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MEDICINE SAN ANTONIO
Why I became a doctor
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A Calling Within My Soul By Wendy B. Kang, MD, JD ......................................19
By Brent Jackson, DO ...............................................20
Expanded my practice by one species A family doctor like my Dad
SUBSCRIPTION RATES: $30 per year or $4 per individual issue
By Lewis Rose, MD ...................................................21
I didn’t go into medicine for that! By Jeffrey Meffert, MD .......................................22 BCMS President’s Message ..........................................................................................................8 BCMS Alliance ..............................................................................................................................10 BCMS News, Mentoring Initiative, Groundbreaking, First Tuesdays ............................................12 BCMS Member Services (BCVI) ..................................................................................................16 Lifestyle: The Art of Charcuterie by Beth Bond ............................................................................24 Lifestyle: Destination Washington County by Julie Catalano ......................................................26 Legal Ease: Do I have to? and How much? Part I of II, by George F. “Rick” Evans ..............................30 UTHSCSA Dean’s Message by Francisco González-Scarano, MD ........................................................32 Business of Medicine: Concepts to consider when measuring physician productivity by Joseph P. Gonzales, MHA, FACHE, PMF ......................................................................................34 BCMS Circle of Friends Services Directory ............................................................................................37 Book Review: Tana French’s “Dublin Murder Squad” Novels, reviewed by Fred H. Olin, MD ..............40 In the Driver’s Seat ..................................................................................................................................43 Auto Review: Mercedes S550, by Steve Schutz, MD..............................................................................44
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Understanding why things happened and how I could improve them
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BOARD OF DIRECTORS
OFFICERS James L. Humphreys, MD, President Leah Hanselka Jacobson, MD, Vice President Maria M. Tiamson-Beato, MD, Treasurer Adam V. Ratner, MD, Secretary Jayesh B. Shah, MD, President-elect K. Ashok Kumar, MD, Immediate Past President
DIRECTORS Jorge Miguel Cavazos, MD, Member Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Bonnie Harriet Hartstein, MD, Military Representative Rebecca Christopherson, BCMS Alliance President Gerald Q. Greenfield Jr., MD, PA, Board of Censors Chair Donald L. Hilton Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., Legal Counsel
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom
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COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Jeffrey J. Meffert, MD, Member Rajam S. Ramamurthy, MD, Member J.J. Waller Jr., MD, Member
6 San Antonio Medicine • May 2015
PRESIDENT’S MESSAGE
Dr. James L. Humphreys (left) was installed as 2015 BCMS President Jan. 24 at Oak Hills Country Club, with his father, Dr. James M. Humphreys, and other family members in attendance.
Why I became a doctor By James L. Humphreys, MD 2015 BCMS President The theme of this month’s issue of San Antonio Medicine is, “Why I became a doctor,” and there are several stories from our colleagues on that topic. I wanted to contribute one myself, and as I reflected on it, the reasoning behind my decision to apply for medical school in the first place is a little hazy to me, since so many years have passed since that day. I know that I enjoyed science, particularly biology, in high school and wanted to major in it at university. My father was an obstetrician, and while I had no desire to practice obstetrics and gynecology, I did like the idea of practicing medicine. My initial reasons were that I would find it interesting (which I did and still do), that I could apply my science education (which is mostly true), that it was a glamorous occupation (not so much, as it turns out), and that it would make my parents proud of the path I chose (which it did). When I applied for medical school, I was careful to add in a desire to help people and build a healthier community through my efforts, both of which are true but were not necessarily primary drivers of my decision.
8 San Antonio Medicine • May 2015
My road to a career in pathology took a few turns along the way, as I’m sure happened to a few of you as well during the medical school experience. I remember being a high school junior and being dead certain that I wanted to practice anesthesiology, all the way up until my first general surgery rotation as a thirdyear. That experience cured me of any interest in pursuing either anesthesiology or general surgery as a career, though I am profoundly grateful for my colleagues who do enjoy that work and pursue it daily. It takes a village to care for most patients these days, as the saying goes. I think it is important to not get lost in the daily frustrations of modern medical practice in the United States and to take a few minutes every now and then to remember why we started doing this work in the first place. Those few moments of reflection usually seem to spark up a bit of my wide-eyed excitement as a brand-new, first-year medical student and keep me going for another week.
BCMS ALLIANCE
We’ve got it going on By Rebecca Christopherson, 2015 BCMS Alliance President
I was conversing with a physician friend the other day about our organization. “The BCMS Alliance has really got it going on,” he said. “This group really knows how to have fun and be out in the community.” His comments made me think. We ARE out there, and he is right — we REALLY do have an awesome time at whatever we do! I encourage those physicians and their spouses reading this article who have not yet joined the Bexar County Medical Society Alliance to come to one of our events and check us out. We have a variety of programs that I believe will appeal to a wide range of interests. Are you a foodie or do you want to acquire the skills to become one? If so, then Tasty Tuesdays is right up your alley. Here, Alliance members get together on the last Tuesday of every other month to learn new culinary skills and try delicious recipes. Want to get out into the community and make a difference? Our civic and philanthropic arm provides many opportunities to do just that! We are a vital volunteer presence at San Antonio’s Siclovia, where we fit children with free bicycle helmets. We also serve the community through our nursing and allied health scholarship program. The Alliance Junior Volunteer Council, or JVC, provides service opportunities for high school-age children of Alliance and BCMS members. We also serve San Antonio’s refugee community by providing medical and office supplies to the Refugee Triage Clinic. If you’re a book lover (or even if you’re not), our monthly Book Club offers stimulating conversation and friendly fellowship. Our social program Sips and Dips provides a venue in which couples can get together over drinks and appetizers. The Alliance also hosts four main programs each year: our New Member 10 San Antonio Medicine • May 2015
BCMS ALLIANCE Welcome Luncheon, the Past Presidents’ Luncheon and Fashion Show, our Fall Coffee and, of course, our Holiday Brunch. We DO have it going on, and we would love for you to join us! We are here to support one another in the family of medicine. Come and see what you’re missing! I am happy to answer any questions you might have about membership or the BCMS Alliance in general.
Just give me a call at 210-387-9544 or shoot me an email at rebeccachristopherson84@gmail.com. I truly would love to hear from you, and I know our Alliance would love to get to know you!
visit us at www.bcms.org
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BCMS NEWS
BCMS Mentoring Initiative: Training the next generation of local physicians By Trevor Memmott
“It is one of the most beautiful compensations of this life that no man can sincerely try to help another without helping himself.” — Ralph Waldo Emerson Bexar County has a vast wealth of licensed physicians, all capable of shaping the future of medicine. According to Texas state records, Bexar County has 5,321 licensed doctors. These physicians have accumulated great knowledge and skills, encompassing all specialties of medicine. By partnering with local physicians, medical students, residents and fellows can expand their understanding and skills in a practical and personalized manner outside the lecture hall or teaching wards. Physicians who mentor these trainees provide the setting and context for developing critical skills required to become healers of the highest caliber.
PROGRAM SPECIFICS The Bexar County Medical Society (BCMS) Mentoring Initiative provides local physicians with a personalized and customizable approach to training medical students, residents and fellows. Members can choose to work with trainees according to their interests and time, whether that means answering questions, going out for a meal, or providing shadowing opportunities. BCMS members can be a part of the initial stages of the Mentoring Initiative in three ways: communicating with trainees via email or telephone, meeting trainees for coffee or a meal, and providing shadowing opportunities. Communicating with trainees provides a simple way to answer trainees’ questions or concerns about your specialty, lifestyle or practice. Meeting trainees for coffee or a meal provides a low-key but more personal opportunity to interact with physicians in training. This could be expanded to include significant others and include discussions on family life and how to nurture healthy relationships during medical training and beyond. Physicians-in-training will be able to see what the art and practice of medicine look like through experienced members’ eyes. Participants will have a chance to share insights and provide clinical context to assist physicians-in-training as they seek out their own professional identity. The last element of the program is called “Journeys in…” This 12 San Antonio Medicine • May 2015
is a program that highlights exceptional physicians in a variety of specialties and allows them to tell their story in a brief speech to physicians-in-training and their fellow BCMS members. This will open the eyes of trainees to the vast array of choices available within each field of medicine, as well as create an avenue for them to network with physicians in the fields in which they are interested.
APPEAL TO PHYSICIANS The School of Medicine at UT Health Science Center San Antonio trains 860 medical students and 730 residents and fellows annually who could benefit from the collective medical experience of Bexar County physicians. Think back to a time when you wished that something was different in medicine, or you wished you had known or done something different in your training years. Now imagine that you can do something about it — because you can. By joining the BCMS Mentoring Initiative, your voice is heard. Your ideas, passions and skills take life outside yourself and give vision and direction to all trainees who have the opportunity to work with and learn from you.
HOW TO PARTICIPATE All BCMS members are able to participate in the Mentoring Initiative. You may have already signed up for the program by checking off the appropriate box on the BCMS annual request for information form sent to you in early March. You also may sign up by contacting BCMS membership director Brissa Vela by email at Brissa.Vela@bcms.org or at 210-301-4371. Trevor Memmott is a first-year medical student at UT Health Science Center at San Antonio and a member of the BCMS Membership Committee. He received his B.A. in Spanish from Brigham Young University in Provo, Utah. Outside of school, he and his wife stay busy keeping up with their two children.
