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Sombrero

Pima County Medical Society
Home Medical Society of the 17th United States Surgeon-General
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SOMBRERO
2 – November 2015 SOMBRERO – December 2016
17
2014
Sombrero
Pima County Medical Jerry Hutchinson, DO
Official Publication of the Pima County Medical Society

Members at Large At Large ArMA Board
Vol. 49 No. 10

Society Officers Roy Loewenstein, MD Charles Krone, MD Robert M. Aaronson, MD
Kevin Moynahan, MD Clifford Martin, MD R. Screven Farmer, MD
President
Timothy C. Fagan, MD Snehal Patel, DO
Wayne Peate, MD Board of Mediation Pima Directors to ArMA
President-Elect Timothy C. Fagan, MD
Michael A. Dean, MD Kenneth Sandock, MD Thomas Griffin, MD
Vice-President Sarah Sullivan, DO Evan Kligman, MD
Delegates to AMA
Susan J. Kalota, MD Salvatore Tirrito, MD George Makol, MD Timothy C. Fagan, MD (alternate)
Secretary-Treasurer Debra Townsend, MD Sheldon Marks, MD Gary R. Figge, MD
Unfilled / Appointment Fred Van Hook, MD Mark Mecikalski, MD Michael F. Hamant, MD (alternate)
Past-President Scott Weiss, MD Thomas H. Hicks, MD
Melissa D. Levine, MD Leslie Willingham, MD Arizona Medical
Jaren Trost, MD (Resident) Association Officers
PCMS Board of Directors Aditya Paliwal, MD (alt. resident) Michael F. Hamant, MD
David Burgess, MD Jared Brock (student)   Vice President
Howard Eisenberg, MD Thomas C. Rothe, MD
Kelly Ann Favre, MD   Outgoing Past President

Executive Director Editor Printing SOMBRERO (ISSN 0279-909X) is published monthly
except bimonthly June/July and August/September by the
Bill Fearneyhough Bill Fearneyhough West Press Pima County Medical Society, 5199 E. Farness, Tucson,
Phone: (520) 795-7985 I welcome your feedback and story ideas. Phone: (520) 624-4939 Ariz. 85712. Annual subscription price is $30. Periodicals
paid at Tucson, AZ. POSTMASTER: Send address changes
Fax: (520) 323-9559 E-mail: billf 5199@gmail.com E-mail: andyc@westpress.com to Pima County Medical Society, 5199 E. Farness Drive,
E-mail: billf 5199@gmail.com Ste. 151, Tucson, Arizona 85712-2134. Opinions expressed
Publisher are those of the individuals and do not necessarily represent
the opinions or policies of the publisher or the PCMS Board
Pima County Medical Society
Advertising Art Director 5199 E. Farness Dr., Suite 151
of Directors, Executive Officers or the members at large,
nor does any product or service advertised carry the
Dennis Carey Alene Randklev Tucson, AZ 85712 endorsement of the society unless expressly stated. Paid
advertisements are accepted subject to the approval of the
Phone: (520) 795-7985 Phone: (520) 624-4939 Phone: (520) 795-7985 Board of Directors, which retains the right to reject any
Fax: (520) 323-9559 Fax: (520) 624-2715 Fax: (520) 323-9559 advertising submitted. Copyright © 2016, Pima County
Medical Society. All rights reserved. Reproduction in whole
E-mail: dcarey5199@gmail.com E-mail: alener@westpress.com Website: pimamedicalsociety.org or in part without permission is prohibited.

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Inside
 5 Dr. Timothy C. Fagan: The past, present and future of
PCMS and Sombrero.

11 UA College of Medicine: Dr. Charles Cairns provides
information on expanding academic medicine in Tucson.

13 Dr. Francisco Garcia: Getting a flu shot is the
responsible thing to do.

14 Makol’s Call: Finding inspiration from industrial
billionaires.

16 Behind The Lens: Dr. Hal Tretbar has fond memories of
his contributions to Sombrero.

18 Road Trip: Head to Keeylocko to experience the
authentic Wild West.

21 In Memoriam: Remembering Dr. John F. Carroll.

22 UA Health Sciences: Pain management specialists are
offering alternatives to addictive opioids.

24 Healthcare Business: Providers should be making
patient access a priority.

25 Practice Policies: One physician offers five ways to On the Cover
engage patients.
Here’s a wonderful image of Spider Rock in Canyon de
26 Physician Training: Should residents be working fewer Chelly. Dr. Hal Tretbar snapped it with his 120 Rolleiflex
hours? during a 1972 visit.

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4 SOMBRERO – December 2016
Pima County Medical Society, Past,
Present and Future:
The Evolution of the PCMS and Sombrero
By Dr. Timothy C. Fagan, PCMS President

W
hy the history for county medical societies to be established in every
lesson? There U.S. state and territory, stating that it was “the
have been responsibility of professionalism to belong to a county
significant changes in the medical society.” The county medical societies would
Pima County Medical be constituents of their respective state or territorial
Society (PCMS) recently societies. The state and territorial medical societies
and more will occur in the would then elect delegates to the AMA. This basic
near future, including the structure persists to this day, even though delegates
consolidation of Sombrero from specialty medical societies, medical students and
magazine with the publica- medical residents are now elect to the AMA.
tions of the Arizona Medical
At its annual meeting in April 1904, ArMA called for the
Association (ArMA) and
formation of county medical societies in Arizona. On
Maricopa Medical Society
October 13, 1904, seven physicians met and adopted
(MCMS). This is part of an
the constitution and bylaws for the Pima County
ongoing evolution, so I
Medical Association. The mission statement included
thought it was important to explore the relationships
“…so that the profession shall become more capable
among the medical societies, changes in the medical
and honorable within itself, and more useful to the
care environment in Pima County, Arizona and the U.S.
public, in prevention and cure of disease, and in
These changes are interrelated with changes in society
prolonging and adding comfort to life.” The original
and methods of communication, which have also
members were William V Whitmore, MD, President;
evolved significantly during the last 170 years.
Arthur W Olcott, MD, Vice President; Joseph W
1847-1904 Lennox, MD, Secretary-Treasurer and charter
members Henry E Crepin, MD; Hiram W Fenner, MD;
The evolution of the Pima County Medical Society
Walter B Purcell, MD; and Mark A Rodgers, MD. Dr.
(PCMS) and Sombrero have paralleled the evolution of
Rodgers later founded The Rodgers Hospital, the first
clinical practice in Pima County and the evolution of
hospital in Tucson with obstetrical services.
national and international clinical communication.
Pima County almost had the first county medical The first functional typewriter was constructed in 1808,
society in Arizona. Mariano Samaniego, MD moved but typewriters were not successfully marketed until
from what is now Ciudad Juarez, Chihuahua, Mexico 1874. In 1904 a typewriter cost about $68, equivalent to
to Tucson in December 1878. The medical community about $1,700 today and did not come into widespread
was very small, and Tucson lacked a modern hospital. use until the 1920s. Consequently, in 1904, the
Dr. Samaniego was involved in the effort to create founding documents of PCMS were hand written.
what was to become St Mary’s hospital, the first
ArMA had already printed standard charters containing
“modern” hospital in Tucson, which was established in
the word “Society,” so the name was changed from
1880. On July 29, 1879, Dr. Samaniego hosted a
Pima County Medical Association to Pima County
meeting to explore the possibility of creating a county
Medical Society. In 1904, Yavapai and Maricopa
medical society. In September, 1879, Dr. Samaniego
Medical Societies reorganized according to the
suffered a family tragedy and returned permanently to
guidelines proposed by the AMA.
Ciudad Juarez.
Multiple historic events and movements affected the
The honor of forming the first county medical society in
medical environment before the turn of the 19 th
Arizona may belong to Yavapai County. Differing
century. The first Medical School for Women, the New
accounts date the formation of the society to either
England Female Medical College, was founded in
1884 or 1893. The Maricopa County Medical Society
1848. The first U.S. Female Dentist, Lucy Hobbs
(MCMS) was formed in 1892. The Arizona Medical
Taylor, began practicing in the 1850s. In the U.S., the
Association (ArMA) was establish+ed on May 25, 1892.
first formal meeting of activists for women’s rights took
The AMA was formed in 1847 and underwent place on July 19-20, 1848. Approximately 100 people
reorganization in 1901. That same year, AMA called attended, about two-thirds were women. The meeting

