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Farewell To Round-Up

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Round-up Staff Editor-in-Chief Adam M. Brodsky, MD, MM abrodsky@mcmsonline.com Editor Jay Conyers, PhD jconyers@mcmsonline.com Content Editor Dominique Perkins

Connect with your Society mcmsonline.com facebook.com/MedicalSociety twitter.com/MedicalSociety instagram.com/Medical_Society Letters and electronic correspondence will become the property of Round-up, which assumes permission to publish and edit as necessary. Please refer to our usage statement for more information.

Advertising To obtain information on advertising in Round-up, or to become a Preferred Partner, contact: Barb Spitzock 602-528-7704 bspitzock@mcmsonline.com

Cover photo and member profile photos by: Denny Collins Photography www.dennycollins.com 602-448-2437

MCMS 2016 Board of Directors Officers President Adam M. Brodsky, MD, MM

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

Secretary Ross F. Goldberg, MD

Periodicals postage paid at Phoenix, Arizona.

Treasurer May Mohty, MD President-Elect John L. Couvaras, MD Immediate Past President Ryan R. Stratford, MD, MBA Directors Jay M. Crutchfield, MD Shane M. Daley, MD Tanja L. Gunsberger, DO Kelly Hsu, MD Lee Ann Kelley, MD Marc M. Lato, MD Richard A. Manch, MD, MHA John Middaugh, MD Tabitha G. Moe, MD Constantine G. Moschonas, MD Anita C. Murcko, MD Steven B. Perlmutter, MD, JD Resident Representative Pamela McCloskey, DO Medical Student Representative Kimberly Weidenbach, MEd

MCMS offers: A FREE physician referral service A benefit of membership – we help drive new patients to your office To learn more contact: Dixie Harris 602-251-2363 dharris@mcmsonline.com Visit us online at: www.mcmsonline.com



Round-up December 2016


December 2016 | Volume 62 | Number 12 Round-up (USPS 020-150) is published 12 times per year by the Maricopa County Medical Society, 326 E. Coronado Rd., Phoenix, AZ 85004. 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.



December 2016 | Volume 62 | Number 12

4 7 10 12


Letters to the Editor What’s Inside


Prediction or Prescription


By James Carland, III, MD

A Hero and a Dreamer:

An interview with

Just Blowing in the Wind By John N. Galgiani, MD & Michael A. Saubolle, PhD

President’s Page

Farewell To Round-Up


27 29

Partner for the Ages:

9 Questions for Arizona Central Credit Union

In Memoriam Marketplace

Troy Anderson, MD By Dominique Perkins


STAT Transcription Accurate, On-Time Reports




Letters To The Editor United and effective voice

As a past president of MCMS who has kept a pulse on physician issues throughout my surgical career, I found it invaluable to not just read Round-up, but to contribute opinion and information that affects us all as physicians, locally and state-wide, in order to best care for our patients. Now, with the inclusion of Pima County and ArMA, I am looking forward to getting more local as well as state information. I believe it can be a more united and effective voice, which is needed now more than ever. Round-up has represented physicians specifically in Maricopa County, but it is more appropriate now than ever to have one voice that includes physicians – more physicians than even ArMA. The issues facing us are more critical than ever as physicians lose more and more autonomy to head-

winds caused by hospitals, large medical and surgical conglomerates, payers, and government that strive to control physicians and patient’s access to healthcare. The only voice we have left is to have a means of gathering information at a grassroots level and informing practicing physicians in their role in remaining independent and autonomous to best serve our patients. Our current political situation is reflected in the Trump Presidential Campaign that returns much of healthcare decision to a more local level. In my opinion, the executive director of MCMS, Jay Conyers, has done more than any previous executive director of MCMS to promote and support physicians as a group. I look forward to seeing what he can do state-wide with the new Arizona Physician magazine format. We need a stable editor-in-chief that can do more than the previous format that had one-year Presidents affect the content and direction of information in the magazine for physicians. Anthony T. Yeung, MD Past MCMS President

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Round-up December 2016

We are all familiar with the quotation that “all good things must come to an end.” Sadly this is true for the Round-up Magazine, whose last issue will be published this month after 61 years. Having arrived in Phoenix in 1961, I have had the opportunity to see all of the changes that have taken place with the publication. Each month, I eagerly look forward to receiving my issue of Round-up to learn about the latest news in the

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Letters To The Editor medical community. There were always articles that were so very helpful in many different areas. I would also learn what my colleagues in the community were doing as well. In recent years, the issues have improved dramatically and had so much useful material and sound advice for those in practice. The layout and illustrations have been nothing but first-rate. Dominique Perkins, the content editor, should receive accolades for her fine work. Our executive director, Jay Conyers, always has editorial comments that provide sage advice. We are indeed fortunate to have individuals of such high caliber in charge of the Medical Society as well as the volunteer physicians who are officers.

So looking to the future, I want to offer my congratulations on the new publication, Arizona Physician, which will serve the entire medical community in the state. I know that the new publication will be a success and I will look forward to receiving it as I did with Round-up. Out with the old, and onward with the new! Robert E. Kravetz, MD, FACP, MACG

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What’s Inside T

he Society has been printing Roundup for sixty-one years, the first issue in January of 1955. It has long been a robust resource of information for our member physicians, and Round-up has evolved as the Society has changed along with the shifting medical landscape. Many of you still read it cover to cover. Some, hopefully not many, toss it in the trash. Some share it with your employees, colleagues, and patients. It’s something that many of you associate with your Society membership. But with this issue, an old tradition ends, and new one begins. In January, we will embark on a new collaborative endeavor and begin printing and circulating Arizona Physician. This new magazine will combine Round-up with ArMA’s Arizona Medicine and Pima

County Medical Society’s Sombrero. Our three organizations agreed there was considerable value in creating a unified voice for our respective physician communities. We also felt it was important that practicing Arizona physicians, not only our own members, receive the new magazine. As is the case with most states, the majority of physicians here reap the benefits of organized medicine’s efforts — ours, ArMAs, AOMAs, the specialty societies, etc. — yet only a small fraction of them are actually members of one or more organizations. With this collaboration, we’ll be able to bring you more relevant content, a more robust magazine, and a more diverse blend of advertisers hopeful to do business with you. We’re evolving, just as the healthcare landscape has changed at a rapid pace. But, despite the enthusiasm for the new publication, I, for one, will miss Round-up.


