MEDICINE SAN ANTONIO
EMERGENCIES! THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY
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MARCH 2015
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VOLUME 68 NO. 3
Active shooters Freestanding centers
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MEDICINE SAN ANTONIO
EMERGENCIES!
THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY
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WWW.BCMS.ORG
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$4.00
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MARCH 2015
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VOLUME 68 NO. 3
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.
The Unthinkable: An Active Shooter in a Hospital By John Edeen, MD ...................................................14
EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Email: editor@bcms.org
Patients choose from proliferating freestanding emergency centers, urgent-care centers, hospital EDs By Robert Frolichstein, MD ........................................17
MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org
BCMS President’s Message ..............................................8 BCMS Alliance..................................................................10
SUBSCRIPTION RATES: $30 per year or $4 per individual issue
BCMS Installation ............................................................11 Member Services: Circle of Friends ................................12 Opinion: Nearly two decades of successfully covering children: The past, present and future of the Children’s Health Insurance Program by Ryan D. Van Ramshorst, MD ................19
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Opinion: Medicine at a Crossroads by Richard Gunderman, MD, PhD ......................................22
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Nonprofit: New hope through the Komen Foundation ................................................................24
call (210) 690-8338 or FAX (210) 690-8638
Lifestyle: Briscoe Western Art Museum’s Night of Artists ..........................................................26 BCMS Advocacy and Legislative News ................................................................................................30 UTHSCSA Dean’s Message by Francisco González-Scarano, MD ......................................................32 Business of Medicine: Human capital investments through mentoring by Lee W. Bewley, PhD, FACHE ........................................................................................................35 BCMS Circle of Friends Services Directory ..........................................................................................37 Book Review: “Letters of Note” compiled by Shaun Usher, reviewed by Fred H. Olin, MD ................................................................41 In the Driver’s Seat ................................................................................................................................43 Auto Review: Chrysler 200C by Steve Schutz, MD ..............................................................................44
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Email: louis@smithprint.net 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.
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BOARD OF DIRECTORS
OFFICERS James L. Humphreys, MD, President Leah Hanselka Jacobson, MD, Vice President Maria M. Tiamson-Beato, MD, Treasurer Adam V. Ratner, MD, Secretary Jayesh B. Shah, MD, President-elect K. Ashok Kumar, MD, Immediate Past President
DIRECTORS Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Bonnie Harriet Hartstein, MD, Military Representative Rebecca Christopherson, BCMS Alliance President Gerald Q. Greenfield Jr., MD, PA, Board of Censors Chair Donald L. Hilton Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., Legal Counsel
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom
DIRECTOR OF COMMUNICATIONS Susan A. Merkner
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Jeffrey J. Meffert, MD, Member Rajam S. Ramamurthy, MD, Member J.J. Waller Jr., MD, Member
6 San Antonio Medicine • March 2015
PRESIDENT’S MESSAGE
Medical students, residents increase involvement in
BCMS By James L. Humphreys, MD 2015 BCMS President
Thinking back over the last year, I ap-
or TMA committee until I was out of res-
does and am more than happy to show
preciate all of the many good things that
idency and in regular practice. Given
off their students and residents in the
Dr. K. Ashok Kumar achieved as last
where I am now, I look back on those
local community and at TMA and
year’s BCMS president. I feel his greatest
times and think sadly about what a waste
BCMS events.
success in the office was raising the in-
that was and all of the opportunities to
In the past, student participation in
volvement of medical students and resi-
meet other doctors and make important
First Tuesdays at the Capitol has included
dents from the University of Texas Health
connections that I let go by. I suppose I
an occasional student accompanying us
Science Center San Antonio to unprece-
can say that at least I caught on to the
for legislative visits. This year, the Health
dented levels within BCMS. Students
value of being involved at some point,
Science Center organized a group of stu-
and residents participated in every med-
and my professional life has been made
dents to attend the first First Tuesday event
ical society committee, and it was won-
exponentially richer because of it.
in February, and I couldn’t have been hap-
derful to see them stepping up to help
Because of that, I am especially happy
pier to have them. Usually UTMB, Texas
to have had so much participation over
Tech and Texas A&M medical schools are
I am delighted that these young physi-
the last year by these doctors at the very
the only ones in the state to have a real stu-
cians are not making the same mistake I
start of their careers. If they can main-
dent presence at any of the First Tuesdays.
made when I was in their shoes in the
tain that interest, they will reap the ben-
It is about time that changed! I urge all of
(increasingly distant) past. I joined the
efits much faster than I was able to. I
our members to encourage the students
BCMS as a medical student years ago and
was a product of the Health Science
and residents, and welcome them whole-
then promptly ignored that membership
Center both for medical school and res-
heartedly to our ranks.
until I was out of residency. I never went
idency and was well-served by the edu-
to a society function in those years and
cation I received there. I am proud of
certainly never participated in a BCMS
the work that the Health Science Center
shape policies and work through issues.
8 San Antonio Medicine • March 2015
James L. Humphreys, MD, is the 2015 president of BCMS. He is a pathologist with Precision Pathology in San Antonio.
BCMS ALLIANCE
MEET THE 2015 ALLIANCE BOARD By Rebecca Christopherson 2015 Bexar County Medical Society Alliance President I am thrilled to be working with the 2015 Alliance board. Together we are striving to become more visible in the community through our exciting programs and civic and philanthropic endeavors. We are continuously building our membership, as more physicians’ spouses discover our organization and what we are about. Jennifer Lewis is our president-elect. I have thoroughly enjoyed working with Jennifer, coordinating the Alliance’s various programs and determining strategies to propel us into the future. Jennifer serves on all of the Alliance’s various committees and is a constant source of inspiration and energy. Rena Baisden is our first vice president of membership. Rena was off to a swift start at the onset of 2015, and the enthusiasm she brings to her office is infectious. Rena has been busy recruiting new members and working with me on the production of the 2015 yearbook. Her support is invaluable, and I am pleased to be working together. Dave Tapia is our second vice president of communications. The expertise he provides the Alliance is invaluable. Dave has been very busy, updating our website and working with the other vice presidents and myself to create our newsletter. Christy Hinchey serves this year as the Alliance’s third vice president of programs. She brings a wealth of expertise and knowledge to her position. Christy’s responsibilities include co-
ordination of the Alliance’s four major programs for the year, and she is doing a fabulous job! Our next program is the May 7 Past Presidents’ Luncheon and Fashion Show at Julian Gold. We hope you will make plans to attend. Our fourth vice president of civic and philanthropic is the very capable and energetic Mona Talukdar. Mona is in charge of coordinating the Alliance’s various community service endeavors, including “Hard Hats for Little Heads” and “Be Wise Immunize.” In addition, Mona advises our Junior Volunteer Committee’s chair, Abbey Pamar. Oemil Rodriguez is the Alliance’s fifth vice president of social. She has the fun position of planning our social calendar and is off to an awesome start. Stay tuned for news regarding an upcoming Sips and Dips event. The board could not run smoothly without the expertise of the following ladies: Anne Foster is our very capable treasurer, Hilda Castillo has the important role of corresponding secretary, Sandra Vela serves as the Alliance’s recording secretary, and Shirley Sanders guides and instructs us as parliamentarian. I would like to extend a special thank you to my 2015 advisors, whose wisdom, support and guidance have proven invaluable to me: Cindy Comfort, Rebecca Waller and Mertie Wood. Thank you to you all for serving. It is a pleasure to be working with you all!
PHOTO ABOVE (from left): 2015 Alliance board members Rebecca Waller, Mertie Wood, Cindy Comfort, Oemil Rodriguez, Jennifer Lewis, Rebecca Christopherson, Anne Foster, David Tapia, Hilda Castillo, Sandra Vela and Shirley Sanders at the January installation.
