San Antonio Medicine March 2016

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EMERGENCY MEDICINE ZIKA VIRUS RESPONSE

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Emergency Medicine

The Zika Virus: Pregnant Women and Women of Reproductive Age

By Herbert Guzman, MD, OB/GYN .....................16

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BCMS President’s Message ...........................................................................................................8 BCMS Legislative News................................................................................................................10 Non Profit: The Boerne Education Foundation..............................................................................24 Lifestyle: Coffee By Julie Catalano ..........................................................................................................26 Around the Block By Dr. Adam Ratner ....................................................................................................28 Legal Ease: Who’s Responsible Besides the Criminal?

By George F. “Rick” Evans, Evans, Rowe & Holbrook..........................................................................30 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................32 Business of Medicine: Market Dynamics in the Wake of the Patient Protection and Affordable Care Act By Lee W. Bewley, Ph.D, FACHE .........................................................................35 BCMS Circle of Friends Services Directory .............................................................................................37 Book Review: Comprehensive Financial Planning Strategies for Doctors and Advisors .......................42 Auto Review: 2016 Range Rover, By Steve Schutz, MD .........................................................................44

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Preparing for Events They Hope Will Never Come

By Mike W. Thomas .........................................20

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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

The Future of Emergency Medicine

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Zika Virus: An Emerging Public Health Threat?

By Patrick S. Ramsey, MD, MSPH .......................12

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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 • March 2016

PRESIDENT’S MESSAGE

Physician Burnout & Electronic Medical Records

By Dr. Jayesh Shah, 2016 BCMS President

Are you a physician who has to save charting until the end of the day? Or until your office staff has left for the day, and you are still finishing up your charting till late in the evening? And by the time you reach home, your kids are already asleep and your spouse is upset because you came home late again? And then you still have to log on from home for a couple more hours to finish up charting?

My physician friends, if you are in any one of these scenarios, you are not alone.

This year, in the Medscape Physician Lifestyle Report, 46 percent of all physicians responded that they have experienced burnout, which is a substantial increase since the Medscape 2013 Lifestyle Report, in which burnout was reported by slightly fewer than 40 percent of respondents.

Every time there is a survey of a group of physicians asking, “What are the top three reasons in your practice day that makes your life difficult and increases your feeling of burnout?”, electronic medical records or EMRs and other documentation issues ALWAYS make the list. This is true regardless of specialty without exception. An EMR is a digital version of a paper chart that contains all of a patient’s medical history from one practice and is used by providers for diagnosis and treatment.

The problem with EMR is that it is designed by people who have never seen a patient. EMR and other documentation issues continue to cause a huge burnout problem for a significant num-

8 San Antonio Medicine • March 2016

ber of doctors. It has forced many doctors to retire early because of continued frustrations.

Let us help these struggling doctors collectively. Let us ask each hospital system and physician practice to find out doctors who are working on documentation till late in the evening or from home at night. I am sure there are doctors in each hospital and in each specialty who finish their work on time and are able to leave the clinic at the same time when their last patient is seen.

It is important that physician leaders who are doing well with EMR help other colleagues who are struggling to decrease physician burnout. All physicians should be able to go home on time and spend quality time with their family so that they can recharge their batteries for a brighter next day.

Let your physician colleagues know if you are struggling with EMR. It may not be a bad idea to hire a scribe or try voice-recognition software such as Dragon. Let EMR not be the reason for your burnout. Bexar County Medical Society has a physician rehabilitation committee that works with physician burnout issues.

Texas Medical Association also has several programs to help with physician burnout issues.

Physicians deserve to be healthy and happy so that they can provide good health care for the community.

Stay well!

With Regards, Dr. Jayesh Shah

BCMS LEGISLATIVE NEWS

BCMS physicians and Alliance members attend reception in honor of Texas House Speaker Joe Straus

By Mary E. Nava, MBA, Chief Government Affairs Officer, Bexar County Medical Society On Feb. 4, Drs. Alex and Candace Kenton hosted a reception in their home honoring Texas House Speaker Joe Straus (District 121). Many thanks to all who turned out in support of Speaker Straus. Among the attendees at the TEXPAC-sponsored event were: Kaashif Ahmad, MD; Michael Battista, MD; Delbert Chumley, MD; Louise Chumley, BCMS Alliance; Pam Hall, MD; David Henkes, MD; Danielle Henkes, BCMS Alliance; John Hinchey, MD; John Holcomb, MD; Scott Kercheville, MD; David Lam, MD; Jesse Moss, Jr., MD; Janet Realini, MD; Jay Shah, MD; David Shulman, MD; Christina Stine, MD; Bernard Swift, Jr., DO; Mary Wearden, MD and Mark Welborn, MD.

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Photo captions: 1. Enjoying the reception for House Speaker Joe Straus on Feb. 4 were (l-r): Michael Battista, MD, Jesse Moss, Jr., MD, Straus and Alex Kenton, MD. 2. BCMS physician members and Alliance members pause for a photo with House Speaker Joe Straus on Feb. 4. 3. In attendance at the Feb. 4 reception honoring Speaker Joe Straus were (l-r): Mary Wearden, MD; Michael Battista, MD; Hanoch Patt, MD; Alex Kenton, MD; Straus; Christina Stine, MD; David Lam, MD; Todd Schamberg, MD and Kaashif Ahmad, MD. 4. BCMS president, Jayesh Shah, MD with Speaker Joe Straus on Feb. 4. 5. Drs. Alex and Candace Kenton, event hosts, stand with their daughter, Victoria and House Speaker Joe Straus on Feb. 4.

10 San Antonio Medicine • March 2016

EMERGENCY MEDICINE

ZIKA VIRUS: An Emerging Public Health Threat?

By Patrick S. Ramsey, MD, MSPH Over the past several months, growing concerns have emerged regarding the Zika virus and potential public health risks, especially with potential perinatal risks. Observations from a major outbreak in Brazil have suggested an increased incidence of a rare birth defect known as microcephaly with Zika virus infection. Zika infection has also been associated with Guillain Barre’ syndrome, a form of ascending motor paralysis.

In early February 2016, the World Health Organization declared the Zika pandemic an “International Public Health Emergency of International Concern,” only the fourth time such a declaration has ever been made by the organization. The Centers for Disease Control and Prevention have also issued Level 2 Travel Advisories to countries with a Zika outbreak and interim guidelines for management related to Zika virus. While it is not known at this time what the true association is between Zika, fetal microcephaly and Guillain-Barre’ syndrome, public health and health care professionals need to be acutely aware of the evolving issues related to Zika and be prepared to address patient concerns and initiate testing when indicated.

What is the Zika virus?

The Zika virus is an enveloped single-stranded RNA arbovirus in the Flavivirus genus which is transmitted to humans primarily through the bites of infected via Aedes mosquitoes, usually Aedes aegypti or Aedes albopictus. The virus was originally identified in 1947 in the Zika Forest of Uganda and for many decades was not thought to be a significant pathogen. With the past decade, however, several outbreaks have occurred, first in Yap Providence in Micronesia (2007) and most recently in Brazil. The recent concerning association with Zika virus infection and severe fetal microcephaly, and possibly Guillain-Barre’ syndrome has prompted the international concern regarding the virus.

What are signs and symptoms of Zika infection or “Zika Fever”?

The incubation period for the Zika virus is between 3 and 12 12 San Antonio Medicine • March 2016

days. 80 percent of those infected with Zika are asymptomatic. In the remaining 20 percent, mild non-specific symptoms may develop (acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis) which typically resolve within 2-7 days. If two or more of the above symptoms are present, illness is considered consistent with Zika virus disease and additional testing in pregnant women.

How is Zika Transmitted?

The Zika virus is transmitted primarily by mosquitos from the Aedes genus. The Aedes mosquito is found in Texas and throughout much of the southern United States and is also the same genus of mosquitos that transmits Yellow Fever, Dengue Fever, and Chikungunya. The Pan American Health Organization has warned that Zika virus could continue to spread throughout the Americas, and potentially local areas in the United States.

Several cases of sexual transmission of Zika have been described including the recent case in Dallas County, Texas. Evidence suggests that the Zika virus can persist in seminal fluid for up to 10 weeks following illness. In some of these cases, hematospermia and prostatitis were present in the male partner.

Concerns have been raised regarding the potential risk of Zika transmission via blood transfusion. In a 2007 Zika outbreak in French Polynesia, 3 percent of asymptomatic blood donors were found to be positive for Zika virus. Several cases of transmission via blood transfusion have also been documented outside of the United States. Because of this concern, American Red Cross has recommended that potential donors who have traveled to one of the affected countries, self-defer, or postpone blood or platelet donations for at least 28 days following their travel.

What are the concerns for pregnant women and their partners?

For most people, Zika infection is a minor self-limited, mild illness. The concern for Zika is primarily with pregnant women given the potential association with fetal microcephaly. Original observa-

EMERGENCY MEDICINE

tions from the outbreak which started in Brazil in 2015, noted a large surge in the cases of fetal microcephaly from an annual incidence of 0.05/1000 live births in 2010-2014 to over 1/1000 live births in 2015. Small numbers of cases have documented evidence of Zika vertical transmission to the fetus. Zika virus RNA has been identified in fetal tissue from early missed abortions, amniotic fluid, term neonates and the placenta.

