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SEPTEMBER 2015
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VOLUME 68 NO. 9
THE WONDERS OF
RETIREMENT
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The Wonders of Retirement
SEPTEMBER 2015
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VOLUME 68 NO. 9
San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.
Easing into retirement, step by step
EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Email: editor@bcms.org
By Julie Catalano.......................................................14
The Exit: Retiring from Academic Medicine, Part 1 By Rajam Ramamurthy, MD.......................18
MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org
No regrets about decision to retire By Richard Thorner, MD ............................................22
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BCMS News ....................................................................10 Book Review: ‘Hausfrau’, Written by Jill Alexander Essbaum, reviewed by Fred H. Olin, MD ....................................................25 Nonprofit: ACEs high: How Magdalena House builds resiliency to beat the odds ....................26
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Lifestyle: 16th Annual Texas Wine Trail set for October by Oliver J. Bourgoin ............................28 UTHSCSA Dean’s Message: San Antonio Breast Cancer Symposium by Francisco González-Scarano, MD ..................................................................................................30 Legal Ease: Disastrous Labor Laws by George F. “Rick” Evans Jr.........................................................32 Business of Medicine: SCOTUS & ACA and the winner is by Joseph P. Gonzalez, MHA, FACHE ........34 BCMS Circle of Friends Services Directory ............................................................................................37 In the Driver’s Seat ..................................................................................................................................43 Auto Review: Ford F-150 by Steve Schutz, MD ......................................................................................44
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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.
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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 Col. Bradley A. Lloyd, 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 Mike Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Jay S. Ellis Jr., MD, Member Karl W. Janich, MD, Member Karen C. McQueen, Alliance Member Jeffrey J. Meffert, MD, Vice Chair Esmeralda Perez, Community Member Rajam S. Ramamurthy, MD, Member J.J. Waller Jr., MD, Member Kenneth C.Y. Yu, MD, Member
6 San Antonio Medicine • September 2015
PRESIDENT’S MESSAGE
Constant vigilance helps protect organized medicine from harmful laws By James L. Humphreys, MD 2015 BCMS President
During a year in which numerous actions of considerable import could have changed the practice of medicine in Texas, not that many aspects actually changed. The list of things that didn’t change is instructive, however, and illustrates just how fluid a situation our practices are in and the need to pay careful attention to our regulating bodies and their actions. We had lots of potential action in both the state and federal legislatures this year and an important case before the Supreme Court to boot. Here’s a quick review of what happened. First, the Affordable Care Act provision for federal subsidies survived a technical attack that easily could have made it fiscally non-viable. This situation could have gone either way, and there was very broad interest in the court decision, which declared the federal premium subsidies to be constitutional and kept the act unchanged. Further attacks by opponents of the act will no doubt be forthcoming, but this looked like their best shot to derail the act. In the federal legislature, the much-hated SGR formula was finally repealed, after 17 years of concerted lobbying to have the broken and misguided formula removed. While this is generally a good thing for physicians, the federal government managed to tack on a lot of potentially bad offsetting conditions in the usual fashion. I consider this a positive first step, but feel that our work on this issue is not complete as long as
8 San Antonio Medicine • September 2015
physician reimbursement is at least partially based on a seriously flawed quality outcome metrics scheme. At the state level, we have just seen the occupations tax repealed and the franchise tax reduced which is good for taking off a few hundred dollars in fees for physicians each year. As an aside, it may be hard to feel the benefit of this in the face of egregious Bexar County property tax assessments that also were levied this year. The state finally increased the funding for graduate medical education in a small step toward easing the physician shortage in the state. What didn’t happen at the state level was any allied health provider scope of practice expansion despite a number of efforts to do so. There was no significant alteration to the hard-won tort reforms of 2003 either this session. Medicaid was neither expanded nor particularly reformed, although I don’t believe that the state will not be able to avoid either of those two things for long. While many of the worst possible changes to medicine were avoided this year, you can see that there is unrelenting pressure on medical practices from a broad number of fronts. Constant vigilance is our only effective defense. 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 NEWS TEXAS PUBLIC RADIO RECEIVES TMA MEDIA AWARD
BCMS LEGISLATIVE AND ADVOCACY NEWS the Attending Border Health Conference and representing BCMS was Jesse Moss Jr., MD (left), speaking here with Congressman Will Hurd (Texas District 23).
David Martin Davies (center) of Texas Public Radio was honored by representatives of BCMS and the Texas Medical Association Aug. 11 with a 2015 TMA Anson Jones Award. Davies received an honorable mention in the in-depth radio category for a special edition of “Texas Matters” entitled “Problems Facing Texas State-supported Living Centers. Entries were judged on accuracy, significance, quality, public interest and impact. On hand for the award presentation were (left) Dr. Rajam Ramamurthy, a BCMS past president, member of the BCMS Communications/Publications Committee, and member of the TMA Council on Health Promotion, which oversees the Anson Jones Awards, and TPR president and CEO Joyce Slocum. Tammy Wishard, TMA’s outreach coordinator, and Marcus Cooper, TMA’s multimedia manager, coordinated and attended the event.
IN MEMORIAM Edward Livingstone Anderson, MD, died Aug. 1, 2015, at age 89. Dr. Anderson was a U.S. Navy veteran, a family medicine practitioner and a BCMS life member. Albert Hugo “Doug” Douglass, 65, died June 18, 2015. Dr. Douglass was a BCMS member. Howard Jay Hassell, MD, died July 28, 2015, at age 72. An orthopaedic surgeon, Dr. Hassell was a BCMS member.
10TH ANNUAL BORDER HEALTH CONFERENCE HELD IN EL PASO By Mary E. Nava, MBA Chief Governmental and Community Relations Officer The TMA Border Health Caucus, of which BCMS is a member, held its 10th annual meeting Aug. 5-6 in El Paso. This year’s conference was led by Congressman Beto O’Rourke (Texas District 16), and Manuel Acosta, MD, of El Paso, and Luis Benavides, MD, of Laredo, chair and co-chair, respectively, of the Border Health Caucus. Panel discussion topics included: healthy eating and active living; emerging diseases; healthcare literacy; GME; physicians and new technology; coordination of care; ACA and a post SGR discussion with Congressman Michael Burgess. For local discussion on this and other legislative topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at Mary.Nava@bcms.org.
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THE WONDERS OF RETIREMENT
Easing into retirement, step by step By Julie Catalano
Photo this page: Dr. Fernando Guerra and his wife, Beverly Purcell Guerra, went to Ecuador in May 2015, and visited El Panecillo, a hilltop just south of Quito’s historic center, and the site of a unique statue of a winged Virgin Mary. Photo opposite page: Dr. Guerra enjoyed the view from a hotel room in Cuenca, Ecuador, during a visit in May 2015. PHOTOS BY ROBERTO ‘BEAR’ GUERRA
14 San Antonio Medicine • September 2015
Retirement is turning out to be a step-by-step process — and a very rewarding one — for notable San Antonio physician Fernando Guerra, MD, MPH, FAAP. As the longtime director of health for the San Antonio Metropolitan Health District, Dr. Guerra oversaw the operation of 32 health locations throughout the city and several additional areas of Bexar County, worked to improve access to underserved populations, established groundbreaking initiatives at the health district, and through it all, maintained an active practice in pediatrics. Along with numerous positions in local, regional and national organizations, appointments to various boards and committees, contributions to medical literature, and much more, Dr. Guerra’s professional life showed a consistent dedication to raising awareness of important issues in public health — a passion that continues to this day, five years after he retired from the health district. “I tried to prepare for retirement,” Dr. Guerra said. “I would say that it was easier to break away from public health and the administrative responsibilities, than from pediatric practice because of the long-standing relationship with children and their families — in some instances, the second- and even a few third-generation families. However, having very experienced and devoted staff in both public health and pediatrics ultimately made the transition easier.”
THE WONDERS OF RETIREMENT
Retirement also has provided Dr. Guerra with the golden opportunity to spend more time with his family. He and his wife of 33 years, retired editor of San Antonio Woman, Beverly Purcell Guerra, travel as much as possible to visit their six children and eight grandchildren in Ecuador, San Francisco, Dallas, New York, Denver and Los Angeles. Family reunions are a challenge, but they do their best to get the entire brood together “maybe every other year. We’ve had some wonderful family gatherings,” he said, “when we can find a house large enough to accommodate us.” Over the years the group has met in Santa Fe, Ojai and San Diego, CA, and last year in a house on the Guadalupe River near Seguin. “That was fun,” he said. Meanwhile, phone calls, Skype and emails keep everybody in touch. For now, the couple remains in the home where the kids grew up. “It gets pretty quiet around here. Beverly and I prefer not to downsize just yet.” When not visiting children and grandchildren, they take drives to the Hill Country, go downtown, visit museums and walk on a regular basis, although not as much as they used to. “I have mobility issues related to some chronic back problems,” Dr. Guerra said. Treatment involved surgery and a fusion “that has really restricted my mobility.”
