November Journal-web.qxp - Travis County Medical Society

TCMS journal
NOVEMBER/DECEMBER
2007
VOLUME 53 NUMBER 6
TRAVIS COUNTY MEDICAL SOCIETY
Christopher S. Chenault, MD
2007 Physician of the Year

Schwanqua Chapel, Germany. Photo by; Albert Gros, MD
2 November/December 2007 TCMS Journal

TCMS
TRAVIS COUNTY MEDICAL SOCIETY
Journal
Editor, Owen Winsett, MD
Managing Editor, Belinda Clare
On the Cover
Christopher S. Chenault, MD
2007 Physician of the Year
November/December 2007 VOLUME 53, NUMBER 6
Photo by Ron Mize
FEATURES AND ARTICLES
THE PRESIDENT’S MESSAGE
On Chance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
David C. Fleeger, MD
TRAVIS COUNTY MEDICAL SOCIETY
Year in Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Stephanie Triggs
Check out Physician
Search feature
on the website at
www.tcms.com
ON THE COVER
Christopher S. Chenault, MD: 2007 Physician of the Year . . . . . . . . . . . . . . .8
Merry Wheaton
TCM ALLIANCE
Literacy Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Wendy Kratzer
PRACTICE MANAGEMENT
Failure to Diagnose Tubo-ovarian Abscess . . . . . . . . . . . . . . . . . . . . . . . . . .13
TMLT Risk Management Department
DEPARTMENTS
In the News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Take 5: Type 1 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
COMMUNICATIONS COMMITTEE: Owen E. Winsett, MD, Chair; John R. Austin, MD; Thomas C. Blevins, MD; John J. Costanzi, MD; John J. Horan, MD;
Vivek Mahendru, MD; Frank G. Mazza, MD; William H. Munyon, MD; Robert O. Northway, III, MD; Audelio Rivera, MD; Douglas Rivera, MD;
Drew G. Sawyer, MD; James C. Sharp, Jr., MD; and Vani Vallabhaneni, MD
Publication Coordinator: Ron Mize
E-MAIL: mail@tcms.com
SECD #277180: Travis County Medical Society Journal (ISSN 1054-2507) is the official bi-monthly publication of the Travis County Medical Society and the Seventh District
of Texas. Periodicals Postage Paid at Austin, Texas. Subscription price $2.00 per year to members. Payment of annual membership dues entitles member to a subscription.
POSTMASTER: Send change of address notices to the Travis County Medical Society Journal; 4300 North Lamar Blvd.; Austin, Texas 78756.
CONTACT: 4300 N Lamar Blvd.; Austin, Texas 78756; Post Office Box 4679; Austin, Texas 78765. Telephone: 206-1245. Advertising rates and requirements available upon
request. Travis County Medical Society Journal assumes no responsibility for statements made by contributors. Advertising in the Travis County Medical Society Journal does
not imply approval or endorsement by the Travis County Medical Society.
MEMBERSHIP: 2,836
TCMS Journal November/December 2007 3

FROM THE PRESIDENT
On Chance
“chance favors only the prepared mind”
Louis Pasteur
David C. Fleeger, MD
President, Travis County Medical Society
As a lowly resident one of
my attending surgeons
would often admonish
me with the above quote.
Usually when I was not as
prepared for a surgery as I
should have been or did
not quickly recite the answers to his
questions during rounds. After six long
years of training they were eventually
able to beat everything into my thick
head and sent me out into the real world.
And I was ready. I knew everything I
needed to know. I could do anything
that needed doing. Or so I thought. I
was not in practice long before realizing
that rare things do happen, that the
unusual is not necessarily uncommon
and that you can do everything right
and still have things turn to feces (given
my specialty, I should know). Yet, with
time came experience, which when
combined with my previously gained
knowledge ultimately led to a state of
preparedness. Now when a unique challenge
comes along I can use my
knowledge, skills, and experience to
manage the situation or recognize the
need for the expertise of my colleagues
to help me. I have no doubt that my
fellow physicians have all had a similar
experience. We are comfortable in our
medical knowledge. We are good at
what we do. We are prepared.
But unfortunately, there is much more
to the practice of medicine in today’s
world. Rapidly changing socioeconomic,
political and demographic conditions
have put health care and our profession
squarely in the middle of a foreign environment
for which we were not trained
and in which we are uncomfortable with
our knowledge base, we question our
skills set and we feel unprepared.
Consequently we feel we are losing
power, respect, autonomy, and financial
security. We are not sure what we did to
deserve this. The frustration amongst
physicians is palpable. A recent survey by
Merritt Hawkins & Associates of physicians
ages 50-65 (the ages of almost half
of all physicians in the U.S.) showed
52% were less satisfied with medicine
and almost half plan to sharply cut or
abandon patient care within the next
three years.
So what do we do Well the first thing
we don’t do is try to predict what the
health care system will look like in five to
ten years and blindly follow the path that
we (or others) think will lead us there.
The variables are too numerous and
poorly understood to be able to accurately
predict what the final outcome
will be. Indeed, in his recent book The
Black Swan, Nassim Nicholas Taleb
suggests that in situations of this
complexity we know far less than we
think we do and models or predictions
are to be viewed with great skepticism.
He suggests the best way to deal with
these high impact, unpredictable and
often rare (i.e. black swan) situations is
to position oneself to benefit from any
number of possible outcomes. I therefore
will not attempt to predict what the
future holds for our profession other
than to say that significant change will
soon be upon us. Rather, I would
propose a strategy that will position us
well no matter what the final outcome.
As I have said before on these pages,
the patient-physician relationship must
always remain the touchstone of our
profession. Our patients have been
repetitively disappointed by the public
and private sectors when it comes to
their health care. We must be their advocates
within the system. To abandon our
patients for economic, lifestyle or other
self interests is to betray their trust and
relegates us to being mere technicians or
tradesman in a medical union. No
matter what the future brings, patient
centered care delivered with quality and
efficiency will put us in good stead.
Sadly, our future survival can not just
depend on medical expertise and altruistic
intentions. To position ourselves for
success in the future requires knowledge
of the political, business, and bureaucratic
environment in which we must
maneuver and ultimately excel.
Physicians must become as facile in the
language of business and bureaucracy as
we are with physiology and pharmacology.
On an individual physician
practice basis we will need to be able to
prove to insurance companies and the
government the quality and efficiency of
care we deliver to our patients. From a
political standpoint every physician will
need to advocate for patients and profession
on a local, state, and national level.
continued on page 5
4 November/December 2007 TCMS Journal

