February 2016 Sombrero

Sombrero
Pima County Medical Society

Home Medical Society of the 17th United States Surgeon-General
FEBRUARY 2016
A familiar PCMS
president returns
Remembering
Dr. Michael R. Manning
Focus on
Retina Associates
SOMBRERO February 2016
Sombrero
Pima County Medical
Society Officers
Official Publication of the Pima County Medical Society
Jason Fodeman, MD
Jerry Hutchinson, DO
Roy Loewenstein, MD
Kevin Moynahan, MD
Wayne Peate, MD
Debra Polson, MD
Sarah Sullivan, DO
Salvatore Tirrito, MD
Fred Van Hook, MD
Scott Weiss, MD
Leslie Willingham, MD
Jaren Trost, MD (Resident)
Aditya Paliwal, MD (alt. resident)
Jared Brock (student)
Juhyung Sun (alt. student)
President
Timothy C. Fagan, MD
President-Elect
Michael A. Dean, MD
Vice-President
Susan J. Kalota, MD
Secretary-Treasurer
Unfilled / Appointment
Past-President
Melissa D. Levine, MD
PCMS Board of Directors

David Burgess, MD
Howard Eisenberg, MD
Kelly Ann Favre, MD
Members at Large
Vol. 49 No. 2
At Large ArMA Board
Charles Krone, MD
Clifford Martin, MD
Robert M. Aaronson, MD
R. Screven Farmer, MD
Board of Mediation
Pima Directors to ArMA

Timothy C. Fagan, MD
Thomas Griffin, MD
Evan Kligman, MD
George Makol, MD
Sheldon Marks, MD
Mark Mecikalski, MD
Delegates to AMA
Timothy C. Fagan, MD (alternate)
Gary R. Figge, MD
Michael F. Hamant, MD (alternate)
Thomas H. Hicks, MD
Arizona Medical
Association Officers
Michael F. Hamant, MD
Vice President
Thomas C. Rothe, MD
Outgoing Past President
Executive Director
Bill Fearneyhough
Phone: (520) 795-7985
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(520) 323-9559
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Editor
Stuart Faxon
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SOMBRERO (ISSN 0279-909X) is published monthly

except bimonthly June/July and August/September by the
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Inside
5 Dr. Timothy C. Fagan: What can organized
medicine and you do for each other?
6 Milestones: Honors for two of our
members, and a very long journey for

another.
7 Membership: We focus on Retina

Associates.
9 PCMS News: Feds penalize hospitals over
patient safety; med school applications way

up.
12 In Memoriam: Remembering Dr. Michael R.

Manning.
13 Makols Call: America takes the good and

bad for being the big guy on the block.
15 Perspective: Our editor looks at a certain

golden anniversary this year.
17 Environment: Since theres no Arizona without

water, Arizona Town Hall examined it.
26 Continuing Medical Education: Coming

CMEvents.
On the Cover
This physicians photo may look familiar because its from our
January 2011 cover, and so is our 2016 president, IM physician
and clinical pharmacologist Timothy C. Fagan, M.D. He has long
been active in organized medicine and education and has
volunteered to serve as PCMS president again this year. He is
vice-governor and treasurer of the Arizona Chapter of the
American College of Physicians, and serves as an ArMA alternate
delegate to AMA. He is a University of Arizona Professor of
Medicine Emeritus (Ryan Fagan photo).
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What is organized medicine doing for me?

By Dr. Timothy C. Fagan
PCMS President
here are today more

challenges to physician
autonomy, freedom to practice
the medicine that is best for
patients, reimbursement and
physician mental health, than at
any time in the past.
Individual physicians may have
some influence on these issues,
e.g. by contacting state and
federal legislators, or as members of groups dealing with a limited
number of issues. However, with increasing time demands for
documentation, prior authorizations, EMR requirements, etc.,
there is very little that physicians can do as individuals.
The AMA, in addition to its annual and interim meetings, holds a
State Legislative Strategy Conference (SLSC) every year. Its
purpose is to help state, local, and specialty medical associations
with the major challenges facing physicians and society today.
The most recent SLSC was Jan. 7-9, in Tucson and consisted of 11
hours of formal presentations and three hours of workshops, as
well as networking opportunities. It was attended by 129
representatives of state, local, and specialty medical societies, 24
nationally prominent invited speakers, 26 members of the AMA
Board of Trustees, and 36 AMA staff members.
Doctors Fagan, Figge, Hicks, and Jared Brock, PCMS student board
member, represented PCMS. Other Arizona representatives were
Katherine Marsh, UofA medical student; Marilyn Laughead, M.D.;
Chic Older, ArMA CEO; and Pele Fischer, ArMA vice-president for
policy and public Affairs.
Topics included several aspects of digital technology, opioid abuse
and prescription drug monitoring, AMA activity at the federal level,
and various aspects of access to care. Timothy S. Jost, J.D. discussed
the national health insurance landscape, including increased access
through Medicaid expansion and the federal Health Insurance
Exchanges, so that only 11.9% of the U.S. population remains
uninsured, including 10.5% of non-elderly adults. He also discussed
problems associated with these programs, including health
insurance company responses to the programs.
The problem of hospital and health insurance consolidation was
discussed by Thomas L. Greaney, J.D., Joshua H. Soren, J.D. and
Joseph M. Miller, J.D., former counsel to Americas Health
Insurance Plans, the national association of health insurance
companies. Antitrust challenges to mergers ideally include proof
of harm. However, antitrust law allows presumption of illegality
based on market concentration.
AMA has researched health insurance company concentration in
all 50 states, the District of Columbia, and 388 metropolitan
service areas (MSAs) using the HHI, a legally accepted index of
market concentration. This is published in Competition in
Health Insurance: A Comprehensive Study of U.S. Markets,

which is available at ama-assn.org.
This study found that the proposed Anthem-Cigna merger can be
legally presumed to enhance the combined companys market
power in 10 states and 85 MSAs, and would raise concerns
regarding increased power in one additional state and 26
additional MSAs. Fortunately, no MSA in Arizona falls into either
of these categories.
The proposed Aetna-Humana merger would enhance market
power in 15 MSAs in seven states, and raise concerns in 43
additional MSAs in seven additional states. Yuma is the only MSA
in Arizona which falls under the raises concern category, and
no Arizona MSAs are in the increased market power category.
AMA has written comprehensive letters to the U.S. Department
of Justice regarding both mergers, based upon this research and
other information, in order to protest the proposed mergers.
AMA has also testified before the U.S. House of Representatives
Judiciary Committee, and makes extensive materials available to
state and specialty medical societies.
These proposed mergers create two problems. The first is
monopoly, in which there is one supplier of a good, product, or
service, in this case health insurance policies. The second
problem is monopsony, in which there is only one purchaser of a
good, product, or service, in this case health insurance company
purchase of physician services. Thus with high market
concentration, health insurance companies have more power to
dictate how much they pay physicians and to dictate the
conditions.
If individual physicians have an inside track to influencing the
multiple problems which confront physicians today, they should
take advantage of it, in order to deal with these problems.
However, the complexity and multiplicity of problems today
require us to work through local, state and specialty medical
societies, by joining, becoming more aware of the problems and,
if possible, by becoming active in these societies.
If you are not a PCMS member, additional information is
available, and membership applications are available for Pima
County Medical Society at pimamedicalsociety.org and for:
Arizona Medical Association at azmed.org; Arizona Osteopathic
Medical Association at az-osteo.org; American Medical
Association at ama-assn.org; and American College of Physicians
at acponline.org. Other specialty medical societies are easily
found online.
IM physician and clinical pharmacologist Timothy C. Fagan, M.D.,
has long been active in organized medicine and education.
He is vice-governor and treasurer of the Arizona Chapter of the
American College of Physicians, and serves as an ArMA alternate
delegate to AMA. He is a University of Arizona Professor of
Medicine Emeritus.
n
5
Milestones
American College of
Physicians honors Dr. Fagan
Dr. Timothy C. Fagan, to the left with fellow PCMS member

and Arizona Chapter of the American College of Physicians
Gov. Robert Aaronson. M.D., and Award Chair Priya
Radhakrishnan, M.D., receives the chapters Laureate
Award (ACP photo).
Coincidental to his returning as PCMS president, Dr. Timothy C.

Fagan recently received the highest honor awarded by the
Arizona Chapter of the American College of Physicians at its
annual chapter meeting in November 2015.
ACP says the Laureate Award is a way to recognize Fellows and
Masters of the College who have demonstrated, by their example
and conduct, an abiding commitment to excellence in medical
care, education and research, and service to their community,
their chapter, and ACP.
Dr. Iserson returns to

Antarctica
Mary Lou Iserson has put out the word that her husband, EM and
improvised medicine specialist Dr. Ken Iserson, is globetrotting
again.
I just wanted to touch base with everyone before Ken leaves for
Antarctica again, she e-mailed. I will be updating everyone with
news while Ken is on the ice. By the time you read this, Dr.
Iserson will have left to spend the Antarctic winter at McMurdo
Station, so he will be gone for several months.
It will be interesting to compare this trip with the last one, which
was during the summer at McMurdo, Mary Lou said. He is
going down to overlap with the summer doctor for two weeks.
Because of weather, the last flight in or out was in mid-February.
It takes him three days to get to New Zealand, and he spends
two days there filling out paperwork and getting the extreme
weather clothing he needs. Then they have a long flight to
McMurdo, assuming weather is good. Last time he spent an extra
four days waiting for good weather!
6
Chamber Music America

honors Dr. Bierny
Jean-Paul Bierny, M.D., Associate
PCMS member who retired in
2008 from Radiology, Ltd., and
past-president of Arizona Friends
of Chamber Music, was chosen
in December 2015 to receive
Chamber Music Americas 2016
CMAcclaim Award.
This award recognizes extraordinary contributions to the
field of chamber music in a
particular region or locale,
CMA CEO Margaret M. Lioi said,
Dr. Jean-Paul Bierny (Chris
complimenting Dr. Biernys
tireless work in bringing high- Tanz photo, courtesy Arizona
Friends of Chamber Music.)
quality chamber music to the
Tucson area, for initiating your most successful commissioning
program, and for the Piano and Friends series that provides
performance opportunities for young artists.
The award will be presented at a future concert, and Chamber
Music magazine will feature Dr. Bierny in an upcoming issue. The
Arizona Daily Stars Caliente noted that Dr. Bierny co-founded
Arizona Friends of Chamber Music and served as its president for
35 years, saying he helped make chamber music central to
Arizonas cultural landscape.
In 2012 AFCM won
an Arts Patron
Lumie award from
the Tucson Pima
Arts Council, the
paper reported. Dr.
Bierny co-founded
AFCMs Tucson
Winter Chamber
Musical Festival,
where new pieces
commissioned by
the Friends are on
the program, and
world-class
musicians settle in
Tucson for a week to
perform
staggeringly good
chamber music,
Caliente opined.
This years
Chamber Music
Festival is March
13-20. For more
info on the event,
please log onto
arizonachamber
music.org.
n
Membership
Retina Associates focal point

