San Antonio Medicine November 2015

MEDICINE SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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NOVEMBER 2015

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VOLUME 68 NO. 11

Complementary

Health

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

MEDICINE SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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Complementary Health

NOVEMBER 2015

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VOLUME 68 NO. 11

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.

Art Heals at the Ecumenical Center

By Edward Ortiz.........................................................14

Fighting Inflammation in the Kitchen

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Email: editor@bcms.org

By Michael J. Wargovich, Ph.D., F.A.C.N. .................18

Massage Therapy as Complementary Medicine By Megan Benson .................................20

MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org

BCMS President’s Message ..............................................8

SUBSCRIPTION RATES: $30 per year or $4 per individual issue

BCMS News ....................................................................10

BCMS News ............................................................................................................................................24

ADVERTISING CORRESPONDENCE: SmithPrint Inc. 333 Burnet San Antonio, TX 78202

Book Review: ‘How to be a Victorian, A Dawn to Dusk Guide to Victorian Life’,

For advertising rates and information

BCMS Events ..........................................................................................................................................22

Written By Ruth Goodman, reviewed by Fred H. Olin, MD ..................................................................26 Nonprofit: Community gardens support Food Bank expansion ..................................................28 UTHSCSA Dean’s Message: SABOR Celebrating 15 Years of Prostate Cancer Research

By Francisco González-Scarano, MD ..................................................................................................30 Legal Ease: The Non-Compliant Patient, By George F. “Rick” Evans Jr. ................................................33 Business of Medicine: Two-Midnight Policy, By Pamela C. Smith, Ph.D. ..............................................35 BCMS Circle of Friends Services Directory ............................................................................................37 In the Driver’s Seat ..................................................................................................................................43 Auto Review: 2016 Subaru Legacy, By Steve Schutz, MD......................................................................44

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Email: louis@smithprint.net 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 W. 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 • November 2015

PRESIDENT’S MESSAGE

BCMS official visit to Mayor Kazufumi Onishi of Kumamoto City on Oct. 2, 2015.

Kumamoto, Japan trips are a valuable experience

By James L. Humphreys, MD 2015 BCMS President As I write this, we are returning from another successful trip overseas. It is fall of an odd-numbered year so that must mean it is time for a BCMS trip to Japan to visit our colleagues in Kumamoto. That always means a few days of sightseeing and riding the bullet train to get down there.

I have made the trip to Kumamoto eight times now, so I obviously enjoy it. I have made a number of friends there, from older doctors that I have seen each time since my first trip all the way to the medical students who came and stayed at my home last year as part of the Kumamoto delegation that visited us.

I think everyone that goes on this trip would readily agree that the members of our sister medical association in Kumamoto are incredibly gracious hosts and really go all out to make us feel welcome and to see how they go about caring for their patients. If you haven’t been on this trip I heartily recommend it as we continue to make refinements every time we go to make the travel easier and more enjoyable for everyone in the delegation.

As much as I enjoy reconnecting and seeing my Japanese friends again on these trips the most valuable aspect to me

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is getting to know the folks from the Bexar County Medical Society who go along with me. Most of the people who have gone on this trip are doctors that I haven’t met at all before and there’s no better way to get to know some folks quickly than to spend a week in a foreign country with them.

I have met some fabulously interesting people on these trips and this year was no exception. Our delegation really got along pretty well and I had some excellent travelling companions. I am grateful for the opportunity I had to get to know them and make some new friends in my home town. They all made this trip special for me and I really appreciate it.

Lastly I need to give a special thanks to Mrs. Hiroko Fay, our long-standing Japanese mom who has gone on all of these trips to help us with translations and to navigate us through Japanese hotel, transportation system, and restaurant bureaucracies to get what we need done. She makes these trips so much easier than they would be otherwise and I owe her a lot for all of the things she has taught me. Love you, Mom!

BCMS NEWS

LEAVING MONEY ON THE TABLE: Doctors are missing out on thousands of dollars in Medicare reimburseCoordinated care ments because they are not taking full advantage of a new federal program dereimbursements signed to promote and encourage coordinated care, according to the Centers for Medicare and Medicaid Services (CMS). going unclaimed The program pays an average of $42 per patient per month for non-faceto-face chronic care management services such as consulting with other doctors caring for the same patient.

CMS estimates 70 percent of Medicare beneficiaries, or roughly 35 million patients, are eligible for the reimbursement funding, but only about 100,000 have applied thus far.

One problem, according to Kathy Bryant, a senior technical advisor at CMS, is that doctors have to get permission from patients who are responsible for a 20 percent copayment. Others say that CMS has not provided enough information on how to properly bill under the codes.

“There is a concern all this documentation, along with their regular workload, is not worth it for the money they would receive,” said Diane Calmus, government affairs and policy manager at the National Rural Health Association. “It’s just too many hoops they would have to jump through.”

But a study from the Stanford University School of Medicine found that physicians who use the service could see a substantial increase in annual revenue — as much as $77,295 per year if they use registered nurses to conduct annual wellness visits and other staff to handle more frequent management.

(L-R) Nathan Mai, Kris King, Calvin Mein, MD, Luke Mein

BCMS FISHING TRIP

By Mark Lachenauer, BCMS systems administrator

On Oct. 2, 2015, BCMS members, some of their family members, and Circle of Friends sponsors traveled to Rockport for a great day of fishing. We had some familiar faces out there as well as some new comers to our little trip. The weather cooperated and it was a great day to be out of the office, spending time with friends and getting some great fish in the boats. There were numerous species caught this year, one was an approximately 31 inch Redfish caught

by Dr. Calvin Mein, but the story of the day came from the boats who got in to some black drum, large black drum, 40+ inches. The fights were long but the stories and the pictures make up for the sore 10 San Antonio Medicine • November 2015

(L-R) Everett Bratcher, MD, David Bratcher, Stacy Berry, Capt. Rhett Price, Kennith Clegg

muscles that come with fighting a fish of the size and power. Hope to see you all next time.

Want to go next time? Keep an eye out for info on the next trip in a future, The Weekly Dose.

We want to thank our Sponsors for the 2015 BCMS Fishing Trip.

RBFCU Business Solutions (rbfcu.org) and SeeKing HR (seekinghr.com). Without their continued support and that of the other Circle of Friends sponsors events like this would not be possible.

Support our sponsors; our sponsors support us!

COMPLEMENTARY HEALTH

Art Heals at the Ecumenical Center

By Edmond Ortiz

The Ecumenical Center is a renowned provider of faith-based counseling and education that helps with healing, growth and wellness. The Center offers counseling services for adults, children, teenagers and couples through psychotherapy and marriage preparation services. There are play and art therapy services for children and neurofeedback to assist with ADD/ADHD, autism, depression and anxiety in people of all ages. Recently, EMDR (Eye Movement Desensitization and Reprocessing) has been added to assist veterans and others with PTSD (Post Traumatic Stress Disorder). The testing and assessment program can assist those who need testing for gifted and talented, learning disabilities, ADD/ADHD, autism, depression and anxiety and many others. The Center also offers CPRT (Child Parent Relationship Training) for parents who would like to use the techniques that the play therapist uses with their children.

Besides counseling, the Center offers The Ethics in Business San Antonio program working in collaboration with local universities to promote awareness and educate university business students in ethical business practices. The center is the home to the noted bereavement program, Life After Loss, and other support and recovery groups. And it hosts the Pastoral Advisory Council which holds events on current issues facing the local clergy.

