san antonio medicine september 2014

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THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • SEPTEMBER 2014 • VOLUME 67 NO. 9

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HEALTHOCCUPATIONAL

HEALTH

4 San Antonio Medicine • September 2014

Occupational HealthAre alcoholism and addiction occupational diseases for physicians? By Neal H. Gray, MD ...................................................12

Strategies for hearing loss preventionBy Jose E. Barrera, MD, FACS....................................14

Hand-washing until it hurts By E. Chad Schmidgal, MS4, and Robert Gilson, MD..16

Impairment isn’t disability By Fred H. Olin, MD ......................................................18

BCMS News: A New Home for Bexar County Medical Society ..................................................10

Physician as Patient Part 6: Recovery by Jay Ellis, MD ..............................................................20

BCMS News ................................................................................................................................22

Lifestyle: Performing Arts by Beth Bond ....................................................................................24

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

In the News: Health Collaborative by Dennis P. Gonzales, PhD ................................................28

HASA: The benefits of HIE accreditaion by Gijs van Oort, PhD ..........................................................30

Business of Medicine by Joseph P. Gonzales, MHA, FACHE, PMP......................................................32

BCMS Circle of Friends Services Directory ..........................................................................................35

Book Review: “The Book Thief,” written by Markus Zusak, reviewed by Fred H. Olin, MD ........40

In the Drivers’ Seat ................................................................................................................................43

Auto Review: Nissan Versa Note by Steve Schutz, MD ........................................................................44

T A B L E O F C O N T E N T S

MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • SEPTEMBER 2014 • VOLUME 67 NO. 9

SAN ANTONIO

San Antonio Medicine is the official publica-tion of Bexar County Medical Society (BCMS).All expressions of opinions and statements ofsupposed facts are published on the authorityof the writer, and cannot be regarded as ex-pressing the views of BCMS. Advertisementsdo not imply sponsorship of or endorsementby BCMS.

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COVER: Photograph courtesy E. Chad Schmid-gal and Dr. Robert Gilson


BOARD OF DIRECTORS

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

DIRECTORSJosie Ann Cigarroa, MD, MemberChelsea I. Clinton, MD, MemberJohn Robert Holcomb, MD, MemberLuci Katherine Leykum, MD, MemberCarmen Perez, MD, MemberOscar Gilberto Ramirez, MD, MemberAdam V. Ratner, MD, MemberBernard T. Swift, Jr., DO, MPH, MemberMiguel A. Vazquez, MD, MemberFrancisco Gonzalez-Scarano, MD,

Medical School RepresentativeCarlos Alberto Rosende, MD,

Medical School RepresentativeCarlayne E. Jackson, MD,

Medical School RepresentativeLuke Carroll, Medical Student RepresentativeCindy Comfort, BCMS Alliance PresidentNora Olvera Garza, MD, Board of Censors ChairRajaram Bala, MD, Board of Mediations ChairGeorge F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTORStephen C. Fitzer

CHIEF OPERATING OFFICERMelody Newsom

DIRECTOR OF COMMUNICATIONSSusan A. Merkner

COMMUNICATIONS/PUBLICATIONS COMMITTEEFred H. Olin, MD, ChairEstrella M.C. deForster, MD, MemberJay S. Ellis Jr., MD, MemberDiana H. Henderson, MD, MemberJeffrey J. Meffert, MD, MemberSumeru “Sam” Mehta, MD, MemberRajam S. Ramamurthy, MD, MemberJohn C. Sparks Sr., MD, MemberChittamuru V. Surendranath, MD, MemberJ.J. Waller Jr., MD, MemberJason Ming Zhao, MD, Member


BCMS NEWS

A new home for the Bexar County Medical SocietyBy Benard T. Swift Jr., DO, MPHDiplomat, ABPM in Occupational Medicine

If you’ve been a member of the BCMS for a decade or more,you’ll remember attending meetings at the old West French Placeoffice building. Approximately 10 years ago that building was sold,the proceeds invested, and a temporary home for the society wasestablished in the space we now occupy at the First National Bankoffice building on I-10.

The lease to that space will expire soon, and the proceeds fromthe French Place sale can’t be used for anything other than a real es-tate investment. So it seems that the time is right to find a perma-nent home.

CONSTRUCTION OF A NEW BUILDINGAfter much research and time spent looking at raw land and exist-

ing office buildings, your board has approved a plan to enter into anearnest money contract to purchase an undeveloped 1.71-acre tractof land on Loop 1604 just to the west of Northwest Military Drive(see accompanying map) to construct what will be a 20,000-square-foot, two-story Class A office building. The top floor (10,000 squarefeet) will be occupied by the medical society, and the bottom will beleased out to prospective office and/or medical tenants.

This will allow us to (1) utilize the funds sitting in a reserve accountfor that purpose; (2) create a permanent “home” for the society withits own identity -- we will have outside building signage; and (3) makean investment that will reap the long-term reward of eventually re-ducing our occupancy costs. Some of you may recall the Texas Med-ical Association having the foresight to undertake this very same kindof project many years ago in Austin.

The total cost of the project is estimated to be in the $4.5 millionrange, though firm numbers have yet to be established. As of thiswriting (end of July), the 120-day due diligence period on the landhas just begun, and we will firm those numbers up before fully com-mitting to close on the land.

FINANCINGFinancing for the project will come from three sources: (1) cash

on hand; (2) bank financing; and (3) fundraising.In order to fulfill the last of these three components, and before

starting any fundraising with our many friends in the community,your board believed it important that each member initially partici-pate in the fundraising effort. They have, therefore, approved a $150assessment from each member, payable in two annual installments of$75 each, the first of which will be payable with your dues statementfor 2015 (the statement will go out in October 2014). The secondinstallment of $75 will be due next year at the same time. Of course,additional sums are welcome, and we are in the process of creating atiered system that will permanently recognize those who make sig-nificant contributions toward this important effort. More about thatin the future as we develop the entire campaign.

The BCMS staff, board and executive committee have workedhard and had many discussions to allow us to get to this point. Themembership’s financial and moral support are of paramount im-portance for us to undertake this project, and to create an identityfor the society that is a symbol of our commitment to our patientsand community.

N


OCCUPATIONAL HEALTH

The headline poses a good question. There are many overlaps

that muddy the process of answering this simple question. Scien-

tific studies in addiction are hampered by sampling errors and

bias. Most of the subjects lie, and populations and incidence

analysis frequently have an unknown denominator. In spite of

that disclaimer, let’s look at a few examples in an attempt to un-

derstand some of the issues.

Do at-risk students preferably choose medicine? Obviously

some with previous drug usage do, thinking that it would really

be cool. Others make the decision to enter nursing or medicine

so that they might then be able to help the crazy, unpredictable

alcoholics and addicts in their dysfunctional families.

BUBBLE UP THROUGH THE SYSTEMDrinking and drugging usually begins before medical school.

A student council president at a North Side high school in San

Antonio told me that probably 30 percent of students were high

before first period. Some of these will bubble up through the sys-

tem and become physicians in spite of their continued abuse.

Physicians probably do not have an incidence of these diseases

more often than other professionals such as lawyers or politicians.

They do differ in the drugs they use, namely legal medicines from

around the office or hospital, stealing from patients, forging Rx

pads of partners or spouse, and thinking all the time that they are

doing a good job of practicing without detection.

No specialty is immune. Family practice and internal medicine

seem to have recently become the most affected probably because

they often can function solo and work undetected. A physician

can drink alcoholically for 10 years before being detected or the

bottom falls out, but the anesthesiologist using fentanyl will come

to light in about three months, if he survives. We see psychiatrists

on massive doses of Valium, surgeons taking their kid’s Ritalin,

OBs doing hydrocodone, or others taking their narcotic long after

a surgical recovery. All of them deny their addiction, assume that

they have control, and are too smart and good to need help. They

are a danger to themselves and others.

Can they recover? Absolutely. They will need to be treated and

they can return to practice better than ever. But continued aftercare,

monitoring, follow-up visits, 12-step support, and family and prac-

tice encouragement are necessary. Do they need to change their spe-

cialty? No, if they are well monitored and motivated.

We all have heard people say that if you had his/her spouse,

job, patients, kids or something else, you would take dope or

drink like he does. Occasionally this person, recognizing a need

for change, will take a spouse cure, practice cure, location cure,

giving up important aspects of his life instead of treating the ad-

diction. It never helps. We always take ourselves wherever we go.

There is a little sticker that one can put on the bathroom mirror

that states, “You are looking at the problem.” It’s not the job.

Neal H. Gray, MD, is a member and past chair-

man of the BCMS Physician Health and Rehabilita-

tion Committee. The 1992 president of BCMS, Dr.

Gray is a retired anesthesiologist.

Are alcoholism and addiction occupational diseases for physicians?By Neal H. Gray, MD

EDITOR’S NOTE: The BCMS Physician Health andRehabilitation (PH&R) Committee's goal is to advocate andaid in recovery success of the impaired physician. Committeemembers are a confidential advocacy group of physicians thatidentify and facilitate recovery success for other physicianswith substance use disorders (alcohol and/or drugs) and de-pression, through support and monitoring, using a series ofmeetings, discussions and other activities. Inquiries, partici-pation, discussions, meeting information and help with re-lated issues can be submitted to: Oliver Johnson Jr., MD,PH&R Committee Chair, at 210-313-3378 or the BCMSoffice at 210-301-4391.

Otitis media is amajor cause of ac-quired hearing im-pairment worldwide,especially in develop-ing countries. Mostapproaches to preven-tion are either unsat-isfactory or veryexpensive and diffi-cult. For example, mi-crodebridement ofcerumen requires spe-cialized equipmentand trained person-nel. Also, the use ofsystemic aminoglyco-side antibiotics forchronic suppurativeotitis media (CSOM)requires long hospi-talization and is po-tentially ototoxic. Aural toilet including wicking the ear andototopical quinolones offer high effectiveness in these high-riskpopulations. With today’s conservative healthcare environment,surgery may be impractical due to cost and lack of trained per-sonnel. Cost-effective prevention is necessary.

REGIONAL ESTIMATESCSOM is commonplace in the developing world. It is the result

of an initial episode of AOM and is characterized by persistentdischarge from the middle ear through a tympanic perforation. Itis a cause of preventable hearing loss, but does account for 28,000deaths worldwide.

Ear wax is the leading cause of reversible hearing loss, followedby CSOM. CSOM frequently leads to mastoiditis, brain abscess,facial nerve palsy, meningitis in high-risk populations. Large num-bers of mastoiditis complicated by brain abscess have been re-ported in Bangladesh and Nepal.

AOM often begins in childhood. CSOM is diagnosed in pa-tients with tympanic perforations that continue to discharge mu-

coid material for greater than 6 weeks to 3 months. The termchronic otitis media is not well defined. It may involve all typesof otitis media that fail to resolve after an acute episode such aspersistent or recurrent middle ear effusion, otherwise classified asOME. It may involve perforations that are dry (from trauma orpressure changes) or those with persistent otorrhea or CSOM.

