san antonio medicine magazine june 2014

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THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • JUNE 2014 • VOLUME 67 NO. 6

MEDICINE

4 San Antonio Medicine • June 2014

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

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

Physician extenders: PAs and NPs draw strongopinions By Jeffrey J. Meffert, MD .........................16

Where will orthopaedic surgery be in 25 years?By Fred Olin, MD .......................................................18

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

President’s Message by K. Ashok Kumar, MD, FRCS, FAAP ........................................................8

Be Fit. Be Cool by Rajam Ramamurthy, MD, and Aruna Venketesh, MD ....................................22

Physician as Patient: In the chemo room by Jay Ellis, MD..........................................................24

BCMS News ................................................................................................................................26

Nonprofit: AugustHeart – From tragedy comes hope by Lisa Street ..........................................30

Lifestyle: Cool spots offer family fun by Beth Bond ....................................................................32

Lifestyle: Private education: A snapshot of San Antonio’s top private schools by Mauri Elbel ..34

UTHSCSA Dean’s Message by Francisco González-Scarano, MD ............................................38

Business of Medicine: The Affordable Care Act by Dana A. Forgione, PhD, CPA, CMA, CFE ........40

HASA: Risk stratification to prevent readmissions by Vince Fonseca, MD, MPH, FACPM....................43

Circle of Friends ....................................................................................................................................44

In the Drivers’ Seat ................................................................................................................................47

Auto Review: BMW 535d by Steve Schutz, MD ....................................................................................48

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BOARD OF DIRECTORS

OFFICERSK. Ashok Kumar, MD, PresidentJayesh B. Shah, MD, Vice PresidentLeah Hanselka Jacobson, MD, TreasurerMaria M. Tiamson-Beato, MD, SecretaryJames L. Humphreys, MD, President-electGabriel Ortiz, MD, Immediate Past President

DIRECTORSJosie Ann Cigarroa, MD, MemberChelsea I. Clinton, MD, MemberJohn Robert Holcomb, MD, MemberLuci Katherine Leykum, MD, MemberCarmen Perez, MD, MemberOscar Gilberto Ramirez, MD, MemberAdam V. Ratner, 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 RepresentativeLuke Carroll, Medical Student RepresentativeCindy Comfort, BCMS Alliance PresidentNora Olvera Garza, MD, Board of Censors ChairRajaram Bala, MD, Board of Mediations ChairGeorge F. "Rick" Evans Jr., General 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, MemberDiana H. Henderson, MD, MemberJeffrey J. Meffert, MD, MemberSumeru “Sam” Mehta, MD, MemberRajam S. Ramamurthy, MD, MemberJohn C. Sparks Sr., MD, MemberChittamuru V. Surendranath, MD, MemberJ.J. Waller Jr., MD, MemberJason Ming Zhao, MD, Member

Indeed, it is a great pleasureand honor to represent BexarCounty Medical Society at this

year’s medical school graduation. I bring greetings to you all from4,400 BCMS members. Graduates! All your hard work and com-mitment is coming to fruition today. My hearty congratulations!Welcome to this great profession and the privilege of serving fel-low human beings.

BCMS in collaboration with the Texas Medical Associationworks constantly to preserve the sacred “doctor-patient” relation-ship, the physician scope of practice, and to provide physicianswith practice solutions they can use to enhance their practices.BCMS and TMA believe in lifelong learning and provide edu-cational opportunities to medical professionals throughout theyear, both online and through in-person meetings.

Students, residents and fellows, you are the future of our pro-fession. Every one of you here is a leader or has the ability to be-come a leader. Therefore, I personally invite every one of you tojoin the medical society. And interestingly you might be the onegiving this speech 20 from now. I would say the odds are verygood. If you want any ideas for the speech, please call me; I willstill be completing my patient charts in electronic medicalrecords!

Graduates, it is time for celebration. Let us rejoice in yourachievements, your hard work and your dedication to the med-ical profession. You are the privileged few among innumerableyoung men and women who aspire to become physicians. Youare the chosen few. You are chosen because you are the “crèmede la crème.” You are the brightest and the best. Appreciate allthe gifts and privileges that come to you as result of graduatingfrom medical school.

It is time to give thanks: Be sure to thank all the people whohelped you to realize your dream. Thank your parents, your fam-ily, your friends and your teachers, starting from kindergarten.They molded you into the unique person you are today. Maketime to thank them now, because in a few weeks you will be sobusy. Talking of busy … Do you remember all those tired internsyou saw on the wards when you were doing clinical rotations?You will be them soon. But then hopefully it will get better,

thanks to the ACGME work-hour rules!When you were in my class, I challenged you to be not just a

good doctor but a great doctor. Today I am confident that youare all going to be great doctors, because I believe you not onlyworked hard to learn the science of medicine but also left nostone unturned to learn the art of medicine. And I am also con-fident because I watched many of you taking care of patientswith great compassion and exceptional bedside manners. I haveno doubt in my mind that you are going to care for every patientwith utmost respect and dignity in a culturally competent man-ner irrespective of their economic and social background.

Today, I want to share with you some of my experiences. Inmy 30 years of practicing medicine, in two specialties (generalsurgery and family medicine) and spanning over three conti-nents, I have seen this occur over and over again. • Caring and compassionate attitude transcends the nationality,

linguistic and cultural barriers. So continue to be caring andcompassionate healers even when you are busy and tired. Yourpatients will appreciate you!

• Time is so precious; give your time generously, your patientswill love you.

• You will be a teacher and a leader in the community you serve.Take the responsibility earnestly and you will be respected.

• Remember the “Kumar Law.” Trusting doctor-patient rela-tionship can produce enduring therapeutic miracles. Continueto nurture this sacred bond. You will be richly rewarded withgrateful patients.

• Humility is a great ornament. Wear it every day.• Please continue to cultivate your communication skills. Not

only you will be adored by your patients but also prevent anylawsuits. And finally let me tell you, whenever you are working hard

without much sleep, extremely tired and frustrated and wonder-ing to yourself, “why am I here and what am I doing,” just re-member you belong to the profession of great physicians andsurgeons like Sushruta, Charaka, Hippocrates and Osler.

You are one of the chosen few! You are the brightest and thebest!

Good luck and God speed.

PRESIDENT’SMESSAGE


A time to celebrateBy K. Ashok Kumar, MD, FRCS, FAAFP2014 BCMS President

NOTE: The following is excerpted from Dr. Kumar’s 2014 graduation speech at theUniversity of Texas School of Medicine at the Health Science Center San Antonio.


Family medicine has developed and changed significantly inthe last four decades. Although based on a generalist tradition, itbecame a specialty with the establishment of the American Boardof Family Practice in 1969. The old tradition of the family doctoras a generalized practicing MD, delivering babies, surgery, housecalls, team physician for the local high school, and available 24/7has become an anachronism.

In 2000, there was a meeting of family physicians at the Key-stone III Conference that included generation I family physicians(entering practice before 1970), generation II (1970 1990), andgeneration III, entering practice after 1990. Attempts were made

to amalgamate the traditions of generations I and II with the for-ward-looking prospects of generation III. In other words, whatconcerned the conference was what was the function of familymedicine? Change was inevitable, and the changes had to becompatible with the core principles of family medicine.

SURVIVAL MODEFuture family physicians should embrace themes of compre-

hensive care practiced with a scientific eye, a humanistic touch,and a broad expertise that included preventative medicine, coun-seling, and patient education. This was to be accomplished in theface of expanding government programs (Medicare and Medi-caid), privatization of healthcare, increasing employer-sponsoredhealthcare programs, etc., all of which has become increasinglycomplicated and irrational.

Family medicine, for years, has been in a survival mode at-

tempting to meet the demands placed on primary care. A recenteditorial (2014) by the original generation III family physicianshas noted the following innovations: “electronic medical records,smart phones, broad-based Internet access, asynchronous com-munication (e-mail and bulletin boards), patient centered medicalhomes, team based care, accountable care organizations, boutiquemedicine, etc.” Many of these changes have been embraced bythe generation of new family physicians and sometimes reluctantlyby generation I and II family physicians. It is hoped that the ap-plication of the above, along with core principles, will produce a“primary care delivered in a wide range of settings and methodsand resulting in improved healthcare, lowered costs, and enhancedpatient experience.”

And what of the training in family medicine? Residencies infamily medicine are provided now by many (but not all) trainingcenters. Unfortunately, many medical universities and residencytraining hospitals particularly stress training in specialties otherthan family medicine. The rate of specialties to primary carephysicians is presently at a ratio of 2:1 (in most countries it is 1:1).Of the internists completing residency, 90 percent enter practiceeither as hospitalists or as subspecialists. Of pediatricians enteringpractice, only 50 percent continue in primary care. Family med-icine specialists almost all enter primary care and hence becomethe “primary” primary care physicians.

Fortunately, our local University of Texas Health Science Centerhas a very active and productive Department of Family and Com-munity Medicine with an excellent residency program compe-

The changing face of

family medicineBy J.J. Waller Jr., MD

THE FATE OF SPECIALTIES

continued on page 12

tently headed by Dr. Carlos Jaer. The president of our BexarCounty Medical Society, Dr. Ashok Kumar, is a distin-guished teaching professor in the Department of FamilyMedicine. The department is actively attempting to inte-

grate the principles of the patient centered medical home asa vital portion of the training and treatment functions of thedepartment.

There exists a definite compensation discrepancy betweenfamily physicians and other specialties approaching a ratioof 1:2-4 or more. This is definitely a deterrent to enteringfamily medicine. However, there is “light at the end of thetunnel.” This March at the Residency Matching Day, therewere 1,416 graduating seniors matched to family medicine.This was an increase of 332 over the year 2009 and an in-crease of 42 over last year. The president of the AmericanAcademy of Family Practice has stated that with an increaseof 65 family residency positions a year through 2025, wewill be producing 4,475 family physicians each year.

‘CARING FOR THE PATIENT’Taking the liberty of reflecting on my own experience, I

fall into the generation I group, having graduated from med-ical school in 1955 and completing my rotating internshipin 1956. I practiced family medicine for 25 years and thenspent the next 25 years in the field of emergency medicine.I passed my boards in family practice in 1971 and have beenrecertified four times. For the last seven years I have beenretired from emergency medicine and am back practicingfamily medicine in a primary care clinic. I have seven chil-dren, plus their spouses, 19 grandchildren and seven great-grandchildren, and I receive a call at least weekly forinquiries about their medical condition, their blood pres-sure, problems with their knees, what their pediatrician hassaid about their children, etc., and I guess that makes me areal “family” doc.

I hope those entering family medicine in the future expe-rience the joy and satisfaction of being not only a “doctorof medicine,” but a “physician.” An older family physician,Dr. F. W. Peabody, stated in the Journal of the AmericanMedical Association in 1927 that, “The secret to the care ofthe patient is caring for the patient.” With the increasedneed for primary care physicians, the future of the specialtyof family medicine is certainly improving.

J.J. Waller Jr., MD, is a member of theBCMS Communications/Publications Com-mittee.



continued from page 10


Dr. Carolyn Walsh slipped on her white coat and began to re-flect on her day. It is 2054 and her 40th birthday, also a few weeksshort of her 15th anniversary as a physician. She took pride inbeing the fifth generation of physicians in her family. Since theearly days of the 20th century, at least one member of each gen-eration of her family went to medical school.

She was now part of a vanishing profession. Advances in in-formation technology and nanotechnology-based monitoringsystems threatened to make the human physician obsolete. Un-like her ancestors, she seldom saw patients. Her task was toevaluate the reaction of the system put into place to monitorthe millions of health inputs from the citizens in her geographicregion. Some questioned whether her presence was necessaryas well. Innovations in self-correcting information technologymade the need for adjustments rare and true system malfunc-tions a thing of the past.

She began her rounds by using her white coat sleeve to reviewthe status of the operation of her hospital. The white coat wasthe one item her ancestors would recognize, but it was no longerjust a symbol of the profession. It was a warehouse and accesspoint for all the information known to mankind about the humanbody, manufactured to be a tailored, formfitting garment

LIMITED HUMAN CONTACTTo her surprise, there were two patients in her tiny facility

today. Most of them were elderly people who felt uncomfortablewith the technology that allowed healthcare delivery at homewithout the presence of a physician, nurse, and most times, with-out human contact. She would stop by and see these individualsand put a human face on the system. Years ago her grandfather, aphysician, and back in the old days of specialization, an anesthe-siologist, accompanied her on rounds. She pulled up data on herwhite coat as she greeted the handful of patients in the hospital.Her grandfather commented that her duties were more akin to agreeter at Walmart than a traditional physician. She had tofurtively search for “Walmart greeter” on the hem of her coat to

understand the reference. Such a person was a welcoming figureback in the days when products were still sold in large, fixed struc-tures. It seemed like a pleasant function.