Mary Beth Fisk, CEO and executive director of the center, said they have a variety of unique technologies and experts trained in many different therapeutic modalities that can assist the San Antonio community to heal and be educated on mental health issues.

But did you know that for the past three years, healing through the expressive arts has become an important addition to the therapeutic process at the Center? Beginning on Sept. 11 and continuing through Jan. 4, the center comes alive with a celebration of the healing that can 14 San Antonio Medicine • November 2015

COMPLEMENTARY HEALTH

come through the visual arts, the art of writing poetry and prose and through music. The celebration is called, “Art Heals Hearts.” It is a festival of amateur and professional artists to recognize the healing that can come through the arts.

Upon entering the Ecumenical Center, one is instantly put at ease by the surroundings.

The view in the waiting room is through a panoramic bank of windows that allows one to experience a serene wooded area that the neighborhood deer call home. Besides the deer, there is something else a visitor can’t help but notice — art is everywhere! The walls of the waiting room and all the hallways are adorned with pieces of art; drawings, sketches, paintings, quilts, origami, tapestries and sculpture. Some of this art has been provided by people between the ages of 6 and 106 who work under the supervision of a licensed art therapist during the free “Open Studio Sessions” held monthly at The Ecumenical Center. Other pieces of art are donated or loaned to the Center from professional artists who have shared their life stories of pain, suffering and triumph over their problems and their difficulties through the visual arts.

“The excitement for the opening of the ‘Art Heals Hearts’ exhibit is building,” said Fisk.

The community is invited to join the celebration of healing through the arts on Sept. 11, 2015, from 6-9 p.m. at the Ecumenical Center. That night, the center will be alive with a celebration of all of the healing arts available at the Ecumenical Center. Visitors will be able to visit us at www.bcms.org

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COMPLEMENTARY HEALTH continued from page 15

view more than 140 works of art from artists displayed through every hall of the Ecumenical Center. Some of the artists’ work will be for sale. A poetry reading will be held in Jones Hall from 6:15 p.m. until 7 p.m., where amateur poets will read some works created during free poetry workshops supervised by the Center’s poetic medicine practitioner. Visitors to the Center that night, will be able to experience the newest modality for healing available at the Ecumenical Center — music therapy.

Musicians will be playing or singing original compositions that tell their healing stories, while visitors will have an opportunity to participate in a therapeutic drum circle. Drum circles are so much fun that one would never realize they are actually participating in a music therapy technique called therapeutic drumming. As with all of the free workshops held at the Center, a licensed therapist supervises the drum circle. Teamwork and expressing one’s emotions through rhythms are two of the skills that therapeutic drumming lets participants experience.

If you miss the Sept. 11th celebration, you can make arrangements for a tour of the Ecumenical Center’s art exhibition which will be running through Jan. 4, 2016. Or, you too, can create visual art, poetic art or musical art by participating in the free open studio sessions at the Ecumenical Center held each month.

So, whether you are age 6, age 106, or any age in-between, you don’t want to miss the chance to participate in “Art Heals Hearts — The Power of Expression” on Sept. 11 this year and help to heal a few more hearts on this day that symbolizes healing for our country.

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COMPLEMENTARY HEALTH

FIGHTING INFLAMMATION in the kitchen

By Michael J. Wargovich, Ph.D., F.A.C.N.

?

Should an anti-inflammatory diet be an integral part of discharge planning?

Here in San Antonio, researchers at the University of Texas Health Science Center are testing the hypothesis that daily exposure to combinations of culinary-based anti-inflammatories might offset health risks.

Amelie Ramirez, Dr. P.H., professor and director of the Institute for Health Promotion Research (IHPR) at the UT Health Science Center, and I teamed with St. Anthony Hotel Chef Iverson Brownell to conduct a six-month intervention trial in overweight breast cancer survivors. The investigation: to see whether education and active consumption of anti-inflammatory foods affected chronic inflammation. The primary goal of the clinical trial is to find out if a diet enriched in anti-inflammatory herbs and spices reduced blood measures of C-reactive protein, a marker used to measure whole body inflammation. Supported by the Komen Foundation for the Cure, the trial is in its analytical phase and results may be known by the end of this year.

Chronic inflammation plays a role in a spectrum of chronic diseases, including Alzheimer’s, arthritis, cancer, diabetes, heart disease and obesity. The Center for Disease Control estimates that seven out of 10 Americans die of chronic inflammatory diseases and these account for the vast majority of doctor-visits.

San Antonio and South Texas are no strangers to the constellation of chronic inflammatory diseases, with residents experiencing some of the highest diagnoses of obesity and diabetes in the nation. It’s

18 San Antonio Medicine • November 2015

a global phenomenon as well: the greatest risk for cancer in the next 20 years will be in the developing world, where acculturation has led to dietary changes consistent with a tidal-wave of chronic inflammatory diseases.

CHRONIC INFLAMMATION: WHEN SOMETHING GOOD GOES BAD In its acute form, inflammation is a natural healing process that marshals the immune system and cellular and chemical mediators to repair tissue damage and repel infection. Then, when healing is achieved, the inflammatory process stops. In its chronic form the inflammatory process is unabated. That causes sustained cellular and tissue injury. Chronic inflammation can result in a “hijacking” of cell signaling pathways that can mute future immune responses and enable cancer cells, for instance, to acquire the ability to invade and metastasize.

Anti-inflammatory drugs control both forms of inflammation and provide a first-line defense to combat the consequences of chronic inflammation. It has been known for some time that persistent use of non-steroidal anti-inflammatory drugs (aspirin, ibuprofen and the like) reduce risk for heart disease, certain cancers, and Alzheimer’s. However, these drugs are unsafe for widespread use due to dangerous side effects like bleeding, ulceration, stroke, and impaired kidney function.

COMPLEMENTARY HEALTH

NATURAL

ANTI-INFLAMMATORIES Turmeric Cinnamon Cloves Black Pepper Rosemary Lemongrass Oregano Green Tea Red Wine

NATURAL ANTI-INFLAMMATORIES ABOUND IN OUR DIET Given the significant side effects associated with long-term use of pharmacologic anti-inflammatories, research has focused on potentially safer sources of anti-inflammatory agents whose continual use might offset chronic diseases. The good news is that nature abounds with anti-inflammatory compounds; indeed, aspirin’s parental compound is found in willow tree bark. For the health-conscious consumer, sources include many common (and uncommon) herbs and spices. Unfortunately, these helpful anti-inflammatories tend to be absent in all-too-popular high calorie fast foods. Research has validated that compounds in turmeric, cinnamon, cloves, black pepper, rosemary, lemon grass, oregano, and in beverages such as green tea and red wine act similarly to aspirin and ibuprofen in protecting against inflammation — without unwanted side effects. The question is how best to take advantage of this scientific smorgasbord of natural anti-inflammatories.

CULINARY ANTI-INFLAMMATORIES AS A PART OF DISCHARGE PLANNING? Some patients who have had their first encounter and treatment for chronic inflammatory disease wonder why nutritional consultation is not part of discharge planning. In view of the extraordinary scientific progress on the role of anti-inflammatories in reducing risk

for chronic disease, we ask the same question: should an “anti-inflammatory diet” be implemented between patient follow-up visits?

