san antonio medicine march 2015

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THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • MARCH 2015 • VOLUME 68 NO. 3

MEDICINEEMERGENCIES!

Active shootersFreestanding centers

4 San Antonio Medicine • March 2015

EMERGENCIES!The Unthinkable: An Active Shooter in a HospitalBy John Edeen, MD...................................................14

Patients choose from proliferating free-standing emergency centers, urgent-carecenters, hospital EDsBy Robert Frolichstein, MD ........................................17

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

BCMS Alliance..................................................................10

BCMS Installation ............................................................11

Member Services: Circle of Friends ................................12

Opinion: Nearly two decades of successfully covering children: The past, present and

future of the Children’s Health Insurance Program by Ryan D. Van Ramshorst, MD ................19

Opinion: Medicine at a Crossroads by Richard Gunderman, MD, PhD ......................................22

Nonprofit: New hope through the Komen Foundation ................................................................24

Lifestyle: Briscoe Western Art Museum’s Night of Artists ..........................................................26

BCMS Advocacy and Legislative News ................................................................................................30

UTHSCSA Dean’s Message by Francisco González-Scarano, MD ......................................................32

Business of Medicine: Human capital investments through mentoring

by Lee W. Bewley, PhD, FACHE ........................................................................................................35

BCMS Circle of Friends Services Directory ..........................................................................................37

Book Review: “Letters of Note”

compiled by Shaun Usher, reviewed by Fred H. Olin, MD ................................................................41

In the Driver’s Seat ................................................................................................................................43

Auto Review: Chrysler 200C by Steve Schutz, MD ..............................................................................44

MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • MARCH 2015 • VOLUME 68 NO. 3

SAN ANTONIO

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BOARD OF DIRECTORS

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

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

CEO/EXECUTIVE DIRECTORStephen C. Fitzer

CHIEF OPERATING OFFICERMelody Newsom

DIRECTOR OF COMMUNICATIONSSusan A. Merkner

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

Thinking back over the last year, I ap-

preciate all of the many good things that

Dr. K. Ashok Kumar achieved as last

year’s BCMS president. I feel his greatest

success in the office was raising the in-

volvement of medical students and resi-

dents from the University of Texas Health

Science Center San Antonio to unprece-

dented levels within BCMS. Students

and residents participated in every med-

ical society committee, and it was won-

derful to see them stepping up to help

shape policies and work through issues.

I am delighted that these young physi-

cians are not making the same mistake I

made when I was in their shoes in the

(increasingly distant) past. I joined the

BCMS as a medical student years ago and

then promptly ignored that membership

until I was out of residency. I never went

to a society function in those years and

certainly never participated in a BCMS

or TMA committee until I was out of res-

idency and in regular practice. Given

where I am now, I look back on those

times and think sadly about what a waste

that was and all of the opportunities to

meet other doctors and make important

connections that I let go by. I suppose I

can say that at least I caught on to the

value of being involved at some point,

and my professional life has been made

exponentially richer because of it.

Because of that, I am especially happy

to have had so much participation over

the last year by these doctors at the very

start of their careers. If they can main-

tain that interest, they will reap the ben-

efits much faster than I was able to. I

was a product of the Health Science

Center both for medical school and res-

idency and was well-served by the edu-

cation I received there. I am proud of

the work that the Health Science Center

does and am more than happy to show

off their students and residents in the

local community and at TMA and

BCMS events.

In the past, student participation in

First Tuesdays at the Capitol has included

an occasional student accompanying us

for legislative visits. This year, the Health

Science Center organized a group of stu-

dents to attend the first First Tuesday event

in February, and I couldn’t have been hap-

pier to have them. Usually UTMB, Texas

Tech and Texas A&M medical schools are

the only ones in the state to have a real stu-

dent presence at any of the First Tuesdays.

It is about time that changed! I urge all of

our members to encourage the students

and residents, and welcome them whole-

heartedly to our ranks.

James L. Humphreys, MD, is the 2015president of BCMS. He is a pathologistwith Precision Pathology in San Antonio.

PRESIDENT’SMESSAGE

Medical students, residents increase involvement in

BCMSBy James L. Humphreys, MD2015 BCMS President



I am thrilled to be working with the 2015 Alliance board.Together we are striving to become more visible in the commu-nity through our exciting programs and civic and philanthropicendeavors. We are continuously building our membership, asmore physicians’ spouses discover our organization and whatwe are about.

Jennifer Lewis is our president-elect. I have thoroughly en-joyed working with Jennifer, coordinating the Alliance’s variousprograms and determining strategies to propel us into the future.Jennifer serves on all of the Alliance’s various committees and is aconstant source of inspiration and energy.

Rena Baisden is our first vice president of membership. Renawas off to a swift start at the onset of 2015, and the enthusiasmshe brings to her office is infectious. Rena has been busy recruitingnew members and working with me on the production of the2015 yearbook. Her support is invaluable, and I am pleased to beworking together.

Dave Tapia is our second vice president of communications.The expertise he provides the Alliance is invaluable. Dave has beenvery busy, updating our website and working with the other vicepresidents and myself to create our newsletter.

Christy Hinchey serves this year as the Alliance’s third vicepresident of programs. She brings a wealth of expertise andknowledge to her position. Christy’s responsibilities include co-

ordination of the Alliance’s four major programs for the year, andshe is doing a fabulous job! Our next program is the May 7 PastPresidents’ Luncheon and Fashion Show at Julian Gold. We hopeyou will make plans to attend.

Our fourth vice president of civic and philanthropic is thevery capable and energetic Mona Talukdar. Mona is in charge ofcoordinating the Alliance’s various community service endeavors,including “Hard Hats for Little Heads” and “Be Wise Immunize.”In addition, Mona advises our Junior Volunteer Committee’schair, Abbey Pamar.

Oemil Rodriguez is the Alliance’s fifth vice president of social.She has the fun position of planning our social calendar and is offto an awesome start. Stay tuned for news regarding an upcomingSips and Dips event.

The board could not run smoothly without the expertise of thefollowing ladies: Anne Foster is our very capable treasurer, HildaCastillo has the important role of corresponding secretary, San-dra Vela serves as the Alliance’s recording secretary, and ShirleySanders guides and instructs us as parliamentarian.

I would like to extend a special thank you to my 2015 advisors,whose wisdom, support and guidance have proven invaluable tome: Cindy Comfort, Rebecca Waller and Mertie Wood.

Thank you to you all for serving. It is a pleasure to be workingwith you all!

BCMSALLIANCE

MEET THE 2015 ALLIANCE BOARDBy Rebecca Christopherson2015 Bexar County Medical Society Alliance President

PHOTO ABOVE (from left): 2015 Alliance board members Rebecca Waller, Mertie Wood, Cindy Comfort, Oemil Rodriguez,Jennifer Lewis, Rebecca Christopherson, Anne Foster, David Tapia, Hilda Castillo, Sandra Vela and Shirley Sanders at theJanuary installation.

visit us at www.bcms.org 11

BCMS NEWSINSTALLATION

2015 BCMS INSTALLATION

1. Outgoing president Dr. K. Ashok Kumar (left) applauds as Dr. James L. Humphreys is sworn in as 2015 BCMS president at the Jan. 24 installation at Oak Hills Country Club.

2. Dr. K. Ashok Kumar and his wife, Elaine Kumar, pause during the BCMS installation event.3. BCMS past presidents gather for their annual photograph at the 2015 BCMS installation.4. The 2015 BCMS Board of Directors includes (from left): treasurer Dr. Maria M. Tiamson-Beato, president-elect Dr. Jayesh

B. Shah, secretary Dr. Adam V. Ratner, 2015 president Dr. James L. Humphreys, 2014 president Dr. K. Ashok Kumar, BCMS CEO/Executive Director Steve Fitzer and vice president Dr. Leah H. Jacobson.

5. Dr. Estrella M.C. deForster (left) chats with Janis Humphreys, wife of Dr. James L. Humphreys.

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MEMBER SERVICES

The Bexar County Medical Society Circle of Friends program isthe ultimate win-win.

BCMS physician-members have information about relevantSan Antonio-area businesses at their fingertips, and Circle ofFriends sponsors may offer their products and services directly toour membership.

“Circle of Friends is the most focused and direct method of reach-ing the medical community,” said BCMS Development DirectorAugust C. Trevino II.

“Circle of Friends vendors provide our physician-members withoutstanding opportunities to save on needed services and products.Vendors also help to underwrite BCMS programs and keep downthe cost of dues,” he said.

“Participating businesses are able to reach physicians, practice ad-ministrators and strategic key decision-makers,” Trevino said.“Through our program, we have helped many businesses grow in ourlocal medical community, and in return their sponsorship monies havehelped BCMS with its many health initiatives and programs.”

