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APRIL 2017
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VOLUME 70 NO. 4
MEDICINE SAN ANTONIO
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APRIL 2017
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VOLUME 70 NO. 4
STRESSED OUT
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.
What makes doctors great also drives burnout: A double-edged sword By Troy Parks, American Medical Association ...................18
EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org
Approaching wellness, understanding the challenges and finding solutions to the crisis in physician wellbeing By Jon Courand, MD ...................................14
Report reveals severity of burnout by specialty By Troy Parks, American Medical Association ....................22
MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue
BCMS President’s Message ..........................................................................................................8 BCMS Legislative News ..........................................................................................................................10 BCMS News.............................................................................................................................................24 Feature: EMR Wars By Robert Johnson, MD...........................................................................................26 Feature: Incredible India! By Roberta Lynn Krueger, MD .......................................................................28 Business: Disruptive Innovation and the Future of Healthcare By Edward Schumacher ......................30 BCMS Alliance.........................................................................................................................................34 Legal Ease By Rick Evans.......................................................................................................................36 Circle of Friends Directory .......................................................................................................................38 In the Driver’s Seat...................................................................................................................................43 Auto Review: 2017 Audi A4 By Steve Schutz, MD .................................................................................44
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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Leah Jacobson, MD, President Adam V. Ratner, MD, Vice President Sheldon Gross, MD, President-elect Jayesh B. Shah, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary John Robert Holcomb, MD, Treasurer
DIRECTORS Rajaram Bala, MD, Member Lori Boies, PhD, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member Arthur D. Cortez, MD, Board of Censors Chair George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Bradley A. Lloyd, MD, Military Rep. Rodolfo Molina, MD, Board of Mediations Chair John Joseph Nava, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Carmen Garza, MD, Community Member Kristi Kosub, MD, Member Lauren Michael, Medical Student Sara Noble, Medical Student Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Adam Ratner, MD, Member David Schultz, Community Member J.J. Waller Jr., MD, Member Jane Yoon, Medical Student
6 San Antonio Medicine • April 2017
PRESIDENT’S MESSAGE
Child Abuse By Leah Jacobson, MD, 2017 BCMS President
This month I focus my article on a very serious topic — child abuse. April is National Child Abuse Prevention Month and it reminds us that it affects us all in some way — whether we know someone who was abused, have been abused ourselves, or care for patients that have been affected by this horrific issue. Currently there are more than 700 legislative bills under consideration in the State Legislature that relate to child abuse. I want to highlight two entities in San Antonio and Bexar County that are available as important resources for physicians when it comes to this topic. The Center for Miracles located at Children’s Hospital of San Antonio (CHOSA) is the primary child abuse assessment center in our area (http://www.chofsa.org/centerformiracles ). At the Center for Miracles, they provide complete medical and psychosocial assessments for children who are referred by Child Protective Services, law enforcement or medical professionals and who are suspected victims of abuse or neglect. The assessment may include any of the following: complete physical examination, forensic photo-documentation, psychosocial evaluation, diagnosis/report, court testimony, and additional services, including short-term counseling, physician consultations, mental health staffings, physical abuse and neglect case staffings, and inpatient consultations at Children’s Hospital of San Antonio. ChildSafe is the only children’s advocacy center in Bexar County. As they describe it, ChildSafe’s mission is to restore dignity, hope and trust to children traumatized by abuse and neglect. At ChildSafe, they collaborate, advocate for children, raise community awareness and raise money for services. Some of the services they provide are CARE (Child Abuse Resource Enhancement), FEAT (Family Enrichment Adventure Therapy), forensic Interview services, referral to medical services, family support services, and counseling. ChildSafe provides in-person training to children and teens, professionals, parents and adults, and licensed mental health providers and clinicians both on and off-site. Some topics of these seminars include “Brown Bag workshops,” “Child Sexual Abuse: victims and offenders,” “What is child abuse?,” “Sexual Behavior Problems in Children,” “Out and About Safety,” and
8 San Antonio Medicine • April 2017
“Interacting with Sexually Abused Children.” Cardboard Kids is a local child abuse prevention campaign. In 2015, there were 4,941 confirmed cases of child abuse and neglect in Bexar County. And while that number is staggering, it’s just as shocking to learn that only 1 in 10 sexually abused children ever make an outcry, meaning thousands more children in and around San Antonio are victims of abuse, typically by someone the child knows, loves, and trusts. To bring awareness to this incredibly urgent issue, ChildSafe created the Cardboard Kids Campaign. Cardboard Kids are 2foot tall cardboard figures shaped like children that represent one of the thousands of children that are abused and neglected at the hands of adults in our community each year. This is ChildSafe’s fourth year to partner with local businesses, clubs, organizations and individuals to decorate and display a Cardboard Kid representing one of the thousands of children who suffer from abuse and neglect at the hands of adults in Bexar County every year. Community members, businesses, and families are encouraged to decorate and display their own Cardboard Kids on “Reveal Day” on April 6, to create awareness about child abuse and neglect and our mission of ending child abuse in Bexar County.
What to do if you suspect child abuse or neglect: Report to Child Protective Services if: • You don’t know who may have abused the child or you suspect a family member.
PRESIDENT’S MESSAGE
• You suspect any type of neglect. • Report to Child Protective Services by phone: 1-800-2525400, or online report: http://www.txabushotline.org Report to law enforcement if: • You suspect a non-family member is the abuser. • You feel rapid intervention may be needed (severe abuse, threatening parents, fear of parent flight with child.) • Note that a law enforcement report should be made to the agency with jurisdiction over the location where the abuse likely occurred — not necessarily where the child lives. • Report to law enforcement by phone. Call your local law enforcement agency. • Make the report as quickly as possible. When you make a report (either to CPS or law enforcement), be sure to record the case report ID number in the medical record. • Consider whether other tests are needed. • Consider whether hospitalization is needed: Serious injuries, especially in younger children and infants. • To facilitate the abuse evaluation. • To keep the child in a safe location pending further evaluation by CPS or law enforcement. • Carefully and completely document any/all interactions with the child or parent, preferably in quotations. How do you interact with the parent? • Stress your role to act in the child’s best interest to ensure they are safe. • If the abuser is unknown, but may be the parent, or the parent appears to be protecting an abuser, then you are not required to release verbal or written information to the parent if it may place the child in danger. This is an exception to the HIPAA rules. What information can you release to CPS or law enforcement? • You can and should promptly release all information pertinent to the child’s injuries promptly to CPS or law enforcement, when they request it. This is also an exception to the HIPAA rules.
• You suspect abuse or neglect and want guidance on the next steps. • You have a question on which diagnostic tests might need to be done and whether a child might need to go to The Children’s Hospital of San Antonio Emergency Room for forensic photo-documentation Other questions we might be able to help with: • “Does the history reasonably explain the injury(s) in this child?” • “Is this appropriate or abusive punishment?” • “Could this child’s failure to gain weight be due to neglect?” • “What other non-abusive causes are possible?” When to call ChildSafe, 210-675-9000, Monday through Friday 8 a.m. to 5 p.m. • You suspect sexual abuse and want guidance on the next steps. • You have a question on whether a child needs a medical examination at ChildSafe, Center for Miracles, or The Children’s Hospital of San Antonio Emergency Department. • To refer a child for a sexual abuse evaluation when the last incident of abuse occurred more than 96 hours ago. When to call/refer to The Children’s Hospital of San Antonio Emergency Department and/or Forensic Nurse Examiner program, 210-704-2190, seven days a week, 24 hours a day; • Ask for the Emergency Physician or Forensic Nurse Examiner on duty when: • Sexual abuse may have occurred within the past 96 hours. • The child is a suspected victim of sexual abuse or assault and has symptoms of ano-genital bleeding or pain. • The child has visible injuries and is in need of forensic photodocumentation. I hope that you find the information in this article helpful in your practices/lives. Sincerely, Leah H. Jacobson, MD FAAP 2017 BCMS President
When to Call When to call Center for Miracles, 210-704-3800, Monday through Friday; 210-704-2100 after hours
**ChildSafe – www.childsafe-sa.org **Center for Miracles – www.chofsa.org/centerformiracles
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BCMS LEGISLATIVE NEWS
Physicians hard at work advocating on behalf of medicine during March 7 First Tuesdays By Mary E. Nava, MBA, BCMS Chief Government Affairs Officer and Lobbyist
A big thank you to the following physician and Alliance members who participated in the March 7 First Tuesdays visits at the Capitol: Physicians — Leah Jacobson, MD, BCMS President; Daniel Deane, MD; John Edwards, MD; Pam Hall, MD; David Henkes, MD; James Humphreys, MD; Alex Kenton, MD; David Lam, MD; John Menchaca, MD; John Nava, MD and Huyen Nguyen, MD; Alliance members — Lisa DeArmond; Danielle Henkes; Jennifer Lewis and Jennifer Shepherd. The group visited with legislators and staff of all the offices of our state representatives and senators from Bexar County. Among the topics discussed were: surprise billing; vaccine exemptions; scope of practice; expanded mediation; Medicaid reimbursement, GME and the prescription drug monitoring program. For more information on the 2017 TMA Legislative Priorities, visit the TMA website at www.texmed.org. The next First Tuesdays is April 4. To register, go to www.texmed.org/firsttuesdays. For local discussion on these and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer and lobbyist, at mary.nava@bcms.org.
10 San Antonio Medicine • April 2017
Clockwise froom the top: BCMS physicians, Alliance and staff attendees greet Rep. Philip Cortez (House District 117) in the Capitol Extension building on March 7. BCMS physicians, Alliance members and staff pause for a photo with Sen. Donna Campbell (Senate District 25), center, in the Capitol Extension stairway during the March 7 First Tuesdays event. BCMS physicians and Alliance members visit with Health and Human Services policy staffer in the office of House Speaker Joe Straus, Heather Fleming (center, right, in dark sweater) on numerous medicine issues during the March 7 First Tuesdays visit to the Capitol. Past BCMS President, Jim Humphreys, MD and 2017 President, Leah Jacobson, MD (right) visit with newcomer to First Tuesdays, Huyen Nguyen, MD during the March 7 visit to the Capitol.