Much is still unknown about the potential risks for Zika virus infection in pregnancy. Some questions include: Is there a clear plausible pathophysiology, is there a specific gestational age range at risk, are there clinical co-factors which influence risk, are there any longterm risks of maternal infection, etc? Preliminary reports from Colombia have noted 2,100 cases of Zika infection in pregnancy, yet at this time, no reported increased rates of microcephaly have been noted. Much research is ongoing at this time to delineate these issues, however, until we have a better understanding of these issues and the true risk potential, making informed management decisions following potential Zika exposure or actual infection is challenging.

In addition to the concern for microcephaly, early reports from French Polynesia and others have suggested potential association between the Zika virus with Guillain Barre’ syndrome. The relationship between Zika and this neurologic condition remains to be defined and likely not isolated to pregnant women.

Emerging concerns exist regarding the documented cases of sexual transmission and risks to pregnant women and women considering pregnancy in the future. We know today that Zika virus is cleared from the bloodstream by one week but may persist in seminal fluid for up to 10 weeks following illness. Partners of pregnant women who travel to a Zika-endemic country are advised to practice safe sex and take precautions for the remainder of the pregnancy. No clear guidelines presently exist to guide counseling or recommendations for future pregnancies.

How to prevent Zika infection?

There is no vaccine for Zika virus at this time and will likely be years in the making. For now, avoiding exposure is the most effective approach to prevent infection. Pregnant women are advised to avoid travel to areas where Zika is endemic. These areas include Mexico, parts of South America and much of Central America and Caribbean. An updated list of affected countries can be found on the CDC website (www.cdc.gov/zika).

If travel to one of the affected countries is unavoidable, pregnant women traveling to countries with reported Zika virus infection should avoid contact with mosquitos by staying inside or in a screened-in area. Long-sleeved shirts and long pants should be worn

and treated with permethrin and use of mosquito repellent with DEET (N,N-diethyl-m-toluamide), picaridin, oil of lemon eucalyptus (OLE) or IR3534 should be used regularly when outdoors.

These measures can be used safely during pregnancy.

While there have been a number of cases of Zika diagnoses in Texas, including at least one in Bexar County so far, all but one of these cases was acquired from travel outside of the United State and the last case was acquired by sexual transmission from an individual who traveled outside of the United States. Because the mosquito vector, Aedes species of mosquito are found throughout South Texas, local outbreaks may be possible. Locally measures in San Antonio and South Texas are being put in place to coordinate community mosquito control. Individuals can assist in these measures by removing containers with stagnant water, such as old tires, barrels, which can serve as a mosquito breeding ground.

What should health providers do?

All health care providers caring for pregnant women should ask their patients about recent travel. Current CDC guidelines recommend Zika testing for all pregnant women who have traveled to one of the countries where Zika is endemic (SEE FIGURE page 14).

Testing can be offered to pregnant women without symptoms anytime between two and 12 weeks following travel. If performed, testing should include Zika virus IgM, and if IgM test result is positive or indeterminate, neutralizing antibodies evaluated on serum specimens. For pregnant women presenting with clinical illness suggestive of Zika, testing can include Zika virus reverse transcription-polymerase chain reaction (RT-PCR), and Zika virus immunoglobulin M (IgM) and neutralizing antibodies on serum specimens. Testing can be coordinated through the San Antonio Metropolitan Health District and the State Health Department.

Providers should evaluate their local clinic/hospital environment and develop processes to facilitate testing.

In pregnant women who test positive or inconclusive for Zika infection, serial prenatal ultrasound assessments every 3-4 weeks are recommended to assess for development of microcephaly or intracranial calcifications. Consideration of amniocentesis is also recommended in these cases to test for Zika virus with RT-PCR testing.

In pregnant women with negative testing for Zika, a baseline prenatal ultrasound is recommended to assess for the above abnormal findings. When these are absent, the CDC currently recommends resumption of routine prenatal care. If abnormal findings are present, retesting of the mother and consideration of amniocentesis is recommended. The Society of Maternal-Fetal Medicine has issued clinical guidance for microcephaly diagnosis recommending that Continued on page 14 visit us at www.bcms.org

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EMERGENCY MEDICINE Continued from page 13

FIGURE 1. Updated interim guidance: testing algorithm for a pregnant woman with history of travel to an area with ongoing Zika virus transmission (Source: Oduyebo T, Petersen EE, Rasmussen SA, et al. Update: Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure — United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65(Early Release):1–6.)

isolated fetal microcephaly should be defined as fetal head circumference >3 SD or more below the mean for gestational age on perinatal ultrasound and that certain diagnosis of pathologic microcephaly is considered certain when the fetal HC is > 5 SD. Providers should be aware that different evaluation/management algorithms are in place for pregnant women who live in endemic areas. This algorithm can be found on the CDC website. Other pregnancy considerations include cases of miscarriage or stillbirth in women with suspected or diagnosed Zika virus infection. In these cases, fetal remains and placenta should be sent to pathology for evaluation for presence of Zika virus. The capacity to breast feed is also an issue that has been questioned. Although the presence of Zika in breast milk has been reported, it is in very small amounts 14 San Antonio Medicine • March 2016

and unlikely to be harmful for the neonate. The benefits of breastfeeding likely outweigh the potential neonatal risks. Therefore, currently the recommendation is that women should continue to breastfeed.

For partners of pregnant women who have traveled to one of the affected countries, because of the concern for possible sexual transmission, current CDC guidelines recommend consideration of abstaining from sexual activity or using condoms consistently and correctly during sex.

For women or their partners considering pregnancy, there are no clear guidelines to base care at this time. There is no evidence available at this time to suggest that Zika virus, after it has cleared from the blood, poses a potential risk of birth defects in future pregnan-

EMERGENCY MEDICINE

cies. It is known that Zika virus is cleared from the blood in about one week and up to 11 weeks in semen. The CDC recommends that the patient discuss their pregnancy intentions and planned travel with their provider.

What’s next?

Unfortunately at this time, there are no available treatments nor vaccine available against the Zika virus. State and local health departments are rapidly working to develop processes to streamline testing for Zika either through the CDC or in state or local laboratories. The National Institutes of Health and Human Services has increased funding for all levels of research to explore the public health and perinatal implications of Zika.

As of Feb. 17, 2016, the CDC has documented 82 cases of travel-associated cases of Zika with no cases of locally acquired vector-borne cases. Cases documented in the United States will likely continue to climb with increased media attention and screening.

As summer approaches in San Antonio and South Texas, it is possible that we may see local outbreaks here in the region given the presence of the mosquito vector here. The San Antonio Metropolitan Health District, in conjunction with the State Health Department and CDC, is prepared and poised to address issues as they arise. For now the best approach is to implement mosquito control efforts (removal and/or treatment of potential mosquito breeding areas) and personal protection against mosquito bites with use or repellants and other measures.

Patrick S. Ramsey, MD, MSPH is Professor and Maternal-Fetal Medicine Specialist in the Department of Obstetrics & Gynecology at the University of Texas Health Sciences Center at San Antonio where he serves as the Medical Director for Maternal Transport and Outreach and Director of the Maternal-Fetal Medicine Fellowship Training Program. He practices at UT Medicine, the faculty practice of the School of Medicine at the UT Health Science Center San Antonio. He cares for women with complicated high risk pregnancies and delivers at University Hospital, the Health Science Center’s clinical partner.

Updates on Zika Virus can be found on the CDC website

(www.cdc.gov/zika)

ZIKA VIRUS FACTS The U.S. Centers for Disease Control and Prevention has issued a travel alert for Mexico, the Caribbean, and Central and South America, where Zika virus is circulating. The virus has been linked to birth defects, and the CDC is advising pregnant women to postpone travel to affected countries.

What is Zika virus?

Zika is a mosquito-borne virus named for the forest in Uganda where it was discovered.

How is it spread?

The Zika virus is transmitted to people by the Aedas family of mosquitoes. It can be transmitted from an infected mother to her child during pregnancy and delivery.

What are the symptoms?

Symptoms can include fever, rash, joint pain and conjunctivitis, or red eyes. The illness, Zika virus disease (sometimes called Zika fever) is usually mild and can last three to 12 days. No vaccine or treatment currently exists.

What is the risk to pregnant women?

Women infected with the Zika virus during pregnancy have been linked to birth defects and poor birth outcomes, especially microcephaly (an unusually small head size and incomplete brain development), fetal death and Guillain-Barre syndrome.

Travelers to affected areas should avoid mosquito bites by staying indoors as much as possible, using a DEET-containing repellant (safe for use in pregnancy), and covering exposed skin.

Protective measures should be used throughout the day, at dusk and dawn.

What countries are affected?

SOUTH AMERICA: Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Paraguay, Suriname, Venezuela; NORTH AMERICA: Mexico; CENTRAL AMERICA: El Salvador, Guatemala, Honduras, Panama; CARIBBEAN: Barbados, Guadeloupe, Haiti, Martinique, Saint Martin; OTHER Puerto Rico, Samoa, Cape Verde.

