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JUNE 2014










The fate of specialties

JUNE 2014


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.

The changing face of family medicine By J.J. Waller Jr., MD .................................................10

A view of anesthesiology in 2054 By Jay Ellis, MD .........................................................14

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Physician extenders: PAs and NPs draw strong opinions By Jeffrey J. Meffert, MD .........................16 Where will orthopaedic surgery be in 25 years? By Fred Olin, MD .......................................................18

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Family medicine services can increase access to allergy care By Bernice Gonzalez, MD ............20

President’s Message by K. Ashok Kumar, MD, FRCS, FAAP ........................................................8 Be Fit. Be Cool by Rajam Ramamurthy, MD, and Aruna Venketesh, MD ....................................22 Physician as Patient: In the chemo room by Jay Ellis, MD ..........................................................24 BCMS News ................................................................................................................................26

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Lifestyle: Private education: A snapshot of San Antonio’s top private schools by Mauri Elbel ..34 UTHSCSA Dean’s Message by Francisco González-Scarano, MD ............................................38 Business of Medicine: The Affordable Care Act by Dana A. Forgione, PhD, CPA, CMA, CFE ........40 HASA: Risk stratification to prevent readmissions by Vince Fonseca, MD, MPH, FACPM....................43 Circle of Friends ....................................................................................................................................44 In the Drivers’ Seat ................................................................................................................................47 Auto Review: BMW 535d by Steve Schutz, MD ....................................................................................48



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OFFICERS K. Ashok Kumar, MD, President Jayesh B. Shah, MD, Vice President Leah Hanselka Jacobson, MD, Treasurer Maria M. Tiamson-Beato, MD, Secretary James L. Humphreys, MD, President-elect Gabriel Ortiz, MD, Immediate Past President

DIRECTORS Josie Ann Cigarroa, MD, Member Chelsea I. Clinton, MD, Member John Robert Holcomb, MD, Member Luci Katherine Leykum, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Adam V. Ratner, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Luke Carroll, Medical Student Representative Cindy Comfort, BCMS Alliance President Nora Olvera Garza, MD, Board of Censors Chair Rajaram Bala, MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel




COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Diana H. Henderson, MD, Member Jeffrey J. Meffert, MD, Member Sumeru “Sam” Mehta, MD, Member Rajam S. Ramamurthy, MD, Member John C. Sparks Sr., MD, Member Chittamuru V. Surendranath, MD, Member J.J. Waller Jr., MD, Member Jason Ming Zhao, MD, Member

6 San Antonio Medicine • June 2014


A time to celebrate By K. Ashok Kumar, MD, FRCS, FAAFP 2014 BCMS President NOTE: The following is excerpted from Dr. Kumar’s 2014 graduation speech at the University of Texas School of Medicine at the Health Science Center San Antonio. Indeed, it is a great pleasure and honor to represent Bexar County Medical Society at this year’s medical school graduation. I bring greetings to you all from 4,400 BCMS members. Graduates! All your hard work and commitment is coming to fruition today. My hearty congratulations! Welcome to this great profession and the privilege of serving fellow human beings. BCMS in collaboration with the Texas Medical Association works constantly to preserve the sacred “doctor-patient” relationship, the physician scope of practice, and to provide physicians with practice solutions they can use to enhance their practices. BCMS and TMA believe in lifelong learning and provide educational opportunities to medical professionals throughout the year, both online and through in-person meetings. Students, residents and fellows, you are the future of our profession. Every one of you here is a leader or has the ability to become a leader. Therefore, I personally invite every one of you to join the medical society. And interestingly you might be the one giving this speech 20 from now. I would say the odds are very good. If you want any ideas for the speech, please call me; I will still be completing my patient charts in electronic medical records! Graduates, it is time for celebration. Let us rejoice in your achievements, your hard work and your dedication to the medical profession. You are the privileged few among innumerable young men and women who aspire to become physicians. You are the chosen few. You are chosen because you are the “crème de la crème.” You are the brightest and the best. Appreciate all the gifts and privileges that come to you as result of graduating from medical school. It is time to give thanks: Be sure to thank all the people who helped you to realize your dream. Thank your parents, your family, your friends and your teachers, starting from kindergarten. They molded you into the unique person you are today. Make time to thank them now, because in a few weeks you will be so busy. Talking of busy … Do you remember all those tired interns you saw on the wards when you were doing clinical rotations? You will be them soon. But then hopefully it will get better, 8 San Antonio Medicine • June 2014

thanks to the ACGME work-hour rules! When you were in my class, I challenged you to be not just a good doctor but a great doctor. Today I am confident that you are all going to be great doctors, because I believe you not only worked hard to learn the science of medicine but also left no stone unturned to learn the art of medicine. And I am also confident because I watched many of you taking care of patients with great compassion and exceptional bedside manners. I have no doubt in my mind that you are going to care for every patient with utmost respect and dignity in a culturally competent manner irrespective of their economic and social background. Today, I want to share with you some of my experiences. In my 30 years of practicing medicine, in two specialties (general surgery and family medicine) and spanning over three continents, I have seen this occur over and over again. • Caring and compassionate attitude transcends the nationality, linguistic and cultural barriers. So continue to be caring and compassionate healers even when you are busy and tired. Your patients will appreciate you! • Time is so precious; give your time generously, your patients will love you. • You will be a teacher and a leader in the community you serve. Take the responsibility earnestly and you will be respected. • Remember the “Kumar Law.” Trusting doctor-patient relationship can produce enduring therapeutic miracles. Continue to nurture this sacred bond. You will be richly rewarded with grateful patients. • Humility is a great ornament. Wear it every day. • Please continue to cultivate your communication skills. Not only you will be adored by your patients but also prevent any lawsuits. And finally let me tell you, whenever you are working hard without much sleep, extremely tired and frustrated and wondering to yourself, “why am I here and what am I doing,” just remember you belong to the profession of great physicians and surgeons like Sushruta, Charaka, Hippocrates and Osler. You are one of the chosen few! You are the brightest and the best! Good luck and God speed.


The changing face of

family medicine By J.J. Waller Jr., MD Family medicine has developed and changed significantly in the last four decades. Although based on a generalist tradition, it became a specialty with the establishment of the American Board of Family Practice in 1969. The old tradition of the family doctor as a generalized practicing MD, delivering babies, surgery, house calls, team physician for the local high school, and available 24/7 has become an anachronism. In 2000, there was a meeting of family physicians at the Keystone III Conference that included generation I family physicians (entering practice before 1970), generation II (1970 1990), and generation III, entering practice after 1990. Attempts were made to amalgamate the traditions of generations I and II with the forward-looking prospects of generation III. In other words, what concerned the conference was what was the function of family medicine? Change was inevitable, and the changes had to be compatible with the core principles of family medicine.

SURVIVAL MODE Future family physicians should embrace themes of comprehensive care practiced with a scientific eye, a humanistic touch, and a broad expertise that included preventative medicine, counseling, and patient education. This was to be accomplished in the face of expanding government programs (Medicare and Medicaid), privatization of healthcare, increasing employer-sponsored healthcare programs, etc., all of which has become increasingly complicated and irrational. Family medicine, for years, has been in a survival mode at10 San Antonio Medicine • June 2014

tempting to meet the demands placed on primary care. A recent editorial (2014) by the original generation III family physicians has noted the following innovations: “electronic medical records, smart phones, broad-based Internet access, asynchronous communication (e-mail and bulletin boards), patient centered medical homes, team based care, accountable care organizations, boutique medicine, etc.” Many of these changes have been embraced by the generation of new family physicians and sometimes reluctantly by generation I and II family physicians. It is hoped that the application of the above, along with core principles, will produce a “primary care delivered in a wide range of settings and methods and resulting in improved healthcare, lowered costs, and enhanced patient experience.” And what of the training in family medicine? Residencies in family medicine are provided now by many (but not all) training centers. Unfortunately, many medical universities and residency training hospitals particularly stress training in specialties other than family medicine. The rate of specialties to primary care physicians is presently at a ratio of 2:1 (in most countries it is 1:1). Of the internists completing residency, 90 percent enter practice either as hospitalists or as subspecialists. Of pediatricians entering practice, only 50 percent continue in primary care. Family medicine specialists almost all enter primary care and hence become the “primary” primary care physicians. Fortunately, our local University of Texas Health Science Center has a very active and productive Department of Family and Community Medicine with an excellent residency program compecontinued on page 12

THE FATE OF SPECIALTIES continued from page 10 tently headed by Dr. Carlos Jaer. The president of our Bexar County Medical Society, Dr. Ashok Kumar, is a distinguished teaching professor in the Department of Family Medicine. The department is actively attempting to integrate the principles of the patient centered medical home as a vital portion of the training and treatment functions of the department. There exists a definite compensation discrepancy between family physicians and other specialties approaching a ratio of 1:2-4 or more. This is definitely a deterrent to entering family medicine. However, there is “light at the end of the tunnel.” This March at the Residency Matching Day, there were 1,416 graduating seniors matched to family medicine. This was an increase of 332 over the year 2009 and an increase of 42 over last year. The president of the American Academy of Family Practice has stated that with an increase of 65 family residency positions a year through 2025, we will be producing 4,475 family physicians each year.

‘CARING FOR THE PATIENT’ Taking the liberty of reflecting on my own experience, I fall into the generation I group, having graduated from medical school in 1955 and completing my rotating internship in 1956. I practiced family medicine for 25 years and then spent the next 25 years in the field of emergency medicine. I passed my boards in family practice in 1971 and have been recertified four times. For the last seven years I have been retired from emergency medicine and am back practicing family medicine in a primary care clinic. I have seven children, plus their spouses, 19 grandchildren and seven greatgrandchildren, and I receive a call at least weekly for inquiries about their medical condition, their blood pressure, problems with their knees, what their pediatrician has said about their children, etc., and I guess that makes me a real “family” doc. I hope those entering family medicine in the future experience the joy and satisfaction of being not only a “doctor of medicine,” but a “physician.” An older family physician, Dr. F. W. Peabody, stated in the Journal of the American Medical Association in 1927 that, “The secret to the care of the patient is caring for the patient.” With the increased need for primary care physicians, the future of the specialty of family medicine is certainly improving. J.J. Waller Jr., MD, is a member of the BCMS Communications/Publications Committee. 12 San Antonio Medicine • June 2014


A view of anesthesiology in

2054 By Jay Ellis, MD

Dr. Carolyn Walsh slipped on her white coat and began to reflect on her day. It is 2054 and her 40th birthday, also a few weeks short of her 15th anniversary as a physician. She took pride in being the fifth generation of physicians in her family. Since the early days of the 20th century, at least one member of each generation of her family went to medical school. She was now part of a vanishing profession. Advances in information technology and nanotechnology-based monitoring systems threatened to make the human physician obsolete. Unlike her ancestors, she seldom saw patients. Her task was to evaluate the reaction of the system put into place to monitor the millions of health inputs from the citizens in her geographic region. Some questioned whether her presence was necessary as well. Innovations in self-correcting information technology made the need for adjustments rare and true system malfunctions a thing of the past. She began her rounds by using her white coat sleeve to review the status of the operation of her hospital. The white coat was the one item her ancestors would recognize, but it was no longer just a symbol of the profession. It was a warehouse and access point for all the information known to mankind about the human body, manufactured to be a tailored, formfitting garment

