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SOMBRERO

Pima County Medical Society
Home Medical Society of the 17th United States Surgeon General

DECEMBER 2013

Dr. Philip Fleishman: Peppermills and novels The safari of a lifetime

Managing under the new tax laws

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SOMBRERO – December 2013

SOMBRERO
Pima County Medical Society Officers
President Charles Katzenberg, MD President-Elect Timothy Marshall, MD Vice President Melissa Levine, MD Secretary-Treasurer Steve Cohen, MD Past-President Alan K. Rogers, MD

Official Publication of the Pima County Medical Society
Soheila Nouri, MD Jane M. Orient, MD Guruprasad Raju, MD Scott Weiss, MD Victor Sanders, MD (resident)

Vol. 46 No. 10

PCMS Board of Directors
Diana V. Benenati, MD R. Mark Blew, MD Neil Clements, MD Michael Connolly, DO Bruce Coull, MD   (UA College of Medicine) Stewart Dandorf, MS, MPH (student) Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD Jamie M. Fleming (student) Alton “Hank” Hallum, MD Evan Kligman, MD Melissa D. Levine, MD Clifford Martin, MD Kevin Moynahan, MD Editor Stuart Faxon Phone: 883-0408 E-mail: tjjackal@comcast.net Please do not submit PDFs as editorial copy. Art Director Alene Randklev, Commercial Printers, Inc. Phone: 623-4775 Fax: 622-8321 E-mail: alene@cptucson.com

Arizona Medical Association Officers
Thomas Rothe, MD   president Michael F. Hamant, MD   secretary

Members at Large
Richard Dale, MD Anant Pathak, MD

At Large ArMA Board

Ana Maria Lopez, MD R. Screven Farmer, MD

Board of Mediation
Bennet E. Davis, MD Thomas F. Griffin, MD Charles L. Krone, MD Edward J. Schwager, MD Eric B. Whitacre, MD

Pima Directors to ArMA Timothy C. Fagan, MD Charles Katzenberg, MD Delegates to AMA
William J. Mangold, MD Thomas H. Hicks, MD Gary Figge, MD (alternate)
SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright © 2013, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Executive Director Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com Advertising Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com

Printing Commercial Printers, Inc. Phone: 623-4775 E-mail: andy@cptucson.com Publisher Pima County Medical Society 5199 E. Farness Dr., Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website: pimamedicalsociety.org

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SOMBRERO – December 2013

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Inside
 5 Dr. Charles Katzenberg: As physicians, we’re where the healthcare ‘buck’ stops.  6 Letters: Dr. David Ruben says his kind of togetherness could help revitalize healthcare.  8 PCMS News: Thank you for supporting Clinica Amistad. 11 Financial Management: Wealth adviser Dr. John Stephens on dealing with the new tax laws. 13 In Memoriam: Dr. Daniel T. Mihalyi died in October. 15 Retirement: Dr. Philip Fleishman is as busy a woodworker and novelist as he was a plastic surgeon. 19 Makol’s Call: Dr. Makol has a ‘modest proposal’ for illegal immigration. 20 Bioethics: The ‘missing piece’ in end-of-life decision-making. 23 Behind the Lens: The patient wins as an African safari photo-shoot encounters an M.I. 26 Mayo CME: Coming events from Mayo Clinic Scottsdale. On the Cover
This sleepy lion in Kenya’s Masi Mara yawns after devouring a meal. You might well freak out if you realized you were having an M.I. while on a safari photo-shoot in Namibia. See this month’s Behind the Lens for the story of a man who lived through it (Dr. Hal Tretbar photo).

CORRECTION

In November’s In Memoriam, the obituary for Dr. B.T. ‘Tom’ Edwards contained a homonymic error in the nickname of the late Dr. Everett “Rett” Czerny.

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The buck stops with us
By Charles Katzenberg, M.D. PCMS President

s I write my last PCMS The ACA requires that premiums do not exceed 9.5 percent of and deductibles. This is not healthy for ou president’s column, seismic premiums, income. co-pays, But on top of premiums, the maximum amount a consumer sustainable. forces are acting upon healthcare. with single coverage will pay out-of-pocket for co-pays and The ACA requires premiums doand not 9.5 perce deductibles in 2014 will that be $6,350 for individual, upexceed to $12,700 These include the Affordable for family. Tax credits and subsidies will be available, yet health Care Act; changes in payment premiums, the maximum amount a consumer with single cov insurance and out-of-pocket cost are expensive and financially pocket for co-pays and deductibles in 2014 will be $6,350 for methodologies leading away from crippling to many Americans. fee-for-service, another surge in $12,700 for family. Tax credits and subsidies will be available The ACA is not the are answer. We need to and think bigger and more the movement toward physiciansout-of-pocket cost expensive financially crippling to m courageously. is noanswer. clean and simple solution that sits well as employees; and our seeming inability to control costs and make The ACA is There not the We need to think bigger and m affordable healthcare available to all Americans. with all Americans. I hope we can all agree that status quo is not is no clean and simple solution that sits well with all American sustainable. The ACA is currently President Obama’s and America’s worst healthcare that status quo is not sustainable. What options are available? nightmare. Whether the hapless healthcare.gov rollout, the “keep your What options are available? own insurance” flub or the fact that people in the same state, Colorado The simplest simplest andand cleanest way to achieve universal coverage The cleanest way truly to achieve truly universal c for example, who happen to live in different counties will pay rates that and effective cost control is to build upon a model that already exists: control is to build upon a model that already exists: Medicare can vary by more than 100 percent for the same coverage. Medicare. This traditional, publicly-financed program could be financed program could be tweaked, improved, and expanded The prognosis is not good. Is the government capable of making tweaked, improved, and expanded as an improved “Medicare-ForI welcome your feedback things right? Regardless, the ACA contains enough positives that at “Medicare-For-All.” All.” I welcome your feedback on other viable options. on other viable We currently treat healthcare as a commodity, available b least some of it will endure. We currently treat healthcare as a commodity, available by ability to treat healthcare as a societal commitment available to all. The Shifts in payment methodologies to healthcare providers will be pay. We do not treat healthcare as a societal commitment available are serious about providing access to affordable healthcare fo messy. Organizations like Carondelet Health Network and Community to all. The question is whether we are serious about providing access As we are the ultimate patient advocates. The to physicians, affordable healthcare for all Americans. Health Systems are banking on the fact that by employing and controlling physicians, they will be in a stronger position to distribute should. Anything that gets in the way of this Hippocratic com As physicians, we are the ultimate patient advocates. The buck stops bundled payments and control costs. TMC has chosen the path of impacts quality healthcare. with us, as it should. Anything that gets in the way of this Hippocratic partnering with physicians, supporting private practitioners, and has commitment negatively impacts quality healthcare. helped launch an Accountable Care Organization. The ACO model Question may be transformational. Time will tell. Question When I joined David Lapan in 1982, we became Pima Heart Associates. I knew nothing about the business of medicine. Thank goodness 1. David did. I relished my independence. The path to success included2. showing up for work, never turning down a consult or request to see a patient, doing quality work, and striving to please both patients 3. and referring physicians. I believed that my commitment to my partner and my practice would lead seamlessly to financial security, quality lifestyle, and family time. I was wrong about the family time. That took a lot of work. For many physicians today, the formula for success has shifted to an employment contract. My daughter is halfway through medical school. Most of these kids don’t see themselves as independent private practitioners, but as employees of a group, hospital, or insurance company. They are facile at, and comfortable with typing and EMRs. Many value lifestyle over income and/or independence. Being an employee is not inherently bad, but it may put physicians further under the thumb of administrators who focus more on the bottom line than on the patient.

