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SOMBRERO

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

NOVEMBER 2013

Bioethics: Minimally conscious states Students, new docs, and ‘doctor malaise’ Upscale! Twin Arrows Navajo Casino Resort

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SOMBRERO – November 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. 9

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.

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SOMBRERO – November 2013

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Inside
 5 Dr. Charles Katzenberg: Conservatives, liberals, and the ACA.  6 Milestones: Recent recognitions for three of our members.  8 PCMS News: Post those prices! 10 In Memoriam: Dr. B. Thomas Edwards, Tucson-born surgeon. 12 Bioethics: Our Bioethics Committee’s Dr. David R. Siegel on vegetative or minimally conscious states. 15 Behind the Lens: Twin Arrows Navajo Casino and Resort is the latest and most ambitious casino project of the Navajo Nation. 20 Perspective: The UofA psychiatry chairman looks at student and new physicians and their new practice world. 23 Time Capsule: A 1979 flashback to the late centennarian Sid Wilson of Tombstone, one of the last of the 19th-century Arizona cowboys. 26 Mayo CME: Coming events from Mayo Clinic Scottsdale.

On the Cover
Fall colors at their peak in Northwestern Missouri (Dr. Hal Tretbar photo).

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Conservatism, liberalism, and the ACA
By Charles Katzenberg, M.D. PCMS President

Oct. 5 I was to leave on a backpacking trip to the Grand Canyon, but due to the partial government shutdown, the Grand Canyon was closed. I was in disbelief that any force on earth could close the Grand Canyon. With my newfound free time, I decided to research why politicians would dig in their heels and shut down the government over the Patient Protection and Affordable Care Act. This journey took me on an exploration of the current differences in ideology between conservatism and liberalism. These differences man ifested during debate and passage of the ACA. With the caveat that conservatism and liberalism represent spectrums of political ideology, the healthcare debate serves to focus some of the differences.

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showed up again in 2006 as “RomneyCare” in Massachusetts, and is now universally panned by Republicans as an affront to personal liberty. Regarding the concern over a government healthcare takeover, yes, there is a mandate to have insurance, and yes, there is more regulation. But the private insurance industry, functioning in a quasi-free market competitive environment, will be the engine that drives the ACA. There is no public option in “ObamaCare.” Long before the ACA, federal, state, and local government footprints in healthcare were already large. If we add up tax dollars spent on healthcare for our teachers, firefighters, police, government workers, military, VA, Medicare, Medicaid, plus tax breaks to employers and employees purchasing insurance, we find that tax dollars and tax subsidies are already funding more than 50 percent of American healthcare. The ACA minimally increases the federal government’s footprint. Individuals and businesses who purchase insurance through the ACA Marketplaces will be purchasing private, not government insurance.

The ACA was passed by a divided Congress and vetted by a divided Supreme Court, but that is how our messy democratic republic works. The Court walked a fine line in finding the law, Conservatives argue that the cost of healthcare is already too including the individual mandate, constitutional. They then high and that the ACA will only increase costs further. The ACA turned around and gave the states the right to does increase the cost of healthcare, but the decide on Medicaid expansion. increases are to be paid for by taxes and America’s healthcare surcharges built into the law. Here is common In healthcare as in other areas, conservatives system is neither healthy, ground. Conservatives and liberals both agree support limited federal government with caring, nor a system. that healthcare costs are too high, are growing emphasis on state involvement. They say –Walter Cronkite at unsustainable rates, and that this needs to individual states should be in charge of how be addressed. dollars are raised and spent on healthcare. Conservatives would spend fewer tax dollars, use vouchers, promote free-market and consumer-directed healthcare, require those who purchase healthcare to have more “skin in the game,” and keep healthcare in the private sector with less regulation.

Liberals believe in an empowered central government and support a government-run single-payer or Medicare-for-all approach. All Americans would have cradle-to-grave coverage funded by tax dollars as outlined in HR 676, the bill proposed by Michigan’s Rep. John Conyers, Jr. This is not socialized medicine because the government will not employ physicians or own hospitals, but it is a clear declaration that liberals consider access to affordable healthcare an individual right, not a free-market commodity. There should be no negotiation required when we unpredictably get sick. Conservatism’s ire over the ACA centers on the individual mandate, more government involvement in healthcare, and the belief that the ACA will be too costly. The mandate has an ironically circuitous history. An exhaustive review [1] identifies the individual mandate as a Nixon-era Republican idea hatched in the 1960s, supported by Republican House of Representatives Speaker Newt Gingrich in the 1990s,

When the conservative Goldwater Institute was asked, “What would be a better solution than the ACA?”, its response was “the free market.” Conservatives identify the free market and the private sector as mechanisms to control costs. Private insurance has been active for the past 30 years and costs have risen an average of seven percent per year despite this “free market.” Would more free market and less regulation decrease cost and improve access, choice, safety and quality? The study has not yet been done. Liberals would address costs with a Medicare-for-all approach which would immediately decrease administrative costs by an estimated $400 billion per year [2]. Additional savings would come through negotiating drug and device prices. This approach would also uncouple the employer-employee health insurance relationship. The ACA is massive in size and scope. I am not an adoring fan of the ACA, but it is law and should be given the chance to sink or swim on its own merits. The battle lines are clearly drawn. I think heels are dug in over the fear that the ACA will be successful.
1. http://www.forbes.com/sites/theapothecary/2012/02/07/the-tortuousconservative-history-of-the-individual-mandate/ 2. Friedman G. Funding HR 676: The expanded and improved Medicare-for-all act; How we can afford a national single-payer health plan. http://www.pnhp.org/ sites/default/files/Funding%20HR%20676_Friedman_final_7.31.13.pdf n

