SAN ANTONIO
WWW.BCMS.ORG
PAID
NON PROFIT ORG US POSTAGE
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY
•
SAN ANTONIO, TX PERMIT 1001
THE OFFICIAL PUBLICATION OF BEXAR COUNTY MEDICAL SOCIETY
•
$4.00
•
FEBRUARY 2018
•
VOLUME 71 NO. 2
MEDICINE SAN ANTONIO
TA B L E O F CO N T E N T S
THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY
•
WWW.BCMS.ORG
•
$4.00
•
FEBRUARY 2018
•
VOLUME 71 NO. 2
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.
Disaster Recovery
The Long and Short of it: Infectious Disease Risks after Hurricanes, Floods, and Displacement By Ruth E. Berggren, MD, MACP .....................14
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
Give Now to Help Practices Recover from Natural Disasters By AMA Wire........................20
MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org
What Happens after the First Responders are Gone? By Alan Preston, MHA, ScD ................22
SUBSCRIPTION RATES: $30 per year or $4 per individual issue
BCMS President’s Message ............................................................................................................8 BCMS Legislative News ............................................................................................................................10 BCMS News .............................................................................................................................................12
ADVERTISING CORRESPONDENCE: SmithPrint Inc. 333 Burnet San Antonio, TX 78202
Medical Care: Diabetes Self-Management Education By Kathy Ann LaCivita, MD, FACE, FACP ................24
For advertising rates and information
UT Health San Antonio’s New Recruitments Bolster City’s Growing Biosciences Stature By William I. Henrich, MD, MACP...........................................................................................................26
Email: louis@smithprint.net
BCMS News: 2018 Installation of Officers Banquet ...................................................................................28 Business of Medicine: Aligning Electronic Health Record Use with Performance Goals By Beth E. Michel, MLD, CPHRM ..........................................................................................................30 Book Review: Modern Death: How Medicine Changed the End of Life By Haider Warraich, MD Revieded by Fred Olin, MD.....................................................................................................................34 Feature: Back to School...Here we go again. By Robery G. Johnson, MD.................................................36 BCMS Circle of Friends Directory ..............................................................................................................38 In the Driver’s Seat ....................................................................................................................................42 Auto Review: 2018 Volkswagen Tiguan By Steve Schutz, MD .................................................................44 PUBLISHED BY: SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net
4
San Antonio Medicine • February 2018
ADVERTISING SALES: SAN ANTONIO: Gerry Lair gerry@smithprint.net
Call (210) 690-8338 or FAX (210) 690-8638
San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.
For more information on advertising in San Antonio Medicine, Call SmithPrint, Inc. at 210.690.8338
Madeleine Justice madeleine@travelingblender.com
SmithPrint, Inc. is a family owned and operated San Antonio based printing and publishing company that has been in business since 1995. We are specialists in turn-key operations and offer our clients a wide variety of capabilities to ensure their projects are printed and delivered on schedule while consistently exceeding their quaility expectations. We bring this work ethic and committment to customers along with our personal service and attention to our clients’ printing and marketing needs to San Antonio Medicine magazine with each issue.
PROJECT COORDINATOR: Amanda Canty amanda@smithprint.net
Copyright © 2018 SmithPrint, Inc.
Janis Maxymof janismaxymof@gmail.com
BUSINESS MANAGER: Vicki Schroder
PRINTED IN THE USA
BCMS BOARD OF DIRECTORS ELECTED OFFICERS Sheldon G. Gross, MD, President Gerald Q. Greenfield Jr., MD, PA, Vice President Adam V. Ratner, MD, President-elect Leah H. Jacobson, Immediate Past President Kristi G. Clark, Secretary John Robert Holcomb, MD, Treasurer
DIRECTORS Rajaram Bala, MD, Member Jenny Shepherd, 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 Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Manuel Quinones, MD, Member 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 Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Pavela Bambekova, Medical Student Darren Donahue, Medical Student Carmen Garza, MD, Community Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member Austin Sweat, Medical Student J.J. Waller Jr., MD, Member
6
San Antonio Medicine • February 2018
PRESIDENT’S MESSAGE
Increasing Our Effectiveness By Sheldon Gross, MD, 2018 BCMS President Dear Colleagues, I have said previously that Bexar County Medical Society is a great organization that has the potential to become even greater. I would like to discuss specific steps we can take to increase our effectiveness locally, at a state-wide level, and at a national level. Many of you are already involved with the Texas Medical Association. There are numerous councils and committees that benefit from input from Bexar County members. The Chairman of the Board of Trustees of the Texas Medical Association, Dr. David Henkes, is from San Antonio and has done an outstanding job leading the governing body of the Texas Medical Association. I would encourage as many as possible to attend meetings of the Texas Medical Association and to find areas of interest. I have long thought that the most effective volunteers for any organization are those who simply enjoy it. Early in my career, I became fascinated with politics and the process of getting people elected. I attended TEXPAC meetings on a regular basis and enjoyed them immensely. Others would enjoy discussing specific legislation. Others would be interested in the socioeconomic aspect of healthcare and others involved in the public health aspect of healthcare. There is a long list of committees and special interest groups under the Texas Medical Association umbrella. This coming May, the Texas Medical Association will have its annual meeting in San Antonio at the JW Marriott. I would encourage as many as possible to attend this. There will be a gala Friday evening to benefit the Texas Medical Association Foundation. I would encourage as many people as possible to support this. The foundation has used its money in the past to accomplish great things and enhance healthcare in Texas. My next recommendation is to join the AMA. I realize this is a controversial area. Certainly, many are still upset by the stance of supporting the Affordable Care Act, or Obamacare, made by the AMA several years ago. That decision deserves some in-depth discussion. The goals of the AMA and the goals of the TMA with regards to an ideal healthcare system were essentially identical. The two organizations wanted the same thing. The Affordable Care Act certainly included many things we both wanted, but also omitted things that we felt were necessary. One then has to make decisions with regards to legislative strategy. If a bill has 60 percent of what you want, do you support it and try to remain in the inner circle with hopes of improving it as time goes on? Do you oppose the 8
San Antonio Medicine • February 2018
bill entirely in hopes of having another bill in the future that would include more of your key points? The AMA made the decision to support the Affordable Care Act and to stay in the inner circle. I would add that this was a controversial decision within the AMA House of Delegates and led to the most heated debates that I had seen within the House of Delegates. The TMA felt it was better to oppose the bill and try to start over. The difference was one of legislative strategy, not one of ultimate goals. I have often had people ask me how their life is better because of the AMA. That is similar to someone asking how is my life any better by controlling my blood pressure. For the patient with high blood pressure, it relates to the horrible things that do not happen such as stroke, myocardial infarction, kidney disease, or other horrible complications of chronic hypertension. In the same way, I would state that the AMA on a regular basis prevents very bad things from happening to our healthcare system. It is oftentimes done quietly with little fanfare. If I have any criticism of the AMA, it is that they do not effectively inform membership of the many things they have done or prevented from happening. The fundamental question is: Are physicians better off having one strong voice in Washington that is recognized as representing physicians as a whole or are we better represented by 30 or 40 different specialty groups with different messages speaking to the same elected officials? I have always felt that one strong voice is the most effective approach to take. I encourage all members of Bexar County Medical Society to join the AMA. It will cost around $400 and will increase our effectiveness politically. During my year as president I will welcome debate and differing opinions from my own. I look forward to hearing from those of you who agree or disagree with my opinions. The wide range of perspectives within our organization is part of what makes us great. Sincerely, Sheldon Gross, MD President, Bexar County Medical Society
BCMS LEGISLATIVE NEWS
SAN ANTONIO ADOPTS TOBACCO 21 ORDINANCE City Council approves raising the sale age for tobacco products from 18 to 21 The San Antonio Tobacco 21 Coalition applauds the leadership and commitment of the San Antonio City Council to improve the health and quality of life for all San Antonians by raising the sale age for tobacco products to 21 with the adoption of the Tobacco 21 ordinance. Raising the tobacco age from 18 to 21 is an important step toward reducing youth smoking and preventing a lifetime of addiction and disease. Tobacco 21 will help counter the efforts of the tobacco industry to target young people and minorities and will help reduce the devastating health and economic consequences of tobacco use in San Antonio. Increasing the legal age for tobacco products to 21 will reduce the pipeline of tobacco products to our youth in middle school and high school and reduce the number of youth who start smoking. Over a lifetime, this policy will reduce the smoking rate, reduce smoking related deaths, and lead to fewer premature deaths. “This is a great day for the city of San Antonio,” said Abigail Moore, CEO of the San Antonio Council on Alcohol and Drug Abuse. “With the leadership of Metro Health and the support of our Tobacco 21 Coalition partners, the City Council has taken a great step towards improving the health and wellbeing of all San Antonians, especially our youth and young adults.”
“The passing of Tobacco 21 is a major public health win for our city,” said Dr. Sandra Guerra, Chief Medical Officer for Humana TRICARE and American Heart Association Board Member. “We applaud the Mayor and City Council for taking a great step in preventing San Antonio youth from a lifelong addiction to tobacco products for generations to come.” Following the City Council vote, there will be a six-month education and phase in plan with the ordinance officially taking effect on October 1, 2018. The San Antonio Tobacco 21 Coalition includes the Bexar County Medical Society, San Antonio Council on Alcohol and Drug Abuse, Bethal Prevention Coalition, EastPoint Promise Prevention Coalition, American Cancer Society Cancer Action Network, American Heart Association, American Lung Association in Texas, Campaign for Tobacco-Free Kids, and March of Dimes, among others. Additionally, institutions such as The University of Texas MD Anderson Cancer Center, The University of Texas at San Antonio and UTHealth San Antonio serve as educational resources. The coalition encourages you to thank your City Council on this historic vote.
