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Bexar County Medical Society's Monthly Magazine
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BCMS CIRCLE OF FRIENDSSERVICES DIRECTORY > > > > > > > >
SAN ANTONIO
MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • JUNE 2015 • VOLUME 68 NO. 6
NON PROFIT ORGUS POSTAGE
PAIDSAN ANTONIO, TX
PERMIT 1001
When doctors
say“I do!”
4 San Antonio Medicine • June 2015
When doctors say ‘I do’Problem-solving skills honed throughtwo careers, familyBy Bruce Akright, MD, and Laura Akright, MD..........12
‘I would never marry another doctor!’By Paula Lyons, MD, and Jeffery Meffert, MD ..........14
BCMS President’s Message ..............................................8
BCMS Legislative and Advocacy News ..........................10
BCMS News ....................................................................11
Opinion: Good recordkeeping essential for proving CME credits by Fred H. Olin, MD ..............16
Risk Management by TMLT ..........................................................................................................19
Nonprofit: Moonlight Fund helps burn survivors and their families ..............................................22
Lifestyle: The DoSeum – new children’s museum hopes to spark a love of learning ..................24
UTHSCSA Dean’s Message by Francisco González-Scarano, MD ........................................................26
Legal Ease: Do I have to? and How much? Part II of II, by George F. “Rick” Evans ..............................30
Business of Medicine: Costly reflections in the ‘Silver Tsunami’
by Dana A. Forgione, PhD, CPA, CFE ................................................................................................34
BCMS Circle of Friends Services Directory ............................................................................................37
Book Review: ‘Flashback’ Written by Michael Palmer, reviewed by Teresa C. Hayes, MD ..................40
In the Driver’s Seat ..................................................................................................................................43
Auto Review: Ford Escape, by Steve Schutz, MD ..................................................................................44
MEDICINETHE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY • WWW.BCMS.ORG • $4.00 • JUNE 2015 • VOLUME 68 NO. 6
SAN ANTONIO
PUBLISHED BY:SmithPrint Inc.333 BurnetSan Antonio, TX 78202Email: [email protected]
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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.
EDITORIAL CORRESPONDENCE:Bexar County Medical Society6243 West IH-10, Suite 600San Antonio, TX 78201-2092Email: [email protected]
MAGAZINE ADDRESS CHANGES:Call (210) 301-4391 orEmail: [email protected]
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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) onbehalf of the Bexar County Medical Society (BCMS). Reproductionin any manner in whole or part is prohibited without the expresswritten consent of Bexar County Medical Society. Material containedherein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right toedit all material for clarity and space and assumes no responsibility foraccuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nordoes the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome andmay be submitted to our office to be used subject to the discretion andreview of the Publisher and BCMS. All real estate advertising is subjectto the Federal Fair Housing Act of 1968, which makes it illegal to ad-vertise “any preference limitation or discrimination based on race, color,religion, sex, handicap, familial status or national orgin, or an intentionto make such preference limitation or discrimination.
6 San Antonio Medicine • June 2015
BOARD OF DIRECTORS
OFFICERSJames L. Humphreys, MD, PresidentLeah Hanselka Jacobson, MD, Vice PresidentMaria M. Tiamson-Beato, MD, TreasurerAdam V. Ratner, MD, SecretaryJayesh B. Shah, MD, President-electK. Ashok Kumar, MD, Immediate Past President
DIRECTORSJorge Miguel Cavazos, MD, MemberJosie Ann Cigarroa, MD, MemberKristi G. Clark, MD, MemberJohn Robert Holcomb, MD, MemberJohn Joseph Nava, MD, MemberCarmen Perez, MD, MemberOscar Gilberto Ramirez, MD, MemberBernard T. Swift, Jr., DO, MPH, MemberMiguel A. Vazquez, MD, MemberFrancisco Gonzalez-Scarano, MD, Medical School RepresentativeCarlos Alberto Rosende, MD,
Medical School RepresentativeCarlayne E. Jackson, MD, Medical School RepresentativeBonnie Harriet Hartstein, MD,
Military RepresentativeRebecca Christopherson, BCMS Alliance PresidentGerald Q. Greenfield Jr., MD, PA, Board of Censors ChairDonald L. Hilton Jr., MD,
Board of Mediations ChairGeorge F. "Rick" Evans Jr., 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, MemberJeffrey J. Meffert, MD, MemberRajam S. Ramamurthy, MD, MemberJ.J. Waller Jr., MD, Member
As I write this, I am sitting at the Texas Medical Associ-
ation’s annual TexMed meeting in Austin. I am always im-
pressed to see such a large group of physicians from all
across the state coming together to share common experi-
ences and frustrations and seeking solutions. It is thera-
peutic to see firsthand that you aren’t alone and that you
have colleagues willing to volunteer their time to serve on
committees and councils for the greater good. We all face
a lot of complicated issues that we need help with as we try
to have a viable practice in the face of an underfunded and
inefficient healthcare system.
The great challenge for organizations such as TMA is uni-
fying a fractious, territorial and generally difficult con-
stituency. It is altogether too easy to forget that it is an
organization of people who genuinely have the intent of steer-
ing legislative and regulatory agency agendas to the pathway
of repairing and rethinking the various glitches in our health-
care delivery system for the broadest general benefit, especially
if a regulatory or legislative effort promoted by TMA seems
to go against the niche interests of a certain specialty or geo-
graphic region.
My personal experience from serving on the Council on
Legislation is that any of these decisions by the organiza-
tion are carefully thought through and debated before any
action is taken. There isn’t always a clear-cut best choice
for everyone when considering how to respond to a pro-
posed bill or Texas Department of Insurance or Medicaid
regulation. That said, a greater effort to make the reason-
ing behind decisions taken by the organization is necessary
in the name of transparency and better communication to
the membership. Often a strategy that seems foolish or
careless at first glance makes sense if the background for
the decision and the possible consequences of not taking
action are understood.
If that improved communication can be achieved, it will
be that much easier for us to be unified in our efforts to im-
prove the healthcare system for our patients and ourselves.
The more we allow ourselves to be divided and dilute our ef-
forts with internecine fighting, the more onerous our practice
environments will become.
James L. Humphreys, MD, is the 2015 president of the Bexar
County Medical Society. He is a pathologist with Precision
Pathology in San Antonio.
PRESIDENT’SMESSAGE
Organized medicine seeks the broadest benefits for the majority of its constituents and their patientsBy James L. Humphreys, MD2015 BCMS President
8 San Antonio Medicine • June 2015
10 San Antonio Medicine • June 2015
BCMS LEGISLATIVE ANDADVOCACY NEWS
The final two TMA/BCMS legislative events ofthe 84th regular session in Austin included a special“Last Thursday” held during TMA’s annual meeting,TexMed, on April 30, and the last “First Tuesdays”event on May 5. A big thanks to the following individuals who par-
ticipated: Carmen Garza, MD; Pam Hall, MD;David Henkes, MD; Bill Hinchey, MD; James L.Mims, III, MD; Gabriel Ortiz, MD; Raymond Os-bourn, MD; Jennifer Rushton, MD; Ryan VanRamshorst, MD; Courtney Hobza, medical student,and Jennifer Lewis, BCMS Alliance president-elect.The newly elected state representative for Texas
House District 124, Ina Minjarez, was sworn in dur-ing the week of April 27. Minjarez assumes the seatformerly held by now-Sen. Jose Menendez (Dist. 26).At the time of this writing, the 84th regular leg-
islative session was scheduled to end sine die on June1. Stay tuned for more information on the sessionwrap-up and results of bills signed into law or vetoed.A complete wrap-up will be coming soon. Look foradditional highlights in the BCMS newsletter, TheWeekly Dose.
For local discussion on this and other legislativeadvocacy topics, consider joining the BCMS Leg-islative and Socioeconomics Committee by contact-ing Mary Nava at [email protected].
84th Regular legislative session closes; last First Tuesdays concludes Minjarez sworn in asstate representative By Mary E. Nava, MBABCMS Chief Governmental and Community Relations Officer
Rep. Lyle Larson (Dist. 122) (left) and Bill Hinchey, MD, vis-ited during the April 30 Last Thursday event in the Capitol.
David Henkes, MD (from left); Bill Hinchey, MD; MaeganCollins, legislative staffer in the office of Speaker Joe Straus; Jen-nifer Rushton, MD, and Jennifer Lewis discussed medicine’s issuesduring the April 30 Last Thursday visit to the Capitol.
BCMS First Tuesdays participants paused for a photo May 5with Sen. Jose Menendez (Dist. 26): (back row from left) JamesL. Mims, III, MD; Menendez; Pam Hall, MD; Ryan VanRamshorst, MD; (front row from left) Gabriel Ortiz, MD; Car-men Garza, MD; Courtney Hobza; Mary Nava and Raymond Os-bourn, MD.
