Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
May/June Index to Advertisers TCMS Officers
Advanced Dermatology Care.........................24
President: Peter J. Dehnel, M.D.
Advanced Spine Associates, P.A. ...................26
President-elect: Edwin N. Bogonko, M.D.
AmeriPride...........................................................29
Secretary: Lisa R. Mattson, M.D. Treasurer: Kenneth N. Kephart, M.D. Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.
Past President: Thomas D. Siefferman, M.D. TCMS Executive Staff
Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Executive Assistant (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Katie R. Snow, Project Coordinator (612) 362-3704 ksnow@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.
Audiology Concepts ...........Inside Back Cover Crutchfield Dermatology.................................. 2 The Davis Group .............. Inside Front Cover Fairview Health Services .................................31 Healthcare Billing Resources, Inc. ...............10 Kathy Madore....................................................... 1 Lockridge Grindal Nauen P.L.L.P. ...............20 Minnesota Epilepsy Group, P.A....................28 Minnesota Physician Services, Inc. ..............11 MMIC Health IT ........... Outside Back Cover Noran Clinic Sleep Center .............................14 Saint Therese.......................................................21 Stillwater Medical Group................................30 Tinnitus and Hyperacusis Clinic....................... Inside Back Cover Toshiba Business Solutions.............................22 Uptown Dermatology & SkinSpa................28 U.S. Navy ............................................................31
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May/June 2012
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The Journal of the Twin Cities Medical Society
Contents VOLUME 14, NO. 3
2
Index to Advertisers
4
May 6 Exercise Will Test Ability of Postal Service to Deliver Medication in a Public Health Emergency
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In thIs Issue
M AY / J U N E 2 0 1 2
Integrative Medicine: Conventional and Holistic Care By Gregory A. Plotnikoff, M.D., MTS
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PresIdent’s Message
Skeptically Embracing the “New”? By Peter J. Dehnel, M.D.
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tCMs In aCtIon By Sue Schettle, CEO
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IntegratIve MedICIne
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Colleague Interview: A Conversation With William D. Manahan, M.D.
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HCMC Offers Integrative Family Medicine at Whittier Clinic By Selma L. Sroka, M.D.
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More Skills—Less Pills for Kids With Developmental and Behavioral Challenges By Timothy Culbert, M.D., FAAP
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Integrative Solutions for Chronic Pain By Mark B. Weisberg, Ph.D., ABPP, Alfred L. Clavel, Jr., M.D., Cory Herman, DDS, M.S., and Suzanne Candell, Ph.D.
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Broadening the Practice Perspective in Women’s Health Care: A Comprehensive Integrative Model for Women By Diana Drake, M.S.N., WHNP, and Carolyn Torkelson, M.D., M.S.
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Finding a Place for an Integrative Approach: Allina’s Penny George Institute for Health and Healing By Jennifer Blair, L.Ac, Ma.O.M.
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Partnering to Provide a New Model of Integrative Health Care By Michael R. Wiles, DC, MEd, MS
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What About the Integration of Naturopathic Medicine? By Andrew Litchy, ND
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New Members/Call for Resolutions and Delegates
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In Memoriam/Honoring Choices/Career Opportunities
31
Senior Physicians Association
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LuMInary of twIn CItIes MedICIne
Paul G. Quie, M.D. Page 25
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The Journal of the Twin Cities Medical Society
On the cover: Physicians and non-physicians work together to deliver clinical care. Articles begin on page 8.
May/June 2012
3
May 6 Exercise Will Test Ability of Postal Service to
Deliver Medication in a Public Health Emergency
O
n May 6, personnel from the U.S. Postal Service will make an unusual Sunday morning run through a number of targeted neighborhoods in the Twin Cities area, leaving a simulated supply of doxycycline at each mailing address. That day will mark the culmination of a two-day exercise known as “Operation Medicine Delivery” (OMD), which will test the ability of the Postal Service to deliver emergency preventive medication to Twin Cities households. The simulated deliveries are tentatively scheduled to occur in up to five Twin Cities ZIP codes — in Minneapolis, St. Paul, and portions of Robbinsdale, Crystal and Golden Valley. As part of the exercise, a simulated supply of medication will be delivered to approximately 35-40,000 separate residential mailing addresses. Each household will get an empty pill bottle and a flyer explaining the purpose of the exercise. The flyer message will emphasize that Operation Medicine Delivery is “only a test,” and no actual emergency has occurred. Recipients will be advised to simply recycle the pill bottle. The flyer will include information in English and five additional languages. Postal workers participating in the exercise will work in tandem with law enforcement escorts. Over 300 Twin Cities postal workers have been recruited and trained to deliver medicine to households in an emergency. The idea of using postal delivery teams to distribute preventive medication during an emergency has already been tested, on a limited basis, in Boston, Philadelphia and Seattle. However, this is the first metro area to recruit a full complement of postal participants, and set up a fully developed postal delivery system. A formal plan for implementing postal delivery in the Twin Cities was adopted in February 2010, and tested through a tabletop exercise in January 2012. The May 6 exercise will be the first “full scale” field test of the Twin Cities postal plan. OMD is a collaborative effort of the Postal Service, local law enforcement, public health 4
May/June 2012
agencies at all levels of government, and a nonprofit specializing in communication with limited-English cultural communities. Public health partners include the U.S. Department of Health and Human Services, CDC, the Minnesota Department of Health (MDH), Hennepin County Human Services and Public Health, Minneapolis Public Health and Family Support, and Saint Paul-Ramsey County Public Health. Participating law enforcement agencies include the U.S. Postal Inspection Service, Hennepin County Sheriff’s Office, Minneapolis Police Department, Minneapolis Park Police, Ramsey County Sheriff ’s Office, and St. Paul Police Department. The nonprofit partner is ECHO Minnesota (Emergency and Community Health Outreach). Postal delivery of emergency medication is part of a larger program called the Cities Readiness Initiative (CRI), which was created to facilitate the rapid dispensing of preventive antibiotics and other medicines in major urban areas during an emergency. The Twin Cities planning area for CRI includes 11 counties in Minnesota and two in Wisconsin. One example of an emergency requiring rapid distribution of medicine is a bioterrorist attack involving widespread, airborne dissemination of anthrax. Under that scenario, the goal would be to get everyone who was exposed on doxycycline or another appropriate antibiotic within 48 hours. Under that scenario, depending on the scale of the emergency, it might be necessary to get medications to more than 3.2 million people in the greater Twin Cities area. The primary tool for distributing the medications would be a network of mass dispensing sites, operated by local public health agencies in the metro area and coordinated by the Minnesota Department of Health. Postal delivery of medication could be used in densely populated neighborhoods to supplement distribution of medicine at the dispensing sites, and take some of the pressure off of those facilities. An ample supply of medication has been stockpiled for use in emergencies by state, local
and federal public health agencies. These medications would be provided to the public free of charge. Emergency distribution of medication during a public health emergency has been approved under an emergency use authorization from the U.S. Food and Drug Administration. In a real emergency, households who received medication through postal delivery would also receive an instruction sheet about how to take them, including appropriate warnings and advisories. For example, in an anthrax emergency, people who shouldn’t take doxycycline would be instructed to go to a dispensing site rather than taking the home-delivered antibiotics. The dispensing site would be able to provide alternatives, such as ciprofloxacin. The instruction sheet will also include dosing information, including information about providing the medication to children. Regardless of whether people get their medication through postal delivery or from a dispensing site, they will most likely need to get additional quantities from a dispensing site at some point. The initial supply will just be enough to get them started, for example, on the 60 day course of treatment required for anthrax exposure. People who get their antibiotics through postal delivery will initially get only 20 adult doses per household (100 mg tablets, taken twice a day), so people in larger households will need to visit a dispensing site sooner. The point is to get people started on preventive medication as soon as possible following an emergency event, such as an anthrax attack. Postal delivery is one way to accomplish that goal. State and local health officials in Minnesota believe that postal delivery is an important tool for protecting the public in a health emergency. Operation Medicine Delivery will be an important early test of how well that tool works in practice. As the exercise date approaches, additional information will be posted to the MDH website at www.health.state.mn.us.
MetroDoctors
The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
Integrative Medicine: Conventional and Holistic Care “For more than 10 years, Mayo Clinic’s Integrative Medicine team has been providing complementary and alternative therapies...” So goes some of the recent advertising for the Mayo Clinic’s new clinical program at the Mall of America. This may seem shocking. However, the Institute of Medicine at the National Academies of Science recently affirmed integrative medicine’s importance via a three-day summit which assessed how integrative medicine can address, or even alleviate, the many troubling challenges of an aging society and the increased burden of chronic illness. (www. imsummitwebcast.org). In this spirit of integration, this issue seeks to inform readers of the range of integrative medicine practices in the Twin Cities. We are grateful for the time and effort each author dedicated to providing MetroDoctors readers with enough background information to stimulate thought and encourage constructive dialogue. Described in this issue are some, but not all, of the most visible examples of integrated clinics where physicians are present. These range from independent practices to HCMC’s innovative family practice residency program/clinic to systems-based primary care or consultative practices. Authors range in backgrounds and experiences. Regretfully, space limited the examples included. This is merely a glimpse: our intent was to generate insights on the potential of multiprofessional integrative teams for clinics of the future. We are pleased that senior family practice physician, former national president and current state co-leader of the American Holistic Medical Association, Bill Manahan, M.D., agreed to describe the promise of integrative medicine via questions from inquisitive members and our co-editors. Key points: integrative medicine is an approach to care that puts the patient at the center as a partner and addresses all factors that influence health, wellness and disease. All appropriate healing sciences are used to facilitate the body’s innate healing response. And, yes, of course, elements of this issue may be controversial. Common concerns nationally include bias, validity, pseudo-science, over claiming of expertise, perceived rejection of physician expertise, scope of practice encroachment, and, not surprisingly, patient safety and increased health care costs. Perhaps most controversial, however, is the topic of integration of non-physician health professionals into conventional clinical care. Andrew Litchy, ND, was kind (and brave enough)
By Gregory A. Plotnikoff, M.D., MTS Member, MetroDoctors Editorial Board
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The Journal of the Twin Cities Medical Society
to introduce naturopathy to us and ask why naturopaths are not part of integrative medicine care teams in Minnesota. In fact, many non-physician doctors, including naturopaths, psychologists, health coaches, chiropractors and TCM acupuncturists may be extremely welltrained in managing the limbic-hypothalamicpituitary-adrenal cortex axis and sympathetic/ parasympathetic imbalance. These are crucial clinical skills as the many forms of stress are incredibly powerful factors in illness. Many practitioners may be well-educated in the robust peer-reviewed literature (somehow missing from the medical school curriculum) on interventional nutrition for modulation of inflammatory pathways, oxidative stress, dybiosis, the many forms of adverse food reactions, nutritional insufficiencies, etc. Others are well trained in resolving the various complications of musculoskeletal disruptions. And others are well trained in alternative medical systems including Ayurveda and the traditional East Asian medicines from China, Korea and Japan. Adding additional skills, and working in partnership with highly talented complementary health professionals, has resulted in profound recoveries from people labeled as difficult, mysteries or prozac deficient. Normal conventional labs, scanning and scoping do not mean that significant underlying metabolic/nutritional, GI or immune issues are not present. Normal results do not mean that profound emotional and spiritual stressors are not present. And, truly, sometimes the best answers are not pharmaceutical. As exemplified by the professionalism of our Luminary this month, Paul Quie, M.D., we physicians can bring a rigorous medical approach to our patients, and to our students, including the extensive knowledge of differential diagnoses, pharmaceuticals, metabolic pathways, in addition to the critical thinking that comes with our education. For these reasons, I do not believe that physicians will ever be replaced. There will always be a need for physicians. Although we are better positioned to recognize an endocrinopathy, we are not trained to recognize what is well understood elsewhere including liver chi stagnation, ouketsu or suidoku. However, with the explosion of medical knowledge, there is no need for physicians to be self-sufficient virtuosos...interdisciplinary teamwork might make a significant difference. And this difference is exactly what health professional students at the Pillsbury Clinic described in this issue may be able to teach us. We welcome your feedback. May/June 2012
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President’s Message
Skeptically Embracing the “New”? PETEr J. DEhNEL, M.D.
