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Sombrero

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

December 2012

Remembering Dr. Elliott Stearns, Jr. Dr. Joseph Mirabile The good work: Clinica Amistad

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SOMBRERO – December 2012

Sombrero
Pima County Medical Society Officers
President Alan K. Rogers, MD President-Elect Charles Katzenberg, MD Secretary-Treasurer John Curtiss, MD Past-President Timothy C. Fagan, MD

Official Publication of the Pima County Medical Society

Vol. 45 No. 10

PCMS Board of Directors
Diana V. Benenati, MD R. Mark Blew, MD Neil Clements, MD Michael Connolly, DO Executive Director Steve Nash Phone: 795-7985 Fax: 323-9559 E-mail: steve5199@simplybits.net Advertising Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: bill5199@simplybits.net

Bruce Coull, MD   (UA College of Medicine) Randall Fehr, MD Alton “Hank” Hallum, MD Evan Kligman, MD Melissa D. Levine, MD Lorraine L. Mackstaller, MD Clifford Martin, MD Kevin Moynahan, MD Soheila Nouri, MD Jane M. Orient, MD Guruprasad Raju, MD Wayne Vose, MD Scott Weiss, MD Victor Sanders, MD (resident) Cambel Berk (student) Christopher Luckow (student)

Members at Large
Kenneth Sandock, MD Richard Dale, MD

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 Officers
Gary Figge, MD,   immediate past-president

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

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 Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright © 2012, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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SOMBRERO – December 2012

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Inside
 5 Dr. Alan Rogers: Dealing reasonably with pain
medication patients.  6 Steve Nash: Our exec has an appreciation of former Sombrero columnist Dr. Michael S. Smith.

 8 Milestones: Most recent of our ever-achieving members. 10 PCMS News: Clinica Amistad would appreciate your help. 16 Diabetes: Endocrinologist Dr. Jonathan Insel has a followup to his PCM Foundation CME presentation Oct. 9. urologist/novelist Dr. Elliott E. Stearns, Jr., and neurologist Dr. Joseph C. Mirabile. scene.

19 In Memoriam: Remembering the long Tucson careers of
On the Cover
‘Star trails’ add beauty and mystery to Mary Colter’s 1932 Watchtower at Grand Canyon on a New Year’s Day eve. The photo was created using 240 images taken over two hours, one every 30 seconds. They were then digitally stacked on top of each other to render the final image. Mary E.J. Colter was chief architect and decorator for the Fred Harvey Co. from 1902 to 1948. Two of her iconic buildings mark the far extremities of the South Rim: Hermit’s Rest, eight miles west of Grand Canyon Village, and Watchtower, 25 miles to the east (Dr. Hal Tretbar photo).

22 Perspective: Dr. Jerry Rothbaum analyzes the healthcare 24 Lifestyle Medicine: Dr. Hunter Yost has a low-tech
measure of obesity.

26 Mayo CME: Upcoming from the Scottsdale clinic. 26 Members’ Classifieds

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Established 1971

Chronic fear
By Alan K. Rogers, M.D. PCMS President
sustained opioid use” and makes a clear distinction between addiction and physical dependence. If a patient has diabetes and must take insulin are they addicted to insulin? Most would say no. But if a patient has chronic pain and must take narcotics, is he or she addicted? Physically dependent yes, but addicted, no.

Fear can be a paralyzing factor. But in medical practice, fear should not limit what we do for our patients. Chronic pain is a real entity that all of us deal with. Chronic pain is hard to measure and define but we all know patients with it. Acute pain due to injury or surgery, or pain in terminal cancer patients, is easy to understand and most physicians have no problem managing these patients. But what about chronic pain from non-terminal conditions like fibromyalgia, back pain, neuropathy, or arthritis? And more to the point, use of sustained narcotic analgesics for these patients? Many physicians are reluctant to use chronic opioids for fear of incurring medical board scrutiny or attracting too many of “those kind of patients.” But are we potentially denying patients an effective from or treatment? There are many chronic pain patients. Unfortunately, we usually have the nagging idea the patient is drug-seeking or malingering. This is a great disservice to the majority of chronic pain patients who in my opinion have legitimate symptoms. The idea of avoiding pain patients and just referring all of them to a pain clinic is impractical due to sheer numbers, and is probably unethical. Therefore primary care physicians must carry much of the load of managing these patients. Domestic sales of oxycodone are enormous. In 2007, 51.6 tons of oxycodone, equivalent to a half-billion 80mg tablets, were sold in the U.S., making the us the No. 1 consumer in the world. What can we conclude from this? Chronic pain is a widespread problem and oxycodone is a useful tool in managing it. Unfortunately, oxycondone and other prescription drugs have also become the epicenter of substance abuse in this country. Misuse of sustained- release oxycodone was so widespread the manufacturer was required to reformulate the tablets to make them more difficult to crush and extract the oxycodone for injection. We as physicians must make every effort to prevent prescription medication abuse and diversion. The Arizona Medical Board takes a stance on chronic pain treatment that would surprise most physicians. As outlined in the board’s “Guidelines for Treatment of Chronic Pain” found on their website AZMD.gov, the board actually encourages physicians to treat chronic pain as part of good medical practice and provides guidelines on the use of narcotics “without fear of disciplinary action from the Board.” AMB goes on to say that “tolerance and physical dependence are normal consequences of
SOMBRERO – December 2012

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on’t be afraid.

AMB also outlines the medical and ethical responsibilities involved if a physician must dismiss a chronic pain patient, stating that the physician must “make an effort to ensure a patient does not undergo uncontrolled or abrupt withdrawal” from narcotics by possibly tapering medication, admission to a treatment facility, or continued prescribing until the patients finds a new physician. I find most clinical practice guidelines annoying or unhelpful; however, sometimes they can be protective. A physician following a few common-sense guidelines while prescribing pain medications should not fear adverse regulatory consequences. Here are are prudent steps for chronic opioid usage: 1) Do a thorough history and physical; 2) Document the cause of the patient’s pain; 3) Use all modalities available to treat the patient’s pain including psychological services, pain clinics, physical therapy, etc.; 4) See the patient on a regular basis and document that goals of pain treatment are being met; 5) Use a pain contract that sets out boundaries for the patient on use and abuse of prescriptions and spells out grounds for dismissal; 6) Take periodic toxicology screens to document compliance; 7) Consult the Arizona State Board of Pharmacy Prescription Monitoring Program website to see if the patient is getting prescriptions from other providers; and 7) Consider consulting court records for criminal activity on the patient’s part. AMB mandates none of these guidelines. The medical profession has been criticized, and I believe rightly, for not giving adequate analgesia to patients in pain. Physicians and physician organizations have been caught up trying to define exactly how much is too much of various analgesics. This is foolish. A better approach is to follow clinical guidelines and just give the patients what is needed to control their pain. We all must do what we can to stop diversion of prescription opioids. Look for aberrant behavior in chronic pain patients: Repeatedly lost prescriptions (the dog ate it, it fell in the toilet), ever-escalating dosage demands, toxicology screens inconsistent with prescribed treatment, the presence of illicit drugs on toxicology screens, criminal activity, multiple prescribers, and so forth. But use your good clinical judgment because sometimes medications really are lost or stolen. Many chronic pain patients resort to non-conventional treatments in an effort to alleviate their pain. Would you dismiss a chronic pain patient if marijuana showed up on the toxicology screen? Knowing your patient and having a long-term relationship based on trust is probably the best approach to prevent prescription medication abuse. So be fearless in your dedication to caring for patients. The next case of Ebola virus infection that comes in may test you, though. n
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Transcript: Michael Spinner Smith, M.D.
By Steve Nash PCMS Executive Director