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Milestones

Dr. Alberts granted emeritus
David S. Alberts, M.D., University of Arizona Cancer Center director 2005 to the present, was recently granted the title of Director Emeritus, the Arizona Health Sciences Center reports. The title is retroactive to July 1 and will accompany his current title of Regents Professor of Medicine, Pharmacology, Nutritional Science and Public Health. Anne Cress, Ph.D., was named interim director of the cancer center on July 19, AHSC reported. “Your career at the University of Arizona has been more than distinguished, and your years of service to advancing our institution is much appreciated,” said Joe G. N. “Skip” Garcia, M.D., UofA senior vice president for health sciences, in a letter addressed to Dr. Alberts on Oct. 4. “We value the renown and prestige you have built for the Cancer Center, and thank you for your dedication and leadership. The passion by which you have served is evident to all.” Under Dr. Alberts’ leadership, the extensive research portfolio of the UofA Cancer Center includes more than $60 million in annual research funding. Clinically, Dr. Alberts pioneered new treatments for advanced ovarian cancers, including in-vitro tumor cell chemosensitivity testing for personalized medicine strategies, intraperitoneal chemotherapy, and maintenance chemotherapy. Currently Dr. Alberts helps to coordinate Phase I and II and pharmacokinetic drug studies at the center for molecularly targeted chemopreventive agents. His laboratory research is concentrated on evaluation of new surrogate endpoint biomarkers for cancer prevention trials. His National Cancer Institute-funded drug and diagnostics research has resulted in more than two dozen patents and the co-founding of five Arizona pharmaceutical and biotechnology companies. Dr. Alberts has advised numerous cancer research foundations and committees, including chairing the Oncologic Drug Advisory Committee to the Food and Drug Administration (1984-1986). He was a member of NCI’s Board of Counselors (to the Division of Cancer Prevention, 1990-1994); the Board of Scientific Advisors (1999-2006); and the coordinating subcommittee to NCI’s Clinical Translational Advisory Committee (2006-2009). Dr. Alberts has authored or co-authored more than 550 peerreviewed publications, more than 100 book chapters and 60 invited articles, and has served as editor and co-editor of eight books. He has served on the editorial boards of several peerreviewed scientific journals, including associate editor for Cancer Research from 1989-2002. Between 2002-2008, he acted as the co-editor-in-chief of the leading cancer public health research journal Cancer Epidemiology, Biomarkers & Prevention.
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Dr. Alberts earned his M.D. in 1966 from University of Virginia School of Medicine. He interned at the University of Wisconsin, before becoming a clinical associate in medical oncology at the National Cancer Institute’s Baltimore Cancer Research Center. He did his IM residency at the University of Minnesota and then served on the faculty of the University of California at San Francisco, for five years, and obtained board certification in medicine and medical oncology in 1973. He joined the UofA College of Medicine in 1975 as an assistant professor, where he has served for 38 years. The University of Arizona Cancer Center is the only National Cancer Institute-designated Comprehensive Cancer Center headquartered in Arizona and is supported by NCI Cancer Center Support Grant No. CA023074. With primary locations at The University of Arizona in Tucson and at St. Joseph’s Hospital and Medical Center in Phoenix, the center has more than a dozen research and education offices in Phoenix and throughout the state, and 300 physician and scientist members working toward cancer prevention and cure. For more information, please see www.arizonacancercenter.org.

Dr. Beiter as leader
Carondelet St. Mary’s Hospital President and CEO Amy Beiter, M.D. was recently highlighted among the nation’s top 125 “physician hospital leaders,” Carondelet Health Network reports. The One Hundred Twenty-Five Physician Leaders of Hospitals and Health Systems in the U.S. feature was by Becker’s Hospital Review in September. The recognition was based on each leader’s healthcare experience, accolades, and commitment to quality care. Dr. Beiter is one of only three physician hospital leaders in Arizona and the only Arizona female CEO on the list. “Under Dr. Beiter’s leadership, [Carondelet] St. Mary’s Hospital has been named a Distinguished Hospital for Clinical Excellence and a Distinguished Hospital for Critical Care by Healthgrades®, CHN reported. It has “also achieved the Healthgrades’ Patient Safety Excellence Award, placing it among the top 10 percent of all hospitals nationwide for quality and safety. St. Mary’s, a JointCommission certified Primary Stroke Center, is also honored as one of the American Heart Association/American Stroke Association’s Gold Plus and Target Honor Roll Hospitals for Stroke Care.” “St. Mary’s is poised to do even greater things for our entire community,” Dr. Beiter said. “ The addition of new service lines, including Carondelet Heart and Vascular Institute (CHVI) and the Breast Center, will heighten the awareness of the availability and quality of services we provide. We have emerged from a community hospital serving Tucson’s West Side to a facility providing tertiary referral care for the entire community and surrounding region.”
SOMBRERO – November 2013

Dr. Beiter is board-certified in IM and pediatrics. She moved to Tucson in 1992 and began her medical practice at El Rio Community Health Center where she served as chief of staff and developed and managed a free clinic for teens. Also that year she joined the medical staff at St. Mary’s Hospital. After leaving El Rio in 1999 she worked as a hospitalist at Carondelet Health Network. Seven years later Dr. Beiter became the medical director of utilization management at St. Mary’s, soon followed by a position as chief medical officer in 2008. She was promoted to chief executive officer in 2012.

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TMC: Save A Limb program saving lives
Tucon Medical Center reports that its Save a Limb program is saving lives by making amputation the last resort. With diabetes rampant in the region and state, and nearly a halfmillion people affected by the disease according to the American Diabetes Association, one of its devastating consequences is amputation. More than 60 percent of non-traumatic lower-limb amputations occur in people with diabetes, and their mortality rates increase with limb loss. The stated goal of TMC’s Limb Salvage Team is, “Save a limb, save a life.” They work to keep these patients functional with this multidisciplinary approach to advanced vascular disease or peripheral artery disease (PAD). A team of vascular and podiatric surgeons, nurses, technicians, and registered dieticians coordinate care to save limbs and prevent amputations. “The surgeons on this team are considered experts in this area,” said Dr. Matthew Namanny, a vascular surgeon with Saguaro Surgical. “If patients are suffering from severe PAD or wounds, or if the patients are identified by physicians and nurses in hospitals and clinics, we want them sent here so that we can do everything possible to prevent that amputation. That’s what we want to be known for.” The team uses the most advanced methods available to treat patients, like rapid endovascular interventions, synthetic skin substitutes, and prophylactic elective surgery to eliminate bio-mechanical foot abnormalities. “We have a prevalent Native American population here,” Dr. Namanny said, “and a lot of our population is at high risk for PAD because of obesity, coronary artery disease, and hypertension. Having the Save A Limb program available at a community hospital is such a huge benefit to patients in Southern Arizona as well as in the rest of the state. Our team helps hundreds of patients a year, but we know there are hundreds more who could benefit.” n
SOMBRERO – November 2013

