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Home Medical Society of the 17th United States Surgeon-General

P i m a C o u n t y M e d i c a l S o c i e t y J a n u a r y 2 012

Meet our new president

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As a part of our continued effort to offer the members of the Pima County Medical Society more value, we are proud to announce our partnership with Medusind Solutions, a leading healthcare business solutions provider. Medusind engages more than 1,000 professionals to serve the needs of more than 20,000 physicians every day to handle end-toend revenue cycle management (RCM) services, including medical coding, healthcare billing, medical transcription, coding documentation and coding analytics. If you are interested in learning more about Medusinds services, please let us know.

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2 SOMBRERO January 2012

Official Publication of the Pima County Medical Society

Vol. 45 No. 1

Pima County Medical Society Ofcers

President Alan K. Rogers, MD President-Elect Charles Katzenberg, MD Vice-President Timothy Marshall, MD Secretary-Treasurer John Curtiss, MD Past-President Timothy C. Fagan, MD

PCMS Board of Directors

Diana V. Benenati, MD R. Mark Blew, MD Editor Stuart Faxon Phone: 883-0408 E-mail: Advertising Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail:

Neil Clements, MD Michael Connolly, DO Bruce Coull, MD (UA College of Medicine) 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 Guruprassad Raju, MD Scott Weiss, MD Victor Sanders, MD (resident)

Members at Large
Kenneth Sandock, MD Richard Dale, MD

Thomas Rothe, MD, vice-president 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, past president

Art Director Alene Randklev, Commercial Printers, Inc. Phone: 623-4775 Fax: 622-8321 E-mail: Printing Commercial Printers, Inc., Andy Charles Phone: 623-4775 E-mail:

Publisher Pima County Medical Society Steve Nash, Executive Director 5199 E. Farness Drive, Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 E-MAIL: Website:
SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/ September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson,

Arizona. 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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Vice President


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6 Presidents Page 9 PCMS News

Help Dr. Alan Rogers help you! Our election results; using social media in your practice. A special memoir by the late Dr. Bud Simons. Dr. Mike Smith on touching others through passion for nature.

Membership .................................. 8 PCMS Alliance News .................... 22 Conferences & Seminars ............... 26 Members Classieds .................... 26

Home Medical Society of the 17th United States Surgeon-General

P i m a C o u n t y M e d i c a l S o c i e t y J a n u a r y 2 012

14 Time Capsule

Meet our new president

23 Reality Check 24 Perspective

Dr. Michael Hamant takes on Dr. George Makol from the Left.

On the Cover
Dr. Alan K. Rogers is 2012 PCMS president (Photo courtesy himself ).

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SOMBRERO January 2012

PResIDents pAGe

Help me help you!

Tom Cruises Jerry McGuire character screams, Help me help you! at a difcult client in a famous movie scene. So I am shouting the same thing to you as Pima County medical providersdont be difcult! Physicians must be active in organized medicine or suffer the consequences! It is not O.K. to sit out and watch the dramatic changes occurring in medicine from the sidelines. Dr. Alan K. Rogers Our nation is in debate over provision of healthcare. Rationing of scarce medical resources, healthcare nancing in difcult economic times, dealing with inadequate numbers of providers for burgeoning numbers of patients, potentially compounded by national health insurance coverage, are just some of the issues. Physician training has lagged behind demand. Cost and lifestyle considerations drive med students to high-income sub-specialties. Now comes Walmart with a war plan to take over the relatively healthy primary care ofce visit market. Do you think Walmart intends to take care of the sickest and most difcult patients? As a provider you must take a position on this issue. The list goes on and on. Doctors are becoming divided and less effective in inuencing the debate. Physicians are being split into ofce-based, hospital- based, academics, and specialists, all of whom seldom meet. I am a stranger from most of the hospitalists who care for my patients during their sickest moments. Gone are the days of hanging out with colleagues in the doctors lounge to discuss the politics of medicine on a rst-name basis. No wonder it is difcult to get physicians to have a common voice in the issues facing us. And yet its no secret that membership in organized medicine has been declining, just when it is most needed. What can you do to help? Or better, how can you help us help you? Before I propose some answers, I charge you with the duty that you must take action. You must lead, follow, or get out of the way! Ignoring all this is not an option. If nothing else, join the Pima County Medical Society and pay your dues! It takes money to defend medicine at the state legislature. Just give us the resources to continue the ght. Contact legislators and voice your opinion. Be willing to reach consensus. Even among our own membership there is controversy over policy. So express your opinions, listen to others, and then agree on the best course of action. Vote for your PCMS Board of Directors members carefullythey are making decisions for you! Lobby with patients one-on-one in the ofce about medicine and the controversies in healthcare. My patients ask about medical marijuana. Do you really think medical marijuana is a good idea? Well, then tell your patients! Read our communications. Educate yourself on our positions on the issues and proposed legislation, both state and federal. Make

yourself ready for that chance discussion with people that could make a difference. Maybe your patient is a state legislator! Attend social functions and know your colleagues. Yes, even fun social events like the PCMS Stars on the Avenue medicine ball. You need to place a face with that radiologist who calls you with reports! Mentor a student and share a positive attitude about medicine. Medicine is and will always be a great career for bright young people to enter. We just need to promote it. Attend PCMS and ArMA meetings. Steve Nash or I will put you to work. Be Doctor of the Day at the Arizona State Legislature. Membership in your specialty organization is ne, but they dont have the clout or connections with state and local issues as PCMS does. To be effective, we need to say PCMS represents the majority of physicians in Pima County. By not joining, you are undermining our ability to be heard and have inuence. But here is a practical problem: If you are reading Sombrero right now, you are probably already a PCMS member. So get your partners, colleagues, referring physicians and friends to join PCMS and pay their dues. Your colleagues have greatly beneted from the efforts of the PCMS and ArMA whether they know it or not. Many debate the reasons for the decline in medical liability claims and premiums in Arizona, but I directly credit our stepwise efforts at tort reform as the major factor. If you do not understand why majority of evidence vs. predominance of evidence makes a difference in court cases, then you havent been reading our communications! Steve Nash and I have deemed membership as the theme for 2012. I am throwing down the gauntlet and setting a goal of 90 new members. Help us help you and make this goal!

Meet Dr. Rogers

By Stuart Faxon
Everyone seems to be running for president these days, from the glib to the doltish. Even a physician, though hes been in the U.S. House of Representatives for years. Our new president is Dr. Alan Keith Rogers, who cant run for U.S. president because he isnt a natural born citizen, in our Framers phrase. Though he was brought here at age 5 and is a citizen now, he was born in Maricaibo in whats become dictator Hugo Chavezs socialist paradise, Venezuela. That was in 1954, when Dr. Rogers father worked in Venezuela for an oil drilling supply company. He earned his M.D. at Baylor College of Medicine in Houston, and did his IM internship and residency at the University of Arizona College of Medicine and University Medical Center. He joined PCMS as a resident in 1983. He practices with PCMS members E. Luis Aguilar, Norman R. Epstein and Leslie Willingham, with two NPs and one PA, at El Dorado Family and Internal Medicine, 1500 N. Wilmot Rd., No. A110, in front of the former El Dorado Hospital. The practice is part of Arizona Community Physicians.
SOMBRERO January 2012

Dr. and Susan Rogers have been married since 1985. Susan has been active with the PCMS Alliance, served as its president, and received the 1998 Marilyn Haas Award. She is also active with the Parseghian Foundation and served on the planning committee for the TMC Foundation gala in November. Susan is the master of child management, Alan says. Shes great with the kids. The Rogerses have four children, who constitute a kind of healthcare family. Alexander is an R.N. and works for The University of Arizona Health Network at University of Arizona Medical CenterUniversity Campus (most of us are still used to saying UMC). Michelle is a scrub tech at UMC. Stephanie works for Kaiser Permanente in Los Angeles as a project manager. Amy is a senior at the University of Southern California and is involved with Global Medical Brigades, an international volunteer sponsor of medical clinics. In fact, Dr. Rogers has gone on one of Global Medical Brigades missions, and is going on one again this month. He jokes, My rst act as PCMS president will be to leave town. Hell be headed to Honduras to do a lot of pediatrics and all kinds of regular outpatient checks such as for diabetes, colds, and parasites for people who have little or no regular medical care. Dr. Rogers was the rst in his own family to go into medicine, and unlike many physicians, he has never soured on the profession and nds daily joy in it. I found it to be a nice blend of people skills and science, he said, while admitting that people skills are at least as much a continuing continuum as CME. I thank God every day that I went into medicine, he said. The people are so nice. The patients are nice to you, and they appreciate what you do.