M
ost people reading this edition of MetroDoctors wholeheartedly embrace the world of “traditional” medicine. We feel very comfortable with its foundational assumptions, supporting evidence and the depth of knowledge that supports the care we provide. It is truly “home” for us. One example we can point to is the National Comprehensive Cancer Network (NCCN). It is a great resource if you are looking for “best practices” in treating just about any type of cancer. If your 6-year-old patient has newly diagnosed acute lymphocytic leukemia or your 60-year-old has BRAF positive melanoma, you can give them reasonable hope that they stand a good chance of many years of survival based on the recommended treatment protocols. These protocols are based on solid science as well as very meticulously collected outcome data. On the other hand, if they are unfortunate enough to have stage IV esophageal carcinoma, you know to have a very different conversation. These treatment protocols found through NCCN make sense because of their foundational principles: reliance on accepted scientific principles, evidence-basis and supported by strong outcome data. In a similar vein, after years of training and clinical experience, many of us who are privileged to carry the title “doctor” (see “Luminaries”) believe we also make recommendations to our patients that are evidence-based and outcome-driven. Then it hits us squarely in the face, so to speak. The reality that a number of our patients, friends or even family members are interested in, and even actively pursuing, “alternative therapies.” Why would they question our recommendations for care, or even just add to them? Why isn’t it enough? A number of answers seem to emerge: • They are dissatisfied with the results that they currently experience with “traditional medicine” and are looking for something that is more effective, has fewer side effects, or both. • They never can see their “real” doctor at a clinic, but it is always who is available that day. • They are concerned about the side effects of the therapy we recommend. • They are distrustful of traditional medicine in general, based on past personal experience or the tragic experiences of others. • They are looking for a closer relationship with their clinician or “high touch” experience in a clinical setting. • They are feeling more and more like a “data point” instead of a person, and more like the third person in an exam room with the first two being the clinician and the computer screen. • Finally, they are looking for hope: a cure for that stage IV esophageal cancer, increased youth and energy at age 55 to 60 through hormone replacement therapy, reversal of Alzheimer’s, and on and on and on…. What could be wrong or bad about these additional options, they ask? Trying to lay aside all prejudice and preconceptions, from a “traditional” standpoint the array of complementary and alternative medicine options is staggering. Keeping abreast of the options available to patients with the explosion of access available through the Internet is literally impossible. How do we find a roadmap of what really works, what is beneficial, what is dangerous and what is simply designed to make a significant profit for the promoter and/or distributor? The skepticism in many of us arises from bogus examples such as the emergence of Laetrile in the 1970s as the latest and greatest cure for cancer. Colonic purges are still promoted as essential therapy for internal cleansing and pathway to great health. At the same time as these are being promoted, similar groups are discrediting vaccinations as poisoning the body or destroying the immune system — or at very least a certain cause of autism. The articles in this edition of MetroDoctors give a much needed “alternative view” to “alternative therapies.” Many therapies have been embraced by “traditional” medicine and conventionally trained physicians — much to the benefit of patients. Many of these do truly “complement” allopathic treatments, with the end result being greater than the sum of their individual parts. One of the great opportunities — and hopes — remaining in this area is an expansion of the disciplined study of what really works. Similar to the progress made in cancer treatment through groups like NCCN, embracing a much greater range of treatment options that we have confidence in would be a very good development for our patients. And that, at the end of the day, is what this profession is really all about. 6
May/June 2012
MetroDoctors
The Journal of the Twin Cities Medical Society
tCMs In aCtIon SUE A. SChETTLE, CEO
TCMS Board Approves Report of the Policy Committee
The TCMS Board, at its March 26, 2012 meeting, moved approval of the report of the TCMS Policy Committee entitled: The Twin Cities Network: A Physician Developed Model for Value-Added Health Care Delivery. The document is the result of an exercise of the Policy Committee that would empower physicians to become active participants in the development of an improved health system; provide a physicians’ vision for better care delivery and complementary payment procedures; inform health reform stakeholders about physician envisioned possible health reform direction and to stimulate public health reform discussion. The TC Network paper will be disseminated to members and others, and will be on our website. My thanks go out to the policy committee members who worked on the report for over a year, and to Roger Kathol, M.D. and Ron Hansen, M.D. who served as co-chairs. Also, thanks to Terri Hyduke, who served as our facilitator.
Perspectives were shared by (clockwise, from top left) Jim Guyn, M.D.; Ken Britton, D.O.; Lisa Mattson, M.D.; Peter Dehnel, M.D.; and Stacy Becker, Citizens League Staff.
TCMS Physicians Weigh in on Health Care Reform
The Citizens League contacted TCMS and asked that we gather a group of physicians who could provide perspectives on health care reform efforts. A focus group was MetroDoctors
conducted by staff from the Citizens League at the TCMS offices on February 24. Their goal was to gather feedback from a number of different perspectives as the Citizens League and the Bush Foundation developed the Citizen Solutions (http://www.citizensleague.org/what/policy/healthreform/index. php) project. Citizen Solutions will engage citizens and businesses in conversations about health reform, and will inform the Governor’s health care reform task force.
Honoring Choices Minnesota
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Kent Wilson, M.D., Honoring Choices Minnesota medical director, and I contributed a chapter in a recently published book, “Having Your Own Say… Getting the Right Care When it Matters Most.” Our chapter called “Honoring Choices Minnesota: A Metropolitan Program Underway,” highlights the success thus far of our Minnesota model. We are quite excited to have this level of exposure to a project of the Twin Cities Medical Society. Please visit www. havingyourownsay.org to learn more.
Eagan City Council News
The Eagan City Council voted on March 20th to approve a resolution that was created and supported by the TCMS led Twin Cities Obesity Prevention Coalition that encourages cities to adopt healthy eating active living policies and practices. TCMS staff member, Jennifer Anderson, led the grassroots effort by organizing coalition partners, creating messaging, and engaging physicians in the discussion with elected officials. Many physicians in the Eagan effort wrote letters and called the mayor and city council members voicing their support of the resolution. Jennifer will be working with more metroarea cities throughout 2012. If you have an interest in joining the effort by participating in the Physician Steering committee please contact Jennifer at janderson@metrodoctors.com. The physician steering committee is headed up by Tom Kottke, M.D. and Courtney Baechler-Jordan, M.D.
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The Journal of the Twin Cities Medical Society
Community Organizer Hired
Thanks to funding received from the Bush Foundation, Honoring Choices MN is beginning a 20-month experiment in collaboration with the Minnesota Council of Churches. The initiative aims to expand the Honoring Choices program through congregational recruitment throughout Minnesota in cooperation with the health care systems. We have hired Helen Jackson Lockett-El to serve as the program organizer. Helen began her position in April.
Foundation Hires a Development Officer
The East Metro Medical Society Foundation has contracted with a part-time development officer. Andrea Carlson Nelson began her work with the EMMF in April and will work with the staff to increase the profile of the Foundation within the TCMS membership by highlighting their efforts and programs. She will also assist in the investigation of additional grant opportunities.
Book Published
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Evaluation
We have contracted with Rainbow Research to assist in the impact evaluation of Honoring Choices Minnesota. Barry Cohen, Ph.D. will assist Honoring Choices Minnesota staff in evaluation planning and identification of qualitative and quantitative outcomes, among other things.
May/June 2012
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Integrative Medicine
Colleague Interview: A Conversation With William D. Manahan, M.D.
W
illiam D. Manahan, M.D. is an Assistant Professor Emeritus of Family Medicine and Community Health at the University of Minnesota Academic Health Center. He graduated from the University of Minnesota Medical School, completed a rotating internship at Santa Barbara County & Cottage Hospitals in Santa Barbara, CA, was a resident in family medicine at University of Oklahoma Health Sciences Center, Oklahoma City, OK, followed by a fellowship in community-oriented primary care at Carney Hospital, Boston, MA. At the present time he is a consultant for physicians, clinics and hospitals interested in initiating or expanding integrative medicine programs. He is also involved in projects to help transform America’s health care system and the healers involved in that system. One of the projects is HEART, a Humanistic Elective in Activism, Alternative Medicine and Reflective Transformation. It is sponsored by the American Medical Student Association and is a fourth-year elective for senior medical students.
“Integrative” practitioners do more than add a chiropractor or acupuncturist to their team. What do you mean when you use the term “integrative”? Various names have been used to describe “alternative” medical practices not taught in U.S. medical schools. The primary ones were complementary and alternative medicine (CAM) and holistic medicine. For the past decade, the term integrative medicine has been most commonly used. There are some minor differences in these types of practices, but the differences are, in my opinion, not substantial. Therefore, let me define what I like calling integrative holistic medicine but for the sake of simplicity will call integrative medicine. Integrative medicine is viewed by some as primarily the use of non-pharmaceutical modalities, but it is so much more than that. It has a number of components. 1) Emphasizing the body’s natural healing potential. Physicians remind patients that bodies can regulate themselves plus repair and regenerate their component parts. 2) Taking into account the whole person — not just the physical aspects but also the mental, emotional, spiritual, and social dimensions of a patient’s life. 3) Focusing on preventing disease and on promoting health. 4) Emphasizing the doctor-patient relationship. 5) Embracing all therapeutic options that may be of value. Of note, one of the common therapeutic options integrative physicians use is pharmaceuticals, which is sometimes surprising to our colleagues. Interestingly, I have many physician colleagues who would not describe themselves as practitioners of integrative medicine whom I believe have a more integrative and holistic practice than do some of my
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May/June 2012
integrative medicine colleagues because they routinely practice medicine incorporating the first four components listed above.
What is the difference between holistic and integrative medicine? Some would say there is a big difference, but I would say they are quite similar — depending on whom you ask. Both terms define practices that include the five components listed above, and then I would add that holistic medicine also encourages the belief that love is at the heart of all healing. I have personally mourned the loss of the term Holistic medicine because holistic is derived from healthy, holy and whole. It embodies what all of us want for our patients and for ourselves.
Integrative practices appear to be more open to non-pharmaceutical approaches such as nutritional supplements, herbal medicines and mind-body self-care skills. Why is this? One reason is because non-pharmaceutical approaches often work. They frequently have a good benefit-to-risk ratio and a good benefit-to-cost ratio, so the practitioner and patient are encouraged to try them first. Another reason is that often the integrative practitioner has had a personal experience with a chronic problem that did not improve or resolve with pharmaceutical treatment but did resolve with some other approach. That kind of experience is often the first step in developing an interest in exploring a wider range of therapeutic options and a commitment to the five principles named in the first question. MetroDoctors
The Journal of the Twin Cities Medical Society
Naturopathic and chiropractic doctors assert that they are now prepared to play a significant role in primary care. As a primary care physician for many years, what role do you see these doctors playing in the future? Over the past 50 years, primary care medical doctors have done a good job of working more closely with nurses, psychologists, physical therapists, podiatrists, dieticians, physician assistants and others. In the same manner, I envision that in the next decade, we will collaborate more closely with naturopaths and chiropractors. Just as nurse practitioners and physician assistants have been a helpful addition to primary care, naturopaths and chiropractors will add a helpful dimension by bringing to the practice a different set of skills and treatments. The majority of the patients coming to the office of a primary care physician today have chronic problems caused in part by lifestyle choices. They are complicated, multifactorial problems which are unique to each patient, and each patient deserves to be treated according to his or her own biochemical individuality. The protocols and fast service used to treat trauma, infections, and severe medical crises are not usually appropriate for these types of patients. Over the past 30 years, primary care practices have been helped by groups of providers working together to offer multidisciplinary support to assist our patients with three difficult primary care problems; chronic pain (pain clinics), chemical dependency (addiction centers), and endof-life challenges (hospice programs). When assisted by these groups of providers, our patients usually receive better care. Consequently, the patients are more satisfied and the physicians happier because they are having better patient outcomes. In the same way, much of what primary care physicians now treat are chronic problems such as obesity, hypertension, type 2 diabetes, hyperlipidemia, arthritis, low back pain, depression, insomnia and others. I am hopeful that when we adopt a similar team approach — using naturopaths, chiropractors, other body workers, mind/body stress reduction experts, nutrition practitioners, and others — our patients and our primary care practitioners will all benefit immensely. In fact, I envision the day when primary care practice will be the most sought after residency for medical school graduates. Teams of practitioners will work together — with the patients — on an exciting journey of discovery. This type of practice will put the doctor-patientteam relationship at the core of primary care practice. It will explore the mind/body/spirit components of our patients’ problem, and it will allow time to help patients focus on their natural healing potential. It will consider all therapeutic options while promoting health. Practicing primary care medicine will be fun!
