2006mayjun by Advocates for Better Health

May/June 2006

MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

METH

Methamphetamine: What every physician should know

INSIDE THIS ISSUE: • Avian Flu • PHOs New Business Model • Primary Care and Community Health • Book Review

The most powerful treatment begins with being treated well.

ellen bellairs, m.d.

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We take the fight well beyond.

Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

Physician Co-editor Y. Ralph Chu, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reﬂect the ofﬁcial position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: bauerfamily@earthlink.net. For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com. MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Doreen Hines at (612) 362-3705.

CONTENTS VOLUME 8, NO. 3

PHYSICIAN’S SOAP BOX

Avian Flu Crisis Tests Trust in Government, Health Care

United States Prepares for Highly Pathogenic H5N1 Avian Inﬂuenza in Wild Birds

Screening for Highly Pathogenic H5N1 Avian Inﬂuenza in Migratory Birds

FEATURE

Getting Up To Speed on Methamphetamine

COLLEAGUE INTERVIEW

Kathleen Watson, M.D.

PHOs: Facing the Winds of Change

Believe in the American Dream? Community University Health Care Center

2006 Winter Medical Conference: Excellent Speakers, Great Weather, Fine Dining

Book Review: Money is not the Cure HMS/RMS Hold Annual Joint Board Meeting Classiﬁed Ads

Index to Advertisers RAMSEY MEDICAL SOCIETY

25 26 27 28

President’s Message 2006 Caring Hearts for Homeless People Supply Drive Saint Paul’s Smoke Free Ordinance Celebration on March 31 New Members/In Memoriam

HENNEPIN MEDICAL SOCIETY

29 30 31 32

MetroDoctors

M AY / J U N E 2 0 0 6

Chair’s Report Minneapolis Books 2007 National Tobacco Conference/ In Memoriam/ New HMS Board Member New Members HMS Alliance

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: Methamphetamine use is increasing in Hennepin County and the surrounding metropolitan areas. Article begins on page 8.

May/June 2006

PHYSICIAN'S SOAP BOX

Avian Flu Crisis Tests Trust in Government, Health Care

THE MESSAGE FROM scientists and public health agencies the world over is clear: A pandemic of avian flu is going to circle the globe, killing millions, and in an age of air travel there will be little advance notice of its impending arrival. It is a time when Americans must believe that their health and safety is in the hands of those whom they can trust. But they don’t. The world is diverting tens of billions of dollars to every measure one can imagine to fight this nasty bug. Experimental vaccines are being rushed to production. Tamiflu and other anti-influenza drugs are being manufactured and stockpiled in overdrive. But no matter what we do, we will not have enough vaccine or pills to protect even a quarter of the American population any time soon. Only two things can slow the spread of avian flu, and they are the scariest things in the armamentarium of medicine: quarantine and rationing. Quarantine was pioneered in 14th-century Venice, where ships were required to wait offshore for 40 days. During the 2003 SARS outbreak in Toronto, quarantine entered the 21st century: 45,000 people in that area were asked to remain in home quarantine for 10 days, and similar measures were ready to go across that nation. The U.S. Centers for Disease Control says that 85 percent of those whom they polled are willing to stay home and care for themselves or their families. More than half would be willing to limit contact with others for a month or more. About half even said that they would be willing to wait months for a vaccine so that clinicians and other leaders could be vaccinated first. But researchers have found people won’t do any of this if it is called a “quarantine.” That term calls to mind images of police and military enforcing what amounts to martial law to protect the well from the sick and the stigmatized. The name isn’t the only problem with public participation in preventative measures before and during a pandemic. Whether you call it, as some suggest, “community shielding” or neighborhood clustering or, for that matter, just a prolonged slumber party, the public will accept public intervention to prevent disease only if they trust the American health care system as well as their government. And they don’t. Trust requires transparency. When public officials fail to reveal in the most public way the stark truth about the plans of cities, counties and states in a pandemic, it is a prescription for panic. Anyone who has read Richard Preston’s best-selling book, “The Hot Zone,” or seen the movie “Outbreak” knows what could happen when troops start marching and police in gas masks begin painting the doors of those who have infected family members. A lot of people will be exceedingly unhappy to find themselves in a police state. BY ARTHUR CAPLAN AND GLENN M cGEE

May/June 2006

Citizens of a country where those in one state have “Live Free or Die” on their license plates will not take kindly to being imprisoned in their homes unless those measures have been presented as part of a comprehensive strategy that takes their sacrifice of liberty into account. They would be much more willing to stay home with their families for a month to prevent the disease’s spread if they trust those deputized by the national and state agencies that implement the directives of the Centers for Disease Control and the Department of Homeland Security — and if they are sure that they will not be left to rot while others receive better care. For these same Americans, rationing is as terrifying as quarantine: If too few drugs, too few health care workers and terrible medical facilities plague our larger urban areas, imagine what could ensue. Cutting in line will be the least of our problems. Americans must believe that the questions about profit in the development and distribution of vaccines and anti-influenza drugs will fly out the window when the bird flu arrives. American medical schools and medical associations must reinstill a strong sense of professionalism in medical students and health care workers or they may not be there in the face of danger. The public has taken notice that more and more physicians have refused to work weekends or nights. What makes us think that they will work 24-hour days knee deep in highly contagious patients unless they have a strong sense of professional ethics and duty? The only answer to these challenges is to build trust. If people understand the rationale for quarantine and why some people must be vaccinated ahead of others, they are more likely to accept hard choices. Building trust means immediate public education, town meetings at which officials listen as well as talk, and plans sensitive to local concerns. And it means that all health care workers, though many will arrive ready to serve, will have to be read the riot act about availability in a time of crisis. Medical ethics has never been tested so dramatically. On the one hand, we had better have a government willing to move fast and err on the side of caution, a better public health sentinel system to prevent avian flu from spreading and a public ready to yield some liberties. On the other hand, the policies under development are frightening and depend for success on public trust that isn’t there. As a pandemic looms, billions spent on surveillance, intervention and quarantine will neither stop avian flu nor those who have it unless the public trusts those who will be kicking the military machinery of quarantine into place. Arthur Caplan is director of the Center for Bioethics at the University of Pennsylvania in Philadelphia. Glenn McGee is director of the Alden March Bioethics Institute at Albany Medical Center. This article was first published February 19, 2006 in the Albany Times Union. It is reprinted with permission. MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

United States Prepares for Highly Pathogenic H5N1 Avian Influenza in Wild Birds Editor’s Note: The following information on Avian Influenza was provided in a News Release received on March 20, 2006 from the United States Department of Agriculture, United States Department of the Interior and the United States Department of Health and Human Services. This material is presented for your information and distribution as you deem appropriate. Introduction Avian influenza (AI) — the bird flu — is a disease caused by a virus that infects domestic poultry, wild birds (geese and ducks and shorebirds). Each year, there is a bird flu season just as there is for humans and, as with people, some forms of the flu are worse than others. The highly pathogenic H5N1 strain of bird flu has been found in an increasing number of countries in Europe, Asia and Africa. Currently, H5N1avian influenza is not present in the United States. It is likely the highly pathogenic H5N1 strain will spread to this country, and the U.S. Government is taking steps to prepare for and minimize the potential impact of bird flu. There are a number of ways that highly pathogenic H5N1 could potentially reach the United States — wild bird migration, illegal smuggling of birds or poultry products, travel by infected people or people traveling with virus-contaminated articles from regions where H5N1 already exists. Historically, highly pathogenic strains of avian influenza have been detected in domestic poultry populations three times in the United States: in 1924, 1983 and 2004. There have been no occurrences of highly pathogenic avian influenza in wild birds in the United States and no significant human illness resulted from any of these outbreaks.

MetroDoctors

• The 1924 H7 outbreak was contained and

• No — the H5N1 bird ﬂu strain is still almost

eradicated in East Coast live bird markets. • The 1983-84 H5N2 outbreak resulted in the destruction of approximately 17 million chickens, turkeys and guinea fowl in the northeastern U.S. to contain and eradicate the disease. • In 2004, USDA confirmed an H5N2 outbreak in chickens in the southern United States. The disease was quickly eradicated thanks to close coordination and cooperation between USDA, state, local and industry leaders. Because of the quick response, which included quarantine and culling of birds, the disease was limited to one flock. “The Department of Agriculture is working on many fronts, with many partners to further strengthen our ability to detect and respond to highly pathogenic strains of avian influenza,” said Mike Johanns, Secretary of Agriculture. “By intensifying our monitoring of migratory bird populations, we increase the likelihood of early detection, which is key to controlling the spread of the virus, particularly in our domestic poultry. Having said that, it’s important for the public to know two things: a detection of Asian H5N1 in the United States would not signal the start of a human pandemic; and properly prepared poultry is safe to eat, because proper cooking kills this virus.” Below are some frequently asked questions and responses regarding bird flu.

entirely a disease of birds. Right now, this is still a “bird pandemic” — not a human pandemic. In rare cases, the H5N1 virus has caused human illness — but only in people who have had extensive, close contact with infected domestic poultry or their droppings. As of March 10, only 176 human cases of this illness had been reported worldwide, over the last three years. No one has been infected through contact with wild birds, or other people. Unless the H5N1 bird ﬂu virus changes dramatically — so it can be passed easily from person to person — we are unlikely to see widespread human disease.

Public Health Talking Points Joint Federal Agency H5N1 “Bird Flu” Briefing, March 20, 2006 What if somebody does find an infected bird — in North America, the U.S., in the Upper Midwest, or here in Minnesota? Does that mean we’re having a pandemic?

The Journal of the Hennepin and Ramsey Medical Societies

•

• •

Does that mean we don’t need to be concerned about a flu pandemic? • Public health officials remain concerned about the possibility of a future pandemic. We need to be prepared for that possibility. • Three worldwide pandemics have occurred in the last century — and scientists believe that another pandemic will occur some day. • If the H5N1 bird flu strain changes so it can be passed easily from person to person, it could still end up causing a pandemic. That may or may not happen. • A pandemic could also be caused by a completely different flu virus — one that we haven’t seen yet. • Public health officials, at all levels of government, are watching closely for changes in the H5N1 bird flu virus — and any other potential pandemic threats. (Continued on page 4)

May/June 2006

Avian Inﬂuenza (Continued from page 3)

How will we know when we have our first infected bird? What’s being done to monitor for H5N1 bird flu in wild birds? • Surveillance for H5N1 bird flu is already underway on major bird migration routes leading into the U.S. • In the coming weeks, the U.S. Geological Survey and the U.S. Fish and Wildlife Service will be working with state officials — primarily in Alaska — to test thousands of wild birds. • Initially, Minnesota will not be directly involved in the federal testing effort. However, the Minnesota Department of Natural Resources will be supporting these efforts, and will be preparing a plan for wild bird surveillance in Minnesota. (See sidebar on page 5). • Anticipated surveillance efforts in Minnesota include investigation of waterfowl die-offs, and sampling of birds in connection with bird-banding and hunter bag-checks. • The University of Minnesota and others will be doing some limited testing of birds, and DNR will also be assisting with those efforts. • There are many strains of bird flu besides the “H5N1” strain — and it’s not uncommon to find them in wild birds. None of them currently pose a threat to human health. • Other bird flu strains are around all the time. We have experience looking for them and responding to them. Do you want us to report it if we see sick or dead wild birds? Do you want people to submit dead birds for testing, the way you did with West Nile Virus? • Neither the Minnesota Department of Health nor the Minnesota Department of Natural Resources will be testing wild birds for H5N1 bird flu, or accepting dead birds for testing. • MDH did test dead birds for West Nile Virus, but that was done to track the presence of the virus in mosquitoes. That isn’t an issue with H5N1 bird flu. • Wild birds can carry the H5N1 bird flu virus, but it usually doesn’t make them sick. 4

May/June 2006

If you find a dead bird, it’s unlikely that it died from H5N1 bird flu. • If you find a dead bird, simply put it in a plastic bag and put it in the garbage — and then wash your hands thoroughly. Should consumers be concerned about buying and eating chickens or turkeys? What can they do to protect themselves? • Commercial poultry is monitored carefully for illness — including different strains of bird flu — by state and federal authorities. • In Minnesota, chickens and turkeys are monitored for disease by the state Department of Agriculture and the Board of Animal Health. • Even if the H5N1 bird flu virus is present in poultry, it is extremely unlikely that you would ever be infected by handling, cooking or consuming it. • Normal precautions for handling and cooking poultry should make it safe to prepare and eat. These precautions include: – Cleaning all utensils and food preparation services thoroughly after working with raw poultry. – Washing your hands thoroughly after handling raw poultry. – Cooking poultry thoroughly — to an internal temperature of 165 degrees or higher — before eating it. • You should be following these precautions anyway, to prevent routine food-related diseases like salmonella. What about eating eggs? Is there any special way eggs should be prepared? • There are no known cases where people have gotten H5N1 bird flu from eating eggs. • Cooking should kill any bacteria or viruses that may be present in eggs. • Eggs should be cooked thoroughly — so the yolks are not runny or liquid. Is this a potential threat to the poultry industry in Minnesota? What’s being done to protect our commercial poultry flocks? • Commercial poultry is monitored carefully for illness — including different strains of bird flu — by state and federal authorities. • In Minnesota, chickens and turkeys are monitored for disease by the state Department of Agriculture and the Board of Animal Health. MetroDoctors

• There are many different strains of bird ﬂu.

