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Sombrero

Pima

County

Medical

Society

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

NOVEMBER

2014

Ebola = donations

Dr. G. Mason Garcia’s direct-pay way

Valley Fever Awareness Week

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Sombrero

Official Publication of the Pima County Medical Society

Vol. 47

No. 9

 

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 Timothy Marshall, 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 immediate past-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

Advertising

Phone:

795-7985

Fax:

323-9559

E-mail:

dcarey5199@gmail.com

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

Letters: Public Health Committee urges donations to Medicins Sans Frontieres.

 6

Milestones: What’s up with doctors Hutchinson, Ruben, Tretbar, Power, and Scully.

 8

Membership: Dr. G. Mason Garcia’s cardiology the direct-pay way.

10

In Memoriam: Longtime Tucson pediatrician Dr. Sandra M. Smith died in July.

12

PCMS News: Working on licensing; Ebola awareness; AZ in NVDRS.

17

Valley Fever: FDA fast-tracks NikZ; VF Awareness Week events.

19

Bioethics: A hospice case vignette by Dr. David Jaskar.

22

Time Capsule: Rains notwithstanding, TMC works to bring back history.

24

Makol’s Call: Dr. Makol gives himself a good talking-to about the future.

26

CME: Credits locally and out-of-town.

Correction

In our October Milestones item about Desert Sun Gastroenterology, we mis-identified Dr. Craig Gross as Cross. We apologize for the typo.

On the Cover

Dr. Hal ‘Travelin’’ Tretbar, PCMS’s unofficial official photographer, recalls that he and his wife, Dorothy, were heading east on Broad- way late on an August afternoon when the stormy clouds looked like they would develop some color at sunset. So they headed to Saguaro National Park East for a potential photo-op.

‘We stopped at Freeman Road and climbed a small hill to look back at the light on the Catalinas,’ Dr. Tretbar said. ‘The soft, slanting light was illuminating the backside of the front range, giving a sense of depth that is not apparent in harsh midday sunlight.

‘This image was taken at 6:09 p.m. with a Nikon D7000 with the 18- 05mm 3.5/5.6 lens set at 105mm. Exposure was 1/400 th second at f5.6 at ISO of 250, normal program and matrix metering. The flash was not fired. I used the faster shutter speed because the camera was hand-held and I was using the longest focal length.

‘Because of how a digital image is recorded, almost all photos need some tweaking to get the desired result. In Photoshop Elements 9, I adjusted the contrast and removed most of the blue haze by using the Hue/Saturation setting. I clicked the Master button and chose blue to partially desaturate it. The final step was to sharpen the image with the unsharp mask—which would be another long explanation!’

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Le ers

An open letter:

The fight against Ebola

To the Editor:

As I write on Oct. 9, the number of Ebola cases in Africa is around 7,000; half of the victims have died.

By the time you read this, these numbers will be significantly higher. This unprecedented outbreak is mostly limited to Sierra Leone, Guinea, and Liberia, but cases were also reported in Nigeria, and now we have had a case in the US.

This outbreak represents a grave threat to the stability of those countries, and in this age of global travel, all countries are at risk. The usual resources such as the World Health Organization, United Nations, NGOs and the countries themselves, are severely challenged regarding personnel and material resources to fight this disease.

Most supplies necessary to control this epidemic are neither esoteric nor costly—gowns, gloves, masks, eye shields, disinfectant, IV solutions, surgical caps, etc. In addition, a major educational effort is needed in order to contain the disease, and there are cultural barriers in West Africa to contend with. The world’s response has been sluggish until recently. The best hope for control is acting now, while the disease is relatively localized.

In recognition of the importance of fighting Ebola, the Public Health Committee of the Pima County Medical Society voted unanimously on on Oct. 9, 2014 that PCMS should encourage donations to Doctors Without Borders (Medecins Sans Frontieres) to help in the battle against Ebola. The PCMS Board of Directors has endorsed this position.

Doctors Without Borders has assumed the lion’s share of responsibility, putting essential medical personnel and equipment on the front lines, and they desperately need additional funding and support. The Public Health Committee knows they are reputable, reliable and dedicated, and the Ebola outbreak is the greatest health crises they currently face.

We encourage Society members and all others to give donations to: www.doctorswithoutborders.org. These donations can be earmarked for the Ebola outbreak. We have confidence that these funds will be used wisely.

Sincerely, Norman Epstein, M.D on behalf of the PCMS Public Health Committee n

on the STARS Campbell Ave PRESENTED BY THE Pima County Medical Society
on the
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Campbell Ave
PRESENTED BY THE
Pima County
Medical Society

AVENUE

Save that date!

The date is April 18,

2015, and the reason is the return of Stars on the Avenue! So that’s SOTA , April, 18, 2015, 7 p.m. at St. Philip’s Plaza, Campbell at River, 4280 N. Campbell Ave. We will have more information monthly as the time nears!

at River, 4280 N. Campbell Ave. We will have more information monthly as the time nears!
at River, 4280 N. Campbell Ave. We will have more information monthly as the time nears!

Milestones

Dr. Scully elected VP of ‘TheWestern’

Thomas B. Scully, M.D., F.A.A.N.S., neurosurgeon with Northwest NeuroSpecialists, was recently elected vice- president of the Western Neurological Society. “The Western” is considered the premier neurosurgical society in the Western U.S. and Canada. Membership is by invitation only. Dr. Scully has been an active member since 2005.

He has previously served as membership chairman on the Scientific Program Committee, and is also current Bylaws chairman.

Dr. Scully came to Tucson in 1994 and has been in private practice since. He has been a PCMS member since relocating to Tucson, and he has previously served as a PCMS Board member. His neurosurgical practice includes general neurosurgery with an interest in cervical spine and minimally invasive procedures.

Comings, goings at Camp Lowell Medical Specialists

Comings, goings at Camp Lowell Medical Specialists Jerry Hutchinson, Jr., D.O. and Shivani S. Ruben, M.D.

Jerry Hutchinson, Jr., D.O. and Shivani S. Ruben, M.D. are the latest additions to the IM practice Camp Lowell Medical Specialists, where they join PCMS members Timothy Fagan, M.D., Daniel Graybill, M.D., Ob-Gyn Laurene Goll, M.D. and dermatologist Mireille (Mimi) Algazi, M.D.

Dr. Hutchinson, a PCMS member since 2007, takes over the practice of the retired Donald Leiberman, M.D. Also, we’re told that Jenora Jolly, M.D. has left the practice to raise her new baby.

Dr. Hutchinson is a 1985 graduate of ATSU College of Osteopathic Medicine in Kirksville, Mo. He did his IM internship and residency at Tucson General Hospital. He is a Fellow of the American College of Osteopathic Internists, and just finished a two-year term chairing the Tucson Osteopathic Medical Foundation Board of Directors.

Dr. Hutchinson has practiced ambulatory and hospital-based internal medicine. He has been

involved with Resident education as a clinical preceptor instructor through the various schools and training hospitals serving Tucson.

the various schools and training hospitals serving Tucson. Dr. Ruben earned her undergraduate degree at the

Dr. Ruben earned her undergraduate degree at the University of California at Berkeley, and her M.D. in 2011 at St. George’s University, St. George’s, Grenada, where she also earned a master’s in public health. She finished her IM residency this year at University of Arizona—South Campus.

Dr. Ruben is a member of the American College of Physicians, through which she has presented several posters and publications. Her clinical focus is on IM and preventive medicine. She joined PCMS as a Resident in February 2014.

With his new association Dr. Hutchinson moves from hospitalist to his roots in primary care. Though Camp Lowell Medical Specialists physicians are part of Arizona Community Physicians (ACP), Dr. Hutchinson is as community as one can get. In 1989 he joined in practice on 1 st Avenue with his father, family practitioner Jerry Hutchinson, D.O., who died in 1994. The younger physician did primary IM for outpatients, and did consultation services until 2003.

“Being a solo practioner at that time in Tucson,” Dr. Hutchinson said, “it was difficult to bring new primary care providers into town. I would not have left primary care if I did not have the advantages of being in a group practice.”

