Sombrero

Pima County Medical Society

Home Medical Society of the 17th United States Surgeon General

February 2013

Inside the new St. Marys Hospital: Merging the heart & soul of Carondelet

Special Issue: Carondelets West Side story

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

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SOMBRERO February 2013

Inside

V ol. 46, No. 2

issue. 6 New Life of a Legacy: Arizonas longest continuously-operating hospital gets a $20 million update. 9 Amy Beiter M.D.: St. Marys new CEO is a physician and a PCMS member. 10 CHVI Relocates: Continuing a long tradition of cardiovascular surgery in Tucson, St. Marys now houses the Carondelet Heart & Vascular Institute. 12 Member Profile: Scott Berman, M.D. has dedicated himself to St. Marys patients and you can learn what that has meant to Southern Arizona. 14-15 Campus Map: It is hard to know the new St. Marys without a scorecard, er, a good map to find where things are now. 17 Primary Stroke Center: A quick look at the team that knows time loss is brain loss. 18 The Breast Center: It took a dream and turned it into a physician-driven vision of breast care. 21 Wound Care: It is tucked away a bit off the main campus but is doing its part to halve amputations. 22 Emergency Center: The re-imagined emergency center aims to see patients within 30 minutes of arrival. 23 A Look Back: St. Marys has served Tucson well since 1880 but there were older hospitals in Arizona, including one founded in Prescott by the Sisters of St. Joseph of Carondelet. 25 Awards: Very quietly St. Marys has been receiving data-driven awards and we list some of the recent honors. 26 Dr. Charles Katzenberg: The PCMS President and Pima Heart Associates co-founder delivers a eulogy for the late Tucson Heart Hospital.

5 Steve Nash: Our executive director explains the rhyme and reason behind this

On the Cover
The cover photo of Carondelet St. Marys and the vast majority of the photos in this issue were taken by Tom Spitz. He has been capturing real life with his camera for nearly 25 years. After earning a degree in photo communication from California State University, Fresno, he began his career at the Reno (Nev.) Gazette-Journal and then spent nearly a decade at the Orlando (Fla.) Sentinel. He struck out on his own in 1993, launching Tom Spitz Photography in Tucson, Arizona. Toms work has won national honors, has been shown in galleries across the country, and has been published in Time, The New York Times, Readers Digest and the Washington Post. Tom specializes in photographing people and their lives, and has developed a reputation for catching moments that reveal his subjects true essence. He can be reached by e-mail at tom@tomspitz.com.

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SOMBRERO February 2013

A word on this issue...

By Steve Nash PCMS Executive Director

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ate last summer your Pima County Medical Society officers began meeting with CEOs of local health organizations. The object was twofold: 1) to learn what strategies they are using to cope with change, and 2) to find how PCMS can help the organizations succeed. As a result of these meetings, easy lines of communication have been established. Weve found that, faced with looming change, no two organizations are using the same tactics. Each has valid data and ideas; innovation and invention are alive in Tucson. Roughly two months after meeting with Carondelets CEO, a tour was arranged of Carondelet St. Marys Hospital so PCMS could see the new location of Carondelet Heart & Vascular Institute. Our tour evolved into a more general look at the hospital and it was filled with I didnt know that moments. At tours end we decided PCMS needed to reintroduce Carondelet St. Marys to the medical community. In text created by the PCMS staff and Carondelet Health Network External Communications, you will see some of the dedication and innovation at the facility, and you will feel the commitment and investment. We are not picking sides, PCMS Past President Alan Rogers said after one meeting, We want all our hospital systems to thrive. In May or June, Sombrero will profile Tucson Medical Centers changes and look at the Accountable Care Organization. In future issues this year, we hope to examine University of Arizona Health Network and the two Northwest Hospitals and allied physicians and facilities. We hope you enjoy this look at the dean of Arizona hospitals. If you arent a member, you can download a membership application at pimemedicalsociety.org (or call for an application, 795.7985). First-year dues are only $100. As a 108-year-old organization we continually strive to increase our influence and outreach. Today is good day to commit and become part of our family of physicians. n
SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily represent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Ofcers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright 2013, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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SOMBRERO February 2013

ST. MARYS HOSPITAL

New life of a legacy

omething extraordinary is afoot within the walls of Carondelet St. Marys Hospital these days. Amidst the more than $20 million in exterior and interior renovations, you can sense that new life has taken hold at this Tucson West Side medical center. There is electricity in the air and pride among the nearly 2,000 physicians, associates, and volunteers at the hospital that is, well, infectious. At first glance, you might attribute this enthusiasm to the recently completed faade that has given the hospital a modern look. Maybe its relocation of Carondelet Heart & Vascular Institute and its specialized cardiac care teams Adorned with a donated cross and new color scheme, the entryway at Carondelet St. Marys to the hospitals campus this Hospital continues to beckon patients, as it has since May 1, 1880. past November. It could even be the technological and programmatic strides being introduction of innovative, physician-driven programs like the made that will place the hospitals oncology service line at the Breast Center at Carondelet St. Marys. forefront of cancer care in this region. Providing nationally recognized quality care All these are important ingredients in this exciting next chapter Beyond Carondelet St. Marys premier cardiovascular and for this legacy hospital; however, it is the medical staff in breast cancer service line offeringsabout which you will learn particular that gives the hospital its sense of strength and longmore in the pages that followthe hospital has been named a term vitality. Top Performer in Quality and Safety by the Joint Commission (2012) and a Distinguished Hospital for Clinical Excellence three Our physicians are not only incredibly dedicated to providing years running (2011-2013) by Healthgrades, with multi-year, our patients with the highest quality care in the safest possible five-star ratings for its care of heart attacks, heart failure, stroke, environment; they pour their hearts and souls into the success respiratory failure, pneumonia and sepsis. of this hospital year in and year out, says St. Marys Hospital When these national awards were first announced, longtime Carondelet St. Marys cardiologist, Dr. John Boulet, noted: Ive been fortunate to work at St. Marys for the past 28 years. Its rewarding to see the hospital grow into a true center of excellence. I enjoy working where everyone is constantly striving to improve patient care. The care provided at [Carondelet] St. Marys Hospital can be characterized with one wordawesome, said Dr. Roy Farrell, chief medical officer at Carondelet Holy Cross Hospital in Nogales, Ariz. Farrell was so certain of the tremendous care heart patients could receive at Carondelet St. Marys that two years ago, he
SOMBRERO February 2013

President and CEO Amy Beiter, M.D.

