Round-up Magazine November 2014 by Maricopa County Medical Society (MCMS)

To learn more visit www.mcmsonline.com

PRESIDENT’S PAGE: “Are we there yet?” Dr. Miriam Anand believes the answer is “yes.” In this month’s editorial she explains how physicians have reached the point where government regulations, pressure to keep costs down and the corporatization of medicine have resulted in decreased quality care and a compromised physician-patient relationship. Page 10

PUBLIC HEALTH: Dr. John Middaugh clarifies public health roles and goals on e-cigarettes and vaporizers. He believes regulations to treat e-cigarettes and vaporizers similar to tobacco would provide the best public health protections while enabling adults to access these products. Read the full summary. Page 22

Volume 60 • November 2014

round-up Providing news and information for the medical community since 1955.

On the cover, page 4. THE MCMS 2014 ANNUAL EVENT: A fun time was had by all on October 17 at the 2014 Maricopa County Medical Society Annual Meeting. Turn to page 42 for a photo album of the event. HONOR ROLL UPDATE: After decades of interest and speculation about what possible genetic influences are involved in determining the severity of Valley Fever infections, there are now two separate studies underway to address this question each taking a different and complementary approach. Dr. John Galgiani summarizes the two approaches for Round-up readers. Page 18

i b k MD il Ph i i MEMBER PROFILE: Leland Fairbanks, MD, MPH MPH, F Family Physician: How a (self-described) “Old Country Doctor” led the fight to eradicate smoking in hospitals. Page 28 FEATURE ARTICLE: Are doctors ethically obligated to sign patients up for Obamacare? Robert B. Doherty with the American College of Physicians believes that physicians’ primary duty to their patients requires it even if they wish to continue to engage in the political process to get it changed or even repealed. Page 36 STUDENT PERSPECTIVE: U of A College of Medicine - Phoenix medical student, Tabarik Ahmad, has thought a lot about the concept of trust and the various ways physicians trust both consciously and unconsciously. Page 40

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round-up

november 2014

the ethics issue

president’s page Are we there yet?

honor roll update How does genetics influence Valley Fever?

public health E-Cigarettes and vaporizers – clarifying public health roles and goals.

member profile: leland fairbanks, MD, MPH, family physician: Taking the golden rule to heart – how a (self-described) “Old Country Doctor” led the fight to eradicate smoking in hospitals.

feature article Are doctors ethically obligated to sign patients up for Obamacare?

student perspective Trust. It’s a funny thing.

2014 mcms annual event “VISTAS DE MEDICINA”

On the cover: MCMS’ 2014 Annual Event Attendees, left to right: Row 1, Photo 1: Ulises Urcuyo, MD, Jay Conyers, PhD, Dr. Anthony Yeung and Mrs. Eileen Yeung.

Row 2, Photo 1: Julie Ritzman, MICA, Joe Hanss, MD and Brendan Thomson, MD.

Row 1, Photo 2: Dejana Grk, OD, Amanda Marquez, Phillip Bennion, MD and Alka Bennion.

Row 2, Photo 2: Julius Grecce, Sami Kabbara, and Ira Quezon.

Row 1, Photo 3: Steve Perlmutter, MD and Nora Perlmutter.

Row 2, Photo 3: Sabrina Daiza, Carol Harrison, Nedra Harrison, MD, and Sumer Daiza, MD.

In every issue New Members ..................................................................................................................................................................5 Letter to the Editor ............................................................................................................................................................7 In Memoriam ....................................................................................................................................................................8 Patient Education Handout..............................................................................................................................................15 Healthcare Happenings ..................................................................................................................................................26 MCMS Board of Directors Meeting Minutes ................................................................................................................44 Marketplace ....................................................................................................................................................................46 4 • Round-up • November 2014 • A monthly publication of the MCMS

new members There’s no place like the Maricopa County Medical Society. Welcome Home! MCMS would like to recognize our new members for helping us become a stronger, more unified voice for our community’s physicians. Please reach out to one or more of our new members and welcome them aboard, and share with them your insight into how the Society can be of service.

IRVIN QUEZON Medical School: Univ. of Arizona College of Medicine – Phoenix Graduation Year: 2018

TABARIK AHMAD Medical School: Univ. of Arizona College of Medicine – Phoenix Graduation Year: 2017

MARYANN DAVIES Medical School: A.T. Still Univ., School of Osteopathic Medicine, Mesa, AZ Graduation Year: 2018

AMY C. PICONE Medical School: Univ. of Arizona College of Medicine – Phoenix Graduation Year: 2018

EDWARD A. DRAPER, DO Emergency Medicine Medical School: Univ. of Kansas, Kansas City, KS Residency: Univ. of Kansas Medical Center, Kansas City, KS Practice: Retired HOWARD M. SHULMAN, DO Internal Medicine Medical School: Univ. of Health Sciences, Kansas City, KS Residency: St. Johns – Oakland General Hospital, Madison Heights, MI Website: www.midwestern.edu Phone: 623-572-3273 ALYCIA ERNST-AMADOR, FNP-BC Pain Management, Family Medicine Medical School: Northern Arizona Univ. Practice: Arizona Pain Management Phone: 602-368-8800

DANIEL CRAWFORD Medical School: Univ. of Arizona College of Medicine – Phoenix Graduation Year: 2018 ANDREW ALBERT Medical School: Univ. of Arizona College of Medicine – Phoenix Graduation Year: 2018

JEREMY K. BINGHAM, DO Dermatology, Family Medicine Medical School: Midwestern Univ. College of Osteopathic Medicine, Glendale, AZ Residency: Midwestern Univ. Opti/Advanced Desert Dermatology Practice: Bingham Dermatology Group Website: www.binghamderm.com Phone: 480-625-4538 WAYNE MCINTOSH Medical School: Arizona State Univ. Doctor of Nursing Practice Program, Tempe, AZ Graduation Year: 2015 ELIZABETH E. SMITH, MD Family Medicine Medical School: Ross Univ. School of Medicine, Roseau, Dominica Residency: Scottsdale Healthcare Family Practice Residency Program, Scottsdale, AZ Practice: Scottsdale Healthcare Primary Care Mesa

A monthly publication of the MCMS • November 2014 • Round-up • 5

round-up:

published by the:

providing news and information for physicians and the healthcare community since 1955 Round-up Staff

MCMS 2014 Officers

Editor-in-Chief Miriam K. Anand, MD

President Miriam K. Anand, MD

Editor Jay Conyers, PhD

President-Elect Ryan Stratford, MD

Advertising, Design and Production Candice Scheibel Advertising To obtain information on advertising in Round-up, contact MCMS. phone: 602-252-2015 advertising@mcmsonline.com

Vice President Elizabeth McConnell, MD Secretary Kelly Hsu, MD Treasurer Mark R. Wallace, MD Immediate Past-President Daniel Lieberman, MD Board of Censors Nathan Laufer, MD, Chair

Postmaster

Daniel Lieberman, MD

Send address changes to: Round-up, 326 E. Coronado Rd., Phoenix, AZ 85004

Michael R. Mills, MD, MPH

mcmsonline.com

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facebook.com/MedicalSociety

Anthony T. Yeung, MD

twitter.com/MedicalSociety linkedin/MaricopaCountyMedical Society

Ryan Stratford, MD Thomas E. McCauley, MD

Board of Directors 2012-2014 Tanja Gunsberger, DO

Periodicals postage paid at Phoenix, Arizona.

Jennifer Hartmark-Hill, MD

Volume 60, No. 11, November 2014.

Susan Whitely, MD

Round-up (USPS 020-150) is published 12 times per year by the Maricopa County Medical Society, 326 E. Coronado, Phoenix, AZ 85004.

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To subscribe to Round-up Magazine please send a check for one-year subscription of $36 to Round-up Magazine, 326 E. Coronado Rd., Phoenix, AZ 85004 or visit mcmsonline.com/subscribe.

Steven R. Kassman, MD

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Adam M. Brodsky, MD John L. Couvaras, MD Robert J. Standerfer, MD 2014-2016 Lee Ann Kelley, MD Richard Manch, MD May Mohty, MD Anita Murcko, MD

6 • Round-up • November 2014 • A monthly publication of the MCMS

Round-up is a publication of the Maricopa County Medical Society (MCMS). Submissions, including advertisements, are welcome for review and approval by our editorial staff at roundup@mcmsonline.com. All solicited and unsolicited written materials and photos submitted to Round-up will be treated as unconditionally and irrevocably assigned to and the property of MCMS and may be used at MCMS’ sole discretion for publication and copyright purposes and use in any publication, website or brochure. MCMS accepts no responsibility for the loss of or damage to material submitted, including photographs or artwork. Submissions will not be returned. The opinions expressed in Round-up are those of the individual authors and not necessarily of MCMS. Round-up reserves the right to refuse certain submissions and advertising and is not liable for the authors’ or advertisers’ claims and/or errors. Round-up considers its sources reliable and verifies as much data as possible, but is not responsible for inaccuracies or content. Readers rely on this information at their own risk and are advised to seek independent legal, financial or other independent advice regarding the content of any submission. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission by the publisher. All rights are reserved.

The cover and annual event photos (pages 42-43) provided by Mike Paulson of Paulson Photo/Graphic. Learn more by visiting www.paulson.com, email photo@paulson.com or call 602-230-1550.

letter to the editor

Kim L. Lucas, MD Thunderbird Internal Medicine

Dr. [Miriam] Anand, I saw and read your article [Round-up Magazine, September 2014, “My Conspiracy Theory”] and it resonated with me because I was having similar thoughts and feelings as of late. The changing “landscape” is one of the decisions that led me to sell my practice to IASIS Healthcare and join Thunderbird Internal Medicine. Through strong leadership and solid management, they have built an IT infrastructure that will allow them to comply with the new metrics and reporting requirements required through the Affordable Care Act. As a solo family practitioner and a single Mom with aging parents living on two continents, a lot rests on me both personally and professionally. The new regulations are not feasible to tackle on my own, nor did I have the resources to fund a model that I believe is weak in terms of growth. I thought of practicing concierge medicine, but decided that was not a good fit and I am not ready yet for retirement. Thunderbird Internal Medicine is physicianowned and managed and I am hoping I can continue in that vein as long as possible. I concur with your conclusions and commend you for stating them. We are sorely missing strong leadership in medicine. Part of the blame rests with academic medicine. In some ways they are defacto “leaders” interested in their narrow areas, and mired in turf wars and securing funds to justify their jobs/department/research (i.e. base of power and influence). For example, I attended a healthcare leadership conference in the late 90’s in Washington D.C. sponsored by the Wall Street Journal. Panelists were leaders from different parts of healthcare: government, industry and academia. It was there I realized that medicine, especially clinically dominated medicine, is practiced by old white men who are

a product of the early 20th century. They don’t function well in the “real world.” The financial reality for practicing physicians is it’s controlled by healthcare administrators, i.e. bean counters. Doctors are primarily incubated on that environment both in medical school and residency. My early ambition was to be in academia in general or internal medicine. After completing my first year as an attending, I pursued academics at Columbia University and quit after nine months due to disfunctionality and a lack of funding. The bottom line, as I see it, nobody is addressing the importance of supporting the profession in a serious concerted manner. I love cooking and have been reading cookbooks and other books related to the profession/industry. In the past decade a well-known chef, Ferran Adria, has been emphasizing and devoting a fair amount of his energy to developing creativity in the field. It caused me to notice how little time we as doctors devote attention to similar aspects in medicine. We just grind (“cook”) away in robot-like fashion too fatigued to look at the big picture. I also think we are stripped of our will during the road to becoming a physician. We are somewhat predisposed to self-abnegation and then training gets rid of the residue. In short, it’s a good method of breeding sheep. I have spent a lot of time pondering this situation. My personal belief is we need a fix to this apathy. The problem is finding others who agree that it is in the physicians best interest to remain independent. Patients have been brainwashed that we are greedy, etc. and unfortunately current conditions reinforce the stereotype. One solution is to find a rich benefactor, but again academia taps available funds for research and our plight gets lost in the messaging. Sincerely, Kim M. Lucas, MD

