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CONTENTS VOLUME 16, NO. 5
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Index to Advertisers
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IN THIS ISSUE
SEPTEMBER/OCTOBER 2014
Reducing Health Disparity By Richard Sturgeon, MD
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PRESIDENT’S MESSAGE:
Gynecologist or Gynechiatrist? By Lisa R. Mattson, MD
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TCMS IN ACTION
By Sue Schettle, CEO Page 32
Page 12
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HEALTH DISPARITY
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Health and Income Disparities in Racial and Ethnic Communities in the Twin Cities
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Colleague Interview: A Conversation with Edward Ehlinger MD, MSPH
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Clippers n’ Curls for the Heart By the American Heart Association
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Barriers to the Basics—Reflections on Health Disparities of Native Americans •
By Lydia Caros, MD
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Minnesota Grown Latino Physician’s Experience •
By Jason Como, MD
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East African Health Care •
By Steven R. Vincent, MD
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Reflections on Hmong Health Disparities •
By Kang Xiaaj, MD
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CBPAR Partnerships Can Address and Redress Health Disparities: Voices from SoLaHmo •
By Kathleen A. Culhane-Pera, MD, MA; Shannon L. Pergament, MSW, MPH; Luis E. Ortega, MEd; Mai See Thao, BA; and Naima Dhore Page 23
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What is Prediabetes and Why Does it Matter? By Elizabeth R. Seaquist, MD
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Senior Physicians Association Holds Summer Event Honoring Choices 5th Annual Conference a Success
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New Members In Memoriam Class of 2018 Medical School Orientation Career Opportunities
Page 18 MetroDoctors
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LUMINARY OF TWIN CITIES MEDICINE
Virginia R. Lupo, MD The Journal of the Twin Cities Medical Society
On the Cover: Disparity, in both health and income, face many in our community. Articles begin on page 6. September/October 2014
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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor 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 reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.
September/October Index to Advertisers TCMS Officers
President: Lisa R. Mattson, MD President-elect: Kenneth N. Kephart, MD Secretary: Carolyn McClain, MD Treasurer: Matthew Hunt, MD Past President: Edwin N. Bogonko, MD TCMS Executive Staff
Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Communications and IT Coordinator (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Karen Peterson, Program Manager, Honoring Choices MN (612) 362-3704 kpeterson@metrodoctors.com Terri Traudt, Project Director, Honoring Choices MN (612) 362-3706 ttraudt@metrodoctors.com
Allina Health.......................................................31 Audiology Concepts .........................................10 Coldwell Banker Burnet....Inside Back Cover Crutchfield Dermatology.................................. 2 Dermatology Consultants...............................20 Fairview Health Services .................................30 Fraser ..................................... Inside Front Cover HCMC ...................................Inside Back Cover Healthcare Billing Resources, Inc. ...............17 HealthEast ...........................................................31 Lakeview Clinic .................................................31 Lockridge Grindal Nauen P.L.L.P. ...............13 Minnesota Epilepsy Group, PA ....................26 MMA/TCMS Prediabetes Webinar ............27 MMIC ................................ Outside Back Cover Saint Therese.......................................................26 Uptown Dermatology & SkinSpa................13
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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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September/October 2014
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The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
Reducing Health Disparity THE INSTITUTE OF MEDICINE SAYS, “Public Health is what we, as a society, do collectively to assure the conditions in which people can be healthy.” Too many people in Minnesota are not as healthy as they could and should be. The health disparities that exist are significant, persistent, and cannot be explained only by bio-genetic factors. The opportunity to be healthy is not equally available everywhere or for everyone in the state. Health is a state of complete well-being and not merely the absence of disease or infirmity. Health is created in the community through social, economic and environmental factors as well as individual behaviors and biology. The groups that experience the greatest disparities in health outcomes also experience the greatest inequities in the social and economic conditions that are such strong predictors of health. These disparities affect many Minnesota populations. For example, African American and Hispanic/Latino women in Minnesota are more likely to be diagnosed with later-stage breast cancer. African American and American Indian babies die in the first year of life at twice the rate of white babies. The 2013 Minnesota Legislature directed the Minnesota Department of Health (MDH) to prepare a report on Advancing Health Equity to provide an overview of Minnesota health disparities and health inequities. In addition to identifying health inequities, this report provides a new approach to addressing health disparities. Recommendations expand from a wholly individual or programmatic response to include a broad focus on social factors and conditions. Foremost is to advance health equity through a health in all policies approach across all sectors, an approach to target efforts which will have the greatest effect on populations with the greatest need, from housing to transportation to education and more. Another recommendation was to establish the Minnesota Center for Health Equity with the intent of bringing an overt and explicit focus to the efforts of the MDH to advance health equity in Minnesota. This has been launched. There is increasing concern that existing policy efforts designed to improve care may, in fact, worsen disparities of care. For example, the Hospital Readmission Reduction Program was found to disproportionately penalize safety-net facilities that primarily care for disadvantaged and poor populations. The Center will serve as a technical resource for the agency and its state and community partners and will create a solid data-driven footing for health equity efforts. Appropriate quality reporting combined with well-designed incentives can drive improvements in care without penalizing hospitals and clinicians that disproportionately care for the poor. This is a goal for the MDH Minnesota Center for Health Equity. By Richard Sturgeon, MD Member, MetroDoctors Editorial Board MetroDoctors
The Journal of the Twin Cities Medical Society
Mia Robillos, et al (MDH) has provided much more detail in an introductory article. Health disparity has an effect on all of us. For a very informative executive summary or the full report: http://www.health.state. mn.us/divs/chs/healthequity/. Commissioner Edward Ehlinger, MD is the colleague interviewed by the Editors. His responses are clear and full of wisdom. He shares inside knowledge about causes and effects of health disparity and plans to improve health equity in all patients. This issue taps into frontline reporters, physicians devoted to patient communities under social and economic stress. They share their personal stories and the challenges facing their patients. They describe some progress over the past decades, albeit way less than desired. We read of hopes, aspirations and suggestions for processes of improvement in the health of these communities. For these erudite submissions, the editors thank: • Kevin Brown, MD/AHA – Barber Shop Hypertension Awareness Project • Lydia Caros, MD – Native American Cultural Center • Jason Como, MD – Westside Clinic (Hispanic) • Steven Vincent, MD – People’s Center Health Services (Somali) • Kang Xiaaj, MD – Hmong perspective • Kathie Culhane-Pera, MD – SoLaHmoPartnership for Health and Wellness. Additional thank you to community scholars Shannon L. Pergament, Luis Ortega, Mai See Thao and Naima Dhore What is Prediabetes and Why Does it Matter? – Elizabeth Seaquist, MD highlights and promotes the Diabetes Prevention Trial. Of note, in recent years, the incidence of type 2 diabetes has increased dramatically in children, particularly in minority populations. Virginia Lupo, MD, our luminary, has served patient populations at risk initially in community clinics, and now through her 30-year career at HCMC. As noted by Dr. Lydia Caros: What this community needs is not answered by patient portals or e-health connections to hospitals. The biggest barriers to health improvement have always been poverty, racism, lack of adequate housing, and unemployment. Society’s focus on those issues, however daunting, will be the key to eliminating health disparities. September/October 2014
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President’s Message
Gynecologist or Gynechiatrist? LISA R. MATTSON, MD
MY 1:45 APPOINTMENT: STI SCREEN. This is a pretty normal concern in a gynecology practice. It could just be someone making sure that she doesn’t have any infections. It could be a cheating partner or a history of many recent partners. It could be a night of heavy drinking that ended with a sexual encounter with a stranger or it could be a history of a sexual assault. All of these scenarios require me to put on my “gynechiatrist” hat, as the more important problem may actually be depression, anxiety, post-traumatic stress, substance abuse, bipolar disorder, or low self-esteem. Compassion, an open ear, and the ability to validate concerns are sometimes all that is needed, but some of these women have more significant mental health disorders. Finding them the help they need is often difficult, depending on their insurance coverage, transportation, support network, and ultimately the availability of mental health providers. The National Alliance on Mental Illness (NAMI) estimates that 61.5 million Americans, or one in four adults, experience mental illness in a given year. Serious mental illness costs America $193.2 billion in lost earnings every year and ties for the third in terms of cost, accounting for $57.5 billion in medical expenditures, equivalent to expenditures for all cancers. Only heart conditions ($78 billion) and trauma ($68.1 billion) are more costly (AHRQ data 2006). Mental health faces many barriers to adequate care. Approximately 60 percent of adults and almost one half of youth ages 8-15 who have mental illness fail to receive treatment, and suicide continues to be the tenth leading cause of death in this country. Some may find it difficult to access the resources that are available because of inadequate housing, lack of transportation, or an inability to leave a job for appointments. Mental health is also still stigmatized as being a sign of personal weakness, lack of character, or poor upbringing which further prevents some people from seeking the help they need or getting the support of family and friends that can be so important to successful treatment. Imagine that mental health and cancer were two equally significant health issues. When someone is stricken with cancer, we go out of our way to support them. We offer them rides to appointments, provide meals to their families, donate money to research, and would never consider blaming them or ostracizing them because of their illness. A cultural shift resulting in less judgmental attitudes toward mental health issues would be a welcome change. Lack of insurance has also been a major barrier to care. The Mental Health Parity Act of 2008 and the Affordable Care Act (ACA) have been important in moving us closer to realizing comprehensive mental health care that is equivalent to that provided for physical health. By allowing young adults to stay on their parent’s insurance until age 26, the ACA may also encourage earlier interventions, since three quarters of mental health conditions begin by the age of 24. The inability to deny coverage to people with pre-existing disease may also allow for better continuity of care and improved outcomes. Yet not all insurance policies are equal and there may still be some gaps that leave some individuals “underinsured” with continued frustrations as they try to navigate the system in search of help. Availability of providers and workforce shortage continue to be a huge barrier to care. Getting appointments in mental health can take anywhere from a few weeks to a few months. In the meantime, some of the patients may attempt to harm themselves or others and some will end up in the Emergency Room and require hospitalization. Improving reimbursement rates in mental health will help attract more qualified people into the field and reduce turnover. Efforts also need to be made to minimize burnout and improve self-care and wellness for mental health providers to reduce turnover and provide more stability to the workforce. Since good mental health is inherent to good physical health, an ability to deal with psychiatric issues should be important to all physicians. One could argue that we should have more emphasis on mental health disease in medical school and as part of our continuing medical education, regardless of our specialty. I’m not a psychiatrist and I know my limits, so an improved system that simplifies access and provides adequate funding/reimbursement for more advanced mental health services would be better for my patients. I look forward to a day when there is parity between mental health and physical health so I can spend less time as a gynechiatrist and more time doing what I was trained to do as a gynecologist. 4
September/October 2014
MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
TCMS Board News
The TCMS Board of Directors welcomes Rupa Polam, MD to the board serving in the Resident/Fellow position. Dr. Polam is a PM&R resident at the University of Minnesota. She received her Doctorate of Medicine degree from the University of Kansas School of Medicine, and her Masters of Public Health from the same school. Honoring Choices MN Updates
We are so pleased that an article discussing the development of Honoring Choices Minnesota will be published in an upcoming issue of the Journal of the American Geriatrics Society. Thanks to Kent Wilson, MD and Tom Kottke, MD for their hard work developing the article and working with the editors. Foundation News
The East Metro Medical Society Foundation and West Metro Medical Foundation boards of directors each took significant steps recently to move toward a merger of the Foundations to be effective January 1, 2015. Throughout 2013 and 2014 the boards reviewed the pros and cons of merging the foundations and discussed at length preserving the legacies, namely the Boeckmann Fund. The structures of the two foundations are different, therefore there are separate requirements that must be considered if the merger is indeed to move ahead. For example, the sole member of the West Metro Medical Foundation is the physician membership of the West Metro. The sole member of the East Metro Medical Society Foundation is the Twin Cities Medical Society board MetroDoctors
of directors. A mailing to the west metro members outlining the plan of the merger occurred in July. The boards of both foundations are expected to take a final vote to approve the merger later this fall if there is not significant opposition expressed. Educational Forums
On August 6, TCMS held a forum on Telemedicine that was well attended. Bryan Burke, MD, a pediatrician and professor at the University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, was the keynote speaker. He currently serves as the pediatric liaison between the American Telemedicine Association and the American Academy of Pediatrics. Dr. Burke provided tools and resources for adopting a tele-education, tele-consultation, tele-practice and tele-research program.
