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Sombrero

Pima County Medical Society


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

DECEMBER 2015

Territory Neurology
& Research Institute

Clinica Amistad:
New room for needy

When physician
becomes patient

SOMBRERO December 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

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)

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

Advertising
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Fax:
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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

$539,000

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

Members at Large

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

Winchester Ranch

Arizona Medical
Association Officers

Snehal Patel, DO (Alt. Resident)


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

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

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Vol. 48 No. 10

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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Inside
5 Dr. Melissa Levine: Tis the (obesity)
season.

7 Membership: Our editor on Territory

Neurology & Research Institute; our


associate director on Clinica Amistad.

13 PCMS News: Charges against longtime

UofA pharmacy college dean surprised


everyone.

18 Arizona Medical Association News:


Updates from our state medical
association.

20 Behind the Lens: Photographing your


honeythe one with wheels.

23 Makols Call: When physician becomes


patient.

25 Mayo Clinic CME: Courses scheduled by


the Scottsdale institution.

On the Cover
Sombrero followers know that two gearheads regularly contribute to the magazine. Can you name them? One is Dr. Hal
Tretbar, who says, A 1955 Porsche 356 Pre A Speedster may go
at auction for between $300,000 and $400,000. I took this
photo with a Nikon D600. By mistake, the ISO was at 1600, yet
the program mode took an excellent image at 1/2000th second
at f22.

SOMBRERO December 2015

Tis the (gluttony) season


By Dr. Melissa Levine
PCMS President

ver the Jewish holidays, I


reflect upon the year:
What was good, what was bad,
what I can change, how I can be
better.
Over Thanksgiving, like most of
us, I try to reflect and be, well,
thankful. I have my health and
my family is healthy and I am
truly thankful for that. As
physicians we see many people
who are not that blessed. But as physicians we are also in a
position to see that some of poor health is bad luck, perhaps bad
genes, but some is simply bad choices. We can also look at the
health of our nation. Unfortunately, I fear that is declining, and a
significant reason is bad choices.
This is the seasonThanksgiving, Hanukkah, and Christmasfor
gluttony. Most of us will find homemade or store-bought goodies
at the office, more days than not. Most of us, and our patients,
will go to holiday parties and over-indulge. We, our patients, and
our children do this every year. It is not uncommon to see
diabetics go out of control over this time, not uncommon for
people to gain 5-10 pounds. or more over the season.

obesity in the U.S. was $147 billion in 2008 U.S. Dollars, or 10


percent of healthcare costs. The annual medical costs for people
who are obese were $1,429 higher than those of normal weight.
The numbers are staggering.
So what can we as physicians do? We need to push for physical
activity in the schools. I do not believe that the obesity epidemic
can be stopped unless we stop it early.
Project Spark in 1999 incorporated physical activity in and out of
school, and showed that kids in the program had higher language,
math, and basic battery scores than kids in the control group. That
was 1999, but since then more and more schools have dropped or
decreased physical education.
I also believe we need to set a good personal example for our
patients. We need to eat well and exercise regularly, and take care
of ourselves. So, here is wishing all of you a happy, healthy, and
weight-neutral holiday season!
REFERENCES
University of Michigan, Physical Education in Americas Schools.
CDC, Division of Nutrition, Physical Activity, and Obesity.
Linyuan Jing, Ph.D., postdoctoral fellow, Geisinger Health System, Danville, Pa.;
Gregg Fonarow, M.D., professor, cardiology, UCLA; Nov 10, 2015, American Heart
Association Scientific Sessions, Orlando, Fla.
Reingberg, Steven, Healthday, News For Healthier Living, online publication,
Nov 11, 2015.
Annals of Internal Medicine, Nov 10, 2015.

According to the CDC, more than one third of adults in the U.S.
are obese. Among children age 2-19, 17 percent are obese. Some
of this is related to socioeconomic status. Preschoolers in families
that live below the poverty level have the highest level of obesity.
In girls, obesity has declined in the approximate 10 years from
2000 to 2010, in families whose adult head of household is a
college graduate, and the rate has increased where the adult
head of household has not completed high school.
Normal-weight men with increased belly fat have significant
increase in premature death than those without. A just-released
study of almost 15,000 adults, from Mayo Clinic Rochester, found
an 87 percent increase in premature death over the 14 years of
the study. Compare those same men with the Santa bellies to
overweight and obese men, the risk of premature death is only
double for the guys with belly fat.
The number for women was not quite as bad, but still stunning.
Normal-weight women with extra belly fat had a 50 percent increase
of premature death over women with a more even distribution, and
compared to obese women the increase was 32 percent.
A recent small study of 40 kids showed kids as young as 8 who are
obese may have structural damage to their hearts. They
compared 20 obese kids ages 8-16 with 20 normal-weight kids.
They excluded kids with diabetes, or who, tragically, were too big
to fit in the MRI machine. They scanned their heart muscle and
found that on average the obese kids had 27 percent increase in
muscle mass of the left ventricle. Forty percent of those kids were
already showing decreased pumping ability.
Once again from the CDC, the estimated annual medical cost of
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SOMBRERO December
December 2015
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Membership

Neurology, research ... and homeyness


Story and photos by Stuart Faxon

pon entering Territory Neurology &


Research Institute, 1631 W. Ina Rd.
No. 151, you soon know its a pet-friendly
place, especially of the canine variety.
Not only will you see a lobby bulletin
board full of wonderful dog (and some
cat) photos, but youll soon see curlyhaired therapy assistant labradoodles
Roxie and Trixie, who are always
interested in whats going on and like to
greet patients and visitors. We try to
provide a nice, homey environment,
obvious dog fan Dr. Jeanette Wendt said.
Territory NRI is a wide-ranging neurology
practice, plus research trials of new
medicines. Medical Director Jeanette Kay
Wendt, M.D. has been a PCMS member
since 1990. Born 1955 in Phoenix, she
earned her M.D. in 1983 at the UofA and
did the rest of her training there,
including internship, neurology residency,
and neurology fellowship. She served on
the PCMS Board of Directors 2000-2002
and as secretary-treasurer in 1998. She is
married to retired engineer Reuben Hill, who built electronics for
satellites and telescopes. She founded Territory about four years
ago, previously practicing with Neurological Associates of Tucson.
Territory NRI has done clinical research trials since 1989, usually
sponsored by NIH or a given pharmaceutical company. There
are new medicines for MS, Parkinsons, Alzheimers, post-hepatic
neuralgia, complications arising from diseases of behavior, and
issues from dementias, Dr. Wendt said. There are so many
new medications today. When I was in school there were no
medicines for Alzheimers and MS, and very few for Parkinsons.
Now there are many; 12 have been approved for MS, with more
to come.
Volunteers are key. If people dont volunteer, Dr. Wendt said,
we dont get any new medications, so we need people to be
in new clinical trials. We do all kinds of pre-clincal trials. Its
important for people to participate, because when we look at
mice, what works in a mouse doesnt necessarily work in people.
Territory advertises for volunteers, using referrals of people in
the practice, other neurologists, and friends of friends, Dr.
Wendt said. We also work with Dogtoberfest, in the week
before Halloween, sponsored by Handi-Dogs, the organization
that teaches pet owners to train their dogs as service dogs.
Neurologist Jeanette Wendt, M.D., with her two therapy
assistant labradoodles, Roxie on the left, and Trixie on the right.
SOMBRERO December 2015