For area businesses, annual membership in Circle of Friends costs$3,000 (silver), $5,000 (gold) or $10,000 (platinum), with varying

benefits according to membershiplevel. Among the benefits are reservedvendor space at BCMS events andmeetings, targeted email distributions,personal introductions, inclusion in themedical society’s weekly electronic newsletter, and other marketingopportunities.

BCMS members are now able to use the Circle of Friends ServicesDirectory to find the products and services they need for their homesand businesses. From accounting firms to staffing services, the di-rectory includes contact information for approximately 75 Circle ofFriends sponsors ranging from major corporations to locally ownedsmall businesses.

The directory is published in every issue of San Antonio Medicineand also is available online at www.bcms.org/busdir/index.html.

The Circle of Friends slogan is: “Support our sponsors; our spon-sors support us.”

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

BCMS Circle of Friends program benefits members, local businesses

August C. Trevino II


EMERGENCIES

FIVE PHASESThe active killer goes through five phases in planning and exe-

cuting his act, according to veteran police trainer Lt. Dan Marcou.

The first is fantasy. This includes picture drawing, website postings

and possible discussion with others. Second is planning. He may

put his plan in writing and discuss with others. Third is prepara-

tion. He acquires weapons and ammunition and may notify others

not to go to school or work that day. Fourth is approach. He

moves toward target carrying tools. And finally, implementation.

The killing starts.

Rapid Mass Murder (RMM) is defined by police trainer and

student of mass murder Ron Borsch as “within 20 minutes, four

or more people are intentionally killed at the same time and in a

public location.” Such incidents have happened in a wide variety

of public places — a coffee shop, a casino, elementary schools,

middle and high schools, university campuses, a rural one-room

school house, a library, shopping malls, churches, hospitals, nurs-

ing homes, a pharmacy, post offices, restaurants, grocery stores, an

island in Norway, military bases, urban daycare center and miscel-

laneous workplaces. They are chaotic and occur with frightening

speed. In the shooting of Congresswoman Gabrielle Giffords, six

people were killed and 13 wounded in an incident that lasted 15

seconds. However, the incident in Norway lasted over an hour and

resulted in 69 killed and 60 wounded. According to Borsch’s re-

search, the average RMM lasts about six minutes. Unfortunately,

the delay in notifying law enforcement also averaged six minutes.

He developed the term “Stopwatch of Death” to describe the num-

ber of murder attempts per number of minutes. At Sandy Hook

Elementary, the death rate was five deaths per minute and at Vir-

ginia Tech, it was eight.

Time is the key element in preventing the death of innocents. If

the response occurs from within the building, two or three people

may be killed; if the response is from outside the building, the death

toll balloons to 12 to 15. Police response is hampered by delay in

notification, distance, communication of the location within the

hospital where the incident is occurring, unfamiliarity with the lay-

out of the hospital, and access to keys held by security. All these fac-

tors lead to delay in police response even under the best of

circumstances. All the while, the stopwatch continues to tick.

‘RUN. HIDE. FIGHT.’The Department of Homeland Security defines an active

shooter as “an individual actively engaged in killing or attempting

to kill people in a confined and populated area, typically through

the use of firearms.” DHS recommends that if an active shooter

(killer) is in your vicinity, you should attempt to evacuate. If that

is not possible, then hide out. At last resort, take action. “Run.

Hide. Fight.”

THE UNTHINKABLE:AN ACTIVE SHOOTER IN A HOSPITAL

By John Edeen, MD

On July 24, 2014, a psychiatric outpatient with a long criminal history and a history of suicide at-tempts attacked a case worker and psychiatrist at the Mercy Fitzgerald Hospital in Darby, Pa. He shot thecase worker, Theresa Hunt, twice in the face, killing her. He then wounded Dr. Lee Silverman, a concealedlicense holder, in the head. However, Dr. Silverman was able to access his own firearm and shoot the killerthree times. The killer was then tackled and disarmed by another doctor and case worker when he attemptedto flee. He was found to have 39 more rounds of ammunition. If Dr. Silverman had not violated hospitalpolicy, he would be dead and many more staff, patients and family members would be dead or injured. Thekiller, a convicted felon who had already served prison time as a felon in possession of a firearm, walked rightby the hospital’s “no guns allowed” signs to execute his evil plan.

EMERGENCIES


You should have an escape route and plan in mind; leave your

belongings behind and be ready to keep your hands visible for law

enforcement. If you must hide, choose an area out of the shooter’s

view, block the entry to your hiding place and lock the doors. Also,

silence your cell phone or pager. You should fight if your life is in

imminent danger. You should attempt to incapacitate the shooter

with physical aggression and throw items at the active shooter.

Call 911 when it is safe to do so. You should report the location,

the number of shooters, their physical description, the number

and types of weapons held by shooters and the number of potential

victims at the location. DHS instructs that when law enforcement

arrives remain calm and follow instructions, put down any items

in your hands, raise hands and spread fingers, keep hands visible,

avoid quick movements toward officers, avoid pointing, screaming

or yelling, and do not stop to ask officers for help or directions

when evacuating.

In their white paper, the Health Care and Public Health Sector

Coordinating Councils remind us that healthcare professionals

have a duty to care for their patients. This brings up several ethical

issues in the event of an active killer event. We must prepare in ad-

vance to address several issues. We must allocate resources fairly

with special consideration to those most vulnerable. We must limit

harm to the extent possible. We must treat all patients with respect

and dignity, regardless of the level of care that can continue to be

provided. We must prepare to decide to discontinue care to those

who may not be able to be brought to safety in consideration of

those who can. We should realize some providers and family will

choose to remain in danger. We must consider the greater good as

well as our own interests. We must strive to maximize the preser-

vation of life.

Texas Government Code Section 411.204(b) requires hospitals

licensed under Chapter 241, Health and Safety Code “shall promi-

nently display at each entrance to the hospital ... a sign that com-

plies with subsection (c) ... that it is unlawful for a person licensed

under this subchapter to carry a handgun on the premises.” Penal

Code Section 46.035(b)4 prohibits a concealed license holder from

carrying a handgun “on the premises of a hospital licensed under

Chapter 241, Health and Safety Code ... unless the license holder

has written authorization of the hospital administration...” Almost

every active killer scenario has occurred in places where concealed

license holders were prohibited from possessing firearms. These

victim disarmament zones allow killers the time to run out the

“stopwatch of death” before law enforcement can arrive. If the

event in Pennsylvania had happened in Texas, Dr. Silverman would

be subject to prosecution for a Class A misdemeanor punishable

by a fine of no more than $4,000, confinement in jail for a term

no greater than one year, or both. In addition, he would lose his

concealed handgun license for a period of five years. In Pennsyl-

vania, the “no guns” signs do not carry weight of law, but the Texas

PC Sec. 30.06 sign does.

We can improve physical security, limit access, arm our security

guards, conduct drills, install cameras and do risk assessments, but

in the end it will be the individual on the scene at the time of the

active killer event who is in the best position to stop the killing.

The Joint Commission requires a hospital to identify its security

risks (JCAHOs Standard EC.2.10). CMS mandates a hospital pa-

tient has the right to receive care in a safe setting (42 C.F. R.

482.13(c)(2)). OSHA released guidelines in 2004 for preventing

violence in healthcare.

Continued on page 16


EMERGENCIES

GUN-FREE ZONES ‘IMMORAL’We must allow our physicians, nurses and technicians who have

the training and willingness to protect us to have effective tools avail-

able to do the necessary job. Concealed license holders have been

shown to commit fewer crimes than the general population and even

police officers. Would it not be better to set up a program to arm

our trusted colleagues and coordinate with law enforcement to pro-

tect staff, patients and families in our hospitals? If we must run and

hide from the active killer threat and cannot avoid direct confronta-

tion, we should not disarm those who would have effective tools on

hand at the scene. It is immoral to continue the fallacy of “gun-free

zones” in our hospitals when experience shows that deranged killers

go out of their way to select such places to do their mass killing. Ac-

cepting this reality will require a culture change among some staff

and hospital administration. We are the last resort when all else fails.

We doctors should take the lead in this moral undertaking, joined

by our co-workers in nursing and the allied health professions. We

should contact our state representatives and state senators to ask them

to remove the requirement of hospitals and nursing homes to post

“no guns allowed” signs. We also should ask them to remove gun-

free zones from as many places as possible in Texas. And finally, we

should petition our hospital administrators to change their “no gun”

policies and allow staff to carry until our legislature changes the law.

Let’s stop the “Stopwatch of Death,” once and for all.

REFERENCESBuckeye Firearms. K.I.D.S. – A Proactive Approach to School Murders. Jun 2012

Buckeye Firearms. The Cause and Effect of Rapid Mass Murder. Jul 2014

U.S. Department of Homeland Security. Active Shooter — How to Respond.

