Sombrero

Pima County Medical Society

Home Medical Society of the 17th United States Surgeon General

APRIL 2013

Bioethics: The deciders Shooting horses at the Tucson Rodeo In Memoriam: Dr. Charles Pullen

D DIIS SA AB BIIL LIIT TY YL LIIM MIIT TS SO ON NT TH HE ER RIIS SE E

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Associates Associatesof ofWealth WealthManagement ManagementStrategies Strategieso o er ersecuri securi titi es esthrough throughAXA AXAAdvisors, Advisors,LLC LLC(NY, (NY,NY NY212-314-4600), 212-314-4600),member memberFINRA, FINRA,SIPC. SIPC. Investment Investmentadvisory advisoryproducts productsand and services serviceso o ered eredthrough throughAXA AXAAdvisors, Advisors,LLC, LLC,an aninvestment investmentadvisor advisorregistered registeredwith withthe theSEC. SEC. Annuity Annuityand andinsurance insuranceproducts productso o ered eredthough thoughAXA AXANetwork, Network,LLC. LLC. Wealth Wealth Management ManagementStrategies Strategiesisisnot notaaregistered registeredinvestment investmentadvisor advisorand andisisnot notowned ownedor oroperated operatedby byAXA AXAAdvisors Advisorsor orAXA AXANetwork. Network. AXA AXAAdvisors Advisorsand andAXA AXANetwork Networkare arenot not a a liated liated with with Pima Pima County County Medical Medical Society. Society. PPG PPG 69384 69384 (07/12) (07/12)

SOMBRERO April 2013

Sombrero
Pima County Medical Society Ofcers
President Charles Katzenberg, MD President-Elect Timothy Marshall, MD Vice President Melissa Levine, MD Secretary-Treasurer Steve Cohen, MD Past-President Alan K. Rogers, MD

Official Publication of the Pima County Medical Society Members at Large

Richard Dale, MD Anant Pathak, MD

Vol. 46 No. 4

PCMS Board of Directors

Diana V. Benenati, MD R. Mark Blew, MD Neil Clements, MD Executive Director Steve Nash Phone: 795-7985 Fax: 323-9559 E-mail: steve5199@simplybits.net Advertising Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com

Michael Connolly, DO Bruce Coull, MD (UA College of Medicine) Stewart Dandorf, MS, MPH (student) Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD Jamie M. Fleming (student) Alton Hank Hallum, MD Evan Kligman, MD Melissa D. Levine, MD Clifford Martin, MD Kevin Moynahan, MD Soheila Nouri, MD Jane M. Orient, MD Guruprasad Raju, MD Scott Weiss, MD Victor Sanders, MD (resident) Editor Stuart Faxon Phone: 883-0408 E-mail: tjjackal@comcast.net Please do not submit PDFs as editorial copy. Art Director Alene Randklev, Commercial Printers, Inc. Phone: 623-4775 Fax: 622-8321 E-mail: alene@cptucson.com

Thomas Rothe, MD, president-elect Michael F. Hamant, MD, secretary

Board of Mediation
Bennet E. Davis, MD Thomas F. Griffin, MD Charles L. Krone, MD Edward J. Schwager, MD Eric B. Whitacre, MD

At Large ArMA Board

Ana Maria Lopez, MD,

Pima Directors to ArMA Timothy C. Fagan, MD R. Screven Farmer, MD Delegates to AMA

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

Arizona Medical Association Ofcers

Gary Figge, MD, immediate past-president

Printing Commercial Printers, Inc. Phone: 623-4775 E-mail: andy@cptucson.com Publisher Pima County Medical Society 5199 E. Farness Dr., Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website: pimamedicalsociety.org

SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Ofcers 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 2013, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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SOMBRERO April 2013

Inside
5 Dr. Charles Katzenberg: The ACA does little to 7 8 14 17 20 22 24 26 26
control costs. Letters: Who really wins in AHCCCS expansion? PCMS News: Honors and achievements of our members and other news. Behind the Lens: Dr. Hal Travelin Tretbar and cameras stay in town for La Fiesta de los Vaqueros. Makols Call: Now about those Best Doctors... In Memoriam: Tireless pediatrician and volunteer Dr. Charles Chuck Pullen dies at 87. Bioethics: Physicians and families in decisionmaking. Perspective: Dr. Jerome Rothbaum analyzes our healthcare delivery. CME: Coming events for Continuing Medical Education credits. Members Classifieds

On the Cover
As his peers watch, this tie-down roper races to the dogie at Tucsons annual La Fiesta de Los Vaqueros. Dr. Hal Tretbar writes about getting those horseplay photos in this months Behind the Lens.

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The ACA: Something for everyone, but little to control costs

By Charles Katzenberg, M.D. PCMS President

o one has asked my opinion, but since I have the privilege of writing this column, here is my spin on what we have to look forward to when the ACA becomes fully operational in 2014. I am not a fan of the ACA, but there are some diamonds in the rough: 1. Pre-existing conditions will no longer be grounds to deny insurance. 2. Insurance cannot be canceled. 3. There will no longer be lifetime or episode-of-illness caps on insurance coverage. 4. Kids can stay on their parents policies until age 26. 5. Insurance companies must spend at least 80-85 cents of every premium dollar on healthcare. They will have 15-20 cents, or less, to spend on marketing, overhead, administrative costs (including high-octane salaries) and/ or profits. 6. 15-20 million currently uninsured will find affordable coverage (definition of affordable is that they will not spend more than 8-10% of income on insurance). 7.Insurance companies must provide easy to understand benefit summaries. Why the ACA will not control costs 1. Insurance companies will be able to set their own prices, copays, and deductibles with limited oversight. 2. More patients will be steered toward private insurance. 3. There are no provisions for Medicare or Medicaid to negotiate prices for pharmaceuticals or devices. 4. Twenty to 30 million Americans will still be uninsured and when they become ill, many will receive uncompensated care. 5. The ACA does nothing to immediately address the intensity of services per patient, fee for service, or use of expensive technology. Granted, the ACA has funds directed to comparative effectiveness research, and that is a worthy cause, but it will be years before that tree bears fruit. 6. We are getting older as a population, have more chronic disease, and have increasing technology available. The ACA supports and promotes the current status quo dominated by hospitals and insurance, pharmaceutical, and device companies. Since 1970 per-capita healthcare spending has increased 8.2% per year. The growth rate of healthcare spending outstrips both GDP and salary growth. This is not sustainable. How did spending go from a 14th to more than a sixth of our economy? Answer this and you solve our dilemma. Hint: The answer lies somewhere between an aging population, technology, human nature, greed, capitalism, and the regulation or lack thereof.
SOMBRERO April 2013

U.S. healthcare spending Spending per capita U.S. healthcare spending as percent of GDP

