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



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SOMBREROSOMBRERO –– DecemberDecember 2016201417


Official Publication of the Pima County Medical Society

Vol. 49

No. 10


Pima County Medical Society Officers

President Timothy C. Fagan, MD President-Elect Michael A. Dean, MD Vice-President Susan J. Kalota, MD Secretary-Treasurer Unfilled / Appointment Past-President Melissa D. Levine, MD

Jerry Hutchinson, DO Roy Loewenstein, MD Kevin Moynahan, MD Snehal Patel, DO Wayne Peate, MD Kenneth Sandock, MD Sarah Sullivan, DO Salvatore Tirrito, MD Debra Townsend, MD Fred Van Hook, MD Scott Weiss, MD Leslie Willingham, MD Jaren Trost, MD (Resident) Aditya Paliwal, MD (alt. resident) Jared Brock (student)

Members at Large

At Large ArMA Board

Charles Krone, MD Clifford Martin, MD

Board of Mediation

Robert M. Aaronson, MD R. Screven Farmer, MD

Pima Directors to ArMA

Thomas Griffin, MD Evan Kligman, MD George Makol, MD Sheldon Marks, MD Mark Mecikalski, MD

Timothy C. Fagan, MD

Delegates to AMA

Timothy C. Fagan, MD (alternate) Gary R. Figge, MD Michael F. Hamant, MD (alternate) Thomas H. Hicks, MD

Arizona Medical


Association Officers


PCMS Board of Directors

Michael F. Hamant, MD Vice President Thomas C. Rothe, MD Outgoing Past President


David Burgess, MD Howard Eisenberg, MD Kelly Ann Favre, MD

Executive Director



West Press


Bill Fearneyhough


(520) 795-7985


(520) 323-9559

E-mail: bil l f

Editor Bill Fearneyhough I welcome your feedback and story ideas. E-mail: bil l f


Art Director

Dennis Carey

Alene Randklev


(520) 795-7985


(520) 624-4939


(520) 323-9559


(520) 624-2715





(520) 624-4939

Publisher Pima County Medical Society 5199 E. Farness Dr., Suite 151 Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website:

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, Ste. 151, 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 © 2016, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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


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


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


Makol’s Call: Finding inspiration from industrial billionaires.


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


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


In Memoriam: Remembering Dr. John F. Carroll.


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


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


Practice Policies: One physician offers five ways to engage patients.


Physician Training: Should residents be working fewer hours?

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Here’s a wonderful image of Spider Rock in Canyon de Chelly. Dr. Hal Tretbar snapped it with his 120 Rolleiflex during a 1972 visit.

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Pima County Medical Society, Past, Present and Future:

The Evolution of the PCMS and Sombrero

By Dr. Timothy C. Fagan, PCMS President

PCMS and Sombrero By Dr. Timothy C. Fagan, PCMS President W hy the history lesson? There

W hy the history lesson? There have been

significant changes in the Pima County Medical Society (PCMS) recently and more will occur in the near future, including the consolidation of Sombrero magazine with the publica- tions of the Arizona Medical Association (ArMA) and Maricopa Medical Society (MCMS). This is part of an

ongoing evolution, so I thought it was important to explore the relationships among the medical societies, changes in the medical care environment in Pima County, Arizona and the U.S. These changes are interrelated with changes in society and methods of communication, which have also evolved significantly during the last 170 years.


The evolution of the Pima County Medical Society (PCMS) and Sombrero have paralleled the evolution of clinical practice in Pima County and the evolution of national and international clinical communication. Pima County almost had the first county medical society in Arizona. Mariano Samaniego, MD moved from what is now Ciudad Juarez, Chihuahua, Mexico to Tucson in December 1878. The medical community was very small, and Tucson lacked a modern hospital. Dr. Samaniego was involved in the effort to create what was to become St Mary’s hospital, the first “modern” hospital in Tucson, which was established in 1880. On July 29, 1879, Dr. Samaniego hosted a meeting to explore the possibility of creating a county medical society. In September, 1879, Dr. Samaniego suffered a family tragedy and returned permanently to Ciudad Juarez.

The honor of forming the first county medical society in Arizona may belong to Yavapai County. Differing accounts date the formation of the society to either 1884 or 1893. The Maricopa County Medical Society (MCMS) was formed in 1892. The Arizona Medical Association (ArMA) was establish+ed on May 25, 1892.

The AMA was formed in 1847 and underwent reorganization in 1901. That same year, AMA called

for county medical societies to be established in every U.S. state and territory, stating that it was “the responsibility of professionalism to belong to a county medical society.” The county medical societies would be constituents of their respective state or territorial societies. The state and territorial medical societies would then elect delegates to the AMA. This basic structure persists to this day, even though delegates from specialty medical societies, medical students and medical residents are now elect to the AMA.

At its annual meeting in April 1904, ArMA called for the formation of county medical societies in Arizona. On October 13, 1904, seven physicians met and adopted the constitution and bylaws for the Pima County Medical Association. The mission statement included “…so that the profession shall become more capable and honorable within itself, and more useful to the public, in prevention and cure of disease, and in prolonging and adding comfort to life.” The original members were William V Whitmore, MD, President; Arthur W Olcott, MD, Vice President; Joseph W Lennox, MD, Secretary-Treasurer and charter members Henry E Crepin, MD; Hiram W Fenner, MD; Walter B Purcell, MD; and Mark A Rodgers, MD. Dr. Rodgers later founded The Rodgers Hospital, the first hospital in Tucson with obstetrical services.

The first functional typewriter was constructed in 1808, but typewriters were not successfully marketed until 1874. In 1904 a typewriter cost about $68, equivalent to about $1,700 today and did not come into widespread use until the 1920s. Consequently, in 1904, the founding documents of PCMS were hand written.

ArMA had already printed standard charters containing the word “Society,” so the name was changed from Pima County Medical Association to Pima County Medical Society. In 1904, Yavapai and Maricopa Medical Societies reorganized according to the guidelines proposed by the AMA.

Multiple historic events and movements affected the medical environment before the turn of the 19 th century. The first Medical School for Women, the New England Female Medical College, was founded in 1848. The first U.S. Female Dentist, Lucy Hobbs Taylor, began practicing in the 1850s. In the U.S., the first formal meeting of activists for women’s rights took place on July 19-20, 1848. Approximately 100 people attended, about two-thirds were women. The meeting

resulted in a “Declaration of Sentiments, Grievances and Resolutions.” One statement in this document was: “We hold these truths to be self-evident that all men and women are created equal.” In 1869, the 15 th Amendment to the U.S. Constitution granted the right to vote to African-American men.

