March 2015 Sombrero

SombreroP i m a C o u n t y M e d i c a l S o c i e t y

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

M A R C H 2 0 1 5

Would you choose physicianhood again?

Looking toward Stars on the Avenue

Spotlight on Northwest NeuroSpecialists

2 SOMBRERO March 2015

I WENT WITH MY HEART.

Carondelet Heart & Vascular Institute. Be well.

Dr. Craig Hoover has joined the Carondelet Heart & Vascular Institute (CHVI) as Director of Cardiovascular Quality. Dr. Hoover received his Bachelor of Science degree from Stanford University and his Doctor of Medicine from Columbia University. He joins our team of physicians as an Interventional Cardiologist, bringing more than 20 years experience - with a focus on a personalized approach and integrating new technology into patient care. He is the Governor of the Arizona Chapter of the American College of Cardiology.

I joined CHVI with one goal in mind to help build a regional Cardiovascular Center of Excellence. We have a core of talented physicians who put their hearts into patient care. Carondelet physicians treat each patient with dignity and respect. When you visit us as a patient, we will work together to nd out what is wrong and put together a comprehensive treatment plan that works for you in a safe and caring setting.

CARONDELET HEART & VASCULAR INSTITUTE Home to some of the best heart and vascular physicians in Arizona. 13 cardiologists, three cardiothoracic surgeons and four vascular

surgeons all focused on improving our heart health.

Highest quality care in a modern, healing environment. Dedicated to the health of the whole person body, mind and spirit. Leaders in adopting minimally invasive techniques to improve patient outcomes. The CHVI hybrid operating room is one of the most advanced operating

suites in the nation.Craig A. Hoover, MD, FACC, FSCAI Director of Cardiovascular Quality

(520) 696-CHVI (2484) Carondelet.org

SOMBRERO March 2015 3

Official Publication of the Pima County Medical Society Vol. 48 No. 3

PrintingCommercial Printers, Inc.Phone: 623-4775E-mail: [email protected]

PublisherPima County Medical Society5199 E. Farness Dr., Tucson, AZ 85712Phone: (520) 795-7985 Fax: (520) 323-9559Website: pimamedicalsociety.org

EditorStuart FaxonE-mail: [email protected] do not submit PDFs as editorial copy.

Art DirectorAlene Randklev, Commercial Printers, Inc.Phone: 623-4775Fax: 622-8321E-mail: [email protected]

Pima County Medical Society OfficersPresident Melissa Levine, MDPresident-ElectSteve Cohen, MDVice-PresidentGuruprasad Raju, MDSecretary-TreasurerMichael Dean, MDPast-President Timothy Marshall, MD

PCMS Board of DirectorsEric Barrett, MDDavid Burgess, MDMichael Connolly, DOJason Fodeman, MDHoward Eisenberg, MDAfshin Emami, MDRandall Fehr, MDG. Mason Garcia, MDJerry Hutchinson, DOKevin Moynahan, MDWayne Peate, MDSarah Sullivan, DOSalvatore Tirrito, MDScott Weiss, MDLeslie Willingham, MDGustavo Ortega, MD (Resident)

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

Members at Large Richard Dale, MDCharles Krone, MDJane Orient, MD

Board of MediationTimothy Fagan, MDThomas Griffin, MDEvan Kligman, MDGeorge Makol, MDMark Mecikalski, MD

Arizona Medical Association OfficersThomas Rothe, MD immediate past-presidentMichael F. Hamant, MD secretary

At Large ArMA Board R. Screven Farmer, MD

Pima Directors to ArMATimothy C. Fagan, MDTimothy Marshall, MD

Delegates to AMAWilliam J. Mangold, MDThomas H. Hicks, MDGary Figge, MD (alternate)

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 repre-sent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright 2015, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

Sombrero

Executive DirectorBill FearneyhoughPhone: 795-7985Fax: 323-9559E-mail: billf [email protected]

AdvertisingPhone: 795-7985Fax: 323-9559E-mail: [email protected]

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5 Dr. Melissa Levine: Our president asks, Would you do it again?

7 Membership: We highlight Northwest NeuroSpecialists.

9 PCMS News: Banner Health announces new staff on the local takeover track.

12 Stars on the Avenue: Something particularly delicious about our coming event.

13 Time Capsule: Dr. Steven Wool as descendant of the black bag era.

16 Behind the Lens: Dr. Hal Tretbar reports on his work with first-year med students and Arizona Arthritis Center.

19 In Memoriam: Obituaries for surgeon Stephen L. Wangensteen, M.D., and anesthesiologist Bohdan J. Bo Jarem, M.D.

22 Bioethics: Ethics of the right to try by Dr. Tim Fagan. Bioethics committees under-consulted, by Dr. Steve Ketchel.

27 Makols Call: Is every patient legit who receives disability payments?

30 CME: Credits locally and out-of-town.

Corrections

In our last months Time Capsule of the History Committees trip to Superior by Dr. Nick Mansour, composition omitted the photo credit. Twas Dr. Ken Sandock behind the lens.

Also, in our February Board of Directors profiles we did not have current contact information for Dr. Scott S. Weiss. It is: Program Medical Director, Sound Physicians, Carondelet St. Josephs Hospital, 350 N. Wilmot Rd., Tucson 85711; phone 520.873.3077.

On the CoverFlowers spring in the Sonoran Desert spring, with colors galore. This composition of local flora was in Redington Pass on March 10, taken with a Nikon D70 with a 35-105 Nikkor lens at 70mm, ISO 200, 1/30th second at f16 (Dr. Hal Tretbar photo).

Inside


RepeatableBy Dr. Melissa Levine

PCMS President

Would you do it again?This is a question that it

seems many physicians are asked these days. I think it is a sign of the changing times and changing ways of medicine. I suspect that question wasnt

asked of doctors 50 years ago, or even 25.

Maybe Im wrong, and it has always been asked, and only the answer has changed. More and more doctors these days say no. A recent article in AAFP News said 50 percent of Family Physicians report burnout in 2015up from 43 percent in 2013. I think that is a shame.

I finished my residency in 1995, so this year marks 20 years of practice in Tucson. I also turn 50 this year, so aside from staring down that colonoscopy, I see this year as one of reflection. I am applying the would you do it again? to a lot of aspects of my life.

As for being a doctor and a family practice doc, let me clearly state for the record, yes. I would do it again. ABSOLUTELY.

Do I like dealing with insurance? No. Prior authorizations? No. Declining reimbursement? No. Narcotic-seeking patients? No. Patients who say they want an Ebola vaccine but not a flu shot? No.

EHRs? Here I will say I have a love-hate relationship. All of these things are a frequent part of my daily life as a doctor, so why on earth would I do it again? Patients. It is really that simple. I have the extraordinary privilege to be involved in patients lives. And I hope my impact upon them is for the better. Every day I go to work is interesting. It is all I ever wanted to do.

While I dont think doctor status is what it was, say in the 1950s or 60s, there is still a certain amount of status and prestige that goes with the title. Perhaps deserved, perhaps not. Perhaps it is good, perhaps not. We are often held to a higher standard. We are not allowed to make mistakes because peoples lives hang in the balance. The thing is that peoples lives hang in the balance even when we dont make mistakes. Sometimes people die. As doctors and as a society, we believe this to be failure. That is probably a topic for another column.

It turns out that doctors in China are afraid of their patients. Really afraid. A typical Chinese hospital averages 30 attacks on physicians per year by patients or their families. Multiply that by the number of medical facilities and contrast that to the average of 15 shootings per year total on American hospital campusesand the vast majority of those are crossfires. Approximately eight percent are directed at medical personnel, three percent at doctors, and five percent at

nurses. According to the federal Bureau of Labor Statistics, of 405 workplace shooting homicides in 2010, four percent were a combined education and healthcare, 17 percent government, and a whopping 27 percent were retail trade. Sadly, there is a pie-graph that shows this.

Some of you may know this story from the recent NEJM article, though I actually learned about it on that bastion of knowledge, Facebook. I venture to say that all Michael Davidson, M.D. wanted to do was be a good doctor, to impact peoples lives in a good way. Here is what I know after reading several articles about him.