How does the everyday busy physician discern the capabilities of the non-allopathic clinicians who are interacting with one’s patients? Their training, competence, integrity, and other attributes. Just as we like to make good referrals to medical doctors, we need to make good referrals to natural medicine practitioners. For those not familiar with natural practitioners, it can be a problem feeling comfortable
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The Journal of the Twin Cities Medical Society
referring outside the medical system. One option is to ask your patients; many of them are already seeing other healers. Another way is to have family members, friends, and ourselves receive treatments from natural medicine practitioners. Another path is reading integrative medicine books and journals while also attending conferences such as the Minnesota Holistic Medicine Group’s quarterly educational forums. Once we all begin to work together more closely, making good referrals to non-allopathic clinicians will become easier.
We rely on licensing and credentialing of allopathic clinicians. Who is looking after patient safety? The majority of the natural medicine practitioners have licensing and credentialing that is quite similar to MDs and DOs who do not work in hospitals. The number of injuries or detrimental outcomes to patients in the natural medicine world is extremely small.
Are they, or should integrative non-allopathic clinicians be held to the same scientific rigor (random sample double blind) to validate their therapies? This is a complicated question. According to the Cochrane Reviews, only 38 percent of what we do in allopathic medicine holds up to scientific rigor. It is also important to evaluate and compare the benefit-to-risk ratio and the benefit-to-cost ratio. For instance, if I treat a patient with a sinus infection with vitamin C, a neti pot, and elimination of dairy while my colleague treats that same person with an antibiotic, which of us is using more scientific rigor? If I treat a person with mild hypertension with exercise, dietary changes, mindfulness-based stress reduction, and group support while my colleague treats that same person with antihypertensive medications, which of us is using more scientific rigor? I suspect that in the near future, practitioners of all kinds initially will use a wide spectrum of low cost and low risk therapies when treating many of the common health problems.
Does integrative care result in any different Tort experience? The few studies have shown that integrative practitioners have a very low rate of malpractice claims brought against them.
Is integrative medicine outside an academic setting significantly different? Practices vary tremendously from no different to extremely different. It is, however, relatively uncommon at this time to see a physician in our academic institutions using acupuncture, elimination diets, herbs, mindfulness-based stress reduction, healing touch, Reiki, or Qigong. But institutions change rapidly, and integrative holistic approaches are becoming less uncommon. Presently, they are being used in over 40 academic medical settings in the U.S.
(Continued on page 10)
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Integrative Medicine Colleague Interview (Continued from page 9
take the University of Arizona Integrative Medicine Fellowship, the Institute of Functional Medicine training, or some other similar programs.
What do medical students really need to be learning that will improve their development as well-rounded holistic healers? I think it would be very helpful if medical students would learn and practice the five components of integrative medicine listed in question one. To recap, those components are as follows: 1) Emphasizing the body’s natural healing potential. 2) Taking into account the whole person — not just the physical aspects but also the mental, emotional, spiritual, and social dimensions of a patient’s life. 3) Focusing on preventing disease and on promoting health. 4) Emphasizing the doctor-patient relationship. 5) Embracing all therapeutic options that may be of value.
If you were starting now on your career as an integrative family physician, how would you train yourself, what skills would you use? I can think of five ways to learn more about integrative medicine. 1) Attend lots of workshops and conferences, and do lots of reading. 2) Routinely ask every patient you see what they are doing to stay healthy besides pharmaceuticals. Ask them what other practitioners they see and learn from their experience. 3) Visit some of those other practitioners for some of your own health problems. 4) Shadow integrative medicine practitioners and learn from watching. 5) Jump in with both feet and
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What economic powers do patients now have to achieve patient-centered care for themselves and their families? High deductibles and health savings accounts are allowing more people to make more choices regarding what type of care they receive. At the same time, cost is a tremendous barrier for the majority of people wishing to receive integrative medicine care.
What are the obstacles to empowering patients to act on their own behalf in today’s health care environment? The four major obstacles are: 1) wanting to be taken care of and not doing much of the hard work ourselves; 2) not being aware that there actually are other choices; 3) lack of money to pay for services outside the medical system; and 4) fear of not following the rules of our culture which emphasizes the superiority of allopathic medicine for most health problems.
Where do you see medicine going; where do you hope medicine will go?
Ah, I could write a book about that, so it is difficult to only answer in a few sentences. I see subspecialty care in medicine continuing to advance and do the amazing things it is presently doing plus lots more. My area of interest, though, is primary care medicine, so that is what I will discuss. At the “big picture” level, I see society uniting government, the private sector, and individuals as they all play a major role in the transformation of primary care. We need an office of Health Education to teach healthy life choices in schools. We need to evaluate government food subsidies and move them in a healthier direction. We need to figure out how to reward farmers for raising free-range animal foods and organic plant foods. The outsourced We need to change medical education for business office solution those physicians wanting to do primary care. for your They will rarely be taking care of patients in hospitals, and yet a majority of their education medical practice still occurs with hospitalized patients. That type of training no longer makes good sense. We are still training physicians in basically the same manner in which I was trained in the sixties, and for primary care practitioners that is a serious waste of time, talent and resources. Finally, I envision many much smaller primary care offices, with five or six practitioners from different disciplines all working
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collaboratively. For instance, a typical office could have an M.D., a body-worker, a naturopathic physician, a psychologist trained in mind body medicine, and an energy medicine practitioner. Can you imagine how fun it would be to practice in that type of setting and how beneficial it would be to our patients with the chronic problems a majority of patients now present to us? We would no longer have to individually carry the load of being responsible for so many aspects of that person’s health and life. In 2011, when I shadowed and interviewed 25 Minnesota integrative medicine physicians, their level of happiness regarding what they were doing was 4.4 on a scale of 1 to 5. They deeply enjoyed seeing patients, and they were happy being doctors. That is where I hope medicine will go.
How can medical centers contribute to true change and healing in patients? Two of the best examples of what can be done in the hospitals to contribute to change are right here in the Twin Cities: Abbott-Northwestern Hospital’s Penny George Institute for Health and Healing and Woodwinds Hospital. Those two places have available outstanding integrative medicine practitioners and programs routinely assisting their patients. The academic medical centers could contribute to true change by commissioning another Flexner Report and dramatically changing the manner in which we now educate our primary care physicians. The changes would be as radical and as extreme as those recommended in 1910 by the Flexner Report and implemented in all medical schools across the United States.
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In your opinion, what steps can organized medicine take to enhance the practice of patient-centered medicine? We need to honor ourselves for medicine’s incredible advances and lifesaving discoveries. At the same time, we need to humbly admit that we do not have many of the answers and that it is time to open our arms and our hearts to many other types of health and healing practitioners. Much is given to those of us in power, and, therefore, much is expected. It is time for organized medicine to seriously figure out how to work cooperatively with natural healers and integrative medicine practitioners so as to benefit the most people possible.
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Integrative Medicine
HCMC Offers Integrative Family Medicine at Whittier Clinic
T
he Integrative Health Program at Hennepin County Medical Center (HCMC) Family Practice Department, is located at Whittier Clinic at 2810 Nicollet Avenue South in inner city Minneapolis, and is thriving. Our approach is unique in that we are developing an integrative family medicine/ primary care model for our clinical practice as well as for residency education. Integrative medicine has been defined by the Arizona Center for Integrative Medicine as “healingoriented medicine that takes account of the whole person (mind, body and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient and makes use of all appropriate therapies, both conventional and alternative.” We feel this sums it up well. Our approach at Whittier Integrative Health Clinic is unique in that we have set our intention to practice integrative family medicine and primary care, instead of being a consultative practice. We do occasional consultations for patients referred by our colleagues, but this plays a minor part. Patients must come with a desire or intention to work on their issues in a holistic and integrative way. Basic screening questions are asked on initial contact to determine whether a patient will be a good fit for our clinic. Family doctors have the option to shape their practices into many niches, e.g. women’s health and geriatrics; we are choosing to take care of the families and individuals who want an integrative approach. Most patients find their way to our clinic by word of mouth and the internet. Most are looking for a new primary care doctor, as they have been disappointed and frustrated with
By Selma L. Sroka, M.D.