LIMITED HUMAN CONTACT To her surprise, there were two patients in her tiny facility today. Most of them were elderly people who felt uncomfortable with the technology that allowed healthcare delivery at home without the presence of a physician, nurse, and most times, without human contact. She would stop by and see these individuals and put a human face on the system. Years ago her grandfather, a physician, and back in the old days of specialization, an anesthesiologist, accompanied her on rounds. She pulled up data on her white coat as she greeted the handful of patients in the hospital. Her grandfather commented that her duties were more akin to a greeter at Walmart than a traditional physician. She had to furtively search for “Walmart greeter” on the hem of her coat to

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understand the reference. Such a person was a welcoming figure back in the days when products were still sold in large, fixed structures. It seemed like a pleasant function. Medicine had changed. Medical knowledge expanded exponentially, and confining even a brief survey of the information to a four-year curriculum was impossible. Medical education now required very little memorization but it required an extensive background in accessing information accurately and rapidly from vast expanses of data. It was no longer a task comprehensible by the human mind. The human genome project allowed medical therapy to be tailored to each individual based on their genetic makeup so that every pharmaceutical regimen was custom-designed to the patient. Next, invention of nanotechnology allowed real-time monitoring of levels of medication in the blood and specific targeting, not for a large organ or cell, but for a specialized, individual receptor in each cell. All of these tasks were automated and delivered without any human input. Her grandfather told her that the development of real-time monitoring of drug effects made anesthesiology obsolete. After the full realization of the human genome project, every patient received an anesthetic regimen that was specifically designed for them. Nanotechnology monitored medication levels in real time and adjusted dose with accuracy that exceeded the capability of individual humans. Development of newer pharmaceuticals eliminated the troubling side effects associated with anesthetic agents used by her grandfather. Furthermore, the development of minimally invasive surgery eliminated the requirements for anesthesia in most patients. Her grandfather told her stories of horrible, disfiguring operations used to treat cancer and other anomalies. New immunological therapies made such operations obsolete. No one would dream of cutting off a woman’s breast to remove cancer. The requirement for any surgery was rare. There were still a few trauma cases, though even those were few and far between with the advent of self-driving vehicles. Even trauma from household accidents, sporting injuries and violent encounters (still too common to the human condition), received minimally invasive repair


without the large incisions made by knives and scissors described by her grandfather. Stimulation of skin cells closed wounds in minutes, hemostatic molecules and nanotechnology hemorrhage hunters within the body quickly eliminated any bleeding and helped the damaged organ repair itself.

NO MORE MONITORING Her grandfather told her that custom-designed anesthetic agents and real-time pharmaceutical monitoring solved the pharmacokinetic problem of what the body does to the drug and the pharmacodynamic problem of what the drug does to the body for all time. Monitoring of individual patients became unnecessary. At first her grandfather was assigned to watch large arrays of old computer monitor screens representing the care of multiple anesthetized patients. It soon became obvious even this was superfluous. Her grandfather retired, stating he did not want to be the last buggy whip maker standing. She needed to research this reference, too. The old man often said strange things. He told old stories of how his specialty was a pioneer in patient safety, reducing the incidence of anestheticrelated death to almost 1 in 100,000. This seemed like a horribly high number. According to the information retrieved by

her coat, no anesthetic-related death occurred in the last 10 years. Admittedly, there was no one receiving anything close to the anesthetic state administered by her grandfather. Dr. Walsh realized her role was now more akin to that of her great-great-grandfather. At the beginning of the 20th century, he provided reassurance and comfort while representing the face of human healing. He otherwise offered little to his patients other than a few, often ineffective pharmaceuticals and limited surgery. She did the same thing, except now she represented a huge automated technology system that provided every individual real-time monitoring of their health and instantaneous treatment when things went awry. Healthcare is now delivered by device and nanotechnology. Dr. Walsh was there to offer explanation and provide the human face of healing. Jay Ellis, MD, is an anesthesiologist and pain management physician with Tejas Anesthesia, as well as a longtime member of the Bexar County Medical Society’s Communications/Publications Committee. Based on his previous success with prognostication, he is absolutely certain that the future of medicine will be entirely different from that described above. visit us at



Physician extenders: PAs and NPs draw strong opinions By Jeffrey J. Meffert, MD

There seem to be few physicians who are truly neutral on the subject of physician extenders (PEs). Those who employ physician assistants (PAs) and nurse practitioners (NPs) see them as ways to shorten appointment waiting time and ways to enhance practice income without further overworking the physician themselves. They may play a critical role on the inpatient wards or in the operating room as experienced members of an efficient healthcare team. One may encounter PEs in general surgery, emergency medicine, orthopaedic surgery, dermatology, anesthesia, addiction medicine, psychiatry, occupational medicine, radiology, oncology and any primary care practice. Critics sometimes portray PEs as a professional “bait and switch” where the patient is given the impression they are seeing an experienced, fully trained physician when they are not. An oft-heard complaint is, “I paid for a doctor and got a PA.” In fact, Medicare will pay only 85 percent of the allowable rate for PE provided care, Medicaid paying up to 92 percent. Other complaints are that the PE is “practicing medicine without a license” and they are inappropriately unsupervised. There are many misconceptions about the supervision requirements of PEs.

SUPERVISION REQUIREMENTS VARY Some believe that a physician must be on site where a PE is providing care and that all records must be reviewed. Every state has its own supervision requirements, and the required closeness of supervision is inversely proportional to how remote and spread out the patients are. A state such as Alaska has very loose supervision requirements, especially when that PE might be the only healthcare resource for hundreds of miles. States in the 16 San Antonio Medicine • June 2014

more urban northeast often have much more restrictive requirements because one cannot argue that it is difficult to find a physician when there are three physicians for every 1,000 patients (Massachusetts). Texas is more on the loose supervision side of the balance. A physician may supervise up to five PAs and has to be on site only 10 percent of the time. Subspecialties may impose additional requirements or expectations upon the use of PEs by their members which may be much more restrictive than state law. Despite anecdotal reports (“My patients hate going to the doctor and seeing a PA.”), there is surprisingly little literature either in the lay press or scientific publications. Several professional publications support the use of PEs, patients usually preferring to see non-physicians earlier rather than waiting to see a


physician. This applies both short term (wait time emergency department visits) and long term (scheduling appointments at

and provide continuing education. PEs have much the same, with both larger professional organizations (American Academy of

the Veteran’s Administration hospital). Other surveys describe physician satisfaction with the performance of PEs in preven-

Physician Assistants and American Nurse Practitioner Association) and smaller specialty organizations (Society of Dermatologic

tion, evaluation and treatment of athletic injuries, utilization in neonate intensive care units, and performance in neuroscience intensive care units. In these latter studies, PEs were considered to function at the level of mid- to upper-level resident physicians. In studies of medico legal liability, employing PEs does not by itself seem to increase the incidence of medical malpractice litigation. What few studies are available are small and often too specific to practice type or practice location to be generalized to all PEs and all PE-employing practices. PEs may be found in primary care practices, medical and surgical subspecialties and also are serving on the wards of hospitals. Some of these have specific training programs, while most have a more general training and then acquire the OTJ training to function in a specialized practice. Physicians will have non-specialized umbrella organizations (AMA, TMA, BCMS, etc.) and their own specialty organizations (AAFP, ASA, etc.) to act as their advocates

PAs, Association of PAs in Psychiatry, etc.) In Texas, PAs are licensed by the same board which licenses physicians, and NPs are licensed by their state nursing boards. The CME requirements for Texas PEs are only slightly less than those for physicians. Complaints about PEs practice should be directed to the appropriate licensure board. If, on the other hand, it is felt they are being used inappropriately or are not being supervised adequately, the complaint should be directed to the physician’s state licensure board or their specialty organization’s ethics committee. Jeffrey J. Meffert, MD, is an associate professor of dermatology and cutaneous surgery at the University of Texas Health Science Center at San Antonio and 2013 chair of the BCMS Communications/Publications Committee.

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Where will

orthopaedic surgery be in 25 years? By Fred Olin, MD I finished my residency in 1977. We were pretty good at what we did, and people generally were improved by our surgical and non-operative care. However, when I look back, I can see that very little of what we do now is the same as we did it then.

A FEW EXAMPLES Today, in trauma care, there is a much more surgically aggressive attitude toward many fractures in adults: Essentially no one is put up in traction for a femoral fracture. External fixation, with pins above and below an open fracture, is used so that the wound can be tended to and the patient can be mobilized sooner. One form of internal fixation or another is used for immediate definitive treatment in many situations that would have been casted in the past. 18 San Antonio Medicine • June 2014

Reconstructive surgery also has advanced. There have been many improvements in the metals and plastics used in total joint replacement. That, along with advancing knowledge of the biomechanics of the joints, makes today’s arthroplasties only remotely like those done in the mid-’70s. Ligament and muscle reconstruction around unstable joints now accomplishes results not dreamed of in the 1960s.

REHABILITATION TIME So, there are bits of the past that have changed to what they are today: What do I see for the future? For starters, even though we have developed great things, such as “minimal incision” surgery, peri-operative pain control and the use of “scopes” for various procedures, we continue to move forward and have


immensely cut down on post-operative discomfort and rehabilitation time. While the use of “robots” has revolutionized surgery in the abdomen and thorax, I don’t believe that at the

cepts developed in the USSR by Ilizarov using external fixation and controlled motion, how much better it would be to use the

current time there is much that can done in bone and joint surgery. I suppose that if the linkages and tools used in arthroscopy

patient’s own cells, applied to a matrix formed from imaging data to grow a replacement part.

could be miniaturized enough that some use could be found there, this would not likely cut down on the two to four onecentimeter incisions used for most arthroscopic procedures. I think that we will see more use of materials that will do the job intended and then be broken down and absorbed by the body — thus no need for later removal. There have been resorbable screws available for various procedures for several years, and I have seen work on larger internal fixation devices, such as

Honestly, I’m probably way off the path of what reality will bring us. Consider: If you had the opportunity to ask a genius of the past, say Benjamin Franklin, what he thought news transmission would be like only a century or two after his time, what might he say? After all, printing hadn’t changed much in the 300 years before him. Somehow I doubt that he would have predicted the linotype machine, much less our current use of computers, imaging and remote visualization. I am certainly not a genius of the present … and progress is a lot faster now than it was in Ben’s day.

bone plates, at meetings and in the literature. Artificial bonegraft substitutes continue to develop, as do various forms of bioactive concepts, such as stem cells, platelet concentrates, etc., which seem to have the ability to aid in healing processes of various tissues. Recent developments in externally grown body parts will undoubtedly somehow be applied to orthopaedics. While it is already possible to assist the body in replacing defects in long

bones and to straighten out deformities with the use of the con-

Fred H. Olin, MD, is a semi-retired orthopaedic surgeon who sort of resents that he won’t be around to see how wrong his predictions are. He is the 2014 chairman of the BCMS Communications/Publications Committee.

