san antonio medicine march 2016

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MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • MARCH 2016 • VOLUME 69 NO. 3

EMERGENCYMEDICINEZIKA VIRUSRESPONSE

4 San Antonio Medicine • March 2016

Emergency MedicineZika Virus: An Emerging Public

Health Threat? By Patrick S. Ramsey, MD, MSPH.......................12

The Zika Virus: Pregnant Women andWomen of Reproductive AgeBy Herbert Guzman, MD, OB/GYN .....................16

The Future of Emergency MedicineBy Mike W. Thomas .........................................18

Preparing for Events They Hope WillNever ComeBy Mike W. Thomas .........................................20

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

BCMS Legislative News................................................................................................................10

Non Profit: The Boerne Education Foundation..............................................................................24

Lifestyle: Coffee By Julie Catalano ..........................................................................................................26

Around the Block By Dr. Adam Ratner ....................................................................................................28

Legal Ease: Who’s Responsible Besides the Criminal? By George F. “Rick” Evans, Evans, Rowe & Holbrook..........................................................................30

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

Business of Medicine: Market Dynamics in the Wake of the Patient Protection andAffordable Care Act By Lee W. Bewley, Ph.D, FACHE .........................................................................35

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

Book Review: Comprehensive Financial Planning Strategies for Doctors and Advisors .......................42

Auto Review: 2016 Range Rover, By Steve Schutz, MD .........................................................................44

MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • MARCH 2016 • VOLUME 69 NO. 3

SAN ANTONIO

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BOARD OF DIRECTORS

OFFICERSJayesh B. Shah, MD, PresidentSheldon Gross, MD, Vice PresidentLeah Jacobson, MD, President-electJames L. Humphreys, MD, Immediate Past PresidentGerald Q. Greenfield Jr., MD, PA, SecretaryAdam V. Ratner, MD, Treasurer

DIRECTORSRajaram Bala, MD, MemberJorge Miguel Cavazos, MD, MemberJosie Ann Cigarroa, MD, MemberKristi G. Clark, MD, MemberJohn W. Hinchey, MD, MemberJohn Robert Holcomb, MD, MemberJohn Joseph Nava, MD, MemberBernard T. Swift, Jr., DO, MPH, MemberFrancisco Gonzalez-Scarano, MD, Medical School RepresentativeCarlos Alberto Rosende, MD, Medical School RepresentativeCarlayne E. Jackson, MD, Medical School RepresentativeJennifer Lewis, BCMS Alliance PresidentRoberto Trevino Jr., MD, Board of Censors ChairJesse Moss Jr., MD, Board of Mediations ChairGeorge F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTORStephen C. Fitzer

CHIEF OPERATING OFFICERMelody Newsom

Mike W. Thomas, Director of CommunicationsAugust Trevino, Development DirectorBrissa Vela, Membership DirectorAlice Sutton, Controller

COMMUNICATIONS/PUBLICATIONS COMMITTEERajam S. Ramamurthy, MD, ChairKenneth C.Y. Yu, MD, Vice ChairFred H. Olin, MD, MemberEsmeralda Perez, Community MemberDavid Schulz, MemberJ.J. Waller Jr., MD, Member

Are you a physician who has to save charting until the end of

the day? Or until your office staff has left for the day, and you

are still finishing up your charting till late in the evening? And

by the time you reach home, your kids are already asleep and

your spouse is upset because you came home late again? And then

you still have to log on from home for a couple more hours to

finish up charting?

My physician friends, if you are in any one of these scenarios,

you are not alone.

This year, in the Medscape Physician Lifestyle Report, 46 per-

cent of all physicians responded that they have experienced

burnout, which is a substantial increase since the Medscape 2013

Lifestyle Report, in which burnout was reported by slightly fewer

than 40 percent of respondents.

Every time there is a survey of a group of physicians asking,

“What are the top three reasons in your practice day that makes

your life difficult and increases your feeling of burnout?”, elec-

tronic medical records or EMRs and other documentation issues

ALWAYS make the list. This is true regardless of specialty without

exception. An EMR is a digital version of a paper chart that con-

tains all of a patient’s medical history from one practice and is

used by providers for diagnosis and treatment.

The problem with EMR is that it is designed by people who

have never seen a patient. EMR and other documentation issues

continue to cause a huge burnout problem for a significant num-

ber of doctors. It has forced many doctors to retire early because

of continued frustrations.

Let us help these struggling doctors collectively. Let us ask each

hospital system and physician practice to find out doctors who

are working on documentation till late in the evening or from

home at night. I am sure there are doctors in each hospital and

in each specialty who finish their work on time and are able to

leave the clinic at the same time when their last patient is seen.

It is important that physician leaders who are doing well with

EMR help other colleagues who are struggling to decrease physi-

cian burnout. All physicians should be able to go home on time

and spend quality time with their family so that they can recharge

their batteries for a brighter next day.

Let your physician colleagues know if you are struggling with

EMR. It may not be a bad idea to hire a scribe or try voice-recog-

nition software such as Dragon. Let EMR not be the reason for

your burnout. Bexar County Medical Society has a physician re-

habilitation committee that works with physician burnout issues.

Texas Medical Association also has several programs to help with

physician burnout issues.

Physicians deserve to be healthy and happy so that they can

provide good health care for the community.

Stay well!

With Regards,

Dr. Jayesh Shah

PRESIDENT’SMESSAGE

Physician Burnout &Electronic Medical RecordsBy Dr. Jayesh Shah, 2016 BCMS President



BCMS LEGISLATIVENEWS

On Feb. 4, Drs. Alex and Candace Kenton hosted a reception in their home honoring Texas House Speaker Joe Straus (District

121). Many thanks to all who turned out in support of Speaker Straus. Among the attendees at the TEXPAC-sponsored event were:

Kaashif Ahmad, MD; Michael Battista, MD; Delbert Chumley, MD; Louise Chumley, BCMS Alliance; Pam Hall, MD; David

Henkes, MD; Danielle Henkes, BCMS Alliance; John Hinchey, MD; John Holcomb, MD; Scott Kercheville, MD; David Lam, MD;

Jesse Moss, Jr., MD; Janet Realini, MD; Jay Shah, MD; David Shulman, MD; Christina Stine, MD; Bernard Swift, Jr., DO; Mary

Wearden, MD and Mark Welborn, MD.

BCMS physicians and Alliance members attend reception in honor of

Texas House Speaker Joe StrausBy Mary E. Nava, MBA, Chief Government Affairs Officer, Bexar County Medical Society

1

3 54

2

Photo captions: 1. Enjoying the reception for House Speaker Joe Straus on Feb. 4 were (l-r): Michael Battista, MD, Jesse Moss,Jr., MD, Straus and Alex Kenton, MD. 2. BCMS physician members and Alliance members pause for a photo with House SpeakerJoe Straus on Feb. 4. 3. In attendance at the Feb. 4 reception honoring Speaker Joe Straus were (l-r): Mary Wearden, MD; MichaelBattista, MD; Hanoch Patt, MD; Alex Kenton, MD; Straus; Christina Stine, MD; David Lam, MD; Todd Schamberg, MD andKaashif Ahmad, MD. 4. BCMS president, Jayesh Shah, MD with Speaker Joe Straus on Feb. 4. 5. Drs. Alex and Candace Kenton,event hosts, stand with their daughter, Victoria and House Speaker Joe Straus on Feb. 4.


EMERGENCYMEDICINE

Over the past several months, growing concerns have emerged re-

garding the Zika virus and potential public health risks, especially

with potential perinatal risks. Observations from a major outbreak

in Brazil have suggested an increased incidence of a rare birth defect

known as microcephaly with Zika virus infection. Zika infection

has also been associated with Guillain Barre’ syndrome,

a form of ascending motor paralysis.

In early February 2016, the World Health Or-

ganization declared the Zika pandemic an “In-

ternational Public Health Emergency of

International Concern,” only the fourth time

such a declaration has ever been made by the or-

ganization. The Centers for Disease Control and

Prevention have also issued Level 2 Travel Advi-

sories to countries with a Zika outbreak and interim

guidelines for management related to Zika virus. While it

is not known at this time what the true association is between Zika,

fetal microcephaly and Guillain-Barre’ syndrome, public health and

health care professionals need to be acutely aware of the evolving

issues related to Zika and be prepared to address patient concerns

and initiate testing when indicated.

What is the Zika virus?The Zika virus is an enveloped single-stranded RNA arbovirus in

the Flavivirus genus which is transmitted to humans primarily

through the bites of infected via Aedes mosquitoes, usually Aedes

aegypti or Aedes albopictus. The virus was originally identified in

1947 in the Zika Forest of Uganda and for many decades was not

thought to be a significant pathogen. With the past decade, however,

several outbreaks have occurred, first in Yap Providence in Microne-

sia (2007) and most recently in Brazil. The recent concerning asso-

ciation with Zika virus infection and severe fetal microcephaly, and

possibly Guillain-Barre’ syndrome has prompted the international

concern regarding the virus.

What are signs and symptoms of Zika infection or “Zika Fever”?

The incubation period for the Zika virus is between 3 and 12

days. 80 percent of those infected with Zika are asymptomatic. In

the remaining 20 percent, mild non-specific symptoms may develop

(acute onset of fever, maculopapular rash, arthralgia, or conjunctivi-

tis) which typically resolve within 2-7 days. If two or more of the

above symptoms are present, illness is considered consistent with

Zika virus disease and additional testing in pregnant

women.

How is Zika Transmitted?The Zika virus is transmitted primarily by mos-

quitos from the Aedes genus. The Aedes mosquito

is found in Texas and throughout much of the

southern United States and is also the same genus

of mosquitos that transmits Yellow Fever, Dengue

Fever, and Chikungunya. The Pan American Health Or-

ganization has warned that Zika virus could continue to

spread throughout the Americas, and potentially local areas in the

United States.

Several cases of sexual transmission of Zika have been described

including the recent case in Dallas County, Texas. Evidence suggests

that the Zika virus can persist in seminal fluid for up to 10 weeks

following illness. In some of these cases, hematospermia and pro-

statitis were present in the male partner.

Concerns have been raised regarding the potential risk of Zika

transmission via blood transfusion. In a 2007 Zika outbreak in

French Polynesia, 3 percent of asymptomatic blood donors were

found to be positive for Zika virus. Several cases of transmission via

blood transfusion have also been documented outside of the United

States. Because of this concern, American Red Cross has recom-

mended that potential donors who have traveled to one of the af-

fected countries, self-defer, or postpone blood or platelet donations

for at least 28 days following their travel.

What are the concerns for pregnant women andtheir partners?

For most people, Zika infection is a minor self-limited, mild ill-

ness. The concern for Zika is primarily with pregnant women given

the potential association with fetal microcephaly. Original observa-

ZIKA VIRUS:An Emerging Public Health Threat?

By Patrick S. Ramsey, MD, MSPH

EMERGENCYMEDICINE

visit us at www.bcms.org 13

tions from the outbreak which started in Brazil in 2015, noted a

large surge in the cases of fetal microcephaly from an annual inci-

dence of 0.05/1000 live births in 2010-2014 to over 1/1000 live

births in 2015. Small numbers of cases have documented evidence

of Zika vertical transmission to the fetus. Zika virus RNA has been

identified in fetal tissue from early missed abortions, amniotic fluid,

term neonates and the placenta.

Much is still unknown about the potential risks for Zika virus in-

fection in pregnancy. Some questions include: Is there a clear plau-

sible pathophysiology, is there a specific gestational age range at risk,

are there clinical co-factors which influence risk, are there any long-

term risks of maternal infection, etc? Preliminary reports from

Colombia have noted 2,100 cases of Zika infection in pregnancy,

yet at this time, no reported increased rates of microcephaly have

been noted. Much research is ongoing at this time to delineate these

issues, however, until we have a better understanding of these issues

and the true risk potential, making informed management decisions

following potential Zika exposure or actual infection is challenging.

In addition to the concern for microcephaly, early reports from

French Polynesia and others have suggested potential association be-

tween the Zika virus with Guillain Barre’ syndrome. The relation-

ship between Zika and this neurologic condition remains to be

defined and likely not isolated to pregnant women.

Emerging concerns exist regarding the documented cases of sexual

transmission and risks to pregnant women and women considering

pregnancy in the future. We know today that Zika virus is cleared

from the bloodstream by one week but may persist in seminal fluid

for up to 10 weeks following illness. Partners of pregnant women

who travel to a Zika-endemic country are advised to practice safe

sex and take precautions for the remainder of the pregnancy. No

clear guidelines presently exist to guide counseling or recommenda-

tions for future pregnancies.