continued from page 4
These efforts will require an enormous
commitment of time and resources on our
part. A task, I dare say, not easily accomplished
alone. Luckily, there is help.
The family of medicine is ready to
help you prepare. Your TCMS, TMA,
specialty society, and AMA all provide
courses, literature, and advice that can
prepare you and your practice for the
opportunities ahead. TEXPAC, AMPAC
and specialty society PACs help to
advance our advocacy positions. The
opportunities provided are limitless.
And indeed, I consider what lies ahead
of us an opportunity - an opportunity to
prepare. And by preparing we can take
advantage of chance. The chance to
advance the health of our patients.
Travis County Medical Society
Blood and Tissue Center of Central Texas
invite you, your spouse or guest to attend the
Annual Business Meeting and
Physician of the Year
Honoring Christopher S. Chenault, MD
Tuesday, December 11, 2007
Austin Country Club
4408 Long Champ Dr.
6:30 pm — Reception 7:30 PM — Dinner
RSVP: 206-1249 or tcms@tcms.com
Sponsored in part by these Friends of the Society: American Express;
Austin Brokerage Company; Austin Radiological Association; Brookdale Senior Living;
Clinical Pathology Laboratories; Commercial Real Estate Solutions; Kenty, Yung, Ozias
& Associates, a financial advisory practice of Ameriprise Financial Services, Inc.; Laura M.
Stephens and Associates; Medical Service Bureau; SNB Bank of Austin; Texas Medical
Association Insurance Trust; and the Texas Medical Liability Trust.
Executive Board
David C. Fleeger, MD, President
Phillip C. Collins, MD, President Elect
Peggy M. Russell, DO, Immediate Past President
Charlotte H. Smith, MD, Secretary-Treasure
C. Mark Chassay, MD, Member At Large
Juan M. Guerrero, MD, Member At Large
Jerald A. Mankovsky, MD, Member At Large
Peter L. Miller, MD, Member At Large
J. Clark Race, MD, Member At Large
Brian S. Sayers, MD, Member At Large
Paula S. Oliver, MD Chair, Board of Ethics
Charlotte H. Smith, MD, Chair, Delegation
Michelle A. Berger, MD, Vice Chair, Delegation
Stephen S. Clark, MD, BTC Representative
Board of Ethics
William D. Caldwell, MD
R. Y. Declan Fleming, MD
Grace Grant-Jennings, MD
Clifford K. Moy, MD
Paula Oliver, MD, Chair
Adam J. Schneider, MD
Archie Dan Smith, MD
TMA Board of Trustees
C. Bruce Malone, MD, Chair
Delegates to AMA
Charles (Bill) Bailey, MD
C. Bruce Malone, MD
Clifford K. Moy, MD
Alternate Delegates to AMA
David C. Fleeger, MD
Charlotte H. Smith, MD
AMA Board of Trustees
Joseph P. Annis, MD
Delegates to TMA
Ira Bell, MD
Michelle A. Berger, MD**
Robert E. Blais, MD
C. Mark Chassay, MD
William J. Deaton, MD
E. Randy Eckert, MD
Lisa C. Ellis, MD
James M. Hicks, MD
Felix Hull, MD
Jeffrey M. Jekot, MD
Thomas D. Kirksey, MD
Robert W. Kincheloe, MD
Greg M. Kronberg, MD
Hillary Miller, MD
Hector E. Morales, MD
Patrick S. Pevoto, MD
Peggy M. Russell, DO
Dora L. Salazar, MD
Catherine L. Scholl, MD
Charlotte H. Smith, MD*
Eric S. Tiblier, MD
Emilio M. Torres, MD
Dennis E. Welch, MD
Robert P. Wills, MD
Guadalupe “Pete” Zamora, MD
* Chair
** Vice-Chair
Alternate Delegates to TMA
Sara Austin, MD
Michael L. Gutierrez, MD
Craig T. Berent, MD Michael L. Kasper, MD
Roberta M. Braun, MD Daniel J. Leeman, MD
Dawn C. Buckingham, MD Bruce A. Levy, MD, JD
Edward D. Buckingham, MD Carla F. Ortique, MD
Jane E. Braunstein, MD Stephen M. Norwood, MD
William D. Caldwell, MD Robina N. Poonawala, MD
Robert S. Crumb, MD Melinda Rainey, MD
James R. Eskew, MD Halsey M. Settle, III, MD
Nancy T. Foster, MD Sarah Smiley, DO
Leigh A. Fredholm, MD
Mary A. Gonzales, MD
TCMS Journal November/December 2007 5