Story and photos by Dennis Carey
phthalmologists at Retina Associates have a kind of tunnel

vision. At their three office locations in Tucson and Green Valley,
they focus only on diseases and injuries of the retina and vitreous.
The four physicians who rotate between the practices three
offices have plenty of work. While the original Retina Associates
opened in 1974, the current version has been in place since 2009
and includes PCMS members Cameron Javid, M.D.; April Harris,
M.D.; Egbert Saavedra, M.D.; and Mark Walsh, M.D.
The main office and surgical center is at 6561 E. Carondelet Drive.
The other Tucson location is at 6130 N. La Cholla Blvd., Suite 230.
In Green Valey they are at 1055 N. La Canada Drive, Suite 103.
All three offices have undergone extensive renovations and
improvements in the last four years, Dr. Javid said. Not only are
we trying to be up to date on the current technologies and
treatments, but we also try to make our patients feel comfortable.
We want the visit to be as smooth and efficient as possible.
Dr. Javid graduated from med school at the University of Illinois in
1994, served his internship at the Scottsdale Mayo Clinic in 1995,
and completed his ophthalmology residency in 1998. He also
completed a fellowship at Massachusetts Eye and Ear Infirmary at
Harvard Medical School before arriving in Tucson in 1999. He
joined PCMS that year and also serves as a clinical associate
professor at the University of Arizona.
Dr. Harris came to Tucson and joined PCMS in 2004. She
graduated from the University of Texas at Dallas Medical School
in 1995, and did her internship at Mayo Clinic in Jacksonville, Fla.
She completed her OPH residency at Louisiana State University,
New Orleans, in 2000. She completed a retinal fellowship at
University of Texas in Dallas in 2002. After two years in private
practice in Vermont, she moved to Tucson. Perhaps anyone
would for the climate change!
Dr. Saavedra has been practicing
in Tucson and a PCMS member
since 2006. He graduated in 2006
from Virginia Commonwealth
University, Richmond, Va. After
an IM internship at Riverside
Regional Medical Center, in
Newport News, Va., in 2001, he
did his OPH residency in at Cole
Eye Institute in Cleveland, 20012004. He completed a fellowship
in medical and retina surgery at
Wilmer Eye Institute at The Johns
Hopkins University 2004-2006.
Dr. Mark Walsh is the latest
addition to Retina Associates,
joining the practice and PCMS in
2009. He graduated from
Washington University in St.
Cameron Javid, M.D., senior physician at Retina Associates,

shows some of the latest diagnostic tools to help in treatment of
retina conditions. Images displayed are from fundus
photography (top), retinal angiography (bottom left), optical
coherence tomography (bottom center) and ophthalmologic
ultrasound (bottom right).
Louis. Mo. In 2003, and finished his IM internship at St. Francis

Hospital in Evanston, Ill. in 2004. His OPH residency was at Johns
Hopkins 2004-2007, and he completed a retina fellowship from
William Beaumont Hospital in Royal Oak, Mich. 2007-2009.
Treating an organ as complex as the eye helps explain why there
are seven OPH sub-specialties. Its also why Retina Associates
does not treat other eye conditions. Conditions treated by retina
specialists include diabetic retinopathy, macular degeneration,
macular holes, retina tears and detachments, pediatric retina
conditions, and ocular tumors.
Ophthalmologists must renew
their board certifications every 10
years. In order to stay on top of
the latest advancements in
diagnostics and treatments,
Retina Associates physicians have
continued their educations.
Depending on the situation, they
can turn to some recent high-tech
innovations.
Retina Associates has three offices in Tucson and Green Valley

that have all been updated in the last four years. State-of-theart workstations help physicians and medical staff provide
the latest treatments for retina conditions.
Fundus photography is a camera

with a low-power microscope
attached to take pictures of the
retina. Filters and dyes can be
used to enhance the cameras
images. Retinal angiography helps
monitor blood circulation in the
eye with the help of contrasting
dyes. Ophthalmologic ultrasound
7
uses high-frequency sound waves to detect different densities in

the eye just as other ultrasound imaging methods do in other
organs. Optical coherence tomography (OCT) provides a threedimensional image of tissue morphology that is more detailed
than traditional ultrasound or MRI.
Recent years have seen treatment advancements such as laser
surgery, vitrectomy surgery, and injections and medications for
macular degeneration. We can improve or stabilize the
condition in 90 percent of the patients we see, Dr. Javid said.
We do try to keep up as much as possible on anything new that
can help our patients.
Patients are usually referred to Retina Associates by primary care
physicians and optometrists who suspect a specific problem
related to the retina. Nearly all of the treatments, including
emergencies, are done at one of the offices.
Our offices are equipped to deal with retina emergencies, Dr. Javid
said. Most hospitals dont have the specialized equipment we have
in our surgery center to work on these kinds of emergencies.
Retina Associates is a leader in ocular oncology. The practice was
part of the Collaborative Ocular Melanoma Study and has a fulltime employee dedicated to coordinating care for ocular tumors.
Retina Associates further commitment to research includes its
current involvement seven active treatment studies, Dr. Javid said
the practice has been one of the most active in clinical trials in
the Southwest. Two two full-time employees are dedicated solely
to research. A list of studies can be found on the practice web site
retinatucson.com.
The practice is looking to the future by providing training to UofA
A strong support staff is one reason Retina Associates says its

physicians can improve or stabilize 90 percent of its patients.
Silvia Neighbor, left, and Ericka Beitman, pictured here with
Dr. Cameron Javid, help coordinate patient care.
OPH residents. They also employ medical scribes for updating

electronic medical records.
The future of ophthalmology is important to us, Dr. Javid said.
It is not just about training, but they help improve our practice.
The scribes get valuable experience as they may move on to
medical careers. They also free up the physicians to concentrate
on patient issues and not spend lot of time updating records.
At its offices and in research, Retina Associates employs 60 staffers
to support its four physicians. It isnt just about the doctors, Dr.
Javid said. I dont think we would have as much success in
helping our patients without the team we have put in place. n
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PCMS News
Massacre memorialized
Feds penalize hospitals over

patient safety
The federal government is penalizing 758 hospitals with higher
rates of patient safety incidents, and more than half of those
places had also been fined last year, Medicare records released in
December 2015 show, according to this December 2015 story by
Joradu Rau in Kaiser Health News.
Among the hospitals getting punished for the first time are some
well-known institutions, including Stanford Health Care in
Northern California, Denver Health Medical Center and two
satellite hospitals run by the Mayo Clinic Health System in
Minnesota, according to the federal data.
Jim Tucker, one of the Tucsonans wounded in the Jan. 8, 2011 mass
shootings, rings a bell for each of 19 victims at a remembrance
ceremony Jan. 8 at Banner-University Medical CenterTucson
Campus. Hospital Chaplain Joe Fitzgerald led hospital staff and
members of the public in a prayer on the fifth anniversary of the
shootings. In the background are architect renderings for a Jan.
8th memorial garden to be built downtown.
A ceremony for hospital staff was given Jan. 8 on the lawn at

Banner-University Medical CenterTucson, the organization
reported. The bell-ringing ceremony was to remember the 19
people killed or wounded in a mass shooting at a Tucson
shopping center five years ago.
The brief ceremony for the hospitals physicians and staff
included a prayer by hospital Chaplain Joe Fitzgerald, and a
reading of the names of each victim, followed by a bell-ringing by
one of the shooting survivors at precisely 10:10 a.m., the
moment when madman Jared Loughner opened fire at a
crowded Congress On Your Corner event hosted by Rep.
Gabrielle Giffords.
There were also comments by hospital CEO Tom Dickson, and an
update on the proposed January 8th Memorial in downtown
Tucson by Crystal Kasnoff, executive director of the January 8th
Memorial Foundation. The foundation is 501(c)(3) organization
with the sole mission of completing a permanent memorial to
the Jan. 8, 2011 tragedy, an unforgettable day in the history of
our community, our state, and our nation, the university
reported. The Together We Thrive capital campaign,
spearheaded by the foundation, is underway to fund the
memorial project. Implementation after the public comment
period is completed. Campaign honorary co-chairs are former
Rep. Gabrielle Giffords and car dealer Jim Click, Jr.
After the shootings in 2011, the wounded were rushed to UMC,
location of the only Level 1 trauma center in Southern Arizona. A
grieving Tucson decorated the hospital lawn with thousands of
flowers, candles, and messages of hope following the shootings.
Every Jan. 8 since the event, the hospital has held a remembrance
ceremony on the hospital lawn.
Sixteen Arizona hospitals were cited, including Tucson Medical

Center, Banner- University Medical CenterTucson, and
Carondelet St. Josephs Hospital. The fines are based on the
governments assessment of the frequency of several kinds of
infections, sepsis, hip fractures, and other complications.
Medicare will lower all its payments to the penalized hospitals by
1 percent over the course of the federal fiscal year, which runs
through this September. In total, Medicare estimates the
penalties will cost hospitals $364 million.
The penalties, created by the 2010 health law, are the toughest
sanctions Medicare has taken on hospital safety, and they remain
contentious. Patient safety advocates worry the fines are not
large enough to alter hospital behavior and that they only
examine a small portion of the types of mistakes that take place.
Medicare plans to add more types of conditions in future years.
I think the penalties are important, said Helen Haskell, a
prominent patient advocate. I think its the only thing that gets
peoples attention. My concern is the measures stay strong or
even be strengthened.
Hospitals say the penalties are counterproductive and unfairly
levied against places that have made progress in safety but have
not caught up to most facilities. They are also bothered that the
health law requires Medicare to punish a quarter of hospitals
each year.
What bothers me the most is when people are improving and
get that penalty, thats money that could be invested into better
care, said Dr. Mark Jarrett, chief quality officer for the North
Shore-LIJ Health System on Long Island, which had several
hospitals penalized this year. Taking the money away, all youve
done is to make it harder for hospitals to function.
The penalties are one prong of the health laws mandate to
leverage taxpayer dollars to improve hospital quality. Each year,
Medicare also docks the pay of hospitals withtoo many patients
comingback within a month, and it doles out bonuses and
penalties to hospitals based on patient satisfaction scores, death
rates and other performance measures.
Nonetheless, Medicare payments to most hospitals continue to
be based primarily on the number and nature of the services they
conduct, a system that health care experts say encourages
hospitals to perform more procedures and focus on complex
and lucrativeones.
9
For hospitals, complications are still profitable, said Dr. Martin