Integrating the knowledge of natural anti-inflammatories into the patient setting has been extraordinarily slow. Even as we seek more precise information, it is safe to say that it is reasonable right now to consume spices, herbs, and fruits and vegetables with anti-inflammatory properties, daily if possible.

A number of venues are considering integrating food-based antiinflammatories into menus at the workplace and in the community. Registered dieticians have paved the way for introducing anti-inflammatory meal plans for individuals, and implementing these concepts into discharge planning may just be around the corner. However, a gentle word of caution: there is always the possibility of certain foods complicating health conditions and the medications that are prescribed for them. So it’s always good advice to check with a doctor before making big changes to the diet; herbs, spices and the like should be enjoyed as foods, not drugs — and variety, especially including more plant-based anti-inflammatory foods, is key.

Michael Wargovich, Ph.D., is a professor of molecular medicine who holds the CTRC Council Distinguished Chair in Oncology at the Cancer Therapy & Research Center at The University of Texas Health Science Center at San Antonio.

visit us at www.bcms.org

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COMPLEMENTARY HEALTH

Massage Therapy

AS A COMPLEMENTARY MEDICINE

Massage therapy is one of the most controversial topics in alternative medicine because there is so much confusion about what it is that licensed massage therapists actually do and claim to do[i]. We aren’t doctors, we aren’t chiropractors, and we certainly aren’t psychics or shamans.

Recent studies have resulted in conflicting evidence that we might do everything from increase mitochondrial expression resulting in future generations of better cellular health in soft tissue,[ii] to manually manipulating fascial adhesions to increase mobility, circulation, and pain relief.[iii] At this time, it is still difficult to say exactly what massage therapy does on a physiological level.

The muscular, integumentary, and neurologic systems are deeply intertwined, and we know that manual manipulation of sore muscles feels good. People have been rubbing our aches and pains since the

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By Megan Benson

first caveman ever threw a spear.

Those pleasurable sensations release endorphins into the brain which, at the barest minimum, decrease perception of pain and psychologically improve the mindset of the client, leading them to feel happier, more active, and more inclined to take steps to improve their own health to prolong those sensations.

Our society works longer hours with greater stress levels than ever before and most people are confined to seated positions for the majority of their waking hours. In Austin, where we lack effective public transportation, my typical client wakes up, commutes an hour to work, sits at a computer for seven to 10 hours, drives home, and plops down on the couch to watch their favorite TV show before going to bed. Many of those same people sleep on their sides, because it feels more comfortable, when that is likely secondary to their mus-

COMPLEMENTARY HEALTH

cles being conditioned to retaining the fetal position. It’s no small wonder that I see so many clients with chronic pain patterns secondary to shortened anterior muscles.

Licensed massage therapists can’t erase 20 years of pain and stress in an hour, or even two. I wish we could. I explain to my clients that massage is most useful as a preventative therapy, much akin to an oil change on a car. You can drive your car for a long time without changing the oil and not see any ill effects. Eventually, the engine is going to start showing signs of wear and tear, and when it does, you’re going to be looking at a much more significant investment than if you’d taken the time to do the preventative maintenance. Massage therapy can still help, but the results will not last forever without following a treatment regimen.

Licensed massage therapists spend more time one-on-one with each individual client than any other physical healthcare professional because we are typically paid by time and have the luxury of listening to our clients go into great detail explaining the circumstances of their complaints while we work. In short, we get the big picture that most doctors don’t, simply because we aren’t rushed. We are also one of the few bridges people have between checking Dr. Google and

running to their primary care physician every time something is sore.

The general populace still considers massage therapy to be a luxury and many doctors aren’t sure exactly how to utilize us, but when a therapist is working within their scope of practice in conjunction with proper medical advice for patient referrals from a doctor, we are a valuable resource within the healthcare community. We may be able to assist in reducing the long-term use of NSAIDs, steroids, muscle relaxants, and narcotic pain medications while increasing quality of life in many patients who are unfamiliar with alternative options.

Megan Benson, LMT has been a Licensed Massage Therapist since 2005. She is currently a junior studying biochemistry at Southwestern University in Georgetown, Texas. Her website is meganbenson.massagetherapy.com. i

Allen, L. Excuse Me, Exactly How Does That Work? Hocus Pocus in Holistic Healthcare. Amazon; 2014. ii Crane J, Ogborn D, Cupido, C, et al. Massage Therapy Attenuates Inflammatory Signaling After Exercise-Induced Muscle Damage. Sci Transl Med. 2012 Feb 1;4(119):119ra13. doi: 10.1126/scitranslmed.3002882. iii Chaudhry H, Schleip R, Ji Z, et al.Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008 Aug;108(8):379-90. https://www.ncbi.nlm.nih.gov/pubmed/18723456

visit us at www.bcms.org

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BCMS EVENTS

General Membership Meeting The General Membership Meeting was Hosted by UT Medicine — the clinical practice of the UTHSCSA School of Medicine Dr. Carlos Rosende and Dr. Francisco Gonzalez-Scarano welcomed over 130 physicians who attended the Fall General Membership Meeting.

Dr. Tomas Garcia, TMA President was the featured speaker at this event. His presentation consisted of highlighting the latest legislative accomplishments that were reached during the 2015 Legislative Session in Austin.

During this meeting, UT Medicine also reiterated their support for the future generations of medicine by presenting a 100% resident membership check to the BCMS and TMA Leaders.

(L-R) Dr. Gonzalez-Scarano, Steve Fitzer, BCMS CEO, Dr. Tom Garcia, TMA president, Dr. Carlos Rosende and Dr. Jim Humphreys, 2016 BCMS Board president.

Dr. Tom Garcia, TMA president

Dr. Donald Gordon and BCMS CEO Steve Fitzer

22 San Antonio Medicine • November 2015

BCMS EVENTS

Veranda Mixer Spice of Life Catering and their beautiful venue, The Veranda hosted the BCMS End of Summer Appreciation Mixer. The venue was filled with physicians, their guests as well as Circle of Friends members who enjoyed a great outdoor venue, a money grabbing machine hosted by IBC Bank and delicious food that delighted all of the attendees.

Several new physicians attended the event such as two new physicians (Dr. Kevin Kirk and Dr. Adewale Adeniran) who are part of the San Antonio Orthopedic Group (a BCMS 100% Group Member) and two new physicians who recently joined Baptist Health System, Dr. Belmund Catague and Dr. Yetunde Sokunbi.

We appreciate everyone’s support and participation for this event. Looking forward to 2016!

Circle of Friends members Jeanne Bennett and Karen Leckie from Amegy Bank with August Charles Trevino, development director BCMS.

Circle of Friends member Gil Castillo, Jr., wealth advisor at SWBC Wealth Management in the money booth.

visit us at www.bcms.org

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BCMS NEWS

Come and join BCMS on social media

By Mike W. Thomas BCMS Director of Communications The Bexar County Medical Society has made the leap into the cyber realm of social media. The society now has its own Facebook page and Twitter account, so anyone who is a registered user of these sites can ‘like’ or ‘follow’ our page and check in regularly for new posts, announcements and links to items of special interest to the medical community.

The new Facebook page can be found at https://www.facebook.com/bcms.org. On Twitter go to https://twitter.com/bcms_org. But as mentioned earlier, you must be a registered Facebook or Twitter user to view the page and its contents.