STRESSED OUT
Approaching wellness, understanding the challenges and finding solutions to the crisis in physician wellbeing By Jon Courand, MD A 43-year-old Family Practitioner dreads the beginning of the workweek and feels little empathy for the next patient asking for pain medications. A 36-year-old Emergency Medicine physician and mother of two yells at a nurse for a minor oversight and later finds herself crying “for no reasonâ€?. A 55-year-old Internist fighting the electronic health record at 8 p.m. to complete his daily notes counts the days until retirement. Do any of these sound familiar? All of them? That would not be a surprise given the current statistics. Currently over one half of all physicians meet at least one criterion for burnout and fully one third are clinically depressed. Burnout is best defined as a constellation of three features: emotional exhaustion, depersonalization, and diminished sense of personal accomplishment. More alarming is the rate of physician suicide equivalent to two full medical school classes, or close to 400 individuals per year. 14 San Antonio Medicine • April 2017
In some recent studies, the occurrence of suicidal ideation in the past year was as high as 10 percent in medical students and 16 percent in surgeons following a medical error. These issues are systemic in medicine, manifesting as early as in the first few months of medical school and continuing through residency training and practice; concerning given the fact that enrollees to medical school are more empathetic and well adjusted than their age matched peers pursing other professional occupations. As a physician practicing in one of the high risk groups, Critical Care, I have personally experienced the effects of anxiety and burnout, and have been fortunate enough to gain greater insight into these issues as the Chair of the Institutional GME Wellness and Resident Work Life Subcommittee and my involvement in physician wellness at the national level.
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Why do we find ourselves in this predicament and how might we see our way clear is a question with no easy answers; but the solutions to this crisis will almost certainly require multiple interventions on a variety of levels. To that end, the Accreditation Council of Graduate Medical Education (ACGME) recently convened its second annual Symposium on Physician Well-Being in Chicago this past December. Over 120 experts from across the nation including representatives from all the major stakeholders from the House of Medicine*, researchers and other highly-engaged individuals met for three days to review the most up to date research, hear directly from content experts, work together to delineate the causal elements and propose interventions. From my perspective, four major action items were identified: 1. Institutions must put into place self-screening programs to identify individuals at risk for burnout, anxiety, depression and suicidal ideation. 2. Institutions must provide access to comprehensive mental health resources for those identified available 24 hours a day, 7 days a week in a convenient, affordable and confidential manner. 3. Hospitals must promote an environment where trainees and faculty can maintain well-being yet fulfill their professional obligations. 4. Hospitals and Institutions must develop system-based actions and tools for preventing, eliminating or mitigating impediments to that well-being; while understanding the role work intensity and work compression contribute in today’s outpatient and inpatient environment. With these four action items as signposts, how do are we actualizing these into the daily operation of our academic institutions and what is being done to help our wider community of physicians? The initial approach of UT Health San Antonio to this crisis has required a dual response: identification and support of those already experiencing difficulties, while at the same time working with our hospital partners to develop programs that enhance the environment, promote community, a just culture, resilience and wellbeing.
Helping Those at Risk To help those already experiencing difficulties, the Office of Graduate Medical Education has identified an interactive on-line screening program or (ISP) that allows biannual, anonymous and voluntary screening of all the institution’s 750 trainees for depression, anxiety, burnout and suicidal ideation. This ISP program stratifies respondents into separate risk groups with escalating levels of response. To operationalize this program, the institution will be funding two Ph.D. behavioral health providers who will be available during regular business hours to respond to these surveys. The behavioral health providers can then develop rapport with respondents and provide counseling either anonymously through a secure channel or face to face with referral to higher level psychiatric care as needed. Trainees can interact with these counselors apart
from the ISP system if they desire, and in addition, all trainees have 24/7 access to counselors through our Employee Assistance Program or (EAP). For residents in crisis, immediate care can be obtained confidentially through our adult emergency center and the Department of Psychiatry. At no time can a trainee be required to see a counselor as a stipulation of employment, and the counselors will never serve in an evaluatory role for the resident’s departmental program. All counseling is strictly confidential.
Promoting Wellbeing The ability of an institution, department or even division to help promote wellness and the development of resilience in their physicians is a much greater challenge, since the essential aspects for wellbeing are different physician to physician. That said, there are some things that may be considered essential to the well-being of all physician providers: a sense of community, a supportive environment and a culture of respect among all members of the healthcare team that eliminates aggressive, demeaning or insensitive conduct. For trainees the availability of adequate, clean work spaces, call rooms and nutritious on-call food is a demonstration of their value and helps them perform at their best for their patients. Faculty and trainees must have allowances to attend to important concerns during working hours, like obstetric appointments or dental care. Updated duty hour rules set to take effect on July 1, 2017 again allow on-call interns to remain beyond their night shifts to present on morning rounds and gain important insights on their thought process and management plans from faculty. In the case of important patient events, e.g. disease progression or end of life care, residents are allowed to exceed maximum weekly hours. In its revisions to the Common Program Requirements Section VI, the ACGME rationale for this change was to strengthen the interprofessional team, provide time for faculty to model professionalism and rebuild the community which had suffered from a “shift work” mentality. In addition to these fundamentals, programs across the country are developing “wellness toolboxes” of methods or practices that promote these ideals. Some examples include team-building retreats, nurse-physician collaborative projects, nutrition counseling, financial planning advice for trainees to manage debt, journaling, Balint-type groups, faculty-resident sporting events and mindfulness, yoga and other stress-reduction techniques. We are also working closely with our Center for Medical Humanities and Ethics to connect with like-mined individuals within the institution and broader community who share a common vision. The Center also has helped invite local and national experts to provide their latest insights and potential solutions. Within the broader community, participation in local specialty societies allow an outlet for discussion of these issues directly with peers and a chance to learn about solutions used by some providers that may benefit others. One Chief Resident offered her elegant solution to this issue by asking her fellow residents to determine the one activity in their lives that was most important to their well-being, e.g. running, playing continued on page 16
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an instrument, cooking gourmet food or spending quality time with a friend and making sure they made time once a day or at a minimum once a week to do it.
On the Horizon Representatives from across medicine are very cognizant of the enormous challenges facing physicians in both community and academic practices. At the top of the list of challenges is the enormous administrative burden due in part to the electronic health record (EHR). In 2013, a joint study by the RAND Corporation and American Medical Association identified the EHR as the largest dissatisfier for physicians, citing issues of excessive data entry, interference with face to face care, high cost of maintenance and inability of EHRs to talk to one another as reasons.1 To this end, representatives from many of the major medical associations are preparing to meet this spring with representatives of the major EHR providers to begin a conversation on making these systems more efficient, effective and collaborative. The increasing use of scribes and other midlevel providers was also discussed as an alternate solution being employed in some settings. Another major issue affecting the wellbeing of physicians involves the stigma of accessing mental health care and the concern that accessing care may potentially affect state licensure. Many states including Texas ask questions about diagnosis and treatment of past mental conditions, and if they resulted in any impairment to physician practice. Affirmative answers may raise fears of excessive administrative burden, cost, need to participate in the Texas Physician Health Program, long term monitoring and even denial of license. Because of these concerns, many physicians choose to avoid accessing care entirely or concealing the care they are getting, likely intensifying the stigma. A recent survey of more than 2,000 female physicians showed over 50 percent believed that they met criteria for some form of mental illness but only 6 percent of physicians with formal diagnosis or treatment of mental illness had disclosed to their state licensing boards.2 Understanding this growing concern, the AAMC, the ACGME and other stake holders are working with the Federation of State Medical Boards to approach this issue. A representative from the Federation of State Medical Boards attending the ACGME Wellness Symposium directly spoke to this issue, acknowledged the concerns and assuring the assembled group that their organization was actively working to address this issue.
Summary Due in large part to the work being done by the ACGME and its CEO, Dr. Tomas Nasca, these issues facing resident and faculty wellbeing are finally being spotlighted, and stakeholders and researchers from across the medical landscape are now working together to understand the underlying causes for physician burnout, depression
16 San Antonio Medicine • April 2017
and suicidal ideation and finding ways to address this growing crisis. Not lost on anyone is the understanding that improved care of resident trainees and practicing physicians in both the academic environment and in the community will translate into improved care of patients and an anticipated decrease in medical errors and poor patient outcomes. In the broadest sense, academic institutions, hospitals, community clinics and private offices must strive to create an environment of cooperation, respect and strengthen the sense of community. The tools of practice must be improved or redesigned to be effective and efficient in their use, and when possible administrative burden must be lightened. There must be robust systems in place to identify physicians or trainees at risk and guide them to appropriate counseling or crisis services. The medical boards must find ways to lessen the stigmatization of physicians with past or current mental health issues while still maintaining its commitment and trust with the general public it serves. Finally, individuals must understand that ultimately their well-being rests within their own hands, and they must determine and put into place the physical, intellectual, emotional and spiritual practices that nourish it while eliminating those unwanted aspects which impair it. The practice of medicine is at its highest a challenging yet fulfilling and sacred calling and we owe it to ourselves and to our patients to bring the best “us” to that physician-patient partnership. 1 Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Mark W. Friedberg et al. for the RAND Corporation, Michael Tutty et al. for the American Medical Association. Copyright 2013 RAND Corporation 2 “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. Dr. Katherine Gold, Dr. Thomas Schwenk November–December, 2016 Volume 43, Pages 51–57 * House of Medicine: Accreditation Council of Graduate Medical Education (ACGME)/ Clinical Learning Environment (CLER) Site Visitors, Liaison Committee on Medical Education (LCME), Educational Commission for Foreign Medical Graduates (ECFMG), America Board of Medical Specialties (ABMS), America Medical Association (AMA), American Association of Colleges of Osteopathic Medicine (AACOM), American Hospital Association (AHA), Veteran’s Administration (VA), Institute of Medicine, American Association of Medical Colleges (AAMC), Centers for Disease Control (CDC), National Board of Medical Examiners (NMBE), Federation of State Medical Board (FSMB), Arthur P. Gold Foundation President, American Foundation of Suicide Prevention(AFSP).
