May 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 Y 2 0 1 5

Medicare at 50

CNIs Brain Academy Dr. Housecall retires

2 SOMBRERO May 2015

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SOMBRERO May 2015 3

Official Publication of the Pima County Medical Society Vol. 48 No. 5

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.

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

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5 Dr. Melissa Levine: Medicare is only 50, so it isnt qualified for Medicare yet.

6 Letters: On Dr. Kalotas vaginal mesh implant update.

7 Milestones: Dr. Gary Figge will serve on the Arizona Medical Board.

10 In Memoriam: Doctors Edward A. Brucker and Donald J. McFarlane died in March.

11 Behind the Lens: An early 1990s Physicians for Social Responsibility calendar had some wonderful Arizona images, recently rediscovered by Dr. Raymond Graap and Dr. Hal Tretbar.

14 Neurology: Carondelet Neurological Institute, Western Neurosurgery, and their Brain Academy seek future neurologists.

17 Makols Call: TV generation meets the Greatest Generation.

20 Retirement: Tucson medical legend Dr. Hector L. Garcias retirement even surprises him.

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

Clarification

George Ridge, formerly of the UofA Journalism Department, is the man providing human perspective in this Dr. Hal Tretbar photo from the Grand Canyons South Kaibab Trail circa 1980. Travelin Tretbar was using Kodachrome Pro film that captured the subtle colors well. See this months Behind the Lens for more fabulous rediscovered images from Arizonas northland.

Reminder

The May Sombrero ends our monthly publishing schedule until October. Members and subscribers will receive bi-monthly magazines for June-July and August-September.

On the CoverDr. Hal Tretbar and George Ridge hiked down the Grand Canyons South Kaibab Trail circa 1980 to do a story on Phantom Ranch for the Arizona Daily Star. Travelin Tretbar was using Kodachrome Pro film that captured the subtle colors well. See this months Behind the Lens for more fabulous rediscovered Arizona images.

Inside

SOMBRERO May 2015 5

Medicare: From whence it cameBy Dr. Melissa Levine

PCMS President

Happy birthday, Medi- care!Like me, Medicare turns 50 this year, having been signed by President Lyndon Baines Johnson on July 30, 1965. It was

a huge congressional battle and no one seemed to like the legislation, but now most of us depend quite heavily on it.

For better or worse, Medicare has become the basis for payment schedules for almost all insurance. Im sure you can see the parallels I might draw to the Affordable Care Act. Timely, too as one of the greatest issues with Medicare was the SGR, which after 17 Band-Aids in 12 years, was finally repealed and MACRA was signed by President Obama in April.

Thank you, Congress and Mr. President for actually doing something. The Medicare Access and CHIP Reauthorization Act (MACRA) clearly is not perfect, but its a start. It gives docs a 0.5% increase per year from 2015-2019not quite cost of living, but a whole lot better than the 21 percent cut the SGR promised on March 31. It funds graduate medical education for a couple of years. It also lays the basis for merit-based incentive payments, always scary to me. Who gets to decide my merit?

Thats what this column WAS going to be about. But in doing some research, I found that the establishment of Medicare was not the start of the campaign for national health insurance. It goes back a couple of generations, so happy birthday to you, Papa.

In the early 20th century while my grandfather was a young child in Russia, President Theodore Roosevelt supported health insurance, believing that sick, poor people did not make for a strong country. But there was no real government initiative to get it started. The following could be called part one of a history on the beginnings of American national health insurance, the seeds of the Affordable Care Act.

In 1915 the American Association of Labor Legislation (AALL) drafted a model bill that provided for coverage for doctors, nurses, and hospitals. It included sick pay, maternity benefits, and a death benefit of $50. All-working class people and their dependents who made less than $1,200 per year were included. Funding for it was shared between workers, employers, and the state. Surprisingly, the AMA strongly supported the proposal, at least initially. The American Federation of Labor (AFL) denounced it, thinking it would weaken unions. The private insurance industry opposed it, as it would have tanked the multimillion-dollar commercial life insurance industry that made most of its money on death benefit policies to pay for funeral costs.

Germany had established a compulsory sickness insurance in 1883, and in 1917 when the U.S. entered the European war and all things German became bad, the opponents to the AALL bill

associated it with Bolshevism and communism and general anti-Americanismsimilar to the opponents of Medicare in the 60s and the Affordable Care Act today.

In the 1920s healthcare costs began to rise. Middle-class people were using hospitals, and actual medical costs became more of an issue than lost wages. Some states made rumblings about compulsory health insurance, but didnt get very far. Nineteen twenty-six saw establishment of the Committee on the Cost of Medical Care (CCMC), funded by eight philanthropic organizations including the Rockefeller Foundation. They met over a six-year period and produced 26 research volumes and 15 reports. The CCMC was a conglomerate of 50 that included economists, physicians, public health specialists, and special-interest groups. Essentially they determined that more medical care was needed for everyone. For the most part they recommended voluntary health insurance as a means to that end. The AMA was no longer on board, and the editor of JAMA called it an incitement to revolution.

