Sombrero December 2014

Sombrero
Pima County Medical Society

Home Medical Society of the 17th United States Surgeon-General
DECEMBER 2014
Dr. Gann’s
Diet of Hope Institute
EMRs impracticality
MRCSA on Ebola,
other preparedness
Winter Medical Conference In Telluride Colorado
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Conference directors Robert Berens, M.D. and Alan Rogers, M.D.

2 SOMBRERO – December 2014
Sombrero
Pima County Medical Michael Connolly, DO
Official Publication of the Pima County Medical Society
Members at Large At Large ArMA Board

Vol. 47 No. 10
Society Officers Michael Dean, MD Donald Green, MD R. Screven Farmer, MD

Howard Eisenberg, MD Veronica Pimienta, MD
President
Timothy Marshall, MD Afshin Emami, MD Pima Directors to ArMA
Randall Fehr, MD Board of Mediation Timothy C. Fagan, MD
President-Elect
Alton Hallum, MD Timothy Fagan, MD Timothy Marshall, MD
Melissa Levine, MD
Vice President Evan Kligman, MD Thomas Griffin, MD
Steve Cohen, MD Kevin Moynahan, MD Delegates to AMA
George Makol, MD
Soheila Nouri, MD William J. Mangold, MD
Secretary-Treasurer Mark Mecikalski, MD Thomas H. Hicks, MD
Guruprasad Raju, MD Wayne Peate, MD Edward Schwager, MD Gary Figge, MD (alternate)
Past-President Scott Weiss, MD
Charles Katzenberg, MD Leslie Willingham, MD Arizona Medical
Gustavo Ortega, MD (Resident) Association Officers
PCMS Board of Directors Snehal Patel, DO (Resident) Thomas Rothe, MD
Eric Barrett, MD Joanna Holstein, DO (Resident) immediate past-president
Diana Benenati, MD Jeffrey Brown (Student) Michael F. Hamant, MD
Neil Clements, MD Jamie Fleming (Student) secretary
Executive Director Editor Printing SOMBRERO (ISSN 0279-909X) is published monthly

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SOMBRERO – December 2014 3

Inside
5 Milestones: What’s up with doctors Johnson,
Oscherwitz, Elliott, Donnelly, Kalumullah, and
Weinstein.
8 Membership: Dr. Dietmar Gann’s new Diet of
Hope Institute.
11 In Memoriam: Obituaries for octogenarian
physicians H. Allan Collier, Remo DiCenso, and
Richard J. Toll.
13 Mix At Six: PCMS Vice-President Steve Cohen,
M.D. hosted this one.
14 Ebola: MRCSA addresses the lethal virus and
other preparedness.
17 Perspectives: Dr. Thomas Scully on EMRs; Dr.
Jason Fodeman on Medicaid care delays.
On the Cover
19 Prostate Cancer: An update on the ‘different
Dr. Hal ‘Travelin’’ Tretbar’s ‘Winter Glitter’ photo was taken in
disease.’ Flagstaff late on a December afternoon, using a Nikon D600 with
the wide-angle lens at 24mm. ‘The camera was sit at ISO 160 with
23 Makol’s Call: Dr. Makol considers effects and aperture priority and spot metering, and exposure was 1/50th
perceptions of firearms’ medical damage. second at f.22. The aperture has to be at the smallest setting
(largest number) to get a star effect from the light source.’
26 CME: Credits locally and out-of-town.
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archaeologists in the Peten jungle of northeastern Guatemala,
Milestones and with U.S. government scientists to eradicate parasites in
China. He assisted medical students with case-based instruction at
the University of Arizona College of Medicine—Phoenix last year.
Arizona Chapter ACS Dr. Oscherwitz is a member of
honors Dr. Johnson the Australasian College of
Tropical Medicine, American
The Arizona Chapter, American Society for Tropical Medicine
College of Surgeons honored and Hygiene, American
Kenneth R. “Scooter” Johnson, Committee on Clinical Tropical
M.D., F.A.C.S. with its Lifetime Medicine and Traveler’s
Achievement Award during its Health, the International
Annual Scientific Meeting Nov. Society of Travel Medicine,
15-16 at the Westward Look American Society for
Resort in Tucson. Microbiology, Infectious
Disease Society of America,
The award is given for Dr. Arizona Infectious Disease
Johnson’s many years of Society, AMA, American
membership and service as an College of Physicians, and both
officer of the organization. His PCMS and ArMA.
reported standing ovation
went on for about a minute. He is one of a few hundred
individuals worldwide to hold the Certificate of Knowledge in
Dr. Johnson is a native of Clinical Tropical Medicine and Travelers’ Health issued by the
Wisconsin, where he went to American Society for Tropical Medicine and Hygiene. He is
college and medical school. He did his surgical residencies at credentialed as an Infection Control Practitioner by the
UCLA and in Tucson. In addition to his 35 years of private practice, Certification Board of Infection Control, and is a Fellow of the
he has served as a University of Arizona Assistant Clinical Society for Healthcare Epidemiology of America.
Professor of Surgery, helping to train the next generation of
medical students and surgery residents. Dr. Oscherwitz has served as a resource for British Airways and
Conde Nast Traveler. He offers expert diagnostic and treatment
He is a member of the PCMS History Committee, is particularly services to ill patients referred to him by other physicians and to
interested in local medical history and the medical history of individuals with difficult-to-diagnose problems. The majority of
American presidents, and has appeared often in these pages.
Father of four, Dr. Johnson is retired from practice
and lives in Tucson with his wife, Cathy, having
recently celebrated their 38th anniversary. Happy Holidays
Dr. Oscherwitz joins From Casa de la Luz Hospice
Southern Arizona Agnes C. Poore

CCO and Co-Founder
Infectious Disease Lynette Jaramillo

CEO and Co-Founder
Specialists
Steven Oscherwitz, M.D., a specialist in
infectious fiseases, tropical medicine and
epidemiology, has joined Southern Arizona
“ Since 1998, our staff has worked
diligently to provide superior hospice
care to our community. Thank you
for allowing us to care for your loved
Infectious Disease Specialists in Tucson, ones. We wish you and your family a
practicing with six other physicians including Lisa peaceful holiday season and a
”
Valdivia, M.D. and Clifford Martin, M.D. happy new year.
Dr. Oscherwitz earned his medical degree from
the University of Texas Health Science Center at
Dallas in 1986, and then completed his IM
residency, chief residency and Infectious
Disease Fellowship at University of Texas Health
Science Center at San Antonio.
He completed the military tropical disease
course at Walter Reed Army Institute of
Research in Washington, D.C., and rotated 520.544.9890 | www.casahospice.com
with military physicians at Lackland Air Force Hospice services are paid for by Medicare
base and Wilford Hall Medical Center in San
Antonio. He has traveled as a physician for

his career has been spent caring for critically ill or unstable A copy of the Governor’s official press release listing the duties
hospitalized patients, and he has used his Asian, African, of the council and other team members can be viewed at
European and South Pacific travel experience to assist in making www.azgovernor.gov/dms/upload/PR102114EOCouncil
diagnoses for returning ill travelers as well as making InfectiousDiseasePreparednessResponse.pdf . A copy of the
prophylactic recommendations for departing travelers on both Executive Order can be viewed at www.azgovernor.gov/
adventure and business itineraries. Newsroom/GovEO.asp .
His DrDetective website, www.drdetective.com, is designed as a
portal for questions and record review for patients without CMG: Dr. Donnelly
access to infectious disease specialists near their homes. Dr.
Oscherwitz has been featured in Nature’s Vampires (Discovery
Channel/ Animal Planet), Mystery ER (Discovery Health Channel),
interim CMO
local TV and radio programming and print media. Nov. 3, 2014 – Carondelet
Medical Group announced
Dr. Elliott on governor’s Nov. 3 that its new Interim

Chief Medical Officer (CMO) is
infections disease council Christine Donnelly, M.D. “Dr.
Donnelly took over this role on
Pediatric infectious disease Oct. 21 when her predecessor
physician Sean Elliott, M.D., stepped down after many
professor of pediatrics and years with Carondelet,” CMG
medical director of infection reported.
prevention for the University
of Arizona Health Network, has Her predecessor was Michael
been appointed by Gov. Jan Connolly, D.O., currently on
Brewer to the newly established the PCMS Board of Directors.
Council on Infectious Disease
Preparedness and Response, “Dr. Donnelly has worked in
the UofA reports. family medicine at Carondelet
Medical Group (CMG) for the last 11 years. She is currently the
The council is of leading CMG Board Chair and her practice’s lead physician. While serving
experts in health, human in her new role as Interim CMO, Dr. Donnelly will take on
services, public safety,
additional administrative duties and continue to see patients at
emergency and military affairs,
education, and more. CMG’s Central office at 630 N. Alvernon Way, Tucson.
Dr. Elliott, together with a multi-disciplinary team at UAHN, has “After receiving her bachelor’s degree in microbiology from the
created an “infection-prevention SWAT team,” developing University of Arizona, Dr. Donnelly went on to earn her M.D.
protocols and training for infection control to safely care for Pennsylvania State University. She returned to Tucson to complete
patients and to protect the well-being of staff and clinicians her residency in Family and Community Medicine at the
throughout the network. University of Arizona, and is board-certified in Family Practice.”
“Governor’s councils have been formed before—as in the council “I’m really excited about my new role here at Carondelet,” Dr.
for H1N1—and they bring together the resources of the state to Donnelly said. “It’s the best of both worlds because I get to
improve communication, training and understanding,” Dr. Elliott continue seeing patients while expanding the ways I serve my
said. “Since we are about to enter the flu season, this council is colleagues. As CMO, I have a wonderful opportunity to support
particularly important.”
our dedicated physicians working across the Network.”
According to Gov. Brewer’s office, the council “has been charged
with developing a coordinated and comprehensive plan to ensure “In addition to her full-time work as a doctor over the last
the state is prepared to manage and respond to potential decade, Dr. Donnelly also has served as Associate Clinical Faculty
outbreaks of infectious diseases, including the Ebola virus and for the University of Arizona’s College of Medicine and College of
Enterovirus, in Arizona.” Nursing, and has been a medical relief volunteer in developing
countries around the world every summer, sometimes bringing
Save that date! her children with her for the experience .”
STARonSthe The date is April 18, “We are thrilled to have Dr. Donnelly as Carondelet Medical
Group’s interim chief medical officer,” said Tawnya Tretschok,
Ca m AVENUE
bell A
p
ve
2015, and the reason is the
vice-president and executive director of physician practices at
return of Stars on the
Avenue! Carondelet. “She is highly regarded among her peers and
PRESENTED BY THE
So that’s SOTA, April, 18, patients, bringing with her a wealth of clinical and leadership
experience. She’s a great fit.”
Pima County
Medical Society
2015, 7 p.m. at St. Philip’s
Plaza, Campbell at River,
4280 N. Campbell Ave.
We will have more information
monthly as the time nears!