SOMBRERO – December 2016 5
resulted in a “Declaration of Sentiments, Grievances An important component of women’s rights is
and Resolutions.” One statement in this document contraceptive needs and rights, which had become a
was: “We hold these truths to be self-evident that all political issue as early as the 1860s. In 1873, the
men and women are created equal.” In 1869, the 15 th Comstock Act prohibited advertisements, information
Amendment to the U.S. Constitution granted the right and distribution of birth control. In 1916, Margaret
to vote to African-American men. Sanger opened the country’s first birth control clinic
but a year later was sentenced to 30 days in jail for
Andrew Taylor Still founded Osteopathic Medicine in
“maintaining a public nuisance.” After being released
1874. He established the first osteopathic medical
from jail, she reopened the clinic but continued to be
school in 1892, as a protest against the medical
arrested and prosecuted multiple times.
system of his day. The American Osteopathic
Association was founded in 1897. The medical school In the autumn of 1934, a meeting of Tucson women was
bearing Dr. Still’s name continues to train osteopathic held for consideration of establishing a birth control
physicians to this day. There are two schools in clinic. The meeting was attended by Margaret Sanger.
Arizona, one Mesa and another in Glendale. The decision was made to establish the clinic and a
Osteopathic medical schools continue to train a higher Board of Directors was elected. In December 1934, at a
percentage of primary care physicians, compared to special meeting of PCMS, a motion was passed
allopathic medical schools. supporting such a clinic. The Chairman of the Birth
Control Clinic of Tucson, Mrs. Marion Smith, appointed
1905-1954
three members of PCMS as the clinic’s Medical
During the years 1905-1954, most physicians in Pima Advisory Board. A building was rented and refurbished
County belonged to PCMS and its meetings were the to house the new clinic, but making women aware it
primary means of communication among physicians. existed was difficult. Word of mouth was the only means
From 1920 to 1928, World War I veterans were treated available, since the Comstock Act was still in effect. In
at Pastime Park Hospital, a refurbished amusement 1938, a judge lifted the Federal ban on birth control,
park on Oracle Road, north of Tucson. Primary medical and in 1939, PCMS passed a motion for use of
conditions of these veterans were poison gas contraceptives. Later the Birth Control Clinic of Tucson
inhalation, tuberculosis and residual effects of Spanish became the local chapter of Planned Parenthood.
Influenza. As a result of the severity of diseases and
1955-1969
the limited treatments available, many of the veterans
did not survive. In 1928, the Tucson VA Hospital was New medications became available in the 1950s and
commissioned. Founded in 1926, the Desert 1960s. These included new oral agents and longer
Sanatorium primarily treated patients with tuberculosis. acting insulins to treat diabetes, beta agonists and
In 1944 the Desert Sanatorium became Tucson methylxanthines to treat asthma and COPD, beta
Medical Center. Several of the original buildings are blockers along with centrally acting agents and alpha
still in use. As more hospitals were built and became a blockers for hypertension. New diagnostic techniques,
major site of patient care, informal discussions in the including radionuclide and ultrasound imaging,
doctors’ lounge and on the wards became another became available.
method of communication among physicians. All of the
During the Administration of Lyndon Johnson,
monthly hospital medical staff meetings were held on
Medicare was enacted in 1965.
Tuesdays, and became another means of physician
communication. PCMS meetings were scheduled for a Membership in the PCMS increased to 280 by 1963
different Tuesday of each month in order to avoid and to about 750 in 1967. The UA College of Medicine
conflict with the hospital medical staff meetings and (COM) admitted its first class in 1967. In the autumn of
continue to be held on Tuesdays to this day. On its 50 th 1968, the University Hospital was still a large hole in
Anniversary in 1954, PCMS had 200 members. the ground. A significant portion of the Tucson faculty
came travel from other universities just long enough to
In 1916, Montana’s Jeanette Rankin was the first
teach their courses and then return home. The hospital
woman elected to the U.S. Congress. She took office in
was completed in 1971, two months after the first
1917, three years before the 19 th Amendment to the U.S.
medical school class had graduated.
Constitution granted her, and all women in the U.S., the
right to vote. As women gradually acquired more rights The 1960s brought new attention to interracial
and educational opportunities, their role in society problems. After many years of effort by legislators,
expanded. In Tucson, one manifestation of this was the physicians, educators and others, passage of the
formation of the 15-member PCMS Auxiliary in 1931, an Voting Rights Act in 1965 prohibited many
organization of physicians’ wives. In the 1990s, as part discriminatory practices including limiting the ability of
of a national movement in which doctors’ wives became African-Americans to vote. African-American medical
“allies,” the name was changed to PCMS Alliance and students were rare. UCLA’s 1969 class had only one
during the coming years membership increased more minority student out of 104. Women represented less
than tenfold. Unfortunately, education of female than 10% of medical students entering the UA COM in
physicians lagged far behind. 1967 and four of 104 entering UCLA in 1969.

6 SOMBRERO – December 2016
Although television became available in the late
1940s, offerings were very limited. The number of
television stations in Phoenix increased from two to
Why choose
four in the 1950s. The early 50s saw the premier of
medical TV dramas City Hospital and The Doctor but
Desert Mountain Insurance?
both were short lived. The very popular shows Dr.
Kildare and Ben Casey premiered in 1961.
see why our customers did...
The first issue of Sombrero was published in October
1967, providing a new means of communication for
physicians in Pima County. It provided a “hat-full” of “Our physicians were so
news to its readers. For the first 12 years, it had a impressed with how multi-
green cover with a picture of a Sombrero.
talented your team was and
1970-2000 that we were able to get our
Medical advances were so rapid and wide ranging during malpractice, office, workers
the next three decades that the only way to keep up was
comp, health and disability
by reading medical journals or attending large medical
meetings. The development of Medicare, Medicare policies in what seemed
Advantage plans and commercial health insurance like an instant. I would not
began impacting physicians’ practices. The number of
hesitate to say Desert
osteopathic and allopathic physicians, as well as the
number of hospitals in Tucson continued to increase. Mountain Insurance is the
PCMS became one of the first county medical societies best insurance source in
to admit DOs as full members. By 1976, women made up
the Southwest!”
20% of medical students, and by 2000 more than 40%.
However, it was not until 1990 that PCMS elected its first – Eric, Administrator
female president Dr. Janis Johnson.
The first description of computer networking at a Read more testimonials at
distance came from MIT in 1962. This took place over desertmountaininsurance.com
dial-up phone lines and was very slow by modern
standards. For individuals to participate, it was
necessary to have personal computers with sufficient
power and speed, something that my Apple IIe did not VALUED VENDOR FOR THE
provide in the early 1980s. On October 24, 1995, the PIMA COUNTY MEDICAL SOCIETY
Federal Networking Council (FNC) unanimously AZ MGMA MEMBER
passed a resolution defining the term Internet. The
definition was developed in consultation with members
of the internet and intellectual property rights
communities. RESOLUTION: The FNC agrees that the ONE STOP INSURANCE FOR…
following language reflects our definition of the term ■ Physicians & Surgeons
“Internet.” “Internet” refers to the global information
■ Other Medical Professionals
system that – (i) is logically linked together by a
■ Healthcare Facilities & Services
globally unique address space based on the Internet
Protocol (IP) or its subsequent extensions/follow-ons;
(ii) is able to support communications using the COVERAGE INCLUDES…
Transmission Control Protocol/Internet Protocol (TCP/
■ Professional Liability
IP) suite or its subsequent extensions/follow-ons, and/
or other IP-compatible protocols; and (iii) provides, ■ General Liability & Property
uses or makes accessible, either publicly or privately, ■ Employee Benefits
high level services layered on the communications and
related infrastructure described herein. This is fairly
simple language by today’s standards.
In 1979 Alliance members Eloise Clymer and Connie
Wry, who both had journalism backgrounds, became
involved with Sombrero and their makeover helped
make it what it is today, a highly circulated and read 866.467.3627
publication for physicians in Pima County. Sombrero 866.467.3611 fax info@desertmountaininsurance.com
continued to be edited and produced by the PCMS www.desertmountaininsurance.com