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PCMS News

New law: Post prices of most common services
A new state law reflecting an effort toward medical cost transparency takes effect Dec. 31, according to information from the Arizona Legislature. House Bill 2045 requires healthcare providers to make available on request or online the direct-pay price for their 25 most commonly provided services, and to update the price list at least annually. Failure to do so is considered unprofessional conduct and subject to AMB discipline. The legislation applies to MDs, DOs, podiatrists, chiropractors, optometrists, physical therapists, and occupational therapists. Are there exemptions? Yes. Healthcare providers who are owners or employees of a legal entity with fewer than three licensed healthcare providers are exempt. Emergency services are exempt. Healthcare services provided by the Veterans Administration, military, Indian Health Service, tribal clinics, and the Arizona State Hospital are exempt. What does “direct-pay price” mean? The price charged by a healthcare provider for a lawful healthcare service, regardless of the health insurance status of the person. This price must be for the standard treatment provided for that service, but may include the cost for complications or exceptional treatment. How do I make this available? Online or on request. The 25 services can be identified by CPT code or in plain language. How do I calculate my 25 most commonly provided treatments? Probably by billing codes. You may use any 12-month period within the last 18 months to calculate your most common treatments. Will I get any guidance from my licensing board? The affected licensing boards have many questions as well about how the new law should work. As of now, there is no effort to interpret the law by the Arizona Attorney General’s office or any of the licensing boards. Anything else? We understand that this new mandate is fraught with legal, professional, contractual, ethical, and antitrust difficulties. Log onto the Society’s website pimamedicalsociety.org and click on the HB2045 tab. You’ll be able to print out the bill’s pages that impact physicians. You will want to at least discuss this with your office manager and, perhaps, others in order to make a good effort to comply with the law. What if someone has an insurance plan I accept, but wants the direct price? Then you need to provide your patient or your patient’s employer a consent form substantially similar to this:
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Important Notice about Direct Payment for Your Healthcare Services The Arizona Constitution permits you to pay a healthcare provider directly for healthcare services. Before you make any agreement to do so, please read the following important information: If you are an enrollee of a healthcare system (more commonly referred to as a health insurance plan) and your healthcare provider is contracted with the insurance plan, the following apply: 1. You may not be required to pay the healthcare provider directly for the services covered by your plan, except for cost share amounts that you are obligated to pay under your plan, such as co-payments, co-insurance, and deductible amounts. 2. Your provider’s agreement with the health insurance plan may prevent the heathcare provider from billing you for the difference between the provider’s billed charges and the amount allowed by your health insurance plan for covered services. 3. If you pay directly for a healthcare service, your healthcare provider will not be responsible for submitting claim documentation to your health insurance plan for that claim. Before paying your claim, your health insurance plan may require you to provide information and submit documentation necessary to determine whether the services are covered under your plan. 4. If you do not pay directly for a healthcare service, your healthcare provider may be responsible for submitting claim documentation to your health insurance plan for the health care service. Your signature below acknowledges that you received this notice before paying directly for a healthcare service.

PCMF CME at PCMS

Far too many initials for a headline, they mean that Pima County Medical Foundation’s Nov. 12 CME event in its Tuesday Evening Speaker Series takes place at the medical society building. It is Robotic Surgery: What it Means for the Future, with the UofA’s Dr. Robert Poston, cardiothoracic surgeon, and Dr. Sanjay Ramakumar of Urological Associates of Southern Arizona.

PCMSA Holiday Luncheon Dec. 11

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

Toward a Science of Consciousness 2014

Toward a Science of Consciousness 2014, the 20th Anniversary “Tucson Conference,” is April 21-26 at Marriott University Park Hotel, 880 E. 2nd St., Tucson. TSC put out a call for abstracts with its announcement:
SOMBRERO – November 2013

“Since 1994 TSC has been the world’s largest and longest-running interdiscplinary conference approaching fundamental questions related to conscious experience. TSC brings together researchers in neuroscience, philosophy, psychology, biology, quantum physics, cosmology, meditation, altered states, machine consciousness, culture, experiential phenomenology and contemplative approaches. “An estimated 800 participants from more than 60 countries are expected. The TSC program will include plenary and keynote talks, concurrent talks, posters, art/science demos and exhibits, pre-conference workshops, side trips, and social events in the TSC tradition. Speakers will reflect on progress over the last 20 years, current state and future directions in the study of consciousness.” Program co-chairmen are Stuart Hameroff, M.D. of the Department of Anesthesiology and Psychology, Center for Consciousness Studies, The University of Arizona, and David Chalmers, Australian National University, New York University. Conference manager is Abi Behar-Montefiore, assistant director of the Center for Consciousness Studies. Submit bbstracts online by Dec. 15. Please see https://sbs. arizona.edu/project/consciousness/ Abstracts will be considered for oral and poster presentations and for art/tech demo sessions. University of Arizona students and faculty are invited and encouraged to submit abstracts. The Center for Consciousness Studies (CCS) at the University of Arizona was established in 1997 by the Arizona Board of Regents with a grant from the Fetzer Institute, and is hosted by the Department of Anesthesiology at the University of Arizona College of Medicine—Tucson.