How to prevent Zika infection?There is no vaccine for Zika virus at this time and will likely be

years in the making. For now, avoiding exposure is the most effective

approach to prevent infection. Pregnant women are advised to avoid

travel to areas where Zika is endemic. These areas include Mexico,

parts of South America and much of Central America and

Caribbean. An updated list of affected countries can be found on

the CDC website (www.cdc.gov/zika).

If travel to one of the affected countries is unavoidable, pregnant

women traveling to countries with reported Zika virus infection

should avoid contact with mosquitos by staying inside or in a

screened-in area. Long-sleeved shirts and long pants should be worn

and treated with permethrin and use of mosquito repellent with

DEET (N,N-diethyl-m-toluamide), picaridin, oil of lemon euca-

lyptus (OLE) or IR3534 should be used regularly when outdoors.

These measures can be used safely during pregnancy.

While there have been a number of cases of Zika diagnoses in

Texas, including at least one in Bexar County so far, all but one of

these cases was acquired from travel outside of the United State and

the last case was acquired by sexual transmission from an individual

who traveled outside of the United States. Because the mosquito

vector, Aedes species of mosquito are found throughout South Texas,

local outbreaks may be possible. Locally measures in San Antonio

and South Texas are being put in place to coordinate community

mosquito control. Individuals can assist in these measures by remov-

ing containers with stagnant water, such as old tires, barrels, which

can serve as a mosquito breeding ground.

What should health providers do? All health care providers caring for pregnant women should ask

their patients about recent travel. Current CDC guidelines recom-

mend Zika testing for all pregnant women who have traveled to one

of the countries where Zika is endemic (SEE FIGURE page 14).

Testing can be offered to pregnant women without symptoms any-

time between two and 12 weeks following travel. If performed, test-

ing should include Zika virus IgM, and if IgM test result is positive

or indeterminate, neutralizing antibodies evaluated on serum spec-

imens. For pregnant women presenting with clinical illness sugges-

tive of Zika, testing can include Zika virus reverse

transcription-polymerase chain reaction (RT-PCR), and Zika virus

immunoglobulin M (IgM) and neutralizing antibodies on serum

specimens. Testing can be coordinated through the San Antonio

Metropolitan Health District and the State Health Department.

Providers should evaluate their local clinic/hospital environment and

develop processes to facilitate testing.

In pregnant women who test positive or inconclusive for Zika in-

fection, serial prenatal ultrasound assessments every 3-4 weeks are

recommended to assess for development of microcephaly or intracra-

nial calcifications. Consideration of amniocentesis is also recom-

mended in these cases to test for Zika virus with RT-PCR testing.

In pregnant women with negative testing for Zika, a baseline pre-

natal ultrasound is recommended to assess for the above abnormal

findings. When these are absent, the CDC currently recommends

resumption of routine prenatal care. If abnormal findings are pres-

ent, retesting of the mother and consideration of amniocentesis is

recommended. The Society of Maternal-Fetal Medicine has issued

clinical guidance for microcephaly diagnosis recommending that

Continued on page 14


EMERGENCYMEDICINE

isolated fetal microcephaly should be defined as fetal head circum-

ference >3 SD or more below the mean for gestational age on peri-

natal ultrasound and that certain diagnosis of pathologic

microcephaly is considered certain when the fetal HC is > 5 SD.

Providers should be aware that different evaluation/management

algorithms are in place for pregnant women who live in endemic

areas. This algorithm can be found on the CDC website. Other

pregnancy considerations include cases of miscarriage or stillbirth

in women with suspected or diagnosed Zika virus infection. In these

cases, fetal remains and placenta should be sent to pathology for

evaluation for presence of Zika virus. The capacity to breast feed is

also an issue that has been questioned. Although the presence of

Zika in breast milk has been reported, it is in very small amounts

and unlikely to be harmful for the neonate. The benefits of breast-

feeding likely outweigh the potential neonatal risks. Therefore, cur-

rently the recommendation is that women should continue to

breastfeed.

For partners of pregnant women who have traveled to one of the

affected countries, because of the concern for possible sexual trans-

mission, current CDC guidelines recommend consideration of ab-

staining from sexual activity or using condoms consistently and

correctly during sex.

For women or their partners considering pregnancy, there are no

clear guidelines to base care at this time. There is no evidence avail-

able at this time to suggest that Zika virus, after it has cleared from

the blood, poses a potential risk of birth defects in future pregnan-

Continued from page 13

FIGURE 1. Updated interim guidance: testing algorithm for a pregnant woman with history of travel to an area with ongoing Zika virustransmission (Source: Oduyebo T, Petersen EE, Rasmussen SA, et al. Update: Interim Guidelines for Health Care Providers Caring forPregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure — United States, 2016. MMWR Morb MortalWkly Rep 2016;65(Early Release):1–6.)

EMERGENCYMEDICINE


cies. It is known that Zika virus is cleared from the blood in about

one week and up to 11 weeks in semen. The CDC recommends that

the patient discuss their pregnancy intentions and planned travel

with their provider.

What’s next?Unfortunately at this time, there are no available treatments nor

vaccine available against the Zika virus. State and local health de-

partments are rapidly working to develop processes to streamline

testing for Zika either through the CDC or in state or local labora-

tories. The National Institutes of Health and Human Services has

increased funding for all levels of research to explore the public

health and perinatal implications of Zika.

As of Feb. 17, 2016, the CDC has documented 82 cases of

travel-associated cases of Zika with no cases of locally acquired vec-

tor-borne cases. Cases documented in the United States will likely

continue to climb with increased media attention and screening.

As summer approaches in San Antonio and South Texas, it is pos-

sible that we may see local outbreaks here in the region given the

presence of the mosquito vector here. The San Antonio Metropol-

itan Health District, in conjunction with the State Health Depart-

ment and CDC, is prepared and poised to address issues as they

arise. For now the best approach is to implement mosquito control

efforts (removal and/or treatment of potential mosquito breeding

areas) and personal protection against mosquito bites with use or

repellants and other measures.

Patrick S. Ramsey, MD, MSPH is Professor and Ma-

ternal-Fetal Medicine Specialist in the Department of

Obstetrics & Gynecology at the University of Texas Health

Sciences Center at San Antonio where he serves as the

Medical Director for Maternal Transport and Outreach

and Director of the Maternal-Fetal Medicine Fellowship Training Pro-

gram. He practices at UT Medicine, the faculty practice of the School of

Medicine at the UT Health Science Center San Antonio. He cares for

women with complicated high risk pregnancies and delivers at Univer-

sity Hospital, the Health Science Center’s clinical partner.

Updates on Zika Virus can befound on the CDC website(www.cdc.gov/zika)

ZIKA VIRUS FACTSThe U.S. Centers for Disease Control and Pre-

vention has issued a travel alert for Mexico, theCaribbean, and Central and South America,where Zika virus is circulating. The virus has beenlinked to birth defects, and the CDC is advisingpregnant women to postpone travel to affectedcountries.

What is Zika virus? Zika is a mosquito-borne virus named for the

forest in Uganda where it was discovered.

How is it spread?The Zika virus is transmitted to people by the

Aedas family of mosquitoes. It can be transmittedfrom an infected mother to her child during preg-nancy and delivery.

What are the symptoms? Symptoms can include fever, rash, joint pain

and conjunctivitis, or red eyes. The illness, Zikavirus disease (sometimes called Zika fever) isusually mild and can last three to 12 days. No vac-cine or treatment currently exists.

What is the risk to pregnant women? Women infected with the Zika virus during

pregnancy have been linked to birth defects andpoor birth outcomes, especially microcephaly (anunusually small head size and incomplete braindevelopment), fetal death and Guillain-Barresyndrome.

Travelers to affected areas should avoid mos-quito bites by staying indoors as much as possi-ble, using a DEET-containing repellant (safe foruse in pregnancy), and covering exposed skin.Protective measures should be used throughoutthe day, at dusk and dawn.

What countries are affected? SOUTH AMERICA: Bolivia, Brazil, Colombia,

Ecuador, French Guiana, Guyana, Paraguay, Suri-name, Venezuela; NORTH AMERICA: Mexico;CENTRAL AMERICA: El Salvador, Guatemala,Honduras, Panama;

CARIBBEAN: Barbados, Guadeloupe, Haiti,Martinique, Saint Martin; OTHER Puerto Rico,Samoa, Cape Verde.


EMERGENCYMEDICINE

The Zika virus infection is a result of the transmission of a virusprimarily through mosquito bites. In November 2015 a possibleassociation between the mosquito bite transmission of the Zika virusin pregnant women and microcephaly was identified in Brazil.

The Zika virus continues to receive top billing in the media be-cause of its connection to this serious birth defects and other abnor-malities of the brain and eye. Though Brazil has had a significantoutbreak of the Zika virus for almost one year and has noted an in-crease in babies with this disorder during this time, the CDC (Cen-ters for Disease Control and Prevention) cites more studies areneeded to determine the degree to which Zika might be linked.

What is microcephaly?Microcephaly is a congenital birth defect where the head of the

child is smaller compared with other children of the same age andsex. Usually it is associated with:• Developmental delays• Seizures• Hyperactivity• Mental Retardation

At the time of this article, Bexar County had reported three sus-pected Zika virus exposures in pregnant women. Most infectionsare asymptomatic, and symptomatic disease is generally mild withpatients not sick enough to go to the hospital. The most commonsymptoms of Zika virus disease include fever, rash, joint pain, muscle

pain, headache and conjunctivitis, with patients very rarely dyingof Zika.

Though there is currently no evidence to suggest that Zika virusinfection poses a risk of birth defects for future pregnancies, it is im-portant for physicians to discuss the risks associated with Zika beforewomen wanting to become pregnant actually travel to areas sus-pected of having Zika. The Zika virus usually remains in the bloodof an infected person for about a week, though Zika virus has beenfound in semen for up to two weeks.

The virus will not cause infections in a baby that is conceivedafter the virus is cleared from the blood.

Treating pregnant patients with ZikaIf you suspect a pregnant patient may have Zika, it is suggested

you do a blood test to look for Zika or other similar viral diseases,like dengue or chikungunya. If confirmed, the CDC suggests thefollowing treatment of symptoms:• Have patient get plenty of rest. • Have patient drink fluids to prevent dehydration. • Prescribe medicine such as acetaminophen (Tylenol®) to reduce

fever and pain. • Do not allow patient to take aspirin or other non-steroidal anti-

inflammatory drugs. • Assess patient’s condition if they are taking medicine for another

medical condition before prescribing medication for Zika symp-toms.

THE ZIKA VIRUSPregnant Women and

Women of Reproductive AgeBy Herbert Guzman, MD, OB/GYN at Metropolitan Methodist Hospital


EMERGENCYMEDICINE

Preventing ZikaBecause the Zika virus may be spread from a pregnant woman

to her unborn baby, the CDC and the American Congress of Ob-stetrics and Gynecology (ACOG) recommend delaying travel toareas where there are active Zika cases. At this time, Zika virus inthe U.S. has only been associated with people who have traveledto the affected areas. (see CDC website for locations atwww.cdc.gov)

If the patient must travel to affected areas the CDC and ACOGrecommend: • Environmental Protection Agency (EPA) insect repellents with

DEET (not contraindicated during pregnancy).• Have patient avoid exposed skin by wearing long sleeves and

long pants.• Pregnant women with partners exposed to the virus should ab-

stain from intercourse or use condoms.• Do not leave standing water around the house that may pro-

mote mosquito breeding.• Remain in air-conditioned areas and indoors if traveling in one

of the affected areas.

What if a patient is exposed to the Zika virus?At this time there are no vaccines or specific treatments for the

Zika virus. Supportive treatment of symptoms include hydration,rest and analgesics. Avoid the use of NSAIDs and aspirin.

Let patients know that once exposed to the virus, it is very im-portant to communicate with their prenatal care provider, espe-cially if they develop symptoms associated with Zika such as fever,rash, joint pain, or red eyes during their trip or within two weeksafter traveling to a region where Zika has been reported.

Prenatal providers may suggest testing for the Zika virus andthe use fetal ultrasounds to detect development of microcephaly.

Zika virus testing is currently very limited. At this time, theZika virus is so new that we are still learning new ways of trans-mission and how to prevent it every day.

More information for physicians and other health careproviders can be found on the Zika virus Information forHealth Care Providers website at www.cdc.gov or at theMethodist Healthcare System Zika CDC microsite at www.sa-health.com/service/zika-virus.