Closing the practice in 2003, Dr. Hutchinson did primary care, IM and hospital coverage with the Southern Arizona Veterans Administration hospital. “I always had a significant component of hospital medicine in my practice,” he said. “In the 1990s the hospitalist movement was getting off the ground. It grew out of mattters of time and efficiency.” As a hospitalist “you give up the administrative duties and personel issues,” he said, because you’re either employed by the hospital or by a group that the hospital hires. “You just do in-house hospital coverage for admitted patients.”

Dr. Hutchinson was a hospitalist from 2007 to this year, working longest at TMC with the group AIM—Arizona Inpatient Medicine, and later with Cogent Healthcare at Carondelet St. Joseph’s Hospital.

“The disadvantages—certainly not to disparage hospitalists or hospital medicine—are that you seldom take a patient through the healthcare process,” Dr. Hutchinson said. “You are part of a team, doing patient care in shifts. When I practiced solo, I always followed the patient through hospital stays.

In hospital medicine, “You also tend not to have a standard working schedule,” he said. “You end up working any shift that needs covering, since a hospital runs 24 hours a day.

“In primary care you get to intercede at an earlier point, interrupt the process of disease, and avoid the crisis-driven intervention. You also get to know people and follow through, which is a lot more enjoyable and interesting. I feel that I can make a bigger impact in primary care than as a hospitalist.”

I feel that I can make a bigger impact in primary care than as a hospitalist.”

Dr. Tretbar honored by alma mater

Dr. Tretbar honored by alma mater ‘Alas, poor Yorick! I knew him, Horatio; a fellow of

‘Alas, poor Yorick! I knew him, Horatio; a fellow of infinite jest, of most excellent fancy.’ O.K., Dr. Hal Tretbar did not play Hamlet, Prince of Denmark, but in 1952 he did play a very convincing freshman at University of Kansas Medical School (Photo courtesy himself).

Harold C. Tretbar, M.D., F.A.C.P., F.A.C.R., longtime photographer/ writer in these pages, says he was a “good medical student” at Kansas University Medical School, from which he graduated in 1956.

He practiced in Tucson from June 1965 at The Tucson Clinic and served as president of the 36-physician practice. He retired in July 1998 from Thomas-Davis Medical Centers after a merger.

He served as a captain in the U.S. Army Medical Corps in Germany 1958-61 in charge of a seven-physician dispensary for Combat Command A, 3 rd Armored Division. He was a Fellow for four years at the Cleveland Clinic to get his boards in IM and rheumatology.

He was PCMS Physician of the Year in 1998, was awarded as an Outstanding Physician-Rheumatologist and Friend by the Arizona State Rheumatology Association, climbed 19,350-foot Mount Kilimanjaro on his 65 th birthday, and served as president of the Southern Arizona Region Porcshe Club of America, but now even all that ain’t all.

Each year graduates of Southwestern College in Winfield, Kan. are nominated for induction into the Southwestern College Natural Science Hall of Fame. This year the three who have been selected have all gone on to get M.D. degrees from the University of Kansas School of Medicine. On Nov. 6 Dr. Tretbar, B.A. chemistry ’52

and M.D. ’56, will be one those honored with a dinner and a special ceremony to unveil the plaques. He is being recognized as a rheumatologist for advanced treatments of arthritis, and for teaching at the University of Arizona Arthritis Center.

He has also been involved in management of medical organizations and chaired the board of Intergroup for 10 years. He was co-founder of the UA Section of Rheumatology, and started the Arthritis Clinic at the Southern Arizona VA hospital.

Dr. Power chairs TOMF Board

Deborah Jane Power, D.O. is the new chairman of the Tucson Osteopathic Medical Foundation Board of Trustees.

Dr. Power is a San Pedro, Calif, native and has been practicing medicine in Arizona for more than a decade. She will serve as chairman until September

2016. She was elected to the

TOMF Board of Trustees in

2004. She has been a member

of the Steering Committee for the Southwestern Conference on Medicine since 2000, and has chaired it since 2010.

Dr. Power was principal investigator for two Juvenile Idiopathic Arthritis (JIA) clinical trials, has participated as an investigator in more than 70 clinical trials, and has presented both nationally and internationally. She practices at Catalina Pointe Arthritis & Rheumatology Specialists, 7520 N. Oracle Rd., Tucson.

Dr. Power earned her Bachelor of Science in Kinesiology from UCLA, and an M.S. in Exercise and Sport Sciences at The University of Arizona. She earned her D.O. in 1997 at Kirksville College of Osteopathic Medicine, Kirksville, Mo., and interned at Midwestern University/Arizona Graduate Medical Education Consortium at Tucson General Hospital.

In 2002 she completed her rheumatology fellowship at The University of Arizona, where she still has a faculty appointment. She continues to provide rheumatology consultation services for UAMC Diamond Children’s.

Dr. Power has a special interest in pediatric rheumatology, and is one of the few rheumatologists in the state with this expertise. In addition to caring for children with juvenile idiopathic arthritis, (formerly called juvenile rheumatoid arthritis), she specializes in the care of children with systemic lupus erythematosus, vasculitis, dermatomyositis and spondylarthropathies. In addition to seeing children and adolescents at Catalina Pointe, she continues to see patients at the Children’s Clinics for Rehabilitative Services, affiliated with TMC, three afternoons per month.

TOMF was founded in 1986 after the sale of Tucson General Hospital. It uses an endowment as an operating foundation to provide medical education, including scholarships and the Southwestern Conference on Medicine, as well as programs that aid public health in Southern Arizona. Executive director is Steve Nash, former PCMS executive director.

in Southern Arizona. Executive director is Steve Nash, former PCMS executive director. n SOMBRERO – November

n

Membership

Story and Photos by Dennis Carey

Cardiology the direct-pay way

T his truly is a labor of love,” cardiologist G. Mason Garcia, M.D. said. “I don’t think you could pay me any amount of money to change what I am doing, and now we are doing it.”

Dr. Garcia has practiced in Tucson 20 years, but as he opened his new practice, Sunrise Cardiology at 2380 N. Ferguson Ave., it was to do healthcare from the heart as much as to it.

Sunrise Cardiology opened its doors July 7 as the only “direct pay” cardiology practice in Tucson. As a direct pay practice, Sunrise has opted out of partnering with any insurance companies—private or public. It also means no relationship with a large medical group or medical management company. It is not part of any physician network.

Patients are a given two-page document explaining what direct pay means and how much office visits, procedures, and services cost. Patients with insurance coverage are welcome, but patients must send any invoices to their own insurance company for reimbursement. Patients on government-funded plans such as Medicare and Medicaid, and supplemental plans associated with those plans such as AARP plans, will not be reimbursed. Patients on those plans are given an opt-out contract that explains in detail. Private commercial plans may reimburse patients anywhere from 20 to 80 percent.

plans may reimburse patients anywhere from 20 to 80 percent. Michigan fan much?!? Dr. G. Mason

Michigan fan much?!? Dr. G. Mason Garcia in what’s left of his office after the flag ate it.

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“We are very transparent about what we charge and what it means to their insurance coverage,” Dr. Garcia said. “We don’t want any surprises in the care we give, or what’s on the bill.”

Dr. Garcia admits that direct pay may not be a good fit for everyone, but can be affordable for many patients when they examine the out-of-pocket responsibility on many commercial insurance plans. Deductibles, co-insurance and co-payments may be as much or more than what his patients will pay.

Some price examples for office visits are:

$500 for a first-time patient office visit consultation. This will include the consultation and any diagnostic testing such as EKG, treadmill stress tests, echocardiograms; $395 for a one-time visit per year, new patient emergency visit, or new patient home visit. Added procedures for the one-time visits could be added on.

Memberships are also offered, to be inclusive of two consultation visits per year, diagnostic procedures, home visits, and emergency visits. Individual memberships are $70 per month or $720 if paid in full in advance. Family memberships are $42 per month or $500 if paid in full in advance.

Dr. G. Mason Garcia and his wife, Kayla, office coordinator and respiratory therapist, welcome patients

Dr. G. Mason Garcia and his wife, Kayla, office coordinator and respiratory therapist, welcome patients to Sunrise Cardiology, Tucson’s only direct-pay cardiology practice.

“I decided to do it this way because it comes down to patient care first, and not dealing with the red tape of any insurance plans,” Dr. Garcia said. “I spend a minimum of 30 minutes and a maximum of one-hour with each patient. I could not do that being part of a large group or insurance network.”

