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Sombrero

Pima County Medical Society


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

NOVEMBER 2015

Dr. Schwagers
hybrid practice
TOIs evening
walk-in ortho clinic

Modern bioethics meets


the Hippocratic Oath

SOMBRERO November 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

Arizona Medical
Association Officers

Snehal Patel, DO (Alt. Resident)


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

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

Members at Large
Richard Dale, MD
Charles Krone, MD
Jane Orient, MD

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)

Executive Director
Bill Fearneyhough
Phone: (520) 795-7985
Fax:
(520) 323-9559
E-mail: billf 5199@gmail.com

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

Printing
West Press
Phone: (520) 624-4939
E-mail: andyc@westpress.com

Advertising
Phone: (520) 795-7985
Fax:
(520) 323-9559
E-mail: dcarey5199@gmail.com

Art Director
Alene Randklev
Phone: (520) 624-4939
Fax:
(520) 624-2715
E-mail: alener@westpress.com

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

60s Retro Mid-Century Home

On 1.74 acre lot in Colonial Solana.


Lovingly renovated to retain original character.
5,426 sq. ft., 4 bedroom, 5 bath, fabulous kitchen,
formal living and dining rooms, family room and
office plus 2 guest houses. Exquisite grounds and
sparkling pool plus 3 car garage and private well.

$925,000

Madeline Friedman

SOMBRERO November 2015

ABR, CRS, GRI

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.

1928 Spanish Colonial

In pristine condition on spacious lot in El Encanto.


4,950 sq. ft., 5 bedroom, 5 bath, formal living room,
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3

Inside
5

Dr. Melissa Levine: The good, the bad, and the


health insurance.

Milestones: Whats up with doctors Addis,


Weinand, Katzenberg, and Alberts.

Membership: D. Ed Schwagers hybrid


practice; TOIs after-hours walk-in ortho clinic.

12

PCMS News: Valley Fever Awareness Week


expands; Emergency Medicine and consumer
safety.

18

Behind the Lens: Iconic Route 66, and equally


iconic Easy Rider.

20 Makols Call: Whats all this income inequality


talk?

22 Bioethics: Canada v. Carter, California, and


aspects of physician-assisted dying for the
terminally ill.
26

Mayo Clinic CME: All this months events are up


the road.

On the Cover
The entrance to the Pine Breeze Inn, just before the section of
old Route 66 that has been abandoned, is deteriorating, but
the gas station, the office, and the green cabins are still in
good shape. In this months Behind the Lens, we take a look at
how this location played into the filming of the iconic 1969
movie Easy Rider (Dr. Hal Tretbar photo).

SOMBRERO November 2015

The good, the bad, and the health insurance


By Dr. Melissa Levine
PCMS President

appy 50th birthday to


Medicare! (Part 3)

Ill start this concluding


Medicare article with a little
quiz. I have five quotes that I
have altered to say either
Medicare or ACA. You decide
which quote goes with which
plan. I will give you the author
and the plan it was said about
at the end of the article.
One of the traditional methods of imposing statism or
socialism has been by way of medicine If you dont (stop
Medicare/ACA) and I dont do it, one of these days you and I
are going to spend our sunset years telling our children and our
childrens children what it was once like in America when men
were free.
(Medicare/ACA) is not about improved healthcare or cheaper
insurance or better treatment or about insuring the uninsured,
and it never has been about that. It is about expanding statism.
It is about expanding the government. It is about control over
the population. It is about everything but healthcare.
(Medicare/ACA) is a headlong rush into socialism.
Socialized Medicine (Medicare/ACA)
I was in there, fighting the fight, voting against (Medicare/
ACA) because we knew it wouldnt work
Whether you got them correctly or not, you can see the
similarities. There are other similarities, one of which is that both
programs are far from perfect. Both need
and have needed a lot of fixing, and I think one thing we can all
agree upon is that Congress has fallen down on that job. If we
took care of patients the way that Congress takes care of the
country, well lets just say that malpractice rates would be a lot
higher. But I digress.
One of the reasons for Medicare was that seniors, despite Social
Security, without insurance were falling into poverty. Prior to
1965, 33 percent of Americans older than 65 lived below the
poverty line. In 2009 it was 14 percent. Is that due to Medicare?
Probably not all of it, but some of it is.
From 1960 to 1998, Americans life expectancy at age 65
increased from 14.3 years to 17.8 years. Disability also decreased
during those years. Is that due to Medicare? Probably not all of it,
but some of it is.
Unfortunately, some of the success of Medicare has also led to
one of its biggest problems: Insolvency. Its a real issue. In 1965
those who crafted Medicare estimated the cost of Part A in 1990
would be just under $9.1 billion; in actual 1990 dollars it was $67
billion. Thats a big difference. To be fair, from what I can tell,
those were 1960 dollars compared to 1990 dollars, I looked on
answers.com and if my math is correct, the 1960 dollars
projection translated to 1990 dollars was more like $39 million
and change. Still, really far off, but not quite so bad.
SOMBRERO June/July 2015

Baby Boomers are reaching retirement and people are living


longer. In 1960 the worker-to-retiree ratio was 5:1, in 2002 it was
3:1. It is projected to be 2:1 in 2050. In the big picture, that is not
such a bad problem to have, if I could live longer and not be
working, I would love it. But just as I have to have the money to
retire on, Medicare does too. That is a huge problem that will have
to be solved by less costs, higher taxes, or a combination of both.
So what has the Affordable Care Act done? I believe its goal is to
provide better healthcare for more people at a lower cost. I think
as physicians we can all get behind that goal. Whether it will do
that remains to be seen. And how it will do that is certainly
contentious.
In September 2010, a small part of the ACA went into effect,
prohibiting insurance companies from denying care to children
under age 19 with preexisting conditions. It allowed kids to stay on
their parents insurance until age 26. It also prohibited insurance
companies from rescinding coverage. These measures were
regulatory and did not cost taxpayer money. I will say, I did notice
that insurance rates started going up. I believe this was the
insurance companies using the ACA as an excuse to pad their
pockets a bit more. In 2009 the CEOs of the 10 largest for-profit
insurance companies in the U.S. collected a combined total of
$228.1 million dollars. Incidentally, that was more than 2.5 times
the year before, and it continues to go up. But once again I digress.
Clearly, the ACA has decreased the number of uninsured people in
the U.S. The most current estimate is almost 10 million. And figures
from early 2015 estimate the uninsured rate dropping to 10.7%.
I see that as an improvement and a victory for the ACA.
It has provided federal marketplace subsidies for non-elderly
people who are below 400 percent of the Federal Poverty Level
also, something I see as good. But there are still a lot of people in
the U.S. without insurance or healthcare. Sadly, seven out of 10 of
those uninsured families have at least one full-time worker. There
is still a long way to go.
The ACA has also added layers of regulation and complicated rules,
read: Meaningful Use, among other things.
In my final analysis, I believe that Medicare has done more good
than bad for the health of the country. I believe the same thing will
eventually bare out for the ACA. But only time will tell.
So happy 50th to Medicare, and good luck to baby ACA.
Answers to quiz:
1.Ronald Regan (1961) Medicare
2.Rush Limbaugh ACA
3.RNC Chairman Michael Steele (2010) ACA
4.George H.W. Bush (1964) Medicare
5.Sen. Bob Dole (1996) Medicare
REFERENCES
Cry Wolf Project Exposing Myths About the Economy and Government.
Volsky, Igor. ThinkProgress, Flashback: Republicans Opposed Medicare in 1960s by
Warning of Rationing and Socialized Medicine, July 29, 2009.
Huntoon, Lawrence R, M.D., Ph.D., http//www.jpands.org/Vol20No3/Huntoon.pdf.
FierceHealthPayer.com
Health Care For America Now, Aug 9, 2011.
Key Facts About the Uninsured Population, Henry J Kaiser Family Foundation,
KFF.org, Oct 5, 2015.

n
5

Milestones

Dr. Addis set for staff chief,


BannerUMC South
BannerUniversity Medical Center
Tucson recently announced that OBG
physician Ilana Addis, M.D. will be chief
of staff at BannerUniversity Center
South in January 2016.
Dr. Addis is an associate professor and
division director in the UA Department
of Obstetrics and Gynecology. She was
elected by members of the medical
staff at BannerUMC South.
Other newly elected medical staff
officers at BannerUMC Tucson
include Martin Weinand, M.D., who
was elected secretary-treasurer.