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Family medicine services can increase access to allergy care By Bernice Gonzalez, MD

In October 2013, millions of Americans began entering the healthcare system for the first time under the Affordable Care Act. By March 2014, the total number of newly insured patients had reached 6 million. To meet the needs of this rapidly expanding patient population, increased focus has been placed on the role of primary care in treating patients with chronic conditions. This is particularly true for seasonal and perennial allergy care. Allergic rhinitis (AR), commonly referred to as hay fever, is the fifth most common chronic condition among all Americans, and costs the U.S. healthcare system approximately $18 billion annually. Historically, allergy care has most commonly fallen into the hands of allergists, with a miniscule population of approximately 5,000 in the United States compared to more than 60 million allergy sufferers. This creates a supply and demand disparity that is causing patients to wait months for an appointment with an allergist, or travel great distances to reach the specialist. With the progression of the Affordable Care Act, this is only the beginning of the access-to-care problem for allergy sufferers. Too

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many patients aren’t receiving the level of care they need. This shouldn’t be the case and must be addressed before the problem escalates further.

FIRST LINE OF DEFENSE The answer lies in primary care. Primary care physicians are well equipped to be the first line of defense for allergy diagnosis and treatment. By doing so, more patients can easily access effective treatment, while specialists are freed up to focus on acute allergy cases. Increasing access to allergy care within the primary care setting ultimately aligns with healthcare reform goals to deliver higher quality, affordable care to more patients. Referring patients with mild to moderate seasonal AR to an allergist is a missed allocation of resources. However, it is important to note that increasing the number of primary care providers who deliver allergy testing and treatment does not displace the critical contribution that allergists make. Allergists are best trained and equipped to manage patients with the most serious allergic and immunologic conditions.


Healthcare service companies such as San Antonio-based United Allergy Services速 (UAS) are committed to broadening access to care for allergy suffers by helping family doctors, general practitioners, pediatricians and pulmonologists act as the first line of defense for allergy diagnosis and treatment. UAS works with physicians and health systems to bring effective and convenient allergy testing and immunotherapy to the mass population of mild to moderate allergy sufferers. UAS simplifies allergy testing and treatment by providing an in-office Allergy Center, staffing and training, reimbursement assistance, and technology services. This level of support allows physicians and their staff to spend more time with patients delivering personalized, quality care. As primary care physicians increasingly act as the first line of defense speaking with patients about potential allergies, it is equally important to educate patients about treatment options. Too often patients are masking symptoms with over-the-counter (OTC) medications rather than treating allergies with effective immunotherapy, known as allergy shots, that desensitizes the response to specific allergens that trigger allergy symptoms. Immunotherapy induces tolerance by introducing the patient to

safely increased doses of an allergen(s) through a series of customized single-injections. The purpose of immunotherapy allergy shots is to desensitize the patient to the allergen that triggers the symptoms. This approach is in stark contrast to OTC and prescription drugs that only temporarily mask allergy symptoms without treating the actual disease. Up to 85 percent of patients receive a significant long-term reduction in allergy symptoms using immunotherapy. The healthcare industry is at a critical point and physicians must work together to ensure patient need is effectively met as the patient population rapidly expands. Primary care physicians can and should take an active role in diagnosing and treating seasonal and perennial allergies, working to ensure that all allergy patients have access to the level of care needed. Bernice Gonzalez, MD, is the founder and chief executive officer of Vital Life Wellness Center in San Antonio. She is also an advisory board member and contracted physician with San Antonio-based United Allergy Services.

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AAPI launches ‘Be Fit. Be Cool’ childhood obesity awareness campaign By Rajam Ramamurthy, MD, and Aruna Venketesh, MD The “Be Fit. Be Cool” childhood obesity awareness campaign, a pioneering health education awareness program by the American Association of Physicians of Indian Origin (AAPI), was launched Dec. 13 at Collins Garden Elementary School. Through the initiative of the Texas Indo-American Physicians Society (TIPS), Southwest Chapter, the Texas program was launched at the San Antonio Independent School District school. “The obesity prevention initiative is one of the top priorities for AAPI,” said Jayesh Shah, MD, president of national AAPI, vice president of Bexar County Medical Society, and a woundcare specialist practicing on the city’s South Side.

EASY TO FOLLOW The Be Fit. Be Cool campaign, which aims to involve up to 100 schools across the nation, is an educational program for youth to encourage them to adopt simple, easy-to-follow tips based on the slogan 5-2-1-0: eat five or more vegetables and fruits daily, limit recreational screen time to two hours each day, engage in at least one hour of daily physical activity, and eliminate sugary drinks. The program is in keeping with First Lady Michelle Obama's childhood obesity initiative, the “Let's Move” campaign, which includes four components: enhancing information parents need to make healthy decisions for their family, improving the quality of food in schools, improving access to and the affordability of healthy foods in communities, and increasing physical activity in and out of schools. President Obama signed a presidential memorandum to create the first-ever federal task force to provide "optimal coordination" between private-sector companies, nonprofits, agencies within the government and other organizations to address the problem of childhood obesity. The San Antonio Mayor's Fitness Council works to increase healthy meal options in the city's schools. Recently, 108 salad bars were placed in area elementary, middle and high schools, making fresh fruits and vegetables available to students. 22 San Antonio Medicine • June 2014

San Antonio also is one of 50 U.S. cities involved in Communities Putting Prevention to Work (CPPW), an initiative designed to make healthy living easier by promoting environmental changes at the local level, with funding through the Centers for Disease Control and Prevention. Last year, BCMS adopted cardiometabolic health as its key public health initiative. According to a recent CDC report, children from low-income homes who tend to be fatter than their counterparts from wealthier families have become slightly, but significantly, leaner in recent years. Data was obtained from the pediatric nutrition surveillance system in which medical workers recorded the height and weight of about 11.6 million preschool children from 43 U.S. states and territories who were enrolled in government nutrition-assistance programs between 2008 and 2011. In New Jersey, which had one of the biggest changes, 17.9 per cent of children were obese in 2008, which declined to 16.6 per cent in 2011. This data is not available for Texas. CDC warns that the trend does not mean that the problem has disappeared. On the contrary, it is a call for more states, cities, schools and neighborhoods to adopt the programs that were successful in other places. Texas is the 13th most obese state in the country. Approximately 29.8 percent of adults in Texas are obese. In 2011, 16 percent of high school students in Texas were obese. In the United States, the combined obesity and overweight rate is 61.6 percent. Overweight is defined as having a body mass index (BMI, a ratio of weight to height) of 25 to 29.9. Obesity is defined as having a body mass index (BMI) above 30. Fifteen years ago, Texas had a combined obesity and overweight rate of 50.3 percent. Ten years ago, it was 58.5 percent. Now, the combined rate is 66.5 percent. Diabetes rates have doubled in 10 states in the past 15 years. In 1995, Texas had a diabetes rate of 5.9 percent. Now the diabetes rate is 9.6 percent. Fifteen years ago, Texas had a hypertension rate of 21.7 percent. Now, the rate is 27.2 percent. During the Be Fit. Be Cool session held at Collins Garden Elementary School, dieticians Vijaya Botla and Sejal Patel,

CARDIOMETABOLIC HEALTH health educator Marie Gavel, and physical therapist Neha Shah presented several food models and taught the children how to prepare a healthy plate for their meals. According to the plan, half the plate will be filled with fruits and vegetables, a quarter with food made of grains and the other quarter with meats, or for vegetarians, lentils and beans. Creating the healthy plate was a highlight for the children, who actively engaged in the process. A foot-long chunk of fat, one of the food models, brought home the message. Kindergarteners through fifth-grade students were given an opportunity to participate during their PE period in a hands-on educational and physical activity that included Zumba and walking nearly a mile. It is symbolic that TIPS Southwest Chapter chose Collins Garden Elementary School as the first in Texas to launch the campaign. Housed in a beautiful red building located at 167 Harriman Place, the school will be 100 years old this year. It is named after Finis Foster Collins, who owed the land and the irrigated truck farms that were a big tourist attraction a century ago. Drs. Anupama Gotimukula, Arathi Shah, Chandana Tripathy, Rajam Ramamurthy, Nive Parachur and Mr. Venky Adivi were part of the team that help organize the debut Be Fit. Be Cool event. A follow-up of how the students retained the information is planned.

CONVENTION IN SAN ANTONIO The organizers believe that these efforts cannot be limited to the schools alone. Involvement of the family and the community will ensure that the habits are lifelong and sustained. The 32nd annual AAPI convention, to be held June 25-29 in San Antonio, will focus on the Be Fit. Be Cool initiative. A health walk is planned from 7 a.m. to 8:30 a.m. June 28 beginning at the Henry B. Gonzalez Convention Center. Miss America and other VIP guests are expected. BCMS members are invited to join this effort. AAPI also invites BCMS members to the convention with an outstanding CME program. Rajam Ramamurthy, MD, is the Rita and William Head Distinguished Professor of Environmental and Developmental Neonatology, Department of Pediatrics, University of Texas Health Science Center San Antonio. Aruna Venkatesh, MD, is an endocrinologist at the Texas Diabetes Institute in San Antonio and assistant professor, medicine, UTHSCSA.

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Physician as Patient

EDITOR’S NOTE: This is the third in a series of articles written by San Antonio anesthesiologist Jay Ellis, MD, a member of the BCMS Communications/Publications Committee. The series, published monthly in San Antonio Medicine, examines the physical, emotional, financial and spiritual burden of life-threatening illness

In the chemo room By Jay Ellis, MD

I doubt anyone was as relieved to start chemotherapy as I was. It was my best hope for recovery and relief from the scourge of the abdominal pain that tormented me nightly. My wife, Merrill, prepared for my first chemotherapy session with a proficiency and precision reminiscent of the logisticians of Desert Storm. She packed enough food for a regiment, assembled what looked like a year’s worth of reading material, and packed a bag full of sweaters and blankets in case I felt cold, or decided on Arctic travel. Carrying all these bags into chemotherapy reminded me of the Clampetts' arriving in Beverly Hills. Greg Gulley saw me that morning to review my lab work and treatment plan. It was comforting to see him. I did complain that I had only 54,000 platelets and everyone seemed to want to draw my blood and take a look at them. He responded by giving me an article from the New England Journal confirming that patients are often phlebotomized into anemia. OK.

