September/October 2017 - Striving for Health Equity by Advocates for Better Health

September/October 2017

Striving for Health Equity

In This Issue: • • • •

Get Involved! Finding Your “Cultural Humility” 8th Annual Sharing the Experience Conference Luminary of Twin Cities Medicine

All in the Family

CRU TCHFIELD DERMATOLO GY

The Crutchfield family has created a rich medical legacy in the Twin Cities.

The Twin Cities was recently named as the ‘Best Place to Live in the United States’ (Patchofearth.com). Why not? We’re green; we have great food and entertainment, and a robust job market. But what really makes a city great? The people. And what makes great people? Great families. Our Capitol City boasts a great family of its own: The Crutchfields. Arriving to pursue education, Dr. Charles Crutchfield Sr. and Dr. Susan Crutchfield became two of Minnesota’s best-known and respected physicians over the past half century. The first African American woman to graduate from the University of Minnesota Medical School in 1963 (at age 22, also the youngest, ever!), Dr. Susan achieved diplomate status on the American Board of Family Medicine, spending twenty years practicing occupational medicine as Vice President and Medical Director for the Prudential Insurance Company of America and has served in a range of positions including medical director of McAllister College and the Metropolitan Health Plan. Dr. Charles Sr. broke ground as the first African-American OB/ GYN in Minnesota. An Alabama native, he went from “shining shoes and picking cotton to saving lives.” An early sign of success, Dr. Charles Sr. was Intern of the Year at Ancker (now Regions) Hospital. In over 40 years of practice, he has delivered nearly 10,000 babies between Fellowships in the American College of OB/GYN and teaching at his alma mater. As civic leaders, Dr. Susan served as chair of the Minneapolis Children’s Hospital Board, and Dr. Charles served as chief of OB/ GYN at United Hospital. They continue to work tirelessly to improve children’s health and health care access for minority women. The Crutchfields’ children and grandchildren excel in medicine, law, movie production, photography, philanthropy, and cultural education. Their accomplishments are featured regularly in published accounts of historical and present-day St. Paul. Their son, Dr. Charles III is one of our community’s leading dermatologists with a practice known as a national model of delivering effective care. He serves as team dermatologist for the Twins, Vikings, Timberwolves, and Wild. He is a frequent guest on TV and radio, has published more than 100 dermatology articles, co-authored a textbook and children’s book on sun protection, and holds multiple patents for skin medication.

Charles Crutchfield Sr., MD and Charles Crutchfiled III, MD, present day

Charles Crutchfield Sr., MD and Susan Crutchfield, MD at the U of M Medical School graduation in 1963. Charles Crutchfield III, was 3 years old.

“My parents’ stature as physicians made practicing medicine in Minnesota easy,” he explains. “Here I am. Same city. Same name. People come to me as a doctor because of their reputations. I do my best to honor the Crutchfield name by serving my patients to the best of my abilities.” Dr. Charles III established the “Doctors Charles and Susan Crutchfield Annual Lectureship” at the University of Minnesota. Focused on advancing the treatments for ‘Skin of Color,’ the Crutchfield Lectureship fittingly reflects a commitment to improving lives in Minnesota and beyond. “My parents and I have the same philosophy,” says Dr. Charles III. “When you do something you love in a place you cherish, it is not work at all. I love the ability to use my skills to help people in my community when they most need it.” The best place to live, indeed.

Charles E. Crutchfield III, MD, is a graduate of the Mayo Clinic Medical School and a Clinical Professor of Dermatology at the University of Minnesota Medical School. Dr. Crutchfield is an annual selection in the “Top Doctors” issue of Mpls. St. Paul Magazine and is the only dermatologist to have been selected as a “Best Doctor for Women” by Minnesota Monthly magazine since the inception of the survey. Dr. Crutchfield has also been selected as one of the “Best Doctors in America,” an honor awarded to only 4% of all practicing physicians. Dr. Crutchfield is the co-author of a children’s book on sun protection and dermatology textbook. He is a member of the AOA National Medical Honor Society, an expert consultant for C I T E H T AES WebMD and CNN, and a recipient of the Karis Humanitarian Award from the Mayo Clinic School of Medicine. L OF APPROVA L SEA

1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS VOLUME 19, NO. 5 SEPTEMBER/OCTOBER 2017

IN THIS ISSUE

Pursuing Health Equity By Thomas E. Kottke, MD

PRESIDENT’S MESSAGE

How Can I Get Involved? By Matthew A. Hunt, MD

5 7

Page 32

TCMS IN ACTION By Sue Schettle, CEO STRIVING FOR HEALTH EQUITY

•

Colleague Interview: A Conversation with Patricia F. Walker, MD

•

Health Equity and Social Cohesion By Edward Ehlinger, MD, MSPH

•

SPONSORED CONTENT:

Promoting Health Equity by Managing Diabetes in Diverse Populations By Jennifer Hines, MD

Page 7

•

The Uganda Research Training Collaborative: Inspiring the Next Generation of Health Science Researchers Through Global Partnerships By Molly McCoy

•

Mutual Trust Between Patients and Physicians: Bridging Cultures, Building Relationships By Steven Vincent, MD

•

Mental Health Care Equity for Latino Community By James Jordan, MD

Page 27

Restricting the Sale of Menthol Flavored Tobacco

Honoring Choices MN: Sharing the Experience 2017

Honoring Choices MN

September/October 2017

Striving for Health Equity

In Memoriam

In This Issue:

Spotlight on Books Career Opportunities

32 Page 26 MetroDoctors

LUMINARY OF TWIN CITIES MEDICINE

Phillip K. Peterson, MD The Journal of the Twin Cities Medical Society

• Get Involved! • Finding Your “Cultural Humility” • 8th Annual Sharing the Experience Conference • Luminary of Twin Cities Medicine

The face of our community is changing. How are you responding? Several authors offer tips. Articles begin on page 7.

September/October 2017

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 Stephanie Misono, 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 Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle 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 reflect the official 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

September/October 2017

TCMS Officers

President: Matthew A. Hunt, MD President-elect: Thomas E. Kottke, MD Secretary: Andrea Hillerud, MD Treasurer: Nicholas J. Meyer, MD Past President: Carolyn A. McClain, MD TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799; sschettle@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 Grace Higgins, Project Coordinator, Physician Advocacy Network (612) 362-3706; ghiggins@metrodoctors.com Annie Krapek, Assistant Project Coordinator, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com Sadie Rubin, Program Coordinator, The Convenings (612) 362-3724; srubin@metrodoctors.com

September/October Index to Advertisers Crutchfield Dermatology..................................... Inside Front Cover Entira Family Clinics .......................................29 Fairview Health Services .................................31 HealthPartners....................................................10 HealthPartners

....................Inside Back Cover

Kinder Village Child Care ..............................26 Lakeview Clinic .................................................31 M Health ............................................................... 6

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.

Mankato Clinic .................................................... 2

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.

PrairieCare PAL .................................................28

MMIC ................................ Outside Back Cover PrairieCare ...........................................................23 St. Cloud VA Medical Center .......................30 U.S. Army .............................................................. 8

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Pursuing Health Equity

WELCOME TO THE SEPTEMBER/OCTOBER ISSUE OF MetroDoctors. The editorial board chose the theme, “Striving for Health Equity,” because it’s time for action, and we have colleagues in the Twin Cities metro who can teach us how we can do better. Dr. Pat Walker, the subject of our “Colleague Interview,” is one of the most fascinating people I know. Born in Taiwan, and living in Southeast Asia until age 11, she saw tremendous health disparities. As a result, not only is she a national and international leader in tropical medicine, she has created both clinical and educational resources right here in our own community. Dr. Ed Ehlinger, as Minnesota’s Commissioner of Health, has directed his agency to promote the “Triple Aim of Health Equity” with the goal of promoting social cohesion. Given our recent events, I wholeheartedly agree that our community can benefit from these efforts. The recent (and perhaps ongoing) measles epidemic reinforces for us the importance of building community partnerships to promote health equity. In the next article, Dr. Michele Allen and Mikow Hang describe the many accomplishments that the University of Minnesota Program in Health Disparities Research has experienced in the 10 years since its inception. In telling the very personal story of Dr. Tedla Kefene, Dr. Edwin Bogonko and Yende Anderson describe the barriers that foreign-trained physicians face when attempting to qualify for practice here. The International Medical Graduate Assistance Program is making it possible for more recently-arrived Minnesotans to visit an experienced physician who speaks their native language. It may seem hard to imagine that you may never see your children again if you try to find food for them; but this is a risk that our undocumented residents face. In an article that moved me, Dr. Eileen Weber, a nurse attorney, describes seven key actions that health care providers can take to help their patients stay safe. With few exceptions, physicians practicing in the Twin Cities metropolitan area have a multi-ethnic, multicultural

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

MetroDoctors

The Journal of the Twin Cities Medical Society

practice. Having practiced in the Midway area for 10 years, Dr. Jennifer Hines describes the “tools of the trade” that she uses to provide high quality care and produce outstanding outcomes for a diverse population of patients. Did you know that the University of Minnesota has a training hub in Uganda? As described by Molly McCoy, the hub was launched in 2015 to give the medical students more opportunities to conduct hands-on global health research. Partnering with their counterparts from Makerere University, the students not only learn the science of research but gain the skills of collaboration. Mutual trust is essential for a successful medical encounter, and Dr. Steven Vincent describes how he approaches this goal at the People’s Center. Among a number of cogent observations that apply to every practicing physician, Dr. Vincent quotes Dr. Francis W. Peabody, “For the secret of the care of the patient is caring for the patient.” In the penultimate article in this issue focusing on the pursuit of health equity, Dr. James Jordan observes that many Latinos could benefit from greater access to mental health services. To encourage their use, Dr. Jordan has created a video series of conversations with individuals who have benefited from mental health services. Dr. Marv Segal concludes this issue with the biography of Dr. Phillip K. Peterson, this issue’s Luminary. Among his many accomplishments, Dr. Peterson has led the Infectious Disease Departments at HCMC and the University of Minnesota, and the International Medicine Department at the University of Minnesota. Among his other gifts to our community is his advocacy for better health through cleaner energy sources. The task of striving for health equity becomes increasingly important as our community becomes more and more diverse. Therefore, I urge you to read this issue of MetroDoctors cover to cover and then engage with both your head and your heart. I predict that you will feel personal benefit as you also benefit your patients and our community. September/October 2017

President’s Message

How Can I Get Involved? MATTHEW A. HUNT, MD

TWIN CITIES MEDICAL SOCIETY (TCMS) IS ABLE TO ACCOMPLISH its impactful

work by utilizing physicians who volunteer their time to support its mission. Every step we make in affecting policy, advocating for change, and supporting physicians in the Twin Cities requires that our members help to move these important goals forward. Physician volunteerism is the lifeblood of the organization. Fortunately, physicians naturally want to pitch in to make medicine and the health of the public better! Personally, I know that what started as a curiosity to learn about TCMS has led to the opportunity to meet and collaborate with colleagues all over the metro area. I believe that TCMS has made a positive impact on physicians and patients throughout the region, and I am proud to be a small part of this great organization. It is also important to recognize that while physicians are working at their “day jobs,” TCMS has staff committed to these efforts behind the scenes to organize, engage, and fund the initiatives that make our communities healthier, our jobs more satisfying, and provide the resources to make Minnesota and the Twin Cities a great place to live and work. Perhaps you are interested in what TCMS does, but aren’t quite sure where to start. Here are some of the many ways you can join in: • Public Health Advocacy Committee: This committee is looking to expand the role of physicians in metrobased public health-related issues including tobacco, and is now looking at obesity-related topics such as putting restrictions around sugared-sweetened beverages. • Honoring Choices MN: Volunteer to serve as an ambassador for our program to help spread the message about the importance of advance care planning. • Physician Advocacy Network: We need physicians interested in expanding their role in advocacy via the PAN. Current issues include: T21 (Tobacco 21 initiatives), menthol cigarettes and other flavored tobacco products, e-cigarettes, and hookahs. We also welcome the opportunity to support physicians, like Caleb Schultz, MD, who championed the T21 issue by himself before we connected with him about 18 months ago. There are other physicians out there doing great things too. How can we help support you in these efforts? • Environmental Health Task Force: This committee is looking for committee members AND local issues that physicians are knowledgeable about happening within their cities and counties. Poor air quality, bad water, health disparity — issues all related to the environment. • Board of Directors: Both the TCMS and the TCMS Foundation are interested in physicians who want to serve on our boards! • Shadow a Physician: We have opportunities for medical student mentoring (1/2 day commitment, all specialties). • Physician Wellness Committee: In 2018, we will be creating a Physician Wellness Committee to support our increasing efforts in this area, particularly as we partner with Physicians Serving Physicians (PSP). • MetroDoctors Editorial Board: Our membership publication. Article suggestions and interest in an editorial board seat are always welcome. Lastly, if one of these areas doesn’t quite fit, let us know what you think we should be doing! We are always looking for new ways to grow and support our medical community. Please feel free to contact me or Sue Schettle with questions. huntx188@umn.edu, or sschettle@metrodoctors.com.