Oct 2008

Stanford Hospitals and Clinics Risk Consulting. The Active Shooter — The New

Threat in Healthcare. Apr 2011

Healthcare and Public Health Sector Coordinating Councils. Active Shooter Plan-

ning and Response in a Healthcare Setting. Jan 2014

John Edeen, MD, is a pediatric orthopaedic sur-

geon in San Antonio and serves on the Bexar

County Medical Society Emergency Preparedness

Committee. He is a graduate of Massad Ayoob’s

MAG-40 and is a certified National Rifle Associ-

ation pistol instructor.

Continued from page 15


EMERGENCIES

There has been significant growth in the number of free-stand-

ing emergency centers in the greater San Antonio area. The reason

for this growth is as varied as the structures and ownership of the

centers themselves.

The main impetus to invest in the establishment of a free-stand-

ing center is much dependent and driven by the ownership model.

For example, a hospital-owned facility might be interested in stak-

ing out physical territory to protect or enhance its market share.

Also, a hospital might locate a new center to facilitate referrals to

its traditional sites with beds and procedure rooms to increase oc-

cupancy or volume of charges. On the other hand, a non-hospi-

tal-owned facility could be established for purely financial

investment considerations.

Licensed free-standing emergency centers in the state of Texas

may charge facility fees, such as room costs, surgical trays, supplies,

etc. They may own equipment and subsequently charge for tests

that can be done onsite for patients at time of service. Additionally,

they may charge a “technical” component for the use of diagnostic

equipment, such as X-rays, CT and MRI scanners. Unlicensed ur-

gent-care centers may not charge facility and equipment fees.

TEXAS LAW CHANGEDFree-standing emergency centers are more numerous in the state

of Texas than in many other states due to differences in licensing

requirements. In 2010, Texas Administrative Code 25 established

rules and licensing requirements for free-standing emergency cen-

ters. The requirements seem to be less stringent than for other

states. Consequently, hospitals and entrepreneurs have seized the


Patients choose fromPROLIFERATING FREE-STANDING EMERGENCY CENTERS

URGENT-CARE CENTERS • HOSPITAL EDSBy Robert Frolichstein, MD


EMERGENCIES


opportunity to establish these centers in prime locations to attract

patients seeking greater convenience.

Houston and Dallas-Fort Worth lead the state in numbers of

free-standing centers. San Antonio is rapidly catching up to the

pace of growth, however. A mixture of hospital-owned and private

facilities continues to grow. To the extent that traditional hospital

emergency department visits are slightly declining in San Antonio

following many years of substantial increases in volume, it seems

apparent that the growth of the free-standings is having its impact.

The financial viability of free-standing emergency centers is

quite different for hospitals, private investors versus physicians.

For the entity that collects the facility charge, the break-even is

about 10 to 15 patients per day. Whereas if physicians are able

only to charge for their professional services, i.e., not the facility

charges, they must treat 35 to 40 patients per day to break even.

This difference in reimbursement for physicians can be even

greater for non-hospital-affiliated free-standing centers. The main

reason for this difference is the fact that Medicare will not reim-

burse non-hospital-affiliated centers for emergency department

professional or facility fees. The physician may bill a Medicare pa-

tient at an urgent-care rate only, and the facility may not charge

anything for the use of the facility. On the other hand, a free-

standing emergency department that is not affiliated with a hos-

pital may charge facility charges and emergency-level fees to

commercially insured or self-pay patients.

ADVANTAGES, DISADVANTAGESFrom the consumer point of view, free-standing emergency cen-

ters provide both advantages and disadvantages. The advantages

begin, obviously, with location. Prior to hospitals or entrepreneurs

building a facility, much research is done on population, demo-

graphic groupings and traffic studies. The result is likely to be a

convenient location for a concentration of residents in San Anto-

nio communities.

Another advantage is that free-standing emergency centers

(FSEC) are equipped to handle higher acuity of presenting medical

conditions or problems. They must be equipped with CT scans

and testing that allows most basic diagnostic evaluations. In theory,

they should function just like hospital-based emergency depart-

ments, including being involved in the city EMS plan. In reality,

what has been observed is that the patients who go to a FSEC are

not as sick as those who go to hospital-based emergency depart-

ments, even if you adjust for the lack of EMS involvement in the

FSEC. Nationally, the percentage of patients presenting to a FSEC

that required admission is around 1 percent. In contrast, the na-

tionwide admission rate at hospital-based emergency departments

varies widely but averages over 20 percent.

The physicians will likely be board-certified physicians whose

specialty is emergency medicine. In contrast to urgent-care centers

that are generally designed to handle minor medical situations,

free-standing emergency centers offer the advantage of having fa-

cilities conveniently located that are well-positioned to provide

critical care to patients.

The disadvantage for consumers or patients is cost. Generally free-

standing centers are much more expensive. This is due to the fact, as

previously stated, that these centers may charge “facility” fees for

rooms, supplies and diagnostic tests that urgent-care clinics do not.

The professional charges for the physician’s time also are slightly

higher to the extent that the charges will be for emergency-level serv-

ices rather than urgent-care level services. The total amount for the

visit may be four to five times higher than a regular office visit.

Healthcare professionals consider the possibility of hitting a sat-

uration point in the case whereby too many free-standing emer-

gency centers are added. No one really knows where or when this

could happen. In comparison to other industries, such as banking,

health clubs and spas, it appears that the axiom that the three most

important things are location, location, location applies to free-

standing emergency centers as well. Ultimately it will be the pa-

tients, the ultimate consumers of healthcare services, who will

determine the success of these ventures.

Robert Frolichstein, MD, an emergency medicine

physician, is president of Greater San Antonio Emer-

gency Physicians, PA, and a BCMS member.


OPINION

“How is healthcare for uninsured children controversial?” I re-

member thinking to myself back in 2007 as I learned that the Chil-

dren’s Health Insurance Program (CHIP) would be a priority topic

to be covered at an upcoming Texas Medical Association First Tues-

days advocacy event in Austin.

I was a naïve first-year medical student in Houston, and this was

my first foray into health policy and physician advocacy. During

that 80th Texas legislative session, CHIP was front and center.

House Bill 109 undertook rolling back restrictions on CHIP which

were detrimental to some of Texas’ most in-need citizens: unin-

sured children. Such restrictions were passed under the guise of

program improvement in an effort to save the state highly sought-

after taxpayer dollars.

In 2003, the legislature voted to decrease coverage eligibility

from 12 to 6 months, impose a 90-day waiting period for unin-

sured children to receive coverage, and increase CHIP premiums.

When these provisions went into effect, more than 100,000 Texas

children lost coverage. Among other important actions, HB 109

restored 12-month continuous eligibility and eliminated the 90-

day waiting period for uninsured children – making the Texas

CHIP program better for the children it served. I am proud that I

played a (very small) role in strengthening this vital program –

even as a junior medical student who still didn’t even understand

what a “SOAP” note was.Continued on page 20

Nearly two decades of successfully covering children:

Texas State Rep. Dawnna Dukes (TX-46) speaks at a 2007 rally for HB 109 in Austin as other state legislators listen. Photo courtesy Texas Medicine

The past, present and future of the Children’s Health Insurance ProgramBy Ryan D. Van Ramshorst, MD



UNINSURED CHILDREN Now, working as a community pediatrician on San Antonio’s

South Side, I have a much better understanding of the critical im-

portance of CHIP for low-income children. Currently, CHIP pro-

vides coverage to more than 8 million children nationwide,

including more than 500,000 children in Texas and 35,000 chil-

dren in Bexar County. Created in 1997, CHIP was designed to ex-

tend health insurance to a targeted group of low-income children

who did not qualify for Medicaid. This group included children

living in families with incomes between 100 percent and 200 per-

cent of the federal poverty level. Since then, the percentage of unin-

sured children in that income range has dropped from nearly 23

percent in 1997 to roughly 10 percent today. Likewise, the per-

centage of uninsured children across all income levels also has

dropped to historic lows (although Texas continues to rank among

the worst three states). In short, CHIP has been a rousing success.

While CHIP tends to be equated with Medicaid during policy

discussions, it is important to delineate its unique aspects. One of

the most salient differences is that CHIP includes cost-sharing in

the forms of insurance premiums and co-payments. Such cost-shar-

ing is affordable for low-income families when compared to the

high deductibles of many private insurance products. CHIP also

is unique because it is not a mandatory program for states. Despite

this, every U.S. state, territory and the District of Columbia have

developed CHIP programs. Another reason that contributes to its

popularity is that the match rate for federal dollars is approximately

20 percent to 30 percent higher than that for Medicaid. States also

have the ability to further customize CHIP programs in terms of

covered benefits, eligibility limits and program design. Finally,

CHIP is highly regarded as a successful public insurance program

which has enjoyed bipartisan support since its inception.

The initial legislation for CHIP was co-authored by an unlikely

couple: the “Lion of the Senate,” the late U.S. Sen. Ted Kennedy

(D-Mass.), and soft-spoken conservative Sen. Orrin Hatch (R-

Utah). To comply with the existing balanced budget agreement,

the program was funded by an increase in the federal cigarette tax.

