September/October 2018 - #EndGunViolence by Advocates for Better Health

Sept/October 2018

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

#EndGunViolence

“Your patients will thank you for referring them to Dr. Crutchfield.”

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves. Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column. Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring underrepresented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota in the names of his parents, Drs. Charles and Susan, both pioneering graduates of the U of M Medical School, class of 1963. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters. Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild 1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS VOLUME 20, NO. 5 SEPTEMBER/OCTOBER 2018

IN THIS ISSUE

Seeking a Solution We All Can Live With By Thomas E. Kottke, MD

PRESIDENT’S MESSAGE

Bringing Back the Joy By Thomas E. Kottke, MD

TCMS IN ACTION By Ruth Parriott, MSW, MPH, CEO #ENDGUNVIOLENCE

Page 32

Colleague Interview: A Conversation with Senator Scott Jensen and Senator Matt Klein

Preventing Firearm Deaths: Counseling on Access to Lethal Means (CALM) By Melissa Heinen, BSN, MPH, Terra Wiens, MPH, Jon Roesler, MS, and Stephanie J. Anderson

The Second Amendment in Historical Context By Matthew Filner, PhD

Band-aids and Bullet Holes: a Trauma Surgeon’s Perspective By Ashley Marek, MD

SPONSORED CONTENT:

Creating a Resilient Workplace: Solving for Organizational Causes of Burnout By Anne Geske Page 7

Jump Starting Tobacco Health Systems Change By Jeyn L. Monkman, MA, BSN, NE-BC, Tani Hemmila, MS, BSW, and Megan N. Whittet, MPH

28 29

The Convenings is Now End in Mind

30 32

In Memoriam/Career Opportunities

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

#EndGunViolence

Environmental Health — Climate Change and Mental Health By Jordan Weil, MD LUMINARY OF TWIN CITIES MEDICINE

Henry Blackburn, MD Page 20

MetroDoctors

Sept/October 2018

Page 7

The Journal of the Twin Cities Medical Society

Join the conversation. Tweet using #endgunviolence to describe the ways you are working to end gun violence. Articles begin on page 7. Photo credit: © David Joles/ Star Tribune/ via ZUMA Wire.

September/October 2018

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Mac Garrett Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Erica Nelson Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reďŹ&#x201A;ect the ofďŹ cial position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Erica Nelson 4084 Jana Ave. NE St. Michael, MN 55376 phone: (763) 497-1778 fax: (763) 497-8810 e-mail: erica@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. 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 Nancy Bauer at (612) 623-2893.

September/October 2018

September/October Index to Advertisers

TCMS OfďŹ cers

President: Thomas E. Kottke, MD President-elect: Ryan Greiner, MD Secretary: Andrea Hillerud, MD Treasurer: Sarah Traxler, MD Past President: Matthew A. Hunt, MD TCMS Executive Staff

Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Karen Peterson, Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Trish Greene, Administrative Specialist, Honoring Choices Minnesota (612) 362-3705; tgreene@metrodoctors.com Amber Kerrigan, Project Coordinator, Physician Advocacy Network (612) 362-3706; akerrigan@metrodoctors.com Annie Krapek, Program Manager, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com Linda Singh, Executive Director, End in Mind (612) 362-3724; LSingh@endinmindproject.org Katie Snow, Administrative Coordinator, End in Mind (612) 362-3739; KSnow@endinmindproject.org

CrutchďŹ eld Dermatology..................................... Inside Front Cover Fairview Health Services .................................30 HealthPartners...................................................... 6 MMIC ................................ Outside Back Cover Protect Minnesota ..............................................19 St. Cloud VA Medical Center .......................31 University of Minnesota Health ........................ Inside Back Cover U.S. Army ............................................................24

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MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Seeking a Solution We All Can Live With

need to warn you right away: Reading this issue of MetroDoctors is unlikely to create a feel-good moment for you. If, however, you would like to be part of the solution to the epidemic of gun violence in America, please read on. The country is locked in a policy trench warfare while shootings at schools occur nearly weekly, suicide rates have increased by double digits, and guns turn domestic disputes into deadly encounters. All of this has created a pall as Americans wonder: Where will the next mass shooting occur? Who among my friends and acquaintances will die by suicide using a gun? When will we next read of a child’s injury or death because he and a playmate stumbled upon a handgun? The evidence is clear (when it is available): Guns kill. They kill their owners, they kill people who live with their owners, they kill people who access them through their owners, and they kill people who just happen to be “in the wrong place at the wrong time.” As Riddell et al. recently documented, risk of both homicide by gun and suicide by gun across the US is highly correlated with gun ownership rates.1 The relationship is particularly strong for non-Hispanic white men. The problem of gun violence is not new. Nearly 30 years ago, Dr. Marvin Segal, one of our co-editors, successfully introduced a resolution at the MMA House of Delegates calling for the responsible use of firearms. Because of the continued burden of gun violence on the public’s health, the MetroDoctors editorial board felt compelled to promote a discussion and seek solutions. In a very special Colleague Interview, Senators Scott Jensen and Matt Klein, both physicians, explain why they elected to serve in the legislature, offer their perspectives on public policy, and suggest how physicians can voice their concerns effectively. In his responses, Senator Jensen tells how some gun advocates tried to influence his decisions with death threats. If there is one action that is un-American, it is the use of death threats to influence public policy. From the Violence Prevention Unit at the Minnesota Department of Health, we learn that suicide is the leading cause of gun-related death in Minnesota. Because the Second Amendment is so frequently cited as the basis for gun ownership, we asked Matthew Filner, PhD, from Metro State University to outline the history of the 2nd Amendment and

what and who it protects today. We did seek input from the other side of the issue, but the NRA did not respond to our invitation, so we present four papers that are closer to ground zero: HCMC trauma surgeon, Dr. Ashley Marek, describes how gun violence impacts her life; Dr. Adnan Ahmed, a University of Minnesota psychiatrist, writes of the psychological damage done to the participants of active shooter drills; Dr. Sheldon Berkowitz, a pediatrician at Children’s Hospital and President-Elect of the Minnesota Chapter of the American Academy of Pediatrics tells of his experience with March for Our Lives and offers advice about what each clinician can do to reduce the risk of gun violence in the households of the children they serve; and finally, Dr. Charles Crutchfield offers advice on how to reduce personal risk in an encounter with the police. We end this issue of MetroDoctors with a biography of Dr. Henry Blackburn. A world leader in cardiovascular disease epidemiology and prevention; a friend to many physicians in our community; and, my mentor for more than four decades, Henry’s work has contributed in no small measure to the 70% world-wide decline in cardiovascular mortality rates since 1960. Fundamental to the decline was his development of standard measurements so that objective data could be generated, shared and discussed as he and scientists around the world identified solutions to the epidemic. I think there is an analogy here as we work to end gun violence. If we use the same methods — objective data and civil discourse — and each one of us is willing to give a little, I am confident we can find solutions we all can live with. So go public, tweet your commitment using the hashtag #endgunviolence, and help us end this public health crisis.

By Thomas E. Kottke, MD Member, MetroDoctors Editorial Board

References 1. Riddell CA, Harper S, Cerdá M, Kaufman JS. Comparison of rates of ﬁrearm and nonﬁrearm homicide and suicide in black and white non-hispanic men, by u.s. state. Annals of Internal Medicine. 2018.

MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2018

President’s Message

Bringing Back the Joy THOMAS E. KOTTKE, MD

he discussion of burnout in the physician community has been dramatically increasing. Over the past year, TCMS has stepped up its programmatic efforts to both relieve the suffering of physicians who are experiencing burnout, and to develop a framework to help physicians at all career stages achieve and retain the joy they seek in their vocation. One clear sign of burnout is dependence on drugs or alcohol. To assist physicians who have become or are at high risk of addiction, TCMS has entered into an agreement to provide management support services to Physicians Serving Physicians (PSP). PSP offers a unique support group where only physicians gather. It strives to decrease stigmatization of impairment and provide a pathway to return to productive medical practice with the support of other physicians who are seeking the same goal. In addition to establishing a relationship with PSP, TCMS is seeking ways to support physicians who are not finding the joy they are seeking in their work. There is little doubt in my mind that the electronic medical record (EMR) is seen as a barrier to joy by many physicians, but it is not the only one. About a year ago, Dr. Matt Hunt, then President of TCMS, passed around an article by David Rock, a researcher who uses functional MRI to explain why interpersonal interaction breaks down. Rock focuses on five factors: status, consistency, autonomy, relatedness, and fairness. He cites data explaining why we feel bad when someone or something violates one or more of these feelings in us. Does that ring a bell with you? It does with me. Although I prefer my EMR over paper, I don’t like it when the EMR forces me to do something—there goes status and autonomy. Formularies vary—there goes consistency. Because we have the ability to access our EMRs 24-7-365 from anywhere in the world, we are seeing our families and fellow physicians less and less—there goes relatedness. And finally, who doesn’t feel that they are being treated a little unfairly when they are simply trying to help a patient by prescribing a drug or other therapy and a voice on the phone says, “No”? Whether these feelings are justified does not affect the fact that they are real and they cause distress. So right now, TCMS has a small task force comprised of physicians from different medical groups charged with developing a proposal to help physicians find joy in work again. When we get their plan, we’ll move on to implementation. But there are two sides to the burnout/joy and happiness coin: Unless we know what will bring us joy and happiness, we will not find it. Joy will never kick down the door and force itself upon us. We need to seek it out and embrace it, and it’s not all that hard. Although there are many other researchers who investigate the determinants of joy, the two that I believe have provided us with great evidence of how to achieve joy and happiness are Sonja Lyubomirsky (http://sonjalyubomirsky.com/) and Martin Seligman (https://www. authentichappiness.sas.upenn.edu/faculty-profile/profile-dr-martin-seligman). Americans tend to believe happiness will come to them if they have health and wealth. This is true to a point but doesn’t provide the whole picture. Most physicians start their careers healthy, and most earn far more than $75,000 per year, the point at which the association between rising income and rising happiness weakens. So what are the behaviors that have been shown to produce happiness? Being kind to people; thanking people when they help out; and, ending every day with the identification of three or more good things that happened that day and why they occurred. (I can think of three right off the bat: I have a job; I have a family; and, I live in a peaceful community.) Over the next year or so, our goal at TCMS is to identify or develop materials and modules that busy physicians and their care teams can use to increase their joy and happiness at work and at home. So stay tuned, stay involved, seek, and I believe you will find joy in work. 4

September/October 2018

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO

Be Part of the Legacy

Several months into my new position, the conversations have developed a familiar flow as I introduce myself to community partners and supporting organizations of the Twin Cities Medical Society and Foundation: s h#ONGRATULATIONS ON YOUR NEW position!” s h9OU KNOW IT JUST MEANT SO MUCH when the medical society spoke out on reducing gun violence; I was very pleased to see that.” s h!ND ) VE ADMIRED THE (ONORING Choices advanced care planning work for years. It’s truly changing health care and families’ lives for the better.” s h3O WHAT ARE SOME OF YOUR NEW projects?” After I explain our role in the T21 movement and our foray into physician wellness and peer support for chemical addiction recovery, the reply comment has become predictable: h4HAT S WONDERFUL 9OU CAN ALWAYS count on TCMS to do the right thing and get involved in relevant issues!” Suffice to say, I’m so grateful to find myself surrounded by committed, engaged physicians who look beyond their practice into the community at large and consistently ask the question, “What can we do as a medical society to make it better?” Now is an ideal time to add your name and expertise to the TCMS leadership legacy! There are several excellent opportunities available: s /NE RESIDENT DIRECTOR ON 4#-3 Foundation Board s 4WO PHYSICIAN DIRECTORS RESIDING IN the East Metro on the TCMS Foundation Board Please contact Nancy Bauer at nbauer@metrodoctors.com or me rparriott@metrodoctors.com to learn more. There’s never a better time than

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the present to become a physician leader and no organization more welcoming to fresh perspectives. Physician Advocacy Network Update