Gretchen Taylor, MPH, RD, Minnesota Department of Health, Center for Health Promotion; and Sheryl Grover, Director of Chronic Disease Prevention, YMCA Twin Cities Area. (See related article on page 27). Volunteers Needed
If you would like to learn more about e-cigarettes, flavored cigars, hookahs and more, let us know. E-cigarettes were not included in the statewide Freedom to Breathe Act despite efforts throughout the last legislative session to include them. As a result, there are many efforts underway in city and county governments to expand their ordinances. Physicians and medical students are important in this discussion. TCMS is offering our members the opportunity to become more informed about this relatively new phenomenon. Contact me at sschettle@metrodoctors.com for more information. CEO Attends National Conference
On October 7, TCMS and MMA, along with the AMA and ADA are co-sponsoring an educational event on prediabetes. Speakers include: Elizabeth Seaquist, MD, 2014 President of Medicine and Science, American Diabetes Association and Pennock Family Chair in Diabetes Research, Professor of Medicine, University of Minnesota; Luke Benedict, MD, Endocrinologist, Allina Health;
The Journal of the Twin Cities Medical Society
The Association for Medical Society Executives recently held its annual conference in Louisville, KY. I was asked to give a presentation to the County CEOs assembled (30+) on the role that county medical societies can play in advancing population health initiatives such as smoke free, obesity prevention and endof-life care/advance care planning.
September/October 2014
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Health Disparity
Heath and Income Disparities in Racial and Ethnic Communities in the Twin Cities
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innesota ranks among the healthiest states in the nation. Still, many Minnesotans are not as healthy as they should be. Health disparities, which are population-based differences in health outcomes, are significant and persistent because the opportunity to be healthy is not always available, especially among low income and minority populations. Addressing these disparities is important if Minnesota is to retain and build on its reputation for a high quality of life. Health is generated through a complex interaction of individual, social, economic, and environmental factors and systems and policies. There is no single predictor of good health. Factors such as jobs, income, transportation, housing, food supply, education, health care access, civic engagement, and social support networks all contribute to health. Sometimes, whether intended or not, decisions made regarding these systems and structures benefit one population unfairly over others. For example, certain people are at a disadvantage when businesses decide to locate in wealthy suburban areas not accessible by public transportation, or when neighborhoods do not have parks or full-scale grocery stores. These structural inequities get in the way of achieving health equity. Income and Health
Income is one of the strongest and most consistent predictors of individual health. People with higher incomes generally enjoy better health and live longer. The health-income relationship is defined not just by access to medical care but a host of other factors. Sir Michael Marmot, who
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September/October 2014
has written extensively on the subject, points out that people with higher incomes are more likely to live in safe homes and neighborhoods, and have access to fullservice grocery stores with healthy foods, safe spaces for physical activity, and highquality schools. All these factors contribute to longer, healthier lives. People with higher incomes also enjoy greater political and social influence and have more meaningful •
income families in the Twin Cities Metro area were uninsured compared to 17.7 percent among lower income families. Minnesota’s 2011 Behavioral Risk Factor Surveillance System data for the Twin Cities Metro area showed that the percentage of adults 18-64 years old reporting they are in fair or poor health declined with income: 27.5
Health equity is achieved when every person has the opportunity to realize their health potential — the highest level of health possible for that person — without limits imposed by structural inequities.
options to choose from because they have the resources to do so. The link between income and health is evident in Minnesota. For example: • People with higher incomes are more likely to live longer. A Wilder Research 2012 study revealed that Minnesotans residing in Twin Cities zip codes with the highest median household income live an average of eight years longer than those in zip codes with the lowest median household income. • People with higher incomes are more likely to be insured. The 2013 Minnesota Health Access Survey data indicated that 4.6 percent of higher •
percent for those with incomes less than $20,000 and only 3.0 percent for those with incomes of $75,000 or more. The percentage of adults who were told they had diabetes also declined as income increased. The 2013 Minnesota Student Survey data related to 9th grade students in the Twin Cities receiving free or reduced price lunch (a proxy measure for income) showed the incomehealth relationship in several ways: ■ 13.9 percent of students receiving free or reduced-price school lunch (FRL) reported fair or poor health compared to 6.8 percent
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The Journal of the Twin Cities Medical Society
■
■
of students not receiving FRL; 13.8 percent of FRL students were obese compared to 6.4 percent of non-FRL students; and 15.9 percent of FRL students reported having seriously considered attempting suicide in the past year, compared to 10.8 percent of non-FRL students.
Income, Race/Ethnicity and Health in Minnesota
In Minnesota, poverty is more concentrated among populations of color, children, people with less education, female-headed households and residents of rural areas. According to the 2012 American Community Survey, poverty rates for populations of color and American Indians are two to four times higher than the rate for Whites. More than 25 percent of African Americans, American Indians and Hispanics in Minnesota live in poverty, compared to 8.8 percent of Whites. In 2012, 17.1 percent of Minnesota children under 5 years of age lived in poverty compared to 13.6 percent for children 5 to 17 years old and 10.4 percent for those 18 years and older. The differences in health measures continue to exist when race/ethnicity is factored in. • 2013 Twin Cities data showed that White was the only racial/ethnic group for which the uninsurance rate fell below the statewide rate, 5.5 percent versus 8.4 percent. This rate was 12.2 percent for African Americans, 12.3 percent for Asians, and 34.8 percent for Hispanics. • Twin Cities Metro area 2007-2011 data on infant mortality, measured in deaths per 1,000 births, show that for all racial/ethnic groups for which data are available, rates are lower for mothers with higher levels of education (another proxy measure for income). While this follows an expected pattern, it should be noted that infants born to African American mothers who have beyond a high school education are at a greater risk of dying during their first year of life than infants born to Asian and White mothers MetroDoctors
with a high school education or less. Poverty has been shown to be a significant contributor to children’s health outcomes, physical and social development, and school success. The impact of wealth on their health is cumulative so that the greater proportion of life spent at the upper end of the income spectrum, the more benefits accrue. Children from affluent families are more likely to grow up in a house their parents own in a neighborhood with healthy food options, safe places to play, good schools, and other quality public services. On the other hand, low wage earning parents tend to work more hours, thus limiting parenting time and family recreation. Data from the 2013 Minnesota Student Survey indicated that among 9th graders in the Twin Cities Metro area, a greater proportion of students receiving free or reduced-price school lunch (FRL) are obese compared to non-FRL students across all racial/ethnic groups. Whether or not they receive FRL, compared to Whites, the proportion of students who are obese is higher for all other racial/ethnic groups except Asians. These are just a few examples that illustrate the link between health and income. The association of lower income
The Journal of the Twin Cities Medical Society
with poorer health suggests policies that contribute to increasing income levels would have a positive impact on health, especially for those in the lowest income groups. And because health inequities are socially determined, change is possible. Thus, income and other factors that create opportunities for people to be healthy deserve consideration by policy makers and society as we build a healthy Minnesota. Authors: Mia Robillos, MS, Kim Edelman, MPH, Ann M. Kinney, PhD, Peter Rode, MA, Melanie Peterson-Hickey, PhD and David Stroud, MBA. To learn more about advancing health equity in Minnesota, visit the Minnesota Department of Health (MDH) Health Equity website: http://www.health.state.mn.us/divs/ chs/healthequity/. Contents from this article are from the MDH, Center for Health Statistics Report “White Paper on Income and Health” and the MDH “2014 Advancing Health Equity in Minnesota, Report to the Legislature,” both of which are available on the MDH Health Equity website. Authors of this article are from the MDH Center for Health Statistics.
