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Pima County Medical Society

Home Medical Society of the 17th United States Surgeon General

January 2013

Surgery, artistry: Remembering Dr. Rock Jackson Dr. Katzenberg: 2013 will never bore


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Associates Associatesof ofWealth WealthManagement ManagementStrategies Strategieso o er ersecuri securi titi es esthrough throughAXA AXAAdvisors, Advisors,LLC LLC(NY, (NY,NY NY212-314-4600), 212-314-4600),member memberFINRA, FINRA,SIPC. SIPC. Investment Investmentadvisory advisoryproducts productsand and services serviceso o ered eredthrough throughAXA AXAAdvisors, Advisors,LLC, LLC,an aninvestment investmentadvisor advisorregistered registeredwith withthe theSEC. SEC. Annuity Annuityand andinsurance insuranceproducts productso o ered eredthough thoughAXA AXANetwork, Network,LLC. LLC. Wealth Wealth Management ManagementStrategies Strategiesisisnot notaaregistered registeredinvestment investmentadvisor advisorand andisisnot notowned ownedor oroperated operatedby byAXA AXAAdvisors Advisorsor orAXA AXANetwork. Network. AXA AXAAdvisors Advisorsand andAXA AXANetwork Networkare arenot not a a liated liated with with Pima Pima County County Medical Medical Society. Society. PPG PPG 69384 69384 (07/12) (07/12)

SOMBRERO January 2013

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. 1

PCMS Board of Directors

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

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: Please do not submit PDFs as editorial copy. Art Director Alene Randklev, Commercial Printers, Inc. Phone: 623-4775 Fax: 622-8321 E-mail:

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: Publisher Pima County Medical Society 5199 E. Farness Dr., Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website:

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 January 2013

6 Dr. Charles Katzenberg: A message from, and
introduction to our 2013 president. 8 PCMS News: Our officer elections; referring to Pima Council On Aging.


Our December 2012 issues In Memoriam contained three errors: Dr. Joseph Mirabiles birthdate of 1942 was mistakenly headlined 1925. Dr. Ray Moldows name was typed incorrectly in the same obit, as was that of Dr. Wes Fee in the obit for Dr. Stearns. We regret the errors and have ensured extra pre-publication checking for this months In Memoriam.

13 Behind the Lens: Native American hoop dancing will be

on display and in competition in Phoenix. relationship to our 2012 haboobs.

16 Valley Fever: The valleys cocci expert examines its 18 Disability: Is that case investigator misusing surveillance?
Specialist attorney Ed Comitz advises. Doug Hirano. art.

21 Hepatitis B: Hep B, liver cancer, and Asian Americans, by 23 In Memoriam: Dr. Rockwell Jacksons life in surgery and 25 Makols Call: Musings of a ... liberal. 26 Mayo CME: Upcoming from the Scottsdale clinic. 26 Members Classifieds
On the Cover
Cardiologist Charles A. Katzenberg, M.D., co-founder of Pima Heart Associates, is 2013 PCMS president (Photo courtesy himself).


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4 SOMBRERO January 2013


Established 1971

SOMBRERO January 2013

A Chinese new year

By Charles Katzenberg, M.D. PCMS President

Chinese proverb wishes, May you live in interesting times. lPhysicians seem to have outdone that, as 2013 will certainly be an interesting medical year. When I list just a random smattering of the happenings in the past few years, I see that the future will be hard to predict, and will offer us challenging opportunities.

2012: Gov. Jan Brewer, maintaining her opposition to ACA or ObamaCare officially refuses to set up an Arizona state insurance exchange, leaving it to the feds. The exchanges must be functioning by Fall 2013a big order, especially since the feds will be creating somewhere between 10 and 20 of the exchanges. 2011-2012: TMC is rolling out its Accountable Care Organization (ACO). ACOs currently have 25 -30 million patients. 2012: Carondelet closes Tucson Heart Hospital and moves the surgery program to Carondelet St. Marys Hospital as Carondelet Heart & Vascular Institute. 2012: The first medical marijuana dispensaries open in Tucson. 2012: Anthem Blue Cross, Californias largest for-profit health insurer, proposes an average rate hike of 18 percent, but some Anthem customers may see increase of as much as 25 percent in February 2013. Will Arizona be next? 2012: The AMA Council on Medical Services recommends that AMA support transitioning Medicare to a defined contribution program that would enable beneficiaries to purchase coverage of their choice through a Medicare exchange of competing health insurance plans. Traditional Medicare would be an option in the Medicare exchange. AMA is breathing life into the Medicare voucher proposals. 2012: Arizona Business Coalition partners with physicians through Pima County Medical Society. Goals of the partnership are to improve quality and control cost by re-designing the way health care is delivered and paid for. 2014: The ACA becomes fully operational. It feels as if Im on several sidelines, trying to watch several ballgames simultaneously. I hope that physicians become more involved in our healthcare tsunami. True north on my healthcare compass will always point to what is best for our patients. PCMS has had a slew of excellent presidents, most recently Dr. Alan Rogers. I hope I can build on his strong work to increase membership and contribute to making our society relevant to physicians, NPs and PAs, whether employed, self-employed, academic, or retired. Questions of the Month (correct answers on page 11 ) 1. Whats the average annual premium for family coverage on an employer health plan? $7,791; $21,248; $15,745; $12,375. 2. On average, what percentage of employer health premiums do workers pay? 27.4 percent; 17.1 percent; 50.3 percent; 5.8 percent.
SOMBRERO January 2013

2009-2010: Carondelet begins hiring specialists, starting with cardiologists, vascular surgeons and cardiothoracic surgeons. Northwest Medical Center broke this ground a few years beforehand. 2010: The Patient Protection and Affordable Care Act is passed without a single Republican vote (seems like long ago). The stimulus package of 2009 had only three Republican senators vote for it and no Republican representatives. The fiscal cliff looms as I write; Washington is partisan, polarized, provincial, and pathetic. 2011: In an effort to balance the budget, the Arizona Legislature changed AHCCCS eligibility requirements, denying coverage for childless adults. In 2000 Proposition 204 passed which directed the state to use tobacco settlement money to cover individuals with incomes up to 100 percent of the federal poverty level, including childless adults. Claiming funds were not available, our legislature knocked 100,000 to 150,000 patients off AHCCCS. The numbers of uninsured presenting to clinics such as El Rio increased by at least 10 percent in the past two years. 2011: Kino Community Hospital is renamed University of Arizona Medical CenterSouth Campus after being renamed University Physicians HealthCare Hospital at Kino Campus in 2005. Many still refer to it as Kino. 2011: Rep. Gabrielle Giffords and 19 others were shot, six fatally. Extended magazines and/or assault weapons were not even discussed in the Arizona Legislature, but they did declare the Colt Single Action Army Revolver (also known as the Peacemaker) to be our official state gun. 2011-2012: TMC replaces its ED physician group and repopulates through a national provider of ED services, EMCare. SJH replaces its hospitalists and re-populates with Cogent HMG Hospitalist Group. EMRs are up and running in all hospitals, some further along than others. 2012: UA Medical School in Phoenix completed its new building after taking its first students in 2007. 2012: Green Valley Planning Commission approved a new hospital to be built by TMC, anticipated opening in late 2014.

The man who never returned

My wife, Pam, is an attorney. Our daughter Jenny is in her second year at The University Arizona College of Medicine Tucson. Our son Ben is an attorney for the International Atomic Energy Agency in Vienna, Austria. I like to hike, bike, swim, sail, ski, read, and make movies. My favorite place is the Grand Canyon, and my favorite thing to do is take a family trip. My practice life began at [Carondelet] St. Marys Hospital in 1982, when I joined Dr. David Lapan and we started Pima Heart Associates. I moved to Northwest Hospital [now Medical Center], and then Tucson Heart Hospital where I was medical director 1997-2004.

Charles Alan Katzenberg was born in 1950 in Chicago and grew up in its suburbs. My wife, dog, and I came to Tucson in 1980 for me to do a cardiology fellowship, he said. Our plan was to return to Chicago after the fellowship, but that never happened.

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I have served as the president of Health Horizons, a PPO. I volunteer at St. Elizabeths Health Canter [formerly St. Elizabeth of Hungary Clinic] and with Tucsons Mended Heart Group. My major medical interest is prevention of heart disease, and with Edna Silva, R.N., we have created the Heart Series, a 12-week course for people interested in prevention of CAD. Dr. Katzenberg, a PCMS member since 1984, is board-certified in IM and cardiology. He graduated from the University of Illinois College of Medicine, did his IM internship and residency at Michael Reese Hospital & Medical Center in Chicago, and had a fellowship in pulmonary diseases there. After that he came to n Tucson for his cardiology fellowship at UMC 1980-81.