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EMERGENCY MEDICINE

THE ZIKA VIRUS

Pregnant Women and Women of Reproductive Age

By Herbert Guzman, MD, OB/GYN at Metropolitan Methodist Hospital

The Zika virus infection is a result of the transmission of a virus primarily through mosquito bites. In November 2015 a possible association between the mosquito bite transmission of the Zika virus in pregnant women and microcephaly was identified in Brazil.

The Zika virus continues to receive top billing in the media because of its connection to this serious birth defects and other abnormalities of the brain and eye. Though Brazil has had a significant outbreak of the Zika virus for almost one year and has noted an increase in babies with this disorder during this time, the CDC (Centers for Disease Control and Prevention) cites more studies are needed to determine the degree to which Zika might be linked.

pain, headache and conjunctivitis, with patients very rarely dying of Zika.

Though there is currently no evidence to suggest that Zika virus infection poses a risk of birth defects for future pregnancies, it is important for physicians to discuss the risks associated with Zika before women wanting to become pregnant actually travel to areas suspected of having Zika. The Zika virus usually remains in the blood of an infected person for about a week, though Zika virus has been found in semen for up to two weeks.

The virus will not cause infections in a baby that is conceived after the virus is cleared from the blood.

What is microcephaly?

Treating pregnant patients with Zika

Microcephaly is a congenital birth defect where the head of the child is smaller compared with other children of the same age and sex. Usually it is associated with: • Developmental delays • Seizures • Hyperactivity • Mental Retardation

If you suspect a pregnant patient may have Zika, it is suggested you do a blood test to look for Zika or other similar viral diseases, like dengue or chikungunya. If confirmed, the CDC suggests the following treatment of symptoms: • Have patient get plenty of rest.

• Have patient drink fluids to prevent dehydration.

• Prescribe medicine such as acetaminophen (Tylenol®) to reduce fever and pain.

• Do not allow patient to take aspirin or other non-steroidal antiinflammatory drugs.

• Assess patient’s condition if they are taking medicine for another medical condition before prescribing medication for Zika symptoms.

At the time of this article, Bexar County had reported three suspected Zika virus exposures in pregnant women. Most infections are asymptomatic, and symptomatic disease is generally mild with patients not sick enough to go to the hospital. The most common symptoms of Zika virus disease include fever, rash, joint pain, muscle 16 San Antonio Medicine • March 2016

EMERGENCY MEDICINE Preventing Zika

What if a patient is exposed to the Zika virus?

Because the Zika virus may be spread from a pregnant woman to her unborn baby, the CDC and the American Congress of Obstetrics and Gynecology (ACOG) recommend delaying travel to areas where there are active Zika cases. At this time, Zika virus in the U.S. has only been associated with people who have traveled to the affected areas. (see CDC website for locations at www.cdc.gov)

At this time there are no vaccines or specific treatments for the Zika virus. Supportive treatment of symptoms include hydration, rest and analgesics. Avoid the use of NSAIDs and aspirin.

Let patients know that once exposed to the virus, it is very important to communicate with their prenatal care provider, especially if they develop symptoms associated with Zika such as fever, rash, joint pain, or red eyes during their trip or within two weeks after traveling to a region where Zika has been reported.

Prenatal providers may suggest testing for the Zika virus and the use fetal ultrasounds to detect development of microcephaly.

Zika virus testing is currently very limited. At this time, the Zika virus is so new that we are still learning new ways of transmission and how to prevent it every day.

More information for physicians and other health care providers can be found on the Zika virus Information for Health Care Providers website at www.cdc.gov or at the Methodist Healthcare System Zika CDC microsite at www.sahealth.com/service/zika-virus.

If the patient must travel to affected areas the CDC and ACOG recommend: • Environmental Protection Agency (EPA) insect repellents with DEET (not contraindicated during pregnancy).

• Have patient avoid exposed skin by wearing long sleeves and long pants.

• Pregnant women with partners exposed to the virus should abstain from intercourse or use condoms.

• Do not leave standing water around the house that may promote mosquito breeding.

• Remain in air-conditioned areas and indoors if traveling in one of the affected areas.

Dr. Herbert Guzman is on the staff at Metropolitan Methodist Hospital where he served as chief of the OBY/GYN Department in 2013-14.

visit us at www.bcms.org

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EMERGENCY MEDICINE

THE FUTURE OF EMERGENCY MEDICINE

By Mike W. Thomas

If someone walks into an emergency room and collapses, their survival may depend on how rapidly doctors can diagnose their condition and effect the right treatment.

Did they have a heart attack? Then they need a certain kind of treatment before being sent to a cardiologist.

Did they suffer a stroke? Then they may need a different kind of treatment and should be sent to a neurologist.

Or maybe they collapsed due to blood loss from a gunshot wound or any number of other medical conditions.

Emergency medicine is all about the acute care that is delivered in those first few minutes of medical trauma and the decisions the doctors make in those moments can make a critical difference in the outcome of a patient’s condition.

18 San Antonio Medicine • March 2016

At the University of Texas Health Science Center at San Antonio a new program is underway to train medical interns to become emergency care physicians. Dr. Bruce Adams, professor and chair of the Department of Emergency Medicine at the Health Science Center, said the new Emergency Medicine Residency Program is dedicated to providing an excellent educational environment which will prepare graduates to successfully complete the American Board of Emergency Medicine certification exam and help them enter the career pathway of their choice.

“We are still just at the beginning of a period of exciting change and tremendous growth for emergency medicine here in South Texas,” Adams said. “In just three years we transitioned from a clinical division to a full academic department recognition by the Uni-

EMERGENCY MEDICINE versity of Texas; started a major residency; started a core clerkship for over 200 students per year and now look forward to opening a new Pediatric Emergency Room in 2016.”

This is the first civilian emergency medicine residency program in South Texas and it is being overseen by Dr. Andrew Muck, an assistant professor in the department. After launching three years ago, they are preparing for their first batch of 10 graduates later this summer.

Emergency medicine has gotten a big boost in recent years from new technologies and is exploding as a specialty in the medical field, Muck said. Portable ultrasound equipment is making it possible for doctors to make rapid diagnoses of patients in emergency situations.

“These are exciting times with all the new technological advancements,” he said. “We are one of the first labs to train all of our students in the use of ultrasound equipment.”

In the hands of a trained individual, the portable ultrasound equipment can be used to quickly rule out certain life-threats, Muck said, making sure there is not an aortic aneurism or some other serious internal condition.

“If I can look at those things quickly it can make a big difference to the patient,” he said. “We are essentially diagnosticians who are responsible for triaging patients and getting them to the best specialty.”

Another new technology, developed right here in San Antonio, that is benefiting emergency medicine is the EZ-IO Intraosseous Vascular Access System which provides fast vascular access for the delivery of essential medications and fluids.

Muck, an Air Force veteran who did a tour in Afghanistan, has helped to train the students to work in extreme conditions of hot and cold weather. The program has conducted training exercises at local parks with simulated explosions and shootings where the students had to react to situations in different environments.

Muck said that the life of an emergency medicine doctor is not like what you see on TV with the constant excitement and glamor.

The most common ailments they see regularly are for chest and abdominal pains, broken bones and sprains and the occasional skin rash. But Muck said the thing the doctors pride themselves on the most is when they can make that difficult diagnosis that helps to save a patient’s life.

“The symptoms don’t read the textbooks,” Muck said. “That is what we teach our students. We train them to not miss those subtle presentations of a life-threatening disease.”

Mike W. Thomas is the director of communications for the Bexar County Medical Society and editor of San Antonio Medicine magazine.

visit us at www.bcms.org

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EMERGENCY MEDICINE

PREPARING FOR EVENTS THEY HOPE WILL NEVER COME

By Mike W. Thomas

San Antonio’s Emergency Preparedness Division employees have had it pretty easy for the last several years and for that they count themselves lucky.

Tasked with overseeing the city’s response to major catastrophes – hurricanes, tornadoes, fires, natural disasters, disease outbreaks, and more – they have had plenty of time to plan and prepare since the last major events to hit San Antonio. That was the H1N1 virus outbreak in 2009-10 and hurricanes Ike and Gustav in 2008.

“We have been very fortunate lately,” said George Perez, senior management analyst. “We have dodged a lot of bullets these past few years.”

Currently, the division is preparing for a possible outbreak of the Zika virus that has been causing problems in other parts of the globe.

But regardless of whether there is ever an outbreak here, the goal is to have a plan of action just in case.

“Failure to plan is a plan to fail,” Perez quipped.

If and when one of these plans has to be put in place, Perez 20 San Antonio Medicine • March 2016

said, they rely on coordinating a host of volunteers to get things done. Their Medical Volunteer Coordinating Center is designed to get an army of volunteers roused and in place in the event of any kind of emergency.

“We must rely on volunteers,” said Evelyn Garza, special activities coordinator. “We need medical professionals to man our shelters and conduct our screening programs. We don’t have any doctors on staff and so it all must be done by volunteers.”