Andrew Taylor Still founded Osteopathic Medicine in 1874. He established the first osteopathic medical school in 1892, as a protest against the medical system of his day. The American Osteopathic Association was founded in 1897. The medical school bearing Dr. Still’s name continues to train osteopathic physicians to this day. There are two schools in Arizona, one Mesa and another in Glendale. Osteopathic medical schools continue to train a higher percentage of primary care physicians, compared to allopathic medical schools.


During the years 1905-1954, most physicians in Pima County belonged to PCMS and its meetings were the primary means of communication among physicians. From 1920 to 1928, World War I veterans were treated at Pastime Park Hospital, a refurbished amusement park on Oracle Road, north of Tucson. Primary medical conditions of these veterans were poison gas inhalation, tuberculosis and residual effects of Spanish Influenza. As a result of the severity of diseases and the limited treatments available, many of the veterans did not survive. In 1928, the Tucson VA Hospital was commissioned. Founded in 1926, the Desert Sanatorium primarily treated patients with tuberculosis. In 1944 the Desert Sanatorium became Tucson Medical Center. Several of the original buildings are still in use. As more hospitals were built and became a major site of patient care, informal discussions in the doctors’ lounge and on the wards became another method of communication among physicians. All of the monthly hospital medical staff meetings were held on Tuesdays, and became another means of physician communication. PCMS meetings were scheduled for a different Tuesday of each month in order to avoid conflict with the hospital medical staff meetings and continue to be held on Tuesdays to this day. On its 50 th Anniversary in 1954, PCMS had 200 members.

In 1916, Montana’s Jeanette Rankin was the first woman elected to the U.S. Congress. She took office in 1917, three years before the 19 th Amendment to the U.S. Constitution granted her, and all women in the U.S., the right to vote. As women gradually acquired more rights and educational opportunities, their role in society expanded. In Tucson, one manifestation of this was the formation of the 15-member PCMS Auxiliary in 1931, an organization of physicians’ wives. In the 1990s, as part of a national movement in which doctors’ wives became “allies,” the name was changed to PCMS Alliance and during the coming years membership increased more than tenfold. Unfortunately, education of female physicians lagged far behind.

An important component of women’s rights is contraceptive needs and rights, which had become a political issue as early as the 1860s. In 1873, the Comstock Act prohibited advertisements, information and distribution of birth control. In 1916, Margaret Sanger opened the country’s first birth control clinic but a year later was sentenced to 30 days in jail for “maintaining a public nuisance.” After being released from jail, she reopened the clinic but continued to be arrested and prosecuted multiple times.

In the autumn of 1934, a meeting of Tucson women was held for consideration of establishing a birth control clinic. The meeting was attended by Margaret Sanger. The decision was made to establish the clinic and a Board of Directors was elected. In December 1934, at a special meeting of PCMS, a motion was passed supporting such a clinic. The Chairman of the Birth Control Clinic of Tucson, Mrs. Marion Smith, appointed three members of PCMS as the clinic’s Medical Advisory Board. A building was rented and refurbished to house the new clinic, but making women aware it existed was difficult. Word of mouth was the only means available, since the Comstock Act was still in effect. In 1938, a judge lifted the Federal ban on birth control, and in 1939, PCMS passed a motion for use of contraceptives. Later the Birth Control Clinic of Tucson became the local chapter of Planned Parenthood.


New medications became available in the 1950s and 1960s. These included new oral agents and longer acting insulins to treat diabetes, beta agonists and methylxanthines to treat asthma and COPD, beta blockers along with centrally acting agents and alpha blockers for hypertension. New diagnostic techniques, including radionuclide and ultrasound imaging, became available.

During the Administration of Lyndon Johnson, Medicare was enacted in 1965.

Membership in the PCMS increased to 280 by 1963 and to about 750 in 1967. The UA College of Medicine (COM) admitted its first class in 1967. In the autumn of 1968, the University Hospital was still a large hole in the ground. A significant portion of the Tucson faculty came travel from other universities just long enough to teach their courses and then return home. The hospital was completed in 1971, two months after the first medical school class had graduated.

The 1960s brought new attention to interracial problems. After many years of effort by legislators, physicians, educators and others, passage of the Voting Rights Act in 1965 prohibited many discriminatory practices including limiting the ability of African-Americans to vote. African-American medical students were rare. UCLA’s 1969 class had only one minority student out of 104. Women represented less than 10% of medical students entering the UA COM in 1967 and four of 104 entering UCLA in 1969.

Although television became available in the late 1940s, offerings were very limited. The number of television stations in Phoenix increased from two to four in the 1950s. The early 50s saw the premier of medical TV dramas City Hospital and The Doctor but both were short lived. The very popular shows Dr. Kildare and Ben Casey premiered in 1961.

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 news to its readers. For the first 12 years, it had a green cover with a picture of a Sombrero.


Medical advances were so rapid and wide ranging during the next three decades that the only way to keep up was by reading medical journals or attending large medical meetings. The development of Medicare, Medicare Advantage plans and commercial health insurance began impacting physicians’ practices. The number of osteopathic and allopathic physicians, as well as the number of hospitals in Tucson continued to increase. PCMS became one of the first county medical societies to admit DOs as full members. By 1976, women made up 20% of medical students, and by 2000 more than 40%. However, it was not until 1990 that PCMS elected its first female president Dr. Janis Johnson.

The first description of computer networking at a distance came from MIT in 1962. This took place over 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 provide in the early 1980s. On October 24, 1995, the Federal Networking Council (FNC) unanimously 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 following language reflects our definition of the term “Internet.” “Internet” refers to the global information system that – (i) is logically linked together by a globally unique address space based on the Internet Protocol (IP) or its subsequent extensions/follow-ons; (ii) is able to support communications using the Transmission Control Protocol/Internet Protocol (TCP/ IP) suite or its subsequent extensions/follow-ons, and/ or other IP-compatible protocols; and (iii) provides, uses or makes accessible, either publicly or privately, 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 publication for physicians in Pima County. Sombrero continued to be edited and produced by the PCMS

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staff until Steve Nash became editor in 1987. Five years later Nash was named CEO of PCMS and Sombrero was turned over to Fearneyhough and Associates, a local marketing and public relations firm. In 1996, production and editing was brought in-house with the hiring of Bill Fearneyhough as full-time staff.