Now, happy birthday, Dad! President Franklin Roosevelt considered including national health insurance in the Social Security Bill of 1935 but feared, quite reasonably, that it would threaten the passage of Social Security Legislation. He did establish the Tactical Committee on Medical Care in 1937, and out of that came the Wagner bill, the National Health Act of 1939. The Wagner bill gave general support for a national health program funded by federal grants and administered by states and localities. Does this sound a bit like Medicaid to anyone else? Then the 1938 elections brought a wave of conservatism and Sen. Wagner went nowhere until 1943.

Wagner-Murray-Dingell transformed Wagner from federal grants to compulsory national health insurance funded by a payroll tax. The bill generated a lot of debate, but obviously never passed. It was re-introduced in every session of Congress for 14 years. On Jan. 11, 1944, President Roosevelt called for an Economic Bill of Rights that included, The right to adequate medical care and the opportunity to achieve and enjoy good health.

President Harry S Truman (served 1945-1953) continued the theme and then some. In a speech to Congress on Nov. 19, 1945 he called on legislators to implement a comprehensive insurance for all people through Social Security, not just the needy. Although he emphasized that it was not socialized medicine, still a kill-phrase today, many conservatives saw it as just that. Sen. Robert Taft (R-Ohio) declared that compulsory health insurance and the Full Unemployment Act came right out of the Soviet constitution.

Republicans took control of Congress in 1946 elections and national health insurance faced hospice once again. Stay tuned for Part II. I cant wait to see how this turns out!

SOURCESPhysicans for a National Health ProgramCMS Oral History ProjectAAFP News April 15, 2015National Academy of Social Insurance n

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Dr. Figge to serve on AMBOur former board member Dr. Gary Figge, EM physician at Northwest Medical Center, was recently appointed by Gov. Doug Ducey to serve on the Arizona Medical Board. He joins fellow appointee Dr. Lois Krahn, a psychiatrist with Mayo Clinic Scottsdale.

Dr. Figge earned his M.D. in 1992 at Medical College of Wisconsin, Milwaukee, did his EM residency at the UofA, and is board-certified in EM. He served as ArMA president

2010-2011. He has been a PCMS member since 2007.

AMB is comprised of 12 people appointed by the governor and approved by the state senate. Eight of the 12 must be physicians who have practiced and lived in Arizona for at least five years prior to appointment. Four members are from the lay public, one of whom must be a nurse.

There can be no more than five members from any one county, Dr. Figge said, and my appointment brings Pima County to the maximum of five along with doctors Farmer, Gillard, and Berg, as well as public member Jodi Bain, an attorney in Tucson. So Southern Arizona is well represented! Members cannot serve more than two full five- year terms, with the twist that anyone appointed to complete somebody elses five-year term can serve out that term and not have it count as one of their two five-year terms, as happened with me. Thus, my current appointed term is until 2019, as I replaced a member of the board who had left before the end of his new term.

AMB went through a siginficant shakeup in the last few years, Dr. Figge said. Moving forward, AMB is committed to its legislative mandate of protecting the public and monitoring Arizona physicians and Pas with that in mind. The board is charged with, and responsible for, approving licenses to practice as well as addressing any complaints and concerns about practitioners they license and, if necessary, determining disciplinary actions when indicated up to and including revocation of license to practice.

My goal is to become part of a relatively new and revamped, and updated, board in this regard, Dr. Figge said. There is a tremendous amount of work that goes into the tasks required of the board, with many reviews and phone calls in addition to all-day bimonthly public meetings. My intentions,

Gary R. Figge, M.D.

when requested by the governors office to serve on this board, were simply to listen, analyze, and provide insight as requested and required.

I consider this a great responsibility and a great honor. My impression in meeting the board members, going through the confirmation process in the senate, and talking with the governors office, is that any issues, in reality or assumed, of being outdated and not strictly adhering to statute mandated rules and processes, are now remedied and in the past.

The future, I believe, is bright and on track for the board, and I intend to do all I can to continue in that direction and goal of making sure the public has access to the best healthcare available, and that Arizona is a place the best physicians and physician assistants would want to practice.

Dr. Wang collaborates in researchMingwu Wang, M.D., Ph.D., associate professor in the UofA Department of Ophthalmology and Vision Science, recently collaborated in Arizona Health Sciences Center research that found a potential cause of dry eye disease.

Researchers at the UA Steele Childrens Research Center made the unexpected discovery into the role of NHE8, a sodium/hydrogen exchanger protein, the university reported. The research was led by Steele Center Director Fayez K. Ghishan, M.D., and center researcher Hua Xu, Ph.D. in collaboration with Dr. Wang.

8 SOMBRERO May 2015

NHEs are a group of membrane proteins that function to exchange extracellular sodium (Na+) for intracellular hydrogen (H+). NHE proteins contribute to many physiological functions, such as intracellular (within cells) acidic (pH) regulation, cell volume regulation and sodium absorption. They play an important role by transporting sodium and electrolytes through the gastrointestinal tract, the university reported.