September/October 2017

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

UMN Medical School Admissions Committee

TCMS has the opportunity to recommend for appointment two seats on the UMN Medical School Admissions Committee. Dorothy Horns, MD was recently appointed to serve a 3-year term replacing Dan Nichols, MD, and joins Carolyn McKay, MD who occupies the other appointed seat. We appreciate their service on this important committee! Sadie Rubins joins TCMS as The Convenings Program Manager

Sadie Rubin joins The Convenings with a background in nonprofit program development and management. As Program Manager for The Convenings, Sadie serves as the lead staff person for this ongoing initiative, managing and implementing the key stages of The Convenings. A recent transplant from Richmond, VA, Sadie spent the last four years running PALETTE, an intergenerational arts program she founded to connect health professional students with older adults through creative activities. Sadie received her MS from Columbia University School of Social Work, focusing her studies on Social Enterprise Administration in the Field of Aging, and her BA from Kenyon College in Gambier, OH. She has worked in a variety of settings including nursing homes and assisted living facilities. Welcome Sadie! Senior Physicians Association

MDH Health Commissioner Edward Ehlinger, MD will be the featured speaker discussing “The State of Health in Minnesota” at the October MetroDoctors

10 meeting of the Senior Physicians Association. Online registration will be available September 11. White Coat Ceremony

Thomas Kottke, MD, TCMS PresidentElect, and Nancy Bauer, Associate Director, participated in the UMN Medical Student White Coat Ceremony on Friday, August 4. A gift of two penlights was presented to each first year student at this commemorative event. Dr. Kottke also had the opportunity to address the medical students as a guest speaker on the program sharing the mission of TCMS “to connect, represent and engage physicians in improving clinical practice, policy development and public health initiatives.” He encouraged the students to engage their passions for these causes by getting involved in TCMS.

Public Health Advocacy Committee

The TCMS Public Health Advocacy Committee is looking for a few new members. If you’re a public health junkie and want to get involved in advancing public health priorities in the metro area, we want to hear from you! Email Grace Higgins at ghiggins@metrodoctors.com for more information. Physicians Serving Physicians

TCMS and PSP are continuing discussions about a stronger partnership in 2017-2018. A proposal was sent recently to PSP leadership and we are waiting for the next step in the process. Hopefully

The Journal of the Twin Cities Medical Society

by the time I write my next In Action column we will have resolved the remaining issues. Tobacco Initiatives

Thomas Kottke, MD, was recently interviewed by high school students of ThreeSixty Journalism (http://threesixtyjournalism.org/), a program that aims to increase the presence of minorities in newsrooms in order to better reflect and serve increasingly diverse communities. Dr. Kottke spoke to students from the TV Broadcast Camp on the issue of restricting the sale of menthol flavored tobacco products to adult-only tobacco shops, as well as students from the News Reporter Academy on the issue of e-cigarettes and the targeting of youth. Grace Higgins, Project Coordinator for the Physician Advocacy Network (PAN) also spoke to students about the risks of e-cigarettes. WCCO and the Star Tribune will be considering both stories for publication. Ken Kephart, MD, testified at the public hearing on the Health, Environment and Community Engagement Committee in Minneapolis in support of an amendment to include menthol in the city’s existing flavor restrictions. Student advocate Prashasti Bhatnagar also testified on behalf of the University of Minnesota’s Student Advocates Against Menthol, a group composed of medical and public health students supportive of the amendment. Grace Higgins of the PAN testified in support of the measure on behalf of the 3,000 physicians and medical students living in Minneapolis. September/October 2017

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The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ÂŠ 2017 University of Minnesota Physicians and University of Minnesota Medical Center

Striving for Health Equity

Colleague Interview: A Conversation with Patricia F. Walker, MD

atricia F. Walker, MD serves as the Associate Program Director for the Global Health Pathway in the Department of Medicine at the University of Minnesota. She is a Professor, Division of Infectious Disease and International Health in the Department of Internal Medicine at the University of Minnesota, and Adjunct Professor in the School of Public Health, Division of Epidemiology and Community Health. She was the Medical Director at HealthPartners Center for International Health from 1988-2011, a nationally known refugee and immigrant health clinic. She stepped down in 2011 to pursue more research and teaching interests, supported by a Global Health Fellowship from the Medtronic Foundation and continues to provide patient care and teach at the Center for International Health. She is currently serving as President, American Society Tropical Medicine and Hygiene. Dr. Walker attended Mayo Medical School and Mayo Graduate School of Medicine, where she received a Graduate Travel Award for Outstanding Achievement in Internal Medicine. She is board certified in Internal Medicine and holds a Certificate of Knowledge in Traveler’s Health (International Society of Travel Medicine); Certificate of Knowledge in Clinical Tropical Medicine & Traveler’s Health (American Society of Tropical Medicine & Hygiene); and a Diploma in Tropical Medicine & Hygiene (London School of Tropical Medicine and Hygiene).

Editorial board member Thomas E. Kottke, MD, sat down with Patricia Walker, MD, and conducted this colleague interview.

You are now president of the American Society of Tropical Medicine and Hygiene.

When did you first think about medicine from an international perspective?

Yes. Formed in 1903, this is the largest international society dedicated to ridding the world of tropical diseases. The organization brings together the world’s top research scientists, clinicians, and medical educators who are experts on tropical diseases including malaria, tuberculosis, intestinal parasites and neglected tropical diseases such as onchocerciasis (river blindness) or Guinea worm. We focus on sharing scientific information through our journal and annual meeting, supporting our members including trainees and international colleagues, as well as public policy and advocacy surrounding global health and tropical medicine issues.

I’d say medicine was never something separate from my life. I was born in Taipei, Taiwan and moved to Bangkok, Thailand when I was five. I was living a very comfortable life but seeing disparities at every level: political, economic, health. In the ’60s in Bangkok, I saw people with polio, people who were amputees and people with leprosy. I spent a lot of time as a kid at the snake farm in Bangkok. Even now, snake bite is a major killer in India and other rural areas. So I got to learn about how they milked the snakes to get the venom and inject horses to get the anti-venom. I also learned about serum sickness. I was just curious from a young age about tropical diseases. Plus, my father’s work brought me into contact with many people working with refugees in Southeast Asia. It was normal dinnertime conversation to hear about things like cholera epidemics in Laos, or how to start training Hmong girls in nursing for the first time. MetroDoctors

The Journal of the Twin Cities Medical Society

What is the role of funding in preventing outbreaks of tropical diseases? As you know, President Trump’s initial budget proposes to cut 21% from the NIH and funds from many other global health programs. When we “put America first” and only fund programs (Continued on page 8)

September/October 2017

Striving for Health Equity Colleague Interview (Continued from page 7)

in America and not fund the Fogarty International Center, or USAID to do family planning, or the CDC’s work on global migration, we are not as safe, not as healthy. Investment in healthy communities around the world makes all of us healthier because migration is an innate behavior of human beings. Migration is probably one of the most fundamental things we do as humans; we will always migrate in hope for a better future for ourselves or our kids. There is no such thing as diseases “over there” and diseases here. The global is local in healthcare. Studies and experiences with epidemics show that if you try to build walls of any type around research communities or exchange of information, if you try to respond to an epidemic like Ebola by shutting off air transportation to those countries so researchers can’t get in, people will always find a way to move across a border anyway. Isolationism actually threatens global health security.

Where can physicians get help if they have a tropical medicine problem? A physician has two choices: a local infectious disease specialist or a travel and tropical medicine expert. The American Society of Tropical Medicine and Hygiene website (www.astmh.org) has a list of knowledgeable consultants.

Let’s talk about patients. How is it possible to achieve cultural competency when patients in the Twin Cities speak 250 different languages? We no longer teach the old idea of cultural competence; we encourage adopting what we call “cultural humility.” The best thing to do with a new patient from a different culture is to spend time in those first couple of appointments asking, “Tell me about you: where were you born; where have you traveled? Tell me your story. How did you get to America?” If you’re detecting some patient resistance during a consultation, always remember that a patient’s resistance is generally based on either not having experienced or not understanding what you’re asking of them — they may be lacking health literacy. I take the long view with my patients. It may take me three, four, or five visits to convince a woman to have a pap smear. But I stay patient and do not give up on it. We’ve shown in our clinic that our uptake on preventive services is good because we spend enough time on the issue, and don’t give up. Another important tool is the teach-back method. For example, at the end of a visit I would ask, “So, tell me what you’re going to do.” Studies show that, if you don’t ask the patient what they recall, your understanding and the patient’s understanding are likely to be disparate.

THE STRENGTH TO HEAL

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September/October 2017

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The Journal of the Twin Cities Medical Society

Are there online or printed resources if a physician has international patients?

Why is it not appropriate to use the family as interpreters?

Any urban physician in the U.S. is going to be seeing immigrants, refugees and travel patients. I suggest looking at the health profiles for newly arrived immigrants on the CDC website. https://www. cdc.gov/immigrantrefugeehealth/index.html. Among these resources are refugee health guidelines; health profiles; domestic and overseas guidelines; and the meds that a patient might have received overseas. There are also tips for physicians. All of this can be done in about five minutes. Up-to-Date also has a chapter on refugee new arrival screening. I also suggest looking at Immigrant Medicine, a textbook I co-edited with Elizabeth Barnett from Boston. The first of its kind, this book contains the information that any physician in an urban setting in America ought to know about immigrant health, and not only from an infectious disease standpoint. It also contains, for example, instructions on how to do a good cross-cultural interview, how to talk to people about end of life across cultures, and how to set up a clinic which provides best care for immigrants.

Family and friends should never be used to interpret for a number of reasons. It’s an accuracy issue and a privacy issue. The family may not know medical language and there may be issues of confidentiality even within the family. Take the example of a patient who is infertile because she has schistosomiasis of her fallopian tubes, and she needs surgery. Can her 15-year old daughter translate that accurately? And maybe the mom doesn’t want her daughter to know she’s infertile because, if her husband knows, he might divorce her. We have many examples from the old days in the Twin Cities when a patient needed to have emergency surgery for an ectopic pregnancy or a ruptured ovarian cyst, the family member who interpreted the surgery as, “They’re going to take out your pelvic organs,” and patients refused the procedure, with sometimes poor outcomes. So here’s what I do. I say, “Thanks so much for coming today, I appreciate you being here, I need your voice today but I’d like you to relax and be the great son or daughter you are because we have a rule at HealthPartners that we have to use a professional interpreter. Later I will ask you how you think your parent is doing, but you don’t have to be the interpreter.” If there’s a confidentiality issue, I do ask the relatives to leave the room. There’s lots of data — hundreds of articles with great examples — about poor patient outcomes when family members interpret.

