SOMBRERO

Pima County Medical Society

Home Medical Society of the 17th United States Surgeon General

APRIL 2014

ACAs flawed economics A successful Mix-at-Six Taos Pueblo artists visit Tucson

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SOMBRERO April 2014

SOMBRERO
Pima County Medical Society Ofcers
President Timothy Marshall, MD President-Elect Melissa Levine, MD Vice President Steve Cohen, MD Secretary-Treasurer Guruprasad Raju, MD Past-President Charles Katzenberg, MD

Official Publication of the Pima County Medical Society Members at Large

Donald Green, MD Veronica Pimienta, MD

Vol. 47 No. 4

PCMS Board of Directors

Eric Barrett, MD Diana Benenati, MD Neil Clements, MD Executive Director Bill Fearneyhough Phone: 795-7985 Fax: 323-9559 E-mail: billf 5199@gmail.com Advertising Phone: 795-7985 Fax: 323-9559 E-mail: dcarey5199@gmail.com

Michael Connolly, DO Michael Dean, MD Howard Eisenberg, MD Afshin Emami, MD Randall Fehr, MD Alton Hallum, MD Evan Kligman, MD Kevin 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) Editor Stuart Faxon Phone: 883-0408 E-mail: tjjackal@comcast.net Please do not submit PDFs as editorial copy. Art Director Alene Randklev, Commercial Printers, Inc. Phone: 623-4775 Fax: 622-8321 E-mail: alene@cptucson.com

At Large ArMA Board

R. Screven Farmer, MD

Pima Directors to ArMA

Timothy C. Fagan, MD Charles Katzenberg, MD

Board of Mediation
Timothy Fagan, MD Thomas Griffin, MD George Makol, MD Mark Mecikalski, MD Edward Schwager, MD

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

Arizona Medical Association Ofcers

Thomas Rothe, MD president Michael F. Hamant, MD secretary Printing Commercial Printers, Inc. Phone: 623-4775 E-mail: andy@cptucson.com Publisher Pima County Medical Society 5199 E. Farness Dr., Tucson, AZ 85712 Phone: (520) 795-7985 Fax: (520) 323-9559 Website: pimamedicalsociety.org
SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Ofcers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright 2014, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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Inside
6 PCMS News: You can write a PCMS position paper. 11 Valley Fever: Dr. John N. Galgiani has a cocci
update locally and nationally.

14 Behind the Lens: Dr. Hal Tretbar visits with Taos

Pueblo artists in town for the Southwest Indian Arts Fair at the Arizona State Museum.

17 In Memoriam: Dr. Diane Bracht, 59. 18 Makols Call: Dr. George Makol finds more than a
little irony in the Lefts economic portrait of the Right. a regulatory perfect storm for medical practices.

20 Practice Management: Sandy Goodsite forecasts 22 Mix-at-Six: The inaugural PCMS social at

President Timothy Marshalls home was very successful. Dr. Jason Fodeman on the ACAs flawed economics. On the Cover
Looks like August 2013 had true dog days at New Mexicos Taos Pueblo, whose five-story building has stood for a millennium. See this months Behind the Lens for the work of Taos artists who visited Tucson recently (Dr. Hal Tretbar photo).

23 Perspective: Whos providing this care, anyway? 25 CME: TOMFs 23rd Southwestern Conference on
Medicine is here this month; AAPS says you can regain control of your practice.

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PCMS News

PCMS to write position papers

Ever have a strong opinion about a health-related issue confronting the medical profession, and wish the Society would take a stand? The Society, as part of its general policy to encourage members to speak out about issues, has established a procedure you can use in asking the PCMS Board of Directors to take a position on a subject of importance to the community or the profession. State your views and forward them to Bill Fearneyhough by writing to him at the Society, 5199 E. Farness Drive, Tucson 85712, or e-mail billf5199@gmail.com. PCMS President Timothy Marshall will take the issue to the board for discussion. If approved for further study, physician leaders will be assigned to do background research and prepare a position paper for board approval. When the paper is in final form, it will be published in Sombrero, presented to our national and Southern Arizona legislative delegation and, if appropriate, presented in resolution form at the annual meeting of the Arizona Medical Association. Media will also receive a copy. Take this opportunity to speak out!

Sept. 9: Dermal fillers and Fat Stem Cells in Plastic Surgery presented by plastic surgeon Dr. John Pierce. Oct. 14: New Medical and Surgical Treatments for Prostate Cancer presented by Rick Ahmano, M.D. Nov. 11: Newer Anticoagulants and Their Role in A-Fib, DVT, and Pulmonary Embolism presented by Timothy Fagan, M.D.

MRCSA building awareness, cooperation

By Tim Siemsen Executive Director Medical Reserve Corps of Southern Arizona
Just like you, the Medical Reserve Corps has a strong interest in improving the lives of others. By making a strong and positive impact in local communities, MRC volunteers engage in strengthening public health, emergency response, and community resiliency. Through collaboration with local public health departments, emergency management, fire departments and law enforcement, community organizations, and other volunteer programs, MRC is building awareness for public health initiatives, such as disease prevention and health literacy, as well as better preparing for, responding to, and recovering from emergencies. Through these partnerships that support health and safety, our communities are more likely to respond well to emergencies and rebuild more quickly.

Wine Country in the Desert May 3

Pima County Medical Society Alliance invites you to Wine Country in the Desert, Saturday May 3, 6-9 p.m. at St. Phillips Plaza courtyard, 4280 N. Campbell Ave. Please join us for wine-tasting and tapasSpains finger food as we raise money for Mobile Meals of Tucson and honor hardworking PCMSA members. Tickets are $75. For information about tickets or sponsorships, call 820.1622, e-mail Anatasha Lynn at msdesertprincess@gmail. com, or visit itrulycare.com/events/wine-country-in-the-desert .

Medical Reserve CorpsPartner With a Purpose The mission of Medical Reserve Corps of Southern Arizona is to improve the health and safety of communities across Pima County and Southern Arizona by organizing and using medical, public health, and non-medical volunteers. MRCSA provides its partners with opportunities for resource sharing, training, volunteers, medical and public health expertise, cross-promotion of initiatives, and so much more. MRCSA volunteers are physicians, nurses, pharmacists, mental health professionals, epidemiologists, and administrative and logistical support personnel who have served in shelters, immunization clinics, call centers, public health preparedness planning, and community health education. To become involved, contact MRCSA at 520.445.7035, or e-mail mrcsa@outlook.com. Together, we can use our collective expertise to create a healthier, better prepared, and more resilient community.

PCMF CME dinnermeets

Pima County Medical Foundation has scheduled these CME events for its Tuesday Evening Speaker series. Dinner is served at 6:30 p.m. and the presentation is at 7. April 8: Alzheimers and Other Degenerative Brain Diseases presented by Geoffrey Ahern, M.D. Also at this meeting, Timothy Fagan, M.D., Hector L. Garcia, M.D., and Jane Orient, M.D. will receive the Foundation Award for Lifetime Achievement in the Furtherance of Medical Education.