YEAR IN REVIEW
Incoming President, David Fleeger, MD, accepts the gavel
from Peggy Russell, DO.
New members were welcomed to Travis County Medical Society at
Threadgill’s in August.
What a tremendous year it has been! TCMS has grown to
over 2,800 members and has gained recognition from peer
groups across the country as one of the most active medical
societies around.
This year TCMS offered its members over 35 educational,
networking, and social opportunities sponsored in part by
the Friends of the Society program. Physician members
mixed and mingled their way through the year at a number
of Austin landmarks.
General membership meeting at the
Bob Bullock Texas State History Museum.
In addition to social events, physicians learned the importance
of sound hiring practices, how to market and brand
their practice, and how to read financial indicators for a
successful business.
In June, Coach Akers spoke at the Project Access physician
appreciation reception held at City Hall.
Nancy Dickey, MD, past president of AMA spoke at the Women
in Medicine event in September.
6 November/December 2007 TCMS Journal

TCMS and TCMA members participated in First Tuesdays at the Capitol.
TCMS Foundation awarded scholarships to medical students.
Colleagues marched to the Texas Capitol on First Tuesdays
to bring a unified medical voice to the 2007 Legislature.
The Retired Physicians Organization continued to meet
monthly for lunch and informative presentations ranging
from meeting the caregiver challenge to the role of electric
generation by coal in Texas.
2007 was also a year of giving. TCMS physicians continued
to show their support and generosity to the Austin community
by presenting scholarships to medical students,
mentoring incoming medical residents, as well as volunteering
their time to see Project Access patients.
2008 promises to be another active year.
www.tcms.com
Everyone enjoyed a fun filled day in July at Commons Ford park.
Over 65 new residents attended June orientation.
Retired Physicians Organization monthly luncheon.
TCMS Journal November/December 2007 7

ON THE COVER
Christopher S. Chenault, MD
2007 Physician of the Year
Merry Wheaton
Freelance Writer
Being elected Physician of the Year by your
peers is a true honor, one Dr. Kit Chenault
was surprised to learn was being conferred
on him. It recognizes integrity, knowledge,
humility, compassion, and service to medicine
in Austin and beyond.
Dr. Kermit Fox, the 94-year-old
retired orthopedist who drew Chenault
to Austin, had plenty to say about his
former partner: “First, his ways in
medicine were conservative, not deviated
by the class or stature of the
patient with whom he dealt. Second,
his principles of treatment were as
consistent as they were persistent.
Third, his support for sound ethics and
good morals, though seldom
pronounced, stood clearly in
evidence...” That’s a ringing endorsement
and Dr. Fox wasn’t finished!
It means a lot to Dr. Chenault to be
recognized locally, because it was locally
that he served the medical community.
“It was more concrete than working with
the TMA and AMA and I wanted to
support the community here,” he says.
He served on many committees at Seton
and St. David’s, and even more at
Brackenridge, where he was chief of staff
in 1990. In 2004 he was president of
TCMS, which he calls “an active and
effective organization—not a good-oldboys’
group, but one that tries to include
all specialties in its activities. Back in the
50s, TCMS was instrumental in getting
the TMA to move to Austin and in
acquiring the land for its original office
building.”
Back in the 50s... Back when Kit
Chenault, the middle-child of an engineer
and a housewife, was a teenager in
the small rural community of Covina,
California, where he and his siblings grew
up on a 10-acre orange grove.
He remembers a childhood both idyllic
and marked by wartime: “We played
Dr. Chenault and his ‘55 Ford tractor.
endlessly outside, digging foxholes, and
building a tree house into which my older
brother would occasionally let me drive a
nail, and driving a 1927 Chevy truck
through the grove long before we had a
license.”He also remembers how searchlights
scanning the skies during blackouts
struck fear in his young heart. With no
family TV until he was in high school, he
listened to radio dramas like The Shadow
and was active in Scouts and Demolay. As
he grew, he worked on that old truck to
keep it running and helped his family
plant hundreds of trees. “I was a farmer
kid,” he says. Yet even before high school
he wanted to become a doctor.
He cites two influences on his career
choice: “I think one thing that interested
me in orthopedics was working on that
truck. My dad had a shop full of tools.”
Then at Pomona College he looked up to
David Green, “a hero type guy” two years
ahead of him who chose Baylor University
College of Medicine and then specialized
in orthopedics. Chenault decided to
follow his lead.
It was a good choice. As strong
influences at Baylor, he cites Dr. Ben
Cooper (neurology), Dr. Donald
Chapman (internal medicine and
cardiology) and Dr. McIntyre (pediatric
cardiology): “They were good
clinicians, thoughtful people who
knew their business, and good
teachers. Dr. Cooper was very thorough
in his exams and that rubs off
on you, and Dr. Chapman impressed
me by always sitting down to talk to
his patients on hospital rounds.”
While at Baylor, Chenault met
and married Sara Stinebaugh, a
Houston native and a UT graduate
working on a Master’s in Virology. They
moved to Torrance, California for his
one-year internship and a year of general
surgery at Harbor General. Then, with
Sara expecting their first child and the
draft looming large, they moved to Cass
Lake, Minnesota, where he spent two
years as a surgeon with the Indian Health
Service. He says that was a great experience,
with the opportunity to do a lot of
general medicine and orthopedics, and
quite a bit of obstetrics: “I delivered 200
babies in my career. Not many orthopedists
can say that.”
After that two-year detour, he did his
orthopedic residency at the University of
continued on page 9
8 November/December 2007 TCMS Journal