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SOMBRERO January 2013


Board election results

Howard Eisenberg, M.D. and Afshin Emami, M.D. were elected, and Michael Connolly, D.O. and Randall Fehr, M.D. re-elected to the PCMS Board of Directors in close election results announced Dec. 11. One hundred eighty-four ballots were cast. Thomas Griffin, M.D. was elected to the Board of Mediation and Anthant Pathak, M.D. and Richard Dale, M.D. were elected Members at Large. Medical students Stewart Dandorf M.S., M.P.H. and Jamie M. Fleming were elected in a student-only ballot in November. Running without opposition, Timothy Marshall, M.D. was elected president-elect; Melissa Levine, M.D. was elected vice-president; and Steve Cohen, M.D. was elected secretary-treasurer. PCMS elections are always close and this one was no exception, PCMS Executive Director Steve Nash said. There are never any mandates, just an expectation the physicians will do their level bestand invariably they do take the responsibility seriously. If you would like to be considered for PCMS office, contact Nash at 795.7985 or e-mail

PCOA offers three community-based programs to aid people age 60 and older in maintaining and enhancing personal health. You might consider referring patients to one or all three programs: Healthy Living: Managing Ongoing Health Conditions is a sixweek program (2.5 hours/week) developed, evaluated, and monitored by the School of Medicine at Stanford University. Also known as the Chronic Disease Self Management Program (CDSMP), these workshops teach techniques to deal with emotions, appropriate exercise and nutrition, proper use of medications, effective communication with family members, and informed choice in treatment. The workshops are designed to complement clinical treatment and disease-specific education programs. Participants learn how to problem solve, and most importantly, take control of their chronic diseases. The workshops involve 12-20 participants and cost is $20/person, $30/couple. Enhance Fitness is a low-to-moderate level exercise class taught by certified fitness instructors. Classes meet for an hour three times weekly and include no- or low-impact aerobics, stretches, and structured strength training providing sitting and standing options. The University of Washington developed and tested this program to include endurance and strengthening activities specifically designed for older adults. A baseline fitness check is completed when someone begins the program, with fitness assessments included at four-month intervals. Cost is $18/ month, $60 for four months. A Matter of Balance is a program emphasizing an active lifestyle in order to reduce the risk of falling. Participants learn to view falls as controllable, strength and balance exercises, to recognize fall hazards and how to get up and down safely. The class meets for four weeks, twice weekly for two hours each session. Cost is $20/person, $30/couple. Several partners including the University of Southern Maine and Boston University developed and evaluated the program. All three programs are taught in a variety of community settings around Pima County. Tell your patients to call PCOA at 790.7262 or to register online at

Just Walk continues

Our Executive Committee decided in December to continue the popular Just Walk and Walk With a Doc program for another year, so if you would like to lead a group of people hungering for fitness and health information, contact Steve Nash at the Society. This program started slowly but has grown nicely, Nash said. We have a group of regulars and add new people all the time. Walks start at Rillito River Park, second Saturdays monthly, at Swan Bridge, east side, south bank. Walks go either one mile or two depending on group preference. Physicians give a brief talk, then head east toward Craycroft. PCMS physicians who led walks in 2012 were Leslie Willingham MD, Melissa Levine MD, Evan Kligman MD, Bruce Lynn MD, John Clymer MD, Bennet Davis MD, Mike Hamant MD, Ana Maria Lopez MD, and Jess Thompson MD.

TMC access improved at Grant-Beverly

TMC Communications reports that road construction is largely complete at Grant Road and Beverly Drive, creating a new, welcoming entryway to the campus of Tucson Medical Center. Motorists heading west on Grant now have a right-turn deceleration lane at Beverly to make it easier to turn north into the campus. The fresh pavement offers motorists two lanes of traffic on Beverly heading toward the Emergency Department and the coming Orthopaedic and Surgical Tower. When leaving the campus on Beverly, vehicles have three lanes: left turn, right turn, or straight ahead. Still being finished is a dedicated drive that leads directly to the original ED entrance. Until that stretch opens, probably by the time Sombrero is published, everyone headed for Emergency or other services in the west end of the hospital will continue using the West Entrance next to Emergency. This includes traffic
SOMBRERO January 2013

Referring to PCOA
Physicians see firsthand the toll chronic diseases take on peoples livesthe pain, limitations, poor emotional health that compromise your patients quality of life. You recognize how hard it is for patients to follow through on your recommendations for basic lifestyle changes such as increasing activity and eating more healthily. As physicians you also tend to refer patients within our health systems because of familiarity. Pima Council On Aging suggests that you add one more referral location to your list, a place where your patients can easily access evidence-based, low cost, self-management programs provided by an organization Tucsonans have trusted since 1967.

headed for the Pediatric Emergency Department, which is back in its original location near adult Emergency after renovation, TMC reported. Next, some final phases of road construction will begin soon in front of the new Orthopaedic and Surgical Tower, to prepare the remaining parking spaces, driveways and patient drop-off areas. The new four-story hospital wing is scheduled to open in 2013 with new clinics, patient rooms, and surgical suites. In addition to handling nearly all surgeries for the hospital, the new tower will support an orthopaedic center of excellence run by TMC and Tucson Orthopaedic Institute. TMC has built a new parking garage, improved all hospital loop roads, and begun a Founders Park at Grant and Beverly to honor important figures in TMC history.

This case is a nice example where the otolaryngology and neurosurgery team approach really helps, Dr. Chiu said. Our ability to refine our technique and our synergy with one another allowed for our patient to go home sooner, Dr. Lemole said. Aragon was referred to the physicians from a community otolaryngologist based on their national reputation in skull-base and minimally invasive surgery. The two pair up to perform as many as 80 sinonasal and skull-base cases per year, commonly treating tumors of the sinuses and skull base, head trauma, and CSF leaks in patients from throughout Arizona and neighboring states. This type of interdisciplinary teamwork has resulted in UAMC becoming a referral center for the best surgical treatment options for patients with complex neurological and otolaryngological disorders, said Rainer W.G. Gruessner, M.D., surgery department chairman. Before her diagnosis, Aragon said she was terrified she might not survive. I was scared to death and desperate, Aragon said. I knew it could not be allergies. The fluid would come out like a puddle. Steroids and antibiotics did nothing. I was walking around with toilet paper shoved up my nose and changing it every 10 minutes, she recalled. Aragon and her husband, Anthony, said they knew they were in good hands with doctors Chiu and Lemole. They were very patient and answered all of our questions, Anthony Aragon said. Both were relieved that minimally invasive surgery could be performed, accessing the cracks through Aragons nasal cavity. They also were relieved to hear the statistics: Performed endoscopically, the procedure is successful in 95 to 99 percent of cases; it is only 60 percent successful when performed via craniotomy, Dr. Chiu said.

Surgery through nose stops brain fluid leak

Doctors Alexander Chiu and G. Michael Lemole of the University of Arizona Department of Surgery are the only surgeons in Southern Arizona who use minimally invasive endoscopic techniques to stop brain fluid leaks, the university recently reported. For more than four months, Aundrea Aragon struggled with what doctors told her were allergies. Whenever she bent over, clear liquidwhich turned out to be brain fluidstreamed out her nose. It took several trips to different doctors before the cause of the leaking fluid was determined. Two small cracks in the back wall of Aragons sphenoid sinus allowed cerebral spinal fluid (CSF) to leak. Most often, surgeons repair such cracks, which are caused by cerebral pressure, through craniotomies, resulting in painful recoveries, extensive scarring and possible side effects. But a team of UA surgeons were able to fix Aragons leaks with an endoscopic procedure through the nose, requiring no incisions on her head and resulting in a shorter hospital stay and faster recovery. Alexander Chiu, M.D., chief of the Division of Otolaryngology, and Michael Lemole, M.D., chief of the Division of Neurosurgery, in the UofA surgery department, used image-guided neuronavigation and fluorescein dye to help find the cracks. They then used tissue from inside Aragons nose, as well as a small piece of belly fat, to repair the cracks and stop the leak.
SOMBRERO January 2013

While the human body replaces brain fluid, Aragon was at risk for developing a lethal infection. If you are leaking brain fluid out your nose, you have the potential for catastrophic meningitis, the kind where bacteria crawls into your brain and 24 hours later you are essentially in a coma or dead, Dr. Lemole said. That is what we worry about in these cases. Aragon is recovering well, and is happy to be home with her husband and childrenArt, 16, Marc, 10, and Reina, 9. Aragon posted about the success of her Oct. 1 surgery recently on Facebook. I am so grateful to them for everything they have done for us, Aragon said. I had great care from a great staff Im here, and I am grateful I can take care of my kids.

TMC gets more recognition for cardiovascular

Tucson Medical Center reports that it is the first hospital in Tucson to be awarded Congestive Heart Failure Accreditation from the Society of Cardiovascular Patient Care (SCPC), an independent, nationally recognized accreditation authority. TMC earned this distinction by meeting or exceeding a wide set of stringent criteria, showing its expertise and commitment to quality patient care, they said. This accreditation demonstrates the hospitals dedication to higher standards in enhancing the quality of care for heart failure patients.

With the addition of this CHF accreditation to our atrial fibrillation and chest pain accreditations, TMC is clearly a leader in exceptional cardiovascular care in Tucson and Southern Arizona, said TMC cardiologist Dr. Gregory D. Pennock from the Heart Center of Southern Arizona. At TMC we work with our heart failure patients to improve their lives while giving them the tools to manage their disease at home, said TMC Chest Pain Coordinator Julie Ward. We educate them about their medications, and what changes they may need to make in their diet. We have a wonderful hospitalto-home program to ensure patients get home safely, do well in the subsequent weeks and months, and that they follow-up with their physician. SCPC is a non-profit, nationally recognized accreditation organization focusing on transforming cardiovascular care by assisting facilities in efforts to create communities of excellence that bring together quality, cost, and patient satisfaction.

emergency medical system that specifially addresses their needs. He edited the first textbook in geriatric emergency medicine, Emergency Care of the Elder Person, and co-edited the textbook Emergency Medicine: An Approach to Clinical Problem Solving.