May 13: Healthcare Update 2014 presented by Timothy Fagan, M.D. Other likely speakers are Marc Leib, M.D. and Bill Mangold, M.D. June 10: Rheumatoid Arthritis presented by Michael Maricic, M.D.
6

Dr. Isersons way to travel

Galen Press, Ltd. recently announced publication of Dr. Ken Isersons latest book, The Global Healthcare Volunteers Handbook: What You Need to Know Before You Go, aimed at healthcare professionals interested in getting started in global
SOMBRERO April 2014

The 23rd Annual

Southwestern Conference on Medicine

April 24 - 27, 2014 | JW Marriott Starr Pass Resort & Spa | Tucson, Arizona

This activity has been approved for 30 AMA PRA Category 1 Credits, 30 AOA Category 1A Credits and 30 AAPA Category 1 CME Credits. 2 Additional AOA Category 1A Credits May Be Earned by DOs Completing the Outcomes Assessment After the Conference.
Presented by Tucson Osteopathic Medical Foundation in Joint Sponsorship with Cleveland Clinic

Register online at www.tomf.org/cme

SOMBRERO April 2014 7

health volunteering (ISBN-13: 978-883620-38-7, softcover, 340pp, annotated bibliography, glossary, index. Available from Galen for $28.95+shipping, 520.577.8363; www.galenpress.com; sales@galenpress.com) . Kenneth V. Iserson, M.D., MBA, FACEP, FAAEM, is a Fellow of the International Federation for Emergency Medicine, and professor emeritus in the UofA Department of Emergency Medicine. Dr. Iserson now limits his practice to global and disaster medicine. He has practiced or taught medicine on all seven continents. He is the author of 12 prior books including one in its eighth edition, and hundreds of scientific articles. Available since March 1, the book provides nuts-and-bolts information for physicians, dentists, advance-practice nurses, and other healthcare professionals about the professional and personal challenges they may face when practicing internationally, including how to find compatible organizations (the book contains an extensive list and description of organizations and their desired healthcare personnel); licensing and credentialing; travel documents; money and customs regulations; food, housing, showers and toilets; personal health issues; communicating from abroad; security concerns; packing; using interpreters; dealing with culture shock; and dealing with reverse culture shock upon returning home. Dr. Iserson has done it again! said Scott Weiner, M.D., chairman of the Global Emergency Medicine Academy of the Society of Academic Emergency Medicine. Even veteran travelers will learn pearls from Dr. Iserson, probably the only physician in the world ever to work on all seven continents! I highly recommend this book.

Kate Fincham, director of program support for Health Volunteers Overseas, called the book a comprehensive survey of all aspects in planning for a successful volunteer placement. The handbook stresses the need to understand ones motives for volunteering, as well as raising awareness that re-entry back home can bring its own challenges.

AMB selects new exec direc

The Arizona Medical Board recently announced its hiring of a new executive director, C. Lloyd Vest, II. Mr. Vest currently serves as the general counsel for the Kentucky Board of Medical Licensure, they said. His first day with the Board will be March 17, 2014. Both the Board and Mr. Vest are looking forward to him joining and helping to lead the Board. We plan to invite Vest to a PCMS Board of Directors meeting in the near future. We will relay more information about that, and him, when we have it.

New owner, name for Palo Verve Mental Health

Tucson Medical Center reports that Universal Health Servicesof Tucson, LLC has officially acquired Palo Verde Mental Health from TMC.It will be re-named Palo Verde Behavioral Health (PVBH).Ownership change was effective March 1. Under UHS, Palo Verde Behavioral Health (PVBH) will become a free-standing, for- profit, private psychiatric facility providing

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inpatient and intensive outpatient psychiatric services.PVBH will continue providing behavioral health services to Southern Arizona in adult psychiatric intensive care, adult general psychiatric treatment, adult inpatient detox, and intensive outpatient treatment. Universal Health Services is one of the nations largest hospital companies, operating more than 196 behavioral health facilities in 37 states, including two in Arizona. The company brings extensive behavioral health experience and best practices to this community, and is expected to provide significant organic growth for Pima County patients in terms of expanded treatment services and their body of clinical expertise. Notably, UHS will be looking to expand child and adolescent behavioral health servicesan area of great need in Southern Arizona. PVBH, along witha strong partnership with Tucson Medical Center, will build on the excellent skills of current psychiatrists, licensed registered nurses, clinical social workers, and licensed professional counselors to support the newprograms. For more information on PVBH services, please callthe helpline at 520.324.1282, or fax 520.324.4841.

physician referral and feedback model. Input from pilot sites will help evolve the model, so that it aligns with practices workflow. Once the pilot phase is complete, AMA will work with state and local medical societies to expand to more physician practices and communities, creating more clinical-community linkages. AMA described the YMCAs Diabetes Prevention Program as a one-year, community-based program led by a trained lifestyle coach. Participants gather in a relaxed classroom setting and work together in small groups for 16 weekly sessions, then eight monthly sessions to incorporate healthier eating and moderate physical activity into their daily lives.

TMC: Structural Heart Program gives care options

Tucson Medical Center reports that it has has launched a Structural Heart Program that expands cardiovascular services, making TMC a one-stop institution for all types of cardiac treatments. It provides a full range of care for things like congenital heart defects, valve problems, or cardiomyopathy, which includes problems with the heart muscle. TMCs Structural Heart and Valve Team consists of physicians from multiple heart and vascular specialties from around Tucson, and is led by Medical Director Dr. William Thomas.We are thrilled to have a full Structural Heart Program, Dr. Thomas said. TMC is providing cutting-edge cardiovascular care to patients in need. By working together, these physicians can provide the best possible outcomes for patients with structural heart diseases and conditions. As part of the program, TMC has become one of 250 sites in the country to offer the transcatheter aortic valve replacement, or TAVR. TAVR is for patients who have been diagnosed with aortic stenosis, a narrowing of the aortic-valve opening that restricts normal blood flow and which can progress quickly and cant be treated medically.It can cause heart failure and shortness of breath. Unfortunately it is a common public health problem affecting millions of people in the U.S., the TMC report said. An estimated seven percent of the population over age 65 has it.Its more likely to affect men than women, as an estimated 80 percent of adults with symptomatic aortic stenosis are men. Patients can undergo surgery to have their valve replaced, but those who are too sick to qualify for the operation had no other options before TAVR was created. The procedure places catheters in a patients groin instead of going through their chest. The difference between providing this service, and not providing this service, is the difference between life and death,Dr. Thomas said. Replacing the valve usually takes three to four hours, and requires a stay of three or four days in the hospital. TMC noted that most of these patients feel immediate relief, and that many TAVR patients also complete outpatient cardiac rehab. Dr. Thomas described the outcome of TAVR as a great step forward in the treatment of aortic stenosis.Not only are these patients alive, but their ability to function in everyday life improves within weeks, sometimes even days to hours after the procedure. It really is remarkable. n