A monthly publication of the MCMS • November 2014 • Round-up • 7

in memoriam

Honoring those we lost. Jack Earl Cook, MD, 93,

John R. Crowell, MD, 76,

passed away October 26, 2014. Dr. Cook was born in Detroit, Michigan, attended Cass Technical High School and was the City of Detroit silver medalist in the Decathlon. He attended Hillsdale College until World War II broke out. Dr. Cook achieved the highest grade on the screening test for the Army Air Corps in Detroit’s history. He flew 50 missions as a B-17 navigator from North Africa over Europe and was the last surviving member of the 99th Bomb Group from World War II. At the end of World War II, Dr. Cook attended the University of Colorado School of Medicine, receiving his medical degree in 1952. He was accepted into Alpha Omega Alpha medical fraternity as a medical school junior; the first junior ever to be inducted. After medical school Dr. Cook moved to Phoenix for his internship, which he completed at Good Samaritan Hospital from 1952-1953. He practiced Family Medicine in Phoenix and Scottsdale from 1953-1976. He was the Director of the Family Practice Residency at Scottsdale Memorial Hospital from 1976-1986, and was Senior Vice President for Scottsdale Memorial Health Systems from 1986-1994. He was Chairman of Scottsdale Health Care’s Institutional Review Board from 1986 for over 10 years, and a member of Good Samaritan’s Institutional Review Board from 2000 until his retirement. He returned to private practice in 1993, retiring at age 89. Dr. Cook is survived by his loving wife Barbara, his son Geoffrey Cook, his daughters Suzanne Isbell, JoAnne Stewart and Adrienne Cook, and his stepdaughters Shelta Sneed and Hillary Jones. Dr. Cook joined MCMS in 1954. ru

passed away peacefully at his summer home in Pinetop, Arizona on October 18, 2014. He was born on October 22, 1937 to Raymond Leroy Crowell and Alice Hill Crowell in Carbondale, Illinois. Dr. Crowell earned his undergraduate degree from Southern Illinois University where he majored in psychology and was the president of his fraternity, Delta Chi. He earned his medical degree from the University of Iowa with a specialty in ophthalmology followed by two years with the CDC and a residency at Los Angeles County Hospital. Dr. and Lynda Crowell moved to Arizona in 1972 where he practiced ophthalmology until his retirement. In 2003, he married JoAnne McCarville. They resided for four years in Paradise Valley and moved to Pebble Creek in 2007. While practicing ophthalmology Dr. Crowell volunteered his services by performing eye surgery in Kenya as a participant in the Kenya Medical Mission. He was always generous with his time, words of encouragement and love for his patients, friends and family. He was a great fan of football and loved watching the Arizona Cardinals, Wildcats, Sun Devils, and Iowa Hawkeyes. He is preceded in death by his wife Lynda in 2001 and his sister Ann Bruner in 2011. He is survived by his brother Tom (Marilyn) Crowell, his daughter October (David) Minnotte, granddaughters Kaitlyn and Madison and daughter April (Rich) Thurfield, grandson Griffin and granddaughter Willa. He is also survived by his stepchildren Ken (Pam), John (Melanie), Kirk (Beth), David (Judy) and Megan McCarville, Jeannine (Jay) Swartwout, Amy (Tony) Tutrone, 14 grandchildren and one great-granddaughter. Dr. Crowell joined MCMS in 1974. ru

8 • Round-up • November 2014 • A monthly publication of the MCMS

in memoriam

John Malfetano, MD, 91, passed away on November 10, 2014 at his home in Paradise Valley, Arizona. He was born in Brooklyn, New York and was a proud Yankees fan. He graduated from Georgetown University and Georgetown Medical School; later becoming a Captain in the U.S. Air Force, stationed at Malmstrom Air Force Base in Great Falls, Montana. He went on to have a successful medical practice as an OBGYN in Long Island, New York and was Chief of Staff at Nassau Hospital. In 1978, he moved to Scottsdale, AZ where he continued to practice medicine till his retirement. He was the consummate doctor, who was adored by his patients, and was admired and respected by his colleagues. He was a beloved husband, father, grandfather and a true friend to those lucky enough to know him. Dr. Malfetano is survived by his loving wife of 64 years, June, sons John (Barbara) and Bob, as well as three wonderful grandchildren, and Sophie, a “wet-nosed” big black labrador retriever. He will be greatly missed by all who knew and loved him. He was a MCMS member from 1978-1995. ru

The members of the Maricopa County Medical Society are the organization's greatest asset, an assemblage of the finest physicians and healthcare providers. On these pages we pay homage to current and past members who are no longer with us on this earth. You will be missed.

Arnold L. Serbin, MD, 83, passed away in Phoenix, Arizona on Monday February 18, 2013. Dr. Serbin moved to Tucson in 1943. He attended Tucson High School and the University of Arizona. While at the U of A, he joined the Musicians’ Union andstarted his own band to help pay for his education. He played in the Arnold Serbin Band throughout college and pharmacy school, up to his first year at Chicago Medical School. After completion of an internship at Maimonides Hospital in Brooklyn, New York and a two-year stint with the United States Air Force, he completed his medical specialty training in pulmonology in Los Angeles, California. Dr. Serbin opened his practice in 1964. He was an expert on Valley Fever and he was one of the first to perform flexible endoscopic bronchoscopies in Phoenix. Dr. Serbin was a Life Member of the American College of Physicians, American College of Chest Physicians, the AMA, and multiple other societies and associations. People breathed easier if they had Dr. Serbin for a doctor. He was involved in training numerous current staff members of both St. Joseph’s and Good Samaritan Hospitals. He was an active member of the Jewish Community and a long time member of Beth El Congregation, where he served on numerous committees and on the Board of Directors. Dr. Serbin is survived by his wife of 58 years, Barbara, his son Gary, his daughters Ellen and Deborah, his daughter-in-law, Lisa, and his son-in-law, Eric Swanson, and his grandchildren, Daniel, Rebecca, Michael, Jacob, Joshua, Matthew, and Noah, and his great-grandchildren, Yaakov and Nosson Tzvi. He is also survived by his sister, Libby Katzke, and many in-laws, nephews, nieces, and cousins. He was proceeded in death by his parents, Samson and Reva, and his two younger brothers, Bernard and George. Dr. Serbin joined MCMS in 1963. ru

A monthly publication of the MCMS • November 2014 • Round-up • 9

president’s page

Are we there yet? By Miriam K. Anand, MD

Miriam Anand, MD President Dr. Anand is an Allergy and Immunology specialist practicing in Tempe. She is the Society’s 120th President, and has been a MCMS member since 1998. Allergy Associates & Asthma, Ltd. Tempe Office 1006 East Guadalupe Road Tempe, AZ 85283 Contact her at manand@mcmsonline.com

sually the question, “Are we there yet?” is asked with almost an hopeful desperation that the intended destination has, in fact, been reached. Unfortunately, this is not the spirit behind my question.

I have spent much of the year writing about my concerns for how changes in healthcare from a regulatory standpoint would affect our autonomy and ability to provide quality care. As an owner of a private, mostly outpatient, specialty practice, I have certainly felt the pressure of how these regulations have made it increasingly difficult to provide care. I have heard patients complain about how they feel rushed by their other physicians and sympathize with them and their primary care physicians, who I know are forced to limit time with patients. I have heard patients say that their physician no longer makes eye contact with them during the visit and am saddened that I am now one of these physicians as I am required to look at the computer screen to make sure I’m documenting correctly in the EMR and clicking all the right buttons to satisfy Meaningful Use requirements. I am aware that most of us struggle, above all, to provide quality care to our patients, despite the ever increasing obstacles put in our way to do so. In a mostly outpatient practice, however, I have admittedly lost touch with the hospital-based practice of medicine and mostly have my training from medical school and residency to fall back on when people are telling me about their hospital experiences. Until recently, I thought it a strange coincidence when I was hearing stories of friends and their family members having to complain to administration or patient liaisons regarding their care. Most of the complaints centered around feeling as if they had been treated rudely and dismissively, but some were for medical mistakes and over medication of family members. Unfortunately, experiences close to home with two of my employees have gotten me wondering…has the corporatization of medicine and emphasis on controlling cost caused a compromise in medical care? It is true that there is an ethical dilemma that all physicians face, which is providing appropriate care in the most cost-efficient manner? Have changes such as ACO’s, the Medicare “two-midnight” rule, and others pushed the pendulum more towards cost-savings as the first priority?

10 • Round-up • November 2014 • A monthly publication of the MCMS

president’s page

I first started asking this question after an experience with one of my employees. The lunch hour was finishing when my nurse, with 30 years of experience as an ER nurse, came to me and told me that she had one of our medical assistants (who is 20 years old) lying down in an exam room because he was complaining of palpitations and was ashen and diaphoretic. I went to check on him and found him alert and oriented, but somewhat slow to respond to my questions. His blood pressure was technically low, but given his age and frame, I thought this could be normal for him. I felt his pulse and listened to his heart and he was mildly tachycardic with skipped beats. In getting a history, I found out that he had gone to the Emergency Room at 16 years old for similar symptoms and was told that he should see a Cardiologist and that he might need an ablation. His parents never pursued this and he continued to get periodic short-lived episodes that were less severe. Hoping that this episode would pass, I asked him some further questions and found out that he had not seen his primary care doctor in more than three years. He would thus be considered a new patient there. He also told me that his teacher during his M.A. training told him that he should see a Cardiologist after his fellow students did a practice EKG on him. In the meantime, he still had the palpitations. I started thinking that maybe I should prescribe a beta blocker for him, but wasn’t comfortable doing this without the appropriate electrocardiographic studies. We discussed having the nurse drive him to an Urgent Care center two buildings down the street, but when he sat up, he became very dizzy. I then thought that the ER would be the better option, but wasn’t com-

fortable with the liability of having one of my employees drive him there. As a last resort, I opted to call 911, comforted by the fact that he would be taken to the same ER where he went when he was 16 and would presumably be taken directly to an exam room since he would be brought in by paramedics, and would at least be put on a monitor where the rhythm could be seen. By the time they arrived, I had a patient waiting and was already running behind. I went in to see my patient, but had planned to call the ER to let them know the history once I was done. When I came out, my nurse informed me, however, that she had seen some abnormalities on the rhythm strip, so I felt certain that he would get a 12 lead EKG and any appropriate treatment and went in with my next patient. It turns out that he was never even brought to an exam room. He was left to wait in the waiting room for an hour and, by the time he got called back, his palpitations had resolved. No EKG was done and he

was told that he probably had an anxiety attack and was discharged with a prescription for a benzodiazepine. The following day, while working in one of our satellite offices with another physician, he had a similar episode. Knowing about the previous day’s events, the physician in that office called his primary care physician to see if they could get him in there, even though he hadn’t been seen in a few years. They were very accommodating and after doing a 12 lead EKG, started him on a beta blocker and facilitated an appointment with a Cardiologist for the following day. Within a week, a second MA was taken by ambulance from her primary care physician’s office to another facility (but in the same hospital system) for an incarcerated ventral hernia and an arrhythmia. She ultimately had a laparoscopic repair, that was reportedly difficult, in the late afternoon. I was very surprised to learn that she was discharged home that same evening.

A monthly publication of the MCMS • November 2014 • Round-up • 11

president’s page

I would have expected that she would have been kept at least overnight to be sure that, at a minimum, she could keep clear liquids down and that her vital signs were normal.

“Stories like these cause me to fear that the answer to my question of, “Are we there yet?” is “yes”. We have reached the point where government regulations, pressure to keep costs down and the corporatization of medicine have resulted in decreased quality care and a compromised physician‐patient relationship.“ — Miriam K. Anand, MD A couple of days after discharge, she was in contact with our Practice Administrator, who told me that she had a fever and was vomiting anything that she tried to ingest. I asked the Practice Administrator to tell her to call the surgeon, fearing an ileus, bowel obstruction or infection. It was a Friday and she apparently never heard back from the surgeon’s office. Over the weekend, she continued to have trouble with nausea and vomiting and then also developed chest pain and severe shortness of breath (to the point of not being able to walk to the bathroom). She called the surgeon again and was instructed to return to the emergency department. She did and, between frequent breaths, told them that she was a post-op patient with chest pain and shortness of breath. She was told to wait in the waiting room. During her 40 minutes there, her chest pain became worse and she, and then subsequently her mother, tried to appeal to the clerk to have her seen. They were told that the nurse was aware and they would just have to wait. Her mother expressed concern that the patient might pass out and was told that a code would be called if that happened. Once the nurse finally came, the patient had to walk back to the vitals area and the nurse told her to get on the scale. While trying to get to the scale, the patient became very dizzy due to the walking and had to steady herself on the wall. The nurse told her to hurry up because she had other patients waiting with similar symptoms. Most readers have hopefully assumed that she had pulmonary emboli. I have admittedly not treated pulmonary emboli since 2001. Perhaps evidence-based medicine has shown that our fears that further clots could break off and

cause saddle emboli were unwarranted. Perhaps I am overreacting in thinking that this was a true medical emergency that required more prompt medical attention. (To give some perspective, the hospital in question is a Level IV trauma center and there were four others in the waiting room in the middle of the night, none of whom appeared to be in severe distress.) I wish that I could say that the remainder of her experience was not so negative. My employee is the single mother of two teenage daughters. As is the unfortunate case with many Americans today, she lives paycheck to paycheck. While in the hospital, the electric company attempted an automatic withdrawal the day before her paycheck was deposited. There were insufficient funds and her electricity was shut off and the food in the refrigerator spoiled. When the case worker came to her on the day of discharge to discuss the cost of her medications with her, she stated that she couldn’t afford them because the electricity had been shut off and she had to buy food to feed her children. While the children were being cared for by a relative, the case worker did not ask where the children were and assumed that the patient had left them home alone with no food or electricity. She, the hospitalist and the charge nurse returned to the patient’s room and told her that they were notifying the Arizona Department of Child Safety. The patient asked to explain, but the hospitalist told her that his mind was made up and nothing that she would say would change it. Later, with permission from the patient, I spoke to the hospitalist expressing my concerns that he was not getting more information before reporting a meritless case to an overwhelmed government agency, thus wasting tax dollars and time. He was unconcerned, stating that even if it took two to three months for the agency to investigate, he was still going to report it. With attitudes like this, it’s no wonder that the former Child Protective Services became overwhelmed with attention detracted from being able to investigate true child abuse and neglect cases. Stories like these cause me to fear that the answer to my question of, “Are we there yet?” is “yes”. We have reached the point where government regulations, pressure to keep costs down and the corporatization of medicine have resulted in decreased quality care and a compromised physicianpatient relationship. The preamble to the American Medical Association’s “Principles of Medical Ethics” includes the following: “As a member of this profession, a physician must recognize

12 • Round-up • November 2014 • A monthly publication of the MCMS

president’s page

responsibility to patients first and foremost, as well as to society, to other health professionals, and to self.” The AMA goes on to say that physicians should work to change laws and regulations that interfere with their ability to provide quality care to patients. Unfortunately, an investigation in 2007 by the AMA found that 15% of surveyed physicians were aware of peer review abuse or misuse. This has been referred to as sham peer review, which has been defined as using the medical peer review process to remove a doctor who is seen to be disruptive or too great an advocate for change. Recall the story of Dr. Katherine Mitchell, a second physician to come forward publically about her concerns regarding patient care at the VA. In a written statement, she said, “I have seen what happens to employees who speak up for patient safety and welfare within the system….devastation of professional careers is usually the end result.” Thus, physicians have been bullied into “going with the flow” and not following their ethical obligation to speak up.