Pausing for a brief visit with Sen. Carlos Uresti (Dist. 19) duringthe May 5 First Tuesdays were (back row from left) Pam Hall, MD;Mary Nava; Ryan Van Ramshorst, MD; James L. Mims, III, MD;(front row from left) Carmen Garza, MD; Uresti; Raymond Os-bourn, MD, and Courtney Hobza.
visit us at www.bcms.org 11
BCMS NEWS
As BCMS First Tuesdays participants visited with ShannonHouston, legislative staffer in the office of Rep. Lyle Larson (fore-ground), Larson approached the mic on the House floor to discussa bill (seen on TV monitor).
A group of pediatricians and subspecialists visited with EduardoZerbe, legislative staffer in the office of Rep. Ruth Jones McClen-don (Dist. 120), during the May 5 First Tuesdays: (standing fromleft) Carmen Garza, MD; Zerbe; Ryan Van Ramshorst, MD, andJames L. Mims, III, MD.
Offering congratulations to the new state representative forHouse District 124, Ina Minjarez, during the May 5 First Tuesdaysvisit were (from left) Raymond Osbourn, MD; Courtney Hobza;Ryan Van Ramshorst, MD; Minjarez; James L. Mims, III, MD;Carmen Garza, MD; Pam Hall, MD, and Mary Nava.
BCMS WISHES TO THANK ITS
CAPITAL CAMPAIGNMAJOR DONORS
Thank you to the following major contributors to theBCMS Capital Campaign in support of the medical so-ciety’s new building now under construction:
BB&T BankFavorite Healthcare Staffing Inc.
Frost BankGastroenterology Consultants of San Antonio
H-E-BMednax/Pediatrix
Northside Ford Dealerships/Mark Wood
Donations of all amounts are appreciated. Pledgesmay be paid over multiple years. All donations are 100percent tax deductible; payable to the Bexar CountyMedical Library Association, tax ID 74-0510530.
For more information, call BCMS at 210-301-4383.
Honoring Our Past ...Building Our Future!
Construction continues on the site of the new BCMSoffice building.
Architectural rendering of new BCMS office building,4334 North Loop 1604 West.
12 San Antonio Medicine • June 2015
WHEN DOCTORSSAY ‘I DO’
Our journey together began at Southern Methodist University in
1975 — meeting in a complex variables math course. We were both
pre-med math majors, and had decided to head into the profession
of medicine without any real idea what that entailed.
Both of us really enjoyed being math majors, and with hindsight
we believe what it gave us was an ability to problem-solve that has
served us well in our marriage and our medical careers. We do not
remember ANY of the complex math we learned, but we do have the
ability to work through difficult and complex situations and prob-
lems. Raising three boys and maintaining two careers has provided
an adequate number of problems for us to work with!
SCRAPING ICE OFF A CARWe graduated from Washington University School of Medicine
in St. Louis in 1980. The experiences we had in medical school to-
gether provided a strong bond, as we shared both the excitement
as well as the frustrations of being medical students. We do not
miss having to scrape ice off a car at 4 a.m. to get in for surgery
rounds, donating blood for spending money, or having to go to
laundromats.
After we married in 1977, we shared the same last name. This
proved difficult during internship and residency in San Antonio with
overhead paging and operators who got us mixed up. We have stories
from working at the Robert B. Green and the Bexar County Hospital
that only those of our age would understand. We forged close friend-
ships with fellow interns and residents, and always enjoy catching up
and re-sharing those stories.
The years of early private practice and raising small children were
challenging ones. We always seemed to be “juggling.” A major house
fire in 1993 and relocation for a year helped to put things in per-
Problem-solving skills honedthrough two careers, family
By Bruce Akright, MD, and Laura Akright, MD
visit us at www.bcms.org 13
WHEN DOCTORSSAY ‘I DO’
spective, and we worked to simplify our schedules. Both of us had
orthopaedic injuries related to ski trips and decided that was not the
sport for us to pursue as a couple. However, our two younger sons
both decided to attend the University of Colorado so the vacations
there obviously had a positive impact.
FACING NEW ISSUESThe later years of private practice have had their own issues with
focus on technology and reimbursement. By this point in our careers,
taking care of and communicating with patients is relatively easy
compared to all the other issues we face. We have morning walks
with the dogs at 5:30 every day, and that is our time to catch up with
all that is going on.
We have shared a love of travel since our first trip to Africa in 1983.
We have been fortunate to be able to travel to all parts of the world
over the years, and we always have new places we would like to see.
Our boys instilled in us a love for soccer as well since that was the sport
we lived and breathed with them during the teen years. We have been
able to take our boys to the last three World Cup games in Germany,
South Africa and recently in Brazil. Last summer, we were cheering the
U.S. team on the Copacabana beach after their victory over Ghana.
This was at the time the Spurs had just won the NBA Finals, and we
were wearing our Spurs jerseys in Brazil. We had more people stop us
and cheer with us in every language imaginable!
Our journey together has been an amazing one – we never lose
sight of how fortunate we are to be able to practice medicine and
care for people all the years that we have. We work to communicate
and to always try to problem-solve together. There have been chal-
lenges that seemed insurmountable, but our faith is strong, and we
have always believed in each other. We will be celebrating our 38th
anniversary in June – planning to do so in Venice, one of our fa-
vorite cities.
Bruce Akright, MD, practices at
Northeast OB/GYN Associates. Laura
Akright, MD, practices at Northeast
Endocrinology Associates. Both physi-
cians are BCMS members.
14 San Antonio Medicine • June 2015
WHEN DOCTORSSAY ‘I DO’
We met in anatomy lab (tanks No. 19 and No. 21) and liked
each other well enough, but it was the long trips to and from Flo-
resville when paired together for the “Psychosocial Aspects of
Healthcare” where we got to know each other well enough to agree
that to get involved with another physician would be really stupid.
Surely the complexities and sacrifices needed in a two-profession
household would be far too much to make it work. We enjoyed
each other’s company enough that we got over that and decided
the only way the U.S. Air Force would keep us together after med-
ical school would be if we were married. It isn’t clear now who pro-
posed to whom but it was likely on a Volksmarsch where one of
us said, “I guess we need to get married before the match,” and
the other said, “I guess so.”
FIRST BIG DECISIONThe first big couples’ decision was Jeff deciding to apply for a
family practice residency instead of transitional internship. In the
residency match now, couples may designate one of the applicants
as the “first priority,” after which the other applicant will be
matched according to the results of the first. This is especially im-
‘I would never marry another doctor!’By Paula Lyons, MD, and Jeffrey Meffert, MD
Photo courtesy Jeffrey Meffert, MD, and Paula Lyons, MD
visit us at www.bcms.org 15
WHEN DOCTORSSAY ‘I DO’
portant to consider when one residency or preferred location is
more competitive than the other.
“No one is allowed any time off on this rotation…unless you
are getting married, in which case you can have a day off.” At the
time, our attending on the inpatient psychiatry service didn’t know
we were already planning on getting married. Our classmates were
invited to the reception in Jeff ’s parents’ back yard, not knowing
we had gotten married that morning because we didn’t want our
loan-broke friends to feel obligated to bring presents. Our honey-
moon was a Sunday night at La Mansion and a Monday off as our
attending reluctantly stood by his flippant comment. Tuesday we
chaperoned a ward full of psychiatric patients at a Brackenridge
Park picnic which we took as an omen of the challenges we would
face trying to balance our married and professional lives.
Over the next several years, work and training limited time off
together with one of us either in-house, on-call or sleeping off a
bad shift all the time. Even after residency is complete, it can be
easy to fall into conflicting work and call schedules so that relaxed
quality time for the twin professional family, especially once chil-
dren enter the mix, may be hard to find. Another physician couple
we know holds Friday nights sacred (Jeff ’s new boss warned him,
“I don’t do Friday call”) as a date night, and this is one way to man-
age this difficult balance.
How did we manage child sick days, doctor appointments, trans-
porting two children to different schools, parent-teacher confer-
ences, school performances, sports events and family vacations?
Fortunately, Paula’s schedule was more flexible than Jeff ’s, so it all
worked out. And looking back, it was all a blur.
We started together in an Air Force Family Practice clinic and
when Jeff was transferred to Alaska in an operational medicine po-
sition, Paula left the service and worked in a private practice setting
until it was time to move back stateside. It can be a significant chal-
lenge to the dual-physician family if one member is in a fulfilling
and profitable practice situation while the other needs to move on.
Once again a decision must be made as to what is essential, what is
survivable, and whose practice takes priority.
Reluctant to get involved in another private practice, Paula took
a job in urgent care with the expectation that another move was
right around the corner. In fact, Jeff spent the last 16 years of his
Air Force career moving around San Antonio, and Paula just cele-
brated her 25th year at Texas MedClinic. Sometimes things work
out fine, but the stress of unanticipated or unwanted practice
changes will strain any relationship.
LOVE AND PATIENCEA recent British Medical Journal article suggests that rather than
having a higher divorce rate, physicians divorce less than the general
population as a whole, although how this applies to dual-physician
families is not clear. The dual income is nice and removes some of
the financial stresses some families suffer, but it comes with the
price of uncoordinated long hours, unpredictable ability to be
where the family wants you to be, and periodic career upheaval if
one partner needs to move. With love and patience it can be done,
and we both feel lucky that we “married well.”
