san antonio medicine february 2015

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THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • FEBRUARY 2015 • VOLUME 68 NO. 02

MEDICINE

‘Why I Create...’

4 San Antonio Medicine • February 2015

CreativityWhy I paint

By Alfred L. Laborde, MD ..........................................10

Why I’m a photographerBy Oliver Johnson, MD...............................................14

Why I create potteryBy Dudley Harris, MD.................................................18

Why I danceBy Rajam Ramamurthy, MD .......................................21

BCMS President’s Message ..............................................8

BCMS News ................................................................................................................................25

UTHSCSA Dean’s Message by Francisco González-Scarano, MD ......................................................26

Business of Medicine: A legal perspective on public health

by Joseph B. Topinka, JD, MBA, MHA, and Dana A. Forgione, PhD ................................................30

BCMS Circle of Friends Services Directory ..........................................................................................33

Book Review: ‘The Happiness Project” by Gretchen Rubin,

reviewed by Rajam Ramamurthy, MD ................................................................................................37

In the Driver’s Seat ................................................................................................................................39

Auto Review: BMW 435i by Steve Schutz, MD ......................................................................................40

T A B L E O F C O N T E N T SSAN ANTONIO

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BOARD OF DIRECTORS

OFFICERSJames L. Humphreys, MD, PresidentLeah Hanselka Jacobson, MD, Vice PresidentMaria M. Tiamson-Beato, MD, TreasurerAdam V. Ratner, MD, SecretaryJayesh B. Shah, MD, President-electK. Ashok Kumar, MD, Immediate Past President

DIRECTORSJosie Ann Cigarroa, MD, MemberKristi G. Clark, MD, MemberJohn Robert Holcomb, MD, MemberJohn Joseph Nava, MD, MemberCarmen Perez, MD, MemberOscar Gilberto Ramirez, MD, MemberBernard T. Swift, Jr., DO, MPH, MemberMiguel A. Vazquez, MD, MemberFrancisco Gonzalez-Scarano, MD, Medical School RepresentativeCarlos Alberto Rosende, MD, Medical School RepresentativeCarlayne E. Jackson, MD, Medical School RepresentativeBonnie Harriet Hartstein, MD, Military RepresentativeRebecca Christopherson, BCMS Alliance PresidentGerald Q. Greenfield Jr., MD, PA, Board of Censors ChairDonald L. Hilton Jr., MD, Board of Mediations ChairGeorge F. "Rick" Evans Jr., Legal Counsel

CEO/EXECUTIVE DIRECTORStephen C. Fitzer

CHIEF OPERATING OFFICERMelody Newsom

DIRECTOR OF COMMUNICATIONSSusan A. Merkner

COMMUNICATIONS/PUBLICATIONS COMMITTEEFred H. Olin, MD, ChairEstrella M.C. deForster, MD, MemberJay S. Ellis Jr., MD, MemberJeffrey J. Meffert, MD, MemberRajam S. Ramamurthy, MD, MemberJ.J. Waller Jr., MD, Member

Our new state legislature has spent the last month memo-

rizing the location of their offices and other important Capitol

landmarks such as conference rooms and the nearest rest-

rooms. The first month of every legislative session gets off the

ground a little slowly as the new guys learn the system and

legislators get a feel for their committee assignments and com-

mittee chairmen and women. With so much change in the

legislature after the November elections, this feeling-out

process has taken even longer than usual.

This month is when things start to heat up and get serious.

Bill filings pick up and committees start to have more frequent

meetings. Advocacy activity at both the TMA and BCMS

never actually stops, but there is a definite uptick in activity

starting in February. The annual collection of First Tuesdays

advocacy visits to the Capitol jointly operated by TMA and

the TMA Alliance run from February through May. If you

have not participated in a First Tuesdays visit to Austin, I

highly recommend attending at least one to see how your state

and local advocacy teams take issues affecting your practice

straight to the legislators.

In the 84th Legislative Session we face the usual list of is-

sues: attempts to undo or weaken tort reform, expansion of

non-physician scope of practice, inadequate Medicaid pay-

ment for services and the numerous bureaucratic obstacles of

the Medicaid program, and lack of sufficient funded residency

slots to take advantage of the newly graduated medical stu-

dents and maintain a sufficient physician workforce in the

state. Additionally we have to attempt to restore the lost

Medicare/Medicaid dual eligible patient funding that hit doc-

tors hard all across the state and particularly in the Rio Grande

Valley. Lastly, the issue of price transparency in medical care

has been pressed to the fore by a media blitz over the past two

years and is sure to be an issue with bill filings this session.

Take advantage of the opportunity to learn our current hot-

button issues at the state house and what new legislation is in

the pipeline that affects them. Every new legislative session is

your chance to be a part of the process directly and take a shot

at shaping new laws (or fixing broken old ones). BCMS will

again be very active in legislative advocacy this session, and

we invite you to join us in these efforts. Feel free to contact

either myself or Mary Nava if you have any questions about

how to help us help ourselves and our colleagues. Remember,

if you aren’t at the table, you are on the menu.

James L. Humphreys, MD, is the 2015 president of BCMS.

He is a pathologist with Precision Pathology in San Antonio.

PRESIDENT’SMESSAGE

It’s time to take a seat at the tableBy James L. Humphreys, MD

2015 BCMS President



CREATIVITY

I have always loved to draw. That love was probably born outof countless hours watching my grandfather entertain my sib-lings and me as he drew for us on his kitchen table. These werewonderful drawings of houses, horses, landscapes or whateverwe shouted out. These drawings were in lieu of watching tele-vision; they did not own one until much later. That was ourentertainment for the evening on the Saturday nights we wouldspend with my grandparents. These evenings were loose, care-free and without any strict rules. My grandfather was not anartist but he was an excellent craftsman who paid very close at-tention to detail. With no formal education past the eighthgrade, he began waiting tables at a popular downtown San An-tonio restaurant. He eventually retired at the age of 50 as co-owner of the establishment.

After passing the age when I was entertained by “horse draw-ings,” my grandfather began buying paint-by-number art sets,

and without fail, Sunday afternoons were spent carefully open-ing the thumb-size containers of oil paints. Not wanting to con-form to the “rules” of paint by numbers, I often begged mygrandfather to allow me to blend colors to give the painting amore personal and realistic look. With the last piece I can re-member painting with my grandfather, he finally conceded de-feat, and I did the painting my way. To this day, I don’t knowwhether it was out of frustration with my whining or out of cu-riosity. The end result was priceless. By no means was it a workof art, but the look on my grandfather’s face, and without sayinga word, reflected approval.