jconyers@mcmsonline.com 602.251.2361

In putting together this last issue, I took a look at the first few issues of Round-up, to get a sense of how the magazine has changed over the years. Dusting off the first few issues was fascinating, and inspiring. To see how active and relevant the Society was six decades ago really tells a lot about how much medicine has changed. After asking nearly every long-standing member of the Society why we named the magazine Round-up, I think I now know why. The seminal issue of Roundup in 1995 had a photograph of the late John Eisenbeiss, MD, on horseback, tending to a herd of cattle in the dusty Arizona desert. Better yet, the caption on the photo: “Rx for Relaxation — John Eisenbeiss punches cattle on his afternoon off.” The only face I recognized in the first issue was Paul Jarrett, MD, longtime Society member and our physician profile from last November. I reached out to Dr. Jarrett and asked if he knew Dr. Eisenbeiss. Those of you who know Dr. Jarrett won’t be surprised to hear that he remembered him well. According to Dr. Jarrett, “John mcmsonline.com/round-up



What’s Inside was the second Neurosurgeon to come to Phoenix, Dr. John Green being the first. He was an outdoorsman, a horseman, a fisherman, a kind and gentle man.” I’m not sure how many of you see patients in the morning and tend to your ranch in the afternoon, but my guess is not many. With the regulatory issues physicians deal with today, and the need to bow down to the mighty EMR (into the wee hours of the night, for many of you), I’m not sure many physicians even get a day off, much less an afternoon! The advertisers have changed quite a bit since the first issues, which included ads for Revicaps (an amphetamine-based appetite suppressant), a few nursing homes, the Camelback Sanatorium, A.L. Moore & Sons (twin-engine air ambulance), pharmaceutical ads for Mycostatin, Elkosin, and Pronemia, several Ma & Pop drug stores, and the Glycolator for, “…reduction of airborne bacteria and virus.” The first ever President’s Page was penned by the late Carlos Craig, MD. His editorial — a few short, yet powerful, paragraphs — touched on the Society’s involvement with the Arizona Legislature in crafting a TB control bill, something desperately needed at the time (Arizona had the highest incidence of TB per capita in 1955). He spoke about physicians knowing better than anyone else the importance of controlling the spread of TB, and the importance of those same physicians engaging their legislators about the public health threat the disease posed. Reading between the lines, it appears a public battle was being waged, with non-physicians advocating vociferously for personal privilege and physicians being targeted in the media as fear mongerers trying to make a buck through TB treatment. Reading ahead to future issues of Round-up, it appeared our effort was successful, as the Legislature passed the TB Control Bill later that year. Also included in the first issue was a thorough summary of the Society’s committee activities. I think we’re doing a good job with our committees today, but admittedly, I feel we’re letting our physicians of yesterday down when I see how actively engaged throughout the community we were back then. In 1955, we had thirty-two committees, and all seemed to be active! Examples of now-defunct committees include intern training, advances in medicine, telephone directory, child guidance, speakers’ bureau, library, county hospital, insurance, public service, grievance, professional conduct, school health, and rest home, among many others. I’m 8


Round-up December 2016

sure Dr. Kravetz, long-time Society member and accomplished medical historian responsible for the beautiful medical antiques displayed in our lobby, will be pleased to know we once had a historical committee that preserved the activities of the Society throughout the years. In 1955, the Society’s physicians and family members were highly involved in the community. One article featured sixteen award recipients from the Society’s 1954 annual awards banquet, with nine awards going to Society members, three going to Society members’ wives, and reporters and cartoonists from the Arizona Republic earning a few. The only face I recognized was that of Dr. Jarrett, recipient of an award for developing a child safety program that was later adopted nationwide. I really enjoyed the “New Doctors” section, where physicians new to the Society had detailed write-ups about their schooling, upbringing, family, practice details, and professional experience, among other things. We even published the home address for each of our new physicians, as well the names and ages of each of their children. I’m not sure we could get away with that in this day and age! One of the more interesting articles in the first issue of Round-up was a great piece on the Maricopa County General Hospital and its evolution over the years. Of concern at the time was the high amount of taxes going to support the county hospital (80% of property tax dollars went to support it) and the growing concerns over patient mistreatment by non-medical personnel. The hospital was busting at the seams with an unmanageable caseload, and the Society was pushing hard for allocation of more appropriated funds for public health infrastructure to quell the spread of disease. One thing that surprised me was the lack of female physicians involved in the Society back in 1955, as well as the lack of cultural diversity. The only mention of a female physician was in the ‘Hobbies’ section of the magazine, where the late Lucille Dagres, MD was profiled for her talent in hand-painting sets of china. No mention of her specialty of involvement in medicine, just a detailed description of her process for creating her works of art. I was especially struck by one sentence, which said, “To date, the attractive doctor has found time between her duties as a physician and homemaker to complete about two dozen pieces of china.” I’m sure all of you will agree that it’s refreshing to see how civil rights and women’s rights have changed not

What’s Inside only the face of our country, but also the face of medicine, where today, roughly 34% of all physicians and 50% of all medical students are female. Similarly, more than one-third of all medical school graduates last year were of non-white race. Times have definitely changed. A staple of each issue in the early years of Roundup was a ‘Vacation Travel’ section, with lengthy writeups on where our members went, full accounts of their stops along the way, and pictures to support their excursions. No selfies, though. I’m sure we could piece together the travel sections of each Round-up from the early years and assemble a travel book that touches on nearly every corner of the world. Times have definitely changed since then, but one thing remains a constant — the Society’s commitment to its physician community and the physicians’ commitment to their community of patients. While we won’t have a hobbies section or travel

picture spread in each copy of Arizona Physician, we will have much of what Round-up has brought our members for more than six decades. It will be informative, relevant, provocative at times, and fun. It’s exciting to embark upon this new endeavor, but I’d be lying if I said I wasn’t going to miss Round-up. We hope you enjoy this last issue, and hope you enjoy the first issue of Arizona Physician, which should arrive on your doorstep — well, not literally — in mid-January. If you have any good ideas about what we should include in the new magazine, please email me and let me know. If you’re interested in writing an article for the new magazine, shoot me an email. We’d love to have more of physician voices in Arizona Physician, and your voice counts. With some luck, we’re confident this time next year Arizona Physician will be widely accepted as the unified voice for physicians throughout our great state. One voice, all physicians. I like the sound of that.


