San Antonio Medicine October 2016

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VOLUME 69 NO. 10

Women in Medicine

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Women in Medicine

Say Yes — How to have a successful medical career regardless of gender

By Col. Gianna Zeh, Vice Comander, AF Medical Operations Agency ...........................18

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

Advice for Women entering the Medical Field — Go for it! A Q&A with Dr. Leah Jacobson, president-elect of the Bexar County Medical Society ....................................................................................22

BCMS President’s Message ...........................................................................................................8 BCMS News..................................................................................................................................10 BCMS Legislative News................................................................................................................12 BCMS General Membership Meeting and Events...................................................................................24 Feature: My Buddy the Apiarist by Fred H. Olin, MD ..............................................................................26 In Real Time: Part 3 by Rajam Ramamurthy, MD. ...................................................................................28 Book Review: Morgue — A Life in Death by Dr. Vincent Di Maio and Ron Franscell reviewed by Fred H. Olin, MD ..............................................................................................................30 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................31 Business of Medicine: The ACA Exchanges and Adverse Risk Selection

by Dana A. Forgione, PhD, CPA, CMA, CFE ........................................................................................34 Financial: When the IRS comes knocking... by Bennett Allison, CPA, Shareholder................................36 BCMS Circle of Friends Services Directory .............................................................................................37 BCMS Auto Program ...............................................................................................................................43 Auto Review: 2017 BMW 750i by Steve Schutz, MD .............................................................................44

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4 San Antonio Medicine • October 2016

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VOLUME 69 NO. 10

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org

Paving Paths for Healthcare Careers through Mentoring By Carly Friedman, PhD and Lori Boies, PhD .....................................................20

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Elizabeth Blackwell — First Woman Doctor in the United States

By Jaime Pankowsky, MD ....................................14

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BOARD OF DIRECTORS

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

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

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director Alice Sutton, Controller

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

6 San Antonio Medicine • October 2016

PRESIDENT’S MESSAGE

Vaccines Protect Children, Families, and the Community

By Dr. Jayesh Shah, 2016 BCMS President

A recent article in the San Antonio Express-News re-

cerning that an elected official in Bexar County would

stir in our city. Parents naturally want to protect their

when, by so doing, he encourages parents to not vacci-

garding the safety of vaccines for children has created a

promote inaccuracies regarding the safety of vaccines

children and keep them healthy. Vaccines were devel-

nate their children. Doing so may jeopardize the health

cause great pain and suffering, birth defects, and even

medically fragile — those whose health may depend on

oped to protect children and adults from diseases that death. However, when an illness or disability strikes a

child, parents want answers and look for causes.

As physicians, we recognize the tremendous impor-

and well-being of not only our young, but our aged, and the widespread use of vaccination.

Dealing with autism or any chronic medical condition

in a family can be painful, and signing onto conspiracy

tance of vaccines. Vaccines keep our children and fam-

theories can be tempting when parents seek answers.

and protect our public’s safety. We know that vaccines

should consult with the medical community and not ap-

ilies healthy, prevent harmful communicable diseases,

are incredibly effective. Widespread measles vaccina-

That said, Bexar County elected or appointed leaders

pear to represent themselves as speaking on behalf of the

tion has led to an over 99% reduction in cases of this

city or county on such matters. Our county needs lead-

ease. Use of the whooping cough vaccine has resulted

Such leadership must have a clear understanding of the

highly infectious and potentially life-threatening dis-

ership to address the unique health challenges we face.

in a greater than 80% decrease in pertussis cases. Polio

tenets of public health and prevention that keep our

also know that vaccines are safe. Research reported

effective vaccination is one such tenet.

has nearly been entirely eradicated from our world. We from trusted scientific bodies including the Centers for

Disease Control & Prevention, the Institute of Medicine, and the American Academy of Pediatrics proves

county healthy and safe. The widespread use of safe and The Op. Ed above, which was published in San Anto-

nio Express-News on Wednesday, Sept. 7, 2016, was de-

this to be true. To be clear, there is no scientific link

veloped as a group effort with the Legislative/

ules, and autism spectrum disorders. To state that a link

BCMS Executive committee and TMA. Special thank

between vaccines, vaccine ingredients, vaccine sched-

Socioeconomics, Public Health committee members,

exists is factually inaccurate.

you to Mary Nava, Dr. John Nava, and Dr. Ryan Van

of infectious disease is ever present, therefore, it is con-

opinion piece for the San Antonio Express-News.

San Antonio is an international city where the threat

8 San Antonio Medicine • October 2016

Ramshorst for helping us formulate a quick response and

BCMS NEWS

OuTSTaNDINg TEaChINg awaRD Congratulations to Dr. K. Ashok Kumar for receiving the 2016 Regents' Outstanding Teaching Award from the University of Texas System Board of Regents. The award is presented annually to faculty members of the UT System who have demonstrated demonstrated extraordinary classroom performance and innovation in undergraduate instruction.

"I love seeing my learners master and apply new knowledge while caring for patients," Dr. Kumar said. "Medical education with compassion and respect is my vision. To me, education is more than acquiring knowledge, skills, and attitudes: It also involves developing the whole person to become a well-rounded clinician."

10 San Antonio Medicine • October 2016

BCMS LEGISLATIVE NEWS

BCMS LEgISLaTIVE aND SOCIOECONOMICS COMMITTEE CONTINuES wORk TO pREpaRE FOR LEgISLaTIVE SESSION The BCMS Legislative and Socioeconomics Committee held their monthly meeting on Aug. 24 to continue working on plans for the upcoming legislative session, which kicks off in January 2017. Among the topics discussed were the committee goals and strategic plan for the committee going forward. Some of the highlights included: having continued visits with each of our state representatives and state senators to discuss issues of importance to medicine and establishing key physician contacts by legislative district to lead discussions with our elected officials as opportunities arise and in preparation for the First Tuesdays visits to the Capitol.

For local discussion on these and other legislative advocacy topics, consider joining the Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

Top — Members of the BCMS Legislative and Socioeconomics Committee held their monthly meeting on Aug. 24 at the Society headquarters.

Middle — (l-r) Drs. Manuel Ybarra, Alex Kenton and John Menchaca visit with Rep. Justin Rodriguez (House Dist. 125) at the Society headquarters on Aug. 31.

Bottom — (l-r) Drs. Ryan Van Ramshorst and John Holcomb visit with Rep. Rick Galindo (Dist. 117) at the BCMS headquarters on Sept. 7.

12 San Antonio Medicine • October 2016

WOMEN IN MEDICINE

Elizabeth Blackwell

First Woman Doctor in the United States

By Jaime Pankowsky, MD Throughout history, women had taken care of sick people and

for treating sick people. She also took care of pregnant women and

provided childbirth care as midwives, but never as trained or licensed

described in detail the childbirth care they received. But other than

physicians until well into the 19th Century. Nuns usually admin-

midwifery, later centuries saw very little participation of women in

istered hospitals and hospices during the Middle Ages and the Ren-

the medical profession.

aissance, but they were concerned mostly with the salvation of the

By the 18th and early 19th Century, young women were discour-

patients’ souls in view of the lack of medical knowledge to help cur-

aged, and sometimes flatly forbidden, to learn medicine or any other

ing diseases.

scientific endeavor for that matter. The so called reason? It was be-

In the 13th Century, Hildegard of Bingen in Germany, a nun and

lieved that women who studied sciences in general and medicine in

later abbess of her convent, developed recipes and formulas of herbs

particular, caused the blood that should go their uterii to detour to

14 San Antonio Medicine • October 2016

WOMEN IN MEDICINE their brain. This, it was alleged, would render them sterile, hysterical and prone to suffering fainting spells.

Elizabeth Blackwell was born in 1821 in Bristol, England, one of nine children born to Samuel and Hannah Blackwell. In 1832, the family moved to New York. Elizabeth became interested in various religious denominations and became active in the abolitionist movement. A few years later the family moved to Cincinnati, Ohio. But shortly thereafter, the family business of sugar refinement went into bankruptcy and Elizabeth’s father died. This forced Elizabeth and her sisters to engag in tutoring children. Eventually, she obtained lodging with a doctor in North Carolina who allowed her to look at and study his medical books. Later, she moved to Philadelphia to improve her chances of enrolling in a medical school. Repeated applications were rejected on account of her gender and the belief that a woman’s intellect was inferior to that of a man.

