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Sombrero

Pima

County

Medical

Society

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

DECEMBER

2014

Dr. Gann’s Diet of Hope Institute

EMRs impracticality

MRCSA on Ebola, other preparedness

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Favorable rates include deep discounts on lodging, ski rentals and lift tickets. Available Feb. 22- March 1st.

ski rentals and lift tickets. Available Feb. 22- March 1st. Conference directors Robert Berens, M.D. and
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Conference directors Robert Berens, M.D. and Alan Rogers, M.D.

SOMBRERO – December 2014

Sombrero

Official Publication of the Pima County Medical Society

Vol. 47

No. 10

 

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

Milestones: What’s up with doctors Johnson, Oscherwitz, Elliott, Donnelly, Kalumullah, and Weinstein.

 8

Membership: Dr. Dietmar Gann’s new Diet of Hope Institute.

11

In Memoriam: Obituaries for octogenarian physicians H. Allan Collier, Remo DiCenso, and Richard J. Toll.

13

Mix At Six: PCMS Vice-President Steve Cohen, M.D. hosted this one.

14

Ebola: MRCSA addresses the lethal virus and other preparedness.

17

Perspectives: Dr. Thomas Scully on EMRs; Dr. Jason Fodeman on Medicaid care delays.

19

Prostate Cancer: An update on the ‘different disease.’

23

Makol’s Call: Dr. Makol considers effects and perceptions of firearms’ medical damage.

26

CME: Credits locally and out-of-town.

damage. 2 6 CME: Credits locally and out-of-town. On the Cover Dr. Hal ‘Travelin’’ Tretbar’s

On the Cover

Dr. Hal ‘Travelin’’ Tretbar’s ‘Winter Glitter’ photo was taken in Flagstaff late on a December afternoon, using a Nikon D600 with the wide-angle lens at 24mm. ‘The camera was sit at ISO 160 with aperture priority and spot metering, and exposure was 1/50 th second at f.22. The aperture has to be at the smallest setting (largest number) to get a star effect from the light source.’

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Milestones

Arizona Chapter ACS honors Dr. Johnson

archaeologists in the Peten jungle of northeastern Guatemala, and with U.S. government scientists to eradicate parasites in China. He assisted medical students with case-based instruction at the University of Arizona College of Medicine—Phoenix last year.

Dr. Oscherwitz is a member of the Australasian College of Tropical Medicine, American Society for Tropical Medicine and Hygiene, American Committee on Clinical Tropical Medicine and Traveler’s Health, the International Society of Travel Medicine, American Society for Microbiology, Infectious Disease Society of America, Arizona Infectious Disease Society, AMA, American College of Physicians, and both PCMS and ArMA.

He is one of a few hundred individuals worldwide to hold the Certificate of Knowledge in Clinical Tropical Medicine and Travelers’ Health issued by the American Society for Tropical Medicine and Hygiene. He is credentialed as an Infection Control Practitioner by the Certification Board of Infection Control, and is a Fellow of the Society for Healthcare Epidemiology of America.

Dr. Oscherwitz has served as a resource for British Airways and Conde Nast Traveler. He offers expert diagnostic and treatment services to ill patients referred to him by other physicians and to individuals with difficult-to-diagnose problems. The majority of

with difficult-to-diagnose problems. The majority of The Arizona Chapter, American College of Surgeons honored

The Arizona Chapter, American College of Surgeons honored Kenneth R. “Scooter” Johnson, M.D., F.A.C.S. with its Lifetime Achievement Award during its Annual Scientific Meeting Nov. 15-16 at the Westward Look Resort in Tucson.

The award is given for Dr. Johnson’s many years of membership and service as an officer of the organization. His reported standing ovation went on for about a minute.

Dr. Johnson is a native of Wisconsin, where he went to college and medical school. He did his surgical residencies at UCLA and in Tucson. In addition to his 35 years of private practice, he has served as a University of Arizona Assistant Clinical Professor of Surgery, helping to train the next generation of medical students and surgery residents.

He is a member of the PCMS History Committee, is particularly interested in local medical history and the medical history of American presidents, and has appeared often in these pages.

Father of four, Dr. Johnson is retired from practice and lives in Tucson with his wife, Cathy, having recently celebrated their 38th anniversary.

Dr. Oscherwitz joins Southern Arizona Infectious Disease Specialists

Steven Oscherwitz, M.D., a specialist in infectious fiseases, tropical medicine and epidemiology, has joined Southern Arizona Infectious Disease Specialists in Tucson, practicing with six other physicians including Lisa Valdivia, M.D. and Clifford Martin, M.D.

Dr. Oscherwitz earned his medical degree from the University of Texas Health Science Center at Dallas in 1986, and then completed his IM residency, chief residency and Infectious Disease Fellowship at University of Texas Health Science Center at San Antonio.

He completed the military tropical disease course at Walter Reed Army Institute of Research in Washington, D.C., and rotated with military physicians at Lackland Air Force base and Wilford Hall Medical Center in San Antonio. He has traveled as a physician for

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his career has been spent caring for critically ill or unstable hospitalized patients, and he has used his Asian, African, European and South Pacific travel experience to assist in making diagnoses for returning ill travelers as well as making prophylactic recommendations for departing travelers on both adventure and business itineraries.

His DrDetective website, www.drdetective.com, is designed as a portal for questions and record review for patients without access to infectious disease specialists near their homes. Dr. Oscherwitz has been featured in Nature’s Vampires (Discovery Channel/ Animal Planet), Mystery ER (Discovery Health Channel), local TV and radio programming and print media.

Dr. Elliott on governor’s infections disease council

Dr. Elliott on governor’s infections disease council Pediatric infectious disease physician Sean El liott, M.D.

Pediatric infectious disease physician Sean Elliott, M.D., professor of pediatrics and medical director of infection prevention for the University of Arizona Health Network, has been appointed by Gov. Jan Brewer to the newly established Council on Infectious Disease Preparedness and Response, the UofA reports.

The council is of leading experts in health, human services, public safety, emergency and military affairs, education, and more.

Dr. Elliott, together with a multi-disciplinary team at UAHN, has created an “infection-prevention SWAT team,” developing protocols and training for infection control to safely care for patients and to protect the well-being of staff and clinicians throughout the network.

“Governor’s councils have been formed before—as in the council for H1N1—and they bring together the resources of the state to improve communication, training and understanding,” Dr. Elliott said. “Since we are about to enter the flu season, this council is particularly important.”

According to Gov. Brewer’s office, the council “has been charged with developing a coordinated and comprehensive plan to ensure the state is prepared to manage and respond to potential outbreaks of infectious diseases, including the Ebola virus and Enterovirus, in Arizona.”

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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!

A copy of the Governor’s official press release listing the duties

of the council and other team members can be viewed at

www.azgovernor.gov/dms/upload/PR102114EOCouncil

InfectiousDiseasePreparednessResponse.pdf . A copy of the Executive Order can be viewed at www.azgovernor.gov/ Newsroom/GovEO.asp .

CMG: Dr. Donnelly interim CMO

Nov. 3, 2014 – Carondelet Medical Group announced Nov. 3 that its new Interim Chief Medical Officer (CMO) is Christine Donnelly, M.D. “Dr. Donnelly took over this role on Oct. 21 when her predecessor stepped down after many years with Carondelet,” CMG reported.

Her predecessor was Michael Connolly, D.O., currently on the PCMS Board of Directors.

“Dr. Donnelly has worked in

family medicine at Carondelet Medical Group (CMG) for the last 11 years. She is currently the CMG Board Chair and her practice’s lead physician. While serving

in her new role as Interim CMO, Dr. Donnelly will take on

additional administrative duties and continue to see patients at CMG’s Central office at 630 N. Alvernon Way, Tucson.

“After receiving her bachelor’s degree in microbiology from the University of Arizona, Dr. Donnelly went on to earn her M.D. Pennsylvania State University. She returned to Tucson to complete her residency in Family and Community Medicine at the University of Arizona, and is board-certified in Family Practice.”

“I’m really excited about my new role here at Carondelet,” Dr. Donnelly said. “It’s the best of both worlds because I get to continue seeing patients while expanding the ways I serve my colleagues. As CMO, I have a wonderful opportunity to support our dedicated physicians working across the Network.”

“In addition to her full-time work as a doctor over the last decade, Dr. Donnelly also has served as Associate Clinical Faculty for the University of Arizona’s College of Medicine and College of Nursing, and has been a medical relief volunteer in developing countries around the world every summer, sometimes bringing her children with her for the experience .”

