Professional Documents
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AUGUST/SEPTEMBER 2013
So, what about the physician shortage? Monument Valley loses a monument
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SOMBRERO
Pima County Medical Society Ofcers
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
Vol. 46 No. 7
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 Soheila Nouri, MD Jane M. Orient, MD Guruprasad Raju, MD Scott Weiss, MD Victor Sanders, MD (resident) 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
Board of Mediation
Bennet E. Davis, MD Thomas F. Griffin, MD Charles L. Krone, MD Edward J. Schwager, MD Eric B. Whitacre, MD
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
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 Ofcers 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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Inside
6 Dr. Charles Katzenberg: Our president
addresses the physician shortage. project support.
Trebar recalls the late Susie Yazzie, Monument Valley tourguide and Navajo matriarch. HITECH regs; a word about drowning; TMC raffle wrapup. Richard F. Dahlen, Jose L. Hurtado, Humberto C. Gonzalez, and Klara I. Swimmer.
On the Cover
The late Susie Yazzie visits with friends and relatives outside her hogan in 2011. In February Monument Valley and its visitors lost this monument, small in stature but large in memory. For the story see this months Behind the Lens (Dr. Hal Tretbar photo).
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predicted that by 2020 we will face a shortage of 91,500 physicians, both primary care and specialists. [1] Reasons for this shortage include too few training slots, physician retirement, the Affordable Care Act, and 10,000 Americans turning 65 every day for the next two decades. How are we going to fill the void?
Come gather round people Wherever you roam And admit that the waters Around you have grown And accept it that soon Youll be drenched to the bone If your time to you Is worth savin Then you better start swimmin Or youll sink like a stone For the times they are a-changin. The line it is drawn The curse it is cast The slow one now Will later be fast As the present now Will later be past The order is Rapidly fadin And the rst one now Will later be last For the times they are a-changin.
Bob Dylan wrote those verses in 1963, a time of monumental political and social upheaval: Vietnam, civil rights, womens rights. His words are timeless and relevant in observing trends and happenings in our healthcare system today. A classic paradigm places the physician as captain of the ship, giving orders which are obeyed without question. There will always be physician captains, but recently other crew members as well as passengers are taking more active roles and shifting the paradigm. The other crew members are Nurse Practitioners and Physician Assistants, and passengers, a.k.a. patients, are beginning to engage in do-it-yourself health care. This paradigm shift is the result of a shortage of primary care physicians, as well as some specialists, and increase in demand for primary care services. The Agency for HealthCare Research and Quality estimated there were 209,000 primary care physicians in 2010, about 32 percent of all practicing physicians (624,434). [2] The average primary care physician was 47 years old and one quarter (50,000) was age 56 or older. [3] A 2012 Association of American Medical Colleges report
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In 2012, 1,335 (8.1%) of U.S. graduates with an M.D. degree chose family medicine. This filled 48 percent of family medicine residency positions. An additional 1,276 other graduates matched to family medicine, including 325 graduates of colleges of osteopathic medicine, 350 non-U.S. citizens educated internationally, and 518 U.S. citizens educated internationally. [4] Even with overseas education of Americans and brain-draining foreign societies, we are not coming close to filling our Primary Care needs. The vacuum is being filled by a variety of creative, contentious and disruptive technologies. Its not clear whether we are adding value or further fragmenting a hopelessly complicated system. One example is blood pressure management. The traditional model is for patients to come to their physicians office to receive evaluation and prescription for BP meds and then return periodically for re-evaluation and medication adjustment. A recent JAMA article documents the benefits of pharmacists monitoring and adjusting BP meds. [5] The physicians office received reports of BP and medication adjustments made by the pharmacists. Then come the younger Generation Xers (born 1965-1980) or the Millenials (born 1981-1999), who are computer/social media/ Internet savvy and see these resources as easier to access and often superior to making an appointment to see their doctor, if they even have a primary care physician. They have spawned a lexicon of new terminology: M-health (mobile health): uses mobile devices such as phones or PDAs to collect data and deliver treatment information. E-health (electronic health): uses the Internet as a source of healthcare information. E-patient: an Internet-savvy patient who uses the net and social media to research symptoms, treatments, and options, and which may result in self-diagnosis and Rx. Dallas-based Teladoc is currently the largest telehealth company in the country. Teladoc offers physician visits either by telephone or online. It is made available by Aetna, other insurers, and directto-consumer marketing. The service allows people to reach a U.S. board-certified doctor from home. The company estimates the average doctor callback time is 16 minutes. Its physicians use electronic medical records and prescribe electronically. The service is available at all times and costs $38 or less per
SOMBRERO August/September 2013
consultation. Teladoc emphasizes that it supplementsnot replacesthe family physician. It expects to do 125,000 consultations in 2013 and claims to have a waiting list of physicians who want to participate. Sound interesting? Web address is http://www.teladoc.com/ Closer to home, Scottsdale-based MeMD is another online, ondemand, telemedicine business which recently contracted with Maricopa Integrated Health System (MIHS). This five-year contract will give MIHSs 4,400 employees access to online medical care in which a board-certified provider can examine, diagnose, and treat online, including prescriptions. Most patients are seen and treated in 30 minutes or less with no drive time or wait time in a doctors office. Their website is http://www. memd.me/ It describes their providers as physicians, nurse practitioners and physician assistants. Consults are $44.95. When physician shortages are considered together with current promotion of team-based care, a.k.a. Accountable Care Organizations, many have identified nurse practitioners and physicians assistants as the able bodies to fill the void. We are currently turning out more NPs and PAs than physicians. One place NPs and PAs have landed is in walk-in clinics, which can be freestanding such as NextCare Urgent Care Clinics, or within businesses such as CVS pharmacies. The growth and successes of Telehealth and walk-in clinics speak volumes about the shortcomings of traditional and current medical practice. Many primary care and specialty physicians currently work closely with NPs and PAs. These advanced practice providers extend physicians and in many cases, they enhance quality and patient satisfaction. I would like to see: 1. Every American have a primary care physician in a medical home (current vernacular). 2. The medical homes range from solo practitioners to groups and be led by physicians who may opt to work with advanced practice providers (NPs and PAs). 3. If an individual chooses to use a walk-in clinic or telehealth, there should be a process to directly transfer information back to the primary care physician and/or a mechanism to connect the patient with a primary care physician if he/she lacks one. 4. PCMS discuss a rewrite of our bylaws to include NPs as Affiliate members just as we do with PAs.
