Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio 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 reect the ofďŹ cial position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.
July/August Index to Advertisers TCMS OfďŹ cers
President: Lisa R. Mattson, M.D. President-elect: Kenneth N. Kephart, M.D. Secretary: Carolyn McClain, M.D. Treasurer: Matthew Hunt, M.D. Past President: Edwin N. Bogonko, M.D. TCMS Executive Staff
Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Communications and IT Coordinator (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Karen Peterson, Program Manager, Honoring Choices MN (612) 362-3704 kpeterson@metrodoctors.com Terri Traudt, Project Director, Honoring Choices MN (612) 362-3706 ttraudt@metrodoctors.com
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The Journal of the Twin Cities Medical Society
CONTENTS VOLUME 16, NO. 4
2
Index to Advertisers
5
IN THIS ISSUE
J U LY / A U G U S T 2 0 1 4
Making a Difference Through Innovation & Technology — An Open Letter By Marvin S. Segal, M.D.
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PRESIDENT’S MESSAGE:
The Challenge of Medical Advances: Responsible Health Care By Lisa R. Mattson, M.D.
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TCMS IN ACTION
By Sue Schettle, CEO EMERGING MEDICAL TECHNOLOGY
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Colleague Interview: A Conversation with Jeffrey W. Chell, M.D.
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Innovators and Providers: Finding New Common Ground By Ryan Baird
Page 12
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Innovation Driven by Unfortunate Circumstances By Steve Brielmaier, MS, DPT
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New Thereapy for Obstructive Sleep Apnea By Kent Wilson, M.D., M.S.
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The Serendipitous Turns in an Odyssey Through Years of Patient Warming By Scott D. Augustine, M.D.
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What is Sure About MNsure? By Peter Dehnel, M.D.
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2014 Minnesota Legislative Session Highlights By James Clark, JD, and Julian Plamann
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Honoring Choices Across Cultures Global Health Course By Barbara Greene, MPH
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Students Improve ACP Skills in Spring Student-Led Symposium By Barbara Greene, MPH
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Advance Care Planning for All — Outreach Program Launched By Karen Peterson, BSN
Page 32
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New Members In Memoriam
29
Senior Physicians Association May 13 Luncheon Senior Physicians Association Annual Event July 22
30
Career Opportunities
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LUMINARY OF TWIN CITIES MEDICINE
Page 15
MetroDoctors
Robert A. Van Tassel, M.D. The Journal of the Twin Cities Medical Society
On the Cover: As medical device technology emerges, Minnesota continues to be a strong leader. Articles begin on page 8.
July/August 2014
3
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IN THIS ISSUE...
Making a Difference Through Innovation & Technology — an Open Letter Dear Reader, Have you noticed that the care outcomes of our patients seem to be continually improving? Decreasing morbidity and mortality rates in cardiovascular disease and cancer certainly stand as evidence of that progress. And…these positive developments aren’t confined just to those high volume conditions, but — as you’ll see in this issue of MetroDoctors — have far reaching implication throughout most fields of medicine. For any given condition, it may be an innovative device, a new drug, a fresh technique or even a unique method of data analysis that may contribute to positive results. Advances such as those could not have occurred without some pretty amazing technological infrastructures in place. Let’s take a look at some interesting examples. Our Colleague Interview features insightful answers by Jeff Chell, M.D. to some profound and provocative questions about bone marrow donation. Scientific, practical and political implications are clearly addressed. Ryan Baird of LifeScience Alley relays a perspective on the considerable numbers of Minnesota technical innovations leading to eventual production, marketing, sales and utilization in the medical device industry. Steve Brielmaier of our VA Health Center addresses the bourgeoning field of prosthetics. The remarkable advancements in this arena may well prove to be a revelation for many practicing physicians. Kent Wilson, M.D. describes a great example of a technological advance for some with a locally conceived product, Inspire®. Entrepreneur, Scott Augustine, M.D., relays a lengthy journey with ups and downs in the “life” of a medical device. A curious twist with future implications should add to our readers’ enjoyment. In an update about MNsure, Pete Dehnel, M.D. provides us with a factual, balanced and unbiased view regarding that sometimes controversial program — and in a separate article, highlights of medical interest in this year’s Minnesota legislative session are recounted. With our President’s Message, Lisa Mattson, M.D. gives us a great historical perspective while wisely discussing the sobering potential downside risks of technological utilization. Lastly, the story of Robert Van Tassel, M.D., our Twin Cities Luminary, demonstrates to us how a leader employs the perfect combination of subjective wisdom and objective technology during a successful career. Happy reading… Sincerely, Marvin S. Segal, M.D. Member, MetroDoctors Editorial Board MetroDoctors
The Journal of the Twin Cities Medical Society
July/August 2014
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President’s Message
The Challenge of Medical Advances: Responsible Health Care LISA R. MATTSON, M.D.
IMAGINE PRACTICING MEDICINE 100 YEARS AGO. The leading cause of death was influ-
enza, followed by tuberculosis. Ten percent of infants died in the first year of life. By 1900 most major hospitals had x-ray machines and Johns Hopkins was just starting to use gloves routinely in surgery. Electrocardiograms weren’t routinely available until the mid 1920s. The advent of antibiotics, vaccines, improved diagnostic testing, developments in molecular biology and genomics, and biomedical engineering have all contributed to our improved abilities to care for patients. We no longer carry little black bags to work, but instead are more likely to have our smart phone or iPad readily available. Our challenge is determining which test or procedure is appropriate for our individual patient. I remember working in small groups in medical school and being presented with medical cases where we were allowed to ask questions pertaining to the history, the physical exam, and diagnostic results to help guide us to a diagnosis and plan of care. Early on, we ordered a lot of CT scans and a battery of lab tests. Luckily, we had good mentors who challenged us to explain how the results of each test we ordered would change our management. As a result, we all became much more discriminating in our use of technology and learned the value of a good history and exam. All medical providers need to be accountable for their actions, properly research the merit and analyze the cost benefits for different procedures and therapeutics. Accountability also pertains to our relationships with industry. Physicians should be involved in the development of new diagnostic and therapeutic health care technology, but we need to be cognizant of the fact that industry interests may conflict with patient interests. Our patients are our first priority and we are obligated to provide them with unbiased medical advice and disclose any relationships that we have with industry. Inappropriate use of our technology potentially endangers our patients. While x-ray technology was first developed in the late 1800s, it wasn’t until 1904 that Clarence Dally, Thomas Edison’s x-ray research assistant, became one of the first to die from the damaging effects of radiation. We should be mindful of the potential for unintended, harmful consequences in medical advances. Expensive technology often seems to hit the market before the guidelines have been developed. Patients hear about them before we do and our understanding of these new modalities is often based purely on what the representative tells us in the hallways. We need to take the time to learn about the new advancements, to understand their intended uses, their side effects, and their limitations. Today, undiscerning use of the latest and greatest advancements often ends up as class-action law suits that we see on late night television or social media, and serves to undermine the integrity of the new products and the physicians who choose to use them. We also need to remember our role as stewards of health care dollars, knowing that new technology often carries a big price tag. Imagine you walk into your living room and turn on the light. Nothing. It’s still dark. What do you do? Most likely you’d check to see if the light bulb is screwed in tightly, check to be sure the lamp is plugged in, or try a new light bulb. Most of us wouldn’t immediately throw away the lamp and then go buy a brand new one before we’d checked a few of these basic functions. Yet, sometimes in medicine we seem to be quick to just replace things before they’re broken. With health care dollars being spread thin, we need to start asking how much does that new instrument or diagnostic test cost. We shouldn’t deny a patient access because of cost, but we should be able to justify the cost in terms of improved outcomes. If it’s just the latest, sexy gizmo that’s fun to use and has no scientifically proven benefit, then maybe we should continue to do things the “old fashion way.” (Continued on page 7)
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The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
It has been a very busy 2014 for TCMS. Along with the constant flurry of activity associated with Honoring Choices Minnesota we have been actively involved in local efforts to restrict the use of e-cigarettes and other flavored tobacco products. We have
provided written testimony and letters of support to local elected officials as they debate enhancing their tobacco ordinances to include prohibiting vaping in indoor spaces. In May, TCMS hosted an educational event for our members on e-cigarettes. What do we know about them? What’s happening at the local, state and national levels? What are other tobacco delivery devices that are becoming more and more prevalent in our society? Speakers included Dr. Anne Joseph, Janelle Waldock, MPH and Betsy Brock,
MPH. Pete Dehnel, M.D. was the moderator. The event was covered by Minnesota Public Radio and promoted by KSTP News. TCMS will be developing a physician toolkit along with key partners including the American Lung Association and the MN Department of Health. Included in the toolkit will be resources for physicians to use as they talk with their patients about e-cigarettes, among others things. TCMS did receive grant funding to support the toolkit development as well as the creation of a spokesperson training program for physicians, medical students and other public health advocates. This program will unfold in 2014 and 2015. TCMS and MMA are partnering with the American Medical Association and the YMCA of the Twin Cities Area on providing education and resources aimed at prediabetes. Join us at a jointly sponsored Forum “Address the Sleeping Giant” on Tuesday, October 7 at 6 p.m. Elizabeth Seaquist,
M.D., President, Medicine and Science, American Diabetes Association, and Luke Benedict, M.D., endocrinologist at Allina Health will describe how to diagnose and manage prediabetes. A representative from MDH will share the
President’s Message (Continued from page 6)
Every day we realize the benefits of modern medicine. Many lives have been improved or saved because of novel medical devices and therapeutics, and we look forward to continued improvements in the future. We need to remember that medical developments potentially pose new challenges to us as physicians and we need to be responsible about our use of new technology. A lot has changed in the last century. Jonas Salk once said, “At one time we had wisdom, but little knowledge. Now we have a great deal of knowledge, but do we have enough wisdom to deal with that knowledge?” The future of health care depends on the hope that our wisdom will trump greed, immediate gratification, and political pressures and we will continue to improve and protect the lives of our patients. MetroDoctors
The Journal of the Twin Cities Medical Society
scope of the problem in Minnesota, and the YMCA will present information on their evidence-based prevention program and resources. Register for this free event at: www.metrodoctors.com. The East and West Metro Foundations of TCMS have been discussing a
possible merger into one Foundation. Many hours of discussion and debate have occurred over the past 12 months and as I write this update for MetroDoctors I am optimistic that a merger will take place effective January 2015. A merged Foundation will allow TCMS the ability to leverage our resources and make a larger philanthropic impact as well as increase the level of support that we can obtain by attracting additional grant dollars. The MetroDoctors editorial board has an opening for a physician interested in contributing to the planning of content and direction of this membership journal. Contact Nancy Bauer, managing editor, for more information at nbauer@metrodoctors.com. Honoring Choices has applied for a grant from the UnitedHealth Group Foundation to support the development of continuing medical education e-learning modules that can be used in Minnesota and elsewhere. We have also been invited to speak at an upcoming meeting of the American Association for Medical Society Executives in Louisville in July. The model that we have created in Minnesota is continuing to grow and spread throughout the country.