Dr. Beiter, who took the helm in November after serving as the hospitals chief medical officer since 2008, noted: It was our physicians unyielding interest in putting a new face on this hospital that led to exterior renovations funded by the Centurions and completed this past summer. It is our medical staff, working in concert with our more than 1,500 associates, that has placed Carondelet St. Marys among the top five percent of hospitals nationwide for quality and safety, and it is our specialistsunited in their interest to provide only the very best carethat has led to relocation of Carondelet Heart & Vascular Institute to our campus, and the
6

embarked on an innovative effort to introduce field-to-balloon treatment protocols for emergent cardiac patients along the I-19 corridor. For instance, instead of a heart attack patient in Santa Cruz County being taken to an emergency department by ambulance or helicopter for additional testing before treatment, paramedics in the field coordinate directly with the St. Marys catheterization lab care team for field-to-balloon intervention. Studies show that EKGs taken in a patients bedroom by EMTs are just as accurate as those taken in the ED, said Farrell. Thanks to the cooperation and coordination of our EMT partners, Lifeline, and the cardiac specialists and care teams at St. Marys, our field-to-balloon treatment times for patients as far south as Nogales can be as quick as 74 minutes. You can get from a paramedic response along the U.S. border to specialized treatment in St. Marys cath lab as quickly as if you had a heart attack at the Tucson Mall. Legacy lives on Since 1880, when the Sisters of St. Joseph of Carondelet opened St. Marys, the hospital has been a vibrant hub of healthcare activity and a vital provider for the medical needs of residents throughout Southern Arizona.

patients the very best experience possible, with more technicians per patient per study, an extremely quiet and comfortable environment, and the least-intrusive monitoring devices available. Its all state of the art. You get the same enthusiastic opinion of Carondelet St. Marys services, programs, and the care it provides from just about every physician you ask. Dr. Toby Freebourn, medical director of Inpatient Rehabilitation, the first program of its kind established in Southern Arizona: Our rehabilitation care team was recognized last year among the top 10 percent nationwide in patient outcomes by Uniform Data Systems, an independent organization that tracks rehabilitation programs across the country. Personally, I am very proud to be a part of this amazing group of caregivers. Dr. Bernardo Rebeil, a radiologist specializing in chemo-embolization and radiofrequency ablation, has worked at Carondelet St. Marys for 23 years: This hospital has carried a stigma simply because of the stereotype surrounding the neighborhood, but that is finally changing for both the hospital and this area of the city.

We have seen an incredible dream realized with the financial commitment Just about ready to give way to combustion power this horse-drawn ambulance made by Carondelet What started as an 11is poised near the landmark Round Building, designed to give sunshine to TB Health Network to this bed hospital, with one patients and others. The Round Building was demolished in 1965 to make way campus, even in times of physician and the for a wider St. Marys Road. economic uncertainty, Seven Sisters serving as Dr. Rebeil said. The network has invested millions in the most nurses, has grown into a nationally recognized, tertiary medical advanced technologies so patients on our campus receive the very center with a medical staff of more than 300. In 2012, best treatment accessible today. Carondelet St. Marys handled almost 50,500 emergency room visits, 139,000 outpatient visits, 8,000 surgeries and 59,000 The hospital now has a multi-disciplinary tumor board that patient days. meets weekly to build integrated treatment plans for each cancer patient and ensure well-coordinated care. Physicians viewpoints Dr. A.J. Emami, an otolaryngologist and PCMS Board member, This integrated team approach among specialists who has dedicated 15 years of his career to the care of patients at St. otherwise work in private practice is truly a cut above what you Marys. As medical director of the Carondelet Sleep Center might expect, Dr. Rebeil said. Our team of pathologists, program and a former St. Marys chief of staff (2007-2009), he radiologists and oncologists are extremely qualified, dedicated knows a great deal about the hospitals recent history. and compassionate physicians. Tucson needs to know that St. Marys is that good. Between the new technologies, renovations, physician engagement and hospital leadership, we have moved forward One patients experience exponentially over the last several years. I am very excited Patients, like Mike Davis, feel the same. The physically fit, about our path forward, he said. athletic 62-year-old Green Valley man woke up one morning in late November, experiencing a severe ischemic stroke. Within Emami is especially proud of the brand new outpatient sleep lab minutes, the blood clot had incapacitated a third of his brain, that opened on the hospitals third floor in December. leaving him incapable of speech and virtually paralyzed. This is the only sleep lab available to patients on the Southwest Paramedics rushed him to Carondelet St. Marys Primary Stroke Side of Tucson. More than that, it is unique in our area, offering
SOMBRERO February 2013 7

Center, where he was able to receive interarterial tPA. The procedure, performed by interventional radiologist Dr. Rajul Shah and with the assistance of Dr. Stella Kahn, certainly saved Daviss life. His wife, Kathy, recently told the Green Valley News that just four days afterward, he was doing so well that some of the staff thought he was a visitor tooling the hallways, not a patient. Today, Mike is back home and no worse for wear. The Davises felt so strongly about making sure others in their community knew about the tremendous stroke treatment available at Carondelet St. Marys that they sought out the editor of their local newspaper to share their story. It appears the mission of the Sisters of St. Joseph of Carondelet 132 years agoto serve every dear neighbor with dignity and respectis still at the heart of the quality care being provided all these generations later by the physicians, nurses, administrators, and volunteers of Carondelet St. Marys Hospital.
The original cornerstone for St. Marys is on display at the hospital. St. Marys was built during a hospital-building frenzy after the Civil War. You may read more about the hospitals founding on pages 23-24.

As it has for decades, St. Marys is poised to accomplish great things, said CEO Dr. Beiter. We have transformed from a community hospital serving the West Dide to a regional tertiary medical center with the capabilities and commitment to provide some of the best care imaginable to the residents of this region. That is both our legacy and our promise. St. Marys Hospital is part of Carondelet Health Network, a Catholic, nonprofit healthcare system dedicated to responding to the health, prevention, education, and wellness needs of Southern Arizonans. Carondelet was founded by the Sisters of St. Joseph of Carondelet more than 132 years ago. Carondelets

family of services also include St. Josephs Hospital and Holy Cross Hospital in Nogales, Arizona; Carondelet Neurological Institute at St. Josephs; nearly two dozen primary and specialty care offices; an ambulatory surgery center; several imaging centers; Hospice and Palliative Care; and a variety of other outpatient services. Carondelet Health Network is a ministry of Ascension Health, the nations largest Catholic, not-for-profit healthcare system. In FY 2012, Carondelet provided nearly $66 million in Community Benefit to improve the health of our community and increase access to healthcare. More information about Carondelet Health Network is available at www.carondelet.org.