hirty-one years ago, with doctors Colin Bamford and W.A. Sibley endorsing him, a just-trained neurologist with seven years in the Navy and Naval Reserve under his belt applied for PCMS membership. All of us are lucky he did. His name was Michael S. Smith, M.D., and I knew of him before I knew him. For years I read the “Under Dark Skies” column in the Arizona Daily Star before learning he wrote it. When I did, I asked him to “write something” about his interest in astronomy. He responded with a terrific article on seeing Solar Eclipse Saros 136 in Baja. It was the first of a remarkable series of stories he did for us. He was elected to the PCMS Board of Directors in 1993, and willingly served as a delegate to the Arizona Medical Association meeting. There is a photo of him at one such ArMA meeting, intently watching the proceedings from a seat between Dr. Jane Orient and Dr. James Dalen. I remember that look: a watcher’s keen observation ready to skewer poorly drafted resolutions filled with high-flown phrasing but little meat. He was soon elected Southern District Director and joined the ArMA Board of Directors. All the while, after hours he’d slip photos of eclipses and his travels into my office for me to discover the next morning. It was always a treat. In 1997 he submitted a searing, honest article about burning out on medicine in 1992. We published it in three parts. After that, regular missives about the Appalachian Trail came from him—and stories about his days as a student, at age 49—in experimental statistics. His writing became sharper, shorter. He began drafting memorable and charming anecdotes that filled one page as he served as a PCMS officer, member of the Public Health and Benefits committees, and as he was elected an ArMA officer. In 2002 he designed a survey method and instrument so that we would have a scientifically valid way to measure attitudes about colonoscopy. He proposed a community health reporting dashboard, an error reporting system for physicians, and designed several other surveys for us. Reality Check as a Sombrero column began in January 2003. He started calling for more measurement in medicine. He said to do otherwise invited the government to react, as they did with EMTALA, HIPAA and CLIA. He chastised those who measured
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things that meant nothing and was especially hard on the Institute of Medicine report that to this day has a majority of Americans believing 100,000 people lose their lives needlessly in hospitals every year. Over the years he made us think. He urged us to really examine statistics. He used personal experience to demonstrate variations in the standard of care, and unnecessary expense. He talked about system change, using modest goals—making things easier to do than not—to achieve change. Awards for writing came his way, but he kept hammering out a monthly column for PCMS members. Some were personal, like being sued for malpractice. Others examined medical quality initiatives near and far. He explored his bucket list, and wondered why physicians defer their dreams so long that they never really get a chance at them. He shared some of his adventures for those of us who will never visit the Boundary Waters backcountry, or the interior of Libya. Best of all, Dr. Smith urged all of us to look around and really observe. He demanded we challenge. His phone calls to me were always fun. He took up teaching math, taught literacy as a volunteer. He decided to learn German. He set out to see all of America’s national parks, and would come back with photos and maps and spread them out on tables here. He bought a house in Oregon. He returned again and again to the Arctic to roam among the caribou and grizzly bears. He started blogging and has a terrific site, Boreal Blog http://michaelspinnersmith.com. He has gone to Nebraska as a volunteer to guide people to the wonder of the Sandhill crane migration. This summer he decided to hang up his column. He said his wife told him once that he would know when it was time to stop writing for Sombrero. “It’s time,” he said. That doesn’t stop him from aiding us. He set up telescopes so we could watch the Venus Transit in June, and his photo of the event was our June cover. His body of work is quite a line of accomplishment for one PCMS member. Dr. Smith loves to quote President Harry Truman: “There is no limit to what a man can accomplish if he doesn’t care who gets the credit.” The credit goes to you, Dr. Smith. Thanks. Thanks a million. n

SOMBRERO – December 2012

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Milestones

Dr. Hutchinson TOMF chair
Jerry H. Hutchinson, Jr., D.O., F.A.C.O.I., a Tucson hospitalist with Arizona Inpatient Medicine Associates, serving as an acute care inpatient physician at several Tucson area hospitals, was recently elected chairman of the Tucson Osteopathic Medical Foundation Board of Trustees. Dr. Hutchinson is a board-certified physician and a 1985 graduate of A.T. Still University—Kirksville College of Osteopathic Medicine in Kirksville, Mo. He served his internship and residency at [the former] Tucson General Hospital. Since 1986 TOMF has provided more than $2 million to nonprofit organizations and has recently reinstated the Trustee Awards, a grant program providing funding for public health projects in Arizona. It also operates programs in medical education for interns, residents, and practicing physicians, and public education programs to create a clear community understanding of the healthcare issues facing Tucson.

CHN names new St. Mary’s, St. Joseph’s leaders
Carondelet Health Network recently named new leaders at St. Mary’s and St. Joseph’s hospitals, citing their “lengthy CHN careers and passion for providing quality care” and “long histories of service in the Tucson community.” The new Carondelet St. Mary’s Hospital president and CEO is Amy Beiter, M.D. Dr. Beiter has been a member of the St. Mary’s medical staff since 1992. In 2007 she joined St. Mary’s administration and was named the hospital’s CM Officer in 2008. “Dr. Beiter has worked tirelessly to improve the quality of care at Carondelet’s west side campus,” the organization said in a press release. “Thanks to her leadership and the efforts of the entire hospital staff and associates there, Carondelet St. Mary’s has been honored with a long list of significant national quality awards over this last year, including as a Top Performer in Key Quality Measures by the Joint Commission, and as a Distinguished Hospital for Clinical Excellence by Healthgrades.” Dr. Beiter is board-certified in IM and pediatrics. Tony Fonze, formerly CHN chief information officer and a vicepresident of Ascension Health Information Systems, has assumed the role of president and CEO at Carondelet St. Joseph’s Hospital. “Tony has enjoyed a successful career in a variety of major leadership positions including healthcare operations, information systems, research and development and as an entrepreneur. He has been integral in the planning and implementation of many key strategic initiatives for CHN. He is a founder, trustee, and vicechairman of Health Information Network of Arizona (the state’s HIE), and has worked extensively toward improvement of patient experience in our hospitals and across our Ministry.” Don Denmark, M.D., F.A.A.C.P., F.C.F.P., M.M.M., C.P.E. was appointed senior VP and CMO of CHN. Most recently Dr. Denmark had been the network’s lead CMO. He will also continue as CMOfficer at Carondelet St. Joseph’s Hospital. Dr. Denmark joined Carondelet in January 2011 after more than two decades of distinguished leadership in healthcare administration, research, academics, and family medicine in Oklahoma and the San Francisco are.
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AASLD awards Dr. Boyer
Dr. Thomas D. Boyer, expert in the diagnosis and treatment of liver disorders and a noted liver transplant physician, has been honored by the American Association for the Study of Liver Diseases (AASLD) with its Distinguished Service Award, The University of Arizona reports. Dr. Boyer is the Robert S. and Irene P. Flinn Professor of Medicine, director of the Liver Research Institute, and chairman of the Department of Medicine for the UofA College of Medicine—Tucson. The AASLD Distinguished Service Award is given to an individual in honor of the recipient’s sustained service to the American Association for the Study of Liver Diseases (AASLD) or to the liver disease community in general. The award recognizes service provided to the community of hepatology researchers and clinicians over an extended period that is well beyond that provided by many members who serve on the AASLD Governing Board and committees. For 25 years Dr. Boyer has received NIH funding to study drug metabolizing enzymes and their regulation of expression. He also has multiple continuing studies sponsored by pharmaceutical companies for treatment of hepatitis C, cirrhosis, NASH, PSC, and hepatorenal syndrome. He has published numerous articles, book chapters and editorials on these areas of investigation. Dr. Boyer has co-edited a leading textbook, “Hepatology, A Textbook of Liver Disease,” currently in its sixth edition.
SOMBRERO – December 2012

JFSA: Dr. Addis ‘extraordinary’
Dr. Ilana Addis, assistant professor of clinical obstetrics and gynecology at the UofA College of Medicine, was recently honored by the Jewish Federation of Southern Arizona (JFSA) Women’s Philanthropy as one of 13 women in its “13 Extraordinary Women Share Their Secrets” program, the college reported. The JFSA outreach program brings successful women from all over the Tucson community together to talk about their secrets of success. During the event, the 13 women had three minutes each to share their formulas for success in their personal, professional and Jewish lives. Dr. Addis is director of urogynecology and associate director of female pelvic medicine and reconstructive surgery for The University of Arizona Medical Center—University and South campuses. A 1998 graduate of the UofA College of Medicine, she completed a residency in Ob/Gyn at University of Tennessee at Memphis, and a fellowship in clinical research at U.C. San Francisco.