Congratulations to Annie Krapek who has stepped into the role of PAN Program Manager. Annie has worked with PAN as its Program Coordinator for the past two and a half years, where she worked closely with health professional students and supported our physician advocates in passing numerous local policies. Amber Kerrigan has joined TCMS as the Physician Advocacy Network’s Program Coordinator. She brings exceptional organizational and relationship building skills, as well as a commitment to improving the health of our community. Richﬁeld and Roseville both passed Tobacco 21 policies, which makes 11 Minnesota communities that have passed Tobacco 21 as of July 2018. St. Paul city council voted unanimously to cap the number of tobacco licensees in the city, which will put a stop to more tobacco shops opening. Senior Physicians’ Association Fall Meeting

Join the Senior Physicians’ Association for our next luncheon and lecture on Tuesday, September 18, 2018. Eileen Weber, DNP, JD, BSN, PHN, RN, Chair, Healthcare Legal Partnership

The Journal of the Twin Cities Medical Society

Collaborative will be the guest speaker. 11:30 am–Social; 12 noon–Lunch followed by guest speaker. Location: Broadway Place East, 3433 Broadway Street NE, ﬁrst ﬂoor conference room, Minneapolis, MN. $25.00. All physicians age 62+ are invited to gather with colleagues for this event. Contact Nancy Bauer for more information: nbauer@metrodoctors.com. (612) 623-2893. MMA Annual Conference and House of Delegates to Convene

The MMA Annual Conference will be held September 21-22 at the River Centre in St. Paul, with the House of Delegates slated to reconvene on Saturday afternoon, September 22 for the purpose of voting on one resolution: to review the work of the Policy Council and vote on its future. TCMS has 95 delegate seats allotted. Register for the Annual Conference at www.mnmed. org/education-and-events/Annual-Conference. Please contact Nancy Bauer (612) 623-2893; nbauer@metrodoctors. com to indicate your desire to serve as a delegate. Physician Wellness

TCMS is continuing to explore programs and opportunities that advance physician wellness. To that end, TCMS is cosponsoring this upcoming conference. Please SAVE THE DATE and watch for additional information: Moving from Surviving to Thriving Conference for Health Care Professionals December 5-6, 2018 at the Crowne Plaza in Plymouth, Minnesota.

September/October 2018

John Misa, MD, Senior Medical Director Beth Averbeck, MD, Senior Medical Director

Meet the Wizard behind the curtain Linking electronic health records with web-based, clinical decision support systems can significantly improve chronic disease care. Clinicians at HealthPartners and Park Nicollet have found success using Priorities Wizard to help manage cardiovascular, diabetes and opioids-related conditions. HealthPartners Institute is one of the largest medical research and education centers in the Midwest. Weâ&#x20AC;&#x2122;re part of an integrated health care organization that includes hospitals, clinics and a health plan. Our teams are helping transform health care across the nation.

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#EndGunViolence

Colleague Interview: A Conversation with Senator Scott Jensen and Senator Matt Klein

Editorâ&#x20AC;&#x2122;s Note: Minnesota is fortunate to have two physicians serving as Senators in the state legislature. For this Colleague Interview, weâ&#x20AC;&#x2122;ve invited Drs. Scott Jensen and Matt Klein to respond to a few questions about their journey to and experience at the legislature.

ENATOR 3COTT *ENSEN -$ 2 $ISTRICT MOVED TO #ARVER #OUNTY YEARS AGO TO RAISE A FAMILY AND CARE for patients with integrity and wisdom. He received his medical degree from the University of Minnesota Medical School and completed a Family Medicine Residency at the Senator Scott Jensen Senator Matt Klein University of Minnesota. He is board certiďŹ ed in Family -EDICINE )N $R *ENSEN RECEIVED THE PRESTIGIOUS AWARD Minnesota Family Physician of the Year, from the Minnesota Academy of Family Physicians, and was elected to the Minnesota State Senate. -ATT +LEIN -$ IS A $&, STATE SENATOR REPRESENTING $ISTRICT AND A PRACTICING PHYSICIAN AT (ENNEPIN #OUNTY -EDical Center, an Assistant Professor of Internal Medicine at the University of Minnesota, and a Fellow in the American College of Physicians. Dr. Klein received his medical degree at Mayo Medical School in Rochester, MN and completed an Internal Medicine residency at Hennepin County Medical Center, Minneapolis, MN. Born and raised in St. Paul, Senator Klein and his wife, Kris, live in Mendota Heights with their ďŹ ve children.

What made you decide to pursue a career in medicine? Sen. Jensen: I am fascinated by the intersection of compassion and science in caring for the concerns and maladies of others. Helping people optimize their health in regard to mind, body, and spirit is a high calling. The challenge of listening to a patientâ&#x20AC;&#x2122;s words â&#x20AC;&#x201D; spoken and unspoken â&#x20AC;&#x201D; is an art and provides daily growth and satisfaction. Sen. Klein: I was an English major in my sophomore year of college when I went to the Emergency Department with a cut on my forehead after a fall. The work of the resident who stitched me up inspired me. During a 30-minute visit he impressed me as caring, erudite, hopeful and purposeful. I donâ&#x20AC;&#x2122;t even remember his name, but I went to the University counselorsâ&#x20AC;&#x2122; ofďŹ ce the next MetroDoctors

The Journal of the Twin Cities Medical Society

day and changed my major. Two years later I was admitted to Mayo Medical School and I have never regretted it.

Please describe your practice. Sen. Jensen: Itâ&#x20AC;&#x2122;s an independent primary care clinic. I did a Bush Fellowship in Dermatology and Plastic Surgery in the 1990s, so a considerable part of my practice is in-ofďŹ ce skin surgery for potential cancers. Sen. Klein: Currently I work nights as an Internal Medicine Hospitalist at Hennepin County Medical Center. I admit patients from the Emergency Department and work with the residents on ICU admissions. (Continued on page 8)

September/October 2018

#EndGunViolence Colleague Interview (Continued from page 7)

What made you decide to run for public office? Sen. Jensen: A widespread encouragement by people in business and healthcare fields pushed my wife, Mary, and I into saying “yes” to this political journey. I was intrigued by the possibility of having a broader impact than simply one-on-one medical care. There hadn’t been a physician in the Senate for 25 years and the escalating role of government in medicine contributed as well. I thought I could have a meaningful impact on how we legislated medical care and health insurance. Sen. Klein: My work as a night hospitalist, or nocturnist, means that my medical career is uniquely contained, allowing me to pursue other interests. As my five kids passed through our local middle school, I became active in forming a parent group to improve the school. This led to a successful run for school board in 2013. I found that I was able to balance a political career with my medical work, and I sensed that a doctor would have a unique perspective to bring to government service. I ran for state senate in 2016.

In what ways does your medical background help to inform policy at the state legislature? Sen. Jensen: In medicine there is a huge premium on being able to listen and read between the lines. Those are skills that are immensely helpful in the legislature as well. Additionally, I think that the internal gnashing of teeth that we do as physicians when we deal with a difﬁcult patient or a patient who doesn’t respond as expected helps up grow as individuals and helps us understand the long view. This ability to see the long view helps me in the legislature. I might not be able to get done what I want done this session, but I may have helped set the stage for the next session. Understanding the reality of incremental progress provides some measure of comfort amidst the remarkable frustrations in the world of partisan politics. Sen. Klein: I believe physicians are uniquely positioned to elevate the work of the legislature. We take an evidence-based and teambased approach to problem solving and are trained to set our own pride aside in pursuit of best solutions. In addition, in our current political climate, science is unfortunately under attack. We need thoughtful people to stand up for scientiﬁc inquiry and discovery on a wide range of issues, from vaccination to gun violence; from opioids to sulfate standards.

September/October 2018

There are several public health topics currently receiving significant attention and legislative debate. Could you address how your experience as a physician impacts your role in these debates? Raising the legal age for tobacco product sales to age 21, for instance. Sen. Jensen: This issue prompts me to realize the need to be thoughtful. As a physician, the immediate thought might be to do whatever it takes to reduce the amount of tobacco used in our society. But on another level, I ask the question, “What do we ask of our 18-21 year olds today?” We ask them to protect our borders, fight on our behalf, put their lives on the line and live in lands and conditions which we would never want to experience. So, the idea of telling a 20-year-old soldier who smokes an occasional cigar that he can’t buy one seems demeaning. The question of personal liberties enters the discussion as well as the question, “What is the age of adulthood?” I would prefer to read any actual proposals before making a knee-jerk decision. Sen. Klein: The issue of raising the tobacco age to 21 has brought my role as a physician into conflict with my ideas about my role as a legislator. There is no question that raising the tobacco purchase age would decrease morbidity and mortality from tobacco use, improve public health and decrease medical costs. I have struggled to balance that knowledge with a respect for individual autonomy, and the right of every Minnesotan to make their own decisions, good or bad. A citizen who is 18 years old generally has the capacity to understand risks of tobacco use and is currently empowered to tolerate those risks at her own discretion. I am reluctant to limit that freedom by statute. Attempts to legislate good health habits have a mixed history — seat belt laws have CHANGED SEAT BELT CULTURE AND IMPROVED MORTALITY AND A .EW 9ORK City ban on trans fats has saved lives. However, a prohibition on alcohol in America was an abysmal failure which had no impact on alcohol use or mortality and spawned a criminal culture which we have never eliminated.

What about gun control regulations, e.g. universal background checks, limiting sales of semi-automatic, military-style weapons, collection of data for public health and epidemiologic investigation? Sen. Jensen: It’s remarkable that we allow organizations that have a powerful vested interest in maintaining the status quo to dominate the very discussion of a significant problem. The declaration that we should not be able to study gun-related deaths is sad and disappointing. Regarding the purchasing age for some specific semi-automatic weapons, this is a ‘slippery slope.’ It should be remembered that many folks use semi-automatic long guns to hunt pheasants and ducks. We need to define terms, be careful of unintended consequences, and try to understand perspectives other than our own. MetroDoctors

The Journal of the Twin Cities Medical Society

In terms of background checks, I understand that people are fearful there might be an agenda directed at trying to constrain or reduce the personal right to bear arms. I’ve always been a strong believer in the Bill of Rights and the 2nd Amendment, but I think both sides of the issue must work to identify common ground which might contribute to decreasing the senseless mass shootings in our country. The highest priority should be to ﬁgure out how to keep guns out of the hands of those few people who simply should not have them — the NRA and gun control advocates have both gone on record that this is of paramount importance. This past legislative session I provided lukewarm support to the discussion of some very preliminary proposals so that there could be bipartisan traction to expand the boundaries of dialogue. I didn’t realize how intense the reaction would be to my willingness to embrace a conversation, but when my social media numbers neared 50,000 ‘hits,’ I realized I had truly kicked a hornet’s nest of major proportion. When the local county sheriff told me there were threats on my life, and his deputies would be modifying the way they patrolled my neighborhood, I was astonished. Similar death threats occurred at the capitol — I really don’t understand how our country became so polarized and divided. I still believe expanding the use of background checks through a voluntary, no-cost mechanism through local sheriff ofﬁces with no registration records could be helpful in keeping guns out of the hands of ‘prohibited’ persons. The fact of the matter is that many churches utilize background checks before they hire Sunday School teachers. I’ve always been a gun owner and a person who likes to hunt, but I will be damned if I will allow political rhetoric from preventing me from discussing issues that many of my constituents want discussed. Sen. Klein: I have no such qualms about advocating for gun safety and gun violence prevention, which is a clear case where individual liberties must be balanced with societal risk of harm. Over 30,000 people die in gun violence each year; those people and their families have a reasonable expectation that legislators will work urgently to reduce that number. I traveled to the March for Our Lives in Washington, D.C. this year with my daughter, Emily, who is a sophomore at Henry Sibley High School in Mendota Heights. Standing with hundreds of thousands of young people, demanding that our schools should be a safe place to learn, was a life-changing experience. Current Minnesota statute prohibits the department of health from gathering data on gun ownership. I have authored a bill which would remove that prohibition and allow the department of health to study gun violence as a public health problem. The bill did not receive a hearing in either of the Republican-controlled chambers this year and was vigorously opposed by the gun lobby. I will continue to pursue this legislation passionately.