Some pose a serious threat to the health of poultry flocks, and others do not. • In the event that a strain of bird flu is found in a poultry flock, procedures are in place to isolate the sick birds, or take other steps to stop the spread of the virus. • Different strains of bird flu are around all the time. We have experience looking for them and responding to them. Should people be concerned about contact with wild birds or their droppings? What should they do to protect themselves? • To date, there have been no reported cases where people have gotten H5N1 bird flu from wild birds. • In general, people should try to avoid contact with wild birds or their droppings— not necessarily because of bird flu, but as a general health precaution. • If you can’t avoid contact with wild birds or their droppings, wash your hands, and avoid bringing feces into your home on shoes or clothing. • Clean your shoes or clothing as necessary. A bleach solution and exposure to sunlight may be helpful for disinfecting shoes. Is it safe to keep “backyard chickens” or other poultry, in or near your place of residence? • If you own birds, a few simple precautions can help you reduce any potential risk to your birds — or to your own health. • Monitor your birds daily for any signs of disease. In birds, flu causes swelling around the head and discharge from the eyes, nose and mouth. The H5N1 strain causes severe illness and death in chickens and turkeys. • Keep wild birds — especially waterfowl — away from your domestic birds. Avoid exposing your birds to feed, water or bedding that may have been contaminated by wild birds. • Avoid exposing your birds to sick birds. If your birds become severely ill — or die — consult a veterinarian promptly. • Wash your hands thoroughly after working with your birds to minimize any potential exposure to bird flu. • If you have questions about safe handling of your birds, contact the U.S Department of Agriculture at http://www.aphis.usda.gov/ vs/birdbiosecurity or 1–866–536–7593. The Journal of the Hennepin and Ramsey Medical Societies

Do bird feeders pose any health risk for humans? • To date, there have been no reported cases where people have gotten H5N1 bird flu from wild birds. • Bird flu is primarily a disease of waterfowl and shorebirds, and is not typically seen in the “backyard” bird species that visit bird feeders. • Because wild birds can also carry other diseases — such as salmonella — a number of precautions are recommended for people who keep bird feeders: – Wear rubber or disposable latex gloves while cleaning bird feeders or bird baths. – Use a plastic bag to pick up any dead birds, and dispose of them in the garbage. – Do not eat, drink, smoke, or rub your eyes or mouth after handling birds, until you can thoroughly wash your hands. Should people be concerned about swimming in lakes where waterfowl are present? • The risk of being infected by swimming in the same water with infected waterfowl is extremely remote. • There is no evidence that anyone has ever been infected in this way. • As a general health precaution, bathers may want to avoid shallow areas were waterfowl may be present — and especially avoid swallowing any water. Is it safe to eat wild game birds? What precautions should hunters take? • To date, there have been no reported cases where people have gotten H5N1 bird flu from wild birds. • Regardless of any potential threat from H5N1 bird flu, routine precautions should always be followed when handling or cooking wild game: – Do not eat or handle any game birds that appear to be sick. – Wear rubber or disposable latex gloves when handling or cleaning game birds. – After handling game, thoroughly wash your hands, as well as any knives, equipment or surfaces that came in contact with game. – Do not eat, drink, smoke, or rub your eyes or mouth while handling game. –Thoroughly cook all game to an internal temperature of 165 degrees or higher. MetroDoctors

What about pets? Are they at risk? And are they a potential threat? • There are no known cases where people have gotten H5N1 bird ﬂu from animals other than chickens. • A few cases of H5N1 bird ﬂu have been reported in large cats or domestic cats, in Europe or Asia. In all cases, these animals were infected by eating raw, infected poultry.

• Regardless of any potential risk from H5N1

bird ﬂu, pet cats should always be kept indoors in order to minimize possible health risks. • Pet birds should not be at any risk as long as they have no contact with wild birds.

Monitoring for Avian Inﬂuenza

he Minnesota Department of Natural Resources is concerned about avian inﬂuenza and will continue to work closely with state and federal agencies to monitor and prepare a response if the disease is detected in North America. Neither the DNR nor the Department of Health will be accepting dead birds from the public for testing. Following are details about efforts to monitor wild birds for the H5N1 strain of avian inﬂuenza in North America.

• Even apparently healthy wild birds can

• Nationwide monitoring efforts are current-

• Wild birds can carry the H5N1 bird ﬂu

ly focused in Alaska, where flyway routes of migratory birds from Asia and North America overlap. It’s very unlikely that the disease will first appear in Minnesota’s wild birds. • Avian influenza is found primarily in ducks

and shorebirds, not in the birds typically seen in your backyard (cardinals, chickadees, ﬁnches). • The DNR is developing plans to monitor

ducks and geese and will continue to collaborate with the University of Minnesota and others conducting waterfowl surveillance later this year. • Future monitoring will be designed to

maximize detection probability by focusing on juvenile waterfowl in mid to late summer when they are more likely to contract avian inﬂuenza.

The Journal of the Hennepin and Ramsey Medical Societies

carry pathogens other than avian inﬂuenza, and some of these are currently of more concern to human health in North America. Basic hygiene, primarily handwashing and use of rubber or latex gloves when handling any wild animals or carcasses is always recommended. • If you ﬁnd a dead bird that must be moved,

place it in a plastic bag and dispose of it in the garbage. Be sure to wash your hands thoroughly. virus but it doesn’t necessarily make them sick. If you ﬁnd a dead bird, it’s unlikely that it died from H5N1 bird ﬂu. • The Department of Health did test dead

birds for the West Nile Virus, but that was done to track the presence of the virus in mosquitoes. That isn’t an issue with the H5N1 bird ﬂu. Additional information is available from the National Wildlife Health Center: http: //www.nwhc.usgs.gov/publications/wildlife_ health_bulletins/WHB_05_03.jsp Additional information is also available from the World Health Organization: www.who.int/ entity/foodsafety/fs_management/No_02_ Avianinﬂuenza_Dec04_en.pdf.

May/June 2006

Screening for Highly Pathogenic H5N1 Avian Inﬂuenza in Migratory Birds “An Early Detection System for H5N1 Highly Pathogenic Avian Inﬂuenza in Wild Migratory Birds — U.S. Interagency Strategic Plan” March 2006

AVIAN INFLUENZA (AI) is a virus that is naturally found in wild birds, particularly in certain species of waterfowl and shorebirds. Occurrences of an H5N1 highly pathogenic avian inﬂuenza (HPAI) virus overseas have heightened concern regarding the potential impact on wild birds, domestic poultry and human health should it be introduced into the United States. To understand the differences and potential threats to U.S. bird populations, this fact sheet provides deﬁnitions, a historical perspective and an outline of the U.S. Department of Agriculture (USDA) and U.S. Department of the Interior (DOI) efforts to detect the H5N1 HPAI virus in wild migratory birds.

Low Pathogenicity Avian Influenza (LPAI): Most AI strains are classified as low pathogenicity and cause few clinical signs in infected birds. LPAI generally does not pose a significant health threat to humans. However, LPAI is monitored because two strains of LPAI— the H5 and H7 strains — can mutate into highly pathogenic forms. High Pathogenicity Avian Influenza (HPAI): This type of avian influenza is frequently fatal to birds and easily transmissible between susceptible species. The strain that is currently of concern in Asia, Europe, the Middle East and Africa is the H5N1 HPAI virus. TIMELINE

BACKGROUND About the Virus

AI viruses are classified by a combination of two groups of proteins found on the surface of the virus: hemagglutinin proteins (H), of which there are 16 (H1-H16), and neuraminidase proteins (N), of which there are 9 (N1-N9). There are 144 possible combinations or subtypes based upon this classification scheme. Wild birds, in particular certain species of waterfowl and shorebirds, are considered to be the natural reservoirs for avian influenza viruses. These subtypes that naturally occur in wild species usually cause little or no disease. However, domestic birds are generally more susceptible to avian influenza virus and mutation or recombination of a virus acquired from wild birds can increase its disease potential in these domestic birds. AI strains also are divided into two groups based on the pathogenicity of the virus — the ability of the virus to produce disease. 6

May/June 2006

Since 1997 when it first appeared in Hong Kong, federal wildlife experts and public health officials have been monitoring the spread of the highly pathogenic H5N1 virus. Since 1998, USDA, in partnership with the University of Alaska, has tested over 12,000 wild migratory birds in the Alaska flyway and almost 4,000 wild migratory birds in the Atlantic flyway. All birds have tested negative for the highly pathogenic H5N1 virus. DOI and USDA stepped up wild bird monitoring and testing programs when the highly pathogenic H5N1 virus spread throughout Southeast Asia and Russia. Since summer 2005, DOI biologists have been working with the State of Alaska to sample migratory birds for H5N1 in the Pacific Flyway. DOI has tested more than 1,700 samples from more than 1,100 migratory birds. There have been 22 avian influenza isolates identified, but none have been highly pathogenic. MetroDoctors

In August 2005, as part of the President’s National Strategy for Pandemic Inﬂuenza Preparedness, the USDA and DOI convened a joint working group with the U.S. Department of Health and Human Services (HHS), State of Alaska and the International Association of Fish and Wildlife Agencies to develop a national strategic plan for early detection of H5N1 HPAI should it be introduced into North America by wild birds. THE WILD BIRD PLAN Plan Overview

The interagency strategic plan, developed by wildlife disease biologists, veterinarians and epidemiologists, provides a uniﬁed national system for conducting H5N1 HPAI monitoring of wild migratory birds throughout the United States. The plan serves as a guide to all federal, state, university and non-governmental organizations involved in avian inﬂuenza monitoring by providing standard procedures and strategies for data sampling, diagnostics, and management. Five Strategies of the Plan

The plan targets bird species in North America that have the highest risk of being exposed to or infected with highly pathogenic H5N1 because of their migratory movement patterns. Key species of interest include ducks, geese, and shorebirds. If wild birds are or become able to effectively move the disease over great distances, scientists believe introduction of H5N1 into the United States would most likely occur in Alaska, where there is signiﬁcant mixing of Asian and North American birds. Therefore, the interagency strategic plan recommends a The Journal of the Hennepin and Ramsey Medical Societies

prioritized sampling system with emphasis ďŹ rst in Alaska, the PaciďŹ c Flyway and PaciďŹ c Islands, followed by the Central Flyway, Mississippi Flyway and Atlantic Flyway. The ďŹ ve strategies are: 1.) Investigation of morbidity/mortality in wild birds: The systematic investigation of signiďŹ cant numbers of sick or dead birds offers the highest and earliest probability of detection, if the highly pathogenic H5N1 virus is introduced into the United States by migratory birds. Biologists and veterinarians in state and federal wildlife and natural resource agencies and animal health agencies and organizations are prepared to detect and respond to such discoveries. In the event that a highly pathogenic H5N1 is detected in wild birds, USDA will identify and monitor domestic poultry and swine operations in the area and minimize contact between the wild birds and domestic animals. 2.) Monitoring live, apparently healthy wild birds: This effort targets wild birds in North America that represent the highest risk of being infected with highly pathogenic H5N1 avian inďŹ&#x201A;uenza, because of their migratory movement patterns. Species that will be sampled include birds that migrate directly between Asia, Oceania (including Hawaii, U.S. PaciďŹ c Territories and Freely Associated States) and North America, and birds that might be in contact with species from areas in Asia with reported avian influenza outbreaks. This includes sampling live-captured, apparently healthy wild birds to detect the presence of highly pathogenic H5N1 virus. Data collected in Alaska will be combined with data from additional bird captures to provide a broad species and geographic monitoring effort. In 2006, DOI, USDA and their cooperators plan to collect 75,000 to 100,000 samples from live and dead wild birds. 3.) Monitoring hunter-killed birds: Hunter check stations operated by the FWS and state natural resource agencies for waterfowl hunting provide an opportunity to collect additional samples to test for the presence of highly pathogenic H5N1 and other subtypes of avian inďŹ&#x201A;uenza. These samples supplement the targeted monitoring samples from live wild birds and

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focus on species that are most likely to have been exposed to highly pathogenic H5N1 viruses in Asia; have relatively direct migratory pathways from those areas to the United States via Alaska or directly to the PaciďŹ c Coast; or that mix in migratory staging areas in Alaska with species that could bring the virus from Asia. Collection of samples from these species will occur at hunter check stations in the lower 48 states, as well as Alaska, during hunting seasons in areas where these birds gather during migration or over-wintering. Samples also will be collected from wild birds taken by native Alaskans during the spring subsistence hunt. USGS, FWS and USDA are working with the four Migratory Bird Flyway Councils to enhance sampling plans for hunter-killed birds. 4.) Use of sentinel animals: There are two groups of animals used as sentinels in avian inďŹ&#x201A;uenza monitoring programs that could provide early detection of the highly pathogenic H5N1 virus along migratory ďŹ&#x201A;yways in the United States. Poultry ďŹ&#x201A;ocks reared in backyards (raised for noncommercial purposes) have been evaluated for diseases of interest to nearby commercial poultry operators as a monitoring method. Also, duck ďŹ&#x201A;ocks can be placed in wetland environments where they may commingle with wild birds. The ducks are then monitored and tested for avian inďŹ&#x201A;uenza viruses. 5.) Environmental sampling of water and bird feces: Waterfowl release avian inďŹ&#x201A;uenza viruses through the intestinal tract and the virus can be detected in both feces and water in which the birds swim. This provides a means of virus spread to new avian hosts and potentially to poultry or other livestock. Analysis of both water and fecal material from waterfowl habitat can provide evidence of avian inďŹ&#x201A;uenza circulating in wild bird populations. In 2006, USDA and others plan to collect 50,000 samples from high-risk waterfowl habitats across the United States. BENEFITS OF MONITORING DATA

In addition to providing an early warning system for disease occurrence in U.S. wild birds and domestic poultry, the monitoring data will be used to create a national database that

The Journal of the Hennepin and Ramsey Medical Societies

incorporates and tracks all avian inďŹ&#x201A;uenza data collected from wild birds in the United States. The database will be available to all agencies, organizations and policymakers involved in avian inďŹ&#x201A;uenza monitoring and response. The data collected in this system will be used by scientists to develop a better understanding of the movement of avian inďŹ&#x201A;uenza viruses among wild and domestic animals, improve risk analyses and target monitoring strategies to track regarding future avian inďŹ&#x201A;uenza spread. Additional Information

For more information about avian inďŹ&#x201A;uenza: â&#x20AC;˘ www.usda.gov/birdďŹ&#x201A;u â&#x20AC;˘ www.nwhc.usgs.gov/research/avian_ inďŹ&#x201A;uenza/avian_inďŹ&#x201A;uenza.html â&#x20AC;˘ www.pandemicďŹ&#x201A;u.gov

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May/June 2006

FEATURE STORY

Getting Up To Speed

Methamphetamine On Methamphetamine

OVER THE PAST FEW YEARS Minnesotans have become increasingly aware of methamphetamine. Until recently, methamphetamine had been considered a problem of rural Minnesota; but there are indications that its use is increasing in Hennepin County and the surrounding metropolitan area. This review will provide basic information about methamphetamine that every medical practitioner should know. History

Amphetamine was first synthesized in 1887 and subsequently methylated (hence, methamphetamine) in 1919. The sympathomimetic properties of these drugs were not realized until the 1920s, and amphetamine’s first medical application was in 1931 as the active vasoconstricting ingredient in over-the-counter Benzedrine nasal inhalers. Shortly thereafter, the stimulant effects of amphetamine became appreciated and abused. Billions of doses of amphetamines were dispensed during World War II to all major combatants and to American troops as recently as the Gulf War. During the 1960s, intravenous use of amphetamine became rampant in the Haight-Ashbury district of San Francisco leading to one of the first modern anti-drug campaign slogans — “Speed Kills.” During the 1970s, anti-drug campaigns and Federal restrictions on pharmaceutical manufacturing of amphetamine led to an increase in the illicit manufacture of methamphetamine. Illicit methamphetamine production has steadily increased since the 1980s. Once the purview of outlaw biker gangs, methamphetamine production has become highly organized and widely disseminated. While there are frequent news stories about clandestine methamphetamine laboratories discovered on farmland, in basements, in hotel rooms, and in the back of minivans, over 80 percent of methamphetamine in Minnesota can be traced to mass production “super labs” in California and Mexico. Epidemiology

Methamphetamine use spans all demographics. In the United States, over 11 million people have used methamphetamine in their lifetime, and approximately one million use it regularly. In Minnesota, more than 325,000 people have used methamphetamine in their lifetime and there are approximately 20,000 who use it regularly. The primary route of methamphetamine administration in Minnesota is intranasal, whereas smoking and intravenous routes are preferred in the West Coast and Southwest, respectively.