Regional estimates of hearing impairment are estimated by theWorld Health Organization (WHO). The Western Pacific hasthe highest burden of hearing impairment due to CSOM withEurope having the smallest (Figure 1). In total, 164 million casesof hearing impairment may be due to CSOM with 90 percent ofthese coming from developing countries. Country prevalenceswere grouped based on WHO regional classification as catego-rized during the WHO/CIBA workshop of otitis media expertsin 1996. CSOM prevalence rates of 1 percent to 2 percent areconsidered low and 3 percent to 6 percent high (Figure 2).

Population-based estimates in developing nations range from0.24 percent (Thailand), 1.8 percent (Africa), 10.4 percent(South Korea). Cholesteatoma varies among regions (60 percent


OCCUPATIONAL HEALTH

STRATEGIES FOR HEARING LOSS PREVENTION:Prevalence and prevention of otitis mediaBy Jose E. Barrera, MD, FACS

Figure 1. Regional Burden of CSOM and Hearing Impairment

in South Korea, 66 percent in South Africa, 0percent among Navajo children, 0.08 percent inSaudi Arabian children). Mastoid abscess is themost common extracranial cause of death, fol-

lowed by labyrinthine fistula. Other less-frequentextracranial complications include facial weak-ness and profound deafness which occurred in14.3 percent of reported cases. Meningitis is themost common intracranial cause usually present-ing as fever, headache and meningeal signs.

Among patients with intracranial complications,18.6 percent died and 28 percent had permanentfacial paralysis, deafness, diplopia, epilepsy, orhemiparesis.

There is no consensus among general and spe-cialist physicians with regard to the medical man-agement of CSOM. However, it is generally agreedthat aural toilet is a necessary part of treating CSOM. Cleaningmucoid discharge reduces infection and could facilitate middleear penetration of ototopicals.

From the Cochrane review, aural toilet combined with antimi-crobial therapy is more effective than aural toilet alone. A trialcomparing clindamycin with aural toilet alone found resolutionrates of 93 percent and 29 percent, respectively. Some oral an-tibiotics are as good as others. Similar rates of otorrhea resolutionwere found between cefotiam, amoxycillin-clavulanic acid, andcefuroxime. All had otorrhea resolution rates between 61 percentand 70 percent.

INCREASING GLOBAL BURDENCochrane review found ototopicals to be more effective in re-

solving otorrhea and eradicating middle ear bacteria. The addi-tion of ototopicals to aural toilet was associated with a 57 percentrate of otorrhea resolution compared to 27 percent with aural toi-let alone. Topical quinolones are better than topical non-quinolones. Specifically, topical oflaxacin or ciprofloxacin weremore effective than gentamycin, tobramycin, and neomycin-

polymyxin. Combined topical and systemic antibiotics are nobetter than topical antibiotics alone. The rates of resolution were50 percent and 53 percent, respectively.

The increasing global burden of otitis media and hearing losscoupled with declining health services and inadequate health in-frastructure make the prevention of hearing loss a difficult prob-lem. Mobile ear clinics may provide surgical services tocommunities that have neither physical access nor financial capa-bility and logistic support. Technical proficiency among primarycare and ENT specialists in developing countries will contributeto the overall success in eradicating CSOM. Finally, the nationalhealth system of a particular nation must make ear care and pre-vention a priority.

Jose E. Barrera, MD, FACS, is a diplomate ofthe American Boards of Otolaryngology – Headand Neck Surgery, Sleep Medicine, and Facial Plas-tic and Reconstructive Surgery. For information onhis San Antonio practice, Texas Facial Plastic Sur-

gery and ENT, visit www.drjosebarrera.com.

visit us at www.bcms.org 15

OCCUPATIONAL HEALTH

References1. WHO: Prevention of hearing impairment from chronic otitis media, re-

port of a WHO/CIBA Foundation Workshop, London, 12-21 Novem-ber 1996, WHO/PDH/98.4.

2. Eason R, Harding F, Nicholson R. Chronic supparative otitis media inSoloman Islands: a prospective microbiological, audiometric and thera-peutic survey. NZ Med J, 1986;99:812-815

3. Cannoni M, Bonfils P, Sednaoui P, et al. Cefotiam hexetil versus amoxi-cillin/clavulanic acid for the treatment of chronic otitis media in adults.Medicine et Mal Infect 1997;27:915-921

4. Dellamonica P, Choutet P, Lejeune JM, et al. Efficacy and safety of cefo-

tiam hexetil in the treatment of chronic otitis media. Medicine et MalInfect 1995;25:733-739

5. Esposito S, D’Errico G, Montanaro C. Topical and oral treatment ofchronic otitis media with ciprofloxacin. Arch Oto Head Neck Surg,1990;116:557-559

6. Frandis M,Brodsky A, Ben-David J, et al. Chronic otitis media treatedtopically with ciprofloxacin and tobramycin. Arch Oto Head Neck Surg,1997;123:1057-1060

7. Smith AW, Hatcher J, Mackenzie IJ, et al. Randomized control of chronicsuppurative otitis media in Kenyan schoolchildren. Lancet,1996;348:1128-1133.

Figure 2. CSOM Prevalence


OCCUPATIONAL HEALTH

Hand-washing until it hurts!By E. Chad Schmidgal, MS4, and Robert Gilson, MD

INTRODUCTION As healthcare providers, most of us have experienced dry, itchy

and cracking skin due to frequent hand washing and sanitizing.Hand eczema or irritant contact dermatitis (ICD) is common inoccupations that involve repeated hand washing or repeated ex-posure of the skin to water, food materials, soaps and other irri-tants. High-risk occupations include cleaning, food preparation,hairdressing and nail salons, and healthcare employees. In health-care settings requiring frequent hand washing, such as ICUs, theincidence of ICD may be as high as 55.6 percent. ICD has a sig-nificant impact on an individual’s ability to work; one study of62 workers with hand eczema reported one-third had a greaterthan 10 percent drop in productivity, 35 percent had missed timeat work, and 28 percent had to change jobs or were not workingdue to hand eczema.

PRESENTATIONThe typical presentation of irritant contact dermatitis is skin

with erythema, scaling, thickening (lichenification), or fissuring.The skin may have a glazed or scalded appearance. Irritant con-tact dermatitis is caused by skin injury, direct cytotoxic effects,

or cutaneous inflammation from contact with an irritant. Symp-toms can include severe itching, pain from open fissures, andmay be functionally limiting or require time away from work.ICD symptoms can occur immediately but may persist if the ir-ritant is unrecognized and exposure continues. The effects ofICD may also be more pronounced in colder, less humid envi-ronments (“winter itch”).

FURTHER CONSIDERATIONSAllergic contact dermatitis (ACD) may present similarly to ir-

ritant contact dermatitis. Allergic contact dermatitis is a delayed-type hypersensitivity requiring previous exposure and sensitizationto the allergen, whereas irritant dermatitis can occur in anyone’sskin with sufficient exposure and provocation. A dermatologistcan perform patch testing when an allergen is suspected for handdermatitis not responding to the usual measures.

PREVENTION Complete avoidance or greatly reducing the number of expo-

sures to cutaneous irritants is the best method for treating andpreventing irritant contact dermatitis. Decreasing the number ofwet-to-dry cycles by reducing the number of times one washestheir hands also will reduce the likelihood of developing ICD.Wash hands with warm, not hot, water using mild soaps such asDove Sensitive or Cetaphil and avoiding harsh soaps such as Ivoryor soaps with added fragrances.

For healthcare workers, utilizing waterless hand sanitizers is alsokey to preventing ICD. Ethanol-based hand sanitizers are themost practical for healthcare workers to use on a daily basis. Theyare cost-effective and have a low incidence of developing resistanceto bacteria. One study at a French hospital comparing 16 differ-ent sanitizers concluded that Purell was the most favorable amongthe study participants. Whatever brand you choose, there maystill be slight drying effects of ethanol on skin though they aregenerally less problematic than other alternatives for those withtendencies for hand eczema. Avoid allergens whenever possible;the most common hand allergens detected by patch testing as re-ported by the North American Contact Dermatitis Group in-

cluded preservatives, metals, fragrances, topical antibiotics, andrubber additives. Due to the rising incidence of rubber or latexallergy, non-latex vinyl or nitrile gloves are better alternates. Forphysicians and dentists and other occupations requiring bettermanual dexterity, nitrile gloves are more form fitting.

TREATMENT To treat ICD, frequent application of a bland emollient such

as Vaseline or Aquaphor to irritated skin is imperative for restoringthe epidermal barrier in workers with irritant contact dermatitis.For more severe cases, a dermatologist can prescribe moderate-strength topical steroids. The most severe cases may even need acourse of oral steroids. Patch testing for the refractory cases canidentify potential allergens for those with allergen contact der-matitis. Identifying the irritants and/or allergens, and preventingthe repeated exposure, remains the penultimate treatment.


OCCUPATIONAL HEALTH

COMPLICATIONSPruritus and scratching already compromised skin can fur-

ther damage the skin barrier and predispose to staphylococcalinfection. The skin may then exhibit signs of infection such

as crusting, weeping and purulence. Though crusting andweeping may be related to the underlying inflammation itself,antibiotic treatment may be indicated for secondarily impetig-inized dermatitis. With compromise of our skin barrier, her-petic infections (herpetic whitlow) can also occur morefrequently, especially in healthcare workers. Tinea manusshould also be included in the differential diagnosis of scaly

eczematous hands.

CONCLUSION In summary, protect your hands as much as you can from the

elements they contact daily. Your hands remain your tools to heal,and they must be kept healthy to continue to do good works inyour profession as physicians.

E. Chad Schmidgal is a fourth-year medical stu-dent at the University of Texas Health Science CenterSan Antonio. He is pursuing a career as a U.S. Navydermatologist and began his training as a transitionalintern at the Navy Medical Center San Diego in July.

Robert Gilson, MD, is a board-certified derma-tologist and associate professor at the University ofTexas Health Science Center San Antonio. Dr.Gilson is a BCMS member.

Hand Eczema — Fast Facts:• Wash hands when necessary with

warm, not hot, water and gentlecleansers.

• Utilize waterless hand sanitizers todecrease hand washing frequency.

• Use gloves to avoid contact with irri-tants and known allergens.

• Treat damaged skin with emollients(Vaseline® or Aquaphor®).

• Visit your dermatologist if handeczema persists.


OCCUPATIONAL HEALTH

Impairment isn’t disabilityBy Fred H. Olin, MD

Any physician who takes care of people who are injured or

made ill by workplace events or in accidents may be asked to

express an opinion about the patient’s “disability” as a result of

whatever occurred. As in those recent TV truck commercials

telling you what to do if asked for a down payment, DON’T

DO IT! Here’s why:

DESIGNATED DOCTOR As the headline here states, “impairment” is not “disability.”

Some years ago I took a course to become a Texas “Designated

Doctor” so that I could do impairment examinations. The in-

structor used an example something like this: “Pretend that you

are two people: one of you is a professional basketball player;

the other you is a receptionist who hardly ever has to get out

of her chair while working. Both of your avatars sustain a se-

rious fracture around the ankle that results in a fusion of the

ankle and subtalar joint, so you have essentially no motion

below the knee. Both of you would have the same percentage

of impairment according to the AMA Guides to the Evaluation

of Permanent Impairment (hereafter “the Guides”), but he

would be 100 percent disabled from his job, while she would

have minimal or no disability in relation to her job.” Another

point made in the Guides is that impairment is “… an alter-

ation of an individual’s health status,” and that disability is “…

an alteration of an individual’s capacity to meet personal, social,

or occupational demands … because of an impairment.” An-

other sort of shorthand way to look at the difference is that im-

pairment is a medical term and disability is an

administrative/legal term.