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What advice would you give to health professionals who wish to advocate for legislative policy changes? Sen. Jensen: I think they need to get off their backside — get engaged! The inclination to sound off in small quarters but do nothing is hypocritical. Physicians undersell their impact. Most doctors will be well received by local legislators if they make a phone call to express their concerns and views. Physicians can impact public policy and they should. It also wouldn’t hurt to go to an occasional political event, meet people, shake hands, and gain an understanding of the political and legislative process. Some physicians just don’t realize how much impact they have, and they get frustrated because the political process seldom grants what you seek — it is generally a long slog of discussion, compromise and irritation. Its very nature is to impede action, but I would remind physicians that in the early 1990s when the “Gang of Seven” established MinnesotaCare, there were no physicians at the table. That was not accidental — “you reap what you sow.” Sen. Klein: Health professionals should visit their legislators and share their stories. Their experiences and education lend tremendous credibility to their advocacy and can change the course of our state. We face a number of issues as a state which require the input of trained health professionals. In the absence of that input, these decisions are susceptible to political calculations or crass populism.

In what way(s) can your physician colleagues support you in your work at the capitol? Sen. Jensen: They can contact me and let me know what their views are. Personal contacts are better than a pre-printed post card. They can ask me how they can help. I would appreciate that and might suggest that they call such-and-such legislator and express their perspective. I would not waste their time. Just because I happen to be the one with Senator in front of my name doesn’t mean that it’s all on me to address the problems. We’re in this together, and if people aren’t willing to be involved then they’re just — as Teddy Roosevelt said — “sitting in the cheap seats.” Maybe they could get in the arena and get dirty right alongside me — I would welcome that level of activism. Sen. Klein: I hope my physician colleagues follow my work on social media and in my weekly newsletters during session. I will use these outlets to update my work on all issues, particularly health related issues. Physicians who wish to pursue or advocate on any subject should contact my ofﬁce and my legislative assistant, Mike Purtell, will help them ﬁnd opportunities to express themselves at the Capitol. My senate email is sen.matt.klein@senate.mn.

September/October 2018

#EndGunViolence

Preventing Firearm Deaths: Counseling on Access to Lethal Means (CALM) While the common public perception may be that homicide is the most frequent cause of firearm deaths in Minnesota and nationally, suicide is actually the most common firearm-related death. In Minnesota, almost 80% of firearm deaths are suicides.1 In 2016, there were 432 firearm deaths in Minnesota (age-adjusted rate of 7.6 per 100,000) — 332 were suicides (5.7 per 100,000) and 83 were homicides (1.6 per 100,000). Nationally, in 2016, there were 38,658 firearm deaths (11.8 per 100,000) with 22,938 suicides (6.8 per 100,000) and 14,415 homicides (4.6 per 100,000). While Minnesota had a suicide-to-homicide firearm death ratio of 4 to 1 in 2016, the U.S. experienced a ratio of 1.6 to 1.

times more likely to die by homicide than Whites (29.5 per 100,000 and 3.2 per 100,000). Overall, White and Black Minnesotans fare better than U.S. White and Black populations. The U.S. White population is 1.4 times more likely to die by a ﬁrearm compared to White Minnesotans (rate of 10.0 per 100,000 and 6.9 per 100,000, respectively). The U.S. Black population is 1.6 times more likely to die by a ﬁrearm compared to Black Minnesotans (rate of 19.4 per 100,000 and 11.8 per 100,000, respectively). Due to small numbers, we were unable to calculate reliable rates for other racial groups.

Firearm Deaths by Gender, 2016

Firearm deaths vary by gender, race and geography. While males experience the majority of firearm deaths, both in Minnesota and nationally, Minnesota males had a much lower firearm death rate compared to the overall U.S. male population. In 2016, 376 Minnesota males died of firearm deaths (rate of 13.3 per 100,000); 80% of these were suicides. In the U.S., there were 32,994 firearm deaths for males (rate of 20.5 per 100,000) and 60% of these were suicides. Minnesota female firearm death rates are similar to overall U.S. rates. In Minnesota, 56 females died by firearm in 2016 (2.1 per 100,000), and 57% were suicides (1.2 per 100,000). In the U.S., 58% of all female firearm deaths were suicides (1.9 per 100,000). By Melissa Heinen, BSN, MPH, Terra Wiens, MPH, Jon Roesler, MS, and Stephanie J. Anderson

September/October 2018

Firearm Deaths by Race, 2014-2016

When analyzing firearm deaths by race, Whites are more likely to die by suicide than homicide, and Blacks are more likely to die by homicide than suicide. In Minnesota, 87% of White firearm deaths are suicides compared to 15% of Black firearm deaths. Among males, White males are 3.1 times more likely to die by suicide than Black males (rate of 10.7 per 100,000 and 3.4 per 100,000, respectively), and Black males are 18 times more likely to die by homicide than White males (rate of 16.2 per 100,000 and 0.9 per 100,000, respectively). Nationally the racial disparity among males is not as great. Among U.S. males, Whites are 2.5 times more likely to die by suicide than Blacks (13.3 per 100,000 and 5.3 per 100,000) and Blacks are 9.2

Firearm Deaths by Geographical Location, 2015-2016

Firearm deaths vary greatly by geographic region in Minnesota and compared to

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U.S. populations. Nationally, metropolitan residents are 1.3 times more likely to die by suicide as homicide (rate of 6.0 per 100,000 and 4.5 per 100,000, respectively). In Minnesota, metropolitan residents are 2.7 times more likely to die by suicide than homicide (4.9 per 100,000 compared to 1.8 per 100,000). Minnesota’s nonmetropolitan ﬁrearm deaths are 85% suicides, compared to 74% for nonmetropolitan ﬁrearm deaths nationally.

Suicide Prevention in Minnesota

Preventing suicides in Minnesota will reduce ﬁrearm deaths. According to the Centers for Disease Control and Prevention (CDC) Vital Signs Report “Suicide Rising Across the U.S.,” the suicide rate in Minnesota has increased 40% since 1999 to 745 suicides in 2016, making it the eighth leading cause of death in Minnesota (suicide is the 10th leading cause of death nationally).2 Minnesota is approaching the national rate of 13.5 per 100,000, with a rate of 13.2 per 100,000.1 The Minnesota Suicide Prevention Plan calls for a 10% reduction in suicide in ﬁve years, a 20% reduction in 10 years and ultimately working toward zero suicide deaths in Minnesota.3 This call to decrease suicide is based on the evidence that suicide is preventable, mental illness is treatable and recovery is possible. MetroDoctors

Suicide Prevention: Health Care’s Role

In February 2018, the Minnesota Department of Health (MDH) held its first Zero Suicide Academy. There are 16 health and behavioral healthcare agencies across the state implementing Zero Suicide, which is a system-wide approach to improve outcomes and close gaps to decrease suicide deaths. Learn more about Zero Suicide at www.zerosuicide.com. Zero Suicide is an organizational commitment to patient safety through safe suicide care and begins the moment a patient walks through the door. A key component of patient safety is clinician and staff trainings. In primary care settings, physicians, nurses, nurse practitioners, physician assistants, paraprofessionals and administrative staff should be trained to recognize risk factors and warning signs and be expected to follow policies and protocols for referring and managing patients at risk for suicide. All people identified at risk of suicide need to have a safety plan (http:// zerosuicide.sprc.org/toolkit/engage), and every safety plan needs to address limiting access to lethal means. Firearms are the most lethal and most common method of suicide in Minnesota. There is overwhelming evidence that access to a firearm is a risk factor for death by suicide.4 While firearm owners are not more likely to attempt suicide, suicide attempts with a firearm are more likely to be fatal than attempts by other means. Most people who attempt suicide are ambivalent about dying and decide to attempt during a short period of crisis. Therefore, limiting access to lethal means during a time of crisis can possibly delay and perhaps prevent the attempt, thereby increasing the likelihood a person will not attempt or will survive the attempt. Ninety percent of those who attempt suicide do not go on to die by suicide later. Rather, they find hope and help.5 Limiting access to lethal means is an effective strategy to prevent suicide deaths. The Suicide Prevention Resource Center offers free online training — Counseling on Access to Lethal Means (CALM) — to teach providers how to ask patients/clients at risk for suicide about their access to lethal means and work with them and their

The Journal of the Twin Cities Medical Society

families to reduce their access. (https:// www.sprc.org/resources-programs/ calm-counseling-access-lethal-means). Limiting access to lethal means is just one strategy in a comprehensive approach. Primary care providers can take action to reduce suicide by using the Suicide Prevention Toolkit for Primary Care Practices (http://www.sprc.org/settings/ primary-care/toolkit). Minnesota Firearm Deaths: Understanding the Facts

To better understand Minnesota firearm deaths and prevent them, we need to understand the facts. MDH is working with CDC to collect and analyze information about violent deaths in Minnesota through the Minnesota Violent Death Reporting System (MNVDRS). MNVDRS collects data on all homicides, suicides, firearm deaths and deaths of undetermined intent in Minnesota. MNVDRS gathers information from death certificates and death investigation reports from medical examiners, coroners and law enforcement to understand better the circumstances surrounding the death. MDH uses these data to identify themes to see where to improve systems and intervene to prevent these deaths. MDH believes that suicide deaths will decrease with greater awareness and by partnering across systems to implement comprehensive suicide prevention. The analysis presented in this article was derived from the Minnesota Violent Death Reporting System (MNVDRS), which does not collect data on individuals regarding lawful firearm ownership or data related to an individual’s right to carry a weapon. Melissa Heinen, BSN, MPH, Minnesota Violent Death Reporting System Epidemiologist, and the Director for the Community Partners Preventing Suicide Project; Terra Wiens, MPH, CSTE Fellow, Drug Abuse Epidemiologist; Jon Roesler, MS, Epidemiologist Supervisor; and Stephanie J. Anderson, MDH Injury Section Communications Coordinator. References available upon requst.

September/October 2018

#EndGunViolence

The Second Amendment in Historical Context

he Second Amendment, one of a package of rights that the states adopted in 1791 as the Bill of Rights, is perhaps the best known, yet least understood, constitutional amendment. These Amendments, proposed by James Madison, passed by Congress and ratiﬁed by the states, were a compromise between the pro-Constitution Federalists and the anti-Constitution Anti-Federalists. In his initial draft of the Second Amendment, presented to Congress on June 8, 1789, Madison proposed: “The right of the people to keep and bear arms shall not be infringed; a well armed (sic) and well regulated (sic) militia being the best security of a free country: but no person religiously scrupulous of bearing arms shall be compelled to render military service in person.”1 Madison, a Virginian, began with a relatively clear statement about an individual right to bear arms, which was widely understood in the South to refer only to white, male, property-owning pro-slavery citizens. But Congress was deeply split on the question of slavery, and in order to pass Congress, therefore, the language had to be less direct. On September 24, 1789, the House of Representatives passed a more convoluted version: “A well regulated (sic) militia, composed of the body of the People, being the best security of a free State, the right of the People to keep and bear arms, shall not be infringed, but no one religiously scrupulous of bearing arms, shall be compelled to render military service in person.”2 Here, the individual right of slave-owning citizens appears after the more ambiguous clause protecting the right to organize a well-regulated militia. A day later, the Senate reﬁned the language further and passed: “A well regulated (sic) militia, composed of the body of the People, being the best security of a free State, the right of the People to keep and bear arms, shall not be infringed.” Finally, both houses of Congress agreed to cut the second clause and passed the version that we know today: “A well regulated Militia, being

By Matthew Filner, PhD

September/October 2018

necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” The ﬁnal language of the Second Amendment was intentionally left open to interpretation so that it could pass Congress with the necessary two-thirds vote and be ratiﬁed by three-quarters of the states, within which there was substantial disagreement. With the experiences of the Revolution and unrestrained monarchy, Anti-Federalists feared that the federal government would become too strong,3 and Federalists such as Madison and Alexander Hamilton feared unrestrained and armed citizens.4 Northerners interpreted the Second Amendment as protection against the twin threats of unrestrained government and unrestrained citizens, while pro-slavery Southerners interpreted the Second Amendment as a guarantee that the federal government could not prohibit “citizen’s militia,” organizations whose primary role was to quell slave rebellions and police debtors.5 Throughout the 19th and 20th centuries, the Supreme Court emphasized the “collective right” interpretation of the Second Amendment. In cases such as United States v. Cruikshank (1875), Presser v. Illinois (1886), and United States v. Miller (1939), the Court interpreted the Second Amendment