Dr. Kalimullah joins Massachusetts General Hospital (“Mass General”), both affiliated
with Harvard Medical School.
Skin Spectrum “The Massachusetts-based organization is recognized Dr.

Weinstein for his ‘groundbreaking work in bringing healthcare to
Faiyaaz Kalimullah, M.D., the farthest corners of the state of Arizona and beyond, and for
board-certified dermotologist, his vision and leadership that propelled telehealth to its current
has joined the three-physician state of adoption.’”
dermatology practice Skin
Spectrum at 6127 N. La Cholla “It’s a homecoming for me,” said Dr. Weinstein, who did his
Blvd, Suite 101 (797.8885). It is residency in pathology at Mass General, and participated there in
also the practice of PCMS the very first telemedicine cases in the country, in 1968. That
member Tina Pai, M.D. program is of enormous historical interest, and to receive an
award from the people who are now the custodians of the Mass
Dr. Kalimullah graduated from General-connected program has special significance for me.”
the University of Chicago with
Multispecialty telemedicine got its start in 1961, following a tragic
honors in Near Eastern
plane crash at Boston’s Logan International Airport, Dr. Weinstein
Languages and Civilizations,
said. “City leaders approached Mass General about the possibility
and subsequently earned his
of somehow bringing emergency services more rapidly to the
medical degree at Rush
airport, since the only access to the airport then was through
Medical College, where he was
Callahan Tunnel,” Dr. Weinstein recalled. “Over a period of six
elected to the Alpha Omega Alpha Honor Medical Society.
years they studied the request and devised a plan linking Logan
Following med school he completed his IM internship at University Airport to Mass General by point-to-point microwave. Not only
of Chicago Medical Center. He went on to complete a dermatology that, they developed a total telemedicine solution that is almost
residency at University of Arizona Medical Center, where he was identical to what we use today—electronic
appointed chief resident during his final year of training. stethoscopes, teleradiology, teledermatology, telepsychiatry,
even the first telepathology.”
“Dr. Kalimullah is committed to providing his patients with
expert skin care,” the practice said. “using the latest “The Mass General-Logan International Airport Telemedicine
technologies in aesthetic dermatology. He is particularly Program became the model for two of the first statewide
interested in the use of neuromodulators such as Botox programs, one started in Georgia by Dr. Weinstein’s fellow Mass
Cosmetic, dermal fillers and volumizers, and laser surgery for General resident and friend Jay Sanders, M.D. in 1993, and the
skin rejuvenation. second in Arizona in 1996.
“We welcome him and hope you will get a chance to meet ‘Dr. “Former State Sen. Bob Burns, a machine language computer
K.’ soon!” programmer at General Electric early in his career, heard of the
Georgia program in 1993. He flew to Georgia then back to
Center for Connected Health Arizona with a video recording of what he saw, and consulted
with James Dalen, M.D., then-dean of the University of Arizona
honors Dr. Weinstein College of Medicine, about starting a telemedicine program at
the UofA. Burns energetically took on the role of legislative
Ronald S. Weinstein, M.D., champion. He co-founded the Arizona Telemedicine Program
founding director of the with Dr. Weinstein and they still manage the large, 70-community
Arizona Telemedicine Program enterprise together, 20 years later.
(ATP) at the Arizona Health
“The Arizona Telemedicine Program formally launched in 1996,
Sciences Center and one of the
following two years of planning, and began connecting UA
“fathers” of telemedicine, was
physicians to doctors and patients in Nogales, Ariz., and other
honored for “distinguished rural communities in 1997.”
service in advancing
technology-enabled care Dr. Weinstein is often called the “father of telepathology” for
delivery and help promoting “inventing, patenting and then commercializing robotic
health and wellness,” on Oct. telepathology, a technology that has benefited tens of thousands
23, at the 11th Annual of patients on five continents. He is founding director of the
Connected Health Symposium, Arizona Telemedicine Program, headquartered at the Arizona
hosted by the Center for Health Sciences Center of the UofA, and is executive director of
Connected Health, Partners the T-Health Institute at the UA College of Medicine—Phoenix.”
HealthCare, in Boston, the Among Dr. Weinstein’s honors is the Lifetime Achievement Award
university reported. of the Association for Pathology Informatics for his work leading
“The Center for Connected Health is part of Boston-based to creation of telepathology services around the globe (remote
Partners HealthCare, a non-profit integrated health system, and laboratory diagnostics). He has been president of six medical
was started in 1994 by two of the nation’s leading academic organizations, including the U.S. and Canadian Academy of
medical centers: Brigham and Women’s Hospital and Pathology, and the American Telemedicine Association. n

Membership
Story and Photos by Dennis Carey
Anti-carb crusade
Dr. Dietmar Gann’s Diet of Hope Institute
D ietmar Gann, M.D. can’t be accused of conventionality, so
why should his retirement be any different?
At 70, and a PCMS member since 1979, Dr. Gann decided to end a
very successful cardiology career three years ago and focus full-
time on his Diet of Hope. In September the Diet of Hope Institute
opened its doors at 4892 N. Stone Ave. with Dr. Gann as medical
director and his wife, Elizabeth, as certified nutritional consultant.
Dr. Gann has long been an anti-carb crusader, including doing a
three-part series on it in these pages, and he’s well-versed in the
low-carb/low-fat discussion. The Ganns developed the Diet of
Hope to help patients lose weight, lower blood pressure, lower
cholesterol, reverse the effects of Type 2 diabetes, and reduce or
eliminate expensive medications needed to treat many obesity-
related conditions.
“I finally decided I wanted to focus on the prevention and help
patients without expensive medications and procedures,” Dr. At the new facility at 4892 N. Stone Ave., opened in September,
Gann said. “Many patients have been told that once they develop Dr. Gann’s Diet of Hope Institute now gets billing over its
diabetes, they are stuck with it. They will have to be on expensive cardiology predecessor, Tucson Heart Group. DOHI still has
drugs or insulin the rest of their lives, and it is just not true.” offices at 50 Croyden Park Rd. and 2046 N. Kolb Rd., and is also
in San Carlos, N.M.
It’s not unusual for Dr. Gann to think

“outside the box.” In 1979 he came to
Tucson to start his cardiology practice. In
the 1980s he pioneered the atherectomy, a
non-surgical device that uses rotating
blades to unblock arteries. In 2003, he was
the first cardiologist in Tucson to place a
drug-coated stent in an artery to help
prevent reclogging. He was also one of the
founding cardiologists of Tucson Heart
Hospital, which became Carondelet’s and
morphed into Carondelet Heart and
Vascular Institute at the St. Mary’s campus.
He was born and raised in Germany, where
he graduated from med school at the
University of Tuebingen in 1967. He studied
cardiology and was an Associate Professor
of Cardiology at the University of Miami. He
served as intensive care director at Mount
Sinai Medical Center in Miami 1974-1979.
In 2004 Dr. Gann trekked to the North Pole,
and has conquered the Matterhorn and
Mt. Kilimanjaro. In a talk at PCMS, he said
the polar trip was a great experience, but
not one he would repeat!
While in the low-carb/low fat debate the
Diet of Hope still has some detractors, Dr.