EGALITARIAN GATHERING PLACE The chemotherapy room is a great egalitarian gathering place, like the DMV or divorce court. Cancer is an affliction that crosses all social barriers without prejudice. We were the first ones there, and Merrill staked out a plum position, then began making friends as others arrived. While we were in chemotherapy we would meet other professionals, laborers, little old ladies, little old men, and too many young people. Everyone is there for the same purpose and everyone asks your diagnosis, not unlike being in prison and asking, "What are you in for?" It is a mutual support society. There are even moments of humor, such as one man who 24 San Antonio Medicine • June 2014

spent his entire treatment session standing and yelling, “I'm not sick. I don't know why I'm here. I don't need this," all the while hooked up to his infusion. The chemotherapy nurses are caring, professional, and they inspire confidence. They reviewed each medication with me. I did have memories of CHOP (Cytoxin, vincristine, doxorubicin, prednisone) therapy from my medical student and resident years. I can still recall the hemorrhagic cystitis, heart failure and peripheral neuropathy experienced by my patients. I had vivid memories of the intractable nausea and vomiting they all developed with each session of therapy and for days later. The specialty of oncology should be commended for improving this bleak picture. First, I received several pre-medicant drugs to minimize my symptoms and risk for side effects. I experienced mild nausea, but not the intractable vomiting so starkly remembered. In addition, I would get the CHOP-R version with the addition of the monoclonal antibody drug rituximab. Unlike the old days where chemotherapy was an applied exercise in selective toxicology, I now had the "magic bullet." Rituximab would be specific for the lymphocytes of my lymphoma, sparing me from many of the side effects of the old CHOP regimen. After I finished my premedication, the rituximab infusion began. My bride is a great doer, but not good at sitting and watching. I can tell when she is getting fidgety and asked her to go and get me a Starbucks coffee. Soon after she left things got strange. I started getting the rigors/shaking chills I once had with pneumonia. They started small, but began to crescendo in intensity and


duration. I raised my hand like a school child and the nurses quickly recognized my problem and descended on me. I became the center of attention in the chemo room, not a distinction I wanted. The nurses rapidly went through the algorithm to treat symptoms they saw often. One nurse stopped my infusion. One covered me with blankets and another brought the diphenhydramine and steroids to treat my symptoms. My symptoms became worse. I was shaking uncontrollably and wondered if this is what seizures felt like. The muscles in my neck began to contract, and my head bent to the left with a strange, torticollis-like position. I had never felt so helpless in my entire life. I had no control over my body, and I thought I would vibrate myself right out of my chair. Fortunately, after some meperidine, my symptoms subsided. I was exhausted. I doubt the whole episode lasted more than 10 minutes, but I felt like I had been exercising for hours. The combination of the medication and the physical exertion of the shaking chills left me exhausted. I fell asleep and woke later with Merrill sitting next to me with a cold cup of coffee. The nurses slowed my infusion rate. It took the entire day to finish my regimen, and we left late that afternoon.

SMOLDERING EMBERS I woke the next morning feeling is if someone had lit a fire throughout my body. It wasn't the flaming inferno of the forest fire. It was a low, smoldering sensation like the last embers of the campfire as it consumes the final ounce of fuel. I felt the smoldering most intensely in my back at my biopsy site. I wondered if it was my tumor shrinking away from the effects of chemotherapy, but quickly extinguished that thought as the silly wishes of a desperate man. I was tired, in pain and just felt awful. Merrill began what soon became our thrice-daily ritual. She would prepare something for me to eat, and I would refuse to eat it, lacking any appetite and certain that ingesting food would result in catastrophe. She would respond by first persuading, then cajoling and finally insisting that I eat. I only made the attempt because I knew it was important to her. I'm convinced that had she not been there I would not have eaten anything that day, or for several days after. Friends called and sent text messages of encouragement. I tried to respond to everyone, but fell asleep. Merrill swiped my phone and answered the messages for me so that I would rest during the day. The next day the diarrhea started. The smoldering now became a hot torch centered in my rectum. Every time I tried to lie down the diarrhea would return. The burning sensation in my rectum was accompanied by spasmodic contractions of the viscera of my abdomen. It was misery. I began to pray to God fervently for re-

lief. I was afraid to be more than a few steps away from the bathroom. The designer who placed three commodes at different locations in our downstairs now seemed like an architectural genius. By the next day these symptoms passed as well, and I went from being severely distressed to just miserable. Then I noticed something remarkable. My abdominal pain was gone. I hadn't touched any pain medication for 24 hours. The stabbing torment in my abdomen vanished. The distress I felt over the previous days seemed like more than a fair trade. There was hope that the chemotherapy was working. After five days, I tried to go back to work. I overestimated my recuperative powers. The walk from the parking garage to my office took every morsel of physical energy I possessed. I sat at my desk, completely exhausted. After two cups of coffee and a 30minute rest, I began to rally. As always, work was a tonic, and I survived the day. My office staff could not have been more supportive. They made little changes to make my work easier and my life more comfortable. Their concern increased my resolve to get through the day. I did finish my schedule, but when I arrived home I was exhausted. I was too tired to argue with Merrill about whether or not I would eat. After I ate, I just went to bed. I would repeat this routine for several days, but as the days went by my strength seemed to grow and my stamina increased. I certainly wasn't well, but I had hope that I was moving in the right direction.

ROUND TWO I approached my next chemotherapy with some trepidation. The nurses were a great comfort, telling me that by slowing the infusion rate they could get me through my chemo without the drama of the first encounter. They were right. This session went smoothly, without the near-epileptic activity associated with the first visit. Three weeks later, I went for my first CT scan since my diagnosis. I did have to choke down two bottles of oral contrast which, despite the flavoring, will never replace Coke or Pepsi. The CT scan would determine my progress on chemotherapy. The staff at South Texas Radiology was polite and encouraging. After my scan, Dr. Todd Tibbett’s took the time to review the images with me. The results were obvious even to the average anesthesiologist. The abdominal mass, the lesions in my spleen and the lymph nodes shrank to a fraction of their former size. The chemotherapy was working, and the success was better than anything I could have imagined. For the first time I understood what it felt like to want to weep for joy.

NEXT MONTH: Complications. visit us at



BCMS Delegation to TMA wraps up TexMed 2014: TMA House of Delegates adopts resolutions By Mary E. Nava, MBA Chief Governmental and Community Relations Officer

The BCMS Delegation to TMA meets three times per year: one meeting is to review all BCMS resolutions submitted for consideration; Delegation Chairman James another meeting is to review Humphreys, MD, leads the discussion on reference committee reports the TMA House of Delegates on resolutions during the TexMed Handbook, which the DeleBCMS Caucus breakfast May 3. gation reviews and takes a position on all resolutions submitted from around the state. All of this work leads up to the annual meeting, TexMed, which culminates in the final vetting (in reference committees) of resolutions under consideration for adoption by the TMA House of Delegates. Resolutions that are adopted become part of TMA policy. TexMed 2014 was held in Fort Worth May 2-3, and the BCMS Delegation to TMA achieved success with the passage of three resolutions which were adopted by the TMA House of Delegates. The resolutions adopted are as follows: Resolution 308 – Improving the ImmTrac Registry by Reverting Back to an Opt-Out System Resolution 408 – Permanent Delay of ICD-10 Implementation Resolution 419 – Opposition to Laboratory Reporting Provisions of HR 4302 Additionally and simultaneously, the Delegation worked to cam-

paign for the elections of Dr. Jesse Moss Jr., for TMA Board of Trustees (BOT), and Dr. Michael Battista for AMA Alternate Delegate. Unfortunately, neither won their respective races. Moss, who was facing a second run at a BOT position, stated, “I appreciate the support of Bexar County Medical Society for nominating me and for all who supported me in this election.” Battista, who was running for the first time, stated, “I appreciate all the support of the Bexar County Medical Society. I look forward to continue working with the Texas Medical Association and also participating in AMA meetings.” Many thanks to the members of the BCMS Delegation to TMA who attended this year’s TexMed: Chairman, James Humphreys, MD; Rajaram Bala, MD; Michael Battista, MD; Adam Bruggeman, MD; Chelsea Clinton, MD; Estrella De Forster, MD; Suresh Dutta, MD; John Edwards, MD; Alberto Fernandez, MD; William Gordon, MD; Sheldon Gross, MD; Pam Hall, MD; Gregory Hamon, MD; David Henkes, MD; William Hinchey, MD; John Holcomb, MD; Wendy Kang, MD, JD; Margaret Kelley, MD; Alex Kenton, MD; Malathi Koli, MD; Vijay Koli, MD; BCMS President Ashok Kumar, MD; Jesse Moss Jr., MD; Rajam Ramamurthy, MD; Somayaji Ramamurthy, MD; Adam Ratner, MD; Janet Realini, MD; Walter Root, MD; Jennifer Rushton, MD; Roberto San Martin, MD; Jayesh Shah, MD; David Shulman, MD; Bernard Swift Jr., DO; Jiesing Tan (medical student delegate); Roberto Trevino Jr., MD; and David Webster, MD. For more information, contact

NOTEWORTHY BCMS President K. Ashok Kumar, MD, received the C. Frank Webber, MD, Award from the Texas Medical Association Medical Student Section on May 2 in Fort Worth. The honor recognizes a Texas physician for outstanding service to the section and its members.

Dr. Kumar also was selected to chair the newly created healthcare committee of the Mayor’s Fitness Council. Annette Zaharoff, MD, is chair of the council’s Active Living Council and Peter Wald, MD, chairs the San Antonio Business Group on Health.

IN MEMORIAM Howard A. Britton, MD, a BCMS Life member, died March 1, 2014. Dr. Britton, 87, was a pediatrician and also served as a flight surgeon in the U.S. Air Force.

26 San Antonio Medicine • June 2014

BCMS member James F. Jennings, MD, a psychiatrist, died April 12, 2014. Dr. Jennings, 81, was a U.S. Air Force retired colonel.

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SAVE THE DATE June 3, 6-8 p.m. New Member Welcome The Argyle Club, 934 Patterson Ave. Mix and mingle – complimentary buffet and cocktail party. Jacket but no tie required, no jeans. Come meet your fellow members at our popular annual event. Sept. 24, 6:30-8:30 p.m. Fall General Membership Meeting Hilton at the Airport, 611 N.W. Loop 410 Talk to the new TMA president for legislative updates (1 CME ethics credit). Complimentary Polynesian buffet, cash bar, update and Q&A; give TMA your input.

28 San Antonio Medicine • June 2014

Oct. 16, 5-9 p.m. BCMS Auto Show BCMS office parking lot, 6243 IH-10 West Mix and mingle – complimentary buffet and cocktail party. See the new 2015 models; family and friends welcome. Oct. 2-3 BCMS Fishing Trip Rockport, Texas For information and pricing, please contact Mark Lachenauer at (210) 301-4391. Have fun with your fellow physicians at the happy hour and dinner, and morning guided fishing trip! Nov. 1, 11a.m. to 3 p.m. Women in Medicine Appreciation Omni Hotel at the Colonnade, 9821 Colonnade Blvd. Luncheon with celebrity speaker Dr. Robin Eickhoff, style show, gifts and prizes. Bexar County Medical Library Association fundraiser showcasing female physician models.