YMCA, AMA seek prediabetes referrals

Thanks to its prevalence and treatability, prediabetes is a new buzzword in preventive medicine. We recently received an AMA news release about a related local program. Given that 79 million Americans have prediabetes, it is likely that you have patients with this common, but treatable, condition, they said. To help these patients, and to improve outcomes for your practice, physicians can refer people who have prediabetes to the Diabetes Prevention Program (DPP) at the TMCA of Southern Arizona. The evidence-based DPP can have a positive impact on patients, providers, and communities such as ours that are seeking to reduce the incidence of Type 2 diabetes. At YMCASA, a grant covers the cost for people over age 65 with prediabetes to attend a DPP at the YMCA. Adults under 65 who have prediabetes can participate by paying out-of-pocket or by being in a health plan that covers participation. YMCA of the USA is participating in a Center for Medicare & Medicaid Innovation (CMMI) award that pays for at-risk people over age 65 to attend the diabetes prevention program in 17 communities across the country including Tucson and Phoenix. The YMCAs Diabetes Prevention Program is based on the CDCs National Diabetes Prevention Program. AMA has partnered with the YMCA of the USA on the CMMI award project. The two organizations are collaborating to increase the number of Medicare participants in the YMCAs Diabetes Prevention Program. While physician practices can already refer patients with prediabetes to the YMCAs DPP, the AMA wants to help create a referral process and feedback loop that works well across different types of practices. AMA has chosen three pilot locations: Delaware, and the cities of Indianapolis and Minneapolis/St. Paul. In each community AMA is engaging physician practices to test an AMA DPP
SOMBRERO April 2014

THE PCMS A LLIANCE

Cordially Invites You To Join Them For:

Please join us for wine tasting and tapas as we raise money for Mobile Meals of Tucson and honor the hardworking PCMSA members.

Wine Country In The Desert

Tickets are $75. Sponsorships available.

6:00-9:00 p.m. Saturday, May 3 St. Philip's Plaza (Courtyard)

4280 N. Campbell Ave.
For Information / Tickets / Sponsorships: https://itrulycare.com/events/wine-country-in-the-desert Contact: Anastasha Lynn Email: msdesertprincess@gmail.com or Phone: 520-820-1622
10 SOMBRERO April 2014

Valley Fever

Cocci gets some national props, but how about here?

By Dr. John N. Galgiani
Arizona has not always been the coccidioidomycosis epicenter, as it is today. A century ago, coccidioidal granuloma, as it was first named [1], was thought to be a rare, nearly always fatal infection. In the 1930s, as a result of the collaboration between a Stanford professor and the public health physician for Californias Kern County, the connection was made between these few devastating infections and a cryptic, common, and self-limited illness, San Joaquin Valley Fever. These historical roots in Kern and its major city, Bakersfield, carry forward to today, as evidenced by that communitys very strong support of Valley Fever research to produce a preventive vaccine. For example, Kevin McCarthy, while Bakersfields representative to the California Legislature, insisted on vaccine research funds to support the Valley Fever Vaccine Project. Now, in the U.S. Congress, McCarthy has formed a Congressional Valley Fever Task Force. Eventually, Arizona was discovered to also be endemic for the causative fungus, Coccidioides spp [2]. In fact, the first ever symposium on coccidioidomycosis, sponsored by the Centers for Diseases Control, was held in Phoenix in 1956. However, most of the research and medical publications addressing this problem originated from clinicians and scientists in California. The difference between the first half of last century and the situation now is that demographics have reshuffled the deck. In the 1950s and before, both the California Central Valley and the south and central portions of Arizona were essentially vast rural expanses. Table 1 shows how that has changed. The enormous population growth in the Arizona Sonoran deserts, particularly within Maricopa, Pinal and Pima counties, has no parallel in the most intensely endemic counties of California. Arizona population growth has largely involved migration of people from parts of the country that are not endemic for Coccidioides spp. This has dramatically increased the number of susceptible persons exposed to spores and the consequent number of infections. In addition, a large proportion of newcomers are seniors, attracted to Arizona as a place to retire. Since seniors are several times more likely to be diagnosed with cocci (3), this trend further increases the number of new infections reported to the state. As metropolitan communities, Phoenix and Tucson have expanded their medical programs, increasingly caring for patients with compromised immune systems. Compromised cellular immunity is the greatest risk factor for serious coccidioidal complications.
SOMBRERO April 2014

Because of these continuing trends, Arizona has emerged as the nations leader in reported cocci cases. Approximately 20,000 VF cases were reported to the CDC in 2011, and more than 16,000 of them were from Arizona. In total, two-thirds of all cases in the U.S. originate in Arizona, and 80 percent of Arizona infections come from Maricopa County [4]. Cocci is so common here that it is responsible for at least a quarter of all community-acquired pneumonias diagnosed in ambulatory patients [5,6].
Table 1. Populations (in millions of persons) of selected counties within regions highly endemic for coccidioidomycosis.

Year County (City) 1950 1970 1990 2010

Arizona selected counties 0.9 1.5 2.9 5.2 Maricopa (Phoenix) 0.33 1.0 2.1 3.8 Pima (Tucson) 0.14 0.4 0.7 1.0 Pinal 0.43 0.1 0.1 0.4 California selected counties 0.3 0.6 1.0 1.5 San Louis Obispo 0.05 0.1 0.2 0.3 Kern (Bakersfield) 0.23 0.3 0.5 0.8

Totals

1.2

2.1

3.9

6.7

Source: US Bureau of the Census

Like it or not, the communities along the 150 miles of Interstate 10 from Tucson to Phoenix have become the Valley Fever Corridor, and this comes with a price. How large the cost was made clear by an Arizona Department of Health Services publication, reporting the findings from a questionnaire survey of newly diagnosed patients with Valley Fever in 2007 [7]. Some of the highlights from this report are: Illness lasted an average of six months. Seventy-five percent of employed persons stopped working, with half of them missing two or more weeks work. Forty percent were hospitalized. Hospital costs alone in 2007 amounted to $86 million. More recent data from 2012 shows this number to exceed $100 million. Considering additional outpatient care costs and lost productivity, the economic impact of Valley Fever on Arizona is easily $0.25 billion annually. A recent publication from California estimated that VF hospital costs for a 12-year period totaled $2 billion, a similar but even higher total for that state as well [8]. The medical community of Arizona in general has been slow to realize how large a public health problem Valley Fever has become. Coccidioidomycosis causes many persons to become ill, and patients with cocci likely constitute a significant proportion of most general practices or urgent care clinics within the Valley
11

Fever Corridor counties. Even so, clinicians throughout Arizona are surprisingly slow to consider this diagnosis, much less try to rule it in with the needed specific diagnostic tests. In another ADHS survey, Arizona clinicians were asked about their knowledge, attitudes, and practice with respect to Valley Fever [9]. Only 12 percent of respondents reported that they had learned medicine in Arizona schools, and 47 percent had no clinical training in Arizona prior to starting practice here. Moreover, 40 percent lacked confidence in diagnosing a coccidioidal infection. In another study of two physician group practices, only two percent and 13 percent of patients with community-acquired pneumonia were actually evaluated for the possibility that it could be caused by Coccidioides [10]. It is time for the medical community throughout Arizona to raise its standard of care. To help catalyze this effort, the Maricopa County Medical Society last month initiated its Honor Roll Program and has chosen Valley Fever along with viral hepatitis, both HBV and HCV, as the leading diseases to address. This program was also highlighted in last years Valley Fever Awareness Week, Nov. 10-19. The Honor Roll program is available to any clinician anywhere in Arizona, whether or not they are members of the Maricopa County Medical Society. Details about the program can be found at http://www.mcmsonline.com . This timing could not be better. Across the U.S. and even internationally there is increased attention to Valley Fever. Stories about its impact on persons in the southwest and the special problem for prisoners in California have been featured on CBS and BBC news reports. In January of this year The New Yorker published a long article entitled Death DustThe Valley Fever Menace. Last fall, a two-day symposium was given in Bakersfield featuring presentations by heads of both the CDC and the NIH. As a followup, Rep. David Schweikert (R-6-Ariz.), co-chair of the Congressional Valley Fever task force, had Town Hall meetings in Phoenix and Tucson. For all of these reasons, patients are more in tune with what VF is and why physicians are looking for it.