In previous research, Ghishan and Xu discovered that NHE8 plays a role in mucosal protection in the intestinal tract and in male reproduction. When we deleted NHE8 in mice, we observed that they developed gastric ulcerations, became more susceptible to infections and the male mice became sterile, Dr. Ghishan said, And now, we have discovered that mice lacking NHE8 expression also develop dry eye disease.

Dry eye disease (DED) is a very common eye disease, especially in Arizona, due to low humidity and high temperatures. Individuals with DED have symptoms of discomfort, visual disturbance and even loss of vision. The disease affects millions of people, and billions of dollars are spent annually for treatment in the United States alone.

Ghishan and Xu collaborated with Dr. Wang, who is an expert in treating patients with dry eye disease. Dr. Wang helped characterize dry eye phenotypes in NHE8-deficient mice. It was very interesting to observe clinical dry eye characteristics in the NHE8-deficient mice in comparison to the wild type mice, Dr. Wang said. Much more research needs to be done to delineate the exact underlying mechanism.

Their study, Loss of NHE8 expression impairs ocular surface function in mice, was published in January in the American Journal of PhysiologyCell Physiology, the university reported. This work was supported by National Institute of Diabetes and Digestive and Kidney Diseases Grant R01-DK-073638 (F. K. Ghishan and H. Xu), Research to Prevent Blindness Foundation (M. Wang), and University of Arizona Faculty Research Seed Grant (M. Wang).

Gold for Carondelet St. Marys stroke careThe American Heart Association recently awarded Carondelet St. Marys Hospital with its Get With the GuidelinesStroke Gold Plus, and Target: Stroke Honor Roll quality achievements awards, Carondelet Health Network reports.

This is the fourth consecutive year St. Marys has been honored for its continued implementation of national quality guidelines scientifically linked to improved treatment rates in stroke patients, they said. The AHA/ASA awards recognize St. Marys for complying with each of the associations seven stroke achievement measures in at least 85 percent of eligible patients.

William Nevin, M.D. was presented with the Pima County Medical Foundation Award in recognition of Exemplary Lifetime Achievment in Furtherance of Medical Education April 14 at PCMS. Dr. Nevin is a pulmonologist, educator, local HMO pioneer, and volunteer at Clinica Amistad. (Stuart Faxon photo.)

Ophthalmologist Mingwu Wang, M.D., Ph.D., center, with Hua Xu, Ph.D., and Fayez Gishan, M.D.

Francisco R. Valdivia, M.D.

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Dr. Tyler J. Kents plaque speaks for itself, but he had a good excuse for not being there April 14, as he was in Hawaii getting married. Dr. Kent is a general and vascular surgeon, graduate medical instructor, and director of outpatient clinics at St. Elizabeths Health Center, Tucson. (Stuart Faxon photo).

Measures include administering the blood clot-busting agent IV rt-PA within three hours of patients arrival; prescribing medication to prevent and/or reduce blood clots to patients by the end of their second day in the hospital or at discharge; and providing advice or counseling on smoking cessation to patients with a history of smoking. A full list of qualifications can be found on the American Heart Associations website heart.org

You often hear in stroke cases that time lost is brain lost, and certainly it is critical that someone suffering a stroke is treated as soon as possible, said Dr. Francisco Valdivia, medical director of the stroke program at St. Marys Hospital. Just as important in improving the patients condition is the treatment they receive in the hours and days immediately after their stroke. This award proves our commitment to following the American Heart Associations guidelines to care not only for the patients immediate, acute need, but to help prevent future strokes.

The team of professionals in our stroke program has done an outstanding job ensuring that the stroke care provided by St. Marys Hospital is among the best in the nation, said Amy Beiter, M.D., the hospitals president and CEO. Our repeat awards demonstrate that we are committed long-term to the health of our community; and further, that we will continue to pursue treatment that meets or exceeds proven national standards. n

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In Memoriam

By Stuart Faxon

Edward A. Brucker, M.D. 1924-2015

Edward A. Brucker, M.D., anatomical and clinical pathologist who joined PCMS in 1962, and who served as a medic in World War II, died after a long illness March 21 at his home, the family reported in the Arizona Daily Star. He was 90.

Edward Arthur Brucker, Jr. was July 24, 1924 in Chicago, where he earned his M.D. at Loyola University Stritch School of Medicine in 1951. He interned at Chicagos Cook County Hospital, and his residency at Milwaukee County Hospital,

Wisconsin. For six years he was director of laboratories at St. Marys Hospital, Madison, Wis. He was American Board of Pathology-certified. Before coming to Tucson he was a member of Dane County (Wis.) Medical Society.

In 1979 Dr. Brucker retired from active practice with Associates in Laboratory Medicine, Inc. a seven-physician practice with five Tucson locations. He then became director of laboratory services for Group Health Medical Associates, P.C. on East Carondelet Drive.