Garza said they work closely with the Bexar County Medical Society to find doctors willing to volunteer their time and services in the event of a crisis. Soon they will also be working closely with medical students at University of the Incarnate Word when the school opens its medical campus at Brooks City Base next door to the city’s Emergency Preparedness offices.

Perez said San Antonio has an excellent reputation for emergency preparedness and has been recognized nationally for its emergency response systems. San Antonio is typically the go-to city for many

EMERGENCY MEDICINE

people evacuating the Texas coastline during a hurricane.

“Historically, all roads lead to San Antonio,” Perez said.

“Our hotels fill up quickly during those times and we have to be prepared for the overflow and the people who can’t afford other accommodations. But we don’t turn anyone away regardless of where they come from.”

The following Q&A gives a good overview of San Antonio’s Emergency Preparedness vision: In a nutshell: The Public Health Emergency Preparedness (PHEP) Division is called upon to support response activities umbrellaed under the public health initiative.

What is Metro Health prepared to do in an emergency?

Access and coordinate the necessary resources in response to allhazards events, from flooding, hurricane, disease outbreaks, biological and natural occurring health related events.

What kind of capabilities do you have at your disposal in case of an emergency?

We will respond with a coordinated All-Hazards Plan with all the different levels of government and with governmental and non-governmental partnerships locally. We are fully equipped with our 44 foot Mobile Medical Response Unit (MMRU) that can be used as a medical station or office while responding to an event. We are also equipped with eight (8) trailers stocked with durable medical equipment and a wide array of medical supplies. We can also call on our local, regional and state partners in the event we need support with any all-hazards response.

What are Metro Health’s responsibilities under the law in case of an emergency?

As indicated by the National Response Framework, MH is re22 San Antonio Medicine • March 2016

sponsible for Emergency Services Function – 8 (ESF) Health and Medical for San Antonio/Bexar County. We have the duty to warn and protect our community and visitors within our jurisdiction. We would be called upon to respond by our local health authority the San Antonio Metropolitan Health District (SAMHD) Director of Health, our Mayor, County Judge, Region 8 Director of Health, Department of State Health Services (DSHS), The Governor, and Homeland Security Presidential Directive/ HSPD 8.

What’s the number one thing folks should know/do about preparedness?

“The GOLDEN RULE” Always stay informed during emergencies and follow all recommendations/safety tips provided by the authorities.

Before any disaster, formulate a plan. Decide where you will go if you must leave. Put together a supply kit, emergency contact list, and an important document container. Be prepared to have resources at your disposal to sustain you/your family, and pets for a minimum of (72) hour. The list attached is a good start to building your family Emergency Preparedness disaster Plan/Supply Kit.

For more information: • http://emergency.cdc.gov/preparedness/kit/ disasters/ • www.medicalreservecorps.gov Mike W. Thomas is the director of communications for the Bexar County Medical Society and editor of San Antonio Medicine magazine.

EMERGENCY MEDICINE

Members of BCMS are encouraged to register with the Alamo Area Medical Reserve Corp (MRC) MRC is a partner program of Citizen Corps, a national network of volunteers dedicated to ensuring hometown security.

Citizen Corps, along with the Corporation for National and Community Service, and the Peace Corps are all part of the President's USA Freedom Corps, which promotes volunteerism and service throughout the nation.

MRC units are community-based and function as a locally-organized group of volunteers, medical professionals and others, who promote healthy living, prepare for and respond to emergencies. MRC volunteers supplement existing local emergency and public health resources. www.sanantonio.gov/Health/EmergencyManagement/VolunteerEducation/MedicalReserveCorps.aspx

Texas Disaster Volunteer Registry (TDVR) Physicians and medical professionals can also register with the Texas Disaster Volunteer Registry (TDVR). The TDVR allows volunteer health professionals and lay volunteers wishing to support medical preparedness and response to register as a responder with participating organizations to provide services during a disaster or public health emergency. The registration system will collect basic information about you and your professional skills. To register go to https://www.texasdisastervolunteerregistry.org/ and click on the "Register Now" button to begin the registration process.

Registering with one or both of these organizations will help Metro Health and BCMS increase the pool of physicians and other medical professionals that are willing to volunteer when needed.

NOTE: Registering with either agency does not commit you to responding, it only indicates you would consider volunteering when needed.

visit us at www.bcms.org

23

NON PROFIT

SUPPORTING 21ST CENTURY LEARNING IN THE BOERNE ISD Almost 20 years ago a group of involved and passionate parents came together to ensure their children would excel in education by providing the learning tools and classroom materials needed to support the students, teachers and staff in the Boerne Independent School District. While the group’s members have changed over the years, their determination is stronger than ever.

24 San Antonio Medicine • March 2016

Established in 1997, the Boerne Education Foundation (BEF) is a volunteer-driven organization, employing one staff member. The Board of Directors represents a group of community-minded individuals, ranging from parents, to educators and business people, who believe that providing a strong education for Boerne ISD students significantly contributes to the success of the students. They also understand the value that the positive impact of quality public education has on a community, its businesses, property values and the families that live there.

Revenue generated through BEF’s fundraising efforts extends above and beyond Boerne ISD’s normal operating budget. The educational resources funded through BEF support a child’s education whether their path is to be college-ready or workforce-ready, and every child benefits in some way through the many remarkable academic tools that have been purchased through BEF support.

“BEF is Boerne ISD’s greatest source of funding outside of the district’s operating budget,” says foundation president Angie Lemmons. “It provides our schools with everything from much-needed classroom

tools like microscopes and calculators to ‘out-of-the-box’ items like the Star Lab—a type of mobile planetarium, and the robotics program.”

Many other remarkable academic tools available because of BEF’s contributions include software and technological materials for all academic courses, supplemental text books in reading and math, eBooks, a DNA lab and a forensic unit, ecosystems, digital cameras, art exhibits and a ceramic kiln, geo mats and climbing walls for physical fitness, musical instruments and numerous other learning tools to use in the classroom.

“In addition, there’s our contribution to the ITSA program, which stands for Information Technology and Security Academy,” Lemmons says. “Upon completion of this two-year program, students have both advanced placement credit for college, plus computer technology certification that allows them to be workforce-ready if that is their career path.”

As state funding continues to decline, BEF’s contributions are now more necessary than ever to meet the needs of students and teachers through basic 21st Century classroom materials such as Smart Boards, laptops and iPads.

NON PROFIT

In 1993, the Texas Legislature, in an effort has distributed over $2.1 million to Boerne plus music and dancing.” to equalize funding throughout all school ISD schools.

BEF will continue to raise much-needed districts in Texas, instituted school financing To accomplish its mission, BEF sponsors funds to ensure Boerne ISD remains a leader laws where certain tax-based school districts an Annual Giving Campaign in the fall that in education. No contribution is too small as return to the state a portion of their tax rev- solicits donations from organizations and in- every dollar donated to BEF stays in Boerne enue to be redistributed among other dis- dividuals and also hosts the Rock On Gala, ISD to provide an excellent education for its tricts. This became known as the “Robin a popular spring fundraiser offering an students.

Hood” tax law. Last year, Boerne ISD was re- evening of food, music and fun.

Lemmons concludes, “We endeavor to enquired to return approxhance education not only for imately $8 million in kids at every grade level, but “BEF is Boerne ISD’s greatest source of funding tax revenue to the state. even more importantly, for outside of the district’s operating budget. It Because state budget kids at every learning ability cuts and “Robin Hood” —whether they are collegeprovides our schools with everything from legislation have required bound, workforce-bound or much-needed classroom tools like microscopes Boerne ISD to make just need to be able to take and calculators to ‘out-of-the-box’ items like budget cuts to numercare of themselves independthe Star Lab—a type of mobile planetarium, ous programs, the fundently. It makes me happy to and the robotics program.” ing provided by the know that every child in generous supporters of Boerne ISD is benefitting BEF has become vital to providing a quality “Rock On 2016 will be held Saturday, from what BEF provides and it is leaving our education for the district’s students. Every April 16, at the Cana Ballroom,” Lemmons students better prepared for whatever they year, each of the nine schools in Boerne re- says. “The Cana Ballroom sits on one of will do next.” ceives monies on a per capita basis for its stu- the highest hills in Boerne and offers a For more information about the Boerne dents, and many teachers are awarded spectacular view of the Hill Country. It was Education Foundation’s Annual Giving teaching incentive grants for materials to em- the venue for last spring’s event and is back Campaign, Rock On Gala and other power them to give their students an exem- by popular demand. The Rock On Gala fundraising efforts, please visit BoerneEduplary education. Additional funding is will feature delicious appetizer stations and cationFoundation.org or contact Leslie extended to address evolving educational dinner by the award-winning caterer Don Pickus at 210.834.2809. BEF is a 501(c)(3) needs on a district-wide basis. To date, BEF Strange of Texas, silent and live auctions, organization as designated by the IRS. visit us at www.bcms.org

25

LIFESTYLE

Coffee

By Julie Catalano

Here’s a fun fact for Texans: After crude oil, coffee is the most traded commodity on the planet. More than 400 billion with Americans consuming 350

HINEE GOURMET COFFEE, HELOTES

million of those. No stats on

210.695.2000 • HINEEGOURMETCOFFEE.COM Photography, Courtesy of Hinee Gourmet Coffee

cups are downed worldwide,

Texas, but considering the hundreds of independent coffee shops, bars and roasters around—with more on the way—we are holding our own with the best of them.