Makary, a pancreatic surgeon and researcher at Johns Hopkins
Medicine in Baltimore who studies safety. Much of what we do
in healthcare still has the incentives aligned the wrong way.
This second round of the Hospital-Acquired Condition Reduction
Program was based on the governments assessment of the
frequency in 2013 and 2014 of infections in patients with central
lines inserted into veins, urinary catheters, and incisions from
colon surgeries and hysterectomies. Those infection rates
comprise 75 percent of Medicares evaluation.
The rest is based on eight other complications, such as surgical
tears, collapsed lungs, broken hips and reopened wounds,
between July 2012 and June 2014. Most of these complications
were part of last years penalty assessments, but the infections
from colon operations and hysterectomies were added to the
calculations this year.
In practice, only about one in six hospitals are getting the penalty
because Congress exempted veterans hospitals, childrens
hospitals and critical access hospitals, which are generally the
sole providers in their areas.
In releasing the numbers, Medicare said average hospital
performance improved for two of the three measures that the
government relied on for the penalties both last year and this
year. Infections from catheters used to collect urine from patients
who are not mobile increased slightly over the year.
The HAC penalties have come under criticism by the hospital
industry and researchers. A paper in JAMA examined the first
year of the program and found that the hospitals that were
penalized were more likely to have characteristics usually
associated with quality. These included accreditation by the Joint
Commission, the presence of the most extensive types of trauma
centers, and more nurses per patient.
Daron Cowley, a spokesman for Intermountain Healthcare in Salt
Lake City, said in a statement that the penalty evaluation is
flawed and there are clearly refinements and changes needed.
Intermountains flagship hospital in Murray, Utah, has been
penalized both years. Cowley said the penalty assessments do
not properly consider the substantial variations in size and
number of procedures performed by different hospitals.
Another paper published in May 2015 in the American Journal of
Infection Control suggested that while health experts recommend
hospitals use urinary catheters as rarely as possible to limit the
chance of infections, those same hospitals may look worse
because the catheters are mostly used in the sickest patients,
who are more prone to infections.
A number of hospitals, such as those run by UCLA Health, have
focused on decreasing the use of catheters in response to the
penalty program. Both UCLA Medical Center, Santa Monica and
Ronald Reagan UCLA Medical Center were penalized this year. Dr.
Robert Cherry, chief medical and quality officer of UCLA Health,
said in a statement that infection rates decreased this year.
Dr. Brian Whited, vice-chair of operations at Mayo, endorsed the
penalties even though they were levied against Mayo hospitals in
Fairmont and Albert Lea. As an organization, were not satisfied
with these results and understand we have work to do to reduce
10
hospital-acquired conditions, Whited said in a statement. We

support the objectives of the Hospital-Acquired Condition
Reduction Program, and all our practices have been developing
improvement strategies and other changes to reduce those
conditions.
Stanford said it had reduced injuries since the end of the period
examined in determining the penalties. Dr. Rajneesh Behal, chief
quality officer, said in a statement: It should be noted, the HAC
program lags and does not reflect our current performance.
A total of 407 hospitals were penalized in both years of the
program.
Nearly 6,500 apply to

med school 2020 class
The University of Arizona College of MedicineTucson reports
that it is outpacing other medical schools in terms of the
increasing number of applicants who aspire to become
physicians. College admissions officials cite several reasons for
the increased interest in the UAs Tucson medical school.
The college has received a record 6,457 applications for
enrollment in the class of 2020, a nearly 14 percent increase over
the 5,667 applications the college received for admission to the
Class of 2019. Its more than two-and-a-half times the 2,500
applications the college received in 2009, the first year it
accepted applications from students outside Arizona, said
Tanisha Price-Johnson, Ph.D., UA College of MedicineTucsons
executive director of admissions and financial aid. The college of
medicine in Tucson limits enrollment to 115 students per year.
Medical schools across the nation are averaging a 6.2-percent
increase in applications this year, compared with last year, the
Association of American Medical Colleges reported in October, 2015.
Of the 6,457 applicants, 883 are Arizona residents, and 2,134 are
from California, the Tucson colleges largest feeder state, PriceJohnson said. A lot of different elements influence the decision
to pursue careers in medicine. Of course, these are people who
want to help others. I think it also has to do with the fact that
nationwide, we are facing a serious shortage of physicians.
According to AAMC estimates, the U.S. faces a shortage of
between 46,000 and 90,000 physicians by 2025.
Price-Johnson and Tejal Parikh, M.D., a 1990 graduate of the
college and now assistant dean for admissions and financial aid,
identified several reasons why the UAs Tucson medical school is
seeing a much higher increase than other U.S. medical schools.
Arizona offers a lot of opportunity to learn about border health
and to work with under-served and rural communities, Dr. Parikh
said. Weve also been getting a lot of recognition over the past
year, she said, citing the U.S. News & World Reports Best
Graduate Schools issue in March 2015, which ranked the UA
College of MedicineTucson 42nd in the nation for primary care
training in family medicine, IM, and pediatrics. There are 145
accredited medical schools in the U.S., according to the AAMC.
The UA College of MedicineTucson also offers programs that
students are unlikely to find at other medical schools, Dr. Parikh
said. For example:

The college offers eight distinction tracks for medical
students who want to delve into such specialized areas as
global health, integrative medicine, and medical Spanish.

The colleges Rural Health Professions Program offers
students opportunities to work in clinics and hospitals in
communities throughout the state.

The colleges Societies Program pairs each new first-year
student with a faculty mentor for all four years of medical
school.

The Commitment to Under-served People (CUP) program
holds clinics for refugees, abused women and children, and
others who have limited access to healthcare. CUP was cited
last year by the Liaison Committee on Medical Education,
the accrediting organization for medical schools nationwide,
as one of the colleges institutional strengths, and
described by numerous medical students as a major
influence in their decision to attend the college.
The college also is receiving applications from people who are
interested in the University of Arizonas partnership with Banner
Health, Dr. Parikh said. The college provides a warm and
welcoming environment for applicants when they come for
interviews, she said. After a recent interview, one prospective
medical student wrote to Dr. Parikh: Going to the UA College of
MedicineTucson has always been a dream of mine. But after my
interview, I came to realize its more than just attending a dream
school. Its about becoming part of something more: a family.
The University of Arizona College of MedicinePhoenix does not
yet have a final report on numbers of
applicants for the class of 2020, but last
year the college, which opened in 2007,
saw a 22.5-percent increase in applications
over the year before; 5,088 people applied
for a chance at just 80 spots in the class of
2019.
evidenced by programs, activities and student and faculty

diversity.
The UA Health Sciences is committed to becoming a national
leader in the training of a diverse faculty, staff, student body and
health-care workforce, they reported. Substantial research
underscores that minority health professionals are much more
likely to treat minority patients and to serve in rural and underserved areas. These professionals bring improved understanding of
cultural diversity and other issues that help better meet the needs
of patients and other health service users from minority groups.
The university noted that according to the U.S. Census Bureau, in
2012, individuals from ethnic and racial minority groups
accounted for more than one-third of the U.S. population, or
about 37 percent. By 2043, minority populations are projected to
become the majority.
According to a 2013 survey conducted by the National Council of
State Boards of Nursing and the National Forum of State Nursing
Workforce Centers, nurses from minority backgrounds represent
19 percent of the registered nurse workforce, and only three
percent identify as Hispanic. At the UA College of Nursing,
minority students represent 39.3 percent of the total student
population, with 11.2 percent identifying as Hispanic.
HSHPS status allows nursing college faculty and students to apply
for additional programs that advance Hispanic health research,
education, and workforce development, and to access resources
for identifying and securing funding for research, including grant
preparation assistance and a bi-national network of potential
collaborators.
n
Nursing college
recognized for
Hispanic service
The UA College of Nursing is only the fourth
nursing school in the U.S. to become a
Hispanic-Serving Health Professions
School member, joining the UA Health
Sciences College of MedicineTucson, and
the Mel and Enid Zuckerman College of
Public Health, the university reports.
HSHPS is a member-based, nonprofit
organization that consists of schools and
colleges of medicine, public health,
nursing, dentistry and pharmacy
throughout the United States. Membership
is granted to schools with a demonstrated
commitment to increasing the Hispanic
health workforce that will serve and
promote the health of Hispanics, as
11
In Memoriam
Dr. Michael R. Manning, 1944-2015

R
adiation
oncologist
Michael R. Manning,
M.D., prominent
Tucson physician
who helped establish
the Arizona Cancer
Center, whose
family stretches
four generations in
Arizona history, and
who joined PCMS in
1982, died Dec. 18,
2015. He was 71.
Born here on Oct.
19, 1944, Michael
graduated from
Rincon High School
and the University
Dr. Michael R. Manning in 1984
(PCMS photo).
of Arizona. Upon
completion of his
undergraduate degree, the family told the Arizona Daily Star, he
pursued graduate studies at the UofA, later spending time as a
medical technician with the 152nd Fighter Intercept Squadron of
the Arizona Air National Guard. He entered the University of
Arizona College of Medicine in the fall of 1969, and completed his
M.D. degree in June 1973.
Dr. Manning spent time at the Cleveland Clinic and later joined
the faculty, and later completed a fellowship at the University of
California at San Francisco. Upon completion of residency in
1977 Dr. Manning joined the University Medical Center faculty
in radiation oncology and helped establish the Arizona Cancer
Center.
During his tenure Dr. Manning participated in numerous clinical
research programs, most notably the use of hyperthermia as a
cancer treatment. This later became the subject of two books
written and edited by Dr. Manning, as well as more than 50
peer-reviewed articles. Upon leaving the University of Arizona,
Dr. Manning helped develop the largest radiation oncology
private practice in Southern Arizona, Southwestern Radiation
Oncology, Ltd., where he practiced with doctors Eric G. Mayer,
Edward E. Rogoff, Robert S. Heusinkveld, Michael J. Moore, and
Silvio A. Aristizabal.
12
Dr. Michael R. Manning in 2007 with a portrait of his father,

pioneer Tucsonan Dr. Wilkins R. Bill Manning (PCMS photo).
Dr. Mannings parents were Marjorie Sullinger Manning and Dr.

Wilkins R. Bill Manning, and the younger physician enjoyed
deep roots in the community, the family reported. His lineage
dates back to former Tucson mayor Levi Howell Manning [known
as General Manning], surveyor-general for the Arizona Territory,
cotton farmer at Canoa Ranch, developer of the Santa Rita Hotel,
the Owls Club, Seinfeld Mansion, and the Manning House.
Dr. W.R. Manning, born 1910 in Tucson, was the co-founding
physician of the UofA College of Medicine, former Arizona
Medical Association president, and former PCMS president,
served on BOMEX [now AMB], and was chief of staff of both Pima
County Hospital and St. Marys Hospital, the family reported. He
died in 1973.
His father was a giant in this town, Dr. Manning told us in 2007.
Colleagues will remember Dr. Michael Manning as a leader,
confidant, and friend, the family reported. Patients have
described him as truly caring, warm, compassionate and
insightful, using accolades such as encouraging, empathetic,
supportive, professional, sensitive, hopeful, advocate, and fatherfigure.
Dr. Mannings wife, Elaine; sister Muggsy Manning Hildreth;
daughter Catie Novogradac; and grandson Mason Manning
Novogradac survive him. He will also be remembered by nieces
Heidi Montijo and Egan Whitley, nephew Michael Hildreth, sisterin-law Clarice Mathis, and many other extended family members,
colleagues, and friends.
A toast to Dr. Manning was given Dec. 30, 2015 at Tucson Country
Club. Memorial donations may be made to the Arizona Oncology
Foundation, 2624 N. Craycroft, Suite 100, Tucson 85712.
n
Makols Call
The bigand everyone else