Leah Jacobson, MD, BCMS immediate past president and Mary Nava, BCMS chief government affairs officer represented BCMS on the Coalition Steering/Leadership Committee. For more information, contact Mary Nava at mary.nava@bcms.org. 10
San Antonio Medicine • February 2018
BCMS NEWS
WELCOME
BEXAR COUNTY MEDICAL SOCIETY BUILDING TENNANTS FAVORITE HEALTHCARE STAFFING 4334 N. Loop 1604 W. | Suite 104 | San Antonio, TX 78249 (210) 301-4362 Favorite Healthcare Staffing is recognized as one of North America’s 2017 Largest Healthcare Staffing Firms, serving communities across the U.S. since 1981 in all settings of the healthcare industry. In addition to the San Antonio branch, Favorite has four other Texas branch locations, as well as offices in metropolitan areas across the country. Favorite Healthcare offers clients comprehensive workforce solutions and staffing, including nursing, advanced practice, allied health, physician office and practice management professionals. Favorite helps employees, job candidates and clients match needs by offering a wide range of assignment options, such as contract, per diem, temp-to-perm, travel, and permanent placement. Learn more at favoritestaffing.com or call 800-676-3456.
PATRICIA MACKIN, MD 4334 N. Loop 1604 W. | Suite 102 | San Antonio, TX 78249 (210) 892-2971 North San Antonio Family Medicine is the new practice of Patricia A. Mackin, MD. We are proud to provide Shavano Park and northern San Antonio with comprehensive outpatient family medicine services. As a family medicine practice we welcome patients of all ages from newborn through older adults. We provide well child and adult care including immunizations and physicals. We provide treatment for common illness as well as chronic conditions such as diabetes, asthma, high blood pressure, and more. We do minor office-based procedures as well. New patients welcome and all major insurance plans accepted.
BRYAN STEWART, DDS 4334 N. Loop 1604 W. | Suite 101 | San Antonio, TX 78249 (210) 549-2842 RESTORE Complete Dental offers general, cosmetic and family dentistry on site in exam and procedure rooms custom built for your comfort. We also offer sedation for those who are nervous about having dental work. A business-friendly waiting room will minimize the amount of time away from your busy work schedule. Extended hours of operation are offered for your convenience. RESTORE Men’s Health is San Antonio’s newest cosmetic & health center for men. We currently offer a variety of facial aesthetic injectables, laser treatments, weight loss procedures using Obalon Balloon system, as well as plastic surgery. RESTORE will also provide a discreet atmosphere where you can feel comfortable addressing sensitive issues such as sexual dysfunction, hormone therapy, vasectomy and reversals. We also offer non-surgical treatments for joint pain, such as stem cells, blood products and biological allograft injections.
12
San Antonio Medicine • February 2018
DISASTER RECOVERY
THE LONG AND THE SHORT OF IT:
Infectious Disease Risks after Hurricanes, Floods, and Displacement By Ruth E. Berggren, MD, MACP he ultra-rapid media news cycle has long displaced the 2017 Hurricanes Harvey and Maria from our radar screens, yet places like Houston, Rockport, Port Aransas, and Puerto Rico must wrestle with the aftermath of storms that wrought havoc on economic and public health infrastructure, destroyed buildings, and disrupted health care. The grisly images of destruction quickly fade from memory as new threats appear on the horizon. As custodians of our community’s health, we are compelled to reflect on these experiences, to cull from learned lessons and always prepare for improved responses in future scenarios. As an internist/infectious disease specialist with experience from providing care during and after Hurricane Katrina in New Orleans, and after Haiti’s massive 2010 earthquake, I joined our community
T
14
San Antonio Medicine • February 2018
response in December 2016 when hundreds of asylum-seeking women and children were displaced from the Immigration and Customs Enforcement (ICE) detention centers in Dilley and Karnes City (http://www.mysanantonio.com/news/local/article/ICE-releases-neary-500-from-Dilley-Karnes-City-10692447.php), and again when thousands of people were evacuated to San Antonio from flood zones after Hurricane Harvey (August 2017). There were some specific challenges from which we can learn, after these events, as well as some general themes that highlight what we should prepare for after mass evacuations of traumatized humans, be they from New Orleans, Haiti, Central America, or Texas. In the paragraphs below, I outline some of the infectious disease-related short, medium and long-term challenges we observed, and offer links to resources, as well as personal observations for future disaster responses.
DISASTER RECOVERY
Short term challenges:
1. Medicine reconciliation, and identification of immunocompromised hosts in an environment of confidentiality: When a volunteer doctor arrives at a shelter to care for displaced people, the first order of business is situational assessment, emergency triage, and first-responder mobilization. Triage of the critically injured is usually addressed by pre-shelter emergency personnel. My observations on short-term challenges pertain to evacuees seeking medical attention in short-term shelters. Nearly 7 in 10 American adults take a prescription medication, with 20 percent using five or more of these (Mayo Clinic Proceedings 2013, Vol 88(7);697-707). When they show up in a shelter, evacuees almost never have their pills with them, nor do they recall dosages. Some patients will have been precipitously discharged from medical facilities in anticipation of evacuation orders, and will present with confusion and anxiety about care plans. A majority of U.S. disaster evacuees need prescriptions renewed, replaced, or re-explained. Especially helpful to me in Texas were H-E-B pharmacists who provided immediate information from prescription records, facilitating accurate and prompt prescription renewals. In shelters for disaster victims, it is especially important to spot
people with immunocompromising conditions such as HIV/AIDS, or contagious infections like tuberculosis (MTB) or chicken pox. Patients with stigmatizing diseases are reluctant to self-identify when confidentiality is compromised by a chaotic environment. Because interruption of treatment for either HIV or MTB can lead to drug resistant organisms and subsequent public health consequences, every effort should be made to provide patients with a modicum of privacy despite the environmental upheaval. Extra efforts are necessary to assure non-interruption of treatment for patients with HIV and/or MTB, including help from state and local health authorities. According to the Centers for Disease Control (CDC), one month after Hurricane Katrina, only 71 percent of known TB patients from Louisiana had been located, though most were believed to have been non-contagious at the time of evacuation (MMWR Sept 30, 2005. Vol 54(38);961-964). Interruption of HIV care for the displaced of New Orleans was problematic in the early days after the hurricane, as many reported taking a subset of medications every other day, trying to make them last as long as possible before seeking refills in an unfamiliar city (New England Journal of Medicine 2006;354, 1549-22). Post-Katrina follow up studies have observed that “the change in CD4 counts of non-returning evacuees dropped more sharply than those of the returning [persons living with HIV/AIDS] PLWH/A or non-residents. …results [which] … provide important data on the effect that large-scale disasters and stressful life events may have on individuals with chronic disease.” While CDC and health officials play primary roles in tracking populations with chronic infectious diseases, alert first responders can greatly enhance outcomes with careful history-taking, and respectful attitudes. In the immediate disaster aftermath, public health infrastructure is often disrupted, which necessitates non-standard mechanisms for disease reporting. In post-Katrina New Orleans, the CDC sent officers to meet weekly with first responders. Non-standard mechanisms were the only means of reporting disease trends for months, illustrating the critical value of local health professionals who volunteered for the recovery effort. 2. Infectious Disease Threats for evacuees and rescue workers: In the early aftermath of a flood, water, sanitation and hygiene limitations are problematic. Access to flush toilets and potable water is limited (New Engl J Med 2005. Vol.353;1550-1), and flooding increases the risk of waterborne pathogens. Skin and soft tissue injuries become easily infected when submerged in contaminated floodwater (Am J Clin Dermatol. 2015 Oct;16(5):399-424); a Dallas evacuation facility after Hurricane Katrina reported a cluster of 30 patients with Methicillin-resistant Staphylococcus aureus (MRSA) skin/soft tissue infection; there were 24 cases of hurricane Katrina-
continued on page 16
visit us at www.bcms.org
15
DISASTER RECOVERY continued from page 15
related Vibrio vulnificus and V. parahemolyticus wound infections, including six deaths (MMWR Sept 30, 2005. Vol 54(38);961-964) V. vulnificus is a gram negative rod-shaped bacillus present in marine environments including brackish ponds and flood waters in coastal areas. Vibrio infection must be considered in any patient with blistering dermatitis after exposure of broken skin to contaminated marine water (Epidemiol Infect. 2005 Jun; 133(3): 383–391). Recognition of a blistering skin infection, and awareness of lifethreatening complications such as necrotizing fasciitis and sepsis from Vibrio infections is critical in patients with underlying chronic liver disease, iron overload, or diabetes; these individuals are at high risk of septicemia and may have mortality rates greater than 50 percent. Treatment of V. vulnificus includes aggressive wound debridement as well as combination antibiotic therapy with ceftazidime and doxycycline. Rescue workers with skin conditions after Hurricane Katrina were found to have Tinea corporis, prickly heat, mite and insect bites, highlighting the effects of working in hot, wet environments with restricted access to clean water. There were about 1,000 reported cases of diarrhea and vomiting in Katrina evacuation centers, but only one documented outbreak of Norovirus. Some sporadic non-typhoidal Salmonella cases were documented. The CDC offers guidelines for the acute management of diarrhea after disasters, including whom to refer for medical evaluation, at www.cdc.gov/disasters/disease/diarrheaguidelines.html. Of note, no Shigella, typhoid or cholera cases were reported after Hurricane Katrina, and by three weeks after the population displacement began, there were no further significant outbreaks of gastrointestinal disease (MMWR Sept 30, 2005. Vol 54(38);961-964). In contrast, first responders to post-earthquake Haiti came vaccinated against typhoid and Hepatitis A, and well-supplied with medications to treat anticipated outbreaks of typhoid or shigellosis. However, with rapid deployment of potable water by rescue workers, minimal diarrheal illness was observed in makeshift relief centers during the first two weeks of earthquake relief (personal observation). Many patients who had suffered crush injuries actually developed constipation from prescribed narcotics, and startled volunteers were dispatched to purchase stool softeners from local outlets (Tyler Curiel, MD, personal communication). It was months later, as Haiti’s already fragile health infrastructure unraveled, that the cholera epidemic, inadvertently introduced by U.N. peacekeepers, gained its momentum (N Engl J Med 2011; 364:33-42).
