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Sombrero

Pima

County

Medical

Society

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

An ACA update

JUNE/JULY

2014

Handling board complaints

In Memoriam:

Dr. Samuel H. Paplanus Dr. John S. Welsh

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Sombrero

Official Publication of the Pima County Medical Society

Vol. 47

No. 6

Pima County Medical Society Officers

Michael Connolly, DO Michael Dean, MD Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD Alton Hallum, MD Evan Kligman, MD Kevin Moynahan, MD Soheila Nouri, MD Wayne Peate, MD Scott Weiss, MD Leslie Willingham, MD Gustavo Ortega, MD (Resident) Snehal Patel, DO (Resident) Joanna Holstein, DO (Resident) Jeffrey Brown (Student) Jamie Fleming (Student)

Members at Large

At Large ArMA Board

Donald Green, MD Veronica Pimienta, MD

R. Screven Farmer, MD

President Timothy Marshall, MD President-Elect Melissa Levine, MD Vice President Steve Cohen, MD Secretary-Treasurer Guruprasad Raju, MD Past-President Charles Katzenberg, MD

Pima Directors to ArMA

Board of Mediation

Timothy C. Fagan, MD Charles Katzenberg, MD

Delegates to AMA

Timothy Fagan, MD Thomas Griffin, MD George Makol, MD Mark Mecikalski, MD Edward Schwager, MD

William J. Mangold, MD Thomas H. Hicks, MD Gary Figge, MD (alternate)

Arizona Medical

 

Association Officers

PCMS Board of Directors

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

 

Eric Barrett, MD Diana Benenati, MD Neil Clements, MD

Executive Director

Bill Fearneyhough

Phone:

795-7985

Fax:

323-9559

E-mail:

billf 5199@gmail.com

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Phone:

795-7985

Fax:

323-9559

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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 repre- sent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright © 2014, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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Inside

 5

Milestones: Books, awards, lectures for our members.

8

PCMS News: University reactivates heart transplant program.

12

Makol’s Call: And we thought our Behind the Lens columnist was our only car nut!

14

Behind the Lens: Some of Dr. Hal Tretbar’s old friends are old cameras.

17

In Memoriam: We have lost doctors Sam Paplanus and John Welsh.

19

The ACA: An update at PCMS from a panel for Pima County Medical Foundation.

22

Practice Management: Dr. Steve Perlmutter on handling medical board complaints.

25

Perspective: Dr. Jason Fodeman warns about graduate medical education funding cuts.

26

Mayo CME: Coming offerings from the folks up the road.

Mayo CME: Coming offerings from the folks up the road. On the Cover A Hatch River

On the Cover

A

Hatch River Expeditions tail-dragger raft approaches Hance Rapid

in

the Grand Canyon in 1967. The image is from a 120 Ektachrome

transparency shot with a Rolleiflex and mounted in glass. It shows how the famed Hatch riverboats have changed from when they used only one pontoon, and were called tail-draggers because, unlike today’s rigid designs, they were dangerously flexible. That year Dr. Hal Tretbar was with a group of 30 Tucson physicians that was among the first to float the Colorado through the Canyon. See this issue’s Behind the Lens for stories behind his old friends, the cameras that shot ’em. (Dr. Hal Tretbar photo).

Correction

In our May issue’s Valley ENT feature’s list of PCMS East-Side Tuscon OTO members, Dr. Thomas J. Tilsner told us we left him out, which indeed accidentally we did. Dr. Tilsner has practied on the East Side since 1979 and tells us he the seinor OTO physician in Tucson. He joined PCMS in 1986. Our apologies to Dr. Tilsner!

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Milestones

Dr. Rosenthal:

they felt their physician cared about them as a person. TMC was ranked in the 99 th percentile for this patient satisfaction question.

ED patients are triaged an average of 13 minutes after they arrive.

On average, children are consistently treated and released in less than two hours.

Patient satisfaction scores have consistently run in the 80 th to 90 th percentile.

“While some major changes have been made in TMC’s Emergency and Pediatric emergency departments, which have led to successful outcomes, we will continue to work on improving our service and increasing patient satisfaction,” Dr. Rosenthal said.

That dedication and commitment to improving care for the community is one of the reasons Dr. Rosenthal was selected as EmCare’s Emergency Physician of the Year. “So many of our physician leaders do so much more than their physician job duties or their leadership job duties require,” said Dr. Dighton Packard, EmCare CMO. “They help their communities. They help people outside of their communities. They offer outstanding patient care while improving operations for their organizations. We feel an obligation to recognize these outstanding clinicians in a grand way, in front of all of their peers.”

Award is team effort

By Tucson Medical Center

Tucson Medical Center Emergency Department Medical Director Richard Rosenthal, M.D. was recently honored as Emergency Physician of the Year for 2014 by EmCare, the nation’s leading national practice management company.

Dr. Rosenthal received the Commitment to Care Award for Emergency Medicine and was selected from more than 10,000 affiliated clinicians.

An EmCare press release said Dr. Rosenthal received the award because of his commitment to, and implementation of lean methodologies that helped guide TMC’s emergency and pediatric emergency departments to improved and sustained quality metrics.

“Awards are nice, and certainly appreciated,” Dr. Rosenthal said, “but it is our team here— the nurse managers, the pediatric emergency medical director, and a fantastic, dedicated administration—that allows us to work together to improve the processes and improve the care we deliver.”

Dr. Rosenthal said his team continually works on improving the patient experience by decreasing wait times and the total amount of time a patient spends in the ED.

Some highlights of TMC’s Emergency Department improvements include:

The wait time to see a physician decreased 48 percent down to an average of 37 minutes, according to data from July 2012 to December 2013.

Patient satisfaction scores increased by more than 43 percent from July 2012 to March 2014.

During the same time frame, more TMC Emergency Department patients reported

2014.  During the same time frame, more TMC Emergency Department patients reported SOMBRERO – June/July
2014.  During the same time frame, more TMC Emergency Department patients reported SOMBRERO – June/July
2014.  During the same time frame, more TMC Emergency Department patients reported SOMBRERO – June/July
2014.  During the same time frame, more TMC Emergency Department patients reported SOMBRERO – June/July
2014.  During the same time frame, more TMC Emergency Department patients reported SOMBRERO – June/July

Dr. Goldberg lectures on lasers

Gerald N. Goldberg, M.D. reports that he lectured at the American Society for Laser Medicine & Surgery’s 2014 Annual Conference April 4-6 in Phoenix.

The conference is the premier venue for medical laser education internation- ally, he said. Dr. Goldberg moderated an all-day session on “Fundamentals of Lasers in Healthcare” in which he presented three hours of lectures on

Fractional and full Ablative CO2 Laser Skin Rejuvenation, Vascular Lesions (with emphasis on Port Wine Stains) and video endpoints of cutaneous laser therapy. He was also on a panel of experts discussing the Cutera Excel V Laser, the newest state-of- the-art vascular laser for cutaneous vascular anomalies.

Dr. Goldberg said his 30-year history with lasers makes him an international authority on lasers for the skin and an integral contributor to ASLMS. He is a Clinical Professor of Dermatology at

to ASLMS. He is a Clinical Professor of Dermatology at the University of Arizona College of
to ASLMS. He is a Clinical Professor of Dermatology at the University of Arizona College of

the University of Arizona College of Medicine, where he has been on faculty since 1984 instructing medical students and residents. He is a preceptor for dermatology residents for the American Society of Dermatologic Surgery (ASDS) as well as ASLMS.

Dr. Goldberg said he uses more than 16 laser modalities at his Tucson practice, Pima Dermatology. This summer he will be lecturing at Canyon Ranch Health Resort for guests and staff. He will also lead a training session for their aesthetics team to further aid in identifying common skin cancers and skin conditions.

In Fall, for the fourth consecutive year, he will lecture on a variety of topics at the prestigious Beckman Laser Institute in Los Angeles. For more information, please visit www.pimaderm.com.

Dr. Gann in book form

Dr. Dietmar Gann and his wife, Elizabeth Gann MBA CNC, have become known for Dr. Gann’s Diet of Hope, about which they say “no surgery, no drugs, no gimmicks.” Those who frequent PCMS headquarters know that our conference facility is where they give meetings about the diet.

Now the diet is in book form, Diet of Hope—Your Journey to Health, which the Ganns have recently published in an easy-to-read, well categorized 136 pages with an introductory price of $14.95.

As Dr. Gann described awhile back in a series of Sombrero columns, he comes down firmly on the anti-carbohydrate side of the low-carb/low fat diet debate, which might be called the Atkins side, if it’s even still debated. The results of the poor American diet are certainly not debated because the evidence is in.