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Emerging Medical Technology
Colleague Interview: A Conversation with Jeffrey W. Chell, M.D.
J
effrey W. Chell, M.D. has been the Chief Executive Officer, National Marrow Donor Program since 2000. He received his medical degree from the University of Minnesota Medical School; completed an internship and residency in Internal Medicine at the University of Wisconsin, Madison; and completed an Executive Management Course at Carlson School of Management at the University of Minnesota. Prior to this position Dr. Chell was President of Allina Medical Group (1994-1999), Vice President Allina Health Systems (1997-1999) and Chairman of the Board and then Medical Director at Columbia Park Medical Group in Fridley, MN.
Please describe and provide short examples of how two or three research-oriented technological advances have improved the mission of your organization. Matching between donor and recipient of a stem cell transplant is mostly dependent on the Human Leukocyte Antigen (HLA) system. The National Marrow Donor Program (NMDP) has been a leader in identifying the HLA loci that are important to match for the best outcomes for patients. NMDP is also studying other factors in matching donors to patients that might have an impact on outcomes; factors such as gender, blood type, Cytomegalovirus exposure, etc.
What computer-oriented improvements have allowed your organization to make certain that a fair selection process is in place to match huge numbers of donors and recipients? NMDP has made significant investments in technology that allow us to search all of the potential adult donors worldwide. The Be The Match Registry has nearly 12 million donors. Sixty-six other registries worldwide add another 12 million donors to the list. Our technology allows us to search all of these donors to find the best possible match. We can also search the 450,000 umbilical cord blood units that have been collected by public cord blood banks. 8
July/August 2014
We present all of this data to the physician that is searching on behalf of the potential recipient. The physician can then choose what is best for their patient, then NMDP donor management and logistics teams arrange for the collection and transportation of the cells to the patient’s bedside.
What are the criteria used for placing recipients in an appropriate queue position on the listing of potential recipients, and how important a role does age play as one of the variables used? The need for unrelated blood and marrow transplant in the United States is about 12,500 per year. We are currently performing around 5,000 transplants for U.S. patients. With nearly 24 million donors worldwide, the NMDP doesn’t have a waiting list of patients waiting for a donor. The most likely reasons a patient doesn’t progress to transplant is lack of insurance or they are too sick to be considered a candidate. If a patient can’t find an acceptable matched donor among the 24 million, it is likely that they have a very rare HLA type and an alternative therapy should be chosen. Patient age does not factor into the decision regarding a transplant. In fact, the most rapidly growing population segment for hematopoietic transplant is 65 and older.
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How did the political issue related to utilization of cord stem cells during the early 2000s affect your organization then and how has the situation changed to the present time? NMDP was still determining its role in cord blood transplant in 2000 as our focus, until then, was on adult donors. But many of the systems and much of the technology we had in place to respond to a transplant center’s request to find an adult donor would also be of benefit for patients for whom a cord blood transplant would be a good choice. Cord blood, with its less mature cells, does not need to be as precisely matched to the patient as adult donors cells. This opened the door to transplantation for patients that were more difficult to find a match — often ethnic minorities. The NMDP made a significant investment in cord blood inventory and systems to support listing cord blood units from public banks. The NMDP also encouraged the U.S. Congress to create a program for federal funding of cord blood inventory, which it did in 2004. Today, NMDP facilitates over 1,200 cord blood transplants per year.
What federal and/or state governmental regulations have you found to be helpful/obstructive? Three federal programs have been key to the success of hematopoietic stem cell transplantation. NIH supports the Blood and Marrow Transplant Clinical Trials Network providing funding for phase III clinical trials. The U.S. Navy provides a grant to fund a contingency program in the event of a nuclear accident or act of terror. The Health Resources and Services Agency of HHS administers the national stem cell program authorized by U.S. Congress. This program provides funding to recruit donors, cord blood units and supports patient advocacy services. From a state government standpoint, there is much the individual states could do to expand access to transplant for the underserved. Minnesota is a leader in this area.
Describe the relationship NMDP has with transplant programs. Are there outcome criteria requirements or implications? The NMDP has contracts with all of the unrelated transplant programs in the United States. Each center is required to submit their outcomes data to our research partner, the Center for International Blood and Marrow Transplant Research (CIBMTR). Every year, the information is made available to the public through our website, bethematch.org. The NMDP visits about 40 transplant programs per year to learn how we can help improve access and outcomes.
cure. Four years ago, the NMDP began a study called the System Capacity Initiative (SCI) to examine the barriers and remove the barriers that would prevent us from serving all in need by the year 2020. In addition to financial issues and the patient’s burden of illness/co-morbidity mentioned earlier in the article, we learned that there are not enough inpatient beds, out-patient facilities, professional workforce members (physicians, nurses, pharmacists, advanced practice professionals, social workers) trained or in the pipeline to meet the need. The SCI has continued to meet to look for creative ways to resolve these bottlenecks as we strive to serve all patients.
What funding sources enable you to do this work? The majority of our funding is fee-for-service revenue from our domestic transplant center and the international registries that serve their domestic transplant centers. About 20 percent of our funding is from the federal programs identified earlier in the article. The remaining 5 percent is philanthropic support through our Be The Match Foundation. The foundation raises money to support patients undergoing a transplant, for donor recruitment and for research.
Is there an insurance coverage or reimbursement opportunity to cover expenses for the donor? Means testing for recipients? The NMDP covers all of the costs of donation. The donor’s health insurance is not billed and the NMDP will reimburse any out-of pocket expenses a donor may experience. The NMDP will also replace any wages a donor may forfeit because of the donation process. The NMDP does not directly bill the patients or their insurance carrier. Means testing, if any, would be done by the Transplant Center.
Is there anything else our readers/your colleagues should know about NMDP? You can learn more at our site for physicians and other health care professionals at bethematchclinical.org. One of the most important roles for physicians is to refer patients at an optimal time in their disease to the transplant program at the University of Minnesota or the Mayo Clinic. Early assessment and intervention will improve outcomes.