Medicine had changed. Medical knowledge expanded exponen-tially, and confining even a brief survey of the information to afour-year curriculum was impossible. Medical education now re-quired very little memorization but it required an extensive back-ground in accessing information accurately and rapidly from vastexpanses of data. It was no longer a task comprehensible by thehuman mind. The human genome project allowed medical ther-apy to be tailored to each individual based on their geneticmakeup so that every pharmaceutical regimen was custom-de-signed to the patient. Next, invention of nanotechnology allowedreal-time monitoring of levels of medication in the blood and spe-cific targeting, not for a large organ or cell, but for a specialized,individual receptor in each cell. All of these tasks were automatedand delivered without any human input.

Her grandfather told her that the development of real-timemonitoring of drug effects made anesthesiology obsolete. Afterthe full realization of the human genome project, every patientreceived an anesthetic regimen that was specifically designed forthem. Nanotechnology monitored medication levels in real timeand adjusted dose with accuracy that exceeded the capability ofindividual humans. Development of newer pharmaceuticals elim-inated the troubling side effects associated with anesthetic agentsused by her grandfather. Furthermore, the development of mini-mally invasive surgery eliminated the requirements for anesthesiain most patients. Her grandfather told her stories of horrible, dis-figuring operations used to treat cancer and other anomalies. Newimmunological therapies made such operations obsolete. No onewould dream of cutting off a woman’s breast to remove cancer.The requirement for any surgery was rare. There were still a fewtrauma cases, though even those were few and far between withthe advent of self-driving vehicles. Even trauma from householdaccidents, sporting injuries and violent encounters (still too com-mon to the human condition), received minimally invasive repair

A view of anesthesiology in

2054By Jay Ellis, MD



visit us at www.bcms.org 15

without the large incisions made by knives and scissors describedby her grandfather. Stimulation of skin cells closed wounds inminutes, hemostatic molecules and nanotechnology hemorrhagehunters within the body quickly eliminated any bleeding andhelped the damaged organ repair itself.

NO MORE MONITORINGHer grandfather told her that custom-designed anesthetic

agents and real-time pharmaceutical monitoring solved thepharmacokinetic problem of what the body does to the drugand the pharmacodynamic problem of what the drug does tothe body for all time. Monitoring of individual patients be-came unnecessary. At first her grandfather was assigned towatch large arrays of old computer monitor screens representingthe care of multiple anesthetized patients. It soon became ob-vious even this was superfluous. Her grandfather retired, statinghe did not want to be the last buggy whip maker standing. Sheneeded to research this reference, too. The old man often saidstrange things. He told old stories of how his specialty was apioneer in patient safety, reducing the incidence of anesthetic-related death to almost 1 in 100,000. This seemed like a horri-bly high number. According to the information retrieved by

her coat, no anesthetic-related death occurred in the last 10years. Admittedly, there was no one receiving anything close tothe anesthetic state administered by her grandfather.

Dr. Walsh realized her role was now more akin to that of hergreat-great-grandfather. At the beginning of the 20th century, heprovided reassurance and comfort while representing the face ofhuman healing. He otherwise offered little to his patients otherthan a few, often ineffective pharmaceuticals and limited surgery.She did the same thing, except now she represented a huge auto-mated technology system that provided every individual real-timemonitoring of their health and instantaneous treatment whenthings went awry. Healthcare is now delivered by device and nan-otechnology. Dr. Walsh was there to offer explanation and providethe human face of healing.

Jay Ellis, MD, is an anesthesiologist and painmanagement physician with Tejas Anesthesia, aswell as a longtime member of the Bexar CountyMedical Society’s Communications/PublicationsCommittee. Based on his previous success with prog-

nostication, he is absolutely certain that the future of medicine willbe entirely different from that described above.


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


There seem to be few physicians who

are truly neutral on the subject of physi-

cian extenders (PEs). Those who employ

physician assistants (PAs) and nurse prac-

titioners (NPs) see them as ways to

shorten appointment waiting time and

ways to enhance practice income without

further overworking the physician them-

selves. They may play a critical role on the

inpatient wards or in the operating room

as experienced members of an efficient

healthcare team. One may encounter PEs

in general surgery, emergency medicine,

orthopaedic surgery, dermatology, anes-

thesia, addiction medicine, psychiatry, oc-

cupational medicine, radiology, oncology

and any primary care practice.

Critics sometimes portray PEs as a pro-

fessional “bait and switch” where the patient

is given the impression they are seeing an experienced,

fully trained physician when they are not. An oft-heard com-

plaint is, “I paid for a doctor and got a PA.” In fact, Medicare will

pay only 85 percent of the allowable rate for PE provided care,

Medicaid paying up to 92 percent. Other complaints are that the

PE is “practicing medicine without a license” and they are inap-

propriately unsupervised. There are many misconceptions about

the supervision requirements of PEs.

SUPERVISION REQUIREMENTS VARYSome believe that a physician must be on site where a PE is

providing care and that all records must be reviewed. Every state

has its own supervision requirements, and the required closeness

of supervision is inversely proportional to how remote and

spread out the patients are. A state such as Alaska has very loose

supervision requirements, especially when that PE might be the

only healthcare resource for hundreds of miles. States in the

more urban northeast often have much more restrictive require-

ments because one cannot argue that it is difficult to find a

physician when there are three physicians for every 1,000 pa-

tients (Massachusetts). Texas is more on the loose supervision

side of the balance. A physician may supervise up to five PAs

and has to be on site only 10 percent of the time. Subspecialties

may impose additional requirements or expectations upon the

use of PEs by their members which may be much more restric-

tive than state law.

Despite anecdotal reports (“My patients hate going to the

doctor and seeing a PA.”), there is surprisingly little literature

either in the lay press or scientific publications. Several profes-

sional publications support the use of PEs, patients usually pre-

ferring to see non-physicians earlier rather than waiting to see a



physician. This applies both short term (wait time emergency

department visits) and long term (scheduling appointments at

the Veteran’s Administration hospital). Other surveys describe

physician satisfaction with the performance of PEs in preven-

tion, evaluation and treatment of athletic injuries, utilization in

neonate intensive care units, and performance in neuroscience

intensive care units. In these latter studies, PEs were considered

to function at the level of mid- to upper-level resident physi-

cians. In studies of medico legal liability, employing PEs does

not by itself seem to increase the incidence of medical malprac-

tice litigation. What few studies are available are small and often

too specific to practice type or practice location to be generalized

to all PEs and all PE-employing practices.

PEs may be found in primary care practices, medical and sur-

gical subspecialties and also are serving on the wards of hospitals.

Some of these have specific training programs, while most have a

more general training and then acquire the OTJ training to func-

tion in a specialized practice. Physicians will have non-specialized

umbrella organizations (AMA, TMA, BCMS, etc.) and their own

specialty organizations (AAFP, ASA, etc.) to act as their advocates

and provide continuing education. PEs have much the same, with

both larger professional organizations (American Academy of

Physician Assistants and American Nurse Practitioner Associa-

tion) and smaller specialty organizations (Society of Dermatologic

PAs, Association of PAs in Psychiatry, etc.)

In Texas, PAs are licensed by the same board which licenses

physicians, and NPs are licensed by their state nursing boards.

The CME requirements for Texas PEs are only slightly less than

those for physicians. Complaints about PEs practice should be di-

rected to the appropriate licensure board. If, on the other hand,

it is felt they are being used inappropriately or are not being su-

pervised adequately, the complaint should be directed to the

physician’s state licensure board or their specialty organization’s

ethics committee.

Jeffrey J. Meffert, MD, is an associate professor of

dermatology and cutaneous surgery at the University

of Texas Health Science Center at San Antonio and

2013 chair of the BCMS Communications/Publi-

cations Committee.


Where willorthopaedic surgery

be in 25 years?By Fred Olin, MD


I finished my residency in 1977. We were pretty good at what

we did, and people generally were improved by our surgical and

non-operative care. However, when I look back, I can see that

very little of what we do now is the same as we did it then.

A FEW EXAMPLESToday, in trauma care, there is a much more surgically aggres-

sive attitude toward many fractures in adults: Essentially no one

is put up in traction for a femoral fracture. External fixation,

with pins above and below an open fracture, is used so that the

wound can be tended to and the patient can be mobilized

sooner. One form of internal fixation or another is used for im-

mediate definitive treatment in many situations that would have

been casted in the past.

Reconstructive surgery also has advanced. There have been

many improvements in the metals and plastics used in total joint

replacement. That, along with advancing knowledge of the bio-

mechanics of the joints, makes today’s arthroplasties only re-

motely like those done in the mid-’70s. Ligament and muscle

reconstruction around unstable joints now accomplishes results

not dreamed of in the 1960s.

REHABILITATION TIMESo, there are bits of the past that have changed to what they

are today: What do I see for the future? For starters, even

though we have developed great things, such as “minimal inci-

sion” surgery, peri-operative pain control and the use of “scopes”

for various procedures, we continue to move forward and have



immensely cut down on post-operative discomfort and rehabil-

itation time. While the use of “robots” has revolutionized sur-

gery in the abdomen and thorax, I don’t believe that at the

current time there is much that can done in bone and joint sur-

gery. I suppose that if the linkages and tools used in arthroscopy

could be miniaturized enough that some use could be found

there, this would not likely cut down on the two to four one-

centimeter incisions used for most arthroscopic procedures.

I think that we will see more use of materials that will do the

job intended and then be broken down and absorbed by the

body — thus no need for later removal. There have been re-

sorbable screws available for various procedures for several years,

and I have seen work on larger internal fixation devices, such as

bone plates, at meetings and in the literature. Artificial bone-

graft substitutes continue to develop, as do various forms of bio-

active concepts, such as stem cells, platelet concentrates, etc.,

which seem to have the ability to aid in healing processes of var-

ious tissues.

Recent developments in externally grown body parts will un-

doubtedly somehow be applied to orthopaedics. While it is al-

ready possible to assist the body in replacing defects in long

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

cepts developed in the USSR by Ilizarov using external fixation

and controlled motion, how much better it would be to use the

patient’s own cells, applied to a matrix formed from imaging

data to grow a replacement part.

Honestly, I’m probably way off the path of what reality will

bring us. Consider: If you had the opportunity to ask a genius

of the past, say Benjamin Franklin, what he thought news trans-

mission would be like only a century or two after his time, what

might he say? After all, printing hadn’t changed much in the

300 years before him. Somehow I doubt that he would have

predicted the linotype machine, much less our current use of

computers, imaging and remote visualization. I am certainly

not a genius of the present … and progress is a lot faster now

than it was in Ben’s day.

Fred H. Olin, MD, is a semi-retired orthopaedic

surgeon who sort of resents that he won’t be around

to see how wrong his predictions are. He is the 2014

chairman of the BCMS Communications/Publica-

tions Committee.


Family medicine services canincrease access to allergy care

By Bernice Gonzalez, MD


In October 2013, millions of Americans began entering the

healthcare system for the first time under the Affordable Care

Act. By March 2014, the total number of newly insured pa-

tients had reached 6 million. To meet the needs of this rapidly

expanding patient population, increased focus has been placed

on the role of primary care in treating patients with chronic

conditions. This is particularly true for seasonal and perennial

allergy care. Allergic rhinitis (AR), commonly referred to as hay

fever, is the fifth most common chronic condition among all

Americans, and costs the U.S. healthcare system approximately

$18 billion annually.

Historically, allergy care has most commonly fallen into the

hands of allergists, with a miniscule population of approximately

5,000 in the United States compared to more than 60 million

allergy sufferers. This creates a supply and demand disparity that

is causing patients to wait months for an appointment with an

allergist, or travel great distances to reach the specialist. With

the progression of the Affordable Care Act, this is only the be-

ginning of the access-to-care problem for allergy sufferers. Too

many patients aren’t receiving the level of care they need. This

shouldn’t be the case and must be addressed before the problem

escalates further.

