san antonio medicine novermber 2014

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THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • NOVEMBER 2014 • VOLUME 67 NO. 11

MEDICINE

4 San Antonio Medicine • November 2014

LETTING OFF STEAMKrav maga: “Stuff” that worksBy Robert G. Johnson, MD .........................................12

The great balancing act:Music, theater help mind and spiritBy Teri Hospers, MD ...................................................14

Diseases and conditions of the healthcare systems By Adam V. Ratner, MD.................................................16

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

Opinion: Shamelot by Robert G. Johnson, MD ..........................................................................18

BCMS News ................................................................................................................................20

Nonprofit: San Antonio Food Bank’s new Pharm2Farm program ................................................26

Business of Medicine: Understanding economic dynamics to survive and thrivein healthcare markets by Lee W. Bewley, PhD, FACHE............................................................28

Nonprofit: FAQs: The Rape Crisis Center by Deana Buril ....................................................................30

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

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

Book Review: “Spillover: Animal Infections and the Next Human Pandemic,” written by David Quammen, Reviewed by Fred H. Olin, MD ..................................................40

In the Driver’s Seat ................................................................................................................................42

Auto Review: Audi A3 Sedan 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 • NOVEMBER 2014 • VOLUME 67 NO. 11

SAN ANTONIO

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BOARD OF DIRECTORS

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

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

Medical School RepresentativeCarlos Alberto Rosende, MD,

Medical School RepresentativeCarlayne E. Jackson, MD,

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

CEO/EXECUTIVE DIRECTORStephen C. Fitzer

CHIEF OPERATING OFFICERMelody Newsom

DIRECTOR OF COMMUNICATIONSSusan A. Merkner

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

Each November, our Bexar County Medical Society celebratesWomen in Medicine Month. I take this opportunity to salute all mywomen physician colleagues in San Antonio, Bexar County and SouthTexas for their contributions to improving the health of the commu-nities in which they live. Women physicians, like their male counter-parts, care for patients in San Antonio and throughout South Texas,teach medical students and residents, and serve in the military. Manyfemale physicians are leaders in medical education, research and or-ganized medicine.

This year the American Medical Association selected Women inMedicine Month’s theme as "Innovators and Leaders ChangingHealthcare." This theme reaffirms our commitment to increase theinfluence of women physicians and recognize their advocating forwomen's health issues.

Many women physicians have made significant contributions tomedicine and society. Since Dr. Elizabeth Blackwell, the first womanawarded a medical degree in the United States, graduated from theMedical College of Pennsylvania in 1849, we have had many shiningexamples of women serving in high positions in the field of medi-cine. Three of the past five U.S. Surgeon Generals are women: Dr.Antonia C. Novello, the first woman and first Hispanic appointedas the U.S. Surgeon General (1990-1993), followed by Dr. JoycelynElders (1993-1994), and Dr. Regina Benjamin (2009-2013). Texas’own Dr. Nancy Dickey was the first woman elected as the presidentof the American Medical Association in 1998. In Bexar County, Dr.Rajam Ramamurthy was the first woman elected as president of theBexar County Medical Society (2004), followed by Dr. Diana M.Burns-Banks (2006).

Women’s participation in the medical profession was limited by lawuntil the 19th century. When women routinely were barred frommedical schools, they formed their own schools. The Women’s Med-ical College of Pennsylvania was founded in 1850, and London Schoolof Medicine for Women was founded in1874. The number of womengraduating from medical schools gradually gained momentum andaccelerated during the latter part of 20th century. The proportion ofwomen in medical school increased from 5 percent in 1952 to 48 per-cent in 2011.1

Unfortunately, even today, gender disparities persist in the percent-age of practicing women physicians, the number of women who owntheir practices, and the number of women who practice part-time. In2010, women comprised 34 percent of practicing physicians and sur-geons in the United States.2, 3 Women physicians are less likely to haveownership in the practices where they work. In 2004, 41 percent ofwomen owned at least part of their practice, compared to 59 percentof men.3 A 2006 survey of physicians under 50 found that 24 percentof women physicians and 2 percent of men reported working part-time at some point in their career.4

Disparities also exist in the representation of women physicians inhigher-paying specialties. Women are over-represented in traditionallylower-paying specialties such as pediatrics, family medicine and psy-chiatry. Pediatrics, for example, is the only specialty in which women

are the majority (56 percent in 2011).5 Women have the lowest rep-resentation in surgery. In 2005, women composed less than 6 percentof orthopaedic, thoracic, urological and neurological surgeons.3 Gen-der segregation among specialties remains constant even as morewomen become physicians. A pay gap also exists between womenphysicians and their male colleagues. Women physicians and surgeonsearn 79 percent of their male colleagues’ income. This income dispar-ity between genders exists even within the higher-paying specialtiesafter controlling for age, specialty and hours worked.4

Academic medicine and research are not immune to gender dispar-ities in rank and income. The percentage of women medical schoolfaculty increased from 26 percent in 1997 to 37 percent in 2012.4

However, women make up only 20 percent of full professors.6 Evenamong physician researchers awarded prestigious National Institutesof Health grants, women receive lower salaries than men. This in-equality persists when studies control for specialty, institutional char-acteristics, productivity, academic rank, work hours and other factors.7

The reasons for these disparities are multifactorial. Some of thesedisparities might correct themselves with time as more women physi-cian graduates become experienced and advance to higher positions inprivate practice, and academic and research fields. We can acceleratethe elimination of these disparities by mentoring more women physi-cians to become leaders in their practices and/or in their academic andresearch institutions. We also must encourage women physicians whoare in higher positions to mentor their junior colleagues. We need toidentify women physicians with leadership and management skills ear-lier in their career and encourage them to attend leadership develop-ment programs. One such program is the Executive Leadership inAcademic Medicine Program for Women that is offered by the Asso-ciation of American Medical Colleges.

It is time we, the medical community as a whole, correct these dis-parities between men and women physicians, and do our duty to en-sure equality within our profession.

REFERENCES1. American Association of Medical Colleges (AAMC). 2010. Table 1: Medical Stu-

dents, Selected Years, 1965-2010. https://www.aamc.org/download/170248/data/2010_table1.pdf.

2. Bureau of Labor Statistics, U.S. Dept of Labor. 2012. “Table 11. Employed personsby detailed occupation, sex, race, and Hispanic or Latino ethnicity.” HouseholdData Annual Averages. http://www.bls.gov/cps/cpsaat11.htm.

3. Stacy J. Williams, Laura Pecenco, and Mary Blair-Loy. 2013. “Medical Professions:The Status of Women and Men.” Center for Research on Gender in the Professions,UC San Diego. http://crgp.ucsd.edu.

4. Langston, E. 2008. Report 19 of the Board of Trustees: Gender Disparities in Physi-cian Income and Advancement. American Medical Association.

5. http://www.aap.org/en-us/about-the-aap/departments-and-divisions/department-of-education/Documents/women_med_demographics.pdf#search=women%20de-mographics

6. AAMC. 2012. Table 3: Distribution of Full-Time Faculty by Department, Rank,and Gender, 2012. https://www.aamc.org/download/305522/data/2012_table3.pdf.

7. Jagsi, Reshma et al. 2012. “Gender Differences in the Salaries of Physician Re-searchers.” JAMA 307 (22): 2410-2417

PRESIDENT’SMESSAGE

A salute to women physicians,A call to end gender disparitiesBy K. Ashok Kumar, MD, FRCS, FAAFP2014 BCMS President


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LETTING OFF STEAM

As brutal as an ultimate fighting championship (UFC) fight

appears on television to the casual observer, those guys are holding

back. Believe it or not, full-contact mixed martial arts (MMA)

has rules; there are certain moves and strikes that are verboten,

even in the apparent no-holds-barred-free-for-all that it seems to

represent. Ironically, the forbidden techniques are the precise ones

most effective in defending ourselves on the street. MMA fighters

cannot strike to the groin, eye-gouge, head butt or attack the

throat, just to list the major no-no’s. (Did I mention biting?)

Most traditional martial arts have restrictions inherent to each

sport. Boxers cannot hit below the belt or kick; wrestlers can’t

punch; karate and tae-kwon-do do not teach ground fighting. In

medicine, this would be tantamount to disallowing vancomycin

for the ID doc, taking EKGs from the cardiologist, or — God

forbid — pedicle screws from the spine surgeon. “Just do the best

you can with half the assets.”

