San Antonio Medicine November 2017 by Traveling Blender

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Medical Technologies: Star Trek or Star Wars By David A. Schulz, CHP, CIPP ......................... 20 Electronic Ballots Save BCMS Time and Money By Mike W. Thomas, Editor, San Antonio Medicine .................................................... 22 BCMS President’s Message ............................................................................................................8 BCMS Legislative News ............................................................................................................................10 BCMS Alliance News ................................................................................................................................12 Health: Skin Cancer Screening Community Event by Pavela Bambekova and Kavina Patel.......................24 New Member Welcome ............................................................................................................................26 UT Health San Antonio Presidents Gala ....................................................................................................27 BCMS Auto Show ....................................................................................................................................28 Feature: Raising Standards for Accountability: Implementation of Transparency Laws for Disclosure of Environmental Disaster Data By Ammar Navid Saigal, BA (Hons), MPH, MD, Candidate (2018) .............30 Business: Tax Savings By Eric Kala, CFP, CIMA, AEP, CLU, ChFC ............................................................32 See Something, Say Something By Fred H. Olin, MD................................................................................34 The Martyrdom of Ignaz Semmelweis By Jaime Pankowsky, MD, FACS ...................................................36 BCMS Circle of Friends Directory ..............................................................................................................38 In the Driver’s Seat ....................................................................................................................................42 Auto Review: 2017 Volkswagen GTI By Steve Schutz, MD ......................................................................44

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VOLUME 70 NO. 11

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

DATA Helps Clinical Decisioning By Dr. Bob Teague, Chief Medical Officer SocialCare .........................................................18

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San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

Surge of Records-for-Ransom Attacks Makes Tightened Digital Security More Important Than Ever By Joey Berlin, Reporter, Texas Medicine ...........14

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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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San Antonio Medicine • November 2017

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Leah Jacobson, MD, President Adam V. Ratner, MD, Vice President Sheldon Gross, MD, President-elect Jayesh B. Shah, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary John Robert Holcomb, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Lori Boies, PhD, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Bradley A. Lloyd, MD, Military Rep. Rodolfo Molina, MD, Board of Mediations Chair John Joseph Nava, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative James E. Remkus, MD, Board of Censors Chair Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

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

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Carmen Garza, MD, Community Member Kristi Kosub, MD, Member Lauren Michael, Medical Student Sara Noble, Medical Student Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Adam Ratner, MD, Member David Schulz, Community Member J.J. Waller Jr., MD, Member Jane Yoon, Medical Student

San Antonio Medicine â&#x20AC;¢ November 2017

PRESIDENT’S MESSAGE

Outstanding Women in Medicine in History and Bexar County By Leah Jacobson, MD, 2017 BCMS President

“If society will not admit of woman’s free development, then society must be remodeled.” -Elizabeth Blackwell, MD

In honor of our Women in Medicine event, I reflected on the many women who blazed a path — in the United States and worldwide. As a female physician—and, according to the Association of American Medical Colleges, one of over 281,000 active women doctors in the United States — I am deeply grateful to the courage of Britishborn Blackwell. She was, in fact, one of several women medical pioneers around the world. Brazilian obstetrician, Dr. Marie Durocher (1809–1893), was the first female physician in Latin America. Gynecologist, Elizabeth Abimbola Awoliyi, became Nigeria’s first female doctor (1940s). When I think about the diverse career paths achieved by women armed with a medical education — from academia and research to global health and government — I am filled with inspiration and admiration. Over the past century, we have seen Dr. Barbara Ross-Lee become the first African American female Dean of a U.S. medical school; Dr. Virginia Apgar revolutionized neonatology; Dr. Antonia Novello became the first female (as well as Hispanic) U.S. Surgeon General (Dr. Joycelyn Elders was the first African American U.S. Surgeon General); and Dr. Margaret Chan was elected as the director-general of the World Health Organization. Today we are witnessing a larger percentage of women physicians in the U.S., up from 9.7% in 1970 to 32% in 2010. Nearly 50% of medical students are female, however only one-third of practicing physicians are women. Specialties such as cardiology and orthopedics remain male-dominated. Historically and presently, in many parts of the world, women's participation in the profession of medicine (as physicians or surgeons for instance) has been significantly restricted. However, women's informal practice of medicine in roles such as caregivers or as allied health professionals has been widespread. Twenty-seven years ago, the American Medical Association established September as Women in Medicine month. Each year, the AMA Women Physicians Section (WPS) honors physicians who have offered their time, wisdom and support to advance women with careers in medicine. The Bexar County Medical Society has supported a Women in Medicine committee for 25 of those years. The purpose of the committee is to promote women leaders in medicine, recruit and retain women members in Bexar County Medical Society and the TMA, and address special needs and issues for 8

San Antonio Medicine • November 2017

women physicians. Our primary activity is the annual “Women In Medicine Appreciation Dinner" which is held in November. The AMA's 2017 theme was “Women in medicine: Born to lead.” In that tradition, the Bexar County Women In Medicine committee is proud to recognize 20+ outstanding women in their fields. At this year's event which is being held at the University of the Incarnate Word's Sky Room, Dr. Colleen Bridger, the health director for the Metropolitan Health Department, will deliver a State of Health in San Antonio presentation and serve as the Mistress of Ceremonies. The women that are being recognized represent a large cross-section of the health care industry, including many of the large health care systems, academic institutions, and private groups. Some of those recognized are Dr. Jennifer Rushton of Clinical Pathology Associates - she was recently elected to represent TMA as an AMAalternate delegate; Dr. Teresa Ruiz, medical director of Community First Health Plans; Dr. Kristi Clark of Health Texas and a BCMS Board of Directors member; Dr. Corinne Bell of the University of Incarnate Word School of Medicine; and Dr. Nida Emko of UTHealth San Antonio Family and Community Medicine Department. I would like to congratulate all of our recipients. They are all very deserving. I hope that they will get involved, or more involved, with the Bexar County Medical Society. I have been very fortunate to be a part of this committee for most of its existence, starting as a medical student member, over 20 years ago. It is a part of the Medical Society that holds a special place in my heart. We must continue to cultivate today’s female medical professionals into leaders of tomorrow and of generations to come. The challenges of navigating unknown paths may seem daunting, but the rewards can be transformative — as eloquently articulated by Dr. Blackwell: “It is not easy to be a pioneer — but oh, it is fascinating! I would not trade one moment, even the worst moment, for all the riches in the world.” Sincerely, Leah H. Jacobson, MD, 2017 BCMS President

BCMS LEGISLATIVE NEWS

BCMS HOSTS GENERAL MEMBERSHIP MEETING AND LEGISLATIVE FORUM Last Thursday, Oct. 12, BCMS held its Fall General Membership meeting at the UT Health San Antonio Holly Auditorium, which included a Legislative Update CME presentation by TMA President, Carlos Cardenas, MD. Under the direction of Alex Kenton, MD, chair of the BCMS Legislative and Socioeconomics Committee and Mary Nava, BCMS chief government affairs officer, new to this event was the addition of a Legislative Forum, which included a panel discussion with some of our members in the Texas Legislature. All state senators and representatives from Bexar County were invited to attend. Many thanks to our legislators and their staffs for taking time out of their busy schedules to join us. Thanks also to UT Health San Antonio and Dr. Alex Kenton for hosting the event.