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Pima Dermo, the place to be
Dr. Gerald Goldberg and Pima Dermatology recently announced that “our team has been selected as a 2012 Copper Cactus Awards’ Best Place to Work finalist! Out of 400 nominees, Pima Dermatology was one of only 15 selected in the Best Places to Work category.” The Copper Cactus Awards is presented jointly by Wells Fargo and the Tucson Metro Chamber of Commerce and serves to recognize and celebrate the accomplishments of Southern Arizona’s best small businesses in categories such as innovation, work environment, growth and community stewardship. “We wanted to reach out to extend our heartfelt appreciation for your continued support of our practice and team over the years. You are a vital business associate and close friend of the Pima Dermatology Family, and for that, we thank you. “We attribute much of our success to the team of super stars we’ve assembled. Collectively, they deliver top-notch, compassionate care in our state-of-the art center of dermatologic excellence. We are proud of the work culture we’ve created where collegiality, honesty, safety, customer service, and fun are values encouraged and cultivated above all.” To commemorate the accomplishment, the practice made sure to take all 20- plus staff members to the 2012 Copper Cactus Awards Ceremony Nov. 13. While they were unsure if they would win the official title, they said it was “clear from the prestigious nomination and the vibe around the office that we already felt like winners!” n
SOMBRERO – December 2012

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PCMS News

Stars on the Avenue update

Clinica Amistad: Doing good
If PCMS doctors Evan Kligman and Raymond Graap were practicing in a religious context, they’d be said to be doing the Lord’s work. We’ll let them introduce you to their sanctuary: “In operation since March, 2003, Clinica Amistad is a fully volunteer clinic in South Tucson offering healthcare to uninsured patients of all ages. We often see up to 40 patients per evening and serve more than 1,500 patients per year. The clinic provides these services every Wednesday and Thursday evening. “Our clientele is largely low-income and primarily Hispanic, though we have seen people of many nationalities and ethnicities. Since the recession began in 2008, we have seen a major increase in patients coming to our free clinic due to loss of employment and health insurance. Clinica Amistad is usually their only opportunity to see a healthcare practitioner, have their health monitored, and possibly receive one or more complementary therapies: physical therapy, massage, counseling, or acupuncture. “Our all volunteer staff includes medical doctors, NPs, PAs, nurses, psychological and nutritional counselors, physical therapists, and practitioners of massage therapy and acupuncture. We deliver primary and urgent care, provide medications, and send patients for laboratory tests and X-rays as possible without cost to the patients. “We appreciate the support we have received since 2003 from PCMS members. There are many ways to help:   4 Physicians and Mid-Level Practitioners: We always need more practitioners who carry their own malpractice insurance and are willing to volunteer. If you have the time or the inclination, we would welcome your presence for as many or as few Wednesday evenings as you can spare. 4 Referrals: We need specialists to whom we can refer perhaps one client per month and who would see them for free or on a sliding fee scale. Because we serve many diabetic patients, services of a podiatrist would be most beneficial. We have a limited budget due to grant support to cover some specialist visits and services. 4 Radiology Services: Imaging services are costly and urgently needed. Any assistance with reduced cost radiology services would be a great benefit to our patients. 4 Monetary Donations: We have non-profit status, so you can make tax-deductible donations, directly to us, tax ID No. 753060875. We are registered with the state, so any amount up to $200 ($400 per couple) you may wish to donate can be taken directly out of your state income tax. We are also a member of Community Shares of Southern Arizona. “If you would like more information about this option for workplace giving, please call 237.5434. Donations can be made out to Clinica Amistad and sent to Box 27146, Tucson, Ariz. 85726. For more information call 237.5434. And we sincerely thank you!” Dr. Evan Kligman Dr. Raymond Graap
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When physicians gather April 27, 2013 for Stars on the Avenue at St. Phillip’s Plaza, they will be holding a souvenir cookbook/ program, and we’d like you to be in it. If you have a favorite food or drink recipe to share with colleagues, send it by Feb. 15 with your name to steve5199@simplybits. net, or PCMS, 5199 E. Farness Drive, Tucson 85712. If your group wants a table or sponsorship, call Steve Nash at the Society, 795.7985. At our last event 308 people attended. This year we are planning for more. And yes, we heard you. Instead of a dance band, background music will allow conversation to flow. Food from many restaurants will give you a wide selection, and drinks will run the gamut from water to well, and between. Watch for your invitations early next year. Meanwhile, consider sending a recipe or sponsoring a table! Stars on the Avenue Committee members are Kynn Escalante, Joy Chapeskie, Kay Dean, Kate Hiller, Alan Rogers, M.D., Bill Fearneyhough, and Steve Nash.

Joint Commission certifies Favorite
Favorite Healthcare Staffing, Inc., PCMS’s full-service healthcare placement service, reports that it has been awarded a the Joint Commission’s coveted “Gold Seal of Approval.” According to Michele Sacco, executive director of healthcare staffing services certification for JCAHCO, “Healthcare organizations that contract with Favorite Healthcare Staffing can look to Joint Commission certification as an assurance that Favorite demonstrates a commitment to providing and continuously improving quality services.” Certification was awarded after a comprehensive nation-wide evaluation of Favorite’s operations, including national standards compliance, verification procedures for credentials, qualifications and competencies of their healthcare professionals, and assessment of Favorite’s staffing and placement services. Favorite has participated in Joint Commission certification since 2005, shortly after the certification program was introduced. The Tucson branch underwent a three-and-a-half hour deficiency-free, onsite review Oct. 23. In July PCMS joined Favorite to provide discounted placement services for its members. Amy Erbe, PCMS representative and Favorite’s branch director for Arizona, can be reached at her Tucson office by calling 319.5766. You can learn more about Favorite or fill out a staffing request form by clicking on “Healthcare Staffing Svs” at pimamedicalsociety.org.

THMEP trip filling up
Tucson Medical Education Program’s Fourth Bi-Annual Colorado River Medical Conference, tripping down the river through the Grand Canyon, isn’t until July 2013, but there are a few spots left, Dr. Richard Dale said. If you are interested, please call Dr. Dale at 721.8505 or e-mail rdale9136@aol.com as soon as possible.
SOMBRERO – December 2012

SOMBRERO – December 2012

11

“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. “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 night’s lodging at Marble Canyon. This could be the trip of a lifetime!” Dr. Dale also serves on the PCMS History Committee and has put out the call for any physicians who previously worked at the Southern Pacific Hospital, re-named Carl Hayden Memorial Hospital in the early 1970s. If you worked there, the committee would like meet you for possible presentation to the committee in the interests of recording and preserving Southern Arizona medical history. Contact Dr. Dale as above.

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 UofA’s Dr. Poston (cardiology) and Dr. Sanjay Ramakumar of Urological Associates of Southern Arizona.