SOMBRERO – December 2016 7
staff until Steve Nash became editor in 1987. Five PCMS and MCMS are the only remaining county
years later Nash was named CEO of PCMS and medical societies in Arizona.
Sombrero was turned over to Fearneyhough and
After making major contributions to PCMS during his
Associates, a local marketing and public relations firm.
27 years with the Society, Executive Director Steve
In 1996, production and editing was brought in-house
Nash resigned in 2013 in order to assume a similar
with the hiring of Bill Fearneyhough as full-time staff.
position with the Tucson Osteopathic Medical
2001-2016 Foundation (TOMF). Bill Fearneyhough was promoted
to replace Mr. Nash.
Membership in PCMS has been stable during the past
decade but with the adoption of “group” memberships The availability of all types of medical information from
the rolls have increased to more than 1,000 active journals and the Internet has made information
members, the largest number of active members in the exchange at society meetings much less important.
Society’s 113-year history. Unfortunately, the Yavapai The increase in Hospitalists, from nearly nonexistent
County Medical Society is no longer in operation, so 20 years ago, to 50,000 today, has reduced
communication in the hospital
between primary care physicians and
specialists, to an insignificant level.
Increasing time demands of practice
have made attendance at society
meetings difficult. Faxing of medical
records has become a major means of
inter-practice communication.
By 2015, the PCMS building was in

AS POWERFUL AS OUR NAME.
need of extensive and expensive
renovation. Since attendance at
general meetings had declined to
nearly zero, the Board of Directors
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the Waterfall lawyers know the ins and outs of Tucson and Southern Arizona. office space in the refurbished building
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Barry Kirschner professionally handles claims of persons who have become medically
The proliferation of new medications,
disabled from employment through personal or group disability insurance policies and are
new imaging modalities and improved
denied benefits. Barry has successfully litigated on behalf of doctors, lawyers, and other
resolution, as well as “personalized
professionals. Barry has handled ERISA terminations administratively and in court, opposing medicine” and gene therapy, have been
every major disability insurance carrier. Barry continues to be selected by his peers for so great that communication of
inclusion in The Best Lawyers in America® in the field of Litigation — ERISA and continues information about these changes is only
to receive the highest AV ranking for quality and ethics from Marindale Hubbell. possible through large specialty society
meetings, journals and electronic
media. These changes have also
altered medical school curricula.
Informatics, as a discipline, has entered
the curriculum. Electronic health
records (EHRs) have been almost
universally adopted in clinical practice,
but both information sharing between
different systems and the analysis of
patient information within the EHR are
severely limited. Telemedicine was
invented and has assumed a significant
role in patient care. The UA is one of
four hospital systems in the nation,
which have been chosen to collect
patient health information and biological
specimens for the NIH-sponsored
Precision Medicine Initiative. This has
now been renamed the ALL OF US
Research Program, and will enroll a
database of 1 million patients.

8 SOMBRERO – December 2016
Women have entered every area of science, private Medical knowledge will increase, and previously
enterprise and government, but they are incurable and untreatable diseases will respond to new
underrepresented at the highest levels. Women therapies. Genome knowledge and editing, as well as
constitute about 50% of medical school classes. The other gene therapies, will play a large role. Medicine
average woman is paid about three quarters of what will have a more preventive focus. Physician mastery
the average man is paid. In 2016, for the first time, a and utilization of Biomedical Informatics will become
woman was selected by a major U.S. party as a U.S. essential to the modern practice of medicine. The role
Presidential candidate. of telemedicine will continue to grow. EHRs will
seamlessly share data with other EHRs. Decision
In 2002, Americans of African descent comprised
support tools within the EHR will analyze multiple
seven percent of students entering allopathic medical
types of information, trigger alerts to physicians and
schools. In 2015, they made up six percent of
other providers, and assist in medical decision making.
allopathic medical students, a fraction of their
percentage of the U.S. population. African-American
women made up eight percent of enrolled women, but
African-American men were only a
little more than four percent of
enrolled men. African-American
women outnumbered men 3,234 to
2,011. Americans of Hispanic and
Asian descent also make up a
significant part of medical school
classes. The first African-American
President of PCMS, Joseph S Whaley,
MD, was elected in 2003. The first
African-American President of the
U.S. was elected in 2008.
The number of osteopathic medical
schools and osteopathic physicians
continues to increase. There are two
schools of osteopathic medicine and
three Internal Medicine osteopathic Your partner
residency programs in Arizona. in behavioral health care.
Students in osteopathic schools
constitute 20% of all medical students.
In 2014, there were 86,765 osteopathic At Community Partnership Care Coordination,
physicians licensed in the U.S. The our multidisciplinary team of behavioral
first osteopathic physician to serve as health care professionals can improve the
President of PCMS was Edmund emotional well-being and coping skills of
your clients through counseling, therapy
Krasinski, DO, in 2002. Today, in
and other services for all ages.
nearly all respects, MDs and DOs are
treated and accepted as equals. • Psychiatric and psychotherapeutic
services
The Future • Coordination of care with other
New Name. New Services.
providers
Here are some of my views and hopes Same Community Mission. • Screening, education and treatment for
for the future. Directly, and indirectly DUI and domestic violence
through ArMA and the AMA, PCMS A subsidiary of • Psychological testing
will continue to serve as a strong Community Partners, Inc. • Dedicated children’s practitioners
voice for southern Arizona physicians Formerly Community Partnership • Specialized care for veterans and their
of Southern Arizona (CPSA).
in the Arizona Legislature and U.S. families
Congress, as well as serving as a • Services in American Sign Language
clearing house for communication and Spanish
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attain equal status at the highest cpcc@communitypartnersinc.org at our centrally located Tucson clinic.
levels of science, private enterprise
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African descent. The first woman
President of the U.S. will be elected. www.CommunityPartnersInc.org/CPCC

SOMBRERO – December 2016 9
Sombrero magazine important first step. Arizona Physician will be a
monthly magazine that provides all physicians with a
The December, 2016 issue of Sombrero will be the last
collective voice. It will strive to capture the views and
issue published. After nearly 50 years of providing our
concerns of the nearly 18,000 physicians (MD and DO)
members with the 10-times-a-year publication, the
practicing in Arizona. It will inform physicians in our
Society has decided to pursue an exciting new
state about issues that stand to impact the way they
endeavor. In January, you will begin receiving a new
practice medicine, and it will be a valuable resource to
publication that we have named Arizona Physician.
connect with other physicians. Our primary objective
This will be a combined effort with ArMA and MCMS
with Arizona Physician will be to provide you with the
and will replace the journals that each currently
highest quality magazine each month. We are
distributes to members. This means that Sombrero,
confident this effort will enhance the practice of
Arizona Medicine, and Round-up will cease publication
medicine in our state and will encourage collegiality
at the end of the year. Why the change? For one, our
among our physicians. We also believe that it will
three organizations have been discussing ways that
serve as a resource for busy practitioners who may not
we can work more collaboratively. We each strive to
know where to look for legislative updates,
protect the practice of medicine here in Arizona, and
opportunities to network, employment and practice
much of what we publish in our journals has
opportunities, and CME offerings, among other things.
considerable overlap. Issues that pertain to our
Physician representatives of the three societies will
readers – MACRA, ICD-10, AHCCCS expansion,
serve on the journal’s editorial board. Initially, Michael
scope of practice concerns, etc. – apply to ArMA and
Dean, PCMS President for 2017, resident Jaren Trost
MCMS readers as well as ours. Additionally, our three
and Timothy Fagan will represent PCMS.
organizations contract with many of the same
advertisers, a number of whom prefer a single ad buy Arizona Physician will also be available each month
in a magazine with more widespread distribution. By electronically. For those of you who prefer to read
combining efforts, we are able to reduce the costs of publications online, please simply email us at
production and can now afford to distribute this new information@arizonaphysician.com and we will make
publication to all Arizona physicians, since our issues sure you are added to the distribution list for the
and activities impact every physician. electronic version.
We are creating a new alliance to move forward on With the healthcare landscape evolving rapidly, so
behalf of physicians and their patients. This this is an must organized medicine. Each of our three
organizations is committed to protecting what every
physician does best – caring for his or her patients and
being a valuable resource to every physician. This
magazine is a big step in the direction of more
collaboration among our organizations, and we are
confident it will be something you look forward to
reading each month.
Has this been done elsewhere? To the best of our
knowledge, it has not. We cannot find an example of
other state and local organized medicine groups
coming together to provide more value to their
members, as well as every licensed physician in the
state. This is admittedly a huge undertaking, but we
are up to the task!
We welcome any comments you have about this
exciting endeavor, and encourage you to let us know if
you have interest in providing content or ideas for new
articles.
Since applying to medical school in 1968, I have
personally witnessed 48 years of dramatic changes in
health care and society and have personally
experience many of those presented in this column.
Acknowledgements: James Klein, MD, Steve Nash,
Jay Conyers, Bill Fearneyhough, William Thrift, MD,
and Brett Dinner provided valuable information and
feedback. n