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Health Disparity
Colleague Interview: A Conversation with Edward Ehlinger, MD, MSPH
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innesota Gov. Mark Dayton appointed Edward Ehlinger, MD, MSPH, to serve as Minnesota Commissioner of Health in Jan. 2011, responsible for directing the work of the Minnesota Department of Health. Prior to this appointment, Dr. Ehlinger served as director and chief health officer for Boynton Health Service at the University of Minnesota, from 1995–2011. He has also served as an adjunct professor in the Division of Epidemiology and Community Health at the U of M School of Public Health. From 1980 to 1995, Dr. Ehlinger served as director of Personal Health Services for the Minneapolis Health Department. Dr. Ehlinger was the first president of the (newly merged) Twin Cities Medical Society. He received his medical degree from the University of Wisconsin, Madison and MSPH from University of North Carolina Chapel Hill.
Minnesota is reported to be one of the healthiest states in the nation — what needs to be done to preserve that title from a population health standpoint? Almost every study and report ranks Minnesota as one of the healthiest states in the country. Minnesota has the second longest life expectancy at birth and one of the lowest infant mortality rates. The state also has the sixth longest life expectancy after age 65 and Minnesota seniors are considered the healthiest in the country. The common belief is that our good health is due to our great medical care system (rated number one in the country) and good insurance coverage (second best in the country). The reality is that medical care is a relatively small contributor to our overall health — around 10 percent by most calculations. The biggest contributors to health (40–60 percent) are socio-economic factors like education, income, individual and community-level wealth, mobility, and housing. Overall, Minnesota does well in these categories which is reflected in our health status. However, Minnesota also has some of our country’s greatest disparities in these “social determinants of health,” so it’s not surprising that our state also has some of the greatest health disparities. These disparities are manifested most dramatically in populations of color and American Indians. Given the rapidly increasing number of individuals of color in our state, simple math 8
September/October 2014
tells us that unless we reduce these health disparities we will not be able to maintain our ranking as one of the healthiest states. Evolving research on this topic is demonstrating that disparities negatively affect everyone in the community. The health of people at the top of the socio-economic spectrum is diminished by health disparities. Paul Wellstone was correct when he said that “we all do better when we all do better.” To reduce these disparities, we must first change the narrative about what creates health. We need to recognize that the biggest determinants of health are not medical care and personal choices but the socio-economic factors that affect all of us. We also have to acknowledge that how these factors affect us didn’t occur by accident; they were established by policy decisions at national, state, and local levels and that many of these decisions benefit the white population and disadvantage populations of color and American Indians. This is known as structural racism. Achieving health equity is the central challenge for Minnesota if we are to remain one of the healthiest states in the nation. Modifying our policies, systems, and environments to support the achievement of that goal is crucial to the success of our state. MetroDoctors
The Journal of the Twin Cities Medical Society
How does Minnesota compare to the rest of the country in terms of health disparities? Are there any models of health care equality from other states/ countries being used as guides for Minnesota’s plan for the future? Minnesota has some of the greatest health disparities in the country, including the greatest black/white disparity in infant mortality and the third greatest disparity in unhealthy life after age 65. Some of that is due to the good health of the white population but a great deal is due to the poor socio-economic status of minorities in our state. While national comparisons are useful, we’ve begun to focus our comparisons on the states in which Big 10 universities are located (states more comparable to MN and which also have some of the highest levels of disparities). Even with this focus, Minnesota does not fare well. Minnesota has the greatest black/white disparity in income, poverty, high-school graduation, and home ownership. Given this, our health disparities are not surprising. Even though Minnesota has some of the greatest health disparities in the country, no state is doing well in achieving health equity. Although there are currently no good state models about how to effectively address disparities, there are some historical examples about what works. During the “War on Poverty” in the 1960s and 1970s, there was a concerted, comprehensive, and community-based effort to address the social determinants of health. Concurrent with that was a more balanced investment of health and human service resources between medical care, public health, and social services. This strategy led to an overall improvement in health along with a narrowing of health disparities. When this approach was abandoned for a more individual-focused, means-tested, and medically-based approach and funding for public health and social services was reduced, the rate of health improvement slowed, disparities increased, and health care costs began to rise. The experiences in other countries reinforce what was seen in the U.S. War on Poverty. Where there is a community-based effort to address the social determinants of health and a more balanced investment in medical care, public health, and social services, health outcomes improve and disparities are reduced. These experiences are serving as models for the Accountable Communities for Health that are being developed as part of Minnesota’s State Innovation Model (SIM) grant efforts. A new collaborative between Big 10 universities and their state health departments will also be addressing these issues.
Disparities in health outcomes — what do you see as causes, possible solutions and what can individual health providers do to combat health disparities? Is there a role for TCMS? While health care accounts for only 10 percent of overall health, medical care can play a significant role in addressing disparities.
MetroDoctors
The Journal of the Twin Cities Medical Society
Increasing the focus on primary care and integrating that care with public health and social service interventions has been shown to help reduce disparities. Including community health centers and community providers in health care networks can also help. Other approaches that show promise are integrating behavioral and mental health services into primary care, care coordination, home visiting, and use of community care teams, navigators, community health workers, and trained interpreters. Diversifying the workforce and enhancing cultural competence would also be helpful. Standardized collection of race, ethnicity, and language data would help to better target and evaluate health care services. More importantly, the World Health Organization has noted that medical care is also a social determinant of health and that “when appropriately designed and managed, health systems can address health equity…when they specifically address the circumstances of socially disadvantaged and marginalized populations… excluded through stigma and discrimination…and they may be influential in building societal and political support for health equity.” This is where TCMS can play a leadership role. As the voice for physicians in the Twin Cities area, TCMS can continually raise health equity as an issue in policy and health care discussions and help influence the broader socio-political environment that impacts “upstream” factors like poverty, education, and housing.
Are there community/population specific unique health metrics? One of the challenges in developing and evaluating programs to address and eliminate health disparities is the relative lack of data for many communities on many of the contributing factors/ social determinants, and even on health status itself. Improving the infrastructure for health data collection is a necessary and important step for the development and evaluation of programs to eliminate disparities. Work is being done on standardizing the collection and reporting of race, ethnicity, and language data within the health care, public health, and social service systems. Efforts are also underway to incorporate data into the analysis of community health metrics that impact the social determinants of health from non-health agencies, like education, transportation, housing, and economic development.
Federally Qualified Health Centers — how do they play into the mix of serving the underserved, especially in this new reality of expanded health care coverage? Do we need more centers or clinics willing to see people who still may be underinsured or confronting the higher than expected deductibles that they now have through their new health insurance plans? Community clinics will play an increasingly important role in advancing health equity. Not only will they be sensitive and (Continued on page 10)
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Health Disparity Colleague Interview (Continued from page 9)
responsive to the financial issues that will continue to influence health care decisions by both the patient and provider but, more importantly, they are better suited to address the language, cultural, and community issues that attend many health concerns in immigrant and minority communities. Their community-oriented approach to primary care will be increasingly important as our community becomes more diverse. They can also play a role in organizing communities to advocate for policy changes at the state and local levels that address the disparities affecting their health and prosperity.
Does the psychological stress associated with poverty contribute to poor health? If so, how is this manifested? Are there specific approaches planned or in place to treat and support those afflicted? The stresses of poverty, racism, historical trauma, and adverse childhood experiences are well documented as significant factors contributing to poor health. On an individual level, the development and implementation of “trauma-informed care” is showing promise in reducing the harms caused by these stressors. On a
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broader level, a “health in all policies” approach is being initiated to change the policies and systems that disproportionately affect populations of color and American Indians. This approach has the potential to reduce the level of toxic stress experienced by some communities. Reducing community-level poverty, improving educational outcomes, and stabilizing housing will help prevent the adverse childhood experiences that are negatively affecting the health of numerous children.
Does the acknowledged shrinkage of the middle class contribute to poor health in our population? If so, is the eventual solution a political/socioeconomic one or a clinical one? Where disparities in wealth are the widest, the disparities in health are the greatest. As these disparities increase, the health of everyone suffers, even those at the top of the socio-economic strata. Despite having the best medical care system in the country, our disparities have increased which puts our overall health at risk. The long-term solution is socio-political, not clinical. Investing more in our clinical care system is not the answer. The most effective approach is to invest in a community development strategy that provides everyone an equal opportunity to be healthy.
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What are some of the specific mechanisms in place for dealing with the health of children in poverty circumstances? Family and community health and stability are at the core of addressing the issues of children in poverty. The increase in the minimum wage will play a huge role in improving the health status of children and their families. Minnesota data show that moving from the lowest quintile of income to the second lowest, increases life expectancy by over three years and reduces days of poor health by almost 50 percent. The investments being made in safe and secure housing will also be significant. Paid parental leave and paid sick leave would particularly help improve the economic and health security of low-income families. Ten weeks of paid maternity leave has been shown to reduce infant mortality rates by 10 percent. Other income enhancements and a focus on the prenatal to three period in a child’s life show promise of improving the health of low-income children.
Who will be able/eligible to use the services and resources of the Center for Health Equity? How will the Center’s performance be judged? Advancing health equity is the central focus of all of the activities of the Minnesota Department of Health. Every division, office, program, and center will approach their work with the question of how does their efforts advance health equity. The Center for Health Equity will be a resource for data and health equity expertise for all parts of the agency, help facilitate and coordinate health equity efforts across the agency, and identify new opportunities. The Center for Health Equity contains the Center for Health Statistics, the Office of Minority and Multicultural Health, and the Eliminating Health Disparities Initiatives grants. These resources will be available to anyone in the community. In particular, racial and cultural liaisons and data related to health equity will be available to communities of color and American Indians and to organizations working with those communities. Targeted grants addressing specific high priority needs will also be available.
Where do you hope to see the most significant change in Minnesota’s health care delivery in the next five years? Health is not solely the responsibility of the health care sector. Overall health is a community responsibility. To optimize the health of all Minnesotans, health care must be embedded in the community and be responsive to the needs of the community as determined by the community. Health is a public good and how resources are invested to create health should be determined by and accountable to the public. The community-based models being implemented through the Statewide Health Improvement Program (SHIP), county-based purchasing, and Hennepin Health MetroDoctors
The Journal of the Twin Cities Medical Society
show promise in improving health, advancing health equity, and reducing health care costs. Using what is being learned from these efforts to better integrate clinical care, public health, and social services and in Accountable Communities for Health will play a major role in designing a more effective approach to creating a healthy Minnesota.