Participants in the panel, included:

Senate District 25 - Krista Heiden, legislative director, representing the office of Senator Donna Campbell Senate District 26 - Senator Jose Menendez House District 116 - Representative Diana Arevalo House District 117 - Representative Philip Cortez House District 118 - Representative Tomas Uresti House District 120 - Representative Barbara Gervin-Hawkins House District 124 - Representative Ina Minjarez

Legislative staff members in attendance, included:

Bryant Villa, director of constituent services, office of Sen. Carlos Uresti Cynthia Cabral, communications director, office of Sen. Menendez Marc Hoskins, chief of staff, office of Rep. Arevalo Clarissa Rodriguez, chief of staff office of Rep. Cortez Biridiana Navarro, district director, office of Rep. Uresti J.D. Pedraza, chief of staff, office of Rep. Gervin-Hawkins Naomi Miller, district director, office of House Speaker Joe Straus Lynlie Wallace, chief of staff, office of Rep. Lyle Larson At left: On Oct. 12, TMA President, Carlos Cardenas, MD, at the podium, along with members of our state legislature, (seated l-r): Krista Heiden, legislative director in the office of Sen. Donna Campbell (Dist 25) ; Senator Jose Menendez (Dist 26); Rep. Diana Arevalo (Dist 116) and Rep. Philip Cortez (Dist 117), discuss legislative topics updates from the 85th Legislative Session during the BCMS Fall General Membership Meeting.

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

San Antonio Medicine â&#x20AC;˘ November 2017

BCMS ALLIANCE NEWS

INTRODUCING THE 2018 BEXAR COUNTY MEDICAL SOCIETY ALLIANCE BOARD

Members of the BCMSA gathered for the third general membership meeting of 2017 on October 6th at the beautiful residence of Alliance member Kathy Swift, who graciously opened her home for the event. Aside from the typical general membership meeting agenda items such as bylaw changes, Alliance members also enjoyed a fun and informative cooking demonstration by Diana Barrios (of

San Antonio Medicine â&#x20AC;˘ November 2017

Los Barrios restaurant). Furthermore, the 2018 slate of BCMSA officers proposed by the nominating committee were voted on and approved. The 2018 BCMSA Board led by President Jenny Shepherd includes: Rena Baisden, President-Elect; James Duerr, VP of Membership; Liz Wilson Huang, VP of Communication; Valerie Garrison, VP of Programs; Jennifer Torres, VP of Civic and Philanthropic; Nichole Eckmann, VP of Social; Kelly King, Recording Secretary; Danielle Henkes, Corresponding Secretary; and Becki Wortham, Treasurer. Stay tuned for future updates, as I know that Jenny and her board have an exciting year planned! Details to come soon on our final general membership meeting in December, which will be a Holiday Afternoon Tea. We are asking members to bring a cuddly stuffed animal friend to be donated to the University Hospital Emergency Room for the pediatric patients! All the best, Lori Boies, 2017 BCMS Alliance President bcmsalliance@bcms-alliance.org

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MEDICAL TECHNOLOGY

Surge of Recordsfor-Ransom Attacks Makes Tightened Digital Security More Important Than Ever By Joey Berlin, Reporter, Texas Medicine

Millions of dollars are making digital transfers from reputable entities to criminals, exposing just how vulnerable physician practices are to technological invaders. All it takes for this nightmare scenario to transpire is one person in a physician's office coming into contact with computer malware. Big practice, small practice, or in-between, the recent rise of ransomware poses a serious threat. When that threat becomes reality, it can leave physicians feeling helpless. In a ransomware attack, cyber criminals use malware to lock an organization, such as a medical practice, out of its computer data and demand digitally paid ransom in exchange for an encryption key to regain access to the information. Ransomware has reached Texas, and its emergence highlights the importance of up-to-date security. Matt Murray, MD, chair of the Texas Medical Association Ad Hoc Committee on Health Information Technology (HIT), notes that until recently, cyber attack prevention strategies focused on maintaining confidentiality of electronic health records (EHRs). But the threat of ransomware is creating a "new normal," Dr. Murray says, and a ransomware attack is a different threat than an EHR data breach. "It impedes the ability to take care of patients who are in the office, as well as those who call the office," Dr. Murray said. "At the end of the day, the physician is left struggling to take care of patients who are sick without access to information that is really needed." The Texas Medical Liability Trust (TMLT) has received cyber extortion-related reports from 12 policyholders. John Southrey, direc14

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tor of product development and consulting services at TMLT, notes the level of sophistication in ransomware attacks can be high. The difficulty in battling the new threat once it hits means physicians need strong preventive measures. "The people who are doing this are not some geeks in the garage or in their apartment," Mr. Southrey said. "I mean, that can be the case. â&#x20AC;Ś You've got some really smart people out there, but a lot of this is organized." Insurance coverage in the event of a ransomware attack is crucial, and TMLT's medical professional liability policies include cyber liability coverage for cyber extortion. Those policies cover the expenses of an attack and, with TMLT's consent, reimbursement for the payment of cyber extortion funds to terminate the threat.

It Could Happen to You

Health care is particularly vulnerable to the ransomware threat. KPMG's 2015 Health Care and Cyber Security Survey, which polled 223 U.S.-based health care executives, found four-fifths of respondents said cyber attacks had compromised their information technology.

Several large health systems have been high-profile ransomware targets.

In 2016, a ransomware attack knocked the computer systems at Hollywood Presbyterian Medical Center in Los Angeles off-line for more than a week, according to reports. The hospital ultimately decided to pay the ransom of about $17,000 in bitcoins, a digital form

MEDICAL TECHNOLOGY of currency, to obtain the decryption key and regain access to records. When smaller shops are the target, the perpetrators adjust their ransom demands accordingly. As Mr. Southrey explains, "Usually the ransom is reasonable because they know if it's too expensive, the practice is not going to pay it. "In general, when we do our risk assessments for medical practices, we find privacy and security vulnerabilities, and they're not even aware of these vulnerabilities," he said. "They're a target because cyber criminals know that they don't have those resources like some organizations do. â&#x20AC;Ś They're kind of a training ground, or as some commentators have stated, 'low-hanging fruit' for cyber criminals to be able to get into their systems. And it's a quick buck for these cyber criminals if their ransom demand is reasonable, such as $500 or $600." Part of the problem stems from small-practice physicians either not being aware of the pervasiveness of cyber threats or believing their operation isn't large enough to interest hackers. Patrick Casey, then-meaningful use and quality assurance specialist for the North Texas Regional Extension Center (NTREC), said in May there hadn't been any inquiries from physician practices about protecting themselves from ransomware. NTREC, scheduled to close in June, assisted small practices in transitioning to EHRs and also performed security risk assessments. Mr. Casey says many physicians have "an overconfidence â&#x20AC;Ś in technical solutions. They usually believe a certified EHR system completely takes care of security for them," he said, adding that most small practices "don't think they're interesting enough to be attacked in any sense." "There is very little awareness of the issue and there's very substantial overconfidence that somebody else, like their EHR vendor or IT contractor, is taking care of this for them. It doesn't surprise me that they're usually not worried about it. The only time they're worried about it is when they get hit or when they get audited [for meaningful use or HIPAA compliance]. And so far, nobody who's gotten hit has given us a call."

Protecting Yourself

Common vulnerabilities TMLT has identified include out-ofdate data security, careless use of passwords, and outdated computer systems. Prevention of a ransomware attack starts with strong data security training for staff, IT security, and making sure backup data exists. Malware often infects a practice's computer system when someone in the office unknowingly opens an infected email attachment or clicks on an infected link. TMA recommends physicians back up their computer systems regularly to an external drive or a backup service, such as a cloud service provider. Physicians should equip computers with reputable anti-malware software and a firewall to help detect threats. TMA also recommends practices set up their email accounts to deny

emails with executable file attachments, patch or update their software regularly, and enable automatic software updates. "It's really having that backup and then good patch management, making sure that you do all your updates. You don't use end-of-life systems like Windows XP or a Windows Server 2003 because it's not supported anymore by Microsoft," Mr. Southrey said. TMA Practice Consulting offers HIPAA compliance assessments that evaluate the strength of a practice's cyber security. Abilene family physician D. Allen Schultz, MD, a member of the Ad Hoc Committee on HIT, calls ransomware "a likely threat of severe intensity." "You really assess threats two ways: Is it likely, and how severe would it be if it occurred?" he said. "I think that it is likely and that the damage would be severe. I'm very concerned about that and interested in making sure that we've got good firewalls and try not to use any of my office computers for surfing the Web or downloading email or anything like that." Dr. Murray says, along with a backup of EHR data, the most effective, foolproof protection against a ransomware attack is the ability to quickly restore the EHR and its data. "If the practice can do that, they will not have to pay a ransom, and the impact on patient care can be minimized if the backup and restore tools and processes are effective," he said. But he says no system is completely cyber attack-proof, and physicians must have a business continuity plan for technology downtimes or disasters. The primary focus of a preventive strategy, he says, should be to ensure a degree of clinical continuity when the EHR system goes down. "Physician practices should understand the tools and processes that are in place to back up and restore the [EHR] in the event of a disaster and to make sure they get tested. I emphasize again, to make sure they get tested," Dr. Murray said. "The first time a physician discovers that it will take a week to restore their [EHR] should not be after a real disaster strikes. Instead, the practice and their vendor should periodically undertake a disaster drill to test the backup and restore tools and processes."

