“Your patients will thank you for referring them to Dr. Crutchfield.”
A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves. Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column. Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring under-represented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.
AES
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CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters. Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild 1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com
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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Mac Garrett Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Erica Nelson Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Erica Nelson 4084 Jana Ave. NE St. Michael, MN 55376 phone: (763) 497-1778 fax: (763) 497-8810 e-mail: erica@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.
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July/August 2018
July/August Index to Advertisers TCMS Officers
President: Thomas E. Kottke, MD President-elect: Ryan Greiner, MD Secretary: Andrea Hillerud, MD Treasurer: Sarah Traxler, MD Past President: Matthew A. Hunt, MD
Crutchfield Dermatology..................................... Inside Front Cover Entira Family Clinics .......................................31
TCMS Executive Staff
Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Karen Peterson, Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Trish Greene, Administrative Specialist, Honoring Choices Minnesota (612) 362-3705; tgreene@metrodoctors.com Annie Krapek, Project Coordinator, Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com Linda Singh, Executive Director, The Convenings (612) 362-3724; lsingh@theconvenings.org Katie Snow, Administrative Coordinator, The Convenings (612) 362-3739; ksnow@theconvenings.org
Fairview Health Services .................................31 HealthPartners.................. Outside Back Cover MN Dept. of Health – Sage Programs ...........1 MN Dept. of Health – Sage Programs .........11 Schuster Clinic ...................................................30 St. Cloud VA Medical Center ............................ Inside Back Cover University of Minnesota Health ..................... 4 U.S. Army ............................................................18
NEED HELP? Feeling overwhelmed and turning to alcohol and/or drugs for relief?
Physicians Serving Physicians is an independent, physician-centric organization that was established in 1981 by a group of physicians in recovery to help other physicians and their families struggling with chemical dependency. The core of PSP’s mission is to provide active help and service to physicians (including residents), medical students and their family members affected by alcohol and drug addiction.
Physicians Serving Physicians can help! For confidential assistance: • Call: (612) 362-3747; email: psp@metrodoctors.com • Jeffrey Morgan, MD, Interim Medical Director, (612) 267-8912 • Psp-mn.com
MetroDoctors
The Journal of the Twin Cities Medical Society
CONTENTS V O L U M E 2 0 , N O . 4 J U LY / A U G U S T 2 0 1 8
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IN THIS ISSUE
The Spectrum of Medical Education —Where Bedside and Technology Meet By Marvin S. Segal, MD
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PRESIDENT’S MESSAGE
Inviting All Innovators-in-Training By Thomas E. Kottke, MD
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TCMS IN ACTION By Ruth Parriott, MSW, MPH, CEO MEDICAL EDUCATION
8 Page 32
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Page 7
Colleague Interview: Compiled by the Office of Medical Education, University of Minnesota Medical School: Jakub Tolar, MD, PhD; Mark Rosenberg, MD; Robert Englander, MD, MPH; Anne Pereira, MD, MPH, FACP; Dimple Patel, MS; Kirby Clark, MD; David Satin, MD; and Michael Pitt, MD. • A Focus on the First Year By James Pathoulas, MD Candidate 2021 •
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“Trust me, I’m (almost) a Doctor” Secrets of the Rural and Metropolitan Physician Associate Programs Revealed By Kirby Clark, MD
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Reshaping Medical Education Starts at the U By Robert Englander, MD, MPH
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Environmental Health —Climate Change: Preparing Physicians to Address Emerging Challenges By Kristen Bastug, MS4
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Results of the National Residency Match at the University of Minnesota Medical School By Michael H. Kim, MD
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SPONSORED CONTENT: Serving the Underserved: Training Family Medicine Residents
at the University of Minnesota in Comprehensive Care By James Pacala, MD
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Graduate Medical Education from 2001 to Today: Change is the New Constant By Meghan Walsh, MD, MPH
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A Return to the Bedside: Teaching Point-of-care Ultrasound at Abbott Northwestern Hospital By David Tierney, MD, FACP, Bob Miner, MD, FACP, and Terry Rosborough, MD, FACP
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SPONSORED CONTENT:
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Learning to Talk About End-of-Life Preferences
Page 7
Training Practice-Ready Clinicians to Meet Workforce Needs By Felix K. Ankel, MD, Kelly K. Frisch, MD, and Shannon E. Kojasoy, MPP
Career Opportunities LUMINARY OF TWIN CITIES MEDICINE
Marvin S. Segal, MD Page 7
MetroDoctors
The Journal of the Twin Cities Medical Society
This issue of MetroDoctors highlights innovations in medical school and residency curricula, blending traditional learning with new technology. Articles begin on page 8.
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is for cardiology. University of Minnesota Health Heart Care As leaders in heart care interventions for over 60 years, we make innovative care our mission. We’ve transformed lives with major breakthroughs in valve replacements, transplants, cardiac resuscitation and other pioneering techniques to treat heart disease. With multiple centers and clinic locations throughout the region, we’re just a heartbeat away. We see patients six days a week. Learn more about our expert, innovative care.
Visit MHealth.org/heartcare
University of Minnesota Health is a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ©201 University of Minnesota Physicians and University of Minnesota Medical Center
IN THIS ISSUE...
The Spectrum of Medical Education — Where Bedside and Technology Meet The words of the brilliant scientist/philosopher, Albert Einstein, ring true: “Education is only a ladder to gather fruit from the tree of knowledge, not the fruit itself.” Ah yes, and in our dynamic world of medicine, both the “ladder” and the “fruit” are continually changing. This issue of MetroDoctors explores some of the more meaningful educational elements in today’s health care landscape. Authors from the Office of Medical Education, in the Colleague Interview article, provide us with an excellent overview of our U of M Medical School including — its mitigations of past disparities, demographics, economic considerations, approach to diversity and a very interesting discussion regarding the “hidden curriculum.” To appreciate ways in which medical school has changed in recent years, our readers should relish a neat, interactive interview by our newest editor, James Pathoulas, and his first year classmates highlighting the excellent uses of technology. Kirby Clark, MD acquaints us with a popular and unique rural and metropolitan physician associate program that contributes significantly to the popularity of Minnesota-based primary care practices among our medical school graduates. A new strategic initiative to reshape methods of training future doctors is discussed by Dr. Robert Englander, and he shares details of an exceptional program in pediatric teaching as an example of how the U of M Medical School remains in the forefront of educational innovation. An article by the Environmental Task Force written by another talented medical student, Kristen Bastug, discusses the important topic of climate change and justifies the recommendation that it be included in medical school curricula. They and their references support the notion that health-related sequelae of global warming have far reaching aversive consequences. The excitement of Residency Match Day mounts and is captured by Michael Kim, MD as trends in postgraduate decisions are recounted.
By Marvin S. Segal, MD Member, MetroDoctors Editorial Board
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The Journal of the Twin Cities Medical Society
Dr. James Pacala takes us through the gamut of excellent educational endeavors resulting in the provision of needed services throughout the Twin Cities and our state. An emphasis on more subjective societal oriented topics by the Family Medicine training program is both interesting and commendable. Meghan Walsh, MD describes some important changes in graduate medical education. Her first-person experiences — including both good and tough times — help to relate the story of how we’ve moved to our current status in the training of young physicians. The practicalities in house staff education of a meaningful technical advance in bedside diagnosis is described by Drs. Tierney, Miner and Rosborough. The article should be of particular importance to physicians who have been away from training for some time. As clinicians are being prepared to meet a variety of workforce needs, a distinctive programmatic approach at HealthPartners is explained to us by authors Ankel, Frisch and Kajasoy. We welcome back a former editorial colleague, Dr. Greg Plotnikoff, whose writing talents are aptly displayed in the Luminary feature. As medicine moves toward greater emphasis on value-based care, there seems to be increasing focus on educational trends toward population and public health issues which go beyond — but are still profoundly inclusive of — individual health, and technological advances immeasurably aid in that dynamic process. So, our readers, you have some thought-provoking perusing ahead of you. Enjoy!
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President’s Message
Inviting All Innovators-in-Training THOMAS E. KOTTKE, MD
The medical education focus of this issue of MetroDoctors has led me to review the diverse opportunities to innovate offered by the Twin Cities Medical Society (TCMS) to metro area medical students, residents and fellows — all physicians-in-training. For example: • Holding seats on TCMS and TCMS Foundation Boards of Directors; • Participating in Physician Advocacy Network’s tobacco initiatives by testifying at public hearings and meeting with council members regarding the restriction of tobacco and related products; • Serving on the MetroDoctors editorial board; • Advocating for ways to improve the environmental health of our communities as they serve on the TCMS Environmental Health Task Force; • Participating in Honoring Choices Minnesota, a program that promotes advance care planning; and • New this summer, the Dr. Pete Dehnel Public Health Advocacy Fellowship program will provide opportunities for all medical students enrolled at UMN-Twin Cities Campus to engage in local public health advocacy activities relevant to a personal area of interest. We also offered opportunities within the medical school curriculum for independent study projects on Epic and advance care planning; LGBTQ-focused information cards on advance care “I’m so grateful for the opporplanning; advance care planning directives designed for psychiatric illness; and the translation of tunity to have served on the advance care directives to Mandarin. TCMSF board as a medical TCMS is honored to participate in the annual entering-student White Coat Ceremony; we student, and now as a resident. sponsor lunch-and-learns; and, we offer a two-hour introduction to advance care planning and The experience offered a unique family care conferencing during the fourth-year student ICU rotation. leadership opportunity as well These are only a few of the perhaps dozens of opportunities available to physicians-in-training at no cost; TCMS membership for them is free. as a setting to collaborate with A personal story illustrates why I am so enthusiastic about recruiting physicians-in-training to physician leaders to address real TCMS-sponsored activities. My involvement in heart disease prevention started in Finland as a public health needs in our surmedical student, and several years ago I was chatting with the famous Finnish physician, Martti rounding community.” Karvonen, a “founding father” of cardiovascular disease epidemiology and prevention. I asked him Solveig Hagen Ophaug, MD, how the then-young North Karelia Project team was Resident able to generate the changes in society that ultimately “As a medical student volunteer, I have been led to an 85% reduction in coronary heart disease afforded incredible opportunities and privilege mortality rates, a 50% reduction in total mortality rates, and a 10-year increase to contribute toward both my patient and profesin life expectancy. His reply? “They didn’t let old ways of thinking impede sional communities. I have served in a number of their innovation, and they didn’t know that what they were doing couldn’t be capacities at the local, state, and national levels, done.” Medical students, residents and fellows have this same advantage over representing the Twin Cities Medical Society older physicians: They haven’t had the time to learn the traditions that serve at the Minnesota Medical Association’s Policy no purpose other than to impede progress, and their optimism has not been Council and pushing for Tobacco 21 through the eroded by experience. Thus, they bring new ideas and new energy to the table Physician Advocacy Network in my hometown. unencumbered by yesterday’s beliefs about the possible. As I move into residency here at the University TCMS has long been an organization through which innovators at every of Minnesota, I am honored to join the board of level of training and career have been testing their ideas and exploring the posTCMS, representing my resident and physician sible. I, for one, would like to see that expand. So my message to you, whether colleagues.” or not you are still in a formal training program, is, “We’re open for business; Alex Feng, MD, Resident we’re answering the phone (or email); and, we’ve reserved a seat for you at the innovators’ table.” 6
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The Journal of the Twin Cities Medical Society
TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO
Ruth Parriott, MSW, MPH, CEO
On April 30, 2018, I became the newest member of the TCMS/TCMSF leadership team as CEO. My experience includes a strong background in nonprofit and philanthropic management, most recently as Regional Vice President for the American Cancer Society Cancer Action Network. In that capacity, I managed the local, state, and federal government relations programs for a 19-state region, including deployment of a grassroots network of trained volunteer and professional advocates. Locally, I also served in leadership with the Neighborhood Health Care Network, strengthening funding and management support for community clinics, and as a program officer for The Minneapolis Foundation, supporting organizations advocating for economic, social, racial, and environmental equity. My public health career began with the Minnesota Smoke-free Coalition, managing a campaign to increase the state tobacco excise tax; I have fond memories of partnering with the dedicated physicians of the Ramsey and Hennepin County Medical Societies in that effort. My credentials include Masters of Public Health and Social Work degrees from the University of Minnesota (in addition to wife, mother, snorkeler, and hampster lover). I look forward to working on your behalf and can be reached at rparriott@metrodoctors.com; (612) 362-3799.