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President’s Page W Adam Brodsky, MD, MM

MCMS PRESIDENT 2016 abrodsky@mcmsonline.com 602.307.0070

Dr. Brodsky specializes in Interventional Cardiology He joined MCMS in 2005. Contact Information: Heart & Vascular Center of Arizona 1331 N. 7th Street Suite 375 Phoenix, AZ 85006 http://heartcenteraz.com



ell, it’s hard to believe it’s already December. Another year has come and gone, the 124th year since the founding of the Maricopa County Medical Society in 1892. Next year, 2017, will begin the Society’s 125th year. Over the past several years the Society MCMS has had some remarkable achievements, from overhauling our finances, to working with the Arizona Medical Association on several legislative victories, to the wonderful programs we have hosted in our newly renovated building and courtyard. Our events this year, including the Beers with Peers mentoring event, the Health Care Policy Forum event, and the Philanthropy Roundtable event were well attended and well received. We are looking forward to continuing those programs as annual events which will keep our members engaged with the younger generation of up-andcoming physicians, with our state legislators and elected representatives, and with our community at large. Our Public Policy Forum will be held in January as well, rounding out our annual programming. I would like to publicly thank our MCMS staff for all their hard work, and especially our Executive Director, Jay Conyers. The motivation, drive, and energy of Jay and his staff has been readily apparent to me over the course of my presidency this past year and has allowed the Society to reach new heights. Under Jay’s stewardship our membership has grown and I think many in our county have been pleasantly surprised to see the new vitality of our organization. 2017 promises to be an interesting year, as is usually the case after a presidential election, perhaps more so this year. We will have to wait and see how the Trump presidency will affect the practice of medicine. The obvious question will be how much change will there be to President Obama’s Affordable Care Act. While initially calling for a complete

Round-up December 2016

repeal of the legislation, already Trump and his staff have begun to walk back from that claim, stating that they intend to keep certain of the more popular parts of the legislation intact. Questions have also been raised regarding MACRA (the Medicare Access and CHIP Reauthorization Act of 2015), the program which replaced the SGR (sustainable growth formula) as Medicare’s payment mechanism to physicians, and whether a Trump administration would seek to change that as well. I am not going to make any predictions, except to say that after finally beginning to understand the details of these programs, my office administrator will not be happy if she has to unlearn and then relearn an entirely new program - it may be a good time to invest in practice management consulting firms! At the state level, while we, in collaboration with the Arizona Medical Association, were successful in many of our legislative efforts this year, many of those issues will certainly be resurrected this

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President’s Page coming year. This includes several nursing scope of practice issues, the consolidation of the Arizona Medical Board with all other state regulatory boards into one single entity, the prescription drug monitoring program for controlled substances, as well as ongoing issues with the University of Arizona Medical School’s Phoenix campus. I would be remiss if I did not mention that this will be the last issue of the Round-up, the publication of the Maricopa County Medical Society. Of course, the content of Round-up will not disappear, rather, you will now be privileged to receive a new magazine, a collaborative effort between the Maricopa County Medical Society, the Arizona Medical Association, and the Pima County Medical Society. This new publication will be called Arizona Physician, and will commence publication next month. It will be sent to

every practicing physician in the state of Arizona, and will hopefully serve to better connect all the physicians in our state. I would like to thank you all for the opportunity to serve as your president. I have learned much over the past year, and hopefully I have been able to shepherd our society in a positive direction. As I did at the beginning of the year, I once again encourage you to become more involved in organized medicine. Your patients, and indeed the entire population of our state, need to have a strong and unified physician voice. As I have said before, there are numerous other stakeholders who would like to impact how we practice medicine, but there is only one who everyday has to directly look the patient in the eye and answer for the decisions we make. And that is us.

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Prediction or Description? BY JAMES CARLAND, III, MD


t appears after ten years of declining claims frequency and only a modest, but steady, rise in severity we may be moving into a period of increasing frequency and cost. It may be that this is the beginning of the separation of prudent from aggressive medical professional liability (MPL) carriers, those that have priced appropriately from those that have sought market share through optimistic pricing, those that have focused on providing enduring value for their members from those that have used their insureds to finance growth and acquisitions. Are we beginning to move from a market of soft pricing for MPL coverage to a market of limited availability and higher cost? What is the evidence?

In 2006, MICA had a little more than 400 open active claims at mid-year.1 As of June 30 this year we had fewer than 350. Our open active claim count has re1 Active claims exclude precautionary claims or reports. An active claim involves the demand or the expected demand for an indemnity payment.



Round-up December 2016

mained below 400 since 2008, and has remained within a very narrow range for the last five years, while our policyholder count has been relatively stable. What is changing is the number of suits that we have open. Our open suit count at mid-year ten years ago was twice today’s number, but that number rose in 2015 and it did so again at the close of the second quarter this year. We still have fewer open suits than in 2006, but we have experienced a two-year increase of 17%, and a single year-over-year increase of just over 10%. Growth in the number of open suits could be due to a slowed closing of suits. When suit files remain open and “on the books” for a longer period of time the number of open suit files and suit reserves grow, even if incoming new suits remain unchanged. The “life cycle” of active claims and precautionary claims, the time between the report and the close, has remained unchanged for ten years. Precaution-