BY GAVIN BART, M.D.

May/June 2006

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Frequently, as intranasal methamphetamine users progress in the addictive process, they shift to the more potent modes of administration (i.e., injection and smoking). In 2004, approximately 6,000 Minnesotans entered treatment for amphetamine use (available statistics lump methamphetamine with amphetamine, although more than 90 percent of these admissions were related to methamphetamine). Admissions were fairly evenly split between men and women, approximately 90 percent were Caucasian, and more than half of all admissions were 25 years of age or younger. While these numbers are impressive, it should be pointed out that in 2003 there were an estimated 107,000 Minnesotans needing but not receiving treatment for illicit drug use. Emergency room and crime statistics provide further insight to the methamphetamine problem in Minnesota. In 2004, Twin Cities’ emergency rooms logged 874 methamphetamine related visits and there were 20 methamphetamine related deaths. The Hennepin County Attorney’s Ofﬁce reports that 2005 will see an estimated 312 methamphetamine related felony charges (the number for 2004 represented 14 percent of all drug related felonies); half of all Drug Court treatment referrals for women will be for methamphetamine; and almost 4 percent of all urine toxicology results for adult probationers are methamphetamine positive. Pharmacology

Methamphetamine is a crystalline powder and has several “street” synonyms including: meth, speed, crystal, glass, crank and, for smokeable “rock” methamphetamine, ice, tweak, and raw. It can be used through several different routes of administration including nasal insufﬂation, dissolution in liquid for oral consumption or intravenous injection, and pyrolysis for smoking. It is highly bioavailable (i.e., most of a consumed dose is systemically absorbed) and readily crosses the blood-brain barrier. Onset of action through nasal and oral routes is ﬁve and 20 minutes, respectively. Following injection or smoking, effects are more rapid < 1 minute. The half-life through all routes of administration is approximately 10 hours compared to cocaine’s 90-minute half-life. Approximately 45 percent of methamphetamine is metabolized to amphetamine and the primary route of excretion for methamphetamine and amphetamine is renal. Methamphetamine is relatively easy to manufacture and the Internet offers several easy to follow recipes. Chemicals involved in the manufacturing process are toxic and volatile and can include phenyl-2-propanone, benzene, Freon, toluene, acetic anhydride, lead acetate, mercuric oxide, phosphorus, hydrochloric acid, and sodium hydroxide. The

Methamphetamine use spans all demographics. In the United States, over 11 million people have used methamphetamine in their lifetime, and approximately one million use it regularly.

(Continued on page 10)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

May/June 2006

Methamphetamine (Continued from page 9)

environmental and toxicological impact of these compounds cannot be covered in this forum, but do impart risk for burn injury (both ﬁre and chemical), lung related injury, anemia, and even malignancy. Neurobiology

The addictive diseases are complex diseases of the brain with etiological factors that include genetics, environmental/ sociocultural factors, and the pharmacological effects of drugs of abuse. While drugs of abuse may differ in their range of effect, they all act either directly or indirectly through opioidergic and dopaminergic pathways. Mesolimbic and mesocortical dopamine pathways in the brain impart the reinforcing and rewarding effects of drugs. Gene knockout studies, however, have shown that the endogenous opioid system, more speciﬁcally the mu opioid receptor, is necessary for the development of alcohol, cocaine, amphetamine, opiate, and nicotine dependence. The primary site of methamphetamine action is the dopamine transporter. Methamphetamine binds the dopamine transporter and reverses synaptic vesicular dopamine uptake thereby increasing dopamine within the synaptic space. This increase in synaptic dopamine produces its rewarding and reinforcing effect. Methamphetamine has similar effect on serotonin and norepinephrine uptake. Through indirect effects, methamphetamine also increases brain levels of the neuroexcitatory transmitter glutamate. With prolonged use of methamphetamine there can be a reduction in the above mentioned monoamine transporters and, therefore, reductions in dopamine, serotonin and norepinephrine in brain reward pathways. Positron emission 10

May/June 2006

tomography and post mortem studies of human methamphetamine users’ brains confirm a reduction in dopamine D2 receptors and dopamine transporters in the striatum. Abnormalities in regional cerebral blood flow and brain glucose metabolism have also been noted. Abnormalities in these various brain imaging studies may correlate with length of methamphetamine use but it is unclear to what extent they represent cognitive impairment. Many cognitive functions remain intact in methamphetamine users; however, there may be a decreased ability to make decisions based on information predictive of reward. A recent functional magnetic resonance study has shown that impaired performance during a predictive task exercise in combination with decreased activation of specific cortical regions during the task was predictive of relapse to methamphetamine use whereas impaired performance in the task by subjects without the concomitant reduction in cortical activation was not. Other neuroimaging and anatomical studies have indicated that brain morphology is altered by chronic methamphetamine use. Animal and neuronal cell culture studies confirm that methamphetamine is neurotoxic and can cause a reduction in neuronal dendrites in dopaminergic and serotonergic neurons. Oxidative stressors from nitric oxide production and the neurotoxic effects of increased glutamate may contribute to these findings as well as to the increased gliosis noted in brains of methamphetamine users. To what extent these and the described cognitive effects of chronic methamphetamine use persist following abstinence is unknown. Methamphetamine also stimulates the stress responsive hypothalamic-pituitary-adrenal (HPA) axis. Acute doses will increase peripheral levels of adrenocorticotropic hormone (ACTH) and cortisol. MetroDoctors

Following chronic use, however, this effect becomes blunted. One hypothesis of chronic methamphetamine use is that use continues as a means of recapturing the rewarding effect of the initial elevations seen in levels of these stress hormones and other neurotransmitters. Following chronic use, HPA response to common stressors (emotion, illness, etc.) may also become blunted. This inability to mount a normal stress response may play a role in relapse to methamphetamine use, which frequently occurs during periods of stress. Clinical Effects

Most methamphetamine initiates express curiosity and availability as the main reasons for trying methamphetamine (women also include a desire for weight control). Parental methamphetamine use is also a predictor. In small to moderate amounts, methamphetamine produces stimulant effects such as increased alertness, energy, and attentiveness. Larger amounts produce a heightened sense of well-being, euphoria, hypomania, decreased appetite, and hypersexuality. Adverse effects include tachycardia, pupillary dilation, diaphoresis, restlessness, insomnia, weight loss, and bruxism. Overdose of methamphetamine can cause hypertension, hyperpyrexia, arrhythmia, psychosis and violent behavior. With chronic use, tolerance is achieved and larger amounts of methamphetamine must be used to produce the desired effect. The typical pattern of use is one to three week binges with a few days to weeks between binges. As use continues, weight loss and insomnia become more pronounced. Alteration in eating and oral hygiene habits, reduced saliva production from sympathomimetic effects, and bruxism may all lead to signiﬁcant dental disease (“meth mouth”). Chronic use may also cause formication

The Journal of the Hennepin and Ramsey Medical Societies

(a crawling sensation on the skin) and lead to skin picking and extensive scarring. In addition, psychotic symptoms may develop and persist for up to one month following discontinuation of methamphetamine. While it may take greater than one year of use for a methamphetamine addict to first experience psychotic symptoms, once psychosis develops it is likely that it will occur with each subsequent use, even if preceded by a prolonged period of abstinence. There is significant psychiatric comorbidity in methamphetamine users. The most frequent comorbidities include depressive and anxiety disorders. While depressive and anxiety symptoms are common, it should be noted that in the context of drug use it is extremely difficult to make non-addiction related psychiatric diagnoses unless there is a clear onset of symptoms prior to drug initiation or occurrence of symptoms during prolonged periods of abstinence. As with diagnosis, treatment of psychiatric illness in the context of active drug use is extremely difficult and requires a combined mental illness-chemical dependence (MICD) approach. Withdrawal from methamphetamine usually begins within 24 hours of last use and may last for up to one week (insomnia may persist for months). Unlike withdrawal from alcohol or benzodiazepines, methamphetamine withdrawal is not a medical emergency. Withdrawal symptoms generally include irritability, musculoskeletal complaints, anhedonia, insomnia, and poor concentration — all of which are mild to moderate and resolve in three to five days. Less often, methamphetamine withdrawal may cause transitory although profound depression and suicide may be a risk. Diagnosis

Methamphetamine dependence is deﬁned

MetroDoctors

as a maladaptive pattern of methamphetamine use and may be diagnosed if a patient meets at least three of the following seven criteria within a 12 month period: 1) development of tolerance to the effects of methamphetamine; 2) characteristic withdrawal syndrome in the absence of methamphetamine; 3) use in greater amounts or for longer duration than intended; 4) persistent desire or unsuccessful attempts to cut down or control use; 5) signiﬁcant amount of time spent procuring, using, or recovering from use; 6) forfeiture of important social, family, or economic responsibilities related to use; and 7) continued use despite knowledge of physical or psychological harm to self or others. Methamphetamine abuse, on the other hand, is deﬁned as a maladaptive pattern of methamphetamine use and may be diagnosed if a patient meets at least one of the following four criteria in the same 12 month period: 1) recurrent use

resulting in failure to meet major family, social, or occupational responsibilities; 2) recurrent use in hazardous situations (e.g., while driving); 3) recurrent methamphetamine related legal problems; and 4) continued use despite recurrent methamphetamine social or interpersonal problems. Health care professionals must ask their patients directly and specifically about methamphetamine use. Questions about drug and alcohol use are part of routine history taking. Initiation of drug use, including methamphetamine, is most frequently during the early and mid teens; therefore, it is particularly important to include a drug and alcohol history as part of pediatric evaluations. Patients who use methamphetamine should also be asked what they do to relieve unwanted stimulation. This question is important because (Continued on page 12)

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www.triium.com Email: info@triium.com 952.883.3288

May/June 2006

Methamphetamine (Continued from page 11)

it may reveal excessive alcohol, benzodiazepine, or opiate use; or use of potentially dangerous amounts of over-the-counter preparations such as antihistamines and acetaminophen containing sleep or cold medications. Urine toxicology may be used as part of clinical evaluation and care but should not replace a thorough drug and alcohol history. Clinical Management

The management of acute methamphetamine intoxication or withdrawal is generally supportive. Reduction of noise and light stimuli, a calm bedside manner, and interruptions only for necessary medical evaluations are helpful. Benzodiazepines may be needed in the acute setting for the more agitated patient. Psychotic or violent patients may require neuroleptics. Urinary acidiﬁcation will increase the renal excretion of methamphetamine but should not be performed in the presence of rhabdomyolysis. Methamphetamine use may lead to several cardiac emergencies. It can cause hypertensive urgency and cardiac conduction abnormalities. Blood pressure management may be necessary, but avoid use of selective beta-blocking agents since there is a theoretical risk of unopposed alpha-adrenergic stimulation. As with cocaine, methamphetamine-induced chest pain does occur and a small case series has found that 25 percent of admissions for methamphetamine associated chest pain had acute coronary syndrome. Monitoring for cardiac conduction abnormalities, especially when other medications such as tricyclic antidepressants or antihistamines have been used, is also appropriate in the acute setting. Other medical emergencies in the context of methamphetamine use include 12

May/June 2006

cerebral vascular accident, rhabdomyolysis, and multiorgan failure and disseminated vascular coagulopathy related to hyperpyrexia. Sepsis and endocarditis may develop in injection methamphetamine users. Methamphetamine users should be counseled about and screened for infectious diseases. Given the frequent use of methamphetamine in the context of risky sexual activity and its use by injection, all methamphetamine users should be tested for HIV, hepatitis B, and hepatitis C. HIV positive patients should be referred for treatment and viral resistance screening. Hepatitis C positive patients should be referred for treatment (a signiﬁcant period of sobriety may not be necessary for treatment, and continued drug use is not a contraindication to treatment). Hepatitis C positive patients should also receive vaccination for hepatitis A. All patients who are hepatitis B negative should receive vaccination for this virus. Cutaneous infections from skin picking or injection drug use should be treated accordingly. Methamphetamine is an illicitly manufactured drug and patients may present with toxicological problems caused by drug adulterants and impurities in the manufacturing process. Acute lead and mercury poisoning have been associated with methamphetamine use. Evaluations of unexplained neuropathies, anemia, hepatic or renal damage should include methamphetamine use in the differential diagnosis. Treatment

Medicine has highly effective treatments for opiate addiction and fairly effective treatments for alcohol and nicotine dependencies. Unfortunately, we are lacking in similarly effective treatments for methamphetamine addiction. Recent neuroscience research has provided new