1970 $75 billion $356 7.2%

2010 $2,600 billion $8,402 17.9%

Financing the law will involve some smoke and mirrors as well as real money. 1. There is a 0.9% increase in the Medicare Part A Payroll Tax on wages of more than $250,000 per year. 2. Increased Medicare tax on net investment income of 3.8% if modified gross income is greater than $250,000. 3. Private Medicare Advantage plans will receive lower capitation payments. 4. Device, pharma, and insurance companies will pay a tax. 5. Tanning facilities and Cadillac plans will pay a tax. Raising revenue through taxes or assessments may supply dollars to pay for healthcare, but does not control costs. Summary of cost control options: 1. Reduce payments for administration, physicians, hospitals, devices, medication, and ancillary services. 2. Allow comparative effectiveness research to guide reduced use of services, medication, and technology (long-term). 3. Alter the financing mechanisms. The lowest hanging fruit is $400 billion/year in administrative costs. I dont see a groundswell in Washington ready to discuss this one. Physician reimbursements account for about 20% of healthcare costs, but costs will not be controlled on the backs of physician salaries. Name another profession that has seen reimbursements drop over the past 10+ years while overhead as well as the costs of healthcare have increased? One real key to controlling costs is not through our direct incomes, but by controlling our pens and computer strokes that order tests and treatments. Here is where tort reform and comparative effectiveness research may offer some hope. The ACA moves the ball only a few yards down the field. If we are serious about affordable access to healthcare, we must address both costs and financing mechanisms. Everything should be on the table, including fee-for-service, fee-per-pill, fee-per-device, fee-per-hospital day, out-of-pocket- fees, administrative fees, private insurance financing, and public financing, including the public option some call Medicare-For-All.
5

The bottom line is we have a hopelessly complex healthcare system with too many moving parts. For those who whine that we cant afford the ACA, I agree. So how do we re-engineer our healthcare system to deliver more efficient, cost-effective, high-quality care to more people for less money? Can we do this within the context of our current system? No. We need a major redesign/overhaul. ___________________________________________________ Question 1: Will the health reform law provide tax credits to small businesses that offer coverage to their employees? Question 2: How many Americans were uninsured in 2010? 35.8 million 40.2 million 50.7 million 63.5 million (ANSWERS ON PAGE 18) ___________________________________________________
REFERENCES Summary of New Health Reform Law Kaiser Family Foundation 2011. Marcia Angell, M.D., former editor of NEJM in USA Today 4/26/12. Health Care Costs A Primer http://www.kff.org/insurance/ upload/7670-03.pdf Bitter Pill by Steven Brill, Time March 4, 2013. The Cost Conundrum by Atul Gawande, M.D., The New Yorker June 1, 2009. n

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Leers

Who really wins from AHCCCS expansion?

To the Editor: In the March Sombrero, issue, Dr. Katzenberg says that expanding AHCCCS is a win, win, win. People who probably think they will be winners were standing behind Gov. Jan Brewer at a March 5 press conference at the Capitol, wearing their white coats. Some of the real winners were probably in the audience wearing suits. And losers were there wearing black. The real winners are the multibillion-dollar managed care companies who will get most of the AHCCCS funding. From their standpoint, Arizona is indeed the gold standard since all the money goes through them here, whereas varying smaller proportions go through them in other states. In materials made available by AHCCCS concerning estate recovery (how much the state may be able to get from your estate if you are on AHCCCS at age 55 or older), the program contractors get approximately $3,800 per head per month whether any services are delivered or not. From the coffers of managed-care giants, less than 25 percent trickles down to hospitals, and about 20 percent to physicians. The winners reassure Arizona taxpayers that the money will be leveraged something like seven to one through an accounting gimmick, and federal dollars will come to us that otherwise would have gone to other states. We dont know who those losers are, so of course they were not represented at the press conference. Other losers, who might have benefited from other ways in which these individuals might have used their money sending it to the federal government, were likewise invisible. Todays taxpayers are not the only losers, since 46 percent of all the money the federal government spends is borrowed. There is no way that the debt can ever be paid back in dollars that are worth the same as the ones that were invested. Those who work hard and save see a constant erosion of the purchasing power of their earnings. At the moment, people are still lending us money, apparently because they still think that they will get at least some of it back someday. And how is this loan collateralized? With the future labor of Americans. How many generations will be laboring to pay back this debt? The way things are going, it may possibly never be paid back. Is this slavery? Since it applies to whites as well as blacks and everybody else, and since the people cant be sold on an auction block (theyre not even born yet), perhaps not, but what do you call it? Taxation without representation?
SOMBRERO April 2013

In Marchs Makols Call, Dr. George Makol says that the cost of care is not going to get any cheaper. This is generally believed, but not necessarily true. If we could get the third-party winners out of the equation, the cost could drop dramatically. People who have to pay their own bills, at least for elective procedures, are willing to travel. They may go to Costa Rica, or New Delhi, but a more attractive opportunity is Oklahoma City. Because of the Surgery Center of Oklahomas posting its package prices on the Internet (surgerycenterok.com), many other facilities there are following suit and giving people a firm price ahead of time. Hospitals dont particularly like this because they may have to explain why their prices are six to 10 times higher. Transparency would be a big step, and there is a bill in the legislature to this effect, but Gov. Brewer may veto it, as she is threatening the heavy-handed tactic of vetoing everything if the legislature doesnt pass her Medicaid expansion. Do we call this democracy in action? Sincerely, Jane M. Orient, M.D. Tucson n

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PCMS News

Stars on the Avenue: This is the month

With a classic Hollywood theme, the PCMS Alliance and PCMS event Stars on the Avenue is set for Saturday, April 27, in the courtyard at St. Philips Plaza. There will be great food, better conversation, and a chance to recognize several outstanding physicians for their contributions to our community. Feel free to come as a character from 1920s or early 1930s Hollywoodor stick to Tucson casual. Stars on the Avenue is fun, and where we get to socialize with one another, said event Chairman Alan Rogers, M.D., PCMS immediate past-president. Last time, I got to talk to a dozen doctors I had not seen in years, even though I talk professionally on the phone with them almost every week. The evening will honor PCMS Physician of the Year Gulshan Sethi, M.D. Also recognized that evening will be the PCMS Volunteers of the Year Evan Kligman, M.D. and Mohammed Nomaan, M.D. Gary Figge, M.D. will also receive the Rose Marie Malone Award for Service to Organized Medicine. John Clymer, M.D. and his wife, former Sombrero editor Eloise Clymer, will be honored for a lifetime of achievement on behalf of the medical society, PCMS Alliance, and the people of Tucson. Pima County Medical Foundation will honor Richard Dale, M.D.; James Dunn, M.D.; Frank Marcus, M.D.; and John Wilson, M.D. for exemplary lifetime achievements in furtherance of medical education. Food is being provided by several fine Tucson restaurants. Brad Nichols, M.D. is leading the band and the music is designed for listening, not dancing. Tickets are $150 each, with a portion going to support Mobile Meals of Tucson. Operators, er, PCMS personnel are standing by to take your orders! Call 795.7985. We take VISA or MasterCard. Give us the number of tickets you want. We need the card number, expiration date and the three- digit security code. We need the name as it appears on the card. We need the cards billing address and zip code If you call and get voicemail, leave a message for a convenient time to call you back (including evening hours). You may also ask us to call you by e-mailing Steve Nash at steve5199@ simplybits.net.
Marian Rogerson and Ana Maria Lopez, M.D. wait on a cold, breezy morning to begin the physician-led walk along the Rillito March 9. PCMS sponsors the walks that take place on the second monthly Saturday. One- and two-mile walks are offered and begin at the Swan Bridge, south bank, east side at Rillito River Park. Physician leaders are always needed, and you can prescribe walks for your patients who need more physical activity (Steve Nash photo).

Travelin Tretbar and his wife Dorothy spent 12 days traveling through Cuba in 2012, and as our readers know, where Dr. Tretbar goes, so goes his camera. Id like to share these with PCMS members and the people who rent the meeting hall, Dr. Tretbar said. Beats leaving them in boxes. Come on by and take a look! PCMS is open 8-4, Monday through Friday.