STRUCTURE, DISCIPLINEWith the rigors of college work, part-time jobs and medical

school, I did not have much time for drawing or painting. Thestructure and discipline required to advance through various lev-

Why I paintBy Alfred L. Laborde, MD

Untitled. Copyright Alfred L. Laborde, MD

CREATIVITY

visit us at www.bcms.org 11

els of education and training superseded any desire to enrich thewhimsical, artistic side of the brain -- the same side I would laterlearn complemented my career perfectly.

After graduating from medical school at Texas Tech Univer-sity, I accepted a surgical residency in Chicago. I soon learnedthat decision-making in the medical profession does not allowa lot of room for error. Pursuing a surgical specialty and later avascular sub-specialty drove that point home over and over. Mysurgical residency taught me precision, and I learned the skill tovisualize actions, two or three steps ahead. The attention to de-tail brought back memories of my grandfather’s early art lessons.A true appreciation for the craftsmanship in a surgical careerwas brought to light.

Needless to say, the leisure time usually allotted for paintingwas rarely available. After completing a surgical residency inChicago, followed by a vascular fellowship at the University of

Iowa, I accepted a position with my current partners at Periph-eral Vascular Associates and returned to my hometown. Mydaughter, Veronica, was born in Iowa one month before ourmove back to San Antonio. My son, A.J., was born the follow-ing year.

The inspiration to resume my artistic side didn’t occur untilmy children were at an age when their artistic curiosity waspeeking through. Weekend mornings were transformed into amix of pancake making and art sessions. I was eager to exploremy children’s unabashed artistic side. My true fascination waswith how 4- and 5-year-olds would convert a blank piece ofpaper into a “work of art.” On one hand, my perfectionistdaughter spent more time with the eraser than with the freedomthe blank piece of paper could afford her. My son, on the otherhand, could spend the entire time drawing, coloring and paint-ing without any regard to artistic rules or regulations. His ses-

Untitled. Copyright Alfred L. Laborde, MD

Continued on page 12


CREATIVITY

sions were relaxed and carefree.At those innocuous moments I began to see the contrasts in

my own life. My surgical career was exact and unforgiving, andI severely missed the relaxed and carefree side. I certainly feltthat my creative, relaxed side could compliment my surgeon’spersonality.

EARLY BEDTIMESIn addition to those relaxed Saturday mornings, I took advan-

tage of my kids’ early bedtimes to begin drawing and paintingat night. I began to look forward to these late-night paintingsessions because I could feel a better sense of balance returningto my life. I soon realized that my love of watercolors truly rep-resented that sense of balance. In the operating room, being incomplete control of the situation often meant the difference be-tween life and death. With watercolors, losing control of themedium was the difference between a beautiful outcome verses

a rigid, confined painting totally lacking creativity.In surgery, planning is everything. Picturing the end result

gives you the best results. With art, my best work has been byaccident. The work that has received the most compliments wasnever planned. I have always said that a masterpiece is neverplanned in advance.

For several years, I used art at a therapeutic tool, never realiz-ing that anyone would be interested in what I produced.Thanks to my family, I have had more than 10 art shows withthe sale of more than 300 pieces. The majority of the proceedshave gone to educational scholarships.

I consider myself extremely lucky to find this balance in mylife which has benefited both my professional ca-reer as well as my artistic side.

Alfred L. Laborde, MD, is a vascular surgeon atPeripheral Vascular Associates and a BCMS member.

Autumn on the Banks of Sister Creek. Copyright Alfred L. Laborde, MD

Continued from page 11


CREATIVITY

As an anesthesiologist in San Antonio for the past 25 years, I

have lived my life mostly in my left brain. My father (another very

left-brainer) told me that photographs are only for recording a mo-

ment in time — nothing more. It wasn’t until 10 years ago that I

came to see the photograph as an opportunity to make a statement,

to convey an idea or emotion visually. I began with the question,

“Why don’t my photographs look anything like the ones in mag-

azines,” and I started a search for what was lacking in my photos.

A simple Google search uncovers a wealth of information, some

of it free, regarding how good photographers create their finished

images. A new world was beginning to open for me, as I was at-

tracted to the creative side of photography. I began learning the

craft on my own with Internet resources. There is a plethora of tu-

torials, written and video, authored by some of the great photog-

raphers if we have the interest, patience and most especially time

to devote to learning a new craft.

Why I’m a photographerBy Oliver Johnson, MD

Castle Grotti Sunrise. Copyright Oliver Johnson, MD

CREATIVITY


Palouse Fields. Copyright Oliver Johnson, MD

Continued on page 16Dune. Copyright Oliver Johnson, MD


CREATIVITY

But to really learn a complex subject, one must have mentor(s)

to learn effectively, people with long-term, intimate knowledge

and experience of photography who can directly teach the nuances

and give feedback in real time. I bought a Canon 40-D camera

and associated lenses and began to learn how to manipulate an

image to make it say something to the viewer. I signed up my wife

and myself for a 10-day photographic workshop. Jim Chamberlain

is a well-known European landscape photographer, and we went

for an adventure in travel and learning in Italy. We travelled all

over Tuscany, Florence, Rome, Venice and the islands of Murano

and Burano. When I first asked, “What do you take pictures of,”

the answer was, “What do you want to say with your image?”

CONVEY EMOTIONThe answer requires a complete turn-around in thinking. In-

stead of taking a picture and hoping for a lucky shot as most am-

ateurs do, one must consider the message or emotional impact one

is trying to convey. Only then can one decide how to get that feel-

ing into an image which will impact another person who views it.

I had to become a right-brain person where photography was con-

cerned.

It continues to be an evolving process, and as my skills have pro-

gressed, so my work has improved, as has my equipment. Today I

shoot with a Canon 5D Mark III and some very good lenses. Since

that time, my wife and I have done photo-shoots in France, Sicily,

Dallas, and I have been to Death Valley and the Palouse in eastern

Washington state with Scott Stulberg, another professional pho-

tographer. I’ve been told by several pros that I’ve got “the eye” of

a photographer. My images will have to speak for themselves.

My future plans include another 12-day trip to Italy with my

wife next spring where we also will be driving one of the vehicles

on a workshop with Jim Chamberlain and his wife for 12 people.

Cars Night Stars. Copyright Oliver Johnson, MD


CREATIVITY


I have been asked to help scout locations in

northern France with Jim in the fall, just the

two of us. This is high praise for me.