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the limitations of a standard, allopathic approach to their issues. Many have done extensive study on their own to try to find solutions for their problems, and are often quite sophisticated in their understanding of their health issues. Some say they feel they know more than their doctor From left: Kara Parker M.D., Selma Sroka M.D. and Susan Haddow M.D. knows about their problems, e.g. hypothyroid, and can’t underindustry. Our patients want doctors with both stand why doctors aren’t keeping up with the health and medical knowledge; doctors that can literature and research. Many tell us they have partner with them to explore options. Most are not felt they were “heard” by their former docinterested in primary prevention, and want to tors/medical systems. Some patients say they work on their psychological, emotional, lifestyle have even felt hurt and traumatized by their and spiritual issues. doctors and the health care system’s high-tech, Because many of our patients have felt high-pharmaceutical focus. This is their percepdisenfranchised by the standard medical system tion of their experience. We can’t argue with approach, we have come to recognize them as perception; we can only try to meet them where an underserved population. Although many they are and hope the new experience will shift have incomes, shelter and insurance, they are their perception. “underserved” because we, the system, don’t Like most patients, ours want patient“meet them where they are.” As a consequence, centered care. They also want their doctors to they have either looked elsewhere for help, be holistic and open minded about treatment i.e. outside of the standard allopathic medioptions. Some are already on prescription medical system, or they go without care/guidance. cations, and they also want to do more through At Whittier, we are working to reach out and nutrition, herbs, manual therapies, etc. Others invite them back into a system where they want to find balance in their lives through feel safe. We have friends in the “alternative” natural, healthy approaches, and are distrustful community, e.g. chiropractors, acupuncturof pharmaceuticals. Many have been paying out ists, naturopaths, massage therapists and are of pocket for their health care with “alternative building strong bridges for a referral base. This practitioners” for many years, and are part of works because there is mutual respect, and the the multi-billion dollar alternative medicine bridges are bidirectional. Patients often sign MetroDoctors
The Journal of the Twin Cities Medical Society
information releases as they want us to be collaborative about their care. They are all driving us to learn to be more culturally intelligent. The community responded at a greater rate than we anticipated, and we were recently able to hire another doctor. We now have three Integrative Family Doctors here at HCMC Whittier Clinic providing primary care: Dr. Susan Haddow, Dr. Kara Parker and Dr. Selma Sroka. All three doctors are certified by the American Board of Family Medicine, and have prepared to practice in a more expanded way. All have attended courses/conferences with the American Holistic Medical Association and the Institute of Functional Medicine. All have been certified by the American Board of Integrative Holistic Medicine. Each one has invested significant personal resources according to their personal interest to study a wide variety of topics including nutrition, functional medicine, herbs, hands-on healing and mind-body skills. Dr. Selma Sroka has also been certified as a fellow in Integrative Medicine by the Arizona Center for Integrative Medicine. In our clinic, we are working with many common primary care issues, e.g. depression, anxiety, hormonal imbalances, fatigue, sleep trouble, digestive complaints, headaches and pain. We use conventional approaches as well as non-pharmaceutical therapies in working with our patients as they present, adapting ourselves as much as possible to what the patient is looking for. Using the skills of motivational interviewing, starting from a patient-centered focus, we can identify where each patient is in their process and negotiate some steps toward their goals. As the partnership between doctor and patient develops, we often find ourselves working toward relationship-centered care, which is mutually beneficial and rewarding. We have ongoing collaboration with the skilled chiropractors and acupuncturists at HCMC’s Alternative Medicine Clinic. We share patients and complement each other’s work. We are optimistic that we will soon have the benefit of their skills onsite here at Whittier and we plan to have regular interdisciplinary case conferences on a periodic basis for residents, nurse practitioners and faculty. These conferences will model a collaborative approach between chiropractic care, acupuncture, holistic physical therapy, nutrition and integrative family medicine, all for the benefit of the patient. MetroDoctors
Integrative Medicine Residency
IMR resources include: • Web-based curriculum designed by leading integrative medicine educators • Case-based, interactive learning and streaming video • Online access to seminal literature and reference materials • Experiential exercises and process-oriented group activities • Participation in a community of learners through online dialogues with faculty and colleagues IMR curriculum IMR is designed to enhance residency training with content that integrates conventional medicine with complementary and alternative approaches. This integrative medicine core is delivered in modular sections that can be implemented longitudinally, as elective coursework, or as a complement to specific rotations. Curriculum includes: • Introduction to Integrative Medicine • Prevention and Wellness: U.S. Preventive Services, Nutrition and Diet, Supplements for Prevention, Physical Activity, Sleep, Stress and Mind-Body Medicine, Spirituality • Tools in Integrative Medicine: Integrative Medicine Intake and Care Plan Process, Botanicals, Mind-Body Medicine, Manual Medicine, Intro to Energy Medicine and Whole Systems, Practice Management, Motivational Interviewing for Behavioral Change • Pediatric Topics • Women’s Health Topics • Acute Care Topics • Chronic Illness • Special Topics: HIV, Cancer Survivorship, Environmental Medicine
We clinicians are also faculty in the HCMC Family Medicine Residency Training Program, which is based at Whittier Clinic. Residents participate in experiential learning sessions in Physician Wellness and Self-Care, e.g. meditation, yoga and breath-work. We intentionally teach core curriculum topics in an integrative way so that residents are learning about tools they can offer in addition to a standard allopathic approach. This curriculum prepares our residents to speak more comfortably with their patients about many of the cultural and traditional remedies that patients already use, enhancing their cultural intelligence, and therefore improving the patient experience. All residents spend time in our clinic observing a patient-centered, integrative approach to patient care. Our residency program has been part of a
The Journal of the Twin Cities Medical Society
pilot project which is a collaboration of eight Family Medicine Residency Training Programs across the country since 2008. The Arizona Center for Integrative Medicine (AZCIM) initiated the development, evaluation and coordination of this project; implementation of the curriculum happens at each of the eight sites. Each resident is required to go through an online curriculum, called Integrative Medicine in Residency (IMR). This IMR curriculum is a 200 hour competency-based, online and onsite curriculum, designed to be incorporated into residency education. This curriculum is NOT alternative medicine; it has standard, evidence-based medicine integrated with the evidence-based nutrition, herbs, mind-body
(Continued on page 14)
May/June 2012
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Integrative Medicine Whittier Clinic (Continued from page 13)
and manipulative therapy knowledge that is available in the literature. There are ongoing papers and national presentations coming out of this pilot study, which models how this curriculum can be integrated into residency training. IMR was chosen in 2011 for the Most Innovative Curriculum Award by the Society for Teachers in Family Medicine. The IMR project is helping to attract highly qualified medical students to our residency program. We have embedded required study of the IMR modules into their rotations, so that this knowledge complements what they are learning in their clinical/hospital experience and it will become routine to think more expansively. Completion of the IMR curriculum and passing the final test earns a certificate of completion from the IMR. Because of their exposure to the integrative clinic, curriculum and philosophy and the IMR curriculum, we expect residents will carry this approach into their practices to varying
degrees, depending on their individual interests and priorities. While I wish I could say that all our residents are transformed into integrativeminded, patient-centered family doctors, I know we have a lot more work to do to reach that goal. We have been preparing the soil and planting the seeds, which will sprout and grow in their own time, in each family doctor we train. Each year shows more progress in this direction. This year, one of our residents, Dr. Anshul Gupta, will be piloting a track using elective time to focus more on his interests in Integrative Health. We hope that others will follow his lead. In summary, our integrative primary care practice at HCMC Whittier Clinic is providing a model for our residents, as well as our colleagues, staff and administrators. New patients keep coming. We are learning from the success stories, as well as the challenges. Many of the clinic staff receive care in our Integrative Health Clinic and refer their friends and family members. Residents and faculty are curious and asking “what else” they can do for their
patients, in addition to the standard medicine that they already practice. We recognize that standard allopathic medicine is excellent in certain areas and is limited in others, e.g. for primary prevention, some chronic illness syndromes and many of the more emotional, stress related issues. Having more tools gives us more options to try, and helps our patients feel better about their care. As our program continues to grow, we have established a clear demand for integrative primary care in the Twin Cities metropolitan area. Selma Sroka M.D. received her medical degree at the University of Minnesota in 1991. She did her family medicine residency training at Hennepin County Medical Center from 19911994. Dr. Sroka was certified by the American Board of Holistic Medicine in 2000 and completed the Fellowship in Integrative Medicine with the Arizona Center for Integrative Medicine in December 2009.
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The Journal of the Twin Cities Medical Society
More Skills—Less Pills
for Kids With Developmental and Behavioral Challenges
W
e live in a time when childhood normalcy in the United States is being redefined almost daily. The diagnosis of ADHD has risen dramatically, from 250,000 in 1975 to four million today. Autism diagnoses have increased 10 times since the 1980s. And childhood depression has become an epidemic. How has the medical field responded? Often — and increasingly so — with medication. Prescriptions for ADHD grew an astounding 369 percent from 2000 to 2003. The use of antipsychotics in children is up five fold from 1993 to 2002, and the use of antidepressants in children up to age five increased 21 percent in three years. Little data exists for efficacy of outside stimulants and the longterm safety of pediatric psychopharmacology, and the neurological and hormonal impact is mostly unknown. And yet alternatives that are quite safe and that benefit children exist — alternatives that are increasingly being sought by parents and children. The use of psychotropic medication is necessary for some children, but often its use can By Timothy Culbert, M.D., FAAP
MetroDoctors
be minimized by optimizing lifestyle factors, including sleep, exercise, nutrition, sleep and stress management, while using selected complementary and alternative medical therapies. Many parents, teens and children want natural, gentle approaches that include learning more self-care skills and taking fewer pills. Ridgeview Specialty Clinic–Pediatric Integrative Medicine does just that. Opened in March 2011 at the new Two Twelve Medical Center in Chaska, the innovative clinic offers conventional assessment and treatment services for children and teens with ADHD, learning disabilities, depression, anxiety, sleep disorders, autism spectrum disorders and chronic pain, as well as the best in complementary, non-drug strategies including biofeedback, meditation, acupuncture, massage, aromatherapy and nutritional interventions. Pediatric integrative medicine draws on a variety of healing traditions, blending the best of conventional and complementary therapies in a personalized plan that best fits each child and family. Providers consider a child’s health from a holistic perspective — whether it is prevention, concerns of general wellness, or care for complex, ongoing illness — and embraces a philosophy of pediatric care involving partnership of patients, families, health care practitioners and community services. The integrative medicine program offers innovative, holistic care for the whole child — mind, body and spirit. Under the direction of board-certified developmental/behavioral pediatric physician Timothy Culbert, M.D., FAAP, the clinic’s staff includes two licensed psychologists, a licensed teacher, pediatric nurse practitioner and a massage and energy therapist; the clinic will soon add an aromatherapy specialist and certified acupuncturist. Staff works in partnership with
The Journal of the Twin Cities Medical Society
parents, counselors and physicians to help children identify and cultivate their own natural healing abilities while actively participating in their recovery and health maintenance. Members of the IM team are conventionally trained and certified (physician, psychologists, and nurse practitioner) but have had extensive additional training in a variety of holistic, complementary therapies. Options include holistic assessment — by either a single provider or an interdisciplinary team, personalized information/resource consultation, and individual or multimodality treatment approaches, including: • Academic therapy and organizational skills coaching • Acupuncture and acupressure • ADHD Quotient computerized evaluation • Aromatherapy • Biofeedback • Psycho-educational testing and evaluation • Healing touch and Reiki • Herbals and botanicals consultation • Nutritional interventions • Massage therapy • Medication consultation for ADHD • Psychotherapy (individual and family) • Relaxation and mental imagery • Self-regulation skills training In terms of research, reviewing all the CAM research is well beyond the scope of this article, but increasingly there are many excellent studies on the pediatric application of CAM therapies that demonstrate a very favorable “risk to benefit” ratio for therapies such as massage, acupuncture, vitamins, biofeedback and imagery, to name a few.
(Continued on page 16)
May/June 2012
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Integrative Medicine More Skills — Less Pills (Continued from page 15)
Case Study
Will is a 15-year-old male with anxiety, insomnia and irritable bowel syndrome (IBS; people who have IBS commonly get stomach pain and urgent loose stools in response to stress and food sensitivity). Will did not like the idea of using prescription medications that had been offered to manage his symptoms and wondered about more natural treatment options. Over a 12-week time frame with one visit every two weeks to the Integrative Medicine clinic, Will was able to put together a treatment for addressing his core symptoms that allowed him to return to regular daily function at school and with friends, with much-improved sleep, minimal anxiety and almost complete resolution of his IBS symptoms. His plan included: For sleep: Establishment of effective sleep rituals, melatonin 3 mg prior to bedtime, 15 minutes each morning of light therapy and inhaling essential oil of lavender prior to bedtime to help calm himself down, done with some pleasant mental imagery. For IBS: Will completed food sensitivity testing, eliminated dairy products from his diet, added probiotic and peppermint oil capsules to his daily regimen, and learned effective anxiety management techniques. For anxiety: Will learned biofeedback-based relaxation techniques where he could control anxiety and nervous system balance across the day by using regular breathing, meditation and mental imagery techniques with consistency. He also started basic vitamins to help
with “healthy neurochemistry” that included Omega-3 fatty acids, B-complex, magnesium and inositol. He tried massage therapy as well. ADHD Quotient Testing
The only clinic in Minnesota with this system, the clinic offers the 20-minute computerized neuropsychological screening tool that assesses the core elements of ADHD: impulsivity, inattention and hyperactivity. The test is available to aid in screening patients ages six years and up for ADHD and can also be helpful in evaluating the efficacy of psychiatric medications for ADHD. Academic Therapy
The clinic offers academic therapy with oneon-one tutoring/coaching sessions to encourage academic success and confidence in the classroom. A customized lesson plan will be designed by a licensed teacher. Free, 30-minute consultations are available. Massage Therapy
A CPMT (Certified Pediatric Massage Therapist) has received specific advanced training to enhance skills in providing pediatric massage therapy. A CPMT has knowledge of massage techniques for working with children with various physical, developmental, emotional and mental challenges. Massage is also available for parents. Children benefit from pediatric massage in a number of ways. The following benefits have been documented: • Improved muscle tone • Improved joint mobility • Improved respiratory function • Improved sleep patterns • Improved gastrointestinal function • Reduced anxiety • Better sleep • Reduction in pain symptoms Self-Care Skills Training
• Call for Resolutions • Attend the TCMS Caucus • Serve as a Delegate at the MMA Annual Meeting See details on page 29
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May/June 2012
All staff at Pediatric Integrative Medicine are extensively trained in a variety of special techniques that are utilized for teaching all patients “self-care” skills so they can become more active participants in their own health, wellness, symptom management or recovery from illness. This training is presented in a playful, interactive format that is developmentally appropriate for each child/teen. These include non-drug, holistic tools and techniques they practice and
apply in real life to help manage troublesome symptoms like anger, anxiety, insomnia, pain, nausea, fatigue and so on. Skills can include mind-body techniques such as biofeedback, relaxation, mental imagery, breathing and meditation; the use of essential oils (aromatherapy); stimulation of acupressure points; creative arts therapies (music, drawing, movement); journaling and even sharing iPad mobile apps that have therapeutic benefits. Pediatric Wellness Retail Products
In addition, the clinic offers a variety of kidfriendly retail vitamins/supplements that parents, families and those involved in the patient’s care may find useful. The clinic, a nonprofit that doesn’t offer retail to make money, has researched what the best, safest and most appropriate products are for kids (as opposed to adult products) and offers them as a service to families so they don’t have to drive all over the metro area trying to find an appropriate product. The clinic offers relaxation CDs, books, biofeedback devices, supplements, therapeutic toys, aromatherapy oils and other healthsupporting products. A product list is available online. The clinic is located in Suite 470 at Two Twelve Medical Center, 111 Hundertmark Road, Chaska. For more information, call (952) 361-2476 or visit www.ridgeviewclinics.org. Timothy Culbert, M.D., FAAP, is a board-certified developmental/behavioral pediatric physician and practices at Ridgeview Specialty ClinicPediatric Integrative Medicine. He is assistant professor of Clinical Pediatrics at the University of Minnesota; adjunct professor at the Center for Spirituality and Healing at the University of Minnesota. Dr. Culbert is certified in developmental/ behavioral pediatrics, biofeedback, medical hypnosis and holistic medicine. He has additional training in interventional nutrition and Reiki. Practicing since 1992, Dr. Culbert is a graduate of the University of Minnesota Medical School, completed his internship and residency in pediatrics at the University of Vermont, and a fellowship in developmental/behavioral pediatrics at the University of Minnesota.