For those who are unfamiliar with these social media tools, you can be reassured that it is a relatively painless and cost-free process to set up an account. You will be asked for basic information and a working email address, but you do not have to share this information online if you do not want to. Facebook allows you to control the privacy settings on anything that you post so that it can be

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viewed by as many or by as few people as you choose. You can even post things that can only be seen by you. Or you can choose not to post anything at all.

Facebook is the world’s largest social networking service with more than 1.8 billion monthly active users as of August 2015. It was founded in 2004 by Mark Zuckerberg while he was a student at Harvard University. The company launched its initial public offering in 2012 and had a market capitalization of $250 billion by July 2015.

The company does not charge anything for its services and makes most of its money off of advertising.

Twitter is a separate online social media tool which limits users to short, 140-character messages called “tweets.” It had more than 500 million users as of May 2015.

So come on in if you are not there already. Come follow us on Twitter, Like our Facebook page and be a part of the online discourse.

visit us at www.bcms.org

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BOOK REVIEW

HOW TO BE A VICTORIAN A Dawn to Dusk Guide to Victorian Life Written by Ruth Goodman Reviewed by Fred H. Olin, M.D.

You are SO lucky to be living now rather than in the 19th century.

When we see expositions of life during the reign of Queen Victoria (June 1837 to January 1901) on TV or in films, most of us seem to think of the sort of things you might see on “Downton Abbey” or the descriptions of life in the Sherlock Holmes books.

If we imagine living then, we mostly see ourselves in some manifestations of what we are in our own world, or even someone rich and/or famous. Crash Davis, a character in the movie “Bull Durham” says “How come in former lifetimes everybody is someone famous? How come nobody says they were Joe Schmo?”

Here’s a quotation from this book: “The Victorian era was a catastrophic time to be poor. People’s skeletal remains provide the most graphic and incontrovertible evidence of lifelong hardship…the chances of long-term malnutrition and of body-deforming dietary deficiencies in Victorian Britain were as bad as we have ever known.”

Most of the working poor, who were a majority of the population, subsisted on diets consisting mostly of porridge and potatoes in the north and bread in the south. A favorite baby food was bread soaked in water. Protein and vitamin deficiencies were rife.

This book describes how things were in Great Britain during the Victorian period. It’s likely that there were similar conditions in the USA. Ms. Goodman did more than academic-style research: She spent a year living the life of a Victorian farmwoman. She tried on and wore actual clothes from the era and she cooked and ate foods according to recipes of the time.

The book is organized as if the reader is going through a day in the lives of folks in the mid- and late-19th century, starting with Chapter One, “Getting Up,” and ending with the last two chapters, “A Bath Before Bed” and “Behind the Bedroom Door.”

Think of your day, from the time you put your feet on the floor until your eyes close at night. Think of every moment: up, to the bathroom, eat breakfast, get to work, work, lunch (maybe,) home, evening meal, and so on. To the best of her ability, the author carries us through the days of people of not only the upper classes, but of the growing middle class and the working class, rural and urban.

What does your 5 to 10 year-old child do? In the mid-1800s, he or she would go to work, perhaps in a mine, in the fields, in spinning or weaving mills or as a servant in a grand house. “By 1872, 10 was 26 San Antonio Medicine • November 2015

the minimum age for boys to work underground…”

Prior to that time, children as young as 5 had jobs in the mines.

Medically, have any of you doctors prescribed opium, laudanum or heroin tonics for children? Have you advised a man to visit a prostitute to keep his “vital fluids” flowing? Have you experienced 15 members of the same family die within weeks of each other from cholera? Those are just a few of the medical bits described here.

Not all of the descriptions are of horrors. There is considerable space devoted to how the people dressed, from how to fold nappies (diapers) to the vagaries of female fashion through time. I didn’t know that a “crinoline” wasn’t something made of fabric, but the framework that held out what I always heard called “hoop skirts.” Additionally, there are descriptions of things as mundane as table settings, chamber pots, sewing techniques, children’s clothing and men’s hats.

This is a pretty dense book (in the sense of lots of information per chapter) and the San Antonio Public Library copy I borrowed had other people’s requests for it, so when the three weeks were up, I had only gotten half-way through. I waited a few days, put in another request and was able to finish it a month or so later. Great book!

If you have the urge, I suggest that you go online and read the New York Times Sunday Book Review of this book, by Judith Newman. I only wish I could have written one as good.

Fred H. Olin, MD, is a semi-retired orthopaedic surgeon and chair of the BCMS Communications/Publications Committee.

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NONPROFIT

Community gardens support

Food Bank expansion A Special to San Antonio Medicine

In 2007 when the San Antonio Food Bank moved to its current location at Hwy 151 and Old U.S. Hwy 90, one of the benefits the organization envisioned was once again putting a till in the soil that was for decades part of one of the largest and most respected of the old Belgian farms on the City’s Westside: the Vanderwalle Farm.

The Food Bank began tilling the old Vanderwalle farm first with a modest, two-acre community garden, generously supported with help from our San Antonio Spurs. Thousands of volunteers helped sup-

28 San Antonio Medicine • November 2015

port the Spurs Community Garden for its first five years. The volunteers tilled, planted, pruned, and harvested tens of thousands of pounds of produce over those first years, with each and every pound being used to nourish a hungry individual in San Antonio.

Simultaneous to establishing the Spurs Community Garden, the Food Bank also began to cultivate a half-acre teaching garden. The teaching garden aims to educate the local community with all the basics of building and maintaining a modest garden at one’s own home, school, or business. Hundreds of local children, youth, and adults have visited the teaching garden and learned first-hand the joys and responsibilities of cultivating and maintaining their own garden.

When the Food Bank went into expansion mode in 2012-2013, the Spurs Community

Garden was plowed up and moved to a part of the campus just between the Food Bank and the City’s Animal Care Services complex. The new and improved garden, which reopened in 2013, also anchors the Harvey Najim Children’s Pavilion. The Pavilion was built as a large outdoor market structure, harkening back to the area’s original roots in farming. Today, the Pavilion is used by volunteers who work the Community Garden (bathrooms, lockers, shade, tool storage, and picnic tables), as well as being home to a monthly Farmers’ Market one Saturday a month. The Farmers’ Market features produce from the Community Garden along with other produce from local farmers.

Two tremendous “green”energy strategies support the Community Garden. First, the Food Bank has a wind turbine in the mid-

NONPROFIT

dle of the garden, with the turbine generating 100 percent of the energy for the Najim Pavilion from wind power; and, second, the Food Bank has partnered with neighboring food manufacturer Bay Valley Foods to secure and store re-used water that is then pumped back to the garden to water the crops. In fact, the Food Bank can store up to 500,000 gallons of water onsite; catching rainwater, condensate from its air conditioners, as well as the water from Bay Valley Foods.

In 2013, the San Antonio Food Bank negotiated with the City of San Antonio, along with neighboring food manufacturer Bay Valley Foods, to begin farming an additional 25 acres of adjacent land. The Food Bank’s Urban Farm is the crown jewel in its agricultural initiatives and is thought by many to be the largest urban farm in a major metropolitan area in the State.