MetroDoctors

insights into the underlying pathophysiology of methamphetamine addiction that will hopefully translate into clinical care. In the interim, some treatment options are available. The approach to treatment of methamphetamine addiction should be the same as it is for other chronic diseases such as hypertension or diabetes. It is a chronic relapsing disease that requires ongoing, and at times intensive, management. A seeming truism, the greatest predictor of ongoing abstinence is the length of time abstinent. However, only 66 percent and 59 percent of patients complete inpatient and outpatient treatment programs, respectively. While sustained abstinence six months following initial intensive treatment is rare, a reduction in days per month of self-reported methamphetamine use may be noted, with roughly 30 percent of urine toxicology screens remaining positive. Poor results such as these must be met with patience and perseverance. As methamphetamine use decreases there may be an increased opportunity for gradual clinical improvement. The initial treatment approach for methamphetamine addiction should be intensive and often requires inpatient or outpatient day-treatment program models. Traditional 12-step programs do not work in isolation and must be part of a multidimensional treatment approach that includes non-confrontational, nonjudgmental, positive reinforcement conducted by trained therapists. Cognitive behavioral therapy, family education, social support and relapse prevention groups must be combined with individual therapy sessions. A promising approach is the use of prize-based incentives as an adjuvant to psychosocial treatment. In this model, patients receive immediate positive reinforcement for methamphetamine negative urine toxicology and acquire “points” in

The Journal of the Hennepin and Ramsey Medical Societies

an increasing manner for each negative urine. These points may be exchanged for prizes ranging from bus passes to small radio or television systems. Behavioral interventions alone, no matter how intensive, are less likely to succeed unless combined with appropriate pharmacotherapy. This is true for the treatment of opiate, alcohol, and nicotine dependencies and is likely to be the case for methamphetamine addiction. A number of medications have been used to treat methamphetamine addiction with minimal success. The majority of trials have included antidepressants, neuroleptics and anticonvulsants. Selective serotonin or norepinephrine acting medications may provide some benefit, especially for patients with underlying depressive disorders. MAO inhibitor antidepressants should be avoided due to harmful interactions should the patient use methamphetamine. Tricyclics antidepressants should be used with caution due to potentially cardiac conduction effects should the patient continue to use methamphetamine. Neuroleptics have not proven helpful in the treatment of methamphetamine addiction, although they may be useful in the treatment of methamphetamine induced psychosis. Anticonvulsants may be of slight benefit although the results from only a few small short-term clinical trials may not be generalizable. Substitution of methamphetamine with a long-acting prescription stimulant has not been studied in a controlled manner; however, this approach was not helpful when longacting amphetamines were used to treat cocaine addiction. Results from a recent pilot study of modafinil in the treatment of cocaine addiction are promising but will need replication in a larger controlled trial. Future treatment directions include the use of medications that are directed at specific neurobiological processes altered MetroDoctors

by methamphetamine. For example, medications that reduce the neurotoxic effect of methamphetamine are in preclinical development and medications that alter dopamine metabolism are already being studied in cocaine addicts. Our understandings of genetic variants that contribute to the vulnerability to develop methamphetamine addiction offer the potential for genetically directed pharmacotherapy and possibly even gene therapy. Conclusion

Methamphetamine use is increasing in Minnesota. Advances in neuroscience have shown profound effects of methamphetamine and are slowly providing insight to therapeutic strategies that will optimally combine behavioral and pharmacological treatments. In the meantime, it is every health care professional’s mandate to “do no harm and comfort always” by dispelling the stigma of addiction as a moral issue of will power and weakness and to offer patients the best available evidenced based medical treatment. Helpful Resources: • National Institute on Drug Abuse: http://www.drugabuse.gov/ • Substance Abuse & Mental Health Services Administration: http:// www.samhsa.gov/ Gavin Bart, M.D. is Director, Division of Addiction Medicine, Department of Medicine, Hennepin County Medical Center, and Assistant Professor of Medicine, University of Minnesota. Acknowledgement: Dr. Milton Bullock provided useful comments in the preparation of this manuscript.

The Journal of the Hennepin and Ramsey Medical Societies

May/June 2006

COLLEAGUE INTERVIEW

Kathleen Watson, M.D.

Kathleen Virginia Watson, M.D., FACP is the Interim Senior Associate Dean for Education and the Internal Medicine Residency Program Director at the University of Minnesota Medical School, Twin Cities. She graduated from Carleton College and the University of Minnesota Medical School. She completed an internship and residency at the University of Minnesota Hospitals and was chief resident at the Minneapolis Veteran’s Administration Hospital. She completed a fellowship in Hematology/Oncology at the University of Minnesota Hospitals. Dr. Watson is board certiﬁed in internal medicine and hematology. Questions were provided by Drs. Michael B. Belzer, Edward P. Ehlinger, Amy Gilbert, James Jordan, Paul A. Kettler, and Richard K. Simmons.

Q A

What have been the major curriculum changes in medical education over the last 10 years? What new and different educational changes are you introducing in the medical school? The University of Minnesota Medical School’s medical education program has been evolving and now is prepared to transform medical education. I will discuss that transformation in a moment. First, I’d like our medical community colleagues to know that in the last decade, we have addressed the increasing demands of our changing society, of our accreditation agencies, and of our medical students with many significant changes. Technology has allowed innovations such as offering lectures online, posting online a password-protected curriculum for faculty and students, and developing a virtual patient panel that students can access electronically. In the last five years, we have upgraded our Objective Structured Clinical Exams, which are important for evaluating our students’ relationships with patients. These OSCEs also help them succeed in the relatively new clinical skills board exam. And we continue through our Physician and Society and Physician and Patient courses, offered during the first two years, to introduce our medical students to changing health care systems, to the concepts of diversity, health disparities, cultural competency, and to the communication skills they need for successful patient relationships. We now are launching a transformation of medical education, called MED 2010, which is based upon a very thoughtful planning process initiated last year by Dean Deborah Powell, M.D. In responding to forces of change such as empowered patients, an explosion of scientific discoveries and technology, financial concerns, increasing diversity, and

May/June 2006

concerns about quality, such as that expressed in Institute of Medicine reports. We have recognized the need to re-examine how we educate future physicians, especially as public confidence in health care erodes. We have established project groups to address aspects of our work with the overall goal of transforming medical education. These groups of faculty, staff and students will focus on: • Developing mentoring relationships more fully and formally among medical students and faculty, through learning communities, societies, or other approaches. • Integrating community and global health, health disparities, and diversity into the entire medical school experience, with the interwoven values and understanding of diverse communities and global health. Cultivating professionalism, the development of medical professionals, from nurturing individuals to fulfilling the social contract, from relating to patients, colleagues, and society to ethical considerations. Using outcomes measures and other assessments to help transform medical education, from admissions through residency and into physicians’ practice lives. We also launched some initiatives that are more limited in scope. The topics include chronic-illness management, interprofessional education, and portfolios for students and residents (see answer to question below.) Our goals are to educate future U of M physicians who are excellent members of health care teams, who strive to continuously improve quality of care and have the tools to do so, who have the ability to care for patients in increasingly diverse local and global societies, who are experts in knowledge management so they can acquire the latest care information to benefit their patients, who thrive in health care systems that constantly assess their capabilities; and who take responsibility for their own process of learning, so they might be educated in the ways they learn best. Dean Powell and I see this transformation as an ongoing process. While 2010 is the year chosen as our goal for accomplishing a thorough transformation in medical education, it will not end then. MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

With the oncoming â&#x20AC;&#x153;baby boomerâ&#x20AC;? numbers, what is the medical schoolâ&#x20AC;&#x2122;s reaction to an increased need for primary physicians? There are projections that the U.S. population 65 and older will increase by 35 million by 2030 and, because their need for care tends to be much higher than that of younger people, the health care workforce will have to grow. In collaboration with the Universityâ&#x20AC;&#x2122;s other health professional schools â&#x20AC;&#x201D; nursing, pharmacy, dentistry, public health and veterinary medicine â&#x20AC;&#x201D; we, in the medical school, have been examining health workforce issues across the professions and for the entire state of Minnesota. Currently, we are not planning to increase the size of our University of Minnesota Medical School class. While the population may need more health care providers, we believe that the need for more physicians in Minnesota has not been completely established. In addition, we already rely heavily on our community volunteer faculty to help us teach medical students. To teach a larger number of medical students and residents, we would need to ask even more volunteer service of our colleagues in our communities.

Please assess how the University Departments evaluate residents on the six ACGME competencies, since in January 2007 JCAHO will require hospitals to â&#x20AC;&#x153;rateâ&#x20AC;? their medical staff on the same competencies.

The ACGME Web site provides a toolbox of assessment methods as well as examples of effective and useful approaches to assessment of the competencies.

Given the recent NEJM article about how some of the personal and behavioral problems that affect some practicing physicians are ďŹ rst evident during medical school, what is the medical school doing to address those issues (alcohol and drug use, for example) in a proactive way? Good physicians come about through nature and nurture. Starting with our applicants, our admissions committee seeks to ďŹ nd and interview those who will become caring, professional physicians. Those admitted to our medical school learn about physician wellness and the values of our medical profession at orientation, from occasional presentations by national experts such as the Sotiles, and through the examples of role models â&#x20AC;&#x201D; their teachers. We offer a conďŹ dential peer assistance program for students having difďŹ culty with stress, as well as two programs that link medical students with professional counseling. When problems do arise, in anything from appearance, to attendance, to alcohol, our administrative staff addresses the situation as soon as possible and communicates with the individuals involved. (Continued on page 16)

Our University of Minnesota residency programs have made considerable progress incorporating evaluation of the six ACGME core competencies â&#x20AC;&#x201D; patient care, ( ) medical knowledge, practice-based learning and * improvement, interpersonal and communication

skills, professionalism, and systems-based prac

!" tice. The competencies provide physicians-in # training with a lens to see systems in their daily $ % & activities, and to perform a role in improving the quality of health care. For example, competency ! in Practice-based Learning and Improvement ' ( )"* + , - $ means that physicians have the knowledge ' + $ and tools to evaluate and improve their own ' ,

' . / 0 performance and medical practices. It requires 1 # #2 ( 1 # application of information technology to man.3 4. age information, and knowledge of clinical ' + 1 *1. / 5 + % # 6 # 2 + + # 7 .3 study design and translation of that knowledge to individual patient care. (For details on the ' 8 + competencies as part of the ACGME Outcome 3 ,

9 Project, go to www.acgme.org/outcome.) One $ promising tool, the portfolio, is being developed $ for our medical school by a group led by Louis Ling, M.D., Brad Benson, M.D., James Nixon, M.D., and Linda Perkowski, Ph.D. Portfolios are for use by learners at every level during !" !# "! $# % & #!#&#! & their career, from medical student to practicing "# $ % physician. Portfolios incorporate self-assess&&& ments as well as collating evaluations by others. "'" MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

May/June 2006

Colleague Interview (Continued from page 15)

What are the opportunities for future physicians to have training and instruction in relational and inter-personal psychology to prepare them for the humanistic components of medical practice that require empathic skills? Is there an undue emphasis on training in biological psychiatry in the training of medical students, without an equal emphasis on developmental psychology? Responsible, meaningful relationships with patients foster humanism in medical students and physicians. While the medical school has rich curriculum in medical humanism, it is at the bedside where students learn humanism. We try to prepare students in courses such as Physician and Society, a course in humanism, medical ethics, and knowledge management that runs as a thread through the ﬁrst two years of medical school. The highlight of the ﬁrst year is a live performance and discussion by Guthrie Theater actors of “Miss Evers Boys.” Students are spellbound. Secondly, we know that having a role and making a difference in a community context builds humanism and transforms students. All second year students are required, as part of Physician and Society, to work in teams on community-based, quality improvement projects. Thirdly, we have several nationally recognized teachers of humanism at the bedside, for example Dr. Peter Weissman at Hennepin County Medical Center and Dr. Craig Roth at the Veterans Administration Medical Center. Students’ training in psychiatry and behavioral medicine extend from the classroom to the communications training lab, where students work with real, standardized and simulated patients to learn the biopsychosocial dimensions of health care.

More and more people are going without health insurance, and others are choosing HSAs (market-driven health care). How are young doctors learning to be aware of the costs of their practice? The health care system is an abstraction to most medical students until they are engaged as participants. Our challenge is to teach about the systems while engaging them in becoming agents for change. The students themselves come up with the best ideas. Examples include the Clarion Project, a group of interprofessional health care students who have created a national case competition for solving major health systems problems. Another example is the managed care colloquium during the primary care clerkship, where Dr. Jim Pacala poses case studies for students to dissect along with leaders of some of Minnesota’s health care systems. At a residency level, residents are engaged in a variety of quality improvement projects such as the Achieving Competency Today (ACT) III program where a team of inter-professional advanced students have paired with the University of Minnesota Medical Center on a high priority health system problem. In the process, students learn the tools of quality improvement, team skills and medical economics.

May/June 2006

Why has the medical school inaugurated an optional 5-year program? Won’t this complicate course scheduling? As part of its transformation of medical education, the medical school last fall announced the Flexible M.D. Students entering the University of Minnesota Medical School may take anywhere from three and onehalf to six years to complete their studies and pay the same price to earn their M.D. In the past, the school offered a great deal of flexibility informally to students in the third and fourth years of the program. The school is increasing that flexibility in order to unleash the creativity of students. With greater flexibility, they might more easily construct an individualized educational program that meets their needs and addresses their passions. This uniquely flexible M.D. program is a radical departure from the typical lock-step medical school program of four years of instruction. It is expected that students would take advantage of this program to explore specialties, work in research at the U or for a biomedical company, or work in a community locally or overseas. Students pursuing this path will need to outline their plans to an educational enrichment committee and gain approval. And, because they are engaged in individualized learning, they may need more guidance than students on a more traditional track. While it may take more administrative effort to coordinate student learning, we do not believe that this additional flexibility will unduly complicate course scheduling.