My website is under construction. I print

my own images in my office at home up to

24 inches by 36 inches. I have a framer who

works with clients on proper matting and

framing of each image according to their

budget and tastes. My wife also has a great

eye and helps clients pick images and sizes to

compliment the walls of their office or

home. My “real” job prevents me from ded-

icating as much time to photography as I

would like. Perhaps some day I’ll be able to

concentrate only on the images.

Oliver Johnson, MD, (left) is an anesthesiol-

ogist at Star Anesthesia and a BCMS member.


CREATIVITY

What will I do with myself while my 12-

year-old son takes his first pottery class?

Well, dang! I’ll just take the class with him!

That was more than 30 years ago. I’m still

making pottery. Who knew?

There’s work time, and there’s free time.

What do we do with our free time? We seek

entertainment -- travel, movies, television,

etc. Making stuff is entertainment. It just

so happened that it was making pottery that

chose to entertain me.

Pottery is a beautiful thing for an intro-

vert with a touch of the obsessive. Hours

of solitude working on the potter’s wheel

making the same thing over and over and

striving only for just a bit more refine-

ment … a bit more beauty … with each

thousand pots.

KINSHIP, CONNECTIONThere is nostalgia surrounding pottery.

It’s a feeling of being connected ... to early

man around his campfire working clay, to

the Japanese tea master and to all the un-

known craftsmen through the centuries.

This is not something I think about all the

time, but when I sit down at my wheel and

slap down a ball of clay on the wheel head,

I do feel a kinship with all the potters who

have made exactly that same maneuver and

stared at exactly that same potential.

Making pottery on the potter’s wheel is

not easy. It requires a single-mindedness

that might seem excruciatingly boring. But

that spinning wheel with its lump of clay

has an allure that drives me today and has

driven me for decades. I don’t even bother

asking why.

Turning a ball of clay into a mixing bowl

Why I create potteryBy Dudley Harris, MD

Above: Pottery bowls are readied for an open house sale, with proceedsbenefiting local charities. Photos courtesy Dr. Dudley HarrisBelow: A mixing bowl with a Shino glaze was created by Dr. Harris.


CREATIVITY

in two minutes is a beautiful thing. It’s pleas-

urable to do, and it’s mesmerizing to watch.

(See link at end of article.)

The potter’s tools are very simple. The more

skilled the potter, the fewer tools he needs. But

one tool that every potter uses is a “rib.” These

are made of wood or stiff plastic. Old credit

cards make good ribs. Ribs are held in one

hand to scrape or shape the clay while the other

hand pushes against the clay. Ribs used by

American potters are usually quite thin, but

Japanese potters prefer thicker ones. It oc-

curred to me that I could make a thick rib by

shaping a piece of hardwood on the wood-turn-

ing lathe. I tried many shapes and many woods

before settling on a wood called Padauk. It’s

easy to turn, takes a nice finish and has a beau-

tiful red color. These round, thick ribs became

popular, and I started a little business from my

wood shop.

Dr. Harris holds a wooden rib he makes and sells from his workshop.



CREATIVITY

I do have to ask myself, “What am

I going to do with all the pots?” You

can’t store pots like you can memo-

ries. I use about 300 pounds of clay

per week. That’s 8 tons a year. That

makes for a lot of pottery. I have a

pottery sale each December and give

the proceeds to assorted charities.

This clears out enough space in my

studio so that I can start over again

in the spring.

For more information, visit

www.dudleyharris.com and www.

the-beautiful-bowl.com.

To watch a video of Dr. Harris

throwing a pot, visit http://youtube/

mZcMk9FFt1A.

Dudley Harris, MD, (left) is an

ophthalmologist at San Antonio Eye

Center and a BCMS member.


CREATIVITY


Why do you like dance? That is a

more difficult question to answer thanwhy you like to entertain with dance. Ihave to dance. My parents and grand-parents used to say that I was dancingat age 2. I do remember dancing as a 4-year-old every night when my mom’ssix brothers and two sisters gatheredafter dinner in her parents’ home inKollam (Quilon) Kerala when we wentfor long vacations.

In my family there has never been adancer, trained or natural. Also at thetime I was growing up, the most populardance form in south India,“Bharathanatyam,” was taboo for usyoung girls as it was denigrated and sti-fled during the British occupation ofIndia and was practiced mostly by thecommunity of courtesans. However, bythe time I was in school, the art had been

Why I dance By Rajam Ramamurthy, MD


Dr. Rajam Ramamurthy of the Arathi School of Indian Dance performs in August 1998 at theSan Antonio Folklife Festival. Photo courtesy University of Texas at San Antonio Institute ofTexan Cultures


CREATIVITY

revived as part of the nationalistic movement; it just had not reachedthe small gold-mining town where I was growing up. My formal train-ing in dance began in San Antonio with my 5-year-old daughter, fourother women and their daughters. The Arathi School of Indian Dance,

founded in 1981, is the first Indian dance school in San Antonio.Why do humans like to dance? Are there animals who like to

dance? In an elegant scientific research paper published in 2006, neu-roscientist Dr. Anirudh Patel found that a species of cockatoo couldmove to a beat, whereas our closest genetic relative, the chimpanzee,does not move to music. Other animals that have evolved with hu-mans for millions of years and that live closely with us, such as dogsand cats, do not move to musical beats. Patel concludes, “Dance mayhave evolved as a byproduct of our ability to mimic sounds -- a rareability shared by humans, cockatoos and parrots.” It is not knownwhy humans have this innate ability. However, it is well known thatbabies as young as five months sway to a beat.

Dance is in each one of us. Dancing was a way for our prehistoricancestors to communicate, and those who were thus bonded had anevolutionary advantage. Another study found that dancers sharedtwo genes associated with a predisposition for being good social com-municators. The degree to which you take to dance could be an evo-

lutionary process influenced by social, religious and economic factorsthat thwart our natural tendency. Famous dancer Agnes de Millesaid, “The truest expression of a people is in its dance and in itsmusic. Bodies never lie.”

Music invokes pleasure and reward areas like the orbitofrontal cor-tex, located directly behind one's eyes, and stimulates a midbrain re-gion called the ventral striatum. The degree of activation matcheswith how much we enjoy some particular music.

I have taught dance every Friday evening for the past 33 years. Thestudents range from age 5 to adults. The moment I start teaching,the rest of the world is tuned off. My mind is empty of everythingbut movement. It is my meditation, my mantra.