If that sounds the Pollyanna, hes knows that, too. I am always the Pollyanna optimist about medicine. Im glad I went into it, and Im glad to see my kids go into it. Its always going to be a great profession. If you go into it solely to make money or for some other reason, youre going to be disappointed. Dr. Rogers has been ahead of the trend in tness and prevention. He has used a personal trainer twice weekly for three years, and he has always been a bicyclist and has participated in El Tour de Tucson. So as you might expect, he endorses the shift into preventive medicine, but as long as its scientically valid. He offers the counter-example of green tea as having no proof that it actually does anything. Dr. Rogers describes himself as a committed Christian and is a member of Catalina Foothills [Presbyterian] Church. Last and certainly not least, he is a testicular cancer survivor. He had surgery for anaplastic seminoma in 1996 plus six weeks of radiation therapy. He downplays its seriousness compared to other cancers, but were certainly glad his treatment was successful anyway!

In order to be an effective organization, PCMS must be able to communicate quickly with its members. We need your e-mail address! I promise we wont abuse it. Tonight when you get home, send an e-mail to steve5199@ No need for a message. But do use the e-mail return address you prefer for communications.


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Established 1971


Our newest members

By Bill Fearneyhough
Please welcome these physicians to the Pima County Medical Society. Physicians need to be heard more than ever, and membership is our strength.

Thomas Boyer, M.D.

Dr. Boyer practices at The University of Arizona Medical CenterUniversity Campus on Campbell Avenue, Tucson. His clinical/research interests include hepatitis treatment; treatment of complication of cirrhosis; diagnosis and management of all forms of liver diseases; mechanisms of liver cell injury; and treatment of viral hepatitis. He graduated from USCs Keck School of Medicine in 1969. He also served his residency and fellowship at USC. Dr. Boyer is certied by the American Board of Internal Medicine and Gastroenterology. His ofce phone is 626.5952.

clinical/research interests include inammatory bowel disease, GI malignancy, and endoscopic therapy for GI disorders. He is a 1980 graduate of Wayne State University, Detroit. He served his IM residency and GE fellowship at University of South Florida College of Medicine, Tampa. Dr. Goldschmid is certied in both Internal Medicine and Gastroenterology. He may be reached at The University of Arizona at 626.0993.

Stephen Goldstein, M.D.

Dr. Goldsteins practice is at UPH Surgery Clinics, UMC. His afliations include the AMA, American Academy of Facial Plastic and Reconstructive Surgery, and the American Academy of OTO-HNS. He is a 1996 graduate of State University of New York (Upstate Medical University). He served his OTO residency at Thomas Jefferson University Hospital, Philadelphia, and a fellowship at Buckhead Facial Plastic Surgery, Atlanta, Ga. He is OTO board certied. His phone number is 626.6673.

Alexander Chiu, M.D.

Dr. Chiu currently practices OTO and Facial Plastics at UMCUPH Surgery Clinics. His afliations include BrianLab Surgical Navigation (National Consultant) and Medtronic ENT (National Consultant). He graduated from medical school at Albany (N.Y.) Medical College in 1997. He served his residency at Georgetown University Hospital, Washington, D.C. and a fellowship at Stanford University Medical Center Palo Alto, Calif. He is certied by the American Board of Otolaryngology. He may be reached at the University of Arizona at 626.6673.

Nicole M. Gullick, M.D.

Dr. Gullick is a 1994 graduate of USCs Keck School of Medicine. Her family practice is at 268 E. River Rd., Suite 130. Her clinical interests include weight loss and aesthetics. Dr. Gullick is certied by the American Board of Family Practice. He ofce phone is 495.0151.

Francisco Moreno, M.D.

Dr. Moreno practices at The University of Arizona Medical CenterUniversity Campus on Campbell Avenue. His clinical/ research interests include biology and treatment of mood and anxiety disorders; improving our understanding of the brain basis for mental illness; and action mechanisms of pharmacological and device-mediated treatment and treatment resistance. His afliations include the American Board of Psychiatry and Neurology and the American Psychiatric Association. He graduated in 1988 from the Autonomous University of Baja California, Mexico. He served his psychiatry residency and fellowship at The University of Arizona. He is ABMS board-certied in psychiatry. You may reach him at 626.5198.

Conrad Clemens, M.D., M.P.H.

Dr. Clemens practices at The University of Arizona Medical CenterUniversity Campus on Campbell Avenue. His afliations include the Council on Medical Student Education in Pediatrics, Ambulatory Pediatric Association, American Academy of Pediatrics and Internal Clinical Epidemiology Network. He graduated from Johns Hopkins University School of Medicine in 1990. He served his pediatric residency Johns Hopkins Hospitals, Baltimore, and a research fellowship at the University of Washington (Seattle) School of Medicine (Medical Genetics). His ofce phone is 626.6303.

Susan Dickson, M.D.

Dr. Dickson has a personalized medicine (concierge) IM practice at 5210 E. Farness Drive. She is a 1995 graduate of The University of Arizona and served her IM with the Tucson Hospitals Medical Education Program. at THMEP. Her ofce phone is 795.1661.

Richard Van Rhoads, M.D.

Dr. Boyer currently practices at The University of Arizona Medical Center South Campus. His clinical interests include adult inpatient psychiatry and his afliations include the American Psychiatric Association. He graduated from University of Massachusetts Medical School in 2001 and serviced his residency at The University of A rizona. He is board-certied in psychiatry. You may call him at 874.4105.
SOMBRERO January 2012

Steve Goldschmid, M.D.

Dr. Goldschmid currently practices at The University of Arizona Medical CenterUniversity Campus on Campbell Avenue. His

pcms neWs

Election results posted

Ballots were counted Dec. 12, and the results of the PCMS elections made public during the Regular Membership Meeting Dec. 13. Elected to the Board of Directors were Diana Benenati, M.D.; Neil Clements, M.D.; Alton Hank Hallum, M.D.; Scott Weiss, M.D.; Evan Kligman, M.D.; and Soheila Nouri, M.D. Victor Sanders was elected as the resident member to the Board of Directors. Edward Schwager, M.D. and Charles Krone, M.D. were reelected to the Board of Mediation. Aiding the Nominating Committee next summer will be Kenneth Sandock, M.D. and Richard Dale, M.D., who were elected Members at Large.

Regular Membership Meeting Jan. 10 Rocky Mountain spotted fever spotted

The next PCMS Regular Membership Meeting is Tuesday Jan. 10, and will coincide with the years rst PCMS Board of Directors meeting. The meetings begin at 6:30 p.m. Light refreshments will be served. Please RSVP at 795.7985, or to

Because Dr. Peter Crowe was at his ranch during our Stars on the Avenue event last September, Dr. Rock Jackson accepted Dr. Crowes award for him. Dr. Jackson, left, was nally able to catch up with Dr. Crowe in early December to give him the plaque noting that he is our 2011 Lifetime Achievement Award winner (Steve Nash photo).

Rocky Mountain spotted fever is now endemic in rural Pima County, the Pima County Health Department told the PCMS Public Health Committee Dec. 5. If you suspect the disease, go ahead and treat, then report to the health department at 443.7797.

Healing display runs til Feb. 26

The exhibit Healing in Tucsonthe Healing Response to the Violence of Jan. 8, 2011 opened Dec. 1 in the Behavioral Health Pavilion Gallery in the lobby of the Behavioral Health Pavilion at The University of Arizona Medical Center South Campus, 2800 E. Ajo Way, the organization reported. As the one-year anniversary of the mass shooting approached, The University of Arizona Medical CenterSouth Campus hosted the art exhibit to focus on the healing process and response to the murders of six people and injury of 13, including Rep. Gabrielle Giffords (D-8). The exhibit features pieces created by visual artists in Southern Arizona. The exhibit will remain on display through Sunday, Feb. 26. The Behavioral Health Pavilion Gallery is open for viewing 8 a.m.7 p.m. Monday through Friday and 1:30-4 p.m. on weekends.

activity space at River Road and La Cholla Boulevard that has a marketing opportunity for large donors. The Southern Arizona Indoor Sports Center will start construction in July and open in early 2013. The 40,000-square-foot facility accommodates ve basketball courts or eight volleyball courts and will be available for regular exercise classes. It will not be a drop-in place, but more of a resource for leagues, for the young, and for the not-so-young. Area schools discourage use of their gyms, either by saying no to all comers, or by making the price too high. Pima County will build and continue routine maintenance of the Southern Arizona Indoor Sports Center and a private charitable organization, Southern Arizona Community Sports, will fund part of the construction and run the building. Tucson Conquistadors has provided half the private fund budget, and there is about $200,000 needed to nish the public part of the funding. Courts can be sponsored, and there are message opportunities on the walls to encourage kids to continue activity all their lives. Individual donations are welcome. To donate, learn more, or nd out about marketing opportunities, please log onto, or call 797.2585.

