Jan/February 2011
Expect More… Kathy and Lisa Madore For 24-hour information on these listings, call the Hotline 1-800-799-5858 (952-858-5858) and enter the Hotline Code.
HOTLINE #47443
HOTLINE #47446
HOTLINE #47431
AN ISLAND RETREAT!
8.49 ACRES OF PRIVACY ON O LONG O G LAKE!!
ALMOST 10 ACRES IN STILLWATER!
Enjoy over 4 acres of private grounds on Bald Eagle Lake! Architect designed home provides geothermal and passive solar to insure low energy costs. Incredible water views from almost every room! No need to leave home with your own in-home theatre, racquetball or basketball court, croquet court, putting green, hot tub room, screen porch and separate outdoor entertainment area.
With almost 10,000 finished square feet, an in-ground pool, all new granite counter tops in the kitchen, new owner’s bath, in addition to every aspect of this home being totally updated and in perfect condition, it is a 10! You will note the attention to detail and the care the seller has taken throughout from the entertainment area to the storage area on the walkout level to the floors of the 10 car garages.
HOTLINE #47590
HOTLINE #47432
107.5 FEET OF SAND BEACH CH ON THE ST. CROIX RIVER!
A PRIVATE ACRE IN THE HEART OF DELLWOOD!
Enjoy seasonal views of the St. Croix River from this classic Southern colonial with hardwood floors throughout the main floor. Enjoy front and rear porches and a third floor newly designed and completed specially for the children’s domain with its own laundry area and open space. Truly a rare find in setting and style.
HOTLINE #47454 3.1 ACRES OVERLOOK POND AND WILDLIFE WITH LAKE ACCESS!
Enjoy St. Mary’s Point and walk right out from your deck or stone patio to your own sandy beach front and deep water beyond for your boat! This two-story is all new from the ground up in 2002-2003 with maple and granite kitchen. Windows on three sides enjoy views both up and down river from your location on the point! Year round or riverfront get away.
This custom walkout rambler was designed by a well know area builder as his personal residence and is irreplaceable at today’s price! Main floor owner’s suite with heated bath floors has its own private deck overlooking the White Bear Yacht Golf Course in the distance. The cherry and granite kitchen is open to family room, wide planked wood floor porch and deck beyond. A must see!
HOTLINE #47473
HOTLINE #47536
HOTLINE #47448
ALMOST 10 ACRES IN AFTON!
ON LAKE DEMONTREVILLE! VILLE!
NESTLED ATOP THE MISSISSIPPI SISSIPPI RIVER R BLUFFS!
Wind down your tree lined drive to your walkout two-story with a two-story great room open to four season room and kitchen all overlooking the pool and private grounds! Four bedrooms in addition to a library or guest suite with a separate entrance. Five car garage is of special interest in addition to a separate 38’ x 26’ skateboard arena, basketball or hockey practice area or?
Totally renovated to the studs in 2009-2010 by well-known local builder affords open floor plan with extremely spacious center kitchen island with all new cherry cabinets. Cherry trim throughout and specially designed owner’s bath. The interior is a wow and must be seen to totally appreciate the quality of workmanship and design.
Just a short drive to both downtowns of Minneapolis and St. Paul from this 1 acre setting! Enjoy views year round of boats going through the lock and dam, eagles soaring overhead, the luminous lights of a bridge in the distance or the countryside across the river with its changing scenery. A must to see this Cape Cod style home to truly appreciate the value and views!
KATHY MADORE, 651-592-4444 kathymadore@edinarealty.com
Here is an opportunity to entertain in style with your own private dance floor or yoga studio. There is also a separate billiard room and wet bar area on the walkout level. The main floor in addition to the walkout level has been totally renovated in 2010 with all new kitchens, baths, flooring and more. You will not want to leave the main floor owner’s suite. This is truly a retreat that offers pond views with wildlife beyond!
LISA MADORE, 651-216-1335 lisamadore@edinarealty.com
www.kathymadore.edinarealty.com
Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
November/December Index to Advertisers TCMS OfďŹ cers
President: Thomas D. Siefferman, M.D.
CrutchďŹ eld Dermatology................................20
President-elect: Peter J. Dehnel, M.D.
The Davis Group .............. Inside Front Cover
Secretary: Edwin N. Bogonko, 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 reect the ofďŹ cial position of TCMS.
Fairview Health Services .................................31
Past President: Ronnell A. Hansen, M.D.
Healthcare Billing Resources, Inc. ...............30
TCMS Executive Staff
Kathy Madore....................................................... 1
Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Assistant 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
Lockridge Grindal Nauen P.L.L.P. ...............25 Minnesota Epilepsy Group, P.A....................23 Minnesota Physician Services, Inc. ................ 4 The MMIC Group .............Inside Back Cover MMIC Health IT ........... Outside Back Cover Pediatric Home Service .....Inside Back Cover Saint Therese.......................................................18 Toshiba Business Solutions.............................12 Uptown Dermatology & SkinSpa.................. 2 U.S. Navy ............................................................31 Weber Law OfďŹ ce .............................................23 Woodbury Medical Building .........................18
For a complete list of TCMS Board of Directors go to www.metrodoctors.com.
Uptown Dermatology & SkinSpa
Welcomes Rehana Ahmed, MD, PhD
Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.
Dr. Rehana Ahmed joins the staff of Uptown Dermatology. She specializes in Medical and Surgical Dermatology. Same Day urgent referrals
For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com
and Same week routine appointments available at our clinic. We are located in Uptown Minneapolis, one block east of Calhoun Square. We accept all major insurance and offer discounted parking. Call us at 612-455-3200 to schedule an appointment.
MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Katie Snow at (612) 362-3704.
Healthy Skin is Gorgeous Skin.
Rehana Ahmed, MD, PhD Dermatologist
Uptown Row, 4VJUF t 8. Lake StrFFU t .JOOFBQPMJT ./ t XXX 6QUPXO%FSNBUPMPHZ DPN
2
November/December 2011
MetroDoctors
The Journal of the Twin Cities Medical Society
CONTENTS VOLUME 13, NO. 6
2
Index to Advertisers
5
IN THIS ISSUE
NOVEMBER/DECEMBER 2011
Bringing Psychiatric Services into Mainstream Medicine By Lee H. Beecher, M.D.
6
PRESIDENT’S MESSAGE
Oh Wherefore Art Thee Psychiatry? By Thomas D. Siefferman, M.D.
7 Page 28
TCMS IN ACTION By Sue Schettle, CEO
PSYCHIATRIC SERVICES
8
s Colleague Interview George Dawson, M.D.
13
s Emergency Psychiatric Evaluation and Referral By Doug Brunette, M.D. and Kathleen Heaney, M.D.
15
s Access to Psychiatric Services—Training and Trainee Perspective By Thomas B. Mackenzie, M.D. and Kaz Nelson, M.D.
Page 7
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s The “C’s” of DIAMOND in Primary Care By Timothy Hernandez, M.D.
19
s Behavioral Health Clinics Improve Depression Care By Michael Trangle, M.D. and Pam Pietruszewski, MA
22
s Understanding Depression, Hope Through Treatment By James J. Jordan, M.D.
24
s Frontiers of Psychiatric Research By Charles Schulz, M.D.
26
s PrairieCare: Access to In-patient Services for Children and Adolescents By Joel V. Oberstar, M.D.
Page 29
28
TCMS Physicians Participate in MMA House of Delegates
29
Charles Bolles Bolles-Rogers Award Presented Honoring Choices Minnesota Happenings
30
In Memoriam/New Members
31
Career Opportunities
32
LUMINARY OF TWIN CITIES MEDICINE
Edward W. Posey, M.D. Page 32
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The Journal of the Twin Cities Medical Society
On the cover: Access to psychiatric services can be challenging for patients and physicians. Articles begin on page 8.
November/December 2011
3
Search for Twin Cities Medical Society on Facebook
Proceeds from MPS help to support the operations of TCMS. Please consider our business partners listed below as you look to reduce your operational costs.
Our Partners Include: ◆ AmeriPride Services (linens and apparel) ◆ Berry Coffee (beverages and food) ◆ Gallagher Benefit Services (group insurance) ◆ SafeAssure Consultants (OSHA compliance) ◆ AED Professionals (AED distributor) ◆ IC System (debt collection)
To Learn More, Call (612) 362-3704
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November/December 2011
MetroDoctors
The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
Bringing Psychiatric Services into Mainstream Medicine This issue of MetroDoctors features psychiatric services in the Twin Cities area. Looking back to our May/June 2002 issue of MetroDoctors which described “Challenges for Mental Health Care,â€? improvements in patient access to quality services has improved through recent government health care insurance mandates. s )N #ONGRESS PASSED MENTAL HEALTH CARE INSURANCE PARITY LEGISLAtion. The legislation is a legacy to the advocacy of former Minnesota U.S. Senator Paul Wellstone and our own Jim Ramstad. http://www. nytimes.com/2008/03/06/washington/06health.html. s )N -ARCH THE 0ATIENT 0ROTECTION AND !FFORDable Care Act (PPACA) expanded mental health coverage while also dramatically increasing Medicaid eligibility. http://www.foxbusiness.com/personal-ďŹ nance/2010/11/04/ mental-health-coverage-expanded-ppaca/. Keep in mind that most patients who have major mental disorders in Minnesota depend on medical assistance (Medicaid) and/or Medicare disability for their health care insurance. Also, the Minnesota Comprehensive Health Association (MCHA) high risk pool, which is subsidized by Minnesota insurance health plans, has nearly 20 percent of its enrollees who are unable to buy private insurance coverage due to their psychiatric diagnoses. So, the caveat: Will federally mandated expansions of mental health coverage actually result in better reimbursement or decreased payment for psychiatric services, given the reality of state and federal ďŹ scal and budgetary restraints? Here is an overview of the articles in this issue: s )N AN INFORMATIVE Colleague Interview, George Dawson, M.D., formerly at Regions Hospital and now on staff at Hazelden, ďŹ elds a wide range of questions from his colleagues and explains why he spent the last 25 years practicing psychiatry and won’t quit. (page 8) s ER Perspectives on Psychiatric Evaluation and Referral: When psychiatric patients show up in hospital emergency departments, informed communications with outpatient clinicians and families is too often the “exception rather than the rule,â€? say Doug Burnette, M.D., and Kathleen Heaney, M.D. at Hennepin County Medical Center (page. 13) s $RS 4HOMAS -ACKENZIE and Kaz Nelson, residency program directors at the U of M, write on the Training and Trainee Perspectives for psychiatrists with comments from medical students and residents on their interests and practice opportunities. (page 15) By Lee H. Beecher, M.D. Member, MetroDoctors Editorial Board
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The Journal of the Twin Cities Medical Society
s
s
s
s
s
s
)MPROVING Psychiatric Services in Primary Care Settings, Tim Hernandez, M.D. of Family Health Systems Minnesota describes the “C’sâ€? of the ICSI DIAMOND project methodology: culture, continuity, collaboration, care coordination and consultation. (page 17) -ICHAEL 4RANGLE - $ , associate medical director, HealthPartners, and Pam Pietruszewski, MA, education program lead, ICSI, explains the Minnesota Behavioral Health Depression Collaborative (MBHDC) The PHQ-9 depression questionnaire is a useful tool to help identify and monitor patients at risk for suicide and those needing treatment and monitoring. (page 19) 0UTTING A FACE TO DEPRESSION Jim Jordan, M.D. and collaborator/ producer Mary Hanson, LISW, of MN public TV’s Mary Hanson Show, have done a series of television interviews on Understanding Depression. What led to this condition and what helps patients recover? Jim is an expert on applied psychotherapy techniques and a past head of the Hamm Clinic in Saint Paul. (page 22) #HARLES 3CHULZ - $ professor and head of the U of M Department of Psychiatry describes Frontiers of Psychiatric Research including ongoing work on neuroimaging. (page 24) PrairieCare is a psychiatric services hospital/clinic in the Twin Cities providing access to psychiatric care for children, adolescents, and adults of all ages. Joel Oberstar, M.D., CEO and chief medical ofďŹ cer, describes their offerings, which in 2011 includes a new 20-bed inpatient service in Maple Grove. (page 26) Luminary, Ed Posey, M.D. This is a tribute to a deserving recipient and esteemed psychiatric colleague authored by Marv Segal, M.D. (page 32)
Please Mark Your Calendar: TCMS and Minnesota Psychiatric Society are co-sponsoring an educational Forum on “Mental Health: Improving Access and Quality� Thursday, December 8, 7-8:30 a.m. Watch your email for more details. We want to hear from you. Please submit a Letter to the Editor on your experiences with access, quality, and cost of psychiatric services in Minnesota.