Membership in PCMS has been stable during the past decade but with the adoption of “group” memberships the rolls have increased to more than 1,000 active members, the largest number of active members in the Society’s 113-year history. Unfortunately, the Yavapai County Medical Society is no longer in operation, so

PCMS and MCMS are the only remaining county medical societies in Arizona.

After making major contributions to PCMS during his 27 years with the Society, Executive Director Steve Nash resigned in 2013 in order to assume a similar position with the Tucson Osteopathic Medical Foundation (TOMF). Bill Fearneyhough was promoted to replace Mr. Nash.

The availability of all types of medical information from journals and the Internet has made information exchange at society meetings much less important. The increase in Hospitalists, from nearly nonexistent 20 years ago, to 50,000 today, has reduced communication in the hospital

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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 need of extensive and expensive renovation. Since attendance at general meetings had declined to nearly zero, the Board of Directors decided to sell the building, lease back office space in the refurbished building and hold meetings at the Osteopathic Medical Foundation facility.

The proliferation of new medications, new imaging modalities and improved resolution, as well as “personalized medicine” and gene therapy, have been so great that communication of information about these changes is only 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.

Women have entered every area of science, private enterprise and government, but they are underrepresented at the highest levels. Women constitute about 50% of medical school classes. The average woman is paid about three quarters of what the average man is paid. In 2016, for the first time, a woman was selected by a major U.S. party as a U.S. Presidential candidate.

In 2002, Americans of African descent comprised seven percent of students entering allopathic medical schools. In 2015, they made up six percent of 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 residency programs in Arizona. Students in osteopathic schools constitute 20% of all medical students. In 2014, there were 86,765 osteopathic physicians licensed in the U.S. The first osteopathic physician to serve as President of PCMS was Edmund Krasinski, DO, in 2002. Today, in nearly all respects, MDs and DOs are treated and accepted as equals.

The Future

Here are some of my views and hopes for the future. Directly, and indirectly through ArMA and the AMA, PCMS will continue to serve as a strong voice for southern Arizona physicians in the Arizona Legislature and U.S. Congress, as well as serving as a clearing house for communication among physicians. Women will achieve equal pay with men and will attain equal status at the highest levels of science, private enterprise and government, as will Americans of African descent. The first woman President of the U.S. will be elected.

Medical knowledge will increase, and previously incurable and untreatable diseases will respond to new therapies. Genome knowledge and editing, as well as other gene therapies, will play a large role. Medicine will have a more preventive focus. Physician mastery and utilization of Biomedical Informatics will become essential to the modern practice of medicine. The role of telemedicine will continue to grow. EHRs will seamlessly share data with other EHRs. Decision support tools within the EHR will analyze multiple types of information, trigger alerts to physicians and other providers, and assist in medical decision making.

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us at: (520) 901-4800 SOMBRERO – December 2016

Sombrero magazine

The December, 2016 issue of Sombrero will be the last issue published. After nearly 50 years of providing our members with the 10-times-a-year publication, the Society has decided to pursue an exciting new endeavor. In January, you will begin receiving a new publication that we have named Arizona Physician. This will be a combined effort with ArMA and MCMS and will replace the journals that each currently distributes to members. This means that Sombrero, Arizona Medicine, and Round-up will cease publication at the end of the year. Why the change? For one, our three organizations have been discussing ways that we can work more collaboratively. We each strive to protect the practice of medicine here in Arizona, and much of what we publish in our journals has considerable overlap. Issues that pertain to our readers – MACRA, ICD-10, AHCCCS expansion, scope of practice concerns, etc. – apply to ArMA and MCMS readers as well as ours. Additionally, our three organizations contract with many of the same advertisers, a number of whom prefer a single ad buy in a magazine with more widespread distribution. By combining efforts, we are able to reduce the costs of production and can now afford to distribute this new publication to all Arizona physicians, since our issues and activities impact every physician.

We are creating a new alliance to move forward on behalf of physicians and their patients. This this is an

on behalf of physicians and their patients. This this is an important first step. Arizona Physician

important first step. Arizona Physician will be a monthly magazine that provides all physicians with a collective voice. It will strive to capture the views and concerns of the nearly 18,000 physicians (MD and DO) practicing in Arizona. It will inform physicians in our state about issues that stand to impact the way they practice medicine, and it will be a valuable resource to connect with other physicians. Our primary objective with Arizona Physician will be to provide you with the highest quality magazine each month. We are confident this effort will enhance the practice of medicine in our state and will encourage collegiality among our physicians. We also believe that it will serve as a resource for busy practitioners who may not know where to look for legislative updates, opportunities to network, employment and practice opportunities, and CME offerings, among other things. Physician representatives of the three societies will serve on the journal’s editorial board. Initially, Michael Dean, PCMS President for 2017, resident Jaren Trost and Timothy Fagan will represent PCMS.

Arizona Physician will also be available each month electronically. For those of you who prefer to read publications online, please simply email us at and we will make sure you are added to the distribution list for the electronic version.

With the healthcare landscape evolving rapidly, so 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.


UA College of Medicine

Building Academic Medicine’s Future

By Charles B. Cairns, MD, Dean, UA College of Medicine – Tucson

B. Cairns, MD, Dean, UA College of Medicine – Tucson T he footprint of academic healthcare

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.

These new structures will improve patient care and health care delivery, and enhance interdisciplinary research and medical education across the University of Arizona Health Sciences. They will improve the experiences of the College of Medicine – Tucson students, residents and fellows, faculty and patients, and will impact the way our faculty teach, our students learn and health care is provided.

Health Sciences Innovation Building:

220,000 square feet

Completion date: September 2018

Interdisciplinary training of future doctors, nurses, pharmacists and public health professionals

State-of-the-art simulation and innovation

The Health Sciences Innovation Building (HSIB) will triple the space allocated to students’ community life and interactive education. With an entire floor dedicated to simulation and the ability to expand our clinical teaching activities, we will be able to keep up with the changing demands of undergraduate medical 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

research in many health science disciplines The new 670,000 sq. ft. University Medical Center Tucson is

The new 670,000 sq. ft. University Medical Center Tucson is expected to be completed in 2019.