A team of three farmers prepare and handle all matters of the Urban Farm: irrigation, crop rotation, planting, pruning, and of course harvesting. When possible the farm team integrates volunteers into the Urban Farm experience, especially when the Spurs Community Garden does not need the extra attention. A portion of the produce from the Urban Farm supports the meals for the homeless at Haven for Hope, the homeless campus downtown, prepared by the Food Bank’s chefs. The remaining produce goes largely to hundreds of food pantries throughout the region, providing them with a healthy, locally-grown offering for the hungry who visit them.

Finally, the Food Bank operates the San Antonio Food Bank Farmers’ Market Association, a conglomeration of local farmers who support the many Food Bank farmers markets across the City. The Food Bank op-

erates six farmers markets that are open a total of 11 times in a given month. Sites for the markets are not your typical farmers’ market locations, including sites like the downtown site at Main Plaza (every Tuesday), a location at a San Antonio Housing Authority complex, a market at Sam Houston High School, and one on the Eastside at the Ella Austin Community Center. All areas, identified as food deserts, welcome the availability and selection they would otherwise not be able to add to their diet.

The Food Bank would love for the community to learn more about the many agricultural initiatives. The easiest way to get acquainted is to either come for a tour or volunteer. You can ask for a tour or request a volunteer shift by visiting the Food Bank’s website: www.safoodbank.org. Check it out. You won’t regret the investment of your time.

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UTHSCSA DEAN’S MESSAGE

San Antonio Center of Biomarkers of Risk for Prostate Cancer (SABOR) Celebrating 15 Years of Prostate Cancer Research

By Francisco González-Scarano, MD

A 60 year old man has about a 60 percent chance of developing prostate cancer in his lifetime. On average, 80 percent of men will develop some form of prostate cancer. It is second only to lung cancer in mortality rates for men and with the downward trend in smoking, prostate cancer will probably be No. 1 at some point. However, only about 2-3 percent of men with prostate cancer die of it.

Prostate cancer takes many forms and further complicating the equation is the fact that about 75 percent of men with elevated PSA levels don’t have the disease. And, even though a man may have been diagnosed with it, in many cases, he will die of old age before he dies of the cancer. Most men in this category would not even know they had the disease if they had not been biopsied.

Unfortunately, treatments for prostate cancer (radiation and surgery) are associated with a substantial risk of side effects, including sexual, urinary, and bowel complications that can dramatically affect quality of life. Even a biopsy carries with it the risk of incontinence and impotence.

In general, prostate cancer biopsies fall in to three categories of need: unnecessary, possibly beneficial, and crucial. The unnecessary and possibly beneficial ones are wrought with risk. If diagnosed with a non-progressive, non-lethal form of the disease, the person is labeled with a cancer diagnosis, affecting life and health insurance rates as well as triggering potentially harmful tests and procedures.

The challenge becomes how to identify the small percentage of men who are at a high risk for the aggressive disease form, without putting all the other men who are at a much lower risk through the possibly serious side effects of a prostate biopsy and/or treatment.

This identification equation — being able to pinpoint what combination of genetics and other factors put a man into the higher risk categories — is the goal the San Antonio Center of Biomarkers of Risk for Prostate Cancer (SABOR) which began here at the School of Medicine 15 years ago and continues to make significant strides in how we diagnosis and treat prostate cancer.

One perspective is that the equation is too complex — all men are at risk and the variables that make up who is and who is not at risk and should be treated (versus not treating/surveillance), is so complex as to not be worth solving. The U.S. Preventative Task Force, which 30 San Antonio Medicine • November 2015

is a body authorized and supported by the Agency for Healthcare Research and Quality (AHRQ), took this position in early 2012, declaring that PSA screening of men for prostate cancer is not recommended. Focusing on the cost and harm caused by unnecessary early detection and treatment of non-progressive cancers, the group has decided that risk of death/mortality rates of men from prostate cancer is not sufficiently high to warrant use of the PSA test. The Task Force does believe that more research is urgently needed to distinguish nonprogressive/ slow-progressive prostate cancer from the ones that are more aggressive and deadly.

Dr. Ian M. Thompson Jr., director of the Cancer Therapy & Research Center (CTRC) here — who is also a busy prostate cancer surgeon as well as a professor of urology in the School of Medicine — disagrees with the no-PSA recommendation, but very much agrees with the urgent need for new screening methods and biomarkers. As the founder of the SABOR program, Dr. Thompson has dedicated a significant portion of his career to pursuing these and other prostate cancer elements for prevention, diagnosis and treatment. SABOR, which was founded in 2001 with a grant from the National Cancer Institute (NCI), has become a leading center for research and has produced a number of advancements in prostate cancer screening and detection. As important, it has become a national resource as a statistical database and biologic sample source with an unprecedented cohort of men sampled before diagnosis. This base can be used to test new and novel approaches to other biomarkers for prostate cancers.

The genesis of the SABOR program was the lack of consistency and scope of most prostate cancer studies which focus on PSA and, as Dr. Thompson points out, were based on data from white males who self-selected to go to their doctor and have a blood test done for PSA. We know race and ethnicity have a great impact on prostate cancer risk, and as the nation will soon be 30 percent Hispanic, the SABOR study looks at men from a perspective that will soon be much more in line with the profile of the American male. Currently the participants are 38 percent Hispanic, 15 percent African American and the remainder Caucasian. Along with PSA results, the program also focuses on the genetics of men with prostate cancer, as well as environmental and physiological factors such as sun exposure,

UTHSCSA DEAN’S MESSAGE

smoking, diet, weight and other patterns of risk.

One of the most significant outcomes of the SABOR research is the online Prostate Cancer Risk Calculator which gets right to the goal of the program — creating tools to help physicians and their patients decide if the patient should have a prostate biopsy after receiving a PSA test result that is outside of what is considered the “normal” range. It’s a sophisticated discussion most doctors are not equipped for and this tool combines many different factors into an easy-to-interpret risk profile.

The calculator’s architect is faculty member Donna Ankerst, PhD, a biostatistician who trained at the Harvard University School of Public Health. Dr. Ankerst designed the algorithm for the online calculator which sees about 100,000 hits a month from countries all over the world. Launched in 2006 and updated several times since then to reflect new findings, the most recent version (2.0) of the calculator incorporates the % free-PSA result and was validated by a study published in the June 2014 journal Urology. (PSA is found either bound to other proteins or on its own, which is called “free PSA”. The typical PSA test measures the total of both free and bound PSA. The free-PSA test reports the percentage of unbound PSA.) I put “normal” in quotes when referring to PSA results because

historically, and even today, a PSA of 0-4 (ng/mL) is considered normal and >4 is abnormal. Drs. Thompson and Ankerst demonstrated in a paper published in JAMA that this is not an accurate indicator for prostate cancer or a biopsy. The paper, published in 2005 (JAMA. 2005;294(1):66-70), uses data from another historic study conducted by our Urology Department, the Prostate Cancer Prevention Trial (PCPT), which looked at nearly 19,000 healthy men without prostate cancer and a PSA of three or less. I’ll quote the abstract’s conclusion directly: “There is no cutpoint of PSA with simultaneous high sensitivity and high specificity for monitoring healthy men for prostate cancer, but rather a continuum of prostate cancer risk at all values of PSA.” More simply, PSA is a factor, but alone it has too much variability in regards to prostate cancer. This is why the SABOR program is so important.

