san antonio medicine may 2016

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MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • MAY 2016 • VOLUME 69 NO. 5

4 San Antonio Medicine • May 2016

Vacation InjuriesVacation Injury Prevention By David A. Sleet, David J. Ederer, Michael F.

Ballesteros, Center for Disease Control ...............14

Foodborne Illness: Hazards and PreventionBy Lawrence R. Suddendorf, PhD ......................19

Lessons from Vacation ExperiencesBy Evan Ratner, MD ........................................22

Aquatic DangersBy Barbara R. Schmitz, LCSW ...........................24

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

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

The Walking Med by Robert G. Johnson, MD...............................................................................27

Business: Buy and Hold Index Funds and the Next Bear Market by Aspect Wealth Management........28

Lifestyle: African Adventure by Janis Turk...............................................................................................30

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

Business of Medicine: Legal and Tax Strategies for Healthcare Organizations and Professionals

By Dana A. Forgione, PhD, CPA, CMA, CFE........................................................................................35

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

The ROI of your Online Reputation by Lilly Ibarra ..................................................................................42

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

Auto Review: 2016 Nissan Maxima, By Steve Schutz, MD .....................................................................44

MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • MAY 2016 • VOLUME 69 NO. 5

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

Telemedicine is becoming popular in the healthcare industry.There are more than a dozen telemedicine companies that are al-ready working with doctors and patients and seen virtually for theirnon-emergency visits. Telemedicine is also playing an importantrole for chronic disease management. After the patient comes fora doctor’s visit for the first initial complete evaluation, follow upcare can be done virtually.

At centers like Joslin Diabetes Center, doctors have started usingvirtual visits for follow-up appointments with out-of-state patients.Medicare, Medicaid, some United Health Care plans, some Hu-mana plans and a few more have approved payments for telehealthservices. As telemedicine is trending upward, other insurance car-riers will soon come on board. Are we ready for this new model?

Clearly there are some advantages of telemedicine:• Reduced health care costs• Easy access to referring physicians and specialists• Easily accessible to patients - reduces travel time and related

stresses for the patient, makes healthcare accessible to people,especially to those living in remote areas

However, problems facing telemedicine aremany and need to be resolved before telemedicine becomes widespread.• Added cost for fast reliable broadband connections, technical

training and equipment• Complicated policies and reimbursement rules• Quackery (how to verify a doctor’s credentials on the Internet)• Special Licensing requirements• Decreased in-person visits can lead to misdiagnosis• Decreased personal care and missing opportunities to hold

hands and develop psychological consultation on some otherfamily issues.

According to CMS, “Telemedicine seeks to improve a patient’shealth by permitting two-way, real-time interactive communica-tion between the patient and the physician or practitioner at thedistant site. This electronic communication means the use of in-teractive telecommunications equipment that includes, at a mini-mum, audio and video equipment.”

“Telemedicine is viewed as a cost-effective alternative to themore traditional face-to-face way of providing medical care (e.g.,face-to-face consultations or examinations between provider andpatient) that states can choose to cover under Medicaid. This def-inition is modeled on Medicare’s definition of telehealth services.”(42 Code of Federal Regulations 410.78)

“As CMS gets ready to pay primary care physicians on a differentmodel starting in 2017, from a fee-for-service to a monthly fee formanaging patients, provider practices will be able to participate intwo ways. In Track 1, the agency will pay a monthly fee to practicesthat provide specific services. That fee is in addition to the fee-for-service payments under the Medicare Physician Fee Schedule forcare. In Track 2, practices will also receive a monthly care manage-ment fee, and instead of full Medicare fee-for-service payments forevaluation and management services, they will receive reducedMedicare fee-for-service payments and up-front comprehensiveprimary care payments. This hybrid payment design will allowgreater flexibility in how practices deliver care outside of the tradi-tional face-to-face encounter, the agency said. For example, prac-tices might offer telemedicine visits or simply provide longer officevisits for patients with complex needs. Practices in both tracks willreceive upfront incentive payments that they might have to repayif they do not perform well on quality and utilization metrics.”

I feel that there is a need to preserve the sanctity of a patient-physician relationship. Part of our problem is not responding tothe evolving trends and leading the way, rather than being pointedout, complaining and wondering why we are losing ground.

Telemedicine can be used as a valuable add-on service to enhancepatient care rather than replacing much needed face-to-face inter-action. In-person, face-to-face interaction between a physician andpatient allows physicians to handle many complex social and psy-chological issues pertaining to the patient and their family mem-bers which cannot be achieved by telemedicine. Telemedicine lacksthe “touch” which has the power of healing.

For more information on telehealth services,please visit the CMS website.

Centers for Medicare & Medicaid Services (CMS)Policy (visit www.cms.gov/medicare/medicare-general-informa-tion/telehealth/index.html).

The State of Texas Medical Board has answers to frequentlyasked questions pertaining to telemedicine at www.tmb.state.tx.us/(Telemedicine FAQs).

PRESIDENT’SMESSAGE

Telemedicine DebateContinues...By Dr. Jayesh Shah, 2016 BCMS President


BCMS Delegation to TMA heading to Dallas for TexMed 2016

Dr. David Henkes running for TMA president-elect

At the time of this writing, the BCMS Delegation to TMA has reviewed

over 30 resolutions under consideration by the TMA House of Delegates

and is headed to Dallas to represent BCMS in TMA's annual meeting tak-

ing place April 29-30 at the Hilton Anatole. The BCMS Delegation has

submitted a resolution entitled: Physician Collaboration in Active Child

Protective Services Investigations, which asks that

TMA work with the Texas Department of Family and Protective Services

and Child Protective Services to eliminate barriers to useful and productive

interaction with physicians for the benefit of the children. To read the full

resolution, visit www.bcms.org.

A major highlight of this year's Delegation's work has been to encourage

colleagues from around the state to support our own, Dr. David Henkes,

in his bid to become TMA president-elect. Elections take place during TexMed on April 30. For more details, visit

www.drdavidhenkes.com.

For more information on activities of the BCMS Delegation to TMA, contact Mary Nava at [email protected].


BCMS NEWS

The BCMS General Membership meeting on April 5 was hosted by Cumber-land Surgical Hospital at 5330 N. Loop 1604 West.

BCMS Delegation to TMA members discuss and prepare ac-tion for the TMA House of Delegates business meeting.

Wendell England of TMA Insurance Trust,Dr. Ubaldo Beato and BCMS DevelopmentDirector August Trevino.

Dr. Pavithra Pattabiraman gave an overview of DocbookMD, aHIPAA-compliant texting service that is free for members ofTMA and BCMS.

April 5 General Membership Meetingheld at Cumberland Surgical Hospital

BCMS NEWS


VACATIONINJURIES

According to the World Health Organization (WHO), injuriesare among the leading causes of death and disability in the world,and they are the leading cause of preventable death in travelers.Among travelers, data show that injuries are one of the leadingcauses for consulting a physician, hospitalization, repatriation, anddeath. Worldwide, injuries are the leading cause of death for youngpeople aged 15–29 years. Estimates have reported that 18%–24%of deaths among travelers in foreign countries are caused by injuries.Infectious diseases accounted for only 2% of deaths to travelersabroad. Contributing to the injury toll while traveling are exposureto unfamiliar and perhaps risky environments, differences in lan-guage and communications, less stringent product safety and vehiclestandards, unfamiliar rules and regulations, a carefree holiday or va-cation spirit leading to more risk-taking behavior, and overrelianceon travel and tour operators to protect one’s safety and security.

From 2011 through 2013, an estimated 2,466 US citizens diedfrom non-natural causes, such as injuries and violence, while in for-eign countries (excluding deaths occurring in the wars in Iraq andAfghanistan). Motor vehicle crashes—not crime or terrorism—arethe number 1 killer of healthy US citizens living, working, or trav-eling in foreign countries. From 2011 through 2013, 621 Americansdied in road traffic crashes abroad (25% of all non-natural deathsto US citizens abroad). Another 555 were victims of homicide(23%), 392 committed suicide (16%), and 309 were victims ofdrowning (13%) (Figure 2-02). Other less common but serious in-juries are related to natural disasters, aviation accidents, drugs, ter-rorism, falls, burns, and poisoning.

If a traveler is seriously injured, emergency care may not be avail-able or acceptable by US standards. Trauma centers capable of pro-viding optimal care for serious injuries are uncommon outside urbanareas in many foreign destinations. Travelers should be aware of theincreased risk of certain injuries while traveling or residing abroad,particularly in developing countries, and be prepared to take pre-ventive steps.

ROAD TRAFFIC INJURIESGlobally, an estimated 3,300 people are killed each day, including

720 children, in road traffic crashes involving cars, buses, motorcy-cles, bicycles, trucks, and pedestrians. Annually, 1.24 million arekilled and 20–50 million are injured in traffic crashes—a numberlikely to double by 2030. Although only 53% of the world’s vehicles

are in developing countries, >90% of road traffic casualties occur inthese countries.

International efforts to combat road deaths command a tiny frac-tion of the resources deployed to fight diseases such as malaria andtuberculosis, yet the burden of road traffic injuries is comparable. Inresponse to this crisis, in March 2010 the 64th General Assembly ofthe United Nations described the global road safety crisis as “a majorpublic health problem” and proclaimed 2011–2020 as “The Decadeof Action for Road Safety.” On April 19, 2012, the United NationsGeneral Assembly adopted a new resolution (A/66/PV.106) to im-prove global road safety by implementing plans for the decade, settingambitious targets, and monitoring global road traffic fatalities.

According to Department of State data, road traffic crashes arethe leading cause of injury deaths to US citizens while abroad (Fig-ure 2-02). Of the 621 US citizens killed in road traffic crashes from2011 through 2013, approximately 110 (18%) deaths involved mo-torcycles. Unlike in the United States, in many countries, 2- and 3-wheeled vehicles outnumber cars, and travelers unfamiliar withdriving or riding motorcycles may be at higher risk of crashing. Mostnon-natural American deaths in Thailand and Vietnam, populartravel destinations, were related to motorcycle use. Motorcycle useis also dangerous for travelers in countries where motorcycles are notthe primary mode of transportation. The reported rate of motorbikeinjuries in Bermuda is much higher in tourists than in the local pop-ulation, and the rate is highest in people aged 50–59 years. Motorvehicle rentals in Bermuda and some other small Caribbean islandsare typically limited to motorbikes for tourists, possibly contributingto the higher rates of motorbike injuries. Loss of vehicular control,unfamiliar equipment, and inexperience with motorized 2-wheelerscontributed to crashes and injuries, even at speeds <30 milesper hour.