REFERENCES 1. http://www.ahrq.gov/research/findings/factsheets/primary/ pcwork1/index.html 2. http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/ Reports/twentiethreport.pdf 3. https://www.aamc.org/download/304026/data/2012aamcworkforce policyrecommendations.pdf 4. Results of the 2012 National Resident Matching Program. Fam Med 2012;44(9):614-19. 5. Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure ControlA Cluster Randomized Clinical Trial. JAMA 2013;310(1):46-56. SOMBRERO August/September 2013
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possibly a 100% death tax on 100% of the assets of the poor or middle class. At present, in Arizona, it applies only to those requiring long-term care services. However, it can potentially apply to any and all items or services received, depending on state law, so the situation could easily change in the future. While it is true, that $3,800 per month may be less than the value of care received, it could also be much more. The recovery applies to the amount paid to the program contractor, not the value of care that the patient might or might not have received. Do you suggest that not expanding AHCCCS means applying the equivalent of estate recovery to all patients, with the additional burdens of bankruptcy, destroyed credit, and denied services due to inability to pay? And that expanding AHCCCS solves these problems? What about people whose income is 138.1% of poverty? What about those who are on AHCCCS but dont get services because the program denies them? What about forcing everybody into AHCCCS? And if not, why not? One important reason to oppose expansion of AHCCCS is patients inability to get the timely services that they need. Historically low payment is one problem, but by no means the only one. Raising pay rates to 100% of Medicare might increase the number of patients accepted by physicians, but maybe not many physicians are also refusing new Medicare patients. Maybe some of them will read the story told by Dr. Tamra Whiteley Myers in the May Sombrero about how she survived her Medicare audit. She spent hundreds of hours fighting the attempted recoupments, and not everybody has the same favorable outcome that she apparently has had (at least so far). My point about the circuitbreaker provision is that (1) the federal government probably will renege on its promises and (2) the state will not be able to opt out of the expanded program. Thus, it should not be considered a serious proposal, but only a political appeal to fiscal conservatives. You make the very interesting suggestion to modify the circuitbreaker to automatically raise funding from the corporate beneficiaries of the program. If that were done, I wonder what would happen to their expensive lobbying campaign for the program? We have a lot of experience with expanding entitlement programs in the past, and Arizona has had the same experience when it previously expanded AHCCCS: Costs explode. After we have spending trillions of dollars on welfare and entitlements starting in 1965, poverty and ill health still exist and, if anything, are getting worse. Bureaucracies and program contractors, however, are doing better and better. For them, poor people are just a pretext to milk the taxpayer. Medicaid is a cash cow for special interests. Do you have any better ideas than constantly expanding programs that repeatedly have the same dismal result? Sincerely, Jane M. Orient, M.D. Tucson
If you are interested in lending your name, or that of your business or organization to this effort, and to declare that you or your group are a Friend of the Tucson Streetcar, please let me know.Also please let me know if you wish to get more actively involved with the effort. I thank you in advance of your stepping forward to join me in Friends of the Tucson Streetcar. Sincerely, Ron Spark, M.D. Tucson rpsparkmd@yahoo.com n
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Milestones
2001 and also as UofA vice-president for health sciences from 1995 to 2001. He started the School of Public Health, which became the UA Mel and Enid Zuckerman College of Public Health. Also during his tenure as dean and vice-president, the Arizona Center for Integrative Medicine and the Arizona Telemedicine Program were established, and the College of Medicine began offering third- and fourth-year medical students the opportunity to complete their training at Phoenix-area hospitals, leading to the development of the UA College of MedicinePhoenix and Phoenix Biomedical Campus in downtown Phoenix. He was editor of the prestigious Archives of Internal Medicine for many years and continues to be an outspoken advocate forhealthcare reform. In 2012, Dr. Dalen received the Herbert K. Abrams, M.D., Award from the College of MedicineTucson Department of Family and Community Medicine for his demonstration of a lifetime commitment to public health and social justice. He now serves as executive director of the Weil Foundation, which supports research and education in integrative medicine, a field Dr. Dalen developed with Andrew Weil, M.D. He also serves as professor emeritus, teaching in the UA College of Medicine Tucson and the Zuckerman College of Public Health.