What can we do about health disparities in these populations? The big reasons why there are health disparities are: health system-level barriers such as access/insurance issues and language; patient-level issues such as cultural differences; and provider-level issues such as implicit bias and lack of knowledge of immigrant health issues. We have really granular demographic data at HealthPartners — meaning not just the OMB (Office of Management and Budget) required stuff — but we have country of origin, and lacking that, language as a proxy for country of origin. We can look at that data and use it to drive our health equity efforts through our Equitable Care Sponsors Group. For example, we saw disparities for Somalis in colorectal screening, so we did some specific outreach. We saw disparities for foreign-born black women compared to U.S.-born black or U.S.-born white women for mammograms. These were dramatic disparities, so we did a pink ribbon program where the patient can be given a bus token and get their mammogram the same day. There are three levels to moving to reduce health disparities. The first one is knowing who you’re taking care of. The last time I looked only about 15% of big integrated care systems in the U.S. have that level of demographic granularity, as reflected by language and country of origin, not just race/ethnicity. The second level is knowing how you’re doing in caring for them; having a health disparities report card; having it be part of your regular reporting mechanisms and PDSA cycles. The third level is the really hard work where you’re actually beginning, trying to understand those disparities and intervening.

What about those of us who know a bit of a second language? If you’re a provider and you think you’re bilingual, really test whether you are capable of using your bilingual skills without a professional interpreter. I’ll give myself as an example. I’m fluent in Thai, so I wouldn’t need an interpreter for Thai. But my Cambodian is about 80%, so I always use an interpreter for Cambodian. So the general rule is that you use an interpreter if you have the slightest doubt about your fluency. Some health systems are instituting testing language proficiency of providers before they allow them to work without an interpreter.

Do second generation patients need a different approach? There are two things in particular to think about that are different with a second generation patient. One is the unique cultural stressors they have as they navigate two worlds. So I would use the same approach. “Tell me about you, what you believe about your health, what you are worried about.” In addition, second generation children are at risk for tropical diseases because they’re

(Continued on page 11) MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2017

Improving diabetes care in diverse communities Approximately 9.3 percent of the U.S. population has diabetes. Clinicians at HealthPartners and researchers at HealthPartners Institute are working together to eliminate ethnic and cultural barriers that prevent optimal diabetes treatment. HealthPartners Institute is one of the largest medical research and education centers in the Midwest. As 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.

450+ ACTIVE RESEARCH STUDIES EACH YEAR Jennifer Hines, MD Internal Medicine

Colleague Interview (Continued from page 9)

more likely to be traveling back to their home country with their parents. The visiting friend and relative (VFR) traveler will include second generation children, and they are at higher risk for acquiring tropical diseases.

Does it help to have diverse caregivers? Or is it too soon to tell? That’s an area where there is some literature, but I want to see more literature about it. There are some studies that suggest there’s no difference. There are studies that suggest that clinicians are happier if they have concordance of some type with the patient: gender, sexual preference, language or culture. Other studies suggest gender concordance, either female to female or male to male, may improve uptake on preventive services. More studies need to be done about language and cultural concordance and their impact on satisfaction and outcomes. There is good data on patient satisfaction. Levels of trust, “would I recommend this office?”, “would I recommend this provider?” are all higher if the patient and provider are concordant with language or country.

What are your fears and shortcomings in the current delivery system model? My biggest fear is that of every other American, it’s access. Defunding. It’s really sobering. I’m generally really optimistic about the next generation. These resident physicians have traveled a ton since high school and medical school. They get this ‘global is local’ stuff. They’re also really savvy on the web so they search for answers they don’t have. Those are two really positive things. We still have a lot of work to do to acquire the body of knowledge and incorporate it into the medical and other graduate school curricula. I’m really proud of the University of Minnesota program at the graduate medical education level — the Global Health Pathway in the Internal Medicine residency. We’ve had more than a hundred graduates of the global health pathway in the last 12 years, and our published data show that resident physicians are acquiring the knowledge they need. Many have obtained outstanding positions in global health around the world. In addition, they do not have to leave the country to provide great care to immigrants and travelers. At Regions Hospital, they add to the differential diagnoses for the 12% of admission who don’t speak English. Another example that I feel really strongly about is the move toward advance directives discussions with every patient above 65. That really worried me around doing harm with patients. I had multiple examples of that occurring in clinic where the patient thought, “My doctor’s giving up on me,” or “I have to leave my doctor of 25 years. I must have some unknown diagnosis that they’re not sharing with me.” Or, “My doctor’s cursing me; my

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doctor is shortening my life.” We did a survey of patients which showed that you cannot generalize about any ethnic group in relationship to advance directives; you cannot assume anything about how a Hmong or Somali or European American patient will feel about the issue. A bunch of us in the Twin Cities spent a year developing a best practices curriculum: Honoring Choices Across Cultures. It gives 4.5 hours of CME credit. It begins with the theme about how you approach issues like this. You say, “May I have permission to talk with you about something we usually talk to patients about in America at age 65: thinking ahead to your future if you got sick?” That goes back to the basic introduction, “Tell me about you. What would you like to do at the end of your life?” So ask permission. If the patient says no, just stop. Just don’t do it. (https://www.dom.umn.edu/global-health/education-training/ courses/online/honoring-choices-across-cultures-end-life-andadvance-care-planning)

Something else you want to tell the reader? Maybe it’s because I’m more Asian than American, but I tend to take the long view on things. That I look back over my career, 37 years in the field, and there were no professional interpreters, no one trained in tropical medicine, no textbooks, and no guidelines. In addition, I did not have many of the incredible first-generation immigrant colleagues working side-by-side with me as I do now. So, I’m extremely pleased with the progress we’ve made, and also remain very humble about the work that needs to be done. For young physicians going into the field of global health, travel and tropical medicine, refugee and immigrant health — there’s plenty of work to do. Many, many research questions to be answered, teaching that should be done both personally and being a teacher, and it’s fun. Approximately 50% of our residency applicants at the University of Minnesota come because of the global health program. We are the only residency program in the country where, if you fulfill all the requirements of our pathway, you can sit for the tropical medicine exam at the end of your residency. So what cost me twenty thousand dollars in London, a medical resident gets for free.

What is your wish for the state of medicine when you are ready to retire? I’ll 1) 2) 3)

be ready to retire when three things happen consistently: Physicians ask, “Where were you born?”; “Where have you traveled?”; and Physicians actually know what to do, or who to call for the answer.

September/October 2017

Striving for Health Equity

Health Equity and Social Cohesion

“The greatest epidemic today is not TB, HIV, or leprosy — it is being unwanted. … Being unwanted, unloved, uncared for, forgotten by everybody is a much greater hunger, a much greater poverty than (having) nothing to eat.” – Mother Teresa1 The standard approaches of contemporary medical care and public health have been insufficient in reducing the persistent and seemingly intractable health disparities in our society; challenging us to rethink how we do our work. Continued improvements in the provision of affordable, accessible, and culturally responsive health services are essential but insufficient to achieving our health equity goals. Given our current understanding of what determines health,2 we must expand our focus beyond health status disparities to include the inequities in opportunities in our political, economic, educational, healthcare, and social systems that are at the core of health disparities. We must then work to change the policies, structures, and environments that make those systems inequitable and which disproportionately impact the health of populations of color and American Indians, the LGBTQ population, the disabled, immigrants, and refugees. Most importantly, we must recognize that creating health and health equity is not about the health of individuals but the health of a community. As poet and farmer Wendell Berry said, “…the community in the fullest sense is the smallest unit of health…to speak of the health of an isolated individual is a contradiction in terms.”3 By Edward Ehlinger, MD, MSPH

September/October 2017

Unfortunately, too many view health as a zero-sum issue, i.e., if one groups benefits others are disadvantaged. This leads to a form of competition that creates health winners and losers and inequities. Therefore, it is critical that we address the lack of social cohesion — the lack of a sense of community and belonging or, as Mother Theresa noted, “being unwanted” — that is at the root of so many health disparities. In its 2014 Advancing Health Equity Report to the Minnesota Legislature,4 the Minnesota Department of Health (MDH) made the case for addressing the root causes of health inequities and disparities by focusing on the social, economic, and environmental conditions that create health. In addition, recognizing that health disparities and inequities are particularly stark and persistent for populations of color and American Indians, MDH chose to lead this effort with a focus on racial equity, recognizing that race often compounds disparities and inequities linked to gender, sexual orientation, age, and

disability. Advancing health equity is now at the core of the state’s Healthy Minnesota 2020: Statewide Health Improvement Framework5 and MDH’s strategic plan.6 To more effectively advance health equity, MDH created the Triple Aim of Health Equity7 — a set of practices necessary for changing the work of public health. The components of the Triple Aim of Health Equity are based on a theory of change that builds the power and capacity to improve living conditions in every community. The Aims are: • Expand the understanding about what creates health, • Implement a health in all policies approach with health equity as the goal, and • Strengthen the capacity of communities to create their own healthy future. With this framework, efforts are underway to expand the narrative about what creates health; that ill health is not just due to lack of access to healthcare and bad personal lifestyle choices but mostly due to the policies and systems that impact economic, educational, housing, physical, criminal justice, and transportation environments. The Triple Aim of Health Equity also recognizes that health is not solely the responsibility of the healthcare and public health sectors but is impacted by the policies in all other sectors of society. This recognition highlights the need for new and expanded partnerships to advance health equity. Finally, the Triple Aim of Health Equity acknowledges the importance and necessity of strengthening civic participation so the collective voice of community members can effectively impact decisions made by institutions and

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government at all levels that affect their community. All this work is centered on building social cohesion, a prerequisite for achieving health equity. Social cohesion is defined as a group or population that “works toward the well-being of all of its members, fights exclusion and marginalization, creates a sense of belonging, and promotes trust.”8 Among the constituent elements of social cohesion are social capital (the resources that result from people working together toward a common goal), social mobility (the ability to move up in social or economic status), and social inclusion (having connection to and ownership of community goals, having a sense of belonging — being wanted and needed). According to John A. Powell, Director of the Haas Institute for a Fair and Inclusive Society, that sense of “belonging means more than just being seen. Belonging means being able to participate in the design of political, social, and cultural structures. Belonging means the right to contribute and make demands upon society and institutions.” Social cohesion can be developed only if all parts of the Triple Aim of Health Equity are being actualized. A common understanding about what creates a thriving and prosperous community (expand understanding) is essential for building the social capital necessary for a socially cohesive society. An inclusive, coordinated, and accountable policy-making process that incorporates the views of all stakeholders in all sectors of the community enhances MetroDoctors

social cohesion. Equitable fiscal, employment, housing, educational, and social policies (health in all policies) are key to building a sense of social inclusion and belonging and creating social mobility, key components of social cohesion. Providing community members with a space and opportunity to share their perspectives and impact policy decisions is also fundamental to creating social capital and a sustainable, socially cohesive society (strengthening community capacity). Enhancing civic participation and political feedback mechanisms are essential components. The process of policy making is as important as the policies themselves for building social cohesion.9 That process should always include these questions about policy decisions: • Do they lead to more or less social inclusion and a sense of belonging? • Do they foster trust, civic participation, and social capital? • Do they help improve social mobility? Public health is defined by the Institute of Medicine as “what we, as a society, do collectively to assure the conditions in which (all) people can be healthy.”10 Those conditions are influenced by the policy decisions made at all levels of society. If we are to change the policies to improve health equity, we must constantly ask the basic question: what would our work be like if health equity was the starting point for all policy and programmatic decisions? I believe our work would be different. Our work would be shaped by the Triple Aim of Health Equity; we would expand the understanding of what creates health,