What supply/demand issues do you experience? There are 12,500 patients per year in the U.S. with 70 different diseases for which an unrelated transplant may be the only hope for
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Emerging Medical Technology
Innovators and Providers: Finding New Common Ground
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here is an old episode of the Rockford Files featuring a scene that appears almost anachronistic today: a medical device sales representative arrives at a clinic with a product kit intended for surgery that day. Upon entry, the representative scrubs into the operating room with the surgeon and proceeds to guide him through the implantation procedure. While that was likely a commonplace scenario at the time, in today’s culture of increasingly limited interactions between device company sales professionals and care providers it produces feelings of perceived impropriety and non-compliance. For better or worse, the interactions between medical technology companies and health care providers have changed dramatically in recent years. Patient-driven preferences, regulation and cost pressures are rapidly changing the way devices are designed, regulated, valued and purchased today. Factor in global market opportunities and pressures and the scene is set for a radical shift in the creation and delivery of health technologies. The effects can be seen rippling through the halls of St. Paul, Washington, D.C., hospitals and clinics and companies across the U.S. When the dust cleared after the collapse of the mainframe computing industry, Minnesota was left with a highlyskilled talent pool of electrical and software engineers looking for new opportunities. Along came an entrepreneurial engineer and University of Minnesota surgeon whose work in a humble garage gave rise to a medical device industry envied around the globe. Combine this industry with some of the most advanced academic and By Ryan Baird
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delivery-focused health care networks in the world and the result is Minnesota’s renowned Medical Alley. For decades, health care innovation has blossomed at the intersection of the industry and provider communities. Companies interact with researchers or clinicians, identifying unmet needs. Entrepreneurial doctors reach out to industry with problems that need solving. World-class research institutions develop technologies ripe for commercialization. While these models still exist today in part or whole,
larger portion of startup capital being invested and acquisitions have already taken place. Traditional device companies have increased the telecommunication capabilities of their technologies, allowing for enhanced transmission of patient monitoring data to care providers. At a strategic level, many of these companies have invested in technologies focused on providing broader health care services in order to create economic value for patients, payers and providers. Enough growth has taken place in this space to prompt the FDA to begin
State and Federal legislation regulating certain industry-physician relationships has impacted the way we innovate. What gets commercialized, whether it gets covered by insurance and who buys it continue to change to meet the shifting demands of patients and the health care system as a whole. At the heart of all new innovation in health care technology today is the need to deliver better value at lower cost. Evaluating “value” is a constantly morphing dialogue hinging on patient wants and needs, government incentives, regulation and many other factors. However, no matter what rubric is applied to define this value, the capture and analysis of health data is a vital piece of the puzzle. Over the past several years, the Twin Cities have seen an explosion of growth in the Health IT market. Startups in this sector have begun to attract an increasingly
issuing guidances around the regulation of Health IT and its application when informing clinical decision-making. Beyond driving the functionality of new products and enhancing the remote care and monitoring capabilities of providers, health data is also being used to make purchasing decisions at the administrative level in hospitals and clinics. Initiatives like SharedClarity, a collaboration among UnitedHealthcare and several provider networks, are using data on individual products and patient outcomes to direct the selections of certain categories of medical devices available to patients within those networks. This type of system-wide decision-making, especially within larger providers, is already changing the individual physician’s role in the supply chain. With this shift comes an opportunity for care providers to play a larger role in the development of new products meeting the
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The Journal of the Twin Cities Medical Society
criteria of a more cost- and outcome-conscious environment. Whether it is through the support of an individual technology or company, or the founding of an accelerator or incubator dedicated to commercializing health care technology, there are many effective ways to bridge the bench and point of care. It is worth mentioning the irony in navigating the waters of change in these markets again today. Thirty years ago, a group of life science industry leaders, together with representatives of the payer and provider communities, came together to form Medical Alley. At the time, the non-profit organization was created to convene all stakeholders in the broader health care community to address challenges and navigate through the regulatory and reimbursement environments. As Lee Berlin, founding chairman of Medical Alley (LifeScience Alley today) wrote in a dedication text in 1984, Minnesota found itself in the unique position of having a health care community willing to work collaboratively toward innovating and launching “new medical products and systems that result in health care cost reduction for the world.” It is in this spirit that industry, payers and providers are beginning again to work more collaboratively for the sake of better outcomes and overall cost savings. A particularly fascinating new model can be found downtown at the Mill City Innovation and Collaboration Center (ICC). With the support of the University of Minnesota Physicians and organizations like Oracle, Medtronic, Optum, Sprint and Intel, Mill City ICC brings technology producers, patients and care providers together to engage in research and multidisciplinary collaboration in order to ease the adoption of technology, specifically for chronic and ambulatory care patients. On the other side of the Mississippi River, the University of Minnesota’s Medical Devices Center has taken a novel approach to uniting innovators and physicians with regional hospitals. The Innovation Fellows spend the beginning of their one-year fellowship immersed in clinic settings to identify unmet medical needs. Over the course of the year, a MetroDoctors
list of hundreds of identified needs are culled down to a small list of viable commercial opportunities for further development with the ultimate goal of producing technologies for licensing or companies to spin-out. Most recently, Optum Labs — a health care research and innovation group co-founded by the Mayo Clinic and UnitedHealth’s Optum — announced a partnership with Boston Scientific to research treatments for cardiac related diseases. Similarly, Aetna and Medtronic recently announced a collaboration to provide treatment, education and patient support for type 2 diabetes patients. Due to the Affordable Care Act, global economic pressures, changes in patient preferences or any of the myriad other factors squeezing and reshaping today’s health care system, we are living through a period of reinvention. As is always true in these times, there will be winners and losers, unintended consequences, revolutionary discoveries and truly novel approaches to how we prevent, treat and cure ailments and disease. What remains to be seen is what role each stakeholder will play in determining the new culture of health care, but if today’s trends are any indication, it will require a collaborative approach with a keen eye on defining and delivering better value at lower costs to patients worldwide.
Ryan Baird serves as the Director of Communications for LifeScience Alley, overseeing all external relations and marketing activity. Since joining the organization in 2005, his main responsibilities have included media relations, brand management, communications design and implementation and news content and production. Before joining LifeScience Alley, Ryan worked in vendor relations for a local Fortune 500 company and in media purchasing and placement. He holds dual Bachelors degrees from the University of Notre Dame.
About LifeScience Alley
LifeScience Alley is a global leader in enabling life science business success with a 30-year track record of delivering resultsoriented outcomes. We are committed to leading the conversation in improving our community’s operating environment and supporting advancement in research and health care innovation. By influencing proactive policy change, leading solutionsbased initiatives, delivering vital information and intelligence and uniting members with critical resources, LifeScience Alley works to ensure that collectively we remain the world’s strongest life science community. The Association’s membership and supporting community extends throughout the world, employing more than 300,000 Minnesotans and many more globally. www.LifeScienceAlley.org.
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Emerging Medical Technology
Innovation Driven by Unfortunate Circumstances
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he oldest recorded use of a prosthesis after injury is found in the Reg-Veda, an Indian Sanskrit book from 3500 BC. The warrior queen, Vishpla, had her leg amputated on the battlefield. After recovering from her wounds, she was fitted with an iron limb in order to return to the fray. As a physical therapist specializing in amputee rehabilitation within the Minneapolis VA Healthcare System, I am especially drawn to this story. It is striking to me that the first written account of a functional prosthesis is about a veteran of war. The modern orthotics and prosthetics industry as we know it was founded on the need for prosthetic limbs by the multitude of Confederate and Federal soldiers who suffered amputations during the Civil War. Nearly 60,000 men required functional prosthetic devices to be able to provide for their families. The devices were basic but they worked. World Wars I and II brought about other advancements in amputee rehabilitation through the advent of physical and occupational therapies. At the same time, new prosthetic joints, feet, and hands allowed for prostheses that were more adaptable and flexible in their uses but only slightly different from their predecessors. They were still made (mostly) of wood, they took hours to fabricate, and the selection of accessories, though greater than before, was limited. Plastic and modular components were the next innovations to make their mark. After Vietnam, the use of plastic for sockets and modular components for fabrication opened the door to huge changes in By Steve Brielmaier, MS, DPT
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prosthetic design. Specialized joints, feet, and hands were rapidly developed to meet the growing demand of the very active service members with limb loss. The process is continuing during the Global War on Terror. In the past several years, the Department of Defense has ramped up the research budget to work on bringing current prosthetic designs forward. There has been an increase in durability and reliability to the point that many wounded warriors are now able to return to their units on deployment overseas. This research, driven by unfortunate circumstance, ultimately benefits all amputees. You may have recently seen in the news that the FDA has approved the DEKA Arm for distribution to the public. It is the most highly advanced prosthetic arm developed to date. With multiple joints in the fingers and wrist controlled by EMG electrodes on remaining target muscles, its dexterity is remarkable and has earned it the nickname, the “Luke” arm, after the Star Wars hero. The research and refinement leading to the creation of this prosthesis was funded by the Defense Advanced Research Projects Agency (DARPA), an agency of the U.S. Department of Defense. The i-Limb hand by Touch Bionics is another upper-extremity prosthesis with amazing features. Its design is versatile enough to allow for its use with people with full or partial hand amputations. If necessary, a single digit prosthesis can be built to restore missing function to a hand. Like the DEKA Arm, the i-Limb is an active prosthesis that moves through battery powered motors controlled by the wearer. Significant advances have come in
This Veteran, originally injured by a blast in Viet Nam in 1969, was recently fitted with two Ossur Power Knees. These prosthetic devices mimic the function of the quadriceps and provide lift for functional activities like rising from a chair, getting up from the floor, and climbing stairs.
lower-extremity prostheses as well. The original C-leg Microprocessor Knee for transfemoral amputees was introduced by the Otto Bock Company in 1997. Now the next generation of the C-leg, the X2 and X3, have entered the market after research, funded by a government grant aimed toward producing an advanced microprocessor knee (MPK) for military use.