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President’s Message
Oh Wherefore Art Thee Psychiatry? THOMAS D. SIEFFERMAN, M.D.
I
f you have been following my articles, by now you are well aware of my love for pediatrics and caring for children. There are not many things that endanger my love of medicine and caring for kids. All right, a few things bother me: divorce, abuse and abandonment from the parental side of the equation; stupidity and preventable trauma from the child’s side; cancers and metabolic disorders from who knows where; and lastly, complex psychiatric disorders. Obviously, many of these are avoidable and some are quite random and tragic, but many of my fellow pediatricians will agree (as well most internists, surgeons, gynecologists, et cetera) that we need more pediatric and adult psychiatrists, and we need to be aided in better screening methods for psychiatric disorders and when to refer. Unfortunately, the reimbursement levels for cognitive care have been so abysmal that there is a chronic need for more psychiatrists, both adult and pediatric. None of us feel well prepared for the level of psychiatry that we are forced to practice. I only had two Attention Deficit Disorder (ADD or ADHD) patients in my Continuity Clinic during my three years in residency, yet in private practice I probably exceed 10 percent. Many of my families have learned of my wife and I being blessed with two children with ADHD, and they understand that I feel their trials and joys, and fears and concerns. One of my children was provided with outstanding psychiatric insights and guided therapy, and currently reads at a college level in early Senior High School. But too often I am thwarted in referring patients for similar great care. Sadly, new psychiatrists come to the Twin Cities and have their schedules filled within weeks. Too often our patients have their need for psychiatric care dashed upon the rocks of prior authorization and a limited panel of psychiatrists that they are allowed to visit. The other more worrisome side of primary care doctors practicing psychiatry, is how to screen and when do we need to refer. Our own reimbursement for such care is also tragic, and there are not many free tools we can use to adequately gauge the need for advanced care. I have to emphasize free tools because 10 percent of 10 thousand active patients’ files equal a lot of screening that insurance companies refuse to pay for, unless there are positive findings. Interesting how insurance companies get by with such ploys. The flip side is they withhold “Performance dollars” unless we adequately screen our patients, but then they do not want to pay to have the tests read or interpreted. Many a pediatrician has gotten in over their head in treating with “Poly-pharmacy” (multiple medications used in varying doses to treat a disease that one medication has been unable to treat). Luckily there are more books available and additional resources for medications. But many of the conditions like depression, anxiety and ADHD need a significant amount of psychological counseling as well as medications, and many schedules become too tight to adequately treat the more complex cases. Setting aside more time that not only is not reimbursed but also requires seeing fewer sick or injured children leads to resentment from the mentally healthy brethren. When heated words are forwarded in my direction, I have often found the “there for me but the grace of God” speech calms the angry parents, as they too have heard of sad outcomes from children that were missed or forgotten by the system. Parents are more forgiving of broken schedules when they are made aware of the seriousness of the psychiatrically affected child. Physicians caring for adults are more frequently burdened by unforgiving adult patients in similar cases. No one should be so burdened. If only we could improve payment models for providing psychiatric care so the market could quickly fill with providers.
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November/December 2011
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The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
MMA Annual Meeting Wrap Up The Minnesota Medical Association Annual Meeting was held in Duluth, MN September 15 and 16, 2011. This was the first year of the new format for the annual meeting with streamlined events and shortened proceedings. We had good representation at the annual meeting but fell short of our goal to fill our allotted 100 seats in the House of Delegates. As a plea for next year, please consider attending the 2012 MMA Annual Meeting which will be held at the Minneapolis Marriot on Friday, September 14 and Saturday, September 15, 2012. Mark the dates on your calendar now! You can sign up with us early — just send us an email at TCMS@metrodoctors.com. See page 28 to view the highlights of the 2011 meeting which includes the installation of Lyle Swenson, M.D. as MMA president. Board Actions Sanne Magnan, M.D., Ph.D., CEO of Institute for Clinical Systems (ICSI), spoke at the September meeting of the Board of Directors, providing an overview of their current work and outlined their four values to achieve the Triple Aim: Co-creation, Trust, Nimbleness, and Innovation. She also complimented TCMS on Honoring Choices Minnesota as a community-wide resource and stated that she recently completed training as an Honoring Choices Ambassador.
Sanne Magnan, M.D. talks to TCMS Board about ICSI's Triple AIM initiatives.
MetroDoctors
The TCMS board of directors recently approved the recommendation of the Nominating Committee to appoint Ken Kephart, M.D. as Treasurer of TCMS completing the remaining term recently vacated by Dr. Melody Mendiola. Dr. Kephart is a geriatrician and medical director of Fairview Health Services. He is also an associate professor of Family Medicine at the University of Minnesota and serves in an advisory capacity to the TCMS Honoring Choices Minnesota project. Please join me in congratulating Dr. Kephart on this appointment. The board also appointed Lisa Mattson, M.D. to the TCMS executive committee as an At Large Director. Dr. Mattson is an obstetrician/gynecologist from the Allina Medical Clinic in Fridley. Dr. Mattson also serves on the TCMS Policy Committee. We wish to express our many thanks to Melody Mendiola, M.D. for her leadership and service to TCMS having served as its first Treasurer since the merger of the East Metro Medical Society and West Metro Medical Society in 2009. Honoring Choices Minnesota Leaders from the Wisconsin Medical Society have been consulting with me and Dr. Kent Wilson about the Honoring Choices Minnesota (HCM) initiative. They have been following our progress and are interested in embarking on a similar initiative in Wisconsin. Our discussions have led to two more “official” public meetings that have been held recently with Wisconsin health care leaders. I spoke at the first meeting which was held in Milwaukee. There were 40+ senior leaders of health care industries including hospitals, health plans, long term care and senior groups. The second meeting was in Madison and included many of the same health care leaders as in Milwaukee. The good news is that the HCM model is getting some attention from outside of Minnesota. If you haven’t looked at the www.honoringchoices.org website, I’d encourage you to do so. Three documentaries will be airing this year
The Journal of the Twin Cities Medical Society
and are included on the website. It’s great to see our work coming to fruition through these documentaries. The Star Tribune has recently published two articles related to HCM. The first was located on the front page of the local section and can be found here: http://www.startribune.com/ local/130032813.html. The second was an editorial and can be found at: http://www.startribune. com/opinion/editorials/130472343.html. Obesity Prevention Work Continues Jennifer Anderson, project director, has been making terrific progress in engaging communities, elected officials and public health advocates in the adoption of obesity prevention resolutions. There have been meetings and interactions in Eagan, Bloomington, Edina and Richfield. Jennifer has identified a handful of physicians to work with her on this initiative however, is always looking for more physician engagement. If you are a physician, medical student or resident who is interested in partnering with TCMS on obesity prevention efforts, please email Jennifer Anderson at janderson@metrodoctors.com. TCMS Joins Other Health Care Leaders in RARE Coalition TCMS recently partnered with other health care organizations to support the Reducing Avoidable Readmissions Effectively (RARE) campaign. The RARE effort was launched by the Institute of Clinical System Improvement, the Minnesota Hospital Association and Stratis Health and aims to prevent 4,000 avoidable hospital readmissions in Minnesota and surrounding areas by December 31, 2012. Go to: www.RAREreadmissions.org to learn more.
November/December 2011
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Psychiatric Services COLLEAGUE INTERVIEW
A Conversation With
George Dawson, M.D.
G
eorge Dawson, M.D. received his medical degree from the Medical College of Wisconsin, Milwaukee, WI. His postgraduate training included an internship at St. Paul-Ramsey Medical Center, followed by a residency in psychiatry at the University of Minnesota Hospitals and Clinics and the University of Wisconsin Hospitals and Clinics. He is board certified by the American Board of Psychiatry and Neurology, and has added qualifications in geriatric psychiatry and addiction psychiatry. Dr. Dawson is an assistant professor, Department of Psychiatry, University of Minnesota Hospitals and Clinics, and a staff psychiatrist at Hazelden, Center City, MN. Questions were provided by: Renee Koronkowski, M.D., Peter Dehnel, M.D., Marvin Segal, M.D, and Lee Beecher, M.D.
What attracted you to psychiatry when you first made that career decision? I had a lot of exposure to people with severe mental illnesses as a child growing up in a small town. I had a five block walk to school every day and on that walk I went past the homes of many people who were afflicted with mental illness. Additional motivation occurs when you have affected family members. You realize that this is something that is very real and that you have to do something about it. When you move away, the effects of the illness haunt you and your family for decades. In medical school, I had the good fortune to encounter psychiatrists who had strong identities as physicians and they were confident that they could help people with these problems. I could talk directly with patients without any pretense that I was different from them. I was interested in everything about medicine but it was a perfect time to be a psychiatrist.
In your 25 years of experience as a psychiatrist, what are the greatest advances you have seen in the field? What are the biggest setbacks you have witnessed? The biggest advance has been the accumulation of information over the past 25 years. Much of the information has been compiled into treatment guidelines. I was an early adopter of the National Library of Medicine as a resource for medical practice and other informatics based approaches. This probably is the best example of how the government can impact 8
November/December 2011
quality in medical practice. Every day tens of thousands of physicians check Medline looking for the best scientific solutions for their patients. There has been an explosion in how information is processed in biological systems to include cell signaling, genomics and proteomics, and brain based models that attempt to integrate diagnoses and more specific behaviors. A major clinical advance was the start of the community-based treatment for people with severe chronic mental illnesses in Madison, Wisconsin by Len Stein, M.D. and others. Today in Minnesota, Assertive Community Treatment based on that model is one of the few modalities offering comprehensive community based care to persons with severe mental disorders. The biggest setback for psychiatry has been managed care and using both utilization review and prior authorization to ration care to patients needing psychiatric care. The evolution of this process is lost on people who did not witness it happening and only see the end result — severely compromised psychiatric care. I was at a meeting in 1994 when a managed care consultant addressed a large crowd of psychiatrists and told us all that we were highly paid specialists. According to him, managed care was going to buy up all of the high priced specialists, put them out of business, and greatly expand primary care. Instead we find that managed care has expanded specialty care and promotes their own specialty care and imaging facilities. Primary care access may be at an all time low. Access to psychiatric care and addiction treatment is far worse and in many cases nonexistent. Most significantly, costs have not been MetroDoctors
The Journal of the Twin Cities Medical Society
contained and that was their initial selling point. Politicians seem to be unaware of that piece of history.
Over the past few years there has been a push to try and measure quality of care in medicine in general, including psychiatry. The PHQ-9 has been used to measure response and remission in patients with depression. What are your thoughts on the use of this measure in assessing treatment response and remission? The application of the PHQ-9 has nothing to do with quality. This is a measurement problem and a problem in data analysis. There is a lot of political rhetoric attached to measurement and the fact that psychiatry is “now being held accountable like other specialties.” Any psychiatrist who is face-to-face with a suicidal or an aggressive patient is already in a situation where the accountability is as high as any encounter in medicine. There is a legitimate scientific question about whether the data has quality implications and whether any scientific approach has been used to analyze it. It is a naïve view of medicine to suggest that a physician is somehow “accountable” for the cure of an illness with multiple genetic and environmental determinants and where a significant number of patients do not respond to all of the indicated therapies. It is that same naïve world view that has cast psychiatrists as pill prescribers. There may be a group of people seeing primary care physicians who might benefit from a faster way to prescribe antidepressants, but we don’t know that number and we don’t know the downside. The FDA just came out with a warning on citalopram, one of our most widely prescribed antidepressants, suggesting that high doses of this medication can potentially lead to serious cardiac arrhythmias. Even rare complications are more common if we are using a blunt tool to potentially expose more people to medication. When people talk about “pay-for-performance,” they are generally politicians. There is no more poorly performing group of people than politicians at either the state or national levels. The first question is how can a group of people who are not mindful of how poor their performance has been suggest criteria for groups of professionals when they have no expertise in that profession and no expertise in scientific measurement? In that context, a so-called “quality” metric becomes a rationing tool for whoever has what appears to be the worst data set. The problems with pay-for-performance approaches are just being written about and will always be significant until the problems involved in quality measurement are acknowledged.