Pathology Associates, as a director; Alex Feng, MD as a resident/fellow section director; and Bruce Gregoire, filling a vacant medical student seat. Senior Physicians Association
The Senior Physicians Association held their spring meeting on May 15, 2018. Denise Young, EdD, Executive Director, Bell Museum delivered an enlightening presentation on the new Bell Museum, describing how the art pieces were removed, stored and restored and shared a few “sneak peek” photos of the displays. The museum opens to the public on Sat. July 14.
MetroDoctors
Honoring Choices MN
On April 16, National Healthcare Decisions Day, Honoring Choices joined with Gilda’s Club and Cancer Legal Care to present a full day of Advance Care Planning (ACP) seminars and one-on-one assistance to individuals and families dealing with cancer. Volunteer physicians and lawyers were on-site to answer specific questions. Over half of all attendees completed their healthcare directives during the day, with the remainder committing to do so soon.
Eugene Ollila, MD, SPA President with Denise Young, EdD, Executive Director, Bell Museum.
PAN Update
The cities of Shoreview, Minneapolis, and Falcon Heights joined other local communities restricting access to tobacco to persons age 21 and older. In addition to passing Tobacco 21, Falcon Heights restricted the sale of all flavored
TCMS Board Member Update
Sarah Traxler, MD, Medical Director, Planned Parenthood MN, was recently voted TCMS Treasurer and appointed to the Executive Committee. Welcome new members: Milton Datta, MD, Hospital
tobacco, including menthol tobacco, to adult only stores. Mendota Heights also restricted flavors, excluding menthol tobacco. Watch for future T21 action in Richfield and Roseville!
PAN advocates at Minneapolis City Council T21 hearing.
The Journal of the Twin Cities Medical Society
Lindy Yokanovich, JD, Cancer Legal Care; Karen Peterson, Honoring Choices; and Alison DiCamillo, Gilda's Club.
Spring was filled with several Honoring Choices MN presentations, including: ACP strategies at the MAFP Annual Conference; Communication in Serious Illness at HealthPartners Aging Conference; three presentations on ACP to Stearns County Employees and a staff seminar on ACP at Andrew Residence, a Minneapolis program for people with mental health diagnoses. July/August 2018
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Medical Education
Colleague Interview This interview was compiled by the Office of Medical Education, University of Minnesota Medical School: Jakub Tolar, MD, PhD, Dean, Medical School; Mark Rosenberg, MD, Vice Dean for Education & Academic Affairs; Robert Englander, MD, MPH, Associate Dean for Undergraduate Medical Education; Anne Pereira, MD, MPH, FACP, Assistant Dean for Clinical Education; Dimple Patel, MS, Associate Dean of Admissions, Medical School; Kirby Clark, MD, Director, Rural Physician Associate Program & Metro Physician Associate Program; David Satin, MD, Assistant Professor, Dept. of Family Medicine and Community Health; and Michael Pitt, MD, Assistant Professor, Director of Global Health Education; Associate Residency Program; Director, Dept. of Pediatrics.
What do you see as the biggest problems facing medical education today? What changes need to occur? The biggest problem facing medical education today, particularly at the medical school level, has been the inflexibility of medical schools to change and adapt. By and large, medical schools are still organized structurally based on a report by Abraham Flexner in 1910. As the notion of what it means to be a doctor has expanded beyond the domains of patient care skills and medical knowledge, and as information has exploded, the primary strategy of medical schools has been to add continuously to the curriculum in a onesize-fits-all manner. The result is cognitive overload and burnout. A second major challenge for medical education is the fragmentation, often self-imposed. Undergraduate Medical Education (UME; the four years of medical school) and Graduate Medical Education (GME; residency and fellowship) are often structured in blocks, antithetical to the literature on how we learn. Education and training are additionally fragmented by the siloed nature of UME and GME. They have completely different accrediting bodies resulting in a disconnect between the message to medical students versus residents about what it means to be a doctor in the 21st century. As new schools have emerged, it has been interesting to watch the degree to which they have often scrapped the old way of doing things in favor of more continuity, better integration of the clinical and foundational sciences, an emphasis on concepts over content, and a focus on new skills critical to the current practice of medicine, such as interprofessional collaboration. 8
July/August 2018
Describe the change in diversity/ethnicity of U of Minnesota Medical School applicants over the last 10-15 years. What fraction are typically non-U.S. students? The University of Minnesota Medical School Admissions Committee facilitates a holistic review process ensuring the consideration of every candidate’s curricular and co-curricular experiences, academic metrics, and personal and professional attributes. Through this process, balanced consideration is given to a variety of factors that make up an applicant’s portfolio of preparation. Reviewing each candidate’s contributions to diversity is directly in line with the Medical School mission. We aim to attract candidates from diverse communities as defined by the Medical School Diversity Statement, and also expect all candidates to demonstrate their continued commitment to their development of cultural awareness. Underrepresented in medicine (UIM) is defined as “racial and ethnic groups that are underrepresented in the medical profession relative to their numbers in the general population.” This definition includes African American, Hispanic, American Indian, Pacific Islander, and Hmong students. Over the last 10-15 years the percentage of our students classified as UIM rose from about 8-9% to the current level of 18-20%. The Medical School has accepted a very small number of non-U.S. or international students in this time period. The majority of racial and ethnic diversity in our classes comes from our domestic students.
MetroDoctors
The Journal of the Twin Cities Medical Society
What instruction is being given to help students better understand gender, race and socio-economic disparities of their patients? In their first year of medical school, our students face these topics head on. We were one of the first schools to tackle the social construction of race. We partner with experts from the Department of Family Medicine and Community Health’s Center for Sexual Health to help students explore gender in depth. Our students learn about the social determinants of health in their very first week of school and examine Minnesota’s health disparities from the extensive data collected in the state. Each year, our students come to medical school with a greater baseline knowledge of these topics. This is both a credit to our admissions team as well as a heartening generational trend. Our student body’s dedication to understanding the social science, the history, and even the philosophical underpinnings of these topics is laudable. Our students will be ambassadors for these topics with patients, faculty, and society.
Regarding the cost of medical education; has the escalation in student expense plateaued or has escalation continued? We are very concerned about the expense of medical school and the debt incurred by our graduates. For this reason we have held tuition stable for the past six years for Minnesota residents (8085% of the class) and have only increased non-resident tuition a small amount. Out of the 88 public medical schools reporting data, we have dropped from the 4th most expensive public medical school in 2012 to the 38th. For non-resident tuition we are ranked 66th among the public medical schools reporting their data. We remain very concerned about student debt, which for our 2017 graduates was $171,870 (the national average.)
Does the current cost limit the scope of applicants or perhaps preclude certain populations? While the cost to attend medical school anywhere in the country is relatively high, the University of Minnesota Medical School has taken an active approach in supporting students with limited financial resources to pursue medical education. Our senior leadership has successfully advocated for keeping tuition the same for the past six years. The Dean of the Medical School has provided recruitment awards, including full scholarships and non-resident tuition waivers. Candidates are considered for these awards through our comprehensive review process, by which we consider academic achievement, socioeconomic status, candidates’ contributions to diversity, research experience, and several other factors. The University of Minnesota Foundation has also facilitated the establishment of several full and half tuition awards for incoming medical students to help lessen the cost of medical education.
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The Journal of the Twin Cities Medical Society
These funds are awarded using the same criteria mentioned above. These awards have allowed us to attract students from broadly diverse backgrounds while also meeting our mission of educational excellence, innovation, and diversity. In addition to these awards, we have a robust recruitment program to introduce students to our Medical School. Specifically we facilitate two pipeline programs: the Minnesota Future Doctors (MFD) and the Joint Admissions Scholars Program (BA/MD). Both of these pathway programs attract students from broadly diverse backgrounds including those who are first generation college students and from lower socioeconomic communities. These programs provide resources and advising to prepare students for their medical school applications and future careers. We are also developing new recruitment tools to attract a larger audience of candidates who may be limited in their abilities to attend recruitment fairs or other on-campus visits, as well as more support for students from non-traditional backgrounds and community colleges. We hope the creation of new programs and expansion of current programs will allow us to attract students from diverse backgrounds and garner support for scholarships to recruit students who will meet and expand our educational mission.
Describe the initial teaching of and subsequent honing of skills to clinically manage the exploding volume of online clinical information. Throughout their four years of training, students are developing skills to clinically manage the exploding volume of online clinical information. Just as our students must master a large number of foundational scientific and clinical concepts, they must also learn how to seek, critically appraise, and apply new knowledge. During the first two years of the MD curriculum, during our doctoring course, Essentials of Clinical Medicine, students learn about the need to engage in lifelong learning and have many opportunities to practice the critical appraisal of new evidence. Furthermore, we have an interactive, case-based course that runs throughout the first two years, Foundations of Clinical Thinking. In this course, students develop skills in clinical decision-making and differential diagnosis, and also learn how to seek, appraise and apply information to answer a clinical question. During their clinical training, based on patients they encounter, students are required to develop and answer clinical questions by reviewing best practice guidelines and emerging evidence in the literature.
Is there a place for MD Primary Care going forward? Meeting the state’s physician workforce needs is a critical part of the mission of the University of Minnesota Medical School, especially since 70% of the doctors practicing in Minnesota have
(Continued on page 10)
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Medical Education Colleague Interview (Continued from page 9)
either gone to the University of Minnesota Medical School, trained in one of our graduate medical education programs, or both. A major component of meeting workforce needs is training primary care physicians. The University of Minnesota Medical School produces more students who enter Family Medicine residency programs than any other U.S. medical school. We rank in the top percentile of schools with graduates who enter other primary care residencies, in the percent practicing in Minnesota, and in the number practicing in rural and underserved urban areas.
leveraging our own comfort with app-based touch screen devices, incorporating voice recognition technology specifically designed for medical purposes, and developing clinical decision support algorithms to help with patient care.
Most students are trained with Epic, but are they given instruction in how to utilize it to its full potential, e.g. trend patterns? Any special training to deal with the post-graduate spectrum of EMRs?
Ensuring rural Minnesotans are cared for by excellent physicians is a high priority of the University of Minnesota Medical School. Our regional campus at Duluth, and the Rural Physician Associate Program (RPAP) are central to our success in developing rural physicians. About 60 students each year are admitted to Duluth’s medical school, where they complete their first two years of training. The curriculum at Duluth includes robust rural medicine training and mentorship. The Duluth campus is mission driven, focusing on rural and native health.
One of our goals is to help all of our trainees understand the full potential of the electronic medical record and their role in that space. We have developed a curriculum that orients medical students early in their training to the evolution of the EHR, what it can do, and what it may be able to do in the future. Most important, this curriculum focuses on what makes a good citizen of the EHR ecosphere and provides trainees with practical tools to employ as they begin to use an EHR. We chose to make the curriculum about EHRs in general, knowing that each system is different, but the core concepts behind our role with the EHR remain the same. Many of our students get involved in informatics initiatives to improve EHR workflows, and as we have several faculty whose academic careers are focused in this space, there are many opportunities for mentorship. We also aim to keep students up-to-date as new developments happen in this space.
Electronic Health Records. How is the medical school dealing with the time burden required by record keeping and documentation to preserve time for direct patient interaction?
As medicine is becoming more of a business than an art, how are students prepared for the business aspects of medicine? Should economics courses be offered along with the traditional curriculum?