process, updated URLs provide additional sources of updated information, and the Must/Want Analysis provides a way to rank residency program selections. Dr. Iserson has YouTube videos that give an overview of the process. Topics include: What specialty is best for me? How will I know? Should I take a transitional internship? Where can I get information about specialties and programs? To which programs should I apply? How many applications should I send? How do I complete applications? Rsums? Personal statements? What special problems will I encounter if I am a woman? Minority? IMG? Osteopathic graduate? Older physician? Couple? Physically impaired? How do I prepare for the interview? How do I dress? What questions should I ask? What shouldnt I ask? What questions will they ask me? How should I answer? What matching program do I use? How do they work? How and when do I apply? How do I choose between programs? After I match, then what? The eight new YouTube videos for residency and fellowship applicants are: Choosing a Specialty-Part 1: http://bit.ly/118hKZS Choosing a Specialty-Part 2: http://bit.ly/ZU4dIW The Residency Interview-Part 1: http://bit.ly/116syYD The Residency Interview-Part 2: http://bit.ly/XIlD9Y The IMG Residency Applicant-Part 1: http://bit.ly/ZgoMfB The IMG Residency Applicant-Part 2: http://bit.ly/10SrvKy D.O. Residency Applicants-Part 1: http://bit.ly/10XyBig D.O. Residency Applicants-Part 2: http://bit.ly/15apvmH
At http://ahsl.arizona.edu/spec-coll/pcms-pfh on the Arizona Health Sciences Librarys website, you can find a list of the Prescription for Health programs, Piper said. Programs are listed by date, by program topic and by guest speaker name, and the listings are of all the 284 known programs. For the subset of 218 programs for which we were able to create a digital version, there is a link from the librarys site to the state librarys Arizona Memory Project (AMP) website where there is complete descriptive information about the episode andmost importantly!a link for viewing the program. At the AMP click on the title of the program to go to the video. The program focused on providing in-depth medical information on a broad range of topics of interest to the general public. At least 284 episodes were produced, and perhaps as many as 320. The enduring value of Prescription for Health is not the medical information that is conveyed, but rather the historical glimpse this program provides into the communitys health concerns at the time, Piper said, and the opportunity to see and hear hundreds of Tucson physicians responding to those concerns using a newly available mediumpublic access cable TV. Local physicians and other medical professionals were the expert guest speakers. Occasionally laypersons, such as patients or high school students, were program guests. With only a few exceptions Dr. Spark hosted the program and Constance D. Connie Wry was the producer for each 30-minute episode. Anatomical models and other props were sometimes used by guest speakers and occasionally the program left the studio and was shot on location in an operating room, in a patients home, or outdoors. While most episodes were in English, approximately two dozen were done in Spanish or bilingually in Spanish and English.
ROC #278632
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In more contemporary Dr. Spark news, he tells us that on July 1 he assumed the duties of medical director of the University of Arizona Campus Health Service Laboratory. Dr. Spark is a Clinical Associate Professor at the UofA College of Medicine and a pastpresident of PCMS and the Arizona Society of Pathologists. He also serves as medical director for the laboratories based at New Pueblo Medicine and Wickenburg Community Hospital.
He said he would maintain his home in Tucson and keep a few shifts at Tucson Medical Center to make sure he stays active as a physician. Dr. Heinz said he had worked on securing the appointment since January, and that it included a six-week vetting process.
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contributed the most students to the national pipeline of family physicians, the foundation of primary care, at a time when the U.S. is facing a shortage of these physicians, the university reported. From 2010 through 2012, 17.2 percent of UofA med school grads chose family medicine residency programs for their post-doctoral training. That includes 25 of the 146 UofA med school students who graduated last year: 19 of the 105 Tucson campus grads, and six of the 41 Phoenix campus grads. At the other schools ranked by the AAFP, the percent of graduates choosing family medicine over the three-year period ranged from 15.4 percent to nearly 21 percent. Tucson campus department head Tammie Bassford, M.D. said the AAFP ranking recognizes our efforts to nurture students interest in family medicine. We have a serious shortage of family doctors and other primary care doctors, in Arizona and across the nation. We as faculty make a strong effort to familiarize students with the variety and opportunities that a career in family medicine offers. Part of that effort is the Family Medicine Interest Group, which AAFP honored in 2012 with one of its 10 Program of Excellence Awards. The interest group is open to students from the time they enter medical school until they graduate. It offers a variety of activities, including lunch-hour talks and demonstrations on various procedures, as well as the chance to connect with like-minded students. The Family Medicine Interest Groups Baby Beeper Program is a great example of the opportunities the group provides medical students, even in their first year, said Tejal Parikh, M.D., UofA assistant professor of family and community medicine. Medical students are contacted whenever a family medicine physician is about to deliver a baby, so they can observe the delivery.
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facility because of our capacity to provide transplantation or longterm mechanical circulatory support.
the Minnesota Dermatological Society, the American Society for Dermatologic Surgery, and most recently at the 45th Annual Mohs College Meeting. We are excited to be adding a physician to our team who has such a distinguished educational background and so much enthusiasm for exceptional patient care, said Pima Dermatologys medical director and owner, Gerald N. Goldberg, M.D. Dr. Beals significant talents will further enhance our practice offerings to benefit our patients. He is extremely personable, well-rounded, and very hard-working. Dr. Beal said his greatest focus in joining the practice is establishing long-lasting patient relationships. Considering Pima Dermatologys long history of caring for patients for decades, Im looking forward to seeing all of the friendly faces and knowing Im now contributing to the great care theyve come to expect and deserve. Appointments are available with Dr. Beal at 795.7729. Dr. Goldberg reports having a busy Spring, giving talks to national, regional and local audiences. He said he attended various annual meetings and provided his knowledge and expertise throughout his travels. At the American Academy of Dermatologys Annual Meeting in March in Miami Beach, Fla., Dr. Goldberg led a two-hour forum of video endpoints of skin lasers. He presented on vascular lesions and port wine stains at the American Society for Laser Medicine and Surgery 33rd Annual Conference in Boston in April, highlighting video treatments using skin lasers. In addition, he conducted a full one-hour course on the use of vascular lasers for a course on Fundamentals of Lasers in Healthcare. Also in April, Dr. Goldberg lectured on Skin Signs of Systemic Disease to the secondyear class at The UofA College of Medicine. In May he spoke to Residents in dermatology at UC San Francisco (UCSF) on Practical Pearls from 30 Years of Private Practice. Pima Dermatology, at 5150 E. Glenn St., is a comprehensive dermatological group serving the region nearly 30 years, saying it is the only full-service dermatology center in southern Arizona accredited through the Accreditation Association for Ambulatory Health Care (AAAHC), demonstrating its strong commitment to patient safety and quality care performance achievements. The office currently features more than 18 laser modalities and has almost 30 years of unique laser treatment expertise, making it one of the Southwests leaders in lasers. For more info about the practice, please visit www.pimaderm.com. n
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This year Monument Valley lost a monument. Susie Yazzies family believes she was born in the spring of 1914, but back then no records were kept. She passed on quietly Feb. 3 after a brief hospital stay. I met Susie in the 1980s on one of my many trips to Monument Valley. The first photos I could find of her are from 1991. The last ones are from 2011 on a photo workshop for Arizona Highways.
