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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor 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. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS.
November/December Index to Advertisers TCMS OfďŹ cers
President: Edwin N. Bogonko, M.D. President-elect: Lisa R. Mattson, M.D. Secretary: Carolyn McClain, M.D. Treasurer: Kenneth N. Kephart, M.D. Past President: Peter J. Dehnel, M.D. TCMS Executive Staff
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, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Communications and IT Coordinator (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Karen Peterson, Program Manager, Honoring Choices MN (612) 362-3704 kpeterson@metrodoctors.com Terri Traudt, Project Director, Honoring Choices MN (612) 362-3706 ttraudt@metrodoctors.com
Billing Buddies MN .........................................26 CrutchďŹ eld Dermatology.................................. 2 DMG Financial Group ... Inside Front Cover Fairview Health Services .................................31 Fraser ....................................................................... 1 Greenwald Wealth Management .................... 4 HCMC .................................................................17 Healthcare Billing Resources, Inc. ...............24 Lockridge Grindal Nauen P.L.L.P. ................. 9 Minnesota Epilepsy Group, PA ....................11 MMIC ................................ Outside Back Cover Multicare Associates .........................................20 Novartis Pharmaceuticals Corp. ........................ Inside Back Cover St. Cloud VA Medical Center .......................30 Saint Therese.......................................................22 Uptown Dermatology & SkinSpa................20 U of M CME........................................................ 4 Whitesell Medical Locums, Ltd. ..................31
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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 MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.
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November/December 2013
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The Journal of the Twin Cities Medical Society
CONTENTS VOLUME 15, NO. 6
2
Index to Advertisers
5
IN THIS ISSUE
NOVEMBER/DECEMBER 2013
“I Know That I Don’t Know” Socrates By Charles G. Terzian M.D.
6
PRESIDENT’S MESSAGE
Many Thanks By Edwin N. Bogonko, M.D.
7
TCMS IN ACTION
By Sue Schettle, CEO
Page 32
COLLABORATIVE MEDICAL MODEL
8
•
Aligning Minnesota with National APRN Consensus Model By Senator Kathy Sheran
10
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A Focused Effort on Team-Based Care By Julie Anderson, M.D.
12
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Colleague Interview: A Conversation with Connie W. Delaney, Ph.D., RN, and Dawn Ludwig, Ph.D., PA
16
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The Future Primary Care Dilemma By Leah Anderson, MS2
Page 16
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The Case for Collaboration By Laurie Drill-Mellum, M.D., MPH
21
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You Don’t Know What You Don’t Know By Judith Shank, M.D.
23
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PNPs, PAs, Let Us Count the Ways... By Mary Jenkins
Page 7
25
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Embracing Advanced Practice Clinicians By Leslie Milteer, and Matt Brandt
27
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Your Voice: Me or We: Independence Versus Collaboration By Lisa Mattson, M.D.
28
MMA Annual Meeting and House of Delegates
29
Healthy Eating Minnesota Celebrates Accomplishments/ White Coat Ceremony
30
Career Opportunities
32
LUMINARY OF TWIN CITIES MEDICINE
Deane C. Manolis, M.D.
Page 28
MetroDoctors
The Journal of the Twin Cities Medical Society
On the Cover: With the primary care workforce shortages, more advanced practice clinicians are being used to fill the gaps. Articles begin on page 8.
November/December 2013
3
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University of Minnesota Continuing Professional Development 2013 CME Activities Donald Gleason Conference on Prostate & Urologic Cancers November 8, 2013 Internal Medicine Review & Update November 13-15, 2013 Emerging Infections in Clinical Practice & Public Health: New Developments November 22, 2013
2014 CME Activities Psychiatry Update: Promoting Healthy Eating & Lifestyles April 3-4, 2014 Cardiac Arrhythmias April 4, 2014
Integrated Behavioral Healthcare Conference April 25, 2014 Pediatric Dermatology April 25, 2014 Annual Surgery Course: Vascular Surgery May 1-2, 2014 Global Health Training (weekly modules) May 5-30, 2014 Midwest Cardiovascular Forum May 17-18, 2014 Bariatric Education Days: Decade of Bariatric Education May 21-22, 2014 Workshops in Clinical Hypnosis June 5-7, 2014
ONLINE COURSES (CME credit available)
www.cme.umn.edu/online U Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health U Nitrous Oxide for Pediatric Procedural Sedation U Fetal Alcohol Spectrum Disorders (FASD) - Early IdentiďŹ cation & Intervention
For a full activity listing, go to www.cmecourses.umn.edu (All courses in the Twin Cities unless noted)
OfďŹ ce of Continuing Medical Education 612-626-7600 or 1-800-776-8636 U email: cme@umn.edu
Promoting a lifetime of outstanding professional practice
4
November/December 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
“I Know That I Don’t Know” Socrates
I REMEMBER BACK IN THE EARLY 1990s there was a physi-
cian surgeon in the southwestern United States who held a conference every year expounding on “what we do not know regarding the proper medical care a patient should receive.” Recently, one of my patients surprised me by saying she appreciated that I said I didn’t know what was causing her problem. I told her I would enlist the help of my colleagues to assist in determining the cause. When she asked about further tests, I mentioned that I didn’t know which would be the best, and I would defer any further testing until my colleagues gave their opinions. I told the patient I did not want to order the wrong tests, increase the cost of her care unnecessarily and, unfortunately too often, get led down the wrong path in my helping to find a diagnosis. It is important to understand our limitations as health care professionals, whether one is a physician, a physician assistant or in the nursing profession. Equally important is to be cost conscious when ordering tests and studies. Knowing what you don’t know is probably the most important aspect of health care management and knowing when to ask for help is second. Dr. Mattson, the president-elect of TCMS reminds us of the words physicians cite in their “Hippocratic Oath.” Another of our colleagues, Dr. Shank addresses this concept in her transformation from nursing to medicine. In this issue of MetroDoctors we explore/contrast/define what has become the overwhelming current collaborative practice of medical/surgical management of patients. Yet, it is done not without significant varying perspective and controversy. Our (the editors) ambitions were to present some of this information to you the reader and allow you to make your own decisions. (As a disclaimer, I work as a hospitalist and I have been involved in teaching and educating residents, medical students, PA and CNP students.) This edition provides insight based on colleague interviews with the director of the University of Minnesota Nursing Program and the director of Augsburg’s PA program. We are educated about the extent and scope of these advanced degree professionals and their training. Some of the opinions expressed in their responses are strong but not unexpected.
By Charles G. Terzian, M.D., Member, MetroDoctors Editorial Board
MetroDoctors
The Journal of the Twin Cities Medical Society
Various models for collaboration exist. The range is considerable from close scrutiny to quasi-independent practice. We have articles from a few group practices which have successfully integrated advanced practice clinicians into their care management. In collaboration we need to be aware of everyone’s role on the health care team and accurately identify the health care professional. At the facility where I work we have undergone a process (though not without controversy) to accurately identify the members of the health care team by large badges and color-coded apparel. This is to ensure that patients understand who is walking into the room to care for them. Information is included about the excellent patient satisfaction scores and decrease in overhead costs credited to nurse practitioners and physician assistants. However, little data is available concerning overall cost of health care for the individual and the system. Dr. Drill-Mellum, medical director at MMIC, addresses the risk management perspective where she notes effective collaboration has led to increased safety and better outcomes. This is disputed, however, in the information presented by one of our medical students, Leah Anderson where she discusses the literature (noting inherent biases) is not overwhelmingly convincing that advanced practice clinicians can and should practice independently. This is further collaborated by a position statement from the Minnesota Academy of Family Physicians. The counterpoint is provided by Sen. Kathy Sheran where she is advocating for the independent practice of APRNs. One important question is the need to expend resources on these legislative issues versus addressing the real problem of access. Dr. Deane Manolis is highlighted as this issue’s Luminary of Twin Cities Medicine — a respected team player, passionate for medicine and his chosen specialty of psychiatry. In conclusion, we are all aware of the current and expected future shortage of primary care physicians and how advanced practice clinicians can help ease the demands needed for health care services. As a health care team we can all work together to provide good access, quality and cost-effective care with desired outcomes.
November/December 2013
5
President’s Message
Many Thanks EDWIN N. BOGONKO, M.D.
Dear colleagues, In so many ways, this has been a very eventful year. With the sun heading south, the reality of a Midwestern cold front comes into focus. Plan to stay warm. Perhaps the most intriguing event of the year was the Minnesota Medical Association (MMA) annual delegates conference where the debate centered on the much talked about proposed MMA governance changes. Witnessing first-hand the intensity and passion behind the debate and practically evenly matched opinions for and against was, frankly, refreshing. There are a lot of physicians in this great state who care about how we govern ourselves, who are keen on the oversight needed to keep our leaders accountable and are determined to make our fraternity a bottom up organization driven by grassroots participation. After a year of varied efforts to educate all of us for or against the changes, the curtain did come down with several changes approved. First, the House of Delegates (HOD) will be in abeyance for the next three years, its function taken over by a 40-member policy council. The MMA has yet to enact the said council and the real question of how it will eventually form is everyone’s guess. Second, component medical societies will still have the ability to recommend candidates to fill assigned positions based on trustee districting. Third, the HOD mandated the MMA to develop and share with the membership a measurement metric to show progress in the areas the Board of Trustees (BOT) so relentlessly pursued — increased membership and engagement, nimble operations and ultimately a demonstration of the effectiveness of the policy councils. All of us have a role to play in determining what should really be measured — play your part. What is instructive to note is that during this at times acrimonious debate, the ability to reach young people was the guiding light for the BOT position. However, during the HOD, young people thought otherwise and a majority expressed skepticism that the changes would necessarily achieve the stated purpose. They were not enthusiastic about the suspension of the HOD. At a minimum, I am hopeful that the MMA will reflect on the sentiment of our younger members and ensure they have a seat at the table in the new policy council dispensation. Only time will tell. In the meantime, we must all respect the vote and support efforts to keep the MMA relevant, responsive and accountable to the membership. A small board and staff with a narrower focus on a few strategic priorities is the choice of the MMA, but longer term we have to invest in developing our grassroots — strengthen the component medical societies, aggregate smaller ones into stronger regionals and provide local entry points for physician participation. I reiterate my remarks at the annual meeting, now we must turn the page — to cultivate a unity we must forge and be mindful of those who have alternative opinions. We must equally serve even a minority of one. To preserve the rights of everyone, active participation and shaping the policy councils will become a key task for all of us. We can all make it work. As Craig Bruce quips “Never question the relevance of truth, but always question the truth of relevance.” Anyway, this issue of MetroDoctors highlights the next frontier of the ongoing erosion of physician space. The definition of the role of advanced care professionals in the marketplace is taking shape. Let us all take time to understand the gist of the debate. Likely to be contentious are issues of scope of practice, patient safety and liability on the one hand as well as the role of physicians, if any, on the other. Stay informed. Friends, I have always been guided by three simple principles — respect for and service to my colleagues and my profession and in doing so, putting my best foot forward — every day. 2013 has been an incredible journey serving you all in the metro full of challenges and sometimes difficult conversations. I enjoyed it enough to know that a lot of work needs our collective consideration, time and sacrifice if we are to stay relevant. Thank you for your support of the TCMS and I look forward to continuing to play my part. Together, we will make a difference for our beloved profession. 6
November/December 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
Former CEOs Come for a Visit
What do you get when you pull together former CEOs of Hennepin and Ramsey Medical Societies? A lot of free (and good) advice…and a lot of laughs. Recently, TCMS hosted Jack Davis, Roger Johnson, Thomas Hoban, Kathy Welte and Doug Shaw (along with their spouses) for a lunch meeting — all of whom held various senior leadership roles in the medical society. It was a great opportunity for me to share what has been happening at TCMS since the organizations merged in 2010. I am pleased to report that everyone is very happily retired and enjoying life which is apparent in this photo.
