San Antonio Medicine May 2016

MEDICINE SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNT Y MEDICAL SOCIET Y

WWW.BCMS.ORG

SAN ANTONIO, TX PERMIT 1001

PAID

NON PROFIT ORG US POSTAGE

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

•

•

$4.00

•

MAY 2016

•

VOLUME 69 NO. 5

MEDICINE SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

•

WWW.BCMS.ORG

•

$4.00

Vacation Injuries Vacation Injury Prevention

...............14

Foodborne Illness: Hazards and Prevention

By Lawrence R. Suddendorf, PhD ......................19

By Barbara R. Schmitz, LCSW ...........................24

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

BCMS President’s Message ...........................................................................................................8 BCMS News..................................................................................................................................10 The Walking Med by Robert G. Johnson, MD...............................................................................27 Business: Buy and Hold Index Funds and the Next Bear Market by Aspect Wealth Management........28 Lifestyle: African Adventure by Janis Turk...............................................................................................30 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................32 Business of Medicine: Legal and Tax Strategies for Healthcare Organizations and Professionals

By Dana A. Forgione, PhD, CPA, CMA, CFE ........................................................................................35 BCMS Circle of Friends Services Directory .............................................................................................37 The ROI of your Online Reputation by Lilly Ibarra ..................................................................................42 In the Driver’s Seat...................................................................................................................................43 Auto Review: 2016 Nissan Maxima, By Steve Schutz, MD .....................................................................44

ADVERTISING SALES: SAN ANTONIO: Gerry Lair gerry@smithprint.net

PUBLISHER Louis Doucette louis @smithprint.net

ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net

4 San Antonio Medicine • May 2016

Janis Maxymof janismaxymof@gmail.com

PROJECT COORDINATOR: Amanda Canty amanda@smithprint.net

BUSINESS MANAGER: Vicki Schroder

VOLUME 69 NO. 5

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

Aquatic Dangers

PUBLISHED BY:

•

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

Lessons from Vacation Experiences

By Evan Ratner, MD ........................................22

SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net

MAY 2016

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.

By David A. Sleet, David J. Ederer, Michael F. Ballesteros, Center for Disease Control

•

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

For advertising rates and information

call (210) 690-8338 or FAX (210) 690-8638

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.

For more information on advertising in San Antonio Medicine, Call SmithPrint, Inc. at 210.690.8338 SmithPrint, Inc. is a family owned and operated San Antonio based printing and publishing company that has been in business since 1995. We are specialists in turn-key operations and offer our clients a wide variety of capabilities to ensure their projects are printed and delivered on schedule while consistently exceeding their quaility expectations. We bring this work ethic and committment to customers along with our personal service and attention to our clients’ printing and marketing needs to San Antonio Medicine magazine with each issue.

Copyright © 2016 SmithPrint, Inc. PRINTED IN THE USA

BOARD OF DIRECTORS

OFFICERS Jayesh B. Shah, MD, President Sheldon Gross, MD, Vice President Leah Jacobson, MD, President-elect James L. Humphreys, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary Adam V. Ratner, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Jorge Miguel Cavazos, MD, Member Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John W. Hinchey, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Jennifer Lewis, BCMS Alliance President Roberto Trevino Jr., MD, Board of Censors Chair Jesse Moss 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 Alice Sutton, Controller

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Fred H. Olin, MD, Member Esmeralda Perez, Community Member David Schulz, Member J.J. Waller Jr., MD, Member

6 San Antonio Medicine • May 2016

PRESIDENT’S MESSAGE

Telemedicine Debate

Continues...

By Dr. Jayesh Shah, 2016 BCMS President

Telemedicine is becoming popular in the healthcare industry.

There are more than a dozen telemedicine companies that are already working with doctors and patients and seen virtually for their non-emergency visits. Telemedicine is also playing an important role for chronic disease management. After the patient comes for a doctor’s visit for the first initial complete evaluation, follow up care can be done virtually.

At centers like Joslin Diabetes Center, doctors have started using virtual visits for follow-up appointments with out-of-state patients.

Medicare, Medicaid, some United Health Care plans, some Humana plans and a few more have approved payments for telehealth services. As telemedicine is trending upward, other insurance carriers will soon come on board. Are we ready for this new model?

Clearly there are some advantages of telemedicine: • Reduced health care costs • Easy access to referring physicians and specialists • Easily accessible to patients - reduces travel time and related stresses for the patient, makes healthcare accessible to people, especially to those living in remote areas

However, problems facing telemedicine are many and need to be resolved before telemedicine becomes widespread.

• Added cost for fast reliable broadband connections, technical training and equipment • Complicated policies and reimbursement rules • Quackery (how to verify a doctor’s credentials on the Internet) • Special Licensing requirements • Decreased in-person visits can lead to misdiagnosis • Decreased personal care and missing opportunities to hold hands and develop psychological consultation on some other family issues.

According to CMS, “Telemedicine seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”

8 San Antonio Medicine • May 2016

“Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient) that states can choose to cover under Medicaid. This definition is modeled on Medicare’s definition of telehealth services.”

(42 Code of Federal Regulations 410.78) “As CMS gets ready to pay primary care physicians on a different model starting in 2017, from a fee-for-service to a monthly fee for managing patients, provider practices will be able to participate in two ways. In Track 1, the agency will pay a monthly fee to practices that provide specific services. That fee is in addition to the fee-forservice payments under the Medicare Physician Fee Schedule for care. In Track 2, practices will also receive a monthly care management fee, and instead of full Medicare fee-for-service payments for evaluation and management services, they will receive reduced Medicare fee-for-service payments and up-front comprehensive primary care payments. This hybrid payment design will allow greater flexibility in how practices deliver care outside of the traditional face-to-face encounter, the agency said. For example, practices might offer telemedicine visits or simply provide longer office visits for patients with complex needs. Practices in both tracks will receive upfront incentive payments that they might have to repay if they do not perform well on quality and utilization metrics.”

I feel that there is a need to preserve the sanctity of a patientphysician relationship. Part of our problem is not responding to the evolving trends and leading the way, rather than being pointed out, complaining and wondering why we are losing ground.

Telemedicine can be used as a valuable add-on service to enhance patient care rather than replacing much needed face-to-face interaction. In-person, face-to-face interaction between a physician and patient allows physicians to handle many complex social and psychological issues pertaining to the patient and their family members which cannot be achieved by telemedicine. Telemedicine lacks the “touch” which has the power of healing.

For more information on telehealth services, please visit the CMS website.

Centers for Medicare & Medicaid Services (CMS) Policy (visit www.cms.gov/medicare/medicare-general-information/telehealth/index.html).

The State of Texas Medical Board has answers to frequently asked questions pertaining to telemedicine at www.tmb.state.tx.us/ (Telemedicine FAQs).

BCMS NEWS

BCMS Delegation to TMA heading to Dallas for TexMed 2016 Dr. David Henkes running for TMA president-elect At the time of this writing, the BCMS Delegation to TMA has reviewed over 30 resolutions under consideration by the TMA House of Delegates and is headed to Dallas to represent BCMS in TMA's annual meeting taking place April 29-30 at the Hilton Anatole. The BCMS Delegation has submitted a resolution entitled: Physician Collaboration in Active Child Protective Services Investigations, which asks that TMA work with the Texas Department of Family and Protective Services and Child Protective Services to eliminate barriers to useful and productive interaction with physicians for the benefit of the children. To read the full resolution, visit www.bcms.org.

BCMS Delegation to TMA members discuss and prepare action for the TMA House of Delegates business meeting.

A major highlight of this year's Delegation's work has been to encourage colleagues from around the state to support our own, Dr. David Henkes, in his bid to become TMA president-elect. Elections take place during TexMed on April 30. For more details, visit www.drdavidhenkes.com.

For more information on activities of the BCMS Delegation to TMA, contact Mary Nava at mary.nava@bcms.org.

April 5 General Membership Meeting held at Cumberland Surgical Hospital Dr. Pavithra Pattabiraman gave an overview of DocbookMD, a HIPAA-compliant texting service that is free for members of TMA and BCMS.

Wendell England of TMA Insurance Trust, Dr. Ubaldo Beato and BCMS Development Director August Trevino.

10 San Antonio Medicine • May 2016

The BCMS General Membership meeting on April 5 was hosted by Cumberland Surgical Hospital at 5330 N. Loop 1604 West.

BCMS NEWS

12 San Antonio Medicine • May 2016

VACATION INJURIES

Vacation Injury Prevention David A. Sleet, David J. Ederer, Michael F. Ballesteros Center for Disease Control According to the World Health Organization (WHO), injuries are among the leading causes of death and disability in the world, and they are the leading cause of preventable death in travelers.

Among travelers, data show that injuries are one of the leading causes for consulting a physician, hospitalization, repatriation, and death. Worldwide, injuries are the leading cause of death for young people aged 15–29 years. Estimates have reported that 18%–24% of deaths among travelers in foreign countries are caused by injuries.

Infectious diseases accounted for only 2% of deaths to travelers abroad. Contributing to the injury toll while traveling are exposure to unfamiliar and perhaps risky environments, differences in language and communications, less stringent product safety and vehicle standards, unfamiliar rules and regulations, a carefree holiday or vacation spirit leading to more risk-taking behavior, and overreliance on travel and tour operators to protect one’s safety and security.

From 2011 through 2013, an estimated 2,466 US citizens died from non-natural causes, such as injuries and violence, while in foreign countries (excluding deaths occurring in the wars in Iraq and Afghanistan). Motor vehicle crashes—not crime or terrorism—are the number 1 killer of healthy US citizens living, working, or traveling in foreign countries. From 2011 through 2013, 621 Americans died in road traffic crashes abroad (25% of all non-natural deaths to US citizens abroad). Another 555 were victims of homicide (23%), 392 committed suicide (16%), and 309 were victims of drowning (13%) (Figure 2-02). Other less common but serious injuries are related to natural disasters, aviation accidents, drugs, terrorism, falls, burns, and poisoning.

If a traveler is seriously injured, emergency care may not be available or acceptable by US standards. Trauma centers capable of providing optimal care for serious injuries are uncommon outside urban areas in many foreign destinations. Travelers should be aware of the increased risk of certain injuries while traveling or residing abroad, particularly in developing countries, and be prepared to take preventive steps.

ROAD TRAFFIC INJURIES Globally, an estimated 3,300 people are killed each day, including 720 children, in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks, and pedestrians. Annually, 1.24 million are killed and 20–50 million are injured in traffic crashes—a number likely to double by 2030. Although only 53% of the world’s vehicles 14 San Antonio Medicine • May 2016

are in developing countries, >90% of road traffic casualties occur in these countries.

International efforts to combat road deaths command a tiny fraction of the resources deployed to fight diseases such as malaria and tuberculosis, yet the burden of road traffic injuries is comparable. In response to this crisis, in March 2010 the 64th General Assembly of the United Nations described the global road safety crisis as “a major public health problem” and proclaimed 2011–2020 as “The Decade of Action for Road Safety.” On April 19, 2012, the United Nations General Assembly adopted a new resolution (A/66/PV.106) to improve global road safety by implementing plans for the decade, setting ambitious targets, and monitoring global road traffic fatalities.