Here in Texas we are obligated by legislative action to use the

4th edition of the Guides, which was first published in 1993,

to determine impairment. Since then there have been two more

editions produced, each of which has had significant changes

in methodology. In my opinion, each new edition has im-

proved on the process of arriving at an appropriate level of im-

pairment to submit to whatever authority has requested the

evaluation. But, the Texas Legislature and Department of In-

surance being what they are, I wouldn’t expect them to allow

us to update any time soon.

Even if you aren’t a “Designated Doctor” for the state, it is

possible that you could be asked to come up with a numerical

impairment rating by an attorney or an insurance company. It’s

not hard: what you need is a copy of the 4th edition of the

Guides, the ability to read, and a copy machine. The copier is

particularly useful in the musculoskeletal section, which makes

up about half of the book, as there are forms there that, if filled

out carefully, will essentially automate the rating process.

APPROPRIATE RATINGWriting the report is essentially doing what we were all taught

in medical school: document a history of the current problem,

the patient’s current complaints, and the findings of a careful,

appropriately limited physical examination. Then, referring to

the Guides, come up with an appropriate rating. When you

do this, you become responsible to several individuals and en-

tities.

First and foremost, you are responsible to the patient who,

assuming that there are residual problems from the incident in


OCCUPATIONAL HEALTH

question, deserves an accurate evaluation.

Secondly, you are obligated to the requesting authority to

give them an impairment rating that neither overstates nor un-

derstates the problem. Overestimating the impairment can cost

an insurance company money that they shouldn't have to pay

out, or induce an attorney to take action not truly in his client’s

best interests. Underestimating has the obvious risk of possibly

preventing the injured party from receiving appropriate com-

pensation, as well as perhaps causing unnecessary repeated re-

quests for re-evaluation.

Next, there is an obligation to the potential payors to detect

malingering and the potential for fraud. A gentle suggestion

in the report that further observation of the patient in non-

clinical settings might have value gets the message across. Of

course, use of such terms as “fraudulent” or “malingering” could

open you up to problems.

I have a side gig examining impairment reports from several

states for a company that services claims adjusters who question

the validity of an impairment rating. While many of these re-

ports are well done, I never cease to be amazed and appalled by

the lack of attention to detail combined with arrogance of some

examiners. You can’t just snatch a number out of the air because

you like or dislike the patient.

It’s really not hard to write a report that will treat all parties

fairly. It requires a bit of study, and perhaps taking a course on

the subject that deals with whatever edition of the Guides you’re

using. Then you’ll be ready to do an efficient job.

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

thopaedic surgeon who was one of the physician

reviewers of the AMA Guides to the Evaluation

of Permanent Impairment , 6th edition. He is

chairman of the BCMS Communications/Publi-

cations Committee.

PHYSICIANAS PATIENT

as

RecoveryBy Jay Ellis, MD

EDITOR’S NOTE: This is the sixth in a series of ar-ticles written by San Antonio anesthesiologist JayEllis, MD, a member of the BCMS Communica-

tions/Publications Committee. The series, publishedmonthly in San Antonio Medicine, examines the phys-ical, emotional, financial and spiritual burden of life-threatening illness

PhysicianPatient

After I left the hospital, I re-turned home a feeble, debili-tated man. For the first time inmy life I had to face the possi-bility that I might be perma-nently impaired. I alsoworried that I might not bestrong enough to tolerate anymore chemotherapy. I had al-ready missed one session, andDr. Greg Guzley told me itwould be at least a week beforehe would even think about let-ting me attempt another treat-ment. I could not climb aflight of stairs. I could barelymake it around the backyard.Greg gave me specific instruc-tions before I left the hospital.I would do nothing morestrenuous than walk a mile onlevel ground at no more than a15-minute-mile pace. At thatmoment, 15-minute miles seemed the equivalent of running amarathon. I would have to stay home. If I were to go out in acrowd and get the flu, I would not survive the event.

My life assumed a very dull existence. I would get up in themorning and read three newspapers. I would go and try to takemy walk hoping to see signs of improvement. Greg also allowedme to lift with light weights, and I used my wife Merrill's 12-

pound dumbbells which in my impaired condition felt like theOlympic weightlifter workout. That would take me to lunchtime, and I had the rest of the day to kill. It was so boring. Ittruly was house arrest without the ankle bracelet.

On my first attempt at walking away from the house Merrillneeded to run some errands, and I went on my own. She gaveme strict instructions to be careful, but I decided I would get


Dr. Greg Guzley discusses my treatment plan. I credit him with saving my life.

out there and push it. After all, no pain,no gain, right? I took my pulse oximeterwith me and found that if I walked asteady, measured pace I could keep mysaturation above 90 percent, but justbarely. I made it six-tenths of a mile andturned to go up a slight hill that I hadrun hundreds of times before. Afterabout 10 yards, my oxygen saturationhit 85 percent, my heart rate was 120,and I was feeling very lightheaded. Iquickly bent over and put my head be-tween my legs. I have no idea what thetraffic passing by thought of this strangeposture, but after a few minutes I ralliedenough energy to turn for home. Iwalked 1.2 miles, it took me over 30minutes, and I was exhausted. Merrillreturned home to see me collapsed onthe couch. She didn’t say a word, but shenever let me walk alone again.

CATCHING MY BREATHIt was humbling to walk with Merrill.

She has always been an avid walker,moving at a brisk pace that challengesmost people. In my recovering state I could not keep up withher. I would put my pulse oximeter on and watch as I struggledto keep my heart rate under 120 and my saturation greater than90 percent. If we walked up any sort of incline, I would have

to stop and catch my breath – or just pass out, which did notseem as appealing. I let her borrow the pulse oximeter for awhile just to check her heart rate and oxygen saturation. Thenormality of her readings was a stark contrast to my physiologicinfirmity. It only reaffirmed how impaired the pneumocystispneumonia left me.

Despite a difficult start, I did see signs of progress. We mon-itored our pace with a free app on my iPhone, and my pace permile went from over 20 minutes a mile to under 18 minutes. Iwas hoping this would be enough to let me resume mychemotherapy. When I saw Greg for my next appointment, heconcurred that I could start treatment again. It was a great re-lief, at least until the next day. In my debilitated state thechemotherapy hit even harder. I couldn't even go for a walk. Idid rally, and Merrill and I continued our daily walks. I triedto do light chores around the house to make myself feel useful.

I went out to clean the pool and when I came in I realized thatmy wedding band fell off my skinny, emaciated finger. Isearched the pool, the yard and the filter equipment withoutsuccess. I was heartsick, but Merrill told me to stop fretting.

The monotony of my existence was broken by good friends.Ed Rashid came by and brought me some books and movies towatch, as well as a delicious cake. Friends sent notes, email andcalled. Merrill stood guard at the front door and anyone withthe appearance of illness was given a polite shove toward thestreet. I made vain attempts to escape. I told her I thought Imight go to the gym and she responded, “How many sick peo-ple use that exercise equipment?” I thought we might go tochurch and sit off by ourselves, and she reminded me howmany people we heard cough when we watched services online.She was an effective and diplomatic warden.

I decided I would use my month of enforced confinement asan opportunity for self-improvement and did some onlineCME. I continued to read three newspapers every day, and Iconsidered myself the world's expert on current events for themonth of January 2014. Each day seemed to get a little better.

Continued on page 22

PHYSICIANAS PATIENT


These are just a few of the nurses from Cancer Care Centers of South Texas who guided methrough my chemotherapy.

PHYSICIANAS PATIENT


Continued from page 21

My ability to lift weights improved, and I was even able to startdoing push-ups again. I would take great pride in my little victo-

ries. I began to have some hope that I would recover from thisnear-life-ending event.

Just before my fifth chemotherapy, I went for my fourth CTscan. After the study Dr. Michael Lane was again good enough toreview the results with me. My lungs were dramatically improved,but even more heartening was the effect of chemotherapy. The ab-dominal mass, the lymphadenopathy, even the splenic changeswere undetectable. The results of the chemotherapy after just fourtreatments were dramatic. I was euphoric.

IMPROVEMENT WAS POSSIBLEMerrill and I began to push my daily walks even farther. By the

end of January, we were able to walk 3 1/2 miles at just under 16minutes a mile. I felt like Roger Bannister breaking the four-minute mile. I was certainly exhausted after I performed this oth-erwise mundane feat, but it gave me hope that greaterimprovement was possible.

I returned for my fifth chemotherapy and got even better news.My hemoglobin, which had been under nine for most of the courseof my illness, was now over 11. No wonder I felt better. Greg al-lowed me to return to work half-time. It was great to be back inthe office and working, even on a reduced schedule. I was able tostart going to Spurs games again and to go out to dinner. Prior tothis Merrill and my mother were my primary connections to theoutside world. It was great to feel part of society again.

I finished my sixth chemotherapy and began counting the daysuntil the ultimate test, my PET scan. I received a list of preopera-tive instructions for the PET scan. It rivaled the user's manual foryour car. No heavy exercise 24-48 hours, no sweeteners or artificialsweeteners for 24 hours, high-protein, low-carb meal the night be-fore. No eating for eight hours prior to the procedure. I showedup on the day of the procedure and received my injection fromthe steel container containing the radionuclide, while sitting insidethe metal-walled room. I felt like a toxic fund cleanup site. Thescan takes 20 to 30 minutes, but by this time I was so used to theCT scanner that I fell asleep during the procedure. I was hopingto be able to review the results as I had with previous studies, butdidn't get the opportunity this time. I promptly went home andpulled the results up on my computer. Me reading a PET scan issecond only to me trying to read Sanskrit. I did know that brightactivity outside my kidneys was not good. There was only one tinyspot outside my kidneys that lit up, and it was in my lung. I wasconfident that this was nothing more than residual effects of mypneumonia, and it was just a matter of time until Greg called me

to tell me that I was in remission. It seemed miraculous. Unfortunately, when Greg called it wasn't quite what I expected.

He did confirm that there was a spot in my lung. However, therewould be no way to determine whether this was lymphoma orresidual pneumonia without a biopsy. I would need CT scan num-ber six and a needle-directed biopsy to answer the question. OK,I can do this. I believed it to be merely a formality, but if it wouldsave me from more chemotherapy I would let them stick a needlebetween my eyes. Dr. Beatriz Escobar did my biopsy, and it wentsmoothly. I began waiting for the results. I would log into theMeditech system and check my results each day waiting to see thereport. It took days, but it seemed like eternity. Greg allowed meto go back to work full time since I felt so well. I was even begin-ning to run again, though anyone watching me would have a hardtime calling it running, considering my pace was hardly better than12 minutes a mile.