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as preserving the right for a state to maintain a militia, but not protecting the right of individuals to bear arms. In Miller, for example, the Court upheld a section of the National Firearms Act which banned “dangerous and unusual weapons” (e.g., sawed off shotguns) and stressed the “preservation of a well regulated (sic) militia.” It was not until 2008, in District of Columbia v. Heller (2008), that the Court overturned over 200 years of constitutional interpretation and declared an individual’s constitutional right to bear arms. In Heller, the Supreme Court declared that the right to bear arms is an individual right and thus rewarded a decades-long effort by pro-gun organizations to transform the way Americans view the Second Amendment.6 In the words of Justice Antonin Scalia, author of the majority opinion in Heller: “Nowhere else in the Constitution does a ‘right’ attributed to ‘the people’ refer to anything other than an individual right” (554 U.S. 570). This “individual right” interpretation governs gun-related statutes in the United States today. However, in both interpretations of the Second Amendment, the Supreme Court has consistently ruled that all rights have limits. As Justice Oliver Wendell Holmes wrote in Schenck v. United States (1919), freedom of speech does not extend to creating a “clear and present danger” for others. Justice Scalia agreed: “Thus, we do not read the Second Amendment to protect the right of citizens to carry arms for any sort of confrontation, just as we do not read the First Amendment to protect the right of citizens to speak for any purpose” (554 U.S. 570). Justice Scalia further noted that it was constitutional to “prohibit the carrying of dangerous and unusual weapons,” and that the Court’s opinion should not be taken to cast doubt on longstanding prohibitions on the possession of firearms by felons and the mentally ill, or laws forbidding the carrying of firearms in sensitive places such as schools and government buildings, or laws imposing conditions and qualifications on the commercial sale of arms. The story of the Second Amendment interpretation is thus not dissimilar from that of the Constitution itself: vague and contestable language had led to interpretation through a political lens that had changed focus over time. Thus, history

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belies the claim that there is a single, definitive and correct interpretation of the amendment. It remains contested to what extent governments can take steps to identify felons and the mentally ill, and it remains contested which weapons an individual may bear. However, the Supreme Court has clearly stated that the Second Amendment includes within it a constitutional mechanism to prohibit certain individuals with particular characteristics from bearing arms, and the types of arms that individuals may possess and carry can likewise be limited. Matthew F. Filner is an Associate Professor of Political Science and Chair of the Social Science Department at Metropolitan State University. Professor Filner holds a PhD in political science from Indiana University and teaches courses in constitutional law and political philosophy. In 2015-16, Professor Filner was a Fulbright scholar in Japan, where he taught courses on American constitutional law and global politics. He has published articles in journals such as Polity, The State and Local Government Review, the International Journal of Interdisciplinary Cultural Studies, a chapter of Democracy’s Edges, a chapter in the recently published Future Courses in Human Societies, and is a regular contributor to the online journals Public Seminar and MinnPost. He can be reached at matthew.filner@metrostate.edu or (651) 793-1850. (Endnotes) 1. https://www.archives.gov/legislative/features/bor. 2. https://www.archives.gov/legislative/features/bor. 3. Notably, see Dissent of the Pennsylvania Minority (1787), and Richard Henry Lee’s Letters from the Federal Farmer (1787), both available in Michael Cummings, ed. American Political Thought, Washington, DC: CQ Press, 7th edition (2015). 4. The most notable example of the dangers of unrestrained, armed citizens was Shays’ Rebellion, in which Daniel Shays and the four thousand armed men attempted to overthrow the weak federal government in 1786. For more detail on Shays’ Rebellion, See the Massachusetts Historical Society, https://www.masshist.org/object-of-the-month/may-2013. 5. For more detail on how Southerners viewed the Second Amendment, see Saul Cornell and Eric M. Ruben, “The Slave State Origins of Modern Gun Rights,” The Atlantic, September 30, 2015. https://www.theatlantic.com/ politics/archive/2015/09/the-origins-of-public-carry-jurisprudence-in-theslave-south/407809/. 6. For a detailed history of the NRA’s effort to change the public debate over the Second Amendment, see for example Adam Winkler, Gunfight: The Battle Over the Right to Bear Arms in America, New York: W.W. Norton (2013).

September/October 2018

#EndGunViolence

Band-aids and Bullet Holes: a Trauma Surgeonâ&#x20AC;&#x2122;s Perspective h) M $R -AREK 9OU DON T REMEMBER me, but I am the surgeon who operated on you.â&#x20AC;? This is a sentence Iâ&#x20AC;&#x2122;ve uttered often. Itâ&#x20AC;&#x2122;s what you must say when youâ&#x20AC;&#x2122;re a trauma surgeon whose patients are many times so sick they donâ&#x20AC;&#x2122;t remember their stay in the hospital. In my surgery clinic where he returned to see me in follow-up, I examine my patientâ&#x20AC;&#x2122;s incisions which have long healed. I removed his tracheostomy. This, heâ&#x20AC;&#x2122;s most excited about. Heâ&#x20AC;&#x2122;s been off the ventilator and out of the hospital for a month now. His mother asks me to remind her how many times he was shot, as if to emphasize to her son how lucky he is to be alive. â&#x20AC;&#x153;Thirteen,â&#x20AC;? I say, then quickly clarify that while he had 13 bullet holes, I am not sure exactly how many times he was shot. I calculated that it was probably 7 to 9 based on the bullet fragments remaining and trajectories I had traced out in the operating room. Many of the wounds, I explained, are entrance and exit wounds from the same bullet. When patients sustain penetrating trauma such as a gunshot wound, they are in and out of our stabilization bay quickly. Sometimes itâ&#x20AC;&#x2122;s off to the CT scanner to identify or rule out injuries if the patient is stable. The unstable patients head straight to the operating room. I remembered this patientâ&#x20AC;&#x2122;s emergency department stay well because as the number of holes I counted increased, By Ashley Marek, MD

September/October 2018

so did my dread. What was injured? What would I have to ďŹ x? Could I do it in time? My eyes darted between the monitor showing his vital signs and the organized chaos around me. We had only a few minutes to gain as much information as we safely could before whisking him to the operating room, which was already preparing for our arrival. The residents were placing a chest tube to evacuate blood in his chest while the staff emergency medicine doctor was looking at the patientâ&#x20AC;&#x2122;s heart with the ultrasound. There was no blood around the heart. I breathed a sigh of relief. We had bought a little more time to ďŹ gure out where all those bullets had ripped through his body and could plan my incision. Minutes later, after intubation, IVs, X-rays, and with blood transfusions ďŹ&#x201A;owing,

we were packaged up for the OR with as much information as I was going to get from the outside of the patient. Mass shootings make the news and spark national outrage, but this is my day-to-day. Penetrating trauma makes up about 12% of the trauma patients we admit at Hennepin Healthcare, with gunshot wound comprising about half of that. The number may seem small, but these patients leave a lasting impact on the healthcare systems and workers who treat them. Advocates for gun rights say that it is the intent and not the weapon that causes these deaths; if someone really wants to do harm to another person, they will ďŹ nd a way. This sentiment is misguided for several reasons. In seconds, a gun allowed one person to put 13 bullet holes in my patient. We know the mortality of gunshot wounds is higher than for other traumatic mechanisms. It is well-published in the literature and reďŹ&#x201A;ected in our own data. In 2016, for example, the mortality rate for gunshot wounds at our center was 11.3% while mortality for our entire trauma population was only 3.8%. Victims of ďŹ rearm injury tend to be sicker and have a higher cost of care. At Hennepin, those patients are a higher proportion of our total cost of treating trauma. To compound the issue, in 2016, an astounding 65% of gunshot wound victims were on Medicaid, compared to 29% of patients in the general trauma population. When one considers the reimbursement rate

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for Medicaid is between 25-35% and commercial insurance is around 50%, the math is clear — gunshot wounds are more deadly and expensive than other types of trauma. According to the Minnesota Department of Health, 432 people died from ﬁrearm injuries in 2016 in Minnesota. Most patients never make it to a hospital. This is because in stark contrast to the most common type of injury we see at

number. Population-rich states like New 9ORK #ALIFORNIA AND )LLINOIS INTERESTingly are on the low end of the list with Minnesota. Mortality is well measured, but disability from injury is not. Many patients are permanently disabled after sustaining a gunshot wound. For those who are able to walk away physically unscathed, the emotional toll remains. And in some cases, patients walk out of the hospital

In a 2017 study of our patients at Hennepin who sustained assault, patients with gunshot wounds at each successive admission were at the highest risk of mortality compared to recidivists with other mechanisms of interpersonal violence.

Hennepin (where around two thirds of firearm injuries are secondary to assault), the overwhelming majority of firearm deaths in the rest of the state and nation are from suicide. A study of gun violence in the United States from 2015 found that 85% of people who use a firearm to attempt suicide die from their injury while only about 20% of people die after firearm-related assaults. The death rate from firearm injuries in Minnesota is low compared to other states. According to the CDC, we are number seven in the nation with firearm deaths at 7.6 per 100,000 population. In states like Alaska, Louisiana, Alabama, Mississippi, and Montana, the death rate is more than double that MetroDoctors

into an unsafe environment again. In a 2017 study of our patients at Hennepin who sustained assault, patients with gunshot wounds at each successive admission were at the highest risk of mortality compared to recidivists with other mechanisms of interpersonal violence. The gun control debate is a polarizing issue but there is no question that ﬁrearm injury is a healthcare crisis in the United States. We own half of the world’s guns and are 25 times more likely than other developed countries to die from them. That’s why the American Medical Association, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the

The Journal of the Twin Cities Medical Society

American College of Physicians and the American Psychiatric Association have stepped forward calling for gun reform. While most Americans support some degree of gun regulation, it is imperative that we come at the problem from all angles. Better mental healthcare affordability and accessibility is a start to prevent the 60 to 70% of gun deaths that occur from suicide. Second, we must support programs such as Next Step, a hospital-based violence intervention partnership between the City of Minneapolis and Hennepin Healthcare. In 2017, Next Step provided services to 98 young adult victims of trauma to help them recover and break the cycle of violence. Since its inception, only 3% of participants in the program have been treated again for violent injuries. While vital to their recovery, my patients’ circumstances are initially less important to me than the number of holes that I have to quickly sort out in the operating room. I eventually got to know my patient’s family who told me he had been in some trouble in the past and was trying, in the middle of his life, to start over. With help from his church, he had just started a new job. Then, 13 bullet holes happened. He ended up with an incision from his neck to his groin and a month-long ICU stay, dependent on a ventilator to keep him alive. I don’t know if he was able to start over after I saw him for his last clinic visit. I can only hope that he did, because the data tells us he might not be so lucky next time. Ashley Marek, MD practices General and Trauma Surgery as well as Critical Care at Hennepin Healthcare. She completed a General Surgery residency at HCMC as well as a Surgical Critical Care fellowship at the University of Minnesota. She is board certiﬁed in General Surgery and Surgical Critical Care. September/October 2018

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Gun Violence is More Than Mass Shootings and Mental Illness Contributed by Adnan Ahmed, MBBS

KNEW IT WAS A DRILL 9ET AS ) HEARD THE â&#x20AC;&#x153;active-shooter drillâ&#x20AC;? announcement on the overhead paging system, the thought that this could actually happen at my workplace â&#x20AC;&#x201D; a hospital and an academic learning center â&#x20AC;&#x201D; became very real. It made me sick. I have never been in a life-threatening situation. If going through an active shooter drill provoked so much anxiety for me, a trained psychiatrist, I cannot imagine what this must be like for children, or even adults. Active shooter drills have not been studied in detail, but critics say they have detrimental psychological effects because they heighten our anxiety while preparing us for a rare scenario.1 This experience made me think about how active shooters came to be this unpredictable hazard warranting an emergency preparedness plan. The purpose of emergency preparedness drills is typically to ensure safety in the face of an unpredictable event that can potentially result in mass casualties. These include events that are typically beyond our control such as earthquakes, tornadoes, ďŹ&#x201A;oods, or ďŹ res. The inclusion of active shooter drills in our emergency preparedness plans after the Columbine massacre in 19992 is a telltale sign that preemptive measures to curb gun violence have so far been insufďŹ cient. In order to understand how we got here, we need to look at the conďŹ&#x201A;icting information that supports our diverging opinions on gun violence. The news media plays a key role in shaping our opinions about and reactions to gun violence. Although mass public 16