It was first passed by the Republican-controlled Congress and

signed into law by President Bill Clinton. However, despite its bi-

partisan origins, its history hasn’t been without controversy. Per-

haps most notable were two prior presidential vetoes of CHIP

reauthorization during the second term of President George W.

Bush. Thankfully, CHIP was eventually extended by passage of the

Children Health Insurance Program Reauthorization Act

(CHIPRA), one of the first bills signed by President Barack Obama

in early 2009. CHIPRA both reauthorized and funded the pro-

gram through 2013. With the passage of the Affordable Care Act

(ACA), funding was continued until Sept. 30, 2015. Complicating

matters was how the ACA simultaneously called for states to con-

tinue offering CHIP coverage at current eligibility levels through

2019 (without allocating additional dollars). This has left state

health officials with quite a sense of unease.

If Congress does not act, it is estimated that most states will run

out of federal CHIP dollars in the first two quarters of FY 2016.

Congressional inaction would leave millions of low-income chil-

dren without viable insurance options while creating uncertainty

for state legislatures attempting to plan budgets. As CHIP is re-

examined, some have argued that funding should be decreased. In

theory, low-income children should have access to affordable cov-

erage options through the exchanges and associated tax credits.

Unfortunately, “theory” has not necessarily translated into health

insurance reality for these kids.

‘FAMILY GLITCH’Numerous states have been stubborn in implementing the ACA.

The “family glitch” describes faulty math related to how the IRS

identifies qualified health plans as affordable based on the cost of

insuring the employee only (not accounting for the cost of covering

dependents such as children). As such, pediatricians and child ad-

vocates everywhere are concerned that children currently covered

by CHIP would be “lost in transition” if the program is diminished

in size or significantly altered. It is for this reason that the American

Academy of Pediatrics is calling for a four-year extension of CHIP

during which the program can be more thoroughly studied in the

ever-changing health insurance marketplace.

Federal legislators recognize the need to consider the future of

CHIP. During the final months of the 113th Congress, both House

and Senate versions of the “CHIP Extension and Improvement Act

of 2014” were introduced and subsequently discussed at two separate

congressional hearings. Democratic and Republican elected officials

alike pledged their support for CHIP and celebrated its history as ev-

idenced by glowing rhetoric. Unfortunately, such rosy commentary

did not translate into legislative progress for kids.

OPINION


For the health of my pediatric patients, and that of the many

other Texas children who are able to have a true medical home be-

cause of CHIP, it is my hope that the 114th Congress acts quickly

to extend funding at its current level. As evidenced by numerous

gloomy child-health indicators, Texas has much to gain from the

continued success of CHIP. As such, our Texas congressional del-

egation should lead the charge to ensure uninterrupted health cov-

erage for this vulnerable segment of our population.

Ryan D. Van Ramshorst, MD, is a specialist in the University ofTexas Health Science Center at San Antonio Department of Pediatricsand a staff physician at University Health System/Community Medi-cine Associates. He is a member of the Bexar County Medical SocietyLegislative/Socioeconomics Committee.

Disclaimer: The views expressed in this article do not neces-sarily reflect those of the University of Texas Health Science Cen-ter at San Antonio, University Health System/CommunityMedicine Associates, or the Bexar County Medical Society.

OPINION

Drs. Christine and Ryan Van Ramshorst attended their first TMA First Tuesdays event in Austin in 2007 before they were married. They both attendedthe Baylor College of Medicine in Houston 2006-10 and completed residencies at UTHSCSA. Dr. Christine Van Ramshorst is an OB/GYN in privatepractice in San Antonio. Photo courtesy Van Ramshorsts


OPINION

Today American medicine stands at a daunting crossroads. Soloand small physician practices are being assimilated by large groupsand hospitals. The perspectives of individual physicians are beingdevalued in favor of general guidelines and algorithms. And thelocus of much medical decision-making is shifting away from thepatient-physician relationship toward systems and payers.

Albert Einstein once said that the problems we face cannot besolved using the same patterns of thought that were used to createthem. In confronting contemporary medicine’s quandary, we needto look beyond the boundaries of the profession for deeper insightsinto the nature of the problem and the range of solutions that areavailable to us.

INTELLECTUAL HOUSEHOLDIn this spirit, we turn to Peter Drucker, the 20th century’s most

widely influential, highly regarded and oft-quoted managementexpert. Drucker was born in 1909 in Austria, the son of a physicianmother and attorney father, and he grew up in a richly intellectualhousehold that served as a meeting place for prominent thinkersof the day.

As a young man, Drucker moved to Germany to start a careerin business, then switched to journalism, a job that required himto file no fewer than eight newspaper stories per week. He also

earned a doctorate in international law. He then went to Englandand worked as an economist at a bank before immigrating to theUnited States and becoming a university professor, writer and busi-ness consultant.

Drucker’s output as a writer was prodigious and included 39books, hundreds of academic articles, and a regular column in TheWall Street Journal for more than a decade. He also consulted formany top U.S. corporations and innumerable nonprofits, oftenserving the latter clients gratis. He also was a highly sought-afterlecturer. Drucker died in 2005 at the age of 95.

Perhaps Drucker’s greatest work was also one of his first, an articleon the Danish philosopher and theologian Soren Kierkegaard, whosewritings Drucker had devoured when he first encountered them atthe age of 17. His essay, “The Unfashionable Kierkegaard,” was writ-ten in 1933, during the age of Stalin and Hitler. Though not obvi-ous, the insights it offers contemporary medicine are profound.

Drucker’s reading of Kierkegaard convinced him of two things.First, those who expect technology or politics to produce a perfectsociety – and for our purposes, a perfect practice of medicine or aperfect healthcare system – are certain to be disappointed. Second,the more a society – or the profession of medicine – defines successin strictly economic terms, the more it ends up losing itself.

On one side of this conflict stands the French political philosopher

Medicine at a crossroads:

By Richard Gunderman, MD, PhD

Peter Drucker, 1909-2005

SAVE THE DATENoon, March 13UTHSCSADr. Richard Gunderman


OPINION

Jean Jacques Rousseau, who argued that society should take priorityover the individual, and that whatever meaning there is to be foundin individual life must be defined by its meaning for society, to whichthe rights of every individual are ultimately subordinate.

In medicine, Rousseau’s outlook may be restated this way: Indi-

vidual physicians are first and foremost workers in a larger systemof healthcare, and their work must be regulated by the needs ofthe healthcare system as a whole. The professional freedom andfulfillment of individual physicians are important only to the de-gree that they serve these ends.

Drucker regards Kierkegaard as providing perhaps the only vi-able alternative to Rousseau. If Rousseau represents the pragmaticconcerns of society, often represented in medicine by healthcarecorporations, licensing boards and accrediting agencies, thenKierkegaard represents something like the timeless ideals of theprofession as embodied in the heart of each professional.

LONGER PERSPECTIVEThose who seek to rationalize the practice of medicine according

to sound business principles, transforming physicians from pro-fessionals with minds of their own into reliably homogeneous fol-lowers of established policies and procedures, believe that, in theend, no freedom can be allowed in the practice of medicine except

for things that don’t really matter.Those whose perspectives align with Kierkegaard naturally re-

gard the healthcare tumult of the day from a somewhat longer per-spective, one that treats the freedom of individual physicians andpatients as intrinsic goods that deserve to be protected and pro-

moted for their own sake, independent of their effect on the bot-tom line.

Ultimately, Drucker would say that it is out of the tension betweenthe Rousseaus and Kierkegaards of contemporary healthcare that wemust strike the appropriate balance between a fully rationalizedhealthcare system and a way of practicing medicine that respects thedignity and humanity of individual physicians and patients.

Where, why and how Drucker thought we should strike this bal-ance will be the subject of the author’s talk at noon March 13 theUniversity of Texas Health Science Center San Antonio. The eventis cosponsored by UTHSCSA, The Patient Institute and BCMS.

Richard Gunderman, MD, PhD, is the Chan-cellor’s Professor of Radiology, Pediatrics, MedicalEducation Philosophy, Liberal Arts, Philanthropyand Medical Humanities and Health Studies at In-diana University and a contributing writer for TheAtlantic.


NONPROFIT

Every year, more than 40,000 women in

the United States die from breast cancer.

Triple negative breast cancer (TNBC) repre-

sents a disproportionately higher number

(~50 percent) of breast cancer deaths, even

though it represents a relatively small per-

centage (15 percent to 25 percent) of total

cases. TNBC also contributes to survival dis-

parities among African Americans and His-

panics because of its higher prevalence (~30

percent) among these minority groups.

Since TNBC, which is more common

among younger women and minority

women, does not respond to targeted breast

cancer therapies, harsh chemotherapy is the

standard treatment for these patients. Luck-

ily there is new hope: San Antonio’s own

breast cancer research team, led by Dr.