What has been your biggest “aha” moment since becoming Commissioner? I’ve been (and continue to be) an advocate of a single-payer system for health care. However, what I’ve learned since becoming health commissioner is that the mechanism of financing health care is far from the most important factor in creating a healthy society. What’s most important are the conditions and circumstances in which people are born, grow, live, work, learn, play, pray, and age; and that these circumstances are often determined by forces beyond the control of the individual including: economics, social policies, politics, and the distribution of money and power. Yet, most people have been indoctrinated into the narrative that health is created by their personal choices about diet and exercise and the quality of the health care system. The biggest “aha” moment for me was when I saw the energy unleashed by articulating a different narrative about what creates health. The narrative that health is really created by economic, environmental, and social conditions resonates with what most people intuitively know about health. It also helps them realize that these conditions are not immutable and can be changed by an organized community effort; that creating a healthy society is their responsibility not just that of health professionals. Seeing communities throughout the state becoming engaged in and empowered to create the conditions in which people can thrive and be healthy has been astounding and makes this an exciting time to be health commissioner.
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Clippers n‘ Curls for the Heart
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o where the people are. Speak with them not at them. That is the philosophy of an innovative program that has integrated blood pressure screenings and hypertension education into several local barbershops and beauty salons on the west side of the Twin Cities. The goal of this program, called Clippers n’ Curls for the Heart, is to reduce the incidence of high blood pressure in the African American population and ultimately lower heart attack and stroke rates. In the United States, African Americans have a 30 percent higher death rate from heart disease and a 40 percent higher death rate from stroke than white Americans. “Incidence of hypertension and stroke remain at exceedingly high levels in the African American community,” said Dr. Kevin Brown, neurologist with Hennepin County Medical Center. “Morbidity and mortality associated with these conditions can be directly linked to lack of routine physician visits. Our program puts a delivery system in place where patients already are and allows for early diagnosis and entry into the health care system.” Clippers n’ Curls for the Heart was piloted in seven Minneapolis and St. Paul barbershops and beauty salons. Blood pressure kiosks or automated blood pressure machines were placed in each of the
By the American Heart Association
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locations. The barbers and beauticians were trained to screen blood pressure, engage in heart-health conversations and ultimately refer their clients to clinics for continued care. Nurses also made bimonthly visits to shops to answer questions and provide additional assistance.
Since the program launched in May, over 1,700 people have been screened and hundreds have been referred to area clinics and organizations for further care. “Within the first two weeks of the program, one young man found out his blood pressure was dangerously
Quantrell Fields (left) and Fred Evans (right) work with a customer at Fields of Hair in St. Paul.
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high, something he was unaware of before,” said Clarence Jones, director of Q-Health Connections at Southside Community Health Services in Minneapolis. “The young man was referred for follow-up care where he also discovered he was diabetic. Life-saving medications and lifestyle changes were prescribed for him.” “The barbershops provided a safe place to enter into the question about health,” Jones explained. “The clients were provided with a medical access point and barbers are trusted messengers with difficult conversations.” Brown added that the “program has illuminated the feasibility of utilizing barber/beauty shops as entry portals into the health care system. Our future focus will be on solidifying ways to ensure ongoing compliance and follow up.” The program will continue through August at which point its success in each barbershop and salon will be evaluated to determine if the kiosks should remain or be moved to different shops/salons. Additional funding and grants are also being sought to continue and grow the program. Clippers n’ Curls for the Heart project is a partnership of Q-Health Connections (a division of Southside Community Health Services); American Heart Association and American Stroke Association; Minnesota Department of Health, Heart Disease and Stroke Prevention Unit; Office of Minority and Multicultural Health; Minnesota Black Nurses Association; and Hue-MAN Partnership Project. The project was funded by sponsorships from The St. Paul Foundation and Associated Bank.
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Barriers to the Basics— Reflections on Health Disparities of Native Americans
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ative Americans have some of the worst health disparities of any race or culture in the United States. When you look at the overall MDH or national statistics for Native Americans, the picture is pretty grim along the life cycles, and the numbers don’t seem to improve much over time, with the exception of the infant mortality rates. After 31 years of medical practice with the Native American community, I’m reflecting more on the changes I can see in the population and in the individuals I’ve been privileged to treat. Has anything we’ve done made a difference? Fresh from pediatric residency training in 1983, I moved to the Twin Cities and began my medical practice at the Indian Health Board of Minneapolis. I worked there for 18 years as a pediatrician and medical director. In 2003, three women physicians (including myself ) created another clinic, the Native American Community Clinic (NACC), also in Minneapolis. The core of NACC’s mission statement is “to decrease health disparities of Native Americans in the metropolitan area.” Working to tackle those issues has been our primary focus since the clinic opened. Like all of the Federally Qualified Health Centers (FQHCs) in the area, the clinic provides medical, dental and counseling services. Although this is one small geographic corner of the overall population, it represents the majority of Native Americans living in the metropolitan area. When I began working with this community, lead poisoning was rampant in the Phillips neighborhood due to the By Lydia Caros, MD
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irresponpoor rental housing conditions, irrespon sible landlords and lack of lead screening in children. With regular screening, we found new cases of elevated lead levels almost daily, with levels between 35 and 60ug/dl (normal is less than 5ug/dl). These cases required ongoing tracking and treatment of the children and education for the families. It also involved dealing with housing access, with the city officials and the landlords — what we now call care coordination. Over time, the landlords were pressured, the housing was renovated and the families were taught to protect children from the exposure. Now it’s unusual to see a lead level greater than 3ug/dl. Lead poisoning was never listed as an “official” health disparity, but most of the Native children lived in this deteriorated housing and risked neurodevelopmental damage. It’s a relief to know that this health problem has dramatically improved. Prenatal alcohol use was an even bigger problem 30 years ago when hardly anyone knew that drinking during pregnancy caused irreversible brain damage.
Patients were uninformed and most health care professionals were without tools to address the issue. Close to a hundred alcohol-exposed children were born every year in the neighborhood, resulting in far too many children with fetal alcohol spectrum disorder. We developed a detailed prenatal screening assessment that emphasized support for women during pregnancy, and education about the dangers of alcohol for the fetus. We took time to identify each woman’s stresses and the support she had for sobriety, then provided ongoing support with case managers. This support helped the majority of our prenatal patients to stop using alcohol during pregnancy. First trimester care, regular prenatal visits and healthy pregnancies can be achieved with that kind of support. There is a much higher awareness of the issue now — a true shift in the population. There’s much more to be done, however, to tackle other aspects of chemical dependency issues in this population. Nutrition awareness and efforts at improvement continue to increase. The messaging about cholesterol, obesity and the link to heart disease, diabetes and hypertension is clear to Native families. Many families are working to decrease the amount of junk food their children eat. When I talk to parents and children about diet and exercise, I tell them that we’re trying to prevent the next generation from diabetes. Since many have someone in the family living with diabetes, that approach makes sense to them. About 20 percent of our adult patients have diabetes. NACC is certified by the American Diabetes Association as a Diabetes Education Center, and we have a group
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education meeting every month and a support group for those living with diabetes. We also have a Diabetes Prevention Project (funded by MDH) which screens adults at risk for diabetes and provides classes to help them learn how they can change their lifestyle for better health. NACC is involved in a neighborhood community garden project where individuals can grow and access fresh foods. NACC’s dietician meets with patients about specific diet recommendations and provides classes. She also takes patients on grocery store field trips for families to learn to shop for nutritious food on a limited budget. We provide cooking classes for adults and children, with recipe books and food shopping guides.
track the progress of patients and provide coordination and support for their medical needs. Most of our experience with this has been with diabetes and prenatal care. In the last year, NACC expanded its tracking and care coordination to include patients who have asthma or depression, as well as following up ED visits and hospitalizations. Our patient advocates (who work specifically on the social services needs of patients), have been crucial for helping patients to access insurance, housing and various service options. Whenever possible, these advocates are also from the Native community. In addition, patient advisory groups for our diabetes program and for Health Care Home have helped
What this community needs is not answered by patient portals or e-health connections to hospitals. The biggest barriers to health improvement have always been poverty, racism, lack of adequate housing, and unemployment. Society’s focus on those issues, however daunting, will be the key to eliminating health disparities. Exercise is also on the rise. Families are seeking membership at the Y and other fitness programs. Many have participated in our walking groups, and more are riding bikes. Parents are telling their children about their traditional history with strong and fit Native people hunting and gathering for their families and tribe. This is an enormous change from the general view in the early 1980s. Obesity is still a serious problem, but there is a foundation building with an understanding and desire to make changes. NACC’s programming has always been geared toward the spirit of what has now become the Health Care Home model, where care coordination, case management and population management are the focus. We have had our best success over time with activities that involve oneon-one or small group interactions with patients and case managers. The NACC case managers at this time are RNs who MetroDoctors
us by participating in the progress and building of our programs. We get feedback from the group about our education materials, our scheduling, and our services. The things that make a positive difference for our patients are the programs and encounters where individuals feel that they are cared about, respected, and that they play an important part of what we are doing. For the last two years NACC has been part of a virtual ACO (now called IHP) which is made up of 10 metro FQHCs as one of the demonstration projects contracting with MN DHS. The DHS project’s purpose is to decrease the total cost of care, increase quality and patient satisfaction. Our 10 clinic group is called FUHN (Federally Qualified Health Center Urban Health Network). This collaboration improves our ability to provide coordinated services by having access to patient data regarding in-patient and ED
The Journal of the Twin Cities Medical Society
services, along with the cost of their care. Subgroups of the FUHN clinics (CEOs, CFOs, Quality and Clinical Staff ) meet regularly. We share processes and outcomes of our efforts to encourage more preventative care, stronger Health Care Homes and better tracking and coordination. FUHN succeeded in decreasing the overall ED visit rate by 15 percent last year. Over the years I have seen positive changes that give me hope for the future. I’m concerned, however, that with the new technological requirements, providers often need to spend as much time jumping through bureaucratic hoops as we do listening to our patients. We are mesmerized with our EMRs and our technological networks, but our patients are still in need of the basics — bus tokens, thermometers, access to medications, decent housing, a safe place for their children to play outside, money to buy food, consistent phone access. What this community needs is not answered by patient portals or e-health connections to hospitals. The biggest barriers to health improvement have always been poverty, racism, lack of adequate housing, and unemployment. Society’s focus on those issues, however daunting, will be the key to eliminating health disparities. Lydia Caros, MD, is a pediatrician and the CEO of the Native American Community Clinic, a Federally Qualified Community Clinic in Minneapolis. Dr. Caros received her medical degree from Des Moines University in Iowa. Following an internship in pediatrics at Iowa Methodist Medical Center, she completed her residency training at the Mayo Clinic in Rochester, MN. She is board certified in pediatrics and is a Fellow of the American Board of Pediatrics. From 1983 to 2002 Dr. Caros practiced pediatrics at the Indian Health Board where she was also the medical director. In 2003 Dr. Caros and two other physicians founded the Native American Community Clinic. She has served there as a pediatrician and CEO since it began. Dr. Caros can be reached at: (612) 8728086 x 1007, or: lcaros@nacc-healthcare.org.