This was this realization that struck a Czechoslovakian Jew

named Imrich “Imi” Lichtenfeld in the 1930s. The Nazis were

disarming civilians, and roving gangs of thugs dispensed their own

brand of justice, on Jews in particular. Imi was a trained boxer

and wrestler, but soon discovered that his skills were no match for

the unregulated violence of his street foes. So, he developed krav

maga (Hebrew for “contact combat”). Imi took the last boat out

of Europe in 1940 and moved to Palestine where he helped in the

struggle to create the State of Israel in 1948. Refined over the

years, krav is the official training and self-defense program for the

Israeli Defense Force, and has been adopted by police and many

military units (including Navy Seals) around the world.

SELF-DEFENSE SYSTEMKrav maga has borrowed the best from other disciplines — box-

ing, wrestling, jiu jitsu, muay thai, karate — but maintains its

own signature. It is a system for self-defense against unarmed foes

as well as guns, knives and blunt objects. Imi Lichtenfeld (1910-

1998) and those to follow have created a comprehensive and de-

tailed discipline to counter any assault, from any angle or

direction, with any body part or weapon. It teaches its user how

to defend, counter attack, and end a fight ASAP, and follows a

tiered progression of training from level 1 (yellow belt) up to level

6 (black belt). No actual belts are worn nor are there uniforms or

gis, just comfortable workout gear and a krav T-shirt. In the early

levels (1-3), the student learns basic kicks, strikes and combatives:

punches (straight, hook, hammer fist), kicks (front, side, back),

elbows and knees. It includes practical stuff — how to defend

against chokes, hair grabs, bear hugs (unwanted ones), how to fall

(fall breaks), then continue fighting once you hit the ground.

Upper levels (4-6) learn advanced combatives in addition to

weapon defenses. What would you do if a bad guy shoves a gun

in your face? In the movies people panic, throw up their arms,

stare at the gun barrel for what seems like endless minutes. Krav

will teach you how to turn the tables a few seconds; the same with

knives, baseball bats, axes, etc.

KRAV MAGA:

Dr. Robert Johnson pummels away the day’s frustration. Courtesy photos

“Stuff” that worksBy Robert G. Johnson, MD

LETTING OFF STEAM

Sounds very uncivilized and pugilistic,

right? Here’s how I see it. Disease is unciv-

ilized and pugilistic. It usually strikes with-

out warning and with a vengeance; its

unswerving intent is to cripple, maim and

kill — no-holds-barred, no rules. And as

doctors we fight back with no mercy or re-

strictions (FDA a qualified exception). We

don’t “wait and see” if that sarcoma is

going to spread, or if the “touch of pneu-

monia” might be just passing through, or

the cauda equina syndrome will go away

on its own. We strike and strike hard: with

knives, and chemo, and antibiotics; we in-

tubate, start IVs, infuse, drain, debride,

amputate — with every weapon in the ar-

senal. Street violence is a disease. Bad guys

strike without warning, swiftly, and with

unmetered violence: joggers are stabbed in

parks, vehicles carjacked, homes invaded.

We should stock our self-defense phar-

macy — today.

STAYING FIT ALSO HELPSStill not your cup of tea? Then consider

just staying fit. Enter a room with a hun-

dred 120-pound bags waiting to be

punched, kicked, pounded into submission (and they don’t hit

back), taking with it the day’s stress and anxiety. Krav breaks away

from traditional fitness gyms; you won’t find endless rows of weight

machines and treadmills. You will use kettle bells (great resistance-

aerobic workout), battle ropes (best shoulder-chest-back exercise,

bar none), rings (use your body weight to tone up). Want to train

like a UFC fighter without ever entering the octagon? Take a fit-to-

fight or advanced heavy bag class with non-stop combatives, ropes,

spinning, running, medicine ball, burpies, crunches — and that’s

only the warm-up.

I’ve been working out at krav for 10 years, going slowly on the

self-defense (I’m only at level four) but I try to make three of the

cardio bag and advanced bag classes a week. My 16-year-old often

accompanies me and has become a self-defense machine. We attend

many of the numerous seminars on defense against all manner of

weapons, how to handle an active shooter scenario, parking lot as-

saults. Members of my office staff have taken women’s self-defense

seminars. Krav has an impressive safety record; there’s the usual

bumps and bruises of any work-out, but few serious injuries. While

fitness is a goal, one does not have to be in top shape to start krav.

It was designed for the average person to learn; its techniques are

not complex (no spinning aerial kicks with a half-twist), and utilize

the body’s natural protective movements. For those who have limited

workout time, want the most bang for their buck, and get to the

real thing ASAP, krav maga is the “stuff” that works.

There are two krav gyms in San Antonio: 100 Crossroads Blvd.

(near the Medical Center, 210-348-6127) and 18450 Blanco Road

(at Loop 1604, 210- 545-3900).

Robert G. Johnson, MD, is an orthopaedic spine surgeon with Neu-

rosurgical Associates of San Antonio. A frequent contributor to San An-

tonio Medicine, he has been a BCMS member since 1989. The author

has no financial interests in krav maga, nor received anything of value

for this article.

visit us at www.bcms.org 13

A krav maga instructor (left) works with Dr. Robert Johnson on a defense against a knife attack.


I still had the acceptance letter to medical

school at the University of Texas Health Sci-

ence Center in my back pocket when I went

to a Longhorn Singers (LHS) party at an

apartment complex in Austin. My future was

bright, and I had no intention of meeting any-

one, much less the person I would spend the

rest of my life with.

I was in my last year of pre-med studies at

the University of Texas at Austin and had a lab

that interfered with the show choir’s class pe-

riod. I made time to attend the social events

since I had spent three years of my time in col-

lege singing, traveling and partying with these

great people. Making music with this fun-lov-

ing group of people from all different areas of

study at UT was a great way to balance the

many hours in the lab or studying bio-

chemisty.

One of my friends at the party said I needed

to meet Lee, the newest LHS member who

had just auditioned weeks before. I had no

idea that Lee was a he, not a she. I also didn’t know that we would

talk for three hours on the couch at the party and laugh more than

I recall laughing my entire time in college. We saw each other almost

every day after that meeting. Lee was a “he,” and we have been mar-

ried for 26 years, with three very tall and musical children.

NO TIME FOR MUSICWhen Lee went to law school and I was a pediatric resident, there

was no time for music. There was time for work, diapers, washing

clothes, reading to the kids and maybe a minute to myself. We didn’t

make music a priority and it was not a part of our lives.

As happens with many people, we had more time when our chil-

dren got older, started to drive and had their own interests. I started

playing the piano and singing again, and was even a “back-up chick”

for a band of rocker lawyers. Lee pulled out his guitar again and

started singing with a group of lawyers who were all having their

own renaissance of sorts.

The reason I think we gravitated back toward having music in our

lives is it provides a balance of mind and spirit. When it comes to

living happily as a busy family, balance is key. I don’t know that I

would have had any music to go back to if my parents hadn’t given

me piano lessons as a child. For that, I’m very grateful.

As our interest in music has grown, we’ve returned to the the-

ater, becoming involved with different productions and have en-

joyed the feeling of live performance again. Lee writes and directs

a show to raise money for charity each year called Ethics Follies

at the Charline McCombs Empire Theatre. We both have per-

formed in the Follies for nine years. Lee also has chaired the

THE GREAT BALANCING ACT:Music, theater help mind and spirit

By Teri Hospers, MD

LETTING OFF STEAM

Lee Cusenbary and wife Dr. Teri Hospers enjoy performing live as a break from their busy personal and pro-fessional lives. Courtesy photos


board of trustees at The Playhouse San Antonio for two years and still sits

on that board. Lee will direct Fiddler on the Roof in November for The Play-

house as well.

FIND BALANCE IN LIFEWe have thoroughly enjoyed attending local theater productions and have

met so many people who have similar stories of rediscovering music and theater

again after a break due to busy lives.

Consider finding some balance in your lives by coming to The Playhouse

to have a cocktail before the show with friends and then see a well-produced

show that rivals touring companies at a fraction of the price. The production

quality of local theater in San Antonio is so much better than it was even five

years ago; you will be pleasantly surprised. You can learn more about The Play-

house and the new season of shows at ThePlayhouseSA.org.

Teri Hospers is a pediatric cardiologist at Pediatric Cardiology Associates and a

BCMS member. She is married to C. Lee Cusenbary Jr., general counsel at Mission

Pharmacal Co.

LETTING OFF STEAM


Over the years, scientists and physicians have developed various

methods of identifying, classifying and organizing the diseases and

conditions that affect all life forms. In the day-to-day practical

healthcare system of the United States, we generally employ a sys-

tem called ICD-9 and will sooner or later be adopting ICD-10

and/or ICD-11. Whether we like them or not, they represent gen-

erally accepted organizational schemes for identifying and classi-

fying diseases and conditions affecting humans. Having such a

scheme makes it easier to identify, study, understand and ulti-

mately treat the diseases. The ICD-X systems represent a com-

mon, albeit imperfect, system of communicating human

diagnoses.