This image from 1991 shows Susie Yazzies award-winning weaving skills.
Almost all Monument Valley tours included a stop at her hogan next to her daughter Effies house. She was always gracious and loved to pose for photographers in her hogan, where she was a talented weaver. I think the best description of Susies life is an excerpt from a book to be published this year by Collette Wadell, Shade House Conversations: the Story of an American Family. It should be available now from TopCat Press. Collette spent 10 years talking to Susie and her family: Susie Yazzie, matriarch of Monument Valley, renowned weaver, revered storyteller, and one of the last great symbols of an iconic West, passed away quietly on Feb. 3, 2013, Wadell wrote. She was surrounded by her family during her last days on Earth, and she must have known she was deeply loved. I suspect Susie was unaware, however, of the impact she had on those of us who traipsed through her hogan, eyes wide and full of questions. This kind and patient woman politely referred to ustourists, writers, photographers, anthropologistsas visitors. This did not mean we were unimportant to her. In many ways, we helped her maintain the traditional life she held so dear. We were simply different in that we were not blood, and certainly not Navajo. Because of this, Susie may not have realized how heartbroken we would all be when word came of her passing. But to her visitors, Susie was more than a gifted artist, a photo opportunity, or a representative of traditional
SOMBRERO August/September 2013
Navajo life that is slowly slipping away. To us, Susie was a friend, an adopted grandmother, and an inspiration. I met Susie Yazzie on one of the many guided horseback-riding
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A relative had stopped by for a visit two years ago, and Susie brought out one of her smaller weavings.
excursions offered by her son, Lonnie. My husband and I became very close with Lonnie and the rest of the Yazzies living in Monument Valley when, at Lonnies request, I began to record the family history dating back to the Long Walk of 1864. In the warm darkness of Susies hogan I learned about FourHorned Lady, a revered ancestor who survived Kit Carsons forced march to the Bosque Redondo internment camp. I heard about Susies great-grandmothers escape from that dreadful camp and the magical odyssey of her return home. We moved on to record Susies own rich history, as well as the stories of her children and grandchildren. Every interview was filled with more laughter than tears, though the tears did come. I was hypnotized by the way Suzie quietly but deliberately wove her stories as beautifully as she wove her rugs. Her hands gently danced in the air as she described the adventures, tragedies, and intricacies of everyday Dine life in the early 20th century. Each time I drove the bumpy washboard road out of the tribal park, my head felt cloudy with stories and my heart full of the love so evident amongst this tightly knit family. I recorded the Yazzies history over the course of 10 years, earning the name Woman Who Asks Many Questions. I came to love the Yazzies, and like others who met Susie, I felt protective of this quietly wise matriarch of Monument Valley. There are no words to describe how much the Yazzies loved Susie, though I saw plenty of evidence they were all completely devoted to her. There were always a number of family members helping with
SOMBRERO August/September 2013
her livestock, taking turns with the hogan business of entertaining visitors, chopping wood for the ever-burning wood stove, or conversing with her over endless cups of the strong coffee brewed in an old, blue camp percolator. Susie prided herself on managing her home and business, and she learned her self-sufficient ways while growing up on the reservation. Her family believes she was born in the spring of 1914; however, no one could be absolutely certain of Susies age. Records were not kept in those days, and the Navajo traditionally looked at time as cyclical rather than in the Western linear manner. Like any young Navajo child in the early 20th century, Susie spent her days watching over her familys livestock, and she helped with the many chores that came with living a hardscrabble life on the reservation. Unfortunately, when Susie was 10, her mother became very ill. Susie then began to weave, selling her rugs at Gouldings Trading Post in order to provide for her siblings. Though she never had the benefit of attending school, Susie knew exactly how many sheep and goats she had and how to manage her money. She spent untold hours shearing, carding, dying and spinning her own wool in order to create her beautiful rugs. She went on to marry her husband, Tully, and raised a family of five strong children. During that time Susie served her community as a midwife, and offered her skills as a diagnostic hand trembler. She appeared as an extra in John Fords Western dramas, as well as in a number of later films that helped to make her home a
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Susie loved to wear her red velveteen blouse that showed off her turquoise jewelry.
Susie stands outside her hogan in the southern part of Monument Valley in 1991.
Susies family members keep their sheep near their home deep inside Monument Valley.
mecca for those seeking Monument Valleys stark beauty. Through all of these endeavors, Susie kept her family close, teaching her children and the generations that followed the traditions she held dear. Her weaving earned worldwide recognition, and many came to see her demonstrate her art upon the big loom made of juniper wood. She was the favorite subject of many gifted photographers, and even appeared in national advertisements. Susie remained unaffected by the attention, and she kept her desires simple. She
enjoyed evenings filled with storytelling, and she favored several beautiful pieces of silver and turquoise jewelry created by her family. She relished the cupcake snowballs we brought her, and I was told she liked my spaghetti. Most of all, she loved the valley and the people in it, earning the love and respect of her community for her devotion to family and traditional Navajo life. Attending Susies memorial service was special because everyone had a story to share about this strong but quiet woman. Her granddaughters fondly recalled the many summers they spent playing and working at Susies place. Every morning they were awakened by a gentle pull on the ear, and their grandmothers urging to help get the chores done. Then Susie gave them a lunch of canned tomatoes accompanied by Saltine crackers, and they spent the rest of the day playing on the rock formations surrounding Susies home. Even as the granddaughters shared their memories, Susies great- grandchildren were climbing those very same rocks. Many relatives spoke of a renewed determination to maintain family ties, because it was important to Susie. Just as in Susies stories, there was enough laughter to temper the tears we all shed in remembering her, and I know she would have been proud of the way her family pulled together in honoring her life and her legacy. I once asked Susie if she minded me taking down her stories. I had been told by family members that she imagined I was a crazy white lady, and that all the time she wants to know about how things were in the old days. Susie wondered why I wanted to know about the sheep and her weaving, and she thought that perhaps I wanted to know peoples secrets. I could never deny that I truly wished to experience Susies life through her stories. After all, it appeared that she had enjoyed a very good life. Upon our last interview in her shade house, Susie let me know that she had decided my constant questioning would be
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This is my favorite image of Susie, in 2007 as she demonstrates how she makes yarn for her weaving.