A

Between 2000 and 2009 which has increased more? Between 2000 and 2009 which has increased more? Medicare reimbursements to physicians 1. Medicare reimbursements to physicians The2. cost of running a practice (MEI – medical economic index)) The cost of running a practice (MEI – medical economic index)) Medicare spending per beneficiary 3. Medicare spending per beneficiary

Our current trajectory will never control costs or provide all with access to affordable healthcare. In our current system, if we increase Decreasing fee-for-service payment to physicians will not control costs. The Decreasing fee-for-service payment to physicians will not control c bottom red line shows fee increases which are minimal. The green line is the cost access, we increase cost, and if we decrease cost, we may limit of operating a medical practice. Reimbursement is not keeping up with the cost of cost of shows fee increases which are minimal. The green line is the access and basic healthcare. There are a finite number of available operating a practice. The black line, spending per beneficiery, outstrips the others. Reimbursement is not keeping up with the cost of operatin healthcare dollars and it becomes a zero-sum game as to how they practice. Increased total cost is not about increases in fees but increases in volume of services rendered per patient. outstrips the others. Increased total cost is are distributed. The trend is for people to pay larger and larger spending per beneficiery, percentages of their premiums, co-pays, and deductibles. This is notbut increases in volume of services rendered per patient. (Uwe E Reinhardt, http://economix.blogs.nytimes.com/2010/12/17/the-annualhealthy for our economy, and is not sustainable. drama-of-the-doc-fix/) n
SOMBRERO – December 2013 5

LeƩers

Togetherness
To the Editor: Dr. Ole J. Thienhaus’s article, headlined “Med students, new docs undeterred by doctors’ ‘malaise’” [Perspective, November Sombrero], is right on two counts. Doctors-to-be are “fired up” to be doctors, and many of the rest of us may feel some malaise at where medicine has gone. When I spend my few minutes interviewing med school hopefuls, I’m excited about their smarts and enthusiasm. I want to tell them, though, what it might be like after 20 or 30 years of practice, but hold myself back and focus on the job at hand. I do not agree with Dr. Thienhaus that newcomers will all be working for an institution and that the future for private practice is dead—although it will be different from today’s. I believe we can develop a model of practice that is built on what worked in the past, and meets the expectations of the present. My friend David Minter, M.D. and others founded Arizona’s first HMO in the 1970s with such a goal. It meant Health Maintenance Organization, not health management organization. Its premise was based on doing preventive and educational care to keep patients well, and thus reduce the use and costs of more complex care. It was called capitation, and its success depended on patients staying with their physicians for long enough for them to realize

the benefits of the doctor-patient relationship and savings from healthy lifestyles. It failed, in part because people moved or were moved around, and although the incentives were correctly placed for better health, they were not always clear or strong enough for patients to follow the health prescriptions their doctors proposed. The failed program made sense for another reason: its success depended on outcomes. We measure outcomes every day in every patient interaction we have. Although healthy outcomes were good for payers, regulators, primary care providers, and patients, it didn’t sufficiently reward suppliers, and most specialists who did procedures for the sickest patients. It failed in that it didn’t focus everyone in the system on working for a common goal. A good example from industry would be John D. Rockefeller’s Standard Oil. It had many parts that did different things—finding, distilling, marketing and selling product, all while finding ways to work together. Their common goal was profit; ours would first be improved health of those we treat which would lead to profit. If every part of the medical system were rewarded by how patients did, they would be asking one another how they could work together in new and better ways. To set this up so it works, we must learn from the past. First, have the patients stays long enough with their health group for all to reap the rewards. Second, we would use outcome measures of how our population is staying, or increasing their health, in order to determine the rewards distribution. Third, and the part that needs the most thinking, would be to work out who would administer the rewards and where they would come from. The government already provides half of our healthcare dollars. Much of the other half is done in conjunction with employers, insurance companies, and patients. Some may suspect that government involvement will screw things up, but we elect them and pay taxes for them to do their job of organizing and regulating ideas that we implement. A step toward the success of this plan would be to organize the change as a health cooperative, owned by it participants, the patients, providers, regulators, and payers. The most important idea is to have the incentive of all parts working together for the goal of improved health. Rewards could include tax deductions and bonuses for care that succeeds. Patients would also be receiving incentives for their participation and working along with improved heath. It is incumbent on us to find a plan that will better help patients, revitalize medicine, and make it both enjoyable and profitable for those coming along to treat them. Sincerely, David A. Ruben, M.D., M.B.A. Tucson n
SOMBRERO – December 2013

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PCMS News

Clinica Amistad: We spend it well
The staff of Clinica Amistad thanks PCMS members for their generous support in the past. Because of your kindness, PCMS members, Clinica Amistad continues to serve the healthcare needs of the poor and uninsured in Arizona. The clinic is on firm financial footing, with several months of operating expenses in the bank. Consequently, Clinica Amistad has increased the range of services it provides through an expanded network of medical professionals, testing facilities, and surgical centers. Implementation of the Patient Protection and Affordable Care Act, and the decision to restore AHCCCS coverage to many, provide hope that the healthcare needs of Arizona’s poor will be better served. However the clinic’s directors believe that these changes will not eliminate the need for the services by Clinica Amistad. Currently the clinic sees patients by reservation to handle the overwhelming patient load. Consequently, we have a two-month wait time before a new patient may be seen. A donation to Clinica Amistad is money well spent. Ninety-six percent of every dollar goes directly to patient care. Owing to careful negotiation and the generosity of the medical community, the majority of physician consults, lab tests, diagnostic studies, and surgical procedures are obtained at or below actual cost. Medications provided to patients are either generic or over-the-counter. The staff of Clinica Amistad wrings the most value out of every dollar. As we enter the season of giving, Clinica Amistad solicits your financial support to enable continuance of its service to the Southern Arizona community. As Clinica Amistad is a project of Amistad y Salud, a 501(c)(3) organization, all donations to the clinic are federal tax-deductible. The Taxpayer Identification Number for Amistad y Salud is 75-3060875. Even better is that Amistad y Salud is registered with the state of Arizona as a Qualifying Charitable Organization providing assistance to the working poor. Arizona donors may claim a state tax credit of up to $200 for single filers and $400 for married filing jointly. This credit is in addition to other state tax credits, such as credits for donations to educational organizations. New for 2013 is that all Arizona income tax payers are eligible for this credit even if they don’t itemize deductions on their federal return. More information may be found at:
http://www.azdor.gov/TaxCredits/QualifyingCharitableOrganizations.aspx

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You may send a check to our mailing address or visit our website (clinicaamistad.org) and use the donation button to securely contribute by credit card through PayPal. There are many other ways to help: Physicians and mid-level practitioners: We always need more practitioners who are licensed in Arizona and are willing to volunteer. If you have the time or the inclination, we would welcome your presence for as many or as few Wednesday evenings as you can spare.
SOMBRERO – December 2013

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Referrals: We need specialists to whom we can refer perhaps one client per month and who would see them for free or on a sliding fee scale. Because we serve many diabetic patients, additional podiatrists to supplement the two we now have would be most beneficial. We have a limited budget due to grant support to cover some specialist visits and services. We are grateful for your generous support of the clinic! For more information about Clinica Amistad and options for workplace giving, please call us at305.5107. Our mailing address is Box 27284, Tucson, Ariz. 85726. Sincerely, Evan Kligman, M.D. Raymond Graap, M.D.