PCMF schedules CME series
Pima County Medical Foundation has updated its CME Tuesday Evening Speaker Series schedule for the coming months: Feb. 12, 2013: 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

Tips for competing for PCPs
By Joan Pearson
Your organization may have firsthand experience with the high demand for primary care providers (PCPs). But you should expect the demand to increase further as more PCPs retire and as 30 million uninsured Americans are added to the system through healthcare reform. If you follow these recommendations, you will be better prepared to compete for top choice candidates. Start early. Strategic and recruitment plans should allow ample time to recruit PCPs: Family Physicians: 6-12 months; Pediatricians: 6-12 months; General Internists: 12-18+ months; Geriatricians: 9-18 months; Advanced Practice Providers: 4-8 months. If the practice is rural, allow an additional three months because the candidate pool for those opportunities will be smaller. Add another two to three months for experienced providers to relocate. Add up to 12 months or more for residents or fellows to complete their training and relocate. Be prepared to begin the search. When planning to recruit PCPs to your organization, you will attract more candidates if you are well prepared. Make sure you have adequate space and staff for the new provider. Plan to have some of your existing patients transfer to the new provider or offer to assist the new provider in building his/her practice. Prepare a letter of intent and employment contract so you can make an offer quickly. Financially prepare to pay the provider’s first year salary or guarantee. Offer flexible work schedules and recruitment incentives. A thorough interview will help identify the issues and incentives most important to each candidate. Flexibility, creativity and customization of these incentives can make the difference in your hiring successes:   4 Opportunity to work part-time or fulltime based on family needs.   4 Signing bonus ranging from $5,000 to $25,000.

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SOMBRERO – December 2012

 4 Education loan repayment (graduating physicians average $145,000 in debt).  4 Relocation assistance of $3,000 to $10,000 or more. 4 Stipend of $1,000 to $1,500 per month during the last 12 months of training. Recognize that your competition is national, not local. With the use of the Internet, your recruitment competition is no longer just the group next door or the hospital down the street. By turning on their smart phones or computers, providers can quickly see opportunities all over the country posted on job boards and social media sites as well as those that come directly into their e-mail inboxes. Consider adding an advanced-level practitioner. Your organization may be well served by adding a Nurse Practitioner or Physician Assistant instead of a physician, particularly if you need a PCP in three to six months. Hiring a PA or NP can favorably affect the profitability of a hospital or medical practice. Primary care advanced practice providers can receive 60 to 100 percent of physician fees for services. Compensation surveys report median primary care PA and NP salaries in the $85,000–95,000 range. Staffing with PAs or NPs allows your physicians to manage patients with complex medical problems while advanced practice providers manage routine patient care such as health history, physicals, diagnosis and treatment. The primary care provider demand is high and the supply is low! With the challenges in healthcare and the shortage of physicians, it is more important than ever to be prepared while competing for top notch, quality, primary care physicians and advanced level practitioners. Joan Pearson is president of Catalina Medical Recruiters, Inc., 602.331.1655; www.catalinarecruiters.com

“In addition, the program is linked to strong school performance. Each child must write a brief essay explaining why braces would be important to them and through teacher reports, show continual improvement in math and English. Good grades will provide further financial incentives to reduce the overall cost of their braces.” The first screening to determine participation eligibility was set for Dec. 7 at St. E’s. Eligibility criteria are available at www. SmilesAheadTucson.org, or call St. Elizabeth’s Health Center at 520.628.7871. St. Elizabeth’s Health Center, founded in 1961, is one of the six agencies through Catholic Community Services. The center, at 140 W. Speedway Blvd. No. 100, provides medical and dental services to low-income families without regard to race, religion, national origin and physical and mental challenge. Last year St. E’s provided care for more than 14,000 uninsured and underserved individuals. A small paid staff with more than 100 volunteer dentists, dental hygienists, physicians, and other medical professionals runs the clinic.

EMRs use study available
The ASU Center for Health Information and Research (CHIR) has conducted surveys of Arizona physicians since the 1990s in cooperation with the allopathic and osteopathic licensing boards. The information is used to track the physician workforce and to address specific issues that change over time. Current survey questions focus on the use of EMRs and compares physicians’ experiences in the 2009-2011 license renewal to the

St. E’s says every child deserves a smile
St. Elizabeth’s Health Center reports that it is now providing braces to children with severely misaligned teeth. “This unique program will give children ages 10-16 in families with financial hardships a beautiful and healthy smile and confidence in their future,” they said. “This opportunity was created through the support of long-time local orthodontists, Dr. Larry Leber and his son, Dr. Eric Leber who will volunteer their time to provide braces to children through St. Elizabeth’s Health Center’s Dental Clinic. “While standard braces may cost from $4,000 to $6,000, eligible families will receive braces for their children for $500 to $1,000. This includes two to three years of braces, retainers, and one year follow-up.
SOMBRERO – December 2012 13

results for 2007-2009. The survey, “The Use of Electronic Medical Records and Physicians’ Attitudes Toward a Health Information Exchange,” included an opportunity for interested physicians to request a copy of the report. The response was so overwhelming that CHIR is unable to provide printed copies to everyone but it is available for download at the CHIR website, http://chir.asu.edu. The 2011-2013 survey is greatly expanded and offers physicians a unique opportunity to rank specific EMR software packages. Inquiries concerning the survey or related matters can be made to its director, Prof. William G. Johnson at william.g.johnson@ asu.edu.

The event was part of the 101st Arizona Town Hall, Civic Leadership for Arizona’s Future. The award is named for Shirley Agnos, President Emerita of Arizona Town Hall. “A third-generation Tucsonan, Giffords dedicated herself to public service for more than a decade and is a longtime member of the Arizona Town Hall. She resigned from Congress in January 2012 to focus on her recovery after being seriously wounded” by assassin Jared Loughner at a 2011 Congress on Your Corner event in Tucson. “After undergoing physical and speech therapy in Houston for more than a year, she recently moved back to Tucson with Kelly. A formal naval aviator who flew combat missions in the Gulf War, Kelly became a NASA shuttle pilot in 1996 and flew his first mission in 2001. Last year he led the final flight of space shuttle Endeavor. The couple also penned their memoir, Gabby: A Story of Courage and Hope, in 2011.” Arizona Town Hall is a private, statewide, nonprofit organization that has been “a catalyst for civic action and the advancement of issues important to Arizonans. 2012 marks the organization’s Golden Anniversary of convening diverse Arizonans to develop solutions to the state’s most pressing issues. The organization’s signature events include large, statewide Town Halls held in the spring and fall, while multiple smaller Community Outreach Programs add diverse perspectives to the solutions each To wn Hall develops.” More information about Arizona Town Hall can be found online at www.aztownhall.org n

Arizona Town Hall honors famous couple
Former Arizona Rep. Gabrielle Giffords and her husband, retired NASA astronaut Capt. Mark Kelly were honored Nov. 27 by Arizona Town Hall at a public luncheon at Talking Stick Resort in Scottsdale, the organization reported. Giffords and Kelly were recognized for “their and dedicated public service, as well as outstanding support of civic engagement,” the Town Hall organization reported. “We are thrilled to be honoring this highly respected couple at our 101st Town Hall focusing on civic leadership, ” ATH President Tara Jackson said. “We can’t imagine two more fitting recipients during the same year that the Town Hall celebrates 50 years of bringing civic engagement, civic leadership, and civil discourse to Arizona.”