10 San Antonio Medicine • March 2015
BCMS NEWS INSTALLATION
2015 BCMS INSTALLATION 1
2
3
4
5
1. Outgoing president Dr. K. Ashok Kumar (left) applauds as Dr. James L. Humphreys is sworn in as 2015 BCMS president at the Jan. 24 installation at Oak Hills Country Club. 2. Dr. K. Ashok Kumar and his wife, Elaine Kumar, pause during the BCMS installation event. 3. BCMS past presidents gather for their annual photograph at the 2015 BCMS installation. 4. The 2015 BCMS Board of Directors includes (from left): treasurer Dr. Maria M. Tiamson-Beato, president-elect Dr. Jayesh B. Shah, secretary Dr. Adam V. Ratner, 2015 president Dr. James L. Humphreys, 2014 president Dr. K. Ashok Kumar, BCMS CEO/Executive Director Steve Fitzer and vice president Dr. Leah H. Jacobson. 5. Dr. Estrella M.C. deForster (left) chats with Janis Humphreys, wife of Dr. James L. Humphreys.
visit us at www.bcms.org
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MEMBER SERVICES
BCMS Circle of Friends program benefits members, local businesses The Bexar County Medical Society Circle of Friends program is the ultimate win-win. BCMS physician-members have information about relevant San Antonio-area businesses at their fingertips, and Circle of Friends sponsors may offer their products and services directly to our membership. “Circle of Friends is the most focused and direct method of reaching the medical community,” said BCMS Development Director August C. Trevino II. “Circle of Friends vendors provide our physician-members with outstanding opportunities to save on needed services and products. Vendors also help to underwrite BCMS programs and keep down the cost of dues,” he said. “Participating businesses are able to reach physicians, practice administrators and strategic key decision-makers,” Trevino said. “Through our program, we have helped many businesses grow in our local medical community, and in return their sponsorship monies have helped BCMS with its many health initiatives and programs.” For area businesses, annual membership in Circle of Friends costs $3,000 (silver), $5,000 (gold) or $10,000 (platinum), with varying
12 San Antonio Medicine • March 2015
benefits according to membership level. Among the benefits are reserved vendor space at BCMS events and August C. Trevino II meetings, targeted email distributions, personal introductions, inclusion in the medical society’s weekly electronic newsletter, and other marketing opportunities. BCMS members are now able to use the Circle of Friends Services Directory to find the products and services they need for their homes and businesses. From accounting firms to staffing services, the directory includes contact information for approximately 75 Circle of Friends sponsors ranging from major corporations to locally owned small businesses. The directory is published in every issue of San Antonio Medicine and also is available online at www.bcms.org/busdir/index.html. The Circle of Friends slogan is: “Support our sponsors; our sponsors support us.” For more information, call August C. Trevino II at 210-3014366, email August.Trevino@bcms.org, or visit www.bcms.org.
EMERGENCIES
THE UNTHINKABLE: AN ACTIVE SHOOTER IN A HOSPITAL By John Edeen, MD
On July 24, 2014, a psychiatric outpatient with a long criminal history and a history of suicide attempts attacked a case worker and psychiatrist at the Mercy Fitzgerald Hospital in Darby, Pa. He shot the case worker, Theresa Hunt, twice in the face, killing her. He then wounded Dr. Lee Silverman, a concealed license holder, in the head. However, Dr. Silverman was able to access his own firearm and shoot the killer three times. The killer was then tackled and disarmed by another doctor and case worker when he attempted to flee. He was found to have 39 more rounds of ammunition. If Dr. Silverman had not violated hospital policy, he would be dead and many more staff, patients and family members would be dead or injured. The killer, a convicted felon who had already served prison time as a felon in possession of a firearm, walked right by the hospital’s “no guns allowed” signs to execute his evil plan.
FIVE PHASES The active killer goes through five phases in planning and executing his act, according to veteran police trainer Lt. Dan Marcou. The first is fantasy. This includes picture drawing, website postings and possible discussion with others. Second is planning. He may put his plan in writing and discuss with others. Third is preparation. He acquires weapons and ammunition and may notify others not to go to school or work that day. Fourth is approach. He moves toward target carrying tools. And finally, implementation. The killing starts. Rapid Mass Murder (RMM) is defined by police trainer and student of mass murder Ron Borsch as “within 20 minutes, four or more people are intentionally killed at the same time and in a public location.” Such incidents have happened in a wide variety of public places — a coffee shop, a casino, elementary schools, middle and high schools, university campuses, a rural one-room school house, a library, shopping malls, churches, hospitals, nursing homes, a pharmacy, post offices, restaurants, grocery stores, an island in Norway, military bases, urban daycare center and miscellaneous workplaces. They are chaotic and occur with frightening speed. In the shooting of Congresswoman Gabrielle Giffords, six people were killed and 13 wounded in an incident that lasted 15 seconds. However, the incident in Norway lasted over an hour and resulted in 69 killed and 60 wounded. According to Borsch’s re-
14 San Antonio Medicine • March 2015
search, the average RMM lasts about six minutes. Unfortunately, the delay in notifying law enforcement also averaged six minutes. He developed the term “Stopwatch of Death” to describe the number of murder attempts per number of minutes. At Sandy Hook Elementary, the death rate was five deaths per minute and at Virginia Tech, it was eight. Time is the key element in preventing the death of innocents. If the response occurs from within the building, two or three people may be killed; if the response is from outside the building, the death toll balloons to 12 to 15. Police response is hampered by delay in notification, distance, communication of the location within the hospital where the incident is occurring, unfamiliarity with the layout of the hospital, and access to keys held by security. All these factors lead to delay in police response even under the best of circumstances. All the while, the stopwatch continues to tick.
‘RUN. HIDE. FIGHT.’ The Department of Homeland Security defines an active shooter as “an individual actively engaged in killing or attempting to kill people in a confined and populated area, typically through the use of firearms.” DHS recommends that if an active shooter (killer) is in your vicinity, you should attempt to evacuate. If that is not possible, then hide out. At last resort, take action. “Run. Hide. Fight.”
EMERGENCIES
You should have an escape route and plan in mind; leave your belongings behind and be ready to keep your hands visible for law enforcement. If you must hide, choose an area out of the shooter’s view, block the entry to your hiding place and lock the doors. Also, silence your cell phone or pager. You should fight if your life is in imminent danger. You should attempt to incapacitate the shooter with physical aggression and throw items at the active shooter. Call 911 when it is safe to do so. You should report the location, the number of shooters, their physical description, the number and types of weapons held by shooters and the number of potential victims at the location. DHS instructs that when law enforcement arrives remain calm and follow instructions, put down any items in your hands, raise hands and spread fingers, keep hands visible, avoid quick movements toward officers, avoid pointing, screaming or yelling, and do not stop to ask officers for help or directions when evacuating. In their white paper, the Health Care and Public Health Sector Coordinating Councils remind us that healthcare professionals have a duty to care for their patients. This brings up several ethical issues in the event of an active killer event. We must prepare in advance to address several issues. We must allocate resources fairly with special consideration to those most vulnerable. We must limit harm to the extent possible. We must treat all patients with respect and dignity, regardless of the level of care that can continue to be provided. We must prepare to decide to discontinue care to those who may not be able to be brought to safety in consideration of those who can. We should realize some providers and family will choose to remain in danger. We must consider the greater good as well as our own interests. We must strive to maximize the preservation of life. Texas Government Code Section 411.204(b) requires hospitals licensed under Chapter 241, Health and Safety Code “shall prominently display at each entrance to the hospital ... a sign that complies with subsection (c) ... that it is unlawful for a person licensed under this subchapter to carry a handgun on the premises.” Penal Code Section 46.035(b)4 prohibits a concealed license holder from carrying a handgun “on the premises of a hospital licensed under Chapter 241, Health and Safety Code ... unless the license holder has written authorization of the hospital administration...” Almost every active killer scenario has occurred in places where concealed license holders were prohibited from possessing firearms. These victim disarmament zones allow killers the time to run out the “stopwatch of death” before law enforcement can arrive. If the event in Pennsylvania had happened in Texas, Dr. Silverman would
be subject to prosecution for a Class A misdemeanor punishable by a fine of no more than $4,000, confinement in jail for a term no greater than one year, or both. In addition, he would lose his concealed handgun license for a period of five years. In Pennsylvania, the “no guns” signs do not carry weight of law, but the Texas PC Sec. 30.06 sign does. We can improve physical security, limit access, arm our security guards, conduct drills, install cameras and do risk assessments, but in the end it will be the individual on the scene at the time of the active killer event who is in the best position to stop the killing. The Joint Commission requires a hospital to identify its security risks (JCAHOs Standard EC.2.10). CMS mandates a hospital patient has the right to receive care in a safe setting (42 C.F. R. 482.13(c)(2)). OSHA released guidelines in 2004 for preventing violence in healthcare. Continued on page 16 visit us at www.bcms.org
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EMERGENCIES Continued from page 15
GUN-FREE ZONES ‘IMMORAL’
“no guns allowed” signs. We also should ask them to remove gunfree zones from as many places as possible in Texas. And finally, we
We must allow our physicians, nurses and technicians who have
should petition our hospital administrators to change their “no gun”
the training and willingness to protect us to have effective tools available to do the necessary job. Concealed license holders have been
policies and allow staff to carry until our legislature changes the law. Let’s stop the “Stopwatch of Death,” once and for all.
shown to commit fewer crimes than the general population and even police officers. Would it not be better to set up a program to arm our trusted colleagues and coordinate with law enforcement to protect staff, patients and families in our hospitals? If we must run and hide from the active killer threat and cannot avoid direct confrontation, we should not disarm those who would have effective tools on hand at the scene. It is immoral to continue the fallacy of “gun-free zones” in our hospitals when experience shows that deranged killers go out of their way to select such places to do their mass killing. Accepting this reality will require a culture change among some staff and hospital administration. We are the last resort when all else fails. We doctors should take the lead in this moral undertaking, joined by our co-workers in nursing and the allied health professions. We should contact our state representatives and state senators to ask them to remove the requirement of hospitals and nursing homes to post
16 San Antonio Medicine • March 2015
REFERENCES Buckeye Firearms. K.I.D.S. – A Proactive Approach to School Murders. Jun 2012 Buckeye Firearms. The Cause and Effect of Rapid Mass Murder. Jul 2014 U.S. Department of Homeland Security. Active Shooter — How to Respond. Oct 2008 Stanford Hospitals and Clinics Risk Consulting. The Active Shooter — The New Threat in Healthcare. Apr 2011 Healthcare and Public Health Sector Coordinating Councils. Active Shooter Planning and Response in a Healthcare Setting. Jan 2014
John Edeen, MD, is a pediatric orthopaedic surgeon in San Antonio and serves on the Bexar County Medical Society Emergency Preparedness Committee. He is a graduate of Massad Ayoob’s MAG-40 and is a certified National Rifle Association pistol instructor.