The Bioscience Research Laboratory Building (BSRL) will provide new space for interdisciplinary research, which is a key component of the College’s strategic vision for the future. By identifying the intersection of health care issues and our areas of expertise, and then working across disciplines – across departments, centers and other colleges – we can find innovative solutions to the health care needs of today and tomorrow.

Banner Health – University Medical Center Tucson:

670,000 square feet

Completion date: Spring 2019

336 private patient rooms, 22 operating rooms, imaging suites and public spaces

New diagnostic imaging, diagnostic cardiology, cardiac cath labs and interventional radiology

More than $50 million in new patient care equipment and computers for state-of-the-art care

care equipment and computers for state-of-the-art care The Bioscience Research Laboratory Building will provide

The Bioscience Research Laboratory Building will provide much needed space for interdisciplinary research.

The Health Sciences Innovation Building will triple the space allocated to students’ community life and

The Health Sciences Innovation Building will triple the space allocated to students’ community life and interactive education.

For a perspective on this massive project, take a look at the cranes cutting into the Tucson skyline at the hospital construction site. The 400-foot cranes weigh 700,000 pounds and are taller than any building in town. It is truly a big project that will have a major impact on patient care in Arizona. The new nine-story hospital provides new, updated patient rooms and will house more than $50 million in new patient-care equipment. Additionally, when the new hospital is complete, the old hospital space will be repurposed for academic office and research space.

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 pharmacy. A new parking garage is also under construction, which will offer free covered parking.

Many positive changes are underway for health care in Tucson thanks to these capital improvements at the University of Arizona and by Banner Health.

You can find the most up-to-date construction information, including webcams at the BSRL, HSIB and hospital construction sites, at n

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Health Risk

Getting a flu shot is being responsible

By Francisco Garcia, MD, PCHD Director and Chief Medical Officer

Garcia, MD, PCHD Director and Chief Medical Officer M y wife, Amy, reminded me this weekend

M y wife, Amy, reminded me this weekend that the

boys had not had their flu shots yet this year. It’s always a bit of a challenge coordinating schedules for two working parents and two kids, but this is something that has to be a priority.

Aside from the hassle of

being sick and missing work or school, getting your flu shot is a responsibility we all take part in to help protect the health of the folks we come into contact with. Amy’s pregnant patients and their families count on her to keep them well, and the last thing they need is to get sick from an encounter with their OB doctor. The same thing with my boys, not only are they protected from getting the flu, they are reducing the risk of potentially spreading the flu with children at school who may not be vaccinated or whose immune system may not be working well. For me, I am out every day meeting with many different community members and I would hate to think that I made someone ill. Like many families’ we spend time with older parents/grandparents who are more vulnerable and for whom the consequences of the are more serious.

It is important that we take care of ourselves in getting

a flu shot every year and know that in doing so we are

also taking care of our families and our community. So in that spirit, the following information includes a few good reasons to get vaccinated this year:

Being sick is costly in terms of productivity for everyone. None of us have enough time and it makes good sense to protect ourselves from a virus that could take valuable time away from other activities, both work and play. The vaccine is safe, generally has few side effects and doesn’t give you the flu.

Limit the risk of serious illness for yourself and

others. Last year there were more than 3,400 confirmed cases of flu in Pima County and of those, 18 died. Even those who are not sick can still be carriers and expose vulnerable populations including children, pregnant women, seniors and people who have pre-existing respiratory conditions. Health care workers in particular should get a flu shot as they are caring for medically compromised members of the community.

Routine annual influenza vaccination is recommended for most persons over the age of six months and ideally, vaccinations should occur before the onset of flu activity in the community. That is why it’s important to get your flu shot early or as soon as the vaccine becomes available.

Where to get flu shots:

Many major employers offer flu shots at the worksite for little or no cost. Check with your human resources department to get information on flu shot clinics at work.

Many drugstores offer onsite flu shots for a minimal cost with little or not wait.

Local health clinics offer flu vaccinations for free or at reduced costs.

The VA offers flu shots for those eligible

Contact your health care provider. Most insurance plans cover it at little or no cost to you.

In addition to getting the flu shot, there are other ways to protect yourself and others from getting sick. Flu viruses spread from person to person through coughing, sneezing, by touching something with flu viruses on it and in some cases through the air. Make sure to wash your hands frequently, always cover your cough (use your elbow, not your hand) and stay home when you are sick.

The flu is more serious than the common cold, so it’s important to do everything you can to prevent its spread. Don’t wait—protect yourself by getting a flu vaccination. You can be sure my boys, my wife and I will be doing the same.


Makol’s Call

Thank You Charles Simonyi

By George J. Makol, MD

Call Thank You Charles Simonyi By George J. Makol, MD I ’m taking this occasion to

I ’m taking this occasion to thank Charles Simonyi for inspiring

me to create my December column. He created the main writing instrument that I used, the same tool that you probably use every time you dictate a letter, enter a paragraph into a computerized record, or prepare one of those

corny, self – aggrandizing

than 200 feet long lined up along the intercostal waterways. I even knew a captain or two, and on occasion while the rich owner was away, I would tie my little 17 foot ski boat to one of their anchor lines and party on board with friends.

However, I had never seen a ship such as this. It was more than 230 feet long, covered in military gray with no corners, no sharp edges, no visible windows and no identifying marks on its military-style hull except a cryptic number 9906. On the upper deck was a battle- ready McDonald Douglas MD – 520N helicopter. It appeared to me that the ship was designed to be completely invisible to radar. Awestruck, I approached our captain and asked, “Is that a new battleship of Danish Navy design?” I was thinking it was meant to stealthily cruise the Barents Sea, invisible to Russian submarines known to frequent the area.

“No,” he replied. “That super yacht belongs to the fellow who created Microsoft Word and Excel.” He was referring to Charles Simonyi who, somewhat penniless, immigrated to the US from communist 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.

“Johnny made the honor roll” holiday letters to friends and relatives.