Dr. Davidson was director of endovascular cardiac surgery at Bostons Brigham and Womens Hospital, and assistant professor at Harvard Medical School. By all accounts he was a star, a brilliant surgeon who pioneered less-invasive surgeries to help the sickest of patients who otherwise were too sick to survive conventional surgery. He tried his best to help those who would have otherwise heard, Im sorry, there is nothing else we can do.

He was a mensch. He cared about his patients and their families and took time with them and to know them. For his 40th birthday he ran the Boston Marathon with Team Brigham and was quoted as saying, There is no better way to commemorate a birthday, run the marathon to achieve a personal goal and, in the process, support Team Brigham and its mission to help so many people.

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He was a father of three, almost four. His wife was seven months pregnant with their fourth child. He had a sense of humor. He played lead guitar in a rock band called Off Label, comprised of physicians. He liked fly fishing.

He was well liked and well respected. Almost 1,000 people crowded into the synagogue for his funeral. He was shot on Jan. 21 by Stephan Pasceri, the son of a patient, who then turned the gun on himself. Dr. Davidson died in surgery nine hours later.

What do I know about Pasceri? He was an accountant, active in his church, and licensed to carry his handgun. Not a lot is known about Mrs. Pascerishe was 78, had valve surgery by Dr. Davidson, shortly after developed complications, possibly from chronic lung disease, and was admitted to another hospital. She died from a pulmonary hemorrhage shortly after being extubated.

I share the story of Dr. Davidson for two reasons. First it happened in a week when much of America was focused on deflated footballs and I think it deserves more than it got. Second, I believe Michael Davidson, M.D., if asked, would have said he would do it again.

It is something I reflect upon.

REFERENCES

Being like MikeFear, trust, and the tragic death of Michael Davidson. Lisa Rosenbaum, NEJM, Feb 4, 2015.

KevinMD.com, Shirie Leng MD, Jan 27, 2015.

A look at Michael Davidson, the surgeon fatally shot at Brighams. WBURs Common Health, Jan 21, 2015.

When patients kill doctors: The horrifying murder of Dr. Michael Davidson. Dan Diamond, Forbes, Jan 21, 2015.

Bureau of Labor Statistics, fact sheet/ workplace shootings, July 2010. n

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Northwest NeuroSpecialistsThe service of neurology specialty

While neurology and neurosurgery have undergone huge changes with new technology and knowledge, Northwest NeuroSpecialists also likes to acknowledge their qualities that do not change, and thus set them apart.

It started with customer service, Practice Administrator David Robinson says, and we are still about customer service.

Patients will talk to a person when they contact us. We dont want them listening to lengthy recordings with a maze of options. We also take as much time as necessary for any concerns they have when they come to the office or call, and we dont rush them. Neurological problems are usually not simple.

Neurosurgeons Thomas Scully, M.D. and Timothy Putty, M.D. established Northwest NeuroSpecialists in 2003, founding it with this focus on service. We were in practice for 10 years when we elected to start NNS, Dr. Scully said. We realized that to truly provide excellent patient care, we should focus on one office, and one hospital [Northwest Medical Center].

Dr. Scully has been a PCMS member since 1994. He served on the Board of Directors from 2005 to 2011 and is a frequent contributor to Sombrero. He was recently elected vice-president of the Western Neurological Society, a prestigious neurological organization that includes members from the Western U.S. and Canada. Hhe concentrates on cervical spine surgery, brain tumor management, and spinal vascular malformations.

Dr. Putty started his practice in Tucson in 1992, and hes been a PCMS member since then. His expertise is degenerative spine surgery and motion preservation techniques.

Richard Chua, M.D. completes the groups staff of neurosurgeons. He joined NNS and PCMS in 2005. His areas of concentration are degenerative spine disease, motion restoration techniques, brain and pituitary tumor surgery, and aneurysm surgery.

All three surgeons are American Board of Neurological Surgeons-certified, and completed their residency and internship programs at Indiana University in Indianapolis.

Advances in technology and techniques have made neurosurgery much less invasive in the last decade. It has improved recovery time and success rates following surgery. But the practice is not all about surgery. Sarah Sullivan, D.O., and Kai Denski, D.O. are the latest editions to the staff. Both are board-certified neurologists who completed their medical training at the Arizona College of Osteopathic Medicine at Midwestern University in Glendale.

Dr. Sullivan joined PCMS in 2009 and was elected to our Board of Directors in November 2014. Her special interests include stroke, peripheral neuropathy, and Parkinsons disease. She is also taking

Northwest NeuroSpecialists, established in 2003, is at 5860 N. La Cholla Blvd.

the lead on NNSs tele-neuro program. This allows patients to be seen electronically with teleconference technology. The doctor and patient can see and talk to each other on monitors. A registered nurse is usually with the patient to help with the examination and follow the physicians recommendations.

We are very excited about this program, Robinson said. This will enable patients who dont have the ability to get to our office to still receive help. It will also help patients in rural areas where it is very difficult to come see us.

Dr. Denski graduated with honors from the University of Michigan in 2002 before receiving her medical training in Arizona. Last year, she completed her neurology residency at UAMC where she was chief resident. She received an Epilepsy Fellowship from the University of Arizona GME Consortium from 2010-2013. Her areas of concentration are headache, epilepsy, and stroke.

The neurologists are not limited to their areas of interest. Patients are treated for a wide range of neurological disorders including all forms of dementia, multiple sclerosis, muscular disorders including ALS, sleep disorders, headaches, stroke, back pain, and neuropathies.

We treat the entire range of neurological disorders, Robinson said. The methods of treating some of these disorders have


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advanced with new medications and procedures. Most of these are very serious conditions that need serious attention. It still comes down to treating patients with respect and dignity.

Robinson said that about 75 percent of NNS patients are seniors, not unusual when many neurological maladies occur in older patients, and Tucson is a popular retirement location.

Many of the changes experienced at the practice are

administrative, including insurance reimbursement, medical records, and privacy regulations.

Simply, the manner which we operate in people has morphed, Dr. Scully said, but through all the changes, the general principles that we started with at NNS 12 years ago hold true today: Give each patient the time they need. Give them the respect they deserve. Do what is ethical, necessary, and proper to get them better. If one follows those general rules, its hard to go wrong. n

Neurosurgeon Thomas Scully, M.D., right, is a founder of Northwest NeuroSpecialists. Neurologist Kai Denski, D.O., joined the staff after completing her residency at The University of Arizona in 4014.

Support staff at Northwest NeuroSpecialists help provide the customer service that is practices main focus.


PCMS News

Academic Management Council launches, pending regents approval of mergerThe merger of University of Arizona Health Network into Banner Health will create a critical and exciting relationship between Banner and The University of Arizona, the university opined Jan. 20. The merger, which still requires approval by the Arizona Board of Regents, creates an Academic Management Council (AMC) to assist in managing the relationship.

Three leaders from Banner Health and three from the University of Arizona will be appointed to serve as the initial AMC board of directors, overseeing faculty operations and activities associated with teaching, research and clinical care within BannerUniversity Medicine, a new division of Banner Health that focuses on academic medicine. The AMC board will replace the University Physicians Healthcare board that currently governs the medical group.

BannerUniversity Medicine includes the three newly named academic medicals centers (BannerUniversity Medical Center Phoenix, Tucson, and South campuses), affiliated ambulatory care sites and the BannerUniversity Medical Group, comprised of physicians and other providers who are faculty for the University of Arizona Colleges of Medicine and the academic medical centers in Phoenix and Tucson.

University of Arizona President Ann Weaver Hart will appoint the following University leaders to the AMC board: Alex Chiu, M.D., Professor and Chair, Otolaryngology, University of Arizona, College of MedicineTucson; Gregg Goldman, Senior Vice-President for Business Affairs and CFO, University of Arizona; and Charles Cairns, M.D., Vice-Dean, University of Arizona College of MedicineTucson, Assistant Vice-President, Clinical Research, Arizona Health Sciences Center.