Speaking of omens, we were married on the day Mount St. Helens
blew up, so we can honestly say the “earth moved” on our wedding
day. This summer we will continue our occasionally volcanic marriage
by celebrating our 35th anniversary in Pompeii. The trip to Italy was
carefully planned to be sure we would be back in Texas for the first
birthday of our first grandson. This life adventure isn’t over yet.
Paula Lyons, MD, is a family medicine practitioner at Texas Med-
Clinic. Jeffrey Meffert, MD, is a dermatologist at the University of
Texas Health Science Center San Antonio and a BCMS member.
16 San Antonio Medicine • June 2015
So, you’re at home, it’s a beautiful day, and you happen to look
out the window and see the postman pushing some mail into your
street-side mailbox. It’s the first week of the month, so you know
that it’s probably mostly one form of junk mail or another: sale
brochures, “free” meals that just happen to require you to listen to a
pitch about retirement plans, campaign literature for politicians who
think that you live in a completely different district than you actually
do, maybe a bill or two, and a much-anticipated issue of San Antonio
Medicine. But wait! What’s this? It’s an envelope with the return ad-
dress of the Texas Medical Board! Now, try to convince me that your
little heart didn’t skip a beat, or that you didn’t gasp with apprehen-
sion. Maybe not as much as you would have if it said Internal Rev-
enue Service, but still…
I received one of those TMB letters not long ago, and it turned
out to be seemingly benign: I had been chosen, totally at random, to
confirm that I had obtained (as I had claimed on my registration
form) enough CME credits over my last two-year registration period.
The requirements are that you have to have at least 48 credits every
24 months, and that at least 24 of them are AMA/PRA Category 1
or its equivalent from the American Orthopaedic Association, the
American Academy of Family Physicians, the Texas Medical Associ-
ation, etc. Furthermore, at least two of those 24 must be in “medical
ethics and/or professional responsibility.”
“OK,” you say. “No problem. I’ve gone to several professional
meetings, grand rounds, and so on, just shouldn’t be a problem.”
Then you come to the line that says, “Please provide copies of cer-
tificates to document medical ethics and all other formal hours and
also a log of informal hours, if applicable, which should include dates
and hours completed.” Certificates? Who has certificates? And what
are “informal” hours? The letter says, “Informal hours include activ-
ities such as reading journals, attending case conferences, etc.” Wait
a minute. Who writes down the time he spends reading journals?
Come on, guys! Are you serious?
Turns out that they are.There are some good things in the very small-print copy of the
Texas Administrative Code, Title 22, Part 9, Chapter 166, §Section
166.2 Continuing Medical Education that the TMB is kind enough
to send to you. For example, if you managed to get more than the
48 Category 1 credits, you can carry the excess forward and apply
them toward the next registration period’s requirements. That’s nice,
and I had 8.25 extras. I made a note.
Anyway, being a compulsive soul, every time I went to a course or
meeting, I made an entry into an Excel spreadsheet. I’ve been doing
OPINION
Good recordkeeping essential for proving CME credits
By Fred H. Olin, MD
Continued on page 18
18 San Antonio Medicine • June 2015
so since 1980 and have nearly 300 meetings of one sort or another
on it. So, I took a look at the 2012 to 2014 list, and there were more
than enough, and there were two hours of ethics, both from the med-
ical school’s orthopaedic department’s grand rounds. I had certifi-
cates for the Academy meetings I’d been to, and for all of the online
material I had completed, but none from grand rounds. I found out
how to get those and downloaded them. I was checking their list
against mine and noticed that neither of the ethics lectures was there.
Oh, boy! After a bunch of phone calls to some really nice and helpful
people at UTHSCSA’s CME office and the orthopaedic department,
they finally were able to prove to themselves that I had indeed been
there and to get that information into their database so that I could
download a complete copy to send to the board.
All’s well that ends well, right? Well, I don’t really know. I
haven’t heard from the board that my stuff was adequate, but it’s
only been a month or so since I sent it in. We shall see. Here are
today’s lessons:
KEEP RECORDS!If at all possible, get the certificate of attendance, with the appro-
priate language and documentation of the credits allowed, at the time
of the meeting.
Don’t lose/misplace the certificates…in fact, maybe make a couple
of copies and file them somewhere else.
Be ready a month or two after your biennial registration ends to
get the letter. It may not happen, but if it does, you’ll be equipped.
Epilogue: A couple of weeks after I wrote this, I received a letter
from the TMB saying that I had passed their scrutiny, and all was
well. This was about five weeks after I had submitted the material.
Fred H. Olin, MD, is a semi-retired orthopaedic sur-
geon who was greatly relieved when he finally got all of
that documentation together.
OPINION
Continued from page 16
visit us at www.bcms.org 19
RISK MANAGEMENT
Failure to treat postoperative infection
By TMLT Risk Management Department
This closed claim study is based on an actual malpractice claim
from Texas Medical Liability Trust (TMLT). This case illustrates how
action or inaction on the part of physicians led to allegations of pro-
fessional liability, and how risk management techniques may have ei-
ther prevented the outcome or increased the physicians’ defensibility.
The ultimate goal in presenting this case is to help physicians practice
safe medicine. An attempt has been made to make the material more
difficult to identify. If you recognize your own claim, please be as-
sured it is presented solely to emphasize the issues of the case.
PRESENTATIONA 69-year-old woman was referred to an orthopaedic surgeon for
a defect in her Achilles tendon. She was diagnosed with a chronic
rupture of the Achilles tendon. The patient was given the options of
either living with the defect or undergoing reconstruction to regain
strength and function. The patient chose to proceed with the recon-
struction. The orthopaedic surgeon — the defendant in this case —
performed a repair with transfer of the flexor hallucis muscle.
The surgery was uneventful, and the patient was administered a
one-time dose of vancomycin post-operatively. Vancomycin was se-
lected because the patient was allergic to penicillin. The patient was
discharged the following day with instructions to leave her foot in a
splint. She was to follow up with the orthopaedic surgeon within 10
days.
PHYSICIAN ACTIONThe patient followed up with the surgeon eight days after surgery.
She was noted to have some skin irritation and some minimal
drainage. Because the wound was slow to heal, the surgeon made the
decision to leave the sutures in place for another week.
The patient returned a week later, and the sutures were removed.
The wound was observed to have some minimal wound granulation
and drainage from the incision. These observations of the wound
were written in a different handwriting from the surgeon’s, but were
not initialed. The surgeon believed that they were in his nurse’s hand-
writing, but he could not be sure. It was also unclear if the entry was
what the patient had relayed to the nurse, or if those observations
were made by the nurse herself. The patient was fitted with a splint
to continue immobilization of the foot and was told to only remove
the splint to bathe. She was also advised to complete wet-to-dry dress-
ing changes, to monitor the wound for signs of infection, and to re-
turn to the office in four weeks.
Nearly one week after this office visit, the patient called the sur-
geon’s office and received a prescription for ciprofloxacin. The only
record of this encounter, which occurred five days after the patient’s
last visit, was the pharmacy record. There is no record of the phone
call, what was discussed, or the reason for the prescription.
Two days later, the patient came to the surgeon’s office complain-
ing that her foot was “feeling hot” and noting a “hole” in the wound.
She was not wearing her splint. The patient claimed that she was not
advised to do wet-to-dry dressing changes, but instead was told by
the surgeon’s nurse to clean the wound with peroxide, then dress with
dry gauze. The surgeon examined the wound, noted minimal celluli-
tis, but did not feel the area was hot. He advised the patient to con-
tinue taking ciprofloxacin, discontinue the improper peroxide
cleanings, and proceed with wet-to-dry dressing changes.
The patient called three days later, while the surgeon was on vaca-
tion, to report that the wound drainage was getting worse and now
had an odor. The patient was advised to come to the office, and was
seen by the surgeon’s partner. This office note was incomplete, only
stating: “post-op wound infection, culture taken.” This second sur-
geon, not realizing the patient had a penicillin allergy, gave the pa-
tient a prescription for amoxicillin clavulanate. Fortunately, this
mistake was caught by the pharmacy, and another antibiotic was sub-
stituted. The patient stated in her deposition that this was what made
her lose confidence in the surgeon’s office. She sought treatment from
a wound care facility four days later. The wound care physician di-
agnosed her with full thickness dehiscense, necrotic subcutaneous
fatty tissue, and necrotic areas of the tendon in the wound base.
Six days later after the patient’s appointment with her surgeon’s
Continued on page 20
20 San Antonio Medicine • June 2015
RISK MANAGEMENT
partner, the lab results were returned indicating staphylococcus and
actinomyces meyeri infections. The patient was called and asked to
come to the surgeon’s office that day. She was emergently referred to
a plastic surgeon, who admitted her for IV antibiotics and several
debridements of the wound.
ALLEGATIONSA lawsuit was filed against the orthopaedic surgeon, alleging that
he failed to timely and adequately treat the patient’s post-operative
infection. She claimed that function of her lower leg was impaired
as a result of the infection and the failed Achilles tendon graft.
