December 2013 Sombrero

SombreroP i m a C o u n t y M e d i c a l S o c i e t y

Home Medical Society of the 17th United States Surgeon General

D E C E M B E R 2 0 1 3

Dr. Philip Fleishman: Peppermills and novels

The safari of a lifetime

Managing under the new tax laws

2 SOMBRERO – December 2013

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SOMBRERO – December 2013 3

Official Publication of the Pima County Medical Society Vol. 46 No. 10

PrintingCommercial Printers, Inc.Phone: 623-4775E-mail: [email protected]

PublisherPima County Medical Society5199 E. Farness Dr., Tucson, AZ 85712Phone: (520) 795-7985 Fax: (520) 323-9559Website: pimamedicalsociety.org

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Pima County Medical Society OfficersPresident Charles Katzenberg, MDPresident-ElectTimothy Marshall, MDVice PresidentMelissa Levine, MDSecretary-TreasurerSteve Cohen, MDPast-President Alan K. Rogers, MD

PCMS Board of DirectorsDiana V. Benenati, MDR. Mark Blew, MDNeil Clements, MDMichael Connolly, DOBruce Coull, MD (UA College of Medicine)Stewart Dandorf, MS, MPH (student)Howard Eisenberg, MDAfshin Emami, MDRandall Fehr, MDJamie M. Fleming (student)Alton “Hank” Hallum, MDEvan Kligman, MDMelissa D. Levine, MDClifford Martin, MDKevin Moynahan, MD

Soheila Nouri, MDJane M. Orient, MDGuruprasad Raju, MDScott Weiss, MDVictor Sanders, MD (resident)

Members at Large Richard Dale, MDAnant Pathak, MD

Board of MediationBennet E. Davis, MDThomas F. Griffin, MDCharles L. Krone, MDEdward J. Schwager, MDEric B. Whitacre, MD

Arizona Medical Association OfficersThomas Rothe, MD presidentMichael F. Hamant, MD secretary

At Large ArMA Board Ana Maria Lopez, MD R. Screven Farmer, MD

Pima Directors to ArMATimothy C. Fagan, MDCharles Katzenberg, MD

Delegates to AMAWilliam J. Mangold, MDThomas H. Hicks, MDGary Figge, MD (alternate)

SOMBRERO (ISSN 0279-909X) is published monthly except bimonthly June/July and August/September by the Pima County Medical Society, 5199 E. Farness, Tucson, Ariz. 85712. Annual subscription price is $30. Periodicals paid at Tucson, AZ. POSTMASTER: Send address changes to Pima County Medical Society, 5199 E. Farness Drive, Tucson, Arizona 85712-2134. Opinions expressed are those of the individuals and do not necessarily repre-sent the opinions or policies of the publisher or the PCMS Board of Directors, Executive Officers or the members at large, nor does any product or service advertised carry the endorsement of the society unless expressly stated. Paid advertisements are accepted subject to the approval of the Board of Directors, which retains the right to reject any advertising submitted. Copyright © 2013, Pima County Medical Society. All rights reserved. Reproduction in whole or in part without permission is prohibited.

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On the Cover

This sleepy lion in Kenya’s Masi Mara yawns after devouring a meal. You might well freak out if you realized you were having an M.I. while on a safari photo-shoot in Namibia. See this month’s Behind the Lens for the story of a man who lived through it (Dr. Hal Tretbar photo).

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5 Dr. Charles Katzenberg: As physicians, we’re where the healthcare ‘buck’ stops.

6 Letters: Dr. David Ruben says his kind of togetherness could help revitalize healthcare.

8 PCMS News: ThankyouforsupportingClinica Amistad.

11 Financial Management: Wealth adviser Dr. John Stephens on dealing with the new tax laws.

13 In Memoriam: Dr. Daniel T. Mihalyi died in October.

15 Retirement: Dr. Philip Fleishman is as busy a woodworkerandnovelistashewasaplasticsurgeon.

19 Makol’s Call: Dr. Makol has a ‘modest proposal’ forillegalimmigration.

20 Bioethics: The ‘missing piece’ in end-of-life decision-making.

23 Behind the Lens: ThepatientwinsasanAfricansafari photo-shoot encounters an M.I.

26 Mayo CME: Coming events from Mayo Clinic Scottsdale.

InsideCORRECTIONIn November’s In Memoriam, the obituary for Dr. B.T. ‘Tom’ Edwards contained a homonymic error in the nickname of the late Dr. Everett “Rett” Czerny.


The buck stops with usBy Charles Katzenberg, M.D.

PCMS President

As I write my last PCMS president’s column, seismic

forcesareactinguponhealthcare.

TheseincludetheAffordable Care Act; changes in payment methodologies leading away from fee-for-service, another surge in the movement toward physicians

as employees; and our seeming inability to control costs and make affordablehealthcareavailabletoallAmericans.

The ACA is currently President Obama’s and America’s worst healthcare nightmare. Whether the hapless healthcare.gov rollout, the “keep your owninsurance”fluborthefactthatpeopleinthesamestate,Coloradoforexample,whohappentoliveindifferentcountieswillpayratesthatcan vary by more than 100 percent for the same coverage.

The prognosis is not good. Is the government capable of making thingsright?Regardless,theACAcontainsenoughpositivesthatatleast some of it will endure.

Shiftsinpaymentmethodologiestohealthcareproviderswillbemessy.OrganizationslikeCarondeletHealthNetworkandCommunity Health Systems are banking on the fact that by employing and controllingphysicians,theywillbeinastrongerpositiontodistributebundled payments and control costs. TMC has chosen the path of partneringwithphysicians,supportingprivatepractitioners,andhashelpedlaunchanAccountableCareOrganization.TheACOmodelmaybetransformational.Timewilltell.

WhenIjoinedDavidLapanin1982,webecamePimaHeartAssociates. I knew nothing about the business of medicine. Thank goodness David did. I relished my independence. The path to success included showing up for work, never turning down a consult or request to see apatient,doingqualitywork,andstrivingtopleasebothpatientsand referring physicians. I believed that my commitment to my partnerandmypracticewouldleadseamlesslytofinancialsecurity,qualitylifestyle,andfamilytime.Iwaswrongaboutthefamilytime.That took a lot of work.

Formanyphysicianstoday,theformulaforsuccesshasshiftedtoanemployment contract. My daughter is halfway through medical school. Most of these kids don’t see themselves as independent privatepractitioners,butasemployeesofagroup,hospital,orinsurance company. They are facile at, and comfortable with typing and EMRs. Many value lifestyle over income and/or independence. Being an employee is not inherently bad, but it may put physicians further under the thumb of administrators who focus more on the bottomlinethanonthepatient.

Our current trajectory will never control costs or provide all with accesstoaffordablehealthcare.Inourcurrentsystem,ifweincreaseaccess, we increase cost, and if we decrease cost, we may limit accessandbasichealthcare.Thereareafinitenumberofavailablehealthcare dollars and it becomes a zero-sum game as to how they are distributed. The trend is for people to pay larger and larger percentagesoftheirpremiums,co-pays,anddeductibles.Thisisnothealthy for our economy, and is not sustainable.

The ACA requires that premiums do not exceed 9.5 percent of income. But on top of premiums, the maximum amount a consumer with single coverage will pay out-of-pocket for co-pays and deductiblesin2014willbe$6,350forindividual,andupto$12,700for family. Tax credits and subsidies will be available, yet health insuranceandout-of-pocketcostareexpensiveandfinanciallycrippling to many Americans.

The ACA is not the answer. We need to think bigger and more courageously.Thereisnocleanandsimplesolutionthatsitswellwith all Americans. I hope we can all agree that status quo is not sustainable.

Whatoptionsareavailable?

The simplest and cleanest way to achieve truly universal coverage andeffectivecostcontrolistobuilduponamodelthatalreadyexists:Medicare.Thistraditional,publicly-financedprogramcouldbetweaked, improved, and expanded as an improved “Medicare-For-All.”Iwelcomeyourfeedbackonotherviableoptions.

We currently treat healthcare as a commodity, available by ability to pay. We do not treat healthcare as a societal commitment available toall.ThequestioniswhetherweareseriousaboutprovidingaccesstoaffordablehealthcareforallAmericans.

Asphysicians,wearetheultimatepatientadvocates.Thebuckstopswithus,asitshould.AnythingthatgetsinthewayofthisHippocraticcommitmentnegativelyimpactsqualityhealthcare.

Question

Between 2000 and 2009 which has increased more?

1. Medicare reimbursements to physicians

2.Thecostofrunningapractice(MEI–medicaleconomicindex))

3.Medicarespendingperbeneficiary

Decreasing fee-for-service payment to physicians will not control costs. The bottomredlineshowsfeeincreaseswhichareminimal.Thegreenlineisthecostofoperatingamedicalpractice.Reimbursementisnotkeepingupwiththecostofoperatingapractice.Theblackline,spendingperbeneficiery,outstripstheothers.Increased total cost is not about increases in fees but increases in volume of servicesrenderedperpatient.