The other significant contribution made by the SABOR program is the creation of its comprehensive data and tissue collection which has resulted in it becoming the premiere institute in the world for testing other predictors of prostate cancer. SABOR is a NCI (National Cancer Institute) EDRN (Early Detection Research Network) sponsored Clinical Validation Center. This means other researchers around the world request tissue samples from the SABOR collection, Continued on page 32 visit us at www.bcms.org 31

UTHSCSA DEAN’S MESSAGE Continued from page 31

run their biomarker tests on these samples and then send their results (predicting risk for prostate cancer) back to SABOR for evaluation against the database of medical history of the men who provided the samples. This is all done blind. The SABOR team then compares the report (which typically gauges risk for prostate cancer) against what actually happened to the men in the cohort. The SABOR analysis tells the test group whether or not they hit the mark.

There is a great deal of money to be made in the diagnostic arena, so the stakes are high and a great number of companies are investing significantly in the pursuit. Most are disappointed with their SABOR evaluation and it’s no surprise — as mentioned earlier in the article, most of their data is from the self-selected men who show up for a PSA test. This bias was and is the source of most data outside of the SABOR program.

The validation function is crucial for both sides of the diagnostic coin. If a new test is showing promise, it helps to establish efficacy. If the test/biomarker parameters do not fare well, it helps to prevent their progress and the subsequent negative consequences. This includes possible false negatives as well as unnecessary biopsies and other procedures with the aforementioned risk. In this complex equation with prostate cancer, it is important to turn off research with tests that don’t work.

Even though the research is coming from some of the most prestigious institutions in the world, most other cohorts do not contain samples from men before they were diagnosed with prostate cancer. Following the men in the study and identifying who developed cancer and who did not — and being able to look at a wide range of biomarkers — has proven an invaluable asset in the prostate cancer world. The SABOR team is also always watching the literature for other tests coming up so they can evaluate them against their database.

The EDRN function is overseen by SABOR geneticist Robin Leach, PhD, who has been with the SABOR program since day one.

She is a molecular geneticist who in addition to her appointment in the Department of Cellular and Structural Biology, is appointed in the Department of Urology where she is the chief of the Division of Research. She is the co-leader of the Genomics Research Core for the CTRC and also chairs the biobanking and education committees.

Her lab focuses on identifying and evaluating biomarkers for prostate cancer. In addition, she is working to identify factors that contribute to significantly higher incidences of dying from the disease.

Brandi Weaver, SABOR Regulatory Coordinator, has also been with the program since its inception and runs the urologic tissue bank. She has been a co-author on the research and Drs. Thompson and Leach credit her attention to detail and hard work with helping to make the program the distinguished center it has become in the

32 San Antonio Medicine • November 2015

world of prostate cancer research. As the main contact for SABOR, Weaver oversees patient recruitment as well as all aspects of the data collection, including all health informatics and much more.

As Dr. Leach likes to say, with all the data they have on their cohort — age, weight, genetics, lifestyle and environmental factors and more, they know more about these men than their mothers. It was Dr. Leach’s work that helped demonstrate the importance of % free PSA in the risk calculator. Many other biomarkers, including some that were very promising, were found to have no correlation. Two others that were found to have significance and subsequently added as options to the risk calculator, were the PCA3 urine marker and a detailed family history. When using the risk calculator, you can select these options to enhance your calculation.

These theories and technology can be applied to other cancers and the diagnostic dynamics surrounding them. The team is looking at partners for other cancer calculators that can further enhance the delivery of individualized, patient-directed medical care.

That men can have prostate cancer with a low PSA and be cancer free with an elevated PSA is exactly why the SABOR program is so important. Age, race, ethnicity, family history, genetics, and other factors play a role in the risk for developing the cancer and also the risk for which form of prostate cancer one might develop. SABOR has created the most sophisticated, yet easy-to-use, tool available for estimation of prostate cancer risk.

Thirty million men in the United States will develop prostate cancer. That number will be nearly 300 million worldwide. We do nearly 1.5 million biopsies a year in the U.S., perhaps as many as 100,000 are unnecessary. Nearly the same number of men are not biopsied but should be. These statistics underscore the SABOR goal: to biopsy those who truly need it, and leave the ones who don’t alone. SABOR is the hub around which this equation will be solved, with their prostate cancer risk calculator and other research becoming an integral part of healthcare in the United States.

Learn more about SABOR and the Prostate Cancer Risk Calculator, including an excellent video by Dr. Thompson explaining the calculator’s use and benefit, visit http://myprostatecancerrisk.com.

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.

LEGAL EASE

The Non-Compliant Patient

By George F. “Rick” Evans Jr. Evans, Rowe & Holbrook

Let’s start by making it clear this article is written solely from the lawyer’s perspective. Not from the eyes of a medical ethicist. Medical professionals may disagree and suggest a variety of educational and rehabilitative strategies intended to work with uncooperative patients. You’re the one who ultimately makes the choice on how to handle these patients, so let me share with you a legal viewpoint of the subject.

Why is non-compliance important to a lawyer? Two reasons. First, it frequently leads to bad outcomes when patients don’t do what they should. And bad outcomes lead to lawsuits since, after all, nobody sues over good outcomes, do they? Second, Texas law stops a patient from winning a lawsuit if the jury believes he was 51 percent or more at fault for the outcome. Non-compliance is considered a form of “patient fault” which is why it’s important to a defense attorney. We need to show the bad outcome was due to non-compliance instead of suboptimal medical care.

Lawyers may have a slightly broader view of non-compliance than doctors. To us, it’s more than an intentional refusal to follow physician instructions. It’s any failure to do whatever the patient should have done, whether intentional or not. It includes things like missing a scheduled appointment, not attending all the physical therapy sessions, not losing weight or changing a diet when told to do so, and so forth. These are events that may be the result of absent mindedness or lack of willpower, rather than intent, but it makes no difference in the eyes of the law.

Now let’s talk about what are “instructions”. Again, lawyers may have a broader view of it than physicians. It’s more than just a clear mandate from the physician to his patient (i.e. don’t eat anything after midnight before you come in for your day surgery”). It’s everything about which a patient is informed to better his condition.

Lose weight, stop smoking, exercise more, eat less fat and sugar, wear sunscreen and long shirts, etc. It’s also things that may not be an actual instruction by the physician, but fall more into the category of

a soft recommendation. Things like “perhaps you should consider a mastectomy instead of lumpectomy, or a CABG instead of a stent, or being admitted rather than treated as an outpatient, etc.” And, of course, it’s anything the patient was told to do (return appointments, limits on activity, take these meds, etc.)

So, what do you do about this patient? Here’s my laundry list. Compare it to your daily practice and see how you score.

All instructions of any kind to the patient should be documented in written format. Remember, instructions also include even your recommendations or suggestions.

Instructions further encompass pamphlets or videos given or shown to the patient. The fact it was shared with the patient must be documented. A lawyer’s definition of pamphlets, by the way, is pretty broad and would include things like physical therapy instruction sheets, pre and post procedure take home instructions, wound care instructions, and even copies of the PDR cautionary statements to patients that many doctors give their patients along with the prescription.