So. Az. Indoor Sports Center coming

As part of PCMSs networking with other agencies involved in the obesity ght, the society learned Tucson is getting a new indoor
SOMBRERO January 2012

Twitter and Facebook in your practice

By Lucien W. Roberts, III, MHA, FACMPE and Barbara Brownlee, MT (ASCP)
We will never follow celebrities escapades on Twitter or Facebook, but we think they both have a place in a medical practice

when used judiciously and in moderation. Even if used just for lling open slots in the appointment schedule, these social media can help todays medical practice run more efciently. Both of us have Facebook accounts, but neither of us look at them daily, nor do we give friends a minute-by-minute account of our activities. Many love to drink from the Facebook well every day, but thats not our cup of tea. We dont twitter, which used to be a perfectly serviceable adverb, and were not on anybodys twit list, whether or not we think theyre twits. With all due respect to twits and twitterers, we need no play-by-play of your day. Happy you stopped by the cleaners, sorry you overslept 10 minutes, but we dont really need to know about either. Nothing personal; we just dont give a twit. And with the 140-character limit for each tweet, were not sure we can say anything that matters in 140 characters, much less 140 words. In fairness to those who tweet well, often a tweet will include a link to a page on your website where there are no 140-character limits. Filling your scheduleHad it up to here with patients cancelling their appointments on short notice? Twittering is a great way to let patients know you have just-opened spots in your schedule. First come, rst servedpatients like it, your front ofce will like it better than calling ten patients to ll one slot, and your bottom line will love it. Facebook is a way to let potential patients know that your practice has appointments available. Post something to your practices Facebook page about same-day or same-week appointment availability, and your number of unlled appointments will drop in the next year. Specialists should consider using this approach to let referring physicians know that you have openings. Let the referral coordinators at the PCP ofce know that you send out updates via Facebook or Twitter when slots open. Clinical research studiesTrying to enroll patients for a new clinical research study? Twitter a link to the clinical research page of your website. Make it part of your patient recruitment strategy. You wont know if it works until you try it. Several practices have used Facebook as an effective portal. Just arrived: u vaccineWanna be a superhero? In u season, twitter patients about the shipment of u vaccine that just arrived. It works. And if you are out of vaccine and dont expect any shipments, twitter a website link of places that still have u vaccine. Your patients will be most appreciative. A Facebook post about the availability of u vaccine may even bring you new patients. New, new, newTwitter your patients about a new provider, a new ofce, new extended hours, or a new service. Include a link to your website for more details. The same goes for Facebook, which engages your practice with those who live and breathe a steady diet of Facebook. Patient educationPromote coming seminars or webinars to your patients. Offer a link to the registration page. Remind patients of the patient education pages on your website while youre at it. Job postingThis can be tricky; you may not want one of your patients to be your employee. But if your patients tell their friends that your practice has an opening and is a great place to work, you just might strike gold. We never thought Facebook would be an effective means of recruitment, but it works. Another free and effective recruitment venue you might try is Craigslist, which medical practices in some cities routinely use to nd new employees. In conclusionBarbara confesses that she recently used Facebook to post a picture of her dog wearing a graduation cap on the

On the UofA Mall near Old Main, manning the booth at the Tucson Marathon Festival Dec. 10 were Dr. Carol Henricks and Dr. Paul Gee, who instructed kids and their parents about the diseases caused by obesity, and what levels of activity and nutrition are needed to avoid the fat trap (Steve Nash photo).

last day of obedience school, and her status update mused about how the dog got the certicate but Barbara learned all the lessons. Sometimes we cant help but share our little successes with friends and family. But the rest of the above is how we envision Facebook or Twitter use in the practice environment. Lucien W. Roberts, III, MHA, FACMPE, is vice-president, and Barbara Brownlee, MT (ASCP) is sales executive of Pulse Systems, Inc., a provider of practice management software, EHR, and revenue cycle management applications for medical practices. For more information, call 1800.444.0882 ext. 1286, or visit

Raytheon donation targets UofA trauma

Raytheon Missile Systems has donated $100,000 to the Division of Trauma, Critical Care and Emergency Surgery in the University of Arizona Department of Surgery, the university reported in December, saying the gift will fund research on treatment of wounded soldiers on the battleeld, and trauma victims here at home. The Raytheon donation will fund advancements in care for wounded warghters, they said. Potential advancements that can be implemented the quickest will get the highest priority. Specic research areas will include developing devices to detect and treat chest injuries, new human-based resuscitation uids, and new treatments to stop bleeding. Studies also will focus on traumatic brain injury, tissue transplantation and suspended animation. Advancement for warghters also will have an immediate impact at home as it will be just as applicable for civilian trauma, said Peter Rhee, M.D., chief, UA Division of Trauma, Critical Care and Emergency Surgery. We are excited to partner with one of Tucsons largest employers through their support in trauma research. Research is a systematic way of improving human life now and forever. Raytheon is proud to provide the UA trauma division with this donation to help further the word-class work that is already under way there, said RMS President Taylor W. Lawrence, Ph.D. Because our two organizations have a focus on the warghter, we see tremendous synergy between Raytheon and the UA Trauma team in this area. The tragic shooting in January [2011] exemplies why we
SOMBRERO January 2012

The Arizona Board of Regents has endorsed the afliation, and at its Dec. 2 meeting in Tucson approved the construction of a UA Cancer Center facility on the Phoenix Biomedical Campus. Construction will begin this year.

PCMS 2012 meetings

The ArMA Legislative Reception is Jan. 23 in Phoenix. Try to attend; its worth it. The ArMA Annual Meeting (delegates only) is June 1-2. Our Regular Membership Meetings are Tuesday Jan. 10, 6:30 p.m. when members are invited to the Board of Directors meeting; 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. Pima County Medical Foundations Evening Speaker Series is on the second Tuesdays in February, March, April, May, June, September, October, and November, often including CME. Watch for topic announcements in the between Sombreros newsletter. The PCMS Board of Directors and Executive Committee (ofcers only) meet:

Kids lined up for the one-mile run during the Tucson Marathon Festival at the UofA Mall Dec. 10 (Steve Nash photo).

need an excellent trauma program in Tucson and Southern Arizona, said Rainer W.G. Gruessner, M.D., chairman, UA Department of Surgery. Excellence comes from not only providing outstanding clinical care for patients in our community, but also from innovative research to discover new treatments and cures and to retain the high-caliber academic trauma and surgical teams we have at the University of Arizona. Raytheon, headquartered in Waltham, Mass., employs 72,000 people worldwide and provides state-of-the-art electronics, mission systems integration, and other capabilities in the areas of sensing; effects; and command, control, communications and intelligence systems, as well as a broad range of mission support services.

UACC, St. Joes Phoenix collaborate

University of Arizona Cancer Center has entered an afliation agreement with St. Josephs Hospital and Medical Center/CHW in Phoenix for transformational cancer care, the UofA reported in December. The UACC is the only National Cancer Institute-designated comprehensive cancer care center headquartered in Arizona. The vision is to create an afliation that leverages the strengths of both organizations, in collaboration with community-based oncologists, to transform the delivery of cancer care and to establish a premier center for ambulatory and inpatient oncology, with an emphasis on high-quality, patient-centered, evidence-based multidisciplinary care and clinical/translational research, they said. We envision our operations in Phoenixat St. Josephs and at our future outpatient facilityas a national and international model of integrated health care to ght cancer, said UACC Director David S. Alberts, M.D. The university reports that since 1976, UACC has conducted research toward cures for and the prevention of cancer. It is one of just 40 NCI-designated comprehensive cancer centers in the United States. St. Josephs also has a long history of cancer research and innovative care for some of the most challenging patients in the country. It will serve as UACC at Phoenixs primary inpatient clinical site. St. Josephs also will provide outpatient clinical facilities at its central Phoenix medical center campus, with eventual expansion of Cancer Center outpatient activities to a multi-story, 250,000square-foot outpatient center to be constructed on the downtown Phoenix Biomedical Campus.
SOMBRERO January 2012