Susie was always outside, living with nature and watching her sheep.
put to good use. I see you writing, she said with an approving nod, and now my grandkids will be able read my story. I think it would be a pretty good story and good history for the kids. She sat quietly for a while, then admitted, I thought it over, and I dont mind if other people read my story. People should know how we used to live. With that Susie stood and smoothed the deep red velveteen blouse and satiny skirt she always wore. She gave me the shy smile I had come to love, and slowly walked from the shade house to her hogan. I like to remember Susie in this way. She was on her way to sit with family and visitors alike, to weave and to continue her traditions. The path she had worn over the years must certainly hold the essence of this wonderful woman. And if you come to
visit the valley, I invite you to find her amidst the towering monuments. If you stand very quietly, you might hear her spirit whispering in the wind. On my last trip to the valley two years ago, Susies daughter Effie pulled me aside. She whispered to me, I know that you have some money for her. Dont give it all to her because we know she hides some of it. You can give the rest of it to me later. It was thought that Susie didnt speak much English, just Navajo. After we spent time in her hogan photographing Susie at her loom and later outside, I gave her $50 which was about half of our usual modeling fee. Susie squinted at the money and in clear English declared, Not enough. n
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PCMS News
The final regulations require immediate action. Privacy Notices must be updated and comply with the final regulations. Agreements between Covered Entities and Business Associates, and between Business Associates and their Subcontractors, must also be in placethat means signed by all partiesby Sept. 23. If an agreement was in place as of Jan. 25, 2013, the agreement only needs to be updated to comply with the final regulations, and the deadline in that situation is Sept. 23, 2014. These agreements must address a variety of issues, including notification obligations if PHI is improperly disclosed. These agreements matter, and while they include many standard terms and some non-negotiable terms, they are not simple forms and should not be signed, whatever they may say, and shoved in a file. In addition to having Business Associate agreements in place, Covered Entities, Business Associates, and Subcontractors must be aware of new breach notification rules. Generally, Covered Entities or Business Associates must now notify HHS when PHI gets disclosed. Further, Covered Entities bear responsibility to patients and the public, even when one of their Business Associates or its Subcontractor disclosed the PHI. Historically, breach notificationsto affected individuals, the media, or HHSwere only required if the Covered Entity determined there was a significant risk of financial, reputational, or other harm. Under the final rule there is a presumption of harm that can only be overcome with a risk assessment, to be completed by the responsible party or parties. If the risk assessment process demonstrates a low probability of compromise, notification need not occur; in all other instances, notification must occur. This substantial change requires that both Covered Entities and Business Associates modify their internal processes to establish a risk assessment process, and that they treat notification as the norm, not the exception. In the final regulations, HHS did retain the limited exceptions to the definition of breach that existed in the temporary regulations. So, a breach does not include the following situations: 1. An authorized Covered Entity/Business Associate employee accidentally looks up the wrong chart, yet clearly was acting in good faith and no further disclosure/use occurred; 2. Inadvertent disclosure of PHI where the disclosing party believes the other person/entity has a right to see the PHI, for example discussing a patients condition with another doctor under the erroneous, good-faith belief that that doctor is also on the case; 3. Inadvertent receipt of PHI where it cannot reasonably be retained, including situations where incorrect discharge papers are briefly given to the wrong patient (common name issue, typically) but the papers are quickly recovered. HHS enforces HIPAA/HITECH, so there are significant penalties for non-compliance. Penalties ranging from $100 to $50,000 for each violation, depending on the degree of knowledge that the entity had or should have had regarding the violation. In extraordinary circumstances, the criminal justice system may get involved.
In sum, while the law that has as its goal protecting patient privacy rights, there is a very complicated regulatory scheme associated with meeting the goal. This article only provides the highlights associates with the law, as it has been fleshed out with the final regulations. Healthcare providers and those who facilitate the delivery of health care services must follow the rules! Having sufficient privacy protection systems in place are necessary, but they are not sufficient to comply with the law. If this leaves your head spinning, please contact Susan Goodman (sgoodman@mcrazlaw.com) or Mark Rubin (mrubin@mcrazlaw.com) at Mesch, Clark & Rothschild, 624.8886, for assistance.
Everyone who goes near the water needs to recognize when a person is drowning. The instinctive drowning response was described in the Coast Guards On Scene magazine (http://www. uscg.mil/hq/cg5/cg534/On%20Scene/OSFall06.pdf): 1. Except in rare circumstances, drowning people are physiologically unable to call out for help; speech is secondary to breathing. 2. Drowning peoples mouths alternately sink below and reappear above the surface of the water. The mouth is not above the surface long enough to inhale, exhale, and call out. 3. Drowning people cannot wave for help. Their arms are extended laterally and they press down on the water surface to permit them to lift their mouths out of the water to breathe. 4. Drowning people cannot voluntarily control their arm movements to wave, move toward a rescuer, or reach out for a piece of rescue equipment. 5. From the beginning to the end of the instinctive drowning response, peoples bodies remain upright in the water, with no evidence of a supporting kick. Drowning people are only able to struggle on the surface of the water from 20-60 seconds before submersion occurs. Remember, drowning does not look like drowning, and the sound of drowning is the sound of silence. For more information see Slate magazine, June 4, 2013: www. slate.com/articles/healthandscience/family/2013/06/ rescuingdrowning.