EMERGENCIES
Patients choose from PROLIFERATING FREE-STANDING EMERGENCY CENTERS URGENT-CARE CENTERS • HOSPITAL EDS By Robert Frolichstein, MD There has been significant growth in the number of free-standing emergency centers in the greater San Antonio area. The reason for this growth is as varied as the structures and ownership of the centers themselves. The main impetus to invest in the establishment of a free-standing center is much dependent and driven by the ownership model. For example, a hospital-owned facility might be interested in staking out physical territory to protect or enhance its market share. Also, a hospital might locate a new center to facilitate referrals to its traditional sites with beds and procedure rooms to increase occupancy or volume of charges. On the other hand, a non-hospital-owned facility could be established for purely financial investment considerations. Licensed free-standing emergency centers in the state of Texas
may charge facility fees, such as room costs, surgical trays, supplies, etc. They may own equipment and subsequently charge for tests that can be done onsite for patients at time of service. Additionally, they may charge a “technical” component for the use of diagnostic equipment, such as X-rays, CT and MRI scanners. Unlicensed urgent-care centers may not charge facility and equipment fees.
TEXAS LAW CHANGED Free-standing emergency centers are more numerous in the state of Texas than in many other states due to differences in licensing requirements. In 2010, Texas Administrative Code 25 established rules and licensing requirements for free-standing emergency centers. The requirements seem to be less stringent than for other states. Consequently, hospitals and entrepreneurs have seized the Continued on page 18 visit us at www.bcms.org
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EMERGENCIES Continued from page 17
opportunity to establish these centers in prime locations to attract patients seeking greater convenience. Houston and Dallas-Fort Worth lead the state in numbers of free-standing centers. San Antonio is rapidly catching up to the pace of growth, however. A mixture of hospital-owned and private facilities continues to grow. To the extent that traditional hospital emergency department visits are slightly declining in San Antonio following many years of substantial increases in volume, it seems apparent that the growth of the free-standings is having its impact. The financial viability of free-standing emergency centers is quite different for hospitals, private investors versus physicians. For the entity that collects the facility charge, the break-even is about 10 to 15 patients per day. Whereas if physicians are able only to charge for their professional services, i.e., not the facility charges, they must treat 35 to 40 patients per day to break even. This difference in reimbursement for physicians can be even greater for non-hospital-affiliated free-standing centers. The main reason for this difference is the fact that Medicare will not reimburse non-hospital-affiliated centers for emergency department professional or facility fees. The physician may bill a Medicare patient at an urgent-care rate only, and the facility may not charge anything for the use of the facility. On the other hand, a freestanding emergency department that is not affiliated with a hospital may charge facility charges and emergency-level fees to commercially insured or self-pay patients.
ADVANTAGES, DISADVANTAGES From the consumer point of view, free-standing emergency centers provide both advantages and disadvantages. The advantages begin, obviously, with location. Prior to hospitals or entrepreneurs building a facility, much research is done on population, demographic groupings and traffic studies. The result is likely to be a convenient location for a concentration of residents in San Antonio communities. Another advantage is that free-standing emergency centers (FSEC) are equipped to handle higher acuity of presenting medical conditions or problems. They must be equipped with CT scans
18 San Antonio Medicine • March 2015
and testing that allows most basic diagnostic evaluations. In theory, they should function just like hospital-based emergency departments, including being involved in the city EMS plan. In reality, what has been observed is that the patients who go to a FSEC are not as sick as those who go to hospital-based emergency departments, even if you adjust for the lack of EMS involvement in the FSEC. Nationally, the percentage of patients presenting to a FSEC that required admission is around 1 percent. In contrast, the nationwide admission rate at hospital-based emergency departments varies widely but averages over 20 percent. The physicians will likely be board-certified physicians whose specialty is emergency medicine. In contrast to urgent-care centers that are generally designed to handle minor medical situations, free-standing emergency centers offer the advantage of having facilities conveniently located that are well-positioned to provide critical care to patients. The disadvantage for consumers or patients is cost. Generally freestanding centers are much more expensive. This is due to the fact, as previously stated, that these centers may charge “facility” fees for rooms, supplies and diagnostic tests that urgent-care clinics do not. The professional charges for the physician’s time also are slightly higher to the extent that the charges will be for emergency-level services rather than urgent-care level services. The total amount for the visit may be four to five times higher than a regular office visit. Healthcare professionals consider the possibility of hitting a saturation point in the case whereby too many free-standing emergency centers are added. No one really knows where or when this could happen. In comparison to other industries, such as banking, health clubs and spas, it appears that the axiom that the three most important things are location, location, location applies to freestanding emergency centers as well. Ultimately it will be the patients, the ultimate consumers of healthcare services, who will determine the success of these ventures. Robert Frolichstein, MD, an emergency medicine physician, is president of Greater San Antonio Emergency Physicians, PA, and a BCMS member.
OPINION
Nearly two decades of successfully covering children: The past, present and future of the Children’s Health Insurance Program By Ryan D. Van Ramshorst, MD
Texas State Rep. Dawnna Dukes (TX-46) speaks at a 2007 rally for HB 109 in Austin as other state legislators listen. Photo courtesy Texas Medicine
“How is healthcare for uninsured children controversial?” I remember thinking to myself back in 2007 as I learned that the Children’s Health Insurance Program (CHIP) would be a priority topic to be covered at an upcoming Texas Medical Association First Tuesdays advocacy event in Austin. I was a naïve first-year medical student in Houston, and this was my first foray into health policy and physician advocacy. During that 80th Texas legislative session, CHIP was front and center. House Bill 109 undertook rolling back restrictions on CHIP which were detrimental to some of Texas’ most in-need citizens: uninsured children. Such restrictions were passed under the guise of program improvement in an effort to save the state highly sought-
after taxpayer dollars. In 2003, the legislature voted to decrease coverage eligibility from 12 to 6 months, impose a 90-day waiting period for uninsured children to receive coverage, and increase CHIP premiums. When these provisions went into effect, more than 100,000 Texas children lost coverage. Among other important actions, HB 109 restored 12-month continuous eligibility and eliminated the 90day waiting period for uninsured children – making the Texas CHIP program better for the children it served. I am proud that I played a (very small) role in strengthening this vital program – even as a junior medical student who still didn’t even understand what a “SOAP” note was. Continued on page 20
visit us at www.bcms.org
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OPINION Continued from page 19
UNINSURED CHILDREN
Bush. Thankfully, CHIP was eventually extended by passage of the
Now, working as a community pediatrician on San Antonio’s
Children Health Insurance Program Reauthorization Act
South Side, I have a much better understanding of the critical im-
(CHIPRA), one of the first bills signed by President Barack Obama
portance of CHIP for low-income children. Currently, CHIP pro-
in early 2009. CHIPRA both reauthorized and funded the pro-
vides coverage to more than 8 million children nationwide,
gram through 2013. With the passage of the Affordable Care Act
including more than 500,000 children in Texas and 35,000 chil-
(ACA), funding was continued until Sept. 30, 2015. Complicating
dren in Bexar County. Created in 1997, CHIP was designed to ex-
matters was how the ACA simultaneously called for states to con-
tend health insurance to a targeted group of low-income children
tinue offering CHIP coverage at current eligibility levels through
who did not qualify for Medicaid. This group included children
2019 (without allocating additional dollars). This has left state
living in families with incomes between 100 percent and 200 per-
health officials with quite a sense of unease.
cent of the federal poverty level. Since then, the percentage of unin-
If Congress does not act, it is estimated that most states will run
sured children in that income range has dropped from nearly 23
out of federal CHIP dollars in the first two quarters of FY 2016.
percent in 1997 to roughly 10 percent today. Likewise, the per-
Congressional inaction would leave millions of low-income chil-
centage of uninsured children across all income levels also has
dren without viable insurance options while creating uncertainty
dropped to historic lows (although Texas continues to rank among
for state legislatures attempting to plan budgets. As CHIP is re-
the worst three states). In short, CHIP has been a rousing success.
