June-July 2014 Sombrero

Sombrero
Pima County Medical Society

Home Medical Society of the 17th United States Surgeon-General
J U N E / J U LY 2 0 1 4
An ACA update
Handling
board complaints
In Memoriam:
Dr. Samuel H. Paplanus
Dr. John S. Welsh
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SOMBRERO June/July 2014
Sombrero
Pima County Medical
Society Officers
Official Publication of the Pima County Medical Society
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)
President
Timothy Marshall, MD
President-Elect
Melissa Levine, MD
Vice President
Steve Cohen, MD
Secretary-Treasurer
Guruprasad Raju, MD
Past-President
Charles Katzenberg, MD
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
Editor
Stuart Faxon
Phone: 883-0408
E-mail: tjjackal@comcast.net
Please do not submit PDFs as editorial copy.
Advertising
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Fax: 323-9559
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Members at Large
Vol. 47 No. 6
At Large ArMA Board
R. Screven Farmer, MD
Donald Green, MD
Veronica Pimienta, 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 Officers
Thomas Rothe, MD
president
Michael F. Hamant, MD
secretary
Printing
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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 Officers or the members at
large, nor does any product or service advertised carry the
endorsement of the society unless expressly stated. Paid
advertisements are accepted subject to the approval of the
Board of Directors, which retains the right to reject any
advertising submitted. Copyright 2014, Pima County
Medical Society. All rights reserved. Reproduction in
whole or in part without permission is prohibited.
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3
Inside
5 Milestones: Books, awards, lectures for our
members.
8 PCMS News: University reactivates heart

transplant program.
12 Makols Call: And we thought our Behind the

Lens columnist was our only car nut!
14 Behind the Lens: Some of Dr. Hal Tretbars old

friends are old cameras.
17 In Memoriam: We have lost doctors Sam

Paplanus and John Welsh.
19 The ACA: An update at PCMS from a panel for

Pima County Medical Foundation.
22 Practice Management: Dr. Steve Perlmutter on

handling medical board complaints.
25 Perspective: Dr. Jason Fodeman warns about

graduate medical education funding cuts.
26 Mayo CME: Coming offerings from the folks up

the road.
On the Cover
A Hatch River Expeditions tail-dragger raft approaches Hance Rapid
in the Grand Canyon in 1967. The image is from a 120 Ektachrome
transparency shot with a Rolleiflex and mounted in glass. It shows
how the famed Hatch riverboats have changed from when they
used only one pontoon, and were called tail-draggers because,
unlike todays rigid designs, they were dangerously flexible. That
year Dr. Hal Tretbar was with a group of 30 Tucson physicians that
was among the first to float the Colorado through the Canyon. See
this issues Behind the Lens for stories behind his old friends, the
cameras that shot em. (Dr. Hal Tretbar photo).
Correction
In our May issues Valley ENT features list of PCMS East-Side Tuscon
OTO members, Dr. Thomas J. Tilsner told us we left him out, which
indeed accidentally we did. Dr. Tilsner has practied on the East Side
since 1979 and tells us he the seinor OTO physician in Tucson. He
joined PCMS in 1986. Our apologies to Dr. Tilsner!
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4
Milestones
Dr. Rosenthal:
Award is team effort
By Tucson Medical Center
Tucson Medical Center
Emergency Department
Medical Director Richard
Rosenthal, M.D. was
recently honored as
EmergencyPhysician of the
Year for 2014 by EmCare,
the nations leading
national practice
management company.
Dr. Rosenthal received the
Commitment to Care
Award for Emergency
Medicine and was selected
from more than 10,000
affiliated clinicians.
they felt their physician cared about them as a person. TMC

was ranked in the 99th percentile for this patient satisfaction
question.
ED patients are triaged an average of 13 minutes after they
arrive.
On average, children are consistently treated and released in
less than two hours.
Patient satisfaction scores have consistently run in the 80th to
90th percentile.
While some major changes have been made in TMCs
Emergency and Pediatric emergency departments, which have
led to successful outcomes, we will continue to work on
improving our service and increasing patient satisfaction, Dr.
Rosenthal said.
That dedication and commitment to improving care for the
community is one of the reasons Dr. Rosenthal was selected
asEmCares Emergency Physician of the Year. So many of our
physician leaders do so much more than their physician job
duties or their leadership job duties require, said Dr. Dighton
Packard, EmCare CMO. They help their communities. They help
people outside of their communities. They offer outstanding
patient care while improving operations for their organizations.
We feel an obligation to recognize these outstanding clinicians in
a grand way, in front of all of their peers.
An EmCare press release said Dr. Rosenthal received the award

because of his commitment to, and implementation of lean
methodologies that helped guide TMCs
emergency and pediatric emergency
departments to improved and sustained
quality metrics.
Awards are nice, and certainly appreciated,
Dr. Rosenthal said, but it is our team here
the nurse managers, the pediatric
emergency medical director, and a fantastic,
dedicated administrationthat allows us to
work together to improve the processes and
improve the care we deliver.
Dr. Rosenthal said his team continually works
on improving the patient experience by
decreasing wait times and the total amount
of time a patient spends in the ED.
Some highlights of TMCs Emergency
Department improvements include:
The wait time to see a physician
decreased 48 percent down to an average
of 37 minutes, according to data from July
2012 to December 2013.
Patient satisfaction scores increased by
more than 43 percent from July 2012 to
March 2014.
During the same time frame, more TMC
Emergency Department patients reported
Dr. Goldberg lectures

on lasers
Gerald N. Goldberg, M.D.
reports that he lectured at
the American Society for
Laser Medicine & Surgerys
2014 Annual Conference
April 4-6 in Phoenix.
The conference is the
premier venue for medical
laser education internationally, he said. Dr. Goldberg
moderated an all-day
session on Fundamentals
of Lasers in Healthcare in
which he presented three
hours of lectures on
Fractional and full Ablative
CO2 Laser Skin Rejuvenation, Vascular Lesions (with emphasis on
Port Wine Stains) and video endpoints of cutaneous laser
therapy. He was also on a panel of experts discussing the Cutera
Excel V Laser, the newest state-of- the-art vascular laser for
cutaneous vascular anomalies.
Dr. Goldberg said his 30-year history with lasers makes him an
international authority on lasers for the skin and an integral
contributor to ASLMS. He is a Clinical Professor of Dermatology at
the University of Arizona College of Medicine, where he has been

on faculty since 1984 instructing medical students and residents.
He is a preceptor for dermatology residents for the American
Society of Dermatologic Surgery (ASDS) as well as ASLMS.
Dr. Goldberg said he uses more than 16 laser modalities at his
Tucson practice, Pima Dermatology. This summer he will be
lecturing at Canyon Ranch Health Resort for guests and staff. He
will also lead a training session for their aesthetics team to further
aid in identifying common skin cancers and skin conditions.
In Fall, for the fourth consecutive year, he will lecture on a variety
of topics at the prestigious Beckman Laser Institute in Los
Angeles. For more information, please visit www.pimaderm.com.
Dr. Gann in book form

Dr. Dietmar Gann and
his wife, Elizabeth Gann
MBA CNC, have become
known for Dr. Ganns
Diet of Hope, about
which they say no
surgery, no drugs, no
gimmicks. Those who
frequent PCMS
headquarters know that
our conference facility is
where they give meetings
about the diet.
Now the diet is in book form, Diet of HopeYour Journey to Health,
which the Ganns have recently published in an easy-to-read, well
categorized 136 pages with an introductory price of $14.95.
As Dr. Gann described awhile back in a series of Sombrero
columns, he comes down firmly on the anti-carbohydrate side of
the low-carb/low fat diet debate, which might be called the Atkins
side, if its even still debated. The results of the poor American
diet are certainly not debated because the evidence is in.
Two thirds of the U.S. population is overweight or obese, the
Ganns write. One hundred million Americans are pre-diabetic or
diabetic. What causes obesity and diabetes? By now, most of us
agree: Carbohydrates. Our government and [professional
specialty] medical societies disagree. They are still on the fat
makes us fat bandwagon. They insist carbohydrates are healthy
and tell us we should eat a lot of it, and that at least 60 percent of
our calories should come from carbohydrates.
Where is the disconnect? Our dietary guidelines come from the
Department of Agriculture, whose mission is to promote
agriculture, not your health. The business model of the food
industry is to addict us to cheap, sugary, salty, fatty food produced
in huge factories. Our government supports sugar and corn
production with billions of dollars to benefit the food industry.
This book describes the pseudo-science of the low-fat diet and
debunks the thinking of our government and [professional
specialty] medical societies. In 1980 the president of the
American Heart Association announced that if we all went on a

low-fat diet, heart disease would be wiped out in the year 2000.
Heart disease is still with us, as are the side-effects of a low-fat
diet: obesity and diabetes. Dr. Ganns Diet of Hope helps treat
and prevent diabetes through teaching proper nutrition.
For the book on Dr. Ganns approach, please log onto www.
dietofhope.org .
Dr. Rhees Trauma Red