Road traffic crashes are common among foreign travelers for anumber of reasons: lack of familiarity with the roads, driving on theopposite side of the road, lack of seat belt use, the influence of alco-hol, poorly made or maintained vehicles, travel fatigue, poor roadsurfaces without shoulders, unprotected curves and cliffs, and poorvisibility due to lack of adequate lighting. In many developing coun-tries, unsafe roads and vehicles and an inadequate transportation in-frastructure contribute to the traffic injury problem. In many ofthese countries, motor vehicles often share the road with vulnerableroad users, such as pedestrians, bicyclists, and motorcycle users. The

Vacation Injury PreventionDavid A. Sleet, David J. Ederer, Michael F. Ballesteros

Center for Disease Control


VACATIONINJURIES

mix of traffic involving cars, buses, taxis, rickshaws, large trucks,and even animals increases the risk for crashes and injuries.

Millions of US citizens travel to Mexico each year, and >150,000people cross the US–Mexico border daily. Travelers should be par-ticularly cautious in Mexico; from 2011 through 2013, 27% of all

deaths of US citizens abroad occurred in that country, where >200Americans died in road traffic crashes.

Strategies to reduce the risk of traffic injury are shown in Table2-12. The Association for International Road Travel (www.asirt.org)and Make Roads Safe (www.makeroadssafe.org) have useful safetyinformation for international travelers, including road safety check-lists and country-specific driving risks. The Department of State has

safety information useful to international travelers, including roadsafety and security alerts, international driving permits, and travelinsurance (www.travel.state.gov).

Leading causes of injury death for US citizens in foreign countries, 2011-20131,2

1 Data from US Department of State. Death of US citizensabroad by non-natural causes. Washington, DC: US Depart-ment of State; 2014 [cited 2014 March 26]. Available from:http://travel.state.gov/content/travel/english/statistics/deaths.html.

2 Excludes deaths of US citizens fighting wars in Afghanistanor Iraq, and deaths that were not reported to the nearest USembassy or consulate.

Figure 2-02.

Recommended strategies to reduce injuries while abroad

Table 2-12. HAZARD PREVENTION STRATEGIESRoad Traffic CrashesLACK OF SEAT BELTS AND CHILD SAFETYSEATS

DRIVING HAZARDS

COUNTRY-SPECIFICDRIVING HAZARDS

MOTORCYCLES,MOTOR BIKES, ANDBICYCLES

ALCOHOL-IMPAIREDDRIVING

CELLULAR ACTIVITIES

TAXIS OR HIRED DRIVERS

Always use safety belts and child safety seats. Rent vehicles with seat belts; when possible, ride in taxis withseat belts and sit in the rear seat; bring child safety seats and booster seats from home for children to rideproperly restrained.

When possible, avoid driving at night in developing countries; always pay close attention to the correctside of the road when driving in countries that drive on the left.

Check the Association for Safe International Road Travel website for driving hazards or risks by country(www.asirt.org).

Always wear helmets (bring a helmet from home, if needed). When possible, avoid driving or riding onmotorcycles or motorbikes, including motocycle and motorbike taxis. Traveling overseas is a bad time tolearn to drive a motorcycle or motorbike.

Alcohol increases the risk for all causes of injury. Do not drive after consuming alcohol, and avoid ridingwith someone who has been drinking.

Do not use a cellular telephone or text while driving. Many countries have enacted laws banning cellulartelephone use while driving, and some countries have made using any kind of telephone, including hands-free, illegal while driving.

Ride only in marked taxis, and try to ride in those that have safety belts accessible. Hire drivers familiarwith the area.

continued on page 16

visit us at www.bcms.org 15

VACATIONINJURIES

WATER AND AQUATIC INJURIESDrowning accounts for 13% of all deaths of US citizens abroad.

Although risk factors have not been clearly defined, these deaths aremost likely related to unfamiliarity with local water currents andconditions, inability to swim, and the absence of lifeguards on duty.Rip currents can be especially dangerous, as are sea animals such asurchins, jellyfish, coral, and sea lice. Alcohol also contributes todrowning and boating mishaps.

Drowning was the leading cause of injury death to US citizensvisiting countries where water recreation is a major activity, such asFiji, the Bahamas, Jamaica, and Costa Rica. Young men are partic-ularly at risk of head and spinal cord injuries from diving into shal-low water, and alcohol is a factor in some cases.

Boating can be a hazard, especially if boaters are unfamiliar withthe boat, do not know proper boating etiquette or rules for water-craft navigation, or are new to the water environment in a foreigncountry. From 2011 through 2013, maritime accidents accountedfor 8% of deaths to healthy Americans abroad. Many boating fatal-ities result from inexperience or failure to wear lifejackets.

Scuba diving is a frequent pursuit of travelers in coastal destina-tions. The death rate among all divers worldwide is thought to be15–20 deaths per 100,000 divers per year. Travelers should eitherbe experienced divers or dive with a reliable dive shop and instruc-tors. See the Scuba Diving section later in this chapter for a moredetailed discussion about diving risks and preventive measures.

OTHER INJURIESFrom 2011 through 2013, aviation incidents, drug-related inci-

dents, and deaths classified as “other unintentional injuries” ac-counted for 22% of deaths to healthy US citizens abroad (Figure 2-02). Fires can be a substantial risk in developing countries wherebuilding codes do not exist or are not enforced, there are no smokealarms, there is no access to emergency services, and the fire depart-ment’s focus is on putting out fires rather than on fire prevention orvictim rescue.

Travel by local, lightweight aircraft in many countries can be risky.From 2011 through 2013, an estimated 82 US citizens abroad werekilled in aircraft crashes. Travel on unscheduled flights, in small air-craft, at night, in inclement weather, and with inexperienced pilotscarries the highest risk.

Before flying with children, parents and caregivers should checkto make sure that their child restraint system is approved for use onan aircraft. This approval should be printed on the system’s infor-mation label or on the device itself. The Federal Aviation Adminis-tration (FAA) recommends that a child weighing <20 lb use arear-facing child restraint system. A forward-facing child safety seatshould be used for children weighing 20–40 lb. FAA has also ap-proved a harness-type device for children weighing 22–44 lb.

Travel health providers, vendors of travel services, and travelers themselves should consider the following:• Purchasing special travel health and medical evacuation insurance

if their destinations include countries where there may not be ac-cess to good medical care (see the Travel Insurance, Travel HealthInsurance, & Medical Evacuation Insurance section later in thischapter).

Recommended strategies to reduce injuries while abroad (continued)

Table 2-12. HAZARD PREVENTION STRATEGIESRoad Traffic CrashesBUS TRAVEL

PEDESTRIAN

HAZARDS

Other TipsAIRPLANE TRAVEL

DROWNING

BURNS

Avoid riding in overcrowded, overweight, or top-heavy buses or minivans.

Be alert when crossing streets, especially in countries where motorists drive on the left side of the road.Walk with a companion or someone from the host country.

Avoid using local, unscheduled aircraft. If possible, fly on larger planes (>30 seats), in good weather, duringthe daylight hours, and with experienced pilots. Children <2 years should sit in a child safety seat, not ona parent’s lap. Whenever possible, parents should travel with a safety seat for use before, during, and aftera plane ride.

Avoid swimming alone or in unfamiliar waters. Wear life jackets while boating or during water recreationactivities.

In hotels, stay below the sixth floor to maximize the likelihood of being rescued in case of a fire. Bring yourown smoke alarm.

continued from page 15


VACATIONINJURIES

• Because trauma care is poor in many countries, victims of injuriesand violence can die before reaching a hospital, and there maybe no coordinated ambulance service available. In remote areas,medical assistance and modern drugs may be unavailable, andtravel to the nearest medical facility can take a long time.

• Adventure activities, such as mountain climbing, skydiving,whitewater rafting, dune-buggying, and kayaking, are popularwith travelers. The lack of rapid emergency trauma response, in-adequate trauma care in remote locations, and sudden, unex-pected weather changes that compromise safety and hamperrescue efforts can delay access to care.

• Travelers should avoid using local, unscheduled, small aircraft. Ifavailable, choose larger aircraft (>30 seats), as they are more likelyto have undergone more strict and regular safety inspections.Larger aircraft also provide more protection in the event of acrash. For country-specific airline crash events,see www.airsafe.com.

• When traveling by air with young children, consider bringing achild safety seat approved for use on an aircraft.

• To prevent fire-related injuries, travelers should select accom-modations no higher than the sixth floor. (Fire ladders generallycannot reach higher than the sixth floor.) Hotels should bechecked for smoke alarms and preferably sprinkler systems.

Travelers may want to bring their own smoke alarm. Two escaperoutes from buildings should always be identified. Crawlinglow under smoke and covering one’s mouth with a wet clothare helpful in escaping a fire. Families should agree on a meetingplace outside the building in case a fire erupts.

• Improperly vented heating devices may cause poisoning from car-bon monoxide. Carbon monoxide at the back of boats near theengine can be especially dangerous. Travelers may want to carrya personal detector that can sound an alert in the presence of thislethal gas.

• Travelers should consider learning basic first aid and CPR beforetravel overseas with another person. Travelers should bring atravel health kit, which should be customized to the anticipateditinerary and activities (see the Travel Health Kits section later inthis chapter).

• Suicide is the third-leading cause of injury death to US citizensabroad, accounting for 16% of non-natural deaths. For longer-term travelers (such as missionaries and volunteers), social isola-tion and substance abuse, particularly while living in areas ofpoverty and rigid gender roles, may increase the risk of depressionand suicide. See the Mental Health section later in this chapterfor more detailed information.



BIBLIOGRAPHY1 Ball DJ, Machin N. Foreign travel and the risk of harm. Int J Inj

Contr Saf Promot. 2006 Jun;13(2):107–15.

2 Cortes LM, Hargarten SW, Hennes HM. Recommendations forwater safety and drowning prevention for travelers. J Travel Med.2006 Jan–Feb;13(1):21–34.