In October 1847, Elizabeth’s luck changed due to what might be considered an accident or a joke. Geneva Medical

her left eye became contaminated and developed a severe infection,

School (now Hobart College) in upstate New York, was in a situa-

which led, eventually, to the surgical removal of her left eye. This

tion of disagreement between the dean, the faculty and the student

loss foreclosed for her the possibility of being admitted for surgical

body. One of the issues in question was Elizabeth Blackwell s appli-

training, which she was hoping to receive in Europe.

cation. The faculty and the dean could not decide whether to admit

By 1854, she was back in the United States and again found it

her or not. They turned the decision over to the student body, with

difficult to develop a medical practice, probably due to the belief

the proviso that if a single student opposed her admission, her ap-

that women doctors were often abortionists. In New York she

plication would be rejected. The student body, to embarrass the dean

founded a clinic to treat indigent women. To aid in the work, she

and as a “joke,” approved her admission by unanimity.

took under her sponsorship a young German immigrant wanting

At school, Elizabeth’s efforts were directed first toward orienting

to pursue a medical career. Her name was Marie Zarkszewski. Even-

herself in this unfamiliar environment without sympathy for her sit-

tually, Marie became the second woman in this country to obtain a

uation, and then toward the study of the subjects required in the

medical degree. The two doctors were soon joined by Elizabeth s

curriculum. She rejected all suitors and had few or no friends. She

younger sister, Emily, who was the third woman to obtain a medical

graduated in 1849 and, aware of her limitations, decide to go to Eu-

degree in the United States. The three of them founded the Infir-

rope to advance her medical knowledge and experience. It was cus-

mary for Indigent Women and Children in New York, which by

tomary for all American doctors who could afford it, to do so then.

now had gained public support, including that of the newspaper

France, Germany and England were the most common destinations.

“The New York Tribune.”

In England, she was confronted by the usual wall of rejections due

Elizabeth continued to be involved in other social issues and sup-

to her gender. In Paris, she finally gained admission to the Maternite

ported the abolition of slavery. During the Civil War, in conjunction

Hospital, where she was well recognized and appreciated. Unfortu-

with Dorothy Dix, she helped to train nurses for the Union Army s

nately, while taking care of an infant with ophtalmia neonatorum,

continued on page 16 visit us at www.bcms.org

15

WOMEN IN MEDICINE continued from page 15

field hospitals. She actively supported women s rights, family plan-

prevented vivisection in the Woman s Medical School established

ning and what she called Christian socialism. She was anti-vivisec-

in London by her and Dr. Jex-Blake whom she had helped train.

tionist. She also mentored and helped other women physicians,

Nevertheless, Dr. Blackwell was one of the pioneer women doctors

including Elizabeth Garrett Anderson, the first woman doctor in

who in the 19th Century tore down barriers to women s education

England and others in the United States.

in sciences. With her on the front line were Elizabeth Garrett An-

Eventually she left the practice of medicine to dedicate herself

derson in England and Sophie Jex-Blake. One should also mention

to writing papers, books and thesis on the different causes that

James Miranda Barry, who was born a woman but lived all her life

she supported. She traveled extensively and kept correspondence

posing as a man, only being discovered at autopsy after her death.

with a number of people. In spite of all this, she had few close

Today, it is estimated that 50 percent of physicians in the

friends. She was often critical of other people’s work, like those

United Kingdom are women. Probably, the same estimate applies,

of Florence Nightingale, her past associate, Marie Zarkszewsi and

or will soon apply, to the United States as well. To the best of our

even her sister Emily.

knowledge, they are able to have all the babies they wish to have,

In 1856, she adopted an Irish orphan, Kitty Barry, who became a

showing that her studying medicine did not damage their uterii.

household companion, part daughter, part servant, who stayed with

And of course they do not get hysterical even when told a bad

her until her death in 1910 in England. Kitty died in 1930 and re-

joke and they are not prone to fainting spells. So much for con-

quested her ashes to be buried alongside Elizabeth Blackwell s tomb.

ventional wisdom.

Dr. Blackwell was strong-willed and at times uncompromising to an extreme. She never accepted the fact that diseases could be caused by bacteria, declaring they were spiritual failures instead. She also

16 San Antonio Medicine • October 2016

Dr. Jaime Pankowsky, MD is a general surgeon in San Antonio and a member of the BCMS Communications Committee.

WOMEN IN MEDICINE

Say

YES

How to have a successful medical career regardless of gender

By Col. Gianna Zeh, Vice Commander, AF Medical Operations Agency

18 San Antonio Medicine • October 2016

WOMEN IN MEDICINE

If someone had told me when I graduated from college that by the age of 50 I would have been Chief of the Medical Staff at three

my best. A positive attitude and a lifelong passion for learning, I believe, are keys to a successful medical leadership career.

separate facilities, CEO of a 55-bed community hospital in

Sandberg has one more point that I want to share and that is

Florida and then command the largest Level 1 trauma center in

“make your partner a real partner.” I am where I am today be-

Afghanistan, I would have found this quite curious.

cause of the incredible support of my husband. I recently returned

I was asked to write an article to support the month of October

in March 2016 after a 12-month deployment to Afghanistan and

theme: Female Leaders in Medicine. If there is one message I

instead of just surviving, my husband approached the year as op-

would like to share it is simply that there are so many opportuni-

portunities for thriving. The whole family, including our two sons,

ties to lead and that it doesn’t matter if you are male or female.

took on new challenges and at the end we grew academically,

Say yes.

physically, socially, professionally and spiritually. It turned out to

My name is Gianna Zeh and I have had the privilege of being

be one of the best years ever. As the Task Force Medical

a pediatrician in the United States Air Force for 23 years. Every

Afghanistan Commander as well as Commander of Craig Joint

assignment I have had in the Air Force has been my favorite job.

Theater Hospital at Bagram Airfield, I had the privilege of leading

I completed my pediatric residency here in San Antonio from

all medical forces in eight separate operation locations throughout

Wilford Hall Medical Center in 1996. I love being a pediatrician

Afghanistan. We provided trauma response and theater aeromed-

and I found myself heading to Mountain Home Air Force Base

ical evacuation for all U.S. and coalition forces.

in Idaho to practice following graduation.

Presently, I’m assigned as the vice commander of Air Force

Serving my patients became my passion. I wanted my patients

Medical Operations Agency at Joint Base San Antonio-Lack-

to trust me and to know that I was there for them. Continuity of

land, Texas. We implement Air Force Medical Service (AFMS)

care was very important to me. My asthma patients knew that if

policies and procedures in support of 2.6 million beneficiaries

they were having an exacerbation I would walk them in or meet

in 76 Military Treatment Facilities world-wide. What excites me

them in the ER anytime.

most about my current position is to be walking the journey of

Pediatrics was not my only love. I met and married my husband

Trusted Care. We are building and sustaining a high reliability

in Idaho who also was serving in the Air Force. Our journey as

organization with a goal of zero harm. Lt. Gen. Mark A. Ediger,

joint spouses began; meaning the military would try to locate us

USAF Surgeon General, is quoted as saying “those we serve de-

together but mission took priority. This is relevant because I didn’t

serve the very best.”

map my career path. Opportunities in the form of jobs were pre-

What inspires me to get up every morning is this quote in com-

sented to me and I said YES because keeping our family together

bination with a patient’s perspective on reliability: don’t harm me,

was the most important priority. Sheryl Sandberg describes this

heal me and be nice to me. I believe the foundation of this pa-

idea in her book Lean In: Women, Work and the Will to Lead.

tient’s perspective is trust and their trust is an incredible privilege.

Don’t turn down leadership opportunities early in your career be-

Our profession has work to do and I am up for the challenge and

cause you are too busy or it isn’t the right timing for your family

opportunity to reduce preventable harm. To bring about this cul-

and children. Sandberg states that you should find your seat at

tural change of Trusted Care the AFMS is focusing on four do-

the table and “don’t leave before you leave.” However the oppor-

mains: leader engagement, continuous process improvement,

tunities were presented to me, I never said no. I never said I don’t

patient safety and the patient experience. I’m excited for this next

have the skill set. My approach was always to determine what I

level of leadership and appreciate the opportunity to share my

needed to learn to accomplish the mission and to always give it

journey with you.

visit us at www.bcms.org

19

WOMEN IN MEDICINE

Pathologist Dr. David Henkes mentors St. Mary’s medical student Bettina Babu as they view slides together.

paving paths for healthcare Careers through Mentoring

By Carly Friedman, PhD and Lori Boies, PhD

As healthcare professionals know, the path from being an undergraduate student to practicing in the field of interest is not easy and the guidance mentors can offer is invaluable. To be successful, students need to be confident that they are choosing a career that matches their strengths and interests. Therefore, they need to be aware of the true nature of healthcare careers, including paperwork, running a business, long hours, and patient care. It is also crucial that students are personally invested and highly motivated in their education. Shadowing a health professional can aide students in both of these areas.

20 San Antonio Medicine • October 2016

Spending time with a health professional in his or her daily routine reveals to students what being a healthcare professional truly entails. Students are often exposed to patient care in a range of different settings and fields, which can allow them to explore their career options and choose one that is truly best suited for them. Also, shadowing is the only way for students to experience interactions with patients from the healthcare professional’s perspective. This can instill in students a respect for patient care that serves as motivation through the years of schooling.