MetroDoctors
The Journal of the Twin Cities Medical Society
The design needed to be more durable, more stable, and with a greater battery life in order to hold up to the rigors of a soldier’s duties in the field. The X2 met those goals and the X3 added the advantage of being waterproof and fully submersible. Each prosthetic knee is controlled by a microprocessor that receives data from force sensors, a gyroscope, and an accelerometer embedded in the unit. This data is sampled thousands of times per second to help produce a more natural gait pattern as well as aid in stumble recovery. It remains, however, a passive system with the wearer supplying the force and power to advance the leg, step over obstacles, or lift themselves up stairs. Other manufacturers of prosthetic components have designed MPKs. Some use pneumatic cylinders to control flexion and extension resistance; others use hydraulic resistance or fluids with viscosities that can be instantly manipulated through electromagnetic pulses. Each may have differences when compared to their competitors, but all have the same goals: to increase walking safety of the wearer, and an increased flexibility of use. Many MPK units have modes that allow the person with a transfemoral amputation to perform a number of tasks such as walking, jogging, running, and biking. By analyzing data received, the processors learn to distinguish when a person is walking up a hill, or down a flight of stairs. The MPK can tell if the person is sitting or standing or stumbling and change its response accordingly. Today, there is only one truly active MPK system on the market. The Össur Power Knee is a motor driven unit with the ability to lift a person to standing from a seated position and even propel them up stairs. The motor in the knee, the same type of motor that drives NASA’s Mars rovers, has enough torque to simulate the quadriceps and provide powered knee extension. A wearer can be trained to use the prosthesis to go step-over-step up stairs or even get up from the floor. It is especially beneficial for persons with bilateral lower extremity amputations or those with a compromised remaining limb. However, it takes the right type of person. A candidate MetroDoctors
must be willing to spend three months or more in rigorous training with a physical therapist in order to utilize all of the functions of the limb. Within the last few years, microprocessor technology has been applied to prosthetic feet with impressive results. BiOM, a company founded in 2007 by Massachusetts Institute of Technology’s Dr. Hugh Herr, who also happens to be a bilateral transtibial amputee, has received funding
The Journal of the Twin Cities Medical Society
and support from the U.S. Department of Veterans Affairs and the U.S. Army’s Telemedicine and Advanced Technology Research Center (TATRC), as well as several private groups. Dr. Herr’s company has developed the BiOM T2 System. Their innovative, active foot design incorporates a battery-powered motor, controlled by a microprocessor, which provides propulsion (Continued on page 14)
We’re pleased to welcome… Bethany A. Cook, MD to Dermatology Consultants beginning August 2014. Dr. Cook will be practicing: s General Dermatology s Dermatologic Surgery s Cosmetic Dermatology s Pediatric Dermatology
After attending Carleton College, Dr. Cook obtained her medical degree from the University of Minnesota. Her internship in Internal Medicine at the University of California Irvine was followed by a Dermatology residency at the University of Minnesota. She was selected as Chief Resident in her final year. We look forward to Dr. Cook continuing our tradition of excellent care for skin diseases. Dr. Cook will see patients in our Vadnais Heights office. Please call 651-209-1600 or visit us online at dermatologyconsultants.com to make an appointment and for more information. Offices located in Eagan, St. Paul, Vadnais Heights and Woodbury.
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dermatologyconsultants.com
July/August 2014
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Emerging Medical Technology Innovation Driven by Unfortunate Circumstances (Continued from page 13)
by mimicking the function of the missing calf muscles with nearly instant changes in assistance depending on the terrain. As a result, BiOM T2 users report feeling less fatigued and more stable. The Proprio by Ă–ssur, and the ĂŠlan Foot by Endolite, do not provide propulsion but do have MP controlled dorsiexion and plantarexion which allow the wearer to have better stability and toe clearance when walking on uneven terrain. They are also able to sense when a person is walking on an incline or on stairs and then make appropriate adjustments. These two feet have now been incorporated into synergistic MP controlled knee and ankle systems. Ă–ssur created the ďŹ rst of its kind Symbionic Leg by combining the Proprio foot with their Rheo MPK. The two devices work together with a single processor to provide seamless integration of function. Endolite combined their ĂŠlan Foot with the Orion MPK to produce a prosthesis that also allows for coordinated
function and a smoother and more stable gait pattern. When it comes time for prosthetic prescription, the more information the physician can give regarding what is desired, the better. The top stumbling block for prosthetists is too little information regarding justiďŹ cation for the prescribed prosthesis. Without proper justiďŹ cation, billing and fabrication are put on hold until it is sorted out which causes an unnecessary delay for the patient. Regardless of the prosthetic device prescribed, it is important to note that the rehabilitation of the person with limb loss does not end when they receive the new limb. On average, it takes around two weeks for a new amputee to learn to use a transtibial prosthesis. Increase that time to three weeks for a person with a transfemoral amputation or an upper-extremity amputation. Generally speaking, the more complex the prosthetic device, the longer it takes to become proďŹ cient in its use. Work needs to be done on balance, weight shift, gait pattern, and stability on a variety of
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terrains. All of this training is completed in close cooperation with the prosthetist who adjusts alignment and ďŹ t of the prosthesis as the wearer progresses. Once the person is proďŹ cient, it’s a good idea to have occasional refresher appointments with them to make sure their recovery continues as smoothly as possible. The future of prosthetic design is limited only by the imagination and resourcefulness of the talented people driving the development of new products. But it is a team approach, with the patient in the lead, which insures a successful return to function for the person who will be using those innovative creations. Employees of the Veterans Health Administration do not endorse one manufacturer or a speciďŹ c prosthetic device over another. Steve Brielmaier, MS, DPT has been the Amputee Rehab Clinical Specialist at the Minneapolis VA Health Care System for over 14 years and lectures on Amputee Rehabilitation several times a year to the Physical Therapy programs at the University of Minnesota and Saint Catherine’s University. He graduated from UMN with an M.S. in Physical Therapy in 2000 and from St. Kate’s with his DPT in 2009. Steve helped develop the Amputee System of Care within the VA, is one of the co-authors of the VA/DoD Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation, is a co-investigator on ďŹ ve VA funded research projects on prosthetic foot design, and has lectured within the VA system across the country. Spencer Mion, CPO, and Kyle Barrons, CP contributed to this article.
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MetroDoctors
The Journal of the Twin Cities Medical Society
New Therapy for Obstructive Sleep Apnea
O
n May 1, 2014 the FDA approved the use of Inspire® Upper Airway Stimulation Therapy in selected patients with moderate to severe Obstructive Sleep Apnea (OSA) who could not be treated effectively with continuous positive airway pressure (CPAP). This device is a revolutionary addition to the armamentarium of treatments for OSA. The fully implantable device consists of a sensing lead which monitors respiratory cycle, a pulse generator and a stimulation lead encircling the hypoglossal nerve. The device gently and episodically stimulates the pharyngeal musculature to maintain airway patency during sleep. It has been found that pharyngeal muscular relaxation, which results in pharyngeal collapse, is a major contributing factor to nocturnal airway obstruction resulting in OSA. The Upper Airway Stimulation device once implanted is programmed in the sleep lab to maintain airway patency. It is turned on at bedtime and off upon awakening with a remote device. OSA is a disorder which affects approximately 18 million Americans. It is more frequent in males than females. One study showed that 2 percent of females and 4 percent of males of working age had some degree of significant OSA. The disorder results in sleep disruption, sleep deprivation and cardiovascular disturbances. The pathologic effects of OSA include: loud snoring, daytime sleepiness, depression, weight gain, increased automobile
By Kent Wilson, M.D., M.S.
MetroDoctors
and industrial accidents, diminished quality of life, hypertension, heart failure, cardiac rhythm disturbances, strokes, and diabetes. Placement of the Upper Airway Stimulation Device is similar to placement of a cardiac pacemaker. The stimulation lead is placed to encircle the right hypoglossal nerve and tunneled to the pulse generator pocket in the right infraclavicular area. The sense lead is placed in the right 4th rib intercostal space between the internal and external intercostal muscles. The device is implanted under general anesthesia on either an inpatient or outpatient basis. One month after placement the patient returns to the sleep lab where the device is programmed to achieve optimal respiration during sleep.
The FDA’s action was based on a determination that the device was safe and effective as demonstrated in the pivotal STAR (Stimulation Therapy for Apnea Reduction) trial. Results of this study were published in the January 9, 2014 New England Journal of Medicine vol 370, no. 2, p139. The study which included 126 implanted patients was conducted at 22 centers in the U.S. and Europe. The study was a prospective single-group cohort design which has a one year follow-up for primary outcome measures. Participants served as their own controls and one feature of the study was a randomized withdrawal of therapy trial at one year post implant. Participants were selected who had OSA with an apnea-hypopnea (Continued on page 16)
Inspire® therapy senses breathing patterns and delivers mild stimulation to key airway muscles, which keeps the airway open during sleep.
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July/August 2014
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Emerging Medical Technology New Therapy for Obstructive Sleep Apnea (Continued from page 15)
index of 20-50 and body-mass index of 32 or less. Evaluation involved medical and surgical assessment, drug induced sleep endoscopy and polysomnographic study. The study’s major findings are: 1. 68 percent reduction in apnea-hypopnea events. 2. 70 percent reduction in oxygen desaturation events. 3. Significant improvement in daytime functioning as measured by the Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ). 4. At one year the therapy withdrawal subset (23) showed substantially higher apnea-hypopnea indexes than the therapy maintenance (23) subset, 25.8 to 7.6 events per hour respectively. Oxygen desaturation figures were similar.
The indications for Inspire Upper Airway Stimulation (UAS) follows as do partial lists of contraindications, warnings and precautions. The interested reader should refer to the user’s manual for complete lists and guidance. UAS is for treatment of mild-moderate obstructive sleep apnea (OSA) in adult patients (22 years and older) with apnea-hypopnea indices (AHI) in the 20-65 range. Inspire UAS therapy is indicated for patients who are either unable to use positive airway pressure therapy or are unwilling to use it after a trial. The patient must have appropriate pharyngeal anatomy on sedated endoscopy with no evidence of concentric collapse at the level of the soft palate. Contraindications include the following: a. central & mixed apneas >25 percent of total AHI, b. obstructive pharyngeal anatomy on sedated endoscopy, c. pharyngeal neurologic dysfunction, d. inability to operate sleep remote, e. pregnancy, actual or planned, f. patients
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requiring magnetic resonance imaging (MRI) g. a previously implanted device which may be susceptible to adverse interaction. Warnings regarding the device include: a. Physicians must be properly trained in the implantation technic and operation of the device, b. pediatric cases of upper airway obstruction are usually of anatomic origin hence UAS would not be appropriate, c. only Inspire components should be used, d. Diathermy (electromagnetic radiation) should not be used, e. MRI should not be used, f. caution should be exercised with the use of the sleep remote, g. Body Mass Index (BMI) greater than 32 was not studied in the pivotal trial. Feasibility study data suggest a decreased likelihood of success with Inspire UAS Therapy in patients with BMI >32, hence implantation in patients with BMI >32 is not recommended. UAS therapy is a revolutionary new therapy for a select group of OSA patients unable or unwilling to use positive airway pressure treatment. Kent Wilson, M.D., M.S., a retired otolaryngologist from St. Paul, has served as a medical consultant to Inspire Medical Systems since 2009 and chaired the STAR trial Clinical Events Committee and Data Safety Monitoring committee. Dr. Wilson can be reached at: thewilsons01@comcast.net.
