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SOMBRERO

Pima County Medical Society


Home Medical Society of the 17th United States Surgeon General

AUGUST/SEPTEMBER 2013

So, what about the physician shortage? Monument Valley loses a monument

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SOMBRERO August/September 2013

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

Official Publication of the Pima County Medical Society Members at Large


Richard Dale, MD Anant Pathak, MD

Vol. 46 No. 7

PCMS Board of Directors


Diana V. Benenati, MD R. Mark Blew, MD Neil Clements, MD Executive Director Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com Advertising Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com

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

Thomas Rothe, MD, president-elect Michael F. Hamant, MD, secretary

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

At Large ArMA Board


Ana Maria Lopez, MD,

Pima Directors to ArMA Timothy C. Fagan, MD R. Screven Farmer, MD Delegates to AMA


William J. Mangold, MD Thomas H. Hicks, MD Gary Figge, MD (alternate)

Arizona Medical Association Ofcers


Gary Figge, MD, immediate past-president

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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SOMBRERO August/September 2013

Inside
6 Dr. Charles Katzenberg: Our president
addresses the physician shortage. project support.

8 Letters: Dr. Ron Spark urges streetcar 10 Milestones: Myriad accomplishments


of our members, their programs, and even a spouse.

17 Behind the Lens: Dr. Hal Travelin

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.

22 PCMS News: Looking out for HIPAA/

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).

26 In Memoriam: Obituaries for doctors

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SOMBRERO August/September 2013

DIY healthcare
By Charles Katzenberg, M.D. PCMS President

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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Leers

ACA expanded needed coverage


To the Editor: Dr. George Makols regrettable experience on a Eurail train [Makols Call, May Sombrero] does not translate to anything more then a bad experience on a train. It is not a logical commentary on the European healthcare system or on any single-payer model. The issue is whether we canremain complacent with the status quo. For many Americanshealthcare had become inaccessible and unaffordable.Plus, ouroutcomes are not as stellar as Dr. Makol would lead us to believe. The U.S. ranks highest in the industrial world for infant mortality. Healthcare needs to be more then a luxury of the privileged. The Affordable Care Act despite its faults is an attempt to expand needed coverage. Sincerely, Jonathan R. Insel, M.D. Tucson

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

AHCCCS expansion explodes costs


To the Editor: In response to Dr. Charles Kaplan [Letters, May Sombrero] thank you for your letter on comparing choices on AHCCCS expansion. You asked me to reply to several points. It appears that we agree on many subjects, so I will discuss only the issues related to AHCCCS. You state that it is immoral to deny humans basic necessary healthcare such as treatment of fractures, gallbladder surgery, cancer and so on, under threat of bankruptcy and loss of home. I have not heard of any patient who ever lost his home because of a doctor bill. Hospital bills are a different story, and I understand that Parkland Memorial Hospital in Dallas, a county-owned hospital, owns a lot of low-cost housing. In contrast, at the for-profit (and profitable) Surgery Center of Oklahoma, when Dr. Keith Smith found out that a patient had sold his truck in order to pay cash up front for his surgery, he gathered up all the patients money, gave it back to him, told him that his money was not any good there, instructed him to buy his truck back, and arranged for his surgery to be performed at no charge. Could you do that, too? What about TMC or Carondelet? I did not suggest that the estate recovery program was a reason not to expand AHCCCS, but it is a reason for patients not to wish to accept AHCCCS. I understand that at present, they have to sign a disclosure form stating that they know about this policy, but I am not sure what will happen if they are obligated to accept AHCCCS because of ObamaCare. Unlike the estate tax for the rich, which kicks in only after a threshold of $2 million and takes only a certain proportion of the assets, AHCCCS estate recovery does not have a threshold or a limit on the percentage. It is
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SOMBRERO August/September 2013