I, like you, had no idea who the heck Charles Simonyi was until recently. I was cruising on my way to see Copenhagen’s famous Little Mermaid, when our sightseeing boat turned south and headed for most incredible ship I have ever seen. Growing up around Fort Lauderdale, I was used to super yachts of more

around Fort Lauderdale, I was used to super yachts of more As I stared at this

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

millions of other people use every day – Microsoft Word. If you figure he earns a few pennies every time one of us writes a letter, prepares a medical report, creates a legal document, or even authors a novel it adds up to a lot of dough, a mega-mansion in Seattle, and a super yacht

While Charles brought useful writing and spreadsheet tools to the masses, Henry Ford brought the $495 model T within the reach of the average consumer. While Ford did not invent the automobile, his mass production techniques revolutionized and changed our society by vastly increasing the mobility of Americans.

Then again there is Andrew Carnegie. Born in 1835, he would go on to lead the enormous expansion of the American steel industry. Or consider Cornelius Vanderbilt, who, without formal education, built incredible wealth through railroads and shipping, and like Carnegie went on to become a major philanthropist.

While not all of these icons of industry were perfect men, they vastly improved life for the everyman.

While I do admire Simonyi’s elegant software creations and the great 19th century industrialists mentioned above, I find myself a little confused and confounded by the people we are making rich today.

WhatsApp is an instant messaging application allowing one to send text messages, PDF files, and instant messages over smartphones. Ukrainian immigrant Jan Koum cofounded this company and later sold it to Facebook for $19 billion. Even accounting for inflation this dwarfs the fortune of Simonyi, Ford, Carnegie, and Vanderbilt. Nineteen billion bucks so people can chat and send files to each other?

I use a Wi-Fi app called Viber sometimes. It enabled me to make calls from Australia to the US for practically nothing. Useful, but probably not worth billions.

Technology has also caused some notably undesirable side effects.

Just the other night my wife and I were at dinner and nearby was a table occupied by four notably handsome young men and women. I couldn’t help but notice that the four were continually consulting their phones and “chatting” with people in some other sphere. There was little conversation going on among the four, but they could communicate with somebody in Kansas for free during desert!

My daughter is a manager an upscale retailer here in town. She interviews young people seeking employment for positions that demand the ability to talk with the public. She says half the people she interviews cannot carry on a conversation; I told her she’d be better off placing them in another room and texting them.

Believe me, I’m no Luddite; I do carry a Galaxy pad room to room. My letters to other doctors are in fact dictated using Microsoft Word. I spend lots of time, away from patients, using Dragon Naturally Speaking to talk to my word processor. There is a time and place in medicine for technology, but only after spending time talking, listening and treating the patient. Most patients are typically nervous, a little scared, and sometimes overwhelmed when they seek our help. A keyboard is not the patient; a computer screen is not the patient.

I’m glad Simonyi immigrated to this country to join other entrepreneurial greats, many of whom have made my life better. None of us physicians may end up

being billionaire industrialists, but we can be icons to our patients by providing effective, personal, and compassionate care. The only difference is, like me,

you’ll have to settle for a much smaller boat.


care. The only difference is, like me, you’ll have to settle for a much smaller boat.

Behind the Lens

Fond memories of “Behind the Lens”

By Hal Tretbar, MD

Fond memories of “Behind the Lens” By Hal Tretbar, MD W ay back when the editor

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 many worldwide adventures.

For several years George and I had a monthly Travel Page in the Arizona Daily Star. We were in Istanbul, Turkey when the Twin Towers came down. Shortly thereafter, the columns ended when powers that be announced no one would now be interested in traveling.

My wife Dorothy and I had always tried to visit interesting places after an international medical meeting – such as a meeting in Singapore on Systemic Lupus followed by a stay with headhunters in Borneo, or driving for a week from brewery to brewery in Bohemia after a meeting in Prague on Vasculitis.

I retired from the daily grind of medical practice in 1998, after which I became a Trip Leader for Arizona Highways Photo Workshops. While leading these workshops throughout the American West, I have had

these workshops throughout the American West, I have had Here is the Sombrero from December 1982

Here is the Sombrero from December 1982 with the Matterhorn reflection image on the cover.

the good fortune to work with many well known nature photographers.

I was just looking at some of my old Sombrero magazines. For the December 1982 issue Editor Eloise Clymer had a special section of photographs submitted by PCMS members. This issue featured three full pages of color, a novelty for the magazine. Dr. Paul Schnur had a page of three black-and-white images. Dr. Harold Kohl Jr. had Mooney Falls, Havasu Canyon and Dr. Robert P. Friedman submitted San Xavier Mission. My color photo was of a Swiss man and his dog with the mountain in the background titled On a Matterhorn Trail.

The December issue was also my first Sombrero cover. It is a black-and-white photo titled The Majesty

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.


Lens has provided many pleasant experiences and memories. n More than ink on paper. At West
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Road Trip

Going off road to offbeat Keeylocko


West, in a cowtown run by one unique rancher-cowboy.


ain’t your everyday tourist attraction. It’s the authentic, wild and wonderful

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 three miles further, you’ll travel through four more signposts that encourage you onward through twisty ranchlands. Then, there’s a left turn that reveals a dog-eared entrance gate. Take your car up the uneven, dusty rise…passing junk oddities and old trucks. Finally, there it is, Keeylocko – one gritty, bizarre street set within the wild desert abutting the Coyote Mountains.

The Cowboy of Keeylocko At 85-plus, Ed Keeylocko still runs his Keeylocko ranch, a spread of 30-plus acres with 10 wood-tin buildings that form a Main Street-turned-roadside oddity.

He checks the fences around his ranch of about 100 head of cattle and a couple of dozen horses, with the help of a few friends who double as trail bosses, ranch

the help of a few friends who double as trail bosses, ranch Reach Keeylocko off of

Reach Keeylocko off of Arizona State Route 86, approximately 40 miles southwest of Tucson.

hands and cooks when needed. A Korean Army vet born in the Carolinas, Ed traveled the country after his Army career before settling in the Sonoran desert grasslands. He attended the University of Arizona, learning about agriculture, because he wanted to breed well-armed cattle that could protect themselves on the range. (“Give them back their horns,” he says.) He bought the land and built his Keeylocko tin-wood town with his own hands in the 1970s, mainly because he wanted a working ranch to breed his cattle and horses.

Folk Art and Funky Over the years Ed’s eccentric Keeylocko was most

Funky Over the years Ed’s eccentric Keeylocko was most Pigs outnumber humans on most days in

Pigs outnumber humans on most days in Keeylocko.