By Dr. George J. Makol
heres nothing worse than

having Canadian cousins.
citizens will pay for pharmaceuticals, severely elevating the cost

to American consumers. In fact, we pay for basically all the drug
company profits that fund research and development of new
medications. The rest of the world hops on our back for a free
ride.
Perhaps upon further thought,

it is possible there are worse
things, like having amoebic
dysentery, or having to listen to
a 90-minute timeshare
presentation with no exit door
nearby.
A Dec. 15, 2015 article in The Wall Street Journal detailed a study
done of the cost of the top 40 branded drugs in the U.S.
compared to Norway. Prices were higher for 93 percent of these
drugs in the U.S. The Norwegian Medicines Agency reviews
patient data to decide whether a new drug is cost-effective. The
NMA can deny a drug altogether if its not cost-effective, and also
if accepted, the price the government health system will pay for
that drug. Although in Norway a Big Mac costs $5.65, and a gallon
of gasoline is $6, the cancer drug Routaxin costs the NMA $1,527,
while the U.S. Medicare program pays $3,678.
My Canadian cousins on my
mothers side, like me, are the
grandchildren of Lebanese
immigrants, and of course they
are therefore into oil. No, not
olive oil for hummus, but as Jed Clampetts narrator said when
the mountaineer was shooting at some food, ... up from the
ground came a bubbling crude, oil that is, black gold, Texas tea.
In central Canada its buried deep in the tar sands, and has now
proven technologically extractable. Its why gasoline is so much
cheaper around here lately.
Its kind of like the arcade game Whack a Mole in that if you
hammer down the prices everywhere else in the world, one big
mole is going to pop up and bust the U.S. budget. I do love my
Canadian cousins, but when they start up, I merely ask them
what their approximately 44-million person-country would do if
Russia or China attacked it. Would they perhaps send
INGMountie
Of course, that means those Canadian cousins are rich, and that
TINNITU
in itself can be aggravating, but thats not
S
what I find annoying. What gets my goat is
that whenever I see them, they have effusive
praise for their country, and tend to point
TINNITUS
out how they have universal healthcare, and
BUZZING
how Canadians can afford to buy whatever
medication is prescribed by their physicians.
Some of you may have European cousins,
HUMM
and Im sure they sing the same tune. My
answer is to quote P.J. ORourke: You take
your Germany, France, and Spain, roll them
together, and it wouldnt give us [Americans]
RINGING
NG
room to park our cars.
UMMI
RING
BUZZ
RING
RINGING
HUMMING
You may ask, as many of my patients do, why

cant America, the richest country in the
world, afford to provide comprehensive
medical care for everyone, and why are
pharmaceuticals so darn expensive in the
U.S.? As youd expect, I have a simple
answer or in this case two simple answers.
1. The United States shoulders the expense
for nearly the entire military defense of the
Western world. As a matter of fact, among
our allies the highest defense budget behind
ours is one 17th of the amount we spend.
Hence, they have lots of money left over to
pay for healthcare, etc. 2. Drug prices are so
high here because the governments in
Europe, Canada, and Central and South
America arbitrarily set ceilings on what their
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13
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Dudley Do-Right and a couple of dozen other RCMP officers to

face the onslaught? Or, would they ring up the American
president, assuming he wasnt playing golf, and ask for assistance
from our 350-million-person country?
One can of course make the argument that the United States
cannot be the worlds policeman. One president who did not
play much golf but actually ran the country pretty well was
Harry Truman, who always thought that American prosperity
at home depended on the security of our friends abroad. It was
I think 1947, a year before my birth, when President Truman
said, Lasting peace can never be secured if we permit our
dangerous opponents to plot future wars with impunity at any
mountain retreat, however distant. Pretty prescient for a
working-class Democrat, no? Todays Democrats are not so good
at foreign policy. Ill leave arguments about the size of our
defense budget to our esteemed representatives. But it is hard to
argue that the absence of a strong America for the past seven
years under the leadership of a professorial dilettante has left
the world a safer place.
But back to the costs of things medical and pharmaceutical. How
did prices get so high? Our largest purchaser of medications is the
United States government, so one would think they would be a
deft bargainer, considering the clout they should have. Well, our
brilliant representatives when crafting the Medicare D program
outlawed any price bargaining by the government for
medications provided under Medicare D. This is kind of like telling
your spouse when you enter the automobile dealership, just be
quiet and we will take the first price that they throw out, even if
its greater than the window sticker price, so we wont hurt
anyones feelings.
We do have the free market operating, but that didnt work so
well for youthful Martin Shkreli, who recently bought Turing
Pharmaceuticals, and raised the price of its newly acquired but
generic drug for toxoplasmosis, Daraprim, from $13.50 to $750
per pill. He recently was arrested for embezzling money from a
prior drug firm that he owned, called Retrofin, to pay off investors
from his hedge fund, who invested millions that he promptly lost
in the market.
Shkreli had previously come to the medias attention when he
paid $2 million for the only copy of an album made by the group
Wu-Tang Clan. I thought Wu-Tang Clan was a Chinese takeout
joint, and I couldnt figure how he could be such a financial whiz
after paying that much for won-ton soup.
Further evidence of his lack of brillianceor need for greed
occurred in early December 2015, when the holding company
Express Scripts made arrangements with the drug compounder
Imprimis Pharmaceuticals, to make a generic Daraprim for its
enrollees for $1 per capsule. Its pretty hard to get $750 for a pill if
its available for a buckunless youre one of our lawmakers and
buying for the government! Hows that for a real bargain?
Once again, the free market beat the government at its own
game.
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14
Sombrero columnist George J. Makol, M.D., PCMS member

since 1980, practices at Alvernon Allergy and Asthma, 2902 E.
Grant Rd.
Perspecve
1966 + 50 = 2016
By Stuart Faxon
eres a solid, reliable New

Year prediction. It will
happen. Its based on my
decades of the news business
and its reflection of our
obsession with 50.
Fifty is a golden wedding
anniversary. Fifty is the age of a
war, or a natural disaster. Fifty is
the age of an assassination. Or a
hit record. Fifty is the age of 25
twice. Fifty is even the age of this
magazine in 2017. Is 50 really
any different from 49 or 51?
Nope. But it has this permanent
significant ring in our social consciousness, as if the universe cared
that we earthlings think 50 is some sort of achievement.
So in summer 2013 we heard about things significant, or even
trivial, that happened in 1963. In 2013 we heard about 50 years
of the Kennedy assassination, and 50 years of the Beatles coming
here. We even heard about 50 years of Its My Party by the late
Lesley Gore. I wanted celebration of 50 years of Surfin Bird by
the Trashmen, surely the greatest record ever made. But at
least we got 50 years of the Ronettes.
In 2014 we heard about 50 years of everything 1964, and the
same last year for 50 years of 1965. So now here comes 50 years
of 1966. Could be a Baby Boomer thing, but I say its a general
obsession with 50. Perhaps we Boomers are just unjustifiably
amazed at ourselves, or maybe there are too many of us still in
media who have not yet been ousted by its desire for attractive
albeit emptyheaded youth.
Im a newsman, so the unwritten law says I have to talk about
1966 this yearbecause its 50. My 18th year was significant. Id
escaped the public schools, mostly by failing, so I hadnt the
record or inclination to go to college. To me public education was
a form of psychological torture and I was finally free. Id gotten
my first retail clerk job, in a record store. Id started playing drums
and was in my first band (always musical, in younger youth Id
been a choral singer with perfect pitch, then a bongo player, and
later an accordionist).
I was still living at home. Its where you live on Long Island, if
allowed, when you cant support yourself at 18. It was the start of
my nine wilderness years, without direction, as I waited
unknowingly for my front brain to finish developing. As soon as it
did, it told me to go to university, which changed everything, right
down to placing me here upon this page. But thats another
storyperhaps for 50 years of 1975!
In the news business we like to do an advance. That means
telling folks whats going to happen. This is usually preferable to
coverage of something as it happens, or after the fact. So here in
February Im getting the jump on those summer slow news days
by doing 50 years of 1966 now.
I was a political neophyte at 18, just as are todays 18-year-olds,

those undergrads whom speech so easily offends. You think you
have trouble? In my time the president was Lyndon Baines
Johnson, one of the two most dishonorable, despicable men to
hold that office in my lifetime, a bully, a sexual predator, and a
low-information war prosecutor. After he imploded over Vietnam
and refused to run for a second full term in 1968, what did we
do? We elected not his niceguy vice-president, but dark prince
Richard Milhouse Nixon, the other of the two rats.
The so-called Selective Service Act was still in force, and Nixon
tried to conscript me in 1969, and Im so glad he failed. It seems
his army didnt like my hypothyroidism. I would not have made a
good soldier even Id made it through basic training. I probably
would have died in vain in Vietnam, as, unfortunately, all who
died there did. Its amazing that Im even here, like Ishmael, to tell
you. Somewhere I still have my draft card bearing 4F.
Because there was no 24th Amendment, I was age-barred from
voting against Nixon, so my first presidential vote was cast for
George McGovern in 1972. Nixon landslid him, though in two
years hed implode, too. Nixon and Johnson. Fifty years later, even
after they got their supposedly just political desserts, I still hate
those guys The worst presidents weve had since cant compare
to those two cases of advanced jerkism. Who ARE these people
we allow to be president, anyway? Obama? G.W. Bush? People of
no accomplishment? Family dynasties? I could have done a better
job then either of em.
Nineteen sixty-six was also the year when, of all people. Frank
Sinatra returned to the hit parade with Strangers in the Night, a
song he later said he always hated, as he did My Way, though
he continued to fill requests for both songs for the rest of his life.
The song made the top 10 in 20 countries. But I was a rocker, and
I hated it. Now I find Sinatra agreed with me! And he wasnt the
most agreeable guy. That Italo-American toughguy braggadocio
of his was another thing I hated about him. He seemed too like
the bullies who had at me in high school.
Though one of them is as dead as Sinatra, you may hear about 50
years of the Monkees, the fake rock group created from actormusicians for a lighthearted TV show with the general vibe of the
Beatles 1964 movie A Hard Days Night. Hipsters hated them
because they did not play on their own first records. But their
songwriters and session musicians created for the Monkees
music that still stands up today as classic pop. So I bought
Monkees records, just as I bought more hip albums by Frank
Zappas satiric Mothers of Invention, and the incredibly dark New
Yorkers Velvet Underground.
Nineteen sixty-six was fabulous for music, as it was the year of
the Beatles Revolver, the Beach Boys Pet Sounds, The Kinks Face
To Face, The Byrds Fifth Dimension, the debut albums by Buffalo
Springfield and Jefferson Airplane, plus Motown, and gangs of
garage-rockers like Count Five, and Question Mark and the
Mysterians. Just try to forget 96 Tears. You know you want to.
I was also a jazzer, so I dug all the post-bop and hard bop, but not
the avant garde or New Thing, those experiments in modality
and tonality that broke jazz away from its swing and chord
changes. As a New Yorker I was attuned to every issue of down
beat and was absorbed in the critical battles over the new forms
of jazz. I hated John Coltranes cacophonous Ascension as soon as
I heard it. It was so awful, it made the late Ornette Colemans
1960 Free Jazz sound good.
15
This movement was followed by the jazz-rock known as fusion,

which I thought robbed jazz of its melody and attractive
complexity, while rock only contributed volume, and too few
chord changes for jazzs required virtuosity. Later in Boston, I
fought for my side in the local music press, and in the eventual
shakeout, I won. Avant garde never found an audience, and
fusion was the stylistic dead-end Id predicted.
Of high significance to 18-year-old males, 1966 was also the year
of the miniskirt. There exists no heterosexual male of any age
who does not like a miniskirt unless the female it adorns is his
daughter. Im told that in Swinging London, a maximum of
seven inches above the knee was recorded. The miniskirt also
opened up huge marketing possibilities for the hosiery trade, as
miniskirt wearers adopted stockings and especially leotards. The
new colors and textures became important in the total look, Im

told by the 1967 Britannica Book of the Year, a record of 1966.
Yes, its from an actual set of Britannica yearbooks I now keep in
my garage.
Nineteen sixty-six of course was more than fashion, music, and
politics. In medicine the year was concerned with prolongation of
life, accenting mouth-to-mouth artificial respiration, hospital
respirators, external heat massage, the defibrillator, and the
external pacemaker, most of which we now take for granted. It
was the year Houston heart surgeon Michael DeBakey implanted
a plastic artificial heart that sustained a woman through a threeand-a-half-hour valve-replacement operation and, six days later,
enabled her to survive postoperative heart failure. The pump was
removed on the 10th day after the heart had healed.
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It was reported in 1966 that 62,939 cases of

smallpox, with 10,324 deaths had occurred in
the world in 1965. The World Health
Organizations smallpox eradication program
had begun in 1958, but was moving more
slowly than expected. In 1966 a new 10-year
program was begun, looking forward to the
eradication since achieved. Fifty years later
we talk mainly about preserving the
dangerous viruses we have, in order to create
vaccines in case the disease reasserts itself.
Also important in 1966 was the U.S.
government becoming environmentally
active enough to implement the amended
Clean Air Act, notifying the car industry that
exhaust control systems would be required
on 1968 model cars.
Can you believe that so many of us once lived
without integrated circuits? By the end of
1966 this quiet revolution of
microelectronic components saw them well
established in computers, and in military and
space equipment, and they were getting
underway in the consumer market. Now, we
dont even not know what to do with
ourselves that does not require a silicon chip
to complete our circuits. We want our new
cars to act like one big smart-phone.
In one way 1966 sounds like now. The most
serious refugee situations were in Africa
south of the Sahara, but it was because
frontiers of newly independent nations cut
across tribal boundaries, and political
instability caused across-the-board
movements of peoplesnot because
Islamists set out to kill anyone not just like
them.
Myriad such events and activities happened
in 1966 that were far beyond, and more
important than, my sheltered 18-year-old
American life. But I was slowly learning. So
glancing madly backward from 67-and-a-half,
heres to 50 years of 1966!
Williams Centre | 8th Floor | t 520.790.5828