“We are thrilled to have Dr. Donnelly as Carondelet Medical Group’s interim chief medical officer,” said Tawnya Tretschok, vice-president and executive director of physician practices at Carondelet. “She is highly regarded among her peers and patients, bringing with her a wealth of clinical and leadership experience. She’s a great fit.”

bringing with her a wealth of clinical and leadership experience. She’s a great fit.” 6 SOMBRERO

Dr. Kalimullah joins Skin Spectrum

Faiyaaz Kalimullah, M.D., board-certified dermotologist, has joined the three-physician dermatology practice Skin Spectrum at 6127 N. La Cholla Blvd, Suite 101 (797.8885). It is also the practice of PCMS member Tina Pai, M.D.

Dr. Kalimullah graduated from the University of Chicago with honors in Near Eastern Languages and Civilizations, and subsequently earned his medical degree at Rush Medical College, where he was

his medical degree at Rush Medical College, where he was elected to the Alpha Omega Alpha

elected to the Alpha Omega Alpha Honor Medical Society.

Following med school he completed his IM internship at University of Chicago Medical Center. He went on to complete a dermatology residency at University of Arizona Medical Center, where he was appointed chief resident during his final year of training.

“Dr. Kalimullah is committed to providing his patients with expert skin care,” the practice said. “using the latest technologies in aesthetic dermatology. He is particularly interested in the use of neuromodulators such as Botox Cosmetic, dermal fillers and volumizers, and laser surgery for skin rejuvenation.

“We welcome him and hope you will get a chance to meet ‘Dr. K.’ soon!”

Center for Connected Health honors Dr. Weinstein

Ronald S. Weinstein, M.D., founding director of the Arizona Telemedicine Program (ATP) at the Arizona Health Sciences Center and one of the “fathers” of telemedicine, was honored for “distinguished service in advancing technology-enabled care delivery and help promoting health and wellness,” on Oct. 23, at the 11th Annual Connected Health Symposium, hosted by the Center for Connected Health, Partners HealthCare, in Boston, the university reported.

“The Center for Connected Health is part of Boston-based Partners HealthCare, a non-profit integrated health system, and was started in 1994 by two of the nation’s leading academic medical centers: Brigham and Women’s Hospital and

academic medical centers: Brigham and Women’s Hospital and Massachusetts General Hospital (“Mass General”), both

Massachusetts General Hospital (“Mass General”), both affiliated with Harvard Medical School.

“The Massachusetts-based organization is recognized Dr. Weinstein for his ‘groundbreaking work in bringing healthcare to the farthest corners of the state of Arizona and beyond, and for his vision and leadership that propelled telehealth to its current state of adoption.’”

“It’s a homecoming for me,” said Dr. Weinstein, who did his residency in pathology at Mass General, and participated there in the very first telemedicine cases in the country, in 1968. That program is of enormous historical interest, and to receive an award from the people who are now the custodians of the Mass General-connected program has special significance for me.”

Multispecialty telemedicine got its start in 1961, following a tragic plane crash at Boston’s Logan International Airport, Dr. Weinstein said. “City leaders approached Mass General about the possibility of somehow bringing emergency services more rapidly to the airport, since the only access to the airport then was through Callahan Tunnel,” Dr. Weinstein recalled. “Over a period of six years they studied the request and devised a plan linking Logan Airport to Mass General by point-to-point microwave. Not only that, they developed a total telemedicine solution that is almost identical to what we use today—electronic stethoscopes, teleradiology, teledermatology, telepsychiatry, even the first telepathology.”

“The Mass General-Logan International Airport Telemedicine Program became the model for two of the first statewide programs, one started in Georgia by Dr. Weinstein’s fellow Mass General resident and friend Jay Sanders, M.D. in 1993, and the second in Arizona in 1996.

“Former State Sen. Bob Burns, a machine language computer programmer at General Electric early in his career, heard of the Georgia program in 1993. He flew to Georgia then back to Arizona with a video recording of what he saw, and consulted with James Dalen, M.D., then-dean of the University of Arizona College of Medicine, about starting a telemedicine program at the UofA. Burns energetically took on the role of legislative champion. He co-founded the Arizona Telemedicine Program with Dr. Weinstein and they still manage the large, 70-community enterprise together, 20 years later.

“The Arizona Telemedicine Program formally launched in 1996, following two years of planning, and began connecting UA physicians to doctors and patients in Nogales, Ariz., and other rural communities in 1997.”

Dr. Weinstein is often called the “father of telepathology” for “inventing, patenting and then commercializing robotic telepathology, a technology that has benefited tens of thousands of patients on five continents. He is founding director of the Arizona Telemedicine Program, headquartered at the Arizona Health Sciences Center of the UofA, and is executive director of the T-Health Institute at the UA College of Medicine—Phoenix.”

Among Dr. Weinstein’s honors is the Lifetime Achievement Award of the Association for Pathology Informatics for his work leading to creation of telepathology services around the globe (remote laboratory diagnostics). He has been president of six medical organizations, including the U.S. and Canadian Academy of

n

Pathology, and the American Telemedicine Association.

Membership

Story and Photos by Dennis Carey

Anti-carb crusade

Dr. Dietmar Gann’s Diet of Hope Institute

D ietmar Gann, M.D. can’t be accused of conventionality, so why should his retirement be any different?

At 70, and a PCMS member since 1979, Dr. Gann decided to end a very successful cardiology career three years ago and focus full- time on his Diet of Hope. In September the Diet of Hope Institute opened its doors at 4892 N. Stone Ave. with Dr. Gann as medical director and his wife, Elizabeth, as certified nutritional consultant.

Dr. Gann has long been an anti-carb crusader, including doing a three-part series on it in these pages, and he’s well-versed in the low-carb/low-fat discussion. The Ganns developed the Diet of Hope to help patients lose weight, lower blood pressure, lower cholesterol, reverse the effects of Type 2 diabetes, and reduce or eliminate expensive medications needed to treat many obesity- related conditions.

“I finally decided I wanted to focus on the prevention and help patients without expensive medications and procedures,” Dr. Gann said. “Many patients have been told that once they develop diabetes, they are stuck with it. They will have to be on expensive drugs or insulin the rest of their lives, and it is just not true.”

insulin the rest of their lives, and it is just not true.” At the new facility

At the new facility at 4892 N. Stone Ave., opened in September, Dr. Gann’s Diet of Hope Institute now gets billing over its cardiology predecessor, Tucson Heart Group. DOHI still has offices at 50 Croyden Park Rd. and 2046 N. Kolb Rd., and is also in San Carlos, N.M.

Rd. and 2046 N. Kolb Rd., and is also in San Carlos, N.M. It’s not unusual
Rd. and 2046 N. Kolb Rd., and is also in San Carlos, N.M. It’s not unusual
Rd. and 2046 N. Kolb Rd., and is also in San Carlos, N.M. It’s not unusual
Rd. and 2046 N. Kolb Rd., and is also in San Carlos, N.M. It’s not unusual

It’s not unusual for Dr. Gann to think “outside the box.” In 1979 he came to Tucson to start his cardiology practice. In the 1980s he pioneered the atherectomy, a non-surgical device that uses rotating blades to unblock arteries. In 2003, he was the first cardiologist in Tucson to place a drug-coated stent in an artery to help prevent reclogging. He was also one of the founding cardiologists of Tucson Heart Hospital, which became Carondelet’s and morphed into Carondelet Heart and Vascular Institute at the St. Mary’s campus.

He was born and raised in Germany, where he graduated from med school at the University of Tuebingen in 1967. He studied cardiology and was an Associate Professor of Cardiology at the University of Miami. He served as intensive care director at Mount Sinai Medical Center in Miami 1974-1979.

In 2004 Dr. Gann trekked to the North Pole, and has conquered the Matterhorn and Mt. Kilimanjaro. In a talk at PCMS, he said the polar trip was a great experience, but not one he would repeat!

While in the low-carb/low fat debate the Diet of Hope still has some detractors, Dr.

Gann believes the research and results are on his side. The latest statistics from 1,000 Diet of Hope patients indicate that after the first phase (six weeks), 330 pre-diabetic patients lost an average of 17.6 pounds and A1C normalized in 67 percent of those patients. Diabetic patients (210) on prescription option (PO) drugs on injection with Byetta or Victoza lost an average of 18.1 pounds, 28 percent normalized A1C, 67 percent stopped or dropped PO medications, and 43 percent stopped Byetta or Victoza. Diabetic patients on insulin (90) lost an average of 19.3 pounds, A1C changed and average of -15.7 percent and 59 percent were taken off insulin. Non-diabetic patients (370) lost an average of 16.6 pounds.