No similar scheme exists for identifying and classifying prob-

lems encountered in our immensely complex healthcare systems.

Those of us who practice medicine are all too aware of the short-

comings of the healthcare systems in which we work. Depending

on the individual characteristics of our respective practices, we see

from our own unique perspective what works and what doesn’t.

The amazing fragmentation of our healthcare systems makes it

difficult to identify, understand and heal those acute and chronic

conditions that impair healthcare delivery and adversely affect our

patients, our practices, our institutions, our payors and ourselves.

Seeing the need to identify and organize healthcare system

problems, The Patient Institute, a 501(c)(3) nonprofit organiza-

tion serving our community, has initiated a new project called the

Diseases and Conditions of Healthcare Systems (DCHS). The

DCHS will be open and available freely on the Internet via The

Patient Institute’s website, patientinstitute.org.

While many of the conditions and diseases have what appear

to be ironic or amusing names (and are written in “medicalese”

demonstrating medical jargonosis), they are all serious conditions

that affect the well-being of patients and other stakeholders in the

healthcare system. By its nature this compendium will always be

a work-in-progress and is always subject to expansion and modi-

fication.

We invite contributions to the DCHS via info@patientinsti-

tute.org. If you truly have a passion for this new enterprise and

are interested in becoming a DCHS curator/editor, please contact

The Patient Institute at the same email address.

Below is a sample of some of the categories and listings in the

newly formed DCHS:

HEALTHCARE SYSTEMIC SYNDROMESBUREAUCROSIS: The required production of large quanti-

ties of non-clinical/administrative work, often in an inefficient

manner, which distracts healthcare providers and staff from de-

livering care to individual patients. Extremely common in

health/medical record systems and as part of the third-party payor,

benefit management and accreditation/compliance/regulatory

processes.

HYPERMETRICOSIS: The collection of large quantities of

metrics/data, often in an inefficient manner, which distracts

healthcare providers and staff from delivering care to individual

patients. Extremely common in electronic health/medical record

systems and as part of the third-party payor, benefit management

and accreditation/compliance/regulatory processes. A variant of

bureaucrosis.

MALIGNANT DISSOCIATIVE HYPERMETRICOSIS: A

variant of hypermetricosis where the data collection process not

only does not yield meaningful and useful data but also impairs,

sometimes dangerously, the delivery of care to individual patients.

MALIGNANT HYPERBUREAUCROSIS: A variant of bu-

reaucrosis where the non-clinical/administrative workload not

only does not yield meaningful and useful results but also impairs,

sometimes dangerously, the delivery of care to individual patients.

PATIENT/PAYOR/(PHYSICIAN-PROVIDER) INCEN-

TIVE MALALIGNMENT SYNDROME (PPPIMS): A funda-

mental condition of healthcare systems where the interests of

DISEASES AND CONDITIONSof the Healthcare Systems

By Adam V. Ratner, MD

LETTING OFF STEAM


patients, healthcare providers and those who pay for services are

not in alignment. It is argued that PPPIMS in the root cause of

most of the problems extant in healthcare systems today.

JARGONOSIS SYNDROMESMEDICAL JARGONOSIS (“MEDICALESE"):Use of terms

and acronyms by physicians and other healthcare providers to aid

in the efficiency of communication among such providers. Med-

ical jargon, not well understood by patients, impedes communi-

cation and understanding between providers and their patients.

Medical jargonosis exacerbates the nearly ubiquitous health illit-

eracy among patients at all socioeconomic and educational levels.

HEALTHCARE SYSTEM JARGONOSIS: Use of terms and

acronyms by healthcare system administrators and regulators

which aid in the efficiency of communication among such indi-

viduals. Healthcare system jargon is not well understood by most

physicians and other providers or their patients. Healthcare system

jargonosis impedes communication and understanding among all

healthcare stakeholders and exacerbates bureaucrosis syndromes.

HYPOPYROSIS SYNDROMESIATRIC HYPOPYROSIS: PHYSICIAN BURNOUT. Physi-

cians lose their sense of purpose and humanity. Often caused and

exacerbated by healthcare systemic syndromes and working with

others who also suffer from hypopyrosis syndromes.

PROVIDER HYPOPYROSIS: Non-physician provider

burnout. Often caused and exacerbated by healthcare systemic

syndromes and constantly dealing with behavioral issues caused

by physicians and other providers who also suffer from hypopy-

rosis syndromes themselves.

Adam V. Ratner, MD, FACR, is chairman of

The Patient Institute and clinical professor and

deputy chair for strategic development and socioe-

conomics of the Department of Radiology at the

University of Texas Health Science Center at San

Antonio. He also advises individual physicians

and medical practices to more successfully navigate changing health-

care environments.

LETTING OFF STEAM


OPINION

A short time to go in a land near away, in the coun-try of CitrUS, there was a young boy/girl who had aclever idea. Now the land of CitrUS was green andverdant, a land of hopes and dreams, flowing withmilk and fruit trees. The child opened up a lemonadestand, round in shape, as all were equal in CitrUS.They also dispensed limes and oranges and otherfruits, and their business thrived.

But the government of the Grand Duchy of Cit-rUS also expanded along with the fattening econ-omy. Before long, the Council of Elders passed anedict enabling seniors free access to orange-lemon-aid, with Medipear Insurance, cutting reimburse-ments for the health-giving beverages in half (muchto the boy/girl’s des-pear). At first it seemed like theright thing to do — helping the elderly with accessto delicious nectars, but soon, every customer hadsome low-bid HMO insurance (Help yourself toMy Orange).

Before long, several regular clients came down withbird flu, and the lemonade stand was served its firstlawsuit. Vitamin C was supposed to guarantee perfecthealth, and birds did build nests in fruit trees — thecorrelation was obvious. Following on the heels ofthe plaintiffs’ attorneys arrived the Fruit and DrugAgency. “We’ll need proof,” said the FDA, ”in theform of double-blinded, controlled, prospective stud-

ies with 10-year follow-ups, that your lemonadewon’t cause Lime Disease in its current dosages.” Thenow-struggling small business was slapped with aDon’t-Squeeze-and-Desist order.

The People’s Republic of CitrUS continued its me-ander into bigger and bigger government. HIPA(HypochondrIacal Potability Act) disallowed the useof client names, lists, spoken greetings, etc., and cus-tomers were assigned IDs: “Good morning, Unit24601. Would you like your usual beverage? Oh no,I see you’ve had a recent birthday — 70 — the lawstates you’ll have go home and die of thirst.”

JCCO (Joint Commission for Citrus Oversight )spot inspections became more frequent and demand-ing. Clothed in black capes and riding boots, andarmed with pruning shears, they appeared unan-nounced and snooped about the stand and surround-ing orchards. This elite force wielded the power tocut Medipear payments to the lemonade stand on awhim. The graying boy/girl, unfortunately havingbecome dependent on business from the elderly, wasforced to hire seers and extra scribes to deal with theexpanding paperwork. High guard towers wereerected around the stand, with lookouts, to warn ofimpending raids by inspectors.

OHSA (Orange you Happy Someone gives A—) required breakrooms for the staph (no coffee), cov-

Shamelot… a medi-evil tale of the Plights of the Round StableBy Robert G. Johnson, MD


ered stables, disabled-friendly outhouses, ramps, foam-in-foam-out protocols, and a-peeling work environment. The

list went on: ACO, UnACcountable DisOrganization; CMS,Citrus Manglement DiSservice; STARK, Stop ThinkingAbout Referring Kinfolk; IRB, Irresponsible Research withBananas …

By this time, with the fruit stand gasping to keep its headabove the juice line, the United Socialist Feudal Kingdom ofCitrUS introduced a deadline for EMR (Electronic MandarinRecording). No more fruit-tree-killing paper — go green! Eachand every citizen’s consumption habits was recorded in the Na-tional Juicers Data Bank, located in the nation’s capital city ofWashemandhangemoutodry. (One tiny bit of good news: Thelatest and most popular flavor, Melon Entitle-mint (it’s allabout ME), was becoming a huge hit.) All were equal in Cit-rUS, but some, it seemed, more equal than others.

The lemonade stand owner, now bent and feeble, was forcedto sell out and move to Florida. As their time grew near, theyreturned for one last glimpse of where it all had started. Theyhardly recognized the place, with electrified fences, chimneysbillowing lemon-lime scented smoke, rows of computerizedself-check-in counters, voice recognition robots, conveyor beltsdelivering hermetically sealed and sterilized containers of FDA-approved, government-inspected Citrus Flavored Beverage.