Today, following an STA-MCA bypass (a direct revascularization procedure) Dr. Abdu’s patient has new hope, CNI reports. “Dr. Abdu’s specialized training, coupled with the unique facilities available at CNI, allowed her to perform this complex vascular surgery that increases blood flow to this patient’s brain, using state-of-the-art BrainSuite iCT technology currently available at only 17 hospitals in the U.S. This technology eliminates the need to move brain surgery patients in and out of surgery, or subject them to an invasive imaging procedure.” Dr. Abdu was born in Addis Ababa, Ethopia in 1979. After high school in her home town, she graduated maga cum laude in laboratory medicine at the University of Washington, Seattle, and graduated in 2004 from University of Michigan Medical School. She completed her general surgery internship and neurosurgery residency at Oregon Health and Science University, Portland. Her cerebrovascular/endovascular Fellowship was at Swedish Neurological Institute, Seattle. Practicing with Western Neurosurgery, Ltd., she specializes in brain and spinal cord tumors, trigeminal neuralgia, hemificial spasms, and degenerative spine disease.

PCMSA Holiday Luncheon is here
The Pima County Medical Society Alliance Holiday Luncheon, benefiting Mobile Meals of Tucson, is 11 a.m. to 2 p.m. Wednesday Dec. 11 at Fleming’s Wine Bar & Steakhouse. To donate a raffle/auction item or for additional information, please call Chairperson Lupita Borboa at 548.0608, or e-mail lupita@wemovetucson.com .

College of Medicine awarded Reynolds grant
The UofA College of Medicine—Tucson recently announced that is has been awarded a “prestigious grant from the Donald W. Reynolds Foundation to strengthen physician training in geriatrics. “With the rapid growth of the American elderly population, especially in Arizona, an urgent need exists to assure that all physicians are prepared to provide the best of care for older adults,” they said. “This $1 million grant—the University of Arizona Health Network provided an additional $847,845 in matching—provides much-needed support to train Arizona’s physicians in geriatric care, with an emphasis on hospitalists and surgical and medical specialists.” Founded in 1954, headquartered in Las Vegas, Nev., the Reynolds Foundation is a national philanthropic
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Dr. Abdu treats rare brain disease
Moyamoya disease is a rare brain disorder caused when arteries at the base of the brain become progressively narrowed to the point of blockage. The name means “puff of smoke” in Japanese and describes a tangle of blood vessels that form to compensate for the obstruction. Without surgery, Moyamoya patients experience multiple strokes with mental decline, and it can be fatal if left untreated.

Dr. Emun Abdu is one of the very few women physicians in the U.S. specializing in rebrovascular neurosurgery (Photo courtesy CHN).

Carondelet Health Network and Carondelet Neurological Institute at St. Joseph’s Hospital report that it was “a blessing that a 40-year-old Tucson woman, suffering Moyamoya symptoms, found her way to Dr. Emun Abdu’s office at CNI in September. Before meeting with Dr. Abdu, the patient and her family were exploring going out of state for treatment.” Emun Na Abdu, M.D. is a Fellowship-trained cerebrovascular and endovascular neurosurgeon, joined CNI this past spring, and recently joined PCMS. She specializes in the treatment of vascular diseases of the brain and spine, including Moyamoya disease.
SOMBRERO – December 2013

organization that has committed more than $245 million to its Aging and Quality of Life program. “The grant program will support and extend the successes of the Arizona Reynolds Program of Applied Geriatrics, founded in 2006 by a previous Reynolds grant, which built an infrastructure of excellence in geriatric education and training,” the university reported. “This generous grant from the Reynolds Foundation will ensure that hospitalized older adults will be cared for by specialists who have been trained to meet the unique health-care needs of older adults,” said Principal Investigator Mindy Fain, M.D., division chief of geriatrics, general internal medicine, and palliative medicine at the UofA College of Medicine–Tucson, and co-director of the UofA Center on Aging. Targeted specialties are those for acute care or older, frail adults, the university reported: emergency medicine; pulmonary/critical care; hospital medicine; orthopedics; and surgery. “In addition to training key specialists in geriatric principles, the program will develop high-value, team-based models of geriatric care for older, frail adults, such as a Senior Emergency Room, and an Acute Care of Elders program.
Sombrero 0 2 7 10 9 9 0 9 X 9-30-13 $30 Dennis Carey 5199 E. Farness Drive, Tucson, AZ 85712-2134 (520) 795-7985 Monthly except bimonthly June/July & Aug/Sept

5199 E. Farness Drive, Tucson, AZ 85712-2134

Pima County Medical Society, 5199 E. Farness Drive, Tucson, AZ 85712-2134

Stuart Faxon, 4200 S. Chacoan, Tucson, AZ 85735-9460

Dennis Carey, 5199 E. Farness Drive, Tucson, AZ 85712-2134

Pima County Medical Society

5199 E. Farness Drive, Tucson, AZ 85712-2134

‘Northern Arizona telemedicine corridor’ called model ‘telehealth ecosystem’
The Arizona Health Sciences Center reports that Northern Arizona’s rapidly growing telemedicine cooperating programs “provide accessible, top-quality healthcare and critically needed services to rural Arizonans and healthcare professionals.” Rapid growth of northern Arizona’s telemedicine cooperating programs in recent years was reported at the Arizona Telecommunications and Information Council’s fifth annual meeting, Oct. 30, in Phoenix. “When telemedicine programs reach a critical size,” they said, “the programs can achieve sustainability and even experience accelerated growth. That’s happening in northern Arizona along a 340-mile-long corridor surrounding Interstate 40, between Arizona’s borders with New Mexico and California. Many of the hospital facilities and community health centers in this large swath of Arizona are members of the Arizona Health Sciences Center’s Arizona Telemedicine Program (ATP), established in 1996 by the state legislature.” “The ‘Northern Arizona Telemedicine Corridor’ fulfills our highest expectations of what we could achieve via telemedicine when we started the ATP in 1996,” said Ronald S. Weinstein, M.D., ATP founding director. “Not only have these organizations established a ‘telehealth ecosystem,’ they are national models of healthcare excellence in their own right.” They called the impact “significant. Mayo Clinic neurologists, for example, have provided remote teleneurology services for nearly 1,000 patients in Flagstaff alone. The devastating longterm effects of strokes have been averted for dozens of Arizonans, saving lives, improving quality of life, and reducing future healthcare costs.” n
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X