What is the current range of debt, and the average debt by graduating medical students? Helping medical students avoid or manage debt is a responsibility we take very seriously. The University of Minnesota Medical School class that graduated in 2005 had an average debt of $132,988. The national average was $120,317, ranging from very few people with no debt at all to one person carrying a debt burden of $205,000. Dean Deborah Powell launched a Dean’s Scholars Society a couple of years ago to fund four-year, full-tuition packages to attract promising medical students from Minnesota to our medical school. For fall 2005 entrants, we were able to give these Dean’s Scholar scholarships to three students. (For more information, go to www.mmf.umn.edu.) Dean Powell also chaired an Association of American Medical Colleges working group on medical education costs and student debt. Among its recommendations were better education of medical students about ﬁnancial matters, as well as seeking creative local, state, and federal funding help for students involved in community service. (To read the report, go to: http://www.aamc.org/ studentdebt/.)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

PHOs: Facing the Winds of Change

THE LAST 40 YEARS have witnessed tremen-

dous innovations in medicine and the methods used to finance it. Beginning with the establishment of Medicare in the mid 1960s, to Dr. Paul Elwood’s popular concept of HMOs in the 1970s, to the implementation of Diagnosis Related Groups (DRGs) and Integrated Delivery Systems (IDSs), the delivery of health care services has been subjected to an ongoing assortment of political and economic pressures. Coupled with these pressures has been the acceleration of new therapies and technologies available for clinicians to diagnose, monitor and treat diseases and injuries. Clearly, changes in health care delivery continue at an ever-increasing rate. The dynamic market presents business challenges for all and, in particular, Physician Hospital Organizations (PHOs). PHOs gained prominence during the mid-1990s partly in response to IDS development. Typically, a PHO was formed by affiliate primary care and specialty members in association with a hospital or regional hospital group. Sources of funding for PHOs were from its affiliate members, the hospital and payer contracts. In most cases, hospitals funding the PHOs were non-profit, 501(c)(3)-qualified institutions funding a notfor-profit PHO providing services to clinics, which are generally “for-profit” entities. In the last few years, payer contract revenues have declined and legal regulations have increased. The implementation and strengthening of Stark regulations has dampened joint ventures, including what seem like reasonable support programs for families of chronically or terminally ill patients. The federal government has a new preoccupation with the taxation status of non-profit hospitals. In Minnesota, all

providers and payers have had a heightened sense of scrutiny resulting from work of the state attorney general. Where does this leave PHOs in the current flux of financing, scrutiny and regulation? The simple answer is “change or dissolve.” The problem with dissolution is that PHOs provide services to its affiliate members that are not available through any other venues, including the opportunity to collaborate on quality initiatives and provide needed patient services through a network. Group purchasing and the coordination of business services across a num-

ber of participating clinics are other “added value” aspects of PHOs. Some groups have successfully made this organizational transformation. Examples of pediatric-related PHOs that, for a period of approximately 10 years, have been successful in establishing a wide-range of services for (Continued on page 18)

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The Journal of the Hennepin and Ramsey Medical Societies

May/June 2006

PHOs (Continued from page 17)

physicians include Rocky Mountain Health Network, based in Montana; Children’s Health Network of Atlanta; and, Pediatric Physicians Organization of Children’s Hospital in Boston. Children’s Physician Network (CPN), located in the Twin Cities, is one local counterpart to these organizations. Like its peers, CPN is in the process of restructuring what services it provides, who pays for these services and how it can develop new revenues. These changes are mandatory in the new legal environment, now that the “traditional PHOs” need to become financially self-sufficient and no longer dependent on “undue financial support” from its member, non-profit hospital. CPN was initially established in 1994 as a “true PHO,” providing support services to its member clinics, all associated with Children’s Hospitals and Clinics of Minnesota. These services have ranged from negotiating payer contracts on behalf of providers, conducting

clinical audits and developing guidelines for quality assurance and performance improvement, group purchasing, promotion of clinic members to the public and payers, as well as lobbying payers and state government on behalf of pediatrics in general, and encouraging insurers to always look at their pediatric population separately from adults. As the funding considerations change, CPN needs to re-evaluate what, and how, it can continue to provide to its affiliated members. The need for these services to support medical professionals in their clinics and practices is substantial. The challenge, based on the dynamics of the health care marketplace, is who should pay for these now-valued services? Like other PHOs that remain vibrant, CPN has embarked on a new business model that will offer many of its existing services to a broader range of customers. This new model, more of a “management services organization” versus a “physician hospital organization,” allows non-profits, such as CPN, to develop and market service programs to new customers such as non-affiliated clinics outside of the network. As found in many

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other markets, the marketplace will drive former PHOs (including CPN) to develop and provide high-quality and competitively priced services in order to fund their futures. Examples of how CPN is facing these “winds of change” include the expansion of its Nurse Triage Service. This is a 24/7 telephone answering and triage center, staffed by experienced RNs that handle a variety of phone triage services for clinics, home health providers and hospitals. In spite of competition from for-profit national companies, CPN has found the response to the quality of its personnel, its emphasis on personal service and its well-founded clinical protocols to be creating a demand for these services. By offering the Nurse Triage Service to clinics not affiliated with Children’s Physician Network, CPN can build the critical mass needed to allow this service to operate securely into the future. Another example of program development is working with a leading national retailer to provide education about nutrition and exercise, accessible in traditional retail and employment locations. This new model also allows greater expansion of services to physician clinics such as pay-for-performance audits and coding training for clinic staff to maximize reimbursement for services rendered. While it is theoretically possible for an individual clinic or some other physician-based organization to replicate this kind of program development, it is not currently happening in the Twin Cities. The goal of the new business model is financial strength through diversified service offerings. Financial health will provide the fuel to support doctors, maximizing the quality, affordability and availability of needed medical services. As a result, the financial health of individual clinics and the clinic group is likewise more secure. Finally, these projected improvements in financial health will allow organizations previously known as PHOs to successfully deal with the dynamic health care market well into the future. Peter Dehnel, M.D., is the Medical Director, Children’s Physician Network, which works with pediatric clinics throughout the Twin Cities to improve health care for children and teenagers. Dr. Dehnel is a board certified pediatrician practicing at All About Children.

The Journal of the Hennepin and Ramsey Medical Societies

Believe in the American Dream? Bring your tired, sick, hungry and poor to Community University Health Care Center (CUHCC) where everyone is welcome

AT THE INTERSECTION of Bloomington

and Franklin Avenues in the Phillips neighborhood, one can visibly see why Phillips is considered the most diverse neighborhood in Minneapolis. At the corner, one ﬁnds a Halal Somali grocery store across the street from the Minneapolis American Indian Center, and a parking lot with a large gray building, which is the Community-University Health Care Center (CUHCC). This clinic is where global and community health issues intersect on a daily basis. Governed by a board with strong consumer representation (51 percent) consistent with the Community Health Center model, CUHCC’s mission is to advance the well-being of people experiencing health disparities. The clinic provides comprehensive medical, dental and mental health care to 9,000 patients annually, with over 50,000 visits. Over 80 percent of patients served live at or below 200 percent of the poverty level. In 2004, nearly 13 percent of patients were uninsured and paid on a sliding fee scale, while 77 percent were covered by government health care programs that cover most but not all of the cost of services. Only 10 percent of patients had private insurance. The health disparities faced by patients are large and far ranging due to a lack of access to care because of income level, immigrant status, cultural or linguistic access, and/or sexual orientation. Seventy-two percent of the patients walking through the door are African American, American Indian, Hispanic, or immigrants who come from various regions around the world including West and East Africa, Southeast Asia, Central and South America. To engage patients from diverse eth-

BY CHRIS REIF, M.D.

MetroDoctors

nic groups, CUHCC has a staff reﬂective of the communities it serves: 40 percent of staff are people of color, American Indians, immigrants or refugees. Clinical staff provides services in partnership with bilingual providers or longterm interpreter staff. Services are available in Cambodian, Hmong, Laotian, Thai, Somali, Spanish and Vietnamese. The welcoming atmosphere attracts other communities including Sudanese and Tibetan refugees. Patients coming to CUHCC often have multiple physical and mental health diagnoses. CUHCC represents one of a few safety net clinics where people can go for primary and specialty care services. Medical providers talk about the every day discoveries: “We had a woman who was abusing substances come in because she had overdosed on her psychotropic medications. She came because she said that she needed a new prescription, and could barely stand up. After some brief counseling from one of our on-staff social workers and a quick assessment, we called the paramedics who took her to the emergency room. After the woman left, one of the patients sitting in the waiting room turned to us and said, ‘she came to the right place.’ So when people ask me what we do here, I tell them we are saving souls,” states Sahra Noor, RN.

Reducing Health Disparities The need for culturally appropriate primary care services that include dental and mental health care has received attention from government ofﬁcials. The commitment to reduce health disparities remains the cornerstone to CUHCC’s care delivery model. An integrated model of clinical and ancillary services (interpretation, referrals, and social services) leads to patient engagement in their care and ultimately to better health outcomes.

The Journal of the Hennepin and Ramsey Medical Societies

“The mission to reduce health disparities goes beyond a ‘feel good’ effort to a commitment that all staff seek to fulﬁll everyday,” states Colleen McDonald, Director of Development. “In this era we, and especially our patients, come up against systems barriers that prevent people from being healthy. We constantly strive to ﬁnd new solutions to meet patient’s needs and integrate care for our patients.” Dental access is one area of great disparity, particularly for people who are uninsured or receiving public assistance. The scarcity of dental providers willing to serve people on Medical Assistance or who don’t have insurance has contributed to the rise in the number of people seeking emergency dental care at the ER in local hospitals. To increase access to dental care, CUHCC dental providers have enacted a triage system to pull people in when there are no-shows or cancellations. CUHCC has stepped up its efforts to reach a greater number of children from six months to two years to lay the foundation for healthy oral habits. A dental liaison (Continued on page 20)

May/June 2006

American Dream (Continued from page 19)

will coordinate care with the pediatric nurse practitioner, so that when children come in for their routine Well Child check-ups they can receive an oral health screening and get set up for restorative care if needed.

Engaging Patients to Become Informed Advocates of Their Own Health Medical providers at CUHCC play multiple roles. They are doctors and they are teachers: they teach residents how to become effective doctors and simultaneously educate patients about their health issues. Dr. Susan Ferron comments on the patient-provider dialogue, “Despite language and cultural differences we cannot underestimate or fail to respect a patient’s capacity to understand and make decisions about their own health. This often gives us an opportunity to go the extra mile as a provider-interpreter team.” One case in point: several years ago a young woman in her late teens came to the clinic. She was pregnant, had arrived in the U.S. only six months prior to her ﬁrst visit, and spoke very limited English. She was happy about the pregnancy and felt well, but after routine testing was told she had a potentially malignant disease. Her midwife referred her to specialists at the University of Minnesota. After consultation, she was told that she should undergo chemotherapy as soon as possible to save her live and the life of her fetus, and that her obstetrical care should be completed by an obstetrician specializing in high-risk pregnancies. She declined this treatment, but because of a good relationship with her midwife and the interpreters at CUHCC, was willing to continue to come to our midwife clinic for care. However, two ethical questions arose: How could we ensure that she understood the disease process and the risks and beneﬁts of immediate treatment to the extent that made her fully informed to make the best choice she could for herself and her family? How could we clarify for her, our clinic, and any other health care provider she might encounter what her rights were to decline care while pregnant? Dr. Ferron gathered together the patient, her husband, her midwife, her interpreter, a bioethics consultation team from the Univer20

May/June 2006

sity of Minnesota Center for Bioethics, and her subspecialty physician for what turned out to be a two-hour discussion. The nature of the system her illness involved — in health and in disease — was carefully explained, as were the details about what medicine could and could not predict about the course of her illness and the outcome of the pregnancy. Her rights to decline treatment were fully explored and understood. The young woman decided to undergo treatment during her pregnancy only if she began to show signs of the disease. Everyone was satisﬁed that her decision was fully informed. She was provided with a copy of the consultation so that if she needed emergency care from providers unfamiliar with her case her rights would be able to be immediately observed. She felt more comfortable about seeing subspecialty physicians at the University, and she delivered a healthy baby after an uneventful pregnancy. Following that she underwent treatment for her disease and she is currently healthy. She continues to be a patient at CUHCC.

Building a Future Workforce Who Understands Community Health Issues The community health center model came out of the War on Poverty during President Johnson’s administration. Dr. Jack Geiger and fellow physician Dr. Count Gibson opened the ﬁrst health center in Boston, and then subsequently opened a second in Mound Bayou, Mississippi. Their shared dedication to health as a human right gave birth to the community health center movement in the 60s. The unique character of the movement is that it is of the community, by the community, and for the community being served. While CUHCC espouses the values of serving those people who are underserved, CUHCC seeks to also pass on the community health center legacy to prospective health care providers and to advance program innovation through participatory evaluation. CUHCC serves as a placement and a continuity of care site for dental residents, students and hygienists, medical and psychiatry residents, MetroDoctors

pharmacy residents, and students from public health within the Academic Health Center at the University of Minnesota. Students from the School of Social Work come to gain experience working with diverse individuals, many of whom live below poverty. Prospective health care providers come to advance their firsthand knowledge of community health issues “in the trenches.” Both students and residents speak of the great opportunity to work on a team with health care providers from all different fields, and the challenges their patients have in accessing health care services. “With the changing Minnesota demographics, we need to deepen our knowledge around community health issues as well as engage more providers in meeting the needs of patients who rely on our health care safety net. The knowledge gained through CUHCC and the community health center movement must be passed on to the next generation,” states Karl Self, DDS, MBA. Chris Reif, M.D., first started his career in community health at CUHCC as a student intern in medicine and public health in 1974. Dr. Reif later worked on community health issues at various clinics serving vulnerable populations in the East Metro area: Face to Face Teen Clinic, St. Paul Homeless Health Care, Ramsey County Department of Corrections, and Health Start St. Paul school-based clinics. He also has experience in training medical residents for 17 years at Regions Hospital in St. Paul and four years at HCMC. He serves on the National Assembly of School Based Healthcare. His specialization is family medicine and he has an interest in adolescent medicine. He currently serves as the Clinical Director at the Community-University Health Care Center (CUHCC). The Journal of the Hennepin and Ramsey Medical Societies

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The Journal of the Hennepin and Ramsey Medical Societies

CPN is a servicemark of Childrenâ&#x20AC;&#x2122;s Physician Network, an affiliate of Childrenâ&#x20AC;&#x2122;s Hospitals and Clinics of Minnesota. May/June 2006

2006 Winter Medical Conference: Excellent Speakers, Great Weather, Fine Dining

THE 2006 WINTER Medical Conference

was held at the Melia Puerto Vallarta Resort in Puerto Vallarta, Mexico February 18 to February 25, 2006. Thirty physicians participated in the CME program that was designed to provide the participants with the latest information regarding the diagnosis and the technology used for the management of medical problems encountered in the day-to-day practice of medicine. Conference topics ranged from advanced imaging technologies to complementary medicine. The faculty included eight physicians who provided 20 hours of CME. Physicians were

awarded 20 Category I credits toward the AMA Physician’s Recognition Award or 18 Prescribed and two Elective credits by the American Academy of Family Physicians. The faculty members received excellent evaluations for their presentations by the participants. Dr. Brent Bauer, Associate Profes-

Faculty (from left): Jennifer Kyllo, M.D., Michael Wilcox, M.D., Robert Moravec, M.D., Charles Crutchﬁeld, III, M.D., Brian Koller, M.D., Ji-Chia Liao, M.D. and Ronnell Hansen, M.D. Not pictured: Brent Bauer, M.D.