STRESSED OUT
What makes doctors great also drives burnout: A double-edged sword By Troy Parks, Staff Writer for the American Medical Association
A physician burnout expert from the Mayo Clinic explained earlier this month at the 2016 AMA Annual Meeting how physicians in the current health care system often have an intrinsic risk of burnout. Learn about the role that the “physician personality” can play in burnout and ways Mayo has found to help address burnout as a system-wide issue.
What’s happening to physicians? “If I told you we had a system issue that affected quality of care, limited access to care, and eroded patient satisfaction, that affected up to half of patient encounters,” said Tait Shanafelt, MD, a hematologist and physician burnout researcher at the Mayo Clinic, “you would immediately assign a team of systems engineers, physicians, administrators at your center to fix that problem rapidly.” Tait Shanafelt, MD, hematologist and physician burnout researcher at the Mayo Clinic That’s what burnout is, he said. It’s a system issue. “And we have not mobilized the way we would to address other factors affecting quality access and patient satisfaction,” Dr. Shanafelt said.
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“On a societal level folks would look at us and think we have a recipe for great personal and professional satisfaction,” he said. “We engage in work that society values and thinks is meaningful work. And yet our own literature has been telling a different story about the experience of being a physician.” A recent study published in Mayo Clinic Proceedings took a look at how physician burnout compares to the general population and found that physicians displayed almost double the rate of emotional exhaustion as the general working population and reported lower satisfaction with work-life balance (36.0 percent for physicians, versus 61.3 percent of the general working population). Dr. Shanafelt said that burnout is often the result of three components: • Depersonalization: Treating people as though they’re objects rather than human beings • Emotional exhaustion: Losing enthusiasm for your work • Low personal accomplishment: Feeling you’re ineffective in your work, whether or not that is an accurate perception
STRESSED OUT
“All of us have those feelings to some frequency and some severity,” he said. “But when they come too often and to too severe an extent, they can begin to undermine your effectiveness in your work.” “This syndrome differs from the global impairment of depression,” he said. “It primarily relates to your professional spirit of life, and it primarily affects individuals whose work involves an intense interaction with people—so professions such as teachers, social workers, police officers, nurses and physicians.”
The survival mentality and the physician personality “I think we all remember that survival mentality of residency,” Dr. Shanafelt said. “‘I’ve just got to make it through; things will get better when I’m done with residency.’ But what we find is that physicians perpetuate that framework throughout their whole career.” Dr. Shanafelt said that in one study, 37 percent of physicians reported looking forward to retirement as an effective wellness strategy. “This is the same thing as the survival mentality … and what was notable was that it was equally common to report that strategy for those under the age of 40 as those who were older,” he said. “It’s not just those who were actually getting closer to retirement.” It’s a mentality of “work now, when I retire I’ll get to personal life,” he said. Dr. Shanafelt said that one suggestion many researchers have found to be a possible cause of physician burnout is “that we are also at inherently higher risk due to what they’ve coined the ‘physician personality,’” he said. “Now, this is where if I wasn’t a physician myself you would start throwing rotten fruit.” “They say … that the characteristics that define many doctors are doubt, guilt and an exaggerated sense of personal responsibility,” he said. “But these are the qualities that make you a good physician. They lead you to be thorough, committed, leaving no stone unturned, to always be thinking about Mrs. Jones and what else I could do, what am I missing? How could we do a better job taking care of her?” “The qualities that make people good physicians are a doubleedged sword,” he said. “It’s those who are most dedicated to their work who are at greatest risk to be most consumed by it.”
A strategy to examine work-life balance If you’re experiencing burnout, identifying values—both personally and professionally—is an important factor in addressing what causes burnout, Dr. Shanafelt said. One way to do that is to engage in a series of questions to examine the two sides. The first set of questions: • What are the things you care about in your personal life? • What does it look like for you to live in a way that demonstrates those are the things you care about? The second set of questions: • What are the things you care about in your professional life? • How are you devoting and spending your time to align with those things? “Physicians usually are relying on things around being a healer, teacher, making discoveries or operating a successful practice,” Dr. Shanafelt said. “The thing I can guarantee you is that your two lists are incompatible and that you cannot achieve everything on those lists.” “If I think that I’m going to be a world expert in my field,” he said, “but never miss a soccer game to be away at study section, presenting at a meeting, to be writing a grant or manuscript, that’s an unrealistic expectation. I will miss soccer games to make a difference continued on page 20
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for the patients with this disease that I care about.” “The question is,” he said, “how many soccer games is it OK to miss to still have the relationship with my kids that I want and the impact professionally that I aspire to? It’s this integration of these two spheres that’s really where the rubber meets the road.”
Addressing isolation Due to some of the changes to the medical profession over the past few decades that have resulted in busier schedules, higher productivity expectations and more time spent documenting, physicians have less time to interact with each other. “That interaction has always been part of the fabric of the profession,” Dr. Shanafelt said. “We have amazing colleagues, and getting to work with those people is what makes this profession great. But we have less of that interaction now than we did in the past.” In a study at the Mayo Clinic, Dr. Shanafelt and colleagues randomized 75 physicians and “bought” an hour of their time. One-half of them used the hour every other week however they wanted for nine months — for instance, to catch up on administrative tasks or get home early. The other one-half used it to meet with a group of colleagues to engage a curriculum largely around sharing their experience of the challenges and virtues of being a physician. “We measured a variety of personal and professional characteristics,” he said. Both groups saw a reduction in physician-reported burnout symptoms, but the group who met with their colleagues also had an improvement in meaning of work, “and we came back a year after the intervention ended.” “The group who had that hour to catch up on admin went immediately back to baseline with respect to burnout as soon as they stopped getting an hour,” he said, “but those who had met with their colleagues every other week for nine months, the burnout and meaning in work remained improved a year after the intervention ended.” As a result, Mayo conducted a second study during which physicians met for happy hour, breakfast, lunch or dinner. Mayo would buy the meal and send five questions the physicians could choose from to talk about as a group. The study saw the same outcomes as the previous study in improvement in burnout and meaning in work just from that interaction. The Mayo Clinic’s board approved the program, which they now offer to all physicians. As a standard practice, Mayo pays for groups 20 San Antonio Medicine • April 2017
of colleagues every two weeks to go out to a restaurant in town with their colleagues. Dr. Shanafelt said about 1,000 physicians have signed up. One physician in the audience who teaches in a residency program noted, “One of the questions that I got once — that I still don’t know how to answer —is: ‘Aren’t you just teaching us how to trick ourselves into being happier when we really are in this horrible situation?’” “I look at it just like clinical skills,” Dr. Shanafelt answered. “You as an individual want to do your [continuing medical education] and keep yourself current and refine your art as best you can. And the system in which you plug into is also going to make you a better or less effective physician.” “The answer is: ‘Yeah, I get it, this isn’t all yours and the organization has to do its part,’” he said. “But you want to be as good as you can at navigating the choppy water and knowing it’s going to come. And we’re trying to give you that skill set.”
More resources to help combat burnout The AMA’s STEPS Forward™ collection of practice improvement strategies helps physicians make transformative changes to their practices. It offers modules on preventing physician burnout in practice, preventing resident and fellow burnout and improving physician resiliency.
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STRESSED OUT
REPORT REVEALS SEVERITY OF BURNOUT BY SPECIALTY By Troy Parks, Staff Writer for the American Medical Association Physicians from 27 specialties graded the severity of their burnout on a scale of one to seven in a recent Medscape survey — one being that it does not interfere, and seven indicating thoughts of leaving medicine. All but one specialty selected a four or higher. The most affected specialty? Emergency medicine, with nearly 60 percent of ED physicians saying they feel burned out, up from half in 2013. How can the rising prevalence and severity of burnout be addressed? Regulatory, systemic and practice environment issues appear to be key. Too many bureaucratic tasks, spending too many hours at work, feeling like just a cog in a wheel, increased computerization of practice: In the “Medscape Lifestyle Report 2017,” more than 14,000 physicians surveyed designated these four concerns as the top causes of burnout. “Today’s medical practice environment is destroying the altruism and commitment of our physicians,” said Tait Shanafelt, MD, a hematologist and physician-burnout researcher at the Mayo Clinic, in a presentation at a NEJM Catalyst event last June. “We need to stop blaming individuals and treat physician burnout as a system issue … If it affects half our physicians, it is indirectly affecting half our patients.” Dr. Shanafelt delivered a presentation that same month at the 2016 AMA Annual Meeting in Chicago, where he examined this scenario: “If I told you we had a system issue that affected quality of care, limited access to care, and eroded patient satisfaction … you would immediately assign a team of systems engineers, physicians, administrators at your center to fix that problem rapidly.” And burnout is a system issue just like that, Dr. Shanafelt said. In order to address the issue, the focus should be on changing the practice environment and the system, but “we have not mobilized the way we would to address other factors affecting quality, access and patient satisfaction,” he said.
cent. That specialty, in 2017, is now close to 60 percent. Meanwhile, on the severity scale urology landed in the uncoveted top spot with a 4.6 rating. That compares with a 4.2 burnout severity rating for emergency medicine. Infectious disease medicine physicians rated their burnout severity lowest, at 3.9 on the seven-point scale. Yet, over the four years between reports, infectious disease medicine burnout rates rose 15 percentage points to make that specialty the fifth highest in share of physician burnout. For infectious disease medicine, it is hard to ignore the two pandemics that arose. First, Ebola entered the global sphere in 2014 and put pressure on infectious disease specialists, and it was almost immediately followed by the Zika virus. Rheumatology also saw a big jump in burnout. While about onethird of rheumatologists reported burnout in 2013, more than half scored as burned out in the 2017 edition of the Medscape report. Pediatrics, cardiology and general surgery also saw increases in burnout over the years. No specialty reported less burnout. When the types of issues identified by physicians in this report get in the way of a physician’s ability to provide care to a patient, burnout symptoms may present. “[Burnout] primarily relates to your professional spirit of life, and it primarily affects individuals whose work involves an intense interaction with people,” Dr. Shanafelt said. The question then arises whether physician burnout differs from the general working population. The AMA and the Mayo Clinic provided an answer in a recent study published in Mayo Clinic Proceedings. Compared with the general U.S. population, physicians worked a median of 10 hours more per week, displayed higher rates of emotional exhaustion and reported lower satisfaction with worklife balance, the study found. Though the general U.S. population does experience burnout, the current state of the health care system is clearly driving increases in physician burnout at a higher rate.