Often you never know who or what will roll into the PCMS parking lot, and Nov. 29, 2011 was no different. Stephen Jones, a volunteer for Physicians for Civil Defense, left Marthas Vineyard Sept. 23 bound for San Diego, stopping at 10 rst-responder ofces per day to distribute tiny radiation stickers and a 60-second training. Most re guys and patrolmen, as well as Homeland Security folks, welcome the information, Jones said. Every 1950s schoolkid knows what to do if there is a nuclear blast, but most young guys and women dont get any training. He said he wants rst responders to be able to detect spikes in radiation and know how to calmly react during a nuclear accident or terror attack. With these small RadStickers, we have a net of detectors all the way back to New England, he said. Jones, 61, owns a successful business in Salt Lake City and has not ridden this far since he rode across the U.S. when he was 14, and from Alaska to Mexico when he was 16 (Steve Nash photo). 11

entities with the object of a joint effort to reform health care locally. The Board of Directors, chaired by PCMS President Timothy Fagan MD, did not meet in November. Board of Mediation: Chairman Edward Schwager MD. An appeal from a Board of Mediation decision was given to the PCMS president. Public Health Committee: Sky Hilts MD presided Nov. 7, 12:25 -1:31 p.m. Bike fatality stats were studied. There were 25 deaths in 2009. Obesity plans now include a booth at a health expo on the University of Arizona Mall Dec. 10. Bioethics Committee: Chairman David Jaskar MD presided Nov. 15, 12:40-1:34 p.m. The committee discussed the call for reconsideration of liver Pima County Medical Society, founded in 1904, is at 5199 E. transplants for alcoholics, and a note that Carondelet St. Marys Farness Drive, Tucson, Ariz. 85712, in Tucson Medical Park off Hospital had the third hospice in the U.S. Rosemont Avenue from Grant Road. Ofce hours are 8 a.m.-4 Revisions were made in a new case to be offered for publication p.m. Monday through Friday. Phone is 795.7985; fax 323.8558. in Sombrero. A letter from a member about the last published case After hours, an answering service can put you through to see if anywas reviewed. one is answering, or you may leave a message. Our back line for afHistory Committee: Chairman James Klein MD presided Nov. 8. ter hours is 795.7986. E-mail: The committee met and made nal plans to the Nov. 12 tour of Our holiday closings this year are New Years Day Jan. 2, Methe Florence Highway. That tour was a great success, with stops at a morial Day May 28, Independence Day July 4, Labor Day Sept. 3, Titan Missile site, where a former commander, Jerry Freund, gave a Thanksgiving half-day Nov. 21 through Nov. 23, Christmas Dec. feel for what manning this Cold War facility was all about. The 24-26, New Years Eve Dec. 30, and Jan. 1. 2013 New Years Day. property owner said that the silo was blown up, but that the rest of the site is still underground and a great place for rattlesnakes to live. The tour climbed Poston Butte, stopped at the prisoner store, and had a wonderful tour of the museum. Look for the commitReferrals to physicians: 103 tees future guided tours involving Arizonas past. Meeting rooms occupied: 20.9 percent (8 a.m.-10 p.m., seven Pima County Medical Foundation, Inc.: President James days per week) Klein MD presided Nov. 14. Executive Committee: PCMS President Timothy Fagan MD Evening Speaker Series topics for 2012 were set and Dr. Krempresided Nov. 8, 5:37-7:05 p.m. pen went to work on the CME documentation. Several disability programs for physicians were evaluated and Regular Membership Meeting: President-Elect Alan Rogers recommendations will be made to the board. MD presided Nov. 8, 7:05-7:55 p.m. The execs resolved a personnel matter, and examined nominees Dr. Bennet Davis outlined efforts so far to engage business leadfor honorary membership, meeting dates, and budget ideas for 2012. ers in the operations of local health reform. He made it clear that Bennet Davis MD gave an overview of progress with business business leaders want physician leadership. A subcommittee of PCMS will work to articulate a vision and principles for local healthcare reform, and PCMS members will continue to work with the Arizona Business Coalition on Health. The slate of nominations was read and additional nominations invited. Odds & Ends: PCMS attended meetings with the Pima Community Access Program, EL DORADO INTERNAL MEDICINE Leslie Willingham, M.D. the National Disaster Medical System, the E Luis Aguilar, M.D., Alan Rogers, M.D., Norman Epstein, M.D. Family Medicine Health Information Network of Arizona, the Welcomes Joint Technical Education District (health caLeslie Willingham, M.D. reer education in high schools), and the ExerFamily Medicine cise is Medicine Conference Planning Committee meetings in November. On Nov. 8 PCMS was on hand to see the Wellness for the whole family On site lab handwashing ordinance defeated at the Pima Sports Physicals Convenient location, just north of County Board of Supervisors. Immunizations Speedway on Wilmot On Nov. 17, PCMS attended a casual breakfast Same day appointments available with state Sen. Al Melvin (R-26-NW Tucson), state Sen. Frank Antenori (R-30-E Tucson), and 1500 N Wilmot, Suite A110 Tucson, Arizona 85712 state Rep. Ted Vogt (R-30-E Tucson) at KVOI Phone 520-886-4181 radio studios.

BOARD: Tues. Jan. 10, 6:30 p.m. Tues. Mar 27, 6:30 p.m. Tues. April 24, 6:30 p.m. Tues. May 22, 6:30 p.m. (Memorial Day May 30) 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. Jan. 10, 5:30 p.m. Wed. Feb 15 5:30 p.m. Tues. Mar 27, 5:30 p.m. Tues. April 24, 5:30 p.m. Tues. May 22 5:30 pm Tues. June 26, 5:30 p.m. 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.

PCMS 2012 info

November monthly report


SOMBRERO January 2012

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tIme cApsULe

By Bernard W. Bud Simons, Jr., M.D.

Editors note: In retirement the late surgeon Dr. Bud Simons was known in these pages as an engaging raconteur, memoirist, and chronicler of Tucson medical history. Because he encompassed so much history, we did not always have space to print his pieces while doing them justice. We are pleased to present this one, from 2006, in his memory. pare this world with the one I lived in back then, in the San Francisco Bay area. The phlebotomists caught my attention. They are still young, bright-eyed, and pleasantas I hope we werebut different in many respects. They are either the product of formal training, or in a formal training program, with their sole function in many hospitals and large labs, just to draw blood! No such person existed 50-60 years ago. Usually the job fell to junior members of While having some blood drawn the lab, and was just a step above washing equipment and making recently for a spectrum of tests, I was solutions. If you were a special friend or a VIP, the senior lab perstruck by the number of changes Ive son would use his expertise to draw blood. Some states then had seen in medicine over 50 years. Sitlaws saying only doctors and specially trained people could draw ting therein a specially designed blood, and the few medical labs were a favorite source of employchair, no lessand looking around, ment for med and pre-med students. I could see nothing that would have In the midst of high school, I was eager to swim in the medical been available to my colleagues and stream and thought working in a medical lab would be a good me in the past. start. Fortunately, a small, one-man lab in the Valley Bank building Im pleased to report that while at Stone Avenue and Congress Street downtown accepted my offer the objectives were the same, the to do menial chores around the lab in exchange for whatever he materials, equipment, and methods The late Dr. Bernard W. Bud Simons, Jr. in 1984. had time to teach me. Soon I was very much involved with the were all different. I began to comfew procedures he did, and I found this new world very interesting. We never drew blood; it arrived in vials, each having been lled in one of the many doctors ofces in the building. Most of my excitement came from my introduction to using a high-power microscope as well as learning about the components of blood and urine. The next year, I nagled a job as an assistanta gopherat the Southern Pacic Hospital lab on West Congress. The lab was a busy, moderate-sized unit with two technicians. It turned out one of my female classmates was one of the technicians, who had essentially been taught the procedures by an older friend who worked in another of the loWe are preferred providers cal labs. These two people were ne teachers on most insurance plans. and not only taught me how to use and clean Helping you hear your best the equipment, but also made sure I saw whatever was interesting, which included seeing my Janis Wolfe Gasch, Au.D. We appreciate your referrals! rst intestinal tapeworm. Doctor of Audiology, Founding Director This lab was also my introduction, by many 7574 N La Cholla Blvd 6969 E Sunrise Dr, #203 512 E Whitehouse Canyon Rd, #196 hours at the sinks and scrub brushes, to the Tucson, AZ 85741 Tucson, AZ 85750 Green Valley, AZ 85614 large amounts of glassware labs used. Nothing 520.742.2845 520.742.2845 520.648.3277 was disposable! My next stint in a lab was six years later as a second-year med student, working the overnight shift in a large, private hospital lab as a

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second job. That was not much fun, not only because of the hours, but because the heavy responsibilities included doing a lot of blood-typing and cross matching for patients in severe shock. This was my introduction to the leaden mantle of medical responsibility that I wore until I retired at age 60. Up into the 1960s in many medical ofces throughout the U.S., the doctor himself or an ofce nurse did many of the more basic tests such as CBCs, hemoglobins, urinalyses, and even a few simple chemistries. Small, independent labs, staffed and run mainly by one or two well-trained technicians, were often located near wherever medical ofces clustered. For many years there were no ethical or legal restraints on doctors owning, or investing in these labs. While many physicians took some nancial advantage from this, it should be remembered that these doctors were also doing their patients and community a big favor in saving time, investing their own money, and providing considerable convenience. Very few sick people want to be moved about in a building, or driven many miles for lab work. At one time many mail order labs advertised in the medical journals or in the mail. These outts offered a wide range of tests, including water and food analysis. Their charges were very competitive and most did very good work. When contacted, these big labs sent to ones ofce a large assortment of specimen and mailing containers with adequate instructions on collecting and sending the blood serum or whatever. Results were usually available in a week to 10 days. These labs were most helpful to physicians in very small towns, and always provided them some nancial incentive to patronize them. They would bill the doctor, who in turn would pass

