November 2012

Sombrero
Pima County Medical Society

Home Medical Society of the 17th United States Surgeon General
November 2012
Healthcare critical thinking Coming to your TV: The Dust Bowl
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SOMBRERO November 2012
Sombrero
Pima County Medical Society Ofcers
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. 9
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 Ofcers

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 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 2012, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.
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Inside
5 Letters 6 Dr. Alan Rogers: Our president on helping our patients to 7 12 19 20 22 23 25 26 26
think critically about their healthcare. PCMS News Behind the Lens: Our Dr. Hal Travelin Tretbars family has roots in the 1930s Dust Bowl. In Memoriam: Remembering Dr. William E.G. de Alva and his unusual path to physicianhood. Membership: The volunteer work of urologist Susan Kalota, M.D. Book Review: impressions of self by psychiatrist Dennis C. Westin, M.D. Makols Call: Crash! Analog Guy meets Digital World. Time Capsule: Local evolution of urgent care by Dr. Bob Cairns. Mayo CME Members Classifieds
CORRECTION
In Octobers In Memoriam, after getting the numbers correctly elsewhere, rapidly aging dysnumeric editor typod the birth year of Dr. John H.H. Penners, which was 1923, not 1938.
On the Cover
The aspens colors were the most brilliant in years at the Snow Bowl north of Flagstaff (Dr. Hal Tretbar photo).
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Leers
Choosing prosperity
To the Editor: In trying to decide just what are historys lessons? [Makols Call, June-July Sombrero] I suggest that physicians study some economic history instead of reading only biographies of presidents and a history of the early republic. The best book is probably The Mainspring of Human Progress by Henry Grady Weaver (1947), which explains why America achieved a level of prosperity unprecendented in history. It was because of freedom and respect for individual rights. One could also read the history of the dozens of American utopian communities, based on collectivist principles, every one of which failed. Milder forms of socialism, such as in the European social welfare states, are on the brink of economic chaos and collapse. The American mixed economy appears to be headed in the same direction In its most extreme form, collectivism has resulted in at least 100 million deaths worldwide, as explained in The Black Book of Communism: Crimes, Terror, Repression by Jean-Louis Pann, Andrzej Paczkowski, Karel Bartosek and Jean-Louis Margolin (1999). A model that promises to be more economically successful than communism is being implemented in many places today, but it is not new. It was called fascism in Italy, National Socialism in Germany, and is generally called public-private partnership in the U.S. This model involves nominal private ownership with pervasive government control. Prominent Americans admired this model in pre-war Europe before the atrocities of Hitler and Mussolini came to light. Many American intellectuals are still in love with this model, Ira Magaziner and the Clinton healthcare taskforce among them. And it is the new way in China. Can we have the trains run on time in a fascist economy without a totalitarian regime? The trend is not promising. Among nations ranked on the list of economic freedom, we have fallen to 18th place. In almost every way except sexual expression, we are less free than we were 40 years ago. We are not happier, healthier, safer, more compassionate, more virtuous, or more prosperous. Sincerely, Jane M. Orient, M.D. Tucson n
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SOMBRERO November 2012 5
Critical thinking for health

By Alan K. Rogers, M.D. PCMS President
hysicians are teachers. We are to teach our patients about medicine and help them understand their diseases. This is our mission. Yet I think we have let our patients down by failing to teach them the art of critical thinking. Is it poor schooling or media advertisingor what?that makes our patients not question false medical claims? Every physician is trained to look carefully at studies designed to measure treatments. Any of us in medical research knows how difficult it is to sort out truth and eliminate observer bias and confounding variables. Our patients dont understand how to critique medical treatments.
nutriceuticals and the like? One reason is simply the money patients waste on worthless treatments, but the other is the potential for delaying or avoiding legitimate treatment for serious diseases. Steven Jobs comes to mind. Belief in unproven treatments suggests mistrust of conventional medicine. By going to a clinic in Tijuana, Mexico, Steve McQueen did the world a disservice by implying there were treatments unavailable in the United States, withheld by American medial authorities, that would cure people if only they could get them. This undermined trust in legitimate medicine in a big way for many people. Diet and lifestyle is another huge arena of unproven claims. We in medicine know that good health and avoidance of disease boils down to a very few basic principles: reduce calories, keep your weight down, reduce fat, and eat more fiber, dont smoke, alcohol in moderation, take regular exercise. Yet the belief among patients is there must be some ultimate diet or supplement to make them healthy forever. Recently one of my patients told me she is on the paleo diet. She eats like prehistoric cavemen because they ate only natural foods without the preservatives, genetic manipulation, and artificial colorings of our modern diet. I suggested the paleo diet would be fine as long as she only eats meat she has personally run down and killed like a caveman! So lets help our patients! Encourage them to question claims for treatments and diets they hear every day. They need to understand testimonials are of no scientific value. I find telling a patient something is less effective than asking pointed questions to induce a little insight. So what was the average lifespan of a caveman after all? How much time and effort did it take a caveman to just feed himself? How would you do a study to prove anti-oxidants make you live longer? What does that mean exactly when they say this product supports your immune system? Patients may resist out efforts at education out of a lack of trust, or the nagging fear that establishment medicine has perverse incentives to keep them from the ultimate diet or supplement. No, we are not hiding anything. We must gain the trust of our patients lest they seek unproven or sometimes dangerous treatments. Teach them to ask questions and think critically. n
Our culture is awash in medical advi ce, treatments, diets, remedies, and cures offered by unqualified people with various motives. Just look at the newspaper or online and treatments leap out with claims and testimonials that make them sound like incredible breakthroughs. Some are obvious hoaxes: cures for cancer and the like. But some claims are so pervasive and so close to legitimate science that they are difficult for the lay public to judge. This is where we as physicians must help our patients. Take anti-oxidants, for example. Anti-oxidants are everywhere. They are in vitamins, added to foods, in sports drinks, and supplements. Surely anti-oxidants are a multi-billion-dollar industry. Yet do they do anything for our health? In chemistry 101 we learned an oxidizer is a substance the steals away an electron in chemical reaction. So without them am I in danger of rusting? Proponents of anti-oxidants must believe diseases are caused by oxidation and therefore preventing oxidation prevents the disease. The polite thing to say about this is that it is unproven. Recently in Tucson, a construction worker with no medical background was convicted of offering intra-vaginal ozone to patients as a cure for uterine cancer. Three of his patients offered testimonials that his ozone therapy had eased menstrual cramps, cured Lyme disease, and helped one to conceive. This fellow is obviously evil. But what about his patients? At the very least they were exceedingly gullible. Could it be their mistrust of establishment medicine was so profound they would accept treatment that was so obviously fraudulent? These patients did not critically question the validity of the construction workers claims. Why is it bad for patients to believe the unproven claims for
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PCMS News
PCMS meets
This years remaining Regular Membership meetings are Tuesday Nov. 8, 7 p.m. including reading of the nominees slate, and Tuesday Dec. 11 after the Board of Directors meets, for ballot count and declaration of election winners.
Marc Leib, M.D., AHCCCS CMO, said in an e-mail to PCMS Oct. 9 that federal law requires all Medicaid prescriptions to be on TRPPs. He added, however, if the prescription is transmitted by e-prescribing methods, such as those used in an EMR, the TRPP requirement does not apply.
When the old is Modern

