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Sombrero

Pima County Medical Society


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

OCTOBER 2014

Our HQ needs intensive care


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Spotlighting Northwest Tucson


Emergency Physicians

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LOCATIONS

Tucson Craycroft
2625 N. Craycroft Road, #200
Tucson 85712
TEL 520.324.2409
FAX 520.324.2454

Tucson River Road


2450 E. River Road
Tucson 85704
TEL 520.624.7445
FAX 520.623.6145

Tucson St. Marys


1620 W. St. Marys Road
Tucson 85745
TEL 520.624.7445
FAX 520.623.6145

Green Valley
1315 S. La Canada Drive
Green Valley 85614
TEL 520.625.6600
FAX 520.625.8467

Mariposa Community
Health (Satellite)
1852 N. Mastik Way
Nogales 85621
TEL 520.624.7445
FAX 520.623.6145

Western Avenue
(Satellite)
507 N. Western Avenue
Nogales 85621
TEL 520.624.7445
FAX 520.623.6145

Rita Ranch
(Satellite)
8290 S. Houghton Road
Tucson 85747
TEL 520.625.6600
FAX 520.625.8467

Safford
(Satellite)
2115 W. 16th Street
Safford 85546
TEL 520.624.7445
FAX 520.623.6145

Y. Haroon
Ahmad, MD

Guillermo
Gonzalez-Osete, MD

Robert J.
Brooks, MD

Manuel R.
Modiano, MD

Bruce W.
Porterfield, MD, PhD

Jonathan E.
Schwartz, MD

Natalie
Swansen, MD

SOMBRERO October 2014

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Sombrero
Pima County Medical
Society Officers

Official Publication of the Pima County Medical Society

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)

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

PCMS Board of Directors


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

Editor
Stuart Faxon
Phone: 883-0408
E-mail: tjjackal@comcast.net
Please do not submit PDFs as editorial copy.

Advertising
Phone: 795-7985
Fax: 323-9559
E-mail: dcarey5199@gmail.com

Art Director
Alene Randklev, Commercial Printers, Inc.
Phone: 623-4775
Fax: 622-8321
E-mail: alene@cptucson.com

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SOMBRERO October 2014

Members at Large

Vol. 47 No. 8

At Large ArMA Board

R. Screven Farmer, MD

Donald Green, MD
Veronica Pimienta, MD

Pima Directors to ArMA


Timothy C. Fagan, MD
Timothy Marshall, MD

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

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

Arizona Medical
Association Officers
Thomas Rothe, MD
immediate past president
Michael F. Hamant, MD
secretary
Printing
Commercial Printers, Inc.
Phone: 623-4775
E-mail: andy@cptucson.com
Publisher
Pima County Medical Society
5199 E. Farness Dr., Tucson, AZ 85712
Phone: (520) 795-7985
Fax: (520) 323-9559
Website: pimamedicalsociety.org

SOMBRERO (ISSN 0279-909X) is published monthly


except bimonthly June/July and August/September by the
Pima County Medical Society, 5199 E. Farness, Tucson,
Ariz. 85712. Annual subscription price is $30. Periodicals
paid at Tucson, AZ. POSTMASTER: Send address
changes to Pima County Medical Society, 5199 E. Farness
Drive, Tucson, Arizona 85712-2134. Opinions expressed
are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS
Board of Directors, Executive 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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3

Inside
5 Dr. Timothy Marshall: Our HQ needs intensive
6
7
8
12
13
16
19
22
24
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care.
Letters: CHN CEO on Carondelets settlement
with Justice.
Milestones: Notes on three of our members.
Membership: Spotlighting Northwest Tucson
Emergency Physicians.
In Memoriam: Longtime Tucson dermatologist Dr.
Robert Friedman died in August.
Medical Missions: Sometimes a jaguar attack is
part of a regular days work for globetrotting
medical improviser Dr. Ken Iserson.
Behind the Lens: Dr. Hal Tretbar gets out his
Leica M3 and gets behind Cartier-Bressons lens.
PCMS News: A court victory for Dr. Rainer
Gruessner.
Arizona Medical Board News: AMB loses yet
another director.
Makols Call: Always listen to the patient
including that self-diagnosis.
CME: A new local conference tradition from
Tucson Osteopathic Medical Foundation
happens Nov. 1.

On the Cover
My Leica M3 was brand-new in 1958, photographer Dr. Hal Tretbar
says. To me the subject, lighting and composition in this image
from Germany looks like a French Impressionist painting. Even
though the German state of Hesse was considered a backwater of
West Germany, this was a rare scene of a couple plowing with cows.
Grandmas wore black with layered skirts. For another kind
of French pictorial heritage, see Dr. Tretbars homage to Henri
Cartier-Bresson in this issues Behind the Lens.

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PIMA COUNTY MEDICAL


SOCIETY SINCE 1981

Se Habla Espaol

2434 N. Pantano

Medical Society
Exchange

790-2121

Established
1971

www.RinconCommunications.com
4

SOMBRERO October 2014

Our future, our building


By Timothy Marshall, M.D.
PCMS President

everal years ago it was


brought to the PCMS
Executive Committees
attention that the medical
society building needed repair.
It still does.
Despite the efforts and
contributions of many members, and especially the late Dr. John
Clymer during Project Restore several years ago, there are
structural issues that threaten our 33-year-old buildings viability.
Most evident and threatening is the leaky roof; when it rains, our
Executive Director Bill Fearneyhough mans a bucket and mop to
clean up the water damage.
One of the responsibilities of the Executive Committee and Board
of Directors is to strive to maintain the financial health of our
Society. We recognized years ago that a catastrophic roof leak or
collapse would make the building uninhabitable, unsellable, and
a huge financial liability.
We examined options, one of which was to sell the building.
When the execs introduced the concept to the board, lively and
emotional debate ensued. Some members were part of the
process when the building was first conceived and built. Many
have spent time, effort and money on rehabilitation. All are
reluctant to sell.
We have three current options: do nothing, renovate, or attempt
to sell the building. Lets look at the options.
First, each Executive Committee and Board of Directors member
would love to keep the current building and renovate it to the
highest standards, a marble palace that we could all be proud of.
Unfortunately our coffers are not full of gold. We are currently
financially viable, but we do not have the funds to renovate or
withstand Mother Nature in perpetuity.
Building renovation would be our preferred option. Three quotes
have been obtained. There are three high-ticket items: the
plumbing is not up to code, the roof needs reconstruction, and
we are not handicap-accessible. If we abandon any attempt to
meet code, and just rebuild the roof and make cosmetic
improvements, the cost would be $250,000 to $300,000. The
committee and board would like the building to be modern,
inviting, and comfortablesomething we can be proud of.

TMC Holdings, maintenance, or repairs. Bill could pitch the mop.


We could invest the money from the sale and possibly have some
investment proceeds. The Society would no longer face the risk of
bankruptcy from structural catastrophe.
Inaction would lead to a continuation of our current status. I
dont mind coming to an aging building in which great physicians
have held important meetings for decades. Much good work has
been done here, and this work will continue with or without a
building. The Executive Committees concern is for the future
viability of the Society.
You have received a survey request about building renovation. If
each member agrees to donate a few hundred dollars, the
building can be structurally restored and cosmetically enhanced.
If not, the Board of Directors will be obliged to seek other
options. Please let us know your thoughts: billf5199@gmail.com.
The Society will celebrate its 110th anniversary next month. The
PCMS building has been present for 33 years of that time. Although
the Board of Directors and Executive Committee would like to
maintain the building, I do not believe that the Society will cease to
exist if the building is sold. We are a relevant Society protecting the
ability and rights of physicians to treat patients effectively.
If you would like to see the building restored to a condition
appropriate to this mission, please vote to donate. If not, please
Support the Society by sharing your thoughts and advice, and
helping us increase membership by urging your friends and
colleagues to join PCMS and participate.
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Sale of the building, even if possible, would change our dynamics.