Back row from L: Thomas Hoban, Nancy Bauer, Doug Shaw, Jack Davis, Sue Schettle, Roger Johnson. Front row: Mary Kay Hoban, Marilyn Davis, Kathy Welte.
Senator Klobuchar
Edwin Bogonko, M.D., president of TCMS and Kent Wilson, M.D., medical director for Honoring Choices Minnesota and I met with staff from Senator Amy Klobuchar’s staff in September. The purpose of the meeting was to inform the Senator about the work of TCMS and to highlight the Honoring Choices Minnesota program in particular.
Full House at the TCMS MNsure Forum
The TCMS legislative and policy committee hosted a forum for physicians, medical students and clinic administrators on MNsure, the state’s new health insurance exchange on Thursday, September 26, 2013. Sixty-five people attended the two-hour event and heard from Dr. Kathryn Duevel, the lone physician on the MNsure board. Other panelists included Kathryn Kmit, MN Council of Health Plans and Troy Mangan, MN Department of Human Services. Resources for physicians can be found on the TCMS website, www.metrodoctors.com. We also have a comment section for you to ask us questions about MNsure. TCMS is hosting another forum on December 5, 2013: The Collaborative Medical Model: Utilizing Advanced Practice Practitioners in the Delivery of Quality Patient Care; 6-8 p.m. at the Ramada Plaza Hotel; $25 members, $40 non-members. To register: www. metrodoctors.com. Honoring Choices Minnesota to present at Institute for Healthcare Improvement National Forum
The IHI asked TCMS to submit a story board on the Honoring Choices Minnesota program at the upcoming IHI Forum in December in Orlando. Thousands of ideas are submitted to IHI each year so we are pleased to be given this opportunity to share our story.
MetroDoctors
The Journal of the Twin Cities Medical Society
Senior Physicians Association
Also speaking on the topic of MNsure, Commissioner Lucinda Jesson was the keynote speaker at the fall gathering of the Senior Physicians Association held at the Town and Country Club in September.
TCMS Staffing News
I am pleased to report that Karen Peterson joined our staff on October 1 as Program Manager, Honoring Choices Minnesota. Karen is a nurse by training and has a passion for end-of-life care issues which is a perfect fit for her work with Honoring Choices Minnesota. While I am very happy to have Karen on board, I am sad to report that Katie Snow has left TCMS to be a stay-athome mom. Katie had been with TCMS for over nine years and played a critical role in building the EMMS Foundation and Honoring Choices Minnesota in particular.
November/December 2013
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Medical Care Medical Telemedicine Collaborative Organizations Model
Aligning Minnesota with National APRN Consensus Model
T
he Minnesota State Legislature is considering a proposal that would enact the Advanced Practice Registered Nurse (APRN) Consensus Model. It is a national model developed and endorsed by 48 nursing organizations for the preparation and licensure of Advanced Practice Nurses. The legislation provides standardized licensure, accreditation, certification and education. Implementing standardization measures assures that APRNs are competent and prepared to practice independently within their defined scope of practice. The model establishes a national standard for regulating APRN practice by instituting four components. First, the APRN license will specify the population and role of the APRN, thereby limiting the practice. Second, a national certification exam will be implemented and continued certification requirements established that will be specific to the APRN license. Third, graduation must be from a fully accredited graduate program. Finally, the fourth component will be to institute standardized educational requirements. The legislation places sole responsibility for APRN regulation under the Minnesota Board of Nursing. It removes language requiring an APRN to practice in a setting that provides for a “collaborative management” of patients with a physician. APRNs are able to practice within their same and current scope without enforced/regulated collaboration. However,
By Senator Kathy Sheran
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November/December 2013
collaboration, consultation and referral is expected and specifically referenced in the legislation. The legislation removes the requirement that APRNs maintain a written prescriptive agreement with a physician in order to prescribe pharmacologic and non-pharmacologic agents. The limits or breadth of this role will be defined by the nurse’s education and license, and monitored by the Board of Nursing. Enactment of the APRN Consensus Model legislation in Minnesota has been fully endorsed by the Institute of Medicine in their report, “Future of Nursing” and by the Minnesota Governor’s Health Reform Task Force. These endorsements occurred because APRNs demonstrate two decades of safety track records for high-quality care and excellent patient outcomes. In addition, the Institute of Medicine states that nurses should be “full partners with physicians and other health professionals and must be accountable for their own contributions to high-quality care.”
There is often a struggle to precisely define professions by the activities they perform. This is not the best way to differentiate professionals because various providers do the same tasks competently. Of course, there are and ought to be limits to a scope of practice for physicians, nurses and other allied health professionals. However, the limits are better established by educational preparation, testing and demonstration of competence upon which a license is earned. Once these are established, and studies determine the graduates provide care that is at least as safe and effective as physician colleagues, it is important to acknowledge that there is more than one way to educate and regulate competent health professionals. To continue to limit their practice is no longer about protecting quality and public safety. A resistance to independent practice for APRNs (by some) appears to be tangled up with either a desire to keep a hierarchical medical model system or frustration over the amount of time and money spent on an education to become a general practice physician only to see others allowed to serve within a defined scope. In a 2012 report from the Physicians Foundation, there is a clear intent to resist any substitute for establishing a primary care physician as the “linchpin” of the nation’s health care system. Failure to do so, the report states, will leave us with a rudderless model of patient care, greater fragmentation, higher costs and inferior outcomes. The report calls for a centralized reporting system to allow physicians to report negative health outcomes resulting from non-physician care and to undertake
MetroDoctors
The Journal of the Twin Cities Medical Society
a concerted effort to engage non-medical allies, especially patients and consumer groups, to counteract efforts to support mid-level practitioners. Any discussion of APRN errors in practice, centralized or otherwise, will be seen as suspect if it is not presented in relationship to the reports of negative outcomes from physicians in similar states and situations. Some argue that there is a higher cost and an inferior outcome; however, a recent report from the National Conference of State Legislatures contradicts this idea. The report states that access and the quality of primary care services can be improved and certain costs can be reduced with targeted expansions of scope of practice for non-physician practitioners. The counter-effort promoted by the Physicians Foundation appears to be a planned opposition to protect a medical hierarchy model of care with physicians at the top. Through their legislation, APRNs support the goal reforming how health care is delivered. The new Nurse Practice Act would increase the public’s access to demonstrated quality primary care through partnerships and collaboration. Increased access to appropriate primary care services has been proven an important component to maintaining and improving health. Those who obtain regular care and receive preventive services are shown to have improved compliance with a treatment program. As a result they have lower rates of illness, which also results in cost savings. It is generally agreed that additional primary care practitioners are needed to meet demand in rural America. The rural population ages 55 to 75 is estimated to grow 30 percent between 2010 and 2020. About 1/3 of rural primary care physicians are retired or near retirement. The Affordable Care Act expands eligibility for Medicaid for those with incomes up to 133 percent of poverty. These factors increase the demand for primary care practitioners, which has resulted in15 states already doing what this APRN legislation proposes. Restricting the capacity of competent persons to provide primary care will not MetroDoctors
lead to health care affordability. Keeping health care in a hierarchical system rather than in partnerships is counterproductive to patient empowerment, collaboration and reform of care. Both the Institute of Medicine and the Governor’s Health Reform Task Force believe in the capacity of APRNs to serve with equivalent quality outcomes, which is why they support APRNs pursuit of the model that allows practice to full capacity and as partners. It is for these reasons and others that APRNs are seeking legislation to establish the Consensus Model in the Minnesota Nurse Practice Act. The changes will remove barriers for nurses to practice in partnership with their physician colleagues. Additionally the law clearly outlines the exclusive responsibility of the Board of Nursing to determine who can practice at an APRN level, assure the education is adequate for the services the nurse will provide and monitor the profession for quality. It is my hope that in Minnesota the discussion and perspective
The Journal of the Twin Cities Medical Society
of this legislation will not be approached in the manner suggested in the Physician Foundation report. Kathleen “Kathy” Sheran (DFL) represents SD 19, which includes portions of Blue Earth, Le Sueur and Nicollet counties in the south central part of the state. She was first elected to the Senate in 2006 and then was re-elected in 2010, and 2012. Sheran is currently the chair of the Senate’s Health and Human Services, Housing policy committee, and a member of HHS finance, judiciary and higher education committees. She serves on the Minnesota Insurance Marketplace Legislative Oversight Committee, Emergency Medical Services Regulatory Board, Non-Emergency Medical Transportation Board, Sports Authority Legislative Commission, the Interstate Compact for Juveniles Council, and the Council of State Governments; Midwestern Legislative Conference. Sen. Sheran can be reached at (651) 296-6153; sen.kathy.sheran@senate.mn.