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Seaquist, MD and Luke Benedict, MD will discuss evaluation and diagnosis of prediabetes. MN Dept of Health will share the scope of the problem in Minnesota, and the Twin Cities YMCA will present an evidence-based program available to patients, and funded by CMS.
REGISTER NOW at HTTP://GOO.GL/EXJFQ0 The MMA designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit™.
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The Journal of the Twin Cities Medical Society
The Serendipitous Turns in an Odyssey Through Years of Patient Warming
I
can still remember my first patient as an anesthesia resident. She was shivering so violently when I checked her into the recovery room that her teeth were chattering. When I trained in the early ’80s, nearly all patients became hypothermic during surgery and it was regarded as normal. It took me a few months to realize that my patients’ most vivid memory of the entire surgical experience was the extreme discomfort of feeling like they were “freezing to death.” There had to be a better method of patient warming than the warm cotton blankets and water mattresses that we were using. When I learned that anesthesia causes patients to become poikilothermic, and like our reptilian friends we take on or lose heat depending on the temperature of our environment, the solution was obvious. Warm air mimicking a hot summer day seemed like a good place to start. After a number of tries, I had a prototype blanket that could be inflated with warm air vented over the patient. I was pretty sure that that the idea would work when, after falling into the cold creek behind our house, our 4-year-old son fell asleep under the warming blanket prototype. After getting out of the Navy, I joined a private practice anesthesia group and decided that in my spare time I would pursue the idea that we called “Bair Hugger.” My father retired from the ministry and joined me. The two of us, with zero business experience between us, started Augustine Medical in his garage. It was a bootstrap startup with my wife, Sue, drawing the logo at the kitchen table. Sometimes it’s By Scott D. Augustine M.D.
MetroDoctors
better to not realize all of the things that you don’t know because you may never start if you did. Bair Hugger® aka forced-air warming (FAW) hit the recovery room market in 1988 and immediately caught on because the patients loved it. It also turned out to be remarkably effective in treating hypothermia compared to the other warming technologies of the day. Soon Bair Hugger migrated into the operating room and over the next 10 years FAW became the standard of care for patient warming. We sponsored dozens of research projects including many studies that showed that warm surgical patients had far fewer complications than mildly hypothermic patients. Mild perioperative hypothermia was linked to: more wound infections, more blood loss, more adverse cardiac events, longer ICU and hospital stays and higher death rates. I wish I could say that I predicted all of this when we started the project, but no, it was just serendipity. I am particularly proud that FAW was one of the first therapies to be mandated by Medicare for most surgeries in order to comply with the SCIP guidelines for improved outcomes. I left the company about 12 years ago and it has been sold twice since then. When my team and I started another company to focus on innovative product
The Journal of the Twin Cities Medical Society
development, none of us wanted to get back into patient warming — 15 years was enough. We were working on a pillow that can form a bubble of HEPA-pure air around the head of an allergy or asthma sufferer while they sleep. We were optimizing the bubble in a smoke-filled room with lasers to show the air currents, when we stumbled on an unintended consequence of FAW — heat rises! For all of the years that I ran the company, our assumption was that the 40 CFM of airflow was easily diluted by the 1,000’s of CFM of ventilation airflow, and vented harmlessly from the OR. How wrong we were. Along with everyone else, we overlooked the 1,000 watts of waste heat. Standing in the smoke, we found that the waste FAW heat escapes from (Continued on page 18)
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Emerging Medical Technology Serendipitous Turns (Continued from page 17)
under the surgical drapes near the floor, mixes with the contaminated floor air and then rises like a rocket up the side of the table, finally depositing contaminates and bacteria in the sterile surgical field (www. Heat-rises.blogspot.com). This phenomenon has now been corroborated in five published studies, documenting the increased contamination and infection risk. Legg showed that there are 2,000 times more particles above the wound with FAW than with air-free conductive fabric warming. Legg also showed that the 1,000 watts of waste heat can create a vortex near the anesthesia screen that acts exactly like a tornado, literally sucking particles from the floor and depositing them in the surgical field. McGovern reported that when they discontinued the use of Bair Hugger warming and switched to air-free conductive fabric warming, their deep joint infection rate dropped 74 percent in total hip and knee arthroplasties. (References at www.HotDog-USA.com) The waste heat contamination of the sterile field probably does not matter in soft tissue surgery because it takes over one million bacteria to cause most soft tissue infections. Bacteria cannot make effective biofilm in soft tissue. Implant infections are totally different because bacteria can make very effective biofilm in the presence of implanted materials. It has been known for
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HotDog® blankets and mattresses use a flexible conductive fabric to warm surgical patients air-free, which research shows is safer than forced-air during implant surgery.
decades that a single airborne bacterium can cause a catastrophic periprosthetic joint infection (PJI). The missing link in the “Chain of Infection” methodology for linking a PJI infection to its source was the “Mode of Transport.” How do bacteria, that are known to be on or near the floor, get mobilized upward into the ventilation airflow and end up in the surgical field? The unintended consequence of my invention is the rising waste heat that mobilizes bacteria, and is now linked to causing PJIs. While Bair Hugger has brought improved outcomes to hundreds of millions of patients, it is now apparent that there is a subset of patients having total joint replacements who are at higher risk of catastrophic infections. Since most of my team are ex-Bair Hugger developers, we decided that it would be our “mission” to get FAW out of orthopedic surgery. When I was running the Bair Hugger project, I was quite certain that the next
generation patient warming technology was going to be air-free, conductive fabric warming — electrically conductive cloth that creates an electric blanket with even heat output. A few companies in Europe were trying to develop electric blankets and were using carbon fiber cloth (car seat heaters) as the heater material. Since all of the failure modes of carbon fiber result in hotspots, these products were regularly burning patients and they never made it to the U.S. market. About the time that we stumbled upon the rising waste heat phenomenon, we also read about a semi-conductive polymer called polypyrrole that had been developed as a radar absorbing material for stealth aircraft. We found that when polypyrrole was coated onto cloth it could make effective electric heaters — serendipity strikes again! There were still many technical challenges to overcome, but the solutions resulted in a stack of patents. Now we have the world’s most durable, flexible heaters and if they fail, they fail cold (meaning safe). We call our new air-free patient warming product HotDog® (www.HotDogUSA.com). It should not be surprising
MetroDoctors
The Journal of the Twin Cities Medical Society
that the space-age heaters in HotDog warming have many advantages over the 25-year-old FAW technology. The electric heaters can be made into blankets and mattresses allowing simultaneous warming from both above and below the patient, which is obviously more effective than FAW. Air-free HotDog is safer because the 200 watts of heat are effectively confined to the patient, in contrast to FAW venting 1,000 watts under the table. HotDog is sleek, ergonomic, and quiet and does not annoy the surgeon with waste heat. It’s a safely reusable product, which means that it’s much less expensive and is “green.” Competing against your own invention is both unusual and uncomfortable, especially in an industry where competition can get pretty intense. Only time will tell if HotDog warming will become the next patient warming standard. However, I can tell you for sure that due to the patient safety risks my team and I will not rest until FAW is out of orthopedic surgery. If I have learned anything on this odyssey it is this: appreciate serendipity but realize that it is not just luck. If you let your curiosity lead you down untraveled paths, serendipity will find you. Embrace it as an opportunity. Conflict of interest: Dr. Augustine is the founder and CEO of Augustine Temperature Management LLC, which manufactures and sells HotDog warming. Scott Augustine, M.D. is the Founder and Chief Executive Officer, Augustine Temperature Management, LLC (ATM) and Augustine Biomedical + Design, LLC (ABD). He earned his medical degree at the University of Minnesota and was trained in anesthesiology in the U.S. Navy. Dr. Augustine also did fellowship training in intensive care medicine at Stanford University and cardiac anesthesiology at the Mayo Clinic. He was a staff anesthesiologist at the Research Medical Center in Kansas City, MO and the University of Minnesota in Minneapolis, from 1987 to 1994. Dr. Augustine can be reached at saugustine@augbiomed.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
July/August 2014
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What is Sure About MNsure?
N
ow that we have been through the inaugural open enrollment period of MNsure, what do we know and where are we at now? As part of the Twin Cities Medical Society’s ongoing effort to keep physicians in the Twin Cities area appraised of changes that affect their day-to-day practice, this six month update on some of the key features of MNsure is provided. MNsure, of course, is the Minnesotabased health insurance marketplace that is part of the 2010 Affordable Care Act legislation. It is designed to provide Minnesotans who are eligible to purchase individual and family health insurance plans an online option with a true marketplace experience of side-by-side comparisons of the different products available. All of the policies have to comply with the inclusion of 10 essential benefit categories, which covers items like preventive services, hospital services, a pharmacy benefit plan and maternity care. There are four different “metal” category options, which define the network of hospital and clinics available at the best level of coverage, monthly premiums, amount of deductible per year, percentage of co-insurance and maximum out-of-pocket expenses per year. So what do we know about MNsure and the experience of Minnesotans since October 1, 2013 when MNsure went “live”? Here are some of the facts: • As of the end of April, 2014 there were over 200,000 individuals who enrolled for insurance coverage By Peter Dehnel, M.D.