Viva Fidel?
Well, not really. But photos of Cuba will adorn the walls of the PCMS conference room in a rotating exhibit over the next several months, courtesy of Sombrero Behind the Lens columnist Harold C. Hal Tretbar, M.D., whose work you enjoy in nearly every Sombrero.
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Notice: Notify the PA Board of any prescribing modifications in your Delegation Agreement
Recent changes in the statutes and rules governing physician assistants give Arizona Licensed PAs approval to prescribe up to 30 days of Schedule II and III drugs with an active DEA registration. (A.A.C. R4-17-203.D, A.R.S. 32-2532.C, and A.R.S. 32-2504.A.11)
SOMBRERO April 2013

Supervising physicians and their PAs are no longer required to submit notices of supervision or Prescribing Authority Forms to the board, and the board, part of AMB, no longer tracks the SP/ PA relationships. In place of these forms, each SP/PA team must have a Delegation Agreement on file at the practice which delineates any and all tasks the supervising physician delegates to the Physician Assistant, states that the physician will exercise supervision over the PA, and that he/she will retain professional and legal responsibility for the care rendered by the PA. The agreement must be signed by the supervising physician and the PA, and updated annually. The agreement must be kept on file at the practice site and made available to the board upon request. (A.R.S. 32-2531.H.4) A supervising physician must notify the PA Board if he or she exercises the option to modify or lower the standard 30-day prescribing privilege in the delegation agreement. This link is to the form that can be used to notify the board of modifications: http://www.azpa.gov/PDFs/Prescribing%20Modification%20 Form.pdf The board shall then note any modifications on the PA website profile in compliance with A.R.S. 32-2532.

Two UofA EM programs accredited for 10 years

Two academic physician training programs at The University of Arizona Medical CenterSouth Campus are the latest programs in the nation to gain accreditation for a 10-year cycle, to advance the quality of graduate medical education for physicians. The emergency medicine and toxicology programs are both academically and clinically a part of the University of Arizonas Department of Emergency Medicine at the UA College of MedicineTucson. The clinical sites include: The University of Arizona Medical Center (UAMC) University Campus is a Level One trauma center where UA Department of Emergency Medicine physicians see more than 70,000 patients annually. The University of Arizona Medical Center (UAMC)South Campus, where UA Department of Emergency Medicine physicians see more than 40,000 patients annually. The Accreditation Council for Graduate Medical Education (ACGME) is a private, non-profit council that evaluates and accredits more than 9,000 residency programs in 135 specialties and subspecialties in the United States. The UAMCSouth Campus resident training programs have been accredited through the ACGMEs Next Accreditation System ( NAS), an enhanced peer-review system developed to improve health care in the United States by assessing and advancing the quality of graduate medical education for physicians in training through accreditation.

We knew it all along: Dr. Shapiro is a champ

By the time you read this, Childrens Action Alliance, community leaders, legislators, and fellow advocates gathered April 2 at the Jewish Community Center to honor CAAs 2013 Tucson Champion for Childrenand PCMS pastpresidentDr. Eve C. Shapiro. CAA honored her outstanding commitment to children and called her a caring pediatrician, active member of the Tucson community, and dedicated advocate for childrens health. Childrens Action Alliance, headquartered in Phoenix, has advocated for children since 1988. The award honors an individual from Southern Arizona who is an outstanding leader and advocate on behalf of vulnerable children and families. Dr. Shapiro specializes in working with adolescents and children with chronic illnesses and school and learning problems, CAA said. She is actively involved in teaching premedical, medical and nurse practitioner students, as well as pediatric residents. She has also worked in health advocacy, heading the successful Healthy Arizona voter initiative campaign in 2000. Healthy Arizona uses tobacco settlement dollars to increase access to healthcare for more than 200,000 working poor Arizonans. She has worked on a number of other public health efforts, such as the tobacco tax initiative, which lead to decreased smoking rates, particularly among teens.
SOMBRERO April 2013

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The UA Department of Emergency Medicine is the only resident training program in the nation to offer three residency options: the UAMCSouth Campus Emergency Medicine Residency Program, the UAMCUniversity Campus Emergency Medicine Residency Program, and the combine Emergency Medicine and Pediatric Residency Program. Residents train alongside UA Department of Emergency Medicine faculty who are internationally recognized physicians with expertise in toxicology, sports medicine, emergency medical services, education, research, critical care, global health, ultrasound, simulation and disaster preparedness. Working to clinically train tomorrows physicians both within the hospital setting and academically, the UA emergency medicine faculty and residents have authored more than 500 publications with faculty receiving several million dollars in grants and contracts. The accreditation is the result of our opportunity to create an outstanding emergency medicine residency program that combines excellent academics with a focus on rural and global health, said Kristi J.H. Grall, M.D., M.H.P.E., director of the UAMCSouth Campus Residency Program. Farshad Mazda Shirazi, M.D., Ph.D., who directs the UAMCSouth Campus Medical Toxicology Fellowship, said, We have an outstanding toxicology fellowship training program that accepts fellows from pediatrics, emergency medicine, family practice, psychiatryand internal medicine. The Medical Toxicology Fellowship is a twoyearcollaborative trainingprogram among

UAMC University campus,UAMCSouth Campus and the Arizona Poison and Drug Information Center.

CHN: Dr. Berman in Arizona first

Scott Berman, M.D. of Tucson Vascular Specialists and Carondelet St. Marys Hospital recently performed what Carondelet is calling Arizonas first minimally-invasive endovascular aneurysm repair (EVAR) on a patient with a juxtarenal aneurysm. A juxtarenal aneurysm is a ballooning of the abdominal aorta very close to the kidneys. Until now, minimally invasive surgery was not an option for patients with abdominal aneurysms of this kind. Most repair work of this sort required open surgeries that led to much longer recovery times for these patients. In early 2012, however, the U.S. Food and Drug Administration approved the Cook fenestrated and branched endovascular aneurysm repair system that expands the option of minimally invasive treatment to patients previously excluded from EVAR due to their anatomy. Because of Tucson Vascular Specialists extensive experience and consistent success with EVAR and Thoracic Endovascular Aneurysm Repair (TEVAR), Carondelet Heart & Vascular Institute at St. Marys Hospital became the first facility in Arizona to offer this innovative therapy, Carondelet reported. The impact of these technologies on patients with aneurysm disease has been far-reaching, Dr. Berman said. There has

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SOMBRERO April 2013

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been nothing more satisfying to me in my career than to see a patient walking in the halls, enjoying a regular diet, and able to be discharged home on the first day after an EVAR or TEVAR procedure. This is in stark contrast to traditional open surgeries that require days in the intensive care unit, a week in the hospital and months to fully recover. Dr. Berman said that about 70 percent of abdominal aneurysms he currently sees can be treated through minimally invasive procedures. The added ability to repair juxtarenal aneurysms in this same way increases the number of patients who can receive minimally invasive surgery of this kind by an additional five to 10 percent.