(UweEReinhardt,http://economix.blogs.nytimes.com/2010/12/17/the-annual-drama-of-the-doc-fix/) n

2

premiums, co-pays, and deductibles. This is not healthy for our economy, and is not sustainable.

The ACA requires that premiums do not exceed 9.5 percent of income. But on top of premiums, the maximum amount a consumer with single coverage will pay out-of-pocket for co-pays and deductibles in 2014 will be $6,350 for individual, and up to $12,700 for family. Tax credits and subsidies will be available, yet health insurance and out-of-pocket cost are expensive and financially crippling to many Americans.

The ACA is not the answer. We need to think bigger and more courageously. There is no clean and simple solution that sits well with all Americans. I hope we can all agree that status quo is not sustainable.

What options are available? The simplest and cleanest way to achieve truly universal coverage and effective cost

control is to build upon a model that already exists: Medicare. This traditional, publicly-financed program could be tweaked, improved, and expanded as an improved “Medicare-For-All.” I welcome your feedback on other viable options.

We currently treat healthcare as a commodity, available by ability to pay. We do not treat healthcare as a societal commitment available to all. The question is whether we are serious about providing access to affordable healthcare for all Americans.

As physicians, we are the ultimate patient advocates. The buck stops with us, as it should. Anything that gets in the way of this Hippocratic commitment negatively impacts quality healthcare. Question Between 2000 and 2009 which has increased more? 1. Medicare reimbursements to physicians 2. The cost of running a practice (MEI – medical economic index)) 3. Medicare spending per beneficiary

Decreasing fee-for-service payment to physicians will not control costs. The bottom red line shows fee increases which are minimal. The green line is the cost of operating a medical practice. Reimbursement is not keeping up with the cost of operating a practice. The black line, spending per beneficiery, outstrips the others. Increased total cost is not about increases in fees but increases in volume of services rendered per patient.


Le�ers

TogethernessTo the Editor:

Dr.OleJ.Thienhaus’sarticle,headlined“Medstudents,newdocsundeterred by doctors’ ‘malaise’” [Perspective,NovemberSombrero], is right on two counts.

Doctors-to-beare“firedup”tobedoctors,andmanyoftherestof us may feel some malaise at where medicine has gone. When I spend my few minutes interviewing med school hopefuls, I’m excited about their smarts and enthusiasm.

Iwanttotellthem,though,whatitmightbelikeafter20or30yearsofpractice,butholdmyselfbackandfocusonthejobathand. I do not agree with Dr. Thienhaus that newcomers will all beworkingforaninstitutionandthatthefutureforprivatepracticeisdead—althoughitwillbedifferentfromtoday’s.Ibelievewecandevelopamodelofpracticethatisbuiltonwhatworkedinthepast,andmeetstheexpectationsofthepresent.

MyfriendDavidMinter,M.D.andothersfoundedArizona’sfirstHMOinthe1970swithsuchagoal.ItmeantHealthMaintenanceOrganization,nothealthmanagementorganization.Itspremisewasbasedondoingpreventiveandeducationalcaretokeeppatientswell, and thus reduce the use and costs of more complex care.

Itwascalledcapitation,anditssuccessdependedonpatientsstaying with their physicians for long enough for them to realize

thebenefitsofthedoctor-patientrelationshipandsavingsfromhealthy lifestyles. It failed, in part because people moved or were movedaround,andalthoughtheincentiveswerecorrectlyplacedforbetterhealth,theywerenotalwaysclearorstrongenoughforpatientstofollowthehealthprescriptionstheirdoctors proposed.

Thefailedprogrammadesenseforanotherreason:itssuccessdepended on outcomes. We measure outcomes every day in every patientinteractionwehave.Althoughhealthyoutcomesweregoodforpayers,regulators,primarycareproviders,andpatients,itdidn’tsufficientlyrewardsuppliers,andmostspecialistswhodidproceduresforthesickestpatients.Itfailedinthatitdidn’tfocuseveryone in the system on working for a common goal.

A good example from industry would be John D. Rockefeller’s StandardOil.Ithadmanypartsthatdiddifferentthings—finding,distilling,marketingandsellingproduct,allwhilefindingwaystoworktogether.Theircommongoalwasprofit;ourswouldfirstbeimprovedhealthofthosewetreatwhichwouldleadtoprofit.

If every part of the medical system were rewarded by how patientsdid,theywouldbeaskingoneanotherhowtheycouldworktogetherinnewandbetterways.Tosetthisupsoitworks,we must learn from the past.

First,havethepatientsstayslongenoughwiththeirhealthgroupfor all to reap the rewards. Second, we would use outcome measuresofhowourpopulationisstaying,orincreasingtheirhealth,inordertodeterminetherewardsdistribution.Third,andthe part that needs the most thinking, would be to work out who would administer the rewards and where they would come from.

The government already provides half of our healthcare dollars. Much of the other half is doneinconjunctionwithemployers,insurancecompanies,andpatients.Somemay suspect that government involvement will screw things up, but we elect them and pay taxes for them to do their job of organizingandregulatingideasthatweimplement.

A step toward the success of this plan would be to organize the change as a health cooperative,ownedbyitparticipants,thepatients,providers,regulators,andpayers.The most important idea is to have the incentiveofallpartsworkingtogetherforthe goal of improved health. Rewards could includetaxdeductionsandbonusesforcarethatsucceeds.Patientswouldalsobereceivingincentivesfortheirparticipationand working along with improved heath.

Itisincumbentonustofindaplanthatwillbetterhelppatients,revitalizemedicine,andmakeitbothenjoyableandprofitableforthose coming along to treat them.

Sincerely,David A. Ruben, M.D., M.B.A.

Tucsonn

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PCMS News

ClinicaAmistad: We spend it wellThestaffofClinicaAmistadthanksPCMSmembersfortheirgenerous support in the past. Because of your kindness, PCMS members,ClinicaAmistadcontinuestoservethehealthcareneeds of the poor and uninsured in Arizona.

Theclinicisonfirmfinancialfooting,withseveralmonthsofoperatingexpensesinthebank.Consequently,ClinicaAmistadhas increased the range of services it provides through an expandednetworkofmedicalprofessionals,testingfacilities,andsurgical centers.

ImplementationofthePatientProtectionandAffordableCareAct, and the decision to restore AHCCCS coverage to many, provide hope that the healthcare needs of Arizona’s poor will be betterserved.Howevertheclinic’sdirectorsbelievethatthesechanges will not eliminate the need for the services by Clinica Amistad.Currentlytheclinicseespatientsbyreservationtohandletheoverwhelmingpatientload.Consequently,wehaveatwo-monthwaittimebeforeanewpatientmaybeseen.

AdonationtoClinicaAmistadismoneywellspent.Ninety-sixpercentofeverydollargoesdirectlytopatientcare.Owingtocarefulnegotiationandthegenerosityofthemedicalcommunity,themajorityofphysicianconsults,labtests,diagnosticstudies,andsurgicalproceduresareobtainedatorbelowactualcost.Medicationsprovidedtopatientsareeithergenericorover-the-counter.Thestaffof Clinica Amistad wrings the most value out of every dollar.

As we enter the season of giving, Clinica Amistad solicits your financialsupporttoenablecontinuanceofitsservicetotheSouthern Arizona community. As Clinica Amistad is a project of AmistadySalud,a501(c)(3)organization,alldonationstotheclinicarefederaltax-deductible.TheTaxpayerIdentificationNumberforAmistadySaludis75-3060875.

EvenbetteristhatAmistadySaludisregisteredwiththestateofArizonaasaQualifyingCharitableOrganizationprovidingassistance to the working poor. Arizona donors may claim a state taxcreditofupto$200forsinglefilersand$400formarriedfilingjointly.Thiscreditisinadditiontootherstatetaxcredits,suchascreditsfordonationstoeducationalorganizations.Newfor2013is that all Arizona income tax payers are eligible for this credit eveniftheydon’titemizedeductionsontheirfederalreturn.Moreinformationmaybefoundat:http://www.azdor.gov/TaxCredits/QualifyingCharitableOrganizations.aspx

You may send a check to our mailing address or visit our website (clinicaamistad.org)andusethedonationbuttontosecurelycontribute by credit card through PayPal.

Therearemanyotherwaystohelp:

Physicians and mid-level practitioners: We always need more practitionerswhoarelicensedinArizonaandarewillingtovolunteer.Ifyouhavethetimeortheinclination,wewouldwelcome your presence for as many or as few Wednesday evenings as you can spare.