When patients don’t do anything that falls into this broad definition of instructions, it has to be documented. Bear in mind this includes even those times when the patient’s decision isn’t a failure to follow your instructions, but when it arguably may have been a reasonable decision for the patient not to. For example, you may simply offer a treatment or procedure for the patient’s consideration (although you don’t feel strongly about it), and the patient nonetheless declines (i.e. a cardiologist does a non-invasive nuclear stress test on the patient but suggests that a cardiac catheterization would provide even greater accuracy. The patient declines because he thinks the stress test was sufficient and doesn’t want the risk of a cath.) The patient’s decision may not rise to the level of non-compliance, but it does have consequences. They should bear those consequences, not Continued on page 34 visit us at www.bcms.org

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LEGAL EASE Continued from page 33

you, and good documentation helps assure that.

When patients don’t do as told or don’t accept treatment options (even if their decision is possibly reasonable), your documentation should include a statement that the patient has been advised of the potential consequences. In other words, your documentation should show the patient knows what could happen if he doesn’t take a certain course of action. In some cases, that’s obvious (if you don’t stop smoking, you’re at high risk of developing serious, if not fatal, disease). In other cases, it may be more subtle (if you don’t have the cardiac cath, we may not identify an arterial lesion that is present).

Your documentation doesn’t necessarily have to specify exactly what you told the patient. It can be sufficient to simply note “patient advised of possible consequences/outcomes.” Or “patient advised of risks/benefits of X.” Terminate your relationship with serious or chronic offenders. And even those patients who aren’t technically non-compliant, but are making really bad choices when offered good treatment options. You have the right to terminate your relationship with any patient. How to do that will be the subject of a future article. But patients who are always missing appointments, not taking their meds, not calling for

34 San Antonio Medicine • November 2015

care as early as they should have, not doing what you told them to do, are ticking time bombs. They probably will have bad outcomes and that’s the first step towards a lawsuit. And, lawsuits aside, those types of patients are just plain frustrating for the physician and her staff. They consume more of your resources and time, too.

When dealing with cognitively impaired patients (any person under 18, mentally obtunded or whatever), make sure your instructions are also conveyed to the caretaker. The same rules apply. And impairment doesn’t have to be permanent such as dementia. It can also be temporary such as intoxication.

Non-compliance is a serious problem in your profession. Estimates show that it costs hundreds of billions of dollars each year. It also takes a toll in the courtroom. These steps can at least help minimize that cost.

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.

BUSINESS OF MEDICINE

Two-Midnight Policy –

Rates, Enforcement and Professional Judgment

By Pamela C. Smith, Ph.D. The ‘Two-Midnight’ policy continues to raise questions of authority. Does the secretary of the Department of Health & Human Services (HHS) have the authority to make across-the-board reductions in payments? Are physicians still allowed to use their professional judgment when admitting patients? These are valid questions that have yet to be answered in today’s world of fraud, abuse, oversight, and accountability.

The secretary’s ability to make across-the-board reductions was partially decided on Sept. 22, 2015, when a U.S. District judge ruled the secretary can reduce reimbursement rates. But the agency failed to adequately explain and justify its 0.2 percent reduction under the two-midnight policy. The decision of Shands Jacksonville Medical, et al. v. Burwell provides a quick stay in the battle over who has authority to reduce reimbursement rates.

The timeline for this rate reduction battle dates back to 2013, when the Centers for Medicare & Medicaid Services (CMS) updated its FY 2014 payment policies and rates regarding inpatient hospital admissions. According to CMS, these changes were made to “provide greater clarity to hospital and physician stakeholders”[1]. Estimates indicated that implementing the two-midnight rule would cost approximately $220 million which led to the across-the-board reduction of 0.2 percent for inpatient service payments.

The plaintiffs in Shands argued the reduction in payment is invalid because the Medicare Act does not authorize the Secretary to make across-the-board reductions. They also argued the secretary did not disclose critical information about the methodology used to obtain the 0.2 percent reduction. The court determined the secretary failed to disclose critical information in her methodology and deprived interested parties an opportunity to comment. The secretary was not forced to adjust the 0.2 percent reduction, but must provide the court (by Oct. 1) with a timetable for repromulgation of the proposed rule and comment opportunity.

Physician judgment is the other critical element of the two-midnight policy. When first issued in 2013, critics complained that these new rules undermined clinical decision making. In response to this criticism, CMS proposed changes to the policy in July 2015 which will allow physicians to exercise judgment for admitting patients.

CMS proposed to allow exceptions to the two-midnight policy “to be determined on a case-by-case basis by the physician responsible for the care of the beneficiary, subject to medical review.” The proposal would classify certain short stays as inpatient, based on the admitting physician’s judgment. If patients are expected to be short stays, physicians must document numerous factors that support that decision. In the era of documented Medicare fraud, it appears physician judgment and decision making must now be spelled out in black

and white, and regulated by the government.

Notwithstanding the across-the-board cuts, the two-midnight policy has seen other changes to its enforcement policies since first issued — specifically review strategies. Upon initial implementation, Medicare Administrative Contractors (MACs) would conduct Inpatient Probe and Educate reviews for admissions prior to Sept. 30, 2015. CMS will now have Quality Improvement Organization (QIO) contractors conduct reviews of short inpatient stays, rather than the MACs.[2] CMS initially instructed MACs to implement patient status reviews, and Congress imposed a moratorium on certain patient reviews by Recovery Audit Contractors. This moratorium has been lifted through the “Medicare Access and CHIP Reauthorization Act of 2015” — which states “nothing in this section shall be construed as limiting the secretary’s authority to pursue fraud and abuse activities…”[3] According to CMS, beginning in 2016, recovery auditors will conduct reviews that have been referred by QIOs that exhibit persistent noncompliance. Recovery auditors may also conduct reviews unrelated to patient status — including coding reviews, and determining the medical necessity of procedures.

The two-midnight policy will continue to raise concerns about fairness, decision making, accountability and enforcement. To answer the two questions proposed earlier — yes, the secretary can make across-the-board reductions in payment rates. However, disclosure of critical assumptions and detailed methodology should be provided to promote active discussion and comment by stakeholders. Secondly, yes, physicians are still ‘allowed’ to use their professional judgment when admitting patients. Will ‘allowing’ professional judgment create a slippery slope between professional judgment and legislative oversight intended to prevent fraud and abuse? These and numerous other questions concerning decision making and enforcement have yet to be answered.

REFERENCES 1 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Factsheets/2015-Fact-sheets-items/2015-07-01-2.html 2 https://www.federalregister.gov/articles/2015/07/08/201516577/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment 3 https://www.congress.gov/114/plaws/publ10/PL AW114publ10.pdf Pamela C. Smith, PhD, is a professor in the department of accounting at the University of Texas at San Antonio.

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36 San Antonio Medicine • November 2015

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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.

38 San Antonio Medicine • November 2015

Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com

RC Page Construction, LLC (HHH Gold Sponsor) Commercial general contractor specializing in ground-up and interior finish-out projects. Services include conceptual and final pricing, design-build and construction management. Single-source management from concept to completion ensures continuity through all phases of the project.

Clay Page 210-375-9150 clay@rcpageconstruction.com

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 830-832-0949 Stacy.berry@greenwayhealth.com www.greenwayhealth.com

FINANCIAL SERVICES

CUSTOM HOME BUILDERS

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.”

Northwestern Mutual Wealth Management (HHHH 10K 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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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. Patients 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/ 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.”

clinical excellence through coordinated care.

Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

SWBC (HHH Gold Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships.

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Mortgage Jon M. Tober, Sr. Loan Officer NMLS#212945 210-317-7431 JTober@swbc.com Professional Employer Organization Bryce Fegley 830-980-1200 BFegley@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services

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 10K 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 Society 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.”