Nightmare strain a new MRSA

A nightmare antibiotic-resistant bacteria that kills half of those it infects has surfaced in nearly 200 U.S. hospitals and nursing homes, the U.S. Centers for Disease Control and Prevention reported last month through many media outlets. The CDC said 4 percent of U.S. hospitals and 18 percent of nursing homes had treated at least one patient with the bacteria, called Carbapenem-Resistant Enterobacteriaceae (CRE), within the first six months of 2012. CRE are nightmare bacteria, CDC Director Dr. Thomas Frieden said in a news release. Our strongest antibiotics dont work and patients are left with potentially untreatable infections. Doctors, hospital leaders, and public health [officials] must work together now to implement the CDCs detect and protect strategy and stop these infections from spreading. The good news, Frieden added at a teleconference, is we now have an opportunity to prevent its further spread but we only have a limited window of opportunity to stop this infection from spreading to the community and spreading to more organisms. CRE are in a family of more than 70 bacteria called enterobacteriaceae, including Klebsiella pneumoniae and E. coli, that normally live in the digestive system. In recent years, some of these bacteria have become resistant to last-resort antibiotics known as carbapenems. Although CRE bacteria are not yet found nationwide, they have increased fourfold in the U.S. in the past decade, with most cases reported in the Northeast. One type of CRE, a resistant form of Klebsiella pneumoniae, has increased sevenfold in the past decade, according to the CDCs March 5 Vital Signs report. To see bacteria that are resistant is worrisome, because this group of bacteria are very common, said Dr. Marc Siegel, clinical associate professor of medicine at NYU Langone Medical Center in New York City. Most CRE infections to date have been in patients who had prolonged stays in hospitals, long-term facilities and nursing homes, the report said. The bacteria kill up to half the patients whose bloodstream gets infected and are easily spread from patient to patient on the hands of health-care workers, the CDC said. As with MRSA, this is the result of overuse of antibiotics, Dr. Siegel said. The more you use an antibiotic, the more resistance is going to emerge. This is an indictment of the overuse of this class of antibiotic.
12 Attentive listeners hear Dr. Normal Levine give a CME talk about dermatological manifestations of systemic disease, presented at PCMS March 12 by Pima County Medical Foundation. PCMF CME Director John Krempen, M.D. encourages everyone to attend: Weve been stuck on 50-60 attendees for several months, so please invite your colleagues to attend. The next PCMF CME program is April 9, when doctors Julie Zaeta and Stephen Smyth will discuss interventional radiology. Dr. Krempen also invites any PCMS member who would like to speak on a CME topic to contact him through the medical society (Steve Nash photo).

To help prevent spread of these bacteria, the CDC wants hospitals and other healthcare facilities to take the following steps: Enforce infection-control precautions. Group together patients with CRE. Segregate staff, rooms and equipment to patients with CRE. Tell facilities when patients with CRE are transferred. Use antibiotics carefully. Additional funding of research and technology is critical to prevent and quickly identify CRE, the CDC said. Countries where CRE is more common have had some success controlling it. Israel, for example, worked to reduce CRE in its 27 hospitals, and CRE rates dropped by more than 70 percent. Some U.S. facilities and states have also seen similar reductions, the agency said. Dr. Siegel said there are measures patients can take to reduce their risk of infection. No. 1 on the list is [not to] wish that your hospital stay is extended. Patients think they are safer at the hospital, but that may not be true, he said. And try to go into a clean hospital. n
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Behind the Lens

They shoot horses...and more

By Hal Tretbar, M.D.

Shirley Schaller was in the exclusive Vaquero Club tent on the Tucson Rodeo Grounds. She looked around, and sashayed up to the bar on the corral fence. She staked out her spot with her tripod and Canon shooter. She glanced around to make sure no one was going to push her aside and waited for the action to start. Shirley had joined the Canon Camera photo workshop that the company has run for the past three years at the Tucson RodeoLa Fiesta de los Vaqueros, which comes around every February. Its an opportunity to try out their SLR (single lens reflex) bodies and lenses.

Bronc-riding may look better in black and white. Canon 170 mm. ISO 400. 1/1250 second at f 5.6.

It was as if she had swung open the doors to an 1880s Tucson saloon and bellied up to the bar near the faro table. She would have hitched up her gun belt and scanned the crowd for troublemakers while waiting for the fun to begin. Shirley, of Boulder, Colo., spends her winters in Green Valley. She had a ball at the 2012 Rodeo. Her goal was to spend a day photographing a rodeo clown from make-up to action in the arena. Last year she shot from the stands. Now she had a prime location to shoot the rodeo action form the north end using a telephoto lens. The Vaquero Club has been the site of Canons workshop, sponsored by Gregs Camera Shop at 6336 N. Oracle Rd., Tucson. Canon brings many different bodies and lenses for use by anyone who signs up for the workshop. The $85 fee includes free parking on Saturday the first day of the rodeo, admission to the Vaquero Club, and instruction on the use of the Canon cameras to capture the best rodeo images. I saw many photographers with Nikon gear who were there to take advantage of the location, an excellent lunch, and three large cups of Banquet Beer on tap. (You say you are a Westerner and yet dont
14 SOMBRERO April 2013

Bull riders often need the help of bullfighters. Canon 400 mm. ISO 400. 1/2000 second at f 7.1.

know that Banquet Beer is Coors, made in Golden, Colo. with pure Rocky Mountain water?) After shooting some fast action Shirley gave up her spot at the fence so she could hit the trail to the other end of the arena where the cowboys and their horses were hanging out. She said she wanted to have enough close-ups of cowboy broncos, belt buckles, and buttes to make a rodeo calendar. I had signed up because I have been a Nikon man for many years and I really wanted a chance to try out some new Canon gear. I started using Nikon when I bought a new S2 rangefinder with a Nikkor 50mm f 1.4 lens in 1956. To jog your memories, much of the Japanese camera industry recovered after World War II by bringing out new models based on pre-war German makes. Canons were modeled after the Leica III g. Nikons were based on the Zeis Ikon Contax. In fact, my S2 had a type of lens mount that took both Nikkor and Zeis lenses. One of my favorites was a 35mm Zeis Biotar. Because I wasnt familiar with Canon cameras I checked out an entry-level body, the 18 MP EOS Rebel T4i. It had all of the controls that you could want, including a speedy five shots per second.
SOMBRERO April 2013 15

With team roping one cowboy takes the head and the other gets the hind legs. Nikon 85 mm. ISO 100. 1/50 second at f 13.

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The first lens I tried was the 70-200mm IS (Image Stabilized) f4 L. It has a reputation for bring easy to handle and super sharp. I was very pleased with its performance and got some great sharp images. I used the fiveshots-a-second with continuous focusing to nail the moment of greatest action. Then I tried a big gunthe 400mm IS f 5.6 L that weighs 44 ounces. Because the Rebel has a smaller sensor than a full frame camera, the focal length equivalent increases by 1.5. It is fairly easy to handle for rapid moving sports or bird images. It also is very sharp and has fast internal focusing. I got my best action close ups with this lens, but because the 400mm was equal to a 600mm on a full frame camera, I had to move high up in the stands to frame the scene. I went back several days later with my Nikon 7000 and the AF-S Nikkor ED 70-300mm VR (vibration reduction) lens. I shot from the north end of the arena to the south to get backlighting on the dust kicked up by the horses. I had excellent results with both the Canon and the Nikon. I still havent decided which images are the best! At Gregs Camera Shop the Rebel T4i sells for $1,149 with the standard 18-135mm kit lens. The 70-200mm f 4L is priced at $1,349. The 400mm f 5.6L costs $1,339. n
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Makols Call
By Dr. George J. Makol

Who are the Best Doctors?