SOMBRERO February 2013

ST. MARYS HOSPITAL

Dr. Amy Beiter: Physicians administrator

Even as a student, Dr. Amy Beiter, F.A.C.P. and PCMS member, had a clear vision of the physician she wanted to be. Her interest in biology and science led her to the field; her desire to contribute something greater to her community drove her commitment. Now, after nearly 25 years as a clinician, Dr. Beiter is applying her vision of healthcare to her new role as president and CEO at Carondelet St. Marys Hospital. My vision for St. Marys is to continue to serve the community but in an expanded and more visible manner, she said. The addition of new service lines, including Carondelet Heart and Vascular Institute (CHVI) and the Breast Center, will serve to heighten the awareness of the availability and quality of services we already provide, many of which are highlighted in the Sombrero this month. Looking back Dr. Beiter, an Indiana native, first attended veterinary school before making the leap to medicine at Indiana Universitys School of Medicine. During her senior year she traveled to Liberia, in West Africa, where she worked for a couple months at a hospital. The experience, though short, grounded her, she said. It helped form my vision of who I wanted to be as a physician instilling that drive to make things better for the community. Upon graduating from medical school in 1988, Dr. Beiter moved west, opting to complete her residency in Internal Medicine/ Pediatrics at Good Samaritan Medical Center/Phoenix Childrens Hospital. In 1992, she moved to Tucson to practice at El Rio Community Health Center, where she served as chief of staff and developed and managed a free clinic for teens. Also in 1992, Dr. Beiter joined the medical staff at Carondelet St. Marys Hospital where, she said, I very quickly became comfortable and embraced the challenges of caring for complex patients. I loved the patients and physicians with whom I worked. After leaving El Rio in 1999 she worked as a hospitalist at Carondelet Health Network, and at Tucson Medical Center and University Medical Center. Seven years later, Dr. Beiter became the medical director of utilization management at Carondelet St. Marys, soon followed by a position as chief medical officer in 2008.
SOMBRERO February 2013

I took the position in utilization management in part so I could spend time with my kids. I had no idea I would like it so much, she said. Her experience and leadership at St. Marys did not go unnoticed, and last October, Dr. Beiter was promoted to CEO of the hospital. Moving forward As CEO, Dr. Beiter has had a smooth transition from her prior position as CMO. Shes still tasked with making rapid decisions in complex situations, a skill that she developed over her many years as a physician. My tenure at St. Marys has allowed me to be part of many of the operational aspectstheres just a whole lot more of that now, she said. I feel very at home in the role. I enjoy seeing healthcare from a very different perspective and I like being able to speak both languagesclinical and administrative. Since first entering the doors of St. Marys 20 years ago, shes had a unique perspective on the changes taking place at the 132-year old hospital. Technological advances and a renewed focus on safety and quality have improved patient care. The awardsby national review organizations such as the Joint Commissionreaffirm their success. I believe St. Marys is poised to do great things for our entire community. We have emerged from a community hospital serving the West Side to a facility providing tertiary referral care for the entire community and surrounding region, Dr. Beiter said. Im just really proud of the physicians and the staff here and what theyve built over the past several years. Its not me. Its the team. Dr. Amy Beiter is board-certified in internal medicine and pediatrics; a fellow of American College of Physician; member of the Society of Hospital Medicine; and a member of the American College of Physician Executives. As a physician/CEO, Dr. Beiter joins a select group. Of the roughly 6,500 U.S. hospitals in 2010, only 235 had a physician at the helm. In 2009, physician-led hospitals more often than not ended up in the top 100 of US News & World Reports rankings in cancer, heart and heart surgery, and digestive disorders. In Tucson Dr. Beiter joins a select group of physicians who have held the top position at local hospitals. Dr. Janis Johnson and Dr. Richard Carmona each had a term at Kino Community Hospital. Prior to that, physicians ran the county hospital on Sixth Avenue from the mid-1930s through the late-1960s. From the turn of the last century through the 1920s, several Tucson hospitals were founded and operated by physicians, including Whitwell Hospital, Rogers Hospital, and the Desert Sanatorium, forerunner of Tucson Medical Center.

ST. MARYS HOSPITAL

Carondelet Heart & Vascular Institute relocates to St. Marys campus

arondelet Heart & Vascular Institute (CHVI), now located on the campus of Carondelet St. Marys Hospital, offers nationally recognized, award-winning care for the treatment of cardiac and vascular conditions. In its new home, CHVI also offers patients multi-disciplinary care under one roof.

More than 50 years ago, doctors at St. Marys were pioneers in cardiovascular surgery, observed James K. Beckmann, president and CEO of Carondelet Health Network. In 1959, St. Marys was the first hospital in Arizona to perform open heart surgery and the first in Southern Arizona to use a heart-lung machine. Today, our surgeons are modern-day pioneers, offering the most technologically advanced and minimally invasive options available to patients facing heart and vascular surgery.

The specialized care team relocated from what was originally Tucson Heart Hospital to the St. Marys campus in November 2012. Relocating Carondelets cardiovascular program to a tertiary medical center provides a unique opportunity to serve the complex medical needs of cardiac patients from across the region who often face a multitude of problems beyond cardiac and vascular. Whats more, all emergency room care is now provided exclusively by board-certified Emergency Department physicians at Carondelet St. Marys Hospital. Physician education, too In addition to all the improvements for patients, CHVIs surgeons will train other experienced physicians in the latest procedures and treatments for cardiac care using streaming A/V communications.

Part of the $17 million CHVI transformation includes a very impressive new lobby.