When young moms observe a class in which I teach their 5- or 6-year-old, they tell me, “You are something else, aunty.” In the Indiancommunity, you are respectfully addressed as aunty or uncle. InBharathanatyam, you stamp the feet to create various rhythmic beats.My calloused soles are an enigma for the pedicurist who will meeklyask,”What do you do?” The main posture in Bharathanatyam is ahalf sitting stance called “Araimandi,” meaning half-bent knee. Andit does take a toll on your knees if you don’t exercise. Dancers arephenomenal athletes with a unique variety of health-related issues.


CREATIVITY


Caregivers require a strong knowledge and appreciation of their craft.They are performing at the highest levels of human performance.

One scientific study asked the question, what is the toughest, mostdifficult to master, most challenging sport? Researchers looked at 60

sports and rated them based on more than 20 performance criteria,including physical, intellectual and environmental. The conclusionwas that ballet was the most exacting physical endeavor. I am surethat is true of Bharathanatyam and other dance forms, too.

Another group of researchers sought to examine if dancers' beliefscorrelate with actual use of provider services when they are injured.Dancers perceived dance teachers to be first-line treatment providers(47.5 percent), followed by physical therapists (30 percent). Physi-cians were ranked third (12.5 percent) and only marginally higherthan a dance colleague (10 percent). The dancers expressed a strongpreference for nonsurgical rather than surgical physicians (87.5 per-cent versus 5 percent), and among physicians, the majority of dancerspreferred subspecialists (60 percent), namely nonsurgical sports med-icine doctors and physiatrists.

I have found it very difficult to convey the technical aspect of thedance form to orthopaedic, sports or rehabilitation practitioners. Thescience has advanced much more for ballet and other Western formsof dance. In 1990, the International Association for Dance Medicine

and Science was formed by an international group of dance medicinepractitioners, dance educators, dance scientists and dancers. Mem-bership began with 48 participants and has grown to more than 900members in 35 countries today.

The question, why you like to entertain with dance, is answeredin a poem in the ancient treatise on dance, “Natya Shastra:”

Yatho Hastas Thato Dhrishti: Where the hand goes there shouldyour eyes follow.

Yatho Dhristi Thato Manaha: Where your eyes follow there shouldbe your mind.

Yatho Manaha Thatho Bhavaha: Where your mind is there shouldbe your emotions.

Yatho Bhavaha Thatho Rasaha: Where your emotions are it elicitsa response in the Other, meaning the audience or “Rasika.”

I dance to convey to you the joy I feel.

Rajam Ramamurthy, MD, is an adjunct professorof pediatrics at the University of Texas Medical Schoolin San Antonio and senior guru at Arathi School of In-dian Dance. She was BCMS president in 2004 and isa member of the BCMS Communications/PublicationsCommittee.

visit us at www.bcms.org 25visit us at www.bcms.org 25

BCMS NEWS

Legislature begins new session in AustinBy Mary E. Nava, MBABCMS Chief Governmental and Community Relations Officer

The Texas Legislature convened Jan. 13 for the 84th LegislativeSession in Austin.

One again, as your lobbyist and representative in Austin, Iwill attend the legislative session daily to keep you informed onthe work of the House and Senate as we prepare to participatein First Tuesdays and also work with the Texas Medical Associ-ation on legislative bills and meetings with our elected officialsand their staffs.BCMS President James Humphreys, MD, en-courages members to sign up and attend at least one First Tues-days visit to the Capitol during the coming session. Sessions are

scheduled for Feb. 3, March 3, April 7 and May 5. "We need all our physicians to get involved in our discussions

with our elected officials," Dr. Humphreys said.To register for a First Tuesdays visit, visit www.texmed.org.For regular updates during the legislative session, read The

Weekly Dose, the BCMS electronic newsletter.

For local discussion on this and other advocacy topics, consider join-ing the BCMS Legislative and Socioeconomics Committee by contact-ing Mary Nava at [email protected].

SAVE THE DATEMarch 11: BCMS General Membership Meeting

6:30 p.m. Watch The Weekly Dose for details.

March 13: Medicine at the CrossroadsNoon, University of Texas Health Science Center at San Antonio. Special

guest speaker will be Richard Gunderman, MD, PhD, (right) Alpha OmegaAlpha Visiting Professor at the School of Medicine. Dr. Gunderman is theChancellor’s Professor of Radiology, Pediatrics, Medical Education Philosophy,Liberal Arts, Philanthropy and Medical Humanities and Health Studies at In-diana University. Free and open to the public. Sponsored by BCMS, The Pa-tient Institute and UTHSCSA.

In MemoriamDavid K. Jameson, MD, age 84, died Dec. 11, 2014. A family

practitioner, Dr. Jameson was a BCMS life member.Robert Travis Jensen, MD, died Dec. 5, 2014. Dr. Jensen, 88,

was an internal medicine and preventive medicine specialist and aBCMS life member. Reginald Brian Furness Smith, MD, died Dec. 22, 2014, at age

83. Dr. Smith was an anesthesiologist and a BCMS retired member.Michael Grant Zeigler, MD, age 80, died Dec. 26, 2014. Dr.

Zeigler was a general surgeon and BCMS member.

BCMS is purchasing land to build its new headquarters. To donate and learn more, visit http://bcms.org/building.html.

Honoring our past … Building our future


UTHSCSADEAN’S MESSAGE

The Department of Neurosurgery at the School of Medicine isexpanding in size and scope, and also in its reach, changing thelandscape of adult and pediatric patient care in innovative ways.With a focus on minimally invasive approaches, the department,chaired by Dr. David Jimenez, now has one of the largest neuro-surgery residency programs and is playing an expanding role inadvancing the standard of care for a host of conditions.

Our neurosurgeons operate at University Hospital, at St. Luke’sand North Central Baptist hospitals, and at the Veterans Admin-istration Hospital. They also care for patients at the Cancer Ther-apy & Research Center (CTRC). Many patients find out aboutour expertise because they are admitted to one of these hospitals,but others seek out Dr. Jimenez and his team, especially for thetreatment of craniosynostosis. In fact, treatment of craniosynos-tosis is one of the areas in which our department has become thedestination for patients from around the world. The department’sphilosophy is to deliver maximum benefit with the minimum pos-sible disruption to the lives of the patients and their families. Thisis how the neurosurgery team approaches all cases, and it has aprofound impact in children with this condition.

PREMATURE FUSIONCraniosynostosis is the result of the premature fusion of one or

more of the sutures of the skull. The National Institutes of Healthreport that it occurs in about 4/10,000 births. Because the braingrows so rapidly during the first few years of life, the skull musthave open, expandable sutures. If these sutures are prematurelyfused, the growing brain will create deformations in the skull.This condition results in a myriad of other complications thatoften include learning and other development delays as well asproblems with vision, respiration, hearing and other neurologicalfunctions.

