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Sombrero

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

MARCH 2015

Would you choose
physicianhood again?
Looking toward
Stars on the Avenue

Spotlight on Northwest
NeuroSpecialists

I WENT WITH
MY HEART.
Dr. Craig Hoover has joined the Carondelet Heart & Vascular Institute (CHVI)
as Director of Cardiovascular Quality. Dr. Hoover received his Bachelor of
Science degree from Stanford University and his Doctor of Medicine from
Columbia University. He joins our team of physicians as an Interventional
Cardiologist, bringing more than 20 years’ experience - with a focus on a
personalized approach and integrating new technology into patient care.
He is the Governor of the Arizona Chapter of the American College of Cardiology.

CARONDELET HEART & VASCULAR INSTITUTE
• Home to some of the best heart and vascular physicians in Arizona.
• 13 cardiologists, three cardiothoracic surgeons and four vascular
surgeons – all focused on improving our heart health.
• Highest quality care in a modern, healing environment.
• Dedicated to the health of the whole person – body, mind and spirit.
• Leaders in adopting minimally invasive techniques to improve patient outcomes.
• The CHVI hybrid operating room is one of the most advanced operating
suites in the nation.

Craig A. Hoover, MD, FACC, FSCAI
Director of Cardiovascular Quality

I joined CHVI with one goal in mind – to help build a regional Cardiovascular Center of Excellence. We have a
core of talented physicians who put their hearts into patient care. Carondelet physicians treat each
patient with dignity and respect. When you visit us as a patient, we will work together to find out what is
wrong and put together a comprehensive treatment plan that works for you in a safe and caring setting.

Carondelet Heart & Vascular Institute. Be well.
(520) 696-CHVI (2484)
Carondelet.org

2

SOMBRERO – March 2015

Sombrero
Pima County Medical
Society Officers

Official Publication of the Pima County Medical Society

PCMS Board of Directors
Eric Barrett, MD
David Burgess, MD
Michael Connolly, DO
Jason Fodeman, MD
Howard Eisenberg, MD
Afshin Emami, MD
Randall Fehr, MD
G. Mason Garcia, MD
Jerry Hutchinson, DO
Kevin Moynahan, MD
Wayne Peate, MD
Sarah Sullivan, DO
Salvatore Tirrito, MD
Scott Weiss, MD
Leslie Willingham, MD
Gustavo Ortega, MD (Resident)

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

Snehal Patel, DO (Alt. Resident)
Joanna Holstein, DO (Alt. Resident)
Jeffrey Brown (Student)
Juhyung Sun (Alt. Student)

At Large ArMA Board

R. Screven Farmer, MD

Pima Directors to ArMA
Timothy C. Fagan, MD
Timothy Marshall, MD

Board of Mediation
Timothy Fagan, MD
Thomas Griffin, MD
Evan Kligman, MD
George Makol, MD
Mark Mecikalski, MD

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

Printing
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Phone: 623-4775
E-mail: andy@cptucson.com

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

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

Publisher
Pima County Medical Society
5199 E. Farness Dr., Tucson, AZ 85712
Phone: (520) 795-7985
Fax: (520) 323-9559
Website: pimamedicalsociety.org

$395,000

SOMBRERO – March 2015

SOMBRERO (ISSN 0279-909X) is published monthly
except bimonthly June/July and August/September by the
Pima County Medical Society, 5199 E. Farness, Tucson,
Ariz. 85712. Annual subscription price is $30. Periodicals
paid at Tucson, AZ. POSTMASTER: Send address
changes to Pima County Medical Society, 5199 E. Farness
Drive, Tucson, Arizona 85712-2134. Opinions expressed
are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS
Board of Directors, Executive Officers or the members at
large, nor does any product or service advertised carry the
endorsement of the society unless expressly stated. Paid
advertisements are accepted subject to the approval of the
Board of Directors, which retains the right to reject any
advertising submitted. Copyright © 2015, Pima County
Medical Society. All rights reserved. Reproduction in
whole or in part without permission is prohibited.

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Thomas Rothe, MD
  immediate past-president
Michael F. Hamant, MD
  secretary

Richard Dale, MD
Charles Krone, MD
Jane Orient, MD

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

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Inside
 5 Dr. Melissa Levine: Our president asks, Would
you do it again?

 7 Membership: We highlight Northwest
NeuroSpecialists.

 9 PCMS News: Banner Health announces new staff
on the local takeover track.

12 Stars on the Avenue: Something particularly
delicious about our coming event.

13 Time Capsule: Dr. Steven Wool as descendant
of the ‘black bag era.’

16 Behind the Lens: Dr. Hal Tretbar reports on his

On the Cover

19 In Memoriam: Obituaries for surgeon Stephen L.

Flowers spring in the Sonoran Desert spring, with colors galore.
This composition of local flora was in Redington Pass on March
10, taken with a Nikon D70 with a 35-105 Nikkor lens at 70mm,
ISO 200, 1/30th second at f16 (Dr. Hal Tretbar photo).

work with first-year med students and Arizona
Arthritis Center.
Wangensteen, M.D., and anesthesiologist
Bohdan J. “Bo” Jarem, M.D.

22 Bioethics: Ethics of ‘the right to try’ by Dr. Tim

Fagan. Bioethics committees under-consulted,
by Dr. Steve Ketchel.

27 Makol’s Call: Is every patient legit who receives
disability payments?

30 CME: Credits locally and out-of-town.

Corrections
In our last month’s Time Capsule of the History Committee’s trip to
Superior by Dr. Nick Mansour, composition omitted the photo credit.
‘Twas Dr. Ken Sandock behind the lens.
Also, in our February Board of Directors profiles we did not have
current contact information for Dr. Scott S. Weiss. It is: Program
Medical Director, Sound Physicians, Carondelet St. Joseph’s Hospital,
350 N. Wilmot Rd., Tucson 85711; phone 520.873.3077.

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SOMBRERO – March 2015

Repeatable
By Dr. Melissa Levine
PCMS President

W

ould you do it again?”

nurses. According to the federal Bureau of Labor Statistics, of 405
workplace shooting homicides in 2010, four percent were a
combined education and healthcare, 17 percent government,
and a whopping 27 percent were retail trade. Sadly, there is a piegraph that shows this.

This is a question that it
seems many physicians are
asked these days. I think it is a
sign of the changing times and
changing ways of medicine. I
suspect that question wasn’t
asked of doctors 50 years ago, or even 25.

Some of you may know this story from the recent NEJM article,
though I actually learned about it on that bastion of knowledge,
Facebook. I venture to say that all Michael Davidson, M.D. wanted
to do was be a good doctor, to impact people’s lives in a good
way. Here is what I know after reading several articles about him.

Maybe I’m wrong, and it has always been asked, and only the answer
has changed. More and more doctors these days say no. A recent
article in AAFP News said 50 percent of Family Physicians report
burnout in 2015—up from 43 percent in 2013. I think that is a shame.

Dr. Davidson was director of endovascular cardiac surgery at
Boston’s Brigham and Women’s Hospital, and assistant professor
at Harvard Medical School. By all accounts he was a star, a brilliant
surgeon who pioneered less-invasive surgeries to help the sickest
of patients who otherwise were too sick to survive conventional
surgery. He tried his best to help those who would have otherwise
heard, “I’m sorry, there is nothing else we can do.”

I finished my residency in 1995, so this year marks 20 years of
practice in Tucson. I also turn 50 this year, so aside from staring
down that colonoscopy, I see this year as one of reflection. I am
applying the “would you do it again?” to a lot of aspects of my life.
As for being a doctor and a family practice doc, let me clearly
state for the record, yes. I would do it again. ABSOLUTELY.

He was a mensch. He cared about his patients and their families
and took time with them and to know them. For his 40th birthday
he ran the Boston Marathon with Team Brigham and was quoted
as saying, “There is no better way to commemorate a birthday,
run the marathon to achieve a personal goal and, in the process,
NG people.”
ZImany
support Team Brigham and its mission toBhelp
UZso

Do I like dealing with insurance? No. Prior authorizations? No.
Declining reimbursement? No. Narcotic-seeking patients? No.
Patients who say they want an Ebola vaccine but not a flu shot? No.
EHRs? Here I will say I have a love-hate relationship. AllTof
these
IN
NITUS
things are a frequent part of my daily life as a
doctor, so why on earth would I do it again?
Patients. It is really that simple. I have the
extraordinary privilege to be involved in
TINNITUS
patient’s lives. And I hope my impact upon
BUZZING
them is for the better. Every day I go to work
is interesting. It is all I ever wanted to do.

RING
BUZZ

RING

HUMM

While I don’t think doctor status is what it
was, say in the 1950s or ‘60s, there is still a
certain amount of status and prestige that
goes with the title. Perhaps deserved,
perhaps not. Perhaps it is good, perhaps not.
We are often held to a higher standard. We
are not allowed to make mistakes because
people’s lives hang in the balance. The thing
is that people’s lives hang in the balance
even when we don’t make mistakes.
Sometimes people die. As doctors and as a
society, we believe this to be failure. That is
probably a topic for another column.