I have always been blessed with good health. Of course, genetics is a factor, and longevity runs on both sides of my family. Not dying does not assure one of good health, but it is a good start. I also laughingly attribute a lot to my blend of a dairy/protein/vegetable diet. In other words, I have consumed about 10,000 cheeseburgers in my life thus far, all adorned with tomato and grilled onionhence the vegetables. Everyone is bound to have a health peccadillo or two, and sure enough one day a couple of years ago after working out at the gym, I sat down to watch the playoff games, and noted that my new big-screen television had spots moving around the picture! When I closed my left eye, however, the spots disappeared, not a good sign and definitely not covered under the TVs warranty. The next morning my first two patients providentially canceled, so I walked next door to the ophthalmologist. In two minutes I was in the chair, and in 10 minutes he had me cancel the rest of my day and I was whisked by one of my nurses to the retinal specialists office. She confirmed the diagnosis of a torn retina, and within 30 minutes I was staring at the coolest laser show, this one taking place in my head. She then informed me that she was going to inject my eye with a large needle (it looked large to me) filled with nitrogen gas that would create a bubble to lift my torn, flapping retina back up. My response was, Are you serious? But she was, and she was seriously good at her craft, and six days later after another colorful laser show, kind of reminiscent of the 60s, I was healed. I also am one of the few human beings who knows what it is to feel like being trapped in a carpenters level, trying to keep that air bubble in my eye right at 7 oclock for six days. (Because the lens refracts and inverts the incoming light, the bubble appears to the brain 180 degrees its opposite). I just had a cataract operation and lens implant by an incredibly skilled ophthalmologist hand-picked by my first eye doc, and in 10 minutes the shower curtain I had been looking through for six months was lifted.
SOMBRERO April 2013

What is my point? I always have one if you hang on long enough (a sticking point with my editors), and my point is that there are a lot of great doctors out there in Tucson. I think I have the best doctors, and most of my patients describe to me their various physicians as the best doctors, but there should be a way for the public to further evaluate doctors other than just board certification and licensure. You may have heard some background noise about the Best Doctors annual feature in Tucson Lifestyle magazine. One of my surgical buddies was named to the list, and when I congratulated his wife she said he thought such lists were silly, or had no real significance. One of my associates was informed she will be on the 2013 lists under Best Allergist/ Immunologist. She approached me and asked, Is this some kind of popularity contest? O.K., its time to take a closer look at the three major current national databases rating doctors. I will start with the one that I am intimately familiar with, the national database of Best Doctors. This Boston-based organization is headed by a vice- chairman at Brigham and Womens Hospital, a teaching affiliate of Harvard Medical School. This is a peer-to-peer system, whereby local doctors, usually starting with university affiliated physicians, choose who in their particular specialty they would send their own family to. I have been told that our university physicians have made a conscious effort over the past few years to include community physicians in their polling, and now lots of us local docs are being considered. After being on the list for a few years, I was allowed to vote, but not only on local allergist/immunologists, but on those from the Southwest region, including Los Angeles, San Diego, Las Vegas, Phoenix, and Albuquerque. Best Doctors is a national organization, and their listings are published in regional magazines all over the U.S. You would be surprised, but you get to know who is really good in your field after attending lots of regional and national meetings and having patients transfer from such physicians, giving one a chance to review their work. Best Doctors goes one further by providing consultations by their physiciansthose interested in participatingfor patients who do not have access to experienced specialists, perhaps because of their rural location or financial constraints. I have been involved in this program and have completed three or four such consultations from all over the U.S. and I even had the chance to review a difficult immunology case from Ireland. I was able to make helpful suggestions and through my contacts in the American Academy of Allergy, Asthma and Immunology I
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found an immunologist in Dublin for her follow-up, which was only a three-hour drive from her home. The next prominent database is Guide to Americas Top Physicians, published by the Consumers Research Council of America. Their website is: www.consumersresearchcncl.org. Their website details how physicians are picked, including their experience, education and continuing education, membership in professional organizations, and board certification. There is no peer voting, just an objective review of these factors. In my specialty, roughly 40 percent of the practicing allergist/ immunologists in Tucson are listed. I did notice that several

excellent allergy physicians who have started here in town in the last few years are not yet listed. The third prominent listing is Castle Connollys Americas Top Doctors, published in conjunction with US News and World Report. They publish a huge paperback book annually which lists most of their picks, but a more complete listing is available at http://health.usnews.com/topdoctors. Castle Connolly uses a peer recommendation system augmented by contacting prominent local physicians in each specialty including, but not limited to, university chairmen. Their team also reviews the same criteria listed by the Consumer Research Council. This is by far the most selective of processes. In my field only one Allergist/Immunologist is listed for Tucson, and about a half a dozen for Maricopa County, where there are at least 40 practicing allergists. I am not usually big on lists. The only listing I check religiously are the obituaries in the Arizona Daily Star to make sure Im not among them. After that, my day is usually pretty good. So no one would say that these databases contain all of the best doctors, and they all disclose that there lists are not infallible, and that younger, less experienced physicians may take some time to be appreciated by their peers in such surveys. Its worth noting, however, that one should be proud to be listed by any of these three organizations, and it is not in my studied opinion silly or just a popularity contest, even if they are always going to miss some great docs. Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been a PCMS member since 1980. n __________________________________ (ANSWERS FROM PAGE 6) Answer 1: Yes. Beginning in 2010, business with fewer than 25 full-timeequivalent employees and average annual wages of less than $50,000 that pay at least half of the cost of health insurance for their employees are eligible for a tax credit.

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SOMBRERO April 2013

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In Memoriam
By Stuart Faxon

Dr. Charles W. Chuck Pullen, 1925-2013

He did a GP residency at Thomas D. Dee Memorial Hospital in Ogden, Utah. In 1954-56 near the end of the Korean War he served in the U.S. Air Force, stationed at Davis-Monthan. He did his pediatric residency at University of Utah College of Medicine and Affiliated Hospitals, Salt Lake City, finishing in 1958. He began practicing in Tucson at Craycroft Medical Center in 1959, and was board-certified in 1964. While Dr. Pullen was a pediatric resident, the Southern Arizona Hiking Club was organized in Tucson. Dr. Pullen became a guide as well as member, said Dr. James Klein, hiking club member and PCMS History Committee chairman. Around 1980 the club gave Dr. Pullen an award celebrating his efforts as a guide for 20 years. In 1971 the Catalina Council, Boy Scouts of America gave Dr. Pullen the Silver Beaver Award, its highest award for volunteers, Dr. Klein said. Dr. Pullen chaired the councils health and safety committee in the 1960s and early 1970s. At the health lodge, the infirmary at the Scouts Camp Lawton in the Catalinas, Dr. Pullen volunteered to monitor the boys health records and do any checkups necessary. He would stay a week up there and be available 24/7. If anyone deserved the label community asset, it surely was Dr. Pullen, a man whom only death could stop. In the 1960s Dr. Pullen served on executive boards of the Boy Scouts of America Catalina Council and the Breakfast Lions Club; sang in the choir of Catalina United Methodist Church; was a member of the Southern Arizona Hiking Club, the Sierra Club, and the Southern Arizona Rescue Association; served as director of the medical advisory board of the National Cystic Fibrosis Research Foundation Tucson Chapter; was on the medical staff of St. Elizabeth of Hungary Clinic including a term as medical staff president; was director of Sunday Evening Forum; and served as treasurer of the Arizona Chapter of the American Academy of Pediatrics. He was also a member the Arizona State Pediatric Society, chaired ArMAs Committee on Poison Control, served on the PCMS Red Cross Committee, was a PCMS representative to the Arizona Childrens Home Association, and was a PCMS representative to Los Amigos de las Americas. Today vehicle child safety seats are a matter of course, and law. Dr. Pullen was a pioneer in the effort to stop a child from becoming a projectile in a car crash, and 1979 found him advocating for an Arizona law that would make the parent or guardian responsible for the safety of the child. The whole idea, he told the Arizona Daily Star, is to provide an adequate child passenger-restraint system for a child from zero though age 4. At the time a similar bill had been passed in Tennessee. I think the burden should be on the parent to see that this is the most important thing they can do for their child, Dr. Pullen said, and its damn well worth any amount of money they have to pay for it.
SOMBRERO April 2013