In 2012 the University of Arizona and the St. Josephs Hospital teamed up to open a Valley Fever Center in Phoenix. This new program is the latest initiative of the Valley Fever Center for Excellence, originally approved by the Arizona Board of Regents in 1996 to help the entire state deal with this disease. Since its inception the Valley Fever Center has been supporting the expansion of research at all three state universities and raising awareness both in the community and among health care professions. The Valley Fever Center in Phoenix provides a muchneeded resource for patients with VF who are seeking a referral or a second opinion about their infection. Just as importantly, the Valley Fever Center in Phoenix is planned to be the hub for an expanding network of clinicians, not just at St. Josephs but across Maricopa County and the rest of Arizona to manage VF patients. As the center becomes more established, it can also provide a platform not previously available for the testing of better diagnostics, new therapies, and eventually clinical trials of preventative vaccines, goals that are all actively being pursued by Arizonas scientists and clinicians. I hope all Arizona clinicians will join in this effort to make Arizona the place where patients with VF routinely and in all practice groups receive the best care for their infections. Much of this can be done by primary care physicians, following the algorithm shown in Figure 1. Training for managing the commonest forms of Valley Fever can be found at the Valley Fever for Excellences website www.vfce.arizona.edu in a general syllabus or in a free online CME course. Also, on Nov. 8 of this year there will be a CME program about Valley Fever especially for primary care clinicians, at Good Samaritan Medical Center in Phoenix. Details for this will be on the centers website as they become available. For patients who are at risk for or have complications of Valley Fever, the Valley Fever Center in Phoenix is now a ready resource to assist all physicians with their patients problems, either at St Josephs or by connecting the patient to a member of the Valley Fever Alliance of Arizona Clinicians, a state-wide organization established for this purpose.

12

SOMBRERO April 2014

Care and knowledgeable management of patients with coccidioidomycosis is both a highly rewarding challenge for clinicians, and often results in very good results for patients. Lets all become familiar with how to do this, incorporate it into our practices, and encourage other clinicians to do the same. Dr. Galgiani directs the Valley Fever Center for Excellence, University of Arizona College of Medicine, Tucson and Phoenix. REFERENCES Hirschmann JV. The early history of coccidioidomycosis: 18921945. Clin Infect Dis 2007;44(9):1202-7. Farness OJ, Mills CW. Coccidioides infection: A case of primary infection in the lung with cavity formation and healing. Am Rev Tuberc 1939;39:266-73. Hector RF, Rutherford GW, Tsang CA, Erhart LM, McCotter O, Komatsu K, et al. Public health impact of coccidioidomycosis in California and Arizona. International Journal of Environmental Research and Public Health. 2011;8(4):1150-73. CDC. Increase in reported coccidioidomycosis - United States, 1998-2011. MMWR Morb Mortal Wkly Rep 2013;62:217-21. Valdivia L, Nix D, Wright M, Lindberg E, Fagan T, Lieberman D, et al. Coccidioidomycosis as a common cause of communityacquired pneumonia. Emerg Infect Dis 2006;12(6):958-62. Kim MM, Blair JE, Carey EJ, Wu Q, Smilack JD. Coccidioidal pneumonia, Phoenix, Ariz. USA, 2000-2004. Emerg Infect Dis 2009;15(3):397-401.

Center for Neurosciences Welcomes

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As a native Arizonan who was born and raised in Nogales, Dr. Rivero looks forward to serving our Southern Arizona community. He is uent in Spanish.

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WELCOME

MATTHEW J. WELCH, M.D.

February 2014
Board certified and fellowship trained, Matthew J. Welch, M.D. joins Retina Specialists of Southern Arizona in early February. Dr. Welch, originally from Minnesota, did his undergraduate training at the University of Arizona. He went to Illinois to complete his medical education and residency where he was appointed Chief Resident in Ophthalmology. Fellowship trained in Phoenix at Associated Retina Consultants, Dr. Welch specializes in treatment of diseases of the retina and vitreous, adult and pediatric, with compassion and skill. Dr. Welch is fluent is Spanish and is accepting appointments now!

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SOMBRERO April 2014

13

Behind the Lens

Native American art drops in on Tucson

By Hal Tretbar, M.D.
I first met the Taos Pueblo artists, drum maker Frank Mirabal and his niece, potter Pam Lujan-Hauer, at the 2014 Southwest Indian Arts Fair at the Arizona State Museum Feb. 22 and 23. The annual fair draws the best of Native American arts from all over the Southwest. Dorothy and I were poking around the Taos Pueblo last year, and we didnt see any change from our first visit, in 1957not surprising, since its probably been there for more than 1,000 years. It is the northernmost of the eight pueblos near the Rio Grande in Northern New Mexico. When Francisco Vasquez de Coronados expedition reached there in 1540, the pueblo was described as having adobe houses built very close together and stacked five or six stories high. The homes became narrower as they rose, with each level providing floors and terraces for those above. It looks the same today. The Rio Pueblo, also called Red Willow Creek, starts in the foothills of the nearby Taos Mountains. It flows through the middle of the compound, dividing the pueblo into north and south sets of adobe buildings. Originally there were few windows and no doors. The rooms were entered through square holes in the roof reached by climbing long wooden ladders, which could be withdrawn in case of attack. Doors and scattered windows now allow better access. A wall still surrounds the pueblo, and electricity, running water and indoor plumbing are prohibited. Quite a few families live elsewhere, but visit their two-room homes often. Many of the 100 permanent residents are artists, and a gallery is open to the public. One of the galleries Dorothy and I looked into featured drums made by Frank Mirabal and his nephew Bobby Bales. Frank is famous for the superior quality of his drums. They are in demand by most Native American dance groups performing that use drums in performance. When Bobby told me they have attended the Southwest Indian Arts Fair for many years, I told him we would look them up.
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We had to push our way through the crowds attending the recent fair to reach Bobbys booth. He was pleased to see us and spent time talking about his paintings as well as showing us his newest drum. The four-foot-long cottonwood drum had an open knothole in the side that gave it a distinctive sound. Several booths over, under the big tent, I met Frank Mirabal with his display. He is a softspoken artist from a family of drum makers. A Marine who served three tours in Viet-Nam, he has followed in the footsteps of his grandfather and father. In an excerpt from an Internet interview, he describes the tedious hours of hard work in making a drum: Tree trunks of aspen and cottonwood that are dead and down are gathered, blocked off, and allowed to dry for several months or years, depending on the size of the log. Hides of deer, elk, buffalo, or cow are dried, dehaired, and soaked. Hides are then cut, stretched over the hollowed-out log, and tied. The hides must be pulled very tight to secure the drums durability and ensure the best sound The pitch of the drum depends on the diameter and depth of the drum, the strength of the ties, the type of the wood, and dryness of the wood. Mirabal has won many awards around country and has been included in a Smithsonian exhibit. In 2011 our Southwestern Indian Arts Fair recognized his craftsmanship with the Award of Excellence in Traditional Tribal Arts. I use either cottonwood or ash because they dont split, Frank told me. Im a hunter, so I like to use my own elk hides. I always twist the tiedown thongs for a better hold. Later he said, One of my biggest drums was from a 100-year- old cottonwood about 10 feet in diameter. I sold it in Sedona for $3,000. Franks niece Pam Lujan-Hauer had her pottery on display at a booth near the entrance. As a member of Taos Pueblo she started making pottery as a child. She was inspired by two greataunts who were traditional potters. She attended college at the Institute of American Indian Arts in Albuquerque, N.M.