Front row l to r: Ed Remaley, Laura Chenault with her boys,
Alex and Matthew, brother Larry and son Christopher.
Back row l to r: Dr. Chenault, Alicia Remaley (daughter) with
Mackenzie, wife Sara holding Alaina Chenault, Michelle Crider
(step grand daughter), Laura Chenault (Chris’s wife), and
Andrew Crider (step grand son).
continued from page 8
Iowa Hospitals. Then, giving careful
thought to the future, he explored 25
practices. A professor at Iowa suggested
he look up Dr. Kermit Fox. He did and
from the beginning, it felt like a good fit.
Chenault joined Austin Bone and Joint
Clinic in 1971 and worked with the
group until he retired last December.
“My partners were a huge influence on
me. They were good surgeons and very
ethical people. I never heard any of them
utter a harsh word to each other in 35
years,” he says.
This supportive environment proved
especially important because orthopedics
matured enormously during Chenault’s
career. Orthopedists got a whole new tool
kit with a lot more tools in it, and new
tools meant new procedures like total hip
and knee replacements, rotator cuff
repairs, and new techniques for bunion
surgery, tendon surgery in the hand, and
anterior cruciate ligament replacement in
the knee. Chenault says he was the first
physician in Austin to use a cast brace and
one of the first, if not the first, to use an
external fixator. He notes that almost all
surgeries changed from the way he did
them in residency. Such change made
continuing education a necessity.
He attended professional meetings
regularly to get the most up-to-date information
and read a lot to follow the gurus
and their new techniques, and says the
partners also taught each other a lot:
“One would pick up a pearl and share it
with the rest of us.” They were as happy
with him and he was with them.
“He proved to be an easily
compliant and valuable partner,
fitting well the setting of our
group practice,” says Dr. Fox.
Dr. Don Greenway, another
longtime partner, concurs: “He
took on responsibilities no one
else in the practice wanted... for
example, planning our new office
space. He was the project
manager.” Greenway describes
Chenault as “a superb orthopedist,
very conservative in his
approach, who very much loved
teaching.”
Dr. Chenault estimates that
over the course of 15 to 20 years,
he worked with 75 to 80 residents in the
Central Texas Medical Foundation’s
Family Practice and Internal Medicine
programs. Some are still in town, he
reports happily: “That was the point of
the program: to train physicians and
encourage the best to stay.”
One who stayed is Steve Blair, MD,
now in family practice, who recalls
phoning Chenault during his orthopedics
rotation about a patient with a
dislocated finger: “He told me, ‘You can
take care of it. You know what to do.’ His
attitude was: ‘It’s not as mysterious as it
looks. You can see on the X-ray what you
have, so think it through.’ He gave us a
good grounding in analyzing a clinical
problem. And he was always very
respectful of what the patient wanted.”
For Dr. Chenault, practicing, teaching,
and serving the medical community
made a satisfying career. He especially
liked taking people out of wheelchairs
and, through hip or knee replacements,
enabling them to walk. He also enjoyed
fixing children’s broken arms. “They’d
come in crying, I’d give them a shot, set
the bone and six weeks later, they’d be all
healed up and I’d send them off saying,
‘Well, be a little careful, but we’ll never
see you again.’”
He says most physicians like medicine,
“which means most have two loves—medicine
and their family - and since medicine
is a priority given the importance of
patients’ needs, it can pull you away from
family activities.” He coped by having partners
that could cover for him, giving up
some of his interests like tennis and
hunting, and making the commitment to
be part of family activities. He helped Sara
run PTA meetings, went on nine band
trips, attended countless horse shows, and
spent most weekends involved in the children’s
activities, even grooming horses with
them when he was on call. He says, “If they
were going to have horses, we wanted them
to take care of them, so they had chores:
they watered them, fed them, and shoveled
out their stalls.” That confirms Dr. Fox’s
fifth observation about Chenault: “He
appeared comfortable living a lifestyle more
simple than glamorous.”
Now retired, Dr. Chenault still has a
few duties as past president of TCMS and
works part-time doing utilization review
in Worker’s Compensation cases. He still
Working on the farm
has horses, does some farming and enjoys
woodworking. He made a handsome
rocking-goat for his wife (who collects
goats) and his grandchildren to enjoy. He
sings bass in his church choir, is writing
about growing up when he did, and is
working on a history of graduate medical
education in Austin from its inception in
1931 until UTMB took it over.
“I see a fair amount of unhappiness in
practicing doctors, primarily concerning
financial issues,” he says. “Although that’s
important, I’d encourage them not to lose
sight of what they went into medicine
for: to take care of patients. And to enjoy
the green trees (Austin is a great place!)
and to develop some hobbies they can
pursue when they quit practicing.”
TCMS Journal November/December 2007 9