Pima County Medical Society Happy Holidays Healthy and Prosperous New Year!
14 SOMBRERO – December 2012

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Diabetes

Containing Pima County’s diabetes epidemic
A virtual tsunami of diabetes is approaching. Thirty-five percent of Americans over age 20 are pre-diabetic, surging to 50 percent for those over age 65.1 One in three people born in the U.S. after 2000 is projected to become diabetic.2 This comes as no surprise given that nearly 70 p-percent of Americans are overweight or obese.3 With A1c screening we are readily and regrettably all too frequently diagnosing pre-diabetes and diabetes. What is the impact on the nation’s health? Diabetes is the seventh leading cause of death in the U.S.4; it leads to a two-to-four-fold increase in heart attacks and strokes. Type 2 diabetes is a cardiovascular event waiting to happen, particularly when accompanied by dyslipidemia, hypertension, and/or smoking. Untreated diabetes is a leading cause of kidney failure,
Dr. Jonathan R. Insel

amputation, visual loss and neuropathy.5 Pre-diabetes by itself is associated with a 21-26 percent increased risk of stroke.6 Can we contain the diabetic epidemic? How do we cope with our obesogenic-diabetogenic environment? How do we promote a healthier community without interfering with individual freedom and choice? Diabetes is a preventable disease. Modest weight loss, 5.6 kg (12.3 lbs.) and regular exercise for 150 minutes a week prevents Type 2 diabetes in 58 percent of folks at risk.7 How do we enable our patients to embrace a healthy lifestyle? We need to start early. Nutrition education has an impact when directed at our youth, particularly if reinforced in the home and the school cafeteria. My son’s experience is illustrative. When he was learning fractions, his third-grade teacher asked the kids to bring in a food label and calculate the fractions of carbohydrates, fats, and protein for the item. This simple exercise prompted him to read food labels and eat healthier. Years later he informed me with a smile that he had brought in the butter label: “The math was easy.” If folks are overweight, we need them to eat smart and in moderation. Giving up a few simple carbohydrates, particularly sugared beverages, can make a profound difference. One of our colleagues diagnosed with Type 2 diabetes reversed it in two weeks by eliminating the soda. A recent study demonstrated a significant weight decline when sugarless beverages were placed into the homes of adolescents, particularly in a subgroup of Hispanic families.8 We need to limit sugared beverage access in schools. Food subsidies need to stop paying for these drinks. We need to constrain the sugar campaign that TV ads direct at our youth. Now is the time for a debate or proposition for or against a sugared-beverage tax; the money could potentially fund diabetes prevention programs. Whether you agree or disagree with the New York City 16-oz. sugared beverage limit, it has at least made us more conscious of the risk of drinking giant amounts of these drinks. Can we as a community incentivize healthy eating? A good start is being able to see the calories of every item posted on restaurant menus. Perhaps one day, grocery stores will flag the high-caloric and high-sugar foods one color, and healthier choices with another. We also need to address the candy displayed by the cash register, a promotional strategy referred to as “impulse marketing.”9 Ours is a sugar culture, one we resist relinquishing. We use the word “sweet” for
SOMBRERO – December 2012

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anything positive. We reward ourselves with sugar and desserts. It feels sacrilegious and perhaps draconian to change it. Yet perhaps it is time for the Girl Scouts to consider selling healthy snacks rather than sugar-rich cookies? Isn’t it time we cut back on the candy at holidays? What about the donuts and cookies at work? We need to encourage bakeries to produce pastries with less sugar in the recipes. How about bake-off competitions awarding the tastiest with the least sugar? How about more restaurants catering to our palate and our health? Effective weight-loss programs are available. Weight Watchers, with a point system that freely allows fruits and veggies, is a great start. Dr. Dietmar Gann’s Diet of Hope is a gem. Jenny Craig and Overeaters Anonymous are successful, as are low carbohydrate diets such as South Beach or Sugar Busters. Mark Twain once said, “Will power lasts two weeks and is soluble in alcohol.” We need ongoing reinforcement. A colleague has each of his overweight employees place $5 in a bowl; whomever loses the most weight at the end of the month takes all as Biggest Loser in the Workplace. Insurance is starting to incentivize weight loss and exercise with premium reductions. Insurance companies and Medicare are covering wellness programs such as the 16-week diabetic prevention program at the local YMCAs. We need to educate the lifestyle and health coaches for tomorrow: university programs that integrate physical training, nutrition, motivational psychology, and diabetes education. We also need continuing studies to ascertain which prevention programs are most effective. Medications are also emerging for weight loss and to treat sugar addiction. Phentermine has long been available. A combination with Topiramate, Qsiva was just approved. Lorcacerin, Belviq, will be available in the next few months. The diabetic drugs, the GLP-1 agonists, Exanatide and Liraglutide, promote weight loss by producing satiety but are not currently approved for diabetes prevention. Metformin, despite being a relatively weightneutral drug, prevents diabetes in 33 percent of patients.10 For refractory obesity, bariatric surgery can be the solution. A 15year prospective study found that bariatric surgery prevented diabetes in 78 percent of patients, regardless of the type of surgery.11 We also need to incentivize exercise. We are blessed in Pima County with year-round sunshine and countless choices: a bike ride along the Rillito, the Santa Cruz, or through Saguaro National Monument East (or West); a hike in Sabino Canyon; downtown at Meet Me at Maynards or uptown at La Encantada; tennis, lap swimming, golf, gardening, exercise programs at the YMCA, the JCC, or at the local gym. A buddy can enable, be it a friend, a spouse, or the family dog. A trainer can keep us accountable. Our youth also need to be kept physically active. PE needs to be a daily school event. Innovative, versatile PE programs as initiated at Marana Middle School may engage more youngsters. Under the supervision of three PE teachers, students have a choice; this month they can choose to play football, work out in the fitness center, or swim in the pool. Can we build our community to promote exercise? Attractive, safe stairwells constructed centrally rather than at the far end of buildings encourage stair climbing. At the Cleveland Clinic signs by the elevators read: “Free exercise equipment nearby— the stairwell.” We need gyms and wellness programs at work as
SOMBRERO – December 2012

currently exist at Raytheon and UMC. We need cushioned playgrounds for young children where they can fall without injury. Tucson is a cycling paradise, rated second in the nation. We need to continue to build safe bicycling and walking paths in and out of town, buffered from oblivious motorists. A few healthy watering holes along the routes would also attract more cyclists and joggers. In Pima County we are blessed with ideal weather and natural resources. We can be a model for the country, the epicenter for healthy living. PCMS, in conjunction with The University of Arizona Zuckerman School of Public Health, can lead the charge. Dr. Insel’s practice is Western Endocrine Associates, 6365 E. Tanque Verde Rd., No. 200. He has been a PCMS member since 1980 and was awarded Physician of the Year in 1995. This article follows his Oct. 9 CME presentation at PCMS for Pima County Medical Foundation, Inc.
REFERENCES  1. CDC National Diabetes Fact Sheet 2011, Center for Disease Control and Prevention.  2. JAMA 2003:290(14);1884-1890.  3. JAMA 2010:303;235-241.  4. CDC National Diabetes Fact Sheet 2011 www. cdc.gov/diabetes/ pub./pdf  5. CDC National Diabetes Fact Sheet 2011 www. cdc.gov/diabetes/ pub./pdf  6. BMJ 2012:344;e3564.  7. N Engl J Med 2002:346;393-403.  8. N Engl J Med 2012:367;1397-1406.  9. N Engl J Med 2012:367;1381-1383. 10. N Engl J Med 2002:346;393-403. 11. N Engl J Med 2012:67;695-704. n

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In Memoriam
By Stuart Faxon

Dr. Joseph C. Mirabile, 1925-2012
In 1978 the American Board of Neurological Surgery certified Dr. Mirabile. In 1981 he was elected to the PCMS Board of Directors. From then to 1984 he served as a PCMS delegate to ArMA. His beloved wife, Lynn M. Mirabile, 46, died on Nov. 10, 1998 after being ill for about five years. Dr. Mirabile took out a “thank you” ad in the Arizona Daily Star, expressing his deep gratitude to TMC and those friends who helped and comforted him and his wife during that time, including Dr. Charles Krone and Dr. Ray Moldol. “Although Lynn is gone from this earth,” Dr. Mirabile said in the ad, “I take solace and comfort in knowing that she is with my father, who also died on Dec. 5 [1998] at age 90. I know that he is taking care of my beloved Lynn for me. They are my first thoughts in the morning, my last at night, and always will be so.” In 2004 Dr. Mirabile retired, or as he put it, “The scalpel has been hung up.” Dr. Goldfarb practiced with Dr. Mirabile for about 10 years in Neurological Associates before leaving in 1980 to form Western. “I found Joe to be a very caring surgeon,” Dr. Goldfarb said. “He was always upbeat, and he took care of his patients in a very caring manner. We had a very collegial relationship even after I left the practice.
Dr. Joseph C. Mirabile in 1976.