From the time of Charcot, and before, psychiatric/psychologic/behavioral illnesses have been separated from “mainstream medicine” in the areas of clinical treatment and sites for such treatment to be administered. Was this ever appropriate and is it appropriate now? The physical separation of patients with severe psychiatric illness is necessary for safety reasons, either in terms of aggressive or suicidal behavior or a complete inability to function. Patients need close supervision and they also need protection from others who in many cases are trying to MetroDoctors
The Journal of the Twin Cities Medical Society
be helpful but do not know how to help. Acute medical care needs to be administered to restore a person back to their normal level of functioning as soon as possible. As a historical point, I would add that current treatment approaches have been highly successful in reducing the mortality of severe psychiatric illness. Psychiatrists are routinely treating patients with diagnoses that had a 75 percent mortality rate in the early 20th century with essentially no current mortality. Separating psychiatric care from general medical care for rationing has never been appropriate. That separation was done initially by state governments when they assumed responsibility for people with chronic mental illnesses. When there is no rational way to manage a state budget, we cannot expect to have a rational system for treating public patients with the most severe mental health problems. In that situation, we end up with a flood of ways to ration medical and psychiatric care to the people needing it the most. In recent times, that has included state hospital system redesigns and a new cut rate system of medical care requiring patients from all over the state to come to a Twin Cities hospital system that had accepted the plan.
Have there been meaningful attempts in the past to change this? If not, what corrective action do you suggest should be instituted, given the status of our current health care milieu, to correct this perceived injustice? The most meaningful attempt has been the parity legislation by Wellstone and Domenici. Professionals and lay people alike seem quite excited about the effect of this legislation. I listened to a presentation at the APA on how chemical dependency services were all going to be part of the “medical home” and what a difference that would make. At the end I asked the question: “What would prevent a managed care company from administering a drug or alcohol checklist in their primary care clinics and proclaiming that they have fulfilled the chemical dependency function of the medical home?” The answer of course was “nothing.” There are companies right now who are trying to get around the parity legislation. Some are so bold that they are essentially using the same carve out techniques that managed care has been using for the past 20 years. I think at this point, the political question is: “Will the managed care companies who have been so successful in rationing care for mental health and addiction and their allies in Congress be able to get around the parity legislation or will it actually be implemented in the spirit intended by Senators Wellstone and Domenici?” At the state level, we need more input from psychiatry and medicine. We have a political and bureaucratic system that marginalizes us. We are asked to participate at the level of stakeholder when in fact we are the only accountable stakeholders at the table. We cannot sit back and expect anything good to come from a series of administrative decisions. We are typically inhibited by the argument that physicians are not trained in business. By contrast, the people trained only in business do not hesitate to change practically all aspects of the practice environment, even when it has nothing to do with business practice.
(Continued on page 10)
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Psychiatric Services Colleague Interview (Continued from page 9)
With our current health care system in crisis, energies are focused on the accountable care organization as a possible remedy. What are your thoughts on this system and how do you see the role of the psychiatrist functioning within this system? If you could design the perfect health care system what would it look like? Accountable care organizations are managed care organizations on steroids. It represents another attempt by the government and health care businesses to redefine physicians in order to get us to continue the dual role of physician and fiscal agent for the government or the insurance company. ACO legislation is much more far reaching than the usual risk-sharing equations and in that regard is a redefinition of medical practice. It is a continuation of the explosion in growth of health care administration since the advent of managed care. Businesses in this country are not managed to optimize service. They are managed to optimize profit. There is no easier way to make money than to have a captive pool of premium dollars and ration what they can be used for. If I am correct about ACOs, access to psychiatry will remain limited or get significantly worse. Inpatient units in a few hospitals will be heavily subsidized because there is no practical way to move patients with psychiatric problems out of emergency departments or off of medical services if there are no psychiatric beds. Quality of service will continue to fall because of the managed care model on inpatient psychiatric services and a lack of outpatient care. The worst case scenario has played out in some states where the managed care has been applied to the public sector and patients with severe mental illness are discharged to the street. The reform of health care starts with a model that looks strictly at payment mechanisms. It makes no sense at all to tie any payments to quality measures at this point because there are few legitimate quality markers. There are valuable lessons to be learned from other countries where high tech medicine is practiced. Japan has significantly more health care utilization by senior citizens but only half the per capita health care expenditure as the U.S. Pricing has a lot to do with these savings. I would also look at the system used to train psychiatrists. As an ideal system I would favor one described by Thomas Insel, M.D. the director of NIMH that he presented a couple of years ago. He suggested modifying residency training so that all psychiatry, neurology, and neurosurgery residents did a two year neuroscience rotation in their years of residency training. That basic change on the training side presents us with significant opportunities to advance clinical practice. Continuing education and recertification is a critical area of the practice environment that is being modified by special interests. The specialty boards have decided on an elaborate recertification process that is costly and in my opinion fails to achieve the necessary goal of assuring that all of the specialists in a particular field are up to speed on the latest technical information. I have advocated for a system that assures that physicians are up-to-date on the most current evidence and tested in a CME format rather than an exam with a high pass rate and no feedback to the examinees. 10
November/December 2011
You have written about how clinics and health care insurance companies mismanage physician “knowledge workers.” How would you advise Minnesota’s medical organizations and societies to affirm principles of physician professionalism? I can’t take the credit for “knowledge workers.” That concept is from the late management guru Peter Drucker. It implies that knowledge workers have special characteristics independent of their productivity that create value for businesses and create the need for special approaches to their management. Practically all physician management in the U.S. is based on a flawed billing and coding system. Physician management in many places is right out of a Dilbert cartoon. One of the mistakes that I have discussed with many physicians is the use of outside consultants to “improve” the practice. The conclusions are predictable. Focus on the high margin business and use the failed productivity and RVU based model to slash reimbursement to any physician groups who are currently out of favor. In today’s world that comes down to primary care and psychiatry. In many cases, the consultation is a way to rationalize a move that the administration wants to make and defuse the physician reaction to it. Professionalism does not mean blind cooperation. Professionalism means first and foremost that you have and maintain technical expertise. Secondly, it means that you are very clear about what you know and what you don’t know. Thirdly, it means that you are bringing your expertise to bear on the patient’s problem and providing treatment in the context of an informed consent based dialogue. At some point the idea was introduced that physicians are also stewards of resources. That implies cooperation with insurance companies and their business tactics. It also incorrectly implies that physicians don’t routinely talk about the possible economic constraints of treatment and I don’t know when that ever occurred. Minnesota medical societies need to combine forces and remove all of the existing health insurance leverage that is codified in the state statutes. It also means a functional complaint system to report health insurance abuses of physicians and patients. Physicians should not be intermediaries for PBMs or health plans who can make their own completely independent decisions on rejecting patient claims without involving hours of unreimbursed physician time. All disputed claims could go through a government run complaint system.
In a recent Minnesota Psychiatric Society commentary, you said that psychiatrists are often disrespected and even “hated.” By whom and why? If true, are psychiatrists now an endangered species? There is a long list of people who hate psychiatrists and it is a popular activity to try to extend that list every day. In my original commentary the spectrum varies from fellow physicians to anti-psychiatry cults to people trying to make a buck by fanning the flames of controversy. In recent times, it is popular to portray psychiatrists as mindless zombies controlled by the collective Big Pharma and prescribing medications to enrich pharmaceutical companies.
MetroDoctors
The Journal of the Twin Cities Medical Society
In the past, we have persevered because there was nobody else to turn to during a mental health crisis. The health care system has been restructured to the point that psychiatrists are marginalized. Patients are discharged when they are still acutely symptomatic and those decisions may be forced by non-physician administrators. People go to work every day in hospitals under the specter that the state is trying to shut them down. Patients with severe disabling illnesses are seen for 20 minutes two to four times a year and the cognitive dysfunction that is at the core of their disability is never addressed. We hear that anyone can diagnose and treat very complicated illnesses and despite the criticisms leveled at psychopharmacology, that it is easy to do. We have more evidence than ever that psychotherapy is effective and have few psychotherapy resources. We have professors in academic programs who are being held to the same “productivity” standards as clinicians — diluting the academic environment for psychiatry. Many, if not all, of these problems are at least a partial product of anti-psychiatry rhetoric and the associated mindset.
What is the current status of independent private psychiatric practices in Minnesota? How many cash practices? How many participate in Medicaid and Medicare? I don’t know exactly how many psychiatrists are cash based. It has long been established that Medicare does not adequately reimburse psychiatrists well enough to cover practice expenses. Most insurers use those same rates or discounts to those rates. Any psychiatrist seeing complicated patients four times a year will be reimbursed by Medicare at a rate that is about 45-50 percent of the submitted bill and that is about 10 percent lower than the cost of doing business. This is before the anticipated 40 percent reduction in Medicare physician payment rates by 2014. Reimbursement by ACOs will conceivably be even worse. The reimbursement rate could be 25 percent of the current Medicare rate. At those levels there are no known practices that can be supported and the usual physician adaptation of increased “productivity” is unrealistic. If physicians are not being paid as professionals how can they be expected to pay malpractice premiums and ongoing professional expenses?
What are some potential solutions to the current challenges of access to psychiatry and behavior health services in general? Telepsychiatry and collaborative care models provide solutions for providing access to quality psychiatric care in an efficient manner. There are several technologies and companies that allow for secure and cost-effective psychiatric treatment on the internet. There are groups of psychiatrists currently engaged in this type of practice. Internet based groups will eventually see patients anywhere. There is a collaborative care model for the diagnosis and treatment of dementia through the University of Wisconsin that incorporates geriatric psychiatrists, neurologists, and primary care physicians in many counties across the state. All of the participants receive training twice a year and patients are assured of quality care. This model has potential in controversial areas like the treatment of adult attention deficit disorder and chronic pain. It can assure that all of the physicians involved have MetroDoctors
The Journal of the Twin Cities Medical Society
the latest information and it provides a safeguard against practice drift and inappropriate prescribing. A final and potentially extremely cost-effective solution is the use of computer-based psychotherapy that is performed by the computer rather than a therapist. Some forms have been documented to be as effective as seeing a therapist. Patient acceptance is high and this modality could easily be added to the prescription for treatment of anxiety and depressive disorders.
Will enhancing the ability of primary care clinicians to address depression, anxiety and other common disorders (DIAMOND Project) work to meet the access needs of patients, or is this not a reasonable solution? The DIAMOND project is a reasonable solution for some patients but not everybody. The actual number of people that will be helped is really unknown. The best experiment would compare that information to what occurs with a PHQ-9 rating and an encounter not focused on the PHQ-9. My experience suggests that those two results are worlds apart especially when additional variables like substance abuse diagnoses, bipolar spectrum disorders, anxiety disorders and personality disorders are taken into account. There has not been enough recognition that many primary care physicians do a good job of diagnosing and treating depression. The professional societies for both internists and family physicians have their own practice guidelines for treating depression.
You have been active in many areas as an advocate for your profession and for patients (e.g. leadership roles as an editor, MPS president, etc.) In your opinion, how have physicians been effective in advocating for ourselves and our patients and where have we fallen short? The central problem is that physicians generally believe that they are above the fray. They fail to understand the importance of politics and the adverse effect it has on the practice environment. They allow a wide range of politicians to treat them with impunity and continue to donate to candidates despite a lack of results. Given the poor success rates, physicians are surprisingly compliant with politics as usual. The professional societies become the targets of physician anger about the deteriorating practice environment rather than the political process. This Colleague Interview has been edited due to space limitations. A complete version is available upon request. Contact nbauer@metrodoctors.com or George Dawson, M.D. at dawso007@yahoo.com.
November/December 2011
11
Emergency Psychiatric Evaluation and Referral
By Doug Brunette, M.D. and Kathleen Heaney, M.D.
MetroDoctors
(or as is sometimes euphemistically labeled, “supratentorial” reasons). The mistake of premature closure in diagnostic assessment (or the “Nah, it couldn’t be” euphemism coined by Dr. Joseph Clinton, chief of Emergency Medicine at HCMC) can lead to catastrophic misdiagnosis. For example, the anxious patient with chest pain and shortness of breath may be having their 20th panic attack, but could also be suffering their first myocardial infarction or pulmonary embolism. The diagnostic workup and therapeutic management of the patient with mental illness is more complex, more time consuming, and requires increased utilization of emergency department time, space, and resources. It is abundantly clear to the emergency medicine physician that the presence of significant psychiatric disease complicates the management of patients with medical and surgical pathology. Medication interactions, the complex interplay of psychiatric and medical disease, increased diagnostic uncertainty, and the ability of the
The Journal of the Twin Cities Medical Society
©Sheila Ryan Photography.