Although Dr. Iserson had worked in resource-poor situations in Latin America throughout his career, he found that “practicing in rural Africa required an entire change in mindset and involved a more intense cultural adaptation, as well as increased concerns about security and my own health.” His new guide is the result of his work on all seven continents, including six months as USAP Lead Physician in Antarctica, is for those who want to take the plunge into global healthcare, but are unsure how to choose an organization and prepare for the experience and for living abroad. Dr. Iserson says he wrote the book “to encourage healthcare professionals and students to volunteer globally without making the easily avoidable mistakes that I made. I learned the information in this book through hard experience, rather than through the easier process of reading it in a book. There was no book!” Despite his caveat about global work, Expect the Unexpected, Dr. Iserson’s book provides “a wealth of practical information, including the nuts-and-bolts details of vaccinations, travel documents, international communication and what to pack—all tailored for the healthcare professional and student. The book contains extensive information about NGOs (non-governmental organizations) and other groups whose goals are to improve global medical care. “Perhaps most valuable, the author addresses the professional challenges volunteers may face when working in developing countries, illustrated by personal anecdotes from around the globe. Dr. Iserson’s international work also led him to write Improvised Medicine: Providing Care in Extreme Environments [McGrawHill 2012], a manual for those doing clinical work in resource-poor settings. International volunteering can put professionals in busy practices back in touch with the reasons they entered healthcare. As Dr. Iserson says, “I had always worked a bit on the edge, as medical director of our wilderness search and rescue team and, more recently, as part of our state’s Disaster Medical Assistance Team (DMAT), but my international medical work took me to the edge of my professional comfort zone. I learned a lot, helped patients and local healthcare providers, and reminded myself why I love to practice medicine.” n
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Dr. Iserson writes on
Dr. Kenneth V. Iserson’s latest book is The Global Healthcare Volunteer’s Handbook: What You Need to Know Before You Go, available from Galen Press in January 2014 and with a 20 percent discount before Dec. 31. Apropos of that, Dr. Iserson tells us he will be leaving around Thanksgiving on his next international medical trip to spend a month in Georgetown, Guyana as the Visiting Professor of Emergency Medicine at their residency program. Kenneth V. Iserson, M.D., M.B.A., F.A.C.E.P., F.A.A.E.M is a Fellow of the International Federation for Emergency Medicine and Professor Emeritus, Department of Emergency Medicine, University of Arizona College of Medicine—Tucson. Information about the book is at Galen Press, Ltd., Box 64400, Tucson, Ariz. 85728-4400; www.galenpress.com; sales@ galenpress.com; phone 520.577.8363; fax 520.529.6459. The need for global healthcare volunteers is critical, Dr. Iserson says. More than a billion people worldwide lack access to quality health services, in large part due to both a shortage of trained doctors, nurses, and support workers and their uneven geographical distribution. Yet, for the many healthcare professionals and students who would like to volunteer their services, the path to global volunteering can be confusing and disorienting. Once they arrive abroad, life can be stressful, if unprepared for the differences from home.
SOMBRERO – November 2013

In Memoriam
By Stuart Faxon

during the 1960s, in whose service he practiced medicine at the old Pima County Hospital on South 6th Avenue. Dr. Edwards deeply enjoyed his medical practice and his patients, and devoted his entire efforts to bringing them back to health.” In 1961 Dr. Edwards became the second full-time surgeon hired for Pima County Hospital. In 1964 the Star reported that Dr. Edwards had been hired as a physician for the City of Tucson at an annual salary of $10,000. He examined and treated city prisoners, did physical exams of city job applicants, and re-examined police and fire personnel. At PCMS Dr. Edwards served on the Insurance and Industrial Relations Committee and as PCMS’s representative on the Advisory Committee to the Tucson Committee on Economic opportunity. “At home, his instincts as a physician benefited a family of dogs and cats and, at times, abandoned young javalinas,” the family reported. “Dr. Edwards’ wonderful sense of humor, often including off-color jokes (when appropriate), earned him friendship with anyone and everyone at any time. He was a master at random acts of kindness.” Dr. Edwards’ sister, Helen Edwards Osborne of Tucson; brother John Milton Edwards of Palmer, Alaska; nephews John Edwards Osborne of Tucson, Bryant Edwards of Palmer, Alaska, and Earle Jason Osborne of Sunsites; nieces Nelta Edwards of Anchorage, Alaska, and Pamela Ruth Osborne of Arivaca;and their children and grandchildren. Memorial services were on Sept. 20 at Adair Funeral Homes Avalon Chapel, Tucson. The family suggests memorial donations be made to the shelter for the homeless of the donor’s choice. n

B. Thomas Edwards, M.D., 1925-2013
Dr. B. Thomas Edwards, general surgeon and Tucson native who practiced here for nearly 40 years, and who joined PCMS in 1964, died of natural causes on July 10, the family reported in the Arizona Daily Star Oct. 17. He was 88. Benjamin Thomas Edwards, known as Tom, was born March 31, 1925 in Tucson to Benjamin Bryant Edwards, M.D., and Gladys M. (Nicholson) Edwards.

Dr. B. Thomas Edwards in 1964.

Tom went to Tucson public schools and attended The University of Arizona 1943-46, where he took pre-med courses. He earned his M.D. in 1950 at Columbia University College of Physicians and Surgeons, New York City. He interned and did his GS residency at Charity Hospital of Louisiana at New Orleans. (The senior Dr. Edwards, born in Alabama in 1887, a pulmonologist who joined PCMS in 1949, also earned his M.D. at Columbia, in 1914.) After graduating from med school Tom joined the U.S. Air Force, the family reported. “He was primarily stationed in Turkey,” serving as chief of surgery at USAF hospitals in Ismir, Turkey, and Tripoli, Libya. “Upon his return … he continued in public service, acting as the only doctor serving the Defense Early Warning system—the DEW line” as it was then called, “radar stations in Alaska that protected our country from the threat of nuclear war in the late 1950s. He flew all over Alaska to serve the service personnel on the DEW line as well as, when called upon, the Native American communities. He often provided the only medical care these communities had seen on-site before, and brought many children into the world there. “Upon his return to Tucson to start his medical practice in 1960, Dr. Edwards opened a practice with Brett Czerny, M.D. Dr. Edwards also acted as a surgeon for Pima County
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SOMBRERO – November 2013

11

Bioethics

Prognoses for patients in persistent vegetative state, and minimally conscious state
By Dr. David R. Siegel

I

n our illustrative and very imaginary case, Dick and Jane Small emerge from the Heart Attack Café after a nifty 5,000-calorie midday repast on the first full day of their dream vacation to Las Vegas.