Members achieve at
Sarver, UA Cancer Center
Interim Dean of the UA College of
MedicineTucson Chuck Cairns, M.D.
recently announced that COM-T faculty
members awarded Influential Health
and Medical Leaders awards included
PCMS past-president Charles
Katzenberg, M.D. of UA Sarver Heart
Center.
Dr. Katzenberg received an
Achievement in Wellness Programs
award for The Heart Series, a program
of the Foundation for Cardiovascular Health that Dr. Katenberg
created. Last month at Banners DuVal Auditorium he took part in
the Sarver Heart Center public presentation Weve Got the Beat:
An Update on Atrial Fibrillation, speaking on Three Lifestyle
Factors and A-Fib Management.
Honored as a finalist for the Lifetime
Achievement in Health Care award was
David Alberts, M.D. , director emeritus
of the UA Cancer Center, and regents
professor of medicine, pharmacology,
nutritional sciences and public health,
and PCMS member since 1975.
n

SOMBRERO November 2015

Membership

Managing the elusive


Story and photos by Stuart Faxon

o doubt in some situation youve heard someone say, Time


got away from me. Yep, times a slim customer, a slippery
commodity.
In 1895 English author H.G. Wells imagined a time machine, a
device that could deliver its user to a point in the past, or a future
that turns out to be disappointingly dystopian. There was and is no
such machine, but Einsteins relativity theory shows us that time is
indeed malleable.
Similarly, a geriatrician must be a kind of time pilot, using his time
to best guide his patients through their time. Carondelet Medical
Groups Edward J. Schwager, M.D. has found not a device, but a
membership practice hybrid method to guide that time better.
Native Tucsonan Dr. Schwager, born here in 1954, earned his M.D. in
1983 at The University of Arizona College of Medicine, and did his
residency in family medicine there. He has been practicing in Tucson
and been a PCMS member since 1986. He chaired our Board of
Mediation for many years, and served on BOMEXnow the Arizona
Medical Boardfor six-and-a-half years, including one year as
president. He is Carondelet Medical Group regional medical director
for one of two CMG groups, mainly in Central and East Side Tucson.
I knew that I wanted to become a physician from childhood days,
he says. My mother was a Type I diabetic, and she used insulin in
the days of reusable syringes and needles. She had many of the
common diabetic complications, and she died at a relatively young
age, two months after my medical school graduation. I suspect that
I wanted to do something to help her and others with chronic
medical conditions.
Dr. Schwager and his wife,
Robyn, have been married 38
years. She works at the Jewish
Community Foundation of
Southern Arizona doing
development. They have three
daughters: Melissa Kreitner,
married to Ryan, is a respiratory
therapist at Banner University
Medical Center. Erica Schwager
is a coffeehouse manager in
Brooklyn, N.Y.C. Rachel Gelman,
married to Gabe, is in marketing
with Western Union in Denver,
Colo.
Dr. Schwager started what he
calls his hybrid concierge
practice four years ago. Not
SOMBRERO November 2015

Dr. Ed Schwager takes a phone call and looks calls up a patients


record. Off the top of my head is not good enough, he says.

everyones favorite term, concierge has become the most


frequent label for membership medicine, or retainer medicine, or
direct care, in which the patient pays a primary care physician an
annual fee or retainer, and in exchange, the physician provides
enhanced care, including limiting patient numbers to ensure
enough time for each patient.
Enhancement is the key word for Dr. Schwager. For example, if you
are an airline passenger you already expect to get to the planned
destination, but if you buy a first-class ticket, you expect
enhancements. He calls his model hybrid because part of my
practice is patients who pay for the enhanced service, and part are
patients who carry traditional insurance of all types.
Currently his fee is $1,800 per year. The fee is for what goes
beyond traditional insurance coverage, Dr. Schwager said. In our
enhanced services, patients receive an executive physical. This
includes a full battery of lab tests, EKG, pulmonary function tests, a
detailed review of nutrition and lifestyle. Rather than just a
10-minute physical, we might
spend an hour and a half. If a
patient has a problem day or
night, they can call me, and they
have my cell phone number.
If you are a physician, Dr.
Schwager says, you have to
take care of people correctly
regardless of how you get paid.
This [time management] allows
me to have a much more
reasonable office day. Previously
I was seeing 24-33 patients per
day and headed for burnout.

Some of Dr. Schwagers entertaining shelf-full of physician-related


miniatures. We swear theres nothing else Mickey-Mouse about
his practice.

He wasnt alone. Dr. Dike


Drummond of TheHappyMD.
com, author, speaker, and
consultant on physician
7

burnout, quoted last month by the American Academy of Family


Physicians, noted, There is an epidemic of physician burnout in
the U.S., and it has a pervasive negative effect on all aspects of
medical care, including your career satisfaction. According to one
researcher, Numerous global studies involving nearly every
medical and surgical specialty indicate that one in every three
physicians is experiencing burnout at any given time. At your
next physician staff meeting, take note of your colleagues sitting on
either side of you. At least one of you is likely experiencing
burnout.
Dr. Drummond notes that burnout leads to lower patient
satisfaction and care quality, higher medical error rates and
malpractice risk, higher physician and staff turnover, physician
alcohol and drug abuse and addiction, and even physician suicide.
Burnout can be a fatal disorder, he said.
Dr. Schwager didnt get near fatality before he made a change.
Now I see about 12-15 patients per day, he said. As a family
doctor, my primary role is to take the time to deal with all the
physical systems, and thats very hard to do well with quick visits. I
dont discriminate based on age, sex, or organ system. Well just
take care of it all.
Dr. Schwager says that locally, hes the only physician he knows of
doing this kind of practice hybrid. I like being able to care for
patients across the spectrum, he said.
His hybrid has brought much more balance to my practice life and
allowed me to enjoy practicing medicine again, Dr. Schwager said.
Before, I wasnt having a good time.

Looks like a happy practitioner to us. Dr. Ed Schwager


poses with his longtime medical assistant, Victoria
Miller.

WE ANSWER FOR YOU!


Live Answering

Remote Receptionist
Appointment Scheduling
Order Taking

Message Delivery via Pagers


Live Operator, Email, Voice Mail
Text Messaging,
I.V.R. (InterActive
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Voice Response)

24 Hours 7 Days A Week


Authorized Answering Service for

PIMA COUNTY MEDICAL


SOCIETY SINCE 1981

Se Habla Espaol

2434 N. Pantano

Medical Society
Exchange

790-2121

Established
1971

www.RinconCommunications.com
8

SOMBRERO November 2015

Membership

Whats up with
this joint?
Story and photos by Dennis Carey

e might say that Tucson Orthopaedic Institutes After-Hours


Clinic is becoming one of Tucsons most popular nighttime
joints. Folks at the new clinic say its exceeded expectations since
it opened in April.
The clinic offers walk-in orthopedic care and services on the
campus of Tucson Medical Center at 5301 E. Grant Rd. No
appointments and no referrals are necessary.
We thought we might get eight to 10 patients a day, orthopedic
surgeon and TOI President Lawrence Housman, M.D. said, but we
are seeing an average of 15 to 20 each day. He said they knew
Tucson had a need for non-emergency orthopedic treatment after
regular business hours. Other large communities have started
these clinics, and we thought Tucson was ready for one.
Dr. Housman, PCMS member since 1979, practices total joint
replacement surgery with emphasis on shoulder, hip, and knee
replacement, and has a special interest in hip resurfacing. He led
the TOI committee that decided to start the After Hours Clinic.
Patients check in on the first floor of the TMC
Orthopaedic and Surgical Tower. Office staff
will do insurance verification if necessary.
Physician Assistant Jason Humphrey, who has
15 years of orthopedic experience, is the only
full-time orthopedic clinician. There is an
orthopedic surgeon on call at all hours the
clinic is open. The on-call surgeon is rotated
among the TOI surgeons and provides instant
support if Humphrey needs it. On-site X-ray,
bracing, and casting services are available.
The surgeons have been very supportive of
the clinic, Humphrey said. The clinic
provides unique orthopedic expertise that
you cant get at a regular urgent care clinic or
drop-in clinic. This way they get proper X-rays
and dont have to get a referral to an
orthopedic specialist who may not have an
appointment available right away. It also
gives patients another option, other than the
long waits and expensive care at a hospital
emergency room.
Humphrey and Dr. Housman are both quick
to point out that if someone does have a lifethreatening situationan open wound or
severe trauma injuriesthey should be seen
at an ER. If someone does come to the After
Hours Clinic with these conditions, thats
where they will be sent.
SOMBRERO November 2015

TINNITU

Lawrence Housman, M.D., Tucson, orthopedic surgeon and


Tucson Orthopaedic Institute president, uses one of the exam
rooms available at the After-Hours Clinic now open at the
TMC Orthopaedic and Surgical Tower.
UZZING

ING
G
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BUZZING

RING
BUZZ
TINNITUS

BUZZING

RING

HUMM

RINGING
HUMMINGGING
RIN

Your patients
deserve the
best hearing
care possible

ING

HUMM

USG
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I
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IN
IN

BUZ

G
N
I
G

We offer
comprehensive
tinnitus
consultations.