November/December 2013
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Medical Care Medical Telemedicine Collaborative Organizations Model
A Focused Effort on Team-Based Care
F
amily physicians in Minnesota are proud of what we do. We are over 3,000 strong, serving in clinics, hospitals, urgent care, and emergency rooms across urban and rural corners of the state. We are professionals who pride ourselves on collaboration. Not only do we work with other physician colleagues who have chosen another specialty, we have formed important and meaningful relationships with Nurse Practitioners (NPs) and Physician Assistants (PAs). NPs across the country as well as in Minnesota have asked legislators to consider changes to their practices by revoking the requirement that, by law, requires physician oversight of the care that they provide to patients. Their reasoning is based partly on the desire to practice independently, an assertion that they have the same training and qualifications, and the promise that they will help solve the primary care and rural access to care crises that could come with the ACA and aging population. No “I” in Team
One point that all of us that care for patients can agree upon is that the delivery of medical care has changed significantly over the last decade, becoming more complicated with more demands than ever. Greater emphasis has been placed on team-based and coordinated care, and with good reason. A recent Health Affairs article noted that the team-based approach — not independent practice — is more efficient and provides high quality care. A By Julie Anderson, M.D., Immediate Past President, MAFP
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November/December 2013
HealthPartners initiative implementing the Minnesota Health Care Home, which relies on collaborative care, showed decreased wait times, increases in diabetes and cardiac optimal care, 39 percent fewer ER visits, 24 percent fewer hospital admissions and decreased outpatient costs to the tune of $1,200 per patient per year for the most complicated patients. Safety
This issue is not just about turf and independence. The AMA and AAFP both strongly advocate for physician oversight of advanced practice practitioners. Family medicine is one of the most challenging specialties in medicine. At any moment, we may see a newborn, diagnose cancer, treat a rash, perform a physical, or manage a cardiac arrest. The challenge in our profession is to try to be something for everyone and know when and when not to refer to a specialist. This keeps patients safe and brings costs down. Many NPs are very good at what they do, but they often do not have the breadth of knowledge to meet the demands of family medicine. This may be why less than half become Family NPs. Training
Family physicians spend over 11 years training to provide high quality, evidence-based medicine to our patients, compared to five to seven years that an NP will complete before treating patients. Put another way: 21,700 hours vs. 5,350 hours, of which less than ¼ are clinical. Lesser-trained professionals cannot equal a physician’s depth of understanding of
complex medical problems. We must rely on our extensive hours of experience and education in critical analysis to care for our patients. Imagine a complicated 747 aircraft with inflight difficulties — would you rather have a knowledgeable crew or one with limited flight experience? When asked, most people believe that a health professional’s training has a direct impact on the depth and quality of patient care. Many people may not know that family physicians across Minnesota spend countless hours educating NPs and PAs during their training. Even at the end of training, we have noted that most are uncomfortable to “practice on their own.” In fact, two recent studies show that patients prefer having access to a team of care providers that are led by a physician and onehalf of patients oppose NP independent practice.
MetroDoctors
The Journal of the Twin Cities Medical Society
A recent Institute of Medicine report highlights the lack of standardization of nursing education and certiďŹ cation. Efforts should be placed on ensuring that patients understand who is walking in the room to care for them, whether it be a nurse with an associate, masters, or doctorate of philosophy. Our patients deserve to know who they are consulting and what credentials they have. Physicians have recognized across the state that NPs and PAs have an incredibly useful role as advanced practice practitioners for routine visits and education in both primary care and specialty settings. They help provide more physician expertise to a wider breadth of patients. What we must acknowledge is that it is about playing on the same team, but the physician must be the quarterback. Patients expect and deserve to have access to all levels of expertise in their care. Cost
New studies show that family physicians working in teams with PAs and NPs provide high quality and lower cost care than independent advanced practice practitioners. NP to physician ratios of around 1:1 have the lowest cost as well as the fewest hospital discharges, while higher ratios (more NPs than FPs) are associated with higher costs and utilization of services.
at an average of eight patients per week per physician for years and we will continue to do so. We do not need to tie up legislative efforts with scope of practice disagreements. What we do need is a national primary care workforce policy that rebalances the health care system toward primary care and trains more family physicians and advanced practice practitioners to provide team-based care and ensures that patients get the right care at the right time from the right professional. We must focus our concerted efforts on working together to provide high quality and cost-effective care to patients. Julie Anderson, M.D. is a family physician practicing at St. Cloud Medical Group in St. Cloud, MN. She is the immediate past president of the MAFP and an Alternate Delegate to the AAFP. She graduated from the University of Minnesota Medical School and can be contacted at janderson@stcloudmedical.com.
TCMS Forum The Collaborative Medical Model: Utilizing Advanced Practice Practitioners in the Delivery of Quality Patient Care Thursday, December 5, 2013 6:00-8:00 p.m. A question and answer panel discussion facilitated by Lisa Mattson, M.D., president-elect, TCMS
Ramada Plaza Minneapolis 1330 Industrial Blvd, NE Minneapolis, MN, 55413
Cost: $25 Members; $40 Non-Members; FREE: Medical Students & Residents
To Register: www.metrodoctors.com Co-sponsored by: Twin Cities Medical Society and Minnesota Academy of Family Physicians
Access
Despite NP assertion that they will help improve rural access to care, the current distribution in terms of rural practice setting on a national level is around 25 percent; however, the actual number of physicians are higher that serve underserved settings (46,981 FPs vs 14,351 NPs). Furthermore, the assertion that NPs will help to solve the primary care access problem is difďŹ cult to uphold when about half of all NPs go into specialty care. The fact that 32 million patients across America will enter the insured pool with the ACA does not mean they will suddenly knock down doors. Family physicians have been caring for uninsured or underinsured
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Stephen Geffre, Augsburg College Photographer
Colleague Interview: A Conversation with Connie W. Delaney, Ph.D., RN, and Dawn Ludwig, Ph.D., PA
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onnie White Delaney is professor and dean, School of Nursing, University of Minnesota. She also serves as director, Biomedical Health Informatics (BMHI), associate director of the CTSI-BMI, and acting director of the Institute for Health Informatics (IHI) in the Academic Health Center. She is an active researcher and writer in the areas of national standards development for essential nursing care and outcomes/ safety data. She holds a BSN with majors in nursing and mathematics, MA in Nursing – Adult Health, Ph.D. in Educational Administration and Computer Applications, and completed postdoctoral study in nursing and medical informatics at the University of Utah.
D
awn Ludwig is the current program director and department chair for the Augsburg College Department of Physician Assistant Studies. She has been a physician assistant since 1988, graduating from the University of Colorado Health Sciences Center with a Masters in PA Studies and has maintained a part-time clinical practice in an urgent care setting during her tenure as the PA Program Director. She earned her Ph.D. in 2000 in Interdisciplinary Studies from Capella University. Within her role as program director, she has been actively involved in several state-wide initiatives such as the Minnesota Rural Health School, Medical Education and Research Advisory Committee, and Minnesota Workforce Planning. She teaches in cardiology, pediatrics and otolaryngology within the PA program.
How have you seen the practice of advanced practice nursing/physician assistants change over the last 10 years? CD – Advanced Practice Registered Nurses (APRN) education has evolved especially over the past 10 years. The 2008 APRN Consensus Model (developed and approved by more than 47 nursing organizations) has led to significant standardization across all APRN programs with regard to educational standards, core courses and competencies, and requirements to meet national certifying organizations standards. The latest evolution has been to transition APRN programs from M.S. degree programs to DNP programs with expansion of clinical hours to a minimum of 1,000 and addition of systems thinking and problem solving with emphasis on quality improvement, evidence-based practice, and population health to improve patient outcomes. In addition, the APRN role has become more familiar and accepted by the general public as the public experiences NPs or PAs as primary care providers; providing services in retail pharmacies, Target, grocery stores; more NPs are being used in acute care settings or working with specialty practices (e.g. to provide follow-up care for surgeries, manage chronic cardiovascular conditions, etc.). 12
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DL – The practice for physician assistants has broadened significantly in that there are so many more opportunities for a PA than there were 10 years ago. Nearly every specialty of medicine is using a PA to enhance their practice.
How has your training program changed over that same time? CD – We’ve made significant changes based on national standardization of core curricula, courses, and clinical competencies. For example, in 2009 we transitioned from the master’s degree preparation for advanced nurse specialists to the Doctorate of Nursing Practice (DNP) degree. The focus areas include population health, system change, evidence-based practice, and informatics. Again, this programming includes more than 1,000 clinical hours. DL – In 2004, we graduated our first class of students in a master’s program. Between 2004 and now, we have enhanced our curriculum by including more interprofessional education, more geriatric education and a greater emphasis on patient education. In addition, we recently condensed some of our curriculum and will now offer the MetroDoctors
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degree program in 31 months (as opposed to 36 months in the past). We believe that this will provide the same quality education but allow the student to graduate and begin practice sooner.
Discuss some of the specifics of your training program: How has your organization determined the level of education, training and certification needed to provide appropriate care to patients that is safe, effective, and at an appropriate cost to the entire system? CD – This is determined by national accreditation standards and competencies; national certification requirements; see comments above about APRN Consensus Model. DL – The main means of determination of these factors arise from the accreditation standards, the performance of our graduates on the national board exam, the employment record of our graduates and discussion with the clinical instructors who educate our students in the clinical setting.
How many clinical hours of training are required to receive a license and/or certification in your field? Are these hands-on hours? CD – APRNs come to the program with their previous undergraduate nursing education and clinical hours. At a minimum these APRN students have accrued more than 2,000 additional clinical hours working as a staff nurse prior to beginning their APRN training. Consequently, most of our students start their DNP APRN specialty programs with well over 3,000 to 4,000 clinical hours working with patients, performing physical assessments, treatments, administering fluids and medications, etc. All of this experience prior to entry into an APRN program must be included when examining clinical hours. This situation is very different than the PA who may come into the PA program with minimal exposure to health care or a number of hours working as a nursing assistant, which is quite different than functioning at a staff nurse level. DL – There is not a specific requirement of hours; however, the national mean number of direct patient contact hours is 2,000. The Augsburg PA program educates its students in the clinical setting with 2,100 hours of direct patient contact.
Are your students exposed to a variety of different primary care practice settings? Do they have the opportunity to compare and contrast different methods of physician and advanced practice provider collaboration? CD – All students practice in a variety of settings specific to their advanced practice specialty (again this is different than the PA or medical student approach which includes multiple rotations in a variety of specialties). The APRN student has already completed MetroDoctors
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their various general rotations as an undergrad or post-bacc/ MN). During the APRN clinical specialty rotations, faculty track students’ clinical setting, population mix (e.g. racial, ethnic, SES, geographic diversity) and specifically assign students each semester. This assures that all students will have a wide breadth of patient experiences. More recently, we’ve also prioritized experience for our students in settings that allow for interprofessional teamwork and collaboration. DL – All Augsburg PA students must complete the following clinical experiences: family medicine, internal medicine, pediatrics, women’s medicine, emergency medicine, general surgery and mental health. Throughout their 52 weeks of clinical experiences, they are exposed to and work with as many varieties of providers as possible, from physician to advanced practice nurse to social worker to physical therapist, etc.