Gann believes the research and results are on his side. The latest
statistics from 1,000 Diet of Hope patients indicate that after the
first phase (six weeks), 330 pre-diabetic patients lost an average
of 17.6 pounds and A1C normalized in 67 percent of those
patients. Diabetic patients (210) on prescription option (PO)
drugs on injection with Byetta or Victoza lost an average of 18.1
pounds, 28 percent normalized A1C, 67 percent stopped or
dropped PO medications, and 43 percent stopped Byetta or
Victoza. Diabetic patients on insulin (90) lost an average of 19.3
pounds, A1C changed and average of -15.7 percent and 59
percent were taken off insulin. Non-diabetic patients (370) lost an
average of 16.6 pounds.
“This is important because it is very expensive to treat diabetes.
Those drugs and insulin are not cheap,” Dr. Gann said.
The cost of going through the Diet of Hope program is $895 for
those not using insurance. Dr. Gann says 95 percent of insurances
will cover the plan. It costs nearly $2,000 per year to treat a
diabetic patient, he says. Many insurance coverages, including
Medicare, will cover the program if it is related to the treatment
of a disease or condition such as obesity, diabetes, or high blood
pressure. Several Diet of Hope patients come from physician
referrals. Nearly 5,000 patients, including 400 physicians, have
participated in the Diet of Hope in the last four years.
It is a three-phase program that takes a year to complete. Phase 1 is Dr. Dietmar Gann has his Diet of Hope Institute seminars—
six weeks in which diets are restricted the most. Diabetics and pre- where else?—at the famous PCMS conference rooms, outside
diabetics are monitored closely at this point because the blood sugar which these folks were recently registering.
levels can drop quickly and medications will have to be adjusted.
Sometimes patients may stay longer in Phase 1 if they feel they have American Diabetes Association and American Heart Association
not made enough progress in six weeks. Phase 2 allows for some did not work.
foods to be reintroduced into the diet. Phase 3 is maintenance.
And don’t get him started on the problems with the “food
The Diet of Hope is a modification of the Atkins diet principle that pyramid”! “The food pyramid was developed by the United States
restricts intake of carbohydrates, and for Type 2 diabetes, various Department of Agriculture,” Dr. Gann says. It promotes
sources of sugar. Physician, cardiologist and nutritionist Robert C. agriculture.” He concurs with Harvard Medical School that the
Atkins published his diet book in 1972 and it became the best- guidelines in the “food pyramid” are not only wrong, but
selling diet book in history. With his own history of M.I., congestive dangerous. He believes that the severe increase in obesity,
heart failure and hypertension, Dr. Atkins died at 72 in 2003. diabetes, and high blood pressure in the last 40 years in the U.S. is
linked to the low-fat, high-carbohydrate diet. The Diet of Hope is
Dr. Gann became interested in using a low-carbohydrate diet to
also gluten-free. Gluten, found in many whole grains, causes an
help lower cholesterol and improve lipid levels when one his
immune reaction in those who have celiac disease. Dr. Gann
patients lost 20 pounds and lowered his cholesterol significantly
believes this is another reason to avoid “food pyramid” guidelines.
using the Atkins. Dr. Gann tried the diet himself, and lost weight
and saw an The Diet of Hope is not
improvement in his considered a high-
lipid levels. protein diet. It is about
portion control,
He followed up with
sufficient proteins,
conversations with the
and good fats.
late Dr. Atkins and was
Vegetables are the
provided much of the
source of
research used to
carbohydrates, and
develop the Atkins
refined carbohydrates
Diet. Dr. Gann did
such as breads, pasta,
some of his own
rice, and cereal are
research. This led him
avoided.
to believe the low-fat,
high-carbohydrate The Diet of Hope
diets being promoted Institute is staffed full-
by the government time by six NPs who
and special-interest monitor patients’
groups such as the Dr. Gann introduces his Diet of Hope Institute office staff at a recent seminar. progress. Dr. Gann has

PCMS’s Basel Skeif, M.D. and George Makol, M.D. attended
the Diet of Hope Institute open house in September. Dr. Skeif Practicing what they preach, Elizabeth and Dr. Dietmar Gann
practices cardiology with Tucson Heart Group and helps at explain their diet’s benefits of exercise to participants at a
the institute, while allergist Dr. Makol is ‘famous’ in Sombrero. PCMS-sponsored Walk With a Doc event Nov. 1 along the Rillito.
also recruited some of his former colleagues to help. Cardiologists

James Evans, M.D., Lionel Faitelson, M.D. and Basel Skeif, M.D. of
Now you’re Tucson Heart Group rotate weekly rounds.

“This is not a substitute for a primary care physician or an
Thinkin’ Smart
endocrinologist,” Elizabeth Gann said. “We provide regular
updates to be given to the patient’s regular physician. We don’t
want patients to stop going to their regular doctors.”
Simplify your communications with Dr. Gann encourages exercise to go along with the Diet of Hope.
Simply Bits state-of-the-art managed They practice what they preach by hiking, playing tennis regularly,
and continue to sponsor a 10K run on Cinco de Mayo with Tucson
voice and data services Heart Group.
Dr. Gann points to the Arctic Inuit and the Masai in Africa as
examples of staying healthy on a high-fat, low carb diet. Both
cultures have little or no clinical heart disease, low blood pressure
and cholesterol, and are free of cancer. The Ganns spent time
with the Masai in 2000 and sampled the diet of goat blood, milk,
and roasted meat.
The Diet of Hope is not that extreme, but it is a lifestyle change.
The Ganns have published two books on the diet. One explains
the diet itself, while the other is a cookbook with recipes to help
stay on the program. Both are available on the Diet of Hope
website dietofhope.org.
“We know it is not easy to change after getting bombarded by the
food industry and government for years,” said Dr. Gann. “It is has
become an addiction like alcohol and tobacco. We believe our
program can provide the support to help our patients get over
ROC #278632 their addiction. It is something they will have to work on the rest
of their lives, even after they leave the program.” n
raising and cutting horses, obtaining his private pilot’s license,
In Memoriam making jewelry, reading, and driving his 1952 MG.”
By Stuart Faxon Dr. Collier was a member of what was then the federation of
AMA, ArMA, and PCMS. He was an adjunct instructor at the UofA
and member of the Southwest Obstetrics & Gynecology
H. Allan Collier, M.D. Association, Central Association of Obstetrics and Gynecology,
and a Fellow of the American College of Obstetrics and
1928-2014 Gynecology. He was a diplomate of the American Board of
Obstetrics and Gynecology. At PCMS he chaired our Medical
Ob-Gyn physician H. Allan Careers Committee 1967-68, and served on the Committee on
Collier, M.D., PCMS member Medical Standards. In 1973 he chaired the Perinatal Mortality
for nearly 30 years, died Oct. 3 and Morbidity Committee.
in Ohio, his family reported in
the Arizona Daily Star Oct. 15. Citing health reasons, Dr. Collier retired in 1990. In 1991 he was
He was 85. elected to the Board of Trustees of the Foundation for St. Joseph’s
Hospital. He was a member of Our Saviour’s Lutheran Church. At
Replying to a Sierra Vista the time of his death Dr. Collier had been “visiting relatives and
Community Hospital query in friends and had just attended a reunion of his high school,” the
1968, PCMS Executive Director family reported. “A faithful believer in God, Allan will be
Wesley A. Barton said Dr. remembered for his love of his family, his wonderful friendships,
Collier was “highly regarded in and his warm manner with his patients.”
the community as a person
and a practitioner.” “Allan is survived by their four children and their families: sons
Keith and Todd; daughter Kim and her husband Joe and their
Harry Allan Collier was born sons, Quinn, Caleb and Cole and son, Michael and his wife, Beth
Dec. 3, 1928 in Raceland, Ky., and their daughters, Kate and Sarah.”*
and attended Holmes High Dr. H. Allan Collier in 1984.
School in Covington. “After A celebration of Dr. Collier’s life was given Oct. 18 at The Lodge on
graduation,” the family reported, “Allan joined the U.S. Army, and the Desert. Memorial donations may be made to the Alzheimer’s
on his 18th birthday in 1946, he sailed on a troop ship into Tokyo Association, Box 96011, Washington, D.C. 20090-6011 (www.alz.org).
Bay, where he would be stationed. While in Japan, he became a *Editor’s note: The survivors information was punctuationally
paratrooper with the 11th Airborne. Allan left the army in 1948 to garbled in the newspaper. We’ve quoted it as it appeared because
go to college on the G.I. Bill.” no source was available to correct it.
He went to the University of Louisville 1948-50, and graduated
from the University of Cincinnati in 1953 with a B.S. in zoology. In
1957 he earned his M.D. at the University of Louisville School of
Remo DiCenso, M.D.
Medicine. He interned at the Navy Bureau of Medicine and
Surgery’s U.S. Naval Hospital at Portsmouth, Va. He did his Ob-
1927-2014
Dr. Remo DiCenso, psychiatrist
Gyn residency at Cincinnati General Hospital.
and PCMS member 1962-77,
Shortly after earning his bachelor’s degree, “Allan married died Nov. 4, the family
Patricia Reuthe in Cincinnati,” the family reported. “They were reported in the Nov. 7. He was
married for 57 years until Patti passed away in 2010. 86.
“Allan knew that he wanted to be a physician. He was accepted at Remo DiCenso was born Dec.
the University of Louisville’s School of Medicine in 1953 as an 3, 1927 in Italy, and his family
alternate from the waiting list. Allan worked two jobs during “emigrated to Buffalo, N.Y.,
medical school to pay his tuition, a task that was not encouraged where he attended elementary
by the school, but showed his resolve to get his medical degree … and high school,” the family
He finished first in his class in his senior year.” reported. “He moved with his
family to Tucson in 1946.”
“After completing his residency in 1962, Dr. Collier moved his
wife and two young sons to Tucson where he would set up his He graduated in May 1952
private practice and escape the Midwest winters.” He joined from the University of Arizona
PCMS that year and established his Ob-Gyn practice at Craycroft as a liberal arts baccalaureate,
Medical Center at the fomer offices of Donald S. Bethune, M.D., Dr. Remo DiCenso in 1962 many years before the UofA
Craycroft Road at East 2nd Street. when he joined PCMS. had a medical college. He
earned his M.D. in 1956 from
“Allan practiced medicine in Tucson until 1990,” the family
University of Southern California School of Medicine.
reported. “During that time, Allan and Patti had two more
children—a daughter and a son. Allan balanced his family and his Dr. DiCenso then did his psychiatric residency at the Veterans
busy medical practice with his many hobbies, which included Administration Hospital (Neuropsychiatric) at Los Angeles. “He