These factors have contributed to us arriving “there” to the current state of medicine. It can be very daunting for an individual physician to speak up. This underscores the importance of being a part of organized medicine and a member of the Maricopa County Medical Society. As a reminder the mission of the Maricopa County Medical Society is: “To promote excellence in the quality of care and the health of the community, and to represent and serve its members by acting as a strong, collective physician voice. In fulfilling this Mission, the Society will initiate, respond to, and implement efforts through which professionalism in medicine is enhanced; the ethics of medicine are fostered and preserved; the patient’s rights and choice are supported; and quality practice of medicine is preserved.” Your membership is very important to help us strive to meet this mission. Please renew your membership for 2015 and encourage your colleagues to become members. ru

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Mayo Clinic Education Center Phoenix, Arizona

Course Highlights: • Current trends in assessment and treatment options including opioids and marijuana • Emphasis on future trends and care models • Unique split curriculum for surgeons, medical spine care providers and allied health providers • Interactive discussion with expert faculty during lunch sessions Medical and surgical spine care providers will learn the skills and knowledge to tackle the spectrum of spine disease in the current and future health care environment.

REGISTER TODAY! Registration and additional course information can be found on our course website: www.mayo.edu/cme/spine2015 A monthly publication of the MCMS • November 2014 • Round-up • 13

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What is a specialist? A “specialist” is a physician who has completed four years of medical school to obtain either a “Doctor of Medicine” degree (MD) or a “Doctor of Osteopathy” degree (DO) who then goes on to complete further training. After completing a residency (that may last one to five years after medical school, depending on the area of focus), physicians may pursue more training that allows them to further focus on a specific area. Technically, this is called “sub-specialty” training, since the physician is focusing on a more specific area than their general specialty training. For example, after completing a five year general surgery residency, the physician may choose to do two to three years of further training in cardiothoracic surgery, or surgery of the heart and lungs. Similarly, a pediatrician may choose to complete three more years of training to sub-specialize in treating kidney diseases, for a total of six years of training after medical school. The terms “sub-specialist” and “specialist” are often used interchangeably.

When should I see a specialist? There are times when this may be very clear-cut and other times where it may be difficult to know. Some insurance policies may not cover seeing a specialist unless you have a referral from your primary care physician. You should see a specialist if your primary care physician or another physician recommends it. Often, your primary care physician can address many of your medical issues, but there will be times when a sub-specialist evaluation may be needed. If you and your primary care physician are having trouble satisfactorily addressing a problem, it may be time to see a specialist.

What type of specialist should I see? There are many different types of medical specialties. To read a full list, visit http://www.webmd.com/a-to-z-guides/medical-specialists-medical-specialists It is important to understand a few things when choosing a specialist. First, many patients may not be aware that an Arizona medical license does not require a physician to practice in the specialty that he or she was trained in. This means that a physician who trained in Pediatrics, for example, can legally perform cosmetic surgery, even if he or she did not do the same training as a plastic surgeon. It is therefore very important to research the type of training the physician has had. A good starting point may be to see if the physician is board-certified in the specific area in question by visiting the American Board of Medical Specialties site at www.abms.org. Second, most medical specialty training programs are held to very high standards of training and meet approval of the Accreditation Council for Graduate Medical Education (ACGME). While medicine is always advancing and newer sub-specialties may result, there are some who create “specialties” that are not based on rigorous science and research. They may offer weekend courses or other “training” that does not meet the strict educational standards required by the ACGME. To learn more about programs that are approved by the ACGME, visit www.acgme.org.

Other considerations when choosing whom to see: What is the difference between a chiropractor and an orthopedic surgeon? A chiropractor most commonly focuses on treating conditions of the spine and uses a process known as spinal manipulation to treat back and neck pain. A chiropractor typically has seven years of training after high school. Orthopedic surgeons treat conditions of the spine, as well as other bones and joints in the body. To become an orthopedic surgeon, one must first get an MD or DO and then complete one year of internship and at least four years of residency training. After that, a one year fellowship is required to specialize specifically in treating conditions of the spine. An orthopedic spine surgeon, therefore, has 14 years of training after high school. Unlike chiropractors, they can perform surgery, but they are also trained and skilled at diagnosing and treating problems that do not require surgery.

What is the difference between an ophthalmologist and optometrist? Both ophthalmologists and optometrists specialize in eye and vision care. An optometrist has a “Doctor of Optometry”, abbreviated “OD”. To get this degree, one needs to have at least 3 years of college and then attend 4 years of optometry school. Some may do one year of further training after obtaining a OD. An optometrist, therefore, has at least 7 years of education beyond high school. An optometrist can examine the eyes and prescribe eye glasses/contact lenses, diagnose some conditions of the eye, and may be able to prescribe medicines for some eye conditions. To become an ophthalmologist, one must first get an MD or DO and then do one year of internship in internal medicine, where they learn about diseases that affect various organs of the body. This is important since certain diseases can be associated with eye problems and medicines used to treat eye issues may impact certain medical conditions or organs in the body. They must then complete at least three years of residency in ophthalmology. An ophthalmologist is trained in the full spectrum of eye care, including prescribing glasses and contact lenses, treating medical conditions of the eye, and performing surgical procedures on the eye. An ophthalmologist, therefore, has at least 12 years of education after high school.

What is the difference between a psychologist and a psychiatrist? Both psychologists and psychiatrists diagnose and provide counseling and therapy for mental health conditions. This may vary from anxiety or depression to more involved conditions, such as schizophrenia and bipolar disorder. To become a psychologist, one must get a four year degree or bachelor’s degree and then complete two more years of school to get a master’s degree and then two additional years and get a PhD. After this, they must complete 1500 hours of supervised practice, which would require nine months to complete at 40 hours per week. A psychologist, therefore, has at least eight to nine years of education after high school. Psychiatrists, on the other hand, must first obtain an MD (after completing a four year degree). They then complete four years of residency training and can therefore prescribe medicines. Psychiatrists, therefore, have at least 12 years of education after high school.

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honor roll update

How does genetics influence Valley Fever? Research underway now to answer this question. By John N. Galgiani, MD

Introduction.

John Galgiani, MD Dr. Galgiani has been working with Valley Fever (Coccidioidomycosis) for the last three decades. As Director of the Valley Fever Center for Excellence his passion is research in the treatment of Valley Fever. This involves studies to improve the detection of the fungus in the environment, to increase the sensitivity of diagnostic tests for patients, and to develop a vaccine to prevent the disease in both humans and animals.

Of the roughly 150,000 new infections of Coccidioidomycosis (Valley Fever) that occur each year, there is an enormous range of severity and outcomes. As depicted in Figure 1 (page 19), approximately one-third seek medical attention because of a significant illness and even fewer of these are accurately diagnosed and reported (1) to state officials. The community-acquired pneumonia syndrome that most symptomatic patients experience often takes many weeks to many months to completely resolve and is anything but trivial.(2) Even so, for most patients, the illness is eventually self-limited whether treated or not. In contrast, a relatively small proportion of all infections result in the spread through the blood stream beyond the lungs (extrathoracic dissemination) to produce progressive tissue destruction in skin, bones, joints, the central nervous system, and almost any other part of the body. As a result, about 160 people die of Valley Fever each year.(3) What accounts for this striking spectrum of disease has been the subject of speculation for decades. Now two research programs have been initiated to try to answer this question.

Genetic differences among persons is the prime suspect.

Contact him by calling 520-6264968 or email spherule@u.arizona.edu

For many infectious diseases, the size of the microbial inoculum determines whether disease will result. Indeed, there are very good examples of this when the exposure to coccidioidal spores is very high. For example, when archeologists or construction projects involve soil rich in spores of Coccidioides spp., infection rates are higher and symptomatic illness is more common than found in the general population within endemic regions.(4-6) However, in such clusters, there is little or no evidence that high inoculum is more likely to result in extrathoracic dissemination.

This column is reprinted with permission from AzMedicine, Vol. 25, No. 3.

Another possible source of differences in disease severity could be due to differences among strains of Coccidioides spp. While this cannot be entirely ruled out, the evidence that exists is not supportive. For example, in the clusters of infections cited above where like-

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honor roll update

ly most infections came from genetically similar spores, there is still a wide spectrum of illness. Similarly, in laboratory accidents where all persons are definitely exposed to the same strain, there are also diverse clinical manifestations.(7) In contrast to inoculum and fungal virulence, several lines of evidence implicate genetic differences among individuals as a factor responsible for disseminated infection. First and most apparent, normal control of coccidioidal infection is critically dependent on competent cellular immunity. When this is severely compromised either by an underlying disease such as AIDS(8,9) or by immunosuppression for organ transplantation or treatment of autoimmune disorders,(10-12) coccidioidal infections are very much more likely to result in extrathoracic dissemination. That broad immunosuppression is a major risk factor for disseminated Valley Fever opens up the possibility that more subtle differences in the immune response to coccidioidal infection could account for differences in disease severity.

Figure 1 500,000

Total Infections (150,000) 50000

Seek Medical Attention (50,000)

Diagnosed/Reported (20,000) 5000

500

Disseminated Infection (600)

Deaths (160) 10

Second, men are much more likely to develop disseminated coccidioidal infection than women. Evidence for this comes from the enrollment statistics for clinical trials conducted by the Mycoses Study Group for patients with disseminated coccidioidal infection where between 1988 and 2007 three-quarters of 367 subjects were male.(13-17) Similar results are apparent in other reports as well.(18-20) Third, at least one specific genetic marker, that of B and AB blood groups, has been associated with disseminated infection.(19, 21) This is not likely to be a causal relationship but does clearly suggest a genetic component. Finally, numerous studies have implicated increased risk of certain ethnic groups for disseminated infection, most notably those of African and Filipino ancestry.(22) Estimates of how much more susceptible African-Americans are to developing disseminated disease range as high as 41.9 times more than Caucasians (Table 1, page 20). An ADHS presentation in 2011 based upon chart review of reported cases found dissemination in Blacks was 25% compared to 6% in Whites, roughly a four-fold increase in incidence of dissemination. The denominator for these statistics was all cases reported to the state and therefore avoid referral bias and some other confounding factors in earlier studies (Table 1). Despite all of these associations suggesting a genetic component to a risk for disseminated infection, there have been essentially no observations as to which specific genes

are involved and how genetic differences affect disease susceptibility. Dr. Stephen Holland, a physician scientist, and his colleagues at the National Institutes for Health have recently identified in a small number of patients specific gene mutations which appear responsible for more severe infections. The mutated genes were the interferon-gamma receptor 1,(28) the interleukin-12 receptor beta,(29) and STAT1.(30) As important as these findings are, all of the patients described in these reports are not typical of most patients who experience disseminated coccidioidomycosis. The patient with the interferon-gamma receptor 1 deficiency had two other opportunistic mycobacterial infections at other times in his life, and multiple opportunistic infections are not typical for patients with disseminated Valley Fever. The patients with the interleukin-12 beta deficiency were siblings from a consanguineous family. Disseminated coccidioidomycosis is very uncommon in multiple members of the same family. The two patients with the STAT1 mutation had a clinical presentation that included disseminated infection but also included a consumptive pulmonary process that was strikingly devoid of cavitation. However, Dr. Holland has identified additional patients who appear to have functional immunologic deficits, even though he and his team were unable to determine the genetic basis for those altered responses.(31)

A monthly publication of the MCMS â&#x20AC;˘ November 2014 â&#x20AC;˘ Round-up â&#x20AC;˘ 19

honor roll update

Table 1. Relative risk of disseminated coccidioidomycosis in African-Americans as compared to Caucasians. Report

Year

Study type

Fold increased risk

Smith et al (23)

1946

Retrospective

+14.0

Flynn et al (20)

1979

Outbreak, retrosp.