How does your program assure that the preceptors provide quality and appropriate clinical experiences (within their scope of practice) at the training institutions? CD – We use a tracking system to monitor all clinical sites and preceptors. We track each student for education, certification, preceptor experience, licensure, etc. Preceptors are expected to complete an online clinical preceptor training program. Students complete a preceptor evaluation and clinical site evaluation at the conclusion of each semester. Faculty assign all students to preceptors and sites. Students do not self-select or find their own preceptors. DL – All of our clinical instructors (preceptors) must meet standards the program has set including regular review of licensure, onsite assessment of the clinic/hospital setting for number and type of patients seen, etc.
How will your graduates be prepared to practice in accountable care organizations? CD – During the academic experience students have practicum experiences in organizations that are part of ACOs; course work includes health economics, health policy, and leadership. For example, in the Health Care Economics course, Health Policy Leadership Course, Health Informatics course, and the three DNP seminar courses, students learn about ACOs, health care homes, and new payment models that move away from fee-for-service toward population outcome-based payment models. They have didactic and practical experience in mining EHRs for population outcome information. They learn about continual process/quality improvement and clinical metrics for tracking population health. DL – We have tried to place all students in various health care systems so upon graduation they have been exposed to Team Care, Accountable Care, Medical Home Teams, etc. (Continued on page 14)
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Medical Care Medical Telemedicine Collaborative Organizations Model Colleague Interview (Continued from page 13)
Do you see your graduates functioning independently, e.g. allowing them to diagnose, develop a treatment plan and implement treatment, prescribe medication, order and interpret laboratory and radiographic studies? If supervision is required, define specifics of the supervision function in both inpatient and outpatient settings. CD – In MN, all APRN roles (except certified nurse midwives) are required to have a signed written agreement with a physician in order to prescribe pharmacologic and non-pharmacologic agents. All APRNs in MN are required to practice in a setting that allows for “collaborative management” of patients with a physician (may also be a dentist or podiatrist for CRNAs). The prescriptive agreement requires an annual signature by a physician and APRN on a document that simply lists various drug categories (e.g. antibiotics, anti-emetics, analgesics, etc.). MN law does not make distinctions in these requirements based on setting (e.g. outpatient versus inpatient). DL – This is built into the legislative language in the PA practice act. The PA is able to function in a semi-independent way in that the PA evaluates, diagnoses, and manages all of their own patients. The supervision is built upon regular review of the MD/DO/PA relationship, the scope of practice of the MD/DO, the prescribing practice of the PA and ongoing quality assurance review. In both inpatient and outpatient settings, the physician must be in either physical or other means of immediate communication to the PA for assistance when seeing patients.
There has been a lot of talk about health care workforce shortages, especially with primary care physicians. How do you see advanced practice providers as a solution to this primary care physician shortage? CD – Aurbach, a professor of health economics from Columbia University has researched primary care needs and workforce issues. He states that nurse practitioners can address about 65-85 percent of the issues patients bring to their primary care providers. Moreover, a recent 10-year retrospective of nurse midwifery care has demonstrated excellent outcomes (healthy mother/baby, fewer C-sections, decrease in preterm births, and better adherence to recommended schedule of prenatal care visits) for non-medically high-risk populations of women. The nature of nursing education with its focus on holistic patient assessment, health promotion and prevention, emphasis on symptom management, and consideration of the importance of context (e.g. family, work, home environments, social determinants of health) in working with patients to manage their chronic conditions make APRNs (e.g. nurse practitioners, clinical nurse specialists, and nurse 14
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midwives) particularly skilled in working with patients with chronic conditions. DL – There are many models being discussed where advanced practice providers may be the first point of contact into the health care system, thus providing increased access at decreased cost.
Some physicians view advanced practice providers moving into what has historically been the practice of medicine. How would you distinguish the care provided by an advanced practice provider versus a physician? How will patients differentiate the qualifications of your graduates from an MD/DO? CD – See some of my previous comments. There is some overlap in APRN and MD/DO skills; the key difference, however, is in the paradigm from which these knowledge-based skills are learned and practiced. Nurse practitioners are educated within a holistic, person (patient)-centric, context of family and community, with health promotion/disease prevention foci. APRNs are educated to function in a particular role (Nurse Practitioner, Nurse Midwife, Clinical Nurse Specialist, and Certified Registered Nurse Anesthetist) for a specific population. The evidence shows that APRN education is sufficient to function in these specific roles and within specific populations. Comparing MD/DO and APRNs is an apples to oranges comparison. DL – No question, the physician is clearly more educated about the intricate details of complex disease systems. Therefore, the advanced practice provider plays a critical role but will never replace the role of the physician. In general terms, in an outpatient family medicine setting, a physician, PA or advanced practice nurse, would all function nearly identically, seeing very similar patients on any given day. We are very clear that our graduates refer to themselves as “PA [last name]” and never as doctor. Our graduates are taught to be able to explain the difference between a PA and MD/DO and how their scope of practice is similar but still different.
Discuss the role of collaboration with physicians and other practitioners. Can advanced practice providers practice good care without collaboration? How should the law be drafted to ensure that collaboration exists? CD – Best practice suggests that all health care providers, including physicians, collaborate, consult, and refer as necessary to meet the needs of the patient. APRNs are no exception. APRNs should collaborate, consult and refer when the patient condition calls for this. The question is not “should APRNs be expected to collaborate.” The real question at issue in scope of practice discussions is “should APRNs be required or mandated to collaborate with a specific physician in order to practice their scope of practice.” Does it make sense to prevent APRNs from being able to practice unless they have a prescribed collaborative agreement with
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a specific physician in place? We (nursing) support that APRNs be allowed full practice authority that includes the expectation that they will collaborate, consult, and refer when the patient condition warrants these actions. Enforced collaboration is really supervision. APRNs do not need supervision to practice safely and effectively. DL – I don’t believe there is any level of health care today who can function without collaboration. It is critical to ensuring quality health care is delivered to patients. But, as far as drafting a law, I would be against that as there needs to be a built in desire to do what is right and we should not be trying to legislate that aspect of care.
With the trend toward “team-based care” what role will the advanced practice practitioner play? CD – We educate our students to view team care as a preferred approach when team care is possible. It may not be possible in all settings or areas. We also educate our students to understand that team leadership should be based on the needs of the patient. Consequently, the leader will vary depending on the needs of the patient. The physician role is not always the best provider to lead the team. For example, the oncologist may be the best person to lead the team for a woman newly diagnosed with breast cancer that will require chemotherapy and radiation, or for a patient with diabetes who is unstable and poorly managed. However, a nurse manager or NP may be the best team leader in working with a socially high-risk, but otherwise adolescent woman who is pregnant. We see APRNs as being excellent professional team players when physicians should be leading the team as well as being leaders of the team when the patient’s needs warrant a holistic, nursing approach to care. DL – A key role. I think that has been covered in other answers.
Are there any data on the cost effectiveness of advanced practice practitioners when global cost of care is considered? What are the outcomes data? CD – The Center to Champion Nursing in America put together an excellent fact sheet on the cost of care provided by APRNs; it is available in total online at: http://www.thefutureofnursing.org/resource/ detail/cost-care-provided-advanced-practice-registered-nurses-aprns. Two most recently published articles contain some current outcomes data. I will provide the references as well as the summary quoted from each.
“This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included. Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients. These results extend what is known about APRN outcomes from previous reviews by assessing all types of APRNs over a span of 18 years, using a systematic process with intentionally broad inclusion of outcomes, patient populations, and settings. The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.” 2. The Journal for Nurse Practitioners — JNP Volume 9, Issue 8, September 2013. The Quality and Effectiveness of Care Provided by Nurse Practitioners Julie Stanik-Hutt, Robin P. Newhouse, Kathleen M. White, Meg Johantgen, Eric B. Bass, George Zangaro, Renee Wilson, Lily Fountain, Donald M. Steinwachs, Lou Heindel, and Jonathan P. Weiner. “Evidence regarding the impact of nurse practitioners (NPs) compared to physicians (MDs) on health care quality, safety, and effectiveness was systematically reviewed. Data from 37 of 27,993 articles published from 1990-2009 were summarized into 11 aggregated outcomes. Outcomes for NPs compared to MDs (or teams without NPs) are comparable or better for all 11 outcomes reviewed. A high level of evidence indicated better serum lipid levels in patients cared for by NPs in primary care settings. A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of emergency department visits and hospitalizations, blood glucose, blood pressure, and mortality are similar for NPs and MDs.” DL – This is from the American Academy of Physician Assistant’s website: “Studies have shown that PAs can increase the cost-effectiveness of healthcare. PA labor costs are more affordable. A practice employing a PA pays less in overhead costs for that PA compared to a physician, while having a healthcare provider on board who can provide most of the same services. A study examining a national sample of patients found that those who saw a PA for most of their yearly office visits had approximately 16 percent fewer visits per year than patients who only saw physicians.”
1. NURSING ECONOMIC$/September-October 2011/Vol. 29/No. 5 Advanced Practice Nurse Outcomes 1990-2008: A Systematic Review Robin P. Newhouse. Julie Stanik-Hutt, Kathleen M. White, Meg Johantge, Eric B. Bas, George Zangar, Renee F. Wilson, Lily Fountain, Donald M. Steinwachs, Lou Heindel, and Jonathan P. Weiner.
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The Future Primary Care Dilemma
Scope/Potential Solution
The concern over a shortage of primary care physicians is not new news. In fact, according to Macaran A. Baird, M.D., M.S., head of the University of Minnesota Department of Family Medicine and Community Health, the Council on Graduate Medical Education predicted a shortage of primary care physicians in the early 1990s. The American Association of Medical Colleges predicts a shortage of 45,000 primary care practitioners by 2020. And, in a December 2012 article in JAMA, Dr. Colin West, an internist at the Mayo Clinic in Rochester, MN, stated “In the next decade, we will be 50,000 primary-care physicians short for the needs of the country.” Reasons cited for the shortage include: fewer medical students/residents choosing careers in primary care; poor reimbursement; an aging population and the retirement of current practicing physicians. An estimated 32 million people will gain access to health coverage in 2014 under the Affordable Care Act (ACA). That number equates to an estimated 300,000 in Minnesota, according to John Gruber, MIT economist. To meet this demand, many clinics have already incorporated nurse practitioners (NPs) advanced practice nurses (APNs) and physician assistants (PAs) into their practice. The Institute of Medicine’s 2010 report identifies nurses as a key component to addressing the healthcare needs of the nation, especially the need for primary-care practitioners. But, is this the right answer?