was a practicing staff member at the VA Mental Hygiene Clinic in Los Committee, the Public Health and School Medicine Committee,
Angeles until 1961,” the family reported. “He returned to Tucson in and the Rehabilitation Committee. In the late 1960s he served on
1961 and served as chief at the VA Mental Hygiene until 1962. PCMS’s Liaison Committee to the Rehabilitation Center at the
UofA, and as our representative to the Tucson Area Chapter of
“As well as practicing psychiatry for many, many years, Dr.
the Muscular Dystrophy Association of America. MDA was
DiCenso was a consultant for the Southern Arizona Mental Health
headquartered in Tucson for many years.
Center, Santa Cruz Family Guidance Center, Greenlee County
Human Resources Center, La Frontera, and the Pima County Adult “In 1972 Dick began his relationship with the UofA Intercollegiate
Detention Center. He was a life member of the American Athletic Department,” the family reported, “and he was team
Psychiatric Association, Arizona Psychiatric Society and Tucson physician for the Wildcats until his retirement in 1992. He was
Psychiatric Society. instrumental in development of the Athletic Training Education
Program, designed to prepare futire trainers to care for and
“Our father, a lifelong learner, was multilingual and passionate
monitor athletics at the high school and college levels.
about opera, the humanities, classical music, gardening, and
political and social causes,” the family said. “At the time of his “In 1981 Dick married Glenda and they began a wonderful life full
death, he was attending weekly French classes at Pima of travel, enjoying their time in the Colorado mountains. Dick was
[Community] College and was active in UofA alumni events and a man of diverse interests. He was an avid reader and admirer of
the USC alumni group.” Western art. A natural athlete, he enjoyed show skiing, golf,
tennis and cycling, and played a mean hand of bridge. He was
Dr. DiCenso’s parents, Angela and Giuseppe, and brother Dr. Dino
known to work hard and play hard.
DiCenso predeceased him. His brother Dr. Sabatino DiCenso;
children Cecilia DiCenso Leal, Jerome Martin DiCenso and “Dick was a great father, husband, friend, and talented surgeon
Rosanna Helene DiCenso; and grandchildren Nicolas Leal, Allegra who will be greatly missed by all who knew him.”
Leal, Stefano DiCenso and Sofia DiCenso survive him.
Dr. Toll’s wife, Kathleen, predeceased him in 1994, and he was
A funeral mass was given Nov. 8 at Saints Peter and Paul Catholic also predeceased by his brother, Ted.
Church, with burial at Holy Hope Cemetery, the family reported.
His wife, Glenda; his children by his marriage to the late Ann
“In lieu of flowers, please make donations to the charity of your
MacDonald: Tanis Duncan-Kashman of Wellington, Colo., David
choice … We miss you, Dad.”
Toll of Denver, and Jody K. Toll of Amsterdam, Netherlands,
Richard J. Toll, M.D. survive him. “Dick and Ann extended their family to include
Richard Lochert of Scottsdale,” the family said. “Glenda’s children
1929-2014 completed the family with James Shelby of Scottsdale, Michael

Shelby of St. Petersburf, Fla., and Christina Grisillo of Tucson. Dick
Dr. Richard J. “Dick” Toll, and Glenda’s blended family includes 10 grandchildren and Dick
orthopedic surgeon and PCMS enjoyed each and every one of them!”
member 1963-1980, died Oct. At Dick’s request no memorial services was given, and his remains
26 of Alzheimer’s disease in were scattered in the Animas River in Durango, Colo., the family
Tucson, his family reported said. Memorial donations may be made to TMC Hospice, the
Nov. 9 in the Arizona Daily Star. Alzheimer’s Association, or Planned Parenthood. n
He was 85.
Richard James Toll was born
Corrections
Feb. 5, 1929 in Milwaukee, Wis.
He earned his bachelor’s In our November In Memoriam for Dr. Sandra M. Smith,
degree in liberal arts at the we missed a typo in the final quote, which should have
Univerity of Wisconsin at read: “She leaves behind a large circle of living and devoted
Madison, where he also earned friends who will miss her generosity and unique spirit
his M.D. in 1954. Serving in the immensely.” We apologize for typing “miss” as “mess,”
U.S. Army during the Korean and then missing it in proofing.
War, Dr. Toll interned at Tripler In the same obituary, member comment came up about
Dr. Richard J. Toll in 1963 Army Hospital in Honolulu. who did not work at The Tucson Clinic after the story
when he joined PCMS. After three years in general supposedly derived information from a clinic letterhead
practice in Shawano, Wis., Dr. with their names. But did it? Like an IRS criminal’s e-mails,
Toll did orthopedics residencies in Salt Lake City at Latter Day that letterhead has disappeared and was not revealed in
Saints Hospital and (Shriners) Primary Childrens Hospital. two subsequent searches of the deceased’s file. If the
letterhead never existed, how was that kind of error
“Moving his family to Tucson,” the family said, “he began his created? While we cannot locate the source that took over
private practice in 1963.With his friend and fellow surgeon our editor’s brain, we can certainly confirm that doctors
Morton Aronoff, M.D., they founded Tucson Surgical Specialists. William Neubauer, Ron Spark, Gary Henderson, and
Associated with the Crippled Children’s Clinic, he put to use the Christopher T. Maloney did not work at The Tucson Clinic.
skills and expertise he acquired at the Shriners’ hospital.” We may send our editor for neurological imaging, just in
case it’s a tumor.
In the mid-1960s Dr. Toll served on our Sports Medicine

Mix At Six
By Dennis Carey
Mix draws members, guests
PCMS Vice-President Steve Cohen, M.D. hosted our Mix At Six

Oct. 25. With him at one of the food tables was Anne Hilts,
spouse to our member Dr. Sky Hilts.
A bout 30 members and guests attended PCMS’s most recent

Mix At Six social Oct. 25. PCMS Vice-President Steve Cohen,
M.D. hosted as “provider” of appetizers and drinks, though no
physician should rightly be called “provider.”
Mix At Six events are designed to allow physicians to meet in a PCMS Alliance Board of Directors member Anastasha Lynn and
casual setting without an agenda. Members can meet new Dr. Bruce Lynn stopped by Mix At Six dressed as super-nerds
colleagues, students, and invite non-members to find out about ‘Dr. Amy Farrahfowler’ and ‘Dr. Sheldon Cooper’ from TV’s
the Society. popular show Big Bang Theory.
Additional Mix At Six socials will be given in 2015. Notifications

about them will be in these pages, by e-mail, and on the Society
website pimamedicalsociety.org . n
PCMS President-Elect Melissa Levine, right, with Linda Byrnes

and Dr. Tom Brysacz, enjoyed the Mix At Six casual atmosphere
and conversion.