MEMBERSHIP UPDATE Active Alonso Osorio, MD, Family Medicine Anne-Marie R. Langerin, MD, Pediatric Hematology/Oncology Cherie L. Hauptmeier, DO, Family Medicine Christian L. Stallworth, MD, Otolaryngology Farbod Malek, MD, Orthopaedic Surgery Gregory Kostur, MD, Pediatrics Jennifer Lynn Pearl, MD, Emergency Medicine Kathryn Stephens, MD, Pediatrics Kerry Latch, MD, Anesthesiology Kevin Delaney, MD, Anesthesiology Marshall B. Packard, MD, Internal Medicine Marvin Eng, MD, Cardiology Matthew C. Murray, MD, Orthopaedic Surgery Michelle J. Muldrow, DO, Obstetrics and Gynecology Paul Randall Lillich, MD, Emergency Medicine Pavan Devulapally, MD, Nephrology Rami G. El-Abjad, MD, Gastroenterology Reid Hartson, MD, Internal Medicine Robert M. Saad, MD, Cardiovascular Disease Roderick W. Lovett, MD, Anesthesiology Sasikanth Nallagatla, MD, Internal Medicine Suzanna P. Garza, MD, Pediatrics

Timothy J. Kosmatka, MD, Family Medicine Yanilda Nuñez, MD, Internal Medicine Military Physicians Brian Faux, MD, Child Neurology Greg Gerasimon, MD, Cardiology Medical Students Blessing Amune Christine Binkley Elizabeth C. Brewer Ian Churnin Jacob Dickson Noah Einstein Tiffany Fisher Nakiuda Hall Lucas Harvey Christopher Lam Nadia V. Silva Michael Watkins Retired Physicians Anthony John Corbet, MD, 37 years in practice Adrian Gresores, MD, 26 years in practice Life Member Physicians J. Leonard Hilliard, MD, 30 years in practice Werner Ned Keidel, MD, 36 years in practice Arvo Neidre, MD, 36 years in practice

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Meet AugustHeart From tragedy comes hope By Lisa Street From one family’s tragedy comes a hope for the future. In October 2008, Doré and

As a result, serious heart abnormalities

develop serious heart problems later in

often go undetected.

life. Yet, most people are unaware of the

Bart Koontz lost their 18-year-old son,

Gaps within our current healthcare sys-

importance of heart screenings, and

August, to an undiagnosed heart condi-

tem put all of our youth at risk. August-

rarely are teens considered susceptible to

tion which resulted in sudden cardiac

Heart creates equal access to cardiac

heart problems or undetected heart con-

death. August was a healthy teenage boy

screening services that save lives and has

ditions. It is this premise that feeds the

and an active athlete. The undiagnosed

offered more than 3,500 free heart screen-

mission of AugustHeart to identify mod-

heart condition was a shocking discovery

ings to teenagers as an added benefit to

erate to severe abnormalities in teenagers;

easily detectable with a simple 20-minute

high school preparticipation physicals

to educate teens and their families about

heart screening.

throughout the city.

heart health; and to raise awareness about

In honor of their son, the Koontzes established AugustHeart, a 501(c)(3) non-

the importance of teenage heart screen-


ings for the prevention of potentially fatal

profit dedicated to preventing sudden

AugustHeart provides cardiac screening

cardiac arrest (SCA) in teens by providing

events across the San Antonio area in col-

cardiac screenings in San Antonio and sur-

laboration with local healthcare systems,

In 2013, AugustHeart screened more

rounding areas. AugustHeart is a commu-

school districts, medical groups and other

than 3,000 high school athletes for heart

nity-wide initiative involving a volunteer

community partners. Each screening in-

abnormalities in the Northside Independ-

team of board-certified pediatric and adult

cludes an electrocardiogram (ECG) and if

ent School District and North East Inde-

cardiologists, sonographers, technicians,

necessary an echocardiogram (ECHO)

pendent School District, the two largest

and area high schools, as well as San An-

performed on every student. These simple,

school districts in San Antonio.

tonio’s major health systems and other

non-invasive tests allow skilled cardiolo-

In May 2014, AugustHeart surpassed

partners. Baptist Health System, Christus

gists to evaluate the structure and electrical

the number of students served last year,

Santa Rosa Health System, Methodist

activity of the heart. Upon review, the test

screening more than 3,500 students from

Healthcare System, University Health Sys-

results may trigger a referral to local pedi-

participating high schools in Northside

tem and UT Medicine San Antonio are

atric cardiology for additional testing,

Independent School District, North East

just a few of the more than 20 community

evaluation and treatment.

Independents School District, Hondo,

outcomes, and is the ultimate purpose of AugustHeart.

partners who help provide equal access to

Since its founding in 2011, August-

Sabinal, D’Hanis, Leakey, Medina, as well

lifesaving technology not typically offered

Heart, in partnership and collaboration

as Alamo Heights High School and St.

to teens and seldom covered by insurance.

with the major medical systems of San

Mary’s Hall.

Rarely does anyone expect a healthy, ac-

Antonio and area school districts, has

tive, athletic teenager to have a heart con-

made great strides in saving lives through

dition. Yet, every three days in the United

education, awareness and free heart

States, a high school-aged athlete suffers


ATHLETES AT HIGHER RISK One in 250 teens in the United States is at high risk of an undetected heart con-

SCA, the leading cause of death in 14-

Adolescents with heart abnormalities,

dition that may cause SCA. That number

to18-year-old athletes on the playing field.

if left undetected, may die suddenly or

increases to one in 20 for student athletes,

30 San Antonio Medicine • June 2014


who are at an even greater risk of sudden

time it is fatal. AugustHeart has learned

lieve every student should be tested as the

cardiac death, because they are more active

the heart is physically immature before the

heart matures.

than teens who lead sedentary lifestyles.

age of 14; high school athletes are pushed

Approximately one in 70 high schools will

to a much higher level of exertion than

have an incident of SCA on campus each

ever before, putting more stress on the

year. In Texas alone, there are an estimated

heart; and medical history and a physical

39,000 youth with undetected heart ab-

exam alone are not enough.

normalities participating in high school athletic programs.

Join AugustHeart to help save the heart of our community — our youth.

As the seventh-largest city in the United States, AugustHeart’s 200-plus volunteer

For more information about August-

SCA is 60 percent more likely to occur

physicians and medical specialists are

Heart or to join the team of dedicated

during exercise or sports activity. It hap-

spread thin. Though the organization’s ini-

volunteer pediatric and adult cardiolo-

pens without signs or symptoms in 80

tial focus was on student athletes, SCA

gists, call 210-841-9207 or email

percent of cases, and 92 percent of the

can affect anyone. At AugustHeart, we be- visit us at



Cool spots offer family fun

By Beth Bond

It's time to start making plans for filling the summer days with fun activities for your children. And you're in luck: Not only is San Antonio a kid-friendly city, but we've put together a list of places that are sure to please when the temperature soars and the days get long. Read on for three of our favorite picks. KIDDIE PARK San Antonio is known for its historical sites, and this one just might be the most fun. Did you know the city is home to America's oldest children's amusement park? Kiddie Park has been entertaining the little ones since 1925 and keeps old-fashioned fun alive with 1920s-era rides, including a carousel with hand-carved wooden horses made in 1918 by the Herschell-Spillman Co., an innovative and prolific carousel maker of the early 20th century. But don’t mistake these for outdated rides weathered by time. Kiddie Park is a safe, clean, affordable place for birthday parties and anytime fun thanks to renovations in 2009 that brought the iconic park back to life while maintaining its original charms. Hop aboard the Ferris wheel for a spin back to the 1920s, then head over to the classic carnival games, a new attraction for the 2014 season. Get into the nostalgia with a milk bottle toss, ring toss, basketball game and more. And don’t forget the cotton candy. Each ride requires one ticket, and you can buy them for $2.50 each, $11.25 for six or $13 for an unlimited ride band. Bargain prices are offered every Wednesday, and you can buy unlimited ride bands for 50 percent off for groups of 20 or more children during the week. 32 San Antonio Medicine • June 2014

Are you on the South Side of the city? Kiddie Park has expanded to your area with a new location called Kiddie Park PicaPica, a modernized take on old-fashioned fun with a carousel, jump houses, an arcade, face painting, a whip ride and more! For more info, visit Kiddie Park 3015 Broadway San Antonio, TX 78209 210-824-4351 Spring and summer hours: 10 a.m.-7 p.m. Wednesday through Sunday and

closed but available for private parties Monday and Tuesday.

SAN ANTONIO ZOO Celebrating its 100th year in 2014, the San Antonio Zoo has an impressive history that includes being one of the first “cageless” zoos in the United States, successfully breeding 53 endangered snow leopards since 1970 and being the first zoo in the country to breed endangered whooping cranes — plus, it’s the site of the first endangered white rhinoceros birth outside of Africa. Part of the zoo’s commemoration of its centennial is the creation of Zootennial

LIFESTYLE young players. There are no windmills or circus-worthy characters on these courses — just the classic green shapes designed to make you consider the geometry of your ball’s path. It’s nostalgia at an affordable price: Admission costs $9 for those ages 13-54, $8 for military with ID and seniors ages 55 and up, $7 for ages 4-12 and it’s free for children 3 and younger. On top of that, additional rounds of golf are $2 off. With a frequent golfer card, the sixth visit is free after five punches. Children 10 and younger must be accompanied by an adult.

Plaza, a thoughtfully designed, $8 million gathering place that includes an upscale restaurant, a centralized family gathering area for casual and reserved occasions, and a custom-designed carousel. The zoo is home to more than 9,000 animals of 750 species that engage more than 1 million guests each year. For a super special visit for your kids, sign up for an overnight summer camp, where children ages 7-11 explore the zoo, venture behind the scenes and play games, then crawl in their sleeping bag to sleep at the zoo. The next Zootennial Overnight is scheduled for July 12 and costs $45 per person, a perfect outing for families, friends and small groups. Register here: There’s also the new Zoobilation Celebration adventure day camp for ages 5-11 and Tiny Tot camps for ages 2-5. Admission to the San Antonio Zoo costs $12 for adults and $9.50 for children 3-11, with free admission for children 2 and younger. San Antonio Zoo 3903 N. St. Mary’s St. San Antonio, TX 78212-3199 210-734-7184 The San Antonio Zoo is open 365 days a year from 9 a.m. to 5 p.m.

COOL CREST MINIATURE GOLF When summer days get hot, you’ll want to find shade. Head over to the historic Cool Crest Miniature Golf, where it’s always reliably cool and shady. You’ll find fun under a canopy of lush banana tree leaves that shade two family-friendly 18-hole courses. With flowing brooks and fountains and gently sloping terraced courses, your kids will enjoy this tropical-feeling getaway spot for miniature golf that’s been entertaining families for more than 80 years. Opened in the late 1920s, Cool Crest is one of the oldest continually operated miniature golf courses in the world. It’s been designated by San Antonio’s Historic and Design Commission as a historically significant site and zoned as a historically significant property by the city’s Zoning Commission and City Council. The original course was built about 1929, and the newer one was built in 1957. Both are challenging but playable for experienced putters and

Cool Crest Miniature Golf 1402 Fredericksburg Road San Antonio, TX 78201 210-732-0222 Summer hours are 10 a.m. to 11 p.m. Tuesday through Saturday, noon to 10 p.m. Sunday, and closed Monday.

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Private education: A snapshot of San Antonio’s top private schools By Mauri Elbel From fostering intellectual curiosity and critical thinking to educating the whole child in a values-based setting, San Antonio and the surrounding area is brimming with private schools focused on preparing young minds for a lifetime of success. Small class sizes, passionate teachers, unique curriculum and high standards are among the common threads linking these independent schools. But each one has its own special qualities and overall objectives that set it apart from the others. For the past several years, San Antonio Medicine has compiled a snapshot of the area’s top private schools –– read on to gain insight behind six schools standing at the forefront of private education.