I look forward to appointing the members of the AMC, Hart said. These initial individuals will help to shepherd this important transition, and subsequently this council will assist in managing the relationship long-term. I have chosen three individuals who will help lead this statewide endeavor to success and guide the changes we are making to the culture and operations of academic medicine for a new era. Financial leadership from the university is vital and Gregg Goldman will represent the interests of the entire university. Doctors Cairns and Chiu bring unique skills and expertise to this council and will support the university leadership and represent the physicians and faculty, who are critical to our success. I believe these individuals are exactly what we need right now to lead this partnership forward and represent the interests of the university statewide.

Banner Health President and CEO Peter S. Fine will appoint the following Banner leaders to the AMC board: Kathy Bollinger, President, BannerUniversity Medicine Division, Banner Health; Dennis Dahlen, Senior Vice-President, Chief Financial Officer, Banner Health; John Hensing, M.D., Executive Vice-President, Chief Medical Officer, Banner Health.

The Banner leaders on the AMC board have broad responsibilities across the Banner system in seven states that will bring that system perspective to our board roles, said Bollinger, who will

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become president of the BannerUniversity Medicine Division with the Feb. 27 closure.

Serving as co-chairs for the AMC board will be Bollinger and Dr. Cairns. The AMC will establish a number of committees that will include faculty representation. Jason Krupp, M.D., CEO of the BannerUniversity Medical Group and president of Banner Academics, is an ex-officio, non-voting member of the board.

The authority of the Academic Management Council (AMC) includes: Development of operating and capital budgets. Approval of strategic and business plans for the Banner

academic enterprise. Approval of hiring, engagement and termination of UPH

clinicians; the University will retain the power to provide

faculty appointments and titles. Approval of the UPH compensation plan, and will template

employment agreements. Approval of teaching programs within the Banner academic

enterprise. Approval of a physician recruitment strategy and plan. Strategic coordination of the residency and fellowship

programs at facilities within the Banner academic enterprise. Approval of all clinical affiliations that support Banner academics.

Banner Health, headquartered in Phoenix, is one of the largest, nonprofit health care systems in the country. The system manages 25 acute-care hospitals, the Banner Health Network and Banner Medical Group, long-term care centers, outpatient surgery centers, and an array of other services including family clinics, home care and hospice services, and a nursing registry. Banner

Health is in seven states: Alaska, Arizona, California, Colorado, Nebraska, Nevada and Wyoming. For more information, log onto www.BannerHealth.com.

MRC calls for actionMedical Reserve Corps, after a decade of service to the country under the auspices of the Office of the Surgeon-General, has recently announced an operational transition to the Office of the Assistant Secretary for Preparedness and Response (ASPR) in the U.S. Department of Health and Human Services.

Medical Reserve Corps of Southern Arizona (MRCSA) is enthusiastically supportive of this evolution to the federal agency whose primary planning and response responsibilities mirror the mission of the Medical Reserve Corps.

The federal Pandemic and All Hazards Preparedness Act gives authority to the Department of Health and Human Services (HHS) as the lead agency for Emergency Support Function 8Public Health and Medical Services of the National Response Framework. The HHS secretary delegates to ASPR the leadership role for all health and medical services support functions to improve the nations public health and medical preparedness and response capabilities for emergencies, whether deliberate, accidental or natural.

The Office of the Assistant Secretary for Preparedness and Response was created in the wake of hurricane Katrina to lead the nation in preventing, preparing for, and responding to the adverse health effects of public health emergencies and disasters. ASPR focuses on preparedness planning and response; building federal emergency medical operational capabilities; counter-measures research; advance development, and procurement; and grants to strengthen

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the capabilities of hospitals and healthcare systems in public health emergencies and medical disasters, as well as medical professionals through the National Disaster Medical System and now Medical Reserve Corps.

Dr. Nicole Lurie, M.D., M.S.P.H, RADM, U.S. Public Health Service, is Assistant Secretary for Preparedness and Response.

Dr. Lurie was previously Senior Natural Scientist and Paul O Neill Alcoa Professor of Health Policy at the RAND Corporation, where she directed RANDs public health and preparedness work as well as the Center for Population Health and Health Disparities. She also served as HHS Principal Deputy Assistant Secretary of Health. She has a long history in health services research, primarily in the areas of access to and quality of care, mental health, prevention, public health infrastructure and preparedness, and health disparities. Under Dr. Luries leadership, MRCSA will continue its mission to serve the communities of Pima County and Southern Arizona.

This is your call to action! We encourage you to become a part of this dynamic and fast-growing organization of volunteer medical professionals. Your skills, expertise, and experience will be vital to community resiliency following a disaster or public health emergency.

Why be the medical professional who wants to volunteer and is turned away until credentials are verified? We understand and appreciate your busy schedules. MRCSA membership application takes less than five minutes. There are no annual dues and no onerous requirements. We ask that you attend a minimum of one training session each year. It is that easy to make a difference in your community!

For more information and to join MRCSA, e-mail us at [email protected] or call 520.445.7035.

Tucsons modern streetcarand its public health impactsBy Ron Spark, M.D.To paraphrase Rudolf Virchow, famous German pathologist and politician: Medicine will eventually improve public health, but politics can do it sooner.

The coming of Sunlink, Tucsons light rail or modern streetcar, represents a watershed for the Old Pueblo, leaving behind its suburban, desert, car-centric orientation. An urban 21st-century city awaits our future.

The political will to make this happen has brought a number of cascading opportunities for a successful and healthier place to live. Both Baby Boomers, suffering with increasingly recognized decrepitude, and Millennials yearn for an urban core with easily access to ample and diverse goods and services. Easy proximity to gathering places, such as we now see Downtown, lend a sense of place, enhanced socialization, and feelings of well-being. As more residential market-rate housing is built, many other age groups will likely opt to enjoy this urban lifestyle. As this happens, more investment will be drawn to the increased numbers of consumers. This raising of the quality of life through urbanization will have obvious public health benefits.

Evidence for the shift toward the desire and need for more

walkable and bike-accessible roads is reflected in national and local data. Theres the obvious decline of Millennials getting driving licenses, as well as the 20-percent decline in their buying cars. More seniors are giving up driving voluntarily or non-voluntarily. If you count kids, about one-third of Tucsons population doesnt drive.

Vehicle travel-miles peaked around 2004. Many of Tucsons streets have seen a decline in traffic. Broadway was projected in 2006 to have increased volumes of 44 percent over 20 years; it is currently carrying 15 percent under the 2006 figures. Similar declining figures are seen on 6th Street and Speedway.

To meet the needs and desires of our future residents, we need to fashion a more urban, denser community with accessible services and jobs with reliable, inexpensive high-capacity mass transit. The modern streetcar, Sunlink, is that starting point. Its arrival has spurred more than $1 billion in Downtown investment. The impact is spreading outward to adjacent neighborhoods where retail goods and services are springing up. The Broadway corridor is scheduled for redevelopment into a vibrant destination with a mixture of small retail and service enterprises.

Sunlink didnt happen overnight. Our vision of Tucsons future sustainabilty rested on the concept of providing accessible, inexpensive and reliable public transit: an effective feeder bus system to a light rail spine network. That was 13 years ago and three elections lost! In the end, we partnered with the road-building crowd and RTA was passed. So here we are with Sunlink.

What we need now, for better public health, is the political will to make the infrastructure investments. High-capacity transit, complete streets (sidewalks, bike paths, shade structures, and destinations), and preservation of our historic built structures that give us a sense of place.

Even medicine has shifted from a disease model to a preventive one. So, we the citizens of the Old Pueblo, need now to adopt a more urban mentality, one with ease of connectivity and a sense of place. Thats the healthy choice.

Over the streetcars opening weekend in July 2014, Southern Arizona Transportation Advocates asked riders where theyd like to see the next streetcar extension. We received nearly 1,000 reponses. The top choices were: extend out Broadway to El Con Mall and Park Place; up Campbell Avenue to Tucson Mall; and south down 6th Avenue to the airport.

Dr. Spark, PCMS member since 1974 and a past-president, is on the steering board of Southern Arizona Transportation Advocates, and is a volunteer for Mayor Jonathan Rothschilds Sustainable Community Transit-Oriented Development effort. SATA is working on how to finance streetcar extensions, expand bus service, and create Tucson-Phoenix rail service.