Make a fashion statement

Dr. Sanders elected to IOM

Arthur B. Sanders, M.D., M.H.A. was recently elected to the Institute of Medicine of the National Academies, the UofA Sarver Heart Center reports. Considered one of the highest honors in the health and medicine fields, the appointment recognizes individuals who have demonstrated outstanding and professional achievement and commitment to service, they reported. Dr. Sanders is a professor in the UofA College of Medicines Department of Emergency Medicine, a member of Sarver Heart Center, and of the Arizona Emergency Medicine Research Center. He is one of 70 new members and 10 foreign associates elected to the IOM at its 42nd Annual Meeting in October. IOM was established in 1970 by the National Academy of Sciences. New members are elected in a selective process that recognizes individuals who have made major contributions to advancement of the medical sciences, healthcare, and public health, Sarver reported. I have spent my entire academic career at The University of Arizona, Dr. Sanders said, and this honor reflects the collegial academic community in our College of Medicine. In particular I would like to thank Dr. Gordon Ewy for being my mentor and teaching me everything I know about clinical research. When I was a young faculty member, Dr. Ewy would always ask, What is the most important question that will impact the clinical care of my patients? This would guide or research efforts. My accomplishments in geriatric emergency medicine were modeled after out success in CPR research, always focusing on the clinical care of our patients. Sarver reported that Dr. Sanders helped develop a more comprehensive model of care for elder patients in the

Youre reading one kind of Hat. Now you can wear another kind of PCMS hat. The Society now offers its own line of embroidered baseball caps for those interested in stepping out in PCMS style. These high-quality all-cotton caps come in dark blue or white with an adjustable head strap. Each features the late Dr. Rock Jackson-designed A Century of Service Centennial logo derived from the traditional caduceus. Stop by the office and for a mere $20, make one your own. Supplies are limited!

Elder suicide watch

Suicide attempts are often more lethal in older adults than in younger adults, Pima Council On Aging reminds us. Older people who attempt suicide are often more frail, more isolated, more likely to have a plan, and are more determined than younger adults. Risk factors contributing to higher rates of suicide among the elderly include the recent death of a loved one, physical illness, uncontrolled pain, fear of prolonged illness, perceived poor health, social isolation and loneliness, and major changes in social roles such as occur at retirement. These factors suggest that older adults are less likely to be rescued and are more likely to die from a suicide attempt than younger adults. An estimated 8,618 older Americans aged 60+ died from suicide in 2010 [Substance Abuse and Mental Health Services Administration and the Administration on Aging. Older Americans Behavioral Health, Issue Brief 4: Preventing Suicide in Older Adults, 2012]. Pima Council On Aging has two evidence-based suicide prevention programs available to you and your staff: 1) safeTalk is a half-day workshop that prepares you to identify persons with thoughts of suicide and connect them to suicide first aid resources.
SOMBRERO January 2013

2) ASIST is a two-day skills-building training that prepares caregivers to provide suicide first aid interventions (attendance at both days is required). Please call PCOA at 790.7262 for more information.

of Medicine, completed his IM residency at Mayo Clinic in Minnesota, received a masters degree in epidemiology from the Harvard School of Public Health, and earned his M.B.A. from University of Michigan.

THMEP trip filling up

PCM Foundation CME series

Coming CMEvents in the Pima County Medical Foundation Tuesday Evening Speaker Series are: Feb. 12: Hand transplant and reconstructive surgery, with Dr. Warren Breidenbach, professor of plastic surgery and hand transplant, University of Arizona College of Medicine. March 12: Newer antibiotics: the how, when, why, and complications and indications of their use, with Assistant Professor of Medicine Anca Georgescu, M.D., Department of Infectious Disease, UofA College of Medicine. April 9: Interventional radiology, with Dr. Julie Zaelta, private practice readiolgist, and Dr. Steve Smyth, UofA assistant professor of radiology. May 10: Healthcare reform symposium on the PPACA: What does it all mean? Speakers TBA. June 11: Breast Cancer treatment, with Dr. Ana Maria Lopez, medical oncologist; Dr. Eric Whitacre, surgeon; and Marilyn Croghan, radiation oncologist. Sept. 10: Dermatological manifestations of systemic disease, with Dr. Norman Levine. Oct. 8: Ocular signs of conditions of systemic disease, with Dr. Robert Snyder. Nov. 12: Cardiac and urological robotic surgery, with UofAs Dr. Poston (cardiology) and Dr. Sanjay Ramakumar of Urological Associates of Southern Arizona.

Tucson Hospitals Medical Education Programs 4th Bi-Annual Colorado River Medical Conference, scheduled for July 16-21 to go down the river through the Grand Canyon, has a few spots left, Dr. Richard Dale said. Please call or e-mail him if you are interested: 721.8505 or Significant others and children age 8 and older are invited, he said. We leave Lees Ferry Tuesday, July 16, 2013 at 8 a.m. and return there Sunday, July 21. This trip is mildly strenuous, potentially dangerous (large rapids) but extremely fun and educational. Conference topics include general and vascular surgery, plastic surgery, orthopedics, and internal medicine. About 12 AMA Category 1 CME credits are pending. Registration is $200 for physicians and affiliated dentists, and $100 for RNs, residents, allied health professionals and medical retirees. Deposit is $500 per person. Cost will be $2,400 for the full trip plus the registration fee, exclusive of one nights lodging at Marble Canyon.

UofA names new Network CEO

Noted physician-hospital administrator Michael R. Waldrum, M.D. has been named president and CEO of The University of Arizona Health Network, the university reports. Michael R. Waldrum, M.D., M.S., M.B.A. is an experienced hospital administrator and a senior leader of the University of Alabama academic medical system effective Jan. 27, they said. As CEO of UAHN, Dr. Waldrum will lead the health networks two hospitals, clinics, health plans, and physician practice plan. Dr. Waldrum currently serves as CEO of the University of Alabama Hospital at Birmingham, and as vice-president of the UAB Health System. Prior to his current role, he served as UAB chief operating officer and chief information officer. He has been a member of the medical staff of the UAB School of Medicine since 1995 in the Division of Pulmonary and Critical Care Medicine. Dr. Waldrum brings vision and experience at a critical time in UAHNs history as we prepare to meet the challenges of healthcare reform, said Steven W. Lynn, UAHN Board of Directors chairman. As a physician executive, Dr. Waldrum has a unique perspective and proven record of leading a highly complex academic medical system. His experience will be critical to the success of the Health Networks mission of providing excellent medical education, patient care and cutting-edge research, said Steve Goldschmid, M.D., dean of the UA College of Medicine Tucson. Dr. Waldrum graduated from the University of Alabama School Answers to Questions of the Month (from page 6) 1. $15,745 2. 27.4 percent
SOMBRERO January 2013

Top 10 reasons candidates decline your offer and addressing it

By Joan Pearson Youve interviewed and made an offer to a candidate and are surprised to learn that he or she has declined your offer. This can happen fora variety of reasons.Here are the top 10 reasons candidates may turn down an offer: 1. Compensation offered was too low or differed from what was discussed. Solution: Never discuss or present a salary or income potential that cannot be achieved.Make your compensation plan as attractive and competitive as possible within the means of the practice potential. If you are uncertain,investigate available compensation surveys or otherpossible data. It is also wise to discuss the candidates expectations before making an offer to avoid this problem. 2. Contract or employment offer was too slow in coming. Solution: The best time to review your contract and or employment agreement is before you begin your search. The recruitment environment is competitive and candidates usually interview with several potential employers, making it likely they are holding offers in hand at the time of their visit. Many

candidates will not wait if your offer is too slow in coming. If your contract is not ready, consider offering a candidate a letter of intent to let them know the formal offer is in process. Better yet, be ready before you bring the candidate out for a visit. 3. Practice did not seem busy enough; no solid evidence of growth potential. Solution: Ensure that your medical staff plan supports the addition of the specialty or position based on solid dataand fully share this information in detail with the candidate. If the business or growth simply isnt there you should not be recruiting. Adding a physician or provider simply to expand the call schedule will be costly and counterproductive in the long run if there is not enough business to support the decision. 4. Practice buy-in was too high orlength to partnership was too long. Solution: Competition in the recruitment marketplace mandates that your offer for partnership match the market conditions in your area. Do your homework to see what your competition is offering to their new hires. Partnership is generally offered after one or two years, anything longer is unusual. Buy-in also needs to be reasonable, explainable and structured or financed over a few years. Remember, this needs to be a win-win for both the new hire and the existing partners. Keep in mind that partnership agreements that were crafted years ago may no longer reflect current market conditions. 5. Candidate got a better offer or another location was a better fit. Solution: Learn in advance what it will take to attract the candidate to your practice. If the other location is truly a better fit, learn what makes it so. Ifnothing can be changed to accommodate the need, probe to see if an alternative may sway the decision, e.g., a stipend during final training year, signing bonus, possibly earlier partnership or some creative solution to meet or exceed the other offer. Caution: do not get into a bidding war. But if you believe the candidate genuinely prefers your location and practice, explore what you can do to make it happen. 6. Candidate received and accepted a counter offer to stay.