BCMS NEWS
BCMS BREAKS GROUND ON NEW OFFICE BUILDING Article and photography by Susan A. Merkner
Turning over the first shovels of dirt at the BCMS groundbreaking March 30 were (from left) Shavano Park Mayor A. David Marne; BCMS CEO/Executive Director Stephen C. Fitzer; San Antonio Mayor Ivy Taylor; San Antonio District 8 City Councilman Ron Nirenberg; Bexar County Judge Nelson Wolff; 2014 BCMS President K. Ashok Kumar, MD; and 2015 BCMS President James L. Humphreys, MD.
Guests at the BCMS groundbreaking represented healthcare, finance, government and other business sectors.
A tent was used for groundbreaking ceremonies at the 1.88-acre site of the new BCMS office in Shavano Park.
Groundbreaking ceremonies included BCMS representatives (from left) Bernard T. “Buddy” Swift Jr., DO; Bonnie H. Hartstein, MD; Adam V. Ratner, MD; Gerardo Ortega, MD; Dr. Maria “Maggie” Tiamson-Beato, MD; Leah Hanselka Jacobson, MD; Jayesh B. Shah, MD; James L. Humphreys, MD; K. Ashok Kumar, MD; and Stephen C. Fitzer.
Approximately 150 people turned out March 30 for the Bexar County Medical Society’s groundbreaking ceremony at the site of its new building, 4334 North Loop 1604 West. The Shavano Park location, on the Loop 1604 east-bound access road between Lockhill-Selma Road and N.W. Military Drive, was chosen for its convenience for physician-members, many of whom work and live nearby, said BCMS CEO/Executive Director Stephen C. Fitzer. Construction of the $5 million project is expected to be completed by December. The medical society will occupy the second floor of the 20,000-squarefoot building, and 8,500 square feet of space is available for lease on the ground floor. General contractor is R.C. Page Construction. The project management/owners’ representative is Huffman Developments. Event sponsors were BB&T, Favorite Healthcare Staffing, Neurosurgical Associates, P.A., River City Cardiovascular, Spice of Life Catering, TMAIT, TMLT Insurance and University Health Systems. Major contributors ($25,000 or more) to the BCMS Capital Campaign as of March 30 include Frost Bank, BB&T Bank, Favorite Healthcare Staffing, Mark Wood/Northside Ford Dealerships, and Mednax/Pediatrix. To learn more and make a contribution, visit www.bcms.org.
visit us at www.bcms.org
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BCMS LEGISLATIVE AND ADVOCACY NEWS
APRIL
FIRST TUESDAYS AT THE CAPITOL A BIG HIT
First Tuesdays attendees from BCMS paused for a photo with the state Capitol in the background: (front row, from left) Gabriel Ortiz, MD; Jennifer Lewis; Mary Nava; Maria Tiamson-Beato, MD; Jayesh Shah, MD; (back row, from left) Pam Hall, MD; Michael Guirl, MD; and Alex Kenton, MD.
By Mary E. Nava, MBA BCMS Chief Governmental and Community Relations Officer
A large contingency of physicians, medical students and Alliance members from around the state met April 7 in Austin to participate in the April First Tuesdays visit to the Capitol. With a multitude of bills making their way through the process, a number of medicine’s issues were discussed, including: occupations tax; preferred provider benefit plans and exclusive provider organizations; ACA exchange plans ID cards; vaccinations and ImmTrac registry; state budget; Medicaid payments; GME and residency slots; ER temporary holds; EpiPens in schools; insurance issues; telemedicine; scope of practice and end-of-life care. Many thanks to the following participants: BCMS Board Treasurer Maria “Maggie” TiamsonBeato, MD; Michael Guirl, MD; Pam Hall, MD; TMA Board of Trustees member David Henkes, MD; Alex Kenton, MD; Gabriel Ortiz, MD; BCMS president-elect Jayesh Shah, MD; David Shulman, MD; Ryan Van Ramshorst, MD; and Alliance members Jun Beato, MD; Danielle Henkes and Alliance president-elect Jennifer Lewis. There were approximately 15 medical students from San Antonio in attendance who participated in separate meetings with TMA and legislators.
BCMS physicians discussed medicine’s bills with Juan Estrada (seated at desk), legislative aide in the office of Rep. Joe Farias (Dist. 118), on April 7. Physicians (from left) are Pam Hall, MD; Maria Tiamson-Beato, MD; Alex Kenton, MD; and Gabriel Ortiz, MD.
The last First Tuesdays visit is May 5. If you are interested in participating, please visit the TMA website at www.texmed.org to register. For local discussion on this and other advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at mary.nava@bcms.org.
14 San Antonio Medicine • May 2015
Visiting with Heather Fleming (in blue jacket), legislative policy director in the office of Speaker Joe Straus, on April 7 were (from left) Alex Kenton, MD; David Henkes, MD; Danielle Henkes and Gabriel Ortiz, MD.
BCMS NEWS
GUEST SPEAKER ADDRESSES FREEDOM, MEDICAL EXCELLENCE
Drs. Jayesh Shah and Pam Hall visited with Rep. Rick Galindo (Dist. 117) during the April 7 First Tuesdays visit to the Capitol.
Dr. Richard B. Gunderman, vice chair of the radiology department at Indiana University School of Medicine, spoke March 13 in San Antonio, addressing medical school students and faculty as the Alpha Omega Alpha Visiting Professor. His visit was sponsored by the Patient Institute, UTHSCSA and BCMS. Pausing for a photo with Rep. Lyle Larson (Dist. 122) on April 7 were (from left) Michael Guirl, MD; Jayesh Shah, MD; Larson; Pam Hall, MD; and Mary Nava. Jayesh Shah, MD, registered his support for an important bill heard in the House Public Health Committee on April 7.
IN MEMORIAM Sister Melba Beine, OP, MD, died Feb. 27, 2015. Sister Melba, 69, was in the 40th year of her religious profession as a member of the Dominican order. She received a doctorate in medicine from the University of Maryland at Baltimore and was a BCMS member since 1996. Robert L. Brusenhan Jr., MD, 83, died March 16, 2015. He served as a flight surgeon in the U.S. Air Force and practiced urology for more than 40 years. Dr. Brusenhan was a BCMS life member. Mauricio A. Escobar, MD, died April 4, 2015, at age 77. A resident of Pearsall, Dr. Escobar was a BCMS member. Jesse D. Ibarra Jr., MD, died April 7, 2015. A resident of Temple, Dr. Ibarra, 96, was a professor of medicine at Texas A&M University College of Medicine and a BCMS member. Odville A. Rinn, MD, died Feb. 19, 2015. After serving in the U.S. Navy in World War II, he served as a physician and surgeon. Dr. Rinn, who died a week before his 90th birthday, was a BCMS life member. Thomas A. Tucker, MD, 77, died March 28, 2015. Dr. Tucker, a psychiatrist, served in the U.S. Air Force and was a BCMS life member.
BCMS NEW MEMBER WELCOME Join us in welcoming the new physician-members of BCMS! Wednesday, June 3 University of the Incarnate Word Rosenberg Sky Room 847 E. Hildebrand Ave., San Antonio 78212
During the April 7 First Tuesdays visits, Jayesh Shah, MD, met with Rep. Justin Rodriguez (Dist. 125) (seated at end of table) and chief of staff Brian Hodgdon.
Mix and mingle: Complimentary buffet and cocktail party. Enjoy an evening of networking, camaraderie and music. The BCMS Foundation will award scholarships to local high school students pursuing careers in the medical profession. To RSVP, call 210-301-4381, ext. 193, or visit www.bcms.org. visit us at www.bcms.org
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MEMBER SERVICES
BCVI FACILITATES CREDENTIALING FOR HEALTHCARE PROVIDERS Bexar Credentials Verification Inc. (BCVI), the credentials verification subsidiary of the Bexar County Medical Society, slashes the time, aggravation and expense of verifying the necessary credentials on San Antonio physicians for the area hospitals and managed-care organizations that contract with them. The objective of credentialing is to ensure the highest quality care for patients through the detailed verification and review of a physician’s background, training and experience. All physicians must go through a formal credentialing process to gain “privileges” with the locations and health plans through which they treat patients. Each entity incurs a substantial expense to verify the authenticity of information provided. Primary source verification involves contacting the original source of education, training, licensure and other physician and allied health professional credentials. BCVI provides primary source verification of credentials data that meet The Joint Commission (TJC) and the National Commission for Quality Assurance (NCQA) for Credentialing Verification Organizations criteria for healthcare entities. Last year, BCVI’s systems and files were reviewed for accuracy and quality control by the NCQA. BCVI received the highest possible scores with no adverse findings in any category for which it applied for certification.
16 San Antonio Medicine • May 2015
“BCVI is the industry leader for health facility primary source verification,” said BCVI director of operations Mary Jo Quinn. “Our goal is to overwhelm our current customers with satisfaction and to encourage those who are currently not part of the team to join.” In 2005, BCVI organized a cooperative approach to provide consistency and efficiency to the process. Initially, several key San Antonio area hospitals, the Bexar County Medical Society, healthcare insurers and the Greater San Antonio Hospital Council joined forces to inaugurate the cooperative program for primary source verification of physicians. Through BCVI, all traditional users of credentialing information in Bexar County can participate in a common database that eliminates duplication and needless expenses. The cooperative subsequently expanded, and currently BCVI provides primary source verification for 73 clients across Texas. Among BCVI’s largest local participants are the Methodist Healthcare Systems, Southwest General Hospital, Warm Springs Rehab/Specialty Hospitals, as well as other area hospitals and healthcare facilities. To learn more about BCVI, contact Mary Jo Quinn at 210-582-6355, email mjquinn@bexarcv.com or visit www.bexarcv.com.