According to Department of State data, road traffic crashes are the leading cause of injury deaths to US citizens while abroad (Figure 2-02). Of the 621 US citizens killed in road traffic crashes from 2011 through 2013, approximately 110 (18%) deaths involved motorcycles. Unlike in the United States, in many countries, 2- and 3wheeled vehicles outnumber cars, and travelers unfamiliar with driving or riding motorcycles may be at higher risk of crashing. Most non-natural American deaths in Thailand and Vietnam, popular travel destinations, were related to motorcycle use. Motorcycle use is also dangerous for travelers in countries where motorcycles are not the primary mode of transportation. The reported rate of motorbike injuries in Bermuda is much higher in tourists than in the local population, and the rate is highest in people aged 50–59 years. Motor vehicle rentals in Bermuda and some other small Caribbean islands are typically limited to motorbikes for tourists, possibly contributing to the higher rates of motorbike injuries. Loss of vehicular control, unfamiliar equipment, and inexperience with motorized 2-wheelers contributed to crashes and injuries, even at speeds <30 miles per hour.

Road traffic crashes are common among foreign travelers for a number of reasons: lack of familiarity with the roads, driving on the opposite side of the road, lack of seat belt use, the influence of alcohol, poorly made or maintained vehicles, travel fatigue, poor road surfaces without shoulders, unprotected curves and cliffs, and poor visibility due to lack of adequate lighting. In many developing countries, unsafe roads and vehicles and an inadequate transportation infrastructure contribute to the traffic injury problem. In many of these countries, motor vehicles often share the road with vulnerable road users, such as pedestrians, bicyclists, and motorcycle users. The

VACATION INJURIES mix of traffic involving cars, buses, taxis, rickshaws, large trucks, and even animals increases the risk for crashes and injuries.

Millions of US citizens travel to Mexico each year, and >150,000 people cross the USâ&#x20AC;&#x201C;Mexico border daily. Travelers should be particularly cautious in Mexico; from 2011 through 2013, 27% of all deaths of US citizens abroad occurred in that country, where >200 Americans died in road traffic crashes.

Strategies to reduce the risk of traffic injury are shown in Table 2-12. The Association for International Road Travel (www.asirt.org) and Make Roads Safe (www.makeroadssafe.org) have useful safety information for international travelers, including road safety checklists and country-specific driving risks. The Department of State has safety information useful to international travelers, including road safety and security alerts, international driving permits, and travel insurance (www.travel.state.gov).

Leading causes of injury death for US citizens in foreign countries, 2011-20131,2 Figure 2-02.

1 Data from US Department of State. Death of US citizens abroad by non-natural causes. Washington, DC: US Department of State; 2014 [cited 2014 March 26]. Available from: http://travel.state.gov/content/travel/english/statistics/deaths .html.

2 Excludes deaths of US citizens fighting wars in Afghanistan or Iraq, and deaths that were not reported to the nearest US embassy or consulate.

Recommended strategies to reduce injuries while abroad Table 2-12.

HAZARD Road Traffic Crashes

PREVENTION STRATEGIES

LACK OF SEAT BELTS AND CHILD SAFETY SEATS

Always use safety belts and child safety seats. Rent vehicles with seat belts; when possible, ride in taxis with seat belts and sit in the rear seat; bring child safety seats and booster seats from home for children to ride properly restrained.

DRIVING HAZARDS

When possible, avoid driving at night in developing countries; always pay close attention to the correct side of the road when driving in countries that drive on the left.

COUNTRY-SPECIFIC DRIVING HAZARDS

Check the Association for Safe International Road Travel website for driving hazards or risks by country (www.asirt.org).

MOTORCYCLES, MOTOR BIKES, AND BICYCLES

Always wear helmets (bring a helmet from home, if needed). When possible, avoid driving or riding on motorcycles or motorbikes, including motocycle and motorbike taxis. Traveling overseas is a bad time to learn to drive a motorcycle or motorbike.

ALCOHOL-IMPAIRED DRIVING

Alcohol increases the risk for all causes of injury. Do not drive after consuming alcohol, and avoid riding with someone who has been drinking.

CELLULAR ACTIVITIES

Do not use a cellular telephone or text while driving. Many countries have enacted laws banning cellular telephone use while driving, and some countries have made using any kind of telephone, including handsfree, illegal while driving.

TAXIS OR HIRED DRIVERS

Ride only in marked taxis, and try to ride in those that have safety belts accessible. Hire drivers familiar with the area. continued on page 16

visit us at www.bcms.org

15

VACATION INJURIES continued from page 15

Recommended strategies to reduce injuries while abroad (continued) Table 2-12.

HAZARD Road Traffic Crashes

PREVENTION STRATEGIES

BUS TRAVEL

Avoid riding in overcrowded, overweight, or top-heavy buses or minivans.

PEDESTRIAN HAZARDS

Be alert when crossing streets, especially in countries where motorists drive on the left side of the road.

Walk with a companion or someone from the host country.

Other Tips AIRPLANE TRAVEL

Avoid using local, unscheduled aircraft. If possible, fly on larger planes (>30 seats), in good weather, during the daylight hours, and with experienced pilots. Children <2 years should sit in a child safety seat, not on a parent’s lap. Whenever possible, parents should travel with a safety seat for use before, during, and after a plane ride.

DROWNING

Avoid swimming alone or in unfamiliar waters. Wear life jackets while boating or during water recreation activities.

BURNS

In hotels, stay below the sixth floor to maximize the likelihood of being rescued in case of a fire. Bring your own smoke alarm.

WATER AND AQUATIC INJURIES Drowning accounts for 13% of all deaths of US citizens abroad.

Although risk factors have not been clearly defined, these deaths are most likely related to unfamiliarity with local water currents and conditions, inability to swim, and the absence of lifeguards on duty.

Rip currents can be especially dangerous, as are sea animals such as urchins, jellyfish, coral, and sea lice. Alcohol also contributes to drowning and boating mishaps.

Drowning was the leading cause of injury death to US citizens visiting countries where water recreation is a major activity, such as Fiji, the Bahamas, Jamaica, and Costa Rica. Young men are particularly at risk of head and spinal cord injuries from diving into shallow water, and alcohol is a factor in some cases.

Boating can be a hazard, especially if boaters are unfamiliar with the boat, do not know proper boating etiquette or rules for watercraft navigation, or are new to the water environment in a foreign country. From 2011 through 2013, maritime accidents accounted for 8% of deaths to healthy Americans abroad. Many boating fatalities result from inexperience or failure to wear lifejackets.

Scuba diving is a frequent pursuit of travelers in coastal destinations. The death rate among all divers worldwide is thought to be 15–20 deaths per 100,000 divers per year. Travelers should either be experienced divers or dive with a reliable dive shop and instructors. See the Scuba Diving section later in this chapter for a more detailed discussion about diving risks and preventive measures.

OTHER INJURIES From 2011 through 2013, aviation incidents, drug-related inci16 San Antonio Medicine • May 2016

dents, and deaths classified as “other unintentional injuries” accounted for 22% of deaths to healthy US citizens abroad (Figure 202). Fires can be a substantial risk in developing countries where building codes do not exist or are not enforced, there are no smoke alarms, there is no access to emergency services, and the fire department’s focus is on putting out fires rather than on fire prevention or victim rescue.

Travel by local, lightweight aircraft in many countries can be risky.

From 2011 through 2013, an estimated 82 US citizens abroad were killed in aircraft crashes. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with inexperienced pilots carries the highest risk.

Before flying with children, parents and caregivers should check to make sure that their child restraint system is approved for use on an aircraft. This approval should be printed on the system’s information label or on the device itself. The Federal Aviation Administration (FAA) recommends that a child weighing <20 lb use a rear-facing child restraint system. A forward-facing child safety seat should be used for children weighing 20–40 lb. FAA has also approved a harness-type device for children weighing 22–44 lb.

Travel health providers, vendors of travel services, and travelers themselves should consider the following: • Purchasing special travel health and medical evacuation insurance if their destinations include countries where there may not be access to good medical care (see the Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance section later in this chapter).

VACATION INJURIES

• Because trauma care is poor in many countries, victims of injuries and violence can die before reaching a hospital, and there may be no coordinated ambulance service available. In remote areas, medical assistance and modern drugs may be unavailable, and travel to the nearest medical facility can take a long time.

• Adventure activities, such as mountain climbing, skydiving, whitewater rafting, dune-buggying, and kayaking, are popular with travelers. The lack of rapid emergency trauma response, inadequate trauma care in remote locations, and sudden, unexpected weather changes that compromise safety and hamper rescue efforts can delay access to care.

• Travelers should avoid using local, unscheduled, small aircraft. If available, choose larger aircraft (>30 seats), as they are more likely to have undergone more strict and regular safety inspections.

Larger aircraft also provide more protection in the event of a crash. For country-specific airline crash events, see www.airsafe.com.

• When traveling by air with young children, consider bringing a child safety seat approved for use on an aircraft.

• To prevent fire-related injuries, travelers should select accommodations no higher than the sixth floor. (Fire ladders generally cannot reach higher than the sixth floor.) Hotels should be checked for smoke alarms and preferably sprinkler systems.

Travelers may want to bring their own smoke alarm. Two escape routes from buildings should always be identified. Crawling low under smoke and covering one’s mouth with a wet cloth are helpful in escaping a fire. Families should agree on a meeting place outside the building in case a fire erupts.

• Improperly vented heating devices may cause poisoning from carbon monoxide. Carbon monoxide at the back of boats near the engine can be especially dangerous. Travelers may want to carry a personal detector that can sound an alert in the presence of this lethal gas.

• Travelers should consider learning basic first aid and CPR before travel overseas with another person. Travelers should bring a travel health kit, which should be customized to the anticipated itinerary and activities (see the Travel Health Kits section later in this chapter).

• Suicide is the third-leading cause of injury death to US citizens abroad, accounting for 16% of non-natural deaths. For longerterm travelers (such as missionaries and volunteers), social isolation and substance abuse, particularly while living in areas of poverty and rigid gender roles, may increase the risk of depression and suicide. See the Mental Health section later in this chapter for more detailed information. continued on page 18

visit us at www.bcms.org

17

VACATION INJURIES continued from page 17

BIBLIOGRAPHY 1 Ball DJ, Machin N. Foreign travel and the risk of harm. Int J Inj Contr Saf Promot. 2006 Jun;13(2):107–15.

7 Leggat PA, Fischer PR. Accidents and repatriation. Travel Med Infect Dis. 2006 May–Jul;4(3–4):135–46.

2 Cortes LM, Hargarten SW, Hennes HM. Recommendations for water safety and drowning prevention for travelers. J Travel Med. 2006 Jan–Feb;13(1):21–34.