From comforting ritual to grab-and-go, coffee fuels millions of Central Texans.

Here are just a few people, places and things on your journey to the perfect cup.

26

San Antonio Medicine • March 2016

“I like to say we’re Everyman’s coffee shop,” says Jeff Marsh, co-owner with wife Mary. “We’re small, very customer focused and rely totally on customer feedback.” The cozy shop — sandwiched between a donut shop and a hair salon—makes for lively conversation sometimes. “If you don’t know someone when you walk in, you’ll probably know someone when you walk out,” says Marsh, although others choose the shop for alone time or computer time. Some “fairly unique flavored coffees” bring customers back, says Marsh, to see what they come up with next. They still rotate the first two they ever brought in—jalapeno coconut and maple bacon coffee. “Our whole approach is that we’re not brain surgery.

People who come in ought to have a positive, fun experience. That’s what we try to do, with an outstanding barista staff that is second to none.”

And about that name: “It comes from an old radio series, a vignette that revolved around Hiney Winery. People still talk about it, so we’ve had fun with it. Our motto is ‘Funny name, serious coffee. No ifs, ands, or butts.’”

Open daily.

LIFESTYLE

THE WANDER’N CALF ESPRESSO BAR & BAKERY, BOERNE 830.331.9156 • WANDERNCALF.COM

HALCYON, SAN ANTONIO, AUSTIN AUSTIN, 512.472.9637 • HALCYONCOFFEEBAR.COM SAN ANTONIO, 210.277.7045 Photography by Kevin G. Saunders, Photography, Courtesy of Halcyon

A beverage hotspot in San Antonio’s Southtown, Halcyon is a coffee bar by day and a cocktail bar by night, drawing sippers looking for high-end espressos and specialty cocktails amid the creative ambience of the Blue Star Arts Complex. Open for three years, general manager Seth Williams says business is very good, thanks to a diverse crowd that ranges from teenagers to 50s and beyond who enjoy a friendly, laid-back vibe with occasional live music. Their guest roaster program is a popular draw, with barista manager John Lauber choosing some of the best coffee in the country to showcase for six weeks at a stretch.

Chef Alex Dayoc creates sandwiches and salads in an upscale comfort food vein, and also serves up weekend brunch from 10-2 (and you can toast your own s’mores at your table). The original location in Austin will be joined by a new one set to open at the former Miller Airport this year. Halcyon shares the building with Stella Public House, with craft beer and wine and farm-to-table small plates, salads and pizzas. Open daily.

BLACK IVORY COFFEE, THE ELEPHANT STORY, COMFORT 830.995.3133 • THE-ELEPHANT-STORY.COM Photography, Courtesy of The Elephant Story

A registered nurse by profession, owner Wendy Rigott started her pop-up coffee shop in 2015 because “I love coffee and I’ve always struggled to find good coffee.” Now she makes great coffee for herself and her fellow coffee lovers in Boerne, next to Ye Kendall Inn and Cibolo Creek. No brewed coffee here. “We do Chemex, pourovers, or French press, and we grind the beans fresh for each cup.” Originally from the Miami area, Rigott’s Cuban coffee—a shot of espresso with abundant white sugar—has been a real hit. Pastries earn a rave, especially decadent scones and their tasty spinoff, the scookie—a thinly sliced scone, great for dipping. Rigott’s special needs daughter also pitches in (“we’d love to eventually reach out to more kids to help train”), and there’s a dog-friendly front porch where pooches hang with their caffeinated humans. The shop shares space with Sugar Belle’s Cake Shop, known for their luscious cupcakes and more. Closed Sundays.

What kind of coffee bean merits a feature on ABC’s Nightline? The kind that has been on a wild ride, namely the digestive tract of an elephant, making it one of the most exotic coffees in the world. The only place to find it in North America is at The Elephant Story (TES) in Comfort, Texas. “[Black Ivory Coffee] founder Blake Dinkin agreed to let us carry it because we are a not-for-profit organization,” says Bobby Dent, co-owner with Ed Story and wife Joey, who founded TES to promote elephant conservation, primarily in Thailand. Up to 26 mostly rescued Asian elephants munch coffee cherries along with their daily diet of fruits, vegetables and plants (“they are not force-fed anything,” assures Dent). About 10 percent of the beans are recovered at the other end, cleaned, roasted and shipped. The result is one smooth brew. “An enzyme in the elephant’s system removes the protein, which is what makes coffee bitter,” explains Dent. For home use, one packet makes one large mug or four demitasse cups, $40. For the complete in-store experience, up to five people enjoy table service, a short presentation, fresh ground beans prepared in a copper and brass coffeemaker, and one demitasse serving each. Reservations required, $50. Bottoms up! Closed Tuesday and Wednesday. visit us at www.bcms.org

27

AROUND THE BLOCK

AROUND THE BLOCK

This column is for you. You are smart. You probably have a lawyer (or 2 or 3) and at least one accountant, financial planner/insurance expert, clergy, etc. You may or may not have an empathetic and understanding spouse.

Despite the small army of experts at your disposal, there are many challenges you face as a physician that affect your success and happiness that they don’t understand. Most likely, none of them went to medical school, and none of them face the same stresses that you must face on a day-to-day basis, year after year.

So, who do you ask when you have critical practical questions about living the life of a physician? Who do you ask when even asking the question might be embarrassing? Who do you ask who really “gets it” and knows where you’re coming from?

Around the Block is a forum where we will discuss your practical and philosophical questions about life as a physician and the practice of medicine that you might not feel comfortable asking anywhere else. Most importantly, this column is here to help you find a clearer path to your own professional success and happiness.

Your questions will be the basis for this conversation and may be submitted anonymously. While there are typically no simple and universal answers to the tough challenges we will discuss, the goal is to provide you with, at the very least, practical follow-up thoughts and questions you can ask yourself to create your own personal solutions.

To get you started thinking about questions you might want to ask, here are a few to consider: Why are so many physicians unhappy? What can be done about it?

How much money do I really need to make to live the life I want?

Why don’t I like most of my partners/associates? Why don’t they seem to like me?

How can I better adapt to the new realities of medical practice?

I’m smart. Why do I feel so powerless?

You get the idea. Bring ‘em on!

You may submit your questions to me at advisory@aratner.com or you can send them anonymously on paper to: Around the Block—San Antonio Medicine Bexar County Medical Society 4334 N Loop 1604 W., Shavano Park, TX 78231 Adam V. Ratner, MD is the Chairman of The Patient Institute, Clinical Professor of Radiology and Reuter Professor of Medical Humanities at UTHSCSA. He has been observing and interacting with physicians for more than half a century and has enjoyed advising them formally and informally for years. He may be reached at The Ratner Private Advisory, LLC.(advisory@aratner.com)

28 San Antonio Medicine • March 2016

visit us at www.bcms.org

29

LEGAL EASE

WHO’S RESPONSIBLE BESIDES THE CRIMINAL?

By George F. “Rick” Evans, Jr., BCMS General Counsel Evans, Rowe & Holbrook

Who’s to blame when a crime happens on somebody’s property?

I mean, other than the criminal. Who else is responsible? Since all crimes have to happen someplace, then this question obviously arises whenever a crime happens.

THE TWO QUESTIONS WE’RE LOOKING AT IN THIS MONTH’S ARTICLE ARE (1) what’s your exposure when a crime happens on your property and, (2) what are your rights when you’re the victim of some criminal act.

These aren’t some far-fetched questions. Let me give you some concrete examples that happen every day in San Antonio. A woman is raped in an apartment you lease to her. Your car is stolen from a North Star Mall parking lot. The office you lease is broken into and computers are stolen. A guest at your ranch is shot by a poacher.

Your secretary is attacked in the parking lot of the office building you own. While in the hotel gym, your laptop is stolen from your hotel room. Who’s responsible for these things?

Obviously, the person who commits the crime is. But what if he can’t be found? Or maybe he’s found, but has no money or assets by which to make restitution. Can anybody else be held accountable?

If your car is broken into while dining at the local bistro, does the property manager have to pay you for your loss? If you own some apartments and one of your tenants is assaulted in the hallway, are you on the hook?

The short answer is, yes, the owner or manager can be liable.

30 San Antonio Medicine • March 2016

What? How is it that you, as an apartment landlord, can be liable for a tenant who is assaulted? How are you supposed to control the conduct of these criminal miscreants who snuck upon the property to commit that heinous crime? Here’s how.

The Texas Supreme Court established a rule of law in Timberwalk Apartments v Cain that was recently reaffirmed once again. Here’s the rule: [o]ne who controls . . . premises does have a duty to use ordinary care to protect invitees from criminal acts of third parties if he knows or has reason to know of an unreasonable and foreseeable risk of harm to the invitee.” In a nutshell, whoever is responsible for that property (owner or manager or both) can be liable for the crimes of others if there was reason to believe something bad might just happen and reasonable steps weren’t taken to avoid it.

