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ZOONOSES
By Fred H. Olin, DVM, MD.........................................14
By Barbara R. Schmitz, LCSW ..................................18
BCMS Alliance..................................................................10
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BCMS Legislative and Advocacy News ..........................11 BCMS News ....................................................................12 Lifestyle: Does your home have an IQ? ......................................................................................22 Lifestyle: San Antonio Restaurant Weeks by Ginger McAnear Robinson ....................................24 UTHSCSA Dean’s Message by Francisco González-Scarano, MD ........................................................26 Education: Demystifying the doctor by Lori Boies, PhD, and Annette Gutierrez, MEd ..........................30 Legal Ease: Six tips to becoming an expert on FMLA by George F. “Rick” Evans ................................32 Business of Medicine: Understanding value in the healthcare market by Lee W. Bewley, PhD, FACHE ........................................................................................................34 BCMS Circle of Friends Services Directory ............................................................................................37 Book Review: ‘Killing Jesus’ written by Bill O’Reilly and Martin Dugard, reviewed by J.J. Waller Jr., MD ..........................................................................................................40 In the Driver’s Seat ..................................................................................................................................43 Auto Review: VW Golf TDI, by Steve Schutz, MD ..................................................................................44
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Fleeing from fleas: The most efficient killers in human history
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Zoonotic diseases: When animals share with humans
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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., General Counsel
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom Susan A. Merkner, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director
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 • July 2015
PRESIDENT’S MESSAGE
Plans being finalized for BCMS trip to Japan By James L. Humphreys, MD 2015 BCMS President
This is the time of year when we begin to prepare for our annual cultural exchange with our fellow physicians from our sister city of Kumamoto, Japan. I always look forward to seeing my friends from Kumamoto and catching up with them. This year it is our turn to visit Japan, and we are planning a spectacular visit for our delegation. This will be my eighth or ninth trip there with the medical society — I have honestly lost track at this point. I never get tired of this trip (other than the flight over, which is long!) Every time I see so many new things and appreciate other aspects of being in Japan that have become familiar to me after all these trips and yet are so different from things at home in San Antonio. This year’s trip currently is planned for Sept. 26 to Oct. 3. For veterans of this trip, I am cutting the itinerary down by one city and allowing more time in the places we visit so that the trip doesn’t seem so rushed from the time we arrive to the time we leave. We will be spending extra time in Tokyo and maintaining a long stayover in Kyoto before moving southward into Kumamoto for the final phase of the visit. Tokyo and Kyoto are both wonderful places to visit, with many exotic and interesting sites, but for me the best part of the trip is when we arrive in Kumamoto. It is a nice place to visit in and of itself but the doctors from the Kumamoto City Medical Association are such excellent hosts that it is impossible
8 San Antonio Medicine • July 2015
to have a bad time there. It is always fascinating to meet these physicians and see how it is to practice in a medical system with a very different funding scheme than our own. If you have never gone on this trip, it is an excellent way to see a fair swath of Japan in a short time and really have some meaningful and personal cultural exchanges that would be difficult to replicate on an individual basis. For veterans of the trip, you know what a great time it always is, and I invite you to join us again as we have been able to refine this voyage and add some improvements to the experience over the years. I went the first time just because I had always wanted to see Japan, and this seemed like a good way to get an introduction to the country. I was totally hooked from the get-go, as you can probably tell by now. With the invaluable help of Hiroko Fay, my Japanese “mom” and fellow guide on these trips, we can assure you an experience you will not forget. We need to solidify the list of people going on the trip by mid-July at latest, so please contact either myself or Melody Newsom at the medical society (210-301-4391), and we can get you further trip details and anticipated cost information. I look forward to travelling with you soon. James L. Humphreys, MD, is the 2015 president of the Bexar County Medical Society. He is a pathologist with Precision Pathology in San Antonio.
BCMS ALLIANCE
ALLIANCE PAST PRESIDENTS HONORED By Rebecca Christopherson, BCMS Alliance President
The hottest trends in fashion were on display at the Alliance Annual Spring Luncheon and Fashion Show held May 7 at Julian Gold. Several members had the opportunity to model beautiful clothing. A fabulous lunch was served by Ruth Stone Catering, while members chatted and caught up with one another.
ALLIANCE PAST PRESIDENTS Cindy Comfort Lee Robin Lisa Trevino Linda Ruiz Hema Viswanathan Rebecca Waller Merrill Ellis
Anne Foster Magda Nava Cheri Schilling Katrina Theis Julie Bradshaw Edwina Youngblood Louise Chumley
Day Smith Peggy Belasco Rosie Elizondo Veronica Boldt Maureen Mimari Shirley Sanders Kay Fitch
Elizabeth Benavides Aurelia Krueger Kathy Barnhart Anita Taylor Sandi Drummond Mertie Wood Felicitas Meyer
Rosemary Weber Sylvia Branch Helen Glass Fae Hardy Dorothy Harle June Bratcher
BEXAR ALLIANCE WINS TMAA AWARD The BCMSA was selected as recipient of the 2014-15 Durham Award for Membership at the 97th annual TMAA conference held April 29 in Austin. Interested in becoming a member? Contact Rena Baisden, VP of Membership, at renabaisden@gmail.com. 10 San Antonio Medicine • July 2015
BCMS LEGISLATIVE AND ADVOCACY NEWS
84th Legislative Session Adjourned sine die June 1
Governor signs into law TMA-backed bills; vetoes two By Mary E. Nava, MBA BCMS Chief Governmental and Community Relations Officer
At the time of this writing, Texas Gov. Greg Abbott signed into law three TMA-backed bills four days prior to the end of the 84th Legislative Session, which adjourned sine die June 1: Senate Bill 66, on the use of epinephrine auto-injectors in public schools; Senate Bill 97, on restricting a minor’s access to e-cigarettes; and House Bill 1945, on removing restrictions on direct contracting for primary care. As of press time for this issue of San Antonio Medicine, several more bills of importance to medicine had been passed and were awaiting the governor’s signature: Senate Bill 195, which would eliminate the state’s Controlled Substance Registration (CSR) permit program, effective Sept. 1, 2016; Senate Bill 202, which extends the life of the Texas Department of State Health Services for another 12 years, with extensive changes to agency operations; Senate Bill 207, on the Medicaid Office of Inspector General, improves the OIG’s accountability and institutes fair rules and processes for physicians accused of waste, fraud or abuse; Senate Bill 239, would establish an additional loan remittance program to medical graduates choosing to practice as psychiatrists or other mental health professionals in an underserved Texas county; Senate Bill 760, on improving oversight and accountability of Medicaid HMO’s physician networks; Senate Bill 791, would increase the availability of educational material on congenital cytomegalovirus (CMV) in infants; House Bill 1621, on utilization review appeals, would require a 30-day advance notice of an adverse utilization review determination involving prescription drugs or IV infusions; House Bill 1624, on tougher requirements for health plans to post accurate and up-todate drug formularies and network directories on publicly accessible Internet pages; House Bill 3519, would allow Medicaid to pay for home telemonitoring services for patients with two or more specific medical conditions and a history of frequent hospital ad-
missions or ER visits; and House Bill 3781, would create the Texas Health Improvement Network, a collaborative, multi-entity initiative, housed within the UT system, to address significant health disparities in our state. In addition, the legislature approved a $203 billion state budget for the 2016-17 biennium, which includes $53 million for GME expansion grants, appropriates $4 million for existing family medicine residency programs and $3 million to revitalize the Statewide Primary Care Preceptorship Program. The budget also includes significant increases for women’s health, mental health programs and tobacco cessation programs. On the tax front, House Bill 7 includes the repeal of the $200 per year occupation tax, which physicians and other professionals in Texas pay; and House Bill 32 cuts the state franchise tax by 25 percent. It was quite a shock and a real disappointment to physicians that Abbott vetoed two mental health bills soon after the session ended. The first bill, Senate Bill 359, would have allowed a four-hour emergency department hold for a mentally ill patient that a physician would deem to be a danger to themselves or to others. The other bill, House Bill 225, would have protected from prosecution people who seek emergency care for someone suffering a drug overdose, and also would have allowed first responders to administer an opioid antagonist to save someone from a potentially fatal overdose. To stay current on the most recent legislative news, read the BCMS electronic newsletter, The Weekly Dose, and visit www.bcms.org. For local discussion on this and other legislative advocacy issues, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at Mary.Nava@bcms.org.
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BCMS NEWS
BCMSA members join scholarship recipients (seated) at the New Member Welcome.
BCMS Foundation representatives and donors pose with students (seated) at the event.