+9.5

Pappagianis (24)

1988

Outbreak, retrosp.

+9.1

Rosenstein et al (25)

2001

Retrospective

+ 7.0

Crum et al (26)

2004

Retrospective

+41.9

Drake et al (27)

2009

Retrospective

+11.0

Foley et al* (18)

2011

Prospective

+4.0

* https://www.vfce.arizona.edu/resources/pdf/csg/55Proceedings.pdf.

Two studies now underway involving Arizonans to better understand the genetics of disseminated Valley Fever. Encouraged by his recent findings, Dr. Holland has written a clinical research protocol specifically addressing patients with disseminated coccidioidomycosis. The program, entitled “The Pathogenesis and Genetics of Disseminated Coccidioidomycosis,” is open to any person over the age of two years who has culture or histologic proof of disseminated Valley Fever. Persons who have an already identified immunosuppressing condition or who have a medical or psychiatric condition that would interfere with providing informed consent would not be appropriate for this study. If informed consent is given, subjects will initially have blood specimens collected locally for shipment to the NIH. Then, depending upon initial results, subjects may be invited to visit the NIH for additional testing. After the initial visit, study-related expenses, including travel and treatment of the disseminated Valley Fever infection, will be paid by the NIH (initial travel expenses may be covered for indigent subjects). Dr. Holland’s study is open to patients throughout the United States. However, for those close enough to downtown Phoenix, it will be possible to have the initial blood and urine specimens obtained and shipment arranged by the NIH laboratory located on the Indian Health Hospital campus. This protocol was initiated in the fall of 2014 and is currently active.

A second research initiative is investigating the increased susceptibility of those with African ancestry. Despite the findings shown in Table 1, an underlying problem with all estimates of increased frequency of disseminated coccidioidomycosis in African-Americans is that the relation of self-identified race/ethnicity (SIRE) is a poor surrogate for ancestral genetic origins. Genetic heterogeneity within each racial and ethnic grouping may bias associations in genetic association studies, generating both falsepositive and false-negative results.(32-36) Variations in the distribution of single nucleotides polymorphisms (SNPs), called ancestry informative markers (AIMs), have been found which describe the architecture of genome variations between populations.(37) This discovery has led to an approach which circumvents the genetic ambiguity of SIRE categorizations. One of the benefits of AIMs is that relatively few markers are required (about 1,500 AIMs for African-Americans) to effectively screen the entire genome. As such, we expect it to identify large chromosomal regions of differential ethnic ancestry in clinical samples. For this second study, anyone who is self-declared of African ancestry who has laboratory-confirmed coccidioidal infection is eligible. For those who have not experienced disseminated infection, an adequate length of time off antifungal therapy is necessary (nominally two years(38)) to determine if disseminated infection is not likely to occur.

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honor roll update

Consenting subjects will be asked for a sample of saliva for genetic testing. They may also be asked for a blood specimen in the future for laboratory studies of their leukocyte response to coccidioidal antigens. Collaborators for this study are in both Phoenix and in Tucson. Any Arizona clinician interested in referring a patient for potential inclusion in either study can contact the Valley Fever Center for Excellence at the Arizona Health Sciences Center in Tucson (ph: 520-626-4968) or the Valley Fever Center in Phoenix (ph: 602-406-VALE) located at St. Joseph’s Hospital and Medical Center.

Summary After decades of interest and speculation about what possible genetic influences are involved in determining the severity of Valley Fever infections, there are now two separate studies underway to address this question, each taking a different and complementary approach. At the very least, such information would be valuable for risk stratification, either for persons wanting that information before travelling to the coccidioidal endemic area or early in the course of a new coccidioidal infection. However, depending upon the success of this research, understanding the genetics could possibly suggest new therapeutic options. Most helped by this work will be Arizonans where two-thirds of all Valley Fever infections in the United States occur. ru References 1. CDC. Increase in reported coccidioidomycosis - United States, 1998-2011. MMWR Morb Mortal Wkly Rep. 2013;62:217-21. 2. Tsang CA, Anderson SM, Imholte SB, Erhart LM, Chen S, Park BJ, et al. “Enhanced surveillance of coccidioidomycosis, Arizona, USA, 2007-2008.” Emerg.Infect.Dis. 2010; 16(11): 1738-44. 3. Huang JY, Bristow B, Shafir S, Sorvillo F. “Coccidioidomycosis-associated Deaths,” United States, 1990-2008. Emerg.Infect.Dis.2012; 18(11):1723-8. 4. Werner SB, Pappagianis D, Heindl I, Mickel A. “An epidemic of coccidioidomycosis among archeology students in northern California.” N.Engl.J.Med. 1972; 286: 507-12. 5. “Coccidioidomycosis in travelers returning from Mexico – PA,” 2000. MMWR Morb.Mortal.Wkly.Rep. 2000; 49(44): 1004-6. 6. Cairns L, Blythe D, Kao A, Pappagianis D, Kaufman L, Kobayashi J, et al. “Outbreak of coccidioidomycosis in Washington State residents returning from Mexico.” Clinical Infectious Diseases. 2000; 30(1): 61-4. 7. Stevens DA, Clemons KV, Levine HB, Pappagianis D, Baron EJ, Hamilton JR, et al. “Expert opinion: what to do when there is Coccidioides exposure in a laboratory.” Clin Infect Dis. 2009; 49(6): 919-23. 8. Fish DG, Ampel NM, Galgiani JN, Dols CL, Kelly PC, Johnson CH, et al. “Coccidioidomycosis during human immunodeficiency virus infection. A review of 77 patients” Medicine (Baltimore). 1990; 69: 384-91. 9. Singh VR, Smith DK, Lawerence J, Kelly PC, Thomas AR, Spitz B, et al. “Coccidioidomycosis in patients infected with human immunodeficiency virus: Review of 91 cases at a single institution.” Clin.Infect.Dis. 1996; 23(3): 563-8. 10. Taroumian S, Knowles SL, Lisse JR, Yanes J, Ampel NM, Vaz A, et al. “Management of coccidioidomycosis in patients receiving biologic response modifiers or disease-modifying antirheumatic drugs.” Arthritis Care Res (Hoboken). 2012; 64(12): 1903-9. 11. Vucicevic D, Carey EJ, Blair JE. “Coccidioidomycosis in liver transplant recipients in an endemic area.” Am J Transplant. 2011;11(1):111-9. 12. Vikram HR, Blair JE. “Coccidioidomycosis in transplant recipients: a primer for clini-

cians in nonendemic areas.” Curr Opin Organ Transplant. 2009; 14(6): 606-12. 13. Galgiani JN, Stevens DA, Graybill JR, Dismukes WE, Cloud GA. “Ketoconazole therapy of progressive coccidioidomycosis. Comparison of 400- and 800-mg doses and observations at higher doses.” Am J Med. 1988; 84(3 Pt 2): 603-10. 14. Graybill JR, Stevens DA, Galgiani JN, Dismukes WE, Cloud GA, NAIAD Mycoses Study Group. “Itraconazole treatment of coccidioidomycosis.” Am.J.Med. 1990; 89: 282-90. 15. Galgiani JN, Catanzaro A, Cloud GA, Higgs J, Friedman BA, Larsen RA, et al. “Fluconazole therapy for coccidioidal meningitis. The NIAID-Mycoses Study Group.” Annals of Internal Medicine. 1993; 119(1): 28-35. 16. Galgiani JN, Catanzaro A, Cloud GA, Johnson RH, Williams PL, Mirels LF, et al. “Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group.” Ann.Intern.Med. 2000; 133(9): 676-86. 17. Catanzaro A, Cloud GA, Stevens DA, Levine BE, Williams PL, Johnson RH, et al. “Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis.” Clin.Infect.Dis. 2007; 45(5): 562-8. 18. Foley CGT, C.A.; Christ,C.; Anderson, S.M. “Impact of disseminated coccidioidomycosis in Arizona, 2007-2008.” Proceedings of the 55th Annual Coccidioidomycosis Study Group. University of California at Davis, Davis California: Coccidioidomycosis Study Group; 2011:8. 19. Cohen IM, Galgiani JN, Potter D, Ogden DA. “Coccidioidomycosis in renal replacement therapy.” Arch.Intern.Med. 1982; 142: 489-94. 20. Flynn NM, Hoeprich PD, Kawachi MM, Lee KK, Lawrence RM, Goldstein E, et al. “An unusual outbreak of windborne coccidioidomycosis.” New England Journal of Medicine. 1979; 301(7): 358-61. 21. Deresinski SC, Pappagianis D, Stevens DA. “Association of ABO blood group and outcome of coccidioidal infection.” Sabouraudia. 1979; 17: 261-4. 22. Pappagianis D, Lindsay S, Beall S, Williams P. “Ethnic background and the clinical course of coccidioidomycosis [letter].” Am.Rev.Respir.Dis. 1979; 120: 959-61. 23. Smith CE, Beard RR, Whiting EG, Rosenberger HG. “Varieties of coccidioidal infection in relation to the epidemiology and control of the disease.” Am.J.Public Health. 1946; 36: 1394-402. 24. Pappagianis D. “Epidemiology of coccidioidomycosis.” [Review] [192 refs]. Current Topics in Medical Mycology. 1988; 2: 199-238. 25. Rosenstein NE, Emery KW, Werner SB, Kao A, Johnson R, Rogers D, et al. “Risk factors for severe pulmonary and disseminated coccidioidomycosis: Kern County, California, 1995-1996.” Clin.Infect.Dis. 2001; 32(5): 708-15. 26. Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. “Coccidioidomycosis: A Descriptive Survey of a Reemerging Disease. Clinical Characteristics and Current Controversies.” Medicine (Baltimore). 2004; 83(3): 149-75. 27. Drake KW, Adam RD. “Coccidioidal meningitis and brain abscesses: analysis of 71 cases at a referral center.” Neurology. 2009; 73(21): 1780-6. 28. Vinh DC, Masannat F, Dzioba RB, Galgiani JN, Holland SM. “Refractory disseminated coccidioidomycosis and mycobacteriosis in interferon-gamma receptor 1 deficiency.” Clin Infect Dis. 2009; 49(6): e62-5. 29. Vinh DC. “Coccidioidal meningitis: disseminated disease in patients without HIV/AIDS.” Medicine (Baltimore). 2011; 90(1): 87. 30. Sampaio EP, Hsu AP, Pechacek J, Bax HI, Dias DL, Paulson ML, et al. “Signal transducer and activator of transcription 1 (STAT1) gain-of-function mutations and disseminated coccidioidomycosis and histoplasmosis.” J Allergy Clin Immunol. 2013; 131(6): 1624-34. 31. Duplessis CA, Tilley D, Bavaro M, Hale B, Holland SM. “Two cases illustrating successful adjunctive interferon-gamma immunotherapy in refractory disseminated coccidioidomycosis.” J.Infect. 2011; 63(3): 223-8. 32. Bonilla C, Boxill LA, Donald SA, Williams T, Sylvester N, Parra EJ, et al “The 8818G allele of the agouti signaling protein (ASIP) gene is ancestral and is associated with darker skin color in African Americans.” Human Genetics. 2005; 116(5): 402-6. 33. Caulfield T, Fullerton SM, Ali-Khan SE, Arbour L, Burchard EG, Cooper RS, et al. “Race and ancestry in biomedical research: exploring the challenges” Genome medicine. 2009; 1(1): 8. 34. Choudhry S, Coyle NE, Tang H, Salari K, Lind D, Clark SL, et al. “Population stratification confounds genetic association studies among Latinos.” Human Genetics. 2006; 118(5): 652-64. 35. Shriver MD, Parra EJ, Dios S, Bonilla C, Norton H, Jovel C, et al. “Skin pigmentation, biogeographical ancestry and admixture mapping.” Human genetics. 2003; 112(4): 387-99. 36. Tsai HJ, Choudhry S, Naqvi M, Rodriguez-Cintron W, Burchard EG, Ziv E. “Comparison of three methods to estimate genetic ancestry and control for stratification in genetic association studies among admixed populations.” Human Genetics. 2005; 118(3-4): 424-33. 37. Kittles RA, Weiss KM. “Race, ancestry, and genes: implications for defining disease risk.” Annual Review of Genomics and Human Genetics. 2003;4 (Journal Article): 33-67. 38. Ampel NM, Giblin A, Mourani JP, Galgiani JN. “Factors and outcomes associated with the decision to treat primary pulmonary coccidioidomycosis.” Clin Infect Dis. 2009; 48(2): 172-8.