X

Sombrero

Aug-Sept 2013

900 12 653 0 0 665 11 47 0 0 58 723 177 900 91.97%

900 11 654 0 0 665 9 44 0 0 53 718 182 900 92.62%

X November 2013

Managing Editor

9-30-13

SOMBRERO – December 2013

Financial Management

Tax planning with the new tax laws
By John Stephens, M.D., C.F.A., C.F.P.® , M.B.A.
In the October Sombrero I discussed the new tax law changes and simple strategies that individuals can use to be more tax efficient. Now I’ll address more complex strategies designed to lower a taxpayer’s adjusted gross income, to avoid going over the thresholds that are an important feature of the new tax law. Individual taxpayers don’t do these complex strategies on their own. Rather, the strategies must be initiated at the practice or business level. For these strategies I will cover 1) Qualified Retirement Plans; 2) Non-Qqualified Deferred Compensation Plans; and 3) Captive Insurance Companies. Qualified Retirement Plans There are two major types of qualified retirement plans: Defined Contribution (DC) and Defined Benefit (DB) plans. A major difference in these two types of plans is that in all DC plans, the investment risk is with the participants, whereas in the DB plans, the investment risk is maintained by the company. This is a critical factor in determining the appropriate investments held within each plan, and also important for owners to understand when choosing an appropriate retirement plan. Common features of qualified plans, both DC and DB, are that they are governed by ERISA and are asset- protected. They also can both be rolled into an individual IRA upon retirement. If you have a smaller practice or want to keep it less complex, you might consider a SIMPLE IRA, a SEP IRA or even a solo 401(k). Here, I will focus on the more complex and robust Safe Harbor 401k Profit Sharing, and Cash Balance Defined Benefit plans. Safe Harbor 401(k) Profit Sharing Plan In a Safe Harbor 401(k) Profit Sharing plan, all participants are able to defer $17,500/year from their own compensation, and participants older than 50 can defer an additional “catch up” of $5,500 per year. In addition to the salary deferral, highly compensated physicians may have the company contribute an additional $38,000, resulting in a total pre-tax deferral of $51,000 or $56,500 if older than 50. Because qualified plans must follow Department of Labor and IRS rules, they are not allowed to discriminate against lowercompensated employees. In simple terms, these plans cannot be set up to allow the physicians to max out the plan and not benefit the employees. By electing to use Safe Harbor, the plan passes testing and, if designed properly, allows physicians to defer the maximum amount. One form of Safe Harbor requires that the sponsor contribute three percent of an employee’s salary, which is immediately vested. Investments in the plan can either be pooled in a single account, which is simpler and less expensive, or allow for individual participants to direct their own investment selections. I always recommend that groups considering a Safe Harbor plan have their CPA/attorney involved in addition to a third-party administrator, to make sure all the details are correct. Another facet of DC plans is that some of the payroll providers and
SOMBRERO – December 2013

insurance companies offer simple 401(k) plans, but they are very basic plans that may not meet the owner physician’s objectives. Although they may be less expensive, in the end they may provide significantly less benefit. Defined Benefits Plans (DB Plans) DB plans are retirement plans in which the company provides a certain benefit when a participant retires. The most basic are the typical large company or government pension plans under which a retiree gets a set amount for life. The typical DB plan used by physician groups is the Cash Balance Defined Benefit plan. A Cash Balance DB plan is designed so that participants may accumulate an amount, based on their age and salary, that allows them to draw a set amount in retirement for life. However, with the Cash Balance DB plan there is an expectation that the retiree will take a lump sum rollover to an individual IRA instead of an annuitized income managed by the company. In simple, big round numbers, the actuarial calculation will allow a highly compensated physician making at least $255,000 in salary to accumulate more than $2 million by age 62. As you can see, the calculation allows older physicians to defer very large amounts and younger physicians to contribute a lesser (but still meaningful) amount to fully fund the DB plan. Please note that a group may decide to fund less than the maximum allowed by the actuarial calculations. In a Cash Balance DB plan each participant is provided with an annual summary of their “cash balance,” or the amount that has been funded on their behalf. The funds are always held in a pooled investment account which should be invested in a more conservative allocation, because the company is “on the hook” for investment losses and may be required to contribute additional money to get an underfunded plan back to an actuarially determined balance. Administration of these plans is more involved and subsequently more expensive. Before a group decides to implement a Cash Balance DB plan, the group must have very good stable cash flow. This type of plan is a longer-term commitment and not “profit sharing.” Once the plan is started, the company should plan on funding for a reasonable number of years. The IRS scrutinizes plans that are not in place for three to five years. Lastly, since a Cash Balance DB plan allows for different contribution amounts for each physician, the group needs to think about how that might affect the current compensation structure. Nonqualified Deferred Compensation Nonqualified Deferred compensation is only an option if your group is a C Corporation. These plans allow participants to defer salary, but in a nonqualified investment. The proceeds from plans not qualified under ERISA may not be rolled into an IRA at separation from employment or retirement. Once again, anyone considering this type of plan will need to hire a deferred compensation plan administrator and should make sure to consult with the group’s CPA and attorney. Plans are typically
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structured so that the deferred monies earn a set interest rate, and the participants can arrange to receive the money at retirement or upon leaving the medical group. When the money is paid out, it is treated as ordinary income. A key point, and one that I know personally from my days with the Thomas-Davis Clinic, is that these plans are not qualified and have no ERISA protection. At Thomas- Davis, many of the physicians deferred their salary after the Foundation Health buyout. Unfortunately some of the physicians lost that money when the company failed. At bankruptcy, deferred compensation is an unsecured claim. Captive Insurance Companies Captive Insurance Companies were originally designed for large companies, typically the Fortune 500 kind, to own their own

insurance company and then pay premiums to themselves instead of the prior insurance provider. Of course the captive insurance must be able to track and process claims. The Captive Insurance Company is also allowed to invest a portion of the premiums, given certain restrictions, and ultimately may pay out dividends to the owners if the investment risk pool is above a certain threshold. The main tax advantage is that these dividends typically have favorable capital gains rate treatment. There are now Captive Insurance Company providers that allow smaller companies, such as large medical groups or other large professional companies, to participate. In some cases a number of smaller groups or individual doctors own the Captive jointly. Without question, the decision to start a Captive should be vetted thoroughly with CPAs and attorneys. Of the strategies discussed here, Captives are the most complex and most expensive option, and are at least $50,000 to start and more than $20,000 per year to maintain. When a Captive Insurance Company might make sense for a physician group, I tend to be very conservative with its structure. Some of the turnkey Captive companies have offshore companies and have no independent auditors. There are even cases in which those managing the insurance claims and administration also are trustees of the investment risk pool. This increases the risk of abuse and IRS scrutiny. I also feel strongly that every Captive should have an annual independent U.S. audit to verify the accounting and claims processing. One scary anecdotal story is of an offshore Captive in which the physicians were contributing $1 million in premiums to cover kidnapping insurance. When no insured physician participant was kidnapped, the excess premiums were distributed. As physicians, you have plenty of risk with malpractice and Medicare issues, and you may not want to draw even more IRS attention. All these complex strategies, if executed properly, may allow an individual physician to potentially defer very large amounts of incomes, often as much as $100,000 to $500,000. At this level of deferral, it may indeed keep annual gross income under the $450,000, $300,000, or $250,000 thresholds that now exist in the 2013 tax laws. Dr. Stephens, an Associate PCMS member, specializes in helping physicians and senior-level execs build and maintain wealth, independent of their businesses. In 2010 Medical Economics magazine named him one of the country’s 150 best financial advisers for doctors. He can be reached at TCI Wealth Advisors, Inc., 733.1477 or www.tciwealth.com. n