Assuming weve gotten this before your eyeballs in time, Tucson Modernism Week events include a talk by our Dr. Ron Spark, he of the famous 1940s necktie collection. Not surprisingly, its called The 40s Necktie: A Fabric of Modernism, and will be presented at noon Saturday, Nov. 10 at 3920 E. Broadway. Many Tucson Modernism Week events are within walking distance of the El Encanto neighborhood. Tucson Historic Preservation Foundation reports that it is is proud to help launch Tucson Modernism Week 2012: Nov. 9-11 (http:// tucsonmod.com/home). The threeday event is a series of programs, film, lectures and events highlighting and celebrating Tucsons Mid-Century Modern design and architecture. This inaugural schedule emphasizes the Modernist buildings of Broadway Boulevard between Country Club Road and Campbell Avenue. Tucsons modernism captured the exuberance of the postwar era and is defined by clean, simple lines and a casual informality. In the Southern Arizona desert the movement has come to be defined as Sonoran Modern with the use of regional materials, adaptation to the desert climate and an emphasis on indoor/outdoor living.
Dont forget PCMSA Holiday Luncheon Dec. 5

We got the name a little askew last month! PCMSA is of course Pima County Medical Society Alliance, whose Holiday Luncheon is on Wednesday, Dec. 5, 11 a.m.-2 p.m. at Flemings Prime Steakhouse, 6360 N. Campbell Ave.
Pima County Medical Society Alliance members plus two: In front from left are Anastasha Lynn, Mobile Meals of Tucson Executive Director Priscilla Altuna, and Mobile Meals Development Director Kate Hiller. In back row from left are Kathy Armbruster, Tyna Callahan, Kynn Escalante, Sue Rogers, and Joy Chapeskie (Photo courtesy Anatasha Lynn).
PCMF Evening Speaker Series

For Tuesday Nov. 13, Pima Medical Foundation Inc.s Evening Speaker Series has scheduled Genetics: Molecular Biology for Physicians and Medical Personnel in Understanding the Medical Literature for the 21st Century, presented by a panel led by Johnny Fares, Ph.D. of the University of Arizona. One hour CME credit.
PCMSAs Holiday Luncheon supports Mobile Meals of Tucson with this annual event in addition to delivering meals to clients. To be a part of the luncheon by volunteering, participating, or donating to the silent auction and/or raffle, call Anastasha Lynn (chair) at 820.1622, or e-mail msdesertprincess@gmail.com.
ACP AZ meets Nov. 15

The Arizona College of Physicians Arizona Chapter is hosting its Annual Scientific Meeting, Update, Innovate, Advocate, Celebrate! Nov. 16-18 at Midwestern University Campus in Glendale. The varied program includes many different opportunities for education and interaction, Coordinator Teri Harnisch said. For meeting info and registration, log onto www.acponline.org/ about_acp/chapters/az/news_meet.htm or or contact Teri at 602.347.6903, or teri@azmed.org.
Plan now for THMEP conference trip

Tucson Medical Education Programs Fourth Bi-Annual Colorado River Medical Conference, tripping down the river through the Grand Canyon, isnt until July 2013, but planning starts now. I need a commitment from 28 people (with a non-refundable deposit of $500 per person) payable to R. Dale, M.D., in order to schedule a medical/dental conference for CME credit, Dr. Richard Dale said. The Nov. 15 deadline for this commitment and deposit is fast approaching, so please call Dr. Dale at 721.8505 or e-mail rdale9136@aol.com as soon as possible regarding your interest. Significant others and children age 8 and older are invited. 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
TRPPd out
As of Nov. 1, all prescriptions written for AHCCCS patients need to be written on tamper-resistant prescription pads, or TRPPs. In the past, many members were under the assumption that only scheduled narcotics and other similar prescriptions were subject to this rule.
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full trip plus the registration fee, exclusive of one nights lodging at Marble Canyon. This could be the trip of a lifetime! If you are interested, or for further info or questions, please contact Dr. Dale at 721.8505 or rdale9136@aol.com.
SAO welcomes new hand surgeon

Dr. Lacey Rao, fellowshiptrained orthopedic hand surgeon, has joined Southern Arizona Orthopedics. Her practice, along with fellow PCMS members, R. Wayne Wood, R. Mark Blew, Robert C. Kersey, Timothy B. Dixon and George R. Bradbury, is at 6567 E. Carondelet Drive, Suite 415. Her phone number is 885.6701. Dr. Rao attended medical school at Michigan State Photo by John Batbie University College of Human Medicine, and also completed her residency in orthopedic surgery at Michigan State. She finished her training with a fellowship in hand surgery at Kleinert Kutz Center for Hand and Microvascular Surgery in Louisville, Ky., one of the oldest and most prestigious hand fellowships in the country. Dr. Rao specializes in comprehensive surgical and nonsurgical care for disorders from the elbow to the fingertips, including patients with elbow, forearm, wrist, and hand pain, or numbness and tingling in the hands. She has particular interest in carpal tunnel syndrome and other nerve entrapment disorders, fracture care of the upper extremity, arthritic disorders of the hand and wrist, treatment of hand and wrist masses, and tendon problems of the upper extremity. Dr. Rao is a member of the American Society for Surgery of the Hand, the American Academy of Orthopedic Surgery, and Alpha Omega Alpha Medical Honor Society.
Amy Erbe, branch director for Arizona, opened the operation here in 2000. She grew up in rural New Jersey and moved to Tucson in 1996, and is a founding member of the Old Pueblos Winding Road Theater Ensemble, in which she appears in two to three plays a year. Her husband teaches theater at Catalina Foothills High School. Local staff includes recruiters Sunny Lowe and Galina Ramirez, both native Tucsonans. We are excited about the opportunity to join with the Pima County Medical Society to provide quality healthcare professionals and HR solutions to its members at a discounted rate, Erbe said. Our focus is to provide experienced and highly skilled professionals who can hit the floor running so PCMS physicians can focus on what is most importantpatients. To reach Amy or staff, call 866.877.4512, or e-mail medicalstaffing @favoritestaffing.com.
Summit this!
Setting off from near the Cape Royal parking area, John Klein, M.D. smiles with anticipation of the adventure ahead: to climb Vishnu Temple, the large formation at left in the photo (Photo courtesy Dr. Klein).
Member services now include medical staffing