Still, Dr. Guerra stays busy in much the same way he always has, although he said it’s on a lesser scale. He gives a few carefully selected talks a year, serves on the bioethics committee of the Children’s Hospital of San Antonio, and is a clinical professor of pediatrics at Baylor College of Medicine, and adjunct faculty at University of Texas at San Antonio and the University of Texas School of Public Health where he enjoys “the wonderful opportunity” of interacting with and mentoring some of the public health and pre-med students. Dr. Guerra is on the Community Health Advisory Board at the University of Texas Health Science Center San Antonio and UTSA’s Advisory Council for the College of Science. He also is chairman of the board of the Children’s Environmental Health Institute in Austin. At the national level, he serves on the ethics committee for the March of Dimes, is on the editorial board of a pediatric publication, and is a member of the Institute of Medicine, the Public Health Accreditation Board and the Urban Institute Board of Trustees. Despite the awards and accolades for his many years of teaching, practicing medicine, and providing public service, Dr. Guerra said that in the end, it’s really all about giving back. “When you’ve had the privilege and opportunity to obtain a Continued on page 16 visit us at www.bcms.org
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THE WONDERS OF RETIREMENT Continued from page 15
Dr. Guerra inspected a child with a bad burn at Dong Ba Thin, Vietnam, 10th AVN dispensary, on Feb. 22, 1966. OFFICIAL U.S. ARMY PHOTO COURTESY GUERRA FAMILY.
medical education, to be credentialed as a physician, and to take care of and learn from patients in the community, one cannot get to that level of accomplishment but for tremendous public support that goes into education and training programs for medicine,” he said. “So I feel very strongly about the obligation that we as physicians have to give something back.” Upon his retirement and to that end, Dr. Guerra founded the Fund for Public Health, under the umbrella of the San Antonio Area Foundation. In a recent meeting with his board, they discussed how to “serve and engage the community in public health, and ways to leverage [the fund] to bring the broader community together around specific issues that will hopefully better inform the community about public health, and improve the health and
16 San Antonio Medicine • September 2015
well-being of the population.” They are currently in the process of developing a website. In case this is sounding less and less like retirement, Dr. Guerra explained his post-career lifestyle and why it works: “Our schedules are still fairly busy, and Beverly and I are quite involved with any number of activities, but we do find time for each other.” For two people so embedded in their careers, a full stop was never an option; a gradual reduction seemed a more gratifying and realistic path. “Maybe it’s better to do it this way. It seems to be working, and we’re having a good time, and still taking time to appreciate the beauty around us.” Julie Catalano is a freelance writer in San Antonio.
THE WONDERS OF RETIREMENT
The Exit:
Retiring from Academic Medicine, Part 1 By Rajam Ramamurthy, MD
18 San Antonio Medicine • September 2015
THE EPIPHANY
I really did not want to retire. I had to. I have always functioned at about 10 years below my age level, kind of got stuck at 60 for quite some time now. I never worried about money, my husband did that. There is lab evidence for that in his A1-C hemoglobin and lipid profile. I woke up every morning eager to go to work. Work was overwhelming, and I thrived in that environment. Is that not what physicians like to do? Keep doing what we do best. In academics, we are immortal. We take care of the patient, push the frontiers of research and teach to create new health workforce. We can do this forever. It was 11 p.m. one night two years ago. I was at the home computer. Like clockwork, my husband got up to go to bed. Like clockwork he asked, “What are you doing tomorrow?” In the beginning this annoyed me. What would I do? I will wake up, get dressed and get to work same as him. Later, I realized that it was his way of making me remember my meetings, appointments and
THE WONDERS OF RETIREMENT other commitments. I leaned back in my very comfortable chair and stared at the ceiling. Yes, I will wake up in the morning, get dressed and go to work. The years will fly until illness or death will end the routine. Is it time to complete your life when you still had full control over it? I wanted a completely uncluttered life when I visited my children and grandchildren. I want to chronicle a world of experiences. I cannot get up every morning, get dressed and go to work. I will retire. When I was struggling with the structure for writing about retirement, the three-legged stool — teaching, service and research that faculty are inculcated in — came to the rescue. So in what I am hoping will be a three-part article, teaching, of course, will be first. How did I “still” do the teaching leg of the stool? When I gripe, it is about a system, a philosophy or culture. Individual people have touched my life and shaped it in incredible ways, and to them I give my eternal gratitude. I want you to at least chuckle if not split your sides as you read on.
WHAT SETS AN ACADEMICIAN APART From the moment of that epiphany to 17 days ago (Sept. 30, 2014) was like coming down a gigantic slide. First, the discussion with the division head, “You are sure you want to do this?” The division has grown since the time I joined in 1977 from two neonatologists to 12. Yes, it is time to make space. “What about teaching?” he continued. I thought to myself: “You dazzle every group of eager students with your fascinating collection of skin conditions in the newborn baby.” I decided to give my slide collection to one of my junior colleagues. I think she has the temperament to talk about the mundane Erythema Toxicum, a very benign rash in the newborn baby, as though it is the most intriguing trade secret. Teaching is a calling that keeps many physicians in academics. A reassuring smile to a shy 5-year-old in my dance class who is struggling to balance on one leg, or guiding the hands of a nervous third-year medical student doing the first newborn physical exam — teaching is a calling and a gift. When you get a call in the middle of the night from a colleague who was a former resident, it shows the comfort zone you have created where the learner feels comfortable approaching you. When a smiling dad announces that he sold the television, when you are about to begin your speech on “No TV for your baby for two years,” that is a success story. When in the month of July, a resident confidently enters the delivery room with knowledge of CPR after attending the CPR course for the newborn baby during orientation, that is progress. When in a small village in a developing country, the traditional birth attendant applies modern concepts of resuscitation that are visionary. These interactions have clearly helped my own lifelong learning. They also have given me bright new ideas for teaching in different ways. I know I will always be a learner, striving to find ways to light that
spark of learning in those who seek. After receiving most teaching awards that the university gives to recognize teaching excellence, not teaching will leave a very big void.
TEACHING IN PERSPECTIVE: A REALITY CHECK In September 2014, I was giving my last lecture for the didactic lecture series that is repeated every month. The medical students and residents on rotation in the NICU and newborn nursery had gathered. As usual, I gave them the choice of “skin” or “developmental outcome of the premature infant.” The senior residents chorused “skin.” It is like a choice between “Harry Potter” and “Harriet Lane.” I was delighted. I announced to the group that it was the last time I would be lecturing on the topic and that I was retiring at the end of the month. The lecture went well with one “wow” slide after another, a collection of 44 years of clinical work since my residency. At the end of the lecture, there was dead silence. The residents hurried back to finish the day’s work and get home. The students lingered chatting with each other. Hello! I just gave the last didactic session of my academic career. There was no applause, no thank you. I slowly closed the laptop and turned the projector off. How I wished there was a colleague by my side to acknowledge that small act of my academic life. There was no closure. A new term was forming in my head: post academic stress tolerance (PAST). This would not have happened back in the days when I entered the institution, 37 years ago. Albeit the total amount of time spent in each discipline (medicine, surgery, pediatrics, OB/Gyn, psychiatry, family medicine and others) has not changed, much of the opportunity for bonding between the learner and each faculty involved in their educational process is drastically reduced. In the past, faculty in each rotation got to know the learners more, spent more time together. Besides ensuring that a certain volume of knowledge and skills were being taught, much more learning occurred through observation, bedside laying hands on the patient, emulating behavior, interactions with the team caring for the patient, navigating the system to get things done, conversation with family — all helped shape a physician. At the end of a rotation, a group of mentors knew a group of students reasonably well. It was not uncommon at the end of the rotation to go out or sit in the café to eat where the mentor and students revealed a truer self; this is part of the hidden curriculum. Although changes have been brewing for at least the past 25 years, as early as the 1960s evidence had started to accumulate that the public at large no longer perceived medicine as having an unwavering commitment to public service. To quote The Handbook of Sociology of Medical Education: “The rise of corporate medicine, the emergence of medical marketplace, Wall Street’s discovery Continued on page 20 visit us at www.bcms.org
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THE WONDERS OF RETIREMENT Continued from page 19
of medicine as an object of capital investment, even the growth of academic health centers as a research enterprise and the marginalization of medical schools teaching mission in favor of research and clinical enterprises, all helped to highlight that medicine as an occupation had lost its way.” Today most medical schools in the United States are on an allout effort to recapture the “soul of the profession.” The six core values are the “mantra”: patient care, medical knowledge, practicebased learning and improvements, interpersonal and communication skills, professionalism, and system-based practice. At the same time, the very core of communication, continuity, learning and patient care is threatened by the paranoia about duty hours. You cannot have the cake and eat it also, as my Mom used to say. Let the learner and the teacher be; there is so much to teach and so much to learn. The overly structured attempts to humanize, professionalize and inter-personalize is choking the spirit. The teaching leg for faculty except the ones designated to do that has already gone limp. The medical schools that have a clear track for climbing the academic hill hardly have a half-beaten path on the other side of the hill. Here are some pearls from personal experience. Plan at least a year in advance the date of your retirement; at least two years in advance if you plan to apply for emeritus status. Don’t spend time and money digitizing old slides and don’t save them; they deteriorate over time from some chemical change like photographs in the self- stick albums. If you have more than one lateral file cabinet to clear, consider dying on the job. Someone else will not bat an eyelid throwing your papers in the bin. I had five file cabinets. I would read each document and save at least a third of them for future use! If anyone has found a way to dispose of plaques and awards, please write an article about it. There is nothing you can do with them as sentimental and precious as they are. Never make the mistake of taking them home; there is no wall space. The moment of exit was set. As a prelude you receive multiple emails on which you are only copied, from strange departments in the medical school. “She is good,” one read — I liked that one, it was about not having any payment arrears. Another one stated: “Make sure it is turned in.” Someone in my department replied, “No one has used it in at least 20 years. What does it look like?” Answer, “It is a rectangular thing that has pins at one end to plug into something.” By now I was much stressed and frantically threw everything from my shelf into a box (note, not in the garbage). Bingo! Here it is — the beautiful key to the copy machine. I hugged it, it brought back floods of memories of staying till 9 p.m. copying tests for the NRP course. Then there was the lab coat which I had not worn in years. My savior, our division adminis20 San Antonio Medicine • September 2015
trator, knew exactly where it would be, where the entire division’s lab coats hung except Dr. Stribly and Dr. McCunin, who you won’t catch without their coats. Having been in the military has something to do with it, like you can set your watch by the time Strib (as we call him fondly) comes to work which drove some of us crazy. Finances learn it quickly. There are things like annuity, IRA (It is not the Irish Republican Army), residuals, you are lucky if you have a good financial advisor like I have. Beware of many others who will try to advise. Slow and steady and having a financial whiz for a husband helps. In spite of all his wisdom I have insisted on having my finances managed by a separate person, the old adage don’t put all the eggs in the same basket. One of my goals was to do the charitable activities that are important to know when I am in full control of my faculties. It may mean not doing some things personally but the satisfaction of an endowment for the premature infant development program at the University of Texas Health Science Center has given me enormous joy. It is like leaving a piece of you connected to something that defined you: care of very tiny premature babies. The medical schools have archaic, tedious procedures for the physical aspects of retiring but have nothing for the emotional and psychological aspects of this human being who is making a life change. Retiring from patient care was the most difficult transition that took marathon effort for me. I will talk about that in the next article. Had I submitted my application for emeritus status, would things have been easier? Faculty who are eligible for this honor must consider going through this process years in advance. I was appointed adjunct faculty. It enabled me to continue the research work I want to complete. Edward Burns, executive dean of Albert Einstein College of Medicine, in his advice to a colleague said, “I think the successful formula for the retiree is to pick the one aspect of one’s job that ignited the most passion during the career years, be it clinical work, research or teaching, and devote oneself totally on a volunteer basis to that endeavor. You’ll never be bored or lonely while remaining in the environment you’ve always cherished.” I couldn’t have said it better. It will be interesting to hear our readers’ experiences with retirement or suggestions for the transition. Rajam Ramamurthy is professor emeritus in the department of pediatrics, division of neonatology, UTHSCSA. She retired on Sept. 30, 2015. Dr. Ramamurthy continues to pursue her research interest in the area of prematurity. She is a past president of the Bexar County Medical Society and is active in organized medicine.