In May a pre-release party
and book-signing at UA
Bookstores celebrated the
release of a memoir by Dr.
Peter Rhee, Trauma Red:
The Making of a Surgeon
in War and in Americas
Cities, which Scribner
published in June.
The book blurb
encapsulates how Dr.
Rhee came to public
prominence. On
Saturday, Jan. 8, 2011,
Dr. Peter Rhee was called
in to workon his first
day off in weeksto
Tucsons University Medical Centrers Trauma Center where 10
gunshot victims were being rushed after a man opened fire on a
crowd of people at a local supermarket.
One of the victims was Rep. Gabrielle Giffords. It was a day the
nation would never forget, but for Dr. Rhee, it was also just
another day on the job, saving lives. In his gripping memoir, Dr.
Rhee cecalls that challenging, exhausting, exhilarating,
frustrating, heartbreaking, satisfying, bloody, bloody, bloody day
at the office and the path that led him there.
From his youth South Korea and Ugandawhere he once
watched his surgeon father remove a spear from a mans belly
to frontline surgery in Iraq and Afghanistan, to trauma center on
the urban battlefields of Los Angeles and Washington, D.C., Dr.
Rhees life story is so much more than you already know.
Dr. Isersons here. No, hes not.

Truly a doctor without borders, Dr. Ken Iserson was recently back
long enough to tell us hed been three months working and
teaching at emergency medicine residency programs in Vietnam
and India, and was then off for two weeks in Canada. At the end
of Augustsurprise! hes off for three months teaching/
working at EM residencies in Guyana and Argentina.
Meanwhile, he got a great review of his new book, Improvised
Medicine: Providing Care in Extreme Environments (New York,
McGraw-Hill, 2012, 578pp, $56, paperback.
Dr. Iserson has given us a most remarkable book, wrote Mark K.

Huntington, M.D., Ph.D. of the Sioux Falls Family Medicine
Residency and the University of South Dakota Sanford School of
Medicine, writing in the May Family Medicine. Drawing from his
experience providing care in international, wilderness, and
disaster settings, Dr. Iserson has compiled an impressive
collection of bare-bones equipment and work-around strategies
to provide the best possible care in resource-poor settings. While
presenting many creative examples, the purpose of the book is
not to offer an exhaustive list of solutions to missing resource
challenges, but to inspire creativity in readers who may find
themselves needing to improvise.
Among the more interesting sections to this reviewer were the
Critical Care sections. Although modern ICUs blur the line
between reality and science fiction, quality critical care can often
be provided with less technology and still save lives. Some of the
improvisations presented in this section are not merely relevant
for chronically resource-limited settings; for example, the
technique for using a single ventilator for several patients
simultaneously has clear relevance to the most modern facility in
the event of a respiratory pandemic.
Another valuable section is Dental Care. As physicians, we have
limited experience in this area, yet in many settings, the ability to
treat basic dental problems alleviates a tremendous amount of
human suffering. Very practical, step-by-step procedural
descriptions are included and are well illustrated.
While concise, the work uses an almost folksy style, making for
an easy read. Concepts are presented using engaging
anecdotes, and the ideas are amply illustrated. The appeal for
this book is broad. Obviously it should be required reading for
those involved in disaster response or global health activities
(including medical students doing electives abroad). It would be a
valuable read for any physicians who leave the confines of their
medical centers and may
encounter the words, Is
there a doctor in the
house?
Also, it should be in every
hospital library, in case a
disaster reduces them to
an extreme environment.
Improvised Medicine is a
remarkable compilation of
concepts and
contraptions, both
innovative and historical,
that can improve medical
care in the most difficult
situations. MacGyver
would be proud!
n
PCMS News
UAMC reactivates heart

transplant program
University of Arizona Medical CenterUniversity Campus
reported May 28 that it had reactivated its Heart Transplant
Program after receiving approval from the United Network of
Organ Sharing (UNOS). UAMC temporarily suspended the
program in December to recruit forand strengthenits highly
specialized transplant team.
The reactivation follows the recent recruitment of Scott D. Lick,
M.D., professor in the UA Department of Surgery, Division of
Cardiovascular Surgery, and director of UAMCs Heart Transplant
Program, and Nancy K. Sweitzer, M.D., Ph.D., professor of
medicine and director of the UA Sarver Heart Center and chief of
the Division of Cardiology.
UAMC reported that its surgeons performed the states first heart
transplant in 1979, and have performed 891 heart transplant
procedures to date.
We now have in place at UAMC the strong leadership and multidisciplinary partnerships found in high-achieving transplant teams
across the country, said Alexander Chiu, M.D., Department of
Surgery acting head, and a PCMS member. This is critical in order
to offer the full range of quality, lifesaving care to patients with
advanced heart disease.
The report then detailed the specialists involved and said they are
now fully staffed, but its actually a story with more background
than foreground: Its the latest repercussion of the seven-monthold legal battle between the university and the surgery
department chairman they fired, Dr. Rainer W.G. Gruessner, a
PCMS member.
In the Nov. 21, 2013 Arizona Daily Star, Stephanie Innes reported
that, A charismatic surgeon who attracted high-profile doctors
to the University of Arizona Medical Center says hes being forced
out of his job. Indeed, we published it in these pages whenever Dr.
Gruessner attracted a new surgical specialist to his department.
As Dr. Gruessner expanded the department and its types of
surgeries, the paper reported, he made some significant hires.
Among the doctors he recruited were Peter Rhee, M.D. and G.
Michael Lemole, Jr., M.D., who became known around the world
when they cared for former Rep. Gabrielle Giffords and others
wounded in the Jan. 8, 2011 Tucson mass shooting. Both
surgeons are PCMS members.
The paper reported what can now be seen online: that Dr.
Gruessner, represented by Phoenix law firm Jaburg Wilk, P.C.,
filed a 191-page lawsuit describing professional rivalries and
discord at Southern Arizonas only Level 1 Trauma Center. They
reported that Dr. Gruessner was put on paid administrative leave
in September 2013. A Dec. 13, 2013 letter from University
8
Physicians Healthcare from President and CEO Michael R. Waldrum,

M.D., M.S., M.B.A. to Dr. Gruessner fired him from that organization.
Records that are part of the court filing, the paper reported,
indicate the UA is investigating a claim that Gruessner either
altered records on transplant procedures himself, or directed
others to alter them. Dr. Gruessner denies any wrongdoing.
Rather, he says in court documents, his suspension is retaliation
because he had spoken up about a climate of fear, retaliation
and favoritism that had developed during College of Medicine
Dean Steve Goldschmids tenure, resulting in low morale among
faculty and staff, and a financial system that rewards
Goldschmids supporters. Dr. Goldschmid is a PCM S member.
Dr. Gruessner is not asking for any financial damages, the Star
reported. Rather, the lawsuit seeks reinstatement of his positions
as a tenured professor at the College of Medicine, as chairman of
the Department of Surgery, and as an active staff physician at
University Physicians Healthcare, which staffs UAMC.
The university and UA Health Network say they do not comment
on pending litigation. Jaburg Wilk attorney Kraig Marton said the
ball remains in the universitys court. On March 7 in Pima County
Superior Court, he said, Judge Carmine Cornelio ordered UPH to
have a hearing on Dr. Gruessners dismissal, which the surgeon
charges was done without internal due process. But there has yet
been no hearing scheduled, Dr. Gruessner told the court, and
Judge Cornelio suggested that UPH have the hearing by the end
of June, Marton said. Were anxiously awaiting the hearing in
which Dr. Gruessner will clear his name.
The Star reported in May that Dr. Gruessner is still on paid
administrative leave. They quoted Jaburg Wilks filing saying that
the core of differences between Dean Goldschmid and Dr.
Gruessner is a strong disagreement over how to realize the
research, educational, and clinical objectives of the College of
Medicine and its departments.
Getting assistance for family

caregivers
By Pam Wessel, M.S.S.W.
Physicians often hear about their patients stresses and concerns
about issues when they are caring for a family member.
Possibilities include:
The daughter who calls, concerned about her fathers memory
loss and frustrated by his denial that its an issue.
The son whose blood pressure is elevated due to the stress of
caring for both his aging mother and his own family while
working full-time.
The devoted wife who is trying to care for her husband even
though his care exceeds what she can realistically provide.
As a physician you can advise a patient to avoid stress or to seek
in-home help, but developing a plan to achieve these results may
be more difficult.
How can you best help your patient in these circumstances? Refer
the patient to Pima Council On Aging. PCOAs knowledgeable staff
can take the time to talk in depth with concerned daughters,

stressed sons, and overwhelmed wives to get to the heart of the
matter and discover what is needed most. Caregiver Specialists
provide information to clients about:
Private-pay and publicly funded in-home services.
Comparison of costs and amenities offered by assisted living
communities.
Advance directives.
Transportation options.
Dementia education.
Dealing with emotional stress.
Other issues
PCOA offers Caregiver Support groups with regularly scheduled
meetings in various locations throughout the county, including
Tucson, Oro Valley, and Green Valley. Caregiver Training classes
are available at no cost to family caregivers to teach them the
necessary skills of providing care. PCOA also provides Respite
services to give full-time caregivers a break and a chance to take
care of themselves.
The next time a patient presents with worries and concerns
about caregiving and needs information on assistance available in
the community, please provide him or her with the number for
PCOA. As the treating physician, you can make this referral with
confidence, knowing there is help available and your patients
questions will be answered.
Please call the Pima Council on Aging Help Line at 520.790.7262,
or visit www.pcoa.org .
Pam Wessel, M.S.S.W. is Pima Council On Aging director of services.
A suggested rescue kit