RINGING
HUMMINGGING

It turns out that doctors in China are afraid of
their patients. Really afraid. A typical Chinese
hospital averages 30 attacks on physicians
per year by patients or their families.
Multiply that by the number of medical
facilities and contrast that to the average of
15 shootings per year total on American
hospital campuses—and the vast majority of
those are crossfires. Approximately eight
percent are directed at medical personnel,
three percent at doctors, and five percent at

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SOMBRERO – March 2015

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He was a father of three, almost four. His wife was seven months
pregnant with their fourth child. He had a sense of humor. He
played lead guitar in a rock band called Off Label, comprised of
physicians. He liked fly fishing.
He was well liked and well respected. Almost 1,000 people
crowded into the synagogue for his funeral. He was shot on Jan.
21 by Stephan Pasceri, the son of a patient, who then turned the
gun on himself. Dr. Davidson died in surgery nine hours later.

Now you’re
Thinkin’ Smart

What do I know about Pasceri? He was an accountant, active in his
church, and licensed to carry his handgun. Not a lot is known
about Mrs. Pasceri—she was 78, had valve surgery by Dr.
Davidson, shortly after developed complications, possibly from
chronic lung disease, and was admitted to another hospital. She
died from a pulmonary hemorrhage shortly after being extubated.

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I share the story of Dr. Davidson for two reasons. First it
happened in a week when much of America was focused on
deflated footballs and I think it deserves more than it got.
Second, I believe Michael Davidson, M.D., if asked, would have
said he would do it again.
It is something I reflect upon.
REFERENCES
‘Being like Mike—Fear, trust, and the tragic death of Michael Davidson.’ Lisa
Rosenbaum, NEJM, Feb 4, 2015.
KevinMD.com, Shirie Leng MD, Jan 27, 2015.
‘A look at Michael Davidson, the surgeon fatally shot at Brighams.’ WBUR’s
Common Health, Jan 21, 2015.
‘When patients kill doctors: The horrifying murder of Dr. Michael Davidson.’ Dan
Diamond, Forbes, Jan 21, 2015.
Bureau of Labor Statistics, fact sheet/ workplace shootings, July 2010.

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SOMBRERO – March 2015

Membership
Story and Photos by Dennis Carey

Northwest NeuroSpecialists
The service of neurology specialty

W

hile neurology and neurosurgery have undergone huge
changes with new technology and knowledge, Northwest
NeuroSpecialists also likes to acknowledge their qualities that do
not change, and thus set them apart.
“It started with customer service,” Practice Administrator David
Robinson says, “and we are still about customer service.
“Patients will talk to a person when they contact us. We don’t
want them listening to lengthy recordings with a maze of options.
We also take as much time as necessary for any concerns they
have when they come to the office or call, and we don’t rush
them. Neurological problems are usually not simple.”
Neurosurgeons Thomas Scully, M.D. and Timothy Putty, M.D.
established Northwest NeuroSpecialists in 2003, founding it with
this focus on service. “We were in practice for 10 years when we
elected to start NNS,” Dr. Scully said. “We realized that to truly
provide excellent patient care, we should focus on one office, and
one hospital” [Northwest Medical Center].
Dr. Scully has been a PCMS member since 1994. He served on the
Board of Directors from 2005 to 2011 and is a frequent
contributor to Sombrero. He was recently elected vice-president
of the Western Neurological Society, a prestigious neurological
organization that includes members from the Western U.S. and
Canada. Hhe concentrates on cervical spine surgery, brain tumor
management, and spinal vascular malformations.
Dr. Putty started his practice in Tucson in 1992, and he’s been a
PCMS member since then. His expertise is degenerative spine
surgery and motion preservation techniques.
Richard Chua, M.D. completes the group’s staff of neurosurgeons.
He joined NNS and PCMS in 2005. His areas of concentration are
degenerative spine disease, motion restoration techniques, brain
and pituitary tumor surgery, and aneurysm surgery.
All three surgeons are American Board of Neurological Surgeonscertified, and completed their residency and internship programs
at Indiana University in Indianapolis.
Advances in technology and techniques have made neurosurgery
much less invasive in the last decade. It has improved recovery
time and success rates following surgery. But the practice is not all
about surgery. Sarah Sullivan, D.O., and Kai Denski, D.O. are the
latest editions to the staff. Both are board-certified neurologists
who completed their medical training at the Arizona College of
Osteopathic Medicine at Midwestern University in Glendale.
Dr. Sullivan joined PCMS in 2009 and was elected to our Board of
Directors in November 2014. Her special interests include stroke,
peripheral neuropathy, and Parkinson’s disease. She is also taking
SOMBRERO – March 2015

Northwest NeuroSpecialists, established in 2003,
is at 5860 N. La Cholla Blvd.

the lead on NNS’s tele-neuro program. This allows patients to be
seen electronically with teleconference technology. The doctor
and patient can see and talk to each other on monitors. A
registered nurse is usually with the patient to help with the
examination and follow the physician’s recommendations.
“We are very excited about this program,” Robinson said. “This
will enable patients who don’t have the ability to get to our office
to still receive help. It will also help patients in rural areas where
it is very difficult to come see us.”
Dr. Denski graduated with honors from the University of Michigan
in 2002 before receiving her medical training in Arizona. Last year,
she completed her neurology residency at UAMC where she was
chief resident. She received an Epilepsy Fellowship from the
University of Arizona GME Consortium from 2010-2013. Her
areas of concentration are headache, epilepsy, and stroke.
The neurologists are not limited to their areas of interest. Patients
are treated for a wide range of neurological disorders including all
forms of dementia, multiple sclerosis, muscular disorders including
ALS, sleep disorders, headaches, stroke, back pain, and neuropathies.
“We treat the entire range of neurological disorders,” Robinson
said. “The methods of treating some of these disorders have
7

Neurosurgeon Thomas Scully, M.D., right, is a founder of
Northwest NeuroSpecialists. Neurologist Kai Denski, D.O.,
joined the staff after completing her residency at The
University of Arizona in 4014.

Support staff at Northwest NeuroSpecialists help provide the
customer service that is practice’s main focus.

advanced with new medications and procedures. Most of these
are very serious conditions that need serious attention. It still
comes down to treating patients with respect and dignity.”

administrative, including insurance reimbursement, medical
records, and privacy regulations.

Robinson said that about 75 percent of NNS patients are seniors,
not unusual when many neurological maladies occur in older
patients, and Tucson is a popular retirement location.
Many of the changes experienced at the practice are

Lynn Polonski, M.D.

4021 E. Sunrise Dr.
Ste. 121
Tucson, Arizona 85718
Phone: (520) 576-5110
Fax: (520) 529-7165

“Simply, the manner which we operate in people has morphed,”
Dr. Scully said, “but through all the changes, the general principles
that we started with at NNS 12 years ago hold true today: Give each
patient the time they need. Give them the respect they deserve.
Do what is ethical, necessary, and proper to get them better. If one
follows those general rules, it’s hard to go wrong.”
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SOMBRERO – March 2015

PCMS News

Academic Management
Council launches, pending
regents approval of merger

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The merger of University of Arizona Health Network into Banner
Health “will create a critical and exciting relationship between
Banner and The University of Arizona,” the university opined Jan.
20. “The merger, which still requires approval by the Arizona
Board of Regents, creates an Academic Management Council
(AMC) to assist in managing the relationship.

“Our physicians were so

“Three leaders from Banner Health and three from the University
of Arizona will be appointed to serve as the initial AMC board
of directors, overseeing faculty operations and activities
associated with teaching, research and clinical care within
Banner—University Medicine, a new division of Banner Health
that focuses on academic medicine. The AMC board will replace
the University Physicians Healthcare board that currently governs
the medical group.

comp, health and disability

“Banner—University Medicine includes the three newly named
academic medicals centers (Banner—University Medical Center
Phoenix, Tucson, and South campuses), affiliated ambulatory
care sites and the Banner—University Medical Group, comprised
of physicians and other providers who are faculty for the
University of Arizona Colleges of Medicine and the academic
medical centers in Phoenix and Tucson.
“University of Arizona President Ann Weaver Hart will appoint
the following University leaders to the AMC board: Alex Chiu,
M.D., Professor and Chair, Otolaryngology, University of Arizona,
College of Medicine—Tucson; Gregg Goldman, Senior VicePresident for Business Affairs and CFO, University of Arizona; and
Charles Cairns, M.D., Vice-Dean, University of Arizona College of
Medicine—Tucson, Assistant Vice-President, Clinical Research,
Arizona Health Sciences Center.”
“I look forward to appointing the members of the AMC,” Hart said.
“These initial individuals will help to shepherd this important
transition, and subsequently this council will assist in managing
the relationship long-term. “I have chosen three individuals who
will help lead this statewide endeavor to success and guide the
changes we are making to the culture and operations of academic
medicine for a new era. Financial leadership from the university is
vital and Gregg Goldman will represent the interests of the entire
university. Doctors Cairns and Chiu bring unique skills and
expertise to this council and will support the university leadership
and represent the physicians and faculty, who are critical to our
success. I believe these individuals are exactly what we need right
now to lead this partnership forward and represent the interests
of the university statewide.”