BCMS awards $32,000 in scholarships to 17 students; Foundation, Alliance present awards at New Member Welcome Story and photos by Susan A. Merkner Seventeen area high school graduates received a total of $32,000 in scholarships June 3 from affiliates of the Bexar County Medical Society (BCMS). The scholarship awards were presented during the BCMS annual New Member Welcome at the University of the Incarnate Word Rosenberg Sky Room. More than 250 members and guests attended the event, which also featured food, musical entertainment, vendors’ tables staffed by BCMS Circle of Friends sponsors, a chocolate fountain, and a custom cake shaped like the new BCMS office building. Ten students each received $2,500 from the BCMS Foundation, the organization’s philanthropic affiliate. Scholarship recipients, high schools and intended fields of study included: Victoria Almanza, George W. Brackenridge High School, nursing; Alejandra Barrera, Theodore Roosevelt High School, nursing; Halie Battles, James Madison High School, pre-medicine; Kavitaa Dookran, William H. Taft High School, nursing; Andrea Green, Dillard McCollum High School, nursing; Kristen Guajardo, Earl Warren High School, physical therapy; Monica Guerrero, Winston Churchill High School, medical assisting; Sofia Hernandez, Sidney Lanier High School, nursing; Jacqueline Maldonado, Luther Burbank High School; nursing; and Amber Reyes Valdez, Louis D. Brandeis High School, nursing.
Presenting the scholarship checks on behalf of the BCMS Foundation were representatives from local corporate supporters of the foundation, including: Max Clark, Aspect Wealth Management; Dr. Gerardo Ortega, BCMS Foundation; Dr. Michael Magoon, Complete Urgent Care; Brody Whitley, Favorite Healthcare Staffing; Laura Holland and Fernanda Smith, Frost Bank; Dr. Vivian Ayoub, MCCI; Dr. David Henkes, Monica Delgado and Jennifer Rittimann, Pathology Reference Lab; and Connie Gilbert, PlainsCapital Bank. Seven students each received $1,000 from the BCMS Alliance (BCMSA), which represents the men and women who are spouses of physicians. Awards were presented by Cindy Comfort, BCMSA scholarship chair and past president. Scholarship recipients, high schools and intended fields of study included: Victoria Almanza, George W. Brackenridge High School, nursing; Annette Barraza, William J. Brennan High School, pre-medicine; Karla Estrada, Health Careers High School, biology; Lindsey Gutierrez, East Central High School, radiology; Audrianna Martinez, Luther Burbank High School, medical fields; Alexis Montoya, Highlands High School, nursing; and Samantha Van Koughnet, St. Anthony Catholic High School, biology.
NEW BCMS BUILDING TAKES SHAPE The four walls of the new BCMS building on Loop 1604 were raised June 8 as construction continues at the site, 4334 North Loop 1604 West, between Lockhill-Selma Road and N.W. Military Drive. Passers-by on Loop 1604 have a clear view of the Alamolike facade on the 20,000-square-foot building. Medical society employees have begun preparations for the move, which is expected at the end of the year. The BCMS Capital Campaign continues to raise funds for the new medical society building. Donations are 100 percent tax deductible when made to the Bexar County Medical Library Association, the 501(c)(3) subsidiary that controls the new property. To learn more, visit www.bcms.org. 12 San Antonio Medicine • July 2015
BCMS NEWS
GENERAL MEMBERSHIP MEETING FOCUSES ON HIE
SHANNON VOGEL
GIJS VAN OORT, PHD
BCMS members gathered May 7 at the Security Service Federal Credit Union corporate office for the spring general membership meeting. “Improving Patient Care with Health Information Exchange” was the topic addressed by guest speakers Shannon Vogel, TMA director of health information technology, and Gijs van Oort, PhD, executive director for Healthcare Access San Antonio (HASA), the local HIE provider for Bexar County and 22 surrounding counties. Participants enjoyed refreshments and free CME credit, as well as an opportunity to mingle with colleagues and representatives from the BCMS Circle of Friends program.
IN MEMORIAM Juan Carlos Hernandez, MD, died April 22, 2015, at the age of 56. A radiation oncologist, he was a BCMS member.
THANK YOU TO THE 2015 BCMS NEW MEMBER WELCOME SPONSORS MEDICINE LEADERSHIP TITLE SPONSORS
MEDICINE VISIONARY TITLE SPONSORS
ICD-10 Training
visit us at www.bcms.org
13
ZOONOSES
Zoonotic diseases:
When animals share with humans By Fred H. Olin, DVM, MD
Zoonoses, or zoonotic diseases, are those conditions which are endemic in other animals but which can be transmitted to humans. The word comes from the Greek roots for “animal” and “disease.” There is a related word, “anthroponoses,” which was new to me until I began researching this article. It refers both to diseases transmitted among humans, and those transmitted from humans to animals. For this article, I will use “zoonosis” and “zoonoses” for both situations when nonhuman creatures are involved. Zoonoses can be, and are, caused by all of the usual suspects found in the infectious disease pantheon: viruses, bacteria of all sorts, fungi, protozoa, spirochetes, and rickettsia, as well as multicellular organisms such as helminthes and tapeworms. Here is a list of just some of the conditions known to be zoonotic: Anthrax Avian influenza (bird flu) Babesiosis Bartonellosis Bilharzia Brucellosis (Relapsing fever) Borrelia (Lyme disease and others) Bovine tuberculosis Campylobacteriosis Chlamydophila psittaci Cholera Cowpox Creutzfeldt-Jakob disease Cryptosporidiosis Cutaneous larva migrans Dengue fever Echinococcosis Escherichia coli O157:H7
14 San Antonio Medicine • July 2015
H1N1 influenza virus Western equine encephalitis virus Venezuelan equine encephalitis virus Giardia lamblia Hantavirus Lassa fever Leishmaniasis Leptospirosis Listeriosis Lymphocytic choriomeningitis virus Marburg fever Mediterranean spotted fever Monkey B Ocular larva migrans Ornithosis (psittacosis, parrot fever) Orf (animal disease) Plague Puumala virus
Q-Fever Rabies Rift Valley fever Ringworms Salmonellosis Streptococcus suis Swine influenza Toxocariasis Toxoplasmosis Trichinosis Tularemia, or “rabbit fever” Typhus Venezuelan hemorrhagic fever Visceral larva migrans West Nile virus Yellow fever
ZOONOSES
Zoonoses can be transmitted in different ways. Direct transmission refers to the common way that we humans transmit disease
but nationwide raccoons seem to lead the list. Pet vaccination, required quarantine of domestic pets after a biting incident, and the
among ourselves: aerosolized particles or body fluids. In the case of zoonoses, this method involves three components: the infectious agent, the animal reservoir, and the human who acquires the disease.
use of oral vaccines distributed in baits for coyotes, foxes and raccoons have significantly decreased the prevalence of this nearly uni-
There are relatively few animal infectious diseases that are transmitted this way. Among the more common are rabies, tularemia, Q-Fever and brucellosis. Some ringworm fungi are common to humans and animals, but there seems to be some conflict about who had them first, particularly since some have been found thriving in soil. Indirectly transmitted zoonotic diseases require these three factors as well as a fourth, the vector. The vector can be water, soil, feces, or various arthropods, such as mosquitoes, biting flies (tabanids) or
baits started in 1995, and the latest statistic I could find indicated that 47,683,000 doses had been spread by air drops, over 664,100 square miles of Texas: this is an interesting bit of information from the Texas State Department of State Health Services (DSHS), since Texas has only 268,820 square miles! Compulsory immunization of dogs and cats has greatly decreased the incidence of rabies in much of the western world. According to the World Health Organization, each year more than 60,000 people die from rabies worldwide. In 2012 in the United States, 6,162 cases of rabies were diagnosed in animals; 92 percent of these were in wildlife. There was one human case that year. Below is an illustration from the DSHS website which demonstrates the effectiveness of the oral vaccines. There are two genetic variants of the virus, and two different baits have been used to attack the variants: as you can see, the incidence of animals diagnosed with these viruses has diminished greatly. There is also an oral rabies vaccine that is effective in raccoons and coyotes, but it does not seem to have been used in Texas.
ticks. Included among these conditions are malaria, plague, Lyme disease, and the various encephalitis viruses. Water-borne diseases include Giardiaisis (beaver fever) and cryoptosporidosis. My reading indicated that conditions which include transmission of toxins through animals, such as might occur if we eat fish contaminated by mercury, are not generally thought of as zoonoses. There isn’t time or space here to discuss the etiology, presentation, course and treatment of all of these conditions, but I thought it might be interesting to go over a few that have been around for a while and look at them from both the human medicine and veterinary medicine standpoints.