Dr. Herbert Guzman is on the staff at Metropolitan MethodistHospital where he served as chief of the OBY/GYN Departmentin 2013-14.


EMERGENCYMEDICINE

If someone walks into an emergency room and collapses, theirsurvival may depend on how rapidly doctors can diagnose their con-dition and effect the right treatment.

Did they have a heart attack? Then they need a certain kind oftreatment before being sent to a cardiologist.

Did they suffer a stroke? Then they may need a different kind oftreatment and should be sent to a neurologist.

Or maybe they collapsed due to blood loss from a gunshot woundor any number of other medical conditions.

Emergency medicine is all about the acute care that is deliveredin those first few minutes of medical trauma and the decisions thedoctors make in those moments can make a critical difference in theoutcome of a patient’s condition.

At the University of Texas Health Science Center at San Antonioa new program is underway to train medical interns to becomeemergency care physicians. Dr. Bruce Adams, professor and chairof the Department of Emergency Medicine at the Health ScienceCenter, said the new Emergency Medicine Residency Program isdedicated to providing an excellent educational environment whichwill prepare graduates to successfully complete the American Boardof Emergency Medicine certification exam and help them enter thecareer pathway of their choice.

“We are still just at the beginning of a period of exciting changeand tremendous growth for emergency medicine here in SouthTexas,” Adams said. “In just three years we transitioned from a clin-ical division to a full academic department recognition by the Uni-

THE FUTUREOFEMERGENCYMEDICINEBy Mike W. Thomas

EMERGENCYMEDICINE


versity of Texas; started a major residency; started a core clerkshipfor over 200 students per year and now look forward to opening anew Pediatric Emergency Room in 2016.”

This is the first civilian emergency medicine residency programin South Texas and it is being overseen by Dr. Andrew Muck, an

assistant professor in the department. After launching three yearsago, they are preparing for their first batch of 10 graduates laterthis summer.

Emergency medicine has gotten a big boost in recent years fromnew technologies and is exploding as a specialty in the medical field,Muck said. Portable ultrasound equipment is making it possible fordoctors to make rapid diagnoses of patients in emergency situations.

“These are exciting times with all the new technological advance-ments,” he said. “We are one of the first labs to train all of our stu-dents in the use of ultrasound equipment.”

In the hands of a trained individual, the portable ultrasoundequipment can be used to quickly rule out certain life-threats, Mucksaid, making sure there is not an aortic aneurism or some other se-rious internal condition.

“If I can look at those things quickly it can make a big differ-ence to the patient,” he said. “We are essentially diagnosticianswho are responsible for triaging patients and getting them to thebest specialty.”

Another new technology, developed right here in San Antonio,that is benefiting emergency medicine is the EZ-IO IntraosseousVascular Access System which provides fast vascular access for thedelivery of essential medications and fluids.

Muck, an Air Force veteran who did a tour in Afghanistan, has

helped to train the students to work in extreme conditions of hotand cold weather. The program has conducted training exercises atlocal parks with simulated explosions and shootings where the stu-dents had to react to situations in different environments.

Muck said that the life of an emergency medicine doctor is notlike what you see on TV with the constant excitement and glamor.The most common ailments they see regularly are for chest and ab-dominal pains, broken bones and sprains and the occasional skinrash. But Muck said the thing the doctors pride themselves on themost is when they can make that difficult diagnosis that helps tosave a patient’s life.

“The symptoms don’t read the textbooks,” Muck said. “That iswhat we teach our students. We train them to not miss those subtlepresentations of a life-threatening disease.”

Mike W. Thomas is the director of communications for the BexarCounty Medical Society and editor of San Antonio Medicine magazine.


EMERGENCYMEDICINE

San Antonio’s Emergency Preparedness Division employees have

had it pretty easy for the last several years and for that they count

themselves lucky.

Tasked with overseeing the city’s response to major catastrophes

– hurricanes, tornadoes, fires, natural disasters, disease outbreaks,

and more – they have had plenty of time to plan and prepare since

the last major events to hit San Antonio. That was the H1N1 virus

outbreak in 2009-10 and hurricanes Ike and Gustav in 2008.

“We have been very fortunate lately,” said George Perez, senior

management analyst. “We have dodged a lot of bullets these past

few years.”

Currently, the division is preparing for a possible outbreak of the

Zika virus that has been causing problems in other parts of the globe.

But regardless of whether there is ever an outbreak here, the goal is

to have a plan of action just in case.

“Failure to plan is a plan to fail,” Perez quipped.

If and when one of these plans has to be put in place, Perez

said, they rely on coordinating a host of volunteers to get things

done. Their Medical Volunteer Coordinating Center is designed

to get an army of volunteers roused and in place in the event of

any kind of emergency.

“We must rely on volunteers,” said Evelyn Garza, special activities

coordinator. “We need medical professionals to man our shelters

and conduct our screening programs. We don’t have any doctors on

staff and so it all must be done by volunteers.”

Garza said they work closely with the Bexar County Medical So-

ciety to find doctors willing to volunteer their time and services in

the event of a crisis. Soon they will also be working closely with

medical students at University of the Incarnate Word when the

school opens its medical campus at Brooks City Base next door to

the city’s Emergency Preparedness offices.

Perez said San Antonio has an excellent reputation for emergency

preparedness and has been recognized nationally for its emergency

response systems. San Antonio is typically the go-to city for many

PREPARING FOR EVENTSTHEY HOPEWILL NEVER COMEBy Mike W. Thomas


EMERGENCYMEDICINE

people evacuating the Texas

coastline during a hurricane.

“Historically, all roads lead

to San Antonio,” Perez said.

“Our hotels fill up quickly

during those times and we

have to be prepared for the

overflow and the people who

can’t afford other accommo-

dations. But we don’t turn

anyone away regardless of

where they come from.”

The following Q&A gives a good overview of San Antonio’s Emergency Preparedness vision:

In a nutshell: The Public Health Emergency Preparedness (PHEP)

Division is called upon to support response activities umbrellaed

under the public health initiative.

What is Metro Health prepared to do in an emergency?

Access and coordinate the necessary resources in response to all-

hazards events, from flooding, hurricane, disease outbreaks, biolog-

ical and natural occurring health related events.

What kind of capabilities do you have at your dis-posal in case of an emergency?

We will respond with a coordinated All-Hazards Plan with all the

different levels of government and with governmental and non-gov-

ernmental partnerships locally. We are fully equipped with our 44

foot Mobile Medical Response Unit (MMRU) that can be used as

a medical station or office while responding to an event. We are also

equipped with eight (8) trailers stocked with durable medical equip-

ment and a wide array of medical supplies. We can also call on our

local, regional and state partners in the event we need support with

any all-hazards response.

What are Metro Health’s responsibilities underthe law in case of an emergency?

As indicated by the National Response Framework, MH is re-

sponsible for Emergency Services Function – 8 (ESF) Health and

Medical for San Antonio/Bexar County. We have the duty to warn

and protect our community and visitors within our jurisdiction. We

would be called upon to respond by our local health authority the

San Antonio Metropolitan Health District (SAMHD) Director of

Health, our Mayor, County Judge, Region 8 Director of Health,

Department of State Health Services (DSHS), The Governor, and

Homeland Security Presidential Directive/ HSPD 8.

What’s the number one thing folks shouldknow/do about preparedness?

“The GOLDEN RULE” Always stay informed during emer-

gencies and follow all recommendations/safety tips provided by

the authorities.

Before any disaster, formulate a plan. Decide where you will go if

you must leave. Put together a supply kit, emergency contact list,

and an important document container. Be prepared to have re-

sources at your disposal to sustain you/your family, and pets for a

minimum of (72) hour. The list attached is a good start to building

your family Emergency Preparedness disaster Plan/Supply Kit.

For more information:• http://emergency.cdc.gov/preparedness/kit/ disasters/• www.medicalreservecorps.gov

Mike W. Thomas is the director of communications for the BexarCounty Medical Society and editor of San Antonio Medicine magazine.

EMERGENCYMEDICINE


Members of BCMS are encouraged to register with the Alamo Area Medical Reserve Corp (MRC)MRC is a partner program of Citizen Corps, a national network of volunteers dedicated to ensuring hometown security.Citizen Corps, along with the Corporation for National and Community Service, and the Peace Corps are all part of thePresident's USA Freedom Corps, which promotes volunteerism and service throughout the nation.

MRC units are community-based and function as a locally-organized group of volunteers, medical professionals and oth-ers, who promote healthy living, prepare for and respond to emergencies. MRC volunteers supplement existing local emer-gency and public health resources.www.sanantonio.gov/Health/EmergencyManagement/VolunteerEducation/MedicalReserveCorps.aspx

Texas Disaster Volunteer Registry (TDVR)Physicians and medical professionals can also register with the Texas Disaster Volunteer Registry (TDVR). The TDVR allows

volunteer health professionals and lay volunteers wishing to support medical preparedness and response to register as aresponder with participating organizations to provide services during a disaster or public health emergency. The registrationsystem will collect basic information about you and your professional skills. To register go to https://www.texasdisastervol-unteerregistry.org/ and click on the "Register Now" button to begin the registration process.

Registering with one or both of these organizations will help Metro Health and BCMS increase the pool of physiciansand other medical professionals that are willing to volunteer when needed.

NOTE: Registering with either agency does not commit you to responding, it only indicates you would consider volun-teering when needed.


NON PROFIT

Established in 1997, the Boerne Educa-

tion Foundation (BEF) is a volunteer-dri-

ven organization, employing one staff

member. The Board of Directors represents

a group of community-minded individuals,

ranging from parents, to educators and

business people, who believe that providing

a strong education for Boerne ISD students

significantly contributes to the success of

the students. They also understand the

value that the positive impact of quality

public education has on a community, its

businesses, property values and the families

that live there.

Revenue generated through BEF’s

fundraising efforts extends above and be-

yond Boerne ISD’s normal operating

budget. The educational resources funded

through BEF support a child’s education

whether their path is to be college-ready or

workforce-ready, and every child benefits in

some way through the many remarkable ac-

ademic tools that have been purchased

through BEF support.

“BEF is Boerne ISD’s greatest source of

funding outside of the district’s operating

budget,” says foundation president Angie

Lemmons. “It provides our schools with

everything from much-needed classroom

tools like microscopes and calculators to

‘out-of-the-box’ items like the Star Lab—a

type of mobile planetarium, and the robotics

program.”

Many other remarkable academic tools

available because of BEF’s contributions in-

clude software and technological materials

for all academic courses, supplemental text

books in reading and math, eBooks, a DNA

lab and a forensic unit, ecosystems, digital

cameras, art exhibits and a ceramic kiln, geo

mats and climbing walls for physical fitness,

musical instruments and numerous other

learning tools to use in the classroom.

“In addition, there’s our contribution to

the ITSA program, which stands for Infor-

mation Technology and Security Academy,”

Lemmons says. “Upon completion of this

two-year program, students have both ad-

vanced placement credit for college, plus

computer technology certification that al-

lows them to be workforce-ready if that is

their career path.”

As state funding continues to decline,

BEF’s contributions are now more necessary

than ever to meet the needs of students and

teachers through basic 21st Century class-

room materials such as Smart Boards, lap-

tops and iPads.

Almost 20 years ago a group of involved and passionate parentscame together to ensuretheir children would excel in education by providing the learningtools and classroom materials needed to support the students,teachers and staff in theBoerne Independent School District. While thegroup’s members havechanged over the years,their determination isstronger than ever.

SUPPORTING 21STCENTURY LEARNINGIN THE BOERNE ISD

NON PROFIT


In 1993, the Texas Legislature, in an effort

to equalize funding throughout all school

districts in Texas, instituted school financing

laws where certain tax-based school districts

return to the state a portion of their tax rev-

enue to be redistributed among other dis-

tricts. This became known as the “Robin

Hood” tax law. Last year, Boerne ISD was re-

quired to return approx-

imately $8 million in

tax revenue to the state.

Because state budget

cuts and “Robin Hood”

legislation have required

Boerne ISD to make

budget cuts to numer-

ous programs, the fund-

ing provided by the

generous supporters of

BEF has become vital to providing a quality

education for the district’s students. Every

year, each of the nine schools in Boerne re-

ceives monies on a per capita basis for its stu-

dents, and many teachers are awarded

teaching incentive grants for materials to em-

power them to give their students an exem-

plary education. Additional funding is

extended to address evolving educational

needs on a district-wide basis. To date, BEF

has distributed over $2.1 million to Boerne

ISD schools.

