Sombrero December 2014

8/9/2019 Sombrero December 2014

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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

D E C E M B E R 2 0 1 4

Dr. Ganns Diet of Hope Institute

EMRs impracticality

MRCSA on Ebola,

other preparedness


2/282 SOMBRERO December 2014

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Available Feb. 22- March 1st.

Winter Medical Conference In Telluride Colorado

Conference directors Robert Berens, M.D. and Alan Rogers, M.D.


3/28SOMBRERO December 2014 3

Ofcial Publication of the Pima County Medical Society Vol. 47 No. 10

PrintingCommercial Printers, Inc.Phone: 623-4775

E-mail: [email protected]

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

Website: pimamedicalsociety.org

EditorStuart FaxonPhone: 883-0408

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

Art Director

Alene Randklev, Commerc ial Printers, Inc.Phone: 623-4775

Fax: 622-8321

E-mail: [email protected]

Pima County MedicalSociety Officers

PresidentTimothy Marshall, MD

President-ElectMelissa Levine, MD

Vice PresidentSteve Cohen, MD

Secretary-TreasurerGuruprasad Raju, MD

Past-PresidentCharles Katzenberg, MD

PCMS Board of DirectorsEric Barrett, MD

Diana Benenati, MD

Neil Clements, MD

Michael Connolly, DO

Michael Dean, MD

Howard Eisenberg, MD

Afshin Emami, MD

Randall Fehr, MD

Alton Hallum, MD

Evan Kligman, MDKevin Moynahan, MD

Soheila Nouri, MD

Wayne Peate, MD

Scott Weiss, MD

Leslie Willingham, MD

Gustavo Ortega, MD (Resident)

Snehal Patel, DO (Resident)

Joanna Holstein, DO (Resident)

Jeffrey Brown (Student)

Jamie Fleming (Student)

Members at Large

Donald Green, MD

Veronica Pimienta, MD

Board of Mediation

Timothy Fagan, MD

Thomas Grifn, MDGeorge Makol, MD

Mark Mecikalski, MD

Edward Schwager, MD

Arizona MedicalAssociation OfficersThomas Rothe, MD

immediate past-president

Michael F. Hamant, MDsecretary

At Large ArMA BoardR. Screven Farmer, MD

Pima Directorsto ArMATimothy C. Fagan, MD

Timothy Marshall, MD

Delegates to AMAWilliam J. Mangold, MD

Thomas H. Hicks, MD

Gary Figge, MD (alternate)

SOMBRERO (ISSN 0279-909X) is published monthlyexcept bimonthly June/July and August/September by thePima County Medical Society, 5199 E. Farness, Tucson,

Ariz. 85712. Annual subscription price is $30. Periodicalspaid at Tucson, AZ. POSTMASTER: Send address

changes to Pima County Medical Society, 5199 E. FarnessDrive, Tucson, Arizona 85712-2134. Opinions expressedare those of the individuals and do not necessarily repre-sent the opinions or policies of the publisher or the PCMSBoard of Directors, Executive Officers or the members atlarge, nor does any product or service advertised carry theendorsement of the society unless expressly stated. Paidadvertisements are accepted subject to the approval of theBoard of Directors, which retains the right to reject anyadvertising submitted. Copyright 2014, Pima CountyMedical Society. All rights reserved. Reproduction inwhole or in part without permission is prohibited.

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On the Cover

Dr. Hal Travelin Tretbars Winter Glier photo was taken in

Flagsta late on a December aernoon, using a Nikon D600 with

the wide-angle lens at 24mm. The camera was sit at ISO 160 with

aperture priority and spot metering, and exposure was 1/50th

second at f.22. The aperture has to be at the smallest seng

(largest number) to get a star eect from the light source.

24 Hours 7 Days A Week

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5 Milestones: Whats up with doctors Johnson,

Oscherwitz, Ellio, Donnelly, Kalumullah, and

Weinstein.

8 Membership: Dr. Dietmar Ganns new Diet of

Hope Instute.

11 In Memoriam: Obituaries for octogenarian

physicians H. Allan Collier, Remo DiCenso, and

Richard J. Toll.

13 Mix At Six: PCMS Vice-President Steve Cohen,

M.D. hosted this one.

14 Ebola: MRCSA addresses the lethal virus and

other preparedness.

17 Perspectves:Dr. Thomas Scully on EMRs; Dr.

Jason Fodeman on Medicaid care delays.

19 Prostate Cancer: An update on the dierent

disease.

23 Makols Call: Dr. Makol considers eects and

percepons of rearms medical damage.

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

Inside



Arizona Chapter ACShonors Dr. JohnsonThe Arizona Chapter, AmericanCollege of Surgeons honored

Kenneth R. Scooter Johnson,M.D., F.A.C.S.with its LifemeAchievement Award during itsAnnual Scienc Meeng Nov.15-16 at the Westward LookResort in Tucson.

The award is given for Dr.Johnsons many years ofmembership and service as anocer of the organizaon. Hisreported standing ovaonwent on for about a minute.

Dr. Johnson is a nave of

Wisconsin, where he went tocollege and medical school. He did his surgical residencies atUCLA and in Tucson. In addion to his 35 years of private pracce,he has served as a University of Arizona Assistant ClinicalProfessor of Surgery, helping to train the next generaon ofmedical students and surgery residents.

He is a member of the PCMS History Commiee, is parcularlyinterested in local medical history and the medical history ofAmerican presidents, and has appeared oen in these pages.

Father of four, Dr. Johnson is rered from pracceand lives in Tucson with his wife, Cathy, havingrecently celebrated their 38th anniversary.

Dr. Oscherwitz joinsSouthern ArizonaInfecous DiseaseSpecialistsSteven Oscherwitz, M.D., a specialist ininfecous seases, tropical medicine andepidemiology, has joined Southern ArizonaInfecous Disease Specialists in Tucson,praccing with six other physicians including LisaValdivia, M.D.and Cliford Marn, M.D.

Dr. Oscherwitz earned his medical degree fromthe University of Texas Health Science Center atDallas in 1986, and then completed his IMresidency, chief residency and InfecousDisease Fellowship at University of Texas HealthScience Center at San Antonio.

He completed the military tropical diseasecourse at Walter Reed Army Instute ofResearch in Washington, D.C., and rotatedwith military physicians at Lackland Air Forcebase and Wilford Hall Medical Center in SanAntonio. He has traveled as a physician for

Milestonesarchaeologists in the Peten jungle of northeastern Guatemala,and with U.S. government sciensts to eradicate parasites inChina. He assisted medical students with case-based instrucon atthe University of Arizona College of MedicinePhoenix last year.

Dr. Oscherwitz is a member ofthe Australasian College ofTropical Medicine, AmericanSociety for Tropical Medicineand Hygiene, AmericanCommiee on Clinical Tropical

Medicine and TravelersHealth, the InternaonalSociety of Travel Medicine,American Society forMicrobiology, InfecousDisease Society of America,Arizona Infecous DiseaseSociety, AMA, AmericanCollege of Physicians, and bothPCMS and ArMA.

He is one of a few hundredindividuals worldwide to hold the Cercate of Knowledge inClinical Tropical Medicine and Travelers Health issued by the

American Society for Tropical Medicine and Hygiene. He iscredenaled as an Infecon Control Praconer by theCercaon Board of Infecon Control, and is a Fellow of theSociety for Healthcare Epidemiology of America.

Dr. Oscherwitz has served as a resource for Brish Airways andConde Nast Traveler. He oers expert diagnosc and treatmentservices to ill paents referred to him by other physicians and toindividuals with dicult-to-diagnose problems. The majority of

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his career has been spent caring for crically ill or unstablehospitalized paents, and he has used his Asian, African,European and South Pacic travel experience to assist in makingdiagnoses for returning ill travelers as well as makingprophylacc recommendaons for deparng travelers on bothadventure and business ineraries.

His DrDetecve website, www.drdetecve.com, is designed as aportal for quesons and record review for paents withoutaccess to infecous disease specialists near their homes. Dr.Oscherwitz has been featured in Natures Vampires(Discovery

Channel/ Animal Planet), Mystery ER(Discovery Health Channel),local TV and radio programming and print media.

Dr. Ellio on governorsinfecons disease council

Pediatric infecous disease

physician Sean Ellio, M.D.,professor of pediatrics andmedical director of infeconprevenon for the Universityof Arizona Health Network, has

been appointed by Gov. JanBrewer to the newly establishedCouncil on Infecous DiseasePreparedness and Response,the UofA reports.

The council is of leadingexperts in health, humanservices, public safety,emergency and military aairs,educaon, and more.

Dr. Ellio, together with a mul-disciplinary team at UAHN, hascreated an infecon-prevenon SWAT team, developingprotocols and training for infecon control to safely care for

paents and to protect the well-being of sta and cliniciansthroughout the network.