Ed loved to travel with his wife and family and made many trips worldwide, his family told the paper. He was an avid reader, and had a great desire to learn about everything. He enjoyed playing golf and was a member of Tucson Country Club.

Dr. Brucker was active in the American Society of Clinical Pathology and the Arizona Society of Clinical pathology. He often did criminal pathology and was recognized for his work in that discipline.

He belonged to the Knights of the Equestrian Order and was an active member of St. Thomas the Apostle Catholic Church, the family said. One of Eds passions was studying the Shroud of Turin.* Every Lent, he shared the medical perspective on the Shroud with churches and organizations in Tucson and around the U.S., and he authored a book, The Holy Face.

Dr. Bruckers wife of 61 years, Pat; sons Ed III, Matt, Peter, David and Andrew; daughters Trish Lawler, Suzanne Williams and Betsy Allen; 16 grandchildren; and five great-grandchildren children survive him.

A Memorial Mass was celebrated March 26 at St. Thomas the Apostle Catholic Church. The family expresses sincere gratitude

Dr. Donald J. McFarlane in 1975 when he joined PCMS.

to TMC Hospice nurses and staff for their excellent care. Condolences can be left at www.bringfuneralhome.com .

*In this century the Shroud of Turin was revealed as a medieval fake circa A.D. 1300, a surviving one of many that were distributed, as there was a great trade in faked relics. Pope Francis termed it an icon rather than a relic, a distinction meaning it remains a powerful symbol of Christs suffering, while the Church makes no claim to its authenticity. The cloths image has fascinated believers and skeptics since a negative photographic image was revealed in the late 19th century.

Donald J. McFarlane, M.D. 1926-2015

Donald J. McFarlane, M.D., general surgeon who joined PCMS in 1975, died March 26, the family reported in the Arizona Daily Star. Retired since 1993, he was 88.

Donald John McFarlane was born Oct. 18, 1926 in Toledo, Ohio. In 1944-45 he served in the U.S. Army Air Corps, predecessor to the U.S. Air Force. He attended John Carroll University and earned his M.D. in 1957 at Loyola University Stritch School of Medicine. Chicago. He interned and did his GS residency at St. Vincent Charity Hospital, Cleveland.

Dr. McFarlane practiced in Iowa 1952-73. He and his wife, Kathy, came to Tucson in 1973. He was chief attending at the TMC and UMC emergency departments, the family reported, an adjunct professor of surgery at the University of Arizona College of Medicine, a surgeon in private practice at the Carondelet hospitals, and he treated many members of the Tohono OOdham Nation.

After a brief retirement he worked with the wonderful physicians and staff at Arizona Radiation Oncology. He loved being a surgeon, he loved his patients, and above all he loved his family.

Dr. McFarlanes son Michael predeceased him. His wife of 41 years, Kathy; sons Stephen, Kevin, Jeffrey, and Peter; daughters Amie. Kathleen, and Molly; and eight granddaughters survive him.

A memorial service was given April 19 at Catalina Foothills Church. Memorial contributions may be made to Interfaith Community Services or Gideons International. n

Edward A. Brucker, M.D. in the 1980s.

SOMBRERO May 2015 11

RediscoveryBy Hal Tretbar, M.D.

Behind the Lens

Arizonas world-famous geography and topography always offer discovery and rediscovery for travelers, hikers, tourists, and photographers. We even have our own state-published magazine for them all: Arizona Highways.

Recently I received a package from Ray Graap, M.D., the longtime Tucson endocrinologist. In it were three calendars from 1990, 91, and 92, published by the Tucson branch of Physicians for Social Responsibility. Ray

had enticed me to submit images for possible use.

Recently while cleaning out some shelves, Ray wrote, a long-overdue task which is usually put off by those of us further along

in years, I discovered there were three different calendars printed locally and used as fund-raisers for PSR. The pictures were taken by local physicians and healthcare professionals, using that substance we knew as film. We must say that they came out very well, and look great even to this day, digital technology aside.

In Fall 1988, PSR sponsored a national tour of four Soviet physicians that stopped in four cities, including Tucson. For three days the USSR docs were shown around the city, had discussions with local physicians, and gave presentations on the key topic Medicine, Perestroika, and Security: Soviet Viewpoints. The latter concerned nuclear weapons and the desire to eliminate and/or control this scourge of human survival.

One of the visits was to the Titan Missile Museum, a surreal experience as they observed firsthand the means of nuclear delivery to their country. We left going up the outdoor stairs from the facility, and observed a sign over the outside door: Caution; beware of rattlesnakes! An ironic message considering the threat of global destruction!

Physicians for Social Responsibility, founded in 1963, continues to pursue its original goal of nuclear disarmament. For further information see www.psr.org

The big surprises in the old package were the five original glossy proof pages of my images that had been chosen for the calendars. After 25 years I no longer can find some of the original transparencies.

In 1969 I won first prize in a contest for the best image of Sedonas Bell Rock. A land developer sponsored it, so Im to blame for the sprawl that is now across this once-pristine area. I also won the second month of the contest. That gave Dorothy and me a weekend in Las Vegas!