ANTONIAN COLLEGE PREPARATORY HIGH SCHOOL Celebrating its 50th year this year, Antonian College Preparatory High School was founded in 1964 and is the largest Catholic high school in San Antonio today. Enrollment for the 2014-15 school year is anticipated to be 800 students in ninth through 12th grades. Antonian began as a school for boys and transitioned to co-education about a quarter-century ago. But it is Antonian’s faith and spiritual formation that sets it apart from other private schools in the area. As a Catholic high school, students grow in the knowledge of God and learn to interact with each other in Christian ways through theology classes, class retreats, liturgical services and frequent prayer, said Diann Montemayor, dean of admissions. “In addition, our administrative staff members and faculty continually seek ways to improve our academic program, being very mindful of college readiness, not just for the best and brightest of our students but for all students,” Montemayor said. “We take very 34 San Antonio Medicine • June 2014

seriously the words in our mission statement ‘in partnership with parents,’ as they are the primary educators of their children. We firmly believe that every child can learn, and our academic accolades bear this out.” Antonian strives to attune to the strengths of every child, a goal backed by recognition from the Texas Association of Private and Parochial Schools (TAPPS) and objective rankings as the top school in Texas in the largest division of schools (5A) in recent years. But the students at Antonian serve as one of the best testaments to the school’s success and commitment to prepare young minds for the future.

TMI – THE EPISCOPAL SCHOOL OF TEXAS The Episcopal School of Texas, founded in 1893, celebrated its 120th anniversary this past school year. The coeducational, college preparatory school has 465 students in sixth through 12th grades and offers optional JROTC and boarding programs on its 80acre campus. With college placement a top priority at the school, all 75 students in the class of 2014 will attend four-year colleges and universities including Boston College, Duke, Emory, Harvard, Notre Dame, Southern Methodist University, Trinity, the University of Texas at Austin and Texas A&M Business Honors Program. “We are first and foremost an Episcopal school, dedicated to academic excellence while guiding our students toward moral and spiritual maturity,” said TMI Headmaster John W. Cooper, Ph.D. “This year, we’re celebrating the 120th anniversary of our founding by the Episcopal Diocese of West Texas, and we’re reaching the conclusion of an am-

bitious project –– 120 Acts of Service – that reaffirms our founder’s ideal of developing servant leaders of the future.” Students have achieved that goal by participating in community service projects across the city through TMI’s Interact chapter, on their own or with church, Scouting or other groups, with many surpassing the number of service hours required by the school and by the National Honor Society and National Junior Honor Society. TMI students also enjoy the opportunity to participate in a number of extracurricular activities. “A TMI student can play as many as three sports a year, sing in the choir or play in the band, act in a drama or musical, or join one of more than a dozen student clubs,” Cooper said.

INCARNATE WORD HIGH SCHOOL Providing excellence in education since 1881, Incarnate Word High School is committed to offering the best of the best for young women today. In the past several years, its students have earned $30 million in academic scholarships and provided more than 100,000 hours of community service in the San Antonio area. “Service to the community plays a very important role in the formation of IWHS students, and each year students take time to support the under-served in our community,” said Annette Zahirniak, director of enrollment. “IWHS also has a very active campus ministry that provides opportunities for students to grow in their faith by attending retreats and liturgies offered throughout the year which are primarily planned by students.” This year, the private Catholic school for young women had one student earn the dis-

LIFESTYLE tinction of being named National Achievement Scholar, a handful of seniors named as commended scholars in the distinguished 2014 National Merit Scholarship Program, seven students named National Hispanic Scholars, and 154 students earned high honor roll status and 137 have earned honor roll status. But these same academically-focused students also perform to high standards in athletics, earning high-ranking achievements this year in sports including cross country, golf, swimming and basketball. Incarnate Word High School boasts an average class size of 125 students in ninth through 12th grades, offering outstanding academic programs, enriching spiritual development, programs, a dual enrollment opportunity at the University of the Incarnate Word and multicultural learning.

ST. LUKE’S EPISCOPAL “We become exemplary human beings by repeatedly seeking what is good and doing what is right,” said Thomas McLaughlin, head of the school at St. Luke’s Episcopal. “Rather than being a destination at which we will one

day arrive, excellence is an elusive goal that is tirelessly pursued and occasionally enjoyed.” McLaughlin’s words seem to sum up the philosophy of St. Luke’s Episcopal School, which remains committed to its mission of being a Christian community dedicated to academic and personal excellence, life-long learning and service to others. The over-65-year-old nationally recognized, faith-based independent school provides vibrant and innovative education for students from pre-kindergarten through eighth grade. Because the school isn’t strapped with standardized testing requirements, St. Luke’s teachers are free to teach rich and valuable lessons brimming with creativity in all subject areas and a unique environment that cre-

ates an atmosphere conducive to learning and the development of critical thinking skills. Various electives are offered to students at every grade level including foreign languages, fine arts and physical education, and beginning in fifth grade, students are able to compete athletically for the school, giving them an extra year of in-school, sport-specific training prior to high school. The school also incorporates the latest technology into the classroom: St. Luke’s 1:1 laptop program for middle school students was the first of its kind in independent schools locally, and the school boasts two on-campus 3D printers.

GENEVA SCHOOL OF BOERNE Geneva School of Boerne has grown exponentially in 15 years. Founded in 1999 with 13 students, it will enroll 650 students in kindergarten through 12th grade in 201415. From the 32-acre campus’ small class sizes and its low student-teacher ratios to its unique curriculum, the co-educational school is able to meet its mission of providing a classical and Christian education. continued on page 36

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LIFESTYLE continued from page 35

“ C e r t a i n l y, smaller class sizes and a low student-toteacher ratio are benefits of a private education,” said Amy Metzger, faculty/ development director. But beyond small class sizes and curriculum specifically tailored to meet the school’s objectives, Geneva’s mission is to provide a classical and Christian education. Metzger said teachings come from a Biblical worldview –– a fearless Christian education style fueled by the belief that God is sovereign over all things, combined with classical methods and materials which give students a filter for determining what is good, beautiful and true. The school’s curriculum is based on the medieval philosophy of instruction called the Trivium, a Latin term that means “three roads” and refers to in-

36 San Antonio Medicine • June 2014

struction in grammar, logic and rhetoric. Geneva’s grammar school serves elementary students; its logic school serves middle school students and its rhetoric school serves high school students. Some examples of the unique curriculum include a chronological study of history and literature taught in tandem as opposed to a more traditional social studies and language arts curriculum, formal logic and rhetoric courses, required Latin instruction and senior thesis presentations.

KEYSTONE SCHOOL Tucked inside San Antonio’s historic Monte Vista neighborhood, Keystone School is a coeducational, independent school serving approximately 450 students in prekindergarten classes through 12th grade. Founded in 1948 to meet the intellectual needs of academically talented children and to reward them for scholastic distinction, Keystone focuses on a core curriculum, encouraging students to pursue knowledge, develop study habits and master skills useful to their future success. “Private schools have the ability to deter-

mine their own mission, curriculum, practices, programs and personnel,” said Brian Yager, head of school. “Private schools also can choose the students who attend, which allows for finding mission-appropriate students who can thrive in a given school’s framework.” Keystone School’s mission is to offer an accelerated curriculum to provide motivated students with a nationally recognized, well-rounded educational experience in a supportive, inclusive environment that encourages academic excellence, ethical growth, community involvement and responsible leadership. Essential to its mission are teachers skilled in fostering intellectual curiosity and critical thinking, small classes which encourage close relationships between faculty and students both inside and outside the classroom, and the ready availability of teachers and technology as resources.


Springtime matches, grand rounds update By Francisco González-Scarano, MD

This year’s Match Day took place at Floore’s Store in Helotes on March 21. Although I have participated in this ritual for several years, I always find it is a remarkable and generally joyous experience to watch the-soon-to-be new doctors receive their “matching orders” and find out where they’ll be spending the next few years. As often happens, this is also where they will spend part of their professional careers (in my case, about 35 years). We are happy to report that 102 of our students, or 48 percent of them, will be staying in Texas to train; 30 of those, or 14 percent, will be staying in the San Antonio area. Eighty-two of our graduates (39 percent) matched to primary care programs, which the Association of American Medical Colleges (AAMC) defines as family practice, internal medicine, Ob/Gyn or pediatrics. The young physicians who will be leaving Texas will be situated in institutions all over the country, including many of the elite training programs. Many of them will eventually return to the state, bringing additional vigor to our healthcare programs. Below are our graduating class’ 10 most popular matches by specialty. Internal medicine Anesthesiology Pediatrics Emergency medicine Family practice Psychiatry Orthopaedic surgery Radiology-Diagnostic Ob/Gyn Ophthalmology

31 28 22 18 17 16 12 12 11 7

Nationally, the AAMC estimates that 94 percent of graduating U.S. medical students matched through the program; most 38 San Antonio Medicine • June 2014

of the remainder were able to obtain residencies through the secondary system that has been in place for the past couple of years. However, many of them did not match in their preferred specialty, and the AAMC is concerned that with medical school enrollments increasing (both allopathic and osteopathic), there will be a serious mismatch in the years to come. The longstanding cap on residency positions will not help in this regard. Of the large states, Texas already has the lowest number of physicians per population, and as we all know, it is the fastestgrowing state, putting us in an unenviable catch-up position to adequately provide for our citizens.

WHITE COAT CEREMONY Turning our sight to the onset of the undergraduate medical educational experience, our White Coat Ceremony will take place the morning of July 20. This is a wonderful event for our incoming students, their families and the faculty, and is a relatively recent yet widespread national tradition. It reflects the emphasis on professional identity and professionalism that we imbue throughout our medical curriculum. The White Coat Ceremony takes place the day before orientation week, also a relatively recent development; the first day of classes is the following Monday, July 28. The White Coat Ceremony is open to the public, and alumni are always encouraged to attend. For more information, call the office of Student Affairs at 210-567-5656.

GRAND ROUNDS AND MORE For our faculty and community partners, we offer the most diverse and extensive Continuing Medical Education (CME) activities in the region. Grand rounds, courses, lectures and conferences take place every day of the week at the school. Below are select grand rounds and conferences that highlight the diverse offerings available at the school. The locations are mostly on the

UTHSCSA DEAN’S MESSAGE main campus in the medical center. Grand rounds typically last one hour and are held in the early morning; however, there also are some lunchtime and afternoon presentations and conferences.

Psychiatry Grand rounds are from 1:15 p.m. to 2:30 p.m. Tuesdays, September through May, School of Medicine building, room 409410L. Contact Tamarsha Johnson at 210-562-5401.

Arthroplasty Grand rounds are scheduled for 6 a.m. to 7 a.m. June 9, July 14, Aug. 14, Sept. 15, Oct. 13, Nov. 10, Dec. 12, School of Medicine building, room 409L. For information, email Marsha Guantello,

Family and Community Medicine Grand rounds are held year-round from 12:30 p.m. to 1:30 p.m. Fridays, School of Medicine building, room 309L. For information, call 567-4556.

Pediatrics for the Practitioner – CME Conference, June 13-15 Primary care physicians, advanced practice nurses, and other healthcare providers who treat children will want to consider this conference which offers information updates and skills training in endocrinology, dentistry, neurology, nutrition, otolaryngology, pulmonology, dermatology, neonatology, cardiology and medical ethics. The courses are led by guest faculty specializing in the fields of allergy and immunology, developmental pediatrics and infectious diseases.