Parents seek out Dr. Jimenez and bring their children from allover the United States as well as from China, Japan, Germany,Russia and the Middle East. As this article was being prepared,Dr. Jimenez received a CT scan of a newborn in Bogota, Colom-bia. This child, only a few weeks old, had a very distinct protru-sion of one side of the forehead, causing asymmetry of the eyesockets. Fusion of different skull sutures causes different defor-

mations: one causes a triangular shape, another an oblong shape,and yet another causes one side of the face/head to grow muchlarger and at a different angle than the other side. Multiple fusionscreate other distortions and issues.

Dr. Jimenez began developing a minimally invasive technique17 years ago – including the design of special instruments – withhis partner and wife, Dr. Constance Barone, who is a plastic sur-geon. They have been perfecting their approach ever since.Known as an “endoscopic strip craniectomy,” this procedure hastotally transformed the standard of care for children with cran-iosynostosis.

The traditional approach is one of the few surgeries whereblood transfusions are always necessary as part of the preoperativeprocess. Because of the complexity of the standard surgery, thechild must be at least 6 months old, a time when the skull has al-ready thickened and will bleed profusely. Coupled with long sur-gical times (four to eight hours), it is common to replace thechild’s entire blood volume during a regular procedure; sometimesit is replaced twice.

ZIG-ZAG INCISIONSThe key approach in the traditional surgery is to make large

zig-zag incisions in the scalp from ear to ear across the top of thehead. The skull is then removed and put back together in a more“normal” shape and must then be fixed back together with wires,screws and other hardware. It is an extensive, complex operationthat commonly results in a hospital stay of three to five days, withthe first two or three in the ICU. There is a great deal of post-operative swelling and pain. Typically there are multiple follow-up procedures as well, in order to adjust, repair and reconfigurethe skull. Children treated in the later stages (at 9 to 12 monthsof age) often have a lifetime uncorrectable disfigurement.

In contrast, the endoscopic procedure developed by Dr. Jimenezaverages 57 minutes of operating time. There are no screws, wiresor other appliances used on the skull, and because it takes so littletime, children as young as one or two days old can be operatedon. Unlike the traditional method, the scalp is not peeled back,only a small incision is made, and the fused suture of the skull isremoved relatively quickly -- leaving large spaces for the skull to

Advancing the standard of care in neurosurgery

By Francisco González-Scarano, MD



grow in. Skull growth is then guided by custom-fitted helmets that areworn 23 hours a day over the next 10 – 12 months. Children routinelygo home the next day, with an average hospital stay of one night.

Besides involving less time under anesthesia, less blood loss, and a shorterhospital stay, Dr. Jimenez also has seen a large decrease in developmentaldelays with the new procedure. With the traditional approach, some sur-geons report as many as 60 percent of patients with delayed development.The level of developmental delays in Dr. Jimenez’ patients seems to be sig-nificantly less clinically, and is currently being quantified formally.

Dr. Jimenez attributes developmental delays after the traditional approachto two key factors: first, the lengthy time before surgery leads to effects onthe underlying brain tissue, and second, the extensive nature of the tradi-tional procedure, especially the hours of anesthesia and routine replacementof 100 percent or more of the patient’s blood. He notes that systemic hy-potension, with concomitant brain hypoperfusion, can certainly lead to braindysfunction and developmental problems with these very young brains.

The transfusion rate for the endoscopic procedure is anywhere fromzero to 6 percent, depending on which suture is fused. More than 600children have had this transformative procedure, and the team has per-formed as many as six operations in one day. The youngest patient wasa baby born 11 weeks premature and had the surgery on his due date.They have had zero reoperations.

BARRIERS TO ADOPTIONSurgeons have come from all around the United States and the world

to learn the technique, but the traditional method is still done in the ma-jority of cases. That the procedure also requires training on new instru-ments, including endoscopes, is one of the barriers to widespreadadoption. Like many new approaches, this one has seen a slow, but steadygrowth curve. The department is now doing a study with a neuropsy-

Case 1: Pre-op

Case 2: Pre-op

Case 1: 2.5 years post

Case 2: 4.5 years post

Continued on page 28Photos courtesy of the School of Medicine at the University of Texas Health Science Center San Antonio



chologist to compare the developmental impacts of the endoscopic

and traditional surgeries. Besides the previous research publishedon the procedure, Dr. Jimenez believes the new data will be the finalpoint firmly establishing the endoscopic method’s superiority.

It is easy to see why the department holds their craniosynostosisprocedure up as the epitome of their philosophy of providing amaximum benefit with minimal disruption. They also carry thisphilosophy over to all aspects of neurosurgery. When a minimallyinvasive procedure is an option the team has the expertise to providethis service for spinal, cranial and peripheral nerve operations. Thedepartment offers comprehensive expertise in functional neuro-surgery/movement disorders, especially ones such as Parkinson’s dis-ease that have not responded to treatment; general and complexspinal surgery, neuroendovascular (minimally invasive) proceduresto treat complex vascular lesions in the head, neck and spine; neu-rosurgical oncology for tumors of the brain, spinal cord, spine andskull base; neurosurgical trauma and critical care, peripheral nervesurgery/carpal tunnel release, with an emphasis on minimally inva-sive techniques; skull base/cranial base surgery with specializationin removal of tumors at the base of the skull where many neuro-logical and vascular structures are densely concentrated; and vascu-

lar neurosurgery, to repair damaged or abnormal blood vessels in

the brain.A recent patient had chronic pain relieved through an endo-

scopic procedure to repair the vertebral artery that had shiftednear the brain stem and was putting pressure on the glossopha-ryngeal nerve with every pulsation. After four years of medicaltreatment for pain – with no results – Dr. Jimenez and his teamwere able to identify the issue and bring total relief to the womanthrough a hole in the skull the size of a dime, with an instrumentthe size of a pencil lead.

Another minimally invasive procedure offered is an endoscopictrans-sphenoidal approach to pituitary tumors, an area where Dr.John Floyd has excelled. Dr. Floyd is a neurosurgical oncologist.Because of the use of the endoscope, this procedure is a major ad-vancement from the traditional pituitary surgery, since there is lesspainful swelling of the very sensitive facial tissues and the improvedoperation reduces bleeding, recovery time and, of course, length ofstay in the hospital. Dr. Floyd works closely with colleagues andneuro-oncology team at the CTRC where the team of oncologistsand radiation specialists address all manner of brain, spine and tu-mors of the central nervous system.