Referrals: We need specialists to whom we can refer perhaps one client per month and who would see them for free or on a sliding feescale.Becauseweservemanydiabeticpatients,additionalpodiatrists to supplement the two we now have would be most beneficial.Wehavealimitedbudgetduetograntsupporttocover some specialist visits and services.

We are grateful for your generous support of the clinic!

FormoreinformationaboutClinicaAmistadandoptionsforworkplacegiving,pleasecallusat305.5107.OurmailingaddressisBox27284,Tucson,Ariz.85726.

Sincerely,Evan Kligman, M.D.

Raymond Graap, M.D.

PCMSA Holiday Luncheon is hereThe Pima County Medical Society Alliance Holiday Luncheon, benefitingMobileMealsofTucson,is11a.m.to2p.m.Wednesday Dec. 11 at Fleming’s Wine Bar & Steakhouse.

Todonatearaffle/auctionitemorforadditionalinformation,pleasecallChairpersonLupitaBorboaat548.0608,[email protected] .

Dr. Abdu treats rare brain disease

Moyamoya disease is a rare brain disorder caused when arteries at the base of the brain become progressively narrowed to the point of blockage. The name means “puffofsmoke”inJapaneseand describes a tangle of blood vessels that form to compensate for the obstruction.

Without surgery, Moyamoya patientsexperiencemultiple strokes with mental decline, anditcanbefatalifleftuntreated.

CarondeletHealthNetworkandCarondeletNeurologicalInstituteatSt.Joseph’sHospital report that it was “a

blessingthata40-year-oldTucsonwoman,sufferingMoyamoyasymptoms,foundherwaytoDr.EmunAbdu’sofficeatCNIinSeptember.BeforemeetingwithDr.Abdu,thepatientandherfamily were exploring going out of state for treatment.”

Emun Na Abdu, M.D. is a Fellowship-trained cerebrovascular and endovascularneurosurgeon,joinedCNIthispastspring,andrecently joined PCMS. She specializes in the treatment of vascular diseases of the brain and spine, including Moyamoya disease.

Today,followinganSTA-MCAbypass(adirectrevascularizationprocedure)Dr.Abdu’spatienthasnewhope,CNIreports.

“Dr.Abdu’sspecializedtraining,coupledwiththeuniquefacilitiesavailableatCNI,allowedhertoperformthiscomplexvascularsurgerythatincreasesbloodflowtothispatient’sbrain,usingstate-of-the-art BrainSuite iCT technology currently available at only17hospitalsintheU.S.Thistechnologyeliminatestheneedtomovebrainsurgerypatientsinandoutofsurgery,orsubjectthem to an invasive imaging procedure.”

Dr.AbduwasborninAddisAbaba,Ethopiain1979.Afterhighschool in her home town, she graduated maga cum laude in laboratorymedicineattheUniversityofWashington,Seattle,andgraduatedin2004fromUniversityofMichiganMedicalSchool.

She completed her general surgery internship and neurosurgery residency at Oregon Health and Science University, Portland. Her cerebrovascular/endovascular Fellowship was at Swedish NeurologicalInstitute,Seattle.PracticingwithWesternNeurosurgery,Ltd.,shespecializesinbrainandspinalcordtumors,trigeminalneuralgia,hemificialspasms,anddegenerativespinedisease.

College of Medicine awarded Reynolds grantTheUofACollegeofMedicine—Tucsonrecentlyannouncedthat ishasbeenawardeda“prestigiousgrantfromtheDonaldW.ReynoldsFoundationtostrengthenphysiciantrainingingeriatrics.

“With the rapid growth of the American elderly population,especially in Arizona, an urgent need exists to assure that all physicians are prepared to provide the best of care for older adults,” they said.“This$1milliongrant—theUniversityof Arizona Health Networkprovidedanadditional$847,845inmatching—provides much-needed support to train Arizona’s physicians in geriatric care, with an emphasis on hospitalists and surgical and medical specialists.”

Foundedin1954,headquartered in LasVegas,Nev., the Reynolds Foundationisanationalphilanthropic

Dr. Emun Abdu is one of the very few women physicians in the U.S. specializing in rebrovascular neurosurgery (Photo courtesy CHN).


organizationthathascommittedmorethan$245milliontoitsAging and Quality of Life program.

“The grant program will support and extend the successes of the ArizonaReynoldsProgramofAppliedGeriatrics,foundedin2006bya previous Reynolds grant, which built an infrastructure of excellence ingeriatriceducationandtraining,”theuniversityreported.

“ThisgenerousgrantfromtheReynoldsFoundationwillensurethat hospitalized older adults will be cared for by specialists who have been trained to meet the unique health-care needs ofolderadults,”saidPrincipalInvestigatorMindy Fain, M.D., division chief of geriatrics, general internal medicine, and palliativemedicineattheUofACollegeofMedicine–Tucson,and co-director of the UofA Center on Aging.

Targetedspecialtiesarethoseforacutecareorolder,frailadults,theuniversityreported:emergencymedicine;pulmonary/criticalcare;hospitalmedicine;orthopedics;andsurgery.“Inadditiontotrainingkeyspecialistsingeriatricprinciples, the program will develop high-value, team-based models of geriatric care for older, frail adults, such as a Senior Emergency Room, and an Acute Care of Elders program.

‘NorthernArizonatelemedicine corridor’ called model ‘telehealth ecosystem’TheArizonaHealthSciencesCenterreportsthatNorthernArizona’srapidlygrowingtelemedicinecooperatingprograms“provideaccessible,top-qualityhealthcareandcriticallyneededservices to rural Arizonans and healthcare professionals.”

RapidgrowthofnorthernArizona’stelemedicinecooperatingprograms in recent years was reported at the Arizona TelecommunicationsandInformationCouncil’sfifthannualmeeting,Oct.30,inPhoenix.

“Whentelemedicineprogramsreachacriticalsize,”theysaid,“the programs can achieve sustainability and even experience accelerated growth. That’s happening in northern Arizona alonga340-mile-longcorridorsurroundingInterstate40,betweenArizona’sborderswithNewMexicoandCalifornia.Manyofthehospitalfacilitiesandcommunityhealthcentersin this large swath of Arizona are members of the Arizona Health Sciences Center’s Arizona Telemedicine Program (ATP), establishedin1996bythestatelegislature.”

“The‘NorthernArizonaTelemedicineCorridor’fulfillsourhighestexpectationsofwhatwecouldachieveviatelemedicinewhenwestartedtheATPin1996,”saidRonald S. Weinstein, M.D.,ATPfoundingdirector.“Notonlyhavetheseorganizationsestablisheda‘telehealthecosystem,’theyarenationalmodelsofhealthcareexcellenceintheirownright.”

Theycalledtheimpact“significant.MayoClinicneurologists,for example, have provided remote teleneurology services for nearly1,000patientsinFlagstaffalone.Thedevastatinglong-termeffectsofstrokeshavebeenavertedfordozensofArizonans, saving lives, improving quality of life, and reducing future healthcare costs.” n

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Tax planning with the new tax lawsBy John Stephens, M.D., C.F.A., C.F.P.®, M.B.A.

Financial Management

In the October Sombrero I discussed the new tax law changes and simplestrategiesthatindividualscanusetobemoretaxefficient.NowI’lladdressmorecomplexstrategiesdesignedtolowerataxpayer’s adjusted gross income, to avoid going over the thresholds that are an important feature of the new tax law.

Individual taxpayers don’t do these complex strategies on their own.Rather,thestrategiesmustbeinitiatedatthepracticeorbusinesslevel.ForthesestrategiesIwillcover1)QualifiedRetirementPlans;2)Non-QqualifiedDeferredCompensationPlans;and3)CaptiveInsuranceCompanies.

Qualified Retirement Plans

Therearetwomajortypesofqualifiedretirementplans:DefinedContribution(DC)andDefinedBenefit(DB)plans.AmajordifferenceinthesetwotypesofplansisthatinallDCplans,theinvestmentriskiswiththeparticipants,whereasintheDBplans,theinvestmentriskismaintainedbythecompany.Thisisacriticalfactor in determining the appropriate investments held within each plan, and also important for owners to understand when choosinganappropriateretirementplan.Commonfeaturesofqualifiedplans,bothDCandDB,arethattheyaregovernedbyERISA and are asset- protected. They also can both be rolled into anindividualIRAuponretirement.

Ifyouhaveasmallerpracticeorwanttokeepitlesscomplex,youmightconsideraSIMPLEIRA,aSEPIRAorevenasolo401(k).Here, I will focus on the more complex and robust Safe Harbor 401kProfitSharing,andCashBalanceDefinedBenefitplans.