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The Journal of the Twin Cities Medical Society
Integrative Solutions for Chronic Pain
T
he Minnesota Head and Neck Pain Clinic has spent the last 27 years developing an interdisciplinary and integrative model for the diagnosis and management of patients with many types of hard-to-treat chronic pain. Recognized nationally among pain clinics, and adhering to the principles that the American Pain Society designates for Centers of Excellence in pain management, our team of professionals offers a patient-centered, mind-body approach to care. Our patients suffer with a variety of complex pain conditions that have not improved significantly after standard treatments, including • Temporomandibular disorders (TMD) • Jaw and facial pain • Tooth pain, neuropathic and neuralgia pain • Oral medicine conditions (including lesions, xerostomia and burning mouth) • Dental sleep medicine • Chronic headaches • Migraine headaches • Tension type headaches • Cervical degeneration disorders • Fibromyalgia syndrome (including widespread pain) and • Psychophysiological reactions to injury or illness that interfere with recovery We have a diverse clinical staff. We have seven dentists who all have postgraduate specialty training in TMD and orofacial pain. We have two physicians who practice integrative pain medicine from the vantage point of neurology and physical medicine and rehabilitation (physiatry). We also have a nurse practitioner specializing in pain medicine. Our three By Mark B. Weisberg, Ph.D., ABPP, Alfred L. Clavel, Jr., M.D., Cory herman, DDS, M.S., & Suzanne Candell, Ph.D. MetroDoctors
Suzanne Candell, Ph.D.
Alfred L. Clavel, Jr., M.D.
clinical health psychologists all have postgraduate specialty training in how physiological and psychological factors interact in the causation, maintenance and healing of chronic pain. And we also have four physical therapists, all of whom received advanced training in mindbody approaches to physical therapy treatment. But what makes our clinic effective is our shared belief in the power of the underlying tenets of integrative medicine. For example, we share a strongly held belief in the internal self-healing resources inherent in our patients. We believe that the best treatment is the least amount of intervention necessary to help stimulate a patient’s internal healing resources so they can optimally engage in self-healing. We share the belief that the therapeutic relationship between clinician and patient is a very powerful healing agent in its own right, and we pay close and constant attention to the quality of that relationship. We believe strongly in making the patient aware that they are an integral member of their healing team, and encourage them to be actively involved in every part of the treatment, from initial treatment planning to termination and relapse prevention several weeks or months down the road. Like many pain clinics, we combine traditional allopathic medical treatments with other complementary treatments. We certainly utilize
The Journal of the Twin Cities Medical Society
Cory Herman, DDS, M.S.
Mark B. Weisberg, Ph.D., ABPP
a wide variety of treatments at our clinic, from medications, physical therapy, and trigger point injections to acupuncture, clinical hypnosis and craniosacral therapy. Unlike most pain clinics, our approach to care derives from an understanding that pain is caused, maintained, and exacerbated by a combination of biologic, psychological, social and cultural influences. From this biospsychosocial perspective, the outdated organic versus psychogenic explanation is replaced by an understanding that chronic pain is a psychophysiological condition. This understanding is supported by recent breakthroughs in our understanding of pain mechanisms, such as central sensitization, wind-up, psychoneuroimmunology, and neuroplasticity and cortical reorganization. How do these breakthroughs form our treatment of patients? The literature on central sensitization, the exaggerated CNS pain perception from repeated or prolonged overstimulation of pain nerves, demonstrates the clinical importance of patient training in mindfulness, relaxation and self-hypnosis. The literature on neuroplasticity and cortical reorganization provides empirical support for our confidence in every patient’s inherent capacity to create physical change using the power of their minds. (Continued on page 18)
May/June 2012
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Integrative Medicine Chronic Pain (Continued from page 17)
Our approach to combining allopathic treatments and treatments derived from recent breakthroughs reflects our integrative orientation. For example, when a patient presents with jaw pain and severe muscle tightness, the physician or dentist might prescribe brief use of a muscle relaxant medication. However, the prescriber and the whole team emphasize that this medication is not something to be relied on for a long period of time. Rather, the medication is introduced as a “bridge” or a “reference point” so the patient can have the experience of what it feels like for their muscles to be a little more relaxed. Once they experience this, then they are taught a number of other techniques that they can use (e.g., stretching, exercise, improved sleep, breathing exercises, self-hypnosis, improved earlier self-awareness of tension) so that eventually they can reduce their own muscle tension with multiple skills and may no longer need the medication. This is an integrative approach to medication. Since a majority of chronic pain patients inadvertently maintain their pain by trying to cope by ignoring or distracting from it, our program emphasizes treatment approaches that help patients reconnect with their bodies’ sensations and signals. We ask questions such as “can you feel your jaws? Are they lax or tense?”. As patients expand their awareness of these signals, they use them to prompt use of pain relieving self-care strategies instead of waiting for the pain to be “loud enough” to get their attention. Awareness of these signals is critical to pacing the intensity of physical or postural exercises to optimize benefits and minimize flares, as well as to pace daily activities to prevent the vicious cycle of overdoing it then crashing due to a pain flare. As patients become skilled at using the body’s signals to guide self-care and pacing, they gain more control over their lives. We are used to seeing very complex patients with multiple symptomatic complaints at our clinic. The patients referred to us have typically been to anywhere from three to eight other well-intentioned doctors or clinics before they reach our door. Not uncommonly, patients are distressed and discouraged by the lack of relief from, and cost of, ineffective drug regimens, surgical procedures, nerve blocks, implantable devices, and other interventions that they have 18
May/June 2012
tried. As part of this unfortunate pattern, some patients with chronic pain experience drug dependency, multiple surgeries, high stress levels, and serious disruptions in their relationships and lifestyles. Many of them have come to feel hopeless, and are skeptical that their condition could ever improve. Although occasionally we see a patient who has straightforward, simple TMD or tension headache, a typical patient might present with tension and migraine headache, TMD, ear pain and tinnitus (ringing in the ears), fatigue and insomnia, irritable bowel syndrome, and depression. We follow a coordinated approach. When a patient comes to our clinic, they usually see all the members of the treatment team (dentist, clinical health psychologist, physician, physical therapist and nurse practitioner). After all the team members have met with the patient (and often with a family member), we have the opportunity to confer with each other, share our clinical observations and opinions, and discuss formation of a treatment plan that is tailored to the particular needs of the patient. Each treatment plan is as individualized as a fingerprint, reflecting the uniqueness of each and every patient we see. Sometimes this communication happens informally, conferencing with each other for five minutes between appointments. At other times we will conference formally at what is called a synthesis meeting. At these meetings, the entire team will meet along with the patient and at least one family member, to discuss our impressions, diagnoses, and treatment plans. The patient is an active participant in this conversation. Through this process, we insure that the patient feels ownership early on in his or her own treatment. They are a crucial member, a central partner on their healing team. Close communication between patient and all clinicians is encouraged throughout the treatment process. We are fortunate in this setting because all of us are just a few yards apart from each other, and potentially always available for a quick consult when someone is stumped, confused, concerned, or just needs a second expert opinion on a particularly complicated clinical issue. This allows for constant monitoring of progress. MHNPC is a group of specialized physicians, nurse clinicians, dentists, clinical health psychologists and physical therapists skilled
in treating the spectrum of chronic pain. We are dedicated to using whatever amount and type of treatment necessary to stimulate every patients’ self-healing capacities, meeting the demand for integrative approaches to treating chronic head and neck pain. Suzanne Candell, Ph.D., L.P. is a clinical health psychologist at the Minnesota Head and Neck Pain Clinic, and in private practice in Minneapolis, MN. She has a special interest in addressing the particular needs of patients with chronic illness who also have a history of psychological trauma. Dr. Candell is an approved consultant in Clinical Hypnosis through the American Society of Clinical Hypnosis. Alfred L. Clavel, Jr., M.D. is a neurologist. He is board certified by the American Academy of Neurology and Psychiatry with subspecialty certification in pain medicine by the American Board of Pain Medicine. He is past-president of the Minnesota Society of Clinical Hypnosis. He served as medical director of the Hennepin County Medical Center Pain Program from 1993-2006. Dr. Clavel teaches and trains health professionals nationally on topics related to psychoneuroimmunology, headache, chronic pain and the integration of hypnosis and mind-body medicine with traditional medicine. Cory Herman, DDS, M.S. earned his DDS from the University of Minnesota and completed advanced education clinical training in orofacial pain and temporomandibular disorders with an MS in Dentistry. He is board certified by the American Board of Orofacial Pain and is a fellow of the Academy of Orofacial Pain. Dr. Herman is also a clinical assistant professor at the University of Minnesota TMJ and Orofacial Pain Clinic. He is active with the American Academy of Orofacial Pain and the American Headache Society. Mark B. Weisberg, Ph.D., ABPP is a board certified Clinical Health Psychologist in Minneapolis, Minnesota. He is adjunct community faculty, Academic Health Center, University of Minnesota. Dr. Weisberg is a fellow of the American Psychological Association, American Society of Clinical Hypnosis, and American Academy of Clinical Health Psychology. He has been involved in clinical practice and consultation in integrative mind-body medicine for over 20 years, and lectures on this topic nationally and internationally.