Solution: Call your candidate to learn if the decision is truly final. The best strategy for this situation is not to let it happen! Discuss this option with the candidate during the recruitment process. Learn what the motivating factors are in his/her decision making process and try to anticipate those. If the decision is final, remember to conduct an exit interview. Find out what you could have done differently and learn from the experience. 7. Candidate could not proceed because house wouldnt sell. Solution: Much can depend on how serious your interest is in hiring the candidate and how intense the need. If it is possible, delay the planned start date for a few months. Align yourself with a creative realtor who can assist the candidate in setting the house up for lease or rent, hopefully with anoption to buy. See if a localbank might be able to offera relatively short-term lowinterest loan toaccommodate the candidates needs until the property sells. Look into the possibility of renting a house in your community and help underwrite that cost until the candidates house sells. Be creative. 8. Candidate did not feelwelcomed by or comfortable withthe group or hospital physicians or management/administration. Solution: Consider assigning a peer liaison to act as a host before, during and after the site visit. If your candidate is coming with his/her significant other, be sure to find out about their interests, professional plans and family needs. The courtesy you show will be noted and appreciated. Similarly, ensure all group physicians and executive administration knows the background and interests of the visiting candidate and spouse so they can communicate on a friendly basis that shows genuine interest. Dont leave this to chance. Brief all who they will be meeting and share what is important to know about them. 9. The practice/community did notseem like the right fit to the physician/candidate. Solution: If a candidate tells you this it could be a blanket excuse for any number of other problems or concerns. Probe to learn what the candidate specifically means by this and be prepared to research and offer additional information that might change the candidates mind. Extend an invitation to make a second site visitif you believe it may be beneficial. However, if the candidate expresses a general malaise about everything and offers up no specific objections or reasons they feel this way, they probably truly are not interested and it is best to moveon. 10. Location, location, location. Spouse/family disliked the community or it did not fit their needs. Solution: Again, the best time to address community concerns is at the very beginning of the recruitment process. Skillful interviewing and good listening skills will help screen out candidates who will not be comfortable in your community. Know what they need and whether you have it! Good screening in the beginning of the search process will help eliminate bringing the wrong candidates to interview and visit. Conducting good, in-depth telephone interviews will save money, time and frustration later in the process. Joan Pearson is president of Catalina Medical Recruiters, Inc., 602.331.1655;

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SOMBRERO January 2013

Behind the Lens

Unique hoop-de-doo to be seen, Heard

By Hal Tretbar, M.D.

In an international event of which many may not be aware, about 70 Native American hoop dancers from across North America will compete while showcasing their skills at the 23rd Annual World Championship Hoop Dance contest at the Heard Museum in Phoenix, Saturday and Sunday, Feb. 9 and 10. They will compete in four categories: Adult (aged 18-39); Senior (over 40); Teens (13-17); and Youth (6-12). Evaluation is by a points system to win the prestigious World Champion title. Prizes range from $3,500 for first in Adult, to $200 split equally among tots age 5 and younger.

As many as 10,000 people may attend the competition at the Heard Museum to watch champion dancers such as Moontee Sinquah.


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Moontee Sinquah and his sons are chanting and singing to the drumbeat.

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The hoop or circle is symbolic to all native people and the tradition of dancing with a hoop has an extensive history among them. It represents the circle of life and the eternal cycle of summer and winter, day and night, male and female. Its origin is unclear, but it may have come from Taos Pueblo in New Mexico, when a dancer began passing a hoop over his body. As the dance became more popular in powwows and contests, younger dancers added innovations. Dancers incorporate fancy steps with speed and agility as they manipulate their bodies through as many as 20 to 30 hoops. The 2.5-foot hoops are used to form storytelling shapes such as the butterfly, the eagle, snake, and coyote. Since 1994 women have become active participants. In 1997 Ginger Sykes, a Navajo from Arizona, became the first woman to win the Hoop Dance World Championship by winning the Teen division. Last year there were several women winners. Moontee Sinquah, who is Hopi/Tewa, has been hoop dancing since he grew up in Polanca on First Mesa. In 2010 he won the World Championship in the Senior Division. Last year he placed second in the division losing first place by one point. I was fortunate to see Moontee perform his hoop dancing at the Hopi Cultural Center on Second Mesa. Usually no photography is allowed on the Hopi Reservation, but our group had special permission.
Moontee Sinquah was World Champion Hoop Dancer in 2010.

Moontee and his two grown sons began the performance with lusty singing while pounding on a large drum. He then played a softly haunting flute melody. Moontee awed us with his rapid and vigorous dancing while his sons provided the drumming. He placed the hoops over, around, and above himself, forming intricate designs. As he dripped perspiration his outstanding performance brought cheers from our group. The Heard Museum is at 2301 N. Central Ave., Phoenix. General admission for the dances is $18; $13.50 for seniors; $12 for Native Americans; and $7.50 for children aged 4-12. Events start each day with the Grand Entry at 9:30 a.m. Competition ends at 5 p.m. on Saturday. The Adult Division final round will begin at 2 p.m. on Sunday. For information, call 602.252.884. Log onto and click on the video tab to see some of these amazing performers. n
14 SOMBRERO January 2013

26 AOA Category 1A Credit, 26 AMA PRA Category 1 Credit 4 Additional Credit Hours Available with Bonus Workshops 2 Additional AOA Category 1A Credits May Be Earned by DOs Completing the Outcomes Assessment After the Conference

To join us, please contact Nicole Struck at (520) 299-4545 or Register now at

The 22nd Annual


April 4 - April 7, 2013 | JW Marriott Starr Pass Resort & Spa | Tucson, Arizona

Tucson Osteopathic Medical Foundation presents the 22nd Annual Southwestern Conference on Medicine, jointly sponsored for CME in conjunction with the University of Arizona College of Medicine at the Arizona Health Sciences Center. SOMBRERO January 2013 15

Valley Fever
By Dr. John Galgiani

Cocci risk from recent dust storms?

Valley Fever reported to the Arizona Department of Health Services is on the increase. Some of this is due to changes in laboratory reporting practices. In 2009 a major Arizona clinical laboratory began reporting the more sensitive enzyme-linked immunosorbent assay (EIA) positive test results as diagnostic of a new case of coccidioidomycosis [1]. As a result, state statistics more than doubled from 4,768 in 2008 to 11,888 in 2010 (see a discussion of following three months, a season in past years when virtually no new VF cases were normally reported. The California storm was the result of Santa Ana winds, not the summer downdraft phenomenon known as a haboob. However, both produced very similar dusty conditions. If the findings in Kern County could be extrapolated to the population of Maricopa County, one could easily expect 3,000 or more excess VF infections to be seen in the Maricopa County statistics in the following months. As it turns out, the most recent state statistics have shown very little if any relationship between the July storms and the 2011 increase in VF cases.

this in the April 2011 Sombrero).

This shift in case definition may now include reports of persons who do not actually have VF, reflecting higher numbers of reported disease, which is second only to chlamydia in total number of reported infectious disease cases in Arizona. The most recent state statistics for 2011 are provisional and show the numbers are even larger: 16,448 were reported cases in 2011, a jump of 38 percent over 2010. In contrast to the earlier increase, this cannot be ascribed to changes in reporting practices, begging the question: what is causing this? One possible factor responsible for last years increase could be weather events. Most of the reported valley fever cases occurred in residents of Pima, Pinal, and Maricopa, the so called Valley Fever Corridor, containing most of the states population. For example, because of Maricopas size, 82 percent of all of Arizonas 2011 Valley Fever infections occur in this one county. With this in mind, it is also noteworthy that last year Maricopa County experienced some of the worst July dust storms in recent memory. In particular on July 5, a blow occurred that churned up dust rising more than a mile into the air and blanketing Phoenix and much of eastern Maricopa County. Not only were this and other Arizona windstorms carried on national news, but the question was also raised as to whether these spectacular events would increase VF case numbers. Now that we have last years statistics in hand, do the states higher numbers and the dust storms appear temporally related? There is very little historical information to help predict whether this relationship would likely be expected. One very large storm in Californias Central Valley occurred in December of 1977 and its consequences have been published [2]. It was so large that dust and coccidioidal spores were blown as far north as Sacramento and the San Francisco Bay Area where primary VF infections occurred locally as a result. There were also a large number of cases in Kern County in the

Figure 1.

In Figure 1 are weekly reports for Maricopa, Pima, and Pinal counties, and also weekly reports for all other Arizona counties combined. Despite week-to-week variation, what is most apparent is that the state increase in cases is fairly constant throughout the year, not just coming temporally after the July storms. Not so apparent in this figure is that during the year the reported numbers for the three Valley Fever Corridor counties tended to rise and fall in synchrony.

Figure 2.