Wheeling into a handicapped space, they stared wide-eyed.In the midst of this futuristic city, roped off with yellow bio-hazard tape, stood the now decrepit, original, round woodenlemonade stand. A long forgotten poem stirred: “Don’t let itbe forgot, that once there was a spot …”

A child walked up to the dying owner. “Gee,” he said with wonder in his voice. “I’d like to have my

own lemonade stand some day.”The feeble occupant of the wheelchair stirred. “Can you

write, child?”The child produced a pen and paper (the last remaining on

the planet).“Now listen carefully, and record everything I tell you.”The child nodded, his eyes huge.The ancient voice was weak, but clear. “A short time to go

in a land near away …”

Robert G. Johnson, MD, is an orthopaedicspine surgeon with Neurosurgical Associates ofSan Antonio. A frequent contributor to San An-tonio Medicine, he has been a BCMS membersince 1989.


BCMS NEWS

TMA stands firm in opposition to audiologists' scope proposed legislation By Mary E. Nava, MBAChief Governmental and Community Relations Officer

Recently, TMA joined with more than 110 na-tional organizations, along with state and local med-ical associations and specialty societies, to addressCongress in a letter vehemently opposing H.R.5304, the Audiology Patient Choice Act of 2014,which would provide audiologists with unlimited,direct access to Medicare patients without a physi-cian referral.

Equally troubling is that the proposed legislationalso would amend Title XVIII of the Social SecurityAct to include audiologists in the definition of"physician."

To read the letter to Speaker John Boehner andLeader Nancy Pelosi, visit www.texmed.org.

For local discussion on this and other advocacy top-ics, consider joining the BCMS Legislative and Socioe-conomics Committee by contacting Mary Nava [email protected].

Bexar County recognizes BCMS Women in Medicine

Bexar County Commissioners Court recognized BCMS and its Women in Medicine Committee with a proclamation issued Oct 7. “The progress ofwomen in medicine is a long and continuing journey,” the proclamation stated. “There are many pioneering women physicians to thank and many accom-plishments to celebrate.”

Attending (from left) were Commissioner Tommy Adkisson, Precinct 4; August Treviño, BCMS development director; Commissioner Sergio “Chico”Rodriguez, Precinct 1; Brissa G. Vela, BCMS director of membership; Commissioner Paul Elizondo, Precinct 2; Dr. Janet F. Williams; County JudgeNelson Wolff; Dr. K. Ashok Kumar, BCMS President; Dr. Lan-Anh Ngo; Commissioner Kevin Wolff, Precinct 3; Dr. Leah Jacobson; and Melody Newsom,BCMS COO.

The 22nd annual BCMS Women in Medicine annual recognition event will be held Nov. 1 at the Omni San Antonio Hotel with the theme, “GoodHealth is Always in Fashion – Nurture Your Soul.”

Among those attending the BCMS fishing tournament Oct. 3 were Judy andDr. Lorence Trick (from left), guide/captain Danny Adams, and Dr. Fred andSondra Olin. Special thanks to Dr. and Mrs. Delbert Chumley for happy hourat their bayside retreat, and to sponsor Stefen Brooks, Gateway Mortgage GroupLLC. Photo by Kris King

IN MEMORIAMDavid Clay Wolfe, MD, died Sept. 8, 2014, at age 82.

Dr. Wolfe, a BCMS member, was an orthopaedic surgeonin the U.S. Air Force and in private practice in San Anto-nio and Seguin.


BCMS NEWS

Michael Arambula, MD, has been namedchair of the Texas Medical Board. The board pro-tects and enhances the public’s health, safety andwelfare by establishing and maintaining standardsof excellence used in regulating the practice ofmedicine and ensuring quality healthcare for

Texas. Dr. Arambula is a psychiatrist in private practice, an adjunctassociate professor in the Department of Psychiatry at the Universityof Texas Health Science Center at San Antonio, and a BCMS mem-ber. The length of his TMB appointment as chair is determined bythe governor.

Francisco G. Cigarroa, MD, received the Bio-Med SA 2014 Julio Palmaz Award for Innovationin Healthcare and the Biosciences on Sept. 18.BioMed SA is a nonprofit corporation focused ongrowing and promoting San Antonio’s healthcareand bioscience sector. The ninth annual award,

named after Palmaz Stent inventor Julio Palmaz, MD, honors in-dividuals for significant contributions to advance the fields ofhealthcare and bioscience. Dr. Cigarroa, a pediatric transplant sur-geon and BCMS member, was honored for his roles in medicine,

community health, medical education, and his service as presidentof the UTHSCSA and chancellor of the UT System.

Ernesto Guerra, MD, was honored Sept. 20 atthe Holy Cross of San Antonio third annual Pres-ident’s Blue and Gold Gala with the 2014 Life-time Achievement Award. Dr. Guerra, of SanAntonio Gastroenterology Associates, is a BCMSmember. He was recognized for his support of

Catholic education. Holy Cross is an independent Catholic co-ed-ucational college preparatory middle and high school.

Basil A. Pruitt Jr., MD, FACS, was namedscience committee chair of the National TraumaInstitute, a nonprofit organization that advo-cates for increased federal funding for traumaresearch and research infrastructure to reducedeath and disability. Dr. Pruitt is a clinical pro-

fessor of surgery, the Betty and Bob Kelso Distinguished Chairin Burn and Trauma Surgery, and the Dr. Ferdinand P. HerffChair in Surgery at the University of Texas Health Science Centerat San Antonio and a BCMS member.

NOTEWORTHY


BCMS NEWS


BCMS NEWS

Mary Casiano, automation engineer at Urology San Antonio PA,was named the BCMS Unsung Hero for September.

The Unsung Hero program allows BCMS members to recognizetheir office managers/administrators for their dedication and hardwork in assisting physicians in delivering the best attention and careto patients.

Casiano was nominated by Dr. Clayton H. Hudnall, who wrote:“Mary is one of those quiet individuals who excels based on an innerdrive, who brings insight to every project, and whose exemplary ethicsand strong values guide her life and her interactions with others.”

Casiano joined the practice in 2006 as an administrative assistant,and graduated from the University of the Incarnate Word in Decem-ber 2013 with a degree in engineering management. Casiano has re-worked staff scheduling, developed internal systems for accountingand budgeting, and currently oversees a major update in the practice’sinformation technology.

“She is selfless in her desire to help others, claiming, ‘Look whatwe did,’ when the work was exclusively hers,” Dr. Hudnall said.“Whether it is integrating complex spreadsheets or redesigning clin-ical workflows, she completes tasks efficiently, on time and belowbudget. We call her our ‘Automation Engineer’ but her real titleshould be miracle worker.” Physician members: Please remember to recognize your "Unsung

Hero." Monthly deadlines and additional information are atwww.bcms.org.

Unsung Hero honored

(Front row, from left) Elizabeth Martinez, human resources liaison;Abbey Forney, communications director; Unsung Hero Mary Casiano, au-tomation engineer; and Gloria Clark, chief operations officer.

(Back row, from left) Alan Winkler, executive director; Dr. Clayton Hud-nall, board president; Dr. William Harmon, board vice president; and SteveFlageol, director of finance. Photo courtesy Urology San Antonio


BCMS NEWS

UTHSCSA medical student Gilda Dig-man (left), BCMS President Dr. K. AshokKumar and TMA President Dr. Austin Kingvisit informally at the BCMS General Mem-bership Meeting Sept. 24 at the Hilton SanAntonio Airport.

BCMS President Dr. K. Ashok Kumar(left) listens to a presentation by TMA Pres-ident Dr. Austin King Oct. 6 at the UTH-SCSA medical school. Approximately 150students attended the luncheon program.Dr. King encouraged them to become in-volved in organized medicine, and discussedspecific programs and opportunities for stu-dent involvement, such as the First Tuesdayvisits to the Legislature in Austin. Medicalstudents receive free membership in BCMSand TMA. Photos by Susan A. Merkner

Participants at the BCMS GeneralMembership Meeting Sept. 24 listen asTMA President Dr. Austin King presentsa legislative update and shares personal an-ecdotes about his involvement in organ-ized medicine. Dr. King urged those inattendance to become active in BCMSand in TMA to advocate on behalf of theirprofession.