formly fatal neurologic disease. The use of oral vaccine-containing
TUBERCULOSIS RABIES Rabies is definitely endemic in Texas, and each year members of several species, both domestic and wild, are diagnosed as rabid. Here in Texas the animal most commonly found to be rabid is the skunk,
Bovine tuberculosis, caused by M. bovis, has been largely eliminated in the United States through the efforts of the veterinary profession, the dairy industry and the federal government. Tuberculin-based skin testing of cattle, which can evolve into “test and slaughter� programs, have been around since the early 20th century, and are supplemented by carcass inspection at slaughterhouses. When an animal tests positive, it is slaughtered and the herd is quarantined and tested some more. A carcass that is found to harContinued on page 16 visit us at www.bcms.org
15
ZOONOSES Continued from page 15
bor TB sets in motion an extensive epidemiologic investigation as the authorities attempt to determine the animal’s origin, how it came to slaughter, and how many other cattle it had been in contact with. Currently in the United States, bovine TB represents only about 2 percent of all TB in humans, and seems to be contracted largely by people who ingest unpasteurized dairy products from infected animals, which is the reason that unpasteurized cheeses, etc., from other countries are not permitted to be imported to this country. Bovine TB was the primary cause of bone involvement and its various deformities such as “hunchback.”
GIARDIASIS Giardiasis, or “beaver fever,” is caused by a protozoan parasite, Giardia lamblia, and has earned its colloquial name because it is harbored by beavers (among others) and can infect people who drink from crystal-clear mountain streams inhabited by beavers. There is also person-to-person transmission through fecal-oral contamination. It occurs quite commonly among small children in daycare settings. The disease is characterized by severe diarrhea and has the capability of causing severe dehydration. The most common treatment is with oral metranidozole (Flagyl).
Q FEVER Q Fever, caused by the very durable and highly infectious bacterium Coxiella burnetti, is one of those conditions that can be very difficult for the physician to figure out. The symptoms are those of nearly all generalized illnesses: fever, malaise, myalgia, sore throat, chills, cough, and so on. Researchers have postulated that as few as a single organism inhaled into a susceptible host can cause the disease. The bug is harbored primarily by sheep, goats and cattle, and is shed in large quantities in amniotic fluid and placental tissue. Transmission to humans seems to be mostly by inhalation of dust contaminated by these fluids and tissues containing the organism. It has been noted to have potential as a bioterrorism agent. In the United States, Q 16 San Antonio Medicine • July 2015
fever outbreaks have resulted mainly from occupational exposure involving veterinarians, meat processing plant workers, sheep and dairy workers, livestock farmers, and researchers at facilities housing sheep. Diagnosis depends on serologic testing. There has been a recent increase in funded research on zoonoses. Among others, Washington State and Kansas State universities have dedicated new facilities to these programs, and the University of Chicago, in conjunction with Field Museum of Chicago researchers, has started surveying 1,100 samples from small mammals and birds brought back from an African collecting trip looking for pathogens potentially transmissible to man. Now for my only experience with “reverse zoonosis”: When I was in small animal veterinary practice, we would often have a family bring in their new house-puppy because it became listless, wouldn’t eat, and felt hot. In the process of taking a history, we would often discover that the pup was a gift for a child, who spent a lot of time playing “kissy-facey” with his or her new friend. Examination would reveal a bright-red pharynx with perhaps a bit of pus on the surface, conjunctivitis and temperature of 103º F or greater (normal is 101.5º F). While we rarely did cultures, the almost miraculous response to the administration of procaine penicillin G by injection, followed by a few days of oral dosing, implied to us that the puppy had been infected with a Streptococcus sp. by its new owner. Fred H. Olin, DVM, MD, spent six years in veterinary practice with Thomas E. Vice, DVM, before entering medical school. During that time, he and Dr. Vice also were veterinarians for the San Antonio Zoo. Asking him about his experiences in veterinary medicine is not suggested if you have anything else to do that day. He is also a semi-retired orthopaedic surgeon and chairman of the BCMS Communications/Publications Committee. EDITOR’S NOTE: As this issue of San Antonio Medicine was heading to the printer, a case of Lassa virus was confirmed in a patient who died May 25 at a Newark, N.J., hospital. Lassa virus is a zoonotic disease that kills an estimated 5,000 people in West Africa annually.
ZOONOSES
Fleeing from fleas:
The most efficient killers in human history By Barbara R. Schmitz, LCSW
A young stray dog recently found his way into our home and hearts. He adjusted well, but we didn’t. Everywhere we walked, fleas would jump on our legs and bite us. None of the other animals had fleas before this fella arrived. We thought, “What’s going on? Do fleas attack humans?” Yes, they do! With warm weather comes an explosion in the flea population, which thrives in moist, warm environments. Dr. Edward Wozniak, Texas State Veterinarian, said there are many types of fleas in our area, the most common of which is the cat flea, which both dogs and cats carry. Cat fleas love to attack humans, and their bite hurts. “Flea bite dermatitis and murine typhus (Rickettsia muris and R. felis) are the primary risks associated with it,” Wozniak said. “Both species cause a rash and fever much like Rocky Mountain Spotted Fever with a slightly different distribution on the rash.” The flea, a wingless insect that attacks mammals and birds unmercifully, is a blood-sucking parasite. The word flea comes from the Old English fleah or fleon, “to flee.” The Latin is Pulex, meaning dust. Fleas are insects which seem to fly with their legs. Fleas look like a prawn with a hard, pointed or rounded head. They have an excellent sense of smell and taste, and poor sight. Some do not have eyes. They have powerful leg muscles and tendons and resilin in the thorax. Resilin is a rubber-like protein that delivers power faster than a contracting muscle when it is compressed. Resilin is what powers the wing beat in flying insects and is efficiently used by nonflying insects. They have muscles attached to the outside of their skeleton that they use to jump as much as 130 times their own body length, subjecting themselves to a G force of 200. Their ability to pull up to 50 times their own weight was what prompted humans to have flea circuses through the 1950s. 18 San Antonio Medicine • July 2015
LITTLE PERFORMERS These charming little performers are the most efficient killers in human history. The flea is a member of the insect order Siphonaptera. There are more than 1,370 species, of which 238 are found in North America. Fleas have no family life and are not a social insect. They lay large white eggs that are about l/50-inch-long. Eggs are laid in feathers, fur, carpets, upholstery, bedding, cracks in hardwood floors, dirt and decaying material found in nests, and living quarters of various animals. The flea goes through a metamorphosis. The larvae are small, legless maggots with a pair of antennae and biting jaws. A cocoon forms where larvae mature into adults who must have a steady diet of blood to survive. Larvae can drown or dry out and die. The adults live on live animals. Some even burrow into the host’s skin. Most must have a blood meal before they can develop and lay eggs. Then the cycle starts all over. Most can live several months. Their bite causes irritation and passes organisms into the blood of the host often causing infections. The flea’s mouth has a thin tube formed from three serrated needle stylets that are used for piercing animals and sucking up blood. Clawed feet are used for grasping feathers, fur or hair and getting down to the skin and biting. The three-segmented thorax has a pair of legs attached to each section. Hard plates encase the abdomen where you find its reproductive organs, digestive, respiratory, and circulatory systems. The snap you hear when you attempt to kill a flea is this plated abdomen cracking. To protect itself, the flea can curl into a ball. They inject saliva containing an anticoagulant before blood sucking begins. (Can this saliva be used as a blood thinner?) Most fleas live on rodents, insectivores and bats. Humans, pigs, cats, dogs, primates, opossums, hedgehogs and some birds are known to have infestations. Aquatic mammals and most hoofed mammals
ZOONOSES rarely are bothered. Antarctica has its own penguin flea. Rock doves have their own flea. Some species infest poultry by attaching themselves permanently to the birds’ naked skin. Jigger fleas burrow in the human skin causing a cyst, leading to sores and secondary infection upon removal. Nest fleas are found in swallow and martin nests. Fur fleas mostly live on fur or hair. According to Guinness, at least 13,000 fleas were removed from one red squirrel — squirrels seem to have more fleas than other fur animals. Most fleas feed and breed on various hosts, although some limit themselves to just one host. The most deadly flea in the world in the rat flea. When they bite, if infected, they can transmit diseases through the bacterium Pasteurella and Yersinia pestis, the plague bacteria. Bubonic plague was mostly due to a flea that usually lives on rats which are not immune to the plague. They would infest the rat until it died, then infest people in areas where poor hygiene permitted rats to live in large numbers. The plague is spread from human to rat and rat to human from the saliva of fleas. The black death in mediaeval times created epidemics because most homes were not free of rats. The plague of the Middle Ages (14th century) killed at least 25 million people. They kill more people than wars. According to Dr.