16
Stuart Jazzackal Faxon has been Sombrero

editor not for 50 years, but 18 or so.
n
Environment
The resource
Water is the resource we cannot live without. That obvious fact
was the focus of the 107th Arizona Town Hall Keeping Arizonas
Water Glass Full , Nov. 15-18, 2015 at the Hilton Phoenix/Mesa.
each source; projected future imbalances between water

demands and supplies in various areas; access to water and usage
across various sectors and geographic areas within Arizona;
infrastructure needs and economic challenges; legal challenges;
persistent drought and climate change; political realities;
conservation efforts; and how to prioritize and finance key
investments and other action items. Town Hall reported that
thought not all participants agreed with each of the reports
Partners included Arizona Public Service, Salt River Project,

Arizona Lottery, Freeport-McMoRan Copper & Gold, Arizona
Water Association, Central Arizona Project, EPCOR, Jennings
Strauss Attorneys at Law, and the Nature Conservancy. The three
state universities collaborated to create a
background report as a factual resource for
participants.
Dr. Matthew Clavenna,
Arizona has a long-standing history of water
menagement, the report said, from native
people practicing sustainable forms of
agriculture and building of canals to deliver
water to their people, to the state leaders who
took steps to protect Arizonas rights to
Colorado River water that culminated in the
construction of the Central Arizona Project
(CAP).
Since water is essential for life, it is vital [that]
Arizonans have access to clean-running water.
Fifteen years of drought, increasing growth
pressures, federal regulatory oversight, and
growing environmental concerns, among other
factors, are causing the future of Arizonas
water supply to receive increasing attention.
While Arizonas most populated areas do not
currently face a water crisis, some rural areas
are seeing more immediate problems, and
there is a consensus among experts that,
without action, Arizona will face a gap between
demand for water and available supplies in the
next 25 to 100 years.
Each of the last five decades has seen an
Arizona Town Hall on water. Arizona Town Hall
addressed water in 1965, 1977, 1985, 1997,
and 2004. This was the sixth time a Town Hall
addressed the topic. Because water issues in
an arid state are never settled, there is
consensus that Arizonas leaders and citizens
must continue to develop and refine policies,
practices, and procedures needed for Arizonas
quality of life, economic prosperity and
environment. Intent of the Town Hall was
to discuss how best to improve the reliability
and quality of existing water supplies in the
face of natural and other challenges, and to
identify the means to develop new or
additional water supplies.
Participants considered various sources of
water and unique challenges associated with
MD
Dr. Clavenna was born in Texas but
spent most of his childhood in
Baton
Rouge,
Louisiana.
He
attended Trinity University in San
Antonio for his undergraduate work,
receiving a B.S. in Biochemistry. Dr.
Clavennas desire to personally
help those with ailments, led him
into the field of medicine. He earned his medical degree from
Louisiana State University Medical School in Shreveport in 2009,
where he was elected into Alpha Omega Alpha Honor Society.
While in medical school, he was introduced to Otolaryngology
(ear, nose, & throat), a wonderful field of complex anatomy,
requiring surgical and medical expertise to treat those with
problems of the head and neck. Dr. Clavenna completed a general
surgery internship and otolaryngology surgical residency at
Louisiana State University Health in Shreveport.
Following residency, Dr. Clavenna completed a Fellowship in sinus,
allergy, and anterior skull base surgery at Vanderbilt University in
Nashville, Tennessee. There he trained under internationally
known surgeons, Drs. Rick Chandra, Paul Russell, and Justin
Turner. During fellowship he focused on advanced sinus surgeries,
including management of frontal sinus disease, nasal and skull
base tumors, pituitary surgery approaches, ophthalmological
related procedures and treatment of allergies. Many of these
cases were performed in conjunction with neurosurgeons and
ophthalmologists. One of his most fond memories from fellowship
involved treating a patient emergently transferred to Vanderbilt
for severe sinus disease encroaching on the vision of his right eye.
Using his recently learned endoscopic sinus surgery techniques
with the aid of image guidance, he was able to successfully treat
and drain the infection and preserve the patients vision.
Dr. Clavenna moves to Tucson with the desire of helping those in
the community with their ear, nose and throat related problems.
He is the first fellowship trained sinus and anterior skull base
surgeon to join a private practice group in Tucson. Though he has
a passion for nasal, sinus, and allergy related disorders, he also
enjoys treating the full gamut of ENT related issues, from neck
masses to ear surgery.
Dr. Clavenna in his free time enjoys spending time with his wife,
the outdoors, and looks forward to taking advantage of the
wonderful surroundings Tucson and Arizona have to offer.
www.CarlsonENT.com
17
conclusion and recommendations, the report reflected the

consensus.
Arizona has largely avoided the water shortage crises that have
plagued other states, the report said. Several factors have
significantly influenced Arizonans current use of water. Arizonas
municipal, agriculture, mining, forestry and ranching industries
have shaped Arizonas water priorities as have tribal water
settlements. Instrumental to Arizonans current use of water is
Central Arizona Project, authorized by federal legislation in 1968,
and developed by the Bureau of Reclamation. CAP, a system of
aqueducts, tunnels, pumping plants and pipelines, is Arizonas
single largest resource for renewable water supplies and is
designed to bring water from the Colorado River to Central and
Southern Arizona.
Along with creation of CAP, the passage of the Arizona
Groundwater Management Act of 1980 has significantly
influenced Arizonas current use of water. With the passage of
the GMA, for the first time in our states history, all
responsibilities for water planning and regulation were
centralized in one state agency, the Arizona Department of Water
Resources (ADWR). In addition, the judicial general stream
adjudication proceedings are central to determining the extent
and priority of water rights on the Gila River and Little Colorado
River systems, which in turn impacts water usage.
The factors likely to have the greatest influence in shaping
Arizonas future use of water are land use and ownership;
expected population growth; climate change; droughts; potential
shortage declarations on the Colorado River; water pricing;
The Faces of Casa are the

James Nicolai, M.D.
Associate Medical Director
As a hospice physician, it is
incredibly satisfying to work with
a team of individuals totally
devoted to easing suffering for
patients and their loved ones.
This is why I became a doctor in
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lacking or deteriorating infrastructure; declining groundwater

levels in some areas; legal and political challenges; tribal water
settlements; and economic and agricultural vitality and
sustainability. All these may influence demands on Arizonas
water supply [so] Arizonans need to make tough decisions about
how to manage water resources among competing
considerations, such as agricultural use, metropolitan use, rural
needs, mining use, power use, environmental concerns, tourism
and quality of life issues.
In addition, with a decrease in federal funding for infrastructure,
Arizonans will have to come up with collaborative partnerships,
whether public-private, tribal, or regional, to ensure the necessary
infrastructure needed to provide for current and future water
use. State leaders will be required to pursue innovative ideas
and to address energy issues. It will also require a willingness to
seek investment from the private sector. Arizona will also have to
revise its legal processes, such as the general stream adjudication
process, to more efficiently and effectively define water rights in
the 21st century and avoid costly litigation gridlock.
Resolution of tribal water right claims and addressing core issues
of the relationship between surface and groundwater will be very
important as we move forward. Lastly, Arizona needs to educate
our leaders and citizens about water policy, pricing,
infrastructure, delivery and other matters so as to impact the
manner within which Arizonans consume water.
Successes and challenges in managing Arizona water
Arizona has managed its water resources reasonably well
overall, especially relative to some other Southwest states, but
results have varied across Arizona regions.
For example, management of groundwater
resources has generally been better in the
Active Management Areas (AMAs) and
Irrigation Non-Expansion Areas (INAs)
created under the GMA than in other areas
of the state. Infrastructure and other water
management resources also vary
significantly in quality and availability
among Arizonas urban, rural and tribal
communities. To the extent that Arizonas
management of water in its first century of
statehood was largely a success story, many
factors contributed. Our elected officials
and other dedicated community leaders
have shown vision and worked
collaboratively to address Arizonas
inherent water-related challenges,
establishing Arizona as an early innovator
in effective water management. This
approach has included the GMA, CAP,
SRP, irrigation districts, and investments in
vital infrastructure. Without
entrepreneurship, coordination, and
mutual respect among stakeholders, these
successes would not have been achieved.
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Hospice services are paid for by Medicare
18
We must confront our water management

challenges, the report said, including
environmental challenges such as climate
change, drought and degradation of our forests and environment.

Other challenges are in infrastructure planning, funding, and
maintenance, particularly in rural and tribal communities. Legal
and political factors also present challenges in various forms,
including litigation and other conflicts among users of shared
water resources, complex and interrelated laws and regulations,
and a lack of coordinated planning in certain areas of the state
(e.g., some areas not covered by AMAs or INAs). And, of course,
projected population and industrial growth over the next several
decades will substantially increase our demand for water,
requiring both augmentation and conservation of water
resources within Arizona.
We are also victims of our past successes in the sense that,
because Arizona has done a relatively good job of securing a
reliable water supply and is not currently facing a water crisis,
many of our citizens take water delivery, quantity and quality for
granted and are not as educated as they should be about the
supply/demand gap.
A preeminent concern facing all Arizona communities is
financial, that is, Arizonas ability to obtain the necessary funding
for maintaining and updating degrading and failing infrastructure
as well as building new, high-tech infrastructure. If a portion of
new funding is to come from the population base, rural areas will
be greatly impacted because the population base may not be
sufficient to raise the necessary funding. Further, with federal
funding on the decline, state funding for water and regulatory
agencies, such as ADWR, the Water Supply Development
Revolving Fund and ADEQ are critical. Investment from private
industry will be necessary.
Funding problems are exacerbated by conflicting views and
divergent water use interests among Arizonas population and
special interest groups, all of whom impact the political process.
Uncertainty about the effect of human, environmental, and
economic factors on future water demands may deter investment
in infrastructure and technology that may be required to meet
those demands. The unresolved reserved rights claims of tribal
communities and other federal lands further complicate the
general stream adjudication.
Another challenge is access to quality water in remote areas, or
the infrastructure necessary to deliver water to remote areas,
especially in tribal communities. Because tribal communities
control a significant percentage of current and future Arizona
water supplies, these communities will likely play a significant
role in meeting future water needs.
Inability to decide between competing value judgments and the