TMA president visits San Antonio twice in two weeks


BCMS NEWS

Events recognize links between BCMS, UTHSCSA

BCMS President Dr. K. Ashok Kumar(center) visits with students at a reception inhonor of UTHSCSA medical students July24. Students were encouraged to participate inBCMS and to play an active role in their pro-fession. BCMS representatives also attendedthe event to answer questions from the stu-dents about opportunities for involvement inBCMS activities and committees.

UTHSCSA students enjoy refresh-ments at a reception July 24 while talkingwith BCMS President Dr. K. AshokKumar, who is a member of the medicalschool faculty. Medical students, who re-ceive free membership in BCMS andTMA, were encouraged to become activein organized medicine through the pro-fessional groups. Photos by Brissa Vela

The 2014 President’s Gala of the University of Texas Health Science Center at San An-tonio was held Sept. 13 at the Grand Hyatt San Antonio. University President Dr. WilliamL. Henrich, MACP, honored Tom and Pat Frost for their support of the Health Science Centerand the community. Among those attending were BCMS life member Dr. Charles Rockwood(from left), Jane Rockwood, Missy Rockwood and Dr. Andrew Rockwood, a member of theHill Country County Medical Society. Photo courtesy UTHSCSA

MEMBERSHIPUPDATEACTIVEAdebukola Adedeji, MD, General Surgery

Julio Gutierrez, MD, Hepatology

Parmish Kohlo, MD, Nephrology

Sarah Lopez-Llado, MD,Internal Medicine

Bacel Nseir, MD, Infectious Diseases

Vasudha Panday, MD, Ophthalmology

ACTIVE FIRST YEAR IN PRACTICEMark Glover, MD, General Surgery

MEDICAL RESIDENTSBrian Griffith, DO, Radiology

MEDICAL STUDENTSJamie ArchambaultAnam AzimuddinVitali AzouzJoshua BarkerJacob BoydAlexandra ColeSeth CopeRyan FolsomMashala HortonLuyang JinEllen JohnsonCaleb JonesJade LawSteven MadsenMelissa MeyerNathanael PhillipsMecklin Ragan

MILITARYAlexander Black, MD, Pediatric Cardiology

Kelly Joanne Morales, MD, OB/GYN

Randall Curtis Zernzach, MD, Pediatrics Behavioral/Developmental


NONPROFIT

An apple a day keeps the doctor away, but only for those who can afford applesSpecial to San Antonio Medicine

Remember the old adage, “An apple a day keeps the doctor away”? There is agrowing body of evidence in the field of nutrition science that this sage advice is infact true: a daily helping of fruits and vegetables, in combination with a commitmentto staying physically active, is proving to be the simple and effective prescription tocombat diabetes, obesity and heart disease. But just because the solution is simpledoesn’t necessarily mean it is an easy solution for everyone to implement.

Barriers to staying physically active are probably the easiest for most everyone toovercome. For people who have not been active, something as simple as 30 minutesof walking a day will start to produce big benefits in overall health and well-being.It is in the area of consuming more fruits and vegetables in our diet that many peo-ple, particularly low-income families, seem to face more challenging barriers.

San Antonio Food Bank’s new Pharm2Farm program:


NONPROFIT

Not a week goes by these days when we don’t hear froma doctor or healthcare professional who wants to learnhow to get their low-income patients more fruits and veg-etables. Their patients could benefit from the rewards ofconsuming more produce, but because of strapped fi-nances they often skip these items for cheaper foods that

won’t perish as quickly and will fill them up faster.

LIMITED CASH FOR GROCERIESTo be sure, apples themselves aren’t the most expensive

item in the grocery store. But the reality for most low-income families is that buying perishable fruits and veg-etables just doesn’t seem to be the best way to stretch theirvery limited cash available for groceries. According to theSan Antonio Food Bank, after paying basic household,transportation and healthcare expenses, a low-incomefamily does not have enough cash to meet their monthlynutritional needs.

What do families do to cope? Many work multiplejobs; others visit food pantries; some find temporary helpfrom public programs such as SNAP, but nearly all startto skip meals and steer away from the perishable-produceaisles at the grocery store.

The Food Bank recently launched a new initiativeaimed at getting low-income individuals the fruits andvegetables they need for a healthier lifestyle.Pharm2Farm is a unique program in which a physicianwrites a produce prescription for a low-income patientthat can be redeemed at a Food Bank mobile farmer’smarket. The dose and duration of the produce prescrip-tion will be determined by the doctor, and the Food Bankwill raise the money to allow the prescription to be filledfor free.

WRAP-AROUND SERVICESPharm2Farm also will engage low-income patients

with critical wrap-around services: meal planning, budgetplanning and healthy cooking. Getting a weekly dose ofproduce, in conjunction with learning and implementingnew lifestyle behaviors, is a solution that simultaneouslyimproves health and well-being for the patient and re-duces healthcare costs.

Hippocrates coined the term “Food is medicine.” Jointhe Food Bank as a new prescription for health is broughtto the San Antonio area, and put the idea of food as med-icine into concrete action. The “farmacy” prescription,supported by San Antonio’s world-class medical commu-nity and its generous philanthropy community, is ready.

Learn more and get involved at www.safoodbank.org.



BUSINESS OFMEDICINE

The modern healthcare market often seems to be a cooperativebattlefield. The interactive, multi-disciplinary nature of the practiceof medicine requires that providers, institutions, insurers, and othermarket players dually coordinate and compete for market share andmargins. A prime organizational guiding tenant is that firms seek toremain a “going concern” continuing to generate sufficient value tocustomers and stakeholders that will provide a resource basis to avoidbankruptcy, liquidation, or some other selection from the market-place; however, beyond this tendency of organizations to avoiddying, is a larger goal of generating substantial market value yieldingcompetitive advantage within the marketplace. In simplest terms,organizations first seek to survive and then thrive when competingfor resources. Economics provides a framework to judge the likeli-hood of an organization being able to achieve either or both of theseprime strategic goals within respective markets.1

Efficient or perfectly competitive market conditions serve as a use-ful tool for healthcare executives to judge potential viability of busi-ness models or initiatives. Perhaps an even more valuable applicationof this economic framework in the strategic market game of “surviveand thrive” is possessing a clear understanding of the position of afirm among competitors that will enable development of strategic“shields and swords.” Strategic shields may serve to protect firmsfrom market selection in the face of other firms’ competitive advan-tages while strategic swords may be employed to seize the initiativeand gain market share and resources.

COMPETITIVE MARKETSEconomist Alfred Marshall, building upon the work of others in

the field, is generally credited with establishing the basis for assessingperfectly competitive markets: many buyers and sellers, homogenous

Understanding economic dynamics tosurvive and thrive in healthcare markets

By Lee W. Bewley, PhD, FACHE


BUSINESS OFMEDICINE

product/service, zero transaction costs, free entry/exit from the mar-ketplace, and perfect information. When these conditions exist inmarkets, efficient allocations of resources are expected characterized

by a single market clearing price, balance in value experienced be-tween buyers and sellers, and no market power. In practice, a trulyperfectly competitive market is extremely rare, but deviations fromthese conditions are highly prevalent and can yield both opportuni-ties and threats for firms in the healthcare market.2, 3

Applying the requirement of many buyers and sellers to thehealthcare market finds efficient market problems on both sides ofthe transaction. While virtually every person within a market existsas a potential buyer of health services, varying or no insurance cov-erage and the peculiar nature of third-party payers in our marketsinhibits natural participation in market exchanges. Many factors,including the other conditions for efficient markets, impact thenumber of health services sellers in the market. Healthcare executivesmust assess the level of competitiveness in their own market for thosesegments of the healthcare market that they intend to serve. If scarceor no competition exists, then sword-like initiatives such as cuttingreimbursement discounts may be in order, but in the face of mean-ingful competition, developing shields such as community serviceand loyalty programs may be in order.

The efficient market condition of product or service homogeneityis predicated on making consumer and producer choices simple.While state licensure requirements and accreditation standards es-tablish a baseline of commonality within the market, varying levelsof heterogeneity exist throughout the market in many forms includ-ing reputation, levels of technology, or facilities. Heterogeneity inhealth services creates complexity in the market that can be utilizedto positively differentiate from competition to secure resources (rev-enue, staff, etc.) or disable organizations from demonstrating value.

Transaction costs in markets are those costs that must be borneby a buyer before a normal buyer-seller exchange occurs. For buyers,these costs are often transportation and health services informationseeking related. For sellers, contract negotiations, adherence to li-censing\accreditation standards, procurement of specialized equip-ment, and/or recruitment of staff exist as major transaction costs inthe healthcare market. Strategic success in this area of perfect marketcondition is dependent upon understanding the aggregate balanceof transaction costs serves to protect or compromise organizationalcompetitive viability relative to other competitors.

