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End-of-life Issues
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MEDICINE SAN ANTONIO
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End-of-life Issues
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APRIL 2015
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VOLUME 68 NO. 4
San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.
How far is too far? Physician-assisted suicide By Jeffrey J. Meffert, MD..........................10 Open communication, planning help smooth life’s final path
EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Email: editor@bcms.org
By Marcia Levetown, MD, FAAHPM ..........................12
Wills, living trusts determine how property passes at death By Patricia Sitchler ..................16
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When the twilight years become The Twilight Zone
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BOARD OF DIRECTORS
OFFICERS James L. Humphreys, MD, President Leah Hanselka Jacobson, MD, Vice President Maria M. Tiamson-Beato, MD, Treasurer Adam V. Ratner, MD, Secretary Jayesh B. Shah, MD, President-elect K. Ashok Kumar, MD, Immediate Past President
DIRECTORS Jorge Miguel Cavazos, MD, Member Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Bonnie Harriet Hartstein, MD, Military Representative Rebecca Christopherson, BCMS Alliance President Gerald Q. Greenfield Jr., MD, PA, Board of Censors Chair Donald L. Hilton Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., Legal Counsel
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom
DIRECTOR OF COMMUNICATIONS Susan A. Merkner
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Jeffrey J. Meffert, MD, Member Rajam S. Ramamurthy, MD, Member J.J. Waller Jr., MD, Member
6 San Antonio Medicine • April 2015
PRESIDENT’S MESSAGE
Lessons from
California By James L. Humphreys, MD 2015 BCMS President
The saying “Freedom isn’t free” typically is used to promote military service, but that isn’t the only kind of war it applies to, as the citizens of California have discovered. As this is written, parents in California can use either a religious exemption or a personal belief exemption to not have their children receive the typical vaccinations. A number of reasons for this exist but most of the cases are attributed to upper-middle-class, “all natural” parents who believe that the vaccines are responsible for causing allergies or autism, or else are a profit-generating “snake oil” foisted on the population by unscrupulous pharmaceutical companies. Thanks to that set of circumstances, an outbreak of measles has plagued California and now has spread to several other states. The outbreak originated in 39 cases of children who had visited Disneyland in December, and now has spread to more than 100 people in multiple states. It’s pretty disturbing when you consider that
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measles was a disease largely eliminated in the United States, thanks to widespread vaccination programs. In response, two California state senators, Dr. Richard Pan (Dem.), a pediatrician, and Ben Allen (Dem.), have proposed legislation that will eliminate the “personal belief ” exemption to vaccination. On top of that, the two California U.S. senators, Dianne Feinstein (Dem.) and Barbara Boxer (Dem.), are urging the California legislation to also remove the “religious belief ” exemption. California Gov. Jerry Brown had pushed for more parental choice in application of vaccines to children as of two years ago, but he is now changing his tune and is apparently open to reform of the state vaccine laws. As you can imagine, this is a hot topic of discussion in public health circles, and I will be interested to see if Texas vaccination laws end up strengthened by the end of this legislative session in response to this outbreak. I expect some proposed
legislation presently on this. One of the draft resolutions to be reviewed and potentially submitted from the BCMS delegation to the TMA is in fact urging the TMA to lobby the legislature to make vaccines mandatory with only medical exemptions being valid. TMA has long been a proponent of vaccination, of course, with the ubiquitous and longrunning, “Be wise, immunize” campaign. Texans generally pride themselves as being different from Californians, and many lifelong Texans that I have known have written off Californians as a bunch of “godless hippies and weirdos.” That notwithstanding, I hope our state can learn something from California this time and avoid a similar experience ourselves. Much of the information for this editorial was derived from an excellent article summarizing the situation in California by Lisa M. Krieger and Jessica Calefati that appeared in early February on the site Mercurynews.com.
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How far is too far? PHYSICIAN-ASSISTED SUICIDE By Jeffrey J. Meffert, MD
“I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.” So says at least one variation of the classic Hippocratic Oath. But times change, and the traditional Hippocratic Oath is full of other obsolete guidance and admonitions, such as the demand to teach your colleague’s sons the medical craft for free. “A person commits an offense if, with intent to promote or assist the commission of suicide by another, he aids or attempts to aid the other to commit or attempt to commit suicide.” This is not as artfully worded as ancient oaths but because it comes from the Texas Penal Code, it is much more relevant to the Texas physician 10 San Antonio Medicine • April 2015
who might be considering physician-assisted suicide for a terminally ill patient. A physician or nurse can go to prison for knowingly giving a patient an intentionally lethal prescription. Even if a judge or jury does not send one to prison because of the understandable circumstances of a particular case, the conviction itself will likely cause revoking of one’s license to practice medicine and may preclude any other employment by an official Texas agency.
EXPLICITLY CRIMINALIZED Texas is in the majority of states which explicitly criminalize assisted suicide. Ohio and Virginia are a bit vaguer, while North Car-
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olina, Utah and Wyoming do not address the issue at all. Montana and Bernalillo County in New Mexico have court rulings supporting the practice but no experience. Three states, Oregon, Washington and more recently Vermont, explicitly permit physician-assisted suicide, and it is worth looking at the requirements and experiences in those states should Texans ever wish to consider this. In states where it is allowed, to qualify for the program, a patient must be at least 18 years old, sane, and have a prognosis that gives them less than six months to live (confirmed by two physicians). They must make a written request in the presence of two witnesses and, when the time comes, must make two oral requests to the involved physician at least 15 days apart. It is difficult for many to accept the concept espoused by assistedsuicide proponents that “freedom to end hopeless suffering” might be as important as “freedom to live.” The concern is that somehow the right to end a hopeless and painful life will evolve into the duty to end a resource-consuming life, the concern that “free will’ will become “manipulated will.” Rational discussion of this valid concern is probably impossible in the current social and political environment. The hysterical reaction to imaginary “death panels” that some still believe are hidden somewhere in the Affordable Care Act (Obamacare) suggests that many Americans are not ready to have this discussion yet. Concerned citizens think of the roving euthanasia vans that crisscrossed Germany in the mid-1930s eliminating the weak, the hopelessly infirm and the “mentally feeble.” Professionals and laypeople alike are afraid that this is an inevitable end point although it is hard to imagine a culture that values individual freedoms as much as ours allowing such a thing. That being said, Dr. Jack Kevorkian even lost the support of many “death with dignity” groups when he broadened the indications for his rogue euthanasia program from pre-terminal patients to some with nonlethal chronic pain syndromes and severe depression. So what is the actual experience in places that allow physician-assisted suicide? It may be surprising that many patients who qualify and register for the state-sanctioned program do not ultimately go through the plan, dying instead of their disease. Since it became legal in Oregon in 1997, prescriptions were written for just under 1,200 patients, with only 750 making use of them. Washington’s experience since 2009 shows a closer parity with 525 of the 549 prescriptions being used, although many more patients initiated registration.
‘A WAY OUT’ HELPS More than one survey has shown that patients take a great deal of relief in knowing that there is a way to stop the endless pain if they must, with much of the hopelessness of one’s final days being due to the fear that the pain and assault to dignity is just going to go on indefinitely. The knowledge that there is “a way out” is sometimes comfort enough to patients with incurable disease. Nationwide, however, surveys of professionals and laypeople show about two-thirds still oppose liberalization of assisted-suicide laws in their states or the country as a whole. Physician-assisted suicide is legal in a few other countries (Switzerland, Belgium, Netherlands and Luxembourg) and while illegal or unaddressed in others, physician prosecution is uncommon unless they take a more active role in directly ending a life. Assisted suicide per se is illegal in Germany but physicians are allowed to administer dangerous sedatives to a dying patient at their request. In countries where it is allowed, there are similar findings of more people qualifying and registering for an assisted-suicide program than actually using it. The Hippocratic Oath is considered out of date enough that many medical schools now use alternative affirmations upon graduation. How do modern medical oaths deal with the reality of physician-assisted suicide? Dr. Lasagna’s oath is used by many and includes the following phrase: “Most especially must I treat with care in matters of life and death. If it is given to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty.” The Model Oath for the New Physician developed by the American Medical Student Association does not address this topic directly but does have the more general statement, “I dedicate my career to the compassionate service of humanity — caring for the sick, promoting health, preventing disease, and alleviating pain and suffering.” Perhaps the best way to look ahead to hard choices and tough changes is to distill the discussion to the basics: If it were me or mine, what would I want? Jeffrey J. Meffert, MD, is an associate professor of dermatology and cutaneous surgery at the University of Texas Health Science Center at San Antonio and a member of the BCMS Communications/Publications Committee. visit us at www.bcms.org
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Open communication, planning help smooth life’s final path By Marcia Levetown, MD, FAAHPM
No one wants to talk about dying. It’s uncomfortable and inevitable, so why discuss it? As a doctor who has dealt with death all of her professional life, I can provide a number of good reasons to engage in the difficult conversations surrounding healthcare priorities. Bitter arguments, often creating life-long family rifts, are routine in the absence of knowing what the ill person would have wanted. Caregiving family members often are emotionally and financially bankrupt after providing care that the patient might not have wanted. The vast majority of the healthcare dollar is spent on treatments that are not likely to help and often harm the patient in the 12 San Antonio Medicine • April 2015
last few months of their lives. The dying process can be as beautiful as a birth — enriching and healing — with proper planning. Without planning, deaths are almost uniformly fraught with suffering for all involved. Few of us will die suddenly; most of us will live with a life-threatening condition for 10 to 15 years before we die of it. We will experience the best and the worst that medicine has to offer. We will live with increasingly harsh medical interventions, surgeries and medications that, over time, no longer protect us from disability,
END-OF-LIFE ISSUES weakness, shortness of breath, difficulty thinking and other problems. While more than 90 percent of people state a desire to die at home when the time comes, most of us will die in the hospital, most often in the ICU. No one volunteers for this outcome; it is preventable with open discussion and planning. Further, before 2008, the majority of personal bankruptcies were related to healthcare costs. This, too, is a preventable outcome.