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•
•
through MNsure. This includes just over 50,000 enrolled in private commercial plans. The remaining 150,000 are enrolled in state government sponsored plans — Medical Assistance, Medicaid and MinnesotaCare. The original projected goal of 135,153 was significantly exceeded by the end of this first open enrollment period; however, the goal of 70,000 individuals enrolled in commercial plans was not accomplished. This lack of commercial enrollees may have an impact on funding for MNsure, as commercials policies have a 3.5 percent surcharge on the premiums to fund the program’s operations. The MNsure website has had significant technical issues since it went live on October 1 with a number of fixes proposed and implemented since its rollout. Additional modifications
have yet to be made and it may take another year or two to completely resolve all the glitches in the system. • Minnesota has some of the lowest prices for premiums available through an insurance marketplace in the nation, according to Kaiser Health News. In Hennepin County, a single adult silver policy for a nonsmoker could be obtained for as low as $154.00 per month. • The MNsure program has a new chief executive — Scott Leitz — following the resignation in December of executive director — April Todd-Malmlov. • The initial enrollment period officially closed on March 31, 2014; however, enrollment was extended until April 22 for those individuals who could show that they had tried to sign up during the enrollment period but were unsuccessful due to technical problems with the enrollment process. The other side of the coin is what we don’t know at this point, which is at least as important as what we do know: • We do not yet know the number of previously uninsured Minnesotans who are now insured as a result of MNsure. • We do not know the experience of people who may have purchased policies through the exchange and are now subject to new rules around narrow or limited networks, loss of their previously established physician relationships and the impact of deductibles, co-insurance and out-ofpocket maximums.
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The Journal of the Twin Cities Medical Society
•
We do not know the financial impact of the new policies on clinics, specialty care and hospitals with the burden that deductibles, co-insurance and out-of-pocket maximums will likely put on some people who purchase these policies through MNsure. • We do not know the number of people who have actually paid their first premium for their policy — a term known as effectuated enrollment. We do know nationally that over 8 million people purchased policies through their state-based or federally facilitated insurance exchanges, with nearly half of these individuals signing up during March. We also know that health care spending in the first quarter of 2014 has taken a considerable jump — rising at an annual rate of 9.9 percent — much of which is apparently attributable to the 8 million individuals who have obtained coverage through their respective insurance marketplaces. Additional information will continue to come out regarding the performance of MNsure and other state-based insurance marketplaces. Policy rates for 2015 will be determined by insurers over the summer months. It is unclear what will happen to those rates as the real experience of administering these policies starts to be known. Finally, the open enrollment period for 2015 begins on November 15, 2014 and closes on February 15, 2015. What is your experience with MNsure? What questions do you have? How are you helping your patients understand the implications of narrowed networks, co-insurance, deductibles and essential health benefits? Your feedback is invaluable to the Twin Cities Medical Society. Please forward your impressions, thoughts and comments to nbauer@metrodoctors. com. Peter Dehnel, M.D., serves as co-chair of the TCMS Legislative and Policy Committee and is a medical director at Blue Cross and Blue Shield of Minnesota. He can be reached at Peter_J_Dehnel@bluecrossmn.com. MetroDoctors
The Journal of the Twin Cities Medical Society
July/August 2014
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2014 Minnesota Legislative Session Highlights
T
he Minnesota Legislature gaveled in on February 24, the latest start date in over 40 years. The session was fast paced and the legislature enacted a wide variety of legislation impacting all Minnesotans. The second year of the biennium is generally focused on a capital investment bill, which won approval on the last day, May 16 — three days before the mandatory constitutional adjournment date. Session began with the February Forecast announcement of a $1.2 billion surplus, sending the legislature into a discussion of how to allocate these funds. In the end, $283 million of the surplus was spent on a supplemental budget bill to fund programs ranging from higher education to corrections. A large portion of that bill, $103 million, was spent on health and human services. An additional $533 million of the surplus was spent in the two tax bills passed by the legislature, which contained an array of tax reductions. The legislature passed two capital investment bills, spending $846 million in general-obligation bonds and $198.7 million in general fund cash on additional infrastructure projects. The majority of the package allocated funding for higher education, state capitol renovations, and a number of regionally significant projects, such as civic centers. Two high-profile workplace initiatives passed this session: a minimum wage increase and the Women’s Economic Security Act (WESA). The state minimum wage will now be increased in increments over By James Clark, JD, and Julian Plamann
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the next few years and ending at $9.50 for large businesses and $7.75 for small businesses. There are built-in increases to the minimum wage in subsequent years. The WESA takes steps to close the gender pay gap and implements a number of policies to make the workplace more family friendly and more amenable to expecting and new mothers. Additionally, a number of health care policy initiatives passed, including the Advanced Practice Registered Nurse bill, a medical cannabis compromise, regulations on e-cigarettes, and a rate increase for Intermediate Care Facilities for Persons with Developmental Disabilities. Listed below is a short summary of some of the higher profile initiatives. Advanced Practice Registered Nurse Bill (Chapter 235)
This bill was one of the most hotly debated bills of the session. As first introduced, this bill attempted to remove physician collaboration for all areas of practice under APRNs. APRNs argued that the current requirement of physician collaboration was prohibiting care options for those in rural areas and proved too cumbersome
for those with years of experience. Many from the physician community disagreed, stating that such an increase in scope of practice would directly result in a decrease of patient safety. Physicians testified that their in-depth education and training background has better prepared them to make specialized care decisions. In the end, the law requires newly graduated APRNs to practice under physician collaboration for 2,080 hours. Additionally, CRNAs practicing interventional pain management must continue to practice under physician supervision. The bill was passed in the Senate with a vote of 64-0 and in the House with a vote of 119-13. The bill was signed by Governor Dayton on May 13 and will go into effect on January 1, 2015. MEDICAL CANNABIS (Chapter 311)
One of the final actions of the legislature was the passage of a medical cannabis bill, which becomes one of the most restrictive laws in the country. The bill was a carefully negotiated compromise between advocates, law enforcement, the medical community and legislators. The bill
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includes the patient registry system, which was proposed by the House. It allows the Department of Health to conduct an observational study on the impact of medical cannabis. It also retains the list of qualifying medical conditions from the House bill and adds chronic pain, nausea or severe vomiting and severe wasting associated with cancer or a terminal illness from the Senate bill. Other qualifying medical conditions include: glaucoma, HIV/AIDS, Tourette syndrome, amyotrophic lateral sclerosis (ALS), seizures, including those characteristic of epilepsy, severe and persistent muscle spasms, including those characteristics of multiple sclerosis; and Crohn’s disease. The Commissioner of Health must review whether intractable pain should be added to the list and report on his recommendation by 2016. To participate in the patient registry and obtain medical cannabis for those conditions, patients would need to pay a registry fee of $200, however some individuals may qualify for a lower fee of only $50. The bill allows two manufacturers and eight distribution sites in Minnesota. This is an increase from the one manufacturer and up to two distribution sites in the House proposal and a major decrease from the Senate version, which allowed for 55 distribution sites. Security measures from the Senate bill, as well as penalties for misusing the registry system to provide cannabis to someone not in the registry were also part of the compromise.
Care Facilities for Persons with Developmental Disabilities. To receive this rate increase, facilities must identify a quality improvement project that the facility will implement prior to June 30, 2015. The project must focus on increasing quality of life for the residents, quality of services, or increase the efficiency of the delivery of quality services. Additionally, the bill states that 80 percent of the rate increase must be utilized to directly increase compensationrelated costs for employees of the facility. This rate increase will go into effect on July 1, 2014. Other health care policies of interest that were adopted by the legislature include: a one year extension of electronic drug prior authorization transactions; modifications to the use of All-Payer Claims database; the establishment of a Health Care Home Advisory Committee; Worker Compensation Advisory Council Recommendations; and drug overdose prevention and immunity. All House members and the Governor are up for election this year. Filing
for office began May 20 and the general election is November 4. At stake in this year’s election is the DFL one-party control that has governed for two years. This has been the first time one party has controlled the House, Senate and Governor’s office in over 20 years. Governor Dayton is running for re-election. Fourteen House members announced their planned retirement the last night of session: 10 GOP and four DFL. It will now be up to legislators to make their case in their home districts and ultimately the voters will decide on whether or not this was a successful legislative session. James Clark, JD, Lobbyist and Shareholder. Julian Plamann, Legislative Coordinator, Messerli and Kramer PA. www.messerlikramer.com. Messerli & Kramer are assisting TCMS advance its legislative and policy goals in 2014. www.messerlikramer.com.