best use of Arizonas water resources impedes effective and
timely improvements to Arizonas water management policies.
Some advocate for limited agricultural use, restricted growth in
water limited areas or more astute forest land and watershed
management. Further, the great debate over the impact of
climate change on the environment and water in particular raises
new issues. Water management techniques such as promoting
close proximity between pumping and recharge or
replenishment, augmentation, use of reclaimed water and
desalination must be addressed. The manner and costs
associated with the transportation of water to areas in need are
also challenges.
Lack of education on water issues among Arizonas citizens and
current leaders also presents a significant challenge. Education
efforts should focus the value and importance of water to our
quality of life, conservation efforts, the value of banking water,
and the public perception of water quality, the relationship
between water and energy and tribal water rights. Current
partisan politics only add to the challenges and limit solutions. As
a constituency, we must learn how to better communicate to our
political leaders the importance of water management and the
problems we face as well as offer potential solutions. Leadership
surrounding these issues will continue to be essential moving
forward with a water management system that will sustain
Arizonas water resources for the next 100 years.
Innovation and technology, land use, and the economy
The two most significant Arizona water sources are
groundwater, and surface water from the Colorado River, but
other rivers, groundwater, and reclaimed water also provide
substantial quantities of the water Arizonans use. Within each of
these three principal resource categories are multiple subcategories, such as water obtained from rain and snowfall,
recharge and banked water, reclaimed water, graywater, and
stormwater runoff. On a statewide basis, Arizonas existing water
resources are generally adequate to meet our current needs,
although both the portfolio and adequacy of water resources
vary by region in the state. For example, many rural areas that do
not have access to CAP water rely heavily on surface water from
local rivers and streams, as well as groundwater. In some parts of
Arizona, including the Navajo Nation, running water is not
available to many residents. Water quality and affordability are
also growing issues for some communities.
Arizona must protect its existing water portfolio, specifically its
19
Colorado River supply. The structural deficit on this river must be

addressed to ensure the maximum use of this vital resource.
Arizona will also need to expand its portfolio of water resources
to meet future needs, in light of increasing demand driven by
population growth and other factors, as well as the fact that a
substantial portion of the water we currently use is groundwater
that is replenished slowly.
Many steps can and need to be taken to augment Arizonas
existing water portfolio. Although reclaimed water is already
being used for limited purposes, we should pursue strategies to
expand its use, including for commercial and industrial purposes
and potentially for direct potable reuse. However, using
reclaimed water for human consumption will require changes in
the publics perception. We should continue to enhance our use
of technology to make water usage more efficient in all sectors.
We should invest in water infrastructure and begin to explore the
increased use of brackish water, and existing and new
desalination facilities. We should address the proliferation of
invasive non-native species, such as the salt cedar, that have
contributed to depleted river flows and the degradation of
riparian areas, as well as implement sustainable forest
management programs. We should implement better flood
control policies and other measures to more effectively harvest
rainwater and storm water runoff.
Other short- and long-term options may include increasing
storage capacity, cloud seeding, and importing water from other
regions outside the state via cross-country pipelines or rail
systems, which could become cost-effective in the future. While
allowing the movement of existing and future water supplies
from one user to another is worth exploring, it is a highly
sensitive and controversial topic that has the potential to pit
regions, communities and industries within Arizona against each
other. There may, however, be opportunities to pursue voluntary
redistribution of water resources through collaborative
infrastructure planning and market-based systems in which
willing buyers and sellers can buy, sell or lease their rights within
the existing legal framework.
Impacts of innovation and technology have a beneficial impact
20
on Arizonas water use, generally allowing for a more efficient use

of water. Over the years, Arizona, through ADWR and other
agencies, has developed innovative policies, practices and
institutions to manage its water supply. Already existing and
implemented technologies that positively impact water use are
automatic water readers, automated leak detection systems,
improvements to nano-filtration, modernization of ditch systems,
field leveling, better underground water storage capabilities and
conjunctive use of aquifers. However, there are some existing
technologies that are not being used statewide because they can
be cost-prohibitive. For example, technologies exist for the
effective recycling of waste water, but some communities cannot
afford to construct the necessary facilities. In order to allow for
the implementation of existing technologies in areas where such
technologies are needed, more funding is needed. Future
innovation may require significant financial commitments from
the federal, state, and local governments as well as the private
sector. Arizona should also explore different water pricing
strategies, including financial incentives to those who conserve
water efficiently and effectively.
Arizonans must also invest in stakeholder-driven research and
development for increased water use efficiency and innovation in
agricultural, mining and manufacturing industries, and Arizonas
universities should play a pivotal role in advancing research in the
development of water innovation and conservation. Future
innovation will involve looking deeper into the pricing of water,
the feasibility of the treatment of brackish water, desalination,
and allowing reclaimed water to be made available as potable
water. However, to implement such innovations, Arizona will
need to address regulatory requirements that currently prohibit
these types of innovations as well as obtain buy-in from its
citizens and elected officials, through education and awareness.
Lastly, Arizona needs to provide an education system that trains
future water experts and provide programs of study that foster
innovation and best management practices.
Water effects of land use and development
Land use, development, and population growth have
widespread impact on water use. For example, increased
development in arid rural areas can affect the availability of water

through wells by decreasing groundwater supplies. High-density
urban residential developments typically use less water per
capita than low-density developments, which has mitigated
growth in water demand as Arizonas population has increased
and water usage has shifted in some areas from agricultural to
municipal or commercial uses.
Demographic trends associated with population growth affect
water usage. Millennials have tended to seek out smaller houses
and a desire to use fewer natural resources. Conversely, water
availability and usage also shape our land use, development, and
other policies. To the extent feasible, we should use economic
incentives and other tools to encourage growth in areas where
water supplies are relatively abundant, and discourage
development in hydrologically sensitive areas, such as state trust
lands that do not have adequate water supplies attached to
them. Developing such lands creates the risk of leapfrog or
checkerboard development throughout the state that places
additional strain on, increases the cost of, and decreases the
efficiency of our water supplies and usage.
Some communities should consider implementing assured or
adequate water supply programs or net-zero approaches to
water use as a condition to approving new development. We
should also create appropriate incentives for conservation of
water resources, even in areas where water supplies are
abundant. We should explore innovative strategies to make our
urban communities lower-impact and less sprawling. Local
governments and property owners should be provided incentives
to develop policies that link land use, economic development,
and water usage in ways that advance local priorities.
Finally, we should seek to build upon the successes of existing
programs, such as the AMAs and INAs implemented as part of the
GMA. Development within tribal communities, which comprise
nearly 28 percent of Arizonas land area, presents its own set of
challenges. For example, tribal lands are held in trust by the
federal government for the benefit of tribal members, but some
tribal lands are leased to industrial facilities and uses that may
endanger water quality and may affect availability of water. It is
important to take into account the cultural traditions of tribal
communities with respect to their history on the land. Mending
the trust and cooperation between Native Americans and other
communities is essential to good regional land development and
water management decisions.
development, may already discourage economic engines from

investing in Arizona. Thus, Arizona must inform the public about
the current stability of its water resources, successes in
conservation, and existing strategic plans to secure its water
supply so as to entice businesses to invest in Arizona. Arizona
must also highlight groups like the Water Infrastructure Finance
Authority of Arizona (WIFA) and the Statewide Water Advisory
Group (SWAG) so as to assure long-term investors that Arizona is
a good place to do business.
Further, to attract additional capital and move our economy
forward, Arizona needs to have more definitive certainty about
its water supply, which may involve streamlining the water rights
adjudication process and tribal water rights settlement processes.
Statewide, one of the best investments Arizona could make is to
assure that ADWR is funded to accomplish its mission. Additionally,
public education about water issues and conservation, uses and
practices would be an excellent investment.
Arizona must also appreciate and preserve the quality of
Arizonas environment, including ensuring continued use of
water for recreation. For Arizonas urban economies, Arizona
must provide incentives for industry and business to use less
water, identify and provide incentives for multipurpose projects
that can benefit multiple users and entities by providing new
water supplies.
Arizona must also re-think the engineering of water deployment
systems, including using non-potable sources of water for all nondrinking water uses. For rural economics, Arizona must encourage
and fund alternative water sources so as to avoid further depleting
groundwater through pumping. Arizona must understand and
quantify the economic value of agricultural water uses.
Arizonans who are not Native Americans should take into

account the water needs and circumstances on tribal lands to
help preserve Arizonas overall water supplies and to build a more
trusting and cooperative relationship with respect to both land
use and water use. The relationship between SRP and the Gila
River Indian Community, which provides for the banking of tribal
water in exchange for certain economic benefits to the
community, may serve as a model for future collaborations
between tribal and other communities.
Water as driver of economic growth and sustainable
environment
Water and the economy are inextricably linked. When a
particular industry is limited in its access to water, there are
significant third-party impacts beyond that industry. Misperceptions concerning Arizonas current water supplies, i.e., that
Arizona may not have adequate water to sustain industrial
21
Arizona must work with tribal communities and the federal

government to ensure that any lack of water resources is addressed,
and that tribal water rights are secured and efficiently used. The
settlement of tribal water rights would have many benefits,
including greater certainty for tribal economic development and
other stakeholders, and fostering better relationships and
opportunities between tribal and non-tribal communities.
Conservation and financing its role
Although it is not a panacea for Arizonas water issues,
conservation has playedand will continue to playan important
role in helping Arizona meet its water needs. Efficient use of water
is imperative in an arid climate, and Arizona has done a good job
in the past of implementing conservation measures. Agriculture
has made great strides in conserving water resources, thanks to
technological advances and improved farming and irrigation
methods. We should expand our efforts to conserve water in the
future so that, when combined with our augmentation efforts
discussed elsewhere in this report, we will be able to close the
projected future gap between water demand and supply.
The state and Arizonans can do a number of specific things to
conserve water. Water pricing strategies, including tiered and
seasonal rate structures, can be and are used to promote
conservation while maintaining the financial integrity of utilities.
Building codes that encourage low-impact development,
installation of low-use appliances and xeriscape landscaping are
effective conservation tools.
We can explore opportunities to make better use of graywater in
homes and other settings, reduce evaporation, and pursue
technological innovations that prevent unnecessary water
overuse. Utilities can continue to empower their customers to
conserve water by providing additional information about water
usage, cost and conservation techniques in billing statements and
through other media.
There are also opportunities for agriculture to further conserve
water through better flood irrigation techniques, drip irrigation,
the installation of concrete ditches and other strategies. Many
renewable energy technologies consume less water than
traditional generation facilities and these should be encouraged.
Arizona needs to adopt a flexible approach that fosters
collaboration and public-private partnerships, and allows
communities to focus on localized solutions that meet their
unique needs and circumstances.
We should design and implement conservation programs that
give users choices rather than mandate (or prohibit) specific
practices. Moreover, Arizona should focus on incentives, such as
tax credits, water rebates and similar programs, rather than
penalties. Finally, improved education is critical. Arizona must
create and enhance a culture of conservation by focusing on
consumer awareness and conscientious use of water. We also
need to provide education on water conservation opportunities
and strategies for elected officials, civic leaders, utilities, planning
departments, students at all levels of formal education, and
citizens at-large. Arizonans should understand their water
resources, including the sources of water in Arizona, how it is
delivered, why it is important to conserve water, and how they
can contribute to the future security of Arizonas water supply.
Funding current and future water needs
Arizonas available funding sources to address current and future
water needs are limited in that, with few exceptions, current
22
funding for water needsincluding infrastructure, operations,