Red Rock Crossing, southwest of Sedona on Oak Creek, is one of Arizonas prettiest places and most famous images. Late afternoon light brings out the color of Cathedral Rock. This reflecting pool was washed out long ago.

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Ribbon Falls is on the North Kaibab Trail. It drops from an overhang and this view from behind shows the mossy ground below. I sat there alone, enjoying the warm shower splashing on the soft moss.

Our first trip to Havasupai was in 1967 when it was still under jurisdiction of the National Park Service. This image of Havasu Falls was taken on one of many subsequent visits. The deep travertine pools have been washed out by flash floods. Can you see the people in the pool on the right?


Neurology

Its all about brainBy Stuart Faxon

Photos by Carondelet Neurological Institute

We earthlings have only one means to learn more about our brain: Use more brain. Our young earthlings can always benefit from using more brain as early as possible, even while its still developing; we certainly know what happens when they dont.

By such methods we may even produce the next physician-generations neurologists, which is the aim of Carondelet Neurological Institutes Brain Academy, an annual two-day event for Southern Arizonas best and best-motivated high school students.

Western Neurosurgerys 12 physicians staff CNI, based at Carondelet St. Josephs Hospital and serving Southern Arizona 24-7 with neurology and neurosurgery. Many of Westerns physicians are fellowship-trained in aspects of neurosurgery such as Parkinsons, scoliosis, and vascular diseases of the brain.

As they brainstormed about what became Brain Academy, several physicians at Western agreed that it was very important to get young people involved in the neurosciences, said CNI Chairman Robert P. Goldfarb, M.D., F.A.C.S. Many high school students never have an opportunity to have a one-to-one talk with doctors, have lectures, and exposure to faculty. This is a chance for them to see what the brain surgeons and neurological specialists do.

In 2011 they started collecting the most capable and interested students, CNI Administrative Director Leah Shea said. We targeted Tucson Unified School District science and math students who showed special aptitude. In the four years since, we now cover TUSD, Sunnyside, Marana, Vail, Sahaurita, Flowing Wells, Catalina Foothills, Salpointe, the charter schools and the Christian academies. This year we had 40 applications for 20 spots.

Qualified students must be a junior in high school with at least a 3.0 GPA, write an essay answering why they are interested, and have a teacher recommendation, Shea said. The selection committee reviews al the applicants for the cream of the crop. We keep all district sources considered, including transcripts and course work. This year we have an international student, from China.

In their essays students most often describe a family members experience with Alzheimers, movement disorders, Parkinsons, or stroke. It could be a parent, grandparent, or other family member. We want them to tell us what interests them about science and medicine, or their high school introduction to anatomy.

This years program takes place April 24-25, when the May magazine youre reading was in process of proofing and printing, so we cant tell outcomes in this issue. But the students


Brain Academy 2013 students interact with clinical staff, including clinical bio-engineer Jessie Heisey, who demonstrates the Brainlab technology available in the dedicated Neurosurgical Operating Suite.

will go through a reporting back process, Shea said. Five groups of four students each get a diagnosis scenario, and they must describe sumptoms, diagnosis and treatment options.

In interactive sessions leading up to their reporting back, they see what a stroke looks like, what neurosurgery looks like, and they become familiar with various diagnoses, Shea said. On Day One they get presentations on the most frequent kinds of neurological cases, and they receive reference materials. On Day Two the presentation is made by the group, with an individual or the group making the verbal presentation.

Shea said she finds the program really inspiring. It makes you want to go back and be one of those students again. n

CNI physicians and missionsWhen we asked whats new in neurology these days, Dr. Robert Goldfarb said that recent studies, reported earlier this year, definitively demonstrated that endovascular therapy for ischemic stroke is superior to using tPA alone in patients with clots in the major brain arteries.

Approximately 30 percent of patients with ischemic stroke have involvement of the major brain arteries and are therefore candidates for extraction of the clots utilizing the newest technology, Dr. Goldfarb said. The studies demonstrated that time is of the essence in starting treatment. The sooner the patient reaches a stroke center such as CNI at St Josephs, that has the ability to perform the clot removal procedure, the better the outcome. When clot removal procedures are instituted rapidly, the death rate from strokes was decreased by 50 percent compared to using only tPA.

The American Heart Association/American Stroke Association recently awarded CNISt. Josephs Hospital the Elite award for its stroke program, which makes the program among the first in the U.S. to receive this status, Dr. Goldfarb said. CNI at Carondelet St. Josephs is a Joint Commission Primary Stroke Center, designated for rapid treatment of strokes including tPA treatment, mechanical clot extraction from internal carotid and intracranial arteries, and open surgery and/or endovascular treatment of cerebral aneurysms, avms, and carotid artery stenosis.

Neurologists at Carondelet Neurological Institute at St. Josephs Hospital and Western Neurosurgery, Ltd. are William B. Lujan, M.D.; Diana V. Benenati, M.D.; David R. Siegel, M.D.; L. Roderick Anderson, M.D.; and Hemant S. Kudrimoti, M.D., Ph.D.