3 FIA Foundation for the Automobile and Society. Make roads safereport: a decade of action for road safety. FIA Foundation for theAutomobile and Society; 2009 [cited 2014 Aug 8]. Availablefrom: http://www.fiafoundation.org/connect/publications.

4 Guse CE, Cortes LM, Hargarten SW, Hennes HM. Fatal injuriesof US citizens abroad. J Travel Med. 2007 Sep–Oct;14(5):279–87.

5 Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report onviolence and health. Lancet. 2002 Oct 5;360(9339):1083–8.

6 Lawson CJ, Dykewicz CA, Molinari NA, Lipman H, Alvarado-Ramy F. Deaths in international travelers arriving in the UnitedStates, July 1, 2005 to June 30, 2008. J Travel Med. 2012 Mar–Apr;19(2):96–103.

7 Leggat PA, Fischer PR. Accidents and repatriation. Travel MedInfect Dis. 2006 May–Jul;4(3–4):135–46.

8 McInnes RJ, Williamson LM, Morrison A. Unintentional injuryduring foreign travel: a review. J Travel Med. 2002 Nov–Dec;9(6):297–307.

9 Sleet DA, Balaban V. Travel medicine: preventing injuries to chil-dren. Am J Lifestyle Med. 2013 Mar 10;7(2):121–9.

10World Health Organization. WHO global status report on roadsafety 2013: supporting a decade of action Geneva: World HealthOrganization; 2013 [cited 2014 Sep 19]. Availablefrom: http://www.who.int/violence_injury_prevention/road_safety_status/2013/en/.

VACATIONINJURIES



VACATIONINJURIES

As we enter the spring and summer seasons, typical times of theyear for outdoor activities and travel, we need to protect ourselvesfrom foodborne illness (FBI). Foods prepared by others, foods trans-ported away from kitchens and homes, and mishandled foods be-come support systems for dangerous hazards that result in everythingfrom inconvenience to tragedy.

FBI not only incapacitates but kills victims. We need nourish-ment, we desire convenience, and foods usually add to the enjoy-ment of our activities; therefore, food safety should become aprimary goal of planning our summertime fun. Another potentialconcern is the vague combination of signs and symptoms initiallyobserved in FBI: nausea, vomiting, diarrhea, dehydration, cramps,prostration, chills, fever, headache, and fatigue. Definitive medicalcare is usually not sought; victims often resort to over-the-countercompounds for symptomatic relief. This may result in a delay thatcomplicates a potentially deadly illness. Obvious signs such as jaun-dice (Hepatitis) or hemolytic uremic syndrome (Shiga-toxin pro-

ducing E. coli) appear later and in only these specific circumstances.Some statistics to view:• Over 48 Million FBI cases per year • Or, 1 in 6 Americans get a FBI• Over 128,000 serious cases requiring hospitalization• 3,000 Deaths from food borne diseases• Costs of $152 billion per year in health care and other losses

(CDC, 2011)

Two basic questions will be addressed here: what are the hazards, and how should we prevent or control them?

The answers to our questions will discuss:• the causes of food borne illness • safe preparation and storage to avoid serving contaminated foods

and thereby minimize food borne illness• the role of personal health and hygiene in food safety

FOODBORNE ILLNESS: Hazards and Prevention

By Lawrence R. Suddendorf, PhD



The U.S. Food and Drug Administration (FDA) establishes thefoundation for food safety in its Model Food Code, officially revisedand published every four years. We will refer to the current (FDA,2013) version in our brief discussion here. Food safety depends onstrong partnerships. The Centers for Disease Control and Prevention(CDC), the FDA, and U.S. Department of Agriculture’s (USDA)Food Safety Inspection Service collaborate at the federal level to pro-mote food safety. State and local health departments and food in-dustries also play critical roles in all aspects of food safety. CDCprovides the vital link between illness in people and the food safetysystems of government agencies and food producers. Note that in-dividual states’ legislatures write the enforceable laws and delegateenforcement responsibilities to local health departments, so whilethere is uniformity across the nation, some states adopt more restric-tive standards.

Food safety hazards are divided into three major categories: bio-logical, chemical, and physical. Biological hazards are microorgan-isms such as bacteria, viruses, parasites, and fungi. Chemical hazardsare delineated in two major categories: naturally-occurring and man-made. The several foods identified as potential allergens are catego-rized as chemical hazards. Physical hazards are usually foreignmaterials improperly incorporated into foods, but also natural sub-stances left due to improper processing.

Bacterial hazards grow in foods, so a very small amount of con-tamination can quickly become significant problems. Good tem-perature control is essential to preventing growth, but it must bepracticed along with other clean and sanitary handling techniques.Some bacteria, like Campylobacter, Listeria, Vibrio, Salmonella, andShigella directly infect because they are present as naturally occurringflora in various categories of foods that are usually improperlycooked or mishandled after cooking. Several others, such as Staphy-lococcus aureus, Clostridium botulinim, Bacillus cereus, Clostrid-ium perfringens, and Shiga-toxin producing strains of Escherica coliproduce toxins that quickly cause symptoms to appear. These toxinsare heat stable, so cooking foods will not remedy a situation wherefood was mishandled in its raw state. The most common viral haz-ards include Hepatitis A and Norovirus (the most common of theFBI). Common parasites include Trichinella and Anasakis. Fungi(molds and yeasts) become FBI sources in improperly stored, agedfoods. Most are also toxin producers.

Chemical hazards that occur naturally are toxins found in certaintypes of seafood, mushrooms, rhubarb leaves, potato sprouts, andfava beans. Proteins found in peanuts, egg products, milk products,fish, shellfish, crustaceans, wheat gluten, and soy products are aller-genic chemicals. Man-made chemical hazards include agriculturalchemicals such as herbicides and pesticides, cleaning and sanitizingagents, reactive metals and plastics improperly used as food contact

surfaces, and medications. The best ways to deal with these is knowl-edge of their presence, proper use, and avoidance.

Various physical hazards can cause a choking or laceration hazardif ingested; they may also be a source of biological or chemical haz-ards. Common physical hazards include: glass, jewelry, plastic (wrap-pings, containers), wood (cutting boards, spoons), stones/pits/seeds,metal fragments from can openers, eggshells, and hair. Proper han-dling and preparation procedures should prevent the presence ofthese types of hazards.

Knowing what the various types of hazards causing FBI are, wecan now address their prevention or control.

The most serious FBI cases are caused by bacteria, so our discus-sion will focus on this particular type of hazard. Proper temperaturecontrol focuses on a simple axiom: keep hot food hot, keep coldfood cold, and keep frozen food frozen, or don’t keep it! The FDAconsiders various high-protein, neutral pH, high-water activity foodsas Time and Temperature Control for Safety (TCS) Foods. Foodstraditionally known as “perishable”: meat, dairy, poultry, eggs,seafood, soy, leafy greens, prepared rice and beans, even potatoesand tomatoes fit in this category.

The FDA Temperature Danger Zone (TDZ), a range of 94 de-grees on the Fahrenheit scale, illustrates the versatility of bacterialgrowth. Therefore, keeping foods out of the TDZ or rapidly pro-cessing through the TDZ should be a primary goal. The total timefood is allowed to be in the TDZ should not exceed four hours; thisis all the time it takes for enough bacteria to be generated to causeillness. Acidification and lowering the available water in a food alsohelps prevent bacterial growth. Most of the FBI-causing bacteria areeither anaerobes or facultative anaerobes; therefore, vacuum-packedfoods and canned foods offer little protection from bacterial growth.

Fig. 1, Temperature Standards

The CDC and FDA recommend four essential actions to keepfoods safe: COOK-CHILL-CLEAN-SEPARATE (CDC, 2015).These practices may be paired: cooking and chilling maintain proper

VACATIONINJURIES



temperature control; cleaningand separating prevent contam-

ination and cross-contamina-tion, respectively.

COOK and CHILLAs listed in Figure 2, foods

have different safe cooking tem-perature standards. These arebased upon a combination ofthe necessity to kill typical florawhile not overcooking foods.Higher temperatures/longertimes are allowed as personaldesires. Notice three uniquestandards: rare roast beef main-tains a cool, red center by cook-ing to an internal temperatureof only 130°F, but held for avery long time; reheating anyfood requires cooking to at least165°F; use of a microwave ap-pliance requires a special time standard. Once a hot food is properlycooked, it must be held at 135°F or higher. It is best to use plentifulvolumes of ice or ice-water slush for chilling hot foods and keepingcold foods cold. Crushed or cube ice provides excellent contact withfood containers to help insure that they remain at or below 41°F.Reusable blocks of coolant are satisfactory, but should be placedabove containers within a cooler for best effect. The Code does notprescribe a specific temperature range for frozen foods; it states thatthe food must be frozen solid with no evidence of thawing. Manylabels now include storage and preparation instructions. These pre-dominantly exceed the basic standards discussed here.

CLEAN and SEPARATEProper hand washing is the principle means of preventing spread

of any communicable disease, including the FBI. Sanitizing gelsshould only be used as a last resort, substituting when warm waterand soap are not available. The isopropyl alcohol is not a universalsanitizer, and dirt should be removed from hands first. Dishes andutensils should always be cleaned with the hottest water possible(171°F is the recommended sanitizing temperature, but may not bepossible in home or outdoor locations.). Disposable items can cer-tainly add a safety factor when serving food, but these must be pro-tected or wrapped prior to use. Whenever working with differentfoods, especially between raw and cooked or when handling any ofthe potential allergens, clean and separate containers and surfaces

judiciously. Inadvertent cross-contamination is frequently the causeof serious FBI.

While there are many additional specific practices that promote foodsafety, one can reasonably protect family and friends by remembering:

KEEP HOT FOOD HOT, COLD FOOD COLD, FROZEN FOOD FROZEN, OR DON’T KEEP IT

and: COOK-CHILL-CLEAN-SEPARATEEnjoy your travels and summer fun with safe food practices!

References and Additional Resources:• CDC statistics, 2011: www.cdc.gov/foodborneburden/2011-

foodborne-estimates.html• FDA Model Food Code, 2013: www.fda.gov/Food/GuidanceReg-

ulation/RetailFoodProtection/FoodCode/ucm374275.htm • CDC information for consumers, 2015: www.cdc.gov/food-

safety/groups/consumers.html

Lawrence R. Suddendorf, PhD, MT (ASCP) is orig-inally from Cincinnati, OH. He directed medical lab-oratories and taught Medical Laboratory Science inmany venues, both civilian and military over the past47 years. Currently, Larry serves as a consultant and

instructor in food safety while also continuing to teach online medicallaboratory science. He resides in Kerr County with his wife, Joan, aretired Registered Nurse.