“Two thirds of the U.S. population is overweight or obese,” the Ganns write. “One hundred million Americans are pre-diabetic or diabetic. What causes obesity and diabetes? By now, most of us agree: Carbohydrates. Our government and [professional specialty] medical societies disagree. They are still on the ‘fat makes us fat’ bandwagon. They insist carbohydrates are healthy and tell us we should eat a lot of it, and that at least 60 percent of our calories should come from carbohydrates.

“Where is the disconnect? Our dietary guidelines come from the Department of Agriculture, whose mission is to promote agriculture, not your health. The business model of the food industry is to addict us to cheap, sugary, salty, fatty food produced in huge factories. Our government supports sugar and corn production with billions of dollars to benefit the food industry.

“This book describes the pseudo-science of the low-fat diet and debunks the thinking of our government and [professional specialty] medical societies. In 1980 the president of the

government and [professional specialty] medical societies. In 1980 the president of the 6 SOMBRERO – June/July

American Heart Association announced that if we all went on a low-fat diet, heart disease would be wiped out in the year 2000. Heart disease is still with us, as are the side-effects of a low-fat diet: obesity and diabetes. Dr. Gann’s Diet of Hope helps treat and prevent diabetes through teaching proper nutrition.”

For the book on Dr. Gann’s approach, please log onto www. dietofhope.org .

Dr. Rhee’s ‘Trauma Red’

onto www. dietofhope.org . Dr. Rhee’s ‘Trauma Red’ In May a pre-release party and book-signing at

In May a pre-release party and book-signing at UA Bookstores celebrated the release of a memoir by Dr. Peter Rhee, Trauma Red:

The Making of a Surgeon in War and in America’s Cities, which Scribner published in June.

The book blurb encapsulates how Dr. Rhee came to public prominence. “On Saturday, Jan. 8, 2011, Dr. Peter Rhee was called in to work—on his first day off in weeks—to Tucson’s University Medical Centrer’s Trauma Center where 10 gunshot victims were being rushed after a man opened fire on a crowd of people at a local supermarket.

“One of the victims was Rep. Gabrielle Giffords. It was a day the nation would never forget, but for Dr. Rhee, it was also just another day on the job, saving lives. In his gripping memoir, Dr. Rhee cecalls that ‘challenging, exhausting, exhilarating, frustrating, heartbreaking, satisfying, bloody, bloody, bloody day at the office’ and the path that led him there.

“From his youth South Korea and Uganda—where he once watched his surgeon father remove a spear from a man’s belly— to frontline surgery in Iraq and Afghanistan, to trauma center on the urban battlefields of Los Angeles and Washington, D.C., Dr. Rhee’s life story is so much more than you already know.”

Dr. Iserson’s here. No, he’s not.

Truly a doctor without borders, Dr. Ken Iserson was recently back long enough to tell us he’d been three months working and teaching at emergency medicine residency programs in Vietnam and India, and was then off for two weeks in Canada. At the end of August—surprise!— he’s off for three months teaching/ working at EM residencies in Guyana and Argentina.

Meanwhile, he got a great review of his new book, Improvised Medicine: Providing Care in Extreme Environments (New York, McGraw-Hill, 2012, 578pp, $56, paperback.

“Dr. Iserson has given us a most remarkable book,” wrote Mark K. Huntington, M.D., Ph.D. of the Sioux Falls Family Medicine Residency and the University of South Dakota Sanford School of Medicine, writing in the May Family Medicine. “Drawing from his experience providing care in international, wilderness, and disaster settings,” Dr. Iserson “has compiled an impressive collection of bare-bones equipment and work-around strategies to provide the best possible care in resource-poor settings. While presenting many creative examples, the purpose of the book is not to offer an exhaustive list of solutions to missing resource challenges, but to inspire creativity in readers who may find themselves needing to improvise. …

“Among the more interesting sections to this reviewer were the Critical Care sections. Although modern ICUs blur the line between reality and science fiction, quality critical care can often be provided with less technology and still save lives. Some of the improvisations presented in this section are not merely relevant for chronically resource-limited settings; for example, the technique for using a single ventilator for several patients simultaneously has clear relevance to the most modern facility in the event of a respiratory pandemic.

“Another valuable section is Dental Care. As physicians, we have limited experience in this area, yet in many settings, the ability to treat basic dental problems alleviates a tremendous amount of human suffering. Very practical, step-by-step procedural descriptions are included and are well illustrated. …

“While concise, the work uses an almost folksy style, making for an easy read. Concepts are presented” using “engaging anecdotes, and the ideas are amply illustrated. … The appeal for this book is broad. Obviously it should be required reading for those involved in disaster response or global health activities (including medical students doing electives abroad). It would be a valuable read for any physicians who leave the confines of their medical centers and may encounter the words, ‘Is there a doctor in the house?’

encounter the words, ‘Is there a doctor in the house?’ “Also, it should be in every

“Also, it should be in every hospital library, in case a disaster reduces them to an ‘extreme environment.’ Improvised Medicine is a remarkable compilation of concepts and contraptions, both innovative and historical, that can improve medical care in the most difficult situations. MacGyver

n

would be proud!”

PCMS News

UAMC reactivates heart transplant program

University of Arizona Medical Center—University Campus reported May 28 that it had “reactivated its Heart Transplant Program after receiving approval from the United Network of Organ Sharing (UNOS). UAMC temporarily suspended the program in December to recruit for—and strengthen—its highly specialized transplant team.

“The reactivation follows the recent recruitment of Scott D. Lick, M.D., professor in the UA Department of Surgery, Division of Cardiovascular Surgery, and director of UAMC’s Heart Transplant Program, and Nancy K. Sweitzer, M.D., Ph.D., professor of medicine and director of the UA Sarver Heart Center and chief of the Division of Cardiology.”

UAMC reported that its surgeons performed the state’s first heart transplant in 1979, and have performed 891 heart transplant procedures to date.

“‘We now have in place at UAMC the strong leadership and multi- disciplinary partnerships found in high-achieving transplant teams across the country,’” said Alexander Chiu, M.D., Department of Surgery acting head, and a PCMS member. “‘This is critical in order to offer the full range of quality, lifesaving care to patients with advanced heart disease.’”

The report then detailed the specialists involved and said they are now “fully staffed,” but it’s actually a story with more background than foreground: It’s the latest repercussion of the seven-month- old legal battle between the university and the surgery department chairman they fired, Dr. Rainer W.G. Gruessner, a PCMS member.

In the Nov. 21, 2013 Arizona Daily Star, Stephanie Innes reported that, “A charismatic … surgeon who attracted high-profile doctors to the University of Arizona Medical Center … says he’s being forced out of his job.” Indeed, we published it in these pages whenever Dr. Gruessner attracted a new surgical specialist to his department.

As Dr. Gruessner expanded the department and its types of surgeries, the paper reported, “he made some significant hires. Among the doctors he recruited were Peter Rhee, M.D. and G. Michael Lemole, Jr., M.D., who became known around the world when they cared for former Rep. Gabrielle Giffords and others wounded in the Jan. 8, 2011 Tucson mass shooting.” Both surgeons are PCMS members.

The paper reported what can now be seen online: that Dr. Gruessner, represented by Phoenix law firm Jaburg Wilk, P.C., filed a 191-page lawsuit describing “professional rivalries and discord” at Southern Arizona’s only Level 1 Trauma Center. They reported that Dr. Gruessner was put on paid administrative leave in September 2013. A Dec. 13, 2013 letter from University

Physicians Healthcare from President and CEO Michael R. Waldrum, M.D., M.S., M.B.A. to Dr. Gruessner fired him from that organization.

“Records that are part of the court filing,” the paper reported, “indicate the UA is investigating a claim that Gruessner either altered records on transplant procedures himself, or directed others to alter them.” Dr. “Gruessner denies any wrongdoing. Rather, he says in court documents, his suspension is retaliation because” he had “spoken up about ‘a climate of fear, retaliation and favoritism’” that had “developed during College of Medicine Dean Steve Goldschmid’s tenure, resulting in low morale among faculty and staff, and a financial system that rewards Goldschmid’s supporters.” Dr. Goldschmid is a PCM S member.

Dr. Gruessner “is not asking for any financial damages,” the Star reported. “Rather, the lawsuit seeks reinstatement of his positions as a tenured professor at the College of Medicine, as chairman of the Department of Surgery, and as an active staff physician at University Physicians Healthcare, which staffs” UAMC.

The university and UA Health Network say they do not comment on pending litigation. Jaburg Wilk attorney Kraig Marton said the ball remains in the university’s court. On March 7 in Pima County Superior Court, he said, Judge Carmine Cornelio ordered UPH to have a hearing on Dr. Gruessner’s dismissal, which the surgeon charges was done without internal due process. But there has yet been no hearing scheduled, Dr. Gruessner told the court, and Judge Cornelio suggested that UPH have the hearing by the end of June, Marton said. “We’re anxiously awaiting the hearing in which Dr. Gruessner will clear his name.”