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THE WONDERS OF RETIREMENT
No regrets about decision to retire By Richard Thorner, MD After several years of considering the oftasked question, “When are you going to retire?” and finally becoming comfortable with the concept, last summer I decided that October 2014, just before a longplanned, three-week trip to South Africa, would be the beginning of the next stage in my life’s journey. I was about to turn 67 and though when 30 I expected to retire at the ripe old age of 60, it didn’t feel right at that time. I have been lucky to remain in good health and always thought I walked through the hospital with the same brisk step and confident outlook I had as a senior resident. I do not know how the newer MDs (who are younger than my kids!) see me — as I see myself or as an “old physician” from another era? I took one week of vacation the first year I was in practice, but now I was taking more and more time off (I counted nine planned weeks in 2014 plus long weekends as they might occur) but never left without feeling uneasy about what might happen to my patients in my absence. I was also becoming more aware of the daily emotional toll we accept as “part of the job.” I think most of us downplay how different a clinician’s emotional burden is from that which any other professional is asked to assume. Those stresses, handled by some better than others, have unfortunately contributed to the disruption of many of our colleague’s professional and personal lives. In addition, I was less than enamored of the hospitals’ use of EHR (let alone the
22 San Antonio Medicine • September 2015
THE WONDERS OF RETIREMENT EHR we had installed in the office which does not “speak” with the hospitals’ EHRs) and while I made peace with creating electronic progress notes, I drew the line at CPOE. I felt as if I were being asked to replace a ward clerk. I was open to someone convincing me that patient care would truly be improved by these “innovations,” but, alas, no one did. It just made sense that this was the time to hang up the stethoscope and leave for safari with a clear head.
year veteran of the clinic) who, to my surprise, chose to leave with me. In January 1980 we set up a practice restricted to the Medical Center which has morphed into San Antonio Infectious Diseases Consultants – a group soon to grow to 11 physicians in four locations. The current senior physicians in the group (Luis, Richard Fetchick and Carl Berkowitz) remain among the best doctors I have worked with during my career.
MEDICAL CENTER EXPANSION LONG, INTERESTING JOURNEY It had certainly been a long and interesting journey. I am part of the early boomer generation, born in 1947 and raised in Brooklyn, N.Y. In 1964, I was the first in my family to go away to college where I was not in the 50 percent of my class who identified themselves as “pre-med.” It wasn’t until the following summer that I decided to pursue medicine. Our long-time GP had died that year and when I needed to see a new physician I was struck by the contrast between him and the recently departed Dr. Stein. Corny as it may seem, I felt that emulating my childhood physician would be a noble path to pursue. Though I was a year behind in pre-med studies, I was able to leave college after three years, graduate from Harvard Medical School in 1971, and, by 1978, complete residency at Columbia, my military obligation and an ID fellowship at the Hospital of the University of Pennsylvania. Having been introduced to the Southwest by Uncle Sam (he stationed me in El Paso to guard the border during the Vietnam War!), we (Alice, now my wife of 46 years, and I) chose to settle in San Antonio after we spent two miserable winters in Philadelphia with small kids at home. I love when I meet provincial Northeasterners, who upon hearing we live in San Antonio (to which they have never been) ask, “Do you like it there?” as if we wouldn’t have left if we were unhappy. I joined Chuck Lerner, who was desperate for help, at the Diagnostic Clinic where we shared his small office. Jack Williamson and Gordon Bilbrey gave me my first hospital consult — a diabetic patient with end-stage renal disease and a gangrenous infected foot needing amputation, not antibiotics. Little did I know that stopping antibiotics, rather than prescribing them, would be the “bread and butter” of infectious diseases! For the first year and a half, Chuck and I saw consults all over the city because there were no other ID MDs, exclusive of the university and the military. That came to an end when Luis Cisneros opened his downtown office and Bruce Wood came on staff at Northeast Baptist. I became a partner in the clinic in 1979 but at the same time decided it was not where I wanted to spend my career. With trepidation, I went to explain my decision to leave to Chuck (an eight-
When I came to the Medical Center in 1978 the landscape was certainly different. Methodist Hospital had only a two-story north tower and the south tower; Women’s and Children’s Hospital, the START Center, Christus Santa Rosa, Medical Center Towers, Lifecare, RIOSA, MASH, Kindred and Texsan did not exist. Methodist Plaza was under construction. St. Luke’s Lutheran Hospital had just opened with three oddly configured floors. There was only one Physician’s Plaza. There was no Transplant Institute at MSTH (which was Community Hospital) and there were no, now ubiquitous, parking garages. The medical school had not crossed Medical Drive and it was Bexar County Hospital, not University Hospital. Back then, physicians could smoke – even cigars — in the hospital and have their coffee brought to them in the nurses’ station. There were some physicians who behaved openly like petulant, spoiled little boys. They would scream at and belittle hospital employees and expect no one to correct their behavior. That has come to be seen by all for what it is, totally unacceptable. We did not know of HIV, we only put scopes into the GI tract, we had no cardiac stents – nor statins, and transplanted no organs. Everyone was not hooked up to a monitor. We were just learning that CAT scans could be done of more than just the brain and who knew of an MRI or PET? There were no cyber knives, and only humans, not robots, did surgery. If you were an “FMG” it meant that you had graduated from medical school in Mexico — or north of the Red River! The diversity in the medical community that has since occurred has added many fine new physicians. Family practitioners and internists admitted their patients and there were no hospitalists. Residents and fellows remained at the university, BAMC or Wilford Hall even though we, in the private sector, knew we had wonderful clinical material to contribute to their training. Everyone took ER call and most hated it. In the Medical Center, I recall there were six gastroenterologists, two pulmonologists, seven cardiologists, 10 radiologists (without digital imaging), two nephrologists, an endocrinologist (every primary care doc could take care of diabetes) and three hematologist/oncologists, to say nothing of the surgical Continued on page 24 visit us at www.bcms.org
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THE WONDERS OF RETIREMENT Continued from page 23
specialties. Men actually went into OB/GYN. We had to attend several medical staff meetings monthly at which we often did not accomplish much but they gave us the opportunity to have personal interaction with many of our peers. Doctors were actually able to determine a meaningful charge for their services as opposed to accepting someone else’s valuation of what we do.
GROWTH OF RESOURCES It is somewhat amazing to look back on the growth of both the “bricks and mortar” and human resources since I arrived. One would expect that American medicine has taken us to the Promised Land. Yet, since 1978, we have had a nearly three-fold increase in our inflation-adjusted per capita healthcare costs (now greater than $9,300/year for each American) to achieve a one- to two-year increase in life expectancy! I will leave to others to debate the meaning of this. I did not have a “day-to-day” plan for retirement last year, and I still don’t. I find that I am not at all bored, do not recall twiddling my thumbs and live each day as it comes — wherever that may be for we have had the opportunity to travel widely. This might not be for some but I, after nine months, am without regret of the decision to retire.
24 San Antonio Medicine • September 2015
I cannot imagine having done anything different in my professional life than what I did, for it was rewarding beyond imagination. Personally, living in San Antonio has been a joy; it is a wonderful place to raise a family — echoed by having our older daughter, after 19 years away, return with her husband and kids to live all of three miles from the house in which she grew up. If my other son-in-law’s job would allow, our younger daughter would be here in a heartbeat. Why would we ever move to a “retirement community”? It has been my privilege to have spent my entire medical career in this community in which so many excellent physicians have given superb care to so many in need. Putting the emotional stress aside, I miss the satisfaction and sense of reward one gets from healing the sick. I treasure the personal ties I formed, and intellectual stimulation I received, from many of you who are instilled with the same passion for, and dedication to, the practice of medicine that I lived by. To my colleagues: Please carry on in the best traditions of all who came before us. I wish you well. Richard Thorner, MD, was an Infectious Disease and Internal Medicine physician and is a BCMS retired member.
BOOK REVIEW
‘Hausfrau’ Written by Jill Alexander Essbaum Reviewed by Fred H. Olin, MD
When I read this novel, I was moved more deeply by the protagonist Anna Benz’s problems with life than I had been by any book I’ve read in years. The sadness and disconnectedness of her life depressed me to the point that the distressing feelings lasted a day or two. Then I decided to write a review of it, and went looking for reviews by the professionals … I usually do so when I get the urge to write and submit one of these. I discovered that I must be much less sophisticated than the reviewers for various national publications, websites and blogs. They thought it was superficial, that Anna was boring, that the plot was thin, that the other characters were formulaic and unrealistic, etc., etc. The New York Times reviewer wrote: “There is little air in Anna’s sadness, precious little wit or grit or grace. Her misery is blunt and static, unyielding as a mountain.” Right! That’s what made her whole experience interesting and involving to me: How could someone be so stuck in the mire? How could she fake being a good wife and mother and friend and be so deeply unhappy all the time? Why didn’t her husband, Bruno, and her friend Mary notice? Why was her Jungian psychotherapist so relatively passive? What’s the book all about, you ask? The opening line in the book sort of gives a hint: “Anna was a good wife, mostly.” Indeed she was, but she was an American woman living with her reticent, nondemonstrative Swiss banker husband and their three children. Her somewhat disapproving mother-in-law was always around. She was living in a culture foreign to her, and she never made any real attempt to engage with the community and society until the time of the story: she decided to take German language lessons, and in class she met her first extramarital lover, Archie. (You need to know that there are several scenes that might qualify as pornography in the narrative and that would be mostly “bleeped” if they were read on the radio or dramatized on broadcast television.) Anna’s further decline and fall, stimulated by tragedy and frustration, made me think of a quotation from Madam de Staël, an 18th century intellectual and revolutionary: “The desire of the man is for the woman, but the desire of the woman is for the desire of the man.” So many of her actions and thoughts seemed to me to be driven by a need for recognition of herself as a person and a desirable woman.