Neurosurgeons at Carondelet Neurological Institute at St. Josephs Hospital and Western Neurosurgery, Ltd. Are Robert P. Goldfarb, M.D.; Hillel Z. Baldwin, M.D.; Eric P. Sipos, M.D.; Matthew P. Wilson, M.D., Ryan M. Kretzer, M.D., and Emun Abdu, M.D.

Our most frequent neurosurgical treatments are for spinal disorders (minimally invasive as well as complex spinal surgery), brain cancer surgery, and stroke treatment to include tPA , clot removal, Dr. Goldfarb said. Our medical neurologists most common treatment is for headaches, vascular disease of the brain, epilepsy, and neuromuscular diseases.

Treated spinal disorders include herniated discs, lumbar stenosis, adult scoliosis, and spondylolisthesis. For brain tumors there is surgical treatment and stereotactic radiation treatment.

For Parkinsons disease there are medical treatment and surgical deep brain stimulation procedures. There are surgical treatments for chronic pain, and medical diagnoses and treatment for headaches, MS, cerebral vascular disease, neuromuscular conditions, epilepsy-seizures, and cognitive impairment.

Dr. Emun Abdu talks to Brain Academy 2014 students about interventional neurosurgery and provides a demonstration in Carondelet St. Josephs Hospitals state-of-the-art angiography suite.


Makols Call

Hogans, and other heroesBy Dr. George J. Makol

I hate reality television.Lets face it, television was

invented in the first place so that all of us could escape reality and inhabit a wonderful fantasy world filled with heroes like Superman, Flash Gordon, Davy Crockett, and Daniel Boone. Or, we could slip into uncontrolled laughter following the antics of Lucille Ball, Red Skelton, or Dick Van Dyke.

These days, its almost impossible to turn on your TV

without being confronted by idiotic housewives, ill-tempered chefs, and generally just the kind of people youve spent your whole life trying to avoid and wouldnt allow in your home. And now youre paying outrageous cable TV rates for this privilegestill with commercials. Remember when the proposed pay TV would not have those?

And how much reality is there in reality shows, anyway? If you look at the credits of Survivor, a supposedly death-defying trial for contestants, set in the wilderness, youll notice they have an art department, a sound department, a stunt department, animation, a costume, makeup and wardrobe department, transportation, and catering.

I have resorted to putting up amplified rabbit-ear antennas on all my TVs so I can pick up TV Land and other oldies channels. This led me to a recent fascination with the series Hogans Heroes.

Wikipedia reminds us that the actors who played the four major German rolesWerner Klemperer (Klink), John Banner (Schultz), Leon Askin (Burkhalter), and Howard Caine (Hochstetter)were Jewish. Furthermore, Klemperer, Banner, Askin, and Robert Clary (LeBeau) were Jews who had fled the Nazis during World War II. Clary says he spent three years in a concentration camp, that his parents and other family members were killed there, and that he has an identity tattoo from the camp on his arm (A-5714).

John Banner had been held in a pre-war concentration camp, and his family was

killed during the war. Leon Askin was also in a pre-war French internment camp and his parents were killed at Treblinka. Caine, who was also Jewish (his birth name was Cohen), was American, and Jewish actors Harold Gould and Harold J. Stone played German generals. Jon Cedar played a camp guard.

As a teenager, Werner Klemperer (Klink), son of famed symphonic conductor Otto Klemperer, fled Hitlers Germany with his family in 1933. During the shows production, he insisted that Hogan always win over his Nazi captors, or else he would not take the part of Klink. He defended his playing a Luftwaffe officer by claiming, I am an actor. If I can play Richard III, I can play a Nazi. Banner attempted to sum up the paradox of his role by saying, Who can play Nazis better than us Jews? Klemperer, Banner, Caine, Gould, and Askin played stereotypical World War II Germans, and all had served in the U.S. Armed Forces during World War II.

Wait, you might say, how can a totally unrealistic program about a beneficent prison camp with an incompetent colonel in charge possibly be of interest to a modern physician? It is because of my friendship with a patient, a real Hogans hero, that went on for more than 15 years before he told me of his war experience.


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Lets call him Mr. M, a native Austrian living there in 1935, and being Jewish, he was obliged to flee the country and come to America to avoid persecution. He happened to move to my hometown of Springfield, Mass., where he opened a foreign sports car dealership on Boston Road, near my house.

Although I was only about six years old, I can remember driving by with my parents and seeing the fantastic rides like the Austin Healeys, Jaguars, MGBs, and Alpha Romeo convertibles parked out front. My eyes bugged out, but I never got to see the owner, as my dad in those days only bought Cadillacs.

Fast-forward 25 years or so, and this gentleman moves to Tucson to retire, is followed for his asthma by my senior associate, and then becomes my patient when the older doctor retires. Although this man is 30 years older than I, I discover hes from my hometown, is a former race-car driver, and like most of our seniors has a treasure trove of knowledge to impart. We become fast friends and go out to lunch virtually every other month for many years. In all honesty I think he learned more about me over those years than I did about him, up until just about the last time we went out to lunch.