FIRST LINE OF DEFENSEThe answer lies in primary care. Primary care physicians are

well equipped to be the first line of defense for allergy diagnosis

and treatment. By doing so, more patients can easily access ef-

fective treatment, while specialists are freed up to focus on acute

allergy cases. Increasing access to allergy care within the primary

care setting ultimately aligns with healthcare reform goals to de-

liver higher quality, affordable care to more patients. Referring

patients with mild to moderate seasonal AR to an allergist is a

missed allocation of resources. However, it is important to note

that increasing the number of primary care providers who de-

liver allergy testing and treatment does not displace the critical

contribution that allergists make. Allergists are best trained and

equipped to manage patients with the most serious allergic and

immunologic conditions.



Healthcare service companies such as San Antonio-based

United Allergy Services® (UAS) are committed to broadening

access to care for allergy suffers by helping family doctors, gen-

eral practitioners, pediatricians and pulmonologists act as the

first line of defense for allergy diagnosis and treatment. UAS

works with physicians and health systems to bring effective and

convenient allergy testing and immunotherapy to the mass pop-

ulation of mild to moderate allergy sufferers. UAS simplifies al-

lergy testing and treatment by providing an in-office Allergy

Center, staffing and training, reimbursement assistance, and

technology services. This level of support allows physicians and

their staff to spend more time with patients delivering person-

alized, quality care.

As primary care physicians increasingly act as the first line of

defense speaking with patients about potential allergies, it is

equally important to educate patients about treatment options.

Too often patients are masking symptoms with over-the-counter

(OTC) medications rather than treating allergies with effective

immunotherapy, known as allergy shots, that desensitizes the re-

sponse to specific allergens that trigger allergy symptoms. Im-

munotherapy induces tolerance by introducing the patient to

safely increased doses of an allergen(s) through a series of cus-

tomized single-injections. The purpose of immunotherapy al-

lergy shots is to desensitize the patient to the allergen that

triggers the symptoms. This approach is in stark contrast to

OTC and prescription drugs that only temporarily mask allergy

symptoms without treating the actual disease. Up to 85 percent

of patients receive a significant long-term reduction in allergy

symptoms using immunotherapy.

The healthcare industry is at a critical point and physicians

must work together to ensure patient need is effectively met as

the patient population rapidly expands. Primary care physicians

can and should take an active role in diagnosing and treating

seasonal and perennial allergies, working to ensure that all al-

lergy patients have access to the level of care needed.

Bernice Gonzalez, MD, is the founder and chief

executive officer of Vital Life Wellness Center in San

Antonio. She is also an advisory board member and

contracted physician with San Antonio-based

United Allergy Services.


AAPI launches ‘Be Fit. Be Cool’childhood obesity awareness campaign

By Rajam Ramamurthy, MD, and Aruna Venketesh, MD

CARDIOMETABOLICHEALTH

The “Be Fit. Be Cool” childhood obesity awareness campaign,a pioneering health education awareness program by the Ameri-can Association of Physicians of Indian Origin (AAPI), waslaunched Dec. 13 at Collins Garden Elementary School.

Through the initiative of the Texas Indo-American PhysiciansSociety (TIPS), Southwest Chapter, the Texas program waslaunched at the San Antonio Independent School District school.

“The obesity prevention initiative is one of the top prioritiesfor AAPI,” said Jayesh Shah, MD, president of national AAPI,vice president of Bexar County Medical Society, and a wound-care specialist practicing on the city’s South Side.

EASY TO FOLLOWThe Be Fit. Be Cool campaign, which aims to involve up to

100 schools across the nation, is an educational program foryouth to encourage them to adopt simple, easy-to-follow tipsbased on the slogan 5-2-1-0: eat five or more vegetables andfruits daily, limit recreational screen time to two hours each day,engage in at least one hour of daily physical activity, and elim-inate sugary drinks.

The program is in keeping with First Lady Michelle Obama'schildhood obesity initiative, the “Let's Move” campaign, whichincludes four components: enhancing information parents needto make healthy decisions for their family, improving the qualityof food in schools, improving access to and the affordability ofhealthy foods in communities, and increasing physical activity inand out of schools.

President Obama signed a presidential memorandum to createthe first-ever federal task force to provide "optimal coordination"between private-sector companies, nonprofits, agencies within thegovernment and other organizations to address the problem ofchildhood obesity.

The San Antonio Mayor's Fitness Council works to increasehealthy meal options in the city's schools. Recently, 108 salad barswere placed in area elementary, middle and high schools, makingfresh fruits and vegetables available to students.

San Antonio also is one of 50 U.S. cities involved in Commu-nities Putting Prevention to Work (CPPW), an initiative designedto make healthy living easier by promoting environmentalchanges at the local level, with funding through the Centers forDisease Control and Prevention.

Last year, BCMS adopted cardiometabolic health as its key pub-lic health initiative.

According to a recent CDC report, children from low-incomehomes who tend to be fatter than their counterparts from wealth-ier families have become slightly, but significantly, leaner in recentyears. Data was obtained from the pediatric nutrition surveillancesystem in which medical workers recorded the height and weightof about 11.6 million preschool children from 43 U.S. states andterritories who were enrolled in government nutrition-assistanceprograms between 2008 and 2011. In New Jersey, which had oneof the biggest changes, 17.9 per cent of children were obese in2008, which declined to 16.6 per cent in 2011. This data is notavailable for Texas. CDC warns that the trend does not mean thatthe problem has disappeared. On the contrary, it is a call for morestates, cities, schools and neighborhoods to adopt the programsthat were successful in other places.

Texas is the 13th most obese state in the country. Approxi-mately 29.8 percent of adults in Texas are obese. In 2011, 16 per-cent of high school students in Texas were obese. In the UnitedStates, the combined obesity and overweight rate is 61.6 percent.Overweight is defined as having a body mass index (BMI, a ratioof weight to height) of 25 to 29.9. Obesity is defined as having abody mass index (BMI) above 30. Fifteen years ago, Texas had acombined obesity and overweight rate of 50.3 percent. Ten yearsago, it was 58.5 percent. Now, the combined rate is 66.5 percent.Diabetes rates have doubled in 10 states in the past 15 years. In1995, Texas had a diabetes rate of 5.9 percent. Now the diabetesrate is 9.6 percent. Fifteen years ago, Texas had a hypertensionrate of 21.7 percent. Now, the rate is 27.2 percent.

During the Be Fit. Be Cool session held at Collins GardenElementary School, dieticians Vijaya Botla and Sejal Patel,


CARDIOMETABOLICHEALTH

health educator Marie Gavel, and physical therapist Neha Shahpresented several food models and taught the children how toprepare a healthy plate for their meals. According to the plan,half the plate will be filled with fruits and vegetables, a quarterwith food made of grains and the other quarter with meats, orfor vegetarians, lentils and beans. Creating the healthy platewas a highlight for the children, who actively engaged in theprocess. A foot-long chunk of fat, one of the food models,brought home the message.

Kindergarteners through fifth-grade students were given an op-portunity to participate during their PE period in a hands-on ed-ucational and physical activity that included Zumba and walkingnearly a mile.

It is symbolic that TIPS Southwest Chapter chose Collins Gar-den Elementary School as the first in Texas to launch the cam-paign. Housed in a beautiful red building located at 167 HarrimanPlace, the school will be 100 years old this year. It is named afterFinis Foster Collins, who owed the land and the irrigated truckfarms that were a big tourist attraction a century ago.

Drs. Anupama Gotimukula, Arathi Shah, Chandana Tripathy,Rajam Ramamurthy, Nive Parachur and Mr. Venky Adivi werepart of the team that help organize the debut Be Fit. Be Coolevent. A follow-up of how the students retained the informationis planned.

CONVENTION IN SAN ANTONIOThe organizers believe that these efforts cannot be limited to

the schools alone. Involvement of the family and the communitywill ensure that the habits are lifelong and sustained.

The 32nd annual AAPI convention, to be held June 25-29 inSan Antonio, will focus on the Be Fit. Be Cool initiative.

A health walk is planned from 7 a.m. to 8:30 a.m. June 28 be-ginning at the Henry B. Gonzalez Convention Center. MissAmerica and other VIP guests are expected. BCMS members areinvited to join this effort. AAPI also invites BCMS members tothe convention with an outstanding CME program.

Rajam Ramamurthy, MD, is the Rita andWilliam Head Distinguished Professor of Environ-mental and Developmental Neonatology, Depart-ment of Pediatrics, University of Texas HealthScience Center San Antonio.

Aruna Venkatesh, MD, is an endocrinologist at theTexas Diabetes Institute in San Antonio and assistantprofessor, medicine, UTHSCSA.


I doubt anyone was as relieved to start chemotherapy as I was.It was my best hope for recovery and relief from the scourge ofthe abdominal pain that tormented me nightly. My wife, Merrill,prepared for my first chemotherapy session with a proficiency andprecision reminiscent of the logisticians of Desert Storm. Shepacked enough food for a regiment, assembled what looked likea year’s worth of reading material, and packed a bag full ofsweaters and blankets in case I felt cold, or decided on Arctictravel. Carrying all these bags into chemotherapy reminded meof the Clampetts' arriving in Beverly Hills.

Greg Gulley saw me that morning to review my lab work andtreatment plan. It was comforting to see him. I did complain thatI had only 54,000 platelets and everyone seemed to want to drawmy blood and take a look at them. He responded by giving mean article from the New England Journal confirming that patientsare often phlebotomized into anemia. OK.

EGALITARIAN GATHERING PLACEThe chemotherapy room is a great egalitarian gathering place,

like the DMV or divorce court. Cancer is an affliction that crossesall social barriers without prejudice. We were the first ones there,and Merrill staked out a plum position, then began makingfriends as others arrived. While we were in chemotherapy wewould meet other professionals, laborers, little old ladies, little oldmen, and too many young people. Everyone is there for the samepurpose and everyone asks your diagnosis, not unlike being inprison and asking, "What are you in for?" It is a mutual supportsociety. There are even moments of humor, such as one man who

spent his entire treatment session stand-ing and yelling, “I'm not sick. I don'tknow why I'm here. I don't need this,"all the while hooked up to his infusion.

The chemotherapy nurses are caring,professional, and they inspire confidence. They reviewed eachmedication with me. I did have memories of CHOP (Cytoxin,vincristine, doxorubicin, prednisone) therapy from my medicalstudent and resident years. I can still recall the hemorrhagic cys-titis, heart failure and peripheral neuropathy experienced by mypatients. I had vivid memories of the intractable nausea and vom-iting they all developed with each session of therapy and for dayslater. The specialty of oncology should be commended for im-proving this bleak picture. First, I received several pre-medicantdrugs to minimize my symptoms and risk for side effects. I expe-rienced mild nausea, but not the intractable vomiting so starklyremembered. In addition, I would get the CHOP-R version withthe addition of the monoclonal antibody drug rituximab. Unlikethe old days where chemotherapy was an applied exercise in se-lective toxicology, I now had the "magic bullet." Rituximab wouldbe specific for the lymphocytes of my lymphoma, sparing mefrom many of the side effects of the old CHOP regimen.

After I finished my premedication, the rituximab infusionbegan. My bride is a great doer, but not good at sitting and watch-ing. I can tell when she is getting fidgety and asked her to go andget me a Starbucks coffee. Soon after she left things got strange. Istarted getting the rigors/shaking chills I once had with pneumo-nia. They started small, but began to crescendo in intensity and

as

In the chemo roomBy Jay Ellis, MD

PHYSICIANAS PATIENT

EDITOR’S NOTE: This is the third in a series ofarticles written by San Antonio anesthesiologist JayEllis, MD, a member of the BCMS Communica-tions/Publications Committee. The series, publishedmonthly in San Antonio Medicine, examines thephysical, emotional, financial and spiritual burdenof life-threatening illness

PhysicianPatient


PHYSICIANAS PATIENT

duration. I raised my hand like a school child and the nursesquickly recognized my problem and descended on me. I becamethe center of attention in the chemo room, not a distinction I

wanted. The nurses rapidly went through the algorithm to treatsymptoms they saw often. One nurse stopped my infusion. Onecovered me with blankets and another brought the diphenhy-dramine and steroids to treat my symptoms. My symptoms be-came worse. I was shaking uncontrollably and wondered if this iswhat seizures felt like. The muscles in my neck began to contract,and my head bent to the left with a strange, torticollis-like posi-tion. I had never felt so helpless in my entire life. I had no controlover my body, and I thought I would vibrate myself right out ofmy chair. Fortunately, after some meperidine, my symptoms sub-sided. I was exhausted. I doubt the whole episode lasted morethan 10 minutes, but I felt like I had been exercising for hours.The combination of the medication and the physical exertion ofthe shaking chills left me exhausted. I fell asleep and woke laterwith Merrill sitting next to me with a cold cup of coffee. Thenurses slowed my infusion rate. It took the entire day to finishmy regimen, and we left late that afternoon.