From the PCMS Public Health Committee
Physicians may find themselves at the scene of a natural disaster,
terrorist attack, mass shooting, motor vehicle crash, or other
scenario involving multiple casualties.
This list is based partly on recommendations from the Committee

for Tactical Emergency Casualty Care (C-TECC). More than one
tourniquet is a good idea. Excellent training in rescue by citizen
first-responders in such situations is offered by the Medical
Reserve Corps of Southern Arizona. The course is very valuable
for physicians also. Items are:
Tourniquet such as the CAT, the MET, or the Soft-T-W
Chest seal
Curlex gauze in a Z-fold or roll
A hemostatic agent (combat gauze, Celox, etc.)
Ace bandage for securing the pressure dressing
Nasopharyngeal airway
No. 14 gauge 3-inch needle to decompress tension pneumothorax
Small roll of duct tape
Trauma shears
Cricothyroidotomy kit
LED headlamp
Sources: rescue-essentials.com, mooremedical.com
REFERENCE
Hatfill SJ, Orient JM. Immediate bystander aid is blast and
ballistic trauma. J Am Phys Surg 2013;18:101-104. Available at:
www.jpands.org/vol18no4/hatfill.pdf.
Slides and video from one-day course: http://www.ddponline.
org/hatfill/
MRCSA adds board members,

assesses needs
The Medical Reserve Corps of Southern Arizona reports that
William Mangold, M.D. and Kris Blume have joined its board of
directors just as MRCSA is seeking input from the American Red
Cross, Tucson Fire and area hospitals as to what those organizations
think is the best role the organization can fill for them.
Dr. Mangold, who is a lawyer and a plastic surgeon, is well known
to PCMS members as a former ArMA president and longtime
delegate to the AMA. He recently retired as carrier medical

director for the Medicare program.
role and asking partners throughout the city for thoughts to best
use the wealth of volunteers.
Kris Blume is 14-year veteran of, and captain with, the Tucson Fire
Department and chairs Tucson Metropolitan Medical Response
System. He has teamed up to co-teach, with Sheldon Marks, M.D.
the popular MRCSA offering, Emergency Civilian Casualty Care.
We will finish this process by summers end, Nash said, and

then recruit for the needs identified.
Dr. Mangold and Blume join other board members Dr. Marks,
Mary Stebbins, R.N., Les Caid, Tim Siemsen, and Steve Nash.
MRCSA was one of the first units formed after the call went out
following the events of Sept. 11, 2001. As medicine and
emergency response have changed, MRCSA is re-examining its
And speaking of volunteers
Volunteer opportunities
St. Elizabeth Clinic:The clinic at St. Elizabeths Health Center
(formerly St. Elizabeth of Hungary Clinic) depends on many
physician volunteers. Physician staffing is needed for a half-day
clinic every three months, or four clinics per year. Each clinic
generates a few procedures such as echo,
stress, or holter. If youre interested in
volunteering, e-mail Dr. Charles Katzenberg at
ckatzenberg123@gmail.com .
University Womens Clinics:The clinics
provide free medical care for women and
children. Physician volunteers provide basic
family care such as gynecological and
pediatric services. The clinics operate three
Wednesdays per month near the UofA
College of Medicine. At each clinic, the
attending hears patient presentations by
medical student volunteers, signs off on SOAP
notes, and sees the patient afterward to draw
up a final assessment and plan.
Those interested in volunteering may contact
PCMS Student Member Juhyung Sun at
269.1376, or e-mail jsun00@email.arizona.
edu .
UofA researchers ID
viral genes that control
cytomegalovirus
reactivation
AHSC: Identifying mechanisms that
determine CMV latency could lead to
targeted therapies to prevent CMVrelated disease
Arizona Health Sciences Center reports that
UofA researchers have found genes within
the human cytomegalovirus (CMV) that
control whether it remains latent (inactive) or
actively replicates (multiplies). The discovery
could lead to targeted therapies that prevent
disease caused by reactivation of the virus,
which nearly everyone carries.
Most people are infected with CMV early in
10
life and have no symptoms or even knowledge of the infection.

The virus remains in the body in a latent state that can later
reactivate, causing life-threatening problems in people with
compromised immune systems. Further, a baby infected prior to
birth can have devastating birth defects.
Felicia Goodrum, Ph.D., associate professor in the UA College
of MedicineTucson Department of Immunobiology and UA
Department of Molecular and Cellular Biology, and a member of
the UA BIO5 Institute, researches the latency of CMV. In two
recent papersone a spotlight articlein the Journal of Virology,
Goodrum details her laboratorys discovery of genes within
CMV that promote either latency or reactivation and replication
of the virus.
Viral latency is one of the most poorly understood phenomena
in virology, she says. This work defines a basic molecular switch,
controlling entry into and exit from latency. Therefore, for the
first time, we have identified targets that may allow us to control
virus reactivation.
CMV is one of eight human herpesviruses, infecting 60-99
percent of adults worldwide. Among the extremely common
herpesviruses are those that cause chicken-pox, shingles and
mononucleosis, in addition to herpes simplex.
Most people carry three to four herpesviruses most of the time
without knowing it, Goodrum says. People know viruses like
influenza better because they get sick. After you recover from the
flu, your relationship with that virus is essentially over. But with a
latent virus, you have it forever. There are absolutely no
symptoms of CMV and no way to cure the virus. This is an
exceptionally stealthy virus.
Though typically latent, CMV can cause significant health
problems when reactivated. When an infected person has a
compromised immune system, like in cases of organ or stem cell
transplant, HIV infection and some intensive chemotherapy
regimens in cancer patients, the virus can cause life-threatening
disease. The virus also is the leading cause of infectious diseaserelated birth defects, affecting more babies in the United States
than Downs Syndrome, fetal alcohol syndrome and spina bifida.
CMV is the largest known human virus, with about 200 genes,
and in an effort to understand its unusual persistence, Goodrum
is studying the genetics of the virus, mutating different regions of
the genome to identify ones that impact latency. In one particular
region of CMVs genetic code, she has identified separate genes
that are encoded to either promote or inhibit viral function.
We dont know exactly how these are functioning yet, she says.
Were trying to identify the pathways in the infected cells that
they are targeting. We think theyre targeting the same cellular
pathways, but with opposing effects. Its the balance of these
actions that we think eventually dictates a latent or a productive
infection,
latent cells untouched. Identifying the mechanisms that

determine latency could lead to targeted therapies that prevent
CMV-related disease. Treatments could either force the virus to
reactivate and then clear it out, or prevent reactivation all
together, Goodrum says. Those would be huge medical
successes.
Goodrum and fellow researchers work is supported by a grant
from the National Institutes of Health (National Institute of
Allergy and Infectious Diseases, AI079059, and National Cancer
Institute, CA343111), and the Pew Scholars in Biomedical Science
Award.
PCMF CME dinner events

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.
Sept. 9: New Medical and Surgical Treatments for Prostate
Cancer presented by Rick Ahmann, M.D., and Shanna Dougherty.
M.D.
Oct. 14: Dermal Fillers and Fat Stem Cells in Plastic Surgery
presented by plastic surgeon John Pierce, M.D.
Nov. 11: Newer Anticoagulants and their Role in A-Fib, DVT, and
Pulmonary Embolism presented by Timothy Fagan, M.D.
Writing PCMS position papers