UNWANTED OUTCOMES So how can one prevent unwanted outcomes? Some suggestions follow. • ASK MORE QUESTIONS. We have a natural tendency to focus on the HOPED FOR outcomes, but not the LIKELY ones. By understanding what treatments can and cannot do for you, you can make informed decisions and often avoid surgeries, medications and ICU stays that will not produce the results you want. • HERE ARE SOME QUESTIONS TO ASK: What are the likely short-term benefits from this treatment? What are the short-term problems? What are the long-term benefits? What are the long-term problems? What will the treatment do to my ability to think clearly? To my energy level? How much pain will I have and for how long? Will I regain my independence? When you advise I should have a good response to treatment, what do you mean by that? (Will I be cured?) • DISCUSS OUTCOMES WORSE THAN DEATH — your fears, hopes and concerns — with your family and healthcare providers. In particular, discuss your views of the value of being permanently unconscious and whether you would want your life prolonged in that condition. • DON’T WAIT FOR THE DOCTOR TO BRING IT UP. Doctors think the patient and family are “not ready” to discuss the potential for dying until the patient is already in the ICU filled with tubes. • CHOOSE SOMEONE TO SPEAK FOR YOU IF YOU CANNOT SPEAK FOR YOURSELF (designate a “medical power of attorney” or surrogate decision-maker) and tell him or her your priorities for healthcare. Ask if they will uphold your preferences. • FAMILY GATHERINGS AND HOLIDAYS, WHEN EVERYONE IS TOGETHER, CAN BE GOOD OPPORTUNITIES TO DISCUSS THESE ISSUES. Despite having a surrogate, it is best for all concerned to have heard it from you directly.
• IT IS A GOOD IDEA TO REVISIT YOUR PRIORITIES IF YOUR HEALTH CONDITION OR LIFE CIRCUMSTANCES CHANGE DRAMATICALLY. It is also a good idea to discuss your overall health picture with your doctor. He or she can advise you about the pros and cons of treatments.
ADVANCE DIRECTIVES If you choose to fill out a living will (in Texas it is called a “directive to physicians, family and surrogates”), the forms can be found online at http://www.dads.state.tx.us/news_info/publications/handbooks/advancedirectives.html. You need only two witnesses to verify you are the one who has signed it. There is no need for a notary or a lawyer, so there is no cost. Discuss the document with your doctors on your next visit as well.
HOW HOSPICE CAN HELP Hospice care focuses on helping you and your family live as well as possible when you have a limited life expectancy. You are qualified to receive hospice if you have a life expectancy of six months or less. • There are no out-of-pocket costs for Medicare and Medicaid patients and for most who have insurance as well. • Hospice caregivers are experts in relieving distress, whether it is physical symptoms, spiritual concerns and issues of loss, grief and meaning, or other practical needs. • A package of services and not a place, hospice can be delivered wherever you are. Most hospice care is rendered in your own home or in a nursing home. • Hospice professionals, including nurses, aides, social workers, chaplains and physicians, visit by appointment. They are available by phone and on call to come to you if needed to assist with problems 24/7. • Your medications and any medical equipment needed for your illness are delivered to your residence. • For severe symptoms, short-term inpatient hospice care or eight to 24 hours per day of nursing care is provided in the home until the symptom is under better control. This service is often needed as the end gets nearer. • Respite care is also available if your family gets exhausted and needs a break. Other family-centered services include assistance coordinating benefits, making healthcare decisions and the provision of grief support for 13 months after death. Continued on page 14 visit us at www.bcms.org
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• Most patients’ and families’ only complaint about hospice is that they didn’t know about it early enough and wished they had received it sooner.
CHOOSING A HOSPICE Not all doctors or hospitals are the same quality, nor are all hospices the same. Here are some questions to ask a hospice agency you are considering working with: • Is the medical director board-certified in hospice and palliative medicine? • When I call at night, who will answer the phone? Is it a nurse? • Do you have dedicated hospice inpatient units? • Will you show me your patient and family satisfaction ratings? • Will you let me keep my doctor? • Do you have any specialty programs, such as a cardiac program? • How long have you been in business? • Are you certified by any outside quality certification programs, such as the Joint Commission? Death can’t be avoided, but suffering can. Open communication and planning will help you achieve a better quality of life on your final path and provide a better outcome for those you love, as well. Marcia Levetown, MD, FAAHPM, is regional medical director for VITAS Innovative Hospice Care. 14 San Antonio Medicine • April 2015
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Wills, living trusts determine how property passes at death By Patricia Sitchler We are, all too often, optimistic procrastinators. There will always be time to make a will or transfer assets to that living trust we purchased. But life happens. The following vignettes are just two examples of how procrastination can prove catastrophic.
JIM’S STORY Jim has been trying to sell his mother’s small farm for several years. Taxes are rising along with costs for maintenance. He’s had an interested buyer but the title company is telling him that there was no will probated for his stepfather or his mother, and that the land was still in the name of the estate of each deceased owner. But Jim’s mother had told him that she and his stepfather had left the farm to him, and had given Jim the “notebook” of documents they purchased at an estate planning seminar that was supposed to make sure that Jim inherited the farm. His mother explained that she didn’t really know what the notebook contained but she was sure that the documents would “avoid probate” after she and her husband died. Jim showed the notebook and living trust to the title company but the title company suggested that Jim needed to go to court to settle his ownership rights since the notebook documents were never signed.
JENNY’S STORY Across town, Jenny is struggling with estate problems herself. Her husband was killed in an accident, leaving Jennifer to care for their teenage daughter. Jenny and her husband never got around to signing wills, believing that if one of them died, their community property would naturally pass to the surviving spouse. But her husband’s two children from a prior relationship are demanding their “share” of his estate. And the lawyer Jenny contacted told her that the two stepsons had a right to part of her husband’s estate. How could this happen? Jim’s and Jenny’s dilemmas are typical of probate horror stories — stories of families who failed to create an estate plan that would ease end-of-life issues for the surviving relatives. Jenny would subsequently find out that under Texas law, her husband’s half of their 16 San Antonio Medicine • April 2015
estate (his one-half interest in their community property) passed to their daughter and her husband’s two sons instead of passing to her. So now her minor daughter and her husband’s two sons own one-half of everything including the car and the house, the furniture, bank accounts in her husband’s name and the motor home. Jenny’s attorney is trying to negotiate a settlement with the two stepsons for their one-third interest in everything Jenny and her husband owned.
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Back across town, Jim suspects that his mother and stepfather didn’t understand that following the purchase of the living trust, they had to sign a deed transferring the farm and any other assets to the living trust in order to assure that Jim would inherit the property upon their death. As a result of failing to properly fund the trust they signed, the farm will pass by Texas law partly to Jim and partly to his stepfather’s eight children.
COUNTY JUDGES REVIEW WILLS Under Texas law, a person has the right to decide how their property passes at death. An estate plan found in a will can be simple but it must be in writing, signed by the individual and witnessed by two persons who are not beneficiaries of the estate plan. Then upon death, the will is reviewed by a county judge, and if properly worded and executed, the will is admitted to probate, and the wishes of the testator (person who signed the will) must be followed as long as nothing in the will violates any law (e.g., you cannot leave firearms to persons who are convicted felons). Another way to write out an estate plan is to transfer all of your assets to a trustee of a trust. A trust is nothing more than a set of
instructions for a trustee to follow in handling your assets during your life and who takes your assets on your death. These trusts are often called “living trusts.” However, many people who purchase living trusts don’t understand that, to avoid probate, all of their assets – their house, cars, bank accounts, investment accounts, boat, motor home, etc. – must be owned by trustee of the trust. And when they purchase new assets, such as a vacation home, it too must be purchased and titled in the trust. Living trusts can be advantageous but if the sole purpose of purchasing a living trust is to avoid probate, the individual should reconsider. Probate in Texas is very simple, straightforward and generally inexpensive. Purchasing and properly maintaining a living trust could be difficult, and if not properly maintained, could result in co-owning the farm with eight stepbrothers and stepsisters. Patricia Flora Sitchler is a certified elder law attorney and assists families in planning for disabled individuals. She maintains offices in San Antonio as a shareholder in the firm Schoenbaum, Curphy & Scanlan, P.C.
visit us at www.bcms.org
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When the twilight years become The Twilight Zone: Caregivers can assist physicians who see dementia patients By Marcy Meffert When dealing with dementia patients and their caregivers, physi-
worse yet, the plate is wearing off. Your love may endure but passion
cians may need the same observational skills used by veterinarians whose patients communicate only with behavior and appearance. Unlike veterinary patients, who can’t talk, many dementia patients can talk but don’t want to acknowledge the severity of their mental state by discussing it. They feel betrayed if their caregivers describe escalation of old and appearance of new symptoms. To make matters worse, doctors’ appointments don’t always coincide with their bad days. On their good days, in early dementia, many patients fake it well enough in public to make caregivers wonder if they are the ones with dementia and are imagining the scary driving, obsessive behaviors, peculiar conversations and memory lapses. Wondering if you are the one with dementia is only a minor stress compared to the other frustrations of caregiving. If caregiving for a spouse, you have to accept that the golden years, which you expected to enjoy after retirement, have been only gold plated, and
goes and mere memories don’t make the earth move. Caregiving for parents reverses your roles, which can be uncomfortable for both of you. Caring for both a spouse and a parent simultaneously challenges many members of the “Sandwich Generation.” In all situations, reality hits hard the first time you stop at the drugstore for incontinence products. Changing Depends for someone who was once your lover or who once changed your Huggies conjures up a tangle of emotions that keep you awake at night.
