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Edward Comitz

ecomitz@cobelaw.com | Direct: 480.219.5436

PRACTICE AREAS: Disability Insurance Consultation and Litigation, primarily for medical and dental professionals; Healthcare and Commercial Litigation; Insurance Bad Faith WH WHY YOU CHOSE THIS PRACTICE AREA: After a severe neck injury, I learned how painful it is to not be able to do what you love. The medical community helped me get back to work, but not everyone is as fortunate as I am. Now I use my experience to help doctors who can no longer practice and are being taken advantage of by disability insurers. ACHIEVEMENTS: Martindale-Hubbell AV-Rating, Southwest Super Lawyers, Avvo Superb Rating, AZ Business Magazines Top Lawyers 2011 (Healthcare, Commercial Litigation), Arizona Dental Association Business Affiliate, Arizona Osteopathic Medical Association Endorsed Partner

Michael Beethe

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PRACTICE AREAS: Real Estate Transactions and Leasing; Financing Arrangements; Medical and Dental Practice Transitions FAVORITE ASPECT OF YOUR PRACTICE: I received my MBA along with my J.D., then worked as a trial lawyer for years. I gained a lot of experience litigating commercial contracts that went bad. This perspective allows me to identify pitfalls up front. I enjoy creating value for my clients by structuring and closing solid transactions. ACHIEVEMENTS: Martindale-Hubbell AV-Rating, Southwest Super Lawyers, AZRE People to Know in Commercial Real Estate, AZ Business Magazines Top Lawyers 2011 (Real Estate), Avvo Excellent Rating, Former Editor-in-Chief of the American Bar Associations The Urban Lawyer, Arizona Bar Exam Top Three Score Commendation

Patrick Stanley

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PRACTICE AREAS: Healthcare, Business and Insurance Disputes; Healthcare Regulatory Compliance; Employment-Related Claims BIGGEST CHALLENGE FACING YOUR CLIENTS: Governmental regulation and the insurance industry create a great deal of uncertainty, especially for healthcare professionals. Physicians, dentists and other providers need help navigating the maze of insurance, regulatory, and business issues they face. I enjoy helping doctors solve their legal problems so that they can focus on treating patients. ACHIEVEMENTS: Martindale-Hubbell AV-Rating, Avvo Superb Rating, AZ Business Magazines Top Lawyers 2011 (Healthcare, Commercial Litigation), AzDA Services Business Affiliate

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SOMBRERO June/July 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. 6

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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SOMBRERO June/July 2012

INsiDE
5 6
Dr. Alan Rogers on gun violence control Steve Nash explains how your Society helped change how AMB works

7 PCMS News 11 Our exec rounds up this years ArMA meeting 14 Our Dr. Hal Tretbar talked to world travelers in Flagstaff. 18 Makols Call The debut regular column by Dr. George J.
Makol

20 Remembering Dr. Arnold I. Hollander 22 A major move for Carondelet Heart & Vascular Institute 24 Our Bioethics Committee exams a case of stopping chemo 26 Mayo CME 26 Members Classifieds
On the Cover
The Venus Transit of June 5 will not be seen again by earthlings for 105 years, so members and guests gathered at PCMS that afternoon to view the tiny-to-us planetary silhouette against our star, thanks to Dr. Mike Smiths astronomy equipment and expertise, which also made our cover possible.

Superior Care

Hospice care is the epitome of compassionate care. The expertise and support of hospice staff and volunteers at end of life is unsurpassed.

Carol Clark, Director of Volunteers

Casa de la Luz Hospice offers sensitive medical, emotional, and spiritual support to individuals and their loved ones during the final phase of life. Contact us for more information.

...because every day counts.


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Hospice services paid for by Medicare.


4 SOMBRERO June/July 2012

Just an idea
By Alan Rogers, MD PCMS President

As physicians it is our duty to address health issues that adversely affect patients and its logical to put more effort into diseases that are common, affect lots of people, or cause significant injury or death. In my opinion, there is a very prevalent disease that does not get nearly enough attention from us. What I am referring to is gun violence. Lets face it. Guns are part of the American culture, and even more so in Arizona and the West. I dont own a gun, but enjoy pistol target shooting in the desert. Gabby Giffords owns a Glock. The vast majority of gun owners, target shooters, hunters, collectors, and law enforcement members are responsible citizens that would never want their weapons to be used for evil. I certainly wouldnt. Most ardent gun enthusiasts and civil liberty proponents would agree though that guns should not fall into the hands of the wrong people. How do we prevent this? Attempts to limit or ban sales of guns have been ineffective. In Arizona not only are limits on guns unpopular, but the trend seems to be for even more liberal rules about gun ownership. Previously a special permit was required for a concealed weapon. No longer. There are serious discussions in the legislature of allowing guns in schools and on campus. Permits are not required to own a gun and there is no training or testing required; compare that with obtaining a drivers license. Guns are easily obtainable at gun shows and swap meets with no questions asked. There are enough guns in the publics hands in this country that even if gun sales were banned today there would be plenty of guns in circulation for many years. The same goes for ammunition. Ironically, sales of assault weapons zoomed just before a temporary federal ban was imposed. Extended ammunition clip sales soared after Jared Loughner used a 31-round clip on Jan. 8, 2011 to hit human flesh with each and every bullet he fired. Afterward, the public felt that extended clips should be banned; they were not. The law already bans gun ownership by felons. But to keep guns out of the hands of emotionally unstable individuals is much more difficult. My proposal would be that to buy guns or ammunition, you would need a note from your doctor. When the ball and the runner arrive at home plate at about the same time, the umpire must make a call for the game to go on. Right or
SOMBRERO June/July 2012

ont shoot me, but I have an idea.

wrong. If we are serious about not allowing emotionally disturbed or depressed people from obtaining guns, someone needs to make the call. Who better than a physician? True, a diagnosis of SMI or depression does not necessarily mean a person is violent. But someone must make a judgment about the state of mind of a gun buyer. It might work like this: If someone is interested in buying a gun, they would need to get a form signed by their physician stating they are not Seriously Mentally Ill (SMI), depressed, emotionally unstable, or a danger to others. It would be purely the doctors judgment. The form would be presented to the gun dealer to allow the sale. No form, no sale. Years ago I had an elderly female patient that could be most politely described as bizarre. She lived alone and her behavior, dress, and manners were obviously abnormal. One day her name appeared in the obituaries and I called her daughter to find out why. I learned my patient had gone to a gun shop and purchased a revolver and shot herself the same day. I have always wondered what the sales clerk was thinking when he sold this very unusual person a gun. Jared Loughner, in attempting to purchase ammunition before the shooting, was turned down at one store and sold to at another. In other words, the store clerks involved made an on-the-spot judgment about the mental competency of their customer; a judgment made by someone medically untrained and with an obvious conflict of interest. A physician would do much better. You as physicians might object because of the liability it places on us. But we accept liability for our decisions every day. We give consent for people to drive cars or certify that people are free of tuberculosis to be admitted to an extended care facility. We let people out of jury duty if we feel they are mentally impaired. The specter of liability is actually a good thing here: physicians would have to give careful consideration before signing a permit to buy a gun. Ironically, this editorial may promote gun sales. If the public thinks a physician-signed note will be required to buy a gun, everyone who may have trouble getting the doctor to sign may rush to the gun shop. We as physicians must do whatever we can to promote the health and safety of our patients. Just an idea! n