The ability of buyers and sellers of health services to enter andexit the marketplace ensures that resources are focused to the op-portunity for greatest return (seller) or satisfaction (buyer) acrossmarkets. Encumbrances to the ability of health services sellers toenter the market may effectively shield organizations from compe-

tition while ready access to markets provide organizations the op-portunity to charge into the field to compete.

KNOWLEDGE ASYMMETRYFinally, the condition of perfect information among buyers and sell-

ers of health services ensures clear understanding of the benefits, costs,prices and effects of services and products. Among all conditions ofperfectly competitive competition, knowledge asymmetry is often themost pervasive deficit. Often, this economic problem can be profes-sionally challenging for physicians and other providers trying to serveas “perfect agents” for their patients while also serving the economicinterests of the group practice or organization. The healthcare execu-tive must assess where knowledge deficits exist to protect against ad-verse selection problems and to find where relative knowledgesurpluses or the ability to process information more efficiently thancompetitors facilitates actions leading to thriving activities.

Long ago, Cervantes observed that “all is fair in love and war.”While most citizens should seek and expect efficiency in our eco-nomic markets, those organizations and individuals who have in-vested resources in markets are often well-served to ensure thesurvival and potential thriving success of their enterprise by respond-ing appropriately and legally to less-than-perfectly competitive mar-ket conditions. Much the same as actual war, healthcare executivesand their organizations may be well-served by recognizing conditionsthat are far removed from being fair and competitive.4

REFERENCES1. Ginter, Peter, Duncan, Jack, Swanye, Linda (2013). Strategic

Management of Healthcare Organizations (7th edition).Jossey-Bass. San Francisco, California.

2. Marshall, Alfred (1920). Principles of Economics (8th edition).Cosimo Classics. New York.

3. Baye, Michael (2006). Managerial Economics and BusinessStrategy (5th edition). McGraw-Hill. Boston, Massachusetts.

4. Cervantes Saavedra, Miguel de, and Edith Grossman (2003).Don Quixote (reprint). Harper Perennial. New York.

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

rector of the Army-Baylor University MHA/MBA program and as anadjunct faculty member at the University of Texas at San Antonio, Trin-ity University and University of the Incarnate Word.


NONPROFIT

RESOURCES FOR SURVIVORS OF SEXUAL ASSAULT

If the sexual assault happened less than 96 hours ago, the followinghospitals have certified Sexual Assault Nurse Examiner programs.Advocates are available 24/7 to provide accompaniment.

For adults and adolescents who have gone through puberty:Methodist Specialty and Transplant HospitalPhone: 210-575-8168 (ER)8026 Floyd Curl, San Antonio, Texas 78229

For children and adolescents under the age of 17:The Children’s Hospital of San AntonioPhone: 210-704-2190 (ER)333 N. Santa Rosa, San Antonio, Texas 78207

HOTLINEThe Rape Crisis Center hotline is available 24/7 at 210-349-7273.

Trained hotline operators provide crisis intervention, resources andinformation to survivors and their loved ones.

COUNSELINGAll Rape Crisis Center counseling services are free and open to

children, women and men. For more information or to make an ap-pointment, call 210-521-7273.

The mission of the Rape Crisis Center is to provide comprehensive services to victims of sexual assault andtheir families, and to conduct sexual assault prevention and education programs to youth throughout San An-tonio, Bexar County and surrounding areas.

FAQs: The Rape Crisis CenterBy Deana Buril, deputy director of client services at the Rape Crisis Center

The Rape Crisis Center islocated at 7500 U.S. High-way 90 West, Bldg. 2, Suite201, San Antonio, Texas78227; www.rapecrisis.com.

The following information is provided in response to questions frequently asked by physicians and their staffs.


UTHSCSADEAN’S MESSAGE

We often point out that a medical school grants a degree; a

Graduate Medical Education (GME) program is necessary in

order to obtain a license to practice. The GME system in the

United States is arguably the best in the world, and the thousands

of international medical graduates who seek training here – and

not just to stay and practice in the United States – are a testament

to its success.

However, there are problems with distribution of positions,

both geographically and in terms of specialty. Most importantly,

the number of residency slots has not kept up with the physician

manpower needs of the country. In 2014, 1,800 graduates of U.S.

medical schools were unable to match to a residency program in

the National Resident Matching Program (NRMP). Subsequent

offers reduced this number to closer to 400. The numbers pro-

vided by the NRMP are that in 1996 there were 20,563 positions

with 24,718 active applicants, including AMGs and IMGs.1 In

2014, there were 26,678 positions for 34,270 applicants.2

The current GME funding system came to be as part of the

creation of the Medicare and Medicaid programs in 1965. Put to-

gether as part of the Social Security Act, federal money has pro-

vided billions of dollars to fund GME, which includes residency

and fellowship programs for both osteopathic and allopathic med-

ical education. In 2012, tax dollars contributed more than $15

billion to support residency training, with 90 percent – $10 bil-

lion and $4 billion, respectively – coming from Medicare and

Medicaid.3 The Veterans Administration is another, much smaller

source. These amount to a trivial figure relative to the country’s

healthcare bill, which is roughly $2.9 trillion.

INDEPENDENT REVIEWBecause of concerns about the responsiveness of the system to

the healthcare needs of the country, the Josiah Macy Jr. Foundation

asked the Institute of Medicine (IOM) to conduct an independent

review of GME and persuaded 12 other organizations to contribute

to this effort. Two years in the making, the report was released this

past summer. At 256 pages long, it discusses GME Medicare fund-

ing (though not other sources) and proposes some potentially con-

troversial changes to what they perceive as problems.

The GME funding system was put in place when hospitaliza-

tions for less-severe illnesses were more common. Despite signif-

icant changes since then, in nearly every aspect of healthcare de-

livery, funding and education, the GME system remains mostly

unchanged, although programs themselves shifted to more out-

patient training. The following bullet points, taken directly from

the summary of the IOM report, crystalize the core issues as they

saw them:

There are 3:• a mismatch between the health needs of the population and

specialty makeup of the physician workforce;

• persistent geographic maldistribution of physicians;

• insufficient diversity in the physician population;

• a gap between new physicians’ knowledge and skills and the

competencies required for current medical practice; and

• a lack of fiscal transparency regarding Medicare/Medicaid fi-

nancing.

It is nearly impossible to talk about each of these issues sepa-

rately as they are all interrelated and can be tied back to the fund-

ing system, which makes up a majority of the IOM report’s focus.

Although the GME system has been producing more physicians,

it has not kept pace with the number of medical school graduates,

nor has it produced an increasing proportion of physicians who

choose to practice primary care, or to provide care to underserved

populations. And it is not just a primary care problem; many

other important specialties and subspecialties – such as rheuma-

tology, nephrology and endocrinology – are also in desperate need

of more physicians, particularly as the number of older Americans

increases.

Following the money was a difficult task for the group, noting

in the report that “tracking the flow of GME funds is daunting.”

Further complicating the funding path, most states also support

GME through their Medicaid programs; and some states provide

other GME support through loan repayment incentives or even

direct support. There are also private contributions, difficult to

quantify, but including private insurers who support GME by

paying higher rates to teaching institutions. Many residencies and

fellowships are directly supported by hospitals, universities, physi-

GRADUATE MEDICAL EDUCATION:Institute of Medicine suggests how to improve the system

By Francisco González-Scarano, MD



cians’ organizations and fac-

ulty practice plans as well as

private philanthropy and

gifts or grants from indus-

try. Of course, much of the

resident subsidy is second-

ary to the need for skilled

24-hour coverage in many

specialties, and for main-

taining trauma centers, to

name one major need5.

Furthermore, the Medicaid

portion has been shrinking

as some states opt out of

providing GME funding.

Since 2000, the United

States has added 26 new

medical schools and most

existing schools have in-

creased class sizes. But

budget cuts to

Medicare/Medicaid and virtually no increase in GME funding in

the last decade has resulted in training fewer physicians relative

to the numbers of MDs graduating. This is contrary to the needs

of our growing and aging population – which have dramatically

changed the need for providers. This is ironic given that the orig-

inal funding law in 1965 was tied to the care of the elderly.

BALANCED BUDGET ACTMost of the legislation regarding GME funding has involved

limiting spending or allowing for slight increases only in certain

aspects of the program. In 1997, as part of the “Balanced Budget

Act,” residency slots were capped at FY 1996 levels due to Con-

gress’ perception that there was an excess number of physicians.