WHY I BECAME A DOCTOR
‘Ultimate Altruism’ By Robert R. Ramirez, MD The answer to “Why I Became a Doctor” is as complex and multifactorial as it is individual and personal, but there are some common elements. An obsessive interest in the life sciences at an early age is a must, of course, in order to plant the seed for further exploration of biology, biochemistry and, ultimately, medicine. Also essential are the competitive drive and endless commitment and dedication needed to rise to the ultimate personal challenge of completing the long and arduous training necessary to earn that all-prestigious medical degree, often overcoming difficult obstacles in the process. (Not to mention the many years of residency and, in many cases, fellowship training, that follow.) As the saying goes, “Ad astra per aspera.” But it is the answering of a calling, whether divine or otherwise profoundly metaphysical, that, in my opinion, best characterizes the desire of aspiring physicians to achieve this profession of ultimate altruism in the advancement of healing and in the betterment of the human condition. It is a calling not only to never stop learn-
18 San Antonio Medicine • May 2015
ing, which is inevitable in the always rapidly changing field of medicine; but also to use that knowledge, and any and all skills acquired along the way, to heal. Because only a calling, as with many other professions of customer, community and public service, can justify the incredibly long hours, unselfish devotion, mental taxation and personal sacrifice that medicine demands. Furthermore, the reward, of course, lies not so much in the remunerative aspect, as in the ability to make a difference in the lives of others by helping to save such lives, stamp out disease, provide palliative care, alleviate suffering, or otherwise aid in healing just by listening. For me personally, being a doctor ranks among the most heroic, noble and selfless undertakings of humankind. Robert R. Ramirez, MD, is an internal medicine physician with Gonzaba Medical Group.
WHY I BECAME A DOCTOR
‘A Calling Within My Soul’ By Wendy B. Kang, MD, JD
Some intellectually meander onto the road to medicine. Others like me know from the dawning moments of consciousness to take the only path in life: that of becoming a physician. Predestination or a lucky chance? While many young girls my age played with dolls, I doctored my teddy bear with dressings and tender loving care. Even in my rural Taiwanese village, I took care of my classmates. When my American elementary school classmate had the wind knocked out of him by a large, stiff, red rubber ball, I undid his collar button and laid him flat while sending another classmate to find our teacher. There was no panic, no fear, merely instinct to do what I thought needed to be done for Ricky’s sake. Having no relatives to pattern my future professional behavior after, I lucked upon two family physicians who took care of me as I grew up in a small American town of 5,000. Dr. Vigor was the kindly white-haired G.P. who let me play with his white poodle in their backyard until his nurse/wife would call me into the home office. Dr. Hodges was bald and no-nonsense who still exuded great kindness as he carved out the wart from my finger joint. Both physicians looked after everybody in that small town; they were greatly admired. They are still my role models. The tough road to becoming a physician never appears arduous when you know it is your road in life. I had no doubts. Scholastic achievements, volunteering to help out veterans at the local VA hospital, participating in extracurricular club activities, or looking after an ill mother and active bratty brothers were normal things to do; they were not activities to fill out on a future application form for medical school. In my naiveté, four years of university studies, four years of medical school and the nebulous years of residency were merely part of the price to be paid for the privilege of looking after people. I did know that I needed to be above reproach in my behavior, just like Drs. Vigor and Hodges. No self-respecting doctor
would use marijuana! Besides the ghastly possibility of being arrested for smoking pot, I did not want anything to cloud my mind nor obfuscate my path to medical school. My straight-asan-arrow approach was described by an aunt as a calling within my soul. As I approach my 35th medical school reunion, I muse upon all the cataclysmic changes in medicine. Bigger governmental intrusions, more bureaucratic headaches, increasing quality assurance pink sheets to fill out, learning computer lingo, facing constant threats of medical malpractice lawsuits from disgruntled patients who demand unrealistic perfect care and absolutely no pain after surgeries, less pay while working harder as I become older — what rational person would voluntarily pick this potholed road in life? The answer to that question is getting slightly iffier — until I hear a “Thank you, doc.” Then I remember the first baby I personally delivered as a third-year medical student, the sweet patient who patiently tolerated my inept attempts to draw blood out of anemic veins, or the alcoholic, chain-smoking obese patient who claims I’m the first doctor to explain his health in a way he understands such that he’ll work on taking better care of himself. I am a sucker for patients. It’s relationships, connections to our patients, that keep us physicians wanting to take care of them. Whether it is an innate calling within one’s soul or a thoughtful intellectualization, we understand the great privilege — and hard work! — involved in helping people as their physicians. Fortunately for us, there are many smart and idealistic young people getting on the road to medicine. Wendy B. Kang, MD, JD, is professor/clinical in the Department of Anesthesiology at the University of Texas Health Science Center San Antonio.
visit us at www.bcms.org
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WHY I BECAME A DOCTOR
‘Understanding why things happened and how I could improve them’ By Brent Jackson, DO “Why did you become a doctor?” is a question I receive much more often than I expected. Most commonly, the underlying inquiry relates to changes in medicine and whether I think practicing medicine is worth all the “red tape.” I appreciate the question because it causes me to reflect upon why I undertook the years of training and effort to become an orthopaedic surgeon. I’ve always believed a job or profession is something to be enjoyed and appreciated. Growing up, I learned from my father, a geologist, what it meant to love a job. I never recall hearing him complain about his job, the long hours, or problems with clients. It was obvious he looked forward to work each day and relished what he did. I never let myself imagine the possibility of not enjoying my profession, whatever that might be. As a young adult, my passions and interests fueled my vision for any future job. I considered ideas as varied as being a marine biologist saving coral reefs, to coaching basketball, teaching kids to love a game that meant so much to me. Then, as I headed to college, a theme emerged in my search for a profession as I found myself constantly curious about how things work. While this initially led me to engineering, which may seem very different from medicine, I believe the common thread for me was to understand why things happened and how I could improve them. During college, I took a job with St. Joseph’s Health System as a physical therapy tech and wound care specialist and discovered 20 San Antonio Medicine • May 2015
that medicine offered the opportunity I was looking for, with the added benefit of making a meaningful difference in people’s lives. But what about all the changes in medicine? While more of my time is spent dealing with insurance companies and regulations on how to run my practice, I still see my job as embracing the same simple concept: help people meet their goals of a healthy and active lifestyle. Although the main focus of their treatment is the art and science of medicine, I see these additional changes and hurdles physicians must conquer as pieces of one connected puzzle in treating a patient. I am emotionally moved, sometimes almost visibly, when I see my patients recover and able to get back to the life and activities that they love. It’s like a runner’s high; it keeps me coming back for more. And, now, I am at that point I envisioned many years ago. Each day I wake up with my three wonderful kids, who see me enjoy my job and look forward to each day of work. It is then that I truly realize that all is right, and the years of training were worth the effort, as my kids see what it means to be passionate about a profession. Brent Jackson, DO, is an orthopaedic surgeon at his practice in orthopaedic hand and upper extremity surgery, Jackson Orthopaedics in San Antonio.
WHY I BECAME A DOCTOR
‘Expanded my practice by one species’ By Fred H. Olin, MD In my case, I already had earned the title “Doctor” by becoming a veterinarian, something that had been my goal since I was about 12 years old. In my six years in a small animal and zoo veterinary practice here in San Antonio in the 1960s, there were several events that caused me to consider switching professions. Perhaps the most influential was the fact that there were economic limitations on what we were allowed to do, even though we were educated and trained and had the experience to do the treatment. An animal is a piece of property, and the owner can do as he or she pleases with that property. Too many times a case came along that was diagnosable and/or treatable, but the family would decline, and usually ask that we euthanize their pet … because even the low prices prevalent at the time were perceived as too much. Now, if it is a choice between feeding your children or fixing the dog’s fractured femur, there is no contest. But many times it was, “He’s just a dog (or cat). Go ahead and put him to sleep. We’ll get another one.” Along came Christmas week of 1967, and there was a whole series of these events. That week sort of pushed me over the edge. During 1967 another factor was that the local medical school was coming along in its organization. I had done some research and realized that I had all the prerequisites for admission, except for two math courses. I took them at San Antonio College and aced them both … much to my surprise. I knew my own psyche enough that if I didn’t make the effort, I’d always regret it. Here’s a quotation attributed (probably incorrectly) to Mark Twain: “Twenty years from now you will be more disappointed by the things you didn’t do than by the ones you did do. So throw off the bowlines. Sail away from the safe harbour. Catch the trade winds in sails. Explore. Dream. Discover.”
‘A family doctor like my Dad’ By Lewis Rose, MD
I applied for the class that matriculated in 1968, but my application was late. The Dean of Admissions, Joe G. Wood, PhD, interviewed me and asked me to reapply for the 1969 class, and told me that applications opened on July 1, 1968. I was busy, had a family and a mortgage and friends and activities and greatly enjoyed the practice of veterinary medicine, so I didn’t submit the application on the first of July. About two weeks into July, Dr. Wood called and asked where my application was. I sent it in, and somewhat to my wife’s consternation, I was accepted and eight years later was turned loose on the unsuspecting public. I am asked fairly often if I regret making the change. The answer is a resounding “NO!” The next question is usually along the lines of, “Which education was harder?” That’s unanswerable. Neither was easy. Although the basic knowledge is the same, the emphases are different in the two professions. My usual response includes the line, “I just expanded my practice by one species.”