“This is important because it is very expensive to treat diabetes. Those drugs and insulin are not cheap,” Dr. Gann said.

The cost of going through the Diet of Hope program is $895 for those not using insurance. Dr. Gann says 95 percent of insurances will cover the plan. It costs nearly $2,000 per year to treat a diabetic patient, he says. Many insurance coverages, including Medicare, will cover the program if it is related to the treatment of a disease or condition such as obesity, diabetes, or high blood pressure. Several Diet of Hope patients come from physician referrals. Nearly 5,000 patients, including 400 physicians, have participated in the Diet of Hope in the last four years.

It is a three-phase program that takes a year to complete. Phase 1 is six weeks in which diets are restricted the most. Diabetics and pre- diabetics are monitored closely at this point because the blood sugar levels can drop quickly and medications will have to be adjusted. Sometimes patients may stay longer in Phase 1 if they feel they have not made enough progress in six weeks. Phase 2 allows for some foods to be reintroduced into the diet. Phase 3 is maintenance.

The Diet of Hope is a modification of the Atkins diet principle that restricts intake of carbohydrates, and for Type 2 diabetes, various sources of sugar. Physician, cardiologist and nutritionist Robert C. Atkins published his diet book in 1972 and it became the best- selling diet book in history. With his own history of M.I., congestive heart failure and hypertension, Dr. Atkins died at 72 in 2003.

Dr. Gann became interested in using a low-carbohydrate diet to help lower cholesterol and improve lipid levels when one his

patients lost 20 pounds and lowered his cholesterol significantly using the Atkins. Dr. Gann tried the diet himself, and lost weight and saw an

improvement in his lipid levels.

He followed up with conversations with the late Dr. Atkins and was provided much of the research used to develop the Atkins Diet. Dr. Gann did some of his own research. This led him to believe the low-fat, high-carbohydrate diets being promoted by the government and special-interest groups such as the

by the government and special-interest groups such as the Dr. Dietmar Gann has his Diet of

Dr. Dietmar Gann has his Diet of Hope Institute seminars— where else?—at the famous PCMS conference rooms, outside which these folks were recently registering.

American Diabetes Association and American Heart Association did not work.

And don’t get him started on the problems with the “food pyramid”! “The food pyramid was developed by the United States Department of Agriculture,” Dr. Gann says. It promotes agriculture.” He concurs with Harvard Medical School that the guidelines in the “food pyramid” are not only wrong, but dangerous. He believes that the severe increase in obesity, diabetes, and high blood pressure in the last 40 years in the U.S. is linked to the low-fat, high-carbohydrate diet. The Diet of Hope is also gluten-free. Gluten, found in many whole grains, causes an immune reaction in those who have celiac disease. Dr. Gann believes this is another reason to avoid “food pyramid” guidelines.

The Diet of Hope is not considered a high- protein diet. It is about portion control, sufficient proteins, and good fats. Vegetables are the source of carbohydrates, and refined carbohydrates such as breads, pasta, rice, and cereal are avoided.

The Diet of Hope Institute is staffed full- time by six NPs who monitor patients’ progress. Dr. Gann has

by six NPs who monitor patients’ progress. Dr. Gann has Dr. Gann introduces his Diet of

Dr. Gann introduces his Diet of Hope Institute office staff at a recent seminar.

PCMS’s Basel Skeif, M.D. and George Makol, M.D. attended the Diet of Hope Institute open

PCMS’s Basel Skeif, M.D. and George Makol, M.D. attended the Diet of Hope Institute open house in September. Dr. Skeif practices cardiology with Tucson Heart Group and helps at the institute, while allergist Dr. Makol is ‘famous’ in Sombrero.

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managed voice and data services ROC #278632 Practicing what they preach, Elizabeth and Dr. Dietmar Gann

Practicing what they preach, Elizabeth and Dr. Dietmar Gann explain their diet’s benefits of exercise to participants at a PCMS-sponsored Walk With a Doc event Nov. 1 along the Rillito.

also recruited some of his former colleagues to help. Cardiologists James Evans, M.D., Lionel Faitelson, M.D. and Basel Skeif, M.D. of Tucson Heart Group rotate weekly rounds.

“This is not a substitute for a primary care physician or an endocrinologist,” Elizabeth Gann said. “We provide regular updates to be given to the patient’s regular physician. We don’t want patients to stop going to their regular doctors.”

Dr. Gann encourages exercise to go along with the Diet of Hope. They practice what they preach by hiking, playing tennis regularly, and continue to sponsor a 10K run on Cinco de Mayo with Tucson Heart Group.

Dr. Gann points to the Arctic Inuit and the Masai in Africa as examples of staying healthy on a high-fat, low carb diet. Both cultures have little or no clinical heart disease, low blood pressure and cholesterol, and are free of cancer. The Ganns spent time with the Masai in 2000 and sampled the diet of goat blood, milk, and roasted meat.

The Diet of Hope is not that extreme, but it is a lifestyle change. The Ganns have published two books on the diet. One explains the diet itself, while the other is a cookbook with recipes to help stay on the program. Both are available on the Diet of Hope website dietofhope.org.

“We know it is not easy to change after getting bombarded by the food industry and government for years,” said Dr. Gann. “It is has become an addiction like alcohol and tobacco. We believe our program can provide the support to help our patients get over their addiction. It is something they will have to work on the rest

of their lives, even after they leave the program.”

n

In Memoriam

By Stuart Faxon

H. Allan Collier, M.D.

1928-2014

Ob-Gyn physician H. Allan Collier, M.D., PCMS member for nearly 30 years, died Oct. 3 in Ohio, his family reported in the Arizona Daily Star Oct. 15. He was 85.

Replying to a Sierra Vista Community Hospital query in 1968, PCMS Executive Director Wesley A. Barton said Dr. Collier was “highly regarded in the community as a person and a practitioner.”

Harry Allan Collier was born Dec. 3, 1928 in Raceland, Ky., and attended Holmes High

School in Covington. “After graduation,” the family reported, “Allan joined the U.S. Army, and on his 18 th birthday in 1946, he sailed on a troop ship into Tokyo Bay, where he would be stationed. While in Japan, he became a paratrooper with the 11 th Airborne. Allan left the army in 1948 to go to college on the G.I. Bill.”

He went to the University of Louisville 1948-50, and graduated from the University of Cincinnati in 1953 with a B.S. in zoology. In 1957 he earned his M.D. at the University of Louisville School of Medicine. He interned at the Navy Bureau of Medicine and Surgery’s U.S. Naval Hospital at Portsmouth, Va. He did his Ob- Gyn residency at Cincinnati General Hospital.

Shortly after earning his bachelor’s degree, “Allan married Patricia Reuthe in Cincinnati,” the family reported. “They were married for 57 years until Patti passed away in 2010.

“Allan knew that he wanted to be a physician. He was accepted at the University of Louisville’s School of Medicine in 1953 as an alternate from the waiting list. Allan worked two jobs during medical school to pay his tuition, a task that was not encouraged by the school, but showed his resolve to get his medical degree … He finished first in his class in his senior year.”

“After completing his residency in 1962, Dr. Collier moved his wife and two young sons to Tucson where he would set up his private practice and escape the Midwest winters.” He joined PCMS that year and established his Ob-Gyn practice at Craycroft Medical Center at the fomer offices of Donald S. Bethune, M.D., Craycroft Road at East 2 nd Street.

“Allan practiced medicine in Tucson until 1990,” the family reported. “During that time, Allan and Patti had two more children—a daughter and a son. Allan balanced his family and his busy medical practice with his many hobbies, which included

busy medical practice with his many hobbies, which included Dr. H. Allan Collier in 1984. raising

Dr. H. Allan Collier in 1984.

raising and cutting horses, obtaining his private pilot’s license, making jewelry, reading, and driving his 1952 MG.”

Dr. Collier was a member of what was then the federation of AMA, ArMA, and PCMS. He was an adjunct instructor at the UofA and member of the Southwest Obstetrics & Gynecology Association, Central Association of Obstetrics and Gynecology, and a Fellow of the American College of Obstetrics and Gynecology. He was a diplomate of the American Board of Obstetrics and Gynecology. At PCMS he chaired our Medical Careers Committee 1967-68, and served on the Committee on Medical Standards. In 1973 he chaired the Perinatal Mortality and Morbidity Committee.