Territory NRI includes this conference center.

Territory Neurology & Research Institute has a comfortable


infusion room for patients whose treatment requires IV meds.

Coming clinical trials


Territory Neurology & Research Institute Research
Director Tammy Nakonechny says that all their
clinical trials can be found on clinicaltrials.gov, as
this is the safest and best way to ensure the trial
and doctor are legitimate. We are currently
enrolling for patients with the following ailments:
Spasticity associated with Multiple Sclerosis
Relapsing remitting Multiple Sclerosis
Alzheimers disease
Mild cognitive impairment
Migraine headache
Nakonechny notes that Territorys website,
territorynri.com, is a work in progress at the
moment of our writing, but that by the time
Sombrero is published, it should have material
there for all to see. Meanwhile, their phone
number is still (520) 742.1833.

We work with the Alzheimers Association Desert Southwest


Chapter, and the National Multiple Sclerosis Society Arizona
Chapter.
In all Territory NRIs facility has eight exam rooms, two neuro-psych
exam rooms, and two monitor rooms where independent
contractors with big pharma companies monitor trials for FDA
compliance.
The practice also uses support groups, and the building has activity
8

The outdoor patio is for both patients and pets.

rooms that include exercise space for patients with Parkinsons or


MS, such as kickboxing, chair tai-chi, or yoga.
We try to be more comprehensive in treating our patients, Dr.
Wendt said. We schedule an hour for all patients, new or followup. We have a five-bed infusion center for people who need IV
medssome treatments for MS are IV infusions. We can also do
IV-infusion steroids more conveniently than scheduling hospital
time.
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SOMBRERO December 2015

Membership

A clinic of friendship and health


Story and photos by Dennis Carey

mistad is friendship, plain and simple. Salud is health, or a


toast of Good Health! These are prime qualities for patients of
Clinica Amistad, a clinic providing health services without charge
on Tucsons South Side.
Here, it wont matter if you speak Spanish rather than English. It
wont even matter if you are here undocumented. Your humanity
and your health matter.
The clinic celebrated its 12th anniversary in June by moving from 1631
S. 10th Ave. into its new space at 101 W. Irvington Rd. No. 3. Forget
the traditional 12-year anniversary gifts of silk and linen; Clinica
Amistad would prefer your donations of time, and of course money.
The new location has 10 exam rooms, a dermatology room, a
pharmacy, and expanded front office space and administrative
areas. But the new location was selected for more than more
space. It is strategically located where free healthcare is most
needed. It is in El Pueblo Center at Irvington Road and 6th Avenue,
in the same complex as offices of the Pima County Health
Department and DES, one building north of El Rio Community
Health Center, and a parking lot east of Roy Laos Transit Center,
allowing easy access to bus riders.
We definitely outgrew our old location in South Tucson, said
Evan Kligman, M.D., PCMS member since 1991, one of the
founders of Clinica Amistad, and president of the Amistad y Salud
Board of Directors, the clinics parent non-profit organization. He
has also served on the PCMS board, and on Pima Council On
Agings board. We were in a WIC (women, infants and children)
space with no exam tables and a few desks and chairs, he said.
We are still getting organized, but we really appreciate our new
arrangement. We will be able to expand our services and do so
much more for our patients.
Dr. Kligmans day job is as a family practitioner at Southwest
Integrative Healthcare, 2802 N. Alvernon Way. Clinica Amistad is
also an integrative medicine practice, offering acupuncture,
nutrition and weight management education, and body work
modalities such as zero balancing, physical therapy, psychological
nutritional counseling, and social services provided on site. The
clinic can also refer to outside sources for lab work, medical
imaging, and community specialists as necessary. All services are
by volunteer providers and done at no cost to the patients.
Unfortunately, there seems to be a need for our services more
than ever, Dr. Kligman said. There are still low-income patients
who do not qualify for, or cannot afford regular healthcare through
insurance or other avenues.
Clinica Amistad schedules more than 2,000 appointments per year.
The clinic is open 5-9 p.m. Wednesday and Thursday evenings.
Appointments are recommended, but they do take walk-ins, especially
for urgent care needs. Most of the patients have chronic conditions
such as diabetes, high blood pressure, and cardiovascular disease.
There is hope to expand the hours of operation and eventually
have some Saturday hours, but it will depend on getting the
10

The unpreposessing pastel pink door of Clinica Amistad, with


only a paper sign as yet, belies the large amount of service
space inside.

resources to do it, including providers and financial support.


Currently there are 17 primary care providers including physicians,
NPs and PAs. They also have some specialists who volunteer,
including a dermatologist and optometrists.
More than 100 volunteers do various tasks for the clinic. Many of
the volunteers come from the University of Arizona. Some are
medical students getting practical experience before graduating
into a full-time practice. Students at the Ua Mel and Enid
Zuckerman College of Public Health also intern at the clinic.
Clinic Manager Alicia Swift is a UA public health college graduate.
Shes charged with trying to coordinate all of the administrative
duties of the clinic. Luckily, technology has developed to a point
where those duties are easier to handle. Front office workers can
use computers to schedule lab work or imaging services, or make
an appointment to an outside specialist. Results of any tests or
treatments can be sent back to the clinic much faster for the
providers to review.
Like any non-profit, we rely heavily on our volunteers, Swift said.
We are lucky to have a pipeline through the university, but we can
always use provider volunteers.
SOMBRERO December 2015