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The Journal of the Hennepin and Ramsey Medical Societies

Conference attendees intently taking in one of the presentations.

sor of Medicine at the Mayo Clinic College of Medicine and Director of the Complementary and Integrative Medicine Program, spoke on “Complementary and Integrative Medicine: Medicine for the 21st Century” and on “Herbal Therapy 2006: Snakes in the Grass.” Dr. Charles E. Crutchﬁeld, III, dermatologist with Crutchﬁeld Dermatology, delivered three presentations that included a “Dermatology Update: Common Problems and Effective Treatment,” “Current Concepts in the Treatment of Acne and Psoriasis” and a “Cosmetic Dermatology Update.” Dr. Ronnell A. Hansen, radiologist with Saint Paul Radiology, also made three presentations: “Advanced Imaging Applications of Multi-Detector CT and MRI: Evolving 3D Image Analysis,” “The Cost of Medical Imaging” and “Cardiac Applications of Multi-Detector CT and MRI.” Dr. Brian R. Koller, psychiatrist with Park Nicollet Medical Center, spoke on “Paying Attention to Adult ADHD” and “Bipolar Spectrum Disorders: Recognizing and Treating in a Primary Care Setting.” Dr. Jennifer H. Kyllo, pediatric endocrinologist with Children’s Hospitals and Clinics of Minnesota, presented on “Childhood Obesity” and “Childhood Diabetes, Current Management and New

Technology.” Dr. Ji-Chia Liao, anesthesiology and pharmacology at the University of Minnesota, spoke on “Opioid Induced Respiratory Depression and Arrest, Part I and Part II.” Dr. Robert C. Moravec, emergency medicine at St. Joseph’s Hospital and chair of HealthEast Ethics Committee, presented on “Ethical Dilemmas with Advanced Directives,” “Pressure Ulcer Prevention & Early Intervention” and on “The Clinical Impact of Poor Health Literacy on Clinical Care.” Dr. Michael R. Wilcox, emergency medicine of North Memorial Health Care Center and coordinator of Emergency Care plus program, made three presentations including: “Trauma Care in a Rural Community,” “Mass Casualty Incident: Care and Management” and “Advanced Pediatric Life Support-Issues and Answers.”

Faculty member Brent Bauer, M.D.

Located in the Marina Vallarta in Bandera’s Bay, the Melia provided excellent conference facilities as well as many amenities for the physicians and their spouses and family members who accompanied them to the conference. Excellent dining was enjoyed by all at the Melia all-inclusive resort as well as by those who ventured out to enjoy the cuisine at wellknown Puerto Vallarta restaurants such as Le Kliff and El Panorama. Recreational opportunities in and around the Puerto Vallarta area proved to be almost limitless with sailing and whale watching among the most popular for members of the group. Others tried out ATV jungle tours, scuba diving, and snorkeling boat trips. One of the more popular excursions was a local bus trip into the shopping district to seek out that perfect souvenir that would remind them of an enjoyable time with colleagues in the relaxing ambiance of Puerto Vallarta, Mexico where the weather always seems to be perfect.

Dr. Crutchﬁeld educates the group on dermatology issues.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

May/June 2006

Book Review: Money is not the Cure by Seymour Handler, M.D.

THERE IS NO DOUBT that health care

costs are a current topic of extreme interest to physicians and their patients, as well as government and industry. With costs rising faster than inflation year after year, pension plans and benefits for employees are under real pressure with more and more cost shifting to the employee. Dr. Handler’s book, written for the lay public, lays out what he feels are some of the causes of this rise. He discusses life expectancy as well as life span, and notes the declining benefit of BY THOMAS B. DUNKEL, M.D.

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health care as individuals reach their “120 year maximum life span.” He then expounds on factors which have had a profound effect on life expectancy, including the improvement in controlling infections with sanitation and public health, with a much less cost-beneﬁt ratio with modern antibiotics, etc. As a pathologist, the author spends considerable space looking at cancer and its treatment. He states that “excessive follow-up of already treated cancer clearly is not indicated” and “that the only way to control oncology costs is to appreciate the limits of current oncology care more accurately.” Environmental pollution is the next topic. The author feels that the risks are quite overblown. “Despite the fact that much of the twentieth century has witnessed tremen-

HMS/RMS Hold Annual Joint Board Meeting

n February 15, 2006 the annual meeting of the boards of directors of the Hennepin and Ramsey Medical Societies occurred and was focused largely on what was happening at the legislature. HMS and RMS lobbyist from Lockridge Grindal Nauen, Kathi Michelletti was on hand to provide an update to the boards.

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May/June 2006

dous levels of environmental pollution, the incidence and mortality of cancer has not changed.” Dr. Handler appears to be on solid grounds, to this reader, when he reviews dietary supplements, noting that there is “little scientiﬁc evidence to support the business.” Here, the author who generally decries governmental interference recommends more in this area. Finally, the problem of obesity, much in the public eye these days, is discussed. In this book, Dr. Handler lays out what he feels are some of the reasons why we got to where we are today. He states “money is not the cure.” Unfortunately, he does not give us a very clear picture of how to get from here to there. I look forward to those suggestions in his next book.

MetroDoctors

In addition, Dave Renner, MMA’s director of state and federal legislation, addressed the group and spoke of the MMA’s priorities for the 2006 legislative session. DFL Minority Leader, Matt Entenza (64A), was also invited by the medical societies to speak. He provided some useful insight into the legislative process and also answered questions.

DFL Minority Leader Matt Entenza addresses the boards.

The Journal of the Hennepin and Ramsey Medical Societies

PRESIDENT’S MESSAGE JAMES J. JORDAN, M.D.

Rediscovering Health Care

RMS-Ofﬁcers

President James J. Jordan, M.D. President-Elect V. Stuart Cox, M.D. Past President Charles G. Terzian, M.D. Treasurer Peter B. Wilton, M.D.

Todd D. Brandt, M.D., At-Large Director Charles E. Crutchﬁeld, III, M.D., At-Large Director Laura A. Dean, M.D., Specialty Director Andrew S. Fink, M.D., At-Large Director Ronnell A. Hansen, M.D., Specialty Director Thomas J. Losasso, M.D., At-Large Director Robert C. Moravec, M.D., At-Large Director Jane C. Pederson, M.D., M.S., Specialty Director Lon B. Peterson, M.D., At-Large Director Thomas D. Siefferman, M.D., Specialty Director Stephanie D. Stanton, M.D., Resident Physician Jacques P. Stassart, M.D., At-Large Director Christina J. Templeton, M.D., Specialty Director David C. Thorson, M.D., Specialty Director Kimberly C. Viskocil, Medical Student RMS-Ex-Ofﬁcio Board Members & Council Chairs

Blanton Bessinger, M.D., AMA Alternate Delegate V. Stuart Cox, M.D., Communications Council Chair Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., Ethics & Professionalism Council Chair J. Michael Gonzalez-Campoy, M.D., Ph.D., MMA Immediate Past President Frank J. Indihar, M.D., AMA Delegate Neal R. Holtan, M.D., Community Health Council Chair Mark J. Kleinschmidt, Clinic Administrator Anthony C. Orecchia, M.D. Education Resource Council Chair Lyle J. Swenson, M.D., Public Policy Council Chair Richard W. Anderson, M.D., Sr. Physicians Association President RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Ofﬁcer Katie R. Anderson, Executive Assistant Doreen M. Hines, Manager, Member Services

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The Journal of the Hennepin and Ramsey Medical Societies

with patients. (www.merritthawkins.com/ pdf/2004_physician_50survey.pdf Summary Report 2004 Survey of Physicians 50 to 65 Years Old Based on 2003 Data. Merritt Hawkins Associates. 2004) What can doctors do to reclaim the “care” in healthcare? I believe it will take a three-way approach. First, we need to consider the training of medical students. In an interview with the ACP-ASIM Observer, Abraham Verghese, FACP, notes, “Medical training that subtly teaches young doctors to reduce complex people to ‘the diabetic foot in bed 4’ or ‘the MI in room 6’ can also lead them to distance themselves from their own emotional state….That kind of emotional detachment, both from patient and self… has also contributed to the public’s frustration with what it sees as an often uncaring profession.” (Deborah Gesensway, 2000, April. The plot thickens: physicians who think like writers. ACP-ASIM Observer. Retrieved March 8, 2006 from http://www.acponline.org/journals/news/ renewal.htm) Secondly, we need to communicate with the healthcare organizations, hospitals and network administrators with whom we work, and take the time to ﬁle prior authorizations and appeals. We must communicate with the best practice groups and legislators who make decisions by which we and our patients are bound. With these groups, our communication is more effective if they can hear us as a chorus rather than as individual soloists. Finally, we need to support each other in establishing a practice environment in which health care is our profession and not just our product. We need to communicate with each other. We need creative solutions. Perhaps it is reducing a caseload; perhaps it is forming a regular consultation group; perhaps it is something untraditional. Let the Ramsey Medical Society be a forum for creative discourse. And please let us hear from you.

May/June 2006

Ramsey Medical Society

RMS-Board Members

I CHOOSE TO PRACTICE medicine because it allows me to care for patients. That statement is not as simplistic as it might seem. In the popular vernacular, the words health and care have become linked to become healthcare, and in this hybrid, I sense a loss. What happens when health care becomes healthcare? The dictionary defines health as “the overall condition of an organism at a given time,” implying that health is a dynamic condition subject to variation over time and situation. It is that very dynamism that makes a patient’s health condition interesting. Why does one brother have cardiac disease and not another? Why does this cancer respond to a different mix of chemotherapy than another? Why does depression present at a given time? Physicians’ intellectual batteries are charged by puzzles like these. And if we are to successfully solve such medical puzzles we must get to know the patient. It is in the process of getting to know the patient that a healing relationship between doctor and patient begins. The dictionary defines care as “attentive assistance or treatment to those in need.” Care by definition must be attentive. It goes beyond matching a list of symptoms with the appropriate treatment protocol. The caring doctor listens, the patient feels heard, and the healing relationship develops. Early in my career I turned to a mentor for help with a particularly difficult case, and his words have stayed with me. “Jim,” he said, “do you just want to make her symptoms go away, or do you care about the source of her suffering?” Attentive care isn’t always quick or easy, but it is rewarding. What is lost when health care becomes healthcare? As greater financial and administrative demands exert themselves upon doctors, there is pressure to transform the practice of medicine from a powerful relationship-based dynamic into a system for producing a healthcare product. Physicians become healthcare providers and patients become healthcare consumers. Patients and doctors both feel dehumanized by this approach. A 2004 Merritt Hawkins survey found that the single greatest source of professional satisfaction for 58 percent of physicians was their relationship

2006 Caring Hearts for Homeless People Supply Drive

Thank you to the clinic managers, staff, and physicians of the following clinics that participated: •

JOINTLY SPONSORED by Ramsey Medical

Society and HealthEast Care System, the fourteenth annual “Caring Hearts for Homeless People” supply drive collected personal hygiene and related items for St. Paul programs that offer services to homeless people. In addition to area clinics and HealthEast’s staff, faith congregations and area schools participated in the drive. The drive was held from February 1 through February 28, 2006. In 2005 we collected 5,167 lbs. of donated items with an estimated value of $45,704. This year 16 medical clinics, 25 churches, HealthEast Summary of the 2006 Collection Approx. pounds

Approx. value

Medication

343

$11,463

Health, hygiene and baby products

3,805

$25,846

Item

Miscellaneous

590

$8,206

Cash donations

$7,025

TOTALS

4,738

$52,540

Care System, and many volunteers from the former Ramsey Medical Society Alliance, and many other organizations (4-H clubs, girl scout troops, high school youth groups, elementary class groups) pitched in to collect and sort over (4,738 lbs.) $45,515 worth of hygiene and medical supplies. Supplies were distributed to Listening House of St. Paul and Health Care for the Homeless. In addition, over $7,000 in cash contributions was collected. These organizations rely heavily on donated medications, hygiene supplies, toys, juice and monetary donations to help meet the physical, emotional and mental health needs of their clients. This drive contributes the majority of supplies needed for the entire year. Carole Nimlos coordinated the activities of the former RMS Alliance members who donated their time by picking up the donations from the 16 participating medical clinics and delivering items to our main drop-off site at St. Joseph’s Hospital. Please watch for the 2007 supply drive to be held throughout the month of February.