PCMS heard on Oct. 19 that Dr. Joseph C. Mirabile, neurosurgeon here for 30 years, died in New York on Sept. 27. Retired since 2004, he was 69. Joseph Charles Mirabile was born Dec. 7, 1942 in Brooklyn, New York. He earned his M.D. at SUNY Downstate Medical Center College of Medicine, Brooklyn, in 1967. He interned in general surgery at State University-Kings County Medical Center in 1967-68, and did his neurosurgery residency at Cook County Hospital, Chicago. He served in the U.S. Army in 1969-71. Discharged honorably with the rank of Major, he went on to graduate education in neurosurgery at University of Illinois Hospital (Taylor Unit) in Chicago 1971-74. Dr. Mirabile settled in Tucson in 1975, joining PCMS and practicing with Neurological Associates of Tucson at Tucson Medical Park, with neurosurgeons Robert Goldfarb, Charles Needham and Thomas Norton, neurologists Harvey Buchsbaum, William Masland, Harvey Goodman and Francisco Valdivia, with Dr. Arnold Friedman as consultant. The practice evolved into today’s Center for Neurosciences.
SOMBRERO – December 2012

“Joe had a lot to offer, and he really was taken from us too early. Our thoughts and prayers are with his family.”

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Dr. Elliott E. Stearns, Jr., 1923-2012
aviation” in his teen years, happy with “the dust of balsa wood and the smell of glue thick about me.” He became permanently “imprinted” with the 20th century’s central event, World War II, as it approached in 1939-40. In 1941 he was a freshman at Williams College in Massachusetts and headed for teaching in the biological sciences. But infamous Dec. 7 changed everything with the Japanese strike on Pearl Harbor. “Drafted into the field artillery after my sophomore year,” he wrote in 1995, “I found myself in basic training in the deserts of California. It was midsummer and the heat made Tucson seem like a trip to the seashore! “There followed a series of events that led me to the University of California at Berkeley in the Army Specialized Training Program. My first choice was medicine but the class was full. I spent 18 unhappy months in the engineering program before I was able to transfer to medicine at U.C. San Francisco.” In summer 1945 “the war was winding down,” Dr. Stearns wrote. “On a brief leave I climbed aboard a train for the marathon coach trip to Cleveland. I married Martha Small and brought her back to California. She was able to finish college in Berkeley and San Francisco, and with a new degree in education she went to work to help us traverse those impecunious years.” After his undergrad degree at U.C. Berkeley, he went on to graduate from the University of California School of Medicine at San Francisco in 1948. He interned at the U.S. Public Health Service Hospital in San Francisco and did his residency at Sonoma County Hospital in Santa Rose, Calif. In 1951-53 Dr. Stearns had a Fellowship in urology at the Cleveland Clinic (Cleveland Clinic Foundation Frank E. Bunts Educational Institute) and was chief urology resident at Cincinnati General Hospital.

Dr. Elliott E. Stearns in 1984.

Dr. Elliott E. Stearns, urologist, pilot, historian, author, PCMS member since 1957 and retired since 1987, died on Oct. 24, according to an Oct. 27 death notice in the Arizona Daily Star that we have verified with Adair Funeral Homes. He was 89 and had suffered with Alzheimer’s disease for about the last eight years. Elliott Edmund Stearns, Jr. was born Jan. 11, 1923 in Cleveland, Ohio, where, he said, he was “aged in the dream-cask of

20

SOMBRERO – December 2012

Bob Hastings Sr., Hugh Thompson Sr., A.B. Thompson, Roy Rudolf, and a passel of younger greats who would go on to make the PCMS 50-Year Club.” He wrote that by the early 1960s he was “finally able to scratch the [aviation] itch and start renting planes again. As I got busier it was great to have the likes of San Francisco, San Diego, and Santa Fe available on a long weekend. In 1964 we bought a secondhand Cessna that opened the gate to Mexico. With it, I went on to obtain a commercial license and instrument rating that in a practical way extended our horizons, including flights to postgraduate seminars and medical conventions, SCUBAdiving trips to Baja, and skiing trips to Aspen. Over the years some of our more adventurous friends and colleagues would join us. Among the physicians here in the 1950s and ’60s were John Walsh, Bill Wharton, Tony Forte, Joe Waterman, Joe Waterman, Wess Fee, and Duncan Campbell. Among others who caught the bug early were Ross Magee, Don Ewing, John Carroll, Allan Collier, Duncan Robertson, and Jim Blute the younger.” The American Board of Urology certified Dr. Stearns in 1961. In six terms spanning 1961-67 Dr. Stearns served as PCMS secretary-treasurer. He also served as an alternate PCMS board delegate. He was nominated for president in 1967 but had to decline, citing physical energy and time limitations. In 1970 he served on our Board of Censors. Later he served on the Medical Advisory Board of Planned Parenthood of Tucson.
Dr. Stearns signs copies of his World War II novel, Catapult 1940, July 30, 1998 at Borders Books & Music on Oracle Road. The author outlived the s tore. The book was a finalist in the Hemingway First Novel Competition (Stuart Faxon photo).

In 1956 Dr. Stearns was a Captain serving as urology section chief at the 3450th USAF General Hospital, Warren AFB, Cheyenne, Wyoming. He wrote to us inquiring about urology and hospitals in Tucson and saying the climate would be good for his “minimal pulmonary tuberculosis.” With encouragement from PCMS Dr. Stearns decided to move to Tucson that year after his service discharge. He began practice here in August. In 1959 he relocated to Medical Square, and later to 601 N. Wilmot Rd. as Tucson Urology, Ltd. He was a member of the American College of Surgeons. “The early eastward migration of medical offices extended only as far as Country Club Road in 1956,” Dr. Stearns recalled. “Of the doctors I can recall whose offices were strung out along Country Club were Don McCloud, Dave Minter and Fred Hirsch, a group doing family practice. Mayer Hyman and Elmer Yeoman shared an office in IM. Ross Magee had recently joined Darwin Neubauer. South of Speedway were the offices of Brick Storts, Bill Manning, Bill Schultz and, I’m sure, a few others whom I’ve forgotten. “Dons of the community still in practice in 1956 included such notables as Paul Holbrook, Don Hill, Joe Farness, Art Present,

In retirement in the 1990s, he helped Tucson youth learn chess, supporting the TUSD Summer School Chess program. But that was only the beginning. Turning his restless intellect to writing, he wrote short stories and worked with our History Committee in preserving Southern Arizona medical history. He said that Sombrero publication of his historical vignette The Battle of Ambos Nogales “helped launch a writing career for me.” Eventually he wrote a World War II historical novel, Catapult 1940—Gauntlet of Love and Fire, placing his characters at the fall of France just before America entered the war. Published in 1998 (Pentland Press, Inc., Raleigh, N.C.), it was a finalist in the Hemingway First Novel Competition. He wrote in 1995, “My very close friend, the late Wesley Soland, once said, ‘Old surgeons don’t retire—they get retired.’ That bit of wisdom became apparent as I passed 30-some years of practice in Tucson. Many of my good referring physicians began to relax, retire, or die. Marriage ceremonies attended for the progeny of friends and colleagues gave way to memorial services for those same friends and colleagues. Ah well, 1987 seemed like a good time to step aside and let the many bright and competent young physicians arriving on the scene shoulder the sometimes vexing problems of medicine. Besides, I was eager to try my hand at something new and challenging.” Dr. Stearns’s wife “Marti,”; their three sons Michael, Philip, and Dan.; and three grandchildren survive him. n