8 McInnes RJ, Williamson LM, Morrison A. Unintentional injury during foreign travel: a review. J Travel Med. 2002 Nov– Dec;9(6):297–307.

3 FIA Foundation for the Automobile and Society. Make roads safe report: a decade of action for road safety. FIA Foundation for the Automobile and Society; 2009 [cited 2014 Aug 8]. Available from: http://www.fiafoundation.org/connect/publications.

9 Sleet DA, Balaban V. Travel medicine: preventing injuries to children. Am J Lifestyle Med. 2013 Mar 10;7(2):121–9.

4 Guse CE, Cortes LM, Hargarten SW, Hennes HM. Fatal injuries of US citizens abroad. J Travel Med. 2007 Sep–Oct;14(5):279– 87.

5 Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet. 2002 Oct 5;360(9339):1083–8.

6 Lawson CJ, Dykewicz CA, Molinari NA, Lipman H, AlvaradoRamy F. Deaths in international travelers arriving in the United States, July 1, 2005 to June 30, 2008. J Travel Med. 2012 Mar– Apr;19(2):96–103.

18 San Antonio Medicine • May 2016

10World Health Organization. WHO global status report on road safety 2013: supporting a decade of action Geneva: World Health Organization; 2013 [cited 2014 Sep 19]. Available from: http://www.who.int/violence_injury_prevention/road_safe ty_status/2013/en/.

VACATION INJURIES

FOODBORNE ILLNESS: Hazards and Prevention

By Lawrence R. Suddendorf, PhD As we enter the spring and summer seasons, typical times of the year for outdoor activities and travel, we need to protect ourselves from foodborne illness (FBI). Foods prepared by others, foods transported away from kitchens and homes, and mishandled foods become support systems for dangerous hazards that result in everything from inconvenience to tragedy.

FBI not only incapacitates but kills victims. We need nourishment, we desire convenience, and foods usually add to the enjoyment of our activities; therefore, food safety should become a primary goal of planning our summertime fun. Another potential concern is the vague combination of signs and symptoms initially observed in FBI: nausea, vomiting, diarrhea, dehydration, cramps, prostration, chills, fever, headache, and fatigue. Definitive medical care is usually not sought; victims often resort to over-the-counter compounds for symptomatic relief. This may result in a delay that complicates a potentially deadly illness. Obvious signs such as jaundice (Hepatitis) or hemolytic uremic syndrome (Shiga-toxin pro-

ducing E. coli) appear later and in only these specific circumstances.

Some statistics to view: • Over 48 Million FBI cases per year • Or, 1 in 6 Americans get a FBI • Over 128,000 serious cases requiring hospitalization • 3,000 Deaths from food borne diseases • Costs of $152 billion per year in health care and other losses (CDC, 2011)

Two basic questions will be addressed here: what are the hazards, and how should we prevent or control them?

The answers to our questions will discuss: • the causes of food borne illness • safe preparation and storage to avoid serving contaminated foods and thereby minimize food borne illness • the role of personal health and hygiene in food safety continued on page 20

visit us at www.bcms.org

19

VACATION INJURIES continued from page 19

The U.S. Food and Drug Administration (FDA) establishes the foundation for food safety in its Model Food Code, officially revised and published every four years. We will refer to the current (FDA, 2013) version in our brief discussion here. Food safety depends on strong partnerships. The Centers for Disease Control and Prevention (CDC), the FDA, and U.S. Department of Agriculture’s (USDA) Food Safety Inspection Service collaborate at the federal level to promote food safety. State and local health departments and food industries also play critical roles in all aspects of food safety. CDC provides the vital link between illness in people and the food safety systems of government agencies and food producers. Note that individual states’ legislatures write the enforceable laws and delegate enforcement responsibilities to local health departments, so while there is uniformity across the nation, some states adopt more restrictive standards.

Food safety hazards are divided into three major categories: biological, chemical, and physical. Biological hazards are microorganisms such as bacteria, viruses, parasites, and fungi. Chemical hazards are delineated in two major categories: naturally-occurring and manmade. The several foods identified as potential allergens are categorized as chemical hazards. Physical hazards are usually foreign materials improperly incorporated into foods, but also natural substances left due to improper processing.

Bacterial hazards grow in foods, so a very small amount of contamination can quickly become significant problems. Good temperature control is essential to preventing growth, but it must be practiced along with other clean and sanitary handling techniques.

Some bacteria, like Campylobacter, Listeria, Vibrio, Salmonella, and Shigella directly infect because they are present as naturally occurring flora in various categories of foods that are usually improperly cooked or mishandled after cooking. Several others, such as Staphylococcus aureus, Clostridium botulinim, Bacillus cereus, Clostridium perfringens, and Shiga-toxin producing strains of Escherica coli produce toxins that quickly cause symptoms to appear. These toxins are heat stable, so cooking foods will not remedy a situation where food was mishandled in its raw state. The most common viral hazards include Hepatitis A and Norovirus (the most common of the FBI). Common parasites include Trichinella and Anasakis. Fungi (molds and yeasts) become FBI sources in improperly stored, aged foods. Most are also toxin producers.

Chemical hazards that occur naturally are toxins found in certain types of seafood, mushrooms, rhubarb leaves, potato sprouts, and fava beans. Proteins found in peanuts, egg products, milk products, fish, shellfish, crustaceans, wheat gluten, and soy products are allergenic chemicals. Man-made chemical hazards include agricultural chemicals such as herbicides and pesticides, cleaning and sanitizing agents, reactive metals and plastics improperly used as food contact 20 San Antonio Medicine • May 2016

surfaces, and medications. The best ways to deal with these is knowledge of their presence, proper use, and avoidance.

Various physical hazards can cause a choking or laceration hazard if ingested; they may also be a source of biological or chemical hazards. Common physical hazards include: glass, jewelry, plastic (wrappings, containers), wood (cutting boards, spoons), stones/pits/seeds, metal fragments from can openers, eggshells, and hair. Proper handling and preparation procedures should prevent the presence of these types of hazards.

Knowing what the various types of hazards causing FBI are, we can now address their prevention or control.

The most serious FBI cases are caused by bacteria, so our discussion will focus on this particular type of hazard. Proper temperature control focuses on a simple axiom: keep hot food hot, keep cold food cold, and keep frozen food frozen, or don’t keep it! The FDA considers various high-protein, neutral pH, high-water activity foods as Time and Temperature Control for Safety (TCS) Foods. Foods traditionally known as “perishable”: meat, dairy, poultry, eggs, seafood, soy, leafy greens, prepared rice and beans, even potatoes and tomatoes fit in this category.

The FDA Temperature Danger Zone (TDZ), a range of 94 degrees on the Fahrenheit scale, illustrates the versatility of bacterial growth. Therefore, keeping foods out of the TDZ or rapidly processing through the TDZ should be a primary goal. The total time food is allowed to be in the TDZ should not exceed four hours; this is all the time it takes for enough bacteria to be generated to cause illness. Acidification and lowering the available water in a food also helps prevent bacterial growth. Most of the FBI-causing bacteria are either anaerobes or facultative anaerobes; therefore, vacuum-packed foods and canned foods offer little protection from bacterial growth.

Fig. 1, Temperature Standards

The CDC and FDA recommend four essential actions to keep foods safe: COOK-CHILL-CLEAN-SEPARATE (CDC, 2015).

These practices may be paired: cooking and chilling maintain proper

VACATION INJURIES

temperature control; cleaning and separating prevent contamination and cross-contamination, respectively.

Fig. 2, FDA Minimum Cooking Temperature/Time Standards

COOK and CHILL As listed in Figure 2, foods have different safe cooking temperature standards. These are based upon a combination of the necessity to kill typical flora while not overcooking foods.

Higher temperatures/longer times are allowed as personal desires. Notice three unique standards: rare roast beef maintains a cool, red center by cooking to an internal temperature of only 130°F, but held for a very long time; reheating any food requires cooking to at least 165°F; use of a microwave appliance requires a special time standard. Once a hot food is properly cooked, it must be held at 135°F or higher. It is best to use plentiful volumes of ice or ice-water slush for chilling hot foods and keeping cold foods cold. Crushed or cube ice provides excellent contact with food containers to help insure that they remain at or below 41°F. Reusable blocks of coolant are satisfactory, but should be placed above containers within a cooler for best effect. The Code does not prescribe a specific temperature range for frozen foods; it states that the food must be frozen solid with no evidence of thawing. Many labels now include storage and preparation instructions. These predominantly exceed the basic standards discussed here.

CLEAN and SEPARATE Proper hand washing is the principle means of preventing spread of any communicable disease, including the FBI. Sanitizing gels should only be used as a last resort, substituting when warm water and soap are not available. The isopropyl alcohol is not a universal sanitizer, and dirt should be removed from hands first. Dishes and utensils should always be cleaned with the hottest water possible (171°F is the recommended sanitizing temperature, but may not be possible in home or outdoor locations.). Disposable items can certainly add a safety factor when serving food, but these must be protected or wrapped prior to use. Whenever working with different foods, especially between raw and cooked or when handling any of the potential allergens, clean and separate containers and surfaces

judiciously. Inadvertent cross-contamination is frequently the cause of serious FBI. While there are many additional specific practices that promote food safety, one can reasonably protect family and friends by remembering: KEEP HOT FOOD HOT, COLD FOOD COLD, FROZEN FOOD FROZEN, OR DON’T KEEP IT and: COOK-CHILL-CLEAN-SEPARATE Enjoy your travels and summer fun with safe food practices!

References and Additional Resources: • CDC statistics, 2011: www.cdc.gov/foodborneburden/2011foodborne-estimates.html • FDA Model Food Code, 2013: www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/ucm374275.htm • CDC information for consumers, 2015: www.cdc.gov/foodsafety/groups/consumers.html Lawrence R. Suddendorf, PhD, MT (ASCP) is originally from Cincinnati, OH. He directed medical laboratories and taught Medical Laboratory Science in many venues, both civilian and military over the past 47 years. Currently, Larry serves as a consultant and instructor in food safety while also continuing to teach online medical laboratory science. He resides in Kerr County with his wife, Joan, a retired Registered Nurse. visit us at www.bcms.org

21

VACATION INJURIES

LESSONS FROM VACATION EXPERIENCES

By Evan Ratner, MD

Life is not measured by the number of breaths we take, but by the moments that take our breath away. Vacations are a time away from the routine that we hope will take our breath away. To get it right, we spend a lot of time deciding the specifics of what to take, what is a necessity and what can be left behind. I’ll take my hiking boots, but should I take my running shoes as well? Will I need four pair of socks or five? Should I pack an extra pair just in case, after all, they don’t take up much space? How many of us put the same thoughtfulness into building a vacation emergency first aid kit? It shouldn’t take up much space, but it could make all the difference.

SCENARIO ONE: Teenage boy wants to clear up some acne to ensure the Italian girls will be unable to resist his charms. Starts a new medication one day prior to leaving for the family vacation.

Two hours into the transatlantic flight his ears swell to elephantine proportions, only dwarfed by the swelling of his hands and feet.