It was then, after all that time knowing him, that he told me the story about coming to America to escape the forming Nazi regime, volunteering for the U.S. Army, and being sent back over to fight for the freedom for his countrymen.

He did not just join the Army and get stationed at some outpost behind the front lines, but landed on Omaha Beach on D-Day. This beachhead was center of the Allies Normandy invasion, and as Im sort of a history buff, I thought I knew a lot about this.

What I did not know was that paratroopers were dropped in hours before the 6:30 a.m. arrival of the nautical forces to clear the beaches of German obstructions and mines.

So there was Mr. M, with his fellow soldiers, crawling on his belly on the darkened beach with wire-cutters for the barbed wire, and colored sticks to mark obstructions and danger points. He and his group made their way around the German positions and into the French countryside by the time the main forces landed. Although Allied casualties that first day were nearly 10,000, he was untouched on that day. About 10 days later while walking outside of French village he was grazed in the arm by a snipers bullet, but survived without serious injury.

I cannot tell you how far my jaw dropped while listening to this story, all the while thinking of the Greatest Generation as its been called, and that most of these people are now leaving us. And I think about life today, where we may get upset if we cant find a parking spot in front of the hospital, or there are no seats left in Starbucks, or our dry cleaning order is not ready on time. I was recently inconvenienced myself because the air-conditioned seats in my new car were


not functioning properly; the seat was hot, and it is not even summer yet!

The Hogans Heroes connection is that like Mr. M, Werner Klemperer and his family fled Germany in 1935 for much the same reasons. Klemperer too volunteered for service, joined the Army, and was first stationed in Hawaii. Klemperer was also a singer and violinist, an accomplished a musician like his father. You may remember Col. Klinks awful violin playing, one of the shows regular themes. Its work for a good violinist to play badly!

Now Mr. M, like many of the Greatest Generation, has passed on. I cannot find anyone 30 years older than I am to go to lunch with; in fact, I cannot find anybody 30 years older, period. My mother is 92, and even she is not 30 years older than I!

Maybe its best if I just start watching all the reruns of I Love Lucy. Laughter is truly the best medicine.

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


Rerement

No bucket list for Dr. HousecallBy Dennis Carey

The gallows humor of a list of things to do before you kick the bucket gave rise to the movie title and cultural phrase bucket list, but youll find no such idea in plans of the legendary Hector L. Garcia, M.D., who will retire at the end of this month from his cardiology and IM practice after 54 years. He has been a PCMS member for 51 of those years.

His decision to retire is a little unexpected, even to himself. There was no specific reason, and there is no specific plan for the future.

We are going to play it by ear, said Dr. Garcia about himself and his wife, Ligia. We will be spending some time with our grandchildren in Boston, and will split time between California and Arizona, but there is nothing specific on our calendar. No bucket list. We want to be able to do some things without having to rush back to see patients.

He said he wants to do some non-medical reading and a little traveling. His lifes passion has been the practice of medicine, and there has not been a lot of time to develop other interests. He admits Ligia pushed him toward slowing down a little, but he decided it was time to retire.

We just felt it was time to stop and smell the roses, he said. I love being a doctor, so I kept on doing it. It was what I wanted to spend my time doing. But we dont know how much time we have left, so we finally decided it was time to stop with the practice.

It would be a tough search to find families with more physicians than Dr. Garcias. The son of a physician, he was born Aug. 10, 1926 in a small town in Cuba and grew up there. He also had an uncle and brother who were physicians. He went to Havana Medical School and graduated in 1951. Luckily, he had completed his training and planned to stay in the U.S. prior to Fidel Castros communist revolution of 1959. He interned at Mercy Hospital in Canton, Ohio and completed his residency in cardiology at The Cleveland Clinic in 1958. He did some teaching in Puerto Rico and Georgia prior to coming to Tucson in 1961. He started in Tucson at the Veterans Administration Hospital. After three years he began his private practice, nearly all of it has been spent at his current office at Medical Square, 1601 N. Tucson Blvd.

It is his work outside the office that built his reputation and got him the most attention. TV had Dr. House. Tucson has Dr. Housecall. Dr. Garcia enjoys doing housecalls and has been doing them every week since he started his practice. He has been trying to help his patients adjust to his retirement, but they know it is rare these days to find someone who will make housecalls routinelyor at all.

There are wonderful doctors out there who are very dedicated, Dr. Garcia said, but it has become very difficult for them to include housecalls as part of their practice and be successful. I know there are some practices where a patient rarely sees a

Cardiologist-IM physician Hector L. Garcia, M.D. is retiring after 54 years of practice in Tucson. Known for making regular housecalls a practice cornerstone, Dr. Garcia has received several awards in recognition of his years of service (Dennis Carey photo).

physician even if they go to an office. Many of the procedures are done by nurse practitioners or medical assistants. There is nothing wrong with that, but it is being with the people that made me want to be a doctor, so I would prefer to do it myself. I have always felt communication and trust are the most important parts of practicing medicine and for me that comes with talking to the patients one-on-one.