In support of streetcar project


To the Editor: Dear PCMS members: Friends of the Tucson Streetcar wants to engage individual citizens and civic groups to build a coalition to support the Tucson streetcar project and educate the public on the economic, social, and health benefits from this powerful investment. Would you be willing to lend your name to the coalition? And please feel free to bring other organizations and businesses on board with you. Here is some background on our need to broadcast this transportation paradigm shift. Southern Arizona Transit Advocates (SATA) has founded Friends of the Tucson Streetcar, chaired by former Mayor Bob Walkup, for the purpose of informing the greater Tucson community about the present and future benefits of the streetcar, and hopes to enlist the support of individuals, businesses, investors, organizations, associations, and a broad cross-section of those who believe that the streetcar not only promises a brighter future for Tucson, but has already made a huge difference to attract investment, new business, and excitement. SATA is the same group of forward-thinking Tucsonans who spearheaded the effort to bring light rail and then the modern streetcar to Tucson more than 10 years ago under the name Tucsonans for Sensible Transportation Solutions. With the challenging streetcar roadway construction is largely behind us, we can look forward to the arrival of the first carfor testing by this fall, and service to begin sometime in 2014. We all recognize that beyond those citizens who are transit dependent, there is a growing number, such as seniors, millennials, and urban dwellers, who would like some alternative transportation other than their cars. Significant private investment has come to Tucson because of the streetcars impending arrival. Other benefits include the strengthening the ties between our community and the University of Arizona, and ensuring the viability of our downtown and surrounding historic neighborhoods. The Friends group will soon establish a website and social media presence, and will begin to make its voice heard consistently in support of the streetcar and what it is doing and will do, to make Tucson a more urban, vibrant, walkable, and prosperous place to live, work, and play.
SOMBRERO August/September 2013

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

Dr. Lpez most influential


Ana Mara Lpez, M.D., M.P.H., F.A.C.P., professor of medicine and pathology at the UofA College of Medicine Tucson and medical director of the Arizona Telemedicine Program, has selected this summer by Az Business magazine as one of the 25 Most Influential Hispanic Business Leaders in Arizona, the college reports. The magazine identified Hispanic business leaders who bring spirit and energy to the Arizona business environment. From clinical research with molecular targets to health services research, Dr. Lpez work focuses on optimizing the health of individuals and communities. She is the principal investigator of several breast and ovarian cancer clinical trials focused on quality of life care and innovative treatments. She also is a leader in health disparities and diversity in the health professions. Dr. Lpez received her medical degree from Jefferson Medical College of Thomas Jefferson University in Philadelphia. She completed her IM residency and fellowships in general internal medicine and medical oncology at the UofA College of MedicineTucson. Her MPH is from the UofA Zuckerman College of Public Health.

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.

Dr. Isersons latest guide out


Dr. Kenneth V. Iserson, M.D., MBA, FACEP, FAAEM, Fellow, International Federation of Emergency Medicine and director of www.reeme.arizona.edu, tells us that the new, revised 8th edition of Isersons Getting Into a Residency: A Guide for Medical Students (Galen Press) was recently published. Dr. Iserson is a UofA Department of Emergency Medicine professor emeritus, medical director (emeritus) of the Southern Arizona Rescue Association, a supervisory physician with Arizonas Disaster Medical Assistance Team, and a member of the American Red Cross disaster response team. He retired from the UofA in 2008 to work internationally and teach disaster medicine. He is expert in global and disaster medicine, having practiced or taught on all seven ontinents, including serving six months as lead physician for the U.S. Antarctic Program and working with nongovernmental organizations in rural areas of Central and South America, Zambia, Bhutan, Ghana, and South Sudan. The book is softcover, 680 pages with annotated bibliography, glossary and index, and is available from Galen Press, Ltd., $38.95 plus shipping. Phone: 520.577.8363; fax 520.529.6459; Web: www.galenpress.com ; sales@galenpress.com The residency application process has undergone huge changes since 2006 (the yellow cover), Dr. Iserson said. The new edition of this standard reference has been completely updated and provides a step-by-step guide through the process of selecting a medical specialty and obtaining a residency position. A vital tool for generations of medical students, the book could also be called How to Get the Most Out of Medical School. It provides invaluable information about all the medical specialties, including the difficulty of obtaining a position and the number of available slots. Numerous charts illustrate the specialty selection
SOMBRERO August/September 2013