Have you ever had a strong opinion about a health-related
issue confronting the medical profession, and wish the
medical 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 your opportunity to speak out!
There is no vaccine for CMV and the only drugs existing currently
target cells that are actively replicating the virus, leaving the
11
Makols Call
American motorvation
By Dr. George J. Makol
ather than dissecting

the ACA, or discussing
poverty, tax policy, the digital
revolution, music, the American diet, or illegal immigration,
this month Id like to take on a
really important topic:
Cars.
My childhood was filled with
visions of 20-foot-long Cadillacs
with huge tailfins, shiny Thunderbirds with Continental tire
kits on back, and the heartstopping designs of the late
50s and early 60s Corvettes,
several of which I later had the privilege to own.
Every car maker was distinct in its design. You could identify a
Packard sedan from blocks away. Chryslers had aggressive
grillwork that smiled back menacingly as you approached. Chevys
came in incredible colors, like the Bel-Air convertibles that were
white and eggshell blue and still bring tears to a car lovers eyes.
That era is long gone. Today almost every car looks like a Toyota
or a Honda. I found myself just the other day surrounded by
Toyotas and Hondas that all looked generically the same. It jolted
me to realize I was in my own driveway and that my wife and kids
all drive one of them! I, however, am an American car guy.
How much of an American car guy? In my five decades of driving I
have owned more than two dozen Chevys, a half-dozen Fords, a
few Dodge Chargers, Plymouth Furys and other muscle cars,
Chrysler wagons, and a few Chevy Suburbans. And in driving all
these American cars, I have never had an engine or transmission
fail, and have never broken down and had to be towed. In fact, as
a kid in my trusty 65 Impala convertible, I frequently drove out to
rescue and sometimes tow my friends Austin Healeys, Triumphs,
Jensen Healeys, and even Jaguars.
I will admit that I have had a door handle come off, a radio dial fall
to the floor, and a window or two stick, but it is distinctly easier to
crawl out the window of a Chevrolet Suburban than a German
sports car: I have owned both and done that in both.
So what is it with doctors and foreign cars?
Years ago here in Tucson I had a doctor friend who drove a new
Saab Turbo. Now, to me a Saab looks like a giant petrified
dinosaur-dropping with wheels. He had so much trouble with
that new car. It stalled. It stopped dead in the middle of traffic. It
ran rough all the time. He went back and forth with the dealer so
many times, and got no satisfaction, only more aggravation.
Within a short time the poor fellow had a fatal heart attack, and
his associates swear the it was the car that did him in. That
dealership is long gone, and even the Saab brand is American
history, as previous owner General Motors sold it to Dutch
boutique automaker Spyker Cars. I dont miss it.
12
A few years ago I had the privilege of getting the first Chrysler
300-C Hemi delivered to Tucson. I had to do it. My Chevy
Suburban had just been stolen and I had seen Shaquille ONeil on
TV in his new black 300-C and thought it was one of the most
beautiful cars ever.
This car had Mercedes running gear and suspension, superb and
distinctive American styling by Ralph Gilles, Continental GT Sport
tires, and a Chrysler 360 horsepower Hemi engine. ( A
hemispherical engine is an internal combustion engine in which
the roof of each cylinders combustion chamber is of
hemispherical form, boosting the maximum power at high RPMs.
* This car could fly, but when nursed the engine used only four
cylinders and yielded 17 mpg city, and in the 20s on the highway.
I took this car in to the dealer for my first oil change and full
service. When I picked it up later, I noticed my bill was $38, so I
found my trusty service guy and told him he must not have done
the oil change, the lube and filter, and the 40- point safety check,
because the bill was too low! I told him my doctor friends were
always complaining about $275 to $350 bills for routine service
for their Mercedes Benzes and BMWs. He laughed and told me
that he used to work at a BMW dealership and they did exactly
the same service that my car had just received, but then charged
a couple of hundred dollars more!
Those German brands are certainly fine cars, and today one can
always get a lease that includes routine service. However, to get a
car with similar performance from Mercedes at the time would
have required an AMG model (Mercedes high-performance
tuner division), at about double what I paid. I kept that
American car for four years, and never drove it for one whole day
without receiving compliments from passing strangers on its
design. I never had to fix a thing on that vehicle, and my wife is
still mad at me for trading it in and not giving it to her.
So before you invest in another conservatively styled Teutonic
machine that still looks like a Toyota or Honda, search Cadillac
Poolside Commercial on the Internet, watch the video, and
prepare to laugh out loud!
Then drop by a Cadillac dealer and test drive a new CTS-V with its
unique design, incredible performance, and AMG-level power at
a discount. Visit a Ford dealership and try out a more reasonably
priced Ford Fusion Titanium edition, with a grill reminiscent of
then-Ford-owned Astin Martin, and a twin turbocharged engine
that delivers the best power/mpg ratio in its class.
Or, if you dare, test drive the monstrous 2015 C7 Corvette. I did, and
they are building me one in a good old American factory in Bowling
Green, Ky. As you read this, and I already am planning a track day.
But boy, I really did like that little Mercedes E 350 that I rented in
Miami. Maybe next time Stuttgart.
*Wikepedia, 2014
Sombrero columnist George J. Makol, M.D. practices with
Alvernon Allergy and Asthma, 2902 E. Grant Rd. He has been a
PCMS member since 1980.
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13
Behind the Lens
Some of my best friends...

are cameras
By Hal Tretbar, M.D.
was poking around in a

storage closet recently
where I keep a lot of my photo
gear, mostly pre-digital. As with
a lot of others, I dont throw
much away, in case I might need it later.
Suddenly I was overwhelmed by boxes of old 35mm slides and
sleeves of 120 black-and-white and Kodacolor negatives.
Oh, there are lots of odd-sized filters, extra lenses, flash units,
tripods, and camera bags. But the boxes! Plus quite a few 4x5
negatives in glassine envelopes, plus many more boxes of
mounted 120 transparencies! Does anyone remember when you
mounted your best transparencies in glass to save them?
I was feeling depressed! Then I started looking at my old favorite
cameras. Now these are worth saving!
My favorites are the mechanical marvels that leave a permanent
image on film. They are made of sturdy metal, with touches of
chrome or spun aluminum, while I have some old digital cameras
and cell phones that are almost plastic throwaways. Heck, theres
a new version every six months.
I come from a family of photographers. My father had a top-of-theline Cine-Kodak Special 16mm movie camera in 1941. It was
purchased by the government for military use. Then for many years
he filmed with a Bell & Howell 16mm Filmo with magazine loading.
I still have my mothers Kodak 2a box camera that she used on
their honeymoon to Hawaii in 1929. She was using an exceptional
35mm Contax IIa rangefinder at the time of her fatal accident in
Communist Yugoslavia in 1977. It remained in the family with my
physician/photographer brother.
My mothers Kodak box camera has a sticker from Hawaiis

Kilauea Volcano House. The Filmo still has undeveloped movie
film.
It served me well up until 1950, when the C3 burned up in a

building fire. I replaced it with an Exakta II made in Dresden,
Germany. It had interchangeable lenses and was the first singlelens reflex available in this country. In 1957 I traded the Exakta for
a 4x5 Speed Graphic. Thirty years later the mint-condition Speed
Graphic was sold to a collector for $200.
I hit the jackpot in 1957 when I bought a new 35mm Nikon S2
rangefinder with a 50mm 1.4 Nikkor lens for $250. A friend had
just purchased it in Hong Kong. It was one of the best cameras
I ever had. I sold it to a German collector in 1987 for $1,500. I
wish I still had it.
I still have favorites in that closet, and with them come stories.
In 1950 I was in college when my parents gave me a tiny
camera that they brought back from Hong Kong. The 16mm
Tone camera has a case that is inscribed Made in Occupied Japan.
The 25mm anastigmatic lens
adjusts from f3.5-11. The
shutter speeds are B, 1/25
and 1/100 second. It focuses
down to two feet. Too bad
16mm roll film was not
available here. The best thing
you can say about the Tone is
that it is excessively cute.
I started with a 120 Agfa Ansco in junior high school. I had a

darkroom, and built an
enlarger from an old folding
camera. It wasnt very long
before I had my first 35mm
camera, an Argus C3. The
triplet Cintar f3.5 lens was
coupled to a rangefinder.
Shutter speeds were from
1/10th to 1/300th of a second.
A flash unit plugged into two
holes on the side. It was
popular because of its rugged
durability and sharp images.
With its squared-off shape the
C3 became known as The
The tiny Tone camera has a full set of adjustments for shutter
Brick.
speed, aperture, and focus.
14
When I was in the Army, in