By Leah Anderson, MS2
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Outcomes Of Care
With scope of practice debates occurring nationally, many reports have recently been published examining outcomes of Advanced Practice Nurses care in relation to physician care. Some of the results of these studies are listed below. • In a study comparing the laboratory results for diabetic patients seeing either a nurse practitioner (NP) at a free diabetic clinic or a medical doctor between the years 2004-2009, no statistical differences were found in the number of patients who met American Diabetes Association (ADA) guidelines for A1C, HDL cholesterol or LDL cholesterol goals. These were defined as an A1C < 7, HDL > 50 mg/ dL and LDL < 100 mg/dL.1 • In a meta-analysis review examining the outcomes of APNs and physicians using 18 years of data (19902008), results showed that on seven
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of the 11 outcome measures NP and physician care were equivalent with a high grade of evidence. These outcome measures were patient satisfaction, self-reported patient perception of health status, patient functional status, blood pressure control, rates of ED or urgent care visits, rates of hospitalization, and mortality rates. Furthermore, lipid control and glucose control outcomes showed a high level of evidence that outcomes of patients cared for by NPs were comparable or better than the outcomes of physicians. The emphasis of this study was on the benefits gained by further collaboration between NPs and physicians and not to support expansion of scope of practice laws. This is demonstrated in the discussion section where the authors state, “This systematic review supports that NPs who collaborate with physicians are as knowledgeable, and potentially more successful, in providing care to patients than physicians alone.”2 In a review of 16 studies comparing NP versus physician-based primary care, no appreciable differences were found in patient health outcomes or resource utilization. In urgent care settings, patient satisfaction was higher for NPs than for physicians. The impact of NPs on physician workload and direct costs of care was variable and inconsistent across the studies.3 A study evaluating the quality of HIV care provided by NPs and PAs found that outcomes were similar to that of physician HIV experts and better than general practice physicians. However,
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the authors noted that these results were contingent on high levels of specialized training and expertise of the NPs and PAs in HIV care, specialization within a focused HIV practice, and collaboration in team care with physicians with HIV expertise.4 In a randomized trial involving 1,300 patients over a two-year period, researchers found that the health status of patients treated by NPs was comparable to those treated by MDs. A two-year follow-up found no significant variation in health outcomes, health services utilization, or patient satisfaction.5,6 A case control study was performed in Pennsylvania hospitals looking at outcomes among surgical patients treated by either anesthesiologist or nonanesthesiologist directed teams. The results of this study found that patients treated by non-anesthesiologist directed CRNAs had 2.5 more excess deaths and 6.9 more failure-to-rescue deaths per 1,000 patients than patients treated by an anesthesiologist.7 Using data from the Healthcare Integrity and Protection Data Bank (HIPDB), it was found that states with the least restrictive scope of practice laws for nurse practitioners had a 20 percent higher rate of reported “adverse actions” than the states with the most restrictive scope of practice.8
interest is significant. This is evidenced by the Cochrane Review search methods for a study titled “Substitution of doctors by nurses in primary care.” Of 4,253 articles screened, only 16 studies met the inclusion criteria for the review.3 Furthermore, in the states in which scope of practice restrictions have been lifted, no documentation of gains in access or cost savings have been published as of yet. Different patient populations have varying needs and further research needs to be performed to determine which roles would allow the most efficient utilization of APNs. Leah Anderson is a 2nd year medical student at the University of Minnesota. She currently serves on the TCMS Legislative and Policy Committee and Advanced Practice Practitioner Task Force. Her interests include maternal and child health, global health, and health policy. She can be reached at: and03163@umn.edu.
References 1. Condosta, D. “Comparison Between Nurse Practitioner and MD Providers in Diabetes Care.” Journal for Nurse Practitioners 8.10 (2012): 792-96. Web. 2. Newhouse, R. P., Julie S., Kathleen M.W., et al. “Advanced Practice Nurse Outcomes 19902008: A Systematic Review.” Nursing Economics 29.5 (2011).Web. 3. Laurant, M., Reeves, D., Hermens, R., et al. “Substitution of doctors by nurses in primary care” Cochrane Database of Systematic Reviews 2004.4. Web. 4. Wilson, I.B., Landon, B.E., Hirschhorn, L.R., et al. “Quality of HIV Care Provided by Nurse Practitioners, Physician Assistants, and Physicians,” Annals of Internal Medicine, November 15, 2005, Vol. 143, No. 10, pp. 729-36. 5. Mundinger, M.O., Kane, R.L., Lenz, E.R., et al. “Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians,” Journal of the American Medical Association, January 5, 2000, Vol. 283, No. 1, pp. 59-68. 6. Lenz, E.R., Mundinger, M.O., Kane, R.L., et al. “Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: TwoYear Follow-Up,” Medical Care Research and Review, September 2004, Vol. 61, No. 3, pp. 332-51. 7. Silber, J.H. “Anesthesiologist Direction and Patient Oucomes,” Leonard Davis Institute of Health Economics Issue Brief, October 2000, Vol. 6, No. 2. 8. Isaacs, S., Jellinek, P. “Accept No Substitute: A Report on Scope of Practice,” The Physicians Foundation, November 2012. Web.
Conclusions
While these studies often suggest that nurses and doctors generate similar shortterm health outcomes for patients, it must be considered that the statistical power of these studies to identify adverse outcomes is very low. It will take many years of study with a very large patient population to provide definitive evidence that patient outcomes are equivalent. Additionally, a conflict of interest is present in the design of the majority of these studies as they are performed by nurses or funded by nursing organizations. Because many of the outcome studies are descriptive in nature with very few randomized, controlled trials, this conflict of
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Our new PICU
has pediatric trauma specialists at the ready and offers seriously ill or injured children the best chance at getting better.
We are proud to announce an even higher level of critical care with the grand opening of our new and improved Pediatric Intensive Care Unit. The modern family centered design features private rooms with private baths and enough space for families to gather and sleep in as they attend to a seriously sick or injured child. To speak to a physician, make a referral or admit a patient, call: HENNEPIN CONNECT at 800-424-4262 • hcmc.org/pediatrics
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The Case for Collaboration
A
s chief medical officer at MMIC, a physician-owned mutual medical liability company headquartered in Minnesota, I am immersed in the world of medical malpractice. Through that lens, I view what is occurring at the macro level in our industry, as well as what happens at the micro level…when things go wrong in an individual encounter with a patient. At the macro level, I note, for example, the increasing shortage of primary care physicians, a shortage certain to be exacerbated in the coming years by a large contingent of aging baby boomers and formerly uninsured people who will be moving through the system, creating greater demands on an already stressed system. At the micro level, I see how these stressors play out in increased physician burnout, lack of engagement, strained communication, unspoken conflict, shortchanged patients…in a phrase: increased risk. It’s What We Do
As these pressures mount, I also see, as in any dynamic industry operating under myriad pressures, the emergence of innovative approaches that seek to improve efficiency and decrease costs; in our case, of providing high-quality care. Among these developments are the increased use of advanced practice practitioners (APPs) to deliver primary care and the development of “medical homes” that enlist multidisciplinary teams to deliver care. These developments are forcing changes in many areas, not the least of
By Laurie Drill-Mellum, M.D., MPH
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which is in the mindspace of physicians, whose assumptions about the right, appropriate, best ways to deliver care are being challenged as never before. Even as we accustom ourselves to the unfamiliarity of this changed landscape, we also need to think in new ways about the risks in this landscape, as more players become involved in providing care and new relationships are forged among them. It is increasingly apparent that collaboration among the members of these newly constituted health care teams will be key to realizing the promise and benefits of these new models while minimizing their associated risks. What are the Risks?
One question we are sometimes asked at MMIC, where we have always covered nurses and other allied professions as part of the medical practice, is whether we are seeing more claims against APPs. We are… but there are more APPs providing care, so we would expect that. Whether the increase is disproportionate is harder to get at, primarily because many claims against APPs are dropped owing to the deeper pockets imputed to the supervising MDs or hospitals or clinics that insure the APP. More revealing to look at are the causes of loss specified in those claims. In reviewing malpractice data where physician assistants or nurse practitioners have been named in claims or lawsuits, one thing quickly becomes evident: APPs who provide primary care have many of the same kinds (and percentages) of “underlying causes of loss” as physicians do. In our view, there’s a silver lining in that news: since we’re already addressing
those causes through our risk management programs, we can build on our successes by expanding our efforts to a larger field of practitioners. What we find is that, for physicians and APPs alike, the three causes of loss most frequently specified in claims are: • Delayed or missed diagnosis This category accounts for about 40 percent of paid expenses for investigation, defense, and indemnity or payment to the plaintiff. The most common diagnosis-related allegations involve the failure to diagnose, or a delay in diagnosing, infection/sepsis/ abscess and cancer. The most frequent causes for these delays or misses are failure to order the appropriate tests, failure or delay in requesting/arranging for consultation, and failure or delay in responding to abnormal test results.
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Example: Help APPs know when to seek another opinion. A 50-year-old man presented to his primary care clinic with complaints of rectal bleeding. A PA examined him and diagnosed hemorrhoids. Subsequent visits with the same complaints elicited the same diagnosis by the PA; no physician referral was ever made. Later that year, the patient was hospitalized and a rectal tumor was found. The physician and PA were sued for failure to diagnose colon cancer. •
Treatment-related allegations This category accounts for about 30 percent of closed claims. Allegations include failure to initiate the appropriate treatment, improper or negligent performance of a treatment, and improper or delayed medical management in a variety of scenarios. Example: Ensure that APPs practice within well-defined parameters. A 41-year-old woman presented to the Emergency Department with a hand injury and was examined by a PA. On exam, she could not bend several fingers. X-rays were taken and read by PA as negative. The PA diagnosed a sprain/strain, placed the hand in a splint, and instructed the patient to return to the clinic in one week. When her hand did not heal, the patient saw her physician who diagnosed two fractured fingers and a tendon injury. The patient filed a malpractice claim alleging the PA was not qualified to diagnose and treat a tendon injury and the delay in diagnosis compromised a successful tendon repair.
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Medication-prescribing allegations These include failure to recognize known contraindications to the use of certain drugs in certain clinical circumstances, dangerous adverse drug interactions, wrong medication and/ or wrong dose, and mismanagement of patients on long-term anti-coagulation therapy.
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Minnesota’s Laws
For those supervising physician assistants practicing medicine in Minnesota, the state’s laws and regulations can be found in the 13th Edition, January 2013, of the American Academy of Physician Assistants document. All of the Minnesota Statutes are listed, as are details on the requirements for scope of practice determination, prescribing and dispensing authority, and supervision. For advanced practice registered nurses (APRNs), the Minnesota Board of Nursing has a description of the state laws and regulations that apply to the variety of APRNs.