In Figure 2, where change of 2011 county numbers are shown as a percentage of 2010 numbers on a weekly basis, it can be
SOMBRERO January 2013

seen that for Maricopa there is a lag in the numbers falling off in the late summer and early fall as compared to Pima and Pinal. It is possible that this loss of synchrony is due to excess cases from the July storms. Even if true, however, total impact of these large storms would seem to be surprisingly slight and nothing like the numbers proposed from the California experience. If the Maricopa storms are not primarily responsible for the states increase numbers of VF cases, what else might be? One possibility is that weather may still be a factor. Work over the past several years by Andrew Comrie and his colleagues at The University of Arizona has demonstrated weather models which show strong correlations with precipitation or lack thereof with rates of Valley Fever in both Pima and Maricopa Counties [3]. A hypothesis consistent with his findings is that rain results in a fungal bloom in the soil and in future seasons when the soil dries out this leads to more spores in the air, increasing the risk of exposure and higher reported infections. If Prof. Comrie factored in PM10 readings, which are estimates in the air of particles smaller than 10 microns, the correlation of weather with VF case numbers did not improve. Thus, dramatic dust storms in a current season may not be responsible for the sustained elevated numbers of reported cases last year, but rather rainfall patterns in past seasons may have caused this increase. Another possible explanation for the increased reported VF infection numbers is that clinicians are doing a better job of accurately diagnosing VF in their patients. It is likely that only a minority of all patients seeking medical attention for coccidioidal infections are currently accurately diagnosed by lab testing, either because physicians dont order the necessary tests or because the tests fail to detect the infection [4;5]. ADHS, the Valley Fever Center for Excellence at the University of Arizona, and the Infectious Diseases Society of America [6] have

all recommended that any patient with community-acquired pneumonia and endemic exposure be tested for VF. If physicians are increasingly adhering to that recommendation, it would be expected that more infections would be added to the state statistics even if the actual number of infections were not greater. At present it is not known how much improved detection is contributing to the recent increases. Acknowledgements: The assistance of Clarisse Tsang and others at the Arizona Department of Health Services in providing case numbers of coccidioidomycosis used in this report is very much appreciated. Appreciation is also given to Dr. Rebecca Sunenshine who provided useful suggestions in the revision of this report. John N. Galgiani, M.D. is professor and director, Valley Fever Center for Excellence, The University of Arizona College of Medicine.
REFERENCES 1. Hector RF, Rutherford GW, Tsang CA, et al. Public health impact of coccidioidomycosis in California and Arizona. Int J Environ Res and Pub Health 2011;8(4):1150-73. 2. Pappagianis D, Einstein H. Tempest from Tehachapi takes toll or coccidioides conveyed aloft and afar. West J Med 1978;129:527-30. 3. Tamerius JD, Comrie AC. Coccidioidomycosis incidence in Arizona predicted by seasonal precipitation. PLoS One 2011;6(6):e21009. 4. Chang DC, Anderson S, Wannemuehler K, et al. Testing for coccidioidomycosis among patients with community-acquired pneumonia. Emerg Infect Dis 2008 Jul;14(7):1053-9. 5. Chen S, Erhart LM, Anderson S, et al. Coccidioidomycosis: knowledge, attitudes and practices among healthcare providers Arizona, 2007. Med Mycol 2011 Aug;49(6):649-56. 6. Galgiani JN, Ampel NM, Blair JE, et al. Coccidioidomycosis. Clin Infect Dis 2005 Nov 1;41(9):1217-23. n


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SOMBRERO January 2013 17

By Edward O. Comitz, Esq.

Surveillance misuse in claims investigations

Whenever a disability insurance company receives a claim, it invariably hires a private investigator to conduct surveillance on the claimant. Ostensibly, the purpose is to expose fraudulent claims. However, with pressures to save money in todays economy, disability insurers are increasingly using investigations not to expose fraud, but to manufacture it. This practice can be especially profitable for the insurer when it comes to highdollar claims filed by physicians. In response to insurers high demand for surveillance evidence to use against claimants, a cottage industry of boutique disability investigative firms has sprung up nationwide. In the past, an insurance company investigator might simply stop by your house and take a few photographs. Todays investigators have become increasingly aggressive. Advances in technology have made it possible for even a local one-man operation to perform intensive, sophisticated surveillance operations without a claimant ever knowing. These developments can be disconcerting, but understanding and anticipating surveillance tactics can help disabled physicians safeguard themselves against unfair treatment. Manufacturing evidence The primary problem with todays advanced surveillance techniques is that they provide insurance companies with a comprehensive system for manufacturing evidence that the companies can misuse to argue that a claimant is lying about his or her condition. Disability insurance companies use different tactics depending on various factors, i.e., the alleged disability, the claimant, the insurance company, the type of investigation, and the budget. Even so, many surveillance methods, such as stakeout operations, tailing, pretexting, and GPS and cell-phone tracking, are common across the board. Disability insurance companies are notorious for using photographs and video of people engaging in the most mundane everyday activities as a basis for denying or terminating disability benefits. This is what happened to Evan Werner. A few years ago insurance company The Hartford made headlines when it wrongfully terminated Werners disability benefits based on video made in a surveillance operation. Werner became disabled after suffering a severe back injury in a car accident. The injury was so bad that he could barely walk, could no longer work, and had to file for disability benefits. Each of nine physicians concluded that Werner was totally disabled and could not return to work. Nevertheless, Hartford was apparently determined not to honor his disability claim. It hired an investigator to monitor Werners daily activities. The investigator, stationed outside Werners doctors office, followed him home and videoed him as he went on an errand. A few months after the surveillance was conducted, Werner received a letter from The Hartford informing him that it was terminating his disability benefits. The company said the surveillance produced convincing evidence that Werner was capable of performing full-time sedentary work. It reached this conclusion based on the private investigators video of Werner. According to The Hartford, this so-called convincing evidence was enough for it to reject nine different doctor opinions and terminate Werners benefits. What Hartford failed to disclose, however, was that it also had conducted five previous surveillance operations on Werner, and none of these provided any basis for terminating his benefits. Claim forms as setup Investigators normally plan their surveillance based on information that a claimant provided to the insurance company in claim forms. Every claim form asks the person applying for benefits to specify activities that, as a result of disability, he or she can no longer perform. Whenever an insurance company hires an investigator, it will tell the investigator what activities the policyholder says he or she cant do. The investigator will then tailor surveillance to try to catch the claimant engaging in the proscribed activities. Insurers also frequently require claimants to complete an activity log, a questionnaire wherein the disability insurer asks claimants to disclose, hour by hour, and their typical daily activities. The logs are then passed on to the investigator, who now knows exactly where the claimant will likely be on a given day and time. Stakeout operations and tailing Surveillance can be conducted by way of a stationary stakeout operation, tailing, or both. In a stakeout, the investigator stays in one place, normally for hours on end. Tailing, on the other hand, occurs when the investigator is no longer stationary, but follows and records the disabled physician either by foot or vehicle. Generally an investigator will combine these techniques when monitoring a disability claimant by, for example, getting photos or video of the claimant pulling the trashcan outside his home, and having another person drive behind him as he goes to the grocery store or to a doctor appointment. How can you tell if you are a stakeout subject? Normally an investigator conducting a stakeout will sit in a vehicle, often a van or SUV, on the street outside your home. If you see someone sitting in a vehicle for long periods of time, especially if he or she is using sunscreens on the windshield or windows, you may be the subject of surveillance. If you think so, the best course of action is to stay inside your house with the shades drawn, and cancel any appointments or errands you had planned for the day. This way, there is no chance of the
SOMBRERO January 2013


investigator videoing or photographing you doing something that could be misconstrued as evidence that you arent disabled. Because stakeout behavior has become so familiar, investigators have started to use new tactics meant to conceal their behavior. For example, many PI operations will use female investigators for stakeouts rather than males, based on the assumption that subjects are less suspicious of solitary women than men. Another new tactic is to send one decoy PI, whether on foot or in a conspicuous vehicle, to purposefully make himself known to the subject. The subject, understandably uncomfortable with being watched, will get in his or her car and leave, assuming escape of the investigators sight. Then, as the subject drives away, a second, carefully concealed investigator will start tailing and photographing. Todays investigators will do more than simply sit back and watch; they will lay traps to catch you in activities that you reported you couldnt do. For example, if you have reported to your insurer that you cant bend forward, a private investigator may leave some change next to your car in the parking lot as bait to lure you into bending forward and picking it up. An insurance company may then use this as photographic evidence to try to claim that you are not disabled. So long as the investigator has received a state license to conduct surveillance, staking out and tailing is not illegal per se. Even so, a license to conduct surveillance does not authorize an investigator to harass, stalk, or intimidate you. If an investigator hired by an insurance company acts unlawfully, both the investigator and the insurer can face legal consequences. For example in Arizona, both the insurer and the private investigator are fully liable for any misconduct by the investigator that harms a claimant. With these surveillance tactics in mind, you must stay vigilant after filing for disability benefits. Be aware of your surroundings. Remember that even if an investigator is authorized to conduct surveillance, he may not set foot on your property, and he may not threaten, stalk, or harass you. Contact the police and an attorney if an investigator trespasses onto your property or otherwise makes you feel uncomfortable. Pretexting PIs often use pretexting to acquire a claimants personal information from others.The Federal Trade Commission defines pretexting as the practice of getting your personal information under false pretenses. An investigator pretexts when he pretends to be someone elsetypically a friend of the claimantcontacts people the claimant knows, and then deceives them into sharing the claimants personal information. This practice is not only deceptive and unprincipled, but in some circumstances it may be illegal. The Gramm-Leach-Bliley Act, for instance, explicitly prohibits anyone from pretexting to obtain customer information of a financial institution. Despite this federal law, however, many PI companies continue pretexting to obtain sensitive, albeit nonfinancial, data, such as information about family or a Social Security number. They do so because they assume the