TINNITUS

RINGING
TINNITUS

HUMMING
RINGING

BUZZING

HUMMING

TINN

ITUS
RINGIN
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BU

HU ZZING
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IN
Learn more about why we are a
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We are preferred providers
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520.742.2845

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520.648.3277

Helping you hear your best.

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Green Valley
Janis Gasch, Au.D.
Doctor of Audiology, Founding Director
9

patients wait for hours in an emergency room because


more urgent situations are taken ahead of them. In most
cases we can get a patient seen and treated in less than
an hour from the time they check in. We can set up any
follow-up care that is necessary with an orthopedic
specialist.
Humphrey said he started his first stint with TOI in 2000.
Six years later he took a position at the University of
Arizona, but kept in touch with his TOI colleagues. He
heard about the new clinic and was offered a position to
be its clinician. He continues to assist TOI surgeons when
not working at the clinic. My career has been all about
orthopedics, Humphrey said. It has been my passion.
I jumped at the opportunity when it came up.

Physician Assistant Jason Humphrey poses next to the TOI After-Hours


Walk-In Clinic entrance. With 15 years orthopedic experience, he runs the
clinic with the help of on-call TOI physicians. Orthopedic patients can
avoid the ER by using the TOI clinic without appointment or referral, 5-9
p.m. Monday through Thursday.

One of the beauties of being at TMC is that any care a patient may
need is only a few feet away, Humphrey said. Many orthopedic

Dr. Housman is enthusiastic about the job Humphrey and


the surgical staff are doing at the clinic. Jason has the
experience to handle just about anything that happens at
the clinic, he said. He knows when to consult with the
surgeons, or if it is a situation to be handled in the
emergency room, or it is a general ailment the clinic
should not be handling.

The After-Hours Clinic will take just about any orthopedic


patient. Most of them are a variety of fractures, strains,
and sprains suffered from playing sports, doing activities
around the house, or unexpected aches and pains in the
joints or bones. This is not a clinic for chronic conditions
or surgical follow-up care. It does not take the place of primary
care physicians or urgent care facilities that take care of general
illnesses such as sore throats, fevers, coughs,
flu symptoms or headaches.
We understand there is a need for
orthopedic treatments and specialty care
after regular business hours, Dr. Housman
said. We understand it may be difficult for
people to get an appointment or parents to
schedule time off work to get a child in to
see someone if they have an injury or
accident. The After-Hours Clinic is a start in
getting that care. It starts the process of
getting orthopedic care faster and easier
than waiting for appointments and
referrals.
Clinic hours are Monday through Thursday
from 5 to 9 p.m. TOI is considering expanding
the hours, and another After Hours Clinic is
coming soon at Northwest Medical Center.
Talks have started with Oro Valley Medical
Center about starting one on its campus.
The more patients we steer away from the
emergency rooms and the urgent care clinics
that dont have the orthopedic expertise, the
better it will be for the patients and the
providers, Dr. Housman said.
This would appear to be at least one bad
break we can all avoid.

10

SOMBRERO November 2015

TO OUR REFERRING PHYSICIANS WE THANK YOU FOR YOUR SUPPORT


CELEBRATING OUR 5 YEAR ANNIVERSARY AND OVER 8,000 PATIENTS TREATED
Dr. Ganns Diet of Hope

Diet of Hope Institute


Dietmar Gann MD
Elizabeth Gann CNC

A REVOLUTIONARY DIETARY APPROACH IN THE TREATMENT OF


OBESITY-DIABETES-HYPERTENSION-GERD-SLEEP APNEA-KIDNEY
AND HEART DISEASE

Our Nurse Practitioners Are Ready to Help Your Patients With Their Journey to Health

Abby Michieli FNP-C

LaRae Barnes FNP-C Maria Van Allen FNP-BC Cheryl Parker FNP-C Julie Bailey FNP-C

MaryLou Bradbury FNP-C

Our Research Department has published 3 scientific articles describing the salutary effects
of the Diet of Hope in the Treatment of Heart Disease, Kidney Disease and Diabetes
1. Thirty-eight patients with documented severe heart disease on our program for one year lost on average 31lbs, lowered blood pressure, cholesterol and triglycerides (Clinical Journal of Cardiology)
2. All thirty-four patients with CKD 3 and 4 improved their renal function over a 6 month period.
Diabetes and high blood pressure are the major culprits, causing kidney disease.
Both problems improve on our program. (J Diabetes Metab Disorder Control 2015)
1. Sixty-seven diabetic type 2 patients on insulin were followed for one year. Twenty-six patients were
able to stop all insulin. All other patients were able to lower their insulin dose substantially. These
sixty-seven patients saved a total of $447,426.00 dollars by reducing or stopping their insulin. (Curr
Res Diabetes Obes J, September 2015)

WE DO NOT TAKE OVER THE CARE OF YOUR PATIENTS WE ARE A COMPLIMENT TO YOUR
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Treating Adults and Children
50 E. Croydon Park Road

520-696-3438
Two Locations to serve you

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2096 N. Kolb Suite 107

Www.dietofhope.org
SOMBRERO November 2015

11

PCMS News

Annual cocci awareness week


expanded
The UofA reports that broader dates for Valley Fever Awareness
Week underscore significant research into tools to fight this
respiratory disease endemic to the U.S. Southwest and Northwest
Mexico.
The University of Arizona Valley Fever Center for Excellences
public education campaign gains momentum, they reported.
With two impending clinical trials, VF Awareness Week, Nov. 7-15
in Arizona, is bigger than ever this year. In fact, activities for the 13th
annual observanceby proclamation of the governors office since
2003have grown beyond the official second week in November
with free presentations for the public and health professionals in
Tucson and Phoenix scheduled from Oct. 24 to Nov. 18.
You cant prevent Valley Fever,
but its important that the public
know about this disease largely
of the lungs, so they can ask their
doctor when they get sick
whether or not its Valley Fever,
said John N. Galgiani, M.D., a
UofA professor of medicine,
founding director of the UA
Valley Fever Center for
Excellence, and PCMS member
since 2010. A third of all
pneumonia cases in Phoenix and
Tucson are caused by Valley
Fever, but doctors often may
forget to look for it. Theyre more likely to do that if patients also
know about this possibility and remind them.
Coccidioidomycosis is caused by the Coccidioides species of fungus.
It grows in soils in areas of low rainfall, high summer temperatures
and moderate winter temperatures, the UofA noted. These
fungal spores become airborne when soil is disturbed by winds,
construction, farming, gardening, and other activities. In people
and animals, infection occurs when a spore is inhaled. Most
exposed people never show symptoms. In those who do, the
symptoms resemble those of pneumonia, including cough, chills,

12

and chest pain, as well as fatigue, fever, headaches, and night


sweats. Skin rashes or lumps also may occur.
Most people suffering from VF recover in a few weeks or months.
Of the approximately 150,000 U.S. VF infections that occur per
year, however, about 160 people die. Two-thirds of these infections
affect Arizonans, mostly in the Valley Fever Corridor that runs
between the states two largest cities. Pets, especially dogs, also
are susceptible to Valley Fever.
November Sombrero publication is after most of the scheduled events,
but some remain because of the expansion. Dr. Galgiani was scheduled
to lecture Oct. 24 at the Fourth Annual Southwestern Conference on
Medicine of the Tucson Osteopathic Medical Foundation, with the
theme of Infectious Disease Threats in Primary Care.
Dr. Galgiani was also to discuss the UA Valley Fever Center for
Excellences participation in clinical trials about to start for a NIHfunded study for which Duke Universitys Human Vaccine Institute
was awarded a $5 million contract in June to support research into
VF pneumonia, the UofA reported. That funding could grow to
$9 million if all contract options are explored.
Were working with Duke as an enrollment site both in Tucson and
Phoenix at the BannerUniversity Medical Centers, Dr. Galgiani
said. It also involves study sites in Californias Central Valley.
Meanwhile, the university reported, the center continues
pressing forward on efforts to get a potentially curative anti-Valley
Fever drug, nikkomycin Z (NikZ), into clinical trials. Those efforts got
a boost last October when NikZ won a fast-track designation from
the USFDA a qualifying infectious disease product (QIDP). The UA
has been helping to move the antifungal drug into clinical trials and
eventually to help patients. It licensed development rights for NikZ
to Valley Fever Solutions, Inc., a small start-up business in Tucson.
The public was invited to six VF Awareness Week events, two in the
Phoenix area, three in Tucson, and one in Cottonwood. Remaining
ahead of Sombrero publication week is Dr. Galgianis lecture Valley
Fever, Thursday Nov. 12, 3:30 to 4:30 p.m. in the Great Room at
the Arizona Senior Academy at Academy Village, 13715 E. Langtry
Lane, Tucson. For reservations, e-mail info@arizonasenioracademy.
org or call 520.647.0980.
A silent auction at the Coyote Classic Dog Shows, hosted by the
Tucson Kennel Club and Greater Sierra Vista Kennel Club at the
Pima County Fairgrounds, 11300 S. Houghton Rd., Tucson, will be
Nov. 13-16, 8 a.m. to 4 p.m., and will benefit canine vaccine
research at the UA Valley Fever Center for Excellence. Admission to
the event is free. Learn more at www.CoyoteClassic.org .