Ebola
Ebola: Facts, myths, and hazard preparedness

By Dr. Sheldon Marks
T he Medical Reserve Corps of Southern Arizona is pleased that
many PCMS physicians joined more than 150 community
members at MRC’s Ebola and All-Hazards Preparedness Forum
Nov. 1 at the Hilton East on Broadway.
Our expert panel included Dr. Richard Carmona, 17th U.S. surgeon-
general; Dr. Sean Elliott, Professor of Pediatric Infectious Disease at
University of Arizona and member of the Governor’s Council on
Infectious Disease Preparedness and Response; Dr. Josh Gaither,
University of Arizona Assistant Professor of Emergency Medicine and
Associate Medical Director for the University Campus Base Hospital;
Dr. Keith Boesen, director of the Arizona Poison and Drug
Information Center; and Tucson Fire Dept. Battalion Chief Kris Blume.
Key points and take-home messages were:
➢ Ebola, though very deadly and very infectious, is very unlikely
to be a threat to most of us. Patients with Ebola are only infectious
when they have symptoms; fever, headache, myalgias, vomiting, From left are Dr. Richard Carmona, Tucson Fire Battalion Chief
and diarrhea. Yes, these are the very same symptoms as influenza. Kris Blume, Dr. Keith Boesen, Dr. Joshua Gaither, Dr. Sean
We are more likely to die of the flu than Ebola (as will 25,000 to Elliott, Dr. Sheldon Marks, and Tucson Fire Chief Les Caid at the
event Nov. 1 (Les Caid photo).
30,000 people in the U.S. this year). We should all get flu vaccine
and encourage family, friends and patients to do so.
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➢ We all need to be prepared for Ebola or any emergency came in contact with him. They were involved with his care at the
situation. If we prepare for one event, pandemic, disaster, or very end, when his viral infectiousness was at its peak. We do not
major emergency, then we will be better prepared for them all. know why they contracted Ebola, though presumably there must
As physicians, we have an ethical obligation to be ready to step have been a mistake in PPE coverage with exposed skin, or
up and help our community if and when the need arises. This is donning or doffing their PPE. It is important to note that none of
where the Medical Reserve Corps of Southern Arizona plays a the many thousands of people who were exposed to Duncan on
critical role. Are you ready? If you are not a member, why not? his flights from Liberia to Brussels to Washington, D.C. and finally
➢ Ebola virus structure cannot mutate to become airborne. to Dallas became infected, nor did any of his close friends and
family with whom he spent time while he was symptomatic and
➢ Ebola cannot be contracted from mosquitoes. so infectious before he was hospitalized.
Ebola can only be contracted with exposure to fluids from a Protecting yourself and your staff from Ebola requires the very
symptomatic Ebola patient (vomit, diarrhea, sweat, saliva, breast same hand washing and PPE skills and techniques you should be
milk, blood, semen) or the dead body. The infected fluids enter using with every patient to protect yourselves everyday from
the body through the mouth, eyes or nose or through broken other infections you are more likely to acquire, such as Hepatitis C.
skin. You are at risk if you have done any of these four things:
Surviving an Ebola infection is dependent on a number of factors:
➢ Handled the meat/blood of or eaten infected and partially
cooked African fruit bats (the reservoir of Ebola) and/or Sub- ➢ Quality and timeliness of supportive care
Saharan African “bush meat” (chimpanzees, gorillas, etc.). ➢ Health and age of victim (younger and healthier patients have
➢ Handled dying or dead Ebola victims without proper better recovery)
protection and precautions. ➢ Degree of inoculation of Ebola virus
➢ Shared or had contact with body fluids of a person with active ➢ Strain of the Ebola virus (the current Zaire strain has the
Ebola viral infection. highest mortality)
➢ Participated in the care of Ebola patients using inappropriate, Even though there have been 25 prior outbreaks of the five
untested or inadequate PPE, or the flawed donning and doffing known strains of Ebola since 1976, none has been as devastating
of PPE. or long lasting. There are multiple reasons that have come
Texas Health Presbyterian Hospital nurses who contracted Ebola together at once to create a “perfect storm” for this Ebola
after caring for Thomas Eric Duncan were only two of many that epidemic to become so catastrophic for the people of West Africa
Lynn Polonski, M.D.

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and to scare the world. Some of those factors, in no particular
order are:
➢ Extreme illiteracy of the population in Guinea, Sierra Leone
and Liberia.
➢ Extreme poverty with poor hygiene, limited food and clean
water resources.
➢ No effective governmental or medical infrastructure, thus no
containment or control, with no medical care to diagnose, track
contacts and provide critical supportive care such as IV fluids,
oxygen, antibiotics, managing nutrition and electrolyte
imbalances because of the 10 to 15 liters of fluid lost daily from
diarrhea and vomiting. Local healthcare workers often reuse
needles and syringes.
➢ No medical or health education. People do not believe that
Ebola is real, and the governments have no resources to teach At the MRCSA event, infectious disease specialist Dr. Sean
otherwise. Elliott explains what makes Evola virus particularly dangerous
(Les Caid photo).
➢ Extremely remote, isolated jungle villages with poor roads
and porous borders.
Malaria, and Tuberculosis? We are fine until the healthcare
➢ Local people rely on rumours and superstitions for
workers show up, then people start dying.”
information.
The bottom line is, don’t be afraid, but be prepared. Think. Talk.
➢ Strong local customs and rituals for dying, death, and burials
Plan. Prepare.
of the dead.
Dr. Sheldon Marks, PCMS past-president and local vasectomy
➢ Mistrust of government, doctors, and any outsiders,
reversal expert, is a board member of MRCSA as well as a Tucson
especially foreigners.
Police SWAT volunteer. His said his friends and neighbors were asking
In essence these local people are saying, “Why are you all so him questions, even though he knew nothing about Ebola, which is
worried about Ebola when before no one has ever cared about us why he coordinated and moderated the Ebola forum. To find out
dying of so many other diseases including Lassa fever, Marburg, more about MRCSA or to join, contact mrcsa@outlook.com. n

order sets to use following our surgeries. We will check off boxes
Perspecves of things we wish to order, and then write out freehand new
medications and other items. With EMRs—specifically
The fallacy of electronic Computerized Physician Order Entry (CPOE)—physicians use the
computer to locate “powerplans.” These powerplans are related
medical records to the patient’s diagnosis and/or surgery performed. For a total
knee replacement, there is one set. For a lumbar fusion, a
different powerplan. For congestive heart failure, yet a new one.
By Dr. Thomas B. Scully
In a similar manner, one then picks and chooses what items on
President Obama campaigned those plans to order. These are nationally vetted order sets. Many
on reforming our entire of these order sets conform to what are frequently described as
healthcare system, often subscribing to evidence based medicine (EBM). Unfortunately, for
referring to it as antiquated, and many things done in medicine, there is no definitive EBM. This is
often questioning why paper especially true with spinal surgery. Thus, we often use our own
still dominated medical records. way of taking care of patients. That “art” of medicine disappears
The president clearly stated with CPOE. We are forced to use cookie-cutter, one-size-fits-all
that one of his goals was the orders. There is virtually no room for anything else, and no ability
institution of electronic to free-form-type orders. In fact, we have been chastised and told
medical records in hospitals. not to use so-called communication orders. Those orders are the
He has delivered this promise. only means with which one can freely express how you may wish
First through incentives, and things to be done.
now with monetary penalties, By now you may see some of the issues we face. However, I have
most U.S. hospitals currently still not described the biggest problems. To me, one of the most
employ EMRs for both documentation of the patient’s record and unusual nuances of the CPOE is that the computer system “sees”
for physician orders. all the various units of the hospital as unique entities, almost as if
The hospital where I practice recently went full-bore with a new they are entirely different, unrelated individual hospitals!
EMR system. After nearly three months of using it, I can safely say Imagine it! I may be in the PACU (recovery room), but I cannot
that the current systems are sorely lacking and, rather than start—or in computer lingo “initialize”—my orders. No, I can only
making patients safer, lead to more errors. sign them. Then, once the patient arrives at the stated
Please understand that this is not a condemnation of the hospital destination—ICU, Neuro unit—it is up to the nurse to figure
where I choose to practice. They, similar to physicians’ offices, are which of the order sets, or powerplans, I have signed, and then
under the proverbial government gun. Also please do not accuse initiate them so as to start caring for my patient. I cannot flag the
me of Luddite behavior. Far from being technologically challenged, orders, thus letting the nurse know what plan I want to have
I am an early adopter to iPhones, iPads, etc. Rather, the current initiated. No, that would make sense and provide some safety
systems are based on a faulty premise, and the ultimate net. I must simply hope my orders are discovered and the
implementation of this faulty premise drives the current issues. appropriate set is started.
As a surgeon, I understand learning curves. Doing anything new Judging by my description of this, one can easily tell that on more
will take some time to get better. I have given thought that the than one occasion this has not occurred. The powerplans I
issues we face are simply from a learning curve and the described earlier have pre- and post-operative orders. We can
“newness” of EMRs. However, I have used an EMR in my office for customize them to a degree. However, we cannot separate out
more than a dozen years. Although, I don’t make many mistakes the pre- and post-op orders. I cannot think of any reason why this
on it, I have never been able to get back to a level of efficiency exists. However, my pre-op order set is frequently different than
that was present prior to starting our office EMRs. my post-op order set. Thus, I will start a new powerplan for post-
operative orders. To the nurse who must sort thru this and figure
Also, confirming my non-Luddite status, I have helped install out which one to initiate, there is no way for me to “flag” it as
various computers and point-of-sale software for my wife’s retail such. Thus, on more than one occasion, my post-op orders have
store, Embellish (note the cheap plug!) However, there’s a not been carried out, or the wrong ones have been initiated. And
significant difference between her store and a hospital: Embellish this is supposed to be safer?
is closed Sundays. Thus, one Sunday, we spent some time installing
her system. What a difference from what the hospital must do! The other major issues involve note writing. I do not have as
They do not have the luxury of “closing for a day” to install new much quarrel with that aspect. However, many of the notes on
computers, software, etc. Rather, we must still operate, perform patients have all sorts of data throughout the note—lab values,
cardiac caths, endoscopies, do surgeries and have a full-service ED old findings, etc.—but they say nothing. What matters to most
open. All while fundamentally changing how we document what physicians is the assessment and plan part of the note. What is
we do and how we order medications, tests, etc. the doctor thinking and planning for the patient? In many of the
notes I see, that is the part given the least space. There are
Physicians must write orders on patients in the hospital. The various reasons for it. Suffice it to say that the most highly
orders include diet, activity, IV fluids, medications, tests to be educated people in the system are now data entry clerks,
performed, and so on. As surgeons we often have pre-printed entering data, values, and various other items to meet
“meaningful use” for governmental reasons, yet not really doing In a world with infinite resources, expanding Medicaid would no
anything to further care for the patient. doubt be altruistic. Yet in our world with limited resources, it
requires difficult choices and answers to tough questions:
In sum, I realize many will just assume I am another spoiled
surgeon complaining about inevitable changes. Yet I see this as Do states have the resources to timely process the applications of
far more onerous. We have allowed our profession to be taken 17 million new Medicaid beneficiaries? And more importantly,
over by bureaucrats who think they know what is best for our where will the new beneficiaries receive care?
patients and us.
These are crucial questions that demand answers from any state
I see it differently. Central planning is not effective in general, and looking to expand Medicaid for genuine reasons before it goes
certainly not when it comes to something as individualized as down this path. The stakes are fer too high to wing it. We cannot
one’s health and the appropriate care for that health. afford to see the care of the most needy turn into another
healthcare.gov fiasco.
Thomas B. Scully, M.D., F.A.A.N.S., neurosurgeon with Northwest
NeuroSpecialists, was recently elected vice-president of the Presently, flaws in Medicaid statute get passed along to
Western Neurological Society. He has been a PCMS member beneficiaries in the form of restricted access, long waits for
since 1994. appointments, and compromised care. At the same time, the
program is also replete with waste, fraud, and abuse.
Medicaid expansion could Medicaid leaves state regulators and policymakers with few
add to care delays options to control rising program costs other than paying
providers less, or coming at the expense of other state priorities
By Dr. Jason D. Fodeman like education, transportation, and security. A 2011 Kaiser
Medicaid study concluded, “As in previous years, provider rate
The Affordable Care Act’s restrictions were the most commonly reported cost containment
Medicaid Expansion remains strategy.”
one of healthcare reform’s
most hotly-contested As a result, Medicaid reimbursements have fallen well below
provisions. those of private insurers and Medicare. According to the 2012
Kaiser Family Foundation Medicaid to Medicare Fee Index, across
Arguments surrounding the the country Medicaid reimbursements are 66% of Medicare
expansion have largely focused reimbursements for all services and 59% of Medicare primary
on the economic and political care reimbursements. Medicare reimbursements are already
implications of expanding lower than those of private insurers. Sometimes payments from
Medicaid to 138% of the government health insurers for services can be even less than the
federal poverty level. While cost to provide those services.
these ramifications are
certainly worthy of meticulous Due to declining reimbursements and the program’s
debate, there are important administrative hassle, many providers are reluctant to
medical ramifications of the Medicaid Expansion as well. A recent participate. Thus, Medicaid beneficiaries can have a hard time
Wall Street Journal article raises some of these concerns. getting access to timely care. They can encounter lengthy delays
or be forced to depend for care on expensive, overcrowded,
The article cites significant Medicaid backlogs in certain states. disjointed emergency rooms. Both these factors contribute to
This could be made worse by the Medicaid Expansion. According poor health outcomes for Medicaid patients. This is well
to the article, there are hundreds of thousands of people across documented in the peer-reviewed literature.
the country who have signed up for Medicaid and have waited
months for coverage. Residents in California and Tennessee have The Medicaid Expansion is no panacea for these problems, nor
actually filed lawsuits after encountering lengthy delays in was it ever billed as such. Efforts must be made to improve
acquiring coverage. healthcare access and actual healthcare of the uninsured and
underinsured. Medicaid is a program in need of more reforms,
The article reports that in Tennessee, 10,000 Medicaid not more beneficiaries.
applications are pending, and in New Jersey 12,000 are waiting.
In California there are 159,000 Medicaid applications in the Without a strategy to navigate the tough questions, it is very
queue. Generally, states are required by federal regulation to likely that under the Medicaid Expansion, things could get worse
process Medicaid applications within 45 days. before they get better.
These delays in application processing could result in delays in PCMS member Jason D. Fodeman, M.D. is a board-certified
care that allow diseases to fester and become more severe. IM physician practicing in Tucson. He is a graduate of the Cedars
Sinai Internal Medicine residency program and completed a
The article emphasizes an important point. There is a stark graduate health policy fellowship at the Heritage Foundation.
dichotomy between access to health insurance and access to This article originally appeared in the Knoxville (Tenn.)
healthcare. Clearly the latter is the benchmark, and while Sentinel News. n
government health insurance does provide the former, at times it
can fail to offer timely access to the latter.