St. Mary’s University is committed to ensuring that interested and

WOMEN IN MEDICINE

qualified pre-health profession students are able to take part in these important experiences. As a result, the biological sciences department developed a semester-long “Preceptorship in the Health Professions” course targeted to sophomore-level students. Many BCMS physicians currently play an active role in mentoring our undergraduate students, including St. Mary’s alum Dr. David Henkes.

When asked how he felt that this course changed the experience of a St. Mary’s student, Dr. Henkes responded, “Shadowing is an important step in investigating a medical career and I applaud my alma mater for giving students the opportunity to achieve this in a deliberate, structured manner. Students can better determine hands on if medicine is their passion or not; and if so, what aspects of medicine appeal to them most. I think St. Mary’s is progressive in incorporating this into curriculum and I suspect it is a popular course.”

Students who participated in the course in the Spring 2016 semester mirrored these feelings, such as Junior Stephen Braden: “Matriculation into healthcare universities, currently and exponentially, continues to be a proven challenge. A favorable requirement of these schools is shadowing and interning. Through the St. Mary’s University internship program, I was blessed with the opportunity to intern with a physician for the San Antonio Spurs. Additionally, this phenomenal program counted as an upper biology elective, but more importantly presented educated discussions and further research into current medical developments. This program is unique and a great way to immerse yourself in various medical fields with accomplished professionals.”

Interested students applied to the course and were interviewed concerning their interests and commitment to the course. The thirteen students who were selected in Spring 2016 received HIPAA and OSHA certifications and were matched with a mentor who most closely practiced in the student’s specialty interest. During the semester, students spent at least 40 hours assisting their mentors and learning about current healthcare laws, ethics, and common practices on what makes a good physician. Below are quotes from students that demonstrate the impact these experiences have had: “The class was a great experience! I didn’t realize how important it is to shadow a doctor. It opens your mind to different environments and medical careers. The most important thing I learned working with my mentor was that patient don’t care how much you know about medicine until you show them how much you care.” — Junior Ana Garcia “I loved meeting with Dr. Diaz-Murphy every week. She has taught

me so much about the dental field. I believe this will help me tremendously with my career path. I believe that her and I have built up a good relationship for me to be able to ask her for a recommendation letter for dental school. She has reassured me that dentistry is exactly what I want to do.” — Junior Cassandra Garcia “”Being able to participate in the medical preceptorship course offered

by St. Mary’s University provided me with unforgettable and invaluable experiences at an early point in my career as a student and future physician. Not only was it the highlight of my spring semester, it also affirmed me in my decision to continue to pursue my passion for obstetrics and gynecology.” — Junior Deandra Gonzalez St. Mary’s is currently looking for people in a wide range of healthcare fields to serve as mentors. This includes doctors, dentists, nurses, physician’s assistants, physical therapists, pharmacists, registered dieticians, nutritionists, and others. The teaching of the next generation of healthcare professionals lays in the hands of those currently in the profession, a sentiment echo by Dr. Henkes, “Throughout my medical career, beginning in my undergraduate years, I have had mentors who invested time in me, guided me and helped me shape my future as a physician. It is my responsibility, in turn, to encourage and motivate future generations.”

If you are interested in participating in this program as a mentor, please contact Carly Friedman at cfriedman@stmarytx.edu or 201436-3611.

Carly Friedman, PhD is the Pre-Health Professions Advisor at St. Mary’s University. She has taught and advised college students for over ten years. She is married to BCMS member, Duncan Friedman, MD, who is an ophthalmologist at Braverman, Terry, and Oei Eye Associates. Carly is also a member of the BCMS Alliance.

Lori Boies, PhD is an Instructor at St. Mary’s University in the Department of Biological Sciences. She is married to BCMS member, Brian Boies, MD, who is an anesthesiologist and pain medicine physician at UTHSCSA. Lori is an active member of both the TMA Alliance (VP Communications) and BCMS Alliance (Pres-Elect).

She has also served on TMA councils and committees including Cancer, Socioeconomics, and Medical Education.

visit us at www.bcms.org

21

WOMEN IN MEDICINE

advice for women entering the medical field —

go for it!

A Q&A with Dr. Leah Jacobson, president-elect of the Bexar County Medical Society Q: why did you decided to go into medicine?

A: I am a little odd. I have not only wanted to be a doctor since I was 8 years old, but I wanted to be a pediatrician. I have always enjoyed math and science and absolutely love children. Some of the people that have influenced me are my father who is a large animal veterinarian and my mother who was always volunteering.

Q: what were the biggest challenges or obstacles you had to overcome?

A: I am very lucky to have the support of my family and my desire to become a doctor. I think my biggest challenges towards completing medical school and residency were centered around my son, Andrew. He was born during my fourth year of medical school with a condition called VATER’s Syndrome, a constellation of birth defects.

He was in the NICU for 102 days initially and then spent numerous days-weeks in the hospital for surgeries and infections. It was difficult to be a good mother and complete medical school and residency. I was very fortunate to have the support of family and the UTHSCSA Department of Pediatrics residency program during this time. I completed a three-year residency program over the course of four years, taking three leaves of absences (two for Andrew’s issues and care and one for the birth of my daughter).

I have to say that with all of those challenges, I learned so much.

Andrew was even dubbed “my second residency.”

believe that more women are going into fields that have predominantly be male-dominated, such as certain surgical and subspecialties. I also see more women in academic medicine and military medicine leadership positions which is great.

Medicine has definitely changed over the last 20 years, some things for the better, some things for the worse. But it is still a very noble profession which allows individuals (both men and women) to help others and make a good living.

Q: what advice would you give to women considering going into medical practice today?

Q: have things improved for women in medicine today compared to when you started out?

If so, how?

A: First, make sure you REALLY want to do this! The schooling and training alone, along with the cost, can be daunting.

Second, do what you want! If you want to be a family practice doc — go for it! If you want to be a neurosurgeon — go for it! if you want to be a pathologist or radiologist — go for it!

Third, do what you want, when you want, how you want! If you want to work full time, own your own practice, etc. — go for it! If you want to work part-time, for a group or a hospital — then go for it! Medicine allows one the luxury of, to a certain degree, shaping their profession.

A: I think so. There are definitely more women attending medical school over the last 20 years. I know the latest figures in some medical schools, have women in the majority, which is awesome. I also

Leah H. Jacobson, MD, FAAP is a board certified pediatrician and a Fellow of the American Academy of Pediatrics.

22 San Antonio Medicine • October 2016

visit us at www.bcms.org

23

BCMS NEWS

2016 general Membership Meeting Hosted by IBC Bank at 8650 Fredericksburg Road Featured speakers: TMA President Don Read, MD and TMA Foundation President Deborah Fuller, MD

2

1

1. TMA President Don Read, M.D., TMA Foundation President Deborah Fuller, M.D. and BCMS President Jayesh Shah, M.D. 2. TMA President Don Read, M.D., and his wife Roberta (center) were welcomed by (L-R) BCMS Vice President Sheldon Gross, M.D., BCMS President-Elect Leah Jacobson, M.D., BCMS President Jayesh Shah, M.D., and past BCMS President David Henkes, M.D. 3. Members of the Texas Indo American Physician Society-Southwest Chapter accept a plaque from the Bexar County Medical Society in appreciation for their generous $50,000 donation to the BCMS Building Fund.

TIPS President Aruna Venkatesh, M.D., BCMS President Jayesh Shah, M.D., and TIPS Treasurer Umang Shah, M.D. are flanked on either side by BCMS Executive Director Steve Fitzer and BCMS COO Melody Newsom.

3

4. Dr. Sheldon Gross and Sylvia Salazar, director of membership services for TMA, meet with August Trevino, development director for the Bexar County Medical Society.

5. Sandra Torres-Lynum of First Data, a BCMS Circle of Friends member, works a booth at the GM meeting.

4 24 San Antonio Medicine • October 2016

5

BCMS NEWS

MORE RECENT EVENTS aND happENINgS wITh BCMS MEMBERS

Sister Cities International (SCI) recognized the Bexar County Medical Society with its 2016 Longevity Award on Tuesday, June 14. The organization is celebrating its 60th Anniversary this year. Pictured from L-R are Dr. Neal Gray, Dr. Alfonso Chiscano, BCMS CEO Steve Fitzer, District 8 Councilman Ron Nirenberg, BCMS President Dr. Jayesh Shah, Mary Kane, president and CEO of SCI, Tom Quigley, chairman of SCI, Dr. Roberto San Martin, Dr. Gerardo Ortega, BCMS COO Melody Newsom, Hiroko Fay, Japanese translator, and Brissa Vela, BCMS membership director.

Past BCMS President Dr. Gerardo Ortega and his wife Catherine attended the reception on Aug. 9 to honor the Consul General of Japan and to support earthquake relief efforts for Kumamoto, Japan. The event featured San Antonio Mayor Ivy Taylor and recognized organizations that donated to the relief efforts including BCMS.