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In Memoriam
By Stuart Faxon

Dr. Daniel T. Mihalyi, 1947-2013
r. Daniel T. Mihalyi, of Quality of Life Medical Research Center, Tucson IM physician for 35 years who specialized in age management, who joined PCMS in 2010, died suddently on Oct. 20, his family reported in the Arizona Daily Star. He was 66. Dr. Mihalyi was born Aug. 21, 1947 in Pittsburgh, Pa. He graduated in 1973 from Hahnemann University School of Medicine, Philadelphia. He interned and did his IM residency in the Tucson Hospitals Medical Education Program. “He helped many people,” his family said, “and was dedicated to promoting health and wellness. He enjoyed weight-lifting, golf, swimming, and watching Steelers and Wildcat games with his sons. He loved visiting the Sea of Cortez, and spent many mornings watching the sun rise over the sea. Dr. Milhayi’s wife of 40 years, Stephanie; siblings Tom, Patrick, Patricia, and Erin; sons Ryan and Sean; and many nieces and nephews survive him. A memorial service was given Oct. 24 at Tohono Chul Park. The family suggests that memorial contributions be made to the Community Food Bank.

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SOMBRERO – December 2013

ReƟrement
Story and photos by Dennis Carey

Craftsmanship with a surgeon’s care

P

hilip Fleishman, M.D., does not embrace the idea of coincidence. He was inspired by Albert Einstein to write his first novel, the medical thriller The Gemini Factor. Einstein had little use for coincidences. Dr. Fleishman quotes Einstein on the book jacket: “I do not believe in the word ‘coincidence.’ For me, it is a word created to explain the unexplainable away.” Very little is coincidental in the skills and passions Dr. Fleishman used in his practice as a plastic surgeon, and those now serving him in retirement. He was an Active PCMS member 1973 to 1994, and is now an Associate. A Toronto native born in 1938, Dr. Fleishman graduated in 1964 from University of Ottawa Medical School. After doing an internship at St. Mary’s Hospital in Rochester, N.Y., he served as a general surgery resident at Cleveland Clinic Educational Foundation in Ohio. He was a resident in plastic surgery at the University of Toronto Affiliated Hospitals 1967-1970, and landed in Tucson in 1971. He worked extensively with burn victims as director of the Carondelet St. Mary’s Hospital burn unit. His time outside his office or operating was spent on woodworking projects and reading. Sometimes it was both. It is said, “Write what you know,” and Dr. Fleishman does. His novels are medical thrillers, and it’s no coincidence that The Gemini Factor is set in his two hometowns of Toronto and Tucson. In the novel serial murders happen at the exact same time, the exact same way, but more than 2,000 miles apart. Woodworking was “something I liked, but it was also born of necessity,” Dr. Fleishman said. “I was a poor resident and newly married, and we needed furniture. In those days, it was cheaper to make it than to buy it.” He read books on how to build furniture and took a few courses over the years to help him develop his skills. The projects became more intricate and complex as his knowledge grew. His Tucson house is a 30-year work-inprogress. His most recent project was a complete kitchen remodel .

If Dr. Philip Fleishman made two identical peppermills, that would be coincidence indeed. Here he displays a piano-key design, and one reminiscent of a Central European Christian church.

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“My wife is a designer,” he said. “She tells me what she wants, and I build it. It’s a combination that seems to work.,” Recently Dr. Fleishman took on new roodworking dimensions as a creator of original peppermills. It happened that his wife, Jane, was watching Oprah as the TV host was talking to one Pinky Martin, an artist in his 80s who had a waiting list of seven years for his handcrafted peppermills. At first Dr. Fleishman was not interested. But when he was given a course in woodturning as a gift from his son David, it all changed. Dr. Fleishman ended up contacting Pinky Martin about creating custom peppermills. While he did not find himself on Oprah, one of his creations ended up at the White House with President Barack Obama’s chef. It was not a campaign contribution. A complex connection with a relative of a friend of his wife put the peppermill in the White House kitchen. Dr. Fleishman sells his peppermills in various ways, including his website, Peppermillsofdistinction.com, and gift shops and galleries. The price is usually around $300. He has works on display at the Wood Gallery in Oregon, and at Environmental Realists at the artist-colony Tlaquepaque in Sedona. He has also sold and displayed his peppermills at the Tucson Museum of Art, and in galleries in Tubac and New Mexico. He attends arts-and-crafts shows, such as Tucson’s 4th Avenue Street Fair, two or three times a year. “I suppose there is some similarity to woodworking and my plastic surgery practice,” he says. “Both require delicate work with the hands. In woodworking, if you make a mistake, you can change your plan and make something else. There is no margin for error in plastic surgery. Changing plans is not an option.” The peppermills have not replaced his furniture building and other woodworking projects. The fireplaces in his house are surrounded by handcrafted mantels. No
This recently completed, elaborate clock shows the intricacy Dr. Fleishman’s work can take on.

room is untouched by his work. “Writing a novel was a bucket-list project,” he said, easing back into a chair in front of his computer desk, both previous projects in a remodeled office. “I realized I would have to publish it myself, because I did not have the time to wait to do it the traditional way with a publisher or an agent.” As with so many other businesses, the Internet has changed the game for authors. He has been selling “The Gemini Factor” on his website philipfleishmanmd.com, and on Amazon.com for three years. It reached a peak of No. 219 in the genre in June 2012. His second novel, The Contingency Factor, will be on sale at the end of this year or early 2014. “The big publishers don’t like to take chances,” he said. “They want to go with someone they know will sell books. Sadly, the quality of the writing does not always stay same with some authors. The book sells on the author’s name and not the writing. It’s more about the marketing to become a bestseller. Even some of the top authors are going the way of self-publishing. They have more
16 SOMBRERO – December 2013

control and don’t have to share the profits with as many people. There are a lot of excellent self-published authors out there.” As with his woodworking, Dr. Fleishman started modestly by taking some creative writing courses at Pima Community College. He also credits his reading habits as enhancing his writing skills; he reads two to three books per week. His creative writing instructor, Marjel De Lauer, encouraged him to write the book. He also bent the ear of his editor, Rebecca Dahlke, at a booth at the Tucson Festival of Books, and she helped him get started in selfpublication. He also gave drafts of the book to as many people as he could. “It always helps to have others read your work,” he said. “They can point out things that could slip by. The experiences and knowledge of others may help them point out something that does not fit, or is inaccurate, that you would have otherwise missed. “The books are novels. The plots are fictional, but I try to base them on facts. I don’t want somebody criticizing it because something I put in my book could not actually happen. The vast majority of the reviews online have been very positive. I also got a good review from the Arizona Daily Star. But it is probably easier to win the lottery than to become a best-selling author. There are so many books out there.” Dr. Fleishman usually rises at 4 a.m. and works four hours on writing. The rest of the day is filled with woodworking projects and reading. He may take a break to fill in some craters dug in the yard by his two golden retrievers, Rosie and Sassy. He also has a regular poker game every week with a group of friends who have been getting together for 40 years. He said he probably makes more money at the poker game than from his peppermills or books. It took three years just to break even on the money he spent on publishing his first novel. He usually