Just Pay Up?

After an attack does happen, giving in to the criminals and paying the ransom to restore access is hardly an ideal solution. However, some hacked hospitals, including Hollywood Presbyterian, have done so. "The quickest and most efficient way to restore our systems and administrative functions was to pay the ransom and obtain the decryption key," Hollywood Presbyterian then-Chief Executive Officer Allen Stefanek told the Los Angeles Times. "In the best interest of restoring normal operations, we did this." Mr. Southrey and others point out there is also a risk in paying the ransom. Although they'll get their data back in most cases, Mr. Southrey says, there's no guarantee they will. Also, hackers could continued on page 16

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MEDICAL TECHNOLOGY

continued from page 15

breach the data themselves in addition to locking the practitioner out of it. He says if the hackers do breach the data, the practice may never receive confirmation they deleted it once they handed over the encryption key. A hacker who still has access to the data could use it for other criminal purposes. Kansas Heart Hospital in Wichita learned the hard way hackers aren't always true to their word. The hospital sustained an attack on its files and paid an undisclosed ransom. But the hackers didn't give the hospital full access to its files, instead demanding a second payment. Kansas Heart said it refused to pay the second time, with hospital President Gregory Duick, MD, saying the institution decided paying the ransom was "no longer … a wise maneuver or strategy," according to a news report. Dr. Duick said the hospital had a plan in place for such an attack and put it into action, and that "patient information was never jeopardized" as a result of the hack. An FBI agent made news in security circles when he reportedly told an audience at a Boston cyber security conference some malware is so uncrackable that "to be honest, we often advise people just to pay the ransom." Joseph Bonavolonta, assistant special agent in charge of the FBI's CYBER and Counterintelligence program in its Boston office, told the conference, according to news website The Security Ledger, "The ransomware is that good." Mr. Bonavolonta said while victims of ransomware should contact the FBI, the bureau had been unable to crack the encryptions of some types of malware, adding "the easiest thing to do may be to just pay the ransom." But in a blog post on the ransomware threat, the FBI said it doesn't recommend doing so. "Paying a ransom doesn't guarantee an organization that it will get its data back. We've seen cases where organizations never got a decryption key after having paid the ransom," James Trainor, assistant director of the FBI's Cyber Division, wrote in the blog post. "Paying a ransom not only emboldens current cyber criminals to target more organizations, it also offers an incentive for other criminals to get involved in this type of illegal activity. And finally, by paying a ransom, an organization might inadvertently be funding other illicit activity associated with criminals." The FBI recommends organizations focus on prevention — having both employee awareness and technical controls in place — and creating a solid business continuity plan to act on if an attack does happen.

Increasing Support

TMA plans to raise awareness of the threat of ransomware and help physicians manage all security and technology risks. The Ad Hoc Committee on HIT is keeping its eye on the development of the SECURETexas certification program, one potential cyber se16

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curity risk-mitigation avenue. In 2011, the Texas Legislature passed House Bill 300 by thenRep. Lois Kolkhorst (R-Brenham). The legislation mandated the creation of a state compliance certification program. As a result of the bill, the Texas Health Services Authority contracted with the Health Information Trust Alliance to develop SECURETexas. According to HB 300, certification would be a mitigating factor if a physician violates the Texas Medical Records Privacy Act, potentially leading to reduced civil or administrative penalties in the event of a data breach. Family medicine physician James Stefan Walker, MD, a member of the Ad Hoc Committee on HIT, beta-tested a small-practice version of the program using his practice, Corpus Christi Medical Associates, and reported back to the committee. Through those reports, Dr. Murray said, "We see that there is a lot of value that can be gained by the practice as they have to go through the certification process. But we also see that more work is needed to further simplify the process. Our goal is to have a certification program that uses a security risk analysis process and provides a risk management plan that is designed specifically for a physician practice, is cost-effective, is feasible to achieve without straining physician and staff time, and is able to provide value by reducing and managing technology risks, including ransomware attacks." In many organizations, large and small, Mr. Casey says, "The attitude is, 'What do I need to do to comply with the law?' not 'What do I need to do to protect my patients' data and my patients?' They don't yet have that thought." "Honestly, I don't want doctors having to become experts in HIT security. They've got enough on their plate to be doctors," he said. "We have to find a way to continue to and even increase the support that we make available to the health care community." Large hospital systems, he adds, "can probably afford a chief information security officer who does nothing but … worry about security and get monitoring software and all that kind of jazz. Those resources can be made available to every small practice associated with that hospital; otherwise, security expertise and support are not available to the independent practices in the ambulatory community." Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393.

MEDICAL TECHNOLOGY

DATA HELPS CLINICAL DECISIONING By Dr. Bob Teague, Chief Medical Officer, SocialCare Data in healthcare is good. Data applied for something useful – like a clinical decision that informs individual care – is even better. Despite progress in acquiring data and advances in artificial intelligence and machine learning for analysis, humans remain central to decisioning in healthcare. Decisioning requires the automated delivery of only needed information to the point of decision. Necessary elements include access to requested data, standardization of data, analytics operations and insights from machine learning. These inputs are delivered automatically and organized in a user interface familiar to the decision maker. In this context, data are only useful if they results in an action or a professional judgment. Most of what resides in the clinical data about an individual is not needed for the next clinical decision and should not be presented unless requested. Post-decisioning status creates a set of Actions. Much of Action can be systematized and automated because these functions are largely the assemblage of information and the execution of predictable activities. Post-decisioning automation includes actions like delivery of prescriptions, standard work flows, requests for testing or procedures, reports and communication, analytics and output from machine learning. As with the automation of information flow into the decision process, a wealth of applications can be developed to support these downstream activities as well. The process of analyzing and presenting ever larger data sets at the point of clinical care requires advances in automation and not only machine learning but also systems-level learning. The learning loops and outcomes feedback loops support the systems-level learning. We have reached an inflection point where generating data vastly exceeds our capability to use it in clinical settings or for self-care due to a lack of effective process automation. The process for good human decisioning starts with asking 18

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“why” data are being presented. What is the step required next? Then, after the decision, there are opportunities to develop innovative options for carrying out the downstream activities the results of which become part of the data that feeds the next assess function. Dr. Bob Teague is Chief Medical Officer of SocialCare, a secure, connected software platform built on open API that achieves true interoperability that patients, providers, and regulators now demand. Leveraging SocialCare™, Dr. Teague works with payers and providers to help them achieve the intended purpose of value based care - increased quality, lowered costs and improved satisfaction. He brings a career spanning clinical practice in Houston’s Texas Medical Center and leadership roles in technology to improve healthcare processes and outcomes through multiple entrepreneurial enterprises, major healthcare institutions, and Fortune 50 technology companies. Board certified in Internal Medicine and Pulmonary Disease, Dr. Teague’s prior roles include VP of Clinical Transformation and Physician Services at Quorum Health and Managing Principle for Dell Healthcare Consulting. Before that, he was Corporate Medical Director at Compaq Computer Corp for 18 years including internal, product and market facing roles. He is a veteran of three healthcare services startups as founder and served in C-level roles in three turn around engagements including experience in the public markets.