We encourage our clients to do several things that research has shown reduce risks in the above areas, including: • Developing better systems for tracking abnormal lab data • Ensuring appropriate follow-up or consultation • Developing clearer evidence-based practice guidelines • Focusing on improving communication, with patients and among members of the health care team That last one is more important than many health care practitioners realize — miscommunication is an underlying cause of loss in 80 percent of malpractice cases. Collaboration Improves Patient Care
Not only does working effectively together reduce the risk of lawsuits, research shows that it also leads to increased patient safety and better outcomes. One aspect of effective collaboration is clarity around the roles of each team member as they pursue appropriate standards of care. There are supervisory laws and statutes in place that make clear that physicians are ultimately responsible for the patient care delivered by all employed allied health professionals, and facilities should ensure that all such employees are appropriately credentialed, trained and monitored. But beyond this, there are many ways to expand on these regulations in ways that meet not only legal
The Journal of the Twin Cities Medical Society
obligations, but also ethical commitments. Analysis of malpractice claims indicates that inappropriate treatment and patient injuries are more likely to occur: • when there is lack of clarity on a practitioner’s scope of practice. • when there is an assumption of too much responsibility. • when there is inadequate oversight by a supervisory M.D. • when there is deviation from or an absence of written protocols. • where communication is inhibited between health care practitioners. • where there is cultural resistance to asking for help, resulting in a failure or delay in getting a timely consultation. Important tactics to mitigate risk and increase patient safety include the development of: • a clear “scope of practice and delegation of services” agreement. • clearly delineated protocols for APP practice monitoring. • clear policies for obtaining consultation (e.g., when a patient still has an unclear diagnosis after two APP visits or when a neonate develops a fever). • built-in opportunities for mentoring, especially early in the employment cycle, and as needed. • regular department- or clinic-wide case and quality review meetings. • a culture where open and honest feedback is promoted, expected, modeled (Continued on page 20)
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Collaborative Medical Model The Case for Collaboration (Continued from page 19)
and valued, one where practitioners can request assistance without fear of a put-down. Example: Don’t employ more APPs than you can manage well. A solo physician extended his patient capacity by employing several PAs and NPs. The physician, at one time, was supervising eight advanced level practitioners. The physician rarely had time to review charts or communicate with the PAs and NPs about patient care. As a result, six patients suffered from medical errors and negligent treatment within a short time period, causing the physician to be named in six separate, indefensible lawsuits. Keeping ALL Eyes on the Prize
The manner in which health care is being delivered today, and by whom, is evolving. APPs will be providing a substantial amount of primary care, given the predicted shortages of primary care MDs and the increasing population of patients who will need that care. In addition to ensuring proper education, training, regulation, supervision, and monitoring of APPs, I believe it is in all our best interests to foster collaborative working relationships and good communication in order to provide the best patient care possible. Laurie Drill-Mellum, M.D., MPH, is MMIC’s chief medical officer. She is a board-certified emergency medicine physician, a Bush Medical Fellow, and completed a two-year fellowship in integrative medicine at the University of Arizona. She attended the University of Minnesota Medical School where she also obtained a master’s degree in Public Health. Dr. Drill-Mellum can be contacted at Laurie. Drill-Mellum@MMICgroup.com.
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November/December 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
You Don’t Know What You Don’t Know
I
n this day of electronic communications we are told over and over that nothing we say ever truly disappears in cyber-space and to take care with what we communicate because it could come back to haunt us. Still, it was a considerable surprise to me when Nancy Bauer, the editor of this journal, recalled something I had said decades ago and asked me to expand upon it for this issue on collaboration. What I had said was something like “you don’t know what you don’t know.” I believe we were having a discussion about scope of practice issues, but I can’t remember the specific issue. I am certain my thoughts were sought out for this article because of my background in nursing and nursing education before I became a physician. I started my career in health care in the early sixties as a student in a baccalaureate program in nursing. When I graduated I knew there was much more to be learned. I thought about medical school but was too easily persuaded that this was not an appropriate pursuit for young women. Instead I enrolled in a graduate program where I earned a master’s degree in nursing education and then taught nursing students in a university. As much as I enjoyed this, I found myself always wishing that I knew more, especially about things like physiology and biochemistry, some of my favorite subjects. By the early 70s I realized that I needed to either try to go to medical school or quit wishing that I had. With the support of my husband and children, I enrolled in the pre-med courses that I had not taken and applied to medical school.
By Judith Shank, M.D.
MetroDoctors
Luckily, we lived in Minnesota where the medical school was willing to take a chance on a mom in her mid-thirties. I have often been asked if my nursing experience made medical school easier for me. My answer is that it helped in many ways but they were unexpected. It had been 15 years since I had begun my education so I was really starting over academically. The advantage I did have was in softer skills such as communication and an understanding of how hospitals and health care settings worked. I knew who did what and how to work within a health care team which was often an enormous help. Since my early days in health care, I have seen an explosion of changes — in knowledge, in technology, and in the culture of care giving. We are about to witness even more change with the implementation of the Affordable Care Act. Millions more will have access to and coverage for health care in the United States. We will see and participate in all kinds of innovative
The Journal of the Twin Cities Medical Society
delivery structures. Physicians and their colleagues will be more accountable than ever for the care they deliver and everyone will be challenged to meet the increase in demand for services. There is a wide-spread understanding that if the ACA accomplishes even some of its goals, we will very quickly experience a critical shortage of professionals who provide care. More and more care will be delivered by advanced practice practitioners. Primary care physicians will provide care which has traditionally been provided by specialists. Everyone will be working at “the top” of their license/training. The need for continuing education will be more important than ever. If we are to protect our patients and ourselves the need for collaboration will become critical. As practitioners at all levels take on more responsibility the breadth and depth of everyone’s knowledge will be challenged. How can we know what we don’t know and protect against the errors that could result? I don’t pretend to have the answer but I think a crucial point is to acknowledge the fact and stay open to the possibility that unforeseen and unexpected events may be occurring. We need to recognize when observations may not be what they seem and appreciate that working in silos can lead to serious consequences. Over the course of my career, I have seen many examples of harm or near harm which was caused by “not knowing what you don’t know.” I considered myself a very conservative physician and tried to never venture outside the scope of my
(Continued on page 22)
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Medical Care Medical Telemedicine Collaborative Organizations Model You Donâ&#x20AC;&#x2122;t Know What You Donâ&#x20AC;&#x2122;t Know (Continued from page 21)
experience and training, but I learned some of the most difďŹ cult and humbling lessons of my life in situations where I thought I knew how to solve a problem but I, in fact, did not even have the correct diagnosis or recognize when a patient was in trouble and needed an intervention until almost too late. I remember a situation where I was treating an adult patient with isotretinoin, a drug that can cause elevations in serum lipids. I had carefully monitored the patientâ&#x20AC;&#x2122;s cholesterol and triglycerides, watching the cholesterol level rise substantially above normal. Since the treatment was to be only for a limited time, I watched the level but did not intervene. I was horriďŹ ed at her last visit when, in response to a review of systems, she reported chest pain that â&#x20AC;&#x153;felt as if there was a belt around my chest, but it goes away with aspirin.â&#x20AC;? It took considerable negotiation to convince her to go to an emergency room where she was admitted and monitored.
Her discharge diagnosis was unstable angina. Fortunately, she was not thought to have sustained muscle damage, but she could have and I was very chastened by the experience. Had I sought cardiology consultation as soon as her cholesterol went up, I might have learned that there is risk in even short term elevations of lipids for adults, especially for those with other risk factors. Collaboration would have been a huge beneďŹ t to both patient and doctor and a cost saving as well. On other occasions, I was asked to assist in caring for patients who were confounding other professionalâ&#x20AC;&#x2122;s expectations. This presented opportunities to assist in identifying problems that were unrecognized or confusing because the referring person lacked some piece of information that was not within their knowledge or training. Without collaboration in either of these situations, patients may suffer. We all need to recognize that our knowledge will never be fully complete and adequate, and we need to build in systems
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that allow us to identify our information shortfalls. We need to nurture relationships with other health care professionals who are willing and able to ďŹ ll in our gaps. We should have opportunities to discuss challenging problems on a regular basis with colleagues and be open to the observations and information provided by other team members. And we must have the generosity to share our own knowledge with colleagues who need it. You never know what you donâ&#x20AC;&#x2122;t know, or might learn. Judith Shank, M.D. is a retired dermatologist. She is a graduate of the University of Iowa, Boston University and the University of Minnesota Medical School. She is a past president of the Minnesota Medical Association and chaired the MMAâ&#x20AC;&#x2122;s task force on Health Care Reform. She lives most of the year in Sarasota, Florida but still summers in Minnesota. She can be reached at jfshank@ icloud.com.
Primary Care Physician Workforce Summit: â&#x20AC;&#x153;Finding Solutionsâ&#x20AC;? TUESDAY, NOVEMBER 12, 2013 4:00 â&#x20AC;&#x201C; 8:00 p.m. Ramada Plaza Minneapolis 1330 Industrial Blvd NE Minneapolis, MN 55413 Cost: (includes dinner) $50 for MMA members; $75 for nonmembers; $10 for students To Register: www.mnmed.org/PCPSummit Sponsored by: â&#x20AC;˘ Minnesota Medical Association â&#x20AC;˘ Minnesota Academy of Family Physicians â&#x20AC;˘ Minnesota Chapter American College of Physicians â&#x20AC;˘ OfďŹ ce of Rural Health & Primary Care (MDH)
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November/December 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
PNPs, PAs, Let Us Count the Ways...