this charge to the patient in whatever amount he considered appropriate. In the 1960s solicitations from these labs came to my ofce from as far away as Chicago. In the early-to-mid-60s, Arizona passed laws or regulations that made it very difcult for a physician to have his own ofce lab. I recall considerable anger among a few doctors who lost their labs during that time. I recall that before the legal changes, more than one of these doctors urging me to use their private labs for routine tests. I tried to do this a few times, but it led to awkward moments and questions from patients, such as, Who is Dr. and why did he send me a bill? (instead of billing for lab procedures!) Another big problem that came up around that time was a law or regulation that prevented an M.D. from billing for the lab work done by a lab outside the doctors ofce. Strangely, a doctor could charge for drawing the blood, but not for the test! Prior to this, many doctors, or someone on staff, drew the blood and sent it to a lab that would bill the doctor monthly. The doctors in turn billed individual patients for a lab fee for whatever amount the practice deemed appropriate. The doctor paid the monthly lab bill just like any other. This made for simple bookkeeping for all concerned. But this setup did confuse some patients, particularly about the variation in lab costs among different ofces for the same tests. As more people were being medically insured in the 60s, the insurance companies became more involved. Many did not pay for any kind of laboratory work not done in a hospital as part of an admission. With the laboratories beginning to bill patients directly, the labs had to buy more ofce equipment and hire more personnel, and subsequently had to raise their charges. Some people to this day claim that it raised the cost of care to the patients far more than the few dollars it might have saved from being collected by the few doctors who had labs. It was certainly not wholly to the patients benet that everyone involved had to write more checks, do more mailings, and spend more time on the process. Many physicians, myself included, quit drawing blood in their ofces, as it became more trouble than it was worth in time, capital investment, billing, etc. especially since insurance did not cover it. There are stories saying the insurance companies and authorities soon realized the absurdities of the regulations and considered a return to the older system. But it was brought to their attention that it was their idea in the rst place, and that we were all certain to get bad publicity when the new ofce personnel were red and new ofce equipment payments were defaulted upon. There could hardly be a better example of bureaucratic stupidity and interference. Some believe the upward spiral of medical costs began with such illadvised maneuvers by the insurance companies. While there was a nancial incentive behind the development of many physicians labs, its
SOMBRERO January 2012


important to realize that many of these ofce labs were run by physicians who were highly trained, and maintained very high standards. This was especially pertinent to some ofces that were treating large numbers of patients, or those with special conditions such as kidney and liver problems, or diabetes and blood dyscrasias. The convenience to the sick and disabled was enormous in allowing quick changes in care and medications. I believe that the basis of most of these labs was a great desire on physicians parts to give the best and fastest service. There was considerable competition for patients back then because it was all word-of-mouth, with no advertising and no company or organizational deals. The aforementioned specially designed chair contrasts with the ordinary chair alongside the wood or metal tables we used to use If the blood was to be drawn from the right arm, the chair was turned to place the right arm on the table, and for the reverse of that for the left arm. Today the chair may be like an expensive recliner, and it will have padded extensions on both chair-arms on which to place the arm selected for the phlebotomy. Since so many people get faint or light-headed at blood-drawings (that hasnt changed!), having a table or couch on which to recline was always part of our lives. One cannot help but be impressed, in this litigious age, with the current practice of drawing blood with the patient in some outof-the-way cubicle or closet, with NO facilities for the faint of heartexcept an ampoule of ammonia! And the equipment! It seems now like every tech has a special thin strip of light-colored rubber to use as a tourniquet. Sometimes they use a blood pressure cuffand they both work with the same old discomfort.

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SOMBRERO January 2012 17

Both contrast with the pilfered Penrose drains or old gum rubber tubing that we used. When we needed to replace a tourniquet, we usually dropped in at central supply and stated what we needed, or the problem we had to address. Whomever was in charge would usually refer us to a monstrous coil of gum rubber tubing on a shelf, with instructions to cut off what you needed. Penrose drains were harder to come by, as they were available only in surgery. If you were on good terms with the scrub-nurses, during takedown one might be slipped an unused drain. Remember, in those days the ORs usually recycled everything they could possibly use again, including those drains. Fifty years ago, lab tests required what would today be considered large amounts of a patients blood. Today we can analyze dried blood drops! It was not unusual for very ill patientswho could least tolerate blood lossto sometimes become almost exsanguinated from multiple phlebotomies. In turn, these unfortunate patients had to be given transfusions, further complicating their d iagnoses. Back then, a CBC required at least 5cc, but if a sedimentation rate and hematocrit were also needed, one withdrew a total of 10cc. Blood sugars required 10-15 cc, and most type and cross-matches needed 20-30. It was a rare chemical test that did not need 10-20. When a liver panel of any battery of tests was ordered, it was not unusual to draw 100-150 cc of blood. I recall that when I was an intern, we had a special cart for blood-drawing rounds. While all the syringes were surgically wrapped in sorted by sizes into boxes, the needles were in special metal racks, or stuck like rounds of ammunition in gauze pads in enameled trays. A special box held the collection of 50-100 cc glass

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syringes (I can testify that they broke into many pieces when dropped). A few tourniquets were attached around the sides of the cart. Alcohol sponges were soaked with pink-colored isopropyl alcohol. A jar of them was centered on top layer, along with labeled boxes of small vials, color-coded according to which anti-coagulant they contained. The chart for which anti-coagulant to use for every test hung on the cart, encased in clear, old X-ray sheets. One used grease pencil, also often attached on a long string to the cart, to mark the vials with the patients name. It was standard to use a No. 18 needle for drawing any amount of blood over 25-30 cc, to diminish the clotting that invariably occurred when using a No. 20. Clotting in the needle or small syringes when drawing blood was quite common for a variety of reasons. As a rule, both needles and syringes were washed and sterilized on the ward, with the sterilization standard being boiling water or soaking in a bactericide. Personnel were often too busy to give needles the care the required to stay sharp, free of clots, skin plugs, and residues. They blunted easily from sliding about in enamel trays lled with those bactericidal solutions, and this often gave a kind of hook to the needle tips, which interfered with insertion as well as withdrawal if not detected beforehand. Using glass syringes, one became aware of their frequent freezing, or the sticking and loss of the barrels ability to slide inside the cylinder. Two very common reasons that syringes stuck or froze were that they were not cleaned well to begin with, or were not thoroughly rinsed in distilled water before drying and packaging. While 5cc syringes were kept on the unit, large phlebotomy syringes of 20cc or more came from central supply. We got all our needles from the oor nurses. Every cylinder and plunger came wrapped separately in gauze inside one or two layers of surgical, sterile cotton cloth wrap. The wraps were always saved to be used again! After unwrapping, it was important to check the serial numbers or marking on the two parts to make sure they were supposed to t. Each plunger or piston was made for a specic cylinder. Some of the better-quality brands used a numbering Your expectations are high. After all, you drive system. the best engineered vehicle on the planet. Now theres There was no one-size-ts-all, or intera shop that delivers first-class service to BMWs and changeability between the two parts of syringtheir owners. So keep your expectations sky high; es. One always pulled the plunger back and we wont be satisfied until we exceed them. forth a few times to make sure it slid easily. Then, and only then, did one use the sterile Call 520-300-4220 pick-ups to pick a needle out of the ously, always white enamel with blue trimto 5728 East 22nd Street Tucson, Arizona attach it to the syringe. Then you had to test the setup again to make sure the needle was not plugged and that the syringe would easily slide. It was not uncommon to have to stop in the middle of drawing blood and get a new Maintenance | Repair | Detailing | Products setup when the plunger froze in place.
SOMBRERO January 2012