Prostate Cancer
Why choose
A different disease Desert Mountain Insurance?
By Frederick R. Ahmann, M.D. see why our customers did...
Shona Doughtery, M.B., Ch.B., Ph.D.
P rostate cancer is “one of the most difficult diseases to

understand,” even for physicians, Dr. Frederick R. Ahmann said.
“Why is it different?” Because “we don’t treat 30 to 50 percent of
“Our physicians were so
impressed with how multi-
people, but for others we have to say they are in big trouble.” talented your team was and
Dr. Ahmann, UofA professor of medicine and surgery, and Shona that we were able to get our
Dougherty, UofA associate professor of radiation oncology, were
malpractice, office, workers
speaking on Sept. 9 at PCMS for Pima County Medical Foundation’s
monthly CME presentations, doing A Prostate Cancer Update. comp, health and disability
The biggest risk factor for prostate cancer, Dr. Ahmann said, is policies in what seemed
that inevitable three-letter word: Age. like an instant. I would not
“The number of prostate cancer deaths has been rising since the hesitate to say Desert
1920s,” Dr. Ahmann said, “due to longer lifespans and better
diagnosis. Still, it’s the second leading cause of cancer death in Mountain Insurance is the
men [first is lung & bronchus at 28 percent], but around 1990 best insurance source in
early detection became possible. Ten million men in the U.S. have
prostate cancer right now, and we do almost 1 million biopsies the Southwest!”
per year in order to diagnose it.” – Eric, Administrator
Dietary changes don’t do anything for it, Dr. Ahmann said, and
“we don’t have a great screening test for it.” PSA is good and bad,
he noted: Five to six percent of men will be 4+. “Criteria are not Read more testimonials at
yet perfect for identifying those who have the disease or not.” desertmountaininsurance.com
What do you want to know about any cancer? Dr. Ahmann said
you want to know how common it is, what its biologic behavior is,
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whether we have successful treatments for it, whether it can be PIMA COUNTY MEDICAL SOCIETY
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AZ MGMA MEMBER
He cited 2006 statistics noting that men in China, Japan, and
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highest were in Sweden, Norway, Australia, the U.S., and England.
Death rate stats by race/ethnicity 1999-2003 placed African- ONE STOP INSURANCE FOR…
American men highest at 65 percent, followed by whites at 26.7
■ Physicians & Surgeons
percent. Lowest were Asian-Americans at 11.8 percent. Hispanic
men showed at 22 percent. Familial prostate cancer comprises ■ Other Medical Professionals
about half of the disease cases in men 55 or younger. ■ Healthcare Facilities & Services
What’s good and bad about PSA? “In generic screening and
elevated level is found in up to three to five percent of men over COVERAGE INCLUDES…
50,” Dr. Ahmann said, “but only 20 percent have cancer, and of
those, 40 percent appears to be unaggressive prostate cancers. ■ Professional Liability
We have lowered the death rate from prostate cancer by almost ■ General Liability & Property
40 percent since the introduction of PSA early detection, but at a ■ Employee Benefits
large price of over-treatment.”
He cited the Johansson Data from 2004 in JAMA showing that
between years 15 to 20, progression-free survival fell from 45 to
36 percent, survival without metastases fell from 77 to 51 percent,
and prostate cancer-specific survival fell from 79 to 54 percent.
In the 1989-1999 Scandinavian Prostate Cancer Group update on
“watchful waiting” vs. radical treatment, randomized among 695
men with early prostate cancer, with a 23-year follow-up, 200 of 866.467.3627
347 in the surgery group died, 63 due to CAP, while in the WW 866.467.3611 fax info@desertmountaininsurance.com
group, 247 of 348 died, 99 due to CAP. Eight had to be treated to www.desertmountaininsurance.com
prevent one death, Dr. Ahmann said.
In what he called a “poorly understood U.S. study” of radical Andrew V. Schally, Ph.D. of the University of Miami, noting the
prostatectomy vs. observation (the PIVOT Trial) [NEJM 2012], the potential causes of castration resistance in prostate cancer:
study was designed to enroll 2,000 petients, but failed and only
enrolled 740. Median survival was assumed to be 10 years. “It Emerging dominance of an androgen-insensitive clone that has
was too short,” Dr. Ahmann said. “The study was dramatically been present since malignant transformation.
underpowered. It treated low-risk patients who should have been Transformation of malignant calls to castration-resistant but still
on surviellance.” androgen-sensitive calles due to : Increased number of androgen
In the PLCO Trial [NEJM 2009], from 1993 to 2001, half of 76,693 receptors; mutated androgen receptors; or increased intra-
men at 10 centers were screened annually, with the other half cellular production of androgens. “Total suppression androgens is
receiving usual care. The screening group offered annual PSA for not yet possible.”
six years and DREs for four years. Results were sent to the primary Transformation of malignant cells to total androgen
care physicians and they decided on follow-up. Compliance was independence secondary to mutations in multiple non-androgen-
85 percent for PSA and 86 percent for DRE. Screening in control dependent growth pathways.
group were 40 to 52 percent per year for one to six years for PSA,
and 41 to 46 percent for DRE. Dr. Ahmann noted again that “we are treating with surgery or
radiotherapy large numbers of men who don’t end up benefiting
After seven years there were 2,820 cancers in the screening from therapy. We have successful local therapies that have
group, and 2,322 cancers in the control group. Deaths after seven reduced the death rate and are increasingly better tolerated. We
years were 50 in the screening group, and 44 in the control group. have developed a significant number of new therapies in the last
In a 13-year update of a European PSA screening trial, the 10 to 15 years which have significantly increased the survival of
number of cases found were 7,408 in the screened group, and men with incurable prostate cancer.”
6,107 in the control group. Prostate cancer deaths were 355 Prof. Doughtery provided an overview of the options for active
among ther screened, and 545 among the control. management of prostate cancer and steps involved in delivery of
In a 450-man Canadian surveillance study started in 2000, of two radiation therapy. In counseling patients, cancer is a big word, she
groups of men younger than 70, and older than 70, with PSA of said, so slow down, consider the choices, and place them in
10 or less for the younger men, and 15 or less for the older, they context. “Patients with life expectancies of less than five years
were seen every three months for two years, and then every six should see an oncological urologist and a radiation oncologist.”
months, with repeats biopsies after six to 12 months and then In considering active surveillance vs. active treatment for these
every three years. patients, Prof. Dougherty said, a physician should introduce the
After almost seven years of suveillance (2010), 22 percent of the concept, and consider the expectations for quality of life and the
men died, but only five percent of the 450 men died of prostate patient’s own experience.
cancer. For 70 percent of the men, there was no suggestion of Having choices can be good or bad, she said. If there are too
prostate cancer progression. “However,” Dr. Ahmann said, “there many choices, why? Remember that no choice is perfect,
was evidence of disease progression in 30 percent (135 men) of consider side-effects, sexual function and bladder continence.
the men on the study, and half, after undergoing treatment, had
already failed with a rising PSA level.” She named 11 choices: Do nothing, active surveillance, surgery,
cryotherapy, high-intensity focused ultrasound (HIFU), hormones
What’s new in treatment of incurable prostate cancer? Various (androgen deprivation therapy or ADT, and radiaion therapy that
drugs are being researched. Dr. Ahmann cited the work of Charles may be external beam, radioactive seed implant (LDR
Huggins, M.D. of the University of Chicago and pathologist brachytherapy), high-dose-rate brachytherapy, protons, or a
combination of radiation therapies.