The other critics (see how smoothly I included myself in the group?) also took shots at the author for, in essence, ripping off Tolstoy (“Anna Karenina”) and Flaubert (“Madam Bovary”). There are some parallels, indeed, but our Anna’s attitude and problems aren’t the same. Although it’s been years since I read those books, and they sort of came to mind, I saw this as more of a re-envisioning of the unloved-feeling, lost-in-her-world woman than a form of plagiarism. I wrote the preceding paragraphs in the first few days after I finished the book. The malaise that it brought on couldn’t withstand the fact that I was on vacation in Oregon, visiting relatives, touring, drinking Oregon wine and overeating. Now, a couple of weeks later, I find myself still musing about the book. One feeling is that it is likely that a woman reading it would have a different set of reactions than I had. I was saddened that Anna, a woman who seemed to be intelligent, loving, reasonably attractive and affectionate, was so unfulfilled by her life … even though her alienation was mostly of her own making. It’s not that she was passive; her first affair starts when, during a German class break, Archie asks, “What are you doing this afternoon?” and Anna replies, “You.” In addition, I was fascinated by the interplay between Anna and her therapist, Doktor Messerli. Descriptions of their sessions are interspersed into the main narrative and helped me to see into Anna’s mind … and into Dr. Messerli’s, who utters short, aphoristic phrases, many of which have stuck with me. Here’s one: “Shame is psychic extortion.” I had a definite feeling of acceleration of Anna’s psychological slide, undoubtedly intended by the author. As the book went on I became more and more involved, and yet I was shocked and depressed by the final scenes. They shouldn’t have happened … but their inevitability could only have been thwarted by a nearly complete inversion of her life, which would have required a whole different set of friends, family members and a different milieu. Fred H. Olin, MD, is a semi-retired orthopaedic surgeon and chair of the BCMS Communications/Publications Committee.
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25
NONPROFIT
ACEs high: How Magdalena House builds resiliency to beat the odds Special to San Antonio Medicine
Since the 1990s, researchers at the Centers for Disease Control and Prevention have believed that there is a direct link between one’s biography and one’s biology. In a hallmark study that followed more than 17,000 people for 15 years, a group of Kaiser Permanente physicians and colleagues at the CDC linked Adverse Childhood Experiences (ACEs) to myriad health problems later in life. What is the ACE test? The team developed a 10-question survey, wherein each question is a marker for a possible trauma experienced before the age of 18. Five are personal: physical abuse, emotional abuse, sexual abuse, physical neglect and emotional neglect. Five are related to household dysfunction: mental illness, an incarcerated relative, a mother who was treated violently, substance abuse, and divorce or abandonment. For each trauma experienced, one’s “score” is increased by one. 26 San Antonio Medicine • September 2015
So for example, a child who was verbally abused and had a mother who was treated violently would have an ACE score of 2.
Why does it matter? The team learned that “there is a direct link between childhood trauma and adult onset of chronic disease, as well as mental illness, doing time in prison, and work issues, such as absenteeism.” Compared to those with an ACE score of zero, children with an ACE score of 4 or more are “twice as likely
to be smokers, 12 times more likely to have attempted suicide, seven times more likely to be alcoholic, and 10 times more likely to have injected street drugs. People with high ACE scores are more likely to be violent, to have more marriages, more broken bones, more drug prescriptions, more depression, more auto-immune diseases, and more work absences.” Additionally, an ACE score of 4 or more means a much higher likelihood of having heart disease, pulmonary disease and sexually transmitted diseases.
NONPROFIT ACE vs. Resiliency: While a high ACE score can mean greater likelihood for many risk factors, this is not always the case. ACE scores don’t measure the positive experiences in childhood that can help build resilience and protect a child from the effects of trauma. Research suggests that just one caring, safe relationship early in life gives any child a much better chance at growing up healthy. Having a grandparent who loves them, a teacher who believes in them, a trusted friend to confide in can mitigate the effects of childhood trauma.
Magdalena House provides an environment designed to foster resiliency. Positive relationships are at the heart of the success of women and children who live at Magdalena House, a transitional shelter near the South Texas Medical Center. Magdalena House serves mothers and their children who have fled dangerous and abusive lives by providing “Home. Help. Hope.” to alleviate the effects of high ACE scores.
Home: At Magdalena House, a mother and her children live in a beautiful, safe and nurturing home while they put their lives back together.
Help: An individual program of supportive services is created for each mother and child, focused on educational and vocational training, life enrichment classes, accountability, volunteering in the community, spiritual formation, and outsourcing to other agencies to meet the full gamut of a family’s needs. Families may live at the Magdalena House as long as they remain working toward completion of their educational goals.
Hope: A process that works toward empowerment, self-awareness and achievement of personal goals. Magdalena House strives to create a space that cultivates authentic relationships and nurturing community where families move beyond their past to a future full of hope and new possibilities.
So what does this process look like in the life of a real woman and her children? (The following names have been omitted or changed to protect the family’s identity.) Christine was 7 years old when she first realized her mother was addicted to drugs; she also was 7 the first time she was abused. By age 13, Christine began using drugs, frequently alongside her mother. By eighth grade, she stopped going to school and began taking care of her 9-month-old brother, and while her mother told her that she was out working various part-time jobs, Christine knew, even at her young age, that her mother was working as a prostitute. Although she wanted to finish high school, to become someone different from her mother, Christine ultimately dropped out of school her senior year. At 18, Christine began working as a dancer at a strip club and became addicted to drugs. She danced at the club until she became pregnant with her older daughter, and she and her mother continued to use drugs together. By age 24, Christine’s life was being wrecked by her addiction and also by an abusive relationship with a man who would later go to jail for his violent behavior toward her while she was pregnant with her second child. Ultimately, Christine’s two children were removed from her care. This event, however, proved to be a turning point in Christine’s life. Christine had always promised herself that she’d be a different kind of mother: “It took losing my kids for me to say ‘no more’ to drugs and the lifestyle I was living.” Three months later she was reunited with her children, and she has stayed sober since.
Her greatest desire is to bring her kids up in a stable, loving environment. At Magdalena House, she says, she is “learning to be a better mom, to guide them.” By Christine’s count, she would score a 7 on the ACE test, and her children’s young lives also would indicate a high ACE score (4 or more). However, both Christine and her children are changing things for the better. At Magdalena House, Christine’s girls are taking part in Kids Connection Too, a curriculum-based support group created for kids in shelters as a direct response to the ACE studies. Magdalena House has four trained volunteers to take the children through this curriculum, which builds protective factors to mitigate the high-trauma situations that these children have experienced. The goal is to foster positive beliefs about oneself and a community of healthy relationships. Christine, as well as the other mothers at Magdalena House, have one-on-one parenting coaches through the Methodist Healthcare Ministries’ “Parents as Teachers” program. And as a group, the mothers at Magdalena House take Systematic Training for Effective Parenting (STEP), an eightweek course that helps parents at risk for parenting problems learn effective parentchild interactions. After all, life stories like Christine’s, one in which love, security and stability were rare, are unfortunately common at Magdalena House. Positive relationships, both with the other moms in the house, staff, volunteers and parenting coaches, are producing growth and strength for these families. Christine is determined that her daughters’ lives will be different from hers. Magdalena House is her partner is this quest. Demand for Magdalena House’s services is high. Having recently purchased their 5acre property, staff and board members are working with KFW Engineering to design and build a gated neighborhood with seven homes so eventually 28 families may be served at any one time.
A benefit for Magdalena House is planned for Oct. 24 at the JW Marriott Hill Country Resort. For more information, visit www.maghouse.org. visit us at www.bcms.org
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LIFESTYLE
16TH ANNUAL
TEXAS WINE MONTH TRAIL SET FOR OCTOBER By Oliver J. Bourgoin (aka “Oliver the Wine Guy”)
When people hear the words, Texas Wine Month Trail, it’s fair to assume most are probably thinking about the main event: a yearly celebration that started in 2000 which takes place each year during the month of October.
s a destination event, the wine trail has been growing steadily in scope and entertainment value every year since its inception. Tickets for this year’s wine trail went on sale in mid-August. In addition to the main event, there also is the Christmas Wine Affair (formerly the Holiday Wine Trail), which takes place Dec. 4-20. Tickets for it go on sale in mid-October. Other perennial events include the Wine Lovers Trail, which coincides with — you guessed it —
A
28 San Antonio Medicine • September 2015
Valentine’s Day in February, and the Wine and Wildflowers Trail, which is held the first two weeks of April. This year’s Texas Wine Month Trail is a major event in which 46 wineries — a 30 percent increase from just two years ago — are involved, including some that were already crushing grapes when the Texas wine Industry was still in its infancy. Each will be hosting miscellaneous events of their own Oct. 1-31. A wine trail is a self-guided tour where
visitors go from one winery to another based on a list of participants. Not all wineries offer the same fare but guests can expect tastings of new vintages, the occasional library tasting, and food and wine pairing events.
Note that some of the wineries allow pets and that others do not. Some also require reservations for groups of eight or more.