Citing health reasons, Dr. Collier retired in 1990. In 1991 he was elected to the Board of Trustees of the Foundation for St. Joseph’s Hospital. He was a member of Our Saviour’s Lutheran Church. At the time of his death Dr. Collier had been “visiting relatives and friends and had just attended a reunion of his high school,” the family reported. “A faithful believer in God, Allan will be remembered for his love of his family, his wonderful friendships, and his warm manner with his patients.”

“Allan is survived by their four children and their families: sons Keith and Todd; daughter Kim and her husband Joe and their sons, Quinn, Caleb and Cole and son, Michael and his wife, Beth and their daughters, Kate and Sarah.”*

A celebration of Dr. Collier’s life was given Oct. 18 at The Lodge on the Desert. Memorial donations may be made to the Alzheimer’s Association, Box 96011, Washington, D.C. 20090-6011 (www.alz.org).

*Editor’s note: The survivors information was punctuationally garbled in the newspaper. We’ve quoted it as it appeared because no source was available to correct it.

Remo DiCenso, M.D.

1927-2014

was available to correct it. Remo DiCenso, M.D. 1927-2014 Dr. Remo DiCenso in 1962 when he

Dr. Remo DiCenso in 1962 when he joined PCMS.

Dr. Remo DiCenso, psychiatrist and PCMS member 1962-77, died Nov. 4, the family reported in the Nov. 7. He was

86.

Remo DiCenso was born Dec. 3, 1927 in Italy, and his family “emigrated to Buffalo, N.Y., where he attended elementary and high school,” the family reported. “He moved with his family to Tucson in 1946.”

He graduated in May 1952 from the University of Arizona as a liberal arts baccalaureate, many years before the UofA had a medical college. He

earned his M.D. in 1956 from University of Southern California School of Medicine.

Dr. DiCenso then did his psychiatric residency at the Veterans Administration Hospital (Neuropsychiatric) at Los Angeles. “He

was a practicing staff member at the VA Mental Hygiene Clinic in Los Angeles until 1961,” the family reported. “He returned to Tucson in 1961 and served as chief at the VA Mental Hygiene until 1962.

“As well as practicing psychiatry for many, many years, Dr. DiCenso was a consultant for the Southern Arizona Mental Health Center, Santa Cruz Family Guidance Center, Greenlee County Human Resources Center, La Frontera, and the Pima County Adult Detention Center. He was a life member of the American Psychiatric Association, Arizona Psychiatric Society and Tucson Psychiatric Society.

“Our father, a lifelong learner, was multilingual and passionate about opera, the humanities, classical music, gardening, and political and social causes,” the family said. “At the time of his death, he was attending weekly French classes at Pima [Community] College and was active in UofA alumni events and the USC alumni group.”

Dr. DiCenso’s parents, Angela and Giuseppe, and brother Dr. Dino DiCenso predeceased him. His brother Dr. Sabatino DiCenso; children Cecilia DiCenso Leal, Jerome Martin DiCenso and Rosanna Helene DiCenso; and grandchildren Nicolas Leal, Allegra Leal, Stefano DiCenso and Sofia DiCenso survive him.

A funeral mass was given Nov. 8 at Saints Peter and Paul Catholic

Church, with burial at Holy Hope Cemetery, the family reported. “In lieu of flowers, please make donations to the charity of your choice … We miss you, Dad.”

Richard J. Toll, M.D.

1929-2014

… We miss you, Dad.” Richard J. Toll, M.D. 1929-2014 Dr. Richard J. Toll in 1963

Dr. Richard J. Toll in 1963 when he joined PCMS.

Dr. Richard J. “Dick” Toll, orthopedic surgeon and PCMS member 1963-1980, died Oct. 26 of Alzheimer’s disease in Tucson, his family reported Nov. 9 in the Arizona Daily Star. He was 85.

Richard James Toll was born Feb. 5, 1929 in Milwaukee, Wis. He earned his bachelor’s degree in liberal arts at the Univerity of Wisconsin at Madison, where he also earned his M.D. in 1954. Serving in the U.S. Army during the Korean War, Dr. Toll interned at Tripler Army Hospital in Honolulu. After three years in general

practice in Shawano, Wis., Dr. Toll did orthopedics residencies in Salt Lake City at Latter Day Saints Hospital and (Shriners) Primary Childrens Hospital.

“Moving his family to Tucson,” the family said, “he began his private practice in 1963.With his friend and fellow surgeon Morton Aronoff, M.D., they founded Tucson Surgical Specialists. Associated with the Crippled Children’s Clinic, he put to use the skills and expertise he acquired at the Shriners’ hospital.”

In the mid-1960s Dr. Toll served on our Sports Medicine

Committee, the Public Health and School Medicine Committee, and the Rehabilitation Committee. In the late 1960s he served on PCMS’s Liaison Committee to the Rehabilitation Center at the UofA, and as our representative to the Tucson Area Chapter of the Muscular Dystrophy Association of America. MDA was headquartered in Tucson for many years.

“In 1972 Dick began his relationship with the UofA Intercollegiate Athletic Department,” the family reported, “and he was team physician for the Wildcats until his retirement in 1992. He was instrumental in development of the Athletic Training Education Program, designed to prepare futire trainers to care for and monitor athletics at the high school and college levels.

“In 1981 Dick married Glenda and they began a wonderful life full of travel, enjoying their time in the Colorado mountains. Dick was a man of diverse interests. He was an avid reader and admirer of Western art. A natural athlete, he enjoyed show skiing, golf, tennis and cycling, and played a mean hand of bridge. He was known to work hard and play hard.

“Dick was a great father, husband, friend, and talented surgeon who will be greatly missed by all who knew him.”

Dr. Toll’s wife, Kathleen, predeceased him in 1994, and he was also predeceased by his brother, Ted.

His wife, Glenda; his children by his marriage to the late Ann MacDonald: Tanis Duncan-Kashman of Wellington, Colo., David Toll of Denver, and Jody K. Toll of Amsterdam, Netherlands, survive him. “Dick and Ann extended their family to include Richard Lochert of Scottsdale,” the family said. “Glenda’s children completed the family with James Shelby of Scottsdale, Michael Shelby of St. Petersburf, Fla., and Christina Grisillo of Tucson. Dick and Glenda’s blended family includes 10 grandchildren and Dick enjoyed each and every one of them!”

At Dick’s request no memorial services was given, and his remains were scattered in the Animas River in Durango, Colo., the family said. Memorial donations may be made to TMC Hospice, the

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Alzheimer’s Association, or Planned Parenthood.

Corrections

In our November In Memoriam for Dr. Sandra M. Smith, we missed a typo in the final quote, which should have read: “She leaves behind a large circle of living and devoted friends who will miss her generosity and unique spirit immensely.” We apologize for typing “miss” as “mess,” and then missing it in proofing.

In the same obituary, member comment came up about who did not work at The Tucson Clinic after the story supposedly derived information from a clinic letterhead with their names. But did it? Like an IRS criminal’s e-mails, that letterhead has disappeared and was not revealed in two subsequent searches of the deceased’s file. If the letterhead never existed, how was that kind of error created? While we cannot locate the source that took over our editor’s brain, we can certainly confirm that doctors William Neubauer, Ron Spark, Gary Henderson, and Christopher T. Maloney did not work at The Tucson Clinic. We may send our editor for neurological imaging, just in case it’s a tumor.

Mix At Six

By Dennis Carey

Mix draws members, guests

Mix At Six By Dennis Carey Mix draws members, guests PCMS Vice-President Steve Cohen, M.D. hosted

PCMS Vice-President Steve Cohen, M.D. hosted our Mix At Six Oct. 25. With him at one of the food tables was Anne Hilts, spouse to our member Dr. Sky Hilts.

A bout 30 members and guests attended PCMS’s most recent Mix At Six social Oct. 25. PCMS Vice-President Steve Cohen,

M.D. hosted as “provider” of appetizers and drinks, though no physician should rightly be called “provider.”

Mix At Six events are designed to allow physicians to meet in a

casual setting without an agenda. Members can meet new

colleagues, students, and invite non-members to find out about

the Society.

Additional Mix At Six socials will be given in 2015. Notifications about them will be in these pages, by e-mail, and on the Society website pimamedicalsociety.org .

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and on the Society website pimamedicalsociety.org . n PCMS Alliance Board of Directors member Anastasha Lynn
and on the Society website pimamedicalsociety.org . n PCMS Alliance Board of Directors member Anastasha Lynn

PCMS Alliance Board of Directors member Anastasha Lynn and Dr. Bruce Lynn stopped by Mix At Six dressed as super-nerds ‘Dr. Amy Farrahfowler’ and ‘Dr. Sheldon Cooper’ from TV’s popular show Big Bang Theory.