CHVI at [Carondelet] St. Marys Hospital is setting the pace for cardiac care, bringing significant value to the community and the region, said Carol Erenberger, Carondelets cardiovascular service line executive. The skilled team of providerssurgeons, other physicians, nurses, and the rest of the patient care teamhas a depth of experience and up-to-the-minute knowledge of cardiovascular care thats on par with the best medical care in the nation. Big changes Carondelet Health Network has invested more than $17 million in the relocation and physical transformation of the new CHVI on the campus of Carondelet St. Marys Hospital. This location offers patients the most modern cardiovascular facility, with many advantages including easy access from both Interstates 10 and 19 and using two helicopter pads for emergencies. St. Marys has the most state-of-the-art center for minimally invasive procedures anywhere in the country, said Dr. Derek von Haag, a cardiothoracic specialist. CHVIs new home also allows more space for its cardiovascular and cardiothoracic surgery programs to grow.
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We have two goals, explained Dr. Michael Hecht, chief medical officer of Carondelet Specialist Group. First, to offer the most modern, multidisciplinary care to patients for the best possible outcomes and experiences, and second, to teach other practicing physiciansnot medical studentsthe latest best practices in cardiovascular care. Latest technology One of the features of the new CHVI at St. Marys Hospital is its new hybrid operating room, currently under construction. Its truly one-of-a-kind, built to improve surgical functions and patient safety. Our specialty is minimally invasive surgery for every kind of procedure, individually tailored to be most appropriate for each patient, with the best quality and safest results, Dr. von Haag said. This focus and the use of the new hybrid operating suite will truly separate us from other programs across the country. All the innovation and changes are aimed at better patient outcomes. Now there is better coordination of care than we were able to provide before. With the expertise of the rest of the St. Marys
SOMBRERO February 2013

staff, we have all specialties readily available for patients with multiple co-morbidities, Dr. Hecht said. A regional referral center The new CHVI at St. Marys is a destination for cardiac care throughout the region. Incorporating the best practices of two award-winning facilities, CHVI and St. Marys together form a team thats qualified to reach new levels of excellence in patient care with state-of-the-art surgical techniques. With St. Marys focus on the highest quality patient care and its easy accessibility by two freeways and helicopters, we are truly a regional destination for patients all over the Southwest, Dr. von Haag said. Weve already had patients from New Mexico and Flagstaff.
CHVI improvements include a complete redesign of patient rooms.

If you would like a vascular surgeon caring for patients at Carondelet Heart & Vascular Institute to see one of your patients, you can contact: Tucson Vascular Specialists: 1815 W. St. Marys Rd. Tucson, Ariz. 85745 Phone: 520.628.1400

Now youre Thinkin Smart

Carondelet nurse Stacey Lansdowne cares for cardiac patient Solomon Tolentino, Jr., in the Carondelet Heart & Vascular Institute Progressive Care Unit.

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Beckman puts it another way: Bringing CHVI to St. Marys Hospital combines Carondelets heart and soul in one location. If you would like a cardiologist caring for patients at Carondelet Heart & Vascular Institute to see one of your patients, you can contact: Carondelet Specialist Group Cardiology and Cardiothoracic Surgery: 445 N. Silverbell Rd., Suite 201 Tucson, Ariz. 85745 Phone: 520.396.1370 Pima Heart AssociatesWest Office: 445 N. Silverbell Rd., Suite 200 Tucson, Ariz. 85745 Phone: 520.624.8935
SOMBRERO February 2013

ROC #278632

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ST. MARYS HOSPITAL

Dr. Derek von Haag lives on the cutting edge

CaliforniaIrvine. Following an internship and residency at the University of CaliforniaDavis Medical Center, Dr. von Haag headed east for his residency in cardiothoracic surgery at University of Pittsburgh Medical Center. Dr. von Haag is a board-certified heart and lung surgeon with specialty training in minimally invasive surgical procedures, including closed-chest aortic valve; closed-chest mitral valve; closed-chest coronary artery bypass; closed-chest atrial fibrillation ablation; and closed-chest robotic surgery. Dr. von Haags professional memberships include the International Society for Minimally Invasive Cardiac Surgery, Society of Thoracic Surgery, American College of Surgeons, and the American Medical Association. Dr. von Haag says he loves the excitement of evolving technologies: Modern technology and continuing advancements in minimally invasive surgery bring me tremendous career satisfaction every day. In fact, Dr. von Haag specializes in a wide variety of the most modern closed-chest surgeries. Having all the latest tools and techniques available allows him the flexibility to create an individual treatment plan offering the best and safest outcomes for each patient. Its great being able to customize a treatment plan for each persons particular needs and health situation, making sure they get the very best care possible, he says. Three years ago, Dr. von Haag was working in Phoenix when Carondelet Health Network called. I thought Tucson was a great opportunity. Carondelet, in particular, appealed to me because everyone here is so focused on the quality of patient care, he said. He hasnt been disappointed. Every day there are so many interesting cases. The opportunity to save peoples livesto give a life back to someone who was dying, is just amazing, he said. What brings Dr. von Haag the greatest satisfaction at work? Modern techniques, collaborating with colleagues, and working within Carondelets team approach to taking care of patients. As CHVI medical director of cardiothoracic surgery, Dr. von Haag has been integral in the behind-the-scenes design work to build the new institute at Carondelet St. Marys Hospital. Of particular note is the creation of a state-of-the-art, one-of-a-kind hybrid operating suite. Working to develop CHVI at St. Marys into an established referral center, he says he is excited to see it evolve into a major destination for cardiac care. Weve already had patients from Phoenix, Northern Arizona and New Mexico.

riginally from California, Dr. Derek W. von Haag wanted to be a marine biologist until the day in high school that he saw a video of openheart surgery. His plans changed immediately. Today he serves as medical director of cardiothoracic surgery at Carondelet Heart & Vascular Institute (CHVI). After earning a dual bachelors degree in biology and zoology from California State Polytechnic University, he earned his medical degree from the University of
12