Medium Term Challenges:
1. Respiratory disease management and prevention: Crowded shelter conditions inevitably result in transmission of viral respiratory illness. The majority of mothers and children precipitously discharged from ICE facilities in Dilley and Karnes City 16
San Antonio Medicine • February 2018
in December 2016 presented in San Antonio shelters with cough, with or without fever, pharyngitis, or rhinorrhea (personal observation, personal communication Barbara Taylor, MD, Andrew Muck, MD). The first responder challenges were to distinguish patients with signs and symptoms of serious infection such as pneumonia or tuberculosis from those who merely needed symptomatic care. In more than one instance, patients reported that they had a positive PPD skin test, but had been placed on transport buses without medications. Isoniazid sometimes arrived at San Antonio shelters one or two days after the asylum seekers; in certain instances, the immigration process prevented the pills from catching up with the patients. The ability of a clinician to take a careful history in Spanish, about duration of cough, presence or absence of hemoptysis, fevers, and night sweats, was one of the more important skills required for medical response to this international displacement incident. The importance of tracking potentially infectious patients with respiratory illness cannot be overstated, and our experience with this precipitous, unforeseen episode involving foreign nationals made evident the need for practical solutions like providing transitory patients with their own hand-held records summarizing PPD, vaccine, and chest X-ray status, as well as prescriptions. Such records could be digitized and given to patients on a microchip. In contrast to our dilemmas with displaced, coughing, international asylum seekers, a recent issue of Morbidity and Mortality Weekly Report (MMWR, December 2017) notes that after Hurricane Harvey, most Texan tuberculosis patients stayed in Texas, receiving uninterrupted directly observed therapy (DOT). “… video-enabled DOT using electronic devices, such as smart phones”, became “a useful tool for patients who cannot visit, or be visited by, a health care provider.” In fact, after Harvey, there were 61 patients on video-enabled DOT. MMWR continues: “Immediately after Hurricane Harvey, the DSHS TB program directly contacted all affected regional and local health departments to determine the status of high-priority TB patients (persons with new TB diagnoses, infectious patients, and children), and relayed status of patient care, health care worker safety, and needs of local and regional health departments to CDC. In addition, surveillance questionnaires were distributed to temporary shelters to identify residents or volunteers exhibiting signs and symptoms of TB. Although TB control personnel in Texas were personally affected by the storm’s damage, they remained on duty, with some staff members traveling into flooded communities to follow up patients.” 2. Vector-borne disease. At the time of Harvey’s landfall, South Texas health care professionals were on alert for cases of fever suggesting vector-borne disease such as Zika virus, in the wake of ongoing outbreaks of zika, dengue and chikungunya infections in Central America; all transcontinued on page 18
DISASTER RECOVERY continued from page 16
mitted by the Aedes aegypti mosquito, which is present in Texas. Health departments warned of potential Zika outbreaks due to mosquito breeding in flooded areas. Currently available data from Houston actually show fewer documented cases of Zika (6 cases) in 2017 compared with 32 cases in 2016. (http://www.houstontx.gov/health/Epidemiology/Zika/zika_num bers.html). Among other mosquito control measures post-Harvey (and post-Katrina), the U.S. Air Force sprayed naled (Dibrom), an organophosphate insecticide, over mosquito breeding areas. The Houston Health Department also launched media initiatives to educate the public with campaigns like “3-D Zika Defense: protect yourself from Zika with the 3 D’s”. The “3 D’s” refer to DEET, Dress, and Drain, encouraging people to use insect repellent, protective clothing, mosquito nets, condoms (to prevent sexual transmission of Zika), and to drain standing water. Houston’s success in thwarting a Zika outbreak underlines the importance of public funding for prevention initiatives. Other postdisaster countries with more fragile health infrastructure have been less fortunate, as documented in Haiti, in 2010: “During January 12 –February 25, CDC received reports of 11 laboratory-confirmed cases of P. falciparum malaria acquired in Haiti. Patients included seven U.S. residents who were emergency responders, three Haitian residents, and one U.S. traveler” (MMWR / March 5, 2010 / Vol. 59 / No. 8). 3. Vaccination after disasters: The CDC provides useful guidelines related to vaccination after disasters, emphasizing the need for TdaP for adults who are unsure of the date of their last tetanus booster, Pneumovax and Prevnar for individuals aged >/=65 or >19 years if immunocompromised. In crowded settings, CDC recommends giving most people the following vaccines (unless documentation of prior vaccination is available): influenza, varicella, and MMR (exclude pregnant women and immunocompromised hosts from live vaccines). It is not routinely necessary to vaccinate for Hepatitis A, typhoid, cholera or rabies. Further details may be found at www.cdc.gov/disasters/hurricanes/hcp.html.
Long Term Challenges
After natural disasters, rebuilding infrastructure for safe water and sanitation, reconstitution of primary care services, return of health care personnel, and diagnostic capabilities, take far longer than expected. Eight months after Hurricane Katrina, patients needing MTB or sexually transmitted infection screening still had to be referred outside New Orleans to health clinics in Baton Rouge or adjacent suburbs (N Engl J Med. 2006 Apr 13;354(15):1549-52). A necessary post-Katrina adaptation was fundraising by health professionals to pay for vouchers allowing transport to subspecial18
San Antonio Medicine • February 2018
ists and diagnostic services. Infectious disease faculty from Baton Rouge documented that “the only travel assistance for patients needing to access subspecialty clinics in Baton Rouge has come from limited support…. generated by fundraising efforts by one of the HOP clinic physicians” (Clin Infect Dis, 2006;439(4):485–89). Given the importance of controlling TB and other infectious diseases, it is extraordinary that disaster-responding physicians would have to rise to these occasions, not only out of beneficence for patients, but also on behalf of society at large. One of the most important long-term post disaster medical challenges is providing adequate mental health care, necessary for the high incidence of depression and post-traumatic stress disorder in disaster victims. Louisiana reported that suicide rates among white males were higher post-Katrina (J La State Med Soc. 2012;164(5):274-6). Mental health professionals and other specialists were slow to return to New Orleans after Hurricane Katrina; this would adversely impact adherence levels for patients being treated for chronic infections. During longer term disaster recovery phases, many communities receive an influx of guest laborers: more often than not, these individuals lack health insurance and face other barriers to health care. However, these individuals need healthful accommodations, preventive vaccines, and screening for infectious diseases including HIV, hepatitis, and tuberculosis. Infectious disease screening should only take place in settings that can provide linkage to care.
DISASTER RECOVERY
Conclusions
There are short, medium, and long-term disaster-related infectious disease concerns. In early response phases, triage, prescription renewals, identification and management of immunocompromised or contagious hosts is critical. The latter requires sensitive professionalism and cultural competency due to the stigmatizing nature of HIV and tuberculosis. Outbreaks of gastrointestinal disease are seen after floods before the re-introduction of sanitation and hygiene interventions. Skin and soft tissue infections abound after trauma in contaminated environments, and are problematic for rescue workers as well as disaster victims. Respiratory infections are associated with crowds and lack of handwashing facilities, presenting challenges in distinguishing between self-limited versus serious disease such as pneumonia. Vector born disease prevention can be successful; both rescue workers and victims are vulnerable, and vaccination guidelines should be followed for prevention of influenza, pneumonia and measles outbreaks. In the long term, residents and health professionals in disaster zones can expect prolonged waiting times for rebuilding the infrastructure needed for diagnostic capacity, subspecialty consultation and mental health care.