©Sheila Ryan Photography.
T
he impact of mental illness on the delivery of emergency medical care is significant. The Emergency Department (ED) at Hennepin County Medical Center (HCMC) saw 96,068 patients in 2010. Of those, 12,315 patients (12.8 percent) carried a psychiatric diagnosis on their active problem list (and it’s likely there were many more with undiagnosed or unrecognized psychiatric disease). A patient with psychiatric disease who presents to ED will undergo a medical evaluation as it relates to their presenting complaint or clinical condition. For example, a patient with schizophrenia who presents with the chief complaint of hearing voices and is non-compliant with psychiatric medications will receive a different evaluation than if they presented with comorbid medical condition(s). The same patient with schizophrenia who complains of hearing voices could have alcohol or drug intoxication/ withdrawal, hypertensive crisis, seizure disorder, CVA, head trauma, delirium or dementia. Most often, a psychiatric patient presents a mixed etiology of medical or surgical pathology entwined with psychological distress and illness. Examples include: the anxious patient presenting with chest pain and shortness of breath; the depressed patient with complaints of insomnia or weight loss; and the actively suicidal patient with an acute suicidal gesture. After the history and physical examination, emergency medicine physicians formulate their differential diagnosis not only in terms of the likelihood of the condition existing, but also in the specific order of potential life or limb threats. Emergency medicine physicians must be careful to not fall into the trap of attributing the chief complaint only to psychiatric issues
patient to make informed and competent decisions are a few examples of the added complexity psychiatric disease brings to the practice of emergency medicine. Lastly, emergency medicine physicians do not have the benefit of an established relationship with psychiatric patients or their families. Decisions by emergency medicine physicians are often made with little prior interaction or knowledge of the patient. Deciding if a patient with significant mental illness is safe to discharge is complicated when we don’t know the amount of support, structure, and reliability of the patient or the patient’s family. Also, many of our psychiatric patients are homeless and estranged from family or friends. Once the medical evaluation and treatment are concluded, and the patient does not require hospitalization for medical or surgical reasons, the psychiatric aspect of the patient’s presentation can be more fully addressed. This (Continued on page 14)
November/December 2011
13
Psychiatric Services Emergency Psychiatric Evaluation (Continued from page 13)
is not to suggest that the medical or surgical aspects of patient care can be compartmentalized from the psychiatric care. The psychiatric evaluation and care often occurs at the same time as the patient’s medical or surgical care. Indeed, it is not uncommon for the psychiatric aspect to be addressed ďŹ rst as their psychiatric illness might preclude the ability to conduct a reliable history and physical examination, and to perform any diagnostic testing. As an example, the agitated, combative psychiatric patient complaining of chest pain cannot have their chest pain successfully evaluated without managing their psychiatric issues ďŹ rst. At HCMC, we are thankful to have the APS (Acute Psychiatric Services Department) located just across the hall from the ED. ED patients requiring psychiatric evaluation are generally transferred directly from the ED to APS. In 2010, 1,406 patients were initially evaluated and treated in our ED followed by transfer to APS. The physical proximity of APS to the ED lends itself to a close working relationship and provides a relatively seamless and efďŹ cient transition of medical to psychiatric care. This beneďŹ ts the emergency medicine physicians, and their patients requiring psychiatric evaluation and intervention. It also frees up a lot of time and energy for the emergency medicine physician to devote to other patients. The workup of these patients is divided into medical/surgical, (performed by the emergency medicine physician), and the psychiatric, (performed by the APS staff). The emergency medicine physician and the APS staff communicate directly each time a patient is transferred from the emergency department to APS for psychiatric evaluation. In general, APS staff does not evaluate patients in the emergency department, but rather wait for transfer to APS. The emergency department cares for approximately 260 patients per day, thus requiring rapid assessment and disposition. A thorough psychiatric evaluation is time and resource consuming, and best performed in APS. Unfortunately for most hospital emergency departments, this scenario is the exception rather than the rule. The vast majority of community-based emergency medicine physicians do not have the beneďŹ t of a local APS, making the management of such patients more time consuming and complicated. These emergency medicine physicians will have to adjust 14
November/December 2011
psychiatric medications, perform suicidal risk assessments, and assess patients for psychiatric safety of discharge from the hospital (without the help of psychiatric expertise). HCMC’s Acute Psychiatric Services (previously known as the Crisis Intervention Center) provides emergency services 24 hours a day 7 days a week to persons experiencing mental health problems including psychosis, depression, violence or suicide issues, and other acute crisis situations. A multidisciplinary team of psychiatrists, psychologists and psychiatric nurses, clinical nurse specialists and social workers provide specialized mental health evaluation, referral, treatment and care. APS staff collaborate with community agencies such as the police, Mental Health Crisis Services (COPE), suicide hotline, chemical dependency treatment programs, Nancy Page Crisis Residence, Hennepin County Jail, Juvenile Detention Center, and County Home School, and the Hennepin County Mental Health Center, to name a few. APS has three main functions: s %MERGENCY 0SYCHIATRIC #ARE EVALUATION and treatment of acutely psychotic, suicidal or homicidal patients). s 7ALK IN MEDICATION EVALUATION PRESCRIPtion of psychotropic medication for people who do not have a psychiatric provider). s /BSERVATION HOLDING UNIT FOR PATIENTS waiting for an in-patient psychiatric bed, which can be up to a few days when there are no available beds in the metro area). Here at HCMC, we are fortunate to have a hospital with excellent, yet heavily utilized, psychiatric resources. HCMC has 102 psychiatric in-patient beds, and approximately 14 percent of patients presenting to APS are admitted to in-patient psychiatry (about six patients per day). Despite the apparent abundant number of HCMC psychiatric beds, the average wait time for an APS patient to be admitted to HCMC is 13 hours. Once admitted, the average length of stay of a psychiatric patient is approximately 14 days. This reects the nature and characteristics of psychiatric care which requires much longer lengths of stay for successful treatment than does the typical medical or surgical patient. About 11 patients per month are transferred from HCMC APS to another facility for inpatient therapy. The reasons for these transfers include insurance regulations, patient preference, facility delivering prior psychiatric care, or lack of psychiatric beds.
There is an inverse relationship between the number of people seeking psychiatric care and the availability of resources. As the number of people without work, housing or insurance increases, there are fewer options in the community that provide mental health treatment. That often leaves the ED and APS as the ďŹ nal common pathway for people seeking psychiatric treatment. Emergency psychiatric care falls under the EMTALA guidelines, meaning that patients with psychiatric emergencies must be evaluated and stabilized, regardless of health insurance status or ability to pay. Patients are not discharged from APS until they are deemed safe for discharge. Lack of insurance does result in considerable difďŹ culty in obtaining long-term psychiatric care. The ED and APS do not have a formal morning after clinic to re-evaluate patients recently seen. Patients placed on psychiatric medications by APS will have medication evaluations performed generally every two weeks by the APS staff until the patient is enrolled in long-term outpatient psychiatric resource and care. Available health care resources for patients requiring psychiatric management are wholly inadequate, with demand far exceeding resources. This is true on a national, regional, state, and most certainly local level. Nationwide, increasing numbers of psychiatric patients rely on EDs for their primary care due to decreasing funding of our mental health infrastructure. In summary, many emergency department patients have psychiatric disease interwoven within their medical or surgical disease, complicating their evaluation and management. Effective evaluation and management of these patients necessitates addressing both aspects of their acute care. Doug Brunette, M.D. is the assistant chief for Clinical Affairs at HCMC. He attended medical school at Vanderbilt University; completed a residency in emergency medicine at HCMC in 1985 and has been on the faculty since that time. Kathleen Heaney, M.D. is the director, Acute Psychiatric Services at HCMC. She received her medical degree at Jefferson Medical College; completed a psychiatry residency at HCMC and Regions Hospital, followed by a fellowship in Addiction Psychiatry, Mayo Clinic.
MetroDoctors
The Journal of the Twin Cities Medical Society
Access to Psychiatric Services— Training and Trainee Perspective Residents and Access to Psychiatric Services
Residency training programs in psychiatry impact access to psychiatric services in several ways. First, residents provide psychiatric care under the supervision of attending faculty during their training. Whether residents are care-multipliers for faculty or lessen faculty efficiency is debatable and depends on their level of training, the care setting — inpatient versus ambulatory — and how third party payers manage compensation for resident-based services. If advanced trainees are permitted to provide care in ambulatory settings with post hoc supervision they can be multipliers and provide needed services, often to the underserved. A second, sometimes overlooked, contribution to psychiatric care is the moonlighting services (fee-basis service provided during non-training hours) residents provide in the community. We know of no good estimates of its magnitude, but since in our experience most eligible residents moonlight, it is likely that some care sites are significantly dependent on this source for full service provision. Residents do, however, have to count moonlighting hours when calculating hours on duty. The total of training time + moonlighting cannot exceed 80 hours per week when averaged over a four week period. Moonlighting is divided into internal and external. Internal is at a training site; external is at a site that is not used for training in the program. When the moonlighting is home call (taking calls at home and only coming in when required), only time spent on site counts as duty. It would be impossible to track calls taken at home, but a steady stream throughout the night could By Thomas B. Mackenzie, M.D. and Kaz Nelson, M.D.
MetroDoctors
fatigue a resident nearly as much as being on site, yet would not count. Third, after 48 months of training, residents enter the physician workforce, usually in Minnesota, to join or replace current providers. With 7.03 psychiatrists per 100,000 persons (2010 U.S. Department of Labor statistics) Minnesota ranks 20th among the states. The ratio ranges from 42 in the District of Columbia to two per 100,000 in Idaho. There are three psychiatry training programs in Minnesota: the University of Minnesota (U of M), Hennepin County Medical Center (HCMC) and Mayo Clinic in Rochester. Collectively they welcomed 22 medical school graduates into psychiatric training on July 1, 2011. Residents and the Training Environment
The role of resident physicians in providing care in training environments has shifted in the last decade. Teaching faculty and residents are no longer interchangeable parts on a care continuum. While there may be benefits to these shifts, they have introduced potential
The Journal of the Twin Cities Medical Society
inefficiencies into clinical care. Two developments stand out in this evolution. First, the Accreditation Committee for Graduate Medical Education [ACGME] and the Center for Medicare and Medicaid Services [CMS] have issued stricter guidelines for the presence of an attending physician during resident clinical activities. For example, despite having completed four years of medical school and passed a national clinical skills examination, as of July 1, 2011, beginning PGY1 psychiatry residents require direct supervision [i.e. must be accompanied by an attending] when attending to patient care assignments. They can advance to indirect supervision after faculty has vetted them on several competencies. Another example, Medicare can only be billed for psychotherapy provided by a resident if the supervising physician observed the entire service [typically 50 minutes] in real time. Second, the practice environment at metro teaching hospitals has become dominated by (Continued on page 16)
November/December 2011
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Psychiatric Services Access to Psychiatric Services (Continued from page 15)
electronic medical record systems. Their complexity has made teaching physicians, many only sporadically on service, more dependent on resident mastery of the electronic interface to accomplish tasks such as entering orders, labs, progress notes, discharge summaries, etc. This means that an attending without a resident may have their efficiency reduced by activities such as calling tech support to have an expired password changed. Even as mandated resident supervision is tighter, the role of the resident as “tech support” has increased. Recruitment Into Psychiatry Residencies
There are 183 categorical psychiatry training programs in the United States that offer 1,097 first year positions. In 2011, 97 percent of these slots were filled, 58 percent by U.S.-based allopathic graduates. The three psychiatry residency training programs in Minnesota filled all of their 22 PGY1 slots [U of M = 7, HCMC = 6, Mayo = 9] offered in July 2011. Fiftyfour percent of the Minnesota matriculants were 2011 graduates of a U.S.-based allopathic medical school. At the University of Minnesota (Twin Cities and Duluth) Medical School an average of 3.9 percent of graduates elected psychiatry residency training over the last five years [20072011]. This number appears to be trending upward locally and nationally. A potential barrier for recruitment begins early in one’s medical training. When students apply to medical school, many envision wearing a white coat, with a stethoscope hanging around their neck. In training, the students spend hours listening to heart sounds, detecting subtle cardiac rhythm variations. Considering psychiatry means re-imagining the image of healing. This barrier can be managed by providing rewarding clinical clerkships and electives, by establishing mentoring relationships with psychiatrists in the initial years of medical training, and creating opportunities for medical students to shadow psychiatrists in practice settings. Precise figures are not kept of the percentage of psychiatry residents who stay in Minnesota following their training, however, the U of M program graduated 20 persons (completed 16
November/December 2011
“I am pursuing a career in psychiatry because I enjoy hearing patients’ stories. Psychiatrists have the privilege of learning about patients’ deepest secrets, desires, fears, and aspirations.”