Improving the AMB


By Steve Nash PCMS Executive Director

hen Arizona passes a law, the legislation doesnt go into effect immediately, so although Senate Bill 1188 has passed both houses and has been signed by the governor, you cant rely on it yetbut soon you will, and you can thank PCMS and some tireless physicians. SB 1188 is remarkable. It changes the way the Arizona agency that licenses allopathic physicians does business. The evidence standard for Arizona Medical Board (AMB) discipline will change from preponderance of evidence to the highest civil proof of clear and convincing. In legal terms, preponderance of evidence means evidence that is of greater weight or more convincing than the evidence offered in opposition to it; that is, evidence which shows as a whole that the fact sought to be proved is more probable than not. In reality, judicial critics maintain this is often a coin flip, that the logic of the arguments are so nearly the same that the merest flaw in one witnesss answer can make a difference. Think of a scale with each side representing evidence in a case. To win, you just need to tip the scales a scintilla in your favor. That is scary when your professional reputation is on the line. The new standard, clear and convincing, is generally described as proof beyond a reasonable, i.e. well-founded, doubt. This standard is supposed to be slightly below that used to convict criminals, but commonly the standard is the same. This is one exception: In cases involving sexual misconduct, preponderance of the evidence will still be used. It creates a seven-year statute of limitations for patients to bring charges of unprofessional conduct.
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Although PCMS pushed for a three-year statute of limitations, we are glad to make this start. Too often, moldy grudges or prisoner suits ended up at the Arizona Medical Board. Physicians were asked to respond to long-forgotten incidents for which they no longer had any records upon which to rely. The new limitations do not apply to malpractice settlements or judgments. Board investigators must complete a nationally recognized investigator training program within one year of being hired. Investigations and investigators have long been a source of frustration for physicians under the AMB microscope. Wrong questions are asked, abbreviations misread, too many records are requestedor too few. AMB has tried using retired nurses, secretaries, and cops. Fortunately the Federation of State Medical Boards has recognized the problem and there are avenues now to train investigation skills. AMB meetings will now be audio recorded. Imagine trying to appeal without a transcript of what happened, or having to rely on the barest writeup? One case, involving a license revocation, only listed who spoke, not what was said. Now meetings will be recorded so an accurate record can be used. The drawback here is the written minutes posted on the AMB website will be less explanatory. Still, that is a small price to pay. Changes like these dont happen overnight. PCMS has been involved in looking at AMB (formerly BOMEX) processes since the 1960s. Since 1995, we have intervened many times in cases that have appeared unfair. Just as important, we have tried to maintain relations with six AMB directors,

and by far have the best relationship with the current director. AMB suggested revisions to SB 1188, but did not oppose it. The current reforms were proposed by PCMS at Arizona Medical Association meetings in 2008, 2010, and 2011. Though the PCMS Board of Directors has been supportive, the true driving forces, have been Mark Mecikalski, M.D.; Jane Orient, M.D.; Christopher Puca, M.D.; Bennet Davis, M.D.; Scott Forrer, M.D.; Jennifer Schneider, M.D.; and David Ruben, M.D. So many have contributed ideas to this cause that they cant all be identified. A partial list of those include Michael Hamant, M.D.; Tim Fagan, M.D.; David Siegel, M.D.; Mitch Halter, M.D.; Evan Kligman, M.D.; Robert Osborne, M.D.; John Dommisse, M.D.; and Mike Diesenhouse, M.D. ArMAs legislative team, led by David Landrith, took what was possible in the reforms proposed by PCMS and made it happen. They found the sponsor, supporters, laid the foundation, and built the edifice all the way up to the governors office. None of this work is perfect. For example, it will only take one bad case of patient harm by a physicianwhom the board was unable (through the higher evidence standard) to prove needed discipline or more trainingfor the Arizona Legislature to switch back. That is a fight for another day. In the meantime, tell your colleagues. They should thank you. Without your support, your medical society cant do any of this. n

SOMBRERO June/July 2012

PCMS NEWs
UAMC docs in AZ epilepsy first
Physicians at The University of Arizona Medical Center University Campus in May became the first in the Western U.S. to operate on an adult epilepsy patient with minimally invasive MRI-guided laser surgery, a safer, less invasive alternative to opening the skull and cutting out the brain tissue where the disorder originates, the organization reports. A 48-year-old Tucson man underwent the MRI-guided laser surgery Tuesday at University Campus and was released the following day. Two other patients are scheduled to have the surgery in the next month. About 3 million Americans are thought to have some form of epilepsy, in which surges of electrical activity in the brain result in seizures or loss of consciousness. The disorder is usually controlled with medication. However, more than 30 percent of people with epilepsy do not have seizure control even with medication and, until very recently, major brain surgery or implantation of a device have been their only treatment options. Minimally invasive laser surgery to treat epilepsy was first used late in 2010 at Texas Childrens Hospital in Houston, which reported excellent results on six pediatric patients. A similar surgical technique has been used successfully for more than a decade to treat certain brain tumors. This promising procedure has worked very well elsewhere and we are excited to offer it in Arizona, said neurologist David M. Labiner, M.D., who heads the Department of Neurology and the Arizona Comprehensive Epilepsy Program at UAMC. Its low-risk and far easier on patients than traditional brain surgery. Were optimistic that it will become the treatment of choice for adults and children with epilepsy that does not respond to standard medical treatments. In the procedure, neurosurgeons Martin E. Weinand, M.D., and J.P. Langevin, M.D., of the UA Department of Surgery, working alongside a team of neurologists who make up the Arizona Comprehensive Epilepsy Program of the UA Department of Neurology, placed a thread-like laser applicator into the patients brain. Then the physicians used MRI to visualize epileptic areas inside the patients temporal lobe and guide a thermal laser to heat and destroy them. The surgery is exquisitely precise. With this technique were able to remove only the areas associated with seizures and spare healthy brain tissue only a hairs breadth
AAMA 2012 SCOTTSDALE, ARIZONA

Kinder, Safer, Gentler Cancer Treatment Health Law Update: An Overview of Legal Issues Facing Medical Practices Caring for Special Populations Understanding PTSD Pain and Addiction The Final FrontierThanatology and What You Need to Know Road Blocks to Screening Patient Calls Spanish for Medical Personnel Bullying on College Campuses Who Needs Legs When You Have Wings Drug Recognition for the Medical Assistant Score a Hole in One with ICD-10 Documentation The Many Faces of Lupus 21st Century Advancements in Facial and Breast Rejuvenation Going to the Extremities

Legal Issues to Avoid in Allied Health Education Maintaining the Crash Cart in the Medical Office Caregivers and Their Role Teaching Medical Spanish for Allied Health Bariatrics Update Update on Shingles Teaching with Simulators Female Sexual Dysfunction Robotic Surgery Fun Food for Kids The Medical Assistant as Patient Advocate Rx for BusinessBusiness Course for Office Managers Bullying in the Workplace GERD Update: Its Not Just Heartburn Mind-Body-Spirit Medicine

American Association of Medical Assistants


56th Annual Conference September 710, 2012 Scottsdale, Arizona
Visit the website at www.aama-ntl.org for more information.