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MEDICAL TECHNOLOGY

MEDICAL TECHNOLOGIES: OR By David A. Schulz, CHP, CIPP Wireless functionality of Dick Cheney’s heart implant was disabled in 2013 for fear of hacking. Four years later, those reservations are more than justified. The FDA just recalled 465,000 pacemakers, concerned about unauthorized command access. The recall, happily, only involved a firmware update in a doctor’s office, not in an operating theater. Not yet, anyway. Nevertheless, the promises of interconnected medical devices have not lost luster. Providers and patients are adopting technologies at an unprecedented rate, in the hopes they offer more patient-centric relationships and reduced costs. A recent survey by Imaging Technology News showed 66 percent of Americans would use a medical app to manage health-related issues instead of a doctor. There are now more than 97,000 mobile apps related to health and fitness, most with little or no regulatory oversight. The FDA has established narrow criteria for medical app review and approval, in three cases: if the app controls another medical device; or if the app turns the mobile platform into an actual regulated device; or if the app provides data analysis and offers patient-specific treatment or diagnosis. However, it does not regulate apps that store and/or transmit patients’ information, and admits its rules are a work in progress. Even regulated devices are not immune to skullduggery. The Hospira LifeCare Drug Infusion Pump had a notorious vulnerability allowing remote alteration of drug dosage delivery. Medtronic’s Paradigm Pumps used unencrypted and unauthenticated commands to deliver insulin, opening them to unauthorized interference. Various Implantable Cardioverter Defibrillators (ICDs) were found to be hackable by Bluetooth. The list gets longer as every new device presents new opportunities for malice. 20

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Consider iStan, the $100,000 medical dummy described by manufacturer CAE as “A fully mobile patient simulator with advanced physiology and functionality for unlimited training possibilities.” Researchers at the University of Southern Alabama “killed” it by hacking its embedded pacemaker. "The simulator had a pacemaker so we could speed the heart rate up, we could slow it down," the researchers reported. "If it had a defibrillator, which most do, we could have shocked it repeatedly. It's not just a pacemaker — we could do it with an insulin pump, [or] a number of things that would cause life-threatening injuries or death." For those growing up with visions of the Starship Enterprise’s sickbay and Dr. McCoy’s medical tricorder, med-tech is very enticing. In its emerging stage, though, it presents a significant challenge. The Health Care Industry Cybersecurity (HCIC) Task Force states the conundrum well: “The health care system cannot deliver effective and safe care without deeper digital connectivity. If the health care system is connected, but insecure, this connectivity could betray patient safety, subjecting them to unnecessary risk and forcing them to pay unaffordable personal costs. “Our nation must find a way to prevent our patients from being forced to choose between connectivity and security,” concluded the June report. For now, it is up to providers to question the security and vulnerabilities of new technology before adoption. David Schulz, certified information privacy and certified HIPAA professional, is executive director and CEO of Cyber Risk Associates LLC in San Antonio. He is a community representative on the BCMS Communication/ Publications Committee.

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MEDICAL TECHNOLOGY

ELECTRONIC BALLOTS SAVE BCMS TIME AND MONEY By Mike W. Thomas

The Bexar County Medical Society held its first election this year using electronic ballots and the results were very positive, said BCMS Chief Operating Officer Melody Newsom. "Electronic voting saves our physician members time and is less expensive to administer in terms of staff time and hard costs," Newsom said. “In the past it usually took two to three hours for the physicians and staff on our Nominating Committee to review and count all the ballots. Now the results are automatically calculated and it is all very secure.” One year it took nearly five hours for the committee to count the ballots in a closely contested race, she said. More than 1,000 ballots were cast and they had to be counted three times as the race was decided by fewer than five votes. Newsom said she tested the new voting system to make sure no one can vote twice. The system can also track who has not

voted and send automatic reminders to encourage higher turnout and participation. The electronic ballots are more robust than the paper ballots they have replaced and can include pictures and curriculum vitae about each candidate and even campaign messages. This year more than 2,150 electronic ballots were sent out along with 400 hard or printed ballots to those who requested them. Voting is restricted to active members and does not include students, residents, military, life or retired members. “We will still send mail-in ballots to those who cannot vote electronically, but from here on most voting will be done electronically,” Newsom said. If you did not receive an electronic ballot or a mail-in ballot and feel that you should have, please call the BCMS Membership Department at 210-301-4398 or email membership@bcms.org.

AFFIDAVIT OF RESULTS BCMS 2017 ELECTION FOR 2018 OFFICERS President-elect Adam Ratner, MD

Treasurer John R. Holcomb, MD

Vice President Gerald Greenfield, MD

Secretary Kristi Clark, MD

San Antonio Medicine • November 2017

Board of Directors John D. Edwards, MD Gerardo Ortega, MD Manuel Quinones, MD

BCMS 2017 ELECTION FOR 2018 OFFICERS (cont) Board of Mediations Rajaram Bala, MD Ravi Ganeshappa, MD Richard Hannigan, MD (Chair in 2020) Luis Torres, MD Board of Censors Linda Banta, MD Nora Walker, MD (Chair in 2020) Nominating Committee Jose Santos, MD Christian Woodbury, MD DELEGATES TO TMA Rajaram Bala, MD Josie Ann Cigarroa, MD Chelsea Clinton, MD John D. Edwards, MD Harold V. Gaskill, MD Anupama Gotimukula, MD Gerald Q. Greenfield Jr., MD John W. Hinchey, MD John R. Holcomb, MD Wendy Bay Kang, MD Margaret Ann Kelley, MD Juan Diego Martinez, MD Darleen Metter, MD J. Marvin Smith, III, MD Marc T. Taylor, MD ALTERNATE DELEGATES TO TMA Brian Boies, MD Erika Gonzalez-Reyes, MD Sheldon G. Gross, MD Michael Kim, MD David Lam, MD William Cannon Lewis, MD Milagros A. Martinez, MD Erika Munch, MD Vatsal B. Patel, MD Steven Ramos, MD John Milton Shepherd, MD Iveth Soza, MD Rajeev Suri, MD Roberto Trevino Jr., MD Aruna Venkatesh, MD visit us at www.bcms.org

HEALTH

Skin Cancer Screening COMMUNITY EVENT By Pavela Bambekova and Kavina Patel On August 10th, the Cancer Therapy and Research Center (CTRC) held its annual skin cancer screening event. The skin cancer screening is organized by the dermatology department from UT Health San Antonio. Every year, about 150 San Antonio residents can sign up to see a community dermatologist and have their skin checked free of charge. Skin cancer is a very common finding in San Antonio, given the vast sun exposure people in the Southern part of the United States receive. The most common forms of skin cancer detected in this region are basal cell carcinoma, squamous cell carcinoma, and melanoma. Skin cancer does not spare any ethnicity and skin color, though it is more common in people with lighter tones. People should be alerted to see a dermatologist if they notice a lesion that is not healing and suddenly growing, crusting, bleeding, and recurring.1 According to Dr. Sandra Osswald, Dermatology Division Chief, the best way to try to prevent skin cancer is by “using sunscreen, sun protection, and avoiding prolonged sun exposure.” Dr. Osswald also added that people should avoid tanning. Research from the American Academy of Dermatology shows that tanning beds increase the risk of melanoma by 59%, and melanoma is the leading 24