Nephrology Grand rounds are held year-round from 4 p.m. to 6 p.m. Wednesdays, Dental School building, room 5.303T. Contact Julie Harris at 210-567-1767.

Neurology Grand rounds are held year-round from 8 a.m. to 9:30 a.m. Fridays, School of Medicine building, room 309L. For information, call 210-450-0500.

Ob/Gyn Grand rounds are from 12:30 p.m. to 1:30 p.m. Wednesdays, September through May, School of Medicine building, room 209L. Contact Michelle Lopez at 210-567-4930.

Orthopaedic Surgery Grand rounds are held year-round from 7 a.m. to 8 a.m. Mondays, School of Medicine building, room 409L. For information, call 210-567-5125.

Pediatrics Grand rounds are held year-round from 7:30 a.m. to 8:30 a.m. Fridays, School of Medicine building, room 409-410L. Contact Cindy Buecker at 210-567-4298.

Podiatry Grand rounds are held year-round from 6:30 a.m. to 8:30 a.m. Wednesdays, School of Medicine building, room 444B. For information, call 210-567-5174.

Geriatric and Palliative Care Intensive Review Course – Aug. 27-29 The course will feature short case based didactic presentations and the use of standardized patients for practice and small-group formats. Each of the three days will focus on building different skills: hands-on clinical encounters, specialty care and quality improvement processes. Participants will take advantage of close one on one mentoring and networking opportunities. There is an emphasis on communication techniques used among inter professional team members, families and patients in palliative care and geriatrics, as well as discussion on ethical and quality-of-care concerns related to palliative care and geriatrics. We have much more to offer in lecture format as well as online courses. The Office of Continuing Medical Education, which can be reached at 1-866-601-4448 or 210-567-4491, has more details, or visit Dr. Francisco GonzálezScarano is dean of the School of Medicine, vice president for medical affairs, professor of neurology, and the John P. Howe III, MD, Distinguished Chair in Health Policy at the University of Texas Health Science Center at San Antonio. His email address is

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The AFFORDABLE CARE ACT: A TAxing TAle, in five AcTs (And counTing) By Dana A. Forgione, PhD, CPA, CMA, CFE

The curtain is lifted, and Act One, Scene One, of the Patient Protection and Affordable Care Act (ACA) is under way. The saga is in five acts (at least so far) presented on the stage of legal and constitutional challenges. While the first was played out all the way to the Supreme Court, there are still the second, the third, the fourth, and now the fifth legal challenges — all still waiting in the wings and yet to take center stage. Somehow the legal challenges seem to revolve around taxes. Wasn’t it Shakespeare who said something about first getting rid of all the lawyers? I thought readers might appreciate a light review of the five major legal challenges to the ACA. They’re more than just a captivating soliloquy — they truly plumb the depths of some of our most basic beliefs and values. Act One, Scene Two: The first major legal challenge. You may recall that 28 states immediately filed petitions challenging the constitutionality of the individual mandate, the requirement that everyone in America buy health insurance. They also challenged the penalties as unlawful direct taxes, and the infringement on state sovereignty through mandated expansion of the state Medicaid programs. The actors included Alaska, Al-

40 San Antonio Medicine • June 2014

abama, Arizona, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, North Dakota, Nebraska, Nevada, Ohio, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Virginia, Washington, Wisconsin and Wyoming. Not a cast of thousands, but 56 percent of the states, and only 10 short of the three-quarter super-majority needed to ratify a constitutional amendment. It attracted an audience. There were also similar private lawsuits, played out in smaller venues, but we’ll stick with the greatest legal stage on Earth. The allegations were that the federal government has enumerated powers, e.g., the regulation of interstate commerce and the imposition of taxes. All other powers are reserved to the states and to the people. Enter, stage left: The administration, who argues that the individual mandate is lawful under the interstate commerce clause and the penalties are not a tax. Reply from stage right, by the plaintiffs: who argue that a person who simply does nothing, i.e., who declines to buy health insurance, is not participating in interstate commerce,

BUSINESS OF MEDICINE and therefore the Constitution confers no federal authority to compel them to purchase anything (notably, health insurance). Furthermore, the penalties are an unlawful direct tax. The Constitution allows for two types of taxes: those based on the value of something (e.g., a house, a car, earned income, etc.), and those based proportionately on the population (direct headtaxes). And since the ACA penalties are not assessed on either value or population, but rather on a decision to buy, or not buy, health insurance, they are thus an unlawful direct tax. Further, the mandated expansion of the state Medicaid programs violates state sovereignty and takes away state revenues from schools, law enforcement, pensions and other critically needed public services. The House of Representatives carried out a symbolic vote to repeal the ACA. Two court decisions upheld it, and three opposed it — all generally along partisan lines, although the most recent court decision against the ACA was handed down by a judge who was of the party supporting the law. Then 45 state legislatures filed more than 200 measures opposing elements of the health reforms, or proposing alternatives. The economic meltdown had the states financially strapped. They could not pay their pensions, and the state and local government worker layoffs were the largest contributors to new unemployment claims nationwide. The greatest legal stage on Earth, the U.S. Supreme Court ruled in June 2012 to uphold most of the ACA, including the individual mandate, but under Congressional taxation power, not the interstate commerce clause. The court defined the penalties as a tax, struck down the state Medicaid expansion mandate as a violation of state sovereignty, and allowed states to opt-out of the Medicaid expansion with no reduction of other federal funding. In a surprise twist, the ruling held that because the penalties did not comply with the Constitutional requirements for a direct tax, they were therefore a lawful tax! The four conservative justices (voting against the law), and the four liberal justices (voting for the law), all disagreed with the Chief Justice’s conclusions about the tax. In a complete upset and surprise ending for the audience of all stripes, the conservative chief justice joined with the liberal contingent and tipped the vote five to four in favor of the law. The critics and commentators haven’t stopped talking since.

ACT TWO Act Two. Only 14 states opted to run their own health in-

surance exchanges under the ACA. The other 36 are either federal or joint federal-and-state-run exchanges (25 are federalonly and 11 are federal-state operations). Enter, stage right: Three states and the District of Columbia issue a second legal challenge (Oklahoma, Indiana, Virginia, and DC). They argue that everything in the ACA states that subsidies, tax credits and penalties are made through an exchange “established by the state.” When the Internal Revenue Service issued a tax ruling that the ACA provisions for the states also extend to exchanges established by the federal government, the IRS exceeded its authority and had no statutory basis in the ACA for the ruling. If the challenge is upheld, the 36 federal exchanges would not be able to offer subsidies, tax credits or impose penalties, which would eliminate the employer mandate, and since the penalties only apply if one employee enrolls in a “subsidized” plan through an exchange, it eliminates the individual mandate because penalties can’t be imposed for failure to buy insurance where the subsidy is not available. The first judicial ruling denied the administration’s motion to dismiss the challenge and allowed the case to proceed. The challenge has not yet exhausted its legal stages, and the judicial rulings will likely follow partisan lines, as with the first legal challenge.

ACT THREE Act Three. Enter, stage right: Eleven of the state attorneys general challenge the many ACA delays, exceptions and overrides as “illegal” (Alabama, Georgia, Idaho, Kansas, Louisiana, Michigan, Nebraska, Oklahoma, Texas, Virginia, West Virginia). They argue that the repeated changes to the ACA have no statutory authority, that the president exceeded his authority in implementing changes without Congressional law changes, and that the states were being asked to violate the federal ACA law that was upheld by the Supreme Court. They may pursue state, rather than federal, court venues. You must select your audience strategically.

ACT FOUR Act Four. Enter, stage right: The Catholic Church and several private business owners separately challenge the ACA, arguing that their nonprofit or for-profit organizations are entitled to the same religions protections as the individuals who own or operate them; and that the ACA requirement for coverage of abortifaciant drugs and devices is a violation of concontinued on page 42 visit us at


BUSINESS OF MEDICINE continued from page 41

science and religious beliefs. The church-related challenge is wending its way through the lower court venues. The for-profit related challenge is set for the greatest stage on Earth. With one win and one loss, the stage for the final act is set.

ACT FIVE Act Five. Enter, stage right: A Mister Sissel argues that, since the Supreme Court ruled the ACA penalties are a lawful tax, the ACA violates the “origination clause.” All tax bills must originate in the House of Representatives, not the Senate. The ACA was cited as a “bill for raising revenue,” the tax is imposed directly through Internal Revenue Code, it raises billions of dollars in general revenues for the U.S. Treasury, and the Congress can spend the tax revenue for any purpose. Enter, stage left: The administration argues that the Senate’s ACA bill was merely an “amendment” to H.R. 3590, and therefore it originated in the house. Enter, stage right: Counsel for Mr. Sissel argues that H.R. 3590 was not a revenue-raising bill, the Senate completely replaced the text of H.R. 3590 with new text on totally unrelated matters, that H.R. 3590 provided tax credits to first-time

42 San Antonio Medicine • June 2014

homebuyers while the ACA overhauls the health-insurance market. Finally, if the ACA is an “amendment” to H.R. 3590, then anything would be an amendment. The District Court of Washington, DC, dismissed the challenge. The judge was an appointee of the administration supporting the ACA. The plaintiff appealed, and again, the judicial rulings will likely follow partisan lines, as with the previous challenges. What will be the end of the story? Will the ACA stand, or fall? Could the curtain even come down this far into the production? Will there be more challenges? Be sure to watch for the next scene of the ACA: A Taxing Tale. Dana A. Forgione, PhD, 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.


Risk stratification to prevent readmissions By Vince Fonseca, MD, MPH, FACPM

The recent report, “Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011,” released by the Agency for Healthcare Research and Quality (AHRQ) in April 2014, provides an overview of the scope of this issue in the United States. In 2011, there were about 3.3 million adult hospital readmissions with about $41.3 billion in hospital costs. Readmissions in this study were “defined as a subsequent hospital admission within 30 days following an original admission (or index stay).” Although most attention for preventing readmissions is in the Medicare population for heart failure, pneumonia and myocardial infarction, a community is impacted by readmissions across all ages and insurance categories. We have discussed the CMS Hospital Readmissions Reduction Program and a general overview of an approach to the after-hospital care plan of AHRQ's Re-Engineering Discharge (RED) Toolkit in previous articles in San Antonio Medicine. This article will cover an approach to tailor readmission planning and services based on risk stratification. The risk can be based on comorbid medical conditions or on socio-demographic issues. First, let's review the overall readmission data. Table 1 shows that although age is important (Medicare patients have the highest readmission rate) there are large differences in the readmission rates for the 18- to 64-year-old group with the privately insured at 8.7 percent, uninsured at 10.6 percent and 14.6 percent for Medicaid.

Table 1 Group

% of all % of all readmission rate readmissions readmission costs (per 100 admissions) Medicare (65+ years) 55.9 58.2 17.2 Medicaid (18 to 64 years) 20.6 18.4 14.6 Privately insured (18 to 64 years) 18.6 19.6 8.7 Uninsured (18 to 64 years) 4.9 3.7 10.6

Table 2 shows the most common clinical conditions for readmission by insurance category and also allows comparison of rates across insurance categories. The different patient populations have different outcomes in terms of clinical conditions and readmission rates. In order to prevent readmissions we would need to know what factors put patients at higher risk and who is more likely to need different types and intensity of services in their after-hospital care plan.