examined, some have argued that funding should be decreased. In
While CHIP tends to be equated with Medicaid during policy
theory, low-income children should have access to affordable cov-
discussions, it is important to delineate its unique aspects. One of
erage options through the exchanges and associated tax credits.
the most salient differences is that CHIP includes cost-sharing in
Unfortunately, “theory” has not necessarily translated into health
the forms of insurance premiums and co-payments. Such cost-shar-
insurance reality for these kids.
ing is affordable for low-income families when compared to the high deductibles of many private insurance products. CHIP also
‘FAMILY GLITCH’
is unique because it is not a mandatory program for states. Despite
Numerous states have been stubborn in implementing the ACA.
this, every U.S. state, territory and the District of Columbia have
The “family glitch” describes faulty math related to how the IRS
developed CHIP programs. Another reason that contributes to its
identifies qualified health plans as affordable based on the cost of
popularity is that the match rate for federal dollars is approximately
insuring the employee only (not accounting for the cost of covering
20 percent to 30 percent higher than that for Medicaid. States also
dependents such as children). As such, pediatricians and child ad-
have the ability to further customize CHIP programs in terms of
vocates everywhere are concerned that children currently covered
covered benefits, eligibility limits and program design. Finally,
by CHIP would be “lost in transition” if the program is diminished
CHIP is highly regarded as a successful public insurance program
in size or significantly altered. It is for this reason that the American
which has enjoyed bipartisan support since its inception.
Academy of Pediatrics is calling for a four-year extension of CHIP
The initial legislation for CHIP was co-authored by an unlikely couple: the “Lion of the Senate,” the late U.S. Sen. Ted Kennedy
during which the program can be more thoroughly studied in the ever-changing health insurance marketplace.
(D-Mass.), and soft-spoken conservative Sen. Orrin Hatch (R-
Federal legislators recognize the need to consider the future of
Utah). To comply with the existing balanced budget agreement,
CHIP. During the final months of the 113th Congress, both House
the program was funded by an increase in the federal cigarette tax.
and Senate versions of the “CHIP Extension and Improvement Act
It was first passed by the Republican-controlled Congress and
of 2014” were introduced and subsequently discussed at two separate
signed into law by President Bill Clinton. However, despite its bi-
congressional hearings. Democratic and Republican elected officials
partisan origins, its history hasn’t been without controversy. Per-
alike pledged their support for CHIP and celebrated its history as ev-
haps most notable were two prior presidential vetoes of CHIP
idenced by glowing rhetoric. Unfortunately, such rosy commentary
reauthorization during the second term of President George W.
did not translate into legislative progress for kids.
20 San Antonio Medicine • March 2015
OPINION
Drs. Christine and Ryan Van Ramshorst attended their first TMA First Tuesdays event in Austin in 2007 before they were married. They both attended the Baylor College of Medicine in Houston 2006-10 and completed residencies at UTHSCSA. Dr. Christine Van Ramshorst is an OB/GYN in private practice in San Antonio. Photo courtesy Van Ramshorsts
For the health of my pediatric patients, and that of the many other Texas children who are able to have a true medical home because of CHIP, it is my hope that the 114th Congress acts quickly to extend funding at its current level. As evidenced by numerous gloomy child-health indicators, Texas has much to gain from the continued success of CHIP. As such, our Texas congressional delegation should lead the charge to ensure uninterrupted health coverage for this vulnerable segment of our population.
Ryan D. Van Ramshorst, MD, is a specialist in the University of Texas Health Science Center at San Antonio Department of Pediatrics and a staff physician at University Health System/Community Medicine Associates. He is a member of the Bexar County Medical Society Legislative/Socioeconomics Committee.
Disclaimer: The views expressed in this article do not necessarily reflect those of the University of Texas Health Science Center at San Antonio, University Health System/Community Medicine Associates, or the Bexar County Medical Society. visit us at www.bcms.org
21
OPINION
Peter Drucker, 1909-2005
SAVE THE DATE Noon, March 13 UTHSCSA Dr. Richard Gunderman
Medicine at a crossroads: By Richard Gunderman, MD, PhD Today American medicine stands at a daunting crossroads. Solo and small physician practices are being assimilated by large groups and hospitals. The perspectives of individual physicians are being devalued in favor of general guidelines and algorithms. And the locus of much medical decision-making is shifting away from the patient-physician relationship toward systems and payers. Albert Einstein once said that the problems we face cannot be solved using the same patterns of thought that were used to create them. In confronting contemporary medicine’s quandary, we need to look beyond the boundaries of the profession for deeper insights into the nature of the problem and the range of solutions that are available to us.
INTELLECTUAL HOUSEHOLD In this spirit, we turn to Peter Drucker, the 20th century’s most widely influential, highly regarded and oft-quoted management expert. Drucker was born in 1909 in Austria, the son of a physician mother and attorney father, and he grew up in a richly intellectual household that served as a meeting place for prominent thinkers of the day. As a young man, Drucker moved to Germany to start a career in business, then switched to journalism, a job that required him to file no fewer than eight newspaper stories per week. He also 22 San Antonio Medicine • March 2015
earned a doctorate in international law. He then went to England and worked as an economist at a bank before immigrating to the United States and becoming a university professor, writer and business consultant. Drucker’s output as a writer was prodigious and included 39 books, hundreds of academic articles, and a regular column in The Wall Street Journal for more than a decade. He also consulted for many top U.S. corporations and innumerable nonprofits, often serving the latter clients gratis. He also was a highly sought-after lecturer. Drucker died in 2005 at the age of 95. Perhaps Drucker’s greatest work was also one of his first, an article on the Danish philosopher and theologian Soren Kierkegaard, whose writings Drucker had devoured when he first encountered them at the age of 17. His essay, “The Unfashionable Kierkegaard,” was written in 1933, during the age of Stalin and Hitler. Though not obvious, the insights it offers contemporary medicine are profound. Drucker’s reading of Kierkegaard convinced him of two things. First, those who expect technology or politics to produce a perfect society – and for our purposes, a perfect practice of medicine or a perfect healthcare system – are certain to be disappointed. Second, the more a society – or the profession of medicine – defines success in strictly economic terms, the more it ends up losing itself. On one side of this conflict stands the French political philosopher
OPINION Jean Jacques Rousseau, who argued that society should take priority over the individual, and that whatever meaning there is to be found in individual life must be defined by its meaning for society, to which the rights of every individual are ultimately subordinate. In medicine, Rousseau’s outlook may be restated this way: Individual physicians are first and foremost workers in a larger system of healthcare, and their work must be regulated by the needs of the healthcare system as a whole. The professional freedom and fulfillment of individual physicians are important only to the degree that they serve these ends. Drucker regards Kierkegaard as providing perhaps the only viable alternative to Rousseau. If Rousseau represents the pragmatic concerns of society, often represented in medicine by healthcare corporations, licensing boards and accrediting agencies, then Kierkegaard represents something like the timeless ideals of the profession as embodied in the heart of each professional.
LONGER PERSPECTIVE Those who seek to rationalize the practice of medicine according to sound business principles, transforming physicians from professionals with minds of their own into reliably homogeneous followers of established policies and procedures, believe that, in the end, no freedom can be allowed in the practice of medicine except
for things that don’t really matter. Those whose perspectives align with Kierkegaard naturally regard the healthcare tumult of the day from a somewhat longer perspective, one that treats the freedom of individual physicians and patients as intrinsic goods that deserve to be protected and promoted for their own sake, independent of their effect on the bottom line. Ultimately, Drucker would say that it is out of the tension between the Rousseaus and Kierkegaards of contemporary healthcare that we must strike the appropriate balance between a fully rationalized healthcare system and a way of practicing medicine that respects the dignity and humanity of individual physicians and patients. Where, why and how Drucker thought we should strike this balance will be the subject of the author’s talk at noon March 13 the University of Texas Health Science Center San Antonio. The event is cosponsored by UTHSCSA, The Patient Institute and BCMS. Richard Gunderman, MD, PhD, is the Chancellor’s Professor of Radiology, Pediatrics, Medical Education Philosophy, Liberal Arts, Philanthropy and Medical Humanities and Health Studies at Indiana University and a contributing writer for The Atlantic.
visit us at www.bcms.org
23
NONPROFIT
NEW HOPE for triple negative breast cancer patients BY SARAH MUNROE
Every year, more than 40,000 women in the United States die from breast cancer. Triple negative breast cancer (TNBC) represents a disproportionately higher number (~50 percent) of breast cancer deaths, even though it represents a relatively small percentage (15 percent to 25 percent) of total cases. TNBC also contributes to survival disparities among African Americans and Hispanics because of its higher prevalence (~30 percent) among these minority groups. Since TNBC, which is more common among younger women and minority women, does not respond to targeted breast cancer therapies, harsh chemotherapy is the standard treatment for these patients. Luckily there is new hope: San Antonio’s own breast cancer research team, led by Dr. Pothana Saikumar, an associate professor of pathology in the School of Medicine at the University of Texas Health Science Center San Antonio, was awarded a $1 million multi-year grant in 2013 by the Susan G. Komen Scientific Research Program to find a new targeted therapy. In addition to the body’s immune system, another surveillance mechanism comes in the form of a protein called transforming growth factor beta, or TGF-beta to combat cancer. This protein has a Jekyll and Hyde 24 San Antonio Medicine • March 2015
relationship to cancer. At first it can be helpful in combatting cancer cells in early stages, but once cancer is advanced, the TGF-beta actually begins to promote cancer growth and metastasis (the spread of cancer from one organ to another). Dr. Saikumar and his team are studying this and looking for a way to stop growth from happening.