MetroDoctors
The Journal of the Twin Cities Medical Society
Broadening the Practice Perspective in Women’s Health Care: A Comprehensive Integrative Model for Women
W
omen’s Health Specialists Clinic may be the first in the state to offer women an integrative comprehensive clinical model of care within the foundation services of obstetrics and gynecology in an academic and research setting. The clinic name was recently changed from University Specialists in Women’s Health to Women’s Health Specialists Clinic (WHSC) and the number of providers and specialties has also expanded. It now includes a diverse staff of OB/GYN physicians, midwives, primary care physicians, advanced practice nurses, psychological services and pharmacy consultations, and offers acupuncture, functional nutrition and health coaching. The cornerstone of the clinic continues to serve a diverse obstetric and gynecological community and with the expansion of primary care physicians, it will be able to provide comprehensive care and address complex health issues for women of all ages. WHSC is located in the Riverside Professional Building alongside the University of Minnesota Medical Center and Amplatz Children’s Hospital, on the University’s West Bank. It is at the geographic center of a vibrant academic, research and health care community and provides women with a clinically based collaborative model of care that offers conventional medical providers trained in integrative health and a licensed acupuncturist, functional nutritionist and health coach. While these clinical offerings have been available across the U of M campus as a component of other clinics, offering women all options in one location is convenient, efficient, and patient-centered. The integrative health practice model puts
By Diana Drake M.S.N., WhNP, and Carolyn Torkelson, M.D., M.S. MetroDoctors
From left: Carolyn Torkelson M.D., medical director, Integrative Health; Carrie Terrell M.D., medical director, Women's Health Specialists Clinic; Ann Forster Page, MS, CNM, director, Certified Nurse-Midwife Service; and Diana Drake, MSN, WHNP, program director, Women's Integrative Health.
the patient at the center of care and addresses whole patient needs with a focus on optimal health and disease prevention throughout the lifespan. In the integrative health model, the best of conventional medicine is combined with evidence-based complementary and alternative therapies. Broadening the practice perspective to include integrative health care along with specialties outside of the traditional OB/GYN realm provides an option for patients to continue to receive their health care at the women’s clinic throughout their lifetime. Clinic renovations and redecorating have set the stage for the change, but an actual shift in a clinic model of care is deeper and can be challenging to define. In a 2009 issue of Minnesota Medicine, Carolyn Torkelson M.D. and Bill Manahan M.D. described integrative medicine: Integrative medicine is a healing approach to medicine that looks at the whole
The Journal of the Twin Cities Medical Society
person — body, mind and spirit — and uses appropriate therapies, both conventional and alternative, to improve the health of an individual. It addresses the fundamentals of lifestyle and self-care and emphasizes a therapeutic relationship between patient and practitioner. Looking through the lens of the practicing provider, questions arise as to how a shift to an integrative practice model changes the exam procedure, the length of visits and the billing. While these are important and practical questions to answer, ultimately the shift in integrative medicine is less about new treatments, physical space, or scheduling systems and more about a different way of being with the patient.
(Continued on page 20)
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Integrative Medicine Women’s Health Care (Continued from page 19)
Creating a healing environment for patients to receive care is one component of an integrative care model and not to be minimized. The newly renovated women’s health clinic is done in the soft earth tones of greens, rusts and brown. Textures and colors found in nature are reflected in the etched glass, curved walls and global artwork in the waiting room that hums quietly with the sounds of women’s voices in several languages and a diversely rich representation of the urban and metro area are waiting to be seen. More importantly, not all of the exam rooms have stirrups and sterile gloves. Some of the patient rooms are individualized for acupuncture and massage, there are aromatherapy bottles of essential oils that are used for medicinal purposes, a quiet room for meditation and yoga and spaces where a patient can be at ease; here a provider can quietly lean in and listen as a female patient comfortably tells her unique story. For patients, the change in practice model and the availability of diverse treatments and
providers offers continuity of care and increased accessibility to alternative and complementary therapies that are integrated into regular clinic visits. From office surgery and mammograms to biofeedback and acupuncture; whether the patient is newly pregnant, planning a water birth and non-pharmaceutical treatment for nausea or an older woman concerned about bone health and managing her aging, the integrative practice model at Women’s Health Specialists seeks to meet those needs. A change in clinic practice doesn’t happen overnight and several key women’s health providers worked as change agents for years to create a shift within the University of Minnesota Physicians at Fairview. Seeking a whole systems change, the Women’s Health Specialists Clinic was created to meet the growing consumer need in women’s health care that is driven by aging demographics, an increase in use of complementary and alternative care and an emphasis on prevention and healthy lifestyles. It was also driven by the passion of a group of providers to practice in the integrative model of care that is patient centered and uses
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a multidisciplinary team approach inclusive of a wider array of therapeutic solutions. Dr. Carrie Terrell, OB/GYN, medical director of Women’s Health Specialists and chief of staff, University of Minnesota Medical Center, Fairview, has been instrumental in bringing the integrative model of care into clinical practice reality. Dr. Terrell states “Those of us in OB/GYN realize that caring for women is beyond a medical diagnosis and we have always considered social situations, belief systems and life struggles in our approach to the patient. The integrative practice model improves our resources and tools so that our practice can expand and ultimately, our patients have better outcomes and satisfaction with their care.” Dr. Terrell also has a personal interest in yoga, Ayurvedic therapies and the role the environment plays in health and healing. Most of the clinic providers at WHSC are also on faculty at the University of Minnesota Medical School and School of Nursing. Teaching and mentoring future physicians and health care providers is central to the clinic’s mission. OB/GYN residents, Nurse-Midwife students, Women’s Health Nurse Practitioner students and medical students train regularly with the clinic providers. Ann Forster Page, certified nurse-midwife and director of Nurse-Midwife Services at the University of Minnesota Medical Center leads a bustling nurse-midwife service. She explains “An integrative, comprehensive model of care is the ideal of nurse-midwifery philosophy, and we have always recognized the benefits of evidence-based alternative and complementary therapies, such as a water tub for labor and birth, and aromatherapy in labor. Now, we can offer the services patients sought elsewhere, in the next exam room of our collaborative practice. We’ll broaden our understanding and use of integrative health modalities while working side-by-side with those providers.” Clinical research is a part of the practice environment and it is not unusual for the clinic to be involved in multiple studies. Currently there is research being conducted on the effects of common chemicals on the health and development of infants in The Infant Development and Environmental Study (TIDES). A nursing doctorate student is evaluating women’s access to integrative health care and clinicians are participating in a study on the Quality of
MetroDoctors
The Journal of the Twin Cities Medical Society
Life Comparison of Women Who Experience Treatment-related and Spontaneous Menopause conducted by the University of Minnesota Breast Center. A research study on vulvodynia is underway and WHSC is an international site for the Control of Hypertension in Pregnancy Study (CHIPS). All of these research projects are (broad based) focused on a whole systems approach that links environmental factors, social and psychological factors and the female patient’s personal experience, which is at the center of integrative care. For Carolyn Torkelson, M.D., who is now the medical director of Integrative Health and a family medicine physician at the clinic, “… the opportunity to bridge conventional medicine with complementary and alternative care is what I provide for my patients. Listening and facilitating a patient’s transformation to optimal health is the goal.” Trained in botanical and functional medicine and certified with the American Board of Integrated Holistic Medicine since 2000, she is a pioneer in bringing together practitioners interested in prevention, wellness and exploring healing approaches. For Diana Drake, WHNP, program director of Women’s Integrative Health at WHSC and faculty member of the University of Minnesota School of Nursing, the opportunity to collaborate with like-minded providers in women centered integrative care is a gift to patients and providers alike. “The focus of integrative health care is neither the practitioner nor the medical system, it’s really the patient. Keeping that in mind while building an integrative health home for women at WHSC has guided both my personal practice and our collaborative efforts to create the clinic.” At WHSC, scheduling and billing follows conventional practice guidelines and the individual practitioner determines patient appointment times. Visits to see the alternative and complementary providers for acupuncture, nutritional counseling and health coaching are currently an out-of-pocket expense, however patients can often use their flexible health accounts/health saving accounts for these services. Some of the services are available through a sliding fee program based on income. Patients can see specialty trained integrative providers, Dr. Carolyn Torkelson, M.D. and Diana Drake, WHNP for a wide variety of health care issues that are typically covered under insurance MetroDoctors
plans. Future plans include offering some of the integrative services as group sessions to decrease costs to patients and obtaining insurance coverage for providers not currently covered. A new year, a new name, renovated facilities and a new practice model, Women’s Health Specialists Clinic is broadening its practice perspective to a comprehensive model of integrative health care. Efforts to meet the needs of the female patient and changing health care trends have been influencing factors in the changes at WHSC and they predict that having multiple offerings under one roof can provide safer management, cost-effective collaboration and an increase in readily available therapeutic solutions for their patients. Further information is available at the Women’s Health Specialist website: http:// www.umphysicians.org/Clinics/womenshealth-specialists/specialty-services/integrativeservices/index.htm. Diana Drake is program director of Women’s Integrative Health at the Women’s Health Specialists
The Journal of the Twin Cities Medical Society
Clinic at the University of Minnesota, Fairview and on faculty at the University of Minnesota School of Nursing and the Center for Spirituality and Healing. Ms. Drake is a specialist in women’s health and focuses on an integrative health care approach in her clinical practice and as an educator. Carolyn Torkelson, M.D., is medical director of Integrative Health at the Women’s Health Specialists Clinic at the University of Minnesota, Fairview, assistant professor in the Department of Family Medicine and Community Health and faculty at the Center for Spirituality and Healing. Her clinical practice offers integrative care to women with multiple health concerns, providing services at both Women’s Health Specialists and the Breast Center. Dr. Torkelson is active in clinical research and is Co-PI on studies involving herbal and nutritional interventions and has authored a number of papers. She teaches a medical student course on Integrative Healing and co-chairs the Minnesota holistic physician group.