prohibition in the Act is limited to wrongfully procuring financial information from a financial institution. This is a misconception, however, according to Joel Winston, Associate Director of the FTC, Division of Financial Practices. In an interview with PI magazine, Winston clarifies that the Act is not limited to obtaining financial information from a financial institution: First, we should dispel the misimpression, if there is one, that the pretexting provisions of [the Gramm-Leach-Bliley Act] only apply if the pretexter is getting financial information. Actually, what the statute says is if you are getting any personal, nonpublic information from a financial institutionor the consumer, that is covered by the statute. In other words, Winston says that PI companies are prohibited from pretexting with individuals or financial institutions to obtain any sensitive, non-public information. Those who do so risk a five-year prison sentence and a large fine. Unfortunately, this is not enough to deter many PI operations from pretexting. When you file for disability insurance benefits, your chances of becoming a victim of pretexting increase substantially. Therefore, in order to protect yourself, you need to do more than simply rely on law enforcement. The FTC provides some helpful prevention strategies. u First, after filing for disability benefits, inform your family and alert them to the dangers of pretexting. Tell them that only you are authorized to provide your personal information to others. Ask them to notify you in the event they receive a suspicious phone call. u Second, do not give out your personal information by phone or Internet unless you know to whom you are giving it; avoid providing sensitive information by text and e-mail where it can be stored and transferred. u Third, be informed. Ask your financial institutions about their policies for sharing your personal information, and find out who has access to your personal information at work. Make sure this information is secure. u Finally, know where you leave your personal information in your home, especially if you are living with other people; shred any sensitive documents before you discard them. Although investigators may claim they only use appropriate pretexting methodsthose not illegal on their ownthese same techniques are commonly linked to both identity theft and consumer fraud. GPS devices and cell-phone tracking PIs today may also use GPS and other tracking devices while conducting surveillance. Tracking technology is becoming more sophisticated and less expensive. Now, instead of waiting hours outside claimants homes or doctors offices hoping to find them coming and going, an investigator may simply attach a small tracking device, no bigger than a deck of cards, underneath a policyholders vehicle and monitor every move from a laptop. GPS tracking can be an extremely effective tool for investigators, as it maximizes surveillance efficiency by making subjects much easier to track. But is GPS attachment legal? Unfortunately, in many jurisdictions this is still an open question. However, a recent U.S.

SOMBRERO January 2013

Supreme Court case provides some guidance. In United States v. Jones, the Court held that attaching a GPS device to a vehicle constitutes a search under the Fourth Amendment; therefore, state law enforcement officials are required to obtain a search warrant before secretly installing a GPS device on your vehicle. Although the issue decided in Jones was narrow, limited to the powers of state law enforcement officials under the Fourth Amendment, the Courts decision largely turned on a much broader concept: the physical trespass involved in attaching GPS to another persons vehicle. The Court stated: It is important to be clear about what occurred in this case: The Government physically occupied private property for the purpose of obtaining information. We have no doubt that such a physical intrusion would have been considered a search within the meaning of the Fourth Amendment when it was adopted. In other words, law enforcement officials violated the Fourth Amendment because physically attaching a GPS device to another persons vehicle without that persons knowledge and consent constitutes trespass. This ruling may therefore be used to argue that if an investigator installs a GPS device on your car, he has violated your legal rights. Because of the Jones ruling, many PI companies are now looking into how they can bypass the physical trespass issue by using other technologies than GPS devices that do not require physical attachment. One of these new technologies is a stingray. A stingray is a cell-phone tracking device that operates as a miniature cellular phone tower from inside an investigators vehicle. The device enables an investigator to connect to a claimants cell-phoneeven when it is not being used to make a call and, after taking measurements of the phones signal strength, to triangulate the its location. Since most people tend to always carry their cell-phones, the device has proven to be an effective locator. Like GPS tracking, the law surrounding PI use of stingray equipment is unsettled. Because stingrays are so effective, investigators will, in all likelihood, continue taking advantage of this gray area in the law by using the equipment until a court or a statute explicitly says otherwise. And, unfortunately at this time, outside of scrupulously checking for small electronic objects under your vehicle every day or leaving your cell-phone turned off, there is not a lot you can do to protect yourself from GPS and cell-phone tracking. Nevertheless, although the law is still evolving in these areas, GPS and cell-phone tracking are often considered shady surveillance methods that are not well received by many judges. Conclusion Fueled by demand from the disability insurance industry, private investigators are constantly coming up with new techniques to surreptitiously monitor claimants and catch them off guard. Individuals with legitimate claims often find themselves targeted by improper surveillance or denied benefits based on misconstrued evidence. The best way to avoid being a victim of surveillance misuse is to stay vigilant and stay informed.

Edward O. Comitz, Esq. heads the healthcare and disability insurance practice at Scottsdale-based Comitz / Beethe. Karla Baker Thompson, Esq. is an Associate with the firm. For more information about disability insurance issues, please visit www.
DISCLAIMER: Information in this article has been prepared for informational purposes only and does not constitute legal advice. Anyone reading this article should not act on any information contained therein without seeking professional counsel from an attorney. The authors and publisher shall not be responsible for any damages resulting from any error, inaccuracy, or omission contained in this publication. REFERENCES 1. Cuomo C, Wagschal G. The insurer who spied on me: Disabled man sues claiming The Hartford unfairly cut off benefits, ABC News April 7, 2010, 2. Id. 3. Attorneys multi-case battle with The Hartford over use of surveillance video and intimidation tactics to deny disability claims. ABC Good Morning America. Mass Media Distribution LLC (accessed June 24, 2012), disability-insurance-law-group-7847.html. 4. Walter v. Simmons, 169 Ariz. 229, 238 (Ct. App. 1991) (holding that although an insurer may delegate the performance of its duty of good faith to a non-servant, it remains liable for the actions taken by this delegate because the duty of good faith itself is nondelegable). 5. Pretexting: Your personal information revealed. Federal Trade Commission (last modified Apr 24, 2009), edu/pubs/consumer/credit/cre10.shtm. 6. 15 U.S.C.A. 6821(a). 7. Mesis J. FTC on pretexting: The PI magazine interview with Joel Winston, PI magazine, Jan/Feb 2005, at 43, available at http:// (emphasis added). 8. See 15 U.S.C.A. 6823. 9. See Pretexting: Your personal information revealed, supra note 5. 10. Id. 11. United States v. Jones, 132 S. Ct. 945, 949 (2012). 12. Id. 13. Id. 14. Things to look for when hiring a private detective agency. Shannon Detective Services, Inc. (accessed June 24, 2012), http://www. 15. Lichtblau E. Police are using phone tracking as a routine tool. NY Times March 31, 2012, us/police-tracking-of-cellphones-raises-privacy-fears.html?_ r=2&pagewanted=all. n


SOMBRERO January 2013

Hepas B
By Doug Hirano

Hep B, liver cancer, and Asian Americans

There are 1.4 million individuals with chronic hepatitis B virus (HBV) infection in the U.S. according to Centers for Disease Control estimates, and only 35 percent of them are aware of their HBV infection status. Many of these individuals will be Asian Americans. CDC estimates that 70 percent of all infected HBV individuals are foreign-born. Among Asian Americans, 65 percent are foreign-born. One in 12 Asian Americans is chronically infected with hepatitis B. One in 600 Americans of non-Asian descent are chronically infected with hepatitis B. There are still an estimated 1,300 Asian Americans in Pima County yet undiagnosed with chronic HBV infection. The need for private health sector participation in this process is vital. Most of these individuals see a doctor at least annually. Globally, HBV infection is the most common blood-borne viral infection, with 400 million people infected. One million die annually due to HBV-related liver disease. HBV attacks the liver, and infection over the course of many years can lead to cirrhosis and liver cancer. In many developed regions of the world (i.e., North America, Western and Northern Europe, and Australia), rates of HBV infection are lowless than 1 percent. In most other countries, rates are 2 percent or higher, with many Asians and Africans with prevalence rates for chronic HBV infection exceeding 8 percent. The table below provides estimates of HBV prevalence in Asian countries and the corresponding prevalence rates for individuals born in those countries but now residing in the U.S.
5,975 4,276 3,439 3,392 2,888 2,535 24,308

2006 39

2007 33 4

2008 34

2009 5 45

7 26 6 2 0 26 2 0 82 5 45

9 25 0 2 4 72

0 44

3 2 24 56

This disproportionate amount of chronic hepatitis B reporting among Asian Americans might be even more pronounced if Asian Americans were screened in proportion to their risk. Utilization data from AHCCCS show Asian Americans are tested no more than other racial groups.

4,503 6,803 786 408 32,073 237,564 59,007


Pima County has a relatively small but rapidly growing population of Asian Americans. This group is ethnically diverse (Table 2). While constituting only 2.6 percent of the Pima County population, Asian Americans comprise 26.6 percent of the reported chronic hepatitis B case reports for the period 2006 to 2010. Table 3 provides the number of chronic hepatitis B case reports by race/ethnicity (for those of known race/ethnicity).