The world is moving in new directions. Corporate meetings are
now often held online, with no reason to leave our homes and
offices. I dont drive to Phoenix to meet with the ArMA Board of
Directors, as meetings are done successfully and conveniently on
the Internet. If PCMS were to hold group meetings without a
central building, they could be in different locations around the
city, making it easier for physicians from different locations to
participate, improve inclusion, and perhaps membership.
Building sale would also dramatically change our finances and
sustainability. We would no longer pay property taxes, rent to
SOMBRERO October 2014

ROC #278632

Leers

Carondelet: Responsibility
program works
Editors note: This letter went out Aug. 19. to Carondelet
Community Partners after our last publication deadline.

Why choose
Desert Mountain Insurance?
see why our customers did...
Our physicians were so

You may have read or seen news coverage today about


Carondelet entering into a $35 million settlement with the U.S.
Department of Justice regarding past inpatient rehabilitation
claims that failed to meet technical Medicare/Medicaid billing
requirements. These issues occurred at St. Marys and St.
Josephs hospitals between 2004 and 2011.

impressed with how multi-

By way of background, in 2010, through our own internal review


procedures, Carondelets Corporate Responsibility Program
determined that, in some cases, documentation was lacking to
fully support billing of inpatient rehabilitation services to federal
healthcare programs. As a result of our internal investigation, in
2011 our healthcare system put new protocols and processes in
place to correct these documentation issues. Also as a result of
our investigation, Carondelet voluntarily tendered repayment of
approximately $24 million to Medicare and Medicaid in 2012,
which was subsequently considered in this final settlement
amount. Its important to note there has never been any
allegation that patients were harmed or had their care
compromised in anyway related to the issues in this case.

policies in what seemed

Due to the strength of the Carondelet Health Network Corporate


Responsibility Program, the Office of the Inspector General (OIG)
did not impose a Corporate Integrity Agreement (CIA) in
conjunction with settlement of the investigation. CIAs require
providers to submit annual reports to the OIG on the status of the
entitys compliance activities, and [these] are typically in effect
for a period of three to five years.
Carondelet has always been dedicated to enhancing the health
and well-being of this community and we hold ourselves
accountable to the highest standards of integrity. We commend
all those in Carondelet leadership who reviewed, audited, and
voluntarily disclosed these past billing errors.
We are proud of our pro-active Corporate Responsibility Program
and our ability to identify and resolve these issues which
occurred some years ago.

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SOMBRERO October 2014

Outside of work, Dr. Tiwari loves to travel and spend time with
his family.

Milestones

Dr. Kalota: She passed!


When we interviewed
urologist Dr. Susan J. Kalota in
2012, she mentioned that she
was about to take a
subspecialty board exam,
which this year she did, and
she exultantly let us know the
results.
I am now officially certified as
a Diplomate of the American
Board of Urology, she said,
with subspecialty
certification in Female Pelvic Floor Medicine and Reconstructive
Surgery.
Our congrats to Southern Arizonas original female urologist. She
practices with Urological Associates of Southern Arizona.

Desert Sun Gastroenterology


welcomes Dr. Piyush Tiwari
Piyush Tiwari, M.D. joined
Desert Sun Gastroenterology
in August, the practice reports,
making the practice five
physicians including doctors
Craig Cross and Gary Gottleib.
Dr. Tiwari graduated in 1999
from Calcutta National
Medical College of University
of Calcutta, and then earned a
degree in biotechnology from
McGill University, Montreal.
He did his IM residency at Guthrie Robert Packer Hospital in
Sayre, Pa. and was asked to stay on an additional year to serve as
chief resident.
After training Dr. Tiwari moved to Tucson with his wife and
daughter, where he took a faculty position at University Medical
Center, the practice reported. His primary role was teaching
young physicians and medical students, while caring for
inpatients admitted to the hospital.
Discovering that he had further interests in GI, he left his faculty
position and continued his training in gastroenterology,
hepatology and nutrition at the UofA. At Desert Sun
Gastroenterology he practices all aspects of gastroenterology,
including irritable bowel syndrome (IBS), anorectal disorders,
colorectal cancer screening, esophageal reflux, inflammatory
bowel disease (IBD) and liver diseases. Dr. Tiwari is accepting new
patients. He believes that each patient is unique and deserves to
be treated that way, the practice said. He always strives to work
with patients and their families to recognize their needs and
customize the best care for them as individuals.
SOMBRERO October 2014

Dr. Elliotts expertise


media-available
Sean Elliott, M.D., professor of
infectious diseases with the
UofA Department of Pediatrics
and Pediatric Infectious
Diseases, and a physician with
the University of Arizona
Medical CenterDiamond
Childrens, is available to speak
with organizations and media
on the outbreak of the virus
enterovirus D68, causing
respiratory illness and
hospitalizations among
children in the Midwest, the university reported.
Ten states have contacted the CDC for assistance in investigating
clusters of the virus in Colorado, North Carolina, Georgia, Ohio,
Iowa, Illinois, Missouri, Kansas, Oklahoma, and Kentucky.
Organizations may schedule Dr. Elliott for an interview by
contacting Darci Slaten, 520.626.7774, or by e-mailing darci@
peds.arizona.edu .
n

STARonSthe

ve
bell A

Camp

AVENUE
PRESENTED BY THE

Pima County
Medical Society

Save that date!

The date is April 18, 2015, and the reason


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

Membership
Story and Photos by Dennis Carey

From drama to dull, differing daily

racticing modern emergency medicine is a complex picture.


The public has been bombarded for decades with images of
heroic efforts to save flatlined patients who have suffered heart
attacks or life-threatening injuries.
Hollywood of course takes license to stress the drama, but each
day in the emergency department is undoubtedly different from
the last.
You never know what each day is going to bring, said Gary
Figge, M.D., Northwest Tucson Emergency Physicians attending
physician who served four years as the groups director. Actually,
it can change from hour to hour.
Indeed, the variety of symptoms an ER physician encounters can
be challenging. The same symptoms do not always mean the
same problem. Multiple procedures such as X-rays, MRIs, blood
tests, patient histories, and many more tools can help sort the
simple cases from the complicated.
Chest pains could be a heart attack or maybe it is just anxiety or
indigestion, Dr. Figge said. Injuries can range from minor sprains
to life-threatening injuries from car accidents or falls in the home.
A cough could be a simple cold, flu or the beginning of a serious
infection, or reaction to something. Our job is to sort it all out.

Dr. Gary Figge and Practice Manager Terrie Daughterty help


coordinate NWTEP efforts at Northwest Medical Centers ER.