History Committee schedules next tripThe PCMS History Committee says its next excursion will return to historic Arizona mining areas with a trip to Miami-Globe, Saturday April 18.

As with the previous trip, to Superior, Dr. Nick Mansour and Don Hammer are scouting the area to plan what sites to see, including mine sites and a downtown walking tour.For information or questions, please call History Committee Chairman James B. Klein, M.D. at 795.9484. n


Stars on the Avenue

Word of mouth indeedBy Dennis Carey

PCMSs 2015 Stars on the Avenue celebration April 18 provides many thingseven a chance to get a piece of the pie. Not a metaphor. Pie.

Along with some of Tucsons best restaurants, Lauras Pies is a featured vendor at this years event. Laura Hansen has brought her baking talents from Montana to Tucson. PCMS members and their guests will have an opportunity to sample some pies that have gained national recognition.

These are truly homemade pies, as Hansen has started her Tucson business out of her brothers home. She eventually would like to start a small pie shop in Tucson. If the right place comes along, I would like to find a place where people can enjoy a piece of pie and relax, Hansen said. I dont plan on doing anything big.

Hansen and her close friend, Mary Lou Covey, owned two different restaurants in Montana. It started with the Spruce Park Caf in Coram, just outside Glacier National Park. Later they expanded to a larger location called Loulas Caf in Whitefish, closer to where they lived. Both cafes have a reputation for excellent food, but it was the pies that earned a place in the hearts and stomachs of regulars as well as those of travelers making a food pit-stop.

We had a group of hikers called the Over the Hill Gang who would come in for a piece of pie every Thursday, Hansen said. One of them, George Ostrom, had a radio show and called the bourbon pecan pie the best piece of pie he had ever tasted. The best advertising is word of mouth.

Having an author feature one of your pies in a book doesnt hurt, either. Pascale Le Draoulec chronicled her cross-country trek from San Francisco to New York in a book American Pie: Slices of Life (and Pie) From Americas Back Roads. Her favorite was huckleberry-peach from the Spruce Park Caf. Numerous articles and Internet reviews have been written about these pies, and it still brings in what are called Pie Pilgrims

While huckleberries are not in abundance in Southern Arizona, Laura does have some unique ideas for Stars on the Avenue. She plans to feature a Tucson lemon pie, and sour cream apple pie.

Four years ago Hansen was diagnosed with MS. She moved to Tucson to help her brother, who had his own health concerns after a lung transplant. Covey bought Hansens share of the restaurants. Spruce Park and Loulas are still going strong, and Hansen says she is happy for the continued success.

My MS really does not bother me a lot, she said. I loved working at the restaurants, but I am glad I dont have the stress anymore. I still love making piesjust not as many.

That doesnt mean she cant make Pie Pilgrims out of PCMS members.

Stars on the AvenueCampbell that isis Saturday, April 18 at St. Philips Plaza, 6-9 p.m. Tickets are available at pimamedicalsociety.org. Sponsorship packages are available by calling the Society at 795.7985. n

Itll be easy as pie to get a delicious slice when Laura Hansen of Lauras Pies brings some of her highly acclaimed baked goods to Stars on the Avenue April 18 at St. Philips Plaza. We recommend this as the only method to get pie-eyed at SOTA.


Time Capsule

BaggageBy Stuart Faxon

If you are too young to have carried the once-traditional doctors black bag, youve certainly seen it memorialized, including in our PCMS headquarters lobby display cases.

If you are a physician mainly because your father was, youre even more familiar with the old black bag. So it was for Dr. Steven A. Wool, PCMS member since 1985. About a year ago, Dr. Wool was visited by Lesley Martinez, representative of the pharmaceutical company Abbott. As a physician son, he told her he remembered from years ago an Abbott promotional publication that featured his father, Dr. Frohman Wool, who was a GP in Waukegan, Illinois. The older Dr. Wool had been used as a physician model for sales of erythromycin as treatment for Legionnaires disease, the malady that became all too familiar in 1977.

It was not by themselves that the two Wool generations were a medical family. Dr. Steven Wools brother is a surgeon whose son also became a surgeon. His nephew is a physician. His sister became a homemaker and physicians wife. Only one brother of the four Wool siblings went into non-medical business.

Dr. Wool asked if Martinez could locate this Abbott publication, a brochure for distribution to physicians. Later she showed up in my office with the original article, Dr. Wool said, plus a letter from my mother that they had at the labs. That was the surprise to me.

A Nov. 9, 1978 letter from Abbotts public affairs manager confirmed sending advance copies of their Commitment magazine to Dr. Frohman Wool, and thanked him for his participation. The surprise was the Nov. 13, 1978 response letter to her from Millie Wool:

My husband and I received the advance copies of Commitment magazine with the picture of Ken Stewart and himself. We got a big kick out of it. Thank you for sending them to him.

Now, I wonder if it would be asking too much if we could have

four more copies of the magazine. I would like to send them to each of our children. I know they would enjoy seeing their dad in print. One is a doctor, one is in med school, one is married to a doctor, and the other a freshman in college. If there is any charge, I would be glad to reimburse you

Thank you for the pictures. I think he looks better than Dr. Welby.

Frohmans son Steven earned his M.D. in 1980 at Duke University School of Medicine, interned in family medicine and did his IM residency at UAMC. He is board-certified in IM. He served on the clinical staff of the Department of Medicine, University of Arizona College of Medicine, and as TMC chief of medicine 2005-2009. And as we noted in our February issue, he founded the Cindy Wool Memorial Seminar on Humanism in Medicine, which comes up March 31.

In private practice since 1985, Dr. Wools practice today is Personalized Healthcare of Tucson, what he calls a physician-patient partnership in which he accents education in a different way.

Abbott said of this photo, Ken Stewart (right), professional representative in the Abbott Pharmaceutical Division, reviews the companys report on Legionnaires disease with Waukegan, Ill. physician Frohman Wool. The company said the booklet was available to physicians as outbreaks occur in New York garment district and elsewhere.


Achievement of optimal health is a journey, not an office visit, Dr. Wool says. In 2010 I changed from a traditional medical practice to a physician-patient partnership model. This allows me to provide my patients with the highest level of medical care in the community by maximizing accessibility, clinical competence, and communication.

In this model the physician puts a priority on building a relationship with the patient that removes the barriers between the physician and the patient created by traditional models of healthcare delivery. The physician learns from the patient, and the patient learns from the physician.

My father was a family physician for more than 40 years, Dr. Wool says. He practiced medicine in the old-time tradition, when a doctor had time to get to know his patients. Inspired by his example, I have made building nourishing and strong relationships with my patients a top priority.

Added benefits values at PHC of Tucson include, for urgent health issues, same- or next-day appointments, or access to physician services 24/7, and expedited referrals to quality specialists.

I intend to be a leader in the field of primary care to improve the health outcomes of my patients, Dr. Wool says. n

Robert Young played Marcus Welby, M.D. 1969-76 in the popular medical drama of that name. Was he better-lookin than Dr. Frohman Wool? We know what Dr. Wools wife thought!

Dr. Steven A. Wool poses in his office with his fathers black bag (Stuart Faxon photo).


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I chose Carondelet Heart & Vascular Institute because of the opportunity to work with an exceptional group of specialists. I am able to combine my area of expertise - complex aortic procedures and adult congenital heart disease with the specialties of my colleagues. The team includes two cardiothoracic surgeons besides myself, vascular surgeons, cardiologists, anesthesiologists, nurses, physical therapists, and case managers. Together, our collective insight creates a care program for each patient that is better and stronger. We focus on results. One patient at a time.

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From rumor to rheumaticFirst-year med students meet the real thingBy Hal Tretbar, M.D.

Behind the Lens

For the past several years I have had the privilege of introducing UofA med students to their first patients. Im part of a program sponsored by University of Arizona Arthritis Center in which first-year students meet patients with rheumatic diseases.

The freshman class had just finished the block on musculo-skeletal and autoimmune diseases. They are fascinated when they encounter a person with the actual disease. It is said that each will always remember this point in his or her medical career.