Lessons learned from recent episodes highlight the need for community-based, local physicians to participate in first response and recovery efforts, disease reporting, and patient advocacy. In addition, future efforts will benefit from better record-keeping for displaced populations, innovative approaches for directly observed therapy, more rapid re-staffing of mental health clinics; provision of funding for patient transportation needs and health care/screening for guest workers. Above all, medical professionals should know about and advocate for sustaining the nation’s public health infrastructure, so that successes such as the thwarting of wide-spread Zika-virus outbreaks after Hurricane Harvey can be replicated. Dr. Ruth Berggren is the Director of Center for Medical Humanities & Ethics, Marvin Forland, MD, Distinguished Professor in Medical Ethics, James J. Young Chair for Excellence In Medical Education, and Professor of Medicine, Division of Infectious Diseases, at UT Health Science Center San Antonio.
visit us at www.bcms.org
19
DISASTER RECOVERY
GIVE NOW
TO HELP PRACTICES RECOVER FROM
NATURAL DISASTERS By AMA Wire
new fund that has already provided $75,000 in natural-disaster relief for physician practices is accepting donations to help support that effort. The AMA Foundation (AMAF) created the Physician Disaster Recovery Fund, which has donated $25,000 each to three organized medicine foundations collecting funds to help physician practices recover from Hurricanes Harvey, Irma and Maria. Intended for physicians in federally designated disaster areas, the money is earmarked specifically for practice essentials such as replacing equipment, restoring patient records and meeting other needs related to patient care. “It is essential for doctors to quickly rebuild their medical practices to continue serving their communities, and we are thankful for the generous donors who are enabling physicians to get back to the vital work of caring for their patients,” said AMAF Board President, Joshua M. Cohen, MD. The AMAF is the philanthropic arm of the AMA, and its other activities include grants to community health programs, medical school scholarships and leadership training for medical students.
A
20
San Antonio Medicine • February 2018
The organizations that have received the AMAF donations are:
• Texas Medical Association Foundation, to benefit the TMA Disaster Relief Program for practices damaged by Hurricane Harvey. • Florida Medical Association’s Foundation for Healthy Floridians Medical Disaster Fund for practices damaged by Hurricane Irma. • Indiana Association of Family Physicians Foundation, which is helping physicians in Puerto Rico in the wake of Hurricane Maria. In addition, the AMA has donated $150,000 each to those physician relief efforts in Texas and Florida. The AMAF has established a donations webpage where contributions can be designated for specific locations or where the need is greatest. The site is also collecting contributions for the California Medical Association Foundation to aid practices damaged by wildfires in that state.
DISASTER RECOVERY
The AMAF, in addition to its donations website, is accepting contributions by mail and telephone. Make checks out to AMA Foundation, and send to 330 N. Wabash Ave., Suite 39300, Chicago, IL 60611-5885. For telephone donations, call 312-464-4200.
Related Coverage
HURRICANE-RELIEF EFFORT AIMS TO GET PRACTICES BACK ONLINE ASAP Texas was the first state to suffer devastating damage this hurricane season—from Harvey in August—and some physicians in affected areas are still reeling from the devastation. “There is a huge need for help for these physician practices that have been put out of business and have had to move, or now because of the flood they have to buy all new equipment,” said Immediate TMA Past President Don R. Read, MD, a Dallas surgeon and chair of the TMA’s Hurricane Harvey Disaster Relief Fund Program committee. It is a committee of The Physicians Benevolent Fund, which is a TMA organization. Dr. Read said that most of the requests have been for flood damage not covered by insurance. “We very much appreciate the donation from the AMA Foundation. It has been a great help in assisting physicians and we expect to spend all the money we’ve collected so far in helping all these different practices that were affected by the flood,” he said. The TMA, at last count, had just surpassed its $1 million fundrais-
ing goal thanks to a new gift from organized medicine in Michigan. Almost $570,000 already has been distributed. It went to 49 medical practices employing 135 physicians and 1,048 non-physician staff. A major focus of the Indiana Association of Family Physicians Foundation, which has raised more than $100,000, is to provide generators to aid physicians in Puerto Rico. Hurricane Maria did major damage to the island’s electrical grid. “So far, we have 50 practices open with generators purchased and soon will add 15 more practices and offices” said family physician Kim Yu, MD, a California physician who helped organize the effort. “These generators are being used to not only provide light, but also power for refrigerators for medications, like insulin and vaccines. They are also being used to power machinery required to fix offices and repair from all the hurricane damage.” She added that there remain many physicians “who require generators to help power equipment like EKGs, ultrasound machines, nebulisers and more—but we lack funding. Thank you, AMA Foundation, for helping Puerto Rico doctors get back to doing what they do best: healing, caring and seeing patients.” Dr. Yu said she is “hoping we will be able to raise more funds” for Puerto Rico and the U.S. Virgin Island. “It’s so terrible there, and it looks like many will be without power for many more months,” she said. visit us at www.bcms.org
21
DISASTER RECOVERY
What Happens after the First Responders are Gone? By Alan Preston, MHA, Sc.D hen a natural disaster hits a community, most communities in the USA have many dedicated police, fire, ambulance services that are quick to respond and help those who have fallen victim to the disaster. We are very lucky in this regard and often do not give the thanks to the selfless men and women who work tirelessly to help people in need. Our medical communities play a vital role in helping those in crisis. However, what happens when the news media leaves after the first 48 hours and the communities are left to pick up the pieces? And in other countries that are not as fortunate, their disasters are far worse given a lack of resources. Take the case of the 7.0 earthquake in 2010 that struck Port au Prince in Haiti. First, let’s take a look at the scope of Haiti in terms of GDP, population, and per capita income. Haiti is a poor country. The GDP is approximately eight (8) billion. The population is approximately 10.8 million. The per capita income is approximately $400.00 per year! Thus, it should be clear that Haiti is an impoverished country and their resources are indeed limited particularly
W
22
San Antonio Medicine • February 2018
when a natural disaster occurs. And when a country has such limited financial resources, the infrastructure is representative of the wealth of a nation. The lack of infrastructure in buildings alone was a great contributor to the massive casualties in the 2010 Haiti earthquake. However, the devastation did not stop with the destructions of buildings. Vectors of disease can be as deadly as the underlying natural disaster itself. Months after the earthquake, a new disaster struck the people of Haiti; Cholera. This disease is an infectious disease that causes severe diarrhea, which can lead to dehydration, which often leads to death if untreated. It is generally caused by eating food or drinking water contaminated with a bacterium called Vibrio cholerae. It has been estimated that over 10,000 Haitians died from Cholera and over 100,000 became ill as a result of contamination of the water, food, and spread of the disease. The irony of the etiology of the disease is that scientists believe it was brought to Haiti by United Nations peacekeepers stationed at a base that leaked waste into a river. Rivers tend to be a source of drinking water in impoverished countries like Haiti.
DISASTER RECOVERY
Malaria is another disease carried by mosquitoes that infect populations in areas of natural disasters. In Haiti, it was difficult to access the incidence of malaria the weeks and months following the earthquake. There are many reasons for this. However, the main reasons are that the prevalence rates of the disease were unknown and given the transient displaced population post-earthquake, it was difficult to estimate the prevalence rate of malaria. Nevertheless, The Haitian Ministry of Health and Population (MSPP), in collaboration with the US Centers for Disease Control and Prevention (CDC) and non-governmental organization (NGO) partners, established infectious disease surveillance for a variety of conditions, including malaria. They estimated that 20 percent of the population might have been infected with malaria. Infectious disease can be devastating in a population. Consider the great pandemic of 1918. It is estimated that over 50 million people died from the mass infection of influenza! World War One started in 1914 and ended in November 1918 and took the lives of 9 million soldiers. Five and a half times the number of people were killed by the great influenza than died in war! Scientists believe the outbreak started in Fort Riely, Kansas in an overcrowded camp that was an ideal site for the spreading of the disease of a respiratory virus with 100,000 soldiers in transit every day. Then the soldiers were sent to camps all over the USA and eventually overseas. It is estimated that 10 percent to 20 percent of those who were infected died. The take away is that infectious disease kills. We now live in a very transient world whereby one can go from country to country with little thought of what airborne disease can do to a population. When traveling overseas, it is not uncommon to sit in a plane for eight or more hours with hundreds of individuals of which we have no idea if they have a deadly disease such as Ebola. Many diseases have an incubation period. Thus one can be infected and not have any outward symptoms yet infect many people they come into close contact. The pandemic influenza of 1918 may have killed as many as 25 million people in its first 25 weeks alone! The next time we think of natural disaster such as hurricanes, tornadoes, earthquakes, mudslides, forest fires and alike, we need to think about the lingering disaster that awaits and can be far more devastating than any of the aforementioned “natural disasters.” The media loves to focus on property damage, and it is compelling to watch. However, disease can be far more devastating. One can al-
ways replace damaged property. One cannot replace a loved one who is the victim of a deadly disease. The silent heroes in the deadly disease disasters are all of the caregivers that put their lives at risk to care for patients that present with symptoms that can be dangerous for all who come into contact with these individuals. Additionally, the epidemiologist that identify the source of the disease, the incidence of and prevalence of the disease are the CSI folks of deadly and hurtful disease. The next time you see them, tell them… “thank you”! Alan Preston, MHA, Sc.D., is an independent consultant that helps physicians navigate through the difficult regulatory framework and helps them achieve higher reimbursements from insurance companies; skilled with a tremendous background in managed care and Population Health Management, epidemiology, team building, and biostatistics; strong healthcare professional with a Doctor of Science (Sc.D.) focused on Public Health, Health Services Research from Tulane University School of Public Health and Tropical Medicine. Dr. Preston is involved in risk-sharing contracts, ACOs, Medicare Advantage including RAP scores, HEDIS, and STAR ratings which helps physicians and health plans alike in reducing MLR. Alan@Preston101.com. visit us at www.bcms.org
23
MEDICAL CARE
Diabetes Self-Management Education:
A Healthy Prescribing Habit to Treat Diabetes By Kathy Ann LaCivita, MD, FACE, FACP
Statistics chronicling the growth and seriousness of diabetes in the San Antonio area are shocking. We now see patients as young as five years old with Type 2 diabetes, which is linked to diet and obesity. These young patients are dependent on their parents to help them avoid the health complications diabetes causes over time, but typically, the parents are already at risk for Type 2 diabetes or have been diagnosed themselves. Diabetes can have an emotional and physiological impact on the entire family. Prescribing medication is an effective first-line treatment to control blood sugar, but it’s not sufficient on its own, as demonstrated by the growing number of families with intergenerational cases of diabetes. As physicians, we can and should do more to help patients manage their diabetes and prevent new cases from occurring. Unfortunately, it can be challenging for physicians to change familiar practices, just as it can be difficult for patients to adopt healthy habits to improve their health. “If diabetes education were a pill, would you prescribe it?” That was the question posed at last year’s American Diabetes Association (ADA) Scientific Sessions by Margaret A. Powers, Ph.D., RD, CDE, President, Health Care and Education, ADA. In her address, Dr. Powers cited studies comparing diabetes education and the diabetes pill metformin. She noted that diabetes education is as effective as metformin and has fewer side effects and greater psychosocial benefits. To read the article, visit http://care.diabetesjournals.org/content/39/12/2101. Additional research shows that people who receive DSME are more likely to: • Use primary care and preventive services. • Take medications as prescribed. • Control their blood glucose, blood pressure, and cholesterol levels. • Have lower health costs over time. • Experience reduced stress related to diabetes.