VACATIONINJURIES

Fig. 2, FDA Minimum Cooking Temperature/Time Standards


VACATIONINJURIES

Life is not measured by the number of breaths we take, but by the

moments that take our breath away. Vacations are a time away from

the routine that we hope will take our breath away. To get it right, we

spend a lot of time deciding the specifics of what to take, what is a

necessity and what can be left behind. I’ll take my hiking boots, but

should I take my running shoes as well? Will I need four pair of socks

or five? Should I pack an extra pair just in case, after all, they don’t

take up much space? How many of us put the same thoughtfulness

into building a vacation emergency first aid kit? It shouldn’t take up

much space, but it could make all the difference.

SCENARIO ONE: Teenage boy wants to clear up some acne to

ensure the Italian girls will be unable to resist his charms. Starts a

new medication one day prior to leaving for the family vacation.

Two hours into the transatlantic flight his ears swell to elephantine

proportions, only dwarfed by the swelling of his hands and feet.

Luckily the vibrant red, ever changing, seemingly glowing patches

of skin distract the amazed onlookers from the swelling. My son

was experiencing a pretty impressive allergic reaction to the new

medication. Thankfully his airway was not compromised and he

could still breath. I stopped the new medication and gave Benedryl

and Zantac. Most people know that Benedryl is a histamine blocker

that can be used to reduce allergic reactions, but Zantac (ranitidine)

is also a strong and useful histamine blocker even though it is best

known for reducing heartburn.

LESSON ONE: Over the counter Benedryl and Zantac are great

for most allergic reactions, and as a bonus can also help with a little

heartburn, or occasional trouble sleeping.

SCENARIO TWO: Teenage boy wants a great tan to ensure the

Florida girls will be unable to resist his charms. Spends the entire first

day out in the sun without any sunblock or protective clothing that

may slow his transition to a golden color. That night he once again

turns bright red. this time it is a diffuse color sparing only the area

between his waist and knees that was covered by his shorts. We apply

cool wet towels to help reduce the temperature, and provide sympto-

matic relief. We make sure sure that he drinks a lot of water, juice and

gatoraid to stay hydrated and we give him an anti-inflammatory med-

ication to help control the pain and the injury. We then make sure

that he gets frequent applications of topical aloe.

LESSON TWO: Over the counter Non steroidal anti-inflamma-

tory (Advil, Motrin, Aleve) can be effective treating moderate pain

and inflammation. A small vial of zinc oxide cream can go a long way

in obtaining great protection from the sun.

SCENARIO THREE: Five year old girl swimming at a beach sus-

tains multiple painful jelly fish stings and is very scared and uncom-

fortable. Mother takes her behind a beached sail boat and rinses the

stings with urine.This does not relieve the pain at all and emotionally

scars both Mother and Child for life.

LESSON THREE: Peeing on jelly fish stings is not an effectivetreatment. Thank goodness my wife administered the “treatment” be-

LESSONS FROM VACATION EXPERIENCES

By Evan Ratner, MD


VACATIONINJURIES

cause I could not have done that to my daughter. Could I have

“treated” my son from the first two scenarios, no problem. Would it

have helped the jellyfish stings? Not one bit. Can medications from

lessons one and two be helpful? Absolutely.

SCENARIO FOUR: Adult male sailing across the Gulf of Mexico

with other medical students and sustains a laceration to the calf after

a slip and fall on the wet deck. Fight off, repel, refuse all interventions

ranging from applying a tourniquet, to amputation, to pouring alco-

hol on the wound to clean it — to just manning up and trying not to

bleed everywhere. Ultimately the wound was cleaned with soap and

water, antibiotic ointment was applied and a clean compressive dress-

ing applied.

LESSON FOUR: Stay away from first, second and third year med-

ical students if you are ever injured or sick. Carry some antibiotic oint-

ment, a small tube or a few individual packets to apply to burns and

wounds. A 2-3 inch ace wrap is an incredibly versatile tool. It can be

used to a form a snug dressing. It can also be handy to hold ice onto

an extremity, or support an injured limb, or attach something rigid

to form a splint. Most lacerations can be closed with a dressing that

holds the two skin edges in close approximation. It may not heal as

quickly or with as little scarring as stitches but it usually does the job.

SCENARIO FIVE:After meticulously packing for a trip including

the vacation medical and injury pack an adult male packs his routine

medications in his suitcase and flies to one location as his suitcase

chooses another location. The suitcase is found and reunited with the

adult male 2 days later. Fortunately, none of the medications were

critical on a daily basis.

LESSON FIVE: Your routine medications and your emergency

pack should always be carry-ons.

SCENARIO LAST: Four year old falls down and skins her knee

on the streets of New Orleans. Father and child are clearly upset, she

does not want to move or walk or do anything except cry. Quick ex-

amination by helpful bystander with “magic bandaid” cures the child

and results in a free dinner at the Father’s new cajun restaurant.

LESSON LAST: Always carry a bandaid or two. They are small,

flat and easily stow in your wallet or purse for long periods of time.

They are much more useful than other things that can spend prolonged

times in a young man’s wallet (see scenario one and two). I promise

you will be surprised how often you can save the moment with a

bandaid and how it will enhance your reputation as a physician.

So go make some memories.


AQUATIC DANGERS

This is the season when many of us spend a lot of time outdoors.

Many of us will be going to the coast and various lakes for spring

break. Thousands of marine and freshwater aquatic and semi aquatic

creatures live in these waters. Few actually pose a threat to humans,

but injuries can be inflicted if the animal is frightened or disturbed.

The animals rarely pursue humans but the bites/stings are used as a

defense mechanism to a perceived threat.

Some of the marine animals with whom you might come in con-

tact are: jellyfish, sponges, bristle worms, sea urchins, stingrays, cat-

fish, lionfish, cone-shells, sharks, snakes, alligators, snapping turtles,

and more.

Beware the jellyfish, those gooey blobs that appear delicate or

transparent and are hard to see in the water. You find them in every

ocean, in cold and warm seas. They are made mostly of water and

have no muscles, bones, brains, hearts or eyes; however, they have

nerves in their tentacles that sense light and food. They are among

the most numerous predators on Earth and they can sting. The adult

is called a medusa and it resembles a bell with tentacles.

Have you ever felt stabbing pains on your skin at the coast? It

was probably a Portuguese man o’ war. They are blue, appear on the

surface and are a foot long with dozens of tentacles hanging down

that can stretch 50 feet or more. They will fire their venomous ne-

matocysts at anyone who touches them and they have thousands of

these stinging cells.

Most jellies are highly venomous and free swimming. Often you

see jellies in schools.

The box jelly or sea wasp (found in Australia) is the most ven-

omous animal on land or sea. It can kill a human in less than four

minutes. It has enough venom to kill 60 adults and the sting is in-

stantly unbearable. The Hawksbill turtle is the greatest enemy of the

box jelly. Fortunately, there is antivenom.

Some recommended treatments for jellyfish injury are to carefully

remove the tentacles so as not to release more stinging cells; irrigate

with sea water—NOT freshwater or alcohol wash as more cells

could discharge. Wash with vinegar but don’t rub the area until the

vinegar has been applied to stop the stinging cells. When I was in

What to do if you get stabbed, stung, bit or poisonedBy Barbara R. Schmitz, LCSW

Aquatic Dangers



AQUATIC DANGERS

Australia, we used shaving cream and applied it over the

area and removed the nematocysts with a knife edge.

Stepping on a catfish can get you “finned” which is

painful and can be slow to heal. Some spines also have

venomous glands at their base so the venom can get into

the wound. Again, immobilize, clean the injured area,

use topical antibiotics, soak in hot water and monitor

for infection.

Another danger is cone shells. They are magnificent

but extremely predatory. Look but don’t touch. The

venom is often fatal. The cones can smell their prey.

Their raspy tongue is hollow and used as a harpoon.

Suggested first aid is to have the patient rest; immobi-

lize and use a pressure bandage on the extremity. Pro-

vide CPR if the patient is paralyzed even if they are

not able to communicate. Get prompt medical help.

Sharks found in Texas waters are the bull, black tip, tiger and

hammerhead. Probably one of the most dangerous man-eating

sharks alive is the bull shark who can go between fresh and saltwater.

A few firstaid treatments for sharks are to remove the injured

person from the water and try to control bleeding by direct pres-

sure over the bleeding vessels. If necessary, apply a tourniquet be-

tween the wound and the heart to stop arterial blood flow. Do

not remove the tourniquet until expert help is available. Place the

person head-down (Trendelenburg position) to prevent shock, and

keep them warm. Get medical help quickly.

Other common injuries are puncture wounds from sea urchins

and other animals with spines. While waiting for qualified medical

assistance, apply heat.

Stingray spines often break off into a wound. Stingrays can in-

flict serious injury with their favorite habitat being sandy areas,

shoals, or shallow water. If you step on one you could get punc-

tured and then as the spine is withdrawn you get a jagged lacera-

tion and venom is injected. For heaven’s sake, don’t pull it out

yourself.

Didn’t Steve Irwin, the crocodile hunter, die from one of these?

Their venom is destroyed or altered by heat. There is no anti-

venom available that I know of. It is imperative to debride and ir-

rigate the injury immediately. Clean with soap and water; soak in

hot water for 30 to 90 minutes or apply a heat pack; use topical

antibiotics; immobilize the affected area and minimize activity;

monitor respiratory activity and provide CPR as necessary.

Lionfish, stonefish, and scorpion fish hide in coral. All deliver

venom and fatalities do occur. You will instantly know if you are

attacked as you will experience excruciating pain, inflamed site,

inflammation, puncture wounds, paralysis, and much more. Ab-

solute prompt medical attention is required.

Fire coral burns and can form an abscess. This coral is beautiful

and the color of fire so stay away. If burned, seek medical help;

however, this usually doesn’t cause death.

To prevent injuries, look; don’t touch. Don’t put your hands into

crevices; and try not to let the current force you against an object

If you choose to eat exotic seafood/fish, keep a diary of the food

eaten just in case you become ill.