SMOLDERING EMBERSI woke the next morning feeling is if someone had lit a fire

throughout my body. It wasn't the flaming inferno of the forestfire. It was a low, smoldering sensation like the last embers of thecampfire as it consumes the final ounce of fuel. I felt the smol-dering most intensely in my back at my biopsy site. I wonderedif it was my tumor shrinking away from the effects of chemother-apy, but quickly extinguished that thought as the silly wishes of adesperate man. I was tired, in pain and just felt awful. Merrillbegan what soon became our thrice-daily ritual. She would pre-pare something for me to eat, and I would refuse to eat it, lackingany appetite and certain that ingesting food would result in ca-tastrophe. She would respond by first persuading, then cajolingand finally insisting that I eat. I only made the attempt because Iknew it was important to her. I'm convinced that had she notbeen there I would not have eaten anything that day, or for severaldays after. Friends called and sent text messages of encouragement.I tried to respond to everyone, but fell asleep. Merrill swiped myphone and answered the messages for me so that I would rest dur-ing the day.

The next day the diarrhea started. The smoldering now becamea hot torch centered in my rectum. Every time I tried to lie downthe diarrhea would return. The burning sensation in my rectumwas accompanied by spasmodic contractions of the viscera of myabdomen. It was misery. I began to pray to God fervently for re-

lief. I was afraid to be more than a few steps away from the bath-room. The designer who placed three commodes at different lo-cations in our downstairs now seemed like an architectural genius.

By the next day these symptoms passed as well, and I went frombeing severely distressed to just miserable. Then I noticed some-thing remarkable. My abdominal pain was gone. I hadn't touchedany pain medication for 24 hours. The stabbing torment in myabdomen vanished. The distress I felt over the previous daysseemed like more than a fair trade. There was hope that thechemotherapy was working.

After five days, I tried to go back to work. I overestimated myrecuperative powers. The walk from the parking garage to my of-fice took every morsel of physical energy I possessed. I sat at mydesk, completely exhausted. After two cups of coffee and a 30-minute rest, I began to rally. As always, work was a tonic, and Isurvived the day. My office staff could not have been more sup-portive. They made little changes to make my work easier and mylife more comfortable. Their concern increased my resolve to getthrough the day. I did finish my schedule, but when I arrived homeI was exhausted. I was too tired to argue with Merrill aboutwhether or not I would eat. After I ate, I just went to bed. I wouldrepeat this routine for several days, but as the days went by mystrength seemed to grow and my stamina increased. I certainly was-n't well, but I had hope that I was moving in the right direction.

ROUND TWOI approached my next chemotherapy with some trepidation.

The nurses were a great comfort, telling me that by slowing theinfusion rate they could get me through my chemo without thedrama of the first encounter. They were right. This session wentsmoothly, without the near-epileptic activity associated with thefirst visit.

Three weeks later, I went for my first CT scan since my diag-nosis. I did have to choke down two bottles of oral contrast which,despite the flavoring, will never replace Coke or Pepsi. The CTscan would determine my progress on chemotherapy. The staff atSouth Texas Radiology was polite and encouraging. After my scan,Dr. Todd Tibbett’s took the time to review the images with me.The results were obvious even to the average anesthesiologist. Theabdominal mass, the lesions in my spleen and the lymph nodesshrank to a fraction of their former size. The chemotherapy wasworking, and the success was better than anything I could haveimagined. For the first time I understood what it felt like to wantto weep for joy.

NEXT MONTH: Complications.


BCMS NEWS

The BCMS Delegation toTMA meets three times peryear: one meeting is to re-view all BCMS resolutionssubmitted for consideration;another meeting is to reviewthe TMA House of DelegatesHandbook, which the Dele-gation reviews and takes a po-

sition on all resolutions submitted from around the state. All of thiswork leads up to the annual meeting, TexMed, which culminates inthe final vetting (in reference committees) of resolutions under con-sideration for adoption by the TMA House of Delegates. Resolu-tions that are adopted become part of TMA policy. TexMed 2014was held in Fort Worth May 2-3, and the BCMS Delegation toTMA achieved success with the passage of three resolutions whichwere adopted by the TMA House of Delegates. The resolutionsadopted are as follows:

Resolution 308 – Improving the ImmTrac Registry by Re-verting Back to an Opt-Out SystemResolution 408 – Permanent Delay of ICD-10 Implementa-tionResolution 419 – Opposition to Laboratory Reporting Provi-sions of HR 4302

Additionally and simultaneously, the Delegation worked to cam-

paign for the elections of Dr. Jesse Moss Jr., for TMA Board of Trustees(BOT), and Dr. Michael Battista for AMA Alternate Delegate. Un-fortunately, neither won their respective races. Moss, who was facinga second run at a BOT position, stated, “I appreciate the support ofBexar County Medical Society for nominating me and for all whosupported me in this election.” Battista, who was running for the firsttime, stated, “I appreciate all the support of the Bexar County MedicalSociety. I look forward to continue working with the Texas MedicalAssociation and also participating in AMA meetings.”

Many thanks to the members of the BCMS Delegation to TMAwho attended this year’s TexMed: Chairman, James Humphreys,MD; Rajaram Bala, MD; Michael Battista, MD; Adam Brugge-man, MD; Chelsea Clinton, MD; Estrella De Forster, MD; SureshDutta, MD; John Edwards, MD; Alberto Fernandez, MD;William Gordon, MD; Sheldon Gross, MD; Pam Hall, MD; Gre-gory Hamon, MD; David Henkes, MD; William Hinchey, MD;John Holcomb, MD; Wendy Kang, MD, JD; Margaret Kelley,MD; Alex Kenton, MD; Malathi Koli, MD; Vijay Koli, MD;BCMS President Ashok Kumar, MD; Jesse Moss Jr., MD; RajamRamamurthy, MD; Somayaji Ramamurthy, MD; Adam Ratner,MD; Janet Realini, MD; Walter Root, MD; Jennifer Rushton,MD; Roberto San Martin, MD; Jayesh Shah, MD; David Shul-man, MD; Bernard Swift Jr., DO; Jiesing Tan (medical studentdelegate); Roberto Trevino Jr., MD; and David Webster, MD.

For more information, contact [email protected].

BCMS Delegation to TMA wraps upTexMed 2014: TMA House of Delegatesadopts resolutionsBy Mary E. Nava, MBAChief Governmental and Community Relations Officer

NOTEWORTHYBCMS President K. Ashok Kumar, MD, received the C.

Frank Webber, MD, Award from the Texas Medical AssociationMedical Student Section on May 2 in Fort Worth. The honorrecognizes a Texas physician for outstanding service to the sec-tion and its members.

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

Delegation Chairman JamesHumphreys, MD, leads the discus-sion on reference committee reportson resolutions during the TexMedBCMS Caucus breakfast May 3.

IN MEMORIAMHoward A. Britton, MD, a BCMS Life member, died March

1, 2014. Dr. Britton, 87, was a pediatrician and also served as aflight surgeon in the U.S. Air Force.

BCMS member James F. Jennings, MD, a psychiatrist, diedApril 12, 2014. Dr. Jennings, 81, was a U.S. Air Force retiredcolonel.

SAVETHE DATE

ActiveAlonso Osorio, MD, Family MedicineAnne-Marie R. Langerin, MD, Pediatric Hematology/Oncology

Cherie L. Hauptmeier, DO, Family Medicine

Christian L. Stallworth, MD, Otolaryngology

Farbod Malek, MD, Orthopaedic Surgery

Gregory Kostur, MD, PediatricsJennifer Lynn Pearl, MD, Emergency Medicine

Kathryn Stephens, MD, PediatricsKerry Latch, MD, AnesthesiologyKevin Delaney, MD, AnesthesiologyMarshall B. Packard, MD, Internal Medicine

Marvin Eng, MD, CardiologyMatthew C. Murray, MD, Orthopaedic Surgery

Michelle J. Muldrow, DO,Obstetrics and Gynecology

Paul Randall Lillich, MD,Emergency Medicine

Pavan Devulapally, MD, NephrologyRami G. El-Abjad, MD,Gastroenterology

Reid Hartson, MD, Internal MedicineRobert M. Saad, MD,Cardiovascular Disease

Roderick W. Lovett, MD,Anesthesiology

Sasikanth Nallagatla, MD,Internal Medicine

Suzanna P. Garza, MD, Pediatrics

Timothy J. Kosmatka, MD,Family Medicine

Yanilda Nuñez, MD, Internal Medicine

Military PhysiciansBrian Faux, MD, Child NeurologyGreg Gerasimon, MD, Cardiology

Medical StudentsBlessing AmuneChristine BinkleyElizabeth C. BrewerIan ChurninJacob DicksonNoah EinsteinTiffany FisherNakiuda HallLucas HarveyChristopher LamNadia V. SilvaMichael Watkins

Retired PhysiciansAnthony John Corbet, MD, 37 years in practice

Adrian Gresores, MD, 26 years in practice

Life Member PhysiciansJ. Leonard Hilliard, MD, 30 years in practice

Werner Ned Keidel, MD, 36 years in practice

Arvo Neidre, MD, 36 years in practice

June 3, 6-8 p.m. New Member WelcomeThe Argyle Club, 934 Patterson Ave.Mix and mingle – complimen-tary buffet and cocktail party.Jacket but no tie required, nojeans. Come meet your fellowmembers at our popular annualevent.

Sept. 24, 6:30-8:30 p.m.Fall General Membership MeetingHilton at the Airport, 611 N.W. Loop 410Talk to the new TMA presidentfor legislative updates (1 CMEethics credit). ComplimentaryPolynesian buffet, cash bar, up-date and Q&A; give TMA yourinput.

Oct. 16, 5-9 p.m.BCMS Auto ShowBCMS office parking lot, 6243 IH-10 WestMix and mingle – complimen-tary buffet and cocktail party. Seethe new 2015 models; family andfriends welcome.

Oct. 2-3 BCMS Fishing TripRockport, TexasFor information and pricing,please contact Mark Lachenauerat (210) 301-4391. Have funwith your fellow physicians at thehappy hour and dinner, andmorning guided fishing trip!

Nov. 1, 11a.m. to 3 p.m.Women in Medicine Appreciation Omni Hotel at the Colonnade, 9821 Colonnade Blvd.Luncheon with celebrity speaker Dr.Robin Eickhoff, style show, gifts andprizes. Bexar County Medical Li-brary Association fundraiser show-casing female physician models.

MEMBERSHIP UPDATE


BCMS NEWS


From one family’s tragedy comes a hope

for the future. In October 2008, Doré and

Bart Koontz lost their 18-year-old son,

August, to an undiagnosed heart condi-

tion which resulted in sudden cardiac

death. August was a healthy teenage boy

and an active athlete. The undiagnosed

heart condition was a shocking discovery

easily detectable with a simple 20-minute

heart screening.

In honor of their son, the Koontzes es-

tablished AugustHeart, a 501(c)(3) non-

profit dedicated to preventing sudden

cardiac arrest (SCA) in teens by providing

cardiac screenings in San Antonio and sur-

rounding areas. AugustHeart is a commu-

nity-wide initiative involving a volunteer

team of board-certified pediatric and adult

cardiologists, sonographers, technicians,

and area high schools, as well as San An-

tonio’s major health systems and other

partners. Baptist Health System, Christus

Santa Rosa Health System, Methodist

Healthcare System, University Health Sys-

tem and UT Medicine San Antonio are

just a few of the more than 20 community

partners who help provide equal access to

lifesaving technology not typically offered

to teens and seldom covered by insurance.

Rarely does anyone expect a healthy, ac-

tive, athletic teenager to have a heart con-

dition. Yet, every three days in the United

States, a high school-aged athlete suffers

SCA, the leading cause of death in 14-

to18-year-old athletes on the playing field.

As a result, serious heart abnormalities

often go undetected.

Gaps within our current healthcare sys-

tem put all of our youth at risk. August-

Heart creates equal access to cardiac

screening services that save lives and has

offered more than 3,500 free heart screen-

ings to teenagers as an added benefit to

high school preparticipation physicals

throughout the city.

SAVING LIVESAugustHeart provides cardiac screening

events across the San Antonio area in col-

laboration with local healthcare systems,

school districts, medical groups and other

community partners. Each screening in-

cludes an electrocardiogram (ECG) and if

necessary an echocardiogram (ECHO)

performed on every student. These simple,

non-invasive tests allow skilled cardiolo-

gists to evaluate the structure and electrical

activity of the heart. Upon review, the test

results may trigger a referral to local pedi-

atric cardiology for additional testing,

evaluation and treatment.