To accomplish its mission, BEF sponsors

an Annual Giving Campaign in the fall that

solicits donations from organizations and in-

dividuals and also hosts the Rock On Gala,

a popular spring fundraiser offering an

evening of food, music and fun.

“Rock On 2016 will be held Saturday,

April 16, at the Cana Ballroom,” Lemmons

says. “The Cana Ballroom sits on one of

the highest hills in Boerne and offers a

spectacular view of the Hill Country. It was

the venue for last spring’s event and is back

by popular demand. The Rock On Gala

will feature delicious appetizer stations and

dinner by the award-winning caterer Don

Strange of Texas, silent and live auctions,

plus music and dancing.”

BEF will continue to raise much-needed

funds to ensure Boerne ISD remains a leader

in education. No contribution is too small as

every dollar donated to BEF stays in Boerne

ISD to provide an excellent education for its

students.

Lemmons concludes, “We endeavor to en-

hance education not only for

kids at every grade level, but

even more importantly, for

kids at every learning ability

—whether they are college-

bound, workforce-bound or

just need to be able to take

care of themselves independ-

ently. It makes me happy to

know that every child in

Boerne ISD is benefitting

from what BEF provides and it is leaving our

students better prepared for whatever they

will do next.”

For more information about the Boerne

Education Foundation’s Annual Giving

Campaign, Rock On Gala and other

fundraising efforts, please visit BoerneEdu-

cationFoundation.org or contact Leslie

Pickus at 210.834.2809. BEF is a 501(c)(3)

organization as designated by the IRS.

“BEF is Boerne ISD’s greatest source of fundingoutside of the district’s operating budget. It provides our schools with everything from much-needed classroom tools like microscopesand calculators to ‘out-of-the-box’ items like the Star Lab—a type of mobile planetarium, and the robotics program.”


LIFESTYLE

CoffeeBy Julie Catalano

Here’s a fun fact for Texans:

After crude oil, coffee is the

most traded commodity on the

planet. More than 400 billion

cups are downed worldwide,

with Americans consuming 350

million of those. No stats on

Texas, but considering the

hundreds of independent cof-

fee shops, bars and roasters

around—with more on the

way—we are holding our

own with the best of them.

From comforting ritual to

grab-and-go, coffee fuels

millions of Central Texans.

Here are just a few people,

places and things on your

journey to the perfect cup.

HINEE GOURMET COFFEE,HELOTES210.695.2000 • HINEEGOURMETCOFFEE.COMPhotography, Courtesy of Hinee Gourmet Coffee

“I like to say we’re Everyman’s coffee shop,” says Jeff Marsh, co-owner

with wife Mary. “We’re small, very customer focused and rely totally on

customer feedback.” The cozy shop — sandwiched between a donut

shop and a hair salon—makes for lively conversation sometimes. “If you

don’t know someone when you walk in, you’ll probably know someone

when you walk out,” says Marsh, although others choose the shop for

alone time or computer time. Some “fairly unique flavored coffees” bring

customers back, says Marsh, to see what they come up with next. They

still rotate the first two they ever brought in—jalapeno coconut and

maple bacon coffee. “Our whole approach is that we’re not brain surgery.

People who come in ought to have a positive, fun experience. That’s what

we try to do, with an outstanding barista staff that is second to none.”

And about that name: “It comes from an old radio series, a vignette that

revolved around Hiney Winery. People still talk about it, so we’ve had fun

with it. Our motto is ‘Funny name, serious coffee. No ifs, ands, or butts.’”

Open daily.

LIFESTYLE


HALCYON, SAN ANTONIO, AUSTINAUSTIN, 512.472.9637 • HALCYONCOFFEEBAR.COMSAN ANTONIO, 210.277.7045Photography by Kevin G. Saunders, Photography, Courtesy of Halcyon

A beverage hotspot in San Antonio’s Southtown, Halcyon is a coffee bar by

day and a cocktail bar by night, drawing sippers looking for high-end espressos

and specialty cocktails amid the creative ambience of the Blue Star Arts Com-

plex. Open for three years, general manager Seth Williams says business is very

good, thanks to a diverse crowd that ranges from teenagers to 50s and beyond

who enjoy a friendly, laid-back vibe with occasional live music. Their guest

roaster program is a popular draw, with barista manager John Lauber choosing

some of the best coffee in the country to showcase for six weeks at a stretch.

Chef Alex Dayoc creates sandwiches and salads in an upscale comfort food

vein, and also serves up weekend brunch from 10-2 (and you can toast your

own s’mores at your table). The original location in Austin will be joined by a

new one set to open at the former Miller Airport this year. Halcyon shares the

building with Stella Public House, with craft beer and wine and farm-to-table

small plates, salads and pizzas. Open daily.

THE WANDER’NCALF ESPRESSOBAR & BAKERY,BOERNE830.331.9156 • WANDERNCALF.COM

A registered nurse by profession, owner

Wendy Rigott started her pop-up coffee

shop in 2015 because “I love coffee and I’ve

always struggled to find good coffee.” Now

she makes great coffee for herself and her

fellow coffee lovers in Boerne, next to Ye

Kendall Inn and Cibolo Creek. No brewed

coffee here. “We do Chemex, pourovers, or

French press, and we grind the beans fresh

for each cup.” Originally from the Miami

area, Rigott’s Cuban coffee—a shot of

espresso with abundant white sugar—has

been a real hit. Pastries earn a rave, especially

decadent scones and their tasty spinoff, the

scookie—a thinly sliced scone, great for dip-

ping. Rigott’s special needs daughter also

pitches in (“we’d love to eventually reach out

to more kids to help train”), and there’s a

dog-friendly front porch where pooches

hang with their caffeinated humans. The

shop shares space with Sugar Belle’s Cake

Shop, known for their luscious cupcakes

and more. Closed Sundays.

BLACK IVORY COFFEE, THE ELEPHANT STORY, COMFORT830.995.3133 • THE-ELEPHANT-STORY.COMPhotography, Courtesy of The Elephant Story

What kind of coffee bean merits a feature on ABC’s Nightline? The kind that has been

on a wild ride, namely the digestive tract of an elephant, making it one of the most

exotic coffees in the world. The only place to find it in North America is at The Ele-

phant Story (TES) in Comfort, Texas. “[Black Ivory Coffee] founder Blake Dinkin

agreed to let us carry it because we are a not-for-profit organization,” says Bobby Dent,

co-owner with Ed Story and wife Joey, who founded TES to promote elephant con-

servation, primarily in Thailand. Up to 26 mostly rescued Asian elephants munch cof-

fee cherries along with their daily diet of fruits, vegetables and plants (“they are not

force-fed anything,” assures Dent). About 10 percent of the beans are recovered at the

other end, cleaned, roasted and shipped. The result is one smooth brew. “An enzyme

in the elephant’s system removes the protein, which is what makes coffee bitter,” explains Dent. For home use, one packet

makes one large mug or four demitasse cups, $40. For the complete in-store experience, up to five people enjoy table service, a

short presentation, fresh ground beans prepared in a copper and brass coffeemaker, and one demitasse serving each. Reservations

required, $50. Bottoms up! Closed Tuesday and Wednesday.


AROUND THE BLOCK

This column is for you. You are smart. You probably have a lawyer (or 2 or 3) and at least one accountant, financial planner/insurance

expert, clergy, etc. You may or may not have an empathetic and understanding spouse.

Despite the small army of experts at your disposal, there are many challenges you face as a physician that affect your success and hap-

piness that they don’t understand. Most likely, none of them went to medical school, and none of them face the same stresses that you

must face on a day-to-day basis, year after year.

So, who do you ask when you have critical practical questions about living the life of a physician? Who do you ask when even asking

the question might be embarrassing? Who do you ask who really “gets it” and knows where you’re coming from?

Around the Block is a forum where we will discuss your practical and philosophical questions about life as a physician and the practice

of medicine that you might not feel comfortable asking anywhere else. Most importantly, this column is here to help you find a clearer

path to your own professional success and happiness.

Your questions will be the basis for this conversation and may be submitted anonymously. While there are typically no simple and

universal answers to the tough challenges we will discuss, the goal is to provide you with, at the very least, practical follow-up thoughts

and questions you can ask yourself to create your own personal solutions.

To get you started thinking about questions you might want to ask, here are a few to consider:

Why are so many physicians unhappy? What can be done about it?

How much money do I really need to make to live the life I want?

Why don’t I like most of my partners/associates? Why don’t they seem to like me?

How can I better adapt to the new realities of medical practice?

I’m smart. Why do I feel so powerless?

You get the idea. Bring ‘em on!

You may submit your questions to me at [email protected] or you can send them anonymously on paper to:

Around the Block—San Antonio MedicineBexar County Medical Society

4334 N Loop 1604 W., Shavano Park, TX 78231

Adam V. Ratner, MD is the Chairman of The Patient Institute, Clinical Professor of Radiology and Reuter Professor of MedicalHumanities at UTHSCSA. He has been observing and interacting with physicians for more than half a century and has enjoyed ad-vising them formally and informally for years. He may be reached at The Ratner Private Advisory, LLC.([email protected])

AROUNDTHE BLOCK


LEGAL EASE

These aren’t some far-fetched questions. Let me give you some

concrete examples that happen every day in San Antonio. A woman

is raped in an apartment you lease to her. Your car is stolen from a

North Star Mall parking lot. The office you lease is broken into and

computers are stolen. A guest at your ranch is shot by a poacher.

Your secretary is attacked in the parking lot of the office building

you own. While in the hotel gym, your laptop is stolen from your

hotel room. Who’s responsible for these things?

Obviously, the person who commits the crime is. But what if he

can’t be found? Or maybe he’s found, but has no money or assets by

which to make restitution. Can anybody else be held accountable?

If your car is broken into while dining at the local bistro, does the

property manager have to pay you for your loss? If you own some

apartments and one of your tenants is assaulted in the hallway, are

you on the hook?

The short answer is, yes, the owner or manager can be liable.

What? How is it that you, as an apartment landlord, can be liable

for a tenant who is assaulted? How are you supposed to control the

conduct of these criminal miscreants who snuck upon the property

to commit that heinous crime? Here’s how.

The Texas Supreme Court established a rule of law in Timberwalk

Apartments v Cain that was recently reaffirmed once again. Here’s

the rule: [o]ne who controls . . . premises does have a duty to use

ordinary care to protect invitees from criminal acts of third parties

if he knows or has reason to know of an unreasonable and foresee-

able risk of harm to the invitee.” In a nutshell, whoever is responsible

for that property (owner or manager or both) can be liable for the

crimes of others if there was reason to believe something bad might

just happen and reasonable steps weren’t taken to avoid it.

The Supreme Court focuses on five factors; proximity, publicity,

recency, frequency, and similarity. What that means is the courts

want to know if there’s been a series of similar crimes happening

WHO’S RESPONSIBLE BESIDES THE CRIMINAL?

By George F. “Rick” Evans, Jr., BCMS General CounselEvans, Rowe & Holbrook

Who’s to blame when a crime happens on somebody’s property? I mean, other than the criminal. Who else is responsible? Since all

crimes have to happen someplace, then this question obviously

arises whenever a crime happens.

THE TWO QUESTIONS WE’RE LOOKING AT IN THIS MONTH’S ARTICLE ARE

(1) what’s your exposure when a crime happens on your property and,

(2) what are your rights when you’re the victim of some criminal act.

LEGAL EASE


nearby in the not too distant past that the owner/manager should

be aware of. If only one car in your office parking garage was broken

into in the past five years, you probably don’t have a claim if your

car gets hit next. But if you can show it happened six times last year

alone, and the owner/manager knew about it and didn’t take rea-

sonable steps to stop it (increased security, better lighting, video

cameras, etc.), then you may have a case. Even if there isn’t a history

of precisely identical crimes, the mere fact of somewhat similar

crimes may be sufficient. A car theft may not suggest that next week

somebody will be murdered, but it may suggest that next week

somebody’s apartment will be broken into.

So, here’s the bottom line, take home message. If you own or man-

age property, you can be responsible for the criminal acts that others

commit. You can’t play ostrich. If you should know about crimes

happening, not just on your property, but even just near your prop-

erty, you better take appropriate precautions to protect innocent

people on that property (tenants, guests, whatever). What’s appro-

priate depends on the circumstances. Petty theft, non-violent stuff

happening in a parking lot may only call for increased lighting,

warning signs, and video surveillance. Armed assaults may require a

lot more including 24/7 security forces.