Pothana Saikumar, an associate professor of

pathology in the School of Medicine at the

University of Texas Health Science Center

San Antonio, was awarded a $1 million

multi-year grant in 2013 by the Susan G.

Komen Scientific Research Program to find

a new targeted therapy.

In addition to the body’s immune system,

another surveillance mechanism comes in

the form of a protein called transforming

growth factor beta, or TGF-beta to combat

cancer. This protein has a Jekyll and Hyde

relationship to cancer. At first it can be help-

ful in combatting cancer cells in early stages,

but once cancer is advanced, the TGF-beta

actually begins to promote cancer growth

and metastasis (the spread of cancer from

one organ to another). Dr. Saikumar and his

team are studying this and looking for a way

to stop growth from happening.

‘PARTNER-IN-CRIME’The “partner-in-crime” to TGF-beta’s ac-

tion is an unusual protein called TMEPAI.

Dr. Saikumar’s research team identified

TMEPAI to work alongside TGF-beta in

controlling cell growth and migration while

studying kidney regeneration in 2010.

When TMEPAI was shut off, the cancer cells

returned to a normal state and a number of

benefits occurred. The cancer cells no longer

underwent metastasis, and the tumors

shrunk. Dr. Saikumar’s discovery was pro-

found in that it revealed a novel therapeutic

target to treat triple negative breast cancer

patients.

“We are progressing in developing novel

drugs, and in a few years we will have some-

thing tangible,” Dr. Saikumar said regarding

his progress since receiving the Komen grant

two years ago. He emphasized that not only

will these drugs benefit those diagnosed with

TNBC, but they also will help in preventing

development of hormone receptor negative

breast cancers. These drugs may even bene-

fit those diagnosed with other diseases, in-

cluding colon, lung and prostate cancer.

DIET AND CANCER Dr. Amelie Ramirez, professor of epidemi-

ology and biostatistics and director of the In-

stitute for Health Promotion Research at the

University of Texas Health Science Center

San Antonio, is working on revolutionary

breast cancer research with her $225,000

Komen grant, awarded in 2014.

“We believe eating right plays a vital role

in helping reduce cancer risk,” Dr. Ramirez

said. The two-year study, called “Rx for Bet-

ter Breast Health,” will determine the effects

of nutritional anti-inflammatory diets on

breast cancer survivors by splitting a sample

of 150 randomly assigned breast cancer sur-

vivors into two groups: intervention and

control.

The intervention group will undergo six

monthly anti-inflammatory food work-

shops, including culinary demonstrations,

recipes, meal planning, and a “variety of as-

sistance and services from a patient naviga-

tor,” while the control group will receive

only generic cancer prevention information.

NEW HOPEfor triple negative breast cancer patients

BY SARAH MUNROE


NONPROFIT

Both groups will be evaluated before the study, six months post-study, and

one year post-study.

“Our study is specifically testing the idea that women who get the more

intensive cooking workshops, counseling and newsletters will increase their

intake of anti-inflammatory foods,” Dr. Ramirez said. “We also will exam-

ine how this affects their biomarkers of obesity and inflammation.”

Dr. Ramirez is an internationally recognized cancer health disparities re-

searcher who has spent 30 years directing research on human and organi-

zational communication to reduce chronic disease and cancer health

disparities affecting Latinos. She also founded the SaludToday Latino

health campaign, trains and mentors Latinos in behavioral sciences, and

serves as an advisor for various nonprofit health organizations, including

the Susan G. Komen Scientific Advisory Board. The study features other

noted Health Science Center researchers: Dr. Michael Wargovich in mo-

lecular medicine, Dr. Alan Holden in epidemiology and biostatistics, and

celebrity chef Iverson Brownell.

RESEARCH COMMITMENTBoth researchers attribute the success of their studies largely to funding

from Susan G. Komen. “Komen is able to see the importance of our work

in fighting TNBC,” Dr. Saikumar said.

Dr. Ramirez said, “I would like to warmheartedly thank Susan G.

Komen for its commitment of more than $800 million in research world-

wide and more than $20 million to research on diet, exercise and cancer

prevention.”

Komen encourages women to be proactive about their breast self-aware-

ness by knowing their risk, getting screened, knowing what is normal for

them and making healthy lifestyle choices.

To be part of Komen’s commitment to local families in need of breast

cancer care, education and groundbreaking research, participate in the

2015 San Antonio Race for the Cure April 11 at the Alamodome.

For more information, visit www.komensanantonio.org, email

[email protected] or call 210-222-9009.

Photos:Left: Dr. Pothana SaikumarRight: Dr. Amelie Ramirez


LIFESTYLE

The Briscoe Western Art Museum, 210 W. Market St. in down-

town San Antonio, presents the 14th annual Night of Artists Art

Sale and Exhibition featuring 70 of the country’s top Western

artists. The show kicks off with the popular art sale and reception

March 28, where attendees have the opportunity to bid on exqui-

site paintings and sculptures by artists such as T.D. Kelsey, Sandy

Scott, Ed Mell, Doug Hyde, Billy Schenck, Kent Ullberg and Kim

Wiggins. Complete with a gourmet buffet, cocktails and live

music, the art sale and reception has become the Briscoe Museum’s

biggest annual fundraiser.

The Night of Artists exhibition opens to the public March 29

for a month-long show that is free with museum admission. The

exhibit continues through Fiesta, closing April 26, in the Jack

Guenther Pavilion adjacent to the historic museum building.

“The Briscoe Museum’s Night of Artists art sale and exhibition

represents one of the region’s leading contemporary Western art

shows,” said Tom Livesay, the Briscoe’s executive director. “We are

pleased and excited to invite both Western art collectors and San

Antonio’s many visitors to view this impressive compilation of

works created by many of the top Western artists today.”

The range of subjects will reflect the vastness of the great Amer-

ican West, from dreamy landscape vistas to rugged frontier cow-

boys, historic missions, and detailed Native American subjects.

An important part of the Night of Artists show is the presenta-

tion of the Briscoe Legacy Award. For the past eight years, the

award has been given to an artist whose body of work has left a

lasting impact upon the Western art world. Other show awards in-

clude Artist’s Choice, Committee’s Choice and Patrons’ Choice.

This year’s Briscoe Legacy Award recipient is noted painter

David Halbach who makes his home in the mountains of northern

California. Halbach began his career as an animator at Walt Disney

Studios and later spent many years as an art teacher in five districts

of the Los Angeles Unified School System. In 1985, he was invited

to become a member of the prestigious Cowboy Artists of America

and since then, he has won numerous CAA gold and silver medals.

The Night of Artists art sale and reception from 5 p.m. to 11 p.m.

March 28 is a ticketed event. Tickets are $200 and include art sale

with bid book, beer/wine/cocktails, hors d’oeuvres, buffet dinner and

live entertainment. The event is supported by the GM Foundation.

Briscoe Western Art Museum’s

BRINGS THE BEST OF THE WEST TO SAN ANTONIO

Night of ArtistsSpecial to San Antonio Medicine

For tickets and sponsorship information, call 210-299-4499 or visit BriscoeMuseum.org.

H H

H


LIFESTYLE


Clockwise, from top left: Plumed Regalia, Oil, 30 x 30, $7500, Scott Burdick; Beauty and the Beast, Canvas on Board, 14 x 18, Linda Tuma Robertson; Cow Boss, Bronze, TD Kelsey, Briscoe NOA 2015.

BCMS Unsung Hero Wendy Garza

Wendy Garza is synonymous with the title,“Unsung Hero,” her colleagues say.

Ms. Garza has been with Northeast Or-thopaedics and Sports Medicine, LLP, since thevery beginning, 15 years ago. She has been inthe trenches of the hard work that has con-tributed to growth and continues to be in thetrenches with her staff to get all things billingand collections accomplished.

“What makes Wendy Garza a great nomineefor this recognition is the fact that she does allof this with the best positive attitude and cankeep a smile on her face while there may be chaos in the midst, which has a calming affect for all those around her,” the practice’s physiciansand staff wrote in her nomination letter. “She has a tremendous work ethic and loyalty to this company that makes us proud that she worksfor Northeast Orthopaedics and Sports Medicine.”

Ms. Garza was selected for the December 2014 Unsung Hero award from BCMS. BCMS recognizes physicians’ office managers/administrators who assist BCMS members to deliver the best quality care to area patients.

Winners receive gift certificates and are eligible for annual prizes.To learn more, visit www.bcms.org.

visit us at www.bcms.org 29visit us at www.bcms.org 29

BCMS NEWS

TITLE SPONSORS

Thank you, BCMS 2015 Installation Sponsors

Homero R. Garza, MD, MPH(Gastroenterology), and his spouse,Chief Justice Sandee Bryan Mar-ion, 4th Court of Appeals, expressa heartfelt “Thank you” for yourcontinued support to us both.