A monthly publication of the MCMS • November 2014 • Round-up • 21

public health

E-Cigarettes and Vaporizers – Clarifying Public Health Roles and Goals By John Middaugh, MD

Introduction This year marks the 50th Anniversary of the Surgeon General’s landmark report on Smoking and Health. The Journal of the American Medical Association (JAMA) devoted their January 8th issue to examining its progress and reflect on the future. While recognizing the advances in tobacco control, one editorial pointed out the need to “reaffirm the fundamental resolve to end the tobacco epidemic once and for all, and doing so should not take another 50 years.” More recently, enabled by new technology, unregulated ecigarettes and vaporizers have exploded in use and popularity, potentially threatening the hard-won, painstaking gains against smoking of the past five decades.

John Middaugh, MD

Background

Dr. Middaugh is a Public Health Consultant and retired Epidemiologist. His previous positions include Director, Division of Community Health and Chief Health Officer for the Southern Nevada Health District.

Tobacco Use In spite of the progress made over the past 50 years, the Centers for Disease Control and Prevention (CDC) estimates that 42 million adult Americans struggle with addiction to cigarettes, and the tobacco industry spends more than $8 billion per year in the United States to advertise and market cigarettes and smokeless tobacco.

He joined MCMS upon re-location to Arizona in 2014.

In the United States, the prevalence of cigarette smoking among adults peaked at 43% in 1964 and fell to 18% in 2012. Per capita daily cigarette consumption by smokers decreased from 20 cigarettes per day in 1970 to 13 cigarettes per day in 2012. Over five million children alive today are expected to die, and 480,000 adults are projected to die annually from cigarette use.

He can be reached at jpmidd@cox.net.

Of the estimated 42 million adult smokers in the United States, 70% say they want to quit smoking, but only 3-4% are able to do so, and many relapse within two years. The prevalence of cigarette smoking falls most heavily on the poor, persons with mental illness and substance abuse, persons who are incarcerated, and other stigmatized groups.

22 • Round-up • November 2014 • A monthly publication of the MCMS

public health

E-Cigarettes and Vaporizers E-cigarettes and vaporizers are a recent phenomenon made possible by breakthroughs in technology that enabled miniaturization of batteries and delivery systems. They are basically drug delivery devices that enable nicotine and other liquids to be heated and deliver the vaporized product. E-cigarettes arrived in the United States in 2008-2009. Since 2008, revenues have doubled every year since, projected to reach $2 billion in 2013. Adult use among smokers was 21% in 2011, equivalent to 6% of all adults. Use by teenagers doubled between 2011 and 2012. According to the CDC, in 2012, 10% of high school students said they had tried e-cigarettes. Of these, 7% had never smoked a traditional cigarette. A sophomore in a California high school estimated that 60% of his classmates had tried “vaping”. The National Youth Tobacco Survey found that the use of e-cigarettes had more than doubled from 2011 to 2012 among middle and high school students.

An internet-based survey conducted in California found more than 450 brands available on line with 7,700 flavors, including gummy bear, atomic fireball candy, cookies and cream, mango, watermelon, pina colada, chocolate banana, cinnamon apple, and vanilla, to name just a few. There has been a documented surge in calls to poison control centers regarding e-liquids with a 300% increase in 2013 compared to 2012. Public Health Policy Issues and Industry Conflicts The e-cigarette and vaporizer industry are aggressively marketing these new, currently unregulated devices. The Food and Drug Administration (FDA) has been mired in litigation for the past four years and has currently published proposals for regulating these products that were open for public comment through July 2014. Final rulemaking is not expected for years.

Proponents argue that availability of e-cigarettes provides a safer, much less harmful alternative to traditional cigarettes. They also argue that delivery of nicotine without the tars of traditional cigarettes provides less harmful exposure to the user and to others near-by. They suggest that current smokers who switch to ecigarettes have a safer alternative and that anecdotal reports provide evidence that e-cigarettes have helped cigarette smokers to quit or significantly reduce cigarette smoking. In addition, proponents have stated support for regulations to prevent sales to minors and have been careful not to market e-cigarettes and vaporizers as healthier than traditional cigarettes. Proponents have been very insistent that e-cigarettes and vaporizers should not be taxed, should be allowed to advertise, and that there should be no restrictions on their use indoors or in public areas. Public health officials have voiced concerns over the potential harms to individuals and to society from the widespread use of e-cigarettes and vaporizers. Already the marketing and advertising of e-cigarettes and vaporizers is promoting normalization of smoking. There is every reason to believe that e-cigarettes will become a gateway to nicotine addiction and the subsequent use of traditional cigarettes. While proponents publically express agreement about the need to prevent access to youth, early surveil-

A monthly publication of the MCMS • November 2014 • Round-up • 23

public health

lance data show that youth are already achieving access to e-cigarettes and vaporizers. The astonishing numbers of vaping flavors offered discredits proponents claims they are not targeting youth. Public health officials need to limit advertising and marketing as is the case with tobacco, prohibit flavored nicotine and other e-liquids, and prohibit use of these devices indoors and in public areas as is the case with traditional cigarettes. Currently, only Minnesota has enacted legislation to tax e-cigarettes. Given the exponential growth in the use of these products, all jurisdictions should tax e-cigarettes and vaporizers, and the revenues should be dedicated to support public health monitoring of the use, benefits and harms of these products. Recently, several countries and U.S. cities have acted to regulate these new products. Brazil and Canada have

banned e-cigarettes. San Antonio, Seattle, Los Angeles, Chicago, and New York have also banned e-cigarettes. The FDA has moved glacially and federal regulations are not expected for a period of years.

Conclusion Arizona’s public health and medical community at the state and county level need to join forces urgently to regulate and tax the rapidly developing e-cigarette and vaporizer industry. Enactment of regulations to treat e-cigarettes and vaporizers similar to tobacco would provide the best public health protections while enabling adults to access these products. Nicotine is a powerful, addictive drug. Public policies should be directed to prevent use of nicotine and to prevent new nicotine users, especially among youth and adults. After 50 years of battle with the tobacco industry, it would be a tragedy to backslide and prolong achieving a smoke free generation. ru

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24 • Round-up • November 2014 • A monthly publication of the MCMS

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healthcare happenings

MCMS Members Provide Ebola Public Health Education Drs. Jonathan Weisbuch and Kelly Hsu, and Lydia Plante, MPH, an Epidemiologist with the Arizona Department of Health Services, provided Ebola public health information to the Asian community on November 4th. Sixty Asian Pacific Islander (API) community members and leadership, and media from Filipino, Vietnamese, Chinese and Southeast Asia attended. The event was sponsored by Asian Pacific Community in Action (www.apcaaz.org). APCA is a nonprofit organization advocating for better health for the Maricopa County API population through education, advocacy, translation services, and access to health services, including health education, flu vaccination, and screening for new immigrants. ru

Photo center, left to right: Lydia Plante, Jonathan Weisbuch, MD and Kelly Hsu, MD

CME Opportunity - Update on Psychiatry: Continuing a Proud 23 Year Tradition Presented by the University of Arizona College of Medicine Department of Psychiatry in collaboration with the Arizona Psychiatric Society and the Arizona Psychological Association, this gem in the desert is a fourday accredited course that maintains its strong core in psychopharmacology as it relates to depressive, bipolar, anxiety, and psychotic disorders. The conference will be held February 16-19, 2015 at the J.W. Marriott Starr Pass Report, Tucson. It is a multi-accredited course with 24 CME hours offered. For more information or to register, please visit http://psychopharm.arizona.edu. ru

Training Tomorrow’s Healthcare Teens Midwestern University Offers Hands-on Educational Programs for High School Students in 2015 High school students interested in pursuing healthcare careers can look forward to a full slate of special programs offered by Midwestern University in 2015. February 4, 2015: A live competition similar to a spelling bee, the Arizona Regional Brain Bee offers students the chance to compete for scholarships and other prizes by answering questions about the brain and central nervous system. Participation is free, and the winner will receive a $2,000 first prize scholarship to any Midwestern program as well as up to $900 in reimbursements for expenses to attend the National Brain Bee in Washington, D.C. March 5, 2015: The Health Sciences Career Day is designed for high school classes to visit University labs, tour the campus, and attend interactive presentations by healthcare professionals. Classes will have the opportunity to choose hands-on workshops highlighting careers in osteopathic medicine, optometry, dental medicine, pharmacy, physician assistant studies, occupational therapy, biomedical sciences, perfusion, podiatric medicine, clinical psychology, physical therapy, nurse anesthesia, and veterinary medicine. July 9-18, 2015: For students who want to learn more about health careers, Midwestern University will offer its eight-day Health Careers Institute for High School Students in July. Each day from 9 am to 4 pm, Midwestern faculty and advanced students will teach workshops in anatomy, physiology, and introductory skills for various health professions, with a special focus on how to prepare for college and what to expect from each profession. Guest lectures for this exciting summer program will include current medical topics such as emergency medicine, sports medicine, drug abuse, healthcare volunteer opportunities, and more. In addition, participants will attend a medical field trip to Arrowhead Hospital and an interactive emergency medical services mock rescue scenario presented by the Glendale Fire Department. For more information, email azevents@midwestern.edu or visit www.midwestern.edu/azbrainbee; www.midwestern.edu/azscienceday; or www.midwestern.edu/azhealthcareersinstitute. ru

26 • Round-up • November 2014 • A monthly publication of the MCMS

healthcare happenings

UA College of Medicine – Phoenix Developing Innovative New Fellowship Clinical Informatics Fellowship Will Focus on Improving the Quality and Safety of Clinical Care The University of Arizona College of Medicine – Phoenix is developing an accredited physician fellowship pursuing the effective use of biomedical data to improve health. The two-year Clinical Informatics Fellowship Program, sponsored by Banner Good Samaritan Medical Center, is now possible due to the creation of a new clinical subspecialty by the American Board of Medical Specialties, said Howard Silverman, MD, MS, chairman of the department of Biomedical Informatics at the downtown Phoenix medical school. The American Medical Informatics Association has defined the fellowship as one in which physicians will pursue the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making, motivated by efforts to improve human health. The fellowship is a community-based initiative with a diversity of settings, projects and approaches and is open to physicians of all specialties following completion of a primary residency. Fellows will take on rotations, projects and electives, as well as eight online core content courses from Oregon Health and Science University, totaling 24 credits, and resulting in a Graduate Certificate in Biomedical Informatics from the Oregon school. The fellowship proposal is under review for accreditation, with a determination expected in early 2015 and Dr. Silverman is cautiously optimistic that the program will more than satisfy all the requirements as set by the American Council on Graduate Medical Education for a new program. Two physician fellows will be admitted in July 2015 in the first cohort.

Leonard Kirschner, MD Appointed to Harvard School of Public Health Leadership Council Leonard Kirschner, MD was recently appointed to the Harvard School of Public Health Leadership Council for a three-year term. The Harvard School of Public Health Leadership Council was established in 2003 to convene a diverse group of individuals who share the School’s dedication to the field of public health and who have volunteered to serve as ambassadors and advocates on behalf of HSPH and the cause of public health around the globe. The Council brings together a broad range of influence and expertise to HSPH. Members are business leaders, philanthropists, high-ranking public officials and practitioners, alumni, and media figures. Dr. Kirschner, a MCMS member since 1983, received his Masters of Public Health from Harvard in 1968. ru

Valley Fever Conference – Available Online The Valley Fever Center for Excellence (VFCE) held the seventh annual Coccidioidomycosis (Valley Fever) for the Primary Care Physician CME Conference on November 8th. Fifty-four attendees, including many members of the MCMS, attended the half-day session to learn about identifying, diagnosing and treating patients for Valley Fever. If you missed the live course, it’s available for free on the VFCE website at www.vfce.arizona.edu. The event was cosponsored by the MCMS as an Honor Roll Activity. ru

To find out more about this unique fellowship opportunity, visit http://phoenixmed.arizona.edu/bmi/education/ fellowship or email comphx-dbmi@email.arizona.edu. ru

Do you know of any Healthcare Happenings? Share the information with Round-up readers. To report your information, email mcms@mcmsonline.com. Please refer to page 6 for our usage statement.

left to right: Dr. Kelly Hsu, Dr. Rebecca Sunenshine, Presenter/Maricopa County Dept. of Public Health and CDC, Dr. Janis Blair, Presenter/Mayo Clinic in Arizona, Dr. Neil Ampel, Presenter/UA Valley Fever Center for Excellence, and Lisa Higgins, UA Valley Fever Center for Excellence

A monthly publication of the MCMS • November 2014 • Round-up • 27

member profile

Taking the Golden Rule to Heart – How a (Self-Described) “Old Country Doctor” Led the Fight to Eradicate Smoking in Hospitals

Physician Profile: Leland Fairbanks, MD, MPH, Family Physician Continuing his quest to stomp out smoking, Dr. Fairbanks is president of Arizonans Concerned About Smoking. He also is a former member of the U.S. Surgeon General’s National Advisory Committee on Smoking and Health, and the Team Navajo Coalition, which promotes smoke-free Native American workplaces, as well as serving on many other boards and coalitions. Among his many awards and accolades from the healthcare and business communities, Dr. Fairbanks, was the Phoenix Business Journal’s Healthcare Heroes inaugural Lifetime Achievement winner in 2002. He joined the MCMS in 1981. Contact him at acasinc@msn.com or 480-820-3740.