After examining an employment program specially designed for medical societies, the PCMS Board of Directors voted in August to make Favorite Healthcare Staffing (FHS) the exclusive medical staffing provider for PCMS. Our board liked that Favorites Arizona operations are headquartered in Tucson and that it is a privately owned, debtfree company, founded in 1981. PCMS joins societies in Connecticut, Georgia, Indiana, Massachusetts, Minnesota, Oregon, and Texas who have also joined with Favorite to provide comprehensive staffing solutions. Society members may take advantage of discounts on a full range of staffing services, from front-office reception to search services for permanent physician positions. It can provide members with short-term coverage for vacations, sick leave, or vacancies as well as for long-term and direct-hire solutions.
For 43 years the pages of Sombrero have recorded summits PCMS members have reached, but how about this? What about a climb, right here in Arizona, to a spot fewer than 50 people have ever reached? John Klein, M.D. reached the top of 7,537-foot Vishnu Temple in the Grand Canyon on Sept. 28. He and his climbing companion, Executive Director of the Arizona Trail Matt Nelson, are only the 37th party to stand on top. Vishnu Temple was first climbed by University of Kansas literature professor Merrel Clubb, Ph.D. and his son in 1946. At that time, Clubb said, the sight from the top is, one of the two most thrilling spots in the park visually. Nelson said in 2012 that the best views of the canyon he has ever seen are from the top of Vishnu. As a former Grand Canyon guide, he should know. Before you pack your tennies and plan your trip, consider Dr. Kleins protocol: Pack water, lots of it, enough for two-and-ahalf days (13 liters). The Vishnu climb first entails leaving from the Cape Royal parking lot. Traverse down several Class 4 ledgeslower your pack to these ledges. Then the fun begins when you reach the Coconino Sandstone. Two rappels are required, the longest 100 feet.
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He camped under the Supai layer. To summit Vishnu, one has to climb a 15-foot crack rated at 5.6, he said. Several more Class 4 sections are encountered. Final pitch to the summit is a very exposed Class 5.4 pitch to the top. You have to return basically the same way. On the way back up one must use a fixed rope with prusik knots. All pretty arduous. Dr. Klein had an eventful summer. He topped out on Mount Baker, Glacier Peak, and Mount Stuart in Washington state as well as Mount Shasta. He also climbed Shiprock in New Mexico and Grand Teton in Wyoming. Next year he plans to climb Kawaikini (the high point of Kauai and the wettest spot on earth), Picacho del Diablo in Baja, as well as Mount Blanc, the Matterhorn and the Eiger. He said he hopes to finish 2013 with a trip to Ecuador to climb the high volcanoes Cayambe, Cotopaxi, and Chiborazo.
Dr. Klein is an orthopedic surgeon, practicing at 6618 E. Carondelet Drive. He grew up on Tucson, son of PCMS pastpresident Dr. James B. Klein. He has climbed all 400 peaks in Southern Arizona (within 150 miles of Tucson).
Dr. Schneider published

Associate Member Dr. Jennifer Schneider reports that she is very proud of her recent paper on atypical femur fractures, and that it was recently published in the online Journal of Clinical Endocrinology and Metabolism. Ever since I sustained a spontaneous femur fracture in 2001, she said, Ive been studying the cause and connection with bisphosphonates, the most widely used drug class for prevention and treatment of osteoporosis. Ive maintained a constantly growing online support group for other men and women who had a similar fracture (actually 40 percent of them went on to break the other femur!) We now have 160 members who experienced this supposedly rare phenomenon. I enlisted these members in a survey study I did about their experience, and submitted the results for publication, an unusual way of gathering subjects for a study.
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Handy hotlines reference available

A free guide containing emergency numbers and victim legal rights in domestic abuse situations is available at PCMS. Call 795.7985 to arrange for a copy. The booklet might be helpful for a primary care office or emergency department, PCMS Executive Director Steve Nash said, because it has a complete listing of hotlines in Arizona for domestic abuse and suicide as well as a how-to for restraining orders, filing for separation, and divorce. Prepared by the Pima County/Tucson Womens Commission, the printing was paid for from funds seized from criminals by the Pima County Attorneys office. The guide was printed in July. PCMS has 100 copies.
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Stars on the Avenue redux

Pull your 2013 calendar out and mark this down: Stars on the Avenue, 7-10 p.m., Saturday, April 27, St. Philips Plaza. The Planning Committee is busy lining up an evening that will place heavy emphasis on fun, food, and friends, as well as one that will briefly honor local physicians. As details become available, well share them with you. Stars on the Avenue Committee members
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Bruce Lynn, M.D., flanked by his wife, Anastasha, give some tips about autumn sunscreen use before leading the years biggest group on PCMSs Just Walk event at Rillito River Park Oct. 13. Doctors Mike Hamant and Ana Maria Lopez were set to lead the PCMS walk Nov. 10 (Steve Nash photo).
are Kynn Escalante, Joy Chapeskie, Kay Dean, Kate Hiller, Alan Rogers, M.D., Bill Fearneyhough and Steve Nash.
St. Es may be seeking you

For 50 years St. Elizabeths Health Center, formerly St. Elizabeth of Hungary Clinic, has provided sliding-scale medical and dental care for the uninsured and under-insured in the Tucson community. The clinic, at 140 W. Speedway Blvd., is looking for community physicians to donate time. At this point we can use mainly family or internal medicine, said Mark Schidt, M.D., St. Es medical director. We can work with them to set up a schedule that works for them. Duties would be to see patients in the clinic. Dr. Schidt will do the follow-up on lab results, tests, referrals, etc. St. Elizabeths is also looking for help from specialists in gastroenterology, urology, and orthopedics. If you would like to learn more, please call Dr. Mark Schidt at 628.7871. And speaking of St. Es, you may need to know that you can claim a working-poor tax credit of up to $400 on your itemized state income tax return just by making a gift to the clinic. The charitable or working poor tax credit is a way you can support St. Es mission without it costing you a thing. This credit is also completely separate from the private school tuition and public school activity credits. You can do all three credits! Simply make your gift to St. Elizabeths, an agency of Catholic Community Services, by the end of the year. Checks may be mailed to St. Elizabeths Health Center, 140 W. Speedway, Suite 130, Tucson 85705; credit card gifts may be phoned in to Sandy at 520.670.0854; or gifts may be made online at www.ccs-soaz.org. Log onto donate now and simply select St. Elizabeths Health Center as the fund. Then claim the credit when you file your state income tax. Individual filers may claim a charitable tax credit up to $200; married couples filing jointly may claim up to a $400 credit. The credit actually reduces what you pay in state taxes dollar-fordollar, and you may claim the donation on your itemized federal return as a charitable contribution. n