ary claims close, on average, 25 months after being opened. Active claims close in a shorter time frame of approximately 21 months because almost all are “actively managed.” But the life cycle of suits is increasing. On average a suit file is now open for more than 31 months. Ten years ago the average life cycle of a suit was similar to that of an active claim. There are a number of reasons suit files are taking longer to close. In Maricopa County, the time required to schedule, or reschedule, a trial date has been extending for a number of years, plus the complexity of suits with multiple defendants requires more time to prepare a suit for trial. In addition to increasing the time from report to close of suits relative to claims, the proportion of new suits to new claims reported to MICA has grown. In 2012, 46% of all new claim reports were reported as suits. At mid-year 2016 that increased to 54%. The frequency of new claims over the past three years per 100 physicians has remained constant. The frequency of new suits per 100 physicians has increased 33%. Importantly, an increase in the number of active claims alleging medical malpractice derives from patient unhappiness, dissatisfaction and/or unfulfilled expectations, whereas the increase in the number of new suits represents the additional change in plaintiff attorneys’ assessment of the relative risk versus reward of funding a malpractice suit. Along with the rising frequency of suits and the implication that plaintiff attorneys are again looking at medical professional liability as “profitable”, the average indemnity cost to settle claims and suits has been rising at 3% per year for the past ten years and at 5% per year for the last five years. The possibility of larger awards makes MPL claims more attractive to plaintiff attorneys despite the risks. MICA’s cost to defend a suit is rising at close to 7% per year. By implication, the cost for a plaintiff attorney to bring a suit is increasing at a similar pace. The logical goal on the part of the plaintiff bar is to carefully select and prosecute high value cases that have a high probability of success. Their developing strategy involves new theories of liability, new definitions of standard of care and the attempted conflation of failure to adhere to clinical guidelines with standard of care, new use of the minute-to-minute data often available from electronic records, and new techniques involving the so-called “Reptilian Brain” theory, a technique intended to generate sympathy in jurors’ minds. And there are some “new players” that may stimulate new liability claims: litigation funding companies, such as Trial Funder, Inc., based in Los Angeles, that promise double digit returns for investors willing to fund personal injury, medical professional and similar litigation. According to a recent Wall Street Journal article, Trial Funder’s investors receive between 10% and 25% of any recovery

after the initial investment has been repaid.2 Over the last ten years, MICA members have prevailed at trial more than 80% of the time, and the number of trials has dropped precipitously over the same period. To date, there has been no change in that metric. However, the growth in suit count suggests that the number of trials may increase. National news articles suggest the number of very large verdicts is increasing in value and in frequency. Rating agencies, including A.M. Best, as well as insurance asset managers and reinsurance brokers, indicate reserve redundancies are declining; in other words, actual claim cost is approaching the reserve estimates. If MICA is experiencing this change, so are other carriers, carriers with whom we compete. Fortunately, for MICA’s members our focus has remained on service to and protection of our members. That focus includes appropriate premium pricing and reserving. For physicians and other clinicians insured by companies competing on price and possibly under-reserving their risks, these are not good trends. These are trends reminiscent of the early 2000s when The St. Paul (now part of The Travelers) exited the MPLI market, availability of coverage dried up and premium cost rose substantially. Regrettably, it also suggests there is growing patient unhappiness with the medical care that focuses on “check-the-box” quality measures rather than on the physician-patient relationship, and on the corporate “delivery of healthcare” instead of the practice of medicine. In a recent article, Dr. Robert Kocher, special assistant to President Obama for health care and economic policy from 2009 to 2010, stated that he was wrong about “what would and should happen” with the change in healthcare delivery envisioned by the PPACA.3 Large health systems deliver “personalized” care in the same way that GM can sell you a car with the desired options. Yet personal relationships of the kind often found in smaller practices are the key to the practice of medicine. They are the relationships that doctors want to forge with patients, and vice versa. Perhaps the pendulum will swing back toward that kind of personal relationship. Unfortunately, it is unlikely to do so before patient dissatisfaction levels and the frequency and the cost of MPL suits rise substantially. If that happens, MICA will still be here with the mission, the will, and the resources to protect our members. Perhaps many of our competitors will survive and prosper as well. Perhaps not. 2 Wall Street Journal, Litigation Funding Goes Mainstream by Sara Randazzo, Friday August 5, 2016 3 Wall Street Journal, How I Was Wrong About ObamaCare, Dr. Robert Kocher, Monday, August 1, 2016





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Round-up December 2016





A Hero and a Dreamer: An interview with

Troy Anderson, MD

Article photos by Denny Collins Photography. www.dennycollins.com • (602) 448-2437


any physicians speak of how early they were sure of what they wanted to become, feeling themselves called to the world of medicine and healthcare right from the beginning, and finding mentors and inspiration long before they began their training. However, for Dr. Troy Anderson, true passion for his calling came after he began it. As a young boy, Anderson remembers wishing he could become an astronaut.

Anderson grew up a poor chicken and turkey farmer. His father, who had emigrated from the Philippines at age 17, only had a 3rd grade education, and pushed all his children to be highly educated. He also dearly wished to have a physician in the family. Anderson decided to honor his father by attending medical school at the Loma Linda University School of Medicine in Southern California. mcmsonline.com/round-up



“It wasn’t until I was a physician, taking ownership of patient’s health, that I truly found medicine my true passion. I feel what I do is a blessing and have a passion for humanity and caring,” he said. Anderson completed his internship at the Naval Hospital in Oakland, California, and a residency in Neurology, and a fellowship in Sleep Medicine at the University of Alabama School of Medicine. “Neurology and in particular sleep medicine has always fascinated me,” he said. “Neurology because of the ability to study the unlocked potential of the brain and the human spirit and sleep medicine because it is the basis of amazing health and great performance.”

Heroes Anderson never lost his desire to become an astronaut, and in 1993, he joined the Navy and became a flight surgeon and neurologist, reasoning this would serve to combine the two branches of science. He even applied to the Astronaut Corps, and was officially accepted to interview. “It’s an accomplishment I am very proud of. Because of budget cuts I never did begin training,” he said. Anderson’s time with the Navy was filled with countless adventures. He was stationed in Guam from 1996 to 1998. He describes it as quite amazing, and 16