As clinicians we are fully aware of the double-edged sword that the electronic health record provides. While the technology supports integration and streamlining of clinical workflows previously not possible, the challenges inherent to implementation are many. Time spent at the computer, whether to orchestrate the data gathering and new workflows, to review and act on results, or to respond to queries can take time away from the patient/provider relationship. We know that developing relationships and having face time with patients is important. We know data shows that many attribute the rising epidemic of physician burnout to this increased documentation burden of the EHR taking away from patient connection. We aim to address this early in training. An example of a simple step we’ve taken is working with all the health systems in the state who use the leading EHR vendor to allow for a single training for our medical students that could be accepted by all of these systems. This reduces the time spent in additional computer training classes specific to other institutions by as much as 20fold for some of our students, giving them more time to spend with patients at the bedside. Many of our faculty are involved in cutting-edge work to help providers spend less time at the computer screen by simplifying the documentation processes,
Our students are taught the business of medicine starting in their first year. Understanding the financial incentive structures in which they learn and work is critical to navigating patient care. Appreciating a patient’s financial condition and the impact medical expenses can have is essential to patient-centered medicine. As such, students engage in sessions about the various ways physicians are paid, Medicare, Medicaid, and the micro and macroeconomics of health care — both at home and with international comparisons. We partner with experts from the School of Public Health’s Division of Health Policy to cover the Affordable Care Act, MACRA, and legislation yet to come. A physician who is well versed in the context of health care, both political and economic, is able to effectively advocate for their patients and their profession.
What is being done to ensure rural Minnesota of future physician coverage?
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Does the current curriculum allow/encourage earlier movement/diversion into specialty or subspecialty tracts? The initial years of medical school are focused on the foundational knowledge of medicine. In the third year students rotate through the core clerkships leaving parts of the third and fourth years for more in-depth focus on individual areas of interest and MetroDoctors
The Journal of the Twin Cities Medical Society
additional career exploration. Programs are available for early entry into Pediatrics through our Education in Pediatrics Across the Continuum (discussed elsewhere in this edition) in which students progress from medical school to residency based on achieving a set of required competencies. Students interested in careers as physician-scientists can apply to be accepted into our combined MD-PhD program. There are other opportunities to explore specialty areas through elective and extracurricular activities including student interest groups. One of the guiding principles of our ongoing strategic planning activities is focused on “standardizing outcomes and individualizing pathways” that will likely lead to additional subspecialty tracts for entering students.
A recent article published on faculty ethical behavior (Ann. Int. Med. April 3rd, 2018 – ACP position paper), noted a “hidden curricula” absorbed by medical students from faculty members – e.g. physicians exhibiting “caring” activities [positive] or relating disparaging remarks about a particular specialty [negative]. Do you have discussions with your faculty about issues such as these? Much has been written about the “hidden curriculum” in medical school since Fred Hafferty coined the term in 1994. (Hafferty FW and Franks R. The hidden curriculum, ethics teaching, and
the structure of medical education. Academic Medicine. 1994 Nov;69(11):861-71.) This idea is that through role modeling and behaviors in all of our settings — classroom and clinical — supervisors, staff, and peers reinforce both positive and negative behaviors. Imagine, for example, the attending physician who sits at the bedside throughout the presentation holding the hand of the patient, interpreting correctly the patient’s various emotional responses to his or her story. Through this behavior, the attending has implicitly “taught” some of the tools of compassion. She may not explicitly call attention to the behavior, but the evidence is that she is nonetheless imprinting on the learners present. Conversely, think of the physician who enters the room and remains standing by the door throughout, and criticizes the primary care practitioner (PCP) based on the resident’s presentation. Again the learners in this scenario are “taught” how to appear both rushed (from the patient’s perspective) and unprofessional (from the perspective of the PCP). We are paying attention to the “hidden curriculum” through our learning environment rounds. During these visits to our various clinical partners, we observe students in their learning environment and call attention explicitly to both the good and the bad behaviors we observe. Often neither positive nor negative role models are aware of the power of their performance. In this way, we hope to reinforce the best behaviors and extinguish those that are not desirable for a physician in the 21st century.
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The Journal of the Twin Cities Medical Society
July/August 2018
11
Medical Education
A Focus on the First Year
The first year of medical school is the start down a path of learning and service. Late nights, cadaver lab, microscopes, and long exams are still hallmarks of the first-year experience. However, medical education has evolved with technology and society. For example, we can watch recorded lectures at home, practice the physical exam on simulators, and learn how our microaggressions can impact patient outcomes. Our training is also preparing us for the uncertain future of our nation’s healthcare system. We spend time learning healthcare economics, have interdisciplinary courses, and carry out quality improvement projects. Every day I am privileged to learn interesting facts and draw inspiration from patients, physicians, and peers. I’m excited to embrace the rapid technological and societal advancement that makes for a more innovative and inclusive healthcare system. It is an exciting time to start a career in medicine. I sat down with fellow first-year medical students, Elle Newcome, Bruce Grégoire, Ahmed Mohamed, and D. Brendan Johnson, to talk about the first-year experience. Our full recorded interview is available through the linked QR code and highlights are included below.
By James Pathoulas, MD Candidate 2021
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knew I wanted to do in the future. That is when I decided to go to medical school. Brendan: I have a similar story to Bruce, I have some family members in health care, so when I went to college I tried to get away from it. I got a degree in chemistry and Norwegian language. I took different classes and experienced other things, but I was pulled back to health care. Elle: I ended up studying Spanish and poverty studies and development in college. I had a shadowing experience where a physician was speaking with the patient, put the medicine aside, and talked with the patient in a very vulnerable way. I saw medicine as a way to see more sides of humanity.
Tell me about your journey to medical school?
Bruce: I grew up in Rochester, the ultimate company town when it comes to medicine, and I had a lot of exposure to the medical field growing up there. When I left for university, I tried to branch out a little bit and think about other things that I wanted to do. So, I completed an economics degree. During that time, I did some volunteer work in hospice care, which was the first few times that I interacted with patients and heard their stories. It made me realize why so many people in Rochester were interested in medicine. For me, medicine was like Minnesota, it was something that I came back to once I had some more exposure. Ahmed: After I graduated from college, I went on to work for Pfizer. I was working on drug development when I started volunteering at a local hospital and enjoyed watching the doctors interacting and teaching patients. It was something I
Tell me what an average day looks like?
Elle: I like to go to class on occasion and connect with my classmates and I will also stream lecture sometimes. I try to get outside at least once a day. In the afternoon, I usually post-up in a coffee shop and review the lectures that we had that day. Brendan: Same for me. I have been going to 80% of classes and watching 20%. I really like the social aspect and I feel that I pay more attention in class. I know that a lot of members of our class have gone over to seeing lecture online. Usually we have a class in the morning followed by a free afternoon, lab, or a clinical experience. The evening is for relaxing or studying, depending on what is going on. Ahmed: I usually go to lecture except in the winter (laughter). I do like going to
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The Journal of the Twin Cities Medical Society
class though, it is nice to socialize with people and I can get to know the professor. If I am not at lecture, I am at a coffee shop watching the lecture. Bruce: I live in one of the medical fraternities, Nu Sigma Nu, and I chose to live there so I could conveniently come to class. I like the social aspect, so I come to basically every class. Some readers may remember how isolating medical school can be. I spend the rest of the day pouring over notes. I joke that it is really training to become a radiologist because I am looking at my notes continuously by myself (laughter). Tell me how you learn best.
Ahmed: I learn by going through the PowerPoints. I don’t make outlines. James: So, you have a photographic memory. (laughter) Ahmed: Going through the PowerPoints is easier than taking notes. Brendan: I take notes during class. One of the benefits of not watching on 2X speed is that I get to take detailed outlines, which I review once at the end of the week and once before midterms.
you can watch them at two or three times the original speed. It is efficient and keeps me on my toes. Bruce: This is the first time I’ve been recorded and I’m offended at the possibility that our viewers might be watching this on 2X speed (laughter). What are some alternative learning tools you use?
Brendan: Sketchy Micro is a program that a majority of our classmates use. In Sketchy Micro, each pathogen is a picture and each item in the picture is a fact. For example, Salmonella is portrayed as a salmon dinner including a sickle, meaning asplenic patients are at greater risk for salmonella infections. Bruce: I think programs like Sketchy Micro are where medical education is headed. We are shifting from what is the most comprehensive learning style to what is the most efficient learning style for each person. It helps you create a memory palace and is especially useful for visual learners. What is something in the past year that you have been surprised by during the first year?
Elle: My learning style has certainly changed this past semester. In the past, I would handwrite notes and go over things. I still make outlines but I am very much a solo studier. I am really trying to take the information and put it in its most distilled form followed by repetition.
Bruce: One of my biggest worries when I came to medical school was that it would be stressful and unforgiving. Yet, there has never been a point where I doubted that medicine is what I want to do. It is gratifying to know that concerns I had coming into medical school never came to fruition.
Bruce: I am a real solo studier. I used to always say that my studying style was to “burn it into my brain” but after taking neuroscience, I can describe it a little more in detail. I keep reactivating my hippocampus. (laughter)
Ahmed: One of my worries coming into medical school was that it would be cutthroat and people would not help each other. I was surprised how collaborative this school is and how all of my peers help each other reach their goals.
What does “I’m going to 2X this” mean?
Brendan: I have been surprised by our classmates and how wonderful they are. It has been great to get to know everybody in this collaborative environment. We have student groups and skills learning groups where we get to know each other. Medical school has been a positive experience.
(laughter) Elle: I am a 2X person and on occasion I am a 3X person. What that means is our professors will record their lectures and MetroDoctors
The Journal of the Twin Cities Medical Society
The University of Minnesota Medical School no longer has honors during the first two years. Do you believe this has impacted our class dynamic?
Brendan: I think so. Since everything is pass/fail the desire to do well is internal and you can really engage with the material on the level you feel you need to. On a social level, it has become very collaborative. Overall it is a very positive change. What is one thing you’re looking forward to in medical school?
Elle: I am excited to see what specialties people choose (laughter). In terms of personality and how that lines up, especially in people I know fairly well. Brendan: I am excited to have more contact with patients and connect the basic science to clinical medicine. Bruce: I know this is simple and some of the viewers may laugh, but I’m excited to see my first patient for the second time and follow up with them. It is something to really look forward to. My conversation with Ahmed, Bruce, Elle, and Brendan highlights how medical education is shifting toward tailored learning and the incorporation of technology in training. My classmates all mentioned caring for patients as the reason they entered and continue to pursue medicine. The way we learn is changing. Yet, service, learning, and discovery are still the core values of medical education at the University of Minnesota. James Pathoulas is completing his first-year of medical school at the University of Minnesota Medical School and serves as the Professional Student Representative to the UMN Board of Regents. In addition, he is one of two medical student editors for MetroDoctors. James received his undergraduate degree from The College of Saint Benedict and Saint John’s University in 2016 with a degree in biology.
July/August 2018
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Medical Education
“Trust me, I’m (almost) a Doctor” Secrets of the Rural and Metropolitan Physician Associate Programs Revealed
M
edical students who move from hospital to hospital and clinic to clinic during medical school clerkships reboot the process of gaining and giving trust every few weeks. This is an experience which is inconvenient for some, unbearable for others. If I were to flip through my old medical school 3-ring binders, not only would I find evidence of my lost youth (what, paper notes?), I would also find evidence of how I learned anatomy, pharmacology, differential diagnosis, and even physical exam maneuvers. What I would not find in those binders is a syllabus on trust. Luckily, I don’t need to find those binders to recall the role of trust in my medical training. I remember the patient, during one of the final nights of my OB/ Gyn clerkship who trusted me to deliver her baby boy. The med-surg nurse who paged me to console a family. The family doctor who prompted me to say what I was thinking in front of patients. The surgeon, who, after a couple weeks of retractor duty, trusted me with scalpel and needle driver. Just as important, I trusted that she was carefully ensuring that I would not cut or poke any pulsating structures. In 1971, ABC had a number one rated program, “Marcus Welby, MD.” It was a medical drama starring a family physician with a kind bedside manner, in a two-physician private practice, who frequently made house calls. That same year, innovators led by Jack Verby, MD at the University of Minnesota Medical School came up with their own hit program, the Rural Physician Associate By Kirby Clark, MD
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July/August 2018
Program (RPAP). Over the past 48 years, the program has been an effective response to the challenge of trust in medical education as well as the shortage of physicians practicing in rural areas. During RPAP, 3rd year medical students complete nine months of core clinical clerkship requirements across a number of medical specialties, embedded in a single healthcare community. Students live and learn in the rural communities where they complete their clinical training. Students complete requirements in Family Medicine, General Surgery, Psychiatry, Pediatrics, Emergency Medicine, Obstetrics and Gynecology, among other possible specialty experiences. RPAP is unique in its focus on rural medicine, rural community engagement and advocacy. RPAP has a long history of providing robust training in comprehensive, resource-wise, health care. While this concept may seem natural to those familiar with RPAP, it was revolutionary, and is considered the pioneering “longitudinal integrated clerkship” (LIC) in medical education. These student learning experiences involve the comprehensive care of patients over time and allow for continuous relationships with instructors/ mentors within the context of a community. There is increasing interest and data to support medical student learning in a LIC model, and the model is being replicated throughout our medical school, the country, and the world. Many medical schools from around the world have collaborated with RPAP to develop their own LIC models. The first spin-off of RPAP at the University of Minnesota was the Metropolitan
Photo by Nathan Buege
Physician Associate Program (MetroPAP). MetroPAP was developed and piloted by Dr. Kathleen Brooks in 2010 with two students in response to the shortage of physicians in urban underserved areas. MetroPAP embeds 3rd year medical students for nine months in a Minnesota urban underserved community. MetroPAP has a focus on social determinants of health, population health, community engagement and advocacy. In 2018, ABC’s hit medical drama is no longer “Marcus Welby, MD,” it is now “Grey’s Anatomy.” Television and the practice of medicine have evolved over the years, and so have RPAP and MetroPAP.