Safe Harbor 401(k) Profit Sharing Plan

InaSafeHarbor401(k)ProfitSharingplan,allparticipantsareabletodefer$17,500/yearfromtheirowncompensation,andparticipantsolderthan50candeferanadditional“catchup”of$5,500peryear.Inadditiontothesalarydeferral,highlycompensated physicians may have the company contribute an additional$38,000,resultinginatotalpre-taxdeferralof$51,000or$56,500ifolderthan50.

BecausequalifiedplansmustfollowDepartmentofLaborand IRS rules, they are not allowed to discriminate against lower-compensated employees. In simple terms, these plans cannot be setuptoallowthephysicianstomaxouttheplanandnotbenefittheemployees.ByelectingtouseSafeHarbor,theplanpassestestingand,ifdesignedproperly,allowsphysicianstodeferthemaximum amount.

One form of Safe Harbor requires that the sponsor contribute three percent of an employee’s salary, which is immediately vested. Investments in the plan can either be pooled in a single account, which is simpler and less expensive, or allow for individualparticipantstodirecttheirowninvestmentselections.

I always recommend that groups considering a Safe Harbor plan havetheirCPA/attorneyinvolvedinadditiontoathird-partyadministrator, to make sure all the details are correct. Another facet of DC plans is that some of the payroll providers and

insurancecompaniesoffersimple401(k)plans,buttheyareverybasicplansthatmaynotmeettheownerphysician’sobjectives.Although they may be less expensive, in the end they may providesignificantlylessbenefit.

Defined Benefits Plans (DB Plans)

DBplansareretirementplansinwhichthecompanyprovidesacertainbenefitwhenaparticipantretires.Themostbasicarethetypical large company or government pension plans under which aretireegetsasetamountforlife.ThetypicalDBplanusedbyphysiciangroupsistheCashBalanceDefinedBenefitplan.

ACashBalanceDBplanisdesignedsothatparticipantsmayaccumulate an amount, based on their age and salary, that allows themtodrawasetamountinretirementforlife.However,withtheCashBalanceDBplanthereisanexpectationthattheretireewill take a lump sum rollover to an individual IRA instead of an annuitizedincomemanagedbythecompany.Insimple,bigroundnumbers,theactuarialcalculationwillallowahighlycompensatedphysicianmakingatleast$255,000insalarytoaccumulatemorethan$2millionbyage62.Asyoucansee,thecalculationallowsolder physicians to defer very large amounts and younger physicianstocontributealesser(butstillmeaningful)amounttofully fund the DB plan. Please note that a group may decide to fundlessthanthemaximumallowedbytheactuarialcalculations.

InaCashBalanceDBplaneachparticipantisprovidedwithanannual summary of their “cash balance,” or the amount that has been funded on their behalf. The funds are always held in a pooled investment account which should be invested in a more conservativeallocation,becausethecompanyis“onthehook”for investment losses and may be required to contribute additionalmoneytogetanunderfundedplanbacktoanactuariallydeterminedbalance.Administrationoftheseplansismore involved and subsequently more expensive.

Before a group decides to implement a Cash Balance DB plan, the groupmusthaveverygoodstablecashflow.Thistypeofplanisalonger-termcommitmentandnot“profitsharing.”Oncetheplanis started, the company should plan on funding for a reasonable numberofyears.TheIRSscrutinizesplansthatarenotinplaceforthreetofiveyears.

Lastly,sinceaCashBalanceDBplanallowsfordifferentcontributionamounts for each physician, the group needs to think about how thatmightaffectthecurrentcompensationstructure.

Nonqualified Deferred Compensation

NonqualifiedDeferredcompensationisonlyanoptionifyourgroupisaCCorporation.Theseplansallowparticipantstodefersalary,butinanonqualifiedinvestment.TheproceedsfromplansnotqualifiedunderERISAmaynotberolledintoanIRAatseparationfromemploymentorretirement.Onceagain,anyoneconsidering this type of plan will need to hire a deferred compensationplanadministratorandshouldmakesuretoconsultwiththegroup’sCPAandattorney.Plansaretypically


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structured so that the deferred monies earn a set interest rate, andtheparticipantscanarrangetoreceivethemoneyatretirementoruponleavingthemedicalgroup.Whenthemoneyis paid out, it is treated as ordinary income.

A key point, and one that I know personally from my days with theThomas-DavisClinic,isthattheseplansarenotqualifiedandhavenoERISAprotection.AtThomas-Davis,manyofthephysiciansdeferredtheirsalaryaftertheFoundationHealthbuyout. Unfortunately some of the physicians lost that money whenthecompanyfailed.Atbankruptcy,deferredcompensationis an unsecured claim.

Captive Insurance Companies

CaptiveInsuranceCompanieswereoriginallydesignedforlargecompanies, typically the Fortune 500 kind, to own their own

insurance company and then pay premiums to themselves instead ofthepriorinsuranceprovider.Ofcoursethecaptiveinsurancemustbeabletotrackandprocessclaims.TheCaptiveInsuranceCompanyisalsoallowedtoinvestaportionofthepremiums,givencertainrestrictions,andultimatelymaypayoutdividendstotheowners if the investment risk pool is above a certain threshold. The main tax advantage is that these dividends typically have favorable capital gains rate treatment.

TherearenowCaptiveInsuranceCompanyprovidersthatallowsmaller companies, such as large medical groups or other large professionalcompanies,toparticipate.InsomecasesanumberofsmallergroupsorindividualdoctorsowntheCaptivejointly.Withoutquestion,thedecisiontostartaCaptiveshouldbevettedthoroughlywithCPAsandattorneys.

Ofthestrategiesdiscussedhere,Captivesarethe most complex and most expensive option,andareatleast$50,000tostartandmorethan$20,000peryeartomaintain.WhenaCaptiveInsuranceCompanymightmake sense for a physician group, I tend to beveryconservativewithitsstructure.SomeoftheturnkeyCaptivecompanieshaveoffshorecompaniesandhavenoindependent auditors. There are even cases in which those managing the insurance claimsandadministrationalsoaretrusteesofthe investment risk pool. This increases the riskofabuseandIRSscrutiny.

IalsofeelstronglythateveryCaptiveshouldhave an annual independent U.S. audit to verifytheaccountingandclaimsprocessing.OnescaryanecdotalstoryisofanoffshoreCaptiveinwhichthephysicianswerecontributing$1millioninpremiumstocoverkidnapping insurance. When no insured physicianparticipantwaskidnapped,theexcess premiums were distributed. As physicians, you have plenty of risk with malpracticeandMedicareissues,andyoumay not want to draw even more IRS attention.

All these complex strategies, if executed properly, may allow an individual physician to potentiallydeferverylargeamountsofincomes,oftenasmuchas$100,000to$500,000.Atthislevelofdeferral,itmayindeed keep annual gross income under the $450,000,$300,000,or$250,000thresholdsthat now exist in the 2013 tax laws.

Dr. Stephens, an Associate PCMS member, specializes in helping physicians and senior-level execs build and maintain wealth, independent of their businesses. In 2010 Medical Economics magazine named him one of the country’s 150 best financial advisers for doctors. He can be reached at TCI Wealth Advisors, Inc., 733.1477 or www.tciwealth.com. n


In Memoriam

Dr. Daniel T. Mihalyi, 1947-2013

Dr. Daniel T. Mihalyi, of Quality of Life Medical Research Center, Tucson IM physician for 35 years who specialized in age management, who

joined PCMS in 2010, died suddently on Oct. 20, his family reported in the Arizona Daily Star.Hewas66.

Dr.MihalyiwasbornAug.21,1947inPittsburgh,Pa.Hegraduatedin1973from Hahnemann University School of Medicine, Philadelphia. He interned and did his IM residency in the Tucson Hospitals Medical EducationProgram.

“Hehelpedmanypeople,”hisfamilysaid,“andwasdedicatedtopromotinghealthandwellness.Heenjoyedweight-lifting,golf,swimming,andwatchingSteelersandWildcatgameswithhissons.HelovedvisitingtheSea of Cortez, and spent many mornings watching the sun rise over the sea.

Dr.Milhayi’swifeof40years,Stephanie;siblingsTom,Patrick,Patricia,andErin; sons Ryan and Sean; and many nieces and nephews survive him.

AmemorialservicewasgivenOct.24atTohonoChulPark.ThefamilysuggeststhatmemorialcontributionsbemadetotheCommunity Food Bank. n

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Re�rement

Story and photos by Dennis Carey

Craftsmanship with a surgeon’s care

Philip Fleishman, M.D., does not embrace the idea of coincidence. He was inspired by Albert Einstein to write his

firstnovel,themedicalthrillerThe Gemini Factor.

Einsteinhadlittleuseforcoincidences.Dr.FleishmanquotesEinsteinonthebookjacket:“Idonotbelieveintheword‘coincidence.’ For me, it is a word created to explain the unexplainable away.”