10 SOMBRERO – December 2016
UA College of Medicine

Building Academic Medicine’s Future
By Charles B. Cairns, MD, Dean, UA College of Medicine – Tucson

T
he footprint of
academic
healthcare is
quickly expanding in
Tucson, with nearly $1
billion in state-of-the-art
buildings under
construction at the
University of Arizona
Health Sciences and
Banner – University
Medical Center.
The new 670,000 sq. ft. University Medical Center Tucson
These new structures will is expected to be completed in 2019.
improve patient care and
health care delivery, and enhance interdisciplinary The Bioscience Research Laboratory Building (BSRL)
research and medical education across the University will provide new space for interdisciplinary research,
of Arizona Health Sciences. They will improve the which is a key component of the College’s strategic
experiences of the College of Medicine – Tucson vision for the future. By identifying the intersection of
students, residents and fellows, faculty and patients, health care issues and our areas of expertise, and
and will impact the way our faculty teach, our students then working across disciplines – across departments,
learn and health care is provided. centers and other colleges – we can find innovative
Health Sciences Innovation Building: solutions to the health care needs of today and
tomorrow.
  •   220,000 square feet
  •   Completion date: September 2018 Banner Health – University Medical Center Tucson:
  •   Interdisciplinary training of future doctors, nurses,   •   670,000 square feet
pharmacists and public health professionals   •   Completion date: Spring 2019
  •   State-of-the-art simulation and innovation   •   336 private patient rooms, 22 operating rooms,
The Health Sciences Innovation Building (HSIB) will imaging suites and public spaces
triple the space allocated to students’ community life   •   New diagnostic imaging, diagnostic cardiology,
and interactive education. With an entire floor cardiac cath labs and interventional radiology
dedicated to simulation and the ability to expand our   •   More than $50 million in new patient care
clinical teaching activities, we will be able to keep up equipment and computers for state-of-the-art
with the changing demands of undergraduate medical care
education. Additionally, this new facility fosters
trans-disciplinary collaborations and serves as a
unique place for interactions between teams of
health professionals, students and faculty in
medicine, nursing, pharmacy and public health. It will
serve as the vanguard for interprofessional health
education in the Southwestern United States.
Bioscience Research Laboratory Building:
  •   100,000 square feet
  •   Completion date: January 2018
  •   Collaborative translational research space
(molecular basis for human health, aging and
disease)
  •   Research facilities to support interdisciplinary
research in many health science disciplines The Bioscience Research Laboratory Building will provide much
needed space for interdisciplinary research.

SOMBRERO – December 2016 11
Outpatient Banner Health Center:
  •   200,000 square feet
  •   Completion date: Winter 2017-2018
  •   Outpatient services and adult multi-specialty
clinics
  •   Site improvements and patient care
equipment
This three-story multi-specialty clinic is located
next to the University of Arizona Cancer Center –
North Campus at Campbell Avenue and Allen
Road. The facility will house many outpatient
clinics currently in Banner – University Medical
Center Tucson, in addition to radiation oncology,
medical imaging, lab service and a retail
The Health Sciences Innovation Building will triple the space allocated
pharmacy. A new parking garage is also under
to students’ community life and interactive education. construction, which will offer free covered
parking.
For a perspective on this massive project, take a look
Many positive changes are underway for health
at the cranes cutting into the Tucson skyline at the
care in Tucson thanks to these capital
hospital construction site. The 400-foot cranes weigh
improvements at the University of Arizona and
700,000 pounds and are taller than any building in
by Banner Health.
town. It is truly a big project that will have a major
impact on patient care in Arizona. The new nine-story You can find the most up-to-date construction
hospital provides new, updated patient rooms and will information, including webcams at the BSRL,
house more than $50 million in new patient-care HSIB and hospital construction sites, at
equipment. Additionally, when the new hospital is campus-construction.uahs.arizona.edu. n
complete, the old hospital space will be repurposed for
academic office and research space.

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12 SOMBRERO – December 2016
Health Risk

Getting a flu shot is being responsible
By Francisco Garcia, MD, PCHD Director and Chief Medical Officer

M
y wife, Amy, others. Last year there were more than 3,400
reminded me this confirmed cases of flu in Pima County and of
weekend that the those, 18 died. Even those who are not sick can
boys had not had their flu still be carriers and expose vulnerable
shots yet this year. It’s populations including children, pregnant women,
always a bit of a challenge seniors and people who have pre-existing
coordinating schedules for respiratory conditions. Health care workers in
two working parents and particular should get a flu shot as they are caring
two kids, but this is for medically compromised members of the
something that has to be a community.
priority.  • Routine annual influenza vaccination is
recommended for most persons over the age of
Aside from the hassle of
six months and ideally, vaccinations should occur
being sick and missing
before the onset of flu activity in the community.
work or school, getting your flu shot is a responsibility
That is why it’s important to get your flu shot early
we all take part in to help protect the health of the folks
or as soon as the vaccine becomes available.
we come into contact with. Amy’s pregnant patients
and their families count on her to keep them well, and Where to get flu shots:
the last thing they need is to get sick from an
encounter with their OB doctor. The same thing with
• Many major employers offer flu shots at the
worksite for little or no cost. Check with your
my boys, not only are they protected from getting the
human resources department to get information
flu, they are reducing the risk of potentially spreading
on flu shot clinics at work.
the flu with children at school who may not be
vaccinated or whose immune system may not be
• Many drugstores offer onsite flu shots for a
minimal cost with little or not wait.
working well.  For me, I am out every day meeting with
many different community members and I would hate
• Local health clinics offer flu vaccinations for free
or at reduced costs.
to think that I made someone ill.  Like many families’
we spend time with older parents/grandparents who
• The VA offers flu shots for those eligible
are more vulnerable and for whom the consequences
• Contact your health care provider. Most
insurance plans cover it at little or no cost to you.
of the are more serious.
In addition to getting the flu shot, there are other ways
It is important that we take care of ourselves in getting
to protect yourself and others from getting sick. Flu
a flu shot every year and know that in doing so we are
viruses spread from person to person through
also taking care of our families and our community.  So
coughing, sneezing, by touching something with flu
in that spirit, the following information includes a few
viruses on it and in some cases through the air. Make
good reasons to get vaccinated this year:
sure to wash your hands frequently, always cover your
• Being sick is costly in terms of productivity for cough (use your elbow, not your hand) and stay home
everyone. None of us have enough time and it when you are sick.
makes good sense to protect ourselves from a
The flu is more serious than the common cold, so it’s
virus that could take valuable time away from
important to do everything you can to prevent its
other activities, both work and play. The vaccine
spread. Don’t wait—protect yourself by getting a flu
is safe, generally has few side effects and doesn’t
vaccination. You can be sure my boys, my wife and I
give you the flu.
will be doing the same. n
• Limit the risk of serious illness for yourself and

SOMBRERO – December 2016 13
Makol’s Call

Thank You Charles Simonyi
By George J. Makol, MD

I
’m taking this occasion than 200 feet long lined up along the intercostal
to thank Charles waterways. I even knew a captain or two, and on
Simonyi for inspiring occasion while the rich owner was away, I would tie my
me to create my little 17 foot ski boat to one of their anchor lines and
December column. He party on board with friends.
created the main writing
However, I had never seen a ship such as this. It was
instrument that I used, the
more than 230 feet long, covered in military gray with
same tool that you
no corners, no sharp edges, no visible windows and no
probably use every time
identifying marks on its military-style hull except a
you dictate a letter, enter
cryptic number 9906. On the upper deck was a battle-
a paragraph into a
ready McDonald Douglas MD – 520N helicopter. It
computerized record, or
appeared to me that the ship was designed to be
prepare one of those
completely invisible to radar. Awestruck, I approached
corny, self – aggrandizing
our captain and asked, “Is that a new battleship of
“Johnny made the honor
Danish Navy design?” I was thinking it was meant to
roll” holiday letters to friends and relatives.
stealthily cruise the Barents Sea, invisible to Russian
I, like you, had no idea who the heck Charles Simonyi submarines known to frequent the area.
was until recently. I was cruising on my way to see
“No,” he replied. “That super yacht belongs to the
Copenhagen’s famous Little Mermaid, when our
fellow who created Microsoft Word and Excel.” He was
sightseeing boat turned south and headed for most
referring to Charles Simonyi who, somewhat
incredible ship I have ever seen. Growing up around
penniless, immigrated to the US from communist
Fort Lauderdale, I was used to super yachts of more
Hungary in 1967 to study engineering and math at UC
Berkeley. He eventually joined
Microsoft in 1981 as the head of
Microsoft’s application software
group, and became the chief
architect of Microsoft Word, Excel,
and other widely used application
programs.
Simonyi is also an active
philanthropist. His Charles Simonyi
Fund for Arts and Sciences supports
Seattle area arts, science, and
educational programs Forbes
magazine tags his net worth at an
estimated $1.8 billion. At that time I
did not know he was part of the
Silicon Valley million – dollar club,
but with that boat I knew he had to be
one rich guy.
As I stared at this nautical marvel, a
little envy set in, since I knew that I
would never get to set foot on such a
dream ship, unless Charles had
severe allergies and I was the only
allergist nearby.
That night, as I penned a letter back
home, it dawned on me that was
using one of Charles’s great software
inventions, the same program