With the advent of HBV medications that can suppress viral replication and thereby delay onset of severe liver disease, there is a strong case for increased HBV screening among Asian Americans. In 2011, CDC conducted physician focus groups regarding hepatitis B screening practices. Heres a summary of their findings: u Many physicians are unaware of the increased risk of HBV infection among Asian Americans; u Some physicians incorrectly assume that immigrants receive HBV screening as part of their entry requirements into the U.S.; u Lack of reimbursement for HBV testing plays a role in the decision making process; u Language and culture can be a barrier in communicating with foreign born individuals about HBV screening;

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u Lack of the patients health insurance coverage creates a barrier to testing. In addition, physicians mentioned that the U.S. Preventive Services Task Force guidelines recommend against HBV testing for the general population. Physicians were less familiar with the CDC guidelines, which do recommend screening of individuals from countries with a 2 percent or greater prevalence of chronic HBV infection. Thus, while there are some practical constraints (e.g., lack of reimbursement) towards HBV screening and conflicting national HBV testing recommendations, there is a clear epidemiological imperative to screen most foreign-born individuals, particularly Asian Americans.

According to the 2010 Census, Asian Americans are the fastestgrowing racial/ethnic group in the nation, as well as Arizona. Routinely offering HBV screening to these individuals can potentially save lives and also decrease health care costs over the long haul. With advent of universal HBV immunization among children beginning in 1992, the end of new HBV transmission in this country is in sight within the next two to three decades. Meanwhile there is a large cohort of HBVinfected individuals, mainly foreign-born, who can benefit from early detection, continuing medical monitoring, and treatment as indicated. Doug Hirano, M.P.H. is executive director of Asian Pacific Community in Action. He can be reached at 602.265.4598. n

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In Memoriam
By Stuart Faxon

School artists and worked in oil, pastel, acrylic, pencil, and charcoal. A Henry Newell scholarship sent him as a pre-med undergrad to Stanford University, from which Rock went on to earn his M.D. in 1948 at University of Michigan Medical School. Because he was in a military-accelerated program, he never actually completed his Stanford bachelors degree, about which his graduate kids would rib him a generation later. He interned at University Hospital in Ann Arbor, and also did his four-year surgical residency there 1949-55, interrupted by 24 months as a Navy medical officer during the Korean War, serving on the USS Mount McKinley and at a U.S. Navy hospital in Japan. He was certified by the American Board of Surgery. In Ann Arbor in 1955, after dating her for two years, Rock married Ann Terrill. Unfortunately they later divorced at her instigation, and Rock told us it took him aback, especially that Ann got custody and he lost the children he so loved. But on the other side of fortune, they turned out well after having been raised in Massachusetts and continuing on to postgraduate education levels much as he had. Sarah, the eldest, is an attorney and hospital counsel. Second daughter Ann has her own employee motivational business. Son George, a third generation bearing that name, now in his 40s, is a stockbroker with Wells Fargo. Coming to Tucson in 1955, Rock practiced with the 14 other physicians of the multi-specialty Thomas-Davis Clinic downtown at 130 S. Scott Ave., joining at the same time as pediatrician Philip E. Dew, M.D. The most common surgeries then were hernia, gallbladder, and duodenal ulcers, he said. Rock replaced Dr. Charlie Thomass son Dr. Naugle Thomas, who had developed a neurological problem and could not continue as a surgeon. Charlie was quite a character and a storehouse of stories about early Tucson, Rock said. He told us he was attracted to Tucson because it was remarkable at the time for not having the standard but highly unethical practice of fee splitting, which many areas were attempting to stamp out. Tucson also had physician anesthesia, which was not the case in most of the country at that point, he said. By 1962 Thomas-Davis had 18 physicians and was at Alvernon Way & 5th Street. Dr. Elliott Stearns, Jr., whose obituary was in

Rock or sometimes Rocky is how most folks knew Rockwell E. Jackson, M.D., F.A.C.S. It was such an American name, redolent of our nations history in business, politics, and the arts. Dr. Jackson, general surgeon, educator, PCMS member since 1956, who made a second name for himself in retirement with his Western and fly fishing art, died Dec. 5 after a brief illness, surrounded by his family. He was 87. Rocks paternal forebears were coal miners in Wales, and Rocks father George, mined coal. Rockwell Ernest Jackson was born March 11, 1925 in Kenilworth, in mountainous Southeastern Utah, a 6,000-foot mining company encampment of such small population that it was not a formal town, reaching its highest population of about 300 in the 1930s.
Dr. Rockwell E. Jackson in 1989

As a boy Rock was steeped in the rugged Western environments that were to inform his art. He went to high school in the much larger town of Price, around which a number of mining locations like Kenilworth lay. In our lengthy video interview of him in 2010, he told us how he ended up with the unusual name Rockwell. It was not from 20th century painter and illustrator Norman, already well known in 1925, but from painter, printmaker, illustrator and humorist Rockwell Kent (1882-1971), whose work his schoolteacher mother admired, and she took the name for her son. Both parents contributed greatly to Rocks formation. Like the Mormons, his mother placed great emphasis on education. Rock came to love learning and excelled at chemistry. He first majored in chemical engineering, figuring he would not be able to go to med school, to which the local physician had inspired him. His art was rooted in his father. I learned freehand sketching from my father, who was a gifted amateur artist, Dr. Jackson said in 2003. His dad was well known in the Price and Moab areas of Utah. We had a big blackboard in our kitchen and he would teach me to draw things like horses and trees. He taught me to use perspective. Much later I used to draw out surgical procedures, such as for a gallbladder operation, on the vinyl covers of chart files. In later years Rock studied art formally with several Tucson and Scottsdale Art

Rock Jackson, Western and fly fishing artist, at work in 2003 (Stuart Faxon photo). 23

SOMBRERO January 2013

last months Sombrero, was then PCMS secretary-treasurer. Later Rock was to call T-D a pleasant place to practice, with an emphasis placed on excellence and personal service above profit.

the original of which he gave to Charlies granddaughter, Jean. In our 2010 interview Rock said he was bothered by the changing paradigm in modern medicine. Medicine in his time was a calling in which you, the physician, are personally responsible for your patient and you had to be mindful of all the elements in his or her case. This has changed, he said, and I understand the reasons for it to a degree but it does bother me that I dont see that anymore, and it leads to a discontinuity of care that has replaced the calling.

After an 11-year association with T-D, Rock sought a broader referral base and opened his own surgery office at Craycroft Medical Center, Craycroft Road at E. 2nd Street in 1968, and subsequently partnered with the late Dr. Bud Simons for more than 15 years in Old Pueblo Surgery Associates, P.C. He and Bud were At the medical society centennial celebration in 2004 Dr. Jackson, flanked very different people, by PCMS President Leonard F. Ditmanson, M.D., and Pima County Medical Rocky was the Rock said, but they Foundation President Richard Dale, M.D., receives the Foundations award consummate surgeon, appreciated each others for excellence in furtherance of medical education (Stuart Faxon photo). fellow surgeon and PCMS skills and virtues and History Committee shared many outdoor colleague Dr. Dick Dale said. He was knowledgeable, wellinterests. Among other things, Rock questioned Buds penchant rounded, and had excellent judgment. His remarkable talents for answering the phone as, Short, Fat & Ugly. and wonderful personality will be sorely missed. Nineteen-seventy found Rock lecturing on management of At the PCMS Centennial celebration in 2004, for which Rock open wounds and burns related to emergency care, and at a designed the logo, he was given the Pima County Medical symposium on peptic ulcers. That year ground was broken for Foundation Award for exemplary lifetime achievement in the the medical center including offices for 50 physicians on Wilmot furtherance of medical education. In 2011 Stanford honored Road next to St. Josephs Hospital, with Dr. Jackson as one of six Rock by making him a member of its Cardinal Society, for those development partners, the Tucson Citizen reported. Rock who have been alumni for 65 years. became St. Josephs first surgery chief, and later chief of staff. In 1990 Rock married Pam Smith. Rock was an avid tennis In retirement after 1991, Dr. Jackson taught part-time at the player, she recalled. He was just wild about tennis. He was UofA College of Medicine Department of Surgery, Section of also an avid outdoorsman and first-class fly fisherman. He loved General Surgery, and at Southern Arizona Veterans the West and traveled extensively throughout the Southwest Administration Hospital. In 2000 he was presented with the with his fly rod and beagles in tow. He was a lifelong student Charles Zukoski Faculty Role Model Award from the UofA and had a particular love of history He gave many wonderful General Surgery Residency Program. I have loved this work, talks about the history of surgery. Rock was a member of Tucson he told us in 2003, and I think I have filled a need. I love to Country Club, the Mountain Oyster Club, and Foothills Forum. teach. I get great satisfaction out of that. My kicks come from Despite his many accomplishments, he was a humble man with working with these folks. a kind, gentle nature and a terrific sense of humor. He was a He also did medical volunteer work in Indonesia, St. Lucia in the Renaissance man, a true gentleman. Caribbean, and on the Navajo Reservation at Ganado. Rocks elder brother by five years, George, won the same Working at Thomas-Davis in the late 1950s, Dr. Jackson got to scholarship that the younger Jackson did and had great know surgeon and founder Dr. Charlie C.A. Thomas, 1916 promise. But three weeks before the end of World War II, PCMS president. In July 1998 our Sombrero cover featured George was killed in the Pacific, not in combat but as one of the Rocks charcoal drawing Housecall 1917, showing Charlies twovictims of a shipboard assassin. cylinder Oldsmobile stuck in the Oracle area and being dragged His wife of 22 years, Pam; his children Sarah, Ann, and George; out of the mud by a two-horse team. That year he had a show and six grandchildren survive him. of his Western art, Marlboro Country, at St. Philips in the Hills Churchs Murphey Gallery. He had shows and exhibits in the Memorial services were scheduled for Dec. 15 at St. Michaels White Mountains, at Arizona Cancer Center, PCMS, Old Pueblo and All Angels Episcopal Church, Tucson. Memorial donations Frameworks & Gallery, and at Williams Centre. His art appeared may be made to University of Arizona Foundation/Department in subsequent Sombrero covers, most recently in April 2012. of Surgery, Box 245066, Tucson 85724, or to Carondelet Our February 2003 cover was Rocks charcoal portrait of Charlie, n Foundation, 1200 N. Tucson Blvd., Tucson 85716.
24 SOMBRERO January 2013