Bobby Bales shows his drums in Frank Mirabals gallery in Taos Pueblo.

SOMBRERO April 2014

Well-known Taos drum maker Frank Mirabal mans his booth at the Southwest Indian Arts Fair.

Pam digs and processes her own clay. She mainly uses kaolin and micaceous clay containing bits of sparkly micanative to Northern New Mexico. She told me her car has a mind of its own and pulls over when it goes past a clay deposit! She uses the coil method of potting and fires them in pits or kilns with burning cedar. For several years Pam made microchips at Sandia Labs at Albuquerque. During a process to burn off unwanted rare metals on the chips surfaces, she noticed the colors that formed. After extensive trial and error, she perfected a method of firing silver inlay in the clay. When fired in an oven with precise temperature control, minerals that are present combine with the heated silver to create a rainbow of colors. Pam Lujan-Hauers award-winning work is available in galleries in Taos, Santa Fe, Albuquerque, and the Indian Craft Shop at the Department of the Interior in Washington, D.C. In Arizona her pots can be purchased at the Heard Museum in Phoenix, and in Tucson at Bahti Indian Arts. Taos Pueblo artists Bobby Bales, Frank Mirabal, and Pam Lujan-Hauer have all commented about what an outstanding event the Southwest Indian Arts Fair is, and all plan to return next year. n
SOMBRERO April 2014

Pam Lujan-Hauer displays some of her award-wining pots at the Indian Arts Fair. She likes to use sparkly micaceous clay found in Northern New Mexico.

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SOMBRERO April 2014

In Memoriam
By Stuart Faxon

Dr. Diane Bracht 1954-2014

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Diane L. Bracht, M.D., occupational and emergency medicine physician who joined PCMS in 1997, died Feb. 28 in hospice in Tucson. She was 59. Sidelined by illness, she had been an Associate Member since 1999. Diane Louise Bracht was born Dec. 8, 1964 in Dhahran, Saudi Arabia. The family reported in the Arizona Daily Star that she graduated in 1972 from Salpointe Catholic High School in Tucson, and earned her undergraduate degree in 1975 at The University of Arizona. She graduated from The University of Arizona College of Medicine in 1978, and interned at Maricopa County General Hospital. She was board-certified in emergency medicine and practiced it at Phoenix General and Doctors Hospital in Phoenix, Carson-Tahoe Hospital in Carson City, Nev., and Barton Memorial Hospital in South Lake Tahoe, Calif. She practiced occupational medicine and primary care with Readicare, Inc. in Stateline, Nev., did general practice at Tahoe Womens Care in South Lake Tahoe, and urgent care and occupational medicine at Thomas-Davis Medical Centers in Tucson. Dr. Brachts former husband is PCMS member Dr. Robert Patton of Cholla Pediatrics. Her children Michael and Allison Patton, and her mother, sister Mary, and brother Michael survive her. A memorial service was given March 8 at Adair Funeral Homes Avalon Chapel. The family requests that memorial donations be made to NORDthe National Organization for Rare Disorders (rarediseases.org) n
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Makols Call

Perchance to dream
By Dr. George J. Makol
My maternal grandmother lived into her 90s, after immigrating to the United States in the late 1890s. I used to take long drives with her through the Connecticut countryside, as she reminisced about events she had experienced in her long lifetime. She told me about the first electric lights coming to her home and street, seeing the first mass-produced automobiles traverse the then dirt roads in her small community, and hearing voices emanating from the radio in her own living room. My mother is now in her 90s, and one of the things she says most often is that she would like to fall asleep and come back 100 years in the future for just one day to see the wonders that she can only imagine now. Perhaps medicine will have conquered most disease, people will live in excess of 100 years in good health, world peace will have been achieved, politicians will be honest well, at least a couple of those are more likely. I, however, have no such grandiose thoughts. I cannot imagine what could occur more than 100 years in the future. But how about just six years? Lets say you fell asleep before the presidential election in 2008, and awoke just six years later in 2014. And just for fun, let us say you would be presented with only the headline-stories from the past six years, with all names and political parties excluded. The challenge would be to correctly ascertain which candidate won the presidential election, and which party controlled Congress, just by analyzing the headlines: Headline No. 1, The Wall Street Journal, Jan. 2014: One in three people experienced poverty for at least two months between 2009 and 2011. Further reading shows U.S. census data shows the poverty rate climbed from between 11 and 12 percent in 2007, to 15 percent today, an increase of about 25 percent. Thats an easy one: the investment banker rich guy must have bested the community organizer, the only way such a travesty could occur. Headline No. 2, The Wall Street Journal, Feb. 2014: The story headlined The truth about the one percent reveals that the richest one percent of taxpayers now take in 15 percent of national household income (now at 21.3 percent according to updated census data), even though they add up to only one million persons out of more than 300 million Americans. Again, this is easy, because only the investment banker would favor the rich to such a degree, so he must have won the election! Headline No. 3, from the Bureau of Labor Statistics, March 2014: Black unemployment rate 12 percent. This is double the recent white unemployment rate, with black teens showing an unemployment rate of 32 percent. This is getting too easy! The rich white guy must have won, and thus we have this predicable awful outcome. Lets call Headline No. 4 a compilation of various 2013 sources: Congress passed a bill in 2010 purported to afford health insurance coverage to all Americans. However, the standard policy now covers every health eventuality, no matter how unlikely to occur, sharply driving up insurance premiums for more than five million Americans, or leaving them uninsured. Insurance companies will enjoy record profits, as policies only sold previously to less than two percent of the population will now be the standard. Further, the President authorized insurance tranches that guarantee insurance company profits, leaving the taxpayer to foot the bill if they do not enjoy a windfall. Boy, only a corporate raider or a Wall Street guy would let this happen; this could not occur under a Harvard-educated crusader for the middle class. Headline No. 5, The Wall Street Journal January 2014: Surprises from 25 years covering the economy. This story notes that the typical middle class man who worked full-time made less than his cohort made in 1987 when adjusted for inflation ($49,398 vs. $50,166). And annual family income has dropped almost $5,000 from 2008 to 2014. Talk about a slam-dunk. Only a President who did not care about the middle class, like some rich investment banker, would oversee such an economy. The Grand Old Party must have controlled both chambers under such a President, for what else could account for this? Well, we only have three more years of this kind of leadership, and then perhaps some history or law professor can become President, and due to his friendly nature there will be world peace. Furthermore, everyone will make the same pay, live in the same kind of houses, and be safe from those Wall Street types who I guess ran the country while I was asleep. I can dream, cant I? Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been a PCMS member since 1980. n