SOMBRERO November 2015

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SOMBRERO November 2015

info@desertmountaininsurance.com

www.desertmountaininsurance.com
13

Alcantara Vineyards & Winery, 3445 S. Grapevine Way,


Cottonwood, will host a Wine & Noses benefit wine tasting
Saturday, Nov. 14, 11 a.m. to 5 p.m., with proceeds after expenses
going to the UA Valley Fever Center for Excellence for canine
vaccine research. Tickets are $35 per person.
For medical professionals, Dr. Galgiani will present Some of Your
Patients Have Valley FeverDo You Know Which Ones? on Friday,
Nov. 13, 1 to 4 p.m., during the American College of Physicians
Scientific Meeting at the Doubletree Hilton, 445 S. Alvernon Way.
Register at www.acponline.org/about_acp/chapters/az/news_
meet.htm
Dr. Tom Chiller is featured speaker at the UAs 20th Annual Farness
Lecture. Dr. Chiller is the CDCs deputy chief of the Mycotic

Diseases Branch, Division of Foodborne, Waterborne &


Environmental Diseases, National Center for Emerging and
Infectious Zoonotic Diseases. His lecture, Theres Fungus Among
Us: CDCs Fight Against Fungal Diseases, is on Wednesday, Nov. 18,
noon to 1 p.m., at the UA College of MedicineTucson, room
5403, 1501 N. Campbell Ave. The event will be live-streamed
online, where it also will be archived for later viewing, at http://
streaming.biocom.arizona.edu/categories/?id=10

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integral part of the University of Arizona. The
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Arizonas academic health center with the
University of Arizona, one of the nations
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Our goal is to strongly identify our academic


health center as a key part of the University
of Arizona, which not only benefits the UA
and its health sciences enterprise, but also
our affiliated centers and units, said Joe
G.N. Skip Garcia, M.D., UA senior vicepresident for health sciences and not a
PCMS member.
Communicating our strong connection to
the University of Arizona leverages the
emotional ties and pride associated with the
university, and we know that many
individuals, especially those in other states,
often were unaware the Arizona Health
Sciences Center was part of the University of
Arizona, Dr. Garcia said. Our new name
University of Arizona Health Sciencesis
much more descriptive and definitive, and
simply makes good sense.
The university reported that the re-naming
effort brings the overall UA Health Sciences
name in line with the five UA health colleges.
The University of Arizona Health Sciences,
the statewide leader in biomedical research
and health-professions training, includes: the
UA College of MedicineTucson; the UA
College of MedicinePhoenix; the UA
College of Pharmacy; the UA College of
Nursing; and the UA Mel and Enid Zuckerman
College of Public Health.
The organization called itself a major
economic engine, saying the UA Health
Sciences employs almost 5,000 people, has
nearly 1,000 faculty members, and garners
more than $126 million in research grants
and contracts annually.
SOMBRERO November 2015

Concussion:
Healing military TBI
By Carol Henricks, M.D.
Traumatic brain injury (TBI) is the signature injury of this eras
military conflicts, but its often been misdiagnosed as PostTraumatic Stress Syndrome (PTSD). Diagnosis and treatment issues
have been more than challenging, but the future has arrived.
A team working with Healing Arizona Veterans will be introducing
the Arizona Veterans Traumatic Brain Injury Treatment and
Recovery Act, the goal of which is to establish patriot clinics in
Arizona where military veterans can be evaluated and treated with
Hyperbaric Oxygen Therapy (HBOT) to heal their brain injuries.
The first such clinic was started in Oklahoma City after the
Oklahoma governor signed a bill into law in June 2014. Currently
there are freestanding clinics around the country that are
providing treatment for veterans, but some veterans are opting
to be treated at HBOT treatment centers in Israel.
There is additional information in the Fall issue of Arizona
Veterans Magazine or websites www.healingarizonaveterans.org
or www.northstarhbot.com . Please contact us at 520.229.2122,
or through our websites.

Rural health center granted


$2 million to help insurance
signups here
With the federal Health Insurance Marketplace open enrollment that
began Nov. 1, the Center For Rural Health at the University of Arizona
Mel and Enid Zuckerman College of Public Health is gearing up to
help Arizona residents understand the coverage options and financial
assistance available at HealthCare.gov, the university reports.
The Centers for Medicare and Medicaid Services of the U.S.
Department of Health and Human Services has awarded the
Center for Rural Health a three-year, $2 million Marketplace
Navigator grant. The CRH will focus on enrollment and reenrollment of hard-to-reach uninsured people living in rural and
under-served communities in Arizona.
The CRH is among 100 organizations in 34 states to receive part of
$67 million in Navigator grants from CMS. The funding will support
outreach efforts to connect people with local help as they seek to
understand the coverage options and financial assistance available.

needing additional assistance shopping for, and enrolling in,


health insurance through Arizonas Marketplace. CRH will place
Navigators during the open enrollment period in regional sites to
assist 75,000 uninsured Arizonans with health insurance
enrollment and re-enrollment for 25,000 individuals over the
next three years. The priority is to help people in hard-to-reach
rural areas with historically low participation rates in the
federally-facilitated marketplace among Latino, Native American,
disabled, and special populations.

Collaborating for
consumer safety
Southern Arizona residents treated in the emergency department
at BannerUniversity Medical Center Tucson (BUMCT) may not
be aware that for the past 35 years, they have been helping the
Arizona Emergency Medicine Research Center (AEMRC) and the
and the U.S. Consumer Product Safety Commission prevent
product-related injuries and deaths, the university says.
When you hear according to
the Consumer Product Safety
Commission, followed by a
warning about a dangerous
consumer product, our hospital
assisted in providing some of
the data that helped to prevent
further injury or death from
that product, said Harvey
Meislin, M.D., professor in the
UofA Department of Emergency
Medicine and PCMS member
since 2003.
From setting safety standards
for laundry detergent pods to
banning toys, such as Buckyballs magnets, to recalling defective
bicycles due to potential crash hazards, the CPSC is charged with
protecting the public against unreasonable risks of injuries and
deaths associated with consumer products, the university
reported. The CPSC relies on consumer-product-related injury
and death data from hospital emergency departments across the
country to form consumer product safety policy, identify
potential recalls and injury trends, and implement public health
awareness campaigns.

The centers mission is to improve the health and wellness of


Arizonas rural and vulnerable populations,said Dan Derksen,
M.D., director of the UA Center for Rural Health and professor of
public policy at the public health college. The Navigator grant
will help us provide education and information for hard-to-reach
consumers in rural areas about their choices in health insurance
coverage. We are honored to receive this CMS notice of award,
and are eager to get started on this important work.

The university said BUMCT is among approximately 100 hospitals


across the United States that is contracted with the CPSC to track
data on product-related injuries treated in emergency rooms.
The hospital also participates in the National Electronic Injury
Surveillance System (NEISS), sponsored by the CPSC. Surveillance
data enable CPSC analysts to make timely national estimates of
the number of injuries associated with specific consumer
products. This data also provides evidence of the need for further
study of particular products. Subsequent follow-up studies can
yield important clues to the cause and likely prevention of injuries
and deaths.

Arizonas Marketplace open enrollment and plan renewal remain


open through Jan. 31, 2016, the university reported. Navigators
serve as in-person resources in their communities for consumers

Dr. Meislin leads BUMCTs program through AEMRC. Each day, an


emergency medicine coordinator reviews medical records and
enters non-identifying information into a secure database linked

SOMBRERO November 2015

15

to the CPSC. The information includes the cause of the accident,


the type of injury and any specific products that were involved.
Data from BUMCT and other participating hospitals are analyzed
and trends in product-related injuries are earmarked by CPSC
staff for further study.
BUMCT is the only hospital in Tucson that contracts with CPSC to
provide data, Dr. Meislein said. It was chosen because of its size
and the volume of emergency department patients treated. At
BUMCT, approximately 3,000 injuries treated in the emergency
department each month are product-related. AEMRC has
received more than $6 million from its contracts with CPSC over
the past 35 years.