The Star reported in May that Dr. Gruessner is still on paid administrative leave. They quoted Jaburg Wilk’s filing saying that the “core” of “differences between Dean Goldschmid and Dr. Gruessner is a strong disagreement over how to realize the research, educational, and clinical objectives of the College of Medicine and its departments.”

Getting assistance for family caregivers

By Pam Wessel, M.S.S.W.

Physicians often hear about their patients’ stresses and concerns about issues when they are caring for a family member. Possibilities include:

The daughter who calls, concerned about her father’s memory loss and frustrated by his denial that it’s an issue.

The son whose blood pressure is elevated due to the stress of caring for both his aging mother and his own family while working full-time.

The devoted wife who is trying to care for her husband even though his care exceeds what she can realistically provide.

As a physician you can advise a patient to avoid stress or to seek in-home help, but developing a plan to achieve these results may be more difficult.

How can you best help your patient in these circumstances? Refer the patient to Pima Council On Aging. PCOA’s knowledgeable staff

can take the time to talk in depth with concerned daughters,

stressed sons, and overwhelmed wives to get to the heart of the matter and discover what is needed most. Caregiver Specialists provide information to clients about:

Private-pay and publicly funded in-home services.

Comparison of costs and amenities offered by assisted living communities.

Advance directives.

Transportation options.

Dementia education.

Dealing with emotional stress.

Other issues

PCOA offers Caregiver Support groups with regularly scheduled meetings in various locations throughout the county, including Tucson, Oro Valley, and Green Valley. Caregiver Training classes are available at no cost to family caregivers to teach them the necessary skills of providing care. PCOA also provides Respite services to give full-time caregivers a break and a chance to take care of themselves.

The next time a patient presents with worries and concerns about caregiving and needs information on assistance available in the community, please provide him or her with the number for PCOA. As the treating physician, you can make this referral with confidence, knowing there is help available and your patient’s questions will be answered.

Please call the Pima Council on Aging Help Line at 520.790.7262, or visit www.pcoa.org .

Pam Wessel, M.S.S.W. is Pima Council On Aging director of services.

A suggested rescue kit

From the PCMS Public Health Committee

Physicians may find themselves at the scene of a natural disaster, terrorist attack, mass shooting, motor vehicle crash, or other scenario involving multiple casualties.

This list is based partly on recommendations from the Committee for Tactical Emergency Casualty Care (C-TECC). More than one tourniquet is a good idea. Excellent training in rescue by citizen first-responders in such situations is offered by the Medical Reserve Corps of Southern Arizona. The course is very valuable for physicians also. Items are:

• Tourniquet such as the CAT, the MET, or the Soft-T-W • Chest seal • Curlex gauze in a Z-fold or roll • A hemostatic agent (combat gauze, Celox, etc.) • Ace bandage for securing the pressure dressing • Nasopharyngeal airway • No. 14 gauge 3¼-inch needle to decompress tension pneumothorax • Small roll of duct tape • Trauma shears • Cricothyroidotomy kit • LED headlamp

Sources: rescue-essentials.com, mooremedical.com REFERENCE Hatfill SJ, Orient JM. Immediate bystander aid is blast and ballistic trauma. J Am Phys Surg 2013;18:101-104. Available at:

www.jpands.org/vol18no4/hatfill.pdf.

Slides and video from one-day course: http://www.ddponline. org/hatfill/

MRCSA adds board members, assesses needs

The Medical Reserve Corps of Southern Arizona reports that William Mangold, M.D. and Kris Blume have joined its board of directors just as MRCSA is seeking input from the American Red Cross, Tucson Fire and area hospitals as to what those organizations think is the best role the organization can fill for them.

Dr. Mangold, who is a lawyer and a plastic surgeon, is well known to PCMS members as a former ArMA president and longtime

a plastic surgeon, is well known to PCMS members as a former ArMA president and longtime

delegate to the AMA. He recently retired as carrier medical director for the Medicare program.

Kris Blume is 14-year veteran of, and captain with, the Tucson Fire Department and chairs Tucson Metropolitan Medical Response System. He has teamed up to co-teach, with Sheldon Marks, M.D. the popular MRCSA offering, Emergency Civilian Casualty Care.

Dr. Mangold and Blume join other board members Dr. Marks, Mary Stebbins, R.N., Les Caid, Tim Siemsen, and Steve Nash.

MRCSA was one of the first units formed after the call went out following the events of Sept. 11, 2001. As medicine and emergency response have changed, MRCSA is re-examining its

role and asking partners throughout the city for thoughts to best use the wealth of volunteers.

“We will finish this process by summer’s end,” Nash said, “and then recruit for the needs identified.”

And speaking of volunteers…

Volunteer opportunities

St. Elizabeth Clinic: The clinic at St. Elizabeth’s Health Center (formerly St. Elizabeth of Hungary Clinic) depends on many physician volunteers. Physician staffing is needed for a half-day clinic every three months, or four clinics per year. Each clinic generates a few procedures such as echo,

year. Each clinic generates a few procedures such as echo, stress, or holter. If you’re interested
year. Each clinic generates a few procedures such as echo, stress, or holter. If you’re interested
year. Each clinic generates a few procedures such as echo, stress, or holter. If you’re interested
year. Each clinic generates a few procedures such as echo, stress, or holter. If you’re interested
year. Each clinic generates a few procedures such as echo, stress, or holter. If you’re interested
year. Each clinic generates a few procedures such as echo, stress, or holter. If you’re interested
year. Each clinic generates a few procedures such as echo, stress, or holter. If you’re interested

stress, or holter. If you’re interested in volunteering, e-mail Dr. Charles Katzenberg at ckatzenberg123@gmail.com .

University Women’s Clinics: The clinics provide free medical care for women and children. Physician volunteers provide basic family care such as gynecological and pediatric services. The clinics operate three Wednesdays per month near the UofA College of Medicine. At each clinic, the attending hears patient presentations by medical student volunteers, signs off on SOAP notes, and sees the patient afterward to draw up a final assessment and plan.

Those interested in volunteering may contact PCMS Student Member Juhyung Sun at 269.1376, or e-mail jsun00@email.arizona. edu .

UofA researchers ID viral genes that control cytomegalovirus reactivation

AHSC: Identifying mechanisms that determine CMV latency could lead to targeted therapies to prevent CMV- related disease

Arizona Health Sciences Center reports that UofA researchers have found genes within the human cytomegalovirus (CMV) that control whether it remains latent (inactive) or actively replicates (multiplies). The discovery could lead to targeted therapies that prevent disease caused by reactivation of the virus, which nearly everyone carries.

“Most people are infected with CMV early in

life and have no symptoms or even knowledge of the infection.

The virus remains in the body in a latent state that can later reactivate, causing life-threatening problems in people with compromised immune systems. Further, a baby infected prior to

birth can have devastating birth defects.

“Felicia Goodrum, Ph.D., associate professor in the UA College of Medicine—Tucson Department of Immunobiology and UA Department of Molecular and Cellular Biology, and a member of the UA BIO5 Institute, researches the latency of CMV. In two

recent papers—one a spotlight article—in the Journal of Virology, Goodrum details her laboratory’s discovery of genes within

CMV that promote either latency or reactivation and replication

of the virus.

“‘Viral latency is one of the most poorly understood phenomena

in virology,” she says. ‘This work defines a basic molecular switch, controlling entry into and exit from latency. Therefore, for the first time, we have identified targets that may allow us to control

virus reactivation.’

“CMV is one of eight human herpesviruses, infecting 60-99 percent of adults worldwide. Among the extremely common herpesviruses are those that cause chicken-pox, shingles and mononucleosis, in addition to herpes simplex.

“‘Most people carry three to four herpesviruses most of the time without knowing it,’ Goodrum says. ‘People know viruses like influenza better because they get sick. After you recover from the flu, your relationship with that virus is essentially over. But with a latent virus, you have it forever. There are absolutely no symptoms of CMV and no way to cure the virus. This is an exceptionally stealthy virus.’

“Though typically latent, CMV can cause significant health problems when reactivated. When an infected person has a compromised immune system, like in cases of organ or stem cell transplant, HIV infection and some intensive chemotherapy regimens in cancer patients, the virus can cause life-threatening

disease. The virus also is the leading cause of infectious disease- related birth defects, affecting more babies in the United States

than Downs Syndrome, fetal alcohol syndrome and spina bifida.

“CMV is the largest known human virus, with about 200 genes, and in an effort to understand its unusual persistence, Goodrum is studying the genetics of the virus, mutating different regions of the genome to identify ones that impact latency. In one particular region of CMV’s genetic code, she has identified separate genes that are encoded to either promote or inhibit viral function.

“‘We don’t know exactly how these are functioning yet,’ she says.