June. We were able to cover all our startup costs, which typically takes multiple raffles to accomplish, and we are well positioned for raising significant dollars in the coming years. One of the unexpected benefits of the raffle was the awareness itgenerated for the hospital, Duran said. The stories from raffle participants, patients and winners shared through the media coverage and social media, involved and engaged the community beyond any of our expectations. During the time the raffle was in the market, everyone was talking about TMC. It enabled us to raise a tremendous amount of awareness and gain valuable exposure about specific services and programs that TMC offers that many people were not otherwise aware of. The other major benefit of the raffle is the opportunity it provides us to gain support from people that may not have been connected to TMC through traditional philanthropy. We will always utilize traditional fund-raising methods, but we see the raffle as a new and very effective tool for expanding those efforts. All 24 winners received calls from TMC Mega Raffle Coordinator and Spokesperson Kathy Rice. The remaining winners were verified and their names and prizes were posted on a master list at www.TMCmegaraffle.org on May 30. Participants had a one in 20 chance of winning one of the 2,800 featured prizes. Prizes included a luxury home package, a variety of new cars, dream vacations, and an array of the latest in electronics, jewelry, and home accessories. Kathy Rice hand-selected each of the
more than 2,800 prizes, many of which were purchased locally in Tucson to ensure the raffle not only benefits Tucson Medical Center, but also the Southern Arizona economy. In June the luckiest guy in Tucson was probably Grand Prize winner No. 1, Michael Martin, 38, of the Arizona Air National Guard, originally from Arkansas. He won a brand new home in northwest Tucson that included $30,000 in upgrades, plus $100,000 cash, plus a brand new Mercedes-Benz. He bought three tickets for $250, and admits he was disappointed when he didnt win anything in the Early Bird drawing. I figured I just made a nice donation to a good cause at a great hospital, he said. So when the big win happened, he didnt believe it. At 1 oclock that day, I got a call from Kathy Rice.She left me a voicemail telling me Id won the TMC Mega Raffle.I didnt believe it! My buddies play some pretty elaborate jokes on me. I thought they were messing with me. I called Kathy back, and I still didnt believe it. So he called his parents.My mom said, Mikesomeone has got to be pulling your leg. I wanted to believe it, but there was always that thought in the back of my mind that people dont really win prizes like this.I hopped on the Internet and started checking things out, and all of the pieces started falling into place. Second Grand Prize winner Janet McGee cried when she heard the news she won an A .F. Sterling home in the Campos Adobes community in Southwest Tucson and $50,000 cash, a package valued at $336,000. McGee, 59, is a newlywed, currently caring for her husband, Gary, who was born at TMC and is now disabled and homebound while battling cancer. She expressed her joy and appreciation saying, she felt truly blessed, and that winning this will help ease their financial stress. Janet has been unemployed for more than a year after spending 19 years working in human resources for a childrens behavioral health company. Gary, a retired corrections officer, has been on disability.Finances have been tough for them, she said. We are now excitedly looking at the 2014 calendar to begin planning for our next raffle, Michael Duran said. The first raffle has set the stage extremely well for the coming years. We are very pleased with the response we received from the entire Southern Arizona community and the success we had in introducing everyone to the first TMC Mega Raffle.
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The interprofessional staff included physical therapy, social work, pharmacy, nursing, educational specialists, discharge planners, and quality improvement experts, who all shared their expertise and built collaborative relationships with the chief residents. Conrad Clemens, M.D., M.P.H., associate dean for graduate medical education and associate professor of pediatrics; Andy Theodorou, M.D., professor and chief of the Section of Pediatric Critical Care and associate head of the UA Department of Pediatrics and chief medical officer; and Vicki Began, chief nursing officer, at UAMCUniversity Campus, each emphasized the importance of the Institute for Healthcare Improvements Triple Aim. The Triple Aim effort inspires chief residents to take on the responsibility of improving health, improving health care, and decreasing the cost of healthcare. The chief residents, faculty and their families forged valuable connections during interactive case-based table discussions making connections that translate into close collaborations and optimal problem solving when caring for complex patients, the UofA reported. The training provided an opportunity for experts in multiple specialties and disciplines to come together and brainstorm on how to improve care for patients and families at the University of Arizona Medical Center. The positive attitudes gained toward caring for older adults, and the excitement for interprofessional collaboration and bonding demonstrates the success of this innovative program. n
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In Memoriam
Dick played tennis throughout his adult life. He was a member of Tucson Racquet Club when the club was located in the shadow of El Conquistador Hotel. On his travels he frequented the tennis courts wherever he stayed, looking for pickup games. Once he was paired with a man whom people referred to as Justice. When Dick asked Justice what he did, he replied, Im Justice Stevens of the Supreme Court. As in other areas of his life, Dick was a selfless and committed volunteer. Over the years he donated time to St. Elizabeth of Hungary Clinic [now St. Elizabeths Health Center], Boy Scouts of America, Pima County Medical Society, Our Saviours and Faith Lutheran Churches, and Rotary, among other endeavors. At PCMS in the 1960s and 70s Dr. Dahlen regularly served as an alternate delegate to ArMA, was a member of the Public Health and School Medicine Committee and the Board of Credentials. He was a liaison to the Womens Auxiliary (now PCMS Alliance). In 1977-82 he served two terms as a delegate to ArMA. He was a member of the American Academy of Dermatology, Southwestern Dermatological Society, Pacific Dermatologic Association, Arizona Deramtological Association, ArMA, AMA, and the Better Business Bureau. He was an elder at Faith Lutheran Church. Dr. Dahlens wife, Thelma; sons Robert Niemann and Paul Dahlen; daughters Ann Bakkensen and Andrea Kent; and seven grandchildren survive him. Family and friends attended a celebration of his life on May 18 at Tucson Country Club. The family requests that memorial donations be made to Camp Mishawaka Foundation c/o Blake Hiltabrand, 1136 Ashland Ave., Wilmette, Ill. 60091.