September/October 2018

shootings can dominate the news for days when they happen, many other forms of gun violence are more common but do not generate the same kind of media frenzy. For instance, of the 36,252 ďŹ rearm deaths in the United States in 2015, as reported by the Centers for Disease Control and Prevention (CDC), nearly two-thirds were suicides.3 We all want to be safe from gun violence, but there is bitter division on how we should accomplish that goal. To begin with, there is no consensus on what constitutes a mass shooting. People use either a broad or a narrow deďŹ nition that best aligns with their views. For example, Gun Violence Archive, a nonproďŹ t organization, deďŹ nes â&#x20AC;&#x153;mass shootingâ&#x20AC;? as an event where at least four people are shot and/or killed â&#x20AC;&#x201D; excluding the shooter â&#x20AC;&#x201D; in a single incident, at the same time and location.4 On the other hand, the Congressional Research Service (CRS), in its 2015 report, deďŹ ned â&#x20AC;&#x153;mass shootingâ&#x20AC;? as a ďŹ rearm homicide incident in which four

or more victims are murdered, in one event â&#x20AC;&#x201D; not including the shooter, and in one or more locations that are in close proximity.5 The CRS report differentiated a mass shooting from a mass public shooting by specifying that a mass public shooting had to occur in a public location and the murders could not be related to criminal activity, argument, or a romantic triangle. CRS also deďŹ ned â&#x20AC;&#x153;familicide mass shootingsâ&#x20AC;? and â&#x20AC;&#x153;other felony mass shootingsâ&#x20AC;? as additional categories of mass homicides involving ďŹ rearms.6 The lack of an agreed-upon deďŹ nition yields different statistics and creates a situation where we may be debating similar, but not the same, phenomena without realizing it. Not surprisingly, whether mass shootings have increased over time depends on whom you ask.7 Grant Duwe, research director for the Minnesota Department of Corrections, recently wrote in Politico magazine that mass public shootings have not increased but have gotten deadlier over time.8 In contrast, according to Mother Jonesâ&#x20AC;&#x2122; database of mass shootings, both fatalities per mass shootings as well as the incidence of mass shootings have increased over time.9 As for the causes of mass shootings, mental illness is often incorrectly viewed as the culprit. However, those who claim mass shootings have nothing to do with mental illness are also mistaken. The truth falls outside the realm of absolutes. The vast majority of individuals with mental illness are not violent and are more likely to be victims of violence.10 Individuals with mental illness are responsible

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for only about 3% to 5% of all violence in the United States.11 An even smaller fraction â&#x20AC;&#x201D; 1% â&#x20AC;&#x201D; have a history of using ďŹ rearms against others.12 The presence of mental illness alone does not imply an increased risk of future violence. The incidence of violent behavior in people with mental illness is higher only when there is comorbid substance use.13 People with mental illness tend to report poor social support and adverse life events, which are independent risk factors that increase violence risk.14 15 These risk factors are often manageable with treatment and support, thereby reducing the risk of violence. Portraying mass shootings as a direct result of mental illness without considering contributing factors is misguided and perpetuates unnecessary stigmatization of people with mental illness. It is also dangerous, as it detracts from actual risk factors and potential solutions that could effectively address gun violence. In the book Gun Violence and Mental Illness, a national group of mental health professionals, academics, risk management professionals and others, recently collaborated to craft practical measures to address gun violence on an individual, community and public policy level. Their proposed measures include: s 3AFE GUN STORAGE AND USE OF GUNS THAT can only be ďŹ red by authorized users; s 4RAINING PROFESSIONALS TO OFFER SUPPORT and guidance and perform risk assessments of individuals deemed at-risk for perpetrating violence (regardless of mental illness); s 0REVENTING INDIVIDUALS WHO ARE AT HIGH risk of committing violence from purchasing guns and stopping the illegal possession of ďŹ rearms, regardless of presence of mental illness; s 4HIRD PARTY REPORTING BY FAMILY MEMbers and intimate partners who may have concerns or special knowledge about dangerousness; s ! RESPONSIBLE AND UNIVERSAL REPORTING code by the media that focuses on survivors and community efforts instead of glorifying the perpetrator; and s 0UBLIC HEALTH PROGRAMS AND CONTINUED research to study gun violence trends and effectiveness of safety initiatives to curb gun violence.16 17 MetroDoctors

The â&#x20AC;&#x153;Reducing Gun Violence Policyâ&#x20AC;? statement adopted by the Twin Cities Medical Society in March 2018 incorporates additional steps, including banning assault weapons, increasing the minimum age for ďŹ rearm purchase, closing the Minnesota loophole that allows private sellers to sell ďŹ rearms without a background check, and collecting data about gun violence. Today, we in the United States, ďŹ nd ourselves as the focus of international attention as we debate how to end mass shootings. The debate is analogous, and perhaps simplistically so, to a team of mechanics trying to ďŹ x a broken car. Everyone KNOWS THAT THE CAR IS BROKEN 9ET NO ONE can ďŹ x it because they cannot identify the broken part. It may be worth considering here that this car may have more than one part in need of repair. Gun violence is not unlike the car with many broken parts. Mass shootings are just one deadly manifestation of the public health crisis that is gun violence. Countering it warrants many solutions including cooperation across the political aisles, intellectual honesty and robust research to end all forms of gun violence â&#x20AC;&#x201D; not just mass shootings. Dr. Adnan Ahmed is an Assistant Professor of Psychiatry at the University of Minnesota. He is a graduate of the University of Minnesota Forensic Psychiatry Fellowship Program. He works with a Forensic Assertive Community Treatment (FACT) team in Hennepin County and also provides psychiatric consultation services at University of Minnesota Health integrated primary care clinic. Dr. Ahmed serves on the Diversity and Inclusion Committee and the Advocacy Committee at University of Minnesota, Department of Psychiatry. He has a special interest in conducting and training healthcare providers on how to perform mental health evaluations for asylum seekers. References 1. Blad E. Do Schools â&#x20AC;&#x2DC;Active-Shooterâ&#x20AC;&#x2122; Drills Prepare or Frighten? Education Week. June 20, 2018. https://www.edweek.org/ew/articles/2017/09/20/do-schools-active-shooterdrills-prepare-or-frighten.html. Accessed June 29, 2018. 2. Hamblin J. What are active-shooter drills doing to kids? The psychological effects of realistic simulations could be dangerous. The Atlantic. Feb. 28, 2018. https://www.theatlantic.com/ health/archive/2018/02/effects-of-active-shooter/554150/. Accessed June 29, 2018.

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16.

17.

Murphy SL, Xu J, Kochanek KD, Curtin SC, Arias E. Deaths: ďŹ nal data for 2015. National Vital Statistics Reports. November 27, 2017;66(6):173. https://www.cdc.gov/nchs/data/nvsr/nvsr66/ nvsr66_06.pdf. Accessed June 29, 2018. Gun Violence Archive. General methodology. http://www.gunviolencearchive.org/methodology. Accessed June 29, 2018. Krouse WJ, Richardson DJ. Mass murder with ďŹ rearms: incidents and victims, 1999-2013. Congressional Research Service. July 2015. https://fas.org/sgp/crs/misc/R44126.pdf. Accessed June 29, 2018. Ibid. Deutch T. Did mass shootings spike 200% since assault weapons ban? Politifact. February 23, 2018. http://www.politifact.com/ďŹ&#x201A;orida/ statements/2018/feb/23/ted-deutch/did-massshootings-increase-200-percent-assault-we/. Accessed June 29, 2018. Duwe G, Scola N, Robertson D, Heuser S. Mass shootings are getting deadlier, not more frequent. Politico. October 4, 2017. https:// www.politico.com/magazine/story/2017/10/04/ mass-shootings-more-deadly-frequent-research-215678. Accessed June 29, 2018. Follman M, Aronsen G, Pan D. U.S. mass shootings, 1982-2018: data from Mother Jonesâ&#x20AC;&#x2122; investigation. Mother Jones. June 28, 2018 https://www.motherjones.com/politics/2012/12/mass-shootings-mother-jones-fulldata/. Accessed June 29, 2018. Desmarais SL, Dorn RAV, Johnson KL, Grimm KJ, Douglas KS, Swartz MS. Community violence perpetration and victimization among adults with mental illnesses. Am J Public Health. 2014;104(12):2342-2349. doi:10.2105/ ajph.2013.301680. Pinals DA, Appelbaum PS, Bonnie RJ, Fisher CE, Gold LH, Lee L-W. Resource document on access to ďŹ rearms by people with mental disorders. Behav Sci Law. 2015;33(2-3):186-194. doi:10.1002/bsl.2181. Steadman HJ, Monahan J, Pinals DA, Vesselinov R, Robbins PC. Gun violence and victimization of strangers by persons with a mental illness: data from the MacArthur Violence Risk Assessment Study. Psychiatr Serv. 2015;66(11):12381241. doi:10.1176/appi.ps.201400512. Elbogen EB, Johnson SC. The intricate link between violence and mental disorder. Arch Gen Psychiatry. 2009;66(2):152-161. doi:10.1001/ archgenpsychiatry.2008.537. Elbogen EB, Johnson SC. The intricate link between violence and mental disorder. Arch Gen Psychiatry. 2009;66(2):158. doi:10.1001/ archgenpsychiatry.2008.537. Silver E, Teasdale B. Mental disorder and violence: an examination of stressful life events and impaired social support. Social Problems. 2005;52(1):62-78. doi:10.1525/sp.2005.52.1.62. Gold LH. Gun violence: psychiatry, risk assessment, and social policy. J Am Acad Psychiatry Law. September 2013; 41(3):337-343. http:// jaapl.org/content/41/3/337. Accessed June 29, 2018. Cure Violence. Health movement to prevent violence. http://cureviolence.org/understand-violence/health-movement/. Accessed June 29, 2018.

September/October 2018

#EndGunViolence

What Can You Do to Help Reduce Gun Violence in Our Community

or me, it was the aftermath of the February shootings at Marjory Stoneman Douglas High School in Parkland, Fl. It is not that I wasnâ&#x20AC;&#x2122;t concerned before by all the other shootings and hadnâ&#x20AC;&#x2122;t written many letters to the editor and participated in countless discussions on the topic of reducing gun violence. But three things happened after Parkland that changed me. The ďŹ rst, was reading a powerful piece by a Pediatrician who lives and practices near Parkland and whom I know from residency.1 The next was seeing how the students from Parkland and elsewhere took this on as their own responsibility to ďŹ x â&#x20AC;&#x201D; without waiting any longer for adults to solve it. Finally, it was the March 2018 â&#x20AC;&#x153;March for Our Livesâ&#x20AC;? rally at the Capitol in St.Paul that I participated in with 20,000 others. There, we heard the despair of students and their call for change.2 All of these have combined for me to say enough is enough. It is time to try and make changes to reduce gun violence. In this article, I will present practical ways that you can try to reduce gun violence. The suggestions will be grouped together in three areas: convincing yourself why this is important, what you can do in your exam room with your patients and their families, and what you can do to help make changes at a community level. If you are going to become a leader in reducing gun violence, you need to not only understand the magnitude of the problem, but also feel motivated to make a change. Each of us have only so many

By Sheldon Berkowitz, MD, FAAP

September/October 2018

hours in the day and we all have to decide which projects are important to us. Here are a few statistics that may help you to understand why reducing gun violence is imperative. s &ROM *AN THROUGH *UNE 2018, 1,632 children aged 0-17 have been killed or injured by a ďŹ rearm in the US.3 s 3INCE THE 3ANDY (OOK 3CHOOL SHOOTing in 2012, the number of children in the US killed by gunďŹ re is greater than the total number of US soldiers killed overseas in combat since 9/11.4 s !LMOST PEOPLE OF ALL AGES DIE every day in the US as a result of gun violence.5 s !CCORDING TO THE #$# IN deaths by suicide or homicide due to ďŹ rearms are among the ďŹ ve leading causes for ages 5 and older (including adults).6 s "ETWEEN MORE PEOPLE died in the US from ďŹ rearm violence than all the combat deaths in World War II.7 Death by gun violence in the US is now considered a public health crisis.5 We need to start thinking about and devoting the same energy to preventing injuries and death by gun violence as we do for other public health issues such as motor vehicle accidents, smoking, and cancer. It is also not just a pediatric issue7, 8 â&#x20AC;&#x201D; but rather an issue that affects all of us, regardless of age. And if you need one more reason to get involved, it is the simple statement we have heard over and over from our young people since Parkland â&#x20AC;&#x201D; no one else is doing it. If we, all of us, donâ&#x20AC;&#x2122;t do something â&#x20AC;&#x201D; nothing will change.