SOMBRERO June/July 2012

away, Dr. Labiner explained. The therapeutic effect is immediate for the patient. When the lesions are destroyed, the seizures end. The Division of Neurosurgery at the University of Arizona is constantly seeking to develop and employ new methods and techniques that minimize our surgical footprint while retaining maximal effect. Dr. Weinand and Dr. Langevins recent success demonstrates our highest commitment to advancing patient care through research. This form of less-invasive epilepsy surgery may one day become a standard tool in our arsenal, said G. Michael Lemole, Jr., M.D,, chief of the Division of Neurosurgery. Rainer W.G. Gruessner, M.D., professor and chairman, UA Department of Surgery, added, Dr. Langevin was recruited to the Southern Arizona VA Healthcare System and The University of Arizona Medical Center to join Dr. Weinand in bringing this much-needed treatment option to Arizona.

They have two children and five grandchildren. Dr. Sethi, a member of the UA Sarver Heart Center, is a professor of cardio thoracic surgery in the UA Department of Surgery. Gulshan and I are truly honored and humbled by this beautiful recognition, Neelam said. One does things in life to give back to the community where one lives, and hopefully to make a slight difference in that corner of the world. This recognition will involve us, in a very small way, to help get closer to achieving the goal of the Steven M. Gootter Foundation to determine the cause of, and the treatment for sudden cardiac death. We are proud to be a part of this beautiful legacy honoring an amazing young man, who touched so many lives during his lifetime, and now, because of the wonderful support for research and education being carried out in his name, he will touch thousands more around the world. In the same issue Sarver Heart Center reported establishment of the Steven M. Gootter Endowed Chair for the Prevention and Treatment of Sudden Cardiac Death and its acceptance by Jil C. Tardiff, M.D., Ph.D., who recently joined the faculty as a professor in the Department of Medicine, Section of Cardiology, and the Department of Cellular and Molecular Medicine in the UofA College of Medicine, and the BIO5 Institute.

Sethis honored as philanthropists

UAHN Board resumes CEO search


In a move designed to quickly establish permanent leadership for the The University of Arizona Health Network, the new 17-member board of directors met May 24 and named Steven W. Lynn, recently retired from UniSource Energy and TEP, as interim board chairman, the organization reported June 1. The new board voted to immediately resume the search for a permanent chief executive officer. The networks CEO search was suspended last spring while the Governors Arizona Medical Education Oversight Task Force worked with the UAHN Board to reorganize the board governance structure. To facilitate a smooth transition to a permanent CEO, the board voted to transfer the responsibilities of the current Interim President and CEO Jodi Mansfield to Steve Goldschmid, M.D., dean of the College of MedicineTucson, and to Karen Mlawsky, CEO of The University of Arizona Medical Center. They will jointly manage the Health Network until a permanent CEO is hired. Mansfield has served as the interim president and CEO of the Health Network since August 2011. We want to thank Jodi for her service to the organization, Lynn said. Over the past nine months, Jodi has helped position UAHN for future successes. She has played an integral role in advancing key initiatives and helping with the formation of this new board. Thanks to her efforts, we are now ready to take the next step and resume our search for a permanent CEO. Mansfield will continue to assist the organization as a management consultant for the duration of her contract, he said.
SOMBRERO June/July 2012

Congratulations to Dr. Gulshan and Neelam Sethi, writes The University of Arizona College of Medicines Spring issue of Sarver Heart Center, who were honored as recipients of the Steven M. Gootter Foundation Philanthropic Award at the 2012 Gootter Grand Slam. The Sethis have been married 41 years and have made a wonderful mark in Tucson through numerous philanthropic endeavors, including Angel Charity for Children, the Tucson Childrens Museum, the University of Arizona and its Arizona Center for Integrative Medicine, and as benefactors of the Fox Theatre, where they produce the popular Bollywood at the Fox and BollyKids events.
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PCMS 2012 meetings


Our coming 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. Coming PCMS Board of Directors and Executive Committee (officers only) meetings are: BOARD: Tues. Aug. 28, 6:30 p.m. Mon. Sept. 24, 6:30 p.m. (Yom Kippur starts Sept. 25) Tues. Oct. 23, 6:30 p.m. Tues. Dec. 11, 6:30 p.m. EXECS: Tues. Aug. 28, 5:30 p.m. Mon. Sept. 24, 5:30 p.m. Tues. Oct. 23, 5:30 p.m. Tues. Nov. 13, 5:30 p.m. Tues. Dec. 11, 5:30 p.m.

Three honored for medical education commitment

May monthly report


Referrals to physicians: 192 Meeting rooms occupied: 21.8 percent (8 a.m.-10 p.m., seven days per week) Executive Committee: PCMS President Alan Rogers MD presided May 22, 5:425-6:24 p.m. As usual, the officers went over the financials and issues for the board meeting that follows. Special attention was given to two resolutions that had not gone through the first read process. The execs also examined the hospital reporting system known as Leapfrog, and a pilot-program effort to reduce opioid ED and hospital admissions as well as deaths. Board of Directors: PCMS President Alan Rogers presided May 22, 6:32-8:44 p.m. Although ArMA bylaws have made the PCMS delegation so small that few PCMS Board members can attend the annual meeting, the board takes the resolutions sent to ArMA very seriouslyand a much longer than normal meeting in May was the result. The board rejected term limits for AMA delegates and for ArMA committee chairs and members. It passed, with considerable debate and many no votes, a resolution on gun control and a resolution on changing ArMAs stance on the intrusion issues surrounding abortion legislation. Hassles to practice and licensing were the main issues, however, and after discussion many resolutions were forwarded to the ArMA Annual Meeting. Tree trim bids were accepted and a questionnaire to candidates was approved with changes. The Board of Mediation, Chairman Edward Schwager MD, did not meet in May, although a complaint was received during the month.
SOMBRERO June/July 2012

L-R: Drs. Corrign, Fulginiti, Phibbs (Stuart Faxon photo). Doctors James J. Corrigan, Vincent A. Fulginiti, and Brendan P. Phibbs were recognized with awards May 8 by Pima County Medical Foundation for their exemplary lifetime achievements in furtherance of medical education. Dr.Corrigan, 1988 PCMS President, was the first pediatric hematologist at the UofA College of Medicine. He is Professor Emeritus of Pediatrics at Tulane University and Clinical Professor of Pediatrics at the University of Arizona. He continues to conduct resident rounds frequently at TMC and the UofA HSC. Dr. Fulginiti, founding chairman of the Department of Pediatrics at the UofA, is Chancellor and Professor Emeritus of University of Colorado Health Sciences Center, and Professor and Pediatrics Department Head Emeritus at the UofA HSC. Dr. Phibbs, 95, is a World War II veteran and author, and even though he has retired twice, is a volunteer faculty member and Professor of Clinical Medicine at the UofA Medical CenterSouth Campus. He was Chief of Cardiology and Chief of Medicine at Kino Community Hospital for 30 years, from the time it opened in 1977