Related Coverage A double-edged sword: What makes doctors great also drives burnout In 2013, the first year of the “Medscape Lifestyle Report,” emergency medicine had the highest rates of burnout at just over 50 per22 San Antonio Medicine • April 2017
Organizations can make positive changes One practice in Minneapolis, not far from the Mayo Clinic, found a simple solution to provide their physicians and staff a space to “reset.” Hennepin County Medical Center, through their Office
STRESSED OUT
for Professional Worklife, gathers volunteers from each department to discuss the best ways the organization can address physician burnout. One of their ideas was to create a “reset room” where physicians and other health professionals can retreat if they need a moment to recover from a traumatic event or just to get away for a moment. And this is just one of several ways Hennepin is helping their physicians. A reset room is very much in line with Dr. Shanafelt’s recommendation that, in order to address burnout properly, the solutions have to be numerous, yet organizations and physicians alike must recognize that those fixes will not solve physician burnout overnight. They should be directed at giving physicians the skill set to “navigate the choppy water,” he said, with the understanding that the organization needs to do its part to mitigate the systemic and environmental issues that cause burnout. Electronic health record (EHR) systems are among these systemic issues. Almost one-half of the physician work day is spent on EHR data entry and other administrative desk work, according to a recent time-motion study conducted by the AMA and Dartmouth-Hitchcock Health Care System. Only 27 percent of a physician’s time is spent on direct clinical care, the study points out. Another key finding in the study is that for every hour of face-to-face time with patients, physicians spend nearly two additional hours on their EHR and clerical desk work. Physicians entered medicine to help patients. Anything that is getting in the way of patient care, whether it is systemic or environmental, should be the focus of change. If you have conducted research on physician health and wellness, the American Conference on Physician Health™, which takes place Sept. 28-29 in San Francisco, is open for presentation submissions. Review the submission guidelines and email your abstract proposal to physicianhealth@ama-assn.org. visit us at www.bcms.org
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BCMS NEWS
Mayoral candidates address health issues at forum The three primary candidates in the race for mayor of San Antonio participated in a spirited forum on March 2 at the Tobin Center downtown. The forum was sponsored by the San Antonio Hispanic Chamber of Commerce and the Bexar County Medical Society in partnership with KSAT 12. Bexar County Democratic Chairman Manuel Medina, Mayor Ivy Taylor and City Councilman Ron Nirenberg discussed a variety of topics during the 90minute debate. BCMS President Leah Jacobson, MD, asked the candidates questions about community health and wellness and funding for indigent care. Nirenberg said the next mayor should prioritize funding for agencies that tackle community health issues like diabetes and childhood obesity. Medina promised to work closely with Metro Health and enforce environmental health and air pollution rules. Taylor said health issues have always been a priority for the city and said she would like to see more funding for outdoor parks where people can go to exercise. The municipal election is May 6. Early voting is from April 24 to May 2.
Top to bottom: Chairman Manuel Medina, Mayor Ivy Taylor and Councilman Ron Nirenberg take questions from the audience. BCMS President Leah Jacobson, MD, asks the mayoral candidates about local health issues. Dr. David Cohen, a candidate for City Council District 9, with Ron Nirenberg and BCMS Executive Director Steve Fitzer.
24 San Antonio Medicine • April 2017
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FEATURE
EMR WARS Triumph of the Clones By Robert Johnson, MD
Got suspended the other day (actually a month or two ago; how time compresses under stress). It was for real, my fault, mia culpa… And the letter came from on high — this was no branch office directive — the Ivory Tower itself. “All clinical privileges are hereby suspended etc, etc.” The signature was stamped, not personalized, which I found a little disappointing. “What did Johnson do,” you ask. Surely some heinous crime to merit suspension — clinical incompetence, moral turpitude, drunken surgery? None of the above. Alas, it was far worse… unimaginable, in fact. I allowed my EMR (electronic medical records) computer password to expire. Before you throw the book (laptop?) at me, let me explain.
When NO means NO A long time ago in a galaxy far, far away. Yeah, right. It’s actually here and now in a neighborhood near you. It all began a couple weeks before. I dutifully logged onto my friendly local hospital computer to complete medical records and
26 San Antonio Medicine • April 2017
verbal orders. Entering my user ID and super-secret ……… password, I was accosted by a pop-up: Your password expires in 12 days; do you want to change it. I politely clicked NO. From that moment on, every depressed key elicited the same question: Your password expires etc… NO, NO and H#*! NO. I’ve still got 12 friggin’ days until it expires!!! I thought computers were supposed to remember things. Anyway, one thing led to another and I left town for a week. It was during my vacation that the poop hit the fan and my cyber-suspension went down. Don’t know about you, but I’m feeling like the frog in slowly heating water. The temp rises — imperceptibly — until we’re cooked. Used to be we talked to and examined patients; now we tap on keyboards. We’ve lost control of our profession. Non-doctors are herding us into neat columns. Like the perfectly squared-up clones in Revenge of the Sith.
WHERE ARE THE JEDIS? I get that we’re not going back to pencil and post-its, but here’s my beef. No. 1: Have you ever noticed that the clones in Star Wars,
FEATURE
riodic competition between the Chinese guy with his abacus versus the techie on a keyboard (the Chinese always win). When it comes to orders, Med Recs and progress notes, my cursive always beats Times New Roman. Computers are supposed to simplify our lives. Instead they’ve become like the clingy kid who wants to help straighten the garage — takes twice as long. Beef No. 3: Why can’t all hospital systems attend the same church? Don’t know much about the Catholics, but the Methodists and Baptists are racing each other into computer Purgatory (I know; I’m mixing doctrines, but explain Saint Luke’s Baptist to me). Just when I’m getting a slippery grip on Meditech at Methodist, the Baptist system outdoes them in user-unfriendliness. And they’re in your face — comply or else!! Hey, remember me? I bring you business. I’ve been forced to choose a sect and am now a monogamous Methodist by the lesser-of-two-evil’s doctrine.
despite their shiny, hi-tech exterior, can’t fight worth S#!*? The Jedis mow them down like dominos. It’s kinda like sending out Ewoks, with their spears and rocks, against the Death Star. I’m no IT nerd, but I’ve used Microsoft Word for decades. To make a change you hi-lite, delete, and change — simple. So why do our hospital computers require death by a hundred clicks to do a simple Med Rec or post-op orders? There are windows within windows with ‘accepts’, ‘over-rides’, ‘dones’ and ‘enters’ out the gazoo! I once punched ‘done’ instead of ‘enter’ (they were practically next to each other) and undid 15 minutes of work. Instead of presenting me with a dozen choices for prescribing Vancomycin, let me print my way from the get-go. I keep getting DOS (Digital Operating System) thrown at me as an excuse for why Meditech sucks (We’re a DOS based system). Ever googled DOS? You’ll be greeted with words like ‘old’, ‘vintage’ and ‘retro’; sentences like ‘MS-DOS dominated the market between 1981 and 1995.’ I was a resident in 1981 and I’m ancient. Beef No. 2: I’m busy. I have a tight schedule. I’ll finish a case at 1 p.m. with an office that started at noon. So I sit for 20 minutes typing (a skill that bypassed me in high school). Reminds me of the pe-
DEMISE OF THE FORCE Alas, the clones are winning. They’re sluggish, can’t fight worth #*!, and every satellite has its separate unintelligible language. Unlike C-3P0, I can’t master two forms of communication let along six million. Seems to me that A New Hope has become The Phantom Menace. Robert G. Johnson, MD, is an orthopaedic surgeon, a BCMS member and a frequent contributor to San Antonio Medicine.