E-Cigarettes (Chapter 291)
The legislature adopted a health policy bill notable for its inclusion of e-cigarette regulations. E-cigarettes would be banned in government buildings, school property and day cares. However, the effort to have them treated similarly to cigarettes for purposes of the Clean Indoor Air Act was not successful. It also imposes restrictions and penalties meant to keep minors from buying or using e-cigarettes. ICF/DD Rate Increase (Chapter 312)
The supplemental budget bill contained a five percent rate increase for Intermediate MetroDoctors
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“What Do You Think is Causing the Problem?” Honoring Choices Across Cultures Global Health Course Helps Clinicians Ask Important Questions
H
ow often we forget that we are a nation of immigrants. Many of us lose sight of the simple fact that we cross cultures every day. And when providers, families and patients begin to discuss what has meaning in life, what sickness means, or how best to heal, communication wounds can erupt. On May 7, 2014, 57 interdisciplinary physicians, nurses, social workers, chaplains, care managers, students and others attended a full day UMN School of Medicine Global Health Course, a partnership with Honoring Choices Minnesota and HealthPartners. The purpose of the course was to: • Develop a framework for having conversations with patients and families about advance care planning (ACP). • Learn evidence-based methods for cross cultural communications. • Apply skills learned to live simulated patient encounters. • Improve comfort level in addressing ACP when a language or cultural barriers exists. Health care professionals from across the United States met other practitioners, improved their multicultural communication skills, practiced Stanford University’s LEARN communications model and participated in a cross-cultural simulation lab with Somali, Hmong, Latino and other volunteers in role plays with patients and families. The simulation lab included opportunities to respond in culturally sensitive issues such as, “When you tell me to make an advance directive, it means I am dying. Why are you hiding my real condition By Barbara Greene, MPH
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ACP panel presenters from left: Drew Rosielle, M.D.; Miguel Ruiz, M.D.; Patricia Walker, M.D.; Kathleen Culhane-Pera, M.D.; and Rob Ruff, Chaplain.
from me?” Or “How can you know what God or Allah wishes for me? While I respect the skills of physicians and other providers, it is Allah or God that is the source of life and death and will determine my fate.” Led by University of Minnesota Global Health Course co-director Brett Hendel-Paterson, M.D. and faculty Patricia Walker, M.D., a group of interdisciplinary health care professionals with extensive cross-cultural health experience met for more than six months to help design the course. According to Dr. Walker, a physician at HealthPartners’ Center for International Health in Saint Paul and director of the U of MN Global Heath Pathway, “There are striking similarities and differences across cultural groups relating to advance directives. While many individuals have a universal human response of some fear, anxiety or dread in having this discussion, others may feel more comfortable with the discussion. Some people may feel abandoned and wonder if you are withholding bad news, or even cursing the patient by bringing up end-of-life planning. Our goal is to give providers critical
tools to respond to different values with sensitivity and understanding.” Dr. Hendel-Paterson, a HealthPartners physician in internal medicine, pediatrics, tropical medicine and palliative care, identifies the uniqueness of this course. “Our patient/family/provider sim lab was unique in that participants had both language and cultural barriers in advance care planning. This gave participants opportunities to experiment with the principle “seek first to understand.” We plan to poll participants in three to six months to see if the practices learned have been effective in their practice.” For participant Ashley Styczynski, a George Washington University internal medicine resident, the course filled a huge gap in physician and health care training. “I have no previous education and instruction on cultural nuances of advance care planning. This course is an important beginning in learning to address end-oflife care concerns by understanding the patient’s values and care perspective.” Barbara Greene, MPH, Director of Community Engagement, Honoring Choices MN.
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Students Improve ACP Skills in Spring Student-Led Symposium
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n March 29, 125 interdisciplinary academic health center students spent a half day discussing distinctions between hospice and palliative care, exploring conversations in advance care planning, and probing ethical considerations in end of life. While spending a Saturday morning to discuss better end-of-life care and ACP communications is not everyone’s idea of weekend relaxation, the energy and enthusiasm from attendees and their peer planners was easily visible. Led by second year medical student Kyle Tamminga with former faculty member Therese Zink, M.D. as an advisor, this student Symposium was in planning for more than six months by an interdisciplinary team of medical, nursing and social work students. The goals of “End of Life Planning & Care: An Interprofessional Workshop” were to: • Identify essential resources for hospice, palliative care, and advance care planning. • Explain what hospice and palliative care are, how they are different, and when each should be utilized. • Use pertinent ethical and legal resources when caring for people near the end of life. • Effectively communicate with patients and families about their values and options for end-of-life care. • Describe the components of teamwork necessary for effective, compassionate end-of-life care. According to planner Kyle Tamminga, interactive scenarios, role plays, and participant dialogue successfully engaged
students and provided them with new skills and competencies. “… I knew a symposium like this would be a great addition to our curriculum. It would allow students the opportunity to learn more about this important aspect of medicine and to do so in a safe, supportive learning environment. It was my hope that efforts like this would better prepare my colleagues and me to care for our patients at the end of their lives.”
By Barbara Greene, MPH
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Year 1 nursing student Amran Ahmed identified why attending this event was important to her professional career. “Being of Somali background, I can reflect on cultural beliefs and myths about ACP, hospice and palliative care. Our community does not understand these issues. I believe that education is the key. And I want to be the one to make a difference.” Barbara Greene, MPH, Director of Community Engagement, Honoring Choices MN.
Interdisciplinary participants (from left): Maria Finke, Eileen Weber, Tyler Van Heest, Joan Liaschanko, and Kyle Tamminga.
Therese Zink, M.D. (left) discusses ethical ACP issues with participants.
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Advance Care Planning for All— Outreach Program Launched What will happen to my body after I die? Will anyone even notice if I’m in the hospital or if I die? I don’t want my family ever to be called if I am dying. They aren’t involved in my living, why should they be involved in my dying? These are some of the quotes and questions heard by John Song, M.D. when he began his research project on advance care planning (ACP) with vulnerable populations. Throughout his career in Maryland and Minnesota, Dr. Song found himself wondering about the interest level about ACP among his patients. He formalized his questions into a research project, secured funding, and launched a pilot project (SELPH: Study of End of Life Preferences for Homeless Persons) to find out. Working with staff and volunteers at the clinic he founded, the Phillips Neighborhood Clinic in south Minneapolis, he started to talk about end-of-life health care choices with clients. The initial results were surprising. “Many people assume that people who are homeless have enough to worry about in their daily lives — that there’s simply not time to worry about dying,” says Song. “In fact, they see a lot of death, and they think a lot about death. We were surprised — and then, surprised that we were surprised — to find that people who are homeless have the same concerns for recognition, dignity, and By Karen Peterson, BSN
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(From left) John Song, M.D., Rev. Mark Peterson, Ken Kephart, M.D., and John Cole, Executive Director, The Dignity Center.
legacy that anyone else has.” Song and his team did, however, find some specific concerns within this vulnerable population regarding health care and ACP: 1. Concern about what will happen to their bodies after death. Fears included being used for medical research, being sent to the garbage incinerator, or being tossed into an unmarked grave and forgotten. 2. Lack of trust of the medical system. Many fear they will not be given the same level of treatment as others, or the same level of respect. 3. Fear that a written health care directive could be used against them, by locking them into a decision that could not be changed or updated depending on circumstances. 4. Issues with accessibility. This includes both having access to a system which could offer the directive,
and also to the lack of personnel trained to work with this population and to be ready to assist with their special circumstances, especially mistrust of “the system.” Taking these fears and concerns into account, Song’s team developed a new health care directive, and began offering the form to the clients they worked with at Phillips, where clients had already established relationships with the staff and volunteers. In addition, they trained staff at other area clinics and agencies working with people who are homeless, widening the population they could reach with this project. Now, Dr. Song’s work will expand even more in the metro area, thanks to the Honoring Choices Ambassadors. The Ambassadors are a team of trained volunteers who represent Honoring Choices, an ACP initiative of the Twin
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Cities Medical Society, to the general public. Ambassadors give talks and presentations to groups of people interested in learning more about ACP, and they come together quarterly to learn more about issues and updates related to ACP in Minnesota. When they heard Dr. Song speak in March, many of them were moved to action. One Ambassador, Pastor Mark Peterson, immediately began brainstorming. Already connected with The Dignity Center, a program of Hennepin Avenue Methodist Church in Minneapolis offering a variety of services to people experiencing homelessness, Peterson called the program’s director and asked to meet. The initial meeting occurred a week later, with representatives from The Dignity Center, Honoring Choices Minnesota, and the Downtown Congregations to End Homelessness. Peterson shared his idea — that facilitated discussions about ACP be added to the services already being offered, and it was quickly accepted and planning began. A second meeting was called, this time with Dr. Song and Honoring Choices Medical Director Dr. Ken Kephart. After receiving their feedback on the plan, some adjustments were made and
a timeline was set. The Dignity Center Director, John Cole, shared that ACP will be a natural fit with the services already being offered. The Center already offers their clients the ability to make funeral plans, so ACP simply moves the planning “upstream” a bit, helping people understand their options about the health care they will receive if they cannot speak for themselves. Pastor Peterson will begin over the summer, initially working one morning each week with carefully selected clients. The clients will be chosen based on their age and health status, and their level of familiarity with and trust of the staff of The Dignity Center. Peterson, after being introduced by their case worker, will sit down with them one-on-one and start simply by talking about ACP. He’ll use skills gleaned from his pastoral work, his experience as a hospital chaplain, and his sensitivity to end-of-life issues honed through work with LifeSource and other volunteer roles. He will answer questions and assist as much or as little as needed with the writing of a health care directive, following the lead of the client. Ideally, interest will be high and word will spread, and additional Honoring Choices volunteers will become involved
at The Dignity Center and, eventually, other shelters and service centers working with vulnerable people. The Honoring Choices Ambassadors are ready to give their time and their ACP skills to this project. Several pledged their commitment to the idea of developing a relationship with a clinic or site offering services to people who are homeless, and are currently waiting to be called into action. Comments following Dr. Song’s presentation included “This was eye-opening. It is very helpful to hear about what’s happening and how we can help.” “I’ve worked with homeless people over the years and I always worried what would happen to/with them.” “This is a worthwhile study that has challenged me to be more thoughtful about those dying without a home.” “As an ordained minister, I want to volunteer to conduct a memorial service or funeral any time it is needed or could be helpful. Thank you for sharing this need, and opportunity, with us today.” “Call me. This is important. We must act!” The planning team for this initiative will reconvene in the fall to hear Pastor Peterson’s report. At that time, decisions will be made about where and how to expand. Honoring Choices is proud to be involved in this effort to bring ACP to all people, regardless of socio-economic status, and will continue to explore ways its organizational resources can be shared in outreach activities. For more information, please contact Karen Peterson, Honoring Choices Program Manager, at kpeterson@metrodoctors.com or (612) 362-3704. To read more about Dr. Song’s work: Song, J, Ratner, E, Bartels, D. Dying While Homeless: Is It a Concern When Life Itself is Such a Struggle? The Journal of Clinical Ethics, Vol 16 Nr 3:251-261. Song J, Ratner E, Wall M, Bartels D, Ulvestad N, Petroskas D, West M, Weber-Main AM, Grengs L, Gelberg L. Effect of an End of Life Planning Intervention on the Completion of Advance Directives Among Homeless Persons: A Randomized Trial. Ann Intern Med July 20, 2010 153:76-84.