The Supreme Court focuses on five factors; proximity, publicity, recency, frequency, and similarity. What that means is the courts want to know if there’s been a series of similar crimes happening

LEGAL EASE

nearby in the not too distant past that the owner/manager should be aware of. If only one car in your office parking garage was broken into in the past five years, you probably don’t have a claim if your car gets hit next. But if you can show it happened six times last year alone, and the owner/manager knew about it and didn’t take reasonable steps to stop it (increased security, better lighting, video cameras, etc.), then you may have a case. Even if there isn’t a history of precisely identical crimes, the mere fact of somewhat similar crimes may be sufficient. A car theft may not suggest that next week somebody will be murdered, but it may suggest that next week somebody’s apartment will be broken into.

So, here’s the bottom line, take home message. If you own or manage property, you can be responsible for the criminal acts that others commit. You can’t play ostrich. If you should know about crimes happening, not just on your property, but even just near your property, you better take appropriate precautions to protect innocent people on that property (tenants, guests, whatever). What’s appropriate depends on the circumstances. Petty theft, non-violent stuff happening in a parking lot may only call for increased lighting, warning signs, and video surveillance. Armed assaults may require a lot more including 24/7 security forces.

The flip side of this issue are your rights as a victim. If your car is broken into or stolen, you may have a good claim if the property owner/manager hasn’t done a good job of protecting you. Just putting up a metal warning sign may not be nearly enough if you can show it hasn’t stopped break-ins. Many juries will expect a lot more if there’s an ongoing history that management hasn’t really tried to eliminate. The law doesn’t require that they guarantee you a crime free environment, but the law does require they take reasonable steps to protect you.

So, you’ve got rights as a victim. But, if you own or manage any property, you’ve got obligations. Don’t be legally naïve and just assume the only person who can be hauled into court is the criminal.

The law casts a much broader net than that.

George F. “Rick” Evans Jr., is the founding partner of Evans, Rowe & Holbrook. A graduate of Marshall College of Law, his practice for 36 years has been exclusively dedicated to the representation of physicians and other healthcare providers. Mr. Evans is the BCMS general counsel.

visit us at www.bcms.org

31

UTHSCSA DEAN’S MESSAGE

School of Medicine Update: New Curriculum Students Graduating

By Francisco González-Scarano, MD

The first students to complete four years of a dynamic new cur-

cation of those sciences. Courses such as biochemistry or physi-

riculum at the School of Medicine at the UT Health Science Cen-

ology are no longer taught as stand-alone disciplines, but rather

ter San Antonio will graduate this spring. The new curriculum is

in relation to systems in the body as part of organ system-based

called “CIRCLE,” which stands for “Curricular Integration: Re-

modules. In this way, the basic sciences come alive to students as

searchers, Clinicians, Leaders, Educators.” Led by Vice Dean for

clinically relevant information.

Undergraduate Medical Education, Florence Eddins-Folensbee,

The new curriculum is heavily reliant on technology. Stu-

M.D., and Associate Dean Deborah Conway, M.D., its prepara-

dents are able to access the vast universe of medical information

tion took two years and involved hundreds of hours by multiple

at their fingertips at any time. There are electronic textbooks

teams from throughout the School. Continuously refined since its

and syllabuses; calendar feeds tell the students where they need

launch in 2012, students are now getting a medical education that

to be and what materials belong in that session. Blog posts and

emphasizes active learning in an experiential setting, a model fol-

online chats provide ways to discuss content. Examinations are

lowed by the top medical schools in the country.

administered electronically, giving faculty the ability to more

CIRCLE represents a completely different way of looking at medical school education. The 225 students graduating this May

readily provide individualized feedback on student strengths and weaknesses.

will have completed a medical education unlike anything most

Students benefit from tools that present content in a more in-

of us experienced as medical students. They will have assumed

teractive, user-friendly format. For example, a “flipped class-

more direct responsibility for their education and spent fewer

room” means the material previously conveyed in lectures is now

hours in lectures, all within a coordinated format that focuses the

given to the students for learning on their own. A professor is

content and brings a higher degree of engagement.

able to record a lecture that students can watch as a streaming

Throughout the medical school experience, each student par-

video online, pausing and reviewing again as needed. These vir-

ticipates in faculty-facilitated group learning teams that serve as

tual desktop lectures mean they can stop at any time to research

an accountability tool, a learning modality and a model for the

questions in their texts, with the faculty member, or each other.

team-based world of clinical practice. Now, our students’ first pa-

In class, they are then able to discuss the material with the pro-

tient encounter takes place in the first week of school instead of

fessor and other students to deepen their understanding of the

the end of their second year or later, as was the case in the tradi-

material and its implications.

tional Flexnerian curriculum. The School now also requires stu-

Through an online platform that serves as a guided reading ex-

dents to undertake extensive preparation before a class or

ercise, faculty members can present material in a way that each

group-based learning activity. With this active format, students

student can follow at their own pace, but with a variety of tools

are able to apply knowledge at a higher level in their first two

built into the materials such as learning aids, pedagogic tech-

years of instruction.

niques and quizzes. Innovative methods such as these let students

By using a systems-based approach the curriculum integrates formal knowledge and clinical experience, teaching basic sciences to students while simultaneously exploring the real-world appli-

32 San Antonio Medicine • March 2016

learn on their own while still receiving the guidance and facilitation of faculty members.

Team-based activities teach students that team-work is not only

UTHSCSA DEAN’S MESSAGE

important, but mandatory; after all, nearly everything a physician

The change is one of both mindset and culture. Many faculty

does is team-oriented. The relationships they build with each

members report that the process forced them to think about their

other and with the assigned faculty members become an integral

work as professors in a new and creative way. One described the

part of their learning experience.

previous curriculum as being passive, with lectures consisting of

The benefits of this team-based approach are many. Because

slide after slide while students sat silently. Now, faculty members

students are required to work closely together, even conducting

are actively engaging with students in an exchange of information.

peer evaluations, they learn professional navigation skills. Teams

Many faculty members also report that, like students, the new

also provide learning support. Even for driven, gifted students

curriculum requires them to work harder, yet they also cite a re-

who are accustomed to working independently, the team can ex-

newed sense of excitement for their disciplines and interactions

pose them to new perspectives, ideas, even new questions. In a

with colleagues. Team-based learning activities also require in-

group setting students learn how a broader perspective and col-

depth collaboration among faculty members. Basic science and

laborative effort can benefit them as individuals, and clearly ben-

clinical faculty have forged meaningful relationships with each

efit their future patients. Close access to a faculty member also

other through this integration. Faculty members who had little

creates a setting in which students can more easily get answers to

reason to interact in the past now collaborate to design and write

questions that are challenging to them.

each learning module, from the syllabus to exam questions. The

Clinicians also facilitate the teams’ activities, in which student teams practice real-world reasoning in a formative setting where

collegiality and sharing of different perspectives has been very beneficial to both faculty members and students.

they are not graded, gaining valuable experience and coaching in

Another benefit of the new curriculum is that it is student-cen-

discussing cases or constructing diagnostic plans. This gives stu-

tered. Contributing to this is a shift in the way content is chosen.

dents a “safe” way to comfortably try these activities with a dedi-

To better serve students, we ensure that the information included

cated clinical teacher there to guide them.

in each module is more objectively analyzed for its role before

Our CIRCLE curriculum gives students the clinical skills and

being selected as part of a comprehensive program. Instead of in-

knowledge to go in and identify a chief complaint in a systematic

dividual departments or faculty members, the Curriculum Com-

way. By the end of their first semester they know how to perform

mittee now has the final determination over content. If

a complete history and physical exam. They then learn to apply

information has been included previously that is no longer critical,

these skills to pathological conditions to generate a differential di-

the curriculum committee has the authority to remove or replace

agnosis and evaluation of common presenting complaints.

it. This is a key difference that has contributed to a more robust

Now there is more emphasis on clinical reasoning and devel-

learning experience.

oping a differential diagnosis using assessments called trans-mod-

Once content is selected, faculty works with the team at the

ule cases, with standardized patients. We train and then task

Office of Undergraduate Medical Education (UME) to determine

students with demonstrating their emerging ability to reason and

the best way to design and deliver the information, whether it is

apply the skills they’ve learned in patient examinations. For ex-

a lecture, an interactive lab, or an online activity. UME involve-

ample, instead of instructing a student to interview a patient with

ment also ensures more consistency in the way coursework and

an asthma attack, the student instead talks to a patient who com-

requirements are structured among the specialties, making it easier

plains of shortness of breath, chest pain, or abdominal pain.

to identify gaps or unintentional redundancies in the material.

This new student-centered curriculum demands more of both

The CIRCLE framework also lends itself to adjustment and

students and faculty. While building this new curriculum required

adaptation. It is more responsive to feedback from students and

a tremendous amount of time, skill and communication, faculty

faculty, as well as to important emerging trends in medical edu-

relished the opportunity to create new materials, develop new

cation. Because it is an integrative process, there is an ongoing

courses and convert a passive learning, lecture-based course pres-

fine-tuning and adjusting of courses.

entation to a more active modality.