The patient underwent subsequent surgeries with a plastic surgeon
to remove the original tendon transfer due to necrosis of the tissue.
Tissue from the patient’s wrist was transplanted to the original sur-
gical site to fill the void left by the removed tissue. The patient
claimed the subsequent surgeries resulted in the loss of sensation in
her fingers.
LEGAL IMPLICATIONSTMLT consultants who reviewed this case were generally support-
ive of the orthopaedic surgeon. Infection is a known complication
of Achilles tendon repair. There also appeared to be some question
of patient compliance. However, all of the consultants had some con-
cerns about the lack of adequate documentation pertaining to justi-
fication of the antibiotics chosen.
The surgeon’s partner had also missed elements of the documen-
tation, and did not provide detail about why he chose amoxicillin
clavulanate. However, the only defendant in this lawsuit was the or-
thopaedic surgeon who performed the repair.
DISPOSITIONThis case was settled on behalf of the orthopaedic surgeon.
RISK MANAGEMENT CONSIDERATIONSAlthough infection is a known complication inherent in any sur-
gical procedure, there were several problems with the surgeon’s doc-
umentation that complicated the defense of this case.
It is recommended that all phone calls between the patient and
physician be documented, particularly calls in which medical advice
is given. There was no record of the patient’s call that triggered a pre-
scription for ciprofloxacin, or reason for the change in the treatment
plan. Documentation of the patient’s symptoms, description of the
wound and any noted changes, and the physician’s reasoning behind
treatment not only creates a thorough chart, but in this case, it would
have provided additional information to the surgeon’s partner when
he saw the patient.
Implementing a protocol that requires all staff making entries in
the chart to initial or sign their entries will assist in identifying who
made the entry in case it needs to be verified at a later date.
It is recommended that physicians have a policy and procedure
manual for the practice to ensure that all personnel are operating
under the same guidelines, as expected by the physician. This may
include any routine instructions that are commonly given to pa-
tients, such as how to perform a wet-to-dry dressing change. It is
further recommended that important instructions to the patient
be developed into a handout that can be given to the patient and
to document that the handout was given. Patients often become
confused when instructions are given in the office, which can make
compliance difficult. Should a claim occur, the printed instructions
could be used as evidence to show precisely what information was
given to the patient.
It is appropriate for medication allergies to be consistently and
boldly documented on the front of the chart to prevent them from
being overlooked. All physicians in the same practice should stan-
dardize how allergy information is displayed if they cover for one
other. It was fortunate that the pharmacy caught the error before the
prescription was filled; however, the error made the patient lose con-
fidence in the practice. A patient and/or the patient’s family are more
likely to file a lawsuit if they perceive that the care they are receiving
is substandard.
The information and opinions in this article should not be used
or referred to as primary legal sources nor construed as establishing
medical standards of care for the purposes of litigation, including ex-
pert testimony. The standard of care is dependent upon the particular
facts and circumstances of each individual case, and no generalization
can be made that would apply to all cases. The information presented
should be used as a resource, selected and adapted with the advice
of your attorney. It is distributed with the understanding that neither
Texas Medical Liability Trust nor Texas Medical Insurance Company
is engaged in rendering legal services. © Copyright 2015 TMLT.
Texas Medical Liability Trust is a BCMS Circle of Friends sponsor at
the platinum level. BCMS does not endorse products or services.
Continued from page 19
22 San Antonio Medicine • June 2015
NON-PROFIT
In April 1998, burn survivor Celia Belt
walked onto the burn unit at Brooke Army
Medical Center (now the San Antonio Mili-
tary Medical Center) to volunteer her time
with burn survivors and their families.
Before doing so, she underwent three
months of interviews before being allowed
access to the unit. She also took part in in-
fectious-disease control and burn-unit train-
ing classes required of incoming burn-unit
medical personnel. As a volunteer, she spent
her time visiting with patients and their fam-
ilies. She also helped facilitate support group
meetings on the unit.
It did not take long for her to identify a
gap in services for the burn community.
During this time, she met burn patient
Henry Coffeen III. Together they created the
Moonlight Fund, a 501(c)3 organization, in-
corporated in Texas. Their partnership has
helped thousands of burn survivors and their
families. Henry and Celia were assisted in
their efforts by executives at Ernst & Young
and burn-unit personnel.
HELP WITHOUT DELAYEmotional, financial and in-kind goods
and services all are made available to patients
and their families. The fund is the only non-
profit of its kind, offering assistance from the
onset of the accident through rehabilitation
and into the many years of recovery. The
fund provides this help without delay, pro-
viding immediate assistance in the hour of
need. Original goals for the fund were to
manage an organization that was modest on
overhead, generous in giving and on call
24/7.
Early fundraising efforts included an air-
show from 1999 to 2009, with attendance
near 20,000 at the final airshow hosted. The
events not only provided income for the
funds efforts but also a measure of public
awareness regarding the needs of those suf-
fering with burn injuries. Due to the large
number of wounded soldiers needing hands-
on emotional care, and the move of the
Moonlight Fund’s co-founder to the Fort
Worth area, the shows were disbanded. Thus,
the fund depends on foundation grants,
fundraising galas and personal donations to
continue its efforts.
There exists a substantial lack of services
for burn survivors and their families. The av-
erage length of a hospital stay is 93 days, and
depending on the severity of the injuries,
physical and occupational therapy can take
several years. Without a good protocol of
after-care, many patients find themselves
back in the hospital for ongoing surgeries to
release scar tissue that otherwise would have
been treated by good rehabilitative care.
There also exists a need for ongoing coun-
seling for patients and their families. The
trauma caused by these life-changing injuries
has a long-lasting effect on all involved.
Civilian patients often are uninsured or
under-insured and do not receive the neces-
sary rehabilitation that is crucial to a full re-
covery. Active-duty injuries incurred by
military personnel due to conflicts abroad
also need assistance. Family members many
times find themselves as primary caregivers
and need the support of an outside organi-
zation, such as the Moonlight Fund. The
fund was operating at the onset of the war in
the Middle East, and has adapted to the in-
creased needs and added programs to assist
new groups of burn and blast survivors. The
war has provided for a complex number of
injuries, with most patients also suffering
from post-traumatic stress syndrome and
traumatic brain injuries. The Moonlight
Fund steps in to cover any gap in services to
wounded soldiers and their families.
In 2007, the fund expanded its services to
include those burn and blast survivors who
have undergone amputations. Moonlight
also introduced a retreat program that year,
offering a weekend setting for burn and blast
survivors hosted in the peaceful surroundings
of the Hill Country. Activities such as
archery, horseback riding, hiking, skeet
shooting and painting classes provide a meas-
ure of physical and emotional therapy. At-
tendees find plenty of opportunities to build
comradery and establish friendships. Pa-
tients, caregivers and their children learn they
are not alone in their struggle to regain their
health and wellness. Relaxation massages and
yoga sessions are available throughout the
weekend. Patients and families have the op-
portunity to meet others experiencing some
of the same struggles. They find it a “safe
place” to share their story and gain the emo-
tional healing needed for them to continue
in their healing process and prepare them to
re-enter the world.
Moonlight Fundhelps burn survivors and their families
Special to San Antonio Medicine
NON-PROFIT
TOP NONPROFITIn 2012, the Moonlight Fund was chosen
as the top nonprofit in the United States by
the Fisher House/Newman’s Own Founda-
tion. This award was given specifically for the
group’s healing retreat program. Over the
years, the fund has received many awards and
recognitions, yet it is the care of those less
fortunate that brings the greatest joy.
Today, the Moonlight Fund assists with
everything from wound-care supplies, edu-
cation costs, rehab, counseling, building of
ramps and furnishing homes, among other
options, while operating with the same
founding principles of maintaining the low-
est overhead possible and never restricting
available funds to those in need. Original co-
founder Celia Belt continues to serve as the
fund’s executive director. She is supported in
her efforts by an active and caring board of
directors and a grants manager. Volunteers
also play a big part in assisting with the re-
treats, fundraising and office assistance.
Many volunteers are those who have been as-
sisted by the fund in the past. The circle of
giving continues with their attentive and
dedicated efforts.
With the increase in patient requests, the
fund held a major fundraiser in 2014, which
raised $67,000. This year’s follow-up will be
held Sept. 26 at the Eilan Hotel, 17103 La
Canterra Parkway. The evening will feature
entertainment by aerialists, cirque entertain-
ers and music by the Statesboro Revue band.
Guest speaker will be Dale Petroskey, former
White House assistant press secretary under
President Ronald Reagan. Guests will have
the opportunity to meet Shilo Harris, Iraq
war veteran, burn survivor and author of the
book, Steel Will.
For event tickets and more information,
go to www.moonlightfund.org or call Celia
Belt at 210-445-0971.
Courtesy photos. From the top: A family helped by the Moonlight Fund plays together.Retreatants gather at an Easter event sponsored by the Moonlight Fund. MoonlightFund executive director Celia Belt speaks at an event attended by U.S. Army Gen.Martin E. Dempsey, chairman of the Joint Chiefs of Staff.