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“Banner Health President and CEO Peter S. Fine will appoint the
following Banner leaders to the AMC board: Kathy Bollinger,
President, Banner—University Medicine Division, Banner Health;
Dennis Dahlen, Senior Vice-President, Chief Financial Officer,
Banner Health; John Hensing, M.D., Executive Vice-President,
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“The Banner leaders on the AMC board have broad responsibilities
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SOMBRERO – March 2015

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become president of the Banner—University Medicine Division
with the Feb. 27 closure.
“Serving as co-chairs for the AMC board will be Bollinger and Dr.
Cairns. The AMC will establish a number of committees that will
include faculty representation. Jason Krupp, M.D., CEO of the
Banner—University Medical Group and president of Banner
Academics, is an ex-officio, non-voting member of the board.
The authority of the Academic Management Council (AMC)
includes:
• Development of operating and capital budgets.
• Approval of strategic and business plans for the Banner
academic enterprise.
• Approval of hiring, engagement and termination of UPH
clinicians; the University will retain the power to provide

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• Approval of the UPH compensation plan, and will template
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• Approval of teaching programs within the Banner academic
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• Approval of a physician recruitment strategy and plan.
• Strategic coordination of the residency and fellowship
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• Approval of all clinical affiliations that support Banner academics.
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MRC calls for action
Medical Reserve Corps, after a decade of
service to the country under the auspices of
the Office of the Surgeon-General, has
recently announced an operational
transition to the Office of the Assistant
Secretary for Preparedness and Response
(ASPR) in the U.S. Department of Health and
Human Services.
Medical Reserve Corps of Southern Arizona
(MRCSA) is enthusiastically supportive of this
evolution to the federal agency whose
primary planning and response
responsibilities mirror the mission of the
Medical Reserve Corps.
The federal Pandemic and All Hazards
Preparedness Act gives authority to the
Department of Health and Human Services
(HHS) as the lead agency for Emergency
Support Function 8—Public Health and
Medical Services of the National Response
Framework. The HHS secretary delegates to
ASPR the leadership role for all health and
medical services support functions to
“improve the nation’s public health and
medical preparedness and response
capabilities for emergencies, whether
deliberate, accidental or natural.”
The Office of the Assistant Secretary for
Preparedness and Response was created in
the wake of hurricane Katrina to lead the
nation in preventing, preparing for, and
responding to the adverse health effects of
public health emergencies and disasters.
ASPR focuses on preparedness planning and
response; building federal emergency
medical operational capabilities; countermeasures research; advance development,
and procurement; and grants to strengthen
SOMBRERO – March 2015

the capabilities of hospitals and healthcare systems in public
health emergencies and medical disasters, as well as medical
professionals through the National Disaster Medical System and
now Medical Reserve Corps.
Dr. Nicole Lurie, M.D., M.S.P.H, RADM, U.S. Public Health Service,
is Assistant Secretary for Preparedness and Response.
Dr. Lurie was previously Senior Natural Scientist and Paul O’ Neill
Alcoa Professor of Health Policy at the RAND Corporation, where
she directed RAND’s public health and preparedness work as
well as the Center for Population Health and Health Disparities.
She also served as HHS Principal Deputy Assistant Secretary of
Health. She has a long history in health services research,
primarily in the areas of access to and quality of care, mental
health, prevention, public health infrastructure and
preparedness, and health disparities. Under Dr. Lurie’s leadership,
MRCSA will continue its mission to serve the communities of
Pima County and Southern Arizona.
This is your call to action! We encourage you to become a part of
this dynamic and fast-growing organization of volunteer medical
professionals. Your skills, expertise, and experience will be vital
to community resiliency following a disaster or public health
emergency.
Why be the medical professional who wants to volunteer and is
turned away until credentials are verified? We understand and
appreciate your busy schedules. MRCSA membership application
takes less than five minutes. There are no annual dues and no
onerous requirements. We ask that you attend a minimum of one
training session each year. It is that easy to make a difference in
your community!
For more information and to join MRCSA, e-mail us at mrcsa@
outlook.com or call 520.445.7035.

Tucson’s modern streetcar
and its public health impacts
By Ron Spark, M.D.
To paraphrase Rudolf Virchow, famous German pathologist and
politician: “Medicine will eventually improve public health, but
politics can do it sooner.”
The coming of Sunlink, Tucson’s light rail or “modern streetcar,”
represents a watershed for the Old Pueblo, leaving behind its
suburban, desert, car-centric orientation. An urban 21st-century
city awaits our future.
The political will to make this happen has brought a number of
cascading opportunities for a successful and healthier place to
live. Both Baby Boomers, suffering with increasingly recognized
decrepitude, and Millennials yearn for an urban core with easily
access to ample and diverse goods and services. Easy proximity to
gathering places, such as we now see Downtown, lend a sense of
place, enhanced socialization, and feelings of well-being. As more
residential market-rate housing is built, many other age groups
will likely opt to enjoy this urban lifestyle. As this happens, more
investment will be drawn to the increased numbers of consumers.
This raising of the quality of life through urbanization will have
obvious public health benefits.
Evidence for the shift toward the desire and need for more
SOMBRERO – March 2015

walkable and bike-accessible roads is reflected in national and
local data. There’s the obvious decline of Millennials getting
driving licenses, as well as the 20-percent decline in their buying
cars. More seniors are giving up driving voluntarily or nonvoluntarily. If you count kids, about one-third of Tucson’s
population doesn’t drive.
Vehicle travel-miles peaked around 2004. Many of Tucson’s
streets have seen a decline in traffic. Broadway was projected in
2006 to have increased volumes of 44 percent over 20 years; it is
currently carrying 15 percent under the 2006 figures. Similar
declining figures are seen on 6th Street and Speedway.
To meet the needs and desires of our future residents, we need
to fashion a more urban, denser community with accessible
services and jobs with reliable, inexpensive high-capacity mass
transit. The modern streetcar, Sunlink, is that starting point. Its
arrival has spurred more than $1 billion in Downtown investment.
The impact is spreading outward to adjacent neighborhoods
where retail goods and services are springing up. The Broadway
corridor is scheduled for redevelopment into a vibrant
destination with a mixture of small retail and service enterprises.
Sunlink didn’t happen overnight. Our vision of Tucson’s future
sustainabilty rested on the concept of providing accessible,
inexpensive and reliable public transit: an effective feeder bus
system to a light rail spine network. That was 13 years ago and
three elections lost! In the end, we partnered with the roadbuilding crowd and RTA was passed. So here we are with Sunlink.
What we need now, for better public health, is the political will to
make the infrastructure investments. High-capacity transit,
complete streets (sidewalks, bike paths, shade structures, and
destinations), and preservation of our historic built structures
that give us a sense of place.
Even medicine has shifted from a disease model to a preventive
one. So, we the citizens of the Old Pueblo, need now to adopt a
more urban mentality, one with ease of connectivity and a sense
of place. That’s the healthy choice.
Over the streetcar’s opening weekend in July 2014, Southern
Arizona Transportation Advocates asked riders where they’d like
to see the next streetcar extension. We received nearly 1,000
reponses. The top choices were: extend out Broadway to El Con
Mall and Park Place; up Campbell Avenue to Tucson Mall; and
south down 6th Avenue to the airport.
Dr. Spark, PCMS member since 1974 and a past-president, is on
the steering board of Southern Arizona Transportation Advocates,
and is a volunteer for Mayor Jonathan Rothschild’s Sustainable
Community Transit-Oriented Development effort. SATA is working
on how to finance streetcar extensions, expand bus service, and
create Tucson-Phoenix rail service.

History Committee schedules
next trip
The PCMS History Committee says its next excursion will return to
historic Arizona mining areas with a trip to Miami-Globe,
Saturday April 18.
As with the previous trip, to Superior, Dr. Nick Mansour and Don
Hammer are scouting the area to plan what sites to see, including
mine sites and a downtown walking tour.
For information or questions, please call History Committee
Chairman James B. Klein, M.D. at 795.9484.
n
11

Stars on the Avenue

Word of mouth indeed
By Dennis Carey

P

CMS’s 2015 Stars on the Avenue celebration April 18 provides
many things—even a chance to get a piece of the pie. Not a
metaphor. Pie.
Along with some of Tucson’s best restaurants, Laura’s Pies is a
featured vendor at this year’s event. Laura Hansen has brought
her baking talents from Montana to Tucson. PCMS members and
their guests will have an opportunity to sample some pies that
have gained national recognition.

These are truly homemade pies, as Hansen has started her Tucson
business out of her brother’s home. She eventually would like to
start a small pie shop in Tucson. “If the right place comes along, I
would like to find a place where people can enjoy a piece of pie
and relax,” Hansen said. “I don’t plan on doing anything big.”
Hansen and her close friend, Mary Lou Covey, owned two
different restaurants in Montana. It started with the Spruce Park
Café in Coram, just outside Glacier National Park. Later they
expanded to a larger location called Loula’s Café in Whitefish,
closer to where they lived. Both cafes have a reputation for
excellent food, but it was the pies that earned a place in the
hearts and stomachs of regulars as well as those of travelers
making a food pit-stop.

It’ll be easy as pie to get a delicious slice when Laura Hansen of
Laura’s Pies brings some of her highly acclaimed baked goods to
Stars on the Avenue April 18 at St. Philip’s Plaza. We recommend
this as the only method to get pie-eyed at SOTA.