“The practice of psychiatry necessitates expertise in the fields of biology, psychology, and sociology. Comprehensive knowledge of these three areas allows the psychiatrist to treat the patient as a whole person, rather than simply as the sum of individual organ systems.” Patricia Dickmann M.D. PGY2 resident
48 months of training) in the last five years (not counting residents who transferred to the Child Adolescent Fellowship after three years) and 19 practiced in Minnesota upon graduation. Why Go Into Psychiatry?
The authors serendipitously met with senior medical students interested in psychiatry as well as current residents at the University of Minnesota Psychiatry Residency program as we were preparing this article. We asked that group to discuss “Why go into psychiatry?” and summarized their responses below. According to this group, the reasons to pursue training in psychiatry are numerous. Our trainees have the viewpoint that if mental health is not optimized, then other diagnostic and treatment interventions may fall short. A depressed patient with diabetes may not be managing his illness, even with the most thoughtfully prescribed diabetes management regimen. One student who had recently spent time in the ICU tending to patients who attempted suicide through toxic ingestion felt motivated to treat psychiatric illness at the source, rather than treating the patient medically as a consequence of unmanaged symptoms. Therefore, psychiatric care was seen as an opportunity to improve patient’s quality of life, not just extend it. More tangible benefits follow with a career in psychiatry, as well. Job opportunities, from hospitalist to outpatient practice, are plentiful. Trainees are optimistic regarding job security and excited to know they can pursue sub-specialization within the field and have employers eagerly waiting. Others expressed excitement
that the field integrates “art” along with science. The relative lack of algorithm- and protocolbased care is attractive to those who enjoy creative problem solving. Additionally, psychiatry and the broader field of neuroscience may be considered one of the “last great frontiers” in medicine with ongoing, rapid discovery. They enjoy the idea that well established rapport and therapeutic alliance is a treatment in itself. Sitting with patients as they share thoughts and feelings for the first time is a privilege and interpersonally rewarding. Reaffirming and validating a patient’s “personhood” is a powerful way to connect with others. The students observed those with mental illness are stigmatized in our community and even within the wider medical community. Psychiatry interested students enjoy the role of advocacy and providing a voice and a safe space to those who may feel shame or stigmatization in other settings. They also have an interest in patient narratives and stories. Knowing the whole patient is part of the job. Understanding the patient’s background, environment during development, and other important life events are essential in understanding current brain functioning and this knowledge cannot be captured in a symptom checklist. Thomas B. Mackenzie M.D., program director, University of Minnesota Psychiatry Residency, professor of psychiatry. Kaz Nelson M.D. associate program director, University of Minnesota Psychiatry Residency, assistant professor of psychiatry.
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The “C’s” of DIAMOND in Primary Care DIAMOND (Depression Improvement Across Minnesota Offering A New Direction) is a collaborative care model developed by the Institute for Clinical Systems Improvement (ICSI) for primary care clinics. Jewelers talk about the “C’s” for evaluating diamonds — cut, color and clarity. We could use the same tag line to evaluate the DIAMOND initiative. However, I would change the C’s to culture, continuity, collaboration, care coordination, and consultation to describe how the DIAMOND initiative has enhanced the way that we provide depression care at our clinics at Family Health Services Minnesota (FHSM). When we began implementing DIAMOND in our 12 sites at FHSM four years ago the first change we had to manage was a change in our culture. Our 70 providers are all trained in family medicine and we had little to no experience before DIAMOND on team care. It took time to get the providers to trust the DIAMOND care managers with components of care that they have traditionally performed themselves. Likewise, in primary care we are not accustomed to having a specialist, like the consulting psychiatrist, reviewing our patients and providing feedback outside of the formal referral model. From the beginning of DIAMOND implementation we were sensitive to the culture change that needed to occur, but it was not until we had some patient “stories” that the power of the model gained wider acceptance. We found that when our doctors shared real stories of how their patients received better care due to the DIAMOND model, their colleagues were far more likely to activate patients into the program. The more present that both the DIAMOND care manager and
By Timothy Hernandez, M.D.
MetroDoctors
the consulting psychiatrist can be at the clinic also helps to embed the team concept. The bedrock of primary care is continuity of care and the DIAMOND model is grounded in primary care. Each patient in DIAMOND must be activated by a primary care provider (PCP). We reassure our patients that we are not transferring the care, but rather that the care manager is an extension of ourselves with the time and the resources to reach out to the patients between their visits to their physicians. When providers understand that when patients have multiple touches from the care team between physician visits, they learn to appreciate why patients activated in DIAMOND get better (to remission) faster than those patients in usual care. In fact, there have been at least 38 randomized controlled trials demonstrating that this model is significantly more effective at helping patients achieve remission from their depression. There are multiple reasons for the effectiveness of this model, not the least of which is the role of the DIAMOND care manager. Our DIAMOND care managers at FHSM do not have advanced degrees in psychiatric care. Many are certified medical assistants (CMAs) who have received advanced training through ICSI. Our care managers share a common characteristic in that they relate well with people. Although they do not develop a therapeutic relationship, they develop a caring relationship which helps with healing. They help set small, realistic goals with patients like exercise, setting time for leisure activities and enhancing relationships which supports the medical treatment as well as any counseling or behavioral therapy those patients are receiving. The care managers provide key information like side effects of medications or information regarding medication adherence which allows
The Journal of the Twin Cities Medical Society
Timothy Hernandez, M.D. and granddaughter, Isabella.
me to either contact the patient directly or via the care manager to make the necessary changes. Because they are meeting with the consulting psychiatrist weekly, they can pass on his suggestions to me without unnecessary delays. Although the changes are ultimately the primary provider’s decision to make, the care manager truly coordinates the care for that patient for timely, effective management. As of today there have been a total of 8,376 patients activated in DIAMOND since it was launched in March of 2008. Of those, my organization, FHSM, has activated 3,229 — nearly 40 percent of the total enrollment. (Continued on page 18)
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Psychiatric Services The C’s of DIAMOND (Continued from page 17)
Patients in DIAMOND have experienced a six month remission rate of 48 percent and a 12 month remission rate of 53 percent, while those measured the exact same way in usual care are 23 percent and 30 percent respectively. Comparing DIAMOND to the clinics measured through Minnesota Community Measurement, the average remission rate is <10 percent across the state at six months. The consulting psychiatrist has allowed me and my partners to expand our scope of practice for not only major depressive disorders, but also many other psychiatric conditions. When we introduced DIAMOND four years ago, one of the selling points was better access to psychiatry. Until DIAMOND many of us had not seen a live psychiatrist since our residency. We ask our consulting psychiatrist to go to a different clinic each week for review with the care managers so they can avail themselves for curbside consults about either DIAMOND or non-DIAMOND patients. In addition to
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November/December 2011
the individual patient suggestions that they make, they have been helpful at pointing out trends that they see among our providers with regard to under diagnosis of certain conditions or treatments of certain diagnosis that may be changing. Prior to DIAMOND we had minimal exposure to psychiatry and this program has allowed us and our patients much better access to a scarce resource. In line with the “C’s” theme, our experience with DIAMOND is going through a process of continuous improvement. Although this collaborative model has demonstrated tremendous value for our patients and our providers, barriers like cost need to be constantly addressed. The last time our organization did a return on investment analysis, we were slightly less than breaking even in terms of reimbursement for our dollars invested. Suffice it to say we are not getting rich off the program. The success of the collaborative model for depression begs the question of whether this can be spread to other mental health conditions. In fact, our clinics are teaming up with ICSI as well as programs in Wisconsin and Pittsburgh, to incorporate a substance abuse identification program called SBIRT (Screening, Brief Intervention, Refer to Treatment). As we have improved our ability to screen, diagnose and treat depression with the help of the DIAMOND program, we are recognizing what a significant barrier co-morbid substance abuse is for depression remission. DIAMOND has helped our physicians at Family Health Services Minnesota to provide evidence-based, timely and effective care for depression. The collaborative model has provided a blueprint for the design of our Health Care Home. Our patients who have received care through DIAMOND are very pleased with the relationship they have with the care manager as well as their provider. The DIAMOND program has fulfilled all the “C’s” for our organization and patients. Timothy Hernandez, M.D. is a family physician who has practiced in West St. Paul for the past 23 years. He serves as the medical director for quality for his group, Family Health Services Minnesota and is an adjunct professor at the University of Minnesota, Department of Family Medicine and Community Health. He spends his falls coaching high school football.
MetroDoctors
The Journal of the Twin Cities Medical Society
Behavioral Health Clinics Improve Depression Care
Abstract From its inception in March 2008, the DIAMOND program (Depression Improvement Across Minnesota, Offering a New Direction) has demonstrated that a new approach to delivering and paying for depression care in the primary care setting yields substantially better patient outcomes than standard approaches. Psychiatric leaders in the community began to explore ways to use some of the DIAMOND program elements — especially the standardized use of the Patient Health Questionnaire (PHQ-9) tool and the collaborative process — within behavioral health. From an initial workgroup, a Minnesota Behavioral Health Depression Collaborative (BHDC) was formed in 2009 to establish and implement best practices for depression care in behavioral health clinics. Collecting data in order to measure processes and outcomes was added in the second year of the BHDC. A new state mandate requiring all clinics with physicians on staff to publicly report their depression care performance this year has generated interest among behavioral health groups in this collaborative work. This article describes what the BHDCs have achieved in standardization, process improvement, data collection, measurement and ongoing education to date. Key lessons learned by participating groups are highlighted.
A
ll behavioral health specialists are trained to recognize and treat depression. However, most do not work in settings where measurement-enhanced care is practiced, i.e., many do not use standardized processes and tools to measure their patients’ progress to modify treatment plans and improve outcomes. Measuring outcomes has become more critical in 2011 as quality reporting rules established through the Minnesota Department of Health will require all Minnesota clinics with physicians on staff, including behavioral health groups, to report to MN Community Measurement (MNCM) how many of their patients with depression are in remission six months after treatment starts.
By Michael Trangle, M.D. and Pam Pietruszewski, MA
MetroDoctors
These performance numbers are based on scores from the PHQ-9, a questionnaire that quantifies symptoms of depression such as changes in eating and sleeping patterns and feelings of hopelessness. When administered before treatment begins and at regular intervals thereafter, the PHQ-9 enables providers to monitor the status of patients with depression, adjust therapy and medications as warranted, and quantify improvement.(1, 2) Genesis of the BHDC
Even before the current measurement mandates were implemented for behavioral health clinics, leading psychiatrists became convinced of the value of using the DIAMOND program elements.(3) The 70+ clinics participating in the DIAMOND program use the PHQ-9 as a tool for initial documentation and quantifying symptom severity of depression. Systematic
The Journal of the Twin Cities Medical Society
patient follow-up through additional PHQ-9 scoring and the use of a patient registry, along with regular contact by a care manager between appointments, improve the ability to monitor each patient’s status. Care managers also educate, coordinate and troubleshoot services for patients. A consulting psychiatrist works with each DIAMOND clinic to review and provide recommendations. The DIAMOND program’s results have been dramatic. The DIAMOND clinics collectively have achieved a six-month remission rate of 26 percent for their patients, with some sites achieving remission rates as high as 46 percent. Seeing this significant improvement in patient outcomes in primary care served as a catalyst to form a Behavioral Health Depression Collaborative (BHDC) in 2009. Initially funded by the Minnesota Department of Human Services (DHS) and the Minnesota Association of Community Mental Health Programs (MACMHP), the collaborative was facilitated by ICSI. Its goals were to implement and share best practice methods, get the 18 participating behavioral health organizations to routinely use the PHQ-9 to engage patients in discussions about their progress and clinical decisions, and develop action plans for building processes and measurement into daily workflow. Provider participation ranged from large systems such as HealthPartners Medical Group to smaller, rural groups such as South Central Human Relations Center. Eleven behavioral health groups joined or continued in the 2010 BHDC. Representatives from the Minnesota Psychological Association and Minnesota Psychiatric Society joined the planning committee, and health (Continued on page 20)
November/December 2011
19
Psychiatric Services Behavioral Health Clinics (Continued from page 19)
plans BlueCross and BlueShield of Minnesota, HealthPartners and Medica joined DHS and MACMHP in providing funding. Goals were extended to include: 1. Routine use of the PHQ-9 for initial assessments and to monitor treatment, and reliable tracking of patientsâ&#x20AC;&#x2122; progress via a patient registry; 2. Use of the rapid cycle change model to standardize and improve PHQ-9 administration, workďŹ&#x201A;ow efďŹ ciency and patient follow-up; 3. Team-based care that is efďŹ cient, eliminates gaps in care, and optimizes the role of each team member; and 4. Data collection for process and outcomes measurement. Initial actions included completing readiness assessments to determine a participating clinicâ&#x20AC;&#x2122;s quality improvement infrastructure, identifying a provider champion and team members, and evaluating organizational priorities and resources committed to the project.