11
Behind the Lens
Sodbusters and the Dust Bowl

By Hal Tretbar, M.D.
n Sunday Nov. 19, PBS will show a new Ken Burns documentary, The Dust Bowl. For a long time I have seriously joked that my family helped start the disastrous Dust Bowl that lasted from 1931 to 1939. We recently returned from visiting old friends in Boice City, Okla., epicenter of the suffocating dust storms.
The American Great Plains essentially extends from the Dakotas south down through Nebraska, Kansas, eastern Colorado, and western Oklahoma and Texas. These were the grassy expanses where the deer and antelope played and the buffalo roamed. Western expansion brought the railroads that helped lead to suppression of Native Americans and destruction of the immense buffalo herds. The Homestead Act of 1862 brought farmers and settlers to the plains. A person could claim and
This famous photo, taken by Arthur Rothstein working for the Farm Security Administration, shows a farmer and sons walking in the face of a dust storm.
own 160 acres of federal land in you made improvements, filed a deed, and stayed for five years. My grandparents came from Germany and homesteaded on 160 acres of rich productive land at Inman, Kansas in 1875. That land is still in the family.
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The Plains states became the breadbasket of America with bountiful harvests of wheat, maize, milo, and other grains. During World War I the government encouraged wheat production to support the war effort. Grain prices remained strong in spite of increased production and many farmers prospered during the 1920s. My grandparents were successful farmers and made sure their four children studied hard. My aunt went to college and married a dentist. One uncle became a dentist, another an M.D., and my father was an M.D. They all settled in the farming community of Stafford, Kansas where in 1910 the three brothers formed the Tretbar Clinic, known for its excellent and innovative care.
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My family continued the farming tradition around Stafford. With high grain prices they decided to expand into Oklahoma in 1928. After careful evaluation they decided the best values were in ranch land near Boice City, seat of Cimarron County, farthest west of the three counties of the Oklahoma panhandle. It is unique in that it borders Kansas, Colorado, New Mexico, and Texas. The Tretbars bought nine sections (5,760 acres) of native pastureland from the Thatcher Ranch. They bought tractors, combines, and other farming equipment. They put the plows into the sandy soil and broke the sod. There were three years of great wheat crops. Then the rains stopped and the unrelenting
12
winds began. By 1939 most of the nine sections had been sold on the courthouse steps for inability to pay taxes. The few remaining acres had lost all of the topsoil to the recurrent dust storms. As re-told in Wikipedia, the Dust Bowl or the Dirty 30s was a period of severe dust storms causing major ecological and agricultural damage to American and Canadian prairie lands in the 1930s particularly 1934-36. The phenomenon was caused by severe drought coupled with decades of extensive farming without crop rotations, fallow fields, cover crops, or other techniques to prevent wind erosion. Deep plowing of the virgin topsoil of the Great Plains had displaced the natural deeprooted grasses that normally kept the soil in place and trapped moisture even during periods of drought and high winds. An Encyclopedia.com article notes that the winter storms were the worst. They came from the north with roiling dust clouds reaching thousands of feet into the sky. There were often periods of total darkness where schools and businesses would close. The dust would penetrate everywhere. Meals were hard to prepare and had to be eaten immediately to avoid grit. The dirt would pile up to window level and block doors. People would spit out black phlegm and many children died of dust pneumonia. The summer storms would come from the southwest. The fine sandy soil was lifted by the howling winds and carried east. In 1932, 14 storms were recorded and increased to 38 in 1933. In May of 1934 a two-day dust storm blew all the way to Chicago where it was estimated that 12 millions pounds of dust were deposited. Two days later the storm reached New York City and Washington, D.C. In 1933 Congress established the Soil Erosion Service (SES) in the Department of Agriculture, but paid little attention to the problem until two years later. On April 2, 1935, SES Director H.H. Bennett testified to a congressional committee about need for increased action. He learned that a Plains dust storm was blowing into Washington, and prolonged the committee meeting until he could point out the window when the storm blotted out the sun. This, gentlemen, he said, is what I have been talking about. Three weeks later Congress established a more powerful Soil Conservation Service in the agriculture department. I remember the dust storms as black
The Great Plains no longer are subject to smothering dust storms. Dorothy Tretbar and Wendell Burton stand in the lush native grasses planted under auspices of the Conservation Reserve Program.
blizzards when they hit Stafford in the mid-1930s. The sky would blacken, the wind would growl, and the grit could get in your teeth. My family did their best to deal with the worsening situation with many trips to work with our renters, the Foreman and Burton families in Boice City. My uncles would come back with tales about the storms, how the blowing grit would strip the paint from a car, or how the static electricity was so strong that it would knock out electrical systems. The worst storm struck on Sunday April 14, 1935, which became known as Black Sunday. The National Weather Service reports that the sun broke out in the morning as people were going to church and enjoying other activities. At about 4 p.m., a mountain of darkness with blowing sand and dust blasted across the Oklahoma and Texas panhandles. It reached Boice City at 5:15 and Amarillo, Texas at 7:20 p.m. Winds reached 60 mph, the temperature fell, and the blackness was so complete that one could not see his hand in front of his face. Associated Press reporter Robert Geiger was caught in the storm for two hours six miles from Boice City. The next day his Lubbock Evening Journal report began: Residents of the southwestern dust bowl marked up another black duster today Ever since, this time and place have been known as the Dust Bowl. Folksinger/activist Woody Guthrie was born in Okemah in central Oklahoma in 1912. He moved to live with his father in the Texas panhandle town of Pampa in 1931, at the beginning of the Dust Bowl. He wrote the ballad Great Dust Storm to commemorate Black Sunday April 14, 1935: On the 14th day of April of 1935, There struck the worst of dust storms that ever filled the sky.
Opal and Wendell Burton endured the hardships of the 1930s Dust Bowl. Today they are proud of the flowers at their home in Boice City, Okla.
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You could see the storm comin, the cloud looked deathlike black, We thought it was our judgment, we thought it was our doom. His better-known song is Dusty Old Dust. Among the lyrics: A dust storm hit, and it hit like thunder; It dusted us over, an it covered us under, Blocked out the traffic and blocked out the sun, Straight home all the people did run, Singin: So long, its been good to know yuh. So long, its been good to know yuh. So long, its been good to know yuh. This dusty old dust is a-getting my home, And I got to be driftin along. Although many people in the Dust Bowl region had to leave and many headed to California with their families, some farmers were able to stay and tough it out. Government support programs helped many to survive the Dust Bowl days. Improved farming practices helped stabilize the soil. But Cimarron County still is sandy ground that blows easily, even with the best techniques of crop rotation, terracing, and planting acres of
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trees to form shelter belts. The population of Cimarron County in 1920 was 3,436; in 1930 5,908; in 1940 3,054; in 1950 4,589; and in 2010 it leveled off to 2,475. In 1985 Congress passed a farm bill that established the Conservation Reserve Program (CRP), allowing farmers to voluntarily take marginal or sensitive land out of production. The Farm Service Agency of the agriculture department then pays a negotiated yearly rental. You must plant and maintain native grasses and take steps to prevent erosion. The few remaining quarters of land that I have are all in the CRP. On our recent visit to Boice City I was able to spend time reminiscing with Wendell Burton, whose family has long been one of our renters. Wendell was ready to celebrate his 84th birthday. His wife Opal is also a Cimarron County native. She tells the story about the time her father and brother were caught in a severe dust storm while plowing. Opal, her mother and family were at home where they tried to cover all of the windows and doors. They read the Bible and prayed that their father was safe. Her father and brother held hands through the inky blackness. They found a fence line and followed it home to the safety of the barn. Wendells father had farmed in eastern Colorado where his mother taught school and they had five children. He bought two sections of the Thatcher Ranch in Cimarron County. In 1929 the family moved onto the farm, where they raised seven more kids. Wendell and his five sons rented some of our land. Although they suffered through the Dust Bowl days and lost one section of their land, they were survivors. They kept about 100 acres of native pasture and were able to raise sheep goats, pigs,
Indomitable doc
On our recent visit to Boice City, Okla., I was fortunate to meet the indomitable Doc Wheeler. Now in his 90s, J.L. Wheeler, M.D. still has an active practice. He admits to Cimarron Memorial Hospital and helps cover the ER with his PA. Doc Wheeler graduated from University of Oklahoma Medical School in 1952 and interned at Columbia Presbyterian Hospital. He started his practice in Boice City in 1956. He became well known in 1991. A young boy came in with large angry looking lymph nodes and skin welts. Doc saved his life when he diagnosed bubonic plague and had it confirmed by the Oklahoma state health department. The boy had been around prairie dogs. Doc has had a pilots license since he was a teenager. Recently the Federal Aviation Administration gave Doc an award for 75 years of safe flying. In typical fashion, Doc flew his Piper Cherokee 6 to Texas to pick up his son for the ceremony.
and other livestock. They were able to rent their horses to the Works Progress Administration. I remember seeing Wendell in the early 1940s when my folks would visit Boice City. The crops were again good with the return of the rains. I remember sitting in the grain truck after the combine had emptied its wheat. You could chew a handful of wheat until it formed a wad like chewing gum. Wendell started farming on his own in 1956 and has maintained a quarter of mine since then. Wendell serves as an example that Dust Bowl survivors are a unique, tough breed. Not only did Wendell and his family survive the worst of nature, but he developed severe ankylosing spondylitis in his 20s. Imagine how painful it was to ride the jarring tractor hour after hour because there was no effective treatment. The arthritis has now burned out with only an occasional flare up of iritis. It is a real joy now to go back to Cimarron County where I feel at home. It is encouraging to drive the roads where piles of dirt once blew behind each fencepost and find the fields full of waving native grasses. The best part of coming back is sitting in the mom-and-pop caf talking with all the oldtimers over another cup of coffee. n
16 SOMBRERO November 2012
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Internet. Data. Phone. TV.