“We had a group of hikers called the Over the Hill Gang who
would come in for a piece of pie every Thursday,” Hansen said.
“One of them, George Ostrom, had a radio show and called the
bourbon pecan pie the best piece of pie he had ever tasted. The
best advertising is word of mouth.”
Having an author feature one of your pies in a book doesn’t hurt,
either. Pascale Le Draoulec chronicled her cross-country trek from
San Francisco to New York in a book American Pie: Slices of Life
(and Pie) From America’s Back Roads. Her favorite was
huckleberry-peach from the Spruce Park Café. Numerous articles
and Internet reviews have been written about these pies, and it
still brings in what are called Pie Pilgrims
While huckleberries are not in abundance in Southern Arizona,
Laura does have some unique ideas for Stars on the Avenue. She
plans to feature a Tucson lemon pie, and sour cream apple pie.
Four years ago Hansen was diagnosed with MS. She moved to
Tucson to help her brother, who had his own health concerns
after a lung transplant. Covey bought Hansen’s share of the
restaurants. Spruce Park and Loula’s are still going strong, and
Hansen says she is happy for the continued success.
“My MS really does not bother me a lot,” she said. “I loved
working at the restaurants, but I am glad I don’t have the stress
anymore. I still love making pies—just not as many.”
That doesn’t mean she can’t make Pie Pilgrims out of PCMS
members.
Stars on the Avenue—Campbell that is—is Saturday,
April 18 at St. Philip’s Plaza, 6-9 p.m. Tickets are available at
pimamedicalsociety.org. Sponsorship packages are available by
calling the Society at 795.7985.
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12

SOMBRERO – March 2015

Time Capsule

Baggage
By Stuart Faxon

I

f you are too young to have
carried the once-traditional
doctor’s black bag, you’ve certainly
seen it memorialized, including in
our PCMS headquarters’ lobby
display cases.
If you are a physician mainly
because your father was, you’re
even more familiar with the old
black bag. So it was for Dr. Steven
A. Wool, PCMS member since
1985. About a year ago, Dr. Wool
was visited by Lesley Martinez,
representative of the
pharmaceutical company Abbott.
As a physician’ son, he told her he
remembered from years ago an
Abbott promotional publication
that featured his father, Dr.
Frohman Wool, who was a GP in
Waukegan, Illinois. The older Dr.
Wool had been used as a physician
model for sales of erythromycin as
treatment for Legionnaire’s
disease, the malady that became
all too familiar in 1977.

Abbott said of this photo, ‘Ken Stewart (right), professional representative in the Abbott
Pharmaceutical Division, reviews the company’s report on Legionnaire’s disease with
Waukegan, Ill. physician Frohman Wool.’ The company said the booklet was available to
physicians ‘as outbreaks occur in New York garment district and elsewhere.’

It was not by themselves that the two Wool generations were a
medical family. Dr. Steven Wool’s brother is a surgeon whose son
also became a surgeon. His nephew is a physician. His sister
became a homemaker and physician’s wife. Only one brother of
the four Wool siblings went into non-medical business.

four more copies of the magazine. I would like to send them to
each of our children. I know they would enjoy seeing their dad in
print. One is a doctor, one is in med school, one is married to a
doctor, and the other a freshman in college. If there is any charge,
I would be glad to reimburse you

Dr. Wool asked if Martinez could locate this Abbott publication, a
brochure for distribution to physicians. “Later she showed up in
my office with the original article,” Dr. Wool said, “plus a letter
from my mother that they had at the labs. That was the surprise
to me.”

“Thank you for the pictures. I think he looks better than Dr.
Welby.”

A Nov. 9, 1978 letter from Abbott’s public affairs manager
confirmed sending advance copies of their Commitment
magazine to Dr. Frohman Wool, and thanked him for his
participation. The surprise was the Nov. 13, 1978 response letter
to her from Millie Wool:
“My husband and I received the advance copies of Commitment
magazine with the picture of Ken Stewart and himself. We got a
big kick out of it. Thank you for sending them to him.
“Now, I wonder if it would be asking too much if we could have
SOMBRERO – March 2015

Frohman’s son Steven earned his M.D. in 1980 at Duke University
School of Medicine, interned in family medicine and did his IM
residency at UAMC. He is board-certified in IM. He served on the
clinical staff of the Department of Medicine, University of Arizona
College of Medicine, and as TMC chief of medicine 2005-2009.
And as we noted in our February issue, he founded the Cindy
Wool Memorial Seminar on Humanism in Medicine, which comes
up March 31.
In private practice since 1985, Dr. Wool’s practice today is
Personalized Healthcare of Tucson, what he calls a “physicianpatient partnership” in which he accents education in a
different way.
13

Robert Young played ‘Marcus Welby, M.D.’ 1969-76 in the
popular medical drama of that name. Was he better-lookin’ than
Dr. Frohman Wool? We know what Dr. Wool’s wife thought!

Dr. Steven A. Wool poses in his office with his father’s black bag
(Stuart Faxon photo).

“Achievement of optimal health is a journey, not an office visit,”
Dr. Wool says. “In 2010 I changed from a traditional medical
practice to a physician-patient partnership model. This allows me
to provide my patients with the highest level of medical care in
the community by maximizing accessibility, clinical competence,
and communication.
“In this model the physician puts a priority on building a
relationship with the patient that removes the barriers between
the physician and the patient created by traditional models of
healthcare delivery. The physician learns from the patient, and
the patient learns from the physician.
“My father was a family physician for more than 40 years,” Dr.
Wool says. “He practiced medicine in the old-time tradition,
when a doctor had time to get to know his patients. Inspired by
his example, I have made building nourishing and strong
relationships with my patients a top priority.”
“Added benefits” values at PHC of Tucson include, for urgent
health issues, same- or next-day appointments, or access to
physician services 24/7, and “expedited referrals to quality
specialists.”
“I intend to be a leader in the field of primary care to improve the
health outcomes of my patients,” Dr. Wool says.
n

14

SOMBRERO – March 2015

TUCSON’S SPECIALIST
IN ADULT CONGENITAL
CARDIAC SURGERY.
Dr. Andrea Cooley, a cardiothoracic surgeon, has joined the Carondelet Heart
& Vascular Institute. Her expertise is in adult congenital cardiac surgery
and structural heart disease. Dr. Cooley trained at the University of Texas
Southwestern and at Children’s Medical Center in Dallas. She is board certified
in general surgery and cardiothoracic surgery and holds professional
memberships with the American College of Osteopathic Surgeons, Women in
Thoracic Surgery and the Society of Thoracic Surgeons.

CARONDELET HEART & VASCULAR INSTITUTE
• 13 cardiologists, three cardiothoracic surgeons and four vascular
surgeons – all focused on improving our heart health.
• Dedicated to the health of the whole person – body, mind and spirit.
• Leaders in minimally invasive techniques to improve patient outcomes.
• The CHVI hybrid operating room is one of the most advanced operating suites
in the nation.

Dr. Andrea Cooley, DO
Cardiothoracic Surgeon
(520) 396-1370

I chose Carondelet Heart & Vascular Institute because of the opportunity to work with an exceptional group of
specialists. I am able to combine my area of expertise - complex aortic procedures and adult congenital heart
disease – with the specialties of my colleagues. The team includes two cardiothoracic surgeons besides myself,
vascular surgeons, cardiologists, anesthesiologists, nurses, physical therapists, and case managers. Together, our
collective insight creates a care program for each patient that is better and stronger. We focus on results. One
patient at a time.

Carondelet Heart & Vascular Institute. Be well.
Carondelet.org

SOMBRERO – March 2015

15

Behind the Lens

From rumor to rheumatic

First-year med students meet the real thing
By Hal Tretbar, M.D.

F

or the past several years
I have had the privilege of
introducing UofA med students
to their first patients. I’m part
of a program sponsored by
University of Arizona Arthritis
Center in which first-year
students meet patients with
rheumatic diseases.

The freshman class had just finished the block on musculoskeletal and autoimmune diseases. They are fascinated when
they encounter a person with the actual disease. It is said that
each will always remember this point in his or her medical career.
This year 22 patients with various rheumatic illnesses
volunteered to participate. They find this to be such a rewarding
experience that many return the next year. A rheumatologist
meets and works with one patient in an exam room. The class is
divided into small groups that rotate every 20 minutes to another
exam room. The patients relate their stories and the

Eric Gall, M.D. talks to first-year medical students about how
they will soon meet patients with rheumatic diseases. The class
had just finished the core block on musculoskeletal and auto
immune disorders.

rheumatologist demonstrates the physical
findings.