If you bathe or drink freshwater in exotic areas, be sure to write

down the exact location just in case you come in contact with the

Schistosoma parasite (fluke) found in rural and subtropical areas.

The larva can penetrate skin with serious health complications. I

would also make sure your bathing water is over 122 degrees F to

hopefully kill the larva.

It’s best when you’re going to an unfamiliar area to talk to some-

one familiar with the wildlife and fish so you’ll know what you

might face.

Barbara R. Schmitz, LCSW, attended Carnegie Mellon

University and the University of Pittsburgh, graduating

with a specialization in business education and an avoca-

tion in zoology. She received a master’s degree in social

work from Our Lady of the Lake University. She writes about animal

life and lore for various publications.



WALKING MED

Okay, it’s not a scientific study—neither double blinded norstatistically blessed. But it was prospective and randomized in itsown way. I chose ten colleagues—just ten other docs who hap-pened to be walking toward me in a hospital corridor. I lookedthem in the eye and said ‘Hi’, or ‘Hello’ or, ‘How ya doin’’. Sevenout of ten responded, some with enthusiasm, others with a grunt.A full three out of ten (thirty percent) ignored my salutation—strolled on by like I was a case of smallpox.

A pretty significant number, thirty percent. I found no corre-lation of the response or lack thereof with gender, specialty, ortime of the day (although a couple had just eaten in the doctors’lounge). The one factor that tended toward significance was age.The zombies were younger. I guestimate that the virus probablymutated some ten or fifteen years ago. Older farts (myself at theforefront) have built up an immunity of sorts. We still rememberthe old days, when doctors learned language skills and cursive.

What are the symptoms of this ‘walking med’ virus (I suppose itcould be a fungus)? Flat-ish affect, blank-ish staring, paucity of ex-pressive movement (facial or extremities), monotone voice. Don’tget me wrong—these are well trained and smart zombies; it’s justthat—you know—they only seem to show overt signs of an emo-tional life when seated in front of a computer. Then it’s—wow—flashing pupils, flying spit and whirring fingertips. I’m pretty sure Iwitnessed one of them even kissing their computer bye-bye.

Epidemiologists have looked into the etiology. It has some sim-ilarities to sleeping sickness—could be a trypanosome. Otherssuggest a ‘lack-of-sleeping’ sickness. Hmmm. That’s hard to ex-plain when it’s the old guys like me who went through the 120hours-a-week residencies. I’m no medical sleuth, but I have ahumble opinion on the etiology of the walking med disease. It’s

highly contagious, not controlled by hand washing or foamingin/out and infected fomites are found in every room of everybuilding everywhere.

Signs and symptoms: Mesmerizing stobe-like eyes, flat facialfeatures, droning key-click voice—you guessed it—a forme frusteof folie a deux—you remember from first year psychology: a pre-viously sane person living with an insane partner becomes likethem. What do we live with, breathe with, have nooners with andcaress more passionately than our spouses?

COMPUTERS! Is there a cure (besides the wooden spikethrough the heart—or is that vampires)? Sadly no. But there’streatment: chill out, get some fresh air, purchase a fountain pen(they’re endangered), write your mother a letter…

Marshall McLuhan (1911-1980), was a professor of Englishand communication theory long before laptops and cell phones.His electronic gremlin was television. He coined phrase “themedium is the message”. He taught that the medium is alwaysembedded in its message, forming a symbiotic relationship. Themedium introduces changes subtly and over a long period of time.For example, television regularly reports on the commission ofheinous crimes. After a while, we focus less on the details of thecrime and more on the fact that we watch such events over dinnerand in our living rooms. Television desensitizes and changes publicattitudes to crime.

I’m not paranoid. But my computer is.Does this DELL make my butt look like a flat screen?

Robert G. Johnson, MD, is an orthopaedic surgeon,a BCMS member and a frequent contributor to SanAntonio Medicine.

THE WALKING MEDTHE WALKING MEDBy Robert G. Johnson, MD


According to the Wall Street Journal, in the 1970s most experts

believed that modern economies were fundamentally stable, and

deep recessions and financial crises were unusual events caused by

outside events such as bad government policies, wars and oil price

shocks. Current popular economic theory suggests that recessions

and bear markets occur regularly, and the groundwork for them is

actually laid during periods of relative stability. Regardless of which

camp you fall into, one vitally important question that every investor

must address is “How will you weather the next bear market?”

From the beginning of 1980 through 2014 (35 years) the stock

market rose an astounding 82 percent of the time (only six down

years). However, the severity of the down years derailed some of the

best constructed retirement plans for millions of Americans. In the

past 15 years the S&P 500 Index has fallen by about 50 percent

twice. Most investors reading this article can remember with great

pain seeing their portfolio values down month after month when

reviewing their account statements.

Many academicians and theorists have suggested that the best way

to get through these difficult markets is to buy low-cost index funds,

hold onto them for a long time and you will eventually be rewarded.

Historically, this approach has worked every time but with one big

caveat: your success depends greatly on when you begin taking in-

come from your investment portfolio. For 30-year old investors, the

recent bear market in the “Great Recession” of 2008 and 2009 ac-

tually created a great opportunity to invest more capital at low

prices, and to patiently watch as they were rewarded. However, for

those in or near retirement, declines of 30 percent, 40 percent or

even 50 percent were disastrous. Delaying retirement by five years

or going back to work were not uncommon remedies to get retire-

ment plans back on track.

BUSINESS

Buy andHold,IndexFundsand theNextBearMarketAspect Wealth Management


BUSINESS

In our experience of serving clients over four decades, we have

concluded that, while academic theories seem to work for in-

vestors with unlimited time horizons, we don’t know anyone like

that. Our clients are people who have worked hard, added great

value to their communities through their personal and profes-

sional contributions, and who now want to enjoy their families

without worrying about money.

An investment process that is focused on minimizing the damage

in declining markets has the potential to make retirement much eas-

ier. From 1948 to 2012, a $100,000 investment in the Dow Jones

Industrial Average would have turned into $7.2 million using an

index Buy & Hold strategy. By avoiding the 10 worst quarters, that

number would have grown to $51 million.* However, our research

has shown that some of the best periods of performance immediately

follow the worst periods. So while it’s possible to build a strategy to

miss much of the really bad markets, we don’t know of any way to

capture all the up markets at the same time. However, you don’t

need to do this to have excellent results. By missing both the 10

worst and 10 best quarters the $100,000 investment would have

grown to over $10 million —a 39 percent increase over the Buy &

Hold strategy.

We have concluded that the right way to manage irreplaceable

capital is to have a repeatable strategy that is not dependent on pre-

dicting the future, but that nimbly responds to changes in momen-

tum in order to either protect capital or capture gains. Our clients

have been quite willing to give up some upside during strong bull

markets in order to protect against big declines. We call this process

Fact-Based Investing but our clients might summarize it as good

growth without the worry.

Aspect Wealth Management has managed portfolios for the Bexar

County Medical Society for over 15 years. As a member of the society, if

you would like a complimentary Stress Test of your portfolio to find out

how it is most vulnerable, please contact us at 210-268-1500.

Sources: “Why Bear Markets are Inevitable”, WSJ, 2/13/15;

Morningstar; WBI Investments.

*The hypothetical investment results are for illustrative purposes only and shouldnot be deemed a representation of past or future results. Actual investment resultsmay be more or less than those shown. This does not represent any specific product.Indexes are unmanaged and cannot be invested in directly.


LIFESTYLE

There is perhaps no place quite so civilizedas Africa.

Deep in the bush, surrounded by wildlifeas marvelous and mammoth as the land theyinhabit, travelers soon fall into the easyrhythm of life in the wild.

There, the days are bordered by early sun-rises and too-soon sunsets, while carefree af-ternoons fly by on the wind as it skips likea stone across hippo-filled rivers. On safari,during long game hunts tracking elephant,giraffe, cheetah, rhino and more, hours passat the unhurried pace of clouds castingshadows on the brown-striped backs of ahundred zebras.

“Out of Africa” author Karen Blixen said itbest: “You know you are truly alive whenyou’re living among lions.”

Whether you’ve heard the call of the wildand traveled to Africa to capture extraordi-nary photos, or you’re there to hunt exotics,no other vacation experience rivals an Africansafari adventure.

But that doesn’t mean you have to roughit. These days guests can book safari lodgesthat may be either as luxurious as a 5-starhotel room or as rustic as a small canvas tentwith a bucket shower. Stay in one spot, ortravel to other camps by air or land, and enjoyas many countries and regions as you can.Most all safari lodges offer excellent, highlytrained guides and exciting twice-daily game

drives where guests may see some of theworld’s most spectacular birds and animals.

Life in the bush is quiet and restful. A typ-ical daily schedule is “eat, see animals, sleep,repeat,” and each evening ends with a “sun-downer”: time to toast the sunset and noshon snacks as the rose-colored dusk is over-taken by the night. Then, relax after supperby a campfire beneath the Southern Crossand watch stars as white as elephant tusksfreefall in the sky.

Long ago, Africa was dubbed the “TheDark Continent,” because, in spite of Euro-pean exploration and colonization, it re-mained a place of profound mystery. Today,more than a century later, its wild mystiqueendures.

Texans seem especially drawn to Africa.Wanna-be-cowboys at heart, we’re hard-wiredto love wide open spaces and get the allure of“Big Five” game hunts, tented camps withmosquito-net canopies, rugged Land Roverrides, and Hemingway’s stories of khaki-wear-ing, pith-hat-donning hunters.

Baby Boomers grew up watching Disney’stake on Kipling’s “Jungle Book” and “BornFree” in the sixties. Then in the 80s, we fellin love with Africa all over again with RobertRedford and Meryl Streep in “Out of Africa.”Fast forward thirty years, and we’re still suck-ers for safari romance.

“I’ve met several travelers who told me they

were just going to Africa so they could check‘safari’ off their bucket lists and move on, onlyto find it was better than they ever imaginedand Africa got under their skin. Then, theminute they got home, they began bookingtheir next trip,” says Katie Rees, a young NewYorker who has been to many countries inAfrica and recently climbed Kilimanjaro inTanzania with her boyfriend. She’s so smittenwith Africa that she’s learned some Swahili.