Luckily the vibrant red, ever changing, seemingly glowing patches of skin distract the amazed onlookers from the swelling. My son was experiencing a pretty impressive allergic reaction to the new medication. Thankfully his airway was not compromised and he could still breath. I stopped the new medication and gave Benedryl and Zantac. Most people know that Benedryl is a histamine blocker that can be used to reduce allergic reactions, but Zantac (ranitidine) is also a strong and useful histamine blocker even though it is best known for reducing heartburn.

LESSON ONE: Over the counter Benedryl and Zantac are great 22 San Antonio Medicine • May 2016

for most allergic reactions, and as a bonus can also help with a little heartburn, or occasional trouble sleeping.

SCENARIO TWO: Teenage boy wants a great tan to ensure the Florida girls will be unable to resist his charms. Spends the entire first day out in the sun without any sunblock or protective clothing that may slow his transition to a golden color. That night he once again turns bright red. this time it is a diffuse color sparing only the area between his waist and knees that was covered by his shorts. We apply cool wet towels to help reduce the temperature, and provide symptomatic relief. We make sure sure that he drinks a lot of water, juice and gatoraid to stay hydrated and we give him an anti-inflammatory medication to help control the pain and the injury. We then make sure that he gets frequent applications of topical aloe.

LESSON TWO: Over the counter Non steroidal anti-inflammatory (Advil, Motrin, Aleve) can be effective treating moderate pain and inflammation. A small vial of zinc oxide cream can go a long way in obtaining great protection from the sun.

SCENARIO THREE: Five year old girl swimming at a beach sustains multiple painful jelly fish stings and is very scared and uncomfortable. Mother takes her behind a beached sail boat and rinses the stings with urine.This does not relieve the pain at all and emotionally scars both Mother and Child for life.

LESSON THREE: Peeing on jelly fish stings is not an effective treatment. Thank goodness my wife administered the “treatment” be-

VACATION INJURIES cause I could not have done that to my daughter. Could I have “treated” my son from the first two scenarios, no problem. Would it have helped the jellyfish stings? Not one bit. Can medications from lessons one and two be helpful? Absolutely.

SCENARIO FOUR: Adult male sailing across the Gulf of Mexico with other medical students and sustains a laceration to the calf after a slip and fall on the wet deck. Fight off, repel, refuse all interventions ranging from applying a tourniquet, to amputation, to pouring alcohol on the wound to clean it — to just manning up and trying not to bleed everywhere. Ultimately the wound was cleaned with soap and water, antibiotic ointment was applied and a clean compressive dressing applied.

LESSON FOUR: Stay away from first, second and third year medical students if you are ever injured or sick. Carry some antibiotic ointment, a small tube or a few individual packets to apply to burns and wounds. A 2-3 inch ace wrap is an incredibly versatile tool. It can be used to a form a snug dressing. It can also be handy to hold ice onto an extremity, or support an injured limb, or attach something rigid to form a splint. Most lacerations can be closed with a dressing that holds the two skin edges in close approximation. It may not heal as quickly or with as little scarring as stitches but it usually does the job.

SCENARIO FIVE: After meticulously packing for a trip including the vacation medical and injury pack an adult male packs his routine medications in his suitcase and flies to one location as his suitcase chooses another location. The suitcase is found and reunited with the adult male 2 days later. Fortunately, none of the medications were critical on a daily basis.

LESSON FIVE: Your routine medications and your emergency pack should always be carry-ons.

SCENARIO LAST: Four year old falls down and skins her knee on the streets of New Orleans. Father and child are clearly upset, she does not want to move or walk or do anything except cry. Quick examination by helpful bystander with “magic bandaid” cures the child and results in a free dinner at the Father’s new cajun restaurant.

LESSON LAST: Always carry a bandaid or two. They are small, flat and easily stow in your wallet or purse for long periods of time.

They are much more useful than other things that can spend prolonged times in a young man’s wallet (see scenario one and two). I promise you will be surprised how often you can save the moment with a bandaid and how it will enhance your reputation as a physician.

So go make some memories.

visit us at www.bcms.org

23

AQUATIC DANGERS

Aquatic Dangers What to do if you get stabbed, stung, bit or poisoned

By Barbara R. Schmitz, LCSW This is the season when many of us spend a lot of time outdoors.

Many of us will be going to the coast and various lakes for spring break. Thousands of marine and freshwater aquatic and semi aquatic creatures live in these waters. Few actually pose a threat to humans, but injuries can be inflicted if the animal is frightened or disturbed.

The animals rarely pursue humans but the bites/stings are used as a defense mechanism to a perceived threat.

Some of the marine animals with whom you might come in contact are: jellyfish, sponges, bristle worms, sea urchins, stingrays, catfish, lionfish, cone-shells, sharks, snakes, alligators, snapping turtles, and more.

Beware the jellyfish, those gooey blobs that appear delicate or transparent and are hard to see in the water. You find them in every ocean, in cold and warm seas. They are made mostly of water and have no muscles, bones, brains, hearts or eyes; however, they have nerves in their tentacles that sense light and food. They are among the most numerous predators on Earth and they can sting. The adult is called a medusa and it resembles a bell with tentacles.

Have you ever felt stabbing pains on your skin at the coast? It was probably a Portuguese man o’ war. They are blue, appear on the surface and are a foot long with dozens of tentacles hanging down that can stretch 50 feet or more. They will fire their venomous nematocysts at anyone who touches them and they have thousands of these stinging cells.

Most jellies are highly venomous and free swimming. Often you see jellies in schools.

The box jelly or sea wasp (found in Australia) is the most venomous animal on land or sea. It can kill a human in less than four minutes. It has enough venom to kill 60 adults and the sting is instantly unbearable. The Hawksbill turtle is the greatest enemy of the box jelly. Fortunately, there is antivenom.

Some recommended treatments for jellyfish injury are to carefully remove the tentacles so as not to release more stinging cells; irrigate with sea water—NOT freshwater or alcohol wash as more cells could discharge. Wash with vinegar but don’t rub the area until the vinegar has been applied to stop the stinging cells. When I was in continued on page 25

24 San Antonio Medicine • May 2016

visit us at www.bcms.org

25

AQUATIC DANGERS continued from page 24

Australia, we used shaving cream and applied it over the area and removed the nematocysts with a knife edge.

Stepping on a catfish can get you “finned” which is painful and can be slow to heal. Some spines also have venomous glands at their base so the venom can get into the wound. Again, immobilize, clean the injured area, use topical antibiotics, soak in hot water and monitor for infection.

Another danger is cone shells. They are magnificent but extremely predatory. Look but don’t touch. The venom is often fatal. The cones can smell their prey.

Their raspy tongue is hollow and used as a harpoon.

Suggested first aid is to have the patient rest; immobilize and use a pressure bandage on the extremity. Provide CPR if the patient is paralyzed even if they are not able to communicate. Get prompt medical help.

Sharks found in Texas waters are the bull, black tip, tiger and hammerhead. Probably one of the most dangerous man-eating sharks alive is the bull shark who can go between fresh and saltwater.

A few firstaid treatments for sharks are to remove the injured person from the water and try to control bleeding by direct pressure over the bleeding vessels. If necessary, apply a tourniquet between the wound and the heart to stop arterial blood flow. Do not remove the tourniquet until expert help is available. Place the person head-down (Trendelenburg position) to prevent shock, and keep them warm. Get medical help quickly.

Other common injuries are puncture wounds from sea urchins and other animals with spines. While waiting for qualified medical assistance, apply heat.

Stingray spines often break off into a wound. Stingrays can inflict serious injury with their favorite habitat being sandy areas, shoals, or shallow water. If you step on one you could get punctured and then as the spine is withdrawn you get a jagged laceration and venom is injected. For heaven’s sake, don’t pull it out yourself.

Didn’t Steve Irwin, the crocodile hunter, die from one of these?

Their venom is destroyed or altered by heat. There is no antivenom available that I know of. It is imperative to debride and irrigate the injury immediately. Clean with soap and water; soak in hot water for 30 to 90 minutes or apply a heat pack; use topical antibiotics; immobilize the affected area and minimize activity; monitor respiratory activity and provide CPR as necessary.

Lionfish, stonefish, and scorpion fish hide in coral. All deliver 26 San Antonio Medicine • May 2016

venom and fatalities do occur. You will instantly know if you are attacked as you will experience excruciating pain, inflamed site, inflammation, puncture wounds, paralysis, and much more. Absolute prompt medical attention is required.

Fire coral burns and can form an abscess. This coral is beautiful and the color of fire so stay away. If burned, seek medical help; however, this usually doesn’t cause death.

To prevent injuries, look; don’t touch. Don’t put your hands into crevices; and try not to let the current force you against an object If you choose to eat exotic seafood/fish, keep a diary of the food eaten just in case you become ill.

If you bathe or drink freshwater in exotic areas, be sure to write down the exact location just in case you come in contact with the Schistosoma parasite (fluke) found in rural and subtropical areas.

The larva can penetrate skin with serious health complications. I would also make sure your bathing water is over 122 degrees F to hopefully kill the larva.

It’s best when you’re going to an unfamiliar area to talk to someone familiar with the wildlife and fish so you’ll know what you might face.

Barbara R. Schmitz, LCSW, attended Carnegie Mellon University and the University of Pittsburgh, graduating with a specialization in business education and an avocation in zoology. She received a master’s degree in social work from Our Lady of the Lake University. She writes about animal life and lore for various publications.

WALKING MED

THE WALKING MED

By Robert G. Johnson, MD

Okay, it’s not a scientific study—neither double blinded nor statistically blessed. But it was prospective and randomized in its own way. I chose ten colleagues—just ten other docs who happened to be walking toward me in a hospital corridor. I looked them in the eye and said ‘Hi’, or ‘Hello’ or, ‘How ya doin’’. Seven out of ten responded, some with enthusiasm, others with a grunt.

A full three out of ten (thirty percent) ignored my salutation— strolled on by like I was a case of smallpox.

A pretty significant number, thirty percent. I found no correlation of the response or lack thereof with gender, specialty, or time of the day (although a couple had just eaten in the doctors’ lounge). The one factor that tended toward significance was age.

The zombies were younger. I guestimate that the virus probably mutated some ten or fifteen years ago. Older farts (myself at the forefront) have built up an immunity of sorts. We still remember the old days, when doctors learned language skills and cursive.

What are the symptoms of this ‘walking med’ virus (I suppose it could be a fungus)? Flat-ish affect, blank-ish staring, paucity of expressive movement (facial or extremities), monotone voice. Don’t get me wrong—these are well trained and smart zombies; it’s just that—you know—they only seem to show overt signs of an emotional life when seated in front of a computer. Then it’s—wow— flashing pupils, flying spit and whirring fingertips. I’m pretty sure I witnessed one of them even kissing their computer bye-bye.