• • • • • • • • • • • • • • •

Associated Nephrology Consultants, P.A. Dermatology Consultants, P.A. Hamm Memorial Psychiatric Clinic HealthEast Downtown Clinic HealthEast Roselawn Clinic Metropolitan Obstetrics & Gynecology, P.A. Minnesota Medical Joint Services Organization (MMA, HMS, RMS) NOW Care Medical Centers Northstar Pain Care/Neurological Clinic/ Steven Trobiani, M.D. Partners Obstetrics and Gynecology, P.A. Physicians Neck & Back Clinic, P.A. St. Croix Orthopaedics, P.A. St. Paul Eye Clinic, P.A. St. Paul Infectious Disease Associates, Ltd. St. Paul Surgeons, Ltd. – Maplewood and St. Paul University Affiliated Family Physicians – Phalen Village Clinic

Summary of the Collection Totals for 10 Years $70,000 $63,476

$60,000 $54,670

$52,540

$50,000 $46,670

$45,704

$40,000

Collected items waiting to be sorted. $37,337 $30,813

$30,000

$29,310

$20,000

$19,335 $10,142

$10,000 $0 1997

May/June 2006

1998

1999

2000

2001

2002

2003

2004

2005

2006

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Collected items being sorted by volunteers.

The Journal of the Hennepin and Ramsey Medical Societies

Saint Paul’s Smoke Free Ordinance Celebration on March 31

Council member Dave Thune, Mayor R.T. Rybak of Minneapolis, and St. Paul Mayor Chris Coleman at Schroeders in St. Paul.

Street in St. Paul. Saint Paul Council member Dave Thune, the chief author of the ordinance, joined in the celebration. Late in the day, a Capitol City Trolley tour made the rounds to various Saint Paul restau-

St. Paul Council member Dave Thune boarding the Capital City Trolley.

Council member Dave Thune and St. Paul Mayor Chris Coleman greet smoke free ordinance celebration participants at Schroeders in St. Paul.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

rants and bars to mark the implementation of the smoke free ordinance and to celebrate the new clean air in Saint Paul establishments. Both Saint Paul Mayor Chris Coleman and Minneapolis Mayor R. T. Rybak joined the group in the evening at Schroeders as did Saint Paul Council member Lee Helgen.

St. Paul Mayor Chris Coleman receiving Ramsey Tobacco Coalition presentation from Carmen Robles of Association for Nonsmokers – Minnesota.

From left: Dr. Thomas Kottke, Regions Hospital cardiologist; St. Paul Council member Dave Thune; Dr. Robert Moravec, St. Joseph’s Hospital Medical Director; Roger Johnson, RMS CEO, at the noon celebration on March 31, 2006 at Sweeney’s in St. Paul.

May/June 2006

Ramsey Medical Society

he Ramsey Medical Society joined other members of the Ramsey Tobacco Coalition, and Blue Cross and Blue Shield of Minnesota, and members of the Minnesota Chapters of the American Lung Association, the American Heart Association, and the American Cancer Society, Midwest Division to celebrate the implementation of Saint Paul’s Smoke Free Ordinance on March 31, 2006. The celebration kick-off emcee was Roger Johnson, RMS CEO. The kick-off took place at noon on March 31 at Sweeneys on Dale

RMS UPDATE

Aaron J. Milbank, M.D. Cornell University Urology Metro Urology, P.A.

Resident Physicians

New Members RMS welcomes these new members to the Society. Schools listed indicate the institution where the medical degree was received.

Active M. J. Abuzzahab, M.D. Eastern Virginia Medical School Pediatric Endocrinology Children’s Hospitals and Clinics of Minnesota Gary L. Baker, M.D. University of Nebraska College of Medicine Internal Medicine/Rheumatology Allina Medical Clinic – Internal Medicine Specialties Samy El-Halawani, D.O. Pulmonary & Critical Care Associates, P.A. Martha E. Grandits, M.D. University of Minnesota Internal Medicine/Rheumatology Allina Medical Clinic – Internal Medicine Specialties Ronald F. Less, M.D. Rush Medical College Obstetrics & Gynecology Metropolitan Obstetrics & Gynecology, P.A. John W. McBride, M.D. University of Iowa College of Medicine Cardiovascular Disease/Internal Medicine HealthPartners Regions Specialty Clinics Thomas A. Ophoven, M.D. University of Minnesota Internal Medicine/Geriatrics Aspen Medical Group – Bandana Square

1st Year Active Practice Michael R. Ebbert, M.D. University of Minnesota Medical School Anesthesiology Associated Anesthesiologists, P.A.

May/June 2006

Mark J. Bergeron, M.D. Pediatrics U of MN Graduate School Kimberly A. Borke, M.D. Pediatrics U of MN Graduate School Mark J. Carlson, M.D. University of Minnesota Medical School Family Medicine U of MN Graduate School Yi Catherine Chang, M.D. Pediatrics U of MN Graduate School Rachel S. Darling, M.D. Pediatrics U of MN Graduate School Ketankumar D. Doshi, M.D. Hematology/Oncology U of MN Graduate School Jennifer R. Halverson, M.D. University of Minnesota Medical School Pediatrics U of MN Graduate School Samuel E. Inkumsah, M.D. Family Medicine U of MN Graduate School Michael J. Joyce, M.D. Family Medicine U of MN Graduate School Yasmin J. Khan, M.D. Pediatrics U of MN Graduate School Beth R. Kutzbach, M.D. Pediatrics U of MN Graduate School Taryn Q. Lambrecht, M.D. Pediatrics U of MN Graduate School Katherine E. Marienfeld, M.D. Pediatrics U of MN Graduate School Josy Mathew, M.D. Hematology/Oncology U of MN Graduate School

Matthew C. McClelland, M.D. Dermatology U of MN Graduate School Christina L. Mikesell, M.D. Pediatrics U of MN Graduate School Lori A. Nidever Nidersson, M.D. University of Minnesota Medical School Anesthesiology U of MN Graduate School Jane K.W. Peterson, M.D. Family Medicine U of MN Graduate School Scott A. Schwantes, M.D. Pediatrics U of MN Graduate School Yang Tang, M.D. Neurology U of MN Graduate School Sunn Sunn Htet Thaw, M.D. Family Medicine U of MN Graduate School Melissa A. Tschohl, M.D. University of Minnesota Medical School Emergency Medicine Regions Hospital Stephen D. Vang, M.D. Family Medicine U of MN Graduate School Venkata S. Vundamati, M.D. Family Medicine U of MN Graduate School Yasuko Yamamura, M.D. Ponce Medical School, Ponce Obstetrics & Gynecology U of MN Graduate School

Medical Students (University of Minnesota)

Danielle M. Baker Kevin C. Best Matthew L. Carlson

Benjamin R. Coobs John M. Cunningham Chad A. Cutshall Leah A. Dvorak Dennis A. Faith Laura E. Ford-Nathan Kimberly A. Gauquie Kathryn B. Grande Wen-yu V. Haines Luke M. Healy Joshua S. Huelster Liza Antoin Garcia Jain Janna Jo Johanns Joshua B. Johnson Stephanie L. Koonce Kristina M. Krohn Erin M. Kuisle Melanie W. Lo Dustin A. Lorentz Sara E. Loritz J. Robert Lovrich Christopher M. Mager Stephanie R. Maling Angela B. Martin Joseph P. Mayerle Jordan T. Mazur Barrie R. Miller Joshua J. Mooney David D. Nelsen Theodora A. Nemeth Benjamin J. Novak Megan Olejniczak Matthew D. Olson David C. Ou-Yang Ross W. Perko Brendan H. Pierce Serena M. Pierson Jesse M. Price Katie E. Rau Kristin N. Ritter Ruben J. Ruiz Peter C. Sanders Paul T. Schaefer Matthew G. Scott Nathan J. Smischney Katherine A. Stephenson Sarah E. Turgasen Jay J. Vlaminck Michael P. Walsh Anna M. Weisbecker Ncha D. Xiong

In Memoriam HERBERT W. JOHNSON, M.D. died from cardiac complications on March 21, 2006 at the age of 84. Dr. Johnson graduated from the University of Minnesota Medical School with specialty training in Internal Medicine at the Mayo Clinic. He served as an Army physician in World War II. He practiced in St. Paul from 1951 until his retirement in 1985. Dr. Johnson joined RMS in 1951. MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT JAMES A. ROHDE, M.D.

AMA’s Advocacy Meeting

HMS-Ofﬁcers

HMS-Board Members

Alan L. Beal, M.D. Carl E. Burkland, M.D. Peter J. Dehnel, M.D. Sundeep Dev, M.D. Laurie Drill-Mellum, M.D. Raymond A. Gensinger, Jr., M.D. Frank S. Rhame, M.D. Richard D. Schmidt, M.D. Janette H. Strathy, M.D. Thomas C. Tunberg, M.D. David J. Walcher, M.D. James A. Young, II, M.D. HMS-Ex-Ofﬁcio Board Members

Michael B. Ainslie, M.D., MMA-Trustee Mary Anderson, Co-Presiding Chair, HMS Alliance Martha Arneson, Co-Presiding Chair, HMS Alliance Beth A. Baker, M.D., MMA-Trustee Kelly Cawcutt, Medical Student Representative Karen K. Dickson, M.D., MMA-Trustee David L. Estrin, M.D., AMA Alternate Delegate Donald M. Jacobs, M.D., MMA-Trustee Dawn Lunde, MMGMA Representative Richard K. Simmons, M.D., Sr. Physicians Association Representative Karin M. Tansek, M.D., MMA-Trustee Benjamin H. Whitten, M.D., AMA Alternate Delegate HMS-Executive Staff

Jack G. Davis, Chief Executive Ofﬁcer Sue Schettle, Director, Marketing & Member Services Kathy R. Dittmer, Executive Assistant

MetroDoctors

FOR THE THIRD YEAR in a row I spent five days in Washington D.C. attending the AMA’s advocacy meeting and taking in some of the sights with family members. The three days of meetings are highly structured, intense and conclude with visits to all the offices of Minnesota’s Senators and Congressional representatives. We heard from several members of the House and Senate, governors, party leaders, and health care administrators. The highlights were Senator Hillary Rodham-Clinton’s nearly one-hour speech with questions and answers. No early Christmas present to the AMA by supporting malpractice caps (at least not without other parts of Tort reform). The other worthwhile speech was from Congressman Tom Price of Georgia (an orthopedist and U of Michigan medical school graduate), one of the senior congressmen from Massachusetts (30 years in Congress and married to a physician), and Dr. Howard Dean (former governor and presidential candidate). Sustainable Growth Rate was by far our number one issue as only Congress can fix this. Malpractice caps will probably have to be dealt with on a state-by-state basis. This still, however, is one of the top issues for the AMA. SGR is the system of setting Medicare reimbursement rates agreed on in the 1990s when Clinton and Gingrich came up with the short-lived budget reform to pay down the national debt. It was tied to the gross domestic product (GDR) minus Medicare Part B drug costs. So the 4-5 percent cuts of this year and next will go to 34 percent by 2015. This year’s cut was cancelled in February after months of lobbying and money restored by the CMS. Until the system is fixed (trading-in SGR for a formula that reflects cost of practice) we will have to go back to Congress over and over. The current reimbursement rate is already low enough that we may be losing money — not even covering our costs of keeping the office open. Each of us needs to look at our numbers and decide when we are going to stop taking

The Journal of the Hennepin and Ramsey Medical Societies

new Medicare patients. This is especially hard for small-town doctors. CMS administrators have told Congress that they will not ask for a fix as long as Medicare patients can get care at the discounted rates. Physicians do not tend to be boat-rockers but maybe it is time to quit taking on more dead weight that will soon sink our financial boats. Other highlights of my trip included my first visit to the Holocaust Museum, the Archives building to see the Declaration of Independence, and the Constitution and Bill of Rights, a duck boat tour of Washington and the Potomac River, a tour of the Capitol Building by Kelly Lange, an aide in Congressman John Kline’s office, all with my two daughters, Michelle and Emily. Our Congressional/Senate office visits included time with Sen. Coleman and Rep. Mark Kennedy who showed the most understanding and commitment to fix the SGR problem. Staff visits with Rachel Gustafson (Sen. Coleman’s office), Jonathon Haefitz (Sen. Dayton), Jean Hinz (Rep. John Kline), Erica Nelson (Rep. Mark Kennedy), Chip Gardner (Rep. Jim Oberstar) and Emily Lawrence (Rep. Betty McCollum) were all very helpful and cordial. Finally, a word of thanks to all the MMA leaders for continuing to educate me on the above issues, as well as other issues facing members of HMS, David Luehr (MMA President), Mike Ainslie (MMA Board Chair), Richard Geier (President-Elect of MMA), and Blanton Bessinger (candidate for AMA office and Past MMA President). Of course I always enjoy time with Chuck Terzian, my former counterpart at RMS (now in several MMA positions) and Robert Meiches (MMA CEO), and my predecessor, Mick Belzer.

May/June 2006

Hennepin Medical Society

Chair James A. Rohde, M.D. President Paul A. Kettler, M.D. President-elect Anne M. Murray, M.D. Secretary Edward P. Ehlinger, M.D. Treasurer Eric G. Christianson, M.D. Immediate Past Chair Michael B. Belzer, M.D.

HMS NEWS

graduated from the University of Minnesota Medical School. Dr. Esensten practiced family medicine. He joined HMS in 1954. ROBERT J. “BOB” FINK, M.D., an ophthalmologist, died April 15. He was 80. He graduated from the University of Minnesota Medical School. Dr. Fink joined HMS in 1956.

Minneapolis Books 2007 National Tobacco Conference The GMCVA announced at their March 30th annual meeting the booking of the 2007 National Tobacco Conference that will bring 2,000 to 3,000 attendees to Minneapolis hotels and restaurants. Hennepin Medical Society, along with Blue Cross and Blue Shield of Minnesota and the American Cancer Society were thanked for helping to secure the conference coming here. One of the main reasons that the conference was booked in Minneapolis was due to the fact that it is now smoke-free.

May/June Index to Advertisers Allina Health Systems.................................15 AmeriPride.................................................13 The Birkeland Group .......Inside Back Cover Children’s Physician Network.....................21 Classified Ads .............................................24 Crutchfield Dermatology ..........................17 MMIC .......................................................22 Minnesota Oncology Hematology, P.A.............. Inside Front Cover RCMS, Inc.........................Inside Back Cover Minnesota Healthcare Network and Triium ...........................................11 University of Minnesota CME ....................... Outside Back Cover Weber Law Office ........................................7 Whitesell Medical Locums, Ltd..................18

May/June 2006

MILDRED (NORVAL) INDRITZ, M.D., 93, died on March 6. Dr. Norval was best known for her pioneering efforts on behalf of children in Minnesota as Director of the former Crippled Children’s Services, ﬁrst in the Minnesota Department of Welfare and later the Health Department. She graduated from the University of Illinois Medical School, interned at Cook County Hospital and Research Hospital in Chicago, and completed her residency in pediatrics at the Mayo Clinic. She received a Masters of Pediatrics from the University of Minnesota and a Masters in Public Health from Harvard University School of Public Health. Dr. Indritz joined HMS in 1994.