delivery and maintenanceare borne by the end-users of water
through the pricing of water, user fees, and taxation. Existing
additional funding sources consist of borrowed money, private
equity, revenues from utility operations and cooperatives, Water
Infrastructure Finance Authority (WIFA) loans and grants, and
federal infrastructure funds. However, statewide funding programs
are inadequate to address future water needs funding, and it is clear
that diversification of funding will be needed for sustainability.
Some would argue that end-users should continue to pay both for
their water usage and for the infrastructure necessary to deliver
water, making water a fee for service commodity. However, this
model is more problematic in our rural and tribal communities.
Others maintain that the price of water needs to be increased.
However, merely increasing the price of water is not enough to
ensure long-term availability. While Arizona has funding
mechanisms in place, like WIFA, the Arizona Water Protection
Fund, Natural Resource Conservation Districts, the Water
Resource Development Fund (WRDF) and the Water Supply
Development Revolving Fund, these mechanisms are underfunded and under-used. In order to increase, diversify, and
stabilize funding Arizonans must first ensure funding of existing
funding mechanisms, and this would likely include additional
assessments and increased user fees.
If we do not believe Arizonas legislature would enact laws
providing an increase to water funding, then we must consider a
legislative referendum or voter initiative to provide for additional
assessments or user fees for water priorities. Other suggested
methods of obtaining state-initiated funding include the creation
of special taxing districts, implementation of a user fee on
domestic water use, a fee to support water conservation, and a
tourism fee designated for water conservation and infrastructure.
At the same time we must assure that our leaders are
accountable and ensure that Arizonas water needs are at least
partially met through general fund allocations and the funding of
ADWR. Arizonans must also make their voices be heard in
Washington, D.C., and make our case to our congressional
delegation that federal funding is necessary to meet water
infrastructure needs, especially for rural and tribal communities.
We should ensure that Arizona does not leave federal grants or
matching funds on the table by looking to federal agencies, like
the USDA and the Bureau of Reclamation, for grant and financial
opportunities. ADWR should support the greater access to, and
use of those funds through an investment in a staff position to
assist water users in the identification of and application for these
funding opportunities.
Public-private partnerships are key to a diversification in funding
as well as private dollars from investors, foundations, and greenmarket funds. However in doing this, we must ensure that our
regulatory scheme is not a deterrent to private investment and
public-private partnership, while at the same time ensuring that
regulated utilities and state agencies are able to take advantage
of these financial mechanisms and recover initial investments.
Arizona must also look at creating regional or statewide
programs to issue revenue bonds, in addition to those offered by
WIFA, designated to develop long-term water supply and the
requisite infrastructure. Offering tax credits and financial
incentives to those who engage in innovative conservation is
another option, as well as examining acre-foot withdrawal fees in
AMAs and no longer providing for well fee exemptions.
Further, we should broaden the scope of incentives and

maintain existing incentives for farmers and other agricultural
water users. However Arizona will need to educate its leaders
and citizens on the critical importance of water priorities and this
may be done by using high-profile opportunities like other states
current water crises.
Strategies for pricing water to encourage desired results
Relationships among cost, price, and incentives for desired
outcomes are complex. For example, the price that Arizonans pay
for water has a significant role in shaping their perception of its
value, but that price may not reflect the true cost of the water
being consumed. This disconnect arises for several reasons,
including the lack of premiums associated with scarcity,
environmental impacts, infrastructure needs, and other
externals. Current methods for pricing water and financing
infrastructure include tiered rate structures, in which users are
charged higher rates as the volume of water they consume
increases, and rate increases that are generally recovered by
utilities after the infrastructure is built. These methods have
shortcomings, however, and in some cases they create competing
incentives. For example, while tiered rate structures incentivize
conservation, they can adversely affect the revenue stability and
bottom line of utilities. But rates must also adequately fund the
maintenance and augmentation of Arizonas infrastructure for
water harvesting, storage, and delivery.
The Arizona Corporation Commission has significant influence
over water pricing for private water companies in Arizona. Its
policies and regulations, including its rate case adjudication
process, are cumbersome, and do not sufficiently promote
investment. Water should be priced in a way that more accurately
reflects its total cost, but steps need to be taken to ensure that
Arizona remains competitive and water is affordable for
vulnerable populations.
Water pricing also needs to be relatively stable, both for
consumers and providersand to facilitate responsible levels of
investment in infrastructure. These outcomes can be achieved
through modifications to existing pricing methods, although
statutory and other limitations need to be addressed. One
approach would be to eliminate the uniform low cost of water
assigned to the bottom tier in existing tiered rate structures, such
that costs at the higher tiers would become less variable and
stabilize revenues for utilities. Pricing could also be broken out by
each component of the true cost of water, such that a fixed price
would be assigned to infrastructure costs, and variable pricing
would track water usage.
are necessary to engage in this. Use of technology and social

mediaFacebook, Twitter, Instagramcan provide instant
access to information on water issues, use, up-and-coming
technologies, conservation and augmentation.
We also must educate our citizens and leaders on the nexus
between energy and water use. Arizonas leaders, educators and
innovators must elevate water issue awareness through the
media by providing the media with information and success
stories regarding the efficient and effective use of water. Second,
we must use existing technology to better communicate with our
citizens about personal water usage. Through social media and
apps, information about an individuals relative use of water
compared to others within their community can be disseminated
almost instantaneously. Access to such information may
accomplish greater accountability for water use and conservation
efforts necessary to meet our future water needs.
Third, steps must be taken in the state legislative and executive
branches of government to ensure that Arizonas laws and
regulations encourage smart water use and conservation. For
example, regulations can be implemented related to landscape
design and maintenance, new development infrastructure
design, well impact and spacing requirements, direct potable reuse and flexibility in collaborative approaches across AMAs and
INAs. Arizona Department of Environmental Quality water
standards need to be revisited so as to allow for the greater use
of innovative technologies and re-purposed water.
Fourth, steps must also be taken at the federal level to give
greater autonomy to the states to manage their water resources.
Fifth, local governments should revisit rules and ordinances,
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Additional strategies could include increasing user fees to fund

water infrastructure projects on a statewide basis, and creating
new management strategies to address groundwater concerns.
Given the unique challenges and issues faced by urban, rural and
tribal communities, as well as by water users in different
economic sectors, Arizona must focus on localized solutions.
What can Arizonans do without more or new funding?
There are several actions Arizonans can take that do not
require substantial additional or new funding. However, these
require commitments at the individual, local, regional, state, and
national levels. First, Arizona must educate its citizens on
personal accountability for water use and conservation.
Commitment and collaboration from the private sector, our
universities, K-12 education system and state and local officials
ROC #278632
23
including local building codes, to promote efficient water use.

Localities should also consider implementing water wasting
ordinances as well as voluntary turn off the tap days. Sixth,
utility rate structure incentives should be revised to further smart
water use and conservation. Seventh, water markets and
corresponding legal structures should be developed to take
advantage of the gains we see from water conservation.
Finally, we need to continue our exploration of water augmentation
methods including watershed restoration, weather modification,
desalination, permitting of injection wells, xeriscaping,
detention/retention basin requirements, leak detection programs
and the use of storm water and rain water.
Priorities
Some actions need to be taken immediately, while others will
require longer-term planning and execution. Continuing Arizonas
history of collaboration in addressing water-related challenges
will be critical. Governments at all levels, tribal nations, elected
officials, community leaders, private businesses, educational
institutions, non-profit organizations and individual Arizonans will
all play vital roles in implementingand, in some cases,
fundingthese important actions.
Six top priority action items; responsibility and funding
Arizonas most populated, metropolitan areas do not currently
face an imminent water crisis, but some rural areas are seeing
more immediate challenges. Arizona will need to identify and
develop additional water supplies to meet projected water
demand. In order to do this Arizonans must work together to
increase communication and collaboration. Six top priorities for
Arizonans to pursue are to move forward with Arizonas Strategic

Vision for water supply sustainability; create and fund
mechanisms to finance water supply and new infrastructure;
appropriately fund and staff ADWR; education; education;
conservation and augmentation.
Arizonas Strategic Vision is a legal reform priority that must be
supported and implemented at the tribal, state, county and local
levels. Gov. Doug Duceys new water initiative is a crucial start
and must be supported. Specific actions should include efforts
to promote local water planning, funding of the Water Resources
Development Fund (WRDF), and addressing the structural deficit
of the Colorado River in collaboration with other basin states.
The Strategic Vision identifies both short-term and long-term
action items, and ties these actions to local economic
development plans, but must be continually updated to meet
Arizonas changing needs. Responsible for this action are Gov.
Ducey, the Arizona Legislature, ADWR, and all other stakeholders,
including tribal governments. Proper financing will need to be
established. Whether the entity charged with financing
implementation of the long-term plan is under the purview of an
existing state agency, such as the Water Supply Development
Revolving Fund, or a new agency that understands how the longterm action plan will be implemented must still be determined,
though the preference would be to use existing state agencies.
WRDF is a key mechanism for financing water development
projects and infrastructure. Primarily a self-sustaining revolving
loan fund, WRDF should be sufficiently capitalized to meet its
statutorily defined mission. Responsible are the governor, the
legislature, and Arizona citizenscitizens of Arizona. Stable and
adequate funding of ADWR will allow it to carry out its statutory
responsibilities, which will include implementation of a long-term
strategic water plan. It will further allow ADWR to retain and hire
highly skilled, knowledgeable professionals to carry out its
obligations and serve as leaders on statewide water issues.
Funding will need to be appropriated by the legislature sufficient
to support ADWRs mission, such as protecting Arizonas Colorado
River entitlement. Responsible for this are the governor, the
legislature, and our citizens.
Education, public awareness
It is imperative that we educate the general public and our
political leaders on water issues. Those entities that are especially
knowledgeable about water issues should take the lead in
educational efforts. Water education should be a required
component within our public schools at the K-12 levels. ADWR, in
collaboration with the water education community, should also
develop a focused communication plan and retain staff to lead
statewide discussions among the community and water
stakeholders through public forums and online communities.
The communications plan must include water literacy
information and an outreach program, including a curriculum
that recognizes and includes the diverse sets of water values
throughout the state. Public education or service campaigns, led
by local water providers, should also be implemented, and take
into account cultural and regional demographics, focusing on
regional communities, schools, elected officials and our youth.
These campaigns should promote and provide incentives for
conservation and inform the public about water use by
residential communities and different economic sectors.
Lastly, Arizona needs to promote its water as a valuable
24
commodity to not only justify its current value, but to also

stimulate novel and creative funding mechanisms that will be
needed in the future, i.e., public-private partnerships, private
sector investments in infrastructure, economic development and
land development. Responsible for this are our state universities,
the Arizona Board of Regents, our community college districts,
K-12 school districts, water providers, ADWR, and the Arizona
Cooperative Extension.
Creating a conservation culture
Educating educating consumers about their water usage habits
and strategies for conservation through billing statements or
social media can be effective. Tiered water rates, designed to
promote conservation and revenue stability, and other financial
tools should also be used to encourage conservation, and we
need to develop more effective methods for financing investment
in conservation technologies. Modernized building codes and
other policy initiatives, including in land use and development,
are also needed.
Arizona should also encourage counties, cities and towns to
address water issues as part of their local strategic planning
efforts. Arizona must also take a number of actions to augment
existing water resources. In the short-term, we should focus on
increasing reclaimed water and graywater reuse, investing in
additional water storage capacity and increasing our capabilities
to capture and utilize storm water runoff. Longer-term, we should
explore opportunities to expand reclaimed water re-use including
for human consumption, expand use of brackish and poor quality
water, investigate cost-effective strategies for the desalinization
of ocean water, and make strategic investments in water
production, delivery infrastructure, and exchange opportunities
with other states.
Arizona needs to focus on maintaining and improving the quality
of its watersheds and other natural resources that impact water
supplies and quality for people and the environment. For
example, Arizona should implement sustainable forest
management programs, including support for the current Four
Forest Restoration Initiative underway by the U.S. Forest Services
in all of the forested watersheds, provide incentives to private
industry to thin forests, and remove non-native vegetation and
invasive species from watersheds.
Congress and state government must take a long view by
stopping the diversion of forest restoration funding to fire
suppression uses, and also fund other watershed improvement
projects statewide. Responsible for this are federal and state
governments, municipalities and local governments, regulatory
agencies (including the USFS at the federal level and the Arizona
State Forester at the state level), utilities, private businesses, nonprofit organizations, state universities and individuals. All bear
responsibility for various aspects of these actionsand are
potential sources of necessary funding.
Priority of legal reform
The general stream adjudication process, as litigated in the
Superior Court of Arizona, needs to be streamlined and simplified
so as to ensure more expedient and equitable resolution of water
rights, provided that federal claims are adjudicated first and that
small users are adequately protected in the process and the
outcome. This may involve reassessing the adjudication