SOMBRERO February 2013

ST. MARYS HOSPITAL

cott Berman, M.D., F.A.C.S. has been at the forefront of vascular surgery in Southern Arizona since the mid-1990s. He began the first minimally invasive endovascular program in this area, and his commitment has resulted in many new procedures for patients with vascular disease. These include minimally invasive treatments for blocked leg arteries, blocked carotid arteries, thoracic and thoraco-abdominal aneurysms, deep vein thrombosis, and venous insufficiency. Dr. Berman grew up in Pennsylvania and received a bachelors degree in chemical engineering from Penn State University. He earned his M.D. from Hahnemann University in Philadelphia and completed his residency at the Eastern Virginia Graduate School of Medicine. There, he completed a fellowship in surgical research and clinical nutrition at the Hampton Roads VA Medical Center. Afterward, Berman completed a fellowship in vascular surgery at the University of Arizona. In 1994 he opened his Tucson practice devoted entirely to the specialty of vascular surgery, and in 1997 he founded Tucson Vascular Surgery. In 2010, TVS joined the Carondelet Health Network, establishing the vascular surgery division of Carondelet Specialist Group. Dr. Berman participates in research with a particular interest in vascular biology, medical database design, and bioengineering. He has published more than 50 peer-reviewed articles on many topics in vascular surgery and a textbook on vascular access surgery. Board-certified in vascular surgery and critical care and as a registered vascular technologist, Dr. Berman is a member of the faculty of the University of Arizona College of Medicine with an appointment in biomedical engineering. He is a member of a number of regional, national and international vascular surgical societies and is a fellow of the American College of Surgeons. Berman is also a member of the Society for Vascular Surgery and has been recognized by that society for his contributions to the specialty by his selection as a Distinguished Fellow. In February 2000, Dr. Bermans practice, Tucson Vascular Surgery, and Carondelet St. Marys Hospital ushered in the new era for the treatment of aortic aneurysm disease by performing Southern Arizonas first endovascular stent graft for abdominal aortic aneurysm repair (EVAR). Then, in early 2006, he placed the first endovascular stent graft for the treatment of thoracic aneurysm (TEVAR) disease. Since then, hundreds of patients have been successfully treated using this technology. The impact for patients with aneurysm disease has been far-reaching. There is nothing more satisfying than seeing a patient walking, eating a regular diet, and being discharged home on the first day after an EVAR or TEVAR procedure, Dr. Berman said. This is in stark contrast to traditional open surgery that would
SOMBRERO February 2013

Dr. Scott Berman brings new vascular techniques to Tucson

require days in the ICU, a week in the hospital, and months for full recovery. This year Dr. Berman continues the advancement of minimally invasive treatments for patients with aortic aneurysms by offering EVAR for patients with juxtarenal aneurysms. Early in 2012 the FDA approved the Cook fenestrated and branched endovascular aneurysm repair system that will expand the option of minimally invasive treatment to patients previously excluded from EVAR based upon their anatomy at the renal arteries. With Dr. Bermans extensive experience and consistent success with EVAR and TEVAR, Carondelet Heart and Vascular Institute at St. Marys Hospital will be the first facility in Southern Arizona to offer this innovative therapy.

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When timing matters: Carondelet St. Marys Certied Primary Stroke Center
Its an intense and confusing time when someone has a strokeand time is the main element. When a stroke is suspected, the Primary Stroke Center at Carondelet St. Marys Hospital begins treatment immediatelyoften within 60 or fewer minutes of the patient arrivingminimizing damage and saving brain function. Carondelet St. Marys received its distinction as a Primary Stroke Center by the Joint Commission, a nationally recognized review organization, for proving its ability to provide excellent stroke care that includes critical elements in achieving long-term success by improving stroke outcomes. We collaborate with the Emergency Center physicians, neurologists, interventional radiologists, and vascular and cardiac physicians, as well as a full Brain Attack
CONTINUED ON PAGE 19

ST. MARYS HOSPITAL

Carondelet St. Marys Stroke Treatment Team (L-R): Teri Gilmore, ANP, Herbert McReynolds MD, Stella Kahn MD, Rajul Shah MD and Francisco Valdivia MD.

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ST. MARYS HOSPITAL

reast cancer is terrifying. When a patient receives a positive diagnosis, it raises a number of uncomfortable questions, among them: Whats next? The Breast Center team at Carondelet St. Marys Hospital is ready to answer that question and remove the uncertainty and fear surrounding breast cancer. At The Breast Center, what started as a suggestion three years ago has solidified into a multidisciplinary, integrated group of otherwise independent radiologists, pathologists, oncologists, and breast and plastic surgeons whose focus is the prevention, early detection, and prompt treatment of breast disease.

The Breast Center: A physician-driven vision of breast care

Most of the procedures take place at a single facility on the Carondelet St. Marys Hospital campus, while consultations are done in the private offices of the Centers physicians located nearby. Imaging services are offered onsite, including digital mammography, breast ultrasound, bone densitometry (DEXA scans), breast MRI, and interventional breast proceduresstereotactic, ultrasound, and MR-guided breast biopsy.

The Breast Center is unique in Southern Arizona for its use of the imaging software Invivo DynaCAD with Carondelet St. Marys Breast Center Treatment Team (Standing L-R): ONCAD, which helps Maria Tirado, breast center patient navigator; Felicia Alicea, nuclear med tech; Bruce Porterfield MD, Christopher Gilles MD, Manuel classify lesions based on Modiano MD, Steven Baughan MD and Robert Gin MD. (Seated L-R): their morphology, said Chris Reed MD, Gerlinde Tynan MD and Guillermo Gonzalez-Osete MD. Radiologist Dr. Christopher Reed, who joined The A patient navigator, experienced in cancer education, helps Breast Center following a fellowship at the University of Arizona guide patients through the entire process. Medical Centers Breast Imaging Center. The specialized software is in addition to the standard computer-aided Our Breast Center is different in that were not just a center detection technology that detects lesions based on their for imaging or a single physician office, said Dr. Gerlinde Tynan, enhancement kinetics. medical director of The Breast Center and the Breast Health Program at Carondelet St. Marys Hospital. We encompass the whole scope of breast disease and, more specifically, breast cancer. Everything from the screening mammogram through biopsy, surgery, to chemotherapy and radiation treatment, support groups and educational resources is handled under our auspices. Streamlined, centralized, quality care The Breast Center opened in January 2012, the same year that the National Cancer Institute estimated there were 229,060 new cases of breast cancer diagnosed in the U.S.3,400 of which were women in Arizona.
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Physicians also offer patients the latest technology in treatment options including five-day catheter-based brachytherapy radiation, genetic testing, immediate breast reconstruction, cryoablation of fibroadenomas and participation in oncologic clinical trials. The Breast Center at Carondelet St. Marys is a member of the National Consortium of Breast Centers and uses the National Quality Measures for Breast Centers (NQMBC) program to track and compare data nationally with other breast centers around the country.
SOMBRERO February 2013