U.Mass. Med School, Worcester, honors Dr. Dalen


And speaking of the public health college, its founder James Eugene Dalen, M.D., M.P.H., dean emeritus and professor emeritus of the UofA College of Medicine, was awarded an honorary degree by the University of Massachusetts Medical School Worcester in June for his pivotal role in the early history of the university. Dr. Dalen, a renowned cardiologist and respected leader in academic medicine, has spent his career in university hospitals. From 1975 to 1988, he was a faculty member at the University of Massachusetts where he served as chairman of cardiovascular medicine (1975-1977) and then chairman of medicine (1977-88); from 1986 to 1987 he served as interim chancellor of the University of Massachusetts at Worcester. He served as dean of the UofA College of Medicine from 1988 to
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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.

Prescription for Health programs digitized


Prescription for Health was a PCMS-created public access cable TV medical information program that ran from 1983 to 1997. Digital Resources and Special Collections Librarian Dave Piper, M.L.S., of the UofA Health Sciences Library, reports that a set of more than 200 Prescription for Health programs are now available for viewing on the Web. Prescription for Health began in 1983, the year public access cable TV came to town with formation of the Tucson Community Cable Corporation. PCMS began taping episodes for the series and the first were cablecast in 1984. PCMS had already been doing a Prescription for Health radio program. Pathologist Dr. Ronald P. Spark was a major force in getting the cable TV version going. Im absolutely humbled by Daves Herculean effort to digitally capture these archival videos, Dr. Spark said. Our programmatic intent from the beginning was that the content would be basic and generic so as to have some lasting power as valued information for the public. This notion was pleasingly reinforced by Access Tucson continuing to show episodes over the years. I can only lend my extreme appreciation on behalf of myself, Connie, and Joe, as well as the many underwriters, contributors, panelists, most importantly PCMS, and Access Tucson staff who made P for H possible and a successful educational medium.
SOMBRERO August/September 2013

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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.

Dr. Mackstaller has impact


Lorraine Mackstaller, M.D., clinical associate professor of medicine at the UofA College of MedicineTucson, in June received the inaugural Community Impact Award from the Delta Sigma Theta Sorority, Inc., Tucson Alumnae Chapter, the college reported. The award recognizes a woman whose selfless work positively reflects the sororitys public service program. Dr. Mackstaller holds Sarver Heart Centers Bertram Z. and Hazel S. Brodie and the Edwin J. Brach Foundation Endowed Lectureship for Heart Disease in Women. During the past three years Dr. Mackstaller has worked tirelessly to educate women and minorities on heart disease and how to prevent it, said Wanda F. Moore, Arizona state coordinator for the Deltas Farwest Region, chair of the Tucson Alumnae Chapters Physical and Mental Health Committee, and chair of Sarver Heart Centers Community Coalition for Heart Health Education for Women of Color. Her leadership and commitment to heart health education takes her to the pulpits of churches, school classrooms, minority women conferences, neighborhood centers, and community meetings throughout Southern Arizona. Her work to reduce heart disease in women of color and help them lead healthy lives makes her an exemplary recipient of the first Community Impact Award.

Kathie Insel appointed to PCORI panel


Kathie Insel, Ph.D., R.N., associate professor at the UofA College of Nursing, has been appointed by the PatientCentered Outcomes Research Institute (PCORI) to serve on its newly established stakeholder Advisory Panel on Assessment of Prevention, Diagnosis and Treatment Options, the college reports. Dr. Jonathen Insel, PCMS member since 1980 and 1994 Physician of the Year, calls wife Kathie my better half. The advisory panel will prioritize critical research questions for possible funding initiatives under PCORIs research priority for the Assessment of Prevention, Diagnosis and Treatment Options, and provide information and advice on evaluating and disseminating the programs research. The 21-member panel represents different sectors across the health-care community, including researchers, clinicians, patients, caregivers, insurers, employers, policymakers and industry. Insel will participate in the advisory panel representing clinicians. Kathie Insel traveled to Alexandria, Va. in April for the orientation and first meeting. Advisory panel members are appointed for one-year terms, with the opportunity for reappointment for a maximum of two terms. The Patient-Centered Outcomes Research Institute (PCORI) is an independent, non-profit organization, authorized by Congress, whose mission is to fund research that will provide patients, their caregivers, and clinicians with the evidence-based information needed to make better-informed healthcare decisions.