My father was a gifted and well-recognized family doctor in Britain. When in 1938 he and his partner rebuilt and expanded their office behind our home, I was fascinated by the architect’s plans and watched the plans translated into brick and mortar reality. I decided I wanted to be an architect. Four years later I decided that the math of architecture was beyond me, so I chose to be to be a family doctor like my Dad. I graduated from medical school just before my 24th birthday, and earned my first paycheck as a locum intern two weeks later. I retired last year, just a few weeks shy of my 84th birthday. I enjoyed every day of being a physician for almost 60 years.
Fred H. Olin, DVM, MD, is a semi-retired orthopaedic surgeon who had the pleasure of taking care of some of his veterinary clients when he was in practice.
Lewis Rose, MD, is a BCMS Life Member.
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21
WHY I BECAME A DOCTOR
‘I didn’t go into medicine for that!’ By Jeffrey Meffert, MD There are many reasons to seek a career in the medical profession. To get rich is not a good one, and there are easier and shorter routes to riches than medical school, residency and years of practice. On the other hand, some of our colleagues are doing better than you might think. Of the following, which drug do you think has the SMALLEST marketing budget: a revolutionary new oral medication that allows you to treat hepatitis C without the discomfort and misery of interferon, an injectable biologic treatment for arthritis that has been available for over a decade, or a new “oral biologic” that has close to a 50 percent side-effect rate and on its best day is slightly better than placebo? The answer is the first medication described because, to some extent, it will “sell itself ” and big budget advertising isn’t necessary. The highest marketing budgets go to “me too” medications which have stiff competition with other products in their class and to medications which are not especially effective when used in your clinical practice. That is because marketing is meant to convince you, the prescriber, to give their product a go, and to tell you that even if the efficacy is not great and even if there are other effective and cheaper alternatives, this is something your patients need and want. Part of that marketing, occasionally billed under the expenditure category of research and development, is the employment of your fellow physicians and key opinion leaders (KOLs) in your specialty to write the articles, develop the practice guidelines, give the seminars, and appear at your local society meetings to sing the praises of the “latest and greatest.”
CONFLICTS OF INTEREST Anyone who reads their journals for the latest practice guidelines must first wade through at least a page of stated conflicts of interest. Every acknowledged KOL has taken some money some time from industry. It is the rare industry-sponsored meeting that can make any claim to represent unbiased continuing medical education, and most are now done by consultants who have a company-prepared PowerPoint presentation that, if they are to be paid, must be presented exactly as it is put together with all the graphs, charts and data that will tend to make your eyes glaze over as you enjoy that steak dinner. These presentations give you the message that, whether this is a new product or an old one that has been slightly reformulated and repackaged, this is what you should be using if you really care. Until recently, there was no way to tell how beholden your speaker was to the company picking up the tab, but now there 22 San Antonio Medicine • May 2015
are options to clear the smoke and make more plain whether your speaker is just an expert who had the time to tell you what is really new or a KOL who really should be more properly considered an over-educated (and overpaid) pharmaceutical detail representative. An excellent website worth consulting before you head to the “educational program” at a local steakhouse is Dollars for Docs (http://projects.propublica.org/docdollars/). You key in the speaker’s name, and you not only will find out how much they are getting from the pharmaceutical industry but how much specifically from this meeting’s sponsor. Sometimes you need to check other versions of someone’s name (Ted vs. Theodore) to get the whole picture, and you usually will have to use the speaker’s first name even if they go by their middle name. You also can search by facility name if you want to see how much a research organization or a medical school is getting from industry. Not all companies participate in the program yet, and it seems to be months between updates so not every dollar spent is reported. There are state and national laws coming into effect that will continue to make this industry-physician economy more transparent and accurate reporting a requirement for doing business.
SHOWING GRATITUDE This is not to say that just because a speaker gets $20,000 or $30,000 a year from Company X that they will necessarily be telling lies on behalf of the product. Some of your speakers may have been researchers who developed the product and may feel quite passionately about the value of the treatment. On the other hand, it must be recognized that we are taught from birth to show gratitude for what we are given. If one is not legally required to mention those pesky negative studies (and they aren’t included in my pre-packaged slideshow), why would I do so? I also might gloss over side effects that don’t rise to the severity of “black box” warning, even if they are going to afflict dozens or hundreds of your patients. Also, if I am being paid thousands to talk to you over a steak and a glass of wine, I might forget to make sure you really understand that if the product shows 50 percent improvement and placebo shows 35 percent improvement, that the true efficacy is only 15 percent. I’m only human, right? Jeffrey Meffert, MD, is a dermatologist at the University of Texas Health Science Center San Antonio.
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(210) 772-7777
LIFESTYLE CONTIGO
CHARCUTERIE The Art of By Beth Bond
Say you’ve got a whole pig on your hands and you’re feeling bold. How do you coax out the most intense flavors using only salt, a few spices and the umami-producing magic of time? This is the challenge readily accepted by a handful of chefs in Central Texas, and their answers range from rillettes and pâté to sausage and even face bacon. Yes, face bacon — keep reading and we’ll explain.
In short, they’re turning whole hogs into charcuterie: prepared meats (often but not exclusively pork) preserved to lock in their flavors. Think of it as the all-meat version of a cheese platter: an assortment of textures and tastes best experienced with sweet or sharp accompaniments to cut the richness. Preserved meats predate the refrigerator by hundreds of years, and the styles most popular today were first cured and eaten by Southern European peasants. The local chefs profiled here each work with a strong sense of classic French, Spanish and Italian traditions while adding modern style and distinctively Texas-forward flavors to their charcuterie boards. They each use every last bit of animals ethically raised at area farms — all with the end goal of amusing and even surprising their customers’ taste buds.
CONTIGO AUSTIN Photography by KNOX PHOTOGRAPHICS
This East Austin wonder takes relaxed dining seriously so you can take it easy. Its menu encourages splitting and sampling several small portions, which chef/owner Andrew Wiseheart describes as a selfish design “because it’s the way we like to eat.” But 24 San Antonio Medicine • May 2015
CONTIGO
honestly, we’re just happy he’s generous enough to share his ranch-inspired cooking. Find a spot at a picnic table under a string of lights and pick and choose from the charcuterie options as you please. With the exception of the pork liver pâté, the menu changes daily but typically lists five of the seven to 10 items in rotation at Contigo. “People like that they can try something for $7 rather than make a $20 to $30 commitment,” Wiseheart said. “We offer our
items a la carte so that we can create a composed dish out of each item. We start with the main ingredient and create a dish around that depending on the ingredients and the flavors and how rich it is.” That pork liver pâté? Its texture is complemented by eggplant fritters drizzled with honey from the restaurant’s namesake Contigo Ranch and served with a toasted baguette. “Once you put everything into a bite, it’s all really harmonious,” Wiseheart said. Face bacon is another Contigo mainstay. Here’s the process: A hog’s entire head is seasoned and cured like bacon, then rolled up, smoked, cured and sliced thinly. The finished product is “a really pretty slice with lots of textures because the tongue and ears have lots of cartilage.” Pickled tomatillo and arugula add both acidic and peppery flavors, Texas-style. Give it a shot. You’ll most likely love it — and you get to say, “I ate face bacon for dinner.” Contigotexas.com | 512.614.2260
CURED Photography by DAVID RANGEL
Sure, Cured deals in cured meats, but there’s more to the name than that. After
LIFESTYLE CURED
that,” he said. “It eats like butter and looks like icing. I spread it on cornbread but I’ve seen people put the whipped pork butter on a sausage. “There’s no wrong way to eat it.” Curedatpearl.com | 210.314.3929
on a saltine or a po-boy. If the name gives you pause, here’s the chef speaking in terms we Texans can understand: “It’s bursting with flavors and textures and it’s like the best barbacoa that you’ve ever had.” Lukesanantonio.com | 210.227.5853
LUKE
SALT & TIME Photography by ROBERT LEMA
learning the restaurant ropes in New Orleans working with John Besh for 10 years, Steve McHugh relocated in 2010 to run a new eatery for the acclaimed chef in San Antonio. Around the same time, he was diagnosed with lymphoma. He calls the move “serendipitous — because I couldn’t get the care I needed back in New Orleans.” He went through treatments of chemotherapy, got cured and then got Cured. “When you have that kind of scare in your life, you reevaluate,” he said. “My wife and I decided to do something on our own. Sometimes things like that jumpstart you.” Since December of last year McHugh’s been making what he calls “the best ham you’ll find in San Antonio,” plus blood sausage, braised kidneys, a super-popular smoked duck ham, bresaola and more in a giant custom-built curing case that greets customers as they step through the door. The seasons dictate the daily changes in the Southern-style menu, which features charcuterie made from all parts of a hog because, McHugh said, “there’s no such thing as a pork belly farm.” As Cured’s curator, McHugh creates his charcuterie boards as a mix of animals — from a lamb-and-citrus terrine to venison to a “very approachable” chicken liver mousse — plus housemade brewer’s crackers flavored with coriander and cumin, mustard, marmalades and pickles of cucumbers, broccoli, cauliflower, pumpkin and more. One of the chef/owner’s favorite items? Whipped pork butter. “I don’t know of anyone who is doing
LÜKE Photography courtesy of BESH RESTAURANT GROUP
At Lüke San Antonio, the recipes have been around the world, but the food is from right here. “It’s the food of the Alsace region of France and Germany mixed with Texas ingredients and a whole scoop of New Orleans,” said executive chef John Russ. “Out of all the menu items, 100 percent of that plate comes from within 65 miles from us — with the exception of the glass of the plate.” Whole animals are transformed into pancetta, ham and sausage, and sometimes the process takes up to a year. “It’s so fun because we can show people the product at different stages,” Russ said. “We’re not buying a Cryovaced product and opening it up. We buy it from producers and let it hang and cure it.” A selection of about five charcuterie items varies, but two constants are a pâté de campagne of pork shoulder and a chicken and rabbit liver mousse (“earthy, buttery and spreads so nicely on toast,” Russ raves). A wintertime special is hog’s head cheese, a semigelatinous forcemeat that’s great spread
Sometimes you don’t have to pick between quality and quantity — at Salt & Time, you get both. This capital city lunch-and-dinner spot is also a full-service retail butcher that an produce 80 to 100 different types of charcuterie items, with 40 to 50 of those available on any given day. “We do a lot of things but try to do them all well,” co-owner Ben Runkle said humbly. Order a salumi board to sample a variety of meats or try putting charcuterie to use another way: as a component of entrees like pastas or sandwiches. Runkle suggests adding coppa, which is cured pork shoulder, to ricotta gnocchi or slathering spicy, spreadable salami called n’duja tejano to your burger. Hankering for those Texas flavors? Salt & Time uses classic techniques to create cured meats with a local flavor profile. Try the pecan-studded salami or the salami flavored with chili pequin and Mexican oregano. saltandtime.com | (512) 524-1383
SALT & TIME
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LIFESTYLE
Destination:
Washington County By Julie Catalano
26 San Antonio Medicine • May 2015
Named for the father of our country, Washington County is a top destination for history buffs, antique hunters, music lovers and wildflower enthusiasts. Small towns with evocative names like Independence, Mount Vernon and William Penn dot the rolling landscape in southeast Central Texas, and the county seat of Brenham draws visitors to its historic downtown. Visit a working ranch, attend a world-renowned concert series, or enjoy a quiet stroll through a history-making spot by the Brazos River — none other than the birthplace of the Lone Star State itself.