Sheldon Cooper’ from TV’s popular show Big Bang Theory. PCMS President-Elect Melissa Levine, right, with Linda

PCMS President-Elect Melissa Levine, right, with Linda Byrnes and Dr. Tom Brysacz, enjoyed the Mix At Six casual atmosphere and conversion.

Ebola

Ebola: Facts, myths, and hazard preparedness

By Dr. Sheldon Marks

T he Medical Reserve Corps of Southern Arizona is pleased that many PCMS physicians joined more than 150 community members at MRC’s Ebola and All-Hazards Preparedness Forum Nov. 1 at the Hilton East on Broadway.

Our expert panel included Dr. Richard Carmona, 17 th U.S. surgeon- general; Dr. Sean Elliott, Professor of Pediatric Infectious Disease at University of Arizona and member of the Governor’s Council on Infectious Disease Preparedness and Response; Dr. Josh Gaither, University of Arizona Assistant Professor of Emergency Medicine and Associate Medical Director for the University Campus Base Hospital; Dr. Keith Boesen, director of the Arizona Poison and Drug Information Center; and Tucson Fire Dept. Battalion Chief Kris Blume.

Key points and take-home messages were:

➢  Ebola, though very deadly and very infectious, is very unlikely to be a threat to most of us. Patients with Ebola are only infectious when they have symptoms; fever, headache, myalgias, vomiting, and diarrhea. Yes, these are the very same symptoms as influenza. We are more likely to die of the flu than Ebola (as will 25,000 to 30,000 people in the U.S. this year). We should all get flu vaccine and encourage family, friends and patients to do so.

vaccine and encourage family, friends and patients to do so. From left are Dr. Richard Carmona,

From left are Dr. Richard Carmona, Tucson Fire Battalion Chief Kris Blume, Dr. Keith Boesen, Dr. Joshua Gaither, Dr. Sean Elliott, Dr. Sheldon Marks, and Tucson Fire Chief Les Caid at the event Nov. 1 (Les Caid photo).

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➢  Ebola virus structure cannot mutate to become airborne.

➢  Ebola cannot be contracted from mosquitoes.

Ebola can only be contracted with exposure to fluids from a symptomatic Ebola patient (vomit, diarrhea, sweat, saliva, breast milk, blood, semen) or the dead body. The infected fluids enter the body through the mouth, eyes or nose or through broken skin. You are at risk if you have done any of these four things:

➢  Handled the meat/blood of or eaten infected and partially cooked African fruit bats (the reservoir of Ebola) and/or Sub- Saharan African “bush meat” (chimpanzees, gorillas, etc.).

➢  Handled dying or dead Ebola victims without proper protection and precautions.

➢  Shared or had contact with body fluids of a person with active Ebola viral infection.

➢  Participated in the care of Ebola patients using inappropriate, untested or inadequate PPE, or the flawed donning and doffing of PPE.

Texas Health Presbyterian Hospital nurses who contracted Ebola after caring for Thomas Eric Duncan were only two of many that

came in contact with him. They were involved with his care at the very end, when his viral infectiousness was at its peak. We do not know why they contracted Ebola, though presumably there must have been a mistake in PPE coverage with exposed skin, or donning or doffing their PPE. It is important to note that none of the many thousands of people who were exposed to Duncan on his flights from Liberia to Brussels to Washington, D.C. and finally to Dallas became infected, nor did any of his close friends and family with whom he spent time while he was symptomatic and so infectious before he was hospitalized.

Protecting yourself and your staff from Ebola requires the very same hand washing and PPE skills and techniques you should be using with every patient to protect yourselves everyday from other infections you are more likely to acquire, such as Hepatitis C.

Surviving an Ebola infection is dependent on a number of factors:

➢  Quality and timeliness of supportive care

➢  Health and age of victim (younger and healthier patients have better recovery)

➢  Degree of inoculation of Ebola virus

➢  Strain of the Ebola virus (the current Zaire strain has the highest mortality)

Even though there have been 25 prior outbreaks of the five known strains of Ebola since 1976, none has been as devastating or long lasting. There are multiple reasons that have come together at once to create a “perfect storm” for this Ebola epidemic to become so catastrophic for the people of West Africa

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and to scare the world. Some of those factors, in no particular order are:

➢  Extreme illiteracy of the population in Guinea, Sierra Leone and Liberia.

➢  Extreme poverty with poor hygiene, limited food and clean water resources.

➢  No effective governmental or medical infrastructure, thus no containment or control, with no medical care to diagnose, track contacts and provide critical supportive care such as IV fluids, oxygen, antibiotics, managing nutrition and electrolyte imbalances because of the 10 to 15 liters of fluid lost daily from diarrhea and vomiting. Local healthcare workers often reuse needles and syringes.

➢  No medical or health education. People do not believe that Ebola is real, and the governments have no resources to teach otherwise.

➢  Extremely remote, isolated jungle villages with poor roads and porous borders.

➢  Local people rely on rumours and superstitions for information.

➢  Strong local customs and rituals for dying, death, and burials of the dead.

➢  Mistrust of government, doctors, and any outsiders, especially foreigners.

In essence these local people are saying, “Why are you all so worried about Ebola when before no one has ever cared about us dying of so many other diseases including Lassa fever, Marburg,

of so many other diseases including Lassa fever, Marburg, At the MRCSA event, infectious disease specialist

At the MRCSA event, infectious disease specialist Dr. Sean Elliott explains what makes Evola virus particularly dangerous (Les Caid photo).

Malaria, and Tuberculosis? We are fine until the healthcare workers show up, then people start dying.”

The bottom line is, don’t be afraid, but be prepared. Think. Talk. Plan. Prepare.

Dr. Sheldon Marks, PCMS past-president and local vasectomy reversal expert, is a board member of MRCSA as well as a Tucson

Police SWAT volunteer. His said his friends and neighbors were asking him questions, even though he knew nothing about Ebola, which is why he coordinated and moderated the Ebola forum. To find out

more about MRCSA or to join, contact mrcsa@outlook.com.

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the Ebola forum. To find out more about MRCSA or to join, contact mrcsa@outlook.com. n 16

Perspec ves

The fallacy of electronic medical records

By Dr. Thomas B. Scully

President Obama campaigned on reforming our entire healthcare system, often referring to it as antiquated, and often questioning why paper still dominated medical records.

The president clearly stated that one of his goals was the institution of electronic medical records in hospitals. He has delivered this promise. First through incentives, and now with monetary penalties,

most U.S. hospitals currently employ EMRs for both documentation of the patient’s record and for physician orders.

The hospital where I practice recently went full-bore with a new EMR system. After nearly three months of using it, I can safely say that the current systems are sorely lacking and, rather than making patients safer, lead to more errors.

Please understand that this is not a condemnation of the hospital where I choose to practice. They, similar to physicians’ offices, are under the proverbial government gun. Also please do not accuse me of Luddite behavior. Far from being technologically challenged, I am an early adopter to iPhones, iPads, etc. Rather, the current systems are based on a faulty premise, and the ultimate implementation of this faulty premise drives the current issues.

As a surgeon, I understand learning curves. Doing anything new will take some time to get better. I have given thought that the issues we face are simply from a learning curve and the “newness” of EMRs. However, I have used an EMR in my office for more than a dozen years. Although, I don’t make many mistakes on it, I have never been able to get back to a level of efficiency that was present prior to starting our office EMRs.

Also, confirming my non-Luddite status, I have helped install various computers and point-of-sale software for my wife’s retail store, Embellish (note the cheap plug!) However, there’s a significant difference between her store and a hospital: Embellish is closed Sundays. Thus, one Sunday, we spent some time installing her system. What a difference from what the hospital must do! They do not have the luxury of “closing for a day” to install new computers, software, etc. Rather, we must still operate, perform cardiac caths, endoscopies, do surgeries and have a full-service ED open. All while fundamentally changing how we document what we do and how we order medications, tests, etc.

Physicians must write orders on patients in the hospital. The orders include diet, activity, IV fluids, medications, tests to be performed, and so on. As surgeons we often have pre-printed

performed, and so on. As surgeons we often have pre-printed order sets to use following our

order sets to use following our surgeries. We will check off boxes of things we wish to order, and then write out freehand new medications and other items. With EMRs—specifically Computerized Physician Order Entry (CPOE)—physicians use the computer to locate “powerplans.” These powerplans are related to the patient’s diagnosis and/or surgery performed. For a total knee replacement, there is one set. For a lumbar fusion, a different powerplan. For congestive heart failure, yet a new one.