18 San Antonio Medicine • April 2015
CARE BECOMES PHYSICALLY DEMANDING Learning to deal with each phase of any disease is difficult, but dementia adds a new dimension. As cognitive and physical abilities decline, caregiving becomes as physically demanding as it is emotionally draining, and sleep deprivation exacerbates all frustrations. Watching someone who once did delicate surgery struggle to use a
END-OF-LIFE ISSUES knife and fork saddens the soul. Trying to lift more weight than you can manage when your spouse or parent falls wears on the body. Visiting one specialist after the other, each prescribing another wonder drug, makes you wonder if it’s better to toss the meds and accept, “It is what it is.” New doctors run old tests. You wonder if anyone knows that somebody can pass the simple standard Alzheimer’s test, including drawing that clock with hands at a suggested time, and can start a car, drive into oncoming traffic and get lost in familiar neighborhoods. “Well, how are you doing,” says the new doctor. The patient responds, “Fine, no problems,” and the caregiver wants to say, “No, not fine at all! He’s become incontinent. He sleeps 18 hours a day. He gets up in the middle of the night and roams our neighborhood. He asks for lunch and then forgets that he asked and takes a nap. I don’t know what to do or when to do it!” “Did you have a nice weekend,” asks the doctor, trying to start conversation. “Yes,” she says, and the caregiver wants to say, “She left a frying pan on the stove, and it was so burned we threw it out. So we went out to eat, she ordered a salad, refused to eat it, then said she hates me. She doesn’t recognize our grandchildren; just stares at them like they’re strangers.” When caregivers are torn between loyalty to loved ones’ wishes and the need to reveal what patients won’t, there is a solution: Present a note to the receptionist when checking in at the doctor’s office and ask the doctor to read it prior to seeing the patient. The note should explain how upset and angry the patient gets “when you say those bad things about me” and briefly describe new symptoms and changes in old ones. Doctors can then target specific issues when questioning patients. Although caregivers frequently become interpreters for their loved ones, they should let patients respond to doctors as best as they can.
CRUEL DISEASE WORSENS Some statistics say 65 percent of caregivers die before the person they care for dies. Stress-related illnesses are common, and for many families, placement in a care facility adds more stress from guilt feelings. People who have not had caretaking experience often add more guilt when their advice implies that caregivers aren’t doing their best. Former caregivers acknowledge that this cruel disease only gets worse and eventually, safety becomes more important than anyone’s pride or guilt. It’s not only safety for the
Alzheimer’s/dementia patient who may wander off and get lost or injured, or injures others driving a car. Caregivers’ health and safety needs consideration, too. It’s not merely strained muscles and backs from lifting limp, heavy people from floors, beds or chairs; a seldom-discussed issue is that some dementia patients become physically abusive. Also, sleep deprivation and exhaustion make all caregiver activities more difficult. Caregivers need family and friends, regular time off, and the wisdom to know when to let professionals take over; placing patients in care facilities while they can still communicate their needs to staff may be better than waiting until they need hospice. It’s difficult for optimists to maintain a survival sense of humor when it seems as if one’s twilight years have become a Twilight Zone. But there are moments for laughter. When your loved one is asked if he remembers his favorite actor, John Wayne, and from somewhere in his broken brain comes, ”Of course, that’s like asking me if I remember Jesus Christ.” You laugh because it’s going to be a happy memory, the only kind that keeps tears away and eyes from getting puffy. Marcy Meffert writes the Elder Express column for the San Antonio Express-News and is a former mayor of Leon Valley.
visit us at www.bcms.org
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OPINION
It’s only a flesh wound (on being ‘unwell’) By Robert G. Johnson, MD Queen Elizabeth II recently celebrated her 60th anniversary as monarch. Her husband, Prince Philip, couldn’t make the ceremony because he was, according to one article, “unwell.” A colleague asked me what “unwell” meant. It’s not used much in the United States, and being Canadian, he figured I could explain. Truth is, I’m not sure myself—I guess it’s somewhere between “sick as a dog” and “just fine.” It’s just one of those endearingly vague British-isms. We might label it a euphemism. Over-thinking it later, I concluded it must be a product of our disparate healthcare systems. Let me explain. You heard about the Brit who, upon seeing the doctor for his bad hip, was told he would have surgery three years from next Wednesday. The patient politely asked the surgeon if it weren’t possible to make it Thursday because “the plumber’s coming Wednesday.” The north-south debate over which healthcare system is superior rages on. There are the usual horror stories from Canada: 3-year waits for a pain clinic; 1.5 million Ontarians can’t find a family doctor; the Montrealer who took the provincial government to court over his agonizing one-year delay for a hip replacement; the community in Nova Scotia that held a lottery to mete out doctor appointments. In the United States, the problem is rarely access, it’s the cost. Few Canadians file bankruptcy over medical bills.
BATTLE CONTINUES We all know the stats: Life expectancy is a little higher in Canada (83.1 years vs. 78.1 years), but remember that homicide (which is unrelated to healthcare) and most often affects younger people, is more prevalent in the United States and may explain the five-year discrepancy; healthcare costs as a percentage of GDP (10.1 percent Canada vs. 16 percent United States); physicians per 1,000 population (2.2 Canada vs. 2.4 United States); infant mortality rate (4.5 Canada vs. 6.9 United States). The battle continues with victories on both sides. As I see it, the real difference between Canada and the United States lies in the philosophical chasm separating socialized from private (for-profit) medicine. Government funded healthcare is like a kid’s allowance — a fixed amount has to last all week (or all year). Every expenditure further drains the cistern. A recent article in the
American Academy of Orthopaedic Surgeons (AAOS) newsletter explained how, despite a demand for orthopaedic services that is “greater than ever,” Canada faces “an unprecedented oversupply of orthopaedic graduates.” Seems like a contradiction, until you realize the government controls the jobs. These graduates are doing locums, working as “contract trauma surgeons,” covering call for established surgeons or doing multiple fellowships. There’s 10 years of your life well-spent. Kind of like the situation in England where one remains a “registrar” forever until the “professor” retires or dies. I interned at a huge downtown Toronto hospital which had exactly four (4) orthopaedic surgeons on staff. Another hospital, with the second-busiest ER in the nation, had three-and-a-half (3.5) fulltime orthopods. And remember, in Canada, even back then, bright new graduates couldn’t just get privileges and start working. The hospital (government) decided when to hire. In an American hospital, a new physician is welcomed with open arms; he or she is seen as an asset, a profit center for the hospital. In Canada, that same doctor is seen as just another piglet at the teat, another mouth to feed. In the United States, if a hospital is falling on hard times, they ramp it up, advertise, go looking for new business, buy a robot or two … In Canada (this actually happened last year in a medium-sized hospital in a large city in Alberta), the afflicted hospital stopped all elective surgery during holidays and the summer. In other words, to save money (keep within the budget), they stop spending. Probably the closest we come to this scenario is the VA system.
SUBTLE SEMANTICS So, back to being “unwell.” It’s a word that contains, as its root, a term that implies health. It’s a distraction. If you say it fast enough, or slur a little, it may sound like you’re actually “well.” Like getting a C minus rather than a D plus — they’re both crummy grades, but one sounds better. A northern friend once quipped that, “Canada has the best healthcare system in the world — if you never use it.” So why these subtle semantics? They evolved to make people feel better about long lines. If you’re “sick as a dog,” you need medical help now. If you’re merely “unwell,” you can wait. Continued on page 34
20 San Antonio Medicine • April 2015
LEGAL EASE
Internet defamation and your practice By George F. “Rick” Evans Jr. Do you ever stop to wonder whether things were so much simpler for your colleagues 60 years ago? Managed care hadn’t been invented yet. Deep gouges in physician reimbursement hadn’t been invented yet. Neither had the Internet. And with the Internet has come the opportunity for individuals to make known to the entire world their two cents regarding your skills as a physician. There are many ways to do it: Twitter, Facebook, blogs, self-created websites and, of course, let’s not forget Angie’s List, Yelp and
than flattering. Kinney sued and ultimately, only after going all
other comparable sites. Your patient is peeved because he sat 30
the way to the Texas Supreme Court, won. That decision is now
minutes longer in your reception area than he wanted. Or she
the law of the land for Texans.
thinks your bill was too high. Or he didn’t like the fact he couldn’t
The court held that freedom of speech is not absolute and does
get an appointment within 10 minutes of calling your front desk.
not protect an abuse of that right. Freedom of speech can’t shield
Or she thinks you’re a quack because you couldn’t diagnose some
a person from the consequences of making false and defamatory
obscure problem on the first visit.
statements about another. The court recognized that this is true
Now those patients can broadcast their comments to the world.
even in the wireless, ethereal world of the Internet. In Kinney’s
When your prospective new patients Google you, what might they
case, he had the right to sue his former employer for defamation
find? Or what about a prospective new employer you’d like to work
because of what had been broadcast to the world on the website.