The Journal of the Twin Cities Medical Society

implement a health in all policies approach with health equity as the goal, and strengthen the capacity of communities to create their own healthy future — all with the objective of increasing social cohesion and belonging. Our work would be to build a proper community as described by Wendell Berry: “A proper community… is a commonwealth: a place, a resource, an economy. It answers the needs, practical as well as social and spiritual, of its members — among them the need to need one another.”11 A community where no individual or group is unwanted and where everyone has a sense of belonging and the opportunity to be healthy. Edward Ehlinger, MD, MSPH has served as Commissioner, Minnesota Department of Health, since January 2011. Prior to this appointment Dr. Ehlinger served as Director and Chief Health Officer for Boynton Health Service at the University of Minnesota (1995-2011) and as Director of Personal Health Services for the Minneapolis Health Department (1980-1995). He also held the position as an adjunct professor in the Division of Epidemiology and Community Health at the U of M School of Public Health and was the 2010 President of Twin Cities Medical Society. (Endnotes) 1. https://www.brainyquot e.c om /quot es / authors/m/mother_teresa.html. 2. Determinants of Health Model: Tarlov AR. Ann N Y Acad Sci 1999; 896: 281-93; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17): 20812083. 3. Wendell Berry in Health is Membership. Delivered as a speech at a conference, “Spirituality and Healing,” at Louisville, Kentucky, on October 17, 1994. 4. http://www.health.state.mn.us/divs/chs/healthequity/ahe_leg_report_020114.pdf. 5. http://www.health.state.mn.us/healthymnpartnership/hm2020/1212healthymn2020fw. pdf. 6. http://www.health.state.mn.us/about/strategicplan.pdf. 7. Ehlinger, E.P., We need a Triple Aim for Health Equity, MINNESOTA MEDICINE, October 2015, p 28-29. 8. OECD (2011), Perspectives on Global Development 2012: Social Cohesion in a Shifting World, OECD Publishing, http://dx.doi.org/10.1787/ persp_glob_dev-2012-en. 9. http://wikiprogress.org/articles/poverty-development/social-cohesion/. 10. The Future of Public Health: Institute of Medicine’s 1988 report, J Public Health Policy. 1989 Spring;10(1):19-31. 11. Wendell Berry, The Art of the Commonplace: The Agrarian Essays.

September/October 2017

Sponsored Content

Building Strategies with Communities to Address Health Disparities Contributed by Michele Allen, MD, MS, and Mikow Hang While Minnesota is consistently ranked as one of the healthiest states in the nation, health inequities and the social and structural determinants that drive them are disturbingly prevalent within many of our communities. The Centers for Disease Control and Prevention defines health disparities as “a type of difference in health that is closely linked with social or economic disadvantage.”1 In Minnesota, Michele Allen, MD, MS Mikow Hang the overall cancer mortality rate for African Americans is 14% higher than it is for Whites, whose average cancer mortality rate is lower than the overall nahealthcare and social service initiatives that tional average.2 Although the state’s infant work to eliminate disparities and promote mortality rate is lower than the national averhealth equity. age, among American Indians, it is almost PHDR takes three main approaches to twice that of Whites in Minnesota. addressing health inequities: In response to these health challenges, • Establishing community-engaged rethe University of Minnesota Medical School search and programmatic initiatives established the Program in Health Dispari• Training and supporting a diverse and ties Research (PHDR) in March 2006. equity-oriented healthcare workforce PHDR seeks to address health disparities • Identifying policies that address systhrough collaborative research, innovative tems-level change approaches to health education and medical Engaging the Community training, and the establishment of initiaOver the past 10 years, PHDR has generated tives and partnerships across the medical, multiple partnerships with community orgaresearch, and local communities. PHDR nizations, community members, and stakeworks with community members and inholders in other health institutions. Based cludes faculty from across the University’s on the premise that community members Academic Health Center schools, including and the organizations that serve them have Medicine, Nursing, Dentistry, Pharmacy, the knowledge and wisdom to co-determine and Public Health. research, policies, programs, and projects Collaborative Research and that impact them directly, these partnerships Programs Addressing Health work to ensure that authentic community Disparities engagement takes place at all levels of PHDR PHDR’s mission speaks to the comprehenwork. Establishing community engagement sive, multicomponent approaches needed is complex due to social divisions within our to address health inequities in Minnesota. society, notably structural racism and a hisAlthough PHDR is housed in the Univertorical legacy of research that has prioritized sity and focused on research, we believe its the needs of research and researchers over the work can help identify models for larger interests of communities. For these reasons, 14

September/October 2017

PHDR and our community partners have developed educational materials, tools, and processes that support the development of community-academic partnerships. These support our own work and are available to others on the PHDR website (https://www.healthdisparities.umn.edu/). At a strategic planning level, the PHDR Advisory Board, which is comprised of community and academic leaders in health equity, provides guidance and feedback on PHDR’s strategic plan and programming priorities. At a programmatic level, PHDR prioritizes community interests and topics through events such as the Community Dialogue Series, which brings physicians and researchers to community organizations to speak on health topics that community members have chosen. The Pilot Grant program each year funds research projects on topics defined by community members and that are conducted in partnership with academic researchers. PHDR partners with key community agencies across the metro that provide essential health services and education. Southside Health Services hosts Clipper Clinics — events that provide free preventive health care services and health screenings in local barbershops or beauty salons. PHDR regularly co-sponsors health awareness events with community and academic partners, such as the ANIKA Foundation and Somali, Latino and Hmong Partnership for Health and Wellness — Westside Community Health Services. In collaboration with University of Minnesota’s Masonic Cancer Center, PHDR developed educational materials on cancer and cancer disparities for wide dissemination at health fairs, conferences, and events around the metro and state. At the Minnesota State Fair, PHDR staff offer medical screenings, panel discussions,

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poster presentations, and host community listening sessions. One research project that has successfully used community engagement to build and maintain a community-academic partnership for over 10 years is the tobacco-use prevention effort Padres Informados/Jovenes Preparados (Informed Parents/Prepared Youth). The community-university research team co-led by Michele Allen, MD, MS of UMN; Veronica Svetaz, MD, MPH of Hennepin County Medical Center; and Roxana Linares, executive director of Centro Tyrone Guzman, includes representation from two clinics, one school system, and four social service agencies. The co-developed curriculum, designed to prevent tobacco and other substance use susceptibility among Latino youth, supports strong parenting practices and facilitates relationship-building between parents and youth. The curriculum seeks to emphasize Latino cultural values, while addressing the environmental risks related to socioeconomic circumstances and the challenges the youth face in navigating adolescence and the multiple cultures of their parents’ home countries and the broader U.S. A recent study, supported through a five-year, National Institutes of Health (NIH)-funded grant, showed that this culturally grounded family-skills training program prevented substance use susceptibility in participants, particularly in youth in families most removed from Latino cultural traditions.3 The community-university research team has shared its experiences on the benefits of this type of community-engaged work and the lessons learned in developing and maintaining community-university partnerships with community and academic audiences. Diversifying Research Organizations A diverse research community that more closely mirrors our Minnesota communities is a key component of a plan to reduce health inequities. PHDR is committed to developing the next generation of health disparity researchers through providing high-quality mentoring and research training. PHDR organizes and hosts a mentoring program, Health Equity Leadership and Mentoring (HELM), designed to enhance the academic excellence and leadership capacity of diverse faculty and health disparities researchers at University of Minnesota. Launched in MetroDoctors

2014 with 14 fellows, HELM supports junior faculty and postdoctoral fellows within the Academic Health Center who are from underrepresented minority groups and/or whose work focuses on health equity. The program focuses on some of the challenges that trainees from minority and underserved groups and other faculty whose research addresses health equity may face. This spring, HELM alumna Caitlin Caspi, ScD, received a $3.24 million NIH grant to work with her community partners to address food insecurity in the Twin Cities and advance understanding of the ways to improve the hunger relief system. In addition to mentoring faculty, PHDR also provides mentorship to undergraduate students through its Cancer and Health Disparities Summer Internship, which is implemented in partnership with the Masonic Cancer Center. Since its inception in 2009, this program has provided 75 internships and connected undergraduate students from underrepresented backgrounds with researchers pursuing cancer and health disparities-related work in a nurturing educational environment. Creating System-Level Change PHDR also seeks to improve the relevance of health and social determinant policy and its development. A new component of PHDR, the Health Equity in Policy Initiative (HEPI) is directed by Susie Nanney, PhD, and past PHDR community engagement director Huda Ahmed, MPH. HEPI seeks to bridge persistent information gaps on health disparities that exist among researchers, communities, and policy-making bodies, while leveraging community and researcher input in the hopes of advancing equitable and effective health policies. In its first year, this ongoing initiative successfully engaged residents in three communities on issues pertaining to Minnesota’s Safe Routes to School legislation. The initiative developed community engagement materials and strategies with the goal of making research findings accessible, helping create community-centered materials, and facilitating community engagement with policymakers. The work included the Metropolitan Council, Minneapolis Park Board, and Minneapolis School Board, and outcomes from the initiative focused on school busing policy, community-police interactions, and the need for crosswalks.

The Journal of the Twin Cities Medical Society

Summary A common theme across our programs is the importance of working in partnership with communities most impacted by the systemic inequities that generate health disparities. These partnerships promise to generate the most relevant, appropriate, and long-lasting solutions to complex and pressing health challenges and support the health and wellbeing of all Minnesotans. To learn more or to reach the authors, contact the Program in Health Disparities at phdr@umn.edu or 612-625-1654. Discover reports on PHDR-supported research, upcoming events, and training and research opportunities at healthdisparities.umn. edu. Sign up for the monthly e-newsletter at healthdisparities.umn.edu/about/eventsand-announcements/phdr-mailing-list. Michele Allen, MD, MS, is a University of Minnesota Health physician practicing family medicine and serves as Interim Director of University of Minnesota Program in Health Disparities Research. Prior to joining the faculty, she completed a fellowship in primary care research and the Robert Wood Johnson Clinical Scholars Program. She is active in health disparities research and scholarship and serves as a reviewer for several scientific journals. Mikow Hang is a staff member at the Program in Health Disparities Research and an MPH candidate in the University of Minnesota School of Public Health Community Health Promotion program. Prior to joining PHDR, she was the Administrative Director of the Deborah E. Powell Center for Women’s Health. She is an active member of Somali, Latino and Hmong Partnership for Health and Wellness (SoLaHmo). Her research interests are in women’s health, health equity, and immigrant and refugee health. References 1. Centers for Disease Control and Prevention. NCHHSTP Social Determinants of Health. https://www.cdc.gov/nchhstp/socialdeterminants/definitions.html Accessed July 17, 2017. 2. Minnesota Department of Health. Minnesota Cancer Facts and Figures 2015. http://www. health.state.mn.us/divs/healthimprovement/ data/reports/cancerfactsfigures.html. Accessed July 17, 2017. 3. Allen, M L, Hurtado, G A, Garcia-Huidobro, D, et al. Cultural Contributors to Smoking Susceptibility Outcomes Among Latino Youth: The Padres Informados/Jovenes Preparados Participatory Trial. Family & Community Health. 2017;40(2): 170–179.

September/October 2017

Striving for Health Equity

IMG Assistance Program Offers Hope for Many IMGs Seeking to Re-enter the Health Workforce

arch 13, 2017 (â&#x20AC;&#x153;Match Dayâ&#x20AC;?), the day that aspiring physicians learned whether they were accepted into medical residency programs, served as yet another reminder to Tedla Kefene that he was no closer to realizing his dream of serving his community, in Minnesota, as a physician than he had been since 2008. His journey to practicing medicine had come to a screeching halt at the door of entry into medical residency. This journey began in the late 1990s when he immigrated to the United States from Ethiopia. Prior to coming to the U.S., he had a decade of medical experience serving as a general practitioner, medical director, and medical faculty in Ethiopia and Saudi Arabia. Upon arriving in Minnesota, he quickly learned about the steps necessary to practice medicine in this state. As an International Medical Graduate (IMG) he needed to have his educational credentials certified; pass the United States Medical Licensure Exam (USMLE), Step 1 and Step 2 within three attempts; become ECFMG certified; secure medical residency and complete at least two years in an accredited program; pass the USMLE Step 3 exam; and apply for a Minnesota Medical License. He enthusiastically began this journey not knowing that it would be a long and arduous journey, not understanding that it would take more than just hard work and determination and not appreciating that the cost would be more than just monetary.