This year 22 patients with various rheumatic illnesses volunteered to participate. They find this to be such a rewarding experience that many return the next year. A rheumatologist meets and works with one patient in an exam room. The class is divided into small groups that rotate every 20 minutes to another exam room. The patients relate their stories and the

rheumatologist demonstrates the physical findings.

Eric Gall, M.D., professor of medicine in the Division of Rheumatology, started a program in 1975 in which medical students met patients early in their training. In 1978 a training grant from the National Institutes of Health expanded the program.

After spending time as professor of medicine at the Chicago Medical School, Eric returned to the UofA in 2010. The present program, called Physical Findings in Rheumatic Diseases for First-Year Medical Students, has invited rheumatologists from the community to participate along with arthritis center staff and Fellows. This year Steve Strong, M.D. and I were non-staff teachers. I received arthritis center staff approval to photograph and write about how the students felt when they first met a patient with a chronic rheumatic condition. Permission also was obtained from the patients and the students.

I had the honor of working with Matty Heenan. She has systemic sclerosis, or scleroderma. She is very active in the Scleroderma Foundation and knows more about the illness than I can remember. Her

Eric Gall, M.D. talks to first-year medical students about how they will soon meet patients with rheumatic diseases. The class had just finished the core block on musculoskeletal and auto immune disorders.


tight skin has responded well to treatment and she has only slight restriction in her grips. However, she has developed some of the internal complications of her disease.

Tucson native Matthew Cravens listened to the fine crackles in Mattys lungs. He e-mailed me: Meeting a patient with an incurable disease is always a humbling experience I think compassionate management is essential for the physicianeducating the patient to whats happening with his or her body and what possibilities modern medicine has for treatment This feeling is a great motivator for me toward pursuing research.

Katie Marsh showed a lot of interest in Mattys condition. She stated, As a first-year medical student, it is often rare to encounter real patients. At the UofA College of Medicine this is not the case. Speaking with patients at the rheumatology clinic helped me apply our classroom learning to clinical practicea lesson that is invaluable and I will not soon forget.

Dr. Gall presented Kevin Purcell to the students. Kevin is a successful businessman whose severe juvenile arthritis has been in remission for many years. He has had numerous surgeries and joint replacements for deformities.

After examining Kevin, Kelsea Farrell later commented, It was very hard to see someone so limited in their movements, but I quickly realized he had found a way to compensate and did not seem limited at all. He has a very positive outlook on life, which I think is the most important aspect of living with a chronic serious illness. I felt very privileged that he allowed us to better understand his condition.

Oleksandr Alex Trofymenko is a 27-year-old nontraditional medical student to say the least. He studied finance in college,

worked as a high school math teacher, was a product manager for an insurance company, and owned a smoothie shop. He loves working with people and is interested in healthy living. His interests and career aspirations have led him to pursue a career in medicine.

My first long-term encounter with someone who had a serious disease happened when I worked as a teacher, Alex said. It was my responsibility to provide much more comprehensive care

than just teaching mathematics. Honestly, my initial reaction was anxiety. I worried that I wasnt up to the challenge. The feeling disappeared fairly quickly as I got to know the student personally and established working relationships with many others who took care of him. I learned to just accept people for who they are, rather than letting the disease be the defining characteristic of the student I keep this attitude with me as I go through my training. I want to work with people by treating their illnesses, and not the other way around.

The third group that I photographed was led by Meg Miller, M.D. of the Arizona Cancer Center. She explained the serious complications that Jorge Vega has developed from his systemic lupus erythematosus (SLE). Besides the typical red butterfly rash on his nose and cheeks, he has severe renal involvement. The students found out that SLE usually attacks middle-aged females, although any age group may be affected.

In a summary of the days activities, Dr. Gall reported that the feedback from all of the students was absolutely outstanding. He pointed out that the program also gives the students a chance meet rheumatologists and find out what we do to help these patients with serious rheumatic diseases. n

Medical student Matt Cravens is able to hear the fine crackling sounds from Matty Heenans lungs.

Kelsea Farrell asks permission to examine Kevin Purcells arm. She considered it a

privilege to meet him.

Kevin Purcell describes the joint surgeries he has needed because of the damage from his juvenile arthritis as Alex Trofymenko, in the lavender shirt, listens.


Macular degeneration Diabetic retinopathy Macular diseases, e.g., macular hole and macular pucker

Flashes and fl oaters Retinal tears Retinal detachment Central and branch retinal vein

Pediatric retinal conditions Tumors involving the retina and choroid

Second opinions

St. Josephs Medical Plaza6561 E. Carondelet DriveTucson, Arizona 85710

Northwest Medical Center6130 N. La Cholla Blvd., Suite 230Tucson, Arizona 85741

1055 N. La Caada Dr.,Suite 103Green Valley, Arizona 85614


Macular degeneration Diabetic retinopathy Macular diseases, e.g., macular hole and macular pucker

Flashes and fl oaters Retinal tears Retinal detachment Central and branch retinal vein

Pediatric retinal conditions Tumors involving the retina and choroid

Second opinions

St. Josephs Medical Plaza6561 E. Carondelet DriveTucson, Arizona 85710

Northwest Medical Center6130 N. La Cholla Blvd., Suite 230Tucson, Arizona 85741

1055 N. La Caada Dr.,Suite 103Green Valley, Arizona 85614

In Memoriam

By Stuart Faxon

Stephen L. Wangensteen, M.D.1933-2014

Stephen L. Wangensteen, M.D., general surgeon who joined PCMS in 1977, and served as the University of Arizonas second chief of surgery, died on Dec. 1, 2014 in South Carolina, the Arizona Daily Star reported Feb. 10. He was 81.

Stephen Lightner Wangensteen was born Aug. 30, 1933 in Minneapolis, son of internationally known surgeon Owen H. Wangensteen, the family told the paper. After earning two undergraduate degrees at the University of Minnesota, Stephen earned his M.D. in 1958 at Harvard Medical School. He interned in surgery at The Presbyterian Hospital of the City of New York (now Columbia-Presbyterian Medical Center) including a vascular research fellowship, did his GS residency there and was chief surgical resident 1964-65.

In 1965-67 Dr. Wangensteen was assistant chief, Surgical Research Branch, Research and Development Command, U.S. Army Office of the Surgeon-General. He was an experienced researcher and had special interests in gastrointestinal, hepatic, and biliary physiology; gastrointestinal hemorrhage; portal

Dr. Stephen L. Wangensteen in 1981.

hypertension; gastric hypothermia; and cardiovascular physiology accenting hemorrhage and shock. He served academic appointments at Columbia University, University of Virginia, and the UofA.

The year he joined PCMS, Dr. Wangensteen even had the distinction of clearing a fibrous tissue buildup intestinal tract obstruction for country singer Tammy Wynette. She had flown here from Cleveland because her fiancee at the time, George Richey, had been stationed at Fort Huachuca, and Tucson friends arranged for the singer to have the surgery here at the end of her 1977 concert tour, the Star reported.

It was as professor and head of the Department of Surgery, UofA College of Medicine that Dr. Wangensteen was best known here. He was a member of the Tucson Surgical Society as well as PCMS. He resigned from both when he left in 1987 for Tampa, Fla. and the University of South Florida College of Medicine Department of Surgery.

His father presented Steve with tough shoes to fill and high expectations when he was growing up, the family told the Star. But he did it with pride and amazing grace. At the UofA the Department of Surgery, the department was in great distress and needed someone to turn it around, the family told the Star. Steve was known for his prowess at recruiting excellent surgeons, one being heart surgeon Jack Copeland. In 1979 the department made history performing the first heart transplant in Arizona. In 1985 doctors Wangensteen and Copeland made a historic decision to perform a controversial, yet successful bridge-to-transplant procedure using an artificial heart, the CardioWest predecessor Jarvik-7-100, the worlds first.

Steve built one of the most robust and nationally known surgical departments, famous for its transplant team. His peers would say that he made everything look so easy, as he handled all situations with great elan.

He was a member of AMA, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, Society of University Surgeons, Southern Surgical Association, American Surgical Association, Southeastern Surgical Congress, and the Halstead Society.