for? Or the bank you’re hoping will give you a business loan? Or
And he had the right to obtain a court order requiring that those
the other doctors in town who you hope will send you some refer-
statements be removed from the Internet. The court recognized
rals? What does the Google machine serve up to them when they
damages that he could recover included things such as lost income,
type in your name?
damage to reputation, mental anguish and, if the statements were
Until recently, lawyers were pretty much relegated to telling ag-
made maliciously, punitive damages, too.
grieved physicians to take two aspirins and call them in the morn-
Now, all this said, here are the limits to what the court said. First,
ing. There wasn’t much to be done. After all, we live in a country
the offensive statements must be defamatory. That means they must
founded on the premise of freedom of speech. Courts were loathe
be untrue statements of fact. If they are true, well, then you’re out
to intervene. That might not have been a big deal 60 years ago. A
of luck and deservedly so because they are true and you deserve them.
disgruntled patient could only shout his insults so far. But the In-
If they are just opinions, as distinguished from a statement of fact,
ternet changed all that.
you’re also out of luck. After all, people are entitled to have and share
So, what can you do if you’re the victim of Internet bad-
opinions. For example, it would be OK to say, “I think the food at
mouthing? Thanks to Robert Kinney, now you’ve got something
McDonalds tastes bad,” but not OK to say, “The food at McDonalds
more meaty than “take two aspirins and call me in the morning.”
contains horsemeat,” unless you could prove that was true. So, your
You’ve got a legal remedy with teeth. Here’s the background.
patient can tweet or blog their opinion that they thought you were
Kinney was a recruiter for a firm. He left and set up his own re-
curt or expensive or slow, but, unless it’s true, they couldn’t say you
cruiting firm. His jilted employer sought revenge by posting on a
groped them, discriminated against them because they were of a cer-
website statements about Kinney which, suffice it to say, were less
tain age, race or sex, overbilled them and so on. Continued on page 22 visit us at www.bcms.org
21
LEGAL EASE Continued from page 21
Second, the court limited your
have removed from the Internet any statement against you that is
remedy to only statements that
a false, defamatory statement of the true facts. On top of that, you
have been already published.
can recover any damages you sustained including damages that
The court will not allow you to
aren’t purely economic in nature. That includes punitive damages
stop somebody ahead of time
if you can show the person did this with the intent of harming you.
from publishing a false state-
As a practical matter, hiring an attorney to prosecute the lawsuit
ment. You can only stop them
may not be economically feasible unless you can show real financial
after they’ve done it. That may
harm, mal-intent, or widespread publication such that your repu-
not seem fair but the court doesn’t want to “chill” freedom of speech
tation really was damaged. But the mere fact you have this legal
by silencing somebody before they’ve even said it. That said, if you
right may be sufficient to cause the perpetrator to back down, re-
can prove that there is an imminent danger that will be posed by a
move or recant the statements if he receives a sternly written letter
statement that hasn’t yet been made, the courts can intervene to
from your attorney. In short, you no longer have to put up with
stop it if it’s essential to prevent that danger and if the court uses
cyber bullying.
the least possible means to do so. This is, however, a legal remedy that is very, very sparingly used and only under exigent circum-
George F. “Rick” Evans Jr., is the founding partner
stances. Prior restraint on a person’s freedom of speech is constitu-
of Evans, Rowe & Holbrook. A graduate of Marshall
tionally anathema.
College of Law, his practice for 36 years has been ex-
What does this mean to a practicing doctor like you? The Texas
clusively dedicated to the representation of physicians
Supreme Court has now recognized that you have a legal right to
and other healthcare providers. Mr. Evans is the BCMS legal counsel.
22 San Antonio Medicine • April 2015
MEMBER SERVICES
BCMS Auto Program helps buyers get rolling Buying a vehicle involves navigating a process full of twists and turns, but the BCMS Auto Program smooths bumpy roads into slick superhighways for members, their families and staffs. With one phone call to BCMS Auto Program director Phil Hornbeak, members may set the wheels in motion for their purchase of a new or preowned vehicle. The free program offers assistance with selecting a model, choosing a dealership and taking test rides – with vehicles delivered to a doctor’s home or office for convenience, if needed – and financing.
“Using our recommended dealers cuts red tape and saves time,” Hornbeak said. “The Auto Program also offers convenient online shopping and applications.” Buyers find low, affordable pricing on vehicles, and competitive rates on financing when using the BCMS Auto Program, he said. “We take the hassle out of buying – or leasing – a vehicle,” said Hornbeak, who has managed the BCMS program since 2004.
Currently, 33 dealerships in the San Antonio area participate in the program. (See page 43.) Additionally, the auto program has expanded to Houston and Austin, serving the 11,000 members of the Harris County Medical Society and 3,500 members in the Travis County Medical Society. Each year, BCMS holds an auto show in the fall during which dealers present new models. Members and their families enjoy an evening of free food and entertainment while meeting dealer representatives and previewing vehicles. The 2015 BCMS Auto Show is scheduled for Oct. 15 in the parking lot outside the medical society’s office at 6243 IH-10 West. Since its inception in 1983, the BCMS Auto Program has served thousands of satisfied customers. For more information, call Phil Hornbeak at 210-301-4367, email Phil.Hornbeak@bcms.org or visit www.bcms.org/Autoprogram.html.
visit us at www.bcms.org
23
LIFESTYLE
The event that started it all:
Culinaria’s Festival Week May 13-17 Special to San Antonio Medicine What started out as a small, weekend festival of friends, a few select chefs and a sampling of boutique wines continues to evolve and expand with events such as the 5K Wine and Beer Run, San Antonio Restaurant Week (now twice a year) and the event that started it all, Festival Week. While Culinaria’s Festival Week, set for May 13-17 this year, is the foundation of how the organization began, it has changed by leaps and bounds from the original series of events that started 15 years ago. Now, hopefully, this doesn’t set off panic alarms for attendees who have been loyal patrons for all of these years. It simply suggests that the organization has changed with the times but also has maintained the fundamental premise behind the nonprofit, which is to bring visitors to San Antonio for the emerging scene. In other words, to put San Antonio on the map when it comes to culinary destinations. With key partnerships in the community and nationwide, a passion for supporting the chefs in the community and a diverse demographic base that expands beyond the United States, Culinaria is working toward its mission the best way organizers know how – by creating events that captivate audiences and media.
CULINARY GROTTO ADDED While many culinary festivals across the country host their events in one central location, Culinaria continues to utilize the San Antonio backdrop as the stage for individual events that make up Festival Week. The organization also prides itself in chang24 San Antonio Medicine • April 2015
ing things up a bit when it comes to the specific events. Those changes will be most evident in the Saturday lineup of events. Traditionally, seminars have been conducted throughout the day in venues away from the evening events and have fallen in line with the visiting chefs, winemakers or notable beverages. This year, alternatively, Culinaria is adding the Culinary Grotto, which offers guests the opportunity to visit any one of several “districts” and as many as they would like. The districts will be divided into categories such as the Chef District, Cocktails, Culinaria Cinema, and Wine. There also will be a Dessert Lounge, a silent auction and additional vendors on site to complete the afternoon. The Culinary Grotto is meant to provide an interactive experience for guests and takes the educational component of Culinaria to a new level. It will take place from 1 p.m. to 4 p.m. May 16 at the Henry B. Gonzalez Convention Center. For the dedicated, all-day attendee of Culinaria’s Saturday festivities, a small break will take place between the Culinary Grotto and the Bubble Room, which begins at 6 p.m., or the Grand Tasting, which starts at 7 p.m., both at the Henry B. Gonzalez Convention Center at the River Walk level in the Grotto. Some of the districts will continue through to Grand Tasting, as well as the addition of a new component, the Culinaria Night Market, which will feature a mix of visiting chefs from across the country and a few local chefs to create Asian-inspired menu items that add a bit of diversity to the walkaround event.
Festival Week begins on May 13 with the Wine Dinners that will have a few twists as well. Plans are still in the works for the final schedule of the dinners. May 14 will feature additional dinners as well as the family-favorite Food Truck at H-E-B Alon Town Centre. On May 15, the popular Becker Luncheon at Becker Vineyards will provide the chance to start the weekend early, and, for those who enjoy happy hour festivities, a Tequila Happy Hour has been added to precede the Best of Mexico.
BURGER AND BEER Events on May 17 may be last on the schedule, but there is still plenty of festive left in the festivities. The crowd and chef favorite – Burgers and Beer – remains in the lineup at Pearl and offers a casual afternoon of extreme burgers (beyond the average backyard version), cold beverages, and a live band to spice up the entertainment. Sunday concludes Festival Week with a multicourse Tequila Dinner at Casa Hernán that will feature a blend of culture, cocktails, cuisine and a bit of education along the way. Culinaria is also making it easier for guests to enjoy more than one event of Festival Week by offering various ticket packages. Proceeds from the ticket packages directly benefit the Culinaria Urban Farm, a project that is under way for the nonprofit organization and falls under their Hope for Hospitality umbrella of programs, which also promotes San Antonio as a culinary destination while providing culinary scholarships to local students and financial support to chefs enduring personal hardships.