16

An example of local data that could have played a major role in


consumer safety is the banning of three-wheel all-terrain
vehicles, the university reported. ATV-related injuries and
fatalities are particularly prevalent in Arizona. Hospital
emergency department data showed a large number of patients
were injured from three-wheel ATVs, which were then
determined by CPSC to be too unstable.
That data, along with other hospitals data, helped to halt the
distribution of three-wheel ATVs, Dr. Meislin said. The whole
concept of CPSC is to protect society, to look at health hazards and
prevent injuries. It is societys safety net. We are proud to be a
major contributor to the national database and be recognized by
the CSPC as one of the top providers of data in the country.
n

SOMBRERO November 2015

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17
SOMBRERO December 2014

Behind the Lens

Where the icons abound, or uneasy riding


on old 66
By Hal Tretbar, M.D.

or many years I have been


interested in places that
have survived on the Arizona
section of old Route 66. I have
tried to photograph and
preserve the essence of some
of these icons.
Some of my favorites have
been Jackrabbit trading post,
the Wigwam Motel, the
Museum Club, Snow Cap Inn,
Hackberry, and Cool Springs,
some of which weve featured
in these pages.

Recently I went back to the Pine Breeze Inn to try to capture its
character in detail. The inn is far enough off of the beaten path to
have been overlooked by the many who have followed Old 66.
Movie buffs are familiar with it because of a famous scene in the
1969 movie Easy Rider.
The Pine Breeze Inn is a gas station and motel that was built in the
early 1940s, eight miles west of Flagstaff at Bellemont. Bellemont
was booming because the U.S. Army had recently established the
large Navajo Depot for munitions storage.
Today the well preserved buildings are part of the Pine Breeze Inn
RV Park and Campground. Just beyond the park entrance, the
original Route 66 highway is not maintained. The deteriorating
concrete road is blocked a mile farther on.
The gas station has a large
Richfield sign on the portico
over the one gas pump and
an oil dispenser. The station
door has an old Easy Rider
poster advertising a song
album from the movie.
Roger McGuinn of the Byrds
wrote and sang The Ballad
of Easy Rider for the movie
soundtrack. Subsequently,
as a band performance, it
was the title song of the
Byrds eighth album.
If you peer in through the
dirty windows you can see
old pop machines and some
interesting junk. The side of
the building shows the faint
18

The Pine Breeze Inn gas pump, oil dispenser, office, and green
cabins.

Pine Breeze Inn lettering and lets you know that credit cards are
welcome. Immediately behind the station is a row of greenish,
locked, one- room cabins, each with a basic carport. The old store
and caf are also closed and locked. The owner of the RV Park, Joel
Galbord, says the cabins were being used up into the early 1990s.
The RV Park is located just beyond in the pine trees.
Easy Rider won Dennis Hopper the Best New Director award at
the Cannes Film Festival. The films budget was $360,000, and it
brought in $60 million.
Wikipedia offers a succinct description: Easy Rider is a 1969
American road movie written by Peter Fonda, Dennis Hopper, and
Terry Southern, produced by Fonda and directed by Hopper. It tells
the story of two bikers (Fonda and Hopper) who travel through the
American Southwest and
the South. A landmark
counterculture film, and a
touchstone for a generation
that captured the national
imagination, Easy Rider
explores the social
landscape, issues, and
tensions in the United Sates
during the 1960s, such as
the rise and fall of the
hippie movement, drug
use, and the communal
lifestyle. In Easy Rider real
drugs were used in scenes
showing the use of
marijuana and other
substances.

A peek through the dirty window shows pop machines and an


old cash register with Route 66 on it.

SOMBRERO November 2015

Billy asks, Hey man, you got a room?


Note the Pine Breeze Inn sign and the red neon VACANCY.

Hippies Wyatt, (Fonda as Captain America wearing a jacket with an


American flag and a star- spangled helmet), and Billy (a bearded
Hopper dressed in buckskin pants and shirt) ride their choppers on
Route 66 through Arizona and New Mexico. They are invited to join
a free- love commune, but continue on. They are thrown in jail in a
small Southern town where they meet the local lawyer and drunk
George Hanson, played by Jack Nicholson. George is killed in a fight
later on.
Wyatt and Billy arrive in New Orleans for Mardi Gras and visit a
brothel. An LSD episode with two prostitutes takes place in a
cemetery. The two hippies decide to head to Florida.
The extended opening credits for the movie are backed by
Steppenwolfs Born To Be Wild. The background shows the bikers
starting on Route 66 by crossing the bridge into Arizona at Topock.
There is a brief desert scene followed by fleeting images of
Flagstaff. The bikes move past a lumberjack statue and through
downtown.
The sun is setting at the end of the credits and outlines Wyatt and
Billy as they come up to a gas station and motel. The gas station
has a round neon 76 sign. Wyatt and Billy pull up to the door of the
Pine Breeze Inn displaying a red, neon vacancy sign. Billy honks
his horn and revs the
engine.
The door opens and a man
comes out of the lighted
office. Billy says, Hey man,
you got a room? The man
takes one look at the two
hippies and slams the door
shut. A NO flickers onto
the vacancy sign. As they
drive away Billy yells, You
asshole! This has become
one of the most memorable
scenes in Easy Rider, and
the film made the 1968
Steppenwolf hit Born to Be
Wild into the primo biker
anthem.
SOMBRERO November 2015

A side-view of the office with the door that is seen opening


in the movie.

About a half mile west of the Pine Breeze Inn is the Route 66
Roadhouse Bar and Grill. Inside this nice hangout is the framed
story of the Pine Breeze Inn and Easy Rider. Overhead hangs the
original, lit, red No Vacancy sign. Joel Galbord told me, I would
like to have that sign back, but $1,500 is too much.
To reach this interesting place, take I-40 west of Flag to the
Bellemont turnoff. Go south over the highway to the entrance to
the Navajo Depot. Turn left and you are on old Route 66. The Pine
Breeze Inn is just a mile or so past the Roadhouse Bar and Grill.
Meanwhile, back to our movie for the paralyzing final scenes, as
described in Wikipedia:
The two men continue their trip to Florida. Two rednecks in a
pickup spot them and decide to scare the hell out of them with
their shotgun. As they pull alongside Billy, one of the men lazily
aims the shotgun at him, and threatens and insults him, saying,
Want me to blow your brains out? and Why dont you get a
haircut? When Billy flips his middle finger at them the hillbilly fires
the shotgun at Billy, who immediately hits the pavement, seriously
wounded in the side.
As the truck takes off down the road past Wyatt, Wyatt turns
around and races back to put his jacket over his critically injured
friend, who is covered in
blood, before riding off for
help. By this time, the
pickup truck has turned
around and closes on
Wyatt.

The Route 66 Roadhouse Bar and Grill with the famous


NO VACANCY sign.

The hillbilly fires his shotgun


at Wyatt as he speeds by
the pickup, hitting the bikes
gas tank and causing it to
explode. Wyatt lands by the
side of the road, apparently
dead. As the murderous
rednecks drive away, the
film ends with a shot of the
flaming bike in the middle
of the road, as the camera
n
ascends to the sky.

19

Makols Call

The lefts new buzz: income inequality


By Dr. George J. Makol

s most of my regular readers


will know, I am not a great
fan of the political class. Who is
these days, other than
themselves?
In fact, our country was founded
on the idea of not having a
political class. Citizens were to
serve limited time in government
and then return to their lives, not
make careers out of government.
But sometimes even politicians,
like our current leaders, who
have driven down middle-class
income by $5,000 since
President Obamas inauguration in 2008, can bring up a point or
two worth debating.
With the presidential election coming up next year, the unfairness
of inequality of all sorts has woven its way into the political
discussion. Perhaps the most populist of themes is income
inequality, though there are other inequalities that our political
leaders may choose to overlook.
For my fellow physicians, income inequality does not mean that
you are not earning what you earned just three or four years ago.
Rather, it now seems a revelation to some that everyone does not
make the exact same amount of money! Golly! Did I miss a clause
in the Constitution that says every one has an inalienable right to
the same salary?
Fortunately, we have a president who is leading on this issue; a
man who made his millions writing two autobiographies before he
accomplished anything significant. Some think his Nobel Peace
Prize was also premature. And thank goodness we now have
Hillary Rodham Clinton, who has made millions writing a book that
nearly no one has read, and giving highly compensated speeches
that many people would pay not to hear, as a new crusading voice
of the common man. Does anyone fail to see the irony here?
Hillary Rodham Clinton, who sees the presidency not as leadership
but as a career promotion, was preaching about income inequality
back in July, as reported by Al Jazeera America and others. I
believe we have to build a growth-and-fairness society, she said.
You cant have one without the other. Corporate profits are at
near-record highs, and Americans are working as hard as ever, but
paychecks have barely budged in real terms. Families today are
stretched in so many directions, and so are their budgets.