Participants then conducted team exercises to modify roles and key tasks and eliminate redundancies, as well as develop and implement clinical process workďŹ&#x201A;ows to align with best practices. The participating BHDC groups also began collecting data and measuring depression care effectiveness for adults with major depression and dysthymia. Measurement was based on sample data from 50 random patients per group (roughly 750 total patients) who were evaluated using the PHQ-9. Results showed that behavioral health clinicians administered the PHQ-9 to nearly 83 percent of patients during their ďŹ rst visit, a high level of standardization. More than half of those patients had at least one follow-up PHQ-9. Of that group, 28 percent achieved treatment response (50 percent reduction in the severity of their depression) and nearly 7 percent were in remission upon follow-up (using the standard deďŹ nition of < 5 on the PHQ-9 for remission). The Minnesota collaborative may be one of the ďŹ rst large-scale attempts to utilize this approach and transparently share results. Also,
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November/December 2011
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the work has been done with very limited resources. The 2009 MNCM report revealed that two out of the top 10 performing clinics for treating patients with depression were behavioral health clinics that had participated in the BHDC (seven out of the other eight top performing clinics were DIAMOND primary care clinics). Implementation/ Lessons Learned
Two groups that have changed their approach to depression care stemming from their BHDC involvement are St. Cloud Hospital and Owatonna-based South Central Human Relations Center (SCHRC). St. Cloud Hospital is part of the CentraCare system and is the largest health care provider in a 12- to 15-county referral area. Its outpatient Behavioral Health Services staff of more than 50 people, including 10 psychiatrists, coordinates care with seven CentraCare primary care clinics that offer the DIAMOND program. The 13-clinician SCHRC group provides behavioral health services to residents of Dodge, Steele and Waseca counties. These two groups emphasize the following key lessons from BHDC. Importance of Champions
Process improvements, standardization and measurement represent major culture change for many behavior health specialists. Because a push for change usually meets some resistance, ICSI helped identify and support respected champions within each BHDC organization. At St. Cloud Hospital, the champions are psychiatrist John Schmitz, M.D., who has advocated for the PHQ-9 after using it in his practice for ďŹ ve years, and psychologist Steve Vincent, Ph.D., director of Behavioral Health Services and the Minnesota Psychological Associationâ&#x20AC;&#x2122;s liaison to BHDC. â&#x20AC;&#x153;Screening is underutilized in both primary care and mental health, even though our professional associations recommend these tools and people are aware of them,â&#x20AC;? Schmitz said. â&#x20AC;&#x153;Primary care physicians feel they donâ&#x20AC;&#x2122;t have time for it and mental health practitioners feel they are the experts and donâ&#x20AC;&#x2122;t need it. But the latter are interested when I explain the DIAMOND clinicsâ&#x20AC;&#x2122; experience and how the PHQ-9 has made me less likely to miss symptoms, how it helps me manage my time and how it can help achieve better outcomes.â&#x20AC;? MetroDoctors
The Journal of the Twin Cities Medical Society
Effective Rapid Cycle Change
Collaborative members have discovered that incremental change achieved through ICSI’s teaching of the Plan-Do-Study-Act (PDSA) rapid cycle change process is an effective way to introduce new tools and processes into their practices. The PDSA model involves trying a small change, and then evaluating the results. In the next cycle, modifications can be made or another change can be added. At SCHRC, the staff worked with ICSI to complete 14 PDSA cycles. The group is preparing to switch from paper charts to an electronic health record (EHR). Through the rapid cycle change process they have: s )NTRODUCED STICKERS TO mAG THE CHARTS OF patients identified with depression based on their PHQ-9 score; s %STABLISHED A PROTOCOL FOR ADMINISTERING the PHQ-9 to all of these patients at least once a month; s %XPANDED USE OF THE 0(1 TO ESTABLISHED patients who had never been screened, asking clinicians to do this with three patients per month; and s 2OLLED OUT CONCURRENT DOCUMENTATION which involves discussing progress notes with patients during appointments, to four to five clinicians at a time so that all will be ready to use it with the new EHR. “We’ve done quite a few QI projects but weren’t familiar with PDSA,” said psychologist Mark Skrien, SCHRC’s clinical director. “We have been able to make a lot of progress and achieve continuous quality improvement. We’re all more accountable for the progress we make with patients, and the staff has not resisted. We ask, ‘In what way can we make this happen?’” Value of the PHQ-9
The mental health practitioners at SCHRC and St. Cloud Hospital have found that standardized use of the PHQ-9 has not only prepared them for measurement requirements but has improved the depression treatment process. “The PHQ-9 has become a conversation starter with patients about the changes they are experiencing during the course of treatment,” Schmitz said. “It’s quick to administer, helps me provide a more thorough consult and makes the evaluation more objective and evidencebased for patients. We have patients who are on medications for a long period of time, and we need a way to see how they are doing.” MetroDoctors
Vincent, who sees patients one day a week, said the PHQ-9 can reinforce patients’ progress. He recalled a case where the patient’s PHQ-9 score dropped from 19 to 17 in a month — not a big improvement — with his primary symptom being a sense of hopelessness. Vincent increased treatment to two consecutive weekly visits. After the patient’s PHQ-9 score dropped to 5, Vincent said, the patient could visibly note the impact of the change in treatment, and was pleased and a little surprised. Skrien said a PHQ-9 sticker on a chart is a motivator and gets him focused on making progress with that patient. He said the PHQ9 “makes us more accountable. We can watch the numbers and change the course of therapy more quickly.” Value of Team-Based Care
The BHDC also is focusing on stepped care and team-based care that optimizes the role of each team member. Some SCHRC clients see a therapist through outpatient services and also see a hospital-based psychiatrist. Skrien said the patient registry record is very helpful in tracking these types of cases. He also noted that peer reviews and multidisciplinary staff meetings, both required for Rule 29 licensure for mental health clinics, have fit nicely with the workflow that was developed for PHQ-9 use. The SCHRC plans to use this as an opportunity to “Trace the Case,” bringing in PHQ-9 administered cases for the entire team to discuss. “We would not have made nearly as much progress on our own,” said St. Cloud Hospital’s Vincent. “We look forward to starting to share symptom-specific and (PHQ-9) score-specific treatment ideas. The BHDC is helping us support, reinforce and sustain the new workflow processes and measures we have adopted.” Paradigm Change
Although primary care has long performed measurement-based care (e.g., using a lipid level to decide whether to adjust a patient’s statin), this has not been the case in behavioral health. It is only very recently that there has been enough evidence for practitioners to begin matching quantitative numbers and timelines to recommendations for depression improvement. (4, 5) Measuring and transparently sharing results and using this data to analyze impacts of using PDSA’s, and then repeating these cycles to
The Journal of the Twin Cities Medical Society
improve systems of care and patient outcomes is another big cultural shift. It is rarely seen in the behavioral health world where resources are scarce and no budgets exist for this. Plans for the Future
In 2011, the BHDC is focused on increasing the reliable usage of the PHQ-9, the steppedcare approach, measuring patient outcomes, and connecting BHDC members with DIAMOND primary care clinics. As the MDH depression care reporting requirements kick in and BHDC clinics show better outcomes, a large number of behavioral health groups are showing interest in this collaborative. Current members have indicated strong support for continuing with the effort, and further integrating primary and behavioral health clinics’ treatment of patients with depression. New clinics have also joined the collaborative this year. References 1)
2)
3)
4)
5)
Duffy F, Chung H, Trivedi M, et al. Systematic Use of Patient-Rated Depression Severity Monitoring: Is It Helpful and Feasible in Clinical Psychiatry. Psychiatric Services, October 2008, Vol. 59, No. 10. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a Brief Depression Severity Measure. J Gen Intern Med 2001; 16:606-13. Solberg L, Glasgow R, Unutzer J, et al. A Practical Trial Design for Evaluation of Natural Experiment to Improve Depression Care. Med Care 2010;48: 576–582. Gaynes B, Rush J, Trivedi M. Primary Versus Specialty Care Outcomes for Depressed Outpatients Managed with Measurement-Based Care: Results from STAR*D. Gen Intern Med 23(5):551–60. Rush, AJ, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. Am J. Psychiatry, 2006: 163:1905-1917.
Michael Trangle, M.D. is the associate medical director of Behavioral Health for HealthPartners Medical Group/Regions Hospital. Pam Pietruszewski, MA is the education program lead at the Institute for Clinical Systems Improvement. She is a trainer and facilitator for the DIAMOND depression initiative, and serves as a consultant for the Behavioral Health Depression Collaborative.
November/December 2011
21
Psychiatric Services
Understanding Depression, Hope Through Treatment
M
innesotans can be proud that two of our own, Jim Ramstad and the late Paul Wellstone, spearheaded the Mental Health Parity Act. Beginning January 1, 2012, Medicare will begin implementing mental health parity by covering depression screening. Here in our state we already have made progress screening for depression by utilizing the PHQ-9 as part of the DIAMOND Project. However, screening is something other than evaluation and treatment. The inherent nature of depression, including its complexity and its relation to other health problems, has raised concerns about what constitutes a standard of good practice for the treatment of depression. In the last year, 2010-2011, the Minnesota Medical Association President and family physician, Patricia Lindholm, made it a priority to focus on physician well-being, burnout, and specifically the mental health of physicians who are frequently overwhelmed by the rapid changes, increased workload, and the current pressures of medical practice. After Dr. Lindholm invited me to join the MMA Physician Well Being Task Force she told me that she had suffered major depression and was already speaking out to various medical groups about how common this is among physicians and how important it is to overcome the stigma and receive appropriate care. In turn, I told Dr. Lindholm about my idea for a television and educational series on the varied manifestations of depression across the life cycle and the need for timely treatment. I had been the medical director of the Hamm Clinic for 25 years, and have had an interest in the collaborative inter-discipline care of depression with family practitioners based By James J. Jordan, M.D.
22
November/December 2011
on our consultation work with the United Family Medicine Clinic in St. Paul. Dr. Lindholm was more than willing to be one of the people interviewed about her experience for this possible series. She also said that she would ask the Minnesota Medical Association to support the project as part of their continuing education efforts. Because I had worked James Jordan, M.D. interviews Patty Lindholm, M.D. with Mary Hanson, individuals of different ages, all of whom sufLISW, host/producer of the award-winning fered major depression. Each person told of Mary Hanson Show on a three-part series enhow a depressive illness developed in her/his titled “Voices of Mental Health and Mental life and of the challenge it was to find effective Illness,” I contacted her. Mary and I then set evaluation and treatment. Our four guests were: out to produce a five-part series with the prophysician Patricia Lindholm, nurse Cheree duction assistance from KSTP Television and Langmade, former Minnesota State Senator/ financial and in-kind support from individual donors, foundations and health organizations. Majority Leader and lawyer John Hottinger, and retired bank vice president Peter Gillette. Our new series is entitled “Understanding The four guests talked on camera about Depression, Hope Through Treatment.” The situations that precipitate depression — stress five part series is being aired initially in Minat work, job loss, abuse, loss of loved ones, nesota on cable television this fall and on public and family dysfunction. Each of them told an television (TPT) in early January, 2012. Cable often painful story about the recognizable feabroadcasting kicked off on Monday, October tures of full-blown depression — severe anxiety 3, on the Metro Cable Network, MCN Chanand depressed mood, incapacitating physical nel 6, which interconnects the 14 Twin Cities complaints, sleep disturbances, loss of motivametro cable systems covering the seven county tion and capacity for pleasure, and thoughts of area. The segment with Patricia Lindholm, suicide. Clearly, they understand the benefit of M.D., aired on Monday, October 17. More speaking out, of defusing stigma, and providing detailed broadcast information is available at hope for those in similar circumstances. All MetroDoctors.com. four interviewees spoke to the importance of In our series we interviewed four
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The Journal of the Twin Cities Medical Society
psychotherapy in their recovery, and three of them report that medication was a component part of their treatment plan. In the second part of each program, Mary and I discuss the issues raised by the guests that our viewers would want clariďŹ ed and talk more about major depression in general. Available resources and referral information are also included in each program. Beyond airing this ďŹ ve part series on television here in Minnesota and around the country, we plan to also distribute the series for teaching and learning purposes. We anticipate the series can be used for family practice and psychiatry residents, other mental health professionals, state and local mental health advocates and library systems. James J. Jordan, M.D. served as the executive medical director, Hamm Memorial Psychiatric Clinic, St. Paul, MN for 25 years. He is a clinical professor at the University of Minnesota Department of Psychiatry and has held an appointment on the Minnesota State Advisory Council on Mental Health since 2008.