NWTEP has provided emergency care at Northwest Medical


Center since 1990. The group is also contracted with Oro Valley
Hospital to provide its ER physicians. Community Health Systems
is building a stand-alone emergency care
clinic in Vail which it hopes to open in Fall
2015, and NWTEP is also contracted to
provide the staff for that facility.
We are recruiting new physicians, Dr.
Figge said. Our contract requires our
physicians to be Emergency Medicine
specialists. They must be board- certified,
and have been emergency medicine
residents. We are fortunate that the
University of Arizona has one of the top
emergency medicine residency programs in
the country. They dont all want to stay in
Tucson, but it is nice that we can look to the
university when we are recruiting.
There was a time when doctors in the
emergency rooms may have had other
practices away from the hospital. We
believe it is important for our group to be
residency trained and board-certified in
emergency medicine. This is the only thing
they do.
As a 1995 graduate, Dr. Figge is familiar with
the UofA emergency medicine residency
program. He returned to his home state of
Wisconsin after graduation, but decided to
come back to Tucson and has since been
very active in the medical community. He
has been a member of PCMS since 2007,

SOMBRERO October 2014

and was elected to our Board of Directors in 2008. He


served as ArMA treasurer 2007-2009, vice-president
2009-2010, president 2010-2011, and past-president
2011-2012. PCMS presented him the Rose Marie
Malone Service Award in 2013.
Other than the ER shift, NWTEP members of the
group keep busy schedules. James Hassen, M.D., is
current NWTEP director and also chief of staff at
Northwest Medical Center. Jed Sadalla, M.D., is
director of NWTEP at Oro Valley Hospital.
We try to keep the focus on patient care, Dr. Hassen
said. Some aspects of medicine change over the
years, but the focus still has to be patient care. There
are a lot of pressures coming at us from many
directions, but it always comes back to patient care.
Eight of the 20 NWTEP physicians completed their
residency at the University of Arizona. Other than Dr.
Figge, UofA emergency residency graduates include:
Janelle Doyle, M.D.; Stephen Hocheder, M.D.; Andre
McNulty, M.D.; Jerald Moser, M.D., Cheston Rhoton,
M.D.; Christopher Tarr, M.D.; and Claire West, M.D.

Northwest Medical Centers ER, second home to NWTEP physicians.

Completing the current roster of NWTEP emergency


specialists are Neil Harris, M.D.; Darren Kay, M.D.; Cary Keller,
M.D.; Kristine Moore, M.D.; Catherine Moses, M.D.; Christopher
Nannini, M.D.; Benjamin Roemer, M.D.; Patricia Ryan, M.D.; and
Scott Seifert, M.D.
Like all practices, NWTEP is in the process of converting to
electronic medical records and keeping in compliance with new
federal government laws. An outside group has been in place to
take care of billing, but a strong medical scribe program helps
take care of other administrative tasks generated by new laws
and many day-to-day paperwork issues.
Our scribes have college degrees and usually have a desire to
have a career in medicine, said Practice Manager Terrie
Daugherty said. Many of our scribes go on to medical school. We

SOMBRERO October 2014

rely on them a lot, and believe we have a very strong scribe


program.
Besides a changing healthcare system, there are alerts and
notifications that come in to the emergency department
throughout the day. The administrative staff must keep physicians
and nurses current on any e-mails and other important messages
that come from various agencies and other providers.
Northwest Medical Center once seemed like a remote desert
outpost. But the hospital, the ER, and the practice group have
grown as medical needs of the community have grown. Shifts at
Northwest and Oro Valley usually provide double and sometimes
triple coverage, so there are no emergency physicians on call at
either hospital.

Its important to give physicians a true day off,


Dr. Figge said. We have been able to do this
without any coverage issues.
The definition of a healthcare emergency may
change depending on the situations source. We
need to remember that it does not have to be a
life-or-death situation to be an emergency, Dr.
Figge said. Sometimes we need to try to
understand where the patient is coming from. It
is an emergency to them because they have no
other place to go. Youll always have some who
want to abuse the system and use the
emergency room for everything. But I find it is
rare that the situation is not an emergency from
the patients perspective.
I have been in emergency medicine for 22
years. It is the only thing I have done and the
only thing I have ever wanted to do. I cant see
myself in any other field. Its something I think I
share with most of my colleagues.
n
Dr. Gary Figge in the situation room, the NWMC emergency department staff
room where physicians, administrators and scribes handle daily details.

Dr. James Hassen is director of Northwest Tucson Emergency


Physicians and NWMC chief of staff.

10

Dr. Jed Sadall is NWTEP director at Oro Valley, and puts in


time at NWMC.

SOMBRERO October 2014

SOMBRERO October 2014

11

In Memoriam
By Stuart Faxon

Robert P. Friedman, M.D., 1939-2014


D

r. Robert P. Bob Friedman, dermatologist who joined PCMS


in 1969, and had been retired since 2002, died Aug. 27,
Evergreen Mortuary reported Aug. 30. He was 75.
Robert Paul Friedman was born May 3, 1939 in Jamaica in New
York Citys borough of Queens, but he grew up in Ohio. He
graduated from DeVilbiss High School in Toledo in 1956, and
earned his undergraduate degree at the University of Toledo,
majoring in biology. He graduated from Ohio State University
College of Medicine in 1963.
In 1962 he married Sharon Jaffee in Toledo, the family reported
to Evergreen, with whom he moved to Detroit to complete his
residency. Their first daughter was Diana. He interned at Henry
Ford Hospital in Detroit, and did his dematology residency there.
In 1966 he had a United States Public Health Service Fellowship in
occupational dermatology at Wayne State (Mich.) University
College of Medicine. From July 1967 to July 1969 he was chief of
the Department of Dermatology at the U.S. Naval Academy and
Naval Hospital at Annapolis, Md. He was honorably discharged
with the rank of Lieutenant Commander. He was board-certified
in dermatology.
In 1969 Bob and Sharon, along with Diana and new daughter
Lara, crossed the country to move to Tucson, the family
reported, to join Bobs sister Harriet and her family, for the nice
weather, to play as much
tennis as possible, and to
become one of the
founding families in
Congregation Chaverim.

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12

Dr. Friedman began his


practice in Tucson,
Associated
Dermatologists, P.C., on
East Grant Road, and
served as Associate
Professor of Dermatology
at the UofA College of
Medicine. In 1981 he
began a solo practice at
Southwest Medical and
Professional Center on
East Hampton Street. In
1984 he relocated to
Tucson Medical Park
Northwest on North
Rosemont Avenue.
Dr. Friedman was
interested in
counteracting medical
quackery, and in the early
1970s formed and chaired
a PCMS committee with
that goal. Results appear
to have been lost to

history, while unfortunately the Information Age appears to have


grown rather than quashed quackery.
In 1990, following an amicable divorce, Bob married Patricia
Kniffin and welcomed into his heart and his life two sons, Robert
and Jason Kniffin, the family reported. In the years following his
remarriage and then his retirement, Bob lived life with gusto,
traveled widely with Patty, hiked in Sabino Canyon with his dear
friend Manny Furst, strolled on the beach in Coronado, and
generally spent as much time as possible with those he loved.
Bob was known by all who came in contact with him for his
kindness, his brilliance, his loving nature, and his irrepressible
sense of humor including his love of puns. He was beloved by his
family, his friends, and his patients, and he will be deeply missed.
His sister Harriet; wife Patricia Friedman; daughters Diana and
Lara and their mother Sharon; sons Bobby and Jason; and
grandchildren Sophia, Alex, Ty, Aaron, Aiden and Kaia survive him.
Funeral services were Aug. 31 at Evergreen Mortuary Chapel on
North Oracle Road. To send a flowers or a memorial gift to the
family, please visit the Sympathy Store from the Evergreen
website.

n
SOMBRERO October 2014

Medical Missions
By Kenneth V. Iserson, M.D., M.B.A., F.A.C.E.P., F.A.A.E.M.

Jaguar attack?
All in a days work

he small woman, draped in the rainbow-colored dress typical


of the deep jungle, was hurried into our emergency
department carrying a tiny bundle. Jaguar attack, whispered
the nurse, and everyones adrenaline surged.
Even after two month-long stints as the Guyana Public Hospitals
visiting professor at their EM residency, I found this injury
mechanism a bit unsettling. Jaguars rarely attack humans, and when
they do, the the wounds are often fatal. Now we had a three-yearold girl with extensive injuries. Our ED team, however, was up to the
task, having prepared for nearly every type of traumatic event.
If you plan on doing international work, anticipate that you will
see diseases that you may barely remember from medical school,
and mechanisms of injury that you may only have seen in bad
movies. This has held true on all seven continents on which I have
worked and taught.
When I introduced myself to the regional hospital administrator
in rural Zambiaits always an excellent idea to meet that
individual firsthe looked at my professional card. Since you
TIN
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forN
theITU
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The jaguar-attacked girl in the ED.