Governors councils have been formed beforeas in the councilfor H1N1and they bring together the resources of the state toimprove communicaon, training and understanding, Dr. Elliosaid. Since we are about to enter the u season, this council isparcularly important.

According to Gov. Brewers oce, the council has been chargedwith developing a coordinated and comprehensive plan to ensurethe state is prepared to manage and respond to potenaloutbreaks of infecous diseases, including the Ebola virus andEnterovirus, in Arizona.

A copy of the Governors ocial press release lisng the duesof the council and other team members can be viewed atwww.azgovernor.gov/dms/upload/PR102114EOCouncilInfecousDiseasePreparednessResponse.pdf . A copy of theExecuve Order can be viewed at www.azgovernor.gov/Newsroom/GovEO.asp .

CMG: Dr. Donnellyinterim CMONov. 3, 2014 Carondelet

Medical Group announced

Nov. 3 that its new Interim

Chief Medical Ocer (CMO) is

Christne Donnelly, M.D. Dr.

Donnellytook over this role on

Oct. 21 when her predecessor

stepped down aer many

years with Carondelet, CMG

reported.

Her predecessor was Michael

Connolly, D.O., currently onthe PCMS Board of Directors.

Dr. Donnelly has worked in

family medicine at Carondelet

Medical Group (CMG) for the last 11 years. She is currently the

CMG Board Chair and her pracces lead physician. While serving

in her new role as Interim CMO, Dr. Donnelly will take on

addional administrave dues and connue to see paents at

CMGs Central oce at 630 N. Alvernon Way, Tucson.

Aer receiving her bachelors degree in microbiology from the

University of Arizona, Dr. Donnelly went on to earn her M.D.

Pennsylvania State University. She returned to Tucson to complete

her residency in Family and Community Medicine at theUniversity of Arizona, and is board-cered in Family Pracce.

Im really excited about my new role here at Carondelet, Dr.

Donnelly said. Its the best of both worlds because I get to

connue seeing paents while expanding the ways I serve my

colleagues. As CMO, I have a wonderful opportunity to support

our dedicated physicians working across the Network.

In addion to her full-me work as a doctor over the last

decade, Dr. Donnelly also has served as Associate Clinical Faculty

for the University of Arizonas College of Medicine and College of

Nursing, and has been a medical relief volunteer in developing

countries around the world every summer, somemes bringing

her children with her for the experience .

We are thrilled to have Dr. Donnelly as Carondelet Medical

Groups interim chief medical ocer, said Tawnya Tretschok,

vice-president and execuve director of physician pracces at

Carondelet. She is highly regarded among her peers and

paents, bringing with her a wealth of clinical and leadership

experience. Shes a great t.

Campbell

Ave

PRESENTEDBYTHE

Pima CountyMedical Society

STARS

AVENUEon the

Save that date!The date is April 18,

2015, and the reason is thereturn ofStars on the

Avenue!So thatsSOTA,April, 18,

2015, 7 p.m.at St. PhilipsPlaza, Campbell at River,

4280 N. Campbell Ave.We will have more information

monthly as the time nears!



Dr. Kalimullah joinsSkin SpectrumFaiyaaz Kalimullah, M.D.,

board-cered dermotologist,

has joined the three-physician

dermatology pracce Skin

Spectrum at 6127 N. La Cholla

Blvd, Suite 101 (797.8885). It isalso the pracce of PCMS

memberTina Pai, M.D.

Dr. Kalimullah graduated from

the University of Chicago with

honors in Near Eastern

Languages and Civilizaons,

and subsequently earned his

medical degree at Rush

Medical College, where he was

elected to the Alpha Omega Alpha Honor Medical Society.

Following med school he completed his IM internship at University

of Chicago Medical Center. He went on to complete a dermatologyresidency at University of Arizona Medical Center, where he was

appointed chief resident during his nal year of training.

Dr. Kalimullah is commied to providing his paents with

expert skin care, the pracce said. using the latest

technologies in aesthec dermatology. He is parcularly

interested in the use of neuromodulators such as Botox

Cosmec, dermal llers and volumizers, and laser surgery for

skin rejuvenaon.

We welcome him and hope you will get a chance to meet Dr.

K. soon!

Center for Connected Healthhonors Dr. WeinsteinRonald S. Weinstein, M.D.,

founding director of the

Arizona Telemedicine Program

(ATP) at the Arizona Health

Sciences Center and one of the

fathers of telemedicine, was

honored for disnguished

service in advancing

technology-enabled care

delivery and help promonghealth and wellness, on Oct.

23, at the 11th Annual

Connected Health Symposium,

hosted by the Center for

Connected Health, Partners

HealthCare, in Boston, the

university reported.

The Center for Connected Health is part of Boston-based

Partners HealthCare, a non-prot integrated health system, and

was started in 1994 by two of the naons leading academic

medical centers: Brigham and Womens Hospital and

Massachuses General Hospital (Mass General), both aliated

with Harvard Medical School.

The Massachuses-based organizaon is recognized Dr.

Weinstein for his groundbreaking work in bringing healthcare to

the farthest corners of the state of Arizona and beyond, and for

his vision and leadership that propelled telehealth to its current

state of adopon.

Its a homecoming for me, said Dr. Weinstein, who did his

residency in pathology at Mass General, and parcipated there in

the very rst telemedicine cases in the country, in 1968. That

program is of enormous historical interest, and to receive an

award from the people who are now the custodians of the Mass

General-connected program has special signicance for me.

Mulspecialty telemedicine got its start in 1961, following a tragic

plane crash at Bostons Logan Internaonal Airport, Dr. Weinstein

said. City leaders approached Mass General about the possibility

of somehow bringing emergency services more rapidly to the

airport, since the only access to the airport then was through

Callahan Tunnel, Dr. Weinstein recalled. Over a period of six

years they studied the request and devised a plan linking Logan

Airport to Mass General by point-to-point microwave. Not only

that, they developed a total telemedicine soluon that is almostidencal to what we use todayelectronic

stethoscopes, teleradiology, teledermatology, telepsychiatry,

even the rst telepathology.

The Mass General-Logan Internaonal Airport Telemedicine

Program became the model for two of the rst statewide

programs, one started in Georgia by Dr. Weinsteins fellow Mass

General resident and friend Jay Sanders, M.D. in 1993, and the

second in Arizona in 1996.

Former State Sen. Bob Burns, a machine language computer

programmer at General Electric early in his career, heard of the

Georgia program in 1993. He ew to Georgia then back to

Arizona with a video recording of what he saw, and consultedwith James Dalen, M.D., then-dean of the University of Arizona

College of Medicine, about starng a telemedicine program at

the UofA. Burns energecally took on the role of legislave

champion. He co-founded the Arizona Telemedicine Program

with Dr. Weinstein and they sll manage the large, 70-community

enterprise together, 20 years later.

The Arizona Telemedicine Program formally launched in 1996,

following two years of planning, and began connecng UA

physicians to doctors and paents in Nogales, Ariz., and other

rural communies in 1997.

Dr. Weinstein is oen called the father of telepathology for

invenng, patenng and then commercializing roboctelepathology, a technology that has beneted tens of thousands

of paents on ve connents. He is founding director of the

Arizona Telemedicine Program, headquartered at the Arizona

Health Sciences Center of the UofA, and is execuve director of

the T-Health Instute at the UA College of MedicinePhoenix.

Among Dr. Weinsteins honors is the Lifeme Achievement Award

of the Associaon for Pathology Informacs for his work leading

to creaon of telepathology services around the globe (remote

laboratory diagnoscs). He has been president of six medical

organizaons, including the U.S. and Canadian Academy of

Pathology, and the American Telemedicine Associaon. n



Membership

Anti-carb crusadeDr. Dietmar Ganns Diet of Hope Institute

Dietmar Gann, M.D. cant be accused of convenonality, sowhy should his rerement be any dierent?At 70, and a PCMS member since 1979, Dr. Gann decided to end a

very successful cardiology career three years ago and focus full-

me on his Diet of Hope. In September the Diet of Hope Instute

opened its doors at 4892 N. Stone Ave. with Dr. Gann as medical

director and his wife, Elizabeth, as cered nutrional consultant.

Dr. Gann has long been an an-carb crusader, including doing a

three-part series on it in these pages, and hes well-versed in the

low-carb/low-fat discussion. The Ganns developed the Diet of

Hope to help paents lose weight, lower blood pressure, lower

cholesterol, reverse the eects of Type 2 diabetes, and reduce or

eliminate expensive medicaons needed to treat many obesity-related condions.

I nally decided I wanted to focus on the prevenon and help

paents without expensive medicaons and procedures, Dr.