Finally, at the end of a Wednesday, just as I finished my cases,Greg called. The results were in. There was no lymphoma on thebiopsy, and I was in remission. As Greg would say later, I wasn'tcured, but I had made the first cut. I immediately called Merrilland my Mom to share the news. I tried to stand up, but I couldn't.My entire body went limp. I believed I was handling all this pres-

Race day, May 19, 2014. To be so close to death and disability just fourmonths ago and to feel so well today feels like a miracle. Courtesy photos

PHYSICIANAS PATIENT


sure so well. I then realized that once I had the definite answer, awave of relief swept over me, and I was free from the stress of not

knowing. The subconscious burden had sapped my energy, and Iwas now exhausted. I sat in the doctor's lounge at MSTH for 15minutes surprisingly all alone, until I was finally able to move. Iwent home and hugged Merrill.

RUNNING A RELAYI met with Greg a week later, and we discussed my new plan.

There was a new protocol that might increase my chances of sur-vival by 50 percent. I would start on rituximab every other monthfor two years. If there was no recurrence, I would be done. Thisseemed like a piece of cake. Get one drug every other month in-stead of five drugs every three weeks? I can do that standing onmy head.

My hemoglobin was now over 12, and I felt better than I hadin months. My running partner Bob Johnson and I decided to seeif I could run 3 miles. If I could, I would run an entire leg of theBeach to Bay Relay, an annual event I did with five of my friendseach year for the past 18 years. I had signed us up in October, butdidn’t know if I would be alive on race day and had little hope that

I would be running. If things went well, I hoped I could come tothe race and cheer. I started running with Bob, but it did not begin

well. I would run for 100 paces, walk for 100 paces, gasping forbreath. Slowly but surely we were able to improve the pace. OK,we improved my pace. Bob, as ex-triathlete, wasn’t even winded.

On May 19, 2014, 136 days after I left the hospital and supple-mental oxygen and 89 days after my last chemotherapy, Bob stoodnext to me as I lined up for the start of the race. It was an unbe-lievably cool day for this race. It wasn't over 70 degrees, and I can'tremember better race day weather. If there was ever a day when Iwas going to be able to make it, this would be the day. All I wantedto do was finish without walking. Despite the cool weather, therewas a 30-mile-per-hour head wind blowing sand in my face. Ac-tually, it was a blessing. It kept me from thinking about how muchmy legs hurt. I finished my leg, 3.5 miles, in just over 37 minutes.It seemed like a miracle. After being so sick I was back runningagain, albeit slowly. In January, I thought I would never run again.In October and again in December, I wasn’t sure that I was goingto live. Now I was doing both.

NEXT: What I learned.


LIFESTYLE

TOBIN CENTER FOR THE PERFORMING ARTS

This performance space has been several

years and $203 million in the making, and

it’s finally opening! On Sept. 4, for the first

time ever, Ballet San Antonio, Opera San

Antonio and members of the San Antonio

Symphony will perform together on the H-

E-B Performance Hall stage as the resident

companies of the Tobin Center for the Per-

forming Arts.

Don’t miss guitar great Carlos Santana on

Sept. 30. Then get ready for two Beatles in

one month! Paul McCartney will perform a

benefit concert Oct. 1, topping off a month-

long grand-opening celebration for the new

performing arts center in the heart of down-

town. In his first San Antonio appearance

since 1993, McCartney and his band will

perform as a fundraising event for the new

venue. Ringo Starr With His All Starr Band

will perform favorites on Oct. 7. The Tobin

Center hosts An Intimate Evening With Art

Garfunkel, an acoustic performance with

songs, anecdotes, prose and a unique audi-

ence Q&A session, on Oct. 9.

BALLET SAN ANTONIOBallet San Antonio’s 2014-15 season be-

gins Oct. 16-19 with the critically ac-

claimed Dracula, artistic director Gabriel

Zertuche’s take on the legendary count’s

nocturnal escapades. The Nutcracker, featur-

ing local children and live music by the San

Antonio Symphony, kicks off the holidays

Nov. 28-Dec. 7.

Award-winning choreographer Ben

Stevenson returns to San Antonio to stage

Romeo and Juliet in time for Valentine’s Day

weekend, Feb. 12-15. The Shakespearean

tale of forbidden love will feature sets and

costumes from Houston Ballet and

Prokofiev’s famed score performed live by

the San Antonio Symphony.

The company will round out its season

March 27-29 with Balanchine, an evening

of contemporary works that spotlights

Donizetti Variations by famed choreogra-

pher George Balanchine.

Season tickets for all four Ballet San An-

tonio performances at the Tobin are avail-

able through Oct. 1. Prices start at $99. Call

210-223-8624 or [email protected].

For more detailed information about the

performances, visit balletsanantonio.org.

SAN ANTONIO SYMPHONYNot only will this be the San Antonio

Symphony’s first season in the new Tobin

Center, it’s also the symphony’s 75th an-

niversary season, and part of the celebration

involves the work of composers from Ger-

many, France, Mexico and beyond.

“For each one of our classic concerts, we

have commissioned a composer to write a

short, three- to four-minute prelude to an-

nounce the opening of the Tobin Center

and the 75th anniversary,” said president

David Gross.

Kicking off the celebratory season on

Sept. 20 is a gala evening with soprano

Renée Fleming, who sang for many years

with the Metropolitan Opera. She also

sang the national anthem at this year’s

Super Bowl.

“The game-changer with the Tobin Cen-

ter is that the performance hall was built

with considerations so that the orchestra is

presented in the best acoustical environ-

The next few months promise spectacular dance, musical and theatrical performances in San Antonio. Get your tickets now for the 2014-15 season!

PerformingArtsin San AntonioBy Beth Bond


LIFESTYLE

ment,” Gross said. “The Tobin Center is

built on the site of the old Municipal Au-

ditorium. They left the facade, scooped out

the interior and rebuilt the whole thing.

The space was excavated down to the river

so that people can have dinner on the

River Walk, then take a river taxi from the

restaurants.”

Celebrate the holidays with associate con-

ductor Akiko Fujimoto for Holiday Pops

(Dec. 19-21), a magical celebration of the

season complete with a singalong, special

guests and a program featuring traditional

and popular music.

Experience the music and excitement of

one of the world’s most popular and best-sell-

ing ABBA show bands, Arrival from Sweden,

with The Music Of ABBA, March 6-8.

The annual Fiesta Pops concert (April

17-19) features the music, dance and cul-

ture of San Antonio and South Texas.

Enjoy the beautiful sounds of Campanas

de America and a colorful corps of dancers

with the Guadalupe Dance Company. The

program is sure to get guests into the Fi-

esta spirit.

The symphony’s former home was the

Majestic Theatre, which will continue to

host the symphony for a series called Sym-

phony Goes to the Movies, in which films

will be accompanied by live soundtrack

performances. Check out Star Trek Into

Darkness on Oct. 17-18 and Bugs Bunny

Goes to the Symphony on April 3-4.

MAJESTIC THEATERThe historic Art Deco movie house con-

verted to a live performance space will host

classic Broadway and blockbuster hits this

season. The 2014-15 season of North Park

Lexus Broadway in San Antonio features six

show-stopping productions, two market de-

buts and three season options.

The season opens with passionate ro-

mance and an electric stage adaption of

Dirty Dancing (Nov. 4-9), followed by an

extended run of Disney's phenomenal pro-

duction of The Lion King (Dec. 10-Jan. 4).

Then Chicago (Jan. 27-Feb. 1) kicks off the

new year with everything that makes

Broadway great: a universal tale of fame,

fortune and all that jazz. Winner of eight

Tony Awards including best musical, Once

will captivate audiences March 3-8 with its

powerful music and an enchanting tale of

a Dublin street musician. Leapin’ lizards!

Broadway’s best-loved musical Annie re-

turns to town April 14-19, followed May

12-17 by the smash hit, crowd-pleasing

musical from Disney, Newsies, winner of

the 2012 Tony Awards for best score and

best choreography.

Three season options give Broadway fans

more choices than ever before. Subscribers

can add these shows to their season package.

The eye-popping spectacle Disney’s Beauty

and the Beast (Sept. 30-Oct. 5), presented

by NETworks, features unforgettable char-

acters and dazzling production numbers.

Blue Man Group, best known for their

wildly popular theatrical shows and con-

certs, returns March 24-29 to combine

comedy, music and technology to produce

a totally unique form of entertainment.

Then, have the time of your life at Mamma

Mia! (June 9-14), the ultimate feel-good

show that has audiences returning again and

again to hear ABBA's greatest hits.

Above: Tobin Center for the Performing Arts, river view at night. Left: SopranoRenée Fleming will kick off the celebratory season of the San Antonio Symphony.Courtesy photos


BCMS NEWS

The American Association of Physicians of Indian Origin (AAPI)

held its 32nd annual convention in San Antonio June 25-29. Dr.

Jayesh Shah concluded his year as president by orchestrating a plan

to bring the national AAPI convention to San Antonio for the first

time. The convention was filled with numerous speakers, entertain-

ers and celebrities from the United States and India. Among the

notables attending the convention was India's Hon. Minister of

Health and Family Welfare, Dr. Harsh Vardhan, who delivered a

presentation of the work he and other leaders are doing in collabo-

ration with 24 countries to improve the healthcare climate and ac-

cess to care in India.

The convention included the organization's inaugural "Be Fit. Be

Cool" walk, with the focus of combating obesity. On hand for the

opening ceremony and walk were the 2014 Miss America, Nina

Davuluri, the first Indian American to be chosen as Miss America,

and Sendhil Ramamurthy, an American actor known for his roles

in Heroes and Covert Affairs; he is the son of Drs. Somayaji and

Rajam Ramamurthy.

For the first time in its history, AAPI, through a philanthropic

endowment created by San Antonio plastic surgeon Dr. Rajaram

Bala, announced the newly established Dr. Rajaram Bala Endow-

ment Award for Research. The four winners, who were chosen dur-

ing the 2014 Global Healthcare Summit’s first-ever research and

poster contest held in India in January, were announced during the

San Antonio convention.

"I want to thank the Bexar County Medical Society and its mem-

bers for their strong support in hosting the AAPI national conven-

tion in San Antonio,” said Dr. Shah. “I appreciate the hard work

and commitment by all my colleagues who helped plan and execute

a successful convention culminating my year as president of AAPI.

Also, I want to thank the BCMS Alliance for their support and par-

ticipation in the AAPI inaugural ‘Be Fit. Be Cool’ walk."

For more information, contact Mary Nava at

[email protected].

Dr. Jayesh Shah wraps up year as

AAPI president

Dr. Vijay Koli (second from left) was thanked for his work as AAPI conventionchairman June 28 by AAPI President Dr. Jayesh Shah, Himalchal Pradesh HealthMinister Kaul Singh, and Medical Council of India Chairwoman Dr. JayshreeMehta.

India's Hon. Minister of Health and Family Welfare Dr. Harsh Vardhan (center)is presented a plaque June 28 for his leadership in working to improve access tocare in India.

The 2014 reigning Miss America Nina Davulurispeaks about her personal journey with diabetesduring the inaugural ‘Be Fit. Be Cool’ walk June28.


BCMS NEWS

Lecture planned on ancient health:Financial aid sought

Dr. Alain Touwaide will present a lecture on “The Ar-

chaeology of Health in the Ancient Mediterranean World”

at 7:30 p.m. Oct. 20 in Chapman Hall at Trinity Univer-

sity. The event is free and open to the public.