‘PARTNER-IN-CRIME’ The “partner-in-crime” to TGF-beta’s action is an unusual protein called TMEPAI. Dr. Saikumar’s research team identified TMEPAI to work alongside TGF-beta in controlling cell growth and migration while studying kidney regeneration in 2010. When TMEPAI was shut off, the cancer cells returned to a normal state and a number of benefits occurred. The cancer cells no longer underwent metastasis, and the tumors shrunk. Dr. Saikumar’s discovery was profound in that it revealed a novel therapeutic target to treat triple negative breast cancer patients. “We are progressing in developing novel drugs, and in a few years we will have something tangible,” Dr. Saikumar said regarding his progress since receiving the Komen grant two years ago. He emphasized that not only will these drugs benefit those diagnosed with
TNBC, but they also will help in preventing development of hormone receptor negative breast cancers. These drugs may even benefit those diagnosed with other diseases, including colon, lung and prostate cancer.
DIET AND CANCER Dr. Amelie Ramirez, professor of epidemiology and biostatistics and director of the Institute for Health Promotion Research at the University of Texas Health Science Center San Antonio, is working on revolutionary breast cancer research with her $225,000 Komen grant, awarded in 2014. “We believe eating right plays a vital role in helping reduce cancer risk,” Dr. Ramirez said. The two-year study, called “Rx for Better Breast Health,” will determine the effects of nutritional anti-inflammatory diets on breast cancer survivors by splitting a sample of 150 randomly assigned breast cancer survivors into two groups: intervention and control. The intervention group will undergo six monthly anti-inflammatory food workshops, including culinary demonstrations, recipes, meal planning, and a “variety of assistance and services from a patient navigator,” while the control group will receive only generic cancer prevention information.
NONPROFIT
Photos: Left: Dr. Pothana Saikumar Right: Dr. Amelie Ramirez
Both groups will be evaluated before the study, six months post-study, and one year post-study. “Our study is specifically testing the idea that women who get the more intensive cooking workshops, counseling and newsletters will increase their intake of anti-inflammatory foods,” Dr. Ramirez said. “We also will examine how this affects their biomarkers of obesity and inflammation.” Dr. Ramirez is an internationally recognized cancer health disparities researcher who has spent 30 years directing research on human and organizational communication to reduce chronic disease and cancer health disparities affecting Latinos. She also founded the SaludToday Latino health campaign, trains and mentors Latinos in behavioral sciences, and serves as an advisor for various nonprofit health organizations, including the Susan G. Komen Scientific Advisory Board. The study features other noted Health Science Center researchers: Dr. Michael Wargovich in molecular medicine, Dr. Alan Holden in epidemiology and biostatistics, and celebrity chef Iverson Brownell.
RESEARCH COMMITMENT Both researchers attribute the success of their studies largely to funding from Susan G. Komen. “Komen is able to see the importance of our work in fighting TNBC,” Dr. Saikumar said. Dr. Ramirez said, “I would like to warmheartedly thank Susan G. Komen for its commitment of more than $800 million in research worldwide and more than $20 million to research on diet, exercise and cancer prevention.” Komen encourages women to be proactive about their breast self-awareness by knowing their risk, getting screened, knowing what is normal for them and making healthy lifestyle choices. To be part of Komen’s commitment to local families in need of breast cancer care, education and groundbreaking research, participate in the 2015 San Antonio Race for the Cure April 11 at the Alamodome. For more information, visit www.komensanantonio.org, email info@sakomen.net or call 210-222-9009. visit us at www.bcms.org
25
LIFESTYLE
Briscoe Western Art Museum’s
Night of Artists H
H
BRINGS THE BEST OF THE WEST TO SAN ANTONIO Special to San Antonio Medicine
The Briscoe Western Art Museum, 210 W. Market St. in down-
The range of subjects will reflect the vastness of the great Amer-
town San Antonio, presents the 14th annual Night of Artists Art
ican West, from dreamy landscape vistas to rugged frontier cow-
Sale and Exhibition featuring 70 of the country’s top Western
boys, historic missions, and detailed Native American subjects.
artists. The show kicks off with the popular art sale and reception March 28, where attendees have the opportunity to bid on exqui-
An important part of the Night of Artists show is the presenta-
site paintings and sculptures by artists such as T.D. Kelsey, Sandy
tion of the Briscoe Legacy Award. For the past eight years, the
Scott, Ed Mell, Doug Hyde, Billy Schenck, Kent Ullberg and Kim
award has been given to an artist whose body of work has left a
Wiggins. Complete with a gourmet buffet, cocktails and live
lasting impact upon the Western art world. Other show awards in-
music, the art sale and reception has become the Briscoe Museum’s
clude Artist’s Choice, Committee’s Choice and Patrons’ Choice.
biggest annual fundraiser. This year’s Briscoe Legacy Award recipient is noted painter The Night of Artists exhibition opens to the public March 29
David Halbach who makes his home in the mountains of northern
for a month-long show that is free with museum admission. The
California. Halbach began his career as an animator at Walt Disney
exhibit continues through Fiesta, closing April 26, in the Jack
Studios and later spent many years as an art teacher in five districts
Guenther Pavilion adjacent to the historic museum building.
of the Los Angeles Unified School System. In 1985, he was invited to become a member of the prestigious Cowboy Artists of America
“The Briscoe Museum’s Night of Artists art sale and exhibition
and since then, he has won numerous CAA gold and silver medals.
represents one of the region’s leading contemporary Western art shows,” said Tom Livesay, the Briscoe’s executive director. “We are
The Night of Artists art sale and reception from 5 p.m. to 11 p.m.
pleased and excited to invite both Western art collectors and San
March 28 is a ticketed event. Tickets are $200 and include art sale
Antonio’s many visitors to view this impressive compilation of
with bid book, beer/wine/cocktails, hors d’oeuvres, buffet dinner and
works created by many of the top Western artists today.”
live entertainment. The event is supported by the GM Foundation.
H For tickets and sponsorship information, call 210-299-4499 or visit BriscoeMuseum.org.
26 San Antonio Medicine • March 2015
LIFESTYLE
Clockwise, from top left: Plumed Regalia, Oil, 30 x 30, $7500, Scott Burdick; Beauty and the Beast, Canvas on Board, 14 x 18, Linda Tuma Robertson; Cow Boss, Bronze, TD Kelsey, Briscoe NOA 2015. visit us at www.bcms.org
27
BCMS NEWS
BCMS Unsung Hero
Wendy Garza
Wendy Garza is synonymous with the title, “Unsung Hero,” her colleagues say. Ms. Garza has been with Northeast Orthopaedics and Sports Medicine, LLP, since the very beginning, 15 years ago. She has been in the trenches of the hard work that has contributed to growth and continues to be in the trenches with her staff to get all things billing (Back row from left) Estella Coronado, Sherri Coleman, Dr. John Chance, Unsung Hero and collections accomplished. Wendy Garza, Marshall O’Dowd, Veronica Bishop and Kristina Gomez. (Front row from “What makes Wendy Garza a great nominee left) Brittney Fisher and Teri Graham. Courtesy photo for this recognition is the fact that she does all of this with the best positive attitude and can keep a smile on her face while there may be chaos in the midst, which has a calming affect for all those around her,” the practice’s physicians and staff wrote in her nomination letter. “She has a tremendous work ethic and loyalty to this company that makes us proud that she works for Northeast Orthopaedics and Sports Medicine.” Ms. Garza was selected for the December 2014 Unsung Hero award from BCMS. BCMS recognizes physicians’ office managers/administrators who assist BCMS members to deliver the best quality care to area patients. Winners receive gift certificates and are eligible for annual prizes. To learn more, visit www.bcms.org.
Thank you, BCMS 2015 Installation Sponsors TITLE SPONSORS Homero R. Garza, MD, MPH (Gastroenterology), and his spouse, Chief Justice Sandee Bryan Marion, 4th Court of Appeals, express a heartfelt “Thank you” for your continued support to us both.
EVENT SPONSORS
visit us at www.bcms.org
29
BCMS NEWS
Advocacy and Legislative News
TMA Winter Conference BCMS President Jim Humphreys, MD (sitting at the end of the table, far right), ponders the issues under discussion during the TMA Winter Conference meeting of the Council on Legislation held Jan. 30 at the TMA headquarters in Austin.