Many of the physician providers


are retired. Clinic Medical Director
Rick Graap, M.D. left his regular
endocrinology practice in 2010, but
its been no inactive retirement.
Besides his clinic duties, he
volunteers at St. Elizabeths Health
Center on Speedway, formerly St.
Elizabeth of Hungary Clinic, for
weekly endocrinology consultations.
Diabetes is a prominent issue with
our patients, Dr. Graap said. We
have people coming in who are
undiagnosed diabetics, or have not
been on their medications in years.
We have had patients with blood
sugar levels off the charts, and many
are having complications with vision
related to their diabetes. We are
fortunate to have optometrists that
do screenings on a regular basis.
Dr. Graap also finds some perks from
working at a free clinic. MICA
provides medical liability insurance
for $100 per year to physicians who
work at facilities where they are not
paid and patients are not charged
for services. State law also shields
volunteer physicians from
malpractice lawsuits, except in cases
of extreme gross negligence. A
PCMS member since 1970, Dr. Graap found
a benefit of his membership when he
secured a donation of several stack-able
chairs, storage cabinets, and a conference
room table after the Society sold its
building to TMC in September.

The heart and soul of Clinica Amistad includes, from left, founding board member
Ricardo Elford, Board President Evan Kligman, M.D., Clinic Manager Alicia Swift, and
Medical Director Rick Graap, M.D.

Another founding member of the Clinica


Amistad team is board member and Clinic
Coordinator Ricardo Elford. He has no
formal education in healthcare, but is an
important part of the team as a
representative of the community. Elford
started Amistad y Salud with Dr. Kligman in
March of 2013.
He is our jack-of-all trades, Swift said. He
performs a lot of patient support functions.
He serves as a translator, provides patients
with information about where they can get
support for things the clinic does not
provide.
While the volunteers are the backbone of
the clinic, its lifeblood is donations. The
fund-raising dinner was on Nov. 14, but if
you missed the event, dont worry, you can
donate anytime through the website.
The donate button on the website, www.
clinicaamistad.org, is always available,
Swift said. Our patients are amazing. We
SOMBRERO December 2015

11

The PCMS conference room table has a new home at Clinica


Amistad. The table was part of a donation that included storage
cabinets and several stack-able chairs.

Additions of new equipment and exam rooms have helped Clinica


Amistad provide more efficient and comprehensive medical
services.

dont ask them to donate, but we get about $350 per month in
patient donations.

and patient donations, Dr. Kligman said. The rest come from
grants and fund-raisers.

Other funding sources include private donations from the


community, and grants. This year the clinic received grants from
The Womens Foundation of Southern Arizona, and the Arizona
Diamondbacks. Southwest Gas selected Clinica Amistad as one of
seven charities included in its Gas Fuel for Life Campaign.
Southwest Gas employees were able to make donations through
payroll deductions.

The clinic does not do annual physical exams, but prevention is a big
part of its future. Dr. Kligman said that he would like prevention to be
at the top of his list for expansion of the clinic in the next five years.

I estimate over 50 percent of our funding comes from individual

12

I think we can ultimately save the community a lot of money


providing workshops, classes, and instruction on how patients can
be proactive in their own healthcare, Dr. Kligman said. Of course
that means reaching out for more provider volunteers in all areas
of healthcare. Based on the support we have received in the last
12 years, I think it is possible to achieve our goals.
n

SOMBRERO December 2015

PCMS News

Pharmacy dean indicted


on sexual assault charges
In French law, and in other
nations with a heritage of
Roman law, one is guilty until
proven innocent. At times its
instructive to remember that in
America, with our heritage of
English law, one is innocent
until proven guilty.
In a case echoing that of recent
allegations against Bill Cosby,
Jessie Lyle Bootman, Ph.D., ScD,.
65, dean of the University of
Arizona College of Pharmacy
since 1987 and a faculty
member since 1978, was
J. Lyle Bootman, Ph.D., Sc.D.
indicted by a grand jury Oct. 28
(UofA photo)
on sexual assault charges,
Tucson.com of the Arizona Daily
Star and other media reported Oct. 28. Picked up by Fox News 10 in
Phoenix and The Associated Press, the story quickly went statewide.
The Pima County Sheriffs Department said Bootman was charged
with sexual assault, sexual abuse, and aggravated assault. He was
arraigned on the day of the indictment. A sheriffs spokesman said
Bootman was not taken into custody or booked into jail, but was
released on his own recognizance pending a Nov. 30 hearing in
Pima County Superior Court, Tucson.com reported.
The sheriffs department said the incident occurred on Oct. 2,
Tucson.com reported, and that the victim is an adult female in her
40s later identified as a real estate agent. Deputy Ryan Inglett said
the victim told detectives that she was sexually assaulted in the

SOMBRERO December 2015

professors home, according to the department. The next morning the


victim awoke with multiple injuries, some indicative of sexual assault,
the agency said in a news release. Deputies responded to meet with
the victim at TMC where she had gone for treatment, Inglett said.
The newspaper website, using court documents, reported that the
woman told investigators she passed out at his house and woke
up in a bedroom the next morning with several injuries. At TMC
she was determined to have suffered a broken nose, injuries to
her lip and a knee, and serious bruising according to a search
warrant filed by the sheriffs department.
The victim told detectives [that] on the night of Oct. 2 she was
having drinks with a friend at a restaurant when Bootman, an
acquaintance, joined her and bought her and her friend a drink.
The woman said Bootman asked if she wanted to see his house,
given that she worked in real estate. They arrived at his house and
gave her another drink, the woman told detectives. After getting a
tour of the house, the woman said she was getting her purse to
leave and thats when she blacked out and does not remember
anything until waking up at approximately 8 a.m. On Oct. 3, the
document states.
The woman said she woke up naked in a bed with blood on her
hand and face and in the bathroom noticed a cut on her nose.
The victim asked Mr. Bootman what he did and he stated [that] you
must have scratched it, the records state. She said she has no
prior sexual relationship with Bootman and did not consent to any
sexual act that night, the newspaper and website quoted from
court documents.
Media quoted Pima County Sheriff Chris Nanos as saying that the
woman was brutally assaulted. On Oct. 29 Lupita Murillo of
KVOA News 4 Tucson reported Nanos calling the case cut and
dried. In the same report Bootmans attorney Brad Roach said the
newly appointed sheriff had made patently false and terrible
misleading public statements about Bootmans veracity. KVOA
also reported that the TMC examining NP called this one of the
worst such cases he has seen.
His client absolutely denies and wrongdoing, Roach said, and in a
reported e-mail said that the dean has a global reputation in the

13

pharmacy field and is shocked and saddened that anyone would


make [such] claims against him or his conduct.