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Functional Neuro-Imaging Wenbo Zhang, MD, PhD Neuropsychologists Elizabeth Adams, PhD Robert Doss, PsyD Ann Hempel, PhD Donna Minter, PhD Gail Risse, PhD
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November/December 2011
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Psychiatric Services
Frontiers of Psychiatric Research
I
n examining the question of “What’s New in Psychiatry?” the answer could be that there has not been a historic breakthrough in recent years. On the other hand, the literature in psychiatry and clinical neurosciences continues to expand at a breathless pace, making the summary of all the advances in our field a challenge to track. For this current article, I would like to focus on advances that are being made here in Minnesota or are having an impact on the advance in practice. Some of the advances in clinical care have focused on early recognition of serious psychiatric illnesses which is an underpinning of emerging programs in the region. Of interest is that the expansion of many new approaches may lead to sub specialization — even beyond the current fellowships. One area of advancement in knowledge regarding psychiatric illness has been emerging from the field of brain imaging — especially the use of MRI techniques. The University of Minnesota’s Center for Magnetic Resonance Research (CMRR) has just received a major award from the National Institute of Health to expand on the understanding of brain structure and connections. Interestingly, 45 percent of the scans at the CMRR are performed in the area of psychiatric illness. Recent findings are emerging in schizophrenia, childhood mood disorders, and traumatic brain injury. Contributions by the University of Minnesota, under the direction of Dr. Kelvin Lim, have shown that myelin, the white matter insulating material around nerve axons, has different abnormalities in psychiatric illness.
By Charles Schulz, M.D.
24
November/December 2011
These results point to issues of how the different parts of the brain may communicate with one another in schizophrenia and traumatic brain injury (TBI). A major step forward in connectivity has emerged from research by Dr. Kathryn Cullen, assistant professor of psychiatry at the University of Minnesota, who is now demonstrating functional connectivity in brain imaging and demonstrates its abnormalities in adolescents with depression. This may lead to further work on early diagnosis and perhaps a better understanding of the early onset of depression. Collaborations in the area of pharmacogenomics are emerging between the Mayo Clinic and the University of Minnesota. Drs. Mark Frye, chair of the Department of Psychiatry and Dr. Scott Crow, professor of psychiatry at the University of Minnesota have been working
on ways to predict who might have a manic episode when given an antidepressant. The use of genes to predict either response or sideeffects continues to emerge. Beyond the area of imaging and genetics, one emerging movement in the field is to identify psychiatric illness at its outset or even during its prodromal phase. Research from around the world has demonstrated that early identification and then appropriate treatment for schizophrenia can reduce poor outcome for a number of years in the future. The University of Minnesota has started a First-Episode Program under the medical directorship of Dr. Michael O’Sullivan — a program that not only includes treatment such as hospitalization on the Psychosis Unit at UMMC, but also includes a special clinic for young people in the University of Minnesota Physicians (UMP) outpatient area. Even more important is the creation of the First-Episode Family Psychoeducation Group. These collaborative approaches to address the problems of people at the outset of their illness are leading a number of these young people to be able to return to high school or college. Furthermore, the feedback from parents is that the Family Psychoeducation Group is not only providing excellent information about the illness but also leads to support between families. Another emerging field in clinical neuroscience is neuromodulation. One neuromodulation treatment, deep brain stimulation, is now being studied for refractory depression at the medical school. Amazingly, the first DBS treatment for a patient with OCD in Minnesota was performed this year through collaboration of Drs. Jon Grant and Aviva Abosh. The issue of stigma of psychiatric illness — an area in which many faculty members
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in the area of specialization, there are fellowships in addictions, geriatric psychiatry, forensics, and consultations liaison (psychosomatics). In addition to these fellowships, child and adolescent psychiatry is a two year fellowship so that a psychiatrist can be well prepared to work with childhood illnesses. However, there are discussions about creating specialized programs for people with speciďŹ c psychiatric illnesses because of the large amount of new information and multiple treatment possibilities. For example, Dr. Jon Grant has established a Pathologic Gambling Program at the University of Minnesota and
has combined that program together with Fairviewâ&#x20AC;&#x2122;s Gambling Clinic. At this time, there are not post residency training programs for psychiatrists who focus on becoming a program leader for a speciďŹ c illness. A new issue may be an emerging debate about how such specialization beyond the current sub specialty programs will become established. Some in the ďŹ eld have indicated that internal medicine has specialization based on cardiology, cancer, nephrology and endocrinology and that these fellowship programs lead to importantly focused care on serious illnesses. The ďŹ eld of psychiatry could be examining such approaches as the importance of early intervention, maintenance of appropriate treatment and integration of psychosocial, medication, and perhaps even pharmacogenetics emerges. Charles Schulz, M.D., professor and head, Department of Psychiatry, University of Minnesota.
Depressed teens have lower integrity of white matter in connection between two key emotion centers. Image courtesy of Kathryn Cullen, M.D.
have worked with National Alliance on Mental Illness (NAMI) and its Executive Director, Sue Abderholden â&#x20AC;&#x201D; continues to be a major challenge. Even though the ďŹ eld has shown through careful research that early intervention can lead to better outcomes in the ďŹ rst three-ďŹ ve years of the illness, stigma can get in the way of early referral and treatment. The Department of Psychiatry at the University of Minnesota and NAMI have created the NAMI Research Dinner as a way to have University faculty collaborate with NAMI on information about psychiatric illnesses and ways to extend research. Collaboratively, the NAMI Walk has grown substantially and will hopefully continue to be a way to decrease shame and secrecy about illnesses such as schizophrenia, bipolar disorder, and depression. As noted earlier, many of the advances in the ďŹ eld of psychiatry are leading to much greater complexity in the approaches to these severe illnesses. Many of the advances lead to a broad number of evaluation and medication strategies as well as new psychosocial treatments and of course their combination. Currently MetroDoctors
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November/December 2011
25
Psychiatric Services
PrairieCare: Access to In-patient Services for Children and Adolescents
I
t is well understood that a substantial number of children, adolescents and adults will suffer from mental illness at some point in their life. Indeed, approximately 20 percent of kids are estimated to have a mental illness resulting in at least mild impairment in function, while it is thought that the prevalence of mental illness in adults is approximately 19 percent.1 These prevalence estimates suggest that millions of children, adolescents and adults struggle with mental illness at any point in time, however far fewer seek and receive care. The morbidity and mortality associated with untreated mental illness is profound. Here in Minnesota, suicide is the third leading cause of death for youth ages 10-14, and is the second leading cause of mortality for individuals 15-34.2 Unfortunately, it is often difficult for patients seeking psychiatric care to access services. In the Twin Cities metropolitan area, PrairieCare recognizes this problem and is expanding access to mental health care to patients of all ages. PrairieCare established a presence in the Twin Cities in 2005 as an outreach clinic for Prairie St. John’s psychiatric hospital in Fargo, ND (a physician-owned hospital founded in 1996). It has operated since 2009 as a separate legal entity under the direction and ownership of Dr. Stephen Setterberg, a board certified child, adolescent and adult psychiatrist. In February of this year, PrairieCare opened 20 inpatient psychiatric beds for children and adolescents in Maple Grove, representing the first significant expansion in child psychiatric inpatient services in Minnesota in the previous 15 years. In the past six years, the organization has grown dramatically and now employs or contracts with 13 psychiatrists, 10 of which
By Joel V. Oberstar, M.D.
26
November/December 2011
are child and adolescent psychiatrists. In addition, PrairieCare employs or contracts with 13 social workers, 24 master’s level therapists, four psychologists and four CNS/APRNs, and serves as a training site for the University of Minnesota Department of Psychiatry.
so in the context of their usual environment. Youth in the IOP receive three hours of therapy in programming and three hours of academic work in their usual school, whereas adults can choose either a three hour morning track or a three hour afternoon program. Partial hospital programs (PHP) for youth provide approximately seven hours of programming per day and include time for schooling within the program, allowing patients to maintain academic progress during this more intensive treatment. Patients attending PHP frequently suffer such severe symptoms as to cause impairment in their school functioning; thus, schooling in the PHP allows the patient to receive enhanced psychiatric and psychological support while still keeping up with their schoolwork as able. Lastly, inpatient hospitalization is available for children and adolescents suffering from an acute psychiatric illness or an exacerbation of an existing illness; this level of care includes 24-hour nursing and individual, group, family and milieu therapy. Patients for whom inpatient admission is appropriate include youth who are severely depressed and suicidal, psychotic, or severely aggressive or manic.
Care Continuum:
Needs Assessment:
Psychiatric care is provided along a continuum of different “levels of care.” Outpatient care includes ambulatory psychiatric medication management and individual, family, and/or group psychotherapy. These visits typically occur on a once per week or similar basis; outpatient care is typically thought of as the least intensive level of care. The intensive outpatient program (IOP) provides more concentrated programming, typically three hours per day, five days per week. IOP is appropriate for patients who need organized treatment services, but are able to do
Determining what level of care is appropriate for a patient can be challenging to nonpsychiatrists. To help facilitate access to care, PrairieCare offers a free needs assessment to any patient/family requesting evaluation. The assessment is performed by a master’s level clinician or a nurse — in consultation with a psychiatrist — and is focused on establishing a preliminary diagnosis and referring the patient/family to the appropriate level of care (e.g., inpatient, PHP, etc.). Approximately onehalf of patients seen for a needs assessment
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The Journal of the Twin Cities Medical Society
are referred outside the PrairieCare system. Our needs assessment counselors strive to keep abreast of the wide variety of outpatient and other care settings that may be appropriate for the patient’s needs. The needs assessment itself typically lasts one-two hours and is available at all three locations (Woodbury, Edina and Maple Grove) by calling 1-888-9-PRAIRIE. Clinicians interested in referring cases may call the clinician line directly (952-826-8424) 24-hours per day. As mentioned earlier, it is often difficult for non-psychiatrists to know what level of care is appropriate for a particular patient. The following are hypothetical examples of typical cases for whom a given level of care may be appropriate: Case: Jim is a 13-year-old boy with moderate generalized anxiety disorder who is managing fairly well in his day-to-day life. He has never seen a mental health provider, and failed to mention these symptoms when seen recently by his family physician for a sports physical. Referral: Given his moderate symptoms with fair academic/social functioning, Jim would benefit from referral back to his family physician for consideration of an antidepressant medication trial; he also may benefit from referral to a psychologist specializing in cognitive behavioral therapy. Case: Stacy is a 16-year-old young woman with a long history of depression and more recent self-injurious behavior. She is engaged in weekly outpatient psychotherapy and receives antidepressant medication from her pediatrician. During a routine well-child visit, she discloses that she has been having frequent
thoughts that life isn’t worth living and her self-injury has intensified in frequency and severity. She adamantly denies active suicidal ideation, intent, or plan. She tearfully notes she’s been particularly upset since a break up with her boyfriend and notes her grades have plummeted from A’s to C’s. Referral: Given her fairly severe symptoms, poor school functioning, acute exacerbation in the face of outpatient treatment, along with the absence of active suicidal ideation, intent, or plan, Stacy may benefit from referral to PHP. There she will receive daily psychotherapy along with psychiatric consultation and treatment. Case: Bobby is an 8-year-old boy with reactive attachment disorder and attention-deficit hyperactivity disorder who has recently been removed from his parents’ home in the context of allegations of physical abuse. He is being cared for by his grandparents, who bring him to his pediatrician for evaluation of severely aggressive behavior and mood swings. He has been suspended from school after hitting several students, throwing objects at the teacher, and threatening to stab the principal with a pencil. After several years of no difficulties, he recently has started bedwetting again. Additionally, his grandparents are concerned with his decreased appetite, weight loss, and mood reactivity. Referral: Given his severe mood lability and aggression that has resulted in harm to others, inpatient hospitalization may provide an opportunity to evaluate him in a highly structured therapeutic environment. Following acute stabilization, discharge from inpatient to PHP and then back to school may provide a smooth transition back to outpatient care.