Dr. Charles W. Pullen

Charles W. Chuck Pullen, M.D., F.A.A.P., pediatrician, founding faculty member of the University of Arizona College of Medicine, lifelong avid hiker and volunteer, who joined PCMS in 1958, died Feb. 22 in Tucson. He was 87. Charles William Pullen was born Nov. 9, 1925 in Ann Arbor, Mich. When Chuck was very young his father was a junior high school principal in Charleston, W.Va. Then when the family moved Chuck grew up in Ohio through the 4th grade. His father wanted to come to Arizona, which the family did in 1936. He earned his undergraduate degree in 1948 at Arizona State College at Flagstaff, during which time he aspired to be a photographer. It was also where he met his future wife, Adavern Waas, whom he married in 1950. While he was hospitalized with appendicitis, his physician suggested that he might consider medicine as a career. Chuck took that to heart and went on to University of Texas at Dallas Southwestern Medical School, earning his M.D. in 1952.
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Mexico and the border were always among his interests. In 1980 he moved to Douglas and worked at Cochise County Hospital. Just a few years before he died told us he was helping in trying to establish a free clinic in Mexico, but had not gotten enough cooperation from Mexican authorities at the time. I enjoyed my time in Douglas, Dr. Pullen said in 1998, but near the end of my year the copper miners struck, Mexico devalued the peso, and the economy went down I had already been in touch with the Air Force and the Army about a possible position, civilian or otherwise, and as the Douglas job came to an end, Fort Huachuca found that they badly needed a pediatrician to take over as chief of pediatrics, so I drove 60 miles over to Sierra Vista and became chief of pediatrics at Fort Huachuca. As an Army lieutenant colonel Dr. Pullen served there 1981-1985. In 1985-1994 Dr. Pullen moved to Ganado to practice at Sage Memorial Hospital under the auspices of the Navajo Nation Health Foundation. He practiced mostly pediatrics, but said he had to take all comers. In the ER we had a tremendous number of automobile traumas, horse riding traumas, and running into cows in the dark. Dr. Pullen told us of an amusing experience he had on the res that might happen only to a dedicated pediatrician. While I was on emergency duty one time, a lady calledwhich was very unusual because not many people had telephones in this area of the reservation. She said that she had a kid who had a fractured leg and she had put a cast on it a few days before and now there seemed to be pus coming out of the cast. She wanted to know whether she could bring the kid into the hospital, and I said by all means, come. When she arrived, it really was a kida little sheep. Dr. Pullen added, We did happen to have one of our family practitioners who was interested in animals, so he took care of the kid for her.

Dr. Pullen accepts the PCMS Volunteer of the Year Award from PCMS President Leonard Ditmanson, M.D. in 2004 (Stuart Faxon photo).

snipped my tie off at [the steakhouse] Pinnacle Peak. Eventually, I joined in the laughter. Dr. Pullen knew I liked to hike, PCMS Executive Director Steve Nash said. We had one trail near the San Francisco Peaks in common. When I told him I thought it was a tough climb, he answered, Sorry to hear that; I helped build it. He brought in a slew of topographical maps from the U.S. Geological Survey. Each was annotated, sometime with dates and times for walking, but often with corrections like misnamed peaks and elevations. For comparison I pulled out one of my more recent versions of a map. The errors had been corrected. Despite being retired for many years, his chosen specialty was never far from his mind. One of his last written communications, on Feb. 21, was a pencil message that read, Pediatrics is first, No. 1. Go tell it on any mountain and anywhere!

The 1990s saw Dr. Pullen serving as associate clinical professor of pediatrics at University Medical Center while emergency work with the USAF Primus Urgent Care Clinic in Tucson. He also worked part-time for Dr. Ron Goodsite and did locum tenens for other life lived well pediatricians.

As the 21st century opened, Dr. Pullen served on our History Committee and as a Member-at-Large, and volunteered physical labor for our building restoration.

Dr. Pullens wife, Adavern; sister Berta Richards; children Evelyn Marchese, Memorial services were March 4 at Memorial by Donna (Pullen) Petersen Donna Petersen, Keith Pullen, Carol Catalina United Methodist Church in Pullen, Martha Pullen, and Ruth Tucson. At them, Bernard Englehard of Sokolow; five grandchildren and three the Lions Club noted that Dr. Pullen was an early and active great-grandchildren survive him. Lions member. When he moved to Ganado, he started that towns very first Lions Club. One of his last acts as a Lion was to advocate for, and secure cataract surgery for a refugee to Tucson. That persons eye operation will take place soon. Memorial donations may be made in his name to Tucson Breakfast Lions Club for the Lions Sight and Hearing Foundation, TMC for Children, or University of Arizona Foundation for the College of Medicine. The late Dr. Bud Simons contributed to this report with his 1998 interview of Dr. Pullen. n

In humble, quiet, relentless service With love of learning, exploring, helping, sharing... Hiking a new trail tonight: My hero, My DAD.

Colleague and friend Ron Almgren, M.D. recalled, He encouraged me to locate my practice to Tucson. When I got here, he said for me to put on a tiehe was taking us to dinner. So I bought an expensive tie. Imagine my surprise when they
SOMBRERO April 2013

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Bioethics
By the PCMS Bioethics Committee

Physicians and families in decision-making

The patient is a 78-year-old male with mild dementia who lives independently. His wife died three years ago and he has been depressed since her death. A psychiatrist has recommended an antidepressant, which he has refused. The patient has been hospitalized three times in the past year and has lost 30 pounds. The present case begins when the patient is evaluated in the emergency room for diarrhea and abdominal pain and hospitalized with the diagnosis of c-dif. colitis. When the patient arrives in the step-down unit, the patient states that he wants no treatment for the infection and will be able to join his wife soon. His son, who is medical power of attorney, agrees with this decision. The next day, the patient learns from his PCP that he has a simple condition, easily treated with oral medication, and that he might die of high fever, dehydration, and renal failure if he chooses not to take this medication. The patient decides he would like treatment, and Vancomycin is given. When the son hears of his dads decision, he is angry. Dad has been sick three times this year and he wants to be with mom! He fires the PCP who gave the treatment options to his dad. He orders the treatment stopped. Three days later, the fired PCP, who is on weekend call, is making rounds. The patients diarrhea is very severe and persistent and the patient asks to be treated. The physician finds the patients living will that states he wants treatment and hospitalization except if he is vegetative, incurable or terminally ill. Treatment is started again. The son is flabbergasted, refuses to have the patient treated, and threatens to report the PCP to the medical board for ordering treatment since the PCP had been taken off the case. The local court hears the case. The court interviews the patient by telephone and he states three times that he does not want to end his life and wants treatment. Thus, he is found competent to understand his decision. During the hearing he says, You are talking about doing away with me. The court orders treatment. The patient survives. Questions: 1. What legally does it take to be declared incompetent to make medical decisions? Competency is decided by lawyers and the courts. Physicians determine decision-making capacity. Basically this is done be having the patient explain in his or her own words what the question is being asked, and stating the answer to the question. 2. If the patient has decision-making capacity, why is the son consulted? Too often older patients have their conditions discussed in front of them instead of with them. Patients, even with slight dementia, may be impaired and elderly, but they still have ultimate say in their care. They therefore can have dementia and still have capacity to make medical decisions. 3. Why would the son not want to follow the living will when by Arizona law he is required to? As the person holding a power of attorney, he may feel entitled to make decisions even in opposition to a living will. Many people do not understand their rights and obligations under a power of attorney. In this case the patient has decision-making capacity and should be consulted. If he lacked that capacity, the living will should be followed. There are other possible other reasons, some sinister and selfish, some not. 4. Is there money involved? That could be a motivation, or the son may be tired of the stress in taking care of an elderly relative with progressing dementia. On the other hand, the son may be thinking of lack of quality of life from his perspective, or he may have come to terms with his dad dying and now must come to terms with him continuing to live. Perhaps during the past year the father has, as is often the case, has repeatedly stated, I dont want to live like this and I would rather just join my wife. Thus his son indeed is following his dads wishes.