Dr. Touwaide is a science historian who specializes in

the history of medicinal plants in the cultures that flour-

ished around the Mediterranean Sea from antiquity to the

17th century CE. His lecture is sponsored by the South-

west Texas Archeological Society (SWTAS), a branch of

the Archeological Institute of America.

Financial support is being sought to cover the approx-

imate cost of $2,000 for expenses. Contributions of all

sizes are appreciated by the SWTAS, which is a 501(c)(3)

organization. Contributions can be sent to AIA SWTAS.

The check should be mailed to: Laura Childs, 2858 Burn-

ing Log, San Antonio, TX 78247. The check should stip-

ulate Touwaide Lecture.Dr. Alain Touwaide digitizes information on medicinal plants from ancient herbals.Courtesy photo

SAVE THEDATE Acuity Hospital of South Texas named its board room after anesthesiologist Dr.

Norman L. Wulfsohn on July 18. Dr. Wulfsohn, a BCMS life member, was honoredfor his years of service to the hospital, patients and the South Texas community as aphysician, author and educator.

(From left) Dr. Francisco Gonzalez-Scarano, Dr. Roberto San Martin, Dr. David Malave, Dr. NormanWulfsohn, and Kris Karns, CEO Acuity Hospital of South Texas. Courtesy photo

Sept. 18: BCMS Foundation Golf Tour-nament, Quarry Golf Club. Register atwww.bcms.org.

Sept. 24: BCMS Fall General Member-ship Meeting, Hilton at the Airport.CME and legislative updates. Register at www.bcms.org.

Sept. 28: Siclovia, Alamo Plaza.www.siclovia.org.

Oct. 9-10: Texas Health Literacy Conference,La Quinta Inn and Suites Medical Center. www.healthcollaborative.net.

Oct. 16: BCMS Auto Show, BCMS office parking lot. Buffet andcocktails; new model vehicles; family andfriends welcome.

Dr. Wulfsohn Honored


Measureable goals and strategies to continue improving the healthstatus of San Antonio and Bexar County were unveiled recentlywhen the Health Collaborative released the 2014 Bexar CountyCommunity Health Improvement Plan.

The Health Collaborative is a powerful network of citizens, com-munity organizations and busi-nesses addressing the health needsof San Antonio and Bexar County.The Health Collaborative hostedthe health improvement planprocess, which included a commu-nity health assessment and plan-ning effort conducted over 24months with 85 agency partnersand community stakeholders, in-cluding Metro Health andSA2020.

The plan serves as a vision forthe health of the community anda framework for organizations touse in making that vision a reality.From my perspective, embracingand advancing the plan is the bestway we can improve the health sta-tus of the community in a signifi-cant and measurable way.

As a board member of theHealth Collaborative and regionalvice president for San Antonio’soldest faith-based healthcare sys-tem, I believe the communityhealth improvement plan extendsthe healing ministry established by

the Sisters of Charity in 1866 to even more people. It will help uslift up the least among us — those without access to healthcare fora variety of reasons — to make healthcare better for all.

To survive and thrive we must change our focus, transformingour system from “sick care” to prevention and wellness. Physicians

are key partners in this effort, andwe welcome your participationand input.

For each area, the communityhealth improvement plan provideshealth determinants, objectives,targets, strategies and partners/re-sources with time frames.

We encourage you to reviewthe plan at www.healthcollabora-tive.net. Use it to identify barri-ers that you and your patientsface, and share it with your col-leagues. But most of all, use it asa vehicle to become part of the ef-fort to improve communityhealth.

Dennis P. Gonza-les, PhD, is a boardmember for theHealth Collabora-tive and regionalvice president, mis-

sion integration, at CHRISTUSSanta Rosa Health System.

IN THE NEWS

2014 Bexar County Community Health ImprovementPlan offers opportunity for physicians to get involved

By Dennis P. Gonzales, PhD

Community health improvement plan focus areas and goals are:

HEALTHY EATING AND ACTIVE LIVINGGoal: Foster systemic and social change to support eq-

uity in healthy eating, active living and wellnessto enable all community members to makehealthy choices and lead healthy lives.

HEALTHY CHILD AND FAMILY DEVELOPMENTGoal: Promote access and utilization of preventive

healthcare across the lifespan to improve healthychild and family development.

SAFE COMMUNITIESGoal: Develop community-defined safe neighborhoods

by identifying and implementing local and globalbest practices through community empower-ment.

BEHAVIORAL AND MENTAL WELLNESSGoal: Improve and expand a comprehensive, integrated

behavioral health system to provide holistic serv-ices with access for all.

SEXUAL HEALTHGoal: Ensure all Bexar County community members

of any sexual orientation or gender identificationhave access to culturally appropriate educationand resources to promote sexual health.


HASA

The benefits of HIE accreditationBy Cijs van Oort, PhD

Concerns about patient safety and privacy are nowhere moretelling than in the area of exchanging patient information. The

public has been clear that it appreciates the convenience of havinginformation available at the doctor’s office at the time of a visit. Atthe same time, there remains a level of paranoia that this highly per-sonal information can fall into the hands of marketers, insurancecompanies or “devil of all” – the government.

Organizations which have taken on the task of managing patientinformation among providers are ultimately aware of those seem-ingly contrasting interests. Healthcare Access San Antonio (HASA),a regional nonprofit health information exchange, has been taskedto aggregate patient information from hospital EMRs, physicianEMRs, labs and pharmacies, and aggregate those disparate datasources into single patient records, for physicians and other providersto use at the time a patient seeks care. As a new organization in anew dynamic of healthcare, HASA has needed to establish itself asa trusted source to providers. Submitting to a rigorous independentassessment was one way to accomplish that. HASA thus became afirst participant in the state-endorsed EHNAC certification. As ofJuly 10, HASA now is the first Health Information Exchange or-

ganization in Texas – and the fourth in the nation – to have success-fully completed that process and be fully accredited.

The intent of an accreditation – identical to the process hospitals,health clinics, and physician clinics are going through – is to ensurethat daily practices for exchanging personal health information(PHI) follow national and state guidelines and laws. The accredita-tion process provides a mandate to objectively evaluate how well anorganization operates within those. HASA, as a new entity offeringnew services, verified several important processes and filled multiplegaps in processes that were incomplete.

While the process covered three months and involved many hoursof work, the endpoint is that HASA now can be a trusted utility forproviders who need patient information in real time. Given thatHASA’s role is an aggregator, complete records cannot be guaran-teed, but the way in which this information is stored, indexed and

transferred can assure HASA users that federal andstate guidelines are adhered to.

Gijs van Oort, PhD, is the executive director ofHealthcare Access San Antonio; www.hasatx.org.


BUSINESS OFMEDICINE

I received the following message from the BCMS Communica-tions/Publications Committee: “Many physicians now own all or partof a profit-making business, such as a pharmacy, lab, imaging center,rehab facility, selling back braces in their office, etc. Many physicianssay they can’t make enough income ‘just seeing patients’ and havebranched out to these other businesses. Is there research available onhow owning these businesses might impact the doctors’ decision-making (i.e., do they order more tests at their own facilities?) Is thereany evidence of impact on their patients’ outcomes?” My article isan attempt to shed some light on this topic.

INTRODUCTIONI hesitated to agree to address this issue because it is sort of like the

saying, “Beauty is in the eye of the beholder.” There are studies thataddress various aspects of this issue, and like many other healthcareissues, if you look hard enough you can find a study that supportsyour side. My purpose for this article is not to provide a definitiveanswer, but to give the reader a framework that identifies various as-pects related to physician ownership and perceptions that exist. Mymain references for this article are the Institute of Medicine’s “Con-flict of Interest in Medical Research, Education, and Practice,” pub-lished by the National Academies Press, Washington, D.C., 2009,and “Physician Ownership in Hospitals and Outpatient Facilities,”Center for Healthcare Research and Transformation, by Nancy Baumand Emily Ehrlich, July 2013.

RELATED FACTSThere are federal laws that generally prohibit physicians from re-

ferring Medicare and Medicaid patients to facilities in which thephysicians have financial ownership. There are many similar statelaws that restrict referral of privately insured patients, but despitethese facts, physician ownership in specialty hospitals and outpatientfacilities grew rapidly in the past decade. Today there are more than235 physician-owned specialty hospitals nationwide, and a 2008 na-tional survey found that one in six physicians owned or leased ad-vanced imaging equipment, and nearly one in seven owned or leasedthree or more types of medical equipment.

Historically, the attempt to regulate self-referral resulted in the pas-sage of a series of laws beginning in 1989 with the Stark Law. As faras a definition: “When physicians refer patients to facilities in whichthey have ownership (“self-referral”), the physicians receive paymentfor their professional services and share in the profits of the facilitiesthey own.” In March 2010 the passage of the Patient Protection andAffordable Care Act (PPACA) curtailed growth in physician owner-ship by effectively prohibiting both the creation of new and the ex-pansion of existing physician-owned hospitals and outpatientfacilities after March 2010. As with most issues there are two sidesto this issue: the advocates of physician ownership and the AmericanMedical Association, among others, support efforts to repeal this newban; and the American Hospital Association and other hospitalgroups oppose the repeal efforts.

Physician ownership, conflicts of interest and medical practice:Do they make an impact on patient outcomes?By Joseph P. Gonzales, MHA, FACHE, PMP


BUSINESS OFMEDICINE

THE BASIC QUESTIONMany from each side of the political spectrum suggest that own-

ership arrangements between facilities and physicians and the result-ing self-referrals create an inherent conflict of interest since physiciansdirectly benefit financially from the services provided by these facil-ities. So is there evidence concerning the impact of physician own-ership on costs, quality, and access to care? Various studies haveexamined the direct and indirect effects of physician-owned facilitieson use of services, access, patient mix, and quality of services. Mostof the research deals with utilization of services, and less is knownabout the quality of services that are provided.

A LOOK AT COSTS, UTILIZATIONCosts are a function of the volume, price and efficiency with

which services are provided, regardless of physician ownership.Studies have found that the volume of services provided is higherin areas with physician-owned specialty hospitals than in areaswithout such hospitals. One example of this is that a 2007 studyby Mitchell found that rates of complex spinal fusion surgery andepidural procedures for workers with back injuries increased sig-nificantly as physician ownership increased from 1999 to 2004.The same study found that rates of complex spinal fusion surgerywere higher for Medicare beneficiaries living in areas with physi-cian-owned hospitals compared to areas without physician own-ership. Two other studies in 2006 reported similar growth inutilization in areas after specialty cardiac hospitals opened com-pared to cardiac programs in general hospitals.

A study by Hollingsworth et al. (2010) analyzed the volume ofservices provided in ambulatory surgical centers (ASCs) in Floridafrom 2003 to 2005. This study reported greater use of five commonoutpatient procedures in physician-owned ambulatory surgical cen-ters compared to non-physician-owned ASCs. This study also re-flected that with the accounting for baseline differences in volume,surgeons who acquired ownership in ASCs increased their volume ofservices compared to before they held ownership.