IN THE NEWS
Dr. Celia Neavel, a People’s
Community Clinic physician and
founder of the Center for Adolescent
Health, recently received the Ambassador
Award from St. Luke’s Episcopal Health
Charities in recognition of her leadership
and vision in creating health programs for
uninsured Central Texas youths.
CONGRATS
Ben Coopwood, MD was selected as the
2007 Austin Educator of the Year by the
UTMB School of Medicine Office of
Regional Medical Education. Nominated
by students and clerkship directors, the
award recipient is chosen on the basis of
exemplary student evaluations, time, and
commitment to the education of School
of Medicine students, and role-modeling
of the highest standards of personal and
professional behavior.
Disciplinary Report. Pursuant to the
bylaws of the Society and the disciplinary
procedures of the Texas Medical
Association, the following required report
is made to the membership of the Travis
County Medical Society. Upon recommendation
of the Board of Ethics, the
Executive Board has issued the sanction of
“Censure” to Peter Driscoll, MD effective
September 25, 2007. This Censure
consists of the Society’s official expression
of disapproval of the Respondent member
having left town on vacation without
having appropriate arrangements in place
for cosmetic surgical coverage of his postoperative
patients.
CENSURE
TCMS membership renewal
There’s still time to renew your membership
in one of the most active medical
societies in the country. Look for your
notice and pay before December 31 to
get that 2007 tax deduction. Also,
members who pay 2008 dues by
February 25 will be included in the 2008
TCMS Pictorial Directory. If you have
retired or have any questions regarding
your membership status, call Darla
Blasingame at 206-1221.
John Lee Wait III, MD passed away
October 7, 2007. Dr Wait grew up
on a ranch in the Almeda area of
Houston and as a cowboy at heart,
became known as the “Country Singing
Doctor,” with his guitar in hand, he
taught all who crossed his path.
John Lee Wait III, graduated from
Texas A&M in 1967 with a bachelor of
Science degree. He continued his
medical education at Stephen F. Austin
University with a master’s degree in
biology. Using both his science degrees,
he worked for a pharmaceutical
company and then taught science in the
Beaumont, Texas ISD.
Realizing his dream of becoming a
physician, he pressed on and attended
the internationally known medical
IN MEMORY
school at the University of Autonoma de
Guadalajara, Mexico from 1971-75,
graduating with a Medical Science
degree. Next, he began training as an
intern and resident where he served at
the College of Medicine and Dentistry
in New Jersey and then to Texas Tech
University’s Medical School in El Paso
where he specialized in family practice.
Dr. Wait’s Texas roots and a genuine
love for the Hill Country, brought him
to Austin where he practiced for nearly
25 years. He is survived by his beloved
wife, Linda Lee Wait.
10 November/December 2007 TCMS Journal