Epidemiologists have looked into the etiology. It has some similarities to sleeping sickness—could be a trypanosome. Others suggest a ‘lack-of-sleeping’ sickness. Hmmm. That’s hard to explain when it’s the old guys like me who went through the 120 hours-a-week residencies. I’m no medical sleuth, but I have a humble opinion on the etiology of the walking med disease. It’s

highly contagious, not controlled by hand washing or foaming in/out and infected fomites are found in every room of every building everywhere.

Signs and symptoms: Mesmerizing stobe-like eyes, flat facial features, droning key-click voice—you guessed it—a forme fruste of folie a deux—you remember from first year psychology: a previously sane person living with an insane partner becomes like them. What do we live with, breathe with, have nooners with and caress more passionately than our spouses?

COMPUTERS! Is there a cure (besides the wooden spike through the heart—or is that vampires)? Sadly no. But there’s treatment: chill out, get some fresh air, purchase a fountain pen (they’re endangered), write your mother a letter…

Marshall McLuhan (1911-1980), was a professor of English and communication theory long before laptops and cell phones.

His electronic gremlin was television. He coined phrase “the medium is the message”. He taught that the medium is always embedded in its message, forming a symbiotic relationship. The medium introduces changes subtly and over a long period of time.

For example, television regularly reports on the commission of heinous crimes. After a while, we focus less on the details of the crime and more on the fact that we watch such events over dinner and in our living rooms. Television desensitizes and changes public attitudes to crime.

I’m not paranoid. But my computer is.

Does this DELL make my butt look like a flat screen?

Robert G. Johnson, MD, is an orthopaedic surgeon, a BCMS member and a frequent contributor to San Antonio Medicine. visit us at www.bcms.org

27

BUSINESS

Buy and Hold, Index Funds and the Next Bear Market Aspect Wealth Management

According to the Wall Street Journal, in the 1970s most experts believed that modern economies were fundamentally stable, and deep recessions and financial crises were unusual events caused by outside events such as bad government policies, wars and oil price shocks. Current popular economic theory suggests that recessions and bear markets occur regularly, and the groundwork for them is actually laid during periods of relative stability. Regardless of which camp you fall into, one vitally important question that every investor must address is “How will you weather the next bear market?”

From the beginning of 1980 through 2014 (35 years) the stock market rose an astounding 82 percent of the time (only six down years). However, the severity of the down years derailed some of the best constructed retirement plans for millions of Americans. In the past 15 years the S&P 500 Index has fallen by about 50 percent twice. Most investors reading this article can remember with great

28 San Antonio Medicine • May 2016

pain seeing their portfolio values down month after month when reviewing their account statements.

Many academicians and theorists have suggested that the best way to get through these difficult markets is to buy low-cost index funds, hold onto them for a long time and you will eventually be rewarded.

Historically, this approach has worked every time but with one big caveat: your success depends greatly on when you begin taking income from your investment portfolio. For 30-year old investors, the recent bear market in the “Great Recession” of 2008 and 2009 actually created a great opportunity to invest more capital at low prices, and to patiently watch as they were rewarded. However, for those in or near retirement, declines of 30 percent, 40 percent or even 50 percent were disastrous. Delaying retirement by five years or going back to work were not uncommon remedies to get retirement plans back on track.

BUSINESS

In our experience of serving clients over four decades, we have concluded that, while academic theories seem to work for investors with unlimited time horizons, we don’t know anyone like that. Our clients are people who have worked hard, added great value to their communities through their personal and professional contributions, and who now want to enjoy their families without worrying about money.

An investment process that is focused on minimizing the damage in declining markets has the potential to make retirement much easier. From 1948 to 2012, a $100,000 investment in the Dow Jones Industrial Average would have turned into $7.2 million using an index Buy & Hold strategy. By avoiding the 10 worst quarters, that number would have grown to $51 million.* However, our research has shown that some of the best periods of performance immediately follow the worst periods. So while it’s possible to build a strategy to miss much of the really bad markets, we don’t know of any way to capture all the up markets at the same time. However, you don’t need to do this to have excellent results. By missing both the 10 worst and 10 best quarters the $100,000 investment would have grown to over $10 million —a 39 percent increase over the Buy & Hold strategy.

We have concluded that the right way to manage irreplaceable capital is to have a repeatable strategy that is not dependent on predicting the future, but that nimbly responds to changes in momentum in order to either protect capital or capture gains. Our clients have been quite willing to give up some upside during strong bull markets in order to protect against big declines. We call this process Fact-Based Investing but our clients might summarize it as good growth without the worry.

Aspect Wealth Management has managed portfolios for the Bexar County Medical Society for over 15 years. As a member of the society, if you would like a complimentary Stress Test of your portfolio to find out how it is most vulnerable, please contact us at 210-268-1500.

Sources: “Why Bear Markets are Inevitable”, WSJ, 2/13/15; Morningstar; WBI Investments. *The hypothetical investment results are for illustrative purposes only and should not be deemed a representation of past or future results. Actual investment results may be more or less than those shown. This does not represent any specific product.

Indexes are unmanaged and cannot be invested in directly.

visit us at www.bcms.org

29

LIFESTYLE

CALL OF THE WILD

Whether you hunt exotics, or simply aim to shoot great photos, a wild and wonderful African adventure awaits.

There is perhaps no place quite so civilized as Africa.

Deep in the bush, surrounded by wildlife as marvelous and mammoth as the land they inhabit, travelers soon fall into the easy rhythm of life in the wild.

There, the days are bordered by early sunrises and too-soon sunsets, while carefree afternoons fly by on the wind as it skips like a stone across hippo-filled rivers. On safari, during long game hunts tracking elephant, giraffe, cheetah, rhino and more, hours pass at the unhurried pace of clouds casting shadows on the brown-striped backs of a hundred zebras.

“Out of Africa” author Karen Blixen said it best: “You know you are truly alive when you’re living among lions.”

Whether you’ve heard the call of the wild and traveled to Africa to capture extraordinary photos, or you’re there to hunt exotics, no other vacation experience rivals an African safari adventure.

But that doesn’t mean you have to rough it. These days guests can book safari lodges that may be either as luxurious as a 5-star hotel room or as rustic as a small canvas tent with a bucket shower. Stay in one spot, or travel to other camps by air or land, and enjoy as many countries and regions as you can.

Most all safari lodges offer excellent, highly trained guides and exciting twice-daily game 30 San Antonio Medicine • May 2016

drives where guests may see some of the world’s most spectacular birds and animals.

Life in the bush is quiet and restful. A typical daily schedule is “eat, see animals, sleep, repeat,” and each evening ends with a “sundowner”: time to toast the sunset and nosh on snacks as the rose-colored dusk is overtaken by the night. Then, relax after supper by a campfire beneath the Southern Cross and watch stars as white as elephant tusks freefall in the sky.

Long ago, Africa was dubbed the “The Dark Continent,” because, in spite of European exploration and colonization, it remained a place of profound mystery. Today, more than a century later, its wild mystique endures.

Texans seem especially drawn to Africa.

Wanna-be-cowboys at heart, we’re hard-wired to love wide open spaces and get the allure of “Big Five” game hunts, tented camps with mosquito-net canopies, rugged Land Rover rides, and Hemingway’s stories of khaki-wearing, pith-hat-donning hunters.

Baby Boomers grew up watching Disney’s take on Kipling’s “Jungle Book” and “Born Free” in the sixties. Then in the 80s, we fell in love with Africa all over again with Robert Redford and Meryl Streep in “Out of Africa.”

Fast forward thirty years, and we’re still suckers for safari romance.

“I’ve met several travelers who told me they

By Janis Turk

were just going to Africa so they could check ‘safari’ off their bucket lists and move on, only to find it was better than they ever imagined and Africa got under their skin. Then, the minute they got home, they began booking their next trip,” says Katie Rees, a young New Yorker who has been to many countries in Africa and recently climbed Kilimanjaro in Tanzania with her boyfriend. She’s so smitten with Africa that she’s learned some Swahili.

For others, though, Africa is still unchartered territory; they want to go but feel intimidated. They’re not sure where to go, what tour to book, how to get there, whether or not they want to shoot photos or hunt, what permits they need, how it all works, and if it is really safe.

“No problem,” says Steve Turner, president of a unique San Antonio company offering a bespoke travel service called “Travel with Guns. “We can help. Our team members are all experts in airline rules and international regulations for transporting guns to hunting destinations worldwide. We’ve been in this business for ___ years, and helped __(hundreds? Thousands? ) of travelers travel with guns worldwide. I’ve lived and worked in Africa, so I know just what hunters need. We want our guests to enjoy their trip and have a worry-free, turn-key experience, so we do everything, from arranging airline tickets, to handling transient

points, to your arranging their hunting destination and getting them home. We do all we can to ensure that guests and their guns travel safely and have a great trip.”

Animal lover and professional photographer George Ligon, Jr. of North Carolina says only shoots animals with his Canon camera. “I’ve been able to get the most incredible shots during my safaris in Amboseli National Park along the Kenya-Tanzania border. Besides all the spectacular wildlife I’ve seen, I’ve also been able to capture some wonderful images of the Masai people who live in The Mara. My safari lodge’s staff organized visits to Masai villages and schools for my group, and we were able to meet native tribesmen and women and even visit their homes. I will never forget that experience, and I have felt safe and welcome each time I’ve visited Africa.”

Non-hunting travelers may book their trips through American companies like Premier Tours, which handles Wilderness Safari vacations, or find choose luxury accommodations in Africa through the helpful experts from Elewana Collection (www.elewanacollection.com). Hunters may want to turn to organizations like Travel with Guns (www.travelwithguns) before planning their next trip.

Besides the experience of safari life, there are spectacular hotels to enjoy in Africa, big

cities to explore, lakes and waterfalls to see, and animal orphanages to visit. A favorite stay of many families is Giraffe Manor in Nairobi, where giraffes poke their heads into the dining room and have breakfast with guests each morning. Nearby is Karen Blixen’s house, where the true-life “Out of Africa” story took place, and just down the road, on land that was once part of Blixen’s original farm, sprawls a handsome five-star hotel called Hemingways Nairobi, with a golf course, spa, fine dining, and grand suites.

Other not-to-miss places? Stay at Elsa’s Kopje in Meru, a luxury safari lodge with 11 cottages near the spot where George and Joy Adamson camped and raised Elsa the lioness of “Born Free.” And beach lovers, don’t forget Africa’s stunning coastal resorts in Mozambique, and near cities like Zanzibar, Diani and Lamu.

There is an Africa out there for everybody.

So, if you want to ride in a hot air balloon over desert sand dunes, start at Sossusvlei in Namibia. Want to witness the annual great wildebeest migration? Visit the Masai Mara in Kenya from July through October. Want to climb to see the snows of Kilimanjaro?