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Finding a Place for an Integrative Approach Allina’s Penny George Institute for health and healing
W
hat most strikes people when they arrive at the Penny George Institute for Health and Healing (the George Institute) is how still it is. This level of stillness doesn’t fit with the labyrinthine bustle of bricks, mortar and technology surrounding it on the medical corner that is 28th and Chicago. It does, however, invite a sigh of relief for many of the patients who come here seeking answers, often at what they hope will be the end of a long and frustrating journey through an illness. Patients come through the doors of the George Institute, primarily through physician referrals, to augment their conventional care and, at times, when they feel they have exhausted the resources conventional care has to offer. Over the last decade, the George Institute has established a reputation for providing comprehensive integrative approaches for patients with a wide variety of health issues. The George Institute began with what is now the nation’s largest hospital-based integrative health and medicine program. Since July 2004, the Abbott-Northwestern (ANW) inpatient team has provided over 75,000 inpatient visits and built relationships with a network of physicians, surgeons, specialists and nursing staff. Since July 2006, building on this reputation and with the expertise of a well trained team of integrative clinicians, the ANW outpatient team has logged over 45,000 visits in the quiet space on the ANW campus. Disciplines represented within the clinic include interventional nutrition, traditional Chinese medicine, spiritual counseling, massage and bodywork, clinical psychology, mindfulness approaches, holistic psychiatry, and biofeedback. Additionally, the clinic often refers patients to the exercise physiologists and health coaches at By Jennifer Blair, L.Ac, Ma.O.M. MetroDoctors
Allina’s LiveWell Fitness Center and many of these disciplines are incorporated within Dr. Henry Emmon’s, eight week Resilience Training™ program for chronic depression. Time to Listen Closely
The stillness of the physical environment, although a subtle attribute, is not insignificant to the healing process promoted at the George Institute. It reflects an atmosphere that is dedicated to listening on many levels. Appointments are scheduled to accommodate the one thing both providers and patients crave most in the health care system; time to listen. We believe that an environment that fosters deep listening from provider to provider and from provider to patient will foster that same ability within the patient. Self-reflective listening directed toward one’s own healing can be powerful medicine. Success often follows from the “A-ha” moment when the patient recognizes, and then activates, his/her own internal healing resources. In our experience, this shift results in sustainable improvements in diet, exercise, and coping. A Team Approach
Like so many clinics, we value a team approach to health care. Collaborations occur both by design and spontaneously. We clinicians intentionally gather weekly to develop collaborative approaches to patient care and discuss the challenges and successes of our cases. Patients benefit from enhanced care plans. Everyone benefits from continued learning and celebrations of successes. Our goal is to individualize patient care to best address the person’s unique conditions, needs, and circumstances. A recent and relatively straightforward case history outlines the value of teamwork and of the kind of intake that addresses the whole person — mind body
The Journal of the Twin Cities Medical Society
and spirit — as we consider all the factors that influence optimal health. Sue is a 51 year-old woman referred to our clinic by her primary physician in January 2012. Her chief complaints included urinary incontinence, frequent and urgent bowel incontinence with diarrhea, recurrent bowel and urinary tract infections, kidney stones, depressed mood, and progressive cognitive dysfunction. Her professional work routinely required public speaking engagements and the ability to process information at a high level on behalf of clients. As her cognitive function deteriorated and bouts of incontinence increased, she was forced to take disability leave and her family was considering having her placed in a group home. She was diagnosed with diarrhea-predominant IBS in 1998, following a particularly stressful period in her work life and with an enteroinvasive E. coli 0164 infection in 2007. Following treatment, she suffered from recurrent C. difficile infections, urinary tract infections, asthma attacks, plus sinus, skin, and tooth infections that required antibiotic therapy. She was treated for recurrent intestinal and urinary bladder infections with antibiotics and had subsequently suffered from an increase in bowel and urinary incontinence. She was scheduled for an Interstim placement surgery, but could not do so until she cleared her UTI. However, after four years of recurrent C. diff infection, she was afraid to pursue antibiotic therapy again. Holistic nutritionist, Catherine Bogolub, M.D., first saw her. Dr. Bogolub recognized her significant fear as well as her history of PTSD and saw the relevance of these emotional states to her physical condition. She recommended (Continued on page 24)
May/June 2012
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Integrative Medicine Allina’s Penny George Institute (Continued from page 23)
an elimination diet to identify possible food intolerances and sensitivities that might be contributing to her susceptibility to recurrent infections. Her reasoning: a simple change in diet often provides invaluable information on the etiology of intractable gut issues. Dr. Bogolub placed her on supportive supplements, including probiotics, to optimize nutrient absorption and intestinal ecology. She then referred her for acupuncture both for pain relief and to help support emotional wellbeing. Acupuncturist Bob Decker, LAc, RPh, saw her for back pain and bladder pain worsened with stress. Examination included tongue and pulse diagnostics according to the traditional Chinese medical paradigm. Sue’s diagnostic pattern indicated “damp heat in the lower burner.” The treatment principle to “drain damp and clear heat” indicated using specific acupuncture point prescriptions and medical Qigong. He noted that she felt qi moving during the session and was very relaxed at the end of the session. I, as a licensed acupuncturist, identified
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Eight Righteous Teapills, a traditional multiherb formula for her urinary symptoms, which matched the diagnosed pattern. This combination of nine herbs works synergistically to clear heat, drain dampness, promote urination and dissolve stones. Several of the herbs have documented antimicrobial effect. With the simple addition of targeted supplements and following an initial elimination of citrus, gluten, eggs, dairy, corn, peanuts and nightshades in her diet, Sue experienced significant relief from her diarrhea and incontinence, to the point where she felt comfortable leaving the house for the first time in over a year. With acupuncture, she experienced relief from her back and bladder pain and freedom from her ongoing and debilitating stress response. By the time she saw Gregory Plotnikoff , M.D. in March, her health was much improved and her urinalysis had cleared. After four weeks of the above treatments, she had only one episode of diarrhea, her aches and pains melted away, her concentration improved, and her energy levels increased significantly. Her PHQ9 (Patient Health Questionnaire-diagnostic depression instrument) decreased from 13 to 7, with equally significant improvements in her PIRS-20 (Pittsburgh Insomnia Rating Scale), Brief Pain Inventory and Brief Fatigue Inventory. In pursuit of further gains, he ordered specialized testing to identify reversible factors relevant to her ability to regain her full and robust health. The highly individualized program resulting from the team effort enabled Sue to recover from severe demoralization and experience significant improvements in multiple quantifiable dimensions. She stated that the combination of therapies had improved her cognitive abilities to the point where her family no longer felt compelled to recommend assisted living for her. She is looking forward to returning to work. She wrote: “My back pain and stiffness really improves with every acupuncture treatment. I didn’t realize just how sore and stiff I was until I got relief from the acupuncture.” She emphasized that, “It is a huge lift to my spirits to be able to leave the house feeling secure that I won’t have diarrhea in my diapers while I am away. This confidence has enabled me to feel more comfortable going shopping, being social, etc. I am really grateful for this improvement! Thank you!”
As illustrated in this case, an individualized, collaborative approach that addresses the complex connections between physical and emotional wellbeing, asks new questions, and considers adjunctive therapies, affords patients the opportunity to achieve a level of wellness that goes beyond symptom management. The George Institute is also committed to advancing care through research. To capture the story behind our patient’s stories, we seek the best metrics to measure the successes our patients report. Today, the George Institute has multiple clinical trials and pilot studies underway. Research Director Jeffery Dusek, Ph.D., is a member of numerous NIH study sections and our providers are publishing and presenting research to national audiences. The George Institute supports patient care across all areas of specialty. In April, 2012, in response to burgeoning demand for integrative services system wide, Allina Health established the George Institute as a supportive Clinical Service Line. With the appointment of preventive cardiologist Courtney Baechler, M.D., as a vice-president for this service line, Allina will bring this model of care and the services across the Allina system. In 2012, the George Institute is, ever so quietly, on the move. Jennifer Blair L.Ac., Ma.O.M. Jennifer holds a Masters degree in Oriental Medicine from the Minnesota College of Acupuncture and Oriental Medicine at Northwestern Health Sciences University. She is NCCAOM certified in Acupuncture and Chinese Herbology, and holds a BA from the University of Wisconsin, Madison. She also holds a Certificate in Therapeutic Coaching from the Meta Institute and is trained in NLP, hypnosis, guided imagery and qi gong. In addition to her work at Abbott, Jennifer serves on the adjunct faculty at the Minnesota College of Acupuncture and Oriental Medicine at Northwestern Health Sciences University. She is an active member of the Acupuncture and O.M. community in the Twin Cities and has served as legislative chair and vice president for the Acupuncture and Oriental Medicine Association of Minnesota.
MetroDoctors
The Journal of the Twin Cities Medical Society
Partnering to Provide a New Model of Integrative Health Care
T
ucked away in the Powderhorn community of Minneapolis is a littleknown clinic that’s changing the way people think about health care. Every Wednesday and Saturday, students studying chiropractic, massage therapy, acupuncture and Oriental medicine, psychology, and health coaching team up with nursing and medical students to provide free integrative health care to residents of one of the poorest neighborhoods in south Minneapolis. Since 2007, the Pillsbury House Integrated Health Clinic has combined complementary and alternative medicine with traditional medical care to serve the unique health needs of the neighboring community. The Pillsbury House Integrated Health Clinic is a collaborative effort between Northwestern Health Sciences University (NWHSU), the University of Minnesota Medical School, the School of Nursing, the Center for Spirituality and Healing, and the Adler Graduate School. It is the first studentrun integrated health clinic and operates in the Pillsbury House, located at 3501 Chicago Avenue South in Minneapolis. The idea for the clinic stemmed from a chance meeting at a medical conference between Michael Wiles, DC, MS, MEd, Northwestern Provost, and Carter Lebares, M.D., who was then a U of M medical student. The two envisioned a free clinic that would offer all treatment modalities, with health care providers of all disciplines working together on care plans and treatment options. Pillsbury House Clinic patients are treated with a unique approach to health care that combines medical, psychological, and natural health care treatments. Under the supervision of faculty clinicians, students collaborate to By Michael r. Wiles, DC, MEd, MS MetroDoctors
provide a care plan tailored to each individual patient. The patients get the best of all the professions because the students aren’t competing — they are there to work together to help the patient. Best of all, the care is free and the clinic is open to the public. Providing care in this unique way is one of the clinic’s hallmarks. The care model was designed to benefit both the patient and the student. A patient first visits with a student who serves as a patient advocate and documents their health history. Then the patient visits with an integrated health care unit, an idea designed by the students, which may consist of a combination of one or more students from the acupuncture, chiropractic, massage therapy, psychology, nursing, or medical school. The clinic sees 50-70 patients each week. Many patients live in the surrounding community and have no health coverage. Others are self-employed or working in jobs that have no health benefits. Still others have health insurance, but it doesn’t cover or limits natural health care treatments. All of the students are volunteers, although their time at the clinic counts toward required clinical training hours. The Pillsbury Clinic provides a rich clinical learning experience, says Darcy Ward, Northwestern acupuncture student. “It’s a great experience. I love the diversity of the patient base. We meet as a team at the beginning of each appointment. It’s beneficial for all the students to see the outlook of the
The Journal of the Twin Cities Medical Society
others, and gain respect for the other modalities. It builds trust among the providers.” A swelling patient volume prompted a 2009 expansion of the clinic’s physical space, and over time, patient growth created a demand that was hard to keep up with. The team spent months last summer brainstorming how to enhance the patient experience. The clinic now offers scheduled appointments, instead of 100 percent walk-ins. Also, the clinic added hours on Monday evenings for acupuncture and massage therapy treatments, for patients who have already visited with a care team. Further enhancements were made with the help of a $5,000 grant from the Seward Community Fund to purchase new equipment and supplies. It is still not considered “mainstream” for providers from the allopathic and natural health care fields to join efforts in treating patients. “At Northwestern, we are pushing the boundaries to create new models of care,” says Mark (Continued on page 26)
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Integrative Medicine New Model of Integrative Health Care (Continued from page 25)
Zeigler, DC, president of Northwestern. “We are advocating for legislation that benefits the natural health professions. We are delivering the best natural health care education to ensure a new generation of providers.”
All the students involved at the Pillsbury House Integrated Health Clinic demonstrate a willingness to learn from one another in order to better treat the patients they see. This collaboration and the partnerships that support it are a sign of progress. Today’s health care consumers expect to have all treatments and
Students offer massage therapy to patients as supervisor Beth Burgan, assistant professor at NWHSU, looks on.
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health care options available to them. We hope that clinics like this will inspire others to work together to create new models of providing integrated health care. Dr. Michael Wiles graduated from the Canadian Memorial Chiropractic College (CMCC) in 1976. He also earned a Bachelor of Science from the University of Toronto, a Master of Education (Educational Administration) from Brock University, and a Master of Science (Medical Education Leadership) from the University of New England, College of Osteopathic Medicine. Following graduation as a chiropractor, he completed a residency program in chiropractic sciences and was awarded one of the first earned fellowships in the College of Chiropractic Sciences of Canada. He operated a busy urban multidisciplinary practice for 27 years. From 2005-2009, he served as dean of the College of Chiropractic at Northwestern Health Sciences University (NWHSU) in Bloomington, Minnesota. He is currently provost and vice-president for Academic Affairs at NWHSU.
MetroDoctors
The Journal of the Twin Cities Medical Society
What About the Integration of Naturopathic Medicine? Introduction
private integrative clinics. There are 31 registered NDs in Minnesota. Throughout our state, there are unlicensed practitioners called traditional naturopaths. Traditional naturopaths differ from NDs in that they do not complete the same education and do not have the same competencies as the ND.
Naturopathic doctors (ND) practice holistic medicine. Naturopathic approaches are intended to be reasonable, simple and thorough. Naturopathic philosophy emphasizes individualized, evidence-based treatments directed to support the innate healing capacity of the patient, address the cause of their disorder, enhance wellness, and prevent future illness. As members of an integrative team, they provide expertise in lifestyle medicine and applying Complementary and Alternative Medicine (CAM) with conventional approaches to health care.