For others, though, Africa is still unchar-tered territory; they want to go but feel in-timidated. They’re not sure where to go, whattour to book, how to get there, whether ornot they want to shoot photos or hunt, whatpermits they need, how it all works, and if itis really safe.

“No problem,” says Steve Turner, presi-dent of a unique San Antonio company of-fering a bespoke travel service called “Travelwith Guns. “We can help. Our team mem-bers are all experts in airline rules and inter-national regulations for transporting gunsto hunting destinations worldwide. We’vebeen in this business for ___ years, andhelped __(hundreds? Thousands? ) of trav-elers travel with guns worldwide. I’ve livedand worked in Africa, so I know just whathunters need. We want our guests to enjoytheir trip and have a worry-free, turn-keyexperience, so we do everything, from ar-ranging airline tickets, to handling transient

CALL OF THE WILDWhether you hunt exotics, or simply aim to shoot great photos,a wild and wonderful African adventure awaits. By Janis Turk


LIFESTYLE

points, to your arranging their hunting des-tination and getting them home. We do allwe can to ensure that guests and their gunstravel safely and have a great trip.”

Animal lover and professional photogra-pher George Ligon, Jr. of North Carolinasays only shoots animals with his Canoncamera. “I’ve been able to get the most in-credible shots during my safaris in AmboseliNational Park along the Kenya-Tanzaniaborder. Besides all the spectacular wildlifeI’ve seen, I’ve also been able to capture somewonderful images of the Masai people wholive in The Mara. My safari lodge’s staff or-ganized visits to Masai villages and schoolsfor my group, and we were able to meet na-tive tribesmen and women and even visittheir homes. I will never forget that experi-ence, and I have felt safe and welcome eachtime I’ve visited Africa.”

Non-hunting travelers may book their tripsthrough American companies like PremierTours, which handles Wilderness Safari vaca-tions, or find choose luxury accommodationsin Africa through the helpful experts fromElewana Collection (www.elewanacollec-tion.com). Hunters may want to turn to or-ganizations like Travel with Guns(www.travelwithguns) before planning theirnext trip.

Besides the experience of safari life, thereare spectacular hotels to enjoy in Africa, big

cities to explore, lakes and waterfalls to see,and animal orphanages to visit. A favorite stayof many families is Giraffe Manor in Nairobi,where giraffes poke their heads into the din-ing room and have breakfast with guests eachmorning. Nearby is Karen Blixen’s house,where the true-life “Out of Africa” story tookplace, and just down the road, on land thatwas once part of Blixen’s original farm,sprawls a handsome five-star hotel calledHemingways Nairobi, with a golf course, spa,fine dining, and grand suites.

Other not-to-miss places? Stay at Elsa’sKopje in Meru, a luxury safari lodge with11 cottages near the spot where George andJoy Adamson camped and raised Elsa the li-oness of “Born Free.” And beach lovers,don’t forget Africa’s stunning coastal resortsin Mozambique, and near cities like Zanz-ibar, Diani and Lamu.

There is an Africa out there for everybody.So, if you want to ride in a hot air balloonover desert sand dunes, start at Sossusvlei inNamibia. Want to witness the annual greatwildebeest migration? Visit the Masai Marain Kenya from July through October. Wantto climb to see the snows of Kilimanjaro?Turn to Tanzania. Then go on safari inKruger National Park, followed by a stay inCape Town with side-trips to wine landsnearby in South Africa. While there, visit theLa Residence in Franschhoek, The Steenberg

in the Constantia Valley, and Ellerman Housein Cape Town, or stay downtown at the Tajwith views of Table Mountain. Visit theRobben Island prison where Mandela washeld, or go see the penguins on the warmsandy beach at Fish Hoek on the False BayCoast. Take a helicopter ride above VictoriaFalls in southern Africa on the Zambezi Riverat the border of Zambia and Zimbabwe. Lis-ten to natives sing in a Khoisan language ofclicks in Botswana, and go ape in Uganda, orstay in splendor at The Saxon, Johannesburg’smost elegant hotel. You can even adopt anelephant at the Sheldrick Wildlife Trust Ele-phant orphanage in Kenya.

Whether you’re drawn to this mysteriouscontinent to shoot photos or exotics, it’s timeto heed the call of the wild, for out of Africa,an oh so civilized adventure awaits.


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UTHSCSADEAN’S MESSAGE

A great deal of research is conducted by the esteemed faculty

of the UT School of Medicine San Antonio. At any given time

there are more than 300 studies under way, including clinical tri-

als and related studies of cellular, biochemical and drug interac-

tion and related areas. Many are in funded by national agencies

and organizations, including the National Institutes of Health

(NIH), the Health and Medicine Division of the National Acad-

emies, the Veterans Administration (VA) and the National Cancer

Institute (NCI). The list of conditions and diseases being studied

covers nearly every branch of medicine. Below are a select few of

the publications and announcements from the past year based on

the research of faculty members of the UT School of Medicine

San Antonio.

Identification of Antidepressant Drug Action in Brain

New discoveries with the anti-depressant drug ketamine may

expand its use. The drug, which is known for relieving depression

in a matter of hours—as opposed to weeks with other medica-

tions—is also known for its high risk of abuse and side effects.

Daniel Lodge, PhD., Associate Professor of Pharmacology, and

colleagues from the School of Medicine, were able to idenitfy a

brain circuit that involved in the beneficial effects of ketamine.

They found that activating that circuit in rats had an effect very

similar to ketamine. Lead author and Professor of Pharmacology,

Flavia R. Carreno, Ph.D., says this new study helps to understand

the area of the brain responsible for the beneficial effects, which

will allow us to more specifically target them and hopefully in-

crease the effectiveness of the medication.

The study “Activation of a ventral hippocampus–medial pre-

frontal cortex pathway is both necessary and sufficient for an an-

tidepressant response to ketamine” was published in the

December 2015 Molecular Psychiatry. Daniel Lodge, Ph.D., As-

sociate Professor of Pharmacology, and Alan Frazer, Ph.D., Pro-

fessor and chairman of Pharmacology were co-authors along with

others from the Health Science Center.

Anti-Cancer Mechanism of Protein Connexin Established

Using the eye as a model due to its high levels of the protein

connexin 50, one of our groups established how the protein slows

the growth of tumors. The protein tethers itself to a cell-prolifer-

ating molecule called Skp2. This prevents the Skp2 from traveling

to the cell nucleus to promote more cell growth. The finding has

a great deal of potential for many different cancer therapies. Qian

Shi, Ph.D., a postdoctoral fellow in Biochemistry, is the first au-

thor on the study, with senior author Jean X. Jiang, Ph.D., Pro-

fessor of Biochemistry at the School of Medicine. The study,

“Connexin Controls Cell-Cycle Exit and Cell Differentiation by

Directly Promoting Cytosolic Localization and Degradation of

E3 Ligase Skp2,” was published in Developmental Cell, Novem-

ber 2015.

Risk of Overdose in Chronic Pain Patients Two new studies authored by Barbara J. Turner, M.D., Profes-

sor of Medicine and Public Health and Yuanyuan Liang, Ph.D.,

Assistant Professor in the Department of Epidemiology and Bio-

statistics at the UT School of Medicine San Antonio, reveal im-

portant insights into the overdose risks associated with dosage,

time and mixture of chronic pain medications.

Painkillers such as hydrocodone that are often prescribed along

with sedative-hypnotics, such as alprazolam (Xanax) and zolpi-

dem (Ambien). Many patients are also prescribed antidepressants,

which has pain management benefits independent of their ability

to improve mood. These additional medications can double the

already-significant risk.

The researchers developed a database to analyze health care de-

livery, medications and comorbid conditions for more than

200,000 HMO-enrolled patients who filled at least two prescrip-

tions for opioids for non-cancer pain between 2009 and 2012.

In this national study, they found that a morphine equivalent

dose of 100 milligrams or more a day significantly increased the

risk of drug overdose, but they also found that even lower doses

UT SCHOOL OF MEDICINE SAN ANTONIO UPDATE:REVIEW OF 2015 RESEARCH

PUBLICATIONS & ANNOUNCEMENTSBy Francisco González-Scarano, MD


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


of opioids, from 50 to 99 milligrams a day, were dangerous if the

patient filled prescriptions totaling the equivalent of at least 1,830

milligrams of morphine over a six-month period. Patients pre-

scribed more than four to six weeks of even moderate doses of

opioids often reach this risky level.

Dr. Turner is also director of the Center for Research to Ad-

vance Community Health, also known as the ReACH Center,

which is working with community and state and federal programs

to bring alternatives to medications for treatment of chronic pain,

including behavioral counseling and physical therapy. The re-

searchers’ two articles were published in the August 15, 2015 print

edition of The Journal of General Internal Medicine and the July

2015 edition of The Journal of Hospital Medicine.

Research Imaging Institute’s BrainMapThe School of Medicine’s Research Imaging Institute (RII),

under the direction of director Peter T. Fox, M.D., and the insti-

tute’s BrainMap program, have played a significant role in another

important study; this one on similar brain abnormalities in people

with schizophrenia, depression and addiction. Researchers from

Stanford University and the University of Cambridge led the stud-

ies which utilized the brain atrophy section of BrainMap, a data-

base of published functional and structural neuroimaging

experiments that is maintained here at the RII. The BrainMap

program was begun in 1988 and has been used in nearly 600 pub-

lished studies. The new study found similar gray-matter loss in

the brains of study participants with diverse diagnoses. The studies

appear in the February 4, 2015 issue of JAMA Psychiatry. Visit

www.BrainMap.org to learn more.

PTSD and Suicide ReductionProfessor of Psychiatry Alan Peterson, Ph.D., co-investigator

on a new study, has found that short-term cognitive behavioral

therapy dramatically reduces suicide attempts among at-risk mil-

itary personnel. The two-year study involved 152 active-duty sol-

diers who had either attempted suicide or had been determined

to be at high risk for suicide, and evaluated the effectiveness of a

brief cognitive-behavioral therapy (CBT) in preventing future sui-

cide attempts. The study found that soldiers receiving CBT were

60 percent less likely to make a suicide attempt during the 24-

month follow-up than those receiving standard treatment. The

article, “Brief Cognitive-Behavioral Therapy Effects on Post-Treat-

ment Suicide Attempts in a Military Sample: Results of a Ran-

domized Clinical Trial With 2-Year Follow-Up,” was published

in May 2015 in The American Journal of Psychiatry. The findings

are particularly encouraging, given the increasing rates of suicide

in veterans after the wars in Iraq and Afghanistan.