LIFESTYLE
2015 ROUND TOP MUSIC FESTIVAL May 31-July 15 • Round Top • Festivalhill.org Photography courtesy of Round Top Festival Institute Every summer, the tiny town of Round Top turns into a classical music Mecca that draws audiences from all over Texas and beyond with the Round Top Music Festival, an internationally acclaimed gathering of renowned conductors, esteemed faculty and brilliant young talent. Celebrating its 45th year, the Round Top Festival Institute will once again host a dazzling array of more than 30 concerts from May 31-July 15, featuring a diverse repertoire from ancient to 21st century music. Internationally acclaimed concert pianist,founder and artistic director James Dick can hardly believe this signature Texas event he created in 1971 has spanned almost five decades, but the success of his brainchild is indisputable. In addition to the physical growth of the Festival Institute campus to a 200-acre haven of gardens, historic buildings, library and museum collections, Dick is both proud and happy to witness the growth by leaps and bounds of the Festival Institute’s reputation, putting it on par with legendary music festivals at Tanglewood and
Aspen. Of the 700 applications the Festival Institute received this year, about 98 were accepted to study and perform. They’ve also made full use of social media, he says, adding that their YouTube channel has more than a half million views. Still, there’s no substitute for the real thing, and that includes the experience of attending performances in what is unquestionably one of the most architecturally and acoustically perfect venues anywhere — the magnificent 1,000-seat Round Top Concert Hall. “It’s like sitting inside a glorious instrument,” he says, “and hearing that sound whether it’s orchestral or choral.” Dick says he gets outstanding feedback from visiting conductors who have played some of the greatest venues in the world. “It truly stands out as one-of-a-kind. It was built and fashioned by hand, the wood cut either with a knife or router, every inch of it.” If you miss the summer series, you can make plans for the April to August series which can include everything from West-
For program and ticket info, Festivalhill.org, 979.249.3129 ern music to the holiday favorite The Nutcracker ballet. Visitors are enthralled not only with the concert hall but also the ambiance of the grounds, with one of the highlights being the 1883 Edythe Bates Old Chapel. The various flora are also popular, most notably the McAshan Herb Gardens, along with herbs, medicinal plants, roses and more. Year-round events at the Festival Institute include forums in theater, museums, poetry and herbs. Growing up in Kansas, James Dick says he’s always loved nature. “I even sold vegetables door to door so I know the value of land and how precious it is. I wanted a place that the public could enjoy as a green space. Over the years we have planted 24,000 trees.” He delights in the surroundings and hopes that audiences do, too. “Where else can you picnic on real grass under glorious live oaks and then walk a few feet into a concert hall of such magnificence?” No place but Round Top. Continued on page 28 visit us at www.bcms.org
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LIFESTYLE Continued from page 27
Plenty to see, do, buy, and try,
WASHINGTON-ON-THEBRAZOS STATE HISTORIC SITE, WASHINGTON, BIRTHPLACE Photography courtesy of Brenham/Washington County Chamber and Convention & Visitors Bureau On March 2, 1836, a group of Texas delegates met at a hall by the Brazos River, declared independence from Mexico and a republic was born. The aptly-named Washington-on-the-Brazos is a significant and popular spot that draws nature lovers, birdwatchers, picnickers and anybody interested in standing at the spot where the Texas Declaration of Independence was signed. Expert and knowledgeable guides make history come alive as they take visitors through what led up to that historic event. The award-winning Star of the Republic Museum showcases a fascinating collection of cultural artifacts from 1836 to 1846. Don’t leave without driving over to Barrington Living History Farm where the original restored home of Anson Jones — the last president of the Republic of Texas — features costumed interpreters of life on a 19th century farm. Admission fee: Combo tickets are available for Independence Hall, Star of the Republic Museum and Barrington Farm.
BRENHAM VISITBRENHAMTEXAS.COM Antique Rose Emporium photo by Mike Shoup The county seat of Washington County, Brenham makes an ideal base from which to explore the nearby sights. The charming Ant Street Inn (antstreetinn.com) is a longtime favorite in the heart of downtown. Stop at Must Be Heaven (mustbeheaven.com) for 28 San Antonio Medicine • May 2015
So stay and play for a while: freshmade soups, sandwiches and pie straight from the pastry gods. Ranch Interiors (ranchinteriorstx.com) specializes in custom ranch, modern, Western and transitional design. And no visit to Brenham is complete without a trip to the enchanting Antique Rose Emporium (antiqueroseemporium.com), where “Rose Rustler” and owner Mike Shoup will regale with tales of “rescued” roses from days gone by.
TEXAS RANCH LIFE CHAPPELL HILL TEXASRANCHLIFE.COM No drugstore cowboys here — this is the real deal. Warm and welcoming owners John and Taunia Elick have preserved a working ranch and opened it to visitors looking for an authentic ranch experience. Nine historic Texas homes from the 1800s were saved from demolition, carefully moved to the ranch, and restored and decorated with antiques, rugs and unique Texas furnishings to serve as well-appointed residences for overnight guests (the largest sleep up to 10 or 13). Activities are extra and include day fishing, mountain biking, skeet shooting and open range horseback riding for all skill levels, undoubtedly one of the most popular
pastimes on the 1,800-acre ranch that features one of the largest covered horse arenas in the state. Six organic gardens supply the kitchen with fresh produce. A nice downhome touch is the “meet the horses” section on their website, with notes from the ranch hands, pictures of the nursery, the moms and horses in training.
THE INN AT DOS BRISAS, WASHINGTON DOSBRISAS.COM Photography courtesy of The Inn at Dos Brisas Luxury to the max. There’s no other way to describe what began as a ranch retreat and grew into the ultimate indulgent (and ultraromantic) stay. The only Forbes five-star restaurant in the state is here, with a 7,000bottle wine cellar that earned “Wine Spectator” magazine’s Best of Award of Excellence. An eight-course grand tasting menu is served on custom Bernardaud china in an elegant but relaxed dining room in the main building. The inn touts its 42 acres (out of 300 total) of organic farms that produce vegetables, herbs and fruit that turn up on both your plate and in creative cocktails. Accommodations are off-thechart gorgeous — nine individual haciendas and casitas feature overstuffed leather chairs, stone fireplaces, steam showers, luxe linens, private patios and golf carts should you need to get to the infinity pool, tennis courts or to take a cooking or wine class. Golf privileges are available at nearby clubs. Better yet, stay “home” and have an in-room massage.
For more info, Visitbrenhamtexas.com.
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LEGAL EASE
‘Do I have to?’ and ‘How much?’ Part I of II By George F. “Rick” Evans I’ve heard these two questions so often over my career that I’ve just got to use that hackneyed, old expression of, “If I had a dime for every time X happened, I’d be a millionaire by now.” Maybe that’s an overstatement, but it’s not far from the truth. I get these two questions about once every week from some doctor, some place. Let me try to put them to rest. Exactly what are these two questions? The first one is the phone call I routinely receive in which a doctor has been asked to testify. Sometimes it’s a deposition. Sometimes it’s for a trial. Maybe it’s a request that some attorney is making over the phone or by letter. Or maybe the doctor has received a subpoena demanding he appear at such-and-such a place and time to testify. The doctor wants to know: “Do I really have to do this?” The second question follows from the first. How much money, if any at all, can the doctor charge for testifying? There are some follow-up questions and practice pointers you may not have considered that I’ll also address. This is the first of a two-part article intended to tackle these issues. Let’s begin with the first issue.