LIFESTYLE
To learn more, visit culinariasa.org, find Culinaria on Twitter, Facebook and Instagram, or call 210-822-9555. visit us at www.bcms.org
25
NONPROFIT
American Diabetes Association offers physician, patient resources Special to San Antonio Medicine More than 29.1 million Americans — including 14 percent of the San Antonio population — have diabetes. An estimated 21 million people have been diagnosed, and 8.1 million people are unaware that they have the disease. Another 86 million people have pre-diabetes. If current trends continue, one in three American adults will have diabetes by 2050. More people die from diabetes each year than from AIDS and breast cancer combined. And yet, to some extent, it’s within everyone’s power to change these statistics – by ensuring that all patients are screened for high glucose levels and receive education on how to prevent or better manage diabetes. Type 2 diabetes often can be prevented, delayed, or controlled with a reduced risk for complications. The American Diabetes Association provides local opportunities to inform patients about diabetes risks, complications, treatments and products to help them manage or prevent the disease year-round. It is the association’s mission to prevent and cure diabetes and to improve the lives of all people affected by diabetes. With its local partners, including many from the healthcare industry, the American Diabetes Association offers programs and events throughout the year that include free health screenings for glucose levels and potential complications, professional speakers on related topics, access to physicians and clinics, and an opportunity to increase physical activity. Below is an overview of the events and programs available:
TOUR DE CURE The Tour de Cure is a fundraising cycling event held each year to benefit the American Diabetes Association. The tour is a ride, not a race, with routes designed for everyone from the occasional rider to the experienced cyclist. Whether riders travel 1 mile or 100 miles, they find a route supported from start to finish with rest stops, food to fuel the journey and cheering fans. This year’s Tour de Cure San Antonio is set for May 9 starting at Texas A&M University-San Antonio. Lyssa Ochoa, MD, a vascular surgeon with Peripheral Vascular Associates, is this year’s Red Rider Chair on the tour committee, helping to encourage those living with diabetes to cycle as a way to help manage glucose levels and stay active throughout the year in a low-impact sport. 26 San Antonio Medicine • April 2015
CAMP POWER UP Camp Power Up is a new education program this year designed to help address the crucial need to educate high-risk youth about the health dangers of diabetes. Camp will help youth ages 10 to 14 who have been identified to be at risk of developing diabetes through multiple risk factors identified by their physician. Camp will offer an educational and fun-filled environment and will focus on diabetes education, nutrition, physical activity, and obesity prevention or management. Also included in the curriculum are outdoor play, arts and crafts, and field trips. Youth will meet new friends and learn along-side others with similar health issues. Healthy snacks and lunches will be provided as well as food-preparation demonstrations. Camp is free for participants referred by a physician. Maria S. “Sukie” Rayas, MD, a pediatric endocrinologist with UT Medicine, is the camp’s medical director, helping to develop the curriculum to motivate campers to embrace healthier habits. Camp Power Up also is presented by University Health System’s Children’s Health Program.
STEP OUT: WALK TO STOP DIABETES Step Out: Walk to Stop Diabetes is one of the American Diabetes Association’s signature events. The annual walk brings thousands of people together to raise funds for diabetes research and education as well as to raise awareness about diabetes in San Antonio. Participants will enjoy entertainment and themed rest stops along with prizes, food and a Family Fun Area with children’s activities. This year’s Step Out: Walk will take place on Halloween, Oct. 31, at Mission County Park Pavilion I.
STOP DIABETES DAY Stop Diabetes Day (formerly known as Diabetes EXPO) is San Antonio’s largest diabetes self-care management health fair that features informative speakers, cooking demonstrations, free health screenings and diabetes-focused exhibitors that feature the latest diabetes products, meters, services and medicines. Stop Diabetes Day is free to the public and will be held on World Diabetes Day, Nov. 14, at the newly relocated Norris Conference Center in the Park North Shopping Center near Loop 410 and Blanco Road.
NONPROFIT
AMERICAN DIABETES MONTH November is American Diabetes Month, a time to communicate the seriousness of diabetes and the importance of diabetes prevention and control. For years, the American Diabetes Association has used this month as an opportunity to raise awareness of the disease and its serious complications. The American Diabetes Association will pay tribute to those who work to Stop Diabetes® every day. At the same time, Americans will be rallied to join these champions in the Stop Diabetes movement by pledging to take actions against diabetes.
STOP DIABETES @ WORK For companies large and small, a key to controlling spiraling health costs is to help employees prevent and manage diabetes. Strategies for preventing and controlling diabetes also can reduce the risk for heart disease, stroke, high blood pressure and high cholesterol. For that reason, the American Diabetes Association offers Stop Diabetes @ Work, an evidence-based program that, in cooperation with employers, addresses diabetes awareness, detection, prevention and successful management. This program can be used as a stand-alone healthy worksite initiative or it can be
used in conjunction with a larger worksite wellness program. The diabetes association works with companies throughout the year to create a wellness program that works best for their needs.
POR TU FAMILIA Designed specifically for the Hispanic/Latino community, Por Tu Familia, or “For your Family,” is a fun, activity-based educational program about the prevention and management of diabetes. The program consists of a series of eight workshops available in English and Spanish. The workshops may be taught by trained volunteers or promotoras at faith-based organizations, schools or other community centers. In addition to these events, the diabetes association also delivers diabetes education and awareness to the community throughout the year through health fairs and speaker presentations. Free resources are available for physicians to help patients who are newly diagnosed with type 2 diabetes and are available at www.diabetes.org/atdx. For more information, visit www.diabetes.org/sanantonio or call 210-829-1765. visit us at www.bcms.org
27
BCMS LEGISLATIVE AND ADVOCACY NEWS
MARCH
FIRST TUESDAY WRAPS UP MENENDEZ AND BERNAL SWORN IN By Mary E. Nava, MBA BCMS Chief Governmental and Community Relations Officer The second First Tuesdays visit to the Capitol took place on March 3; many thanks to the following individuals who participated: BCMS President Jim Humphreys, MD; Mark Croley, MD: John Edwards, MD; Theodore Freeman, MD; Pam Hall, MD; Gabriel Ortiz, MD; Raymond Osbourn, MD; Ryan Van Ramshorst, MD, and BCMS Alliance President Rebecca Christopherson. The group participated in 13 office visits with our elected officials and their staffs. Several participants also stopped by the House Public Health Committee hearing to listen in on discussions about immunizations, in addition to signing cards in support of House Bill 465 by Rep. Donna Howard (D-Austin), which would give families and individuals the freedom to opt out of the state immunization registry. In addition, Rep. Diego Bernal (House Dist. 123) and Sen. Jose Menendez (Senate Dist. 26) were sworn in on March 3 and 4, respectively. Bernal assumes former State Rep. Mike Villarreal’s seat, and Menendez replaces the seat previously held by Sen. Leticia Van de Putte. Villarreal and Van de Putte resigned to run for mayor of San Antonio. For local discussion on this and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at Mary.Nava@bcms.org. 28 San Antonio Medicine • April 2015
BCMS physicians and staff visited with Rep. Rick Galindo (House Dist. 117) during the March 3 visit to the Capitol. On hand for the visit were (from left) Ryan Van Ramshorst, MD; John Edwards, MD; Galindo; Pam Hall, MD; Mary Nava and Raymond Osbourn, MD. Pausing for a photo with thenRep. Jose Menendez, now Sen. Menendez, are (from left) Ryan Van Ramshorst, MD; Mary Nava; Menendez; Raymond Osbourn, MD, and Pam Hall, MD.
Joining the BCMS group during the March 3 First Tuesdays visit in the office of Sen. Donna Campbell (Dist. 25) were members of the Texas Asthma and Allergy Society, led by BCMS member and the association’s president, Theodore Freeman, MD (foreground). Raymond Osbourn, MD (seated at left), visits March 3 with Meagan Collins (also seated), legislative assistant in the office of Speaker Joe Straus, along with (standing from left) Pam Hall, MD, Ryan Van Ramshorst, MD, and John Edwards, MD.
Bexar County representatives visit with Carmen Gaddis Tilton (third from left), policy analyst in the office of Sen. Carlos Uresti (Dist. 19), during the March 3 First Tuesdays.
BCMS NEWS
BCMS Unsung Hero Regina Martinez Dr. K. Ashok Kumar, 2014 BCMS president, nominated his office manager, Regina Martinez, for the Unsung Hero award for January 2015, which was presented at the Jan. 24 BCMS installation event at Oak Hills Country Club. “Being a physician and a clinic instructor consumes most of my time,” Dr. Kumar said in his nomination letter. “It is imperative to have a person who is reliable, trustworthy and committed to their job — someone who handles their duties in a thorough and professional manner. I am very fortunate to have such an individual, Regina Martinez.” Ms. Martinez not only handles the day-to-day duties of the department “but keeps me in line and focused on the priorities of my practice and instructor duties,” Dr. Kumar said. “Her support while holding the BCMS president position made my life very easy and smooth. Thank you, Regina, for your hard work and dedication.” The Unsung Hero program recognizes physicians’ office managers and administrative staff who help BCMS members deliver the best quality care to patients. Winners receive gift certificates and are eligible for annual prizes. To learn more, visit www.bcms.org.
IN MEMORIAM
BCMS immediate past president Dr. K. Ashok Kumar presents the BCMS Unsung Hero award Jan. 24 to his office manager, Regina Martinez.