• Macular degeneration
• Diabetic retinopathy
• Macular diseases, e.g., macular
hole and macular pucker
• Flashes and floaters
• Retinal tears
• Retinal detachment
• Central and branch retinal vein
• Pediatric retinal conditions

• Tumors involving the retina
and choroid
• Second opinions
St. Joseph’s Medical Plaza

6561 E. Carondelet Drive
Tucson, Arizona 85710
Northwest Medical Center

6130 N. La Cholla Blvd., Suite 230
Tucson, Arizona 85741
1055 N. La Cañada Dr.,

Suite 103
Green Valley, Arizona 85614

“Treatment targets the prostate gland,” she said, “including the and is minimally invasive. There have been several advances in
gland, seminal vesicales, and pelvic lymph node. The higher the technology, including warming of the urethra and rectum.” Placement
risk, the larger the target.” of the cryoneedles is under ultrasound guidance.
For surgery, inquire about surgical knowledge and discuss open vs. High-intensity focused ultrasound (HIFU) was “originally developed
robotic prostatectomy. Surgery uses unilateral or bilateral nerve for fibroiad,” she said. “It’s for low-risk prostate cancer only.
sparing. Cathetuer use if seven to 10 days and downtime four to Ultrasound is trans-rectal, with a heat transfer of 85-95 degrees
six weeks. Post-surgical radiation therapy is adjuvant or salvage. centrigrade. It preserves the sphincter, rectum and nerves.” The
FDA rejected approval based on issues of safety and efficacy, she
As a sidelight, Prof. Doughtery mentioned Dr. George Goodfellow, said. About 40,000 petients over 15 years were treated with HIFU.
known for medical history in Tombstone for his self-taught
expertise on gunshot wounds. But when he returned to Tucson in Androgen deprivation therapy or ADT is used as a sole therapy or
1891, he performed the world’s first prostatectomy. adjuvant therapy with radiation, Prof. Dougherty said. “There is
lowering of testosterone with testicular suppression, adrenal
Among the 11 choices, cryotherapy involves cryosurgery or cryoblation suppression, and a peripheral blocker. Side-effects include fatigue, hot
of the medium to smaller glands. “It tends to ablate nerves for sexual flashes, muscle wasting, weight gain, appetite stimulationt, decreased
function,” Prof. Dougherty said. “It’s appropriate for radiation failures libido, shrinkage of testicles, muscle/joint pain, mood alteration, mood
lability, hair loss, dry skin, memory issues, cardiac
issues, and osteoporosis.”
Joy
In proton radiation therapy, particles are
accelerated and targeted. But this therapy is
expensive, with limited availability, and not
proven to be superior, Prof. Dougherty said.
“Dats is limited, as it has been available for
fewer than 20 years. It’s no longer approved by
some insurance companies for low-risk disease.”
In high-dose-rate brachytherapy, several
catheters are placed, under general anesthesia,
and their positions identified by CT scan.
Iridium is used, a single, very active radiation
source. “The source is threaded up each
catheter in turn to a predetermined position
and allowed to ‘dwell” there for a specific
length of time before being withdrawn, and
then enters the next catheter,” Prof. Dougherty
said. “There are single treatments, three
fractions on two occasions.”
Radioactive seed implant (LDR brachytherapy)
uses a prostate gland seed implant with a low
dose rate, Eighty to 100 “seeds” are
permanently implanted using five titanium
capsules with iodine or palladium (Cesium).
Carlson ENT Associates would like to Combinations of therapies may be used.
wish you a happy holiday season. “Radiation is like light,” Prof. Doughtery said.
“Several weak beams of this ‘light’ can be
Thank you for your referrals. We aimed at the same target to produce an intense
spotlight.” This is the method of intensity-
appreciate working together to help modulated radiation therapy or IMRT. There is
improve the lives of our patients. “pixel by pixel control of the dose,” she said.
“Shutters open or close part of the aperture. It
gives a more even dose throughout the target,
and can create hot spots within the target.”
Since the target can move, “immobilization is
very important for IMRT, she said.
There are “lots of options for active
treatment,” Prof Dougherty said.
‘Consultations can take one to two hours.
Quality Treatment. Compassionate Care. Convenient Appointments
Surgery and radiation still have the best
outcomes for efficacy and are considered
3172 N. Swan Road • Tucson, Arizona equal for side-effects. Low-rick prostate cancer
is 90-95 percent curable, but do we need to
1521 E. Tangerine Road, Suite 225 • Oro Valley, Arizona treat all, rather than use active surveillance?
“Evolving technology is leading to better
www.carlsonent.com treatments with more cure, fewer side-effects,
and greater quality of life.” n
Makol’s Call
Hiding from our own truth