Dr. Wangensteen and his wife, Lita, known as Squeaky, were known for their unique and highly entertaining parties, whether with dear friends or business associates, the family said. The Wangensteens enjoyed life on their Tucson ranch, and guests may have been surprised when a horse entered the house to greet them, or a slew of bandana-clad dogs happily followed them around.

Steve enjoyed his boating and deep-sea fishing, and traveling up and down the Intercoastal Waterway while stopping at charming spots along the way. He was an incredible chef and loved entertaining. His love of dogs was unmeasured. He and Squeaky retired to South Carolinas horse country and bought the most beautiful horse farm, Pear Tree Farm, where they developed deep friendships and really enjoyed their lives until his passing.

Dr. Wangensteens son William predeceased him in 1999. Squeaky survives him, as do daughter Christine Ecklund; sons Stephen and Philip; and grandchildren Sierra, Owen, Blake, and Madison. Memorial contributions may be made to Walter M. Crowe Animal Shelter, 460 S. Fair St., Camden, S.C. 29020.


Bohdan J. Bo Jarem, M.D.1941-2015

Dr. Bohdan J. Bo Jarem in 1984.

Bohdan J. Bo Jarem, M.D., anesthesiologist who was a PCMS member 1978-90, died Jan. 23 in Tucson, the The Galveston County (Texas) Daily News reported Jan. 15. He was 73.

Bohdan John Jaremczyszyn was born July 22, 1941 in Lodz, Poland, certainly not a good place to be that year considering the 1939 German invasion starting the second world war. Bo and his family immigrated to America in 1948 and settled in Lima, Ohio, the family told the paper, so all his medical training was here.

After an undergrad degree at Harvard without a major, Bo went to The Ohio State University where he earned his M.D. in 1966. He served as a lieutenant in the U.S. Navy Medical Corps 1967-69. He interned at the University of Texas Medical Branch Hospitals at Galveston and did his anesthesiology residency there.

Dr. Jarem began his practice here in 1978 with Tanque Verde Anesthesiologists with doctors Fred Landeen, Thomas Webster, Loren Taylor, Gary Bonwell, Larry Putnam, and Julien Caillet.

Bo practiced medicine in Galveston, Houston, El Paso and Dallas as well as in Tucson, the family reported. He initially specialized in orthopedics, then anesthesia, and finally in pain management

Bo had a multitude of interests outside medicine and was widely traveled. He spent time in Africa, Western Europe, and the Caribbean where he pursued his hobbies of photography and scuba diving. Bo was a loving father and friend, and a gentle soul with a wonderful sense of humor. He loved learning, had a passion for books, and believed life should be lived to the fullest.

Two sisters predeceased Dr. Jarem. Daughters Tina Shockling of Houston and Erika Edris of Tucson; two grandsons; and three step-granddaughters survive him. Memorial services were private. Condolences can be left at DignityMemorials.com or mailed to E. Edris, 10554 S. Sean Drive, Vail, Ariz. 85641. n


Bioethics

Ethics of the right to tryBy Timothy C. Fagan, M.D.

On Nov. 4, 2014 Arizona citizens overwhelmingly approved Proposition 303, amending the Arizona Revised Statutes to allow terminally ill patients to obtain and use medications that are in development, but have not been approved by the U.S. Food and Drug Administration.1 Often, well-intended laws lead to unintended consequences, both practical and ethical.

In order to consider the ethical consequences of 303, it is necessary to understand the new drug development process, the FDA Expanded Access Program (Compassionate Use)2, and the actual content of 303. Relevant portions of 303 include:

36-1311. Definitions

1 (d) The eligible person has given written informed consent for the use of the investigational drug, biological product or device, or if the patient is a minor or lacks mental capacity to provide informed consent, a parent or legal guardian has given written informed consent on the patients behalf.

2 Investigational drug, biological product or device means a drug, biological product or device that has successfully completed Phase One of a clinical trial, but has not been FDA-approved for general use and remains under investigation in a clinical trial.

3 Physician means the physician who is providing medical care or treatment to the eligible patient for the terminal illness but does not include a primary care physician.

36-1312. Availability of investigational drugs, biological products or devices; costs; insurance coverage.

A. A manufacturer of an investigational drug, biological product or device may make available the manufacturers investigational drug, biological product or device to an eligible patient. This article does not require that a manufacturer make available an investigational drug, biological product or device to an eligible patient.

36-1314. Section 2. Findings: intent

A. 4. Patients who have a terminal illness have a fundamental right to attempt to pursue the preservation of their own lives by accessing available investigational drugs, biological products or devices.

Drug development process

The drug development process begins with studies in cells, tissues and animals, in order to provide preliminary information on safety, including cancer-inducing potential, and potential efficacy in a particular disease or condition. If this information is adequate and suggests both safety and efficacy, FDA will issue an Investigational New Drug (IND) approval to allow Phase One testing of the drug in humans. This typically involves no more than a few hundred normal volunteers. Further testing is dependent upon no evidence of serious harm, but the information is limited by the small number of individuals studied and by the fact that they usually do not have the disease or condition for which the drug is intended.

It is rare to have any efficacy information at all at the end of Phase One. If Phase One shows no evidence of significant harm, FDA will approve Phase Two testing, which normally involves hundreds of patients with the disease or condition to be treated, for a period of weeks to months, and provides initial information on efficacy, the appropriate dose to be used and additional safety information.

If Phase Two provides appropriate safety and efficacy information, FDA will approve Phase Three trials. These typically involve thousands of patient for periods up to five years.

After Phase Three, if efficacy and appropriate dosing is established, and side effects identified, and the New Drug Application for marketing is approved, FDA may still require large post-marketing trials in thousands of patients. The process from the beginning of Phase One until approval typically lasts seven or more years.

Expanded access or compassionate use

Compassionate Use (CU)2 has been in place for many years and allows use of investigational medication, biological products and devices (investigational products) for seriously ill, as well as terminally ill patients. Thus, 303 is more restrictive than the CU process already in place, because CU also allows access for seriously ill patients.

In 2011, approximately 1,200 patients received investigational medication under CU. This remains the only option for patients seeking investigational products under 303. Under this program, a physician files an IND for one particular patient with the FDA. The IND must be reviewed and approved by an Institutional Review Board, whose members have expertise in clinical medicine, pharmacology and ethics. An Institutional Review Board is an official entity, which may be freestanding or part of a Medical Center.

If it is not an emergency, and all of the necessary information is provided, FDA usually gives approval after 30 days. If it is an emergency, this usually takes less time. Until all necessary information is provided, the IND will not be approved.

After approval of the IND, based on multiple factors, including all of the available information about the drug and the patient, the manufacturer of the drug decides whether or not to provide the medication to the patient. The more extensive the information about the drug, the more likely it is that the manufacturer will decide to provide the drug. Although the manufacturer is free to


charge for the medication, there is usually no charge to the patient. Insurance companies will not pay for unapproved medications.

AMA Code of Ethics

The American Medical Associations Modernized Code of Ethics3 contains several sections relevant to 303. Physician Exercise of Conscience3 contains the statement: Physicians are not expected to provide care that, in their professional judgment is unlikely to achieve the patients clinical goals. Indeed, they should not do so.

Section 2B.13 Informed Consent:

In seeking a patients informed consent (or the consent of the patients surrogate) physicians have an ethical responsibility to include the burdens, risks and expected benefits of all options, including forgoing treatment.

Section 2B.1.23 Decisions for Adult Patients Who Lack Capacity:

When a patient lacks decision making capacity, the physician has an ethical responsibility to identify an appropriate surrogate to make decisions on the patients behalf: (i) the person the patient designated as a surrogate through a durable power of attorney for health care or other mechanism, or (ii) a family member or other intimate associate, in keeping with applicable law or policy, if the patient has not previously designated a surrogate.

Section 5.53 Medically Ineffective Interventions:

Physicians should only recommend and provide interventions that are medically appropriate, i.e. scientifically grounded, and that reflect the physicians considered medical judgment about the risks and likely benefits of available options in light of the patients goals of care. Before completion of Phase Two, there is no basis for a scientifically grounded judgment.