MetroDoctors
The Journal of the Twin Cities Medical Society
In the early 1970s, only 8% of the RPAP students were female. Beginning in the early 1990s the gender gap had closed, and currently 77% of our RPAP students and 60% of our MetroPAP students are female. Since its inception 1,569 students have graduated from the RPAP program and 20 from the MetroPAP program. The current class has 36 students in RPAP and five in MetroPAP, training in 36 different sites across Minnesota and western Wisconsin. Next year’s class will have 38 students in RPAP and nine in MetroPAP. We are actively growing both programs to meet student interest and our state’s workforce needs. Many accomplished medical students apply to participate in both programs year to year, with a record number of applicants to both programs this year. The students bring a passion for service and high-quality health care to their training communities. MetroPAP has grown from two students just a handful of years ago to nine students for the 2018-2019 academic year. The MetroPAP sites for next year are Phalen Village Clinic in East St. Paul, NorthPoint Health and Wellness in North Minneapolis, Broadway Family Medicine in North Minneapolis, Neighborhood HealthSource in North Minneapolis, Creekside Clinic in St. Louis Park, Smiley’s Clinic in Minneapolis, La Clinica in St. Paul, and CentraCare in St. Cloud. The RPAP and MetroPAP curriculum is evolving to match a changing healthcare delivery landscape and evolving physician roles and responsibilities. Students partner with their community physicians to truly engage in the evolution of local healthcare systems and the way in which their patients engage with health care. Changes in scope of practice, facilities, mergers, acquisitions, and administrative tasks are a reality our students experience. As we match our curriculum to the changes, we are spending more energy on team communication, leadership, advocacy, and the navigation of our electronic tools. Moving forward, the programs will continue to align with the state’s workforce needs. The programs have been a
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fantastic return on investment for both the state of Minnesota and participating communities. Our statistics show 75% of graduates practice primary care, about 66% in Minnesota, and about 50% in rural settings. Many other specialties are represented in the remaining 25%, serving in both rural and urban locations. It is not uncommon for a program graduate to return to their community to practice after residency training. A central team of Medical School RPAP/MetroPAP faculty and staff make major contributions to the success of the programs. They develop curriculum, manage on-line learning resources, facilitate student projects, and travel to observe, teach, and assess students at regular intervals. Students take specialty-specific examinations, make case presentations, and submit assignments throughout the nine-month experience. The central team also develops and sustains relationships with community preceptors, and healthcare administrators as they navigate local challenges to the educational experience. In addition to teaching visits from central faculty, students share multi-day learning experiences together on campus at the beginning, mid-point, and end of the RPAP/ MetroPAP experience. The future of our programs will also employ the science of learning as we design new student experiences. New assessment tools will be more effective in providing formative feedback to students, more clinically relevant, and more efficient for teaching physicians. We are moving away from the idea of only very occasionally “grading” students by comparing them to their peers at the end of a clerkship. Instead, the focus will be on tools to coach all students, daily, to excellence in defined competencies. In the coming years students will be using more robust on-line learning modules, rapid-cycle assessment tools, and technology to collaborate in multidisciplinary learning groups. RPAP and MetroPAP continue to demonstrate the impact of genuine collaboration between communities and the University of Minnesota Medical School. Hundreds of community physicians and
The Journal of the Twin Cities Medical Society
allied health professionals are engaged in the teaching of our 3rd year medical students around the state. Community preceptors include primary care physicians and many other specialty care physicians who teach our students during their ninemonth experience. A primary success of this collaboration has been the pipeline of physicians to communities in need. An important secondary success is a quantity of medical students and physicians in our state (no matter where they practice) who understand the challenges of healthcare access and can support healthcare delivery for our rural or urban underserved Minnesotans. If there is one thing that has held constant from the disco era to today, it is a medical student’s fundamental need for trust. Partners in RPAP and MetroPAP are committed to an authentic, trusting relationship lasting anywhere from nine months to a full career. These programs help personify the vision statement of medical education at the University of Minnesota Medical School, “A community learning together to prepare exceptional physicians to improve the health and well-being of Minnesota and beyond.” If you have questions or comments about RPAP or MetroPAP please contact me at clark130@umn.edu. Dr. Kirby Clark is a family physician at the Phalen Village Clinic in East St. Paul, Director of the Rural and Metropolitan Physician Associate Programs at the University of Minnesota Medical School, faculty with the St. John’s Family Medicine Residency Program, and Assistant Professor in the Department of Family Medicine and Community Health. He is a 2001 graduate of the University of Minnesota Medical School. He completed his Family Medicine residency training at HealthEast St. John’s Hospital. Prior to directing RPAP and MetroPAP, he served nine years as Associate Program Director for the St. John’s Family Medicine Residency Program. His medical interests include primary care delivery innovation, newborn care, geriatrics, inpatient medicine, leadership development and education program design.
July/August 2018
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Medical Education
Reshaping Medical Education Starts at the U
U
ndergraduate medical education in the United States is due for a major overhaul. Left largely unchanged since the early 20th century, medical programs and leaders are recognizing that evolving healthcare environments require a new way of preparing physicians. A heightened focus on outcomes, cost, and quality — along with technology that puts knowledge at doctors’ fingertips — results in expanding parameters of what it means to be a physician. It follows that the model of teaching future doctors only scientific and clinical skills is no longer adequate to prepare them to be paragons of the profession. While this expertise is still paramount, physicians also must pair it with effective communication skills and proficiency in evidence-based medicine. Add a heightened focus on cultural humility, systems thinking, interprofessional collaboration, lifelong learning and continuous improvement, and it’s no wonder traditional approaches no longer fit. To meet these shifting requirements, it’s imperative to start with medical schools. These institutions must consider new models that arm students with the necessary competencies for success. This is no small effort, with tradition-bound, entrenched structures that strictly adhere to the path of medical school/residency/ board eligibility in a certain timeframe. But at the University of Minnesota, we’re game to give it a try. The Medical School is poised to launch a new strategic plan to reshape our methods of training
By Robert Englander, MD, MPH
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comments, we coalesced around the seven principles. Why so many voices? The University is deeply invested in Minnesota and vice versa. About 70% of practicing physicians in the state completed medical school, residency, or both at the U. This creates a mutually beneficial relationship in which the people of Minnesota have an intense interest in our outcomes, and the University has a vested interest in improving health in our state. Vision Into Action
future doctors. It starts with our vision: A community learning together to prepare exceptional physicians to improve the health and well-being of Minnesota and beyond. There are seven strategic guiding principles, all of which carry equal weight: • Putting patients first • Empowering students • Standardizing outcomes and individualizing pathways • Fostering relationships • Providing evidence-based education • Building on diversity and inclusion • Optimizing the learning environment Arriving at these principles involved formulating ideas with a multitude of parties in the Medical School, including students, administrators, and faculty. Next came a strategic planning retreat with stakeholders from across the state, such as alumni, patient advocates, and leaders from our affiliate partners: Hennepin Healthcare, Minneapolis VA Medical Center, HealthPartners, and Essentia Health. Guided by this process and 200 online
Evolving the medical workforce in Minnesota starts with our strategic vision. Next comes the implementation. Each principle has a five-year goal and a team to champion it. The teams are led by a trio comprised of a student, an administrator, and a faculty member. Putting Patients First is the exception, with a patient leader instead of a student. Bolstered by five to 10 additional members, the teams will develop yearly objectives and measures of success. Medical School leaders then will assess where we are succeeding, where we are struggling, and where we are outperforming our goals. Let’s take a look at how this works with one principle. For Standardizing Outcomes and Individualizing Pathways, the Medical School aims to ensure that graduates demonstrate the competencies required for practice and scientific inquiry. To that end, the U will provide the pathways for students to attain those competencies while pursuing their passions and optimizing their learning styles. Its goal states that by 2023, the Medical School will have standardized
MetroDoctors
The Journal of the Twin Cities Medical Society
competency-based outcomes and a framework for assessment. It will provide evidence that all graduates developed the required competencies to be inspired physicians and physician scientists. The University will help students attain these outcomes by individualizing their experiences and optimizing their ability to choose the context of their learning based on their passions and learning styles. Competency-based Training
These aren’t just empty promises. The Medical School already is testing some of these changes with current students. Take the Education in Pediatrics Across the Continuum (EPAC) initiative. The University of Minnesota is one of four American medical schools currently piloting this new program since 2013. Instead of a one-size-fits-all approach of four years of medical school (two years in the foundational sciences and two years in the clinical sciences) and three years of residency, EPAC offers a competency-based model for students who aim to pursue pediatrics. EPAC formally starts during students’ third year. They begin a longitudinal integrated clerkship at the University of Minnesota and then extend their training through residency. But before that residency formally starts, EPAC participants must pass assessments by their preceptor on 13 Core Entrustable Professional Activities for Entering Residency — in the order and time of their choosing. These activities require the students to integrate most of the competencies required to be a physician in a practical way and in the authentic clinical environment. Under this structure, the outcomes are fixed and time becomes the variable in progression. For example, one student might complete medical school in three years, while another might take four and a half. It’s about mastering the competencies that make for excellent doctors and physician scientists, not finishing in a set amount of time. The program is also consistent with our strategic plan’s guiding principles. For example, it puts patients first with
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continuity of care (the students in the program may end up following a patient or family for five-seven years), individualized learning, empowering students, and building relationships with patients and preceptors who guide students through the entire process. From EPAC, the Medical School is learning how to effectively implement competency-based and integrated medical education and scale it for a bigger audience. As the Medical School grows its offerings for third-year students — developing alternatives to traditional block rotations — it’s critical to test, assess, and evaluate such initiatives to gain knowledge as we evolve. Individualizing the Learning Pathways
The EPAC model for the traditional third year of medical school is called a Longitudinal Integrated Clerkship or LIC. For EPAC students, who have chosen pediatrics as a career, that experience is tailored to their needs as it flips the normal ratio of patients from 70% adult and 30% children to 30% adult and 70% children. The notion of LICs tailored to students passions originated at the U, with the advent of the Rural Physicians Associate Program, or RPAP in the early 1970s. This program allowed students to pursue a passion for rural medicine while learning all of the core clinical sciences. Over the past six-eight years, the U has added five additional LICs all meant to provide students a path for learning that also lets them explore a passion. For example, RPAP now has a sister program in MetroPAP, based at family medicine clinics throughout the Twin Cities and now also with a St. Cloud option that allows students to pursue a passion for serving the inner-city underserved through a family-medicine “home” clinic. Similarly, the Minneapolis VA Medical Center offers its LIC: VA Longitudinal Undergraduate Education (VALUE) program. It trains students to meet the unique needs of veterans and seniors through in-depth, continual care, and focuses on quality and patient safety.