24
San Antonio Medicine • February 2018
Every person with diabetes needs individualized education and support to carry out daily diabetes self-management and care to improve quality of life. Yet, less than 60 percent of people with diabetes receive formal diabetes education. Furthermore, there is an average of nine years between the time a person is diagnosed with diabetes and enrollment in a DSME program – time during which the body’s insulin resistance affects extremities and vital organs. As an endocrinologist at the Texas Diabetes Institute, I see many patients with complications that could have been delayed or prevented through DSME. As chair of the Texas Diabetes Council, I often talk with physicians who are not aware of how to take advantage of DSME to help their patients. Here are some facts about DSME that can help you empower patients to help themselves. DSME is supported by major health organizations. The American Diabetes Association (ADA) collaborated with the American Association of Diabetes Educators, Academy of Nutrition and Dietetics, and National Diabetes Education Program to develop a national joint position statement that supports DSME. The American Medical Association and U.S. Centers for Disease Control and Prevention also support education to prevent diabetes in people at risk for the disease. The Texas Diabetes Council, in conjunction with the Texas Department of State Health Services Diabetes Prevention and Control Program developed a helpful toolkit based on the national standards. The toolkit is available online at tdctoolkit.org and offers free provider and patient education materials. There is also a new Diabetes resource guide that was developed by a San Antonio collaborative to link services available in town and give information to people with diabetes and the providers who care for them, available at diabetesresourcesguide.com. Both of these resources offer referral forms and links to licensed diabetes educators or education programs in the area. Getting to know licensed diabetes educators is an important first step in mak-
MEDICAL CARE
ing DSME part of your practice. It’s also important to note that DSME is covered by Medicare and most health plans when provided by a diabetes educator in an accredited/recognized program. Physician attitudes are key to making DSME a success. Patients tend to mirror their physician’s attitudes about therapies. If a physician does not endorse DSME, patients may not take it seriously and therefore, may not succeed in developing self-management skills. Patients are more likely to be successful if the physician endorses DSME as an effective diabetes treatment and expresses confidence in the patient’s ability to self-manage. Physician support is especially important for patients who may not feel they have the time or money for DSME. One of the most important messages physicians can share is that DSME can help improve health and quality of life for the entire family. Physicians who have not had experience with DSME – or whose patients have not benefited in the past – are encouraged to review these resources and learn more about the process and local diabetes education programs. Referral for DSME should be considered at specific times. The joint position statement identifies four times when referral for DSME should be considered: • At diagnosis. • At an annual assessment of education, nutrition, and emotional needs. • When complicating factors influence self-management. Complications may include changes in health conditions, physical limitations, emotional factors, or living situation. • When transitions in care occur. Transitions may include changes in the living situation, medical care team, insurance coverage, or age-related changes. As an endocrinologist, I often see patients who are well on their way to developing complications or are already dealing with serious complications from diabetes. Many of these complications could be delayed or prevented if patients practice effective self-management techniques that are taught by diabetes educators. I encourage primary care providers to refer patients for DSME, as recommended by the joint position statement. Patients with prediabetes can also benefit from education to help them prevent diabetes from developing. One out of eight Bexar county adults has prediabetes. Thirty percent of people with prediabetes will develop
type 2 diabetes within five years without weight loss and exercise. By the time diabetes is diagnosed, damage to the pancreas cells has already occurred. The earlier self-management begins, the greater the opportunity to prevent complications from occurring. Kathy Ann LaCivita, MD, is a Board-certified endocrinologist and Medical Director who specializes in the treatment of diabetes at the University Health System’s Texas Diabetes Institute, one of the nation’s largest and most comprehensive diabetes centers. The DSME toolkit and other free resources are available through the Texas Diabetes Council at tdctoolkit.org.
visit us at www.bcms.org
25
UT HEALTH SAN ANTONIO
UT HEALTH SAN ANTONIO’S NEW RECRUITMENTS BOLSTER CITY’S GROWING BIOSCIENCES STATURE By William L. Henrich, MD, MACP
The marketplace for top-flight bioscience clinician investigators is intense and competitive. If you want the best, you offer a package to attract the best, and that includes the support of a model city like San Antonio. Four physician scientists newly recruited to The University of Texas Health Science Center (UT Health San Antonio™) are individuals of the highest stature in their fields. These nationally recognized experts are innovative leaders in cancer, Alzheimer’s disease and kidney disease, and their presence will certainly enhance San Antonio’s reputation as a major center of health care and the biosciences. I’m extremely proud to report the appointments of: • Ruben Mesa, M.D., FACP, a superb clinician and investigator in the field of bone marrow cancers, who joined us in August from the Mayo Clinic Cancer Center in Greater Phoenix. He is the new director of the UT Health Cancer Center and will lead us in our developing affiliation with The University of Texas MD Anderson Cancer Center.
tor of nine active National Institutes of Health grants, Dr. Seshadri is a superstar in the understanding of dementias. She will be the founding director of the Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases, which will collaborate closely with our Sam & Ann Barshop Institute for Longevity & Aging Studies. • Robert Hromas, M.D., FACP, a prominent physician-scientist and expert in blood cancers, who we announced on Oct. 31 as the new dean of the Joe R. & Teresa Lozano Long School of Medicine at UT Health San Antonio. An effective leader with developed expertise in business who assisted two institutions in becoming National Cancer Institute Cancer Centers, Dr. Hromas is joining UT Health San Antonio in February 2018 from University of Florida Health.
• Kumar Sharma, M.D., FAHA, a distinguished kidney disease specialist with expertise in diabetic kidney disease, who joined us in August from the University of California, San Diego. Dr. Sharma leads National Institutes of Health-funded studies of renal disease and will establish a Center for Renal Precision Medicine at UT Health San Antonio.
These outstanding individuals will contribute new energy to the region’s bioscience space, including expansion of clinical trials to provide more treatment options for patients and enhance UT Health San Antonio’s role as one of Texas’ preeminent leaders in health education, research and care. Each brings sterling credentials and teams of skilled collaborators to our city. Each chose San Antonio over offers elsewhere. What brought them? In the end, they sensed the spirit of optimism and collaboration that defines our city. I am incredibly proud of these highly competitive recruitments and the national searches that identified these great leaders.
• Sudha Seshadri, M.D., FAAN, FANA, an eminent clinician, researcher and educator in the field of Alzheimer’s disease, who joins us Dec. 1 from Boston University. The principal investiga-
William L. Henrich, M.D., MACP, is president of The University of Texas Health Science Center at San Antonio, now called UT Health San Antonio.
26
San Antonio Medicine • February 2018
BCMS NEWS
2018 Bexar County Medical Society Installation of Officers Banquet
Dr. Gross’ fellow BCMS officers for 2018 include (L-R) John Robert Holcomb, MD, treasurer; Gerald Greenfield MD, vice president; Kristi G. Clark, secretary; Adam Ratner, MD, president-elect; and Leah Jacobson, MD, immediate past president.
Dr. Sheldon Gross was formally sworn in as the 2018 President of the Bexar County Medical Society during the Annual Installation of Officers ceremony on Jan. 20 in the Mays Family Center at the Witte Museum.
2018 winners of the Golden Aesculapius Award were Dr. Neal Gray and Dr. Rajam Ramamurthy.
Incoming BCMS Alliance president Jenny Shepherd, on the left, is congratulated by outgoing president Lori Boies.
2018 BCMS Directors at the installation banquet included (back row) Dr. Adam Ratner; Dr. Robyn Phillips-Madson; Dr. Gerald Greenfield Jr.; Dr. Michael Joseph Guirl; Dr. John D. Edwards; (front row) Dr. Bernard T. Swift; Dr. Gerardo Ortega; Dr. Leah Jacobson; Dr. Sheldon Gross; Dr. John R. Holcomb. 28
San Antonio Medicine • February 2018
BCMS NEWS
Past Presidents of BCMS attending the installation banquet included (back row) Dr. K. Ashok Kumar; Dr. Leah Jacobson; Dr. Roberto San Martin; Dr. Vijay N. Koli; Dr. Neal H. Gray; Dr. Jayesh B. Shah; (front row) Dr. Rajam Ramamurthy; Dr. Donald Gordon; Dr. Jose M. Benavides; Dr. Sheldon Gross; Dr. John R. Holcomb; Dr. Gerardo Ortega; Dr. David G. Shulman.