HELP WANTED Bexar County Medical Society members for BCMS Communications/ Publications Committee. Should have little or no experience, be willing to brainstorm, eat supper at the BCMS office once each month, and participate in free-wheeling, stimulating discussions to produce the magazine you’re reading at this moment. For information, call Susan Merkner at
210-582-6399. 30 San Antonio Medicine • March 2015
Doctors from San Antonio and New Braunfels, along with BCMS staff, pause for a photo with Sen. Donna Campbell, MD (center) during the Feb. 3 First Tuesdays.
BCMS NEWS
84th
LEGISLATURE UNDER WAY FIRST TUESDAYS A SUCCESS By Mary E. Nava, MBA BCMS Chief Governmental and Community Relations Officer BCMS physicians, BCMS Alliance member and staff visit with Rep. Justin Rodriguez on Feb. 3 at the Capitol. Standing (from left) Ryan Van Ramshorst, MD; Rodriguez; Janet Realini, MD; Danielle Henkes; David Henkes, MD; Mary Nava and Jim Humphreys, MD. UTHSCSA residents listen as BCMS President Jim Humphreys, MD (foreground) discusses some of medicine’s issues, as Margaret FrainWallace, chief of staff for Rep. Roland Gutierrez, listens Feb. 3.
Visiting with Rep. Lyle Larson during the Feb. 3 First Tuesdays visit to the Capitol are (from left) Raymond Osbourn, MD; Ryan Van Ramshorst, MD; David Henkes, MD; Mary Wearden, MD; Alex Kenton, MD; Jim Humphreys, MD; Mary Nava; Larson; and Danielle Henkes.
BCMS physicians visit with newly elected State Rep. Rick Galindo (seated at desk), who represents House District 117, during the Feb. 3 First Tuesdays.
Representing BCMS during the Feb. 3 TMA and Border Health Caucus news conference on Medicaid issues is Michael Battista, MD.
Doctors, Alliance members, residents and medical students joined their colleagues from around the state during the Feb. 3 First Tuesdays visit to the Capitol. A special thanks to the following individuals who participated: BCMS President Jim Humphreys, MD; TMA Board of Trustees member David Henkes, MD; Michael Battista, MD; David Holck, MD; Alex Kenton, MD; Thomas Mohr, DO; Ray Osbourn, MD; Janet Realini, MD: David Shulman, MD; Ryan Van Ramshorst, MD; Mary Wearden, MD; BCMS Alliance President Rebecca Christopherson, joined by her daughter, Aiden Christopherson; Alliance members Cindy Comfort and Danielle Henkes; and 20 resident members from the University of Texas Health Science Center San Antonio, led by Gillian Schmitz, MD. The next First Tuesdays visit is March 3. If you are interested in attending, please visit the TMA website at www.texmed.org to register. For local discussion on this and other advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at mary.nava@bcms.org. visit us at www.bcms.org
31
UTHSCSA DEAN’S MESSAGE
By Francisco González-Scarano, MD On any given day, there are scores of active-duty, reserve and retired military personnel at the campus of the School of Medicine — attending classes and grand rounds, conducting research, teaching and seeing patients. Besides a large number of former military on our faculty, the School of Medicine has joint training programs with the military in psychiatry and nephrology. This scene plays out over the other Health Science Center schools: dentistry, nursing, Graduate School of Biomedical Sciences, and School of Health Professions. An estimated 12 percent of the total Health Science Center faculty and staff have military backgrounds. There are also many students (including 64 active duty) attending on military scholarships or via the Hazelwood Act, which confers certain tuition benefits to Texans. Seeing an opportunity to strengthen the programs and relationships with the Department of Defense (DoD) and the Veterans Administration – as well as look for other opportunities – Dr. William Henrich, president of the Health Science Center, created the Military Health Institute (MHI) in collaboration with the School of Medicine, and named Byron Hepburn, MD, Major General, U.S. Air Force retired, to lead the effort. Officially begun October 2014, the MHI is founded on the long-standing programs we already have with the Navy, Army, Air Force and the Defense Health Agency. Dr. Hepburn, who recently retired from the Air Force after 38 years of service, began his career as a pilot flying the C-9, which is the military version of the McDonnell Douglas DC-9, the first jet to see wide commercial use on a global scale. The C-9 was the Air Force’s main transport vehicle for military medical evacuation for two decades.
PILOT-PHYSICIAN Graduation from the U.S. Air Force Academy and a career as a military pilot would have been an impressive resume for the officer, but Hepburn also went to the Uniformed Services University of the Health Sciences where he received his MD. He undertook a residency in family medicine at Andrews Air Force Base, and then returned to the Air Force Academy in Colorado Springs to serve as a physician. As one of the few pilot-physicians in the Air Force, he was 32 San Antonio Medicine • March 2015
tapped to be part of the team testing the Boeing C-17 transport plane for the medical evacuation mission when it was first introduced in the 1990s. The C-17 Globemaster is the very large plane often seen in the southwest skies over San Antonio making landing approaches. Hepburn eventually served as the first U.S. Air Force Maj. Gen. (ret.) Byron Hepburn, director of the San MD, leads the Military Health Institute. Antonio Military Health System and as the commander of the 59th Medical Wing at Lackland, which is the Air Force’s largest. He also served as deputy surgeon general of the Air Force, directing all operations of the Air Force Medical Service, which includes 2.4 million covered lives and 75 military treatment centers. He also will hold the title of Assistant Dean for Military Health in the School of Medicine and a faculty appointment in the department of family and community medicine. All the schools at the Health Science Center – Medicine, Dentistry, Nursing and Health Professions – have educational programs that include a military component and most also have research sponsored by, or in collaboration with, the DoD. In the many examples of our collaborations, the largest is STRONG STAR, which is an acronym for the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience – a multidisciplinary and multi-institutional research consortium funded by the DoD and VA to develop and evaluate the most effective early interventions possible for the detec-
UTHSCSA DEAN’S MESSAGE
tion, prevention, diagnosis and treatment of combat-related posttraumatic stress disorder (PTSD) and related conditions in active-duty military personnel and recently discharged veterans. The program is led by Alan Peterson, PhD, who retired from the Air Force as a lieutenant colonel, and is chief of the division of behavioral medicine in the Department of Psychiatry. STRONG STAR brings together a world-class team of military, civilian and VA institutions and investigators from across the country to address this crucial issue. STRONG STAR is very deliberately based in Central Texas, which, with South Texas, contains one of the largest concentrations of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF)/Operation New Dawn (OND) veterans, as well as the DoD’s largest military medical complex, state-of-the-art trauma research facilities and other well-established military, VA and civilian institutional collaborations. This means STRONG STAR investigators’ expertise and innovative treatment programs are helping where they are needed most and can be optimized. Trauma is another important area where we have a robust collaboration. The San Antonio Military Medical Center (SAMMC) and University Hospital are both Level 1 trauma centers and partner in many ways. Bruce Adams, MD, chair of the Department of Emergency Medicine (EM), is a 27-year Army veteran who served as a flight surgeon for special operations. His leadership has been crucial in the rapid growth and the strength of the EM department and its excellent integration with the military. Our collaborations include the SAMMC emergency medicine physicians working and teaching at the SOM and working in the University Hospital emergency room. The SOM is also a primary training site for both their emergency medicine residents as well as their EM physician assistants, and we train a variety of their nurses, medics and allied health students. We also regularly hold joint workshops at Brooke Army Medical Center and SAMMC,
and our EM department also has two active DoD-funded projects working on life-saving battlefield technology, as well as several other joint research programs in various states of development. We also are conducting trauma and related research in many other areas and departments, including the departments of surgery and neurosurgery, who also partner with other branches of the military, DoD and VA. There are joint programs with the School of Dentistry that include a master’s degree in dental sciences, with multiple specialties as well as partnering in endodontics, periodontics and oral maxillo facial surgery. Dr. Kenneth Hargreaves, DDS, PhD, who is chair of the Department of Endodontics, oversees a research program focused on non-narcotic management of pain. With many service members in need of pain medications to deal with injuries, highly addictive medications run the risk of introducing new problems beyond the physical injuries and PTSD. Studies with non-narcotic treatments are now under way with military burn patients. Another study through our Research to Advance Community Health (ReACH) Center focuses on primary care and peer support to improve function and pain control in veterans suffering from chronic pain. Principal investigator is ReACH director Barbara Turner, MD, James D. and Ona I. Dye Professor of Medicine. The ReACH research is another illustration of how many different areas there are here working on similar issues. Previous to the MHI, principal investigators/researchers had no effective way to know that other, related programs existed. The School of Nursing has many active-duty and retired students in their undergraduate and graduate programs, and a unique track that takes enlisted military members as nursing students who then become officers or are eligible to become officers upon graduation. Dr. Penny Flores, assistant professor of nursing, also has a program focused on the unique physical and emotional challenges in the care for active-duty and former Continued on page 34 visit us at www.bcms.org
33
UTHSCSA DEAN’S MESSAGE Continued from page 33
military members. Important outcomes of the new MHI include the creation of a Military Health Interest Group for students from all schools, which will include seminars on medical lessons learned, and encourage knowledge-sharing among the different students and disciplines. The MHI will sponsor military grant-seeker workshops for researchers from all schools, which will not only help share process knowledge, but also will bring together researchers from different schools with similar interests.