Turn to Tanzania. Then go on safari in Kruger National Park, followed by a stay in Cape Town with side-trips to wine lands nearby in South Africa. While there, visit the La Residence in Franschhoek, The Steenberg

PHOTO © JANIS MAXYMOF

PHOTO © JANIS MAXYMOF

PHOTO © JANIS TURK

in the Constantia Valley, and Ellerman House in Cape Town, or stay downtown at the Taj with views of Table Mountain. Visit the Robben Island prison where Mandela was held, or go see the penguins on the warm sandy beach at Fish Hoek on the False Bay Coast. Take a helicopter ride above Victoria Falls in southern Africa on the Zambezi River at the border of Zambia and Zimbabwe. Listen to natives sing in a Khoisan language of clicks in Botswana, and go ape in Uganda, or stay in splendor at The Saxon, Johannesburg’s most elegant hotel. You can even adopt an elephant at the Sheldrick Wildlife Trust Elephant orphanage in Kenya.

Whether you’re drawn to this mysterious continent to shoot photos or exotics, it’s time to heed the call of the wild, for out of Africa, an oh so civilized adventure awaits.

PHOTO © JANIS MAXYMOF

PHOTO © JANIS TURK

PHOTO © JANIS TURK

PHOTO © JANIS MAXYMOF

LIFESTYLE

visit us at www.bcms.org

31

UTHSCSA DEAN’S MESSAGE

UT SCHOOL OF MEDICINE SAN ANTONIO UPDATE: REVIEW OF 2015 RESEARCH PUBLICATIONS & ANNOUNCEMENTS

By Francisco González-Scarano, MD A great deal of research is conducted by the esteemed faculty of the UT School of Medicine San Antonio. At any given time there are more than 300 studies under way, including clinical trials and related studies of cellular, biochemical and drug interaction and related areas. Many are in funded by national agencies and organizations, including the National Institutes of Health (NIH), the Health and Medicine Division of the National Academies, the Veterans Administration (VA) and the National Cancer Institute (NCI). The list of conditions and diseases being studied covers nearly every branch of medicine. Below are a select few of the publications and announcements from the past year based on the research of faculty members of the UT School of Medicine San Antonio.

Identification of Antidepressant Drug Action in Brain New discoveries with the anti-depressant drug ketamine may expand its use. The drug, which is known for relieving depression in a matter of hours—as opposed to weeks with other medications—is also known for its high risk of abuse and side effects.

Daniel Lodge, PhD., Associate Professor of Pharmacology, and colleagues from the School of Medicine, were able to idenitfy a brain circuit that involved in the beneficial effects of ketamine.

They found that activating that circuit in rats had an effect very similar to ketamine. Lead author and Professor of Pharmacology, Flavia R. Carreno, Ph.D., says this new study helps to understand the area of the brain responsible for the beneficial effects, which will allow us to more specifically target them and hopefully increase the effectiveness of the medication.

The study “Activation of a ventral hippocampus–medial prefrontal cortex pathway is both necessary and sufficient for an antidepressant response to ketamine” was published in the December 2015 Molecular Psychiatry. Daniel Lodge, Ph.D., Associate Professor of Pharmacology, and Alan Frazer, Ph.D., Professor and chairman of Pharmacology were co-authors along with others from the Health Science Center.

32 San Antonio Medicine • May 2016

Anti-Cancer Mechanism of Protein Connexin Established Using the eye as a model due to its high levels of the protein connexin 50, one of our groups established how the protein slows the growth of tumors. The protein tethers itself to a cell-proliferating molecule called Skp2. This prevents the Skp2 from traveling to the cell nucleus to promote more cell growth. The finding has a great deal of potential for many different cancer therapies. Qian Shi, Ph.D., a postdoctoral fellow in Biochemistry, is the first author on the study, with senior author Jean X. Jiang, Ph.D., Professor of Biochemistry at the School of Medicine. The study, “Connexin Controls Cell-Cycle Exit and Cell Differentiation by Directly Promoting Cytosolic Localization and Degradation of E3 Ligase Skp2,” was published in Developmental Cell, November 2015.

Risk of Overdose in Chronic Pain Patients Two new studies authored by Barbara J. Turner, M.D., Professor of Medicine and Public Health and Yuanyuan Liang, Ph.D., Assistant Professor in the Department of Epidemiology and Biostatistics at the UT School of Medicine San Antonio, reveal important insights into the overdose risks associated with dosage, time and mixture of chronic pain medications.

Painkillers such as hydrocodone that are often prescribed along with sedative-hypnotics, such as alprazolam (Xanax) and zolpidem (Ambien). Many patients are also prescribed antidepressants, which has pain management benefits independent of their ability to improve mood. These additional medications can double the already-significant risk.

The researchers developed a database to analyze health care delivery, medications and comorbid conditions for more than 200,000 HMO-enrolled patients who filled at least two prescriptions for opioids for non-cancer pain between 2009 and 2012.

In this national study, they found that a morphine equivalent dose of 100 milligrams or more a day significantly increased the risk of drug overdose, but they also found that even lower doses

UTHSCSA DEAN’S MESSAGE

of opioids, from 50 to 99 milligrams a day, were dangerous if the patient filled prescriptions totaling the equivalent of at least 1,830 milligrams of morphine over a six-month period. Patients prescribed more than four to six weeks of even moderate doses of opioids often reach this risky level.

Dr. Turner is also director of the Center for Research to Advance Community Health, also known as the ReACH Center, which is working with community and state and federal programs to bring alternatives to medications for treatment of chronic pain, including behavioral counseling and physical therapy. The researchers’ two articles were published in the August 15, 2015 print edition of The Journal of General Internal Medicine and the July 2015 edition of The Journal of Hospital Medicine.

Research Imaging Institute’s BrainMap The School of Medicine’s Research Imaging Institute (RII), under the direction of director Peter T. Fox, M.D., and the institute’s BrainMap program, have played a significant role in another important study; this one on similar brain abnormalities in people with schizophrenia, depression and addiction. Researchers from Stanford University and the University of Cambridge led the studies which utilized the brain atrophy section of BrainMap, a database of published functional and structural neuroimaging experiments that is maintained here at the RII. The BrainMap program was begun in 1988 and has been used in nearly 600 published studies. The new study found similar gray-matter loss in the brains of study participants with diverse diagnoses. The studies appear in the February 4, 2015 issue of JAMA Psychiatry. Visit www.BrainMap.org to learn more.

PTSD and Suicide Reduction Professor of Psychiatry Alan Peterson, Ph.D., co-investigator on a new study, has found that short-term cognitive behavioral therapy dramatically reduces suicide attempts among at-risk military personnel. The two-year study involved 152 active-duty soldiers who had either attempted suicide or had been determined to be at high risk for suicide, and evaluated the effectiveness of a brief cognitive-behavioral therapy (CBT) in preventing future suicide attempts. The study found that soldiers receiving CBT were 60 percent less likely to make a suicide attempt during the 24month follow-up than those receiving standard treatment. The article, “Brief Cognitive-Behavioral Therapy Effects on Post-Treatment Suicide Attempts in a Military Sample: Results of a Randomized Clinical Trial With 2-Year Follow-Up,” was published

in May 2015 in The American Journal of Psychiatry. The findings are particularly encouraging, given the increasing rates of suicide in veterans after the wars in Iraq and Afghanistan.

Preserving Brain Function after Stroke New research suggests that an anti-convulsant drug already approved for epilepsy could preserve brain tissue after a stroke. In the study, one dose of the anti-epilepsy drug, Retigabine, preserved brain tissue in a mouse model of stroke and prevented the loss of balance control and motor coordination.

Hours after a stroke, both treated mice and a control group of mice were placed on a balance beam to observe motor coordination. The untreated mice displayed a pronounced loss of coordination with slips and falls.

Treated mice had no difficulty with balance, ambulation or turning around on the beam. Histological analysis of the brain tissue of treated mice showed significantly reduced damage to the tissue after the stroke, compared to untreated mice. The protective effects of the medication were observed in treated mice up to five days later.

Senior author was Mark S. Shapiro, Ph.D., Professor of Physiology, and Sonya Bierbower, Ph.D., a postdoctoral fellow, was lead author of the report. The study, “Augmentation of M-Type (KCNQ) Potassium Channels as a Novel Strategy to Reduce Stroke-Induced Brain Injury,” was published in the February 3, 2015, edition of The Journal of Neuroscience.

Reducing Potassium in Kidney Disease Treatments New research from the School’s Nephrology Division has the potential to dramatically improve the lives of people with chronic kidney disease. The study was published in both the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA). Renin Angiotensin Aldosterone System Inhibitors (RAASI) are a standard treatment to protect the heart and kidney in patients with chronic kidney disease, a very common comorbidity of diabetes. A significant percentage of patients using the drug develop dangerously high potassium levels in the blood (hyperkalemia) that puts them at a risk for cardiac arrhythmias. The only solution to reduce the risk is stopping the RASSI or having the patient undergo kidney dialysis, which carries its own problems.

Wajeh Y. Qunibi, M.D., a Professor of Medicine and UT Medicine nephrologist, is one of the investigators in a study using ZSContinued on page 34 visit us at www.bcms.org

33

UTHSCSA DEAN’S MESSAGE Continued from page 33

9 in patients with high blood potassium. Up to 98 percent of patients saw a return to normal potassium levels in the first month.

Non-absorbed zirconium silicate, ZS-9, is designed to preferentially trap potassium ions in order to lower and maintain control of serum potassium levels. The articles appeared in the January 15, 2015 NEJM and December 2014 JAMA. ZS-9 was cleared by the FDA for kidney patients in October 2015.

Refer a Patient or Partner to the School of Medicine We offer the most clinical trials in the region (Phase 1, 2 and 3) for many different conditions and diseases. If you’re interested in referring a patient, please visit our clinical trial website http://vpr.uthscsa.edu/findastudy or our Phase 1 cancer trials at the Cancer Therapy & Research Center www.CTRC.net.

We also have a unique program for private physicians who wish to be involved in clinical research. Called the “Practice-Based Research Network” (PBRN), you can start your own studies or join others already involved in research. Contact our PBRN office at (210) 562-5652.

34 San Antonio Medicine • May 2016

Every study, trial and experiment has many people behind the scenes working to coordinate the many different pieces that come together to conduct and complete these programs. Most of the names do not appear as authors, but they are significant contributors all the same. My congratulations goes out to all the outstanding faculty and their teams for the great work represented here.

All the best, Francisco González-Scarano Dean, School of Medicine Executive Vice President for Medical Affairs University of Texas Health Science Center San Antonio John P. Howe, III, MD, Distinguished Chair in Health Policy Professor of Neurology.

BUSINESS OF MEDICINE

Legal & Tax Strategies for Healthcare Organizations and Professionals

By Dana A. Forgione, PhD, CPA, CMA, CFE

The hardest thing in the world to understand is the income tax.

—Albert Einstein

If you’re setting up a new company, you may be considering what organizational type is most appropriate. Briefly, here are some options.

• Sole Proprietorship • Partnership • General Partnership • Limited Partnership (LP) • Limited Liability Partnership (LLP) • Limited Liability Company (LLC) • Corporation (Inc., Ltd.) • Subchapter S Corporation • Professional Corporation (PC) • Personal Services Corporation (PSC) • Professional Limited Liability Company (PLLC) • Non-profit Organization (35 different categories) The main differences between them are: control, taxes, and legal liability. Everyone wants control, but nobody wants taxes or legal liability.