2018 winners of the Distinguished Service Award were Dr. David J. Cohen and Dr. Janet Realini. Dr. Cohen was absent and his award was accepted by Dr. Gerald Greenfield.
UIW School of Medicine First year medical students in attendance at the 2018 BCMS Installation.
Thank you to our Installation Event presenting Sponsors:
Thank you to our Installation Event Friends of Medicine:
DR. JOHN HOLCOMB
DR. HOMERO GARZA & HONORABLE SANDEE MARION visit us at www.bcms.org
29
BUSINESS OF MEDICINE
Aligning Electronic Health Record Use With Performance Improvement Goals Beth E. Michel, MLD, CPHRM
he concept of performance improvement is discussed frequently among members of the healthcare community. We generally understand that to improve patient outcomes, we must improve performance, or the delivery of care. Yet, when juggling implementation of new evidence-based practices, adoption of new technologies, and healthcare reform, it is easy for “performance improvement” to become just a phrase rather than a daily conscious focus for healthcare providers. This article brings the issue of performance improvement back into focus by examining ways in which you can use an electronic health record (EHR) system to support positive change in your practice.
T
Using an EHR System To Drive Performance Improvement
A well-defined performance improvement process involves identifying opportunities for improvement, designing and conducting an audit, implementing a corrective action plan, and evaluating for 30
San Antonio Medicine • February 2018
continued improvement. Because EHR systems collect a wealth of data, they can be a valuable tool in the performance improvement process. However, the challenge is understanding how to aggregate and analyze the data, evaluate the results, and then develop strategies and initiatives to improve the delivery of care and generate better patient outcomes. The following sections of this article discuss some specific ways in which your practice can meet this challenge and incorporate your EHR system into quality initiatives.
High-Risk Situations
Identifying situations that create high risk for your practice should be the starting point when considering how EHR data can help you develop performance improvement goals. A few common, highrisk situations are discussed below.
Test Result Tracking
Failure to address all test results is a frequent underlying cause of the top allegation in medical malpractice claims — failure to diag-
BUSINESS OF MEDICINE
nose. Having a well-articulated procedure for tracking patients’ lab, radiology, and other test results can help mitigate this risk. Many EHR systems can assist in automating test tracking, improving both timeliness and completeness of the function. For example, evaluate your EHR system to make sure you can generate data showing (a) all tests that have been ordered, (b) all test results that have been received and reviewed by the ordering healthcare provider, and (c) all test results that have been communicated to patients. You may also find it helpful to have your system generate a daily task list that flags certain situations that could lead to risk exposure. Circumstances that should be flagged include (a) tests ordered, but no results received, (b) test results received, but not viewed by the healthcare provider, and (c) test results viewed by the healthcare provider, but not communicated to the patient. Routinely running reports to identify overlooked test results is critical, even if test results are included on your daily task list. These reports can assist in your practice’s efforts to ensure no test results go missing or unnoticed.
Drug Interaction and Allergy Alerts
Many EHRs are capable of alerting providers to potential dangerous drug interactions and allergies. These alerts can sometimes be overwhelming; however, when implemented as part of a welldesigned system, they can protect patients and help prevent prescribing errors. Work with your EHR vendor to (a) ensure your practice is realizing the full potential of the system’s alert functions, and (b) tailor the alerts to meet the specific needs of your practice. Also, it is imperative to realize that drug and allergy alerts work only if current data are available for the system to analyze. Thus, it’s important to make sure the providers in your practice are reviewing patients’ allergies at each office visit and updating the system during the patient encounter.
Cancelled Appointments and “No Shows”
For both patient safety and liability reasons, healthcare practices need thorough processes for identifying, addressing, documenting, and following up on cancelled and missed appointments — especially in regard to noncompliant and/or difficult patients. Although patients share in the responsibility for their care and ultimately need to make the effort to keep appointments, a well-documented follow-up call or letter from the practice can (a) remind and encourage the patient to make a visit, which may ultimately affect the patient’s outcome, and (b) establish the practice’s commitment to ensuring the patient receives necessary care.
Your practice can use its EHR system to document cancelled and missed appointments and better manage these patients. For example, your practice might use its system to generate a daily report showing all appointments for the previous day that were cancelled or missed. This information will help pinpoint and streamline follow-up communication and tracking. Further, with thorough data input, the system can generate reports showing whether follow-up has occurred, how quickly it occurred, and the outcome of the follow-up. This information provides evidence of the practice’s efforts on behalf of the patient.
Audits
The situations described previously — test tracking, drug interactions and allergies, and appointment cancellations and “no shows” — are examples of common risk areas you may want to consider including in your practice’s performance improvement efforts. Once you have selected a specific area for improvement, you will need to design and conduct an audit. An audit is a way of measuring outcomes (performance metrics) against expectations that have been defined in office policies, procedures, standards, or guidelines. When selecting measures to include in your audit, make sure that your office staff has a working knowledge of the data elements and definitions associated with your EHR. Providing the team with a list of these elements and definitions when discussing possible measures is helpful. Information regarding evidence-based standards specific to the patient population you serve and your practice’s involvement in mandatory and/or voluntary quality data reporting initiatives also is relevant to the audit that you design. At minimum, the audit process that you implement should include the following for each measure selected: •
Definition: Create a clear statement of the metric to be measured. For example — “Communication of all tests results to patients.”
•
Goal: Develop a broad statement describing the intended result. For example — “This office will communicate the results of all tests to patients within an appropriate timeframe based on the results and the patient’s condition.” continued on page 32 visit us at www.bcms.org
31
BUSINESS OF MEDICINE continued from page 31 •
Target: Establish a target outcome so the practice can determine the significance of the results. Consider best practices, benchmarking data, and evidence-based treatment when setting targets. For example — “Ninety percent of all test results will be communicated to patients within an appropriate timeframe set by office policy, and 100 percent of all critical test results will be communicated to patients within a timeframe established by applicable professional guidelines. Communication of results will be documented in each patient’s chart with a revised treatment plan, if appropriate.”
•
Methodology: Describe the method you will use to obtain data. For example — “Run EHR system reports to identify all test results that have been received but are still pending follow-up with patients.”
•
Frequency: Explain how often you will measure the metric. For metrics that have an immediate impact on patient safety, consider more frequent measurements, such as daily or weekly.
•
Corrective actions: Describe what you will do to improve the results if your target is not met. Will you implement a new workflow process, reallocate resources, or take another action?
•
Monitoring: Describe how you will monitor any changes over time. Will you continue to measure the metric for a year or longer? How often will you perform spot checks to ensure continued improvement or consistent results?
Conclusion
MedPro Group’s guideline Using an Electronic Health Record System as a Risk-Reduction Tool contains additional details and guidance about the audit process.
Delivery of healthcare in a safe and efficient manner is the goal of all practitioners. Being mindful of opportunities for improvement and willing to invest time and energy to address those opportunities can be a challenge. However, a well-designed EHR system is an excellent tool for risk mitigation, quality checking, and long-term performance improvement monitoring. The activities of aggregating and analyzing data — as well as taking action based on the findings — are critical to delivering quality patient care, preventing errors, and minimizing risk within your healthcare practice. In the long run, efforts to identify and address gaps in performance and develop corrective plans can help improve patient outcomes, increase patient satisfaction, and possibly reduce your liability exposure.
32
San Antonio Medicine • February 2018
BOOK REVIEW
MODERN DEATH: HOW MEDICINE CHANGED THE END OF LIFE By Haider Warraich, M.D. Review by Fred Olin, MD
T
his book is hard for me to describe: It is a history book, a book about ethics, a philosophical tome, and, to a small extent, a professional autobiography. I’ll give you a hint of what’s in it by listing a few of the 13 chapter titles; “When Cells Die,” “How We Learned Not to Resuscitate,” “When Guardians are Burdened,” “When Death is Desired” and “When the Plug is Pulled.” Dr. Warraich is currently a cardiology fellow at Duke University Medical Center, and how he managed to write this book with its 600+ references during his various levels of training is a mystery to me. I bought his book because one day I happened to hear an interview with him on NPR’s “Fresh Air with Terry Gross” and was fascinated with his presentation. Highlights of that interview are available at NPR.org. The history mentioned is integrated into the narrative. It starts in biblical times, moves to ancient Greece, then forward to the present. As I read the book I learned all about some of the famous court cases that have defined physicians’ and families’ duties and options when a person appears to be “dead” but is still being kept “alive” by artificial means. But wait! Before we look at that, we have to know what “alive” and “dead” are. In the chapter entitled “How Death was Redefined” is this line: “…quite shockingly, there is no a single agreed upon definition of life.” This is followed by a long and intellectually stimulating discussion on just that subject. After that comes an equally fascinating tale about how “Progress during the first half of the twentieth century had definitely moved the chalice of life from the heart and lungs to
34
San Antonio Medicine • February 2018
the brain.” So, just because the heart has stopped and the person isn’t breathing no longer means they are “dead.” Nowadays, the criterion in this situation is “brain death.” So, let’s look at these two court cases: New Jersey resident Karen Quinlan overdosed on alcohol and tranquilizers in 1975. She was rendered unresponsive and anoxic. Although she was “revived”, she was brain dead. Her parents wanted life support removed, but the physicians and hospital refused. The parents sued. The case made headlines and intrigued the nation. When she was finally removed from life support she lingered on, comatose, for ten years and died of pneumonia in 1985. Another case was that of Nancy Cruzan, who crashed her car in 1983, and whose fate was argued in Missouri’s courts and in the press. Ultimately, despite the objections of medical, legal and religious factions, the courts allowed the family to have the feeding tube removed and, about two weeks later “…Nancy completed the long and agonizing death that had taken almost eight years to unfold.” Each of these situations resulted in strange bedfellows on each side, and decisions that echo down to the present in both medical and legal circles. The plight of families and caregivers when a loved one is declared to be “dead” by current criteria despite being kept “alive” is discussed at length by Dr. Warraich. Several scenarios are illustrated, including that of a woman whose daughters were at odds over what to do until they were asked to tell the physician about their Mom: What sort of person was she, how did she live, etc.? As they answer that she was
BOOK REVIEW
kind, generous and loving, they realize the reality: that she couldn’t be that person again. Permission was granted to allow her to die. This story was both heartbreaking and reassuring at the same time.