VerylittleiscoincidentalintheskillsandpassionsDr.Fleishmanusedinhispracticeasaplasticsurgeon,andthosenowservinghiminretirement.HewasanActivePCMSmember1973to1994,and is now an Associate.

ATorontonativebornin1938,Dr.Fleishmangraduatedin1964fromUniversityofOttawaMedicalSchool.AfterdoinganinternshipatSt.Mary’sHospitalinRochester,N.Y.,heservedasageneralsurgeryresidentatClevelandClinicEducationalFoundationinOhio.HewasaresidentinplasticsurgeryattheUniversityofTorontoAffiliatedHospitals1967-1970,andlandedinTucsonin1971.Heworkedextensivelywithburnvictimsasdirector of the Carondelet St. Mary’s Hospital burnunit.Histimeoutsidehisofficeoroperatingwasspentonwoodworkingprojectsandreading.Sometimesitwasboth.

It is said, “Write what you know,” and Dr. Fleishman does. His novels are medical thrillers, and it’s no coincidence that The Gemini Factor is set in his two hometowns of Toronto and Tucson. In the novel serial murders happen at theexactsametime,theexactsameway,butmore than 2,000 miles apart.

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If Dr. Philip Fleishman made two identical peppermills, that would be coincidence indeed. Here he displays a piano-key design, and one reminiscent of a Central European Christian church.


“My wife is a designer,” he said. “She tells me what she wants, and I build it. It’s a combinationthatseemstowork.,”

Recently Dr. Fleishman took on new roodworking dimensions as a creator of original peppermills. It happened that his wife, Jane, was watching Oprah as the TV host wastalkingtoonePinkyMartin,anartistinhis80swhohadawaitinglistofsevenyearsforhishandcraftedpeppermills.

AtfirstDr.Fleishmanwasnotinterested.ButwhenhewasgivenacourseinwoodturningasagiftfromhissonDavid,itallchanged.Dr.FleishmanendedupcontactingPinkyMartinaboutcreatingcustompeppermills.Whilehedidnotfindhimself on Oprah,oneofhiscreationsendedupattheWhiteHousewithPresidentBarackObama’schef.Itwasnotacampaigncontribution.AcomplexconnectionwitharelativeofafriendofhiswifeputthepeppermillintheWhiteHousekitchen.

Dr. Fleishman sells his peppermills in various ways, including his website, Peppermillsofdistinction.com,andgiftshopsandgalleries.Thepriceisusuallyaround$300.HehasworksondisplayattheWoodGalleryinOregon,andatEnvironmentalRealistsattheartist-colonyTlaquepaqueinSedona.Hehasalsosoldand displayed his peppermills at the Tucson Museum of Art, and in galleries in Tubac andNewMexico.Heattendsarts-and-craftsshows,suchasTucson’s4th Avenue StreetFair,twoorthreetimesayear.

“Isupposethereissomesimilaritytowoodworkingandmyplasticsurgerypractice,”hesays.“Bothrequiredelicateworkwiththehands.Inwoodworking,ifyou make a mistake, you can change your plan and make something else. There is nomarginforerrorinplasticsurgery.Changingplansisnotanoption.”

The peppermills have not replaced his furniture building and other woodworking projects.Thefireplacesinhishousearesurroundedbyhandcraftedmantels.No

room is untouched by his work.

“Writinganovelwasabucket-listproject,”hesaid, easing back into a chair in front of his computer desk, both previous projects in a remodeledoffice.“IrealizedIwouldhavetopublish it myself, because I did not have the timetowaittodoitthetraditionalwaywithapublisher or an agent.”

As with so many other businesses, the Internet has changed the game for authors. He has been selling “The Gemini Factor” on hiswebsitephilipfleishmanmd.com,andonAmazon.com for three years. It reached a peakofNo.219inthegenreinJune2012.Hissecond novel, The Contingency Factor, will be onsaleattheendofthisyearorearly2014.

“The big publishers don’t like to take chances,” he said. “They want to go with someone they know will sell books. Sadly, the qualityofthewritingdoesnotalwaysstaysame with some authors. The book sells on theauthor’snameandnotthewriting.It’smoreaboutthemarketingtobecomeabest-seller. Even some of the top authors are going the way of self-publishing. They have more

This recently completed, elaborate clock shows the intricacy Dr. Fleishman’s work can take on.


controlanddon’thavetosharetheprofitswithasmanypeople.There are a lot of excellent self-published authors out there.”

As with his woodworking, Dr. Fleishman started modestly by takingsomecreativewritingcoursesatPimaCommunityCollege.Healsocreditshisreadinghabitsasenhancinghiswritingskills;hereadstwotothreebooksperweek.Hiscreativewritinginstructor, Marjel De Lauer, encouraged him to write the book. He also bent the ear of his editor, Rebecca Dahlke, at a booth at the TucsonFestivalofBooks,andshehelpedhimgetstartedinself-publication.Healsogavedraftsofthebooktoasmanypeopleashe could.

“It always helps to have others read your work,” he said. “They can point out things that could slip by. The experiences and knowledge of others may help them point out something that doesnotfit,orisinaccurate,thatyouwouldhaveotherwisemissed.

“Thebooksarenovels.Theplotsarefictional,butItrytobasethemonfacts.Idon’twantsomebodycriticizingitbecausesomething I put in my book could not actually happen. The vast majorityofthereviewsonlinehavebeenverypositive.Ialsogota good review from the Arizona Daily Star. But it is probably easiertowinthelotterythantobecomeabest-sellingauthor.There are so many books out there.”

Dr.Fleishmanusuallyrisesat4a.m.andworksfourhoursonwriting.Therestofthedayisfilledwithwoodworkingprojectsandreading.Hemaytakeabreaktofillinsomecratersdugintheyard by his two golden retrievers, Rosie and Sassy.

He also has a regular poker game every week with a group of friendswhohavebeengettingtogetherfor40years.Hesaidheprobably makes more money at the poker game than from his peppermills or books. It took three years just to break even on themoneyhespentonpublishinghisfirstnovel.Heusually

Safety first, as table saw, lathe and the rest of the tools in Dr. Philip Fleishman’s woodshop keep hin busy.

makes enough money to cover the cost of materials needed to make the peppermills.

“It was never about the money,” Dr. Fleishman said. “I have been fortunatethatIcanspendmytimedoingthingsIlovetodo.”

Andhefindsnothingcoincidentalaboutthat.

Dennis Carey is PCMS associate director. n


J O H N D . L E V I N , C L U 6 0 1 1 E . G R A N T R D . T U C S O N , A Z 8 5 7 1 2

5 2 0 . 7 5 1 . 2 0 0 0 J O H N @ W M S A S S O C I A T E S . C O M

W W W . W M S T R A T . C O M

D I S A B I L I T Y L I M I T S O N T H E R I S E YOU EXAMINE YOUR PATIENTS’ EVERY DAY, OFTEN DISCOVERING RISKS NOT OUTWARDLY APPARENT. BUT HOW OFTEN DO YOU EXAMINE YOUR OWN RISKS? IT MIGHT BE TIME TO TAKE A CLOSER LOOK.

P i m a C o u n t y M e d i c a l S o c i e t y a n d W e a l t h M a n a g e m e n t S t r a t e g i e s a r e p r o u d t o o ff e r m e m b e r s a n e w d i s a b i l i t y i n c o m e i n s u r a n c e p l a n . T h i s e x c i ti n g p l a n o ff e r s d e e p l y d i s c o u n t e d i n d i v i d u a l a n d b u s i n e s s d i s a b i l i t y p l a n s , a n d u n l i k e m a n y p l a n s , t h e s a m e l o w p r i c i n g a p p l i e s t o b o t h m e n a n d w o m e n . D e p e n d i n g o n y o u r n e e d s , y o u c a n c h o o s e a p l a n o r c o m b i n a ti o n o f p l a n s t h a t c a n h e l p y o u : � P r o t e c t y o u r i n c o m e i f y o u a r e u n a b l e t o w o r k , o r u n a b l e t o r e t u r n t o y o u r f u l l d u t i e s � C o n ti n u e r e ti r e m e n t c o n t r i b u ti o n s o n y o u r b e h a l f � C o v e r b u s i n e s s e x p e n s e s � P r o t e c t a n y b u s i n e s s p a r t n e r s � P r o t e c t y o u r r e v e n u e i f a k e y e m p l o y e e i s d i s a b l e d

Associates of Wealth Management Strategies offer securities through AXA Advisors, LLC (NY, NY 212-314-4600), member FINRA, SIPC. Investment advisory products and services offered through AXA Advisors, LLC, an investment advisor registered with the SEC. Annuity and insurance products offered though AXA Network, LLC. Wealth Management Strategies is not a registered investment advisor and is not owned or operated by AXA Advisors or AXA Network. AXA Advisors and AXA Network are not affiliated with Pima County Medical Society. PPG 69384 (07/12)














Makol’s Call

A modest proposalBy Dr. George J. Makol

Swift’s“ModestProposal”wasfar from modest, as he meant

it. I propose something actually modest.