Columnist: ACA in
death spiral
In a piece chosen last month by The Week as among Best Columns
in the U.S., Betsy McCaughey of the New York Post said that the
Affordable Care Act is heading toward a death spiral.
The administration recently admitted that the number of people
enrolled in state insurance exchanges will inch up by around 1
million in 2016to 10 million or sofewer than half the 10 million
enrollees the Congressional Budget Office predicted in March.

Despite federal subsidies to help [enrollees] with premiums and a


hefty increase in the financial penalty for not having [health]
insurance, most uninsured people eligible for ObamaCare are
saying No, thanks.
Younger, healthier Americans arent getting on board because the
premiums are too high, and that in turn is causing a shortfall in the
funds needed to cover the costs of older and sicker enrollees. That
shortfall has led to premium hikes of 30 percent or more in many
states, discouraging even more young people from signing up.
The Obama Administration wont admit this, of course. Instead,
the government will continue to make the ACA look more
affordable than it is by using taxpayer money to subsidize
insurance companies loss-making exchange plans. How much
longer can this obfuscation go on?
Ultimately, trying to sell insurance to sick
and [to] healthy people for the same price is
a strategy destined to fail.

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AMB update

The rules were revised after the boards


significant review of its processes, and with
helpful input from interested stakeholders,
including the Arizona Medical Association.
The new rules have been introduced along
with a new application that reflects the rule
changes and provides clear and concise
instructions to assist applicants in filling out
the application. The new rules modernize
the process by loosening the requirements
for certified documents and allowing for the
electronic submission of documents directly
from a primary source.
In addition, applicants will be permitted to
submit a notarized statement of
identification and a copy of a birth certificate
or passport in lieu of providing certified
documents. Applicants will no longer be
required to submit ABMS certification, AMA
reports or FSMB report; board staff will
obtain these credentialing documents on
behalf of the applicant. The new rules also
allow an applicant to petition the Board for a
waiver if after exercising due diligence the
applicant is unable to provide the required
documentation.
SOMBRERO December 2015

A complete version of the revised rules can be found on the AMB


homepage, www.azmd.gov. AMB is committed to continued
examination of its licensing processes, to eliminate any steps that
do not add value, and seeks continual improvement with regard to
licensing. Now that the new initial application is in place, the board
will be rolling out its online initial application, which will allow an
applicant the ability to file and check the status of the application
electronically.

Andy Tobin appointed director


of state insurance department

Under supervision, both Meritus companies will honor their


individual and group health insurance plans through the end of
2015. As part of the Order for Supervision, Meritus may not issue
new policies or renew existing policies. Current Meritus
policyholders should seek new coverage for 2016 during Open
Enrollment starting Nov. 1.
An affected policyholder may contact the Marketplace to inquire
about a Special Enrollment Period, if the policyholder needs more
time to select a non-Meritus plan. Currently, there are expected to
be eight companies on the Exchange in Arizona, representing
roughly 120 individual plans, and three companies offering
approximately 15 small group plans. There are additional plans
available off the Marketplace.

Gov. Doug Ducey has appointed former Arizona Speaker of the


House Andy Tobin as director of the Arizona
Department of Insurance, ArMAs Medicine
This Week reported Oct. 15. The department
Dr. Matthew Clavenna,
is the state agency responsible for education
and protection of insurance consumers, and
MD
for oversight of the insurance industry in the
state.
Tobin has served as director of the Arizona
Department of Weights and Measures since
January. He has owned and operated a local
Farmers Insurance and his own employee
benefit company. From 2006 to 2015, he
represented rural Arizona in the state House
of Representatives, serving as majority whip,
majority leader, and eventually speaker of the
House from 2011 until 2015. Prior to serving
in the legislature, he was CEO of a local
aerospace company.

Meritus Health
placed under
supervision

From Arizona Department of Insurance


Two Arizona health insurance companies have
been placed under supervision by Arizona
Director of Insurance Andy Tobin.
Tobin filed an Order for Supervision on Oct.
30, 2015, to place Meritus Health Partners
and Meritus Mutual Health Partners into
supervision. Meritus declined to consent to
the Order for Supervision. The Meritus
companies ability to write new policies or
renew existing policies is suspended. CMS has
removed the Meritus plans from the federal
marketplace.
Tobin is appointed as supervisor under
Arizona law and will oversee the two
companies. Meritus has both Preferred
Provider Organization (PPO) and HMO
services that provide coverage for
approximately 59,000 Arizona residents,
mostly in Maricopa, Pima, and Pinal Counties.
SOMBRERO December 2015

Dr. Clavenna was born in Texas but


spent most of his childhood in
Baton
Rouge,
Louisiana.
He
attended Trinity University in San
Antonio for his undergraduate work,
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
15

The Meritus companies were incorporated on Dec. 7, 2012, as


nonprofit corporations for the purpose of becoming Consumer
Operated and Oriented Health Plans (Co-Ops). Meritus received
startup and solvency loans from the Centers for Medicare and
Medicaid Services under the Affordable Care Act in the aggregate
of approximately $93.3 million. The Meritus companies were two
of 23 healthcare Co-Ops formed around the country. The Meritus
entities have yet to make a profit and have lost more than $78
million since their inception.
Its disappointing that the Meritus CEO and board of directors
declined to consent to this order, Tobin said. However, with
Open Enrollment beginning this weekend and many Meritus
policyholders subject to automatic re-enrollment, it was vital that
the insurance department step-in and protect Arizona citizens.
Affected consumers were urged to contact, the Marketplace at
1800.318.2596, work with their agents/brokers, or request help
from a local assistant https://localhelp.healthcare.gov. Questions
about insurance claims, continuation of coverage, health care
appeals, or other issues specific to insurance coverage were
directed to the Arizona Department of Insurance Consumer
Affairs Division at 602.364.2499 (metro Phoenix) or
1800.325.2548 (outside Phoenix).