Public Health Committee: Chairman Jane Orient MD presided May 7, 12:17 -1:17 p.m. Just as highway deaths have plunged to the lowest rate since 1921, a new study by the Pima County Health Department shows that opioid overdoses are leading the way in many age groups in terms of ED visits, hospitalizations, and deaths. A new task force is being proposed and the committee will study the statistics to determine if it will ask the PCMS Board of Directors to take a leadership position on this issue. The committee learned why the norovirus outbreak was so widespread this past winter: it was confounded by C. diff incidence. Assumptions were made that the disease was one or the other, and often patients were transferred without any record of diarrhea in one facility or the other.
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The Bioethics Committee, Chairman David Jaskar MD, did not meet in May. History Committee: Chairman James Klein MD presided May 8, 5:15 5:59 p.m. A packed history committee met and recapped the April 28 tour, with insights about what was seen added during the meeting. The PCMS History Tour of Cochise County, originally scheduled for April 14 (canceled because of rain) definitely will be rescheduled. Plans were made to show a history of the polio vaccine film Sept. 11. The committee will review for possible showing to students and residents as well as the general membership. Pima County Medical Foundation, Inc.: President James Klein MD, presided May 21. No details on the meeting were available at press time. The foundation presented its Evening Speaker Series May 8, featuring medical education awards to doctors Fulginiti, Corrigan, and Phibbs. The large audience was informed and entertained by Dr. Galgianis presentation on cocci. The next Regular Membership Meeting will be Nov. 13. Odds & Ends: John Clymer MD was the emergency replacement for the Walk with a Doc May 12. Tyna Callahan once again preformed yeoman service signing people in and PCMS Alliance President Kynn Escalante joined the walk. United Healthcare came to PCMS in the form of the local, state and regional medical directors May 11. PCMS continued its liaison work on various boards, advisory committees, and steering task forces during May. Among these were the Health Information Network of Arizona; JTED Nursing Advisory Group; Activate Tucson; Andy Nichols Initiative; the Governor Substance Abuse Reduction group; and the Tucson Poverty Commission. More than 50 physicians and/or their staff attended Do EHRs Increase Liability? at PCMS May 24. Kenneth Adler MD was part of the panel. The joint psychology/psychiatry library that has been housed at PCMS for five years ago was removed May 23. The Internet and online journals did away with the need. Richard Carmona MD served as master of ceremonies at an event where awards named after three long-time PCMS members were given. Former Uof A College of Medicine Dean James Dalen MD received the Herbert K. Abrams Award for his lifetime commitment to public health and social justice; Donald Smith MD received the Augusto Ortiz MD Award for work with the under-served; and Barbara Warren MD, MPH was given the Andrew W. Nichols MD Award for carrying on the work and vision of Dr. Nichols. Sadly, PCMS attended three funerals in May. n
Dr. Bruce Lynn talks about sun safety and exercise just before leading a onemile Just Walk June 9. If youd like to volunteer, PCMS walks on the second Saturday monthly, starting at 7 a.m. in summer (Steve Nash photo). SOMBRERO June/July 2012 Dr. Michael Smith, Dr. Wayne Peate and daughter, Sombrero editor Stuart Faxon, and Dr. Richard Dale in the Society parking lot four minutes before Venus started its transit across the face of the sun at 3:08 p.m. June 5 (Steve Nash photo).

Robert Hastings M.D., Ann Hastings at scope, Richard Dale, M.D., Wayne Peate M.D., Mary Lou Iserson, Mike Smith M.D., and Ken Iserson M.D. at the PCMS Venus Transit viewing June 5 (Steve Nash photo).

Just Walk

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Another strong ArMA meet for PCMS


Report and photo by Steve Nash
Despite several contentious issuesthe types that divide American societythe tenor of the 2012 meeting of the Arizona Medical Association Annual Meeting in Phoenix June 1 & 2 was civil and respectful. Delegates worked on issues like gun control and abortion in a spirit that did not compromise core beliefs, but allowed discussion to progress toward workable solutions. Pima County had another strong meeting. Tucson family practitioners Thomas Rothe MD and Michael Hamant MD were, respectively, voted ArMA president-elect and secretary. Thomas Hicks MD was re-elected delegate to the AMA. PCMS also had four of the six reference committee slots filled by its members, including both chairs. Screven Farmer MD chaired reference committee A, and Dr. Timothy Fagan MD served with him on the committee. William Mangold MD chaired reference committee B, joined by Thomas Hicks MD. Fourteen of the 27 resolutions debated by the ArMA House of Delegates originated in Pima County. Several medical society resolutions dealt with hassles facing physicians.

Medicare Advantage Plans that employ physicians for home

visits solely to raise RAF scores, and increase payment, came in for ire. It will now be ArMA policy to fight insurance companies that mandate home visits by physicians who do not have an established physician-patient relationship. license.

Thomas Rothe MD, Timothy Marshall MD, Alan Rogers MD, and Eve Shapiro MD were following the Mike Smith MD summer casual dress rule during break time at the ArMA Annual Meeting June 1 and 2 in Phoenix.

ArMA will oppose efforts to establish a national physician ArMA and AMA will work to require the discharging
physician ordering home health care to sign the face-to-face encounter form. within 24 hours, information adequate for primary care physicians or other specialists involved in the patients care to reassume care for the patient. Trickier were the social questions. ArMA takes no position), was defeated in a close vote. Prior to the vote, however, various compromises were reached based on existing ArMA policy to ensure discussion will take place at the ArMA Legislative Committee. Also defeated was a PCMS resolution calling for term limits for ArMA chairs. But the issue was raised and ArMA officers realized there needs to be more opportunity for physicians to join committees and serve as chairs. ArMA will study two PCMS resolutions regarding the Arizona Medical Board:

ArMA will study requiring discharging physicians to send,

A resolution to re-establish the 1994 assault weapon ban

and keep guns out of the hands of the seriously mentally ill will be studied. During the reference committee, many pointed out the political futility, by both parties, to reinstate the ban. More important, many specialties talked about the archaic language for mentally ill in the existing reporting system. This resolution will be referred to the ArMA Public Health Committee to develop the facts on gun deaths and the correct, modern terms. legislature intrudes into the practice of medicine or tries to criminalize physician actions, even in abortion bills (upon which

A call for an arbitration process for when a physician alleges


misconduct on the part of AMB staff, consultants or members.

A call for an investigation into irregularities, 2005 to present.