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Minnesota Grown Latino Physician’s Experience
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am Colombian by birth; however, I grew up all of my life in Minnesota and have been culturally a Minnesotan — my culture gained from my adoptive American parents. I have learned Spanish in school, rotating in an obstetrics ward in a Colombian hospital, and with much daily use in our clinic over the last six years. However, I attribute much of the successful cross cultural management of my Latino patients to my nurse, Maribel, who provides a “warm hand off ” and ease of follow-up to those who often have to overcome many barriers in order to receive effective care. In general the diseases we deal with in our Latino patients are common to all of our other patient groups. Especially important values in caring for Latinos include personalismo (being warm and friendly) and familismo (being interested in the patient’s family), and asking in nonjudgmental ways about the CAM (complementary and alternative medicines) they are taking, as many have tried or are trying them concurrently. Language remains a large barrier to quality care for the majority of Latinos I see. I find that our primarily Spanishspeaking patients often prefer to speak Spanish even if their handle of English is fairly good. Most people prefer to express their stories, predicaments, ideas, concerns and expectations in their first language. Speaking Spanish directly with my patients is crucial in getting a good patient-centered history.
By Jason Como, MD
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A “code orange” was called and I was the “code orange” provider that Friday afternoon — the physician to handle the potential medical emergency. The 31-yearold female who I will call “Maria” walked in from outside our clinic on East 7th street on St. Paul’s East Side. She presented with abdominal pain and fever. Our bilingual Spanish speaking nurse attended to her vital signs and comfort. The woman was pale, with a fearful look on her face. Her vitals indeed showed fever, tachycardia and she had left lower quadrant abdominal pain. I introduced myself in Spanish and asked her where she was from. She responded that she was from Guatemala and she had been here in the U.S. for about six years. She had been feeling sick for about a week with fevers and chills and now the abdominal pain; she was sure she was not pregnant. She did not want to go to the emergency department due to cost as she had no insurance. She had heard we were a safe place to go and that we spoke Spanish. On exam she had striking pallor and looked as though her hemoglobin might be very low. She had a flow murmur and normal lung exam. Her abdominal exam revealed no masses but she did have voluntary guarding of her left lower quadrant. Her pelvic exam revealed left adnexal tenderness but no obvious mass. We started an IV, got an UA, UPT and a CBC. Her hemoglobin came back at 11 g/dL and her WBC came back at 27,000 with a left shift. The UPT was negative and the decision was made to send her to our local emergency department for further evaluation of a possible infectious process. We were able to arrange a ride
over and she was admitted to the hospital after having a CT scan showing a large obstructing Staghorn Calculus in her left renal pelvis which had precipitated her sepsis. She was hospitalized for three days, given IV antibiotics and referred to urology for further outpatient management. She returned to our clinic a week later, unable to get emergency medical assistance and thus unable to see her specialist. She told me she felt fine and did not have the $150 upfront money to pay for the specialist visit so she was not planning on going. She did care about her health, but since she felt OK she was going to have to risk whatever may come. She hardly would have been able to pay for the percutaneous nephrolithotomy she required. So she runs the risk of recurrent sepsis. This was a not so uncommon case affecting an undocumented immigrant from Latin America in my practice.
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On another day, a group of 12 patients, all Spanish speakers, joined myself, our clinical pharmacist, our diabetic educator, our Spanish speaking nurse and our dietitian to discuss beliefs, myths and concerns they have about diabetes and its management. When working across cultures in medicine, Arthur Kleinmans’ questions focus on getting at explanatory models of illness are important: What do you call your illness? What do you think caused it? How do you think it should be treated?, etc. I use these questions to get my diabetic group members talking. During our diabetes group, while discussing how insulin works we are often eating a Nopales salad made by our nutritionist. (Nopales is a cactus plant high in fiber known to reduce blood sugars in diabetics. Our Latino patients know this as a treatment for diabetes better than they know metformin). We discuss the beliefs of some of our patients that “susto,” or fright, may have caused the diabetes. We use the group to explore these and other ideas about etiologic factors for diabetes. Another point of discussion is the environment change from home countries to the U.S. All our group members agree that in their countries of birth, they moved more and ate more vegetables and less processed food. In fact many studies bear out the fact that Latinos are often healthier before they come to the U.S., as are most immigrants (healthy immigrant effect). With acculturation, this benefit goes away. Some 5-10 percent of my adult patients are diabetics, and in my Latino cohort that number inches up to around 25 percent. Patients presenting with new onset symptomatic diabetes are common. But it is quite difficult discussing chronic disease management when a person feels well. We must get at their explanatory models to have a more lasting impact on their chronic disease management. I have yet to come up with a word for “prevention” that makes sense to the population as a whole. As a U.S. citizen, prevention fits well with my future time orientation. As a new immigrant from a country where a person was poor and did most things just to survive, a present time orientation is MetroDoctors
the norm, so thinking about prevention is often not on the radar. Depression, anxiety and other mental illnesses are common in the Latino community I serve. Given the levels of stress, separation from families still in the home country, working conditions many endure here in low paying unskilled work, stress induced illness is also common. Hand many of my adult Latino population a PHQ 9 and they will score in the depressed range. Yet, finding a mental health provider who is bilingual is almost impossible. The response to medication in my practice is variable. Low doses of SSRIs are often better tolerated than standard doses. Discussing family relationships, work, and children as well as housing seem to be as therapeutic as prescribing medications. We can now connect them with a Spanishspeaking counselor recently located down the road from our clinic. Several other barriers to quality health care exist for our Latino patients, including
The Journal of the Twin Cities Medical Society
the barriers evident in my opening story. Lack of health coverage for all is a major barrier. Limited English proficiency and low health literacy are two more barriers, even for those who do have coverage. Coordinating care with our team at the East Side improves the care for all, and having a $20 out-of-pocket expense at the door is doable for most. Finally, the fact that we don’t turn away any patient, regardless of ability to pay, is why I work where I do. Jason Como, MD is a board certified family physician who has been working with the West Side Community Health Services for the past six years following completion of his family medicine residency at North Memorial Health Care. His interests include international medicine, working with St. Paul’s homeless population, and teaching medical students. He lives on the East Side of St. Paul with his wife, Lisa, and their three children. Dr. Como can be reached at jcomo@westsidechs.org; (651) 772-9757.
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East African Health Care “Subax wanaagsan! Is ka warran!” “Akkam Bultan…nagayaa!”