BCMS Executive Director Steve Fitzer welcomes attendees to the Resident Employment Contract Seminar held at the BCMS headquarters on Sept. 10 with featured speaker Michael Kreager.

visit us at www.bcms.org

25

FEATURE

MY BUDDY THE APIARIST

The hives: The concrete and stone slabs are there in an attempt to prevent a parasite of bees from pupating in the soil near the hives.

By Fred H. Olin, DVM, MD

My friend and veterinary school classmate, Allen Cosnow, D.V.M lives in one of the lakeshore suburbs north of Chicago. His home is one block from Lake Michigan and the village’s beach, with only a leafy park separating them. In the yard on the park side of his home he has six beehives, which, in a good year, produce lots of honey. My wife and I happened to be staying with him the first week of August when there was a lot of bee and honey activity. Here are some pictures I took during our stay.

Dr. Cosnow testing his smoker. The smoke is puffed into the hive to quiet down the bees and allow him to work with the hives.

This day’s chore was to insert miticide-impregnated sheets of paper into each hive to prevent infestations with another parasite. You can see the sheet lying on top of the frames in the background.

26 San Antonio Medicine • October 2016

FEATURE

Here he’s inspecting the frames from a hive that didn’t produce any honey.

He’s looking to see if there are eggs or larvae in the beeswax cells; there weren’t, indicating that the colony has somehow lost its queen.

He also sells honey in the comb. While we visited I tried some, mashed into very hot toast. It was different…and delicious!

Because the bees would build their wax combs haphazardly in the frames, the beekeeper buys pre-molded sheets of purified beeswax. The molding is shallow, and functions as a hint to the bees where and how to build their cells for eggs, larvae and honey.

After using a powered extractor, Dr. Cosnow had over 300 lbs. of honey from the early part of the season. He put signs on his fence saying “Honey For Sale” and set up a store in his front hall. People driving and walking to the park and beach come to his door and buy his honey. The proceeds don’t pay for his hobby, he says, but they surely don’t hurt!

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

visit us at www.bcms.org

27

FEATURE: IN REAL TIME

IN REAL TIME

part 3

Fronto Temporal Dementia To Treat or Not to Treat

By Rajam Ramamurthy, MD

“Dementia” is not a specific disease: It is a catchall term that describes a wide range of symptomatology. Alzheimer’s disease accounts for 60 to 80 percent of all dementia. Vascular dementia, which occurs after a stroke, is the second most common dementia type and is on the decline in the US due to the efforts in stroke prevention. Other conditions that can cause symptoms of dementia include thyroid problems and vitamin deficiencies, and are reversible.

‘Senile Dementia’ is an archaic term that implies that serious mental decline is a normal part of aging. Recently I was pleasantly surprised to hear from my honorary Uncle Sheth, who was a friend and classmate of my father. If my father had lived, he would be 100 years old this year, but he died at age 84 and his mental status was clear as crystal. Uncle Sheth, who is alive at 96, still is. Forgetfulness, which I do believe increases past age 60, must be differentiated from dementia.

The literature states that at least two of the following core mental 28 San Antonio Medicine • October 2016

functions must be significantly impaired to consider dementia: • Memory • Communication and language • Ability to focus and pay attention • Reasoning and judgment • Visual perception Data from both the Centers for Disease Control and the National Institutes of Health indicate increasing prevalence of Alzheimer’s.

Starting at age 65, the risk of developing the disease doubles every 5 years. By age 85 between 25% and 50% of people will exhibit signs of Alzheimer’s disease. As many as 5.3 million Americans currently have Alzheimer’s disease. By 2050, the number is expected to more than double. Alzheimer’s is the sixth leading cause of death in the United States and is the fifth leading cause among persons age 65 and older. Frontotemporal dementia (FTD) comprises about

FEATURE: IN REAL TIME

10% of all dementias. N’s diagnosis was based on lack of judgement, disinhibition and lack of ability to focus. His memory loss was selective in the sense he was completely not aware of his behavior.

There was no remorse, regret or guilt.

A Geriatric Psychiatrist was highly recommended by a friend of ours, a psychiatrist herself. He was an older physician, and was very calm and confident. He had read N’s history from his chart. I was allowed to stay with N during the visit. The psychiatrist took a complete history and then started doing a battery of tests that included a list of questions. One of standard components of the test was to draw a clock and indicate the time. N was no artist, but the clock he drew was egg-shaped and the clock hands were of equal length, however he did indicate the time. He made several errors in shortterm memory; several objects were named and after an interval of doing other things the doctor would ask N to recollect and name the objects. I was struggling to remember the words myself. N made many errors. I ached inside: N’s ability to remember was one of his greatest assets. He remembered chemical formulas, the anatomy of the nervous system, botanical names of plants, dates of events, bank account numbers, the dress I wore to a party, street address of every house we ever lived in and, of course, passwords. He was my virtual web site. The psychiatrist explained his working diagnosis. He said it was a little late in age for N to show symptoms of FTD, however based on the Neuropsychiatric testing and the behavioral symptoms FTD would be the working diagnosis. N asked him how he had done on the test, and was told that he had failed the exit test. N was not happy with the answer. He was placed on medication starting at a very low dose. Since the end of January he had been advised not to drive, and that was reinforced.

N was a voracious reader and an avid grower of fruit trees. He has planted more than 100 fruit trees in our yard. He always mowed our lawn and took care of his trees; He tended to his trees with as much care as he used pointing a needle towards the stellate ganglion for a nerve block. Pruning, grafting, vitamins and minerals, a lot of TLC (and, I suspect, a little singing at times) made these plants blossom. Since we returned from our trip he had not stepped into the garden. When I suggested that he should try reading he said that a book was going through his mind every hour and he is unable to focus. However the tennis matches on TV kept him engaged for the duration of the match. I tried playing a TV serial on DVD every night which he watched with interest.

Our son and daughter came and stayed several days. February and March were the darkest periods of my married life. For N these two

months were an abyss into which he was slipping rapidly, and of which he had no inkling.

In this paragraph, I am sharing the insight I have gained about how important it is, particularly for women, to understand and to be aware of and involved with the family’s finances. All I knew was that my paycheck was automatically deposited to an account. I had an intuitive internal budget that I would not exceed. The rest of our finances were handled by N, who was meticulous and efficient.

There was only one thing I had been stubborn about; that my money be handled by a different financial company. N often pointed out to me how conservative this person was and that my money was not growing. True it did not grow, but I am thankful that it is there.

It is probably the influence of my mother who would say to me and my two sisters “Never put all your eggs in the same basket”. Very quickly we had to work on the medical and financial powers of attorney, access to bank accounts and what seemed like a million pieces of paper. Adversity is a brilliant teacher. I learned quickly to handle finances. This financial indiscretion is a classic symptom of FTD. Amidst all this cloud there was always a ray of hope. N in some remote way knew that we had to do many things. He actually helped me to organize the investment files, cooperated when I had to get the powers of attorney. He did help me pay bills on line, and when I could not recall passwords he asked “Who has dementia?”

I was struggling to create a routine so we could both be engaged without stress for N, but at the same time not shutting ourselves completely from society. We attended special lectures at the UT Health Science Center, visited museums, attended festivals. We avoided parties and large gatherings. N’s sleep disturbance was getting worse. His talked continuously when someone visited. N, for reasons unknown to me, was obsessed with a Filipina web site. I cannot write explicitly about certain behavior issues yet. The purpose of this narrative is to raise awareness. It suffices to say that “disinhibition” is a hallmark of FTD. Then N’s brother came to visit and threw a completely different perspective into the mix, the effect of meditation. I promise to write all about it next time.

Suggested Reading: http://memory.ucsf.edu/ftd/overview/ftd/treatment/single. http://jpubhealth.oxfordjournals.org/content/early/2014/10/20/pub med.fdu080.full Rajam Ramamurthy, MD, Professor Emeritus, Pediatrics, UTHSCSA

BOOK REVIEW

MORguE A life in Death

By Dr. Vincent Di Maio and Ron Franscell Reviewed by Fred H. Olin, M.D. You should read this book. If I were an English professor or a professor of Pathology supervising your residency or fellowship I’d say “You must read this book, there’ll be a test nest week.” Many of us who have been around a while will remember Dr. Di Maio as the Bexar County Medical Examiner, a position he held for 25 years before retiring in 2006. He has written (with help) an eminently readable tome that combines autobiography with gripping case reports, vivid descriptions and, at the beginning of each chapter, an italicized paragraph or two of personal reflection and philosophy. Here’s the introduction to the first chapter: “I don’t know what’s in the human heart.

“I have seen more than my share of hearts, held them in my hands.

Some were young and strong; some were worn-out, shabby, choked.

Many had leaked away an entire life through neat little holes caused by bullets or knives. Some had been stopped by poison or fright. A few had exploded into a thousand tiny bits or were shredded in some grotesque trauma. All of them were dead.