(Back row from left) Estella Coronado, Sherri Coleman, Dr. John Chance, Unsung HeroWendy Garza, Marshall O’Dowd, Veronica Bishop and Kristina Gomez. (Front row fromleft) Brittney Fisher and Teri Graham. Courtesy photo

EVENT SPONSORS


BCMS NEWS

TMA Winter ConferenceBCMS President Jim Humphreys, MD (sitting at the end of the table, far right), ponders the issues under discussion during

the TMA Winter Conference meeting of the Council on Legislation held Jan. 30 at the TMA headquarters in Austin.

Advocacy and Legislative News

HELP WANTEDBexar County Medical Societymembers for BCMS Communications/

Publications Committee. Should have

little or no experience, be willing to

brainstorm, eat supper at the BCMS

office once each month, and partici-

pate in free-wheeling, stimulating

discussions to produce the magazine

you’re reading at this moment.

For information, call Susan Merkner at

210-582-6399.


BCMS NEWS

84th LEGISLATUREUNDER WAYFIRST TUESDAYSA SUCCESSBy Mary E. Nava, MBABCMS Chief Governmental and Community Relations Officer

Doctors, Alliance members, resi-dents and medical students joinedtheir colleagues from around the stateduring the Feb. 3 First Tuesdays visitto the Capitol. A special thanks tothe following individuals who partic-ipated: BCMS President JimHumphreys, MD; TMA Board ofTrustees member David Henkes,MD; Michael Battista, MD; DavidHolck, MD; Alex Kenton, MD;Thomas Mohr, DO; Ray Osbourn,MD; Janet Realini, MD: David Shul-man, MD; Ryan Van Ramshorst,MD; Mary Wearden, MD; BCMSAlliance President Rebecca Christo-pherson, joined by her daughter,Aiden Christopherson; Alliancemembers Cindy Comfort andDanielle Henkes; and 20 residentmembers from the University of TexasHealth Science Center San Antonio,led by Gillian Schmitz, MD.

The next First Tuesdays visit isMarch 3. If you are interested in at-tending, please visit the TMA websiteat www.texmed.org to register.

For local discussion on this andother advocacy topics, consider join-ing the BCMS Legislative and So-cioeconomics Committee bycontacting Mary Nava [email protected].

Doctors from San Antonio and New Braunfels, along with BCMS staff,pause for a photo with Sen. DonnaCampbell, MD (center) during the Feb. 3 First Tuesdays.

BCMS physicians, BCMS Alliance member and staff visit with Rep. Justin Rodriguezon Feb. 3 at the Capitol. Standing (from left) Ryan Van Ramshorst, MD; Rodriguez;Janet Realini, MD; Danielle Henkes; David Henkes, MD; Mary Nava and JimHumphreys, MD.

UTHSCSA residents listen as BCMS President JimHumphreys, MD (foreground)discusses some of medicine’s issues, as Margaret Frain-Wallace, chief of staff for Rep. Roland Gutierrez, listens Feb. 3.

Visiting with Rep. Lyle Larson during the Feb. 3 First Tuesdays visit to the Capitolare (from left) Raymond Osbourn, MD; Ryan Van Ramshorst, MD; David Henkes,MD; Mary Wearden, MD; Alex Kenton, MD; Jim Humphreys, MD; Mary Nava;Larson; and Danielle Henkes.

BCMS physicians visit with newly elected State Rep. Rick Galindo (seated atdesk), who represents House District 117,during the Feb. 3 First Tuesdays.

Representing BCMS during theFeb. 3 TMA and Border HealthCaucus news conference on Medi-caid issues is Michael Battista, MD.


UTHSCSADEAN’S MESSAGE

On any given day, there are scores of active-duty, reserve andretired military personnel at the campus of the School of Medicine— attending classes and grand rounds, conducting research,teaching and seeing patients. Besides a large number of formermilitary on our faculty, the School of Medicine has joint trainingprograms with the military in psychiatry and nephrology. Thisscene plays out over the other Health Science Center schools: den-tistry, nursing, Graduate School of Biomedical Sciences, andSchool of Health Professions. An estimated 12 percent of the totalHealth Science Center faculty and staff have military back-grounds. There are also many students (including 64 active duty)attending on military scholarships or via the Hazelwood Act,which confers certain tuition benefits to Texans.

Seeing an opportunity to strengthen the programs and relation-ships with the Department of Defense (DoD) and the VeteransAdministration – as well as look for other opportunities – Dr.William Henrich, president of the Health Science Center, createdthe Military Health Institute (MHI) in collaboration with theSchool of Medicine, and named Byron Hepburn, MD, Major

General, U.S. Air Force retired, to lead the effort. Officially begunOctober 2014, the MHI is founded on the long-standing pro-grams we already have with the Navy, Army, Air Force and theDefense Health Agency. Dr. Hepburn, who recently retired fromthe Air Force after 38 years of service, began his career as a pilotflying the C-9, which is the military version of the McDonnellDouglas DC-9, the first jet to see wide commercial use on a globalscale. The C-9 was the Air Force’s main transport vehicle for mil-itary medical evacuation for two decades.

PILOT-PHYSICIANGraduation from the U.S. Air Force Academy and a career as a

military pilot would have been an impressive resume for the offi-cer, but Hepburn also went to the Uniformed Services Universityof the Health Sciences where he received his MD. He undertooka residency in family medicine at Andrews Air Force Base, andthen returned to the Air Force Academy in Colorado Springs toserve as a physician.

As one of the few pilot-physicians in the Air Force, he was

tapped to be partof the team testingthe Boeing C-17transport plane forthe medical evacu-ation missionwhen it was firstintroduced in the1990s. The C-17Globemaster is thevery large planeoften seen in thesouthwest skiesover San Antoniomaking landingapproaches. Hep-burn eventuallyserved as the firstdirector of the San

Antonio MilitaryHealth System and as the commander of the 59th Medical Wingat Lackland, which is the Air Force’s largest. He also served as

deputy surgeon general of the Air Force, directing all operationsof the Air Force Medical Service, which includes 2.4 million cov-ered lives and 75 military treatment centers. He also will hold thetitle of Assistant Dean for Military Health in the School of Med-icine and a faculty appointment in the department of family andcommunity medicine.

All the schools at the Health Science Center – Medicine,Dentistry, Nursing and Health Professions – have educationalprograms that include a military component and most also haveresearch sponsored by, or in collaboration with, the DoD. Inthe many examples of our collaborations, the largest isSTRONG STAR, which is an acronym for the South Texas Re-search Organizational Network Guiding Studies on Trauma andResilience – a multidisciplinary and multi-institutional researchconsortium funded by the DoD and VA to develop and evalu-ate the most effective early interventions possible for the detec-

By Francisco González-Scarano, MD

U.S. Air Force Maj. Gen. (ret.) Byron Hepburn,MD, leads the Military Health Institute.



tion, prevention, diagnosis and treatment of combat-relatedposttraumatic stress disorder (PTSD) and related conditions inactive-duty military personnel and recently discharged veterans.The program is led by Alan Peterson, PhD, who retired fromthe Air Force as a lieutenant colonel, and is chief of the divisionof behavioral medicine in the Department of Psychiatry.STRONG STAR brings together a world-class team of military,civilian and VA institutions and investigators from across thecountry to address this crucial issue.

STRONG STAR is very deliberately based in Central Texas,which, with South Texas, contains one of the largest concentra-tions of Operation Iraqi Freedom (OIF)/Operation EnduringFreedom (OEF)/Operation New Dawn (OND) veterans, as wellas the DoD’s largest military medical complex, state-of-the-arttrauma research facilities and other well-established military, VAand civilian institutional collaborations. This means STRONGSTAR investigators’ expertise and innovative treatment programsare helping where they are needed most and can be optimized.

Trauma is another important area where we have a robust col-laboration. The San Antonio Military Medical Center (SAMMC)and University Hospital are both Level 1 trauma centers and part-ner in many ways. Bruce Adams, MD, chair of the Departmentof Emergency Medicine (EM), is a 27-year Army veteran whoserved as a flight surgeon for special operations. His leadershiphas been crucial in the rapid growth and the strength of the EMdepartment and its excellent integration with the military. Ourcollaborations include the SAMMC emergency medicine physi-cians working and teaching at the SOM and working in the Uni-versity Hospital emergency room. The SOM is also a primarytraining site for both their emergency medicine residents as wellas their EM physician assistants, and we train a variety of theirnurses, medics and allied health students. We also regularly holdjoint workshops at Brooke Army Medical Center and SAMMC,

and our EM department also has two active DoD-funded projectsworking on life-saving battlefield technology, as well as severalother joint research programs in various states of development.We also are conducting trauma and related research in many otherareas and departments, including the departments of surgery andneurosurgery, who also partner with other branches of the mili-tary, DoD and VA.