John Song, M.D. speaking at a volunteer Ambassador event last March.
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New Members James C. Agre, M.D. U of M – Department of Physical Medicine Physical Medicine & Rehab Sharon S. Allen, M.D. Women’s Health Center – Fairview University Family Medicine Rafael S. Andrade, M.D. University of Minnesota Physicians General Surgery/Thoracic Surgery John D. Cameron, M.D. U of M – Department of Ophthalmology Ophthalmology, Anatomic Pathology Nicole Chaisson, M.D. Smiley’s Family Practice Clinic Family Medicine
Emily L. Bannister, M.D., MPH HealthPartners Occupational and Environmental Medicine
Tanner Nissly, D.O. Broadway Family Medicine Clinic Family Medicine
William Gershan, M.D. University of Minnesota Physicians Pediatric Pulmonary Care
Michael A. Page, M.D. U of M – Department of Ophthalmology Ophthalmology
Lynn Gershan, M.D. University of Minnesota Physicians Pediatrics
Roderick N. Sembrano, M.D. U of M – Department of Physical Medicine Physical Medicine & Rehab, Spinal Cord Injury
J. Brooks Jackson, M.D. Dean, University of Minnesota Medical School Clinical Pathology
Meenakshi Thirunavu, MBBS Humphrey Cancer Center – North Memorial Internal Medicine/Hematology/Oncology
Michael L. Knudson, M.D. Emergency Physicians Professional Association Emergency Medicine
Eric T. Trehus, M.D. HealthPartners – St. Paul Clinic Family Medicine
Daniel D. Miller, M.D. U of M – Department of Dermatology Dermatology
Scott C. Crowe, M.D. U of M – Department of Physical Medicine Physical Medicine and Rehab
Erin Warshaw, M.D. Minneapolis VA Medical Center Dermatology
In Memoriam INTERNATIONAL HEALTH SERVICE OF MN Providing volunteer healthcare in remote villages of Honduras Consider joining us on a rewarding MEDICAL MISSION TRIP Dates: Sept 28-Oct. 8, 2014 & February 13-27, 2015 Doctors are greatly needed and the experience is truly life changing for those who participate. For more information and to obtain an application for one of our next trips, see information below: International Health Service of MN PO Box 16436 St. Paul, MN 55116-0436 www.ihsmn.org
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ROLF L. ANDREASSEN, M.D., passed away on March 5, 2014. Dr. Andreassen graduated from the University of Minnesota Medical School. He completed a residency and fellowship in cardiology at Temple University in Philadelphia. Dr. Andreassen was a founder of Minneapolis Cardiology Associates and the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation. Dr. Andreassen became a member in 1953. ERNEST GOODMAN, M.D., age 86, passed away on April 1, 2014. Dr. Goodman received his medical degree at the University of Bologna, Italy. He was a founder of Parkview Obstetrics and Gynecology, and served as Chief of Staff at United Hospital. Dr. Goodman became a member in 1959. MICHAEL J. KOZAK, M.D., passed away at the age of 91 on May 2, 2014. Dr. Kozak graduated from the University of Minnesota Medical School and practiced family medicine at Northbrook Clinic and North Memorial Medical Center. Dr. Kozak became a member in 1959. RONALD J. NELSON, M.D., passed away on April 27, 2014. Dr. Nelson attended the University of Minnesota Medical School. Dr. Nelson practiced family medicine at the Maryland Clinic and was President of the East Metro Health Organization until his retirement in 1997. Dr. Nelson became a member in 1966. WILLIAM S. WRIGHT, M.D., passed away on March 29, 2014 at the age of 92. Dr. Wright graduated from the University of Minnesota Medical School specializing in pediatrics. Dr. Wright became a member in 1951. MetroDoctors
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Senior Physicians Association May 13 Luncheon The Senior Physicians Association held their first luncheon of 2014 at Broadway Ridge on May 13. The group welcomed guest speakers Diane Naas and Douglas Soderberg, M.D. from Physicians Serving Physicians (PSP). Diane Naas is the Executive Director of PSP and gave an in-depth overview of PSP and the work being done in helping physicians struggling with addiction. We also had the privilege of hearing Dr. Soderberg share his riveting personal story and experience with PSP on how the program helped him navigate through this difficult time. Both presentations were eye opening leading to an engaging question and answer session afterwards. Thank you to our speakers and to all who attended! For more information on Physicians Serving Physicians, visit their website at http://www.psp-mn.com.
From left: Robert Geist, M.D., SPA President; Diane Naas, PSP Executive Director; Doug Soderberg, M.D., PSP Volunteer; Flora MacCafferty, M.D., SPA Past President.
Registration Now Open! Senior Physicians Association Annual Event July 22 This year’s SPA Annual Event is at the American Swedish Institute. The day begins with a tour of the historic Turnblad Mansion at 10:30 a.m., followed by a three-course plated lunch at 11:30 and a presentation by Stephan Osman on the Dakota and Civil Wars.
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Registration is $30 per person, and members are encouraged to bring guests. Please join us and don’t miss this fun event! For additional details and to register, visit www.metrodoctors. com or call Andrea Farina at (612) 623-2885.
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LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
ROBERT A. VAN TASSEL, M.D. Leadership ability is a marvelous life quality. Dr. Robert Van Tassel’s stunning array of attributes exemplifies that quality and contribute to an obvious moniker…leader. Though born in Wisconsin, he has, since age seven, qualified as a Minnesota product. From Watertown High School he earned his B.A. and M.D. degrees at the U of M. After an internship and internal medicine residency at HCMC, he returned to the U and completed a fellowship in cardiovascular medicine. Generally accepted leadership characteristics include: commitment, communication abilities, confidence, intuition, organization, resourcefulness, initiative, adaptability, positive attitude, proactivity and the ability to inspire. Bob Van Tassel possesses all of the above plus additional distinctive skills that when woven together have resulted in an exemplary career replete with contributions to the specialty of cardiology, its patients and our community. Dr. Van Tassel is described by colleagues as a creative visionary who thinks “out of the box” and strives to build consensus. These talents expressed themselves when he collaborated with others to found the Minneapolis Heart Institute (MHI), and later its Foundation, which facilitated the conduction of literally hundreds of research projects through the years. As an interventional cardiologist, he realized early on that aligning with top-notch cardiac surgeons would aid in providing his patients with exemplary care. While accomplishing that working relationship, it made further sense to welcome the additional specialties of cardiovascular radiology and anesthesiology plus multiple subspecialty cardiologists into the growing institute of cooperating clinicians. Currently, there are over 50 clinicians in that practice — his “brain child” — which Bob shyly states, “Just grew by itself.” Despite being deeply involved in administrative responsibilities, he somehow managed the time required of a busy and productive physician. He was a skillful interventional clinician, performing angioplasties (credited with the first such procedure in Minnesota), and inserted stents and pacemakers. He was an astute diagnostician and a caring practitioner whose patients loved and respected him. He educated both young and experienced colleagues as a long-time faculty member of his alma mater, and 32
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by contributing nearly 80 articles and abstracts to the cardiovascular literature. The breadth of his interests and talents is well demonstrated by the topics of his publications — which, among others, included coronary disease management, catheterization and echocardiographic technological advances, atherectomy, thrombolysis, antiarrhythmics, and left ventricular pumping assistance. During Dr. Van Tassel’s career, evolutions in the treatment of heart disease — though still the leading cause of death — have resulted in a striking decrease of over 50 percent in mortality. Bob modestly states, “My timing was good and I’ve been excited to just be riding the wave of advancements in cardiology.” In reality, he was instrumental in actually creating that wave! This unassuming physician and father of three gifted professionals — who was a flight surgeon during the Viet Nam war and later a Minnesota Orchestra board member, and was honored by Alpha Omega Alpha membership and with the prestigious Ray Bentdahl Award in Cardiovascular Medicine — states that the area he misses the most since his retirement four years ago, is direct patient care. His grateful patients and his profession have duly appreciated the contributions of our Luminary. Bob’s colleagues, who continue to call upon him for counsel and advice, state that he has been the ultimate role model and a joy with whom to work. The legacy of this fine leader will live on for decades. 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.
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