Once you convince yourself that you need to do something, you then need to know what you can do as a clinician in your exam room with your patient and their family.9, 10, 11 I struggled for years to know what to say, to whom to say it and when to say it. We all are concerned with offending our patients/families by asking inappropriate questions. We may be concerned that our patients may wonder why I am asking them about guns in their home â&#x20AC;&#x201D; do I ask everyone? Is it because of their skin color or ethnicity? For me, it has been important to make it clear to families that I am asking everyone about having guns or weapons in their home and I am doing it so that if there are guns or weapons, we can talk about keeping everyone safe in the home. As a pediatrician, I am primarily asking the parents of my patients, but for older children, I also ask them if there are weapons in the home. If you care for adults, you would obviously direct your questions to that individual. If

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a person responds that they do have guns in their home, I will then ask if they are kept locked up, unloaded and with the ammunition stored separately. In addition, if there are individuals in the house with any type of mental health problems, including but not limited to history of attempted suicide, I will discuss how it is even more important not to have guns in the house in these situations. In my practice, I have decided not to ask about guns and weapons in the home at each visit, but rather at certain well child visits (e.g. 2 years old as children are more able to get into things at home, again at 5 years old as they are in school and then again at 12 yrs old as they enter adolescence). I also bring it up if I am dealing with a patient with developmental issues or mental health issues or if there is a history of substance abuse or domestic violence, as individuals with these risk factors might be more at risk of causing harm — to themselves or others, if they had access to a gun. Most importantly, I make it a point to discuss this with my patients and their families myself — not simply to have my nurse ask about it. This way, I believe I impart additional importance to this topic. Finally, I want to give you ideas of what you can do on a community level. The first is to participate in marches and rallies to stop gun violence. I have made a conscious decision not to make this an issue about guns, but rather, about gun violence. For me, the issue is not whether a person owns a gun, but rather are they being safe with it to hopefully prevent gun violence. I am also aware that as a society, we need to work at changing the culture which sees guns as a solution to too many problems. Next, write letters and op/ed pieces to your local newspapers. Don’t get discouraged if they aren’t printed. Keep sending them and hopefully the next one will. Remember, your voice as a clinician is strong and respected. Use it to make a point. Next, talk to your state and national legislators to find out how they stand on the issue of reducing gun violence. Let them know that you believe this to be a high priority. If you find they aren’t supportive of legislation to reduce gun

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violence, consider voting for other candidates that will. And lastly, be willing to ﬁnancially support organizations that are working on a national level to reduce gun violence (e.g. Brady Campaign to Prevent Gun Violence, Americans for Responsible Solutions, Everytown For Gun Safety). While reducing gun violence in our society may seem to be an overwhelming project to accomplish, there are ways we can join together to help make it happen. Connect with the professional medical organizations that you belong to and get out and join with your community when there are rallies to attend. We can make a difference. Sheldon Berkowitz, MD is a pediatrician at Children’s Minnesota where he is also the Medical Director for Case Management, Utilization Management and Clinical Documentation Improvement. Dr. Berkowitz is the President-Elect of the Board of Directors of the MN Chapter of the American Academy of Pediatrics. He can be reached at Sheldon. berkowitz@childrensmn.org or in his ofﬁce at (612) 813-6077.

The Journal of the Twin Cities Medical Society

References: 1. Marcus D. A Community Fractured, A Community Resolved. American Academy of Pediatrics Voices. 3/12/18. https://www.aap.org/en-us/ aap-voices/Pages/Community-Fractured-Community-Resolved.aspx. 2. Berkowitz S. March for Our Lives: March 24, 2018. Minnesota Pediatrician. May/June 2018: 7. 3. Gun Violence Archive. www.gunviolencearchive.org. Accessed 6/25/18. 4. Sit R. More children have been killed by guns since Sandy Hook than U.S. soldiers in combat since 9/11. Newsweek. 3/16/18. 5. Bauchner H, Rivara FP, et al. Death by Gun Violence – A Public Health Crisis. JAMA Pediatr. 2017; 171(12): 1142-1143. 6. Web–based Injury Statistics Query and Reporting system (WISQARS). https:// www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_highlighting_violence_2016_1030w800h.gif. Accessed June 26, 2018. 7. Wintemute GJ. What You Can Do To Stop Firearm Violence. Ann Intern Med. 2017;167(12):886-887. 8. Weinberger SE, Hoyt DB, et al. Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association. Ann Intern Med. 2015; 162(7); 513-516. 9. Best Practices to Prevent Firearm Injuries. MN Department of Health. www.health.state. mn.us/injury/best/best.cfm?gcBest=gun. 10. Teens, Depression and Guns. Seattle Children’s Community Education. www.seattlechildrens. org. 11. Firearm Safety Tips: Ten Tips For Firearm Safety In Your Home. www.ProjectChildSafe.org.

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WŚǇƐŝĐŝĂŶƐ ƵŶĚĞƌƐƚĂŶĚ ƚŚĂƚ ŐƵŶ ǀŝŽůĞŶĐĞ ŝƐ Ă ĐŽŵƉůĞǆ ƉƵďůŝĐ ŚĞĂůƚŚ ƉƌŽďůĞŵ ƚŚĂƚ ŶĞĞĚƐ ĐŽŵƉƌĞŚĞŶƐŝǀĞ͕ ĞǀŝĚĞŶĐĞͲďĂƐĞĚ ƐŽůƵƟŽŶƐ͘ WƌŽƚĞĐƚ DŝŶŶĞƐŽƚĂ ƉƌŽŵŽƚĞƐ Ă ĐƵůƚƵƌĞ ŽĨ ŚĞĂůƚŚ ĂŶĚ ƐĂĨĞƚǇ ĨŽƌ >> DŝŶŶĞƐŽƚĂŶƐ ďǇ ǁŽƌŬŝŶŐ ƚŽ ƉƌĞǀĞŶƚ ŐƵŶ ǀŝŽůĞŶĐĞ ƚŚƌŽƵŐŚ ƌĞƐĞĂƌĐŚ͕ ůĞŐŝƐůĂƟŽŶ͕ ĞĚƵĐĂƟŽŶ ĂŶĚ ĐŽŵŵƵŶŝͲ ƚǇ ŝŶǀĞƐƚŵĞŶƚ͘ tĞ ĂƌĞ ƚŚĞ KE>z ŝŶĚĞƉĞŶĚĞŶƚ͕ ƐƚĂƚĞͲďĂƐĞĚ ŐƵŶ ǀŝŽůĞŶĐĞ ƉƌĞǀĞŶƟŽŶ ŽƌŐĂŶŝǌĂƟŽŶ ŝŶ DŝŶŶĞƐŽƚĂ͘ :ŽŝŶ ŽƵƌ ,ĞĂůƚŚ ĂƌĞ ŽĂůŝƟŽŶ ƚŽ WƌĞǀĞŶƚ 'ƵŶ sŝŽůĞŶĐĞ ĂŶĚ ŚĞůƉ ƵƐ ĚŽ ǁŚĂƚ zKh ĚŽ͗ ƐĂǀĞ ůŝǀĞƐ͘

ǁǁǁ͘ƉƌŽƚĞĐƚŵŶ͘ŽƌŐ

September/October 2018

#EndGunViolence

Preventive Medicine: Police Stops, a Discussion for the Times

he police are here to protect and serve the citizens. The overwhelming majority of the time that is what these essential public servants do. But, like any profession, there can be bad apples, and nearly all are affected by bias that can impact different communities disparately. For example, if you ask non-African Americans if their parents have ever had a sit-down discussion with them on how to behave if ever approached by the police, the vast majority will say â&#x20AC;&#x153;no.â&#x20AC;? That answer reďŹ&#x201A;ects a different cultural experience and explains in part why itâ&#x20AC;&#x2122;s difďŹ cult for them to relate to past abuses shown to have been committed disproportionately against African-Americans. For decades across the entire country, the African-American community has grown painfully accustomed to being treated differently than other communities, leading to the assumption, right or wrong, that police may be as much a threat to community members as an asset. It will take time and a concerted effort by the police and other public ofďŹ cials to turn these fears and opinions around. In the meantime, itâ&#x20AC;&#x2122;s important that we educate our children (and ourselves) on how to behave when approached by police. With that in mind, and considering recent events, I will cover many safe and effective ways of approaching police-citizen encounters. This discussion, an elaborate version of what my father taught me, and so many other African Americans teach their children, is often referred to as â&#x20AC;&#x153;the talk.â&#x20AC;? By Charles E. CrutchďŹ eld III, MD

September/October 2018

Dealing with police-citizen encounters is something everyone needs to consider. This information offers something for everyone, regardless of skin color, to consider personally and review with family members and children. Vehicle Stops Conducted by the Police: Preventing the Stop in the First Place

%VERY TIME YOU CHANGE YOUR OIL make sure to check that your license plate tabs are up to date. Also check all exterior lights to ensure proper function, including tail lights, brake lights, headlights, turn signal lights, side lights, and license plate lights/ tabs. It is surprising to realize how many police stops result from faulty lights/tabs. Check all exterior lights, especially in the dark. This is one of the easiest ways to avoid an interaction with the police.

)F YOU PLAN ON GOING TO AN EVENT WHERE you will or might consume alcohol, either arrange a predetermined designated driver or use an alcohol monitoring device readily available on the Internet for around $30.00 and easily STORED IN THE CAR 5SE IT %6%29 4)-% you consume alcohol before driving and NEVER drive if you are not sober. Call a friend, family member, taxi, sober cab, Uber, or Lyft. Some cab services will even have a separate driver follow you in your own car, so it is there waiting for you the next day! !LWAYS WEAR YOUR SEATBELT )N -INNEsota, law enforcement may pull you over simply for not wearing a seatbelt. Most importantly, seat belts save over 10,000 lives every year in the U.S.