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FEATURE Ranakpur Temple
Incredible India! By Roberta Lynn Krueger, MD Incredible India, as advertised, is that, but so much more. For me, India was an educational immersion into a culture filled with religions, colors, sounds, smells, and tastes new to me, with some of the world’s friendliest people. Upon landing in Delhi, the smell of smoke, the visual of fog at 3 a.m., the traffic was busy by San Antonio standards. On our trip to Apollo Hospital the next morning the traffic was intense. We saw a family of four on a motorcycle, autorickshaws zipping in and out with no apparent lanes, trucks blowing horns and bikes with large platforms on the back all sharing the highway. A trip to a large Hindu temple began our teaching in Hindu religion with a colorful water laser show. On Christmas day, as we saw Gandhi’s 28 San Antonio Medicine • April 2017
cremation site, the Jama Masjid, and Humayans Tomb, we were surrounded by young eighth grade girls wishing us Merry Christmas as they took pictures with us. As an obstetrician, I imagine Shah Jahan’s wife died from hemorrhage after having his 14th child. She was deserving of the legendary white marble Taj Mahal built as her mausoleum. An imposing structure, even now one is struck by the juxtaposition of the haves and have nots that exist in Agra today. Our guide told us in Shah Jahan’s time his third son, tired of his father’s lavish spending (58 million for the Taj in today’s money), killed his two older siblings and put his father in house arrest, taking over the kingdom. Visiting the garden area across the river from the Taj as the afternoon came to a close
gave some peace to this beautiful monument. A change in our flight made us leave Delhi later than planned, which allowed us to see the distinctive Lotus Temple, a Baha'i house of worship. Quiet time in this architectural and structural wonder of white marble was an interesting contrast to the busy Taj. Arriving late in Udaipur at our lovely hotel, we joined the AAPI delegation. At breakfast the next morning I discovered delicious dosa, a crepe-like food filled with potatoes and lentils. As we ventured into the countryside, I was struck by the ancient history this land holds. The Pratap museum told of Pratap and his horse who helped save the day, all narrated in Hindi. Dr. Shah helped me understand this dramatic story. Our next stop was Nathdwara, meaning
FEATURE New Year Celebration Udaipur
Gateway of the Lord Krishna. Hinduism, the world’s oldest religion, has many stories all with valuable lessons for the followers. There were beautiful hand paintings in the shrine. I have no pictures because as with many places there were no cell phones or purses allowed. Afterwards, we went to a busy bazaar where you bargain for jewelry and there are cows wandering about. The bumpy ride home gave us all some extra steps on our fitbits. The AAPI (American Association of Physicians of Indian Origin) program that evening featured the Central Health Minister of India and the President of AAPI. The hall was decorated with flowers and flower petals arranged in designs. A lighting of the flame to Parvati, the colorful sarees and men dressed in silk jackets, I knew I was in India. The Central Minister’s comments concentrated on the decline of infection, specifically yaws, whereas preventable diseases (diabetes, heart disease, etc.) were not discussed. The highlight of the evening were Rajasthan dancing groups in ethnic costumes with music, followed by dinner that was new and delicious. The trip to Mount Abu was a journey back in time. Bumping along we saw primitive farming, oxen used to bring water up from a well, planting by hand, women working construction wearing sarees, little villages with rubble in the streets and country hay stacks out of a Monet painting. We stopped for tea on the way and only had non-Western toilets, a hardship for many of the women. Up on the mountain monkeys dot the stops wanting a handout. The Jain temples built in the 11th Century are like no Western art. They are intricately carved white marble pillars and ceilings that defy description. Jains believe all living things have value. They have Buddha like Gods but their eyes are always open. Our best lunch was an outdoor restaurant called Chacha Restaurant, vegetarian, with great service. Dr. Shah had us all share a special gift we have other than medicine. Later on our way to town and Nakki Lake, the Harpers went in a person drawn cart as we passed a colorful Tibetan market. A trip to Kumbhalgarh Fort, again on a bumpy narrow road, allowed us to talk with
one another getting to know our traveling companions. This fort has a wall second in length to the Great Wall of China. The wall is very steep and the area inside has a great number of temples. We left our bus and took a jeep to one of seven great gates. After hiking the fort and lunch we barely made it to the Temple of Ranakpur. It is the most lovely of the Jain Temples, with the most detailed marble carving of the ones we have seen. Foreign people, all of us really, but myself most notably, had to leave by 5 p.m. Locals could stay until 8 p.m. New Year’s Eve Day showed gorgeous weather for the city called the Venice of the East, Udaipur. The city palace on Lake Pichola is from a fairy tale — a ladies court, carrier pigeons, an elephant fighting area, enameled tiles, and a crystal collection. The scenery on the boat ride was my favorite part of the trip. A stroll around the garden of the maids reminded me of the Alhambra in the era of long ago. It is an experience to celebrate New Year’s in a country other than your own. I decided to dress the part in a sari and bangles. Anupama and her mother helped me get it all straight. The resort had food stations and music. It was a festive night. An early flight to Chennai was delayed in Mumbai, but it was no problem as Viet Do and I did a little shopping. Our hotel in Chennai was serene despite being close to the airport. The silk sarees, flowers, chalk paintings, fruit stands, and Hindu temples are full of color in southern India. Our guide here
was full of rich stories as he drew out explanations of Hindu religion for us. The trip to Mahabalipuram, included the shore temple, from the 8th Century, a UNESCO site. There were also stone rathas carved in 600 A.D. The friendly people of Southern India continued taking pictures with us, being curious about myself and Dr. Do, our Buddhist monk. Despite a cyclone two months ago, Chennai is a busy and thriving city, is also a sister city to San Antonio. That evening we had a joint meeting with their medical society and Dr. Shah conveyed Mayor Ivy Taylor’s kind words. He gave a check on behalf of AAPI to help build a school. On our last day we were able to see the M.V. Diabetic Hospital and finished with site seeing. St. Thomas Cathedral, one of only three cathedrals built over the remains of apostles, is located in Chennai. The government museum has bronze casting of 9th and 12th Century Nataraja and other Gods. A trip to the Murugan Idli shop for a taste of local flavor was Dr. Shahs treat to us. Eating off banana leaves with Prachi and our group was a special memory. The fabric store of my dreams was the Nalli Chinnasamichetta with room after room of colorful silk. Our trip came to a close with a 3 a.m. flight home. We left with new friends, new understandings, time for reflection and peace. I was able to learn more about the culture, country, and religions of the place some of my patients call home. visit us at www.bcms.org
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BUSINESS
Disruptive Innovation
and the Future of Health Care By Edward Schumacher The Term Disruptive Innovation has been a hot topic for many years in the US economy (1). The U.S. health care industry has struggled for decades with the issue of high and rising costs, lack of access, and less than optimal quality (2). As a result, there are many who think that disruption is just what the health care industry needs (3). However, this has been very difficult to achieve. As a new administration comes into office promising huge change in health care, is 30 San Antonio Medicine • April 2017
now the time that we will finally see true disruption? Clayton Christensen describes three types of innovation (1). Sustaining innovation occurs by making good products better. These are products or service of the highest quality sold to the most sophisticated customers for higher profits and continually updated with enhanced features. An example is the iPhone 4, 4s, 5, 5s, 6, 7, etc. Each new version replaced the previous and the size of the market stays
BUSINESS
relatively constant. Efficiency innovation occurs when the same product is produced more cheaply. The consumer may not notice any change in the product other than the price being lower. Efficiency innovation tends to free up resources for future investment. Disruptive Innovation, on the other hand, occurs when a product appears that initially is perceived as inferior and does not appeal to high-end customers, but attracts low-end customers or new “noncustomers.” The product is typically cheaper, simpler, and more convenient. Over time, performance improves and meets the needs of more customers, eventually replacing the existing product. Examples would be how the mini mills disrupted the integrated steel mills in the steel industry, how the cellular telephone disrupted the fixed-line telephone industry, or how the personal computer disrupted the mainframe in the computer industry. Note in all of these cases the end result was that more consumers had access to the product at a cost that was lower than previously available, jobs were created, and living standards arguable improved. Disruptive innovation rarely occurs within the incumbent firms in the industry, rather new entrants from outside the industry tend to be much more open to this type of innovation. Christensen describes this as the innovator’s dilemma (1). Once the business model for the incumbent is established to provide the existing product, the change in the culture required to create a new business model that produces a (initially) lower quality product at a lower margin is very difficult. More often than not, when disruptive innovation occurs, the incumbent firms are either driven to extinction or severely marginalized. A classic example of this is that Kodak was driven to bankruptcy by the digital camera, despite the fact that the technology was invented within Kodak (4). They recognized the value of the new technology, but since the profit margins on digital cameras were very thin while the margins Kodak enjoyed on traditional film were so large, they were unable to change their culture to support this new business model. How does all this apply to health care? I would argue that most innovation in health care has been sustaining — making existing products or services better — and there has been very little true disruptive innovation. An exception to this has been the rise of retail clinics in Walmart, CVS and other convenient locations. Initially these clinics focused on very minor conditions such as strep throat, sinus infections, sports physicals, etc., that tended to be low cost to treat and had relatively thin profit margins. The companies entering this market were largely outsiders to heath care. As my colleague Amer Kaissi discussed in a previous issue of this publication: “When retail clinics first appeared in 2000, primary care physicians (PCPs)
were quick to dismiss them as a low-quality alternative to rigorous physician care” (5). Physician groups and professional associations expressed their strong opposition to them. Today these clinics are an established part of the health care system and are a very common treatment option for today’s busy consumer. Moving forward, these companies are now looking to move up from very simple low cost/low margin business into more complex higher margin business such as imaging and chronic disease management (6). The large majority of innovations in health care, however, have been those that improved existing products and did not result in lower costs or increased accessed to care — rather technological improvement is often cited as one of the main drivers for increased costs in health care (7). Why has disruptive innovation been so difficult in healthcare? One big reason has been the power of the incumbents — what in economics are call barriers to entry. Health care is a difficult industry for an outsider to enter. In part this is due to the scale and scope required in order to be successful. In today’s health care market with the heavy reliance on traditional payer contracts, it is very difficult if not impossible to enter a market as a small player. Another reason is the large regulatory barriers that exist in health care. Regulations exist to protect the best interests of the consumer, but they also have a tendency to favor incumbents and keep new and innovative entrants from the market. Health care is one of the most highly regulated industries at both the federal and state levels. Finally, the patient has largely been a passive player in the health care market. Due to the wedge between the delivery of health care and the payment for health care cause by insurance coverage and the role of the employer, the typical consumer has been largely unresponsive to traditional market forces in healthcare. As a result, true disruptive innovation has been very difficult to achieve in health care, and while there has been lots of innovation, most of it has been sustaining — replacing old technology or services with newer technology or services catering largely to high profit (insured) customers. Much of this innovation has been very positive and has improved the lives of many, however, it has not lead to the increased access and lower costs that disruptive innovation promises. Moving forward, is disruptive innovation more or less likely to occur? There are two competing forces acting on the health care landscape, and the answer depends on which of these dominates. On the one hand there is a push from CMS and from within the industry to incentivize the supply-side of the market to produce higher quality care at lower costs. These include pay-for-performance, bundled payments, ACOs, and other mechanisms that reward providers for producing good health outcomes. This movement towards “population continued on page 32
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BUSINESS continued from page 31
health” produces a strong incentive for mergers, consolidations and other affiliation agreements that will tend to empower the incumbent and make entry more difficult for outsiders. As this consolidation continues, we may also see increased government regulation around pricing and other factors (8). As a result, we would expect this movement to discourage any disruptive innovation, and instead will at best lead to efficiency or sustaining innovation. On the other hand, there is also an increasing move towards consumerism. In 2015, just over 50 percent of those with employer provided insurance had a deductible greater than $1,000 and many of these plans also include a health savings account (9). These and other trends such as narrow networks and private exchanges are shifting the risk to the consumer in an attempt to give he or she the power and incentive to stay healthy and “shop” for health care services. This movement is likely to be much more open to disruptive innovation. The consumer (or employer on behalf of the employees) will be looking for help to overcome the huge information problem he or she is faced with in navigating the health care sector and understanding their own health. If the consumer has the ability to choose how to allocate his or her health care dollars, new entrants will be looked upon more favorably and it will be much more difficult for the incumbent to hold on to their territory. Which of these two movements will dominate is yet to be seen, and it is also unclear which, if either, will be the solution to our health care woes. The past 8 years have pushed the industry very heavily into the supply-side incentives with the Affordable Care Act and other movements attempting to give hospitals and physicians incentives to manage their patients more efficiently. The new administra-
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tion, however, has promised to take a very different approach. As of this writing, their plans are unclear, but signs indicate a heavy emphasis on a market-driven approach, through health savings accounts and other mechanisms that put the power into the hands of the consumer to navigate the health care system. Thus, in this world, we are likely to see much more disruption in the industry. New entrants and new types of delivery models are likely to appear on the scene.