By Jay Conyers, PhD

r. Leland Fairbanks is the humblest of men. If you happen to meet him and ask him about his career, he’ll surely downplay his stature as a true healthcare hero. He is known and respected by many, and has touched countless lives during his impressive career as a healer, advocate, and activist. But he won’t tell you that. “Dr. Fairbanks is one of the most compassionate men I have ever met. He has taken caring for his fellow man or woman to an entirely higher level,” explains Rev. Ozetta Kirby of the East Valley NAACP. “And if anyone could ever be suspected of being color blind, it would be him. He truly exemplifies the saying, ‘He who is greatest amongst us will be a servant of all.’” It seems that many agree. He was recognized as the Arizona Family Physician of the Year in 1998 and includes among his accolades the U.S. Surgeon General’s Exemplary Service Medal (1988), the Health Golden Rule Award from Arizona Interfaith Movement (2011), and a Lifetime Health Hero honor from the Phoenix Business Journal (2002). But perhaps Fairbanks is most recognized for his pioneering work to rid hospitals of smoking; a claim to fame that leads many to now refer to him as the Father of the Smoke-Free Hospital.

28 • Round-up • November 2014 • A monthly publication of the MCMS

member profile

The Start of A Crusade Fairbanks’ passion for the smokefree hospital cause got a jumpstart after he witnessed nurses assisting their patients to smoke. During medical school, several of his clinical rotations were at the Minneapolis VA Hospital, where the typical military veteran had both heart disease and advanced lung disease. Watching how these patients were cared for opened his eyes. “The nurses played a major role in helping nicotine-addicted patients by lighting and holding the cigarettes for the feeble patients to prevent them from dropping burning cigarettes in bed,” recalls Fairbanks. “Many of those patients were on oxygen tanks struggling to breathe, so the nurses would first turn off the flammable oxygen before lighting a cigarette for one of their patients.” While the nurses seemed to be avoiding hazards by shutting off the tanks (before lighting) and holding the cigarettes to minimize the risk of bed fires, they were unknowingly killing themselves. Fairbanks adds, “Breathing in the heavy, truly unhealthy, secondhand smoke pollution was one of their regular medical nurse duties.”

health of Fairbanks’ older brother Arthur, who was experiencing prolonged difficulty breathing due to bilateral pneumonia and was believed to have a limited number of days left. Fairbanks’ mother was cheerful, however, and explained to the family that they had a much better family gift than what could be placed under a tree. Fairbanks recalls, “With much delight, she delivered the news that Christmas morning that the country doctor had followed up, just the day prior, on his promised house call by horse and buggy.” He continues, “She said to us that Dr. Bill exclaimed, ‘You have a wonderful unexpected Christmas gift. Your son Arthur has passed the pneumonia crisis. His high fever has broken and I now hear some good breathe sounds. Your son will live!’ I think I knew then that I would follow in Dr. Bill’s footsteps and care for others.”

Fairbanks worked his way through college loading freight on trucks at night, graduating from Augsburg College in Minneapolis in 1953. After graduating from medical school at the University of Minnesota, he set off for New Orleans to complete his internship in Family Practice. He recounts, “I had been the first Caucasian in 1957 to ride in the back of the racially segregated buses as I traveled back and forth to Charity Hospital each day. For me, it was an easy decision, as it meant elderly unsteady seniors could take a safer empty seat upfront.” Fairbanks’ heroic activism sparked the city to end the practice of bus segregation just a few short weeks later. He credits Rosa Parks – who a year earlier had the courage to do the same in Montgomery, Alabama – as his inspiration, and by the time he and Eunice (his wife of sixty-one happy years!) headed to Arizona in 1958 to

How a Boy Became a Doctor Fairbanks was drawn to medicine as a young boy growing up in rural Minnesota. It was 1935 and the middle of the Great Depression when Fairbanks’ family endured ownership loss of the family farm. Despite the circumstances of poverty, he still expected to see some wrapped gifts under the tree that morning, but instead found it empty. The family was also troubled with the struggling

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member profile

begin his thirty-year career with Indian Health Services (IHS), he was widely recognized as a civil rights advocate.

A Distinguished Career Throughout his three decades of service with IHS, Fairbanks pioneered numerous efforts that helped advance rural healthcare. He served as a Training Coordinator for

the IHS “Community Health Medic” program for Physician’s Assistants (the second such program in the nation) and later its Nurse Practitioners program. He also spearheaded the training of Pharmacists as Pharmacist Practitioners, which is widely recognized as the first expanded role demonstration model in our country. Fairbanks juggled his roles and responsibilities at IHS

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30 • Round-up • November 2014 • A monthly publication of the MCMS

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member profile

with training stops along the way. In 1962 he completed his Family Practice residency in Norfolk, Virginia followed by a Master’s in Public Health and a Preventive Medicine residency at the University of Oklahoma in 1968. Before long, Fairbanks held simultaneous faculty positions at three medical schools (Tulane, Oklahoma, Arizona) as well as the Central Arizona Community College. Despite the academic credentials, Fairbanks believes that students were often sent to train with him because many knew him by his nickname: “Old Country Doctor Grandpa,” a moniker given to him by his Navajo friends. Fairbanks said, “Dr. Philip Beckjord of Tulane University School of Public Health & Tropical Medicine said that the major reason his students were assigned to me as a preceptor in IHS was not to learn from a University Professor, it was to learn unique things of special commitment and value from an ‘Old Country Doctor’ not found in any university textbooks.” Despite being retired from clinical practice, Fairbanks continues to educate and train caregivers of tomorrow. He is a regular participant at the Arizona Coalition for Tomorrow (ACT) Kids Health Fair at which the Maricopa County Medical Society physicians and student members join other dedicated providers in improving the well-being of children from lowincome families. Volunteer physicians spend the day performing health assessments on needy children, and provide hands-on training to local medical students. “I only had the pleasure of working with Dr. Fairbanks for one day. That being said, he taught me more ‘tricks of the trade’ in that one day than I often

“We could just say what a great guy he really is. But thatt would be a real understatement!! y Honestly and most sincerely we have known a lot of fine peo-ple over the past 75 to 80 years.. Dr. Fairbanks However, without any exaggera-y tion, we have never known any person who has served as a fine medical doctor, a very responsible citizen and a very dear friend of so many people who have had the opportunity to know him fairly well. We could give you a long list of the many ways he has served so many people as a physician, neighbor and a very active community civic and public health leader. We are not certain about how many specific examples of his very outstanding pro-health leadership you may want to have us provide. However we can make a sincere and accurate statement that we honestly have never known another individual who has worked so very hard as a physician and leader of so many of public health improvement matters, as when he was a major leader of various pro-health efforts to ban smoking in public places. Dr. Fairbanks is the kind of person who works with others and inspires them to work hard and accomplish things that actually make us all healthier! We've had the privilege of knowing and working with him on various health and charitable efforts in which he was very compassionate in seeing and meeting needs. He has always acted and walked where many others only talked! We're both better persons for having known him and worked with him over the years.” — Dr. Donald N. Morris & Mrs. Patricia L. Morris

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member profile

Through the years, Dr. Fairbanks has volunteered many hours at the ACT Kids Health Fair.

learn in a week in the clinical setting,” said Rebecca Wendt, a third-year medical student at the University of Arizona College of Medicine – Phoenix who had the opportunity to screen children alongside Fairbanks at this year’s health fair.

How a Movement Began In 1983, Fairbanks attended the World Conference on Smoking and Health held in Winnipeg, Canada. He recalls many there speaking of hospital smoking as a universal, international embarrassment with no solution in sight. “No one seemed able to even conceive of such a thing as a 100%

smoke-free hospital ever being a realistic possibility. I even remember a particular nurse, who was one of the conference speakers, breaking down in tears as she explained to the audience that her primary assignment at the major hospital where she worked was to help patients smoke safely so as to not cause fires,” Fairbanks said. But there was a reason so many were reluctant to believe a smoke-free hospital would ever become a reality. According to Fairbanks, “The cigarette was considered the one last absolute ‘comfort crutch’ never to be denied to a patient in pain or fearing death. With hospitalization, many patients developed deep anxiety over severe pain and fear of death from

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32 • Round-up • November 2014 • A monthly publication of the MCMS

their diseases As a result, it was believed then that hospitals might even be last institutions to ban smoking instead of the first.” Fairbanks was discouraged to hear the dissenters and their suggestions to promote some beneficial ‘harm reduction’ by way of smoke-free wings of hospitals, but never an entire facility. So he approached his friend and fellow attendee Dr. Tom Hurst (who later founded the International Network Towards Smoke-Free Hospitals Organization). He asked Hurst to support a project to show that a completely smoke-free hospital was truly attainable. Hurst agreed that if Fairbanks could show it could be done, he would start a companion project in Europe. With Hurst’s support, Fairbanks then set out to convince the U.S. Surgeon General at the time, Dr. C. Everett Koop. Hoping for suggestions, Koop instead explained that in the nineteen years since the 1964 First Report of the Surgeon General on Smoking and Health – championed by former Surgeon General Dr. Luther Terry — the level field argument always proved to be unsuccessful for

member profile

this cause. Koop was referring to the effort of corralling large hospital organizations to reduce leadership risk for anyone carrying the flag alone. He further admitted that, to the best of his knowledge, there was not a single smoke-free hospital anywhere in the world in 1983, and it would therefore take someone proving 100% smokefree attainability in a single hospital before the idea would take hold. Fortunately, Fairbanks was the man for the job. He approached the IHS staff and Native American community leaders of Keams Canyon, Arizona, and then the PHS Indian Hospital on the Hopi Reservation – which served both the Hopi and Navajo nations – soon thereafter. He tried selling them on the idea of becoming the first hospital in the entire world to entirely ban smoking within their hospital. Fairbanks recalls, “Instead of nineteen more years to talk about issues involved, it took them about nineteen minutes of deliberation to say, ‘Yes, we’ll do it!’” By December of 1983, the plan was fully underway and it soon inspired other IHS hospitals and clinics all across the country to follow their lead and ban indoor smoking. By June of the following year, when Koop delivered his smoke-free society challenge at the American Lung Association meeting in Florida and then at the U.S. Public Health Service (USPHS) symposium in Arizona, nearly 200 IHS and Native American clinics and hospitals had embraced the smoke-free concept.

nity leaders were presented a Special Achievement & Commendation Award for being the first smoke-free hospital. Other accolades and recognition have trickled in over time. Earlier this year, the Arizona legislature recognized the courage of the Hopi Tribal Council and the Hospital Board Executive Committee of the Hopi Nation’s Keams Canyon Indian Health Service Hospital when they approved the bans on smoking at the Keams Canyon IHS Hospital. In January, the Arizona House of Representatives unanimously adopted HCR 2006, a resolution proposed by the Native American Caucus to recognize the Hopi Nation’s pioneering position. Rep. Albert Hale, D-St. Michaels (District 7), one of the sponsors of the resolution, said in a January 21st press release by Arizona House Democrats, “Because of this ban, entire generations of nurses, hospital staff and patients have now been free from exposure to secondhand smoke in hospitals.” When asked about Dr. Fairbanks, he added, “What a wonder-

ful caring human being! Dr. Fairbanks has given his entire life to helping others. He is a bright shining beacon and the ultimate example of how people should care for and treat each other. Dr. Fairbanks, Grandpa Country Doctor, thank you for all your contributions. May the Holy People be with you always.”

Still Going Strong Fairbanks’ activism often came with intense scrutiny and was interpreted as adversarial by many, especially those on the big tobacco or liquor industry sides of the debate. Nicknames he picked up along the way while championing smoke-free voter initiatives included “Taliban Health Czar” and “Health Tyrant.” Yet Fairbanks remained focused on the desired outcomes: citizens, by way of vote, demanding healthier environments. Today, Fairbanks remains active and is still involved in the organization he helped found, Arizonans Concerned About Smoking (ACAS). Still serving

In the little more than a year that had elapsed since Fairbanks approached Koop, the effort had gained national recognition. At the 1984 USPHS Symposium, the IHS staff and commuA monthly publication of the MCMS • November 2014 • Round-up • 33

member profile

Dr. Leland Fairbanks, tobacco-cessation champion, “Taliban Health Czar” and “Health Tyrant”

as ACAS’s President, Fairbanks has been instrumental in convincing local universities and municipalities to go smoke free. According to Philip Carpenter, Executive Director, ACAS, Fairbanks has had a lasting impression on him, and he’s taken his words to heart. Carpenter says, “One of my favorite quotes from Dr. Fairbanks is, ‘It’s easier to beg for forgiveness than to ask for permission.’ He’s provided impactful outreach and education over the years and has at times felt it necessary to push the envelope. I feel very fortunate to not only have met him but to work with him on many concerns.” When I asked Dr. Fairbanks about the connection between smoking and ethics, he responded, “Allowing harm to others from preventable pollution of water, food, medicines, and the air we all breathe is more than just bad medical practice. It wastes resources and

involves irresponsible social injustice i for f the victims.”

the complex science behind the dangers of tobacco.