Disclaimer: Okay, before we start this discussion, here’s the disclaimer: the material contained herein is for informative purposes only, and does not constitute legal, medical, accounting, financial, tax or other professional advice. The issues and applicable laws are complex, and relevant legal and tax counsel and/or other professional advice should be sought regarding any particular situation(s), transaction(s) or arrangement(s).

So, first, let’s define some important terms. These are not formal legal definitions, but give you a sense of the issues.

Tax Avoidance—operating your business so that you do not incur a tax. For example, organizing as a tax-exempt, nonprofit entity, or investing in tax-free municipal bonds.

Tax Evasion—failing to pay a tax you properly owe. For example, taking cash from sales and failing to report the revenue on your tax return, or deducting personal vacation travel expenses as if they

were reasonable & necessary business expenses.

Aggressive Business Practice—pushing the limits of interpretation of the law, or trying to put legal form above economic substance. For example, asserting an unusually short depreciable useful lifetime for an asset, or shifting profits into a low-tax jurisdiction through high transfer prices on items that are difficult to value, such as trademark licensing fees, or intermediate electronic components.

Fraud—intentional misrepresentation of a material fact that is reasonably relied upon by a victim who incurs consequent damage.

For example, a healthcare provider billing for services that were never rendered.

S-Corporation One common organizational type for small businesses is the SCorporation. It generally maximizes control while reducing taxes like a proprietorship, and reduces legal liability like a corporation.

However, to qualify as an S-Corp., the organization must meet eight requirements: 1 It is a domestic corporation or entity.

2 It has no more than 100 shareholders (an individual & spouse can be one shareholder).

3 Shareholders must be an individual, estate, trust, tax-exempt organization, or other S corp. A C-Corp. or partnership cannot be the shareholder of an S-Corp.

4 It has no nonresident alien shareholders.

5 It has only one class of stock, all with identical rights to distribution and liquidation proceeds.

6 It is not one of the ineligible corporations, such as a financial institution, insurance company, or domestic international sales corporation (DISC), etc.

7 It has or will adopt a: 12/31 tax year, natural business tax year, ownership tax year, or 52–53 week tax year.

8 It has each shareholder’s consent. If an individual and his or her spouse have a community interest in the corporation, both must sign the consent statement.

Continued on page 36 visit us at www.bcms.org

35

BUSINESS OF MEDICINE Continued from page 35

The S-Corp. must continue to meet all of the above requirements. Failure to comply can result in revocation of the S election.

For example, if a shareholder receives both a salary and dividends from the S-Corp., and the IRS reclassifies some or all of the salary as a dividend (or vice versa), that individual could be deemed to have more (or less) dividend than the other shareholders, thus triggering a violation of requirement no. 5 above. That could trigger revocation of the S-election, and subject the company to the double-taxation of a regular (C) corporation. Ouch. This makes SCorps less attractive.

An NP organization can be incorporated as a stock corporation (but the shares cannot be owned by any individual) or a non-stock corporation, or unincorporated. The primary distinguishing feature is potential eligibility for federal and state tax exemption, although they may be subject to Unrelated Business Income (UBI) taxation.

The IRS allows for 35 different categories of NP entities that generally include: • Charitable Organizations • Churches and Religious Organizations • Political Organizations • Private Foundations

tering national or international amateur sports competition, and preventing cruelty to children or animals. The term charitable is used in its generally accepted legal sense and includes relief of the poor, the distressed, or the underprivileged; advancement of religion; advancement of education or science; erecting or maintaining public buildings, monuments, or works; lessening the burdens of government; lessening neighborhood tensions; eliminating prejudice and discrimination; defending human and civil rights secured by law; and combating community deterioration and juvenile delinquency.

The basic economic bargain is that the government tells the potential investors, “If you will refrain from extracting profits, we will refrain from extracting taxes. That way the organization will have more money to carry out its socially-desirable operations.” There is also the notion that NP organizations relieve the government of burdens in society it would otherwise have to bear. Presumably the private NP organization can carry out those operations more efficiently than government.

Well, this is just a brief introduction. Page space sure runs out fast. “The time has come,” the Walrus said, “To talk of other things.

Of shoes and ships and sealing wax. Of cabbages and kings…”

(Lewis Carroll, Alice in Wonderland). Maybe more, next time…

The most common type is the section 501(c)3 organization. Most NP hospitals are 501(c)3 organizations. To be tax-exempt under sec.

501(c)(3) of the Internal Revenue Code (IRC), an organization must be organized and operated exclusively for exempt purposes set forth in sec. 501(c)(3), and none of its earnings may inure to any private shareholder or individual. In addition, it may not be an action organization, i.e., it may not attempt to influence legislation as a substantial part of its activities and it may not participate in any campaign activity for or against political candidates.

The exempt purposes set forth in sec. 501(c)(3) are charitable, religious, educational, scientific, literary, testing for public safety, fos-

Dana A. Forgione, Ph.D., CPA, CMA, CFE is the Janey S. Briscoe Endowed Chair in the Business of Health at the University of Texas at San Antonio. He is also an Adjunct Professor in the School of Medicine, Department of Cardiothoracic Surgery, the Department of Pediatrics, and in the School of Public Health, all at the University of Texas. He previously held a joint appointment in the School of Pharmacy at the University of Maryland, where he taught in the Doctor of Pharmacy program. His research interests are in international comparisons of healthcare payment systems, costs and quality of care, as well as financial management for hospitals and physician practices.

Limited Liability Company (LLC) LLCs are a popular alternative because they are simpler than an S-Corp. while still providing liability protection. A single-member LLC is taxed like a sole proprietorship, while a multiple-member LLC is taxed like a partnership. An LLC can also opt to be taxed like a corporation. But remember, the limited liability of any organizational form can always be “pierced” in a court of law.

Nonprofit Organization (NP)

36 San Antonio Medicine • May 2016

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.

ACCOUNTING FIRMS Padgett Stratemann & Co., LLP (HH Silver Sponsor) Padgett Stratemann is one of Texas’ largest, locally owned CPA firms, providing sophisticated accounting, audit, tax and business consulting services.

Vicky Martin, CPA 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com “Offering service more than expected — on every engagement.”

Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets.

Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

BANKING

BBVA Compass (HHHH 10K Platinum Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees.

Commercial Relationship Manager Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future.”

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great rela-

tionship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership.”

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future.

Chris Sherman 210-247-2978 csherman@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

Frost (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”

IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC BankSan Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area.

Markham Benn 210-354-6921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”

Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans.

Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com

Regions Bank ( Gold Sponsor) VP Physician Lending Group Moses D. Luevano, 512-663-7743 phone moses.luevano@regions.com

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals

are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com

SSFCU (HHH Gold Sponsor) Founded in 1956, Security Service provides medical professionals with exceptional service and competitive rates on a line of mortgage products including one-time close construction, unimproved lots/land, jumbo and specialized adjustable-rate mortgage loans.

Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Bank of America (HH Silver Sponsor) Bank of America provides people, companies and institutional investors the financial products and services they need to help achieve their goals at every stage of their financial lives.

Jennifer Dooling 210-270-5226 jennifer.dooling@baml.com Courtney Martinez 210-419-2643 courtney.martinez@baml.com http://about.bankofamerica.com/ en-us/index.html Making financial lives better — one connection at a time Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology • Expanding your office space • We offer loans to meet your business or personal needs.

Competitive rates, favorable terms and local decisions.

Gregg Thorne

Continued on page 38 visit us at www.bcms.org 37

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 37 SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org

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

FINANCIAL SERVICES

Generations Federal Credit Union (HH Silver Sponsor) Generations provides a wide array of innovative products including loan, deposit and investment solutions for personal and commercial banking needs.

Yvonne "Bonnie" M. Aguilar 210-229-1800 bonnie.aguilar@ mygenfcu.org www.mygenfcu.org “For this generation and the next.”

ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES

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

RBFCU (HH Silver Sponsor) 210-945-3800 nallen@rbfcu.org www.rbfcu.org

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

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.

38 San Antonio Medicine • May 2016

Med MT, Inc. (HHH Gold Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records.

Ray Branson 512-331-4669 branson@medmt.com www.medmt.com “The Med MT solution allows physicians to keep practicing just the way they like.”

ELECTRONIC MEDICAL RECORDS

Greenway Health (HHH Gold Sponsor) Greenway Health offers a fully integrated electronic health record (EHR/EMR), practice management (PM) and interoperability solution that helps healthcare providers improve care coordination, quality and satisfaction while functioning at their highest level of efficiency.

Regional Sales Manager Jason Siegel: 512-657-1259 Jason.Siegel@greenwayhealth.com www.greenwayhealth.com

EMPLOYEE BENEFITS

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it's all about relationships. We keep our partners compliant assisting with human resource administration/management, workers' compensation/risk management, benefit administration, and payroll. We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.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.”

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

HEALTHCARE REAL ESTATE

San Antonio Comercial Advisors (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

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.

Whit Ehrich, CEO 830-386-4234 whit@hctechguys.com http://hctechguys.com/ “IT problems? Yeah… we can fix that!”

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY HOSPITALS/ HEALTHCARE SERVICES

Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years. Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery.

Business Development Director Blake Pollock 210-243-9151 bpollock@iasishealthcare.com www.swgeneralhospital.com "Quality healthcare with you in mind."

Warm Springs •Medical Center •Thousand Oaks •Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” 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

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it's all about relationships. We keep our partners compliant assisting with human resource administration/management, workers' compensation/risk management, benefit administration, and payroll. We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

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.”

INFORMATION AND TECHNOLOGIES

Henced ( Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build long-last customer relationships by effectively communicating using our text and email messaging system.

Rainey Threadgill 830-331-9995 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum 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.”

Frost Insurance (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com “Business and personal insurance tailored to meet your unique needs.”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

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

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 Ad Valorem Tax Advisor Nikki McNish 210.376.2316 nmcnish@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services 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.

James L. Hayne Jr. 210-222-2161 jhaynejr@catto.com Corey Huffman 210-298-7123 chuffman@catto.com www.catto.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org “Recommended partner of the Bexar County Medical Society.”

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 39 thomas.mohler@medpro.com Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com

Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET/ TELECOMMUNICATIONS The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC, 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

The Doctors Company (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com.

Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” 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 Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease— that’s only fair.

Keith Askew, Market Manager kaskew@proassurance.com

40 San Antonio Medicine • May 2016

Time Warner Cable Business Class (HHH Gold Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterpriseclass technology and communications that are highly reliable, flexible and priced specifically for the medical community.

Rick Garza 210-582-9597 Rick.garza@twcable.com “Time Warner Cable Business Class offers custom pricing for BCMS Members.”

IT SUPPORT/VOIP/ CLOUD SERVICES

ICS (HHH Gold Sponsor) ICS® is a Texas-based provider of business technology integration solutions, including managed IT support, business telephones, VoIP communications, video conferencing systems, surveillance cameras, and voice/data cabling.