ING

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children in beds by the door; they looked
dead or nearly so. I stopped and stared and
soon felt a hand on my elbow. Dont worry,
doc, said the diminutive nurse that ran the
ward. They all have cerebral malaria. But
you and I will save them.
And indeed, although I had seen few malaria
cases and no cerebral malaria, between her
experienced instructions and my intensive
reading, they all lived. This transpired despite
having only the very dangerous parenteral
anti-malarial medication quinine (which they
pronounce kweeneen), no monitors or
X-rays, minimal laboratory capabilities, and IV
lines without a built-in way to control flow
rates. Yet, with improvisation,1 we made it
work and all the patients not only survived,
but also appeared neurologically normal.
SOMBRERO October 2014

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13

The jaguar attack girl recovered.

These patients were in addition to the other 15 children we were


simultaneously treating who had marasmus and kwashiorkor, a
number with HIV complications, a variety of parasites, and the
typical fractures and pneumonias. Luckily, I had had plenty of
experience with sick children in the ED, but it didnt hurt to have
experienced nurses, and reference materials available.
You must prepare for unusual clinical situations before you jump
into the international medical arena. The first step involves
researching what diseases present in the location where you will
work, especially those that appear more commonly during the
season that you will be there. Gather this information from the

The Faces of Casa are the

The Zambian pediatrics ward.

plentiful online sources, including the Centers for Disease Control


and Prevention and the United Nations (description and URLs in
Table 1). If possible, also ask the organization through which you
are traveling or ask colleagues who have been in the same
location about their experiences. Once you know some of the
uncommon problems you may face, use standard texts or online
sources to learn about those illnesses. Also, download them to
your portable brain for easy reference.
If you think you will need to do some uncommon procedures
(ultrasound exams are now common even in remote areas),
download some instructional videos from the Internet. As for
improvising techniques, equipment when it
fails, or supplies when they invariably run
short, you may want to peruse Improvised
Medicine: Providing Care in Extreme
Environments, and take a hard or electronic
copy with you. 2

Dr. Ann Marie Chiasson


Associate Medical Director

Working in hospice allows me to


practice both the science of medicine
and the art of medicine. Put simply,
wonderful holistic patient care focused
on comfort allows patients to live longer
and more comfortably.

520.544.9890 | www.casahospice.com
Hospice services are paid for by Medicare

14

You cannot prepare for or even imagine


everything you may face. However, in any
situation you can apply the skills and
experience you have gained over the years as
a clinician. For example, an elderly farmer was
rushed into the ED on a makeshift litter. Barely
alive, his discolored chest wall and mangled
arm and leg suggested a major accident. Only
after we began doing the standard trauma
assessment/resuscitation did we find that the
injuries resulted from an unfortunate
encounter with a very unhappy bull elephant.
Strange as the mechanism was, our training
and that of our EM residents and staff was
sufficient to smoothly perform the necessary
interventions. In this case, our specialty
training was the preparation we needed.
Of course, many other factors enter into a
successful international medical venture. You
want to find an organization with an
appropriate mission that will continue after
you leave, that matches your clinical skills and
time allocation, that will be within your
SOMBRERO October 2014

physical and emotional comfort zone, and that you can afford. You
will also need to consider the cultural differences, living
arrangements, personal health needs, communication difficulties
(language and electronic), accommodations, local and international
travel arrangements, and required professional documents. For all
these other issues, The Global Healthcare Volunteers Handbook:
What You Need to Know Before You Go may be of help.3
That little girl mauled by a jaguar received rapid and thorough
assessment and treatment from our team, including
identification of a potentially lethal brain lesion resulting from
the big cats tooth penetrating her skull. After a craniotomy,
repair of the extensive soft-tissue injuries, and three weeks of
hospital care, she was discharged back to her home.
Months later, her only residual injuries were some large
lacerations that will take time to completely heal, and ptosis of
one eyelid. Success in this one case was awesome. But this
episode evoked even more pride in the sustainable educational
accomplishments our Vanderbilt University-based EM team has
provided over the past yearsand continues to providein
educating a new generation of Guyanese Emergency Physicians.
Dr. Iserson is a Fellow of the International Federation for
Emergency Medicine and Professor Emeritus, Department of
Emergency Medicine, The University of Arizona, Tucson. He is the
author of two recent books: The Global Healthcare Volunteers
Handbook: What You Need to Know Before You Go, Tucson, Ariz.:
Galen Press, Ltd.; (March 2014), and Improvised Medicine:
Providing Care in Extreme Environments, McGraw-Hill Publishing,
New York, N.Y. (December 2012).

Lynn Polonski, M.D.

4021 E. Sunrise Dr.


Ste. 121
Tucson, Arizona 85718
Phone: (520) 576-5110
Fax: (520) 529-7165

TABLE 1: Online sites for information about country-specific


diseases and injury mechanisms
The UN provides excellent information, though it is often buried
in larger documents. Access it through www.undg.org/ and look
at documents for the country in which you are interested.
CDC Travelers Health site provides country-specific information:
wwwnc.cdc.gov/travel/
CDC Clinician Update gives the latest information about
emerging and prevalent diseases worldwide: wwwnc.cdc.gov/
travel/page/clinician-updates
CDC online reference materials, including information about
specific diseases: wwwnc.cdc.gov/travel/page/travel-medicinereferences
Other sources can be found on the Internet. As with other topics,
beware of superficial or bad information.
REFERENCES
1 [1] Iserson KV. Improvised Medicine: Providing Care in Extreme
Environments, McGraw-Hill Publishing, New York, NY. 2012.
2 [2] Iserson KV. Improvised Medicine: Providing Care in Extreme
Environments, McGraw-Hill Publishing, New York, NY. 2012.=
3 [3] Iserson KV. The Global Healthcare Volunteers Handbook:
What You Need to Know Before You Go. Tucson, AZ: Galen
Press, Ltd; (March 2014)
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SOMBRERO October 2014

15

Behind the Lens

A man and his Leica


By Hal Tretbar, M.D.

ey man, a photographer
shouted from across the
courtyard behind Hotel
Congress, let me see that
Leica! He was getting ready to
record that nights musical
event. K.C., as he was called,
knew a classic when he saw one and thought my Leica M3
camera was really cool.
I was there to scout the layout for the Ho-Co Fest. Hotel Congress
has been putting on this musical party on Labor Day weekend to
celebrate the end of summer for 10 years. I had a plan to
photograph it in the traditional style of famous photojournalist
Henri Cartier-Bresson.
Cartier-Bresson (1908-2004) is considered the father of
photojurnalism and spontaneous street photography as art, and
one of the leading artistic forces of the last century. He was an early
adopter of the 35mm format. He photographed the famous such as
Mohandas Gandhi and Marilyn Monroe, and covered major world
events, but became best known for his candid photography, and his
1952 book The Decisive Moment.
In 1954, Ernst Leitz GMBH Wetzlar, Germany, introduced the

16

Famous French photojournalist Henri Cartier-Bresson, who


used only Leica cameras with black-and-white film, pictured
with an M3.

SOMBRERO October 2014

The Queen insisted that her Leica M3 be on her commemorative


stamp.

Queen Elizabeth ll is fond of her Leica M3, a gift from the


German president.