Fairbanks goes on to describe the next n big threat brought on by the e-cigarette market explosion. He points to the clever deception of a poorly t informed public and impressionable i youth. The marketing of electronic y cigarettes as harmless “water vapor” c promotes the smoking ritual and, p according to Fairbanks, misleads the target audience by suggesting minimal t health risk with no mention of the h severity of nicotine addiction.

Fairbanks believes there’s much work to do to prevent e-cigarettes simply becoming a socially acceptable replacement for smoking. And he believes physicians need to play a larger role to prevent that from happening.

“Vaping advocates carelessly allege no cancer risk after only short periods of testing,” said Fairbanks. p “Despite the fact that the incubation “ period for causing cancer from regular p tobacco and other well-known cart cinogens is often 20-30 years.” c He continued, “Previously suppressed research conducted by Big Tobacco, revealed by one of their own scientists, Dr. Victor DeNoble, showed that heating of nicotine, even in e-cigarette devices, significantly increases heat-induced carcinogenic nitrosamines. Conversely, research done by the FDA demonstrated that carcinogen levels are much lower in room-temperature nicotine products such as patches and gum.” DeNoble was the scientist hired by tobacco company Philip Morris back in 1979 to develop (so he thought) a safer cigarette to reduce the effects of nicotine. DeNoble’s research in rats showed that acetaldehyde – a chemical found in cigarette smoke – strengthened the effect of the nicotine craving. Seeing the power of his findings, DeNoble became the leading Big Tobacco whistleblower, and now helps politicians and regulators understand

34 • Round-up • November 2014 • A monthly publication of the MCMS

“We as physicians should constantly seek to follow the so-called Golden Rule. Using continuity of care as our model, our goal is to achieve the best possible health of the mind, body, and spirit for patients, families and the community health. Turning a blind eye to the dangers of e-cigarettes is counterintuitive to this. Physicians should collaborate more with other educational and social betterment groups on health related community activities, including selected health related voter initiatives as educational advocates, not as political lobbyists. Physicians should help educate the community on medical issues and not sit back and, by non-action, allow community-impacting medical decisions be made by non medical people,” said Fairbanks. Many hope Dr. Fairbanks’ activism is infectious, and that more see the value in what he’s doing and join the fight. Bill Pfeifer, President and CEO, American Lung Association – Southwest adds, “I first met Dr. Fairbanks back in 1994 when we were working to pass the first tobacco tax in the state, and he warmly welcomed me into the non-smoking advocacy community. Dr. Fairbanks is a rare breed in that he was a practicing physician, who also worked to advocate for strong public health controls. He always did this as the ‘country doctor’ without being adversarial.” ru

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feature article

Are doctors ethically obligated to sign patients up for Obamacare? By Robert B. Doherty

ne of the most disheartening developments in the unrelenting political fight over the health reform law is the organized effort by its opponents to dissuade the public from signing up for coverage. Having failed in efforts to block Obamacare in the Supreme Court, or to elect a president or Senate that would work for its repeal, they are now working to kill the law by persuading people to not sign up for coverage through the health exchanges, knowing that if not enough younger and healthier people sign up, premium costs will go up because the people who do sign up will be older and sicker. Then, if premium costs escalate, they figure the whole law will collapse.

Robert B. Doherty Mr. Doherty is Senior Vice President of Governmental Affairs and Public Policy for the American College of Physicians (ACP). Mr. Doherty has more than 35 years of health policy experience and is an accomplished presenter at health conferences. From 1979 to 1998, Mr. Doherty worked in the governmental affairs department of the American Society of Internal Medicine, and with the merger of ASIM and ACP in June, 1998, joined the ACP as Senior Vice President for Governmental Affairs and Public Policy. He has senior staff management responsibilities for ACP’s Division of Governmental Affairs and Public Policy, located in Washington, DC.

This effort to sabotage the law is “unprecedented and contemptible,” the conservative-leaning American Enterprise Institute’s congressional scholar Norm Ornstein writes in the National Journal: It is important to emphasize that this set of moves is simply unprecedented. The clear comparison is the Medicare prescription drug plan. When it passed Congress in 2003, Democrats had many reasons to be furious. The initial partnership between President Bush and Sen. Edward Kennedy had resulted in an admirably bipartisan bill—it passed the Senate with 74 votes. Republicans then pulled a bait and switch, taking out all of the provisions that Kennedy had put in to bring along Senate Democrats, jamming the resulting bill through the House in a three-hour late-night vote marathon that blatantly violated House rules and included something close to outright bribery on the House floor, and then passing the bill through the Senate with just 54 votes—while along the way excluding the duly elected conferees, Tom Daschle (the Democratic leader!) and Jay Rockefeller, from the conference committee deliberations. The implementation of that bill was a huge challenge, and had many rocky moments … Almost certainly, Democrats could have tarnished one of George W. Bush’s signature achievements, causing Republicans major heartburn in the 2004 presidential and congressional elections—and in the process hurting millions of Medicare recipients and their families. Instead, Democrats

36 • Round-up • November 2014 • A monthly publication of the MCMS

feature article

worked with Republicans, and with Mark McClellan, the Bush administration official in charge of implementation, to smooth out the process and make it work—and it has been a smashing success. He continues: What is going on now to sabotage Obamacare is not treasonous—just sharply beneath any reasonable standards of elected officials with the fiduciary responsibility of governing…When a law is enacted, representatives who opposed it have some choices (which are not mutually exclusive). They can try to repeal it, which is perfectly acceptable, unless it becomes an effort at grandstanding so overdone that it detracts from other basic responsibilities of governing. They can try to amend it to make it work better—not just perfectly acceptable but desirable, if the goal is to improve a cumbersome law to work better for the betterment of the society and its people. They can strive to make sure that the law does the most for the Americans it is intended to serve, including their own constituents, while doing the least damage to the society and the economy. Or they can step aside and leave

the burden of implementation to those who supported the law and got it enacted in the first place. But to do everything possible to undercut and destroy its implementation, which in this case means finding ways to deny coverage to many who lack any health insurance; to keep millions who might be able to get better and cheaper coverage in the dark about their new options; to create disruption for the health providers who are trying to implement the law, including insurers, hospitals, and physicians; to threaten the even greater disruption via a government shutdown or breach of the debt limit in order to blackmail the president into abandoning the law; and to hope to benefit politically from all the resulting turmoil—is simply unacceptable, even contemptible. Ornstein doesn’t address the medical profession’s role and responsibility to help their patients sign up for Obamacare coverage, but one has to wonder, will physicians who are against the law also discourage eligible patients from enrolling in it? Will they tell their younger, healthier and uninsured patients to reject buying coverage from the exchanges and applying for the law’s premium subsidies? Will they discourage the poor and near-poor (in states that have agreed to expand Medicaid) from enrolling in Medicaid? Or instead of actively discouraging enrollment, will they use a more passive resistant approach of doing nothing to help their patients understand the new coverage options available to them? Or will they encourage and help their patients sign up, notwithstanding their own partisan leanings and ideological objections to Obamacare? I would argue that the medical profession’s own standards of ethics and professionalism obligate physicians to help their patients understand and take advantage of the health insurance coverage options and subsidies offered by Obamacare. The Physician’s Charter on Professionalism, which was endorsed by ACP and dozens of other physician membership organizations including AMA, states the following: Commitment to improving access to care. Medical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable healthcare. Within each system, the physician should work to eliminate barriers to access based on education,

A monthly publication of the MCMS • November 2014 • Round-up • 37

feature article

laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.

The Institute of Medicine has concluded that lack of health insurance causes tens of thousands of people to die prematurely and unnecessarily. Obamacare will provide access to affordable coverage to people who now can’t afford it or can’t obtain it because of pre-existing conditions.

them and ask for help in understanding the coverage options available to them under Obamacare, as they will, physicians should direct them to resources to help them, independent of their personal opposition to the law. Under no circumstances should they discourage patients from obtaining coverage.

ACP’s ethics manual, Sixth Edition, offers the following guidance:

A physician’s primary duty to their patient then, in my mind, requires that physicians offer help to patients on obtaining coverage through the exchange or (expanded) Medicaid programs. Accordingly, a physician who discourages patients who would benefit from such coverage would be acting in a way that is in conflict with their professional and ethical obligations as determined by their own professional societies.

Society expects much from physicians, much more than we expect from politicians. The medical profession rightly demands much of itself. I hope that even the most militantly antiObamacare doctors will recognize that their primary duty to their patients requires that they help them sign up for Obamacare coverage, even if they wish to continue to engage in the political process to get it changed or even repealed. ru

The physician’s first and primary duty is to the patient. Physicians must base their counsel on the interests of the individual patient, regardless of the insurance or medical care delivery setting. And this: They should work toward ensuring access to healthcare for all persons; act to eliminate discrimination in healthcare; and help correct deficiencies in the availability, accessibility, and quality of health services, including mental health services, in the community.

To be sure, ethics and professionalism do not preclude physicians from engaging in the political process to change or repeal laws they disagree with, and to elect candidates who share their views. But when patients come to

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38 • Round-up • November 2014 • A monthly publication of the MCMS

This column is reprinted with permission from the American College of Physicians and the ACP Advocate Blog, August 2, 2013.

Sources: “Republicans prepare for ‘Obamacare’ showdown, with eye to 2014 elections,” Reuters (http://mobile.reuters.com/article/idUSBRE96O0EJ2 0130725?irpc=932) Norm Ornstein; National Journal; “The Unprecedented—and Contemptible—Attempts to Sabotage Obamacare;” July 24, 2013; http://www.nationaljournal.com/columns/washington-inside-out/the-unprecedented-and-contemptibleattempts-to-sabotage-obamacare-20130724 Ann Internal Medicine; “Ideas and Opinions,” February 5, 2002, “Medical Professionalism in the New Millennium: A Physician Charter;” http://annals.org/article.aspx?articleid=474090 “Ethics Manual, Sixth Edition, Lois Snyder, JD, for the Ethics, Professionalism and Human Rights Committee;” American College of Physicians, Ann Intern Med. 2012; 156: 73-104; http://www.acponline.org/running_practice/ethics/manual/manual6th. htm#physician-patient Institute of Medicine of the National Academies; “America’s Uninsured Crisis: Consequences for Health and Health Care;” February 23, 2009; http://www.iom.edu/Reports/2009/AmericasUninsured-Crisis-Consequences-for-Health-andHealth-Care.aspx

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student perspective

Trust. It’s a funny thing. By Tabarik Ahmad

Tabarik Ahmad Univeristy of Arizona College of Medicine - Phoenix, Class of 2018 Ms. Ahmad was born and raised in Dearborn Heights, Michigan, but her roots extend to Jordan, Egypt and Turkey. She wanted to be a lot of things when she was little, from a sanitation engineer to a teacher and entrepreneur. Her heart, however, has been locked on medicine since the fifth grade. She followed her passion in studying about people, culture, and health during college and graduated from Barrett, the Honors College at Arizona State University, in 2011 with a bachelor’s in Global Health, and completed a Masters degree in the field in 2012 in additon to a Graduate Certificate in Nonprofit Leadership and Management in 2013. She also spent four years volunteering at Banner Cardon Children’s Medical Center in Mesa. In 2014, Ms. Ahmad chose to pursue her medical degree at the University of Arizona College of Medicine – Phoenix, which has been her dream since her freshman year at ASU.

rust. It’s a funny thing. Trust, as defined by Merriam-Webster, is an “assured reliance on the character, ability, strength, or truth of someone or something,” or, “a charge or duty imposed in faith or confidence or as a condition of some relationship; something committed or entrusted to one to be used or cared for in the interest of another.” These definitions encompass the act of believing in something, or an even more precarious act: believing or entrusting someone. We trust people everyday. We even trust complete strangers. For example, I would argue that the daily simple act of driving (or transportation of any sort) requires that we have in us a certain level of trust or confidence in the driving ability, attention, and responsibility of others. We trust our baristas to make the perfect, smooth lattes that we depend on to get us through the day, and our mail carriers to deliver an important letter that carries a part of our heart to someone we miss miles and miles afar. We function on a daily basis depending on the ideation that others will not only do their jobs right, but that they will carry out their duties with the same fiery passion and integrity we choose to carry out in our daily professional responsibilities. We don’t live sustainable or happy lives believing that every one we encounter is going to make a mistake or deliberately “hurt” us. Despite any beliefs that we are independent, our mere hearts, souls and emotions connect and affect us on levels so deep and intricate that we cannot sustainably exist without our dependence on others. Some of us trust in others/humanity on opposite ends of the trust spectrum, however there does exists a level of trust, no matter how minute. We trust our partners, our children’s teachers, etc. We even trust things. We trust our technological gadgets to remind us of our 2 pm meetings and the traffic lights to operate correctly so we don’t get into fatal collisions, etc. I have been thinking a whole lot about the concept of trust and the various ways we exude trust both consciously and unconsciously. Trust speaks the loudest when I observe physicians; all the way from managing simple patient cases to when physicians must confront patients for more invasive clinical situations.