Naturopathic Doctors
The Naturopathic Doctor’s Role in Integrative Departments
Northwestern Health Sciences University’s Natural Health Center (NHC) at the HealthEast Woodwinds campus in Woodbury, MN has several NDs on staff. There are no MDs or DOs at NHC. However, it is common for NDs at NHC and conventional practitioners in the HealthEast system to refer patients to each other. For example, NDs would refer a patient with a suspected condition that is not in his/her scope, such as cancer, to be evaluated and then treated. An MD or DO could refer a patient with rheumatoid arthritis or type 2 diabetes for co-management, or a patient with a condition that can be difficult to resolve with medications, like irritable bowel syndrome. The Providence Health Care System and Oregon Health Sciences University in Portland, OR employ NDs at their integrative medicine departments. NDs in these departments treat patients with a variety of problems including heart disease and endocrine disorders, and also provide adjunctive cancer care. The NDs are By Andrew Litchy, ND MetroDoctors
part of the Providence Health Care System; communication, referrals, and consultations are facilitated between providers. Patients at the Cancer Treatment Centers of America’s (CTCA) three campuses offer ND consultations as part of their treatment. NDs at CTCA consult with patients as part of a multi-disciplinary team. The team develops individualized treatment protocols based on the inputs of all members. NDs at CTCA are some of the few NDs that formally specialize, and are Fellows of the American Board of Naturopathic Oncology (FABNO). They contribute expertise in adjunctive oncology with botanical, nutraceutical, and nutritional interventions. All treatments are coordinated with conventional oncology and surgery, bodymind interventions, dietetics, and acupuncture. Naturopathic Practice in Minnesota
In Minnesota, naturopathic doctors are usually in solo private practices or see patients in
The Journal of the Twin Cities Medical Society
NDs complete four years of naturopathic school, which parallels conventional medical school curriculums: two years of basic and diagnostic sciences followed by two years of clinical studies. ND and MD students’ credit loads are nearly identical during the first two years of training. The second two years differ; ND students focus on primary care and do not complete clerkships. They complete clinical rotations and shadow practicing NDs. Naturopathic curricula are designed to prepare the ND for practice immediately after graduation. Graduates are trained to collaborate with physicians and appropriately refer conditions that fall outside their scope of practice. National standardized board exams, requirements for licensure or registration, are completed after the second and fourth year of training. Approximately 5 percent of NDs complete residencies or fellowships. The naturopathic community is actively working to increase these opportunities. NDs utilize nutrition, herbal medicine, mind/body training, lifestyle medicine, homeopathy, physical medicine including soft tissue modalities, minor surgery, counseling, and pharmaceuticals, including vaccines and scheduled medications. Other modalities, e.g. acupuncture, are utilized by NDs depending on their training. Concurrent training in (Continued on page 28)
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biomedical and CAM modalities develops the ND’s expertise in harmonious or problematic combinations and the respective strengths and limitations of various approaches. NDs treat common conditions presenting to primary care departments not limited to: asthma/allergies, diabetes, hypothyroidism, hypertension, anxiety/depression, musculoskeletal pain, and migraines. They also provide adjunctive care for problems such as cardiovascular diseases, cancer, and autoimmune disorders. There is a growing body of peer-reviewed literature examining the outcomes, practice patterns, and cost effectiveness of naturopathic care. Barriers to Full Integration
In the nine states where NDs have a full scope of practice and are credentialed providers, they frequently practice in institutional integrative and primary care clinics. This is not currently possible in Minnesota for several reasons. In 2008, Minnesota NDs became registered providers with a limited scope of practice excluding pharmaceuticals, minor surgery, and injected medications. These modalities are commonly indicated in primary care settings. NDs in Minnesota may bill as out-ofnetwork providers in commercial insurance plans, but are not credentialed providers. This limits their ability to be employed in commercial health care systems. Lack of insurance credentialing is perhaps the greatest barrier to NDs full integration into Minnesota’s health care systems. Conclusion
ND’s expertise in wellness, holistic approaches to commonly presenting concerns in primary care settings, and optimizing CAM with convention modalities make them assets. They can help synergize treatment choices, avoid deleterious or antithetical combinations of CAM with conventional medicine, and offer unique insights into diagnosis and treatment. The naturopathic doctor offers significant contributions to integrative and primary care settings. Andrew Litchy, ND is a naturopathic doctor who is registered in Minnesota and licensed in Oregon. Mr. Litchy has a private naturopathic practice in Minneapolis, MN.
MetroDoctors
The Journal of the Twin Cities Medical Society
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New Members Heidi M. Coplin, M.D. Allina Medical Clinic Internal Medicine
John D. Mischke, M.D. Associated Skin Care Specialists, P.A. Dermatology
Daniel P. Hoeffel, M.D. Summit Orthopedics, Ltd. Orthopedic Surgery
Kimberly C. Naruko-Stewart, M.D. Obstetrics, Gynecology & Infertility, P.A. Obstetrics and Gynecology
Christine C. Jensen, M.D. Colon & Rectal Surgery Associates Colon and Rectal Surgery
Jonathan C. Tallman, M.D. Northwest Family Physicians, P.A. Family Medicine
Nathaniel S. Kreykes, M.D. Pediatric Surgical Associates, Ltd. General Surgery, Pediatric Surgery
Basir U. Tareen, M.D. Metro Urology, P.A. Urology
Become Involved! Write a resolution, serve as a delegate, attend the MMA Annual Meeting Medicine is rapidly changing. Many powerful influences are impacting our practices. Change will come. It is vital for you to have a say in the future direction and shape of our health care system and our practices. Our patients depend on us to protect them from the worst of these changes and to assure that they have ready access to the best that medicine can offer. If we say nothing, others will decide. This is your opportunity to have your say! All members of the Twin Cities Medical Society are invited and encouraged to become engaged in setting the priorities and next year’s agenda for organized medicine. This is the time to indicate your interest to serve as a Delegate. Being a Delegate keeps you informed and it assures that your voice is heard. The process works like this: •
Call for Resolutions Due by Monday, May 21, e-mail to nbauer@metrodoctors.com Start thinking about issues that you would like to address through the MMA. What issues are important to you, your practice and your patients? Sample resolutions on TCMS website: www.metrodoctors.com. Click on In Action tab, then Caucus.
•
Attend the TCMS Caucuses: Monday, June 4, 2012, 6 p.m. Monday, September 10, 2012, 6 p.m. Broadway Ridge Building 3001 Broadway St. NE, Minneapolis, MN 55413
•
Attend MMA Annual Meeting, Minneapolis Marriott City Center Friday, September 14 and Saturday, September 15, 2012
For more information, contact Nancy Bauer at nbauer@metrodoctors.com or (612) 623-2893.
MetroDoctors
The Journal of the Twin Cities Medical Society
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To schedule a consultation, please contact Eric Garten, HealthStyle Services Consultant, at 612-362-0353 or email at eric.garten@ameripride.com 700 Industrial Blvd Minneapolis, MN 55413
May/June 2012
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In Memoriam LEONARD CROWLEY, M.D., age 86, passed away on February 5, 2012. Dr. Crowley was a pathologist for 40 years. He began a second career after retirement as a professor of biology at Century College. Dr. Crowley authored several textbooks on human disease. He became a member in 1961. JOHN FEE, M.D., passed away at the age of 92 on February 3, 2012. Dr. Fee received his medical degree from the University of Minnesota. He practiced as an internist opening a private practice in 1961 now known as the HealthEast Midway Clinic. Dr. Fee became a member in 1950. DONALD HERRICK, M.D., passed away on January 31, 2012 at the age of 81. Dr. Herrick received his medical degree from the University of Minnesota in 1955. He practiced ophthalmology in Minneapolis. Dr. Herrick became a member in 1962. DONALD F. HOLM, M.D., passed away at the age of 94. Dr. Holm graduated from the University of Minnesota Medical School in 1949. He was in general practice and later practiced radiology until retirement. Dr. Holm became a member in 1951. GEORGE MANN, M.D., passed away at the age of 88. Dr. Mann was the founder, executive director and medical director of St. Mary’s Hospital Chemical Dependency Programs. He authored numerous books on chemical dependency. Dr. Mann devoted much of his life to working with families and individuals affected by alcoholism and chemical dependency. Dr. Mann became a member in 1955. JOSEPH M. TAMBORINO, M.D., age 80, passed away January 31, 2012. Dr. Tamborino received his medical degree in 1956 at the University of Minnesota, and became board certified in orthopedic surgery in 1966. He served on the hospital staffs of Fairview Southdale and Methodist Hospitals. Dr. Tamborino became a member in 1964. V. RICHARD ZARLING, M.D., age 92, passed away on Febuary 17, 2012. Dr. Zarling practiced as a neurologist for several years in Minneapolis. He became a member in 1986.
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SAVE THE DATE! The 3rd annual Sharing the Experience: Honoring Choices Minnesota Conference will be held Thursday, July 19 in Minneapolis. Plan to attend and hear findings from local advance care planning programs and insights from guest speakers. Schedule to be released soon! CAREER OPPORTUNITIES
see additional Career opportunities on page 31.
Internal Medicine? Family Medicine?
Yup.
NEW clinic in Mahtomedi, MN? Internal and Family Medicine Opportunities Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services with locations in the St. Croix Valley, just east of the Twin Cities metro area.
Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education. For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com
We’ll make it all better.
MetroDoctors
The Journal of the Twin Cities Medical Society
CAREER OPPORTUNITIES
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MetroDoctors
The Journal of the Twin Cities Medical Society
May/June 2012
31
LuMInary of Twin Cities Medicine By Marvin S. Segal, M.D.
PauL g. quiE, M.D. The senior medical student entered the professor’s office 50 years ago to take his final pediatric clerkship examination. He introduced himself to Dr. Paul Quie, who efficiently began the exam by asking, “Please trace the movement of a two-year-old child’s drop of blood starting at the left ventricle.” The verbal journey of that blood drop took about an hour as there were many stops along the way: at the closed ductus arteriosus, at the liver while discussing bilirubin metabolism, visiting its precursors in the bone marrow, coursing through the renal arteries and later out of its veins, and at the spleen while speculating on the body’s defense mechanisms. It was a pleasantly instructive time that actually ended too soon with Dr. Quie ushering the student to the door, patting him gently on the back and saying, “Nice job, Doctor.” Paul Quie, M.D. was Minnesota born and farm reared. He attended college and medical school at St. Olaf and Yale respectively. His nearly 60 year tenure with the U of M began first as a resident — later holding staff appointments in pediatrics, laboratory medicine and microbiology. Along the way, he served for five years as chief of staff of the U of M Hospitals and Clinics and attained a prestigious Regents Professorship in 1991. Presently, he is the most senior physician on the medical school staff and holds positions of associate to the dean for Student Counseling and co-director (with former protégé Dr. Phillip Peterson) of the International Medical Education and Research Program. His awards and honors have been numerous and diverse — including those from his alma maters; the Academy of Pediatrics; the Infectious Disease Society of America; the University of Lund, Sweden and our own Hennepin Medical Society and Minnesota Medical Association. His acclaimed ground-breaking work on Chronic Granlomatous Disease received international recognition. Paul Quie’s leadership and Board positions in the following organizations provide a clue to his special interests and talents: the Infectious Disease Society of America; the National Institutes of Health; the National Academy of Science; the Minnesota Academy of Medicine; the American Federation and Society for Clinical Research and Investigation; the Center for Victims of Torture; the Glaser Pediatric AIDS Foundation; the 32
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Biomedical Ethics Center; Physicians for Social Responsibility and the Minnesota Medical Foundation. Global outreach and exchange have played an important role in his career with activities related to many countries virtually spanning the globe. Perhaps the best way to appreciate this easy going and complex physician is to view samplings of descriptions of him by his legion of students and colleagues: “a great family man” (father of four and brother of Minnesota’s 35th Governor); “a healer;” “excellent role model;” “a modest overachiever;” “a savvy non-combatant;” “a peace maker;” “brilliant and inventive;” “a marathoner” (14 completed); “a kind, home spun, regular guy.” We’re proud to now be able to add to the above descriptions of Dr. Quie … a true Luminary. Last summer, Dr. Quie emerged from his office after noticing a senior physician — who was obviously lost in the hospital complex — wandering the halls in search of a welcoming meeting with new freshmen students. After determining the problem and giving the alumnus perfect directions, the doctor reminded the professor of their last meeting in that building some 50 years ago at the time of his oral exam. Paul Quie praised the old chap for his continuing association with their school and once again patted him on the back and said, “Nice job, Doctor.”
This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
Jason Leyendecker, Au.D., Doctor of Audiology
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