Four years into the CIRCLE curriculum, the results are promContinued on page 34 visit us at www.bcms.org

33

UTHSCSA DEAN’S MESSAGE Continued from page 33

ising. Typically, in any educational setting, a curriculum reform

Most importantly, the new curriculum brings us closer to the

will lead to a temporary drop in test scores followed by a return

goal of competency-based assessment, so that we can say with cer-

to the core point and eventually a rise in performance. However,

tainty when students graduate, they have not only performed well

throughout our reform performance did not suffer that typical

on tests, but have truly demonstrated the specific sets of knowl-

lag. Furthermore, clerkship directors are clearly noticing that stu-

edge, skills and experience necessary to embark on successful ca-

dents are entering their third year better equipped to engage as a

reers as competent and compassionate clinicians. I have only one

team member.

regret about the CIRCLE curriculum: that it was not the norm

The new curriculum has also added unique opportunities for

when I was in medical school many years ago.

students at the School. The emphasis on early exposure to realworld clinical skills has led to the establishment of a state-of-the-

Francisco González-Scarano, MD

art ultrasound center, which students begin using early in their

Dean, School of Medicine

first year, along with two new clerkships in neurology and emer-

Vice President for Medical Affairs

gency medicine.

Professor of Neurology

In addition to delivering relevant content in a clinical context,

John P. Howe, III, MD, Distinguished

the CIRCLE curriculum contributes to one of the School’s most

Chair in Health Policy

fundamental missions: teaching students how to be good learners.

The University of Texas Health Science

As students and clinicians, they must have well-developed habits

Center at San Antonio

of inquiry and innovation, knowing how to ask questions, how

scarano@uthscsa.edu

to identify what they don’t know, and how to find the answers.

34 San Antonio Medicine • March 2016

BUSINESS OF MEDICINE

Market Dynamics in the Wake of the Patient Protection and Affordable Care Act Lee W. Bewley, Ph.D., FACHE Whether a provider of healthcare services or patient and beneficiary of one of the many healthcare systems in the United States, most Americans recognize that the Patient Protection and Affordable Care Act of 2010 meaningfully impacted the United States healthcare system.

The prime intended effects of this act were to expand citizens’ access to healthcare and to moderate healthcare cost dynamics through a number of mechanisms including: employer and individual mandates, minimum insurance coverage, elimination of pre-existing conditions and catastrophic coverage caps, constraining insurance medical loss ratios, and implementing a host of expanded eligibility initiatives to facilitate participation in Medicaid and privately-purchased health insurance.

The results after nearly five years indicate a meaningful decrease in the number of uninsured, but nearly 32,000,000 citizens or about 12 percent of the population do not have consistent healthcare financing and healthcare costs continue to rise.1 A summary review of basic economic market dynamics can provide a framework to understand what is occurring in the various healthcare markets across the United States and in aggregate within the entire system.

The preponderance of the Affordable Care Act provisions are focused on stimulating demand for healthcare services. Providing expanded eligibility for Medicaid and subsidized health insurance through exchanges is effectively an increase in resources or income for the market of health services. Furthermore, expanding minimum healthcare insurance coverage, access to health insurance, and eliminating catastrophic coverage caps should be expected to bolster

healthcare consumer expectations.

The dual effect of enhanced income and consumer expectations for healthcare services would be expected to generate substantial demand within individual healthcare markets and in aggregate across the country. On the other hand, the Affordable Care Act did not address supply factors with a corresponding level of emphasis beyond the potential of increasing producer expectations for future revenue and/or profits associated with increased demand; however, the potential positive impact of increased supply through producer expectations may well have been moderated due to the Act’s provisions for cuts to Medicare reimbursement rates, taxes on medical devices, and implications that healthcare organizations and providers may need to fundamentally change delivery systems. The net market effect in the short to intermediate term indicates that an increase in demand matched with constant supply would likely result in increased prices and/or diminished access to services.2 A quick review of market statistics during the period 2010 – 2014 illustrates key elements of the economic market effects of the Affordable Care Act. These data indicate that the demand effects of the Affordable Care Act coupled with other effects such as the “Silver Tsunami” of Medicare-eligible beneficiaries described by my colleague Dr. Dana Forgione yielded substantial increases in healthcare expenditures during the period 2010 – 2014. Given the scant 8 percent increase in the healthcare and social assistance workforce during this period, the apparent modest contraction of hospitals in the United States, and only a 4 percent increase (2012 – 2014) in licensed practicing

Elements of Market Demand for Healthcare3

Continued on page 36 visit us at www.bcms.org

35

BUSINESS OF MEDICINE Continued from page 35

Elements of Market Supply for Healthcare4, 5

physicians, we should expect some combination of increased healthcare prices or short-term disruptions to quantity-supplied manifest in longer wait times or inability to receive care (despite having health insurance and/or the financial ability to pay). 6,7,8 Looking forward, providers of healthcare services should expect substantial and persistent demand amid relatively limited market supply conditions that would normally result in tremendous opportunities for economic profits and nearly unchallenged standing as a going concern. But prevalence of government reimbursement rates and intervening market leverage provided by employers and insurers at the points of market exchange indicate that potential resolutions to supply shortfalls and inadequate access to healthcare may be found through greater collaboration and coordination between providers and patients.

References: 1. Henry J. Kaiser Family Foundation (2016). Key Facts about the Uninsured Population. Available at http://www.kff.org 2. Baye, Michael (2006). Managerial Economics and Business Strategy (5th edition). McGraw-Hill. Boston, Massachusetts.

3. Centers for Medicare and Medicaid (2016). National Healthcare Expenditures.

Available at: https://www.cms.gov 4. Bureau of Labor Statistics (2016). Healthcare and Social Assistance Employees.

Available at: https://www.bls.gov 5. Henry J. Kaiser Family Foundation (2016). State Health Facts: Total Hospitals.

Available at: http://www.kff.org 6. Forgione, D. (2015). Costly Reflections in the Silver Tsunami. San Antonio Medicine. Volume 68. Number 6. 34 – 35.

7. Young, Aaron, Humayun, J., Xiaomei, P., Halbesleben, K., Polk, D. and Dugan, M. (2015). A Census of Actively Licensed Physicians in the United States, 2014.

Journal of Medical Regulation. Volume 101. Number 2. 8 – 23.

8. Martin, Anne, Hartman, Micah, Brenson, Joseph, and Caitlin, Aaron (2015).

National Health Spending in 2014: Faster Growth Driven by Coverage Expansion and Prescription Drug Spending. Health Affairs. Volume 35. Issue 1. 150-160.

Lee W. Bewley, PhD, FACHE, is an Army officer, associate professor of healthcare management, and a boardcertified healthcare executive. He is the program director of the Army-Baylor University MHA/MBA program, and serves as an adjunct faculty member at the University of Texas at San Antonio, Trinity University and University of the Incarnate Word.

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of February 17, 2016.

36 San Antonio Medicine • March 2016

ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA

Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA 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.

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

Continued on page 38 visit us at www.bcms.org 37

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.”

terior 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

RBFCU (HH Silver Sponsor) 210-945-3800 businesslending@rbfcu.org www.rbfcu.org

ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES

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.

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 in-

38 San Antonio Medicine • March 2016

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

EMPLOYEE BENEFITS

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it's all about relationships. We keep our partners compliant assisting with human resource administration/management, workers' compensation/risk management, benefit administration, and payroll. We help our partners

concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

Bob Davidson 210-321 1445 rdavidson02@ft.newyorklife.com www.linkedin.com/in/bobdavidsonnyl “Taking care of those who take care of us.”

FINANCIAL SERVICES

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

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.

HEALTHCARE REAL ESTATE

San Antonio Comercial Advisors (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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 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

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it's all about relationships. We keep our partners compliant assisting with human resource administration/management, workers' compensation/risk management, benefit administration, and payroll. We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

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

Texas Medical Association Insurance Trust (HHHH 10K Platinum 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.”

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

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 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

Continued on page 40 visit us at www.bcms.org 39

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 39 thomas.mohler@medpro.com Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com

Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET/ TELECOMMUNICATIONS 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.”

The Doctors Company (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com.

Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” 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 Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease— that’s only fair.

Keith Askew, Market Manager kaskew@proassurance.com

40 San Antonio Medicine • March 2016

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-

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 (HHH Gold 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

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

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.”

MENTAL HEALTH EDUCATION AND CONSULTING

The Ecumenical Center (HHH Gold Sponsor) The Ecumenical Center provides

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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.”

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

PAYROLL SERVICES

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.”

REAL ESTATE/ COMMERCIAL

San Antonio Comercial Advisors (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

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

Robbie Casey Realty (HHH 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 SWBC (HHH Gold Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits.

Bryce Fegley 830-980-1245 bfegley@swbc.com Working together to help our clients achieve their business objectives.

Robbie Casey Commercial Realty (HHH 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

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!”