QUESTION ONE: DO I HAVE TO? If you are somehow involved, even peripherally, in a legal dispute between two or more people, the answer is usually yes, you have to testify. Sorry, but there you have it. Let me give you an analogy. If you were walking down the street and saw a car run a red light and hit another car, like it or not, you’re an eyewitness to the event. You can be required to come to court and tell the jury what you saw. Just like a district attorney could call you to testify in a criminal case if you happened to see a burglary or some other crime. You can be subpoenaed to testify for any case as to what you saw or heard. You’re an eyewitness. Similarly, if you’re a treating physician of a person involved in a legal dispute, you can typically be required to testify in that capacity. Let me give you some examples. A person is hurt in an accident, and you provide medical care. Your patient files a lawsuit concerning those injuries which has the legal effect of waiving his right to physician/patient confidentiality. Either his attorney or the defense attorney could require you to testify about your care of the patient. If you won’t do it voluntarily, they can drop a subpoena on you and make you do it. You’re a medical eyewitness to an event relevant to the lawsuit. You can be required to testify as to the patient’s condition, what your treatment was, how he’s doing now, and so forth. 30 San Antonio Medicine • May 2015
Or suppose you’ve been caring for a patient for years, and he’s involved in a custody dispute as part of his divorce. If part of your care involved treatment for addiction, mental illness or other issues pertaining to his suitability to care for a minor child, you might be required to testify. I could go on with many examples but the point is simple. You are like the guy who witnessed the car crash. Or the burglary. As an eyewitness, you are uniquely positioned to help the jury decide the case, and the law requires that you share that knowledge with the jury whether you want to or not. The same principle applies when you are the eyewitness to medical care you provided to a patient if that care somehow is relevant to the legal dispute. So, the short answer to, “Do I have to?” is yes, IF you are the equivalent of a medical eyewitness to an issue of relevance to the legal dispute. Here’s a little caveat to subpoenas. They have an effective “range” of no more than 150 miles from where you reside or where you’re served. In other words, you can’t be required to travel more than 150 miles from where you live or where the subpoena is delivered to you. A Houston attorney handling a Houston case can’t force you to come to Houston to give a deposition about a patient you treated. However, that same attorney could just drive over to San Antonio and, using a subpoena, make you testify in San Antonio. You haven’t avoided testifying. You just avoid having to travel more than 150 miles to do it. Now, let’s assume you’re not a “medical eyewitness,” but, instead, have nothing to do with the case or any of the parties. If you’ve got absolutely nothing to do with the patient or the case, then you can’t be forced to testify. You don’t have to. This question arises when some attorney is trying to get you to be an expert witness on some issue relevant to a lawsuit or pending claim. They want you to review something and render an opinion on some issue. The answer to whether you have to do that is a resounding no. The choice is 100 percent yours. Nobody can force you. You can’t be subpoenaed or otherwise made to do it unless you agree. Now, with that behind us, next month we’ll discuss just how much, if anything, you can charge for testifying. George F. “Rick” Evans Jr., is the founding partner of Evans, Rowe & Holbrook. A graduate of Marshall College of Law, his practice for 36 years has been exclusively dedicated to the representation of physicians and other healthcare providers. Mr. Evans is the BCMS legal counsel.
UTHSCSA DEAN’S MESSAGE
Dr. Manzoor Bhat
By Francisco González-Scarano, MD This month I will highlight the work of another recent outstanding addition to our faculty: Dr. Manzoor Bhat, professor and chairman of the Department of Physiology and the Zachry Foundation Distinguished Chair in Neurosciences. A major focus and longstanding interest of Dr. Bhat has been to understand the mechanisms of how nerve cells break down in the nervous system and interrupt the conduction of signals across their length, ultimately leading to many debilitating symptoms and diseases including multiple sclerosis (MS). Dr. Bhat’s scientific curiosity started as a young boy, when he first noticed that tadpoles lose their tails and grow legs as they develop into frogs. His father, a veterinarian, encouraged his son’s exploration and loaned him the tools to dissect frogs. That curiosity expanded as he grew up, and led to a career in science. He obtained his master’s degree in biochemistry and graduated from his university with a gold medal and distinction. He then graduated with a joint Ph.D. degree in molecular biology from the prestigious Indian Institute of Science, Bangalore, and in biochemistry from Shiga Medical University, Japan. He began his postdoctoral training at the Howard Hughes Medical Institute, Department of Molecular and Human Genetics, at Baylor College of Medicine, Houston; later he became a Howard Temin Fellow of the National Cancer Institute. Before joining our school in 2012, he held many positions, including professor and interim associate chair of the Department of Cell and Molecular Physiology, and member of the Neuroscience Center and Carolina Institute for Developmental Disorders at the University of North Carolina School of Medicine. 32 San Antonio Medicine • May 2015
FRUIT FLIES STUDIED During the mid-1990s to 2000, Dr. Bhat and his collaborators worked with genes that affect the development of the peripheral nervous system in the fruit fly, Drosophila. Three specific genes suspected in nervous system disorders had been identified by other groups, but not much follow-up had been performed to fully establish their roles in nerve cell development. As we know, fruit flies have a very fast generational cycle, and they are easier for most genetic manipulations than many other research models. Dr. Bhat’s team first used immunofluorescent methods to identify the location of the newly identified proteins in the fly nervous system and then targeted them for genetic mutations to determine the consequences of their loss on their development. Upon removal of these specific genes (knock-out mutations), they observed specific nervous system dysfunction in various stages of fly development and also in adults. These neurological dysfunctions resembled characteristics of MS and similar human diseases. MS affects nearly 2.5 million people worldwide. In MS, the immune system attacks the insulating membrane (the myelin sheaths) of the nerve axons that carry signals for long distances. Ultimately, nerve conduction becomes severely compromised, a process that is currently deemed irreversible. The damaged myelin forms multiple scar tissues (sclerosis) in the brain, spinal cord and optic nerves, giving the disease its name. Signs and symptoms of MS patients vary widely depending on the amount and neuroanatomic location of the damage. Some people with severe MS might eventually lose their ability to walk, while others experience long periods of remission during which
UTHSCSA DEAN’S MESSAGE
they have no symptoms. The disease is thought to be triggered in a genetically susceptible individual by a combination of one or more environmental factors. While there is no current cure for MS, treatments can help speed recovery from attacks, modify the course of the disease and allow better management of symptoms. Treatments for MS target the immune system and are generally called immunomodulators. A basic nerve cell consists of dendrites on the receiving end, a cell body (soma) and a long, thin axon that runs to the terminal end. The axon has an insulating sheath made up of specialized glial cells known as myelin that covers its entire length leaving intermittent gaps that are devoid of myelin. The thick multilayered myelin sheath facilitates fast conduction of nerve impulses in axons and is therefore critical for fast signal transmission and proper function of axons in the nervous system. The gaps promote this conduction (saltatory conduction). As Dr. Bhat’s team moved from the fruit fly model to targeting the genes in mouse models, they focused on uncovering the specific molecular mechanisms of the nerve dysfunction and came to realize that it was caused by a breakdown of the axon’s myelin sheath.
MOUSE MODELS Dr. Bhat’s research has focused on close to 10 genes, and demonstrated the resultant neurological dysfunction after their manipulation. Their work continues to focus on the genetic and molecular basis of the highly complex and intricate interactions between the neurons and glial cells in the nervous system. Glial cells not only play a key role in axonal insulation for proper and fast transmission of nerve impulses, but also in blood-brain barrier formation and axonal guidance. Part of Dr. Bhat’s research in mouse models is to determine how long the axon remains functional in the process of myelin breakdown. Many questions emerge, such as: At what point does the damage significantly compromise motor function? At what point(s) can the process be halted or reversed? At what point is the loss of function simply beyond recovery? Where is the threshold for “rescuing” a paralyzed mouse? What is the treatment process for rescuing a paralyzed mouse? Can one get it to the point of being able to ambulate again? Addressing these questions requires a genetic strategy, which is also a significant part of Dr. Bhat’s work now. Regrettably, it takes years of meticulous experiments. Determining a terminal breakdown threshold of the axon — and a successful therapeutic intervention before that threshold is reached – is an important goal not only for MS, but has implications in many other neurological disorders, from Parkinson’s disease to ALS and spinal cord injury. It has taken Dr. Bhat’s team a decade to systematically knock out the genes of interest to prove that each was necessary and suf-
ficient to impair nerve function. One of the challenges posed by the knock out mice was that they had a short lifespan, so Dr. Bhat’s team had to find a way to take a healthy adult mouse with a certain genetic makeup, and knock out the gene in these adults. They devised a strategy to suppress the gene(s) after the mice were mature. The mice would then take approximately three months for the symptoms to materialize. Currently, one of the goals is to “turn the genes back on” and see if the nerves are able to recover their function. Will these nerves function after 30, 60 or even 90 days of no function? This research has the potential to provide clues for axon recovery in patients with MS, and hopefully will lead to therapeutic remedies. Dr. Bhat’s team is looking into all aspects of the equation: the pathology and the time course of deterioration, how the postsynaptic tissue processes work, and how to halt and/or reverse the lack of function on the receiving end.