Since its founding in 2011, August-

Heart, in partnership and collaboration

with the major medical systems of San

Antonio and area school districts, has

made great strides in saving lives through

education, awareness and free heart

screenings.

Adolescents with heart abnormalities,

if left undetected, may die suddenly or

develop serious heart problems later in

life. Yet, most people are unaware of the

importance of heart screenings, and

rarely are teens considered susceptible to

heart problems or undetected heart con-

ditions. It is this premise that feeds the

mission of AugustHeart to identify mod-

erate to severe abnormalities in teenagers;

to educate teens and their families about

heart health; and to raise awareness about

the importance of teenage heart screen-

ings for the prevention of potentially fatal

outcomes, and is the ultimate purpose of

AugustHeart.

In 2013, AugustHeart screened more

than 3,000 high school athletes for heart

abnormalities in the Northside Independ-

ent School District and North East Inde-

pendent School District, the two largest

school districts in San Antonio.

In May 2014, AugustHeart surpassed

the number of students served last year,

screening more than 3,500 students from

participating high schools in Northside

Independent School District, North East

Independents School District, Hondo,

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

as Alamo Heights High School and St.

Mary’s Hall.

ATHLETES AT HIGHER RISKOne in 250 teens in the United States

is at high risk of an undetected heart con-

dition that may cause SCA. That number

increases to one in 20 for student athletes,

Meet AugustHeartFrom tragedy comes hopeBy Lisa Street

NONPROFIT


who are at an even greater risk of sudden

cardiac death, because they are more active

than teens who lead sedentary lifestyles.

Approximately one in 70 high schools will

have an incident of SCA on campus each

year. In Texas alone, there are an estimated

39,000 youth with undetected heart ab-

normalities participating in high school

athletic programs.

SCA is 60 percent more likely to occur

during exercise or sports activity. It hap-

pens without signs or symptoms in 80

percent of cases, and 92 percent of the

time it is fatal. AugustHeart has learned

the heart is physically immature before the

age of 14; high school athletes are pushed

to a much higher level of exertion than

ever before, putting more stress on the

heart; and medical history and a physical

exam alone are not enough.

As the seventh-largest city in the United

States, AugustHeart’s 200-plus volunteer

physicians and medical specialists are

spread thin. Though the organization’s ini-

tial focus was on student athletes, SCA

can affect anyone. At AugustHeart, we be-

lieve every student should be tested as the

heart matures.

Join AugustHeartto help save the heart of our community — our youth.

For more information about August-

Heart or to join the team of dedicated

volunteer pediatric and adult cardiolo-

gists, call 210-841-9207 or email

[email protected].

NONPROFIT


LIFESTYLE

By Beth Bond

KIDDIE PARKSan Antonio is known for its historical

sites, and this one just might be the mostfun. Did you know the city is home toAmerica's oldest children's amusement park?Kiddie Park has been entertaining the littleones since 1925 and keeps old-fashioned funalive with 1920s-era rides, including acarousel with hand-carved wooden horsesmade in 1918 by the Herschell-SpillmanCo., an innovative and prolific carouselmaker of the early 20th century.

But don’t mistake these for outdated ridesweathered by time. Kiddie Park is a safe,clean, affordable place for birthday partiesand anytime fun thanks to renovations in2009 that brought the iconic park back tolife while maintaining its original charms.

Hop aboard the Ferris wheel for a spinback to the 1920s, then head over to theclassic carnival games, a new attraction forthe 2014 season. Get into the nostalgiawith a milk bottle toss, ring toss, basketballgame and more. And don’t forget the cot-ton candy.

Each ride requires one ticket, and youcan buy them for $2.50 each, $11.25 forsix or $13 for an unlimited ride band. Bar-gain prices are offered every Wednesday,and you can buy unlimited ride bands for50 percent off for groups of 20 or morechildren during the week.

Are you on the South Side of the city?Kiddie Park has expanded to your area witha new location called Kiddie Park PicaPica,a modernized take on old-fashioned funwith a carousel, jump houses, an arcade,face painting, a whip ride and more! Formore info, visit kiddieparkpicapica.com.

Kiddie Park3015 BroadwaySan Antonio, TX 78209210-824-4351kiddiepark.com

Spring and summer hours: 10 a.m.-7p.m. Wednesday through Sunday and

closed but available for private partiesMonday and Tuesday.

SAN ANTONIO ZOOCelebrating its 100th year in 2014, the

San Antonio Zoo has an impressive historythat includes being one of the first “cageless”zoos in the United States, successfully breed-ing 53 endangered snow leopards since 1970and being the first zoo in the country tobreed endangered whooping cranes — plus,it’s the site of the first endangered white rhi-noceros birth outside of Africa.

Part of the zoo’s commemoration of itscentennial is the creation of Zootennial

Cool spotsoffer family fun

It's time to start making plans for filling the summer days with fun activities for your chil-dren. And you're in luck: Not only is San Antonio a kid-friendly city, but we've put togethera list of places that are sure to please when the temperature soars and the days get long. Readon for three of our favorite picks.


LIFESTYLE

Plaza, a thoughtfully designed, $8 milliongathering place that includes an upscalerestaurant, a centralized family gatheringarea for casual and reserved occasions, anda custom-designed carousel.

The zoo is home to more than 9,000 an-imals of 750 species that engage more than1 million guests each year. For a super spe-cial visit for your kids, sign up for anovernight summer camp, where childrenages 7-11 explore the zoo, venture behindthe scenes and play games, then crawl intheir sleeping bag to sleep at the zoo. Thenext Zootennial Overnight is scheduled forJuly 12 and costs $45 per person, a perfectouting for families, friends and smallgroups. Register here: www.sazoo.org/edu-cation/group-programs.

There’s also the new Zoobilation Cele-bration adventure day camp for ages 5-11and Tiny Tot camps for ages 2-5.

Admission to the San Antonio Zoo costs$12 for adults and $9.50 for children 3-11,with free admission for children 2 andyounger.

San Antonio Zoo3903 N. St. Mary’s St.San Antonio, TX 78212-3199 210-734-7184sazoo.org

The San Antonio Zoo is open 365 daysa year from 9 a.m. to 5 p.m.

COOL CREST MINIATURE GOLFWhen summer days get hot, you’ll want

to find shade. Head over to the historicCool Crest Miniature Golf, where it’s al-ways reliably cool and shady. You’ll find fununder a canopy of lush ba-nana tree leaves that shadetwo family-friendly 18-holecourses. With flowingbrooks and fountains andgently sloping terracedcourses, your kids will enjoythis tropical-feeling getawayspot for miniature golf that’sbeen entertaining familiesfor more than 80 years.

Opened in the late 1920s,Cool Crest is one of the old-est continually operatedminiature golf courses in theworld. It’s been designatedby San Antonio’s Historicand Design Commission asa historically significant siteand zoned as a historicallysignificant property by thecity’s Zoning Commissionand City Council. The orig-inal course was built about1929, and the newer onewas built in 1957. Both arechallenging but playable forexperienced putters and

young players. There are no windmills orcircus-worthy characters on these courses— just the classic green shapes designed tomake you consider the geometry of yourball’s path.

It’s nostalgia at an affordable price: Ad-mission costs $9 for those ages 13-54, $8for military with ID and seniors ages 55and up, $7 for ages 4-12 and it’s free forchildren 3 and younger. On top of that, ad-ditional rounds of golf are $2 off. With afrequent golfer card, the sixth visit is freeafter five punches. Children 10 andyounger must be accompanied by an adult.

Cool Crest Miniature Golf1402 Fredericksburg RoadSan Antonio, TX 78201210-732-0222coolcrestgolf.com

Summer hours are 10 a.m. to 11 p.m.Tuesday through Saturday, noon to 10 p.m.Sunday, and closed Monday.


LIFESTYLE

From fostering intellectual curiosity andcritical thinking to educating the whole childin a values-based setting, San Antonio andthe surrounding area is brimming with pri-vate schools focused on preparing youngminds for a lifetime of success. Small classsizes, passionate teachers, unique curriculumand high standards are among the commonthreads linking these independent schools.But each one has its own special qualities andoverall objectives that set it apart from theothers. For the past several years, San Anto-nio Medicine has compiled a snapshot of thearea’s top private schools –– read on to gaininsight behind six schools standing at theforefront of private education.

ANTONIAN COLLEGE PREPARATORY HIGH SCHOOL www.antonian.org

Celebrating its 50th year this year, AntonianCollege Preparatory High School was foundedin 1964 and is the largest Catholic high schoolin San Antonio today. Enrollment for the2014-15 school year is anticipated to be 800students in ninth through 12th grades. Anton-ian began as a school for boys and transitionedto co-education about a quarter-century ago.

But it is Antonian’s faith and spiritual for-mation that sets it apart from other privateschools in the area. As a Catholic high school,students grow in the knowledge of God andlearn to interact with each other in Christianways through theology classes, class retreats,liturgical services and frequent prayer, saidDiann Montemayor, dean of admissions.

“In addition, our administrative staff mem-bers and faculty continually seek ways to im-prove our academic program, being verymindful of college readiness, not just for thebest and brightest of our students but for allstudents,” Montemayor said. “We take very

seriously the words in our mission statement‘in partnership with parents,’ as they are theprimary educators of their children. We firmlybelieve that every child can learn, and our ac-ademic accolades bear this out.”

Antonian strives to attune to the strengthsof every child, a goal backed by recognitionfrom the Texas Association of Private andParochial Schools (TAPPS) and objectiverankings as the top school in Texas in thelargest division of schools (5A) in recentyears. But the students at Antonian serve asone of the best testaments to the school’s suc-cess and commitment to prepare youngminds for the future.

TMI – THE EPISCOPAL SCHOOLOF TEXAS www.tmi-sa.com

The Episcopal School of Texas, founded in1893, celebrated its 120th anniversary thispast school year. The coeducational, collegepreparatory school has 465 students in sixththrough 12th grades and offers optionalJROTC and boarding programs on its 80-acre campus.

With college placement a top priority atthe school, all 75 students in the class of2014 will attend four-year colleges and uni-versities including Boston College, Duke,Emory, Harvard, Notre Dame, SouthernMethodist University, Trinity, the Universityof Texas at Austin and Texas A&M BusinessHonors Program.

“We are first and foremost an Episcopalschool, dedicated to academic excellencewhile guiding our students toward moral andspiritual maturity,” said TMI HeadmasterJohn W. Cooper, Ph.D. “This year, we’re cel-ebrating the 120th anniversary of our found-ing by the Episcopal Diocese of West Texas,and we’re reaching the conclusion of an am-

bitious project –– 120 Acts of Service – thatreaffirms our founder’s ideal of developingservant leaders of the future.”

Students have achieved that goal by partic-ipating in community service projects acrossthe city through TMI’s Interact chapter, ontheir own or with church, Scouting or othergroups, with many surpassing the number ofservice hours required by the school and bythe National Honor Society and NationalJunior Honor Society. TMI students alsoenjoy the opportunity to participate in a num-ber of extracurricular activities.

“A TMI student can play as many asthree sports a year, sing in the choir or playin the band, act in a drama or musical, orjoin one of more than a dozen studentclubs,” Cooper said.

INCARNATE WORD HIGHSCHOOL www.incarnatewordhs.org

Providing excellence in education since1881, Incarnate Word High School is com-mitted to offering the best of the best foryoung women today. In the past several years,its students have earned $30 million in aca-demic scholarships and provided more than100,000 hours of community service in theSan Antonio area.

“Service to the community plays a very im-portant role in the formation of IWHS stu-dents, and each year students take time tosupport the under-served in our community,”said Annette Zahirniak, director of enroll-ment. “IWHS also has a very active campusministry that provides opportunities for stu-dents to grow in their faith by attending re-treats and liturgies offered throughout the yearwhich are primarily planned by students.”

This year, the private Catholic school foryoung women had one student earn the dis-

Private education: A snapshot of San Antonio’s top private schoolsBy Mauri Elbel


LIFESTYLE

tinction of being named National Achieve-ment Scholar, a handful of seniors named ascommended scholars in the distinguished2014 National Merit Scholarship Program,seven students named National HispanicScholars, and 154 students earned high honorroll status and 137 have earned honor roll sta-tus. But these same academically-focused stu-dents also perform to high standards inathletics, earning high-ranking achievementsthis year in sports including cross country,golf, swimming and basketball.