O
r perhaps we should count the years. Partners in Pediatrics, Ltd. (PIP) has utilized Physician Assistants-Certified (PA-C) and Certified Pediatric Nurse Practitioners (CPNP) since 1975 as important members of the patient care team. The first Physician Assistant who joined the practice was one of the first graduates of the program at Duke University and the tradition of the great care he provided to many children has been maintained by many PA-Cs and CPNPs who have practiced here for the last 38 years. These practitioners are an important part of the care team at PIP. Their training is well suited to the care children need and they have been well accepted by our patients. Parents have relied on these professionals to meet many of their children’s health care needs from birth through adolescence. The practice has been actively involved in precepting PA-C and CPNP students from the local training programs and has found it to be a rewarding experience. A new practitioner joining PIP is assigned a mentor, and participates in an informal training program led by the PIP pediatricians that includes common pediatric health care topics, to insure that all PIP clinicians perform essentially the same services in a consistent manner based on the same treatment principles. New practitioners are mentored for an extended period by a supervising physician, their charts are reviewed and they receive further By Mary Jenkins
MetroDoctors
training in pediatric medicine. All of them are credentialed with the health plans and most plans make little or no distinction in their reimbursement for their billed services. Malpractice coverage is provided as part of the group’s policy and the premium is significantly lower than the average pediatrician’s. Our PA-Cs and CPNPs perform newborn examinations in the hospital. Most of our PA-Cs and CPNPs have training in lactation care and have the opportunity to meet the new mothers in this setting. We are committed to breast feeding support and this model serves our mothers and babies well. After discharge the mother can continue her baby’s well child care with the same practitioner, fostering continuity of care. Parents appreciate the ability to create an on-going relationship with the practitioner of their choice. These practitioners can also provide care for most common childhood illnesses and injuries, and are often found working the clinic’s READY CARE walk-in sessions, in the daytime, and evenings and weekends. The patients who access this care appear with a wide range of concerns and health issues. When a child with severe respiratory distress appears, or an extremely fussy newborn or the immune compromised child with a febrile illness appears in the clinic, the child would be seen by a physician, not one of the PA-C/ CPNP practitioners. It is not unusual to
The Journal of the Twin Cities Medical Society
see a PA-C or CPNP consulting with one of the pediatricians about a patient with complex needs, a serious illness or one who appears to need admission to the hospital. While the PA-Cs and CPNPs can work remotely, the clinic has made it a priority to have practitioners work as a group in all the sites. In the course of a typical day the PA-C or CPNP will see multiple well child exams, acute illness visits and some follow-up visits for chronic illnesses, like asthma or common behavioral health issues. These patients’ issues are most often relatively straight forward, and these children do not have other complicating conditions. The pediatrician sees patients with more complicated medical issues. In a typical (Continued on page 24)
November/December 2013
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Medical Care Medical Telemedicine Collaborative Organizations Model Let Us Count the Ways (Continued from page 23)
day a pediatrician will see some well child exams, but some of those children may be ex-premies with developmental concerns, or congenital conditions. Other patients on their schedule may be children with severe and difficult to control asthma or children whose behavioral issues require multiple medications and more involved monitoring. Serious, acute issues — like severe respiratory distress or injuries would be seen by the pediatrician. Individual practices can define the scope of the practitioner’s responsibilities including their prescriptive privileges. Certified Physician Assistants and Certified Pediatric Nurse Practitioners may prescribe medications, including controlled substances. Minnesota law makes this possible when this authority is delegated to the Physician Assistant by the supervising physician based on a written agreement.
Certified nurse practitioners prescribe also in accordance with a written agreement with a physician based on standards established by the Minnesota Nurses Association and the Minnesota Medical Association in a Memorandum of Understanding that defines the delegated responsibilities related to the prescription of drugs and therapeutic devices. Physician Assistants-Certified and Certified Pediatric Nurse Practitioners prescribe all types of medication at Partners in Pediatrics. Currently Partners in Pediatrics has a total of 37 practitioners in five clinics. Nine of them are PA-Cs/CPNPs. They are all assigned to a primary site where they are able to develop their patient panels, like the physicians do. There is typically one PA-C or CPNP working at each site daily. At PIP the PA-C and CPNPs participate in many of the clinic’s patient care workgroups and are actively involved in
the development of patient care processes. Those work groups focus on all aspects of patient care, including asthma, allergy and tobacco cessation, behavioral medicine, newborn care and other areas of pediatric care. All clinicians at Partners in Pediatrics have their documentation and patient care audited regularly both internally and by external auditors. The clinic conducts topic-based educational meetings periodically and both physicians and PA-Cs and CPNPs are expected to attend. They also must meet their respective organization’s continuing medical education requirements. Our PA-C/CPNP group is scheduled in the same format as the pediatricians, with some minor individual differences, just as there are in the pediatrician workgroup. Many families have had experience with advanced practice practitioners in the adult care settings and understand, accept and prefer to see a PA-C or CPNP for the majority of their children’s care. Like the pediatricians they teach prenatal classes in the local hospitals and also meet new patient’s parents in our “Meet PIP Provider” sessions held in the clinic. In this time of rapidly changing health care models and the concern about the scarcity of primary care practitioners, Partners in Pediatrics has embraced the skills and talents of PA-Cs and CPNPs for many years. They are an essential part of our pediatric care team and we feel we are well prepared to meet the future challenges to access to care for children in our community. Mary Jenkins is the clinic administrator at Partners in Pediatrics, an affiliate of Children’s Hospitals and Clinics of Minnesota. During her 37 years at the clinic she has had many great relationships as a parent, grandparent and administrator with the Physician Assistants-Certified and Certified Pediatric Nurse Practitioners at Partners in Pediatrics. She can be reached at: (763) 278-0840 or (612) 296-1410.
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November/December 2013
MetroDoctors
The Journal of the Twin Cities Medical Society
Embracing Advanced Practice Clinicians
Receptionist: “Hi, Welcome to Multicare Associates. Who are you seeing today?” Patient: “Dr. Milteer.” Receptionist: “You mean Leslie; she is a Certified Physician Assistant.” Patient: “What is the difference?” Over the past few years this has become a common question heard at the check-in desk of Multicare Associates, with physician assistants and nurse practitioners (advanced practice clinicians or APCs) commonly providing the same services and managing their own panel of patients similar to a primary care physician. Multicare Associates is a physician owned multispecialty primary care clinic, offering family medicine, internal medicine, pediatric, OB/GYN, general surgery and occupational medicine services. Today, the practice has evolved to where APCs are part of a team-based care approach that expands patient access with autonomous visits, serves as the patient’s primary care provider, and enhances all levels of practice development including leadership roles. Of Multicare’s 39 clinicians 12 are physician assistants and nurse practitioners in the areas of family medicine, pediatrics, women’s health and occupational medicine. The APCs skill sets are far beyond that of basic follow-up visits, and simple procedures, and involve managing complex medicine patients. An experienced APC rarely needs to review cases with their supervising physician, but does know when to discuss the case or even see the patient with the supervising physician. By Leslie Milteer and Matt Brandt
MetroDoctors
This transition did not happen overnight. Initially many physicians may have perceived APCs as competition. As an example, Multicare at one time had scheduling rules which mandated that patients be booked with physicians before APCs. Oftentimes, when a scope of practice or care issue was brought forward concerning an APC the answer was to just limit the APC from seeing those kinds of patients. Now, when confronted with these issues the physicians seek to teach, provide support and work in collaboration with APCs. When an APC has trouble adjusting medications for a patient with diabetes the physician takes the time to review the case with the APC so that he/she can manage the patient in the future versus simply saying don’t see diabetic patients anymore or just refer the patient to me. Multicare Associates team of physician assistants and nurse practitioners has a broad base of experience, ranging from years of experience in pulmonology
The Journal of the Twin Cities Medical Society
to trauma. Oftentimes an APC could have knowledge in an area where a physician may consult, co-manage or refer a patient to them, i.e. advice on managing sleep apnea or how to create a fake finger nail. The role of physician assistants and nurse practitioners within the practice at Multicare Associates is continuing to grow. APCs are seen as leaders within the clinic much the same as a physician is and are being expected to actively participate in business and practice development. Recently, physician assistants provided training on clinical topics to our medical support staff and were involved in CQI, EMR and Medical Home committee work. A nurse practitioner was chosen as a lead APC and there have been discussions of this role being a part of the board of directors at Multicare Associates. There has even been discussion of opportunities for ownership in the practice. (Continued on page 26)
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Medical Care Medical Telemedicine Collaborative Organizations Model Embracing Advanced Practice Clinicians (Continued from page 25)
At Multicare we view the Minnesota laws regarding supervision and practice scope to be constructive and respectful of the physician assistant and nurse practitioner professions. It may not be fully understood or embraced by the entire medical community or patients, but there has been great progress and we are encouraged by the increased awareness that is developing. For the last 15 years, there has been only one physician assistant program in Minnesota at Augsburg College. Recently two other schools have received accreditation, St. Catherine’s and Bethel, and a fourth, St. Scholastica in Duluth, will be applying for accreditation in the next two years. This increase in schools will hopefully increase the professional presence of physician assistants and improve utilization and awareness. The physician assistant profession is based on a primary care model. Developed in the 1960s by Eugene Stead, M.D. at Duke University, the profession was
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November/December 2013
intended to help fill the shortage of practitioners at the time and focused on primary care. While the profession has expanded and PAs now practice in all areas of medicine, they hold strong to their foundation
practice capacity. NPs are regulated by the State Board of Nursing and certified by specific Nursing Boards. More primary care clinicians of all backgrounds — physicians, PAs and
Advanced Practice Clinicians are not competing with physicians, but rather expanding options for care and allowing practices to create innovative team-based care models.
as primary care clinicians. PA training is formatted to focus on primary care first and foremost. They are trained similar to physicians with didactic and clinical experiences organized similar to medical school, but slightly abbreviated and without residency. A PA can autonomously perform many of the same functions as a physician including assess, diagnose and manage most medical conditions, order tests, prescribe medication and perform in-office procedures. The certification exam, including the recertification exam, is always based on a primary care platform. This focus on primary care makes them well suited to work alongside physicians to provide the full spectrum of care needs in the primary care setting. Nurse Practitioners are registered nurses that have completed advanced training and education in their field. Loretta Ford, RN and Dr. Henry Silver created the first NP program at the University of Colorado in 1965. The length of training depends on the specialty which includes pediatrics, women’s health, family medicine, internal medicine, geriatrics, psychiatry or intensive care. NPs develop advanced skills in diagnosis, evaluation, management, and prevention of illness. An NP can perform all aspects of patient care, ordering any needed tests and prescribing medications when necessary. An NP works in collaboration with a physician for full
NPs — will be needed as we face the increased issues with access to care, the existing shortage of primary care clinicians, and the estimated 30 million Americans that may filter into the care system due to health care reform. Advanced Practice Clinicians are not competing with physicians, but rather expanding options for care and allowing practices to create innovative team-based care models. APCs can be a welcome addition to a practice, to the patients they serve, and the medical community as a whole. Leslie Milteer, P.A.-C. joined Multicare Associates in 2012 as a family practice certified physician assistant at the Blaine Medical Center. She has been in practice for 15 years and previously practiced at the University of Minnesota. She received her training from Texas A&M and Saint Francis University. She can be contacted at: lmilteer@ multicare-assoc.com, or (763) 785-4500. Matt Brandt joined Multicare Associates in 2008 as the chief financial officer. In 2011 he became the chief executive officer. He received his Bachelors of Science from Miami of Ohio University. He can be contacted at: mbrandt@ multicare-assoc.com, or (763) 785-4500.