Leica M3 35mm film camera. Now they are celebrating the 60th
anniversary of the one of the best cameras ever made. It was a
marked change from previous Leicas that were a world standard.
The lens mount was bayonet rather than screw-in. The wide base
rangefinder was superimposed in the viewfinder. The outline of
the frame in the viewfinder changed when the lens was changed
from 50mm to 90mm to 150mm. There was a single-stroke film
advance lever.
The M3 became the camera of choice for most of the worlds
finest 35 mm photographersand for every other enthusiast.
About 220,000 were sold between 1954 and 1966. It is said that

Elvis used a Weston light meter for the best images with his M3.
SOMBRERO October 2014

the M designation comes from the German word Messsucher for


measuring viewfinder. The 3 reflects the three changeable frames
in the viewfinder. The M3 was followed by improved models up
to the current M9, but none had the verve of the M3.
I bought my M3 with a 50 mm f1.4 Summilux lens in 1958 from my
PX when I was stationed 15 miles from Wetzlar. I still have the box
and it shows the price was marked up from $243.95 to $261.75.
Later I took lessons on street photography at the Leica factory.
Many notables, including Elvis Presley, have enjoyed shooting
with an M3. Probably the most famous is Queen Elizabeth II. E.
Leitz gave her a choice of a black or chrome model. She chose
chrome. On the M3 the baseplate is removed to change film. The
Queens camera came with two engraved plates, one in English
and one in German. The German one was inscribed Ihrer
Majestat Konigin Elisabeth II 20 Oktober 1958 Theodor Heuss.
Heuss was president of West Germany. Queen Elizabeth thought
so much of her M3 that she insisted that a photo of her holding it
be included on the stamp commemorating her 60th birthday.

This Bresson-style street photography shows his-and-her


eyecare at a downtown bus stop.
17

Todays Hotel Congress, Labor Day weekend 2014.

Hey man, is that a Leica?

Hotel Congress window and looker.

My trusty Leica M3 sat unused in my closet for almost 20 years. It


was time to take it out, grip the solid-feeling body, see the image
outlined through the bright superimposed rangefinder, and hear
the smooth, faint click of the shutter. I had the shutter speeds
checked at Tucson Camera Repair. They were within tolerance
and everything was working smoothly.

Street crowd at Ho-Co Fest, Club Congress.

It also happens to be the 60th anniversary of Kodaks 35mm blackand-white Tri X film. In the past there had been Super X and
Super XX sheet film with ASA (ISO) speeds of 50 and 100. When
the 400 speed film came out, it was named Tri X.
I decided to use the M3 with Tri X as Cartier-Bresson would have.
Cartier-Bresson always used Leica cameras. He said that shooting
with a Leica was like a long tender kiss. He liked a 50mm lens,
shot in black-and-white, and he crop his images when printing
them. People were not aware of being photographed with his
small, quiet camera, so the final prints showed spontaneity with
good composition.

This is the kind of viewer mystery Cartier-Bresson liked.

For the Ho-Co Fest I wanted to follow his advice in the Oct/Sept
1997 American Photo: Avoid making a commotion, just as you
wouldnt stir up the water when fishing. Dont use a flash out of
respect for natural lighting, even when there isnt any. If these
rules arent followed, the photographer becomes unbearably
obtrusive.

It was a real challenge. With todays digital wonders ISO speeds


up to 25,000 are not unusual. I had forgotten how I had come to
depend on auto everythingexposure, focus, next frame, etc.

First I did some street shooting. The couple at the bus stop was
oblivious to me while I was trying to get the best angle to show
their attention to eye care. I cropped this scene so they could be
compared. But when I shot the Ho-Co Fest at night it was full

All in all it was a delight to get back to basics and try to reach the
excellence of Cartier-Bresson. He said, Photography is, for me, a
spontaneous impulse coming from an ever-attentive eye which
captures the moment and its eternity.
n

18

frame, hand held, black and white at 400 ISO. There was no light
meter and I exposed mostly at 1/15th-1/30th second at f1.8 to 2.4.

SOMBRERO October 2014

The Phoenix law firm Jaburg Wilk reported Aug. 25 that Dr. Rainer
W. Gruessner, renowned transplant surgeon and prior chair of
the Department of Surgery at the University of Arizona College of
Medicine was, cleared of all charges by an independent hearing
panel. The decision came just as the August-September Sombrero
went to press.

In March 2014, a Pima County Superior Court Judge agreed,


finding that Dr. Gruessner was, in fact, denied due process and
ordering that UPH provide Gruessner an independent hearing. At
the hearing Aug. 5, UPH argued [that] Dr. Gruessner had added
his name to a transplant database as the primary surgeon for
several successful procedures and had removed his name from
another procedure. Dr. Gruessners lawyers argued that Dr.
Gruessner had all along contended that it was the hospital that
had submitted incorrect data in the first place to the national
transplantation organization (UNOS). When Dr. Gruessner learned
of the incorrect data reporting, he brought it to the attention of
hospital leadership (including the CEO) and suggested changes
based on a review of the actual medical records.

Dr. Gruessner was suspended in September 2013 when it was


claimed that he improperly altered or directed others to alter
records, Jabug Wilk reported. He was subsequently terminated
in light of the record-changing allegations by University Physicians
Healthcare, the practice plan that employs College of Medicine
faculty at University of Arizona Medical Center.

Dr. Gruessner had repeatedly said that he never changed any


medical or legal record, and that his action of pointing out
incorrect data reporting should have been positively acknowledged
by the hospital and the former dean rather than terminating him
without cause. The independent panel determined that the
changes Dr. Gruessner had suggested were in fact correct.

The charges were widely disseminated in the national media


and caused considerable damage to Dr. Gruessners reputation
and professional career. The three panel members, all nationally
acclaimed liver transplant surgeons, took part in a nine-hour
public hearing August 5th. The panel found that Dr. Gruessner
acted reasonably and felt that UPH did not meet its burden of
proving that the termination was justified. The panel recommended
that UPH should issue Dr. Gruessner a public apology. The panel
concluded that Dr. Gruessner deserves to have his name cleared.

At the hearing Dr. Gruessner contended that his termination was


the culmination of a political witch-hunt to force him out without
giving him the opportunity to respond. Dr. Gruessner has all along
argued that both actionsthe UPH termination and his forced
removal from the Surgery Chair positionwere wrongful and not
according to UPH and UA policies. In fact, Dr. Gruessners most
recent external and internal reviews had been outstanding, and
he had received one of the highest bonus payments based on
objective institutional benchmarks shortly before his removal.
Furthermore, Dr. Gruessner had never received in writing an
annual performance evaluation by the former dean as required
by university policies.

PCMS News

Panel clears Dr. Gruessner


of charges

Jaburg Wilk quoted Dr. Geuessner: I am absolutely delighted


that Ive finally been fully vindicated after fighting to be able to
tell my story. If only the administration would have given me the
opportunity a year ago, we could have avoided all of the costs
and heartache over the last year.
Dr. Gruessner contended all along that the allegations were a
political ploy to force his departure from the university by thenDean Dr. Steven Goldschmid, and the panel somewhat agreed,
Jaburg Wilk reported. Dr. Gruessner had criticized Dr. Goldschmids
leadership and testified he criticized the dean when he was
invited by a University committee to discuss ongoing concerns
about the College of Medicine. According to Dr. Gruessner, his
comments got back to the dean, and the dean began retaliating.
Dr. Goldschmid left his deanship in February 2014 only a few
weeks after Dr. Gruessners case was made public in local and
national media.
The results of a survey conducted by the College of Medicine
around the time of Dr. Gruessners suspension were recently
released, echoing Dr. Gruessners claims, indicating that fewer
than one-third of College of Medicine faculty felt they could voice
their opinion without fear of retaliation.
Nearly a year after Dr. Gruessner was first suspended, the
panels found that he had not improperly altered or directed
others to alter records. Dr. Gruessner had fought for a fair hearing
since he was suspended in September 2013. He filed a lawsuit in
November 2013, seeking reinstatement and complaining that
UPH and the University were unlawfully holding him in limbo.
He argued that he was never asked, and was never given the
opportunity, to tell his side of the story.
SOMBRERO October 2014