The Journal of the Twin Cities Medical Society
The new Hennepin Longitudinal Integrated Experience (HeLIX) allows participants to complete most of their core clerkships at Hennepin County Medical Center. Students build strong relationships with faculty and patients, while obtaining rich medical experience in communities with significant immigrant populations and in underserved urban areas. Finally, Regions Hospital in St. Paul will start a program next year focused on healthcare disparities and the social determinants of health. The University of Minnesota’s individualized pathways align well with our strategic principles. Through these offerings, medical students foster relationships with peers, faculty, supervisors, and patients. This is essential because such relationships boost empathy and decrease the burnout associated with current medical education. These varied options also empower students by giving them a voice in the pace and style of their education and training. In all, one-third of University of Minnesota medical students already participate in one of these learning pathways. They have the opportunity to pick from the largest number of such programs in the country, with the greatest variety of formats and settings. But this is just the start. Stay tuned as the Medical School continues to innovate and evolve the way we educate the next generations of physicians. Change takes time. But the University of Minnesota has been at the forefront in many ways, and is poised to lead the way to a new generation of doctors fully equipped to improve the health and well-being of Minnesota and beyond. Robert Englander, MD, MPH, serves as Associate Dean for Undergraduate Medical Education at the University of Minnesota. A Pediatric Hospitalist, he joined the University from the Association of American Medical Colleges, where he led national efforts around competency-based medical education, including the EPAC initiative.
July/August 2018
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Medical Education
Environmental Health — Climate Change: Preparing Physicians to Address Emerging Challenges
T
he relationship between medical students and the medical school is fraught with expectations. Students are expected to work hard, learn the curriculum, and develop clinical skills. Medical schools are expected to teach a curriculum that equips students with the necessary knowledge and skills required to provide excellent care for their patients. To accomplish this, the curriculum is constantly revised to reflect advances in science and medicine. It is also subject to student feedback. The ultimate goal is to produce successful physicians who can make a positive impact on patient and population health. Recent changes to curriculum in the Academic Health Center at the University of Minnesota attempt to address a relatively new health topic: the intersection of climate change and human health. The health impacts of climate change are currently evident and are not merely a problem of the future. Evidence is nearly unanimous that by the year 2100 a 1.4 to 5.8 °C temperature rise will occur due to human-generated carbon emissions.1 Consequent challenges highlighted by the Lancet Commission include altered disease patterns, food insecurity, water access and sanitation, shelter, population growth and migration, and extreme weather events. Since 2008 an average of 21.5 million people have been forcibly displaced by weather-related events every year,2 and the frequency and magnitude of extreme weather events is predicted to increase as a result of global warming.3 The United States healthcare system experienced the effects of extreme weather when Hurricane Maria made landfall in Puerto Rico on By Kristen Bastug, MS4
MetroDoctors
September 20, 2017. In addition to devastating local communities, the storm also impacted the production of the ubiquitous 0.9% saline and contributed to a national shortage of IV fluids.4 This shortage preceded a particularly severe influenza season and created obstacles to patient care. Considering the above challenges, the Lancet Commission has declared climate change to be the greatest public health threat of the 21st century.3 The Academic Health Center (AHC) at the University of Minnesota is working to address this public health challenge by initiating the “Interprofessional Education and Practice Climate Change Curriculum.” This curriculum has three phases: Phase I, enacted in Fall 2017, integrated basic information about climate change into a course required by all AHC students, the “Foundations of Interprofessional Communication and Collaboration.” Phase II seeks to integrate the science of climate change-related health impacts into the curriculum of all schools in the AHC, and is currently being led by nine interdisciplinary faculty members. To that end, in May 2018 the first-year medical student course “Essentials of Clinical Medicine” included a short lecture, small group discussion, and panel focused on environmental ethics and the role of health care professionals in regard to the environment. Phase III seeks to develop expertise in clinical practice and is currently in development. These curriculum changes were inspired partly by an AHC student survey, led by Health Students for a Healthy Climate and the Global Health Student Advisory Board with assistance from faculty members Dr. Teddie Potter and Dr. Phillip Peterson.
The Journal of the Twin Cities Medical Society
Patients trust physicians with their wellbeing, and the effects of climate change will continue to adversely affect health outcomes. Physicians rely on scientific research to guide the care of their patients and communities, and research tells us that uncontrolled climate change will endanger growing numbers of people. As physicians, we can help by educating ourselves and others about this complex issue. Kristen Bastug, MS4, member, TCMS Environmental Health Task Force. References: 1. Anthony J McMichael, Rosalie E Woodruff, Simon Hales. Climate change and human health: present and future risks. The Lancet, Volume 367, Issue 9513, 2006, pages 859-869. ISSN 0140-6736. https://doi.org/10.1016/S01406736(06)68079-3. (http://www.sciencedirect. com/science/article/pii/S0140673606680793). 2. h t t p : / / w w w. u n h c r. o r g / e n - u s / n e w s / l a t est/2016/11/581f52dc4/frequently-asked-questions-climate-change-disaster-displacement. html. 3. Anthony Costello, Mustafa Abbas, Adriana Allen, Sarah Ball, Sarah Bell, Richard Bellamy, Sharon Friel, Nora Groce, Anne Johnson, Maria Kett, Maria Lee, Caren Levy, Mark Maslin, David McCoy, Bill McGuire, Hugh Montgomery, David Napier, Christina Pagel, Jinesh Patel, Jose Antonio Puppim de Oliveira, Nanneke Redclift, Hannah Rees, Daniel Rogger, Joanne Scott, Judith Stephenson, John Twigg, Jonathan Wolff, Craig Patterson. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. The Lancet, Volume 373, Issue 9676,2009, pages 1693-1733. ISSN 0140-6736. https://doi.org/10.1016/S0140-6736(09)60935-1. 4. https://www.fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm592617.htm.
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Medical Education
Results of the National Residency Match at the University of Minnesota Medical School Match Day
Primary Care
It was Spring Break and a cool day which made an eerie quietness as I approached the University of Minnesota McNamara Alumni Center. As I entered the building I was hit with a loud anxious chatter that echoed throughout the great hall. There, over 200 of our medical students anxiously waited to find out their future careers and where they would be living for the next three to seven years. A brief time later the graduating class of 2018 opened, in unison, the envelopes that contained the information about which residency program they had matched. For most it was an exhilarating and spectacular moment as they celebrated with their close family and friends while many of their advisors and mentors at the Medical School looked on. This same scenario was simultaneously playing out at medical schools across the country. The roughly 18,000 U.S. Seniors were all finding out which of the 33,167 residency positions they were matched in.
Once again, the University of Minnesota has excelled in promoting primary care physicians. Of the 220 graduates, 101 (46%) went into primary care residency programs, defined as Family Medicine (43), Internal Medicine (26), Pediatrics (23), and Internal Medicine-Pediatrics (9). Nationwide only 36.5% of U.S. Seniors matched into one of these specialties. Many of these come from our Duluth campus, which has as part of its mission to train medical students dedicated to serving rural Minnesota and primarily in Family Medicine. Many have also taken advantage of our Rural Physician Associate Program (RPAP) where they experienced a longitudinal clinical experience in a primary care clinic in rural Minnesota. Last year Minnesota ranked 7th in the country for the percentage of graduates going into primary care and 3rd in training rural physicians.2
Match Week
For each applicant the week started by receiving an email titled, “Did I Match?”; a somewhat jarring sentence given the gravity of the situation. For some of our students, this year 21, the answer was no or not completely. For the 1,078 U.S. Seniors across the country who did not initially match, the next few days were filled with unclear expectations, scrambling to retool strategies, and fretful waiting. Those in the “Supplemental Match” applied to the unfilled programs, participated in telephone interviews, and then were offered By Michael H. Kim, MD
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positions in three rounds over two days. In the end, only eight of these students did not have a residency program to go to on July 1st when the official start of residency contracts begins. For the rest, it would be the start of preparations for the next year’s match. A Mainly Minnesota Match
Minnesota programs were the big winners in this year’s Match (see table). For the first time in recent history more than 50% of graduates will be staying here for residency. Most are going to the many programs at the University of Minnesota; however, others are spread out across the state from Mankato and Rochester in the south to St. Cloud and Duluth in the north. We know that some of those that leave the state for residency eventually return to practice as roughly 70% of the state’s physician workforce has trained at the University in either medical school or residency.1
A Cut Above
General Surgery and its subspecialties, based upon the number of unmatched students who apply to those specialties, continues to be competitive. Minnesota applicants, as is typically the case, do well matching into these areas. The U of M applicants included 11 going into General Surgery, seven into Orthopedics, five to Otolaryngology, three to Plastic Surgery, two to Urology and one each in Neurosurgery and Ophthalmology. These 30 represent 13.6% of the class of 2018. Changing Trends
Emergency Medicine continues to increase in competitiveness. Of the class, 15 (6.8%) matched into an Emergency
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Medicine program. Of those that didn’t successfully match, four of them primary applied to EM. Lifestyle considerations was an often-cited reason for students to pursue a career in EM. Having two strong residency programs in the state is likely also a contributing factor to its popularity. Psychiatry, which historically had been a relatively easy specialty to get into, was one of the most competitive specialties this year. Nationwide 16% of graduating U.S. seniors who applied primary to psychiatry did not match into the specialty (unpublished data provided by the National Residency Matching Program). This year, 11 graduates were matched into the specialty while three who primary applied were unable to find positions in Psychiatry. Obstetrics and Gynecology was the major surprise of the season. Nationally, the competitiveness was relatively unchanged; however 22 applicants from our school applied to this specialty; 20 matched successfully. Interestingly, in a
field that is usually overwhelmingly sought by women, this year four (20%) of those who matched from the U of M were men. Consistent with recent admission trends, there were more women than men who matched this year. Of those who matched, 108 (52%) were women. Medical School Outcomes
Our match outcomes for this year were mixed. Having 21 who did not have complete residency plans this year was an increase over last year when this number was 13, and from 2016 when it was 18. The specialties that had the most unmatched were Emergency Medicine (4), Family Medicine (3), Orthopedics (3), and Psychiatry (3). Since 2013 we have maintained a program, called Flex 5, for those who were ultimately unsuccessful that extends their graduation and provides further educational experiences to prepare them for the following year’s Match. We are happy to report that, 13 of the 14
Staying in Minnesota Program
# Placed
2018
2017
2016
MN Total/% matching
107
51.4%
45.4%
41.1%
U of MN Medical School
42
39.3%
36.4%
36.8%
Hennepin Healthcare/HCMC
18
16.8%
18.2%
15.8%
Mayo Graduate School of Medicine
17
15.9%
16.2%
16.8%
U of MN Medical School/St. Joseph’s
7
6.5%
3.0%
4.2%
U of MN Medical School/Duluth
6
5.6%
5.1%
5.3%
U of MN Medical School/N. Memorial
3
2.8%
2.0%
5.7%
U of MN Medical School/St. John’s
3
2.8%
2.0%
4.2%
Abbott Northwestern Hospital
2
1.9%
5.1%
5.3%
Allina Family Residency Program
2
1.9%
4.0%
5.7%
Health Partners Inst/Regions Hospital
2
1.9%
2.0%
4.2%
U of MN Medical School/Methodist
2
1.9%
5.1%
5.7%
U of MN Medical School/St. Cloud
2
1.9%
0.0%
2.9%
U of MN Medical School/Mankato
1
0.9%
1.0%
0.0%
U of MN Medical School/ Smiley’s
0
0.0%
0.0%
0.0%
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students in Flex 5 have subsequently found residency positions. Those who did match were likely to get one of their top choices. In a survey of our graduates 62.2% received their first choice while 84% received one of their top three choices. This compares to 51.1% and 77% respectively nationally. Parting Thoughts
We are proud that 98+% of our matriculants continue to a residency program after graduation and that the majority will practice in Minnesota. Our graduates are going to great programs across the country in a wide range of specialties. We all have work to do to decrease the number of unmatched students and look forward to providing better data and service to future applicants. It takes a vast number of dedicated personnel to facilitate the career development of our students. It is a combined effort of the students, their families, the faculty advisors, specialty mentors, and our dedicated staff which help students decide what specialty they want to spend their career in and how to navigate the Match. Thanks to all of their efforts and best wishes to all of our graduates! Michael H. Kim, MD joined the faculty of the Department of Pediatrics in the Division of Academic General Pediatrics as a hospitalist in 2006 after completing his bachelor’s degree, Medical School, and residency training at the University of Minnesota. Additionally, Dr. Kim did his residency at the University of Minnesota in the Department of Internal Medicine and Pediatrics. Bibliography Match data for the University of Minnesota can be found on our website at: https://www.med. umn.edu/md-students/academic-success-assistance/career-guidance-match/umn-match-listsdata. National Data is provided by the National Residency Matching Program at: http://www. nrmp.org/main-residency-match-data/. 1.