By Dr. George J. Makol
“
F amiliarity so dulls the
edge of perception as to
make us least acquainted with
slithered down to the shoreline, got off his beach as quickly as we
could, and he returned to peacefully basking under the Antarctic
sun. Reality dawned upon me, as I had almost become fur seal
things forming part of our daily lunch.
life.” So wrote Julia Ward
So let us consider what the average American’s perception of gun
Howe, author of Battle Hymn
and knife violence is, and upon what this is surely based. I
of the Republic, in the mid-
remember watching television as a kid, and wondering how come
1800s.
nobody shot by the Lone Ranger or Tonto ever died. Roy Rogers
Can familiarity lead to a managed to flash his guns without ever hurting anybody, and
perception that has very little people were shot on other shows seem to just slump over and
basis in reality, or can it lead to not even have holes in their shirts.
an alternate reality so powerful
Later on, TV got even further from reality, as members of the “A
that it can actually change
Team” shot hundreds of rounds from automatic weapons,
society? I think so, and I think
making the bad guys cower but never killing anybody. In fact I’m
we have become so
pretty sure I never even saw them wound anybody, which is
accustomed to violence in our society that we now see school
incredible, as spraying at least 100 rounds from automatic
shootings, movie theater massacres, and gun- and knife- related
weapons would probably result in injuries to at least a dozen
violence to a degree that one would never think we would see in
bystanders.
this country.
Even today, the heroes in our movies are almost always shot or
To illustrate the difference between one’s perception and reality:
stabbed at least once, and yet they continue to fistfight, are
Not too long ago I was walking along the shore of one of the
BUZZstory
thrown through walls, or climb up to the second INGof the
RINGING
South Shetland Islands in the Antarctic Ocean when I came
T upon
five huge fur seals basking on the beach. I
I NNITUS
was at a distance, but four of them looked RING BUZZING
up, and then scurried down to the beach
BUZZ Your patients TINNITUS
RINGING
and into the water. One rather bold male was
not about to be intimidated, so he put his
TINNITUS
BUZZING
deserve the TINNITUS
head down and headed straight for me.
RING best hearing HUMMING
Now, my previous experience with seals had HUMM care possible RINGING
RINGING
been only interact with them at Sea World BUZZING
and the London zoo, where they were HUMMING
accustomed to humans and trained to do HUMMINGGING RIN
We offer TINNITUS
tricks. So at this point I half expected him to comprehensive RINGIN G
ING BU
pick up a beach ball, balance it on his nose,
HUMM USG tinnitus
and toss it to me. Such was my perception of
T IN N I T
IN consultations. HU ZZING
seals. Instead, this 400-pound creature
BUZ
Z
G MM
slithered across the smooth sand, rapidly
approaching me as I clicked picture after
G I N ING
picture using my trusty pocket camera.
R IN Learn more about why we are a
I suddenly noticed that the creature filled my preferred audiologist—please visit our website: www.arizonahearing.com
entire viewfinder, and it dawned upon me
that I was not using a telephoto lens. I looked We are preferred providers 520.742.2845
up and he was about 25 feet from me, on most insurance plans. 7574 N La Cholla Blvd • Tucson
flashing four-inch teeth. Fortunately the 520.742.2845
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with me, and stepped in front of me and
tossed his bright yellow tote in the sand
520.648.3277
512 E Whitehouse Canyon Rd, Ste 196
between me and the aggravated creature. Helping you hear your best. Green Valley
The seal stopped quicker than a “Real
Housewife of Miami” would upon coming Janis Gasch, Au.D.
upon a Givenchy bag. My group of tourists Doctor of Audiology, Founding Director
SOMBRERO – December 2014 building to rescue the heroine. This scenario, repeated in movies23
and on television shows hundreds of times, gives the impression tissue than a jacketed bullet. On one of the TV cop shows I saw
that being shot or being stabbed is not so bad, and may be more recently, they showed actual footage from a bar, showing a
like a minor inconvenience. 300-pound gun-toting criminal robbing the patrons and
browbeating the barmaid. The owner came out from the back
Those of us who have served in emergency rooms and seen what
room where he was watching on closed-circuit TV and shot the
happens when somebody is shot or stabbed might have a
large gentleman from across the room with a .357 magnum
different perspective. Modern small arms such as semi-automatic
pistol. The perpetrator dropped like a sack of potatoes in less
pistols send a round of ammunition out at 600 to 1,200 feet per
than one second; he did not make any statements, climb any
second. Rifles have a muzzle velocity that can be three times this
ladders, or even finish his beer. He just fell to the floor dead. This
speed. Bullets do not cut tissue, but they crush tissue, creating a
is “reality”; what we see in movies is Hollywood.
wound channel causing nearby tissue to stretch and expand.
Switzerland is said to have more guns per capita than any other
Different types of bullets cause different damage. For instance,
country in the world. This is primarily why the Nazi regime
hollow-point bullets expand more rapidly and destroy more local
accepted their position of neutrality, and never invaded
Switzerland. Going home to home to
confiscate weapons would have resulted in
many soldiers being shot. And while nearly
every Swiss has a gun in his home, the Swiss
almost never shoot each other. We
Americans seem to make a hobby of it.
I happen to be a gun owner, and have
enjoyed many hours of target practice out in
the wild. I was taught to shoot by the
gentleman who at the time instructed the
Tucson SWAT team on firearms, and he
insisted that I memorize all of the gun laws
and pass a test before he would allow me to
handle a gun. On occasion, while out in the
wilderness target shooting with friends,
another group might show up at the site. If
they took any beer out of the back of their
vehicles, we packed up and took off; alcohol
and weapons should never be mixed.
On a transoceanic voyage many years ago, I
learned to shoot skeet. Upon returning to
school I purchased a trap to launch clay
pigeons (discs), and my frat brothers and I
used it for target practice in the woods. I
liked shooting clay discs and watching them
explode in mid-air, but having seen the
damage done by weapons, however I’m not
sure I could shoot another person, even in
self-defense.
Maybe it’s time that everybody—not just
gun owners—gets firearm education, safety
instruction, and perhaps a glimpse into the
reality of what guns can do to a person. As a
result of contracting TMHP syndrome (too
much horsepower) I was recently ticketed
for exceeding the legal speed limit outside
the city. I went to traffic school for four
hours, and after seeing films of the horrible
effects of traffic accidents, I drove home at
25 miles an hour, terrified that somebody
would go through a red light and smash me
to smithereens, as they showed me countless times upon I cringe when I read of accidental shootings at a teenage
the screen. party, when some dummy pulls the clip out of a semiautomatic
pistol, does not know to check the chamber for a live round,
When we oldsters were in high school diver-ed, we were shown
then “accidentally” shoots his friend, The first thing you
prevention-minded filmstrips depicting horrific results of highway
learn when you shoot is there is no such thing as an unloaded
crashes. They seemed often to come from the Ohio State Police.
gun.
In the late 1950s the James Dean death car, a nearly demolished
Porsche Spyder, went on national tour as a warning about excess There are said to be 300 million guns in homes in America, so it is
speed. If memory serves, for a small fee a Dean fan could actually not likely we will ever get rid of them. We just have to give people
sit in the thing. No one ever showed what happened to the ample reasons to stop shooting each other.
magnetic young star himself in 1955. Sombrero columnist George J. Makol, M.D., a PCMS member
since 1980, practices with Alvernon Allergy and Asthma,
Maybe schools should show videos of real shooting victims,
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Sept. 8: Vasectomy Reversals and Impotence with Dr. Sheldon
CME Marks.
Oct. 13: Common GI Viral Diseases—Diagnosis, Mechanisms of
Local CME from Pima County Action, and Treatment with Claire Payne, Ph.D.
Medical Foundation November 10: Pharmacogenomics—How Medicines Affect

Differing Demographics of Patients with Dr. Timothy C. Fagan.
Pima County Medical Foundation, a 501(C)3 nonprofit organization
derived from and separate from PCMS, presents Continuing
Medical Education lectures from our members and others, on
January 2015
second Tuesday evenings monthly at PCMS headquarters. Dinner Jan. 9: The Association of American Physicians and Surgeons
is at 6:30 p.m. and the presentation is at 7. Tentative 2015 presents a workshop and an update in New Orleans, with hotel
schedule is: and meeting location to be announced. The 21st Thrive, Not Just
Survive Workshop is 1-6 p.m., and Politics and Your Practice is
Feb. 10: Hormonal Replacement Therapy with doctors Jonathan 6 p.m.-9 p.m.
Insel and Robert Kahler.
“Build a healthy, independent practice,” AAPS says. “You can
March 10: Breast Reconstruction Surgery—Implants and break out of the third-party payment straitjacket before
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April 14: Cancer of the Lung—Newer Treatments and Cancer government. After the workshop, stay for dinner and updates on
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May 12: Healthcare Reform 2015—“What the Hell is
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June 9: Heart-Healthy Diet with cardiologists Dietmar Gann and
AAPSonline.org/neworleans .
Charles Katzenberg.
Jan. 23: Clinical and Multidiscplinary Hematology and Oncology
2015: The 12th Annual Review is at the Westin Kierland Resort,
6902 E. Greenway Pkwy., Scottsdale 85254. CME credits pending.
Course targets hematologists, oncologists, NPs, RNs, PAs, and all
interested in comprehensive update of diagnosis and treatment
of hematologic and oncologic disorders. Course presents “new
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hematologic diseases (dysproteinemias, acute and chronic
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MICA_Sombrero12'14ad_MICA_Sombrero05'04ad 11/6/14 11:35 AM Page 1
Holiday Greetings and Best Wishes

for a healthy and prosperous New Year.
(602) 956-5276, (800) 352-0402

www.mica-insurance.com

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Pima County Medical Society

Favorable rates include deep

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

Members at Large At Large ArMA Board

Society Officers Michael Dean, MD Donald Green, MD R. Screven Farmer, MD

Executive Director Editor Printing SOMBRERO (ISSN 0279-909X) is published monthly

Charming Townhome Dramatic Custom Contemporary

SOMBRERO – December 2014 3

“WE ANSWER FOR YOU!”

Southern Arizona Agnes C. Poore

Infectious Disease Lynette Jaramillo

SOMBRERO – December 2014 5

Dr. Elliott on governor’s Nov. 3 that its new Interim

6 SOMBRERO – December 2014

Skin Spectrum “The Massachusetts-based organization is recognized Dr.

SOMBRERO – December 2014 7

It’s not unusual for Dr. Gann to think

8 SOMBRERO – December 2014

SOMBRERO – December 2014 9

also recruited some of his former colleagues to help. Cardiologists

Now you’re Tucson Heart Group rotate weekly rounds.

SOMBRERO – December 2014 11

1929-2014 completed the family with James Shelby of Scottsdale, Michael

12 SOMBRERO – December 2014

Mix draws members, guests

PCMS Vice-President Steve Cohen, M.D. hosted our Mix At Six

A bout 30 members and guests attended PCMS’s most recent

Additional Mix At Six socials will be given in 2015. Notifications

PCMS President-Elect Melissa Levine, right, with Linda Byrnes

SOMBRERO – December 2014 13

Ebola: Facts, myths, and hazard preparedness

Superior medical care, right in your neighborhood!

Our services include:

OFFICES LOCATED IN:

14 SOMBRERO – December 2014

Lynn Polonski, M.D.

SOMBRERO – December 2014 15

16 SOMBRERO – December 2014

18 SOMBRERO – December 2014

P rostate cancer is “one of the most difficult diseases to

20 SOMBRERO – December 2014

• Pediatric retinal conditions

St. Joseph’s Medical Plaza

Northwest Medical Center

1055 N. La Cañada Dr.,

SOMBRERO – December 2014 21

Hiding from our own truth

We know Tucson. We are Tucson.

Barry Kirschner was recently selected by his

* Copyright 2012 by Woodward/White, Inc., of Aiken, SC.

For more info on Barry or the firm visit

An independent member of LAW FIRMS WORLDWIDE

Williams Centre | 8th Floor | t 520.790.5828

SOMBRERO – December 2014 25

Medical Foundation November 10: Pharmacogenomics—How Medicines Affect

26 SOMBRERO – December 2014

SOMBRERO – December 2014 27

Holiday Greetings and Best Wishes

(602) 956-5276, (800) 352-0402

28 SOMBRERO – December 2014

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