Preserving Brain Function after StrokeNew research suggests that an anti-convulsant drug already ap-

proved for epilepsy could preserve brain tissue after a stroke. In

the study, one dose of the anti-epilepsy drug, Retigabine, pre-

served brain tissue in a mouse model of stroke and prevented the

loss of balance control and motor coordination.

Hours after a stroke, both treated mice and a control group of

mice were placed on a balance beam to observe motor coordina-

tion. The untreated mice displayed a pronounced loss of coordi-

nation with slips and falls.

Treated mice had no difficulty with balance, ambulation or

turning around on the beam. Histological analysis of the brain

tissue of treated mice showed significantly reduced damage to the

tissue after the stroke, compared to untreated mice. The protective

effects of the medication were observed in treated mice up to five

days later.

Senior author was Mark S. Shapiro, Ph.D., Professor of Physi-

ology, and Sonya Bierbower, Ph.D., a postdoctoral fellow, was

lead author of the report. The study, “Augmentation of M-Type

(KCNQ) Potassium Channels as a Novel Strategy to Reduce

Stroke-Induced Brain Injury,” was published in the February 3,

2015, edition of The Journal of Neuroscience.

Reducing Potassium in Kidney Disease Treatments

New research from the School’s Nephrology Division has the

potential to dramatically improve the lives of people with chronic

kidney disease. The study was published in both the New England

Journal of Medicine (NEJM) and the Journal of the American

Medical Association (JAMA). Renin Angiotensin Aldosterone

System Inhibitors (RAASI) are a standard treatment to protect

the heart and kidney in patients with chronic kidney disease, a

very common comorbidity of diabetes. A significant percentage

of patients using the drug develop dangerously high potassium

levels in the blood (hyperkalemia) that puts them at a risk for car-

diac arrhythmias. The only solution to reduce the risk is stopping

the RASSI or having the patient undergo kidney dialysis, which

carries its own problems.

Wajeh Y. Qunibi, M.D., a Professor of Medicine and UT Med-

icine nephrologist, is one of the investigators in a study using ZS-

Continued on page 34

9 in patients with high blood potassium. Up to 98 percent of pa-

tients saw a return to normal potassium levels in the first month.

Non-absorbed zirconium silicate, ZS-9, is designed to preferen-

tially trap potassium ions in order to lower and maintain control

of serum potassium levels. The articles appeared in the January

15, 2015 NEJM and December 2014 JAMA. ZS-9 was cleared

by the FDA for kidney patients in October 2015.

Refer a Patient or Partner to the School of Medicine

We offer the most clinical trials in the region (Phase 1, 2 and

3) for many different conditions and diseases. If you’re interested

in referring a patient, please visit our clinical trial website

http://vpr.uthscsa.edu/findastudy or our Phase 1 cancer trials at

the Cancer Therapy & Research Center www.CTRC.net.

We also have a unique program for private physicians who wish

to be involved in clinical research. Called the “Practice-Based Re-

search Network” (PBRN), you can start your own studies or join

others already involved in research. Contact our PBRN office at

(210) 562-5652.

Every study, trial and experiment has many people behind the

scenes working to coordinate the many different pieces that

come together to conduct and complete these programs. Most

of the names do not appear as authors, but they are significant

contributors all the same. My congratulations goes out to all the

outstanding faculty and their teams for the great work repre-

sented here.

All the best,

Francisco González-Scarano

Dean, School of Medicine Exec-

utive Vice President for Medical

Affairs University of Texas

Health Science Center San An-

tonio John P. Howe, III, MD,

Distinguished Chair in Health

Policy Professor of Neurology.



Continued from page 33


BUSINESS OFMEDICINE

Legal & Tax Strategies forHealthcare Organizations and ProfessionalsBy Dana A. Forgione, PhD, CPA, CMA, CFE


If you’re setting up a new company, you may be considering what

organizational type is most appropriate. Briefly, here are some op-

tions.

• Sole Proprietorship

• Partnership

• General Partnership

• Limited Partnership (LP)

• Limited Liability Partnership (LLP)

• Limited Liability Company (LLC)

• Corporation (Inc., Ltd.)

• Subchapter S Corporation

• Professional Corporation (PC)

• Personal Services Corporation (PSC)

• Professional Limited Liability Company (PLLC)

• Non-profit Organization (35 different categories)

The main differences between them are: control, taxes, and legal

liability. Everyone wants control, but nobody wants taxes or legal li-

ability.

Disclaimer:Okay, before we start this discussion, here’s the disclaimer: the

material contained herein is for informative purposes only, and does

not constitute legal, medical, accounting, financial, tax or other pro-

fessional advice. The issues and applicable laws are complex, and rel-

evant legal and tax counsel and/or other professional advice should

be sought regarding any particular situation(s), transaction(s) or

arrangement(s).

So, first, let’s define some important terms. These are not formal

legal definitions, but give you a sense of the issues.

Tax Avoidance—operating your business so that you do not

incur a tax. For example, organizing as a tax-exempt, nonprofit en-

tity, or investing in tax-free municipal bonds.

Tax Evasion—failing to pay a tax you properly owe. For exam-

ple, taking cash from sales and failing to report the revenue on your

tax return, or deducting personal vacation travel expenses as if they

were reasonable & necessary business expenses.

Aggressive Business Practice—pushing the limits of inter-

pretation of the law, or trying to put legal form above economic sub-

stance. For example, asserting an unusually short depreciable useful

lifetime for an asset, or shifting profits into a low-tax jurisdiction

through high transfer prices on items that are difficult to value, such

as trademark licensing fees, or intermediate electronic components.

Fraud—intentional misrepresentation of a material fact that is

reasonably relied upon by a victim who incurs consequent damage.

For example, a healthcare provider billing for services that were never

rendered.

S-CorporationOne common organizational type for small businesses is the S-

Corporation. It generally maximizes control while reducing taxes

like a proprietorship, and reduces legal liability like a corporation.

However, to qualify as an S-Corp., the organization must meet eight

requirements:

1 It is a domestic corporation or entity.

2 It has no more than 100 shareholders (an individual & spouse

can be one shareholder).

3 Shareholders must be an individual, estate, trust, tax-exempt or-

ganization, or other S corp. A C-Corp. or partnership cannot be

the shareholder of an S-Corp.

4 It has no nonresident alien shareholders.

5 It has only one class of stock, all with identical rights to distribu-

tion and liquidation proceeds.

6 It is not one of the ineligible corporations, such as a financial in-

stitution, insurance company, or domestic international sales cor-

poration (DISC), etc.

7 It has or will adopt a: 12/31 tax year, natural business tax year,

ownership tax year, or 52–53 week tax year.

8 It has each shareholder’s consent. If an individual and his or her

spouse have a community interest in the corporation, both must

sign the consent statement.

The hardest thing in the world to understand is the income tax.—Albert Einstein

BUSINESS OFMEDICINE


The S-Corp. must continue to meet all of the above require-

ments. Failure to comply can result in revocation of the S election.

For example, if a shareholder receives both a salary and dividends

from the S-Corp., and the IRS reclassifies some or all of the salary

as a dividend (or vice versa), that individual could be deemed to

have more (or less) dividend than the other shareholders, thus trig-

gering a violation of requirement no. 5 above. That could trigger

revocation of the S-election, and subject the company to the dou-

ble-taxation of a regular (C) corporation. Ouch. This makes S-

Corps less attractive.

Limited Liability Company (LLC)LLCs are a popular alternative because they are simpler than an

S-Corp. while still providing liability protection. A single-member

LLC is taxed like a sole proprietorship, while a multiple-member

LLC is taxed like a partnership. An LLC can also opt to be taxed

like a corporation. But remember, the limited liability of any orga-

nizational form can always be “pierced” in a court of law.

Nonprofit Organization (NP)An NP organization can be incorporated as a stock corporation

(but the shares cannot be owned by any individual) or a non-stock

corporation, or unincorporated. The primary distinguishing feature

is potential eligibility for federal and state tax exemption, although

they may be subject to Unrelated Business Income (UBI) taxation.

The IRS allows for 35 different categories of NP entities that gen-

erally include:

• Charitable Organizations

• Churches and Religious Organizations

• Political Organizations

• Private Foundations

The most common type is the section 501(c)3 organization. Most

NP hospitals are 501(c)3 organizations. To be tax-exempt under sec.

501(c)(3) of the Internal Revenue Code (IRC), an organization must

be organized and operated exclusively for exempt purposes set forth

in sec. 501(c)(3), and none of its earnings may inure to any private

shareholder or individual. In addition, it may not be an action or-

ganization, i.e., it may not attempt to influence legislation as a sub-

stantial part of its activities and it may not participate in any

campaign activity for or against political candidates.

The exempt purposes set forth in sec. 501(c)(3) are charitable, re-

ligious, educational, scientific, literary, testing for public safety, fos-

tering national or international amateur sports competition, and

preventing cruelty to children or animals. The term charitable is

used in its generally accepted legal sense and includes relief of the

poor, the distressed, or the underprivileged; advancement of religion;

advancement of education or science; erecting or maintaining public

buildings, monuments, or works; lessening the burdens of govern-

ment; lessening neighborhood tensions; eliminating prejudice and

discrimination; defending human and civil rights secured by law;

and combating community deterioration and juvenile delinquency.

The basic economic bargain is that the government tells the po-

tential investors, “If you will refrain from extracting profits, we will

refrain from extracting taxes. That way the organization will have

more money to carry out its socially-desirable operations.” There is

also the notion that NP organizations relieve the government of bur-

dens in society it would otherwise have to bear. Presumably the pri-

vate NP organization can carry out those operations more efficiently

than government.

Well, this is just a brief introduction. Page space sure runs out

fast. “The time has come,” the Walrus said, “To talk of other things.