The panels other recommendations will be reviewed in time by


Dr. Gruessner and his team; the primary task of the panel was to
make a decision as to whether or not the termination was
justified. All three panel members came to the conclusion that the
termination was not justified, that UPH did not meet its burden of
proof, and that UPH should issue Dr. Gruessner a public apology.
Immediately after the panels decision became public, Dr.
Gruessner issued the following statement: It has taken considerable
time and great effort to fight for the right causeand courage to
stand up against misguided institutional leaders that would not
follow the institutions policies and intentionally try to criminalize
and silence the chairman of one of the most influential departments
for solely political and personal reasons. I hope that my case
encourages others in similar positions to stand up and fight for
justice, honor and integrity no matter how difficult it may be.
I was confident the panel would have no trouble clearing Dr.
Gruessners name once they reviewed the medical records that
supported the changes, said Dr. Gruessners lawyer, Kraig Marton
of Jaburg Wilk. Today is a great day for the people of Arizona.
KVOA-TV News in Tucson reported that the panel recommended
that Dr. Gruessner be reinstated as a faculty member, but not
with his previous privileges or titles. To help him re-enter
practice, he would be considered a Professor of Surgery.
As of Aug. 25 the UPH Board had 30 days to review the findings of
the three-surgeon panel and decide what to do next.
19

On Sept. 5 UPH reported unanimous acceptance of the panels


recommendations, and that in accordance, University Physicians
Healthcare will accept the reinstatement of Dr. Gruessner as a
faculty member without clinical or administrative duties. In
addition, UPH will pay his salary for one additional year or until
he finds a new position, whichever is sooner, and retract its
allegations to the Arizona Medical Board of unethical conduct by
Dr. Gruessner.
In accordance with the panels recommendations, UPH is willing
to apologize to Dr. Gruessner, thank him for his role in building
the transplantation center at UAMC, and wish him well in his
future endeavors.
The UPH Board hopes that Dr. Gruessner will join UPH in
accepting the recommendations generated by the independent
panel of his peers. The UPH Board looks forward to his decision.
We accept the panels recommendations, which clear the way for a
fresh start. It is now time for all parties to move on and get back to
the business of healthcare, UPH Board Chairman Steve Lynn said.

History Committee schedules


Superior field trip
The PCMS History Committee has scheduled a field trip Nov. 1 to
Superior, the mountainous Pinal County community of about
2,800 folks living at about 2,800 feet.
Surrounded by the Tonto National Forest and often used as a
Western film site, Superior has Boyce Thompson Arboretum
State Park, Old
Town Superior, the
Uptown Superior
Theater, and
Magma Arizona
Alco mining.
Tour guides are Dr.
Nick Mansour and
his brother-in-law
Don Hammer, who
have scounted out
places to visit. The
tour meets at
Oracle Junction at
8:30 a.m., and
estimated time to
be back in Tucson is
4 p.m. Dr. Mansour
recommends
bringing water,
hand sanitizers,
hats, and TP or
other tissue.
For information
please call History
Committee
Chairman Jim Klein
at 795.9484.
20

Mix At Six set for Oct. 18


The third Pima County Medical Society Mix At Six social will
be hosted by PCMS Vice-President Steve Cohen 6-8 p.m.
Saturday, Oct. 18 at the Cohens home.
Dress is casual. Hors doeuvres, wine and beer will be
provided. Wives, significant-others and non-member
physicians are welcome.
Mix At Six is just one way the Society is working to rekindle a
sense of community among physicians by offering them an
opportunity to socialize outside their daily practices.
Please RSVP by calling 795.7985 or e-mail Bill Fearneyhough
at billf5199$gmail.com . When confirming your attendance
you will be provided Dr. Cohens home address and phone
number.

Conference focuses on
cardio-metabolic management
Tucson Osteopathic Medical Foundation reports that Eliot A.
Brinton, M.D. is flying down from Utah to present Lipid and
Cholesterol Management for the Cardio-Metabolic Patient at
the 3rd Annual Southwestern Conference on Medicine Primary
Care Update Nov. 1, 7:30 a.m. to 2:30 p.m. at the TOMF
Conference Center, 3182 N. Swan Rd. in Tucson.
Dr. Brinton is a practicing lipidologist and founding board
member of both the National Lipid Association and the American
Board of Clinical Lipidology, said Nicole Struck, program and
meetings manager at the Tucson Osteopathic Medical
Foundation, He is a thought leader in this field.
Other presenters and presentations during the conference include
Sander Zwart, M.D., F.A.C.P. on Diabetes and Insulin Resistance in
the Cardio-Metabolic Patient; Matthew P. Namanny D.O.,
F.A.C.O.S. on Managing Conditions Resulting From Untreated
Cardiometabolic Syndrome; Joy L. Logan, M.D. on Hypertension
and Renal Disease in the Cardiometabolic Patient; and Scott N.
Welle, D.O., F.A.C.O.S, F.A.C.S. on The Effects of Obesity and
Weight Loss Interventions in Cardio-Metabolic Syndrome. There
will also be a lecture on lifestyle modification, monitoring, and
intervention for these high-risk patients.
A continental breakfast and lunch will be provided. The
registration fee is $120. To register, please log onto http://www.
tomf.org/cme .
The Southwestern Conference on Medicine Primary Care Update
began as a means to fill the need for focused, convenient
educational opportunities for Southern Arizona osteopathic
physicians, Struck said, but in a very short time it evolved into
an event like its big sister, TOMFs Southwestern Conference on
Medicine, which has taken place every spring since 1991 and now
boasts an attendance of more than 400 medical professionals
from across the nation.
We feel strongly that this will prove to be another high-quality
educational opportunity fitting the Southwestern Conference on
SOMBRERO October 2014

Medicines reputation as well as the Foundations mission to


enhance medical education, Struck said. We are excited to be
working with THMEP.
TOMF presents the conference in joint providership with Tucson
Hospitals Medical Education Program (THMEP). It is open to MDs,
DOs, PAs and NPs. THMEP designates the program for a
maximum of six AMA PRA Category 1 Credits. AOA also
designates it for a maximum of six AOA Category 1A credits.

UA study researches
sarcoidosis
Sarcoidosis, the disease of unknown cause that leads to
inflammation and affects the bodys organs, is receiving state-ofthe-art research at the University of Arizona, reports Dr. Ana
Maria Lopez. professor of medicine and pathology at University
of Arizona Cancer Center.
Normally, your immune system defends your body against
foreign or harmful substances, Dr. Lopez said. For example, it
sends special cells to protect organs that are in danger. These cells
release chemicals that recruit other cells to isolate and destroy the
harmful substance. Inflammation occurs during this process. Once
the harmful substance is gone, the cells and the inflammation go
away. In people who have sarcoidosis, the inflammation doesnt go
away. Instead, some of the immune system cells cluster to form
granulomas in various organs in your body.
Dr. Joe G. Garcia, UA Senior VP for Health Sciences, is focusing
on sarcoidosis because though it is relatively rare, it is a
significant disease in Arizona.