Dr. Garcia does have experience working in the now-standard healthcare system: He started his career in 1995 with Desert Cardiology following graduation from the medical school of the Autonomous University of the City of Juarez, Mexico. He did residencies in IM and cardiology at Advocate Christ Hospital and Medical Center in Oak Lawn, Ill.

In 1998 he started Vascular Institute of Southern Arizona with Jolyon Schilling, M.D., Brenda Peart, M.D., and the recently retired Michael Lavor, M.D. That practice is now part of Carondelet Health Network.

Dr. Garcia is the only physician at Sunrise Cardiology, but his staff has plenty of experience. Practice Manager Lisa Taylor has 21 years of healthcare administrative experience, and Office Coordinator Kayla Garcia is a licensed respiratory therapist—and Dr. Garcia’s wife.

“That’s the entire staff,” Dr. Garcia said. “Without the paperwork, we have eliminated the need for a large office staff. Since we don’t work with insurance companies, we don’t have to get authorizations for procedures. That also means we only do procedures that are necessary. Our patients feel confident that if I recommend something, they need it. We aren’t under any pressure to generate revenue for another employer or entity.”

Kayla Garcia added, “The biggest chunk of paperwork is the new patient medical history that is about eight pages. Healthcare has gotten so bogged down with forms and protocols. As a direct-pay practice, we don’t have to deal with that.”

Dr. Garcia is from a decidedly medical family. His cardiologist father, Hector L. Garcia, was PCMS Physician of the Year in 2003. He has practiced in Tucson for 50 years and has become legendary for his housecalls. Dr. Garcia’s brothers, Hector F.

Garcia, M.D. and Lawrence Garcia, M.D. are cardiologists in Tucson and Phoenix. His sister Mariali Garcia, M.D. is an endocrinologist in Tucson.

“Every week it seems like there is something new with healthcare,” Dr. Garcia said. “Direct-pay does not mean we don’t have to deal

with the changes, but I can practice the way I think it should be.

I can take my time and be thorough by not having to see a lot of

patients every day. I am accessible to my patients. If something happens, they can come in or call and I will do what I can. I can be me, and not have to be a company doctor and say what somebody else wants me to say, or do what somebody else wants me to do.”

Early reviews have all been positive. Most of Dr. Garcia’s patients have been with him before, but about 10 percent are new. He also has not worked out all the kinks about doing procedures at hospitals. He said he thought he had it worked out, but there are still a few wrinkles.

“Since I don’t plan to charge for the procedures I do, I think I will have it cleared up sooner than later,” he said. “I will visit my patients for no charge, but if anyone has to have a procedure done at a hospital, I am referring them to one of my colleagues.

I think I have an excellent relationship with many Tucson

physicians and other cardiologists. I just have to work out a few

business details, but I am confident I will be able to do procedures at hospitals.”

confident I will be able to do procedures at hospitals.” Dr. Garcia’s waiting room promotes a

Dr. Garcia’s waiting room promotes a relaxing atmosphere.

Dr. Garcia also knows his colleagues are keeping an eye on him, and on other direct-pay practices that are starting around Tucson. There are no immediate plans to add another physician to Sunrise, but he wants to be able to continue his policy of extended patient visits and open access. If the practice is successful, that will probably mean adding to his staff.

“We have to get back to caring for the patient first,” he said. “It feels like patient care is becoming the last thing on the list of things to do. I know I could make more money as an employee of a large group, or as part of an insurance network. But this is the way I thought healthcare should be done, with transparency, and with patients having access to their physicians.”

n

In Memoriam

By Stuart Faxon

Sandra M. Smith, M.D.

1943-2014

Editor’s note: We apologize for missing this obituary that should have appeared in our August-September issue.

L ongtime Tucson pediatrician Sandra Mildred Smith, M.D. died July 7 at her home in Tucson. She was 70.

Dr. Smith, a PCMS member 1974-1988, was a “compassionate pediatric physician, devoted friend, avid reader, and talented athlete,” her family told the Arizona Daily Star.

Sandra Mildred Smith was born was born Sept. 28, 1943 in Oxford, Miss. And graduated from Arkansas High School in Texarkana, Ark. She went to the University of Mississippi as a National Merit Scholar and majored in liberal arts. She then went to Duke University School of Medicine, where she earned her M.D. in 1967. That year she also served as a ward physician John Umstead State Mental Hospital.

She did her internship at Duke University Medical Center, Durham, N.C., and her residency at St. Louis (Mo.) Children’s Hospital. In 1973-74 she had a Fellowship as a Robert Wood Johnson Scholar at the Duke departments of Community Health Sciences, and Pediatrics. She was a diplomate of the National

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Dr. Sandra M. Smith in 1981.

Board of Medical Examiners and a Fellow of the American Academy of Pediatrics.

At The Tucson Clinic she practiced with doctors William N. Neubauer, Ronald P. Spark, Gary L. Henderson. E. Luis Aguilar, and Christopher T. Maloney. In 1985 she relocated to St. Mary’s Medical Park on West St. Mary’s Road

“She spent her professional career caring for children in Tucson, Colorado, and California,” the family told the paper, “and as a volunteer physician in El Salvador, Saudi Arabia, Brazil, Sri Lanka and a Cambodian refugee camp following the Vietnam War. She upheld the highest intellectual and ethical standards throughout her challenging career and was a staunch advocate for her patients and their needs.

“As an athlete, Sandra was a fierce competitor whether at softball, soccer, rugby, touch football, charades, jeopardy, or backgammon, and a masterful bridge player. She routinely tackled New York Times crossword puzzles and the acrostic, in pen, and completed them using her razor-sharp intellect.

“Her door was always open to friends who gathered in her home to play games or watch football, and, if you were lucky, you got to sample her wonderful Southern cooking. When [people were] in need, the welfare of others was paramount to Sandra. Support, love, and laughter came naturally to her.” She also loved her cats, Maggie and Elvis. “She leaves behind a large circle of living and devoted friends who will mess her generosity and unique spirit immensely.”

Her brother David Smith, M.D., and sister Leslie Measel survive her. A celebration of Sandra’a life was given Aug. 2 at Jane and Carolyn’s home. Memorial donations may be made to Hearts That Purr, Box 36418, Tucson 85740.

n

SOMBRERO – November 2014 11

PCMS News

AMB resumes new licenses

The Arizona Medical Board in October approved a motion to resume issuing new licenses.

At issue was an opinion issued by Attorney General Tom Horne interpreting the fingerprinting law in such a way that effectively brought new licenses issuances to a halt.

The Arizona Medical Association, working with support of PCMS and the Maricopa County Medical Society, with backing of the Arizona Hospital and Healthcare Association, took leadership in remedying the situation.

ArMA’s attorneys did extensive legal research and analysis in a short timeframe to issue what became a compelling legal opinion countering that of the AG. Efforts received strong support from the Arizona Legislature leadership, and from Gov. Jan Brewer’s office.

AMB’s action Sept. 8 applies to issuing of new licenses. Renewal licenses were not impacted. Please be certain to closely follow AMB’s instructions for renewing your licenses.

For those of you directly involved with any of the applicants impacted, the licensing board has posted the following language on their website, based on the adopted motion proposed by PCMS and AMB Board member Dr. Screven Farmer:

“The Arizona Medical Board met [Sept. 8] and voted to resume processing and issuing initial licenses effective immediately to applicants meeting all statutory requirements for licensure, with the exception of the FBI criminal background check. These applicants will be issued an Arizona medical license on a provisional basis with the following stipulations: requiring applicants to sign a notarized attestation that there are no undisclosed criminal convictions in other states or countries; requiring applicants to submit a signed statement acknowledging that failure to disclose such information will result in discipline and/or revocation of licensure; additionally, requiring applicants to undergo a third party background check by an entity other than the FBI. The board staff is in the process of investigating and determining the entity that will conduct the criminal background check. Applicants granted a license under these terms and conditions are subject to additional processing once the Board receives approval to obtain criminal background checks from the FBI.”