We are one of the few comprehensive breast centers in the state to go this extra mile, Dr. Tynan said. We are held to high standards and have to show accountability. Further setting The Breast Center apart is the ease and speed with which patients proceed from initial screening to follow-up treatmenta benefit to both patient and referring physician. Like any medicine, said Dr. Robert Gin, a radiation oncologist, we have patients asking, Are you going to tell this to my doctor? The thing about The Breast Center is that all your doctors are already there. The radiologist, the pathologist, the oncologistwere all familiar with your records. Its a team approach. Everything is integrated. When an abnormal biopsy result is found, an appointment with any one of the centers physicians usually can be scheduled within two to three working days. Physician-tophysician calls and notes help keep referring providers informed of their patients progress throughout treatment. Also helping to provide excellent continuity of care is Patient Navigator Maria Tirado. The patient navigator helps oversee the process and verifies that the patient is progressing correctly through their treatment plan, said Dr. Tynan. Its reassuring for the patient, as well as the referring physician who doesnt have to remember, Did I request those labs? Did I write those orders? Tirado explains that its her job not only to ensure that patients understand whats happening, but that theyre aware of the resourcesfinancial, emotional and educational available to them. While the doctors and staff do an excellent job explaining the terms and diagnosis, on that first visit, most [patients] are overwhelmed with all the information theyre receiving. Added Dr. Tynan, Even though youve heard it already from one of the physicians you saw, its always nice to have someone whos always available who can tell you more, who can set you up with community resources, websites, and support groups. [The navigator is] that person whos not the doctor, but who knows a heck of a lot about what is going on. Tirado, who is bilingual (Spanish/English) and bicultural, is especially interested in working with women from rural or medically under-served areas of Southern Arizona. One of the advantages of having a patient navigator in a program like this is that we are not just an advocate for them, but we follow them all the way from diagnosis to completion of their treatment, she said. From screening to survivorship Perhaps the greatest benefit of The Breast Center is the comfort of knowing that every facet of a patients care is considered and monitored on their behalf. Each new cancer case is presented during a weekly conference among the centers multidisciplinary team in which a patients history, risk factors, and exam are discussed and their pathology slides and
SOMBRERO February 2013

radiographic images are reviewed individually. A custom treatment plan is created and adjusted based on National Comprehensive Cancer Network (NCNN) and other national cancer guidelines, as well as patient preference, for the best possible outcome. What weve done is form a partnership where all of us have agreed to make sure these things happen in a streamlined fashion, said Dr. Reed. One of the big things for these patients is that they know the next step. Theyre never in the dark. We as primary care docs are thrilled when we can make one referral, and not only the medical and surgical needs of our patients are met, but also kindness, education and their social needs are incorporated, said Dr. Tom Griffin, F.A.A.F.P. Being able to send my patients to The Breast Center and knowing that theyll activate the complete team of caring is an incredible comfort.

CONTINUED FROM PAGE 17

Team to achieve excellence in care for stroke patients, said Dr. Francisco Valdivia, a neurologist at St. Marys and medical director of the Primary Stroke Center. Together, we will help patients and their families rebuild their lives. Recognizing the teams level of commitment, the Carondelet St. Marys stroke program was honored by the American Heart Association/American Stroke Association with the Get With The Guidelines Stroke Gold-Plus Quality Achievement Award. The program also was placed on AHA/ASAs Target: Stroke Honor Roll for proving its ability to provide acute ischemic stroke patients IV t-PA treatment within 60 minutes of arrival at least 50 percent of the time. With strokes, timing is key Most patients with an acute stroke typically get a head CT, though assessing for an occlusion typically requires a CT arteriogram (CTA), said Dr. Richard Lucio, a neuroradiologist at St. Marys. At [Carondelet] St. Marys Hospital, every acute stroke patient gets both an immediate head CT and CTA. Intraarterial therapy by a neuroradiologist is offered to those patients who may benefit. These cases can be challenging, but to optimize a good outcome, therapy must be initiated as quickly as possible. The stroke team and staff at St. Marys do an outstanding job making this happen. For more information or community education, please contact Joy Pipes, Stroke Program Coordinator, at jpipes@carondelet.org, or call 872.4344.
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SOMBRERO February 2013

ST. MARYS HOSPITAL

Extraordinary healing: Wound care at St. Marys

he high incidence of diabetes in Southern Arizona, especially among the Hispanic and Native American populations, creates a unique challenge for the medical community in our area. The Centers for Disease Control and Prevention says these groups get diabetes at four times the rate of the general population. Carondelet Health Network has been committed to meeting this challenge for decades through aggressive treatment of wounds. At Carondelet St. Marys Hospital, wound care is provided in both inpatient and outpatient settings. Just west of the hospital on West St. Marys Road, St. Marys Wound Healing Center offers additional outpatient care at its Holy Family facility. Because diabetes frequently affects blood circulation to the extremitiespreventing wounds from healing properly and leading to amputationCarondelet employs a variety of new technologies used by a staff of highly trained physicians and medical personnel. I know that were really working hard to reduce the number of amputations. The clinics amputation rate for the last six months is 1.5 percent. Most wound clinics are around three percent, said Dr. Herbert McReynolds, medical director of Carondelet St. Marys Emergency Center and a staff physician at the Wound Healing Center. Engaging the wound care community and saving limbs Dr. Barbara Aung, a podiatric physician and surgeon and board-certified wound care specialist, is also on the outpatient Wound Healing Center staff. She has reached out to the community by working to establish a local chapter of Save a Leg, Save a Life. The idea is to get the people who are doing wound care and peripheral-vascular work throughout the community, such as vascular surgeons and vascular specialists, to educate each other on how we might work together to save limbs, rather than doing amputations, she said. One such treatment is a hyperbaric chamber used by Carondelet that directs woundhealing oxygen to the affected area. Medical experts also use biotechnology in which layers of a product grown from human skin are applied to the wound. Its a cultured skin from a human put back on the wound, Dr. Aung said. That actually helps deliver growth factors and cytokines that promote the wound healing process. In
SOMBRERO February 2013

about three to four weeks, sometimes a little bit longer, the wound is healed. The times that we live in are pretty amazing. The St. Marys Wound Healing Center offers a multidisciplinary panel of physicians who provide initial patient assessment for those with chronic wounds, and will implement a treatment care plan based on an evidence-based pathway, added Dr. Rhonda Quick, F.A.C.S. Patients develop an ongoing relationship with a physician as they are being seen on a weekly basis, and their plan of care is adjusted as the wound changes over time. This comprehensive approach contributes to faster time to heal and a decrease in amputation rates. Positive reputation and pride among physicians Dr. Karl Hekemian is a longtime surgeon at Carondelet St. Marys Hospital and serves as medical director of the inpatient wound care program, in which vascular, reconstructive, and podiatry surgeries are all available in one location. He points with pride to the reputation wound care at St. Marys has throughout the community. Wound care at St. Marys has been providing great care to patients in this community for decades and has a very good track record, he said. Its a well-run facility.