Round-up December 2016

said that by the grace of God he was able to take part in many successful rescues and events. On one such occasion, Typhoon Dale hit the Pacific. In the wake of 85-knot winds, and 35-foot seas, Anderson commanded the rescue of survivors of a capsized 395-foot ship, the Gurnsey Express. A few years later a plane crashed in Guam, and he commanded another incredible rescue. For this he was awarded the Navy and Marine Corps Medal – the highest awarded during peacetime. The Military Times Hall of Valor records: “The President of the United States of America takes pleasure in presenting the Navy and Marine Corps Medal to Lieutenant Troy G. Anderson, United States Navy, for heroism as Search and Rescue Flight Surgeon, Helicopter Combat Support Squadron FIVE on 6 August 1997. Responding directly to the crash site of the Korean Airlines Flight 801, in pitch black darkness, Lieutenant Anderson was immediately confronted with a horrific jungle inferno, full of choking smoke, jagged metal, charred body parts, and raging flames. With total disregard for his personal safety, he descended the 45 degree, rain soaked, mud slick sides of a ravine covered with shoulder-high, ra-


zor-sharp saw grass. With flames all around him, he commenced the search for survivors amidst the carnage. Upon locating the first of the 35 survivors he established a triage site and provided critical care to stabilize them for transport to trauma facilities. Throughout the night, Lieutenant Anderson reentered the twisted, burning fuselage repeatedly until all survivors had been recovered. By his courageous, prompt and selfless actions in the face of grave personal risk, Lieutenant Anderson reflected great credit upon himself and upheld the highest traditions of the United States Naval Service.” Anderson also established a city and system of medical care for 5,000 Kurdish refugees who were granted US asylum as they escaped Sadam Hussein. He also performed health hazmat inspections as the Guam Naval Air Base closed, and his squadron moved to the Andersen Air Force Base. “Because of these actions I was awarded the US Navy flight surgeon of the year award for 1997,” he said.

Sleep Medicine in Arizona Anderson served in various areas, including practicing as a neurologist and sleep physician at Pensacola Naval Hospital from 2003 - 2005. He was slated to train to have his own command, but gave up his Navy career to move to Phoenix and be with his family, whom he speaks of with great love and pride. Initially he was a part of a large group practice. However, feeling the group’s values and philosophies differed too widely from his own ideas, he left and started his own. He currently owns and presides over Phoenix Neurology & Sleep Medicine, which he founded on three principles: •

High quality care

A friendly and caring atmosphere

Being adaptable to meet the needs of patients

“These values have resonated within our community and our patients and we have grown to 8 providers, 4 main offices in the valley, 3 satellite locations in the rural areas, and 3 sleep lab facilities,” Anderson said.

The Dignity of Medicine As the practice of medicine has changed over the last hundred years, so has the percep-

tion of healthcare as a whole. “I have seen a lot of positives in terms of diagnostic capabilities, expanded diagnosis and treatment plans,” he said. “I’ve been blessed to see many diseases that once had no treatment, through the advance of science, to have some good treatments,” Anderson said, citing Multiple Sclerosis and Alzheimer’s disease as examples. However, along with the advances in medical technologies, treatment, and understanding, Anderson said he feels he has seen the decay of physician integrity in the community. With the doctor-patient relationship under siege, opioid addiction stories topping the news, and so many medical treatment decisions being determined by insurance companies instead of physicians, it’s little wonder the sheen of the physician is seeming a little tarnished. In spite of these obstacles Anderson remains a firm believer in the dignity, and the necessity of the medical profession. “I believe with all my heart that we continue to be a medical community dedicated to treating human illness, for the betterment of humanity, for humanity sake,” he said. “I believe, as physicians, we are needed by society to lead and construct communities.” Anderson said he and many of his colleagues have sacrificed so much, and dedicated their lives to the sole purpose of bringing comfort and healing to those in need. “Only a physician can understand,” he said of the sacrifices of training. Many like Anderson are taking steps to restore the dignity and position of physicians in our communities, one physician and one patient at a time. “I do everything I can to be the best physician I can for my patients, and to treat them like family,” he said. He also strives to serve his community outside his practice. He is a member of the Litchfield Rotary, the Maricopa County Medical Society, and also served on the Dignity-Tenet Arizona Care Network Board. Concerned the medical profession as a whole would lose compassionate and talented students to other fields, and seeking to maintain the integrity of the future of healthcare, he founded the Phoenix Health Foundation in 2008. mcmsonline.com/round-up



Anderson describes the goals of the foundation as three-fold: 1. To mentor and scholarship compassionate and talented students wanting to pursue a career as a physician. 2. To provide medical relief foreign and domestic. 3. To provide community education and health screening events. “We have given over $32,000 in scholarships, taken care of over 11,000 patients, and provided nearly 50 community health events,” he said.

The coming years While there are many challenges facing physicians and healthcare as a whole, Anderson feels some of the greatest challenges the next five years will bring center on access, and patient accountability. “We have to make medicine affordable and accessible,” he said. “Patients need the freedom to see any provider they wish without hindrances from the insurance plans.” Right now, Anderson said, healthcare billing plays like a costly game, with the average American still paying far too much in premiums and deductibles, which prevents them from getting the treatments they need, and productive, efficient reform is needed.

Given the elections, Anderson said it is clear that healthcare is one of our top concerns. And, while there have been some significant improvements to the Affordable Care Act (such as ensuring patients with pre-existing conditions have access to care) there is still a gap between the ability to afford coverage, and its cost. In addition to wider patient access and lower costs, Anderson also felt healthcare would benefit over the next few years from greater involvement from the patients themselves. “We need tools to make patients accountable to compliance so we can encourage patients to take ownership of their health,” Anderson said. Anderson knows these kinds of changes cannot happen unless physicians take a more active part. “The politicians have done their best, and I salute them for their effort,” he said. “However, it is clear that the decision-makers who actually do the service, and direct the care, need to be at the table to create a better healthcare model.” Anderson said that all eyes are turned to physicians for leadership, and it is time to stand up and assume that role. “We need to do our part and become active leaders in our local communities. We especially need to work on doing philanthropic events and improve our integrity in society.” “I’m urging all physicians to become part of the community,” he said. “Volunteer for rotary, city council, and to speak on medical topics in the community; sign up for organizations that support us like the Maricopa County Medical Society. It’s time you let your voice be heard and be more active.”

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Round-up December 2016

DOMINIQUE PERKINS Dominique joined Maricopa County Medical Society’s staff in 2014, and is currently serving as the Communications Coordinator. She has a bachelor’s degree in Communications and Journalism, and over 6 years’ experience as a writer, editor, and social media strategist. Dominique also enjoys helping with Society events. Be sure to look for her the next time you attend! Dominique can be reached at dperkins@mcmsonline.com.


Anderson, MD | On the Personal Side Describe yourself in one word. Caring

Favorite Arizona sports team (college or pro)?

What is your favorite food, and favorite restaurant in the Valley?

Favorite activity outside of medicine?