Dick then accepted a position with Associated Dermatologists in Tucson, where he was a partner until his retirement in 1990, the family said. He first partnered with Seymour I. Shapiro. M.D, and Carl Z. Berry, M.D. at 1520 N. Norton. The practice later included Michael M. Schreiber, M.D., Robert P. Friedman, M.D. and Daniel DeBoer, M.D. Dicks patience and compassion were hallmarks of his practice, and endeared him to his patients. In April 1956, Dick married Thelma Niemann, a widow, and adopted her two young children. Subsequently the couple had two more children. Dick was a patient, loving father who enjoyed sharing his passions with his children. He was also a beloved grandfather of seven grandchildren. In retirement Dick and Thelma enjoyed traveling with their family. As a boy, Dick attended Camp Mishawaka in Grand Rapids, Minn., where he developed a lifelong love of canoeing, sailing, and camping. He returned to camp as a counselor, leading canoe trips into the Quetico-Superior Boundary Waters wilderness area. Dicks passion for Mishawaka remained strong throughout his life. In the 1970s he developed an outreach program to contact potential campers in Southern Arizona. His efforts resulted in more than 1,000 Tucson children attending camp. In 2010 Dick was acknowledged for his lifetime of friendship to Mishawaka when a camp cabin was named in his honor. Dick enjoyed two primary hobbies in his adult life: woodworking and tennis. He designed, crafted, and installed a variety of builtins for homes, and created many items of indoor and outdoor furniture. His creativity and attention to detail contributed to the professional quality of his work.
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In 1988 he partnered with Sylvain Sidi, M.D. and Elliot M. Morris, M.D. in their gastroenterology and liver diseases practice at Academy Medical Center on North Wilmot Road. At the time of Dr. Hurtados death, his associate at Tucson Gastroenterology Specialists was Dr. John McNerney. Dr. Hurtado had a distinguished career and enjoyed spending time traveling with his family and friends, the family told the Arizona Daily Star. He was a cherished and extraordinary husband and father to his wife, Ana, and his children Diana and Lalo. His family will remember him as one who dedicated his lifes journey to ensuring that all those around him were well cared for, they said. He loved his family and was known for his humor, kindness, and generosity to all. Dr. Hurtado was an avid reader and often penned encouraging words to his children. He especially enjoyed traveling with his children to extraordinary destinations of learning and to the Hawaiian Islands. They will cherish these wonderful memories forever. He also enjoyed gardening, cooking, and eating out at local restaurants including Yamatos, Caf Poca Cosa, and Casa Vicente. Dr. Hurtados wife, Dr. Ana Luisa Rosales; son Eduardo Jose; daughter Diana Victoria; brothers Raul, Gustavo and Hector; sisters Ana Celia Jimenez, Martha Dufour and Gloria Redman; and many grandchildren, nieces, nephews and in-laws survive him. A Rosary and Vigil Service were given on June 13 at St. Thomas the Apostle Catholic Church, Tucson, and a Mass celebrated on June 14. The family requests that memorial donations be made to Pediatric Hematology Oncology, 1501 N. Campbell Ave., Tucson 85724.
Humberto excelled academically, the family told the Arizona Daily Star, and he graduated from Nogales High School in 1944 as salutatorian and student body president. He served in the U.S. Navy at the end of World War II, and later earned his undergraduate degree in biological sciences from The Leland Stanford Jr. University, from whose School of Medicine he earned his M.D. in 1953. He interned at San Francisco City and County Hospital, and did surgery residencies at [now Carondelet] St. Marys Hospital in Tucson, St. Alexis City Hospital in Cleveland, and St. Elizabeths Hospital in Youngstown, Ohio. More than 300 family, friends and former patients attended his memorial service in Indianapolis. One of Dr. Gonzalezs sons, Dr. George Gonzales, wrote the eulogy and read it, noting that Dr. Gonzales loved medicine so much that he practiced six days per week. Out of the eight orphaned children in his family, the younger Dr. Gonzales said, only two graduated from high school. In high school Dr. G was an excellent student. In addition to his studies he found time to deliver newspapers early in the morning, and also shined shoes to help the family make ends meet. The younger physician quoted from his fathers memoirs: From the very beginning of my education I dreamed of becoming a doctor. I knew it would be a long and expensive process. But he was determined to make his dream come true, Dr. George Gonzales said. Miraculously, he was accepted to Stanford University upon graduation from high school. Dr. Gonzalez ran a successful general surgery practice for 40 years. In 1959 he was the first American board-certified Hispanic general surgeon in Arizona. Ninety percent of his patients were Latino. They came from all over Mexico, and of course from Tucson and Nogales. He was also known in Mexico as The Doctor with the Golden Hands. He donated his time and medical skills to help those less fortunate by going to Mexico and Guatemala. His dream was also that his children become doctors. His dream came true in George, a Family Practice physician in Fresno, Calif., and grandson David Gonzales, now in his last year of FP residency at USC Hospital in Los Angeles. All of his children became successful, including one daughter who became a federal judge, and two who became attorneys. Dr. Gonzalezs wife, Alba Solorzano-Gonzalez; sister Mary Lou Sainz; former wife Lydia Espinoza Graf; children Irma Gonzalez, Carol Gonzalez-Sheak, Christina Gonzalez, Judy Gonzalez, Dr. George Gonzalez, Michele Gonzalez-Arroyo, Humberto RiveraGonzalez, Lisa Gonzalez McLean, and Roberto Gonzalez; 15 grandchildren; and three great-grandchildren survive him. Six older siblings, Lilia Woodhouse, Arturo, Gilberto, Carmen Anderson, Olga Velasquez, and Faustino predeceased him. Funeral services were on June 14 with a Rosary said before the 2 p.m. Mass at Sacred Heart Church, Nogales, Ariz. Memorial donations may be made to Nogales High School or Sacred Heart Church in Nogales.