Peter Dehnel, M.D., (right), chair of the Clean Air Minneapolis smoke-free project, and Sue Schettle, Director of Marketing and Member Services for HMS, stand with Greg Ortale, (center), President and CEO of the Greater Minneapolis Convention and Visitors Association (GMCVA).

In Memoriam GEORGE L. ADAMS, M.D., died on April 8, 2006 from complications of cancer. He was 65. He graduated from Jefferson Medical College of Thomas Jefferson University in Philadelphia. Dr. Adams was the head of the Department of Otolaryngology at the University of Minnesota. He joined HMS in 1974. JOSEPH A. DUPONT, M.D., an anesthesiologist, died February 11, at the age of 94. He graduated from Loyola University Medical School. He was a World War II Veteran and served in the Army as Battalion Surgeon 13th Armored Division in the European Theatre. He practiced family medicine in Excelsior at the Seifert/Dupont Clinic for 20 years. Later, he practiced anesthesia at St. Mary’s Hospital in Minneapolis. Dr. Dupont joined HMS in 1946.

ARNOLD J. KREMEN M.D., a general surgeon, died February 19. He was 92. He graduated from the University of Minnesota Medical School. Dr. Kremen joined HMS in 1947. FRANK KWOK-YIN KAN, M.D., died February 24. He was 84. Born in Canton, China, he graduated from the University of Hong Kong and started a private practice. Later, he worked at the VA Hospital in Minneapolis for 17 years and was the Assistant Chief of Anesthesiology when he retired in 1990. In WWII, Dr. Kan was a B-25 bomber pilot in the 1st Bomber Squadron, 1st Bomber Group, in the 14th Air Force Flying Tigers. He joined HMS in 1976. NANDA YUEH, M.D., age 57, died on January 20, after an 8 1/2 year battle with liver cancer. He graduated from the University of Minnesota. Dr. Yueh specialized in diagnostic radiology. He joined HMS in 1982.

New HMS Board Member James A. Young, II, M.D., Fairview Ridges Hospital, is the newest member of the HMS Board of Directors.

SIDNEY ESENSTEN, M.D., died February 7 in Rancho Mirage, CA at the age of 82. He MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Craig L. Bowron, M.D. Allina Medical Clinic Abbott Northwestern Hospitalist Service Internal Medicine

New Members HMS welcomes these new members to the Society.

First Year in Practice

Aimee S. Klapach, M.D. Sports & Orthopedic Specialists, P.A. Orthopedics Robin F. Kunze, M.D. Northwest Anesthesia, P.A. Anesthesiology Leroy P. McCarty, M.D. Sports & Orthopedic Specialists, P.A. Jeffrey J. Peterson, M.D. Consulting Radiologists, Ltd. Radiology Gavin T. Pittman, M.D. Orthopedic Partners, P.A. Orthopedics Lisa R. Wasserman, M.D. Sports & Orthopedic Specialists, P.A. Orthopedics

Active Sureshbabu N. Ahanya, M.D. Minnesota Perinatal Physicians Gavin B. Bart, M.D. HFA Internal Medicine Clinic Internal Medicine Scott J. Benson, M.D., Ph.D. Apple Valley Medical Center Family Medicine Steven D. Bentz, M.D. Multicare Associates of Twin CitiesFridley Family Medicine William A. Block, Jr., M.D. Minnesota Perinatal Physicians Obstetrics & Gynecology MetroDoctors

Paul M. Cammack, M.D. Northwest Orthopedic Surgeons Orthopedics Vincent R. Collins, M.D. Park Nicollet Clinic–Maple Grove Cardiovascular Disease Roger J. Day, M.D. Psychiatry Elizabeth P. Elfstrand, M.D. John A Haugen Assoc., P.A. Obstetrics & Gynecology Paul T. Fadden, M.D. Metropolitan Urology Clinic, P.A. Urology Brad A. Feltis, M.D. Pediatric Surgical Associates, Ltd. Pediatric Surgery Sheila A. Flynn, M.D. Multicare Associates of Twin Cities–Fridley Family Medicine Jeffrey M. Freed, M.D. Associated Skin Care Specialists, P.A. Dermatology Sheila Goodman, M.D. Associates in Women’s Health Obstetrics & Gynecology Kathy R. Gromer, M.D. Minnesota Lung Center Pulmonary Disease Timothy A. Hestness, M.D. Metropolitan Anesthesia Network Anesthesiology Gerald L. Hill, Jr., M.D. Woodwinds Health Campus Emergency Medicine Michelle L. Johnson, M.D. Valley Family Practice P.A. Family Medicine

The Journal of the Hennepin and Ramsey Medical Societies

David B. Ketroser, M.D. Physicians Spine Care Neurology David F. Labadie, M.D. Western Orthopaedic & Sports Medicine Consultants P.A. Orthopedics Harold N. Londer, M.D. Hubert H. Humphrey Cancer Center–North Memorial Campus Hematology/Oncology

Leslie W. Smith, D.O. Hennepin County Medical Center General Surgery Suzanne S. Teragawa, M.D. Multicare Associates of Twin Cities–Blaine Family Medicine Joel L. Thompson, M.D. Bloomington Lake Clinic, Ltd., Minneapolis Family Medicine Ezgi Tiryaki, M.D. Hennepin Faculty Associates

Jacqueline A. Luong, M.D. Midwest Plastic Surgery Plastic Surgery

Julie G. Topping, M.D. Hennepin County Medical Center Internal Medicine

S. Manjula, MB, BS Hennepin County Medical Center Anesthesiology

Dean G. Tortorelis, M.D. North Urology, Ltd. Urology

Kent D. Molde, M.D. Suburban Radiologic Consultants, Ltd. Diagnostic Radiology

Alexander S. Tretinyak, M.D. Surgical Specialists of Minnesota General Surgery

Steven G. Muehlstedt, M.D. Pediatric Surgical Associates, Ltd. General Surgery

Carole A. Vincent, D.O. Multicare Associates of Twin Cities–Blaine General Surgery

Christopher E. Ott, M.D. Fairview Oxboro Clinic Family Medicine

William E. Wagner, M.D. North Memorial Perinatal Center Maternal and Fetal Medicine

Grace C. Peterson, M.D. North Memorial Clinic–Golden Valley Family Physicians Family Medicine

Ian Weber, M.D. Hennepin County Medical Center Orthopedics

Kathleen M. Pﬂeghaar, M.D. Minnesota Perinatal Physicians Maternal and Fetal Medicine Natarajan V. Raman, MB, BS HFA Oncology Clinic Hematology/Oncology

Hennepin Medical Society

Thomas P. Bodine, M.D. Southdale Pediatric Associates, Ltd. Pediatrics

David R. Burrus, M.D. Minnesota Perinatal Physicians Maternal and Fetal Medicine

J. S. Jones, M.D. Minnesota Perinatal Physicians

Cynthia L. Weisz, M.D. North Clinic, P.A. Internal Medicine Jonathan K. Wood, M.D. Suburban Radiologic Consultants, Ltd.

Lisa L. Saul, M.D. Abbott Northwestern Hospital Obstetrics & Gynecology Matthew S. Segedy, M.D. South Lake Pediatrics Pediatrics

May/June 2006

HMS ALLIANCE NEWS DIANE GAYES

Dianne Fenyk Nominated as 2006-07 AMA Alliance President-Elect

The HMSA is overthe-top proud to be the home Alliance for Dianne Fenyk, 2006/2007 AMAA Nominated President-Elect! Approximately 30,000 AMA Alliance members will beneﬁt from her leadership! Dianne joined the Hennepin Medical Society Alliance (HMSA), Minnesota Medical Association Alliance (MMAA) and the American Medical Association Alliance (AMAA) in the 1980s. She is HMSA PastPresident, 1995-96 & 2000-01, and MMAA Past-President, 1998-99. In addition to her

leadership on numerous county and state Alliance committees and Board of Directors, Dianne has served on and chaired AMA Alliance committees, spoken to Medical Alliances from California to New York as AMAA Field Director, was the 2005/2006 AMAA Treasurer and is currently the AMAA Secretary. Mark your calendars for June 24-26, 2007. HMSA members plan to travel to Chicago and celebrate with Dianne when she is installed as the 2007/2008 AMAA President.

Philanthropic Fund and gathered together to have some good old fashioned holiday fun!

HMSA Holiday Brunch & Silent Auction December 9, 2005

Thank You to Sammi Ugarte for hosting this event at her elegantly decorated home. Thank You to Trish Vaurio for all of your efforts organizing the silent auction. $1100 raised!! Thank You to all the HMSA members who donated items, raised money for the HMSA

From Left: Marlene Ellis, Dianne Fenyk, Judy Nagel, Kathy Larson, Trish Vaurio and Sammi Ugarte

96th Annual Meeting & Luncheon Edina Country Club Friday, May 12, 2006 Please join HMSA members and friends:

• To celebrate with Dianne Fenyk for her nomination as the 2006/2007 American Medical Association Alliance (AMAA) President-Elect. • To thank HMSA Past-Presidents, board members and members for their volunteer work throughout the years. • To offer support and encouragement to the 2006/2007 HMSA Board of Directors. Conrad Schiebel, President-Elect, Minnesota Medical Association Alliance (MMAA), will install the 2006/2007 HMSA Board of Directors and will be our featured speaker. 9:30—Coffee 10:00–11:00 a.m.—Board of Directors Meeting 11:00–11:30 a.m.—Registration & Social 11:30 a.m.—Annual Luncheon 12:00 p.m.—Annual Meeting & Installation 12:30 p.m.—Guest Speaker: Conrad Schiebel, President-Elect, MMAA. “Canoeing Across the Barens of Canada” Cost $28 payable to HMSA at the event RSVP by May 10 to Kathy Dittmer, HMS 612-623-2885 kdittmer@mnmed.org Need a Ride? Call Diane Gayes, 952-935-8828

May/June 2006

MetroDoctors

onrad Schiebel is an avid outdoorsman as a result of a lifetime of hiking and skiing near his home in Edmonton, Canada. His experience includes work as a Park Ranger in the mountains of Alberta and a career as a Paramedic, during which he was involved in developing a non-proﬁt helicopter ambulance service (Alberta Shock Trauma Air Rescue Society). He worked for the ground ambulance service and as a ﬂight Paramedic. He is married to Nicola, Mayo Clinic ER physician, and has two children, Alexandra and Rudi. Conrad and his family moved to Rochester, Minnesota, in 1997 where he joined the Zumbro Valley Medical Society Alliance.

The Journal of the Hennepin and Ramsey Medical Societies

Lake Calhoun Condominium

Magnificent Cottage

Lake of the Isles Landmark

Secluded Retreat

Sophisticated Contemporary

Rarely available condo set on the southern shores of Lake Calhoun in a small and private complex of unique duplex-like homes. This spacious upper level unit offers fantastic views of the water and downtown skyline. Also includes a lower level exercise & amusement room. 2 bedrooms, 2 baths.

Set in the heart of Cottagewood on Lake Minnetonka sits this stunning home completely renovated with materials found in its original “summer cottage” as well as all the best amenities and features offered today. Boasting a warm, casual “at the lake feel” with a rare graceful elegance. 5 bedrooms, 5 baths.

Elegant Lake of the Isles property boasting superb views of the water, graceful and grand entertaining spaces, updated gourmet kitchen, beautiful original details and fabulous old world charm. A true masterpiece set on an idyllic park-like lot. 7 bedrooms, 8 baths.

Former model set on an idylic .5 acre lot with impressive perennial gardens. Features new 3 season porch, super fun lower level amusement and theater room, light filled public rooms with soaring ceilings, and gracious master suite. 4 bedrooms, 4 baths.

Exceptional estate set on a gracious lot overlooking Lake Minnetonka’s Lafayette Bay with 236’ of west facing lakeshore in Minnetonka Beach. Features include indoor and outdoor water features, crisp lines and stunning details, glorious bedroom suites, home theater, wine cellar, incredible lake views and more. 7 bedrooms, 8 baths.

Tranquil Views Gracious Cedar Lake property set on a large lot overlooking the parklands with views of the lake. Features updated eat-in kitchen, main floor family room with full wet bar, elaborate master suite, stone patio & more. 3 bedrooms, 4 baths.

Call: Bruce Birkeland

612-925-8405 www.brucebirkeland.com

Membership Advantages for Physicians and their Practices NEW I.C. System

is a Minnesota (St. Paul) based company specializing in full-service revenue cycle management solutions for the health care industry. They are now offering RMS members effective, ethical, and cost effective solutions to collecting debts, improving cash flow and reducing costs. For more information and a no-obligation price estimate, please contact I.C. System directly at 1-800279-3511 and let them know you are a RMS member.

AmeriPride Apparel and Linen Services is a locally owned and operated company offering rental and cleaning services of medical garments. Their organization is top notch with quality products and services. RMS members receive a discount. For a free price quote, contact Steve Severson from AmeriPride at 612-362-0334.

Schwarz Williams Companies, Inc. offers RMS members individual and group benefits (medical, dental, life, disability) as well as human resource support services, executive benefits, retirement programs, COBRA/HIPAA/ ERISA compliance, and benefit administration. To find out more information, contact Jim Fries at (763) 591-5822 or visit their website at www.schwarzwilliams.com.

SafeAssure Consultants recently partnered with RMS to offer the required OSHA compliance training for our members and their staffs. Our members receive a 50-60% discount on services and training. To meet or exceed the Minnesota OSHA and Federal OSHA requirements talk with SafeAssure at 1-800-920-SAFE or visit their website www.safeassuremedical.com for more information.

Call RMS at 612-362-3704 for details.

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