Gann said. Many paents have been told that once they develop

diabetes, they are stuck with it. They will have to be on expensive

drugs or insulin the rest of their lives, and it is just not true.

Its not unusual for Dr. Gann to think

outside the box. In 1979 he came to

Tucson to start his cardiology pracce. In

the 1980s he pioneered the atherectomy, a

non-surgical device that uses rotangblades to unblock arteries. In 2003, he was

the rst cardiologist in Tucson to place a

drug-coated stent in an artery to help

prevent reclogging. He was also one of the

founding cardiologists of Tucson Heart

Hospital, which became Carondelets and

morphed into Carondelet Heart and

Vascular Instute at the St. Marys campus.

He was born and raised in Germany, wherehe graduated from med school at theUniversity of Tuebingen in 1967. He studied

cardiology and was an Associate Professorof Cardiology at the University of Miami. Heserved as intensive care director at MountSinai Medical Center in Miami 1974-1979.

In 2004 Dr. Gann trekked to the North Pole,

and has conquered the Maerhorn and

Mt. Kilimanjaro. In a talk at PCMS, he said

the polar trip was a great experience, but

not one he would repeat!

While in the low-carb/low fat debate the

Diet of Hope sll has some detractors, Dr.

Story and Photos by Dennis Carey

At the new facility at 4892 N. Stone Ave., opened in September,Dr. Ganns Diet of Hope Institute now gets billing over itscardiology predecessor, Tucson Heart Group. DOHI still hasofces at 50 Croyden Park Rd. and 2046 N. Kolb Rd., and is alsoin San Carlos, N.M.



Gann believes the research and results are on his side. The latest

stascs from 1,000 Diet of Hope paents indicate that aer the

rst phase (six weeks), 330 pre-diabec paents lost an average

of 17.6 pounds and A1C normalized in 67 percent of those

paents. Diabec paents (210) on prescripon opon (PO)

drugs on injecon with Byea or Victoza lost an average of 18.1

pounds, 28 percent normalized A1C, 67 percent stopped or

dropped PO medicaons, and 43 percent stopped Byea or

Victoza. Diabec paents on insulin (90) lost an average of 19.3

pounds, A1C changed and average of -15.7 percent and 59

percent were taken o insulin. Non-diabec paents (370) lost an

average of 16.6 pounds.

This is important because it is very expensive to treat diabetes.

Those drugs and insulin are not cheap, Dr. Gann said.

The cost of going through the Diet of Hope program is $895 for

those not using insurance. Dr. Gann says 95 percent of insurances

will cover the plan. It costs nearly $2,000 per year to treat a

diabec paent, he says. Many insurance coverages, including

Medicare, will cover the program if it is related to the treatment

of a disease or condion such as obesity, diabetes, or high blood

pressure. Several Diet of Hope paents come from physician

referrals. Nearly 5,000 paents, including 400 physicians, have

parcipated in the Diet of Hope in the last four years.

It is a three-phase program that takes a year to complete. Phase 1 is

six weeks in which diets are restricted the most. Diabecs and pre-

diabecs are monitored closely at this point because the blood sugar

levels can drop quickly and medicaons will have to be adjusted.

Somemes paents may stay longer in Phase 1 if they feel they have

not made enough progress in six weeks. Phase 2 allows for some

foods to be reintroduced into the diet. Phase 3 is maintenance.

The Diet of Hope is a modicaon of the Atkins diet principle thatrestricts intake of carbohydrates, and for Type 2 diabetes, various

sources of sugar. Physician, cardiologist and nutrionist Robert C.

Atkins published his diet book in 1972 and it became the best-selling diet book in history. With his own history of M.I., congesve

heart failure and hypertension, Dr. Atkins died at 72 in 2003.

Dr. Gann became interested in using a low-carbohydrate diet to

help lower cholesterol and improve lipid levels when one his

paents lost 20 pounds and lowered his cholesterol signicantly

using the Atkins. Dr. Gann tried the diet himself, and lost weight

and saw an

improvement in his

lipid levels.

He followed up with

conversaons with the

late Dr. Atkins and wasprovided much of the

research used to

develop the Atkins

Diet. Dr. Gann did

some of his own

research. This led him

to believe the low-fat,

high-carbohydrate

diets being promoted

by the government

and special-interest

groups such as the

American Diabetes Associaon and American Heart Associaon

did not work.

And dont get him started on the problems with the foodpyramid! The food pyramid was developed by the United StatesDepartment of Agriculture, Dr. Gann says. It promotesagriculture. He concurs with Harvard Medical School that theguidelines in the food pyramid are not only wrong, butdangerous. He believes that the severe increase in obesity,diabetes, and high blood pressure in the last 40 years in the U.S. islinked to the low-fat, high-carbohydrate diet. The Diet of Hope isalso gluten-free. Gluten, found in many whole grains, causes animmune reacon in those who have celiac disease. Dr. Gannbelieves this is another reason to avoid food pyramid guidelines

The Diet of Hope is not

considered a high-

protein diet. It is about

poron control,

sucient proteins,

and good fats.

Vegetables are thesource of

carbohydrates, and

rened carbohydrates

such as breads, pasta,

rice, and cereal are

avoided.

The Diet of Hope

Instute is staed full-

me by six NPs who

monitor paents

progress. Dr. Gann has

Dr. Dietmar Gann has his Diet of Hope Institute seminarswhere else?at the famous PCMS conference rooms, outsidewhich these folks were recently registering.

Dr. Gann introduces his Diet of Hope Institute ofce staff at a recent seminar.



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also recruited some of his former colleagues to help. Cardiologists

James Evans, M.D., Lionel Faitelson, M.D. and Basel Skeif, M.D. of

Tucson Heart Group rotate weekly rounds.

This is not a substute for a primary care physician or an

endocrinologist, Elizabeth Gann said. We provide regularupdates to be given to the paents regular physician. We dont

want paents to stop going to their regular doctors.

Dr. Gann encourages exercise to go along with the Diet of Hope.

They pracce what they preach by hiking, playing tennis regularly

and connue to sponsor a 10K run on Cinco de Mayo with Tucson

Heart Group.

Dr. Gann points to the Arcc Inuit and the Masai in Africa as

examples of staying healthy on a high-fat, low carb diet. Both

cultures have lile or no clinical heart disease, low blood pressure

and cholesterol, and are free of cancer. The Ganns spent me

with the Masai in 2000 and sampled the diet of goat blood, milk,

and roasted meat.

The Diet of Hope is not that extreme, but it is a lifestyle change.

The Ganns have published two books on the diet. One explains

the diet itself, while the other is a cookbook with recipes to help

stay on the program. Both are available on the Diet of Hope

website dietoope.org.

We know it is not easy to change aer geng bombarded by the

food industry and government for years, said Dr. Gann. It is has

become an addicon like alcohol and tobacco. We believe our

program can provide the support to help our paents get over

their addicon. It is something they will have to work on the rest

of their lives, even aer they leave the program. n

PCMSs Basel Skeif, M.D. and George Makol, M.D. attendedthe Diet of Hope Institute open house in September. Dr. Skeifpractices cardiology with Tucson Heart Group and helps atthe institute, while allergist Dr. Makol is famous in Sombrero.

Practicing what they preach, Elizabeth and Dr. Dietmar Gannexplain their diets benets of exercise to participants at aPCMS-sponsored Walk With a Doc event Nov. 1 along the Rillito



In Memoriam

By Stuart Faxon

H. Allan Collier, M.D.1928-2014Ob-Gyn physician H. AllanCollier, M.D., PCMS member

for nearly 30 years, died Oct. 3

in Ohio, his family reported in

theArizona Daily StarOct. 15.

He was 85.

Replying to a Sierra Vista

Community Hospital query in

1968, PCMS Execuve Director

Wesley A. Barton said Dr.

Collier was highly regarded in

the community as a person

and a praconer.

Harry Allan Collier was born

Dec. 3, 1928 in Raceland, Ky.,

and aended Holmes High

School in Covington. Aer

graduaon, the family reported, Allan joined the U.S. Army, and

on his 18thbirthday in 1946, he sailed on a troop ship into Tokyo

Bay, where he would be staoned. While in Japan, he became a

paratrooper with the 11thAirborne. Allan le the army in 1948 to

go to college on the G.I. Bill.

He went to the University of Louisville 1948-50, and graduated

from the University of Cincinna in 1953 with a B.S. in zoology. In

1957 he earned his M.D. at the University of Louisville School ofMedicine. He interned at the Navy Bureau of Medicine and

Surgerys U.S. Naval Hospital at Portsmouth, Va. He did his Ob-

Gyn residency at Cincinna General Hospital.

Shortly aer earning his bachelors degree, Allan married

Patricia Reuthe in Cincinna, the family reported. They were

married for 57 years unl Pa passed away in 2010.