Germany, I was stationed 15
miles from Wetzler, the home
of Leitz and Leica cameras. For
$300 I purchased one of the
finest cameras in the world: a
Leica M3 rangefinder with an
f1.2 Summilux lens and a 135mm Hector f3.5 telephoto. I have

used it around the world.
Several years after we moved to Tucson in 1965, our family was
fishing at Greer. Our youngest son dropped the Leica M3 into the
Little Colorado River with a loud splash. I immediately had it
cleaned and repaired. It has been good as new ever since. On
eBay, a complete outfit similar to mine with a 135mm Hector, a
Leica light meter, and leather case was offered for $2,895.
I have had both double- and single-lens 120 Rolleiflex cameras.
My standard twin-lens Rolleiflex has been a ubiquitous best
friend since 1952. It has been at my side throughout medical
school, internship, the Army, residency, and now Tucson. Photos
from it have appeared in various books and magazines. A blackand-white shot of Bell Rock in Sedona won a contest with a
weekend for two in Las Vegas.
I have a lightweight metal waterproof camera case for the
Rolleiflex. The case has small knobs for the shoulder strap. It is
clamped tight shut by a large rotating lever. It has protected the
Rolleiflex on numerous trips down the Colorado River through
the Grand Canyon.
Once we were flying out of Denver. I didnt have the shoulder
strap on when I placed the metal case under my aisle seat. Later
during the flight the flight attendant whispered in my ear that
there had been a bomb scare when the case slid down the isle
during the steep takeoff! The co-pilot had to be called to the back
to identify it as a camera case!
I still have my first Nikon SLR, or rather almost first. We were
getting ready for a safari in Kenya in 1983 when I was in New York
On the left is the worlds most expensive camera case. The

waterproof Rolleiflex case can look menacing.
for a conference. I went to a discount camera store and bought a

complete Nikon outfit: a Nikon FE2 camera with a 28-70 f3.5
Nikkor lens, a 70-210 f4 Nikkor telephoto, a 1.5x extender, a
motor drive, a flash, and a case. There was no N.Y. state tax if the
purchase was mailed out of state. So the store mailed just the
case and I took the rest with me in a small travel bag.
It was raining the next day when I took a taxi to the airport. I
jumped out of the taxi with my suitcase, hanger bag, and
briefcase. I watched in surprise as the taxi drove off into the mist
with all of the brand new Nikon gear. I can tell you the phone call
home to Dorothy was not easy. There was nothing else to do but
15
My Leica M3 outfit has had a rigorous life but survives in

pristine condition.
to call an order for the same outfit again from the same dealer. I
now own the worlds most expensive camera case!
Nostalgia took me to eBay for an Argus C3. The Nikon FE

2 has an external motor drive. The Rolleiflex has been a
buddy since 1952.
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Nostalgia overcame me while I was writing this column, I went to

eBay, and bought an Argus C3 in very good shape for $20
including shipping. When I was telling this to friends recently, it
turns out they too had C3s. In fact during the production run
from 1939 to 1966 it was the most popular 35mm camera, selling
more than 2,000,000. Jimmy Carter used one during his naval
career and it is now on display in his presidential library.
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16
In Memoriam
By Stuart Faxon
Dr. Samuel Paplanus,

1928-2014
Dr. Samuel H. Paplanus,
pathologist, educator and
researcher, who joined
PCMS in 1973, died on
June 5. He was 85.
Samuel Harris Paplanus
was born Sept. 10, 1928 in
Columbia, Tenn. He was
raised in Winchester,
Tenn. and graduated
from Columbia Military
Academy in 1946. He
graduated from Vanderbilt
University, Nashville, with
distinction in 1950. He
was a member of Zeta
Beta Tau Fraternity.
Dr. Paplanus graduated
from Vanderbilt Medical School in 1954, and completed his
pathology residency Vanderbilt University Hospital. He he served
in the U.S. Army Chemical Warfare Research Department at Fort
Detrick, Md. 1958-60, earning captains rank. He had a fellowship
in medicine at Yale University, and was a fellow, instructor, and
assistant professor of pathology at The Johns Hopkins University,
Baltimore, 1960-72. He then came to work as a pathologist at
University of Arizona Medical Center and as associate professor,
then in 1979 full professor of pathology, at the University of
Arizona College of Medicine. He did consulting work at
[Carondelet] St. Marys Hospital and the Southern Arizona
Veterans Administration Hospital.
He was a member of the American Society of Clinical
Pathologists, American Association of Pathologists and
Bacteriologists, American Society of Experimental Pathology,
Arizona Society of Pathologists, American Federation for Clinical
Research, Association for Computing Machinery, Inc., American
Society of Nephrology, American Association for the
Advancement of Sciences, and the AMA.
Sam was an avid traveler who loved photography and traveling
with friends, the family told the Arizona Daily Star. Sam not only
would find great places to travel with his companions, said Dr.
John Collins, a Vanderbilt colleague, he would insist on returning
30 years later and re-taking photos from the exact same spot.
With a group of 11 other UofA College of Medicine Department of
Pathology physicians, Dr. Paplanus resigned from PCMS in 1982
over what they called the financial impact of the Building Fund
whose assessment when measured against the economic
priorities of our department is such that we must choose not to
pay. By 1997 he was retired and returned to PCMS as an Associate
Member. In 2006 he contributed to Project Restore for the building
whose construction cost was so troublesome to many members.
After his retirement he wanted to be involved in the medical

community again, former PCMS Executive Director Steve Nash said.
He did excellent work on our History Committee, shedding light on
the Earle Peacock Affair that has had implications at the University
of Arizona College of Medicine Department of Surgery for
decades.He also traced the development of pathology in Tucson.
Dr. Paplanus was a pioneer in electronic medical records,
working on the concept in the 1970s from a pathology point of
viewnot that he would have ever mentioned that himself.He
was self-deprecating about his accomplishments.
In the late 1990s he had an idea for the medical society to take a
hard look at integrative medicine.He brought his proposal to the
PCMS Board of Directors and was asked to chair the
committee.He approached alternative medicine with a healthy
skepticism, but also with a genuinely open mind.He wanted
practitioners to be aware of what worked and what did not.His
work was very valuable. His writing on this and other topics
appeared in these pages.
Nash said hell miss Dr. Paplanuss frequent calls to PCMS about
questions of the day, and his deep voice, filled with echoes of his
Tennessee upbringing.
With AMB CAM guidelines and widespread adoption of
complementary and integrative medicine modalities, the PCMS
Cooperative (Complementary/Alternative) Medicine Committee
was dissolved in 2010, its mission largely accomplished.
Dr. Paplanuss parents Isidore and Fannie Paplanus, and sisters
Charlotte Dreifuss and Reita Franco predeceased him.
His nieces and nephews Sheryl Axelrod of Box Elder, S.D., Marc
Dreifuss of Tonganoxie, Kan., Alan Franco of Metairie, La., Paul
Franco of Atlanta, and Bryan Franco of Brunswick, Maine; seven
great-nieces and nephews; two great-great-nieces and nephews;
and many cousins survive him.
The family requests that memorial donations be made to
Vanderbilt University School of Medicine or the University of
Arizona College of Medicine.
Dr. John S. Welsh,

1931-2014
Dr. John S. Welsh,
pediatrician to many
generations of local
families, and PCMS
member 1962-77, died
peacefully April 16 in
Tucson, his family
reported in the Arizona
Daily Star. He was 82.
John Sheaff Welsh was
born June 2, 1931 in
Kansas City, Mo. He
earned his bachelors
degree at Kansas
University, Kansas City, in 1953. He earned his M.D. there in 1957.
He did his pediatric internship at University of Kansas Medical
17
Center, and his residency at Childrens Mercy Hospital in Kansas

City. He served as chief of the Department of Pediatrics at
Barksdale Air Foce Base, Louisiana, 1960-62. The American Board
of Pediatrics certified him.
In Tucson Dr. Welsh began his pediatric practice in Fall 1962 at
Oracle North Medical Center on West Wetmore Road. Before
joining PCMS he had been a member of Wyandotte County
Medical Society, Kansas City.
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In 1965 he applied to the Federal Aviation Agency [now

Administration] for designation as an aviation medical examiner,
with authority to examine pilots and other airmen and issue
them their medical certificates. [Airmen must have medical
certificates testifying to physical fitness to fly.] As with his Air
Force service, this was consonant with his love of flying, and he
did become an FAA medical examiner. He loved to fly his plane
and travel the world, the family told the Star. John lived his life
to the fullest and always on his own terms. He will be deeply
missed and remembered by many.
Our physicians were so
Later Dr. Welsh served as PCMSs representative to the Arizona

Society for Crippled Children; served on PCMSs Tri-Hospital
Perinatal Review Committee; and our Professional Blue Shield
Committee.
hesitate to say Desert
His wife, Barbara; son Michael; daughters Tamara and Terri;

nine grandchildren; and numerous great-grandchildren
survive him.
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18
The ACA
Four years later