‘We’re trying to identify the pathways in the infected cells that

they are targeting. We think they’re targeting the same cellular

pathways, but with opposing effects. It’s the balance of these actions that we think eventually dictates a latent or a productive infection,’

“There is no vaccine for CMV and the only drugs existing currently target cells that are actively replicating the virus, leaving the

latent cells untouched. Identifying the mechanisms that determine latency could lead to targeted therapies that prevent CMV-related disease. ‘Treatments could either force the virus to reactivate and then clear it out, or prevent reactivation all together,’ Goodrum says. ‘Those would be huge medical successes.’”

Goodrum and fellow researchers’ work is supported by a grant from the National Institutes of Health (National Institute of Allergy and Infectious Diseases, AI079059, and National Cancer Institute, CA343111), and the Pew Scholars in Biomedical Science Award.

PCMF CME dinner events

Pima County Medical Foundation has scheduled these CME events for its Tuesday Evening Speaker series. Dinner is served at 6:30 p.m. and the presentation is at 7.

Sept. 9: New Medical and Surgical Treatments for Prostate Cancer presented by Rick Ahmann, M.D., and Shanna Dougherty. M.D.

Oct. 14: Dermal Fillers and Fat Stem Cells in Plastic Surgery presented by plastic surgeon John Pierce, M.D.

Nov. 11: Newer Anticoagulants and their Role in A-Fib, DVT, and Pulmonary Embolism presented by Timothy Fagan, M.D.

Writing PCMS position papers

Have you ever had a strong opinion about a health-related issue confronting the medical profession, and wish the medical society would take a stand?

The Society, as part of its general policy to encourage members to speak out about issues, has established a procedure you can use in asking the PCMS Board of Directors to take a position on a subject of importance to the community or the profession.

State your views and forward them to Bill Fearneyhough by writing to him at the society, 5199 E. Farness Drive, Tucson 85712, or e-mail billf5199@gmail.com. PCMS President Timothy Marshall will take the issue to the board for discussion. If approved for further study, physician leaders will be assigned to do background research and prepare a “position paper” for board approval.

When the paper is in final form, it will be published in Sombrero, presented to our national and Southern Arizona legislative delegation and, if appropriate, presented in resolution form at the annual meeting of the Arizona Medical Association. Media will also receive a copy.

Take your opportunity to speak out!

n

Makol’s Call

American motorvation

By Dr. George J. Makol

Makol’s Call American motorvation By Dr. George J. Makol R ather than dissecting the ACA, or

R ather than dissecting the ACA, or discussing

poverty, tax policy, the digital revolution, music, the Ameri- can diet, or illegal immigration, this month I’d like to take on a really important topic:

Cars.

My childhood was filled with visions of 20-foot-long Cadillacs with huge tailfins, shiny Thun- derbirds with “Continental” tire kits on back, and the heart- stopping designs of the late

’50s and early ’60s Corvettes, several of which I later had the privilege to own.

Every car maker was distinct in its design. You could identify a Packard sedan from blocks away. Chryslers had aggressive grillwork that smiled back menacingly as you approached. Chevys came in incredible colors, like the Bel-Air convertibles that were white and eggshell blue and still bring tears to a car lover’s eyes.

That era is long gone. Today almost every car looks like a Toyota or a Honda. I found myself just the other day surrounded by Toyotas and Hondas that all looked generically the same. It jolted me to realize I was in my own driveway and that my wife and kids all drive one of them! I, however, am an American car guy.

How much of an American car guy? In my five decades of driving I have owned more than two dozen Chevys, a half-dozen Fords, a few Dodge Chargers, Plymouth Furys and other muscle cars, Chrysler wagons, and a few Chevy Suburbans. And in driving all these American cars, I have never had an engine or transmission fail, and have never broken down and had to be towed. In fact, as a kid in my trusty ’65 Impala convertible, I frequently drove out to rescue and sometimes tow my friends’ Austin Healeys, Triumphs, Jensen Healeys, and even Jaguars.

I will admit that I have had a door handle come off, a radio dial fall to the floor, and a window or two stick, but it is distinctly easier to crawl out the window of a Chevrolet Suburban than a German sports car: I have owned both and done that in both.

So what is it with doctors and foreign cars?

Years ago here in Tucson I had a doctor friend who drove a new Saab Turbo. Now, to me a Saab looks like a giant petrified dinosaur-dropping with wheels. He had so much trouble with that new car. It stalled. It stopped dead in the middle of traffic. It ran rough all the time. He went back and forth with the dealer so many times, and got no satisfaction, only more aggravation. Within a short time the poor fellow had a fatal heart attack, and his associates swear the it was the car that did him in. That dealership is long gone, and even the Saab brand is American history, as previous owner General Motors sold it to Dutch boutique automaker Spyker Cars. I don’t miss it.

A few years ago I had the privilege of getting the first Chrysler

300-C Hemi delivered to Tucson. I had to do it. My Chevy Suburban had just been stolen and I had seen Shaquille O’Neil on TV in his new black 300-C and thought it was one of the most beautiful cars ever.

This car had Mercedes running gear and suspension, superb and

distinctive American styling by Ralph Gilles, Continental GT Sport tires, and a Chrysler 360 horsepower Hemi engine. ( A hemispherical engine is an internal combustion engine in which the roof of each cylinder’s combustion chamber is of hemispherical form, boosting the maximum power at high RPMs.

* This car could fly, but when nursed the engine used only four

cylinders and yielded 17 mpg city, and in the 20s on the highway.

I took this car in to the dealer for my first oil change and full service. When I picked it up later, I noticed my bill was $38, so I found my trusty service guy and told him he must not have done the oil change, the lube and filter, and the 40- point safety check, because the bill was too low! I told him my doctor friends were always complaining about $275 to $350 bills for routine service for their Mercedes Benzes and BMWs. He laughed and told me that he used to work at a BMW dealership and they did exactly the same service that my car had just received, but then charged a couple of hundred dollars more!

Those German brands are certainly fine cars, and today one can always get a lease that includes routine service. However, to get a car with similar performance from Mercedes at the time would have required an AMG model (Mercedes’ high-performance “tuner” division), at about double what I paid. I kept that American car for four years, and never drove it for one whole day without receiving compliments from passing strangers on its design. I never had to fix a thing on that vehicle, and my wife is still mad at me for trading it in and not giving it to her.

So before you invest in another conservatively styled Teutonic machine that still looks like a Toyota or Honda, search “Cadillac Poolside Commercial” on the Internet, watch the video, and prepare to laugh out loud!

Then drop by a Cadillac dealer and test drive a new CTS-V with its unique design, incredible performance, and AMG-level power at

a discount. Visit a Ford dealership and try out a more reasonably

priced Ford Fusion Titanium edition, with a grill reminiscent of then-Ford-owned Astin Martin, and a twin turbocharged engine that delivers the best power/mpg ratio in its class.

Or, if you dare, test drive the monstrous 2015 C7 Corvette. I did, and they are building me one in a good old American factory in Bowling Green, Ky. As you read this, and I already am planning a track day.

But boy, I really did like that little Mercedes E 350 that I rented in Miami. Maybe next time … Stuttgart.

*Wikepedia, 2014

Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd. He has been a PCMS member since 1980.

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Behind the Lens Some of my best friends are cameras By Hal Tretbar, M.D. I

Behind the Lens

Some of my best friends are cameras

By Hal Tretbar, M.D.

I was poking around in a storage closet recently

where I keep a lot of my photo gear, mostly pre-digital. As with

I keep a lot of my photo gear, mostly pre-digital. As with My mother’s Kodak box

My mother’s Kodak box camera has a sticker from Hawaii’s Kilauea Volcano House. The Filmo still has undeveloped movie film.

It served me well up until 1950, when the C3 burned up in a

building fire. I replaced it with an Exakta II made in Dresden, Germany. It had interchangeable lenses and was the first single-

lens reflex available in this country. In 1957 I traded the Exakta for

a 4x5 Speed Graphic. Thirty years later the mint-condition Speed Graphic was sold to a collector for $200.

I hit the jackpot in 1957 when I bought a new 35mm Nikon S2

rangefinder with a 50mm 1.4 Nikkor lens for $250. A friend had just purchased it in Hong Kong. It was one of the best cameras

I ever had. I sold it to a German collector in 1987 for $1,500. I wish I still had it.

I still have favorites in that closet, and with them come stories.

In 1950 I was in college when my parents gave me a tiny camera that they brought back from Hong Kong. The 16mm

Tone camera has a case that is inscribed Made in Occupied Japan. The 25mm anastigmatic lens

adjusts from f3.5-11. The shutter speeds are B, 1/25 and 1/100 second. It focuses down to two feet. Too bad 16mm roll film was not available here. The best thing you can say about the Tone is that it is excessively cute.