Allan knew that he wanted to be a physician. He was accepted at

the University of Louisvilles School of Medicine in 1953 as an

alternate from the waing list. Allan worked two jobs during

medical school to pay his tuion, a task that was not encouraged

by the school, but showed his resolve to get his medical degree

He nished rst in his class in his senior year.

Aer compleng his residency in 1962, Dr. Collier moved his

wife and two young sons to Tucson where he would set up his

private pracce and escape the Midwest winters. He joined

PCMS that year and established his Ob-Gyn pracce at Craycro

Medical Center at the fomer oces of Donald S. Bethune, M.D.,

Craycro Road at East 2ndStreet.

Allan pracced medicine in Tucson unl 1990, the family

reported. During that me, Allan and Pa had two more

childrena daughter and a son. Allan balanced his family and his

busy medical pracce with his many hobbies, which included

raising and cung horses, obtaining his private pilots license,

making jewelry, reading, and driving his 1952 MG.

Dr. Collier was a member of what was then the federaon of

AMA, ArMA, and PCMS. He was an adjunct instructor at the UofA

and member of the Southwest Obstetrics & Gynecology

Associaon, Central Associaon of Obstetrics and Gynecology,

and a Fellow of the American College of Obstetrics and

Gynecology. He was a diplomate of the American Board of

Obstetrics and Gynecology. At PCMS he chaired our Medical

Careers Commiee 1967-68, and served on the Commiee onMedical Standards. In 1973 he chaired the Perinatal Mortality

and Morbidity Commiee.

Cing health reasons, Dr. Collier rered in 1990. In 1991 he was

elected to the Board of Trustees of the Foundaon for St. Josephs

Hospital. He was a member of Our Saviours Lutheran Church. At

the me of his death Dr. Collier had been vising relaves and

friends and had just aended a reunion of his high school, the

family reported. A faithful believer in God, Allan will be

remembered for his love of his family, his wonderful friendships,

and his warm manner with his paents.

Allan is survived by their four children and their families: sons

Keith and Todd; daughter Kim and her husband Joe and their

sons, Quinn, Caleb and Cole and son, Michael and his wife, Beth

and their daughters, Kate and Sarah.*

A celebraon of Dr. Colliers life was given Oct. 18 at The Lodge on

the Desert. Memorial donaons may be made to the Alzheimers

Associaon, Box 96011, Washington, D.C. 20090-6011 (www.alz.org)

*Editors note: The survivors informaon was punctuaonally

garbled in the newspaper. Weve quoted it as it appeared because

no source was available to correct it.

Remo DiCenso, M.D.1927-2014

Dr. Remo DiCenso, psychiatrist

and PCMS member 1962-77,

died Nov. 4, the family

reported in the Nov. 7. He was

86.

Remo DiCenso was born Dec.

3, 1927 in Italy, and his family

emigrated to Bualo, N.Y.,

where he aended elementary

and high school, the family

reported. He moved with hisfamily to Tucson in 1946.

He graduated in May 1952

from the University of Arizona

as a liberal arts baccalaureate,

many years before the UofA

had a medical college. He

earned his M.D. in 1956 from

University of Southern California School of Medicine.

Dr. DiCenso then did his psychiatric residency at the Veterans

Administraon Hospital (Neuropsychiatric) at Los Angeles. He

Dr. H. Allan Collier in 1984.

Dr. Remo DiCenso in 1962when he joined PCMS.



was a praccing sta member at the VA Mental Hygiene Clinic in Los

Angeles unl 1961, the family reported. He returned to Tucson in

1961 and served as chief at the VA Mental Hygiene unl 1962.

As well as praccing psychiatry for many, many years, Dr.

DiCenso was a consultant for the Southern Arizona Mental Health

Center, Santa Cruz Family Guidance Center, Greenlee County

Human Resources Center, La Frontera, and the Pima County Adult

Detenon Center. He was a life member of the American

Psychiatric Associaon, Arizona Psychiatric Society and Tucson

Psychiatric Society.

Our father, a lifelong learner, was mullingual and passionate

about opera, the humanies, classical music, gardening, and

polical and social causes, the family said. At the me of his

death, he was aending weekly French classes at Pima

[Community] College and was acve in UofA alumni events and

the USC alumni group.

Dr. DiCensos parents, Angela and Giuseppe, and brother Dr. Dino

DiCenso predeceased him. His brother Dr. Sabano DiCenso;

children Cecilia DiCenso Leal, Jerome Marn DiCenso and

Rosanna Helene DiCenso; and grandchildren Nicolas Leal, Allegra

Leal, Stefano DiCenso and Soa DiCenso survive him.

A funeral mass was given Nov. 8 at Saints Peter and Paul Catholic

Church, with burial at Holy Hope Cemetery, the family reported.

In lieu of owers, please make donaons to the charity of your

choice We miss you, Dad.

Richard J. Toll, M.D.1929-2014

Dr. Richard J. Dick Toll,

orthopedic surgeon and PCMS

member 1963-1980, died Oct.

26 of Alzheimers disease inTucson, his family reported

Nov. 9 in theArizona Daily Star.

He was 85.

Richard James Toll was born

Feb. 5, 1929 in Milwaukee, Wis.

He earned his bachelors

degree in liberal arts at the

Univerity of Wisconsin at

Madison, where he also earned

his M.D. in 1954. Serving in the

U.S. Army during the Korean

War, Dr. Toll interned at TriplerArmy Hospital in Honolulu.

Aer three years in general

pracce in Shawano, Wis., Dr.

Toll did orthopedics residencies in Salt Lake City at Laer Day

Saints Hospital and (Shriners) Primary Childrens Hospital.

Moving his family to Tucson, the family said, he began his

private pracce in 1963.With his friend and fellow surgeon

Morton Arono, M.D., they founded Tucson Surgical Specialists.

Associated with the Crippled Childrens Clinic, he put to use the

skills and experse he acquired at the Shriners hospital.

In the mid-1960s Dr. Toll served on our Sports Medicine

Commiee, the Public Health and School Medicine Commiee,

and the Rehabilitaon Commiee. In the late 1960s he served on

PCMSs Liaison Commiee to the Rehabilitaon Center at the

UofA, and as our representave to the Tucson Area Chapter of

the Muscular Dystrophy Associaon of America. MDA was

headquartered in Tucson for many years.

In 1972 Dick began his relaonship with the UofA Intercollegiate

Athlec Department, the family reported, and he was team

physician for the Wildcats unl his rerement in 1992. He was

instrumental in development of the Athlec Training EducaonProgram, designed to prepare fure trainers to care for and

monitor athlecs at the high school and college levels.

In 1981 Dick married Glenda and they began a wonderful life full

of travel, enjoying their me in the Colorado mountains. Dick was

a man of diverse interests. He was an avid reader and admirer of

Western art. A natural athlete, he enjoyed show skiing, golf,

tennis and cycling, and played a mean hand of bridge. He was

known to work hard and play hard.

Dick was a great father, husband, friend, and talented surgeon

who will be greatly missed by all who knew him.

Dr. Tolls wife, Kathleen, predeceased him in 1994, and he wasalso predeceased by his brother, Ted.

His wife, Glenda; his children by his marriage to the late Ann

MacDonald: Tanis Duncan-Kashman of Wellington, Colo., David

Toll of Denver, and Jody K. Toll of Amsterdam, Netherlands,

survive him. Dick and Ann extended their family to include

Richard Lochert of Scosdale, the family said. Glendas children

completed the family with James Shelby of Scosdale, Michael

Shelby of St. Petersburf, Fla., and Chrisna Grisillo of Tucson. Dick

and Glendas blended family includes 10 grandchildren and Dick

enjoyed each and every one of them!

At Dicks request no memorial services was given, and his remains

were scaered in the Animas River in Durango, Colo., the familysaid. Memorial donaons may be made to TMC Hospice, the

Alzheimers Associaon, or Planned Parenthood. n

Dr. Richard J. Toll in 1963when he joined PCMS.

Corrections

In our November In Memoriamfor Dr. Sandra M. Smith,

we missed a typo in the nal quote, which should have

read: She leaves behind a large circle of living and devoted

friends who will miss her generosity and unique spirit

immensely. We apologize for typing miss as mess,

and then missing it in proong.

In the same obituary, member comment came up aboutwho did not work at The Tucson Clinic aer the story

supposedly derived informaon from a clinic leerhead

with their names. But did it? Like an IRS criminals e-mails,

that leerhead has disappeared and was not revealed in

two subsequent searches of the deceaseds le. If the

leerhead never existed, how was that kind of error

created? While we cannot locate the source that took over

our editors brain, we can certainly conrm that doctors

William Neubauer, Ron Spark, Gary Henderson, and

Christopher T. Maloney did not work at The Tucson Clinic.