The Faces of Casa are the

Dr. Ann Marie Chiasson
Associate Medical Director

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

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

16

Eric Gall, M.D., professor of medicine in the
Division of Rheumatology, started a program
in 1975 in which medical students met
patients early in their training. In 1978 a
training grant from the National Institutes of
Health expanded the program.
After spending time as professor of medicine
at the Chicago Medical School, Eric returned
to the UofA in 2010. The present program,
called Physical Findings in Rheumatic
Diseases for First-Year Medical Students, has
invited rheumatologists from the community
to participate along with arthritis center staff
and Fellows. This year Steve Strong, M.D. and
I were non-staff teachers. I received arthritis
center staff approval to photograph and write
about how the students felt when they first
met a patient with a chronic rheumatic
condition. Permission also was obtained from
the patients and the students.
I had the honor of working with Matty
Heenan. She has systemic sclerosis, or
scleroderma. She is very active in the
Scleroderma Foundation and knows more
about the illness than I can remember. Her
SOMBRERO – March 2015

Kevin Purcell describes the joint surgeries he has needed
because of the damage from his juvenile arthritis as Alex
Trofymenko, in the lavender shirt, listens.

Medical student Matt Cravens is able to hear the fine crackling
sounds from Matty Heenan’s lungs.

tight skin has responded well to treatment and she has only slight
restriction in her grips. However, she has developed some of the
internal complications of her disease.

worked as a high school math teacher, was a product manager for
an insurance company, and owned a smoothie shop. He loves
working with people and is interested in healthy living. His
interests and career aspirations have led him to pursue a career
in medicine.

Tucson native Matthew Cravens listened to the fine crackles in
Matty’s lungs. He e-mailed me: “Meeting a patient with an
incurable disease is always a humbling experience … I think
compassionate management is essential for the physician—
educating the patient to what’s happening with his or her body
and what possibilities modern medicine has
for treatment … This feeling is a great
motivator for me toward pursuing research.”
Katie Marsh showed a lot of interest in
Matty’s condition. She stated, “As a firstyear medical student, it is often rare to
encounter “real” patients. At the UofA
College of Medicine this is not the case.
Speaking with patients at the rheumatology
clinic helped me apply our classroom
learning to clinical practice—a lesson that
is invaluable and I will not soon forget.”
Dr. Gall presented Kevin Purcell to the
students. Kevin is a successful businessman
whose severe juvenile arthritis has been in
remission for many years. He has had
numerous surgeries and joint replacements
for deformities.

“My first long-term encounter with someone who had a serious
disease happened when I worked as a teacher,” Alex said. “It was
my responsibility to provide much more comprehensive care
than just teaching mathematics. Honestly,
my initial reaction was anxiety. I worried
that I wasn’t up to the challenge. The
feeling disappeared fairly quickly as I got to
know the student personally and
established working relationships with
many others who took care of him. I
learned to just accept people for who they
are, rather than letting the disease be the
defining characteristic of the student … I
keep this attitude with me as I go through
my training. I want to work with people by
treating their illnesses, and not the other
way around.”
The third group that I photographed was
led by Meg Miller, M.D. of the Arizona
Cancer Center. She explained the serious
complications that Jorge Vega has
developed from his systemic lupus
erythematosus (SLE). Besides the typical
red butterfly rash on his nose and cheeks,
he has severe renal involvement. The
students found out that SLE usually attacks
middle-aged females, although any age
group may be affected.

After examining Kevin, Kelsea Farrell later
commented, “It was very hard to see
someone so limited in their movements,
but I quickly realized he had found a way to
Kelsea Farrell asks permission to examine
compensate and did not seem limited at
Kevin Purcell’s arm. She considered it a
privilege to meet him.
all. He has a very positive outlook on life,
which I think is the most important aspect
In a summary of the day’s activities, Dr. Gall reported that the
of living with a chronic serious illness. I felt very privileged that he
feedback from all of the students was absolutely outstanding. He
allowed us to better understand his condition.”
pointed out that the program also gives the students a chance
Oleksandr “Alex” Trofymenko is a 27-year-old nontraditional
meet rheumatologists and find out what we do to help these
medical student to say the least. He studied finance in college,
patients with serious rheumatic diseases.
n
SOMBRERO – March 2015

17

• 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.,
Suite 103
Green Valley, Arizona 85614

18

SOMBRERO – March 2015

In Memoriam
By Stuart Faxon

Stephen L. Wangensteen, M.D.
1933-2014

hypertension; gastric hypothermia; and cardiovascular physiology
accenting hemorrhage and shock. He served academic appointments
at Columbia University, University of Virginia, and the UofA.
The year he joined PCMS, Dr. Wangensteen even had the
distinction of clearing a fibrous tissue buildup intestinal tract
obstruction for country singer Tammy Wynette. She had flown
here from Cleveland because her fiancee at the time, George
Richey, had been stationed at Fort Huachuca, and Tucson friends
arranged for the singer to have the surgery here at the end of her
1977 concert tour, the Star reported.
It was as professor and head of the Department of Surgery, UofA
College of Medicine that Dr. Wangensteen was best known here.
He was a member of the Tucson Surgical Society as well as PCMS.
He resigned from both when he left in 1987 for Tampa, Fla. and
the University of South Florida College of Medicine Department
of Surgery.
His father “presented Steve with tough shoes to fill and high
expectations when he was growing up,” the family told the Star.
“But he did it with pride and amazing grace.” At the UofA the
Department of Surgery, the department “was in great distress
and needed someone to turn it around,” the family told the Star.
“Steve was known for his prowess at recruiting excellent
surgeons, one being heart surgeon Jack Copeland. In 1979 the
department made history performing the first heart transplant in
Arizona. In 1985 doctors Wangensteen and Copeland made a
historic decision to perform a controversial, yet successful bridgeto-transplant procedure using an artificial heart, the CardioWest
predecessor Jarvik-7-100, the world’s first.
“Steve built one of the most robust and nationally known surgical
departments, famous for its transplant team. His peers would say
that he made everything look so easy, as he handled all situations
with great elan.”

Dr. Stephen L. Wangensteen in 1981.

Stephen L. Wangensteen, M.D., general surgeon who joined
PCMS in 1977, and served as the University of Arizona’s second
chief of surgery, died on Dec. 1, 2014 in South Carolina, the
Arizona Daily Star reported Feb. 10. He was 81.
Stephen Lightner Wangensteen was born Aug. 30, 1933 in
Minneapolis, “son of internationally known surgeon Owen H.
Wangensteen,” the family told the paper. After earning two
undergraduate degrees at the University of Minnesota, Stephen
earned his M.D. in 1958 at Harvard Medical School. He interned
in surgery at The Presbyterian Hospital of the City of New York
(now Columbia-Presbyterian Medical Center) including a vascular
research fellowship, did his GS residency there and was chief
surgical resident 1964-65.
In 1965-67 Dr. Wangensteen was assistant chief, Surgical
Research Branch, Research and Development Command, U.S.
Army Office of the Surgeon-General. He was an experienced
researcher and had special interests in gastrointestinal, hepatic,
and biliary physiology; gastrointestinal hemorrhage; portal
SOMBRERO – March 2015

He was a member of AMA, American College of Surgeons,
Association for Academic Surgery, Society for Surgery of the
Alimentary Tract, Society of University Surgeons, Southern
Surgical Association, American Surgical Association, Southeastern
Surgical Congress, and the Halstead Society.
Dr. Wangensteen and his wife, Lita, known as “Squeaky,” were
“known for their unique and highly entertaining parties, whether
with dear friends or business associates,” the family said. The
Wangensteens “enjoyed life on their Tucson ranch, and guests
may have been surprised when a horse entered the house to
greet them, or a slew of bandana-clad dogs happily followed
them around.
“Steve enjoyed his boating and deep-sea fishing, and traveling up
and down the Intercoastal Waterway while stopping at charming
spots along the way. He was an incredible chef and loved
entertaining. His love of dogs was unmeasured. He and Squeaky
retired to South Carolina’s horse country and bought the most
beautiful horse farm, Pear Tree Farm, where they developed
deep friendships and really enjoyed their lives until his passing.”
Dr. Wangensteen’s son William predeceased him in 1999.
Squeaky survives him, as do daughter Christine Ecklund; sons
Stephen and Philip; and grandchildren Sierra, Owen, Blake, and
Madison. Memorial contributions may be made to Walter M.
Crowe Animal Shelter, 460 S. Fair St., Camden, S.C. 29020.
19

Bohdan J. ‘Bo’ Jarem, M.D.
1941-2015

Bohdan J. “Bo” Jarem, M.D., anesthesiologist who was a PCMS
member 1978-90, died Jan. 23 in Tucson, the The Galveston
County (Texas) Daily News reported Jan. 15. He was 73.
Bohdan John Jaremczyszyn was born July 22, 1941 in Lodz,
Poland, certainly not a good place to be that year considering the
1939 German invasion starting the second world war. “Bo and his
family immigrated to America in 1948 and settled in Lima, Ohio,”
the family told the paper, so all his medical training was here.
After an undergrad degree at Harvard without a major, Bo went
to The Ohio State University where he earned his M.D. in 1966.
He served as a lieutenant in the U.S. Navy Medical Corps 1967-69.
He interned at the University of Texas Medical Branch Hospitals at
Galveston and did his anesthesiology residency there.
Dr. Jarem began his practice here in 1978 with Tanque Verde
Anesthesiologists with doctors Fred Landeen, Thomas Webster,
Loren Taylor, Gary Bonwell, Larry Putnam, and Julien Caillet.
“Bo practiced medicine in Galveston, Houston, El Paso and Dallas
as well as in Tucson,” the family reported. “He initially specialized
in orthopedics, then anesthesia, and finally in pain management
“Bo had a multitude of interests outside medicine and was widely
traveled. He spent time in Africa, Western Europe, and the
Caribbean where he pursued his hobbies of photography and
scuba diving. Bo was a loving father and friend, and a gentle soul
with a wonderful sense of humor. He loved learning, had a
passion for books, and believed life should be lived to the fullest.”
Two sisters predeceased Dr. Jarem. Daughters Tina Shockling of
Houston and Erika Edris of Tucson; two grandsons; and three
step-granddaughters survive him. Memorial services were
private. Condolences can be left at DignityMemorials.com or
mailed to E. Edris, 10554 S. Sean Drive, Vail, Ariz. 85641.
n

Dr. Bohdan J. ‘Bo’ Jarem in 1984.