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Pracce Management

A perfect storm for medical practices

By Sandy Goodsite
Looking at the year ahead, all signs point to a perfect storm for private medical practices, with all the worst elements coming together for the attack. Medical Economics magazine published a survey to gauge physician attitudes about EHRs and benchmark data gathered during a separate and novel two-year EHR Best Practices Study of 29 U.S. physicians in independent practices (nearly all were in solo practice.) Coaxed into purchases of EHRs with promises of Meaningful Use money, and threatened with penalties for non-compliance, practices have been faced with an onslaught of salespeople for software companies who in many cases have no intention of progressing through the government required certification upgrades. Rather, they take the money and run, leaving practice staffs to cope with incomplete manuals, little or no tech support, and no live trainers beyond a fast immersion period when the practice goes live. According to Medical Economics, Nearly two-thirds of doctors would not purchase their current EHR system again due to poor functionality and high costs. One of the major certifying companies, CCHIT, left the industry suddenly on Jan. 29, saying that the future of federal health IT program requirements remains uncertain. The survey also found that a large percentage of responders said that they need more staff to handle their EHR software, and that the practice now sees fewer patients per day. This drives up the cost per day to run the practice, while the income per day goes down. The second major storm factor is the Affordable Care Acts demolition of the existing insurance company healthcare contract system as we have known it. Companies like mine, with employee coverage that has been more than adequate for 15 years, are suddenly notified that the coverage does not meet the standards of the Affordable Care Act and will therefore be cancelled at the end of the policy period. Offices have to be sure that their staffs are constantly checking eligibility, photo IDs, and scanning/copying all insurance cards for new information, because millions of patients have been notified of cancellation, and the only question is as of what date? Third on the storm list is the April date for support termination of the Microsoft XP operating system, which has been a great platform for many practices. Add to that the fourth storm surge implementation on Oct. 1 of ICD-10 requirementand every office is bound to have learning curves. Making it more treacherous is that many major insurance carriers have stated that they will not be able to accept ICD-10 claims by the Oct. 1 date, and therefore practices will have to simultaneously use ICD-9 and ICD-10 for claims for some time. This is difficult and time consuming, and requires special billing software. An additional staffing need pops up if you have had to assign staff to confirm eligibility and payment rules for a patient. An average of 15-30 minutes or more on the phone are what your staffer can look forward to, because even though there may be an online eligibility window, it does not give information specific enough to trust that a procedure billing at $400 or more will actually be paid. One of the major carriers in Arizona today told my staffer that the average wait time on hold for a customer rep is two hours! If you have EHR and your billing is going to India, and is being stored on a cloud in some foreign warehouse, you might consider what HIPAA liability you are risking. Watching what has happened with the Target stores data breach, it should be clear to medical practices that they are very vulnerable to loss of medical data and patients confidential demographics once their records leave the relative protection of the practices four walls. How might you plan to deal with some of these issues? Establish a line of credit now with your bank or get a new bank, because if the insurance carriers dont pay in a timely manner, you may need supporting cash flow.
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 If you have an EHR, insist on knowing in writing what their plan is for implementing Certifying Level performance annual advances, and for implementing ICD-10. What training will they be providing your staff in the use of the new coding system? Where is the cloud that stores your data? If you have not purchased an EHR system yet, be very cautious. Consult with the HSAG office in Phoenix to learn which companies are failing to progress to meet performance levels, and what the timeline is for obtaining Meaningful Use money in 2014. Dont be rushed! Dont count on the AMA to protect you and your practice; AMA now earns most of its money through selling and developing codes and all of the accompanying instruction books. After AMA paraded for the media as supporters of the Affordable Care Act when no one knew what would really be involved in it, AMA membership dropped sharply. Finally, consider bringing your billing back to a local company, so that you know where your patient data is, while you are also supporting the Tucson economy. In press releases as recent as late February, AMA said it has lined up support for removing the Medicare Sustainable Growth Rate (SGR). Oh, but one question: How are the results of the repeal to be financed? This message comes now, as the April deadline for more cuts to what you are paid for your services to become mandatory unless the repeal actually is enacted. AMA has talked about this permanent repeal for many years. I hope Im wrong, but they have regularly agreed to a temporary fix. Sandy Goodsite is president of Professional Medical Management, Inc. She worked with former Arizona Rep. Gabby Giffords, and state Sen. Barbara Leff to bring legislation that defined timely payment in Arizona law, to protect medical practices from the thenleisurely pace of payment for services. She has served as president of the Arizona Medical Alliance and the Tucson Symphony, and as Southern Arizona Rotarys district governor in 2007-08. Her husband is pediatrician and former ArMA president Ron Goodsite, M.D. n
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Mix-at-Six

First Mix-at-Six successful

The first PCMS Mix-at-Six social, March 1 at the foothills home of PCMS President Timothy Marshall, M.D., was a resounding success. Dr. Marshall and his wife, Denise, welcomed more than 60 members and guests for an evening of informal conversation and relaxation. The event allowed physicians to socialize in a casual setting, without an agenda. Members mingled with colleagues and friends to discuss a variety of topics, and met new members or other physicians whom they have not had the chance to meet in the past. It was also a chance for non-member physicians to learn about the Society and the advantages of becoming a member. Dr. Marshall and Denise put together a wonderful evening, PCMS Executive Director Bill Fearneyhough said. I thank them for doing such a great job and for being outstanding hosts. By all accounts the event was a huge success. We received many compliments, and many guests thought Mixat-Six was a great idea. Future Mix-at-Six socials will be given throughout the year. Notifications about coming events will be in Sombrero, on the Society website pimamedicalsociety.org, and sent by e-mail. n

PCMS President Dr. Tim Marshall welcomed colleagues and new acquaintances to his lovely foothills home March 1 for the years first Mix-at-Six social (Dennis Carey photo).

Dr. Jane Orient and Dr. Dick Dale, foreground, get to know one of Dr. Marhalls two highly people-friendly Golden retrievers, but we didnt catch whether this is Nitro or his son Cypher (Dennis Carey photo).

A surprise but welcome guest at the Mix-at-Six March 1 was a double rainbow in the Catalina foothills visible from Dr. Tim Marshalls home. (Dennis Carey photo).

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SOMBRERO April 2014

Perspecve

Who will provide the care under the Affordable Care Act?
By Dr. Jason Fodeman
From the beginning, debate over the Patient Protection and Affordable Care Act (ACA) has focused on the economic and political ramifications of the legislation, while the laws clinical consequences cannot be underscored enough. With the ACAs flaws becoming daily more apparent, its time for a long-overdue discussion on the impact ACA will have on medical practice, doctors, and their patients. Its time, as former House Speaker Nancy Pelosi famously said before it was passed, for us to find out what is in it. ACA advocates have billed it as a solution to improve healthcare quality and lower costs, but it actually does neither. It does expand access to health insurance for some, but a better benchmark than than this would be actual access to healthcare. The impact of healthcare reform on these standards is uncertain at best. As interpreted by the U.S. Supreme Court, ACA gives states an option to expand eligibility for Medicaid to people with household incomes up to 138 percent of the Federal Poverty Level (FPL), with the federal government supporting 100 percent of expansion costs in 2014 through 2016. After that, the federal match will gradually decrease, reaching 90 percent by 2020. According to Heritage Foundation research, if every state proceeds with the expansion, 17 million new people would join the Medicaid program. Where will these 17 million new Medicaid patients find care? Its a legitimate question, and a crucial one that any state genuinely hoping to improve care for the most needy must answer before going down this path. As the disastrous start to ACAs website healthcare.gov has shown, the stakes are far too high just to wing it. Medicaid is beleaguered by bureaucracy, ballooning expenditures, poor access, and low-quality care. The current Medicaid statute leaves state policy-makers with little room to control costs other than by paying Medicaid providers less. According to a 2013 Kaiser Foundation report, provider rate restrictions were the most common cost containment strategy when 39 states lowered their reimbursements for Medicaid providers, and 46 states planned to do so the following year. These low Medicaid reimbursements are passed along to patients in the form of compromised care, and restricted access to care. A recent Health Affairs study attempted to better quantify physician attitudes toward new Medicaid patients and found that in 2011, some 31 percent of physicians would not accept new Medicaid patients. This was significantly higher than the 18 percent of physicians who would not accept new patients who had private insurance.
SOMBRERO April 2014