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n any given day, you can come to our clinic and feel as if you are in another world, amidst the colorful dress and language of the patients, families and interpreters in our clinic waiting room. It is a world of new East African immigrants, coming to their nearby neighborhood clinic for primary health care. Located in the heart of the Cedar Riverside neighborhood of Minneapolis, People’s Center Health Services has provided health care since 1970. Our clinic was the first “free clinic” in the state of Minnesota. Since 2003, we have been a Federally Qualified Health Center and have always been a community center for new immigrants arriving in Minneapolis. Our building was built in 1913 by the Minneapolis Westminster Presbyterian Church as a community center for the Cedar Riverside neighborhood. In the early 20th Century, the immigrants were Bohemians, Danes, Swedes, and other Europeans. In the 1980s, immigrant communities from Africa arrived, as Ethiopian immigrants left behind famine and other difficulties in Ethiopia and settled in the neighborhood. After the Somali Civil War in 1991 and the resulting diaspora, a wave of new Somali immigrants settled in the neighborhood, residing in the enormous Riverside Plaza apartment complex near Cedar Avenue, just four blocks from our main clinic. The Cedar Riverside
By Steven R. Vincent, MD
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neighborhood is now one of the most concentrated neighborhoods of Somali families in North America. As a Federally Qualified Health Center, we embrace the vision and daily work of reducing health care disparities in our patient population. In order to do this, we became a Patient Centered Medical Home, providing primary care with extended services to our patients. We have physicians, nurse practitioners, a pharmacist, a dietitian, licensed clinical social workers, dentists, dental therapists and dental hygienists, nurses, community health workers and others providing care coordination. We have staff from Somalia and Ethiopia throughout our clinic: answering telephones, greeting patients at the reception desk, medical assistants and nurses in the clinic, providing x-rays,
and community health workers helping to coordinate care. Our patients work with staff who share their culture and beliefs. The Muslim holy month of Ramadan is a special time at our clinic — for patients and staff alike. During Ramadan, Muslims refrain from conflict and frivolous activities, are mindful of others less fortunate, acknowledge blessings and give prayers. There is no eating or drinking, not even water, from sunrise to sunset. An awareness of our patients being in a state of fasting during the clinic visit heightens our own spiritual awareness. Reducing health disparities in our diabetic patients requires an awareness of Ramadan, as well as the native diet and exercise customs of East Africa. A large majority of our diabetic patients fast during Ramadan and diabetic treatment plans
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must be adjusted to match the patient’s anticipated meal plan. Back in Africa, everyone walks all day long to their destinations, so a diet rich in rice, pasta, bread, goat meat, sambusas and sweet Somali tea was less likely to cause obesity and diabetes. To help patients adjust to their new lifestyle in Minnesota, with funding through a partnership with the State of Minnesota, our clinic has established a successful “We Can Prevent Diabetes” program, working with patients at risk of developing diabetes from all racial and ethnic backgrounds. One of the successful attributes of the program lies in our coordinator, Abiin Mohamud. Ms. Mohamud brings her personal knowledge from the Somali community in order to provide a unique and culturally relevant approach to exercise and diet change for the participants. Post-traumatic stress disorder affects a large number of our patients, being from countries torn by war or afflicted by oppression; they have witnessed and/ or suffered physical and emotional injuries in the past while in Africa. Depression, insomnia and physical muscle pain all are common symptoms that are encountered daily; pain is not always a physical illness, but often a symptom of an underlying psychosocial imbalance. Our integrated behavioral health and medical team, together with the patient’s trusted and dedicated interpreter, provides care for the whole person — mind, body and spirit. It is well known that there is a disparity and increase in the rate of autism in young Somali children in the Twin Cities. While all factors are not understood, there is a continued misunderstanding among parents that this is related to the MMR vaccine and other immunizations. Listening to parents’ concerns and educating our Somali families about immunizations, encouraging them to fully immunize their young children, is an important area of focus to reduce disparities in immunization rates. The concept of routine cancer screening has been taking hold and growing over the past several years in our patient population of East Africans. Our middle-aged female patients are more often embracing MetroDoctors
mammograms to screen for breast cancer. Convincing women to screen for cervical cancer proves to be more difficult, with female genital mutilation and other cultural factors acting as barriers to screening. Our women’s health champion, Dr. Alison Forney-Gorman, is using patient focus groups from the community to develop a grassroots approach to educating and encouraging women to have cervical cancer screening. Not unlike other populations in our society, efforts to convince women and men alike to have a colonoscopy for colon cancer screening continues to be a challenge, with unique cultural barriers. Promoting the primary health care model for our patient population has other challenges. Planned office visits and the use of long-term medications for chronic illness, with refills from the pharmacy, has not always been a health care concept in many East African native communities. In Africa, immediate, urgent doctor visits for medications have often been the norm. Limited English literacy in many of our elderly East African patients makes consistent and accurate medication lists always a challenge — especially when changing medications. Therefore, education about continuing chronic medications, with
The Journal of the Twin Cities Medical Society
regular follow-up in the office instead of visiting the emergency department, is a top priority for us. Our most dynamic partnership is with the different interpreters that are used by our patients. We accept and encourage our patients to choose their own interpreter, employed by a certified interpreter services agency. This chosen professional interpreter helps their client in many other ways: assuring follow-up in our clinic and acting as a point of communication for our patients; helping to schedule specialty appointments; and often serving as interpreter at other visits the patient may have outside our clinic. Our interpreter team members are a part of our clinic family, even sharing in our potluck celebrations with us throughout the year. Here is an example which illustrates how it takes a clinic team and community partners to provide care to the whole family. One of our Somali families — a large family with nine children — moved to Minneapolis from Texas. The father needed heart surgery, one daughter had severe epilepsy, one of the younger twins needed heart surgery and the other twin also had (Continued on page 20)
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Health Disparity East African Health Care (Continued from page 19)
epilepsy. They had no housing and were staying in a homeless shelter when they first arrived. Their first point of connection was with our social worker, Cheryl Champion, who helped with housing and connected the family to their dedicated independent interpreter, Suleeka, who was crucial in helping to arrange follow-up
and specialist physician visits. Over the next 18 months, these successful outcomes were achieved: the mother learned English and found work; the father had successful heart surgery; the son had successful heart surgery; the two daughters with seizure disorders were connected to specialty care at Gillette Hospital and started at Fraser School; the whole family was able to get into affordable housing in a 5-bedroom
house; and the oldest son finished high school and is currently enrolled in college at the University of Minnesota. As this family has proclaimed more than once, “We need to see Cheryl; Cheryl saved our lives!” As we look to the future, with new CEO Sahra Noor leading the organization, we continue to celebrate the diversity of our patients and our neighborhood, as we partner with our community in so many ways to continue to provide comprehensive health care to and reduce health disparities in our patient population. “See you at your next clinic visit… Insha’Allah (if Allah wills).” “Mahadsanid…Nabadeey!” “Galatoomi!”
Please join us in welcoming…
I would like to thank Mohamed Abu, Kristen Zandlo, and Abiin Mohamud, for their invaluable assistance with the ideas, language and photographs for this article. Steven R. Vincent, MD, received his medical degree from the University of Michigan in 1978. As a 4th year medical student in 1977, he found himself at Smiley’s Clinic in the Cedar Riverside neighborhood, where he eventually completed his Family Medicine Residency in 1981and has had a continuous primary care medical practice at People’s Center Health Services since 1992. Dr. Vincent can be reached at vincents@peoplescenter.org, or by U.S. mail at People’s Center Health Services, 425 20th Avenue South, Minneapolis, MN 55454.
Phillip Keith, MD MAYO CLINIC
Jozef Lazar, MD STANFORD UNIVERSITY
Jessica Morrell, MD MARSHFIELD CLINIC
Lydia Turnbull, MD UNIVERSITY OF WISCONSIN – MADISON
… in 2015. Dermatology Consultants continues to grow and next year we will have 20 Dermatologists to serve patients at our four locations. Call 612-209-1600 for appointments or visit our website at dermatologyconsultants.com
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TH ETI C AE S AL OF A PPROVA SE
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Reflections on Hmong Health Disparities
W
hen I think about the health disparities of the patients that I cared for over the last decade, I am amazed at the stories that I have been told, the heartbreaks and triumphs, the barriers that are faced on a daily basis and the hope that exists. This is my reflection of my own personal experiences of some of the disparities that I personally faced growing up that mirrors only a mere glimpse of what many of my patients have to go through every day. My family and I came to the United States in 1976 as part of the initial wave of Hmong refugees after the Vietnam War. I had just turned four years old when we were sponsored to Kalamazoo, Michigan and arrived in the U.S., not understanding any English. Our health care consisted of office visits with no interpreter as there was no one in that town that spoke our language. Fortunately, my father spoke French as he was able to attended school in Laos, and I can only assume that the only family that spoke French in town was the one that went with us to the clinic. I was 4 years old when I underwent a tympanoplasty for a ruptured ear drum and I remember the hospital event as one of anxiety, confusion, and fear. I was brought to the hospital the night before the surgery and I still remember wandering the halls looking for my parents, unable to talk to anyone as I only spoke Hmong and did not understand any English. I did not know what was going to happen in the morning and when I was taken to the operating room, I was terrified. I still remember being lifted and being held as the grape flavor smell of anesthesia washed By Kang Xiaaj, MD MetroDoctors
over me and later awoke to pain and dried blood on my head as part of the procedure. Just being in the hospital was already a scary experience and not being able to communicate your needs to the medical team only amplified that fear. This first major encounter with Western medicine left a lasting impression on me — that physicians and hospitals were entities to be feared. Through much of my childhood, I continued to have many clinic visits due to repeated ear infections and needless to say, I did not trust the medical profession during those years. It was only through the nudging of thoughtful teachers that actually recommended that I become a physician, and a school nurse that went out of her way to ensure I got appropriate care that I began to reconsider what I thought about health care. The Hmong have traditionally cared for their sick with herbal remedies and healing ceremonies involving a shaman when needed. There have been many instances when these belief systems have clashed with the Western world, leading to miscommunication and mistrust. When you suffered from a significantly frightening or traumatic event known as poob plig, or soul loss, a healing ceremony is performed to re-establish the return of your spirit back into you. These healing ceremonies need to occur and are not to be taken lightly as it is believed that opting out can result in severe physical and/or psychological illness and sometimes even death. Other common beliefs are that you
The Journal of the Twin Cities Medical Society
only need to take medications when you are sick and having too much blood taken out would make you weak. These belief systems were looked down upon at times and even ridiculed. I can remember the initial frustration of a physician when meeting my mother where she said that she did not want blood tests done. Shortly thereafter, the encounter went sour. Traditionally, the Hmong believe that what blood you have in your body is a finite amount and the scientific concepts that bone marrow can regenerate blood to replace what is lost does not exist. I can still remember the aggravated look on the physician’s face during that visit. We were at a standstill, and as the designated child translator, I had not reached the maturity level to explain the underlying cultural beliefs nor the medical understanding to bridge this standoff. My mother came in with a complaint of fatigue but left empty handed without a definitive diagnosis or treatment plan. She viewed the visit as a futile event and went back to her herbal elixirs and continues (Continued on page 22)
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Health Disparity Reflections on Hmong Health Disparities (Continued from page 21)