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cause of cancer in people between the ages of 15 and 29.1-2 Trying to prevent skin cancer can be difficult, especially for people who might not know about the danger chronic sun exposure poses to health or who might not have the means to purchase proper sunscreens of 30 SPF or higher, schedule dermatologist appointments, or obtain healthcare. Free skin cancer screenings like the one held at the CTRC make it possible for people of all backgrounds, socioeconomic levels, and skin types to have an opportunity to be evaluated for any abnormal skin changes. “My father had multiple skin cancer lesions, and I hope to help others in his position,” said Kathryn Hinchee-Rodriguez, a third year medical student who volunteered at the event. Kathryn was one of twelve medical students who dedicated time outside of academic coursework to get more exposure to dermatology and contribute to community service. “As medical students, we chauffeured the patients to and from their respective exam rooms,” said Kathryn. “We acted as ambassadors for the physicians we were assisting.” This was Kathryn’s second time volunteering at the event. For many of the other students, however, this skin cancer screening was their first. “I found out about this event through the Dermatology Interest Group,” said Ruby Gibson, a second year medical

HEALTH

Photo (opposite page): Pictured from left to right: Dr. Valerie Shui, Ruby Gibson (second year medical student), Dr. Sandra Osswald, Kathryn HincheeRodriguez (third year medical student), and Pavela Bambekova (second year medical student). Photo (this page): Dr. Valerie Shiu reviews a patient chart with medical student volunteers Daniel Glade (second year medical student), Ruby Gibson (second year medical student), and Kathryn Hinchee-Rodriguez (third year medical student).

student. “I am glad I volunteered - it is a great opportunity to get involved in the community and to apply what we are learning in the classroom in a real clinical setting,” she added. Some of the older students and current dermatology residents have volunteered to screen patients for several years. Dr. Valerie Shiu is a current dermatology resident at UT Health San Antonio and has seen patients at the event for six years. “I volunteered at the skin cancer screening throughout my time in medical school,” she said. In the past two years, she has been performing full body exams by herself. If she sees something that might look suspicious, she refers the patient to a local dermatologist for evaluation and a possible biopsy. The annual skin cancer screening event is sponsored by the American Academy of Dermatology. This year, over 120 patients were seen in just over two hours. Along with medical students and dermatology residents, many dermatology faculty members and community volunteers also assisted with patient screenings. “Volunteering at the event not only helped me understand how to perform a basic dermatological exam, but it also allowed me to better understand the needs and concerns of our city’s population,” said Kathryn. There are other skin cancer awareness and prevention

events for the San Antonio community such as the annual student-organized Run From the Sun 5K in addition to the Travis Park Dermatology Clinic held downtown twice a month. People suspicious of skin changes are encouraged to have their skin checked by a dermatologist because skin cancer is curable - the key to live with it is early detection.

References:

1. Skin cancer. (n.d.). Retrieved August 10, 2017, from https://www.aad.org/media/stats/conditions/skin-cancer 2. Indoor tanning. (n.d.). Retrieved August 10, 2017, from https://www.aad.org/media/stats/prevention-and-care Pavela Bambekova is a second year medical student at UT Health San Antonio, Long School of Medicine. Kavina Patel is a first year medical student at UT Health San Antonio, Long School of Medicine.

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BCMS NEW MEMBER WELCOME

The Bexar County Medical Society held its

New Member Welcome Event on Sept. 26 in the Paramount at The Phipps, 102 9th St.

San Antonio Medicine â&#x20AC;¢ November 2017

UT HEALTH GALA

UT Health San Antonio President’s Gala The UT Health San Antonio President’s Gala was held on Sept. 23 and raised more than $1 million for heart disease research. Joe Gorder, chairman and president of Valero Energy Corp., and his wife Lacie were honored with the naming of endowments in their name. Also, Dr. Steven Bailey, chief of the Janey and Dolph Briscoe Division of Cardiology at UT Health, was honored with a Presidential Commendation.

(Left to right) Honorees Joe and Lacie Gorder visit with Mary Henrich and President William L. Henrich, M.D., MACP, at the 2017 UT Health San Antonio President’s Gala.

During the gala President William L. Henrich, M.D., MACP, (right) presented Dr. Steven Bailey (left), chief of the Janey and Dolph Briscoe Division of Cardiology at UT Health, with a Presidential Commendation. Dr. Bailey was honored for his many contributions to improving cardiovascular procedures, including new, less invasive treatments for valvular heart disease.

Visiting at the gala are (left to right) Dr. Ruben Mesa, director of the UT Health Cancer Center, Carolyn Holly and James Larry Holly, M.D.

Also honored were the Winkler Family. Little Evie was just 1 week old when she underwent her first open-heart surgery for a congenital heart defect. At the gala, the Winkers, (left to right) Zack, Evie and Jennie, were reunited with Evie’s pediatric cardiothoracic surgeon, Dr. S. Adil Husain (right), from UT Health San Antonio.

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BCMS AUTO SHOW

The Bexar County Medical Society held its 31st Annual Auto Show on Oct. 19 at the United Texas Credit Union at 5500 UTSA Blvd. featuring complementary food and beverages, live music and more than 100 vehicles to look at from local dealerships.

San Antonio Medicine â&#x20AC;˘ November 2017

BCMS AUTO SHOW

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FEATURE

Raising Standards for Accountability: IMPLEMENTATION OF TRANSPARENCY LAWS FOR DISCLOSURE OF ENVIRONMENTAL DISASTER DATA By Ammar Navid Saigal, B.A. (Hons), M.P.H., M.D. Candidate (2018) University of Texas Health Science Center at San Antonio School of Medicine Early distribution of protection protocols related to environmental disasters is a critical preemptive measure to limit the associated adverse impact on society. Countless examples exist of populationwide catastrophes resulting from negligent human behavior; however, appropriate disclosure of data to the masses detailing these calamities was often lacking.[1] In order to achieve the highest standards of transparency within healthcare, agencies responsible for collection of environmental disaster morbidity statistics must ensure the distribution of qualitative, factual, and preventive guidance to the public. Health professionals bear an ethical obligation to advocate for the passing of legislation that will require timely, appropriate disclosures to be made in the event of environmental disaster. The enactment of transparency laws will lower the burden of financial expense and mortality experienced during crises such as the lead toxicity of Flint, Michigan water or the insufficiency of failsafe measures that resulted in the Deepwater Horizon oil spill. Retro30

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spective analyses have repeatedly demonstrated that implementing new systems of disclosing epidemiological data into law is an urgent need for the purpose of adequate disaster containment and relief.[3] Legislation directing efforts to disseminate knowledge to the public has emerged in recent history as a force for raising national accountability during environmental crises.[6] The water-poisoning crisis of Flint, Michigan is the most obvious instance in recent memory of failure of transparent disclosure. The Centers for Disease Control and Prevention (CDC) was authorized to initiate counter-measures against childhood lead poisoning via passage of the Lead Contamination Control Act of 1988.[8] One of the CDC's responsibilities in this endeavor was to screen children for the development of lead poisoning. The absence of a well-publicized effort by the CDC to monitor blood lead levels in Michigan illustrates the lack of transparency by health authorities. The CDCâ&#x20AC;&#x2122;s response was not capable of identifying, giving

FEATURE warning of, or remediating the lead exposure. Studies have indicated that the danger of lead poisoning could instead have been discovered in time to avoid extensive harm.[4] In addition to the CDC's widespread monitoring of lead blood levels being rendered ineffective due to non- disclosure, the agency’s failure to provide safety constitutes a nonfeasance that the medical community is ethically bound to address. Publication of hematologic studies to inform the public would likely have resulted in quicker identification and resolution of this tragedy. Medical professionals and policymakers must abide by a humanitarian code of ethics that promotes the interests of citizens nationwide in achieving a high degree of transparency by authorities. Registries for the release of information represent the most promising means of disseminating environmental disaster data to the public and have demonstrated success in limiting consequences for the general welfare.[2][5] In summary, legal enactment of novel methods for transparent, widespread disclosure of epidemiological data has the potential to prevent adverse effects from progressing onward during public health crises. The ethics of transparency should be well-understood by government agencies in order to raise standards for accountability.[7] Implementing transparency laws pertaining to expedient release of information represents the most effective mode of preparation for minimizing disaster impact in existence today.