Multiple peer-reviewed studies have documented that Medicaid patients receive worse care than patients with private insurance. Other studies have suggested that Medicaid patients receive care even worse than that of patients who have no insurance. Placing more patients in the Medicaid program will not rectify these deeply rooted problems. Instead, ACAs Medicaid expansion will cause these problems to affect far more people. Thats because ACA and the Medicaid expansion are unlikely to significantly change provider sentiment toward Medicaid patients. As a result, the expansion will likely culminate in more Medicaid patients competing for a relatively fixed number of Medicaid providers. As demand for Medicaid services increases, it will produce longer wait times, disjointed care, poorer outcomes, and a greater reliance on expensive, overcrowded emergency departments for patients already in the Medicaid program, and those made newly eligible. As costs soarlikely by more than projectedthese pressures will only increase. In addition to expanding Medicaid, ACA also establishes health insurance exchanges in which consumer earning between 100 and 400 percent of the FPL may receive federal subsidies to buy health insurance. It remains to be seen what type of access and care the plans in the exchanges will offer. While the market for health insurance and healthcare services may be far from ideal, a 2012 Gallup survey still found that 82 percent of American rated their healthcare as good or excellent. Yes, that may soon change. With the federal government telling health plans in the exchanges whom they may cover, and how much they may charge, many of the same principles that currently plague the Medicaid system could sink these policies as well. In fact, there is a real possibility that these exchanges will foster a race to the bottom and that these private plans will essentially be transformed into Medicaid lite, with many of the same flaws and drawbacks that plague Medicaid. As government forces health plans in the exchanges to offer more services, and limits the ability of these plans to increase premiums, the business models for these companies to navigate and maintain solvency in this regulatory climate are limited. One strategy is to attract young, healthy patients and charge them more. However, as companies continue to raise premiums based on this demographic, many of the young and healthy insured are likely to leave the market and opt to pay the individual mandates penalty instead because it will be cheaper than the premiums. A more likely strategy is that these health insurance plans will only contract with a narrow network of doctors, hospitals, and
23

providers. This will restrict choice by preventing patients from seeing the primary care physician or specialist that they may want or need. For these patients, this will lead to limited access and compromised care. A September 2013 Los Angeles Times article documents that these concerns are already becoming reality in the California exchange. The article highlights HealthNet, Inc., which boasts the lowest rates in the California exchange, but also offers its customers the fewest doctorsfewer than half the number of providers offered by some of the other companies in Southern California. In Los Angeles County, consumers who purchase HealthNet plans through the state exchanges will have access to only 2,316 primary

care physicians and specialists. This is less than one third of the doctors available to patients with HealthNet employer plans. According to the Times story, it is not only HealthNet that is limiting access to exchange consumers in California. Blue Shield of California is limiting exchange patients to 50 percent of its doctor network, while Anthem Blue Cross is the only insurance plan in the California exchange to have a contract with UCLA Medical Center. The article warns that customers in the California exchange could see long wait times, a scarcity of specialists, and loss of a longtime doctor. As exchange patients are consolidated among fewer doctors, health plans will likely have more market power to drive reimbursements down. This will make providers even less willing to take these patients and, like those in Medicaid, these patients could encounter restricted access and lengthy wait times, forcing them to depend on emergency departments for care. A September 2013 Medical Group Management Association survey of more than 1,000 group practices found that the medical community shares these concerns. Of the practices surveyed, only 29.2 percent planned to accept exchange products, while 14.4 percent had already decided that they would not. The rest of the surveyed medical groups were evaluating the proposition and/or were undecided. Of those practices not planning to participate in the exchanges, 64 percent cited concerns about the administrative hassles, 61.9 percent cited concerns about collections, and 59 percent cited concerns about reimbursements. States, health networks, hospitals, and providers need the flexibility to lower costs and meet the unique health needs of their communities, especially for those patients who are the most medically needy and financially vulnerable. While it is certain that the ACA will change medical care for many patients, it is most uncertain at this point whether the impact of those changes will be for the better. PCMS member Jason D. Fodeman, M.D., is a frequent healthcare columnist for Daily Caller and other Web and print publications, and has done commentary for various cable TV news programs. Board-certified in IM, he earned his undergraduate degree in economic from The Johns Hopkins University, and his M.D. from Albert Einstein College of Medicine. He is a Graduate Health Policy Fellow of the Heritage Foundation. This piece first appeared in the Journal of the James Madison Institute. n
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CME

April
April 24-27: The Tucson Osteopathic Medical Foundation in joint sponsorship with Cleveland Clinic present the 23rd Southwestern Conference on Medicine at JW Marriott Starr Pass Resort and Spa, beginning 7:15 a.m. Thursday and running through 12:45 p.m. Sunday. Accreditation: 30 AMA PRA Category 1, 30 AOA Category 1A, and 30 AAPA Category 1. Conference is designed to bridge practice gaps between primary care providers current knowledge and practice performance and the ever-evolving standards of modern medical care. Last year 400 DOs, MDs, NPs and PAs attended. Twenty-nine-speaker faculty includes Kenneth Adler MD, Timothy Fagan MD, Scott Klewer MD, Ann B. Lettes MD, Michael Maricic MD, Scott Sherman MD, Suzanne Sisley MD, Robert Snyder MD, and Jonathan Tait DO. PCMS member Deborah Jane Power DO chairs the conference. For more information including conference agenda or to register, please visit www.tomf.org/cme or call 520.299.4545.