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SOMBRERO April 2013

5. What are physicians to do when the family is requesting a different treatment than that which the living will says? The living will is the clearest expression of the patients thinking and should control. In this case, however, the patient is able to decide his own course of care. Often the circumstances of a particular case do not lend themselves to using the living will and that is why many/most authorities advocate for a medical POA for healthcare, especially when the patient does not have capacity. 6. Does a hospice patient with a diagnosis of failure to thrive receive comfort care including medicines, food, and fluids? It can depend on the hospice. Most local hospitals know what services each hospice provides and can work with the family and/or patient to understand the needs. Many hospice services believe in the motto, Succor, but dont abandon. Palliative care in most cases includes medicine, food, and fluids because the primary aim is to make the patient comfortable with a high quality of life. This can mean treating the underlying disease (e.g. radiation for bone pain in lung cancer patients), which helps the patient be more comfortable. Furthermore, palliative care clearly means oxygen for shortness of breath, opiates for pain, anxiolytics for anxiety and even antibiotics for symptomatic urinary tract infections or cellulitis. What patients often request is avoidance of hospitalization, aggressive testing, and painful or intensive treatment that is often neither effective nor appropriate, such as intubation for a patient with end-stage COPD. 7. Does a DNR change medical personnels attitude in treating patients? It is a common perception among physicians and hospital workers that patients who sign a DNR are more likely to die from postoperative complications compared to patients without a DNR. This is felt to be due to less aggressive treatment by medical personnel. There is very little literature on this subject. One study presented at the 2012 American Surgical Associations annual conference, however, actually refutes this perception. The study found that it is the patients and their surrogate decision- makers who, after the initial surgery, refuse further aggressive treatment. It is this group of patients who have the high post-op mortality. Therefore, it is patients and their decision-makers who do not support aggressive treatment, not the medical personnel.

8. What would happen if the son had turned the physician in to the Arizona Medical Board (AMB)? It is possible it would be dismissed for lack of jurisdiction. The AMB has jurisdiction over professional misconduct as defined in the statute. If the son alleges gross malpractice (violation of informed consent), breaking of the state law on living wills or that the doctors conduct is such that it could harm a patient or the public, it is possible jurisdiction would be taken. There is an outside chance the son alleges the standard of care was not followed (failure to call for a bioethics consult? Failure to blindly follow patient/son direction?) During the next step, the AMB director could dismiss the complaint. If the director does not dismiss the case, records would be asked for and consultants (at least one) would review the chart. In this case, the consultant would probably try to find how far the dementia had gone, whether capacity was determined. If so, the recommendation would be to dismiss. If the case somehow ended with a full AMB hearing, the physician on the board would be sympathetic to an honest physician trying to do the best for a patient. The PCMS Bioethics Committee is David Jaskar, M.D.; Cynthia Miley, M.D.; Kenneth Sandock, M.D.; Dale Johnson (social worker); David Siegel, M.D.; Steven Ketchel, M.D.; and Neil West, M.D. n

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Perspecve
By Dr. Jerome C. Rothbaum

Where do we go from here?

An analysis of proposed healthcare delivery
In a previous article, Does it Matter? [Sombrero December 2012] I discussed several issues, including the number of errors in a random sampling of medical records, lack of optimal use of EHRs (Electronic Health Records), and the cost of a sub-optimal delivery system in respect to both health outcomes and financial costs. Here are my suggestions for how to improve our medical care system: Strong physician leadership should create an integrated healthcare delivery system to enhance quality of care and contain costs of healthcare throughout the system. Manage clinical care by forming effective teams with each member of the care team operating at the highest level commensurate with training and experience. Provide a coordinated continuum of care. Demonstrate continuous quality improvements. Take part in utilization review and develop practice protocols. Anticipated results of this restructuring would be: Physicians used in a leadership and teaching roles. The definition of a physician is: 1. A person skilled in the art of healing. 2. One exerting a remedial or salutary influence. Note that the word doctor in Latin means teacher. More accurate, higher-quality assessment and focused care. Emphasis on appropriate care leading to decreased diagnostic studies (X-rays, other imaging, testing), and appropriate specialty referrals. Creating ability to work with health insurance companies to encourage them to lower costs by cutting administrative bloat, paying doctors to keep people healthy rather than ordering expensive treatments, and passing on those savings to customers. Continued emphasis on team care. Attributes of new team care would be: Making a goal of continuous improvement. Each member of the care team should operate at the highest level commensurate with training and experience.
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Medical Doctors would not be treating URIs, UTIs, simple dermatologic problems, etc. that can be handled by other team members. Continuous interaction among all providers with availability for curbside consults. Effective, non-threatening, continuing Q/A activity with built in corrective measures. Note: Existing groups such as Radiology Ltd. are using quality assurance activities in their organizations. How should new delivery system function within this system? Physicians and other providers need to re-focus on several issues: 1. Improve diagnostic skills (carpal tunnel, back exam for HNP examples will be given). 2. Focus on the most critical problems. What potential issues are most likely to have significant or serious consequence or the potential for high cost without appropriate gain? 3. Enlist patients in their optimal care by relating to their needs with understanding and empathy, thus establishing a trust relationship. In my previous article, as an example, I described the frequent occurrence of lack of appreciation of the clinical examination of the chest (failure to identify COPD), thereby losing the opportunity of intervention early with consequences of progression of illness with attendant escalation of cost, and loss of ability to sustain effort in a work environment with attendant disability and frequently premature death. The clinical examination needs to re-focus on certain attributes. The physician and other providers need to be aware of the definitions of sensitivity and specificity as applied to diagnosis, enabling us to make appropriate evaluation: Sensitivity: When attempting to make a specific diagnosis, in what percentage of the number of people examined will have this finding mentioned? For example, in examining a group of patients searching for evidence of COPD, what percent will have the appropriate findings on examination? Specificity: Refers to the percentage of normal patients who do not have the specific finding.