Mom and Dad’s Filipino cooking! My wife and I love Hillstone.

What career would you be doing if you weren’t a physician? I probably would be a writer and a pastor.

What’s a hidden talent you have that most wouldn’t know about?

I’m an amazing pool player and I have a 7th degree black belt, but haven’t done either with any consistency in over 20 years.

Best movie you’ve seen in the last ten years?

Hacksaw Ridge. I love his dedication to his faith and standing up against peer pressure.

Arizona Cardinals!! There can be no other! Tennis is my passion! We have won city in several leagues, regionals as well. I have yet to win nationals but have been there twice.


I’m so blessed with my beautiful family. My wife, Heather Anderson, was the first female rescue swimmer to serve in that capacity and was the first female to deploy on ships. She is also the first female rescue swimmer instructor and first female to graduate from the US Coast Guard Advanced Rescue Swimmer School. She takes care of me and the kids. I’m proud of my son, Keoni, who is doing well as a finance major at Grand Canyon University. He is a junior. My 12 year daughter, Brookie, has a voice that evokes emotion and is a beacon of hope and compassion to everyone she comes across. My, 10 year old daughter, Blakely, is one of the most go-getters I know. She is a high achiever at everything she does and is highly competitive. mcmsonline.com/round-up



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Round-up December 2016

Coccidioides spp. spherules with endospores in lower respiratory secretions stained with the Calcofluor White/KOH and observe at 1000X magnification.

Coccidioidomycosis: Just Blowing in the Wind BY JOHN N. GALGIANI, MD & MICHAEL A. SAUBOLLE, PHD


occidioidomycosis (Valley Fever or simply “cocci”) impacts Maricopa County more than any other community in Arizona. Additionally, Valley Fever affects more people in Arizona than any other state in the country (see http://www.azdhs.gov/documents/preparedness/epidemiology-disease-control/valley-fever/ reports/valley-fever-2015.pdf for the most recent Arizona Department of Health report). Fall and early winter until the rains begin is a major season for new infections here. Because symptoms are often nonspecific, Valley Fever is difficult to diagnose. For that reason, the University of Arizona’s Valley Fever Center for Excellence has sponsored a Valley Fever Awareness week each November for the past 14 years. Also of note, the Infectious Diseases Society of America has just published extensively updated practice guidelines for coccidioidomycosis (1). The following guidelines offer an overview of the

wind-borne infection and aid Phoenix Metro clinicians in Valley Fever detection, accurate infection diagnosis and to better address the needs of the state’s at-risk population.

Mycology and Epidemiology: Valley Fever, is caused by the dimorphic fungus, Coccidioides, which contains two species, C. immitis and C. posadasii. Although both species are endemic to the Southwest United States, as well as portions of Mexico and South America, C. immitis seems limited to the West Coast of the United States (Southern California and recently an area in inland Washington State) while C. posadasii is found in the other endemic regions, including Arizona. At this time, there are no significant differences in the clinical presentations or manifestations in humans between the two species (2). mcmsonline.com/round-up



In sandy soil, Coccidioides produces septate hyphae with thick-walled spores called arthroconidia (2 x 5 µm). These become air-borne and are small enough to remain aloft for long periods and long distances. If an arthroconidium is inhaled, it transforms into round spherules, which increase in size (60 to over 100 µm in diameter) and form thick outer walls. The spherules divide internally as they grow, producing vast numbers (600-1000) of uninucleated endospores of 2 to 5 um in size (Figure 2). Upon release, the endospores mature into new spherules in the adjacent lung tissue unless controlled by cellular immunity or antifungal drugs. If not contained locally, endospores migrate via the lymphatics and the blood stream to other areas of the body to establish widespread destructive lesions known as “disseminated infection.”

thralgias (so called desert rheumatism) and skin rashes such as Erythema nodosum or Erythema multiforme. While respiratory complaints are most common, they can be strikingly absent in the other presentations. Fortunately, most of these patients also develop an immune response that eventually resolves their illness and results in life-long immunity to second infections. Unfortunately, about three to five percent of infections result in various pulmonary residua or chronic fibrocavity lesions and about half a percent progress to disseminated infection. These pulmonary and extrapulmonary complications often require years to life time antifungal treatments and, in some, surgical procedures to control the infections.

A wide variety of domesticated and wild animal species may be infected by Coccidioides spp., including dogs, coyotes, cats, cattle, sea otters, and rodents (3). Coccidioidomycosis is not classified as a zoonotic disease, because animals do not transmit to humans. However, its presence in the environment may be perpetuated through infection and carriage of local rodents such as the Cactus Mouse and Kangaroo Rat.

Diagnosis of coccidioidomycosis is beneficial for anyone sick enough to seek medical attention since early and accurate diagnosis results in discontinuation of unnecessary antibacterial agents, avoidance of corticosteroid use, less need for expensive diagnostics, and reducing patient anxiety. However, it is especially important for those with severe pneumonia or disseminated infection (6).

Clinical syndromes: Infection with Coccidioides often produces inconsequential illness and subsequently such persons are immune for life from second infections. On the other hand, about a third of infections come to medical attention. Most commonly, the presentation is that of a community acquired pneumonia (CAP). In Phoenix, a quarter of CAP is due to a coccidioidal infection (4, 5). Other syndromes of early infection include diffuse ar-


1. Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, et al. 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clin Infect Dis. 2016;63(6):e112-46. 2. Saubolle MA, McKellar PP, Sussland D. Epidemiologic, clinical, and diagnostic aspects of coccidioidomycosis. J.Clin. Microbiol. 2007;45(1):26-30.

Laboratory diagnosis:

Valley Fever is most commonly diagnosed by serologic studies (7). The fungus induces the production of specific antibodies that can be detected in serum or other bodily fluids. These persist during active disease, subside as illness resolves, and usually do not remain detectable indefinitely. For this reason, detection of

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3. Shubitz LF. Comparative Aspects of Coccidioidomycosis in Animals and Humans. Ann.N.Y.Acad.Sci. 2007;1111:395-403. 4. Kim MM, Blair JE, Carey EJ, Wu Q, Smilack JD. Coccidioidal pneumonia, Phoenix, Arizona, USA, 2000-2004. Emerg. Infect Dis. 2009;15(3):397-401. 5. Valdivia L, Nix D, Wright M, Lindberg E, Fagan T, Lieberman D, et al. Coccidioidomycosis as a common cause of community-acquired pneumonia. Emerg.Infect.Dis. 2006;12(6):958-62.