SOMBRERO October 2014

The Genomic Research in AAT Deficiency and Sarcoidosis (GRADS)


Study is open andenrolling subjects, Dr. Lopez reported. GRADS
is funded by the National Heart, Lung, and Blood Institute, a
component of the National Institutes of Health. More
information can be found at www.gradslung.org .
UAMC is one of the studys clinical centers, under the direction
of Dr. Garcia and Dr. Kenneth Knox, Dr. Lopez said. All patients
with sarcoidosis are welcome as this work will improve
understanding of the natural history of this disease.
Specifically, outcomes include identifying the types of
microorganisms present in the lungs and in other tissues of
people with sarcoidosis and to correlate the microorganisms
present and the inflammatory patterns in the blood with the
signs and symptoms of their lung disease.
The initial visit will primarily involve reviewing the participants
medical record with the intent of confirming the diagnosis and
severity of sarcoidosis. The subsequent visits may include:
physical examination, blood draw, stool sample collection,
bronchoscopy, CT scan of the chest, pulmonary function tests,
completion of several questionnaires related to their lung
disease. All participants will be compensated for their time for
each visit.
If you have a patient with sarcoidosis, please consider inviting
her/him to participate by calling Study Coordinator Nancy
Casanova at 520.626.2110 with the potential participants
contact information, or by giving the patient Casanovas contact
information at the same number so the potential participant may
make the contact directly.
n

21

Arizona Medical Board News

AMB head resigns abruptly


W

e were as surprised as everyone else when we got reports


from the Arizona Republic Aug. 29, and Fox 8 Live in
Phoenix Sept. 5, that Arizonas top medical licensing entity had
suffered yet a new trauma.
Five months after the Arizona State Medical Board hired a
replacement for ousted Executive Director Lisa Wynn, they said,
its new director has abruptly resigned. According to a

statement from Board Chairman Dr. Gordi Khera, C. Lloyd Vest


resigned Wednesday Aug. 27, effective right then.
While the board has not yet made any formal statements on the
matter, none of the events that led to Mr. Vests decision involved
issues related to public health and safety concerns, according to
the statement.
Vest, 60, was hired in March to replace
Wynn, who was fired days after the release
of a lengthy ombudsman report that found
she and the boards former deputy director
were not fully vetting doctors educations,
work histories and disciplinary actions. Wynn
denied wrongdoing, saying state officials
sanctioned her actions as part of an effort to
speed and modernize licensing practices.
After she left, the licensing procedures were
overhauled, slowing the process and leading
to a backlog of more than 700 pending
physician licenses as of March. The board
was relying on Vest to address the backlog
and continue to improve procedures.
Vest came from Kentucky, where he served
as general counsel for the Kentucky Board of
Medical Licensure. Prior to that, he served as
a staff attorney for a Kentucky Supreme
Court Justice; was an Assistant Attorney
General, prosecuting Medicaid fraud and
representing the Commonwealth in criminal
appeals; and spent six years as a felony
prosecutor.
On the night Vest resigned, the Executive
Director Committee had held a closed-door
meeting to discuss Vests performance. The
committee held a meeting on the same topic
Aug. 6. On July 24, the full board met about
personnel issues surrounding Vest, according
to meeting minutes.
According to Arizona Department of
Administration documents, the state agency
overseeing personnel in June and July
investigated a sexual harassment complaint
from an employee against Vest. The
employees name has not been released.
ADOA does fact-finding investigations and
does not determine guilt or innocence. The
reports findings were turned over to the
medical board for resolution. It remained
unclear whether the report is related to
Vests leaving.

22

SOMBRERO October 2014

According to the fact-finding report, the female employee


stated she had a friendly relationship with Vest in which they
often discussed restaurants, photography and hiking. On one
occasion, the two went to lunch in Vests personal vehicle and
exchanged personal text messages after hours and on weekends
occasionally, most of which focused on restaurant
recommendations.
The two had planned to go hiking, but the employee canceled
at the last minute, sending Vest a text message saying that she
wanted to keep her work relationship above reproach.
I realize that you had absolutely no inappropriate intentions,
but I think that at this point it would be best for me to keep my
work relationships professional, the text states. I would hate
for anything to be misconstrued.
The employee said after that incident, their relationship
changed. She alleged she was denied a promotional opportunity,
was subjected to an uncomfortable work environment and was
required to return books Vest had loaned her. It is unclear
whether the allegations are related to the board executive
session meetings, or Vests resignation.
Patricia McSorley, the medical boards deputy director, is now
interim director.
Vest could not be reached and his last known number was
disconnected.

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23

Makols Call

The fashion phases of self-diagnosis


By Dr. George J. Makol

ne thing Ive learned


about being a good and
conscientious physician is that
we must always, always listen
to the patient. Not every one of
my clinical professors when I
was in training stressed this
dictum, but I learned the best
way one can: by experience.
I was a senior resident on duty
in the busy Jackson Memorial/
University of Miami Medical
School Hospital when a man
was wheeled in from the lobby
in some distress. He promptly tried to sit up, obviously in pain,
and said Doc, I just had my gastric ulcer rupture, and I think I
have an acute abdomen.
Taken aback somewhat by his self diagnosis, I asked a few
questions. Indeed he had symptoms of an ulcer for several
months, but he put up with the discomfort by taking antacids
(PPIs were not yet invented). Then, one hour before coming to
our ER, he had the onset of sudden severe epigastric pain,
radiating to the right shoulder.
He looked up the symptoms in his Merck manual and called an
ambulance. Upon arrival he was sweating, weak, and had
tachycardia, so I yelled for the chief surgical resident to follow
me, and wheeled him to the X-ray facility. We did a quick film, an
upright abdomen shot, and sure enough, he had free air under
the diaphragm!
In less than 20 minutes from when he came through the ER
doors, we had the lab, the X-ray, and the blood typed and
crossed, and the surgical resident and I rapidly pushed his gurney
into the next building, onto the elevator, and up to the surgical
suites on the fourth floor. He was in surgery in less than half an
hour from hitting our parking lot.
And he still died on the table.
Many times I have thought of him, and breathed a sigh of relief
that I chose to take his pronouncements seriously, and I know
that there was nothing more I could have done to change the
outcome.
So, just the other day when a new patient called in advance of her
appointment and asked if I could help her because she was
hearing music at night and had a Medtronic brain stimulating
device in place, I did not hang up. Was she crazy? Why was she
calling an allergist? Should I send her to a shrink?
Well, back when I was a med student on the psych ward, we had
24

a lady who was hearing voices and music at night at home, but
not in the hospital, where she was admitted for observation. We
noticed that even in the hospital she wore large hair curlers at
night, and she told us she usually did the same at her home. She
described in detail the voices and music she was hearing, and it
sounded to me like the nightly show by Rick Shaw, Miamis most
popular DJ.
Back in the Marcus Welby days we actually did housecalls, so
my student partner and I drove out to her address nearby. We
noted that her bedroom faced north, and was almost directly
under a massive WQAM radio antenna, my favorite AM station.
Yes, that was all we had in those days; no Ipods, Sirius satellite
radio or Pandora music service. We only had oldies, but at the
time we did not know that was what they were, only that it was
what we listened to. Anyway, the ladys huge hair curlers were
acting as radio receivers and she was intermittently hearing what
the station was broadcasting. Needless to say, she was discharged
and advised to let her hair down!
This is certainly not to say that everyone who comes in thinking
that they know the etiology of their medical problem is correct,
or even close. Remember that close only counts in horseshoes
and hand grenades. As for medicine, Tyson Herrick wisely said,
Fashion in therapy can have some justification; fashion in
diagnosis has none.
And boy, do we have fashion in self-diagnosis!
A few years ago, almost everyone seemed to have TMJ, or
temporomandibular joint disease, and this was supposedly the
cause of their headaches, fatigue, poor marriages, and failure to
bag an elk when drawn in hunting season. Then, almost every
patient I saw for a while felt they had hypoglycemia, and it was
the cause of their headaches, fatigue, spousal problems, and
their sparse supply of elk jerky.
I dont know about each of you, but I am being bombarded with
patients who think they have celiac disease, wheat allergy, or
gluten sensitivity. I imagine that my colleagues in primary care,
gastroenterology, and allergy/immunology are having the same
experience.
The true incidence of celiac disease is in one person in 133. An
NPD Group poll of 1,000 respondents conducted in May 2014
revealed that about 30 percent, or nearly one in three, is trying to
cut back or avoid gluten in their diets. But being gluten-free does
not mean a certain food product is better for everyone. In fact,
The Wall Street Journal reports that, according to nutritional food
labels, many gluten-free foods contain fewer vitamins, less fiber,
and more sugar than the standard food products. The same
article, published this June 21, notes that manufacturers are
touting foods as gluten-free foods that never contained gluten
SOMBRERO October 2014