24 San Antonio Medicine • June 2015
LIFESTYLE
Young minds have a new place to grow in
San Antonio – The DoSeum.
San Antonio’s museum for kids, which
opened in early June, offers limitless oppor-
tunities for children to discover, explore, cre-
ate and learn. With world-class exhibits and
sustainable, thoughtful architecture, it is
poised to be one of the leading children’s mu-
seums in the nation. At the DoSeum, nearly
60 percent of the exhibits focus on concepts
in science, technology, engineering and math
(STEM), while others emphasize literacy and
the creative arts to create a diverse learning
experience.
Education is critical to the success of any
city, and the goal of the DoSeum is to spark
a love of learning in children that will stay
with them as they grow. In every nook of the
fascinating space, children will find some-
thing to explore, to play with, to puzzle over
and to create.
Kids will be able to use their inner creativ-
ity and curiosity to feed their appetite for
learning as they choose from an impressive
menu of world-class exhibits that include an
interactive robot named Baxter, a spy acad-
emy filled with math challenges, an interac-
tive puppet parade, a musical staircase, a
children’s river, and a significant outdoor ex-
hibit area with plenty of water features, shade
and an ADA-accessible treehouse.
ENVIRONMENTAL SCIENCEThe museum will educate by using every
inch of the 104,000 square feet of indoor-
outdoor exhibit space. The building’s sus-
tainable architecture serves as a teaching aid
in environmental science. The eco-friendly
building is equipped to produce up to 25
percent of the facility’s energy by way of 616
solar panels, to capture approximately
180,000 gallons of HVAC condensate per
year to be used for on-site irrigation, and it
will strive to recycle 90 percent of waste ma-
terials gathered from daily operations. The
DoSeum is set to receive LEED (Leadership
in Energy and Environmental Design) Gold
certification from the U.S. Green Building
Council and is among the most sustainable
museums in Texas.
“From the day we open our doors, the Do-
Seum will be one of the most beautiful, ex-
citing and interactive children’s museums in
the entire United States,” said Vanessa Lacoss
Hurd, chief executive director the DoSeum.
“It will be a place where children tap their
inner creativity and curiosity, and where sci-
ence, math, technology and art become a
playground for their minds and bodies. Our
hope is that the DoSeum will spark a gen-
uine zeal for learning that they will take with
them through childhood and beyond.”
When planning the design of the building,
The DoSeumSan Antonio’s new children’s museum hopes to spark a love of learning Special to San Antonio Medicine
Courtesy photos - The DoSeum
visit us at www.bcms.org 25
LIFESTYLE
one important detail was making sure the
space would be accessible to children from
all backgrounds. The entire museum is
ADA-accessible. Spanish-language signage
and graphics are placed throughout the
space, and museum-goers will have the op-
tion to interact with exhibits in their pre-
ferred language. Additionally, the DoSeum
will roll out new programs and partnerships
in an effort to reach children in every corner
of the community.
In fall 2015, the Little Doers program will
welcome its first class of preschool-age chil-
dren. The weekly program was inspired by
San Antonio’s commitment to quality early
childhood education, and it will offer a play-
based, rich learning environment specifically
targeted to each child’s age and development.
These initiatives are just the start of what the
DoSeum plans to contribute to the city’s goal
of achieving a globally competitive workforce.
The DoSeum will serve as an inclusive
community partner, making its extensive ed-
ucational resources available to local educa-
tors. As a trusted resource for schools, the
museum will offer professional development
resources, provide a learning space to gather,
and share educational resources for teachers
to turn ideas into action, inside and outside
of the classroom.
RENTAL SPACE AVAILABLEIn addition to being a space for learning,
the DoSeum is equipped with charming
rental space available for social and profes-
sional events. Proceeds from facility rentals
will directly benefit the museum and its ed-
ucational programming for the community.
“Children’s museums can be powerful
players in a community’s learning land-
scape,” said Laura Huerta Migus, executive
director of the Association of Children’s Mu-
seums. “They are unique in their ability to
convene stakeholders from all sectors who are
interested and invested in the success and
well-being of children and families.”
“The DoSeum will certainly confirm San
Antonio’s place in the global network of cities
striving to create civic environments for
healthy children, empowered parents and vi-
brant workforces,” she added.
The DoSeum is expected to attract more
than 400,000 visitors annually to experience
its innovative approach to education, and is
another influential addition to the cultural
corridor along Broadway that includes the
Pearl Brewery complex, Witte Museum,
Brackenridge Park, San Antonio Botanical
Garden, San Antonio Zoo, San Antonio Mu-
seum of Art and McNay Art Museum.
For more information, please visit The-
DoSeum.org.
26 San Antonio Medicine • June 2015
UTHSCSADEAN’S MESSAGE
The University of Texas School of Medicine and UniversityHealth System (UHS) are collaboratively developing a comprehen-sive Heart Vascular Institute (HVI) that will be a premier modelfor the care of patients with cardiovascular-related disease. Theleadership teams from both institutions are focused on evolving thecardiovascular service line toward a care delivery model that we be-lieve will become the norm in the future. The opening of the new UHS Sky Tower was a major milestone
in many areas. First, it supports the population growth in San An-tonio and the ability to further develop our healthcare delivery sys-tem. Additionally, the Sky Tower also will be the site of our HVI,which will carry multi-disciplinary collaborative care for heart dis-ease to an unprecedented level for our region. According to JohnCalhoon, MD, CT Surgery Chair and HVI Director, the HVI fa-cility’s design answers the question, “How can we absolutely be thebest place for any heart patient?” The HVI will combine the specialties and skillsets that are re-
quired for the care of cardiovascular patients. These include themany cardiology subspecialties (invasive, non-invasive, electrophys-iology, etc.) as well as cardiothoracic and vascular surgery, anesthe-siology, cardiac rehabilitation, imaging, plus the many otherdiagnostic services, clinical staff and advanced practice providers in-
volved in cardiac care. The HVI will bring them all together to offera streamlined and seamless inpatient and outpatient solution. His-torically, these specialties and subspecialties have worked semi-in-dependently, interacting and consulting with one another in thecare of patients, but not working as an integrated team. In this newfacility, all cardiovascular and related services will be structured andfunction as one, to continually improve the patient experience andtheir outcomes.
CONTIGUOUS PHYSICAL SPACEChief of the Division of Cardiology, Steven Bailey, MD, who has
been deeply involved in the planning process, characterizes it as anextension and expansion of what we have been doing for the past20 years. Cardiology has worked very closely with the surgical spe-cialists for a long time, but they have never had a contiguous phys-ical space. Dr. Bailey says he expects to see best-in-class outcomesin an environment that lowers costs on what he calls “a global scale.”He also points out we will be the first in the region to do this in acompletely comprehensive manner, in a single facility for inpatientand outpatient care. Dr. Calhoon points out that the HVI will care for children as
well as adults, calling it a “one-stop shop for cardiac care, for life.”
HEART VASCULAR INSTITUTE:A premier partnership in a premier facility
By Francisco González-Scarano, MD
The UniversityHealth System SkyTower will be the siteof the Heart VascularInstitute, which willoffer multi-discipli-nary collaborativecare for heart disease.Courtesy photo
visit us at www.bcms.org 27visit us at www.bcms.org 27
UTHSCSADEAN’S MESSAGE
Dr. Calhoon, who performs delicate congenital repair proceduresas well as bypass surgery and valve replacements on patients of allages, points out that the focus here is on the entire team and part-nering in new ways that are better for the patient. The improved
outcomes and efficiencies also will be better for the payors and em-ployers. We have already organized along these lines with the UTMedicine HVI clinic located in the MARC, creating a unique col-laboration of cardiology, cardiac surgery and comprehensive cardiacdiagnostic services in partnership with UHS.Edward Y. Sako, MD, PhD, who is Vice Chairman, CT Sur-
gery, and Chief of Adult Cardiac Surgery, reiterates Dr. Bailey’ssentiment: This arrangement formalizes something we have beendoing for quite some time at a high level of quality. A great ex-ample is the UT Medicine/UHS TAVR program (TranscatheterAortic Valve Replacement), where the cardiologists and cardiacsurgeons work side-by-side. Teams composed of cardiologists andCT surgeons provide multi-disciplinary approach in the initialevaluation, diagnostic and rehabilitation processes. They alsowork together in the hybrid cath lab/operating room located atUHS. The TAVR team was part of the pre-FDA approval processfor TAVR devices and procedures, performing the first case inCentral and South Texas in 2012.
EXPECTED OPENINGThe new HVI facility will occupy the first floor of the UHS Sky
Tower – approximately 47,000 square feet of space – housingcatheterization labs, non-invasive cardiology suites, imaging modal-ities, echocardiography and electrophysiology. The build-out willtake approximately two years, with the opening anticipated soonthereafter. This key piece of the HVI complements the newly fin-ished cardiac and vascular operating rooms and 60 new cardiovas-cular inpatient beds. Tim Brierty, University Hospital Chief Executive Officer, has
been involved in planning the HVI from its conception; he notesthat the power of this new operating structure is not just the day-to-day coordination of care, but the fully engaged approach of theproviders and the hospital. It is a true integration of all these dif-ferent services, with both organizations coordinated at a very deep,strategic level. The HVI will also work with “Variable Acuity Units,” a concept
that is evolving around a multipurpose hospital room, allowingproviders to bring a diverse array of care to the patient, instead oftransferring the patient to another unit or floor. The less you haveto move a patient — which takes more time, requires more stafftime and is more stressful — the better the patient experience.