In Memoriam
By Stuart Faxon
Dr. William de Alva, 1925-2012

of his children led to his passion for medicine. When a son was diagnosed with leukemia, Bill learned all he could about the disease and its treatment. [son] Louis died at age six, and Bill turned to medicine to help others. He sold DeCols for what he estimated his entire education would cost. In two years he earned a BA in zoology at the University of Denver, 1959, was a research Fellow at National Heart Institute 1959-62; and at age 40 earned an M.D. at the University of Nebraska College of Medicine. As an undergrad he minored in political science. While a research Fellow he won an international award from the Angiology Research Association for developing the first method to analyze pulmonary micro-circulation, the family reported. Although skilled in cardiothoracic medicine, he found family practice more rewarding. Board-certified in FP, Dr. de Alva was a charter diplomate of the ABFP, and an associate clinical professor at the University of Colorado. He was medical director of Associates in Family Medicine in Denver. Bill practiced in Denver for 24 years, enjoying performing surgery and occupational medicine as well as family practice, the family reported.
Dr. William E.G. de Alva in 1991.
Family practitioner Dr. William E.G. de Alva, PCMS member since 1989, who trod an unbeaten path to physicianhood, died Oct. 8 in Tucson after complications from a fall. He was 87. William Ernest Garcia de Alva was born April 2, 1925 in San Francisco, Calif. The family reported in the Arizona Daily Star that he joined the U.S. Army Air Corps, predecessor of the Air Force, before he graduated from high school, and served as a photographer in World War II. Afterward he was recruited to work in optics and photography at Los Alamos National Laboratory in New Mexico. During 12 years there he became part of a small group known as the gadgeteers, the family reported. They designed and implemented experiments to determine the biological effects of radiation. He also earned his GED there and took courses from the scientists under the auspices of U.C. Berkeley. His entrepreneurial spirit was evident even as a young boy when he sold and delivered magazines, newspapers, and Christmas wreaths. He also delivered mail throughout the hills of the Bay Area. In Los Alamos, to help support his wife Phyllis and their growing family of six children, he opened a photography supply store on the side, DeCols, which grew into a substantial business. Bill loved the work he did in Los Alamos, but the health of one
Changes in medicine led him to earn a certificate in managed healthcare administration from the University of Denver Graduate Schools Health Care Organization and Systems Division in 1989. This led him to Tucson, where he worked in family practice and administration for Cigna for 10 years. After this, still loving medicine, he became a first surgical assistant until he retired in 2010 at age 85. He was a member of many professional organizations, and a keynote speaker and presenter at several international and national conferences. Bill was an avid skier and regional director for the Colorado/New Mexico Intermountain Ski Areas. He enjoyed sailing. He traveled internationally with his young family many times. Bill married Anne Freimark Crounse in 1991. They traveled extensively and took advantage of every moment together. He loved unconditionally, and left a legacy of love and caring with the survival of his wife, Anne; children Marti de Alva, William A. de Alva, Genevieve McCloud, Paul de Alva and John de Alva; stepchildren Jeannine, Danielle, and Stan Crounse; niece Virginia Brittle; 16 grandchildren; and six great-grandchildren. Bill benefited greatly from the Adult Loss Of Hearing Association, and he recently helped create an Oro Valley chapter. Donations in his memory can be made to ALOHA online at www.alohaaz.org, or at 4001 E. Ft. Lowell, Tucson 85712. A Memorial Mass was celebrated Oct. 17 at Santa Catalina Catholic Church. n
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Membership
By Stuart Faxon
Teach one, reach many