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6. Chang DC, Anderson S, Wannemuehler K, Engelthaler DM, Erhart L, Sunenshine RH, et al. Testing for coccidioidomycosis among patients with community-acquired pneumonia. Emerg.Infect Dis. 2008;14(7):1053-9.


7. Saubolle MA. Laboratory aspects in the diagnosis of coccidioidomycosis. Ann.N.Y.Acad.Sci. 2007;1111:301-14.



Round-up December 2016

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coccidioidal antibodies are typically considered diagnostic of the illness for which the test was ordered. Early IgM (or Tube Precipitin) antibody becomes measurable between the first and third weeks of onset, while later IgG (or complement fixation, CF) antibody becomes measurable between the second and 28th week. Enzyme immunoassays (EIA), immunodiffusion (IMDF) and complement fixation (CF) studies are commonly used to detect antibody. EIA and IMDF tests detect both IgM and IgG antibodies separately, while the CF test detects primarily IgG. EIA tests are most sensitive, followed by the IMDF and CF tests. EIA results, especially those for the IgM class of antibody, may be less specific (2-4% false-positives (8)); these may be confirmed by the IMDF test. EIA tests are qualitative tests, either positive or negative, even though results often appear as a numeric value. Occasionally tests are reported as “indeterminant� which practically should be interpreted as non-diagnostic. Because the CF test is usually the least sensitive, it should never be used alone to diagnose coccidioidomy-

cosis. Conversely, once the diagnosis of coccidioidomycosis is established, the only test useful for ongoing management is the CF. Increasing CF titers in sequentially collected serum specimens suggest worsening infection, while decreasing titers indicate its amelioration. There are significant discrepancies between EIA, IMDF and CF results and a paucity of comparative data as to how rapidly after onset of infection the various methods detect antibody. Variability in commercially-available reagents used in CF tests can result in very different results from different laboratories and test results from different laboratories should not be compared. Serologic studies are frequently negative in early, self-limited infections or in immunocompromised patients. Although positive serologies may be helpful in the diagnosis of coccidioidomycosis, negative serologies cannot be used to rule out the disease. Laboratory diagnosis may also be achieved through direct detection of Coccidioides through histopathologic evaluation or culture of specimens from affected areas, most commonly the respiratory tract. Fungemia is fleeting and routine culture of blood is not indicated. In cases of meningitis, CSF for serologic diagnosis (CF testing) has been the standard approach to diagnosis as culture has poor recovery of the organism even when large volumes are submitted. Recently, a Coccidioides antigen enzyme immunoassay (EIA) test was introduced and may be more sensitive than the CF test for diagnosis of meningitis (9).

New IDSA practice guidelines: The recently updated practice guidelines for coccidioidomycosis have several significant changes from the previous version. First, the format has been completely revised to now present actionable recommendations in response to a series of explicit management questions. The new format is intended to be more useful for clinicians as they try to apply the guidelines to the care of individual patients. Second, much greater attention is paid to the early, most commonly encountered, and often self-limited syndrome of community acquired pneumonia. While these patients may eventually improve whether or not antifungal treatment is instituted, they nevertheless are strikingly debilitated and lose considerable time

8. Lindsley MD, Ahn Y, McCotter O, Gade L, Hurst SF, Brandt ME, et al. Evaluation of the Specificity of Two Enzyme Immunoassays for Coccidioidomycosis by Using Sera from a Region of Endemicity and a Region of Nonendemicity. Clin Vaccine Immunol. 2015;22(10):1090-5. 9. Kassis C, Zaidi S, Kuberski T, Moran A, Gonzalez O, Hussain S, et al. Role of Coccidioides Antigen Testing in the Cerebrospinal Fluid for the Diagnosis of Coccidioidal Meningitis. Clin Infect Dis. 2015;61(10):1521-6.




from employment of other activities of daily living. Recognizing the impact of the early infection, explaining what findings should signal which persons are at risk for complications, and providing a more structured description for managing uncomplicated infections is now much more extensively addressed. Third, management recommendations for coccidioidal meningitis is greatly expanded. This is a challenging and serious complication of coccidioidomycosis which is now discussed from initial diagnosis to alternative management strategies when initial therapies are not adequate. Fourth, the shift in recommendations for treating Valley Fever during pregnancy is provided. More recent understanding of the potential teratogenicity of fluconazole and other similar antifungal drugs identifies the risk as being restricted to the first trimester. The recommendations now provide clinicians with the rational for allowing oral azole treatment after the first trimester and not obligating the use of intravenous and more toxic amphotericin B.

We’re not just fighting cancer Now we’re outsmarting it

Finally, a section is included to advise laboratory personnel as to how to handle an inadvertent exposure while working with Coccidioides cultures.



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JOHN N. GALGIANI, MD Professor with tenure, University of Arizona College of Medicine, Director, Valley Fever Center for Excellence. Dr. Galgiani has focused his career on Arizona’s special problems with Valley Fever. His work has included studies of the impact of Valley Fever on the general population and on special groups such as organ transplant recipients and patients with AIDS. The Valley Fever Corridor Project, begun in 2009, facilitates communication among Arizona clinicians and improves patient care. Dr. Galgiani is currently leading a program to develop a live, avirulent vaccine candidate to prevent Valley Fever. He is also the project leader for developing a new drug, nikkomycin Z, as a possible cure.

MICHAEL A. SAUBOLLE, PHD, DABMM, FIDSA, FAAM Dr. Saubolle is Medical Director of the Infectious Diseases Division for Laboratory Sciences of Arizona, Banner Health. Board-certified in Clinical Microbiology and Public Health after a Fellowship at University of Oregon Health Sciences Center, he is a Fellow of both the American Academy of Microbiology and the Infectious Diseases Society of America. He is also a Clinical Associate Professor of Medicine at the University of Arizona College of Medicine and has worked in Arizona for over 37 years. Email enquiries: Mike.Saubolle@bannerhealth.com.