NEUROSURGERY’S FUTURENeuromodulation for relief of epilepsy, Parkinson’s and intractable

chronic pain symptoms is another area where the department has beenparticipating in the leading edge of care. Informally known as a “pace-maker for the brain,” the treatment involves a stimulation device (typ-ically implanted in the same location as a pacemaker) that has electricalleads going into the spine/nerves, or has leads in the brain for deepbrain stimulation (DBS) or vagal nerve stimulation (VNS).

Department of Neurosurgery faculty also are actively involved inthe care of epilepsy patients who come to the Level 4-designatedEpilepsy Center in partnership with the Department of Neurologyand the University Health System. This is the highest accreditationfrom the National Association of Epilepsy Centers. Using VNS andother interventions, patients can receive surgical treatment that candramatically reduce the occurrence of seizures associated with thecondition.

Additionally, there are a number of psychiatric disorders where DBSor VNS may offer some relief, and Drs. Jean-Louis Caron, professor,and Alexander Papanastassiou, assistant professor, both in the Depart-ment of Neurosurgery, have begun promising research that involvesDBS for post-traumatic stress disorder (PTSD). They are collaborat-ing with Bradley Dengler, MD, a current neurosurgery resident who

graduated from the Uniformed Services University of Health Sciencesand has an interest in PTSD. Using rodent models, they have prelim-inary results that suggest that this approach will be useful in humans.The department also conducts research focused on brain and spinetrauma, as well as many aspects of stroke treatment.

Endovascular neurosurgery has been a game-changer in the treat-ment of many conditions and diseases, and our department, alongwith its extensive residency program, is at the forefront of this move-ment, as well as advancing the standard of more traditional methods.Offering specialization in all aspects of adult and pediatric care – andleading the world in the treatment of craniosynostosis – we are veryfortunate to have Dr. Jimenez and his team at the School of Medicine.To read more about our neurosurgery programs and people, visithttp://neurosurgery.uthscsa.edu. To discuss a case with Dr. Jimenez,please call him directly at 210-567-5625.

Francisco González-Scarano, MD, is dean of theSchool of Medicine, vice president for medical affairs,professor of neurology, and the John P. Howe III, MD,Distinguished Chair in Health Policy at the Universityof Texas Health Science Center at San Antonio. Hisemail address is [email protected].


BUSINESS OFMEDICINE

A legal perspective on public healthBy Joseph B. Topinka, JD, MBA, MHA, and Dana A. Forgione, PhD

In light of recent events surrounding the Ebola virus out-

break, our communities need to have a candid discussion about

infectious diseases, public health emergencies, and how our sys-

tem of laws addresses these important issues. Physicians, clini-

cians, allied health professionals, health system leaders, business

leaders, community leaders and, yes, even lawyers have an im-

portant voice in this discussion. Hopefully, we will learn from

the past, and be better prepared for a future of unexpected pub-

lic health challenges.

U.S. CONSTITUTION There is no mention of public health in the U.S. Constitution.

As a result, public health has normally been the primary respon-

sibility of the state and local governments. Despite that responsi-

bility, the federal government has often asserted its authority over

public health-related activities through its interstate commerce,

taxation and spending powers under Article I, Section 8, of the

U.S. Constitution.

The U.S. Constitution is the source of all legal authority for the

federal government and our state governments. Yet, each state, such

as Texas, has its own constitution and often, subordinate levels of

government have their own legal sources of governance, such as

charters or statutes. Since they all differ, their style of governance

may be different, yet they all still fall under the U.S. Constitution.

The U.S. Constitution is the supreme law of the land, except that

the 10th Amendment specifies, “The powers not delegated to the

United Sates by the Constitution, nor prohibited by it to the

States, are reserved to the States respectively, or to the people.”

That is, if the U.S. Constitution does not contain a provision deal-

ing with a certain matter, that matter is reserved to the states, and

ultimately to the people. Those powers are often referred to as state

police powers. They explain such policies as tobacco taxes and na-

tional speed limits — local-looking matters controlled or influ-

enced by the federal government. This also has been a source of

tension under the concept of federalism.

THE MIX OF FEDERALISM Statutes and regulations are outgrowths of the U.S. Constitu-

tion and the respective state constitutions, such as in Texas with

the Communicable Disease Prevention and Control Act, and

Chapter 121 of the Texas Health and Safety Code. The several

constitutions in the United States give the U.S. Congress and the

various state legislatures the power to pass laws in the form of

statutes. Then federal and state agencies write regulations to im-

plement the statutes. These statutes can impact public health at

the federal, state and local levels.

For example, Congress passed statutes that created the U.S.

Public Health Services with its authorities and powers. It also cre-

ated regulatory agencies like the Food and Drug Administration

(FDA) or the Occupational Safety and Health Administration

(OSHA), and non-regulatory agencies like the Centers for Disease

Control and Prevention (CDC). The Texas Legislature passed the

aforementioned Communicable Disease Prevention and Control

Act which created powers to respond to disease outbreaks. Like

other states, Texas further delegated those powers between the

Commissioner of Health in the Texas Department of State Health

Services (DSHS) and the local health authorities (HAs). As an ex-

ample, the director of public health for the City of San Antonio

also serves as the chief executive officer of the Metropolitan Health

District and the Health Authority for Bexar County. Thus, there

is a mix of federal, state and local laws and regulations.

Law in our system is based on English Common Law, which

by its nature is historical in terms of relying on past precedents as

the basis for current and future judicial rulings. Local, state and


BUSINESS OFMEDICINE

federal courts determine the guilt of accused criminals, resolve

private law disputes between individuals, and review actions of

agencies enforcing civil laws — like public health laws. In general,

the lower courts follow the decisions of higher courts, and state

courts review the state’s laws to determine if they violate the state

or federal constitutions. Federal courts review the constitutionality

of state and federal laws, and the U.S. Supreme Court’s decisions

bind all state and federal courts.

EMERGENCY SCENARIO The federal courts and most of the state courts use common

law precedent — which is critical, especially when it comes to de-

cisions that impact public health matters. That precedent estab-

lished by some decision will then bind us in terms of what we can,

or cannot, do in a public health emergency scenario. Probably the

most important public health legal opinion was in the case of Ja-

cobson vs. Massachusetts, 197 U.S. 11 (1905). This 1905 U.S.