Thats the motto for IVUmed, headquartered in Salt Lake City, incorporated in 1995 to meet what it calls an enormous global health need: Those around the world suffering from diseases and injuries of the reproductive and urinary tracts who have few options for treatment. Thats where volunteer physicians such as our Dr. Susan J. Kalota come in. A PCMS member since 1992, Dr. Kalota is boardcertified and practices at Urological Associates of Southern Arizona with 12 physicians including PCMS members Mitzi Barmatz, Curtis Dunshee and Thomas Hicks. She is often noted as the first woman urologist in Arizona and founding mother of the Tucson Society of Women Physicians, which PCMS helped establish. She earned her M.D. at Howard University in 1986. She did her internship and surgery residency, and urology residency at UCSD Medical Center, San Diego. Starting in 2005, Dr. Kalota has been to Nigeria five times, Mozambique once and Uganda twice. I work primarily with ladies who have vesicovaginal fistula due to prolonged labor, Dr. Kalota said. IVUmed describes vesicovaginal fistula as a traumatic injury that results in an opening between the bladder and vaginal wall. Urine is able to pass from the bladder to the vaginal canal, resulting in incontinence. Approximately two million women, mainly in developing countries, need VVF repair. Often they spend days in labor, producing necrotic tissue from the pressure of the babys head on the vaginal canal, Dr. Kalota said. In the States, she notes, we would have done a C-section long before this could happen. These women are often ostracized because of the odor of constantly leaking urine. Here, fistulas are most often a small hole, caused by surgery or cancer, and we treat them surgically much faster, as our facilities and expertise are available. IVUmed is the expertise exporter, saying it was founded to help address the global need for patient care and professional training in pediatric urology, and that it has grown to include virtually all areas of urology, incorporating education for nurses, anesthesiologists, radiologists, pathologists, and allied healthcare professionals. From congenital malformations like hypospadias, which occurs in one of every 125 boys, to pelvic floor injuries among women, various cancers, and other diseases, urology represents a vastly under-served area of global health. IVUmed is the only organization dedicated to teaching urology in under-resourced countries. Hypospadias is a congenital defect in which the urethra is on the underside of the penis rather than at the tip, resulting in abnormal curvature of the penis upon erection and difficulties in proper urination. If left untreated, there is possible infertility, fistulas, and problems with sexual intercourse in adulthood. Dr. Kalota heard about IVUmed from a friend who became its founding president, Catherine R. deVries, M.D. Besides enjoying
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Dr. Kalota handwashing at a non-functional sink, Jos, Nigeria.
A Nigerian fistula patient, about age 16, in Jos, Nigeria (All photos courtesy Dr. Kalota. Nigerian photos by Pauletta Linaker, M.A., who performed bladder functions tests before surgery).
Vesicovaginal fistula clinic, part of Evangelical Hospital, Jos, Nigeria.
Rounds in the post-surgical urology ward, Mulago Hospital, Kampala, Uganda.
efforts. Their 1012 report notes urology teaching programs in 30 nations on four continents, more than half in Africa. Our volunteers make this happen, Dr. deVries and Executive Director Joshua Wood said in their annual report. IVUmed gives people who are passionate about urological care a safe, efficient way to make a lasting impact on patients and healthcare capacity worldwide. For more information about IVUmed, log onto www.ivumed.org, e-mail info@ivumed.org, or call 801.524.9201. n
Ladies awaiting treatment at Jos.
traveling and working. Dr. Kalota was prepared beforehand, having served in the Peace Corps before med school. The first trip they did that was concerned with female urology, I went on that trip, Dr. Kalota said. It was kind of overwhelming to come from our medicine to theirs. At first you feel you have to be all medical things to all people. But you gradually learn that you can do only what you can do, and you seek out others for the other things. Their problems are so much worse than we see here. With the fistulas, our goal was to help those women who were still leaking after surgery. On my last trip I was more involved in lectures and teaching than in surgery. We go to do the teaching for the local doctors, not just to come in and do the surgery. That way, our influence continues after were gone. And thats the intended IVUmed effect, seeking to build local capacity, magnifying volunteers
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Book Review
By Steve Nash
A book for a time or a lifetime

As scientists, physicians often dream of being gifted with magical powers so that with one swipe of a wand, all ills confronting their specialty would disappear. Over the years doctors have told me their superpower dreams: F Id build a time machine and go back and destroy all plants in the tobacco family. F There has to be a way to strengthen the radiation belts to slow down mutations. F Mandatory national service for two years before college so every American is in shape at least once in their lives. Dennis C. Westin, M.D. has the same dreams but instead of wishing for a staff of power, he did something practical: he wrote a book, impressions of self, a framework for building self esteem. Essentially a self-help book for patients with low esteem, early on Dr. Westin acknowledges that self-examination is scary and often frowned upon as somehow selfish. Perhaps this is the reason for the non-intimidating, lowercase title. After nearly 30 years in psychiatric practice I asked myself what one thing would make the most difference to the greatest number of the people I see, Dr. Westin recalls. It was obvious that the one thing would be to improve the way patients view themselves. He began jotting notes in his limited spare time, linking the notes on weekends and during vacations. I jokingly call this the book I wrote while waiting for my wife to dress for parties and other functions, Dr. Westin says, because there is not a lot of time for a full-time practicing physician to write. Given the circumstances under which the book was written, one would expect a disjointed, repetitive tome. Instead this is a remarkably organized, disciplined book with careful writing that builds on itself in a short 134 pages. Its easy-to-read style feels as though Dr. Westin is speaking directly to you, posing gentle questions, and anticipa ting roadblocks with encouraging metaphors that are simple to comprehend. Each chapter forms a solid step to the next. Dr. Westin has been in private practice for 35 years, and each page is packed with what he has learned over that time. Sometimes it is a surprising question or answer; often it is a doubt tickling deep inside a thought. Yet he never pretends his is the only way, and he usually sweeps his arm out to a beckoning horizon with the invitation of your choice of how to get there. At the end of each chapter are a series of pearls. As in medical training, where the attending would give short statements of wisdom and advice based on the presenting case, these short notes are the chapter takeaways for the reader. Even better, the pearls are followed by what Dr. Westin terms considerations. Here the reader gets a chance to fight what is being offered and seriously work through that resistance. In Westins view, change is not a threat but an opportunity, one that people can choose. He uses a recurring example throughout the book of an eighth-grade- educated woman in her 20s who has an abusive husband. She has two kids and feels trapped. Her name is Mary Ann. At first I had no empathy for Mary Ann wrong gender, bad decisions, poor education. But soon I came to identify with how she reacts to situations as well as the reasons why she so responds. She appears in Chapter Three, and is a concrete example for the thoughts expressed in following chapters. By the end, I was really rooting for her. And what did I get? Mary Ann didnt end with the worlds best abs, or become the richest person in her neighborhood. Her marriage didnt romantically transform, her situation dramatically change. She merely had the opportunity all of us want, to be ourselvesand to be content with that. That is the books goal. It can be skimmed in less than two hours, or over a lifetime. With its simplicity and readability, I recommend it for anyone with patients who have low self-esteem. Copies can be purchased for $18.99 hardback, $11.99 for paperback from Dr. Westins office. Call 795.0309. If physicians wish to offer it to patients, they may call Dr. Westin for pricing options. It is also available from amazon.com, Barnes & Noble.com, and Traffordpublishing.com. There is an e-book version for $3.99. n
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Makols Call
Requiem for an analog guy