The flip side of this issue are your rights as a victim. If your car is

broken into or stolen, you may have a good claim if the property

owner/manager hasn’t done a good job of protecting you. Just put-

ting up a metal warning sign may not be nearly enough if you can

show it hasn’t stopped break-ins. Many juries will expect a lot more

if there’s an ongoing history that management hasn’t really tried to

eliminate. The law doesn’t require that they guarantee you a crime

free environment, but the law does require they take reasonable steps

to protect you.

So, you’ve got rights as a victim. But, if you own or manage any

property, you’ve got obligations. Don’t be legally naïve and just as-

sume the only person who can be hauled into court is the criminal.

The law casts a much broader net than that.

George F. “Rick” Evans Jr., is the founding partner of

Evans, Rowe & Holbrook. A graduate of Marshall Col-

lege of Law, his practice for 36 years has been exclusively

dedicated to the representation of physicians and other

healthcare providers. Mr. Evans is the BCMS general counsel.

UTHSCSADEAN’S MESSAGE

The first students to complete four years of a dynamic new cur-

riculum at the School of Medicine at the UT Health Science Cen-

ter San Antonio will graduate this spring. The new curriculum is

called “CIRCLE,” which stands for “Curricular Integration: Re-

searchers, Clinicians, Leaders, Educators.” Led by Vice Dean for

Undergraduate Medical Education, Florence Eddins-Folensbee,

M.D., and Associate Dean Deborah Conway, M.D., its prepara-

tion took two years and involved hundreds of hours by multiple

teams from throughout the School. Continuously refined since its

launch in 2012, students are now getting a medical education that

emphasizes active learning in an experiential setting, a model fol-

lowed by the top medical schools in the country.

CIRCLE represents a completely different way of looking at

medical school education. The 225 students graduating this May

will have completed a medical education unlike anything most

of us experienced as medical students. They will have assumed

more direct responsibility for their education and spent fewer

hours in lectures, all within a coordinated format that focuses the

content and brings a higher degree of engagement.

Throughout the medical school experience, each student par-

ticipates in faculty-facilitated group learning teams that serve as

an accountability tool, a learning modality and a model for the

team-based world of clinical practice. Now, our students’ first pa-

tient encounter takes place in the first week of school instead of

the end of their second year or later, as was the case in the tradi-

tional Flexnerian curriculum. The School now also requires stu-

dents to undertake extensive preparation before a class or

group-based learning activity. With this active format, students

are able to apply knowledge at a higher level in their first two

years of instruction.

By using a systems-based approach the curriculum integrates

formal knowledge and clinical experience, teaching basic sciences

to students while simultaneously exploring the real-world appli-

cation of those sciences. Courses such as biochemistry or physi-

ology are no longer taught as stand-alone disciplines, but rather

in relation to systems in the body as part of organ system-based

modules. In this way, the basic sciences come alive to students as

clinically relevant information.

The new curriculum is heavily reliant on technology. Stu-

dents are able to access the vast universe of medical information

at their fingertips at any time. There are electronic textbooks

and syllabuses; calendar feeds tell the students where they need

to be and what materials belong in that session. Blog posts and

online chats provide ways to discuss content. Examinations are

administered electronically, giving faculty the ability to more

readily provide individualized feedback on student strengths

and weaknesses.

Students benefit from tools that present content in a more in-

teractive, user-friendly format. For example, a “flipped class-

room” means the material previously conveyed in lectures is now

given to the students for learning on their own. A professor is

able to record a lecture that students can watch as a streaming

video online, pausing and reviewing again as needed. These vir-

tual desktop lectures mean they can stop at any time to research

questions in their texts, with the faculty member, or each other.

In class, they are then able to discuss the material with the pro-

fessor and other students to deepen their understanding of the

material and its implications.

Through an online platform that serves as a guided reading ex-

ercise, faculty members can present material in a way that each

student can follow at their own pace, but with a variety of tools

built into the materials such as learning aids, pedagogic tech-

niques and quizzes. Innovative methods such as these let students

learn on their own while still receiving the guidance and facilita-

tion of faculty members.

Team-based activities teach students that team-work is not only

School of Medicine Update:New Curriculum Students Graduating

By Francisco González-Scarano, MD


visit us at www.bcms.org 33visit us at www.bcms.org 33


important, but mandatory; after all, nearly everything a physician

does is team-oriented. The relationships they build with each

other and with the assigned faculty members become an integral

part of their learning experience.

The benefits of this team-based approach are many. Because

students are required to work closely together, even conducting

peer evaluations, they learn professional navigation skills. Teams

also provide learning support. Even for driven, gifted students

who are accustomed to working independently, the team can ex-

pose them to new perspectives, ideas, even new questions. In a

group setting students learn how a broader perspective and col-

laborative effort can benefit them as individuals, and clearly ben-

efit their future patients. Close access to a faculty member also

creates a setting in which students can more easily get answers to

questions that are challenging to them.

Clinicians also facilitate the teams’ activities, in which student

teams practice real-world reasoning in a formative setting where

they are not graded, gaining valuable experience and coaching in

discussing cases or constructing diagnostic plans. This gives stu-

dents a “safe” way to comfortably try these activities with a dedi-

cated clinical teacher there to guide them.

Our CIRCLE curriculum gives students the clinical skills and

knowledge to go in and identify a chief complaint in a systematic

way. By the end of their first semester they know how to perform

a complete history and physical exam. They then learn to apply

these skills to pathological conditions to generate a differential di-

agnosis and evaluation of common presenting complaints.

Now there is more emphasis on clinical reasoning and devel-

oping a differential diagnosis using assessments called trans-mod-

ule cases, with standardized patients. We train and then task

students with demonstrating their emerging ability to reason and

apply the skills they’ve learned in patient examinations. For ex-

ample, instead of instructing a student to interview a patient with

an asthma attack, the student instead talks to a patient who com-

plains of shortness of breath, chest pain, or abdominal pain.

This new student-centered curriculum demands more of both

students and faculty. While building this new curriculum required

a tremendous amount of time, skill and communication, faculty

relished the opportunity to create new materials, develop new

courses and convert a passive learning, lecture-based course pres-

entation to a more active modality.

The change is one of both mindset and culture. Many faculty

members report that the process forced them to think about their

work as professors in a new and creative way. One described the

previous curriculum as being passive, with lectures consisting of

slide after slide while students sat silently. Now, faculty members

are actively engaging with students in an exchange of information.

Many faculty members also report that, like students, the new

curriculum requires them to work harder, yet they also cite a re-

newed sense of excitement for their disciplines and interactions

with colleagues. Team-based learning activities also require in-

depth collaboration among faculty members. Basic science and

clinical faculty have forged meaningful relationships with each

other through this integration. Faculty members who had little

reason to interact in the past now collaborate to design and write

each learning module, from the syllabus to exam questions. The

collegiality and sharing of different perspectives has been very ben-

eficial to both faculty members and students.

Another benefit of the new curriculum is that it is student-cen-

tered. Contributing to this is a shift in the way content is chosen.

To better serve students, we ensure that the information included

in each module is more objectively analyzed for its role before

being selected as part of a comprehensive program. Instead of in-

dividual departments or faculty members, the Curriculum Com-

mittee now has the final determination over content. If

information has been included previously that is no longer critical,

the curriculum committee has the authority to remove or replace

it. This is a key difference that has contributed to a more robust

learning experience.

Once content is selected, faculty works with the team at the

Office of Undergraduate Medical Education (UME) to determine

the best way to design and deliver the information, whether it is

a lecture, an interactive lab, or an online activity. UME involve-

ment also ensures more consistency in the way coursework and

requirements are structured among the specialties, making it easier

to identify gaps or unintentional redundancies in the material.

The CIRCLE framework also lends itself to adjustment and

adaptation. It is more responsive to feedback from students and

faculty, as well as to important emerging trends in medical edu-

cation. Because it is an integrative process, there is an ongoing

fine-tuning and adjusting of courses.

Four years into the CIRCLE curriculum, the results are prom-


ising. Typically, in any educational setting, a curriculum reform

will lead to a temporary drop in test scores followed by a return

to the core point and eventually a rise in performance. However,

throughout our reform performance did not suffer that typical

lag. Furthermore, clerkship directors are clearly noticing that stu-

dents are entering their third year better equipped to engage as a

team member.

The new curriculum has also added unique opportunities for

students at the School. The emphasis on early exposure to real-

world clinical skills has led to the establishment of a state-of-the-

art ultrasound center, which students begin using early in their

first year, along with two new clerkships in neurology and emer-

gency medicine.

In addition to delivering relevant content in a clinical context,

the CIRCLE curriculum contributes to one of the School’s most

fundamental missions: teaching students how to be good learners.

As students and clinicians, they must have well-developed habits

of inquiry and innovation, knowing how to ask questions, how

to identify what they don’t know, and how to find the answers.

Most importantly, the new curriculum brings us closer to the

goal of competency-based assessment, so that we can say with cer-

tainty when students graduate, they have not only performed well

on tests, but have truly demonstrated the specific sets of knowl-

edge, skills and experience necessary to embark on successful ca-

reers as competent and compassionate clinicians. I have only one

regret about the CIRCLE curriculum: that it was not the norm

when I was in medical school many years ago.

Francisco González-Scarano, MD

Dean, School of Medicine

Vice President for Medical Affairs

Professor of Neurology

John P. Howe, III, MD, Distinguished

Chair in Health Policy

The University of Texas Health Science

Center at San Antonio

[email protected]





BUSINESS OFMEDICINE

Market Dynamics in the Wakeof the Patient Protection andAffordable Care ActLee W. Bewley, Ph.D., FACHE


Whether a provider of healthcare services or patient and beneficiaryof one of the many healthcare systems in the United States, most Amer-icans recognize that the Patient Protection and Affordable Care Act of2010 meaningfully impacted the United States healthcare system.

The prime intended effects of this act were to expand citizens’ ac-cess to healthcare and to moderate healthcare cost dynamics througha number of mechanisms including: employer and individual man-dates, minimum insurance coverage, elimination of pre-existing con-ditions and catastrophic coverage caps, constraining insurancemedical loss ratios, and implementing a host of expanded eligibilityinitiatives to facilitate participation in Medicaid and privately-pur-chased health insurance.

The results after nearly five years indicate a meaningful decreasein the number of uninsured, but nearly 32,000,000 citizens or about12 percent of the population do not have consistent healthcare fi-nancing and healthcare costs continue to rise.1

A summary review of basic economic market dynamics can pro-vide a framework to understand what is occurring in the varioushealthcare markets across the United States and in aggregate withinthe entire system.

The preponderance of the Affordable Care Act provisions are fo-cused on stimulating demand for healthcare services. Providing ex-panded eligibility for Medicaid and subsidized health insurancethrough exchanges is effectively an increase in resources or incomefor the market of health services. Furthermore, expanding minimum

healthcare insurance coverage, access to health insurance, and elim-inating catastrophic coverage caps should be expected to bolster

healthcare consumer expectations. The dual effect of enhanced income and consumer expectations

for healthcare services would be expected to generate substantial de-mand within individual healthcare markets and in aggregate acrossthe country. On the other hand, the Affordable Care Act did notaddress supply factors with a corresponding level of emphasis be-yond the potential of increasing producer expectations for futurerevenue and/or profits associated with increased demand; however,the potential positive impact of increased supply through producerexpectations may well have been moderated due to the Act’s provi-sions for cuts to Medicare reimbursement rates, taxes on medicaldevices, and implications that healthcare organizations and providersmay need to fundamentally change delivery systems. The net marketeffect in the short to intermediate term indicates that an increase indemand matched with constant supply would likely result in in-creased prices and/or diminished access to services.2

A quick review of market statistics during the period 2010 – 2014illustrates key elements of the economic market effects of the Af-fordable Care Act.

These data indicate that the demand effects of the Affordable CareAct coupled with other effects such as the “Silver Tsunami” ofMedicare-eligible beneficiaries described by my colleague Dr. DanaForgione yielded substantial increases in healthcare expendituresduring the period 2010 – 2014. Given the scant 8 percent increasein the healthcare and social assistance workforce during this period,

the apparent modest contraction of hospitals in the United States,and only a 4 percent increase (2012 – 2014) in licensed practicing

Elements of Market Demand for Healthcare3

BUSINESS OFMEDICINE


physicians, we should expect some combination of increased health-care prices or short-term disruptions to quantity-supplied manifestin longer wait times or inability to receive care (despite having healthinsurance and/or the financial ability to pay). 6,7,8

Looking forward, providers of healthcare services should expectsubstantial and persistent demand amid relatively limited marketsupply conditions that would normally result in tremendous oppor-tunities for economic profits and nearly unchallenged standing as agoing concern. But prevalence of government reimbursement ratesand intervening market leverage provided by employers and insurersat the points of market exchange indicate that potential resolutionsto supply shortfalls and inadequate access to healthcare may befound through greater collaboration and coordination betweenproviders and patients.