to do so till this day. All in all, I remember a mixed bag of emotions, feeling that we were belittled and left with a sense of shame and embarrassment. I desperately wanted my mother to do what the physician said but at the same time, I was angry about the lack of care that we received. My resolution to become a physician arose from my belief that changes were needed in caring for patients. I wanted to bridge the gaps that were so apparent to me and hopefully dispel misunderstanding, not only in the medical profession but also in the Hmong community. When I finished residency, I worked as a solo physician for West Side Community Health Services — McDonough Homes Clinic. This satellite clinic was located inside the community center at the McDonough Project Housing unit in St. Paul and had only two exam rooms at that time. This particular project housing community was where I grew up when my family moved from Michigan to Minnesota. I dedicated over 10 heartfelt years there and had a large panel of Hmong refugees that lived in the housing units. The location of the clinic inside the community center was ideal as the people who were unable to drive could just walk in to be seen — many times without appointments. Even with this convenience, the barriers that they encountered were multilevel, from the inability to read, write, or speak English, the lack of transportation, poverty, lack of education, and lack of access to appropriate health care resulting in persistent poorer health outcomes. We can provide the appropriate care when our patients can understand what we are saying. I know that being able to speak Hmong to elderly patients that spoke no English makes a world of difference to them. Being able to understand the subtleties of their complaints has helped me uncover where their fears reside and the miscommunications that have occurred. I have listened to interpreters and have seen a wide variation — younger interpreters know English well but sometimes did not know enough Hmong. On the flip side, an older interpreter understood the cultural beliefs better and would be able to convey 22
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the doctor’s words in a more appropriate cultural context but may not be able to translate back in English as well. This taught me to speak at a level that could be understood easily without a lot of medical jargon and taking that extra time to answer their questions. Pictures, models and attentive listening were invaluable in engaging my patients and empowering them to explain what they believe in. Many of the Hmong patients that I cared for had uncontrolled diabetes, and also suffered from major depression. They had a poor understanding of the disease process and the medical treatments recommended. One of their fears was that they would have to stop eating rice, the primary staple in the Hmong diet. The Hmong translation for noj mov (to eat) literally means “eat rice” and when Hmong patients are instructed to reduce rice intake it can sometimes be misinterpreted as not eating. Even after careful clarification, rice with water may be the only food that they eat all day so the reduction of rice intake down to merely four spoonfuls per meal, is akin to starvation and death. The belief that herbal remedies can cure their diabetes is widely held and this has led to their hesitation in taking medications on a daily basis. Western treatment is viewed as maintenance instead of curative and they fear that insulin use would cause them to go into renal failure. These beliefs lead to a challenging path in obtaining good control of their diabetes but through teasing out their misunderstandings and fears, the adherence to medications improved. There were days that were tough when confronted with situations that I could not change and all I could do was listen to their struggles. I had a lung cancer patient who said to me “Dr. Kang, when I was sick and came in, you were on maternity leave and that was when the doctor told me that I had cancer. If only you were working at that time, I know that you would have made me better.” Her words left a lasting mark on me; that I was trusted enough to help heal her! Another Hmong patient that suffered from major depression would come in every couple of weeks with multiple physical complaints and bring letters that she could not read. The nursing staff would help her with her letters and we
would talk about how she was doing. By the end of these visits, she would leave saying that she felt better, stating that just talking made her better. Acknowledging their fears and being able to empathize with our culturally diverse patients goes a long way in helping them to not only feel emotionally better but actually do physically better. Every day I am reminded of how far I have come, of the opportunities that I have been given and the privilege of being a physician caring for the people who trust me to partner in their care. I had the opportunity to have been mentored by truly compassionate and dedicated preceptors along my journey in becoming a physician. Thanks to their guidance, it helped me solidify my own core values. Being culturally sensitive and building trust is paramount in my physician-patient relationship. Always keeping an open mind and carefully listening have been instrumental tenets for me in soliciting where their beliefs were in regard to their illness. These principles have helped me achieve better health outcomes for my patients. As human beings, we all have biases based on past experiences but if we are willing to examine our own beliefs and ask open-ended questions without judgment, this will bring forth remarkable stories that are culturally rich. These stories accord us the opportunity to identify misunderstanding, the prospect of breaking through these daily barriers, and the hope to make positive differences in the lives of patients facing these health disparities. Kang Xiaaj, MD graduated from Hamline University in 1994 with a BA in Biology and went on to the University of MN Medical School receiving her medical degree in 1998. She completed a family practice residency at Regions Family & Community Residency Program in 2001. Dr. Xiaaj worked for West Side Community Health Services for over 10 years and currently is employed at Fairview-Eagan Clinic. Dr. Xiaaj can be reached at kangxiaaj@gmail.com.
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CBPAR Partnerships Can Address and Redress Health Disparities: Voices from SoLaHmo Kathie Culhane-Pera, MD, MA:
Health disparities are often the result of unequal social conditions that lead to more diseases and less effective treatments for disadvantaged members of society than for privileged members of society. As a family physician and member of the privileged social strata, I have targeted reducing health disparities as my personal professional goal. To that end, I have practiced since 1983 in urban Saint Paul, worked mostly with multicultural populations, learned to speak White Hmong and basic medical Spanish, lived and worked with Hmong villagers in Thailand, conducted qualitative and quantitative research, taught about culturally responsive medical care, and co-edited a book about providing culturally responsive care to Hmong patients. In addition, I have been Associate Medical Director of West Side Community Health Services, a federally qualified health center that is run by a community board and is fundamentally structured to provide medical and dental care that is equitable, affordable, accessible, and is responsive to people’s social and cultural needs. Despite all these efforts through the years, I have wondered about significance: What are the most important things to do? What are the most effective interventions? What will truly improve health and decrease health disparities? My journey has led me to embrace a non-clinical approach — communitybased participatory action research (CBPAR). CBPAR is a partnership between community members, clinicians, and academicians that combines our strengths in an equal partnership to identify, understand, and create actions, which has the MetroDoctors
potential to change the social factors that contribute to inequities and health disparities. While often thought of as a research approach, the sociologist Randy Stoecker in 2003 defined CBPAR thusly: “It is a social change project of which the research is one piece. …‘Doing research’ is not, in itself, a goal. Research is only a method to achieve these broader goals.”(1) This quote motivates me to participate in CBPAR. Through communities and professionals partnering and learning together, we are more likely to be successful in our attempts to address and redress health inequities and health disparities. In 2010, we founded SoLaHmo Partnership for Health and Wellness: CaafimadSalud-Kev Nyob Zoo (SoLaHmo) on the belief that engaged community-professional partnerships can reduce health disparities by building on communities’ cultural assets to maximize community health.(2) True to CBPAR ideals, we have worked together as equal partners in a multi-cultural and multi-disciplinary team to: identify research topics and questions; design research methods; conduct interviews, focus groups, and surveys; analyze the qualitative data; interpret both qualitative and quantitative results; write and record the scripts; and design actions that build upon the asset findings, in hopes of improving health. It is the last aspect that makes me excited — that the CBPAR processes can yield results that can make a difference. My experience with SoLaHmo, as a family physician-anthropologist-researcher, has been exhilarating and humbling. Enough about me…now hear the voices of our SoLaHmo team.
The Journal of the Twin Cities Medical Society
Shannon L. Pergament, MSW, MPH:
It is a joyous experience to engage in work that feeds one’s soul. Prior to discovering CBPAR, during the 12 years that I worked in collaboration with urban and rural communities to reduce health disparities, it never occurred to me that research would be a path that is both personally fulfilling and contributes to health equity. The realization that research, via CBPAR, can lead to social justice was an epiphany for me. During the past six years it has been an honor and a privilege to collectively engage in this work with talented, inquisitive, like-minded people from diverse ethnic, cultural, language and professional backgrounds. SoLaHmo grew out of a series of exploratory community dialogues that West Side Community Health Services had with Hmong, Latino, and Somali community members about health, and built upon Michele Allen and Kathie Culhane-Pera’s 2008 NIH grant called Partners in Research: Improving the Health and Wellness of Immigrants and Refugees in St Paul, MN that trained 10 Hmong, Latino, and Somali community members in CBPAR.(3) In 2010, Hmong, Latino, and Somali community members held a strategic planning process that created SoLaHmo, and identified its mission, vision, goals and priority areas. (See Table #1 on page 25.) Our initial joint project was to identify community cultural strengths and assets by conducting focus groups with Hmong, Latino, and Somali elders, middle-aged adults, and young adults. Despite (Continued on page 24)
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Health Disparity CBPAR Partnerships (Continued from page 23)
distinctly different cultures from different parts of the globe and varied experiences of culture by people of different ages, we heard common core assets and values, from which we created the SoLaHmo Asset Tree. (See Figure #1.) Common assets were social connectedness with family, community, and society; language; religion; knowledge; cultural arts; cultural traditions; and work ethic. Common values included: respect, support, acceptance, honesty, pride, humility, resilience, and love. Our subsequent CBPAR projects
Figure #1: SoLaHmo Asset Tree 24
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have built upon these assets, both enabling us to function and grow as a cohesive team and securing our desire to focus on community cultural assets, rather than social/ health deficits. Highlighting one of our four health priority areas — Preventing Chronic Diseases — we have conducted CBPAR projects that focus on diet and physical activities in order to prevent obesity-related diseases. We conducted focus groups that explored Hmong, Latino, and Somali parents’ concepts of healthy children, including healthy weight. We found that all three ethnic groups had the same main goals in
raising healthy weight children: provide good foods and support physical activity so children are healthy. Parents had three main challenges in meeting those goals: children’s preferences (i.e., wanting sweet and fatty foods); parents’ uncertainties (i.e., about which local and traditional foods are healthy and unhealthy); structural barriers (i.e., no access to indoor gyms during the winter, limited transportation for after school sports); and similar but varied strategies to address those challenges (i.e., cooking one meal for everyone to eat or cooking varied meals to please children; creating indoor winter activities; and trying to be good role models). Building on these findings, we interviewed nine families (three from each ethnic community) who were successfully making changes to deal with obesity, diabetes or hypertension in order to identify what cultural strengths they had used to address lifestyle changes like diet and physical activity. From these real-life experiences, we created nine “radio stories” or radio-novellas (three in each language) to dramatize and share their experiences with other community members. We quantitatively tested community members’ responses both to the stories and to an audiotape of a written pamphlet about obesity prevention. We found that both media were useful in relaying information and in supporting intentions to change, although people had more empathic reaction to the stories, which might lead to their implementing more lifestyle changes at home. To better understand people’s emotional reactions to the stories, we are now exploring a qualitative evaluation. Our implementation plan is to air these “radio stories” on local ethnic radio stations, and incorporate them in clinics for patient education — THUS bringing the results of research into the community and into the clinic where they have the potential to redress health disparities. This is the beauty of CBPAR — it brings key voices with unique areas of expertise together to create viable, sustainable solutions to persistent public health problems — solutions that resonate with communities, clinicians and researchers.