TCM ALLIANCE
Wendy Kratzer
President-Elect, Travis County Medical Alliance
Did you know
A typical middle-class child enters first grade
with approximately 1,000 hours of being read
to, while the corresponding child from a lowincome
family averages just 25 hours
(Neuman, Temple University, 1997).
A child from a low-income family enters
kindergarten with a listening vocabulary of
3,000 words, while a child of a middle-income
family enters with a listening vocabulary of
20,000 words. (Hart & Risley, 1995).
Vickie Blumhagen and her Literacy
Outreach volunteers are working to improve
these startling statistics by providing gently
used children’s books to the Rosewood
Zaragosa Clinic, the Alliance’s “adopted” clinic
through Capital Area Reach Out and Read
(CAROR). One of 25 Travis County community
and free clinics enrolled in this pediatric
literacy program, Rosewood Zaragosa serves
1,400 children age 5 and younger.
Literacy Outreach Committee
Reaches Hundreds of Children
Many of these kids do not have any
books at home. Each Monday or Thursday,
a committee member takes a supply of
used books to stock the clinic’s three
waiting rooms. Children are encouraged to
take home one of these free books. Also, at
each well-check visit, clinic doctors give
each patient a developmentally appropriate
book and advise the parents about the
importance of reading to their child, often
Reach Out and Read Gala
l to r: Beth O’Farrell, Debbie Canby, Patty Loose,
Holly Schneider, U.S. Rep. Lloyd Doggett, Vickie
Blumhagen, and Tiffany Martin
giving a “prescription” for reading. The
doctor also uses the book as a tool to
measure developmental growth. For
example, does the child know how to turn
pages Do they put the book in their
mouth Last year alone, the TCMA delivered
2,815 books or 24% of CAROR’s
total used book distribution, thanks to
book donations by Alliance members and
the dedication of our volunteers.
In the spring of 2007, the TCMA
awarded a $5,000 grant to support Capital
Area Reach Out and Read. Supported solely
by grants and book donations, the Reach
Out and Read office is located at 1604 Rio
Grande, Suite 100, Austin 78701. Do you
have books your family has outgrown that
are in good condition Call Mindy
Gomillion, Executive Director, or Pam
Sears, Outreach and Development
Coordinator at 495-9988 to donate them.
By doing so, you will be joining Vickie and
her committee in the campaign to improve
literacy in our community!
continued on page 12
Member Spotlight: Vicki Zagrodzky, “Warmhearted - Generous - Kind - Gracious”…
These are just a few words that describe Vicki Zagrodzky. Currently our Treasurer, Vicki
has brought her gentle, reasoned style of leadership to many roles, including Treasurer-
Elect, Co-Chair of Spring Brunch, and Bulk Mail Coordinator. When asked why she
joined the Alliance, Vicki says “a good friend invited me to a meeting and I won a door
prize - I was hooked! I was also extremely impressed with the kinds of programs that the
Medical Alliance supported, all of which were related to improving the health of the
people of our community”. Married to Jason, a cardiologist whose specialty is
Electrophysiology, Vicki is mom to Chloe (13), Claire (9), and Will (7). While being
mom is her main job right now, Vicki finds time to serve as chair of the Book Fair at her
daughter’s school, cooks meals at the Ronald McDonald House, and directs Vacation
Bible School at church. As if that isn’t enough, she also helps a Sudanese refugee, a
widowed mother of seven, with English literacy and shopping every week. Vicki holds a
degree in Biochemistry from Texas A&M. After marrying in Houston, she and Jason l to r: Will, Vicki, Chloe, Claire, and Jason
traveled to Boston for residency and then Dallas for fellowship. While Jason was in
training Vicki worked as a pharmaceutical sales representative for Eli Lilly and then went to medical school. She says that during medical
school, “I learned that pregnancy and anatomy lab were NOT a pleasant combination. I dropped out and happily became a stay at home
mom!” The family left Dallas for Austin after Jason’s fellowship and Vicki says, “We love it!” Vicki, the feeling’s mutual. Thanks so much
for lending your many talents to the Alliance and to our greater Austin community.
TCMS Journal November/December 2007 11

continued from page 11
Toast to Doctors Provides a Fantastic
Night Out
More than 100 Alliance members and guests
joined together on Saturday, October 13 to
give a “toast” of appreciation to our physicians.
Helen Gilbert and her committed
volunteers provided a fabulous evening of
delicious drinks, tasty hors d’oeuvres, and
grooving music in a beautiful location.
Many thanks to Helen and her committee!
Join Us
We have new members joining all the time and
we’d like to introduce you to several who
attended our September “Kick Off” meeting
at Ballet Austin. They are Heidi York, Amber
Szcyztowski, Meg Denner, Stacy Jones, and
Robin Hadden. We welcome them to the
Alliance and invite you to join us.
The alliance is available to physicians and
physicians’ spouses and is dedicated to
supporting public health and wellness in
Central Texas. We also serve as a support
system for the greater medical family by
providing fun events and Quality of Life
committees such as Book Review, Mah-Jongg,
Parents of Preschoolers, and Wine and Dine,
among others. Email Arden Harkins at
teamharkins@austin.rr.com for further information
about membership in this growing,
dynamic organization or call her at 306-0611.
A New Kind of Holiday Gift
Wondering what to send to referring practices
and colleagues for the holidays
Consider honoring them! Simply send the
names of up to three physicians to whom you
wish to send holiday thanks along with your
TCMA Fund Drive contribution of $100 or
more no later than December 1. Each
honoree will receive:
• notification, in a lovely holiday card, of the
donation made by you in his or her name
as a token of your appreciation.
• explanation of the many community projects
that the donation helps to support.
• recognition where other physicians can see
it at the annual Gala!
• acknowledgement at the Holiday Luncheon
(don’t forget the 12/1 deadline!).
• appreciation at the spring general meeting.
• listing in the Vital Signs newsletter this spring.
Interested Send your check, made out to
TCMA, to Pat Wallis at 203 Wallis Drive,
Austin 78746. Contact Pat at
pawallis@wallisenterprises.net or 329-9459
with questions.
Upcoming Alliance Events
December 7, 11:30: A TCMA classic, our
Annual Holiday Brunch at Westwood
Country Club, presented by chair Liz Seade
and her able committee. Send in your dues
so that you receive your invitation!
12 November/December 2007 TCMS Journal