INSPIRED HIS DAUGHTER Dr. Bhat always gives all credit to his mentors, trainees and collaborators, which include a dedicated team here, and researchers at NYU Medical Center, UNC at Chapel Hill, University of Chicago and Virginia Commonwealth University, as well as to his continued federal and private funding. He is supported by grants from the National Institutes of Health, the National Multiple Sclerosis Society, the Zachry Foundation for Neuroscience Research, the Simons Foundation as well as generous funds from the School of Medicine at the Health Science Center. All of the work his team and collaborators have performed is cataloged in a number of seminal publications in various highprofile journals, including Nature, Neuron, Cell and The Journal of Neuroscience, as well as in many others. Some of his work has appeared on the covers of these journals, which adorn his office. On a personal level, Dr. Bhat has successfully inspired his daughter, Heba, who is now a neuroscience major at UT Austin, who no doubt has inherited the genes to also be a terrific scientist. We are fortunate to have him among our faculty, and his work has a tremendous potential to help many people with neurological disabilities around the world. To read more about his research, or contact him, please visit our website at http://physiology.uthscsa.edu . Francisco González-Scarano, MD, is dean of the School of Medicine, vice president for medical affairs, professor of neurology, and the John P. Howe III, MD, Distinguished Chair in Health Policy at the University of Texas Health Science Center at San Antonio. His email address is scarano@uthscsa.edu. visit us at www.bcms.org
33
BUSINESS OF MEDICINE
Concepts to consider when measuring physician productivity By Joseph P. Gonzales, MHA, FACHE, PMP
When discussing productivity with respect to a profession, it usually is part of a conversation with respect to compensation, and this may apply to both “employed physicians” and “physician owners in group practices.” The purpose of this article is to provide some information as it relates to the topic of physician productivity. It is not meant as the last word on the topic, nor is it intended to be comprehensive in nature, but it can serve as a sort of primer on the subject both for physicians and others who are interested in the topic.
INTRODUCTION In most professions, to include healthcare, the term “productivity” is used as a measure of output (e.g., widgets, cars, or patient visits) that can be produced given a combination of inputs (e.g., number of employees, hours worked and machines). Productivity can be measured for a specific input, such as labor, or one may consider the productivity of a system — i.e., productivity related to spending in a hospital, physician practice, health system, or within a country — by studying the output achieved for a given amount of resources devoted to healthcare. Like life, the issues related to productivity usually begin and end with some form of measurements. What did the baby weigh and what was its length at birth? How old was she when she passed away? Our development and progress through life, school or sports, is associated with some form of measurement against 34 San Antonio Medicine • May 2015
something or someone. The use of measurements is usually a means of improving a person or situation. An employee’s annual review is designed to determine if they have met their objectives. Raises or bonuses may be based on meeting objectives and comparisons to peers. Now consider patient care. If a child’s weight is off the age-height-weight scale at a well-baby visit, the parents are counseled in an attempt to bring the child to a healthy weight. If an HbA1c result is high compared to norms, the diabetic patient’s medications and diet are managed more closely. To be an effective clinician, one must understand many clinical values, and to be an effective manager, you must understand many business values. As a provider, you are responsible for monitoring not just the health of your patients but also the health of the clinic, practice, or facility in which you work. You also may have responsibility related to mentoring peers or managing other providers. Your compensation also may be tied to productivity and quality measures. Optimal patient care should be the primary objective in any medical practice, clinic, or hospital, but the financial success of the practice is also critical. A business or practice constantly in the red will, at some point, cease to exist and will no longer be able to provide patient care. By having a better understanding of the various performance measures used to determine a practice’s health, a provider can do his part to keep the practice/business viable, even thrive, and remain functioning indefinitely for the patients they serve.
BUSINESS OF MEDICINE
Productivity and efficiency are closely related. However, they are distinct from quality and service. A provider may be very pro-
case, “work,” rather than number of patients or billings, is the behavior being measured and rewarded.
ductive and very efficient, but the quality of his or her work can
In 2007, the Medical Group Management Association’s
be very low. For example, if the provider sees 10 patients in two hours yet does so in such a way that none of the patients’ concerns are addressed and the patients leave the visit feeling like their concerns were not addressed, then the quality of the provider’s work may be considered low, even though the productivity and efficiency are high.
(MGMA’s) Physician Compensation and Productivity Report indicated that 16 percent of group practices used an RVU formula to calculate physician compensation and productivity. This same report also showed that 34 percent of physicians had their compensation/productivity tied to RVUs. In MGMA’s 2010 report, in comparison, 35 percent of group practices were using RVU compensation/productivity metrics, and 61 percent of physicians had their compensation/productivity tied to RVUs. In a similar study, the 2011 Review of Physician Recruiting Incentives, by Merritt Hawkins, found that in 74 percent of the physician search assignments it conducted between April 1, 2010, and March 31, 2011, a salary plus a production bonus was the form of compensation offered to physician candidates. Fifty-two percent of the searches featuring a salary plus production bonus based the production component on RVUs, rather than number of patients seen, revenue generated, or quality and cost effectiveness measurements. There are presently a plethora of RVU formulas being used in employment contracts for determining physician compensation. Frequently these formulas are complicated, confusing, or even beyond comprehension. A problem with tying physician compensation strictly on RVU production is that when insurer payments change or groups have a bad year with a negative operating margin, the model may not be sustainable. For instance, for primary care providers, in addition to RVU productivity, achieving benchmarks for management of chronic diseases like diabetes or hypertension, patient satisfaction, care coordination and other important functions must be in the mix. This concept is more important with the popular medical home concept. Participation and contribution to the group’s overall strategic plan also should be rewarded.
EXISTING MEASUREMENTS One traditional measure is the number and types of patient visits. The number and types of patient encounters says nothing about the efficiency of the provider, so this measure is often accompanied by measures of time. For example, how many total hours did the provider work? How many hours were spent in direct patient care or on-call? Combining patient visits with measures of time allows for measurement of efficiency (visits per hour) as well as productivity. Another measure of provider productivity is dollars generated to a practice. Traditionally this was measured by charges for services rendered. With the prevalence of discounted fee-for-service, collections may be a more accurate measure of dollars generated. This measure is also limited since it is highly dependent on the patient’s type of insurance coverage. Two providers providing the same services may generate entirely different collections for the practice depending on the payer mix of their patients. Similarly, measures of time and patient encounters suffer from the limitation that, conceptually, not every office visit or time period spent with a patient is the same. For example, an office visit for treating tinea pedis with topical therapy is not the same as an office visit to evaluate and manage a patient’s complaint of chest pains. Likewise, an hour spent providing critical care in the hospital is not the same as an hour spent counseling a patient in the office. Today, provider productivity and compensation are moving toward models based on Relative Value Units (RVUs). RVUs reflect the relative level of time, skill, training and intensity required of a physician to provide a given service. This is a method for calculating the volume of work or effort expended by a provider in treating patients. A well-patient visit, for example, would be assigned a lower RVU than an invasive surgical procedure. In this
THE FUTURE AND MEASUREMENTS There are a variety of benchmarks that can be used to set goals and measure success in a medical setting. A benchmark is “a standard by which something can be measured or judged.” By comparing a provider’s practice to a benchmark there is an opportunity to: • Quantify performance measures • Quantify the gap between your organization and “best practices” Continued on page 36 visit us at www.bcms.org
35
BUSINESS OF MEDICINE Continued from page 35
Physician productivity (cont.) • Encourage new ideas, innovation and creative thinking • Make improvements in your operations by using an objective basis for your decision-making. Healthcare reform legislation (PPACA) has provided an environment for the establishment of Accountable Care Organizations (ACOs), and they are being established in every state. Large and small physician groups are becoming part of ACOs, especially in large metropolitan areas. In addition to Medicare ACOs, commercial ACOs also are taking off. According to Bhagwan Satiani, MD, MBA, FACS, FACHE, president of Savvy-Medicine, and author of the three-volume set, “The Smarter Physician,” published by MGMA, “productivity” must include measures other than clinical productivity. The metrics that should be included are patient-satisfaction scores, and mortality and morbidity rates. ACOs also will need physicians to lead in the operations, innovation, and quality and customer service areas. It appears clear
that reimbursements are not going up, and so physician leaders are needed who are intimately aware of costing, budgets and financial controls. These leaders, according to Dr. Satiani, must be compensated or be given credit for these activities when calculating productivity. Although there are many well-defined measures of physician productivity, each has its own limitations. It is important to be aware of these limitations and of the factors that can impact productivity measures especially for providers whose productivity is being evaluated and for those administering a productivity-based system. Joseph P. Gonzales is a specialist master with Deloitte Consulting, LLP. An adjunct faculty member at the University of Texas at San Antonio, he teaches in the MBA program, business of healthcare track.