Wozniak, most endemic foci are centered on prairie dog towns. Tapeworms infest dogs and cats when bitten by an infected flea. Fleas also can transmit typhus, tularemia, undulant fever and other diseases as well as the pneumonic and bubonic plague. Fortunately these parasites have many enemies. Mites eat fleas in all of their stages; small beetles who often live in birds’ nests eat fleas and their larvae; and dogs and cats accidentally eat them when cleaning themselves. There are some effective products on the market that clear fleas from an animal up to 100 percent. There are products placed on the skin of the animal once a month. Getting rid of dirt and debris where they live helps. Wash your pets’ bedding every week in hot water and detergent, groom your pets daily with a flea or finetoothed comb, and drown the fleas you gather in soapy water; vacuum your home frequently especially where your pets hang out; avoid flea collars. Other controls that can be successful are biological, by using other predators, parasites or diseases to control the fleas; sterilization by chemicals or radiation so they can’t reproduce; quarantine which tries to prevent the insects from entering the country, and chemicals which uses insecticides but are dangerous and can upset nature’s balance by destroying beneficial insects. Continued on page 20
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ZOONOSES Continued from page 19
Texas does annual surveillance for plague where it is found, mostly to the west around Brewster County up through the Texas Panhandle. But fleas still lurk in your yard, on wild animals, cracks in the floor, bedding, furniture, rugs — nearly everywhere. They are a battle that seems to be unbeatable.
REFERENCES 1. Arnett, Dr. Ross H. and Dr. Richard L. Jacques, Jr., Guide to Insects, Simon & Schuster, Inc., New York, 1981, pg. 19. 2. Cavendish, Marshall, Ency. of Animal Life, Part 28, Fleas, Marshall Cavendish Publisher, 1973, p. 780. 3. Hanson, Jeanne K., The Beastly Book, Prentice Hall, General Reference, NY, 1993, pg. 135. 4. Kennedy, Des., Nature’s Outcasts, Storey Communications, Inc., Pownal, Vermont, 1993, pp. 24-32. 5. Lehane, Brendan, The Compleat Flea, London. John Murray Ltd., 1969. 6. Mound, Laurence, Eyewitness Books, Insects, Alfred A. Knopf, New York, 1990. 7. O’Toole, Christopher, The Ency. of Insects, Andromeda Oxford, Led., Oxford., 1995, pp. 78-79. 8. Wood, Gerald L., Animal Facts and Feats, Doubleday and Co., Inc., Garden City, New York, 1972, pp. 288-289. 9. World Book, Encyclopedia, , Insect, World Book, Inc., 1992, pp. 278-301. 10.Villee, Claude A., Warren F. Walker, Jr., Frederick E. Smith, General Zoology 2nd edition, W.B. Saunders Co., Philadelphia and London, 1963, p. 763.
Barbara R. Schmitz, LCSW, attended Carnegie Mellon University and the University of Pittsburgh, graduating with a specialization in business education and an avocation in zoology. She received a master’s degree in social work from Our Lady of the Lake University. She writes about animal life and lore for various publications.
20 San Antonio Medicine • July 2015
LIFESTYLE
Does your home have an IQ? Yes, but you may not know what it is. By Bjorn’s Audio, Video and Home Theater Photography courtesy of Bjorn’s Audio, Video and Home Theater
Everyone’s talking about smart homes nowadays and if you believe what some companies are saying, smart homes are going to revolutionize the way we live, solve problems we didn’t know we had and even improve our love life! (No, we’re not making that up.) It sure sounds wonderful. After all, who wants to live in a dumb home? But what exactly is a smart home and how does it work? Well, “smart home” is basically a new term for something that has been available for decades, although not as wide spread. We’ve been calling it “home automation” all this time.
22 San Antonio Medicine • July 2015
S
mart home automation often starts with a single, easy-to-understand home theater remote control that replaces the usual three or four. It can also dim the room lights and lower the shades. You can even use it to lock and unlock your doors and adjust your thermostat’s temperature! But that’s not all a smart home can do. You can install cameras for monitoring your home, seeing who’s at the door or checking on the kids. While you’re at it, you can teach your home to be more comfortable to live in while saving lots of energy - and do it automatically whether you’re at home, at work or on vacation half way around the world. In the not-so-distant future you will be able to control most electronics in your home from your smart phone or tablet. Everything from your coffee maker to
your refrigerator will be controlled, even to the point where you will be able to check the date on the milk or see how many eggs you have. The idea behind a smart home is to make it user friendly and as comfortable as possible while being energy efficient at the same time. Savant, Control 4 and RTI are all companies that offer state-of-the-art smart home systems. These systems communicate with nearly anything with a computer chip. They are all very similar and offer as much or as little connect and control as you want. Savant and Control 4 offer apps that allow you to use your tablet or smart phone to control your new smart home. By doing this, it allows you the ability to control things like door locks, lights, temperature and even music from anywhere at any time.
LIFESTYLE
In addition, the ability to monitor lifestyle and health issues are available and are only going to become easier to use and more affordable as well. Just image having your heart rate, blood pressure and calories burned checked just by pressing a button on your wall or your smart phone. Now add the ability to contact your doctor or emergency help automatically and you can see where things are going. While most of this will work with Bluetooth, you will still need help with the network along with custom installation and wiring. That’s where Bjorn’s Audio, Video and Home Theater in San Antonio comes in. They are specialists in custom installation and networking for all smart home and home automation needs as well as audio, home theater and multi-media rooms.
Whether you’re ready to increase your home’s IQ or you just want a better audio system, Bjorn’s can handle it and even come to you if needed. So if you liked the Jetsons when you were a kid, you’re going to love the new smart home. Smart home or home automation? No matter what you call it, it makes you a very smart homeowner. And what better time to increase your home’s IQ than during a home renovation?
RESOURCES Bjorn’s Audio, Video and Home Theater 210.828.3237 / 800.223.6991 www.bjorns.com
LIFESTYLE
San Antonio Restaurant Weeks expand to accommodate diners By Ginger McAnear Robinson
The increasing popularity of San Antonio Restaurant Week by Culinaria has led to the extension of the event to San Antonio Restaurant Weeks on Aug. 15-29. As participation from the restaurants and the community increases, Culinaria officials agreed that now is the time to extend the offering. “By adding the week in August, patrons have more chances to return to a restaurant that they really enjoyed, or they can continue exploring some that they weren’t able to make it to in the first week,” said Suzanne Taranto-Etheredge, President/CEO of Culinaria. “As we continue adding restaurants to the lineup, we want to make sure that guests have the opportunity to dine at all of the places on their wish list.”
CULINARY COMMUNITY Now in its sixth year, Restaurant Weeks highlight San Antonio restaurants and help promote local business while also providing the ultimate chance for the returning foodie or curious newbie to try new things and maybe find a new favorite restaurant. It’s a celebration of the unique culinary community that San Antonio has to offer, with each participating restaurant preparing to take guests’ taste buds 24 San Antonio Medicine • July 2015
on the culinary adventure of a lifetime. The menus created by the chefs range from decadent and extravagant to fresh and simple with unique twists. Participating restaurants will offer a prix-fixe, three-course menu for lunch and dinner at prices of $15 and $35, respectively, for tier one, and $10 and $25, respectively, for tier two. Restaurants are busy during this time, so reservations are encouraged and should be made directly with the restaurant. During San Antonio Restaurant Weeks, anything goes as some of the restaurants change things up a bit as well. Some that are open only for dinner might open for lunch during the promotional period. Culinaria posts as many of these details as possible on its website, along with menus, so check CulinariaSA.org for updates. Because San Antonio Restaurant Weeks benefit Culinaria, guests’ dining experiences are charitable ones. With each meal purchased from the San Antonio Restaurant Weeks menus, restaurants will donate $1 for lunch and $2 for dinner to Culinaria and the programs it supports. Culinaria is a not-for-profit organization dedicated to benefiting the San Antonio community and promoting the city as an ideal
LIFESTYLE
wine and food destination. By providing culinary scholarships and aid to San Antonio’s chefs enduring personal hardships, Culinaria has long promoted its support of the community. The organization also has plans in the works for the Culinaria Urban Farm that will hone in on nutritional values and education to promote a farm-totable diet. Currently, Culinaria continues to raise funds through a capital campaign while also searching for the perfect plot of land for the venture. Events throughout the year continue to provide guests with a chance to support the San Antonio culinary community while also assisting with funding the causes that Culinaria supports. In addition to Restaurant Weeks, the organization features Rambling Rosé, a blind wine tasting at Becker Vineyards, on Aug. 8.
are witness to the action as well as the recipients of the elegant dishes. The experience is delicious and interactive. The new year for Culinaria begins with the most recent addition to the schedule – the inclusion of a winter Restaurant Week in January. In the spring, the organization hosts a fitness component with the 5K Wine and Beer Run March 21. It’s a 3.1-mile run around the Shops at La Cantera and features a wine, beer, food and fun after-party.