40 • Round-up • November 2014 • A monthly publication of the MCMS

student perspective

The trust I see in these situations is sometimes scared and hesitant, yet it is roaringly eloquent, powerful and peaceful. Although it’s apparent that a mere individual, albeit with many years of experience, training, and expertise, is about to cut through a

my fear of ever having this trust burst through its armor only to fall victim to its inner shakiness and the result be hurting a person and their loved ones. I suppose it is a Catch-22. But nothing is certain; people, we, I fail sometimes. However, this possibility of failure is

“My trust is quite thin, almost, nonexistent in some clinical contexts. However, patients’ trust protects mine. It feeds my trust’s growth and desire to flourish; it offers my trust protection in return. I promise to never let trust feel selfish, foolish or cowardly powerful. I will forever work on strengthening my trust and not allow it to be penetrated by my inner fears or other human influences that cloud my judgment or yearning to serve my patients.” — By Tabarik Ahmad

patient’s chest for an open heart surgery, trust glows in the room, its shiny armor conceals the shakiness and fright, the discomfort and uncertainties of trusting a fellow human being, who may even be a complete stranger. This trust is brave and blind, it is something I admire. It gives me butterflies in my heart, but also kindles

what makes this trust so impressively magnificent and humbling. It is what has kept the patient-physician relationship so very sacred and unlike any other. This is the same armor that physicians wear on their brains. It is because physicians are human too. We trust

our abilities but are also just made up of the same elements, fears, emotions, and excitement, fear, fatigue, happiness, etc. as our patients. While trust’s armor may corrode, the trust physicians’ function with must withstand the greatest bombardments and natural elements of hesitancy, fear, excitement — hope, and its lack-of — amongst many other attackers of trust. It must be cared for and shined regularly with any and all advancements available. This trust is worked on infinitely just as the element of trust immortally transforms and conforms in the patient-physician setting. My trust is quite thin, almost nonexistent in some clinical contexts. However, patients’ trust protects mine. It feeds my trust’s growth and desire to flourish; it offers my trust protection in return. I promise to never let trust feel selfish, foolish or cowardly powerful. I will forever work on strengthening my trust and not allow it to be penetrated by my inner fears or other human influences that cloud my judgment or yearning to serve my patients. The best and strongest defense I use for it will always and forever be the resilient, blindly brave and humbling patientdriven trust. ru

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A monthly publication of the MCMS • November 2014 • Round-up • 41

2014 annual event

Maricopa County Medical Society’s 2014 Annual Event:

“VISTAS DE MEDICINA”

fun time was had by all on October 17 at the 2014 Maricopa County Medical Society (MCMS) Annual Event.

This year’s affair, one of the highest-attended in MCMS history, was held at the El Chorro Restaurant in ParadiseValley. Michael R. Mills, MD, MPH, 2012 President and MCMS member since 1999 said of El Chorro, “What a beautiful location for hosting this annual evening of colleagues new and old in support of our beloved county society. From the ambience to the food, Miriam, the Board, Jay and the MCMS team shined. Bravo!!!” Prior to mingling, attendees listened to remarks from our very special guest speaker, Representative Heather Carter, Legislative District 15 and Health Committee Chairman. Nathan Laufer, MD, 2011 President, and MCMS member since 1985 said, “The MCMS annual event this year was one of the best. Our guest speaker, Rep. Heather Carter gave a very insightful talk on the political process. This was very timely talk, occurring just prior to the midterm elections. My congratulations to Miriam and the board for a wonderful turnout and a great venue.”

42 • Round-up • November 2014 • A monthly publication of the MCMS

Photo left to right: Jay Conyers, PhD, Rep. Heather Carter, & Miriam Anand, MD

2014 annual event

Sherry Lato, Marc Lato, MD, Dean Gain, MD & Suanne Rudley

Nathan Laufer, MD, Judy Laufer, May Mohty, MD & Atef Mohty, MD

Randall Porter, MD, Rep. Heather Carter, Miriam Anand, MD & Tony Lee, MD

After Rep. Carter spoke, members participated in a brief meeting to conduct official MCMS-business, including the 2015 candidates for the MCMS Board presented by Miriam Anand, MD, President, and MCMS Executive Director, Jay Conyers, PhD. The MCMS would like to thank our members — who without your support these events wouldn’t be possible. We also thank Rep. Carter for her informative and inspiring words, and Mike Paulson of Paulson Photo/Graphic for taking the wonderful photos on pages 42, 43 and the cover. ru

Bryan Updegraff, MD & Alyca Avent

Ken Tollackson, MD, Ann Tollackson, Nancy Kravetz, & Bob Kravetz, MD

Kelly Kantartzis, MD & Stamatis Kantartzis, MD

Nancy Kim, MD & Rajan Bhatt, MD

A monthly publication of the MCMS • November 2014 • Round-up • 43

mcms board of directors meeting minutes

The Maricopa County Medical Society

BOARD OF DIRECTORS MEETING August 11, 2014 • 6 pm

BOARD MEMBERS

FINANCE COMMITTEE

Drs. Miriam Anand, Suzanne Sisley, Elizabeth McConnell, Mark Wallace, Ryan Stratford, Adam Brodsky, John Couvaras, Tanja Gunsberger, Jennifer Hartmark-Hill, Kelly Hsu, Steve Kassman, Lee Ann Kelley, Richard Manch, May Mohty, Anita Murcko, and Sue Whitely were present. Jay Conyers, PhD, Executive Director of the MCMS was also present.

Dr. Wallace presented a slide showing a breakdown of the profitability of the Society and individual business units for the first two quarters of 2014 (combined). He highlighted certain revenue centers and costs for the business units, comparing actual to budgeted. The Board approved the June and Q1/Q2 financials, as presented.

GUESTS Dr. Bob England, Chic Older WELCOME At 6:12 pm, meeting called to order by Dr. Anand. The consent agenda was approved. DEPARTMENT OF PUBLIC HEALTH Dr. Bob England presented to the Board and gave updates on some community programs. He provided the Board with a copy of the state’s new opioid prescribing guidelines and asked the Society to consider endorsing the guidelines. The Board agreed that more time was needed to consider an endorsement, and the policy committee agreed to review them during the next committee meeting. Dr. England then provided the Board with copies of syphilis transmission throughout the county and encouraged the Board to promote more widespread screening throughout the physician community. The Board encouraged Jay to work with Dr. England for a Round-up article in the community issue. ROUND-UP MAGAZINE Jay presented to the board the plan for the September issue, with the added print copies and approach to build membership. The Board discussed some ideas for Jay to consider including in the issue, such as a philanthropy article and a student section.

ARIZONA MEDICAL ASSOCIATION Chic Older addressed the Board and updated them on topics ArMA was focusing on. He discussed the IRS scam affecting physicians and the collective work being done by the FBI, IRS, and Secret Service. Nationwide, 50,000 physicians have been impacted, with roughly 120 here in Arizona. Chic encouraged the Board to vote at the August 26th primary and encouraged them to consider the list of candidates endorsed by ArMA. Chic provided brief updates on several other topics, such as the Banner realignment and acquisition in Tucson, the bond issue for the Maricopa County Medical Center, the ArMA leadership conference in March 2015, and the Blue Cross Blue Shield notice about prior authorizations. GUN SAFETY POLL The Board discussed what to do with the results from the gun safety poll distributed to members earlier in the year. The Board agreed that a Round-up article would not be needed, but did recommend an Affordable Care Act section be added in 2015. The Board approved inclusion of an ACA section in Round-up. ADJOURNMENT Dr. Anand adjourned the meeting at 8:01 pm. ru

44 • Round-up • November 2014 • A monthly publication of the MCMS

mcms board of directors meeting minutes

The Maricopa County Medical Society

BOARD OF DIRECTORS MEETING September 9, 2014 â&#x20AC;˘ 6 pm

BOARD MEMBERS Drs. Miriam Anand, Elizabeth McConnell, Mark Wallace, Ryan Stratford, Adam Brodsky, John Couvaras, Jennifer Hartmark-Hill, Kelly Hsu, Steve Kassman, Lee Ann Kelley, Richard Manch, May Mohty, Anita Murcko, and Sue Whitely were present. Jay Conyers, PhD, Executive Director was also present. WELCOME At 6:09 pm, meeting called to order by Dr. Anand. OLD BUSINESS Jay briefed the board on the upcoming website launch, the

September issue of Round-up, and the progress of the building renovation. BY-LAWS REVIEW Dr. Anand explained the work that had gone into preparing the revised version of the bylaws, and then explained some of the changes that were recommended by the review committee. The Board openly discussed the various recommendations, and offered some alternative suggestions. It was agreed that many sections of the current bylaws no longer apply to our organization. They also discussed the various membership categories and the pros and cons of expanding the membership designations by degree

type, professional role, and stage of career. A motion was put forth to submit to the membership a single amendment authorizing the Board of Directors the authority to amend the bylaws, as they deem appropriate. The motion carried. ANNUAL EVENT Dr. Anand reminded everyone about the annual event, and briefly discussed the logistics of the evening. NEW BUSINESS No new business was presented. ADJOURNMENT Dr. Anand adjourned the meeting at 7:29 pm. ru

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A monthly publication of the MCMS â&#x20AC;˘ November 2014 â&#x20AC;˘ Round-up â&#x20AC;˘ 45

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46 • Round-up • November 2014 • A monthly publication of the MCMS

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If interested please email or call Kris Calligan at 480-516-3429 or kcalligan@azgyn.com A monthly publication of the MCMS • November 2014 • Round-up • 47

WWhen you need a primary care physician or specialist

Itâ&#x20AC;&#x2122;s good to have options It It has to be someone you and your family will feel co comfortable with. So Someone with the right credentials. So Someone you can trust. Th The Maricopa County Medical Society offers a FREE te telephone and web-based physician referral service that W Whether you need a routine check-up or re require highly-specialized care, call us.

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Keeping Arizona families healthy for 122 years, and counting.

WEBB MEDICAL PLAZA | SUN CITY WEST, AZ BANNER DEL E. WEBB MEDICAL CENTER

WEBB MEDICAL PLAZA B W WEBB MEDICAL PLAZA A SUN CITY WEST, AZ | BANNER DEL E. WEBB MEDICAL CENTER CAMPUS

WEBB MEDICAL PLAZA A

W WEBB MEDICAL PLAZA B SUN CITY WEST, AZ | BANNER DEL E. WEBB MEDICAL CENTER CAMPUS

MEDICAL OFFICE SPACE AVAILABLE FOR LEASE WHY SUN CITY WEST? POPULATION WITHIN 5 MILES OF WEBB MEDICAL CENTER CAMPUS TO GROW 7.7% BY 2018 * LARGE, RAPIDLY GROWING, AND AFFLUENT PATIENT BASE ** OVER THE NEXT 5 YEARS, THERE WILL BE A GROWTH OF 14.4% IN MEDICAL OFFICE VISITS (APPROXIMATELY 43,508 VISITS – 8,701 VISITS/YEAR) ** *SOURCE: CLARITAS **SOURCE: MONTECITO RESEARCH

OPEN YOUR NEXT SATELLITE OFFICE IN THE GROWING SUN CITY WEST COMMUNITY! FOR MORE INFORMATION ON SPACE AVAILABLE, CONTACT: KATIE KELLEY Leasing Manager, South/Southwest | 480.998.3478 | katiekelley@htareit.com RACHAEL KIMSEY Senior Leasing Associate | 480.998.3478 | rachaelkimsey@htareit.com

A Leading Owner and Operator of Medical Office Buildings

Healthcare Trust of America, Inc. (NYSE: HTA) is committed to providing our tenants and physicians with best in class service. Our on the ground property management, engineering, and leasing teams are focused on establishing long term relationships with our tenants. Headquartered in Scottsdale, HTA is proud to be the leading owner of medical ofﬁce buildings in Arizona. CORPORATE OFFICE | 16435 North Scottsdale Road, Suite 320 | Scottsdale, AZ 85254 | p: 480.998.3478 | f: 480.991.0755 | www.htareit.com

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