Dr. Heinz goes to Washington


Dr. Matt Heinz, former Arizona legislator, told us that in June he was relocating to Washington, D.C. for his appointment as director of provider outreach for the Office of Intergovernmental and External Affairs under the federal Department of Health and Human Services. He will be charged with helping the department engage with healthcare providers at a variety of levels to help them understand the health reform law and facilitate the rollout process. The job will definitely evolve as we see where there are barriers or deficiencies of any kind, or where the need is greatest to focus my attention or the attention of the office, Dr. Heinz said.
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UofA CofM ranks high for grads choosing Family Medicine


Paul Gordon, M.D., PCMS member since 2009 and professor in the Department of Family and Community Medicine at the UofA College of MedicineTucson, continues to help create much-needed family physicians, for which his department was recently recognized. The university reports that the American Academy of Family Physicians has honored the college as one of the top 12 allopathic medical schools that graduated the most students who chose to go into family medicine from 2010 through 2012. The ranking applies to the medical colleges Tucson and Phoenix campuses, which are among the 12 medical schools that
SOMBRERO August/September 2013

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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.

UAMC ECMO program awarded for excellence


The ECMO (Extracorporeal Membrane Oxygenation) Services Program at The University of Arizona Medical CenterUniversity Campus and Diamond Childrens has received the ELSO Award for Excellence in Life Support from the Extracorporeal Life Support Organization (ELSO), the university reports. Program surgical director is cardiothoracic surgeon Jess Lee Thompson, M.D., assistant professor, Department of Surgery, Division of Cardiothoracic Surgery. The award signifies a commitment to exceptional patient care and demonstrates an assurance of high quality standards, specialized equipment and supplies, defined patient protocols and advanced education to all staff members, the university said in a news release. Program medical director is pediatric intensivist Robyn Meyer, M.D., associate professor, Section of Critical Care, Department of Pediatrics. Critical care specialist Yuval Raz, M.D., assistant professor, Department of Medicine, is adult medical director. ECMO is a form of advanced life support for the heart and lungs, the university reported. It is used when a patient is so critically ill that no other support is adequate. A pump circulates blood through a circuit of tubing supporting heart function and through an oxygenator that functions as an artificial lung. It is used to help patients of all ages with life-threatening diseases that impair heart and/or lung function. ECMO is often used on patients waiting for heart or lung transplant. Most patients who need ECMO are almost certain to die without this level of support. The program continues to expand, the university reported. Previously it used only ground transport services in a radius of about 250 miles. More recently the program added airplane transport services, greatly expanding the number of facilities to which they can offer their service. Using a plane, the ECMO team has transported patients from as far away as Flagstaff, New Mexico, New Jersey, and Washington. We can reach patients in need of ECMO, but are in a hospital that doesnt have the equipment or personnel necessary to initiate ECMO, Dr. Thompson said. The ECMO program has developed a rapidresponse ECMO team, consisting of a cardiothoracic surgeon, a perfusionist, and an ICU nurse who travel to the facility and initiate ECMO on the patient. The patient is then carefully transported via ground ambulance or airplane back to UAMC for continued treatment. By partnering with hospitals that dont have ECMO services, we are now able to offer advanced lifesaving therapy to patients that previously didnt have access to it. As one of the busiest ECMO centers in the Southwest, we are routinely consulted regarding ECMO-dependent patients who require advanced organ-failure therapy. Often, ECMO is begun by another facility, and then the patient is transported to our

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facility because of our capacity to provide transplantation or longterm mechanical circulatory support.