14 SOMBRERO – December 2016
millions of other people use every day – Microsoft Technology has also caused some notably undesirable
Word. If you figure he earns a few pennies every time side effects.
one of us writes a letter, prepares a medical report,
Just the other night my wife and I were at dinner and
creates a legal document, or even authors a novel it
nearby was a table occupied by four notably
adds up to a lot of dough, a mega-mansion in Seattle,
handsome young men and women. I couldn’t help but
and a super yacht
notice that the four were continually consulting their
While Charles brought useful writing and spreadsheet phones and “chatting” with people in some other
tools to the masses, Henry Ford brought the $495 sphere. There was little conversation going on among
model T within the reach of the average consumer. the four, but they could communicate with somebody in
While Ford did not invent the automobile, his mass Kansas for free during desert!
production techniques revolutionized and changed our
My daughter is a manager an upscale retailer here in
society by vastly increasing the mobility of Americans.
town. She interviews young people seeking
Then again there is Andrew Carnegie. Born in 1835, he employment for positions that demand the ability to
would go on to lead the enormous expansion of the talk with the public. She says half the people she
American steel industry. Or consider Cornelius interviews cannot carry on a conversation; I told her
Vanderbilt, who, without formal education, built she’d be better off placing them in another room and
incredible wealth through railroads and shipping, and texting them.
like Carnegie went on to become a major philanthropist.
Believe me, I’m no Luddite; I do carry a Galaxy pad
While not all of these icons of industry were perfect room to room. My letters to other doctors are in fact
men, they vastly improved life for the everyman. dictated using Microsoft Word. I spend lots of time,
away from patients, using Dragon Naturally Speaking
While I do admire Simonyi’s elegant software creations
to talk to my word processor. There is a time and place
and the great 19th century industrialists mentioned
in medicine for technology, but only after spending
above, I find myself a little confused and confounded
time talking, listening and treating the patient. Most
by the people we are making rich today.
patients are typically nervous, a little scared, and
WhatsApp is an instant messaging application allowing sometimes overwhelmed when they seek our help. A
one to send text messages, PDF files, and instant keyboard is not the patient; a computer screen is not
messages over smartphones. Ukrainian immigrant Jan the patient.
Koum cofounded this company and later sold it to
I’m glad Simonyi immigrated to this country to join
Facebook for $19 billion. Even accounting for inflation
other entrepreneurial greats, many of whom have
this dwarfs the fortune of Simonyi, Ford, Carnegie, and
made my life better. None of us physicians may end up
Vanderbilt. Nineteen billion bucks so people can chat
being billionaire industrialists, but we can be icons to
and send files to each other?
our patients by providing effective, personal, and
I use a Wi-Fi app called Viber sometimes. It enabled compassionate care. The only difference is, like me,
me to make calls from Australia to the US for practically you’ll have to settle for a much smaller boat. n
nothing. Useful, but probably not worth billions.

SOMBRERO – December 2016 15
Behind the Lens

Fond memories of “Behind the Lens”
By Hal Tretbar, MD

W
ay back when
the editor of
Sombrero
magazine, Stuart Faxon,
asked if I would be
interested in writing a
column about photography
and travel. It was around
2000 A.D. that I started a,
more or less, monthly
column titled “Behind the
Lens.”
Photography has been a
passion since I was a
teenager. I have had a
darkroom everywhere I lived until digital imaging came
along. I have used 120 Rolleiflexs (both double and
single lensed), 4x5 Speed Graphics, under water
Canons, and other brands but I have preferred to shoot
Nikon cameras. My first one was a new, top of the line
35 mm S2 rangefinder with a 50 mm f 1.8 Nikkor lens
that cost me $150 in 1956. Several years ago I sold it
to a German collector for $1500. However I still have
my 35 mm Leica M3 rangefinder and recently shot a
roll of black and white Tri X. Currently I’m using a full
frame digital Nikon D 600.
In 1984 I began working with Tucson travel writer
George Ridge. One of our first publications was about
the Amazon River. We hired a boat, a river pilot and a
guide to take us from Leticia, Columbia up river into
Peru. After exploring the jungle, fishing for piranhas
and hunting crocodiles we would wearily adjourn to our
fishing shack hammocks. It set the standard for our Here is the Sombrero from December 1982 with the Matterhorn
reflection image on the cover.
many worldwide adventures.
For several years George and I had a monthly Travel
Page in the Arizona Daily Star. We were in Istanbul, the good fortune to work with many well known nature
Turkey when the Twin Towers came down. Shortly photographers.
thereafter, the columns ended when powers that be
I was just looking at some of my old Sombrero
announced no one would now be interested in
magazines. For the December 1982 issue Editor
traveling.
Eloise Clymer had a special section of photographs
My wife Dorothy and I had always tried to visit submitted by PCMS members. This issue featured
interesting places after an international medical three full pages of color, a novelty for the magazine.
meeting – such as a meeting in Singapore on Systemic Dr. Paul Schnur had a page of three black-and-white
Lupus followed by a stay with headhunters in Borneo, images. Dr. Harold Kohl Jr. had Mooney Falls, Havasu
or driving for a week from brewery to brewery in Canyon and Dr. Robert P. Friedman submitted San
Bohemia after a meeting in Prague on Vasculitis. Xavier Mission. My color photo was of a Swiss man
and his dog with the mountain in the background titled
I retired from the daily grind of medical practice in
On a Matterhorn Trail.
1998, after which I became a Trip Leader for Arizona
Highways Photo Workshops. While leading these The December issue was also my first Sombrero
workshops throughout the American West, I have had cover. It is a black-and-white photo titled The Majesty

16 SOMBRERO – December 2016
of Switzerland’s Matterhorn. I had backpacked there to
hike the mountain trails before going to an arthritis
meeting in Verona, Italy.
For this last Sombrero cover I searched my files and
selected this 1972 photo of one of my favorite places in
Arizona – Canyon de Chelly. During the first of many
trips, I found that a recent flood had scoured out the
bushes that usually block one’s view of Spider Rock. In
the past, the best angle to see the Rock was from the
rim looking down but on this particular trip nature had
carved out a better perspective of the grandeur of
Canyon de Chelly.
During the years, the Sombrero editors have been kind
enough to allow me to pursue almost any subject. I
have ruminated about many different people, places,
and things. The cover photos have often reflected the
subject of the story and with the introduction of full
color in 2009, it allowed me to take full advantage of
my color images.
It has been my pleasure to present interesting travel
stories and fascinating photographs to readers. I hope
you have enjoyed them during these oh so many
years. For me, Behind the Lens has provided many
pleasant experiences and memories. n

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SOMBRERO – December 2016 17
Road Trip

Going off road to offbeat Keeylocko
Yup...this ain’t your everyday tourist attraction. It’s the authentic, wild and wonderful
West, in a cowtown run by one unique rancher-cowboy.
By Monica Surfaro-Spigelman – Photos by Leigh Spigelman