All too often this time-consuming ritual went on at bedside in Thinking of needles, I must include one of my immunization full view of the patient. Imagine their distress upon seeing those experiences when I joined the Army during what we now call the hugewe called them horsesyringes! The physical difculty of Korean War. As we headed overseas, a rapid series of immunizadrawing blood with a 50-200 cc syringe was that the needle adapter tions was in order for about 600 of us physicians and dentists. was centrally placed at the end of the barrel, a centimeter or more On more than one occasion, we actually got two immunizations from the edge. It was always easier on both patient and doctor if simultaneouslyone in each deltoid area as we led by the several needle adapters on these syringes were placed on the edge of the shot stations! barrel. These syringes were more expensive to buy, so they were not Because I thought I needed to know how the Army did this, I too commonly available. Using one of these better syringes allowed paid close attention one afternoon to our typhoid inoculation. The easier insertion into the vein, less chance of actually transacting the technician used a 10 or 20 cc syringe with a long No. 23 needle vein, and more comfortable aspiration of a large amount of blood. and an alcohol lamp. After each 5 cc injection, he would pass the While we all had some instruction in phlebotomy, it was brief needle through the ame (the glass syringe would be held below and we were expected to learn by doing, as it was OUR house ame level), give it two or three seconds to cool off, and then inject staff job! Phlebotomy was usually regulated to the most junior the next man! Obviously they never pulled back the piston, and I member of any team, unless the veins in question were collapsed had never heard of multiple immunizations from the same syringe or badly damaged. Then, a more senior team member would try and needle beforeor since! Some of us were stunned to see this. to obtain the blood. Fortunately, I never encountered that again. After that, I believe, As you can imagine, many veins were damaged and transacted the air guns came on line for mass inoculations. by us neophytes, and more than one of us were surprised and upset The invention of the double-ended needle in the plastic cup for to nd our syringes lled with ARTERIAL blood! Those of us with phlebotomy, and having a vacuum in the specimen receptacle were surgical aspirations were expected to learn how to do arterial big advances. In our time, we did something of a juggling act that punches as well as those of deep veins and those in awkward places. was almost impossible for those who were not too dexterous. One This was important in cases of dismemberment and massive trauheld the blood-lled syringe in one hand, and in the other hand ma. In one severe burn case, a friend of mine actually drew blood the specimen vial, and used that thumb and forenger to remove from the victims penis! the rubber plug, inject the blood into the vial, re-plug the vial, and Around 1950 individually packaged, disposable needles came then rock it back and forth. This was often rather slow, as it not on the market and everyone enthusiastically adopted them. Then only required some dexterity, but the blood often prematurely clotcame disposable syringes, greeted with the same enthusiasm. Not ted in the syringe before all the vials could be lled. Of course, this only were both products safer and more pleasant for the patient, meant another veni-puncture! One often heard caustic comments but they also eliminated a lot of time lost throughout all hospitals about these maneuvers, some saying they were a test required to and ofces from the onerous, dangerous, and time-consuming jobs enter a surgical program! Obviously it is quicker now and, without of cleaning, sharpening, and packaging of these two items. Needle a doubt, much safer and pleasant to both patient and technician. punctures alone cost thousands of dollars in lost time and cost of care. A nurse or doctor, nally, could be sure that one would always get a sterile syringe and needle that worked and did so smoothly. Needles that were always sharp and free of obstructions? Wow! The glass syringe was a great invention, but you Plan ahead for your increased patient load and physician can see it had its complications and dangers. It often shortages due to: froze in use and often broke when being washed, Retirement tested, and even used. I particularly recall how this up Recruitment set nurses with severe allergies to substances like peni Vacation cillin and horse serum. They didnt appreciate spotting Illness or damaging their uniforms, either! Breakage occa Sabbatical sionally inicted some miserable hand lacerations. Maternity Leave The next logical and most welcome step was the CME complete package of a disposable syringe with an attached disposable needle, both in a broad variety of CMR has provided permanent and locum tenens sizes. Now here was true advancement! It was a giant services in Arizona since 1991. With over 300,000 Catalina Medical Recruiters, Inc. leap forward to those of working on the hospital active candidates in all specialties, we provide P.O. Box 11405 personal, professional, and proven service! oor. I must admit, however, that the sterilizable Glendale, AZ 85318 glass syringe was a huge advance over the hard-tophone: 602-331-1655 clean metal, or glass-and-metal syringes granddad fax: 602-331-1933 had to use!
SOMBRERO January 2012 19

Present-day marvels dont stop with just the act of drawing blood; they extend to the small amount of blood necessary for modern labs to do their tests. At mid-20th century, many laboratories did not do a broad range of analyses and tests because elaborate preparations and considerable time were necessary. Commonly, a technician but one or two of the more complicated tests at a time. Serum analyses determinations were not even done at most hospitals in San Francisco. Blood gases and many other tests were not readily available, and when they were done, it took 24-36 hours to get resultswhich then were rather equivocal. Faster were blood sugars, which took 1-3 hours on an emergency basis from the lab in the county hospital where I trainedif the lab was open and not over-committed. However, as we considered speed to be more important here, we set up an illegal mini-lab on the medical oor to do our own tests in less than 30 minutes, night or day, and especially over weekends. Those of us doing intravenous uid therapy had NO test for K+ blood levels, and those done for Na+ took a full day. The ame photometer was just new on the market but, as I recall, the San Francisco city fathers felt is was just an expensive toy for doctors! Most liver and kidney tests were done two-to-three days per week, and it took the same amount of time to get results. For all practical purposes, the chemistry labs were closed on weekends except for blood sugars and BUNs. There was no way to get blood levels on poisons and medications unless it was sent to a state lab, with results taking at least week or two. At the San Francisco County Hospital all CBCs, sed rates, Hct, platelet counts and urinalyses were done in the ward labs by interns or medical students who carried a small case of equip-

ment and solutions. I understand this was common practice in many teaching hospitals. Not only did our interns and students do all routine CBCs and urinalyses; they did all the follow-up and emergency lab work. All lab work had to be completed for all patients by daily 8 a.m. rounds. When no med students were available, two interns did this on 100-person wards at San Francisco County Hospital. The case they carried was a small black box that accompanied an intern the way a rie goes with a Marine. It contained a hematocytometer with cover slips as well as slides for blood and exudate smears. All the necessary pipettes for blood work were in a special rack in the lid. Below in tted compartments were small bottles of the solutionssupplied generously by the hospital!necessary for counts (WBC, RBC, platelets, smears, hemoglobometry), including Wrights and Grams Stain. The urine specic gravity hydrometer and its cylinder were there, and the testing materials for urine sugar, acetone, and pH. Tape tests had just come out and some people had them, while others did not. Stuck in a piece of rubber or cork in everyones kit was a No. 11 Bard-Parker blade for nger and ear sticks, which were a common way to do the serial counts or hemoglobin checks. These blades were replaced every few weeks and were usually wiped with an alcohol sponge before use. Alcohol sponges were occasionally available in packets, but were most often found in special glass jars at the nursing stations. As students we would do the pneumococcal typing, but this was no longer necessary by 1950. That black box cost us each about $75-100 from our own pockets, and we paid for any broken or lost components. In the private hospitals in San Francisco, and probably in most other hospitals then, technicians did all the blood counts by

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hand, through a microscope using a special ruled slide and special solutions, though a few machines were becoming available. Blood count processing took up to eight hours, unless marked EMERGENCY. Most hospitals tried very hard to have all basic lab work of evening admissions in the charts the next day by 7 a.m., especially for the surgical cases, but often did not succeed. It was common for surgical oor nurses to be calling physicians at 4-6 a.m. about low hemoglobins and such when the lab technician putting the lab work into the charts brought it to the nurses attention. Obviously in cases of massive bleeding the tests would be done in minutes and everyone contacted. While a technician or two might be available all night to do blood counts and cross-matches, it was a rare private hospital that had in-house technicians able to do blood chemistries after 5 p.m. The on call tech would have to come in for those cases. Since most bacteriological studies were done during the day, bacteriological night problems were rare. When exudates and such were to be studied, a sterile swab was used and placed in a culture medium. This was well labeled with grease pencil and immediately taken to the lab for incubation. Blood drawn for septic studies was basically handled in the same way, and often involved a duplicate or backup tube. It might be easy for some to look back at those times as more leisurely, but we house staffers were very busy. Very few private hospitals had ERs or 24-hour emergency services. The nation had fewer people and considerably less violence, but these cannot explain it all: People were different then. People were far less demanding. They understood that we were doing out best. They even seemed appreciative! Commonly, they also understood that a doctors ofce could handle most of their needs more quickly and economically during the course of regular hours. There were none of the my time is as valuable as any doctors comments. There were none of the I want or need this or that because I heard of someone with this or that who dropped dead, or people who needed something done because some media personality said so. One never saw a patient with orders from a lawyer urging certain exams or tests no matter how absurd or expensive. One never heard the threat of a lawsuit if the patient did not get well or fully recover. Comments like, the cost is no problem since I have insuranceor am on Medicarenever came up. Before I retired, I was impressed to hear people demand to be treated like when we were younger, to be normal, to feel goodwhatever all that means. I had people sharply challenge my estimates of recovery time because THEY planned to be well and back at work a day or two after major surgery. People were even saying that since the accident was not their fault, they did not feel an obligation to pay my billor the hospitals! We worked long, demanding hours in the 1940s and 50s, but basically were happy, and proud of our results. We had no serious problems with our equipment and labs because we knew that it was all so much better than what previous generations had. I would like to believe, however, that our collective contribution was constructive and improved the system for future patients and staffs. We all saw the need for improvements, and quicker results. But I will never be convinced that all of our medical advances would not have occurred without all the new harsh, almost unbendable, difcult-to-understand laws and rules.
SOMBRERO January 2012

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We seek an energetic primary care physician with interest in occupational medicine. This physician will provide medical treatment to work-related illnesses and injuries. Previous experience in Industrial Medicine, Emergency Medicine or General Practice is preferred.
Company Benefits:

Flexible hours and Excellent work environment Benefits: health, dental, vision, 401(k) Excellent Training