A study by Baker (2010) shows that the growth in the volumeof advanced imaging services is also positively associated withphysician ownership. It appeared that once they purchased orleased MRI equipment, they ordered more scans for their patientsthan they had before they owned or leased the equipment. Thesame study showed that total Medicare spending per patient in-creased once physicians owned or leased the equipment. A na-tional random sample of physicians surveyed revealed thatnon-radiologists with imaging facilities on-site had rates of utiliza-tion 1.2-1.7 times as high, depending on specialty, as those with-out such facilities. Medpac reports in 2005 and 2006 alsocompared discharge costs for inpatient services delivered to

Medicare beneficiaries in specialty hospitals compared to those incommunity hospitals. Specialty orthopaedic hospitals had highercosts per discharge than community hospitals.

ACCESSDiscussion associated with self-referral is the expectation that re-

ferrals for services within a physician’s practice or in another facilityin which a physician has ownership may provide patients with con-venient, same-day, or one-stop access to services. Studies found thatsame-day referral was quite low for advanced imaging services. A2010 study by Sunshine and Bhargavan found that Medicare bene-ficiaries received same-day service for 74 percent of X-rays but only15 percent of CTs and MRIs. A 2010 Medpac report found that lessthan half of advanced imaging services were performed on the sameday as office visits for Medicare beneficiaries.

Another aspect of “access” has to do with the availability of emer-gency room beds. This is particularly of interest given the tendencyof individuals (even with insurance) to seek care in the hospital’semergency department versus seeking care in their physician’s office.A 2008 report by the Office of the Inspector General of the U.S. De-partment of Health and Human Services found that just over half ofphysician-owned specialty hospitals had an emergency department,and more than half of those had only one emergency bed. Most stud-ies support that specialty hospitals were much less likely to have emer-gency departments than community hospitals (45 percent of specialtyhospitals compared to 92 percent of general community hospitals,2003 GAO report).

PATIENT MIX, COMPETITION, QUALITYA study by Hollingsworth and colleagues noted statistically signif-

icantly lower severity in patients treated in physician-owned ASCsin Florida compared to patients treated in facilities not owned byphysicians, although absolute differences were small. Another studylooked at practices in Arizona, and physician-owners treated propor-tionately more “minor” surgical cases compared to non-owners, andtreated fewer “moderate” or “major” surgical cases. Consistent withother studies, a GAO study found that specialty hospitals treated alower percentage of patients who were severely ill than did the generalhospitals.

A study by Gabel found that physicians who owned ASCs weremore likely to refer patients covered by Medicaid to community hos-pitals, and more likely to refer privately insured patients to the facil-ities they owned.

It may be assumed that quality of care may be greater in specialtyhospitals because of the narrow focus on a limited set of proce-dures, but few studies assess quality of care in addition to patientmix. One study by Cram and colleagues analyzed claims data to



BUSINESS OFMEDICINE

evaluate outcomes from major joint replacement surgery in spe-cialty orthopaedic hospitals and in general hospitals. They foundthat patients in the specialty hospitals had fewer comorbidities

(such as diabetes, congestive heart failure, and renal failure) andlived in wealthier areas than those in general hospitals. It wouldappear that more research is needed to understand the contribu-tion of comorbidities and procedure volumes to patient outcomesto verify claims of higher quality in specialty facilities. A recentWall Street Journal article noted that approximately half of the top100 facilities receiving payment bonuses from CMS were physi-cian-owned facilities.

CONCLUSIONSCan one say that physician ownership resulted in profit incen-

tives and do they negatively affect the care patients receive? Notwith any certainty. It would appear that much more research isneeded to support the claims that specialty hospitals and outpa-tient services (owned by physicians) actually improve the qualityof patient outcomes. There is a large body of research that showsthat ownership and self-referral are associated with increased uti-

lization and higher costs, low same-day referral, and the diversionof complex patients and Medicaid beneficiaries away from physi-cian-owned facilities.

Society has traditionally granted the medical profession consid-erable autonomy to regulate itself. They may be willing to con-tinue to do so in the case of conflicts of interest, but will Congress,state legislatures, federal agencies and other organizations that pushfor stronger measures? Similar to my belief in the need for realhealthcare reform, my position is that physicians can play a vitalrole in designing responsible and reasonable conflict of interestpolicies and procedures to reduce the risks of bias and to avoidundue burdens or harm. Providers should understand public con-cerns when it comes to conflicts of interest and take measures tomaintain public trust.

Joseph P. Gonzales is a "specialist master" with De-loitte Consulting LLP. An adjunct faculty memberwith UTSA, he teaches in the MBA program, busi-ness of healthcare track. He is a fellow in the Ameri-can College of Healthcare Executives.



• ACCOUNTING

Anderson, Johns & Yao CPAs(HH Silver Sponsor)We strive to provide a profes-sional and friendly atmosphere forall your accounting and financialneedsAnn Yao, CPA/PFS, [email protected] Antonio based CPA firm with 30 plus years of experience

Padgett Stratemann & Co. LLP(HH Silver Sponsor)Padgett Stratemann is one ofTexas’ largest, locally-ownedCPA firms, providing sophisti-cated accounting, audit, tax, andbusiness consulting services.Vicky Martin, CPA 210-828-6281Vicky.Martin@Padgett-CPA.comwww.Padgett-CPA.comOffering Service. More Than Ex-pected. On every engagement.

Sol Schwartz & Associates P.C.(HH Silver Sponsor)We specialize in areas that are most critical to a company’sfiscal well-being in today’scompetitive markets. Jim Rice, CPA, 210-384-8000, ext [email protected] to working with physicians and physician groups

• ATTORNEYS

Carabin Shaw Law FirmTexas Prompt Pay Lawyers(HHHH Platinum Sponsor)Paul L. [email protected]

Cox Smith Matthews, Inc.(H Bronze Sponsor)The largest Texas law firm head-quartered in San Antonio andone of the top 25 largest Texas

law firms.Dan G. Webster, III [email protected]

Pulman, Cappuccio, Pullen, Benson & Jones(H Bronze Sponsor)The attorneys at Pulman, Cappuc-cio, Pullen, Benson & Jones, LLPhave over 150 years of combinedexperience providing exemplaryrepresentation for clients.Eric Pullen, [email protected]

• BANKING

Amegy Bank of Texas(HHH Gold Sponsor)We believe that any great rela-tionship starts with 5 core values;Attention, Accountability, Appreciation, Adaptability & At-tainability. We work hard and to-gether with our clients to accomplish great things.Jeanne Bennett [email protected] Leckie [email protected] Banking Partnership

BB&T(HHH Gold Sponsor)Checking, savings, investments,insurance. BB&T offers bankingservices to help you reach yourfinancial goals and plan for asound financial futureEd L. White, Jr. [email protected]

BBVA Compass(HHH Gold Sponsor)A multinational banking group

providing financial services inover 30 countries,and to 50 mil-lion clients throughout the world.Commercial Relationship ManagerZaida Saliba, [email protected] Global Wealth ManagementMary Mahlie 210-370-6029mary.mahlie@bbvacompass.comwww.bbvacompass.comWorking for a better future

Broadway Bank(HHH Gold Sponsor)Broadway Bank is a full servicepersonal and commercial bankwith a specialized Healthcarebanking team committed tosupporting our medical commu-nity. We offer 40 convenient lo-cations in San Antonio, Austinand surrounding areas.Ken Herring, [email protected]’re here for good.

Crockett National Bank(HHH Gold Sponsor)Crocket National Bank is a leading Texas community bank specializing in mortgage, ranch and commercial real estatelending providing superior customer service and competitive financial products.Lydia Gonzales, 210-384-9304lydiagonzales@crockettnational-bank.comwww.crockettnationalbank.comDoing what we promise.

Frost(HHH Gold Sponsor)As one the largest Texas-basedbanks,Frost has helped Texanswith their financial needs since1868, offering award-winning customer service and a range ofbanking, investment, insurance

services to individuals and busi-nesses.Lewis Thorne, [email protected]@Work provides your em-ployees with free personalizedbanking services.

The Bank of San Antonio(HHH Gold Sponsor)We specialize in insurance andbanking products for physiciangroups and individual physicians.Our local insurance professionalsare one of the few agents in the state that specialize inMedical Malpractice and all linesof insurance for the medicalcommunity.Brandi Vitier, [email protected]

Bank SNB (HH Silver Sponsor)Bank SNB combines the re-sources of a full-servicebank with the expertise ofhealthcare specialiststo deliver services that maximizeyour revenue and profit.Sandy Cilone, [email protected] opportunity to work with ateam of healthcare advisors toachieve the financial goals ofyour practice.

Baptist Credit Union(HH Silver Sponsor)It is Baptist Credit Union’s missionto meet our members needs byproviding extraordinary service,quality financial products, andpersonal financial education. Sarah Chatham 210-525-0100, ext [email protected] commend your dedication tothe health & wellbeing of ourcommunity.

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


BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

Cadence Bank(HH Silver Sponsor)Margarita Ortiz [email protected] http://cadencebank.com

Citi Commercial Bank(HH Silver Sponsor)Chris McCorkle [email protected] www.citi.com

Firstmark Credit Union(HH Silver Sponsor)Address Your Office Needs. Upgrading your equipment ortechnology? Expanding your office space?We offer loans to meet yourbusiness or personal needs.Competitive rates, favorableterms, and local decisions.Gregg Thorne, SVP [email protected]

St. Joseph's Credit Union(HH Silver Sponsor)A Credit Union providing savings,checking, IRA, club, and CD ac-counts. Plus, Auto, signature,Lines of Credit, MasterCard and Real Estate Loans.Debra Abernathy, [email protected] Rates on Auto loans, Signature loans and PlatinumMasterCard

Jefferson Bank(H Bronze Sponsor)Full service bank specializing inmortgages, wealth management& trusts.Ashley Schneider 210-734-7848 ext [email protected] www.jeffersonbank.com

Security Service Federal Credit Union(H Bronze Sponsor)Business financing, specializingin low interest commercial realestate transactionsLuis Rosales, [email protected] members can get up to halfa percent off the origination fee

Texas Farm Credit(H Bronze Sponsor)Rural, homestead and acreage lending.Tiffany Nelson, 210-798-6280www.texasfcs.com

• BUSINESS CONSULTING/COACHING

The Growth Coach Kay Wakeham(H Bronze Sponsor)k.wakeham@thegrowthcoach.comwww.thegrowthcoachsananto-nio.com210-492-2400

• CATERING

Corporate Caterers(H Bronze Sponsor)Ricardo Flores210-789-9009

Heavenly Gourmet Catering(H Bronze Sponsor)210-496-9090www.heavenlyg.com

• CONTRACTOR/BUILDERS

Huffman Developments(HH Silver Sponsor)Steve Huffman, 210-979-2500Shawn Huffman, 210-979-2500www.huffmandev.com

San Antonio Retail Builders(HH Silver Sponsor)Specializing in remodeling/finishout of medical offices. H.B. Newman [email protected] Carter [email protected] 6 months ArchitecturalSpace Plan / RenderingNo Cost or Obligation

• EDUCATION

Alpha Bilingual Preschool(H Bronze Sponsor)Our mission is to provide youngchildren with an integral earlyeducation in a Spanish immersionenvironment. Tania Lopez de [email protected] your children the gift ofspeaking a second language.