Risk vs. benefit and informed consent

The FDA development and approval process, as well as the decision to prescribe a medication for an individual patient, always involves an evaluation of risk vs. benefit. Surviving the approval process indicates an appropriate balance of risk vs. benefit for most patients for whom the medication is approved to be marketed. However, the risk vs. benefit ratio is different for each individual patient and situation. A terminally ill patient and his or her physician, or other licensed provider such as a nurse practitioner or physician

assistant may be willing to accept greater risk for any given benefit. Evaluation of risk vs. benefit requires adequate information regarding both. At the end of Phase One, there is typically minimal information regarding risk, and no information regarding efficacy in humans. At the end of Phase Two there may be enough information to make an evidenced-based decision.

Informed Consent3 requires that the physician has adequate knowledge of the safety and efficacy of the proposed treatment or device, and adequate knowledge of the patients views about life and how it should be lived. At the end of Phase One, there is not enough information for a physician to make a scientifically sound determination of the risks and benefits. Informed consent also requires that the patient, or surrogate decision maker, is able

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to understand the information provided by the physician. Informed consent cannot be obtained from children or from patients who do not have adequate mental capacity to understand the relevant information. It can be argued that a terminally ill patient (or surrogate decision maker), may be so desperate that judgment is impaired enough that he or she lacks capacity to make informed consent possible.

Practical and ethical aspects of 303

303 will do nothing to increase availability of investigational products to terminally ill patients, since it provides no new mechanisms or processes to obtain these products.

303 acknowledges that a manufacturer is not required to provide

an investigational product to an eligible patient. This is consistent with the CU process, and does nothing to increase the availability of the products.

303 states: Patients with a terminal illness have a fundamental right to attempt to pursue the preservation of their own lives by accessing available investigational drugs, biological products and devices. The source of this fundamental right is unclear. It is probably a liberal interpretation of the right to life, liberty and pursuit of happiness.

The 303 definition of physician makes it against the law for a physician, who best knows the patient and his or her views about life and how it should be lived, to participate in obtaining

investigational products for the patient. The primary care physician is also the physician most likely to be trusted by the patient. This limits access to investigational products.

The 303 list of appropriate surrogate decision makers fails to recognize many appropriate surrogate decision makers, and thus places limits on patients access to investigational products.

The essence of 303 is that patients have a fundamental right to use investigational products, which, under the conditions of 303, a physician often cannot adequately evaluate, and neither make a rational decision regarding their use, nor obtain informed consent for their use.

Summary

303 does nothing to increase access to investigational products, while it falsely raises the hopes of terminally ill patients, limits their access to investigational products, and creates ethical dilemmas for physicians and surrogate decision makers who could otherwise assist these patients in the process.

Timothy C. Fagan, M.D. is a Tucson internist and clinical pharmacologist. He is a PCMS past-president, Pima County Medical Society Director to ArMA, and Professor Emeritus of Internal Medicine at The University of Arizona College Of Medicine.

REFERENCES

1. Proposition 303 Right to Try,, Arizona General Election Ballot, Nov. 4, 2014.

2. FDA Expanded Access Program, http://www.fda.gov/Drugs/GuidanceComplianceRegulatory Information/Guidances/ default.htm

3. American Medical Association Modernized Code of Medical Ethics.


UnderutilizationBy Steven Ketchel, M.D., F.A.C.P.

Underutilization is one of those words that a syllable-impressed bureaucrat might choose to denote under-use. A good example would be, each of Tucsons hospitals has a biomedical ethics committee. From talking with those who chair them, I have concluded that we all answer approximately the same kind of ethical questions in each of our hospitals.

Each of these committees considers that theirs is under-used, and that if medical staffs and other medical personnel knew that there were such committees in their hospitals dealing with these kinds of questions, they would be consulting them more. We hope that there are more occasions when our committee can answer ethical questions that occur in our hospital.

Biomedical ethics uses a combination of ethical principles that are proposed to relate to the practice of medicine. Biomedical ethics involves both moral principles and their practices, and matters of social policy involving morality in medical practice. AMA has published a Code of Medical Ethics which interested parties are welcome to consult.

In general, biomedical ethics committees at hospitals are composed of physicians, nurses, social workers, and other hospital personnel, as well as community volunteers. The committees major role is to answer questions from medical staff in the hospital, the patients or their families, or other decision-makers as to proper answers that may be proposed for problematic questions. These may include whether it is proper to discharge the patient at a proposed time; whether a patient is capable of making decisions in his or her own care; or whether family members are capable of, or trying to mediate between family members with differing viewpoints about their loved ones care.

Committees also work on hospital policies, such as how to explain to patients that when they go to surgery, their Do Not Resuscitate or Allow Natural Death order is no longer in place, and to work with hospital personnel as to when the DNR or AND order should be restored. The

committees may also review standing hospital policies to make sure they do not compromise ethical principles.

Occasionally these committees will be asked to give their opinion on more controversial subjects, such as whether what appears to be a medically necessary abortion should take place; whether care that is proposed is futile and thus should not be undertaken; or what is quality of life. There are rare cases in which a nurse does not feel he or she can carry out the orders of a physician. Other rare instances may occur when patients are unable to make decisions about emergent care and a decision needs to be made about who may make those decisions.

When the committee is called for consultation, usually one or two committee members go to gather data, and then try to decide if this is an ethical question or a social service question. If it is an ethical question, a committee meeting is called at the patients site with members of the medical staff and family members or other medical powers of attorney. The committee is charged with helping to reach an ethical conclusion to the questions put forth, not to make any medical decisions for the patient, family or physician, but to try to reach a consensus between the parties.

A potentially new area for the committee to discuss is the proper isolation period for those exposed to Ebola and living in Southern Arizona.

Dr. Ketchel chairs the TMC Biomedical Ethics Committee and is a member of the PCMS Bioethics Committee. n


Presented by Tucson Osteopathic Medical Foundation in Joint Providership with Cleveland Clinic

Register online at www.tomf.org/cme

Join us for our 24th year of quality engaged learning! This activity has been

approved for AMA PRA Category 1 Credit and AOA Category 1A Credit.

The 24th Annual

Southwestern Conference on Medicine

April 23 - 26, 2015 | JW Marriott Starr Pass Resort & Spa | Tucson, Arizona

Scan this with yoursmartphone to visitwww.tomf.org/cme


Makols Call

Rubber checksBy George J. Makol, M.D.

T heres nothing as frightening as opening your mailbox and finding a letter from the Internal Revenue Service, but thats the fright I got short time ago.

I was informed that somebody had cloned my identity, and then had filed for an income tax refund in my name. I immediately started to laughprobably not the response you expected, but I quickly thought of someone in Nigeria opening a letter from the IRS, expecting to

find a refund check. To his surprise he would get the $10,000-to-$15,000 bill that I get from the IRS every year, in spite of paying payroll taxes every two weeks and filing quarterly tax payments every three months. Someday I would like to write a novel about my experience with the American tax system; perhaps I would call it Fifty Shades of Pay. And here I thought that after the IRS canned Lois Lerner, the agency had stopped targeting conservatives.

A couple of weeks later I picked up my Sunday, Feb. 1 Arizona Daily Star and read the headline, Tucson doctors wary after-tax identity theft. It seems that more than 20 local physicians found out that someone had filed fraudulently under their names for tax return money.

Apparently many of these scams were successful, and the physicians were scrambling to reestablish their tax identities. I was one of the lucky ones, because the brilliant minds at the IRS noted that after receiving dozens of 1099s attached to my home address, it did not seem logical to send a refund check to a post office box in Memphis, Tenn., or to a street address in Lagos, Nigeria.

Ive digressed here because the IRS is not really the topic of this column, nor is the American tax system, but a problem closely related to both: the federal disability payment system.

Not too long ago I received another government communication, from a different federal agency, asking me to review a disability claim for evidence of fraud. The person involved claimed a life-threatening illness that included potential anaphylaxis and death if exposed to any form of latex rubber. I was sent more than 500 pages of medical records, but did not decide to take the case until I saw two negative Rast tests for specific IGE to latex, performed in a reputable major national laboratory, but performed years apart.