Medicare 2016 fee schedule:


0.5% raise becomes 0.3% cut
The Medicare Access and CHIP Reauthorization Act (MACRA),
passed earlier this year to repeal the broken sustainable growth
rate (SGR), called for an annual raise of 0.5% for physician pay

from 2016 to 2019. At the time of the passage, it was considered


an improvement over the threatened cuts of 21% under the SGR
formula, ArMA reported.
In the final 2016 Medicare fee schedule released last month, a
0.3% cut was implemented instead. Medscape reports that this
cut occurred because the Affordable Care Act and several other
laws that set Medicare reimbursement policy trumped the
Medicare Access and CHIP Reauthorization Act (MACRA).
When the draft form was released this summer, organized
medicine realized that a pay cut was coming and medical groups
urged CMS to alter its methodology for essentially repricing
codes and calculating the savings so it could hit the 1% target and
avoid canceling the MACRA raise. But, when it released the final
fee schedule, CMS had kept the cuts in place, citing current law
requirements under the federal alphabet soup of MACRA, ACA,
PAMA (Protecting Access to Medicare Act), and ABLE (Achieve a
Better Life Experience).
Meanwhile, medical associations are voicing their displeasure at
the canceled MACRA raise.

ACA update: Open enrollment


grace period a provider
problem
Open enrollment on healthcare.gov for 2016 continues until Jan.
31, 2016. HHS is encouraging all enrollees with current plans to
shop and save by comparing current plans with new plans and
premiums.

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Standard and no-shot allergy treatment
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SOMBRERO December 2015

Arizonans earning up to 400 percent of the federal poverty limit


are eligible to receive federal subsidies to help cover their
insurance costs which, on average, are expected to rise 17.5% in
Arizona, compared to 7.5% nationwide. Whether obtaining a new
plan or renewing an existing plan, consumers are encouraged to
shop the marketplace to find the option best-suited for their
needs. The Cover Arizona website offers resources to help
consumers navigate options online, as well as access to locating a
local application assistant.
Recent reports on June 2015 federal data indicate that more than
22 percent of ACA enrollees had dropped their insurance
coverage. Federal regulations allow enrollees a three-month
grace period during which coverage is active even if premium
payments are not made. Insurers must cover care provided

SOMBRERO December 2015

during the first month of the grace period, while providers are
responsible for the remaining two months. Providers have raised
concerns that large numbers of enrollees could receive care
during the grace period without ever paying their premiums,
leaving providers at risk of absorbing the cost of care.
Please encourage your patients to remain current on their
premium payments in order to retain their insurance coverage.
Have your office staff check patient insurance status and
information. Additionally, while participating in an exchange may
be voluntary, physicians may not be certain what plans they are
participating in, and should review their contracts or directly
contact insurance companies to determine what marketplace
plans include them as part of the network.
n

17

Arizona Medical Associaon News

Nurses groups seek


scope-of-practice expansion
The Arizona Nurses Association, along with several other nursing
organizations, has submitted an application for a legislative
change allowing a major scope of practice revision for several
categories of advanced practice nurses, ArMAs Medicine This
Week reported Nov. 6.
It is a sunrise process application, a unique Arizona legislative
process that requires any group seeking certification or an
expansion in its scope of health care practice to notify the
legislature prior to its convening session.
The scope-of-practice request applies to the categories of
Certified Nurse Midwives, Certified Registered Nurse
Anesthetists, Certified Nurse Specialists, and Nurse Practitioners.
Requested changes range from a new definition of
collaboration with physicians to complete independent practice
privileges and full prescriptive authority.
ArMA has mobilized staff and leadership to evaluate these
changes and has been undertaking a medically comprehensive
assessment to determine the potential impact on patients and
their safety in all aspects of the extensive scope revision the ANA
and others are seeking. Elements of this request clearly move
into traditional areas of physician care without requiring the
commensurate training or experience.

Over several weeks we will provide details on all aspects of their


proposal and may seek your input on specific changes being
requested. We will keep you fully up to date through Medicine
This Week on ArMA activities and plans. If you would like more
information, or to review the applications, e-mail or call Pele
Peacock Fischer, vice-president of policy and political affairs, at
pele@azmed.org or 602.347.6910.

ArMA urges congressional


action on Stage 3 MU
shortcomings
ArMA has joined a coalition of 111 medical societies led by the
AMA asking Congress to address shortcomings in the Stage 3
Meaningful Use final rule. Among ArMAs main concerns are the
limited focus on advancing inter-operability, and the apparent
unwillingness of the Department of Health & Human Services
and CMS to respond to stakeholder feedback in a meaningful
way.
In the view of the coalition, urgent congressional action to refocus the Meaningful Use program is necessary in order to
prevent physicians from abandoning the program completely due
to the near impossibility of compliance with meaningless and illinformed bureaucratic requirements. The coalition contends that
Stage 2 has largely been a failure, with only 12 percent of
physicians successfully participating and little improvement in
data exchange across care settings.

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SOMBRERO December 2015

Relying so heavily on the failed construct of Stage 2 will only


guarantee continued failure in Stage 3. Letters to congressional
leadership are available, and media coverage can be read at
Health Data Management and MedCity News. The letters to
Congress follow the recent unveiling of the AMAs comparative
evaluation of electronic health record product design and
usability testing, intended to promote transparency. Read more
at AMA Wire for Oct. 17, 2015.

ArMA joins national groups


urging support under MACRA
Along with other state medical associations and national groups,
the Arizona Medical Association has joined the AMA in
submitting to HHS Secretary Burwell and CMS Acting
Administrator Andrew Slavitt a letter regarding the funding of
quality measure development and technical assistance to small
practices under the Medicare Access and CHIP Re-authorization
Act of 2015, or MACRA Public Law 114-10.
Timely and targeted funding for these two activities is critical to
the success of physician payment reform. The letter is a follow-up
to a May 18, 2015 inquiry, to which there has been no response
to date. The letter urges the release of monies already designated
for funding, and underscores concerns about engaging the
physician community and how MACRA-related mandates can be
adequately met.

ArMA joins groups urging


improvements to NAIC
model act
Along with other state medical associations and national groups,
ArMA has joined the AMA in submitting to the National
Association of Insurance Commissioners a letter regarding its
work to revise its 1996 network adequacy model act to be used
by state legislatures in upcoming legislative sessions.
The latest draft of the model act has been approved by NAICs
network adequacy subgroup and is now moving to the parent
committees for consideration. It makes a number of important
changes, but additional requirements are needed to ensure
meaningful access to care.
ArMA signed onto this letter to encourage adoption of the most
meaningful network adequacy requirements possible. The letter
outlines priorities for further improvement to the bill, including:
1. Require prior approval of networks before health plans are
sold,
2. require states to institute measurable quantitative
standards for network adequacy, and
3. include stronger protections for tiered networks.
These priorities are shared among many stakeholders. The letter
was crafted to demonstrate broad and strong support for these
additional changes to the model act before it reaches state
legislatures.
SOMBRERO December 2015

Preparing for
prescribing report card
Arizona law requires all medical practitioners, including MDs and
DOs, who are licensed under Title 32 and who possess a DEA
registration, to also possess a current Controlled Substances
Prescription Monitoring Program (CSPMP) registration issued by
the State Board of Pharmacy.
Earlier this year, ArMA reported in AzMedicine on the
Prescription Drug Monitoring Program (PDMP) Report Cards
being expanded by the Arizona CSPMP. The PDMP Report Card
offers all prescribers the opportunity to review their prescribing
patterns in relation to the average data of other prescribers in
their specialty type.
The State Board of Pharmacy operates the CSPMP and, as part of
their work to meet new legislative requirements, distributes the
Prescriber Report Card to all registered prescribers. They need
your help to update to e-mail addresses for all registrants. Please
register or log-in to verify that your email address is on file with
CSPMP at https://www.azrxregistration.com/Login.aspx.