They were a loving couple with no children and no close family. Back home they had run their own business, which kept them working pretty much nonstop for the last 10 years. Without close family and without time to socialize and develop friends they depended on, they confided mainly in each other. They were proud to say they could speak with one mind. Both planned on a full, long, happy life together. Illness was not a part of their future, and something they never talked about. And certainly they had no living wills. Nor had they really paid attention to health issues. Neither had had any sort of checkup or preventive medicine evaluation with a primary care physician in years. Both checked in with BMIs ranging between 45 and 50. As the loving couple emerged in the midday sun, Jane suddenly said she was very dizzy and promptly sat down on the sidewalk only to slump to her side without another word. Dick screamed for help. A passerby called 911 and checked for breathing and a pulse. Finding no sign of life he promptly began CPR. Dick was overwrought and at that point fainted, his head hitting the pavement with an audible thud. Paramedics arrived only 10 minutes after the 911 call. Jane was found to be unconscious and in pulseless electrical activity (PEA). Attempted resuscitation in the field was performed with great difficulty. She could not be intubated by the paramedics and successful intubation was only accomplished in the ER. She was finally stabilized and treated with standard hypothermia protocol. Initial CT scan of her brain was normal. As we recall, Dick fainted and suffered severe head injury upon impact with the pavement. He was treated with standard trauma precautions and transported to the local trauma center. Initial CT scanning showed large right-sided SDH with significant mass effect and evidence for 2 cm right to left shift. He was promptly taken to the OR for emergent surgical treatment after which he was treated in a state-of-the-art neurosurgical ICU. He had significant elevation of intracranial pressure which was addressed aggressively. Fast-forward one month: Both of our patients survived but remained critically ill with diagnoses of persistent vegetative state (PVS), also now termed as unresponsive wakefulness syndrome (UWS). At three months, Jane was still classified as in UWS. Dick,
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however, demonstrated inconsistent purposeful responses to different examiners and was reclassified as demonstrating a Minimally Conscious State (MCS). His neurologic exam varied by clinician and/or his overall clinical state. At times he, too, appeared to be in UWS. Since the mid-1990s the concept of persistent vegetative state (or unresponsive wakefulness syndrome or UWS, considered a less pejorative term) has taken hold. The condition results from massive injury, traumatic or not, to the cerebral cortex, thalamic structures, and white matter tracts that connect them. A condition often following eyes closed coma, UWS patients exhibit no awareness of self or environment. They do not follow commands, do not exhibit purposeful reproducible behaviors, and they demonstrate no ability to produce or comprehend language. But such a patient may have intact or partially intact sleep-wake cycles. The patient in UWS may briefly shift gaze in response to a visual stimulus, but does not track. And such wakefulness may be interpreted by the inexperienced (or hurried) clinician as well as family members as awareness of self or environment. They have sufficient intact brainstem and hypothalamic functioning to let the body survive with good nursing care. The “vegetative” state (UWS) becomes persistent when it lasts more than one month. Prognosis for improvement to a state of even partial or intermittent awareness depends in part on etiology. Patients with trauma as etiology may show such recovery up to one year, but rarely beyond. Patients lingering in UWS for three months after anoxic brain injury rarely improve. However, just as patients may improve from coma to UWS after several weeks or months, it has become apparent that patients with UWS may clinically improve to a clinical state of some awareness of self and environment, even if only partial or intermittent. Such patients may demonstrate, if only inconsistently, the ability to follow a simple command, may be able to produce a gesture or verbalization to reliably answer yesor-no questions, produce some intelligible verbalizations, or produce purposeful, not reflexive, motor responses. But the patient who has thus improved to a MCS remains profoundly disabled, requiring full nursing care and having very poor prognosis for recovery to functional independence. Both conditions have underlying severe damage to cerebral cortex, thalamic structures, and white matter connecting tracts. Thus, UWS may be temporary as the patient improves, or may be permanent. Likewise, patients exhibiting MCS may show some improvement with time Skillful clinicians may come to different conclusions regarding the state of awareness and actual diagnosis, that is, UWS or MCS.
SOMBRERO – November 2013

This has led to family members being presented with different diagnoses with quite different prognoses as well as implications regarding current status of their loved ones.

For example, can or cannot the patient perceive pain, physical or t is incumbent upon anyone who wishes emotional? Patients in UWS are But quality of life is at times a very to have a voice in his or her own care, considered insensate in this nebulous and contentious notion. under circumstance such as discussed regard. The patient in MCS, in The slippery slope, or law of here, to consider and execute very contrast, is considered capable of unintended consequences, enters. perceiving pain. Newer objective Where some see no quality of life, explicit advance directives. coma and post- coma recovery others see life and all the potential scales (e.g., Coma Recovery Scale) help to provide consistent that it brings. And certainly if our ability to accurately diagnose the objective measurements to monitor patient progress, or lack UWS state is limited by available clinical and technological tools, the thereof. It is hoped that these types possibility of error in diagnosis is great. There is a fear that the mere of scales should also reduce inter-observer variation and diagnosis of a patient with either condition, UWS or MCS, will lead to examiner bias. termination of care or patient abandonment.

‘I

their loved one has survived and improved to MCS state, then aggressive medical care, including appropriate rehabilitation services should be pursued. Some might see no quality of life in either condition, and support termination of care.

Recent technological innovations have certainly humbled the clinician. Patients who are diagnosed with UWS clinically (and therefore who demonstrate no discernible purposeful response to simple commands, etc.) may demonstrate activation of higher level cerebral cortex on functional imaging studies (fMRI or PET) or by newer EEG paradigms. However, these technologies can still be considered experimental, or at least impractical, at the community level. Nevertheless, such technologies may someday be useful in predicting which patients in clinically diagnosed UWS will recover at least a modicum of awareness. Some have hypothesized that use of functional imaging may lead to ability to enable patients to answer yes-no questions reliably, and thus be the basis for communication. But, for the moment, such speculation is just that and not established science. So what lessons do our imaginary but very instructive patients teach us? Several ethical dilemmas confront the medical provider in caring for such patients. First, what does the patient wish for himself/ herself? The basic principle of autonomy requires that the individual be able to make basic choices over care, including continuation and termination of even lifesupporting care. We as individuals accomplish this in a number of ways. Advance directives may clearly guide health professionals in honoring individual choices even when one is no longer able to communicate and advocate for oneself. The ability to differentiate between UWS and MCS clinical states is crucial. If the UWS patient, reliably diagnosed, has wakefulness but no awareness and cannot feel pain, then that patient, through advance directives, or the patient’s family or other surrogate, may elect termination of critical life-sustaining care. This brings us to a tricky concept: that of quality of life. While some family members, or other surrogate, may conclude that since

So, our imaginary patients are very instructive. It is incumbent upon anyone who wishes to have a voice in his or her own care, under such circumstances as described here, when conscious and able, to face their own mortality. And there is no better way to do that than to consider and execute very explicit advance directives and to share those directives with trusted family and friends. So too could healthier lifestyle choices, and maybe a little preventive care along the way, go a long way toward avoiding these outcomes in people who should be enjoying the prime years of their lives. Neurologist David R. Siegel, M.D., is a member of the PCMS Bioethics Committee and a PCMS past-president. n

SOMBRERO – November 2013

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SOMBRERO – November 2013

Behind the Lens

Newest Navajo casino impressive
By Hal Tretbar, M.D.