Continued on page 28
28 San Antonio Medicine • June 2015
UTHSCSADEAN’S MESSAGE
Michael Little, MD, Director of Cardiothoracic and TransplantAnesthesiology and also a member of the planning committee, seesthis as the next step in the path for cardiac service lines. He pointsout that we now have eight cardiac anesthesiologists who have all
worked very closely in the catheterization laboratory and the operat-ing room with all the cardiologists, surgeons, perfusion specialistsand other technicians. The team has established firm relationshipsamong their members, which translates into better communicationand trust. This effort serves as a template for the School of Medicine and UHS
in partnership by realigning patient care and clinical services from themore traditional departmental lines to focus on the needs of our sharedpatients. It is the right vision for our shared future. The new structureswill better support patient outcomes in a comprehensive, multi-disci-plinary manner, as opposed to focusing on supporting individual med-ical specialty services.
PHILANTHROPIC FUNDINGAn important part of this strategy will be tracking and reporting
outcomes, quality and cost. This is something we have done in manyof the service lines, but this new group gives us the opportunity to seea broader perspective that will be crucial to growing and improving
the quality of our care.With an estimated cost of $45 million for building out the new fa-
cility, only a portion will come from UHS. The remainder will haveto be raised philanthropically. As a member of the University Health
System Foundation Board, Dr. Calhoon and other board members willbe reaching out to community leaders and others to help complete thefunding for the new facility.This new, comprehensive Heart and Vascular Institute facility has
the potential to truly be one of the best in the country for anyone, ofany age suffering from a congenital heart ailment or heart disease ofany type. Programs such this are the future of healthcare and an im-portant part of the solution for dealing with the increase in heart dis-ease in San Antonio and South Texas, as well as across the country.The School of Medicine at the UT Health Science Center is commit-ted to making this vision a reality.
Francisco González-Scarano, MD, is dean of theSchool of Medicine, vice president for medical affairs,professor of neurology, and the John P. Howe III, MD,Distinguished Chair in Health Policy at the Universityof Texas Health Science Center at San Antonio. Hisemail address is [email protected].
Continued from page 27
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30 San Antonio Medicine • June 2015
LEGAL EASE
Last month’s article discussed the issue of whether or not a
physician can be required to testify in a civil or criminal proceed-
ing. I hope I answered the question, even if it may not be the
one you wanted to hear. This month let’s move on and talk about
how much money, if any, you can get if and when you do testify.
QUESTION TWOHow much, if anything, can you charge if you testify? To
answer that we have to first decide if you have to testify because
you’re somehow involved with one of the parties (i.e., a medical
eyewitness of sorts) or whether you’ve got no relationship at all
with the parties or the case (i.e., when you’re asked to be an
expert).
Let’s assume you are somehow involved. Let’s assume that you
provided some care at some time to one of the litigants in the
case. To use the phrase from last month’s article, you’re a “medical
eyewitness” to some event and therefore can be compelled to tes-
tify just like any eyewitness. Things get tricky here. Technically,
any of the attorneys to the parties can have you served with a sub-
poena to testify and all you’ll get is the few dollars that comes at-
tached to each subpoena. It’s literally just a few dollars. Seriously.
But can you get more or is that all?
Texas Rule of Civil Procedure 176.7 provides that any person
who issues a subpoena must take reasonable steps to avoid im-
posing an expense on the person who must respond to the sub-
poena. It further states the court may require that a witness be
compensated for any undue hardship. What that means is up to
each judge to decide. The rule doesn’t expressly say you have to
pay the person for his time. It just says the person must be pro-
tected against any expenses incurred in complying with the sub-
poena. Some judges will be sympathetic to the argument that a
doctor who has to cancel all his Monday afternoon patients to
give testimony should be compensated for that lost income.
Other judges may feel a rich doctor can afford a few hours to tes-
tify, especially if the other side doesn’t have much money with
which to pay for the doctor’s time. There’s simply no clear answer
to whether you have the right to be paid for your time. There is,
however, a strategy you can use which will be discussed later in
this article.
Now, let’s assume you’re not involved as a “medical eyewitness”
but are just being asked to serve as an expert. As discussed pre-
viously, you don’t have to do this. It’s entirely your choice. But
if you do, how much can you charge?
The short answer is as much as you want – as much as the mar-
ket will bear. In other words, as much as the other side is willing
to pay that you’re willing to accept for your time. There are no
laws, rules or regulations which say how much. It’s up to you.
Now, that said, let me at least give you some guidelines based on
almost four decades of experience.
Experts in any field aren’t impossible to find. They even ad-
vertise in many legal publications, on the Internet, in blogs, etc.
So, if you want to be an expert and earn some extra dollars, be
aware that you can price yourself out of the market. You’re not
irreplaceable. Plus, when an expert charges too much per hour,
‘Do I have to?’ and ‘How much?’Part II of IIBy George F. “Rick” Evans
LEGAL EASE
the expert’s credibility is placed in jeopardy because he starts to
look like a paid gun for hire who’ll say anything if the price is
right. Jurors don’t expect you to lose time from your practice for
free, but they may question your objectivity if by testifying you’re
raking in two or three times what you earn caring for patients.
Many attorneys won’t hire such experts; not because they can’t
afford it, but because they know they won’t be credible. So, here
are some guidelines.
I’ve found that many doctors charge about $250 to $350 per
hour. That’s just an average based on experience. The rarer and
more specialized the physician, the higher the rate goes. A neu-
rosurgeon may charge three times that amount and, in some
cases, even as much as $1,000 per hour. And some family prac-
tice doctors may charge only $100 or $150 per hour. But, having
hired and having deposed hundreds of doctors over the years,
throughout the entire country, I can tell you that probably 75
percent of them charge somewhere between $200 and $500 per
hour. Unless you’re from a relatively rare specialty, charging a lot
more than $500 will be a little difficult. There is, however, one
small refinement to these general observations as discussed below.
Although there are plenty of exceptions to this rule, I’ve found
that, on balance, physicians testifying for the plaintiff tend to
charge a tad more than those testifying for the defense. Yes, there
are plenty of exceptions, but I’m talking about a general rule.
Maybe it’s because they think they can afford it. Maybe it’s be-
cause they think they’re going out on a limb by testifying for the
plaintiffs. The difference may not be great but I have found a
difference. Perhaps something in the neighborhood of $100 or
even $200 more per hour. By no means is this always the case,
but it’s happened with enough frequency that I feel confident it’s
a legitimate observation worth sharing with you.
PRACTICAL STRATEGIESNo attorney wants to have a witness testify if that witness is
mad at them. An uncooperative, recalcitrant witness can easily
harm a case, whereas a contented, happy witness wanting to
help can make all the difference in the world. OK, that’s not
rocket science, right? But that’s how you can sometimes make
sure you get paid even when you may not have a clear right to
payment even though Rule 176 requires you be protected
against “expense.” Here’s how to do it.
The next time you receive a subpoena or get a call from an at-
torney asking you to testify, ask yourself if somehow you’re in-
volved with one of the parties to the case. If you are, you may be
a medical “eyewitness” and therefore forced to testify without pay.
But, here’s what you can do.
Option one: call your medical malpractice insurer, tell them
you’ve received a subpoena or a demand to testify regarding one
of your patients. They’ll usually be happy to have one of their
local defense attorneys handle it for you. Ask for the name of the
attorney they’re assigning to you, call him, and tell him one of
two things. One is that you don’t want to testify at all and want
to avoid it if legally possible. Or, two, that you’re willing to testify
but you want to be paid for your time.
If you don’t want to testify at all, you can work with your at-
torney to outline all the things that you might truthfully say
that could actually harm the attorney’s case. If the list is im-
pressive enough, the attorney requesting your testimony may
well back off when he hears all the downsides to your testimony.
Who wants a witness who hurts them? If your testimony looks
like it may damage the case, the attorney almost assuredly will
drop the subpoena.
Or, if you are willing to testify but want compensation, your
attorney can argue Rule 176. Plus, while trying to convince the
other side that Rule 176 requires you be paid for your lost in-
come, your attorney can further remind opposing counsel that a
happy, contented witness will be much easier to work with than
one who is hostile. Paid witnesses are happy. Unpaid witnesses
aren’t. If your rate is reasonable, the other side will typically
agree. If not, you may get a judge who understands the economic
burden to you and require the other side to pay for your time.
Option two: If you don’t want to use an attorney, there’s no
reason you can’t do it yourself or have your office manager make
the same arguments as outlined above. I just think having a
skilled professional do it for you works better, and your med-mal
carrier will usually provide one to you free of charge.
Let me close with a few practical pointers on this subject. Rule 176 also requires that an attorney issuing a subpoena
protect the witness against other burdens apart from expense.