Amicus update: Federal judge


blocks SB 1318
In November a federal district court judge issued a preliminary
injunction to officially block Arizona law SB1318. A trial originally
scheduled on the law was canceled.
This law would require physicians to tell their patients, both on
the phone and in person, that it may be possible to reverse the
effects of a medical abortion. In June, a lawsuit was filed against
the legislation by Planned Parenthood and three Arizona
physicians. The lawsuit alleges the law violates physicians First
Amendment rights as it forces them to communicate a statemandated message that is not medically or scientifically
supported.
The lawsuit further alleges the law violates patients 14th
Amendment rights because they are getting false, misleading
and/or irrelevant information.
ArMA has determined that SB1318 requires physicians to present
non-peer reviewed, questionable medical information that could
be both misleading and dangerous for patients. In accordance
with this, ArMA has joined the AMA and the American Congress
of Obstetricians and Gynecologists as a friend-of-the-court in
support of legal action to stop implementation of the
requirements set forth in SB1318.
According to court records, one reason the state has asked to
postpone the trial is because the research director of the
abortion pill reversal program was found to lack the publication
and research background and experience to be qualified as an
expert witness.
n

19

Behind the Lens

Taking photos of your honeythe one with


wheels

By Hal Tretbar, M.D.

hotographing automobiles can be as


challenging as taking a pleasing person
portrait or shooting a stunning landscape.
Location of the shoot is very important, but
overall its still about lighting, composition
and technique.

I was looking for locations when I spotted this yellow and purple wall on a
furniture store. The store gave me permission to photograph and moved several
parked cars. The magazines art editor had asked for an artsy image, so I laid on
the ground and shot with a wide angle of 27mm for distortion. I lined up the purple
line to meet the bottom of the windshield and kept the yellow bricks perpendicular
on the left edge. I used manual focus at f.16 to ensure depth of field. ISO was 640
with color balance set on cloudy weather to warm up the overcast. The editors like
it so much that they gave it a two-page spread to introduce the seven-page article.

Why are you taking the photo? Is it just to


save a memory of the rare Ferrari at a car
show? It might be showing your buddy on the
racetrack. Is it because you just waxed your baby? Or will you
need a series of images to illustrate a story. The result should
speak for itself.

Weve been in Tucson for a long time, and I have been able to find
some great locations for car photography. I like an area that
doesnt have distracting elements such as buildings in the
background. Usually the light is best early or late in the
day, so keep that in mind.
The most common angle for an auto image is a three
quarters front view with either a slightly high aspect, or
low enough to show some light under the car. But I
usually take side and rear views if possible. I also take
both slight telephoto and mild wide angles to see which
proportion looks best.

On another overcast day, we used a strip of limited access highway for a


driving session. Jill drove with the lights on at about 20 mph. I shot from the
back of a Honda van with the rear door up. The camera settings were ISO
200, f.18 and shutter priority of 1/30th second to blur the background. The
lens was set on vibration reduction at 85mm to keep the car sharp.
20

Several years ago I had an assignment to photograph


a rare Porsche for a story in Excellence Magazine, the
national magazine about Porsches. Jill Davis-Curtis
from Tucson owned a unusual German adaptation of
a 1982 Porsche 930 Turbo called a Porsche Evex. The
magazine did an extended story about the Evex with
five of my images. Here are three (photos A, B, and C)
that were shot over a weekend with perfect overcast
light. They show the importance of location. I used a
Nikon D80 for all.
So the next time you want to shoot an automobile
portrait, put some thought into it. You will enjoy the
result a whole lot more!
SOMBRERO December 2015

Dorothy and I had recently picked up our


first Porsche at the Zuffenhausen factory in
1959. We wanted a nice setting for a formal
portrait of our Guards Red 356 A. We found the
perfect spot by driving on this little path below
a typical Bavarian Castle. I angled the car so
we were looking down slightly with a front
view. It was shot with a Rolleiflex on 120
Agfacolor negative film and converted to
black-and-white.

I wanted to show that my 2008 Cayenne S


with Martini Racing Stripes was not just a
highway vehicle. Dorothy and I were in
Garner Canyon with great late afternoon
stormclouds. I put the Cayenne on top of a
small hill to show the s curve trail leading
into the tantalizing distance. I made sure the
roof was not above the skyline. I used a Nikon
D600 with 28-85 lens at 38mm, ISO 400 and
1/640th second at f13.

I arranged for a location shoot at the Franklin


Automobile Museum, one of Tucsons unknown
jewels, which we have featured in Sombrero.
Here is a contrast of two air-cooled cars: a 1931
Franklin Model 153 Coupe, and a 1982 Porsche
Evex. I used a ladder to set the composition. The
Franklin was lined up so you can see the spare
tire and trunk line meet the intersection of Jill
and the Porsche roof. I had a Nikon SB600 flash
on the camera to light the wheels and Jills
color-coordinated

SOMBRERO December 2015

21

I wanted a moonlit image of my 1987 911


Carrera Targa. The best view was from the
Babad-Doag turnout partway up the Mount
Lemmon highway with the full moon shining
over the Rincon. I used a Nikon D80 with a
55-200 Nikkor at 55mm (85mm full-frame
equivalent) on a tripod, 3 seconds at f.6.3 with
ISO 640 and flash fill. I used Photoshop to even
out the light on the foreground. Note the
moonlit backlighting.