• ELECTRONIC MEDICALRECORDS

Greenway Health(HHH Gold Sponsor)Greenway Health offers a fully integrated electronic healthrecord (EHR/EMR), practicemanagement (PM) andinteroperability solution thathelps healthcare providers improve care coordination, quality and satisfaction while functioning at their highestlevel of efficiency.Jason Siegel 512-657-1259jason.siegel@greenwayhealth.comwww.greenwayhealth.com

• FINANCIAL SERVICES

Northwestern MutualWealth Management Company(HHHH Platinum Sponsor)Comprehensive Financial Plan-ning Insurance and InvestmentPlanning Estate Planning andTrust Services.Eric Kala CFP, CLU, ChFC, Wealth Management [email protected]

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

Frost Leasing(HHH Gold Sponsor)As one the largest Texas-basedbanks, Frost has helped Texans

with their financial needs since1868, offering award-winningcustomer service and a range ofbanking, investment, insuranceservices to individuals and businesses.Laura Elrod Eckhardt 210-220-4135laura.eckhardt@frostbank.comwww.frostbank.comCommercial leasing for a doctor’sbusiness equipment and vehicle.

Platinum Wealth Solutions ofTexas LLC(HH Silver Sponsor)Comprehensive financial plan-ning firm who assists medicalprofessionals to protect theirincome, their wealth, their practice and legacy.Tom Valenti 210-998-5023 [email protected] Eric Gonzalez: 210-998-5032 ericgonzalez@jhnetwork.comwww.platinumwealthsolutionsof-texas.comUnderstanding the uniqueness inthe financial life as a physician.

Retirement Solutions(HH Silver Sponsor)Committed to providing compre-hensive, reliable consultation tohelp you navigate the complexworld of retirement planning.Robert C. Cadena 210-342-2900robert@retirementsolutions.wswww.retirementsolutions.ws

Bold Wealth Management(H Bronze Sponsor)Comprehensive Investment Advisory and Retirement Plan-ning Services for Businesses and Individuals.Richard A. Poligala, 210-998-5787richard.poligala@natplan.comwww.boldfinancialgroup.comComplimentary no-obligation retirement plan review to BCMS members

• GOLF

TPC San Antonio(H Bronze Sponsor)18-hole championship golfcourses designed by two ofgolf's most innovative architects,Pete Dye and Greg Norman.Matt Flory, 210-491-5816www.tpcsanantonio.com

continued from page 35


• HEALTHCARECONSULTING

TNT Healthcare Consulting LLC(H Bronze Sponsor)We want physicians to concen-trate on what they were trainedto do, treating patients.Tom Tidwell, CMPE 210-861-1258 [email protected] TNT healthcare consultantsevaluate your practice and im-prove efficiency and cost.

• HOSPITALS/HEALTHCARESERVICES

Select Rehabilitation of San Antonio (HHH Gold Sponsor)At Select Rehabilitation Hospitalof San Antonio, we providespecialized rehabilitation programs and services for individuals with medical, physicaland functional challenges. Miranda Peck, [email protected]://sanantonio-rehab.com/Offers patients a higher degree ofexcellence in medical rehabilitation.

South Texas Sinus Institute(HHH Gold Sponsor)The South Texas Sinus Institute isa state of the art facility dedi-cated to in-office BalloonSinuplasty using the unique Painless Sinuplasty AnestheticLinked Method.Sue Musgrove, [email protected] will offer convenient sameday or lunch appointments toBCMS members.

Warm Springs Medical CenterWarm Springs Thousand OaksWarm Springs Westover Hills(HHH Gold Sponsor)Our mission is to serve peoplewith disabilities by providingcompassionate,expert care during the rehabilitation process& support recovery througheducation & research.

Central referral Line 210-592-5350Joint Commission COE

Elite Care 24 Hour EmergencyCenter(HH Silver Sponsor)We are a fully equipped emer-gency room open 24 hours aday and 7 days a week, staffedby experienced emergencyphysicians. We provide thesame level of emergency medical care that you would receive in a hospital ER.Clemente Sanchez, [email protected] Clark, 210-771-0141rclark@elitecaremarketing.comwww.elitecareemergency.comGet seen by an experiencedphysician within 10 minutes.

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

Seasons Hospice and Palliative Care(HH Silver Sponsor)Deb [email protected]

Southwest General Hospital(HH Silver Sponsor)Southwest General Hospital is a327-bed, state-of-the-art hospi-tal located in San Antonio, Texas.Southwest General offers com-prehensive healthcare services.Craig Desmond, 210-921-3521Elizabeth Luna, 210-921-3521www.swgeneralhospital.com

• HUMAN RESOURCES

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 andget everyone in the practice on the same page.John Seybold, 210-447-6518jseybold@employerflexible.comwww.employerflexible.comBCMS members get a free HR assessment valued at $2,500.

Pinnacle Workforce Corp HR. Services (H Bronze Sponsor)

Dan Cardenas, [email protected]

�• INFORMATIONTECHNOLOGY

Dahill(HHH Gold Sponsor)Dahill offers comprehensive docu-ment workflow solutions to helphealthcare providers apply, man-age and use technology that sim-plifies caregiver workloads. Theresults: Improved access to pa-tient data, tighter regulatorycompliance, operational efficien-cies, reduced administrative costsand better health outcomes.Stephanie Stephens, [email protected]

Allison Royce Business Technologies(H Bronze Sponsor)Business Technology Provider, specializing in HIPAA CompliantManaged IT Services and IT Sup-port since 1993.Jeff Tuttle,[email protected]

PitCrew IT Services(H Bronze Sponsor)Provides reliability for your business computers or network, enabling you to operatesmoothly.Eric Murcia, [email protected]

• INSURANCE

Blue Cross Blue Shield of Texas(HHH Gold Sponsor)Edna Pérez-Vega, [email protected]

Frost Insurance(HHH Gold Sponsor)As one the largest Texas-basedbanks, Frost has helped Texanswith their financial needs since1868, offering award-winningcustomer service and a range ofbanking, investment, insuranceservices to individuals and

businesses.Bob Farish [email protected] 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.Donnie [email protected]

Nationwide Insurance Joel Gonzales Agency(H Bronze Sponsor)What matters to you, matters to us!Joel Gonzales 210-314-7514 [email protected] www.nationwide.com/jgonzales

Texas Drug Card(H Bronze Sponsor)The Texas Drug Card program is a FREE statewide Rx assistanceprogram available to all residents.Todd Walker [email protected]://texasdrugcard.com/index.php

�• INSURANCE/MEDICALMALPRACTICE

Texas Medical Liability Trust(HHHH Platinum Sponsor)Texas Medical Liability Trust is aphysician-owned health care liability claim trust, providing malpractice insurance productsto the physicians of Texas. Currently, we protect more than14,000 doctors in all specialtieswho practice in all areas of the state. TMLT is endorsed bythe Texas Medical Association,the Texas Academy of FamilyPhysicians, the Dallas, Harris, Tarrant, and Travis County Medical Societies. Patty Spann,





[email protected] Partner of theBexar County Medical Society.

Medical ProtectiveMedical Malpractice Insurance(HHH Gold Sponsor)Medical Protective, the nation'soldest and only AAA-ratedprovider of healthcaremalpractice insurance. Thomas Mohler [email protected]

Texas Medical Association Insurance Trust(HHH Gold Sponsor)Created and endorsed by theTexas Medical Association (TMA), the Texas Medical Association In-surance Trust (TMAIT) helpsphysicians, their families, andtheir employees get the insur-ance coverage they need.James Prescott, [email protected] Isgitt 512-370-1776www.tmait.orgWe offer BCMS members a freeinsurance portfolio review.

The Bank of San Antonio Insurance Group, Inc.(HHH Gold Sponsor)We specialize in insurance andbanking products for physiciangroups and individual physicians.Our local insurance professionalsare one of the few agents in thestate that specialize in Medical Malpractice and all lines of insur-ance for the medical community. Katy Brooks, CIC, 210-807-5593katy.brooks@bosainsurance.comwww.thebankofsa.comServing the medical community.

The Doctors CompanyMedical malpractice insurance(HH Silver Sponsor)Kirsten Baze [email protected]

• INTERNET/TELECOMMUNICATIONS

Time Warner Cable Business Class(HH Silver Sponsor)When you partner with TimeWarner Cable Business Class, youget the advantage of enter-prise-class technology and communications that are highlyreliable, flexible and pricedspecifically for the medical community.Rick Garza, [email protected] Warner Cable BusinessClass offers custom pricing forBCMS Members.

�• MARKETING SERVICES

Phiskal LLC Marketing and Promotion(H Bronze Sponsor)A leading edge marketing anddevelopment firm using propri-etary Artificial Intelligence en-gines to enhance your presencewith websites, apps & databaseapplications.Sundeep [email protected]://PHISKAL.COM/

�• MEDICAL BILLING AND COLLECTIONS SERVICES

DataMED(HHH Gold Sponsor)Providing your practice with thelatest compliance solutions, con-centrating on healthcare regula-tions affecting Medical Billingand Coding changes allowingyou and your staff to continuedelivering excellent Patient Care.Anita Allen (210) [email protected] members receive a discounted rate for our billingservices.

Commercial & Medical CreditServices(H Bronze Sponsor)A bonded and fully insured San Antonio-based collectionagency.Henry Miranda [email protected]

www.cmcs-sa.comMake us the solution for your ac-count receivables.

PriMedicus Consulting Inc.(H Bronze Sponsor)A physician-founded and builtcompany, dedication to yoursuccess. Sally Combest MD. 877-634-5666s.combest@primedicusconsult-ing.comwww.primedicusconsulting.comPriMedicus Consulting for theHealth of Your Practice.

Urgent Care Billing Solutions, LLC(H Bronze Sponsor)UCBS provides superior practicemanagement services and rev-enue optimization services to thehealthcare community in a virtualoffice environment. Ann DeGrassi, CMIS 210-878-4052 adegrassi@ucbillingsolutions.comwww.urgentcarebillingsolutions.net

��• MEDICAL SUPPLIES& EQUIPMENT

Henry Schein Medical(HHHH Platinum Sponsor)From alcohol pads and band aidsto EKG’s and Ultrasounds, we arethe largest worldwide distributorof medical supplies, equipment,vaccines, and pharmaceuticalsserving office based practition-ers in 20 countries. Recognizedas one of the world’s most ethi-cal companies by Ethisphere.Tom Rosol [email protected]/medicalBCMS members receive GPO dis-counts of 15%-50%.

McKesson Medical-Surgical(H Bronze Sponsor)MCKESSON is a leading distributor of Medical Supplies and Equipment.Karan Cook [email protected]

�• PAYMENT SYSTEMS/CARD PROCESSING

Heartland Payment Systems(HH Silver Sponsor)Tanner Wollard, 979-219-9636Tanner.Wollard@e-HPS.comwww.heartlandpaymentsystems.com

• PUBLICATIONMANAGEMENT FIRM

�Traveling Blender(H Bronze Sponsor)Publication Management FirmJanis Maxymof, [email protected]% discount on display advertis-ing in magazine for members.

�• PRINTING SERVICES

SmithPrint(H Bronze Sponsor)SmithPrint offers custom print-ing, branding, graphic design,signage and more!Robert Upton [email protected]://www.smithprint.net/New customers: 10% discount onprint materials at SmithPrint.