MORE UPCOMING EVENTS
Culinaria Festival Week is May 20-22. The festival is what started it all for the organization, and it features multiple events that highlight some of the most delectable wine and food that the San Antonio area has to offer. Featuring local, regional and international chefs, and wine, spirits and beer, Culinaria Festival Week is filled with events for everyone and every taste.
On Sept. 20 is the most exclusive event for the organization, Chefs and Cellars, a multi-course seated dinner showcasing rare and hardto-find wines as part of the pairing. The event takes place in the kitchen of the Culinary Institute of America, San Antonio, and is always a sell-out. Six chefs cook for 12 guests each in the kitchen and
For more information, visit www.culinariasa.org, call 210-8229555 or email info@culinariasa.org. For social media updates on Twitter, Facebook and Instagram, search for Culinaria San Antonio and @CulinariaSA. visit us at www.bcms.org
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UTHSCSA DEAN’S MESSAGE
Center for Research to Advance Community Health strives to improve South Texas health, healthcare By Francisco González-Scarano, MD
Everyone deserves high-quality, cost-effective healthcare that delivers the best possible health outcomes. Achieving this requires identifying those advances that offer the greatest benefit to patients and to define the best ways to provide this care to all members of the community. This is preferably done through collaborative research among investigators from many disciplines in partnership with representative members of the community. The Center for Research to Advance Community Health Center (ReACH) offers a broad-based academic-community partnership that seeks to reduce gaps for those with poor access to high-quality care, improve overall healthcare delivery and, ultimately, promote a healthier South Texas. ReACH is a multidisciplinary collaboration supported by two institutions: the University of Texas Health Science Center at San Antonio and the University of Texas School of Public Health, particularly through its San Antonio Regional Campus. ReACH’s director is Barbara J. Turner, MD, a professor in the department of medicine who came with me from the University of Pennsylvania in 2010 to establish the center in partnership with the Health Science Center’s vice president for research.
DIVERSE DISCIPLINES AT WORK Currently, ReACH has 23 PhD and MD scholars from five institutions: UT Health Science Center, UT San Antonio, South Texas Veterans Health Care System, UT School of Public Health (San Antonio Regional Campus) and UT College of Pharmacy. They are from diverse disciplines, including statistics, epidemiology, health services research, informatics, economics, psychology, anthropology, community engagement and behavioral medicine. ReACH scholars currently are working on a wide array of projects; a few examples include improving outcomes of persons with uncontrolled diabetes or hypertension; preventing liver damage and liver cancer through screening and treatment of hepatitis C virus (HCV) infection; preventing and reducing obesity in Hispanic families; improving functional outcomes of persons suffering from chronic pain; and improving the overall healthcare of persons with HIV. The center also provides educational and research opportunities for students. In the most recent School of Medicine Research Day, held in May, ReACH MD/MPH students presented talks and posters that described results from focus groups with persons recently diagnosed with HCV infection, which explored their understanding of the disease, as well as results from an analysis of patients newly diagnosed with HCV infection, showing that Hispanics who were overweight or obese had three times greater risk of having severe liver disease. 26 San Antonio Medicine • July 2015
Dr. Turner, who also is a practicing general internist at the University Health System’s Robert Green Campus downtown, cites partnerships with the South Texas Area Health Education Center (AHEC) as the place “where the rubber really meets the road.” She credits much of the success of ReACH to South Texas AHEC Director Paula Winkler, MEd, who has more than 30 years of experience developing linkages between academic programs and community-based health promotion and disease prevention initiatives. With responsibilities for Bexar and 11 other counties, Ms. Winkler maintains very effective community relationships that offer the basis for ReACH’s collaborations with community providers and patients.
COMMUNITY EDUCATION The center also is guided by a community advisory board called the Alliance, which is composed of 15 diverse community members representing everything from the military to the city health department and other communities. The advisory board meets monthly to discuss ways to make ReACH’s work relevant and sustainable in the community. Recently these discussions have focused on identifying effective ways to educate the community about chronic pain prevention and management, as it is the most common cause of disability and lost productivity in Texas and throughout the United States. The center also focuses on research that addresses the needs of South Texas’ large medically underserved Hispanic population. In a project funded by the Patient-Centered Outcomes Research Institute (PCORI), a government agency that funds research specifically on patient decision-making and health outcomes, ReACH and the South Central AHEC are partnering with community-based AgriLife Extension programs in Karnes and Frio counties to elicit community members’ priorities for research to improve the function and health of persons with chronic pain. The combined efforts of this partnership engaged 65 primarily Hispanic community members with chronic pain and their caregivers in a series of meetings and focus groups. Most participants had used prescription pain killers (opioids) for chronic pain and many had significant constraints in their activities due to pain; it was evident that the healthcare system and treatment with narcotics were not meeting their needs. The groups generated a wide array of ideas to help community members manage pain more effectively, such as affordable exercise programs, education about stretching, and behavioral support, all of which will guide ReACH’s community-based initiatives and research. Working with local patient groups and local physicians has
UTHSCSA DEAN’S MESSAGE
The Alliance comprises community stakeholders from ReACH and the South Central AHEC (Area Health Education Center), who gather monthly to discuss health priorities and how the partnership can work to build capacity for high-quality healthcare delivery systems.
The Community Engagement Team of the Clinical Translation Science Award at UTHSCSA gathers during the 2015 Community Engagement Symposium. Barbara J. Turner, director of the ReACH Center, works closely with Melissa Valerio, dean of the UT School of Public Health San Antonio Regional Campus.
offered insights about community needs that will increase the relevance and feasibility of planned programs. The collaboration with AgriLife Extension programs, which have strong roots in the community, facilitates community engagement activities and increases the likelihood that community partnerships will be sustainable. This partnership is leading to pilot projects to operationalize some of the priorities identified by the community members.
MONITORING MEDICATIONS In other work on chronic pain management, using data from more than 200,000 persons enrolled in a national healthcare plan, Dr. Turner and Dr. Yuanyuan Liang, an associate professor in the department of epidemiology and biostatistics and a ReACH Scholar, have looked at the risks of medications such as opioids and Valiumtype drugs in regard to drug overdose and future hospitalization. In three studies published this year they offer novel ways for physicians to monitor the amount of medication that a patient has been prescribed in order to reduce the risk of serious complications related to these drugs. Another important ReACH initiative targets persons with diabetes through a program funded by the Centers for Medicaid and Medicare Services (CMS) through the Medicaid 1115 waiver. The program assists physicians in internal medicine and in the Family Health Center at the downtown Robert B. Green campus to reduce high rates of uncontrolled diabetes and or/uncontrolled hypertension in their mostly uninsured Hispanic patient population. This ReACH program is guided by a registry database, overseen by
Shruthi Arismendez, MS, who is currently a doctoral candidate in the department of psychology at UT San Antonio specializing in health psychology. The diabetes intervention program has several components targeted to improving diabetes control in patients with an HbA1c greater than 9 percent, who are at great risk of complications such as kidney failure and loss of vision, and to reducing uncontrolled hypertension which is the most common cause of heart disease. First, two highly trained nurses and three bilingual case managers offer personalized support through phone calls, office visits and educational programs for patients who need to improve their outcomes. Second, primary care physicians are provided feedback about the quality of their patients’ care and offered evidence-based guidelines to utilize when treating patients. Third, patients with mental health issues that are preventing them from managing their diabetes and/or hypertension are being managed in collaboration with Dr. Donald McGeary, assistant professor in UTHSCSA’s department of psychiatry. The next step is to bring in peer support, where other patients suffering from the same medical conditions help coach patients not meeting their healthcare goals. This real-world advice may offer additional support to improve these outcomes.