20

SOMBRERO – March 2015

SOMBRERO – March 2015

21

Bioethics

Ethics of ‘the right to try’
By Timothy C. Fagan, M.D.

On Nov. 4, 2014 Arizona
citizens overwhelmingly
approved Proposition 303,
amending the Arizona Revised
Statutes to allow terminally ill
patients to obtain and use
medications that are in
development, but have not
been approved by the U.S.
Food and Drug Administration.1
Often, well-intended laws lead
to unintended consequences,
both practical and ethical.
In order to consider the ethical
consequences of 303, it is necessary to understand the new drug
development process, the FDA Expanded Access Program
(Compassionate Use)2, and the actual content of 303. Relevant
portions of 303 include:
36-1311. Definitions
1 (d) The eligible person has given written informed consent for
the use of the investigational drug, biological product or device,
or if the patient is a minor or lacks mental capacity to provide
informed consent, a parent or legal guardian has given written
informed consent on the patient’s behalf.
2 “Investigational drug, biological product or device” means a
drug, biological product or device that has successfully completed
Phase One of a clinical trial, but has not been FDA-approved for
general use and remains under investigation in a clinical trial.
3 “Physician” means the physician who is providing medical care
or treatment to the eligible patient for the terminal illness but
does not include a primary care physician.
36-1312. Availability of investigational drugs, biological products
or devices; costs; insurance coverage.
A. A manufacturer of an investigational drug, biological
product or device may make available the manufacturer’s
investigational drug, biological product or device to an
eligible patient. This article does not require that a
manufacturer make available an investigational drug,
biological product or device to an eligible patient.
36-1314. Section 2. Findings: intent
A. 4. Patients who have a terminal illness have a fundamental
right to attempt to pursue the preservation of their own
lives by accessing available investigational drugs, biological
products or devices.
Drug development process
22

The drug development process begins with studies in cells,
tissues and animals, in order to provide preliminary information
on safety, including cancer-inducing potential, and potential
efficacy in a particular disease or condition. If this information is
adequate and suggests both safety and efficacy, FDA will issue an
Investigational New Drug (IND) approval to allow Phase One
testing of the drug in humans. This typically involves no more
than a few hundred normal volunteers. Further testing is
dependent upon no evidence of serious harm, but the
information is limited by the small number of individuals studied
and by the fact that they usually do not have the disease or
condition for which the drug is intended.
It is rare to have any efficacy information at all at the end of Phase
One. If Phase One shows no evidence of significant harm, FDA
will approve Phase Two testing, which normally involves
hundreds of patients with the disease or condition to be treated,
for a period of weeks to months, and provides initial information
on efficacy, the appropriate dose to be used and additional safety
information.
If Phase Two provides appropriate safety and efficacy
information, FDA will approve Phase Three trials. These typically
involve thousands of patient for periods up to five years.
After Phase Three, if efficacy and appropriate dosing is
established, and side effects identified, and the New Drug
Application for marketing is approved, FDA may still require large
post-marketing trials in thousands of patients. The process from
the beginning of Phase One until approval typically lasts seven or
more years.
Expanded access or compassionate use
“Compassionate Use” (CU)2 has been in place for many years and
allows use of investigational medication, biological products and
devices (investigational products) for seriously ill, as well as
terminally ill patients. Thus, 303 is more restrictive than the CU
process already in place, because CU also allows access for
seriously ill patients.
In 2011, approximately 1,200 patients received investigational
medication under CU. This remains the only option for patients
seeking investigational products under 303. Under this program,
a physician files an IND for one particular patient with the FDA.
The IND must be reviewed and approved by an Institutional
Review Board, whose members have expertise in clinical
medicine, pharmacology and ethics. An Institutional Review
Board is an official entity, which may be freestanding or part of a
Medical Center.
If it is not an emergency, and all of the necessary information is
provided, FDA usually gives approval after 30 days. If it is an
emergency, this usually takes less time. Until all necessary
information is provided, the IND will not be approved.
After approval of the IND, based on multiple factors, including all
of the available information about the drug and the patient, the
manufacturer of the drug decides whether or not to provide the
medication to the patient. The more extensive the information
about the drug, the more likely it is that the manufacturer will
decide to provide the drug. Although the manufacturer is free to
SOMBRERO – March 2015

charge for the medication, there is usually no charge to the
patient. Insurance companies will not pay for unapproved
medications.
AMA Code of Ethics
The American Medical Association’s Modernized Code of Ethics3
contains several sections relevant to 303. Physician Exercise of
Conscience3 contains the statement: “Physicians are not expected
to provide care that, in their professional judgment is unlikely to
achieve the patient’s clinical goals. Indeed, they should not do so.”
Section 2B.13 Informed Consent:
“In seeking a patient’s informed consent (or the consent of the
patient’s surrogate) … physicians have an
ethical responsibility to … include the
burdens, risks and expected benefits of all
options, including forgoing treatment.”

assistant may be willing to accept greater risk for any given
benefit. Evaluation of risk vs. benefit requires adequate
information regarding both. At the end of Phase One, there is
typically minimal information regarding risk, and no information
regarding efficacy in humans. At the end of Phase Two there may
be enough information to make an evidenced-based decision.
“Informed Consent”3 requires that the physician has adequate
knowledge of the safety and efficacy of the proposed treatment
or device, and adequate knowledge of the patient’s views about
life and how it should be lived. At the end of Phase One, there is
not enough information for a physician to make a scientifically
sound determination of the risks and benefits. Informed consent
also requires that the patient, or surrogate decision maker, is able

Section 2B.1.23 Decisions for Adult Patients
Who Lack Capacity:
“When a patient lacks decision making
capacity, the physician has an ethical
responsibility to identify an appropriate
surrogate to make decisions on the patient’s
behalf: (i) the person the patient designated
as a surrogate through a durable power of
attorney for health care or other
mechanism, or (ii) a family member or other
intimate associate, in keeping with
applicable law or policy, if the patient has
not previously designated a surrogate.”
Section 5.53 Medically Ineffective
Interventions:
“Physicians should only recommend and
provide interventions that are medically
appropriate, i.e. scientifically grounded, and
that reflect the physician’s considered
medical judgment about the risks and likely
benefits of available options in light of the
patient’s goals of care.” Before completion of
Phase Two, there is no basis for a scientifically
grounded judgment.
Risk vs. benefit and informed consent
The FDA development and approval
process, as well as the decision to prescribe
a medication for an individual patient,
always involves an evaluation of risk vs.
benefit. Surviving the approval process
indicates an appropriate balance of risk vs.
benefit for most patients for whom the
medication is approved to be marketed.
However, the risk vs. benefit ratio is
different for each individual patient and
situation. A terminally ill patient and his or
her physician, or other licensed provider
such as a nurse practitioner or physician
SOMBRERO – March 2015

James R. Carlson, M.D., M.B.A.
Board Certified Otolaryngologist
Fellow American Academy of Otolaryngology
Head and Neck Surgery
Fellow American College of Surgeons
Fellow of American Academy of Otolaryngic Allergy
Federal Aviation Administration
Senior Aviation Medical Examiner

David H. Zacheis, M.D.
Board Certified Otolaryngologist
Fellow American Academy of Otolaryngology
Head and Neck Surgery
Fellow American College of Surgeons
Member of American of Otolaryngic Allergy