“But I never truly knew what was inside these hearts, and never will. By the time I see them, whatever dreams, hopes, fears, ghosts or gods, shame, regrets, anger, and love they might have contained are long gone. The life—the soul—has all seeped out.

“What’s left is just evidence. That’s where I usually come in.”

So, what does Dr. Di Maio write about? He tells us stories about cases he has handled personally, consulted on or just found interesting. These include fairly recent ones such as the Trayvon Martin/George Zimmerman incident in 2012, as well as more remote ones, as in the final chapter, which is titled “The Curious Death of Vincent Van Gogh.”

He gives us one chapter of true autobiography: His grandfather was a general practitioner in Brooklyn who emigrated from Naples in 1911. His father was a pathologist who evolved into a forensic pathologist, and became New York City’s fourth Chief Medical Examiner in 1974. Our Dr. Di Maio becomes an expert on gunshot wounds, writes definitive texts on that subject and on Forensic Pathology. All three of his sisters became physicians. I see a trend here…

The cases include consultations for both prosecutioners and defense lawyers, as well as some that he dealt with in his various jobs around the country. Locally, the 1980s case of the “Killer Nurse,” Genene Jones, L.V.N., is dealt with in considerable detail in a chapter titled “Monsters Among Us.” Even though I read all about it as it 30 San Antonio Medicine • October 2016

occurred, I learned all sorts of bits and pieces that told me how the Ms. Jones was identified, and what Dr. Di Maio and his office contributed to her prosecution. Inserted into this chapter are some rather harsh criticisms of the Bexar County Hospital System (now University Health System) and the local medical school that are accused of denying and covering up that there was a problem with excess baby deaths in the NICU. At her trial, the prosecutor pointed out that there was only one week no kids had unexplained seizures in the Kerrville pediatric practice Ms. Jones worked for after she left Bexar County Hospital. The reason: Genene was in the hospital herself.

Ms. Jones has been denied parole nine times. However, because of a law in force at the time of her sentencing to ninety-nine years in 1984, she has been given three days credit for every good-behavior day served and will be released on March 1, 2018.

Perhaps the grimmest, grimiest chapter deals with the exhumation of Lee Harvey Oswald 18 years after the assassination of President Kennedy. An Englishman named Michael H. B. Eddowes was convinced that the Soviets had substituted a secret agent for Oswald to come here and kill JFK. According to Eddowes the agent was subsequently shot by Jack Ruby and buried as if he was Oswald. Mr. Eddowes was very tenacious and had some credibility because he had successfully proven that an innocent man had been hanged in England, and, as a result, the death penalty was done away with in the U.K. His efforts and those of other conspiracy theorists resulted in the exhumation and second autopsy, which were attended by a rather large group of interested people. It turned out to be Oswald of course, but how it was proven is the story.

The book includes eight pages of photographs (several pictures to each page) that I found myself referring to as I read the related chapters. I don’t know if the pictures would appear in an e-book.

When (not if!) you read Morgue you’ll get an impression of the life of a forensic pathologist, and, I think, a real feel for Dr. Di Maio and his dedication to truth. As I was writing this review I Googled him and found a petition by a Georgia woman which was presented to the Texas Medical Board accusing Dr. Di Maio of harboring a bias for the defense. The TMB’s website says that there haven’t even been any investigations.

The book is available at the San Antonio Public Library where there is currently a fairly long wait for it. Amazon will be happy to sell you either the print version or an e-book.

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

UTHSCSA DEAN’S MESSAGE

UT SCHOOL OF MEDICINE:

CHILDREN’S CANCER RESEARCH Greehey Institute Leading the Curve

By Francisco González-Scarano, MD

Almost 1,200 children and adolescents are diagnosed with cancer in Texas each year, a number that is roughly 10 percent of all pediatric cancers diagnosed in the United States. Approximately 200 of them die of their disease each year, making cancer the most common cause of disease-related mortality for Texans 0-19 years of age.

The good news is that a recent report from the Children’s Oncology Group (COG), from the National Institute of Health (NIH), states that survival rates for all childhood cancer have risen in the past 50 years from below 10percent to almost 80 percent. In Acute Lymphoblastic Leukemia (ALL) — a virtual death sentence when I was in medical school — survival has risen from a median of six months to an 85 percent overall cure rate. The therapies are getting better, but we still deal with a broad range of sequelae, stemming from the toxicity of chemotherapy and radiation. Many adults are now dealing with chronic conditions due to cancer therapy from childhood.

Unfortunately, for most children with advanced or metastatic tumors the survival rate has not changed in the past 20 years despite more intense treatments. There is a large knowledge gap about the underlying causes of pediatric cancers, in contrast to the many advances made in the more common adult neoplastic diseases. For ex-

ample, molecularly targeted treatments based on the genetic changes that induce some adult cancers may not apply to most childhood malignancies. Furthermore, and regrettably, since children’s cancers only represent one percent of all cancers, there is much less commercial incentive for pharmaceutical ventures to pursue pediatriconly treatments.

The Greehey Children’s Cancer Research Institute (GCCRI), opened on the UT Health Science Center campus in 2004. They are focused precisely on this knowledge and treatment gap, with a mission to address the unique processes that result in pediatric cancer, and to develop treatments that will increase the cure rate and improve quality of life for cancer survivors. Studies at GCCRI also address the resulting long-term damage that can be a side effect of chemotherapy and radiation.

The institute was founded through a $200 million appropriation from the Texas Legislature in 1999, part of the lawsuit settlement from the tobacco companies for the cost of treating tobacco-related medical conditions. Texas joined 45 other states in that lawsuit and the settlement eventually resulted in a commitment of $17 billion continued on page 32 visit us at www.bcms.org

31

UTHSCSA DEAN’S MESSAGE continued from page 31

for Texas over 25 years.

The institute benefited again in 2007 when the Greehey Family Foundation led by Bill Greehey of NuStar Energy, donated $25 million to the Health Science Center to focus on children’s diseases, including cancer treatment research. The institute and the campus were given the Greehey name to recognize the significance of this transformative donation.

Dr. Peter Houghton, PhD, Professor of Molecular Medicine at the School of Medicine, was appointed director of the GCCRI in December, 2014, bringing with him four decades of cancer research experience. Dr. Houghton earned his doctorate from the Institute of Cancer Research at the University of London, then spent over 30 years at St. Jude Children’s Research Hospital in Memphis, Tennessee, where he co-lead the Solid Malignancies Program and for 17 years was chairman of the Department of Molecular Pharmacology. Before moving to Texas, he was the Director of the Center for Childhood Cancer and Blood Diseases at the Research Institute at Nationwide Children’s Hospital in Columbus, Ohio. His research focus has been to identify novel therapeutic targets, and to develop new therapies for treatment of pediatric cancers.

Dr. Houghton has been consistently funded by the NIH for over 30 years, has directed an NIH program grants for over 25 years, and served as chair for both the Experimental Therapeutics and Drug Discovery Molecular Pharmacology NIH Study Sections, which evaluate grant proposals in these areas. He has served on several committees within the NIH’s Children’s Oncology Group, and was elected Fellow of the American Association for the Advancement of Science in 2011.

New Tools in Cancer Research The technology of cancer research has taken something of a quantum leap the last decade. When discussing why he came to the GCCRI, Dr. Houghton points out that nearly all the tools that comprise the new era of molecular research are available here in the School of Medicine and the Health Science Center. Besides the tal32 San Antonio Medicine • October 2016

Dr. Peter Houghton, PhD, Professor of Molecular Medicine at the School of Medicine

ented faculty researchers, there are high-throughput genetic and small molecule screening (HTS) approaches that promote the identification of novel targets, and the evaluation of thousands of potential drug molecules. This makes for faster discovery and identification of critical targets and interactions, which means not just a shorter road to possible cures and treatments, but more definitive path-finding along the way.

The very latest in research methods are necessary for the complex and multi-layered approaches being pursued by the GCCRI, which focuses almost exclusively on the very specific molecular processes that drive tumorigenesis and confer resistance to therapy. The arsenal of tools includes an array of biophysical facilities including Nuclear Magnetic Imaging (NMR), X-ray crystallography as well as massspectrometry, and thermal calorimetry, essential components of a successful drug discovery and development program.

Most adult cancers are the result of simple genetic mutations on top of pre-existing mutations that may take place over years, if not decades of cell division. The eventual cancerous cell is many evolutions beyond the original mutation that was its foundation. Pediatric cancers achieve the same complexity in a much shorter time frame.