TESTING BOOMERS FOR HCV Two other large projects, also funded by the CMS 1115 Medicaid Waiver, implement national guidelines for testing of all baby boomers (born 1945-65) for HCV infection and linking those who are chronically infected with appropriate HCV care. Seventy-five Continued on page 28 visit us at www.bcms.org
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UTHSCSA DEAN’S MESSAGE Continued from page 27
percent of the estimated 4 million persons infected with HCV in the United States are baby boomers, and half of them are unaware that they have a disease that can cause their livers to fail or to develop liver cancer. HCV screening and treatment programs are being implemented in primary care practices in the Rio Grande Valley and in Bexar County. These outpatient practices are adopting methods that reflect lessons learned from an HCV screening project funded by the Centers for Disease Control and Prevention where more than 4,500 patients admitted to University Hospital were screened for HCV, and 175 persons were newly diagnosed with HCV and provided assistance to obtain follow-up care and treatment with highly effective medication. These programs rely on extensive physician, staff and patient education as well as use of the electronic medical record to identify eligible patients. Patients who test positive for HCV learn about the infection and its treatment using a mobile device-based educational program in English or Spanish, supplemented by explanations from trained health professionals. This program is being implemented in partnership with Dr. Julio Gutierrez, a hepatologist at the Texas Liver Institute. ReACH welcomes opportunities to partner with primary care providers throughout the South Texas region in improving health outcomes of their patients and in meeting national quality of care metrics. The community advisory board – the Alliance – is also seeking individuals who are interested in promoting the health of the
28 San Antonio Medicine • July 2015
community through research in collaboration with experts from UT Health Science Center. The ReACH Center’s programs and affiliated researchers are involved in so many different departments, programs, studies and specialties that we have only been able to touch on a few here. Because of their work with local providers, clinics and their patients, ReACH really is at “ground zero” of healthcare reform in our region. The center’s impact on our region’s healthcare is already felt and has the potential to improve healthcare broadly in the United States through multi-institutional collaborations around the nation. Creating change and promoting improvement in healthcare is a slow and challenging process at all levels. It will take programs like this, with diverse specialists working together with the community, to achieve the healthcare system that will serve us best. For this reason, the ReACH Center deserves our praise and support. Learn more about ReACH at http://reach.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
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EDUCATION
Annette Gutierrez (left) and Lori Boies
Demystifying the doctor:
An early introduction to a life in medicine By Lori Boies, PhD, and Annette Gutierrez, MEd When interacting with college freshmen, many of whom consider themselves “pre-med,” it is always interesting to hear their varying motivations to pursue a life of medicine. Their reasons range from pure interest in the human body to altruistic motivations to the stereotypical ideal of a “good life” full of fast cars and country clubs with a few patients sprinkled in for good measure. Many, however, do not know what it is like to be in a doctor’s shoes for a day; their experiences with physicians typically have consisted of how physicians are portrayed in the media, movies and sitcoms, as well as intermittent visits to their family’s doctor while growing up. In efforts to help give students a clearer picture of the life of a physician, before devoting years to both medical school and a residency, the department of biological sciences at St. Mary’s University has developed a structured, semester-long course titled, “Internships in Medicine and Dentistry,” targeted toward sophomore-level students. The goal is to allow potential future physicians (and dentists) to build a relationship with a physician mentor and begin to develop an idea of the true experience, responsibility and time commitment required to be a physician. Selected students received HIPAA and OSHA certifications before touring facilities and meeting their mentor in January. Over the 30 San Antonio Medicine • July 2015
course of 14 weeks, the mentors and interns spent 40-plus hours discussing medicine, as the interns shadowed and helped the physicians and dentists. This year, the course included 17 students, 14 physicians and two dentists. In addition to shadowing, students were given opportunities to learn about current healthcare laws, ethics, and common practices on what makes a good physician. Many students experienced life-changing moments that confirmed their interest in medicine/dentistry and became re-energized in studying for their courses. The relationship built between the mentor and the student allowed for honest conversations that, most likely, would not have happened had the student just shadowed the practitioner one or two times as compared to an entire semester. The following quotes truly highlight the value of this course to our students. “If I had to summarize my experiences into lessons, I would explain how I have learned to look past the surface, value and respect human life, and the importance of passion and love in/for the medical field.” – Jacqueline D. Carballa “I’ve been given the great opportunity to shadow my mentor not only in a hospital, but her private practice. Having that opportunity has shown me the difference in working in two different environments, and
EDUCATION helped me decide which kind of environment I wish to work on.” – Itzelth Gonzalez “With the help of St. Mary’s, I was able to get a more in-depth view of what being an OB/GYN is all about. My mentor is amazing! She explains in detail what everything is, and she is always so full of energy. I can honestly see myself being a great physician like she is. My educational goals are to successfully obtain a bachelor of science in biology and a bachelor of arts in chemistry.” – Nancy Garcia “My internship experience has exposed me to the field of medicine and allowed me to spend some days in a doctor’s shoes. It confirmed my love for the field and motivated me to continue the path I have chosen.” — Edith Torres “This experience has expanded my knowledge of the various fields within healthcare, which has motivated me to continue.” – Jesus Bocanegra
“I feel that this internship experience has fortified my decision to pursue a career in the medical field. It exposed me to a variety of aspects of the medical field that I wasn’t aware of.” – Liliana Espinoza
If you are interested in being a physician mentor for this course, please contact Annette Gutierrez at agutierrez56@ stmarytx.edu or 210-436-3611. Lori Boies, PhD, is an instructor at St. Mary’s University in the department of biological sciences. She is married to BCMS member Brian Boies, MD, who is an anesthesiologist and pain medicine physician at UTHSCSA. Lori is an active member of the TMA Alliance and BCMS Alliance. Annette Gutierrez, MEd, serves as the prehealth professions advisor at St. Mary’s University. In her first year of service, she taught and helped to coordinate the internship course.
BCMS Mentoring Initiative links physicians with medical students, residents, fellows The Bexar County Medical Society Mentoring Initiative was launched in May to provide 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 e-mail or telephone, meeting trainees for coffee or a meal, and providing shadowing opportunities. The Mentoring Initiative is open to all BCMS members. For more information, contact BCMS membership director Brissa Vela by email at Brissa.Vela@bcms.org or at 210-301-4371.
visit us at www.bcms.org
31
LEGAL EASE
Six Tips
to becoming an expert on FMLA By George F. “Rick” Evans Another set of initials to remember — just what you wanted, right? FMLA. Short for the Family Medical Leave Act. It isn’t a new law. In fact, it was passed more than two decades ago. Yet, there are still a lot of misunderstandings of what it means, what it does, how it affects you and so on. Here’s the scoop on the basics of what you need to know. The purpose of the law is to support family structures by allowing an employee to take time off to tend to family matters. How much time? What sort of family matters qualify? With or without pay? These are the sorts of questions employers need answers to unless they want to wind up in court. The U.S. Department of Labor received, on average, one complaint by a disgruntled employee every 80 minutes every single working day in 2014. So, what do you need to know as an employer? And, of equal import, what are your rights as an employee? Here are six things that will make you a curbside expert in FMLA. First and foremost, this federal law only applies to companies with 50 or more employees. Smaller businesses don’t fall under its auspices and are exempt from its provisions. But, note that all 50 employees don’t have to work at the same location. It’s legally sufficient if there are 50 employees within 75 miles.
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Second, not all employees benefit from FMLA. Only those who have worked for the employer for at least 12 months and put in 1,250 hours during those 12 months are cov-
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32 San Antonio Medicine • July 2015
ered. Those 12 months of employment don’t have to be consecutive. Instead, the service time can be pieced together over a period of time. Third, any employee seeking to invoke this law is entitled to time off from his/her job but it’s not an unlimited amount of time — it’s 12 weeks per year. Under some circumstances, the employee can take time off in small chunks (i.e., a few hours a day) rather than take entire days and weeks off work.
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Fourth, The employee can’t be fired or replaced during this time. The job, or a substantially similar job (i.e., comparable pay, responsibility, etc.) must be protected for the employee to resume upon his/her return. And the employee can’t be penalized in any way for exercising his/her rights to take leave. Fifth, time off is without pay. Employers may chose to pay some or all of the employee’s time off, but that’s not required under this law. And, the employer may be able to require the employee to first use up his/her vacation or paid time off days which, of course, is typically time off with pay.
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Sixth, the definition of a family matter is exceptionally broad. It includes events such as the employee’s own serious medical problems, pregnancy, the birth or adoption of a child or placement of a foster child, and the serious medical problems of a spouse, child or parent. There are separate, more liberal rules for employees who need time off to care for a member of the military.