2.
Governor’s Blue Ribbon Commission on the University of Minnesota Medical School. Minnesota Office of Higher Education. 2015. US News & World Report. 2017.
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Sponsored Content
Serving the Underserved: Training Family Medicine Residents at the University of Minnesota in Comprehensive Care Contributed by James Pacala, MD
As the research underscores, today’s medical professionals need to approach care with an understanding of the social determinants of health. Poor economic and social circumstances shape health outcomes and responses to treatment so significantly that training programs are challenged to address the care needs of the communities they serve. Medical residents in their practicum training must engage with issues of equity and social justice and bring this perspective to the delivery of effective care. Outreach and public service form a core pillar of the University of Minnesota Medical School’s educational mission. The Department of Family Medicine and Community Health, in particular, is a strong example of this mission of service. Since its inception more than 45 years ago, the department has aimed to provide exemplary care for marginalized and underserved populations by teaching our residents how to best serve communities in need, as well as by building a culture of inclusivity, intercultural competence, and whole-person care. The department sponsors five family medicine residency programs in the Twin Cities metro area and three in Greater Minnesota. All residents receive training in caring for the underserved and gain experience providing care to patients from diverse populations. Highlighted briefly below are the department’s programs and their residents’ experiences. Mentoring Youth The impact of social determinants of health are particularly evident in North Minneapolis, where food and housing insecurities, gun violence, and transportation problems 22
July/August 2018
contribute to severe health disparities. The North Memorial Family Medicine Residency Program at Broadway Family Medicine Clinic strives to address these disparities through community projects such as The Ladder, a popular mentorship program that encourages the community’s youth to pursue health careers. The Ladder provides an integrated program in which residents work with younger generations in leadership development, service learning, and practical skills — from CPR to filling out college applications. In addition to youth mentoring, weekly visits to the Bridge Shelter for Teens and Exodus House give 28 family medicine residents the opportunity to provide basic health screenings to medically ill homeless populations, and North Memorial’s participation as a Second Harvest Heartland drop site allows residents to more fully understand the lived experience of patients with food insecurities. Caring for New Minnesotans An integral part of the diverse East Side of St. Paul, the St. John’s Hospital Family Medicine Residency Program at Phalen Village Family
Medical Clinic serves a culturally diverse community comprising people of European, Southeast Asian, Hispanic, and both African and African American heritages. The program’s comprehensive care includes family planning, education about healthy habits, and geriatric and end-of-life care for all populations — from newly arrived refugee families to lifelong Minnesotans. Residents at St. John’s Hospital provide 24-hour care on all units, including obstetrics and the emergency room. Unique to this residency is colonoscopy training, a provision that is invaluable to improving the colon cancer screening rate for the community. St. John’s emphasis on the mutual relationship between residents, patients, and physicians provides a strong foundation for resident education. One patient, a grandmother who has received care from St. John’s since birth, is now one of the program’s patient advisory members. Her experience with homelessness and complicated medical care offers a perspective that helps residents learn how to better meet the needs of the East St. Paul community. Providing Legal Support to Low-Income Patients Bethesda Clinic, the clinical site for the St. Joseph’s Hospital Family Medicine Residency Program in St. Paul, serves a uniquely diverse and under-resourced population. Many patients are recent immigrants and have legal challenges that impact their health, including housing and employment issues, protection orders, and problems relating to immigration processes and government benefits. In response to the challenges of treating medical issues complicated by social
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determinants of health, St. Joseph’s residency program formed a medicolegal partnership with Southern Minnesota Regional Legal Services (SMRLS), which provides an on-site attorney for patients with legal issues. Within the first two months of the partnership, the legal team received 57 referrals. In most clinics, patients with health-harming legal needs, such as expired food stamp access, are given a card or a phone number to call for support. At Bethesda, they walk down the hallway with their healthcare provider directly to a lawyer. The impact of this simple walk is not to be underestimated: many patients have achieved citizenship or secured safe housing due to the efforts of St. Joseph’s legal counsel. Creating an Inclusive Care Experience for Transgender Patients The mission at Smiley’s Family Medicine Clinic is to serve a diverse patient population and train resident family physicians in advanced primary care. Pharmacy and mental health faculty see patients alongside and in partnership with the physicians and nurse practitioner. In addition to its core practice, the clinic, part of the University of Minnesota Medical Center Family Medicine Residency Program, functions as a training site for pharmacy students and residents, behavioral health fellows, and nurse practitioner students. Four years ago, Smiley’s started transforming into a transgender-friendly clinic. Through partnerships with Rainbow Health Initiative and other Twin Cities leaders in LGBT care, Smiley’s worked to create an inclusive environment by incorporating health care specific to the needs of transgender patients, as well as by making changes to bathrooms, intake processes, and assessment forms. The clinic is now collaborating with the University of Minnesota Health Comprehensive Gender Care initiative and serves as both a primary care clinic open to specialist referrals and a specialty clinic to which the primary care community can refer. Residents are gaining competence in comprehensive transgender care and are bringing their expertise to clinics in the Twin Cities and greater Minnesota. Supporting Teens’ Access to Health Care Through partnerships with schools,
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foundations, and clinics, the Methodist Hospital Family Medicine Residency Program provides community programs and resources focused on serving at-risk youth and patients with financial hardships. CreeksidePark Nicollet Clinic, the residency’s clinic, provides care for uninsured patients through a collaboration with the St. Mary’s Health Clinics. The residency program’s free clinic for youth addresses barriers to care, including financial concerns, access to care, and teen confidentiality. Residents from the Family Medicine program provide services through summer and school breaks. In addition, residents provide after-hour and procedural back up for the MyHealth adolescent clinic in Hopkins.
clinical team include psychologists, a social worker, a Somali community health worker, a community paramedic, a pharmacist, and a lawyer for legal assistance. These overviews share only a few of the ways that the Department of Family Medicine and Community Health embeds care for underserved populations into our residency programs. Because medical students and residents are the next generation of health professionals with an ability to shape policy and provide care that can significantly impact the burden of disease in this country, we believe that integrating care for underserved populations into medical education is not an elective but an imperative and a basic part of our commitment to providing whole-person care.
Reaching Greater Minnesota Dr. James Pacala, a board-certified family In addition to those based in the Twin Cities, physician and geriatrician with University of the Department of Family Medicine and Minnesota Health, is Head of the Department Community Health’s residency programs of Family Medicine and Community Health at in greater Minnesota deepen our mission to the University of Minnesota Medical School. provide excellent care throughout the state. Dr. Pacala has published extensively on models The Duluth Family Medicine Residency of care delivery to geriatric populations and on Program has partnered with several cominnovative teaching methods. A past president munity organizations, including Duluth’s and board chair of the American Geriatrics largest homeless shelter and the Center for Society (AGS), he is co-author of the AGS Drug and Alcohol Treatment, to address practice handbook Geriatrics at Your Fingerhealth system failures that contribute to intips, now in its 19th edition. Dr. Pacala was equities and to provide resident education co-editor-in-chief of the 7th and 9th editions that focuses on care for underserved populaof Geriatrics Review Syllabus. In 2013-14, he tions. Chief among several initiatives of the served as an Atlantic Philanthropies Health Mankato Family Medicine Residency Proand Aging Policy Fellow on the U.S. Senate gram is a focus on pediatric dental disease, HELP Committee, Subcommittee on Aging a prevalent chronic disease among children and Health. He has received several awards in marginalized populations. The program for his research, teaching, and clinical care. offers oral exams, outreach education, and community partnerships to improve health RESIDENCY literacy in this area. PROGRAMS The St. Cloud Family Medicine Residency Program serves a large population of uninsured and non-English speakers through a patient advocate and an income-based discount program. Members of the The University of Minnesota has eight family medicine residencies —
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five in the Twin Cities and three in Greater Minnesota.
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Medical Education
Graduate Medical Education from 2001 to Today: Change is the New Constant Paper Charts and 120 Hour Workweeks I began my residency in Internal Medicine in 2001 at Hennepin County Medical Center. Fresh out of medical school at the University of Wisconsin – Madison, I was thrilled to finally begin my journey into medicine at a trauma center and safety-net hospital. I was surrounded by passionate and dedicated fellow residents — we laughed and learned together, we cried and leaned on one another. I learned to really listen and learn from patients, to hone my curiosity in a place brimming with it, and to feel connected to others as part of a tightknit tribe. I became a resident at a time when nearly a quarter of all U.S. residents were training in Internal Medicine and 39% of residents (across all specialties) were women. There were several specialties with women in the majority including the top three — obstetrics and gynecology (71%), pediatrics (62%) and dermatology (55%). Those with the fewest were neurosurgery (10%) and orthopedics (9%.)1 Upon entering residency, I had $125,000 of medical student debt, surpassing the national average of $99,089 in 2001.2 Fatigue and Duty Hour Reform My training began before the Accreditation Council for Graduate Medical Education (ACGME) enacted its 2003 Duty Hour Standards, which placed an 80-hour work hour limit on all trainees. It was not uncommon to work 120 hours in a week, with call shifts of 36 hours or more. We didn’t know how tired or compromised we were and continued to reinforce the narrative that this was the sacrifice we made to be By Meghan Walsh, MD, MPH
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in medicine. Our admission H&P’s and daily notes were completed on paper, and I can still repeat the mnemonic that got me through countless nights of call (ADC VAN DISML*). We waited in line for the chart — behind the nurses, the consulting teams, and the pharmacist, before our notes were finally entered. We didn’t have the benefits of ultrasound for our central lines, Google as a quick reference tool, or protocols providing safe standard treatments for our patients. We spent so much time in the hospital that we built lasting rituals and support structures — a midnight gathering of all on-call residents around the smoothie bar in the cafeteria — to seek advice or share a laugh. And we were exhausted. We didn’t talk about fatigue or sleep deprivation, burnout or wellbeing. (Burnout: a syndrome characterized by a loss of enthusiasm for work [emotional exhaustion], feeling of cynicism [depersonalization], and a low sense of personal accomplishment.)3 It was definitely not measured. We didn’t discuss the added risk of depression, emotional exhaustion, or depersonalization stemming from residency itself. It would be years later (2012) when a Mayo Clinic Study by Colin West, et al. would begin *ADC VAN DISM A=admit to what service D=Diagnosis C=Condition V=vitals on admission A=activity N=nursing orders D=diet I=IV fluids S=Special orders (drains, tubes) M=medications L=labs
Photo by Michelle Trombetta
to highlight the risks of driving post-call. Motor vehicle incidents were reported in 56.0% of Internal Medicine residents surveyed, with 11.3% reporting a motor vehicle crash and 43.3% reporting a near-miss crash, due to sleepiness and fatigue.4 The 2003 Duty Hours Standards were the first step towards shifting culture towards wellbeing in the clinical learning environment. Multiple subsequent studies offered mixed results on the impact of these changes on patient outcomes, patient safety and resident wellbeing.5 Nevertheless, the ACGME further refined its Duty Hour Standards in 2011: 80-hour work week maximum, intern shifts capped at 16 hours, and one day off per week (averaged over a month). Although these duty hours are well integrated into our training programs today, they also remain controversial. In 2016, Bilmoria, et al. published the results