This means the processes are starkly different, with many cancers being driven by oncogenic fusion proteins, that result from reciprocal translocations of genetic material between chromosomes, which are

UTHSCSA DEAN’S MESSAGE

a key focus of the GCCRI. These fusion proteins often act as transcription factors that regulate positively or negatively many hundreds of genes. These translocation events are extremely rare, and the underlying mechanism for their causation is poorly understood, however they are highly efficient in causing transformation to cancer, and probably account for the short latency of some childhood cancers.

a Focused Mission With Dr. Houghton at the helm, the GCCRI has taken on a very specific focus on processes that lead to cancer and on developing novel therapeutics targeting cancer drivers in pediatric cancers, and is adding faculty and staff toward this mission. The GCCRI is currently comprised of eleven faculty members, with two new researchers coming on board this fall. All are PhD or MD/PhD and include specialists in hematology-oncology, genetics and the broad spectrum of the DNA/RNA processes, epidemiology, computational biology and bioinformatics, molecular medicine and biology, cellular and structural biology, biochemistry and a host of related sciences.

The GCCRI has six central programs in various stages of development: Bioinformatics, which focuses on genetic changes that lead to cancer and is important to all the research programs; Cancer Control, which focuses on current treatments and reducing health disparities in children, as well as improving long-term outcomes; Cancer Genetics, with a specific focus on cancers more prevalent in the Hispanic population in south Texas; Experimental Therapeutics, which aims to use pre-clinical models and other tools to more efficiently evaluate novel therapies, and to elucidate mechanisms of drug resistance or sensitivity; Molecular Oncogenesis, to identify and characterize the genes, gene products, and pathways involved in pediatric cancers, recognizing results will have implications to all cancers; Drug Discovery, the Pediatric Drug Discovery Initiative (PDDI). The latter will build on programs of excellence already established here to create new capabilities for target identification unique in Texas, bringing together experimental scientists from other centers and departments in the School of Medicine and the Health Science Center as well as other universities in Texas.

We truly are in a new era of cancer research and discovery. Just last month at Georgetown University, the first child began a phase 1 clinical trial to test a drug specifically developed to treat Ewing Sarcoma. The new agent works to inhibit the oncogenic fusion protein characteristic of Ewing sarcoma that regulates DNA replication and cell proliferation. This therapy has a tremendous potential to stop this cancer at the molecular level with little to no ancillary tox-

icity and hopefully the clinical trials will be positive.

Dr. Houghton and his team are watching this phase 1 trial very closely as it is very much the type of treatment they are focused on.

In a study co-authored by Dr. Houghton, in vivo and in vitro models demonstrated a distinct reduction in vascularization of Ewing sarcoma cells. Entitled “The Bromodomain BET Inhibitor JQ1 Suppresses Tumor Angiogenesis in Models of Childhood Sarcoma”, the promising study was published in the May 2016 issue of Molecular Cancer Therapeutics.

GCCRI researcher Patricia Rosa de Araujo, PhD, describes the potential to address brain tumors (and other cancer cells) that may be resistant to radiation therapy in the July 2016 issue of The American Journal of Pathology. The article, “Musashi1 Impacts RadioResistance in Glioblastoma by Controlling DNA-Protein Kinase Catalytic Subunit”, details how they induced a reduction in cell production by knocking out the stem cell-related RNA-binding protein Musashi1 (MSI1). The research team led by Araujo, included Aparna Gorthi, PhD, from the Department of Cellular and Molecular Biology, as well as researchers from the Harvard School of Public Health and the University of Southern California.

The GCCRI also has a monthly speaker series with guests from around the country. On Nov. 4, 2016, Melinda Merchant, MD/PhD, formerly of the Sloan-Kettering Cancer Center and the National Cancer Institute (NCI), will discuss “Immunotherapy for Pediatric Solid Tumors.”

On Dec. 2, 2016, Peter McKinnon, PhD, from the Genetics Department at St. Jude Children’s Hospital will present “Integrity matters: Genome integrity and neurologic disease.” All presentations are held in the first floor auditorium from 11 a.m. to noon.

The GCCRI is the largest free-standing children’s cancer research center in Texas. Dr. Houghton describes it as a think-tank of highpowered intellectuals acutely focused on very specific cellular processes that result in children’s cancer. I describe this institute as a gift to a world that wants fewer cancers in children, as well as the new age of deeper genetic science that will most likely benefit all cancer patients and research.

To learn more about the GCCRI, visit their website at www.ccri.uthscsa.edu.

Francisco González-Scarano, Dean, School of Medicine, Executive Vice President for Medical Affairs University of Texas Health Science Center San Antonio Professor of Neurology visit us at www.bcms.org

33

BUSINESS OF MEDICINE

The aCa Exchanges and adverse Risk Selection

By Dana A. Forgione, Ph.D., CPA, CMA, CFE

The media has given front-page coverage to Aetna, UnitedHealth,

prime example is maternity coverage. A young and healthy person

and Humana all dropping out of numerous health insurance ex-

can wait until they need coverage for a baby delivery, and then sign-

change markets across the country under the Affordable Care Act

up. The insurance covers the medical and hospitalization costs of

(ACA). The emphasis has been on what this means for consumers

delivery, and then they can drop the coverage afterward if they want.

in terms of fewer health plan options available and the inevitably

Of course that could result in greater complications of delivery if

higher premium costs. These are large, major companies and their

there was no pre-natal care, and less healthy babies if there is no fol-

absence from the exchanges will no doubt be felt in many commu-

low-up care. And that can be more costly in the long run. But the

nities. They have all reported losing millions of dollars on the ACA

health coverage can be obtained and retained for a sufficiently long

health plans. In the case of Aetna, evidently they were proposing to

pre- and post-delivery timeframe if the subscriber so desires.

merge with Humana for anticipated business advantages and the

Second, the low penalties for not obtaining coverage reduced the

justice department moved to block the merger. As a consequence,

negative incentives for young and healthy individuals who delayed

Aetna found other ways to improve their finances, i.e., drop losing

signing-up. In some cases, cheap, non-ACA compliant health polices

product lines on the ACA exchanges. So why all the reported losses,

can be purchased and the penalties paid, and the total cost may be

and the consequent withdrawals of major companies from ACA

a fraction of the premium cost for a compliant health plan purchased

markets? In a nutshell, adverse risk selection.

through an exchange.

The whole concept of insurance is that large pools of subscribers

Third, it’s just a hard sell. What we are asking our young and

all pay-in premiums, and benefits are paid-out to those with allow-

healthy citizens to do is pay premiums higher than what they need

able claims. That diversifies risk across a large population, and helps

for themselves, in order to subsidize the costs of older sicker people.

make premiums affordable to those in need. Essentially, those who

It’s a noble request, but we are asking this at a time when we are

never make a claim subsidize those who do make claims. A fair and

dropping from about five workers per retiree today, down to 2.3

judicious claims management process is what keeps the system hon-

workers per retiree by 2030. That means they will have less than half

est and efficient. And any given subscriber never knows when they

the relative, collective earning power than their parents have today.

will be the one who needs to make a claim in the future. So it’s a

And we are leaving them with $156 trillion of obligations to pay off

reasonable plan, and a noble mission. When the ACA was devel-

— which is nearly twice the entire wealth of the United States. Our

oped, it was estimated that 40 percent of the subscribers needed to

Medicare and Social Security obligations alone are five-times the na-

be young and healthy so their premiums would subsidize the claims

tional debt. Does it surprise anyone that we have never obtained

of older and sicker subscribers. However, several factors hindered

more than about 25 percent young and healthy subscribers to ACA

that from materializing, resulting in adverse risk selection.

health plans?

First, the guaranteed insurability and elimination of pre-existing

So we have a major shortfall. The folks who signed-up are pre-

condition exclusions removed the positive incentive for young and

dominantly the older and sicker individuals who need the coverage.

healthy individuals to subscribe now. They can save money by pay-

That’s good. But with not enough healthy people signing-up, that

ing just the penalties now, and if they get sick or injured in the fu-

means costs are not being subsidized as planned, and premiums are

ture, they can always sign-up for coverage and pay the premiums. A

going to have to go up. And that’s what we’ve been seeing. All across

34 San Antonio Medicine • October 2016

BUSINESS OF MEDICINE

the country insurance company premium rate increase requests have

with 25 percent young and healthy subscribers (with uncertainty

been in the double digits in many cases. That’s adverse risk selection

about subsidies in the future), are experiencing millions of dollars

at work. The mix of subscribers is less healthy than planned, and

in losses on their ACA plans. So, does it surprise anyone that some

costs are more than planned.

of the companies are making the decision to drop out of the ACA

But didn’t the ACA provide for government subsidies to insurance

market? That’s adverse risk selection at work.

companies in the event of adverse risk selection? Well, yes and no.

The House of Representatives holds the government purse strings

Dana A. Forgione, Ph.D., CPA, CMA, CFE is a Pro-

and never funded the subsidies. They were nonetheless paid last year

fessor of Accounting in the College of Business at the Uni-

anyway, and now there’s a lawsuit at the federal level over whether

versity of Texas at San Antonio. He is also an Adjunct

those payments were lawful or not. So that leaves the insurance com-

Professor in the School of Medicine, Department of Car-

panies with uncertainty about whether they can count on such sub-

diothoracic Surgery, the Department of Pediatrics, and in the School of

sidies in the future. And of course some folks may question why the

Public Health, all at the University of Texas. He previously held a joint

taxpayers should have to subsidize big insurance companies any-

appointment in the School of Pharmacy at the University of Maryland,

way—can’t they just plan and set adequate premiums on their own?

where he taught in the Doctor of Pharmacy program. His research in-

Yup, they can. And they’d need to be higher.

terests are in international comparisons of healthcare payment systems,

The bottom line? Insurance companies who set their premiums based on an expectation of 40 percent young and healthy subscribers

costs and quality of care, as well as financial management for hospitals and physician practices.