When renewing a license:

1) In its first renewal notice following implementation of the requirement, AMB mistakenly informed renewal licensees that they must complete their fingerprinting at the local police or sheriff›s office. Fingerprinting at a law enforcement agency is NOT required by law, and many local police departments no longer offer this as a public service. PCMS has compiled a list of fingerprinting services in the city. A mobile service is also available.

2) AMB has issued specific instructions for submitting their pre- printed fingerprint card sent with your renewal packet. If you adhere to the instructions issued, and submit your renewal packet on time, you will be deemed in compliance. AMB has posted the instructions on their website.

3) We have been asked if physicians might complete the fingerprinting process before their renewal packet arrives, and we advise against doing so. AMB is issuing its own pre-printed fingerprint cards, and are not accepting any FD-258 cards in

advance of license renewal notices. Additionally, there are specific instructions that must be followed by your fingerprinting technician, and finally, keeping a fingerprint card on file prior to submission could expose individuals to potential fraud breaches.

Are we ready for Ebola?

By Jane M. Orient, M.D. PCMS Public Health Committee

Ebola is here, and the most rudimentary public health precautions were ignored in a prominent Dallas hospital, even though an infectious disease specialist there thought his

hospital was ready (Business Insider, Oct 4, 2014, http://www.

businessinsidercom/r-us-nurses-say-they-are-unprepared-to-

handle-ebola-patients-2014-10 ).

The intake nurse obtained a history that the patient came from Liberia, where a deadly epidemic is raging, but the message didn’t get to the doctor who discharged the patient on antibiotics. The doctor, apparently, did not take a history himself.

A travel and exposure history is crucial in a patient with symptoms that could be Ebola (or a lot of other common conditions such as influenza). These include fever, headache, abdominal pain, nausea and vomiting, muscle aches, and sometimes a macular rash.

Patients with possible exposure to Ebola need to be isolated at once. Notify the public health department so that specific testing can be done. Personnel need to be trained in advance, notified, and provided with adequate protective gear. Contaminated items must be disposed of properly, and the area cleaned meticulously with an effective disinfectant such as bleach. Remember that viruses have remained infective for six days on surfaces. Print out and have available CDC guidelines for these precautions (http:// www.cdc.gov/vhf/ebola/hcp/index.html), but check frequently for updates. CDC has changed guidelines, and more stringent precautions may be appropriate.

Be sure that your office has, at a minimum, an adequate supply of gloves, safety goggles or face shields, and N-95 masks. If there is to be more than minimal contact with an Ebola infected patient or body fluids, fluid-resistant gowns are needed. All protective equipment must be removed without touching the outer, contaminated surface.

Be aware that an aerosol loaded with pathogenic organisms is generated by flushing a toilet. When Ebola patients were treated at Emory, water was disinfected for 10 minutes before flushing.

‘River conference’ fills up fast

Tucson Hospitals Medical Education Program Inc.’s 5 th Bi-Annual Colorado River Medical Conference travels down the Colorado River through the Grand Canyon June 27-July 3, 2015 for a grand event along with learning.

“The trip is mildly strenuous,” Dr. Richard Dale said, “potentially dangerous from large rapids, but extremely fun and educational.

“This year the places booked quickly and we only have five left. I need a commitment from 23 persons in order to schedule a medical/dental conference for 12-14 Category 1 CME credits. The conference is sponsored by THMEP. Deadline for commitment is fast approaching, so please call Dr. Richard Dale at 721.8505 or e-mail rdale9136@aol.com as soon as possible regarding your interest.”

Significant others and children (8 and older) are invited. We leave Lee’s Ferry Saturday, June 27, 2015 at 8 a.m. and return to Lees

CAKE OF AGES Associate members Dr. J. Wright Cortner, 91, right, and Dr. John Wilson,

CAKE OF AGES Associate members Dr. J. Wright Cortner, 91, right, and Dr. John Wilson, 97, cut the cake and cut up Oct. 14 at an informal celebration of 110 years of the medical society. Between them is Dr. Jim Klein, Pima County Medical Foundation chairman. Seated on left is PCMS Associate Director Dennis Carey. (Jeremy Snavely photo).

Ferry Friday, July 3. The price will be approximately $2,500 per person (not payable to THMEP) for the full trip, plus the registration fee (payable to THMEP), exclusive of one night’s lodging at Marble Canyon.

“This will be a trip of a lifetime,” Dr. Dale said. “We can carpool, etc. Again, if you are interested, or for further information or questions, contact me at 721.8505 or e-mail rdale9136@aol.com.”

PCMSA Holiday Luncheon is Dec. 10

The Mobile Meals Holiday Luncheon of the Pima County Medical Society Alliance will have a “Black & White Party” theme when it is given Dec. 10 at Fleming’s Steakhouse & Wine Bar, 6360 N. Campbell Ave., 11 a.m.-1 p.m.

Major owner-to-be visits local Carondelet hospitals

Representatives from Dallas-based Tenet Healthcare Corp. were in Tucson last month in anticipation of a joint deal to operate Carondelet Health Network, Stephanie Innes reported in the Arizona Daily Star.

“For-profit Tenet signed a letter of intent on July 22 to own and operate the nonprofit chain of Southern Arizona Catholic hospitals in a partnership with California-based Dignity Health and Missouri-based Ascension. Ascension, which is the current owner, would retain a minority interest, officials said when they announced the deal.

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WALK WITH A DOC Gonzalo Celis, M.D. presented an ‘Obesity and Diabetes’ program at the

WALK WITH A DOC Gonzalo Celis, M.D. presented an ‘Obesity and Diabetes’ program at the September PCMS Walk With a Doc event. Events are given on second Saturdays monthly at Rillito River Park. PCMS seeks physicians interested in presenting the events next year, so if you are interested, call Dennis Carey at 795.7985 or e-mail dcarey5199@gmail.com (Dennis Carey photo).

“Tenet was onsite at Carondelet facilities at different times in September to participate in due-diligence activities, Carondelet spokeswoman Lisa Contreras said.

“Network officials successfully met an Aug. 15 deadline for submitting all requested due-diligence materials, according to a Sept. 10 memo to employees from network Chief Executive Officer James K. Beckmann.

“Beckmann’s memo says the letter of intent is an ‘exclusive, non- binding agreement that allows all sides to enter a period of due diligence and announces to others that we are negotiating exclusively with our potential partners.’

“Beckmann wrotes that Tenet and Dignity are now reviewing thousands of documents provided to them so they can learn as much as possible about Carondelet. He also provided employees with an answer to questions about the deal. ‘It is appropriate to explain that: We are very early in the process, but we are excited about the possibility of coming together with Tenet and Dignity,’ the memo says.

“At the time the letter of intent was announced, the news release said Tenet would be the majority partner with management responsibility for all three of Carondelet’s Southern Arizona hospitals. Officials have not said whether the partnership will be for-profit or nonprofit. The news release also said the agreement would maintain Carondelet’s identity, heritage, and Catholic sponsorship.

“Carondelet Health Network … has a workforce of about 3,500 and is the second-largest local health system behind the University of Arizona Health Network, which operates two local

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hospitals. The UA Health Network is in the midst of negotiating a sale to the nonprofit Phoenix-based Banner Health, one of the country’s largest health systems.

“Both the Banner and the Tenet-Dignity deals would connect local hospitals with larger regional health systems, consistent with a national trend of hospital supersizing with consolidations, mergers and acquisitions.

“In Arizona, Dignity Health already operates four Phoenix-area hospitals. Dignity Health in Arizona also includes imaging centers, clinics, specialty hospitals, urgent-care centers, an insurance provider, an accountable care organization and other clinical partnerships.”

Arizona to track violent deaths

The ASU Center for Violence Prevention and Community Safety reported in September that Arizona will track violent deaths in an effort to prevent suicides and homicides.

PCMS Public Health Committee members Dr. Paul Gee and Dr. Randall Friese will serve on the advisory committee to the ASU Center.

The Center will begin gathering and analyzing data on murders and suicides in Arizona for the National Violent Death Reporting System. The data will help state and local officials better understand when and how violent deaths occur by linking information from law enforcement, medical examiners, vital statistics, and crime laboratories. The collected data will help public health practitioners and violence prevention professionals develop prevention and intervention strategies to reduce violent deaths in Arizona.