Incarnate Word High School boasts an av-erage class size of 125 students in ninththrough 12th grades, offering outstanding ac-ademic programs, enriching spiritual develop-ment, programs, a dual enrollmentopportunity at the University of the IncarnateWord and multicultural learning.

ST. LUKE’S EPISCOPAL www.sles-sa.org

“We become exemplary human beings byrepeatedly seeking what is good and doingwhat is right,” said Thomas McLaughlin, headof the school at St. Luke’s Episcopal. “Ratherthan being a destination at which we will one

day arrive, excellence is an elusive goal that istirelessly pursued and occasionally enjoyed.”

McLaughlin’s words seem to sum up thephilosophy of St. Luke’s Episcopal School,which remains committed to its mission ofbeing a Christian community dedicated to ac-ademic and personal excellence, life-long learn-ing and service to others. The over-65-year-oldnationally recognized, faith-based independentschool provides vibrant and innovative educa-tion for students from pre-kindergartenthrough eighth grade.

Because the school isn’t strapped with stan-dardized testing requirements, St. Luke’steachers are free to teach rich and valuablelessons brimming with creativity in all sub-ject areas and a unique environment that cre-

ates an atmosphere conducive to learningand the development of critical thinkingskills. Various electives are offered to studentsat every grade level including foreign lan-guages, fine arts and physical education, andbeginning in fifth grade, students are able tocompete athletically for the school, givingthem an extra year of in-school, sport-spe-cific training prior to high school. The schoolalso incorporates the latest technology intothe classroom: St. Luke’s 1:1 laptop programfor middle school students was the first of itskind in independent schools locally, and theschool boasts two on-campus 3D printers.

GENEVA SCHOOL OF BOERNE www.genevaschooltx.org

Geneva School of Boerne has grown expo-nentially in 15 years. Founded in 1999 with13 students, it will enroll 650 students inkindergarten through 12th grade in 2014-15. From the 32-acre campus’ small classsizes and its low student-teacher ratios to itsunique curriculum, the co-educationalschool is able to meet its mission of provid-ing a classical and Christian education.



LIFESTYLE

“Cer ta in ly,smaller classsizes and a lows tudent - to -teacher ratioare benefits ofa private edu-cation,” saidAmy Metzger,faculty/ devel-opment direc-tor.

But beyondsmall class

sizes and curriculum specifically tailored tomeet the school’s objectives, Geneva’s missionis to provide a classical and Christian educa-tion. Metzger said teachings come from aBiblical worldview –– a fearless Christian ed-ucation style fueled by the belief that God issovereign over all things, combined with clas-sical methods and materials which give stu-dents a filter for determining what is good,beautiful and true. The school’s curriculumis based on the medieval philosophy of in-struction called the Trivium, a Latin termthat means “three roads” and refers to in-

struction in grammar, logic and rhetoric.Geneva’s grammar school serves elementarystudents; its logic school serves middle schoolstudents and its rhetoric school serves highschool students.

Some examples of the unique curriculuminclude a chronological study of history andliterature taught in tandem as opposed to amore traditional social studies and languagearts curriculum, formal logic and rhetoriccourses, required Latin instruction and seniorthesis presentations.

KEYSTONE SCHOOL www.keystoneschool.org

Tucked inside San Antonio’s historic MonteVista neighborhood, Keystone School is a co-educational, independent school serving ap-proximately 450 students in prekindergartenclasses through 12th grade. Founded in 1948to meet the intellectual needs of academicallytalented children and to reward them forscholastic distinction, Keystone focuses on acore curriculum, encouraging students to pur-sue knowledge, develop study habits and mas-ter skills useful to their future success.

“Private schools have the ability to deter-

mine their own mission, curriculum, prac-tices, programs and personnel,” said BrianYager, head of school. “Private schools also canchoose the students who attend, which allowsfor finding mission-appropriate students whocan thrive in a given school’s framework.”

Keystone School’s mission is to offer anaccelerated curriculum to provide moti-vated students with a nationally recognized,well-rounded educational experience in asupportive, inclusive environment that en-courages academic excellence, ethicalgrowth, community involvement and re-sponsible leadership. Essential to its mis-sion are teachers skilled in fosteringintellectual curiosity and critical thinking,small classes which encourage close rela-tionships between faculty and studentsboth inside and outside the classroom, andthe ready availability of teachers and tech-nology as resources.



UTHSCSADEAN’S MESSAGE

This year’s Match Day took place at Floore’s Store in Helotes

on March 21. Although I have participated in this ritual for sev-

eral years, I always find it is a remarkable and generally joyous ex-

perience to watch the-soon-to-be new doctors receive their

“matching orders” and find out where they’ll be spending the next

few years.

As often happens, this is also where they will spend part of their

professional careers (in my case, about 35 years). We are happy

to report that 102 of our students, or 48 percent of them, will be

staying in Texas to train; 30 of those, or 14 percent, will be staying

in the San Antonio area. Eighty-two of our graduates (39 percent)

matched to primary care programs, which the Association of

American Medical Colleges (AAMC) defines as family practice,

internal medicine, Ob/Gyn or pediatrics. The young physicians

who will be leaving Texas will be situated in institutions all over

the country, including many of the elite training programs. Many

of them will eventually return to the state, bringing additional

vigor to our healthcare programs. Below are our graduating class’

10 most popular matches by specialty.

Internal medicine 31

Anesthesiology 28

Pediatrics 22

Emergency medicine 18

Family practice 17

Psychiatry 16

Orthopaedic surgery 12

Radiology-Diagnostic 12

Ob/Gyn 11

Ophthalmology 7

Nationally, the AAMC estimates that 94 percent of graduat-

ing U.S. medical students matched through the program; most

of the remainder were able to obtain residencies through the

secondary system that has been in place for the past couple of

years. However, many of them did not match in their preferred

specialty, and the AAMC is concerned that with medical school

enrollments increasing (both allopathic and osteopathic), there

will be a serious mismatch in the years to come. The long-

standing cap on residency positions will not help in this regard.

Of the large states, Texas already has the lowest number of

physicians per population, and as we all know, it is the fastest-

growing state, putting us in an unenviable catch-up position to

adequately provide for our citizens.

WHITE COAT CEREMONY Turning our sight to the onset of the undergraduate medical

educational experience, our White Coat Ceremony will take place

the morning of July 20. This is a wonderful event for our incom-

ing students, their families and the faculty, and is a relatively re-

cent yet widespread national tradition. It reflects the emphasis

on professional identity and professionalism that we imbue

throughout our medical curriculum. The White Coat Ceremony

takes place the day before orientation week, also a relatively recent

development; the first day of classes is the following Monday, July

28. The White Coat Ceremony is open to the public, and alumni

are always encouraged to attend. For more information, call the

office of Student Affairs at 210-567-5656.

GRAND ROUNDS AND MOREFor our faculty and community partners, we offer the most di-

verse and extensive Continuing Medical Education (CME) activ-

ities in the region. Grand rounds, courses, lectures and

conferences take place every day of the week at the school. Below

are select grand rounds and conferences that highlight the diverse

offerings available at the school. The locations are mostly on the

Springtime matches,grand rounds update

By Francisco González-Scarano, MD


UTHSCSADEAN’S MESSAGE

main campus in the medical center. Grand rounds typically last

one hour and are held in the early morning; however, there also

are some lunchtime and afternoon presentations and conferences.

Arthroplasty Grand rounds are scheduled for 6 a.m. to 7 a.m. June 9, July

14, Aug. 14, Sept. 15, Oct. 13, Nov. 10, Dec. 12, School of Med-

icine building, room 409L. For information, email Marsha Guan-

tello, [email protected].

Family and Community Medicine Grand rounds are held year-round from 12:30 p.m. to 1:30

p.m. Fridays, School of Medicine building, room 309L. For in-

formation, call 567-4556.

Nephrology Grand rounds are held year-round from 4 p.m. to 6 p.m.

Wednesdays, Dental School building, room 5.303T. Contact Julie

Harris at 210-567-1767.

NeurologyGrand rounds are held year-round from 8 a.m. to 9:30 a.m.

Fridays, School of Medicine building, room 309L. For informa-

tion, call 210-450-0500.

Ob/Gyn Grand rounds are from 12:30 p.m. to 1:30 p.m. Wednesdays,

September through May, School of Medicine building, room

209L. Contact Michelle Lopez at 210-567-4930.

Orthopaedic Surgery Grand rounds are held year-round from 7 a.m. to 8 a.m. Mon-

days, School of Medicine building, room 409L. For information,

call 210-567-5125.

Pediatrics Grand rounds are held year-round from 7:30 a.m. to 8:30 a.m.

Fridays, School of Medicine building, room 409-410L. Contact

Cindy Buecker at 210-567-4298.

Podiatry Grand rounds are held year-round from 6:30 a.m. to 8:30 a.m.

Wednesdays, School of Medicine building, room 444B. For in-

formation, call 210-567-5174.

PsychiatryGrand rounds are from 1:15 p.m. to 2:30 p.m. Tuesdays, Sep-

tember through May, School of Medicine building, room 409-

410L. Contact Tamarsha Johnson at 210-562-5401.

Pediatrics for the Practitioner – CME Conference, June 13-15

Primary care physicians, advanced practice nurses, and other

healthcare providers who treat children will want to consider this

conference which offers information updates and skills training

in endocrinology, dentistry, neurology, nutrition, otolaryngology,

pulmonology, dermatology, neonatology, cardiology and medical

ethics. The courses are led by guest faculty specializing in the fields

of allergy and immunology, developmental pediatrics and infec-

tious diseases.

Geriatric and Palliative Care Intensive Review Course – Aug. 27-29

The course will feature short case�based didactic presentations

and the use of standardized patients for practice and small-group

formats. Each of the three days will focus on building different

skills: hands-on clinical encounters, specialty care and quality im-

provement processes. Participants will take advantage of close

one�on�one mentoring and networking opportunities. There is an

emphasis on communication techniques used among inter�pro-

fessional team members, families and patients in palliative care

and geriatrics, as well as discussion on ethical and quality-of-care

concerns related to palliative care and geriatrics.

We have much more to offer in lecture format as well as online

courses. The Office of Continuing Medical Education, which

can be reached at 1-866-601-4448 or 210-567-4491, has more

details, or visit http://cme.uthscsa.edu.

Dr. Francisco González-

Scarano is dean of the School of

Medicine, vice president for med-

ical affairs, professor of neurology,

and the John P. Howe III, MD,

Distinguished Chair in Health

Policy at the University of Texas

Health Science Center at San An-

tonio. His email address is

[email protected].


BUSINESS OFMEDICINE

The curtain is lifted, and Act One, Scene One, of the Pa-

tient Protection and Affordable Care Act (ACA) is under way.

The saga is in five acts (at least so far) presented on the stage of

legal and constitutional challenges. While the first was played

out all the way to the Supreme Court, there are still the second,

the third, the fourth, and now the fifth legal challenges — all

still waiting in the wings and yet to take center stage. Somehow

the legal challenges seem to revolve around taxes. Wasn’t it

Shakespeare who said something about first getting rid of all

the lawyers? I thought readers might appreciate a light review

of the five major legal challenges to the ACA. They’re more than

just a captivating soliloquy — they truly plumb the depths of

some of our most basic beliefs and values.

Act One, Scene Two: The first major legal challenge. You

may recall that 28 states immediately filed petitions challenging

the constitutionality of the individual mandate, the require-

ment that everyone in America buy health insurance. They also

challenged the penalties as unlawful direct taxes, and the in-

fringement on state sovereignty through mandated expansion

of the state Medicaid programs. The actors included Alaska, Al-

abama, Arizona, Colorado, Florida, Georgia, Idaho, Indiana,

Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Mis-

souri, North Dakota, Nebraska, Nevada, Ohio, Pennsylvania,

South Carolina, South Dakota, Texas, Utah, Virginia, Wash-

ington, Wisconsin and Wyoming. Not a cast of thousands, but

56 percent of the states, and only 10 short of the three-quarter

super-majority needed to ratify a constitutional amendment. It

attracted an audience.

There were also similar private lawsuits, played out in smaller

venues, but we’ll stick with the greatest legal stage on Earth.

The allegations were that the federal government has enumer-

ated powers, e.g., the regulation of interstate commerce and the

imposition of taxes. All other powers are reserved to the states

and to the people.

Enter, stage left:The administration, who argues that the in-

dividual mandate is lawful under the interstate commerce

clause and the penalties are not a tax.