Table 2 Condition-specific readmission rate by insurance group (*not in the most common list) Index hospital stay* Mood disorder

Medicare Medicaid * 19.8

Private Uninsured 10.4 12.7

Index hospital stay* Medicare Medicaid Alcohol-related disorders * 26.1 Diabetes mellitus with complications * 26.6 Congestive heart failure 24.5 30.4 21.3 23.8 Septicemia (except in labor) Pancreatic disorders (not diabetes) * * Schizophrenia and other psychotic disorders * 24.9 COPD and bronchiectasis 21.5 25.2 Acute myocardial infarction 19.8 * Pneumonia 17.9 *

Private Uninsured * 16 14.9 * 15.4 13.8

14.7 16.8

* * * *

15.4 * 9.6 *


The complexity of the patient drives the readmission risk. Patients can be clinically complex, socio-demographically complex, or both.

Socio-demographically complex patients’ risk factors include Personal factors: • Poverty – Low income and/or no liquid assets • Low levels of formal education, literacy or health literacy • Institutional mistrust • Limited English proficiency • History of adverse childhood experiences or other toxic experiences (e.g., violence) • Minimal or no social support -- not married, living alone, no help available for essential health-related tasks; and Place factors: • Poor living conditions – homeless, no heat or air conditioning in home or apartment, unsanitary home environment, high risk of crime • Few community resources – social support programs, public transportation, retail outlets • Physical environment: air pollution, noise. Clinically complex patient factors include: • Functional deficit or disability (e.g., dementia) • Severe primary condition (e.g., severe heart failure, metastatic cancer, end-stage renal disease) • Multiple chronic conditions • Concurrent mental and physical health problems • Concurrent substance abuse and physical health problems • Disease affects multiple organ systems • Condition requires treatment by multiple providers and/or specialized sites of care. continued on page 44 visit us at


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HASA continued from page 43

The risk adjustment algorithms that CMS uses to adjust in the Hospital Readmissions Reduction Program include only clinically complex factors (e.g., comorbid arrhythmia, COPD, or renal failure). There are about 50 variables in the algorithms, but the algorithm is run retrospectively in order to compare a hospital’s readmission rate to others or the national rate. It would be good to know the patient’s clinical complexity as the afterhospital care is being planned. HASAFacts could be the portal that allows the discharge planning team to review the patient’s clinical complexity using the variables that CMS uses. The patient’s past diagnostic history could be used to stratify clinical complexity because the patient’s past discharges and some outpatient data are available in HASA. Although most of the socio-demographic complexity factors are not currently in EHR systems and therefore not in HASA, one is: patient address. This can be a starting point for housing instability (frequent address changes) and for place risk factors. Adding an assessment for the discharge planning team for other socio-demographic complexity factors to the clinically complex factors from HASAFacts will allow a more tailored after-hospital care plan to decrease readmissions and a healthier community. Vince Fonseca, MD, MPH, FACPM, is the director of medical informatics at Intellica Corp., and the medical advisor for Healthcare Access San Antonio (HASA), the local Health Information Exchange (HIE) provider authorized by the state of Texas to create a communitybased, regionwide HIE in Bexar County and 22 surrounding counties. Visit

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TEXAS FARM CREDIT Tiffany Nelson, 210-798-6280

PRIMEDICUS CONSULTING INC. Sally Combest MD, 210-673-9455 Rebecca Orton, 210-673-9455

THE GROWTH COACH Kay Wakeham, 210-492-2400

BROADWAY BANK Ken Herring, 210-283-4026 COMMERCIAL & MEDICAL CREDIT SERVICES Henry Miranda, 210-340-9515 CONCORDIS PRACTICE MANAGEMENT LLC Dina Petrutsas, 210-825-6505 CORPORATE CATERERS Ricardo Flores 210-789-9009

MAXIMUM EXPOSURE MARKETING Janis Maxymof, 210-413-9731 MED MT INC. Ray Branson, 210-446-7569 NATIONWIDE INSURANCE Joel Gonzales, 210-275-3595 NEWMARK GRUBB KNIGHT FRANK Darian Padua, 210-804-4841 NORTHWESTERN MUTUAL Eric Kala, 210-446-5755

COX, SMITH & MATTHEWS INC. Dan Webster, 210-554-5253 DAVID JOHNSON CO. David Johnson, 210-492-1998

PHISKAL LLC MARKETING Sundeep Sadheura, 210-865-4520



REACH YOUR TARGET MARKET Are you trying to reach the 4,400 physician-members of BCMS with your business message? Consider joining the BCMS Circle of Friends program, which provides a unique opportunity for business leaders to network and communicate with physicians through a variety of BCMS-sponsored events and services. By helping to underwrite society events, Circle of Friends members help fund BCMS’ mission of enhancing the practice of medicine for healthcare providers and Bexar County residents.

For more information, contact August C. Trevino at 210-301-4366, email him at, or visit BCMS does not endorse businesses and involves itself only in services and programs that benefit members and their patients.

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46 San Antonio Medicine • June 2014

Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Acura 11911 IH-10 West

* Fernandez Honda 8015 IH-35 South

* North Park Lincoln/ Mercury 9207 San Pedro Ave.

Porsche Center 9455 IH-10 West

Gunn Honda 14610 IH-10 West (@ Loop 1604) Ancira Chrysler 10807 IH-10 West Cavender Audi 15447 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ancira Ram 10807 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

Ancira Dodge 10807 IH-10 West BMW of San Antonio 8434 Airport Blvd.

Ingram Park Auto Center 7000 NW Loop 410

Mercedes-Benz of Boerne 31445 IH-10 W, Boerne Ancira Jeep 10807 IH-10 West

Ancira Elite Motorcars 10835 IH-10 West

Mercedes-Benz of San Antonio 9600 San Pedro Ave.

Ingram Park Auto Center 7000 NW Loop 410 Cavender Toyota 5730 NW Loop 410

Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604) Northside Ford 12300 San Pedro Ave.

North Park Subaru 9807 San Pedro Ave.

Ancira Kia 6125 Bandera Road

* Mini Cooper The BMW Center 8434 Airport Blvd.

* Ancira Volkswagen 5125 Bandera Rd.

Batchelor Cadillac 11001 IH-10 at Huebner Cavendar Cadillac 801 Broadway

Cavender GMC 17811 San Pedro Ave.

* North Park Lexus 611 Lockhill Selma

Ingram Park Nissan 7000 NW Loop 410

* The Volvo Center 1326 NE Loop 410

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BMW 535d turbo diesel proves conformity can be a good thing By Steve Schutz, MD

Once when I was about 14 years old, I was walking home from somewhere when a man driving a BMW 530i sedan stopped to offer me a ride. As it turned out, I knew his son, so I gratefully accepted, and by the time he dropped me off at my house I had decided that I wanted a BMW when I was older. The “fűnfer,” as the BMW 5-series is known in Germany, was first introduced here in 1974. The one I rode in had a manual transmission, and I was struck by how completely different this sedan was from any other car I had ever ridden in before. 48 San Antonio Medicine • June 2014

It was elegant and sporty, and as unlike the floaty Cadillac/Lincoln kind of automotive luxury of the time as it could be.

GRADUAL HOMOGENIZATION It occurred to me as I tested the 2014 535d turbo diesel that the days of national differences among luxury sedans are mostly over. While 30 years ago you could ride in a Mercedes or Cadillac blindfolded and immediately know which was which, that’s no longer true. In fact, I’d bet that anyone riding in the passenger seat of a new BMW 5series, Jaguar XF, or Cadillac CTS would

be hard pressed to tell the difference without looking. What has 30 years of gradual homogenization in luxury cars gotten us? Better cars, for one thing. Cars that are now built to last like Japanese cars, drive and handle well like German cars, and are roomy with a sense of style like American cars. On to the 535d. For comfort and safety rating reasons, the 2014 5-series is larger than it used to be. While the last fűnfer was 191 inches long with a 114-inch wheelbase, the new one is 193.1 inches long with a 117-inch wheelbase. That expansion gets

AUTO REVIEW German companies sell diesel-powered cars and SUVs in this country. The 5’s exterior design is more mainstream than its controversial predecessor’s was. Gone are the sharp edges and strange cut lines of the E60 5-series that so many of the BMW faithful found irritating, replaced by reassuring curves and smooth contours. It’s an attractive look that quietly reflects a sense of life success.


you more passenger space as well as a bigger trunk, but at 4,050 pounds the new model is also heavier than the previous version. The 535d’s interior is luxurious, as you’d expect. The materials look and feel rich, and the seats both front and rear are very comfortable. There’s more high tech, too, and BMW’s iDrive system has been improved (again). I’ve experienced most iterations of the iDrive since its debut almost 15 years ago, and I’ve applauded every improvement along the way. The latest version with six buttons around the central knob and a larger, more attractive screen is my favorite. It now enhances the driving experience. The adjective “refined” describes the experience of driving all BMWs, and the 535d is certainly that. However, as I noted in my review of the 535i, the new 5-er is less athletic than it was, like we all are if we put on some weight. Surprisingly, the 3.0-liter turbo diesel engine that propels the 535d adds to rather than subtracts from the 5’s athleticism. Not

only does the 535d go from zero to 60 faster than its gas-powered 535i sibling -5.6 seconds versus 5.7 -- but it pulls stronger from a stop thanks to an eye-popping 413 ft-lbs of torque. We all talk about horsepower, but it’s torque that gets the job of accelerating done, and diesel engines all have lots of torque. For the record, modern diesel powerplants are nothing like the nasty polluting engines we all remember from the 1980s. Thanks to low-sulphur fuel, lots of engineering advances, and urea exhaust traps, today’s diesels are environmentally conscious, emitting similar levels of standard pollutants and less CO2 than their gasoline-powered counterparts. They’re quiet, too, with virtually no diesel clatter. The 535d’s EPA numbers are an impressive 26 mpg city, 38 mpg highway, which is quite something given that 5.6-second zero to 60 time. As a side note, the availability of diesel engines represents an exception to my car homogenization thought. For now, only

As is generally the case for German cars, the 535d can be had with an almost limitless variety of options and option packages. Interested readers are encouraged to call Phil Hornbeak at 210-301-4367 for details about availability and pricing. While the 535d starts at just over $57,000, expect transaction prices to average around $65,000 to $70,000. Vehicle homogenization is a fact of modern life, and cars like the BMW 5-series are a reminder that conformity can be a good thing. The 535d is a stylish and comfortable conveyance that is sure to be popular with successful men and women of all stripes, and the diesel engine is a delightful difference-maker that shows that the total obliteration of national differences hasn’t happened yet. (By the way, yes, that formerly 14-year-old boy now owns a BMW.) Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. For more information on the BCMS Auto Program, call Phil Hornbeak at 3014367 or visit visit us at



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50 San Antonio Medicine • June 2014

San Antonio Medicine Magazine June 2014  

Bexar County Medical Society Monthly publication.

San Antonio Medicine Magazine June 2014  

Bexar County Medical Society Monthly publication.