If you see a police car with sirens and lights on and realize that you are being pulled over: Tips for a safe encounter. s 5SING YOUR TURN SIGNAL PULL OVER TO the right side of the road quickly and safely, slowing down moderately without braking so hard that the police car has to avoid hitting you. s 0ULL OVER AS FAR TO THE RIGHT AS POSSIBLE to give the ofďŹ cer plenty of room to approach your car on foot without fear of being hit by passing trafďŹ c. s 5NDERSTAND YOUR MOVEMENTS AND actions are now being watched very carefully. Sometimes a police ofďŹ cer will shine a bright light on you as they approach the car to see if you are attempting to hide something below the seat or in a pocket or to throw something out of the car the window. Suspicious, yet innocent, movements may give an ofďŹ cer reason to search

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The Journal of the Twin Cities Medical Society

you or your vehicle, so remain calm and relatively still. Right After You Stop: Keeping Yourself and the Police Calm

Like anyone else, the police appreciate courteous behavior. This is not the time to be angry or argumentative, and disputes or disagreements can be handled at a later date by you or your attorney if necessary. Remember at this point, courtesy is king. s 4URN OFF THE IGNITION s #OMPLETELY ROLL DOWN YOUR WINDOW s 2EMAIN IN YOUR CAR AND PLACE YOUR hands on top of the steering wheel at the 10 and two oâ&#x20AC;&#x2122;clock position, in plain sight, and do not move them until given permission by the ofďŹ cer. s )F YOU ARE BEING PULLED OVER IN THE dark, itâ&#x20AC;&#x2122;s critical to immediately turn on your dome light as a courtesy so that the ofďŹ cer has a clear view of and into your car. Remember, a trafďŹ c stop can feel threatening to both parties, so anything you can do to be cooperative and reduce any anxiety on the ofďŹ cerâ&#x20AC;&#x2122;s part will go a long way in keeping you safe. s 7HEN THE OFlCER APPROACHES YOUR CAR you should say one thing and only one thing: â&#x20AC;&#x153;Hello, OfďŹ cer.â&#x20AC;? s 7AIT FOR THE OFlCER TO MAKE THE NEXT comment while maintaining eye contact. s 4HE OFlCER MAY ASK A QUESTION LIKE â&#x20AC;&#x153;Do you know why I pulled you over?â&#x20AC;? The only answer you can and

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should politely provide is, â&#x20AC;&#x153;I am not sure, ofďŹ cer.â&#x20AC;? s 9OU WILL BE ASKED FOR your driverâ&#x20AC;&#x2122;s license, proof of insurance, and registration. Tell the officer where these items are located and ask the ofďŹ cer for permission to remove your hands from the steering wheel to retrieve them. Do not remove your hands until the ofďŹ cer gives permission â&#x20AC;&#x201D; this is a tense situation, and you donâ&#x20AC;&#x2122;t want the ofďŹ cer to have any reason to believe that you are reaching for a weapon. s !T THIS POINT THE OFlCER MAY TAKE THE materials back into the squad car and check your documents. s 2EMAIN CALM WITH YOUR HANDS ON the steering wheel until the ofďŹ cer returns. If you only receive a warning, thatâ&#x20AC;&#x2122;s great! If you are given a ticket and disagree, youâ&#x20AC;&#x2122;ll have an opportunity to protest it at a later time, but not now. s 7HATEVER THE OFlCER GIVES YOU ACCEPT it and say two things and two things only: â&#x20AC;&#x153;Thank you, OfďŹ cer,â&#x20AC;? and â&#x20AC;&#x153;Will you please instruct me how to re-enter the road as I depart?â&#x20AC;? Because of its importance, I repeat my caution that, even if you do not agree with a citation or how the ofďŹ cer treated you, you should avoid an immediate confrontation, instead following the instructions on the back of the ticket to make your protest. 9OU MAY BE WELL ADvised to consult an attorney to defend your rights. In short, the primary objective is to survive the encounter without incident or injury.

The Journal of the Twin Cities Medical Society

It may seem like a terrible double standard, but as a parent, recognizing and abiding by the double standard gives the best odds for my child remaining safe so we can ďŹ ght the good ďŹ ght against bad behavior another day. Like so many, I look forward to the day when all Americans are free from worrying about these issues and can stand together and appreciate how far weâ&#x20AC;&#x2122;ve come. In the meantime, the most important thing you can do is review this article yourself and cover it with adult family members, and your children and their friends. Print it out and practice by doing a live car test (maybe just in your driveway). Run through a mock trafďŹ c stop and have them follow the list entirely, including turning on the dome light as if it were a nighttime encounter, as you play the role of the police ofďŹ cer. This 10-minute investment in â&#x20AC;&#x153;Preventative Medicineâ&#x20AC;? may pay you and your loved ones very rich rewards. This article is part of a three-article series initially published for the Minnesota Spokesman Recorder, July 2016. Reprinted with permission. Charles E. CrutchďŹ eld III, MD is a Clinical Professor of Dermatology, University of Minnesota Medical School and Medical Director of CrutchďŹ eld Dermatology, Eagan, MN. Email: Charles@CrutchďŹ eldDermatology. com.

September/October 2018

Sponsored Content

Creating a Resilient Workplace: Solving for Organizational Causes of Burnout

he data are clear: thereâ&#x20AC;&#x2122;s an upward trend of burnout in medicine, particularly among physicians who experience professional burnout at twice the rate of the general population.1 Burnout isnâ&#x20AC;&#x2122;t just a problem â&#x20AC;&#x201D; itâ&#x20AC;&#x2122;s a crisis. It affects patient safety, teams and organizations â&#x20AC;&#x201D; and itâ&#x20AC;&#x2122;s costly. Thereâ&#x20AC;&#x2122;s been a lot of attention on individual resiliency skills of late. But the primary drivers of burnout occur at an organizational level, so focusing solely on what individuals can do to manage stress will fall woefully short. Organizational issues include high workloads, inefďŹ ciencies related to electronic health records (EHRs), loss of meaning and social isolation at work, and loss of clinical autonomy.2, 3 The stakes are high because physicians and other clinicians are voting with their feet, according to Laurie Drill-Mellum, MD, Chief Medical OfďŹ cer of Constellation/MMIC. â&#x20AC;&#x153;Millennials stay two to four years in an organization, on average,â&#x20AC;? she says. â&#x20AC;&#x153;If they arenâ&#x20AC;&#x2122;t engaged in being part of something greater than themselves, if they arenâ&#x20AC;&#x2122;t seen for what they can contribute, they arenâ&#x20AC;&#x2122;t staying. The workforce shortage plays in this, too. If we donâ&#x20AC;&#x2122;t treat people differently, weâ&#x20AC;&#x2122;re going to have to close our doors.â&#x20AC;? Dr. Drill-Mellumâ&#x20AC;&#x2122;s work focuses on clinician well-being and its effect on patients and organizations. As an ofďŹ cer of a professional liability insurance company, she knows that clinicians who are burned out are at risk of making medical errors and therefore at risk of getting sued. And she sees the organizational drivers of burnout as eminently solvable. The ďŹ rst step leaders can take, she says, is to administer a measurement tool like the â&#x20AC;&#x153;Mini-Z Surveyâ&#x20AC;? Minnesota Hospital Association members deployed for the past two years. â&#x20AC;&#x153;Now is the time to apply a quality improvement approach to address burnout and promote resiliency,â&#x20AC;? says Dr. Drill-Mellum. â&#x20AC;&#x153;This involves commitment from leadership to use a validated measurement tool, analyze the results, and engage those surveyed on how they want to address opportunities for improvement.â&#x20AC;? Itâ&#x20AC;&#x2122;s crucial to engage the frontline clinicians who were surveyed for their ideas about how to solve any issues that surface. â&#x20AC;&#x153;No one group of people is going to solve this problem â&#x20AC;&#x201D; it

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has to be done in collaboration,â&#x20AC;? Dr. Drill-Mellum states. â&#x20AC;&#x153;When working together, you ďŹ nd ways to solve problems. With consensus on a plan and organizational support for it, you inform everyone what you plan to do. Then, you do it and measure again to look for impact.â&#x20AC;? Many tools are available to tackle speciďŹ c pieces of workďŹ&#x201A;ow issues like prescription reďŹ lls, lab and image result reviews, and documentation. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s not rocket science,â&#x20AC;? Drill-Mellum explains. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s a simple quality improvement program for care TEAMS 9OU RE ONLY GOING TO GET SO FAR IMPROVING PATIENT EXperience, outcomes and costs without attending to the work environment and experience of the people who deliver the care.â&#x20AC;? The interconnection between organizational culture and individual well-being is huge, Dr. Drill-Mellum says. The question to ask is: Does the organizational culture support individual resiliency? There are practices to stop, like asking staff to work double shifts. And there are those to start, like creating ďŹ&#x201A;exible scheduling, supporting people to take vacation time, and offering onsite daycare and exercise or relaxation facilities. For true organizational resilience, whatâ&#x20AC;&#x2122;s needed is a leadership culture that cares about people, engages them, and does what they say theyâ&#x20AC;&#x2122;re going to do in terms of mission, vision and values. Anne Geske is managing editor of Brink magazine, a health care publication from MMIC. MMIC is a member of Constellation, a collective of MPL insurance and partner companies offering solutions that are good for care teams and good for business. To learn more about the services MMIC provides to physicians, hospitals and health systems, visit MMICgroup.com. References 1. AHA, 2018. Be Well: Cultivating Resilience to Address Health and Well-Being. 2. AMA Steps Forward, 2018. Creating the Organizational Foundation for Joy in Medicine. 3. The Physicians Foundation, 2016. 2016 Survey of Americaâ&#x20AC;&#x2122;s Physicians Practice Patterns & Perspectives.

September/October 2018

Jump Starting Tobacco Health Systems Change Smoking is the leading cause of preventable illness and death in the United States.1 While the number of adults smoking in Minnesota has decreased to 14%,2 smoking rates remain high among specific populations, including populations of low socio-economic status.3 New research shows that brief tobacco use Jeyn L. Monkman, MA, BSN, NE-BC Megan N. Whittet, MPH Tani Hemmila, MS, BSW screening and interventions are among the top three preventative serresource-intensive for Community Health vices, providing substantial health benefits Did We Make A Difference? 4-5 Centers. We also discovered there were two and overall cost savings. “[The training] helped me be more mindmain interest areas: First, people wanted The question is, how can busy primaful of how I’m asking questions and havto know “how to ask the question” about ry care clinicians and staff more effectively ing discussions with patients.” tobacco and nicotine use more effectively. address tobacco use alongside everything Of the 107 participants, 50% completed Second, evidence-based prescribing of ceselse they do? evaluations following training and 90% sation medications and nicotine replaceMeeting Clinics Where They of respondents stated they were likely to ment therapies (NRT) was not widely Are: The Jump Start Model apply the motivational interviewing appracticed. ClearWay MinnesotaSM funded the Instiproach. When asked about the one thing We found that shorter, more focused tute for Clinical Systems Improvement they would do differently, most referenced trainings in the clinic setting were needed, project to increase clinic capacity to sysnot giving up on asking about tobacco and and developed the Jump Start for Tobacco tematically address patients’ tobacco use. nicotine use, and several specifically called Health Systems Change trainings. These While we worked with clinics and systems out changing prescribing practices. targeted training sessions were attended of all types and sizes, one of the target To get an understanding of how the by 107 clinic staff from seven Commuaudiences for programming was Comtrainings were applied, we followed up sevnity Health Centers. Sessions consisted of munity Health Centers. With the support eral months later. We interviewed six of the 30-60-minute trainings on motivational of the Minnesota Association of Comseven clinic leaders and sent out surveys interviewing to address tobacco and nicomunity Health Centers (MNACHC), we to clinic participants (18% response rate). tine use for any and all staff interested, and connected with the clinics and worked to While the number of survey responses was medication/NRT education for clinicians. understand their needs. low, we gained useful information from Dr. Pete Dehnel, Medical Director of the We found that typical, longer half-day prescribing clinicians: Twin Cities Medical Society’s Physician or full-day trainings were too time- and s &IVE OF THE SIX CLINICIANS STATED THEY Advocacy Network, provided education were more likely to discuss smoking about cessation medications. Resources cessation and offer medication/NRT included “How to ask about smoking By Jeyn L. Monkman, MA, BSN, NE-BC, with patients after having the training. without lighting a fire,” developed and Tani Hemmila, MS, BSW, and About half said they had patients who Megan N. Whittet, MPH shared by HealthPartners. 26

September/October 2018

MetroDoctors

The Journal of the Twin Cities Medical Society

committed to making a quit attempt. $URING INTERVIEWS WITH LEADERSHIP TWO themes arose. Trainings triggered staff and clinicians to feel more empowered to talk amongst themselves about how to address tobacco use with patients, as well as engaging patients differently about tobacco use.

Considerations

!SKING A YES OR NO QUESTION ABOUT tobacco use is not sufďŹ cient. Motivational interviewing, even in a very brief intervention, supports staff to be able to address tobacco cessation effectively, enabling a safe space for conversations with patients. #ONDUCT TRAININGS AND SHARE RESOURCES on updated, evidence-based prescribing practices for tobacco cessation medications and NRT. $ESIGN TRAINING SESSIONS TO ALIGN WITH the realities of clinic practice. Concise, focused trainings can be effective to motivate staff. 4O LEARN MORE AND TO SEE THE

handouts used in these trainings visit http://clearwaymn.org/policy/ tobacco-health-systems-change/. Disclaimer: Any conclusions or recommendations from this project and the content of this publication are solely the responsibility of the authors and do not necessarily represent the ofďŹ cial views of ClearWay MinnesotaSM. Jeyn L. Monkman, MA, BSN, NE-BC is a Director at the Institute for Clinical Systems Improvement (ICSI) with experience and expertise across the health care continuum in practice facilitation, motivational interviewing, and quality improvement implementation and measurement. Tani Hemmila, MS, BSW is a Director at the Institute for Clinical Systems Improvement (ICSI) convening the MN Health Collaborative mental health initiative and communications. Megan N. Whittet, MPH, is a Senior Cessation Manager at ClearWay MinnesotaSM in Minneapolis.mwhittet@clearwaymn.org.