I

n May the Navajo Nation opened their newest casino at Twin Arrows, 25 miles east of Flagstaff on I-40 at the Nation’s southwestern tip. “It brings jobs that we didn’t have in the past, it brings revenue, and it brings recognition to the Navajo Nation and Navajo people,” Navajo Nation President Ben Shelly said.

As I drove east from Flagstaff to the casino I thought about famous U.S. Route 66 across northern Arizona that later became Interstate 40. Roadside attractions developed along Rt. 66 to lure travelers to stop and spend their money. The town of Two Guns began in the 1920s. It had a zoo that included mountain lions.

The casino wall evokes the feeling of swirling Reservation winds. The entrance and the hotel are at the far end.

A few miles farther west, the Twin Arrows Trading Post had a gas station and an enticing diner. Over the ensuing years these attractions failed and the two became ghost towns. Now the Twin Arrows casino, across the road from the old Trading Post, is a new roadside attraction. The Navajo Nation Gaming Commission was established in 2006 with a long- term goal of building five or six casinos within the Nation’s boundaries. The first was Fire Rock Navajo Casino near Gallup, N.M. in 2008. The second was Flowing Water Navajo Casino in 2010 near Shiprock, N.M. Northern Edge Navajo Casino opened in 2012 near Farmington, N.M. The Twin Arrows Navajo Casino Resort is an ambitious effort to become a desirable resort destination. Currently there are 90 sumptuous hotel rooms including a 2,000-square-foot Presidential Suite with all the upscale amenities. An additional 110 rooms will be completed in 2014. They plan to complete the Hozho Spa next year. “Hozho” is the Navajo concept of balancing life and beauty. Presently the large heated indoor pool and fitness center are open. When completed there will be mineral pools, therapeutic massage, and a tranquility room. The Conference and Banquet Center has already hosted conferences in its multiple meeting rooms and 8,000 square foot ballroom. Audio/visual equipment is the finest available. There are two spacious outdoor event spaces. Plans include a golf course, gas station, and RV park. There is the possibility of housing, shuttle service, and even an airport.
SOMBRERO – November 2013

The casino and resort were designed to reflect Navajo culture and tradition. This became evident as I pulled into the parking lot a half mile north of I-10. The sandstone-colored casino has sweeping contours consistent with swirling desert winds. The five-story hotel windows lookout through had a basket-weavepatterned exterior to the enduring distance. The multicolored main entrance faces east to capture the rising sun in the manner of a hogan. The top of the building displays two outward-bound arrows that serve as a metaphor of the journey of the Navajo throughout time. The Twin Arrows website offers the best description about coming in the main entrance: “Guests enter through a black, textured, stone vestibule—a contemporary abstraction of the First World, a place filled with mist (fountain) and sound, where the Insect People dwelled. “The vestibule leads to the large design captured rotunda. This volume of space features colorful embodied concepts relating to the Emergence and the Four Worlds. Stone walls surround the space, supporting four very large, sweeping panels. Each one depicts a different world and the Dine people who came before. Starting to the south, first World of the Insect people: to the west, the second World of Bluebirds and Swallow people: to the North, the third World of the Grasshopper: and east, the fourth World, where Man and Woman came to be. “A custom, shimmering chandelier is the central focus of the
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rotunda. It symbolically depicts the vertical rise of the people through each world. Hand-blown glass rings, black (north), blue (south), yellow (west) and white (east) represent the colors of each world. Droplets of crystal cascade down through the rings, like water streaming from above. Through the center of the shimmering chandelier, two chrome tubes recall the reeds that were used to enter through the Hard sky of the world.” I toured Twin Arrows Navajo Casino Resort with the help of Lane Archer. He had grown up on the reservation at Pinon and graduated from NAU with a degree in business. He met me at the hotel desk. “Welcome to Twin Arrows,” he said. “Please feel free to photograph any thing but the casino gaming area.” We started by looking down into the fascinating infinity reflection circle in the middle of the rotunda floor, “It is very popular with our guests because it appears to be a bottomless pit,” Lane said. The hotel rooms are tastefully appointed using Navajo themes. Standard room rates start at $159 Sunday through Thursday and $179 Friday and Saturday. Suites start at $389. The conference area was bustling with meeting activities. Delegates were busy talking while standing on the laser-cut stone floor medallion “wedding basket” that is perfect for photo opportunities. Lane took me to the Casino on the south side of the rotunda. “We have over 1,000 slot machines, electronic craps, roulette, and baccarat. There are 18 gaming tables and 12 poker tables. There are keno screens everywhere.” “Look at the ceiling. The light fixtures represent the stars of the Milky Way. And here in the center of the casino is a silver and bronze drapery that has patterns of grasses and reeds.” Lane went on to show me the Dine (Navajo) inspired café and restaurants. The Four Elements Café reflects the attributes of sky, earth, water, and fire. The 24-hour service offers a Southwestern menu with breakfast specialties of Navajo pancakes, baked sweet breads and smoked salmon. The food court on the casino floor offers traditional sandwiches as well as Navajo fry bread tacos and mutton stew. Arrows Sports Bar is surrounded with 19 large-screen TVs. You can munch on the usual wings, nachos, and burgers, and wash them down with various local and international beers. The décor honors traditional Navajo warriors with bow patterns, arrow stripes, and chief-blanket designs. The Reef seafood bar seats only 34, but you can still slurp down raw oysters, savor sushi and sashimi, and partake of many other ocean delicacies. It is open Thursday to Sunday. Twin Arrows’ flagship restaurant is Zenith Steakhouse with its open
16 This rotunda wall panel represents the Second World of the Bluebirds and Swallow people. SOMBRERO – November 2013 The rotunda chandelier with the four glass rings of white, yellow, blue, and black represents the Four Worlds the original Dine (Navajo) passed through. Ya-at-eeh says welcome.