References:1. Henry J. Kaiser Family Foundation (2016). Key Facts about the Uninsured

Population. Available at http://www.kff.org

2. Baye, Michael (2006). Managerial Economics and Business Strategy (5th edi-

tion). McGraw-Hill. Boston, Massachusetts.

3. Centers for Medicare and Medicaid (2016). National Healthcare Expenditures.

Available at: https://www.cms.gov

4. Bureau of Labor Statistics (2016). Healthcare and Social Assistance Employees.

Available at: https://www.bls.gov

5. Henry J. Kaiser Family Foundation (2016). State Health Facts: Total Hospitals.

Available at: http://www.kff.org

6. Forgione, D. (2015). Costly Reflections in the Silver Tsunami. San Antonio

Medicine. Volume 68. Number 6. 34 – 35.

7. Young, Aaron, Humayun, J., Xiaomei, P., Halbesleben, K., Polk, D. and Dugan,

M. (2015). A Census of Actively Licensed Physicians in the United States, 2014.

Journal of Medical Regulation. Volume 101. Number 2. 8 – 23.

8. Martin, Anne, Hartman, Micah, Brenson, Joseph, and Caitlin, Aaron (2015).

National Health Spending in 2014: Faster Growth Driven by Coverage Expansion

and Prescription Drug Spending. Health Affairs. Volume 35. Issue 1. 150-160.

Lee W. Bewley, PhD, FACHE, is an Army officer, as-sociate professor of healthcare management, and a board-certified healthcare executive. He is the program directorof the Army-Baylor University MHA/MBA program,

and serves as an adjunct faculty member at the University of Texas atSan Antonio, Trinity University and University of the Incarnate Word.


Elements of Market Supply for Healthcare4, 5

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 AntonioMEDNAX

Peripheral Vascular Associates, PA

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

San Antonio Kidney Disease CenterSan Antonio Pediatric Surgery Associates, PA

Sound PhysiciansSouth Alamo Medical Group

South Texas Radiology Group, PATejas Anesthesia, PA

Texas Partners in Acute CareThe San Antonio Orthopaedic Group

Urology San Antonio, PAVillage Oaks Pathology Services/Precision Pathology

WellMed Medical Management Inc.

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 practiceparticipation as of February 17, 2016.

BCMS CIRCLE OF FRIENDSSERVICES DIRECTORYPlease support our sponsors with your patronage; our sponsors support us.

ACCOUNTING FIRMS

Padgett Stratemann & Co., LLP(HH Silver Sponsor)Padgett Stratemann is one ofTexas’ largest, locally owned CPAfirms, providing sophisticated ac-counting, audit, tax and businessconsulting services.Vicky Martin, [email protected]“Offering service more than ex-pected — on every engagement.”

Sol Schwartz & Associates P.C.(HH Silver Sponsor)We specialize in areas that aremost critical to a company’s fiscalwell-being in today’s competitivemarkets. Jim Rice, CPA210-384-8000, ext. [email protected]“Dedicated to working withphysicians and physician groups.”

BANKING

BBVA Compass(HHHH 10K Platinum Sponsor)Our healthcare financial team pro-vides customized solutions for you,your business and employees. Commercial Relationship ManagerZaida [email protected] Global Wealth ManagementMary [email protected] Branch ManagerVicki [email protected] Banking OfficerJamie [email protected]“Working for a better future.”

Amegy Bank of Texas(HHH Gold Sponsor)We believe that any great rela-

tionship starts with five core val-ues: Attention, Accountability,Appreciation, Adaptability andAttainability. We work hard andtogether with our clients to ac-complish great things.Jeanne Bennett 210- [email protected] Leckie [email protected]“Community banking partnership.”

BB&T(HHH Gold Sponsor)Checking, savings, investments,insurance — BB&T offers bankingservices to help you reach your fi-nancial goals and plan for asound financial future.Chris Sherman [email protected] Pressentin [email protected]

Broadway Bank(HHH Gold Sponsor)Healthcare banking experts witha private banking team commit-ted to supporting the medicalcommunity.Ken [email protected]“We’re here for good.”

Frost(HHH Gold Sponsor)As one of the largest Texas-basedbanks, Frost has helped Texanswith their financial needs since1868, offering award-winning customer service and a range ofbanking, investment and insur-ance services to individuals andbusinesses.

Lewis [email protected]“Frost@Work provides your em-ployees with free personalizedbanking services.”

IBC Bank(HHH Gold Sponsor)IBC Bank is a $12.4 billion multi-bank financial company, with over212 facilities and more than 325ATMs serving 90 communities inTexas and Oklahoma. IBC Bank-San Antonio has been serving theAlamo City community since 1986and has a retail branch network of30 locations throughout the area.Markham [email protected]“Leader in commercial lending.”

Ozona Bank(HHH Gold Sponsor)Ozona National Bank is a full-ser-vice commercial bank specializingin commercial real estate, con-struction (owner and non-owneroccupied), business lines of creditand equipment loans.Lydia [email protected]

The Bank of San Antonio(HHH Gold Sponsor)We specialize in insurance andbanking products for physiciangroups and individual physicians.Our local insurance professionalsare some of the few agents in thestate who specialize in medicalmalpractice and all lines of insur-ance for the medical community.Brandi Vitier [email protected]

SSFCU(HHH Gold Sponsor)Founded in 1956, Security Serviceprovides medical professionalswith exceptional service andcompetitive rates on a line ofmortgage products includingone-time close construction,unimproved lots/land, jumbo andspecialized adjustable-rate mort-gage loans.Commercial ServicesLuis [email protected] ServicesJohn [email protected] ServicesGlynis [email protected]

Bank of America(HH Silver Sponsor)Bank of America provides people,companies and institutional in-vestors the financial products andservices they need to help achievetheir goals at every stage of theirfinancial lives.Jennifer Dooling [email protected] Martinez [email protected]://about.bankofamerica.com/en-us/index.htmlMaking financial lives better —one connection at a time

Firstmark Credit Union(HH Silver Sponsor)Address your office needs: Up-grading your equipment or tech-nology • Expanding your officespace • We offer loans to meetyour business or personal needs.Competitive rates, favorableterms and local decisions.Gregg ThorneSVP [email protected]

Generations Federal Credit Union(HH Silver Sponsor)Generations provides a wide arrayof innovative products including



BCMS CIRCLE OF FRIENDS SERVICES DIRECTORYContinued from page 37

loan, deposit and investment so-lutions for personal and commer-cial banking needs.Yvonne "Bonnie" M. [email protected]“For this generation and the next.”

RBFCU(HH Silver Sponsor)[email protected]

BIOMEDICAL WASTE DISPOSAL

BioMedical Waste Solutions, LLC (HHH Gold Sponsor)Save costs on your medical wastedisposal! BioMedical Waste Solu-tions provides a compliant, reli-able and low-cost service.Wes Sonnier [email protected] Loyacano1-877-974-1300Joe@BioMed-Disposal.comwww.BioMedicalWasteSolutions.com“BCMS members save 10 percent offor one free month! Request a freequote in 10 seconds at www.Bio-MedicalWasteSolutions.com.”

CONTRACTORS/BUILDERS/COMMERCIAL

Huffman Developments(HHH Gold Sponsor)Premier medical and professionaloffice condominium developer.Our model allows you to own yourown office space as opposed toleasing.Steve Huffman 210-979-2500Shawn Huffman 210-979-2500www.huffmandev.com

RC Page Construction, LLC(HHH Gold Sponsor)Commercial general contractorspecializing in ground-up and in-

terior finish-out projects. Servicesinclude conceptual and final pric-ing, design-build and construc-tion management. Single-sourcemanagement from concept tocompletion ensures continuitythrough all phases of the project.Clay [email protected]

ELECTRONIC DOCUMENTATION ANDTRANSCRIPTION SERVICES

Med MT, Inc.(HHH Gold Sponsor)Narrative transcription is physi-cians’ preferred way to create pa-tient documents and populateelectronic medical records.Ray Branson [email protected]“The Med MT solution allowsphysicians to keep practicing justthe way they like.”

ELECTRONIC MEDICALRECORDS

Greenway Health(HHH Gold Sponsor)Greenway Health offers a fully in-tegrated electronic health record(EHR/EMR), practice manage-ment (PM) and interoperabilitysolution that helps healthcareproviders improve care coordina-tion, quality and satisfaction whilefunctioning at their highest levelof efficiency.Stacy Berry830-832-0949Stacy.berry@greenwayhealth.comwww.greenwayhealth.com

EMPLOYEE BENEFITS

e-ESI(HHH Gold Sponsor)Locally owned since 1999, we be-lieve it's all about relationships. Wekeep our partners compliant as-sisting with human resource ad-ministration/management,workers' compensation/risk man-agement, benefit administration,and payroll. We help our partners

concentrate on what they dobest...Service their customers.Lisa Mochel(210) [email protected]

FINANCIAL SERVICES

Northwestern Mutual WealthManagement(HHHH 10K Platinum Sponsor)Comprehensive financial plan-ning, insurance and investmentplanning, estate planning andtrust services.Eric Kala, CFP, CLU, ChFCWealth Management [email protected]

Aspect Wealth Management(HHH Gold Sponsor)We believe wealth is more thanmoney, which is why we improveand simplify the lives of ourclients, granting them greatersatisfaction,confidence and freedom toachieve more in life.Jeffrey Allison [email protected]“Get what you deserve … maxi-mize your Social Security benefit!”

Frost Leasing(HHH Gold Sponsor)As one of the largest Texas-basedbanks, Frost has helped Texanswith their financial needs since1868, offering award-winningcustomer service and arange of banking, investment andinsurance services to individualsand businesses.Laura Elrod Eckhardt210-220-4135laura.eckhardt@frostbank.comwww.frostbank.com“Commercial leasing for a doctor’sbusiness equipment and vehicle.”

Bob Davidson New York Life(HH Silver Sponsor)Dedicated agent at New York Lifehelping physicians and medicalprofessionals achieve their finan-cial dreams.

Bob Davidson 210-321�1445 [email protected]/in/bobdavid-sonnyl“Taking care of those who takecare of us.”

Retirement Solutions(HH Silver Sponsor)Committed to providing compre-hensive, reliable consultation tohelp you navigate the complexworld of retirement planning.Robert C. Cadena210-342-2900robert@retirementsolutions.wswww.retirementsolutions.ws

HEALTHCARE REAL ESTATE

San Antonio Comercial Advisors(HHH Gold Sponsor)Jon Wiegand advises healthcareprofessionals on their real estatedecisions. These include invest-ment sales- acquisitions and dispositions, tenant representa-tion, leasing, sale leasebacks, site selection and developmentprojectsJon Wiegand [email protected]“Call today for a free real estateanalysis, valued at $5,000”

HIPAA COMPLIANCE SERVICES

Cyber Risk Associates(HH Silver Sponsor)Cyber Risk Associates providesHIPAA compliance services de-signed for small practices, offer-ing enterprise-quality privacy andsecurity programs, customized toyour needs.David Schulz210-281-8151DAS@CyberRiskAssociates.comwww.CyberRiskAssociates.com

HIPAA/MANAGED IT/VOIP/SECURITY

Hill Country Tech Guys(HHH Gold Sponsor)Provides complete technologyservices to many different


BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY



industries, specializing in theneeds of the financial and medical industries. Since 2006,our goal has always been to deliver relationship-based technology services that exceed expectations.Whit Ehrich, [email protected]://hctechguys.com/“IT problems? Yeah… we can fix that!”

HOSPITALS/ HEALTHCARESERVICES

Southwest General Hospital(HHH Gold Sponsor)Southwest General is a full-ser-vice hospital, accredited by DNV,serving San Antonio for over 30years. Quality awards include accredited centers in: Chest Pain,Primary Stroke, Wound Care, and Bariatric Surgery.Business Development DirectorBlake Pollock210-243-9151bpollock@iasishealthcare.comwww.swgeneralhospital.com"Quality healthcare with you inmind."

Warm Springs•Medical Center•Thousand Oaks•Westover Hills(HHH Gold Sponsor)Our mission is to serve peoplewith disabilities by providingcompassionate, expert care dur-ing the rehabilitation process, andsupport recovery through educa-tion and research.Central referral line210-592-5350“Joint Commission COE.”

