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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

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MRCSA on Ebola,
other preparedness

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SOMBRERO – December 2014

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
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Fax: 323-9559
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Art Director
Alene Randklev, Commercial Printers, Inc.
Phone: 623-4775
Fax: 622-8321
E-mail: alene@cptucson.com

Members at Large

Vol. 47 No. 10

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
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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
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Board of Directors, Executive Officers or the members at
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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
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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.

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 1/50th
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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SOMBRERO – December 2014

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.

Milestones

Arizona Chapter ACS
honors Dr. Johnson

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.

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
SOMBRERO – December 2014

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

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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.

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 .

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.

CMG: Dr. Donnelly
interim CMO

Dr. Elliott on governor’s
infections disease council
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.

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.

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.

“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.”

“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.”

“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.”

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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PRESENTED BY THE

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“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.”

SOMBRERO – December 2014

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
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
SOMBRERO – December 2014

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
Pathology, and the American Telemedicine Association.
n
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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 fulltime 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 obesityrelated 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.”

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.

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.
8

SOMBRERO – December 2014

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 prediabetics 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 bestselling 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

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.

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

SOMBRERO – December 2014

The Diet of Hope is not
considered a highprotein 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 fulltime by six NPs who
monitor patients’
progress. Dr. Gann has
9

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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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.

ROC #278632

10

“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
SOMBRERO – December 2014

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
Dr. H. Allan Collier in 1984.
School in Covington. “After
graduation,” the family reported, “Allan joined the U.S. Army, and
on his 18th 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 11th 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 ObGyn 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 2nd 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
SOMBRERO – December 2014

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
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
Dr. Remo DiCenso in 1962
had a medical college. He
when he joined PCMS.
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
11

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
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.
Dr. Richard J. Toll in 1963
After three years in general
when he joined PCMS.
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
12

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
Alzheimer’s Association, or Planned Parenthood.
n

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.
SOMBRERO – December 2014

Mix At Six
By Dennis Carey

Mix draws members, guests

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.

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.

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 .
n

PCMS President-Elect Melissa Levine, right, with Linda Byrnes
and Dr. Tom Brysacz, enjoyed the Mix At Six casual atmosphere
and conversion.
SOMBRERO – December 2014

13

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, 17th U.S. surgeongeneral; 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.

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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➢  We all need to be prepared for Ebola or any emergency
situation. If we prepare for one event, pandemic, disaster, or
major emergency, then we will be better prepared for them all.
As physicians, we have an ethical obligation to be ready to step
up and help our community if and when the need arises. This is
where the Medical Reserve Corps of Southern Arizona plays a
critical role. Are you ready? If you are not a member, why not?
➢  Ebola virus structure cannot mutate to become airborne.
➢  Ebola cannot be contracted from mosquitoes.

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.

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:

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.

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

➢  Quality and timeliness of supportive care

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

Surviving an Ebola infection is dependent on a number of factors:
➢  Health and age of victim (younger and healthier patients have
better recovery)
➢  Degree of inoculation of Ebola virus

➢  Shared or had contact with body fluids of a person with active ➢  Strain of the Ebola virus (the current Zaire strain has the
Ebola viral infection.
highest mortality)
➢  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

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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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15

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,

16

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.
n

SOMBRERO – December 2014

Perspecves

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
SOMBRERO – December 2014

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 postoperative 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
17

“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

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.
18

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.
n

SOMBRERO – December 2014

Prostate Cancer

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

P

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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.”

“Our physicians were so

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.

that we were able to get our

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

policies in what seemed

“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.”

hesitate to say Desert

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 AfricanAmerican 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.”

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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.
SOMBRERO – December 2014

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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

20

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 intracellular production of androgens. “Total suppression androgens is
not yet possible.”
Transformation of malignant cells to total androgen
independence secondary to mutations in multiple non-androgendependent 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.

SOMBRERO – December 2014

• Macular degeneration
• Diabetic retinopathy
• Macular diseases, e.g., macular
hole and macular pucker
• Flashes and floaters
• Retinal tears
• Retinal detachment
• Central and branch retinal vein
• Pediatric retinal conditions
• Tumors involving the retina
and choroid
• Second opinions

St. Joseph’s Medical Plaza
6561 E. Carondelet Drive
Tucson, Arizona 85710
Northwest Medical Center
6130 N. La Cholla Blvd., Suite 230
Tucson, Arizona 85741
1055 N. La Cañada Dr.,
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Green Valley, Arizona 85614

SOMBRERO – December 2014

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.”

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.

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.

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.

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

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.”

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Thank you for your referrals. We
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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 intensitymodulated 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,
and greater quality of life.”
n
SOMBRERO – December 2014

Makol’s Call

Hiding from our own truth
By Dr. George J. Makol

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 mid1800s.

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.

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.

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
To illustrate the difference between one’s perception and reality:
stabbed at least once, and yet they continue to fistfight, are
Not too long ago I was walking along the shore of one of the
thrown through walls, or climb up to the second
INGof the
BUZZstory
South Shetland Islands in the Antarctic Ocean when I came
upon
T
I
NNITUS
five huge fur seals basking on the beach. I
BUZZING
was at a distance, but four of them looked
TINNITUS
up, and then scurried down to the beach
and into the water. One rather bold male was
TINNITUS
TINNITUS
not about to be intimidated, so he put his
BUZZING
head down and headed straight for me.

RING
BUZZ

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
SOMBRERO – December 2014

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building to rescue the heroine. This scenario, repeated in movies23

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
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

24

SOMBRERO – December 2014

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.

n

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CME

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

Local CME from Pima County
Medical Foundation

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

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:

January 2015

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.

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

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 patientcentered 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 12th Annual Review is at the Westin Kierland Resort,
6902 E. Greenway Pkwy., Scottsdale 85254. CME credits pending.
Course targets hematologists, oncologists, NPs, RNs, PAs, and all
interested in comprehensive update of diagnosis and treatment
of hematologic and oncologic disorders. Course presents “new
disease classification, treatments, and challenging cases in key
hematologic diseases (dysproteinemias, acute and chronic
leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU),
and overlap topics of supportive, ancillary and diagnostic care.
Includes breakout sessions for one-on-one interaction with faculty.”
Website: http://www.mayo.edu/cme/hematology-andoncology Contact: Lilia Murray, Mayo School of Continuous
Professional Development, 13400 E. Shea Blvd., Scottsdale
85259; phone 480.301.4580; fax 480.301.8323.
mca.cme@mayo.edu http://www.mayo.edu/cme

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SOMBRERO – December 2014

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MICA_Sombrero12'14ad_MICA_Sombrero05'04ad 11/6/14 11:35 AM Page 1

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SOMBRERO – December 2014