In a similar manner, one then picks and chooses what items on those plans to order. These are nationally vetted order sets. Many of these order sets conform to what are frequently described as subscribing to evidence based medicine (EBM). Unfortunately, for many things done in medicine, there is no definitive EBM. This is especially true with spinal surgery. Thus, we often use our own way of taking care of patients. That “art” of medicine disappears with CPOE. We are forced to use cookie-cutter, one-size-fits-all orders. There is virtually no room for anything else, and no ability to free-form-type orders. In fact, we have been chastised and told not to use so-called communication orders. Those orders are the only means with which one can freely express how you may wish things to be done.

By now you may see some of the issues we face. However, I have still not described the biggest problems. To me, one of the most unusual nuances of the CPOE is that the computer system “sees” all the various units of the hospital as unique entities, almost as if they are entirely different, unrelated individual hospitals!

Imagine it! I may be in the PACU (recovery room), but I cannot start—or in computer lingo “initialize”—my orders. No, I can only sign them. Then, once the patient arrives at the stated destination—ICU, Neuro unit—it is up to the nurse to figure which of the order sets, or powerplans, I have signed, and then initiate them so as to start caring for my patient. I cannot flag the orders, thus letting the nurse know what plan I want to have initiated. No, that would make sense and provide some safety net. I must simply hope my orders are discovered and the appropriate set is started.

Judging by my description of this, one can easily tell that on more than one occasion this has not occurred. The powerplans I described earlier have pre- and post-operative orders. We can customize them to a degree. However, we cannot separate out the pre- and post-op orders. I cannot think of any reason why this exists. However, my pre-op order set is frequently different than my post-op order set. Thus, I will start a new powerplan for post- operative orders. To the nurse who must sort thru this and figure out which one to initiate, there is no way for me to “flag” it as such. Thus, on more than one occasion, my post-op orders have not been carried out, or the wrong ones have been initiated. And this is supposed to be safer?

The other major issues involve note writing. I do not have as much quarrel with that aspect. However, many of the notes on patients have all sorts of data throughout the note—lab values, old findings, etc.—but they say nothing. What matters to most physicians is the assessment and plan part of the note. What is the doctor thinking and planning for the patient? In many of the notes I see, that is the part given the least space. There are various reasons for it. Suffice it to say that the most highly educated people in the system are now data entry clerks, entering data, values, and various other items to meet

“meaningful use” for governmental reasons, yet not really doing anything to further care for the patient.

In sum, I realize many will just assume I am another spoiled surgeon complaining about inevitable changes. Yet I see this as far more onerous. We have allowed our profession to be taken over by bureaucrats who think they know what is best for our patients and us.

I see it differently. Central planning is not effective in general, and certainly not when it comes to something as individualized as one’s health and the appropriate care for that health.

Thomas B. Scully, M.D., F.A.A.N.S., neurosurgeon with Northwest NeuroSpecialists, was recently elected vice-president of the Western Neurological Society. He has been a PCMS member since 1994.

Medicaid expansion could add to care delays

By Dr. Jason D. Fodeman

expansion could add to care delays By Dr. Jason D. Fodeman The Affordable Care Act’s Medicaid

The Affordable Care Act’s Medicaid Expansion remains one of healthcare reform’s most hotly-contested provisions.

Arguments surrounding the expansion have largely focused on the economic and political implications of expanding Medicaid to 138% of the federal poverty level. While these ramifications are certainly worthy of meticulous

debate, there are important medical ramifications of the Medicaid Expansion as well. A recent Wall Street Journal article raises some of these concerns.

The article cites significant Medicaid backlogs in certain states. This could be made worse by the Medicaid Expansion. According to the article, there are hundreds of thousands of people across the country who have signed up for Medicaid and have waited months for coverage. Residents in California and Tennessee have actually filed lawsuits after encountering lengthy delays in acquiring coverage.

The article reports that in Tennessee, 10,000 Medicaid applications are pending, and in New Jersey 12,000 are waiting. In California there are 159,000 Medicaid applications in the queue. Generally, states are required by federal regulation to process Medicaid applications within 45 days.

These delays in application processing could result in delays in care that allow diseases to fester and become more severe.

The article emphasizes an important point. There is a stark dichotomy between access to health insurance and access to healthcare. Clearly the latter is the benchmark, and while government health insurance does provide the former, at times it can fail to offer timely access to the latter.

In a world with infinite resources, expanding Medicaid would no doubt be altruistic. Yet in our world with limited resources, it requires difficult choices and answers to tough questions:

Do states have the resources to timely process the applications of 17 million new Medicaid beneficiaries? And more importantly, where will the new beneficiaries receive care?

These are crucial questions that demand answers from any state looking to expand Medicaid for genuine reasons before it goes down this path. The stakes are fer too high to wing it. We cannot afford to see the care of the most needy turn into another healthcare.gov fiasco.

Presently, flaws in Medicaid statute get passed along to beneficiaries in the form of restricted access, long waits for appointments, and compromised care. At the same time, the program is also replete with waste, fraud, and abuse.

Medicaid leaves state regulators and policymakers with few options to control rising program costs other than paying providers less, or coming at the expense of other state priorities like education, transportation, and security. A 2011 Kaiser Medicaid study concluded, “As in previous years, provider rate restrictions were the most commonly reported cost containment strategy.”

As a result, Medicaid reimbursements have fallen well below those of private insurers and Medicare. According to the 2012 Kaiser Family Foundation Medicaid to Medicare Fee Index, across the country Medicaid reimbursements are 66% of Medicare reimbursements for all services and 59% of Medicare primary care reimbursements. Medicare reimbursements are already lower than those of private insurers. Sometimes payments from government health insurers for services can be even less than the cost to provide those services.

Due to declining reimbursements and the program’s administrative hassle, many providers are reluctant to participate. Thus, Medicaid beneficiaries can have a hard time getting access to timely care. They can encounter lengthy delays or be forced to depend for care on expensive, overcrowded, disjointed emergency rooms. Both these factors contribute to poor health outcomes for Medicaid patients. This is well documented in the peer-reviewed literature.

The Medicaid Expansion is no panacea for these problems, nor was it ever billed as such. Efforts must be made to improve healthcare access and actual healthcare of the uninsured and underinsured. Medicaid is a program in need of more reforms, not more beneficiaries.

Without a strategy to navigate the tough questions, it is very likely that under the Medicaid Expansion, things could get worse before they get better.

PCMS member Jason D. Fodeman, M.D. is a board-certified IM physician practicing in Tucson. He is a graduate of the Cedars Sinai Internal Medicine residency program and completed a graduate health policy fellowship at the Heritage Foundation. This article originally appeared in the Knoxville (Tenn.) Sentinel News.

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Prostate Cancer

A different disease

By Frederick R. Ahmann, M.D. Shona Doughtery, M.B., Ch.B., Ph.D.

P rostate cancer is “one of the most difficult diseases to understand,” even for physicians, Dr. Frederick R. Ahmann said.

“Why is it different?” Because “we don’t treat 30 to 50 percent of people, but for others we have to say they are in big trouble.”

Dr. Ahmann, UofA professor of medicine and surgery, and Shona Dougherty, UofA associate professor of radiation oncology, were speaking on Sept. 9 at PCMS for Pima County Medical Foundation’s monthly CME presentations, doing A Prostate Cancer Update.

The biggest risk factor for prostate cancer, Dr. Ahmann said, is that inevitable three-letter word: Age.

“The number of prostate cancer deaths has been rising since the 1920s,” Dr. Ahmann said, “due to longer lifespans and better diagnosis. Still, it’s the second leading cause of cancer death in men [first is lung & bronchus at 28 percent], but around 1990 early detection became possible. Ten million men in the U.S. have prostate cancer right now, and we do almost 1 million biopsies per year in order to diagnose it.”

Dietary changes don’t do anything for it, Dr. Ahmann said, and “we don’t have a great screening test for it.” PSA is good and bad, he noted: Five to six percent of men will be 4+. “Criteria are not yet perfect for identifying those who have the disease or not.”

What do you want to know about any cancer? Dr. Ahmann said you want to know how common it is, what its biologic behavior is, how variable it is, what are its risk factors, how lethal it is, whether we have successful treatments for it, whether it can be prevented, if it can be detected early.

He cited 2006 statistics noting that men in China, Japan, and Greece had the lowest prostate cancer death rates, while the highest were in Sweden, Norway, Australia, the U.S., and England. Death rate stats by race/ethnicity 1999-2003 placed African- American men highest at 65 percent, followed by whites at 26.7 percent. Lowest were Asian-Americans at 11.8 percent. Hispanic men showed at 22 percent. Familial prostate cancer comprises about half of the disease cases in men 55 or younger.