“Law enforcement tracks the number and manner of murders in Arizona, and health officials do the same for suicides, but no one is looking at the bigger picture,” says Charles Katz, Watts Family Director of the ASU Center for Violence Prevention and Community Safety. “This allows us to get a better idea of what’s going on and why.”

Working in close collaboration with the ADHS, Dignity Health St. Joseph’s Hospital & Medical Center, medical examiners, law enforcement agencies, and injury prevention specialists, the Center will examine violent deaths as both crime and public health concerns. The system will diagnose the scope, nature and source of particular characteristics contributing to violent deaths in Arizona, which will in turn inform prevention efforts.

“We had 1,070 suicides in Arizona in 2012 and 358 murders,” says David Choate, Center associate director. “Having all the facts about the violent deaths that occur in Arizona will help identify the right prevention efforts to save people’s lives.”

Arizona will be one of 32 states collecting data for the National Violent Death Reporting System, run by the Centers for Disease Control and Prevention. The first report is expected to be issued next year.

The ASU Center for Violence Prevention and Community Safety is a research unit of the College of Public Programs at Arizona State University. It conducts use-inspired research that advances scholarly knowledge and practical application of explanations and solutions to the causes and correlates of crime, to reduce violence, and improve the quality of life of our community.

correlates of crime, to reduce violence, and improve the quality of life of our community. SOMBRERO

PCOA: Family caregivers key for older adults

infection control, stress management, nutrition, fall prevention, dementia, personal care, use of a gait belt, proper body mechanics, and more. Both the caregiver and the care recipient benefit from these classes as the caregiver learns skills that increase his or her confidence and effectiveness.

“If you notice that one of your patients, or your patient’s caregiver, is experiencing stress related to caregiving, encourage them to call PCOA at 790.7262 for information about Caregiver Support Groups and Caregiver Training Classes.”

Family caregivers are key to helping older adults continues to live safely and comfortably in their homes, thus reducing the need for costly institutional care,” says Adina Wingate, marketing/PR director for the Pima Council On Aging.

“However, it comes with a substantial cost to the caregivers,” she said. “They may experience stress, physical strain, competing demands, and financial hardship. Because of the many risks associated with family caregiving, it is now viewed as an important health concern.

“Many studies have shown that family caregivers often feel chronically stressed, and this has a negative impact on their mental and physical health. Support groups can relieve some of this stress by promoting social connection, normalizing the emotions and tensions caregivers often feel, and by providing a place where caregivers can share their experiences and learn from one another.

“PCOA offers multiple Caregiver Support Groups throughout Tucson and the surrounding area, including Oro Valley and Green Valley. The groups typically meet once or twice a month and are facilitated by a skilled professional.

“Caregivers can also benefit from taking the Caregiver Training classes PCOA offers in conjunction with Luminaria Home Care. The classes are provided to family caregivers as two four-hour workshops and cover numerous aspects of caregiving, including

The Breast Center, InformedDNA team up

Patients at higher risk for genetic cancer can benefit from the Hereditary Risk Assessment Program at The Breast Center at Carondelet St. Mary’s Hospital, which recently announced that it is collaborating with genetic services specialist InformedDNA to provide risk assessment and genetic counseling.

“Approximately 12 percent of women in the U.S. will develop breast cancer, according to the American Cancer Society. That’s more than 30,000 in Tucson alone, 2,500 of whom are estimated to have a genetic risk factor for cancer. “The breast center’s collaboration is “in response to this growing concern.”

“The program helps identify those at higher risk for cancer— before diagnosis—and helps patients make informed decisions about their medical care. Genetic risk assessments are usually

done after a patient has been diagnosed with cancer, which can be too late. The Breast Center at St. Mary’s is

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“The gold standard of care for a person at high risk for cancer is having genetics experts on an integrated care team, especially if he or she is considering genetic testing,” said David Nixon, InformedDNA CEO. “InformedDNA’s national network of genetics specialists delivers services via phone and online, making it easier and faster for facilities like The Breast Center at Carondelet St. Mary’s to provide the best care possible.”

InformedDNA is largest independent US genetic services provider network. In addition to direct patient care in most major genetics specialties and sub-specialties, InformedDNA works with employers, health plans and physicians, as well as cancer centers, hospitals and mammography centers “seeking to better understand genomic health and its implications for their organizations and the healthcare system

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Valley Fever

fungus, which grows in soils in areas of low rainfall, high summer temperatures, and moderate winter temperatures. The fungal spores become airborne when the soil is disturbed by winds, construction, farming, and other activities.

An estimated 150,000 infections occur each year in the Southwest. About one-third of these result in a self-limited, possibly lengthy, respiratory illness. However in a small percentage, cocci is more serious and potentially lethal.

QIDP designation also provides access to priority review of marketing applications and eligibility for fast-track designation. “This extended market exclusivity makes our Nikkomycin-Z effort much more attractive to investors, a major goal of the GAIN act,” said David Larwood, CEO of Valley Fever Solutions. “This brings us much closer to our dream of commercializing this promising compound.”

Cocci drug gets FDA fast-track

A s Dr. John Galgiani says, “It’s our disease,” right up from our Tucson and Phoenix dirt. The fungus that causes

coccidioidomycosis becomes airborne when soil is disturbed. In susceptible people and animals, infection occurs when a fungal spore is inhaled.

Every year in Arizona 20,000 people are diagnosed with it, and 160 die from it. And we still can’t cure it.

Dr. Galgiani directs the UA Valley Fever Center for Excellence, and the university reports that it received word in October that a potentially curative anti-VF drug has been given a boost in its development by the U.S. Food and Drug Administration.

The UofA’s request has been granted to designate nikkomycin Z (NikZ) as a “qualifying infectious disease product” (QIDP). NikZ is an antifungal drug that the UA has been helping to move into clinical trials and eventually to help patients. The UA has licensed development rights to Valley Fever Solutions, Inc. (VFS), a small start-up business in Tucson.

“Getting a QIDP designation is huge for our program,” said Dr. Galgiani, leader for the NikZ development team and CMO of the VF center. “It makes NikZ much more attractive to investors because of the added protection and other benefits that come with this designation.”

QIDP designation is a key provision of the GAIN Act, approved by Congress in 2012 to increase the incentives for drug manufacturers to produce new antibiotics for serious and hard-to-treat bacterial and fungal infections. Cocci is one such infection that currently has no cure. QIDP designation for a drug adds an additional five years of market exclusivity, which means that the company that brings the drug into clinical use is protected from competitors for that period.

“This is especially valuable for NikZ develop- ment because it is an old drug and most of its patent protection already has expired,” Dr. Galgiani said. This protection is on top of seven additional years of exclusivity that were granted to NikZ when it was designated “an orphan drug,” or one that is used for a relatively uncommon disease such as cocci.

Although cocci is very common in Arizona, it almost never occurs outside the Southwest. Primarily a disease of the lungs in the Southwestern U.S. and Northwestern Mexico, it’s caused by the Coccidioides species of

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NikZ is the first of a new class of antifungal drugs that attack the formation of chitin, a major component of the fungal cell wall, the UofA reported. Given to mice with the cocci fungus, NikZ seems to cure the infection. The drug’s development was started in the 1990s by a small company in California, but was halted when the business failed. The NikZ program was inactive until it was acquired by the university in 2005 and clinical trials were restarted.

Between the UA and VFS, more than $12 million dollars has been raised in research grants from the National Institutes of Health, the FDA and from philanthropic donations, chiefly from the J.T. Tai & Company Foundation in New York City. In September VFS was awarded a $1.7 million small business grant from the NIH to resume clinical trials to treat VF pneumonia patients. NIH is also helping to manufacture the NikZ that will be used in this clinical trial, scheduled to start in late 2015.

Valley Fever Awareness Week Nov. 8-16

The University of Arizona Valley Fever Center for Excellence will host free events in Tucson and Phoenix for the public and health professionals in observance of the 12th annual Valley Fever Awareness Week, Nov. 8-16.

Gov. Jan Brewer proclaimed the week “in recognition of the outstanding treatment and research conducted by the Valley Fever Center for Excellence at the University of Arizona, its new clinical center at St. Joseph’s Hospital in Phoenix, and for the advances in Valley Fever education and public health by the Arizona Department of Health Services.”