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37 Ray Branson 512-331-4669 branson@medmt.com www.medmt.com
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38 San Antonio Medicine • May 2015
Retirement Solutions (HH Silver Sponsor) Robert C. Cadena 210-342-2900 robert@retirementsolutions.ws www.retirementsolutions.ws Bold Wealth Management (H Bronze Sponsor) Richard A. Poligala 210-998-5787 richard.poligala@natplan.com www.boldfinancialgroup.com
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First Choice Emergency Room (HHH Gold Sponsor) Hardy Oak Boulevard 24-hour 210-451-8340 Nacogdoches Road 24-hour 210-447-7560 Tezel Road 24-hour 210-437-1180 www.fcer.com
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(HHH Gold Sponsor) Central referral line: 210-592-5350 Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/ Seasons Hospice and Palliative Care (HH Silver Sponsor) Deb Houser-Bruchmiller 210-471-2300 dhouser@seasons.org www.seasons.org
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39
BOOK REVIEW
Tana French’s ‘Dublin Murder Squad’ Novels Reviewed by Fred H. Olin, MD There are five volumes (so far) in Tana French’s series of books set in Dublin, and I’ve read all six of them. “Wait…didn’t you say there were five? Yeah, you did. Huh?” Let me explain… I recently read a review of the fifth book in the series, “The Secret Place,” and decided that it sounded promising. It was more than that: It was captivating, so I looked up the first four and decided to read them in order of their publication. When I got to the end of the fourth book, I decided to re-read “The Secret Place.” It was even better the second time around. These are books about murders in Ireland, the detectives who work to solve them, the perpetrators and others involved, but, as was said in a New York Times review, “Ms. French is a psychological storyteller much more than a forensic one.” The people and imagery that inhabit these tales represent some of the best characterizations and descriptions I’ve ever run across. At the end of each book, I felt that I knew the individuals involved and the places where the action occurred. Following are brief summaries of each book. Spoiler alert: There are no spoilers here. “In the Woods” involves the disappearance of two children from a patch of suburban woods 20 years or so before the action in the book. They are never found, but the third child who was with them is found, scared, minimally injured, and unable to tell the world what had happened. That child, Rob Ryan, grows up to be a detective whose partner is a woman, Cassie Maddox. They are investigating the murder of a 12-year-old girl in the same area. “The Likeness” finds Cassie Maddox out of the murder squad, but her boyfriend (not Ryan) catches a case where the victim, who looks exactly like Cassie, has been living a sort of communal existence with several other grad students in a mansion one of them inherited. Her ID says that she is Lexie Madison…a name Cassie used years ago in an undercover operation. Lt. Frank Mackey is a secondary character who runs the undercover squad. Nineteen-year-old Frank Mackey lives with his amazingly dys40 San Antonio Medicine • May 2015
functional family on a street named “Faithful Place,” the title of the third book. He’s planning to run away to London with his girlfriend, Rosie, to start a new life. Rosie doesn’t show, and Frank and everyone else assume that she went off without him. Twenty years later, Rosie’s suitcase is found hidden in a derelict house, and her bones are found under the basement floor. By this time Frank is divorced and has weekend custody of his daughter, Holly, who becomes a witness in the murder of one of Frank’s brothers…in the same house. One of the police involved is Mick “Scorcher” Kennedy, whose partner is Stephen Moran. Brianstown is a subdivision developer’s rechristening of “Broken Harbor,” a resort camp on the Irish coast and the title of the fourth book, where Mick Kennedy and his family went for summer holidays in his childhood and a family tragedy occurred. Kennedy is the lead detective investigating the stabbing murder of a man, the smothering of his two children and the serious wounding of his wife. A year later, Holly Mackey, now 16 and a student at an exclusive Dublin high school for girls, finds a note on the “Secret Place,” a bulletin board where the students can post anonymous notes. The note has a picture of the victim, and says, “I know who killed him.” She takes it to Stephen Moran, now a cold case detective with ambitions to be part of the murder squad. If you read this book, you will know the characters – you may not like them, but you will know them. My advice: Go online for that New York Times review of “The Secret Place.” Then start reading with “In the Woods.” The San Antonio Public Library has them all, in various formats. Fred H. Olin, MD, is a semi-retired orthopaedic surgeon and chairman of the BCMS Communications/Publications Committee. On St. Patrick’s Day, he spells his name O’Lin.
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Gunn Acura 11911 IH-10 West
Ancira Chrysler 10807 IH-10 West
* Gunn Infiniti 12150 IH-10 West
Ingram Park Auto Center 7000 NW Loop 410
Cavender Audi 15447 IH-10 West
Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)
Batchelor Cadillac 11001 IH-10 at Huebner Cavender Cadillac 7625 N. Loop 1604 East
Ancira Dodge 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
Mercedes-Benz of Boerne 31445 IH-10 W, Boerne
Cavender Toyota 5730 NW Loop 410
Mercedes-Benz of San Antonio 9600 San Pedro Ave. * Ancira Volkswagen 5125 Bandera Rd.
Ancira Jeep 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
* Mini Cooper The BMW Center 8434 Airport Blvd.
* North Park Lexus 611 Lockhill Selma Northside Ford 12300 San Pedro Ave.
North Park Lexus Dominion 21531 IH-10 West Frontage Road
Ancira Nissan 10835 IH-10 West Ingram Park Nissan 7000 NW Loop 410
Cavender GMC 17811 San Pedro Ave. Gunn GMC 16440 IH-35 North
Tom Benson Chevrolet 9400 San Pedro Ave.
* Fernandez Honda 8015 IH-35 South
Gunn Chevrolet 12602 IH-35 North
Gunn Honda 14610 IH-10 West (@ Loop 1604)
* North Park Lincoln/ Mercury 9207 San Pedro Ave.
Ingram Park Auto Center 7000 NW Loop 410
Ancira Ram 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
North Park Subaru 9807 San Pedro Ave.
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AUTO REVIEW
Mercedes S550: All about the tech By Steve Schutz, MD
The new Mercedes flagship S-class sedan, the S550, is one of the best cars for sale today, but it’s not wrong to say that the S550 is all about the tech. The S550 looks like an alpha car and has an interior like the Four Seasons. But it’s the technology that sets it apart. What kind of technology are we talking about? Some of it is completely new and allworld, though it should be noted that most of the coolest goodies are optional. Let’s start with a few unusual features that aren’t options. The new S-class has two reverse gears. Probably only chauffeurs who need to worry about kidnappers care about this, but it’s nice to know it’s there just in case. There are seven interior mood-lighting colors, which can be switched easily by using the COMAND controller on the 44 San Antonio Medicine • May 2015
center console. I actually checked these out and changed them a few times. It was interesting for a minute, and one or two color options seems fine. But seven? In a car?
UNUSUAL TWISTS ON OPTIONS Then there’s the “Magic Vision Control” that uses nozzles to squirt washer fluid directly in front of the wiper blades so that your vision isn’t momentarily obstructed by a big splash of fluid like it is in lesser cars. I like this feature a lot, but doesn’t it seem like its name was chosen in a Stuttgart bar at 2 a.m.? Mercedes also has added unusual twists on options that we thought we knew. Like seat coolers that suck air in for four minutes before they blow cool air out, which, Mercedes engineers say, results in more
rapid cooling on sweltering days. Massaging seats aren’t new, but Mercedes’ “hotstone massage” feature feels as if somebody’s gently nudging your back with warm golf balls. I loved this gizmo and used it frequently. And the super soft pillows on the headrests of the two optional “executive” rear chairs are much softer than any others on the market (regrettably, my test car didn’t have these.) Also, presumably with South Texas in mind, Mercedes says that the S-class’ new air conditioner is extra powerful — the strongest available, in fact. Still not impressed? Buyers who enjoy constant olfactory stimulation will love the “Air-Balance” system, which perfumes the cabin with your choice of pleasing scents, “a world first,” apparently. Perhaps the S-class’s most high-tech fea-
AUTO REVIEW ture is the “Magic Body Control,” an advanced feature that comes with the optional hydraulic “Active Body Control” suspension. This ingenious system uses the car’s forward viewing cameras to see bumps on the road ahead, and then it relaxes the suspension in order to float you over said bumps. This is really something in 2015, but given how rapidly the computer world moves I can imagine non-luxury cars having this in 10 years. OK, you get it. There’s lots of technology in the new S-class. What about the rest of it? Design-wise it looks like what any master-of-the-universe might drive, though it’s clearly different from the last version of the S-class. While that car was angular in the usual early- to mid-2000s Mercedes manner, the new S is notable for its roundness. In fact, it seems that every angled area on the old S-class sedan has been smoothed out. Mercedes hopes you like that, because if you don’t, too bad. The automotive market of the future, China, prefers soft curves to sharp angles, and those customers drive luxury car development these days. Still, the new design has enough gravitas to make you move over if you see one in your rearview mirror, which is probably all that matters. Driving the new S550 in everyday life is a lot like driving the previous one, which is to say rock-solid and completely confident. Sports car-esque point-and-shoot is not its thing, but otherwise piloting the newest Sclass is like hiring an automotive celebrity bodyguard. It can handle any road situation you might encounter with aplomb, and it makes sure you get where you need to be as efficiently and comfortably as possible. I drive a lot of cars every year, and this one is special.
NOT A FUEL SIPPER Not surprisingly, the S550 does not sip fuel. The standard engine is a twin turbo 4.7-liter V8 that produces 449 HP, so fuel economy figures of 17 mpg city and 25 mpg highway shouldn’t surprise anybody. In fact, the only surprise is that they’re not worse. As always, Phil Hornbeak can fill you in on the particulars, but the S550 starts at
around $95,000, and it’s reasonable to expect to pay quite a bit more than that if you want some of the tech described here. Yes, the newest Mercedes S-class is all about the tech, which is quite amazing. But otherwise it’s a top-shelf luxury sedan that costs a lot of money and is worth it. There are other luxury cars you can buy that cost more than the S550, but none of them are better than this Mercedes tour de force.
Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. For more information on the BCMS Auto Program, call Phil Hornbeak at 3014367 or visit www.bcms.org. visit us at www.bcms.org
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