The obesity epidemic produced two resolutions that passed. One took direct aim at meals marketed to children, and asks both AMA and ArMA to promote voluntary adherence to nutritional standards for those meals.

A resolution to allow ArMA to take positions when the state

SOMBRERO June/July 2012

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The second ask ArMA to encourage Arizona physicians to review and assess patient activity levels, and where appropriate, write prescriptions for exercise and make referrals. Two of the resolutions were from Pima County in 2011. Studied by ArMA officers and committees throughout 2011-2012, they were recommended for passage at the 2012 House of Delegates. The delegates agreed and made them ArMA policy:

ArMA will oppose insurance or PBM policies that mandate

maintenance medications be mailed, be restricted to a onemonth supply at a local pharmacy, impose financial penalties for patient choice of a three-month supply at a local pharmacy rather than by mail, or mandate only a 30- or 90-day supply will be covered. Its 111 out there today, said the resolution author Timothy Fagan MD, d oes anyone really want to argue some medications shouldnt cook in mailboxes? the Arizona Medical Board to mandate that physicians be board-certified, maintain board certification, or participate in maintenance of licensure activities as a condition for obtaining an Arizona license to practice medicine. This final policy combined two PCMS resolutions into one statement. Other resolutions from Arizona physicians that passed include eliminating the patient limits and lengthy certification process for physicians using buprenorphine to treat opioid dependence; prohibiting indoor tanning by those under age 18; pharmacist medication substitution for only financial reasons; a call for elimination of barriers for legitimate cannabis research; opposition to higher malpractice limit minimums for employed physicians; and a change to the ArMA policy on insurance mandates. Bill Thrift MD, a family practitioner from Yavapai County, became ArMA president. Ironically, he and Mike Hamant MD met on the train on the way to medical school years ago. Attending the meeting from Tucson were Alan Rogers MD (who chaired the PCMS delegation), Jane Orient MD and Timothy Marshall MD; Eve Shapiro MD, serving as an at-large delegate; Timothy Fagan MD and Screven Farmer MD, Pima Directors; William Mangold MD, Thomas Hicks MD, Gary Figge MD, from the Arizona AMA delegation; Thomas Rothe MD, Michael Hamant MD, and Ana Maria Lopez MD, from the ArMA Board. The PCMS caucus was joined by Marc Leib MD, ArMA pastpresident and current chief medical officer at AHCCCS, and Anita Murko MD, representing the American College of Physicians, Arizona Chapter. n

ArMA will oppose any efforts by the Arizona Legislature or

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Can you car it around the globe? Sure, but know what youre doing
Have you ever wanted to take a trip around the world? The easiest way is to fly. It costs about $2,000 to travel from Los Angles to London to Madrid to Bangkok and back to L.A. For about $5,000 the standard RWT (Round the World Ticket) gives you many more stops. Of course that doesnt include any time or costs between flights. How about driving around the globe? Pablo Rey from Spain has taken 12 years to do it and has written four books about Dr. Hal Tretbar his adventures. Since 2007 Aussies Neil and Helen Cocks have done it in several stages and documented it on a large map on the side of their vehicle. Recently I visited Overland Expo 2012, given at Mormon Lake Lodge near Flagstaff. Expos goal is to inspire people to get out

Pablo Rey with his latest book and his reliable 1991 Mitsubishi 4x4 diesel Minibus.

and explore the world, by motorcycle or four-wheel drive, whether 100 miles or 10,000 miles from home. Tucsonans Roseann and Jonathan Hanson own and operate the Expo, sponsored by manufacturers of travel vehicles, overlanding equipment, and Overland Journal. The main sponsors were Land Rover vehicles and BMW/RawHyde Adventures. An estimated 5,000 people from 30 U.S. states and 20 nations were there over three days, including participants, vendors, and staff. Classes, roundtables and movies spiked their interest in traveling off the usual routes. One of the classes was Reluctant Overlanders, including how to get your partner to go with you. There was an important seminar on dealing with borders, checkpoints, and bribes. Manufacturer displays varied from SUV roof-top tents to huge expedition vehicles. For several hundred thousand dollars you can go with all of the comforts of home. Global Expedition Vehicles has the Pangea model, set on a 4x4 International truck base. The lift top offers a second story. All amenities are there, from a toilet, shower, and a microwave oven, to marble countertops.

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Mike and Dianna St.Clair from Lake Forest, Orange County, Calif. travel with their two dogs in a 4x4 camper-back pickup pulling a Jeep. They like to be self- contained and avoid campgrounds. They were looking to replace their car top tent that was very cold when they were in Alaska in October. When Pablo Rey and his wife Anna Callau left Barcelona, Spain for their worldwide jaunt 12 years ago, they used a small, sturdy vehicle. They are still finding their adventures in the same 1991 4x4 Mitsubishi L300 diesel minibus. Pablo, 45, has been in advertising and travel writing for more than 20 years. He
SOMBRERO June/July 2012

14

says that he has a special ability to get into troubleand find a way out. When Pablo and Anna went to Africa, the first two months were quite eventful. They had two breakdowns. The first was in the deep sands of the Sudanese Sahara. The second was beside Lake Turkana in Kenya, 500 miles from the nearest mechanic. This was followed by two robberies, a crash, and a runaway from transit police in Addis Ababa. Later they were accosted by armed men on a motorcycle who wanted payment for a cow they said was killed. Pablo was a little upset when an angry soldier threatened him with a Kalashnikov. Another time he and Anna were encircled on a deserted road by 30 drugged men dressed in loincloths. Somehow they were able to escape their demands for money. They were able to drive their minibus, La Cucaracha Libre, through every country in South America. A major problem developed while traversing Bolivias high, desiccated Atacama Desert. The engine had to be rebuilt twice there, and was eventually replaced in Chile after 70 days of frustration. This episode and many other escapades are vividly described in his books. What if you decide to drive around the world on the spur of the moment? You can ask Joe McManus and Lara Soderstrom from Los Angeles how they did it last year. Joe was musing about how much gas would cost if he could drive his Toyota Prius around the world. He took a ruler and roughly wrapped it around a globe to start his calculations. World-traveler friends suggested that there were better ways to go if Joe and Lara were really interestedand so the adventure began. After some map studying they decided to name the trip, East to the Pacific! Joe had to finish roofing their house while Lara arranged for visas they would need in Russia and China. It took about one month before they had it all together and on May 13, 2011, they started driving to the East Coast. Joe had used eBay UK to find a car in London for their expedition. He bought a 1991 Peugeot 405 diesel station wagon for 155 pounds ($245). They blew out the cement dust from the last construction project and after driving around England for a month they decided the car was in better shape than its nearly 200,000 miles would suggest. They fitted out the wagon to be as self-sustaining as possible. Because Lara had never been a camper, she felt completely out of her element when sleeping in the back of a car. She made a deal with Joe that in order to say yes to this hairbrained scheme, they would stay in a hotel every third of fourth night. Lara and Joe headed to Spain to take part in an off-road motorcycle race. Coming back through France they had the only breakdown on their entire drive around the world. In the village of Laon the transmission gave out. What they found out there held
SOMBRERO June/July 2012 Aussies Helen and Neil Cooks with their map before they head to Alaska.

true for the rest of the trip: There is a worldwide spirit of helpfulness. While the local mechanic fixed the transmission, the hotel keeper and a family rallied around to put them up and wine and dine them. As Joe said, What better place for our first and only mechanical problem! Then it was time to move on from France to Belgium, and Holland. They have fond memories of camping by the Rhine River where a Dutch lady took them under her wing. Joe and Lara awoke to find a breakfast basket on the roof with hot coffee, breads, meats, and cheeses served with cutlery, crockery and cloth napkins.