MetroDoctors
The Journal of the Twin Cities Medical Society
YOUR VOICE
Me or We: Independence Versus Collaboration
NO ONE DOES IT ALONE. There’s no “I” in team. Even Stephen
Covey’s Maturity Continuum describes the natural evolution from dependence to independence to interdependence, where “we” combine forces to synergistically and effectively accomplish our goals. Most of us in health care recognize the importance of collaboration and why it is becoming an increasingly important concept in medicine. The basis of Accountable Care Organizations and Medical Homes is that the combined efforts of a team of health care practitioners that includes doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and community members, will work together toward the common goal of providing high quality, cost-effective health care. So it’s interesting that we now see a request for independence at the advanced practitioner level. Most people recognize the importance of having advanced practice practitioners in the future of medicine. Few of us would want to work without them. As we implement the Accountable Care Act, we will see an influx of patients and many are concerned about access and the number of primary care physicians that will be available to care for these patients. Improving access to health care in currently underserved communities may mean giving advanced practitioners greater latitude in their roles so they can function more independently in these circumstances. Encouraging and allowing all health care practitioners the ability to work to the full potential of their training is paramount to the future success of our medical system. That being said, it will also be increasingly important for health care practitioners to understand the limits of their abilities and training. Many of us recited the words of the modern Hippocratic Oath: “I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.” It is important to also acknowledge that the more we know, the more we realize how much more there is to learn. In medicine, the loss of humility can result in dangerous consequences. As a physician, many people think that I can take care of any medical problem. Certainly my medical training allows me to do general medical exams and screen for medical problems, but as an obstetrician and gynecologist, I’m specifically trained
By Lisa Mattson, M.D., Obstetrics/Gynecology, President-elect, TCMS
MetroDoctors
The Journal of the Twin Cities Medical Society
to manage the medical issues of women and this is what I do best. One of the benefits of working in a metropolitan area is my ability to send any non-gynecologic problems to one of many colleagues in the community who are better trained to evaluate such things as heart murmurs, asthma, mental illness, or broken bones. Many would argue that a failure to send my patient to someone with more expertise when they are so readily available could constitute a form of malpractice. My practice style would be different if I was working in a small town in out-state Minnesota where I would be prepared to do more complex gynecology and obstetrics and practice more non-gynecologic issues depending on the number of primary care and specialty physicians that were available in my community. What I can do and what I should do, will vary depending on the situation and the resources available. I chose to study general obstetrics and gynecology and not pursue additional training in specialized areas of women’s health. As a result, if I’m concerned about a gynecologic cancer or a have a complicated obstetrical patient, I send my patient to the physicians who have had additional, specialized training in those areas. They may take over care of the patient, they may outline a plan of care that I can follow on my own, or they may ask me to participate in only a specific aspect of the patient’s medical condition. The additional years of training required for specialty care makes these physicians more qualified to deal with complex issues and they are more apt to be aware of recent advances or research being done that may help in the care of my patients. My patients expect and deserve the best care possible. I took an oath to give them the best, and when the best isn’t me, I should feel obligated to enlist the assistance of someone who may have more to offer. Very rarely do any of us practice independently, so legislation giving advanced practice practitioners more independence seems counter to the direction medicine is heading. Advanced practitioners have an important contribution to make to the medical team. It is imperative that all of us, regardless of our role or title, need to acknowledge evidence-based guidelines and be willing to work and consult with others so that we can continue to learn, become better at what we do, and provide safe and effective health care to all of our patients. November/December 2013
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MMA Annual Meeting and House of Delegates
Sixty-six TCMS physicians participated in the MMA Annual Meeting and House of Delegates.
T
he 160th annual meeting of the Minnesota Medical Association was convened on September 20-21, 2013. Sixty-six delegates representing the Twin Cities Medical Society attended the events. A TCMS presence was prominent and palpable throughout the meeting as several TCMS members were elected to MMA positions, recognized for their involvement and actively participated in the discussions. Edwin Bogonko, M.D., TCMS president, opened the House of Delegates with an eloquent welcome on behalf of his colleagues, calling for unity and passion for the profession of medicine. An election ballot was then distributed with Donald Jacobs, M.D. elected presidentelect of the MMA and Robert Moravec, M.D. re-elected as Speaker of the House of Delegates. Other TCMS members elected include: Fatima Jiwa, MBChB and Michael Tedford, M.D. – MMA Board of Trustees; and Stephen F. Darrow, M.D. and David Estrin, M.D. – AMA Alternate Delegates. Dave Thorson, M.D. serves as the chair of the MMA Board of Trustees. Brian Sick, M.D. received the Community Service Award which honors MMA members who are actively engaged in the practice of medicine and have an outstanding record of community service. And the Distinguished Service Award was awarded to Macaran Baird, M.D. — the MMA’s highest honor, bestowed upon a physician who has made outstanding contributions to medicine and to the MMA. Commendations in recognition of commitment and service to MMA 28
November/December 2013
included: Lyle Swenson, M.D. – outgoing Past-President; Carl Burkland, M.D. and Benjamin Chaska, M.D. – outgoing Board of Trustees members. TCMS put forth 16 resolutions for consideration by the House of Delegates. Generating the most attention was Resolution #300 which called for Governance Changes and Bylaws Amendments. A
compromise resolution was adopted that continues the Annual Meeting, but suspends the House of Delegates until 2016 utilizing Policy Forums and Listening Sessions to gain member input on public policy issues. Please refer to the MMA website for specific details of the full actions taken by the House of Delegates. Thank you to the following TCMS members who served on the Reference Committees: Lindsay Thomas, M.D. Scott Uttley, M.D. Tyler Winkelman, M.D. And, a special thank you to Michael Tedford, M.D. who served as the TCMS Caucus Chair.
Drs. Lisa Mattson, Phillip Stoltenberg and David Thorson converse after the TCMS Caucus.
Edwin Bogonko, M.D., TCMS president, addressed the Caucus and the MMA House of Delegates.
MetroDoctors
Resident representative and first time Delegate, Tyler Winkelman, M.D. served on Reference Committee A.
Resident representative Stephen Darrow, M.D. offered remarks relating to the proposed governance changes with Michael Tedford, M.D., Caucus Chair.
The Journal of the Twin Cities Medical Society
Healthy Eating Minnesota Celebrates Accomplishments In the fall of 2008, the Twin Cities Medical Society was awarded a five year Healthy Eating Minnesota contract from the Center for Prevention at Blue Cross Blue Shield of Minnesota. The purpose of this contract was to increase access to and availability of healthy foods. The medical society and our physician members took it a step further and began working on policy change at the local level. This included a menu-labeling initiative, reducing trans-fats in restaurants, and finally, creating the Twin Cities Obesity Prevention Coalition. The mission of the coalition was to provide leadership to improve public health by advocating for healthy eating/active living strategies in metro area communities. The initial focus called for the elimination of trans fats by restaurants and the posting of food calories at the point of sale. The Affordable Care Act took this work out of our hands by including a national menu-labeling law that requires food establishments to post calories on menus. This is still being rolled out, however, many restaurants have taken it upon themselves to post calories sooner than the law requires. The coalition’s work continued with the communities of Eagan, Eden Prairie and Savage passing healthy eating/active living resolutions which include a range of strategies to improve access to healthy foods and improved active living options for residents in all communities. Communities will be able to continue the work of creating resolutions with online access to a toolkit designed to walk city leaders through the process of and implementation of a resolution. The Twin Cities Medical Society is grateful for the opportunity to be leaders in this work alongside our partners who have been instrumental in the success of this Healthy Eating Minnesota funding opportunity. By Jennifer Anderson, MA, Project Coordinator
White Coat Ceremony
Edwin Bogonko, M.D., TCMS president, along with Kathleen Watson, M.D., Senior Associate Dean for Undergraduate Medical Education, U of M, and Paul Matson, M.D., MMA Foundation, participated in the University of Minnesota Medical Student White Coat Ceremony.
MetroDoctors
The Journal of the Twin Cities Medical Society
November/December 2013
29
CAREER OPPORTUNITIES
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MetroDoctors
The Journal of the Twin Cities Medical Society
November/December 2013
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
DEANE C. MANOLIS, M.D. IT MAY BE REASONABLE TO ASSUME that a multi-
talented physician who has been — and remains — busily involved in a variety of professional and other pursuits, could reasonably be expected to present an extroverted or hyperactive image. Such a depiction is certainly not the case with our current Luminary. Dr. Deane Manolis, a Minneapolis native and Phi Beta Kappa honoree, obtained his B.A. and M.D. degrees at the U of M — where he also completed his psychiatry residency and decades of medical school teaching as a Clinical Professor. He served in the Minnesota National Guard and during the Viet Nam War was the chief of Psychiatry at Fort Wainwright, Alaska. His 30+ years of private psychiatric practice was the anchor for a multitude of professional, community and family activities. Though he was an active psychiatric consultant in rural Minnesota, his main hospital affiliations were Metropolitan, Metropolitan Mount Sinai and Abbott Northwestern Medical Centers. Various leadership appointments attested to the high regard in which he’s always been held by his colleagues — including chief of Psychiatry, president of Medical Staff, president of the Minnesota Psychiatric Society, and medical directorships in Behavior Health/Adult Psychiatry. He’s been an integral member of teams of professionals — often as an advising consultant or the “captain of the ship.” Social workers, psychologists and psychiatric nurse clinicians have praised his wise counsel and calm demeanor as a “great teammate.” He was once referred to by another physician as “the sanest psychiatrist I know.” Before and after his clinical retirement, Deane’s patients simply thought the world of him — probably related to his calm bearing and caring guidance. He was honored by his peers of the Minnesota Psychiatric Society as the Private Practitioner of the Year and by the American Psychiatric Association as a Distinguished Life Fellow. Numerous activities in which he has been engaged, whether as an award winning newsletter editor, a community church leader, a sail and power squadron teacher or a West Metro Medical Foundation trustee, were 32
November/December 2013
addressed by him in a quietly efficient fashion. Such was the case when he and Dr. David Cline organized, promoted and spearheaded an oral history project sponsored by the Minnesota Psychiatric Society and the Minnesota Historical Society. In it, mainly via physician interviews, the relevance of their specialty and its historical changes were traced. They highlighted the progression from days where the perception of psychiatry resulted in it being treated as a poor stepchild of medicine, through the 60s and 70s featuring tragically short early hospital stays for newly diagnosed schizophrenia, severe bipolar disease and other significant conditions — to the current emerging period of hopefulness in new medication development, disease causation discoveries, collegial para-professionals’ assumption of some patient care responsibilities and a closer relationship with the specialty of neurology. Dr. Manolis played a prominent role in achieving many of these positive achievements in his cherished specialty. The good doctor has always valued his family, from the youthful time he worked in his parents’ South Minneapolis restaurant to the raising of three accomplished children with his lovely wife. Under the category of “Special Interests/Hobbies” in his CV, prominently listed along with other pursuits is the word “grandfather-ing.” This brilliant, easy-going and quietly effective physician is also disarmingly modest. In a recent conversation, he protested that he really shouldn’t be considered in the grouping of Luminaries of Twin Cities Medicine. We respectfully disagree! This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
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