Please submit your CV with cover letter to:

pcms ALLIAnce neWs

An out-of-sight step-out
By Tyna Callahan

A sellout crowd stepPlastic Surgery, Tucson ped into Flemings Dec. Dermatology and more. 7, 2011 for the themed Of course, Dr. Philip Step-Out for Mobile Fleischmans pepper mill Meals, Pima County had a prominent place, Medical Society Alliances too. New businesses also Mobile Meals Holiday pitched in this year, Luncheon. among them, Ironwood Nearly 120 people Dermatology, Pretty Sweet joined event chair AnasDesserts, Renees Organtasha Lynn and the Alliic Oven, and Sabino ance in support of Mo Artisan Chocolates. The Tucson Jazz Quartet entertained bile Meals as Flemings PCMSA members at the event. opened their doors to themselves made creative the event off-hours for donations that drew a lot of interestand raised substantial donaKristin Ashdown shows the creative wreath tions by the silent auction. Halla Moussa, famed within the organithe second year running. donated by Michelle Grantham. zation for her outstanding hummus and baklava, offered cooking Members and friends of the Alliance were welcomed into the warm, festively decorated dinlessons; Janice Leff donated a painting that sold at its buy now ing room for their signature steaks and famous cheesecake (with price before it even got in the door, and a set of cards decorated the exibility to accommodate non-meat eaters with sh and vegewith her artwork. More than half a dozen wreath originals crafted tarian choices). and donated by members under the diThe numbers werent in at our time rection of interior designer and member of publication, but given the sellout Joy Chapeskie, were snapped up at auccrowd and tables full of beautiful rafe tion (one was spotted last week hanging and auction itemsand Mrs. As Apples in the Benetton shop at La Encantada). for saleits safe to say that Alliance Thanks go, too, to Askrens for the dismembers once again came through when counts they offered our wreath-making they stepped-out for Mobile Meals 2011. members. PCMSAs tradition of supporting PCMSA members outdid themselves Mobile Meals of Tucson is more than 40 on the event this year, and those who years strong, and members and friends put their own time, money, and creativiof the Alliance always look forward to ty into the event made it truly special. this event to kick off the holiday season, Community-building fund-raising acand to kick off holiday shopping and tivities leading up to the event beneted giving. from the talents of two PCMSA pastFrom left, PCMSA chiefs are Kynn Escalante, Kay Dean, and Mobile Meals of Tucson provides one presidents: Joy Chapeskie, whose leaderAnastasha Lynn. essential service: the delivery of special ship brought us beautiful wreaths for diet meals to homebound individuals to help keep them healthy auction, and Mrs. A herself, Kathy Armbruster, who went all-out and independent. They delivered more than 96,000 meals this past once again, leading the traditional Mrs. As Apple-making. year to more than 670 clients, 55 percent of whom could only pay Other ever-present and tireless volunteers included Tracey Gee, $3 or less toward the almost $11 cost of these meals. To make a dowho organized and collected donations for rafe and auction; Kay nation, visit Dean, who managed reservations and seating; Apples second-inAttendees entered to the sounds of the fabulous Tucson Jazz command Susan Rogers, yet another past president; Tyna Callahan, Quartet, and headed for the auction and rafe room where tables past event chair; and PCMSA President Kynn Escalante. were loaded with beautiful gifts and gift certicates from Tucson Most tireless of all was our chairwoman, Anastasha Lynn, who medical practices, restaurants, and other businesses, including restepped into leadership this year, bringing new ideas and keeping peat donors Eclectic Caf, Flemings, Gadabout, Imagen Salon & old traditions alive with her own unique air. And the good news Day Spa, J. Elise Designs, J. Gilbert Footwear, Pastiche, Perfection is, she has agreed to do it again next year!
22 SOMBRERO January 2012


Touching others
I never knew Jamalee Fenimore, or Stephne Stevie Staples. No one who will read this knew them, either. Both of them loved the Sandhill cranes (Grus canadensis), as do I. A viewing blind is named for them at Rowe Sanctuary in Gibbon, Neb., at the Platte Rivers southern end. Every spring, the Sandhill and Whooping cranes, respectively the most and least common of the 15 crane species, Dr. Michael S. Smith begin their 5,000-7,000-mile migration to the subarctic in North America and Siberia.Their nal staging area is on the Platte River. They go to the Platte because there is food nearbyformerly small animals, but now mostly cornand because of the safety that one of the largest braided rivers in North America affords.They feed in the adjacent elds by day and roost in the river at night, where the shallow water allows them to hear predators approach.Before the Platte was dammed and water used for irrigation, recreation and drinking, it was a mile wide and an inch deep, too thick to drink, too thin to plow. Now the Platte in many areas contains less water, has invasive species and many trees nearby, reducing the suitable habitat to 50 miles from the former 200.Rowe Sanctuary manages four miles of river and owns 1,900 adjacent acres, preserved as habitat. Every night for six weeks in March and April, up to 600,000 Sandhill cranes, 90 percent of the worlds population, roost in the river. Every morning they leave to go to the elds to eat.Jane Goodall has called this one of the top 10 spectacles in nature. Ive been fortunate to have seen much in nature.This migration is in my top three; seeing a solar eclipse and a wolf in the wild are the other two. I love the cranes so much that I volunteer at the sanctuary, along with dozens of others, helping the full-time staff of fourthats right, fourshow visitors the cranes from viewing blinds, for cranes are shy birds and will not let people near them. Many talk about the cranes that migrate to Arizona.I simply reply, You dont understand.And you cant until you witness the a ock of 50,000 cranes darkening the sky. Stevie Staples mentored one of the Rowe Staff and lived 74 years before dying in 2006 from cancer. She was a former canoe racer and a real character. I once raced canoes, and I would have loved to have discussed racing with her.She touched the staff at Rowe.She knew it, for she did live to see a beautiful picture of a Sandhill crane in ight with her volunteer tag with nine years of service on it. The picture hangs on the wall in the hallway of Rowe. A picture of Stevie receiving the picture from the Rowe staff hangs in Keanna
SOMBRERO January 2012

Leonards ofce. The dynamic Keanna is the educational director at Rowe. Jamalee Fenimore grew up in Nebraska and practiced veterinary surgery in Washington State. She died of cancer far too young at 49, donating her estate to Rowe.No one at Rowe knew or remembered her being there.But obviously she was touched by the river, the cranes, and the sanctuary. We volunteers learn that we may touch visitors in ways we never know at the time. When I volunteer at Rowe, I work 17-hour days, sleeping on the oor in the gift shop so I can hear the cranes on the river at night.I guide people to the viewing blinds, and I can teach them everything I know about cranes. Mostly, however, I let people watch, remaining silent, so they can hear the birds. I clean toilets, paint, greet people, build a sundial, carpentry, whatever needs to be done. On one tour, I took a disabled man to Stevies blind in an electric golf cart.Had he been able to walk, all of the group would have gone to Strawbale blind, which had better views at that time. But we still saw many cranes, American white pelicans, and unusual crane behavior. My rider loved the view and tried to tip me, which I of course refused, asking him to put the money in the container at the sanctuary.I planned to talk to other visitors, because as the lead guide, I hadnt spent time with them. But I spent time with this man.He was originally from Singapore; when I told him I had been there twice, his rst comment was, Thank you for saving my country. Ive never heard that before, and it did me good.I hope I and Rowe did him good. We touch each other in ways we may never know. Good people spread kindness throughout their world. The lucky ones receive that kindness and live long enough to discover that their kindness was deeply appreciated and honored. But all who spread kindness are fortunate that they do so. Stevie knew in her nal days that her kindness was appreciated.I hope Jamalee Fenimore did, too. But if not, I know she knew she did the right thing. I deeply appreciate what she did. Every time I guide people to either of the two blinds, I tell them the story, for both deserve to be remembered. To have a viewing blind named for you on a river where a half million cranes visit every March is a wonderful honor. I really cant imagine a better one. Sombrero columnist Dr. Mike Smiths blog is http://michaelspinnersmith. com, where there are previous Reality Check columns, outdoor writing, descriptions and pictures of National Parks, Alaska hikes, eclipsechasing, mental arithmetic, op-eds, and two non-technical neurology articles that physicians might enjoy.