Thenationisatwarwithitselfoverillegalimmigration.Asagrandson of immigrants, I certainly understand why people want to come to the United States. And certainly the huge costsofgivingnon-citizensillegally here free medical care are to be considered. A few years ago I remember reading in the Arizona Daily Star that Tucson MedicalCenterwasmorethan$5

million in debt just for care given to aliens captured while trying to enter the U.S. illegally.

Butthisgoesbeyondjustpoliticsandmedicalcosts.Illegalimmigrationhastouchedmylifeasaphysicianinawaythat,unlessyouhavebeensoaffected,ishardtounderstand.

AfewyearsagoIwasflyingbackfromatwo-weektriptotheCzechRepublic, Budapest, and Vienna, and arrived in Phoenix where I had leftmycarparkedattheAirportHiltonHotel,inawell-litandguardedparkingareainfrontofthehotel.WewouldusuallyflyoverseasfromPhoenixtogetadirectflight,andthenstayovernightuponourreturntoPhoenix,aswewereusuallyexhaustedafterthelongflighthome.Wegotofftheairportshuttleandheadedforthelobbytocheckin,whenInoticedmythree-quarter-tonfour-wheel-drive loaded Chevy Suburban was gone.

WecalledthePhoenixpoliceandfiledareport,andwerestuckatthehoteluntiloursondroveupfromTucsontopickusup.Iwaswellinsured, and in a few weeks I received a nice check from my insurance company, and quickly purchased a new vehicle.

A couple of months later my vehicle was found abandoned in the desert in Florence, stripped of its rear seats and trashed. Police said evidence showed that it had been used for two months to ferry illegal aliens though the desert to and from Mexico. That it had a 6.5-literV8,four-wheeldrive,andchromebrushguardsmadeitaperfect vehicle for the smugglers known as “coyotes.”

Phoenixpoliceinformedmethatatthattime,105carsperdaywerestolen in Phoenix, and about 55 per day in Tucson, with most being divertedtotheaforementionedcriminaluse.SUVsarethevehiclesof choice, and the vehicles of choice for many physicians and their families, according to what I see in hospital and doctors’ parking lots. Since almost no one gets caught, these thieves just help themselves toyourcarandyouarelefttofileastolenvehiclereport.

ThePhoenixPoliceautotheftdetailwasworthless.Theyfoundthevehiclewithkeysinit,butdidnotfingerprintit,researchwherethekeyswere obtained, or follow up on the many calls the perpetrators made on my cell phone, dozens of them to the same numbers. In fact they lost the list of calls I sent them and ignored a second mailing. For the public’s purposestheycouldfiretheautotheftdepartmentandjustretainthesecretarytosendoutformsforvictims’insurancecompanies.

Onanevenmoresombernote,IwalkedintomyofficetwoyearsagoandmystafftoldmethatSouthernArizonarancherRobertKrentz,murdered by an illegal alien drug dealer who had returned to avenge his brotherbeingrippedoffinadrugdeal,wasapatientinmyoffice.Krentz was a gentle man who was known for helping border crossers whentheywereabandonedonhislandbyofferingwaterandfood.Hisshotgunwasathissideanduntouchedwhenhewasshotoffhistractor.

Krentzwassimplyinthewrongplaceatthewrongtime.Butwecanbuylettucefor$1aheadbecausemigrantfarmworkers,manyofthem here illegally, will do the kind of work that we are told “Americanswillnotdo.”However,whenyoucounttheextra$100orso each of you is paying every six months on your car insurance becauseweinSouthernArizona,perhapsthatlettuceisnotsocheap.Iwouldratherpay$3aheadforlettuceandkeepmyowncar!Andiffarmersreceivedjust$2aheadforlettucetheycouldprobablyaffordtopayfarmworkerssay$12anhourandprovidedecentworkingconditions.Inthisrecession,Ibettherearealotofpeoplewhowouldworkinthefieldsfor,say$12perhour.Andthegovernment would not even have to get involved; the free market could solve this problem.

Hereisamodestproposalfordealingwiththeworkerswhostillwishto come to the U.S. to earn money for their families back in Mexico. Mostofthesefolkswanttostayacitizenoftheircountryofbirth;they just have an immediate need for a good-paying job.

“Coyotes”chargeupto$5,000tosneakworkersintotheU.S.andoftenabandonthesepoorfolkstodieofexposureinthedesert.Whydon’t we issue an electronic card for a 30-day “guest worker” to each person who wants to come over and we could provide air conditionedbussestotransportthem.Thiscardwouldbepresentedto the employer, who would withhold 10 percent of the wage weekly, and electronically deposit this sum directly into the U. S. Treasury,perhapscreditedtoreducethedeficit.

The card could easily be channeled through any Visa/Mastercard swipe machine to deposit that 10 percent in the treasury, less maybe a half-percent for the electronic banking privilege. The card and the ride wouldcostperhaps$50,makingtheprogramself-supporting,andthecardcouldberenewedforone-monthperiodsforperhaps$10.

Penaltiesforworkingwithoutaguestcard,orforhiringaworkerwithoutone,shouldbestiff,similartopenaltiesalreadyonthebooks. This could also work for some of the 11 million undocumented persons already here. Cards could be available for purchaseinanypostoffice.Asphysicianswearealwaysconcernedwith quality-of-life issues, and know more than most folks about the tragedyoflivestakentoosoon.Considerthesexamples:

InAugust2012,14peoplediedinaruralSouthTexasaccidentinwhicha pickup truck loaded with 23 Guatemalan and Honduran illegal immigrantsrolledover.Ninesurvivorswerehospitalizedinseriouscondition,atperhapsahalfamilliondollarsincosttotaxpayers.

Earlier in 2012 an SUV crashed near Casa Grande, killing four occupants and injuring six other illegal immigrants.

In South Texas again in April, a van full of illegal immigrants overturned, killing nine of the passengers. They were on the way to a “stash” house near the Mexican border.

Comparetheseoutcomestoa$50rideinanair-conditionedbus,andthink of all that tax revenue, and perhaps I could return from Europe nexttimewithoutbeingafraidtolooktoseeifmycarwasstillthere!

Or,wecouldjustcontinueeatingoursalads,happilyoblivioustohowthatlettuceappearedonourkitchentablessoinexpensively.

Sombrero columnist George J. Makol, M.D. practices with Alvernon Allergy and Asthma, 2902 E. Grant Rd., and has been a PCMS member since 1980. n


Bioethics

The missing piece in end-of-life decision-makingBy Tani Bahti, R.N., C.T., C.H.P.N.

It was bad enough that Gary was feeling the pain of only just understanding that his beloved wife was imminently dying. His

pain was further exacerbated by learning too late that his best intentionsinprovidingcareonlycreatedmorediscomfortandconflictforthewomanwhowastheloveofhislife.

I witness this scenario every week. Perhaps I should be used to it, but despitemy36yearsofworkinginend-of-lifecareandeducation,itstillpainsmetohearthefamiliarlament,“IfIhadonlyknown.”

Inthesesituations,noonealertsthepatientandfamilytothesignsthatdeathwasapproaching.Noonetellsthemthatitwastimetoreplaceapushfortreatmentwithapushforcomfortcare.Nooneexplainsthenaturalcourseofthediseaseandthedyingprocess.Noonetellsthemhowtorespondtotheexpectedchanges to assure comfort and obtain closure.

When facing the end of life, we are natu rally scared. Our problem is that too many of our decisions are based on this fear, or on lack ofinformationormisinformation,whichoftenresultsindevastatingphysical,emotionalandfinancialconsequencesforthepatientandfamilyalike.

Wecanandmustdoabetterjob.

Thequestionisnotifwearegoingtodie,buthowwearegoingtodie,andthereforecompassionateandhonesteducationaboutthenaturalprocessofdyingiscriticaltomakingdifficultend-of-life decisions.

Recognitionofthepointatwhichourlovedonesarecomingtothenaturalendoflifebecomesobscuredwiththeflurryofmedicalinterventions.Weoftenholdontoabeliefthat“moreisbetter,”thattechnologyalwaysholdsthepromiseofsavingusfromdying,evenifforalittlewhile.Qualityoflifeisoftensacrificedforthehopeofquantity,andcaninadvertentlyresultinmorediscomfortortimeinanintensivecareunit.

We have to ask whether we prolong living, or prolong dying.