LIFESTYLE
Visitors also receive a 15 percent discount on any three bottles of wine purchased at each of the wineries. The month-long event costs $60 per couple. Each ticket includes a trail tasting passport which is issued at the first winery visited, which is selected at the time tickets are purchased. At each winery, the passport is stamped with the date. Each day visitors can taste and get stamped at up to four wineries total. Couples purchasing tickets are both allowed to taste although only one booklet per couple will be issued. On average, the cost to sample wine is $9 per person, per winery, with the purchase of the $35 trail pass, which is valid for 31 days at all 46 wineries. In addition, special discounts on the purchase of wine at participating wineries are given to passport holders during the entire month. One of the reasons for the four-per-day winery visits limit is to encourage drinking in a responsible manner and to promote a more in-depth visit and experience at each stop. January Wiese, a native Californian from another famous wine region, Paso Robles, is executive director of the Texas Hill Country Wineries Association. Wiese started as the organization’s wine trail event coordinator in 2009 and became executive director in 2012. Mike Batek of Hye of Meadow Winery said in a statement provided by Wiese: “I believe the major driver behind the decision is two-fold: safety and enjoyment. We as an association want people to come out and enjoy each winery they visit. Part of that is slowing down to taste the wine, have a conversation and have an experience. I personally like to hang a bit longer if there is a view or savor a particular wine without rushing to meet a schedule. Looking at how our wineries are arranged
in pockets across the Hill Country, we felt that it lent itself to this concept. In the process, it allows us to safety visit and not worry about our guests being over-served by the end of the afternoon. We truly want the trail to be an experience to be enjoyed safely.” Wiese noted that $5 from the $35 fee is taken right off the top for the Susan G. Komen Foundation. “We chose to partner with them because October is also Breast Cancer Awareness Month,” she said. “We’ve donated $4,000 each year for the last three years for a total of $12,000.” In addition, there is also the Fredericksburg Food and Wine Festival. Although not directly associated with the Wine
Trails, it coincides with Texas Wine Month. This year the festival celebrates its 25th anniversary and is scheduled from noon to 7 p.m. Oct. 24 in historic downtown Fredericksburg. Sponsored by the city as a benefit for the Market Square Improvement Project, it is billed as a fullcourse celebration of Texas food, wine, beer, music, specialty booths, food courts, and fun for all.
For more information, call 872-216-WINE (9463) or visit texaswinetrail.com.
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UTHSCSA DEAN’S MESSAGE
San Antonio Breast Cancer Symposium:
The world’s hub for breast cancer research, treatment By Francisco González-Scarano, MD
Breast cancer is never welcome news, but the outlook for this terrible disease is much more hopeful than it has been in the past: Its incidence has stabilized and cure rates are rising. The improved cure rates are due to a growing body of knowledge regarding diagnosis and treatment that is shared globally. And the most significant single platform for sharing that knowledge has been the San Antonio Breast Cancer Symposium (SABCS), an icon in the San Antonio medical world for some 37 years. Attendees from 94 countries now participate in the world’s largest breast cancer conference. The next meeting is Dec. 8-12 at the Henry B. Gonzalez Convention Center. The first symposium was held during Breast Cancer Awareness Week in November 1978. Lasting only one day, it was part of a three-year intensive outreach program of public and professional education designed to reduce the death rate caused by breast cancer in San Antonio and surrounding areas. The University of Texas Health Science Center San Antonio was a key partner in the conference, but this was still nearly three decades before the Cancer Therapy & Research Center (CTRC) formally became a part of the university. Other partners were the Texas division of the American Cancer Society and the Bexar County Medical Society. The program was organized by Charles A. Coltman Jr., MD, and William L. McGuire, MD, both professors of medicine in the UT School of Medicine (SOM). The first meeting featured presentations by a panel of internationally known specialists, and was attended by 141 physicians and surgeons representing a five-state area. Three years later the meeting was expanded to two days with a worldwide call for abstracts to attract and draw from a larger, international base. In 1990, the CTRC and the Health Science Center entered into a collaboration known as the San Antonio Cancer Institute (and became an NCI-designated Comprehensive Cancer Center), which in 1995 assumed sponsorship of the symposium. In 2005, six years after C. Kent Osborne, MD, professor of medicine and molecular and cellular biology, and director of the Dan L. Duncan Cancer Center at Baylor College of Medicine in Houston, had moved to Baylor, 30 San Antonio Medicine • September 2015
that institution became a joint sponsor of the symposium. Dr. Osborne’s continued leadership kept the meeting viable throughout many changes at the CTRC and brought in the American Association for Cancer Research (AACR) as another co-sponsor to broaden the research audience on a national and international scale. In 2007, the CTRC became part of the Health Science Center and the SOM, which gave the SABCS a stronger academic and operational foundation.
DISCOUNTS OFFERED SABCS as a mecca for breast cancer information provides a special opportunity for local, area and regional physicians, whether in private practice or academic medicine. But you do not have to be a medical or nursing professional to attend; there are discounts offered to the public and many other healthcare providers. Virginia Kaklamani, MD, professor of medicine and director of the Breast Cancer Center at the CTRC, first attended the meeting in 2000 when she was a hematology/oncology fellow getting a master’s degree in clinical investigation at Northwestern University. Dr. Kaklamani has only missed one symposium in the past 14 years: when she was busy giving birth to her son. Dr. Kaklamani was director of the translational breast cancer program at Northwestern University and co-director of their cancer genetics program before her interest in further study of breast cancer and the SABCS led her to our SOM and the CTRC, which she joined in November 2014. Her research interests include families at high risk for cancers of breast, colon and prostate, and identifying genetic mutations associated with these increased risks. In fact, she has identified several genetic mutations related to obesity that also increase the risk of breast cancer; she has presented these and many other findings at the SABCS. Dr. Kaklamani notes that the SABCS is unlike almost any other cancer conference because of its large international mix, given its relatively small size. On average, there are about 8,000 attendees at the
UTHSCSA DEAN’S MESSAGE
SABC, and 60 percent are international. She describes it as a bridge between the basic scientists and clinicians, where all the subspecialties (surgeons, medical and radiation oncologists, pathologists, laboratory researchers, epidemiologists and others) come together to create the next evolutionary steps in breast cancer treatment and research. She also points out the ancillary benefit brought by being located here, where our underserved and minority populations – who suffer disproportionate risks and incidence of many diseases, including cancer – can be focused on in research and benefit from leading treatments. As co-director of the SABCS, Dr. Kaklamani sits on the committee that reviews an average of 1,650 abstracts every year. Approximately 45 of those will become platform presentations and more than 1,200 will become posters. Credit for the success of the conference also goes to the other codirector: Carlos L. Arteaga, MD, professor of medicine and cancer biology, associate director for clinical research, and director of the breast cancer program, Vanderbilt-Ingram Cancer Center in Nashville, Tenn. Unlike most medical conferences, the SABCS is not affiliated with any medical association or organization, so there are no administrative duties and ceremonies. The meeting is singularly focused on continuing medical education (CME), for which it provides AMA PRA Category 1 credits via the SOM’s CME office. The SABCS also recognizes achievement in the fields of breast cancer research and treatment with three annual awards. The Susan G. Komen® Brinker Award for Scientific Distinction, established in 1992, recognizes leading scientists for significant work in advancing research concepts and for clinical application in breast cancer research, screening or treatment. The award is presented each year to one basic and one clinical researcher who have made seminal advances in the fight against breast cancer. In addition, the award recognizes scholars for a specific contribution, a consistent pattern of contributions, or leadership in the field who have had a substantial impact on the fight against breast cancer. The award includes money to further the recipients’ activities in breast cancer research. The recipients also are invited to deliver plenary lectures during the symposium. The William L. McGuire Memorial Lectureship Award was established in 1992 to commemorate Dr. McGuire’s significant contributions to oncology. His research played a major role in introducing estrogen receptor assays on breast tumor tissue as a guide to treatment decisions for women with breast cancer. Breast cancer patients everywhere now receive these tests. Co-sponsor American Association for Cancer Research (AACR) presents two awards at the meeting. The first is the AACR Outstanding Investigator Award for Breast Cancer Research, which also is
funded by Susan G. Komen® and is presented to an investigator no older than 50 whose novel and significant work has had or may have a far-reaching impact on the etiology, detection, diagnosis, treatment or prevention of breast cancer. Their other award, the AACR Distinguished Lectureship in Breast Cancer Research, is to recognize outstanding science that has inspired or has the potential to inspire new perspectives on the etiology, diagnosis, treatment or prevention of breast cancer.
DOWNLOADABLE MATERIALS The value of the SABCS extends well beyond the meeting itself. For the many investigators and clinicians who would like to attend the meeting but cannot, SABCS update meetings are held throughout the year. They are recognized and supported by the SABCS with all the materials from the general meeting made available through the SABCS website. In the weeks and months after the meeting, the website sees a spike of tens of thousands of visitors, many of which download the many presentations and other materials. The development and operations of the meeting, as well as all the planning, are managed by symposia director Rich Markow, a 14-year veteran. With his small staff of four, their hands are full year-round coordinating and planning – not to mention managing the huge volume of scientific literature distributed at the meeting. Planning the following year’s meeting begins before the current one takes place. In the days immediately following the event, Dr. Kaklamani and other medical oncologists all over the world return to their offices and change their treatment protocols. They are able to improve the treatment options they offer patients with knowledge shared at the symposium. Despite the advances and the great science, there will be approximately 232,000 new cases of invasive breast cancer and approximately 60,000 new cases of carcinoma in situ (CIS) in the United States in 2015. Approximately 40,300 women will die from breast cancer. Obviously, our work is far from done. Hope for all these cases lies in the determination of the thousands of researchers and physicians who will gather here in December, as many of them have for decades, to exchange ideas and discoveries that are driving the evolution of treatments and cures in breast cancer. Learn more at their website: www.SABCS.org. 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
31
LEGAL EASE
Disastrous Labor Laws By George F. “Rick” Evans Jr. Contrary to what the headline suggests, this article is not about absurd laws that wreak havoc in the workplace. It is, however, a general overview about employment law when some type of disaster occurs making it difficult, if not impossible, for employees to work. The calamity may be on a micro level as when an employee’s house burns down. Or it may be on a macro level as when the entire city is brought to a standstill due to a freak snowstorm. Or when employees are told to go home early because of concerns the rains will create flood problems at low water crossings. Preliminarily, note that this article does not apply to medical disasters as when an employee or a spouse or close relative of the employee is sick or needs care. That was covered in an earlier article discussing the Family Medical Leave Act. This article is about different disasters and what you need to know if you’re an employer or an employee. Here’s the bird’s-eye view. First, you have to identify if the employee is exempt or non-exempt. It’s an oversimplification to say hourly wage employees are
32 San Antonio Medicine • September 2015
non-exempt and salaried employees are exempt, but it’s not a bad beginning benchmark. If there’s any doubt about where you or your employees fall, go to http://www.flsa.com/coverage.html and you can find out for yourself.