It seems that the claimant had been receiving at least 18 years worth of disability payments totaling in the six figures, yet the government private investigator who followed the individual for weeks documented dozens if not hundreds of exposure to rubber of all sorts with no clinical symptoms.

In fact, upon reviewing copious medical records, I found one urgent care visit documenting a slightly swollen upper lip. It is likely that this patient had a simple case of idiopathic angioedema sometime in the late 1990s, and parlayed this into a lifetime of federal payments. Generally, idiopathic angioedema patients respond well to continuous antihistamine therapy, and many, but not all, will spontaneously resolve this condition within one or two years.

The case was being managed by a physician with no training in allergy or immunology, and he was providing medical rationale for her, the female claimant, getting full benefits and never being able to work again. In the hundreds of angioedema patients I have managed over the years, I cannot think of one patient who needed, or was granted full disability based on this condition. Yet like it or not, dealing with disability is becoming an increasingly larger problem for probably every physician, regardless of specialty.

In my practice it is not uncommon for a patient with completely normal lung function to ask me to write a letter certifying that he or she is disabled from severe asthma. I see many patients who are sensitive to the myriad chemicals they can be exposed to in everyday life, such as another persons perfume or cologne. While I appreciate their situation, and write notes asking to the

Thomas S. Kang, MD

6340 N. Campbell Ave., Ste. #256 Tucson, AZ 85718

office: 520-775-3333 fax: 520-775-3334www.sonoranent.com

Allergies Nasal/sinusitis problems Hearing & balance disorders Hearing aids & tinnitus Endocrine & salivary gland disease Voice disorders Snoring and sleep apnea Thyroid and parathyroid gland surgery Cosmetic/Aesthetic surgery

Jonathan Lara, DO Amanda Kester, Au.D.


employer to limit such exposures, I am loathe to say this person can never work again because the person next to them might wear a pungent perfume.

According to Money magazines recent analysis, the problem is that the Social Security Administrations disability insurance program is expected to exhaust its trust fund by the end of 2016. The incoming revenue thereafter would only allow payment of 80 percent of the benefits currently being paid to the truly disabled and their families. But the truly disabled are not the only recipients. In January, 40 people including one doctor were indicted in Puerto Rico for Social Security disability fraud. The defendants received an average of $28,000, after the doctor

backdated and falsified their records to show long-standing suffering from illnesses they did not even have.

CBS News reported last January that more than 100 people were indicted in New York State for disability fraud, including 72 first-responders such as firemen and policemen. One individual, who claimed that he was housebound, was pictured riding a Sea-Doo watercraft. Another, claiming he was too traumatized to leave his house, was filmed selling cannolis at a street fair. Another claimed severe on-the-job injuries, but was also filmed taking part in a 400-mile bicycle race while disabled.

In 2013 Fox News and The Associated Press reported, after the Government Accountability Office issued a report, saying that the Social Security Administration made nearly $1.3 billion in

potentially improper disability payments to people who were believed to be employed when they were supposed to be unable to work. The GAO estimated that SSA made the potential cash benefit overpayments to about 80,000 individuals from December 2010 to January 2013. The numbers represent less than 1 percent of beneficiaries and less than 1 percent of disability payments made during the time frame, the story said, but GAO said the overpayments reveal weaknesses in SSAs procedures for policing the system.

Since we have a President who seems obsessed with the concept of fairness, one might ask, is it fair for perfectly fit and able people to be provided a subsidized life of leisure at the expense of the truly disabled who may not be able to get full benefits in the near future?

Perhaps the most significant quote attributed to President John F. Kennedy was when he famously said, Ask not what your country can do for you; ask what you can do for your country. Far too many people today feel that the government owes them something, forgetting that the government really does not produce its own money, but rather confiscates funds from one group and redistributes dollars to other groups that contain more potential voters.

I think that JFK, a great fiscal conservative, would shake his head sadly if he saw the state of the country today. He was a polished politician, but also a man with great ideas. Its too bad that today we do not have a potential leader in either aisle who fits both these qualifications.

Sombrero columnist George J. Makol, M.D., a PCMS member since 1980, practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd. n


Stars on theAvenue 2015

An Evening under the Stars

A Medical Community Celebrationto Honor Tucsons Outstanding Physicians

Stars on the Avenue returns April 18, 6-9 p.m., at St. Phillips Plaza and features an exclusive invitation list limited to physicians and their guests. Progressive dinning is provided by outstanding Tucson restaurants as we honor local doctors and raise money for Mobile Meals of Tucson.

Presented by Pima County Medical Society and PCMS Alliance, Stars on the Avenue expects more than 350 physicians to attend this years event as we honor our Physician of the Year and others for their outstanding service and commitment to organized medicine, volunteerism, and for a lifetime of achievement in the practice of medicine.

Event proceeds go to Mobile Meals of Tucson, an organization that helps preserve the health, dignity and independence of home-bound adults by delivering special diet meals. Volunteers not only deliver meals, but also provide social contact and a connection to other community organizations.

For group discounts or information about event sponsorships please contact PCMS Executive Director Bill Fearneyhough at 795-7985 or email [email protected]. Tickets may be purchased by logging onto pimamedicalsociety.org and clicking on Purchase Stars on the Avenue Tickets tab.


CME

Local CME from Pima CountyMedical FoundationPima County Medical Foundation, a 501(c)3 nonprofit organization derived from but separate from PCMS, presents Continuing Medical Education lectures by our members and others, for our members and others, on second Tuesday evenings monthly at PCMS headquarters. Dinner is at 6:30 p.m. and presentation is at 7. The 2015 schedule is:

March 10: Breast Reconstruction SurgeryImplants and Complications with doctors Swen Sandeen and Richard Hess.

April 14: Cancer of the LungNewer Treatments and Cancer Screening with physicians from Radiology Ltd. This meeting will also present the Foundation Award for Lifetime Achievement in Furtherance of Medical Education to Tyler Kent, M.D. and Bill Nevin, M.D.

May 12: Healthcare Reform 2015What the Hell is Happening?? with several speakers coordinated by Dr. Timothy C. Fagan.

June 9: Heart-Healthy Diet with cardiologists Dietmar Gann and Charles Katzenberg.

Sept. 8: Vasectomy Reversals and Impotence with Dr. Sheldon Marks.

Oct. 13: Common GI Viral DiseasesDiagnosis, Mechanisms of Action, and Treatment with Claire Payne, Ph.D.

November 10: PharmacogenomicsHow Medicines Affect Differing Demographics of Patients with Dr. Timothy C. Fagan.

MarchMarch 25-28: Clinical Reviews 2015: The 26th Annual Family Medicine and Internal Medicine Update is at Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254; phone 480.301.4580; e-mail [email protected] .

Accreditation: 27 PRA Category 1 credits; and 24 AOA and Attendance.

Four-day course on diagnosis and treatment of hematologic and oncologic disorders targets hematologists, oncologists, PAs, NPs, RNs, pharmacists, and allied health professionals, and features

the most recent medical updates and management strategies for various diseases. Program includes lectures, Q&A panel discussions, audience interactive format.

Website: https://ce.mayo.edu/family-medicine/node/1606. Contact: Lilia Murray, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. [email protected] www.mayo.edu/cme

AprilApril 17-19: The 21st Mayo Clinic Urogynecology and Disorders of the Female Pelvic Floor 2015 is at the Hilton Scottsdale Resort and Villa, 6333 N. Scottsdale Rd., Scottsdale 85250; phone 800.498.7396. http://www3.hilton.com/en/hotels/arizona/hilton-scottsdale-resort-and-villas-SCTSHHF/index.html

Accreditation: Mayo Clinic College of Medicine designates this activity for a maximum of 20.50 AMA PRA Category 1 Credits. A record of attendance will be provided to all registrants for requesting credits in accordance with state nursing boards, specialty societies, or other professional associations.

Course presents latest treatments for urogynecology and female pelvic floor disorders emphasizing surgical management of urinary and fecal incontinence, ove

March 2015 Sombrero

Documents

Transcript of March 2015 Sombrero