We may send our editor for neurological imaging, just in

case its a tumor.



By Dennis Carey

Mix At Six

About 30 members and guests aended PCMSs most recentMix At Six social Oct. 25. PCMS Vice-President Steve Cohen,M.D. hosted as provider of appezers and drinks, though no

physician should rightly be called provider.

Mix At Six events are designed to allow physicians to meet in a

casual seng without an agenda. Members can meet new

colleagues, students, and invite non-members to nd out about

the Society.

Addional Mix At Six socials will be given in 2015. Nocaons

about them will be in these pages, by e-mail, and on the Society

website pimamedicalsociety.org . n

Mix draws members, guests

PCMS Vice-President Steve Cohen, M.D. hosted our Mix At SixOct. 25. With him at one of the food tables was Anne Hilts,spouse to our member Dr. Sky Hilts.

PCMS President-Elect Melissa Levine, right, with Linda Byrnesand Dr. Tom Brysacz, enjoyed the Mix At Six casual atmosphereand conversion.

PCMS Alliance Board of Directors member Anastasha Lynn andDr. Bruce Lynn stopped by Mix At Six dressed as super-nerdsDr. Amy Farrahfowler and Dr. Sheldon Cooper from TVspopular show Big Bang Theory.



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Ebola

Ebola: Facts, myths, and hazard preparednessBy Dr. Sheldon Marks

The Medical Reserve Corps of Southern Arizona is pleased that

many PCMS physicians joined more than 150 communitymembers at MRCsEbola and All-Hazards Preparedness Forum

Nov. 1 at the Hilton East on Broadway.

Our expert panel included Dr. Richard Carmona, 17thU.S. surgeon-

general; Dr. Sean Ellio, Professor of Pediatric Infecous Disease at

University of Arizona and member of the Governor s Council on

Infecous Disease Preparedness and Response; Dr. Josh Gaither,

University of Arizona Assistant Professor of Emergency Medicine and

Associate Medical Director for the University Campus Base Hospital;

Dr. Keith Boesen, director of the Arizona Poison and Drug

Informaon Center; and Tucson Fire Dept. Baalion Chief Kris Blume.

Key points and take-home messages were:

Ebola, though very deadly and very infecous, is very unlikely

to be a threat to most of us. Paents with Ebola are only infecous

when they have symptoms; fever, headache, myalgias, voming,

and diarrhea. Yes, these are the very same symptoms as inuenza.

We are more likely to die of the u than Ebola (as will 25,000 to

30,000 people in the U.S. this year). We should all get u vaccine

and encourage family, friends and paents to do so.

From left are Dr. Richard Carmona, Tucson Fire Battalion ChiefKris Blume, Dr. Keith Boesen, Dr. Joshua Gaither, Dr. SeanElliott, Dr. Sheldon Marks, and Tucson Fire Chief Les Caid at theevent Nov. 1 (Les Caid photo).



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We all need to be prepared for Ebola or any emergency

situaon. If we prepare for one event, pandemic, disaster, or

major emergency, then we will be beer prepared for them all.

As physicians, we have an ethical obligaon to be ready to step

up and help our community if and when the need arises. This is

where the Medical Reserve Corps of Southern Arizona plays a

crical role. Are you ready? If you are not a member, why not?

Ebola virus structure cannot mutate to become airborne.

Ebola cannot be contracted from mosquitoes.

Ebola can only be contracted with exposure to uids from a

symptomac Ebola paent (vomit, diarrhea, sweat, saliva, breast

milk, blood, semen) or the dead body. The infected uids enter

the body through the mouth, eyes or nose or through broken

skin. You are at risk if you have done any of these four things:

Handled the meat/blood of or eaten infected and parally

cooked African fruit bats (the reservoir of Ebola) and/or Sub-

Saharan African bush meat (chimpanzees, gorillas, etc.).

Handled dying or dead Ebola vicms without proper

protecon and precauons.

Shared or had contact with body uids of a person with acveEbola viral infecon.

Parcipated in the care of Ebola paents using inappropriate,

untested or inadequate PPE, or the awed donning and dong

of PPE.

Texas Health Presbyterian Hospital nurses who contracted Ebola

aer caring for Thomas Eric Duncan were only two of many that

came in contact with him. They were involved with his care at the

very end, when his viral infecousness was at its peak. We do not

know why they contracted Ebola, though presumably there must

have been a mistake in PPE coverage with exposed skin, or

donning or dong their PPE. It is important to note that none of

the many thousands of people who were exposed to Duncan on

his ights from Liberia to Brussels to Washington, D.C. and nally

to Dallas became infected, nor did any of his close friends and

family with whom he spent me while he was symptomac and

so infecous before he was hospitalized.Protecng yourself and your sta from Ebola requires the very

same hand washing and PPE skills and techniques you should be

using with every paent to protect yourselves everyday from

other infecons you are more likely to acquire, such as Hepas C.

Surviving an Ebola infecon is dependent on a number of factors:

Quality and meliness of supporve care

Health and age of vicm (younger and healthier paents have

beer recovery)

Degree of inoculaon of Ebola virus

Strain of the Ebola virus (the current Zaire strain has thehighest mortality)

Even though there have been 25 prior outbreaks of the ve

known strains of Ebola since 1976, none has been as devastang

or long lasng. There are mulple reasons that have come

together at once to create a perfect storm for this Ebola

epidemic to become so catastrophic for the people of West Africa



and to scare the world. Some of those factors, in no parcular

order are:

Extreme illiteracy of the populaon in Guinea, Sierra Leone

and Liberia.

Extreme poverty with poor hygiene, limited food and clean

water resources.

No eecve governmental or medical infrastructure, thus no

containment or control, with no medical care to diagnose, track

contacts and provide crical supporve care such as IV uids,oxygen, anbiocs, managing nutrion and electrolyte

imbalances because of the 10 to 15 liters of uid lost daily from

diarrhea and voming. Local healthcare workers oen reuse

needles and syringes.

No medical or health educaon. People do not believe that

Ebola is real, and the governments have no resources to teach

otherwise.

Extremely remote, isolated jungle villages with poor roads

and porous borders.

Local people rely on rumours and supersons for

informaon.

Strong local customs and rituals for dying, death, and burials

of the dead.

Mistrust of government, doctors, and any outsiders,

especially foreigners.

In essence these local people are saying, Why are you all so

worried about Ebola when before no one has ever cared about us

dying of so many other diseases including Lassa fever, Marburg,

Malaria, and Tuberculosis? We are ne unl the healthcare

workers show up, then people start dying.

The boom line is, dont be afraid, but be prepared. Think. Talk.

Plan. Prepare.

Dr. Sheldon Marks, PCMS past-president and local vasectomy

reversal expert, is a board member of MRCSA as well as a Tucson

Police SWAT volunteer. His said his friends and neighbors were asking

him quesons, even though he knew nothing about Ebola, which is

why he coordinated and moderated the Ebola forum. To nd out

more about MRCSA or to join, contact [email protected]. n

At the MRCSA event, infectious disease specialist Dr. SeanElliott explains what makes Evola virus particularly dangerous(Les Caid photo).



Perspecves

The fallacy of electronicmedical recordsBy Dr. Thomas B. Scully

President Obama campaignedon reforming our enre

healthcare system, oen

referring to it as anquated, and

oen quesoning why paper

sll dominated medical records.

The president clearly stated

that one of his goals was the

instuon of electronic

medical records in hospitals.

He has delivered this promise.

First through incenves, and

now with monetary penales,most U.S. hospitals currently

employ EMRs for both documentaon of the paents record and

for physician orders.

The hospital where I pracce recently went full-bore with a new

EMR system. Aer nearly three months of using it, I can safely say

that the current systems are sorely lacking and, rather than

making paents safer, lead to more errors.

Please understand that this is not a condemnaon of the hospital

where I choose to pracce. They, similar to physicians oces, are

under the proverbial government gun. Also please do not accuse

me of Luddite behavior. Far from being technologically challenged,

I am an early adopter to iPhones, iPads, etc. Rather, the currentsystems are based on a faulty premise, and the ulmate

implementaon of this faulty premise drives the current issues.

As a surgeon, I understand learning curves. Doing anything new

will take some me to get beer. I have given thought that the

issues we face are simply from a learning curve and the

newness of EMRs. However, I have used an EMR in my oce for

more than a dozen years. Although, I dont make many mistakes

on it, I have never been able to get back to a level of eciency

that was present prior to starng our oce EMRs.

Also, conrming my non-Luddite status, I have helped install

various computers and point-of-sale soware for my wifes retail

store, Embellish (note the cheap plug!) However, theres asignicant dierence between her store and a hospital: Embellish

is closed Sundays. Thus, one Sunday, we spent some me installing

her system. What a dierence from what the hospital must do!