Partner for the Ages: 9 Questions for Arizona Central Credit Union What is the history or background of ACCU, and why did you start it? Arizona Central Credit Union (ACCU) is a not-for-profit, full-service financial institution that is locally owned and operated by its members. With more than 60,000 members, we have proudly served Arizona for over 77 years. We operate ten full-service branches throughout Phoenix, Tucson, Flagstaff and Show Low, and offer ac-

cess to more than 6,500 branches nationwide through our CU Service CentersÂŽ Network. Members also have access to more than 50,000 surcharge-free ATMs nationwide through the Allpoint Network.

What would you say your biggest influences come from? Most certainly our 60,000 members. They have mcmsonline.com/round-up



contributed to our desire to remain nimble, innovative, member-driven, and dedicated to providing information and assistance to achieve their financial goals.

How would you like to be remembered? As a strategic and valuable business partner to our corporate members; a financial resource to achieving fiscal goals to all our members.

What makes this business different from other businesses like it? In 1968, ACCU began adding select employee groups (SEGs) to our field of membership. Arizona Central was the first credit union in the state to start a SEG program, which allowed small businesses to offer the benefits of credit union membership to its employees without the risk or expense of starting an in-house credit union operation. This means customized service for your employees within your practice.

If you were to tell a potential customer why they should come here, what would you say? Personalized customer service is key in your practice. The same one-on-one service is important to us at ACCU. You and your practice are unique, with individual needs and goals. The teams at ACCU work with you to achieve your financial goals.

What is a little-known secret about this business that physicians wouldn’t know? The Board of Directors is made up of credit union members who volunteer their time and experience. Board members are elected by the membership during the annual meeting and serve a two-year term. ACCU is always looking for ways to connect with the community we serve. If there is an interest in becoming a member of the Board, we are open to receive your input.

Are there any tips that you could tell physicians that would improve their experience when they visit? AZ Central is a full-service commercial lender offering lending opportunities similar to larger financial institutions. The unique difference is through local personalized service. We give you and your practice direct contact with the loan decision makers. Contact us to be introduced directly to the branch manager convenient to you, and the VP of Lending.

If we were sitting here a year from now celebrating what a great year it’s been for you and for ACCU, what did you achieve? We celebrate the addition of new Select Employee Groups to our credit union. The engagement of existing Groups remains just as important to ACCU. How to help our members’ businesses grow and remain fi26


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nancially healthy is an annual goal of all branches and team members throughout our company. In addition to business, our community engagement is paramount to our staying good partners and good neighbors. We annually strive to focus on employee volunteerism and raising money for local charities.

Do you have an anecdote about the business that summarizes what you are all about? If yesterday is history…and tomorrow a mystery… then today is a gift. AZ Central Credit Union is committed to being your financial partner to learn from your past and plan for a solid future by working with you at your convenience.


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In Memoriam Brad Thomas Manny, MD

After a hard-fought battle against a rare form of cancer over the last six months, Brad Thomas Manny “El Supremo”, 62, passed away on Sunday, November 6, 2016. From his birth in Kankakee, Illinois, on March 14, 1954, he filled his life with a spirit of freedom and curiosity for the world around him. Many called him a “Mountain Man” as he spent a great deal of time exploring the wilderness; growing fond of the mountains of New Mexico; and climbing Wheeler Peak (Taos), the San Juan and Rocky Mountains of Colorado, Grand Teton, Mt. Rainer, Brooks Range in Alaska, Denali and Kilimanjaro...to name a few. The more remote and wild the location, the better. Brad was a graduate of the University of New Mexico Medical School and completed his

residency in Anesthesiology at the University of Arizona Health Science Center. He moved to Santa Fe, NM, and then to Reno, NV, where he helped build an Anesthesiology group from 4 to 23 Doctors. He was a skilled physician and was known for his intelligence. He relished the adventures of traveling, had a fascination with Science Fiction, enjoyed listening to the Blues, embracing the calamity of fishing, the chaos of his grandchildren and left the world listening to the noises of a football game, which he loved. He is survived by his wife (Rene’); his ex-wife, (Gina); his mother-in-law, (Carol); his two daughters, (Brittany and Alexis); his sons-in-law, (James and Wes); his stepson and daughter-in-law, (Jason and Amy); his stepdaughter and son-in-law (Melissa and Jeramie) his seven, soon to be eight grandchildren, (Kylie, MacKenzie, Ryan, Niko, Summer, Kenzie, Addison and Jace), and his two sisters, (Lori and Mari). Our hearts ache with your departure, but we all know you are now dancing on top of the highest mountaintop imaginable!




In Memoriam Robert H. Waldie, MD Robert Hamblin Waldie, MD, 82, of Tempe, Arizona, passed away peacefully on October 29, 2016. The cause of death was complications of Parkinson’s Disease. Dr. Waldie was born and grew up in Mount Kisco, New York. After graduating from Lafayette College with a degree in biology, he attended the U.S. Navy Officers Candidate School and was commissioned as an Ensign in 1957, serving as a Communications Officer with the Seventh Fleet in Japan and throughout the Far East. He later taught at the U.S. Naval War College in Newport, Rhode Island. He entered New York Medical College in 1960, receiving his MD in 1964. He re-entered the Navy for an internship at St. Albans Naval Hospital in Queens, New York, and completed a residency in ophthalmology in Buffalo, New York. He met his wife Sharon in Buffalo, where they were married in 1969. Bob and Sharon moved to Sacramento, California

following their marriage, where Bob commenced the private practice of ophthalmology. They soon moved to Tempe, Arizona, where Bob was a respected eye surgeon for many years. He was a Fellow of the American Academy of Ophthalmology and many other medical organizations, and served a term as the President of the Phoenix Ophthalmological Society. Bob was a member of the Tempe East Rotary Club for 33 years and served two terms as President. For several years he was Chairman of the Rotary Ambassadorial Scholarship Program, and hosted many students from other countries. He and Sharon returned visits to some of them, in particular New Zealand and Germany. In addition to his wife Sharon, Bob is survived by his beloved dog Baxter and his adoring niece and nephews, as well as his grand-nieces and grand-nephews. Dr. Waldie was loved by his patients, his colleagues, and his family, particularly for his wonderful sense of humor.

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Profile for Maricopa County Medical Society (MCMS)

Round-up Magazine, December 2016  

Round-up Magazine, December 2016  

Profile for mcms2012