Pima Dermo welcomes Dr. Matthew Beal


Pima Dermatology, P.C. reports that they are pleased to welcome Matthew W. Beal, M.D. to the practice. Dr. Beal joins the dedicated staff of Pima Dermatology in providing exemplary patientcentered care, they said. He has an expansive range of training and experience in all aspects of dermatology, including medical and surgical treatment of skin cancers and diseases, laser surgery, and laser skin rejuvenation. Dr. Beal has special interests in cutaneous oncology and psoriasis, they said. Dr. Beal is a Tucson native and earned his M.D. at University of Arizona College of Medicine. Elected to the prestigious Alpha Omega Alpha Honor Medical Society, he graduated at the top of his class. He did his residency at the University Of Minnesota in 2013, where he served as chief resident his final year. He has procured leadership positions in organized medicine and has lectured and presented on a national level at the Mayo Clinic,

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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SOMBRERO August/September 2013

Behind the Lens

If you knew the valley, you knew Susie


By Hal Tretbar, M.D.

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.

In the cold of March 2007, Susie still attended to her sheep.

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

Compliance deadline Sept. 23 for HIPAA/HITECH final regs


By Mark Rubin Mesch, Clark & Rothschild
For those in healthcare, the Health Insurance Portability and Accountability Act (HIPAA) feels like it has been around for a long time. So, not surprisingly, many medical providers have a sense of assuredness that they are HIPAA- compliant. But in March of this year the U.S. Department of Health and Human Services (HHS) issued final regulations that differ significantly from the regimen in place prior to March 2013. And these final regulations include a Sept. 23 compliance deadline. Are you HIPAA-ready? HIPAA is, today, the product of the Health Insurance Portability and Accountability Act of 1996 and the Health Information Technology for Economic and Clinical Health Act (HITECH). Congress passed HITECH in 2009 as part of the American Recovery and Reinvestment Act, also known as the stimulus bill. Through the HHS regulatory process, the final regulations took effect on March 26, 2013. HHS provided six months to allow organizations to comply, hance the Sept. 23, 2013 deadline. To understand HIPAA/HITECH regulations, some key terms need to be defined: Protected Health Information; Covered Entity; Business Associate; and Subcontractor. Protected Health Information (PHI): PHI is individually identifiable health information, including patient name, medical record number, birthdate, Social security number, diagnoses, and other types of information. There are 18 categories of PHI, the last of which is a catch-all that includes anything not previously mentioned. Covered Entity: A Covered Entity is a healthcare provider; a health plan; or a healthcare clearinghouse (most commonly a billing service). Business Associate: A person or entity, not employed by a Covered Entity as an employee, whose work activities involve use or disclosure of PHI, either on behalf of the Covered Entity or to the Covered Entity. Subcontractor: A person or entity that creates, receives, maintains, or transmits PHI on behalf of a Business Associate. The HIPAA/HITECH regimen operates under two main rules: the Privacy Rule and the Security Rule. The Privacy Rule focuses on PHI, requires notice of privacy practicesall of that paperand prohibits verbal disclosure of PHI. The Privacy Rule applies to Covered Entities, Business Associates, and Subcontractors. The Security Rule establishes procedures to ensure that Covered Entities and Business Associates keep PHI private. It also mandates that HHS be informed about improper disclosures of PHI under certain conditions.
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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.

SOMBRERO August/September 2013

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.

Climate conference Sept. 21


The community education and organizing event Climate Smart Southwest Conference is Sept. 21, 7:30 a.m. to 5:30 p.m. at the Tucson Convention Center. Cost is $35 ($15 for current students), including a buffet lunch and on-site parking at the TCC. The event kickoff is a free talk by Eric Klinenberg, professor of sociology at New York University and author of the best-selling book Heat Wave: A Social Autopsy of Disaster in Chicago, about the July 1995 weeklong triple-digit heat wave that took more than 700 lives. Dr. Klinenberg will give his talk Friday Sept. 20, 7-8 p.m. at the TEP Unisource Building Conference Room, 88 E. Broadway Blvd., Tucson. While this event is free and open to the public, please RSVP as space is limited. You can do so by going to the conference website www.psr.org/azclimate. The conference on Sept. 21 focuses on public health and climate adaptation and is sponsored by Physicians for Social Responsibility and 35 other local and national organizations. Morning will be dedicated to nationally and internationally known speakers presenting information about climate change and emerging health problems, food security, mental health, and how we can educate our children, build neighborhood resilience, and address cross-cultural issues as we adapt to climate change. Afternoon will have workshops to prepare and respond to the challenges posed by climate change. To register for Saturdays events, log onto www.psr.org/azclimate. For more information go to www.psr.org/azclimate . If you have questions, please contact Dr. Barbara Warren at bwarre01@gmail.com .