Given these trends, how should proactive physicians respond? Here are a few suggestions: • Expand your competencies. Physician training has historically focused on the clinical side of health care. While this is obviously still very important, it may not be enough to simply focus on clinical care. There is a growing need for physicians to develop business skills and knowledge, as well as a
BUSINESS
broader understanding of the health care system. In addition, leadership and communication skills are vital for future success. If there was ever a right time to obtain additional certification and training around the business of health care, it is now. • Focus on culture As mentioned above, one of the largest challenges for an incumbent is to handle the cultural change required to respond to disruption. The leadership and communication skills mentioned above will be crucial for physicians to help their organizations manage what lies ahead, so that if and when the disruptor arrives on the scene, they are able to respond appropriately and do not become the Kodak of health care. • The patient as customer An example of the culture change the adjustment to treating the patient as a customer. This is not to say that “the customer is always right” but rather to view your practice and its processes from the perspective of the patient. As individuals are pushed to shoulder higher and higher out of pocket costs they are demanding more choice and a more patient-centered focus. The successful practice will be required to redesign its processes to meet this growing demand for convenience, simplicity, and alternative ways of delivering care. What the health care industry will ultimately look like is hard to say. To quote Niels Bohr: “Prediction is difficult, especially about the future.” What is clear, however, is that the status quo is not acceptable and we need to make big changes so that we can improve access, reduce costs, improve quality, and improve the work life of health care providers. As a result, the challenges ahead will require health systems, physician groups, and other incumbents to not only have their ear to the ground to follow all of the latest regulatory and other industry trends, but to be open minded to new ways of delivering care and to have a nimble culture that will allow them to adapt to the changes ahead. Edward Schumacher is Professor of economics and Chair of the Health Care Administration at Trinity University. He has been studying and writing on the health care industry for over 20 years. The Executive Master’s Program at Trinity is ranked in the Top 10 programs nationally. The part-time, hybrid-learning format is designed for physicians and managers currently working in a healthcare setting who have decided to pursue a graduate degree while continuing to work full-time.
References 1. Christensen, Clayton M. (1997), The Innovator's Dilemma: when new technologies cause great firms to fail, Boston, Massachusetts, USA: Harvard Business School Press 2. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs. 2008 May/June;27(3):759-769. 3. Christensen, Clayton M.; Grossman, Jerome H.; Hwang, Jason (2008), The Innovator's Prescription: a disruptive solution for health care, New York, New York, USA: McGraw-Hill 4. Dan, Avi. “Kodak Failed by Asking the Wrong Marketing Question,” Forbes, January 23, 2012, http://www.forbes.com/sites/avidan/2012/01/23/kodak-failed-by-asking-the-wrong-marketing-qu estion/#543eb1d37dd7 5. Kaissi, Amer. “If you Can’t Beat Them Join Them: What can Primary Care Physicians Learn from Retail Clinics?” San Antonio Medicine, December 2016, 69(12):14-17. 6. Copeland, Bill, Michael E. Raynor, Natasha Elsner, and Ryan Carter, “Beyond the Acute Care Episode: Can Retail Clinics Create Value in Chronic Care?” Deloitte University Press, October 14, 2016. https://dupress.deloitte.com/dup-us-en/industry/health-care/retail-clinics-chronic-care-management.html 7. “Growth in Health Care Costs, CBO Testimony, Statement of Peter Orszag, Director, before the Committee on the Budget, United States Senate, January 31, 2008. https://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/89xx/doc 8948/01-31-healthtestimony.pdf 8. “DOJ, FTC Focus on Busy Healthcare Deals Landscape,” PwC Health Research Institute, Regulatory Spotlight, September 2016. 9. “Average Annual Workplace Family Health Premiums Rise Modest 3% to $18,142 in 2016”, The Henry J. Kaiser Family Foundation, September 16, 2016. http://kff.org/health-costs/press-release/average-annual-workplace-family-health-premiums-rise-modest-3-to-18142-in-2016more-workers-enroll-in-high-deductible-plans-with-savings-optio n-over-past-two-years/
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BCMS ALLIANCE
The Alliance Helps Combat Addiction and the Unfolding Opioid Epidemic By Lori Boies, 2017 BCMS Alliance President
In June 2016, Jennifer Lewis (2016 BCMSA President) and I attended the AMA Alliance Annual meeting in Chicago. That meeting was one of the most impactful Alliance meetings I had ever attended. The AMA Alliance has a goal to increase awareness of opioid addiction and, in turn, combat this growing problem in our society. Jennifer and I sat in on informative panels of healthcare professionals, members of law enforcement, and other pertinent individuals in the field. We were enthralled by the riveting talk of Sam Quinones who authored, “Dreamland: The True Tale of America's Opiate Epidemic.” (I found this book to be incredibly amazing, and it will be the Alliance’s book for May book club). We sat in shock and sadness as a fellow AMA Alliance member stood up and told the story of how she lost her beloved son to opioid addiction. The entire experience was eye-opening, educational, and heart-breaking. As the wife to an anesthesiologist and pain management physician, the issues I was aware of in the periphery finally sunk in. My husband, Brian, was a pain medicine fellow when hydrocodone, one of the most commonly prescribed opioid pain medications in the U.S., was changed from schedule III to II, meaning it had to be written on a special prescription pad and could no longer be called into a pharmacy, effectively making it more difficult to prescribe. Many patients were referred to his clinic specifically for hydrocodone continuation, even when not indicated. I heard him complain about the opioid epidemic and how it was a problem, but I was naïve to the fact of how widespread it truly was — how it could so innocently start and take anyone, even those in the medical family. *Our Centennial Year*
34 San Antonio Medicine • April 2017
I came back from Chicago resolved to make a difference in our San Antonio community, but I was baffled about where to start. How could we make an impact on such a large problem? When the opportunity to partner with Sisters in Sobriety to provide Alcoholics Anonymous literature, free of charge, to doctors’ offices surfaced, Chairperson Kelly King and I ran with it. While it is not opioid addiction literature, it gives us an opportunity to combat a similar, and also very prevalent, issue in our community. I highly encourage you to contact Kelly King (KellyMKing@gmail.com) to receive information on how to get FREE Alcoholics Anonymous literature racks for your clinic’s waiting room. This free information will help save lives. Additionally, if you have ideas on how the Alliance can partner with our community to make an impact in opioid addiction, please do not hesitate to contact me (BCMSAlliance@BCMS-Alliance.org). The Alliance looks forward to providing this free resource to our BCMS Physicians!
www.bcmsalliance.org
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LEGAL EASE
Your Flight Was Just Cancelled
Now what? By George F. “Rick” Evans, Jr. General Counsel BCMS
Most of the articles I’ve written for San Antonio Medicine relate to medicolegal issues of particular interest to physicians. I’m deviating from that for the next few articles to talk about something that affects everybody. I’m referring to the hassles of flying in today’s world. Lost baggage, missed connections, overbookings, cancelled flights, and prolonged delays are issues I’ll discuss in upcoming editions of SA Medicine. Statistics from the U.S. Department of Transportation show that last year 14 percent of the flights were cancelled or delayed so the odds are high, sooner or later, this is something you or your family will experience. So let’s begin the discussion with what happens when you hear the gate agent announce your flight has been cancelled. Now what? Maybe you’re stuck in Orlando trying to get back to San Antonio. Maybe you’re trying to make it to a wedding, funeral, or a departing cruise ship. Or you’re waiting for your kid to fly home from college for a holiday when you hear she’s stuck in Denver. Your plans have just been turned upside down. What can you legally demand? Spoiler alert: this is one area in aviation law in which your rights are almost worthless so you’re better off taking steps to avoid cancellation than expect much if it happens. A fundamental principle here is that airlines do NOT guarantee their schedules. That means your rights are pretty darn limited. There are no universal laws in the U.S. that cover this situation. There are federal laws that control other aspects of airline travel, including tarmac delays, but not cancellations. Instead, your rights are typically controlled by general contract principles which, most importantly, include a very specific document called the “Contract of Carriage.” Each airline has one. This document addresses everything from carry-on baggage restrictions to travel by minors. It’s very lengthy and may be 40 or more pages. Importantly, there’s no uniform contract of carriage that all airlines use. Each airline has their 36 San Antonio Medicine • April 2017
own, so your rights will vary from airline to airline. Every contract of carriage has a section dealing with cancellations. That said, at the risk of generalization, most airlines provide you with two rights, neither of which may be of much consolation. First, you usually will have the right to demand a seat on the next flight IF there’s an open seat available. Unfortunately, with planes packed to the gills today, it may not be easy to get on that next flight out. Second, you have the right to a refund of the unused portion of your ticket. If you paid full fare, then buying a ticket on another airline may be an option, but if you bought an advance fare discount ticket, the refund won’t be enough to cover a new ticket bought at the last minute. Some airlines, in their discretion, may offer meal and hotel vouchers, particularly if the cancellation was their fault rather than due to weather or events beyond their control. Some may book you on another airline. But, the operative word here is “discretion.” Unless the contract of carriage provides for it (and few do), you have no right to demand these things. Note: your rights will be different on international flights and are much more robust. This article only addresses domestic flights. Your rights may be expanded if the airline has engaged in some wrongful conduct other than the mere cancellation of the flight. They are still subject to general contract and tort laws which could give you a claim beyond a ticket refund or a seat on the next flight. If an agent makes promises or representations that were broken, false or misleading, you may have a legal claim you can later pursue. For example, if you’re told “for sure we’ll get you on this flight leaving in two hours” and they don’t, you may have a breach of contract claim. But, the sad truth is that you have very limited rights in the event your flight is cancelled so your best strategy is avoiding it in the first place. Here’s how.