There are joint programs with the School of Dentistry that in-clude a master’s degree in dental sciences, with multiple specialtiesas well as partnering in endodontics, periodontics and oral maxillofacial surgery. Dr. Kenneth Hargreaves, DDS, PhD, who is chairof the Department of Endodontics, oversees a research programfocused on non-narcotic management of pain. With many servicemembers in need of pain medications to deal with injuries, highlyaddictive medications run the risk of introducing new problemsbeyond the physical injuries and PTSD. Studies with non-nar-cotic treatments are now under way with military burn patients.Another study through our Research to Advance CommunityHealth (ReACH) Center focuses on primary care and peer sup-port to improve function and pain control in veterans sufferingfrom chronic pain. Principal investigator is ReACH director Bar-bara Turner, MD, James D. and Ona I. Dye Professor of Medi-cine. The ReACH research is another illustration of how manydifferent areas there are here working on similar issues. Previousto the MHI, principal investigators/researchers had no effectiveway to know that other, related programs existed.

The School of Nursing has many active-duty and retired stu-dents in their undergraduate and graduate programs, and aunique track that takes enlisted military members as nursingstudents who then become officers or are eligible to become of-ficers upon graduation. Dr. Penny Flores, assistant professorof nursing, also has a program focused on the unique physicaland emotional challenges in the care for active-duty and former




military members.

Important outcomes of the new MHI include the creation of aMilitary Health Interest Group for students from all schools, whichwill include seminars on medical lessons learned, and encourageknowledge-sharing among the different students and disciplines.The MHI will sponsor military grant-seeker workshops for re-searchers from all schools, which will not only help share processknowledge, but also will bring together researchers from differentschools with similar interests.

TRICAREAn important aspect of patient care is also the military’s health-

care coverage, TRICARE insurance, which is fully accepted at UTMedicine and the Health Science Center. Working with TRICAREto better serve the military and retiree populations of San Antoniowill be part of Dr. Hepburn’s and the MHI’s role as well.

Dr. Hepburn also has been selected by the UT system to serveon their Defense Advisors Group and chair a Military Health Work-ing Group, which will be composed of members from each of the15 UT campuses. Having our school and university representedthere will no doubt mean more and better collaboration – between

our military partners and the broader UT system, in all of the var-

ious categories of education, research and patient care.With a complex web of cross-appointments, partnerships, col-

laborations and other relationships in patient care, teaching andresearch, the work we do with our military partners is crucial tothe advancement of all patient care. In San Antonio, the desig-nation of military or civilian does not matter when teams of like-minded physicians, nurses, emergency medical technicians orother health professionals come together with a singular focus:what is best for the patient at the very moment they need ourcare. With this focus in mind, I am proud to support and endorsethis new group charged with bringing more solidarity to all wedo with our military partners.

Francisco González-Scarano, MD, is dean ofthe School of Medicine, vice president for medicalaffairs, professor of neurology, and the John P.Howe III, MD, Distinguished Chair in HealthPolicy at the University of Texas Health ScienceCenter at San Antonio. His email address [email protected].



BUSINESS OFMEDICINE

Modern healthcare organizations are perpetually seeking to moreeffectively and efficiently provide medical services by acquiring ordeveloping human capital. Pathways to achieve higher levels ofproductivity, quality and clinical outcomes may be found in long-standing and ancient principles of development.

In 1776, while our founding fathers were creating the founda-tion of the United States in Philadelphia, across the Atlantic Oceanin Great Britain, the father of modern economics, Adam Smith,published “The Wealth of Nations,” and established the frame-work of modern human capital theory through the propositionthat investments to enhance the skills, knowledge and abilities oflabor are positively associated with economic returns in the samemanner that investments in tools, equipment or materials in theprocess of production yield revenue and profits.1

Even earlier examples of human capital development may befound in Homer’s “The Odyssey” as Mentor was entrusted togroom Telemachus, son of Odysseus, to become a leader of Greecewhile Odysseus was away from home fighting the Trojan War.Mentor served as a guide and confidant to Telemachus, and ourmodern human capital development concept of mentoring was de-rived Homer’s account of his example.2

DEFINING MENTORSThe human capital development practice of mentoring is gen-

erally characterized as the voluntary developmental relationshipbetween a mentor and a protégé to achieve enhanced personaland/or professional outcomes. Mentoring relationships may beshort-term, episodic or enduring through a life/career. Develop-ment may be provided by a single mentor or a constellation ofmentors depending upon needs of the individual. Additionally,while traditional developmental relationships based on career orlife seniority usually apply to mentor and protégé roles, modernexamples of peer or even subordinate mentoring exist based on sit-uational developmental needs of individuals.3,7

Additional consideration for human capital development andmentoring should be focused on the needs of individuals duringvarying life and career stages. Social science researchers, includingDaniel Levinson, Erick Erickson and Donald Super, have articu-lated and established frameworks for the examination of specificdevelopmental needs based on the life or career stage of an indi-vidual. In my own research, I confirmed a life/career effect on thedevelopmental needs of healthcare professionals in the applicationof mentoring. My research findings indicate that early, middle andsenior healthcare professionals have distinct preferences for devel-opment through mentoring.

Generally, early careerists seek focused training, guidance, or op-portunities to achieve competence and a foundation of valid stand-ing within an organization, society, or field. Mid-careerists seekdevelopment to extend beyond competent standing toward max-imization of their capacity to generate value and achieve career suc-cess. Finally, senior careerists want validation and confirmationthat the content and processes of past and present life/career prac-tices continue to be appropriate in contemporary settings (andthen advice or guidance on adjustments, if necessary).4,5,6,7

How might human capital development principles of mentoringand life/career stage be effectively implemented within an organi-zational setting ranging from a group practice to a comprehensivehealthcare system? Additionally, how might individual healthcareprofessionals enhance their own personal development?

Consider that effective mentoring is usually a voluntary practice.Well-intended professionals who provide a career lecture to a groupor expect that their own example of success without meaningful,dual interaction would not normally be considered mentoring, butrather providing information or serving as a model. Richer devel-opment of individuals occurs with dynamic, focused interactiondirectly between mentor and protégé. Organizations should en-courage interaction among professionals internally and externallyto create conditions in which potential protégés and mentors mayconnect on a voluntary basis and therefore, while lectures, guestspeaking and modeling are not mentoring per se, these practices,particularly when complemented with genuine offers by potentialmentors to provide personal development, can be useful elementsto human capital development. Individuals should seek to engagepotential mentors that have clearly demonstrated development thatmight be transferred through engagement, but also be mindfulthat mentoring requires time and action investments that potentialmentors may not have (particularly if heightened professional re-quirements exist and/or multiple potential protégés are seeking de-velopment).

LIFE/CAREER STAGESOrganizations and individual professionals will likely be well-

served to consider the life/career stage of potential protégés to ap-propriately tailor development opportunities, as well asdevelopmental expectations (Mentor did not teach Telemachus ad-vanced governance techniques on the first day). Early careeristswill benefit from developmental opportunities that enhance com-petencies and provide chances to participate and contribute withtolerance for failure or lack of full understanding of contextualconsiderations coupled with instruction, guidance and support.

Human capital investments through mentoring By Lee W. Bewley, PhD, FACHE



BUSINESS OFMEDICINE

Professionals at mid-career who have clearly established compe-tencies and seek developmental opportunities are often best servedwith challenging assignments, job references for advancement, andbroader authority and responsibility matched with feedback in-teraction from their mentor(s). Finally, senior careerist may findvaluable career development by seeking and recruiting mentors,potentially peers pursuing similar development or even precocioussubordinates, who will provide frank, valid, actionable feedback,and advice as needed, on the effectiveness of their own professionalactions applied in contemporary settings based on (nearly) a fullcareer of development.

The nature of healthcare delivery, predicated on the constantinteraction of people seeking and delivering services, makeshuman capital development a critical component for both orga-nizational and individual consideration. Organizations that de-velop and maintain effective human capital development processesincrease their ability to establish competitive advantages and togenerate substantial value in the market. Individuals who are ableto obtain and master progressively higher levels of developmentshould expect to enjoy a career characterized by competence,achievement and fulfillment.

REFERENCES1 Smith, Adam (2003). The Wealth of Nations (reprint). Bantam Classics. New

York.2 Homer (1961). The Odyssey. Translated by R. Fitzgerald. Doubleday. New

York.3 Kram, Kathy (1985). Mentoring at Work: Developmental Relationships in Or-

ganizational Life. Scott, Foresman, and Company. Glenview, Illinois.4 Erickson, Eric (1959). Identity and the Life Cycle. International Universities

Press. New York.5 Levinson, Daniel (1986). A Conception of Adult Development. American Psy-

chologist. 41:1. Pages 3-13.6 Super, Donald (1957). The Psychology of Careers. Harper and Row. New York.7 Bewley, Lee (2005). Seasons of Leadership Development: An Analysis of a

Multi-Dimensional Model of Mentoring Among Career Groups of UnitedStates Army Officers. Doctoral Dissertation. University of Alabama at Birm-ingham.