I
f you’re ready for a rough and tumble adventure to
a town where the pigs outnumber citizens, about
40 miles southwest of Tucson down a washboard
road is a far out and funky sliver of Arizona cattle
ranching called Keeylocko. It’s a great day trip to an
entertaining hideaway that’s part cattle ranch and part
art installation/movie set.
To reach Keeylocko, head southwest along State
Route 86 to the westerly Hayhock Road turnoff at
Milepost 146. Take this dusty straightaway four miles,
to a Keeylocko signpost that will signal a right turn
onto a passable, bumpy ribbon of a dirt road. Driving Reach Keeylocko off of Arizona State Route 86, approximately
three miles further, you’ll travel through four more 40 miles southwest of Tucson.
signposts that encourage you onward through twisty
ranchlands. Then, there’s a left turn that reveals a hands and cooks when needed. A Korean Army vet
dog-eared entrance gate. Take your car up the uneven, born in the Carolinas, Ed traveled the country after his
dusty rise…passing junk oddities and old trucks. Army career before settling in the Sonoran desert
Finally, there it is, Keeylocko – one gritty, bizarre street grasslands. He attended the University of Arizona,
set within the wild desert abutting the Coyote learning about agriculture, because he wanted to
Mountains. breed well-armed cattle that could protect themselves
on the range. (“Give them back their horns,” he says.)
The Cowboy of Keeylocko
He bought the land and built his Keeylocko tin-wood
At 85-plus, Ed Keeylocko still runs his Keeylocko ranch,
town with his own hands in the 1970s, mainly because
a spread of 30-plus acres with 10 wood-tin buildings
he wanted a working ranch to breed his cattle and
that form a Main Street-turned-roadside oddity.
horses.
He checks the fences around his ranch of about 100
Folk Art and Funky
head of cattle and a couple of dozen horses, with the
Over the years Ed’s eccentric Keeylocko was most
help of a few friends who double as trail bosses, ranch

Pigs outnumber humans on most days in Keeylocko. Photo ops abound around this odd Cowtown.

18 SOMBRERO – December 2016
façade of a library, a general store (you can’t buy
anything), a barn, chicken coop, arena and a “nine-
finger” bank. You can pay respects at the cemetery,
where a few cowboys and friends of Ed are buried.
At the western corner of the main street is his Blue
Dog Saloon; inside there are saddles, photos, ropes,
animal heads and other memorabilia. There are lots of
old clippings of famous people and other visitors who
have traveled to Keeylocko.  Ed also has posted hand-
lettered Cowtown “law” signs (no cussin’ or
disrespecting) around his imaginative place.
Mountainside Meet-Up
Although visitors often pop in unexpectedly to browse
and take photographs, you’ll need to call ahead to
have Ed meet you at his interesting place. Lean with a
swagger and gift for cowboy tales, Ed enjoys
welcoming visitors to the Blue Dog Saloon, usually on
weekends. If you made that call and were lucky
enough to have Ed available, you’ll find this spiffed-up
elderly rancher waiting at the bar for you, with his
silver bolo and proper cowboy hat, hollering his hearty
Keelocko welcome.
On a lazy desert afternoon, Keeylocko’s reigning
buckaroo will encourage you to mosey closer to hear
his tales. Ed spins a lot of stories for visitors to his
ranch – from his early rodeo and cattle drive days, to
the more recent music and movie events that are
drawn to Keeylocko in the fall and winter months.

Keelocko was founded by rancher Ed Keelocko, who began The public is welcome to meander this imaginative
building his wood-tin town in the 1970s. whistle-stop, which has no facilities but plenty of photo
ops. Ed accepts appointments for groups, and for
successful in catching the interest of the avant-garde. these occasions he’ll fire up the generator, put on the
Now it draws unconventional explorers and a handful smoker, load up coolers of ice and open the saloon.
of music festivals, weddings and film productions each He’ll also stomp around town, with the buildings
year. There’s plenty of folk life and character in usually closed until special events like KeeyLocko
Keeylocko’s creative town, which includes a collection Days, an annual weekend fest of music, crafts, trail
of endearingly ramshackle buildings, guarded by a rides, BBQs and primitive camping that happens in
drove of squeaky pigs. There’s a fort to browse, the October.

Wild west memorabilia and an assortment of old vehicles are The Blue Dog Saloon is actually a working bar (but call ahead
situated like outdoor art fixings around the ranch. for the schedule of open times and musical performances).
SOMBRERO – December 2016 19
Ed has a story behind each of his Keeylocko buildings, even this Stop at Todd’s (in historic Ryan Field) to get refreshed or order
“one hand cashier” bank. some good eats prior to your Keeylocko visit.

Before You Go:
Cowtown Keeylocko
12230 South Coleman Road Tucson
(520) 429-5778
Check Cowtown Keeylocko’s Facebook page for
events or to schedule a visit with Ed:
Facebook.com/pages/Cowtown-
Keeylocko/346159755463667
Fuel Up and Refresh
For good eats before you arrive at Keeylocko, check
Todd’s, great little stop at Ryan’s Field, along West
Ajo Highway (State Route 86) at Robles Junction,
Arizona (ToddsRestaurant.com). Todd’s is a neighborly
restaurant-with-a-view, located on State Road 86 at
Ryan Field (which opened in 1942 for flight training
during WWII). Open seven days a week (8am - 2pm),
Todd’s offers homemade baked goods such as
cinnamon buns, and other favorites including hash,
chowder and burgers, as well as a place to refresh
The centerpiece of Keeylocko is the Blue Dog Saloon, with its either before or after a Keeylocko visit.
eccentric décor and Ed storytelling (as long as you schedule
your visit).
A gas station is located at the nearby Robles Junction-
Inner Cowboy Magic Three Points intersection of State Routes 86 and 286.
You’ll be feeling pretty darn maverick after your ride Four-wheel drive is not required, but it’s advisable to
out to this odd and remote place. Ed’s quirky check the weather (and not travel during rains). Carry
handmade masterpiece in all its spunky glory will have plenty of water. Follow directions indicated in this story
something to interest everyone – the photographer, the to recreate this trek: Do not follow GPS or digital map
history buff and the explorer. And of course this place apps, as some Native American roads restrict travel
has something special for the inner cowboy in all of us, and the route ain’t always what GPS tells you it is! n
especially those who are looking to watch a sunset by
the Coyote Mountains, and stuff one of those big
cowboy dreams into his or her pocket.

20 SOMBRERO – December 2016
In Memoriam

Dr. John F. Carroll
1931-2016
J
ohn Franklin Carroll, MD, a 50-year Pima County
Medical Society Member who practiced cardiology
and internal medicine, passed away on October
15. He was 85.
Carroll was born June 8, 1931 in Superior, Arizona. His
grandfather, Selim Franklin, is considered one of the
founders of the UA. As a member of the Arizona
Territorial Legislature, Franklin passed a bill
establishing the university in 1885. Carroll attended
Tucson High School and received his bachelor’s
degree from the UA and played quarterback for the
football team. After graduating from Yale Medical
School in 1956, he completed an internship and
residency at Salt Lake County General Hospital. He
trained three years in internal medicine and cardiology
with a fellowship at the University of Alabama Medical
Center. He served two years in the U.S. Air Force as a
medical officer at Langley Air Force Base, Virginia.
Carroll returned to Tucson in 1963 serving as Assistant
Director of the Cardio-Pulmonary Lab at Tucson
Medical Center. In 1965 and went into private practice
on North County Club Road and
joined PCMS. He moved his practice
to 5210 E. Farness in 1989 and Hearing loss is
retired in 1996. He was a past
president of St. Elizabeth of Hungary
TWICE AS COMMON
Medical Services. He served three in adults with
years as a delegate to the Arizona
Medical Association.
diabetes as those
Aviation was a passion for Carroll,
without.
winning the coveted Tequila Cup for
aerobatics competition in 1997. He Don’t let your patients miss out on the sounds of life.
was also an avid tennis player and
held memberships at the Tucson
Racquet, Tucson Country Club and
River Racquet Clubs.
Diagnosed with pulmonary fibrosis at
age 73, his life expectancy was a
brief two years, but he beat the odds
and lived for an additional 12 years.
He is survived by his wife of 63 Hearing Evaluations
years, Georgiann; children, Cindin Tinnitus Consultations
Carroll, George and Dawn Carroll, Cochlear Implant Candidacy
John and Lori Carroll and, Susan and
Kevin Westfall; grandchildren, Evan,
Preferred Insurance Provider e Doctors of Audiology
Dylan, Douglas, Johnathon, Serving Southern Arizona at Arizona Hearing Specialists
Madison, Tyler and Kori; great- Since 1981 Hear Your Best to Live Your BestTM
grandchildren, Hailey, Braxton and
Bently and by his sister, Mary Rose 3 Offices: NW, Foothills
Duffield. n & Green Valley arizonahearing.com 520-742-2845