They do not have the luxury of closing for a day to install new

computers, soware, etc. Rather, we must sll operate, perform

cardiac caths, endoscopies, do surgeries and have a full-service ED

open. All while fundamentally changing how we document what

we do and how we order medicaons, tests, etc.

Physicians must write orders on paents in the hospital. The

orders include diet, acvity, IV uids, medicaons, tests to be

performed, and so on. As surgeons we oen have pre-printed

order sets to use following our surgeries. We will check o boxes

of things we wish to order, and then write out freehand new

medicaons and other items. With EMRsspecically

Computerized Physician Order Entry (CPOE)physicians use the

computer to locate powerplans. These powerplans are related

to the paents diagnosis and/or surgery performed. For a total

knee replacement, there is one set. For a lumbar fusion, a

dierent powerplan. For congesve heart failure, yet a new one.

In a similar manner, one then picks and chooses what items on

those plans to order. These are naonally veed order sets. Manyof these order sets conform to what are frequently described as

subscribing to evidence based medicine (EBM). Unfortunately, fo

many things done in medicine, there is no denive EBM. This is

especially true with spinal surgery. Thus, we oen use our own

way of taking care of paents. That art of medicine disappears

with CPOE. We are forced to use cookie-cuer, one-size-ts-all

orders. There is virtually no room for anything else, and no ability

to free-form-type orders. In fact, we have been chassed and told

not to use so-called communicaon orders. Those orders are the

only means with which one can freely express how you may wish

things to be done.

By now you may see some of the issues we face. However, I havesll not described the biggest problems. To me, one of the most

unusual nuances of the CPOE is that the computer system sees

all the various units of the hospital as unique enes, almost as if

they are enrely dierent, unrelated individual hospitals!

Imagine it! I may be in the PACU (recovery room), but I cannot

startor in computer lingo inializemy orders. No, I can only

sign them. Then, once the paent arrives at the stated

desnaonICU, Neuro unitit is up to the nurse to gure

which of the order sets, or powerplans, I have signed, and then

iniate them so as to start caring for my paent. I cannot ag the

orders, thus leng the nurse know what plan I want to have

iniated. No, that would make sense and provide some safetynet. I must simply hope my orders are discovered and the

appropriate set is started.

Judging by my descripon of this, one can easily tell that on more

than one occasion this has not occurred. The powerplans I

described earlier have pre- and post-operave orders. We can

customize them to a degree. However, we cannot separate out

the pre- and post-op orders. I cannot think of any reason why this

exists. However, my pre-op order set is frequently dierent than

my post-op order set. Thus, I will start a new powerplan for post-

operave orders. To the nurse who must sort thru this and gure

out which one to iniate, there is no way for me to ag it as

such. Thus, on more than one occasion, my post-op orders have

not been carried out, or the wrong ones have been iniated. And

this is supposed to be safer?

The other major issues involve note wring. I do not have as

much quarrel with that aspect. However, many of the notes on

paents have all sorts of data throughout the notelab values,

old ndings, etc.but they say nothing. What maers to most

physicians is the assessment and plan part of the note. What is

the doctor thinking and planning for the paent? In many of the

notes I see, that is the part given the least space. There are

various reasons for it. Suce it to say that the most highly

educated people in the system are now data entry clerks,

entering data, values, and various other items to meet



meaningful use for governmental reasons, yet not really doing

anything to further care for the paent.

In sum, I realize many will just assume I am another spoiled

surgeon complaining about inevitable changes. Yet I see this as

far more onerous. We have allowed our profession to be taken

over by bureaucrats who think they know what is best for our

paents and us.

I see it dierently. Central planning is not eecve in general, and

certainly not when it comes to something as individualized asones health and the appropriate care for that health.

Thomas B. Scully, M.D., F.A.A.N.S., neurosurgeon with Northwest

NeuroSpecialists, was recently elected vice-president of the

Western Neurological Society. He has been a PCMS member

since 1994.

Medicaid expansion couldadd to care delaysBy Dr. Jason D. Fodeman

The Aordable Care Acts

Medicaid Expansion remains

one of healthcare reforms

most hotly-contested

provisions.

Arguments surrounding the

expansion have largely focused

on the economic and polical

implicaons of expanding

Medicaid to 138% of the

federal poverty level. While

these ramicaons are

certainly worthy of meculous

debate, there are important

medical ramicaons of the Medicaid Expansion as well. A recent

Wall Street Journalarcle raises some of these concerns.

The arcle cites signicant Medicaid backlogs in certain states.

This could be made worse by the Medicaid Expansion. According

to the arcle, there are hundreds of thousands of people across

the country who have signed up for Medicaid and have waited

months for coverage. Residents in California and Tennessee have

actually led lawsuits aer encountering lengthy delays in

acquiring coverage.

The arcle reports that in Tennessee, 10,000 Medicaid

applicaons are pending, and in New Jersey 12,000 are waing.

In California there are 159,000 Medicaid applicaons in the

queue. Generally, states are required by federal regulaon to

process Medicaid applicaons within 45 days.

These delays in applicaon processing could result in delays in

care that allow diseases to fester and become more severe.

The arcle emphasizes an important point. There is a stark

dichotomy between access to health insurance and access to

healthcare. Clearly the laer is the benchmark, and while

government health insurance does provide the former, at mes it

can fail to oer mely access to the laer.

In a world with innite resources, expanding Medicaid would no

doubt be altruisc. Yet in our world with limited resources, it

requires dicult choices and answers to tough quesons:

Do states have the resources to mely process the applicaons of

17 million new Medicaid beneciaries? And more importantly,

where will the new beneciaries receive care?

These are crucial quesons that demand answers from any state

looking to expand Medicaid for genuine reasons before it goes

down this path. The stakes are fer too high to wing it. We cannotaord to see the care of the most needy turn into another

healthcare.gov asco.

Presently, aws in Medicaid statute get passed along to

beneciaries in the form of restricted access, long waits for

appointments, and compromised care. At the same me, the

program is also replete with waste, fraud, and abuse.

Medicaid leaves state regulators and policymakers with few

opons to control rising program costs other than paying

providers less, or coming at the expense of other state priories

like educaon, transportaon, and security. A 2011 Kaiser

Medicaid study concluded, As in previous years, provider rate

restricons were the most commonly reported cost containmentstrategy.

As a result, Medicaid reimbursements have fallen well below

those of private insurers and Medicare. According to the 2012

Kaiser Family Foundaon Medicaid to Medicare Fee Index, across

the country Medicaid reimbursements are 66% of Medicare

reimbursements for all services and 59% of Medicare primary

care reimbursements. Medicare reimbursements are already

lower than those of private insurers. Somemes payments from

government health insurers for services can be even less than the

cost to provide those services.

Due to declining reimbursements and the programs

administrave hassle, many providers are reluctant toparcipate. Thus, Medicaid beneciaries can have a hard me

geng access to mely care. They can encounter lengthy delays

or be forced to depend for care on expensive, overcrowded,

disjointed emergency rooms. Both these factors contribute to

poor health outcomes for Medicaid paents. This is well

documented in the peer-reviewed literature.

The Medicaid Expansion is no panacea for these problems, nor

was it ever billed as such. Eorts must be made to improve

healthcare access and actual healthcare of the uninsured and

underinsured. Medicaid is a program in need of more reforms,

not more beneciaries.

Without a strategy to navigate the tough quesons, it is very

likely that under the Medicaid Expansion, things could get worse

before they get beer.

PCMS member Jason D. Fodeman, M.D. is a board-cered

IM physician praccing in Tucson. He is a graduate of the Cedars

Sinai Internal Medicine residency program and completed a

graduate health policy fellowship at the Heritage Foundaon.

This arcle originally appeared in the Knoxville (Tenn.)

Sennel News. n



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A different diseaseBy Frederick R. Ahmann, M.D.

Shona Doughtery, M.B., Ch.B., Ph.D.

Prostate cancer is one of the most dicult diseases tounderstand, even for physicians, Dr. Frederick R. Ahmann said.Why is it dierent? Because we dont treat 30 to 50 percent ofpeople, but for others we have to say they are in big trouble.

Dr. Ahmann, UofA professor of medicine and surgery, and ShonaDougherty, UofA associate professor of radiaon oncology, werespeaking on Sept. 9 at PCMS for Pima County Medical Foundaonsmonthly CME presentaons, doingA Prostate Cancer Update.

The biggest risk factor for prostate cancer, Dr. Ahmann said, isthat inevitable three-leer word: Age.

The number of prostate cancer deaths has been rising since the1920s, Dr. Ahmann said, due to longer lifespans and beerdiagnosis. Sll, its the second leading cause of cancer death in

men [rst is lung & bronchus at 28 percent], but around 1990early detecon became possible. Ten million men in the U.S. haveprostate cancer right now, and we do almost 1 million biopsiesper year in order to diagnose it.