Whenthebodyispreparingforitsfinalmonths,weeks,andevenhours, many natural processes kick in to promote comfort. When families understand the wisdom of the body as it works to protect itself, they usually make decisions that honor the pro cess of shuttingdowntodie.

There is ample research about how the body begins to shut down todie.Weknowthattheuseofartificialnutritionandhydrationat the end of life can actually increase discomfort and even

hastendyingthroughfluidoverload,aspiration,orincreasingtumor growth. We know that the natural and normal cause of death for a number of dis eases is pneumonia, once considered “the old man’s friend.” We know that physical pain is not a part of the dying process, but that if it is a part of the disease, it can be managed. We know that the dying process will usually lead to coma, whichallowstheindividualstoessentially“dieintheirsleep.”

Unfortunately, the dying process is rarely taught in medical and nursing schools and is a frightening mystery to the general public. This lack of knowledge contributes to our discomfort with end-of-life discussions.

Sometimesit’sthediscomfortofthehealthcareprofessionalswhobelieve that death is failure, or that telling the truth is “taking awayhope.”Itbecomeseasiertoofferatreatment,howeverfutile,seekingsolaceintheillusionthatdoinganythingisbetterthanfacingthedifficultemotionsofpatientsandfamilieswhenthey are told that reversal or cure is no longer possible.

Sometimesit’stheinabilityofthepatientorfamilytoletgo,ortheirfearoftheunknownthatdrivesfutilecare.Sometimesit’sthe belief that by refusing treatment they are somehow declaring that it’s okay for their loved ones to die.

It’snoteasytotalkaboutdying,butthereisclearbenefit.AstudyconductedattheDanaFarberCancerInstitutebytheNationalInstituteofHealthandNationalCancerInstitutewasreleasedin2009andrevealedthathavingtheconversationaboutend-of-lifeissuesresultsinlessdepression,improvedsatisfactionwithinformed decision-making, improved use of avail able resources, andbetterqualityoflifeanddeath.

My own experience is that people want to know what to expect. They want the best possible care and comfort for their loved ones. They just don’t know that it’s O.K. to ask, and do not know whatquestionstoasktodeterminethebestcourseofcare.

It will take all of us to improve how we talk about and prepare for the end of life. Healthcare personnel must improve their knowledgeandcommunicationaboutthedyingprocess.Thepatientandfamilymustunderstandthenaturalprogressionofadiseaseandbenefitandburdenoftreatmentoptions.Theymustaskmorequestions,matchingtheanswerstotheirowngoalsandvalues.Theymustkeepupdatingtheirpersonaldefinitionofquality of life and document their wishes.

Wemustallfacethefactthatultimately,dyingisnotanoption


and how we talk about, prepare for and honor the dying process is our right and our responsibility. Let’s provide road maps and comfortonthefinallegofourjourney.

Important questions for you and your family when making treatment decisions

• DoIhavetheinformationIneedtomakethisdecision?

• Isfearorlackofinformationpushingmetowardsaparticulardecision?

• WhatamImostafraidof?

• Whataremygoalsatthistimeinmylifeandwillthistreatment help me reach them?

• Am I making a treatment decision based on what I believe someone else wants me to do or what I really want to do? Have I sat down with that person to clarify what each of us want?

• WhoorwhatismysourceofstrengthandsupportandhaveIutilizedthat?

• IfIhavealimitedlifeexpectancy,howdoIwanttospendthetimeIhave?

• Whatdoesfightingthegoodfightmeantome?Seekingaggressivetreatmentuntiltheendorallowinganaturaldeath?

• HaveIcompletedmyadvancedirectives(LivingWillandMedicalPowerofAttorney),whichdeclaremywishesfortheextent of medical treatment I wish to receive in the event I cannot speak for myself?

• HaveItalkedwithmyfamilyandphysicianaboutmyadvancedirectives?

• HaveIaskedallmyquestions,expressedallmyfears,andshared what I truly feel with my family and physician?

Important questions to ask the physician

• Isthegoalofthistreatmenttocure,prolonglifeorrelievesymptoms?

• WhatisthebestIcanhopeforwiththistreatment?

• WhatistheworstIshouldprepareforifthisdoesn’twork?

• Isthisastandardtreatmentorexperimental?Whatarethechancesforsuccessinmyparticularcase?

• HowandwhenwillIknowit’sworking?

• Howwillthisimpactmydailyliving,comfortand/orgoals?What are the physical changes I may experience and how will you help me manage them?

• IfIhavesideeffects,howlongmighttheylast?Whatcanbedone to prevent or minimize them?

• Arethereanypotentiallypermanentsideeffects?

• Isthiscoveredundermyinsurance?Whatwillthecostbetome?

• WillIneedextrahelptomanageathome,andifso,forhowlong?

• IfIrefusethistreatment,whatcanIexpecttohappen?

• IfIrefusethistreatment,willyoustillbemydoctor?

• Isthereacounselor,supportgrouporsomeoneIcantalktoabout this?

• DoyouhavematerialaboutthistreatmentthatIcantakehome and review?

• Arethereotherwaystomanagemydiseaseandwouldyourecommend them? Why or why not?

Although medicine doesn’t have a crystal ball to know how you aregoingtorespondtoaparticulartreatment,itisimportantthatyouhaveenoughinformationtomakeaninformeddecision.Consider your lifestyle, your beliefs, your goals and values. Consideryourfamily,financesandspiritualbeliefs.Youalwayshave the right to know and to choose.

Tani Bahti is founder of Passages—Support & Education in End of Life Issues www.pas sageseducation.org, and author of “DyingtoKnow—StraightTalkAboutDeath&Dying.” www.bookaboutdying.com. n

Now you’reThinkin’ SmartSimplify your communications with Simply Bits state-of-the-art managed voice and data services

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The safari of a lifetimeBy Hal Tretbar, M.D.

Behind the Lens

“ h,shit,”JackJordanmutteredunderhisbreath.

TheretiredPhoenixFireDept.supervisorhadalsoworkedatSt.Joseph’sHeartandLungInstituteinPhoenix.Whenthecrushingpainstartedinhisshoulderandwentdownhisleftarmtohisfingers,heknewwhatitwas.

“Oh,she-it,”hethought.“HereIamonsafariinNamibia,Africa,andI’mhavingaheartattack.”

Jack,74,hadbeenfeelingalittletiredandshortofbreathfortheprevious several days. He had been photographing birds with a tour group. They were staying in the secluded Erongo Wilderness Lodge, 13kilometersfromthetownofOmaruruincentralNamibia.Itisaluxury,tentedcamponarockyridge,sohedidn’tpayattentiontothe vague symptoms when he was climbing the steps.

WhenthegroupreturnedtoOmaruru,population14,000,hedidsomeshoppingandafterlunchwenttohisroomtoliedown.Hefelt very anxious just before the chest pressure and arm pain started.Hisroommate,aretiredLosAngelesEMT,andaretiredM.D.withthegroupcheckedhimover, and as far as Jack remembers, he never had an irregular pulse or low blood pressure. He said he was very scared, and wondered what was going to happen to him.

They helped Jack to their small bus and took him toalocaldoctor’soffice.TheGermandoctorgaveJack some pain meds and took an EKG. He said, “Youarehavingaheartattack,butIcan’ttreatyou here. Here are some nitroglycerin tablets and here is the address of a doctor in Windhoek.”

So began a remarkable journey.

Jack doesn’t remember much of the three hour tripinadrafty,rattlybusoverbadroadstoreachWindhoektheNamibiancapital.Hedoesn’tremember receiving any oxygen or IVs. He doesn’t remember much pain. He just remembers bring scared. Very scared.

When they arrived at the small hospital, a deposit was demanded before he could be seen in the ER. An IV was started, some meds were given, and tests performed. Jack was groggy but appeared stable, so he was sent out to stay in a guest house.

O

ShortlythereafterthehospitalcalledandsaidhistestswerepositiveforM.I.anditwouldbeagoodideaforhimtoreturn.HewasadmittedtotheICU.Oneofthepeoplefromthetourcompanystayedwithhimwhilehistwofriendsreturnedtofinishthe safari.

SeveraldayslaterJacktookhisfirstambulanceridewhenhewastransferredtothe87-bedRomanCatholicHospitalofWindoek.Establishedin1907,ithasbeenmanagedbytheBenedictineSisters of Tutzing since 1933.

A$10,000depositwasaskeduponadmission.Thatisenoughtoput some strain on a healthy heart, and even worse when one of hiscreditcardsrefuseda$5,000advance.Butthankfullyitwasworked out.

Jack came under the excellent care of Simon Brashear, M.D., a Scottish-andEuropean-trainedcardiologist.Hedidacoronaryangiogramintheirmoderncardiacoperatingtheater.Itshowedanoccludedleftanteriordescendingarteryalongwith50percentblockageofthecircumflex.Dr.Brashearperformedaballoonangioplasty of the LAD and inserted a long stent. Jack recovered uneventfullyinaprivateroomwithconstantmonitoring.