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LEGAL EASE Let’s look at some scenarios. Can you take off to care for your dying uncle? No, he’s not a parent, child or spouse. Can you take time off to drive your mom back and forth to her regular doctor visits? Probably not, because it’s not a serious medical condition. Can a gay employee take time off to care for his critically ill partner? Probably not in those states which don’t recognize gay marriage, although some federal courts may well rule to the contrary. A Texas federal judge recently didn’t allow it although the Supreme Court will likely soon settle the matter. Can a husband take time off to care for his newborn child even though he obviously wasn’t the one who was pregnant? Yup, FMLA treats moms and dads the same. Now that you’re an expert in FMLA, you should have no trouble identifying when you or your employees can invoke it. It’s a potent law intended to assure that employees can get unpaid time off, without risk of losing their position, in order to address parenthood and to deal with important medical issues facing themselves and their immediate family. George F. “Rick” Evans Jr., is the founding partner of Evans, Rowe & Holbrook. A graduate of Marshall College of Law, his practice for 36 years has been exclusively dedicated to the representation of physicians and other healthcare providers. Mr. Evans is the BCMS general counsel.
visit us at www.bcms.org
33
BUSINESS OF MEDICINE
Understanding value in the healthcare market By Lee W. Bewley, PhD, FACHE Value in healthcare has become a dominant theme in the U.S. healthcare market, driven in part by the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA). Indeed, given national expenditures of nearly $3 trillion for healthcare among approximately 300 million people, many economists might reasonably report that the U.S. healthcare system generates more value than any other market in the world; however, a complete review of the system also would indicate that more healthcare waste, perhaps as much as 20 percent to 30 percent of total expenditures, is a product of that same value-generating system in the United States. 1, 2 A number of market developments associated with value are attributed to the PPACA, including reimbursement processes tied to quality, Accountable Care Organizations (ACOs), and evolved relationships between healthcare institutions and providers. Each of these trends is derived from an over-arching principle that health-
34 San Antonio Medicine • July 2015
care resources should be more effectively matched with value. 3 To provide a clearer sense of how healthcare resources might be more effectively managed within a value-based market, a few economic concepts and principles are reviewed in this article. Additionally, the following model is provided as a framework for understanding how value generation and resource exchanges are achieved in contemporary markets. Michael Porter has provided a substantial basis for understanding the nature of how value is created and measured in the healthcare market. The prime variable of measurement, value, is found by evaluating the ratio of healthcare outcomes relative to total healthcare costs (financial and economic). In normal human assessment of benefits and costs, a person or group of people would use value to determine if a service or product was “worth it” in terms of what was received vs. what was spent. 4
BUSINESS OF MEDICINE
or systems generate value by the interconnected elements of service and support systems. Service systems include pre-service, point of
Porter’s value chain provides a model of how health organizations
ACOs are actions taken to improve or enhance the ability of healthcare organizations and systems to generate value matched against current and expected resource exchanges. In many cases, principles
service, and after-service elements which correspond to each incre-
of quality management, economies of scale and economies of scope
mental step of how a patient receives service. Similarly, support systems including culture, structure, and resources drive each of the service systems. In essence, an organization or system’s value chain represents the potential capacity for value generation. Organizations or systems that have well-integrated services and comparatively rich support elements have greater value-generating capacity. On the other hand, ill-developed service systems or resource-constrained organizations or systems can be expected to have diminished valuegenerating capabilities. 4,5 Finally, the fundamental theorem of exchange illustrates how goods, services and resource consideration interact in markets. The basic point of this principle is that individuals and groups of people seek to be “better off ” or to enjoy some incremental level of benefit or satisfaction in life which provides a basis for resources to be exchanged to achieve those outcomes. Exchanges of resources should be expected to occur naturally between parties in a market provided the estimation of what is given and received are judged to be mutually beneficial. 6
are driving business decisions in reshaping value chains. Going forward, patients and providers may be well-served to consider each of the value elements associated with the exchange of resources in healthcare markets. Healthcare organizations and systems will naturally seek to provide services and products that are needed and/or wanted, but should consider that the costs to meet market demand may substantially decrement evaluations of value. Similarly, patients, beneficiaries and other stakeholders may be well-served to consider expected outcomes and associated costs necessary to generate healthcare products and services in consideration for payments, insurance premiums, and taxes provided to facilitate the exchange of resources.
MEETING THE THRESHOLD
York Times. Economix Blog. Available at: http://economix.blogs.nytimes.com
REFERENCES 1. Centers for Medicare and Medicaid Services (2015). National Health Expenditures Highlights. Available at: http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/high lights.pdf 2. Reinhardt, Uwe (2013). Waste versus Value in American Health Care. New
To understand current and forward-looking healthcare developments associated with the value-based market system, consider the elements of the model. The center element, exchange of resources, is predicated on the principles of the fundamental theorem of exchange and holds that healthcare consumers, third-party payers, government institutions and taxpayers will provide financial resources to fund value-generating healthcare activities if the exchange is mutually beneficial. These individuals and groups will use value (ratio of health outcomes to cost) to assess whether current or ongoing resource exchanges meet the beneficial threshold. Healthcare organizations and systems must consider and shape their own capacity to generate value within their value chain in a manner that favorably corresponds with estimates and/or perceptions of value in order to remain a going concern. Consider changes in the current healthcare market within this framework. When Centers for Medicare and Medicaid Services adjust reimbursement for readmissions after surgical procedures, resource exchanges are being adjusted to match “what is given” and “what is received” in the market. Healthcare organizational mergers, increased integration of providers and organizations, and the rise of
/2013/09/13/waste-vs-value-in-american-health-care/?_r=0 3. Gamble, Molly and Herman, Bob (2013). Becker’s Hospital Review. Three Years of PPACA: The 5 Biggest Changes in Healthcare Since the Law’s Passage. Available at: http://www.beckershospitalreview.com/hospital-management-administration/3years-of-ppaca-the-5-biggest-changes-in-healthcare-since-the-laws-passage.html 4. Porter, Michael (2010). What is the Value of Health Care? New England Journal of Medicine. Volume 363. 2477 – 2481. 5. Ginter, Peter, Duncan, Jack, Swanye, Linda (2013). Strategic Management of Healthcare Organizations (7th edition). Jossey-Bass. San Francisco, California 6. Getzen, Thomas (2010). Health Economics and Financing (4th Edition). Wiley Publications. Hoboken, New Jersey.