Lee W. Bewley, PhD, FACHE, is a retired Army of-ficer, associate professor of healthcare management, anda board-certified healthcare executive. He is a facultymember in the Walker School of Business at WebsterUniversity in St. Louis. He has served as the program

director of the Army-Baylor University MHA/MBA program and asan adjunct faculty member at the University of Texas at San Antonio,Trinity University and University of the Incarnate Word.


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“Letters of Note” has more than 125 authors, including Win-ston Churchill, Kurt Vonnegut … and his son, Beethoven,Queen Elizabeth II, Mary Stuart (Mary Queen of Scots,) thewidow of Eung-Tae Lee, Iggy Pop and many others. Whileyou’ve undoubtedly heard of many of them, there are quite a

few who were unknown even in their own times and places.Now, this isn’t a book one sits down and reads cover to cover.

It’s big, but not coffee table big, and it’s a bit too heavy to holdup and read in bed. It’s a beautiful book: The dust cover looksgood, and the layout, typography and reproductions of manyof the letters are superlative. Even the introduction is like a let-ter. Everyone I know who has started with it seems to have hadpretty much this experience: seeing it sitting there, picking itup, opening it at random, and being stuck for a while. Eachof the letters has a short introduction from the editor, ShaunUsher, that explains its provenance. The publisher has consid-erately included an attached ribbon to use as a bookmark, butfor me the random-access method was part of its charm.

LOVE, DEATH, HUMORThere is no obvious organization to the book, but there are several themes that I became aware of: love and death being two of the

most engaging, and they often appear in the same letter. The 16th century Korean widow of Eung-Tae Lee, whom I mentioned above,wrote to her dead husband: The letter was found on his chest when his tomb was discovered a few years ago. She was pregnant whenhe died, and she bemoans her fate and that of her unborn child. Katherine Hepburn’s letter to Spencer Tracy was written 18 years afterhis death. There is Virginia Woolf ’s suicide note, expressing her love for her husband, and a letter to the family of a victim of the Pan-Am airliner that crashed in Lockerbie, Scotland, from the people who found his body on their farm. At least a few caused my vision to

cloud up … age, you know.Lest you think it’s all gloom and doom, there’s a letter from Groucho Marx to Woody Allen, and Queen Elizabeth’s handwritten

letter to President Eisenhower includes her own recipe for “Drop Scones.” Three girls from Montana wrote to Ike as well, begging himnot to have Elvis Presley’s sideburns cut off when he was inducted into the Army or they “…will just die!” After the Soviets launchedSputnik, a 12-year-old Australian boy wrote to “A Top Scientist…” at the Australian rocket range with a drawing of a rocket ship, a fewlabels and the instruction that they should “…put in the details.”

The “compiler” of this collection must have put in hundreds, if not thousands, of hours researching letters from all over the world,in all kinds of collections. How else could he have located a clay tablet with incised cuneiform letters, dating from the 14th centuryBCE, that is from Ayyab, the king of the city of Atartu, to Amenhotep IV, the Egyptian pharaoh? Or how could he have known of theexistence of Mary Stuart’s letter to her dead husband’s brother, written just six hours before she was executed at the behest of QueenElizabeth I?

Here’s my ultimate recommendation: This is being written just before Thanksgiving, and I’m strongly considering buying copies ofthis entrancing book as Christmas gifts for friends and members of my family. It doesn’t get any stronger than that.

Fred H. Olin, MD, is a semi-retired orthopaedic surgeon and chair of the BCMS Communications/Publications Committee.He used to write letters, but his fountain pen broke and email came along. Pity.

BOOK REVIEW

‘Letters of Note’Compiled by Shaun UsherReviewed by Fred H. Olin, MD

Gunn Acura11911 IH-10 West

Cavender Audi15447 IH-10 West

BMW of San Antonio8434 Airport Blvd.

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North Park Subaru9807 San Pedro Ave.

Cavender Toyota5730 NW Loop 410

*Ancira Volkswagen5125 Bandera Rd.

*Volvo of San Antonio1326 NE Loop 410


“This is the Motor City, and this is whatwe do.” So said recording artist Eminem atthe end of the best car commercial of the last25 years. That momentous ad, which airedduring the 2011 Super Bowl, changed howChrysler was viewed by many people. Just asLee Iacocca’s ads did in the early 1980s, the“Imported From Detroit” Eminem commer-cial told customers to take Chrysler seriously,not pity them.

Given how moving the ad was, it hardlymattered that the car it featured, the firstgeneration Chrysler 200, wasn’t very good.The point was to change how Chrysler wasviewed by car buyers, and, not incidentally,Chrysler employees.

‘AD CHANGED OUR LIVES’In fact, a few months ago I had the chance

to talk with two Chrysler engineers who toldme that that ad changed their lives. It madethem believe in the company again and in-spired them to work extra hard on the secondgeneration 200 to ensure that it was worthyof the commercial.

That car, the all-new 200, wasintroduced earlier this year andis massively better than its pred-ecessor.

It certainly looks better. Sporting a flowingroofline, sculpted front and rear ends, and

numerous nicely integrated styling elements,the 200 is undeniably handsome. My re-viewer’s eyes told me, “Well done, but I seemore Hyundai Sonata in the profile and tail-lights than I’d like,” but my neighbors andcoworkers all said something like, “Wow!Nice — what is it?” No one ever said thatabout the previous Chrysler 200.

The interior is even better than the exte-rior. Inconsistent describes most Chrysler in-teriors over the past several years, andthankfully that’s not the case with the 200.The materials are good everywhere, and thereare some nice highlights such as attractiveblue lighting, buttons and knobs where youwant them, and a cool storage area under the

AUTO REVIEW


Chrysler 200CFrom near-obscurity to a competitive sedanBy Steve Schutz, MD

slide-away cup holders. I couldtake or leave the Jaguar knock-off

rotary shift knob, but I suspectmost owners will like it, and itdoes provide a touch of class in amarket segment that’s generally fo-cused on utility.

It should be noted that the optionalUConnect user interface, which syncs witha smartphone and controls the audio, HVACand satnav systems via a front-and-centertouch screen, is best in class. It’s easy, and itworks.

Best in class does not describe the drive-train, however. You’d think a 9-speed trans-mission would be an ideal way to get the fueleconomy of a CVT and the drivability of a6-speed automatic. But in this case you’d bewrong. While this transmission does helpwith fuel efficiency — we’re talking 18 mpgcity, 29 mpg highway with the 3.6-liter V6and AWD which my 200C test car had —drivability is disappointing because the trans-mission hunts for gears more than it should,even during ordinary driving on suburbanroads. These days fixing this sort of problemmostly involves tweaking software, but sinceevery engine/transmission software changecarries significant emissions and fuel-econ-omy implications, those changes are nevermade quickly.

Handling is surprisingly good for a 3,473-pound sedan with most of its weight over thefront wheels. I credit enthusiastic engineerslike the ones I mentioned earlier, who wereeager to show me exactly what they did withthe suspension, steering and braking systemsto make the 200 as fun to drive as possible.They succeeded.

The Chrysler 200 comes standard with a2.4-liter 4-cylinder engine rated at 184 HP,while the optional V6 engine like the one inmy test car provides 295 HP. Front-wheeldrive is standard, and all-wheel drive is a V6-only option.

FOUR TRIM LEVELS AVAILABLEThe Chrysler 200 is available with four

trim levels: LX, Limited, S, and C, and amultitude of options.

The LX doesn’t get you much, but it doesinclude keyless ignition and entry. Why abase Chrysler 200 comes standard with thissuper-handy feature, while buyers of$100,000-plus cars like the Mercedes SL andPorsche 911 Turbo have to pay extra for it isbeyond me.

Anyway, the 200 Limited has alloy wheelsand other enhancements. The S, which is thesporty 200, comes with all of the Limited’sequipment plus suspension upgrades andother goodies. The top-of-the-line 200C isthe most luxurious 200 and comes loaded.

Notable options are an 8.4-inch touch-screen, smartphone app integration, text-to-voice capability for compatible phones,blind-spot warning, adaptive cruise control,frontal collision warning, lane departurewarning, automatic high-beam control, andrain-sensing windshield wipers. In the not-too-distant past many of those options couldbe found only on top-of-the-line Germansedans and Lexuses. How far we have comewith our automotive tech.

Four years ago, Chrysler was an almost-ir-

relevant car company that many industry ob-servers like me had written off. Thanks to in-spired leadership, can-do employees, and akick-ass commercial for the ages, Chrysler isgrowing impressively. As long as they con-tinue to make vehicles like the 200C, theirwinning streak will continue.

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

Force. He has been writing auto reviews for SanAntonio Medicine since 1995.

For more information on the BCMSAuto Program, call Phil Hornbeak at 301-4367 or visit www.bcms.org.

AUTO REVIEW


san antonio medicine march 2015

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