What’s good and bad about PSA? “In generic screening and

elevated level is found in up to three to five percent of men over 50,” Dr. Ahmann said, “but only 20 percent have cancer, and of those, 40 percent appears to be unaggressive prostate cancers. We have lowered the death rate from prostate cancer by almost

40 percent since the introduction of PSA early detection, but at a

large price of over-treatment.”

He cited the Johansson Data from 2004 in JAMA showing that

between years 15 to 20, progression-free survival fell from 45 to

36 percent, survival without metastases fell from 77 to 51 percent,

and prostate cancer-specific survival fell from 79 to 54 percent.

In the 1989-1999 Scandinavian Prostate Cancer Group update on “watchful waiting” vs. radical treatment, randomized among 695 men with early prostate cancer, with a 23-year follow-up, 200 of 347 in the surgery group died, 63 due to CAP, while in the WW group, 247 of 348 died, 99 due to CAP. Eight had to be treated to prevent one death, Dr. Ahmann said.

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In what he called a “poorly understood U.S. study” of radical prostatectomy vs. observation (the PIVOT Trial) [NEJM 2012], the study was designed to enroll 2,000 petients, but failed and only enrolled 740. Median survival was assumed to be 10 years. “It was too short,” Dr. Ahmann said. “The study was dramatically underpowered. It treated low-risk patients who should have been on surviellance.”

In the PLCO Trial [NEJM 2009], from 1993 to 2001, half of 76,693 men at 10 centers were screened annually, with the other half receiving usual care. The screening group offered annual PSA for

six years and DREs for four years. Results were sent to the primary care physicians and they decided on follow-up. Compliance was

85 percent for PSA and 86 percent for DRE. Screening in control

group were 40 to 52 percent per year for one to six years for PSA, and 41 to 46 percent for DRE.

After seven years there were 2,820 cancers in the screening group, and 2,322 cancers in the control group. Deaths after seven years were 50 in the screening group, and 44 in the control group.

In a 13-year update of a European PSA screening trial, the number of cases found were 7,408 in the screened group, and 6,107 in the control group. Prostate cancer deaths were 355 among ther screened, and 545 among the control.

In a 450-man Canadian surveillance study started in 2000, of two groups of men younger than 70, and older than 70, with PSA of

10 or less for the younger men, and 15 or less for the older, they

were seen every three months for two years, and then every six months, with repeats biopsies after six to 12 months and then every three years.

After almost seven years of suveillance (2010), 22 percent of the men died, but only five percent of the 450 men died of prostate cancer. For 70 percent of the men, there was no suggestion of prostate cancer progression. “However,” Dr. Ahmann said, “there was evidence of disease progression in 30 percent (135 men) of the men on the study, and half, after undergoing treatment, had already failed with a rising PSA level.”

What’s new in treatment of incurable prostate cancer? Various drugs are being researched. Dr. Ahmann cited the work of Charles Huggins, M.D. of the University of Chicago and pathologist

Andrew V. Schally, Ph.D. of the University of Miami, noting the potential causes of castration resistance in prostate cancer:

Emerging dominance of an androgen-insensitive clone that has been present since malignant transformation.

Transformation of malignant calls to castration-resistant but still androgen-sensitive calles due to : Increased number of androgen receptors; mutated androgen receptors; or increased intra- cellular production of androgens. “Total suppression androgens is not yet possible.”

Transformation of malignant cells to total androgen independence secondary to mutations in multiple non-androgen- dependent growth pathways.

Dr. Ahmann noted again that “we are treating with surgery or radiotherapy large numbers of men who don’t end up benefiting from therapy. We have successful local therapies that have reduced the death rate and are increasingly better tolerated. We have developed a significant number of new therapies in the last 10 to 15 years which have significantly increased the survival of men with incurable prostate cancer.”

Prof. Doughtery provided an overview of the options for active management of prostate cancer and steps involved in delivery of radiation therapy. In counseling patients, cancer is a big word, she said, so slow down, consider the choices, and place them in context. “Patients with life expectancies of less than five years should see an oncological urologist and a radiation oncologist.”

In considering active surveillance vs. active treatment for these patients, Prof. Dougherty said, a physician should introduce the concept, and consider the expectations for quality of life and the patient’s own experience.

Having choices can be good or bad, she said. If there are too many choices, why? Remember that no choice is perfect, consider side-effects, sexual function and bladder continence.

She named 11 choices: Do nothing, active surveillance, surgery, cryotherapy, high-intensity focused ultrasound (HIFU), hormones (androgen deprivation therapy or ADT, and radiaion therapy that may be external beam, radioactive seed implant (LDR brachytherapy), high-dose-rate brachytherapy, protons, or a combination of radiation therapies.

high-dose-rate brachytherapy, protons, or a combination of radiation therapies. 20 SOMBRERO – December 2014
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• Macular degeneration • Diabetic retinopathy • Macular diseases, e.g., macular hole and macular pucker
• Macular degeneration • Diabetic retinopathy • Macular diseases, e.g., macular hole and macular pucker
• Macular degeneration • Diabetic retinopathy • Macular diseases, e.g., macular hole and macular pucker
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21

Treatment targets the prostate gland,” she said, “including the gland, seminal vesicales, and pelvic lymph node. The higher the risk, the larger the target.”

For surgery, inquire about surgical knowledge and discuss open vs. robotic prostatectomy. Surgery uses unilateral or bilateral nerve sparing. Cathetuer use if seven to 10 days and downtime four to six weeks. Post-surgical radiation therapy is adjuvant or salvage.

As a sidelight, Prof. Doughtery mentioned Dr. George Goodfellow, known for medical history in Tombstone for his self-taught expertise on gunshot wounds. But when he returned to Tucson in 1891, he performed the world’s first prostatectomy.

Among the 11 choices, cryotherapy involves cryosurgery or cryoblation of the medium to smaller glands. “It tends to ablate nerves for sexual function,” Prof. Dougherty said. “It’s appropriate for radiation failures

and is minimally invasive. There have been several advances in technology, including warming of the urethra and rectum.” Placement of the cryoneedles is under ultrasound guidance.

High-intensity focused ultrasound (HIFU) was “originally developed for fibroiad,” she said. “It’s for low-risk prostate cancer only. Ultrasound is trans-rectal, with a heat transfer of 85-95 degrees centrigrade. It preserves the sphincter, rectum and nerves.” The FDA rejected approval based on issues of safety and efficacy, she said. About 40,000 petients over 15 years were treated with HIFU.

Androgen deprivation therapy or ADT is used as a sole therapy or adjuvant therapy with radiation, Prof. Dougherty said. “There is lowering of testosterone with testicular suppression, adrenal suppression, and a peripheral blocker. Side-effects include fatigue, hot flashes, muscle wasting, weight gain, appetite stimulationt, decreased libido, shrinkage of testicles, muscle/joint pain, mood alteration, mood lability, hair loss, dry skin, memory issues, cardiac issues, and osteoporosis.”

In proton radiation therapy, particles are accelerated and targeted. But this therapy is expensive, with limited availability, and not proven to be superior, Prof. Dougherty said. “Dats is limited, as it has been available for fewer than 20 years. It’s no longer approved by some insurance companies for low-risk disease.”

In high-dose-rate brachytherapy, several catheters are placed, under general anesthesia, and their positions identified by CT scan. Iridium is used, a single, very active radiation source. “The source is threaded up each catheter in turn to a predetermined position and allowed to ‘dwell” there for a specific length of time before being withdrawn, and then enters the next catheter,” Prof. Dougherty said. “There are single treatments, three fractions on two occasions.”

Radioactive seed implant (LDR brachytherapy) uses a prostate gland seed implant with a low dose rate, Eighty to 100 “seeds” are permanently implanted using five titanium capsules with iodine or palladium (Cesium).

Combinations of therapies may be used. “Radiation is like light,” Prof. Doughtery said. “Several weak beams of this ‘light’ can be aimed at the same target to produce an intense spotlight.” This is the method of intensity- modulated radiation therapy or IMRT. There is “pixel by pixel control of the dose,” she said. “Shutters open or close part of the aperture. It gives a more even dose throughout the target, and can create hot spots within the target.” Since the target can move, “immobilization is very important for IMRT, she said.