When I was in the Army, in Germany, I was stationed 15 miles from Wetzler, the home of Leitz and Leica cameras. For $300 I purchased one of the finest cameras in the world: a Leica M3 rangefinder with an

a lot of others, I don’t throw much away, in case I might need it later.

Suddenly I was overwhelmed by boxes of old 35mm slides and sleeves of 120 black-and-white and Kodacolor negatives.

Oh, there are lots of odd-sized filters, extra lenses, flash units, tripods, and camera bags. But the boxes! Plus quite a few 4x5 negatives in glassine envelopes, plus many more boxes of mounted 120 transparencies! Does anyone remember when you mounted your best transparencies in glass to “save” them?

I was feeling depressed! Then I started looking at my old favorite cameras. Now these are worth saving!

My favorites are the mechanical marvels that leave a permanent image on film. They are made of sturdy metal, with touches of chrome or spun aluminum, while I have some old digital cameras and cell phones that are almost plastic throwaways. Heck, there’s

a new version every six months.

I come from a family of photographers. My father had a top-of-the-

line Cine-Kodak Special 16mm movie camera in 1941. It was purchased by the government for military use. Then for many years he filmed with a Bell & Howell 16mm Filmo with magazine loading.

I still have my mother’s Kodak 2a box camera that she used on their honeymoon to Hawaii in 1929. She was using an exceptional 35mm Contax IIa rangefinder at the time of her fatal accident in Communist Yugoslavia in 1977. It remained in the family with my physician/photographer brother.

I started with a 120 Agfa Ansco in junior high school. I had a darkroom, and built an

enlarger from an old folding camera. It wasn’t very long before I had my first 35mm camera, an Argus C3. The triplet Cintar f3.5 lens was coupled to a rangefinder. Shutter speeds were from

1/10th to 1/300th of a second.

A flash unit plugged into two

holes on the side. It was popular because of its rugged durability and sharp images. With its squared-off shape the C3 became known as ‘The Brick.”

squared-off shape the C3 became known as ‘The Brick.” The tiny Tone camera has a full

The tiny Tone camera has a full set of adjustments for shutter speed, aperture, and focus.

f1.2 Summilux lens and a 135mm Hector f3.5 telephoto. I have used it around the world.

Several years after we moved to Tucson in 1965, our family was fishing at Greer. Our youngest son dropped the Leica M3 into the Little Colorado River with a loud splash. I immediately had it cleaned and repaired. It has been good as new ever since. On eBay, a complete outfit similar to mine with a 135mm Hector, a Leica light meter, and leather case was offered for $2,895.

I have had both double- and single-lens 120 Rolleiflex cameras.

My standard twin-lens Rolleiflex has been a ubiquitous best friend since 1952. It has been at my side throughout medical school, internship, the Army, residency, and now Tucson. Photos from it have appeared in various books and magazines. A black- and-white shot of Bell Rock in Sedona won a contest with a weekend for two in Las Vegas.

I have a lightweight metal waterproof camera case for the Rolleiflex. The case has small knobs for the shoulder strap. It is clamped tight shut by a large rotating lever. It has protected the Rolleiflex on numerous trips down the Colorado River through the Grand Canyon.

Once we were flying out of Denver. I didn’t have the shoulder strap on when I placed the metal case under my aisle seat. Later during the flight the flight attendant whispered in my ear that there had been a bomb scare when the case slid down the isle during the steep takeoff! The co-pilot had to be called to the back to identify it as a camera case!

I still have my first Nikon SLR, or rather almost first. We were

getting ready for a safari in Kenya in 1983 when I was in New York

ready for a safari in Kenya in 1983 when I was in New York On the

On the left is the world’s most expensive camera case. The waterproof Rolleiflex case can look menacing.

for a conference. I went to a discount camera store and bought a complete Nikon outfit: a Nikon FE2 camera with a 28-70 f3.5 Nikkor lens, a 70-210 f4 Nikkor telephoto, a 1.5x extender, a motor drive, a flash, and a case. There was no N.Y. state tax if the purchase was mailed out of state. So the store mailed just the case and I took the rest with me in a small travel bag.

It was raining the next day when I took a taxi to the airport. I jumped out of the taxi with my suitcase, hanger bag, and briefcase. I watched in surprise as the taxi drove off into the mist with all of the brand new Nikon gear. I can tell you the phone call home to Dorothy was not easy. There was nothing else to do but

tell you the phone call home to Dorothy was not easy. There was nothing else to
Nostalgia took me to eBay for an Argus C3. The Nikon FE 2 has an

Nostalgia took me to eBay for an Argus C3. The Nikon FE 2 has an external motor drive. The Rolleiflex has been a buddy since 1952.

motor drive. The Rolleiflex has been a buddy since 1952. My Leica M3 outfit has had

My Leica M3 outfit has had a rigorous life but survives in pristine condition.

to call an order for the same outfit again from the same dealer. I now own the world’s most expensive camera case!

Nostalgia overcame me while I was writing this column, I went to eBay, and bought an Argus C3 in very good shape for $20

including shipping. When I was telling this to friends recently, it turns out they too had C3s. In fact during the production run from 1939 to 1966 it was the most popular 35mm camera, selling more than 2,000,000. Jimmy Carter used one during his naval

career and it is now on display in his presidential library.

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In Memoriam

By Stuart Faxon

Dr. Samuel Paplanus,

1928-2014

In Memoriam By Stuart Faxon Dr. Samuel Paplanus, 1928-2014 Dr. Samuel H. Paplanus, pathologist, educator and

Dr. Samuel H. Paplanus, pathologist, educator and researcher, who joined PCMS in 1973, died on June 5. He was 85.

Samuel Harris Paplanus was born Sept. 10, 1928 in Columbia, Tenn. He was raised in Winchester, Tenn. and graduated from Columbia Military Academy in 1946. He graduated from Vanderbilt University, Nashville, with distinction in 1950. He was a member of Zeta Beta Tau Fraternity.

Dr. Paplanus graduated from Vanderbilt Medical School in 1954, and completed his pathology residency Vanderbilt University Hospital. He he served in the U.S. Army Chemical Warfare Research Department at Fort Detrick, Md. 1958-60, earning captain’s rank. He had a fellowship in medicine at Yale University, and was a fellow, instructor, and assistant professor of pathology at The Johns Hopkins University, Baltimore, 1960-72. He then came to work as a pathologist at University of Arizona Medical Center and as associate professor, then in 1979 full professor of pathology, at the University of Arizona College of Medicine. He did consulting work at [Carondelet] St. Mary’s Hospital and the Southern Arizona Veterans Administration Hospital.

He was a member of the American Society of Clinical Pathologists, American Association of Pathologists and Bacteriologists, American Society of Experimental Pathology, Arizona Society of Pathologists, American Federation for Clinical Research, Association for Computing Machinery, Inc., American Society of Nephrology, American Association for the Advancement of Sciences, and the AMA.

“Sam was an avid traveler who loved photography and traveling with friends,” the family told the Arizona Daily Star. “‘Sam not only would find great places to travel with his companions,” said Dr. John Collins, a Vanderbilt colleague, “he would insist on returning 30 years later and re-taking photos from the exact same spot.’”

With a group of 11 other UofA College of Medicine Department of Pathology physicians, Dr. Paplanus resigned from PCMS in 1982 over what they called “the financial impact of the Building Fund” whose “assessment when measured against the economic priorities of our department is such that we must choose not to pay.” By 1997 he was retired and returned to PCMS as an Associate Member. In 2006 he contributed to Project Restore for the building whose construction cost was so troublesome to many members.

“After his retirement he wanted to be involved in the medical community again,” former PCMS Executive Director Steve Nash said. “He did excellent work on our History Committee, shedding light on the Earle Peacock Affair that has had implications at the University of Arizona College of Medicine Department of Surgery for decades. He also traced the development of pathology in Tucson.

“Dr. Paplanus was a pioneer in electronic medical records, working on the concept in the 1970s from a pathology point of view—not that he would have ever mentioned that himself. He was self-deprecating about his accomplishments.

“In the late 1990s he had an idea for the medical society to take a hard look at integrative medicine. He brought his proposal to the PCMS Board of Directors and was asked to chair the committee. He approached alternative medicine with a healthy skepticism, but also with a genuinely open mind. He wanted practitioners to be aware of what worked and what did not. His work was very valuable.” His writing on this and other topics appeared in these pages.

Nash said he’ll miss Dr. Paplanus’s frequent calls to PCMS about questions of the day, and his “deep voice, filled with echoes of his Tennessee upbringing.”

With AMB CAM guidelines and widespread adoption of complementary and integrative medicine modalities, the PCMS Cooperative (Complementary/Alternative) Medicine Committee was dissolved in 2010, its mission largely accomplished.

Dr. Paplanus’s parents Isidore and Fannie Paplanus, and sisters Charlotte Dreifuss and Reita Franco predeceased him.