SOMBRERO – December 2012

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PerspecƟve
By Dr. Jerome C. Rothbaum

Does it matter?
An analysis of current healthcare delivery
What we do as physicians and healthcare workers is complex and frequently difficult. Most of us, however, are interested in achieving the best possible results and having optimal outcomes for our patients. Review of medical records and access to information as to how patients are actually cared for gives us pause in answering the question: Is this the best we can do and are the outcomes of care what we should expect, particularly since the potential for harm is so great? In a systematic review of outpatient care and intensive hands-on evaluation of actual patients, and with extensive records review, certain deficiencies become apparent. These salient deficiencies have become obvious in a medical experience in examining approximately 11,000 patients over a period of 10-plus years. This experience has been gained after 40 years in the clinical practice of medicine. Some of the more egregious patient care deficiencies are as listed below. These are not the only deficiencies found, but merely a brief listing of some of the more typical and significant errors discovered. Case One: Female, 34. History of chest pain. CT of the chest negative, chemical stress test negative. No mention in the medical record examinations of a gr. 2- 3/4 localized precordial systolic murmur. My presumptive diagnosis: Ventricular septal defect. Case Two: Male, 45. Chest examinations by pulmonologist x1 and PCP x6 described as “normal.” Physical exam, however, shows classic gr. ¾ fine, bilateral interstitial (Velcro) crackles. My presumptive diagnosis: Diffuse interstitial fibrosis. Case Three: Male, 48. Multiple outpatient examinations describe lungs as clear to percussion and auscultation (clear P & A). Actual examination shows marked hyper resonance to percussion and 4+ diminished breath sounds. My presumptive diagnosis: Severe COPD (emphysema). Case Four: Female, 49. Diagnosis of COPD and rheumatoid arthritis. Physical examination by rheumatologist: “lungs clear to P & A.” Physical examination by cardiologist: “Symmetric chest, normal breath sounds bilateral without wheezes, crackles, or rhonchi.” Actual examination by this examiner: Increased A-P diameter, hyper resonance to percussion, grade 1-2/4 fine interstitial crackles bilaterally. My presumptive diagnosis: COPD, interstitial fibrosis, possibly associated with rheumatoid arthritis. N.B. In my experience, the classic errors as described above in cases three and
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four are the most common and significant errors in the clinical examination. Note: “clear chest” does not mean normal chest examination. Case Five: Two visits with cardiologist. Murmur noted in list of chronic conditions, but two visits with cardiologist describe “entirely normal cardiac examination” (no murmur, no click). True findings: gr. 2/4 systolic murmur left third intercostal space and loud systolic click. My presumptive diagnosis: Mitral valve prolapse. Case Six: Record shows height 5 feet, 11 inches. Actual height measured 5 feet, 6 inches. Was this actually measured previously? The examples above are only a few selected, but undoubtedly representative errors, missed diagnoses, and inaccuracies. Many others were also discovered in records perusal and patient examinations. So now we now return to the original question: “Does it matter”? Yes, it matters: 3 Missed or delayed diagnoses lead ultimately to progression of disease and potentially the inability to effectively intervene. e.g.: missing the diagnosis of COPD early allows for progression of disease, loss of opportunity for counseling as to cigarette avoidance, and undoubtedly hastens loss of productivity. 3 Multiple other examples of the benefit of early diagnosis and treatment are easily perceived. 3 The effect of allowing further degradation of clinical skills, especially on the part of primary care providers, is self evident: 3 Early and confident use of diagnostic skills will help to prevent unnecessary referrals, and unneeded (and expensive) diagnostic testing, for example scans, inappropriate use of diagnostic testing (MRI and CT scans) which in many instances is expensive, not helpful, and may lead to further inappropriate
SOMBRERO – December 2012

testing and/or injury, such as radiation exposure. This is obviously not compatible with optimal smooth and seamless continuity of care. 3 As clinical skills deteriorate, there becomes a lack of confidence between providers so that the optimal interactions necessary between physicians—primary care providers, specialists—become degraded. This is obviously not compatible with optimal, smooth, and seamless continuity of care. 3 As clinical skills deteriorate, or are not practiced, there is a loss of confidence on the part of the physician or physician’s extenders so that ultimately, less and less care is effectively provided. The consequences in terms of cost are obvious. Where the medical record is inaccurate, and especially where errors are repeated on a continuing basis, as is seen in many electronic health records, the question arises as to the accuracy of the examination, and indeed whether the examination has actually been performed. Obviously in this scenario is the looming issue of liability. As quality of medical care degrades, peoples’ respect for the medical profession and trust continues to deteriorate. This is not good for society or the profession. Role of the Electronic Health Record (EHR) Ideally, the EHR should enhance communication between all components of the health system. What does the EHR do? 3 It should provide a printed, legible record that ideally should allow all necessary components to access information. 3 It should provide a format allowing for appropriate monitoring of the system as a whole, costs, appropriate utilization, etc. 3 It should provide a reliable record of patient care. Unfortunately, expectations for the EHR are not always met: 3 Input into the system is sub-optimal. The old GIGO—“garbage in, garbage out” is still a reality. 3 The computer not infrequently functions as an interface between patient and physician. The result is that loss of traditional respect and confidence on the part of the patient is lost, and the personal relationship is fractured. 3 Smooth exchange of information between users of the system is impaired: • Abbreviations are used that are not familiar to all providers. • Use of hackneyed phraseology or “computer-speak.” • Potentially important information is buried in a mass of non-information and redundancy. Six pages of “information” in a patient visit are related to a runny nose. Corrective measures: Where do we go from here? 3 The reimbursement system is a major cause of the problems discussed above. By paying “piecework” for medical care—how
SOMBRERO – December 2012

many shirts can you sew in one day?—we encourage the problems previously discussed. We need a system that truly rewards quality work. (More on this at a later date). 3 By truly empowering primary care as the gatekeeper and manager of patients’ needs, quality will be enhanced and undoubtedly costs will decline. 3 The system as a whole needs to look to other systems for appropriate quality control measures. Look to the airline system and the methodology used to maintain quality and prevent accidents. 3 Build into delivery systems an in-house monitoring system whose purpose is to provide continuing review and education, to prevent predictable and recurrent deficiencies. By doing so, it would appear that insurance companies and owners and managers of delivery systems would have a strong marketing tool to assure success in the marketplace. Systems of care should include physicians, physician extenders (PAs, NPs), pharmacists, and other healthcare providers. Physicians need to be more involved in the educational component and the quality assurance aspect then they have been. Physicians don’t necessarily have to be directly involved in every patient interaction for simple problems. They do need to be involved in the monitoring and educational components of healthcare delivery. The specific aspects will depend on precisely how the group is organized, but the basic function should be prominent. Dr. Jerome C. Rothbaum is a PCMS Associate Member who practiced IM and pulmonary medicine. n

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Lifestyle Medicine
By Hunter Yost M.D.

