 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 December 17, 2015.

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