The Seventh Annual Public Forum on Valley Fever will be Sunday Nov. 9, 1-4 p.m. at the UA BIO5 Institute, Room 103, 1657 E. Helen St., Tucson. The free forum features UA experts:

Kenneth Ramos,. M.D., Ph.D., PharmB, associate vice-president for precision health sciences at the AHSCenter and professor of medicine in the UA Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, on “Precision Health: A Bold Initiative at the Arizona Health Sciences Center.”

Dr. Galgiani will speak on “Precision Health in Valley Fever— Does Ancestry Matter?”

Zaid Shehab, M.D., professor of pediatrics and pathology and section chief, Division of Pediatric Infectious Diseases, UA Department of Pediatrics, will speak on “Valley Fever in Kids.”

Lisa Shubitz, D.V.M., associate research professor, Department of Veterinary Science and Microbiology, UA School of Animal and Comparative Biomedical Sciences, will speak on “A Valley Fever Vaccine for Dogs.”

Valley Fever 101, a free event for the public, will be Tuesday Nov. 4, 9-11 a.m. at Banner Del E. Webb Medical Center, 14502 W. Meeker Blvd., Sun City West, and features presentations by Dr. Galgiani and others.

Primary care physicians are invited to attend a free conference, Coccidioidomycosis (Valley Fever) for the Primary Care Physician, Saturday Nov. 8, 8 a.m.-noon, at Banner Good Samaritan Medical Center Amphitheater, 1111 E. McDowell, Phoenix. CME credits are available.

To register for these events, or for more information, please visit the Valley Fever Center for Excellence website, www.vfce. arizona.edu .

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Bioethics

A hospice case vignette

By Dr. David Jaskar

T he PCMS Bioethics Committee presents this clinical case to illustrate how physicians can help patients manage common

end-of-life symptoms while in hospice. While this case presentation focuses on the physician’s role, hospice care is a multi-disciplinary group with crucial roles played by many disciplines.

Central to patient care in hospice is a coordinated care team comprised of a physician, R.N. case manager, social worker, chaplain, home health aide, bereavement counselor, a thoroughly-trained volunteer and after-hours R.N., and on-call physician. A hospice patient is usually treated in his place of residence, with cohesive and collaborative visiting and on-call medical attention. Although the hospice team does not remain with the patient around-the-clock, hospice staff is always available to promptly manage symptoms that arise at any time of day.

This case vignette involves a 55-year-old male with metastatic non-small-cell lung cancer. He has metastases to the anterior ribs, scapula, and clavicle. A comorbidity included severe chronic obstructive pulmonary disease. The patient’s prognosis was six months or less as determined by his oncologist, so she recommended that the patient consider hospice care.

On admission to hospice, the patient was on 2 L/min of oxygen per nasal cannula as needed for sleep and exercise. He had been taking low-dose hydrocodone/acetaminophen (Vicodin) 5/325mg about five to six times per day. The patient rated the pain in his chest and upper back as ranging between 4 and 7 out of a possible 10.

Upon admission, the opiate analgesic was changed to plain oxycodone (immediate release) with a range of 10-20 mg every four hours as needed for pain. This regimen reduces the risk of hepatoxicity that might occur if acetaminophen were to be taken in larger doses (exceeding 3 grams in the elderly or 4 grams in younger users—assuming no alcohol consumption).

After several days of taking immediate release oxycodone it was determined that he needed approximately 60-100mg of oxycodone in a 24-hour period to manage his pain. Thus a long acting oxycodone formulation, Oxycontin, was started at 30mg every 12 hours while the “pm” short-acting oxycodone was continued. The patient was now taking 60mg daily of long acting Oxycontin and supplementing with three or four breakthrough doses of oxycodone lOmg per 24 hours. If more than just a few breakthrough doses were required, then the long-acting opiate would be increased.

After a few weeks, the patient’s back pain became much more severe and dexamethasone (Decadron) was added for bone pain (4mg twice per day). This provided transient pain control. However, after a period of time his pain again worsened more dramatically and an X-ray revealed a pathologic T4 fracture; of note, there were no neurological deficits. The patient was then sent to radiation oncology and given a one-time dose of palliative radiation to the involved area. The patient’s pain improved over a

period of weeks and dexamethasone was tapered and discontinued.

The patient’s symptoms continued to evolve as he became increasingly short of breath. His 2L/min of oxygen was incrementally increased to 5 L/m and ultimately an Oxymizer high-flow oxygen delivery system was added to further increase the delivery of oxygen to 8 L/min.

After several weeks, the patient’s shortness of breath increased more dramatically, his sputum became purulent, and he developed generalized wheezes with localized left lower lobe rhonchi. For the presumed pneumonia, we prescribed doxycycline 100mg twice per day for 10 days and steroids were again added in the form of dexathasone 4mg daily. Albuterol/ipratroprium nebulizer treatments were administered four times per day.

Later in the course of his illness, morphine was also given via nebulizer treatments for control of air hunger and shortness of breath—the data on the effectiveness of nebulized opioids compared to saline in this situation are equivocal, but in our experience some patients seem to benefit significantly, and even placebos can be very effective in pain and dyspnea.

A few weeks after the episode of pneumonia, the patient’s pain

again became much more severe and was not well controlled with escalating doses of oral analgesics. Additionally, he had increasing abdominal girth with palpable liver enlargement. Patient was therefore admitted to the inpatient hospice unit where he was started on parenteral (subcutaneous) doses of opiates, in this case hydromorphone (Dilaudid) which is less dependent on liver function than is morphine. Subcutaneous hydromorphone was titrated up to patient comfort, ultimately settling at 4mg per hour continuously via a pump with boluses of 2mg every 30 minutes as needed. With the patient’s pain now well controlled he was again sent home where he was cared for

by his elderly mother.

At home he developed significant ascites from liver metastases. The ascites was significant in that it caused discomfort as well as a significant increase in dyspnea. He was then sent to outpatient interventional radiology where a paracentesis was done with relief of symptoms. He needed one more paracentesis before he decided the discomfort from ascites was less than that of undergoing the procedure.

After the dexamethasone had been weaned off, the patient developed significant fatigue and depression and a course of methylphenidate (Ritalin) at 5mg and later 10mg was started, with improvement in fatigue and depression at institution and escalation of dosage. Parenthetically the methylphenidate was used because it has a much quicker onset of action and better efficacy when compared to an SSRI.

Constipation was an ongoing issue throughout the course of his care while on hospice. On admission, he was started on

scheduled docusate with sennasides (Senna-S) at 2 tablets twice

a day with additional laxatives such as magnesium citrate or

bisacodyl (Dulcolax) suppositories as necessary. At one point the patient was given an injection of .methylnaltrexone (Relistor) 12mg to counter the constipating effects of opioids by blocking the mu receptor in the bowel (while leaving the CNS action of the opioid uninhibited, thus minimizing the impact on pain control

while countering the peripheral side effects of the opioid). The patient had a large bowel movement within a few hours of receiving the methylnalotrexone.

The patient’s status continued to worsen and he became confused (delirious) with increasingly short of breath, inability to swallow, and severe pain that required very frequent dose adjustments in his subcutaneous hydromorphone infusion. The patient’s mother was no longer able to care for him at home and he was therefore re-admitted to the inpatient hospice unit for control of his symptoms.

Treatment was expanded to include parenteral lorazepam (Ativan) for anxiety, as well as haloperidol (Haldol)—which was used not only to help control his severe confusion but also for treatment of nausea. His symptoms were well-controlled with this regimen and he gradually became less responsive. The medications were titrated to keep patient comfortable but not to intentionally suppress respirations or hasten death. He died peacefully three days after his re-admission to the inpatient unit.

The patient’s family was very satisfied with his care during the course of his illness. It must be noted that control of pain and end-of-life symptoms have been demonstrated to not only improve the patient’s comfort, but also the duration of their life in instances of lung cancer.

Gerontologist Dr. David Jaskar is medical director of Casa de la Luz Hospice, Tucson. He chairs the PCMS Bioethics Committee, which includes Ann Marie Chiasson, M.D.; social worker Dale Johnson; Steven Ketchel, M.D.; Cynthia Miley, M.D.; Kenneth Sandock,

M.D.; and David Siegel, M.D.