Supreme Court case (http://caselaw.lp.findlaw.com/scripts/get-

case.pl?court=US&vol=197&invol=11), concerned an order

based on state statute compelling vaccinations of residents against

small pox after a recent outbreak in Massachusetts. The Cam-

bridge Board of Health ordered the vaccinations, and Henning

Jacobson refused the vaccination and refused to pay the $5 fine.

The U.S. Supreme Court decided that “Upon the principle of

self-defense, of paramount necessity, a community has the right

to protect itself against an epidemic of disease which threatens the

safety of its members.”

With its decision in support of the law, the U.S. Supreme Court

began our modern constitutional approach to disease control law,

which includes the:

• Use of police powers for public health concerns;

• Delegation of certain authorities to health agencies and other

government subdivisions; and

• Use of actions limiting liberty for well-established public

health interventions.

More importantly, the Jacobson case addressed the balancing

of public good vs. individual rights — a concept that physicians

and healthcare leaders must address as we face future public health

matters.

TEXAS PERSPECTIVE Every state does things in its own unique way regarding pub-

lic health law, especially as the law relates to public health emer-

gencies. While you don’t need to be a scholar in Texas public

health law, having a basic idea of available Texas resources is

critical. One of our favorite resources is the Community Pre-

paredness section of the Texas Department of State Health

Services (www.dshs.state.tx.us/commprep). This site is very user

friendly and contains a tremendous amount of source material

and background publications. Another great source is the Uni-

versity of Houston Law Center’s Health Law and Policy Insti-

tute’s bench book designed for judges, entitled Control

Measures and Public Health Emergencies

(www.law.uh.edu/healthlaw/#). This book provides a compre-

hensive summary and simplifies public health law, federalism,

executive branch authority in Texas, and judicial authority in

Texas, regarding public health emergencies. Finally, all physi-

cians should be familiar with the City of San Antonio’s Metro-

politan Health District website, and specifically its link at

www.sanantonio.gov/Health/EmergencyManagement.aspx,

which has important contact information for reporting public

health emergencies. We hope these resources will be a help to

you when facing an everyday, or unusually daunting, public

health challenge.

Joseph B. Topinka, JD, MBA, MHA, LLM,

FACHE, FHFMA is a recently retired military

attorney whose focus is on health law. He previ-

ously was an assistant professor in the Army-Bay-

lor Graduate Program in Health and Business

Administration, and has taught as an adjunct

professor at several local universities.

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

the Janey S. Briscoe Endowed Chair in the Business

of Health at the University of Texas at San Antonio.

He is also an adjunct professor in the School of

Medicine, Department of Cardiothoracic Surgery,

the Department of Pediatrics, and in the School of

Public Health, all at the University of Texas.


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Author Gretchen Rubin quotes writer Robert Louis Stevenson as saying,“There is no duty we so much underrate as the duty of being happy.” In herbook “The Happiness Project,” Rubin writes about her efforts to bring hap-piness to her life.

The author is married to Jamie, a tall, dark and handsome man who is thelove of her life. Rubin has two delightful daughters. She is highly educated, alawyer who gives up a lucrative law practice to write, and she becomes a suc-cessful author with two bestsellers to her credit. Bring happiness to her life?You have got to be kidding, lady, I thought as I picked up the book in the At-lanta airport and read the reviews, a little about the author and the openingpages. I bought the book and raced to the gate to sit and read.

What grabbed me were the next few sentences: “… Often I sniped at myhusband or the cable guy. I felt dejected after even a minor professional set-back. I drifted out of touch with old friends … listlessness, free-floating guilt.”Rubin’s book fell into the category of books I stole time to read when I shouldhave been doing more urgent things such as answering e-mails.

“The Happiness Project” resonated with me, and I think many who readSan Antonio Medicine will feel the same. In launching her happiness project,Rubin took up a phase of it every month. Some activities, such as clearing clutter or changing shopping habits will probably grab uswomen, as these tasks by default do fall on us, employed or not. But the book is filled with well-researched and referenced statementsto which everyone can relate.

Her July project was to buy some happiness. She writes: “In particular, I kept seeing the argument money can’t buy happiness, butit seemed that people appeared fairly well convinced about the significance of money to their happiness.” A 2006 Pew Research Centerstudy in the United States found the percentage of reported happiness increased as income rose, from 24 percent for those earning lessthan $30,000 per year to 49 percent for those earning $100,000. Could it be possible that there is some reverse correlation: Happypeople become rich faster because they’re more appealing to other people and their happiness helps them to succeed? This chapter wasparticularly informative. A sense of growth is so important to happiness that it’s often preferable to be progressing to the summit ratherthan to be at the summit. Rubin’s argument for growth in the happiness project is thought-provoking.

One statement in the book stuck with me. Happiness, some people think, is not a worthy goal; it’s a trivial American preoccupation,the product of too much money and too much television. They think that being happy shows a lack of values and being unhappy is asign of depth. It vaguely reminded me of an Indian philosophical statement wherein you strive to reach a state of equanimity whereyou are neither happy nor unhappy. Will I ever forget the day when Sridevi and I ran to her grandfather to announce that we jumpedoff the highest level of the spring board in the swimming pool, and all I heard was a grunt from him? We were both 8 years old; a bravoand a pat on the head might have created two Olympic athletes.

It takes energy, generosity and discipline to be unfailingly lighthearted, Rubin says. One fact of human nature is that people have a“negativity bias.” In a marriage, it takes at least five good acts to repair the damage of one critical destructive act. With money, the painof losing a certain sum is greater than the pleasure of gaining that sum. Distraction is a powerful, mood-altering device. When you feelunhappy, find an area of refuge. These and many more thought-provoking statements push you to keep reading. Happiness is in you.Rubin has used a method to feel it. Why not seek yours?

Rajam Ramamurthy, MD, is a member of the BCMS Communications/Publications Committee and 2004 BCMS president.

BOOK REVIEW

‘The Happiness Project’Written by Gretchen RubinReviewed by Rajam Ramamurthy, MD


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Gunn Acura11911 IH-10 West

Cavender Audi15447 IH-10 West

BMW of San Antonio8434 Airport Blvd.

Cavender Buick17811 San Pedro Ave.(281 N @ Loop 1604)

Batchelor Cadillac11001 IH-10 at Huebner

Cavendar Cadillac801 Broadway

Tom Benson Chevrolet9400 San Pedro Ave.

Ancira Chrysler10807 IH-10 West

Ingram Park Auto Center7000 NW Loop 410

Ancira Dodge10807 IH-10 West


Northside Ford12300 San Pedro Ave.

Cavender GMC17811 San Pedro Ave.