The infinity reflection circle fascinates visitors of all ages. You can’t see the bottom.

exhibition kitchen, fireplace, and wine cellar display. The high nest of the eagle inspires the decor. The entrance light fixture is woven like an eagle’s nest. The entrance stone walls evoke shear cliffs where nests are built. Intimate eating areas are created and booths are separated with partitions of small birch tree trunks. Cocktails and 250 fine wines are available to complement the Kobe steaks. Zenith also offers the finest of Navajo-raised and carefully selected beef from the reservation. It’s another way of supporting the Dine nation. In the other Navajo casinos, alcohol is available only in certain restaurants. In July of this year Navajo Nation President Ben Shelly signed legislation that allows alcohol on the casino floor of Twin Arrows. It was deemed necessary to meet competition from other Arizona casinos. I thanked Lane for his tour and helpful information. He reminded me that Twin Arrows is on the Navajo Reservation and that it observes Daylight Savings Time, unlike the rest of Arizona. I was impressed by how Navajo culture and traditions have been worked into every aspect of the attractive Twin Arrows Navajo Casino Resort. (www.twinarrows.com)
SOMBRERO – November 2013

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The ‘wedding basket’ design in the floor of the conference center is the perfect place for a photograph

Shane Archer appears ready to order a Kobe beef steak in the suave Zenith Steakhouse. Birch tree trunks act as decorative dividers.

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SOMBRERO – November 2013

SOMBRERO – November 2013

19

PerspecƟve

Med students, new docs undeterred by doctors’ ‘malaise’
By Ole J. Thienhaus, M.D., M.B.A.

W

e hear a lot about morale problems of American physicians. Quite a few doctors retire early. Others declare that they would not choose medicine as a profession again if they had the option.

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Common issues include the intrusion of bureaucratic requirements into our practices; hassles of dealing with insurance companies’ malpractice concerns; competitive threats from nonphysician providers; and the difficulty making a decent living while also enjoying life outside the office or hospital. Most recently the advent of the Affordable Care Act becomes another for feelings of dejection. As a member of the faculty at The University of Arizona College of Medicine, I have these well-publicized issues on my mind when I work with medical students, and even more when I interview applicants for medical school admission. Are these young people misguided? Are they so naïve that they do not understand what awaits them? Have they read about corporate medicine in the papers? Do they really think they can work hard, make it through medical school and residency training, and then hang a shingle on their door and start seeing patients? Hardly. Today’s medical students are well aware of the challenges that await them; yet they are motivated by the same feelings that caused me and my generation to become doctors. They want to work with people, fix diseases, make patients well or at least better, and are drawn to the unique combination of natural sciences and personal rapport that is at the core of most of clinical medicine. They are also well aware of the reported disenchantment of so many of our current physicians. After all, they are exposed to media. They also have had encounters with the healthcare system as volunteers or as patients. They are anything but naïve. I propose that we, the current generation of doctors, may confuse the context of practice with practice itself. When I graduated from residency at the University of Cincinnati in 1985, most of my peers opened private practices or joined existing small group practices. In our last graduating residency class in psychiatry here in Tucson, not a single
SOMBRERO – November 2013

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graduate chose that option. Rather, our newly minted, independently licensed physicians choose to work for an employer who reimburses them with a paycheck, whjether it’s the Veterans Administration, the College of Medicine, a private healthcare service organization like Kaiser-Permanente, or a community clinic. And, as far as I can make out, they don’t mind. If we consider the widely reported doctor’s malaise epidemiologically, I believe that their discontent with medicine is a cohort phenomenon. I propose that it is predicated on the older generations’ concept of a fee-for-service practice model. In fact, that model in its pure form was already unrealistic by the time any currently practicing physician entered the workforce. The days of patients paying for care by handing the doctor cash or a check for services rendered have fallen victim to the technical advances medicine has enjoyed over the past half-century or so. The fee-for-service model will continue for barbershops and restaurants, for instance, but is doomed in the context of a capital-intensive industry like ours. An economist might question whether it ever was appropriate to treat medical services that way, given the non-discretionary context of most purchase situations. The large discrepancy in knowledge between consumer and provider about the services purchased further distorts the possibility of a straightforward market transaction. The reforms coming with the Accountable Care Act are obvious signals that the final nails to the coffin of fee-for-service medicine are being hammered. Delivery models such as Accountable Care Organizations (ACOs), Patient-Centered Medical Homes, etc. are adaptive market responses to this new environment. Sombrero recently detailed the ACO developed by Tucson Medical Center, and undoubtedly, there will be more opportunities to showcase adaptive and innovative pilot projects in our community over coming years. Bundled payments and value-based purchasing are the watchwords. A zero-sum, rewardversus-penalty formula for reimbursement of quality-rated care has already come into existence. The distribution of bundled reimbursements to, say, an ACO, will be the responsibility of the team that owns the care product, and the tensions that in the past occurred between payers and providers will be displaced by negotiations between providers. Traditionally, physicians have been somewhat shielded from truly competitive pressures thanks to licensure requirements and the necessity for most clinical services to have a clinician on site. But the massive intrusion of non-physicians into the independent medical practice arena has begun to redefine scope of practice boundaries for many of us. Farming out of diagnostic radiology services, for instance, to low-cost third world countries is a
SOMBRERO – November 2013

harbinger that in the long run we are no more secure in our privileged position than are, for example, computer service technicians. That American medicine is going through revolutionary change is hardly an exaggeration. Trying to sum up the developments succinctly, it is reasonable to state that medicine is coming into greater alignment with other service industries in which the consumer is driving transactions, and perceived as the focus of the vendors’ efforts who compete for his or her business. We may deplore this development. And I understand that many of my contemporaries find it hard to adjust—after all, I am in this group of established doctors myself. Our nostalgia is partly rooted in traditional professional ideals, but also in a yearning for a less exposed and competitive position in society. All this is plausible. But let’s not throw out the baby with the bathwater. Medicine as a profession is as rewarding as ever on its own merits. It is a testament to our students, trainees, and future students that they seem to appreciate that for our 115 spots in the 2013 incoming class at the University of Arizona College of Medicine— Tucson, we had 4,200 applicants. Our future physicians see themselves as participants in the new service-oriented environment, and they cherish the opportunity to practice their profession in it. Dr. Thienhaus heads the University of Arizona College of Medicine Department of Psychiatry. He joined PCMS in 2012. n

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SOMBRERO – November 2013

Time Capsule
Story and Photos by Stuart Faxon

A Tombstone epitaph

Y

ou know what old men do. They talk about the past because they have plenty of it and very little future. So here goes: The last street-level journalism experience I got before getting my first newspaper job in Cottonwood in 1980 was working as a UofA grad student on the Tombstone Epitaph community edition, then and now run by UofA journalism grad students, though now it’s mainly online. Shortly after my time there, our new Executive Director Bill Fearneyhough was editor. We were all known to each other as “Epistaffers.”