By Edwin N. Bogonko, MD, MBA and Yende Anderson, JD

September/October 2017

Edwin N Bogonko, MD, MBA

Yende Anderson, JD

As required, his educational credentials were certified and he passed the USMLE, Steps 1 and 2 on his first attempt with high marks. He became ECFMG certified and applied to residency programs. Despite his experience and efforts he was denied. Understanding that there is intense competition for limited residency spots, he took the denial in stride and reapplied the following year. He was denied. He reapplied again. He was denied. He sought help from a non-profit organization, New American Alliance for Development, which provided support and guidance for international medical graduates to recertify as physicians in Minnesota. He even took USMLE, Step 3, an exam taken post residency, to demonstrate that he would be successful in a residency program. Yet every application to a residency program was denied. Kefene was facing two impenetrable barriers. First, the recency of his graduation from medical school. Most residency programs prefer and/or require that

applicants be recent graduates of medical school â&#x20AC;&#x201D; those graduating from medical school within five years of applying to residency. Kefene graduated from medical school over a decade prior to his application to U.S. residency programs. Second, U.S. clinical experience. Residency programs require at least one year of U.S. clinical experience. Most U.S. medical graduates obtain this during the 4th year of medical school. It is extremely difficult to obtain hands-on U.S. clinical experience outside of medical school. In the interim, he worked as an interpreter, laboratory assistant, adult rehabilitator for mental health services, and a health screening provider. He also volunteered in his community providing health education at his church and participating in efforts of non-profit to advocate for the integration of IMGs. After applying to residency programs for over a decade, he was stuck and could get no further despite all his efforts. For the first time in his life, failure to achieve

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his goals seemed to be a possibility. But he wasn’t ready to give up. How does he give up when so many Ethiopians now living in the state of Minnesota long for a physician who speaks their language and knows their culture? How does he give up when he knows his new home needs physicians in the rural and underserved areas of the state? How does he just give up when his son is watching? How does he respond to his son who asks “aren’t you supposed to be a doctor”? Kefene’s journey, commitment to serving as a physician in Minnesota’s medical high need areas and never-ending disappointment is not unique to him. Minnesota is home to roughly 350 IMGs similarly situated. Every year, only a handful enter medical residency, mostly outside of Minnesota, and many more face the disappointment of the denial of acceptance into medical residency. Now a two-year-old program administered by the Minnesota Department of Health is igniting a new hope for many of Minnesota’s IMG community who recognize the needs of the community and want to be a part of the solution to issues like healthcare disparities, access to primary care in the rural and underserved areas of the state and workforce shortages. While Minnesota’s population is growing and becoming increasingly diverse, the state’s primary care workforce is not keeping pace. Currently, 19% of Minnesota’s population is comprised of minority and immigrant communities, but only 13% of the primary care workforce is from minority and immigrant communities. Minnesota is projected to experience a shortage of primary care providers in the next decade. The state also has long and persistent disparities, with minority and immigrant populations experiencing poorer health outcomes and poorer general health than their white counterparts. These disparities are significant for a number of reasons, including their contribution to rising health care costs. Studies show that greater diversity in the health workforce, specifically increased cultural and linguistic competency, leads to improved clinical MetroDoctors

outcomes for racial minorities and immigrant populations. Integrating individuals trained as physicians in other countries into medical practice or an alternate health profession is an important strategy to increase the number and diversity of primary care providers in Minnesota. In 2014, the Minnesota Legislature created a task force on foreign-trained physicians, whose report documented the significant and longstanding barriers immigrant physicians face in entering practice and made broad-based recommendations to integrate these physicians into the healthcare workforce. These recommendations addressed areas such as competency and clinical readiness, as well as the need for additional residency positions, and formed the basis of the unprecedented 2015 legislation when the Minnesota Legislature created the International Medical Graduate Assistance Program. The creation of this program was an important milestone in achieving health equity and diversifying the health workforce. Minnesota is now the first state in the nation to implement a comprehensive program to integrate immigrant and refugee physicians into the physician workforce, taking an innovative step to realize the potential of these uniquely qualified professionals to address the state’s health care needs. The program offers grant funding to community-based grantees, residency programs and other training programs to provide the following activities: career guidance and support, clinical assessment, clinical preparation, assistance with residency applications and dedicated residency positions funded by a public– private revolving fund. The Minnesota Department of Health and its program advisory committee have established a strong collaboration with additional stakeholders, multiple state agencies and educators, and the program has potential as a state and national model. To date, 158 program participants are enrolled in the Career Guidance and Support programs, 15 participants have completed clinical assessment, four will be

The Journal of the Twin Cities Medical Society

chosen to participate in a hands on clinical experience program at the University of Minnesota and four are being funded in residency programs at the University of Minnesota, Pediatric Residency Program and Hennepin County Medical Center, Internal Medicine Residency Program. In addition, 12 IMGs were accepted into residency programs through the national match program in part due to participation in a verifiable process involving U.S. clinical experience, competency and clinical readiness. The program is positioned to have great impact in increasing the use of primary care, thus eliminating healthcare disparities through a more culturally competent workforce and increasing the number of physicians in rural and underserved areas of the state. As Minnesota leads the way, we are grateful for the support of the medical community both in terms of participating as key and valuable stakeholders as well as providing leadership to the task force through representation of the MMA who provided the task force chair. This is a great source of encouragement to Minnesota’s IMG community and Kefene who is anxiously awaiting the announcement of those selected to participate in the clinical experience program at the University of Minnesota. His hope is that he is one of those selected. He is the owner of a dream deferred but now possible as he sees new opportunities on the horizons. Edwin N. Bogonko, MD is a practicing physician/hospitalist in the Twin Cities and served as Chair, of the International Medical Graduate Task Force. He graduated medical school from the University of Nairobi, Kenya, completed an Internal Medicine residency at HCMC and recently graduated with an MBA from the Carlson School of Management. He sits on the boards of both TCMS and MMA. Yende Anderson, JD is the Program Coordinator for the IMG Assistance Program, Minnesota Department of Health. She can be contacted at yende.anderson@state.mn.us or (651) 201-5988. September/October 2017

Striving for Health Equity

Concern for Patients’ Health and Safety Spurs Interprofessional Teamwork “Healthcare providers are ethically bound to protect the health and safety of those in their care. They occupy a unique and vital role in communities and often have greater contact with particularly vulnerable populations, including undocumented immigrants, refugees and asylees.” So starts an interprofessionally written memo authored by a team of lawyers, nurses, physicians, administrators and dentists for their colleagues in various healthcare systems. The memo was written in March, 2017, in response to a growing number of concerning stories from providers about people avoiding or declining necessary health care due to rising fears of deportation and family disruption. Stories included: Patients not applying for food stamps because it might draw attention. Parents not signing consent forms for routine dental care for their children because of fear that the form might be seen by immigration officers. Parents keeping children home from school because of fear of losing them to deportation. Wary patients missing follow-up clinic appointments after hospital discharge because leaving home might lead to never returning. Fear of seeking needed emergency care because of the presence of hospital security guards. Clinic managers wondering what to do if federal immigration enforcement officers showed up in their waiting rooms. Healthcare professionals from other countries, legally in the U.S. themselves, reluctant to speak out because doing so might engender harassment. Victims of violence in our communities afraid to seek help for fear of being sent back to possibly worse violence in another country. Healthcare professionals who witnessed this suffering in their patients started speaking out publicly. Patricia Walker, MD, a University of Minnesota medical professor, President of the American Society of Tropical Medicine and Hygiene, and staff physician at HealthPartners Center for International Health, wrote a compelling op-ed published in the Jan. 20, 2017, Star Tribune decrying President Trump’s “xenophobic, nationalist message” in suspending the nation’s refugee resettlement program. She cited the words emblazoned on the Statue of Liberty, an icon of American values and origins: “Give me your tired, your poor, your huddled masses yearning to be free.”1 By Eileen Weber, DNP, JD, BSN, PHN, RN

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The Upper Midwest Healthcare Legal Partnership (HLP) Learning Collaborative, a growing network of healthcare providers offering integrated legal services to meet health-harming legal needs at no charge to patients, pulled together the interprofessional memo authors mentioned above. The team consisted of attorneys with experience in immigration and privacy law, and healthcare providers seeing first-hand their patients’ heightened fears following President Trump’s executive orders and heightened enforcement from Immigration and Customs Enforcement (ICE). Working in person, by conference call and email, the team quickly compiled a four-page memo of information about the impact of the executive orders and links to resources providers can use to answer questions and promote the health and safety of the people and families in their care. Key points include: • While it can be changed at presidential whim, the Department of Homeland Security’s current ICE policy states that, barring “exigent circumstances” like terrorist threats, enforcement will not take place in “sensitive locations,” which include “medical treatment and healthcare facilities, such as hospitals, doctors’ offices, accredited health clinics, and emergent or urgent care facilities.”2 • Emergency Medical Assistance is a “payer of last resort” that pays for emergency care for undocumented immigrants/ refugees/asylees, including care for women in labor.3 • Providers must meticulously follow safety and sensitivityconscious protocols for EHR documentation of insurance status, e.g., “uninsured” not “undocumented,” and rigorous compliance with HIPAA privacy protections. • Clinics should consider building community partnerships, such as with churches, to provide emergency food and household items for people too afraid to apply for food stamps, i.e., Supplemental Nutrition Assistance Program (SNAP). MetroDoctors

The Journal of the Twin Cities Medical Society

•

Patients may be eligible for special visas designed to protect U.S. victims of domestic assault or other qualifying violent crimes, human trafficking, violations of the Violence Against Women Act (VAWA), child abuse, and poor working conditions that include substandard housing or injury or unpaid wages. Such patients should be sent to the clinic lawyer if the clinic has an HLP, or referred to an immigration or legal aid attorney, where fees may apply. • Patients should be warned against using “notarios” who suggest they are not only notaries but attorneys, as is true in some countries. People here have suffered when local “notarios” fraudulently imply they can provide bona fide legal assistance that they are not licensed to provide. • Providers can encourage patients to plan for what they would do if they or a loved one are suddenly detained for deportation,4 or if they suspect that a child has been detained into custody,5 or what their rights are if they encounter an ICE officer6 like not opening the door of their home, not signing any papers, and remaining silent. Wallet-sized “red cards” are available for free downloading and printing in various languages to remind people of their rights if ICE stops them.7 The advisory memo is available on the HLP website (midwesthlp.org) and was discussed at a March 22, 2017, presentation by Walker and immigration law expert Ana Pottratz Acosta at a Tropical and Travel Medicine Seminar sponsored by the University of Minnesota’s Global Health Department of Medicine. The memo and the issues it highlights were featured at the HLP network’s From Aim to Impact conference on June 1, 2017, in St. Paul, which included a panel of patients discussing the help they received from the growing number of healthcare providers who appreciate the improved health outcomes achieved when lawyers are added to the healthcare team. A common example that providers who work with HLP lawyers are becoming more aware of is when children with asthma need frequent crisis care due to substandard housing, an attorney-authored demand letter to negligent landlords can more quickly result in removal of asthma aggravants like mold and pestilence, resulting in fewer ED visits and hospitalizations. As rules change, the interprofessional team updates the information. For example, team member Dena Birkenkamp, a legal aid attorney with the HCMC/Whittier Clinic HLP, notified us when Minnesota’s Dept. of Human Services, in compliance with the Affordable Care Act, stopped requiring paper documentation of immigration status when verifying eligibility for healthcare programs. As of June 1, 2017, eligibility is first to be done through more efficient electronic sources like SAVE (Systematic Alien Verification for Entitlement).8 This streamlines getting help for people who may be undocumented because papers are lost. Another update: “Dreamers,” or people who entered the country before age 16, still have some protection from deportation under the Deferred Action for Childhood Arrivals (DACA) program, but “undocumented” parents of children who are legal U.S. residents or citizens are not similarly protected.9 MetroDoctors