*Fernandez Honda8015 IH-35 South

Gunn Honda14610 IH-10 West(@ Loop 1604)

*Gunn Infiniti

12150 IH-10 West

Ancira Jeep10807 IH-10 West


*North Park Lexus611 Lockhill Selma

*North Park

Lincoln/ Mercury9207 San Pedro Ave.


Mercedes-Benzof Boerne

31445 IH-10 W, Boerne

Mercedes-Benzof San Antonio

9600 San Pedro Ave.

*Mini Cooper

The BMW Center8434 Airport Blvd.

Ingram Park Nissan7000 NW Loop 410

Porsche Center9455 IH-10 West

Ancira Ram10807 IH-10 West


North Park Subaru9807 San Pedro Ave.

Cavender Toyota5730 NW Loop 410

*Ancira Volkswagen5125 Bandera Rd.

*The Volvo Center1326 NE Loop 410


As many readers know, BMW recentlytook a page out of Audi's playbook and de-cided to call what used to be 3-series coupesand convertibles 4-series cars. That cleveridea, which Audi first used when theylaunched the A5 coupe in 2008, allowedthem to charge more for a car that, whileusing the exact same platform as the A4sedan, was one number "better." Shades of"This is Spinal Tap," I know, but it worked,as robust A5 sales will attest.

For the record, it was actually BMW thathad the idea first back in the 1970s whenthey created a coupe based on the 5-seriessedan platform and called that (gorgeous andclassic) car the 6-series.

FOR BETTER, FOR WORSERecently, I had the chance to sample a

BMW 4-series convertible, and after a weekwith it I can say that, for better and forworse, it is quite different from the belovedE93 3-series convertible that preceded it.

For starters, the interior is more spacious.Front foot- and head-room have been in-creased, and the cabin feels bigger from be-hind the wheel. Still, despite the expandedpassenger space, the rear seats in the 4-seriesare tight and appropriate only for childrenand out-of-favor in-laws.

As with the 3-series sedan, the 4-series' in-terior has been upgraded with nicer materialsand a more integrated look. The level of lux-

ury you perceive when you sit behind thewheel is now what it is in the Audi A5, andthe iDrive user interface is as good as theclass-leading Audi MMI system.

That's two Audi mentions in one sentence,by the way, which should serve as a reminderto BMW (and Mercedes and Lexus) that thestatus quo in the automotive luxury marketcan shift rapidly. It was only 10 years ago thatAudi was an also-ran in this segment, andnow they're the benchmark in many if notmost areas.

The designers at BMW obviously spenttime ensuring that the 4-series was visuallydistinct from the 3-series sedan. The wheel-base is the same on both cars, but the profile

AUTO REVIEW


BMW 435iNew, attractive, athletic and a hall-of-fame engineBy Steve Schutz, MD

and rear views of the 4 are sleeker andsportier than on its four-door sibling. Over-all, the 4-series looks new, attractive and ath-letic, though it doesn’t quite manage to be ascomfortably handsome as the A5.

Driving the 435i is another matter as itleaves the A5 in the dust thanks to superiorweight distribution and a much better en-gine. Yes, the Audi has a nice turbo four-cylinder power plant that moves it along justfine, but that engine is nothing comparedwith BMW's delicious twin turbo in-line six.With a lusty 300 HP, 295 ft-lbs of torque,and a to-die-for exhaust note, this is a hall-of-fame engine, and I hope it's a long timebefore this jewel is replaced with a three-cylinder diesel hybrid or some other suchnonsense. The sound and potency of this en-gine are quite something to experience, and

I'd grab it while you can before fuel economyand emission standards take it away as theyhave so many normally aspirated V8s.

Despite all that horsepower, the 435i doessurprisingly well at the pump, with fueleconomy that the EPA estimates at 20 MPGcity/30 highway. Those numbers are less thanwhat you'll see with the turbo four-cylinder428i, but they're still respectable and no rea-son to resign your Sierra Club membership.

As hinted at above, the 4-series has an al-most perfect 50-50 weight distributionwhich helps handling. No, the 435i isn'tquite as sharp as the last-gen 335i convertiblethat it replaced, but I'd defy anyone to takea 435i on their most challenging back roadand not be impressed. Composed, confidentand fast were the adjectives that came tomind when I took my test car on a spiritedjaunt on a twisty back road near my home.

The 435i convertible uses a folding hardtoprather than one made of canvas, and that's a

mixed blessing. A folding hardtop helps keepthe cabin quiet when the top is up but takesup a lot of trunk space when the top is down.

And, truth be told, the convertible with thetop up lacks the coupe's graceful lines. Natu-rally, if you love convertibles those disadvan-tages won't matter much to you.

AUTO PROGRAM BENEFITSAs always, the price you pay for a 435i will

depend greatly on which option packagesand stand-alone features you choose, but afinal tab of $55k or so seems about right. AskPhil Hornbeak (see contact information,below) for your best BCMS price as well asother member benefits before you buy thisor any other new or used car.

BMW may be following Audi's lead bychanging the name of their 3-series-basedcoupe to the 4-series, but making that switchstill makes sense and should result in moresales, which is the point. It helps that the435i comes in coupe and convertible ver-sions, both of which sport a delightful in-linesix. If your curiosity is piqued, call Phil.

Steve Schutz, MD, is aboard-certified gastroenterol-ogist who lived in San Anto-nio in the 1990s when he wasstationed here in the U.S. Air

Force. He has been writing auto reviews for SanAntonio Medicine since 1995.For more information on the BCMS

Auto Program, call Phil Hornbeak at 301-4367 or visit www.bcms.org.

AUTO REVIEW



THANK YOU to the large group practices with

100% MEMBERSHIP in BCMS and TMA

Contact BCMS today to join the 100% Membership Program!*100% member practice participation as of January 15, 2015.

ABCD Pediatrics, PA

Clinical Pathology Associates

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Gastroenterology Consultants of San Antonio

General Surgical Associates

Greater San Antonio Emergency Physicians, PA

Institute for Women's Health

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MacGregor Medical Center San Antonio

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Peripheral Vascular Associates, PA

Renal Associates of San Antonio, PA

San Antonio Gastroenterology Associates, PA

San Antonio Kidney Disease Center

San Antonio Pediatric Surgery Associates, PA

South Alamo Medical Group

South Texas Radiology Group, PA

Tejas Anesthesia, PA

Texas Partners in Acute Care

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Urology San Antonio, PA

Village Oaks Pathology Services/Precision Pathology

WellMed Medical Management Inc.

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