LEGAL EASE
PRACTICAL TIPS This is a case where a stitch in time saves nine. Here’s what experienced travel agents and/or the Department of Transportation recommend. 1. If you have a choice, fly as early as you can so there’s still time to find other flights if yours is cancelled. If your 9 p.m. flight from Dallas cancels, odds are slim there will be other flights at that time of night. 2. Select airlines which have lots of flights at the airports you’ll be using. An airline that only has one or two flights a day from Airport X could leave you with limited options if your flight is cancelled. 3. If you have a connection, try to avoid airports known to have delays or those located where the weather may be bad at that time of year (i.e. In January, connect through Phoenix instead of Chicago). 4. When booking, allow yourself some extra time so if there’s a delay, it won’t be the end of the world. This is particularly true when flying during holidays or when weather is typically bad. 5. Unless you must use a particular airline, take the time to look at the contract of carriage for the different airlines you have the option to use. Each airline has them on line so it’s easy to get one. Or, you have the right to ask the gate agent give you a copy. You may still decide to book a seat based on convenience or price, but at least you’ll know what your rights are if there’s a cancellation on the airline you select. 6. If you’re cancelled, get on the internet and see what other flights are going to your destination even if it’s on a different airline. Check to see if there are flights which, although not going to your specific destination, are arriving close to it (i.e. flying to Oakland’s airport instead of across the bay to San Francisco’s airport). Gate agents are more likely to help you if you’ve already done the research and talk to them about concrete, specific options rather than expecting them to do the homework for you. 7. The minute you know you’ve been cancelled, be immediately proactive rather than passive. Specifically, don’t wait in line with 100 of your fellow passengers waiting to talk to a frazzled gate agent. Consider getting on the internet and booking yourself on the airline’s next flight if there’s a seat and worry about getting a
refund later. Or find a Customer Service Agent not at your gate so he/she has the time to give you personal attention rather than the gate agent who’s dealing with a mob of 100 angry passengers. 8. Remember that going backwards may be your best option. If you’re enroute to L.A. and get stuck in El Paso, your fellow passengers are all trying to continue westward. There may be more seats available if you went backwards to Dallas and then to L.A. Or if you never got off the ground and are still in San Antonio, it might be faster to have the agent book you to Houston and then L.A. if there aren’t many seats available on the next few flights from here to L. A. 9. Be nice and politely beg for help from the gate agent. A threatening, belligerent approach isn’t likely to get you a discretionary perc like a free hotel or meal. Plead your case if you’ve got small children, an elderly or disabled companion, etc. 10.Filing a formal complaint with the airline and/or Federal Department of Transportation may get you some relief even though it will be after the fact. Perhaps a travel voucher. Or at least the satisfaction that the airline has to respond to the DOT. You can contact the Aviation Consumer Protection Division (ACPD). You can call, write or use a web-based complaint form 24-hours-a-day at 202-366-2220 to record your complaint or send them a letter at Aviation Consumer Protection Division,C-75, U.S. Department of Transportation, 1200 New Jersey Ave, S.E., Washington, D.C. 20590. Or you can do it electronically at www.airconsumer.dot.gov. So, that’s the bad news. The bottom line is that passengers have very little recourse when a flight is cancelled. The good news is that in next month’s article, you’ll see that you do have a lot of rights when it comes to other aviation maladies. George F. “Rick” Evans Jr. is the founding partner of Evans, Rowe & Holbrook. A graduate of Marshall College of Law, his practice for 36 years has been exclusively dedicated to representation of physicians and other healthcare providers. Mr. Evans is the BCMS general counsel.
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.
ACCOUNTING FIRMS RSM US LLP (HH Silver Sponsor) RSM US is one of Texas’ largest, locally owned CPA firms, providing sophisticated accounting, audit, tax and business consulting services. Vicky Martin, CPA 210-828-6281 Vicky.Martin@rsmus.com www.rsmus.com “Offering service more than expected — on every engagement.” Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”
ACO/IPA
ASSET MANAGEMENT
Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives. Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management”
ATTORNEYS IntegraNet Health (HHHH 10K Platinum Sponsor) IntegraNet Health is an Independent Physician Association that helps physicians achieve higher reimbursements from insurance companies whereby some of our higher performing physicians are able to achieve up to 200% of Medicare FFS. Executive Director Alan Preston, MHA, Sc.D. 1-832-705-5674 Apreston@IntegrNetHealth.com www.integraNetHealth.com
ARMY HEALTHCARE 5th Medical Recruiting BN (HH Silver Sponsor) We recruit quality men and women who would like to be a part of our team. SFC Cherie Kirk 210-692-7376 Cherie.k.kirk.mil@mail.mil www.youtube.com/watch?v=kweqi 3TelO8 "Serving to heal, Honored to serve"
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Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”
Strasburger & Price, LLP (HHH Gold Sponsor) Strasburger counsels physician groups, individual doctors, hospitals, and other healthcare
providers on a variety of concerns, including business transactions, regulatory compliance, entity formation, reimbursement, employment, estate planning, tax, and litigation. Carrie Douglas 210.250.6017 carrie.douglas@strasburger.com Cynthia Grimes 210.250.6003 cynthia.grimes@strasburger.com Marty Roos 210.250.6161 marty.roos@strasburger.com www.strasburger.com “Your Prescription for the Common & Not-So Common Legal Ailment”
BANKING
Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Stephanie Dick Vice President- Commercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com
BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Commercial Relationship Manager — Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future”
Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”
IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC BankSan Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area. Markham Benn 210-518-2500, ext. 26921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY www.firstmarkcu.org Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans. Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com
The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com
SSFCU (HHH Gold Sponsor) Founded in 1956, Security Service provides medical professionals with exceptional service and competitive rates on a line of mortgage products including one-time close construction, unimproved lot/land, jumbo, and specialized adjustable-rate mortgage loans. Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology? Expanding your office space? We offer loans to meet your business or personal needs. Competitive rates, favorable terms and local decisions. Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org
Frost (HH Silver Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses. Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.” RBFCU (HH Silver Sponsor) 210-945-3800 nallen@rbfcu.org www.rbfcu.org
CONTRACTORS/BUILDERS /COMMERCIAL
Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer. Our model allows you to own your own office space as opposed to leasing. Steve Huffman shuffman@huffmandev.com 210-979-2500 Shawn Huffman shhuffman@huffmandev.com 210-979-2500 www.huffmandev.com
RC Page Construction, LLC (HHH Gold Sponsor) Commercial general contractor specializing in ground-up & interior finish out projects. Services include conceptual & final pricing, design-build & construction management. Single-source management from concept to completion ensures continuity through all phases of the project. Clay Page 210-375-9150 clay@rcpageconstruction.com www.rcpageconstruction.com
FINANCIAL SERVICES
Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor)
Our mission is to help you enjoy a lifetime of financial security with greater certainty and clarity. Our outcomebased planning approach involves defining your objectives, creating a plan to maximize potential and inspiring action towards your goals. Fee-based financial plans offered at discount for BCMS members. Eric Kala CFP®, AEP®, CLU®, ChFC® Wealth Management Advisor | Estate & Business Planning Advisor 210.446.5755 eric.kala@nm.com www.erickala.com “Inspiring Action, Maximizing Potential”
Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@ aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”
e3 Wealth, LLC (HHH Gold Sponsor) Over $550 million in assets under management, e3 Wealth delivers truly customized solutions to individuals and businesses while placing heavy emphasis on risk minimization, tax diversification, proper utilization and protection for each client's unique financial purpose. Managing Partner Joseph Quartucci, ChFC® 512-268-9220 jquartucci@e3wealth.com Senior Partner Terry Taylor 512-268-9220 ttaylor@e3wealth.com Senior Partner Jennifer Taylor 512-268-9220 jtaylor@e3wealth.com www.e3wealth.com
Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor)
Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives. Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management” First Command Financial Services (HH Silver Sponsor) Nigel Davies 210-824-9894 njdavies@firstcommand.com www.firstcommand.com
GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time. Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration
HEALTHCARE REAL ESTATE SAN ANTONIO COMMERCIAL ADVISORS (HH Silver Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39
HOME HEALTH SERVICES Abbie Health Care Inc. (HH Silver Sponsor) Our goal at Abbie health care inc. is to promote independence, healing and comfort through quality, competent and compassionate care provided by skilled nurses, therapists, medical social worker and home health aides at home. Sr. Clinical Account Executive Gloria Duke, RN 210-273-7482 Gloria@abbiehealthcare.com "New Way of Thinking, Caring & Living"
Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”
INFORMATION AND TECHNOLOGIES HOSPITALS/ HEALTHCARE SERVICES
Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years. Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery. Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 www.swgeneralhospital.com “Quality healthcare with you in mind.”
Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com
Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system. Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.
INSURANCE
SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships. VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com SWBC Mortgage www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services
TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the
40 San Antonio Medicine • April 2017
Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”
Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com
INSURANCE/MEDICAL MALPRACTICE
Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.
Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” The Doctors Company (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com. Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best. Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair. Keith Askew Market Manager kaskew@proassurance.com Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY INTERNET/ TELECOMMUNICATIONS
Spectrum Business Class (HHH Gold Sponsor) When you partner with Spectrum Business Class, you get the advantage of enterprise-class technology and communications that are highly reliable, flexible and priced specifically for the medical community. Sales Leader Medical Market Rick Garza 210-582-9597 rick.garza@charter.com “Spectrum Cable Business Class offers custom pricing for BCMS Members.”
MERCHANT CARD/CHECK PROCESSING
PROFESSIONAL ORGANIZATIONS
Firstdata/Telecheck (HH Silver Sponsor) We stand at the center of the fastpaced payments ecosystem, collaborating to deliver nextgeneration technology and help our clients grow their businesses. Sandra Torres-Lynum SR. Business Consultant 25 years of dedicated service 210-387-8505 Sandra.TorresLynum@FirstData.com ‘The true leader in the payments processing industry’
The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, non-profit, R&D, healthcare delivery, professional services and more! President Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Program Coordinator Valerie Rogler 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”
OFFICE EQUIPMENT/ TECHNOLOGIES
MARKETING ADVERTISING SEO
Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system. Rainey Threadgill 210-647-6350 Rainey.Threadgill@rainman.com www.henced.com Henced offers BCMS members custom pricing.
MEDICAL SUPPLIES AND EQUIPMENT
Henry Schein Medical (HHHH 10K Platinum Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”
Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes. Major Account Executive Wayne Parker 210-326-8054 WParker@dahill.com Major Account Executive Bradley Shill 210-332-4911 BShill@dahill.com Add footer: www.dahill.com “Work Smarter”
PAYROLL SERVICES
SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits. Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.
To join the Circle of Friends program or for more information,
call 210-301-4366 or email August.Trevino@ bcms.org
VISIT www.bcms.org
SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment. Shane Brown Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”
STAFFING SERVICES
Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”
visit us at www.bcms.org
41
42 San Antonio Medicine • April 2017
RECOMMENDED AUTO DEALERS AUTO PROGRAM
• • • •
We will locate the vehicle at the best price, right down to the color and equipment. We will put you in touch with exactly the right person at the dealership to handle your transaction. We will arrange for a test drive at your home or office. We make the buying process easy! When you go to the dealership, speak only with the representative indicated by BCMS.
Ancira Chevrolet 6111 Bandera Road San Antonio, TX
Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX
Jude Fowler 210-681-4900
Esther Luna 210-690-0700
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Honda 14610 IH 10 W San Antonio, TX
GUNN Infiniti 12150 IH 10 W San Antonio, TX
GUNN Acura 11911 IH 10 W San Antonio, TX
GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209
Bill Boyd 210-859-2719
Pete DeNeergard 210-680-3371
Hugo Rodriguez and Rick Tejada 210-824-1272
Coby Allen 210-625-4988
Abe Novy 210-496-0806
Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216
Cavender Audi 15447 IH 10 W San Antonio, TX 78249
Cavender Toyota 5730 NW Loop 410 San Antonio, TX
Northside Ford 12300 San Pedro San Antonio, TX
David Espinoza 210-912-5087
Sean Fortier 210-681-3399
Gary Holdgraf 210-862-9769
Wayne Alderman 210-525-9800
Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230
Ancira Nissan 10835 IH 10 West San Antonio, TX 78230
Jarrod Ashley 210-558-1500
Jason Thompson 210-558-5000
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154
Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900
Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX Alan Henderson 210-681-6300 KAHLIG AUTO GROUP
Ingram Park Auto Center Dodge 7000 NW Loop 410 San Antonio, TX
Ingram Park Auto Center Mazda 7000 NW Loop 410 San Antonio, TX
Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX
Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX
North Park Subaru 9807 San Pedro San Antonio, TX 78216
Daniel Jex 210-684-6610
Frank Lira 210-381-7532
Richard Wood 210-366-9600
John Wang 830-981-6000
Mark Castello 210-308-0200
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257
North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211
North Park Mazda 9333 San Pedro San Antonio, TX 78216
North Park Lexus 611 Lockhill Selma San Antonio, TX
North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX
Stephen Markham 877-356-0476
Justin Boone 210-635-5000
Scott Brothers 210-253-3300
Jose Contreras 210-308-8900
Justin Blake 888-341-2182
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Lincoln 9207 San Pedro San Antonio, TX
North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257
Sandy Small 210-341-8841
James Cole 800-611-0176
Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.) San Antonio, TX
Porsche Center 9455 IH-10 West San Antonio, TX
AUTO PROGRAM
Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org
AUTO REVIEW
2017 Audi A4 By Steve Schutz, MD
The new Audi A4 has been completely re-
ness, maybe Audi's consistent and quiet ex-
Audi continues to lead in interiors, and
done, which used to be a really big deal back
terior elegance is the way to go. Who knows,
the A4’s is especially nice. Most of your at-
when cars mattered and SUVs and
but growing A4 sales argue convincingly that
tention will be drawn to the “virtual cock-
crossovers didn't wag the proverbial automo-
staying the course is probably smart. That
pit,” the big screen behind the steering wheel
tive dog. Still, as a lifelong car enthusiast, the
and the fact that five-year-old A4s still look
which can display general vehicle informa-
dawn of a new A4 matters to me, and I was
good to me while new Lexus RX 350s make
tion, electronic facsimiles of a standard
pleased to note that it now has completely
me squirm, and not in a good way. (Having
tachometer/speedometer — with a black
new bodywork, an interior that's both techy
said all that, I doubt I’m the only one who
background, white numbers, and red nee-
and warm — why can only Audi do this? —
thinks that the new A4 looks too much like
dles, as always — or a huge map view. But,
and presence.
the smaller/cheaper A3.)
while that (optional) feature is undoubtedly
It must be said though, that the new A4
For the record, the 2017 A4 sedan has
cool, and certainly a must-order, don't let it
looks so much like the old one that even a
grown by 0.5 inch in wheelbase, 1.0 inch in
blind you to the other pluses of this Audi's
gearhead like me has to look twice to be sure
length, and 0.6 inch in width, all despite
cabin such as high grade plastics, plush soft
it’s not the previous version. Is that bad?
dropping some 70 to 100 pounds. Exactly
surfaces, and wonderful ergonomics.
Probably not. In a world where BMW de-
how much weight has been dropped de-
The multi-media Interface (MMI) user
sign is fading into the realm of, oh-I'm-
pends on options and trim levels, but we can
interface is worth a word. Using a rotary
sorry-were-you-saying-something?,
and
thank Audi engineers for the use of light-
controller knob surrounded by a few but-
Mercedes and Lexus styling departments act
weight materials such as aluminum all over
tons, the MMI gets you to the climate con-
as though using subtlety is a sign of weak-
and through the A4.
trol, audio, and navigation systems as well as
44 San Antonio Medicine • April 2017
AUTO REVIEW
a myriad of other vehicle settings, all with a
modus operandi of this popular luxury
or anything else is to call Phil Hornbeak,
minimum of distraction. Thankfully, the
sedan. Audi has endeavored to make the new
who will gladly help you get the car you
comprehensiveness of the menus is offset by
A4 sportier than the last one, and presum-
want for the best possible price.
a good number of redundant buttons and
ably they did, but I was not able to tell much
The all-new Audi A4 is really all-new,
even a (tiny) pad you can write on with your
of a difference during my time with the car.
though you'll be forgiven for not noticing
finger. While not as immediately intuitive as
Certainly the A4 is quiet. Car and Driver
given its remarkably unremarkable new
an iPhone, getting comfortable with the
reports that the 2017 A4 has almost the qui-
styling. Still, it's an impressive piece, and a
MMI is easy, and it's about as good as it gets
etest interior noise levels they've ever meas-
car you'd be foolish not to consider seriously
in a car in 2017. (My son, who works in web
ured, just behind the Rolls Royce Phantom.
if you're looking to buy a luxury sedan in the
development for a well known Silicon Valley
I never found myself thinking, “Wow, I
BMW 3-Series class.
corporation recently explained all of this to
don't hear anything in this car,” but at the
me by saying, “Dad, if you're good at tech
same time driving it was always a nicely
you work for a tech company. If you're not
hushed experience.
you work for a car company.” Something to keep in mind.)
If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.
Not surprisingly, a wide variety of options and option packages can move the price of
Steve Schutz, MD, is a
On the road, the A4 is nicely buttoned
an A4 from its just under $40,000 base
board-certified gastroenterolo-
down and easy to enjoy. As always, Audi is
MSRP all the way to around $55,000, so
gist who lived in San Antonio
shooting for overall dynamic goodness rather
configuring your car online after a few
in the 1990s when he was sta-
than race track edginess, so neutral handling
glasses of Cabernet is not recommended.
tioned here in the U.S. Air
in most conditions with a touch of under-
Smart BCMS members know that the best
Force. He has been writing auto reviews for
steer if you enter a turn too quickly is the
way forward whether you're buying an A4
San Antonio Medicine since 1995. visit us at www.bcms.org
45
THANK YOU
to the large group practices with 100% MEMBERSHIP in BCMS and TMA
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ENT Clinics of San Antonio, PA
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Gastroenterology Consultants of San Antonio
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General Surgical Associates
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Institute for Women's Health
Tejas Anesthesia, PA
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Texas Partners in Acute Care
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The San Antonio Orthopaedic Group
MacGregor Medical Center San Antonio
Urology San Antonio, PA
MEDNAX
WellMed Medical Management Inc.
Contact BCMS today to join the 100% Membership Program!
46 San Antonio Medicine • April 2017
*100% member practice participation as of March 23, 2017.