Ms. Whittet has 16 years of tobacco control experience, including program development, project management, health systems change, evaluation and research. References: 1. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, OfďŹ ce on Smoking and Health;2014. 2. ClearWay Minnesota, Minnesota Department of Health. Minnesota Adult Tobacco Survey: Tobacco Use in Minnesota: 2014 Update. February 2015. 3. OfďŹ ce on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. Cigarette Smoking and Tobacco Use Among People of Low Socioeconomic Status February 3, 2017. https://www.cdc.gov/ tobacco/disparities/low-ses/index.html. 4. Maciosek M, LaFrance A, Debmer S, McGree D, Xu Z, Flottemesch T, Solberg L. Health BeneďŹ ts and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults. Annals of Family Medicine. 2017;15:37-47. https://doi. org/10.1370/afm.2022. 5. Maciosek M, LaFrance A, Debmer S, McGree D, Xu Z, Flottemesch T, Solberg L. Updated Priorities Among Effective Clinical Preventive Services. Annals of Family Medicine. 2017;15:14-22. https://doi.org/10.1370/ afm.2022.

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The Journal of the Twin Cities Medical Society

September/October 2018

The Convenings is Now End in Mind

Background

End in Mind, formerly known as The Convenings, is an award-winning statewide initiative launched in 2016 with Honoring Choices Minnesota (a project of Twin Cities Medical Society), to help Minnesotans talk about living full and meaningful lives until the very end of life. End in Mind has involved an unprecedented collaboration among Minnesota civic leaders, health care, faith, and commercial and public media professionals. The success of this work continues, thanks to generous funding from Allina Health, HealthPartners, CentraCare Health and the George Family Foundation.

that people have a voracious appetite for honest, meaningful conversations about dying. Creative engagement is a gateway to making those conversations less fearful and more meaningful. Using a community forum for discussion of end-of-life issues provides opportunities for self-inquiry among peers within a safe and supportive environment.

Honoring Choicesâ&#x20AC;&#x201C;Duluth, at an event broadcast live on WDSE TV.

Work Beginning in Shakopee and Duluth

Building on our success in six initial Minnesota communities, End in Mind is excited to launch new efforts in Shakopee and Duluth this fall. The work in Shakopee is a joint collaboration with St. Francis Regional Medical Center. Each six-month timeline starts with a live event hosted by Cathy Wurzer, with follow-up activities ranging from book clubs to pop-up podcast recording sessions to â&#x20AC;&#x153;Death-over-Dinnersâ&#x20AC;? and advance care planning facilitator training sessions. The Duluth partnership with End in Mind will launch this fall, coupled with the start of

Audience members enjoy a Convening in Central MN.

HealthCare Community Engagement

In response to early successes, funders HealthPartners and Allina have engaged End in Mind to plan a live event over the winter, speciďŹ cally designed for their employees who provide end-of-life care. The event will help create space to have the peer conversations and support needed to provide excellent care to patients. Looking Ahead

The organization grew out of the interviews Cathy Wurzer conducted on Minnesota Public Radio with Bruce Kramer as he was dying from amyotrophic lateral sclerosis (ALS). Through those conversations and the co-authoring by Cathy and Bruce of We Know How This Ends, Living While Dying, Cathy discovered 28

September/October 2018

The End in Mind kick-off event for Shakopee will be held at Mystic Lake on /CTOBER AT PM Scott County residents are warmly invited to attend.

End in Mind plans to further develop and operationalize community, corporate and healthcare company initiatives including events and a â&#x20AC;&#x153;turnkey toolkitâ&#x20AC;? throughout Minnesota in the coming two years. We are gaining attention across the state! Read the latest news and thoughtful writings on living well and end of life at our Facebook page, or sign up for our e-newsletter. Would you like to bring this work to your clinic or community? For more information, e-mail Executive Director, Linda Singh, at LSingh@endinmindproject.org. MetroDoctors

The Journal of the Twin Cities Medical Society

Environmental Health — Climate Change and Mental Health Editor’s note — Jordan Weil, as a fourth year medical student, visited Puerto Rico as part of a research project studying the mental health crisis that followed Hurricane Maria. The project is coordinated by Associate Professor Miguel Fiol (UM Dept. of Neurology). This account is based on his experience. Driving into the small town of Morovis in rural Puerto Rico reminded me of waiting room posters of Santorini: white houses with blue roofs built into a steep hillside that drops to the Mediterranean. Here, instead of meeting the sea, the lush hills around Morovis fall until they are mirrored by the opposing valley wall. Another difference here is that these blue roofs — emergency tarps from FEMA — stand as testimony to the most powerful hurricane to hit the island eight months before I got there. Intense storms like Maria are becoming more frequent as human-driven climate change drives up global temperatures. The same is true of other extreme weather events such as ﬂoods, droughts, and heat waves. Traumatic injuries, infectious disease, and decompensated chronic conditions pose increased risk when infrastructure and systems of care fail. Climate change-driven extreme weather can also trigger mental health pathologies. Survivors (adults and children) have elevated risks of persistent anxiety, depression and PTSD. Patients with chronic mental illness are more likely to decompensate while access to

treatment is sharply curtailed. From late September when the storm hit, thousands of calls, many related to suicidal thoughts or plans, have overwhelmed an emergency hotline for psychiatric crises maintained by the Puerto Rican health department — more than double the expected volume. Many Puerto Ricans continue to deal with a lack of basic services, loss of jobs, community displacement, collapse of transportation and power, and damaged housing. The 2018 hurricane season has begun along with intense summer heat. The crisis situation is far from over.

By Jordan Weil, MD

MetroDoctors

The Journal of the Twin Cities Medical Society

NOW

Annual Conference

#MNMED18

September 21-22, 2018 Saint Paul RiverCentre

MNMED.ORG/AC2018 September/October 2018

In Memoriam

MINCEP Epilepsy Care. He joined the medical society in 1966.

MELVIN P. BAKEN, JR., MD, passed away on May 3, 2018. Dr. Baken ďŹ rst earned his BS, MS, and DDS at the University of Minnesota, before obtaining his MEDICAL DEGREE (E PRACTICED /" '9. IN Minneapolis for 33 years. He was a member of the medical society since 1959.

JAMES E. JENSON, MD, passed away on July 7, 2018. He received his medical degree from the University of Minnesota, and was a co-founder of the Stillwater Medical Clinic where he practiced Family Medicine for over 40 years. Dr. Jenson joined the medical society in 1948.

JOHN BURNS, MD, a member of the medical society since 1960, practiced Internal Medicine in the Twin Cities from 1960-1981 before leaving practice to work in health care management. He eventually started a healthcare consulting group in Florida.

WILLIAM LINDSAY, MD, passed away on April 23, 2018. A cardiac surgeon, Dr. Lindsay was a part of the surgical team completing the ďŹ rst successful heart transplant in Minnesota. He was co-founder of both the Minneapolis Heart Institute and the St. Paul Heart and Lung Surgical Division. Dr. Lindsay joined the medical society in 2002.

ROBERT GUMNIT, MD, died unexpectedly on October 15, 2017. He was described as â&#x20AC;&#x153;A pioneer of modern comprehensive epilepsy care.â&#x20AC;? In 1987 he founded the National Association of Epilepsy Centers and for 25 years, he served as its president, and was a retired president of

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RICHARD MAGRAW, MD, passed away on November 30, 2017. Dr. Magraw held numerous academic positions, including Professorships at the University of Minnesota, Dean of the University of Illinois

Medical School, President of the Eastern Virginia Medical School, and Chief of Psychiatry at the Minneapolis VA Hospital. In addition, he served as the Assistant Director of the Bureau of Medical Services and as Deputy Assistant Secretary for Health Manpower at HEW. Dr. Magraw was featured as the Luminary of Twin Cities Medicine, MetroDoctors, July/August 2010. JOHN (JACK) REED, MD, PhD, passed away in July 2018. He served in the US Army and worked for NASA Project Mercury in Houston, TX. He also was the Director of Research at Medtronic. He received a PhD in Cardiovascular Physiology and completed a residency in clinical cardiology. Dr. Reed joined the medical society in 1964. WILLIAM R. SCHROEDER, MD, passed away on May 13, 2018. Dr. Schroeder was a family physician practicing in North St. Paul for over 35 years. He joined the medical society in 1974.

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September/October 2018

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The Journal of the Twin Cities Medical Society

LUMINARY of Twin Cities Medicine By Marvin S. Segal, MD

HENRY BLACKBURN, MD It has been said that the construct of medicine is representative of a “Three Legged Structure,” a dynamic amalgamation of clinical practice, education and research. And, as is the case with its metaphorical counterpart, the “Three Legged Stool,” all three legs must be sturdy or it is sure to become a bit wobbly. Though our Luminary’s activities have encompassed all three of those legs, his pursuits have been most deeply associated with research of the clinical variety. Let’s see just how this involvement has transpired over these past 70 years. Dr. Henry Blackburn, born in Florida with his undergraduate and medical education at the University of Miami and Tulane respectively, first came to our U of M for his residency/ fellowship and masters degree in the early 50s — and despite extensive national and world-wide travel, he has figuratively never left us. His early interest in direct general patient care morphed into the fields of internal medicine, cardiology, public health and epidemiology as he eventually ascended to joint professorships in the Department of Medicine and the School of Public Health. Henry’s contributions to the strength and stability of the above mentioned research leg have been truly monumental. Before and after he assumed the directorships of the Laboratory of Physiological Hygiene and the Division of Epidemiology from the legendary Dr. Ancel Keys (of WW II “K” Ration and hypercholesterolemia fame), Blackburn was deeply involved in a variety of meaningful studies dealing with cardiovascular primary and secondary prevention and treatment, including: The Seven Countries Study, The Coronary Drug Project, The Multiple Risk Factor Intervention Trial, The Prevention of Sudden Coronary Death and the Minnesota Heart Health Program. There is little doubt that this body of work contributed significantly to the striking decline of 70% in age-adjusted cardiovascular mortality since 1960. Dr. Blackburn’s energetic clinical research endeavors were done in conjunction with the authorship of some 400 journal articles and book chapters, extensive international visiting professorships and a full teaching load associated with administrative duties in our medical school. Dr. Thomas Kottke, our colleague and a former mentee of Henry’s, marvels at his striking array of accomplishments, mainly carried out prior to easier travel and the more efficient technical computer-assisted 32

September/October 2018

aids present in the population research of today. Much of his success has been fueled by supportive collaborations with his co-researchers and his personal high expectations. He modestly has stated, “I just helped doctors do what they’ve always wanted to do!” And . . . to dispel the notion that the good Doctor’s pursuits have been all just professionally oriented, somehow through the years of hard work and the well-deserved acceptance of many honors and kudos, he has found the time to engage in the wonderful avocation of music. It began at age six with him playing the triangle in a ﬁrst grade musical production, which grew into an appreciation of gospel inspired harmonies, and eventually evolved into a secondary career of making beautiful music — mainly of New Orleans creole-like jazz — with his expertly played soprano saxophone. The famous New Orleans Preservation Hall owes much to his musical gift and decades of support. It’s mind-boggling to reﬂect upon the multitude of lives he has physically improved and actually saved through his medical efforts in addition to the pure listening enjoyment that he has provided for those experiencing his sweet music. Those of us from all “Three Legs” of our medical profession owe a debt of gratitude, our thanks and hearty appreciation for the extensive and fascinating achievements of our Luminary.

This last page series is intended to honor esteemed colleagues who have contributed signiﬁcantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

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