It specifically provides the witness must be provided “an ade-
quate time for compliance.” If you receive a subpoena on late
visit us at www.bcms.org 31visit us at www.bcms.org 31
Continued on page 32
32 San Antonio Medicine • June 2015
LEGAL EASE
Friday afternoon to testify first thing Monday morning, you
can argue this is unreasonable and that you require more ad-
vance notice. A judge will likely cut you some slack. Not nec-
essarily weeks of time, but most judges will try to work with
your schedule so it won’t wreak havoc with it, especially if you
paint it in terms of what it does to your patients rather than
how it inconveniences you.
When the other side has agreed to pay for your time and you’ve
agreed upon a rate, you may want to ask to be paid in advance
rather than after the fact. This is particularly true when dealing
with attorneys you don’t know and haven’t worked with before.
And for law firms that aren’t known to you to be well established
and respected. And for lawyers outside of Texas and, frankly, out-
side your own community. Ask for a retainer that you will keep
like a landlord keeps the first month’s deposit. You’ll still bill
hourly and, at the very end of your services, you’ll bill from the
retainer and refund the balance.
Some doctors working as experts will bill at different rates de-
pending on what they’re doing. Not uncommonly, I’ve heard ex-
perts bill at one rate for reviewing medical records and writing a
report, a slightly higher rate for testifying in deposition, and third,
even higher rate, for testifying at trial. Because your hourly rate
should be a replacement for the income you lost caring for pa-
tients, this stair-step system of rates doesn’t make sense to some
juries. Your lost income should be the same regardless of whether
you’re setting time aside to review records or to give a deposition.
Yet, this happens with enough frequency that you can do it, if
you want, without much problem.
Some witnesses working as experts like to charge a flat rate for
certain events such as giving a deposition or coming to a trial.
This rate is fixed regardless of how much time is required. For
example, you may decide to charge $3,000 for a deposition
whether it takes two hours or 8 hours. The rationale is that, be-
cause you don’t know how long the event may take, you have to
set aside an entire morning, afternoon, or the full day. If it only
takes one hour and you cancelled all afternoon appointments,
you might lose money on the deal. There’s no hard and fast rule
here. You might charge hourly with the condition that it be no
less than “X” amount. Again, the choice is yours and is subject
only to the limits of the market place and your imagination.
The “other side” is entitled to know how much you charge,
how much you’ve been paid, and what other financial arrange-
ments you have with any party that has retained your services.
If it’s unusually high, or the income you generate working as
an expert is substantial when evaluated over the course of time,
expect some harsh cross examination. The other side will chal-
lenge you as a paid gun for hire rather than a disinterested, ob-
jective expert witness.
You can’t charge based on the outcome of a case. Don’t even
go there. And your rates can’t vary depending on the outcome
of the case. Again someplace you shouldn’t go.
So, that’s your primer on whether you have to testify and, if
you do, can you require payment for your time and how much
you probably can fairly charge. The rules aren’t crystal clear,
carved in stone, and easy to apply. But this should give you a
good sense of what you can and can’t do.
George F. “Rick” Evans Jr., is the founding partner of
Evans, Rowe & Holbrook. A graduate of Marshall Col-
lege of Law, his practice for 36 years has been exclusively
dedicated to the representation of physicians and other
healthcare providers. Mr. Evans is the BCMS general counsel.
Continued from page 31
visit us at www.bcms.org 33
34 San Antonio Medicine • June 2015
BUSINESS OFMEDICINE
Ten thousand a day. My baby-boom generation is turning age 65
and enrolling in Medicare at the rate of 10,000 a day. My parents’
World War II generation is dying at the rate of 1,000 a day. That’s
a 10-to-1 increase in new Medicare beneficiaries. Actually, I’ve only
got a little silver on the sideburns — mostly I think I’m losing my
hair at the rate of 10,000 strands a day.
And what is the cost of this great silver-haired tsunami? And why
does it seem so unnoticeable right now? To address the latter first, no
tsunami is noticeable as long as it’s out in the open ocean, or general
population. It seems like just a slight rise and fall of the ocean level as
it passes by. But, when it reaches the shallows near land, it rears up in
its devastating force. Such are the baby boomers. We hardly notice
their cost, until they hit the Medicare and Social Security rolls. Then
their cost begins to show in enormous economic terms.
ADD IT ALL UPSo how much are we talking about? The answer: five times the
current national debt. That’s right. The national debt (when you
count all of it), is about $21.7 trillion. The present value of our fu-
ture Medicare obligations at current benefit rates is $46 trillion
(that’s twice the national debt), and the present value of our Social
Security benefits at current benefit rates is $64.3 trillion (another
three-times the national debt). So add them together, and they total
five-times the national debt. If you add a few other obligations, like
federal employee and Veterans Administration retirement and
health benefits, all 50 state Medicaid and employee pension, health-
Costly reflections inthe ‘Silver Tsunami’By Dana A. Forgione, PhD, CPA, CMA, CFE
visit us at www.bcms.org 35
BUSINESS OFMEDICINE
care and other post-retirement benefit obligations, as well as the
cost of renovating our 50- to 100-plus-year-old infrastructure
(roads, bridges, levees, dams, water, sewer, rail, schools, aviation,
transit, etc.), it all adds up to $156.2 trillion. Or, to put it in terms
even I can understand, that’s almost twice the entire wealth of every-
one in the United States, and works out to $1.3 million per house-
hold. Yes, if we were to confiscate all of the wealth of the entire
country — from Bill Gates, Warren Buffet, George Soros, the Rock-
efeller Foundation, the Bill and Melinda Gates Foundation, all the
hospital and university endowment funds, your wealth, mine…
everyone’s wealth in the entire country — we could meet just a little
more than half of these obligations. The entire wealth of the United
States is $81.5 trillion. Our obligations are $156.2 trillion.
Thirty percent of the population is moving out of the worker col-
umn and into the retiree column by 2030. This silver tsunami will
swamp our current healthcare provider capacity — especially since
many of the providers are in the same baby-boom generation and
also will be retiring along with the rest of us. No matter how steeply
we cut healthcare payment rates, the total cost will continue to es-
calate with the aging population.
AN EYE-OPENERFor years, the trustees of the Medicare and Social Security Trust
Funds have called for a 25 percent cut in benefits. You have experi-
enced the 2 percent Medicare sequestration of your payments. Can
you imagine if that went up to a 25 percent sequestration? You
would lose a quarter of your Medicare collections. Your patients
might self-pay the difference, but only those who were able to afford
it. You’ll either have to find significantly lower-cost ways to deliver
health services, or major new sources of income, or both. I know
this is not all news — but maybe the dollar amounts are a bit of an
eye-opener.
At the start of the Medicare program, we had eight workers per
retiree to support the entitlement programs. Today we are down to
about five workers per retiree. By 2030, we will be down to just 2.3
workers per retiree. That is, our kids will have less than half the col-
lective earning power we have right now, when we cannot meet
these obligations. And they will have only a quarter of the relative,
collective earning power that existed at the time these programs
were started. I tell my students, every two of you will be supporting
each one of us in our nursing homes. And they frankly won’t have
the money to pay for it. Not unless we come up with incredible
new sources of wealth.
I had high hopes the shale oil might be a source of wealth that
could make a serious difference. But our competitors have not just
sat idly by as we raised our oil production. As I’m sure you’ve read
in the news, they’ve kept up production to drive oil prices down,
to nip our fledgling oil boom in the bud. So while the shale oil de-
velopment has been the main driver of economic recovery for us,
I’m not sure oil is going to be the panacea I had hoped. As I ask
folks when I speak at conferences, can you think of any other source
of wealth that could come anywhere near $150 trillion? Not even
oil produces that much. The high-tech sector? Maybe, but the rest
of the world is getting amazingly sophisticated in high-tech inno-
vations, too.
LOOK AT SOUTH KOREABy the way, South Korea has an amazing electronic healthcare
payment system. As the physician treats a patient, they log onto a
web portal and enter all the salient information. It goes straight to
one main computer system where every claim is reviewed by an ar-
tificial intelligence (AI) system. After the AI review, 800,000 live
claims reviewers give a 100 percent claims review, and payments are
sent out in just 15 days. That’s right — they do 100 percent claims
review on 2 billion claims a year, and pay in just 15 days. How’s
that for high-tech efficiency? In contrast, we waste $200 billion a
year in the United States just on inefficiencies in the administration
of our healthcare system. I had the privilege of visiting the South
Korean command headquarters for their healthcare payment sys-
tem. It looks like something right off the bridge of the Enterprise
on Star Trek (only baby-boomers will appreciate that). They fend
off 3,000 hacker attacks a day. And their system is so sophisticated
they can immediately trace each attack directly back to its originat-
ing computer IP address. Most come from North Korea. Their sys-
tem is so good, they actually package it and sell it to other countries.
We could learn a few high-tech lessons from the South Koreans.
So will our energy or technology sectors save us? I don’t know.
What I do know is, it’s my generation, and I see a costly reflection
in that silver tsunami.