Elite Care Emergency(HH Silver Sponsor)24/7 full-service, no-wait, free-standing ER with board-certifiedphysicians and RNs offering EliteCare advantage for patients.Marketing LiaisonDlorah [email protected] liaisonKylyn Stark210-978-4110kstark@elitecareemergency.comwww.elitecareemergency.com“When seconds count, Elite Care

can make ALL the difference.”

Methodist Healthcare System(HH Silver Sponsor)Palmira [email protected]://sahealth.com/

Select Rehabilitation of San Antonio (HH Silver Sponsor)We provide specialized rehabili-tation programs and services forindividuals with medical, physicaland functional challenges. Miranda [email protected]://sanantonio-rehab.com“The highest degree of excel-lence in medical rehabilitation.”

HUMAN RESOURCES

e-ESI(HHH Gold Sponsor)Locally owned since 1999, we be-lieve it's all about relationships. Wekeep our partners compliant as-sisting with human resource ad-ministration/management,workers' compensation/risk man-agement, benefit administration,and payroll. We help our partnersconcentrate on what they dobest...Service their customers.Lisa Mochel(210) [email protected]

Employer Flexible(HHH Gold Sponsor)Employer Flexible doesn’t simplylessen the burden of HR adminis-tration. We provide HR solutionsto help you sleep at night and geteveryone in the practice on thesame page.John Seybold210-447-6518jseybold@employerflexible.comwww.employerflexible.com“BCMS members get a free HRassessment valued at $2,500.”

INSURANCE

Texas Medical Association Insurance Trust(HHHH 10K Platinum Sponsor)Created and endorsed by the

Texas Medical Association (TMA),the TMA Insurance Trust helpsphysicians, their families and theiremployees get the insurance cov-erage they need.Wendell [email protected] [email protected] Isgitt512-370-1776www.tmait.org“We offer BCMS members a freeinsurance portfolio review.”

Frost Insurance(HHH Gold Sponsor)As one of the largest Texas-basedbanks, Frost has helped Texanswith their financial needs since1868, offering award-winningcustomer service and a range ofbanking, investment and insur-ance services to individuals andbusinesses.Bob [email protected]“Business and personal insurancetailored to meet your uniqueneeds.”

Humana(HHH Gold Sponsor)Humana is a leading health andwell-being company focused onmaking it easy for people toachieve their best health withclinical excellence through coor-dinated care.Jon Buss: [email protected] Kotfas: [email protected]

SWBC(HHH Gold Sponsor)SWBC is a financial services com-pany offering a wide range of insur-ance, mortgage, PEO, Ad Valoremand investment services. We focusdedicated attention on our clientsto ensure their lasting satisfactionand long-term relationships.VP Community RelationsDeborah Gray Marino210-525-1241 [email protected] AdvisorGil Castillo, CRPC®[email protected]

Ad Valorem Tax AdvisorNikki [email protected], investments, personaland commercial insurance, bene-fits, PEO, ad valorem tax services

Catto & Catto(HH Silver Sponsor)Providing insurance, employeebenefits and risk-managementproducts and services to thou-sands of businesses and individu-als in Texas and the United States.James L. Hayne [email protected] [email protected]

Joel Gonzales Agency Nationwide(HH Silver Sponsor)Joel Gonzales210-275-3595www.nationwide.com/jgonzales

INSURANCE/MEDICALMALPRACTICE

Texas Medical Liability Trust(HHHH 10K Platinum Sponsor)Texas Medical Liability Trust is anot-for-profit health care liabilityclaim trust providing malpracticeinsurance products to the physi-cians of Texas. Currently, we pro-tect more than 18,000 physiciansin all specialties who practice in allareas of the state. TMLT is a rec-ommended partner of the BexarCounty Medical Society and is en-dorsed by the Texas Medical As-sociation, the Texas Academy ofFamily Physicians, and the Dallas,Harris, Tarrant and Travis countymedical societies.Patty [email protected]“Recommended partner of theBexar County Medical Society.”

MedPro Group(HHH Gold Sponsor)Medical Protective is the nation'soldest and only AAA-ratedprovider of healthcare malprac-tice insurance. Thomas Mohler, 512-213-7714

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORYContinued from page 39

[email protected] [email protected]

The Bank of San Antonio Insurance Group, Inc.(HHH Gold Sponsor)We specialize in insurance and banking products for physiciangroups and individual physicians.Our local insurance professionalsare some of the few agents in thestate who specialize in medical malpractice and all lines of insur-ance for the medical community. Katy Brooks, CIC, [email protected]“Serving the medical community.”

The Doctors Company(HH Silver Sponsor)The Doctors Company is fiercelycommitted to defending, protect-ing, and rewarding the practice ofgood medicine. With 78,000members, we are the nation’slargest physician-owned medicalmalpractice insurer. Learn more atwww.thedoctors.com.Susan SpeedSenior Account Executive(512) [email protected] NicholsonDirector, Business Development(512) [email protected]“With 78,000 members, we are thenation’s largest physician-ownedmedical malpractice insurer”

NORCAL Mutual Insurance Co.(HH Silver Sponsor)Since 1975, NORCAL Mutual hasoffered medical professional lia-bility coverage to physicians and is “A” (Excellent) rated byA.M. Best.Patrick Flanagan844-4-NORCAL [email protected]

ProAssurance (HH Silver Sponsor)ProAssurance Group (rated A+(Superior) by A.M. Best) helpsyou protect your important iden-tity and navigate today’s medicalenvironment with greater ease—that’s only fair.Keith Askew, Market [email protected]

Mark KeeneyDirector, [email protected] 800.282.6242www.proassurance.com

INTERNET/TELECOMMUNICATIONS

Time Warner Cable Business Class(HHH Gold Sponsor)When you partner with TimeWarner Cable Business Class, youget the advantage of enterprise-class technology and communications that are highlyreliable, flexible and pricedspecifically for the medical com-munity.Rick Garza [email protected]“Time Warner Cable BusinessClass offers custom pricing forBCMS Members.”

IT SUPPORT/VOIP/CLOUD SERVICES

ICS(HHH Gold Sponsor)ICS® is a Texas-based provider ofbusiness technology integrationsolutions, including managed ITsupport, business telephones,VoIP communications, video con-ferencing systems, surveillancecameras, and voice/data cabling.Family owned since 1981.Daniel [email protected] Foehrkolb [email protected]“Providing IT, voice and video so-lutions for business.”

LABORATORY SERVICES

PGX TESTING(HHH Gold Sponsor)PGX Testing is a multi-faceted di-agnostics company currently of-fering pharmacogenomics, urinetoxicology, women's health test-ing, cancer screening, and well-

ness testing to the medical pro-fession.Charlie Rodkey [email protected] [email protected] [email protected]

Clinical Pathology Laboratories(HH Silver Sponsor)Mitchell Kern [email protected]

MARKETING SERVICES

Digital Marketing Sapiens(HHH Gold Sponsor)Healthcare marketing profession-als with proven experience andsolid understanding of compli-ance issues. We deliver innovativemarketing solutions that drive re-sults.Irma Woodruff [email protected] Ajay Tejwani 210- [email protected] www.DMSapiens.com

MEDICAL BILLING ANDCOLLECTIONS SERVICES

DataMED(HHH Gold Sponsor)Providing your practice with thelatest compliance solutions, con-centrating on healthcare regula-tions affecting medical billing andcoding changes, allowing you andyour staff to continue deliveringexcellent patient care.Betty Aguilar210-892-2331 [email protected]“BCMS members receive a dis-counted rate for our billing services.”

Kareo(HHH Gold Sponsor)The only cloud-based medical office software and services platform purpose-built for small

practices. Our practice manage-ment software, medical billing solution, practice marketing toolsand free, fully certified EHR hashelped 30,000+ medicalproviders more efficiently manage their practice.Regional Solutions ConsultantLilly [email protected]

MEDICAL SUPPLIESAND EQUIPMENT

Henry Schein Medical (HHHH 10K Platinum Sponsor)From alcohol pads and bandagesto EKGs and ultrasounds, we arethe largest worldwide distributorof medical supplies, equipment,vaccines and pharmaceuticalsserving office-based practitionersin 20 countries. Recognized asone of the world’s most ethicalcompanies by Ethisphere.Tom [email protected]“BCMS members receive GPOdiscounts of 15 percent to 50percent.”

CASA Physicians Alliance(HHH Gold Sponsor)Locally owned, nationwide Multi-Specialty Physicians BuyingGroup which provides significantsavings on Pediatric, Adolescentand Adult vaccines as well asother products. Physician’s mem-berships are free.Shari [email protected] [email protected]“Providing meaningful vaccinediscount programs, products andservices.”

MENTAL HEALTH EDUCATION AND CONSULTING

The Ecumenical Center(HHH Gold Sponsor)The Ecumenical Center provides


BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY


faith-based counseling and ed-ucation for healing, growth andwellness. The center is a cata-lyst, bringing together commu-nity leaders in research,education, ethics, medical andmental health professions.Mary Beth Fisk210-616-0885, ext. [email protected]

MERCHANT PAYMENTSYSTEMS/CARD PROCESSING

Heartland Payment Systems(HH Silver Sponsor)Heartland Payments is a truecost payment processor exclu-sively endorsed by over 250business associations.Tanner Wollard, 979-219-9636tanner.wollard@e-hps.comwww.heartlandpaymentsystems.com“Lowered cost for AmericanExpress; next day funding.”OFFICE EQUIPMENT/TECHNOLOGIES

Dahill(HH Silver Sponsor)Dahill offers comprehensive document workflow solutionsto help healthcare providersapply, manage and use tech-nology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes.Ronel Uys210-805-8200, ext. [email protected]

PAYROLL SERVICES

SWBC(HHH Gold Sponsor)Our clients gain a team of employment experts providingsolutions in all areas of humancapital – Payroll, HR, Compli-ance, Performance Manage-ment, Workers’ Compensation,Risk Management and Employee Benefits. Bryce [email protected] together to help ourclients achieve their businessobjectives.

PHYSICIANS BUYINGGROUP

CASA Physicians Alliance(HHH Gold Sponsor)Locally owned, nationwideMulti-Specialty Physicians Buying Group which providessignificant savings on Pediatric,Adolescent and Adult vaccinesas well as other products.Physician’s memberships are free.Shari [email protected] [email protected]“Providing meaningful vaccinediscount programs, productsand services.”

REAL ESTATE/COMMERCIAL

San Antonio Comercial Advisors(HHH Gold Sponsor)Jon Wiegand advises health-care professionals on their realestate decisions. These includeinvestment sales- acquisitionsand dispositions, tenant repre-sentation, leasing, sale lease-backs, site selection anddevelopment projectsJon Wiegand [email protected]“Call today for a free real estate analysis, valued at$5,000”

Robbie Casey Commercial Realty(HHH Gold Sponsor)Robbie Casey Commercial Realtywas founded on the principles ofproviding thorough marketstrategies, innovative advertising,superior service, and uncompro-mising integrity. Robbie is dedi-cated to each of her clients. Shebrings enthusiasm and creativityto each project and knows howto get the job done. Robbie [email protected]://robbiecaseyrealty.com

Endura Advisory Group(HH Silver Sponsor)Endura Advisory Group specializes in representingphysicians and clients in thepurchase, lease, sale, management or sublease ofcommercial real estate. Vicki Cade, CCIM 210-366-2222Mobile [email protected] [email protected]

REAL ESTATE/RESIDENTIAL

Robbie Casey Realty(HHH Gold Sponsor)My extensive experience andexpertise in the San Antonio,Alamo Heights and Terrell Hillsreal estate market will benefityou whether you are looking tobuy or sell a home in the area.Realtor, ABS, ILHM, ALMSRoslyn [email protected]://roslyncasey.kwrealty.com“Communication is key”

Kuper Sotheby's International Realty(HH Silver Sponsor)My hometown roots are basedin Fredericksburg while myhome away from home is SanAntonio. Local knowledge —exceptional results.Joe Salinas III [email protected]“Embrace your new life ...I'll help you become a connoisseur.”

SENIOR LIVING

Legacy at Forest Ridge(HH Silver Sponsor)Legacy at Forest Ridge provides residents with top-tiercare while maintaining their pri-vacy and independence, in a luxurious resort-quality environment.Shane BrownExecutive Director210-305-5713hello@legacyatforestridge.comwww.LegacyAtForestRidge.com“Assisted living like you’venever seen before.”