(or a government subsidy in case there were fewer), and ended up

visit us at www.bcms.org

35

FINANCIAL

when the IRS comes knocking...

By Bennett Allison, CPA, Shareholder

The last thing a medical practice wants to face is an IRS audit. Fortunately, audit rates are low (around 1 percent), and IRS audits are the exception rather than the rule. However, if your practice is unlucky enough to be audited, there are three important points to remember.

Excellent books and records are essential Well documented bookkeeping and records are going to be your best assets if your practice is selected for audit. If an IRS agent sees an organized set of books, he or she is likely to perceive that your practice is more compliant which may cause the examination to be curtailed. Conversely, a messy set of books will be more difficult for the agent to follow and create a real or perceive belief that additional examination is needed.

Through an IRS audit, taxpayers are required to provide supporting documentation (typically for expenses) for their bookkeeping. It is certainly helpful to have canceled checks to document your various payments to vendors and suppliers. However, do your records also include items such as purchase orders, bills of lading, and receipts? If not, the IRS agent may understand that you have made payments but not know why the payments were made and attempt to deny the associated deductions. It is, therefore, essential that your practice maintain not only bank records but other supporting documentation that corroborates the bookkeeping entries. In fact, IRS agents are willing to overlook an unsupported deduction here and there if they see that most of the other deductions are well supported.

Another important point to note is that certain expenses are treated differently for income tax purposes. For example, life insurance is typically a nondeductible expense for income tax purposes.

If the practice’s books simply report “Insurance Expense” with no breakout, then the income tax return may be inadvertently deducting nondeductible life insurance payments.

If the bookkeeping and record keeping processes in your practice are deficient, action should be taken now to resolve these weaknesses.

Otherwise, your practice may be scrambling to repair books on the eve of an examination and trying to find supporting documentation that is no longer available.

Travel, meals, and entertainment Travel, meals, and entertainment are seen by the IRS as an area with high potential for taxpayer abuse. Not surprisingly then, a special Internal Revenue Code provision (Section 274) exists to combat 36 San Antonio Medicine • October 2016

potential abuse and requires taxpayers to substantiate deductions through adequate records with the amount of the expense, the time and place of the expense, the business purpose, and the business relationship of the person(s) associated with the travel, meals, and entertainment. For example, a medical practice pays for hotel costs of several of it doctors to attend an out of town conference. A credit card statement showing the payment to the hotel would not be adequate evidence. Instead, a bill from the hotel showing the various components of the hotel charges is required. The key point with travel, meals, and entertainment is that the documentation requirements are more stringent and require those who maintain the records to adequately understand the rules.

appointing a third-party to represent you Taxpayers have the option to have a third-party representative conduct the audit on their behalf. A third party representative is authorized by presenting a completed and signed Form 2848, Power of Attorney and Declaration of Representative, to the IRS. Considering the stress that an audit can have, it is generally a good idea for a taxpayer not to handle the examination directly. In most cases, a practice’s CPA can assist with an examination, and it is typically best to have the CPA work on the examination from the start. A CPA help can help present the available information in the best light and also take the emotion out of the examination process.

Although rare, an IRS audit is still an ever present and daunting reality for medical practices. With good books and records, especially for travel, meals, and entertainment and strong professional CPA representation, your practice can make the most of a difficult situation.

Bennett Allison, CPA, CFP™ is a shareholder at Sol Schwartz & Associates, P.C. (cba@ssacpa.com). He has over 20 years public accounting experience serving individuals, corporations, S-corporations, partnerships, trusts, estates, and non-profit organizations. In addition, Bennett works with a high concentration of physician practices and high net worth individuals. Contact Bennett at (210) 384-8000 Ext. 138.

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

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

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

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

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

aRMY hEaLThCaRE 5th Medical Recruiting BN (HH Silver Sponsor) We recruit quality men and women who would like to be a part of our team.

SFC Cherie Kirk 210-692-7376 Cherie.k.kirk.mil@mail.mil www.youtube.com/watch?v=kwe qi3TelO8 "Serving to heal, Honored to serve"

aSSET MaNagEMENT

Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives.

Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com

Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management”

BaNkINg

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

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

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

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

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

Stephanie Dick Vice President- Commercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

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

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

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

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

IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC Bank-

San Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area.

Markham Benn 210-518-2500, ext. 26921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”

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

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

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

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

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

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

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

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37 adjustable-rate mortgage loans.

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

Courtney Martinez 210-270-5494 courtney.martinez@baml.com Denise Smith 210-270-5058 Denise.C.Smith@baml.com bankofamerica.com Making financial lives better — one connection at a time Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology? Expanding your office space? We offer loans to meet your business or personal needs.

Competitive rates, favorable terms and local decisions.

Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org RBFCU (HH Silver Sponsor) 210-945-3800 nallen@rbfcu.org www.rbfcu.org

CONTRaCTORS/BuILDERS /COMMERCIaL

Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer.

Our model allows you to own your own office space as opposed to leasing.

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

38 San Antonio Medicine • October 2016

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

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

ELECTRONIC DOCuMENTaTION aND TRaNSCRIpTION SERVICES Med MT, Inc. (HH Silver Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records.

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

EMpLOYEE BENEFITS

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it’s all about relationships. We keep our partners compliant assisting with human resource administration/management, workers’ compensation/risk management, benefit administration, and payroll.

We help our partners concentrate on what they do best...Service their customers.

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

FINaNCIaL SERVICES

Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor) Our mission is to help you enjoy a lifetime of financial security with greater certainty and clarity. Our outcomebased planning approach involves

defining your objectives, creating a plan to maximize potential and inspiring action towards your goals.

Fee-based financial plans offered at discount for BCMS members.

Eric Kala CFP®, AEP®, CLU®, ChFC® Wealth Management Advisor | Estate & Business Planning Advisor 210.446.5755 eric.kala@nm.com www.erickala.com “Inspiring Action, Maximizing Potential”

John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management” First Command Financial Services (HH Silver Sponsor) Nigel Davies 210-824-9894 njdavies@firstcommand.com www.firstcommand.com

gRaDuaTE pROgRaMS Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Jeffrey Allison 210-268-1530 jallison@ aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

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

Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com “Commercial leasing for a doctor’s business equipment and vehicle.”

Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives.

Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President

Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time.

Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration

hEaLThCaRE REaL ESTaTE

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

hIpaa/MaNagED IT/VOIp/SECuRITY

Hill Country Tech Guys (HHH Gold Sponsor) Provides complete technology services to many different industries,

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY specializing in the needs of the financial and medical industries.

Since 2006, our goal has always been to deliver relationship-based technology services that exceed expectations.

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

hOME hEaLTh SERVICES Abbie Health Care Inc. (HH Silver Sponsor) Our goal at Abbie health care inc. is to promote independence, healing and comfort through quality, competent and compassionate care provided by skilled nurses, therapists, medical social worker and home health aides at home.

Sr. Clinical Account Executive Gloria Duke, RN 210-273-7482 Gloria@abbiehealthcare.com "New Way of Thinking, Caring & Living"

hOSpITaLS/ hEaLThCaRE SERVICES

Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years.

Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery.

Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 www.swgeneralhospital.com “Quality healthcare with you in mind.”

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

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/ Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

Miranda Peck 210-482-3000 Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

huMaN RESOuRCES

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

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

Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page.

John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com “BCMS members get a free HR assessment valued at $2,500.”

INFORMaTION aND TEChNOLOgIES

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

Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

INSuRaNCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

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

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

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve

their best health with clinical excellence through coordinated care.

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

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

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com SWBC Mortgage Jon M. Tober 210-317-7431 JTober@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services Catto & Catto (HH Silver Sponsor) Providing insurance, employee benefits and risk-management products and services to thousands of businesses and individuals in Texas and the United States.

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

INSuRaNCE/MEDICaL MaLpRaCTICE

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

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39 Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

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

MedPro Group (HHH Gold Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Thomas Mohler 512-213-7714 thomas.mohler@medpro.com Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com

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

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

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

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

Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liabil-

40 San Antonio Medicine • October 2016

ity coverage to physicians and is “A” (Excellent) rated by A.M. Best.

Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

Keith Askew Market Manager kaskew@proassurance.com Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

MaRkETINg SERVICES

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

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

MEDICaL BILLINg aND COLLECTIONS SERVICES

INTERNET/ TELECOMMuNICaTIONS

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

Enterprise Account Executive West Region - Healthcare Sales Leader Medical Market Rick Garza 210-582-9597 rick.garza@charter.com “Time Warner Cable Business Class offers custom pricing for BCMS Members.”