Safety first, as table saw, lathe and the rest of the tools in Dr. Philip Fleishman’s woodshop keep hin busy.

makes enough money to cover the cost of materials needed to make the peppermills. “It was never about the money,” Dr. Fleishman said. “I have been fortunate that I can spend my time doing things I love to do.” And he finds nothing coincidental about that. Dennis Carey is PCMS associate director. n

SOMBRERO – December 2013

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SOMBRERO – December 2013

Makol’s Call

A modest proposal
By Dr. George J. Makol
wift’s “Modest Proposal” was far from modest, as he meant it. I propose something actually modest. The nation is at war with itself over illegal immigration. As a grandson of immigrants, I certainly understand why people want to come to the United States. And certainly the huge costs of giving non-citizens illegally here free medical care are to be considered. A few years ago I remember reading in the Arizona Daily Star that Tucson Medical Center was more than $5 million in debt just for care given to aliens captured while trying to enter the U.S. illegally. But this goes beyond just politics and medical costs. Illegal immigration has touched my life as a physician in a way that, unless you have been so affected, is hard to understand. A few years ago I was flying back from a two-week trip to the Czech Republic, Budapest, and Vienna, and arrived in Phoenix where I had left my car parked at the Airport Hilton Hotel, in a well-lit and guarded parking area in front of the hotel. We would usually fly overseas from Phoenix to get a direct flight, and then stay overnight upon our return to Phoenix, as we were usually exhausted after the long flight home. We got off the airport shuttle and headed for the lobby to check in, when I noticed my three-quarter-ton four-wheeldrive loaded Chevy Suburban was gone. We called the Phoenix police and filed a report, and were stuck at the hotel until our son drove up from Tucson to pick us up. I was well insured, and in a few weeks I received a nice check from my insurance company, and quickly purchased a new vehicle. A couple of months later my vehicle was found abandoned in the desert in Florence, stripped of its rear seats and trashed. Police said evidence showed that it had been used for two months to ferry illegal aliens though the desert to and from Mexico. That it had a 6.5-liter V8, four-wheel drive, and chrome brush guards made it a perfect vehicle for the smugglers known as “coyotes.” Phoenix police informed me that at that time, 105 cars per day were stolen in Phoenix, and about 55 per day in Tucson, with most being diverted to the aforementioned criminal use. SUVs are the vehicles of choice, and the vehicles of choice for many physicians and their families, according to what I see in hospital and doctors’ parking lots. Since almost no one gets caught, these thieves just help themselves to your car and you are left to file a stolen vehicle report. The Phoenix Police auto theft detail was worthless. They found the vehicle with keys in it, but did not fingerprint it, research where the keys were obtained, or follow up on the many calls the perpetrators made on my cell phone, dozens of them to the same numbers. In fact they lost the list of calls I sent them and ignored a second mailing. For the public’s purposes they could fire the auto theft department and just retain the secretary to send out forms for victims’ insurance companies.
SOMBRERO – December 2013

On an even more somber note, I walked in to my office two years ago and my staff told me that Southern Arizona rancher Robert Krentz, murdered by an illegal alien drug dealer who had returned to avenge his brother being ripped off in a drug deal, was a patient in my office. Krentz was a gentle man who was known for helping border crossers when they were abandoned on his land by offering water and food. His shotgun was at his side and untouched when he was shot off his tractor. Krentz was simply in the wrong place at the wrong time. But we can buy lettuce for $1 a head because migrant farm workers, many of them here illegally, will do the kind of work that we are told “Americans will not do.” However, when you count the extra $100 or so each of you is paying every six months on your car insurance because we in Southern Arizona, perhaps that lettuce is not so cheap. I would rather pay $3 a head for lettuce and keep my own car! And if farmers received just $2 a head for lettuce they could probably afford to pay farm workers say $12 an hour and provide decent working conditions. In this recession, I bet there are a lot of people who would work in the fields for, say $12 per hour. And the government would not even have to get involved; the free market could solve this problem. Here is a modest proposal for dealing with the workers who still wish to come to the U.S. to earn money for their families back in Mexico. Most of these folks want to stay a citizen of their country of birth; they just have an immediate need for a good-paying job. “Coyotes” charge up to $5,000 to sneak workers into the U.S. and often abandon these poor folks to die of exposure in the desert. Why don’t we issue an electronic card for a 30-day “guest worker” to each person who wants to come over and we could provide air conditioned busses to transport them. This card would be presented to the employer, who would withhold 10 percent of the wage weekly, and electronically deposit this sum directly into the U. S. Treasury, perhaps credited to reduce the deficit. The card could easily be channeled through any Visa/Mastercard swipe machine to deposit that 10 percent in the treasury, less maybe a half-percent for the electronic banking privilege. The card and the ride would cost perhaps $50, making the program self-supporting, and the card could be renewed for one- month periods for perhaps $10. Penalties for working without a guest card, or for hiring a worker without one, should be stiff, similar to penalties already on the books. This could also work for some of the 11 million undocumented persons already here. Cards could be available for purchase in any post office. As physicians we are always concerned with quality-of-life issues, and know more than most folks about the tragedy of lives taken too soon. Consider these xamples: In August 2012, 14 people died in a rural South Texas accident in which a pickup truck loaded with 23 Guatemalan and Honduran illegal immigrants rolled over. Nine survivors were hospitalized in serious condition, at perhaps a half a million dollars in cost to taxpayers. Earlier in 2012 an SUV crashed near Casa Grande, killing four occupants and injuring six other illegal immigrants. In South Texas again in April, a van full of illegal immigrants overturned, killing nine of the passengers. They were on the way to a “stash” house near the Mexican border. Compare these outcomes to a $50 ride in an air-conditioned bus, and think of all that tax revenue, and perhaps I could return from Europe next time without being afraid to look to see if my car was still there! Or, we could just continue eating our salads, happily oblivious to how that lettuce appeared on our kitchen tables so inexpensively. Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been a PCMS member since 1980. n
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Bioethics