Of shoes and ships and sealing wax. Of cabbages and kings…”

(Lewis Carroll, Alice in Wonderland). Maybe more, next time…

Dana A. Forgione, Ph.D., CPA, CMA, CFE is the

Janey S. Briscoe Endowed Chair in the Business of

Health at the University of Texas at San Antonio. He is

also an Adjunct Professor in the School of Medicine, De-

partment of Cardiothoracic Surgery, the Department of Pediatrics, and

in the School of Public Health, all at the University of Texas. He previ-

ously held a joint appointment in the School of Pharmacy at the Uni-

versity of Maryland, where he taught in the Doctor of Pharmacy

program. His research interests are in international comparisons of

healthcare payment systems, costs and quality of care, as well as financial

management for hospitals and physician practices.

Continued from page 35

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Select Rehabilitation of San Antonio (HH Silver Sponsor)We provide specialized rehabili-tation programs and services for

individuals 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.”

INFORMATION ANDTECHNOLOGIES

Henced( Gold Sponsor)Henced is a customer communi-cations platform that providesbusinesses with communicationsolutions. We’ll help you buildlong-last customer relationshipsby effectively communicatingusing our text and email messag-ing system. Rainey Threadgill [email protected] offers BCMS memberscustom pricing.

INSURANCE

TMA Insurance Trust(HHHH 10K Platinum Sponsor)Created and endorsed by theTexas 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] 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]

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 ADVERTISING SEO

Henced( Gold Sponsor)Henced is a customer communi-cations platform that providesbusinesses with communicationsolutions. We’ll help you buildlong-last customer relationshipsby effectively communicatingusing our text and email messag-ing system. Rainey Threadgill [email protected] offers BCMS memberscustom pricing.

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 smallpractices. 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]

Commercial & Medical CreditServices(Silver)A bonded and fully insured SanAntonio-based collection agency.Henry Miranda [email protected]“Make us the solution for your ac-count receivables.”

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.”


BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY


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

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 providing

solutions 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 Realty

was 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 March 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.


ONLINE ROI

As patient expectations change so does the value of a physician’sonline reputation. An accurate, positive online reputation nowtranslates into new patients and increased revenue. An inaccurateone can result in lost opportunities and might even impact yourpractice’s long term success.

Most physician rating and review sites get their initial infor-mation from the Physician Blue Book. This information isoften out of date or becomes so quickly. It can also be lackingcrucial items like your website address. Finding and correctinglistings on these and other sites like Yelp improves your overallsearch rankings, supports better search engine optimization(SEO) for your practice website, and makes it easier for patientsto find you.

You might be saying to yourself that you get most of your pa-tients through word of mouth and referrals from other patients.This could be true, but today patients who get referrals fromfriends and family, checkout the physician online before book-ing. In fact, according to Google almost 80 percent of patientsconduct an online search before booking an appointment. So itis critically important that you can be found, your informationis accurate and up to date, and that you have positive reviewsfrom existing patients.

Why do you need the reviews in addition to listings? Becauseprospective patients trust them, maybe even more than the referralfrom their friend. And they can translate directly into revenue.Professor Michael Luca at Harvard Business School published astudy, Reviews, Reputation, and Revenue: The Case of Yelp.com.He found shows that where Yelp reviews penetrated a local mar-ket, the business of chain restaurants declined because consumersbegan trying more independent businesses as they gained confi-dence about their quality. This points to an opportunity for in-dependent practices to compete effectively against larger healthsystems by embracing an aggressive and effective positive reviews

strategy. The survey also found that an increase in star rating canbe tied to an increase in revenue—a one star increase equated toa 9 percent increase in revenue.

If you haven’t taken the time to check out your online reputa-tion, make 2016 the year that you do. It’s easy to get a sense ofwhere you are listed and the accuracy of your listings by doing asimple Google search. You’ll quickly see how many listings are outthere and how many of them have inaccuracies or missing infor-mation as well as those that have reviews or ratings already. Youcan update these all manually, but that can take a lot of time andeffort. Same goes for increasing positive online reviews. Today,there are practice marketing platforms that can help you do bothmuch faster and more effectively.

Updating these sites and increasing reviews will also help withyour search engine rankings. When you do your Google searchyou should do some searches using common search terms forwhich you would want to be found. For example, you want toshow up first for OB/GYN in Austin, TX. So search for OB/GYNAustin TX and see where you show up. If your ranking is low, up-dating your online profiles and adding your website and socialmedia pages will help. Increasing your positive online reviews canhelp here as well.

Updating and improving your online reputation plays a muchbigger role today in recruiting new patients, generating revenue,and staying successful. There are other things you can do tostrengthen your online presence but online listings and reviewsare as a good a place to start as any. It probably won’t be long be-fore you start to see your practice rise in your search engine rank-ings and find new patients booking appointments as well.

Lilly Ibarra is a regional solutions consultant with Kareo in SanAntonio. She has been in the industry for six years helping clientsreach their financial goals.

The ROI of Your ONLINE REPUTATION

By Lilly Ibarra


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

The floating roof is a new design trend

out of Japan that’s “the thing” right now.

Floating roofs are optical illusions created by

rear windows that connect with side win-

dows via dark panels of some type. Those

panels make it look like the roof of the car is

floating over the top of the vehicle. While

floating roofs are eye-catching and novel de-

sign elements, I personally don’t see them

lasting much past the current generation of

cars and crossovers that have them now.

Having said that, floating roofs can be

found on three very popular (and recently

redesigned) mainstream vehicles, the Nissan

Murano, Lexus RX, and the subject of this

review, the Nissan Maxima. Those three ve-

hicles alone will account for around 250,000

sales in 2016, so a lot of floating roofs will

be, umm, floating around the US this year.

The Maxima is Nissan’s biggest and most

expensive sedan, and while sedans aren’t the

Big Man on Campus that they used to be

thanks to the ever-increasing popularity of

crossovers, they still sell well and satisfy the

needs of many car buyers today.

The Maxima’s exterior design reflects what

some industry observers have called the

death of understatement. From the promi-

nent grille to the assertive head- and tail-

lights to the cavalcade of creases on the

bodywork—and let's not forget that floating

roof—the Maxima’s look suggests that Nis-

san’s design team used as many styling flour-

ishes as they thought they could.

It works, though. The Maxima looks

good. Maybe I’ve been beaten down by over-

styled Nissans, Lexuses, and Mercedes, but

the Maxima always struck me as attractive

when I walked up to it. Let’s call it happily

extroverted and leave it at that.

That same enthusiasm for excess seems to

have carried the day when the interior was

created, as buttons, knobs, and screens are

seemingly everywhere. Thankfully, once you

take the time to sit down and make sense of

the controls, it becomes apparent that a lot

of thought went into them. And truth be

told, once you see that most functions can

be accessed through the central control

knob, you realize that a lot of the buttons

and knobs on the dash are redundant. (Since

everybody has their preferred way to do

things, extra options are fine with me.)

Driving the Maxima is very pleasant thanks

primarily to a nicely sorted chassis and lots of

horsepower. The only engine available, Nis-

san’s ubiquitous 3.5L V6 provides a muscular

300 HP--enough to pull the 3545 Lb sedan

from zero to sixty MPH in 5.9 seconds. Yes I

said, “pull”. The Maxima is a FWD car,

which limits sportiness as does the buzz

killing continuously variable transmission

(CVT). Still, the Maxima feels athletic and

AUTO REVIEW


2016 Nissan MaximaBy Steve Schutz, MD

fast in most driving situations, especially

highway entrance ramps and high speed back

roads. And using the standard paddles to ac-

celerate or decelerate gives you pseudo-gears,

which augment any driving situation.

For the record, fuel economy is22 MPG city/30 highway.

A quick aside to driving enthusiasts: ever

tightening fuel economy and emissions reg-

ulations are bringing CVTs, shrinking en-

gines, and hybrid technology to an

increasing percentage of new vehicles. Is that

bad? Not necessarily, but it’s worth noting

that RWD cars with naturally aspirated en-

gines and manual transmissions are endan-

gered species.

Japanese vehicles generally come well

equipped compared with anything from Ger-

many, and that’s the case with the Maxima.

Standard features of the base S model include

18-inch alloy wheels, automatic headlights,

keyless ignition and entry, dual-zone auto-

matic climate control, power front seats

(eight-way driver and four-way passenger),

and an auto-dimming rearview mirror. Nav-

igation, a rearview camera, Bluetooth phone

and audio, two USB ports, HD radio, and a

six-disc CD changer are also standard in every

Maxima. If this were Twitter, I’d type #nev-

erinagermancar in my tweet.

SV, SL, and Platinum Maximas provide

many more options and option packages, so

you can easily add as much luxury features

as a Lexus, but it’s nice to know that going

for the base Maxima won’t embarrass you.

For enthusiasts, the sportier SR adds 19-

inch wheels with available performance tires,

a more athletic suspension, Active Ride

Control, Active Trace Control (Nissan’s ver-

sion of torque vectoring), and active engine

braking to enhance spirited driving. This

Maxima, which would be my choice, also

has LED headlights, premium leather, and

heated and ventilated front seats.

As regular readers know, any car search

should begin with a call to Phil Hornbeak,

who will guide you through the entire

process of choosing a vehicle that will work

best for you and your budget.

While hamstrung by FWD, a relatively

high curb weight, and a CVT, the new Nis-

san Maxima is fun to drive. And while de-

signed with many styling elements including

but definitely not limited to a floating roof,

it looks good. If you’re looking for a sporty

sedan with luxury, don’t overlook the Max-

ima. It’s a very good car.

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



ABCD Pediatrics, PA

Clinical Pathology Associates

Dermatology Associates of San Antonio, PA

Diabetes & Glandular Disease Clinic, PA

ENT Clinics of San Antonio, PA

Gastroenterology Consultants of San Antonio

General Surgical Associates

Greater San Antonio Emergency Physicians, PA

Institute for Women's Health

Lone Star OB-GYN Associates, PA

M & S Radiology Associates, PA

MacGregor Medical Center San Antonio

MEDNAX

Peripheral Vascular Associates, PA

Renal Associates of San Antonio, PA

San Antonio Gastroenterology Associates, PA

San Antonio Kidney Disease Center

San Antonio Pediatric Surgery Associates, PA

Sound Physicians

South Alamo Medical Group

South Texas Radiology Group, PA

Tejas Anesthesia, PA

Texas Partners in Acute Care

The San Antonio Orthopaedic Group

Urology San Antonio, PA

Village 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

April 23, 2016.

san antonio medicine may 2016

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