Dana A. Forgione, PhD, CPA, CMA, CFE, is the
Janey S. Briscoe Endowed Chair in the Business of Health
at the University of Texas at San Antonio. He is also an
adjunct professor in the School of Medicine, Department
of Cardiothoracic Surgery, the Department of Pediatrics,
and in the School of Public Health, all at the University of Texas.
36 San Antonio Medicine • June 2015
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visit us at www.bcms.org 39
The headline said, “‘Resistant’ by Michael Palmer, his last and 20th novel.” After surf-
ing the Internet, I realized that Michael Palmer, MD, died the year before last, at the
age of 71. Memories from the 1980s and ‘90s flooded my brain. My bedtime reading
materials, in those days, often were Palmer’s books. This prompted me to look up the
previous 19 books that he wrote and put them all on my reading list, as a tribute to his
memory. The San Antonio Public Library stocks 18 of them. I was not able to locate a
copy of “On Call: Original Short Story.”
Talk about can’t put a book down: Over the course of three months, book after book,
thriller after thriller, I read and, in some cases, re-read, all 18 books. What a roller-coaster
ride, absolutely thrilling and entertaining. Palmer’s first novel was “The Sisterhood,”
published in 1982. In his early career, Palmer published one novel every three years. He
then became quite prolific, publishing a novel every two years and later almost one a
year. As I read, I also noticed that the price of a paperback went from $5.99 in the 1980s
and early ‘90s to $9.99 currently. The backbone of all his novels is associated with med-
icine or occurring in a medical environment, which I can’t get enough of, even though
I have been spending most of my waking hours in a hospital environment for more than
30 years.
It is “Flashback,” the third novel Palmer published in 1988, that I like the best. It was
written with sincerity and passion. The story is believable, even after all these years, unlike
some of his later novels which seem too far-fetched and so cookie-cutter, on top of having
a political tilt to some of the events told in the stories. The plot can be summarized as
corporate versus community medicine, sibling rivalry, a pair of pathological liars (father
and son), and evildoers, mixed with a dose of romance. At the end, the community band-
ing together won over the corporation. The unfolding of the conspiracy began when a
young boy continued to suffer flashbacks related to his surgery, months after a “routine”
operation for hernia. The new doctor in town took an interest in the boy’s case (and the
boy’s mother), and subsequently uncovered a whole string of suspicious incidents linking
a successful surgeon and the anesthesiologist he always worked with. Twist after twist,
this book will keep you up even though you have a real hospital to go to in the morning.
By the way, if you are going to check out the author’s books, don’t make the mistake
I made. I checked out “The Thread” by a Michael Palmer and trust me, a thriller, it is
not. This Michael Palmer is a poet and, as far as I know, is alive and well. There is also
a Michael. A. Palmer, who authors naval histories, in case you come upon this name
during your search.
Teresa C. Hayes, MD, is a pediatric pathologist in San Antonio and a
BCMS member.
BOOK REVIEW
‘Flashback’Written by Michael PalmerReviewed by Teresa C. Hayes, MD
40 San Antonio Medicine • June 2015
Gunn Acura11911 IH-10 West
Cavender Audi15447 IH-10 West
Cavender Buick17811 San Pedro Ave.(281 N @ Loop 1604)
Batchelor Cadillac11001 IH-10 at Huebner
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Northside Ford12300 San Pedro Ave.
Cavender GMC17811 San Pedro Ave.
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12150 IH-10 West
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*North Park
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Mercedes-Benzof Boerne
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*Mini Cooper
The BMW Center8434 Airport Blvd.
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Ingram Park Nissan7000 NW Loop 410
Ancira Ram10807 IH-10 West
Ingram Park Auto Center7000 NW Loop 410
North Park Subaru9807 San Pedro Ave.
Cavender Toyota5730 NW Loop 410
*Ancira Volkswagen5125 Bandera Rd.
visit us at www.bcms.org 43
If you’re like most car buyers in the UnitedStates, you’ve never heard of the Ford Kuga.The Kuga is an important vehicle, though,not for what it is but for what it became.First, a little background. When Alan Mu-
lally, perhaps the most consequential Amer-ican automotive executive of the last 25years, took the reins at the Ford Motor Co.in 2006, he instituted his now-famous OneFord plan. The essence of One Ford is thatinstead of building different vehicles aroundthe world for the same market segment, onevehicle should be built, whenever possible.Like a lot of things, it was easy to say buthard to do. Mulally did it before his retire-ment from the company in 2014.Enter the Ford Kuga. While Ford sold the
Escape compact SUV in North America, itsold a similarly sized Kuga compact SUV inEurope. They were two very different vehi-cles, which ultimately were designed to ap-peal to the same customers. A new Kugalaunched in Europe in 2008, and when theEscape was due for replacement in 2012,One Ford meant that the Kuga would be
sold in North America as the Escape.
FRESH, NEW LOOKHow did that go? In a word, well. In 2007,
a strong sales year in the United States, Fordsold about 166,000 Escapes. After rebadgingthe European Kuga as the new Escape, Fordmoved an astounding 296,000 units in2013, a comparable sales year. Ford has donethe same thing with the Fusion, Focus andFiesta with similar results. And this year,we’re seeing a new full-size van, the Transit,replacing the venerable E-series. Is nothingimpossible with One Ford? Umm, yes. Therewill be no “One Ford-ing” the F-150 pickup,which will stay purely American and will notbe changed to make it more attractive inFrance, or Thailand, or Brazil, or anywhere.Anyway, back to the Kuga/new Escape,
which looks much more modern than theold Escape. It’s a testament to how dreary theprevious Escape looked that its Kuga succes-sor appeared remarkably fresh and new whenit debuted in 2012 even though it was al-ready four years old. And it still looks good
today, with an angular and aerodynamic de-sign that seems like it might have inspired theultra-cool Range Rover Evoque.The interior of the Escape is standard issue
Mulally-era Ford, with good materials andclear attention to detail combined with asharply modern vibe. The use of black orgray as the predominant color along with anabundance of metallic accents won’t appealto everyone, but the cabin of the Escape isnothing if not tasteful. And then there’s MyFord Touch, a touch screen-driven user in-terface that controls the audio, HVAC,phone and navigation systems. Yes, you canwork it with voice commands, but the screenis small so using that can be a distraction.You get used to it in time, but it could bemore user friendly. The term compact SUV means that the
Escape is not big, and that fact is reflected inthe interior, which is roomy enough to seatfour comfortably with space for your gearunder the rear hatch. But asking three peopleto share the back seat will not result in hap-piness for those three passengers, and it’s
AUTO REVIEW
44 San Antonio Medicine • June 2015
Ford Escape traces lineage to Kuga By Steve Schutz, MD
worth noting that there’s only 34.3 cubic feetof storage space behind the rear seats (68.1 ifyou fold down those seats). For the record,that’s comparable to its main competitors,the Honda CRV and Toyota RAV-4.A six-speed automatic transmission and
front-wheel drive come standard, and all Es-capes except the S can be had with all-wheeldrive (AWD). The base engine is a normallyaspirated 2.5-liter four-cylinder with 168 HPand respectable fuel efficiency (22 mpgcity/31 highway). The SE and Titaniumcome standard with an EcoBoost — in Ford-speak, that means the engine has turbocharg-ing and direct injection — 1.6-liter engine
good for 178 HP and 23 mpg city/32 high-way. Optional on the SE and Titanium Es-capes is the best engine, a 2.0-literfour-cylinder EcoBoost motor that pumpsout 240 HP but still gets 22 mpg city/30highway.
HANDS-FREE HATCHPricing ranges from just over $22,000 for
a stripped model that no one but a labcourier would ever drive to over $35,000 fora loaded Titanium version. We don’t havespace here to delineate the various trim pack-ages and options available on the Escape, butas always, BCMS Auto Program director Phil
Hornbeak can fill you in on those details.One notable option is the hands-free
hatch, which allows you to open the hatchby kicking your foot below the rear bumper.I thought it was gimmicky at first, but withtime I found myself using it frequently.Thank you, Ford.Mulally’s One Ford program makes a lot
of sense, but could easily have resulted in carsthat customers didn’t want. So far that hasn’thappened, and instead we’ve been treated tonice vehicles from other regions of the worldthat work fine here. Such is the case with theFord Escape, nee Kuga.
Steve Schutz, MD, is aboard-certified gastroenterol-ogist who lived in San Anto-nio in the 1990s when he wasstationed here in the U.S. Air
Force. He has been writing auto reviews for SanAntonio Medicine since 1995.For more information on the BCMS
Auto Program, call Phil Hornbeak at 301-4367 or visit www.bcms.org.
AUTO REVIEW
visit us at www.bcms.org 45
46 San Antonio Medicine • June 2015
HELP WANTEDBexar County Medical Societymembers for BCMS Communications/
Publications Committee. Should have
little or no experience, be willing to
brainstorm, eat supper at the BCMS
office once each month, and partici-
pate in free-wheeling, stimulating
discussions to produce the magazine
you’re reading at this moment.
For information, call Susan Merkner at
210-582-6399.