Dietary changes dont do anything for it, Dr. Ahmann said, andwe dont have a great screening test for it. PSA is good and bad,he noted: Five to six percent of men will be 4+. Criteria are notyet perfect for idenfying those who have the disease or not.

What do you want to know about any cancer? Dr. Ahmann saidyou want to know how common it is, what its biologic behavior is,how variable it is, what are its risk factors, how lethal it is,whether we have successful treatments for it, whether it can beprevented, if it can be detected early.

He cited 2006 stascs nong that men in China, Japan, andGreece had the lowest prostate cancer death rates, while thehighest were in Sweden, Norway, Australia, the U.S., and England.Death rate stats by race/ethnicity 1999-2003 placed African-American men highest at 65 percent, followed by whites at 26.7percent. Lowest were Asian-Americans at 11.8 percent. Hispanicmen showed at 22 percent. Familial prostate cancer comprisesabout half of the disease cases in men 55 or younger.

Whats good and bad about PSA? In generic screening andelevated level is found in up to three to ve percent of men over50, Dr. Ahmann said, but only 20 percent have cancer, and ofthose, 40 percent appears to be unaggressive prostate cancers.

We have lowered the death rate from prostate cancer by almost40 percent since the introducon of PSA early detecon, but at alarge price of over-treatment.

He cited the Johansson Data from 2004 inJAMAshowing thatbetween years 15 to 20, progression-free survival fell from 45 to36 percent, survival without metastases fell from 77 to 51 percent,and prostate cancer-specic survival fell from 79 to 54 percent.

In the 1989-1999 Scandinavian Prostate Cancer Group update onwatchful waing vs. radical treatment, randomized among 695men with early prostate cancer, with a 23-year follow-up, 200 of347 in the surgery group died, 63 due to CAP, while in the WWgroup, 247 of 348 died, 99 due to CAP. Eight had to be treated toprevent one death, Dr. Ahmann said.



In what he called a poorly understood U.S. study of radicalprostatectomy vs. observaon (the PIVOT Trial) [NEJM2012], thestudy was designed to enroll 2,000 peents, but failed and onlyenrolled 740. Median survival was assumed to be 10 years. Itwas too short, Dr. Ahmann said. The study was dramacallyunderpowered. It treated low-risk paents who should have beenon surviellance.

In the PLCO Trial [NEJM2009], from 1993 to 2001, half of 76,693men at 10 centers were screened annually, with the other halfreceiving usual care. The screening group oered annual PSA for

six years and DREs for four years. Results were sent to the primarycare physicians and they decided on follow-up. Compliance was85 percent for PSA and 86 percent for DRE. Screening in controlgroup were 40 to 52 percent per year for one to six years for PSA,and 41 to 46 percent for DRE.

Aer seven years there were 2,820 cancers in the screeninggroup, and 2,322 cancers in the control group. Deaths aer sevenyears were 50 in the screening group, and 44 in the control group.

In a 13-year update of a European PSA screening trial, thenumber of cases found were 7,408 in the screened group, and6,107 in the control group. Prostate cancer deaths were 355among ther screened, and 545 among the control.

In a 450-man Canadian surveillance study started in 2000, of twogroups of men younger than 70, and older than 70, with PSA of10 or less for the younger men, and 15 or less for the older, theywere seen every three months for two years, and then every sixmonths, with repeats biopsies aer six to 12 months and thenevery three years.

Aer almost seven years of suveillance (2010), 22 percent of themen died, but only ve percent of the 450 men died of prostatecancer. For 70 percent of the men, there was no suggeson ofprostate cancer progression. However, Dr. Ahmann said, therewas evidence of disease progression in 30 percent (135 men) ofthe men on the study, and half, aer undergoing treatment, hadalready failed with a rising PSA level.

Whats new in treatment of incurable prostate cancer? Variousdrugs are being researched. Dr. Ahmann cited the work of CharlesHuggins, M.D. of the University of Chicago and pathologist

Andrew V. Schally, Ph.D. of the University of Miami, nong thepotenal causes of castraon resistance in prostate cancer:

Emerging dominance of an androgen-insensive clone that hasbeen present since malignant transformaon.

Transformaon of malignant calls to castraon-resistant but sllandrogen-sensive calles due to : Increased number of androgenreceptors; mutated androgen receptors; or increased intra-cellular producon of androgens. Total suppression androgens isnot yet possible.

Transformaon of malignant cells to total androgenindependence secondary to mutaons in mulple non-androgen-dependent growth pathways.

Dr. Ahmann noted again that we are treang with surgery orradiotherapy large numbers of men who dont end up benengfrom therapy. We have successful local therapies that havereduced the death rate and are increasingly beer tolerated. Wehave developed a signicant number of new therapies in the last10 to 15 years which have signicantly increased the survival ofmen with incurable prostate cancer.

Prof. Doughtery provided an overview of the opons for acvemanagement of prostate cancer and steps involved in delivery of

radiaon therapy. In counseling paents, cancer is a big word, shesaid, so slow down, consider the choices, and place them incontext. Paents with life expectancies of less than ve yearsshould see an oncological urologist and a radiaon oncologist.

In considering acve surveillance vs. acve treatment for thesepaents, Prof. Dougherty said, a physician should introduce theconcept, and consider the expectaons for quality of life and thepaents own experience.

Having choices can be good or bad, she said. If there are toomany choices, why? Remember that no choice is perfect,consider side-eects, sexual funcon and bladder connence.

She named 11 choices: Do nothing, acve surveillance, surgery,cryotherapy, high-intensity focused ultrasound (HIFU), hormones(androgen deprivaon therapy or ADT, and radiaion therapy thatmay be external beam, radioacve seed implant (LDRbrachytherapy), high-dose-rate brachytherapy, protons, or acombinaon of radiaon therapies.



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Treatment targets the prostate gland, she said, including thegland, seminal vesicales, and pelvic lymph node. The higher therisk, the larger the target.

For surgery, inquire about surgical knowledge and discuss open vs.roboc prostatectomy. Surgery uses unilateral or bilateral nervesparing. Cathetuer use if seven to 10 days and downme four tosix weeks. Post-surgical radiaon therapy is adjuvant or salvage.

As a sidelight, Prof. Doughtery menoned Dr. George Goodfellow,known for medical history in Tombstone for his self-taught

experse on gunshot wounds. But when he returned to Tucson in1891, he performed the worlds rst prostatectomy.

Among the 11 choices, cryotherapy involves cryosurgery or cryoblaonof the medium to smaller glands. It tends to ablate nerves for sexualfuncon, Prof. Dougherty said. Its appropriate for radiaon failures

and is minimally invasive. There have been several advances intechnology, including warming of the urethra and rectum. Placementof the cryoneedles is under ultrasound guidance.

High-intensity focused ultrasound (HIFU) was originally developedfor broiad, she said. Its for low-risk prostate cancer only.Ultrasound is trans-rectal, with a heat transfer of 85-95 degreescentrigrade. It preserves the sphincter, rectum and nerves. TheFDA rejected approval based on issues of safety and ecacy, shesaid. About 40,000 peents over 15 years were treated with HIFU.

Androgen deprivaon therapy or ADT is used as a sole therapy oradjuvant therapy with radiaon, Prof. Dougherty said. There islowering of testosterone with tescular suppression, adrenalsuppression, and a peripheral blocker. Side-eects include fague, hotashes, muscle wasng, weight gain, appete smulaont, decreasedlibido, shrinkage of tescles, muscle/joint pain, mood alteraon, mood

lability, hair loss, dry skin, memory issues, cardiacissues, and osteoporosis.

In proton radiaon therapy, parcles areaccelerated and targeted. But this therapy isexpensive, with limited availability, and notproven to be superior, Prof. Dougherty said.Dats is limited, as it has been available forfewer than 20 years. Its no longer approved by

some insurance companies for low-risk disease.In high-dose-rate brachytherapy, severalcatheters are placed, under general anesthesiaand their posions idened by CT scan.Iridium is used, a single, very acve radiaonsource. The source is threaded up eachcatheter in turn to a predetermined posionand allowed to dwell there for a speciclength of me before being withdrawn, andthen enters the next catheter, Prof. Doughertysaid. There are single treatments, threefracons on two occasions.

Radioacve seed implant (LDR brachytherapy)

uses a prostate gland seed implant with a lowdose rate, Eighty to 100 seeds arepermanently implanted using ve taniumcapsules with iodine or palladium (Cesium).

Combinaons of therapies may be used.Radiaon is like light, Prof. Doughtery said.Several weak beams of this light can beaimed at the same target to produce an intensespotlight. This is the method of intensity-modulated radiaon therapy or IMRT. There ispixel by pixel control of the dose, she said.Shuers open or close part of the aperture. Itgives a more even dose throughout the target,and can create hot spots within the target.