Makols Call
By Dr. George J. Makol

Musings of a liberal
Most of us doctors are liberals, are we not? Surprised to hear me say this? Well, I think most of us are liberals regarding human rights, and certainly the rights of the truly handicapped. There are, according to government census information current to May of 2011, about 35 million disabled persons in the U.S. Not all, however, are severely disabled. In fact, this same census shows that among persons with disabilities age 21 to 64, nearly 46 percent were still employed, and 31 percent of persons with severe disabilities were employed. We should praise this courageous group and to their employers. So let me say now, and have it hold for any future editorials, that none of us, least myself, would deprive the truly disabled of public assistance, healthcare coverage, and whatever support they would need throughout life. But now to the scammers: A Wall Street Journal report published March 22, 2012 chronicled telecomm company AT&T being tied to Nigerian fraudsters. Let me explain. We all have hearing-impaired patients, and there is a service called IP relay to provide them with a communication outlet. Essentially they are provided with government-subsidized equipment that allows them to place phone calls by typing messages over the Internet that then are read aloud to parties on the other end. I have occasionally answered hearingimpaired patients questions over the phone using such a system, and it works pretty well. AT&T billed the government during the past two years about $16 million for this service. The trouble is that by the governments own estimate, 95 percent of such services were provided to overseas callers, with most of the calls originating in Nigeria. Scammers there use stolen credit card numbers to place large orders with U.S. merchants, even using text read aloud by the operators to request wired funds to transport the items. Ten of the top 12 users of this system make calls originating in Lagos, Nigeria. How likely is it that most of your hearing-impaired patients are visiting Nigeria at this time of year? A single Internet address
SOMBRERO January 2013

accounted for more than 100 hours of IP Relay time, and yes, authorities suspect it originates in Nigeria. So here is a government program with a five percent effectiveness rate. I was recently asked to provide such an example, and this is only one of many that are easy to find with a little research. How can they get away with this? Well, if you remember my favorite federal program HIPAA, and also that FCC regulations protect the privacy of both the callers identity and the contents of the conversation. Its the perfect crime, and taxpayers subsidize it. Why, in the age of Internet and text messaging, is such a program even needed? Why spend tens of millions when even people living on public assistance have cell phones, and texting would give the same results as operator-assisted relay? The intermediary could just be eliminated along with the fraudsters. We could find the few hearing-impaired persons who do not own cell phones (none of them are teenagers), buy them Blackberries, and still save a fortune. Speaking of the hearing-impaired, the federal government requires doctors to provide a reasonable accommodation to provide effective communication. Local groups demand deaf interpreters at the doctors expense, and you run a terrific risk if you disregard that demand.For example, New Jersey rheumatologist Robert Fogari, M.D. was sued in 2008 and had to pay a $400,000 punitive judgment even though the patient testified that she had no trouble communicating with the doctor by writing and lip reading, and care quality was never questioned. So for a routine re-check visit, I am reimbursed maybe $64, and I must pay the interpreter about $100 to $120 for a two-hour minimum consultation for their assistance, even if I only need them for 15 minutes. I can afford this, and I can write this off as office expense, but why are doctors being singled out to pay for services for the deaf? Why not lawyers, accountants, or even plumbers? After all, only a deaf person would not recoil when the plumber tells them how much they are about to be charged to unclog a sink! I remember the orthopedists spouse who, upon calling in a plumber to fix a leaky faucet, was stunned by a $150 charge for a quick turn of a wrench at the faucets base. She said, My husband is a doctor and he doesnt charge this much for a few minutes! The plumber replied, Lady, when I was a doctor I didnt charge that much either! Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been a PCMS member since 1980. n

Mayo CME

Feb. 10-15: The Mayo Clinic Interactive Surgery Symposium is at Waikoloa Beach Marriott Resort & Spa, 69-275 Waikoloa Beach Drive, Waikoloa Beach, Hawaii 96738; phone 808.886.6789; fax 808.886.3601. CME: 27 Category I; 27 AOA. Current trends for management of general surgical patients are constantly changing and as technological advances progress, options for surgical treatments continue to expand. Symposium is designed for general surgeons to assist them in decisionmaking involving multiple aspects of general surgical practice. Audience participation will be encouraged during case presentations and panel discussions. Website: Mayo School of Continuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca.cme@ ; Feb. 21-24: Mayo Clinic Gastroenterology and Hepatology 2013 is at Westin Kierland Resort & Spa, 6902 E. Greenway Pkwy, Scottsdale 85254; phone 480.624.1000 or 1800.354.5892. Mayo Clinic College of Medicine designates this activity for a maximum of 27 AMA PRA Category 1 Credits (20.75 general course; 3.5 ACG SAP for MOC; 2.75 Hands-On Endoscopy Workshop; 17.75 live webcast only). It has been reviewed and is acceptable for up to 27 Prescribed credit(s) by the American Academy of Family Physicians. It is accredited by the American Osteopathic Association for 27 credits of AOA Category 2-A. Course is designed to update physicians practicing in gastroenterology and hepatology and other health care providers on new approaches to the diagnosis and management of gastrointestinal and liver diseases. Faculty will present data on multiple topics, including inflammatory bowel disease, colo-rectal cancer, general GI, motility and nutrition, pancreaticobiliary disorders, endoscopy and hepatology. General didactic sessions each day will be available via live webcast. Visit website for system requirements and registration information. Two optional educational activities are offered: A review course to help GI physicians prepare for board recertification will be offered Thursday afternoon, and on Saturday afternoon, new endoscopic techniques will be featured at the Hands-On Endoscopy Workshop using state-of-the-art technology. Websites:

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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 AVAILABLE: New Ofce Space available for rent in Northwest Tucson off of Oracle Rd adjacent to a busy rheumatology practice. Up to 2,000 sq ft available. Can be built to suit for ofces, physical therapy or other medical needs. For information, contact Sue Haeger 382-4795. OFFICE SPACE NEEDED: Seeking a medical ofce approx. 2000 sq ft. with 3-4 exam rooms for sale or lease. Location between TMC and St. Josephs area. Please contact Roxann at 520-320-1369. OFFICE SPACE: Professional/Medical Ofce Space for Lease. Central location, tenant friendly rates, move-in ready. See details & photos at: <> OFFICE TO SHARE: We are currently looking for a fourth ofce mate in a furnished 4 ofce building. Each practitioner is independent - this is not a group. Drs. Marla Reckart and Lawrence Cronin are psychiatrists with psychologist Mike Vickroy PhD in the Santa Cruz Medical Ofces building, 7333 Tanque Verde across from Udall Park behind Zona 78. Rent 26 is $1150 per month and includes virtually everything - janitor, rental taxes, utilities, waiting room (furnished), kitchen, alarm, parking, copier and phones. Stafng is negotiable and not even necessary for many styles of practice. We can refer a substantial number of people continuously due simply to convenience. We can supply some or all reception services for additional money and we have an exceptional billing company afliated with us for ten years, but this does not need to be part of the arrangement. There is room to bring your own receptionist. We can also fully furnish the individual ofce for no additional cost. The ofce is easily found and accessed. The building is only 2 years old and all the new building bugs are worked out. Its solar powered! Parking is plentiful. Staff is excellent. Collections are superb. This does not have to be a mental health clinician, but is ideal for one. Interested parties contact Dr. Larry Cronin at 975 8520. (5-12) CONDO FOR RENT: Lovely Condo in Central Tucson for Lease by owner: La Plazuela de las Encantadas is a small community of 17 units surrounding a lush central courtyard, with pool, Jacuzzi, covered carport and storage. The condominium (3744 E. 4th St.) has been freshly painted, has new AC unit, washer/dryer, dishwasher and lots of sweet touches. With 1025 sq. feet, 2 bedrooms, 1 baths it will not stay vacant for long. If interested call Annemarie at(520)440-0872 or John Curtiss, MD,at(520)749-3640. We are asking $995 per month, with minimum year lease. SOMBRERO January 2013

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