Bibliography

1) Biachi, A., & Peters, A. (2013). Transparency in International Law. University of Cambridge: Cambridge University Press. 2) Berro, L., & Leao, C. (2016, January 27). Understanding One of the worst environmental disaster in brazil’s history. Oxford Human Rights Hub: A Global Perspective on Human Rights 3) Verchick, R. R. M. (2012). Facing catastrophe: Environmental action for a post-katrina world. Cambridge, MA: Harvard University Press. 4) Campbell, C., Greenberg, R., Mankikar, D., & Ross, R. (2016). A case study of environmental injustice: The failure in flint. International Journal of Environmental Research and Public Health, 13(10), 951. doi:10.3390/ijerph13100951 5) Ker, M. (2014, July). Getting Down to Business: Deepening Environmental Transparency in China. Solutions: For a Sustainable, Desirable Future 6) Bouthillier, Y. L., & Canada (2012). Poverty alleviation and environmental law. United Kingdom: Edward Elgar Publishing. 7) Transparency in the haze. (2014, February 8). Environmental Accountability: Beijing. The Economist. 8) CDC. (2016, May 4). Learn more about CDC’s childhood lead poisoning data. Retrieved from https://www.cdc.gov/nceh/lead/data/learnmore.htm

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BUSINESS

TAX SAVINGS: 401(k) Nice, Cash Balance Better By Eric Kala CFP®, CIMA®, AEP®, CLU®, ChFC® Wealth Management Advisor | Estate & Business Planning Advisor Avid Wealth Partners Affiliated with Northwestern Mutual

Most practitioners today in private practice have established a 401(k) plan. This plan has a dual purpose. First, the 401(k) plan provides the practice and its employees with a qualified retirement plan. Second, the business owner receives a tax deduction. The 401(k) plan has its limits though. The most that can be put away for retirement in a year is $54,000 in 2017 ($60,000 if you are age 50 or older). What if we could take the attributes of your current 401(k) plan and significantly scale it up? How could we do that? By adding a cash balance plan to your retirement and tax planning arsenal. A cash balance plan is another type of retirement plan that is fully qualified by the Internal Revenue Service (IRS). It allows an owner that makes more than $265k annually to accumulate in excess of $2.5 million dollars over a tenyear period. With the addition of a cash balance plan your deductible contribution increases from $54,000 to as much as $250,000 or more. A cash balance plan is a pension plan that looks and acts very much like your 401(k) plan. It has an account balance that grows each year by the addition of an employer contribution and an interest credit. That account balance is also the benefit that you will receive from the plan. The contributions funding the plan are tax deductible. The growth in the plan is tax deferred and the option 32

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to rollover your distribution to an IRA so that it continues to remain in a tax deferred vehicle is also available. These are the same features that make your 401(k) plan so attractive, but now we are able to do this on a much larger scale. Think of your 401(k) plan as your employee benefit plan. Now think of the cash balance plan being added on as your plan. Typically your 401(k) plan is designed today to take advantage of the IRS’s rules on non-discrimination. This allows you to get a relatively high percent of the overall contribution for yourself. When we add the cash balance plan on top of your 401(k) plan we get a result that adds even more leverage to your overall retirement program. Here is an example. A physician who is 64 years old making $265k per year with a staff of three employees whose payroll is $135,000. Currently he has a 401(k) plan where he is contributing $59,000 for himself and $6,200 for his staff. By adding a cash balance plan his contribution increases to $269,000. As a result of the addition of the cash balance plan his staff cost has only increased to $22,000. Over 92 percent of the contribution is going to the owner and the tax savings jumped from $26,000 to $116,000 (based on a 40 percent tax rate), with an estimated decrease of $90,000 on his tax bill. The previous example was for a small company. The cash balance

BUSINESS concept is scalable, which means we could get similar results with multiple owners and a larger staff. Large doctor groups have begun to use cash balance plans more often. They are being used for both the tax deduction and as a tool to help attract and retain high end talent. These groups often have 10 doctors or more and we can usually get very good results which potentially include large tax savings. The cash balance plan is not a solution in all instances but when you are looking for larger deductible contributions than you are able to get just in your 401(k) plan the cash balance plan may well be worth looking into. The leveraged tax savings that a cash balance plan can offer may be a good answer to your tax and retirement questions.

Age 60-65

Avid Wealth Partners is a marketing name for Eric Ilmari Kala in their capacity as a representative of Northwestern Mutual and is not a legal business name. Northwestern Mutual is the marketing name for The Northwestern Mutual Life Insurance Company, Milwaukee, WI (NM) (life and disability insurance, annuities and life insurance with long-term care benefits) and its subsidiaries. Eric Ilmari Kala is a Representative of Northwestern Mutual Wealth Management Company (NMWMC) Milwaukee, WI (fiduciary and fee-based financial planning services), a subsidiary of NM and a federal savings bank. Certified Financial Planner Board of Standards Inc. owns the certification marks CFP®, CERTIFIED FINANCIAL PLANNER™ CFP® (with plaque design) and 2017 MAXIMUM CONTRIBUTION LIMIT CFP® (with flame design) in the U.S., which it 401(k) with Tax Savings 401(k) Only Profit Cash Total (39.6% Tax awards to individuals who successfully complete Sharing Balance Bracket) CFP Board's initial and ongoing certification re$24,000 $60,000 $256,000 $316,000 $125,136 quirements.

55-59

$24,000

$60,000

$206,000

$266,000

$105,336

20-54

$24,000

$60,000

$157,000

$217,000

$85,932

45-49

$18,000

$54,000

$120,000

$174,000

$68,904

40-44

$18,000

$54,000

$92,000

$146,000

$57,816

35-39

$18,000

$54,000

$70,000

$124,000

$49,104

Eric Kala is a San Antonio based advisor that works extensively with physicians and business owners on their financial wellness and their specific needs around protecting and growing their assets.

visit us at www.bcms.org

FEATURE

SEE SOMETHING SAY SOMETHING A True Tale of Travel By Fred H. Olin, M.D. Not long ago (and two days before I’m writing this) my wife and I were flying home after about a week away. It wasn’t a pleasure trip, and we were pretty tired, both physically and emotionally. We were sitting in the gate area awaiting the call for our departing flight to San Antonio. We had our backs to the windows and thus were facing the rows of seats lined up on our side of the concourse. Sitting directly in front of us at the end of one of the rows was a young man, probably in his twenties. He was Anglo, had very long shaggy, uncombed hair, no facial hair, wore a black tshirt with the word “Hate” on it, black jeans and running shoes. He had a well-worn, very stuffed backpack at his feet. He was talking loudly, seemingly mostly nonsense, rambling, singing, gesticulating, waving his hands about and making miscellaneous other sounds. Periodically he would pull a small brown teddy bear out of the top of the pack, hug it, kiss it, talk to it as if it were a person, and then stuff it back in the pack. The bear had a bandage wrapped around its left elbow. As the pre-flight announcements began, he suddenly said this, somewhat paraphrased: “I’ve got my passport, my drivers license, my birth certificate and I’m ready to fly and die.” This concerned us. After a moment of reflection and talking with my wife, I rose and went to the side of the gate-agents’ desk and got one of them to come over and talk with me. I told him what we had observed and heard. He thanked us and moved toward the jet bridge while I returned and sat down again. Finally, our seating group was called. Just after our boarding passes were scanned, there stood the captain of our plane with the gate agent nearby. He stopped us and asked us if we were the ones who had reported what we had heard, and we admitted that we were. He quizzed us just a little bit, then said “He’s not flying on this plane. I’m the captain and it’s my call.” We 34

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proceeded to board and get seated, and as we settled in we saw the young man pass us toward the rear. Shortly thereafter, he accompanied a flight attendant to the front, and was removed from the plane with no furor. After he passed us the young man announced rather loudly, “I’m just a musician taking a vacation.” The flight to SAT was (thank goodness) uneventful. We came in at Terminal A, but because of the airline we were on had to walk to Terminal B for our luggage. As we proceeded, a First Officer (copilot) came up along side of us and said that he had been “deadheading” and sitting in the seat in front of us. He had stopped to talk with his colleagues in the cockpit who had told him what had happened and pointed us out. He thanked us rather profusely, saying that without someone saying or doing something the crew would never know if there was a potential problem. He told us that the young man would be evaluated somehow, and decisions made as to his fitness to fly on a later flight. Soooo….that little four-word phrase I used for the title of this story should remain in your psyche: perhaps the young man was harmless, perhaps he was high on something, or, perhaps, as one of the flight attendants suggested, he suffers from some generally benign psychiatric illness such as ADD, but my wife and I didn’t want to find out the hard way that we should have done something and didn’t.