Since the target can move, immobilizaon isvery important for IMRT, she said.

There are lots of opons for acvetreatment, Prof Dougherty said.Consultaons can take one to two hours.Surgery and radiaon sll have the bestoutcomes for ecacy and are consideredequal for side-eects. Low-rick prostate canceris 90-95 percent curable, but do we need totreat all, rather than use acve surveillance?

Evolving technology is leading to beertreatments with more cure, fewer side-eects

and greater quality of life. n



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Makols Call

Hiding from our own truthBy Dr. George J. Makol

Familiarity so dulls theedge of percepon as tomake us least acquainted withthings forming part of our daily

life. So wrote Julia Ward

Howe, author of Bale Hymn

of the Republic, in the mid-

1800s.

Can familiarity lead to a

percepon that has very lile

basis in reality, or can it lead to

an alternate reality so powerful

that it can actually change

society? I think so, and I think

we have become soaccustomed to violence in our society that we now see school

shoongs, movie theater massacres, and gun- and knife- related

violence to a degree that one would never think we would see in

this country.

To illustrate the dierence between ones percepon and reality:

Not too long ago I was walking along the shore of one of the

South Shetland Islands in the Antarcc Ocean when I came upon

ve huge fur seals basking on the beach. I

was at a distance, but four of them looked

up, and then scurried down to the beach

and into the water. One rather bold male was

not about to be inmidated, so he put his

head down and headed straight for me.

Now, my previous experience with seals had

been only interact with them at Sea World

and the London zoo, where they were

accustomed to humans and trained to do

tricks. So at this point I half expected him to

pick up a beach ball, balance it on his nose,

and toss it to me. Such was my percepon of

seals. Instead, this 400-pound creature

slithered across the smooth sand, rapidly

approaching me as I clicked picture aer

picture using my trusty pocket camera.

I suddenly noced that the creature lled my

enre viewnder, and it dawned upon me

that I was not using a telephoto lens. I looked

up and he was about 25 feet from me,

ashing four-inch teeth. Fortunately the

naturalist accompanying our group caught up

with me, and stepped in front of me and

tossed his bright yellow tote in the sand

between me and the aggravated creature.

The seal stopped quicker than a Real

Housewife of Miami would upon coming

upon a Givenchy bag. My group of tourists

slithered down to the shoreline, got o his beach as quickly as we

could, and he returned to peacefully basking under the Antarcc

sun. Reality dawned upon me, as I had almost become fur seallunch.

So let us consider what the average Americans percepon of gun

and knife violence is, and upon what this is surely based. I

remember watching television as a kid, and wondering how come

nobody shot by the Lone Ranger or Tonto ever died. Roy Rogers

managed to ash his guns without ever hurng anybody, and

people were shot on other shows seem to just slump over and

not even have holes in their shirts.

Later on, TV got even further from reality, as members of the A

Team shot hundreds of rounds from automac weapons,

making the bad guys cower but never killing anybody. In fact Im

prey sure I never even saw them wound anybody, which isincredible, as spraying at least 100 rounds from automac

weapons would probably result in injuries to at least a dozen

bystanders.

Even today, the heroes in our movies are almost always shot or

stabbed at least once, and yet they connue to sight, are

thrown through walls, or climb up to the second story of the

building to rescue the heroine. This scenario, repeated in movies



and on television shows hundreds of mes, gives the impression

that being shot or being stabbed is not so bad, and may be more

like a minor inconvenience.

Those of us who have served in emergency rooms and seen what

happens when somebody is shot or stabbed might have a

dierent perspecve. Modern small arms such as semi-automac

pistols send a round of ammunion out at 600 to 1,200 feet per

second. Ries have a muzzle velocity that can be three mes this

speed. Bullets do not cut ssue, but they crush ssue, creang awound channel causing nearby ssue to stretch and expand.

Dierent types of bullets cause dierent damage. For instance,

hollow-point bullets expand more rapidly and destroy more local

ssue than a jacketed bullet. On one of the TV cop shows I saw

recently, they showed actual footage from a bar, showing a

300-pound gun-tong criminal robbing the patrons and

browbeang the barmaid. The owner came out from the back

room where he was watching on closed-circuit TV and shot the

large gentleman from across the room with a .357 magnum

pistol. The perpetrator dropped like a sack of potatoes in less

than one second; he did not make any statements, climb any

ladders, or even nish his beer. He just fell to the oor dead. This

is reality; what we see in movies is Hollywood.

Switzerland is said to have more guns per capita than any other

country in the world. This is primarily why the Nazi regime

accepted their posion of neutrality, and never invaded

Switzerland. Going home to home to

conscate weapons would have resulted in

many soldiers being shot. And while nearly

every Swiss has a gun in his home, the Swiss

almost never shoot each other. We

Americans seem to make a hobby of it.

I happen to be a gun owner, and have

enjoyed many hours of target pracce out in

the wild. I was taught to shoot by the

gentleman who at the me instructed the

Tucson SWAT team on rearms, and he

insisted that I memorize all of the gun laws

and pass a test before he would allow me to

handle a gun. On occasion, while out in the

wilderness target shoong with friends,

another group might show up at the site. If

they took any beer out of the back of their

vehicles, we packed up and took o; alcohol

and weapons should never be mixed.

On a transoceanic voyage many years ago, I

learned to shoot skeet. Upon returning to

school I purchased a trap to launch clay

pigeons (discs), and my frat brothers and I

used it for target pracce in the woods. I

liked shoong clay discs and watching them

explode in mid-air, but having seen the

damage done by weapons, however Im not

sure I could shoot another person, even in

self-defense.

Maybe its me that everybodynot justgun ownersgets rearm educaon, safety

instrucon, and perhaps a glimpse into the

reality of what guns can do to a person. As a

result of contracng TMHP syndrome (too

much horsepower) I was recently cketed

for exceeding the legal speed limit outside

the city. I went to trac school for four

hours, and aer seeing lms of the horrible

eects of trac accidents, I drove home at

25 miles an hour, terried that somebody

would go through a red light and smash me



to smithereens, as they showed me countless mes upon

the screen.

When we oldsters were in high school diver-ed, we were shown

prevenon-minded lmstrips depicng horric results of highway

crashes. They seemed oen to come from the Ohio State Police.

In the late 1950s the James Dean death car, a nearly demolished

Porsche Spyder, went on naonal tour as a warning about excess

speed. If memory serves, for a small fee a Dean fan could actually

sit in the thing. No one ever showed what happened to themagnec young star himself in 1955.

Maybe schools should show videos of real shoong vicms,

their emergency care, and subsequent surgical intervenons.

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I cringe when I read of accidental shoongs at a teenage

party, when some dummy pulls the clip out of a semiautomac

pistol, does not know to check the chamber for a live round,

then accidentally shoots his friend, The rst thing you

learn when you shoot is there is no such thing as an unloaded

gun.

There are said to be 300 million guns in homes in America, so it is

not likely we will ever get rid of them. We just have to give people

ample reasons to stop shoong each other.

Sombrerocolumnist George J. Makol, M.D., a PCMS member

since 1980, pracces with Alvernon Allergy and Asthma,

2902 E. Grant Rd. n



CME

Local CME from Pima CountyMedical FoundaonPima County Medical Foundaon, a 501(C)3 nonprot organizaon

derived from and separate from PCMS, presents Connuing

Medical Educaon lectures from our members and others, onsecond Tuesday evenings monthly at PCMS headquarters. Dinner

is at 6:30 p.m. and the presentaon is at 7. Tentave 2015

schedule is:

Feb. 10: Hormonal Replacement Therapywith doctors Jonathan

Insel and Robert Kahler.

March 10: Breast Reconstrucon SurgeryImplants and

Complicaonswith doctors Swen Sandeen and Richard Hess.

April 14: Cancer of the LungNewer Treatments and Cancer

Screeningwith physicians from Radiology Ltd.

May 12:Healthcare Reform 2015What the Hell is

Happening??with several speakers coordinated by Dr. Timothy

C. Fagan. Foundaon Awards are presented at this me.

June 9: Heart-Healthy Dietwith cardiologists Dietmar Gann and

Charles Katzenberg.

Sept. 8: Vasectomy Reversals and Impotencewith Dr. Sheldon

Marks.

Oct. 13: Common GI Viral DiseasesDiagnosis, Mechanisms of

Acon, and Treatmentwith Claire Payne, Ph.D.

November 10: PharmacogenomicsHow Medicines Aect

Diering Demographics of Paentswith Dr. Timothy C. Fagan.

January 2015Jan. 9: The Associaon of American

Sombrero December 2014

Documents

Transcript of Sombrero December 2014