STAFFING SERVICES

Favorite Healthcare Staffing(HHHH 10K Platinum Sponsor)Serving the Texas healthcarecommunity since 1981, FavoriteHealthcare Staffing is proud tobe the exclusive provider ofstaffing services for the BCMS.In addition to traditionalstaffing solutions, Favorite of-fers a comprehensive range ofstaffing services to help mem-bers improve cost control, in-crease efficiency and protecttheir revenue cycle.Brody Whitley, Branch Director210-301-4362bwhitley@favoritestaffing.comwww.favoritestaffing.com“Favorite Healthcare Staffingoffers preferred pricing forBCMS members.”

TRAVELCONSULTANTS

Alamo Travel Group(HH Silver Sponsor)Locally owned travel agency forover 30 years, offering personalized travel services foryour next family vacation, business travel needs or grouptravel. American Express Travel Network representative.Patricia Pliego Stout210-593-5500pstout@alamotravel.comwww.amazingjourneysbyalamo.com“See what a difference we can make for you!”

As of February 18, 2016

To join the Circle of Friends program or for more information,call 210-301-4366, email [email protected], or visit www.bcms.org/COf.html.


BOOK REVIEW

This ambitious text is a 600+ pageencyclopedic opus authored by morethan two dozen healthcare, financial,and legal succors serving today’s health-care providers. It was conceived andedited by a former board certified sur-geon, Dr. David Edward Marcinko,MBA, CMP who is the current CEOfor the Institute of Medical BusinessAdvisors based in Atlanta which is re-sponsible for the CERTIFIED MED-ICAL PLANNER certification. Dr

Marcinko holds numerous medical, financial & technology basedprofessional designations and degrees. In the late 90’s Dr. Marcinkowas president of a privately held physician practice management cor-poration which consolidated 95 solo medical practices for a pre-IPOlisting. His cross discipline background is evident in his organiza-tion of this comprehensive text into four orderly life cycle sectionswhich directly correlate to a physician’s career path.

Tip: for an efficient alternative to the full 600 page chronologicalreading after reading the first section titled “For All Practitioners”(142 pages) consider skipping to the most personally relevant sec-tion either “New Practitioner” (160 pages), “Mid Career Practi-tioner” (104 pages) or “Mature Practitioner” (110 pages). Theremaining text is fully categorized and can be used as a reference asrelevant topics are encountered.

The needs discussed and solutions provided are specific to theunique disadvantages and circumstances physicians currently findthemselves dealing with i.e. “entering the workforce a decade laterthan contemporaries…enormous student debt…family and friendsperception of them as affluent…health reform and managed carereducing remuneration…burdensome government scrutiny…IT,privacy rules, and PP-ACA regulations…a three decades long bullmarket in bonds and equities is over…changes in the tax code, elec-tronic connectivity initiatives, various new practice risks, healthcarereform and the PP-ACA”.

Thankfully, the ambitiousness and scope of the book still resultedin a germane, fact-based and easily assessable read which avoids un-necessary technical jargon. The practical knowledge is not buried insuperfluous pages of information, proof of this can be found in thevery first chapter, section one easily one of my favorite chapters“Unifying the Physiologic and Pysychologic Financial Planning Di-vide ~ Holistic Life Planning, Behavioral Economics, Trading Ad-dition, and the Art of Money”. This holistic chapter on money andour psychological relationship to it prepares a reader for all the fol-lowing chapters. Based on the contributing authors backgroundsand the final work Dr Marcinko’s modus operandi seems to havebeen “by physicians for physicians”.

“Comprehensive” in the title refers to both personal as well asmedical practice financial issues with both spheres being extensivelyaddressed for the health care professional. Chapter 8 in the “NewPractitioner” section titled “Modern Risk-Management Issues forPhysicians ~ It’s Not Just about Medical Malpractice Liability In-surance Anymore” is a condensed 20 pages addressing 69 separaterisks a medical practice can be faced with in today’s new healthcare2.0 environment. While these 20 pages are sobering, the risks canbe planned for and largely mitigated.

The dozens of contributing authors are respected experts in theirrespective fields and are either doctors themselves or have specializedin serving the medical community. The book taps into the various au-thors and their wealth of expertise to guide the reader through a myr-iad of medically related financial topics in the order in which they canbe expected to be faced in a typical contemporary medical career.

One contributing author, Dr. Michael J. Burry, was one of thefirst to recognize the sub-prime mortgage crisis (and to profit fromit) and is portrayed by actor Christian Bale in the current Hollywoodhit “The Big Short”. Dr. Burry authored chapter 14 in the “Mid-Career Practitioner” section titled “Hedge Funds: Wall Street Per-sonified”. This is relevant for most mid-career physicians since thisis typically the point when their assets and income have reached alevel where the government regulators will deem them “accreditedinvestors”. Once deemed to have enough wealth to risk, the “accred-ited investor” is fair game for the hedge fund salesmen. Dr. Burryarms the reader with 23 concise pages on hedge funds with which aphysician can defend themselves.

Local San Antonio-based author Timothy J. McIntosh (MPH,MBA, CFP, CMP) founder and chief investment officer of StrategicInvestment Partners (SIPCO), author of the “Bear Market SurvivalGuide”, “The Sector Strategist” and an upcoming book “The Div-idend Manager” authors chapters 11, 13, & 19 on investment vehi-cles, risk and return analysis, investment banking, and securitiesmarkets for the new, mid-career and mature practitioner sections ofthe book. McIntosh prepares the physician reader for their invest-ment conversations with Wall Street and finance industry represen-tatives and discusses separate account management a method ofreducing or even eliminating Wall Street products from an invest-ment portfolio.

Comprehensive Financial Planning Strategies for Doctors and Ad-visors…this timely tome is available from Amazon in both hardcover (99.95) as well as kindle versions (79.96) and would make agreat gift for any physician.

Terry Langston is a Registered Investment Advisor with Strategic In-vestment Partners LLC (SIPCO) a national fee only fiduciary RIA firmspecializing in serving physicians and their families headquartered inSan Antonio, Texas.

COMPREHENSIVE FINANCIAL PLANNING STRATEGIES for DOCTORS and ADVISORSBest Practices from Leading Consultants and Certified Medical PlannersBy Dr. David Edward Marcinko & Prof. Hope Rachel Hetico (Editors)


Gunn Acura11911 IH-10 West

Cavender Audi15447 IH-10 West

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

Batchelor Cadillac11001 IH-10 at Huebner

Tom Benson Chevrolet9400 San Pedro Ave.

Gunn Chevrolet12602 IH-35 North

Ancira Chrysler10807 IH-10 West

Ingram Park Auto Center7000 NW Loop 410

Ancira Dodge10807 IH-10 West


Northside Ford12300 San Pedro Ave.

Cavender GMC17811 San Pedro Ave.

Gunn GMC16440 IH-35 North

*Fernandez Honda8015 IH-35 South

Gunn Honda14610 IH-10 West(@ Loop 1604)

*Gunn Infiniti

12150 IH-10 West

Ancira Jeep10807 IH-10 West


*North Park Lexus

611 Lockhill Selma

North Park LexusDominion

21531 IH-10 WestFrontage Road

*North Park

Lincoln/ Mercury9207 San Pedro Ave.


North Park Mazda9333 San Pedro Ave.

Mercedes-Benzof Boerne

31445 IH-10 W, Boerne

Mercedes-Benzof San Antonio

9600 San Pedro Ave.

Ancira Nissan10835 IH-10 West

Ingram Park Nissan7000 NW Loop 410

Ancira Ram10807 IH-10 West


North Park Subaru9807 San Pedro Ave.

North Park Subaru at Dominion

21415 IH-10 West

Cavender Toyota5730 NW Loop 410

North Park Toyota10703 SW Loop 410

*Ancira Volkswagen5125 Bandera Rd.

North Park VW at Dominion

21315 IH-10 West

Land Rover is expanding its Range Rover,

um, range with a new long wheel base

(LWB) version, and—finally!—a Diesel en-

gine option. This is welcome news and clear

evidence that Jaguar-Land Rover is commit-

ted to expanding their market share by going

the extra mile to appeal to any customer who

might be interested in their products. Good

thing, since it’s not like the competition is

sitting still.

I recently tested the Range Rover LWB,

which soccer moms with tall kids (basket-

ball moms?) will certainly appreciate. Orig-

inally designed for China, where

high-status people prefer to be chauffeured

rather than drive themselves, the Range

Rover LWB has been created with the focus

on the rear-seat passengers.

Usually I wait until later in a review to dis-

cuss a vehicle’s interior, but it seemed appro-

priate to talk about the Range Rover LWB’s

larger cabin first because it’s the reason buy-

ers will choose this version over the standard

one. The additional 7.8 inches of wheelbase

is mostly used to increase legroom for those

fortunate enough to be seated in back, and

that change makes a significant difference.

Rather than sit at attention which you will

in the rear seats of the standard Rangie, you

inevitably find yourself stretching out. Either

a three seat bench or twin Captain’s chairs

may be selected, though only the two seat

option allows you to recline up to 17 per-

cent, should you so desire, which let’s face it,

there’s no way you won’t.

When you look at the Range Rover LWB

from the front or rear, you’re reminded of

why the brand has won so many design ac-

colades. From those views, its exterior styling

is fabulous, just like the standard length ver-

sion. You just want one. But from the side it

looks a touch too long, as if it were made of

taffy and the engineers held the front and

rear axles and pulled, which they kind of did.

The rest of the interior is also excellent,

with top-shelf leather, wood, and other ma-

terials just where you expect them to be. I’ve

noted this previously, but in my view, the

whole off road SUV ju-ju is diminished by

the Jaguar-esque rotating shift knob on the

center console. In Jaguars, this styling flour-

ish is a good thing, but in a Range Rover, I

don’t think it works. Otherwise, the rest of

the Range Rover’s cabin is best in class.

On the road, the Range Rover LWB drives

a lot like the standard one, which is a good

thing. Completely comfortable cruising

AUTO REVIEW


2016 Range Rover LWBBy Steve Schutz, MD

through town or hustling over the highway

on the way to the lake house, the Range

Rover LWB imparts a distinctive sense of

well being to driver and passengers under all

circumstances. In fact, the only times I could

even sense the extra wheelbase was around

tight turns or while parking.

When the latest (fourth generation) ver-

sion of the Range Rover launched in 2013,

only two engines were offered, both V8s.

Now the base engine is a 340 HP super-

charged V6, with 510 HP supercharged V8

and 245 HP turbocharged V6 Diesel en-

gines available as options. While the two gas

powered motors are unsurprisingly thirsty at

17/23 and 14/19 MPG city/highway for the

V6 and V8 respectively, the Diesel does

much better at 22/28 MPG. Most owners

won’t care about those fuel economy num-

bers, but if you do, the Diesel Range Rover

is the way to go.

Naturally, Range Rovers, which start at

around $85,000, come well equipped, but a

sampling of interesting options includes sur-

round-view parking cameras, adaptive head-

lights with automatic high-beams, blind-

spot warning, automated parallel-parking

assist, adaptive cruise control, nicer wheels,

ventilated and massaging front seats, and a

front cooler box.

As always, innumerable options are there

for the choosing. And if you really want to

stand out, the ultra-lux Autobiography pack-

age gets you a loaded vehicle with unique

21-inch wheels, upgraded leather trim on

the headliner, dashboard, and other places,

nicer front seats with massaging capability,

and lots of extra exterior color choices.

For a fortunate few able to shell out

$190,000 or so, the Autobiography Black

edition comes with many bespoke trim

pieces, large entertainment screens in the

front seatbacks, electronically deployed

leather lined tables for rear seat passengers,

and many other niceties. Only 100 Autobi-

ography Black edition Range Rovers will be

available this year, and all will be LWB.

The Range Rover has been the luxury

SUV since the glorious third generation ap-

peared almost 15 years ago. But competitors

like the Lexus LX 570, Cadillac Escalade,

and Infiniti QX80 have all been improv-

ing—and let’s not forget the just launched

Bentley Betayga—so Range Rover is staying

vigilant with new versions to maximize their

appeal. I can’t relate to the Autobiography

Black, but the LWB and diesel variants make

a lot of sense. Here’s to competition and all

the good things it brings.

If you’re in the market for this kind of ve-

hicle, call Phil Hornbeak at 210-301-4367.

Steve Schutz, MD, is a

board-certified gastroenterol-

ogist who lived in San Anto-

nio in the 1990s when he

was stationed here in the U.S. Air Force. He

has been writing auto reviews for San Anto-

nio Medicine since 1995.

AUTO REVIEW


san antonio medicine march 2016

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