Lloyd Berry, MD, 91, died Feb. 13, 2015. Dr. Berry served in the U.S. Army during World War II as a medic. He was a family medicine practitioner and a BCMS life member. George E. Schafer, MD, died Jan. 23, 2015, at age 92. Dr. Schafer served in the U.S. Air Force as a surgeon. A specialist in aerospace medicine and preventive medicine, he was a BCMS life member. William H. Schlattner, MD, 90, died Jan. 27, 2015. Dr. Schlattner served in the U.S. Air Force Medical Corps. He was a plastic surgeon and a BCMS retired member.
visit us at www.bcms.org
29
ADVOCACY
TEXPAC focuses on pro-medicine candidates With the Texas Legislature in full swing, organized medicine is working hard to forge government changes that will help physicians and their patients. The Texas Medical Association Political Action Committee (TEXPAC) is a bipartisan political action committee of the Texas Medical Association (TMA) and is affiliated with the American Medical Association Political Action Committee (AMPAC) for congressional contribution purposes only. Its goal is to support and elect pro-medicine candidates on the federal and state levels. TEXPAC and TMA work hand in hand to achieve medicine’s goals at the local, state, and federal level. Each has an important role. In the government relations arena, TMA focuses on policy. TEXPAC is all about electing the right candidates, and educating candidates and elected officials about Texas medicine so they can make informed decisions. In addition, TEXPAC makes monetary contributions to election campaigns, whereas TMA does not. That is why TMA membership does not automatically make you a mem-
30 San Antonio Medicine • April 2015
ber of TEXPAC. TEXPAC is a voluntary, nonpartisan political arm of TMA, but it is a separate entity that must follow strict rules governing political action committees. TEXPAC works to advance TMA’s mission of improving the health of all Texans and enables TMA members to protect Texas patients through political education and activism. TEXPAC operates under the motto, “United in protecting our patients.” TEXPAC’s 7,000 members advocate on behalf of TMA’s 48,000-and-counting Texas physicians and medical student members, and nearly 8,000 TMA Alliance members. TEXPAC is one of the largest nonpartisan PACs in the state and ranks first in size among other state medical association PACs. TEXPAC is dues-funded. Where does the money go? On the campaign trail, it goes to: direct contributions to a TEXPAC-endorsed candidate’s campaign; in-kind support to candidates through mailers, push cards and other promotional items; polling to help better understand the dynamics of key races; and assistance
ADVOCACY
for physicians hosting events and fundraisers for their elected officials or candidates.
ENDORSING CANDIDATES TEXPAC’s diverse board of physician leaders represents different geographical areas, practice types and political philosophies. The board makes endorsement decisions by democratic vote to represent TEXPAC’s varied political membership. TEXPAC endorses candidates based on their public record of standing up for medicine’s issues, and a combination of subjective and objective scores, not by their party. With 59 Republicans and 55 Democrats endorsed in the Texas House during the 2014 election, it is clear the approach is not party-driven. TEXPAC does not endorse candidates simply because they are incumbents. The candidate must have a proven record of supporting medicine.
TEXPAC leaders encourage county medical societies to interview all local candidates running for office, then give TEXPAC their recommendation for endorsement. TEXPAC also encourages county societies to conduct letter-writing campaigns to the TEXPAC board in which physicians explain why they support the candidate they believe is the most qualified. These letters are invaluable to TEXPAC and help the board make the right endorsements. What about candidates and officials who do not support TMA’s legislative agenda? TEXPAC encourages local physicians to meet with them and use their poor voting record as an opportunity to educate them on issues important to the doctors and patients they represent. TMA and TMA Alliance members may choose from various membership levels in TEXPAC. For information, call 800-8801300, ext. 1361.
Voluntary contributions by individuals to TEXPAC should be written on personal checks. Funds attributed to individuals or professional associations (PAs) that would exceed federal contribution limits will be placed in the TEXPAC statewide account to support nonfederal political candidates. Contributions are not limited to the suggested amounts. TEXPAC will not favor or disadvantage anyone based on the amounts or failure to make contributions. Contributions used for federal purposes are subject to the prohibitions and limitations of the Federal Election Campaign Act. Contributions or gifts to TEXPAC or any county medical society PAC are not deductible as charitable contributions or business expenses for federal income tax purposes. Federal law requires TEXPAC to use its best efforts to collect and report the name, mailing address, occupation, and name of employer of individuals whose contributions exceed $200 in a calendar year. To satisfy this regulation, please include your occupation and employer information in the space provided. Contributions from a practice business account must disclose the name of the practice and the allocation of contributions for each contributing owner. For more information, call TEXPAC at 512-370-1363.
BCMS physicians visit with newly elected State Rep. Rick Galindo (seated at desk), who represents House District 117, during the Feb. 3 First Tuesdays.
Representing BCMS during the Feb. 3 TMA and Border Health Caucus news conference on Medicaid issues is Michael Battista, MD.
visit us at www.bcms.org
31
UTHSCSA DEAN’S MESSAGE
By Francisco González-Scarano, MD
Our immune system is one of miracBorn in Italy, Dr. Casali received his ulous design and deep complexity. It degree in medicine and surgery (magna regularly saves us from intruders such as cum laude) from the University of viruses, bacteria or tumors; it is the sysMilan, where he was then a resident in tem that responds to vaccines and prointernal medicine and also obtained a vides immunity to illnesses. The study specialty in clinical immunology and alof the immune system integrates many lergy as well as microbiology and viroldifferent disciplines and has resulted in ogy. He pursued postgraduate work in immunology at the Medical School of some of the most important breakthe University of Geneva, Switzerland, throughs of our time – such as vaccines along with assignments as a field officer for smallpox and polio and more rein Ethiopia by the World Health Organcently for the cancer-inducing human ization where he trained at the All Africa papillomavirus. This research has been Leprosy Training and Research Center integral to the high standards of health (now known as ALERT). and extended the life-expectancy most At UC-Irvine Dr. Casali is credited developed countries now enjoy. Paolo Casali, MD with building the renowned Institute On the other hand, the immune sysfor Immunology and the National Intem can also be our worst enemy – producing autoantibodies and/or killer T-cells that destroy tissues in stitutes of Health-funded immunology training graduate proevery major organ system – leading to diseases like type 1 diabetes, gram. Prior to joining the University of California, Dr. Casali lupus and Crohn’s disease. was a tenured professor at the Weill Medical College of Cornell University in New York. At Cornell, he developed a successful research program in addition to fulfilling administrative and RECENTLY JOINED FACULTY teaching duties. Dr. Casali was the director of the integrated This month I would like to highlight Paolo Casali, MD, a reCornell/Sloan-Kettering/Hospital for Special Surgery graduate cent addition to our faculty. Dr. Casali, – a world-renowned improgram in immunology, for which he obtained an N.I.H. munologist whose work is in the field of autoimmune disorders training grant, as well as co-director of the Host Defense (Imand its processes – was recruited as the new chairman of the Demunology/Microbiology/Pathology) course for medical stupartment of Microbiology and Immunology in the School of dents, for which he received the Outstanding Teacher award Medicine. He is also the holder of the Zachry Foundation Disin 2000. tinguished Chair in Microbiology and Immunology. He came to For the past 25 years, Dr. Casali has conducted pioneering reSan Antonio approximately one year ago from the University of search on the molecular mechanisms used by B-lymphocytes to California School of Medicine at Irvine, where he was a professor produce antibodies. Dr. Casali’s primary field of expertise is in of medicine, molecular biology and biochemistry, and director of the understanding and regulation of antibody gene expression, the Institute for Immunology. His specialty is the genetics in the somatic hypermutation and class switch DNA recombination process of B-cell differentiation, and the means through which — processes that critically underpin the body’s response to DNA recombination and somatic hypermutation lead to the exviruses, bacteria, cancer cells and tissue/organ damage in aupression of a virtually infinite array of antibodies with high affinity toimmune diseases. for specific antigens. 32 San Antonio Medicine • April 2015
UTHSCSA DEAN’S MESSAGE UNINTERRUPTED FUNDING Dr. Casali’s groundbreaking work in human B cells and antibodies in the 1980s and ‘90s was instrumental in the development of the first human monoclonal antibodies that neutralize rabies virus, as well as those that treat some autoimmune diseases. His laboratory was one of the few in the world at the time that could produce specifically targeted human monoclonal antibodies, and contributed significantly to the creation of a human monoclonal antibody to tumor necrosis factor alpha (TNF-α which was approved by the FDA as the drug adalimumab (brand name Humira®), an effective treatment which is now one of the most popular drugs in the world. Adalimumab has been FDA approved for treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, moderate to severe chronic psoriasis and juvenile idiopathic arthritis. Dr. Casali’s research has been funded uninterruptedly by the N.I.H. for almost three decades as well as by private foundations. His work has been published in high-profile journals such as Science, Nature Immunology, Immunity, Cell, Journal of Experimental Medicine and the Journal of Immunology. Since 2002, he has also served as editor-in-chief of Autoimmunity, an international peer-reviewed journal that publishes clinical and basic science articles on immunology, genetics and the molecular biology of immunity and autoimmunity. Throughout his career he has served as a member of many N.I.H. review panels and study sections, and received many formal acknowledgements of his scientific accomplishments. His work on drugs termed epigenetic modulators is the basis of a $600,000, three-year grant Dr. Casali received last year from the Alliance for Lupus Research. Epigenetic modulators, often used in the treatment of lymphomas, may turn out to be useful therapies for lupus as well. Systemic lupus erythematosus (SLE) is an autoimmune disease that debilitates approximately 1 million people in the United States, mostly women in their fertile years. Approximately 16,000 new cases are diagnosed each year. In SLE patients, the immune responses typically attack the kidneys, lungs, heart, skin, brain and even the central nervous system. It is a generalized attack that systematically destroys the inner core of most cells of the body, including the DNA and other constituents of the cellular nuclei. Dr. Casali has contributed to fundamental understandings about the immune system abnormalities that occur in SLE. These findings provide a scientific rationale for why epigenetic modulators might be effective in humans. In addition, the Alliance for Lupus Research grant will identify novel targets for new lupus therapeutics. Dr. Casali’s strategy now is to dig even deeper, trying to understand in precise detail more of how these processes work and how they are modulated. This includes the identification of what are
known as “HDAC” (histone deacetylase) inhibitors, such as the naturally occurring butyrate, which is produced by gut flora and modulates microRNAs, acting as an inhibitor to unwanted autoimmune response, suggesting that it is critical in the homeostasis of the immune response.