520-795-8777
3172 N Swan Rd.
Tucson, AZ 85712

1521 E. Tangerine Rd.
Suite 225
Oro Valley, AZ 85755

Monday – Friday 7am – 5 pm
Saturday 9 am – 12 Noon

www.carlsonent.com
23

to understand the information provided by the physician.
Informed consent cannot be obtained from children or from
patients who do not have adequate mental capacity to
understand the relevant information. It can be argued that a
terminally ill patient (or surrogate decision maker), may be so
desperate that judgment is impaired enough that he or she lacks
capacity to make informed consent possible.
Practical and ethical aspects of 303
303 will do nothing to increase availability of investigational
products to terminally ill patients, since it provides no new
mechanisms or processes to obtain these products.
303 acknowledges that a manufacturer is not required to provide

an investigational product to an eligible patient. This is consistent
with the CU process, and does nothing to increase the availability
of the products.
303 states: “Patients with a terminal illness have a fundamental
right to attempt to pursue the preservation of their own lives by
accessing available investigational drugs, biological products and
devices.” The source of this “fundamental right” is unclear. It is
probably a liberal interpretation of “the right to life, liberty and
pursuit of happiness.”
The 303 definition of “physician” makes it against the law for a
physician, who best knows the patient and his or her views about
life and how it should be lived, to participate in obtaining
investigational products for the patient. The
primary care physician is also the physician
most likely to be trusted by the patient. This
limits access to investigational products.
The 303 list of appropriate surrogate decision
makers fails to recognize many appropriate
surrogate decision makers, and thus places
limits on patients’ access to investigational
products.
The essence of 303 is that patients have a
fundamental right to use investigational
products, which, under the conditions of
303, a physician often cannot adequately
evaluate, and neither make a rational
decision regarding their use, nor obtain
informed consent for their use.
Summary
303 does nothing to increase access to
investigational products, while it falsely
raises the hopes of terminally ill patients,
limits their access to investigational
products, and creates ethical dilemmas for
physicians and surrogate decision makers
who could otherwise assist these patients in
the process.
Timothy C. Fagan, M.D. is a Tucson internist
and clinical pharmacologist. He is a PCMS
past-president, Pima County Medical Society
Director to ArMA, and Professor Emeritus of
Internal Medicine at The University of
Arizona College Of Medicine.
REFERENCES
1. Proposition 303 “Right to Try,, Arizona General
Election Ballot, Nov. 4, 2014.
2. FDA Expanded Access Program, http://www.
fda.gov/Drugs/GuidanceComplianceRegulatory
Information/Guidances/ default.htm
3. American Medical Association Modernized
Code of Medical Ethics.

24

SOMBRERO – March 2015

‘Underutilization’

committees may also review standing hospital policies to make
sure they do not compromise ethical principles.

By Steven Ketchel, M.D., F.A.C.P.

Occasionally these committees will be asked to give their opinion
on more controversial subjects, such as whether what appears to
be a medically necessary abortion should take place; whether
care that is proposed is futile and thus should not be undertaken;
or what is “quality of life.” There are rare cases in which a nurse
does not feel he or she can carry out the orders of a physician.
Other rare instances may occur when patients are unable to
make decisions about emergent care and a decision needs to be
made about who may make those decisions.

“Underutilization” is one of
those words that a syllableimpressed bureaucrat might
choose to denote “under-use.”
A good example would be,
each of Tucson’s hospitals
has a biomedical ethics
committee. From talking with
those who chair them, I have
concluded that we all answer
approximately the same kind
of ethical questions in each of
our hospitals.
Each of these committees
considers that theirs is under-used, and that if medical staffs and
other medical personnel knew that there were such committees
in their hospitals dealing with these kinds of questions, they
would be consulting them more. We hope that there are more
occasions when our committee can answer ethical questions that
occur in our hospital.
Biomedical ethics uses a combination of ethical principles that
are proposed to relate to the practice of medicine. Biomedical
ethics involves both moral principles and their practices, and
matters of social policy involving morality in medical practice.
AMA has published a “Code of Medical
Ethics” which interested parties are
welcome to consult.

When the committee is called for consultation, usually one or
two committee members go to gather data, and then try to
decide if this is an ethical question or a social service question. If
it is an ethical question, a committee meeting is called at the
patient’s site with members of the medical staff and family
members or other “medical powers of attorney.” The committee
is charged with helping to reach an ethical conclusion to the
questions put forth, not to make any medical decisions for the
patient, family or physician, but to try to reach a consensus
between the parties.
A potentially new area for the committee to discuss is the proper
isolation period for those exposed to Ebola and living in Southern
Arizona.
Dr. Ketchel chairs the TMC Biomedical Ethics Committee and is a
member of the PCMS Bioethics Committee.
n

In general, biomedical ethics committees at
hospitals are composed of physicians,
nurses, social workers, and other hospital
personnel, as well as community
volunteers. The committee’s major role is
to answer questions from medical staff in
the hospital, the patients or their families,
or other decision-makers as to proper
answers that may be proposed for
problematic questions. These may include
whether it is proper to discharge the
patient at a proposed time; whether a
patient is capable of making decisions in his
or her own care; or whether family
members are capable of, or trying to
mediate between family members with
differing viewpoints about their loved
one’s care.
Committees also work on hospital policies,
such as how to explain to patients that
when they go to surgery, their Do Not
Resuscitate or Allow Natural Death order is
no longer in place, and to work with
hospital personnel as to when the DNR or
AND order should be restored. The

SOMBRERO – March 2015

25

The 24th Annual

Southwestern Conference on Medicine

®

April 23 - 26, 2015 | JW Marriott Starr Pass Resort & Spa | Tucson, Arizona

Join us for our 24th year of quality engaged learning! This activity has been
approved for AMA PRA Category 1 Credit™ and AOA Category 1A Credit.
Presented by Tucson Osteopathic Medical Foundation in Joint Providership with Cleveland Clinic

Scan this with your
smartphone to visit
www.tomf.org/cme

Register online at www.tomf.org/cme
26

SOMBRERO – March 2015

Makol’s Call

Rubber checks
By George J. Makol, M.D.

T

here’s nothing as
frightening as opening
your mailbox and finding a
letter from the Internal
Revenue Service, but that’s the
fright I got short time ago.

I was informed that somebody
had cloned my identity, and
then had filed for an income
tax refund in my name. I
immediately started to laugh—
probably not the response you
expected, but I quickly thought
of someone in Nigeria opening a
letter from the IRS, expecting to
find a refund check. To his surprise he would get the $10,000-to$15,000 bill that I get from the IRS every year, in spite of paying
payroll taxes every two weeks and filing quarterly tax payments
every three months. Someday I would like to write a novel about
my experience with the American tax system; perhaps I would call it
“Fifty Shades of Pay.” And here I thought that after the IRS canned
Lois Lerner, the agency had stopped targeting conservatives.
A couple of weeks later I picked up my Sunday, Feb. 1 Arizona
Daily Star and read the headline, “Tucson doctors wary after-tax
identity theft.” It seems that more than 20 local physicians found
out that someone had filed fraudulently under their names for
tax return money.
Apparently many of these scams were successful, and the
physicians were scrambling to reestablish their tax identities. I was
one of the lucky ones, because the brilliant minds at the IRS noted
that after receiving dozens of 1099s attached to my home address,
it did not seem logical to send a refund check to a post office box in
Memphis, Tenn., or to a street address in Lagos, Nigeria.
I’ve digressed here because the IRS is not really the topic of this
column, nor is the American tax system, but a problem closely
related to both: the federal disability payment system.
Not too long ago I received another government communication,
from a different federal agency, asking me to review a disability
claim for evidence of fraud. The person involved claimed a lifethreatening illness that included potential anaphylaxis and death if
exposed to any form of latex rubber. I was sent more than 500
pages of medical records, but did not decide to take the case until I
saw two negative Rast tests for specific IGE to latex, performed in a
reputable major national laboratory, but performed years apart.
It seems that the claimant had been receiving at least 18 years’
worth of disability payments totaling in the six figures, yet the
government private investigator who followed the individual for
weeks documented dozens if not hundreds of exposure to rubber
of all sorts with no clinical symptoms.
SOMBRERO – March 2015

In fact, upon reviewing copious medical records, I found one
urgent care visit documenting a “slightly swollen upper lip.” It is
likely that this patient had a simple case of idiopathic angioedema
sometime in the late 1990s, and parlayed this into a lifetime of
federal payments. Generally, idiopathic angioedema patients
respond well to continuous antihistamine therapy, and many, but
not all, will spontaneously resolve this condition within one or
two years.
The case was being managed by a physician with no training in
allergy or immunology, and he was providing medical rationale for
her, the female claimant, getting full benefits and never being able
to work again. In the hundreds of angioedema patients I have
managed over the years, I cannot think of one patient who needed,
or was granted full disability based on this condition. Yet like it or
not, dealing with disability is becoming an increasingly larger
problem for probably every physician, regardless of specialty.
In my practice it is not uncommon for a patient with completely
normal lung function to ask me to write a letter certifying that he
or she is disabled from severe asthma. I see many patients who
are sensitive to the myriad chemicals they can be exposed to in
everyday life, such as another person’s perfume or cologne.
While I appreciate their situation, and write notes asking to the









Allergies
Nasal/sinusitis problems
Hearing & balance disorders
Hearing aids & tinnitus
Endocrine & salivary gland disease
Voice disorders
Snoring and sleep apnea
Thyroid and parathyroid gland surgery
Cosmetic/Aesthetic surgery

Jonathan Lara, DO

Thomas S. Kang, MD

Amanda Kester, Au.D.