TRICARE An important aspect of patient care is also the military’s healthcare coverage, TRICARE insurance, which is fully accepted at UT Medicine and the Health Science Center. Working with TRICARE to better serve the military and retiree populations of San Antonio will be part of Dr. Hepburn’s and the MHI’s role as well. Dr. Hepburn also has been selected by the UT system to serve on their Defense Advisors Group and chair a Military Health Working Group, which will be composed of members from each of the 15 UT campuses. Having our school and university represented there will no doubt mean more and better collaboration – between
34 San Antonio Medicine • March 2015
our military partners and the broader UT system, in all of the various categories of education, research and patient care. With a complex web of cross-appointments, partnerships, collaborations and other relationships in patient care, teaching and research, the work we do with our military partners is crucial to the advancement of all patient care. In San Antonio, the designation of military or civilian does not matter when teams of likeminded physicians, nurses, emergency medical technicians or other health professionals come together with a singular focus: what is best for the patient at the very moment they need our care. With this focus in mind, I am proud to support and endorse this new group charged with bringing more solidarity to all we do with our military partners. Francisco González-Scarano, MD, is dean of the School of Medicine, vice president for medical affairs, professor of neurology, and the John P. Howe III, MD, Distinguished Chair in Health Policy at the University of Texas Health Science Center at San Antonio. His email address is scarano@uthscsa.edu.
BUSINESS OF MEDICINE
Human capital investments through mentoring
By Lee W. Bewley, PhD, FACHE
Modern healthcare organizations are perpetually seeking to more effectively and efficiently provide medical services by acquiring or developing human capital. Pathways to achieve higher levels of productivity, quality and clinical outcomes may be found in longstanding and ancient principles of development. In 1776, while our founding fathers were creating the foundation of the United States in Philadelphia, across the Atlantic Ocean in Great Britain, the father of modern economics, Adam Smith, published “The Wealth of Nations,” and established the framework of modern human capital theory through the proposition that investments to enhance the skills, knowledge and abilities of labor are positively associated with economic returns in the same manner that investments in tools, equipment or materials in the process of production yield revenue and profits.1 Even earlier examples of human capital development may be found in Homer’s “The Odyssey” as Mentor was entrusted to groom Telemachus, son of Odysseus, to become a leader of Greece while Odysseus was away from home fighting the Trojan War. Mentor served as a guide and confidant to Telemachus, and our modern human capital development concept of mentoring was derived Homer’s account of his example.2
DEFINING MENTORS The human capital development practice of mentoring is generally characterized as the voluntary developmental relationship between a mentor and a protégé to achieve enhanced personal and/or professional outcomes. Mentoring relationships may be short-term, episodic or enduring through a life/career. Development may be provided by a single mentor or a constellation of mentors depending upon needs of the individual. Additionally, while traditional developmental relationships based on career or life seniority usually apply to mentor and protégé roles, modern examples of peer or even subordinate mentoring exist based on situational developmental needs of individuals.3,7 Additional consideration for human capital development and mentoring should be focused on the needs of individuals during varying life and career stages. Social science researchers, including Daniel Levinson, Erick Erickson and Donald Super, have articulated and established frameworks for the examination of specific developmental needs based on the life or career stage of an individual. In my own research, I confirmed a life/career effect on the developmental needs of healthcare professionals in the application of mentoring. My research findings indicate that early, middle and senior healthcare professionals have distinct preferences for development through mentoring.
Generally, early careerists seek focused training, guidance, or opportunities to achieve competence and a foundation of valid standing within an organization, society, or field. Mid-careerists seek development to extend beyond competent standing toward maximization of their capacity to generate value and achieve career success. Finally, senior careerists want validation and confirmation that the content and processes of past and present life/career practices continue to be appropriate in contemporary settings (and then advice or guidance on adjustments, if necessary).4,5,6,7 How might human capital development principles of mentoring and life/career stage be effectively implemented within an organizational setting ranging from a group practice to a comprehensive healthcare system? Additionally, how might individual healthcare professionals enhance their own personal development? Consider that effective mentoring is usually a voluntary practice. Well-intended professionals who provide a career lecture to a group or expect that their own example of success without meaningful, dual interaction would not normally be considered mentoring, but rather providing information or serving as a model. Richer development of individuals occurs with dynamic, focused interaction directly between mentor and protégé. Organizations should encourage interaction among professionals internally and externally to create conditions in which potential protégés and mentors may connect on a voluntary basis and therefore, while lectures, guest speaking and modeling are not mentoring per se, these practices, particularly when complemented with genuine offers by potential mentors to provide personal development, can be useful elements to human capital development. Individuals should seek to engage potential mentors that have clearly demonstrated development that might be transferred through engagement, but also be mindful that mentoring requires time and action investments that potential mentors may not have (particularly if heightened professional requirements exist and/or multiple potential protégés are seeking development).
LIFE/CAREER STAGES Organizations and individual professionals will likely be wellserved to consider the life/career stage of potential protégés to appropriately tailor development opportunities, as well as developmental expectations (Mentor did not teach Telemachus advanced governance techniques on the first day). Early careerists will benefit from developmental opportunities that enhance competencies and provide chances to participate and contribute with tolerance for failure or lack of full understanding of contextual considerations coupled with instruction, guidance and support. Continued on page 36 visit us at www.bcms.org
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BUSINESS OF MEDICINE Continued from page 35
Professionals at mid-career who have clearly established competencies and seek developmental opportunities are often best served with challenging assignments, job references for advancement, and broader authority and responsibility matched with feedback interaction from their mentor(s). Finally, senior careerist may find valuable career development by seeking and recruiting mentors, potentially peers pursuing similar development or even precocious subordinates, who will provide frank, valid, actionable feedback, and advice as needed, on the effectiveness of their own professional actions applied in contemporary settings based on (nearly) a full career of development. The nature of healthcare delivery, predicated on the constant interaction of people seeking and delivering services, makes human capital development a critical component for both organizational and individual consideration. Organizations that develop and maintain effective human capital development processes increase their ability to establish competitive advantages and to generate substantial value in the market. Individuals who are able to obtain and master progressively higher levels of development should expect to enjoy a career characterized by competence, achievement and fulfillment.
REFERENCES 1 Smith, Adam (2003). The Wealth of Nations (reprint). Bantam Classics. New York. 2 Homer (1961). The Odyssey. Translated by R. Fitzgerald. Doubleday. New York. 3 Kram, Kathy (1985). Mentoring at Work: Developmental Relationships in Organizational Life. Scott, Foresman, and Company. Glenview, Illinois. 4 Erickson, Eric (1959). Identity and the Life Cycle. International Universities Press. New York. 5 Levinson, Daniel (1986). A Conception of Adult Development. American Psychologist. 41:1. Pages 3-13. 6 Super, Donald (1957). The Psychology of Careers. Harper and Row. New York. 7 Bewley, Lee (2005). Seasons of Leadership Development: An Analysis of a Multi-Dimensional Model of Mentoring Among Career Groups of United States Army Officers. Doctoral Dissertation. University of Alabama at Birmingham.
Lee W. Bewley, PhD, FACHE, is a retired Army officer, associate professor of healthcare management, and a board-certified healthcare executive. He is a faculty member in the Walker School of Business at Webster University in St. Louis. He has served as the program director of the Army-Baylor University MHA/MBA program and as an adjunct faculty member at the University of Texas at San Antonio, Trinity University and University of the Incarnate Word.
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37 FINANCIAL SERVICES
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Matin Tabbakh is well known for his “Make it Happen” attitude. He has been actively involved in the Real Estate industry for over a decade. Having experience in both Luxury Residential and Commercial properties, Matin has a proven record of Excellence! He has earned a Broker’s Real Estate License which is the highest professional licensing in the state of Texas and an Accredited Luxury Home Specialist (ALHS) designation; he is an active member of the CCIM Institute (Certified Commercial Investment Member) as well. Matin’s real estate education, business academics and experience are exceptional; his success comes from his unsurpassed need of excelling at what he does! Matin’s expertise in the Luxury and Commercial market makes his knowledge priceless! If you want to achieve outstanding results, call Matin for a private consultation.