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Steven Ketchel, M.D.; Cynthia Miley, M.D.; Kenneth Sandock, M.D.; and David Siegel, M.D. n 20 SOMBRERO
Steven Ketchel, M.D.; Cynthia Miley, M.D.; Kenneth Sandock, M.D.; and David Siegel, M.D. n 20 SOMBRERO
Dizziness Balance & SUPPORT GROUP Hosted by Carlson Ear Nose & Throat Associates Date &
Dizziness Balance & SUPPORT GROUP Hosted by Carlson Ear Nose & Throat Associates
Dizziness
Balance &
SUPPORT GROUP
Hosted by Carlson Ear Nose &
Throat Associates

Date & Time:

Location:

Tuesday,

November 11th,

2014

Date & Time: Location: Tuesday, November 11th, 2014 3172 N. Swan Road • Tucson, AZ 85712
Date & Time: Location: Tuesday, November 11th, 2014 3172 N. Swan Road • Tucson, AZ 85712

3172 N. Swan Road Tucson, AZ 85712

Join us for free informational and educational meetings to learn more about your symptoms of dizziness, lightheadedness, vertigo, imbalance, and associated concerns. The support group will meet on the second Tuesday of each month at our Swan Road office location. Meet other individuals who are experiencing similar symptoms and circumstances. A variety of topics will be discussed throughout the year including: What is Vertigo? Anatomy and Physiology of the ear. Proper Diagnosis of symptoms. Treatment options.

3:30 PM

Space is limited. RSVP today by calling 520-795-8777.

PM Space is limited. RSVP today by calling 520-795-8777. Meeting are facilitated by: Amanda Kester, Au.D.,

Meeting are facilitated by:

Amanda Kester, Au.D., CCC-A, FAAA

Doctor of Audiology

To learn more about the Dizziness & Balance Disorder Support Group, hosted by Carlson Ear Nose & Throat Associates, please call 520-795-8777 today.

Time Capsule

Patio Building from 1928 gets makeover in TMC campus upgrade

Story and photos by Tucson Medical Center

T ucson Medical Center is marking its 70 th anniversary this year,

commemorating the day its first patient was admitted, on Nov. 9, 1944. But it’s root extend back long before that.

The historic Patio Building is being restored, harkening back to its construction in 1928 when it was meant to serve as the Institute of Research and Diagnostic Clinic for the Desert Sanatorium.

Before TMC was born, the “Desert San” served as a TB treatment center and as a healthy retreat for those seeking the benefits of dry desert air and abundant sunshine. The San, a cluster of buildings out in the desert northeast of Tucson, faded in popularity through the Great Depression and World War II. In 1943, owner Anna Erickson donated the property as the foundation for a community-run

donated the property as the foundation for a community-run In the Patio Building project, the adobe
donated the property as the foundation for a community-run In the Patio Building project, the adobe
donated the property as the foundation for a community-run In the Patio Building project, the adobe
donated the property as the foundation for a community-run In the Patio Building project, the adobe
donated the property as the foundation for a community-run In the Patio Building project, the adobe

In the Patio Building project, the adobe mud surface is removed to assess the structural brick repairs needed. Then adobe mud is re-applied according to historical processes. Helical piers are installed at critical points under the foundation to help alleviate settling fractures. Other repairs include replacing much of the rotted wood lintels and porch beams; replacing the hand-troweled porch concrete walk with a new hand-troweled one; and re-roofing almost half the existing roof. Two non-functional copper domes will be installed to restore the original appearance of the domes on the two east corners of the building.

hospital—TMC—that began admitting patients in 1944.

Today, this significant building from the San’s early days still stands at the TMC entrance at Beverly and Grant. Designed by architect Roy Place with later renovations by Henry Jaastad, the Patio Building perpetuates the Hopi-inspired motif used in the Sanatorium’s first buildings, including the use of battered walls and parapets and wood- beam details.

The U-shaped building features a central patio surrounded by a covered arcade graced with hand-hewn beams and columns. Finished with a smooth stucco finish, the building has walls constructed of brick, floor and roof slabs of concrete, and support beams of steel. At the eastern corners of the building are two towers that

The Patio Building not long after its opening with an Open House given in January

The Patio Building not long after its opening with an Open House given in January 1929.

which it shall hereafter acquire under this agreement any building which shall exceed one storey in height.”

That agreement only lasted a couple of years, as it became void upon Mrs. Erickson’s death in February 1961. Yet the agreement cast a shadow for many years as the hospital considered and rejected several high-rise concepts.

After extensive preparation work by TMC in 2006 and 2007, the Tucson City Council unanimously approved a Planned Area Development plan that now governs how vertical construction could take place on the TMC campus.

Today, TMC has upgraded its grounds and facilities with new roads

and walkways, plus larger patient care areas. TMC now celebrates 70 years of patient care with a new four-storey “skyscraper” that

houses sophisticated surgical and patient care services.

n

once housed specialty research equipment, designed to enable treatments using the rays of the sun. Copper domes atop the towers protected the equipment at both corners.

Now in 2014, one of the final phases of a seven- year, $250 million campus improvement project is the Patio Building renovation. The new Orthopaedic and Surgical Tower is the centerpiece of the project, which also has included new roads, parking areas, walkways, and expanded Pediatric and Mother/Baby units.

The historic Erickson Building, once home to the Desert San’s owners, has already been restored. Work on the Patio Building is expected to last until the end of the year.

Speaking of buildings, what about that “decree” that kept TMC a single- storey hospital for so long?

It became a local truism that TMC was prohibited by code, deed, or law from building any structures taller than one storey. There was a whiff of truth to the tale, but the stipulation about building height expired more than half a century ago.

The one-storey story dates from when the Desert Sanatorium was founded as health retreat Dr. Bernard Wyatt in the 1920s. The San was transferred to financial backers Alfred and Anna Erickson in 1927, and the Ericksons built a home on the site as their winter retreat from New York City.

After her husband’s death, Anna Erickson held the Desert San until 1943, by which time the Depression and World War II had left the facility no longer viable. She donated it to become a community hospital, and continued living part of the year in the Erickson home on campus.

Years later, the specification of the “low-level concept” for the hospital finally appears in TMC’s 1959 deed to the medical office park across Grant Road [home to PCMS since 1981]. The deed reflects Anna Erickson’s desire for unobstructed views, stating that TMC “…hereby agrees with Erickson that it will not during her lifetime erect on any of the land

agrees with Erickson that it will not during her lifetime erect on any of the land

Makol’s Call

Quit? Why, I’ve barely begun!

By Dr. George J. Makol

Call Quit? Why, I’ve barely begun! By Dr. George J. Makol T his month I would

T his month I would like to write about something that

I know little or nothing about. I can hear you saying, “Doesn’t he do that every month?”

But this is different. I am talking about the great unknown, the modern mystery, a concept that never really existed except in very recent history. Most people do not know how to do it, do not know how to start it, how long it is supposed to last, and if they should do it in the first place.

I am talking about retirement.

Up until the last 100 years or so, retirement was not really an issue for most people. You simply got up in the morning, worked until it was dark to feed your family, went to sleep, and then awoke and did the same thing repeatedly until you died. When Social Security was instituted in the 1930s, the average person died by age 65, so that was the age they set for people to start receiving benefits. You can see that politicians have not changed much in the past nine decades.

Lifespans have changed, however, and today one can expect to live into her or his (more often her) late 80s, according to life insurance tables. Despite that, 65 seems to have stuck as a “retirement age.” We as physicians don’t really get into our careers until we are at least 30, so quitting at 65 leaves a relatively short career, considering it takes you 30 years to get started.

And what happens when a doctor does retire? Is he no longer a healer, a physician, and counselor to his fellow man? Do his relatives no longer ask him questions that are totally out of his field, such as asking an immunologist about complex Ob/Gyn situations? Will your patients, when they see you on the street, no longer say, Bugs Bunny-like, “What’s up, Doc?” and revert to “Mister” or “Madam”? Perish the thought!

And if someone collapses right in front of you, do you yell “Somebody call a doctor!”?

I remember a lady friend of mine telling the story of one Saturday when she was worshiping at temple. A woman in front of her suddenly collapsed to the floor, and someone yelled, “Is there a doctor in the house?” So many doctors rushed forward to help that they had to make them all step back so the lady could get some fresh air!