By Stuart Faxon
o, the politically named Patient Protection and Affordable

Care Act has not been with us for the decades that it seems.
Its only four years old.
Where are we? How did we get here? Where are we going? Marc
Leib, M.D., J.D., AHCCCS CMO until recently, who makes policy
wonk a compliment, took his shot at posing and answering
those questions May 13 as part of a panel assembled for a Pima
County Medical Foundations CME event. Dr. Leib was part of a
panel moderated by Dr. Timothy Fagan and including family
practitioner and medical informatics expert Dr. Ken Adler, and
Jean Tkachyk, COO and CFO of Meritus Health Plans.
In 2010, Dr. Leib noted, confusion and uncertainty abounded and
politics, lawsuits, and mistrust prevailed. Much of that remains,
he said, but some things are clearer now.
We now have the Supreme Court ruling its interpretation that the
Acts individual mandate to buy health insurance is constitutional,
while ruling that it is not constitutional to threaten states with
loss of Medicaid funding if they refuse the Medicaid expansion.
States can decide whether or not to expand Medicaid, which
Arizona finally did after a furious fight in which our governor
opposed our legislature.
Arizona, like about half the states, decided
not to set up its own Health Insurance
Exchange and to go with exchanges in the
federal marketplace. [We use quotes here
because of governments promotionally
slanted English.]
Last years rocky start featured regulations and
standards that were not published until after
the 2012 elections, Dr. Leib noted. There was
less than one year to develop and implement
ACA infrastructure, and no end-to-end testing
of federal-facilitated market or connections
with state exchanges. They way it was run up
the flagpole was a clear black eye for President
Obama and his HHS secretary. As Dr. Leib put
it, Although widespread political differences
on ACA still exist, there is little disagreement
on its initial implementation.
The Oct. 1, 2013 public program rollout was a
disaster in capital letters, Dr. Leib said, adding
that it has been significantly improved. More
than 6 million individuals are covered under
the various Exchanges. Some disagree about
who those policy-holder are, newly or
previously insured. It remains to be seen how
many will continue to pay premiums to
remain covered.
Dr. Ken Adler, medical informatics specialist, speaks May 13

at PCMS.
The Faces of Casa are the
Agnes C. Poore, RN, Co-founder

and Chief Clinical Officer
Hospice is a special field of work.

I love hospice because we can truly
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Hospice services are paid for by Medicare
Today states have functioning Exchanges or

participate in the Federal Facilitated Market.
19
But, little information has been exchanged between these

markets and states Medicaid programs to enroll applicants across
programs. Applicants might need to go to both the FFMs and state
Medicaid program to ensure enrollment in the proper program.
an AHCCCS applicant is actually eligible for a subsidized plan, the

patient may need to apply directly to the FFM. If an FFM
applicant is AHCCCS-eligible, it may be easier and quicker to apply
directly to AHCCCS.
Everyone above 133 percent of the Federal Poverty Level has

access to some insurance product, with subsidies for those up to
400 percent of the FPL. In states without Medicaid expansion,
some of those below 133 percent of the FPL may not have access
to either insurance or Medicaid. This leaves many uninsured,
based on state government decisions.
Other ACA provisions
Medicaid expansion
About 25 states, including some red [mainly Republican] states
have expanded their Medicaid programs because it was fiscally
prudent to do so, Dr. Lieb said. Federal funds for expansion cover
more than the costs of providing care to those covered by the
expansion. This reduces states costs for the remainder of their
covered populations, saving state tax dollars.
Arizona Health Care Cost Containment System expansion
AHCCCS expansion will add approximately 350,000 members
and approximately $1.9 billion in additional federal funds, Dr.
Leib said. It restores Prop 204 AHCCCS coverage to
approximately 200,000 childless adults, consolidates KidsCare
into Medicaid and restores coverage to approximately 60,000
children, and adds about 57,000 new childless adults not
previously eligible under Prop 204.
AHCCCS and the Federal Facilitated Market
There is little effective communications between the FFM
healthcare.govand the AHCCCS enrollment system, he said. If
Dr. Leib noted that Accountable Care Organization and other

bundled payment programs may be adopted by state Medicaid
programs, including AHCCCS. The dreaded Medicaid RAC audits
are required, and OIG audits of Medicaid providers will increase.
There will be reduced fees for provider preventable conditions;
currently this only applies to hospitals.
AHCCCS payment modernization
AHCCCS contractors must use five percent of their capitated
payments for payment modernization activities designed to
lower total costs, Dr. Leib said. Examples might include PatientCentered Medical Home, bundled payments, increased care
coordination projects, better integration with behavioral health
services, or programs to reduce emergency department use and
hospital inpatient readmissions.
Value-based reimbursement
Dr. Ken Adler spoke on aspects of value-based reimbursement
including tools and methods, compensation options, Accountable
Care Organizations and similar ones, and P4P or Pay for Performance.
He said value-based compensation options include quality
bonuses, care management fees, shared savings, adjustable feefor-service rates based on cost and quality performance,
episodes of care, and capitation or full-risk.
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Phoenixs Banner Health Network was one of 32 original Pioneer

Accountable Care Organizations, Dr. Adler said. Nine dropped
out, leaving 23. Banner reported savings of $13 million in their
first year. Pioneer ACOs have increased potential risk and reward.
If successful, they are eligible to transition to full-risk at year four.
Medicare Shared Savings plans among ACOs have been
pioneered in Phoenix, Dr. Adler noted. These include the
physician-based Arizona Priority Care, Arizona Care Network
including Dignity and Abrazo, John C. Lincoln ACO, and Scottsdale
Health Partners, new this year. Elsewhere are Southern Arizona
ACO in Tucson, physician-run Yavapai Accountable in Prescott,
and physician-run Yuma Connected Care there.
As of January 2014 there were 360 Medicare Shared Savings
Plans nationally, Dr. Adler said. Of the initial 114 from 2012, 54
of them, or 47 percent saved money, and 29, or 25 percent
earned a bonus.
He noted that there are 33 measures of quality in four domains:
Patient-Caregive Experience with seven measures; Care
Coordination/Patient Safety with six measures; Preventive Health
with eight; and At-Risk Populations with 12.
Among the At-Risk Populations measures are patients with
diabetes, hypertension, ischemic vascular disease, congestive
heart failure, and/or CAD.
Among commercial ACOs, Cigna is a good example, Dr. Adler said.
Cigna Collaborative Accountable Care has about 80 locations in
the country including three in Arizona. There is a prospective
quarterly care-management fee, and the fee is adjusted quarterly
based on cost and quality performance.
He noted that Medicare Advantage ACOs include the United and
Humana organizations, and that they have cost-reduction targets.
Humana is trying Pay For Performance (P4P) as are BCBS and Aetna.
One of many CMS pilot programs is Bundled Payment for Care
Improvement Initiatives, he said. In one model used at Banner
hospitals and two others, there is retrospective payment for
hospitalization and 30 to 90 days of post-acute care under 48
clinical conditions. In another model used at four Phoenix
hospitals, there is prospective payment for hospitalization and
30 days of post-acute care, including any re-admissions within the
30 days, and all physician fees.
Health insurance landscape

Jean Tkachyk, COO and CFO of Meritus Health Plans, addressed
Current Health Insurance Landscape and Practical Strategies for
Financial Success. She said Meritus is the only non-profit
cooperative health insurance company in Arizona.
Organized in 2012 and headquartered in Phoenix, physicianfounded Meritus began as a community coalition dedicated to
making quality healthcare available and affordable to all
Arizonans. It is prohibited by law from ever being sold to, or
reorganizing as, a for-profit corporation. Products and services
are provided both as PPO and HMO types.
The Southern Arizona market is unusual, she said: Arizona has
exceeded CMS targets for first-year enrollment. Who enrolled?
She said available demographics show middle-to-lower, and
middle-class people, 28 percent of whom are 18-34, and 35
percent younger than 35.
Open enrollment in the federal healthcare exchange closed on