FOCUS ON TWO ELEMENTS Dr. Casali’s studies focus on two elements that are critical to antibody production and differentiation in B cells. The first is mediated by the enzyme activation-induced cytidine deaminase (AID), which is critical for class-switch recombination and somatic hypermutation. The second is B lymphocyte-induced maturation protein-1 (Blimp-1), which is required for B lymphocytes to differentiate into antibody-secreting cells. AID and Blimp-1 are elevated in SLE. Reducing AID and Blimp-1 expression in a mouse model of lupus decreases autoimmunity and improves health. The hormone estrogen and epigenetic factors called microRNAs also play roles in AID and Blimp-1 expression. With the Alliance for Lupus Research grant, his team will systematically test the ability of different epigenetic modulators to blunt the lupus autoantibody response and the disease. This grant complements and expands the scope of two additional and larger National Institutes of Health research grants that Dr. Casali holds to address the basic molecular and cellular mechanisms of the antibody response in health and disease. His laboratory is part of an integrated immunology research operation that also includes two new junior faculty members who moved with Dr. Casali from California to San Antonio: Hong Zan, Ph.D., associate professor, and Zhenming Xu, Ph.D., an assistant professor, both in the Department of Microbiology and Immunology, who focus on the genetics of the autoimmune response. We are grateful and excited to have Dr. Casali here continuing his important work in autoimmune research. I have no doubt it will have significant implications beyond any single disease. As well, his partnership with other faculty and leadership for students and other researchers has already resulted in the creation of a formidable team that is addressing the damage done to bodies from an unregulated immune system. Learn more about the Department of Microbiology and Immunology at http://uthscsa.edu/micro-immunology/index.asp. Francisco González-Scarano, MD, is dean of the School of Medicine, vice president for medical affairs, professor of neurology, and the John P. Howe III, MD, Distinguished Chair in Health Policy at the University of Texas Health Science Center at San Antonio. His email address is scarano@uthscsa.edu. visit us at www.bcms.org
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OPINION Continued from page 20
Case in point: my dear mother. In the 1980s she had a mild heart attack and was told she would need a stent (Canada was doing these years before the FDA okayed them here). She was put on a list and told she would be contacted by telephone when her time came. She lived in a town in Northern Ontario, and only one hospital in that region could (was allowed to) perform the procedure. She was further told that if she didn’t answer the first and only phone call, they (the government-funded hospital) would move on to the next name. Needless to say, she was wedded to her telephone for nine (count ‘em, 9) months (this was before cell phones). She eventually had her stent and helped make Canada’s survival stats look real good (the sicker people all died before their phones rang). And did my mother complain about her wait? Not a whimper. She was delighted not to pay (directly, at least) one penny for her care.
ping in the streets for lack of healthcare. When friends meet for a Molson, they talk about football (hockey), the stupidity of their politicians, and the latest movie, just like us. Canadian medical schools are bursting at the seams with lengthy wait-lists. Childrens’ medical issues and acute trauma are always dealt with immediately. I think Elisabeth Kubler-Ross provides the best explanation of this dichotomy with her five stages of grieving. Americans are still in the denial, bargaining and anger phases. Canadians (and Brits) have evolved into lemming-like acceptance. Obviously, Prince Philip won’t be waiting in line for his doctor’s appointment. But he is still a Brit and speaks the lingo. It brings to mind the poor knight in Monty Python. With both arms lopped off at the shoulders and blood spurting like two garden hoses, he insists it’s “only a flesh wound.” That positive attitude will make his six-month wait to see a surgeon just fly by.
LENGTHY WAIT-LISTS Reminds me of the old couple out for a stroll, when they come upon the end of a long queue. The woman shoves her husband into the line and says, “Save a place — I’ll go see what we’re waiting for.” Having said all this, let me explain that Canadians are not drop-
34 San Antonio Medicine • April 2015
Robert G. Johnson, MD, is an orthopaedic spine surgeon with Neurosurgical Associates of San Antonio. A frequent contributor to San Antonio Medicine, he has been a BCMS member since 1989.
BUSINESS OF MEDICINE
Telemedicine legislation may gain momentum By Pamela C. Smith, PhD
Medicare Part B allows payments for telehealth services (42 CFR §410.78), including “office or outpatient visits, subsequent hospital care services (with the limitation of one telehealth visit every three days).” Defining telehealth services requires understanding such terms as “asynchronous store and forward technologies,” “distant site,” “interactive telecommunications system” and “originating site.” These terms on the surface might require a law degree to truly understand. In simple terms, according to the American Telemedicine Association (a nonprofit telemedicine advocacy group), telemedicine “is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.” 1 Oftentimes, the words telehealth and telemedicine are used interchangeably, but each has a distinct definition. According to the Texas Medical Association, telehealth “refers to a broad scope of remote healthcare services that may include clinical care but also encompasses education and administrative components.” Telemedicine “refers specifically to the delivery of remote clinical services” and is “not considered a separate medical specialty.”2 A third term, used more in the telehealth industry, is telecare, which “refers to technology that allows patients to stay safe and independent in their own homes, through the use of telecommunications technology.”3 Currently, Medicare reimburses for services provided to beneficiaries who seek care at approved facilities in designated rural areas. Legislators over the years have viewed these reimbursement rules as antiquated and oblivious to today’s high-tech environment. Congressional members have attempted to update the re-
imbursement regulations to better meet the demands of our mobile population. For example, in 2012, Rep. Mike Thompson (D-Calif.) put forth the Telehealth Promotion Act of 2012. The bill sought to allow telehealth services to be covered “to the same extent the item or service would be covered if furnished in the same location of the beneficiary, and benefits shall not be denied … solely on the basis that the item or service is being furnished via a telecommunications system.” 4 Despite this bill failing to get out of committee, the telemedicine topic is not dead. In July 2014, Thompson again sought to change the rules surrounding telehealth services. Serving on the House Energy and Commerce Subcommittee, Thompson, along with nine cosponsors, introduced HR 5380, the Medicare Telehealth Parity Act of 2014, in another attempt to change the way telemedicine services are reimbursed. The bill proposed to expand telehealth services to urban areas, lift restrictions on “store and forward” technology [i.e., video conferencing technologies], and authorize payments for remote patient monitoring for those with chronic health conditions. As in prior history, the Medicare Telehealth Parity Act of 2014 also failed to get out of committee. However, less than five months later, on Jan. 27, Rep. Fred Upton (R-Mich.) led the House Energy and Commerce Committee to release a discussion draft entitled the 21st Century Cures Act. The Energy and Commerce Committee argues the provisions “would advance opportunities for telemedicine and new technologies to improve the delivery of quality healthcare services to Medicare beneficiaries.” 5 Particularly, the draft is seeking to include services that meet unmet service needs, are substitutes for in-person visits, are proven to reduce admissions (or other costly Continued on page 36 visit us at www.bcms.org
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BUSINESS OF MEDICINE Continued from page 35
services), and allow patients to be treated at a lower level of care (including home healthcare). The would be required to develop a methodology within four years to address these needs. To address potential costs, the draft requires the ’ chief actuary to ensure payments “would reduce (or would not result in any increase in) net program spending.” Since telemedicine affects practitioners and hospitals, the American Hospital Association (AHA) agrees, in theory, with the goal of expanding coverage of telehealth services. The AHA argues geographical restrictions must be addressed in the legislation, since Medicare only pays for telehealth services for facilities located in rural Health Professional Shortage areas. The AHA also noted that “only 75 individual service codes out of more than 10,000 physician services covered through the Medicare physician fee schedule are approved for payment when delivered via telehealth.” 6 Only time will tell if this latest legislative draft will make it out of committee. Advocates and opponents must make their concerns heard to have productive dialogue. The end result should be changes to the reimbursement system that provide benefits to all interested parties – without significantly raising costs.
REFERENCES 1 h t t p : / / w w w. a m e r i c a n t e l e m e d . o r g / a b o u t - t e l e m e d i c i n e / w h a t - i s telemedicine#.VNEwKcUxpyI 2 http://www.texmed.org/Template.aspx?id=30999&terms=telehealth#glossary 3 http://www.globalmed.com/additional-resources/telehealth-telecare-and-telemedicine-whats-the-difference.php 4 http://www.gpo.gov/fdsys/pkg/BILLS-112hr6719ih/html/BILLS112hr6719ih.htm 5 http://energycommerce.house.gov/sites/republicans.energycommerce. house.gov/files/114/Analysis/Cures/20150127-Cures-Discussion-Document-Section-by-Section.pdf 6 http://news.aha.org/article/aha-calls-for-more-global-approach-to-coverage-inhouse-telehealth-proposal
Pamela C. Smith, PhD, is a professor in the department of accounting at the University of Texas at San Antonio.