When I was an intern, I was standing in line at the pharmacy behind a fortyish gentleman who had just left a cardiology clinic with a relatively clean bill of health. He collapsed in front of me in ventricular tachycardia. I started CPR and called a Code Blue. We had to shock him 12 times over the next 30 minutes, but amazingly he walked out the hospital on his own two weeks later.

On his way home he stopped by my clinic to have a cup of coffee with me during my break, and I was glad that he finally left

because I was nervous the whole time he was going to collapse again. A story like that does not really inspire one to call it quits. But there are forces that do push a physician in that direction.

I have a friend who lives in the Midwest, a 55-year-old

cardiovascular surgeon. He told me recently that he would like to retire in the next year or two. Yesterday I heard from a local patient that his excellent 62-year-old internist is leaving active practice in one more month. These are both tragic losses for the medical field.

I’m sure that fighting with insurance company clerks over what is medically necessary; asking a nurse practitioner in Michigan if it’s O.K. to order a CT scan on your Tucson patient; or sometimes

feeling like you are in the employment of an insurer who sets your pay, all were factors in those two docs quitting so early. Medicine is the only field in the U.S. in which price fixing is allowed and universally followed, from Medicare on down through monopolistic insurers. It is hard to deny these discouraging truths, although I recently did a column highlighting the great and inspiring things about being a physician, and I still see things mostly that way.

The biggest question of all is, what does a doctor, one of the most productive persons on the planet, do when there is nobody to cure? I suppose there is always golf, but I for one have never been an acolyte of this sport. In fact, I inadvertently skipped the class in med school one afternoon where they introduced golf, country club living, and Mercedes-Benz driving. That is why I do not play golf, why I drive a Ford or Chevy, and why the closest I’ve come to Country Club is building an office a couple blocks from there. I could never see the sense of hitting a ball and then going to chase it. At least in tennis somebody has the decency to hit the ball back to you. Even in football when you kick the ball in one direction, 11 men bring it back to you, even if their intention is to run you over and into the dirt.

Technology, however may have come to the rescue according to the new issue of Forbes. The Stuart Golf X9 Follow ($3,000 at stewartgolf.com) is a roving contraption that holds your golf bag and connects via Bluetooth to a transponder, so that bag will follow you around the course. I suppose if you put the transponder in the lounge at the end of the 18 holes, the bag would just go right there carrying a small flask of your favorite spirit. You could avoid the heat, the walking and the sweating and just meet your golf bag there in the first place.

I don’t know about each of you, but I do not intend to retire any

time soon. I will keep going as long as I am healthy and there are

patients that appreciate what you and I do—or perhaps until they perfect holographic chase-free video golf.

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

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SOMBRERO – November 2014 25
SOMBRERO – November 2014 25
SOMBRERO – November 2014 25
SOMBRERO – November 2014 25
SOMBRERO – November 2014 25

CME

Local CME from Pima County Medical Foundation

PCMF schedules CMEvents for its Tuesday Evening Speaker series. Dinner is served at 6:30 p.m. presentation follows at 7.

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

November

Nov. 14-15: The Primary Care Refresher and Update: Cardiology

& Pulmonary and Critical Care Medicine presented by Med

Study, 8 a.m.-12 p.m. daily at Delano Las Vegas at Mandaly Bay, 3940 S. Las Vegas Blvd., Las Vegas, Nev.; phone 1800.841.0547.

Accreditation: Receive 12 hours morning lecture from top presenters + 100 free online Q&As for up to 37 CME credits, plus bonus one-year subscription to MedStudy Heart Sounds. Email: customerservice@medstudy.com Register at http://www.medstudy.com/CME-course.html Website: www.medstudy.com

MedStudy produces study/review materials that target the professional development of physicians at every stage of their careers, aiming to bring “our innovative approach to medical education to a growing audience of medical professionals.”

Nov. 15: Mayo Clinic Arizona sponsors Thoracic Oncology for the

Non-Oncologist: Family Practitioners, Internists, Pulmonologists

& Surgeons at Mayo Clinic Education Center, 5777 E. Mayo Blvd.,

Phoenix 85054.

CME credits: 6.25 AMA PRA Category 1; 6.25 AOA; AAFP pending. Website:

http://www.mayo.edu/cme/internal-medicine-and-

subspecialties-2014s429

Contact: CME Dept., Mayo Clinic Scottsdale, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca. cme@mayo.edu http://www.mayo.edu/cme

Course focuses on recent developments in comprehensive care of patients with malignancies of the chest. Faculty will provide info on lung cancer, mesothelioma, and esophageal cancer. Attendees will learn about the latest recommendations for lung cancer screening and about causes, prognosis, and treatment for thoracic malignancies. Important clinical advances including surgical, medical, radiation, and supportive techniques will be presented.

January 2015

Jan. 9: The Association of American Physicians and Surgeons presents a workshop and an update in New Orleans, with hotel and meeting location to be announced. The 21st Thrive, Not Just Survive Workshop is 1-6 p.m., and Politics and Your Practice is 6 p.m.-9 p.m.

“Build a healthy, independent practice,” AAPS says. “You can break out of the third-party payment straitjacket before healthcare ‘reform’ puts you to work for big insurance or the government. After the workshop, stay for dinner and updates on physician-led initiatives in D.C. and nationwide to protect patient- centered medicine.”

CME accreditation through New Mexico Medical Society and Rehoboth McKinley Christian Health Care Services is up to 4.75 hours Category 1. Online signup and more info is at www. AAPSonline.org/neworleans .

Jan. 23: Clinical and Multidiscplinary Hematology and Oncology 2015: The 12 th Annual Review is at the Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254. CME credits pending.

Course targets hematologists, oncologists, NPs, RNs, PAs, and all interested in comprehensive update of diagnosis and treatment of hematologic and oncologic disorders. Course presents “new disease classification, treatments, and challenging cases in key hematologic diseases (dysproteinemias, acute and chronic leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU), and overlap topics of supportive, ancillary and diagnostic care. Includes breakout sessions for one-on-one interaction with faculty.”

Website: http://www.mayo.edu/cme/hematology-and-oncology Contact: Lilia Murray, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca.cme@mayo.edu http://www.mayo.edu/cme

February 2015

Feb. 5-7: The Mayo Clinic Third Annual Collaborative Update in Minimially Invasive Gynecologic Surgery is at the Fairmont Princess Scottsdale, 7575 E. Princess Drive, Scottsdale 85255, sponsored by Mayo, Harvard Medical School and Cleveland Clinic. Phone 1800.344.4758 or 480.585.4848.

Accreditation: 9.75 AMA PRA Category 1; 19.75 AOA Category 2-A; ACOG assigns 19 cognate credits.

Course is designed to provide practical update on minimally invasive gynecologic surgery by offering tips and wisdom-pearls for practicing gynecologists. Topics include laparoscopic, vaginal, and robotic surgical procedures for endometriosis, pelvic pain, fibroids, urogynecology, and other conditions. Hysterectomies, myomectomies, and excision of endometriosis will be discussed. Goal is to maximize practical take-home value for participants. Mayo faculty and guest faculty from Harvard and Cleveland Clinic will provide information in lectures, video presentations, and unedited pre-recorded surgeries.

Website: http://www.mayo.edu/cme/surgical-specialties-

2015s978

Members’ Classifieds

MEDICAL EQUIPMENT FOR SALE:

GYNEMED Colposcope. Good condition made by Medtronics with Japanese lenses, no camera, $500.00 obo. MILEX Western Portable Office Suctions Machine. Hands- Free pedal and variable speed with gauge. Good Condition. $50.00. Interested parties should e-mail: houseofmontrose@msn.com.

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To learn more about NeuroQuant ® , visit our website at www.radltd.com . Please consult with your health care provider to determine if NeuroQuant ® would be appropriate for you.

Did you know? MICA Risk Management provides onsite in-service presentations for MICA members and their
Did you know?
MICA Risk Management provides
onsite in-service presentations
for MICA members and their staff.
Call today to get us on your calendar.
Medical Professional
Liability Insurance
(602) 956-5276
(800) 352-0402
www.mica-insurance.com