His nieces and nephews Sheryl Axelrod of Box Elder, S.D., Marc Dreifuss of Tonganoxie, Kan., Alan Franco of Metairie, La., Paul Franco of Atlanta, and Bryan Franco of Brunswick, Maine; seven great-nieces and nephews; two great-great-nieces and nephews; and many cousins survive him.

The family requests that memorial donations be made to Vanderbilt University School of Medicine or the University of Arizona College of Medicine.

Dr. John S. Welsh,

1931-2014

of Arizona College of Medicine. Dr. John S. Welsh, 1931-2014 Dr. John S. Welsh, pediatrician to

Dr. John S. Welsh, pediatrician to many generations of local families, and PCMS member 1962-77, died peacefully April 16 in Tucson, his family reported in the Arizona Daily Star. He was 82.

John Sheaff Welsh was born June 2, 1931 in Kansas City, Mo. He earned his bachelor’s degree at Kansas University, Kansas City, in 1953. He earned his M.D. there in 1957. He did his pediatric internship at University of Kansas Medical

Center, and his residency at Children’s Mercy Hospital in Kansas City. He served as chief of the Department of Pediatrics at Barksdale Air Foce Base, Louisiana, 1960-62. The American Board of Pediatrics certified him.

In Tucson Dr. Welsh began his pediatric practice in Fall 1962 at Oracle North Medical Center on West Wetmore Road. Before joining PCMS he had been a member of Wyandotte County Medical Society, Kansas City.

In 1965 he applied to the Federal Aviation Agency [now Administration] for designation as an aviation medical examiner, with authority to examine pilots and other airmen and issue them their medical certificates. [Airmen must have medical certificates testifying to physical fitness to fly.] As with his Air Force service, this was consonant with his love of flying, and he did become an FAA medical examiner. “He loved to fly his plane and travel the world,” the family told the Star. “John lived his life to the fullest and always on his own terms. He will be deeply missed and remembered by many.”

Later Dr. Welsh served as PCMS’s representative to the Arizona Society for Crippled Children; served on PCMS’s Tri-Hospital Perinatal Review Committee; and our Professional Blue Shield Committee.

His wife, Barbara; son Michael; daughters Tamara and Terri; nine grandchildren; and numerous great-grandchildren survive him.

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The ACA

The ACA Dr. Ken Adler, medical informatics specialist, speaks May 13 at PCMS. Four years later

Dr. Ken Adler, medical informatics specialist, speaks May 13 at PCMS.

Four years later

By Stuart Faxon

N o, the politically named Patient Protection and Affordable Care Act has not been with us for the decades that it seems. It’s only four years old.

Where are we? How did we get here? Where are we going? Marc Leib, M.D., J.D., AHCCCS CMO until recently, who makes “policy wonk” a compliment, took his shot at posing and answering those questions May 13 as part of a panel assembled for a Pima County Medical Foundation’s CME event. Dr. Leib was part of a panel moderated by Dr. Timothy Fagan and including family practitioner and medical informatics expert Dr. Ken Adler, and Jean Tkachyk, COO and CFO of Meritus Health Plans.

In 2010, Dr. Leib noted, confusion and uncertainty abounded and politics, lawsuits, and mistrust prevailed. “Much of that remains,” he said, “but some things are clearer now.”

We now have the Supreme Court ruling its interpretation that the Act’s individual mandate to buy health insurance is constitutional, while ruling that it is not constitutional to threaten states with loss of Medicaid funding if they refuse the Medicaid expansion. States can decide whether or not to expand Medicaid, which Arizona finally did after a furious fight in which our governor opposed our legislature.

Arizona, like about half the states, decided not to set up its own “Health Insurance Exchange” and to go with “exchanges” in the federal “marketplace.” [We use quotes here because of government’s promotionally slanted English.]

Last year’s rocky start featured regulations and standards that were not published until after the 2012 elections, Dr. Leib noted. There was “less than one year to develop and implement ACA infrastructure, and no end-to-end testing of federal-facilitated market or connections with state exchanges.” They way it was run up the flagpole was a clear black eye for President Obama and his HHS secretary. As Dr. Leib put it, “Although widespread political differences on ACA still exist, there is little disagreement on its initial implementation.”

The Oct. 1, 2013 public program rollout was a disaster in capital letters, Dr. Leib said, adding that it has been significantly improved. “More than 6 million individuals are covered under the various Exchanges. Some disagree about who those policy-holder are, newly or previously insured. It remains to be seen how many will continue to pay premiums to remain covered.

“Today states have functioning Exchanges or participate in the Federal Facilitated Market.

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But, little information has been exchanged between these markets and states’ Medicaid programs to enroll applicants across programs. Applicants might need to go to both the FFMs and state Medicaid program to ensure enrollment in the proper program.

“Everyone above 133 percent of the Federal Poverty Level has access to some insurance product, with subsidies for those up to 400 percent of the FPL. In states without Medicaid expansion, some of those below 133 percent of the FPL may not have access to either insurance or Medicaid. This leaves many uninsured, based on state government decisions.

Medicaid expansion

About 25 states, including some “red” [mainly Republican] states have expanded their Medicaid programs because it was fiscally prudent to do so, Dr. Lieb said. “Federal funds for expansion cover more than the costs of providing care to those covered by the expansion. This reduces states’ costs for the remainder of their covered populations, saving state tax dollars.”

Arizona Health Care Cost Containment System expansion

“AHCCCS expansion will add approximately 350,000 members and approximately $1.9 billion in additional federal funds,” Dr. Leib said. “It restores Prop 204 AHCCCS coverage to approximately 200,000 childless adults, consolidates KidsCare into Medicaid and restores coverage to approximately 60,000 children, and adds about 57,000 new childless adults not previously eligible under Prop 204.”

AHCCCS and the Federal Facilitated Market

“There is little effective communications between the FFM— healthcare.gov—and the AHCCCS enrollment system,” he said. “If

an AHCCCS applicant is actually eligible for a subsidized plan, the patient may need to apply directly to the FFM. If an FFM applicant is AHCCCS-eligible, it may be easier and quicker to apply directly to AHCCCS.”

Other ACA provisions

Dr. Leib noted that Accountable Care Organization and other bundled payment programs may be adopted by state Medicaid programs, including AHCCCS. The dreaded Medicaid RAC audits are required, and OIG audits of Medicaid providers will increase. There will be reduced fees for “provider preventable conditions”; currently this only applies to hospitals.

AHCCCS payment modernization

AHCCCS contractors must use five percent of their capitated payments for payment modernization activities designed to lower total costs, Dr. Leib said. “Examples might include Patient- Centered Medical Home, bundled payments, increased care coordination projects, better integration with behavioral health services, or programs to reduce emergency department use and hospital inpatient readmissions.”

Value-based reimbursement

Dr. Ken Adler spoke on aspects of value-based reimbursement including tools and methods, compensation options, Accountable Care Organizations and similar ones, and P4P or Pay for Performance.

He said value-based compensation options include “quality bonuses,” care management fees, shared savings, adjustable fee- for-service rates based on cost and quality performance, “episodes of care, and capitation or full-risk.

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• Marana

Phoenix’s “Banner Health Network was one of 32 original Pioneer Accountable Care Organizations,” Dr. Adler said. “Nine dropped out, leaving 23. Banner reported savings of $13 million in their first year. Pioneer ACOs have increased potential risk and reward. If successful, they are eligible to transition to full-risk at year four.”

Medicare Shared Savings plans among ACOs have been pioneered in Phoenix, Dr. Adler noted. These include the physician-based Arizona Priority Care, Arizona Care Network including Dignity and Abrazo, John C. Lincoln ACO, and Scottsdale Health Partners, new this year. Elsewhere are Southern Arizona ACO in Tucson, physician-run Yavapai Accountable in Prescott, and physician-run Yuma Connected Care there.

“As of January 2014 there were 360 Medicare Shared Savings Plans nationally,” Dr. Adler said. “Of the initial 114 from 2012, 54 of them, or 47 percent saved money, and 29, or 25 percent earned a bonus.”

He noted that there are 33 measures of quality in four domains:

Patient-Caregive Experience with seven measures; Care Coordination/Patient Safety with six measures; Preventive Health with eight; and At-Risk Populations with 12.

Among the At-Risk Populations measures are patients with diabetes, hypertension, ischemic vascular disease, congestive heart failure, and/or CAD.

Among commercial ACOs, Cigna is a good example, Dr. Adler said. “Cigna Collaborative Accountable Care has about 80 locations in the country including three in Arizona. There is a prospective quarterly care-management fee, and the fee is adjusted quarterly based on cost and quality performance.”

He noted that Medicare Advantage ACOs include the United and Humana organizations, and that they have cost-reduction targets. Humana is trying Pay For Performance (P4P) as are BCBS and Aetna.