Dr. Garcias legacy looms large in Tucsons medical community, including four children who are physicians, three of whom practice in Tucson. Hector F. Garcia, M.D. has practiced cardiology with his father at offices in Tucson and Douglas. PCMS Board member G. Mason Garcia, M.D. recently opened Sunrise Cardiology, a direct-pay practice near TMC. His daughter Mariali Garcia, M.D. is a Tucson endocrinologist. Son Lawrence Garcia practices cardiology in Boston.

My wife deserves most of the credit for our wonderful family, Dr. Garcia said. She dedicated herself to the kids while letting me


dedicate my life to practicing medicine. I am very proud of my family. They are making their own marks as doctors.

Dr. Garcia also has impacted local medicine by serving on the PCMS Board of Directors 1999-2001, and from 2002 to 2004. He was elected Southern Arizona District Director of the Arizona Medical Association in 1997, but left after one year.

I did not want to spend that much time in Phoenix talking about the politics of medicine, he said. I wanted to practice medicine. I felt it was taking too much time from my patients. I did enjoy serving on the board at PCMS. I looked forward to those Tuesday night meetings with my colleagues. It was a wonderful time.

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His colleagues must have felt the same way. He was named PCMS Physician of the Year in 2003. In 2005 he received the Rose Marie Malone Award for Service to Organized Medicine. Last year Pima County Medical Foundation gave him its Foundation Award for Exemplary Lifetime Achievement in Furtherance of Medical Education.

Dr. Garcia appreciates the acknowledgment he has received from his peers, but says the everyday interaction with his patients is what he will miss most in retirement. I have had some patients for almost 50 years, he said. I am not sure new patients want to start with a doctor my age! n


CME

Local CME from Pima County Medical 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. Scheduled presentations are:

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: To be announced.

MayMay 15-17: The Second Annual Southwest Laryngology Conference: Focus on Dysphagia and Laryngeal Hyper-Responsiveness is at Mayo Clinic Talor Auditorium on the Mayo Clinic Scottsdale campus, 13400 E. Shea Blvd., Scottsdale.

Accreditation: 18.0 AMA PRA Category 1 (General Session); 4 AMA PRA Category 1 (Optional Workshopseparate fee). Course is offered for 1.7 ASHA CEUs (Intermediate level, Professional area).

Conference designed to provide state-of-the-art discussion on comprehensive evaluation and management of dysphagia related to head and neck cancer and neurological disorders, as well as a thorough assessment of laryngeal hyper-responsiveness, including chronic cough, presented by a faculty of world-renowned experts in laryngology, dysphagia, and laryngeal hyper-responsiveness from across the country. Program uses multidisciplinary team approach with presentation topics including:

Physiology of Normal Swallowing Skill Acquisition in Volitional Laryngeal Control Muscle Tension DysphagiaDysphagia Evaluation and Treatment in Head and Neck CancerDiagnostic Imaging of Swallowing Collaborative Management of Chronic CoughParadoxial Vocal Fold MotionNeural Control of Swallowing

Targets physicians, NPs, PAs, and speech-language pathologists. Specialists are welcome in otorhinolaryngology, general surgery, IM, allergy, gastroenterology, pulmonology and neurology.https://ce.mayo.edu/otorhinolaryngology/node/1827

You may register for the live-stream webcast, which will include the option to submit questions. Website: https://ce.mayo.edu/otorhinolaryngology/node/3270Website: https://ce.mayo.edu/

Contact: Cassandra Skomer, Mayo Clinic Scottsdale, phone 480.301.4580; fax 480.301.8323. [email protected] https://ce.mayo.edu/

JuneJune 5: The Association of American Physicians and Surgeons presents the 22nd Thrive, Not Just Survive Workshop at the Embassy Suites, 201 Harrison Oaks Blvd., Cary, N.C. in the Raleigh area. Workshop is 1-6 p.m., immediately followed by Politics and Your Practice focusing on updates on physician-led initiatives in Washington, D.C. And nationwide to protect patient-centered medicine.

For $124-per-night room reservations, call 919.677.1840 and mention AAPS or use the link at aapsonline.org/raleigh

Accreditation maximum 4.75 Category 1 credits by New Mexico Medical Society through joint providership of Rehoboth McKinley Christian Health Care Services and AAPS. Online signup and more information is at www.aapsonline.org/raleigh

Members ClassifiedsMEDICAL PRACTICE FOR SALE: Hector L. Garcia MD and Hector F Garcia are selling their Internal Medicine practices located in Tucson and Douglas. The offices are located at 1601 N. Tucson Boulevard, Suite 1A, Tucson, and 1116 G. Avenue, Suite 7, Douglas. Interested parties may call 298-7251 for details.


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May 2015 Sombrero

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