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

Photo ops abound around this odd Cowtown.

Keelocko was founded by rancher Ed Keelocko, who began building his wood-tin town in the

Keelocko was founded by rancher Ed Keelocko, who began building his wood-tin town in the 1970s.

successful in catching the interest of the avant-garde. Now it draws unconventional explorers and a handful of music festivals, weddings and film productions each year. There’s plenty of folk life and character in Keeylocko’s creative town, which includes a collection of endearingly ramshackle buildings, guarded by a drove of squeaky pigs. There’s a fort to browse, the

by a drove of squeaky pigs. There’s a fort to browse, the Wild west memorabilia and

Wild west memorabilia and an assortment of old vehicles are situated like outdoor art fixings around the ranch.

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.

The public is welcome to meander this imaginative whistle-stop, which has no facilities but plenty of photo ops. Ed accepts appointments for groups, and for these occasions he’ll fire up the generator, put on the smoker, load up coolers of ice and open the saloon. He’ll also stomp around town, with the buildings usually closed until special events like KeeyLocko Days, an annual weekend fest of music, crafts, trail rides, BBQs and primitive camping that happens in October.

rides, BBQs and primitive camping that happens in October. The Blue Dog Saloon is actually a

The Blue Dog Saloon is actually a working bar (but call ahead for the schedule of open times and musical performances).

Ed has a story behind each of his Keeylocko buildings, even this “one hand cashier”

Ed has a story behind each of his Keeylocko buildings, even this “one hand cashier” bank.

Keeylocko buildings, even this “one hand cashier” bank. The centerpiece of Keeylocko is the Blue Dog

The centerpiece of Keeylocko is the Blue Dog Saloon, with its eccentric décor and Ed storytelling (as long as you schedule your visit).

Inner Cowboy Magic You’ll be feeling pretty darn maverick after your ride out to this odd and remote place. Ed’s quirky handmade masterpiece in all its spunky glory will have something to interest everyone – the photographer, the history buff and the explorer. And of course this place has something special for the inner cowboy in all of us, 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.

one of those big cowboy dreams into his or her pocket. Stop at Todd’s (in historic

Stop at Todd’s (in historic Ryan Field) to get refreshed or order 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:


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 ( 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 either before or after a Keeylocko visit.

A gas station is located at the nearby Robles Junction- Three Points intersection of State Routes 86 and 286.

Four-wheel drive is not required, but it’s advisable to check the weather (and not travel during rains). Carry

plenty of water. Follow directions indicated in this story to recreate this trek: Do not follow GPS or digital map apps, as some Native American roads restrict travel

and the route ain’t always what GPS tells you it is!


In Memoriam

Dr. John F. Carroll


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 retired in 1996. He was a past president of St. Elizabeth of Hungary Medical Services. He served three years as a delegate to the Arizona Medical Association.

Aviation was a passion for Carroll, winning the coveted Tequila Cup for aerobatics competition in 1997. He 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 years, Georgiann; children, Cindin Carroll, George and Dawn Carroll, John and Lori Carroll and, Susan and Kevin Westfall; grandchildren, Evan, Dylan, Douglas, Johnathon, Madison, Tyler and Kori; great- grandchildren, Hailey, Braxton and Bently and by his sister, Mary Rose



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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 offering patients effective treatments for chronic pain, most often without prescribing

potentially addictive opioid-based medications.

In several cases, patients whose pain rendered them unable to work have been able to resume working.

Mohab Ibrahim, MD, PhD, and Amol Patwardhan, MD, PhD, both assistant professors in the UA College of Medicine – Tucson departments of Anesthesiology and Pharmacology, are director and co-director of the Chronic Pain Management Clinic, an outpatient clinic at Banner – University Medical Center South. In July, a third pain specialist, Vasudha Goel, MD, assistant professor of anesthesiology, joined the Chronic Pain clinic team.

“Pain clinics nationwide are under-utilized,” Ibrahim said. “Patients think pain clinics are where you go to get prescription, which you can probably get from your primary care provider.

“In fact, prescribing medications is the least of what we do in our clinic. What we do most is procedures, and we often have very good results.”

One example is the spinal cord stimulator, a small, implantable device that resembles a heart pacemaker and sends electrical signals to the brain to block the sensation of pain.

Patwardhan and Ibrahim are quick to point out that

opioid drugs not only are safe when used correctly, but necessary for patients with chronic pain related to cancer, surgery and severe trauma.

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But whenever possible, patients who visit the Chronic Pain Management Clinic will be offered non-opiate solutions to their pain.

A non-opioid medication offered at the clinic is Dronabinol, less dependence producing, synthetic cannabinoid developed and FDA- approved to control chemotherapy- induced nausea and vomiting, and to increase appetite in patients with AIDS. More recently, it’s been used to treat neuropathic and multiple sclerosis related pain.

One patient with severe left-sided 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.

The comprehensive pain clinic offers patients several other procedures to help reduce pain, including epidural steroid injections, joint injections,

high temperature and pulse radiofrequency ablations, spinal cord and peripheral nerve stimulators and Botox injections for migraine and other painful conditions. Goel has a special interest in the management of cancer-related pain. “We still have a long ways to go in managing cancer pain,” she said. “There are simple nerve blocks that can help significantly with the pain, allowing the patient to spend more quality time with loved ones.”

Ibrahim and Patwardhan are members of the University of Arizona College of Medicine-based Arizona Pain Research Group, led by Frank Porreca, PhD, UA professor of anesthesiology and pharmacology, who is known for his pioneering research on the molecular origins of chronic pain, and discoveries that may lead to new treatments.

Developing improved therapies for chronic pain has been Porreca’s goal since the early 1990s.

Porreca described as “revolutionary” the increased understanding of pain since the early 1990s. “What has been lagging is the introduction of new molecules that can lead to new treatments. But there are efforts and ongoing trials that can hopefully lead to some success.”

When new patients come to the clinic, Dr. Ibrahim said, “We will evaluate their situation, give our honest opinion and offer certain options. We like to see patients early on, rather than after they’ve tried months of different medications. Our main goal is to get the patient functioning again. And the majority do get better.”