wealth is controlled by a tiny handful of individuals. The issue of


wealth and income inequality is the great moral issue of our time,
it is the great economic issue of our time, and it is the great
political issue of our time. America now has more wealth and
income inequality than any major developed country on earth, and
the gap between the very rich and everyone else is wider than at
any time since the 1920s.
The reality is that since the mid-1980s, there has been an enormous
transfer of wealth from the middle class and the poor to the
wealthiest people in this country. That is the Robin Hood principle in
reverse. That is unacceptable and that has got to change. There is
something profoundly wrong when the top one-tenth of one percent
owns almost as much wealth as the bottom 90 percent.
Ah, populism! And from a self-described socialist.
To paraphrase one of Hillary Clintons recent themes, she
expressed outrage that Twenty-five hedge fund managers in
America earn more than all the nations kindergarten teachers put
together. [campaign speech in New Hampshire, 2015] She
neglected to point out that those hedge fund managers earn tens
of millions for retirement funds such as that of California teachers
and union pension funds, and that they are paid by commission
based on their performance. If they dont produce consistently,
they will lose their clients, and have to close up business as many
hedge funds have had to do lately. Try getting rid of your childs
incompetent kindergarten teacher and see what happens.
In todays political discussions I was shocked, shocked to find out
that there are rich and poor people in the United States, and that
apparently this is something new! I guess it is possible that the
colonists revolted against Englands George III because they did not
like his hat, not because they were being taxed to death, resulting
in the king having all the wealth in the kingdom.
When I toured The Breakers, the Newport, Rhode Island mansion
built by Cornelius Vanderbilt of the railroads/shipping Vanderbilts,
they pointed out that laborers worked for two dollars a day to build
this imposing, palace-like retreat. I bet that Cornelius, known as
Commodore, earned annually way more than 300 times what his
laborers were paid, but back then nobody gave it much thought.
But today, with mass media help, we see the peoples earning
contrasted more readily and more often.

Of course this is familiar nonsense, but new for HRC, because shes
worried about Vermont Sen. Bernie Sanders on her left. Al Jazeera
America also claimed she was trying to counter the perception that
she is overly cozy with Wall Street.

While many of the wealthy today pour their incomes back into
their communities through purchases and charities, there are the
portrayed as the shallow rich so often in media that it can easily
arouse our resentment. This has become an emotionally charged
issue for the political left. It is hard to ignore that today, people
with absolutely no talent such as Paris Hilton and the Kardashian
family are gloriously paid for letting us look into their trivial daily
lives. They dont do anything interesting, but they do it in Jimmy
Choo or other designer shoes.

Meanwhile the Bernie 2016 campaign is hot on it, reporting on


his website, Today, we live in the richest country in the history of
the world, but that reality means little because much of that

Obviously in a capitalist, competitive society, you wont see


everyone getting rich. But on the spectrums other end, what do
we do about the poor? Eliminating poverty is a noble but vastly

20

SOMBRERO November 2015

impractical pursuit. When in the mid-1960s President Lyndon


Johnson started his War on Poverty, poverty in the U.S. hovered
at about 14 percent of the population. Fifty years later, with
hundreds of billions spent on the 92 different government poverty
programs, we have a poverty rate of 15 percent. This could be
called an admirable success rate for government program; were
lucky the poverty rate didnt double!

spouse if your girlfriend/boyfriend looked exactly the same. There


would really be no reason for war if everybody had the same
amount of money, was the same height, and looked identical.
What the devil would we fight about? But more importantly, how
will we then value the individual?
As to the perceived value of the individual in society, a very
influential political theorist once wrote: Our mutual value is for us
the value of our mutual objects. Hence for us, man himself is
mutually of no value.

Why limit outrage about inequality solely to this income


inequality? It has come to my attention that there are numerous
published psychological studies that demonstrate that taller
That theorist was Karl Marx.
persons are more successful in life. They apparently achieve higher
salaries and are promoted more often than the vertically
Sombrero columnist George J. Makol, M.D., a PCMS member since
challenged. Perhaps in the studies no one asked Tom Cruise or
1980, practices at Alvernon Allergy and Asthma, 2902 E. Grant Rd.
Dustin Hoffman about their short careers. One could therefore
make a good case that is inherently unfair for
one person to be taller than another. There
is no reason why, with modern plastic
Dr. Matthew Clavenna,
surgery, orthopedic techniques, and elevator
shoes, while we could not have all men at
MD
the same height, say five-foot-eight, and all
women at the same height, say five-footDr. Clavenna was born in Texas but
sixperhaps five-foot-seven for male-tospent most of his childhood in
female transgendered persons. (Youre
Baton
Rouge,
Louisiana.
He
welcome Caitlyn! Though youre six-two
attended Trinity University in San
Antonio for his undergraduate work,
without heels.)
Another glaring inequality in todays society
is that everybody is not equally endowed
with good looks and charm. Is this not
inherently unfair? Where are the politicians
on this? Studies have shown that the
exceptionally good-looking among us also
get a career jump, earn more money, and
dont wince as often in the morning while
looking in the mirror. Take model Heidi Klum,
for example. She is astounding. She is 42
years old, has had three children, and puts to
shame most of the 20-year-old starlets in
Hollywood who think themselves so sexy.
While strolling through the mall recently I
noticed several women that look like four or
five Heidis rolled up and covered with a
muu-muu.
Then theres Harrison Ford, whose new
movie I recently attended: The guy is 70 and
looks better than all the rest of us guys at any
age. Does he take handsome lessons? Where
does all that hair come from? Can he really
pull off Indiana Jones at 70? I think so.
Through the wonders of modern surgery and
medicine, and by opening mandatory health
spas on every block, theres no reason why
we could not make all the women look like
Heidi Klum, or say Halle Berry, and all the
men look like Harrison Ford types.
So now we need a political leader to insist
not only that people make the same amount
of money, but they are all the same height,
and all are equally endowed physically. Think
of the harmony this would bring in society!
There would be no reason to cheat on your
SOMBRERO November 2015

receiving a B.S. in Biochemistry. Dr.


Clavennas desire to personally
help those with ailments, led him
into the field of medicine. He earned his medical degree from
Louisiana State University Medical School in Shreveport in 2009,
where he was elected into Alpha Omega Alpha Honor Society.
While in medical school, he was introduced to Otolaryngology
(ear, nose, & throat), a wonderful field of complex anatomy,
requiring surgical and medical expertise to treat those with
problems of the head and neck. Dr. Clavenna completed a general
surgery internship and otolaryngology surgical residency at
Louisiana State University Health in Shreveport.

Following residency, Dr. Clavenna completed a Fellowship in sinus,


allergy, and anterior skull base surgery at Vanderbilt University in
Nashville, Tennessee. There he trained under internationally
known surgeons, Drs. Rick Chandra, Paul Russell, and Justin
Turner. During fellowship he focused on advanced sinus surgeries,
including management of frontal sinus disease, nasal and skull
base tumors, pituitary surgery approaches, ophthalmological
related procedures and treatment of allergies. Many of these
cases were performed in conjunction with neurosurgeons and
ophthalmologists. One of his most fond memories from fellowship
involved treating a patient emergently transferred to Vanderbilt
for severe sinus disease encroaching on the vision of his right eye.
Using his recently learned endoscopic sinus surgery techniques
with the aid of image guidance, he was able to successfully treat
and drain the infection and preserve the patients vision.
Dr. Clavenna moves to Tucson with the desire of helping those in
the community with their ear, nose and throat related problems.
He is the first fellowship trained sinus and anterior skull base
surgeon to join a private practice group in Tucson. Though he has
a passion for nasal, sinus, and allergy related disorders, he also
enjoys treating the full gamut of ENT related issues, from neck
masses to ear surgery.
Dr. Clavenna in his free time enjoys spending time with his wife,
the outdoors, and looks forward to taking advantage of the
wonderful surroundings Tucson and Arizona have to offer.