The missing piece in end-of-life decision-making
By Tani Bahti, R.N., C.T., C.H.P.N.
t was bad enough that Gary was feeling the pain of only just understanding that his beloved wife was imminently dying. His pain was further exacerbated by learning too late that his best intentions in providing care only created more discomfort and conflict for the woman who was the love of his life. I witness this scenario every week. Perhaps I should be used to it, but despite my 36 years of working in end-of-life care and education, it still pains me to hear the famil­ iar lament, “If I had only known.” In these situations, no one alerts the pa­ tient and family to the signs that death was approaching. No one tells them that it was time to replace a push for treatment with a push for comfort care. No one explains the natural course of the disease and the dying process. No one tells them how to respond to the expected changes to assure comfort and obtain closure. When facing the end of life, we are natu­rally scared. Our problem is that too many of our decisions are based on this fear, or on lack of information or misinformation, which often results in devastating physical, emotional and financial consequences for the patient and family alike. We can and must do a better job. The question is not if we are going to die, but how we are going to die, and therefore compassionate and honest education about the natural process of dying is critical to making difficult end-oflife decisions. Recognition of the point at which our loved ones are coming to the natural end of life becomes obscured with the flurry of medical interventions. We often hold onto a belief that “more is better,” that technology always holds the promise of sav­ ing us from dying, even if for a little while. Quality of life is often sacrificed for the hope of quantity, and can inadvertently result in more discomfort or time in an intensive care unit. We have to ask whether we prolong living, or prolong dying. When the body is preparing for its final months, weeks, and even hours, many natural processes kick in to promote comfort. When families understand the wisdom of the body as it works to protect itself, they usually make decisions that honor the pro­cess of shutting down to die. There is ample research about how the body begins to shut down to die. We know that the use of artificial nutrition and hydra­ tion at the end of life can actually increase discomfort and even
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hasten dying through fluid overload, aspiration, or increasing tumor growth. We know that the natural and normal cause of death for a number of dis­eases is pneumonia, once considered “the old man’s friend.” We know that physical pain is not a part of the dying process, but that if it is a part of the disease, it can be managed. We know that the dying process will usually lead to coma, which allows the individuals to essentially “die in their sleep.” Unfortunately, the dying process is rarely taught in medical and nursing schools and is a frightening mystery to the general public. This lack of knowledge contributes to our discomfort with end-oflife discussions. Sometimes it’s the discomfort of the healthcare professionals who believe that death is failure, or that telling the truth is “taking away hope.” It becomes easier to offer a treatment, however futile, seeking solace in the illusion that doing anything is better than facing the difficult emotions of patients and families when they are told that reversal or cure is no longer possible. Sometimes it’s the inability of the patient or family to let go, or their fear of the un­ known that drives futile care. Sometimes it’s the belief that by refusing treatment they are somehow declaring that it’s okay for their loved ones to die. It’s not easy to talk about dying, but there is clear benefit. A study conducted at the Dana Farber Cancer Institute by the National Institute of Health and National Cancer Institute was released in 2009 and revealed that having the conversation about end-of-life issues results in less depres­ sion, improved satisfaction with informed decision-making, improved use of avail­able resources, and better quality of life and death. My own experience is that people want to know what to expect. They want the best possible care and comfort for their loved ones. They just don’t know that it’s O.K. to ask, and do not know what questions to ask to determine the best course of care. It will take all of us to improve how we talk about and prepare for the end of life. Healthcare personnel must improve their knowledge and communication about the dying process. The patient and family must understand the natural progression of a disease and benefit and burden of treatment options. They must ask more questions, matching the answers to their own goals and values. They must keep updating their personal definition of quality of life and document their wishes. We must all face the fact that ultimately, dying is not an option
SOMBRERO – December 2013

and how we talk about, prepare for and honor the dying process is our right and our responsibility. Let’s provide road maps and comfort on the final leg of our journey. Important questions for you and your family when making treatment decisions • Do I have the information I need to make this decision? • Is fear or lack of information pushing me towards a particular decision? • What am I most afraid of? • What are my goals at this time in my life and will this treatment help me reach them? • Am I making a treatment decision based on what I believe someone else wants me to do or what I really want to do? Have I sat down with that person to clarify what each of us want? • Who or what is my source of strength and support and have I utilized that? • If I have a limited life expectancy, how do I want to spend the time I have? • What does fighting the good fight mean to me? Seeking aggressive treatment until the end or allowing a natural death? • Have I completed my advance directives (Living Will and Medical Power of Attorney), which declare my wishes for the extent of medical treatment I wish to receive in the event I cannot speak for myself? • Have I talked with my family and physician about my advance directives? • Have I asked all my questions, expressed all my fears, and shared what I truly feel with my family and physician? Important questions to ask the physician • Is the goal of this treatment to cure, prolong life or relieve symptoms? • What is the best I can hope for with this treatment? • What is the worst I should prepare for if this doesn’t work? • Is this a standard treatment or experimental? What are the chances for success in my particular case? • How and when will I know it’s working? • How will this impact my daily living, comfort and/ or goals? What are the physical changes I may experience and how will you help me manage them? • If I have side effects, how long might they last? What can be done to prevent or minimize them? • Are there any potentially permanent side effects?

• Is this covered under my insurance? What will the cost be to me? • Will I need extra help to manage at home, and if so, for how long? • If I refuse this treatment, what can I expect to happen? • If I refuse this treatment, will you still be my doctor? • Is there a counselor, support group or someone I can talk to about this? • Do you have material about this treatment that I can take home and review? • Are there other ways to manage my disease and would you recommend them? Why or why not? Although medicine doesn’t have a crystal ball to know how you are going to respond to a particular treatment, it is important that you have enough information to make an informed decision. Consider your lifestyle, your beliefs, your goals and values. Consider your family, finances and spiritual beliefs. You always have the right to know and to choose. Tani Bahti is founder of Passages—Support & Education in End of Life Issues www.pas­ sageseducation.org, and author of “Dying to Know—Straight Talk About Death & Dying.” www.bookaboutdying.com.

n

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SOMBRERO – December 2013

Behind the Lens

The safari of a lifetime
By Hal Tretbar, M.D.
Shortly thereafter the hospital called and said his tests were positive for M.I. and it would be a good idea for him to return. He was admitted to the ICU. One of the people from the tour company stayed with him while his two friends returned to finish the safari. “

O

h, shit,” Jack Jordan muttered under his breath.

The retired Phoenix Fire Dept. supervisor had also worked at St. Joseph’s Heart and Lung Institute in Phoenix. When the crushing pain started in his shoulder and went down his left arm to his fingers, he knew what it was. “Oh, she-it,” he thought. “Here I am on safari in Namibia, Africa, and I’m having a heart attack.” Jack, 74, had been feeling a little tired and short of breath for the previous several days. He had been photographing birds with a tour group. They were staying in the secluded Erongo Wilderness Lodge, 13 kilometers from the town of Omaruru in central Namibia. It is a luxury, tented camp on a rocky ridge, so he didn’t pay attention to the vague symptoms when he was climbing the steps. When the group returned to Omaruru, population 14,000, he did some shopping and after lunch went to his room to lie down. He felt very anxious just before the chest pressure and arm pain started. His roommate, a retired Los Angeles EMT, and a retired M.D. with the group checked him over, and as far as Jack remembers, he never had an irregular pulse or low blood pressure. He said he was very scared, and wondered what was going to happen to him. They helped Jack to their small bus and took him to a local doctor’s office. The German doctor gave Jack some pain meds and took an EKG. He said, “You are having a heart attack, but I can’t treat you here. Here are some nitroglycerin tablets and here is the address of a doctor in Windhoek.” So began a remarkable journey. Jack doesn’t remember much of the three hour trip in a drafty, rattly bus over bad roads to reach Windhoek the Namibian capital. He doesn’t remember receiving any oxygen or IVs. He doesn’t remember much pain. He just remembers bring scared. Very scared. When they arrived at the small hospital, a deposit was demanded before he could be seen in the ER. An IV was started, some meds were given, and tests performed. Jack was groggy but appeared stable, so he was sent out to stay in a guest house.
SOMBRERO – December 2013