MaRkETINg aDVERTISINg SEO

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

Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

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

Regional Solutions Consultant Lilly Ibarra: 210.714.9815 lilly.ibarra@kareo.com www.kareo.com Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICaL SuppLIES aND EQuIpMENT

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

Tom Rosol 210-413-8079

tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”

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

Physician’s memberships are free.

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

MERChaNT CaRD/ChECk pROCESSINg Firstdata/Telecheck (HH Silver Sponsor) We stand at the center of the fastpaced payments ecosystem, collaborating to deliver nextgeneration technology and help our clients grow their businesses.

Sandra Torres-Lynum SR. Business Consultant 25 years of dedicated service 210-387-8505 Sandra.TorresLynum@FirstData.com ‘The true leader in the payments processing industry’

MERChaNT paYMENT SYSTEMS/CaRD pROCESSINg Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by over 250 business associations.

Tanner Wollard 979-219-9636 tanner.wollard@e-hps.com www.heartlandpaymentsystems.com “Lowered cost for American Express; next day funding.”

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY OFFICE EQuIpMENT/ TEChNOLOgIES

phYSICIaNS BuYINg gROup

Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes.

Major Account Executive Wayne Parker 210-326-8054 WParker@dahill.com Major Account Executive Bradley Shill 210-332-4911 BShill@dahill.com Add footer: www.dahill.com “Work Smarter”

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

Physician’s memberships are free.

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

REaL ESTaTE/ COMMERCIaL

paYROLL SERVICES

Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page.

John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com “BCMS members get a free HR assessment valued at $2,500.”

SWBC (HHH Gold Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits.

Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.

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

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

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

REaL ESTaTE/RESIDENTIaL

Roslyn Casey Realty (HHH Gold Sponsor) My extensive experience and expertise in the San Antonio, Alamo Heights and Terrell Hills real estate market will benefit you whether you are looking to buy or sell a home in the area.

Realtor, ABS, ILHM, ALMS Roslyn Casey 210-710-3024 Roslyn@roslyncasey.com http://roslyncasey.kwrealty.com “Communication is key” Kuper Sotheby's International Realty (HH Silver Sponsor) My hometown roots are based in Fredericksburg while my home away from home is San Antonio. Local knowledge – exceptional results.

Joe Salinas III 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com “Embrace your new life ... I'll help you become a connoisseur.”

STaFFINg SERVICES

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

Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

SENIOR LIVINg Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment.

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

To join the Circle of Friends program or for more information,

call 210-301-4366 or email August.Trevino@bcms.org

Visit www.bcms.org

visit us at www.bcms.org

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42 San Antonio Medicine • October 2016

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

We will locate the vehicle at the best price, right down to the color and equipment.

We will put you in touch with exactly the right person at the dealership to handle your transaction.

We will arrange for a test drive at your home or office. We make the buying process easy!

When you go to the dealership, speak only with the representative indicated by BCMS.

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

Ancira Volkswagen 6125 Bandera Road San Antonio, TX 78238

Jude Fowler 210-681-4900

Carl Carper 210-681-2300

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 IH 10 W San Antonio, TX

GUNN Infiniti 12150 IH 10 W San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209

Bill Boyd 210-859-2719

Bill Boyd 210-859-2719

Hugo Rodriguez and Rick Tejada 210-824-1272

Coby Allen 210-625-4988

Bill Boyd 210-859-2719

Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Toyota of Boerne 31205 I-10 W Boerne, TX 78006

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Julie Herrera 210-681-3399

Gary Holdgraf 210-862-9769

George Ramirez 210-748-4412

Wayne Alderman 210-525-9800

Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX

Ingram Park Auto Center Dodge 7000 NW Loop 410 San Antonio, TX

Ingram Park Auto Center Mazda 7000 NW Loop 410 San Antonio, TX

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

Alan Henderson 210-681-6300

Daniel Jex 210-684-6610

Frank Lira 210-381-7532

Richard Wood 210-366-9600

John Wang 830-981-6000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Subaru 9807 San Pedro San Antonio, TX 78216

North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257

North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211

North Park Mazda 9333 San Pedro San Antonio, TX 78216

Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX

Mark Castello 210-308-0200

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

Scott Brothers 210-253-3300

Esther Luna 210-690-0700

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX

North Park Lincoln 9207 San Pedro San Antonio, TX

North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257

Jose Contreras 210-308-8900

Justin Blake 888-341-2182

Sandy Small 210-341-8841

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230

Ancira Nissan 10835 IH 10 West San Antonio, TX 78230

Jarrod Ashley 210-558-1500

Jason Thompson 210-558-5000

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154

Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900

James Cole 800-611-0176

Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org

AUTO REVIEW

2017 BMW 750i The battle of large import luxury sedans heated up last year with the introduction of the new 7-series BMW. BMW spent a lot of time and money making sure their new flagship sedan had what it took to legitimately compete with the class-leading Mercedes S-class, and after spending a week with it I can say that it does.

I’ve been watching this battle with interest since it began in earnest with the launch of the second generation 7-series in 1988, and it occurred to me as I drove BMW’s new “7” that maybe this competition doesn’t really matter anymore. It’ll always matter to some degree, of course, but no way does it matter as much as it used to. Think about it: in the 1980s, ‘90s, and early 2000s people with money drove large luxurious sedans like the Lincoln Town Car, Lexus LS 400, and Jaguar XJ, in addition to the aforementioned BMW and 44 San Antonio Medicine • October 2016

Mercedes models. Now those same high demographic individuals are just as likely — and maybe even more likely — to be driving an SUV. I regularly peruse my local doctors’ parking lots and have noted the rise of Range Rovers, Escalades, Cayennes, et al, just as I’ve seen fewer sedans. Still, let’s not forget that sedans, especially big luxury sedans, are very pleasurable to drive and own.

Anyway, the new 750i is definitely gunning for the Mercedes S-class, which was completely re-done just two years ago. While the S-class is clearly going for a substantial and intimidating look, the big BMW is much more sleek and understated. Actually, you can get all the information you need about each car’s design just by looking at their grilles. The one on the Mercedes is huge and bright — move over now, it seems to say — while the one on the 7-series is,

By Steve Schutz, MD umm wait a sec, let me look at it again. OK, it’s there and is undoubtedly handsome, but wow is it unassuming.

In fact, the BMW’s exterior design is more complicated and intricate than the big Merc’s, but you have to really look to even notice that. Numerous character lines adorn the hood and flanks of the 7, tasteful chrome accents are everywhere, and the flowing shape is as aerodynamic as it is beautiful.

Whether understated elegance counts more than ostentatiousness is your call. For the record though, buyers are going with the Benz. So far in 2016 through July, the scoreboard says 10,276 S-class sales versus 6,808 for the 7-series.

Inside, the 750i is every bit as technologically advanced as the Benz, and maybe more so. While everything in the new 7 is exactly where you left it the last time you sat in a modern Bimmer, it’s all been mas-

AUTO REVIEW

saged and updated. And then there’s that tech, which includes an all-digital gauge cluster, updated iDrive infotainment with a touchpad-enhanced rotary controller, BMW ConnectedDrive, Gesture Control, onboard Wi-Fi, and wireless phone charging among other cool doo-dads.

BMW Connected Drive, a system that integrates your smartphone into the car and then augments its functions, is worth a word. Frankly, our phones are so good at so many things that it doesn’t make sense for automakers to install overlapping systems, which invariably work less well. In addition to connecting to your smartphone, ConnectedDrive adds point-of-interest voice search, enhanced navigation, and special features that you access via a phone app such as saving directions to a destination which you then access in the car, remote locking and unlocking of your

vehicle’s doors, and even locating the car if you forgot where you parked it.

OK, what about ActualDrive? It’s nice, as you’d expect in any BMW, but it’s not much different from its competitors, candidly. While the S-class feels heavier and less lithe, and the Lexus LS 460 is quieter and less involving, all sedans in this class are heavy and big so it’s not like the 750i really stands out. On the open road the 750i is hard to beat, but on a twisty back road, give me an M2.

The 750i is powered by a modern 4.4L twin-turbo V8 engine that makes 445 HP and gets 17 MPG City/26 MPG highway.

A pretty good alternative is the 3.0L twinturbo in-line six that goes for around $82,000, or about $16,000 cheaper than a comparable 750i. The plug-in hybrid 740e will set you back around $90,000.

As always, BCMS’ Phil Hornbeak will

answer all of your questions and get you the best possible deal.

The BMW 750i is a top-shelf luxury sedan that’s expensive but worth it. It has amazing tech as well as luxury befitting a room at the Four Seasons. The only question is: does any of that matter in an age when it seems like everybody who can afford one of these wonderful cars is looking to buy an SUV? If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit us at www.bcms.org

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46 San Antonio Medicine • October 2016