TMC Mega Raffle mega success


TMC reported that on May 29 the Tucson Medical Center Mega Raffle had its final draw for the remaining 2,822 prizewinners. The two grand prizewinners of A.F. Sterling homes were Tucson residents. Other top prizewinners were from cities and towns throughout Southern Arizona. Despite several calls, Sombrero was not able by deadline to get a figure on how much was raised, but we were told that about 43,000 tickets were sold at $100 apiece, or three for $250. Introduced in March, the TMC Mega Raffle was the first largescale raffle focused in Southern Arizona. Net proceeds benefit TMC and its commitment to providing the highest standard of patient care to Southern Arizonans. The raffle gives Tucson Medical Center the opportunity to expand on innovative healthcare programs and services with unrestricted dollars available to invest in patient care, said Michael Duran, vice-president and chief development officer of TMC Foundation. While we do not have a full tally of all the numbers yet,I can say with certainty the raffle was extremely successful, Duran said in
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Drowning: a quiet affair


The PCMS Public Health Committee notes that if you see someone in the water thrashing about and screaming, that person is in distress and may drown. But he isnt drowning yet. Those who are drowning are perfectly quiet. Children have drowned with their parents in the water 10 feet away from them. Drowning is the leading cause of injury deaths in children age 1 to 4, with 436 such deaths reported by the CDC in 2010. In this age group, there were 343 traffic deaths, 163 unspecified homicide deaths, and 43 homicide deaths by firearm.
SOMBRERO August/September 2013

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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24 SOMBRERO August/September 2013

Coming PCMF CMEvents


Coming CME events in the Pima County Medical Foundation Tuesday Evening Speaker Series, presented at PCMS, are: Sept. 10: Newer Antibiotics: How They Work and Why and When We Use Them with Assistant Professor of Medicine Anca Georgescu, M.D., Department of Infectious Disease, UofA College of Medicine. Oct. 8: Ocular Signs of Systemic Disease with Dr. Robert Snyder. Nov. 12: Robotic Surgery: What it Means for the Future with the UofAs Dr. Robert Poston, cardiothoracic surgeon, and Dr. Sanjay Ramakumar of Urological Associates of Southern Arizona.

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

Elder care immersion program gives residents special training


In June the UofA College of MedicineTucson had its annual leadership, teaching, and quality improvement trainingthe Interprofessional Chief Resident Immersion Training Program (IPCRIT)aimed at improving health outcomes for older adults. This year it hosted 38 chief residents from 15 specialties who received training in the care of older adults, the UofA reported. Mindy Fain, M.D., College of MedicineTucson division chief, said, With our rapidly aging population, all physicians need to acquire the special knowledge and skills to provide the best of care for older adults who are often hospitalized with complex conditions that require all healthcare providers to work together seamlessly for the best outcomes. Dr. Fain co-hosted the conference with Jane Mohler, Ph.D., M.P.H., N.P. The IP-CRIT program is targeted to incoming chief residents because of the key role they play in ensuring safe, high quality patient care, training of medical students and residents, and communicating with patients and families, the university reported. The program provides the residents with the structure and support to transform their key ideas into meaningful change to promote quality and safety for patients. They participate in quality improvement project planning in partnership with the University of Arizona Health Network quality improvement staff and Arizona Center on Aging faculty, focusing on the following areas: delirium prevention and management, improving transitions of care, pain management and palliative care, and improving communication and professionalism. Equally important, the program included time for socializing and bonding with College of MedicineTucson faculty and family members. In addition to the 38 chief residents, attendees included three program directors, 22 interprofessional faculty and staff, as well as five Reynolds Scholars in Aging specialty faculty. The chief residents included general surgeons, anesthesiologists, urologists, psychiatrists, obstetricians-gynecologists, orthopaedists, emergency medicine physicians, neurologists, family physicians, internists, ophthalmologists, radiologists, radiation oncologists, neurosurgeons and pediatricians.
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In Memoriam