www.CarlsonENT.com
21

Bioethics

As the Hippocrates turns


By Stuart Faxon

Hippocrates couldnt help it. He lived in the 5th century B.C. He


never heard of multiple sclerosis, or amyotrophic lateral sclerosis.
No one knows who first penned the Hippocratic Oath, reported
Peter Tyson in 2001 for the PBS series Nova. It seems to have
emerged a century after his time, but carries his name in the
consideration that he was the father of medicine. Tyson was asking
if today, the Oath is a meaningless relic, or an invaluable moral
guide?
The AMAs Code of Medical Ethics 1996 edition holds that the Oath
has remained in Western civilization as an expression of ideal
conduct for the physician, Tyson reported. Today almost 100
percent of med students swear to some version of the Oath. Yet,
paradoxically, even as the modern oaths use has burgeoned, its
content has tacked away from the classical Oaths basic tenets.
Tyson noted that according to a 1993 survey of 150 U.S. and
Canadian medical schools, only 14 percent of modern medical
oaths prohibit euthanasia, 11 percent hold covenant with a deity,
eight percent forswear abortion, and a mere three percent forbid
sexual contact with patientsall maxims held sacred in the
classical version. Indeed, a growing number of physicians have
come to feel that the Hippocratic Oath is inadequate to address the
realities of a medical world that has witnessed huge scientific,

economic, political, and social changes, a world of legalized


abortion, physician-assisted suicide, and pestilences unheard of in
Hippocrates time.
Our time is 2015, and earlier this year Canada decreed that in
terms of physician-assisted dying, it is Canadians time. In a
unanimous ruling released on Feb. 6, 2015, reports Bioethique
Online, the Supreme Court of Canada found in Carter v Canada
(Attorney General) that the federal Criminal Code prohibitions on
physician-assisted dying to have infringed on Canadians Charter
rights to life, liberty, and security
With this historic judgment, Canada has become the second
country in the world, after Colombia, to have allowed for physicianassisted dying on constitutional grounds. Carter v. Canada had its
origin with the death of a British Columbia woman, Kay Carter, at
the Dignitas assisted suicide clinic in Switzerland. Slightly more
than a year later, Carters daughter and son-in-law launched
constitutionally-based litigation, along with the British Columbia
Civil Liberties Association, a family practitioner, and Gloria Taylor,
an ALS patient.
In 2012, the trial judge found for the claimants, and ruled as
unconstitutional the impugned prohibitionsa decision that was
later overturned by the B.C. Court of Appeal. The SCC granted the

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SOMBRERO November 2015

claimants leave to appeal, and heard oral arguments on Oct. 15,


2014.
The SCC found that the law in the Charter of the Rights and
Freedoms infringes on the right to life insofar as it has the effect
of forcing some individuals to take their own lives prematurely for
fear that they may be unable to do so at a later time when they will
have become disabled or their suffering is too great. The law
infringes on the right to liberty insofar as it deprives individuals of
the right to make medical decisions concerning their own bodily
integrity; and it infringes on theright to security because it forces
some individuals to endure intolerable suffering.
The SCC also found the law to be overly broad, Bioethique Online
reported, in that its purpose is to protect vulnerable individuals
from being induced to commit suicide. The law, however, catches
others outside of this group of protected personsi.e., other nonvulnerable individuals who wish to hasten their own deaths. More
importantly, the infringement is not saved by section 1 of the
Charterthe Charter provision that allows the state to curtail
constitutional rights in the interests of societybecause the Court
agreed with the trial judge that evidence from Canada and abroad
showed there to be less restrictive means to protect vulnerable
individuals, other than an absolute prohibition.
The SCC, Bioethique Online noted, did not make the decision based
exclusively on physician-assisted dying, but it surely did
decriminalize both euthanasia and physician-assisted suicide,
practices that many bioethicists have long recognized to be
ethically related, but which may be distinguished in practical terms.

respectively, but that these decisions were based on state


constitutions and their effects are thus limited to those
jurisdictions.)
Tonda MacCharles in Torontos The Star online for Feb. 6, 2015,
reporting from the Ottawa bureau, called it a historic and farreaching decision declaring [that] desperately suffering patients
have a constitutional right to doctor-assisted suicide. The
Conservative government that vowed never to reopen the
question of assisted suicide is seeking to buy time in the wake of
the bombshell ruling.
Justice Minister Peter Mackay said the federal government needs
to absorb the ruling on a matter so sensitive for many Canadians.
He hinted it could take the whole year granted by the court to
develop a legislative response. Neither the NDP nor Liberals stated
a clear party position, but both hinted at the need for federal
guidelines to protect the vulnerable.
The SCC suspended the effect of the ruling for 12 months. Eight
have passed since.
Parliament now has several options, MacCharles reported. It
could enact a new law laying out a scheme for physician-assisted
suicidessetting out guidelines for determining consent, timelines, residency requirements, or the extent of medical assistance
for example, as Quebec has done. It could decide not to draft a
new law, allowing the ruling to stand as an expression of principles
and leave details up to provinces or medical regulatory bodies and
authorities to oversee. If Parliament does not draft a new law
within that time, the effect of the decision would be to allow
physician-assisted suicides within those limited circumstances. But

The American Medical Associations Code of Medical Ethics, for


example, defines physician-assisted suicide
as when a physician facilitates a patients
death by providing the necessary means
The Faces of Casa are the
and/or information to enable the patient to
perform the life-ending act. Euthanasia is
distinguished from PAS in that another
persona physician in places that have
James Nicolai, M.D.
legalized euthanasiaadministers the
Associate Medical Director
life-ending act. Specifically, the SCC
decriminalized physician-assisted death or
As a hospice physician, it is
physician-assisted dying and it accepted
incredibly satisfying to work with
the claimants definition of this term as a
a team of individuals totally
situation where a physician provides or
devoted to easing suffering for
administers medication that intentionally
patients and their loved ones.
brings about the patients death, at the
request of the patient.
This is why I became a doctor in
the first place.
The SCC used the term euthanasia much
as a bioethicist would use the term involuntaryeuthanasia, that is, killing someone
against their own wishes, or culpable
homicide. So it ought to be clear ... that
Carter v. Canada decriminalized both
physician-assisted suicide and voluntary
active euthanasia, as they are
conventionally understood in the bioethics
literature, Bioethique Online reported.

(They noted that courts in Montana and


New Mexico decriminalized physicianassisted suicide in 2009 and 2014
SOMBRERO November 2015

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

23

it would not permit anyone to aid individuals to commit suicide at


any time. The general prohibition still stands.
Kay Carter and Gloria Taylor, another British Columbia woman,
suffered from different debilitating conditions when they launched
the landmark case, MacCharles reported. Both have since died.
Carters family escorted her to Switzerland which allows physicianassisted suicide. The British Columbia Civil Liberties Association
took up their challenge. The court said the litigation was in the
broad, national public interest and deserved full legal costs
estimated to be in the millionsto be paid by the federal
government with some costs to be paid by the government of
British Columbia.
While it was a decisive victory for civil libertarians and right-to-die
proponents, advocates for the disabled agonized over the
decision. In a statement, the Council of Canadians with Disabilities
(CCD) and the Canadian Association for Community Living
challenged governments to maintain or expand home-care
services and supports, a national suicide prevention strategy for
persons with disabilities and degenerative conditions, and most
critically questioned whether governments would provide access
to palliative care as a universally available service at the end of life.
CCD spokeswoman Catherine Frazee, shaken by the ruling, said,
Disabled people are very much at risk, and I think we have to rise
up and assert that disabled lives matter.
The SCC decision overturned the courts 1993 ruling in Sue
Rodriguezs bid for help to end her life before ALS made it
impossible to even ask, MacCharles reported. The high court said
it was time to revisit that because of legal changes in how courts

analyze the constitutionality of statutes, and evidence based on


the international experience that now shows how safeguards can
be built into a permissive regime to protect vulnerable people
from error or abuse. It rejected a notion of a practical slippery
slope.
Just as Canada did, our states, and eventually our federal
government, are addressing the same issues whether theywe
like it or not. Reporting in By the Numbers: Death With Dignity
Laws in America, Emily Barone of Time, Inc. noted last year that
aid-in-dying practices are legal in five states, either by legislation or
case ruling:
Oregon since 1994, Washington since 2009, and Vermont since
2013 have laws that allow terminally ill adults to acquire
prescriptions for lethal doses of medications from their physicians.
New Mexico since since last year has ruled that residents who are
terminally ill have a constitutional right to obtain aid in dying,
following a judges decision in 2014. The states attorney-general
was to appeal the ruling.
Montana since 2009 does not have a law that sets a protocol for
aid-in-dying. A court case established that physicians are protected
if they write a lethal medical prescription per a terminally ill
patients request.
The Washington Times reported in January that the assisted
suicide movement is gaining traction across the U.S., and that
states expected to follow the others with similar legislation include
Colorado, Connecticut, Delaware, and Missouri. Behind the
scenes, the conservative newspaper said, is Compassion &
Choices, a right-to-die group funded by [octogenarian] liberal
billionaire George Soros, a frequent villain in right-wing media.
As Time, Inc. put it, advocates say, Death-with-dignity laws allow
terminally ill patients to die on their own terms. The laws give
patients the chance to use aid in dying if their suffering becomes
unbearable.
Opponents say, Patients might be pressured to take their own
lives by family members and others who wish to save money or
end the burdens of caring for someone with a debilitating illness.
Opponents say that Once the pills are available anyone can
administer themparticularly if the patient has lost mental and
physical facultieseven if that patient has decided against taking
the pills.
Opponents also say that Because aid-in-dying is less expensive
than end-of-life care, its availability could affect decision-making at
the insurance, doctor, and patient levels.
Advocates say, The practice of aid in dying does not replace endof-life care. Patients still have the choice of dying in their own
homes, and receiving hospice and palliative care as an alternative
to acute hospital care.
Advocates also say, Ending the dying process by withdrawing life
support for terminally ill patients is a routine practice in which
patients may not be consulted if they are unconscious. Aid in dying
provides patients with autonomy and allows them to avoid life
support that would extend their dying process, but not their
quality of life.
As an indicator of how the issue is proceeding, last month in the

24

SOMBRERO November 2015

nations social laboratory state, California passed and Gov. Jerry


Brown signed a right-to-die law granting terminally ill people the
right to end their own lives, reported Elizabeth Whitman in
International Business Times.
It was a years-long contentious debate that split doctors and
patients, academics and politicians alike, Whitman reported.
Inspired by Californias success, advocates of assisted suicide in
Maryland want to achieve the same victory in 2016, after an
initiative this year failed in Annapolis. Maryland was founded as a
Roman Catholic colony, but today Protestants predominate.
Sombrero would like to hear what our readers think about
physician-assisted suicide. If, as a physician, it is not your issue now,
it will be.
REFERENCES
Sources for this report are credited in the text and were mostly
gleaned by placing Carter v Canada into the Internets
predominant search engine.
Retired newspaperman Stuart Faxon has been Sombrero editor
since 1997. He earned his bachelors degree in English and
journalism in 1978 at Suffolk University, Boston. He earned his
M.A. in journalism in 1979 at The University of Arizona.