I recently worked with professional automobile


photographer Mike Maez. Mike takes many of the
images you see in the catalogs put out by Gooding
and Co. Auctions. He photographs as many as 30
cars before the three or four national auctions per
year. He was in town to photograph a white 1955
Porsche 356 Pre A Speedster that has been
restored by local expert Chuck Croteau. It will be
auctioned at Scottsdale in January 2016 and is
expected to bring between $300,000 and
$400,000. We were looking for a place where we
could shoot the Speedster with a background of
stormclouds over the Catalinas. We finally found
it after driving around the Alvernon and River
Road area for awhile, though the location is a
closely guarded photographers secret! I used a
Nikon D600 with 24-85 lens at 36mm, ISO 250,
1/800th second at f14, using the spot meter on the
bright white car.

When the Southern Arizona Region of the


Porsche Club of America had a display at the
Pima Air and Space Museum, there was an
opportunity to shoot sports cars against fighter
planesfor posing, not racing! Here is retired
Air Force pilot Ron Sable with his 1988 Porsche
930 Turbo Coupe with an F86 Saberjet. I used a
Nikon D70 with unknown lens at 33mm on a
tripod with flash fill, 1/80th second at f.14 with
ISO 200.

22

SOMBRERO December 2015

Makols Call

The doc, the patientand theyre both me


By Dr. George J. Makol

ften in the past Ive either


heard or read the phrase,
My whole world was turned
upside down. Until recently, Id
not found any deep, personal
meaning in this phrase. It
sounded like an Alice in
Wonderland phenomenon in
which up was down and down
was up.

top it off, the airline moved our trip up by two hours on short
notice, cutting our sleep severely the night before our ridiculously
early morning takeoff. At least there were no flying birds to be
sucked into the enginethey were all still sleeping in the trees
when we took off.
For the last couple of years Ive had a borderline hypertension
condition, a borderline elevated cholesterol, and some have
claimed even a borderline personality disorder. I truly do wish
that my IQ had been going up as fast as my blood pressure
reading and cholesterol numbers. I also cant figure why I am
growing so much hair on my ears and so much less hair on my
head. But I digress. My main point is that eventually, every one of
us will become a patient, and perhaps this can be a learning
experience.

I could be talking here about


todays topsy-turvy world, in
which a Russian dictatorial
midget is an acknowledged
world leader; Germanys Angela Merkel is de-facto leader of the
free world; and in which an obvious seven-year vacuum of
American leadership has opened the way to genocide at a level
not seen since World War II.
But Im not.
I write here not about the world stage but about something more
important on a personal level. I recently had an experience that
probably every physician will eventually
have, if one lives long enough. After 40
years as an M.D., giving patients almost
The Faces
daily advice and counsel, I found myself on
the receiving end, and to boot in real
trouble. I ended up in the hospital!
To begin, I quote the greatest-ever oneliner comedian, Henny Youngman, who
said, I went on a pleasure trip the other
day; I took my mother-in-law to the
airport. Earlier this year, my wife and I did
take my mother-in-law to the airport, and
we accompanied her on perhaps her last
trip back to the Midwest. I do not wish to
give the wrong impression; I happen to
have a terrific mother-in-law, probably
mostly because I saved her from the
internist/gastroenterologist who was trying
to manage her asthma a good seven or
eight years before I met her daughter. She
really hasnt had a wheeze since, and hence
she never really complains about me, her
son-in-law, no matter what I do.
My mother-in-law, however, does have
severe osteoarthritis and very limited
mobility. So preparing for this trip involved
lots of planning, including setting up
wheelchairs, arranging for porters, and for
first-class seats in the front of the plane. To
SOMBRERO December 2015

Some of you may remember the 1991 movie The Doctor,


starring William Hurt, playing a successful doctor who suddenly
was diagnosed with cancer and has a harrowing experience with
the medical field, including his colleagues. The head of my clinic
department insisted the entire staff go see the movie so we
would have increased compassion for the people we take care of.
Frankly, seeing the movie just made me never want to go in the
hospital, unless it was to get a free lunch in the doctors lounge.

of Casa are the

James Nicolai, M.D.


Associate Medical Director

As a hospice physician, it is
incredibly satisfying to work with
a team of individuals totally
devoted to easing suffering for
patients and their loved ones.
This is why I became a doctor in
the first place.

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

23

There is no free lunch, and it was lunch at my favorite barbecue


restaurant in Ames, Iowa, just after landing, where we resume our
story. We did arrive safely and in one piece, and of course my first
stop was barbecue. I no sooner ordered a glass of water and a Diet
Coke, when it suddenly felt like pro wrestler Hulk Hogan grabbed
me by the throat and was holding me up in the air. I could barely
breathe, and since Iowa is flat, I can guarantee you it was not the
elevation.

they admitted me upstairs for observation, but the pressure in my


throat never went away. Therefore, being a doctor, I negotiated by
cell phone with the admitting doc, who finally said, I am going to
give you some Ativan [a benzodiazepine type tranquilizer]
intravenously. At the time I thought this was ridiculous because
the problem was not in my head, it was in my neck, but sure
enough five minutes after the intravenous Ativan everything went
away. I am pretty sure that no matter what you have, after
intravenous Ativan it would go away too.

I did not touch my plate, and so my wife knew there was really
something wrong with me, and she said, Im going to take you to
Mary Greeley Hospital. Its a great hospital. I was born there, Of
course she neglected to tell me she had not been back there since
she was born, so we rode around for a bit looking for the hospital,
all the while Hulk Hogan still holding me by the throat. Finally, after
following one of those posted H for Hospital signs, we arrived at
the emergency department, and once they knew I was insured I
was whisked into a treatment room, and greeted by a lovely Aussie
nurse. Now I had just come back from Australia so we had a great
time talking about her country, but she did pause to tell me my
blood pressure was 198/104 and my pulse 120.

The story does have a happy ending. I passed a stress test on the
third day in the hospital, have no evidence of cardiovascular
disease, and my Tucson cardiologist thinks that it was a muscle
spasm in my neck. Interestingly, they did discharge me on no
medications, but luckily I was headed to Cedar Rapids, where I
have a friend who is a cardiovascular surgeon. He saw me as a
patient that next day, and immediately joked that because he was
a surgeon, he really didnt know much about treating hypertension,
but then proceeded to dazzle me with his knowledge of cardiovascular physiology. One beta blocker later my pressure was
controlled, and my pulse fell from 118 to 69 BPM.

This was followed by an IV, nitroglycerin under my tongue and


smeared on my arm, CT scans to rule out pulmonary embolism,
EKGs, enzymes, and lots more that I cant remember. My favorite
moment was when the nurse asked me the last time I was in the
hospital, and when I told her 1965, she blinked and told me that
she wasnt even born then. I doubt even her mother had been
born by 1965.