EXEMPT EMPLOYEES Let’s start with exempt employees. If you’re a doctor, and you’re employed by somebody, odds are you’re exempt. Or if you have a high salaried employee working for you, odds are he/she is exempt. Anyway, here are the general guidelines. If the office or workplace is shut down, then the employee’s salary can’t be cut or reduced. The employee still gets paid. The employer may, however, ask the employee to take his/her vacation or paid time-off days for each day the office is shut down. This scenario obviously applies for any disaster that shuts the business down that day. It could be that freak snow storm. Or maybe the
LEGAL EASE
business itself is shut down due to some minor calamity. If, however, the business is open (perhaps even despite the freak snowstorm), the employee has to decide whether to work or not. If the employee reports for work, there’s no problem. Business as usual. If the employee opts to stay home, the employer may deduct the day from the employee’s pay provided the employee doesn’t do any work that day. If the employee just works for a few minutes, however, even if remotely via the computer, the employee can’t be docked.
NON-EXEMPT EMPLOYEES Non-exempt employees are typically the folks who receive an hourly rate for their work. In that case, the employee is only entitled to be paid for the time he/she actually works. Whether the office is open or closed makes no difference. Typically, the employer only has to pay for actual hours worked. Even if the boss decides to shut down the office early so employees can get home before the rain, snow or sleet arrives, the non-exempt employee is only entitled to pay for the actual hours worked before the office shut down.
These explanations are just to get you started. Each situation can be different, in which case any decent labor law attorney can advise you. But at least you’ll start the conversation with a leg up when you know these basic rules. 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.
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BUSINESS OF MEDICINE
SCOTUS & ACA and the winner is By Joseph P. Gonzales, MHA, FACHE
Once again, the Supreme Court of the United States (SCOTUS) was asked to decide the constitutionality of an aspect of the Affordable Care Act (ACA), and in turn the resulting decision could very well mean that healthcare reform (as described in the ACA) is here to stay, or not. In a New York Times article, it was stated that four words “care34 San Antonio Medicine • September 2015
lessly” included in the 900-page ACA could have derailed the president’s signature piece of legislation: “established by the state.” The Supreme Court was asked to issue a ruling on the legality of providing health insurance subsidies (King v. Burwell) to people in 37 states that did not set up their own healthcare exchanges. The other 13 states that operate their own exchanges would not be affected.
BUSINESS OF MEDICINE
Prior to the ruling, the lawmakers who drafted the law said there was never meant to be a demarcation for subsidies for those who purchased insurance on state-run exchanges versus the federal marketplace. Former New Mexico Democrat Sen. Jeff Bingaman chalked the controversial four words up to an oversight, or “it would have been deleted, because it contradicted the main purpose of the legislation.” Speculation was that the decision as to this aspect of Obamacare could put Republicans in a bind in the run-up to the 2016 U.S. presidential election if SCOTUS upended the part of the law designed to make healthcare accessible to all Americans, leaving about 6.4 million people without health coverage. Republicans have criticized ACA as a bloated, big-government solution and objected to its mandate (basis for the first Supreme Court challenge) requiring insurance coverage. Yet, some 16 million Americans have acquired health coverage under the law. The Congressional Budget Office (CBO) stated, “Repealing the ACA would increase the federal deficit by $137 billion or more over the next 10 years and would increase the number of uninsured Americans by 19 million in 2016.” These projections are the first official score of full Obamacare repeal since 2012. Their report further projects that in later years, about 50 million nonelderly Americans would be uninsured starting in 2020 and onward. Earlier this year the CBO estimated that there are about 35 million uninsured Americans, and the number should drop to 24 million by 2020 under the ACA. The CBO report admits that these projections are based on a repeal taking effect on Jan. 1, 2016, but does not account for any alternative healthcare policy being passed to take its place. A final word of clarity by the CBO: “The overall effect is difficult to project, given the complexity of the law and the difficulty in projecting economic effects so far into the future.” In a 6-3 decision June 26, the Supreme Court ruled in favor of the administration and helped to save the controversial healthcare law. The ruling holds that the ACA’s federal tax credits for eligible Americans is applicable for all 50 states. This prevented the need for states to act to prevent millions from losing healthcare coverage. So from many perspectives one can say that the real winners are the patients who qualify for the subsidies and who seek care because they have insurance. Are there other aspects that make this difficult to declare a winner? Yes, and I’ll mention a few.
LOOKING AHEAD AFTER COURT RULING Sylvia Burwell, secretary of Health and Human Services, said she expected enrollment in both the state and federal health insurance exchanges established under the 2010 ACA to decline from 10.2 million currently to 9.1 million by the end of 2015. She said the
decline would occur because some people will get insurance through new employment; others will marry and go on their spouses’ coverage; and some may not be able to pay their premiums. Now that SCOTUS has ruled, she said she looks forward to building on the five-year-old program’s progress by continuing to expand Medicaid, making benefits available to additional low-income people.
EFFECTS ON HEALTHCARE SINCE ACA PASSED In an article by Dina Overland, dated April 17, 2015, she identifies that it is good to be an insurer in a state that expanded Medicaid. The reason is that expansion states lowered their uninsured rate by more than 50 percent, compared to 30 percent in non-expansion states (Texas did not expand Medicaid.) A survey by the Robert Wood Johnson Foundation found that the ACA has decreased the uninsured rate by 15 million people total in the last two years, dropping the nation’s uninsured rate to just about 10 percent. This ongoing shrinkage of the uninsured population, according to the Government Accountability Office, is a direct result of the subsidies made available to millions of people who couldn’t afford coverage. This impact was particularly pronounced for groups with high levels of un-insurance before the ACA, young adults and Hispanics. The young adults who were insured grew almost 10 percentage points, compared with 6 points for older adults. Meanwhile, Hispanic adults had an almost 15 percentage point increase, whereas nonwhite, non-Hispanic adults had a 9 percentage point growth. According to the survey, Hispanics are the most underserved by both insurers and providers. Another recent study from the Commonwealth Fund shows that 70 percent of people with medical debt say the bills are from times when they had insurance. This dynamic may be further explained by the fact that onequarter of people with health insurance are paying so much in deductibles and out-of-pocket expenses, that they are considered “underinsured”. So even with millions more people insured there are some downsides, according to Wyoming Republican Sen. John Barrasso, “All across the county, Americans are struggling under the costs of healthcare, under this healthcare law (ACA).”
RELATED FACTORS: EHRS In related legislation that impacts providers and the care they deliver, government regulators are backing down from many of their toughest requirements for doctors’ and hospitals’ use of digital medical records. Both doctors and hospitals are required to have electronic health records (EHRs) to meet quality provisions of Obamacare. The original intent was by having EHRs doctors could exchange information about patients they share, which Continued on page 36 visit us at www.bcms.org
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BUSINESS OF MEDICINE Continued from page 35
would improve quality and avoid duplication of tests and procedures. The problem is that EHRs are not good yet! The software isn’t to the stage that it needs to be and as a result these records remain a thorn in many doctor-patient relationships. It impacts the time with the patients, and it takes extra time to enter data. Many providers have spent hundreds of thousands of dollars to implement an EHR system that doesn’t connect with other systems in hospitals and elsewhere. It is a good thing the government is realizing that it needs to slow down implementation, and the emphasis needs to be on “reliability, safety and liability,” according to an article by Jayne O’Donnell, and Laura Ungar in USA Today May 26.
IMPACT ON PROVIDERS In a June 26 article by Tamara Rosin, additional impacts on the providers of care as a result of the ACA are identified. In a Jackson Healthcare survey of 1,804 physicians across the United States, it was identified that many physicians believe the ACA is driving up the cost of healthcare. Sixty-one percent reported an increase in overhead costs for items such as EHRs and other
36 San Antonio Medicine • September 2015
administrative layers to comply with ACA provisions. They also said the law is costing patients more: 51 percent of patients delay routine screenings because of the cost of high-deductible plans associated with ACA. Fifty-nine percent of physicians responding to the survey said the positive effects of the ACA do not outweigh the negative effects when it comes to their medical practice. About 23 percent of providers said they were planning to retire, or thinking of retiring, or becoming part-time locum tenens contract employees in 2015, and 90 percent attribute this decision to the ACA. So it is difficult to say who the “winner” is with respect to Obamacare when it comes to the patient or provider. I believe we can afford care for all, but I am not sure I could say that the ACA is the best means to that end. Joseph P. Gonzales is a specialist master with Deloitte Consulting, LLP. An adjunct faculty with the University of Texas San Antonio, he teaches in the MBA program, business of healthcare track.
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.
ACCOUNTING FIRMS Padgett Stratemann & Co., LLP (HH Silver Sponsor) Padgett Stratemann is one of Texas’ largest, locally owned CPA firms, providing sophisticated accounting, audit, tax and business consulting services. Vicky Martin, CPA 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com “Offering service more than expected — on every engagement.” Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”
BANKING
BBVA Compass (HHHH Platinum Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Commercial Relationship Manager Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com“Working for a better future.”
Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great rela-
tionship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership.”
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Chris Sherman 210-247-2978 csherman@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com
Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”
Frost (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.
Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”
IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC BankSan Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area. Markham Benn 210-518-2500, ext. 26921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”
Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans. Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com
The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com
SSFCU (HHH Gold Sponsor) Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Cadence Bank (HH Silver Sponsor) Cadence Bank is a full-service financial institution serving commercial, consumer, treasury and wealth management clients in Texas and the Southeast. Margarita Ortiz, 210-764-5500 maggie.ortiz@cadencebank.com Steve Edlund, 210-764-5573 steve.edlund@cadencebank.com http://cadencebank.com “Explore Cadence Bank’s innovative financing options and treasury management solutions.” Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology • Expanding your office space • We offer loans to meet your business or personal needs. Competitive rates, favorable terms and local decisions. Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org Generations Federal Credit Union (HH Silver Sponsor) Generations provides a wide array of innovative products including loan, deposit and investment solutions for personal and commercial banking needs. Yvonne "Bonnie" M. Aguilar 210-229-1800 bonnie.aguilar@ mygenfcu.org www.mygenfcu.org “For this generation and the next.”