The Journal of the Twin Cities Medical Society

The Minnesota Dept. of Health’s (MDH) milestone 2014 report, Advancing Health Equity in Minnesota, cited the persistent societal obstacles to reducing health disparities in Minnesota’s increasingly diverse population. Certainly a major obstacle, cited by both the MDH report and Patricia Walker’s op-ed, is the “structural racism”10 and “xenophobic nationalist message” that many in law and health care argue underlie the current aggressive actions that bring pain and suffering to some patients in our care. In contrast, all healthcare professionals enjoy a large measure of public trust because of the common values shared among their respective codes of ethics. Among them are medicine’s “first do no harm” and nursing’s “respect for the inherent dignity, worth, unique attributes, and human rights of all individuals” which recognizes that “the need for and right to health care is universal, transcending all individual differences.”11 As demonstrated by a Twin Cities-based interprofessional team that added lawyers to a patient-centered mix of physicians, nurses, dentists and healthcare administrators, perhaps health equity can indeed be advanced when we combine our knowledge and values towards the health and safety our patients deserve. The latest version of the Immigration Memo For Health Care Providers can be found at midwesthlp.org. Dr. Eileen Weber, DNP, JD, BSN, PHN, RN is a nurse attorney and clinical assistant professor at the University of Minnesota School of Nursing, where she teaches ethics, leadership, and public policy in the context of a continuum of interprofessional healthcare. She founded and leads the Upper Midwest Healthcare Legal Partnership Learning Collaborative. Her mission is to advance innovations in Healthcare Legal Partnerships that promote just, equitable, and fair healthcare for all through the integration of legal services and healthcare delivery. Weber earned both her BSN degree, summa cum laude, and her Doctor of Nursing Practice (DNP) degree in Health Innovation and Leadership from the University of Minnesota. She earned her JD degree in the founding class of the University of St. Thomas School of Law in Minneapolis. (Endnotes) 1. http://www.startribune.com/executive-order-on-refugees-here-s-what-iknow-about-the-most-vetted-people-around/412215643/. 2. https://www.ice.gov/ero/enforcement/sensitive-loc. 3. h t t p s : / / w w w. l a w h e l p m n . o r g / f i l e s / 1 7 6 5 C C 5 E - 1 E C 9 - 4 F C 4 - 6 5 E C 957272D8A04E/attachments/B8DA870D-2DE0-4552-A3BB-C4071721A381/ g-17-emergency-ma.pdf AND https://www.dhs.state.mn.us/main/ idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMeth od=LatestReleased&dDocName=dhs16_157743. 4. https://www.ilrc.org/community-resources. 5. Child and Family Services Agency’s 24-hour hotline: 202-671-7233. 6. https://imdefense.org/ice-home-and-community-arrests?=/. 7. https://www.ilrc.org/red-cards. 8. http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_FILE&RevisionSel ectionMethod=LatestReleased&Rendition=Primary&allowInterrupt=1&no SaveAs=1&dDocName=dhs-294373. 9. https://www.dhs.gov/news/2017/06/15/rescission-memorandum-providingdeferred-action-parents-americans-and-lawful. 10. http://www.health.state.mn.us/divs/chs/healthequity/ahe_leg_report_020414.pdf. 11. Code of Ethics for Nurses with Interpretive Statements (2015); page 1. http:// nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html.

September/October 2017

Sponsored Content

Promoting Health Equity by Managing Diabetes in Diverse Populations Contributed by Jennifer Hines, MD

Primary care management of diabetes mellitus and prediabetes is one of the most complex undertakings in adult medicine today. In 2012, 29.1 million Americans (9.3 percent of the population) had diabetes, and 86 million had prediabetes.1 In my clinic, my patients and I also face the confounding factors of socioeconomic gaps, insurance concerns, health illiteracy, a heightened political atmosphere, high unemployment, low educational status, high rates of mental illness and language, ethnic and cultural barriers. I am a proud general internist with a multiethnic, multicultural practice in the Midway area of St. Paul. My clinic site is the home of two dynamic clinics, HealthPartners Midway Clinic (the general community clinic) and our Center for International Health, which focuses on caring for immigrants and refugees. My clinic sees many international patients, but our main population consists of white, African-American, Native American and Hispanic patients. People of color make up over 70% of our clinical diabetes practice; two-thirds of them are African-American. As we address the growing medical problems in our service community, diabetes and prediabetes are our top concerns due to the intensive resources needed to prevent and treat diabetes complications. When I joined HealthPartners in 2006, I was surprised that the organization had been gathering data about our diverse populations in terms of language, ethnicity and country of origin that we could use on a systems and clinical practice scale. It allowed us to identify health disparities, groups that needed more resources and how we needed to adjust our interactions 20

September/October 2017

have had to confront back home in the Midwest. Addressing Health Disparities in Minnesota

with patients. One cannot assume that every patient wants the same level and type of health care. Over the years, I have learned a lot about how the patient-clinician relationship is affected by the cultures of both parties. Clinical Experience in the South

I spent nine years in a county-based primary care practice in urban southeast Atlanta in the 1990s. There, 98% of my patients were African-Americans with a poor understanding of diabetes and low adherence to medical care; most staff members were African-American as well. Looking back on the experience of treating very poor people with many social challenges, I wondered why they seemed resigned to being poor and needy, with few or no aspirations for socioeconomic change for themselves or their community. It was my first encounter with institutional, structural and individual racism, up close and personal. In the short-term, this made me less of a caring physician and more of a passive custodian for my patients. I had to face the fact that I was prejudiced against my brothers and sisters in the South, something I wouldn’t

The Minnesota Department of Health’s 2014 “Advancing Health Equity in Minnesota: Report to the Legislature” opened my eyes to the health inequities in our state — especially in the metro area. How do we meet the needs of our communities of color and still provide high-quality care for all? I recently saw a 36-year-old Ethiopian immigrant patient who was asked to come in and discuss her diabetes. She was facing foot surgery and had been told that her blood sugars were not at goal, so healing would be problematic. Unfortunately, she didn’t know she had diabetes, although it was in her chart and her primary care clinician’s progress notes. Through an interpreter, she said that she didn’t understand that the man who had been treating her for the past 6 months was her primary care clinician or what the word “diabetes” meant. She had not been given medications, a change in diet or education about this disease. Her hemoglobin A1cs were in the upper 6% range, and no one had pushed even dietary changes. What were the barriers to high-quality care in this scenario? Why do we Still Have Health Disparities?

A “health disparity” is a higher burden of illness, injury, disability or mortality in one population than another.2 A “health care disparity” is a difference between groups in health insurance coverage, access to and use of care and quality of care. For example, this could be related to race,

MetroDoctors

The Journal of the Twin Cities Medical Society

gender or socioeconomic status. With all of the thought put into services that help all patients, why do health disparities remain? We have to acknowledge that the most common barriers involve how patients perceive clinicians—especially physicians—and vice versa. We must value trust, respect and the ability to speak one’s mind. I have not always been received well, and I have lost patients who felt that I was too assertive about the changes they needed to make and did not consider where they were in their lives. Over 50% of my patients with diabetes are African-American, as am I, which can be problematic at times. Advancing Health Equity in Minnesota

It takes communication, high praise for small wins, shared goal and expectation setting, empowerment and encouragement to help patients understand their health issues. We need more than just vital patient information; we need to know how to individually engage patients with respect, openness and equity without assuming what they know about their health. We know that a team approach in any clinical endeavor makes a difference for our patients and their families. We use a number of “tools of the trade” every day in reaching all patients — but especially our patients of color: • Electronic medical record access for everyone. • Interpreter services (we have nine interpreters at our clinic, and we employ 107 across our system). • Primary care teams consisting of a clinician, rooming staff, a registered nurse and a clinical assistant who focuses on individual patient goals. • Chronic disease registries to help teams monitor patients’ clinical measures and identify when an intervention may be helpful. • Ancillary support staff providing onsite pharmacy education and management and diabetes education. • Diversification of the clinic workforce to make our care teams more relatable to patients (my clinic has a very diverse workforce). • The Cardiovascular Wizard, a very useful clinical decision support tool MetroDoctors

we created within our electronic medical record; it provides suggestions for treatment and tools to educate patients. • Community health workers, members of our team who meet patients in their homes or in the clinic to link them to resources, education and support. • The Minnesota Community Measurement health equity report helps us identify the gaps and results from certain segments of the population by care group so that we can learn and share across the health care communities in our state.3 We can also promote health equity by developing programs and creating spaces to encourage health-promoting behaviors, such as: • Sponsoring self-management activities such as patient peer mentors and support groups. • Hosting clinic activities such as cooking demonstrations and clubs for walking and exercising. • Using online resources for education. • Training and using more community health workers to facilitate community programs and activities such as field trips to grocery stores. • Partnering with community organizations with resources, exercise facilities and educational spaces. Making a Difference

We have to invest time, energy and patience to engage our patients in improving their health. It takes a village to support patients with diabetes, but one of the loudest voices is the physician’s. With cultural sensitivity, we must teach our patients from Eastern Africa, Southeast Asia, Eastern Europe and the Middle East that chronic diseases don’t get cured with one treatment and that they must access the health care system regularly and participate in shared decision making. As a state, we usually do not meet the diabetes benchmark measures we strive for through Minnesota Community Measurement.* However, we have found a way to meet our patients where they are to help them achieve their health goals. When I started treating patients with diabetes in 2006, my diabetic measures were at 6%;

The Journal of the Twin Cities Medical Society

currently, they are at 29% with seeing two or three patients with newly diagnosed diabetes or prediabetes a week. I am making progress. In May, the optimal diabetes scores for African-American patients treated at Midway Clinic were identical to the scores for white patients, at 40%. I am very thankful for the teamwork and commitment of our staff to make a difference in our community. *Minnesota Community Measurement Optimal Diabetes Measures

• • • • •

Control blood pressure to less than 140/90 mm Hg. Lower low-density lipoprotein cholesterol with statins. Maintain hemoglobin A1c to less than 8 percent. Be tobacco-free. Take aspirin as recommended.

Jennifer Hines, MD is the Medical Director at HealthPartners Midway Clinic. She received her medical degree from Mayo Medical School and completed an Internal Medicine Internship and Residency at Emory School of Medicine. She is board certified in Internal Medicine and Hospice and Palliative Medicine. Dr. Hines is the Equitable Care Champion for HealthPartners Medical Group. Prior to returning to Minnesota, she was the Past Medical Director, Sihanouk Hospital, Center of Hope in Phnom Penh, Cambodia-Director of Diabetes Clinic and Director of Physician Training; 1990-2004 and an Assistant Professor, Department of Community Medicine, Emory School of Medicine and Staff Physician of Dekalb Grady Clinic, Atlanta, GA; 1989-1997. References 1. American Diabetes Association. Statistics about diabetes. http://www.diabetes.org/diabetesbasics/statistics/. 2. Kaiser Family Foundation. Disparities in health and health care: Five key questions and answers. http://www.kff.org/disparities-policy/ issue-brief/disparities-in-health-and-healthcare-five-key-questions-and-answers/. 3. Minnesota Community Measurement. Health Equity of Care Report. http://mncm.org/healthequity-of-care-report/. 4. Minnesota Community Measurement. The D5 and the V4. http://mncm.org/reports-andwebsites/the-d5/.