I would like to point out that I was covered by Medicare and a good
AARP supplement policy, and out of the $11,000 bill for just five
hours in the ER, not counting the hospital stay, I have been billed for
$17.65 so far; they have even offered me a payment plan! Medicare
is a terrific insurance, not free, but available at a reasonable
monthly cost, and of course I have paid 2 percent of my income for
the last 20 years in Medicare taxes before ever being covered.

BUZZING

My blood pressure came right down, the tests were all normal, and

Perhaps instead of the Affordable Care Act with its crummy


coverage, average $6,000-per-person
deductible, and limited physician panels
BUZZING
available, the politicians could have just
TINNITUS
dropped the Medicare age from 65 to 60.
This could have been done for a two-year
TINNITUS
experiment to see the net costs, and this
probably wouldve been negligible compared
the to quatrillions that the Affordable Care
Act is costing.
BUZZIN

RINGING

TINNITU

RING
BUZZ
TINNITUS

BUZZING

RING

HUMM

RINGING
HUMMINGGING

Your patients
deserve the
best hearing
care possible

RIN

NG
UMMI

USG
T
I
N
IN
IN

BUZ

G
N
I
G

We offer
comprehensive
tinnitus
consultations.

RINGING

HUMMING
RINGING
G

HUMMING

TINNITU

RINGING

BU

HU ZZING
MM
ING

IN
Learn more about why we are a
R
preferred audiologistplease visit our website: www.arizonahearing.com
We are preferred providers
on most insurance plans.

520.742.2845

7574 N La Cholla Blvd Tucson

520.742.2845

6969 E Sunrise Dr, Ste 203 Tucson

520.648.3277

Helping you hear your best.

512 E Whitehouse Canyon Rd, Ste 196


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

24

The next step could have been dropping the


age from 60 to 55, and so on. Since Medicare
has no preexisting disease clause and
everyone pays into it, and considering that
the government is finally looking into
Medicare fraud, I think this wouldve been a
much better solution than the monstrosity
written by the health insurance corporations
lobbyists, and jammed through our hapless
Congress by one party holding a tenuous
majority.
I remember that one of our Society members
wrote in some time ago that at least they
did something.
Really?
Sombrero columnist George J. Makol, M.D.,
a PCMS member since 1980, practices at
Alvernon Allergy and Asthma, 2902 E.
Grant Rd.
n
SOMBRERO December 2015

MAYO CLINIC CME

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 essentials of coccidioidomycosis with an update
on how to manage infections encountered in the outpatient
setting. 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 moretools to help you
recognize and prevent spread of emerging infections; antimicrobial
stewardship; whats new in infectious diarrhea; update on UTIs;
whats new in management of skin, soft tissue and MRSA
infections; antibiotic prophylaxis for primary care; and 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 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.

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 .

March 2016
March 16-10: The 27th Annual Family Medicine and Internal Medicine
Update is at Westin Kierland Resort & Spa, 6902 E. Greenway Pkwy.,
Scottsdale 85254. Accreditation from AMA, AOA, AAFP.
Four-day course features the most recent medical update and
management strategies for various diseases, presenters say.
Program includes didactic lectures, Q&A panel discussions with
interactive format allowing for immediate audience participation,
Meet the Preceptor (MTP) luncheons for one-on-one interaction
with faculty, and various afternoon breakout sessions.
Contact: Mayo School of CPD, 13400 E. Shea Blvd., Scottsdale
85259; phone 480.301.4580; fax 480.301.9176. Website: http://
ce.mayo.edu/node/4985 mca.cme@mayo.edu .
March 31-April 2: Tackling Problematic Sinusitis: Module-Based
Solutions is at Mayo Clinic Education Center, 5777 E. Mayo Blvd.,
Phoenix 85054; phone 480.301.8000. Accreditation from AMA,
AOA, AAFP.

Website: https://ce.mayo.edu/surgical-specialties/content/enhancingrecovery-after-surgery-improving-quality-recovery-patient-2016

Mayos fifth symposium on challenging sinus disease is a modulebased approach to problematic sub-types of sinus disease. Experts
present latest research in patho-physiology and treatment, and a
live prosection, and hands-on nasal endoscopy training for medical
providers will be offered.. World leaders in otolaryngologyrhinology, allergy-immunology and basic sciences address most
challenging aspects of managing sinusitis and other rhinologic
disorders. Program includes expert debates and brainstorming
sessions using interactive formats with the goal of synthesizing
innovative management strategies based on the latest evidence,
and experience of global experts.

Feb. 25-28: Mayo Clinic Gastroenterology and Hepatology 2016 is


at Westin Kierland Resort & Spa, 6902 E. Greenway Pkwy.,
Scottsdale 85254. Accreditation TBD.

https://ce.mayo.edu/otorhinolaryngology/content/tacklingproblematic-sinusitis-module-based-solutions-2016
Contact: Mayo School of Continuous Professional Development,
Mayo Clinic Scottsdale,

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

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
SOMBRERO December 2015

13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax


480.301.9176.
mca.cme@mayo.eduhttps://ce.mayo.edu
25

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.

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SOMBRERO December 2015

IMAGING 2016

Enhanced Care with


Advanced Imaging

Youre
Invited!
Marcus J. Dill-Macky, M.D.
Breast Cancer Screening:
What if I Do Nothing?

Saturday, February 20, 2016


7:00AM - 12:00PM
Breakfast Buffet Provided
Westin La Paloma
3800 E. Sunrise Drive
Tucson, AZ 85718

RSVP to Professional Relations


at 520-545-1836 or online at
www.radltd.com/cme2016
This symposium is free of charge
and is being held to educate
physicians and providers on updated
imaging modalities and techniques.

Chad A. Kohl, M.D.


What You Dont See Can Hurt
You: MRI of Radiographically
Occult MSK Pathology

Mark S. Peterson, M.D.


Low-Dose CT Lung
Cancer Screening

Creed M. Rucker, M.D.


Treatment of Stroke

Jason E. Wright, M.D.


3T MRI: Current
Applications in Prostate
and Abdominal Imaging

A TUCSON TRADITION FOR MORE THAN 80 YEARS

SOMBRERO December 2015

27

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Holiday Greetings and Best Wishes


for a healthy and prosperous New Year.

(602) 956-5276, (800) 352-0402


www.mica-insurance.com

28

SOMBRERO December 2015