MEDICAL HISTORY

THE MARTYRDOM OF IGNAZ SEMMELWEIS By Jaime Pankowsky MD, FACS Before there was Louis Pasteur demonstrating that microbes caused illnesses, there was Fracastorius (XVI century) who told us in verse about “seminaria contagiosa” (infectious seeds in the air). Before there was Joseph Lister, who introduced antisepsis in the operating room and in hospitals, there was Ignaz Semmelweis, who through bitter and controversial efforts helped save the lives of thousands of pregnant women exposed to the risk of post-partum puerperal fever. He was born in 1818 in Buda (present day Budapest) at that time part of the AustroHungarian Empire. His parents were ethnic Germans. He studied medicine at the University of Vienna and graduating in 1845, he ended up taking a position as assistant to Dr. Johann Klein, head of the obstetrics department at the Vienna General Hospital. The obstetrics department at the Vienna General Hospital took care of single, mostly, but not always, poor mothers and pregnant prostitutes. It was divided into two sections: Section 1 was attended in part by medical students receiving their Obstetrics training, and the patients were of a somewhat better class position. Section 2, the poorer clientele, was used to train midwives. Semmelweis , as assistant to the chief, (today s equivalent to being chief resident), supervised activities and results in both sections. He was concerned about the incidence of puerperal fever and greatly distressed of the mortality caused by it, in those unfortunate young women. More puzzling yet, to him, was the fact that incidence and mortality were considerably higher in section 1 than section 2. He ruled out age, as the two groups were similar. Same regarding ventilation and food provided. Section 1 had a mortality of 10 percent, and some times as high as 30 percent, whereas section 2 had generally a mortality of only 3 percent. He was puzzled and could not find an explanation for this discrepancy. Then, one of his best friends, the forensic examiner Jakob Kolletchka, was pricked by a knife while doing an autopsy. Shortly afterwards, Kolletchka developed fever and sepsis, dying of it in short order. At autopsy, Semmelweis saw the same identical lesions seen in the women with puerperal fever. He then realized than in section 1, the medical students came directly from doing dissections on cadavers to the labor room to attend women in labor. He concluded the students were carrying invisible “cadaveric particles” that caused 36

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the disease in the women. He ordered that all medical students returning to the labor and delivery rooms after participating in cadaveric dissections, had to wash their hands in chlorinated water. After one month, the numbers of deaths and sepsis began to look alike in both sections, 1 and 2. But there was strong opposition to his orders. First, his chief, Dr. Klein, considered those measures as a criticism on the way he directed the Obstetrical service. Students and even patients felt that Dr. Semmelweis was considering them dirty and complained about him. The result was that when his contract expired at the end of the year, Dr. Klein refused to renew it. Without a job, and unable to find another position, he returned to Budapest. There, he began writing to many doctors and professors explaining his finding and urging them to follow his advice. At times, he became offensive and insulting, calling some of those doctors murderers of young mothers, if they did not wash their hands before delivering babies. This did not endear him to many, and he became increasingly obsessed and isolated, having nightmares which alarmed his wife and friends. He wrote a book describing his studies and findings in Vienna, which found very little response and distribution. He wrote it in Hungarian. But, who reads Hungarian anyway? Finally, a friend and his wife convinced him to make a trip to relax and somehow tricked him into going into an asylum (mental institution), where he was grabbed by the guards and locked in. A few weeks later he was dead, supposedly of sepsis, but an autopsy performed on him almost one hundred years later, revealed several broken bones. It is believed now that he was murdered by the guards in the asylum who beat him to death. His funeral was attended by fewer than half dozen persons. One of them was the famous pathologist Rokitansky. His wife did not show up. Today, the Obstetrics hospital in Vienna is named after him. In Budapest, a statue stands in his honor showing him protecting a prostrated mother. Too late, too little for a consolation! Some people call the Semmelweis effect when a new idea is rejected off-hand because it contradicts traditional beliefs and conventional wisdom. Fortunately, we see this behavior less and less in Medicine.

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

ACCOUNTING FIRMS 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.”

ASSET MANAGEMENT

Avid Wealth Partners (HHHH 10K Platinum Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and well-served by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor Specializing in Investment Management and Fee-Based Financial Planning 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank. Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohn-

San Antonio Medicine • November 2017

ston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Employment & Labor Mario Barrera 210 270 7125 mario.barrera@nortonrosefulbright.com Life Sciences and Healthcare Charles Deacon 210 270 7133 charlie.deacon@nortonrosefulbright.com Real Estate Katherine Tapley 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

Strasburger & Price, LLP (HHH Gold Sponsor) Strasburger counsels physician groups, individual doctors, hospitals, and other healthcare providers on a variety of concerns, including business transactions, regulatory compliance, entity formation, reimbursement, employment, estate planning, tax, and litigation. Carrie Douglas 210.250.6017 carrie.douglas@strasburger.com Cynthia Grimes 210.250.6003 cynthia.grimes@strasburger.com Marty Roos 210.250.6161 marty.roos@strasburger.com www.strasburger.com “Your Prescription for the Common & Not-So Common Legal Ailment”

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BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. 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”

BANKING

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

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.”

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. Rick Tatum richardt@ozonabank.com www.ozonabank.com

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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

RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more. Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org

Adaptability and Attainability Financial Consultant Doug Elley 210-961-9991 delley@ft.newyorklife.com www.newyorklife.com

CONTRACTORS/BUILDERS /COMMERCIAL

Cambridge Contracting (HHH Gold Sponsor) We are a full service general contracting company that specializes in commercial finishouts and ground up construction. Rusty Hastings Rusty@cambridgesa.com 210-337-3900 www.cambridgesa.com

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

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 shuffman@huffmandev.com Lauren Spalten 210-667-6988 lspalten@huffmandev.com www.huffmandev.com

Frost (HH Silver 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.”

FINANCIAL SERVICES

BUSINESS SERVICES

New York Life Insurance Company (HHH Gold Sponsor) We believe that any great relationship starts with great core values: Attention, Accountability, Appreciation,

Avid Wealth Partners (HHHH 10K Platinum Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor Specializing in Investment Management and Fee-Based Financial Planning 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

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!”

Beyond (HHH Gold Sponsor) Beyond strives to simplify operations, reduce costs and streamline payments for small and mid-size businesses. We provides reliable, flexible, and secure business solutions in a clear, transparent manner. San Antonio and Austin Division Director Crystal Patterson 210-810-0403 Crystal.patterson@getbeyond.com www.getbeyond.com “The business of Medicine is our specialty”

e3 Wealth, LLC (HHH Gold Sponsor) Over $550 million in assets under management, e3 Wealth delivers truly customized solutions to individuals and businesses while placing heavy emphasis on risk minimization, tax diversification, proper utilization and protection for each client's unique financial purpose. Managing Partner Joseph Quartucci, ChFC® 512-268-9220 jquartucci@e3wealth.com Senior Partner Terry Taylor 512-268-9220 ttaylor@e3wealth.com Senior Partner Jennifer Taylor 512-268-9220 jtaylor@e3wealth.com www.e3wealth.com

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning). Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org

GRADUATE PROGRAMS 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

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visit us at www.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

HEALTHCARE REAL ESTATE SAN ANTONIO COMMERCIAL ADVISORS (HH Silver 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”

HEALTHCARE TECHNOLOGY RubiconMD (HH Silver Sponsor) RubiconMD enables primary care providers to quickly and easily discuss their e-Consults with top specialists so they can provide better care - improving the patient experience and reducing costs Shang Wang Business Development (845) 709-2719 shang@rubiconmd.com Cyprian Kibuka VP of Business Development (650) 454-9604 cyprian@rubiconmd.com www.rubiconmd.com “Expert Insights. Better Care."