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of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial which examined how liberalizing surgical resident duty hour restrictions (waiving the maximum shift length, and time off between shifts) impacted patient care, surgical outcomes and resident education and wellbeing. Researchers found that flexible, less-restrictive duty-hour policies for surgical residents were not associated with worsened patient outcomes and revealed no significant difference in residents’ satisfaction or overall well-being.6 Apart from a change to the intern shift length (from 16 hours to 28 hours) which began in July 2017, previously established duty hour standards have remained in place. Duty hour reform is only one of many changes that have profoundly shifted residency training in the last decade. The electronic health record (EHR) has transformed how we care for patients in a myriad of ways — some good, some less so. In 1999, Dr. Faith Fitzgerald warned the medical community in the Annals of Internal Medicine about the impact of the EHR on education and training: “For whatever reason — economics, efficiency, increased demands on physicians for documentation, technology, or the separation of education from patient care — curiosity in physicians is at risk.”7 Burnout and a Call for Change Burnout in medicine is significant and rising across the continuum of medical education from student to practicing doctor. Among faculty physicians, it is around 40%, and as high as 66% in some specialties. Among residents, the prevalence of burnout is around 50%, with some studies showing burnout as high as 80%.8 Burnout in health care is at a crisis point and is calling out health systems, training programs, specialty societies and physicians to push for change. Interventions for the mitigation of burnout in medicine vary from individual resiliency-building initiatives such as mindfulness and meditation to system-based initiatives such as duty hour reform, creative scheduling to increase control and minimize fatigue, and use of scribes in clinical practices. As a practicing faculty member, I joined the ranks of the majority — more than half (54.5%) of the physicians who
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completed residency training from 2007 through 2016 are practicing in the state where they did their training. Despite GME funding challenges, there has been nearly a 20% increase in the number of trainees over the last decade, with nearly 130,000 in residency today.9 Medical school debt also has grown. Graduating students are now burdened with a median debt of $192,000, with many interns (14%) starting residency with debt surpassing $300,000.10 The gender breakdown has improved slightly since 2001, with women representing 44% of the residents in programs today.9 Data from the Minneapolis metro hospitals is slightly better than the national average, as 47% of our trainees in 2017 were women. The specialties with the lowest percentage of women nationally remain similar to 2001, although with a slightly increased percentage of women present in these fields than in my era — orthopedics (14%); Interventional Radiology-integrated (15%); neurosurgery (15%.)9 The diversification of our residents by race, gender, ethnicity is mirroring our communities and adding value and impact to our learning environments. The Ever Evolving Clinical Learning Environment Medical training has evolved tremendously in only 15 years. Training programs are rooted in a culture of continuous improvement, while incorporating competency-based assessment and advancement, enhanced supervision and feedback, and promotion of wellbeing of its learners. Our new generation of residents are actively engaged in institutional quality initiatives, multidisciplinary rounds, wellbeing initiatives, and simulation-based education. Residents have curriculum that spans areas not taught when I was a resident: error disclosure and the second victim, person and family-centered care, health equity and disparities in medicine, and opioid addiction and treatment. These trainees are more diverse than they were a decade ago, as well as digital natives who navigate complex technology with skill and efficiency. They are learning about systems of health care, have been trained to work in interprofessional teams, and value these varied roles in patient care. They recognize the importance of partnering with
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their patients and their families for the best possible care. Their wellbeing is at the forefront, and this generation is unlikely to continue to tolerate a continued culture of overwork and exhaustion. A lot has changed since my internship in 2001. Change is the new constant in health care. Although I am nostalgic for my own residency experience, it was not the best way to learn or to practice in many ways. Today’s residents are better poised for the future of health care. The future of medicine is bright. Meghan Walsh, MD, MPH is the Chief Academic Officer at Hennepin HealthCare and a practicing internist. She is also an Associate Professor of Internal Medicine at the University of Minnesota School of Medicine. She can be reached at Meghan.walsh@hcmed.org and (612) 873-3418. References: 1. Association of American Medical Colleges, “Women in U.S. Academic Medicine and Science: Statistics and Benchmarking Report. 2011-2012. Available at https://members.aamc. org/eweb/. Accessed April 28, 2018. 2. Santana S. Paying the price to become a doctor: the impact of medical school debt. Association of American Medical Colleges Web site. Available at: http://www. aamc.org/newsroom/ reporter/jan02/medschooldebt.htm. Accessed April 24, 2018. 3. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377 1385. 4. West, Colin P. et al. Association of Resident Fatigue and Distress With Occupational Blood and Body Fluid Exposures and Motor Vehicle Incidents. Mayo Clinic Proceedings, Volume 87, Issue 12 , 1138 - 1144 5. Romano, Patrick S., and Kevin Volpp. “The ACGME’s 2011 Changes to Resident Duty Hours: Are They an Unfunded Mandate on Teaching Hospitals?” Journal of General Internal Medicine 27.2 (2012): 136–138. PMC. Web. 2 May 2018. 6. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med 2016;374:713-727. 7. Fitzgerald F. Curiosity. Ann Intern Med 1999; 130: 70–72. 8. IsHak WW, Lederer S, Mandili C, et al. Burnout During Residency Training: A Literature Review. Journal of Graduate Medical Education. 2009;1(2):236-242. doi:10.4300/ JGME-D-09-00054.1. 9. Association of American Medical Colleges, “December 2017 Report on Residents.” Available at https://www.aamc.org/data/484710/ report-on-residents.html. Accessed May 2, 2018. 10. Association of American Medical Colleges, “Medical Student Education; Debt, Costs and Loan Repayment Fact Card 2017.” Available at https://students-residents.aamc.org/financial-aid/. Accessed May 4, 2018.
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Medical Education
A Return to the Bedside: Teaching Point-of-care Ultrasound at Abbott Northwestern Hospital Did you learn to distinguish mitral regurgitation from aortic stenosis by the quality and location of the murmur? Maybe you used percussion to detect pleural effusion and ascites and used your hands to palpate an enlarged liver or spleen? If you mastered these traditional exam maneuvers, then you spent many hours at the bedside practicing. The traditional bedside physical exam has been in decline within Internal Medicine (IM) for many years with various contributory causes.1–5 Once the erosion in skills began, a shortage of teachers and mentors developed ensuring weak skills and interest by successive classes of medical students and residents. Despite strong efforts by the Abbott Northwestern IM Residency Program leadership over many years to continue strong teaching of the traditional exam, we agree that the traditional exam is held in predominantly weak regard and is usually cursorily performed. Yet, two factors support the necessity of a competent bedside exam. First, as Verghese, et al. have argued, there is a ritual aspect of the exam that should be preserved. Second, because of radiation exposure and resource use, it is difficult to imagine a future in which all patients simply undergo serial complete body imaging and laboratory panels without focus.4 Thus, an IM bedside exam must be found that maintains physician/patient contact but that also contributes importantly to the diagnostic ability of the physician, allowing appropriate selection of subsequent diagnostic and therapeutic interventions. We believe that such an exam is created through the strategic addition of point-of-care ultrasound (POCUS).5–7 By David Tierney, MD, FACP, Bob Miner, MD, FACP, and Terry Rosborough, MD, FACP
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David Tierney, MD, FACP
Bob Miner, MD, FACP
There is strong evidence that POCUS is superior to most traditional exam maneuvers and to many forms of plain radiography.7–11 Specialties such as emergency medicine, critical care, rheumatology, sports medicine and orthopedic surgery have already made POCUS commonplace in practice and training. In some countries general internists are also routinely trained to use POCUS, and a rapidly growing number of United States medical schools have added ultrasound education to their curricula (101 of 134 schools participating in the AAMC 2015-16 Curriculum Inventory).12,13 The Society of Hospitalist Medicine and the American College of Physicians have incorporated POCUS certificate programs and training courses at the local and national levels over the last 5-10 years to keep up with this reality. In 2011, we began one of the first, and most robust, residency-based IM ultrasound training programs in the country known as IMBUS (Internal Medicine Bedside UltraSound). We started by training 12 of our core faculty and program leaders in a breadth of POCUS applications targeted at weak areas of the traditional physical exam. After a year of faculty training, the first group of IM
Terry Rosborough, MD, FACP
residents entered a longitudinal, three-year curriculum. To date, over 175 providers, including residents, faculty, and advanced practice providers have gone through training at Abbott Northwestern in both in- and outpatient POCUS. One month into residency, our 1st year residents enter a five-day IMBUS “boot camp.” The goal of this intensive course is to familiarize residents with the core areas of IMBUS and give them enough handson time to reach an efficiency and comfort with image acquisition. Following this week of intense training, residents have a “learner’s permit” and enter “behind-the-wheel” training. Residents then continue POCUS learning at the bedside of patients they are caring for with one of our faculty mentors at their side until they reach certification with each skill. Though some POCUS knowledge can be taught away from the bedside, the critical skill of clinical integration necessitates physician-mentored bedside practice. It takes much experience to understand the strengths and pitfalls of POCUS, the appropriate clinical weight of a finding within the context of other available data, the spectrum of “normal” such that abnormal begins to
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stand out, and the art of this exam and how it is also integral to the physician-patient relationship. Though frequently thought of as an inpatient tool, POCUS for internists is equally impactful in the outpatient setting where the spectrum of disease is different, and a variety of POCUS needs exist that rarely surface in the hospital. In 2013 we established a dedicated outpatient POCUS rotation for our 2nd year residents that has extensive formal and experiential learning and takes residents beyond the core level of IMBUS skill using an advanced POCUS machine. There are many program investments beyond training a necessary fleet of inpatient and outpatient IMBUS faculty mentors. Laptop/cart-based ultrasound machines are housed on all hospital stations and in both resident and faculty clinics. In 2017, we added tablet-sized ultrasounds right next to stethoscopes in the pockets of our ward team residents. Each exam performed on these devices, and the findings observed, are recorded on an internally-developed, smartphone-based, mobile tracking application. The study images from the exam can be wirelessly archived for follow-up or to facilitate inter-provider communication, and these archived images can be immediately viewed from any computer or smartphone when the need arises. An online educational portal and textbook (http://imbus.anwresidency. com), regular IMBUS case conference and
image review sessions, as well as a POCUS curriculum specific for our rotating medical students, are key components of ongoing education. Finally, a faculty reimbursement model that compensates our core IMBUS faculty for time spent teaching at the bedside is a requirement for optimization of the educational efficiency, quality, and safety of the program. In addition to the obvious challenge of POCUS training and program logistics, the current major barrier to wide-spread POCUS implementation in IM is the reimbursement model. POCUS takes additional time and current RVU based compensation models bring little if any additional revenue for physicians performing it. Thus, while the patient and the entire health system can benefit from IM POCUS, the individual physician (and usually the hospitalist group or clinic) can actually lose. Reimbursement systems need to better recognize clinical outcomes and the total cost of care for POCUS to reach its potential in IM. The POCUS mountain is difficult for a residency and its faculty to climb, but the future of IM will revolve around residents entering practice that have been trained in a longitudinal, residency-based pathway like IMBUS. Short courses offered at local and National meetings are helpful as introductions, but development of true competency in POCUS takes mentored practice at the bedside that these courses cannot provide.
So, what are the benefits of such a climb? Here are a few we know to be true after almost seven years and over 18,000 exams performed (chart below) within the IMBUS program: 1) a reduction in radiation-based imaging; 2) better diagnostic accuracy than traditional exam often resulting in more timely diagnosis, decreased cost, and a reduction in antibiotic use; 3) safer invasive procedures; 4) an enthusiasm among students, residents, and faculty of all ages to see physiology, anatomy and pathology at the bedside; 5) a satisfaction among patients tied to visual rather than verbal explanations; and 6) preparing for the future of medical students and residents who are leaving training with this skillset. Last but not least, the IMBUS experience has been about a return to the bedside for us as internists, now with an ability to diagnose, efficiently treat, and engage patients in the relationships that drew many of us to internal medicine in the first place. David Tierney, MD, FACP is the Internal Medicine Residency Director at Abbott Northwestern Hospital where he has been since 2003 after graduating from the University of Minnesota Medical School. He is the founder (2011) and current director of the IMBUS program, the ultrasound-based IM bedside procedure team (2006) and the Center for Clinical Simulation (2008) at Abbott Northwestern Hospital. He teaches and speaks about point-of-care ultrasound internationally and is involved in POCUS leadership for several physician societies at the national level. David. Tierney@allina.com. Bob Miner, MD, FACP is the current Director of Medical Education at Abbott Northwestern and prior to that, he was the Internal Medicine Residency Director from 2005-2016. He was the founder of the first hospitalist service at Abbott Northwestern in 1993. Terry Rosborough, MD, FACP was the Internal Medicine Residency Director at Abbott Northwestern for 22 years, the Director of Medical Education for 33 years, and now is working half-time continuing the development of outpatient IMBUS in the ANGMA clinic at the Abbott Northwestern Center for Outpatient Care. References available upon request.