PRACTICE MANAGEMENT
Failure to Diagnose,
Treat Tubo-ovarian Abscess
Texas Medical Liability Trust
Risk Management Department
Presentation and physician action
Approximately three weeks after an
uneventful labor and delivery, a 32-yearold
woman contacted her ob-gyn. She
complained of a fever of 102 degrees the
previous day, persistent bleeding, and
left lower quadrant pain.
The obstetrician ordered an ultrasound,
but the patient was not seen in
the office. The ultrasound was
completed that day, and the radiologist
called the ob-gyn’s practice later that day
to report a “somewhat amorphousappearing
soft tissue mass, hypervascular,
of uncertain significance but may represent
neoplasm.” The ob-gyn had a member of
his staff contact the patient and schedule
an office appointment.
The patient was seen five days later.
Upon examination, the physician
suspected a cystic mass. A pelvic CT scan
was ordered to check for a vascular or
ovarian mass, and the study was done
that day. Oral Augmentin and pain
medication were prescribed. A call to the
practice later that day from a pharmacy
reported that the patient had filled the
pain prescription but not the antibiotic
because it was too expensive. The radiologist
who interpreted the CT scan called
to report the study revealed a 4 cm mass
consistent with an inflammatory process.
The ob-gyn contacted the patient to
advise that he was adding a second antibiotic
and emphasized the importance of
filling and taking the antibiotics. The obgyn
called the patient the next day to
inquire about the patient and learned the
antibiotics had not been started because
she did not have the money. Medication
samples were offered but the patient never
picked them up.
Later the same day the patient came
to the local emergency department
complaining of left lower quadrant pain.
Her temperature was 102.4 degrees and
WBCs were 27,000. The on-call gynecologist
admitted the patient with a
diagnosis of tubo-ovarian abscess.
The next day, the defendant requested
a surgical consultation. The surgeon indicated
that the patient had a gynecologic
infection that may require laparoscopy,
but deferred to the ob-gyn’s discretion.
The following day the defendant
performed laparoscopic surgery. The
abscess was drained and cultured, and the
pelvis was irrigated and suctioned.
Postoperatively, the patient experienced
a drop in oxygen saturation.
Cultures returned were positive for
Group A Strep. An internal medicine
consult was requested, and that physician
felt the patient was suffering from
ARDS as a consequence of the pelvic
infection. The patient underwent emergent
hysterectomy, left oophorectomy,
and bilateral salpingectomy. Pathology
revealed a large central ovarian abscess
surrounding benign cysts, purulent
serosal exudates, and the adjacent
fallopian tube and soft tissue with acute
and chronic inflammation, edema,
organizing granulation tissue, hemorrhage
and adhesions. The right
fallopian tube showed acute inflammation,
stromal edema, hemorrhage and
purulent serosal exudates.
The patient’s subsequent postoperative
course was extremely stormy. She
reportedly went on to develop ischemic
changes on ECG with a possible
myocardial infarction. She was felt to
have had coronary artery spasm with
myocardial stunning. Subsequent
echocardiograms demonstrated improvement
in her left ventricular ejection
fraction, wall motion and mitral regurgitation.
She developed infarcts of her
kidney, spleen, and brain, with multiple
bilateral cortical infarcts in the parietal
regions and in the right occipital lobe.
The patient was eventually diagnosed
with antiphospholipid antibody
syndrome, required prolonged rehabilitation,
and continues with neurologic
sequelae. She continues to require assistance
with activities of daily living.
Allegations
A lawsuit was filed alleging that the obgyn
was negligent in his failure to
promptly see the patient in the office,
diagnose, and treat a tubo-ovarian
abscess. The subsequent perforation of
the abscess caused systemic sepsis and
multiple complications.
Legal implications
Negligence is defined as the failure to
exercise ordinary care, that is, failure to
do that which a physician of ordinary
prudence would have done under the
same or similar circumstances, or doing
that which a physician of ordinary
prudence would not have done under
the same or similar circumstances.
In this case, the plaintiff’s attorneys
retained qualified experts who
supported their claims that earlier
continued on page 14
TCMS Journal November/December 2007 13