Recently while spinning the dial on Sirius Satellite Radio, I almost drove off the road laughing when they played Joe Walshs recent release Analog Man in a Digital World. Joe is a renowned guitarist who first fronted the James Gang, and for 15 years or so has lent his hard rock edge to the Eagles. You may know how sometimes a song can seem to convey a message as if it was written just for Dr. George J. Makol you, like listening to the Blues Imperials sing Opportunity knocked, but the door was locked, or Big Joe Sheltons blues classic, The Older I Get, the Better I Was. Well, Joe Walshs song begins, Welcome to cyberspace, Im lost in the fog, everythings digital, Im still analog. Wow, can I relate to this! I was fortunate enough to come from a family comfortable enough that I never had to eat chicken potpies, and never any Spam. Now I am fed a continuous diet of the other spam every time I fire up my computer. I am just savvy enough an investor to avoid wasting money on lottery tickets, yet in the past month according to my e-mails I have won the Irish Sweepstakes, the U.K. lottery, the Canadian Super 7, and Spains El Gordo. And long lost cousins from Nigeria (really, how many Lebanese live in Nigeria?) have left me millions; every cent of which I can claim if I just send lots of money. And, let us now consider our next cyber wonder, Electronic Medical Records or EMRs. I admit there could be some value in every person in America having the same review of systems. Perhaps turning a sixminute visit with a pediatrician into six pages of single spaced information will serve some greater purpose. Whatever happened to Professor Laurence Weeds brilliant SOAP system to simplify medical records? Now all we have is SUDS (Supremely Un-useful Digital Silliness) and lots of it. I am not against technology, but I
am pretty sure that when a particular technology makes me scream, there is something wrong with it. I do have an analog solution for this problem. Remember the yellow highlighter that got you through college? All EMRs should be equipped with an electronic highlighter so the physician creating the record could outline just the few lines of relevant information, i.e. the medical stuff, not the extraneous repetitive nonsense stuck in for billing purposes. This would be like the Cliff Notes I used in college that allowed me to understand William Faulkners complex novel The Sound and the Fury, which incidentally is easier to interpret than half of the EMRs I see today. I just cannot get used to digitally compressed music: Yes, when you fire up that IPOD and play MP3 format music, you are listening to part of the music, mainly the bass and drums and the high treble notes. We have a whole generation of people who cannot recognize the mid-range of sound, because they have never heard it! Compressed music is like eating a tuna sandwich with the tuna squeezed out. I long for the days of my Bang and Olufsen system, with its $1,500 turntable, my vinyl records, and Klipsch speakers that cost what a Volkswagen did back then. The only things compressed about that system were my walls, as the sound forced them back into the insulation.
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23
Sure, I could not hang this system around my neck, but it would be worth hiring a bunch of porters to carry it around for me just to hear real music. I grew up in a home with three television channels that, incidentally, were free, due to the advertising that they carried. There never was much to watch; just the genius of Sid Caesar, Lucille Ball, Red Skelton, and real athletes that did not take steroids playing ball. Now I pay about $150 a month for TV, and I am continually assaulted with ridiculous advertising anyway, on the 300 or so digital channels I now receive. And much of the time there is still nothing good to watch, except football players who are paid $15 million a year to tackle people, and insist on doing a ridiculous dance after making a simple tackle. One would think they just developed an AIDS vaccine or solved world hunger to justify such bizarre ballet! I could never get enough of the Three Stooges, but just can not fathom the three Kardashians. And are they really all that different? I must admit that I am enamored of the Global Positioning System, perhaps the greatest of the new digital gadgets. Being a man, I am usually lost and of course will not admit it, and whenever I would stop and ask directions, the person I approached had usually just moved to town and knew nothing. I bought the first commercial GPS available, which cost about $1,000 and was as portable as a small refrigerator. It had to be placed in continuous contact with the open sky, which meant that it really only worked well in a convertible, or if you hung it
out the window. Now you can buy a GPS that fits in your front pocket and works anywhere in the automobile, even with the windows up. GPS programs are even available for your smart phone! However I, for one, do not want my smart phone telling me where to go; I have my wife for that. And speaking of smart phones, it should be required that all persons that carry them be smart, too! The other day I was at Starbucks (yes, I still sometimes go there) and there was a perfectly gorgeous girl standing in front of me in line, waiting for our orders to be filled. She was talking to her friends and playing with her phone, and although she had already picked up and was drinking her coffee, she picked up my Macchiato in her left hand after tucking the smart phone into her belt, and proceeded to drink it too. When I pointed out that she already had her own coffee in her right hand she seemed quite surprised. And how do young men now approach such beautiful girls, since they are all now staring into their smart phones and never even give a guy a glance? Maybe you just wait for them to pick up your coffee by mistake, or to run into you because they were texting while walking, or to run you off the road as they text and talk while driving next to you. For us analog guys its all a bit too much. I do have a recurring nightmare involving digital answering systems. In my dream, I call my gastroenterologists office and I hear: You have reached the medical office of doctors Dewey, Scopem and Howe. If you do not speak English and cannot understand one word of this message, please press 1. If you are deaf, and can not hear this message, press 2. If you wish to receive a faxed copy of our privacy practices, please make sure your fax machine has at least 50 sheets available, and press 3. If you wish to talk to a live person, press 4. If you were nave enough to press 4 and did not get a live person, press 5 and you will hear the main menu again. I awoke from this dream the other morning, and in a panic dialed my primary care doctors office. I was greeted with a digital recording saying, If this is an emergency, hang up and dial 911. Whats an analog guy to do? To quote Joe Walshs song again, The whole worlds living in a digital dream, its not really there, its all on the screen. At least I can shut off that screen once in a while and dream about the good old days. So I did just that recently, popping in a CD and firing up Roxettes Shes Got Nothing On But the Radio, and drifted off Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been n a PCMS member since 1980.
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Time Capsule
By Dr. Bob Cairns
Urgent care then and now