This had the possibly unintended effect of also freezing geo-

graphic distribution (the Northeast has the largest concentration

of training slots). In 1999, the cap for rural hospitals was increased

by 130 percent of their 1996 levels. The Affordable Care Act cre-

ated a five-year, $230 million program to increase primary care

GME, and attempts to move some GME slots from hospitals with

excess capacity to those in need of more physicians in the area

(more rural hospitals).

The geographic “freeze” resulting from the 1997 Balanced

Budget Act is troubling for states such as Texas, since there is a

well-established connection between a physician’s residency train-

ing and where he or she will ultimately practice. The graph pub-

lished with the article, which was used in the report, speaks for

itself in regards to the geographical funding disparity.

The graph, reprinted by permission above, and a study from a

2013 article in Health Affairs, 4 estimates that nearly 20 percent

of all Medicare GME funding goes to the state of New York. For

various reasons including the higher preponderance of teaching

hospitals, the northeastern states have the most residencies slots,

and generally, receive the most dollars/resident.

The IOM report notes there is very little tracking of Medicare

funding and how it is spent. The group states that as they at-

tempted to “follow the money,” they found a lack of accountabil-

ity for the results. As the report says, “The financial underpinnings

of the GME enterprise are complex and largely undocumented.

Hospitals are only required to report the data that are needed to

calculate hospital GME payments.”6 Almost nothing about the

GME programs is tracked or reported.

RECOMMENDATIONSAccording to the report, the fundamental question of

Medicare/federal dollars as the main funding source was debated

at length by the committee. Undergraduate medical education

and many other professions also valuable to society receive no sim-

ilar federal support as their foundation, so why GME? They

looked at other scenarios such as an all-payer GME funding sys-

Continued on page 34



tem or a completely new federal GME program. In the end, they

recommended continued federal funding through Medicare (as pro-

gram for the greater public good), noting that its effectiveness de-

pends on secure and predictable funding – which would be less

feasible as a private system or a discretionary line item subject to the

politics of the federal budget process.

Public funding brings with it a responsibility for strong steward-

ship of the system, with appropriate supervision and tracking of the

results of the investment. The committee’s recommendations get

immediately to the difficulty of “rebuilding the plane while in flight”

(my quote, not theirs) – and calls for funding the status quo (current

amount with increases for inflation) while simultaneously “carving

out” the development of a new system with innovative performance-

based methodology.

The report also calls for building a graduate medical education

policy and financing infrastructure as a GME policy council under

the secretary of Health and Human Services. The council would be

tasked with establishing a strategic plan and then establishing a de-

partment in Medicare and Medicaid Services to oversee and govern

the distribution of GME payments. As a sign of the controversial

nature of this recommendation, the American Association of Med-

ical Colleges (AAMC) points out the inconsistency of recommend-

ing stable funding while taking out a portion of payments for

innovative programs, and creating a new bureaucracy for adminis-

tration. Furthermore, the committee recommended that Medicare

support end after 10 years. This would almost immediately jeopard-

ize the longest residencies such as neurosurgery (seven years), since

programs would be in funding “limbo” three years into a proposed

phase-out period. However, the proposal that some funds be de-

voted to research in graduate medical education (what works well,

how can we develop even better physicians) is sound, and based on

a dearth of data in this area.7

Graduate Medical Education funding and distribution is in

need of an in-depth analysis and overhaul in order to ensure that

it will meet the future needs of our population. The IOM report,

which is free online, brings together the main points very clearly.

The other report, on geographic distribution, is much shorter.

Links to the reports are included here, as well as a link to the

AAMC site where their thoughts are summarized. I encourage

anyone interested in medical education to read them, and con-

sider how you can influence the changes needed to secure our na-

tion’s healthcare needs for the immediate and long-term future.

While the IOM report does not provide the final answer, it is a

good start for an important conversation.

LINKSGraduate Medical Education

That Meets the Nation's Health

Needs, Institute of Medicine: 2014

http://www.iom.edu/Reports/2014/Graduate-Medical-Educa-

tion-That-Meets-the-Nations-Health-Needs.aspx

The Geography of Graduate Medical Education: Imbalances Signal

Need for New Distribution Policies; Health Affairs, 32, no. 11

(2013):1914-1921

http://content.healthaffairs.org/content/32/11/1914.full.html

Medical Experts Say Physician Shortage Goes Beyond Primary Care

AAMC Reporter: February 2014

https://www.aamc.org/newsroom/reporter/february2014/370350

/physician-shortage.html

Innovation in Medical Education

David A. Asch, M.D., and Debra F. Weinstein, M.D.; N Engl J

Med 2014; 371:794-795 August 28, 2014

http://www.nejm.org/toc/nejm/371/9/

REFERENCES1. NRMP Match Report 1996.

2. NRMP Match Report 2014 (Incomplete; as of April 2014).

3. Graduate Medical Education That Meets the Nation's Health

Needs; Institute of Medicine: 2014; (Summary).

4. The Geography of Graduate Medical Education: Imbalances

Signal Need for New Distribution Policies; Health Affairs, 32,

no.11 (2013):1914-1921.

5. Medical Experts Say Physician Shortage Goes Beyond Primary

Care; AAMC Reporter: February 2014.

6. Graduate Medical Education That Meets the Nation's Health

Needs; Institute of Medicine: 2014; ( Sec. 3, page 1.)

7. Innovation in Medical Education; NEJM; Aug. 2014.

Dr. Francisco González-Scarano is dean

of the School of Medicine, vice president

for medical affairs, professor of neurology,

and the John P. Howe III, MD, Distin-

guished Chair in Health Policy at the Uni-

versity of Texas Health Science Center at

San Antonio. His email address is

[email protected].

Continued from page 33


• ACCOUNTING

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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

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]

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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

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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]

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


BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

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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.

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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]

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• 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]

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 [email protected] Isgitt512-370-1776www.tmait.orgWe offer BCMS members a freeinsurance portfolio review.

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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]

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)We relentlessly defend, protectand reward the practice of goodmedicine. As the patient safetyindustry leader, we proudly offera comprehensive selection ofCME opportunity and risk-miti-gation resources.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.

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Know Your Doctor SA(HH Silver Sponsor)Increase your practice’s uniquemarketing/communications pro-gram. Connect with SA commu-nity through video, advertising,PR and medical opinion e-news.Limited to 300 physicians.Lorraine Williams, RN210-884-7505LWilliams@KnowYourDoctorSA.comwww.KnowYourDoctorSA.com

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

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�

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 invaluableto 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 be

the 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 Cleary210-301-4362BCleary@FavoriteStaffing.comwww.favoritestaffing.com/pub-lic/medicalsocieties/bexar_county/bexarcounty_index.aspxFavorite Healthcare Staffing offers preferred pricing for BCMS members.

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

As of October 13, 2014

For more information, call 210-301-4366,

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



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 October 15, 2014.

ABCD Pediatrics, PAClinical Pathology Associates

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

ENT Clinics of San Antonio, PAGastroenterology Consultants of San Antonio

General Surgical AssociatesGreater San Antonio Emergency Physicians, PA

Institute for Women's Health

Lone Star OB-GYN Associates, PAM & S Radiology Associates, PA

MacGregor Medical Center San AntonioMEDNAX

Peripheral Vascular Associates, PARenal Associates of San Antonio, PA

San Antonio Gastroenterology Associates, PASan Antonio Kidney Disease Center

San Antonio Pediatric Surgery Associates, PA

South Alamo Medical GroupSouth Texas Radiology Group, PA

Tejas Anesthesia, PATexas Partners in Acute Care

The San Antonio Orthopaedic GroupUrology San Antonio, PA

Village Oaks Pathology Services/Precision PathologyWellMed Medical Management Inc.


BOOK REVIEW

My sister called me and strongly recommended “Spillover: AnimalInfections and the Next Human Pandemic” by David Quammen.When I was about three-quarters of the way through it, I called herback and told her that I was glad there wouldn’t be a test on it. It ispacked full of information about the epidemiology of zoonotic diseases,virology, viral phylogenetics, zoology, agriculture and so much moreit’s hard to remember it all … and I just finished the book this morning.

Quammen’s writing style manages to take difficult, complicated con-cepts and express them in terms that any educated person should beable to understand. He is a contributing writer for National Geo-graphic, and with their help (and the help of others) traveled all overthe world to produce this book. As an example of his style, this comesfrom the next-to-last chapter:

“That’s the salubrious thing about zoonotic diseases: They remindus, as St. Francis did, that we humans are inseparable from the naturalworld. In fact there is no “natural world,” it’s a bad and artificial phrase.There is only the world. Humankind is part of that world, as are theebolaviruses, as are the influenzas and the HIVs, as are Nipah and Hen-dra and SARS, as are chimpanzees, and bats and palm civets and bar-headed geese, as is the next murderous virus — the one we haven’t yetdetected.”