Family owned since 1981.

Daniel Simons 210-581-9020 daniel.simons@ics-com.net Robert Foehrkolb 210-225-5427 rfoehrkolb@ics-com.net www.ics-com.net “Providing IT, voice and video solutions for business.”

LABORATORY SERVICES

PGX TESTING (HHH Gold Sponsor) PGX Testing is a multi-faceted diagnostics company currently offering pharmacogenomics, urine toxicology, women's health testing, cancer screening, and well-

ness 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 ADVERTISING SEO

Henced ( Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build long-last customer relationships by effectively communicating using our text and email messaging system.

Rainey Threadgill 830-331-9995 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

MARKETING SERVICES

Digital Marketing Sapiens (HHH Gold Sponsor) Healthcare marketing professionals with proven experience and solid understanding of compliance issues. We deliver innovative marketing solutions that drive results.

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

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.”

Kareo (HHH Gold Sponsor) The only cloud-based medical office software and services platform purpose-built for small practices. Our practice management software, medical billing solution, practice marketing tools and free, fully certified EHR has helped 30,000+ medical providers more efficiently manage their practice.

Regional Solutions Consultant Lilly Ibarra 210-714-9815 lilly.ibarra@kareo.com www.kareo.com Commercial & Medical Credit Services (Silver) 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.”

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide Multi-Specialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products.

Physician’s memberships are free.

Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

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.”

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

PAYROLL SERVICES

SWBC (HHH Gold Sponsor) Our clients gain a team of employment experts providing

solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits.

Bryce Fegley 830-980-1245 bfegley@swbc.com Working together to help our clients achieve their business objectives.

PHYSICIANS BUYING GROUP

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide Multi-Specialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products.

Physician’s memberships are free.

Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

REAL ESTATE/ COMMERCIAL

San Antonio Comercial Advisors (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

Robbie Casey Commercial Realty (HHH 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 (HHH 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 top-tier care while maintaining their privacy and independence, in a luxurious resort-quality environment.

Shane Brown Executive Director 210-305-5713 hello@ legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”

STAFFING SERVICES

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.

Patricia Pliego Stout 210-593-5500 pstout@alamotravel.com www.amazingjourneysbyalamo.com “See what a difference we can make for you!”

As of March 18, 2016 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.

visit us at www.bcms.org

41

ONLINE ROI

The ROI of Your

ONLINE REPUTATION

By Lilly Ibarra

As patient expectations change so does the value of a physician’s online reputation. An accurate, positive online reputation now translates into new patients and increased revenue. An inaccurate one can result in lost opportunities and might even impact your practice’s long term success.

Most physician rating and review sites get their initial information from the Physician Blue Book. This information is often out of date or becomes so quickly. It can also be lacking crucial items like your website address. Finding and correcting listings on these and other sites like Yelp improves your overall search rankings, supports better search engine optimization (SEO) for your practice website, and makes it easier for patients to find you.

You might be saying to yourself that you get most of your patients through word of mouth and referrals from other patients.

This could be true, but today patients who get referrals from friends and family, checkout the physician online before booking. In fact, according to Google almost 80 percent of patients conduct an online search before booking an appointment. So it is critically important that you can be found, your information is accurate and up to date, and that you have positive reviews from existing patients.

Why do you need the reviews in addition to listings? Because prospective patients trust them, maybe even more than the referral from their friend. And they can translate directly into revenue.

Professor Michael Luca at Harvard Business School published a study, Reviews, Reputation, and Revenue: The Case of Yelp.com.

He found shows that where Yelp reviews penetrated a local market, the business of chain restaurants declined because consumers began trying more independent businesses as they gained confidence about their quality. This points to an opportunity for independent practices to compete effectively against larger health systems by embracing an aggressive and effective positive reviews 42 San Antonio Medicine • May 2016

strategy. The survey also found that an increase in star rating can be tied to an increase in revenue—a one star increase equated to a 9 percent increase in revenue.

If you haven’t taken the time to check out your online reputation, make 2016 the year that you do. It’s easy to get a sense of where you are listed and the accuracy of your listings by doing a simple Google search. You’ll quickly see how many listings are out there and how many of them have inaccuracies or missing information as well as those that have reviews or ratings already. You can update these all manually, but that can take a lot of time and effort. Same goes for increasing positive online reviews. Today, there are practice marketing platforms that can help you do both much faster and more effectively.

Updating these sites and increasing reviews will also help with your search engine rankings. When you do your Google search you should do some searches using common search terms for which you would want to be found. For example, you want to show up first for OB/GYN in Austin, TX. So search for OB/GYN Austin TX and see where you show up. If your ranking is low, updating your online profiles and adding your website and social media pages will help. Increasing your positive online reviews can help here as well.

Updating and improving your online reputation plays a much bigger role today in recruiting new patients, generating revenue, and staying successful. There are other things you can do to strengthen your online presence but online listings and reviews are as a good a place to start as any. It probably won’t be long before you start to see your practice rise in your search engine rankings and find new patients booking appointments as well.

Lilly Ibarra is a regional solutions consultant with Kareo in San Antonio. She has been in the industry for six years helping clients reach their financial goals.

Ancira Chrysler 10807 IH-10 West Gunn Acura 11911 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ancira Dodge 10807 IH-10 West Cavender Audi 15447 IH-10 West

* Gunn Infiniti 12150 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ingram Park Auto Center 7000 NW Loop 410

North Park Mazda 9333 San Pedro Ave.

North Park Subaru at Dominion 21415 IH-10 West

Mercedes-Benz of Boerne 31445 IH-10 W, Boerne

Cavender Toyota 5730 NW Loop 410

Ancira Jeep 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410

Mercedes-Benz of San Antonio 9600 San Pedro Ave. Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)

Northside Ford 12300 San Pedro Ave.

Cavender GMC 17811 San Pedro Ave. Batchelor Cadillac 11001 IH-10 at Huebner

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

North Park Subaru 9807 San Pedro Ave.

* North Park Lexus 611 Lockhill Selma North Park Lexus Dominion 21531 IH-10 West Frontage Road

Ancira Nissan 10835 IH-10 West Ingram Park Nissan 7000 NW Loop 410

North Park Toyota 10703 SW Loop 410

* Ancira Volkswagen 5125 Bandera Rd. North Park VW at Dominion 21315 IH-10 West

Gunn GMC 16440 IH-35 North

* Fernandez Honda 8015 IH-35 South

* North Park Lincoln/ Mercury 9207 San Pedro Ave.

Ancira Ram 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410

Gunn Honda 14610 IH-10 West (@ Loop 1604)

visit us at www.bcms.org

43

AUTO REVIEW

2016 Nissan Maxima

By Steve Schutz, MD The floating roof is a new design trend out of Japan that’s “the thing” right now.

Floating roofs are optical illusions created by rear windows that connect with side windows via dark panels of some type. Those panels make it look like the roof of the car is floating over the top of the vehicle. While floating roofs are eye-catching and novel design elements, I personally don’t see them lasting much past the current generation of cars and crossovers that have them now.

Having said that, floating roofs can be found on three very popular (and recently redesigned) mainstream vehicles, the Nissan Murano, Lexus RX, and the subject of this review, the Nissan Maxima. Those three vehicles alone will account for around 250,000 sales in 2016, so a lot of floating roofs will be, umm, floating around the US this year.

The Maxima is Nissan’s biggest and most expensive sedan, and while sedans aren’t the 44 San Antonio Medicine • May 2016

Big Man on Campus that they used to be thanks to the ever-increasing popularity of crossovers, they still sell well and satisfy the needs of many car buyers today.

The Maxima’s exterior design reflects what some industry observers have called the death of understatement. From the prominent grille to the assertive head- and taillights to the cavalcade of creases on the bodywork—and let's not forget that floating roof—the Maxima’s look suggests that Nissan’s design team used as many styling flourishes as they thought they could.

It works, though. The Maxima looks good. Maybe I’ve been beaten down by overstyled Nissans, Lexuses, and Mercedes, but the Maxima always struck me as attractive when I walked up to it. Let’s call it happily extroverted and leave it at that.

That same enthusiasm for excess seems to have carried the day when the interior was

created, as buttons, knobs, and screens are seemingly everywhere. Thankfully, once you take the time to sit down and make sense of the controls, it becomes apparent that a lot of thought went into them. And truth be told, once you see that most functions can be accessed through the central control knob, you realize that a lot of the buttons and knobs on the dash are redundant. (Since everybody has their preferred way to do things, extra options are fine with me.)

Driving the Maxima is very pleasant thanks primarily to a nicely sorted chassis and lots of horsepower. The only engine available, Nissan’s ubiquitous 3.5L V6 provides a muscular 300 HP--enough to pull the 3545 Lb sedan from zero to sixty MPH in 5.9 seconds. Yes I said, “pull”. The Maxima is a FWD car, which limits sportiness as does the buzz killing continuously variable transmission (CVT). Still, the Maxima feels athletic and

AUTO REVIEW fast in most driving situations, especially highway entrance ramps and high speed back roads. And using the standard paddles to accelerate or decelerate gives you pseudo-gears, which augment any driving situation.

For the record, fuel economy is

22 MPG city/30 highway.

A quick aside to driving enthusiasts: ever tightening fuel economy and emissions regulations are bringing CVTs, shrinking engines, and hybrid technology to an increasing percentage of new vehicles. Is that bad? Not necessarily, but it’s worth noting that RWD cars with naturally aspirated engines and manual transmissions are endangered species.

Japanese vehicles generally come well equipped compared with anything from Germany, and that’s the case with the Maxima.

Standard features of the base S model include 18-inch alloy wheels, automatic headlights, keyless ignition and entry, dual-zone automatic climate control, power front seats (eight-way driver and four-way passenger), and an auto-dimming rearview mirror. Navigation, a rearview camera, Bluetooth phone and audio, two USB ports, HD radio, and a six-disc CD changer are also standard in every Maxima. If this were Twitter, I’d type #neverinagermancar in my tweet.

SV, SL, and Platinum Maximas provide many more options and option packages, so you can easily add as much luxury features as a Lexus, but it’s nice to know that going for the base Maxima won’t embarrass you.

For enthusiasts, the sportier SR adds 19inch wheels with available performance tires, a more athletic suspension, Active Ride Control, Active Trace Control (Nissan’s version of torque vectoring), and active engine braking to enhance spirited driving. This Maxima, which would be my choice, also has LED headlights, premium leather, and heated and ventilated front seats.

As regular readers know, any car search should begin with a call to Phil Hornbeak, who will guide you through the entire process of choosing a vehicle that will work best for you and your budget.

While hamstrung by FWD, a relatively high curb weight, and a CVT, the new Nissan Maxima is fun to drive. And while designed with many styling elements including but definitely not limited to a floating roof, it looks good. If you’re looking for a sporty sedan with luxury, don’t overlook the Max-

ima. It’s a very good car.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

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

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

WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of April 23, 2016.

46 San Antonio Medicine â&#x20AC;˘ May 2016

Peripheral Vascular Associates, PA