SOMBRERO – December 2016 21
UA Health Sciences

UA chronic pain researchers help patients
discontinue use of potential addictive opioids
By Jane Erikson, UA Health Sciences Office of Public Affairs

U
niversity of Arizona pain specialists are “Pain clinics nationwide are under-utilized,” Ibrahim
offering patients effective treatments for said. “Patients think pain clinics are where you go to
chronic pain, most often without prescribing get prescription, which you can probably get from your
potentially addictive opioid-based medications. primary care provider.
In several cases, patients whose pain rendered them “In fact, prescribing medications is the least of what we
unable to work have been able to resume working. do in our clinic. What we do most is procedures, and
we often have very good results.”
Mohab Ibrahim, MD, PhD, and Amol Patwardhan, MD,
PhD, both assistant professors in the UA College of One example is the spinal cord stimulator, a small,
Medicine – Tucson departments of Anesthesiology and implantable device that resembles a heart pacemaker
Pharmacology, are director and co-director of the and sends electrical signals to the brain to block the
Chronic Pain Management Clinic, an outpatient clinic sensation of pain.
at Banner – University Medical Center South. In July, a
Patwardhan and Ibrahim are quick to point out that
third pain specialist, Vasudha Goel, MD, assistant
opioid drugs not only are safe when used correctly, but
professor of anesthesiology, joined the Chronic Pain
necessary for patients with chronic pain related to
clinic team.
cancer, surgery and severe trauma.
But whenever possible, patients who
visit the Chronic Pain Management

Happy Clinic will be offered non-opiate
solutions to their pain.

Holidays A non-opioid medication offered at
the clinic is Dronabinol, less
dependence producing, synthetic
From Casa de la Luz cannabinoid developed and FDA-
Agnes C. Poore, CCO, and Co-Founder approved to control chemotherapy-
Lynette Jaramillo, CEO, and Co-Founder induced nausea and vomiting, and to


increase appetite in patients with
Thank you for trusting us to AIDS. More recently, it’s been used
care for your patients and their to treat neuropathic and multiple
families. We wish you a peaceful sclerosis related pain.
holiday season and a happy


One patient with severe left-sided
new year. pain following a stroke was getting
excellent relief from Dronabinol and
only infrequently resorted to an
opiate for additional relief.
Unfortunately, Patwardhan said, his
health insurance plan terminated
coverage for the medication.
520.544.9890 | www.casahospice.com The comprehensive pain clinic offers
Hospice services are paid for by Medicare patients several other procedures to
help reduce pain, including epidural
steroid injections, joint injections,

22 SOMBRERO – December 2016
high temperature and pulse radiofrequency ablations, About Dr. Ibrahim
spinal cord and peripheral nerve stimulators and Botox Mohab Ibrahim, MD, PhD,
injections for migraine and other painful conditions. came to Tucson from his
Goel has a special interest in the management of native Egypt in 1993 with
cancer-related pain. “We still have a long ways to go in the intent of becoming a
managing cancer pain,” she said. “There are simple physician. At the UA he
nerve blocks that can help significantly with the pain, earned a bachelor’s
allowing the patient to spend more quality time with degree in biochemistry
loved ones.” and a master’s degree and
PhD in pharmacology and
Ibrahim and Patwardhan are members of the
toxicology. He graduated
University of Arizona College of Medicine-based
from the UA College of
Arizona Pain Research Group, led by Frank Porreca,
Medicine – Tucson in
PhD, UA professor of anesthesiology and
2008, then completed a
pharmacology, who is known for his pioneering
surgical internship at the
research on the molecular origins of chronic pain, and
UA and did his residency
discoveries that may lead to new treatments.
in anesthesiology at Brigham and Women’s Hospital in
Developing improved therapies for chronic pain has Boston. He followed that with a clinical pain fellowship
been Porreca’s goal since the early 1990s. at Massachusetts General Hospital.
Porreca described as “revolutionary” the increased
About Dr. Patwardhan
understanding of pain since the early 1990s. “What
Amol Patwardhan, MD,
has been lagging is the introduction of new molecules
PhD, studied medicine in
that can lead to new treatments. But there are efforts
his native India, where he
and ongoing trials that can hopefully lead to some
earned his MD. After
success.”
receiving his PhD in
When new patients come to the clinic, Dr. Ibrahim pharmacology from the
said, “We will evaluate their situation, give our honest University of Texas Health
opinion and offer certain options. We like to see Science Center in San
patients early on, rather than after they’ve tried Antonio, he completed his
months of different medications. Our main goal is to internship in surgery and
get the patient functioning again. And the majority do his residency in
get better.” anesthesiology at the UA,
followed by a pain
NOTE: Physicians and patients are welcome to call the
medicine fellowship with
Chronic Pain Management Clinic at 520-874-7246
the anesthesiology
(PAIN).  
program at the University of California, San Diego. Dr.
Patwardhan has published more than 30 peer
About Dr. Goel
reviewed papers about pain mechanisms, holds two
Vasudha Goel, MD,
patents and has received numerous grants for his
studied medicine in her
research studies.
native India before coming
to the U.S., where she
completed her internship About Dr. Porreca
at Long Island College of Frank Porreca, PhD, professor of pharmacology and
Medicine, followed by her anesthesiology, is a member of the UA Cancer Center
residency in and principal investigator of the UA Pain Research
anesthesiology at SUNY Group. He has served as editor-in-chief of Life
Downstate School of Sciences, and as pharmacology section editor for
Medicine, and a fellowship Pain, and has authored more than 450 peer-reviewed
in pain medicine at Loma papers providing insight into pain mechanism and
Linda University Medical treatment. He is founder and scientific organizer of the
Center. Pain Mechanisms and Therapeutics Conference, a
biennial event that attracts world-renowned members
of academia and industry. n

SOMBRERO – December 2016 23
Pracce Administraon

Healthcare’s top priority:
Fast and easy appointments
By Jonathan Bush

I
go to a lot of health care conferences, and of late organizational vein that, once tapped, has the power to
there’s a seemingly obligatory slide that crops up in drive other downstream improvements as it
nearly every PowerPoint. It’s a now-iconic image of reverberates through an organization. In the case of
a triangle divided in equal parts and labeled as follows: Alcoa, once employees were asked to suggest ideas
“improve the patient experience,” “improve the health for safety improvement they began to surface other
of populations” and “reduce the per capita cost of issues that had been buried. The rising tide of a more
care.” This is health care’s “Triple Aim,” and it is open, problem-solving culture helped raise all of
definitely trending. Alcoa’s boats – and profits.
I must confess that I’m not a fan of the Triple Aim. It’s At my company, Athenahealth, we are big believers in
not that I don’t believe those three outcomes are vitally focusing ourselves and our clients on keystone habits
important. I just don’t believe it’s possible to aim at and corresponding “sentinel” metrics. Our corporate
three things at once. As a manifesto or creed, it’s scorecard, for example, is a waterfall that begins with
inspiring. As a roadmap, it’s a bit hard to follow. workforce stability - over 17 years, we’ve found that
our success depends on focusing first on managing
A more effective approach to change, I’d argue, is the
voluntary turnover, ahead of all other traditional
one taken by Paul O’Neill back in 1987 when he was
performance measures (including the ones our
first appointed CEO of the aluminum giant Alcoa. As
investors care about). Any spike in voluntary turnover
New York Times reporter and author Charles Duhigg
is a canary in our coal mine and raises an alert that we
recounts in his bestseller, “The Power of Habit”,
take very seriously.
accidents were commonplace at Alcoa, as they would
be at any company in the business of handling molten So, what should health care providers focus on as their
metal on a regular basis. But the company’s safety keystone habit? For my money it’s patient access -
figures weren’t bad – in fact, they were better than that making it as easy, quick and worry-free to get an
of their competitors. appointment with a provider.
Nevertheless, O’Neill stood up in front of his investors When provider organizations make it a habit of
that year and declared that the company would focus opening their schedules and committing to same-
its entire strategy on bringing workplace injuries to week-or-sooner appointments, other good things can
zero. “If you want to understand how Alcoa is doing, happen. Appointment types can be simplified and
you need to look at our workplace safety figures,” he streamlined, driving other opportunities for process
argued. No talk of profits, opening new markets, or improvement and efficiency. Care is more likely to be
any of the usual crowd pleasers. Everyone thought he directed as appropriate to lower-cost providers and
was nuts. nurse practitioners or even to virtual consults, cutting
costs and eliminating unnecessary care.
By the time O’Neill left Alcoa in 2000 to become
Treasury secretary, the company’s market cap had And, most important, physicians can be freed up to
increased by $27 billion and by 2010 not a single see the sickest patients when they need to be seen.
employee day was lost to workplace injury at 82% of
Jonathan Bush is the CEO and president of
Alcoa locations.
Athenahealth and the author of “Where Does it Hurt?
So what happened at Alcoa? An Entrepreneur’s Guide to Fixing Healthcare.”
2015 Harvard Business School Publishing Corp. &
O’Neill had located and had the discipline to focus on
The New York Times Syndicate. n
what Duhigg calls a “keystone habit,” a deep