As of February 18, 2016 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.”

visit us at www.bcms.org

41

BOOK REVIEW

COMPREHENSIVE FINANCIAL PLANNING STRATEGIES for DOCTORS and ADVISORS Best Practices from Leading Consultants and Certified Medical Planners

By Dr. David Edward Marcinko & Prof. Hope Rachel Hetico (Editors) This ambitious text is a 600+ page encyclopedic opus authored by more than two dozen healthcare, financial, and legal succors serving today’s healthcare providers. It was conceived and edited by a former board certified surgeon, Dr. David Edward Marcinko, MBA, CMP who is the current CEO for the Institute of Medical Business Advisors based in Atlanta which is responsible for the CERTIFIED MEDICAL PLANNER certification. Dr Marcinko holds numerous medical, financial & technology based professional designations and degrees. In the late 90’s Dr. Marcinko was president of a privately held physician practice management corporation which consolidated 95 solo medical practices for a pre-IPO listing. His cross discipline background is evident in his organization of this comprehensive text into four orderly life cycle sections which directly correlate to a physician’s career path.

Tip: for an efficient alternative to the full 600 page chronological reading after reading the first section titled “For All Practitioners” (142 pages) consider skipping to the most personally relevant section either “New Practitioner” (160 pages), “Mid Career Practitioner” (104 pages) or “Mature Practitioner” (110 pages). The remaining text is fully categorized and can be used as a reference as relevant topics are encountered.

The needs discussed and solutions provided are specific to the unique disadvantages and circumstances physicians currently find themselves dealing with i.e. “entering the workforce a decade later than contemporaries…enormous student debt…family and friends perception of them as affluent…health reform and managed care reducing remuneration…burdensome government scrutiny…IT, privacy rules, and PP-ACA regulations…a three decades long bull market in bonds and equities is over…changes in the tax code, electronic connectivity initiatives, various new practice risks, healthcare reform and the PP-ACA”.

Thankfully, the ambitiousness and scope of the book still resulted in a germane, fact-based and easily assessable read which avoids unnecessary technical jargon. The practical knowledge is not buried in superfluous pages of information, proof of this can be found in the very first chapter, section one easily one of my favorite chapters “Unifying the Physiologic and Pysychologic Financial Planning Divide ~ Holistic Life Planning, Behavioral Economics, Trading Addition, and the Art of Money”. This holistic chapter on money and our psychological relationship to it prepares a reader for all the following chapters. Based on the contributing authors backgrounds and the final work Dr Marcinko’s modus operandi seems to have been “by physicians for physicians”.

42 San Antonio Medicine • March 2016

“Comprehensive” in the title refers to both personal as well as medical practice financial issues with both spheres being extensively addressed for the health care professional. Chapter 8 in the “New Practitioner” section titled “Modern Risk-Management Issues for Physicians ~ It’s Not Just about Medical Malpractice Liability Insurance Anymore” is a condensed 20 pages addressing 69 separate risks a medical practice can be faced with in today’s new healthcare 2.0 environment. While these 20 pages are sobering, the risks can be planned for and largely mitigated.

The dozens of contributing authors are respected experts in their respective fields and are either doctors themselves or have specialized in serving the medical community. The book taps into the various authors and their wealth of expertise to guide the reader through a myriad of medically related financial topics in the order in which they can be expected to be faced in a typical contemporary medical career.

One contributing author, Dr. Michael J. Burry, was one of the first to recognize the sub-prime mortgage crisis (and to profit from it) and is portrayed by actor Christian Bale in the current Hollywood hit “The Big Short”. Dr. Burry authored chapter 14 in the “MidCareer Practitioner” section titled “Hedge Funds: Wall Street Personified”. This is relevant for most mid-career physicians since this is typically the point when their assets and income have reached a level where the government regulators will deem them “accredited investors”. Once deemed to have enough wealth to risk, the “accredited investor” is fair game for the hedge fund salesmen. Dr. Burry arms the reader with 23 concise pages on hedge funds with which a physician can defend themselves.

Local San Antonio-based author Timothy J. McIntosh (MPH, MBA, CFP, CMP) founder and chief investment officer of Strategic Investment Partners (SIPCO), author of the “Bear Market Survival Guide”, “The Sector Strategist” and an upcoming book “The Dividend Manager” authors chapters 11, 13, & 19 on investment vehicles, risk and return analysis, investment banking, and securities markets for the new, mid-career and mature practitioner sections of the book. McIntosh prepares the physician reader for their investment conversations with Wall Street and finance industry representatives and discusses separate account management a method of reducing or even eliminating Wall Street products from an investment portfolio.

Comprehensive Financial Planning Strategies for Doctors and Advisors…this timely tome is available from Amazon in both hard cover (99.95) as well as kindle versions (79.96) and would make a great gift for any physician.

Terry Langston is a Registered Investment Advisor with Strategic Investment Partners LLC (SIPCO) a national fee only fiduciary RIA firm specializing in serving physicians and their families headquartered in San Antonio, Texas.

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

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

43

AUTO REVIEW

2016 Range Rover LWB

By Steve Schutz, MD Land Rover is expanding its Range Rover, um, range with a new long wheel base (LWB) version, and—finally!—a Diesel engine option. This is welcome news and clear evidence that Jaguar-Land Rover is committed to expanding their market share by going the extra mile to appeal to any customer who might be interested in their products. Good thing, since it’s not like the competition is sitting still.

I recently tested the Range Rover LWB, which soccer moms with tall kids (basketball moms?) will certainly appreciate. Originally designed for China, where high-status people prefer to be chauffeured rather than drive themselves, the Range Rover LWB has been created with the focus on the rear-seat passengers.

Usually I wait until later in a review to dis44 San Antonio Medicine • March 2016

cuss a vehicle’s interior, but it seemed appropriate to talk about the Range Rover LWB’s larger cabin first because it’s the reason buyers will choose this version over the standard one. The additional 7.8 inches of wheelbase is mostly used to increase legroom for those fortunate enough to be seated in back, and that change makes a significant difference.

Rather than sit at attention which you will in the rear seats of the standard Rangie, you inevitably find yourself stretching out. Either a three seat bench or twin Captain’s chairs may be selected, though only the two seat option allows you to recline up to 17 percent, should you so desire, which let’s face it, there’s no way you won’t.

When you look at the Range Rover LWB from the front or rear, you’re reminded of why the brand has won so many design ac-

colades. From those views, its exterior styling is fabulous, just like the standard length version. You just want one. But from the side it looks a touch too long, as if it were made of taffy and the engineers held the front and rear axles and pulled, which they kind of did.

The rest of the interior is also excellent, with top-shelf leather, wood, and other materials just where you expect them to be. I’ve noted this previously, but in my view, the whole off road SUV ju-ju is diminished by the Jaguar-esque rotating shift knob on the center console. In Jaguars, this styling flourish is a good thing, but in a Range Rover, I don’t think it works. Otherwise, the rest of the Range Rover’s cabin is best in class.

On the road, the Range Rover LWB drives a lot like the standard one, which is a good thing. Completely comfortable cruising

AUTO REVIEW

through town or hustling over the highway on the way to the lake house, the Range Rover LWB imparts a distinctive sense of well being to driver and passengers under all circumstances. In fact, the only times I could even sense the extra wheelbase was around

round-view parking cameras, adaptive headlights with automatic high-beams, blindspot warning, automated parallel-parking assist, adaptive cruise control, nicer wheels, ventilated and massaging front seats, and a front cooler box.

SUV since the glorious third generation appeared almost 15 years ago. But competitors like the Lexus LX 570, Cadillac Escalade, and Infiniti QX80 have all been improving—and let’s not forget the just launched Bentley Betayga—so Range Rover is staying

tight turns or while parking.

When the latest (fourth generation) version of the Range Rover launched in 2013, only two engines were offered, both V8s.

Now the base engine is a 340 HP supercharged V6, with 510 HP supercharged V8 and 245 HP turbocharged V6 Diesel engines available as options. While the two gas powered motors are unsurprisingly thirsty at 17/23 and 14/19 MPG city/highway for the V6 and V8 respectively, the Diesel does much better at 22/28 MPG. Most owners won’t care about those fuel economy numbers, but if you do, the Diesel Range Rover is the way to go.

Naturally, Range Rovers, which start at

As always, innumerable options are there for the choosing. And if you really want to stand out, the ultra-lux Autobiography package gets you a loaded vehicle with unique 21-inch wheels, upgraded leather trim on the headliner, dashboard, and other places, nicer front seats with massaging capability, and lots of extra exterior color choices.

For a fortunate few able to shell out $190,000 or so, the Autobiography Black edition comes with many bespoke trim pieces, large entertainment screens in the front seatbacks, electronically deployed leather lined tables for rear seat passengers, and many other niceties. Only 100 Autobiography Black edition Range Rovers will be

vigilant with new versions to maximize their appeal. I can’t relate to the Autobiography Black, but the LWB and diesel variants make a lot of sense. Here’s to competition and all the good things it brings.

around $85,000, come well equipped, but a sampling of interesting options includes sur-

available this year, and all will be LWB. The Range Rover has been the luxury

nio Medicine since 1995.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

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 Anto-

visit us at www.bcms.org

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46 San Antonio Medicine • March 2016