“One of many CMS pilot programs is Bundled Payment for Care Improvement Initiatives,” he said. In one model used at Banner hospitals and two others, there is “retrospective payment for hospitalization and 30 to 90 days of post-acute care under 48 clinical conditions.” In another model used at four Phoenix

hospitals, there is “prospective payment for hospitalization and

30

days of post-acute care, including any re-admissions within the

30

days, and all physician fees.”

Health insurance ‘landscape’

Jean Tkachyk, COO and CFO of Meritus Health Plans, addressed “Current Health Insurance Landscape and Practical Strategies for Financial Success.” She said Meritus is “the only non-profit cooperative health insurance company in Arizona.”

Organized in 2012 and headquartered in Phoenix, physician- founded Meritus began as a community coalition “dedicated to making quality healthcare available and affordable to all Arizonans.” It is prohibited by law from ever being sold to, or reorganizing as, a for-profit corporation. Products and services are provided both as PPO and HMO types.

The Southern Arizona market is unusual, she said: “Arizona has exceeded CMS targets for first-year enrollment.” Who enrolled? She said available demographics show middle-to-lower, and middle-class people, 28 percent of whom are 18-34, and 35 percent younger than 35.”

Open enrollment in the federal healthcare “exchange” closed on March 31, and prospective insurees can only enroll during “life event” implications, Tkachyk said. “ These still include many because the life events could be job loss, births and marriages, and loss of eligibility for Medicaid. She quoted DHHS as saying, “Up to 129 million Americans with pre-existing conditions, including 17 million children, no longer have to worry about being denied health coverage or charged higher premiums because of their health status.”

She noted that National enrollment on the Exchange was reported to be 8 million Americans. “Three million young adults gained coverage through their parents’ plans, 3 million enrolled in Medicaid and CHIP, and 5 million enrolled in plans outside the ‘marketplace’.”

Carriers in Pima County include Meritus, BlueCross BlueShield, Cigna, Health Choice, Canyon Plans of The University of Arizona Health Plans, Aetna, Humana, and Health Net, she noted. “There are more than 100 plans offered in Pima County,” she said. “More than 70 are Silver Level plans.”

She gave several website examples from the 39 Silver plans, 24 Bronze, 33 Gold, and 14 Platinum plans for individuals, most often comparing Metitus Health Partners and Health Net. On the high end, the Health Choice Essential Platinum plan was $339 per month with zero deductible and out-of-pocket maximum of $2,000 per year. Lowest was Health Net CommunityCare HAS at $139 per month with $5,000 annual deductible and out-of-pocket maximum of $6,000 per year.

Tkachyk quoted Azcentral.com on subsidy eligibility: “In Pima, Maricopa and Pinal counties, the benchmark plans are sold by Woodland Hills, Calif.-based Health Net and are among the cheapest across the federal marketplace. The nation’s least expensive over-all in Pima County’s benchmark plan, which charges $138 per month for a 27-year-old nonsmoker. That means Pima County residents will get the least generous subsidies among all communities on the federal marketplace.”

Cost-charing reductions for out-of-pocket costs and deductibles are available only on Silver Level plans and are available for levels below 250 percent of the Federal Poverty Level, she noted.

The new “landscape” means that “many people have never had health insurance before,” Tkachyk said. “They don’t know what a network is, or how to get a referral, or to whom,” so providers and facilities have to be part of the patient education process.

Practical implications for physicians mean first knowing which carrier with whom you are contracted, she said. “There are many networks and lots of products, and reimbursement rate may vary by type. Understand the fincial implications, Upfront payments will be key. Understand what benefits are covered, and what is subject to prior authorization. Don’t make assumptions! Beware of grace periods. Marketplace products have 30-, 60-, and 90-day periods. Off-marketplace products have 30-day periods. Prior- authorize when applicable, and re-check eligibility immediately before procedures.”

She advised outreach to your currently uninsured patients, and to consider if your practice’s employee coverage could benefit from a group policy. She also noted that open enrollment for 2015 is Nov. 15, 2014 to Feb. 15, 2015, and that “plans will change, and members will transition to other plans and carriers. Statewide enrollment is expected to increase, and Hispanic enrollment is

n

also expected to increase.”

Prac ce Management

Anatomy of a board complaint

By Steve Perlmutter, M.D., J.D.

Anatomy of a board complaint By Steve Perlmutter, M.D., J.D. C hances are if you practice

C hances are if you practice medicine long enough, at

some point you will have a board complaint filed against you at some point.

When you receive that letter, it will be a disturbing experience. A board complaint ranks high among the sources of anxiety and anger, perhaps only second to IRS letters and medical malpractice claims.

Of all those in healthcare fields, physicians have the most emotionality about board complaints. Doctors take these complaints personally, and who can blame them? A doctor spends the majority of his or her time and energy creating favorable outcomes for patients. A complaint by a patient or another physician is a personal affront. It is an attack against one’s integrity. Moreover, it is an attack against your license, your privilege to practice medicine, your livelihood, your future.

Board complaints are sometimes a thinly veiled test balloon floated by a plaintiff’s medical malpractice attorney. If the board sides with the injured party against the physician, there is a strong impetus to file a medical malpractice claim. After all, if a board comprised of mostly doctors thinks you are negligent, won’t a jury come to the same conclusion?

There is some good news about board complaints. The vast majority of them will be dismissed at an early stage, soon after the charges have been answered. Of the complaints that ultimately come in front of the board, most of them are dismissed.

Even if the board finds fault with your actions, the case is usually settled with a non-disciplinary letter of concern and perhaps a continuing-education requirement. Only a minority of cases go on to censure, probation, suspension, and license revocation. Nonetheless, the best scenario is to get out of the case quickly. Most professionals with experience in front of healthcare licensing boards agree that the presence of an attorney has a salutary effect on the case outcome.

Although numerous articles have been written about the “five” or “10” steps to take or not take upon receiving a board complaint, I have attempted here to write from the perspective of one who is both attorney and physician. I have had board complaints. I have defended them by myself and with the help of an attorney. If I had to do it over again, I would never answer a board complaint without an attorney. And chances are that your professional liability policy has a provision that requires the insurer to pay for legal counsel if a board complaint should arise.

My best advice is to hire an attorney to represent you before you respond to a board complaint. Abraham Lincoln once said, “A

person who represents himself has a fool for a client.” A medical or osteopathic board proceeding may not seem like much on the surface, but it is a legal proceeding that can determine if you will continue to practice medicine. And while you are under no obligation to obtain legal representation and can appear on your own behalf—pro se—it is not advisable. Some legal scholars suggest that the right to proceed pro se is akin to allowing the defendant to waive his right to a fair trial.[1] Self-representation may provide one with a clear opportunity to shoot oneself in the foot.[2] Even the U.S. Supreme Court has opined that, “a pro se defense is usually a bad defense.”[1]

However, for those physicians who have the intestinal fortitude to proceed on their own, here are some principles that should be considered before and during answering a complaint. But first, the usual disclaimers. This information: (1) does not constitute legal advice; (2) does not create an attorney-client relationship; and (3) may not apply to your specific circumstances. In other words, caveat emptor.

1. Respond in a timely fashion.

Some physicians get the letter, or e-mail, and file it in a drawer somewhere as though hiding the complaint will make it go away. That is akin to hiding a basal cell carcinoma with a Band-Aid and thinking it will go away. In fact, it makes it worse. Every complaint has a deadline for the filing of an answer, and it may be as short as 14 days. If an answer is not filed promptly, you now have a second problem. Failure to respond may be deemed to be unprofessional conduct in itself. So, make sure your response is in by the deadline. If you are unable to comply with the deadline, ask the board for an extension. It will usually be granted.

2. Prepare a concise, complete, and persuasive response.

Complaints often reference that elusive term, “standard of care.” Standard of care is the degree of care, skill, and learning expected

of a reasonable, prudent physician in Arizona in the same or similar circumstances. Standard-of-care complaints typically involve one of four scenarios: (1) You didn’t act when you should have; (2) You acted when you shouldn’t have; (3) You did the wrong thing; or (4) You did the right thing but in a negligent or reckless manner. The purpose of your answer to the complaint is to explain how your actions were reasonable and rational, to wit, in compliance with the standard of care.

Physicians are used to being complete and concise on histories and physicals, operative reports, and hospital notes. It is also necessary to apply these skills to prose. For example, imagine the complaint concerns a complicated eye surgery with a poor result (a topic I know something about). My response would discuss my initial visit with the patient and all the visits up to the time the decision to have surgery was made. I would detail the preoperative examination and my discussion of the risks, benefits, and alternatives of the procedure. The surgical complication that occurred during the procedure would be

explained. My response would detail the postoperative care— how I managed the complications and any referrals made. Then, I would go to the medical literature and pull articles that discussed the prevalence of the complication and how it should be managed. In summary, my response would show that what I did was proper in all respects.