March 31, and prospective insurees can only enroll during life
event implications, Tkachyk said. These still include many
because the life events could be job loss, births and marriages,
and loss of eligibility for Medicaid. She quoted DHHS as saying,
Up to 129 million Americans with pre-existing conditions,
including 17 million children, no longer have to worry about
being denied health coverage or charged higher premiums
because of their health status.
She noted that National enrollment on the Exchange was reported
to be 8 million Americans. Three million young adults gained
coverage through their parents plans, 3 million enrolled in Medicaid
and CHIP, and 5 million enrolled in plans outside the marketplace.
Carriers in Pima County include Meritus, BlueCross BlueShield,
Cigna, Health Choice, Canyon Plans of The University of Arizona
Health Plans, Aetna, Humana, and Health Net, she noted. There
are more than 100 plans offered in Pima County, she said. More
than 70 are Silver Level plans.
She gave several website examples from the 39 Silver plans, 24
Bronze, 33 Gold, and 14 Platinum plans for individuals, most
often comparing Metitus Health Partners and Health Net. On the
high end, the Health Choice Essential Platinum plan was $339 per
month with zero deductible and out-of-pocket maximum of
$2,000 per year. Lowest was Health Net CommunityCare HAS at
$139 per month with $5,000 annual deductible and out-of-pocket
maximum of $6,000 per year.
Tkachyk quoted Azcentral.com on subsidy eligibility: In Pima,
Maricopa and Pinal counties, the benchmark plans are sold by
Woodland Hills, Calif.-based Health Net and are among the
cheapest across the federal marketplace. The nations least
expensive over-all in Pima Countys benchmark plan, which
charges $138 per month for a 27-year-old nonsmoker. That
means Pima County residents will get the least generous
subsidies among all communities on the federal marketplace.
Cost-charing reductions for out-of-pocket costs and deductibles
are available only on Silver Level plans and are available for levels
below 250 percent of the Federal Poverty Level, she noted.
The new landscape means that many people have never had
health insurance before, Tkachyk said. They dont know what a
network is, or how to get a referral, or to whom, so providers
and facilities have to be part of the patient education process.
Practical implications for physicians mean first knowing which
carrier with whom you are contracted, she said. There are many
networks and lots of products, and reimbursement rate may vary
by type. Understand the fincial implications, Upfront payments
will be key. Understand what benefits are covered, and what is
subject to prior authorization. Dont make assumptions! Beware
of grace periods. Marketplace products have 30-, 60-, and 90-day
periods. Off-marketplace products have 30-day periods. Priorauthorize when applicable, and re-check eligibility immediately
before procedures.
She advised outreach to your currently uninsured patients, and to
consider if your practices employee coverage could benefit from
a group policy. She also noted that open enrollment for 2015 is
Nov. 15, 2014 to Feb. 15, 2015, and that plans will change, and
members will transition to other plans and carriers. Statewide
enrollment is expected to increase, and Hispanic enrollment is
also expected to increase.
n
21
Pracce Management
Anatomy of a board complaint

By Steve Perlmutter, M.D., J.D.
hances are if you practice

medicine long enough, at
some point you will have a
board complaint filed against
you at some point.
When you receive that letter, it
will be a disturbing experience.
A board complaint ranks high
among the sources of anxiety
and anger, perhaps only
second to IRS letters and
medical malpractice claims.
Of all those in healthcare fields, physicians have the most
emotionality about board complaints. Doctors take these
complaints personally, and who can blame them? A doctor
spends the majority of his or her time and energy creating
favorable outcomes for patients. A complaint by a patient or
another physician is a personal affront. It is an attack against
ones integrity. Moreover, it is an attack against your license, your
privilege to practice medicine, your livelihood, your future.
Board complaints are sometimes a thinly veiled test balloon
floated by a plaintiffs medical malpractice attorney. If the board
sides with the injured party against the physician, there is a
strong impetus to file a medical malpractice claim. After all, if a
board comprised of mostly doctors thinks you are negligent,
wont a jury come to the same conclusion?
There is some good news about board complaints. The vast
majority of them will be dismissed at an early stage, soon after the
charges have been answered. Of the complaints that ultimately
come in front of the board, most of them are dismissed.
Even if the board finds fault with your actions, the case is usually
settled with a non-disciplinary letter of concern and perhaps a
continuing-education requirement. Only a minority of cases go
on to censure, probation, suspension, and license revocation.
Nonetheless, the best scenario is to get out of the case quickly.
Most professionals with experience in front of healthcare
licensing boards agree that the presence of an attorney has a
salutary effect on the case outcome.
Although numerous articles have been written about the five
or 10 steps to take or not take upon receiving a board
complaint, I have attempted here to write from the perspective
of one who is both attorney and physician. I have had board
complaints. I have defended them by myself and with the help of
an attorney. If I had to do it over again, I would never answer a
board complaint without an attorney. And chances are that your
professional liability policy has a provision that requires the
insurer to pay for legal counsel if a board complaint should arise.
My best advice is to hire an attorney to represent you before you
respond to a board complaint. Abraham Lincoln once said, A
22
person who represents himself has a fool for a client. A medical

or osteopathic board proceeding may not seem like much on the
surface, but it is a legal proceeding that can determine if you will
continue to practice medicine. And while you are under no
obligation to obtain legal representation and can appear on your
own behalfpro seit is not advisable. Some legal scholars
suggest that the right to proceed pro se is akin to allowing the
defendant to waive his right to a fair trial.[1] Self-representation
may provide one with a clear opportunity to shoot oneself in the
foot.[2] Even the U.S. Supreme Court has opined that, a pro se
defense is usually a bad defense.[1]
However, for those physicians who have the intestinal fortitude
to proceed on their own, here are some principles that should be
considered before and during answering a complaint. But first,
the usual disclaimers. This information: (1) does not constitute
legal advice; (2) does not create an attorney-client relationship;
and (3) may not apply to your specific circumstances. In other
words, caveat emptor.
1. Respond in a timely fashion.
Some physicians get the letter, or e-mail, and file it in a drawer
somewhere as though hiding the complaint will make it go away.
That is akin to hiding a basal cell carcinoma with a Band-Aid and
thinking it will go away. In fact, it makes it worse. Every complaint
has a deadline for the filing of an answer, and it may be as short
as 14 days. If an answer is not filed promptly, you now have a
second problem. Failure to respond may be deemed to be
unprofessional conduct in itself. So, make sure your response is in
by the deadline. If you are unable to comply with the deadline,
ask the board for an extension. It will usually be granted.
2. Prepare a concise, complete, and persuasive response.
Complaints often reference that elusive term, standard of care.
Standard of care is the degree of care, skill, and learning expected
of a reasonable, prudent physician in Arizona in the same or
similar circumstances. Standard-of-care complaints typically
involve one of four scenarios: (1) You didnt act when you should
have; (2) You acted when you shouldnt have; (3) You did the
wrong thing; or (4) You did the right thing but in a negligent or
reckless manner. The purpose of your answer to the complaint is
to explain how your actions were reasonable and rational, to wit,
in compliance with the standard of care.
Physicians are used to being complete and concise on histories
and physicals, operative reports, and hospital notes. It is also
necessary to apply these skills to prose. For example, imagine the
complaint concerns a complicated eye surgery with a poor result
(a topic I know something about). My response would discuss my
initial visit with the patient and all the visits up to the time the
decision to have surgery was made. I would detail the
preoperative examination and my discussion of the risks,
benefits, and alternatives of the procedure. The surgical
complication that occurred during the procedure would be
explained. My response would detail the postoperative care

how I managed the complications and any referrals made. Then, I
would go to the medical literature and pull articles that discussed
the prevalence of the complication and how it should be
managed. In summary, my response would show that what I did
was proper in all respects.
Physicians are trained in empiricism and the scientific method,
not in persuasion. Your response to a complaint is different. You
are not writing to the board as an objective, uninvolved party.
This is not grand rounds or a curbside consultation. You are
writing to try to persuade the board that you are rightthat you
took the correct action, or did the proper evaluation, or the
complication that occurred will happen to every surgeon sooner
or later. You need to be credible, convincing, and compelling.
At the same time, you must be honest. If you made a mistake, it is
usually better to admit it than try to hide it. Boards look at
dishonesty and arrogance with disfavor. However, the way that
the mistake is framed linguistically may have a significant impact
on how it is viewed. In other words, the language used to explain
a circumstance can have a dramatic effect on each board
member. How do you describe an eight-ounce glass with only
four ounces of water in it? Whether you refer to the glass as half
empty or as half full can make all the difference in whether the
adjudicator accepts your point of view.
3. Dont respond when you are angry or unprepared.
As part of the investigation into the complaint, you will be asked
to provide your medical records and a narrative response. At
some point you may also be interviewed by board staff or
questioned by board members in an open, public forum. It is
important that you respond to board staff and board members
with courtesy and dignity at all times. Keep in mind that these
people did not bring the complaint to your doorstep. They are
just doing their jobs. It will not help your case to be rude or
critical. It will hurt it.
Another tendency that physicians exhibit is to blame the
complainant. While the complainant may have created his or her
problem, it is seldom beneficial for the doctor to recriminate or
censure the patient. It is better to explain how the complainant is
incorrect, either based on facts or misperceptions.
records are replete with metadata. In other words, you will not
outsmart individuals specially trained to find altered records. If it
is determined that you have altered the record, you lose
automatically. You will lose all credibility, and no one will believe
anything you say. Always take the high road.
In summary, if you are confronted with a board complaint, take it
seriously but remain optimistic. Retaining an attorney is generally
a good idea. Check with your professional liability insurer. If you
decide to handle the complaint on your own, respond in a timely
fashion. Make the response concise, but complete and
persuasive. Remain calm and courteous. Be prepared.
Chances are that the complaint will just be a blip in a long and
productive career.
Steve Perlmutter, M.D., J.D. is an Arizona attorney and physician.
His firm, Perlmutter Medical Law, represents doctors and other
healthcare providers with licensing board complaints. Dr.
Perlmutter practiced ophthalmology in the Phoenix metro area
for 25 years before becoming an attorney. He can be reached at
steve@boardcomplaint.com or by calling 480.346.1212.
REFERENCES
[1] United States v. Farhad, 190 F.3d 1097, 1106-07 (9th Circuit, 1999).
[2] Decker, The Sixth Amendment Right to Shoot Oneself in the Foot: An
Assessment of the Guarantee of Self-Representation Twenty Years After
Faretta, 6 Seton Hall Const. L.J. 483, 598 (1996).
[3] Martinez v. Court of Appeal of Cal., 4th Appellate District, 528 U.S.
152 (2000).
Now youre
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Preparedness is essential. Just as you would not go into an exam