A number of different terms and euphemisms for “assisted death” are discussed. Do you know the difference between “physician assisted suicide,” and “euthanasia”? Can you define “comfort measures only,” “withdrawing treatment,” “terminal sedation,” and “terminal dehydration?” How many of you have had anything to do with letting an old, sick, debilitated, demented patient die rather than taking some action that would have extended their “life?” Could you have been indicted for murder? Did you even think about that? It has happened. How about the nurse who, one late night when I was an orthopaedic resident doing a consult in the Medicine ICU, told me that a different patient wasn’t doing well, had no future, and that the nurses had informally decided to “…make haste slowly…” if the alarms went off in the patient’s room? Was she breaking a law or some standard of ethical nursing behavior, or were she and her col-
leagues sympathetic and merciful, or did all of those terms apply? I don’t know the answer to that question, but this book made me think
much more deeply about an incident from more than forty years ago
than I had at the time. Dr. Warraich intersperses his various chapters with personal anecdotes and observations that bring a touch of humanity to what otherwise could have been a somewhat dry and didactic read. Many of the stories are like illustrative case reports that are approached with a level of sympathy and empathy which told me that he has a maturity in his ability to interact with patients and their families which is far above his current age of about 30. In sum, I feel that this is a wonderful book that should cause everyone who reads it to reflect on what he or she would have done (or might yet have to do) if faced with a situation of a loved one in the in-between state of “life” and “death” described here. Further, I think it is a book that is pertinent to almost every physician in clinical practice, no matter his or her specialty.
visit us at www.bcms.org
35
FEATURE
BACK TO SCHOOL
…here we go again By Robert G. Johnson, MD
Checked your report card lately? Hmmm… Didn’t even know you had a report card? Double Hmmm… Mom and Dad are looking at it. So is big brother. So are your patients. Just got a letter from Baptist Health System Ongoing Professional Practice Evaluation (OPPE): “The ongoing data regarding your practice and performances have been evaluated based on the approved, specialty specific OPPE metrics. These findings will support the credentialing and privileging recommendations that are made by the Credentials Committee, Medical Executive Board and Board of Trustees.” There follows a table with three headings: % Complications of Care / Mortalitity Observed/Expected Ratio / Packed Cell Transfusion Rate (what does this have to do with competence?). Wow!!! Since there’s no actual exam I took, it seems that my mark is based on classroom participation and weekly quizzes. My secretary spent two hours on the computer and telephone trying to log onto crimsonservices.com to obtain and review the data used for my Baptist ‘report card’. I was eventually told that I was not ‘registered’ and that my data was unavailable to me. Despite my best efforts to register, at the time of this writing, I have no idea how OPPE works. Turns out I passed their performance standards, but who knows about next year or the next. Our next contestant goes by the name SURGEONRATING.org by Consumers Checkbook. This is a website available to the public. Its ‘Overview’ states: “This is the first-ever website to report nationwide on such a range of procedures (12 major types of surgery), estimates of specific surgery results in terms of patient deaths, complications (which we identify based on prolonged lengths of stays), or need to be readmitted to a hospital.” The government has such data on millions of patients (Medicare) over a five year period (2000-2014) and recently, individual doctor’s names were released. By this system a doctor is assigned from one star (horrrible!) to five stars (grrreat!). The criteria by which we were
36
San Antonio Medicine • February 2018
judged fell into three categories: prolonged lengths of stay / readmissions / deaths. Readmissions and deaths extended out to 90 days from the first admission. Double wow!!! Where does one start the repeal and replace of this mess? Here’s a scary example. A group of anesthesia/pain management doctors recently faced a five figure fine from Medicare because of the ‘death’ criterion. Cancer patients (in terminal phases and with a lot of pain) underwent pain management (injections, pain pumps, celiac blocks) procedures and these doctors were held responsible for their deaths (which was due to their cancer, not the procedure). Oncologists must flunk this exam miserably. Which brings up another point: Are both pain doctor and oncologist penalized for the same death? (double-dipping). What about consultants on the case? Do they share the blame? Here’s the point: it appears that this country’s finest doctors are being held responsible for the natural history of a disease that, not only did they not invent, but have dedicated their careers to treating (I’m not making this stuff up). Another example: Hip fractures in the elderly are associated with a significant mortality rate (50%) going out 90 days. This is due to the complications inherent in the injury in a compromised patient— not the treating physician’s incompetence. Orthopedists will flunk this quiz just because they take ER call. Back to SURGEONRATING.org. Read these inane statements on their website: “you (the patient) might prefer a more recent graduate who may be more up to date on recent developments…” Ha! These buffoons don’t get it. Surgery is an experiential-critical specialty. You want the oldest, grayest surgeon who’s still breathing to do complex operations. Here’s another fallacy they propagate: “a well known university might provide some reassurance…” Doubleha! Not all the best doctors are at universities. SURGEONRATING provides great detail into how death rates
FEATURE
are calculated. They calculate an ‘average’ death rate for a certain procedure (CABG, heart valve etc) then score individual surgeons against this statistical mean. They insist that their programs even out the inconsistencies of age, the complexity of the operation, coexisting medical conditions, previous similar surgeries, risk factors such as smoking etc. (but they don’t say how they do this). Listen to this statement on their website: “There is reason to believe that a surgeon can affect 90-day outcomes by doing better work during the surgery itself, by making sure the hospital provides high quality and safe care, by following up with the patient and the patients’ other providers after the patient’s hospital release, and by helping to ensure that the patient is released to a safe and supportive environment.” Now that’s a lot of responsibility on one pair of shoulders. So, I suppose the schoolteacher is responsible for the cafeteria food, toilets getting flushed, the kid getting home, doing homework, not fighting with his brother and being in bed by nine! Another fallacy—length of stay. Boy, did I blow it recently. One of my patients almost a year post-op developed a redness to his back incision. I felt that a ten minute I&D (incision and drainage) was appropriate. All went well until he hit recovery and went into pulmonary edema. He had a cardiac history, needed a new pacemaker, but was cleared for surgery by his cardiologist. Two weeks in cardiac ICU and four weeks later he goes (alive and well) to rehab. That’s a big, fat ‘F’ on my report card. And don’t get me started on inpatient rehab. My patient undergoes a spinal fusion on Monday and is ready for transfer by Thursday. On Monday a week after surgery we’re still waiting for insurance approval. Guess who gets dinged for excessive length of stay? (Hint: not the hospital, insurance company, or cafeteria food). There’s length of stay and there’s length of stay. Personally, I am not a special agent for hospitals or insurance companies whose job it is to get patients the heck out. If a patient feels the need for another day in hospital, so be it! I think that this component of the ‘grading’ system is merely to pressure us to save them money. The website admits that low income, the uninsured, Medicaid, patients with social problems and poor family support—these issues may contribute to length of stay, complications and readmissions. What they don’t get is that there are specialties, sub-specialties, and sub-sub-specialties; that is doctors in the same specialty may select what they do and don’t do. For instance, nearly 50% of MD’s do not accept Medicaid. This sets up the following discrepancy: surgeon A does operation X on insured-only patients while surgeon B takes all comers (including Medicaid and uninsured). The operations are equally well done but one patient goes to rehab then home to a supportive family. The other patient’s insurance won’t pay for rehab
and he goes home to the third floor of a rooming house with no elevator. Guess which doc gets one star and who gets the fiver? Here’s another trait that the almighty computer cannot account for. Two surgeons may be technically of similar competence but one is timid, unsure of himself, or diagnostically challenged. Here’s the scenario: The patient has severe 5-level lumbar disc disease and presents to the above surgeon. Being, younger and less experienced, the surgeon chooses to perform a thirty minute laminectomy at the two worst levels. The patient leaves hospital the next day, has zero complications, and doesn’t die. His surgeon scores a big, fat 5-star rating. Here’s the catch: the patient doesn’t get better because the operation he needed was a five-level fusion. A year later the patient sees another, more experienced surgeon who does the correct operation. Because of the previous laminectomy, the patient gets a spinal fluid leak requiring another surgery and three more hospital days. When all is said and done, the fusion works great and the patient is happy. Again, which doc gets the one and which the five? Enough of this back and forth. What I did was put the SURGEONRATING.org system to the test. I looked up all the spine surgeons they had listed in San Antonio. I’m certain not all were listed but it provided me with 27 names, both neurosurgeons and orthopedic surgeons. I’ve practiced in San Antonio since 1989 so I know everyone and the kind of practice they have. I know who does the big cases that most other spine surgeons avoid (in fact, many spine surgeons refer these cases to other spine surgeons—this is a phenomenon that the computer geeks don’t understand). Of the 27 total spine docs, I identified seven who do the big, bad stuff on a routine basis. Don’t get me wrong, the others are great surgeons; they just generally avoid the 10-hour, 12-level, re-re-do high risk procedures. Remember I said that SURGEONRATING had a one star (bad surgeon) through five star (superman) rating. The average for the seven complex guys was a 1.42 (range1-3). The average for the other 20 surgeons was 3.30 (range3-5). I’m no statistician but, as Yoda said, “significant it is”. So, what does this mean? If we believe that SURGEONRATING is onto something then all seven complex spine surgeons in San Antonio are incompetent (including yours truly). If a complicated patient sees one of the other twenty docs, chances are they’ll be referred on to one of the seven. May as well head for the Mayo Clinic!!! Here’s the bottom line. Doctors who take on the tougher cases will score toward the lower end of the spectrum and those who do simpler cases will be at the top of the class. Period. These rating systems, while noble in concept, are flawed and misleading. Patients would do as well with a blindfold, dart, and the Yellow Pages.