Feature writing was my forte and in 1979—the original Epitaph story now long-lost—I wrote a feature on century-old Sid Wilson of Tombstone (18791981). My photos were blackand-white. I always used b&w film back then. I was strictly a newspaper guy and it seemed more authentically “newspaper.” I recently rediscovered those photos in a corner cache unchecked for a dozen years after my 2000 move to my present house. “Cowboy” was coined in Tombstone’s heyday to describe the Clantons and other horse thieves who battled thenlawman Wyatt Earp, the Earp brothers, and their friend the notorious Doc Holliday. The cowboys eventually lost to the Earp faction, but not before plenty of blood was spilled. In the 20th century “cowboy” came to mean all the hardworking jamokes who ride and work horses and cattle on the range, or ranch, or in rodeo.
SOMBRERO – November 2013

Sid Wilson was a wiry little guy who made his hats look even bigger. Here he displays one of those touristy joke headlines made up for his birthday.

The sign for Sid Wilson’s ‘A Pick ’Em Up’ ranch south of Tombstone’s O.K. Corral.
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By the late 1970s Sid Wilson was one of last of the 19thcentury Arizona cowboys. He played that role in Hollywood movies and bronc-rode in Buffalo Bill Cody’s Wild West Show. The show performed before Queen Victoria in 1901, the last year of her 60-year reign. Sid entered the film business as a stuntman for “Bronco Billy” Anderson in the years before World War I. Born in 1880, Anderson was a year older than Sid. Billy acted three parts in the first big-box-office hit Western, 1903’s “The Great Train Robbery.” Sid had a longtime interest in horsedrawn vehicles and built and repaired them in a shed on his “A Pick ’Em Up” ranch south of the O.K. Corral, where these photos were taken. He also served as mayor of Tombstone, and did an early restoration of the O.K. Corral. American civilization’s advance knocked off the Old West quickly, as historical epochs go. At the time I interviewed the often-drunk old rascal, he was celebrating his 100th birthday, as one of these photos indicates. What a legacy! I did get to pass around the bourbon bottle with him, which seemed to be required of guests. In 1980 Sid responded to an interviewer who asked how much the West had changed since his youth. “In every way that’s imaginable,” Sid said, adding that the sun and moon still come up and down the same, “and that’s about it!” He lived two more years. n A stagecoach in creation at Sid Wilson’s ranch.

Part of Sid Wilson’s workshop with tools of his wooden trade.

Sid Wilson’s water tower—or something.
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Sid and celebrants pose for one of the endless photos taken that day— including mine.
SOMBRERO – November 2013

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1938-2013

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Mayo CME

December

Dec. 6-8: The 8th Annual Practical Course in Dermoscopy & Update on Malignant Melanoma is at Westin Kierland Resort & Spa,6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.624.1202 or 1800.354.5892. Accreditation 21.75 AMA PRA Category 1; 21.75 AOA Category 2-A. Course designed to “provide multidisciplinary review of standard of care management practices and state-of-the-art advances in care of patients with cutaneous melanoma.” First day focuses on epidemiology, prevention, pathology, advances in genomics, and medical and surgical treatment in association with melanoma. Last two days are in-depth immersion in dermoscopy for imaging of melanocytic and non-melanocytic skin lesions, including three breakout sessions. Dermoscopy section primarily targets clinicians, but also educators and residents. Website: http://www.mayo.edu/cme/dermatology-2013s959 Contact: Cassandra Skomer, Mayo Clinic Scottsdale, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323 mca.cme@mayo.edu http://www.mayo.edu/cme

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 .

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.

January 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, 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

February 2014

Members’ Classifieds
SEEKING NP FOR PAIN MANAGEMENT PRACTICE: The Integrative Pain Center of Arizona is currently recruiting a Nurse Practitioner. We are Arizona’s only pain clinic to be designated by our specialty society as a Center of Excellence. If you are interested in working in a patient centered environment where the goal is to help patient’s find their way to wellness, whatever it takes, this is for you. Candidates are urged to review the IPCA website www.ipcaz.org. Job duties include intake evaluation; assessment of physical activity, diet, health risk factors and screening for mental health/behavioral risk factors; ongoing management of patients that includes pain treatment, diet and exercise, oversight of the integration of behavioral health treatment into the care plan, use of complementary and alternative medicine consultants, use of procedures to treat pain including routine injections, minimally invasive techniques and referral for surgical evaluation, and more. You will be working closely with experienced pain medicine practitioners. Successful candidates must have a current Arizona license and unrestricted prescribing privileges. Interested applicants please send resumes to bdavis@ipcaz.org. PAIN MANAGEMENT PHYSICIAN NEEDED: Physician needed to join our Pain Management group practice that is expanding to meet current demand in our community. Full-time/parttime. Previous experience in a clinic setting is a plus, however, we are willing to train the qualified candidate that has the ability to work and collaborate in a team-effort environment with providers, supervisor, and ancillary staff. Patient care to include physical assessment, exam, formulation of care plans, new patient intakes, patient follow-ups, ordering, performing and interpreting diagnostic tests such as UDS, labs, imaging, etc., review and maintenance of records, patient education, and medication management with prescription writing and appropriate referrals. We offer competitive pay and benefits, including PTO, medical/dental insurance with a discount vision plan available, & paid holidays. Will share on-call approximately 2 - 3 times per month with 1 weekend approximately every 5 - 6 weeks. Send Resume to karla@desertpainandrehabspecialists.com or fax: 602-331-2499. ATTN: Karla. MEDICAL OFFICE SPACE AVAILABLE: Modern, professional office space is available at Swan and Pima. Easy accessibility for patients and conveniently located near TMC and St. Joseph’s Hospital. Space is available immediately. Number of exam rooms, space, terms and rent is negotiable. Please contact Susan Wolff at 520-546-2420. CABIN FOR SALE: Idyllic Mt. Lemmon retreat, with breathtaking view of Marshall Gulch. Arguably the best view on the Mountain. Located on deeded land in Sabino Loma Pines subdivision with the largest individual lots on the mountain. Extremely private with year round access. For details contact: Philip Fleishman M.D. at 444-8226.

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