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25

MAYO CLINIC CME

December
Dec. 4-5: The Third Annual Mayo Clinic Esophageal Disease
Course is at Mayo Clinic Education Center, 5777 E. Mayo Blvd.,
Phoenix. Accreditation: 14.5 AMA PRA Category 1.
Course is comprehensive approach to significant advances in
diagnosis, therapy, and identification of new diseases in the
rapidly developing esophageal disease area, including advances
in high-resolution manometry and impedance monitoring, new
techniques in endoscopic detection and treatment of Barrets
esophagus, and insights into new diseases such as eosinophilic
esophagitis. Hands-on workshop is special feature with
interpretation and performance of motility studies, new
endoscopic imaging techniques, endoscopic mucosal resection
and ablation, and transnasal endoscopy.
Contact: Mayo School of Continuous Professional Development,
13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax
480.301.8323. mca.cme@mayo.edu

January 2016
Jan. 9: The Mayo Clinic 1st Annual Update on Infectious Diseases
is at Mayo Clinic Education Center, 5777 E. Mayo Blvd., Phoenix
85054; phone 480.301.8000. Accreditation TBD.
Course combines the essentials of coccidioidomycosis with an
update on how to manage infections encountered in the
outpatient setting. This new course is designed to enhance
physicians knowledge and ability to diagnose, treat, and prevent
the infections they will commonly see in practice. Topics include
cocci; rapid diagnostic tests for infectious diseases; differentiating
viral and bacterial infections in the office setting; managing
common infections in an era of multi-drug resistance; how to use
new immunizations; measles, MERS, chikungunya and more
tools to help you recognize and prevent spread of emerging
infections; antimicrobial stewardship; whats new in
management of skin, soft tissue and MRSA infections; update on
UTIs; whats new in infectious diarrhea?; antibiotic prophylaxis
for primary care; Get smart: When to suspect ABX resistance and
what to do about it.
Contact: Mayo School of CPD, Mayo Clinic, 13400 E. Shea Blvd.,
Scottsdale 85259; phone 480.301.4580. mca.cme@mayo.edu
https://www.ce.mayo.edu

February 2016
Feb. 12-13: Mayo Clinic Scottsdales Enhancing Recovery After
Surgery 2016Improving the Quality of Recovery for the
Patient is at Pointe Hilton Tapatio Cliffs Resort, 11111 N. 7th St.,
Phoenix 85020. Accreditation TBD.
Enhanced recovery after surgery (ERAS) is a multidisciplinary
perioperative care pathway designed to reduce the stress
response during a patients surgical procedure and preserve
organ function while promoting early recovery, presenters say.
This proactive approach is comprised of interventions starting at
26

preoperative planning and continuing through intraoperative


management and post-operative care. The course will provide
evidence-based best practices on the ERAS approach. Breakout
sessions provide learners the opportunity to exchange ideas into
improve patient outcome and speed up patient recovery.
Surgical, perioperative and post-op teams are invited to attend.
Contact: CME Department, Mayo Clinic Scottsdale, 13400 E. Shea
Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323.
mca.cme@mayo.edu www.mayo.edu/cme
Website: https://ce.mayo.edu/surgical-specialties/content/
enhancing-recovery-after-surgery-improving-quality-recoverypatient-2016
Feb. 25-28: Mayo Clinic Gastroenterology and Hepatology 2016
is at Westin Kierland Resort & Spa, 6902 E. Greenway Pkwy.,
Scottsdale 85254. Accreditation TBD.
Program is designed to update physicians and allied healthcare
professionals practicing in gastroenterology and hepatology
about new approaches to diagnosis and management of GI and
liver diseases. Faculty presents data on topic including
inflammatory bowel disease, colorectal neoplasia, general GI,
esophageal, motility, nutrition, pancreaticobiliary disorders,
endoscopy, and hepatology. Controversies in diagnosis and
management are analyzed in discussions and concurrent
breakout sessions. Expert endoscopists present complex
endoscopy cases and cutting-edge technology in video forum.
Optional sessions offered to help gastroenterologists and
hepatologists prepare for re-certification and obtain MOC credit.
Course includes participation by the presidents of all four
gastroenterology societies and who are also Mayo Clinic faculty:
Doctors Keith D. Lindor, Kenneth R. DeVault, Michael Camilleri,
and Douglas O. Faigel, of AASLD, ACG, AGA, and ASGE
respectively). Attendees can interact with these physicians at
breakfast and luncheon sessions.
Website: https://ce.mayo.edu/gastroenterology/gi. Contact:
Jenny Kundert CMP, Mayo Clinic Scottsdale, 13400 E. Shea Blvd.,
Scottsdale 85259; phone 480.301.4580; fax 480.301.8323.
mca.cme@mayo.edu htttps://ce.mayo.edu .

Members Classifieds
MEDICAL OFFICE FOR LEASE - Well situated on Northwest Medical Center
campus with great visibility on Orange Grove. Well designed, 4,300 square
feet, aesthetically-pleasing with high efficiency, suited for 4-6 providers, built
in 2006. Features 12 exams rooms, including 1 procedure room; 4 offices;
and 1 large reception area; spacious storage area for supplies; at door
parking. Available April 2016 (Current leaser is merging with another practice)
Competitive rates. Contact Catherine Westerband, MD, 520-488-7515 or
cwesterband@genesisobgyn.net
FULL-TIME PEDIATRICIAN Great family and golf community. Full-time
Pediatrician BC/BE to join well established Pediatric practice in Tucson,
Az. Competitive salary with excellent benefit package, including bonus
compensation. Send CV to kolleenr@comcast.net
ATTENTION CARDIOLOGISTS Very busy central Tucson cardiology office is
seeking an experienced cardiologist to join its practice. Interested candidates
contact Denise at timm@flash.net with resume or any questions about the
position.

SOMBRERO November 2015

Lung Cancer Screening

Its quick, easy and could save your life.


Lung cancer is responsible for 1 of every 3 cancer deaths and is the most
common cause of cancer death in most populations. Low-Dose Chest CT
(LDCT) screening can detect many small lung cancers before they are visible
on a regular chest X-ray, increasing treatment options and survival rates.
By finding a lung cancer with a screening LDCT scan when the cancer is small,
more effective and potentially curable treatment options become available.
Does insurance cover this exam?
As of February, 2015, Medicare now covers LDCT Lung Cancer Screening for
beneficiaries who meet the eligibility criteria listed below.
Who should be screened?
Smokers age 55 to 77 years who have smoked for 30 pack-years or more
(pack-year smoking history is calculated by multiplying the number of
years you have smoked by the number of packs you smoke a day).
Former Smokers age 55 to 77 years who quit smoking less than 15 years
ago and have smoked 30 pack-years or more.

If you are a smoker, have


a history of smoking or
have other risk factors for
lung cancer, please contact
your doctor to see if LDCT
Lung Cancer Screening is
appropriate for you.

For more information


about this and other
screening exams provided
by Radiology Ltd., please
visit our website at
www.radltd.com.

A TUCSON TRADITION FOR MORE THAN 80 YEARS

SOMBRERO November 2015

27

MICA_Sombrero11'15ad.qxp_Layout 1 10/15/15 9:08 PM Page 1

Did you know?


As a mutual insurance company,
MICA uses part of its
investment income to offset
premium rates.

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

The policyholder benefits presented here are illustrative and are not intended to create or alter any insurance coverage. They should
not be relied on and may differ from actual MICA policy language. Coverage provided by MICA is always subject to the terms and
conditions of your policy, and MICA strongly encourages you to read your policy in its entirety.

28

SOMBRERO November 2015