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There were no problems traveling through Germany, Poland, and on to Ukraine. From there the sturdy Peugeot took over the rough roads and across Russias nine time zones. One of their favorite memories is from Siberia. They had stopped at Lake Baikal, the largest and deepest freshwater lake in the world. Here they were adopted by a Russian father and son who took them to Arshan, a small hot- springs town near the Mongolian border. Joe recalls, It was just like an old Wild West town where everyone rode horses and there were no cars. At last Joe and Lara fulfilled their dream of Going East to the Pacific when they reached Vladivostok. There, was a quandary. They couldnt drive into China and they were not allowed to sell their faithful Peugeot in Russia. Finally Joe took the car to a large parking lot and carefully indicated the car was for sale. Shortly a Korean man slipped him 2,000 rubles ($60) and arranged for tickets to China. The last stops on their adventure around the world were in Hong Kong and Seoul, Korea. They returned to Los Angeles in September 2011. It had taken them about six months to plan and circumnavigate the earth. When I asked them about memories of their adventures, Lara said, I was afraid something bad would happen to us, but now I just remember how friendly all the people were. Joe pondered for a moment and said, We drove 7,500 miles going east in the Prius and over 12,000 miles with the Peugeot. n I still dont know how much all the fuel cost.

On their travels, Joe McManus and Lara Soderstrom found that there is a worldwide spirit of helpfulness.

16

SOMBRERO June/July 2012



SOMBRERO 17 June/July 2012

Makols Call

Historys lessons are todays


Today far too many Americans are woefully unaware of their own nations history, despite that ours is a rich history and far more fascinating than fiction. My family has only been here for 110 years, and I am amazed at how much history there is to learn and appreciate. Its also more interesting than whom Katie Perry is currently dating and other such trivia, though many in todays celebrityDr. George J. Makol infatuated populace would be able to provide far more detail on celebs than on our history. Yet our history relates to us all. Washington and his men then spent the winter of 1777-78 at Valley Forge, where his men were being devastated by disease. They faced hunger, dysentery, exposure, and worst of all, the dreaded disease smallpox. Martha Washington, who frequently visited her husband at Valley Forge, had heard that even 50 years earlier, inoculation of pus from active smallpox sites into uninfected individuals could protect those persons from acquiring smallpox. Washington had his surgeons take pus from those with active smallpox wounds with a sharp knife and cut the skin of his recruits, placing the pus in the cuts. Although some became briefly ill, most became immune and only one in 50 succumbed to smallpox. Baron Von Steuben, a storied Prussian soldier, helped Washington train his troops, and Lafayette and the French joined Washington after that winter, a turning point in the war. Washington and his men went on two seasons later to victory at the battle of Yorktown.

Of course, inoculation is different than vaccination, which was being developed at the same time in England by Edward Jenner. Legend has it that the handsome Jenner, living near the English coast, had been a womanizer, as the opportunity existed due to We are doctors. But for a medical intervention in winter 1777-78 the popularity of the area as a vacation spot. He noticed that at Valley Forge, we might all today be city girls were more likely to have smallpox speaking with a British accent. Gen. scars on their bodies, whereas country George Washingtons troops had just been ou cant tell me that girls had less severe scarring, only on their defeated at the battles of Brandywine and watching a reality star shop, hands. A less exciting version of the story is Germantown, and the War for that local lore had it that farm girls who or a bunch of bored rich Independence was not going well. milked cows did not seem to get smallpox. housewives gossip, is Today we know that is because they were I was in Pennsylvania, Delaware and as interesting as history. exposed to cowpox virus, a much less Washington, D.C. about five years ago serious malady. Jenner went on to directly visiting historic sights including the White inject cowpox into an eight-year-old child, and later exposed the House and the U.S. Treasury, and Revolutionary War and Civil child to smallpox, which did not cause disease in this child. War battlesites. Brandywine Creek is in Delaware near Chads Ford, and runs through Pennsylvania and Northern Delaware. Well, so what if lots of us, including me, were not until recently This is where Washington made a stand against the troops of aware of such bits of history? So what if many folks do not even British Gen. William Howe, aided by the experienced French understand why the colonists were willing to fight and die to get general, the Marquis de Lafayette (1757-1834). out from under King George III? After all, we now do not have a

Today Brandywine is a small creek, easily crossed by just getting your feet wet, but back then it was a river that had to be forded at only certain spots. Washington was sure that Howe would not march his heavily equipped British troops seven-and-a-half miles up the creek to the nearest fording spot, but Howe did, and the British managed to come up behind Washingtons troops and attack their left flank. Washington was forced to retreat, and Philadelphia was subsequently lost.

king, we have a representative democracy. But were taking it for granted. Our freedoms and capitalism have allowed prosperity unheard of anywhere else in the world. Our poor have color TVs, air conditioning, cell phones, food stamps, free healthcare. Take a look at the poor in Africa or South America if you want to see the poor. I have seen people in Colombia living in empty Jack

18

SOMBRERO June/July 2012

Daniels crates, and recently a few blocks from grand apartment buildings in Buenos Aires I walked past brick shanties with no electricity or running water. You cant tell me that watching a reality star shop, or watching a bunch of bored rich housewives gossip is as interesting as history; in fact there is no reality in reality TV. Instead of scriptwriters are producers who set up artificial situations. But there is wealth-envy being taught, and I am not surprised that our politicians are taking advantage of this. Who cares if you tax to death a bunch of brain-dead basketball wives? But do these people really represent what rich Americans stand for? Maybe the one percent do have more money than they need. Bless them. Recently Elon Musk of PayPal, Mark Zuckerberg of Facebook, Broadcom co-founder Henry Samueli, Arthur Blank of Home Depot, Bill and Karen Ackman of Pershing Square Capital Management, and many more billionaire families have joined Bill Gates and Warren Buffett in pledging most if not all of their wealth to charity. But now people who do not know the first thing about America and its history want to redistribute the wealth through government, subject to the petty needs of politicians foaming at

the mouth to be re-elected, filtered through layers of bureaucrats, and taking maybe 90 cents on the dollar before delivering anything to the needy. Goodbye prosperity, hello Greece. Under the Keynesian economics practiced for the last seven years we have more poor people than ever, and the largest ever number of Americans on unemployment insurance, food stamps, and welfare. I never saw poverty like this in the 1990s after the Reagan revolution. The Nobel Prize-winning Austrian economist Friedrich Hayek was right, as was his teacher, Ludwig von Mises, author of The Theory of Money and Credit (1912). John Maynard Keynes was dead wrong. Government cannot spend its way to prosperous times, as our once comrades-in-arms the French seemed to re-proclaim in their recent election of socialist Francois Hollande as president and rejection of Nicolas Sarkozy. I just pray that our electorate figures this out before its too late. George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd. He has been a PCMS member since 1980. Makols Call will be a regular Sombrero feature. n