One day Jack remembered a card in his wallet. He showed it to hisdoctorandasked,“Canthishelpany?”Justbeforeheleftonsafari,Jackhadvisitedadoctortogethisimmunizationsand

Catalina Medical Recruiters, Inc.P.O. Box 11405

Glendale, AZ 85318

phone: 602-331-1655fax: 602-331-1933

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Plan ahead for your increased patient load and physician shortages due to:

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malarialpillsforAfrica.Whiletherehepickedanadvertisementfor something called an Airambulance card. It is like AAA in that therearecertainbenefitsformembers.Sinceitwasn’ttravelinsurance, he almost threw it away. But then he reconsidered. He’d been traveling a lot. He had photographed hummingbirds in Ecuador in March. He had just returned from photographing bearsinAlaska.Besides,itwasn’texpensive.Oneyearcost$225,so he bought it. It turned out to be one of his smartest and most fortunate decisions.

The card company was contacted, and they agreed that Jack was covered. They arranged for him to be evacuated by an air ambulanceflyingoutofMontreal—justlikeAAAsendsatowtruck when you are broken down by the roadside.

Jackwasreleasedfromthehospitalafteraweekandwalkedouttothe sleek LearJet at the airport to meet the crew of two pilots and twonurses.Hesettledinforhis30-hourflighthome.ButadelayinthistransitshowedhimapartofAfricahewasn’texpecting.

Bad weather over the Azores Islands forced an overnight stay in Dakar,Senegal.ItwasdifficultforJacktoimagethepovertyandsqualor that he saw on the way to the hotel. It was heavily guarded,butquitesatisfactory,ratherlikeaHolidayExpress.Later at dinner, the pilot remarked, “I’ve never eaten dinner with apatientbefore.Theyusuallyareundersedationonastretcher.Bytheway,doyouknowthisflightwouldhavecostyouaround$160,000withoutthecard?”

From there the route home went to the Azores, to St. John, Newfoundland,toMontreal,andtoGreenBay,Wisconsin,wheretheywentthroughCustoms.Duringtheflightback,Jackhadtime

to muse about the string of events. What could have brought on theheartattack?

Jackhadalwayswatchedhisdiet,withlittlesaltorredmeat,andlots of ethnic foods. He worked out regularly with a personal trainer. His cholesterols were low at 130. Could the stress of a personhittinghiscar,causing$7,000worthofdamagedaysbefore the trip, have been a factor? Who knows?

It is probably in his genes. One grandmother died in her 50s of diabetes and heart trouble. His mom had a coronary bypass but livedto91.Hisfatherdiedat79afteranM.I.andquadruplebypass.

When Jack arrived in Phoenix, arrangements had been made for his admission to Thompson Peak Parkway Hospital. His cardiologist there reviewed all of the records that had been sent on a disc. The angiograms were very good and showed that the stent was well placed. His care in Windhoek had been excellent.

Jackspentfivedaysrelaxingwithhissonandfamilybeforeresuminghisregularactivities.Heisnowinfullcardiacrehabandontheappropriatepreventivemedications.

Jack commented recently, “I was really fortunate to have my healthinsurance.EventhoughtIhaveMedicare,IcontinuedtopayfortheinsuranceIhadwiththefiredepartment.Ithasreallyhelped pay for all of the hospital costs.”

If the story has a moral, it may be that the unexpected is always possible, it helps to be lucky, and it’s certainly wise to have enough insurance. n

Pima CountyMedical Society

wishes you

Happy Holidaysand a

Healthy and ProsperousNew Year!



January2014Jan. 24-26: Mayo CME’s Clinical and Multidisciplinary Hematology and Oncology 2014, 11th Annual ReviewisatWestinKierlandResort,6902E.GreenwayPkwy.,Scottsdale85254;phone480.624.1000or1800.354.5892.Accreditation:TBD.

Course is comprehensive update and management strategies on issuesinhematologicandoncologicmalignancies,presentingnewdiseaseclassification,treatment,andchallengingcases.Topics include updates from the American Society of Hematology (ASH)annualmeetingandinmedicaloncology,focusingonkeyhematologic diseases (dysproteinemias, acute and chronic leukemias, lymphomas), key solid tumors (breast, thoracic, GI, GU),andoverlaptopicsofsupportive,ancillary,anddiagnosticcare.Courseoffers“challengingandinteractivesessionsonpertinentissuesinvolvedwithcareofpatients.”

Website:http://www.mayo.edu/cme/internal-medicine-and-subspecialties-2014s431Contact:CMEDept.,MayoClinicScottsdale,13400E.SheaBlvd.,Scottsdale;phone480.301.4580;[email protected].

February2014Feb. 16-21: The Mayo Interactive Surgery Symposium is at WaileaBeachMarriottResort,3700WaileaAlanui,Wailea-Maui,Hawaii;phone877.622.3140.AccreditationAMAandMOC.Trendsinmanagementofgeneralsurgicalpatientsareconstantlychanging.Astechnicaladvancesprogress,optionsofsurgicaltreatmentscontinuetoexpand.Thissymposiumforgeneralsurgeonsassistsindecision-makingformultipleaspectsofsurgicalpractice.

Website:http://www.mayo.edu/cme/surgical-specialties-2014s152Contact:MayoSchoolofContinuousProfessionalDevelopmentRegistrar,13400E.SheaBlvd.,Scottsdale85259;phone480.301.4580;[email protected] http://www.mayo.edu/cme

March2014March 6-8: The 10th Annual Mayo Clinic Women’s Health Update isatFireSkyResort,4925N.ScottsdaleRd.,Scottsdale85251phone480.945.7666or800.528.7867.AccreditationAMA,AOA,AAFP, ACOG.Courseaddressesneedsoffemalepatientsandtheirhealthcareproviders for “comprehensive insight into relevant medical problems uniquely found in women, as well as a basic approach to addressing and improving common health concerns.”

Website:http://www.mayo.edu/cme/women-s-health-2014s307 Contact:MayoSchoolofContinuousProfessionalDevelopmentRegistrar,13400E.SheaBlvd.,Scottsdale85259;phone480.301.4580;[email protected] http://www.mayo.edu/cme

March 27-29: Tackling Problematic Chronic Rhinosinusitis: A Conclave of Global Experts isatMayoClinicEducationCenter,5777E.MayoBlvd.,Phoenix;phone480.301.8000.Accreditation:AMA, AOA, AAFP.

MayoClinicpresents“thefirstsymposiumonmanagingyourmostchallengingsinusitispatients.”Globalleadersinotolaryngology-rhinology, allergy-immunology, and basic sciences cometogethertobrainstorminhighlyinteractivesessions.Thegoalofthesymposiumistosynthesizeitsinformationintoinnovativestrategiesandtipsonmedicalandsurgicalmanagementoftherecalcitrantchronicrhinosinusitis(CRS)patient.Bringtogetheryourchallengingcasestodiscuss.

Website:http://www.mayo.edu/cme/otorhinolaryngology-2014s378

Contact:MayoSchoolofContinuousProfessionalDevelopment Registrar,13400E.SheaBlvd.,Scottsdale85259;phone480.301.4580;[email protected] http://www.mayo.edu/cme

Members’ Classifieds

SEEKING NP FOR PAIN MANAGEMENT PRACTICE: The Integrative Pain Center of Arizona is currently recruiting a Nurse Practitioner. We are Arizona’s only pain clinic to be designated by our specialty society as a Center of Excellence. If you are interested in working in a patient centered environment where the goal is to help patient’s find their way to wellness, whatever it takes, this is for you. Candidates are urged to review the IPCA website www.ipcaz.org. Job duties include intake evaluation; assessment of physical activity, diet, health risk factors and screening for mental health/behavioral risk factors; ongoing management of patients that includes pain treatment, diet and exercise, oversight of the integration of behavioral health treatment into the care plan, use of complementary and alternative medicine consultants, use of procedures to treat pain including routine injections, minimally invasive techniques and referral for surgical evaluation, and more. You will be working closely with experienced pain medicine practitioners.

Mayo CME

Successful candidates must have a current Arizona license and unrestricted prescribing privileges. Interested applicants please send resumes to [email protected].

MEDICAL OFFICE SPACE AVAILABLE: Modern, professional office space is available at Swan and Pima. Easy accessibility for patients and conveniently located near TMC and St. Joseph’s Hospital. Space is available immediately. Number of exam rooms, space, terms and rent is negotiable. Please contact Susan Wolff at 520-546-2420.

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It’s that time of year to wish you

a wonderful Holiday Season

and a New Year filled with joy and success.

(602) 956-5276, (800) 352-0402www.mica-insurance.com

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