• REAL ESTATE/COMMERCIAL

Cano and Company CommercialReal Estate(HH Silver Sponsor)Experienced and respected com-mercial real estate representation.We specialize in office leasing,property acquisition, and com-mercial real estate investment. Dennis Cano, Agent 210-731-6613 [email protected] commercial real estatesolutions for your practice andinvestments.

Newmark Grubb Knight Frank(H Bronze Sponsor)Commercial Real EstateDarian Padua [email protected]

Stream Realty Partners(H Bronze Sponsor)Carolyn Hinchey Shaw [email protected]

• REAL ESTATE/RESIDENTIAL

SA Luxury Realty(HH Silver Sponsor)Effective real estate transactions(Buy, Sell, Lease, Syndicate, etc.)within the shortest time possibleand for maximum results!Matin Tabbakh 210-772-7777



[email protected] Luxury Home Special-ist. Call us today.

Becky Aranibar Realty GroupKeller Williams(H Bronze Sponsor)Offering Real Estate Services to the San Antonio Medical Community.Carlo G. Aranibar, MBA, [email protected] free comparative mar-ket analysis to determine yourhome's value.

�• REAL ESTATE/INVESTMENTS

Texas Premier Capital(HH Silver Sponsor)A real estate development company offering and managingreal estate investment funds inthe South Texas area.H.B. Newman [email protected] Carter [email protected]

www.texaspremiercapital.com

��• REGULATORYCOMPLIANCE

Hildebrand Regulatory Compliance(H Bronze Sponsor)HEDIS, Accreditation, PCMH, ICD10Patricia Hildebrand, 432-352-6143Pati.Hildebrand@Hildebrand-Healthcare.comwww.hildebrandhealthcare.com

• RESEARCH STUDIES/BIOTECHNOLOGY

�

ICON Development Solutions(HHHH Platinum Sponsor)We are a respected clinical re-search organization that has anextensive reputable history in di-abetes research. Dependingupon the current studies, ICONmay establish working relation-ships with local physicians.Your expertise may be invaluable

to our efforts to identify subjectsDr. Dennis Ruff [email protected] out how ICON can help yourPractice.

• STAFFING SERVICES

Favorite Healthcare Staffing(HHHH Platinum Sponsor)Serving the Texas healthcarecommunity since 1981, FavoriteHealthcare Staffing is proud to bethe exclusive provider of staffingservices for the BCMS. In additionto traditional staffing solutions,Favorite offers a comprehensiverange of staffing services to helpmembers improve cost control, in-crease efficiency, and protecttheir revenue cycle!Brian Cleary, [email protected]/pub-lic/medicalsocieties/bexar_county/bexarcounty_index.aspxFavorite Healthcare Staffing

offers preferred pricing for BCMS members.

• TRANSCRIPT SERVICES

Med MT, Inc.(H Bronze Sponsor)Narrative transcription is physi-cians’ preferred way to createpatient documents and populate electronic medicalrecords.Ray Branson, [email protected] Med MT solution allowsphysicians to keep practicing justthe way they like.

As of August 11, 2014

For more information, call 210-301-4366,

[email protected] or visit www.bcms.org.




BOOK REVIEW

“The Book Thief,” by Australian authorMarkus Zusak, is about love, hate, friendship,captivity, freedom, girls, boys, men, women, a

house painter/accordionist and his wife, a Jewish fist fighter, war,life, death, Death, burning books, rescuing books, stealing books,giving books, reading books, listening to books being read, stealingapples, stealing potatoes, capture, escape, more war, and, ultimately,peace … just a few pages of peace, but there it is. It is narrated byDeath, who has a really clear vision of reality and the human race,and who is likeable, humane and has a sense of humor. Despite allthat, this will be a short review.

I saw this book sitting on a table at the Cody Branch Public Li-brary marked “Express Collection No Renewals No Holds.” I hadheard of it, but never thought much about it. I picked it up, read acouple of pages and was hooked. Now, if you go looking for reviewsonline, you will likely find it called a “Young Adult” novel. I totallydisagree. I’m an adult, but if there’s one thing I’m not, it’s young. Ithink it probably got classified that way because the protagonist isLiesel Meminger, 9 years old at the start of the story. In reality, Ibelieve that this is one of the most adult books I’ve ever read. Itmoved me in many ways.

Liesel’s parents were Communists … not a good thing to be in

Nazi Germany. It is January 1939. Her father is gone, and she istaken from her mother and lodged with foster parents in a suburbof Munich. They live in a poor area on a street named “Himmel,”which is German for “Heaven.” It isn’t. As the fortunes of Hitler’sarmies change over the next few years, the residents of HimmelStreet try to live normal lives despite the fear, privations and bomb-ings. Liesl’s adventures and relationship with her foster parents andher best friend, a neighbor boy named Rudy Steiner, form the coreof the story. By the end of the book you know these people and abunch more. Some are admirable, some are pitiful, and some arehorrid, just like real life. As I write this I’m beginning to think thatI may have to break down and buy a copy. I seldom re-read novels,but this one is calling me. Please consider giving it a look.

Zusak’s view of the human race and humanity (they are differentthings) was on The New York Times’ best-seller list for 230 weeks. Itdeserved it.

Fred H. Olin, MD, is a semi-retired orthopaedic sur-geon who, if sleep were unnecessary, would read morebooks on paper, online, on his Kindle, or any other waythey were available. He is chair of the BCMS Communi-

cations/Publications Committee.

The Book ThiefReviewed by Fred H. Olin, MD

“

“

THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA

Contact BCMS today to join the 100% Membership Program!*100% member practice participation as of August 15, 2014.

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Gunn Acura11911 IH-10 West

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Ancira Elite Motorcars10835 IH-10 West

Northside Ford12300 San Pedro Ave.

Cavender GMC17811 San Pedro Ave.

*Fernandez Honda8015 IH-35 South

Gunn Honda14610 IH-10 West(@ Loop 1604)

*Gunn Infiniti

12150 IH-10 West

Ancira Jeep10807 IH-10 West


Ancira Kia6125 Bandera Road

*North Park Lexus611 Lockhill Selma

*North Park

Lincoln/ Mercury9207 San Pedro Ave.


Mercedes-Benzof Boerne

31445 IH-10 W, Boerne

Mercedes-Benzof San Antonio

9600 San Pedro Ave.

*Mini Cooper

The BMW Center8434 Airport Blvd.

Ingram Park Nissan7000 NW Loop 410

Porsche Center9455 IH-10 West

Ancira Ram10807 IH-10 West


North Park Subaru9807 San Pedro Ave.

Cavender Toyota5730 NW Loop 410

*Ancira Volkswagen5125 Bandera Rd.

*The Volvo Center1326 NE Loop 410


Recently, I read an article in Automotive

News about an upcoming feature from Nis-

san that seems amazing: self-cleaning paint.

Nissan took the idea which RainX pioneered

for windshields more than 30 years ago and

made paint that doesn't hold on to dirt but

rather lets it slide off. An accompanying

video was convincing, and I found myself

wondering why it took so long for this great

concept to come to fruition. (I'm not a paint

engineer, but I'm going to guess that it took

so long because it was really difficult.)

Anyway, I was surprised to see that, rather

than introducing this exciting new technol-

ogy on a top-shelf Infiniti, Nissan chose to

unveil it on their B-class Versa Note hatch-

back. Is that a signal that the company in-

tends to make their new paint a feature that

any customer can have? Nissan's not saying,

but I'm hoping that's the case.

STUDENT LOAN HELL?Self-cleaning paint notwithstanding, the

Versa Note is a good car. At a price that

starts at just under $15,000, it's not likely

to make the shopping lists of most BCMS

members — let alone our neurosurgeon

and orthodontist friends — but it's worth

a look if you're a resident or young physi-

cian just beginning a long climb out of stu-

dent loan hell.

The Versa Note is small — about the same

size as the Ford Fiesta — but thanks to its

hatchback configuration it makes the most

of a (very) diminutive footprint.

Sales figures tell us that hatchbacks don't

do well in this country, but I can't for the

life of me understand why. In my book,

compact hatchbacks make more sense than

sedans. Yes, the Versa Note has a sedan sib-

ling, the Versa, but I'd take the hatchback

every time because of its extra utility. Gro-

AUTO REVIEW

Nissan Versa Note: Inexpensive, fuel efficient,but not a kick to driveBy Steve Schutz, MD


ceries and packages fit under the hatch eas-

ily, and if you fold down the rear seats

there's a lot of space — enough for my 29-

inch mountain bike, actually. And the

hatchback looks better to my eyes because

of a design that emphasizes the car's utili-

tarian bent.

Nevertheless, if you prefer a traditional

four-door-with-a-trunk design, the Versa

sedan gets you the same small car virtues

mentioned below in a look that's more

khakis and polo shirt than jeans and T-shirt.

Nissan won't release the breakdown, but as-

suming that the Versa sedan outsells the

Versa Note is a good bet.

While at 6-feet, 2-inches I approached my

week with the Versa Note with trepidation,

in fact I fit into the driver's area easily and

comfortably. I had plenty of headroom, and

the steering wheel moved to where I needed

it without any special effort. Still, the center

stack and shifter are closer than I'm used to,

and I doubt I'd enjoy sitting in the rear seat

behind someone my size very much. Again,

this is a small car.

Of course, the biggest benefit of small cars

is that they're inexpensive to buy and own,

and the Versa Note is certainly that. In addi-

tion to the low price tag quoted above, Nis-

san's pint-size hatchback gets 31 mpg city

and 40 mpg highway. That's almost Prius

territory.

One of the reasons the Versa Note does so

well on gas is its continuously variable trans-

mission (CVT), an automatic gearbox with-

out gears (!) that's the bane of driving

enthusiasts everywhere. CVTs work by con-

necting the engine to the driving wheels —

the front ones in this case — via a belt rather

than normal gears. That belt along with lots

of computer power helps keep the engine in

its most efficient rev range at all speeds, re-

sulting in maximal fuel efficiency and min-

imal emissions. From behind the wheel,

CVTs under acceleration feel and sound like

an airplane taking off. Despite the fact that

you are indeed accelerating, the engine revs

at the same level the whole time until you

let off the throttle. I find the whole process

to be annoying, but my wife, who's not an

enthusiast, neither noticed nor cared, even

after I pointed it out to her.

FUN FACTOR LIMITEDNot surprisingly given the Versa Note's

charge to be inexpensive and fuel efficient,

it's not exactly a kick to drive. While the fun

factor would certainly increase with a manual

transmission, choosing that option would

make commuting and errand running more

of a headache than they already are.

The Nissan Versa Note is an inexpensive

but nice hatchback that's not going to ring a

bell for most BCMS members, but would be

a very reasonable choice for their offspring,

and for residents or physicians just starting

out. If Nissan were to see fit to offer it with

self-cleaning paint, it would appeal to even

more customers. Here's to seeing that option

on all new cars soon!

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

Antonio Medicine since 1995.

For more information on the BCMS

Auto Program, call Phil Hornbeak at 301-

4367 or visit www.bcms.org.

AUTO REVIEW


san antonio medicine september 2014

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