September/October 2017

Striving for Health Equity

The Uganda Research Training Collaborative: Inspiring the Next Generation of Health Science Researchers Through Global Partnerships

pon the launch of the University of Minnesota’s hub in Uganda in November 2015, Dr. Brooks Jackson, Senior Vice President of Health Sciences and Dean of the Medical School at the U of M, envisioned more opportunities for students to gain hands-on experience in global health research. He tasked the Center for Global Health and Social Responsibility with developing an experiential research program in partnership with faculty from across the U of M’s Academic Health Center and Makerere University, the primary Ugandan partner institution. From this initial charge grew the Uganda Research Training Collaborative, where student-led teams propose and implement small scale research projects under the mentorship of health science researchers. Teams are comprised of students and mentors from both the U of M and Makerere University, with both institutions benefiting from the training. The inaugural recruitment in December 2016 yielded students studying medicine, public health, veterinary medicine, and biomedical sciences. Students were grouped into four teams based on their areas of research interest and expertise. By January, teams were drafting study proposals, outlining their preliminary research questions and identifying methods to collect the necessary data. Online workshops introduced students to a broad range of topics from developing a research hypothesis to understanding human subjects’ requirements in each country. Along the

By Molly McCoy

September/October 2017

Molly McCoy

way, student teams consulted with their mentors from both institutions. Kagimu Enock is a student member of Team 3 and completing his 5th (and final) year of his Bachelor’s degree in Medicine and Surgery at Makerere University. He underscores the importance of mentors and teammates with diverse experience, “Having mentors from both universities has introduced me to collective thinking and group work to define a researchable hypothesis and make it progress. This has not only improved my interpersonal skills but also has enabled exchange of knowledge among my teammates.” In July, student teams began their data collection and, in many instances, met some of their teammates in person for the first time after months of virtual planning. The questions guiding their research are broad-ranging and reflect the diverse experience and training of the students and mentors: • Team 1: A study to determine the prevalence of Mycobacterium Bovis in slaughtered

cattle in the city abattoirs of Kampala, Uganda. • Team 2: Lung function and quality of life in survivors of drug-resistant tuberculosis. • Team 3: Evaluating the first year of the routine CrAg screening program in the reduction of HIV-associated cryptococcal meningitis in Uganda. • Team 4: Effect of adherence and malnutrition on pharmacokinetics and virologic outcomes of atazanavir in HIV-infected adolescents. Though the concept of research training in Uganda isn’t new for many University of Minnesota faculty, the notion of a research training collaborative is an innovation building on many years of research collaborations between the U of M and Makerere University. Dr. Paul Bohjanen, Chair of the Division of Infectious Diseases and International Medicine, has been among key faculty leaders who work to build research capacity at Makerere University. Faculty from other disciplines, notably the College of Veterinary Medicine, the School of Nursing, and the School of Public Health, have also paved the way

Students of URTC Team 3

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for this initiative through collaborative training and capacity building through the USAID-funded OneHealth Workforce project. The NIH-funded Fogarty Global Health Fellowship program has added to the rich history of U of M global health research training in Uganda. The URTC was in Anna Stadelman Dr. David Meya many ways the next logical step to advance the U of M’s work in global health research training outstanding mentorship at the University by supporting student-led interdisciplinof Minnesota and Makerere University. ary research teams. The URTC has the “We have a great partnership with Makpotential to be a catalyst for future colerere University, so this collaborative relaborations between students and mentors search opportunity for students is a logical while equipping students in both countries next step,” said Dr. Rhein. with skills and experience in global health Dr. Rhein works in tandem with Makresearch. erere University’s Dr. David Meya of the Anna Stadelman is a second-year MasInfectious Diseases Institute. Dr. Meya ters of Public Health student working with has been a champion for this program Team 2 to assess lung function and qualwith Ugandan institutions through his ity of life in survivors of drug-resistant advocacy. He continues to be an important TB. Through this experience she’s been contributor to the program design and twinned with Makerere medical students through recruiting mentors, developing and faculty mentors with expertise in pulresearch tools, and connecting teams with monology, infectious disease, and clinical local resources. pharmacology. She describes her experiDr. Meya explains, “Expanding this ence with her team: collaboration to include the student“The benefits that motivated me to centered research training collaborative apply for the URTC are: gaining will yield a high return on investment, by experience implementing a research focusing on the leaders of the future.” project in Uganda, working with The Center for Global Health and students in Uganda who were also Social Responsibility is evaluating the pilot motivated to do public health reyear of the program and anticipates it will search, and the mentorship. There accept applications for a second cohort of have also been many challenges URTC teams during the 2017-2018 acaalong the way that have also prodemic year. Learn more about the program vided an opportunity to learn from and how to support the URTC, visit www. our mentors and peers.” globalhealthcenter.umn.edu/URTC. Joshua Rhein, Assistant Professor, Infectious Diseases and International MediMolly McCoy is the Global Research and cine, U of M Medical School, guides the Training Coordinator at the Center for program under his new role as Research Global Health and Social Responsibility. and Training Director of the AHC Uganda She manages the University of Minnesota’s Hub. Dr. Rhein is well positioned to adFogarty Global Health Fellowship, the Doris vance this new program as he splits his Duke International Clinical Research Feltime between Uganda and Minnesota. He lowship, the URTC, and the AHC Hub in also has first-hand experience, as a medical Uganda under the guidance of numerous student and research fellow, of the value of global health science faculty leaders. MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2017

Striving for Health Equity

Mutual Trust Between Patients and Physicians: Bridging Cultures, Building Relationships

utual trust between a patient and their healthcare provider is at the core of the physicianpatient relationship. As stated by Dr. David Thom, “…patient and physician trust are closely linked in that both refer to expectations of future behavior with respect to complementary roles. … Physician trust in the patient appears to enhance patient trust in the physician; conversely, lack of physician trust is perceived quite negatively by patients and likely affects patient behavior. Mutual trust improves cooperation …. successful and sustainable cooperation must be built on a foundation of trust and reciprocity.”1,2 Despite differences in cultural history and customs, there are core human values that transcend religion, race, gender and other differences. We must first care genuinely and often deeply for our patients as we enter a space of acceptance and healing in the exam room. This was never stated more perfectly than by Dr. Francis W. Peabody in a lecture to Harvard Medical School students on October 21, 1925, when he famously stated, “For the secret of the care of the patient is caring for the patient.”3 The “unconditional positive regard” of Dr. Carl Rogers is another foundation belief and approach to open the clinician’s mind and heart to their patient. Unconditional positive regard means that the healer shows overall acceptance of the client by setting aside their own personal opinions and biases. Mindfulness and clinician self-awareness are essential entering into each patient interaction. We must be fully present, able to hear the story of the patient fresh every time, actively listening and meeting the patient at the place they are in that day in their life.4 By Steven Vincent, MD

September/October 2017

Once these core values of compassion and genuine concern for the patient are established, a truly heightened cultural awareness of the patient’s culture further develops patient trust in their primary care clinician and the healthcare team. Even if not fluent in the language, knowing key phrases and a little of the language and using them in the conversation of the interaction, goes a long way towards building mutual trust. Incorporating cultural customs into the treatment plan are important, such as an awareness of the holy month of Ramadan in patients of the Muslim faith, especially for treatment plans of diabetic patients. Using non-traditional, non-allopathic approaches that embody and embrace the cultural practices of the patient are an important part of the therapeutic encounter. Team-based care with team members from the same culture as the patient, speaking the same language, is essential to developing the trust of the patient. In our organization, staff are from the same culture as our patients. When our patients come to the clinic, they are greeted in their own language by a member of their community. Our care

coordinators working with the patient are bilingual and from the same culture as the patient. Our integrated behavioral healthcare providers and spiritual faith leaders provide a holistic approach to an integrated mindbody-spirit model of providing comprehensive care. Outside of the clinic walls we have community partners in the community of the patient that complement and support the care given in the clinic. This patient-centered approach, with a compassionate clinician as a leader of a culturally aligned and enlightened team of care givers, is at the heart of good patient care, with mutual trust between a patient and their primary care clinician. Being mindful of these principles, our patients will develop trust in our care, ever increasing with each passing year. Steven Vincent, MD, received his medical degree from the University of Michigan in 1978. As a 4th year medical student in 1977, he found himself at Smiley’s Clinic in the Cedar Riverside neighborhood, where he eventually completed his Family Medicine Residency in 1981and has had a continuous primary care medical practice at People’s Center Health Services since 1992. Dr. Vincent can be reached at vincents@peoples-center.org, or by U.S. mail at People’s Center Health Services, 425 20th Avenue South, Minneapolis, MN 55454. References: 1. Thom, David H. Physician Trust in the Patient: Development and validation of a new measure. Annals of Family Medicine. Volume 9, number 2. March/April 2011: 148-154. 2. Thom, David H; Hall, Mark A; Paulson, Gregory. Measuring patients’ trust in physicians when assessing quality of care. Health Affairs: Volume 36, number 6. June 2017. 3. Oglesby, Paul. The Caring Physician: The Life of Dr. Francis W. Peabody. Francis A. Countway Library of Medicine, 1991. 4. Rogers, Carl. On Becoming a Person. Houghton Mifflin, 1961, 1988.

MetroDoctors

The Journal of the Twin Cities Medical Society

Mental Health Care Equity for Latino Community The Problem The debate over the repeal of the Affordable Care Act, known as the ACA or Obamacare, has led to increased emotional strain on the Latino community. Many members of Latino families traditionally have not received adequate healthcare services, including mental health care, because they work at jobs that do not provide health insurance, or because they are undocumented and do not qualify for insurance, or because language barriers make it difficult for them to access or communicate effectively. Those Latinos who qualify for Medicaid often present only a portion of an extended Latino family. Demographics Nonetheless, millions of Latinos have benefited from the ACA. According to the Commonwealth Fund (January, 2017), “Since passage of the ACA Latinos have experienced the largest decline in the uninsured rate of any ethnic group,” going from 43% in 2010 to 25% in 2016. Latinos benefitted in those states that expanded Medicaid under the ACA, including Minnesota. Furthermore, the Obama administration, under the ACA, allowed Minnesota to broaden the coverage provided by Minnesota Care (MNsure), which resulted in 96% of MN residents receiving heath insurance. The continuing controversy among Minnesota physicians about the MNsure tax presents a threat to the viability of MNsure. If the ACA is repealed and/or replaced by a law that undercuts Medicaid or MNsure in any way, Latinos will be among those most hurt. Population History Latino culture’s perspective on mental illness and resources are major problems for By James Jordan, MD

MetroDoctors

for Childhood Arrivals) student or asylum refugee, all carry the burden of anxiety and depression not knowing if or when they may be apprehended and deported. The children of parents at risk and young adults (especially Latinas) have been reported to be at risk for self harm, suicide, and increased drug and alcohol abuse to cope with this constant threat.

consideration in the Twin Cities. The community has long underutilized professional mental health services. Ambivalent about the stigma associated with mental health and lacking good information on resources, the Latino culture has long relied on strong family ties, spiritual sensibility, and a fundamental communal generosity (“Mi Casa es Su Casa”) as the pillars of strength and resilience that protect their mental health. Many Latinos in our community have thrived professionally in law and medicine, in small business, construction, maintenance service, along with local politics. Latinos frequently reside in residential areas, like the west side of St. Paul and sections of north and south Minneapolis, proximate to a Catholic Church with bilingual services. The growth in population and acculturation, however, may lead some Latinos to pursue self-reliance and isolate themselves from their community, including the extended family support needed for early intervention and care. The need for mental health services has never been greater. The increased number of deportations, beginning under Obama and increasing under the Trump presidency, has increased the stress levels of families that touches almost every member of the Latino community directly or indirectly. A friend, relative, parent, a DACA (Deferred Action