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Dr. Swimmer devoted a great deal of her time to keeping remembrance of the Holocaust vital and in the present, fighting the forces of diminution and distortion that are so powerful. She believed that deep reflection on this monumental horror is required if we wish to honor the many millions slaughtered, and if society is to move forward with some hope of constructively reducing its worst tendencies. She spoke regularly on the Holocaust at schools, military bases and other organizations. Her last presentation was to the Maimonides Society and others at UAMC in connection with the exhibit Deadly Medicine, organized by USHMM. She was a member of a number of medical, Jewish, and community organizations. Her ceramics gave her great joy late in life. Dr. Swimmers husband, George, predeceased her. Her son Gary, his wife Karen, and beloved grandson Isaac survive her. Graveside funeral services were July 21 at the Congregation Anshei Israel section of Evergreen Cemetery, Tucson. The family requests memorial donations be made to the Jewish Federation of Southern Arizona, Congregation Anshei Israel, American Cancer Society, the Arthritis Foundation, or any responsible national or local organization. n
Born Oct. 30, 1924 in a small town in Hungary, Klara Ilona Swimmer was raised in an innocence that allowed her love of people, of life, and her wide- ranging intellectual curiosity to flourish, the family said. She met her husband, George, as a teenager and they married in May of 1944 on the steps of the then-locked synagogue. Soon thereafter she, along with her mother, her in-laws and thousands of other Hungarian Jews, was put on a train and taken to Auschwitz. Her father had been taken away much earlier and her husband, George, was taken to forced labor. Upon arrival in Auschwitz, her parents and in-laws were immediately taken to the gas chambers, and she was soon sent with many other Hungarian young women to Kaunitz-Lippstat as a slave laborer. Surviving this experience and typhus, thanks to medicines likely provided by American liberators, she was able to return to Hungary and find her husband who had escaped from forced labor. They were then able to attend medical school, surviving thanks to the assistance of American relatives who had somehow discovered their presence after the war. In 1956, along with many others, they chose to leave during the Hungarian Revolution as refugees. They, along with their young son, made their way to Israel for a number of years, and from there they re-started life in New York with the support of those same relatives. She earned her M.D. in 1952 from the Medical University of Budapest, and did her internship, residency, and a fellowship in hematology cancer research at Grasslands Hospital in Westchester County, N.Y. Later she focused on geriatrics for many years. In 1983 she relocated to Tucson due to health needs of her husband, the family said. They made a productive life in the Southwest and she practiced medicine for a number of years before her husbands illness demanded her full-time attention. After retirement she became outspoken in her commitment to peace in the world, for human dignity and rights, and for medical, scientific and technological advances that would serve both humanity and the planet. She was especially interested in renewable energy efforts, particularly solar energy as the logical way to solve the challenges facing us and the environment.
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Members Classieds
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 qualied 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 benets, 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 (9-13) MEDICAL OFFICE SPACE AVAILABLE: Modern, professional ofce space is available at Swan and Pima. Easy accessibility for patients and conveniently located near TMC and St. Josephs Hospital. Space is available immediately. Number of exam rooms, space, terms and rent is negotiable. Please contact Susan Wolff at 520-546-2420. (6-17) OFFICE EQUIPMENT FOR SALE: Professional ofce reception desk. More than $4,000 new, but willing to sacrice for $1,500. Datum classic stack letter le holder. Perfect for medical or legal ofces or any ofce with lots of records that need to be organized. Retailed for more than $8,000 but only asking $4,000. Contact mmoran@retinacenterspc.com. (7-13) MEDICAL OFFICE SUITES FOR SALE OR LEASE, great opportunity in Sahuarita! Join Sheftel & Associates Dermatology, LLP in a brand new professional plaza located at 1855 S. La Canada. Suites ready for occupancy in October 2013. Sale price of $200 psf for shell space, lease rate of $21 psf NNN includes $50 psf tenant improvement allowance. Contact Daryl with United Properties Management, LLC at (216) 577-5531 for more details. For more information, please view our online yer: http://sheftelderm.com/pdf/sahuaritaofcespace.pdf (5-14) MEDICAL INVESTMENT/USER OPPORTUNITY: 3,522 leased medical ofce at $23 psf NNN with increases $916,000 with 8.8% annual investment return. Located in premier Northwest Center across from Foothills Mall. Built 2007 / reserved covered parking. Contact Jordan Simon 722-9292 X103 or jsimon@venturewestaz.com. You may also email pgcarter@aol.com. (5-13) EQUIPMENT FOR SALE: Two standard examining tables, one professional scale, and eight neutral-colored waiting room chairs. Joanie, 298-6324. (5-13) OFFICE FOR LEASE: Medical or Professional Ofce Space for Lease or Sale. 1,806 sq.ft. near St. Josephs Hospital on Carondelet Drive. Five exam rooms and two physician ofces. Favorable lease rate and terms. Call 749- 1454 or 885- 6701 (Dr. Wood). OFFICE SPACE: Professional/Medical Ofce Space for Lease. Central location, tenant friendly rates, move-in ready. See details & photos at: http://www.space-4-lease.com.
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I chose MICA because of its strong reputation and friendly service. They are a great source of information when I have questions. Susan J. Kalota, MD MICA Member Since 2002
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