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37 RBFCU (HH Silver Sponsor) 210-945-3800 businesslending@rbfcu.org www.rbfcu.org St. Joseph's Credit Union (HH Silver Sponsor) A credit union providing savings, checking, IRA, club and CD accounts, plus auto, signature, lines of credit, MasterCard and real estate loans. Armando Rodriguez 210-225-6126 arodriguez@sjcusatx.net www.sjcusatx.com “Better rates on auto loans, signature loans and Platinum MasterCard.”
BIOMEDICAL WASTE DISPOSAL
BioMedical Waste Solutions, LLC (HHH Gold Sponsor) Save costs on your medical waste disposal! BioMedical Waste Solutions provides a compliant, reliable and low-cost service. Wes Sonnier 1-877-974-1300 Wes@BioMed-Disposal.com Joe Loyacano 1-877-974-1300 Joe@BioMed-Disposal.com www.BioMedicalWasteSolutions.com “BCMS members save 10 percent off or one free month! Request a free quote in 10 seconds at www.BioMedicalWasteSolutions.com.”
CONTRACTORS/BUILDERS/ COMMERCIAL
Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer. Our model allows you to own your own office space as opposed to leasing. Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com
RC Page Construction, LLC (HHH Gold Sponsor)
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Clay Page 210-375-9150 clay@rcpageconstruction.com
830-832-0949 Stacy.berry@greenwayhealth.com www.greenwayhealth.com
CUSTOM HOME BUILDERS
FINANCIAL SERVICES
Diamante Custom Homes (HHH Gold Sponsor) Diamante Custom Homes: Experience your new custom homebuilding process through San Antonio’s leading design-build firm. Over two decades of streamlining the balance between your budget and your dreams. The name you know from the builders you trust! Keith Norman 210-341-6430 knorman@diamantehomes.com www.diamantehomes.com “Special promotions for all BCMS members – call us today!”
ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES
Med MT, Inc. (HHH Gold Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records. Ray Branson 512-331-4669 branson@medmt.com www.medmt.com “The Med MT solution allows physicians to keep practicing just the way they like.”
ELECTRONIC MEDICAL RECORDS
Greenway Health (HHH Gold Sponsor) Greenway Health offers a fully integrated electronic health record (EHR/EMR), practice management (PM) and interoperability solution that helps healthcare providers improve care coordination, quality and satisfaction while functioning at their highest level of efficiency. Stacy Berry
Northwestern Mutual Wealth Management (HHHH Platinum Sponsor) Comprehensive financial planning, insurance and investment planning, estate planning and trust services. Eric Kala, CFP, CLU, ChFC Wealth Management Advisor 210-446-5752 eric.kala@nm.com www.erickala.com
Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@ aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”
Frost Leasing (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses. Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com “Commercial leasing for a doctor’s business equipment and vehicle.” Bob Davidson New York Life (HH Silver Sponsor) Dedicated agent at New York Life helping physicians and medical professionals achieve their financial dreams. Bob Davidson 210-321 1445
rdavidson02@ft.newyorklife.com www.linkedin.com/in/bobdavidsonnyl “Taking care of those who take care of us.” Retirement Solutions (HH Silver Sponsor) Committed to providing comprehensive, reliable consultation to help you navigate the complex world of retirement planning. Robert C. Cadena 210-342-2900 robert@retirementsolutions.ws www.retirementsolutions.ws
HIPAA COMPLIANCE SERVICES Cyber Risk Associates (HH Silver Sponsor) Cyber Risk Associates provides HIPAA compliance services designed for small practices, offering enterprise-quality privacy and security programs, customized to your needs. David Schulz 210-281-8151 DAS@CyberRiskAssociates.com www.CyberRiskAssociates.com
HIPAA/MANAGED IT/ VOIP/SECURITY
Hill Country Tech Guys (HHH Gold Sponsor) Provides complete technology services to many different industries, specializing in the needs of the financial and medical industries. Since 2006, our goal has always been to deliver relationship-based technology services that exceed expectations. Bill Gower 877-315-0788 Bill@hctechguys.com http://hctechguys.com/ “IT problems? Yeah… we can fix that!”
HOSPITALS/ HEALTHCARE SERVICES
First Choice Emergency Room (HHH Gold Sponsor) The nation's oldest and largest network of independent freestanding emergency rooms. Pa-
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY tients seen almost immediately; board-certified physicians and emergency-trained registered nurses. In-house CT scanner, ultrasound, digital X-ray and COLA/CIA accredited on-site lab to handle emergencies 24/7/365. 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 “Check-in online — free, easy, fast!”
Warm Springs •Medical Center •Thousand Oaks •Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Elite Care Emergency (HH Silver Sponsor) 24/7 full-service, no-wait, freestanding ER with board-certified physicians and RNs offering Elite Care advantage for patients. Marketing Liaison Dlorah Martin 509-592-7998 dmartin@elitecareemergency.com Marketing liaison Kylyn Stark 210-978-4110 kstark@elitecareemergency.com www.elitecareemergency.com “When seconds count, Elite Care can make ALL the difference.” Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/ Seasons Hospice and Palliative Care (HH Silver Sponsor) Seasons Hospice and Palliative Care engenders hope in the lives of its patients and their family members. We are here for you. Deb Houser-Bruchmiller Executive Director 210-471-2300 dhouser@seasons.org www.seasons.org
Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”
HUMAN RESOURCES
Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page. John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com “BCMS members get a free HR assessment valued at $2,500.”
INSURANCE
Blue Cross Blue Shield of Texas (HHH Gold Sponsor) Edna Pérez-Vega 210-558-5162 Edna_Perez-Vega@bcbstx.com www.BCBSTX.com
Frost Insurance (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses. Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com “Business and personal insurance tailored to meet your unique needs.”
Humana (HHH Gold Sponsor) Humana is a leading health and
well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com
Texas Medical Association Insurance Trust (HHH Gold Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.” Catto & Catto (HH Silver Sponsor) Providing insurance, employee benefits and risk-management products and services to thousands of businesses and individuals in Texas and the United States. Crystal Metzger James L. Hayne Jr. 210-222-2161 www.catto.com Joel Gonzales Agency Nationwide (HH Silver Sponsor) Joel Gonzales 210-275-3595 www.nationwide.com/jgonzales
INSURANCE/MEDICAL MALPRACTICE
Texas Medical Liability Trust (HHHH Platinum Sponsor) Texas Medical Liability Trust is a physician-owned healthcare liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 17,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Soci-
ety and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis counties medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org “Recommended partner of the Bexar County Medical Society.”
MedPro Group (HHH Gold Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Thomas Mohler, 512-213-7714 thomas.mohler@medpro.com www.medpro.com
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC, 210-807-5593 katy.brooks @bosainsurance.com www.thebankofsa.com “Serving the medical community.” NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best. Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) ProAssurance helps you control your professional risk and navigate today’s changing medical environment with greater ease — that’s only fair. Keith Askew, 512-314-4368 Kaskew@proassurance.com Mark Keeney 512-314-4347, ext. 7347 Mkeeney@api-proassurance.com www.proassurance.com “A.M. Best-rated A+ (Superior), ProAssurance treats you fairly.”
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 39 The Doctors Company Medical Malpractice Insurer (HH Silver Sponsor) We relentlessly defend, protect and reward the practice of good medicine. As the patient safety industry leader, we proudly offer a comprehensive selection of CME opportunity and risk-mitigation resources. Kirsten Baze 512-275-1874 KBaze@thedoctors.com www.TheDoctors.com
INTERNET/ TELECOMMUNICATIONS
Time Warner Cable Business Class (HHH Gold Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterpriseclass technology and communications that are highly reliable, flexible and priced specifically for the medical community. Rick Garza 210-582-9597 Rick.garza@twcable.com “Time Warner Cable Business Class offers custom pricing for BCMS Members.”
IT SUPPORT/VOIP/ CLOUD SERVICES
ICS (HHH Gold Sponsor) ICS® is a Texas-based provider of business technology integration solutions, including managed IT support, business telephones, VoIP communications, video conferencing systems, surveillance cameras, and voice/data cabling. Family owned since 1981. Daniel Simons 210-581-9020 daniel.simons@ics-com.net Robert Foehrkolb 210-225-5427 rfoehrkolb@ics-com.net www.ics-com.net “Providing IT, voice and video solutions for business.”
LABORATORY SERVICES
PGX TESTING (HHH Gold Sponsor) PGX Testing is a multi-faceted diagnostics company currently offering pharmacogenomics, urine toxicology, women's health testing, cancer screening, and wellness testing to the medical profession. Charlie Rodkey Sr. charlie@pgxt.com 210-218-8610 Ryan Rodkey ryan@pgxt.com 210-323-7717 Ron Inselmann ron@pgxt.com 210-382-7761 www.PGXT.com Clinical Pathology Laboratories (HH Silver Sponsor) Mitchell Kern 210-229-2513 mkern@cpllabs.com www.cpllabs.com
MARKETING SERVICES Digital Marketing Sapiens (HH Silver Sponsor) Healthcare marketing professionals with proven experience and solid understanding of compliance issues. We deliver innovative marketing solutions that drive results. Irma Woodruff 210-410-1214 irma@dmsapiens.com Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com Know Your Doctor SA (HH Silver Sponsor) Increase your practice’s unique marketing/communications program. Connect with SA community through video, advertising, PR and medical opinion e-news. Limited to 300 physicians. Lorraine Williams 210-884-7505 LWilliams@KnowYourDoctorSA.com www.knowyourdoctorsa.com
MEDICAL BILLING AND COLLECTIONS SERVICES
DataMED (HHH Gold Sponsor) Providing your practice with the
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latest compliance solutions, concentrating on healthcare regulations affecting medical billing and coding changes, allowing you and your staff to continue delivering excellent patient care. Betty Aguilar 210-892-2331 baguilar@datastreamllc.net www.datamedbpo.com “BCMS members receive a discounted rate for our billing services.”
yolanda.garza@linrontraining.com www.linrontraining.com
MENTAL HEALTH EDUCATION AND CONSULTING
Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”
The Ecumenical Center (HHH Gold Sponsor) The Ecumenical Center provides faith-based counseling and education for healing, growth and wellness. The center is a catalyst, bringing together community leaders in research, education, ethics, medical and mental health professions. Mary Beth Fisk 210-616-0885, ext. 215 mbfisk@ecrh.org www.ecrh.org
MEDICAL SUPPLIES AND EQUIPMENT
MERCHANT PAYMENT SYSTEMS/CARD PROCESSING
Henry Schein Medical (HHHH Platinum Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”
MEDICAL TRAINING/ HANDS ON
LINRON® Bioskills Training Institute (HHH Gold Sponsor) LINRON® is dedicated to providing hands-on medical training to healthcare professionals who want to improve their clinical skills and offer their patients the latest in treatment modalities while using state-of-the-art medical equipment and technology. Yolanda S. Garza, RN 210-572-2434
Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by over 250 business associations. Tanner Wollard 979-219-9636 tanner.wollard@e-hps.com www.heartlandpaymentsystems.com “Lowered cost for American Express; next day funding.”