The Journal of the Twin Cities Medical Society

Recommendations Physicians wishing to learn more about mental health resources can access a regularly updated guide produced by the Hennepin County Spanish-speaking Provider Consortium (www.washburn.org/Spanish clinical guide) for accessible, affordable care. Twin City providers, CLUES, Washburn Center for Children, and Hamm Clinic, are examples of mental health agencies with decades of experience in special services for Latinos. Finally, the website understandingdepression.org includes a video series in English focusing on conversations with men and women who sought professional help for mental illness. They talk openly about depression signs and symptoms, detection across the life cycle, and the treatments that enabled them to recover and lead a healthy life of work and family. A second series on the risk of suicide for untreated major depression is available on the same website in both English and Spanish (entendiendodepresion.org). This series focuses on the risk of suicide when mental health treatment is not available or accessed. It also provides resources for Spanish speakers. Dr. James Jordan is a consultant psychiatrist for Blue Cross/Magellan Health and a member of the Board of Directors of the TCMS Foundation. He served as Medical Director of Hamm Clinic for 25 years. September/October 2017

Restricting the Sale of Menthol Flavored Tobacco

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September/October 2017

two years to bring this important policy inneapolis voted on August 4 to into Minneapolis and St Paul. Last month, clude menthol in its existing policy restricting the sale of flavored tobacco to PAN intern Hlee Yang, a 4th year pubadult-only tobacco shops. Physicians and lic health student at St. Kates and Dave medical students of TCMS’ Physician AdBergstrand, a 2nd year medical student vocacy Network (PAN) provided essential at the University of Minnesota met with St. Paul City Council Member Dai Thao support for the amendment, contacting to discuss his support of the amendment. council members from all Minneapolis wards. St. Paul also plans to consider the TCMS Board Member Tyler Winkelman, inclusion of menthol in their existing flaMD also attended a meeting with Council vor restrictions in September. Updated Member Chris Tolbert to discuss the isordinances will keep menthol tobacco sue. Twenty healthcare organizations have products and their advertisements out of signed a letter in support of amendments sight of those most at risk for starting the to the existing ordinance in both cities, habit. including the Minnesota Medical AssoMenthol makes it easier to start smokciation, Minnesota Doctors for Health ing and harder to quit. It also increases Equity and the Minnesota Academy of nicotine addiction and the chance that Family Physicians. youth will go on to be established smokers Physician and medical student adin adulthood. Nearly half of Minnesota vocacy has been essential in moving this high school smokers use menthols, and policy forward in Minneapolis and we that’s no accident. The tobacco industry need your continued support in St. Paul. has been targeting young people, in parFor more information on how you can ticular African Americans and the LGBTQ help to pass this groundbreaking policy community, with menthol tobacco for devisit panmn.org/menthol or contact PAN cades. This lures disproportionate numbers Project Coordinator Grace Higgins at of youth from marginalized communities ghiggins@metrodoctors.com. into nicotine addiction and perpetuates health inequities among these populations. The inclusion of menthol in the existing flavor restrictions is the next step toward preventing youth tobacco use in our communities. The PAN has been working with a coalition of more Hlee Yang (far left) and Dave Bergstrand (far right) joined advocates than 50 organiza- from the Menthol Coalition at a meeting with Council Member tions over the past Thao (center). MetroDoctors

The Journal of the Twin Cities Medical Society

Save the Date: Honoring Choices 8th Annual ACP Conference Thursday, October 26 marks the date of the yearly Sharing the Experience conference — a time to come together to discuss, learn, share and network around topics relevant to Advance Care Planning in Minnesota. This year’s conference is at the Ramada Plaza Hotel, next door to the Twin Cities Medical Society office building, and runs from 8:00AM until 4:30PM. Throughout the day, speakers and panels will share stories of their work, program growth, and specific areas of interest. The emcee for the event, Richard Shank, MD, is a former St. Paul hospitalist who now shares his retirement with Honoring Choices as a volunteer. In addition to introducing other speakers during the event and keeping things on track, Dr. Shank will talk about how volunteering has kept him active in the healthcare world in an arena that is important to him personally. Emily Downing, MD, opens the conference with reflections on her practice as a Palliative Care physician with Allina. Other topics to be included in the day’s line-up are bringing spirituality into advance care planning, better working with attorneys to help clients complete healthcare directives, and updates from students of medicine, nursing, social work and public health who have specialized interest in end-of-life planning. A panel of representatives from communities in Greater Minnesota will share how they have begun building strong ACP programs in their areas, and breakout sessions will go into greater depth on the topics of prognosis, guardianship, and what is happening nationally with the issue of medical aid in dying. Our closing keynote speaker is Cathy Wurzer, sharing her thoughts following the first year of The Convenings, a community-based series of events she began following a series of radio interviews and co-authoring a book with Bruce Kramer, from his diagnosis of ALS in 2010 until his death in early 2015. Cathy made a promise to Bruce that she would continue his mission of helping people learn to live before they were dying, and partnered with Honoring Choices and the Bruce Kramer Foundation to keep that promise.

Registration is available online at www.HonoringChoices.org.

Photos, top to bottom: Dr. Richard Shank; Dr. Emily Downing; University of MN Medical Students Noah Gavil and Megan Crow; Cathy Wurzer.

MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2017

Your Link to Mental Health Resources

Are you helping all of your patients think about, talk about, and plan for their healthcare future? Advance Care Planning resources abound in our state. Our annual conference helps you learn more, network, and share your own experiences. Please see the article on page 27 for more information.

Sharing the Experience 2017 Thursday October 26, 2017 mnpsychconsult.com

calling PAL

Ramada Plaza Minneapolis

In Memoriam DONALD L. FOSS, MD, passed away on July 21, 2017. A surgeon in St. Paul, Dr. Foss co-founded the first Hospice facility in St. Paul at Bethesda Hospital. He joined the medical society in 1972. PAUL GANNON, MD, PhD, passed away on July 6, 2017. He practiced cardiovascular and thoracic surgery in the Twin Cities for over 40 years and was active in the Twin City Thoracic & Cardiovascular Association and the International Heart Relief Organization. He joined the medical society in 1968. JOSEPH GARAMELLA, MD, PhD, passed away on June 21, 2017. He was a pioneer in open heart surgery, operating primarily at Minneapolis area hospitals. Dr. Garamella joined the medical society in 1955. CAROLYN ADAIR JOHNSON WESENBERG, MD, passed away on July

September/October 2017

18, 2017. In a career that spanned 50+ years, Dr. Johnson joined her fatherâ&#x20AC;&#x2122;s St. Paul practice in the field of family medicine and delivered over 6,000 babies. Dr. Johnson joined the medical society in 1955. BRADLEY KUSSKE, MD, passed away on May 31, 2017. Following in his fatherâ&#x20AC;&#x2122;s footsteps, Dr. Kusske practiced otolaryngology in St. Paul. He joined the medical society in 1947. GEORGE ROBERT (BOB) NOREN, MD, passed away on June 11, 2017. Active in Pediatrics and Pediatric Cardiology, Dr. Noren served as Chief of Pediatrics at HCMC (1989-1991) and the Medical Director for the Hennepin County Juvenile Justice Center (19901996). Dr. Noren joined the medical society in 1985.

MetroDoctors

The Journal of the Twin Cities Medical Society

Spotlight on Books Mishegas—A Comedic Memoir Written by Harley Dresner, MD Senseless behavior — that’s Mishegas. According to Harley Dresner, it means life with melodramatic parents and a pugilistic, caffeine-addicted octogenarian uncle. Blend Jerry Seinfeld’s and Raymond Barrone’s parents together. The result is the Vesuvius mess that Dresner calls his family in chapters like, “Even Leona Helmsley Would Have Apologized,” “Henry Ford Would Have Had a Stroke,” and “Wasting Away in Geriatricville.” Dresner’s

CAREER OPPORTUNITIES

MetroDoctors

take-no-prisoners sarcasm makes his memoir a laugh-out-loud study of life-long relationships that proves one can embrace familial roots while maintaining sanity. Anyone who wouldn’t dream of running away from the family they would love to escape understands Mishegas. Mishegas will be released on September 1, 2017 by WriteLife Publishing, Inc. It is currently available for pre-order on www.amazon.com and www.barnesandnoble.com. For more details, explore www. mishegasthebook.com.

Passion for Patients A 2017 book written with Dave Racer tells the story of Dr. Lee Beecher’s 42year independent psychiatric practice and long-standing mental health APA and community advocacy. For book reviews, chapter summaries, policy recommendations for future patientcentered care and to purchase the book, go to www. Leebeecher.com.

See Additional Career Opportunities on page 30.

The Journal of the Twin Cities Medical Society

September/October 2017

CAREER OPPORTUNITIES

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MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2017

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

PHILLIP K. PETERSON, MD

It is indeed exceptional for the stars to be so perfectly aligned in one member of our profession who owns an extraordinary knowledge base + the capacity to ever enlarge upon it through study and creativity + the talent to educate and transmit those concepts to others with amazing passion and enthusiasm. Let’s see how our Luminary has achieved all of that during his long and fruitful career. Dr. Phillip Peterson came to the Twin Cities after highly successful educational experiences — having completed his B.A. at Northfield’s St. Olaf College (Phi Beta Kappa) and his M.D. (AOA) and internal medicine residency at New York’s Columbia College of Physicians and Surgeons — interspersed with two years of U.S. Public Health Service. He was then accompanied to Minnesota — beginning an infectious disease fellowship at our U of M — by his wife, whom he met at St. Olaf, as they began their long-standing Minnesota residence with their two children. Dr. Peterson gives much credit for his numerous honors and accomplishments to his mentors. During his Columbia days, esteemed Professors Neu and Brown “peaked my interest and pleasantly hooked me into the fields of infectious disease, parasitology and tropical medicine.” Drs. Al Schultz and Paul Quie (two former Luminaries) were also valued mentors along the way — Dr. Quie still helpfully serving in that capacity at the ripe old age of 94. Phil’s 263 peer reviewed articles + book and book chapters provide us with the array of topics in which he’s been involved as he headed the Infectious Disease Departments of HCMC and the U of M, and the International Medicine Department at the U’s medical school. He has been fascinated with the connection between the brain and the immune system in which host defense plays a pivotal role, particularly in immunocompromised patients afflicted with central nervous system infections where a staggering degree of morbidity is encountered. Dr. Peterson’s research and teaching has focused upon the crucial aspects of the diagnosis, treatment and rehabilitation of these folks. Chronic Fatigue Syndrome, psychoneuroimmunology, opiate effects, and neuroimmune pharmacology are facets of this engaging pursuit of which he’s considered an acknowledged authority. 32

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In collaboration with Dr. Quie, Dr. Phil directed the U of M’s international medical education and research curriculum that augmented students’ attention to existing worldwide medical globalization. The knowledge and capabilities of our students and those from foreign lands is enhanced by the cross pollination that is engendered by this program. Dr. Peterson’s professional activities aren’t confined to purely scientific and objectively clinical matters. He has been engaged in practical messages to clinicians and the lay public in widely read published materials, examples being his 2013 book, Get Inside Your Doctor’s Head: 10 Commonsense Rules for Making Better Decisions About Medical Care, and his recent book flap endorsement of his colleague Jay Cohn’s patient-oriented book on hypertension and cardiovascular disease. Phil has no specific favorite among his meaningful range of work in the areas of population infective disease, global health issues, epidemiological conclusions and profound social responsibilities. However, they have resulted in his firm opinions on the man-made climate change of global warming and its untoward health effects. This diligent work continues as he delivers crucial messages regarding those ominous realities. Our Luminary’s prodigious body of work has contributed mightily to striking improvements in the health of our world’s inhabitants, and it will leave an everlasting legacy for those who follow us. It’s very comforting to know that even now Dr. Phil Peterson’s phenomenal work continues. 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

Artificial pancreas gets FDA approval after testing at International Diabetes Center For 50 years, research and education at International Diabetes Center has paved the way for people with diabetes to live healthy, fulfilling lives. As part of HealthPartners Institute, our teams translate research findings into clinical practice. We develop innovative ways to use technology, such as continuous glucose monitoring and insulin pumps, to improve diabetes care.

Richard Bergenstal, MD Executive Director International Diabetes Center

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