We all know a little about some zoonoses such as rabies, flu and Qfever. Some of these conditions are only transmitted from animals toman, under most circumstances, but others (such as influenza andSARS) adapt, mutate and become epidemic among humans withoutthe animal reservoir being needed for the transmission. That’s the def-inition of “spillover.” And that brings up a large portion of the book:the search for the “reservoir” for various diseases.

HOST ANIMALThe reservoir is defined as the host animal (mammal or bird) that

has lived and evolved with a potentially pathogenic organism for a long,long time. It has reached a mutual non-aggression pact with the virusfor the most part, and everyone gets along. But if that virus is acci-dentally transmitted to a species that doesn’t have the ability to fight itoff, and it can be passed on to others, it can become a disease-causingproblem. Remember the SARS outbreak in 2003? At first, a creatureknown as a palm civet, which is a delicacy in South China, was thoughtto be the reservoir host because people who developed SARS had hadcontact with civets, and animals tested from local civet farms and mar-kets had evidence of antibodies to the causative coronavirus. So thegovernment ordered the death of all farm and market civets. But wait!Scientists trapped and sampled a bunch of wild civets, all of whomwere found to be free of the virus! But then, where did it come from?

And what was the civets’ role?It turns out that the civets

were an “amplifier host.” This isan animal that can harbor the pathogen without toomuch problem. The virus propagates and lives there, and then can bespread to yet another species for which it is pathogenic. After exploringseveral dead-ends, zoologists, virologists, veterinarians and others dis-covered that the reservoir was probably horseshoe bats. Bats, too, areeaten in South China. How did it get into the civets? One of the re-search groups wrote, “An infectious consignment of bats serendipi-tously juxtaposed with a susceptible amplifying species could result ina spillover and establishment of a market cycle while susceptible animalsare available to maintain infection.” Quammen calls this “infectionby association.”

One of the most educational and informational sections of thebook is the one titled “Going Viral.” It contains a history of virol-ogy, a short course on the difference between DNA and RNAviruses, and a somewhat scary description of why RNA viruses arethe really, really bad guys.

Among the diseases explored in this wonderful book are HIV/AIDS,Ebola, Q fever, Marburg virus, and good old influenza. Flu seems tobe mostly a bird-borne virus, and pigs are occasionally an amplifierhost. African fruit bats probably host Ebola. One strain of malaria iszoonotic: macaques in Southeast Asia host Plasmodium knowlesi. Theother malarias appear to be ours alone, as are measles and polio.

If you like adventure books, do not despair. Quammen tells fasci-nating tales about catching bats in caves in Africa and in nets on a roofin Bangladesh, trekking through West African jungles to collect chimpfeces, and exploring goat farms in the Netherlands. In my opinion,the best section of the whole book is chapters 99 to 101, where he tellsthe hypothetical story of the “real” HIV “Patient Zero.” This is notthe unfortunate, massively promiscuous homosexual Canadian airlineflight attendant Gaetän Dugas, who died in March 1984, but a luckyhunter in the southeastern part of Cameroon in 1908. He catches achimpanzee in a trap, kills and butchers it (they still eat chimps there),and starts down river, fetching up in Leopoldville, later Kinshasa, onthe Congo River. He is infected by the chimp (who probably got itfrom a fruit bat) and starts the whole HIV/AIDS ball rolling. You’llread every word. It’s Huckleberry Finn without Jim, and echoesthroughout the world today.

Fred H. Olin, MD, is a semi-retired orthopaedic surgeon,former veterinarian and 2014 chair of the BCMS Communi-cations/Publications Committee.

“Spillover: Animal Infections and the Next Human Pandemic”

Reviewed by Fred H. Olin, MD

Gunn Acura11911 IH-10 West

Cavender Audi15447 IH-10 West

BMW of San Antonio8434 Airport Blvd.

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

Batchelor Cadillac11001 IH-10 at Huebner

Cavendar Cadillac801 Broadway

Tom Benson Chevrolet9400 San Pedro Ave.

Ancira Chrysler10807 IH-10 West

Ingram Park Auto Center7000 NW Loop 410

Ancira Dodge10807 IH-10 West


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


*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


I've written about Audi's amazing sales

growth a number of times before, but their

progress has accelerated, so it's time to talk

about it again.

First some data: Audi has posted month-

over-month sales gains — that is, one

month’s sales this year versus the same month

last year — for more than 40 consecutive

months. Their sales are double what they

were just five years ago. Ten years ago, Audi

sold just 77,917 vehicles, compared with

287,917 Lexuses. This year the totals will be

about 168,000 for Audi and roughly

276,000 for Lexus. For the first time ever,

Audi sold more units in a month than Cadil-

lac. And let's not forget that in the dark days

following a sudden acceleration scare in the

late 1980s, Audi almost pulled out of the

United States after selling just 12,283 cars

here in 1991. (They moved 16,867 units just

in June 2014.)

There are many reasons for Audi's remark-

able surge, but ultimately it boils down to one

sine qua non: product. Audi now has excellent

products, and customers are responding.

FOUR-DOOR HELPS SALESThe new A3 sedan, famously launched

with a hilarious Super Bowl ad featuring a

Chihuahua-Doberman mix and Sarah

McLachlan, is a representative example of an

excellent Audi product. After doing just OK

with the previous generation A3 hatchback,

Audi decided to go with a more conventional

four-door sedan. And it's outselling the old

A3 almost 10:1 and would be doing even

better if dealers could get more cars. Not

only is the four-door configuration helping

sales, but the A3's good looks and the pres-

ence of numerous upscale amenities are also

driving customer interest.

So far large numbers of first-time Audi

buyers are purchasing A3s. It's probably

worth noting that those new customers will

go away if they find that busy Audi dealers

don't provide a better owner experience than

they received from Ford, Honda or Toyota.

Audi, you are warned.

Driving the A3 is a treat, as a recent top-

place finish in a Car and Driver comparison

test against the Mercedes CLA and BMW 2-

series emphasizes. Audi's parent company

Volkswagen spent a rumored $2 billion on a

modular architecture that is expected to un-

derpin everything from the tiny Euro-only

Volkswagen Polo to the upcoming 2016

Audi Q5 SUV. The A3 is the first vehicle for

sale here to sit on that MQB platform, and

you can feel all that money in the solidity of

the driving experience. Despite most of the

AUTO REVIEW


Audi A3 sedan:Pleasurable driving, top-shelf interior;hatchback model due out next yearBy Steve Schutz, MD

weight of the A3 being forward of the car's

center, there's no discernible understeer, even

when you're in a hurry. And cruising on the

interstate is comfortable without those

OMG moments you get in other small cars

as you're passing a semi pulling two trailers.

No, the A3 isn't an A8, so there's more noise

and less poise than you get with vehicles of

that ilk at speed on the highway, but the A3

is still better than it was and better than most

of the competition.

While it's a surprise to see Audi equaling

Mercedes and BMW in driving dynamics, a

top-shelf interior is expected from Volkswa-

gen's luxury arm, and the A3 delivers in that

department. Despite it being Audi's entry-

level vehicle, the materials in the A3's cabin

look expensive and feel special, and the Ger-

man brand's typically gorgeous gauges with

sharp white numbers and red lighting are

present as they are in every other Audi.

Packaging is a downer, though. For now

the Germans have given up on hatchbacks,

which means that when it comes to bringing

it with you, you're limited by a small trunk.

While the rear seat back can be folded down,

no way can the A3 sedan haul as much a sim-

ilarly sized hatchback can. If that's a prob-

lem, you might consider the Lexus CT 200h

hatchback. Or if you can wait, a new A3

hatchback is expected here in 2015 (with an

available diesel engine).

QUATTRO AIDS HANDLINGAudi is following Mercedes' lead with their

CLA marketing and has framed the A3 as a

$30,000 car. It's not. Average transaction

prices are running around $35k as customers

find they can't resist upgrades like the bigger

engine, upgraded upholstery, and, especially,

Quattro all-wheel drive. Obviously, Texans

don't need AWD for snow and sleet, but I

wouldn't own an A3 without Quattro because

it helps handling in all weather conditions.

Only time will tell how long Audi can

continue to march up the sales charts, but as

long they keep producing hits like the new

A3, it's likely to be a while. The A3 may be

small, but it delivers.

Steve Schutz, MD, is a

board-certified gastroen-

terologist who lived in San

Antonio in the 1990s when

he was stationed here in the

U.S. Air Force. He has been writing auto re-

views 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