Several days later Jack took his first ambulance ride when he was transferred to the 87-bed Roman Catholic Hospital of Windoek. Established in 1907, it has been managed by the Benedictine Sisters of Tutzing since 1933. A $10,000 deposit was asked upon admission. That is enough to put some strain on a healthy heart, and even worse when one of his credit cards refused a $5,000 advance. But thankfully it was worked out. Jack came under the excellent care of Simon Brashear, M.D., a Scottish- and European-trained cardiologist. He did a coronary angiogram in their modern cardiac operating theater. It showed an occluded left anterior descending artery along with 50 percent blockage of the circumflex. Dr. Brashear performed a balloon angioplasty of the LAD and inserted a long stent. Jack recovered uneventfully in a private room with constant monitoring. One day Jack remembered a card in his wallet. He showed it to his doctor and asked, “Can this help any?” Just before he left on safari, Jack had visited a doctor to get his immunizations and

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malarial pills for Africa. While there he picked an advertisement for something called an Airambulance card. It is like AAA in that there are certain benefits for members. Since it wasn’t travel insurance, he almost threw it away. But then he reconsidered. He’d been traveling a lot. He had photographed hummingbirds in Ecuador in March. He had just returned from photographing bears in Alaska. Besides, it wasn’t expensive. One year cost $225, so he bought it. It turned out to be one of his smartest and most fortunate decisions. The card company was contacted, and they agreed that Jack was covered. They arranged for him to be evacuated by an air ambulance flying out of Montreal—just like AAA sends a tow truck when you are broken down by the roadside. Jack was released from the hospital after a week and walked out to the sleek LearJet at the airport to meet the crew of two pilots and two nurses. He settled in for his 30-hour flight home. But a delay in this transit showed him a part of Africa he wasn’t expecting. Bad weather over the Azores Islands forced an overnight stay in Dakar, Senegal. It was difficult for Jack to image the poverty and squalor that he saw on the way to the hotel. It was heavily guarded, but quite satisfactory, rather like a Holiday Express. Later at dinner, the pilot remarked, “I’ve never eaten dinner with a patient before. They usually are under sedation on a stretcher. By the way, do you know this flight would have cost you around $160,000 without the card?” From there the route home went to the Azores, to St. John, Newfoundland, to Montreal, and to Green Bay, Wisconsin, where they went through Customs. During the flight back, Jack had time

to muse about the string of events. What could have brought on the heart attack? Jack had always watched his diet, with little salt or red meat, and lots of ethnic foods. He worked out regularly with a personal trainer. His cholesterols were low at 130. Could the stress of a person hitting his car, causing $7,000 worth of damage days before the trip, have been a factor? Who knows? It is probably in his genes. One grandmother died in her 50s of diabetes and heart trouble. His mom had a coronary bypass but lived to 91. His father died at 79 after an M.I. and quadruple bypass. When Jack arrived in Phoenix, arrangements had been made for his admission to Thompson Peak Parkway Hospital. His cardiologist there reviewed all of the records that had been sent on a disc. The angiograms were very good and showed that the stent was well placed. His care in Windhoek had been excellent. Jack spent five days relaxing with his son and family before resuming his regular activities. He is now in full cardiac rehab and on the appropriate preventive medications. Jack commented recently, “I was really fortunate to have my health insurance. Even thought I have Medicare, I continued to pay for the insurance I had with the fire department. It has really helped pay for all of the hospital costs.” If the story has a moral, it may be that the unexpected is always possible, it helps to be lucky, and it’s certainly wise to have enough insurance. n

Pima County Medical Society
wishes you

Happy Holidays
and a

Healthy and Prosperous New Year!
24 SOMBRERO – December 2013

SOMBRERO – December 2013

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Mayo CME

January 2014

Jan. 24-26: Mayo CME’s Clinical and Multidisciplinary Hematology and Oncology 2014, 11th Annual Review is at Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.624.1000 or 1800.354.5892. Accreditation: TBD. Course is comprehensive update and management strategies on issues in hematologic and oncologic malignancies, presenting new disease classification, treatment, and challenging cases. Topics include updates from the American Society of Hematology (ASH) annual meeting and in medical oncology, focusing on key hematologic diseases (dysproteinemias, acute and chronic leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU), and overlap topics of supportive, ancillary, and diagnostic care. Course offers “challenging and interactive sessions on pertinent issues involved with care of patients.” Website: http://www.mayo.edu/cme/internal-medicine-andsubspecialties-2014s431 Contact: CME Dept., Mayo Clinic Scottsdale, 13400 E. Shea Blvd., Scottsdale; phone 480.301.4580; fax 480.301.8323 mca.cme@mayo.edu www.mayo.edu .

March 2014
March 6-8: The 10th Annual Mayo Clinic Women’s Health Update is at FireSky Resort, 4925 N. Scottsdale Rd., Scottsdale 85251 phone 480.945.7666 or 800.528.7867. Accreditation AMA, AOA, AAFP, ACOG. Course addresses needs of female patients and their healthcare providers for “comprehensive insight into relevant medical problems uniquely found in women, as well as a basic approach to addressing and improving common health concerns.” Website: http://www.mayo.edu/cme/women-s-health-2014s307 Contact: Mayo School of Continuous Professional Development Registrar, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.9176. mca.cme@mayo.edu http://www.mayo.edu/cme March 27-29: Tackling Problematic Chronic Rhinosinusitis: A Conclave of Global Experts is at Mayo Clinic Education Center, 5777 E. Mayo Blvd., Phoenix; phone 480.301.8000. Accreditation: AMA, AOA, AAFP. Mayo Clinic presents “the first symposium on managing your most challenging sinusitis patients.” Global leaders in otolaryngology-rhinology, allergy-immunology, and basic sciences come together to brainstorm in highly interactive sessions. The goal of the symposium is to synthesize its information into innovative strategies and tips on medical and surgical management of the recalcitrant chronic rhinosinusitis (CRS) patient. Bring together your challenging cases to discuss. Website: http://www.mayo.edu/cme/otorhinolaryngology2014s378 Contact: Mayo School of Continuous Professional Development Registrar, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.9176 mca.cme@mayo.edu http://www.mayo.edu/cme

February 2014
Feb. 16-21: The Mayo Interactive Surgery Symposium is at Wailea Beach Marriott Resort, 3700 Wailea Alanui, Wailea-Maui, Hawaii; phone 877.622.3140. Accreditation AMA and MOC. Trends in management of general surgical patients are constantly changing. As technical advances progress, options of surgical treatments continue to expand. This symposium for general surgeons assists in decision-making for multiple aspects of surgical practice. Website: http://www.mayo.edu/cme/surgical-specialties2014s152 Contact:Mayo School of Continuous Professional Development Registrar, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.9176 mca.cme@mayo.edu http://www.mayo.edu/cme

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SOMBRERO – December 2013