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Sponsored Content
Training Practice-Ready Clinicians to Meet Workforce Needs Contributed by Felix K. Ankel, MD, Kelly K. Frisch, MD, and Shannon E. Kojasoy, MPP
Felix K. Ankel, MD
Health professions education and the clinical learning environment are evolving to better integrate education and clinical operations. This includes aligning clinical training with the cultures and needs of health systems, and ensuring that residents and advanced practice clinician trainees are prepared for the transition from training to independent practice. In 2015, HealthPartners assessed its graduate medical and advanced practice clinician residency and fellowship programs and discovered a blend of high-quality educational programs that operated with minimal input from care delivery or its health plan. HealthPartners trains over 500 residents in 25 specialties, as well as over 300 physician assistant and nurse practitioner students, each year in programs sponsored by HealthPartners or the University of Minnesota. Similar to other health systems, HealthPartners’ health professions education system inventory and structure were based on historical precedence, micro-financial considerations 28
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Kelly K. Frisch, MD
Shannon E. Kojasoy, MPP
(cap count), operational unit dynamics and relationships with medical schools. Acting on recommendations from the Institute of Medicine report Graduate Medical Education That Meets the Nation’s Health Needs1 and the Josiah Macy JR. Foundation’s report Innovations in Graduate Medical Education: Aligning Residency Training with Changing Societal Needs,2 HealthPartners sought to align its workforce needs, distribution of professions and specialties, and health professions education. The result would be a system-wide approach that supported HealthPartners’ healthcare strategy and ensured “practice-ready” graduates through graduate medical education and advanced practice clinician training. While still in its early stages, the system-wide health professions education project is already having a positive impact on medical education at HealthPartners. It has enhanced the understanding of the importance of health professions education, promoted a greater appreciation for
the role of faculty and preceptors, and increased engagement in connecting education to healthcare strategy. Work Groups Address Components of Health Professions Education
The System Design for Health Professions Education, which took 15 months, engaged HealthPartners education and operations leaders in developing a framework to train residents and fellows in a manner that supports our workforce needs and mission. We formed four work groups to address specific components of a health professions education system. • People: Who should HealthPartners train to support workforce needs? • Quality: How can training at HealthPartners provide the highest-quality care for patients and highest-quality education for health professions? • Experience: How can training ensure the best experience for patients, learners and teachers?
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The Journal of the Twin Cities Medical Society
•
Finance: How can a HealthPartners health professions education finance model maximize value to patients, learners and the health system?
Development of Practice-Ready Competencies
We wanted to ensure that physicians graduating from HealthPartners were “practice-ready,” or prepared to enter a value-based model, work on interdisciplinary teams, continually improve quality, and serve the larger community. To do so, we developed competencies to define effective HealthPartners clinicians: • Communication: Uses active listening techniques and has awareness of nonverbal communication • Patient-centeredness: In partnership, provides patient- and family-centered care and experience • Builds trust: Develops a connection with patients built on trust through humility and cultural awareness • Teamwork: Works effectively in teams in which all members have a voice and clear role • Resiliency: Practices self-care and reflection to remain healthy and adaptable, and avoid burnout • Stewardship: Considers health care cost impact on patients and the health system • Quality improvement: Leads others in practice-based learning dedicated to improving system quality Creation of a Clinician Workforce Plan
Another objective of the design project was to connect health professions education to HealthPartners’ workforce strategy. To define this strategy, we created a clinician workforce committee composed primarily of operational leaders to forecast our needs. The initial strategy will be finalized in Fall 2018 to guide future health professions education strategy as to the number and distribution of resident and fellow trainees. The strategic direction will more closely align health professions education with changing healthcare demands at HealthPartners and in our community. MetroDoctors
Enhancement of the Clinical Learning Environment
Evidence shows that clinicians practice much like they did where they trained, particularly in regard to the quality3 and cost4 of care they deliver. In addition to providing the training experience, the clinical learning environment affects behavior and style of practice years later. In order to enhance the environment, HealthPartners clinical and operational leaders want to support and develop those individuals with the greatest impact on learners. To do this, we are formulating an enterprise-wide approach to providing administrative support for faculty and preceptors. Support will include greater access to training opportunities and learning tools and increased efforts to grow the clinical educator culture throughout HealthPartners. Building a Finance Support Structure for Health Professions Education
The final objective of the System Design for Health Professions Education Project was to ensure funding more accurately represented the role of health professions education at HealthPartners. The process showed the positive impact of health professions education on the whole system, but suggested an overreliance on hospital funding streams. After studying different models and approaches across the country, we developed an enterprise-wide finance support structure for education. We defined common finance language to enable accurate measurement of the costs and benefits of health professions education throughout HealthPartners. While considering the flow of reimbursement of graduate medical education, we focused our effort on conducting a financial analysis that permitted costs to remain at teaching hospitals and ensured financial support from other business units when appropriate. The process brought together finance leaders from across the system who addressed individual concerns and created an enterprise approach to education finance that ensures central ownership and strategy.
The Journal of the Twin Cities Medical Society
HealthPartners operational and educational leaders strongly support an enterprise-wide approach to health professions education to align education with strategy, and ensure that HealthPartners trainees are practice-ready. When fully implemented, the health professions education system will increase efficiencies, adapt to changing healthcare demands, and accelerate best practices throughout HealthPartners and the community. Felix K. Ankel, MD, is Vice President and Executive Director of Health Professional Education at HealthPartners and HealthPartners Institute. He’s also an Emergency Medicine physician at Regions Hospital and HealthPartners Specialty Clinics, and a member of the American Board of Emergency Medicine Board of Directors. Kelly K. Frisch, MD, is Chief of Clinical Learning at Regions Hospital and supports graduate and medical student education across HealthPartners. She has practiced Internal Medicine for more than 20 years, and sees patients at the HealthPartners University Avenue Clinic. Shannon E. Kojasoy, MPP, is a project management consultant specializing in health care. She is currently working closely with HealthPartners on organizational initiatives, including establishment of a rural residency. References 1. Berwick D, Wilensky GR, Alexander B, et al. Graduate Medical Education That Meets the Nation’s Health Needs. Institute of Medicine, July 2014. 2. Josiah Macy Jr. Foundation. Innovations in Graduate Medical Education: Aligning Residency Training with Changing Societal Needs. November 2016. 3. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ. Evaluating obstetrical residency programs using patient outcomes. JAMA. 2009;302(12):1277-1283. doi:10.1001/ jama.2009.1356. 4. Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393. doi:10.1001/ jama.2014.15973.
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Learning to Talk About End-of-Life Preferences Honoring Choices works with medical students at the University of Minnesota to provide information about Advance Care Planning and healthcare directives, and partners with students on independent projects. When asked, the students
have positive feedback about their learning experiences: “The Honoring Choices program has not only given me insight on the importance of advance directives in the medical field,
but has also allowed me to reflect on my own wishes, and to have the same conversation with my family members that I will ask my future patients to have.” Mckinzy Butler, Class of 2020 “Working with Honoring Choices taught me how to talk to patients about their priorities for their care and gave me opportunities to practice having these conversations which can be difficult and intimidating to initiate. On my clinical rotations, I have found that I don’t shy away from discussions on goals of care or end of life because the training and practice I received with Honoring Choices has made me more comfortable in those situations.” Sarah Ringstrom, Class of 2019
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THE T E THYROID TH THY HYR RO OID ID CENTER CEN NTE TER
www.schusterclinic.com
“We are doing a project focusing on awareness of Advance Care Planning for the Chinese community in the Twin Cities. Partnering with Honoring Choices has made our initial efforts successful as we have benefited from their experience and resources. We are not only learning how to have better conversations with patients about end-of-life preferences, but also about how to adapt the conversations and resources to a culturally unique population.” Monica Ngo, Minna Ding, and Elizabeth Kim (not picutred), Class of 2021 Each year Honoring Choices increases their involvement with students to help these future physicians begin their careers with confident knowledge of how to help their patients consider, discuss, and document their healthcare choices.
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LUMINARY of Twin Cities Medicine G u e s t A u t h o r, G r e g o r y P l o t n i k o f f , M D
MARVIN S. SEGAL, MD This month’s Luminary column celebrates Marvin S. Segal, MD, the physician whom, over the past eight years, has written more than 50 essays that have honored our esteemed colleagues. Through his Luminary essays, Dr. Segal has highlighted colleagues whose story can enlighten, encourage and inspire us. In doing so, he is actively celebrating and preserving the finest traditions of our calling. Of course, being a physician, being a professional in the service of healing, is itself an honor. We work hard in service of patients, families and the profession. And we each benefit vicariously from the dedication demonstrated by our colleagues. But we all need inspiration. As do future generations of physicians. Where do we find it? Thankfully, there are no Halls of Fame for physicians. Our metaphorical home runs and gold records are not for public display and certainly not achieved for entertainment. Our best clinical work on behalf of patients is mostly hidden, witnessed at best by a few colleagues or a few family members. Dr. Segal has shown us that inspiration can come from learning of the lives of highly respected colleagues. For eight years now, each issue of MetroDoctors has a finely woven narrative of the life of one of our colleagues — each thoughtfully written by Marv. How does he do it? Care, skill, and a little bit of magic. How has their personal and professional life unfolded? What gives them the greatest joy? What do they consider their greatest honor? Dr. Segal’s magic transforms a CV into a story and in doing so brings out the humanity of the honoree. From where does Marv’s magic come? Of course, some magic comes from his family and his upbringing here in Minnesota. But could it also be from the U? He graduated from the University of Minnesota with three degrees: a BA, a BS and an MD. Could it be from writing for colleagues for nearly 50 years? His first article, “The Elusive Treatment of Angina,” appeared in Minnesota Medicine before he was even board certified. Could it be from his curiosity? He is known as an outstanding clinician and researcher who pursued new frontiers in medical research as well as medical quality. (We should think of him every time we recommend aspirin for prevention of heart attacks. He was the Minnesota co-PI for the famous aspirin study.) Could it be from his experience? 32
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He served in significant leadership roles in several organizations including the Berman Center for Clinical Research, Metropolitan Mt. Sinai Hospital, the Hennepin County Medical Society and its Foundation as well as Health One, SelectCare and Medica. His magic has resulted in numerous honors including the Physician Communicator award from the MMA for the “rare capacity to move and inspire others.” Equally rare is his triple status as a Fellow of the American College of Physicians, a Fellow of the American College of Cardiology and a Fellow of the American College of Physician Executives. One admirer, Burt Schwartz, MD, describes Marv as a mensch, a person of exceptional honor and integrity. “I could always rely on Marv to be supportive and helpful during very difficult times in my life. He has done the same for so many people. His steady and calm approach has helped solve difficult problems for so many.” Dr. Segal is more modest. When asked to comment he noted, “I’m pleased that my writing, which is a wonderful avocation, has been appreciated. I’d really most like to be thought of as a pretty good doc who truly loved his patients, his colleagues and his profession . . . ‘beyond all words’.” Dr. Segal, on behalf of your colleagues, please allow me to extend a deeply felt “Thank you.” Your gifts are a blessing to us all. Per the great physician Maimonides, “May the love for (our) art actuate (you) at all times.” 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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The new school of thought on medical education Medical training programs need constant input and evaluation from doctors, care teams and health plan experts. At HealthPartners, we’re redesigning education to solve organizational needs and create practice-ready graduates. HealthPartners Institute is one of the largest medical research and education centers in the Midwest. We’re part of an integrated health care organization that includes hospitals, clinics and a health plan. Our teams are helping transform health care across the nation.
Kelly K. Frisch, MD Felix K. Ankel, MD Shannon E. Kojasoy, MPP
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