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(210) 772-7777
BOOK REVIEW
‘Letters of Note’ Compiled by Shaun Usher
Reviewed by Fred H. Olin, MD
“Letters of Note” has more than 125 authors, including Winston Churchill, Kurt Vonnegut … and his son, Beethoven, Queen Elizabeth II, Mary Stuart (Mary Queen of Scots,) the widow of Eung-Tae Lee, Iggy Pop and many others. While you’ve undoubtedly heard of many of them, there are quite a few who were unknown even in their own times and places. Now, this isn’t a book one sits down and reads cover to cover. It’s big, but not coffee table big, and it’s a bit too heavy to hold up and read in bed. It’s a beautiful book: The dust cover looks good, and the layout, typography and reproductions of many of the letters are superlative. Even the introduction is like a letter. Everyone I know who has started with it seems to have had pretty much this experience: seeing it sitting there, picking it up, opening it at random, and being stuck for a while. Each of the letters has a short introduction from the editor, Shaun Usher, that explains its provenance. The publisher has considerately included an attached ribbon to use as a bookmark, but for me the random-access method was part of its charm.
LOVE, DEATH, HUMOR There is no obvious organization to the book, but there are several themes that I became aware of: love and death being two of the most engaging, and they often appear in the same letter. The 16th century Korean widow of Eung-Tae Lee, whom I mentioned above, wrote to her dead husband: The letter was found on his chest when his tomb was discovered a few years ago. She was pregnant when he died, and she bemoans her fate and that of her unborn child. Katherine Hepburn’s letter to Spencer Tracy was written 18 years after his death. There is Virginia Woolf ’s suicide note, expressing her love for her husband, and a letter to the family of a victim of the PanAm airliner that crashed in Lockerbie, Scotland, from the people who found his body on their farm. At least a few caused my vision to cloud up … age, you know. Lest you think it’s all gloom and doom, there’s a letter from Groucho Marx to Woody Allen, and Queen Elizabeth’s handwritten letter to President Eisenhower includes her own recipe for “Drop Scones.” Three girls from Montana wrote to Ike as well, begging him not to have Elvis Presley’s sideburns cut off when he was inducted into the Army or they “…will just die!” After the Soviets launched Sputnik, a 12-year-old Australian boy wrote to “A Top Scientist…” at the Australian rocket range with a drawing of a rocket ship, a few labels and the instruction that they should “…put in the details.” The “compiler” of this collection must have put in hundreds, if not thousands, of hours researching letters from all over the world, in all kinds of collections. How else could he have located a clay tablet with incised cuneiform letters, dating from the 14th century BCE, that is from Ayyab, the king of the city of Atartu, to Amenhotep IV, the Egyptian pharaoh? Or how could he have known of the existence of Mary Stuart’s letter to her dead husband’s brother, written just six hours before she was executed at the behest of Queen Elizabeth I? Here’s my ultimate recommendation: This is being written just before Thanksgiving, and I’m strongly considering buying copies of this entrancing book as Christmas gifts for friends and members of my family. It doesn’t get any stronger than that. Fred H. Olin, MD, is a semi-retired orthopaedic surgeon and chair of the BCMS Communications/Publications Committee. He used to write letters, but his fountain pen broke and email came along. Pity.
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Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Acura 11911 IH-10 West
Gunn Chevrolet 12602 IH-35 North
* Fernandez Honda 8015 IH-35 South
* North Park Lincoln/ Mercury 9207 San Pedro Ave. Porsche of San Antonio 9455 IH-10 West
Gunn Honda 14610 IH-10 West (@ Loop 1604) Ingram Park Auto Center 7000 NW Loop 410
Cavender Audi 15447 IH-10 West
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* Gunn Infiniti 12150 IH-10 West
Ancira Ram 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
Mercedes-Benz of Boerne 31445 IH-10 W, Boerne BMW of San Antonio 8434 Airport Blvd.
Ancira Dodge 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
Ancira Jeep 10807 IH-10 West
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North Park Subaru 9807 San Pedro Ave.
Ingram Park Auto Center 7000 NW Loop 410
Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604) Northside Ford 12300 San Pedro Ave.
Batchelor Cadillac 11001 IH-10 at Huebner Cavender Cadillac 7625 N. Loop 1604 East
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* Mini Cooper The BMW Center 8434 Airport Blvd.
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* Ancira Volkswagen 5125 Bandera Rd. Ancira Nissan 10835 IH-10 West Ingram Park Nissan 7000 NW Loop 410
* Volvo of San Antonio 1326 NE Loop 410
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AUTO REVIEW
Chrysler 200C From near-obscurity to a competitive sedan By Steve Schutz, MD “This is the Motor City, and this is what we do.” So said recording artist Eminem at the end of the best car commercial of the last 25 years. That momentous ad, which aired during the 2011 Super Bowl, changed how Chrysler was viewed by many people. Just as Lee Iacocca’s ads did in the early 1980s, the “Imported From Detroit” Eminem commercial told customers to take Chrysler seriously, not pity them. Given how moving the ad was, it hardly mattered that the car it featured, the first generation Chrysler 200, wasn’t very good. The point was to change how Chrysler was viewed by car buyers, and, not incidentally, Chrysler employees. 44 San Antonio Medicine • March 2015
‘AD CHANGED OUR LIVES’ In fact, a few months ago I had the chance to talk with two Chrysler engineers who told me that that ad changed their lives. It made them believe in the company again and inspired them to work extra hard on the second generation 200 to ensure that it was worthy of the commercial.
That car, the all-new 200, was introduced earlier this year and is massively better than its predecessor. It certainly looks better. Sporting a flowing roofline, sculpted front and rear ends, and
numerous nicely integrated styling elements, the 200 is undeniably handsome. My reviewer’s eyes told me, “Well done, but I see more Hyundai Sonata in the profile and taillights than I’d like,” but my neighbors and coworkers all said something like, “Wow! Nice — what is it?” No one ever said that about the previous Chrysler 200. The interior is even better than the exterior. Inconsistent describes most Chrysler interiors over the past several years, and thankfully that’s not the case with the 200. The materials are good everywhere, and there are some nice highlights such as attractive blue lighting, buttons and knobs where you want them, and a cool storage area under the
AUTO REVIEW
slide-away cup holders. I could take or leave the Jaguar knock-off rotary shift knob, but I suspect most owners will like it, and it does provide a touch of class in a market segment that’s generally focused on utility. It should be noted that the optional UConnect user interface, which syncs with a smartphone and controls the audio, HVAC and satnav systems via a front-and-center touch screen, is best in class. It’s easy, and it works. Best in class does not describe the drivetrain, however. You’d think a 9-speed transmission would be an ideal way to get the fuel economy of a CVT and the drivability of a 6-speed automatic. But in this case you’d be wrong. While this transmission does help with fuel efficiency — we’re talking 18 mpg city, 29 mpg highway with the 3.6-liter V6 and AWD which my 200C test car had — drivability is disappointing because the transmission hunts for gears more than it should, even during ordinary driving on suburban roads. These days fixing this sort of problem mostly involves tweaking software, but since every engine/transmission software change carries significant emissions and fuel-economy implications, those changes are never made quickly. Handling is surprisingly good for a 3,473pound sedan with most of its weight over the front wheels. I credit enthusiastic engineers like the ones I mentioned earlier, who were eager to show me exactly what they did with the suspension, steering and braking systems to make the 200 as fun to drive as possible. They succeeded. The Chrysler 200 comes standard with a 2.4-liter 4-cylinder engine rated at 184 HP, while the optional V6 engine like the one in my test car provides 295 HP. Front-wheel drive is standard, and all-wheel drive is a V6only option.
FOUR TRIM LEVELS AVAILABLE The Chrysler 200 is available with four
trim levels: LX, Limited, S, and C, and a multitude of options. The LX doesn’t get you much, but it does include keyless ignition and entry. Why a base Chrysler 200 comes standard with this super-handy feature, while buyers of $100,000-plus cars like the Mercedes SL and Porsche 911 Turbo have to pay extra for it is beyond me. Anyway, the 200 Limited has alloy wheels and other enhancements. The S, which is the sporty 200, comes with all of the Limited’s equipment plus suspension upgrades and other goodies. The top-of-the-line 200C is the most luxurious 200 and comes loaded. Notable options are an 8.4-inch touchscreen, smartphone app integration, text-tovoice capability for compatible phones, blind-spot warning, adaptive cruise control, frontal collision warning, lane departure warning, automatic high-beam control, and rain-sensing windshield wipers. In the nottoo-distant past many of those options could be found only on top-of-the-line German sedans and Lexuses. How far we have come with our automotive tech. Four years ago, Chrysler was an almost-ir-
relevant car company that many industry observers like me had written off. Thanks to inspired leadership, can-do employees, and a kick-ass commercial for the ages, Chrysler is growing impressively. As long as they continue to make vehicles like the 200C, their winning streak will continue. Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. For more information on the BCMS Auto Program, call Phil Hornbeak at 3014367 or visit www.bcms.org. visit us at www.bcms.org
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46 San Antonio Medicine • March 2015