procedures and hiring additional staff. Adjudications are critical to
long-term economic development and water use planning.
Similarly, quantifying tribal water rights claims is critical but can
be lengthy and expensive if done through litigation. Settlement of
tribal claims benefits all parties by providing the water certainty
necessary to plan long-term economic development.
While settlement may be less expensive than litigation, it is a
very lengthy process. Thus, the settlement process should be
expedited whenever possible while preserving due process and
community engagement. In addition, some of the standards
implemented by environmental regulatory agencies could be
revised as they can be too cumbersome and restrictive and may
stifle water use innovation. Recommended regulatory changes
include addressing augmentation of surface water supplies;
water quality standards related to use of reclaimed waterl
limitations on deep well-injection of brine water; expanded uses
of lower quality groundwater; acceptable pollutant and toxin
levels; and development of regulations specific to the permissible
uses of potable and non-potable water, keeping in mind the
implications to the environment. Arizona should allow new
groundwater management frameworks to be established in
groundwater basins outside of AMAs. Responsible are
Congress, federal regulatory agencies, the Arizona Legislature,
Arizona regulatory agencies, the General Stream Adjudication
Special Master, Superior Court of Arizona; tribal governments;
attorneys; and lobbyists.
Role of individuals
Although collective action will be essential given the importance
and magnitude of water-related challenges facing Arizona,
individual Arizonans can and should:
Educate themselves about our states water resources and
challenges, including seeking out formal and informal
educational opportunities through Arizonas institutions of
higher education, K-12 school systems, and other entities;
Educate othersincluding elected officialson water issues,
with a view toward raising public awareness and creating a
climate in which Arizonas water-related 17 strategic initiatives
gain widespread understanding and support;
Advocate for federal and state funding of programs and
policies that will help ensure Arizonas water security, including
by lobbying elected officials;
Support funding for ADWR and investment in sensible water
infrastructure projects;
Build trust and collaborative relationships among the different
Arizona communities, including tribal governments, and with
the states of Nevada and California and the Republic of
Mexico;
Promote Arizonas historic and recent successes in water
management and conservation efforts, including through
social media;
Involve young people in conservation efforts from an early
age; and
Use water responsibly in daily life.
n
25
Connuing Medical Educaon
February
Feb. 25-28: Mayo Clinic Gastroenterology and Hepatology 2016
is at Westin Kierland Resort & Spa, 6902 E. Greenway Pkwy.,
Scottsdale 85254. Accreditation TBD.
Program is designed to update physicians and allied healthcare
professionals practicing in gastroenterology and hepatology
about new approaches to diagnosis and management of GI and
liver diseases. Faculty presents data on topic including
inflammatory bowel disease, colorectal neoplasia, general GI,
esophageal, motility, nutrition, pancreaticobiliary disorders,
endoscopy, and hepatology.
Controversies in diagnosis and management are analyzed in
discussions and concurrent breakout sessions. Expert
endoscopists present complex endoscopy cases and cutting-edge
technology in video forum. Optional sessions offered to help
gastroenterologists and hepatologists prepare for re-certification
and obtain MOC credit.
Course includes participation by the presidents of all four
gastroenterology societies and who are also Mayo Clinic faculty:
Doctors Keith D. Lindor, Kenneth R. DeVault, Michael Camilleri,
and Douglas O. Faigel, of AASLD, ACG, AGA, and ASGE
respectively). Attendees can interact with these physicians at
breakfast and luncheon sessions.
Website: https://ce.mayo.edu/gastroenterology/gi .
Contact: Jenny Kundert CMP, Mayo Clinic Scottsdale, 13400 E.
Shea Blvd., Scottsdale 85259; phone 480.301.4580; fax
480.301.8323. mca.cme@mayo.edu htttps://ce.mayo.edu .
Program includes didactic lectures, Q&A panel discussions with

interactive format allowing for immediate audience participation,
Meet the Preceptor (MTP) luncheons for one-on-one interaction
with faculty, and various afternoon breakout sessions.
Contact: Mayo School of CPD, 13400 E. Shea Blvd., Scottsdale
85259; phone 480.301.4580; fax 480.301.9176. Website:
http://ce.mayo.edu/node/4985 mca.cme@mayo.edu.
March 31-April 2: Tackling Problematic Sinusitis: Module-Based
Solutions is at Mayo Clinic Education Center, 5777 E. Mayo Blvd.,
Phoenix 85054; phone 480.301.8000. Accreditation: AMA, AOA,
AAFP.
Mayos fifth sinusitis symposium is a module-based approach to
problematic sub-types of sinus disease. Experts present latest
research in patho-physiology and treatment. A live prosection
and hands-on nasal endoscopy training for medical providers will
be offered.
World leaders in otolaryngology-rhinology, allergy-immunology
and basic sciences address the diseases most challenging
management aspects and other rhinologic disorders. Program
includes expert debates and brainstorming sessions using
interactive formats with the goal of synthesizing innovative
management strategies based on the latest evidence, and
experience of global experts.
https://ce.mayo.edu/otorhinolaryngology/content/tacklingproblematic-sinusitis-module-based-solutions-2016
Contact: Mayo School of Continuous Professional Development,
Mayo Clinic Scottsdale,
13400 E. Shea Blvd., Scottsdale 85259; phone 480.301.4580;
fax 480.301.9176.
mca.cme@mayo.edu https://ce.mayo.edu
March
March 3-5: The 12th Annual Mayo Clinic Womens Health Update
is at FireSky Resort, 4925 N. Scottsdale Rd., Scottsdale 85251.
Accreditation: AMA, AOA, AAFP, ACOG.
Course addresses the unique needs of female patients and their
healthcare providers. Participants gain comprehensive insight
into relevant medical problems uniquely found in women, as well
as a basic approach to addressing and improving common health
concerns. Topics include cardiovascular health, breast health,
gynecology and menopause, well woman exam revisited, and
sexual dysfunction.
Course is designed for primary care physicians/practitioners,
general internists, gynecologists, specialists in preventative care,
and other healthcare professionals interested in womens health.
Contact: Gloria Cadden, Mayo Clinic Scottsdale, 13400 E. Shea
Blvd., Scottsdale 85259; phone 480.301.4580; fax 480.301.8323.
mca.cme@mayo.edu https://ce.mayo.edu/
March 16-10: The 27th Annual Family Medicine and Internal
Medicine Update is at Westin Kierland Resort & Spa, 6902 E.
Greenway Pkwy., Scottsdale 85254. Accreditation: AMA, AOA, AAFP.
Four-day course features the most recent medical update and
management strategies for various diseases, presenters say.
26
Members Classifieds
MEDICAL OFFICE FOR LEASE - Well situated on
Northwest Medical Center campus with great visibility
on Orange Grove. Well designed, 4,300 square feet,
aesthetically-pleasing with high efficiency, suited for
4-6 providers, built in 2006. Features 12 exams rooms,
including 1 procedure room; 4 offices; and 1 large
reception area; spacious storage area for supplies;
at door parking. Available April 2016 (Current leaser
is merging with another practice) Competitive rates.
Contact Catherine Westerband, MD, 520-488-7515 or
cwesterband@genesisobgyn.net
FULL-TIME PEDIATRICIAN Great family and golf
community. Full-time Pediatrician BC/BE to join
well established Pediatric practice in Tucson, Az.
Competitive salary with excellent benefit package,
including bonus compensation. Send CV to kolleenr@
comcast.net
IMAGING 2016
Enhanced Care with

Advanced Imaging
Youre
Invited!
Marcus J. Dill-Macky, M.D.
Breast Cancer Screening:
What if I Do Nothing?
Saturday, February 20, 2016

7:00AM - 12:00PM
Breakfast Buffet Provided
Westin La Paloma
3800 E. Sunrise Drive
Tucson, AZ 85718
RSVP to Professional Relations

at 520-545-1836 or online at
www.radltd.com/cme2016
This symposium is free of charge
and is being held to educate
physicians and providers on updated
imaging modalities and techniques.
Chad A. Kohl, M.D.

What You Dont See Can Hurt
You: MRI of Radiographically
Occult MSK Pathology
Mark S. Peterson, M.D.

Low-Dose CT Lung
Cancer Screening
Creed M. Rucker, M.D.

Treatment of Stroke
Jason E. Wright, M.D.

3T MRI: Current
Applications in Prostate
and Abdominal Imaging
Enter to win a
staycation at the
Westin La Paloma!
Must attend to win.
A TUCSON TRADITION FOR MORE THAN 80 YEARS
(520) 545-1836
27
MICA_Sombrero02'16ad.qxp_MICA_Sombrero05'04ad 1/11/16 2:18 PM Page 1
MICAs Board of Trustees is pleased to announce

a $27 million dividend for the 2015 policy year.
This is our 11th consecutive dividend and our
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Medical Professional Liability Insurance

(602) 956-5276, (800) 352-0402
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Dividends declared for a policy year reflect the Companys financial performance.
Past performance does not guarantee future dividends.

February 2016 Sombrero

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Sombrero

Pima County Medical Society

SOMBRERO February 2016

Official Publication of the Pima County Medical Society

PCMS Board of Directors

At Large ArMA Board

Pima Directors to ArMA

SOMBRERO (ISSN 0279-909X) is published monthly

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SOMBRERO February 2016

ABR, CRS, GRI

Madeline is Your Connection to

6 Milestones: Honors for two of our

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7 Membership: We focus on Retina

9 PCMS News: Feds penalize hospitals over

patient safety; med school applications way

12 In Memoriam: Remembering Dr. Michael R.

13 Makols Call: America takes the good and

15 Perspective: Our editor looks at a certain

17 Environment: Since theres no Arizona without

26 Continuing Medical Education: Coming

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SOMBRERO February 2016

What is organized medicine doing for me?

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Dr. Timothy C. Fagan, to the left with fellow PCMS member

Coincidental to his returning as PCMS president, Dr. Timothy C.

Dr. Iserson returns to

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Retina Associates focal point

phthalmologists at Retina Associates have a kind of tunnel

Cameron Javid, M.D., senior physician at Retina Associates,

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Retina Associates has three offices in Tucson and Green Valley

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SOMBRERO February 2016

Feds penalize hospitals over

A ceremony for hospital staff was given Jan. 8 on the lawn at

SOMBRERO February 2016

Sixteen Arizona hospitals were cited, including Tucson Medical

For hospitals, complications are still profitable, said Dr. Martin

hospital-acquired conditions, Whited said in a statement. We

Nearly 6,500 apply to

evidenced by programs, activities and student and faculty

Dr. Michael R. Manning, 1944-2015

Dr. Michael R. Manning in 2007 with a portrait of his father,

Dr. Mannings parents were Marjorie Sullinger Manning and Dr.

SOMBRERO February 2016

Connuing Medical Educaon