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ST. MARYS HOSPITAL

When minutes matter: Rened emergency care

arrival.

he Emergency Center (EC) at Carondelet St. Marys Hospital is committed to seeing patients within 30 minutes of

To streamline the process, and shave minutes off wait times, every step in the patient care process was examined.Among these steps was getting patients directly to a bed in one of 44 private exam rooms soon after arrival. Carondelet St. Marys EC works diligently to have an emergency physician at the patients bedside as soon as possible after they arrive. We want the best care for our patients, said Dr. Herbert McReynolds, medical director of Emergency Services. The earlier we see them, the sooner we can determinewhats wrong and begin treatment quickly. He noted the

The newly renovated nurses station at St. Marys Emergency Center will assist in meeting the hospitals long-standing commitment to see EC patients in 30 minutes or less.

importance of time especially for patients presenting with stroke symptoms or chest pains. Carondelet St. Marys EC is double covered 24/7 by board-certified emergency physicians and midlevel practitioners (who average more than 15 years of experience) as well as by specialized emergency nurses. They team to provide the initial assessment and emergency care for patients presenting to the hospitals Primary Stroke Center and Chest Pain Center. Aiding in the ECs ability to provide rapid care is the use of new technology, such as limited bedside ultrasoundused by many of the emergency physicians at St. Marys to diagnosis conditionsand video laryngoscopy to aid in airway emergencies.

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ST. MARYS HOSPITAL

t. Marys Hospital opened its doors in May 1880. Now Carondelet St. Marys, it not only brought sincere care to Tucson and graduated a cadre of nurses from its nursing school; it also brought the latest equipment and advances in disease management and surgery to the Old Pueblo. From polio care to open-heart surgery, St. Marys is well known for its firsts in Tucson and the Southwest. It might not be the first Arizona hospital, but St. Marys is the oldest Arizona hospital still in operation. Surprisingly, though, it isnt even the first Arizona hospital founded by the Sisters of St. Joseph of Carondelet. The PCMS History Committee has researched Arizona hospitals off-and-on for 20 years. It has found no evidence of a hospital within the present boundaries of Arizona during the Spanish or Mexican eras; indeed, an 1858 report states that there were only three Mexican physicians in the entire state of Sonora. The committee determined there was a hospital for American troops at Fort Buchanan, founded near present-day Sonoita on or about March 7, 1857. Sick-call reports from the fort have been examined in the state archives that say troopers suffered from a variety of fevers, pains, wounds, and broken limbs. Dr. Bernard John Dowling Irwin was assigned to the fort. Dr. Irwin, who published medical, natural history, and presidential reports while stationed there, was awarded the first (in chronology) Medal of Honor for leading a relief expedition to Apache Pass. The post hospital closed when the Civil War broke out and Fort Buchanan was abandoned. When Arizona became a U.S. Territory in 1863, one of the new Territorys first laws was an order to counties to care for the indigent sick. The law wasnt easy to live up to in the sparsely settled Territory, according to PCMS History Committee Chairman James B. Klein, M.D., whose encyclopedic memory shines back into most aspects of Arizonas past.
SOMBRERO February 2013

Carondelet St. Marys: Arizonas longest continuously operating hospital

Yavapai and Pima counties often contracted or shared space with Army hospitals to care for the indigent at Fort Whipple near Prescott, or Camp Lowell in Tucson, both of which were founded in 1864. Camp Lowell was south of Broadway and east of Scott, but the hospital was located outside of the camp in a civilian building, Dr. Klein said. A [n early] Tucson map located the military hospital at the block bordered by Alameda and Court. When Fort Lowell was established at its current location in 1873, a hospital was built and continued to operate until the fort closed in 1891. You still can see the remains of the post hospital under the canopy at Fort Lowell Park. Apart from the military, Dr. Klein noted that the United States was in a hospital building frenzy after the Civil War. Tucson was not immune and neither was Prescott. In 1878, two years before St. Marys opened, the Sisters of St.

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Seven Sisters of St. Joseph of Carondelet journeyed for a month from St. Louis to reach Tucson in May 1870. Several pictured here were involved with the founding of a hospital in Prescott and St. Marys. Standing (from left) Sister Emmerentia Bonnefoy, Sister Euprasia Suchet, Sister Monica Corrigan, Sister Hyacinthe Blanc. Seated (from left) Sister Ambrosia Arnichaud, Sister Martha Peters, Sister Maxine Croissant.

Joseph of Carondelet opened Prescotts first civilian hospital. That hospital cared for paying patients, primarily miners, as well as for the indigent. Most sources indicate the hospital closed in 1883 despite being profitable and well attended. In early 1879, Bishop J. B. Salpointe began raising money for a hospital from Tucsons business leaders. The Benevolent Association of St. Marys Hospital was established and Dr. Mariano Samaniego, who also tried to start a Pima County Medical Society that summer, served as the associations vicepresident. In July 1879, according to Medicine in Territorial Arizona, Tucsons County Physician Dr. John C. Handy proposed using a building he rented for $10 a month as a space to provide indigent and prisoner care for $1.50 per day. A month later, Dr. Handy announced plans for a hospital three miles from town on Ft. Lowell Road in to care for indigent and paying patients. The

hospital does not seem to have been built, although adobes were prepared and a well dug. Nine months later, St. Marys Hospital was dedicated on April 24, 1880, and opened its doors to patients on May 1. Dr. Handy served as the first doctor, assisted by the Sisters of St. Joseph of Carondelet. St. Marys charged the county $1 per day for indigent care. The railroad ward, added at St. Marys in April 1881, helped offset the expense of caring for the indigent. There were approximately 20 sick and injured railroad employees each month by 1882. Other hospitals in the territory had financial problems. Catholic sisters appeared to be the only organizations that could operate hospitals successfully, reported Medicine in Territorial Arizona, doubtless due to their devotion and attendance without salary.