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BOOK REVIEW
‘When You Hold a Patient’s Hand ... Don’t Wear a Glove’ Written by Stuart Gilbert, MD Reviewed by Franklin C. Redmond, MD
I recently read the new book, “When You Hold a Patient’s Hand … Don’t Wear a Glove: The Experiences of a Maine Radiation Oncologist.” I felt it was a book worth sharing with the entire physician/patient community. I sent the title to Fred Olin, MD, who often reviews books for San Antonio Medicine. He suggested I do the review myself. The author, Stuart Gilbert, MD, is an old friend from 42 years ago when our families were thrown together at USAF Regional Hospital, Sheppard AFB, Wichita Falls, Texas. Dr. Gilbert was a general radiologist at the time, and I was a psychiatrist. After “the war,” I returned to San Antonio and he to the Boston area. We have enjoyed keeping up over the ensuing years including reciprocal visits. On our most recent visit, Dr. Gilbert was excited about his new book that was soon to arrive from his publisher. Of course, I had to order a copy, if only to be supportive of his effort. As he stated in his introduction, his goal was to leave an accounting of his professional life and career for his grandchildren. Dr. Gilbert accomplished far more. He left a blueprint of the striving for, and attainment of, true medical professionalism. Dr. Gilbert begins with a brief family history and a recounting of his early life experiences, included having a physician father, a supportive family, educational opportunities, and a culture that supported and valued the characteristics that go into a successful professional life. The author describes the process of going back into training in radiation oncology. Dr. Gilbert discusses the various pathways he took, ending up in Portland, Maine, where he reared his children and became an accomplished radiation oncologist and a highly respected member of the community. His career accomplishments and examples of the learning that he obtained from his experiences with patients and colleagues demonstrate many qualities of professionalism. Honesty and basic human consideration were evident in all of the situations he described. Dr. Gilbert’s career, as described, is a clear example of the successful management of the contractual and reciprocal relationships that occur between a true professional and the members of his/her defined community. The “meat” of the book includes many anecdotes of personal in40 San Antonio Medicine • April 2015
teractions with real cancer patients. The accountings are well written with clarity and humility, and demonstrate the compassion he showed his patients and their families. The author includes facts and recent research about radiation, chemo, breast cancer, lung cancer, leukemia, colon cancer, prostrate cancer and the side effects of medications. He describes the detailed information that he discussed with his patients, demonstrating an intimate collaborative style. In recounting the anecdotes of his cancer patients, some with good survival outcomes and some not, he gives a convincing argument that without a positive personal physician/patient relationship, the likelihood of a positive experience is diminished. Being a contemporary physician with Dr. Gilbert, I was struck by how many similar experiences of my own his personal and poignant examples brought back to memory. Many who aspire to become a medical professional (or any other professional) often are not as fortunate to have the ready and appropriate role models that Dr. Gilbert had. As it turns out, he himself became an exceptional role model for those who have been associated with him through the years. Through his book one can appreciate some of the types of experiences that help develop professional behavior. I can wholeheartedly recommend this book for anyone embarking on a professional career, particularly those working in the healthcare field. In addition, it would be very helpful to cancer patients and their families as they struggle with a very difficult time of life. Finally, it is a pleasant and easy read about life in general. Franklin C. Redmond, MD, is a semi-retired psychiatrist and a clinical professor at the University of Texas Health Science Center San Antonio. He is a BCMS member.
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(210) 772-7777
Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Acura 11911 IH-10 West
Gunn Chevrolet 12602 IH-35 North
* Fernandez Honda 8015 IH-35 South
* North Park Lincoln/ Mercury 9207 San Pedro Ave. Porsche of San Antonio 9455 IH-10 West
Gunn Honda 14610 IH-10 West (@ Loop 1604) Ingram Park Auto Center 7000 NW Loop 410
Cavender Audi 15447 IH-10 West
Ancira Chrysler 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
* Gunn Infiniti 12150 IH-10 West
Ancira Ram 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
Mercedes-Benz of Boerne 31445 IH-10 W, Boerne BMW of San Antonio 8434 Airport Blvd.
Ancira Dodge 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
Ancira Jeep 10807 IH-10 West
Mercedes-Benz of San Antonio 9600 San Pedro Ave.
North Park Subaru 9807 San Pedro Ave.
Ingram Park Auto Center 7000 NW Loop 410
Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604) Northside Ford 12300 San Pedro Ave.
Batchelor Cadillac 11001 IH-10 at Huebner Cavender Cadillac 7625 N. Loop 1604 East
Cavender GMC 17811 San Pedro Ave. Gunn GMC 16440 IH-35 North
* North Park Lexus 611 Lockhill Selma North Park Lexus Dominion 21531 IH-10 West Frontage Road
* Mini Cooper The BMW Center 8434 Airport Blvd.
Cavender Toyota 5730 NW Loop 410
* Ancira Volkswagen 5125 Bandera Rd. Ancira Nissan 10835 IH-10 West Ingram Park Nissan 7000 NW Loop 410
* Volvo of San Antonio 1326 NE Loop 410
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AUTO REVIEW
Volvo V60 sport wagon A fun-to-drive car with Scandinavian roots By Steve Schutz, MD
The 2015 Volvo V60 sport wagon is very Euro. It’s sleek, sophisticated, luxurious and fuel efficient. But it’s also smaller than other vehicles in its price range, which will limit its appeal. The V60 is certainly handsome. Long, low and wide are good adjectives to describe its stance, and Volvo designers added tasteful accents such as a large grille, aluminum-colored trim, and attractive head- and taillights. The headlights in particular are well done, managing to look bright and modern without being yet another Audi knock-off. While numerous styling elements subtly connect the new V60 with classic Volvos from 40 years ago, the new wagon introduces a new design language for Sweden’s last surviving car company. Volvo executives hope you like it, be44 San Antonio Medicine • April 2015
cause all new Volvos for the next five to 10 years will look a lot like the new V60.
QUALITY MATERIALS ARE NEW Inside, the V60 benefits from a new emphasis on quality materials. Owners of Volvos from 10 years ago remember interiors that seemed to brag, “We saved money here, and here, and here.” The company obviously listened to those owner complaints and addressed them in the new V60. One area that needed no correcting was the seats, and the V60’s are — as usual for Volvo — best in class. Seemingly crafted specifically for whoever’s driving it, the V60’s seats support you during spirited driving and comfort you on long trips. I don’t get how other luxury brands can’t seem to make seats
as “just right” as Volvo, but they can’t. Volvo clearly took pains to integrate the tech we all enjoy inside modern vehicles — satellite radio, smartphone compatibility, satnav and the like — with a touch of style, in this case Scandinavian style. For years I’ve been hoping Volvo would give car-buyers an interior with the functionality and inspired good looks of any Bang and Olufsen product. Anyone who’s encountered one of those unique devices knows that they’re gorgeous to look at and elegant to use, yet totally different from a Sony, Samsung or Apple product. Is the V60 cabin as good as that? No, but it gives you what you want in a luxury-car interior with a nice Scandinavian accent. Otherwise, the sense you get from inside the V60 is that it’s small. Not small in an
AUTO REVIEW absolute sense, as Volvo’s mid-size wagon is roughly equivalent to a Toyota Camry with even more storage space under the rear hatch. But customers looking for family vehicles at the V60’s price point of approximately $40,000 can choose among the Ford Explorer, Toyota Highlander, Buick Enclave, or even a decontented Chevy Tahoe, all of which provide much more passenger and luggage space than the (admittedly cooler) Volvo wagon. Where you sit on the style/luxury/space graph is a personal decision, but keep in mind that the V60 is more about style and luxury than passenger and luggage space.
DRIVE-E TO TAKE OVER At least the Volvo drives a lot better than those aforementioned competitors. Like all wagon versions of sporty European sedans, the V60 drives just like the S60, which means it’s more fun than any SUV or crossover. The V60’s low center of gravity and athletic suspension tuning provide an invigorating experience behind the wheel. For now, the AWD versions of the V60
make do with a holdover duo of 5- and 6cylinder engines, but a new slate of “DriveE” turbocharged 4-cylinder motors will soon power all V60s. Turbo fours are already de rigueur at Audi, Mercedes and even Cadillac, so Volvo’s a little late to the party. But once Drive-E takes over, expect excellent drivability and improved fuel efficiency. The AWD turbo 6-cylinder V60 I tested was quick, with a zero to 60 mph time of 5.5 seconds, but the EPA rates it at an uninspiring 19 mpg city/22 highway. Compare those figures with the FWD V60 Drive-E’s still-impressive 6.4 second zero to 60 time and 25/37 mpg. (Of note, the industry bible, Automotive News, predicts that even smaller Drive-E 3cylinder engines are on the way, too, probably in 2016.) Naturally, the V60 features the latest safety innovations, including electronic stability control, airbags galore, active front head restraints, and Volvo's City Safe system that can automatically apply the brakes at speeds of up to 31 mph to prevent or minimize a frontal collision. Other more advanced safety technologies, such as lane departure warning
and lane-keeping assist, blind-spot protection, rear cross-traffic alert, and a driver inattention warning system, are offered as options. BCMS Auto Program manager Phil Hornbeak can supply any and all trim and option information, as well as special BCMS pricing, but expect nicely equipped V60s to go for $40,000 to $45,000 or so. The new V60 is the first truly modern Volvo offered in the United States in several years. Sleek, stylish and very Euro, the V60 won’t appeal to everybody because of its size, but its fun-to-drive nature and Scandinavian roots are an attractive mix. Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. For more information on the BCMS Auto Program, call Phil Hornbeak at 3014367 or visit www.bcms.org.
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