Reply from stage right, by the plaintiffs: who argue that a

person who simply does nothing, i.e., who declines to buy

health insurance, is not participating in interstate commerce,

The AFFORDABLE CARE ACT:A TAxing TAle, in five AcTs (And counTing)

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


BUSINESS OFMEDICINE

and therefore the Constitution confers no federal authority to

compel them to purchase anything (notably, health insurance).

Furthermore, the penalties are an unlawful direct tax. The Con-

stitution allows for two types of taxes: those based on the value

of something (e.g., a house, a car, earned income, etc.), and

those based proportionately on the population (direct head-

taxes). And since the ACA penalties are not assessed on either

value or population, but rather on a decision to buy, or not buy,

health insurance, they are thus an unlawful direct tax. Further,

the mandated expansion of the state Medicaid programs vio-

lates state sovereignty and takes away state revenues from

schools, law enforcement, pensions and other critically needed

public services.

The House of Representatives carried out a symbolic vote to

repeal the ACA. Two court decisions upheld it, and three op-

posed it — all generally along partisan lines, although the most

recent court decision against the ACA was handed down by a

judge who was of the party supporting the law. Then 45 state

legislatures filed more than 200 measures opposing elements of

the health reforms, or proposing alternatives. The economic

meltdown had the states financially strapped. They could not

pay their pensions, and the state and local government worker

layoffs were the largest contributors to new unemployment

claims nationwide.

The greatest legal stage on Earth, the U.S. Supreme Court

ruled in June 2012 to uphold most of the ACA, including the

individual mandate, but under Congressional taxation power,

not the interstate commerce clause. The court defined the

penalties as a tax, struck down the state Medicaid expansion

mandate as a violation of state sovereignty, and allowed states

to opt-out of the Medicaid expansion with no reduction of

other federal funding. In a surprise twist, the ruling held that

because the penalties did not comply with the Constitutional

requirements for a direct tax, they were therefore a lawful tax!

The four conservative justices (voting against the law), and the

four liberal justices (voting for the law), all disagreed with the

Chief Justice’s conclusions about the tax. In a complete upset

and surprise ending for the audience of all stripes, the conser-

vative chief justice joined with the liberal contingent and tipped

the vote five to four in favor of the law. The critics and com-

mentators haven’t stopped talking since.

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

surance exchanges under the ACA. The other 36 are either fed-

eral or joint federal-and-state-run exchanges (25 are federal-

only and 11 are federal-state operations).

Enter, stage right: Three states and the District of Columbia

issue a second legal challenge (Oklahoma, Indiana, Virginia,

and DC). They argue that everything in the ACA states that

subsidies, tax credits and penalties are made through an ex-

change “established by the state.” When the Internal Revenue

Service issued a tax ruling that the ACA provisions for the states

also extend to exchanges established by the federal government,

the IRS exceeded its authority and had no statutory basis in the

ACA for the ruling. If the challenge is upheld, the 36 federal

exchanges would not be able to offer subsidies, tax credits or

impose penalties, which would eliminate the employer man-

date, and since the penalties only apply if one employee enrolls

in a “subsidized” plan through an exchange, it eliminates the

individual mandate because penalties can’t be imposed for fail-

ure to buy insurance where the subsidy is not available. The

first judicial ruling denied the administration’s motion to dis-

miss the challenge and allowed the case to proceed. The chal-

lenge has not yet exhausted its legal stages, and the judicial

rulings will likely follow partisan lines, as with the first legal

challenge.

ACT THREEAct Three. Enter, stage right: Eleven of the state attorneys

general challenge the many ACA delays, exceptions and over-

rides as “illegal” (Alabama, Georgia, Idaho, Kansas, Louisiana,

Michigan, Nebraska, Oklahoma, Texas, Virginia, West Vir-

ginia). They argue that the repeated changes to the ACA have

no statutory authority, that the president exceeded his authority

in implementing changes without Congressional law changes,

and that the states were being asked to violate the federal ACA

law that was upheld by the Supreme Court. They may pursue

state, rather than federal, court venues. You must select your

audience strategically.

ACT FOURAct Four. Enter, stage right: The Catholic Church and sev-

eral private business owners separately challenge the ACA, ar-

guing that their nonprofit or for-profit organizations are

entitled to the same religions protections as the individuals who

own or operate them; and that the ACA requirement for cov-

erage of abortifaciant drugs and devices is a violation of con-



BUSINESS OFMEDICINE

science and religious beliefs. The church-related challenge is

wending its way through the lower court venues. The for-profit

related challenge is set for the greatest stage on Earth. With one

win and one loss, the stage for the final act is set.

ACT FIVEAct Five. Enter, stage right: A Mister Sissel argues that, since

the Supreme Court ruled the ACA penalties are a lawful tax,

the ACA violates the “origination clause.” All tax bills must

originate in the House of Representatives, not the Senate. The

ACA was cited as a “bill for raising revenue,” the tax is imposed

directly through Internal Revenue Code, it raises billions of dol-

lars in general revenues for the U.S. Treasury, and the Congress

can spend the tax revenue for any purpose.

Enter, stage left: The administration argues that the Senate’s

ACA bill was merely an “amendment” to H.R. 3590, and there-

fore it originated in the house.

Enter, stage right: Counsel for Mr. Sissel argues that H.R.

3590 was not a revenue-raising bill, the Senate completely re-

placed the text of H.R. 3590 with new text on totally unrelated

matters, that H.R. 3590 provided tax credits to first-time

homebuyers while the ACA overhauls the health-insurance

market. Finally, if the ACA is an “amendment” to H.R. 3590,

then anything would be an amendment.

The District Court of Washington, DC, dismissed the chal-

lenge. The judge was an appointee of the administration sup-

porting the ACA. The plaintiff appealed, and again, the judicial

rulings will likely follow partisan lines, as with the previous

challenges.

What will be the end of the story? Will the ACA stand, or

fall? Could the curtain even come down this far into the pro-

duction? Will there be more challenges? Be sure to watch for

the next scene of the ACA: A Taxing Tale.

Dana A. Forgione, PhD, CPA, CMA,

CFE is the Janey S. Briscoe Endowed Chair

in the Business of Health at the University

of Texas at San Antonio. He is also an ad-

junct 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.



HASA

Risk stratification to prevent readmissionsBy Vince Fonseca, MD, MPH, FACPM

The recent report, “Conditions With the Largest Number ofAdult Hospital Readmissions by Payer, 2011,” released by theAgency for Healthcare Research and Quality (AHRQ) in April2014, provides an overview of the scope of this issue in the UnitedStates. In 2011, there were about 3.3 million adult hospital read-missions with about $41.3 billion in hospital costs. Readmissionsin this study were “defined as a subsequent hospital admissionwithin 30 days following an original admission (or index stay).” Al-though most attention for preventing readmissions is in theMedicare population for heart failure, pneumonia and myocardialinfarction, a community is impacted by readmissions across all agesand insurance categories.

We have discussed the CMS Hospital Readmissions ReductionProgram and a general overview of an approach to the after-hospitalcare plan of AHRQ's Re-Engineering Discharge (RED) Toolkit inprevious articles in San Antonio Medicine. This article will cover anapproach to tailor readmission planning and services based on riskstratification. The risk can be based on comorbid medical conditionsor on socio-demographic issues.

First, let's review the overall readmission data. Table 1 shows thatalthough age is important (Medicare patients have the highest read-mission rate) there are large differences in the readmission rates forthe 18- to 64-year-old group with the privately insured at 8.7 per-cent, uninsured at 10.6 percent and 14.6 percent for Medicaid.

Table 1

Group % of all % of all readmission ratereadmissions readmission costs (per 100 admissions)

Medicare (65+ years) 55.9 58.2 17.2Medicaid (18 to 64 years) 20.6 18.4 14.6Privately insured (18 to 64 years) 18.6 19.6 8.7Uninsured (18 to 64 years) 4.9 3.7 10.6

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

Table 2Condition-specific readmission rate by insurance group (*not in themost common list)

Index hospital stay* Medicare Medicaid Private UninsuredMood disorder * 19.8 10.4 12.7

Index hospital stay* Medicare Medicaid Private UninsuredAlcohol-related disorders * 26.1 * 16Diabetes mellitus with complications * 26.6 14.9 14.7Congestive heart failure 24.5 30.4 * 16.8Septicemia (except in labor) 21.3 23.8 15.4Pancreatic disorders (not diabetes) * * 13.8 15.5Schizophrenia and other psychotic disorders * 24.9 * 15.4COPD and bronchiectasis 21.5 25.2 * *Acute myocardial infarction 19.8 * * 9.6Pneumonia 17.9 * * *

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

Socio-demographically complex patients’ riskfactors include

Personal factors:• Poverty – Low income and/or no liquid assets • Low levels of formal education, literacy or health literacy • Institutional mistrust • Limited English proficiency • History of adverse childhood experiences or other toxic expe-

riences (e.g., violence)• Minimal or no social support -- not married, living alone, no

help available for essential health-related tasks; and

Place factors:• Poor living conditions – homeless, no heat or air conditioning

in home or apartment, unsanitary home environment, high riskof crime

• Few community resources – social support programs, publictransportation, retail outlets

• Physical environment: air pollution, noise.

Clinically complex patient factors include:• Functional deficit or disability (e.g., dementia)• Severe primary condition (e.g., severe heart failure, metastatic

cancer, end-stage renal disease) • Multiple chronic conditions • Concurrent mental and physical health problems• Concurrent substance abuse and physical health problems• Disease affects multiple organ systems • Condition requires treatment by multiple providers and/or spe-

cialized sites of care.



AMEGY BANK OF TEXAS Jeannie Bennett, 210-343-4556Karen Leckie, 210-343-4558www.amegybank.com

ASPECT WEALTH MANAGEMENTJeff Allison, [email protected]

BB&TEd White Jr., [email protected]

CROCKETT NATIONAL BANKAshley Rodriguez, 210-384-9303Dahlia Garcia, 210-384-9301http://crockettnationalbank.com

DATAMEDAnita Allen, [email protected]

EMPLOYER FLEXIBLEJohn Seybold, 210-447-6518jseybold@employerflexible.comwww.employerflexible.com

FROSTAnne Foster, Lewis Thorne,Phil Norman, 210-220-4011www.frostbank.com

FROST INSURANCEShanan Wagoner, Raul Barberena, 210-220-6420 www.frostbank.com

FROST TRUSTVernon [email protected]

GREENWAY HEALTHJason.siegel@greenwayhealth.com512-657-1259www.greenwayhealth.com

HUMANADonnie Hromadka, [email protected]

MEDICAL PROTECTIVEThomas Mohler, [email protected]

SELECT REHABILITATION HOSPITAL OF SAN ANTONIOMiranda Peck, [email protected]://sanantonio-rehab.com/

SOUTH TEXAS SINUS INSTITUTESue Bajus-Musgrove, [email protected]://southtexassinusinstitute.com

TEXAS MEDICAL ASSOCIATIONINSURANCE TRUSTJames Prescott, 512-370-1776Larry Stein, 512-370-1776www.tmait.org

THE BANK OF SAN ANTONIOBrandi C. Vitier, [email protected]

THE BANK OF SAN ANTONIOINSURANCE GROUPKaty Brooks, [email protected]

PLATINUM LEVEL

GOLD LEVEL

TEXAS MEDICAL LIABILITY TRUST (TMLT)(Insurance)

Don Chow, [email protected]

www.tmlt.org

CARABIN & SHAW, P.C.(Texas Prompt Pay Lawyers)Paul L. Sadler, [email protected]

www.carabinshaw.com

HENRY SCHEIN MEDICAL (Medical supplies, equipment, vaccines)

Tom Rosol, [email protected]

www.henryschein.com

FAVORITE HEALTHCARE STAFFING (Temporary and permanent staffing)

Brian Cleary, [email protected]

www.bcmsstaffing.org

ICON DEVELOPMENT SOLUTIONS(Research Biotechnology)

Dr. Dennis Ruff, [email protected]

www.iconplc.com

BCMS SponsorsPlease support our sponsors with your patronage; our sponsors support us.


HASA

The risk adjustment algorithmsthat CMS uses to adjust in the Hos-pital Readmissions Reduction Pro-gram include only clinically complexfactors (e.g., comorbid arrhythmia,COPD, or renal failure). There areabout 50 variables in the algorithms,but the algorithm is run retrospec-tively in order to compare a hospital’sreadmission rate to others or the na-tional rate.