anyway, such as Green Giant vegetables and Chobani Greek


yogurt.
This desire to avoid gluten has led to an explosion in the use of
Quinoa (pronounced keen-wah). Ive not been taken in by this
craze because I never eat anything I cannot spell, or that sounds
like the name of an Eastern religious sect.
Celiac disease is not an allergy; it is mediated by IgG- and IgA-type
antibodies formed against gluten, a substance found in wheat,
barley, and rye. The gut is a bystander and is injured by
byproducts of inflammation, leading to malabsorption and a host
of symptoms. Wheat allergy is caused by IgE (allergic)- type
antibodies, and can occur in children, but true IgE-mediated food
allergy probably affects less than one percent of adults.

Sensitivity, on the other hand, does not involve antibodies at all.


It also does not involve getting tears in your eyes when you hear
Barry Manilow sing; thats a different kind of sensitivity. In fact, I
am not really sure how to quantify sensitivity or even intolerance
to a substance. We have a long way to go in nutritional research,
food allergy, and adverse reactions to foods, but it will be an
interesting ride for all of us.
Meanwhile, dont brush off that casual complaint offered by a
patient. He or she may be tossing you a cue!
Sombrero columnist George J. Makol, M.D., a PCMS member
since 1980, practices with Alvernon Allergy and Asthma, 2902 E.
Grant Rd.
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25

CME

Local CME from Pima County


Medical Foundation
PCMF has scheduled these CMEvents for its Tuesday Evening
Speaker series. Dinner is served at 6:30 p.m. presentation
follows at 7.

Oct. 14: Dermal Fillers and Fat Stem Cells in Plastic Surgery
presented by plastic surgeon John Pierce, M.D. A birthday cake
will be served in honor of Pima County Medical Societys 110th
anniversary Oct. 13.
Nov. 11: Newer Anticoagulants and their Role in A-Fib, DVT, and
Pulmonary Embolism presented by Timothy Fagan, M.D.

October

Oct. 15-18: Mayo Clinic Hospital Medicine: Managing Complex


Patients is at Omni Scottsdale Resort & Spa at Montelucia, 4949
E. Lincoln Drive, Scottsdale 85253; 888.627.3202; 480.627.3200.
www.montelucia.com .
CME credits: Maximum 24.25 AMA PRA Category 1 (18.75 general
course; 2.5 ABIM MOC; 3.0 Bedside Procedures Workshop). The
American Osteopathic Association accredits program for 24.25
credits of AOA Category 2-A (18.75 general course; 2.5 ABIM
MOC; 3.0 Bedside Procedures Workshop). AAFP pending.
Program targets inpatient care providers including IM, FP and
hospitalist physicians, NPs and PAs, and addresses many of the
challenges experienced by hospital-based healthcare
professionals, and is meant to provide a forum for exchange of
clinical and practice ideas to enhance healthcare delivery and
provide better patient outcomes. Using an interactive, casebased format, key highlights from most major areas of IM and its
subspecialties will be presented.
The ABIM MOC session Update in Hospital Medicine will be
offered Thursday, Oct. 16. A Bedside Procedures Workshop will
be offered Friday, Oct. 17 at Mayo Clinic Hospitals simulation
center. Workshop is designed for clinicians interested in point-ofcare diagnostic ultrasound and performing ultrasound
examinations and procedures on anatomic and live models with
bedside instruction.
Website: http://www.mayo.edu/cme/internal-medicine-andsubspecialties-2014s561 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
Oct. 16-19 and Oct. 30-Nov. 2: Mayo Clinic sponsors the 17th
Annual Mayo Clinic Internal Medicine Update: Sedona 2014
Session 1 at Hilton Sedona Resort, 90 Ridge Trail Drive, Sedona,
Ariz. 86531; phone 928.284.4040.
CME credits: 20.0 AMA PRA Category 1; 18.0 AOA Category 2-A.
Registration: Online rate $570; on or after Sept. 16: $645.
Course targets primary care physicians, NPs and PAs and offers a
practical update on a variety of subspecialty topics including
allergy, cardiovascular diseases, dermatology, endocrinology,
gastroenterology, hematology, infectious diseases, integrative
medicine, neurology, psychiatry, pulmonary, rheumatology, and
others applicable to todays primary practice and patients.
26

Contact: Registrar, Mayo School of Continuous Professional


Development, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale
85259; phone 480.301.4580; fax 480.301.9176. mca.cme@
mayo.edu http://www.mayo.edu/cme
Course website: http://www.mayo.edu/cme/internal-medicineand-subspecialties-2014s162

November

Nov. 1: The Tucson Osteopathic Medical Foundation in joint


providership with THMEP presents the 3rd Annual Southwestern
Conference on Medicine: Primary Care Update at the TOMF
Conference Center, 3182 N. Swan Rd., Tucson 85712, 7:30-2:30 p.m.
Participants will be able to recognize, analyze, and assess patients
with high risk factors for cardio-metabolic syndrome, identify and
use treatment methods and interventions, review new guidelines
for treatment of risk factors, discuss cases regarding new
treatment options, technological advances and interventional
techniques, and appropriately evaluate patients for referral.
This activity has been planned and implemented in accordance
with the Accreditation Requirements and Policies of the Arizona
Medical Association (ArMA) through the joint providership of
THMEP and TOMF. THMEP designates this activity for a maximum
of six AMA PRA Category 1 credits.
The American Osteopathic Association accredits TOMF to
sponsor physician CME. AOA designates this activity for a
maximum of six AOA Category 1A credits.
Registration is $120. To register or view the complete agenda,
please log onto www.tomf.org./cme. A very limited number of
exhibit spaces are available. Details for interested parties are also
available on the website.
For additional information contact Nicole Struck, Program and
Meetings Manager Nicole Struck at 520.299.4545 or e-mail
nicole@tomf.org.
Nov. 7-8: Parkinsons Disease and Other Movement Disorders
for the Practitioner is at Mayo Clinic Education Center, 5665 E.
Mayo Blvd.,
Phoenix 85054. Accreditation: 9.25 AMA, AOA, AAFP.
Program emphasizes fundamental diagnosis and treatment of
issues that commonly confront the clinician. Format of lectures,
case presentations, panel discussions and video vignettes is
designed to provide a thorough review of the differential
diagnosis and treatment of these movement disorders. Audience
participation is encouraged.
Website: www.mayo.edu/cme/neurology-and-neurologicsurgery-2014s449 Contact: Mayo School of Continuous
Professional Development Registrar, 13400 E. Shea Blvd.,
Scottsdale 85259; phone 480.301.4580; fax 480.301.8323 mca.
cme@mayo.edu http://www.mayo.edu/cme

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. HandsFree pedal and variable speed with gauge. Good Condition. $50.00. Interested
parties should e-mail: houseofmontrose@msn.com

SOMBRERO October 2014

SOMBRERO October 2014

27

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28

SOMBRERO October 2014