The two Americas

By Dr. Michael Hamant
I have a very different perspective from that of Dr. George Makol [Perspective, December 2011 Sombrero]. Dr. Makol rst gave PCMS readers a nice story about his familys immigration to America in 1903 and the quintessential American success story that followed. It is interesting that two Tucson physicians, from the same generation, practicing only a few miles apart, could have such different worldviews. It is impossible to illustrate all our differences in a few paragraphs, but I would like to offer a different perspective on a few of Dr. Makols points. Dr. Makols family history is certainly inspiring. He states, This could happen only in the America in which I grew up. But Dr. Makol and I grew up in the 1950s and 60s in an era of great free public education and inexpensive health care. My parents generation went to excellent free public schools in 1930s Chicago, lled with ethnic immigrants. I too had one grandfather who was a millionaire, but he lost his fortune in the 1929 stock market crash and changed from a Republican to a Roosevelt Democrat. My other grandfather only nished the eighth grade, but his son obtained a professional degree on the GI bill. So my family legacy was to appreciate the positive effect of government on education and on nancial regulation. These family history vignettes are as important in shaping my worldview as Dr. Makols family history is in shaping his. We diverge on many other points as well, especially our opinions on global warming, a.k.a. climate change. As evidence, Dr. Makol cites some examples of unusual local weather conditions as skepticism about whether global climate warming is occurring. In fact, the models of global climate warming predict the wild uctuations in local weather, just as Dr. Makol reports. The global mean temperature, however, is determined by billions of temperature measurements, not a few spot readings. It is incumbent upon physician-scientists to use the scientic method and statistics to present data in a meaningful way instead of repeating inaccurate talking points. Dr. Makol had many statements and themes that were not clear and illustrations that dont sustain close inspection. For example, there was a contention that the globe is 95 percent uninhabited and that the worlds population would t into Texas at a population density of Manhattan. I am not sure if this is a comment on potential unlimited resources that exist, or that population control is necessary or not. But 70 percent of the globe is ocean and uninhabited. Of the remaining 30 percent, probably half is arctic or desert. And can you imagine what damage a tornado like the one that hit Joplin. Mo. or a hurricane like Katrina would do to Texas with 7 billion people? This would be a silly speculation since it would be physically impossible to transport the water into Texas or


SOMBRERO January 2012

the feces out for 7 billion people. We can barely accomplish this in the limited space of Manhattan with a few million people! Regardless, the planets resources are nite and cannot support unlimited population growth. The thought that mans activity could warm the whole atmosphere is narcissistic to say the least is quite a shocking statement. Certainly our civilizations effect on the atmosphere is visible everywhere as a worldwide haze at best, and as lthy smog in most cities at worst. Most of our effects on the environment are much more subtle than smog and quite invisible. The profound effect we have on the planets environment is not narcissism, but is strongly supported by the scientic evidence. There was an evocative, yet false, statement about the Arctic National Wildlife Refuge that read, If you made a football eld sized map of Alaska, ANWR would be the size of a postage stamp. In fact, the ANWR is 19 million acres (about the size of South Carolina) and is 4.477 % of Alaskas land mass. This computes to about 2,578 square feet on a 360-by-160-yard football eld, or the size of a good-sized home. Certainly quite a bit bigger than a postage stamp. Dr. Makol spends a good part of his essay addressing the current political debate over the size of government and the taxes used to support it. We can certainly disagree about these issues, but many of his supporting facts are not accurate. For instance, the G.W. Bush budget decit was not only $161 billion in 2007 after 9/11 and two wars because Bush never included the wars in the budget. It might be a neat accounting trick to keep the wars off budget, but the reality is that two unfunded wars at $2 trillion dollars and counting, while simultaneously giving a tax rate reduction, brought us from the Clinton era budget surplus to our current debt problems. The Bush-era tax cuts were a total failure in creating jobs. The current mantra about not taxing the job creators simply has no factual basis. We are not talking about returning to the 1950s era of 70 percent maximum tax rate, but Progressives are asking for a return to the Clinton-era maximal rate of 3-4 percent higher than the historically low current rates. Reagan raised taxes seven times and the economy grew jobs. Corporations like General Electric pay no taxes, yet ship jobs overseas. So lets be realistic about tax policy and job creation and not pander to Americans for Tax Reforms lobbyist Grover Norquist. Yes, I totally agree that we are rapidly becoming two types of Americans. Not Dr. Makols types, but rather the very rich and everyone else. Average CEO salary increased 27 percent in 2011 and corporations are sitting on trillions in cash, yet unemployment is at near-historic highs, the median annual income is $27,000, and nearly a third of the population is in poverty or very near it. Middle-class income has been stagnant for nearly 20 years. It is the lack of buying power of the middle class that is the crux of the economic problems, not excessive taxation of the wealthy. When the middle class does well, everyone does better, including the wealthy. It is trickle up, not trickle down. So yes, if you are fortunate enough to be in the top 1 percent, you need to pay slightly higher taxes to bring America to a prosperous economic future for all. If not, the future looks a lot like Marie Antoinettes 18 th-century Frances income distribution. The 99 percent need more than let them eat cake as an economic model for success. Michael F. Hamant, M.D. practices family medicine and is a PCMS past-president.
SOMBRERO January 2012

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Jan. 29-Feb. 4: Mayo Clinic EMG EEG and Neurophysiology in Clinical Practice is at the Westin Kierland Resort & Spa, 6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.624.1000. CME: 60 AMA PRA Category 1 credits, and self-assessment 8 AMA PRA Category 1. Topics include fundamental basis for CNP tests including physiology, pathophysiology, clinical correlation, and appropriate use of these techniques. Specic procedures include EEG, EMG/nerve conduction studies, evoked potentials, movement disorders studies, autonomic studies, polysomnography, and intraoperative monitoring. Clinical correlation with sleep and neurologic- based diseases are stressed. Newer techniques for this years course include vestibular testing. Also take away pearls on coding, billing, and proposed quality metrics for managing the person with epilepsy. Website: http:// Contact: Staci King, Mayo School of Continuous Professional Development; phone 480.301.4580; fax 480.301.8323. E-mail:

Feb. 10-11: Latino Health Promotion Summit: A Focus on Prevention & Community Collaboration. The University of Arizona College of Medicines Ofce of Outreach and Multicultural Affairs, and the Hispanic Center of Excellence, in collaboration with the National Hispanic Medical Association (NHMA),

the Arizona Latin-American Medical Association (ALMA), and the Latino Medical Student Association (LMSA) are pleased to invite you to attend the 2012 Latino Health Promotion Summit. The goal of the summit is to bring together community physicians, residents, medical students, pre-health students, promotoras, and community members to increase awareness about Latino health and co-develop community based health promotion solutions. Program begins Feb. 10 with a community lecture by Elena Rios, M.D., M.S.P.H., president and CEO of the National Medical Association (NHMA), who will also give the keynote talk on Feb. 11. Online registration: Registration and lunch are free of charge. Please e-mail questions to Matt Stelling at, or call 520.626.7146. Feb. 15-18: The Mayo Clinic Department of Gynecologys 23rd Annual Advanced Techniques in Minimally Invasive Pelvic Surgery: The Leading Edge and Hands-on Cadaveric Workshop, is at the Fairmont Scottsdale Princess, 7575 E. Princess Drive, Scottsdale 85255. CME credits: 27.5 AMA PRA Category 1; 27.5 AOA Category 2-A. Symposiums goal is a well-balanced program truly reective of a practice committed to minimally invasive surgery. The attendee will walk away from our course understanding the many aspects of MIS and the roles of vaginal, laparoscopic, and robotic approaches in a surgeons practice. Phone 480.301.4580; fax 480.301.8323. Website: http://www.

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OFFICE FOR LEASE: Elegant modern medical ofce suite available for lease. Located on the rst oor of the Oro Valley Hospital Medical Ofces complex, within walking distance from Oro Valley Hospital. Beautifully decorated 3,158 rentable square feet with 2,789 usable square feet. Four exam rooms, two procedure rooms, staff kitchen and three ofces. Most xtures stay, including furniture if interested. Ample parking. Lease Term and Rate Negotiable. Call Samantha Marques at (520) 293-5757, ext. 7113 for more details (11-11). SHELVING SYSTEM FOR SALE: Original purchase price $20,000. Exceptional condition. 20 ft X 9 ft, 7 levels high. Asking $5,000 or best offer. Please contact Cindy, 3279573, ext. 245. (12-11) PCMS member, certied physician assistant with alternative medicine background, seeks 32-36 hours of employment in an internal medicine practice starting January 1. Contact PCMS, 795-7985, if interested. OFFICE SPACE FOR LEASE: Free-standing single-story building with Grant Road frontage. Ample on-site covered parking. Move-in ready; currently congured as medical ofce space of approximately 4,100. sq. ft. Ideally located across the street from Costco between Tucson Medical Center and St. Josephs Hospital. Contact Ted Kalota, 2505040. (11-11)


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Radiology Ltd. has focused on providing radiology services in the Tucson community for over 70 years. Each of our physicians is a specialist in their area of expertise. They, and the rest of our staff, are dedicated to providing quality patient care with an emphasis on both patient comfort and safety. Our imaging is now entirely digital, providing the highest image quality and quick turn around of results.
Radiology Ltd also provides: RadVision The clear choice for immediate viewing of digital imaging and patient reports via a secure online connection. Images are also available on CD and high resolution paper. Easy access to reports accurate reports with rapid turnaround time faxed preliminary and/or nal reports recent and remote study reports always available online Professional Relations Team rapid staff responses to your needs dedicated phone line for physician to physician consultation full-time couriers deliver studies/reports to you quickly Radiology Ltd. is locally owned and operates ten imaging centers in Southern Arizona to serve you and your patients. Consider working with the radiology specialists at Radiology Ltd.

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Great News!
Through a true partnership of efforts, MICA's Board of Trustees is pleased to announce a $50 million dividend for 2011 - our 7th consecutive dividend. Thanks again, MICA members.

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SOMBRERO January 2012