SOMBRERO April 2013

Other considerations are the concept of parsimonious examination: what is the simplest, least burdensome (and least expensive) means to establish a diagnosis? Precision means the agreement of two or more observers on the presence or absence of a finding. Lacking precision suggests a question as to the accuracy of a finding and therefore, what action, if any, should be taken. Examples of above are in the examinations for: 1. Carpal tunnel examination. While there are a number of clinical tests performed (Tinels Sign, Phalens Sign, etc.), The most useful sign in the examination for carpal tunnel is the compression test (by the examiner) over the carpal ligament. A positive test (pain over the ligament with appropriate radiation along the median nerve). There is greater than 90 percent sensitivity and specificity when compared to either NCV testing or surgical exploration. Obvious, therefore, is how this simple testing may save time and expense. 2. Low back pain and sciatica (radiculopathy). Most primary care practitioners are uncomfortable dealing with this issue and tend to either ignore the complaint or refer the patient with or without imaging. The reality is that in an individual with obvious back pain, imaging is rarely helpful. In the absence of evidence of sciatica (radiculopathy), consultation is rarely needed. Most acute episodes of low back pain will resolve spontaneously within six weeks. The testing that is helpful in predicting sciatica (and, therefore, HNP (Herniated Nucleus Pulposus) are a positive straight leg raising test which means pain induced in the lumbar region with elevation of the leg 30 to 70 percent with appropriate radiation along the appropriate nerve in an anatomic pattern. It does not mean complaints of low back pain alone with the maneuver. Also note that crossed straight leg raising (CSLR) is more sensitive than SLR above. The lower the angle of a SLR test, the more specific the test becomes and the larger the disk protrusion found at surgery. Also of note is that testing for back pain/and or sciatica frequently involves issues of secondary gain. Not infrequently in these cases, there will be a marked disparity in SLR testing when done in the usual supine position and when done in the sitting position; especially if the individuals attention is diverted. These examples show the need for improved diagnostic skills and improvement in the performance of our delivery system. Implied from the above is a need for continuing improvement in the quality of our healthcare system. This also implies changes in the role of the physician to assume a role as a teacher. I propose that physicians who have been called primary care physicians be renamed physician leaders, which is appropriate

in their role as teachers and educators. This name change represents a critical change in the function of the primary care physician as currently designated. As I mentioned, the reimbursement system is crucial and needs to be modified to afford physicians appropriate reimbursement for quality of work and not quantity of work. I hope that implementation of some of these concepts will assist us in our search for the Holy Grail of topnotch medical care rendered in a cost-effective manner with an emphasis on prevention and maintenance of good health. Dr. Jerome C. Rothbaum is a PCMS Associate Member who practiced IM and pulmonary medicine. n

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CME

April
April 18: Trauma Update 2013 is at Pima County Health Department Abrams Public Health Building. Registration is through Carmen Martinez at 520.694.4806 or Carmen. martinez@uahealth.com. (TNCC registration is through Arizona ENA website.) For more information on any trauma education opportunities, contact Dan Judkins at UAMC Trauma: daniel.judkins@ uahealth.com or call 520.490.7770. April 18-20: A Multidiscplinary Update in Pulmonary & Critical Care Medicine is at Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.624.1000; fax 480.624.1001 info@kierlandresort.com http://www.kierlandresort.com/ CME: AMA Category I, AOA accreditation 2A. Course targets pulmonary physicians, internists, hospitalists, and specialists in critical care medicine and brings together a multidisciplinary faculty to provide a state-of-the-art update in pulmonary and critical care medicine. Lectures given by leaders in pulmonary and critical care medicine, pulmonary pathology, and radiology provide a comprehensive approach to the current evaluation and management of various respiratory diseases. Course features new and pertinent information plus reviews on developments in respiratory and critical care medicine, and includes lectures and Q&A sessions and an interactive format that allows for immediate audience participation. Website: http://www.mayo.edu/cme/pulmonary-medicine2013s963 Mayo School of Continuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323 mca.cme@mayo.edu http://www.mayo.edu/cme

Mayo School of Continuous Professional Development, Mayo Clinic, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca.cme@mayo.edu http://www.mayo.edu/cme May 23: Trauma Update 2013 is at Sierra Vista Fire Dept. Registration is through Carmen Martinez at 520.694.4806 or Carmen.martinez@uahealth.com. (TNCC registration is through Arizona ENA website.) For more information on any trauma education opportunities, contact Dan Judkins at UAMC Trauma: daniel.judkins@uahealth.com or call 520.490.7770.

July
July 16-21: Tucson Hospitals Medical Education Programs 4th Bi-Annual Colorado River Medical Conference trips ripping down the river through the Grand Canyon. Conference topics include general and vascular surgery, plastic surgery, orthopedics and internal medicine. If you are interested, please call Dr. Richard Dale at 721.8505 or e-mail rdale9136@aol.com. Significant others and children age 8 and older are invited, he said. We leave Lees Ferry Tuesday, July 16, 2013 at 8 a.m. and return there Sunday, July 21. This trip is mildly strenuous, potentially dangerous (large rapids), but extremely fun and educational. Registration is $200 for physicians and affiliated dentists, and $100 for RNs, residents, allied health professionals and medical retirees. Deposit is $500 per person. Cost will be $2,400 for the full trip plus the registration fee, exclusive of one nights lodging at Marble Canyon.

Members Classieds
To advertise in Sombrero classifieds, call Bill Fearneyhough, 795-7985.
PART TIME OBGYN NEEDED: The University of Arizona, Campus Health Service (CHS) is seeking a Part-Time, .50 FTE, Board Certied OB-GYN Physician for the Womens Health Clinic. This is a year round position in an interesting and rewarding medical practice that provides health care to a population that includes a wide range of ages, cultures, clinical presentations and needs. Duties will include compassionate and excellent OB-GYN patient care; early diagnosis and referral for pregnancy; pre-conception counseling; family planning; screening and treatment of STIs; pap screening and follow up; and providing technical direction for the RN and MA support staff. Procedures include LEEP, colposcopy, IUDs, I and D of abscesses. The ability to practice in a harmonious and collegial fashion with the four experienced NPs in the department is essential. (3-13) Outstanding UA benets include health, dental, vision, and life insurance; sick leave and holidays; UA/ASU/NAU tuition reduction for employee and qualied family members; access to campus cultural and recreational activities; retirement; malpractice insurance coverage and more! For more information, please go to www.uacareertrack.com/applicants/ Central?quickFind=207193 OFFICE FOR LEASE: Medical or Professional Ofce Space for Lease or Sale. 1,806 sq.ft. near St. Josephs Hospital on Carondelet Drive. Five exam rooms and two physician ofces. Favorable lease rate and terms. Call 749- 1454 or 885- 6701 (Dr. Wood). OFFICE SPACE AVAILABLE: New Ofce Space available for rent in Northwest Tucson off of Oracle Rd adjacent to a busy rheumatology practice. Up to 2,000 sq ft available. Can be built to suit for ofces, physical therapy or other medical needs. For information, contact Sue Haeger 382-4795. OFFICE SPACE NEEDED: Seeking a medical ofce approx. 2000 sq ft. with 3-4 exam rooms for sale or lease. Location between TMC and St. Josephs area. Please contact Roxann at 520-320-1369. OFFICE SPACE: Professional/Medical Ofce Space for Lease. Central location, tenant friendly rates, move-in ready. See details & photos at: www.space-4-lease.com

May
May 3-5: The Mayo Clinic Headache Symposium is at Hotel Nikko San Francisco, 222 Mason St., San Francisco, Calif. 94102; phone 415.394.1111http://www.hotelnikkosf.com/ CME: AMA, AAFP, AOA. Course provides attendees with expert panel discussions, skill stations in occipital nerve blocks and neurotoxin injection, posttraumatic headache from sport concussion, self-assessment activity, and discussion on audience-provided cases. Updates in the diagnosis and management of both primary and secondary headache disorders. Some of the special topics are pediatric headache, migraine headaches and hormones, adjunctive treatment in migraine, new and emerging treatments in migraine, low- and high-pressure headaches, thunderclap headaches, and headaches in the elderly and in special populations. Website: http://www.mayo.edu/cme/neurology-andneurologic-surgery-2013s156

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SOMBRERO April 2013

SOMBRERO April 2013

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SOMBRERO April 2013