It would be good to know the pa-tient’s clinical complexity as the after-hospital care is being planned.HASAFacts could be the portal thatallows the discharge planning team toreview the patient’s clinical complex-ity using the variables that CMS uses.The patient’s past diagnostic historycould be used to stratify clinical com-plexity because the patient’s past dis-charges and some outpatient data areavailable in HASA. Although mostof the socio-demographic complexityfactors are not currently in EHR sys-tems and therefore not in HASA, oneis: patient address. This can be astarting point for housing instability(frequent address changes) and forplace risk factors. Adding an assess-ment for the discharge planning teamfor other socio-demographic com-plexity factors to the clinically com-plex factors from HASAFacts willallow a more tailored after-hospitalcare plan to decrease readmissionsand a healthier community.

Vince Fonseca,MD, MPH, FACPM,is the director of med-ical informatics at In-tellica Corp., and themedical advisor for

Healthcare Access San Antonio(HASA), the local Health InformationExchange (HIE) provider authorized bythe state of Texas to create a community-based, regionwide HIE in BexarCounty and 22 surrounding counties.Visit www.hasatx.org.

ALLISON ROYCE & ASSOCIATES INC.Jeff Tuttle, [email protected]

BECKY ARANIBAR REALTY GROUPKELLER WILLIAMSCarlo G. Aranibar, MBA, 210-862-4022BARgrouptx.gmail.com

BROADWAY BANKKen Herring, 210-283-4026www.broadwaybank.com

COMMERCIAL & MEDICAL CREDITSERVICES Henry Miranda, 210-340-9515www.cmcs-sa.com

CONCORDIS PRACTICE MANAGEMENT LLCDina Petrutsas, 210-825-6505www.concordispracticemgmt.com

CORPORATE CATERERSRicardo Flores210-789-9009

COX, SMITH & MATTHEWS INC.Dan Webster, [email protected]

DAVID JOHNSON CO. David Johnson, 210-492-1998www.davidjohnsoncompany.com

HEAVENLY GOURMET CATERINGPerla Marino, 210-496-9090www.heavenlyg.com

HILDEBRAND HEALTHCARE CONSULTINGPatricia Hildebrand, RN, [email protected]

MAXIMUM EXPOSURE MARKETINGJanis Maxymof, [email protected]

MED MT INC. Ray Branson, 210-446-7569www.medmt.com

NATIONWIDE INSURANCEJoel Gonzales, [email protected]

NEWMARK GRUBB KNIGHT FRANKDarian Padua, [email protected]

NORTHWESTERN MUTUALEric Kala, [email protected]

PHISKAL LLC MARKETINGSundeep Sadheura, [email protected]

PINNACLE WORKFORCE CORP.Dan Cardenas, [email protected]

PITCREW IT SERVICESEric Murcia, [email protected]

PRAXIS MEDICAL MANAGEMENTFred Mills, 210-521-2544www.praxismedical.net

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

PULMAN, CAPPUCCIO, PULLEN,BENSON & JONESEric A. Pullen, [email protected]

SAN ANTONIO MEDICAL GROUPMANAGEMENT ASSOCIATIONJason Lott, 210-344-7287www.samgma.org/boardofdirectors.cfm

SECURITY SERVICE FEDERALCREDIT UNIONLuis Rosales, [email protected]

SMITH PRINTCece Smith, [email protected]

STREAM REALITY PARTNERS L.P.Carolyn H. Shaw, 210-930-3700www.streamrealty.com

TEXAS DRUG CARDJeremey Bryant, 210-798-6280www.texasfcs.com

TEXAS FARM CREDITTiffany Nelson, 210-798-6280www.texasfcs.com

THE GROWTH COACHKay Wakeham, 210-492-2400www.thegrowthcoachsanantonio.com

TNT HEALTHCARE CONSULTING LLCTom Tidwell, CMPE, [email protected]

TPC SAN ANTONIOMatt Flory, 210-491-5816www.tpcsanantonio.com

URGENT CARE BILLING SOLUTIONS LLCAnn DeGrassi, CMIS, [email protected]

WARM SPRINGS HOSPITALS/POSTACUTE MEDICAL SAN ANTONIOGenaline Escalante-Valdez 210-557-8189, www.warmsprings.org

ALAMO TITLE CO.Corina Cashion, [email protected]

ANDERSON, JOHNS & YAO, CPAs Ann Yao, CPA/PFS210-696-9400www.ajycpa.com

API/PROASSURANCE Paul Schneider, [email protected]://www.proassurance.com

BAPTIST CREDIT UNIONSarah Chatham, [email protected]

CITI COMMERCIAL BANKMoses Luevano, [email protected]

ELITE CARE 24 HR EMERGENCY CENTERClemente Sanchez, 210-269-8028Rosie Clark, 210-771-0141www.elitecareemergency.com

FIRSTMARK CREDIT UNIONGregg Thorne, [email protected]

HEARTLAND PAYMENT SERVICESSherry Willis, 210-885-0201Sherry.willis@e-hps.comwww.heartlandpaymentsystems.com

HUFFMAN DEVELOPMENTSSteve Huffman, 210-979-2500Shawn Huffman, 210-979-2500www.huffmandev.com

PLATINUM WEALTH SOLUTIONS OF TEXAS LLCThomas Valenti, 210-998-5023tvalenti@jhnetwork.comwww.platinumwealthsolutionsoftexas.com

PS & CO. PADGET STRATEMANNVicky Martin, [email protected]

RETIREMENT SOLUTIONSRobert C. Cadena Jr., 210-342-2900robert@retirementsolutions.wswww.retirementsolutions.ws

SA LUXURY REALTY.COMMatin [email protected]

SNB BANK OF SAN ANTONIOSandy [email protected]

SOL SCHWARTZ & ASSOCIATES P.C.Jim Rice, CPA210-384-8000, ext. [email protected]

SOUTHWEST GENERAL HOSPITALCraig Desmond, 210-921-3521Elizabeth Luna, 210-921-3521www.swgeneralhospital.com

ST. JOSEPH’S CREDIT UNION Armando Rodriguez, [email protected]

THE DOCTORS COMPANYKirsten Baze, RPLU, [email protected]

TIME WARNER CABLE BUSINESS CLASSRick Garza, [email protected]

SILVER LEVEL

BRONZE LEVEL

REACH YOUR TARGET MARKETAre you trying to reach the 4,400 physician-members of BCMS with your business message?

Consider joining the BCMS Circle of Friends program, which provides a unique opportunity for business leaders to network and communicate with physicians through a variety of BCMS-sponsored events and services.

By helping to underwrite society events, Circle of Friends members help fund BCMS’ mission of enhancing the practice of medicine for healthcare providers and Bexar County residents.

For more information, contact August C. Trevino at 210-301-4366, email him at [email protected], or visit www.bcms.org.

BCMS does not endorse businesses and involves itself only in services and programs that benefit members and their patients.


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


Ancira Elite Motorcars10835 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


Ancira Kia6125 Bandera Road

*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


Once when I was about 14 years old, I

was walking home from somewhere when

a man driving a BMW 530i sedan stopped

to offer me a ride. As it turned out, I knew

his son, so I gratefully accepted, and by the

time he dropped me off at my house I had

decided that I wanted a BMW when I was

older.

The “fűnfer,” as the BMW 5-series is

known in Germany, was first introduced

here in 1974. The one I rode in had a man-

ual transmission, and I was struck by how

completely different this sedan was from

any other car I had ever ridden in before.

It was elegant and sporty, and as unlike the

floaty Cadillac/Lincoln kind of automotive

luxury of the time as it could be.

GRADUAL HOMOGENIZATIONIt occurred to me as I tested the 2014

535d turbo diesel that the days of national

differences among luxury sedans are mostly

over. While 30 years ago you could ride in

a Mercedes or Cadillac blindfolded and im-

mediately know which was which, that’s no

longer true. In fact, I’d bet that anyone rid-

ing in the passenger seat of a new BMW 5-

series, Jaguar XF, or Cadillac CTS would

be hard pressed to tell the difference with-

out looking.

What has 30 years of gradual homoge-

nization in luxury cars gotten us? Better

cars, for one thing. Cars that are now built

to last like Japanese cars, drive and handle

well like German cars, and are roomy with

a sense of style like American cars.

On to the 535d. For comfort and safety

rating reasons, the 2014 5-series is larger

than it used to be. While the last fűnfer was

191 inches long with a 114-inch wheelbase,

the new one is 193.1 inches long with a

117-inch wheelbase. That expansion gets

AUTO REVIEW

BMW 535d turbo dieselproves conformity can be a good thingBy Steve Schutz, MD


you more passenger space as well as a bigger

trunk, but at 4,050 pounds the new model

is also heavier than the previous version.

The 535d’s interior is luxurious, as you’d

expect. The materials look and feel rich,

and the seats both front and rear are very

comfortable. There’s more high tech, too,

and BMW’s iDrive system has been im-

proved (again). I’ve experienced most iter-

ations of the iDrive since its debut almost

15 years ago, and I’ve applauded every im-

provement along the way. The latest version

with six buttons around the central knob

and a larger, more attractive screen is my

favorite. It now enhances the driving expe-

rience.

The adjective “refined” describes the ex-

perience of driving all BMWs, and the

535d is certainly that. However, as I noted

in my review of the 535i, the new 5-er is

less athletic than it was, like we all are if we

put on some weight.

Surprisingly, the 3.0-liter turbo diesel en-

gine that propels the 535d adds to rather

than subtracts from the 5’s athleticism. Not

only does the 535d go from zero to 60

faster than its gas-powered 535i sibling --

5.6 seconds versus 5.7 -- but it pulls

stronger from a stop thanks to an eye-pop-

ping 413 ft-lbs of torque. We all talk about

horsepower, but it’s torque that gets the job

of accelerating done, and diesel engines all

have lots of torque.

For the record, modern diesel power-

plants are nothing like the nasty polluting

engines we all remember from the 1980s.

Thanks to low-sulphur fuel, lots of engi-

neering advances, and urea exhaust traps,

today’s diesels are environmentally con-

scious, emitting similar levels of standard

pollutants and less CO2 than their gaso-

line-powered counterparts. They’re quiet,

too, with virtually no diesel clatter.

The 535d’s EPA numbers are an impres-

sive 26 mpg city, 38 mpg highway, which

is quite something given that 5.6-second

zero to 60 time.

As a side note, the availability of diesel

engines represents an exception to my car

homogenization thought. For now, only

German companies sell diesel-powered cars

and SUVs in this country.

The 5’s exterior design is more main-

stream than its controversial predecessor’s

was. Gone are the sharp edges and strange

cut lines of the E60 5-series that so many

of the BMW faithful found irritating, re-

placed by reassuring curves and smooth

contours. It’s an attractive look that quietly

reflects a sense of life success.

STYLISH AND COMFORTABLEAs is generally the case for German cars,

the 535d can be had with an almost limit-

less variety of options and option packages.

Interested readers are encouraged to call

Phil Hornbeak at 210-301-4367 for details

about availability and pricing. While the

535d starts at just over $57,000, expect

transaction prices to average around

$65,000 to $70,000.

Vehicle homogenization is a fact of mod-

ern life, and cars like the BMW 5-series are

a reminder that conformity can be a good

thing. The 535d is a stylish and comfort-

able conveyance that is sure to be popular

with successful men and women of all

stripes, and the diesel engine is a delightful

difference-maker that shows that the total

obliteration of national differences hasn’t

happened yet. (By the way, yes, that for-

merly 14-year-old boy now owns a BMW.)

Steve Schutz, MD, is a

board-certified gastroen-

terologist who lived in San

Antonio in the 1990s when

he was stationed here in the

U.S. Air Force. He has

been writing auto reviews for San Antonio

Medicine since 1995.

For more information on the BCMS

Auto Program, call Phil Hornbeak at 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 May 7, 2014.

ABCD Pediatrics, PAClinical Pathology Associates

Dermatology Associates of San Antonio, PADiabetes & Glandular Disease Clinic, PA

ENT Clinics of San Antonio, PAGastroenterology Consultants of San Antonio

General Surgical AssociatesGreater San Antonio Emergency Physicians, PA

Institute for Women's HealthLone Star OB-GYN Associates, PAM & S Radiology Associates, PA

MacGregor Medical Center San Antonio

MEDNAX Peripheral Vascular Associates, PA

Renal Associates of San Antonio, PASan Antonio Gastroenterology Associates, PASan Antonio Pediatric Surgery Associates, PA

South Alamo Medical GroupSouth Texas Radiology Group, PA

Tejas Anesthesia, PATexas Partners in Acute Care

The San Antonio Orthopaedic GroupUrology San Antonio, PA

WellMed Medical Management Inc.

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