Dr. Richard F. Dahlen, 1926-2013


Richard F. Dahlen, M.D., (pronounced Da leen), partner in Associated Dermatologists in Tucson, who joined PCMS in 1959 and had been retired since 1990, died May 2. He was 86. Richard Frederick Dahlen was born Dec. 6, 1926 in Rock Island, Ill. to Andrew and Anetta Dahlen. After graduating from high school in 1945, he served in the U.S. Army for a year. After a brief career as a selfprofessed ski bum, the family told the Arizona Daily Star, Dick began a pre-med course at the University of IllinoisUrbana. He earned his M.D. from the University of Illinois College of Medicine, Chicago, in 1954. In 1956-59 Dr. Dahlen did his IM residency at Robert Packer Hospital and Guthrie Clinic, Sayre, Pa., and a fellowship in dermatology at University of Minnesota Medical School at Minneapolis.
Dr. Richard F. Dahlen in 1986.

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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Dr. Jose L. Hurtado, 1956-2013


Jose L. Hurtado, M.D., gastroenterologist who joined PCMS in 1988, and practiced in Tucson for 25 years, and was elected to our Board of Directors in 1998, died June 6, 2013. He was 56. He was an accomplished physician, his family told the Arizona Daily Star. He excelled in all his endeavors from a young age and throughout his career as a physician. He was know for his dedication, compassion, and Dr. Jose L. Hurtado in 1988. kindness to his patients. Jose Luis Hurtado, known to family and friends as Pepe, was born June 16, 1956 in Douglas to Fernando and Gloria Hurtado. He did his undergraduate education at the University of Arizona, earning a bachelors degree in microbiology and studying medical technology. He earned his M.D. in 1983 at The Medical College of Wisconsin, Milwaukee, and did his residency in the Tucson Hospitals Medical Education Program. His gastroenterology fellowship was Tufts University School of Medicine, Medford, Mass. He was board-certified in IM and gastroenterology.
SOMBRERO August/September 2013

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SOMBRERO August/September 2013

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.

Dr. Humberto C. Gonzalez, 1926-2013


Humberto C. Gonzalez, M.D., F.A.C.S., longtime Tucson general surgeon who then practiced in Indianapolis, Ind., who joined PCMS in 1959, died June 3 in Indianapolis of complications from T-cell lymphoma. He was 87. We grieve the loss of Dr. Humberto Gonzalez, the family said, who, even though he was 87, was full of life and had a vision of the future with Dr. Humberto C.Gonzalez in a plan to continue doing what 1959 when he joined PCMS. he loved best: practicing medicine. Indeed, he worked up to three weeks before his death. Humberto Cano Gonzales was born the seventh of eight children Feb. 5, 1926 in Nogales, Ariz. to Amelia and Faustino Gonzalez. He lost his parents early and was raised by his paternal grandmother, Refugio Cano, and his great-aunts Conchita and Matilde Cano.

SOMBRERO August/September 2013

29

Klara Ilona Swimmer, M.D., 1924-2013


Klara I. Swimmer, M.D., New York IM physician and death camp survivor who joined PCMS as an Associate Member in 1984, died quietly at her home in Tucson in the early hours of July 18. She was 88. Dr. Swimmer was a retired physician and Holocaust survivor who led a quiet, dignified and often joyous life of service to her patients and her community, with a profound and loving commitment to her family and her friends, the family told the Arizona Daily Star.

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

Dr. Klara I. Swimmer in 1984.

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.

SOMBRERO August/September 2013

9 Locations throughout Tucson . RadLtd.com .

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SOMBRERO August/September 2013

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MICA_Sombrero09'13ad_MICA_Sombrero05'04ad 8/13/13 2:36 PM Page 1

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

Medical Professional Liability Insurance


(602) 956-5276 (800) 352-0402 www.mica-insurance.com
Endorsed by the Arizona Medical Association and the Arizona Osteopathic Medical Association

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SOMBRERO August/September 2013