Factors for ‘normal weight’ patients
 Beneath the surface of the “obesity crisis” (BMI>30) there is a virtual tsunami of individuals with BMI in the “normal range” who pass under scrutiny by physicians and their staff, and who threaten the financial viability our healthcare system despite efforts to the contrary. In a 1981 American Journal of Clinical Nutrition article, The metabolically-obese normal weight individual, the abstract noted, “It is proposed that such individuals might be characterized by hyperinsulinism and possibly an increase in fat cell size compared to patients of similar age, height, and weight and/or to themselves at an earlier time. The possibility is also discussed that inactivity is a contributing factor in some of these individuals and that for them, the appropriate therapy might be exercise.” Ruderman, in 1998 in The metabolically obese, normal-weight individual revisited (Diabetes;47(5):699), said that “available evidence also suggests that MONW individuals could account for the higher prevalence of type 2 diabetes, cardiovascular disease, and other disorders in people with a BMI in the 20-27 kg/m2 range who have gained modest amounts of weight (2-10 kg of adipose mass) in adult life. According to Pub Med, 132 articles have been published on MONW, the most recent being the Sept. 11, 2012 issue of American Journal of Physiology Endocrinology and Metabolism. Researchers using dynamic PET scans found “Excess amounts of abdominal subcutaneous (SAT) and visceral (VAT) adipose tissue (AT) are associated with insulin resistance, even in normal weight subjects (emphasis added). In contrast, gluteal-femoral AT (GFAT) is hypothesized to offer protection against insulin resistance … These dynamic PET imaging studies indicate that both quantity and quality of specific AT depots have distinct roles in systemic insulin resistance and may help explain the metabolically obese but normal weight phenotype.” St. Onge et.al., in 2004 in Metabolic syndrome in normal-weight Americans—New definition of the metabolically obese, normalweight individual (Diabetes Care Sept 27;(9):2222-8), stated, “We observed that men and women in the upper end and just above the normal BMI range are more likely to have the metabolic syndrome compared with those with BMI 18.5–20.9 kg/m2. These results are in accordance with a report noting that the incidence of diabetes, hypertension, and coronary heart disease increases well below the normal BMI cutoff of 25.0 kg/m2.” Rexode et.al. in Abdominal adiposity and coronary heart disease in women, (JAMA
SOMBRERO – December 2012

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1998, 280:1843-1848) found that women with a waist circumference (WC) of 30 inches or more was associated with more than a two-fold higher risk of CHD. WC of >35 inches in women is considered to be obese. For men, others have found that risk of CHD increases at 35 inches with above 40 inches considered obese. In 1995 Richelsen and Pedersen in Associations between different anthropometric measurements of fatness and metabolic risk parameters in non-obese, healthy, middle-aged men (Int J Obes Relat Metab Disord;19(3):169), concluded that even a minor accumulation of adipose tissue in the abdominal region in these otherwise non-obese men was associated with a considerably adverse metabolic risk profile. In addition, the most pronounced effect of abdominal fatness in these nonobese men was a reduction of HDL-cholesterol, an elevation of the triglyceride level and an elevation of the insulin level. TG/HDL ratio is a well known indicator of insulin resistance. Jeppesen et.al. fo und, “The present results showed that high TG–low HDL-C, the characteristic dyslipidemia seen in insulinresistant subjects, was at least as powerful a predictor of IHD as isolated high LDL-C. The results suggest that efforts to prevent IHD should include intervention against high TG–low HDL-C, and not just against hypercholesterolemia” (Arteriosclerosis, Thrombosis, and Vascular Biology. 1997;17:1114-1120). A TG/ HDL ratio of greater than 3 is indicative of insulin resistance and therefore metabolic obesity. Lindeberg and colleges in their article, Low serum insulin in traditional Pacific Islanders—the Kitava Study (Metabolism 1999;Oct:48(10):1216-9) found that increased serum insulin is related to abdominal obesity and high blood pressure in affluent societies where insulin, weight, and blood pressure typically increase with age. The increased insulin level has been thought to reflect insulin resistance, a well-known associated factor in the metabolic syndrome. In most non-Westernized populations, body weight and blood pressure do not increase with age and abdominal obesity is absent. Fasting insulin among the native people of the Melanesian island of Kitava is 3-6 uIU/mL, which does not increase with age. In the 60-74 age group, in both men and women, the average fasting insulin on Kitava is 3.5 uIU/mL compared to 8.3-13 ulU/mL in the US and Canada, i.e. metabolic obesity. (LabCorp fasting insulin level reference range: 2.6-24.9 uIU/mL). Very few Westerners, however, would want to adapt the Kitava diet and lifestyle. Some have suggested that a compromise for non-Kitavans could be below 8.4. So what can physicians do? You could start by purchasing a lowtech medical device at your favorite big-box store or sewing shop, a tape measure costing $2-3. You don’t need bright shiny objects like PET scans for fat distribution or even a bioimpedance analysis machine (which I use in my office) for body composition. If virtually every one today knows their cholesterol number. Shouldn’t people also know their waist circumference? (Men, this is not your pant waist size). Hunter Yost, M.D. practices Lifestyle and Nutritional Medicine in Tucson. n
SOMBRERO – December 2012
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Mayo CME

January 2013
Jan. 18-20: Case-Based Clinical Hematology and Oncology 2013 The 10th Annual Review is at Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.624.1000; fax 480.624.1001. info@kierlandresort.com http://www.kierlandresort.com/  CME: 18.75 AMA PRA Category 1; American Academy of Family Physicians (AAFP) credit pending; American Osteopathic Association: 18.75 Category 2-A.  Course is comprehensive update of issues in hematologic and oncologic malignancies presenting new disease classification, treatment, and challenging cases. Topics include updates from the American Society of Hematology (ASH) annual meeting and in medical oncology and focus on key hematologic diseases (dysproteinemias, acute and chronic leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU), and overlap topics of supportive, ancillary and diagnostic care. Important recent advances in managing breast, genitourinary, gastrointestinal and thoracic malignancies will also be discussed. Challenging and interactive sessions on pertinent issues in patient care.  Website: http://www.mayo.edu/cme/internal-medicineand-subspecialties-2013s841 Mayo School of Continuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca.cme@mayo.edu http://www.mayo.edu/cme

Jan. 21-23: Transoral Surgery for Head and Neck Cancer is at Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.624.1000. info@ kierlandresort.com http://www.kierlandresort.com/  CME: 22 AMA PRA Category 1 (16 general course; 6 optional workshop); 22 credits of AOA Category 2-A.  Course is designed to give otolaryngologists, head and neck surgeons, oral maxillofacial surgeons, and head and neck oncologists a focused educational experience in transoral endoscopic techniques for resecting primary head and neck tumors. Both transoral laser and robotic surgery will be featured, as well as flexible laser surgery in inpatient and outpatient environments.  An optional cadaveric hands-on workshop offers opportunities to perform various transoral procedures with laser technologies and delivery systems. Renowned faculty will emphasize fundamental transoral anatomy, microsurgical and robotic techniques, and wound exposure, as well as other transoral techniques. Workshop participants will gain experience in the art of tumor exposure using various retractors and appropriate and safe use of multiple transoral systems.  Website: http://www.mayo.edu/cme/otorhinolaryngology2013s151 Mayo School of Continuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323 mca.cme@ mayo.edu http://www.mayo.edu/cme

Members’ Classifieds
To advertise in Sombrero classifieds, call Bill Fearneyhough, 795-7985. OFFICE SPACE AVAILABLE: New Office 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 offices, physical therapy or other medical needs. For information, contact Sue Haeger 382-4795. OFFICE SPACE NEEDED: Seeking a medical office approx. 2000 sq ft. with 3-4 exam rooms for sale or lease. Location between TMC and St. Joseph’s area. Please contact Roxann at 520-320-1369. OFFICE SPACE: Professional/Medical Office Space for Lease. Central location, tenant friendly rates, move-in ready. See details & photos at: www.space-4-lease.com   http://www.space-4-lease.com/ OFFICE TO SHARE: We are currently looking for a fourth office mate in a furnished 4 office 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 Offices building, 7333 Tanque Verde across from Udall Park behind Zona 78. Rent is $1150 per month and includes virtually everything - janitor, rental taxes, utilities, waiting room (furnished), kitchen, alarm, parking, copier and phones. Staffing is negotiable and not even necessary for many styles of practice. We
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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 affiliated 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 office for no additional cost. The office is easily found and accessed. The building is only 2 years old and all the “new building bugs” are worked out. It’s 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 ¾ baths it will not stay vacant for long. If interested call Annemarie at(520)440-0872 or John Curtiss, MD, at(520)7493640. We are asking $995 per month, with minimum year lease.

SOMBRERO – December 2012

SOMBRERO – December 2012
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SOMBRERO – December 2012