visit us at www.bcms.org
37
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-
38
San Antonio Medicine • February 2018
ston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."
ATTORNEYS
Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence. Partner and Office Head Mark R. Flora 512-382-8800 mflora@constangy.com Partner William E. Hammel 214-646-8625 whammel@constangy.com Senior Counsel John E. Duke 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”
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”
ASSETS ADVISORS/ PRIVATE BANKING
U.S. Trust ( Gold Sponsor) At U.S. Trust, we have a long and rich history of helping clients achieve their own unique objec-
tives. Since 1853, we've been committed to listening, building long-term relationships, and helping individuals and their families realize the opportunities they create for themselves, their children, businesses, communities and future generations. SVP, Private Client Advisor, Certified Wealth Strategist® Christian R. Escamilla 210.865.0287 christian.escamilla@ustrust.com “Life’s better when we’re connected®”
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 210-762-3175 bpressentin@bbandt.com www.bbt.com
BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees.
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com “Working for a better future”
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 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
Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals. Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!” 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.”
BUSINESS CONSULTING Alto Vista Enterprises, LLC (HH Silver Sponsor) We specialize in helping physicians grow their business according to the goals and timeline of the practice. Customized business development strategies are executed by an experienced and dedicated team of consultants. Owner Michal Waechter (210) 913-4871 MichalWaechter@gmail.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”
BUSINESS SERVICES
New York Life Insurance Company (HHH Gold Sponsor) We believe that any great relationship starts with great core values: Attention, Accountability, Appreciation, Adaptability and Attainability Financial Consultant Doug Elley 210-961-9991 dougelley@financialguide.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
EMPLOYEE MANAGEMENT
Beyond (HHH Gold Sponsor) Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire employee life cycle. From online onboarding to certification tracking to payroll processing, manage your people anytime, anywhere. Founding Member Division Sales Director | San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"
FINANCIAL ADVISOR
Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"
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 ommitted 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 ( Gold Sponsor) Beyond is a financial technology company offering a suite of business tools including payment processing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference. Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"
FINANCIAL SERVICES
Avid Wealth Partners (HHHH 10K Platinum Sponsor)
Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.
continued on page 40
visit us at www.bcms.org
39
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39
Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"
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
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/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."
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
40
San Antonio Medicine • February 2018
https://new.trinity.edu/academics/departments/health-careadministration
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
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”
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 company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships. VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Mortgage 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
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. 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 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
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”
MEDICAL BUSINESS CONSULTING
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."
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 (HHH Gold 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.”
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 dougelley@financialguide.com www.newyorklife.com “20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”
PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people
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
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”
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.” United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients Physician Recruiter MSgt Robert Isarraraz Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"
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 AUTO GROUP
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
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 KAHLIG AUTO GROUP
Cavender Toyota 5730 NW Loop 410 San Antonio, TX
Northside Ford 12300 San Pedro San Antonio, TX
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
Gary Holdgraf 210-862-9769
Wayne Alderman 210-525-9800
William Taylor 210-366-9600
James Godkin 830-981-6000
Mark Castello 210-308-0200
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
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 Toyota 10703 SW Loop 410 San Antonio, TX 78211
Scott Brothers 210-253-3300
North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257
Jose Contreras 210-308-8900
Justin Blake 888-341-2182
Stephen Markham 877-356-0476
Justin Boone 210-635-5000
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Lincoln 9207 San Pedro San Antonio, TX
North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257
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
Sandy Small 210-341-8841
James Cole 800-611-0176
Ed Noriega 210-561-4900
Matt Hokenson 210-764-6945
Dale Haines 210-341-2800
15423 IH-10 West San Antonio, TX 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
43
AUTO REVIEW
2018 Volkswagen Tiguan By Steve Schutz, MD
“We understand Europe, we understand China, and we understand Brazil. But so far we understand the US to a limited extent.” So said then Volkswagen Supervisory Board Chairman Ferdinand Piech in 2013 when asked about declining sales in this country. As was always the case when Dr Piech expressed displeasure with one aspect of VW or another, changes happened in short order, and here we are four years later with a very different Volkswagen USA. A quick aside, in addition to customer tastes, VW obviously also had a limited understanding of US emissions laws. In Europe prior to the big VW scandal, all manufacturers had to do to make regulators happy was roll their vehicles onto government dynamometers and pass their proscribed emissions tests. If they drove out of the testing facility polluting much more than they did during the test, that was OK. It was the test that mattered. That’s not how the laws are written in this country, which is why Volkswagen has had to spend billions of dollars in fines and restitution here but not in Europe despite using emissions defeat devices in both places. (Those European loopholes have since been closed, by the way.) 44
San Antonio Medicine • February 2018
Anyway, the US automotive market in 2013, like now, was moving rapidly away from family sedans--cars in general, really--and towards SUVs and crossovers. While VW back then had two SUVs, the Tiguan aimed at Honda CRV/Toyota RAV4 buyers, and the Touareg charged with attracting Honda Pilot/Toyota Highlander intenders, neither vehicle sold well because they were both too small and too pricey (among other problems). Fast forward to 2018, and Volkswagen, now without the leadership of the aforementioned Ferdinand Piech, has nevertheless taken his advice and learned more about the US market, which is the obvious take away if you’ve driven either two new crossovers launched in 2017, the Atlas and (all new) Tiguan. The Tiguan is the crossover we’ll focus on here, and it’s a much better fit in the US than the last one was. For starters, the new Tiguan is significantly larger than the previous one, adding 7.3 inches of wheelbase and 10.6 inches of length. Not only does that make it big enough inside to fit a third row of seats (standard in FWD models and a no-brainer $500 option in AWD models. I know, weird. Blame
AUTO REVIEW arcane federal regulations that define what a truck is and isn’t), but the 2018 Tiguan is now more spacious than competitors Honda CRV and Nissan Rogue. As always, avoid putting nonkids in the way back unless you don’t mind whoever you put in those seats hating you forever. All the tech you need and want is either standard or available for a reasonable markup, including adaptive cruise control, automated emergency braking, lane-departure warning, blindspot protection, front seat heating and even a heated steering wheel (OMG is that a great thing when it’s cold), a surround-view camera system, an Audi-esque configurable digital instrument cluster, and an 8.0-inch touchscreen with navigation. While some of the tech is indeed Audi-esque, most of the interior materials aren’t, which is a bit of a downer. To be fair though, the mega-selling competing Nissan Rogue has nothing on the Tiguan’s interior materials. It’s a reality of this end of the market. The exterior design is more angular and involving than before. The previous Tiguan’s styling is best described as “late ‘90s rounded”, which I didn’t like then and don’t now. The new one doesn’t blaze new visual trails, but neither does it completely disappear into the background like the old one did. Driving the Tiguan is actually less fun than it used to be. It weighs more--about 400lbs more--so that’s no surprise, but it’s always discouraging when a German engineered vehicle loses its verve and moves toward the dynamic center. There’s still a conventional automatic transmission--that’s very good at finding the right gear, BTW-instead of an odious CVT, but in no way is the Tiguan a raised and enlarged GTI. In the case of the Tiguan the specs actually say a lot: 8.2 second zero-to-sixty time, 22MPG city/27 highway, 184 HP turbocharged four-cylinder engine, 8-speed automatic transmission, 33 ft3 of cargo space below the rear hatch (66 ft3 if you lower the second
row of seats; yes, my 29” mountain bike fit in there easily), 3900 lbs (FWD version; add around 140 lbs if you choose AWD), and a starting price of just over $26,000. All of those figures are right where the market for compact family crossovers is in the US in 2018. And that’s exactly what Volkswagen’s Board Chairman wanted four years ago. As future Volkswagens better align with the (ever changing) tastes of US consumers as the Atlas and Tiguan are doing now, expect VW to start approaching Toyota and Ford in sales totals. That will take a while, but you know what they say about a 100 mile journey... If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367. Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit 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 January 25, 2018.
46
San Antonio Medicine • February 2018