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In Memoriam

Dr. Arnold I. Hollander, 1936-2012


By Stuart Faxon

Dr. Arnold I. Hollander, longtime Tucson internal medicine physician, educator, and PCMS member since 1970, died May 23 in Tucson. He was 75. Arnie was a longtime Maimonides Society member and supporter, and physician extraordinaire, said Marlyne J. Freedman, senior vice-president of the philanthro pic Jewish Federation of Southern Arizona. May his memory be for a blessing. Arnold Israel Hollander was born Nov. 11, 1936 in Clinton, Mass. He grew up in Easton, Pa., where he earned his bachelors degree from Lafayette College. He earned his M.D. in 1962 at The Jefferson Medical College of Philadelphia. He interned at William Beaumont General Hospital (now William Beaumont Army Medical Center) in El Paso, Texas. He did his IM residency at U.S. Army Tripler General Hospital, Honolulu, Hawaii. He was ABIM-certified.
Dr. Arnold I. Hollander in 1984.

from the eligible database. In 2004 through 2006 he served on our Board of Mediation, and again in 2007 through 2009. Arnolds passion in life was helping others and caring for his patients, the family reported. He volunteered his time with the Tucson Jewish Community Center, St. Elizabeth of Hungary Clinic [now St. Elizabeths Health Center], Carondelet St. Josephs Hospital, and El Dorado Hospital. Arnold enjoyed many hobbies, sports, and travel, and was an avid birdwatcher and poker player. He had many friends and a large family including six grandchildren who will remember him for his kindness, generosity, and zest for life. Dr. Hollanders wife, Carol; sons David, Robert and Todd; daughter Suzie; and six grandchildren survive him. Memorial services were on May 25 at the Jewish Community Center where a standing-room only crowd attended. Condolences may be expressed to the family in care of Carol n Hollander, 7545 Sabino Vista Drive, Tucson 85715.

While at medical school, the family told the Arizona Daily Star, he met the love of his life, Carol Berger, whom he married in 1961, and together they shared a wonderful life of more than 50 years. Dr. Hollander served as a U.S. Army physician, reaching the rank of Major, including service in Vietnam where he was awarded the Bronze Star, among other commendations, the family reported. Arnold moved his family to Tucson in 1969, the family reported. He opened his medical practice at Wilshire Medical Center on South Craycroft Road and specialized in internal medicine for the next 40 years, helping and caring for thousands of patients. He also taught at the University of Arizona College of Medicine and taught interns and residents at Tucson Medical Center. He served as a team physician for the Arizona Wildcats and volunteered at the Arizona Athletic Treatment Center. In 1990 Dr. Hollander moved his practice to 1200 N. El Dorado Square. In the late 1990s he served on the Board of Directors of Carondelet St. Josephs Hospital, where he had been on staff since 1969 and chaired the Department of Medicine. In 2004 he was named one of Tucsons Best Doctors in the IM specialty
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21

Carondelet moves Heart & Vascular Institute to St. Marys campus


On April 19, Carondelet Health Network announced that the Carondelet Heart & Vascular Institute will relocate to the campus of St. Marys Hospital in six to nine months. The relocation of the institute to a tertiary campus better positions us for growth of our cardiovascular healthcare. As a result, we are making a sig nificant capital investment to design and construct the in stitutes James K. Beckmann new home at Carondelet St. Marys and to purchase and place the very latest technologies on site to support the institutes work. Carondelet has been a significant provider of healthcare in Tucson and Southern Arizona for more than 132 years. As our healthcare ministry looks forward, we are concentrating on providing increased access to excellent care and meeting the needs of the growing community we serve. The expansion, relocation and investment in our cardiovascular service line are perfect examples of our commitment to that. Carondelet Heart & Vascular Institute has a reputation for premiere patient experiences and superb outcomes, and we are prioritizing that continuity of care as a major element in this relocation. For patients, the advantages are dramatic. Relocating the institute to the campus of an acute care medical center with a full complement of medical specialties ensures the highest quality of care for our patients who may face a variety of health needs. The institutes close proximity to I-10 and I-19 is another plus. It allows more immediate access for patients to Carondelets nationally recognized cardiac care, cardiothoracic surgery and vascular surgery programs. We believe this relocation will provide additional conveniences for populations in communities such as Green Valley, Sahuarita, Rio Rico, Nogales, and Marana

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who seek our institutes highly reliable, holistic, comprehensive cardiovascular care. There is significant physical work already underway. This involves creation of a dedicated CV ICU; redesign and renovation of private patient rooms; upgrading of telemetry units and cath labs; and construction of the most technologically advanced hybrid operating suites available today. Additionally, cath labs at Carondelet St. Josephs Hospital will be upgraded to support the cardiac services Carondelet offers on the east side of the city. While this work is underway at both St. Marys and St. Josephs, the institutes River & Stone facility will continue operating at full strength. Our future plans for that location are to be determined. We have a comprehensive transition plan involving the institutes associates. The majority of the cardiovascular care team members will move with the program at the time of its transition; others are being identified for positions within Carondelet in which their skill sets meet a significant need, or which work more appropriately into their career interests or personal preferences, such as working in a location closer to home. The networks geographic footprintwith hospitals east, west, and south; 23 primary and specialty care practices; and outpatient surgery and ambulatory careallows for this flexibility. Addition of the Carondelet Heart & Vascular Institute to the St. Marys campus integrates two strong teams: an institute that provides the community with modern, minimally-invasive solutions to cardiac surgery, and a multi-specialty medical center recognized nationally for its clinical excellence. Both this year and last, St. Marys has been designated as a HealthGrades Distinguished Hospital for Clinical Excellence. It is also the recipient of the 2012 American Heart Association/ American Stroke Associations Get with the Guidelines Gold Plus Quality Achievement Award for Stroke Care and Gold Quality Achievement Award for Heart Failure, as well as the Midas+ Platinum Quality Award. Carondelet St. Marys provides this region with access to some of the most advanced and most compassionate care available in orthopedics, oncology, diabetes, stroke, cardiac care, wound care, emergency medicine and physical rehabilitation. Visually, the campus is undergoing a renaissance. People have recognized the facility for decades by the eight-story white tower, built in the early 1950s. But by midsummer 2012, the entire hospital, including
SOMBRERO June/July 2012

that tower, will look dramatically different as the campus undergoes a $2 million exterior facelift. This renovation will create a modern look and cohesiveness between what the public sees on the outside and what patients experience inside. We invite you to become more closely acquainted with the tremendous work being done throughout Carondelet Health Network, on the campus of Carondelet St. Marys Hospital, and within our Heart & Vascular Institute. You will see that Carondelet is moving forward, revitalized and energized. In the spirit of our founders, the Sisters of St. Joseph of Carondelet, we have a mission to fulfill and a century-old legacy to continue. James K. Beckmann is president and CEO of Carondelet Health Network. n