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) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 mipeck@selectmedical.com Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

INFORMATION AND TECHNOLOGIES

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”

San Antonio Medicine • November 2017

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.”

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

INSURANCE/MEDICAL MALPRACTICE

INSURANCE

SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services com-

pany offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships. VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Mortgage Kristie Arocha 210-255-0013 karocha@swbc.com SWBC Mortgage www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice

insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

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” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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

INTERNET TELECOMMUNICATIONS

MEDICAL BUSINESS CONSULTING

MEDICAL BILLING AND COLLECTIONS SERVICES

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations. Owner Lettie Cantu 210-363-1735 Lettie@progressivebilling.com Administrator Richard Hernandez 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice." 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.”

PAYMENT SYSTEMS/ CARD PROCESSING

PROFESSIONAL ORGANIZATIONS

Beyond (HHH Gold Sponsor) Beyond strives to simplify operations, reduce costs and streamline payments for small and mid-size businesses. We provides reliable, flexible, and secure business solutions in a clear, transparent manner. San Antonio and Austin Division Director Crystal Patterson 210-810-0403 Crystal.patterson@getbeyond.co m www.getbeyond.com “The business of Medicine is our specialty”

The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, non-profit, R&D, healthcare delivery, professional services and more! President Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Program Coordinator Valerie Rogler 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

PAYROLL SERVICES

SWBC (HHHH 10K Platinum 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.

PRACTICE CONSULTANTS

New York Life Insurance Company (HHH Gold Sponsor) Our Goal, increase patient & employee satisfaction, generate more free time for practitioners and mitigate both business and personal financial risk. (No Cost Financial and Business consulting including HIPAA audit evaluations, BCMS members only). Doug Elley 210-961-9991 delley@ft.newyorklife.com www.newyorklife.com “20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”

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.”

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.” 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 www.bcms.org 41 41 visit usus atatwww.bcms.org

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. GUNN AUTO GROUP

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Cary Wright 210-558-1500

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

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

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

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

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

Bill Boyd 210-859-2719

GUNN AUTO GROUP

GUNN Honda 14610 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

Pete DeNeergard 210-680-3371

Coby Allen 210-625-4988

Abe Novy 210-496-0806

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

Gary Holdgraf 210-862-9769

Wayne Alderman 210-525-9800

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

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Sean Fortier 210-681-3399

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

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

Daniel Jex 210-684-6610

Frank Lira 210-381-7532

KAHLIG AUTO GROUP

Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX Alan Henderson 210-681-6300

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

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

William Taylor 210-366-9600

James Godkin 830-981-6000

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

Mark Castello 210-308-0200

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

North Park Mazda 9333 San Pedro San Antonio, TX 78216

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

Scott Brothers 210-253-3300

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

James Cole 800-611-0176

13660 IH-10 West (@UTSA Blvd.) San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Barrett Jaguar 15423 IH-10 West San Antonio, TX

15423 IH-10 West San Antonio, TX

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

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

visit us at www.bcms.org

AUTO REVIEW

2017 Volkswagen GTI By Steve Schutz, MD

In 1983, Volkswagen USA breathed new life into its aging Golf lineup by introducing a sporty GTI version. Based loosely on the European Golf GTI, which had been immensely popular since its launch in 1976, the original GTI was relatively underpowered but lots of fun to drive. And like its continental namesake, the American GTI became an instant hit over here. A quick aside: in 1984, your humble automotive writer bought a new GTI days after finding out he had earned an Air Force scholarship to medical school. I drove it for four years before trading it in on a “better” car that was totally not better, a move I regretted for a long time. 44

San Antonio Medicine • November 2017

AUTO REVIEW Thirty four years later, the Golf GTI remains a staple of the VW product lineup, though it's far different from its first-gen predecessor. While a 1983 GTI was 155" long, 64" wide, and weighed 1,750 lbs, the 2017 version is 13" longer, 7" wider, and — OMG gurl, what happened? — 1,281 lbs heavier. Of course, that extra size and girth means larger crumple zones and creature comforts, so a new GTI is both safer and more luxurious than it used to be. And despite the additional weight, a 2017 GTI can scamper from 0-60MPH in just 5.9 seconds compared with 10.6 seconds back in 1983 thanks to a huge boost in horsepower (210 now vs 90 then). Amazingly, thanks to continuous improvements in powertrain technology, modern GTIs are more fuel efficient than they were back in the day (1983 - 21 MPG city/26 MPG highway, 2017 - 24/34). For the record, the new GTI comes with a turbocharged 2.0 liter four cylinder that can be had with either a twin-clutch sixspeed automatic or six-speed manual. The manual would be my choice, though it should be noted that the first three gears are a little tall for this engine and its turbo lag, so the automatic actually feels more lively at lower speeds. While I will always say that my old (and slow) analogue GTI was more fun to drive than the new one is, that's probably my rose colored memory glasses at work, because the new one is a lot of fun. It's very agile, especially around town, and it gives you very pleasing feedback as you drive, including excellent steering feel and nice engine sounds. The GTI is good on the interstate or high speed back roads, but it's most at home on zippy/twisty roads, be they urban or rural. And driving it reminded me of why so many enthusiast publications call the GTI a great all-arounder. That would include giving owners utility, by the way. I used the GTI to carry my 29"

mountain bike to my favorite trail, and it fit easily. Yes, I had to fold down the rear seats

and remove the bike's front wheel, but still, pretty good. We all know that US buyers generally shun hatchbacks, but after a week with this car I started to wonder if maybe I shouldn't just eschew my usual urge for ever more power and luxury and get a GTI as my next car. A physician friend and car enthusiast who lives in Southern California alternates between a new GTI and—oh yes, I am envious—Ferrari 430 for his daily commute, and he loves the spunky VW. The GTI's design is best described as understated, which is the way it's always been. Recently retired Volkswagen Group chairman Ferdinand Piech—the most influential automotive figure of the last 50 years, in my opinion — preferred restrained exterior styling, and he generally got his way. Do I wish the GTI attracted as much attention as a Ford Focus ST, one of its main competitors? If I were 28, the answer might be, "Hell yeah, bro!" but 54-year-old me respects VW for ignoring fads and staying true to their principles. I wish they had made the GTI's interior look more special, though. The plastics and other materials are mostly black and boring to behold, with a look that hasn't changed enough since the early '00s. All the tech you expect is there including a modern central touch screen that works very well and is even

intuitive, but every time I sat in the GTI I thought it could really use an update. Is it

crazy to suggest Joanna Gaines for the job? If it's been a while since you shopped a GTI, they're all five doors now. The three door versions were dropped a couple of years ago, which is fine with me since those extra doors provide extra utility. Many options and option packages are available, and as always, BCMS' own Phil Hornbeak is available to help you find the GTI (or whatever) that's right for you. Despite being 34 years more advanced than my wonderful 1984 model, the 2017 Volkswagen GTI is a fun car that's good at pretty much everything, and yet somehow feels remarkably like my old car to drive. I wish it had a better interior, but it's impossible not to recommend a new GTI to anybody who values driving dynamics and doesn't need SUV helpings of space for family, pets, and Costco stuff. If you’re in the market for this kind of

vehicle, call Phil Hornbeak at 210-3014367. 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 www.bcms.org 45 45 visit us us at at www.bcms.org

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA

Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of October 24, 2017.

San Antonio Medicine â&#x20AC;˘ November 2017