continued from page 13
treatment with antibiotics and surgical
drainage of the abscess would have
avoided the complications of systemic
sepsis. Physician reviewers felt that the
patient should have been seen in the
office as soon as possible based on her
reported complaints of fever, abdominal
pain, and a mass reported on
sonogram. They concurred that it was
not reasonable to schedule an office
visit the following week, and felt the
patient should have been hospitalized
that day for treatment with IV antibiotics.
These reviewers opined that the
patient’s outcome would have been
significantly improved if she had been
hospitalized and treatment started on
the day she first reported complaints.
Defense consultants offered differing
opinions of the care given in this case.
One physician questioned the notes that
the patient was doing well postpartum,
suggesting the patient might be partially
responsible for her condition by failing
to report earlier symptoms and failing to
comply with physician recommendations.
Others were not supportive
indicating that a postpartum patient who
reports abdominal pain with fever
requires immediate evaluation. Another
consultant questioned the aggressiveness
of treatment in the first 24 hours of the
patient’s hospitalization.
Disposition
The case was settled before trial with the
consent of the defendant.
Risk management considerations
Hindsight offers an unfair advantage,
creating conjecture and opinion
regarding what “should have been
done.” Add to the scenario a patient who
is not fully compliant and the challenges
for timely care escalate. It is frustrating
to read that six days passed without the
benefit of antibiotics for the patient.
This physician and his staff checked on
this patient and reiterated the importance
of getting and taking the
antibiotics. In retrospect, proceeding
with admission after the sonogram
makes perfect sense.
Managing the noncompliant patient
creates additional work for the physician
and staff but, in the event of a bad
outcome, the scales measuring responsibility
tip toward the well-educated and
trained physician. The physician is seen
as the professional who understands the
patient’s condition and recommends
appropriate and timely care. Upon the
first contact from the patient with symptoms,
the physician ordered an
ultrasound. The study was done the
same day and the patient was compliant.
The patient kept her office
appointment five days later. Upon
discovery that antibiotics had not been
started, aggressive intervention and
management of the patient with
insistence on inpatient admission may
well have altered the outcome.
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
expert 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.
This closed claim study is based on an actual
malpractice claim from TMLT. This case illustrates
how action or inaction on the part of
physicians led to allegations of professional
liability, and how risk management techniques
may have either prevented the outcome or
increased the physician’s defensibility. The ultimate
goal in presenting this case is to help
physicians practice safe medicine. An attempt
has been made to make the material less easy to
identify. If you recognize your own claim, please
be assured it is presented solely to emphasize the
issues of the case.
© 2007 TMLT
14 November/December 2007
TCMS Journal

Type 1 Diabetes
TAKE FIVE
for your
HEALTH
Our bodies need fuel for proper function. Glucose (sugar) is the fuel that our cells
use to produce energy. In order to process the sugar we eat in various foods, our
bodies produce insulin. Insulin is a hormone made by beta cells, clusters of cells in
the pancreas (an organ located in the upper abdomen). In type 1 diabetes, the beta
cells in the pancreas are unable to make insulin because of autoimmune disease. This
means that the body’s immune system makes autoantibodies that attack and destroy
the pancreatic beta cells. Type 2 diabetes is the result of the body’s inability to properly
use the insulin made by the pancreas and almost always occurs in adults and
children who are overweight. Because type 1 diabetes usually starts in childhood, it
is sometimes called juvenile diabetes. Type 1 diabetes is a serious illness that cannot
be cured, but it can be treated and controlled.
Type 1 Diabetes
CHARACTERISTICS OF UNTREATED TYPE 1 DIABETES
• Thirst
• Frequent urination
• Weight loss
• Poor infant growth
• High blood glucose level
COMPLICATIONS OF TYPE 1 DIABETES
Diabetic ketoacidosis − a life-threatening medical condition, also known as
diabetic coma, caused by the body’s need to break down fats for energy instead of
using sugars.
• Kidney failure
• Diabetic retinopathy − damage to the retina of the eye
• Gastroparesis − the stomach does not empty properly, allowing partially
digested food to accumulate
• Diabetic neuropathy − loss of sensation and nerve control of
body functions
• Increased occurrence of infections
• Poor circulation, especially in the feet and legs
• Coronary heart disease
MANAGEMENT OF TYPE 1 DIABETES
Insulin injections or an insulin pump − oral medications do not work
• Diet
• Exercise
• Frequent checks of blood glucose levels
• Management of other medical problems including high blood pressure
and coronary heart disease
• Screening for and early recognition of diabetes complications
• Kidney dialysis or transplantation for kidney failure
For More Information
National Institute of Diabetes and
Digestive and Kidney Diseases
http://www.niddk.nih.gov
American Diabetes Association
http://www.diabetes.org
Make copies of this article to
share with your patients
TCMS Journal November/December 2007 15