NOTE: Physicians and patients are welcome to call the Chronic Pain Management Clinic at 520-874-7246 (PAIN).

the Chronic Pain Management Clinic at 520-874-7246 (PAIN). About Dr. Goel Vasudha Goel, MD, studied medicine

About Dr. Goel Vasudha Goel, MD, studied medicine in her native India before coming to the U.S., where she completed her internship at Long Island College of Medicine, followed by her residency in anesthesiology at SUNY Downstate School of Medicine, and a fellowship in pain medicine at Loma Linda University Medical Center.

in pain medicine at Loma Linda University Medical Center. About Dr. Ibrahim Mohab Ibrahim, MD, PhD,

About Dr. Ibrahim Mohab Ibrahim, MD, PhD, came to Tucson from his native Egypt in 1993 with the intent of becoming a physician. At the UA he earned a bachelor’s degree in biochemistry and a master’s degree and PhD in pharmacology and toxicology. He graduated from the UA College of Medicine – Tucson in 2008, then completed a surgical internship at the

UA and did his residency in anesthesiology at Brigham and Women’s Hospital in Boston. He followed that with a clinical pain fellowship at Massachusetts General Hospital.

clinical pain fellowship at Massachusetts General Hospital. About Dr. Patwardhan Amol Patwardhan, MD, PhD, studied

About Dr. Patwardhan Amol Patwardhan, MD, PhD, studied medicine in his native India, where he earned his MD. After receiving his PhD in pharmacology from the University of Texas Health Science Center in San Antonio, he completed his internship in surgery and his residency in anesthesiology at the UA, followed by a pain medicine fellowship with

the anesthesiology program at the University of California, San Diego. Dr. Patwardhan has published more than 30 peer reviewed papers about pain mechanisms, holds two patents and has received numerous grants for his research studies.

About Dr. Porreca Frank Porreca, PhD, professor of pharmacology and anesthesiology, is a member of the UA Cancer Center and principal investigator of the UA Pain Research Group. He has served as editor-in-chief of Life Sciences, and as pharmacology section editor for Pain, and has authored more than 450 peer-reviewed papers providing insight into pain mechanism and

treatment. He is founder and scientific organizer of the Pain Mechanisms and Therapeutics Conference, a biennial event that attracts world-renowned members

of academia and industry.


Prac ce Administra on

Healthcare’s top priority:

Fast and easy appointments

By Jonathan Bush

I go to a lot of health care conferences, and of late there’s a seemingly obligatory slide that crops up in nearly every PowerPoint. It’s a now-iconic image of

a triangle divided in equal parts and labeled as follows:

“improve the patient experience,” “improve the health of populations” and “reduce the per capita cost of care.” This is health care’s “Triple Aim,” and it is definitely trending.

I must confess that I’m not a fan of the Triple Aim. It’s not that I don’t believe those three outcomes are vitally important. I just don’t believe it’s possible to aim at three things at once. As a manifesto or creed, it’s inspiring. As a roadmap, it’s a bit hard to follow.

A more effective approach to change, I’d argue, is the

one taken by Paul O’Neill back in 1987 when he was first appointed CEO of the aluminum giant Alcoa. As New York Times reporter and author Charles Duhigg recounts in his bestseller, “The Power of Habit”, accidents were commonplace at Alcoa, as they would be at any company in the business of handling molten metal on a regular basis. But the company’s safety figures weren’t bad – in fact, they were better than that of their competitors.

Nevertheless, O’Neill stood up in front of his investors that year and declared that the company would focus its entire strategy on bringing workplace injuries to zero. “If you want to understand how Alcoa is doing, you need to look at our workplace safety figures,” he argued. No talk of profits, opening new markets, or any of the usual crowd pleasers. Everyone thought he was nuts.

By the time O’Neill left Alcoa in 2000 to become Treasury secretary, the company’s market cap had increased by $27 billion and by 2010 not a single employee day was lost to workplace injury at 82% of Alcoa locations.

So what happened at Alcoa?

O’Neill had located and had the discipline to focus on what Duhigg calls a “keystone habit,” a deep

organizational vein that, once tapped, has the power to drive other downstream improvements as it reverberates through an organization. In the case of Alcoa, once employees were asked to suggest ideas for safety improvement they began to surface other issues that had been buried. The rising tide of a more open, problem-solving culture helped raise all of Alcoa’s boats – and profits.

At my company, Athenahealth, we are big believers in focusing ourselves and our clients on keystone habits and corresponding “sentinel” metrics. Our corporate scorecard, for example, is a waterfall that begins with workforce stability - over 17 years, we’ve found that our success depends on focusing first on managing voluntary turnover, ahead of all other traditional performance measures (including the ones our investors care about). Any spike in voluntary turnover is a canary in our coal mine and raises an alert that we take very seriously.

So, what should health care providers focus on as their keystone habit? For my money it’s patient access - making it as easy, quick and worry-free to get an appointment with a provider.

When provider organizations make it a habit of opening their schedules and committing to same- week-or-sooner appointments, other good things can happen. Appointment types can be simplified and streamlined, driving other opportunities for process improvement and efficiency. Care is more likely to be directed as appropriate to lower-cost providers and nurse practitioners or even to virtual consults, cutting costs and eliminating unnecessary care.

And, most important, physicians can be freed up to see the sickest patients when they need to be seen.

Jonathan Bush is the CEO and president of Athenahealth and the author of “Where Does it Hurt? An Entrepreneur’s Guide to Fixing Healthcare.” 2015 Harvard Business School Publishing Corp. & The New York Times Syndicate.


Pa ent Care

Five ways to engage patients

By Sachin H. Jain, MD

M edical science has enabled our health care system to deliver outcomes that would have been impossible a generation ago, and

advances in fields such as genomics and stem-cell therapy offer immense promise to further accelerate medical innovation.

As extraordinary as insights from the laboratory often are, better understanding the experiences of patients and health care providers can provide a roadmap for the critical last mile of medical care, where all policies, procedures and practice converge into action.

Below, I offer some approaches drawn from my experiences working in health-care-delivery organizations, government and industry. (The principles I propose are my own and do not reflect official policies of any organizations with which I am affiliated.)

1. We must strive to move beyond our own experiences. Those of us who work in health care inevitably refer to our own experiences with the health care system when making decisions about strategy and program design. Even at high levels of policy or strategy discussions, it is common to hear, “when I was at the doctor.” or “when my mom was sick.” And while we can gain insights from these personal encounters, it’s critical to remember that our expertise inside the field strongly informs our experience.