Lee W. Bewley, PhD, FACHE, is a retired Army officer, associate professor of healthcare management, and a board-certified healthcare executive. He is a faculty member in the Walker School of Business at Webster University in St. Louis. He has served as the program director of the Army-Baylor University MHA/MBA program and as an adjunct faculty member at the University of Texas at San Antonio, Trinity University and University of the Incarnate Word. visit us at www.bcms.org
35
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BIOMEDICAL WASTE DISPOSAL The Bank of San Antonio (HHH Gold Sponsor) Brandi Vitier 210-807-5581 brandi.vitier@thebankofsa.com Baptist Credit Union (HH Silver Sponsor) Sarah Chatham 210-525-0100, ext. 201 memberservices@baptistcu.org www.baptistcu.org
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37 ELECTRONIC MEDICAL RECORDS
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38 San Antonio Medicine • July 2015
Warm Springs Medical Center Warm Springs Thousand Oaks Warm Springs Westover Hills (HHH Gold Sponsor) Central referral line: 210-592-5350 Elite Care Emergency (HH Silver Sponsor) Marketing Liaison Dlorah Martin, 509-592-7998 dmartin@elitecareemergency.com Marketing Liaison Kylyn Stark, 210-978-4110 kstark@elitecareemergency.com www.elitecareemergency.com Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/
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39
BOOK REVIEW
‘Killing Jesus’ Written by Bill O’Reilly and Martin Dugard Reviewed by J.J. Waller Jr., MD “Killing Jesus” is the third book by Bill O’Reilly and Martin Dugard considering the “death” of an important figure in history, which includes “Killing Lincoln” and “Killing Kennedy.” This presentation concerns one of the most influential individuals who ever lived, Jesus of Nazareth. The first third of the book concerns the 50-year era of Roman history preceding the birth of Jesus. Details of the lives of certain prominent historical figures are presented, providing a clear background of the times, including Julius Caesar, Herod the Great, Caesar Augustus, Cleopatra, Anthony, Tiberius and Pontius Pilate. Beginning with the birth of Jesus during the reign of Herod the Great, Herod’s attempt to eliminate all newborns is discussed. What is actually known of the early life of Jesus is reliably represented. Life was extremely hard with severe oppression and high taxation from Rome. Religious observances had to be celebrated in the high temple in Jerusalem where purchase of animals for sacrifice and money changing was controlled by the Sadducees (the high priests). At 30 years of age, Jesus was baptized by John the Baptist in the river Jordan. This was the first suggestion that Jesus was someone special. He realized that he could no longer remain silent and that it was time to commence fulfilling his destiny. Over the next several years, his preaching and his discussions with thousands of common people were based on his message of peace and love. This, together with his episodes of healing, began to entrench in the many that he actually was the Messiah who for centuries had been predicted by the ancient Jewish prophets. With his ideas, he began to challenge the world’s most powerful men. Near the time of Jesus’ death, Herod Antipas (the son of Herod the Great) was tetrarch of Galilee. Pontius Pilate was the new governor of Israel, and Tiberius was the ruler of Rome. The religious head of the Jews was the temple high priest, Caiaphas. He along with certain other Sadducees and Pharisees constituted the 40 San Antonio Medicine • July 2015
79-member religious court, the Great Sanhedrin, which had absolute authority to enforce Jewish religious law. Caiaphas was not a moral, honest high priest, and he and Pontius Pilate collaborated to keep the Jewish people subdued and under the authority of Rome. Various Sadducees tried repeatedly to trap Jesus into admitting he was the Messiah and the Son of God (a blasphemy punishable by death). Agents of Pilate tracked Jesus and his disciples continuously to determine if he was promoting rebellion. However, the time eventually came. The people were declaring Jesus the prophesied king of the Jews and the son of God. Betrayed by Judas as to his location, Jesus was arrested by the Sanhedrin. They tried him for the highest blasphemy, convicted him, and sentenced him to death. However, the civil law of Rome dictated all death sentences must be reviewed by the local governor. Jesus was brought before Pilate, who listened but was unable to find that Jesus had legally broken any Roman law. He referred the case to the tetrarch Herod, who refused to accept any responsibility and sent him back to Pilate. This was a touchy legal dilemma because Tiberius, the ruler in Rome, respected the Jews and their moral stand on issues. Pilate finally “washed his hands” (a legal way to indicate no responsibility), and gave the Sanhedrin the right to decide. They declared Jesus must be executed. Jesus of Nazareth was dead at age 36. The man who preached the gospel fearlessly, who introduced a new faith of goodwill and love for all, was finished. He never was forgotten and now has billions of followers throughout the world. The book is an excellent narrative. Historical basis is found in the gospels of the New Testament, and in histories by Josephus, Pliny the Younger, Philo and many other Jewish, Greek and Roman authors. This is a most entertaining read. J.J.Waller Jr., MD, is a member of the BCMS Communications/Publications Committee.
Matin Tabbakh is well known for his “Make it Happen” attitude. He has been actively involved in the Real Estate industry for over a decade. Having experience in both Luxury Residential and Commercial properties, Matin has a proven record of Excellence! He has earned a Broker’s Real Estate License which is the highest professional licensing in the state of Texas and an Accredited Luxury Home Specialist (ALHS) designation; he is an active member of the CCIM Institute (Certified Commercial Investment Member) as well. Matin’s real estate education, business academics and experience are exceptional; his success comes from his unsurpassed need of excelling at what he does! Matin’s expertise in the Luxury and Commercial market makes his knowledge priceless! If you want to achieve outstanding results, call Matin for a private consultation.
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(210) 772-7777
Ancira Chrysler 10807 IH-10 West Gunn Acura 11911 IH-10 West
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* Gunn Infiniti 12150 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
Ancira Nissan 10835 IH-10 West Ingram Park Nissan 7000 NW Loop 410
Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)
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Cavender GMC 17811 San Pedro Ave. Batchelor Cadillac 11001 IH-10 at Huebner
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Tom Benson Chevrolet 9400 San Pedro Ave.
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Gunn Chevrolet 12602 IH-35 North
Gunn Honda 14610 IH-10 West (@ Loop 1604)
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* North Park Lincoln/ Mercury 9207 San Pedro Ave. North Park Subaru 9807 San Pedro Ave.
Ingram Park Auto Center 7000 NW Loop 410
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43
AUTO REVIEW
VW Golf TDI
worthy of all its accolades By Steve Schutz, MD
The 2015 Volkswagen Golf, the seventh generation of that familiar car, is remarkably unassuming for a vehicle that’s won so many prestigious awards. North American car of the year, Motor Trend Car of the Year, Car and Driver Ten Best, you get the idea. And yet the new Golf doesn’t turn any heads when you drive it around. I suspect that’s fine with the decision-makers at Volkswagen who care about sales more than awards or looks from pedestrians, and the Golf certainly sells. At least it does internationally, where the Golf is a perennial bestseller in countless countries. Here in the 44 San Antonio Medicine • July 2015
United States, though, the Golf lags behind its more popular showroom sibling, the Jetta. With the newest Golf, Volkswagen clearly intends to increase Golf sales, first by making a very good car (check), and then by flooding the American market with more variations of the Golf than we’ve ever seen before (they’re getting there).
SEVERAL VARIATIONS We’ll get to that first bit in a second, but the Golf variations that are coming soon are worth discussing. The first Mk7 Golf sold here was the GTI which launched in early
2014, followed by the standard two- and four-door hatchbacks with their numerous conventional drivetrains, including the TDI diesels. Now we have a hybrid Golf, and soon the Jetta Sportwagen, which currently sits on the previous Golf platform, will be replaced by the more logically named Golf Sportwagen. True Volkswagen enthusiasts will get the Golf R, an AWD performance car for drivers who think the GTI is too tame, and certain markets — I’m guessing not to include San Antonio — will get the all-electric eGolf. Despite utilizing an all-new modular platform called MQB that’s engineered to under-
AUTO REVIEW
pin everything from the small and not sold here VW Polo to the Audi Q3 CUV, the new Golf looks a lot like the old one. Yes, the 2015 Golf has more modern head- and taillight assemblies that are very well done and almost Audi-esque, and the familiar shape includes more angles and creases than before, but I’d be surprised if any casual observer could confidently tell the sixth and seventh generation Golfs apart. Inside, on the other hand, the new Golf is significantly more up to date. The Golf has always had a nice interior, but the new one has even better materials and a state-of-theart user interface for all of the various func-
tions that we used to not have and now can’t live without, like automatic climate control, satellite radio, Bluetooth audio, navigation, and smartphone connectivity. With each new Golf, the car gets a little bit bigger, which is good for interior space and crash worthiness, but not good for weight, so VW engineers are to be commended for keeping the Golf down to around 3,000 pounds. Credit the increased utilization of lightweight materials such as aluminum and titanium. While the media and your usual assortment of experts have been focusing on hybrid technology and electric cars, automotive engineers have been busy making the internal combustion engine better with ever-improving fuel efficiency and emissions. The latest TDI engine — TDI stands for turbo direct injection, by the way — like the one in my test car is a revelation. Quiet with very little diesel rattle, fuel efficient like a hybrid, surprisingly quick thanks to all that diesel torque, and very green, the Golf TDI is a treat to drive in all situations. It’s most comfortable cruising on the interstate (using low revs and very little fuel), but the Golf TDI does fine running errands in town or zipping around your favorite back roads. For the record, the TDI engine is 2.0 liters in size and uses twin turbochargers to produce 150 HP and 236 lb-ft of torque. The Golf TDI is rated at 31 mpg city and 43 highway. As always, while hybrids generally get worse fuel economy than the EPA cycle would have you believe, diesels usually beat their EPA numbers.
MANUAL GEARBOX For 2015, the only other (non-GTI/R/hybrid) engine option for the Golf is the 1.8liter turbo four-cylinder gas-powered TSI. The vast majority of buyers will select the sixspeed automatic transmission, but Volkswagen thankfully hasn’t killed the manual gearbox yet. Get it while you can. As a car designed to appeal to a wide array of income levels, the Golf has an almost infinite number of options and packages. BCMS Auto Program director Phil Hornbeak will happily help you decide how to equip your Golf to make it best fit your own personal reality. The seventh generation Golf is the best one yet and is worthy of all the accolades it has received. It won’t get you noticed by valets or even your neighbors, but the Golf is a pleasure to experience. Its essential goodness plus the increased variations now coming to the United States will certainly increase its popularity here. How much is yet to be seen, but I’d like to see more out there, especially TDIs. 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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HELP WANTED Bexar County Medical Society members for BCMS Communications/ Publications Committee. Should have little or no experience, be willing to brainstorm, eat supper at the BCMS office once each month, and participate in free-wheeling, stimulating discussions to produce the magazine you’re reading at this moment. For information, call Susan Merkner at
210-582-6399. 46 San Antonio Medicine • July 2015