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Stopping chemo
By the PCMS Bioethics Committee
I wanted to make my parents happy. There is only one thing shittier than biting it from cancer when youre 16, and thats having a kid who bites it from cancer. Hazel Grace Lancaster, 16, protagonist in the John Green novel, The Fault in Our Stars. The young patient, however, is quiet. When prodded, Mary quietly says, I really do not want any more medicines that make me sick. She finds the treatment side effects to be unbearable. Ive been sick for two years, she says, and I just dont want to face the side-effects anymore. Her parents lovingly try to convince Mary to change her thinking and agree with them to try the new regimen. She is adamant: no more treatments that make her sick. Marys parents look at one another, come to silent agreement, and turn to the doctor. Enough of this nonsense, the father says, When can we start? The oncologist gathers thoughts. Normally Mary, dependent as she is on her family for care and finance, lacks the legal right to make the decision, and her parents wishes would carry the day. But Mary has spent two years in treatment. She knows and dreads the side- effects. She seems to understand that forgoing treatment will hasten her death. Mary has made a rational decision in the face of awful choices. Or has she? Depression, as with insanity and some organic disease, can overwhelm our rational thinking and cause us to make choices or take actions we normally would not. Given her condition, however, should Mary see a psychiatrist? If the psychiatrist confirms depression, does depression necessarily mean she made a less than rational decision? Wouldnt depression be normal in a similar situation? If the psychiatrist recommends a different blend of SSRIs, they take time to have effect. If Marys depression recedes in three to five weeks, is there still time to begin the new regimen if she changes her mind? In the meantime, the oncologist has no experience with forcing treatments on patients and doesnt want to begin with restraining Mary and forcing her to undergo the new regimen.
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A mother, father, and daughter pay another visit to the cancer clinic. They know the sign-in routine by heart. The daughter, Mary, 17, has a hematologic malignancy of two years duration. She has been treated with courses of various chemo regimens with only partial or short remissions gained. She has again failed her current regimen and her disease is active and her prognosis at this point is less then three months. Mary has been depressed in the past and even took SSRIs for a short time, without apparent benefit. Her oncologist offers a new regimen that is predictably very toxic, but which may gain her up to several months of life. The patients mother and dad readily agree that starting this new regimen is the only way to go.

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SOMBRERO June/July 2012

Beneficence requires a physician to act in the best interest of the patient. Most scholars define the term as a duty to be of benefit and take positive steps to prevent and remove harm. Some, however, argue that healing is the sole purpose of medicine, its only core principle, and that, citing Hippocrates, physicians themselves must do no harm to the patient. If this were the only principle involved, this case would, theoretically, be complicated: forced treatments vs. extra months of life, side effects vs. worsening condition. But what it really comes down to is, who decides what is in the best interest of this patient? We believe Mary decides. Although Mary is not legally able to make this decision we believe she can, and must. Respecting Marys decision serves the paramount bioethical principle of autonomy. She has lived with this disease, suffered with it. She knows side- effects and understands she is going to die, sooner if she does not accept the new regimen. Any observer can understand a person wishing to enjoy their final months without those effects. Mary may not have the legal right to make such a decision, but ethically she has that right. From a practical standpoint, things are not over. The parents are having a hard time letting go. If this were a hospital setting, there would be many resources to aid the parents, from clergy to social workers. A bioethics consult could be obtained. The oncologist, in an outpatient private practice, is on his/her own. Experience, however, is an aid. The oncologist has probably seen this type of situation before and, if so, can speak about relationships being ruined when treatment vs. non-treatment ends in a stalemate. Perhaps the oncologist knows how to speak with desperate parents, but if there are magic words, we dont know them. Sometimes pointing parents in a direction they can control will help. Suggesting that family (siblings, grandparents, cousins, etc.) meet to discuss this may lead to discussion of what is ahead and what the quality of life is for this 17-year-old girl. Maybe this can help the family find the best way to have loving time, for whatever months/ weeks she has left, that will give them all a sense of enjoyment and somecontrol over her life.Since the end appears inevitable anyway, they would not want to turn the relationship into a contest at this point.
SOMBRERO June/July 2012

Although the oncologist has seen Mary and her parents for two years, does he or she really know them? Do they have a trusted pediatrician or family physician who knows them better, understands the family dynamic? If so, the oncologist could offer to call that physician with the current situation and an appointment can be made. There may be dozens of influential people in this familys life that the primary physician either knows or suspects exist. Are the parents depressed? Are they over-controlling? Are they at a loss as to how to cope? Depending on the answer(s), appropriate referrals can be made to mental health professionals and/or grief, end-of-life counselors, or the familys clergy. Finally, it is as important for families as it is for physicians to come to a point of acceptance. If it is not quite letting go, it is a special time for doing things, saying things, which celebrate her life while Mary is still with them. We wish we had more to offer. Several years ago, PCMS tried to set up the Bioethics Committee to advise individual private practice physicians in these situations, but insurance protection proved to be prohibitive. The PCMS Bioethics Committee is David Jaskar, M.D.; David Siegel, M.D.; Dale Johnson; Steven Ketchel, M.D.; Cynthia Miley, M.D.; Neil West, M.D.; and Kenneth Sandock, M.D. n

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Mayo CME
August
Aug. 3-5: The Mayo Clinic Cardiology Update 2012 is at Enchantment Resort, 525 Boynton Canyon Rd., Sedona 86336; phone 928.282.2900. CME credits to be determined. Contact: Staci King, CME Dept., Mayo Clinic Scottsdale, 13400 E. Shea Blvd.; phone 480.301.4580; fax 480.301.8323. Website: www.mayo.edu/cme

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September
Sept. 15: Mayo Clinic Acute and Chronic Leukemias 2012: A Case-Based Discussion is at Mayo Clinic Education Center, 5777 E. Mayo Blvd., Phoenix 85254; phone 480.301.4580. CME: 7.5 AMA PRA Category 1 credits. American Osteopathic Association (AOA) 7.5 hours of Category 2-A credit. American Academy of Family Physicians (AAFP) credit pending. Contact: Heather Langdon, Mayo School of Continuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. Website: http://www.mayo.edu/cme Sept. 28-29: The Mayo Clinic Symposium on Concussion in Sport is at Mayo Clinic, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580. AMA, AOA, AAFP CME credits to be determined. Contact: Jodi Lee Beert, Mayo School of Continuous Professional Development, mca.cme@mayo.edu; phone 480.301.4580; fax 480.301.8323. Website: www.mayo.edu/cme/internal-medicine-and-subspecialties-2012s814.

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SOMBRERO June/July 2012


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SOMBRERO June/July 2012