All leaders in health care have a level of access, familiarity and comfort with medical care that vastly exceeds that of the average patient. Consequently, as health care providers, we have to ask ourselves this question: What stories are we not hearing? If we don’t keep ourselves honest and consider the voice of the patient not in the room, we overlook opportunities to improve care for a substantial number of people.

2. Get authentic patient voices in the room. To lead change in health care, organizations must get in 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.

There are, of course, limitations, one of which is self-selection bias. People participating in an online community around their disease are already more engaged, more informed and more tech savvy than many others. So while leaders in the health care system integrate the (undeniably valuable) insights from these communities into decision-making processes, we have to account for these patients’ above-average sophistication and its implications for their treatment choices.

4. Remember the other influences of patient health. As impactful as the increasing focus on patient voice can be, it’s critical for organizations to consider the other influencers of a patient’s health that the patient himself might take for granted. Family members, cultural traditions, stress levels, sleep habits and numerous other lifestyle factors impact health but are often considered “just how things are.”

5. Overcome the risks - they’re usually worth the benefits. Because protecting patient privacy is so important in health care, integrating patient voice is not as simple as one might expect. Meeting the regulatory needs of any health care organization takes planning, flexibility and cooperation across teams.

Through engaging the patient voice, we have a powerful tool to inspire and shape new solutions in health care, and there is real value in working through the associated challenges. As the health care system takes a more collaborative approach to helping patients and as patients become active participants, everyone wins.

Dr. Sachin H. Jain is chief medical information and innovation officer at Merck, an attending physician at the Boston VA Medical Center and a lecturer in health care policy at Harvard Medical School.

© Harvard Business School Publishing Corp. Distributed by The New York Times Syndicate.


Medical Educa on

Should Doctors-in-Training work fewer hours?

By Dhruv Khullar, MD

H ow many hours should medical residents work?

Hospital care is a 24-hour-a-day enterprise,

but the question of which doctor should be

there — and how long he or she should already have been there — is among the most controversial and unsettled in medicine. It’s a question that comes up almost daily among my peers, and my own feelings about the issue often depend on whether I’m trying to grasp details about a new patient or struggling to stay awake at the end of a very long shift.

In 2003, at the genesis of the modern patient safety movement, the Accreditation Council for Graduate Medical Education mandated that residents work no more than 80 hours per week. In 2011, it limited individual shifts for first-year residents to 16 hours. Since then, research has been mixed on whether reducing the length of shifts or total number of hours worked has improved resident health, medical education or patient outcomes.

This year, two large national trials, known as iCompare and First, aim to shed new light on the issue. Researchers randomized first-year residents at internal medicine or general surgery programs across the country to work either 16-hour shifts, the current maximum, or longer shifts of 28 hours or more. Shortly after the iCompare trial began, two advocacy groups sent an open letter to the Office for Human Research Protections, calling the trial “unethical” and arguing that it exposes patients to dangerously sleep-deprived residents while exposing residents to a greater risk of car accidents, needlestick injuries and depression.

These trials come at a critical time, amid mounting evidence of serious mental health concerns for medical trainees. A recent study found that almost one-third of residents exhibit symptoms of depression; other studies show that almost 10% of fourth-year medical students and 5% of first-year residents admitted to having suicidal thoughts in the previous two weeks — with higher rates among minorities.

And yet, it’s not clear whether more restrictive work hours will make things better for residents or patients. When residents work fewer hours, there are more patient “handoffs” — when a patient is transferred from one doctor to another. The process makes it more likely that important details are overlooked, and intimate familiarity with a patient’s recent clinical course is often left behind. And residents may not even be reporting their hours accurately. Whistleblower protections are lacking, and the penalty for work hour violations is loss of program accreditation, which could hurt the resident reporting the problem.

In the face of uncertainty, we need more data — and we’re starting to get it. Results from the First trial, published on Tuesday, Feb. 2, found no significant differences in patient outcomes, resident satisfaction or educational quality when surgical trainees worked longer shifts. (Results from iCompare, which is looking at internal medicine residents, are expected in June.)

But I worry about how to interpret the results of trials like these, and what positive or negative findings may mean for residency training discussions going forward. In a profession driven by evidence, data is useful. But it’s important to recognize data’s limitations.

Many patient-care metrics we use to evaluate the impact of duty hour restrictions — mortality, procedural complications, adverse events, readmission rates — are crude. They might make sense for hospitals and health systems designed to increase efficiency and insulate patients from human fallibility. But they fail to capture the nuances of care delivered at the doctor-patient level. Good patient care is about more than surgical infection rates and medication errors. At the end of a long shift, am I the kind of doctor — and person — I want to be? Do I make time to sit with a suffering patient? Do I snap at a well-meaning colleague?

Well-being is similarly difficult to study. Research suggests that one’s judgment of happiness and life satisfaction is surprisingly fickle. For example, people interviewed on sunny days report being more satisfied with their entire lives than those interviewed on rainy days. So if you ask me about my training program after a particularly bad 16-hour shift, I’m likely to rate it worse than during a particularly good 30-hour shift.

Medical educators also worry that work hour restrictions force residents to see fewer patients and miss important educational experiences. At the same time, we allow residents to spend hours scheduling appointments, faxing medical records, gathering vital signs, obtaining prior authorization, and completing many other nonclinical tasks. We don’t learn to do these tasks in medical school; we shouldn’t be spending our time on them as residents. If we’re concerned about resident education, let’s focus on increasing quality time spent on direct patient care and educational activities.

The right answer on how many hours residents should work may be more nuanced than we’ve been willing to accept. It isn’t the same today as it was 20 years ago, as the complexity of caring for patients and medical technology continue to evolve. It varies by subspecialty — discontinuity may have graver consequences for neurosurgery, say, than for radiology. And it hinges more on the character of work than the length of it — I’d spend twice as long at a patient’s bedside if I could spend half as long at a computer.

Ultimately, the answer may be as philosophical as it is empirical. What kind of doctors do we want to be? What kind of doctors do patients want us to be? And does what we can’t measure still matter in a profession that’s now judged and motivated by what we can?

Dhruv Khullar, MD is a resident physician at Massachusetts General Hospital and Harvard Medical School.

© The New York Times. Distributed by The New York Times Syndicate



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