INSURANCE

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.”

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.”

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

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

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

Continued on page 40 visit us at www.bcms.org 39

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 39 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.”

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.”

40 San Antonio Medicine • November 2015

IT SUPPORT/VOIP/ CLOUD SERVICES

210-410-1214 irma@dmsapiens.com Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com

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.”

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

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

MEDICAL BILLING AND COLLECTIONS SERVICES

DataMED (HHH Gold Sponsor) Providing your practice with the 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.”

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.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHHH 10K Platinum Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”

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 yolanda.garza@linrontraining.com www.linrontraining.com

MENTAL HEALTH EDUCATION AND CONSULTING

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

MERCHANT PAYMENT SYSTEMS/CARD PROCESSING 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.”

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY OFFICE EQUIPMENT/ TECHNOLOGIES Dahill (HH Silver 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

REAL ESTATE/ COMMERCIAL

Robbie Casey Commercial Realty ( Gold Sponsor ) Robbie Casey Commercial Realty was founded on the principles of providing thorough market strategies, innovative advertising, superior service, and uncompromising integrity. Robbie is dedicated to each of her clients. She brings enthusiasm and creativity to each project and knows how to get the job done.

Robbie Casey 210-872-8453 robbie@robbiecaseyrealty.com http://robbiecaseyrealty.com 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

REAL ESTATE/ RESIDENTIAL

Robbie Casey Realty ( Gold Sponsor ) My extensive experience and

expertise in the San Antonio, Alamo Heights and Terrell Hills real estate market will benefit you whether you are looking to buy or sell a home in the area.

Realtor, ABS, ILHM, ALMS Roslyn Casey 210-710-3024 Roslyn@roslyncasey.com http://roslyncasey.kwrealty.com “Communication is key” 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.”

SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with toptier 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

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Brody Whitley Branch Director 210-301-4362 bwhitley@

favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TRAVEL CONSULTANTS 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 October 20, 2015 To join the Circle of Friends program or for more information, call 210-301-4366, email August.Trevino@bcms.org, or visit www.bcms.org/COf.html.

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

WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of September 15, 2015. visit us at www.bcms.org

41

42 San Antonio Medicine • November 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 Ingram Park Auto Center 7000 NW Loop 410

* North Park Lexus 611 Lockhill Selma

Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Chevrolet 12602 IH-35 North

Ancira Nissan 10835 IH-10 West

* 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

Mercedes-Benz of San Antonio 9600 San Pedro Ave.

North Park Toyota 10703 Southwest Loop 410

Gunn GMC 16440 IH-35 North

Ancira Ram 10807 IH-10 West * North Park Lincoln/ Mercury 9207 San Pedro Ave.

* Fernandez Honda 8015 IH-35 South Gunn Honda 14610 IH-10 West (@ Loop 1604)

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

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AUTO REVIEW

2016 Subaru Legacy

By Steve Schutz, MD

In a world where customers are losing interest in cars and migrating rapidly towards crossovers, mid-size sedans - vehicles that used to dominate sales charts - seem oddly irrelevant. That’s particularly true at Subaru, where crossovers have been the primary focus since the advent of the Outback wagon way back in 1995. (Who could forget those great old ads featuring Crocodile Dundee?)

But Subaru is not only about crossovers, of course. Their Legacy sedan, while never presenting much of a challenge to the class leading Toyota Camry and Honda Accord, continually improves and is designed to make most mid-range mid-size car buyers happy.

It’s probably worth a moment to emphasize how far Subaru has come in the 20 years since the first Outback debuted.

44 San Antonio Medicine • November 2015

Thanks to the Forester and WRX, important niche buyers have discovered the brand, and now we have vehicles like the XV Crosstrek hatchback for the outdoor sports crowd that’s selling well (my personal trainer who rides her road bike at least 20 miles a day wants one badly). All Subarus these days are all-wheel drive, by the way, and naturally, the Outback continues to be very popular. Subaru is on a roll.

Oh, and as I’ve noted at length previously, their “Love, it’s what makes a Subaru a Subaru” ads are the best in the business.

Anyway, back to the Legacy. Created to appeal to a 30-something professional with a family - think the young man or woman who actually does your taxes after you discuss things with the senior partner who you call

your accountant - the Legacy looks like a middle of the road sedan, which it is. And that’s OK. Pretty much the same size as the aforementioned Accord and Camry, the Legacy is clearly gunning for those sedans’ customers, but using the Subaru difference as bait.

While standard all-wheel drive is an important differentiator for the Legacy, its styling is not. Contemporary but low key describes the Legacy’s exterior design, and not even a new hexagonal grille was enough to make anybody notice this Subie during my time driving it.

The interior is similarly middle-of-theroad with good materials and workmanship evident throughout. Truth be told, though, while the Legacy is a nicer place to sit than a

AUTO REVIEW Nissan Altima, both the Camry and Accord have nicer cabins.

Legacies are offered with either a 175 HP 2.5 liter four-cylinder engine or the 3.6 liter six that pumps out a heftier 256 HP. Both motors are naturally aspirated. My test car came with the smaller engine, and there was sufficient power for everyday driving including passing or getting up to speed on the interstate. All Legacies are equipped with CVT automatic transmissions, which enthusiasts like as much as nails on a chalkboard but everyday drivers don’t even notice.

Base 2.5i models, which cost around $22,000, come surprisingly well equipped with automatic headlights, rearview camera, Bluetooth phone and audio connectivity, and smartphone integration with Pandora and Aha audio streaming. The 2.5i Premium adds alloy wheels, heated exterior mirrors, dual-zone climate control, eight-way power driver seat, heated front seats, upgraded gauges, a telematics system called “Starlink Connected” (no, it can’t get you a star named after your favorite dog), an upgraded audio system with 7-inch touchscreen display, voice commands, and internet-connected music, news, and weather applications.

A selection of options that you can get with the 2.5i Premium includes sunroof, satnav, an auto-dimming rearview mirror, rear cross-traffic and blind-spot warning protection, additional connected services, and something that Subaru calls its EyeSight system. EyeSight combines the adaptive cruise control, lane departure warning, lane departure intervention, forward collision warning/mitigation, and brake intervention to actively avoid a crash. Previously seen only on luxury cars, it’s nice to see these life saving technologies available on average price cars.

Upgrading to the 2.5i Limited trim gets you bigger alloy wheels, a more pliant suspension, leather seats, driver’s seat memory, heated rear seats, power folding side mirrors, a blind spot warning system with rear cross-traffic alert, and a 12-speaker Harman Kardon sound system. Optional equipment is nearly identical to what’s of-

fered on the Premium, but keyless entry and ignition are available.

Not surprisingly, standard and optional equipment for the 3.6 Limited is similar to that of the 2.5i Limited, with the addition of the bigger motor and xenon headlights.

Mid-size sedans may be fading compared with crossovers, but they’re not dead yet, and Subaru seems determined to get a bigger piece of this mainstream action. No, the Legacy with its CVT transmission isn’t the enthusiast’s choice, but the Legacy isn’t just another Camry or Accord, and it does come

with standard all-wheel drive that those competitors don’t even offer as options.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367 and take a look at the Subaru Legacy.

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. visit us at www.bcms.org

45

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 • November 2015