OFFICE EQUIPMENT/ TECHNOLOGIES
Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes. Ronel Uys 210-805-8200, ext. 10105 ruys@dahill.com www.dahill.com
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY ORGANIZATIONS CRIT USA (HH Silver Sponsor) Ricardo Guzman Hefferan 210-257-6260 guzman@teletonusa.org www.teletonusa.org
REAL ESTATE/ COMMERCIAL Cano and Company Commercial Real Estate (HH Silver Sponsor) Experienced and respected commercial real estate representation. We specialize in office leasing, property acquisition, and commercial real estate investment. Dennis Cano, Agent 210-731-6613 Dennis@canoandcompany.com “Effective commercial real estate solutions for your practice and investments.”
tier care while maintaining their privacy and independence, in a luxurious resort-quality environment. Shane Brown Executive Director 210-305-5713 hello@ legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”
STAFFING SERVICES
Endura Advisory Group (HH Silver Sponsor) Endura Advisory Group specializes in representing physicians and clients in the purchase, lease, sale, management or sublease of commercial real estate. Vicki Cade, CCIM 210-366-2222 Mobile 210-827-7640 vcade@endurasa.com Teresa Corbin 210-366-2222 tcorbin@endurasa.com www.endurasa.com
Favorite Healthcare Staffing (HHHH Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”
REAL ESTATE/ RESIDENTIAL
TRAVEL CONSULTANTS
Kuper Sotheby's International Realty (HH Silver Sponsor) My hometown roots are based in Fredericksburg while my home away from home is San Antonio. Local knowledge — exceptional results. Joe Salinas III 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com “Embrace your new life ... I'll help you become a connoisseur.”
Alamo Travel Group (HH Silver Sponsor) Locally owned travel agency for over 30 years, offering personalized travel services for your next family vacation, business travel needs or group travel. American Express Travel Network representative. Mary Jo Salas, 210-593-5500 msalas@alamotravel.com www.amazingjourneysbyalamo.com “See what a difference we can make for you!”
As of August 14, 2015
SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-
For more information, call 210-301-4366, or email August.Trevino@ bcms.org, or visit www.bcms.org.
visit us at www.bcms.org
41
THANK YOU
to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA
Renal Associates of San Antonio, PA
Clinical Pathology Associates
San Antonio Gastroenterology Associates, PA
Dermatology Associates of San Antonio, PA
San Antonio Kidney Disease Center
Diabetes & Glandular Disease Clinic, PA
San Antonio Pediatric Surgery Associates, PA
ENT Clinics of San Antonio, PA
Sound Physicians
Gastroenterology Consultants of San Antonio
South Alamo Medical Group
General Surgical Associates
South Texas Radiology Group, PA
Greater San Antonio Emergency Physicians, PA
Tejas Anesthesia, PA
Institute for Women's Health
Texas Partners in Acute Care
Lone Star OB-GYN Associates, PA
The San Antonio Orthopaedic Group
M & S Radiology Associates, PA
Urology San Antonio, PA
MacGregor Medical Center San Antonio
Village Oaks Pathology Services/ Precision Pathology
MEDNAX Peripheral Vascular Associates, PA Contact BCMS today to join the 100% Membership Program! 42 San Antonio Medicine • September 2015
WellMed Medical Management Inc. *100% member practice participation as of July 15, 2015.
North Park Mazda 9333 San Pedro Ave. Ancira Chrysler 10807 IH-10 West Gunn Acura 11911 IH-10 West
* Gunn Infiniti 12150 IH-10 West
Cavender Toyota 5730 NW Loop 410
Ingram Park Auto Center 7000 NW Loop 410 Mercedes-Benz of Boerne 31445 IH-10 W, Boerne Ancira Dodge 10807 IH-10 West
Cavender Audi 15447 IH-10 West
Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)
Ingram Park Auto Center 7000 NW Loop 410
Northside Ford 12300 San Pedro Ave.
Ancira Jeep 10807 IH-10 West
Mercedes-Benz of San Antonio 9600 San Pedro Ave.
Ingram Park Auto Center 7000 NW Loop 410
* North Park Lexus 611 Lockhill Selma
Ancira Nissan 10835 IH-10 West
North Park Toyota 10703 Southwest Loop 410
* Ancira Volkswagen 5125 Bandera Rd. North Park VW at Dominion 21315 IH-10 West
Ingram Park Nissan 7000 NW Loop 410
North Park Lexus Dominion 21531 IH-10 West Frontage Road Cavender GMC 17811 San Pedro Ave.
Batchelor Cadillac 11001 IH-10 at Huebner
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)
Ancira Ram 10807 IH-10 West * North Park Lincoln/ Mercury 9207 San Pedro Ave.
Ingram Park Auto Center 7000 NW Loop 410
North Park Subaru 9807 San Pedro Ave. Ingram Park Auto Center 7000 NW Loop 410
North Park Subaru at Dominion 21415 IH-10 West
visit us at www.bcms.org
43
AUTO REVIEW
Ford F-150
Aluminum body outside, new technology inside By Steve Schutz, MD
44 San Antonio Medicine • September 2015
AUTO REVIEW The new Ford F-150, the best-selling vehicle in the United States by a country mile, looks a lot like the model it replaces. A lot like it. In fact, unless you’re a truck aficionado, you’d be hard-pressed to tell the 2015 model from the 2014. While the visual similarities suggest that Ford played it safe with its popular truck, the exact opposite is actually the case. Ford took a big chance with the new F-150 by using aluminum extensively in the body and bed, a first for a pickup. Why did they do it? CAFE fuel economy standards are pretty low now but will require progressively better gas mileage over the next 10 years, yet safety requirements are also tightening. That means that trucks will need to get lighter for better fuel efficiency, without getting smaller because bigger means safer. So the same size new F-150 now weighs 500-700 pounds lighter than an equivalent F-150 from last year. There are other advantages to lowering weight, too. Crucially in a market segment where customers spend a lot of time hauling mulch and pulling trailers, a lighter pickup can carry and tow more. Towing capacity for the new F-150 ranges from 7,600 pounds in base trim to a maximum of 12,200 pounds with the 3.5-L EcoBoost V6 and towing package. (For comparison, 10 years ago a Super Duty Ford F-250, a much bigger truck, was rated at 12,500 pounds maximum towing capacity.)
FUEL ESTIMATES VARY
gineers, factories and marketers. In fact, it’s fair to say that only Ford could have made this major change because only Ford had a CEO, Alan Mulally, who had spent most of his career with Boeing. Airliner manufacturers know aluminum, so an executive who knows how to build a big airplane understands a lot about that metal, including where to get it, how to use it, how much it costs today, and how much it’s likely to cost in the future. In addition to plenty of aluminum, Ford also has made sure that the latest F-150 includes state-of-the-art technology. Video cameras are nothing new, but the F-150 can be had with one that sits just above the trailer hitch and incorporates a dynamic guideline to make lining up a trailer an easy one-person job. In addition, a bird’s-eye camera system available on luxury cars for years is now an option on the F-150, as are lane-keeping assist and adaptive cruise-control systems. Driving a pickup truck is never any better than an OK experience dynamically, and the F-150 is no exception. Over twisty roads or in town you’ll wish you were back in your Honda Accord, but on the highway you’ll love the stable ride and your ability to see over other cars. The 2015 model is noticeably more nimble than its predecessor, but, as this is a big truck, nimble is not really the right adjective to use.
TOUGHER-LOOKING INTERIOR While the exterior of the F-150 looks a lot
like the previous version, the inside looks tougher. The center console is wider, numerous trim pieces are blockier, and the switchgear seems beefier. It’s all very Tonkaish, as though Ford wanted to tell owners, “Yes, we’re using aluminum now, but this truck is as tough as it’s always been.” As anybody who has shopped or owned a pickup recently knows, there is an almost infinite number of possible variations from which to choose your truck. Think hard about exactly how you’re going to use your F-150, and then call Phil Hornbeak (see below). He will get you the version you need for the best price possible. Don’t be fooled by the familiar shape of the new 2015 Ford F-150 pickup. While it looks a lot like the 2014 truck, it’s lighter yet even more capable, and even nicer to drive, thanks to the extensive use of aluminum. The F-150 is a great vehicle, and I pity the Dodge and Chevrolet engineers whose job it is to keep up. 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.
Of course, a lighter truck also can accelerate more quickly and burn less fuel. Since the F-150 is available in so many different variations with four engines to choose from, there are several EPA fuel estimates for it. The standard 283 HP 3.5-liter V6 twowheel-drive version gets 18 mpg city/25 highway. Move up to the 325 HP 2.7-liter EcoBoost V6 (EcoBoost means turbocharged with direct injection, by the way) with twowheel-drive and the numbers are 19/26, while the two-wheel-drive 385 HP 5.0-liter V8 and 365 HP 3.5-liter EcoBoost V6 get 15/22 mpg and 17/24 mpg city/highway, respectively. So aluminum is a no-brainer right? No. Every piece of the bring-a-new-vehicle-tomarket matrix is comfortable with steel, so switching to aluminum stresses designers, envisit 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 Mike Thomas at
210-582-6399. 46 San Antonio Medicine • September 2015