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ST. MARYS HOSPITAL

Carondelet St. Marys considered among best for quality and safety
The Joint Commission named St. Marys a Top Performer in 2012. In its Annual Report on Quality and Safety 2012, the hospital was recognized for achievements in the treatment of heart attacks, heart failure, pneumonia, and stroke as well as the quality of its surgical care. In addition, it has been designated as a Joint Commission-certified Primary Stroke Center since 2010. The American Heart/American Stroke Association also awarded the hospital its Stroke Gold-Plus Quality Achievement and Heart Failure Gold Quality Achievement awards in each of the last two years. By far, one of the hospitals most significant awards comes from Healthgrades, which has named the west side campus a Distinguished Hospital for Clinical Excellence three years in a row (2011, 2012, and 2013). This places St. Marys among the top five percent of hospitals nationwide. Healthgrades also named St. Marys a Distinguished Hospital for Critical Care in 2012. The hospital received five-star ratings from Healthgrades in the categories of: Heart attacks Heart failure Stroke Sepsis Pneumonia Bowel obstructions

n recent years Carondelet St. Marys Hospital has established itself as one of this nations leading healthcare facilities, receiving a vast array of national awards and acknowledgements.

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Tucson Heart Hospital 1997-2012: An obituary

By Charles Katzenberg, M.D. PCMS President

1996: I am in a private jet with several other docs and execs from MedCath Corp. heading for McAllen, Texas to tour one of the countrys first heart hospitals. The trips mission was to see, ask questions and formulate ideas we could incorporate into the formative Tucson Heart Hospital. By the time THH opened we had collaborated with MedCath on physical design, cath lab equipment, monitors, and even weighed in on the hospital menu. October 1997: THH opens, with much excitement among staff and physicians, in a conflicted Tucson, where existing hospitals all joined in the mantra of We dont need more hospital beds, a controversy reflected in this magazines pages and elsewhere. Why was THH built? An entrepreneurial company, Charlotte, N.C.-based MedCath presented a group of Tucson cardiologists with a vision of building a state-of-the-art, 60-bed facility dedicated to patientfocused cardiovascular care. Physicians were offered ownership, partnership, and a place at the table where decisions were made on staff, supplies, policies, and procedures Tucson, with the exception of University Medical Center, was experiencing cardiac surgery mortality in excess of twice the national averages. Five hospitals were dividing up 1300 cases per year. MedCaths pro-forma predicted profitability with a census of about 35 patients. THH opened with great fanfare and some terror. We had planned to do two cases on day one, one at a time, so we could debrief between cases in the event of problems. But two surgeons insisted on doing the first case, so the first two THH surgeries were done simultaneously, starting and finishing within minutes of each other. Everything went well whew Then reality set in. THH opened without a helipad. Despite much planning and lobbying, it never got a helipad. This limited THHs ability to draw patients from Southern Arizona. And patients, they did not miraculously appear. The ED supplied < 15% of admits, and the remaining 85% were directed in by staff physicians. Any patient coming to THH represented loss of market share by other Tucson hospitals and many cardiologists were caught in the conflicts of loyalty with their primary institutions. Some hospitals limited cardiologists privileges, some threatened insurance companies with higher rates if they contracted with THH, and all hospitals grumbled. Nevertheless, within two years of THH opening, St Marys, St Josephs and El Dorado had all retired their heart surgery programs.
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n Nov. 7, 2012, Tucson Heart Hospital passed away quietly after a prolonged bout of a community acquired, iatrogenic, self-inflicted, recurrent, and relapsing illness.

By 2001 things were looking good for THH, but as with many hospitals, THH experienced high turnover of top management. In the first eight years we had five CEOs, and the first did not even make it to opening day. This did not bode well. The middle years saw profitable months in the winter and losses in the summer. Right-sized staffing was a continual challenge. Outcomes were good, often better than national norms. Patient satisfaction was high. Physicians enjoyed ease of scheduling and appreciated flexible hours for doing procedures. Administrators offered open-door policies. The staff was well trained and enjoyed the work. Caseloads of both cardiac and vascular surgery were increasing. In 2004-2005, Carondelet Health Network showed interest in THH. Over several years CHN purchased ownership from physicians and MedCath. In 2007, THH became part of the Carondelet Health Network. The CHN takeover did not occur in a vacuum. TMC created a service line agreement with cardiologists, while NWH was hiring cardiologists and a cardiac surgeon. CHN also hired cardiologists and employed several heart surgeons. The THH core of cardiology supporters was shrinking. Then the recession hit, putting a dent in hospital business and increasing uncompensated care. In 2009 THH was renamed the Carondelet Heart and Vascular Institute (CHVI) and a last-ditch attempt was made to pull the rabbit out of the hat. Twelve cardiologists chosen by CHN were offered a vaguely outlined co-management opportunity. There was interest on the part of most of the cardiologists, but CHN backed away from partnering with cardiologists. In 2011 CHN brought in a new CEO who raised the question of CHVI viability. After six months of intense discussion, CHNs board elected to close CHVI and move it to the St Marys campus. The last month was sad and emotional. On Nov. 7, 2012, the facilitys doors were closed. An autopsy was not requested, but post mortem analysis reveals several lessons: It is difficult for an organization/institution to be successful in the face of high levels of top management turnover. Hospitals/organizations working with physicians can create something stronger than the individual parts. High quality is essential, but not sufficient for a successful program. Relationship, trust, transparency, and communication are critical ingredients to success. The Legacy of the Tucson Heart Hospital is that even before it opened, cardiac care in Tucson was improving. THH made everyone better. RIP, THH 1997-2012. THH is survived by the CHVI, on the campus of Carondelet St Marys Hospital. Disclaimer: I was THHs medical director 1997-2004. n

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As owners, our policyholders benefit directly when claims experience is favorable.

This is clearly demonstrated with the Board of Trustees declaration of our for members of record on December 31, eighth consecutive dividend: $42 million 2012. The $42 Million dividend reflects an average reduction of approximately 35% of 2012 premiums written.

Dividends declared in any given policy year reflect MICAs financial performance

during that year. Past performance does

not guarantee future dividends.

Medical Professional Liability Insurance (602) 956-5276 (800) 352-0402 www.mica-insurance.com

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SOMBRERO February 2013