There are “lots of options for active treatment,” Prof Dougherty said. ‘Consultations can take one to two hours. Surgery and radiation still have the best outcomes for efficacy and are considered equal for side-effects. Low-rick prostate cancer is 90-95 percent curable, but do we need to treat all, rather than use active surveillance?

“Evolving technology is leading to better treatments with more cure, fewer side-effects,

n

and greater quality of life.”

Joy
Joy
fewer side-effects, n and greater quality of life.” Joy Carlson ENT Associates would like to wish

Carlson ENT Associates would like to wish you a happy holiday season. Thank you for your referrals. We appreciate working together to help improve the lives of our patients.

working together to help improve the lives of our patients. Quality Treatment. Compassionate Care. Convenient

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www.carlsonent.com

Makol’s Call

Hiding from our own truth

By Dr. George J. Makol

Call Hiding from our own truth By Dr. George J. Makol “ F amiliarity so dulls

F amiliarity so dulls the edge of perception as to

make us least acquainted with things forming part of our daily life.” So wrote Julia Ward Howe, author of Battle Hymn of the Republic, in the mid-

1800s.

slithered down to the shoreline, got off his beach as quickly as we could, and he returned to peacefully basking under the Antarctic sun. Reality dawned upon me, as I had almost become fur seal lunch.

So let us consider what the average American’s perception of gun and knife violence is, and upon what this is surely based. I remember watching television as a kid, and wondering how come nobody shot by the Lone Ranger or Tonto ever died. Roy Rogers managed to flash his guns without ever hurting anybody, and people were shot on other shows seem to just slump over and not even have holes in their shirts.

Later on, TV got even further from reality, as members of the “A Team” shot hundreds of rounds from automatic weapons, making the bad guys cower but never killing anybody. In fact I’m pretty sure I never even saw them wound anybody, which is incredible, as spraying at least 100 rounds from automatic weapons would probably result in injuries to at least a dozen bystanders.

Even today, the heroes in our movies are almost always shot or stabbed at least once, and yet they continue to fistfight, are thrown through walls, or climb up to the second story of the

Can familiarity lead to a perception that has very little basis in reality, or can it lead to an alternate reality so powerful that it can actually change society? I think so, and I think we have become so accustomed to violence in our society that we now see school shootings, movie theater massacres, and gun- and knife- related violence to a degree that one would never think we would see in this country.

To illustrate the difference between one’s perception and reality:

Not too long ago I was walking along the shore of one of the South Shetland Islands in the Antarctic Ocean when I came upon five huge fur seals basking on the beach. I

was at a distance, but four of them looked up, and then scurried down to the beach and into the water. One rather bold male was not about to be intimidated, so he put his head down and headed straight for me.

Now, my previous experience with seals had been only interact with them at Sea World and the London zoo, where they were accustomed to humans and trained to do tricks. So at this point I half expected him to pick up a beach ball, balance it on his nose, and toss it to me. Such was my perception of seals. Instead, this 400-pound creature slithered across the smooth sand, rapidly approaching me as I clicked picture after picture using my trusty pocket camera.

I suddenly noticed that the creature filled my entire viewfinder, and it dawned upon me that I was not using a telephoto lens. I looked up and he was about 25 feet from me, flashing four-inch teeth. Fortunately the naturalist accompanying our group caught up with me, and stepped in front of me and tossed his bright yellow tote in the sand between me and the aggravated creature. The seal stopped quicker than a “Real Housewife of Miami” would upon coming upon a Givenchy bag. My group of tourists

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building to rescue the heroine. This scenario, repeated in movies

23

and on television shows hundreds of times, gives the impression that being shot or being stabbed is not so bad, and may be more like a minor inconvenience.

Those of us who have served in emergency rooms and seen what happens when somebody is shot or stabbed might have a different perspective. Modern small arms such as semi-automatic pistols send a round of ammunition out at 600 to 1,200 feet per second. Rifles have a muzzle velocity that can be three times this speed. Bullets do not cut tissue, but they crush tissue, creating a wound channel causing nearby tissue to stretch and expand.

Different types of bullets cause different damage. For instance, hollow-point bullets expand more rapidly and destroy more local

tissue than a jacketed bullet. On one of the TV cop shows I saw recently, they showed actual footage from a bar, showing a 300-pound gun-toting criminal robbing the patrons and browbeating the barmaid. The owner came out from the back room where he was watching on closed-circuit TV and shot the large gentleman from across the room with a .357 magnum pistol. The perpetrator dropped like a sack of potatoes in less than one second; he did not make any statements, climb any ladders, or even finish his beer. He just fell to the floor dead. This is “reality”; what we see in movies is Hollywood.

Switzerland is said to have more guns per capita than any other country in the world. This is primarily why the Nazi regime accepted their position of neutrality, and never invaded Switzerland. Going home to home to

and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many
and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many
and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many
and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many
and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many
and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many
and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many
and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many
and never invaded Switzerland. Going home to home to confiscate weapons would have resulted in many

confiscate weapons would have resulted in many soldiers being shot. And while nearly every Swiss has a gun in his home, the Swiss almost never shoot each other. We Americans seem to make a hobby of it.

I happen to be a gun owner, and have enjoyed many hours of target practice out in the wild. I was taught to shoot by the gentleman who at the time instructed the Tucson SWAT team on firearms, and he insisted that I memorize all of the gun laws and pass a test before he would allow me to handle a gun. On occasion, while out in the wilderness target shooting with friends, another group might show up at the site. If they took any beer out of the back of their vehicles, we packed up and took off; alcohol and weapons should never be mixed.

On a transoceanic voyage many years ago, I learned to shoot skeet. Upon returning to school I purchased a trap to launch clay pigeons (discs), and my frat brothers and I used it for target practice in the woods. I liked shooting clay discs and watching them explode in mid-air, but having seen the damage done by weapons, however I’m not sure I could shoot another person, even in self-defense.

Maybe it’s time that everybody—not just gun owners—gets firearm education, safety instruction, and perhaps a glimpse into the reality of what guns can do to a person. As a result of contracting TMHP syndrome (too much horsepower) I was recently ticketed for exceeding the legal speed limit outside the city. I went to traffic school for four hours, and after seeing films of the horrible effects of traffic accidents, I drove home at 25 miles an hour, terrified that somebody would go through a red light and smash me

to smithereens, as they showed me countless times upon the screen.

When we oldsters were in high school diver-ed, we were shown prevention-minded filmstrips depicting horrific results of highway crashes. They seemed often to come from the Ohio State Police. In the late 1950s the James Dean death car, a nearly demolished Porsche Spyder, went on national tour as a warning about excess speed. If memory serves, for a small fee a Dean fan could actually sit in the thing. No one ever showed what happened to the magnetic young star himself in 1955.

Maybe schools should show videos of real shooting victims, their emergency care, and subsequent surgical interventions.

I cringe when I read of accidental shootings at a teenage party, when some dummy pulls the clip out of a semiautomatic pistol, does not know to check the chamber for a live round, then “accidentally” shoots his friend, The first thing you learn when you shoot is there is no such thing as an unloaded gun.

There are said to be 300 million guns in homes in America, so it is not likely we will ever get rid of them. We just have to give people ample reasons to stop shooting each other.

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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CME

Local CME from Pima County Medical Foundation

Pima County Medical Foundation, a 501(C)3 nonprofit organization derived from and separate from PCMS, presents Continuing Medical Education lectures from our members and others, on second Tuesday evenings monthly at PCMS headquarters. Dinner is at 6:30 p.m. and the presentation is at 7. Tentative 2015 schedule is:

Feb. 10: Hormonal Replacement Therapy with doctors Jonathan Insel and Robert Kahler.

March 10: Breast Reconstruction Surgery—Implants and Complications with doctors Swen Sandeen and Richard Hess.

April 14: Cancer of the Lung—Newer Treatments and Cancer Screening with physicians from Radiology Ltd.

May 12: Healthcare Reform 2015—“What the Hell is Happening??” with several speakers coordinated by Dr. Timothy C. Fagan. Foundation Awards are presented at this time.

June 9: Heart-Healthy Diet with cardiologists Dietmar Gann and Charles Katzenberg.

with cardiologists Dietmar Gann and Charles Katzenberg. Sept. 8: Vasectomy Reversals and Impotence with Dr.

Sept. 8: Vasectomy Reversals and Impotence with Dr. Sheldon Marks.

Oct. 13: Common GI Viral Diseases—Diagnosis, Mechanisms of Action, and Treatment with Claire Payne, Ph.D.

November 10: Pharmacogenomics—How Medicines Affect Differing Demographics of Patients with Dr. Timothy C. Fagan.

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.”

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