office: 520-775-3333 • fax: 520-775-3334
www.sonoranent.com
6340 N. Campbell Ave., Ste. #256 • Tucson, AZ 85718
27

employer to limit such exposures, I am loathe to say this person
can never work again because the person next to them might
wear a pungent perfume.
According to Money magazine’s recent analysis, the problem is
that the Social Security Administration’s disability insurance
program is expected to exhaust its trust fund by the end of 2016.
The incoming revenue thereafter would only allow payment of 80
percent of the benefits currently being paid to the truly disabled
and their families. But the truly disabled are not the only
recipients. In January, 40 people including one doctor were
indicted in Puerto Rico for Social Security disability fraud. The
defendants received an average of $28,000, after the doctor

backdated and falsified their records to show long-standing
suffering from illnesses they did not even have.
CBS News reported last January that more than 100 people were
indicted in New York State for disability fraud, including 72 firstresponders such as firemen and policemen. One individual, who
claimed that he was housebound, was pictured riding a Sea-Doo
watercraft. Another, claiming he was too traumatized to leave his
house, was filmed selling cannolis at a street fair. Another claimed
severe on-the-job injuries, but was also filmed taking part in a
400-mile bicycle race while “disabled.”
In 2013 Fox News and The Associated Press reported, after the
Government Accountability Office issued a report, saying that the
Social Security Administration made nearly $1.3 billion in
potentially improper disability payments to
people who were believed to be employed
when they were supposed to be unable to
work. The GAO estimated that SSA made the
potential cash benefit overpayments to about
80,000 individuals from December 2010 to
January 2013. “The numbers represent less
than 1 percent of beneficiaries and less than 1
percent of disability payments made during the
time frame, “ the story said, “but GAO said the
overpayments reveal weaknesses in SSA’s
procedures for policing the system.”
Since we have a President who seems
obsessed with the concept of fairness, one
might ask, is it fair for perfectly fit and able
people to be provided a subsidized life of
leisure at the expense of the truly disabled
who may not be able to get full benefits in the
near future?
Perhaps the most significant quote attributed
to President John F. Kennedy was when he
famously said, “Ask not what your country can
do for you; ask what you can do for your
country.” Far too many people today feel that
the government owes them something,
forgetting that the government really does not
produce its own money, but rather confiscates
funds from one group and redistributes dollars
to other groups that contain more potential
voters.
I think that JFK, a great fiscal conservative,
would shake his head sadly if he saw the state
of the country today. He was a polished
politician, but also a man with great ideas. It’s
too bad that today we do not have a potential
leader in either aisle who fits both these
qualifications.
Sombrero columnist George J. Makol, M.D.,
a PCMS member since 1980, practices with
Alvernon Allergy and Asthma, 2902 E.
Grant Rd.

n

28

SOMBRERO – March 2015

Stars on the
Avenue 2015
“An Evening under the Stars”
A Medical Community Celebration
to Honor Tucson’s Outstanding Physicians
Stars on the Avenue returns April 18, 6-9 p.m., at St. Phillips Plaza and features an
exclusive invitation list limited to physicians and their guests. Progressive dinning is
provided by outstanding Tucson restaurants as we honor local doctors and raise money
for Mobile Meals of Tucson.
Presented by Pima County Medical Society and PCMS Alliance, Stars on the Avenue
expects more than 350 physicians to attend this year’s event as we honor our
“Physician of the Year” and others for their outstanding service and commitment to
organized medicine, volunteerism, and for a lifetime of achievement in the practice of
medicine.
Event proceeds go to Mobile Meals of Tucson, an organization that helps preserve the
health, dignity and independence of home-bound adults by delivering special diet
meals. Volunteers not only deliver meals, but also provide social contact and a
connection to other community organizations.
For group discounts or information about event sponsorships please contact PCMS
Executive Director Bill Fearneyhough at 795-7985 or email billf5199@gmail.com.
Tickets may be purchased by logging onto pimamedicalsociety.org and clicking on
“Purchase Stars on the Avenue Tickets” tab.
SOMBRERO – March 2015

29

CME

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

the most recent medical updates and management strategies for
various diseases. Program includes lectures, Q&A panel
discussions, audience interactive format.
Website: https://ce.mayo.edu/family-medicine/node/1606.
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 www.
mayo.edu/cme

April

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

April 17-19: The 21st Mayo Clinic Urogynecology and Disorders
of the Female Pelvic Floor 2015 is at the Hilton Scottsdale Resort
and Villa, 6333 N. Scottsdale Rd., Scottsdale 85250; phone
800.498.7396. http://www3.hilton.com/en/hotels/arizona/
hilton-scottsdale-resort-and-villas-SCTSHHF/index.html

April 14: Cancer of the Lung—Newer Treatments and Cancer
Screening with physicians from Radiology Ltd. This meeting will
also present the Foundation Award for Lifetime Achievement in
Furtherance of Medical Education to Tyler Kent, M.D. and Bill
Nevin, M.D.

Accreditation: Mayo Clinic College of Medicine designates this
activity for a maximum of 20.50 AMA PRA Category 1 Credits. A
record of attendance will be provided to all registrants for
requesting credits in accordance with state nursing boards,
specialty societies, or other professional associations.

May 12: Healthcare Reform 2015—“What the Hell is
Happening??” with several speakers coordinated by Dr. Timothy
C. Fagan.

Course presents latest treatments for urogynecology and female
pelvic floor disorders emphasizing surgical management of
urinary and fecal incontinence, overactive bladder, and repair of
pelvic organ prolapse. Course features didactic lectures
supplemented with video presentations of advanced
laparoscopic robotic and vaginal surgery. Surgical case
presentations, panel discussions, and an interactive system will
be utilized to communicate immediate feedback, providing an
optimal learning experience for interaction between faculty and
course participants.

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

March
March 25-28: Clinical Reviews 2015: The 26th Annual Family
Medicine and Internal Medicine Update is at Westin Kierland
Resort, 6902 E. Greenway Pkwy., Scottsdale 85254; phone
480.301.4580; e-mail info@kierlandresort.com .
Accreditation: 27 PRA Category 1 credits; and 24 AOA and
Attendance.
Four-day course on diagnosis and treatment of hematologic and
oncologic disorders targets hematologists, oncologists, PAs, NPs,
RNs, pharmacists, and allied health professionals, and features

Members’ Classifieds
MEDICAL PRACTICE FOR SALE: Hector L. Garcia MD and Hector F Garcia are
selling their Internal Medicine practices located in Tucson and Douglas. The
offices are located at 1601 N. Tucson Boulevard, Suite 1A, Tucson, and 1116
G. Avenue, Suite 7, Douglas. Interested parties may call 298-7251 for details.
SHARED SPACE FOR RENT: Active Neurology office in Northwest Tucson
has office space to lease. Renter does not need to be in Neurology field.
If interested, contact Mike at Northstar Neurology at 520-229-1238 or
e-mail clhmaxwell@aol.com and refer to Space for Rent.
30

Website: https://ce.mayo.edu/women-s-health/women-shealth-2015s983
Contact: Mayo School of Continuous Professional Development,
Bobbi Carter CMP, Mayo Clinic Scottsdale, 13400 E. Shea Blvd.,
Scottsdale 85259[ phone 480.301.4580; fax 480.301.8323
mca.cme@mayo.edu https://ce.mayo.edu/
April 23-26: Tucson Osteopathic Medical Foundation, in joint
providership with Cleveland Clinic, present the 24th Annual
Southwestern Conference on Medicine at JW Marriott Starr Pass
Resort and Spa, 7:30 a.m. Thursday through 12:45 p.m. Sunday.
Accreditation: Approved for AMA PRA Category 1 Credit™ and
AOA Category 1A Credit.
Conference is designed to bridge practice gaps between primary
care providers’ current knowledge and practice performance, and
the ever-evolving standards of modern medical care. Last year
400 DOs, MDs, NPs, and PAs attended.
Faculty members include Shonda Banegas, D.O., Bennet E. Davis,
M.D., Edward A. Dominguez, M.D., Timothy C. Fagan, M.D.,
Anne C. Goldberg, M.D., Jonathan R. Insel, M.D., Arthur
McCullough, M.D., Jamie Moenster, D.O., J.D. Polk, D.O.
PCMS Board of Directors member Jerry H. Hutchinson, D.O.
chairs the conference.
For more information, including the conference agenda or to
register please visit www.tomf.org/cme or call 520.299.4545.
SOMBRERO – March 2015

Welcome to the
Radiology Ltd. team!
Munish Chitkara, M.D.
Musculoskeletal Radiologist
Radiology Ltd. is proud to introduce
Dr. Munish Chitkara, who specializes
in musculoskeletal imaging. He has
particular interest in MRI and ultrasound
for diagnosis and treatment of
musculoskeletal disorders.
Dr. Chitkara is a graduate of the University
of Arizona College of Medicine. He then
completed his residency in Diagnostic
Radiology at Albert Einstein College of
Medicine, followed by a fellowship in
musculoskeletal radiology at New York
University – Hospital for Joint Diseases.
Please join us in welcoming Dr. Chitkara.
We are excited to have him as a member
of the Radiology Ltd. team.
If you would like to reach any of our
radiologists, please call our Physician
Hotline at (520) 901-6777.
A TUCSON TRADITION FOR MORE THAN 80 YEARS

SOMBRERO – March 2015

31

MICA_Sombrero03'15ad_MICA_Sombrero05'04ad 2/13/15 9:46 AM Page 1

2014 MICA announces
tenth consecutive
year of dividends.
But MICA’s history of dividend
payments extends well beyond the
last ten years. In fact, since our
founding in 1976, MICA has
distributed over half a billion
dollars in dividends to its members.

Medical Professional
Liability Insurance
(602) 956-5276
(800) 352-0402
www.mica-insurance.com

Dividends declared for a given policy year
reflect the Company’s financial performance
during that year. Past performance does not
guarantee future dividends.

32

SOMBRERO – March 2015