Although sometimes referred to as free-standing emergency centers, early urgent care clinics actually marketed convenience. But this convenience care was not the motivating force behind Tucsons first urgent care centers. In 1981, the concept of urgent care medical services was new, and urgent care clinics were limited to a few large urban areas, such as Chicago and Los Angeles. At a typical urgent care clinic, a patient with an acute non life-threatening medical problem, or a painful minor injury, could walk in to a conveniently located medical care center, without an appointment, be evaluated and treated, and avoid the expense, inconvenience, and long waits typical of hospital emergency departments. In Tucson, some of us recall that the early 1980s were when the first HMOs and capitated reimbursement came to town. Capitated reimbursement meant that a participating physician or medical group was paid a fixed amount per month for each patient enrolled in their HMO health plan, even if care was provided outside of the doctors or medical groups offices. The groupnot the patient or the insurance companypaid for specialist care, ER visits, complex diagnostic tests, etc. Group Health Medical Associates (later GHMA Medical Group) was one of the early HMO participants. At GHMA the typically cited financially painful situation was the seven-year-old with an earache at 4 a.m. being evaluated and treated at St. Marys Hospitals ER, for $120. GHMAs management was first to recognize that a groupaffiliated primary care center, open 24/7, 365 days per year, could probably pay for itself by providing round-the-clock care for patients with acute, non-life-threatening emergency medical conditions and painful, non disabling injuries simply by keeping these patients out of hospital emergency departments. In August 1981 GHMAs medical director asked me, a newly hired GHMA family practitioner, to open Tucsons first urgent care center at GHMAs office at 6th Street and Tucson Boulevard. Demand for urgent care was immediate and grew rapidly, and demand always seemed to exceed the supply of available staff and office space. Two-, three-, even four-hour waiting times became common. Convenience was an objective, but one seldom met. Within three years all of Tucsons largest medical groups had urgent care centers. By 1987 GHMA opened two new centers, one at Bellevue and Country Club and one at Ina and Shannon. Many Tucson hospital emergency departments opened oncampus urgent care centers or developed fast tracks within their existing ER triage processes to facilitate care and treatment of patients without true life-or-limb-threatening emergency conditions. Before 1999, Tucsons urgent care centers were different from those today. Most were open 24 hours. Many could accommodate 100 or more patients in 24 hours. These centers were staffed and equipped to evaluate, treat, and observe patients with severe, but non-life-threatening medical conditions: mild diabetic ketoacidosis, non-lethal cardiac arrhythmias, severe asthmas requiring patients to endure
prolonged theophylline drips. You are a true Tucson medical old timer if you recall instructing your patients nurse to titrate the theophylline drip until the patient vomits! Stays in urgent care of 12 to 24 hours were not unusual, and patients were usually discharged home, not to the hospital. Breakup of Tucsons large multi-specialty medical groups in the late 1990s spelled the end of Tucsons high-volume, 24-hour urgent care centers. Operations were financially impossible without affiliation with a hospital or large medical group. Only one urgent care center survived, albeit with shorter hours and smaller patient volume. The original GHMA Bellevue and Country Club urgent care center, founded in 1981, was reincorporated as Urgent Care Associates by founding physicians Bob Cairns, M.D., and one of the original GHMA physicians, George Sokol, M.D. Doctors Sokol and Cairns have continued to run and operate Urgent Care Associates to the present. Lease issues in 2006 required a move to the present Urgent Care Associates office at 1622 N. Swan Rd. (Swan just south of Pima). A second, smaller urgent care clinic was opened in Rita Ranch in late 2006 at 9348 E. Rita Rd., across from Mesquite Elementary School. Since 1999 weve seen changes in urgent care that go beyond reduced size, patient volume, and services offered. Urgent care medicine has become a subspecialty of primary care with its own mini board examination and certification. Other primary care residencies, such as family medicine and internal medicine, have established one-year urgent care medicine certificate programs. Most urgent care providers are board-certified or eligible in a primary care specialty, usually family medicine, and consider urgent care medicine their primary care career. (This includes all current Urgent Care Associates providers.) But the greatest change has been our patients, and the type, acuity, and complexity of medical problems that bring them to urgent care. Todays urgent care centers are not free-standing emergency rooms. Actually, they never were. Urgent care staff at all levels are trained and expected to recognize patients and patient symptoms that require emergency department evaluation and treatment. They are also expected to expedite transport of such patients to the appropriate emergency department using Tucsons excellent EMS transport system. Ninety-nine percent of the patients evaluated and treated in todays urgent care centers are patients that could easily be cared for in a primary physicians officeif the primary physician had the time and resources, and if the patient had a primary care physician. More and more Tucsonans dont. Although urgent care medical providers appear to specialize in episodic care, we, like our office-based primary care colleagues, regard continuity of care as essential to the best possible patient care. In an ideal medical care world, urgent care centers would be unnecessary. However, because we are necessary, Urgent Care Associates makes three commitments: 1. To our patients: we are here to see you only when your own provider cannot. 2. To our primary care colleagues: we will see your patient when you cant, and we will get your patient back to you as soon as we can. 3. Also to our primary care colleagues: we will share with you as much data collected during your patients visit as we can. Most urgent care centers share this philosophy, but only Urgent Care Associates made these commitments in 1981, and have done so continuously, for 30 years, right up to today. n
25
Mayo CME
November
Nov. 16-17: Mayo Clinic Thoracic Oncology for the Oncologist: State of the Art Evaluation and Management of Thoracic Cancers, is at Mayo Clinic Hospital Education Center, 5777 E. Mayo Blvd., Phoenix 85054; phone 480.301.4580. CME: 9.0 AMA PRA Category 1 credit; American Academy of Family Physicians determination of credit pending; American Osteopathic Association 9.0 hours of AOA Category 2-A credit. Activity will focus on recent developments in medical, surgical, radiation, and medical oncologic care of patients with malignancies of the chest. A special scientific minisymposium within the activity will focus on novel developments in molecular pathways of carcinogenesis and immunobiology. Important advances and clinical trials including surgical, medical, radiation and palliative management will be presented by a distinguished faculty. Attendees are invited to submit an example of a challenging case scenario for possible discussion by the panel and attendees. All cases will be reviewed by the course directors for inclusion as they relate to current topics in the treatment and management of lung and esophageal cancers. Website: http://www.mayo. edu/cme/hematology-and-oncology-2012s793 Contact: 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
December
Dec. 7-9: The 7th Annual Practical Course in Dermoscopy & Update on Malignant Melanoma is at Westin Kierland Resort & Spa, 6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.624.1000. Determination of credit pending. Three-day course is multidisciplinary review of standard of care management practices and state-of-the-art advances in care of the patient with cutaneous melanoma. First day focuses on epidemiology, prevention, pathology, genetic syndromes, advances in genomics, imaging and medical and surgical treatment in association with melanoma. Final two days are in-depth immersion into dermoscopy for imaging of melanocytic and non-melanocytic skin lesions, including three breakout sessions. Dermoscopy section is primarily for clinicians, but also for educators and residents seeking a springboard to develop dermoscopy training programs. Website: http://www.mayo.edu/cme/dermatology2012s651 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 Classieds
To advertise in Sombrero classifieds, call Bill Fearneyhough, 795-7985. 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: www.space-4-lease.com. 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 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
26
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.

Y EA R S
O F CA R E
27
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Sombrero

Pima County Medical Society

Healthcare critical thinking Coming to your TV: The Dust Bowl

D DIIS SA AB BIIL LIIT TY YL LIIM MIIT TS SO ON NT TH HE ER RIIS SE E

SOMBRERO November 2012

Official Publication of the Pima County Medical Society

PCMS Board of Directors

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

At Large ArMA Board

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

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Requiem for an analog guy