24 SOMBRERO – December 2016
Paent Care

Five ways to engage patients
By Sachin H. Jain, MD

M
edical science has enabled our health care There are, of course, limitations, one of which is
system to deliver outcomes that would have self-selection bias. People participating in an
been impossible a generation ago, and online community around their disease are
advances in fields such as genomics and stem-cell already more engaged, more informed and more
therapy offer immense promise to further accelerate tech savvy than many others. So while leaders in
medical innovation. the health care system integrate the (undeniably
valuable) insights from these communities into
As extraordinary as insights from the laboratory often
decision-making processes, we have to account
are, better understanding the experiences of patients
for these patients’ above-average sophistication
and health care providers can provide a roadmap for
and its implications for their treatment choices.
the critical last mile of medical care, where all policies,
procedures and practice converge into action. 4. Remember the other influences of patient health.
As impactful as the increasing focus on patient
Below, I offer some approaches drawn from my
voice can be, it’s critical for organizations to
experiences working in health-care-delivery
consider the other influencers of a patient’s
organizations, government and industry. (The
health that the patient himself might take for
principles I propose are my own and do not reflect
granted. Family members, cultural traditions,
official policies of any organizations with which I am
stress levels, sleep habits and numerous other
affiliated.)
lifestyle factors impact health but are often
1. We must strive to move beyond our own considered “just how things are.”
experiences. Those of us who work in health care
5. Overcome the risks - they’re usually worth the
inevitably refer to our own experiences with the
benefits. Because protecting patient privacy is so
health care system when making decisions about
important in health care, integrating patient voice
strategy and program design. Even at high levels
is not as simple as one might expect. Meeting the
of policy or strategy discussions, it is common to
regulatory needs of any health care organization
hear, “when I was at the doctor.” or “when my
takes planning, flexibility and cooperation across
mom was sick.” And while we can gain insights
teams.
from these personal encounters, it’s critical to
remember that our expertise inside the field Through engaging the patient voice, we have a
strongly informs our experience. powerful tool to inspire and shape new solutions in
health care, and there is real value in working through
All leaders in health care have a level of access,
the associated challenges. As the health care system
familiarity and comfort with medical care that
takes a more collaborative approach to helping
vastly exceeds that of the average patient.
patients and as patients become active participants,
Consequently, as health care providers, we have
everyone wins.
to ask ourselves this question: What stories are
we not hearing? If we don’t keep ourselves Dr. Sachin H. Jain is chief medical information and
honest and consider the voice of the patient not in innovation officer at Merck, an attending physician at
the room, we overlook opportunities to improve the Boston VA Medical Center and a lecturer in health
care for a substantial number of people. care policy at Harvard Medical School.
2. Get authentic patient voices in the room. To lead © Harvard Business School Publishing Corp.
change in health care, organizations must get in Distributed by The New York Times Syndicate. n
the room the voices of real patients - people
whose lives are touched by our products and
services.
3. Embrace online communities, but know their
limitations. Online communities are a powerful,
emerging avenue for insight into patient sentiment
about a disease or therapy. Many communities
are focused on particular diseases and focus
groups, offering a locus of conversation on
specific topics.
SOMBRERO – December 2016 25
Medical Educaon

Should Doctors-in-Training work fewer hours?
By Dhruv Khullar, MD

H
ow many hours should medical residents work? But I worry about how to interpret the results of trials like
Hospital care is a 24-hour-a-day enterprise, these, and what positive or negative findings may mean
but the question of which doctor should be for residency training discussions going forward. In a
there — and how long he or she should already have profession driven by evidence, data is useful. But it’s
been there — is among the most controversial and important to recognize data’s limitations.
unsettled in medicine. It’s a question that comes up
almost daily among my peers, and my own feelings about Many patient-care metrics we use to evaluate the impact
the issue often depend on whether I’m trying to grasp of duty hour restrictions — mortality, procedural
details about a new patient or struggling to stay awake at complications, adverse events, readmission rates — are
the end of a very long shift. crude. They might make sense for hospitals and health
systems designed to increase efficiency and insulate
In 2003, at the genesis of the modern patient safety patients from human fallibility. But they fail to capture the
movement, the Accreditation Council for Graduate nuances of care delivered at the doctor-patient level.
Medical Education mandated that residents work no more Good patient care is about more than surgical infection
than 80 hours per week. In 2011, it limited individual rates and medication errors. At the end of a long shift, am
shifts for first-year residents to 16 hours. Since then, I the kind of doctor — and person — I want to be? Do I
research has been mixed on whether reducing the length make time to sit with a suffering patient? Do I snap at a
of shifts or total number of hours worked has improved well-meaning colleague?
resident health, medical education or patient outcomes.
Well-being is similarly difficult to study. Research
This year, two large national trials, known as iCompare suggests that one’s judgment of happiness and life
and First, aim to shed new light on the issue. Researchers satisfaction is surprisingly fickle. For example, people
randomized first-year residents at internal medicine or interviewed on sunny days report being more satisfied
general surgery programs across the country to work with their entire lives than those interviewed on rainy
either 16-hour shifts, the current maximum, or longer days. So if you ask me about my training program after a
shifts of 28 hours or more. Shortly after the iCompare particularly bad 16-hour shift, I’m likely to rate it worse
trial began, two advocacy groups sent an open letter to than during a particularly good 30-hour shift.
the Office for Human Research Protections, calling the
trial “unethical” and arguing that it exposes patients to Medical educators also worry that work hour restrictions
dangerously sleep-deprived residents while exposing force residents to see fewer patients and miss important
residents to a greater risk of car accidents, needlestick educational experiences. At the same time, we allow
injuries and depression. residents to spend hours scheduling appointments,
faxing medical records, gathering vital signs, obtaining
These trials come at a critical time, amid mounting prior authorization, and completing many other
evidence of serious mental health concerns for medical nonclinical tasks. We don’t learn to do these tasks in
trainees. A recent study found that almost one-third of medical school; we shouldn’t be spending our time on
residents exhibit symptoms of depression; other studies them as residents. If we’re concerned about resident
show that almost 10% of fourth-year medical students education, let’s focus on increasing quality time spent on
and 5% of first-year residents admitted to having suicidal direct patient care and educational activities.
thoughts in the previous two weeks — with higher rates
among minorities. The right answer on how many hours residents should
work may be more nuanced than we’ve been willing to
And yet, it’s not clear whether more restrictive work hours accept. It isn’t the same today as it was 20 years ago, as
will make things better for residents or patients. When the complexity of caring for patients and medical technology
residents work fewer hours, there are more patient continue to evolve. It varies by subspecialty — discontinuity
“handoffs” — when a patient is transferred from one doctor may have graver consequences for neurosurgery, say,
to another. The process makes it more likely that important than for radiology. And it hinges more on the character of
details are overlooked, and intimate familiarity with a work than the length of it — I’d spend twice as long at a
patient’s recent clinical course is often left behind. And patient’s bedside if I could spend half as long at a
residents may not even be reporting their hours accurately. computer.
Whistleblower protections are lacking, and the penalty for
work hour violations is loss of program accreditation, Ultimately, the answer may be as philosophical as it is
which could hurt the resident reporting the problem. empirical. What kind of doctors do we want to be? What
kind of doctors do patients want us to be? And does what
In the face of uncertainty, we need more data — and we can’t measure still matter in a profession that’s now
we’re starting to get it. Results from the First trial, judged and motivated by what we can?
published on Tuesday, Feb. 2, found no significant
differences in patient outcomes, resident satisfaction or Dhruv Khullar, MD is a resident physician at Massachusetts
educational quality when surgical trainees worked longer General Hospital and Harvard Medical School.
shifts. (Results from iCompare, which is looking at © The New York Times. Distributed by The New York
internal medicine residents, are expected in June.) Times Syndicate n

26 SOMBRERO – December 2016
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