Minneapolis Airport, 2020 E. American Blvd. E, Bloomington, Minnesota 55425. Right now doctors are under attack from many different fronts, said AAPS Executive Director Jane M. Orient, M.D. Restrictions are being put upon doctors from those outside medicine as we struggle to care for our patients. Now is the time to put control of medicine back in the hand of patients and their physicians. I invite you to join me in Minneapolis May 9 to attend this workshop and learn physician-developed proven solutions to regain control of your practice. CME accreditation is up to 7.5 hours Category 1 through New Mexico Medical Society with joint sponsorship of AAPS and Rehoboth McKinley Christian Health Care Services. Title program is 12:30-6 p.m., followed by Politics & Your Practice 2014, updates on physician-led initiatives in Washington, D.C. and nationwide to protect patient-centered medicine. Reservations: 952.854.7441, mention AAPS, or use link at aapsonline.org/mn

September
Sept. 13: Acute and Chronic Leukemias 2014: A Case-Based Discussion is at Mayo Clinic Education Center, 5665 E. Mayo Blvd., Phoenix 85054. Accreditation is to be determined. Activity is designed to provide up-to-date information on practical, current and evolving therapies using real-case-based scenarios. Attendees will be able to discuss practical cases with faculty knowledgeable in specific specialties. Course has breakout sessions for one-on-one interaction between faculty and learners. The one-day comprehensive symposium targets for hematologist and oncologist physicians, NPs, RNs, PAs and pharmacists. Full program details, including schedule, faculty, accommodations, and registration will be available four months prior to meeting date. Website: http://www.mayo.edu/cme/hematology-and-oncology2014s435 Contact: Lilia Murray, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca.cme@mayo.edu http://www.mayo.edu/cme

May
May 5-7: The University of Arizona Center for Integrative Medicine has announced that registration is open for the 2014 Nutrition and Health Conference in Addison, Texas, just north of Dallas. In the 11th year of this conference, experts from around the world including internationally recognized researchers, clinicians, educators, and chefs gather to explore good nutrition and health. This years faculty include Robert Chapkin, Ph.D., of Texas A&M; John Foreyt, Ph.D. of Baylor College of Medicine; Frank Hu, M.D., Ph.D. of Harvard Medical School; Tieraona Low Dog, M.D. of the University of Arizona; Belleruth Naparstek, M.S., L.I.S.W., psychotherapist, author, and guided imagery authority; and Andrew Weil, M.D., director of the University of Arizona Center for Integrative Medicine. The conference leads by example by featuring meals that are flavorful and delicious, but also adhere to the high standards set forth in lecture, the CIM said. Chef Rebecca Katz, M.S. has designed artful menus that provide satisfying meals with solid nutrition so attendees can experience and absorb materials in lecture. Open to virtually any healthcare professional with an interest in preventive medicine and healthful living, the conference offers up to 19 units of CME credit through CME Solutions, valid for several different professional organizations, the CIM said. Conference underwriters are California Walnut Commission, Vital Choice Wild Seafood & Organics, Pure Encapsulations, Gaia Herbs, Host Defense Organic Mushrooms, Nordic Naturals, and Seroyal. For more information, please visit www.nhconference.org May 9: The Association of American Physicians and Surgeons 20th Thrive, Not Just Survive Workshop is at the Marriott
SOMBRERO April 2014

November
Nov. 12-15: The Multidisciplinary Update in Breast Disease is at One Ocean Resort & Spa, 1 Ocean Blvd., Atlantic Beach, Fla.; 1800.874.6000 or 904.249.7402. E-mail: sales@oneoceanresort. com . Website: http://www.oneocenresort.com/ . Accreditation to be determined. Course is multidisciplinary update in prevention, evaluation, diagnosis, management, and treatment of benign and malignant breast diseases and survivorship issues, and targets hematologists, oncologists, NPs, RNs, PAs, pharmacists, and anyone interested in diagnosis and treatment of hematologic and oncologic disorders.
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Highlights: Benign Breast Disorders Surviving Breast Cancer Surgical Management Update in Plastic Surgery Techniques Advances in Oncology Quality Measures in Breast Diseases Panel Presentations Pre-Conference Workshop: Radioactive Seed Localized Breast Surgery: An Alternative to Wire Localization: This workshop, consisting of didactic and hands-on skills sessions, for surgeons, radiologists and radiation safety officers is designed to provide a simulated environment for the placement of live seeds in the breast cancer patient. Website: http://www.mayo.edu/cme/internal-medicine-andsubspecialties-2013s846 Contact: Lilia Murray, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale; phone 480.301.4580; fax 480.301.8323. mca.cme@mayo.edu http:// www.mayo.edu/cme

January 2015
Jan. 23: Clinical and Multidiscplinary Hematology and Oncology 2015: The 12th Annual Review is at the Westin Kierland Resort, 6902 E. Greenway Pkwy., Scottsdale 85254. Accreditation is to be determined. Course is comprehensive update and management strategies of issues in hematologic and oncologic malignancies, presenting new disease classification, treatments, and challenging cases. Topics include key hematologic diseases (dysproteinemias, acute and chronic leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU), and overlap topics of supportive, ancillary and diagnostic care. Breakout sessions for one-on-one interaction between faculty and learners are included. Course targets hematologists, oncologists, NPs, RNs, PAs, and all interested in diagnosis and treatment of hematologic and oncologic disorders. Website: http://www.mayo.edu/cme/hematology-and-oncology Contact: Lilia Murray, Mayo School of Continuous Professional Development, 13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323. mca.cme@mayo.edu http://www.mayo.edu/cme

Members Classieds
PHYSICIAN NEEDED: HealthySkin Medical and Cosmetic Dermatology is seeking a dedicated professional to join our growing practice! We are a team of 9 providers committed to our patients, staff and each other. Were looking for a compassionate, personable BC/ BE Dermatologist interested in practicing clinical dermatology. Our group consists of 4 general dermatologists, 1 Mohs Fellowship trained surgeon, 4 physician assistants, an onsite radiation therapy department, clinical and cosmetic lasers, and a fully staffed skin care department. HealthySkin Dermatology has been established in Southern Arizona for over 20 years with 4 main practice locations. We offer a 4-day work week (no nights, no weekends), a competitive guaranteed salary, production bonuses, comprehensive benets including insurance, disability, 401(k), prot sharing, CME time and allowance, vacation time, and an opportunity for partnership. You will enjoy instant success with our EMR, established patient base and new ofces encompassing over 20,000 sq. ft. of state of the art facilities. Call today for details, Samantha Marques, Practice Administrator (520) 293-5757, ext. 7113 or smarques@ healthyskinderm.com. Visit our website at www.healthyskinderm.com. (1-14) PRACTICE OPPORTUNITY: Growing Sub acute and long-term care practice is looking for part time, full time or per diem Physicians (MD/DO-Internal medicine/Family Practice) to provide care in Post-acute care facilities (SNFs), assisted living, adult care homes in Tucson and Green Valley. Experience in these settings is a plus. Flexible hours, competitive salary, make your own schedule. Contact: Harbir Singh, MD, Pinnacle Healthcare. Phone: 247-7665, Fax: 204-1940.

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For eighty years, Radiology Ltd. has been working with community physicians to provide the highest quality care for those closest to you. World Class Imaging Services Board-Certied Radiology Physicians Certied by the American College of Radiology Nine Locations throughout Tucson Patients are welcomed by our Guest Services staff who help them feel comfortable and answer any questions about their visit. Our nine warm and welcoming facilities house state-of-the-art technologies and caring, highly trained technologists who ensure outstanding image quality, compassionate patient care, and safety. Our 38 nationally-known, board certied and subspecialty trained radiologists interpret the images and, together with your doctor, determine the most effective treatment for you and your family members.

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MICA_Sombrero04'14ad_MICA_Sombrero05'04ad 3/7/14 12:16 PM Page 1

Nine Years and $310 Million!

Over the past nine years, MICA has distributed a policyholder dividend each year to our qualifying members. Our nineyear total of dividends distributed to MICA policyholders is $310 Million.
Dividends declared for a policy year reflect the Companys financial performance during that year. Past performance does not guarantee future dividends.

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SOMBRERO April 2014