Physicians are trained in empiricism and the scientific method, not in persuasion. Your response to a complaint is different. You are not writing to the board as an objective, uninvolved party. This is not grand rounds or a curbside consultation. You are writing to try to persuade the board that you are right—that you took the correct action, or did the proper evaluation, or the complication that occurred will happen to every surgeon sooner or later. You need to be credible, convincing, and compelling.

At the same time, you must be honest. If you made a mistake, it is usually better to admit it than try to hide it. Boards look at dishonesty and arrogance with disfavor. However, the way that the mistake is framed linguistically may have a significant impact on how it is viewed. In other words, the language used to explain a circumstance can have a dramatic effect on each board member. How do you describe an eight-ounce glass with only four ounces of water in it? Whether you refer to the glass as “half empty” or as “half full” can make all the difference in whether the adjudicator accepts your point of view.

3. Don’t respond when you are angry or unprepared.

As part of the investigation into the complaint, you will be asked to provide your medical records and a narrative response. At some point you may also be interviewed by board staff or questioned by board members in an open, public forum. It is important that you respond to board staff and board members with courtesy and dignity at all times. Keep in mind that these people did not bring the complaint to your doorstep. They are just doing their jobs. It will not help your case to be rude or critical. It will hurt it.

Another tendency that physicians exhibit is to blame the complainant. While the complainant may have created his or her problem, it is seldom beneficial for the doctor to recriminate or censure the patient. It is better to explain how the complainant is incorrect, either based on facts or misperceptions.

Preparedness is essential. Just as you would not go into an exam room or an operating room without being prepared, neither should you speak to an investigator or draft a response without contemplation, deliberation, and a thorough knowledge of the facts. Responses such as, “I don’t know,” or “I don’t remember” will be discounted if you had the opportunity to review the records and know the answers. On the other hand, it is not prudent to speculate. Consider that every word you write or say will be recorded and analyzed. As they say in the crime shows, anything you say can and will be used against you.

4. Medical records

Never alter your medical records. It is both a legal and ethical violation. Someone will figure it out, and you will lose the case. There may be a copy of the records somewhere else. If you use paper records, your handwriting may change or you may use a different pen. The ink can be dated. The difference in the pressure on the page may be ascertainable. Computerized

records are replete with metadata. In other words, you will not

outsmart individuals specially trained to find altered records. If it

is determined that you have altered the record, you lose

automatically. You will lose all credibility, and no one will believe anything you say. Always take the high road.

In summary, if you are confronted with a board complaint, take it

seriously but remain optimistic. Retaining an attorney is generally

a good idea. Check with your professional liability insurer. If you decide to handle the complaint on your own, respond in a timely fashion. Make the response concise, but complete and persuasive. Remain calm and courteous. Be prepared.

Chances are that the complaint will just be a blip in a long and productive career.

Steve Perlmutter, M.D., J.D. is an Arizona attorney and physician. His firm, Perlmutter Medical Law, represents doctors and other healthcare providers with licensing board complaints. Dr. Perlmutter practiced ophthalmology in the Phoenix metro area for 25 years before becoming an attorney. He can be reached at steve@boardcomplaint.com or by calling 480.346.1212.

REFERENCES

[1] United States v. Farhad, 190 F.3d 1097, 1106-07 (9 th Circuit, 1999).

[2] Decker, The Sixth Amendment Right to Shoot Oneself in the Foot: An Assessment of the Guarantee of Self-Representation Twenty Years After Faretta, 6 Seton Hall Const. L.J. 483, 598 (1996).

[3] Martinez v. Court of Appeal of Cal., 4 th Appellate District, 528 U.S. 152 (2000).

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Perspec ve

Paging Congress: Don’t cut GME funding

By Dr. Jason Fodeman

Congress: Don’t cut GME funding By Dr. Jason Fodeman T his summer new doctors will start

T his summer new doctors will start their residency

training in a host of hospitals across Arizona and across the nation.

These new doctors enter medicine at a time when uncertainty about the future of medical practice is at an all- time high. Much of this is a result of the Affordable Care Act, yet other uncertainties remain, including ambiguities about the future of the very funding that supports residency training.

As Congress looks to curtail runaway government spending and rising deficits, one expenditure that has repeatedly drawn interest is funding for Graduate Medical Education (GME). The so-called Super Committee, the Simpson-Bowles Commission, and the Medicare Payment Advisory Commission have all paid particular attention to this funding that supports the mandated training doctors must complete at regular intervals in the years following med school graduation. While budgets must be tightened, cuts to GME would endanger patients.

A recent study by the Accreditation Council for Graduate Medical Education (ACGME) attempted to quantify the devastating effects of possible GME cuts. The authors found that a 33 percent funding reduction would lead to the closure of 1,639 residency/ fellowship programs and a loss of 19,879 post-graduate training positions. A 50 percent reduction in funding would cause 2,551 training programs to close and lead to the elimination of 33,023 training spots.

Since all physicians must complete residency training, fewer residents in the pipeline will ultimately translate into fewer practicing physicians. Thus, GME cuts will inevitably exacerbate the physician shortage, which the Center for Workforce Studies puts at 91,000 primary care physicians and general surgeons by 2020. As a result, patients will have an increasingly difficult time receiving care they need and want because they won’t be able to find doctors. It is likely that patients on Medicaid and Medicare, who already experience trouble finding treatment, will be affected most.

This will create a serious access problem for those patients desperately seeking care. At the same time, those patients fortunate enough to arrange a medical appointment will likely see their face-time with a doctor diminished, as physicians will have to see an increasing number of patients in a day to

overcome the dwindling supply of doctors. Patients will likely find

it very frustrating when physicians do not have the time to have

their questions answered, or to understand the treatment options. This could easily foster a more paternalistic approach to medical care and put patients at risk.

Cuts to GME will be a detriment to the quality of life and quality of training for medical residents as well. Despite the work load of completing a residency, life does not stop for these young doctors. Residents have personal, professional, family, and social obligations outside of residency. Yet, fewer spots means that there will be fewer positions in the city or region where a resident may want to work, or where a resident may need to be.

The 80-hour work weeks and 28-hour shifts of residency are demanding enough, but residents should not have to also suffer through that while being separated from their spouses because the closest spot to their partner in Texas was one in Connecticut. Unfortunately, due to a limited supply of opportunities, this already happens and will only become more prevalent if GME funding is cut. This will not only create unnecessary personal and professional hardships for young doctors, but lower morale— both of which could distract a resident from his or her education and jeopardize patient care.

The timing for cuts to GME could not be worse. As more and more of the Baby Boomers find themselves on Medicare and as the healthcare reform law adds millions to Medicaid, more residents, not less, will be needed to ensure that these patients receive the necessary care.

In fact, our healthcare system already lacks an adequate supply of doctors to meet demand. This is in part attributable to Congress’ shortsighted decision to cap residency funding in the 1997 Balanced Budget Act. To double down on this flawed policy now by further cutting GME would be penny-wise and pound-foolish. This would create critical patient access problems and lower the quality of available care across-the-board, with the sickest and poorest patients being harmed most.

A better prescription would be for Congress and the federal

Department of Health and Human Services to work with hospitals and healthcare providers to invest in residency training programs and increase the number of spots.

The fate of our healthcare system depends on it!

Jason D. Fodeman, M.D. is a board-certified IM physician practicing in Tucson. He is a graduate of the Cedars Sinai Internal Medicine residency program, and completed a graduate health policy fellowship at the Heritage Foundation.

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Mayo Clinic CME

July

July 27-Aug. 1: The Mayo Clinic Diagnostic Imaging Update and Self-Assessment with Advanced Radiology Life Support™ Workshop is at the The Ritz-Carlton, Laguna Niguel, 1 Ritz-Carlton Drive, Dana Point, Calif. 92629; phone 877.266.6065; fax 949.240.2000. www.ritzcarlton.com/LagunaNiguel

Accreditation: Mayo Clinic College of Medicine designates this live activity for a maximum of 30.0* AMA PRA Category 1 credits™. *ARLS workshop–4.75; General course–25.25.

Course is designed to provide practicing radiologists, residents and fellows-in-training with a review of state-of-the-art imaging techniques. An optional Advanced Radiology Life Support™ (ARLS) workshop is offered Sunday, July 27. Self-assessment modules (SAMs), required for maintenance of board certification, are also offered.

Course targets hematologists, oncologists, PAs, NPs, RNs, pharmacists, and anyone interested in the diagnosis and treatment of hematologic and oncologic disorders. Website:

http://www.mayo.edu/cme/radiology-2014s430 Contact:

Mayo School of Continuous Professional Development, Jenny Kundert, CMP, 13400 E. Shea Blvd, Scottsdale 85259; phone 480.301.4580; fax 480.301.8323 mca.cme@mayo.edu http://www.mayo.edu/cme

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