room or an operating room without being prepared, neither
should you speak to an investigator or draft a response without
contemplation, deliberation, and a thorough knowledge of the
facts. Responses such as, I dont know, or I dont remember
will be discounted if you had the opportunity to review the
records and know the answers. On the other hand, it is not
prudent to speculate. Consider that every word you write or say
will be recorded and analyzed. As they say in the crime shows,
anything you say can and will be used against you.
4. Medical records
Never alter your medical records. It is both a legal and ethical
violation. Someone will figure it out, and you will lose the case.
There may be a copy of the records somewhere else. If you use
paper records, your handwriting may change or you may use a
different pen. The ink can be dated. The difference in the
pressure on the page may be ascertainable. Computerized
ROC #278632
23
24
Perspecve
Paging Congress: Dont cut GME funding

By Dr. Jason Fodeman
his summer new doctors

will start their residency
training in a host of hospitals
across Arizona and across the
nation.
overcome the dwindling supply of doctors. Patients will likely find

it very frustrating when physicians do not have the time to have
their questions answered, or to understand the treatment
options. This could easily foster a more paternalistic approach to
medical care and put patients at risk.
These new doctors enter

medicine at a time when
uncertainty about the future
of medical practice is at an alltime high. Much of this is a
result of the Affordable Care
Act, yet other uncertainties
remain, including ambiguities about the future of the very
funding that supports residency training.
Cuts to GME will be a detriment to the quality of life and quality

of training for medical residents as well. Despite the work load of
completing a residency, life does not stop for these young
doctors. Residents have personal, professional, family, and social
obligations outside of residency. Yet, fewer spots means that
there will be fewer positions in the city or region where a resident
may want to work, or where a resident may need to be.
As Congress looks to curtail runaway government spending and

rising deficits, one expenditure that has repeatedly drawn
interest is funding for Graduate Medical Education (GME). The
so-called Super Committee, the Simpson-Bowles Commission,
and the Medicare Payment Advisory Commission have all paid
particular attention to this funding that supports the mandated
training doctors must complete at regular intervals in the years
following med school graduation. While budgets must be
tightened, cuts to GME would endanger patients.
A recent study by the Accreditation Council for Graduate Medical
Education (ACGME) attempted to quantify the devastating effects
of possible GME cuts. The authors found that a 33 percent
funding reduction would lead to the closure of 1,639 residency/
fellowship programs and a loss of 19,879 post-graduate training
positions. A 50 percent reduction in funding would cause 2,551
training programs to close and lead to the elimination of 33,023
training spots.
Since all physicians must complete residency training, fewer
residents in the pipeline will ultimately translate into fewer
practicing physicians. Thus, GME cuts will inevitably exacerbate
the physician shortage, which the Center for Workforce Studies
puts at 91,000 primary care physicians and general surgeons by
2020. As a result, patients will have an increasingly difficult time
receiving care they need and want because they wont be able to
find doctors. It is likely that patients on Medicaid and Medicare,
who already experience trouble finding treatment, will be
affected most.
This will create a serious access problem for those patients
desperately seeking care. At the same time, those patients
fortunate enough to arrange a medical appointment will likely
see their face-time with a doctor diminished, as physicians will
have to see an increasing number of patients in a day to
The 80-hour work weeks and 28-hour shifts of residency are

demanding enough, but residents should not have to also suffer
through that while being separated from their spouses because
the closest spot to their partner in Texas was one in Connecticut.
Unfortunately, due to a limited supply of opportunities, this
already happens and will only become more prevalent if GME
funding is cut. This will not only create unnecessary personal and
professional hardships for young doctors, but lower morale
both of which could distract a resident from his or her education
and jeopardize patient care.
The timing for cuts to GME could not be worse. As more and
more of the Baby Boomers find themselves on Medicare and as
the healthcare reform law adds millions to Medicaid, more
residents, not less, will be needed to ensure that these patients
receive the necessary care.
In fact, our healthcare system already lacks an adequate supply of
doctors to meet demand. This is in part attributable to Congress
shortsighted decision to cap residency funding in the 1997
Balanced Budget Act. To double down on this flawed policy now
by further cutting GME would be penny-wise and pound-foolish.
This would create critical patient access problems and lower the
quality of available care across-the-board, with the sickest and
poorest patients being harmed most.
A better prescription would be for Congress and the federal
Department of Health and Human Services to work with hospitals
and healthcare providers to invest in residency training programs
and increase the number of spots.
The fate of our healthcare system depends on it!
Jason D. Fodeman, M.D. is a board-certified IM physician
practicing in Tucson. He is a graduate of the Cedars Sinai Internal
Medicine residency program, and completed a graduate health
policy fellowship at the Heritage Foundation.
n
25
Mayo Clinic CME
July
July 27-Aug. 1: The Mayo Clinic Diagnostic Imaging Update and
Self-Assessment with Advanced Radiology Life Support
Workshop is at the The Ritz-Carlton, Laguna Niguel, 1 Ritz-Carlton
Drive, Dana Point, Calif. 92629; phone 877.266.6065; fax
949.240.2000. www.ritzcarlton.com/LagunaNiguel
Accreditation: Mayo Clinic College of Medicine designates this
live activity for a maximum of 30.0* AMA PRA Category 1
credits. *ARLS workshop4.75; General course25.25.
Course is designed to provide practicing radiologists, residents

and fellows-in-training with a review of state-of-the-art imaging
techniques. An optional Advanced Radiology Life Support
(ARLS) workshop is offered Sunday, July 27. Self-assessment
modules (SAMs), required for maintenance of board certification,
are also offered.
Course targets hematologists, oncologists, PAs, NPs, RNs,
pharmacists, and anyone interested in the diagnosis and
treatment of hematologic and oncologic disorders. Website:
http://www.mayo.edu/cme/radiology-2014s430 Contact:
Mayo School of Continuous Professional Development,
Jenny Kundert, CMP, 13400 E. Shea Blvd, Scottsdale 85259;
phone 480.301.4580; fax 480.301.8323
mca.cme@mayo.edu http://www.mayo.edu/cme
We know Tucson. We are Tucson.

We are Tucsons homegrown law firm providing
legal services for Southern Arizona since 1969.
We can assist with all legal needs, from Business
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Barry Kirschner was recently selected by his

peers for inclusion in The Best Lawyers in America
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disability insurance law. He understands the specialty
occupation and own occupation features of disability
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doctors practicing subspecialties within radiology,
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the commitments made in their own Policy of insurance.
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For more info on Barry or the firm visit
www.learnaboutwechv.com
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 oneon-one interaction between faculty
and learners.
One-day comprehensive symposium
targets hematologist and oncologist
physicians, NPs, RNs, PAs and pharmacists.
Full program details, including schedule,
faculty, accommodations, and registration
will be available prior to event.
Website: http://www.mayo.edu/cme/
hematology-and-oncology-2014s435
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.
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Pima County Medical Society

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SOMBRERO June/July 2014

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Madeline is Your Connection to

8 PCMS News: University reactivates heart

12 Makols Call: And we thought our Behind the

14 Behind the Lens: Some of Dr. Hal Tretbars old

17 In Memoriam: We have lost doctors Sam

19 The ACA: An update at PCMS from a panel for

22 Practice Management: Dr. Steve Perlmutter on

25 Perspective: Dr. Jason Fodeman warns about

26 Mayo CME: Coming offerings from the folks up

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Dr. Iserson has given us a most remarkable book, wrote Mark K.

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You may reach all locations at

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