Maple Grove, MN (12915 63rd Avenue North) Child/Adolescent: Inpatient, PHP, IOP. Edina, MN (6545 France Ave. South, Suite 302) Child/Adolescent: PHP, IOP, clinic. Adult: IOP (Spring 2012), clinic. Woodbury, MN (7616 Currell Blvd.) Adult: IOP, clinic. Needs assessments performed at all sites.
MetroDoctors
The Journal of the Twin Cities Medical Society
As noted, the cases described are purely fictional, but provide examples of how patients may benefit from different treatments available. PrairieCare welcomes referrals from clinicians as well as family, friends, teachers and others. All major payers including Medical Assistance, are accepted within the PrairieCare system. PrairieCare’s financial assistance program is also available to patients and families who qualify. Clinicians and patients/families are encouraged to call with any questions or concerns (1-888-9-PRAIRIE). (Endnotes) 1. Mental Health: A Report of the Surgeon General. Available at: http://www.surgeongeneral.gov/library/mentalhealth/home. html. Accessed 9/19/2011. 2. National Center for Health Statistics (NCHS), National Vital Statistics System. Available at: http://www.cdc.gov/injury/wisqars/index. html. Accessed 9/19/2011.
Joel V. Oberstar, MD, is a board certified child, adolescent and adult psychiatrist. He trained in general psychiatry at Harvard Medical School and in child/adolescent psychiatry at the University of Minnesota. An assistant professor of psychiatry, he is associate training director of the child/adolescent psychiatry fellowship at the University of Minnesota and recently assumed the positions of CEO and Chief Medical Officer at PrairieCare.
TCMS Forum co-sponsored by Minnesota Psychiatric Society
“Mental Health: Improving Access and Quality” Thursday, December 8 7:00-8:30 a.m. Watch for more details.
November/December 2011
27
TCMS Physicians Participate in MMA House of Delegates
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ifty members of the Twin Cities Medical Society participated in the Minnesota Medical Associationâ&#x20AC;&#x2122;s annual meeting and House of Delegates September 15-16, 2011 in Duluth, MN. Topping the list of highlights was the installation of Lyle Swenson, M.D. as MMA president. He is a TCMS member and a cardiologist at East Metro Cardiology in St. Paul. At a pre-inaugural reception, Dr. Swenson described his passion for the â&#x20AC;&#x153;profession of medicineâ&#x20AC;? and is committed to â&#x20AC;&#x153;supporting and advocating for physicians and their patients.â&#x20AC;? In addition to Dr. Swensonâ&#x20AC;&#x2122;s installation as President, the following TCMS physicians were elected:
Stephen Darrow, M.D., Resident Fellow Section representative, and incoming TCMS Board member.
Son of Drs. Ron and Elisa Hansen, this is the second meeting of the MMA House of Delegates Logan has attended.
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s
2OBERT -ORAVEC - $ 6ICE 3PEAKER House of Delegates s -ACARAN "AIRD - $ "OARD OF 4RUSTEES At-Large Member s "ETH "AKER - $ "OARD OF 4RUSTEES s $ONALD *ACOBS - $ "OARD OF 4RUSTEES s 0HILLIP 3TOLTENBERG - $ "OARD OF 4RUSTEES s $AVID %STRIN - $ !-! !LTERNATE Delegate s 7ILLIAM .ICHOLSON - $ !-! !LTERNATE Delegate s 3TEPHEN $ARROW - $ !-! !LTERNATE Delegate; Speaker, Resident Fellow Section. TCMS members submitted 10 of the nearly 30 resolutions which were discussed in reference committees and debated on the ďŹ&#x201A;oor of the House of Delegates. Drs. Vikram Jakhav (resident), Ken Kephart, Renee Koronkowski, Louis Ling, and Lisa Mattson served as members of the reference committees. (Final actions of the House of Delegates will be posted on the MMA website when available.) In recognition of their commitment of time and expertise for serving and representing their colleagues in a professional and exemplary manner, commendations were acknowledged for Blanton Bessinger, M.D., alternate delegate to the American Medical Association House of Delegates, and Charles Terzian, M.D., MMA Board of Trustees.
Medical students Laura Gorsuch and Rebecca Stepan enjoy the President's reception.
A toast to incoming MMA President Lyle Swenson, M.D. (right) by TCMS President Thomas Siefferman, M.D.
Drs. Amy Gilbert and Mac Baird (far right) welcome ďŹ rst-time delegate Christopher Reif, M.D.
Kent Wilson, M.D., George Lange, M.D., president, Wisconsin Medical Association, and Sue Schettle, TCMS CEO.
MetroDoctors
The Journal of the Twin Cities Medical Society
West Metro Medical Foundation Presents Charles Bolles Bolles-Rogers Award
O
n Thursday, October 6, 2011, West Metro Medical Foundation chair, Richard D. Schmidt, M.D., presented Stacy A. Roback, M.D., a retired pediatrician, with the Charles Bolles Bolles-Rogers Award at a meeting of the Professional Staff of Children’s Hospitals and Clinics of Minnesota, held at the Town & Country Club in St. Paul, MN. Susan Sencer, chief of staff, Children’s Hospitals and Clinics of Minnesota, stated “Dr. Roback has never lost sight of what is truly important in his job: caring for his patients and their families.” He exudes warmth and empathy and does whatever he can to make the journey, and outcome, the best it can be.” His personal mission to help foster a new generation of researchers and inspire student curiosity and leadership earned him the recognition of an outstanding teacher. His passion and commitment to serve as a mentor has inspired possibly several hundred students as he actively guided them down the right path to
success. Testimony from two of his protégés achievement or leadership. Award nominations confirmed his dedication and loyalty to their are submitted by west metro medical staff leadpersonal journeys as they have also achieved ers; the WMMF Board of Directors selects the goals of becoming physicians. recipient. Dr. Roback received his medical degree from Tulane University School of Medicine; completed an internship and residencies in pediatrics, general surgery, pediatric surgery and thoracic/cardiovascular surgery at the University of Minnesota. He is board certified in all four specialties. The Charles Bolles Bolles-Rogers Award is given annually by the West Metro Medical Foundation of the Twin Cities Medical Society to an outstanding physician Richard Schmidt, M.D., WMMF chair, and Susan Senser, M.D., for his/her professional con- chief of staff, Children's Hospital and Clinics of MN, present the tribution to medical research, Charles Bolles Bolles-Rogers Award to Stacy A. Roback, MD.
Honoring Choices Minnesota Happenings
T
he message of Honoring Choices Minnesota continues to spread rapidly. TCMS is consistently receiving emails and phone calls from members and other Minnesotans who are eager to learn more about the advance care planning methods and find out how to get involved. Recent events and opportunities for Honoring Choices included: s $OCUMENTARIES ON 4WIN #ITIES 0UBLIC Television — Honoring Choices at the End of Life aired in September, End of Life Choices: Through History aired in late October and Honoring Choices: Medical Care will air in November. The documentaries can also be viewed online at www.honoringchoices.org. MetroDoctors
s
s
The Journal of the Twin Cities Medical Society
.EW ADVANCE CARE PLANNING PATIENT EDUcation materials are now available for purchase at www.metrodoctors.com. The content for these six pieces was licensed from Gundersen Lutheran Medical Foundation and revised with input from several health systems in the Twin Cities. The materials can be purchased with the ability to place your organization’s logo at the top. (UNDREDS OF CALLERS LISTENED IN DURING A recent AARP Minnesota tele-townhall meeting, hosted by AARP MN Director, Michele Kimball, and featuring Sandy Schellinger, RN, NP, program development manager for Advance Care Planning
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at Allina Home and Community Services; Kent Wilson, M.D., Honoring Choices medical director; and Honoring Choices staff. !MBASSADOR TRAINING PROGRAMS — one for health care professionals and one for lay community members — have been developed by Barbara Greene, Honoring Choices Minnesota community engagement director. Twenty-four ambassadors will be trained in 2011; a second cohort will begin in early 2012. Honoring Choices Ambassadors serve as community educators to introduce advance care planning in Minnesota communities.
November/December 2011
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In Memoriam Give to the Max Day November 16, 2011
Donate to t &BTU .FUSP .FEJDBM 4PDJFUZ 'PVOEBUJPO t 8FTU .FUSP .FEJDBM 'PVOEBUJPO
LOWELL W. WEBER, M.D., passed away on August 15, 2011 at the age of 88. Dr. Weber practiced internal medicine in Minneapolis for over 40 years. He earned his medical degree at the University of Illinois â&#x20AC;&#x201C; Chicago in 1946. Dr. Weber served in the Army and practiced at a VA hospital before joining a medical practice in Minneapolis. He enjoyed the outdoors and nature, spending time feeding the wildlife around his home and cabin. Dr. Weber has been a member of TCMS since 1952. DENO JOHN WEDES M.D., age 87, passed away on July 28, 2011. Dr. Wedes served in the Navy during World War II as well as the Korean War where he received the Bronze Star Medal for valiant actions. Dr. Wedes obtained his medical degree from the University of Minnesota and served as a family physician for over 50 years in Maplewood and East St. Paul. He loved and valued his family and friends, visiting his cabin, and gardening. Dr. Wedes has been a member of the medical society since 1950.
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November/December 2011
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The Journal of the Twin Cities Medical Society
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November/December 2011
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
EDWARD W. POSEY, M.D. One certainly didn’t have to start out in the Upper Midwest to make an exceptional contribution to Twin Cities medicine. Such was the case with Dr. Ed Posey whose roots were in Youngstown, OH prior to his graduations from Ohio State University and the Meharry Medical College in Nashville, TN. After taking general surgery residency work at Case Western Reserve University, he moved to Minneapolis in 1956 and practiced family medicine. While engaged in his private practice, he spent two years as a staff physician at Anoka Metro Regional Medical Center. It was there, influenced by Dr. Bill Bernstein, that his interest in psychiatry was engendered. Dr. Posey completed his psychiatry residency in the U of M/Veterans Administration (VA) program, became board certified and three years later was elevated from a staff position at the VA Medical Center to become its chief of psychiatry — later becoming the long standing chief of the VA’s Mental Health Clinic. He has been a psychiatric examiner for the American Board of Psychiatry and Neurology (ABPN) for 30 years. During that amazing time frame, he examined countless applicants, which interestingly included Dr. Carolyn Robinowitz, a future president of the ABPN. Dr. Posey’s accomplishments and honors are many. He served our country in Korea and Japan as a U.S. Marine medical officer. He founded the Day Hospital for veterans in Minneapolis, a model for such programs in numerous other VA centers. He was the first licensed African American psychiatrist in Minnesota, and was honored as a Distinguished Life Fellow in the American Psychiatric Association. In 2009, he was named Professional of the Year by the National Alliance on Mental Illness-Minnesota Chapter. In addition to the striking periods of service with the ABPN and VA, he was the adult psychiatrist at North Point Health and Wellness Center (formerly Pilot City) for over 40 years. The good doctor rightfully received a commendation from the Hennepin County Board of Commissioners for this epic period of dedicated work. When he first came to our community, he noted a general reluctance of white patients having a black physician minister to their needs. Numerous accounts of his gentle, caring and compassionate approach soon resulted in essentially
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total acceptance of this superb physician by all. His welcome to the Twin Cities was then complete. Dr. Lee Beecher, a respected psychiatric colleague in his own right, stated, “Ed has been a Bridge Over Troubled Waters for thousands of Minnesotans of all racial and ethnic backgrounds.” When Dr. Posey, a mentor, examiner, administrator and academician was asked what portion of his career was most gratifying, he replied without hesitation, “Directly being with and caring for my patients.” Dr. Beecher went on to state, “Ed, in his practical approach to treatment, demystifies, destigmatizes, and imparts a can-do attitude. He is a presence!” Dr. Posey, recently retired and recently widowed, currently spends much quality time with his three successful Minnesota-educated children and their families. His impact on our community, a place he has contentedly called home for over half a century, has been profound. How fortunate we have been that he chose to grace the Twin Cities with his presence those many years ago.
This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
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