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Luis E. Ortega, MEd:
As a career child and adult educator with over 35 years experience in public schools and universities, I had read and used research, but had limited experience in conducting research. As an educator I am all too familiar with the challenging task of needing to collect and deliver information in a meaningful way so that it will be used effectively. My participation in CBPAR through Partners in Research (an NIH funded research project in 2008) gave me the opportunity to learn and apply community-based research processes. After that year and a half, we community scholars supported the community dialogue work that had been started by West Side to form SoLaHmo as a community research collaborative. I see SoLaHmo as being an important part of our community’s need to gather and use information to improve health and reduce health disparities. First, its structure brings different people around the table for a common purpose, which is one of the basic tenets of developing cultural competencies, working against segregation and racism, and working toward diversity. Second, it provides an opportunity for individuals to bring their expertise to the table in order to conduct relevant research together. Third, we are striving to be an organization that conducts credible health disparities research that can impact our most vulnerable communities in Minnesota. We are a dedicated collaborative of Somali, Latino and Hmong community members and West Side professionals with a four-year history of conducting research together with academic researchers. Latinos have been here for generations, and we have learned a lot about the health impact of life in the United States on our families. The Hmong community has been here a shorter time, and the Somali community is one of Minnesota’s newest arrivals. The intercultural sharing and learning that goes on within SoLaHmo, both around the research team table between SoLaHmo members, and the insights we gain and share with the larger community that come from analyzing the similarities and differences that emerge in our data across MetroDoctors
Table #1: Mission and Vision • SoLaHmo’s community driven mission is to build upon the unique cultural strengths of Somali, Latino, and Hmong communities to promote health and wellness through research, education and policy. • SoLaHmo’s vision is committed to the reality that community members have the knowledge, skills and power to participate as equal partners with researchers and health care professionals to maximize community health and wellness. • SoLaHmo’s four priority areas are: 1) Prevent Chronic Diseases; 2) Promote Healthy Youth and Families; 3) Improve Mental Health; and 4) Increase Culturally Competent Health Care. the three communities, provides unique opportunities for growth and change that could reduce health disparities of our most recently arrived communities. Mai See Thao, BA:
To ask a room full of young Hmong college men if they have family members who are suffering from type 2 diabetes and watch all their hands go up is a visual representation of health disparities. It is this image of the reality that many Hmong families are affected by diabetes after only living in the U.S. for 10-40 years that drives my commitment to SoLaHmo as a community member and an anthropological student: working together with other recently arrived communities to understand and address health disparities. In SoLaHmo, we work in ethnic teams to seek to understand our communities’ shared experiences while valuing our own cultural specifics. We serve not as representatives of our ethnic communities but as individual voices. My CBPAR work is not only informed by my personal experience as a Hmong woman but also by my anthropological training on the complexities of culture and community identity. From our various social backgrounds, we remain committed to asking one another about the relevance and the receptivity of the research projects within our own communities and about the benefits as well as the possible consequences of such work. What has been most academically rewarding about SoLaHmo to me is that we are able to challenge the components of research such as appropriateness of research questions, ethical content of
The Journal of the Twin Cities Medical Society
consent forms, and effectiveness of interview questions in order to make research more relevant to community problems. We challenge one another to think critically about the equality of our institutional partnerships, and the truthfulness of our community engagement. Together we are actively partaking in a dialectic construction of research and community in order to ultimately improve the health of our individual and shared communities. Naima Dhore:
One of the many things I appreciate about SoLaHmo’s CBPAR work is the collaborative relationship between our participants — community researchers, clinicians, academic researchers, and other partners. It is phenomenal to see a group of individuals with different backgrounds come together to contribute their expertise, passion, and curiosity, directly to the challenges of research in order to improve community health. It has been eye opening to see and build on our communities’ strength in finding solutions to daily health challenges. It has been incredibly satisfying to be a part of several projects that illustrate the effectiveness of CBPAR. I believe that CBPAR results and education can equip people to take action on their problems and build stronger communities. Over the past two years, CBPAR has provided me with opportunities to conduct research and be more vocal on issues that matter to my community and myself. The core aim of CBPAR is developing social action; I believe when individuals from the (Continued on page 26)
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Health Disparity CBPAR Partnerships (Continued from page 25)
community take a stand on the main issues and become advocates for voiceless people, it sets the stage for a better, healthier, and stronger community. References: 1. Stoecker R. “Are Academicians Irrelevant?” Approaches and roles for scholars in community based participatory research. In Minkler M, Wallerstein N. editors. Community Based participatory Research for Health. San Francisco: Jossey-Bass; 2003: 98-112 (with quote on page 102). 2. Culhane-Pera KA, Allen M, Pergament SL, Call K, Adawe A, dela Torre R, Hang M, Jama F, Navas M, Ortega L, Vue P, and Yang TT. Improving Immigrant and Refugee Health in Minnesota with Community-based Participatory Action Research. Minnesota Medicine. 2010: 4:54-57. 3. Allen ML, Culhane-Pera K, Pergament S, Call KT. A Capacity Building Program to Promote CBPR Partnerships Between Academic Researchers and Community Members. Clinical and Translational Science. 2011 Dec;4(6):42833. Acknowledgements: 1. Initial community dialogues funded by University of Minnesota School of Public Health & The Blue Cross and Blue Shield Foundation of Minnesota. 2. NIH funded by National Institutes of Health, Partners In Research (R03). 3. SoLaHmo’s strategic planning process funded by The St. Paul Foundation. 4. SoLaHmo’s Cultural Asset Assessment and Framework funded by The Blue Cross and Blue Shield Foundation of MN. 5. SoLaHmo’s parents focus groups “Healthy Kids/ Healthy Lives,” Funded by UCare Fund research grant. 6. SoLaHmo’s radio stories funded by UMN CTSI Community Collaborative Grants program and UCARE Fund research grant.
Kathleen A. Culhane-Pera, MD, MA, Associate Medical Director, West Side Community Health Services. Shannon L. Pergament, MSW, MPH, Co-Director of Community-based Research, West Side Community Health Services. Luis E. Ortega, MEd, Community Researcher with SoLaHmo and Community Faculty, MetroState University. Mai See Thao, BA, Community Researcher with SoLaHmo and PhD Candidate in Sociocultural Anthropology, University of Minnesota-Twin Cities. Naima Dhore, Community Researcher with SoLaHmo.
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What is Prediabetes and Why Does it Matter?
A
ccording to newly released data from the Center for Disease Control and Prevention,(1) an estimated 86 million Americans over the age of 20 years have prediabetes — the metabolic condition that precedes the development of type 2 diabetes. This represents 37 percent of U.S. adults and 51 percent of those aged 65 years and older. Prediabetes is defined by a fasting blood of 100-125 mg/dl or a hemoglobin A1c of 5.7-6.4 percent. 15-30 percent of people with prediabetes will go on to develop type 2 diabetes within five years. It is critical that clinicians identify these individuals in their practice because it is now well established that implementation of a lifestyle intervention like that employed in the Diabetes Prevention Trial will prevent persons at risk from developing diabetes. The Diabetes Prevention Trial randomized more than 3,000 people with prediabetes to lifestyle intervention that included a 7 percent loss in body weight and at least 150 minutes of physical activity per week, treatment with metformin, or placebo.(2) The study was stopped early, after an average follow-up of 2.8 years, because the lifestyle intervention arm reduced the incidence of diabetes by 58 percent, as compared to only 31 percent in those treated with metformin. To prevent one case of diabetes during a period of three years, the investigators determined that 6.9 persons with prediabetes would have had to participate in the lifestyle intervention program and 13.9 would have had to receive metformin.
This approach has attracted widespread attention. Across the country organizations like the YMCA are partnering with health care companies to draw people with prediabetes into a 16 session program that encourages them to improve their eating habits and exercise more. In 2009, Minnesota Senator Al Franken co-sponsored the Diabetes Prevention Act with Indiana Senator Dick Lugar to increase access to this kind of prevention program. Multiple studies have demonstrated that this intervention is very cost effective.
The American Diabetes Association recommends that screening for diabetes begins at age 45 years for everyone. Screening is done most simply by measuring a fasting glucose or a hemoglobin A1c, but some may prefer to perform a two hour glucose tolerance test with 75 grams of glucose. If the screen is negative, the screening test should be repeated every three years. If people are overweight (BMI > 25 kg/m2) or known to have factors associated with increased risk such as a family history of (Continued on page 28)
FORUM
ADDRESS THE SLEEPING GIANT:
Effective prediabetes management for physicians Tuesday, October 7, 2014 | 6pm - 7:30pm CDT | Ramada Plaza Minneapolis Prediabetes is a health condition characterized by higher than normal blood glucose levels, but levels not high enough to be diagnosed as diabetes. Prediabetes increases the risk of developing type 2 diabetes, heart disease and stroke. Elizabeth
Seaquist, MD and Luke Benedict, MD will discuss evaluation and diagnosis of prediabetes. MN Dept of Health will share the scope of the problem in Minnesota, and the Twin Cities YMCA will present an evidence-based program available to patients, and funded by CMS.
REGISTER NOW at HTTP://GOO.GL/EXJFQ0 The MMA designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit™.
By Elizabeth R. Seaquist MD MetroDoctors
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Health Disparity What is Prediabetes? (Continued from page 27)
type 2 diabetes or a past history of gestational diabetes, screening should be initiated at a younger age. Screening should also be provided to individuals identified as
nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or small for gestational age birth weight), or exposure to maternal diabetes in utero should be screened starting at age 10, or the onset of puberty. Those with prediabetes should be
“In recent years, the incidence of type 2 diabetes has increased dramatically in children, particularly in minority populations.�
being at high risk using the Diabetes Risk Test developed by the American Diabetes Association (http://www.diabetes.org/areyou-at-risk/diabetes-risk-test/?loc=atriskslabnav). This test gives higher scores for people with greater risk based on age, gender, history of gestational diabetes, a first degree relative with diabetes, personal history of hypertension, physical activity, and weight. This simple to use test could be given to patients as they sit in the waiting room. All who receive a score of 5 or higher should be screened for diabetes. Those who are found to have prediabetes should be referred to a lifestyle intervention program modeled after the Diabetes Prevention Program. In the future, we may have genetic tests that can identify risk. Several genes have been linked to the disease, including TCF7L2, but currently these tests are not clinically available. In recent years, the incidence of type 2 diabetes has increased dramatically in children, particularly in minority populations. This is presumably associated with an increase in prediabetes in children as well. Children who are overweight and have two or more other risk factors such as family history of type 2 diabetes, member of an ethnic minority, signs of insulin resistance (such as acanthosis 28
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counseled to lose weight and become more active to reduce their risk of developing diabetes. What are the consequences of not identifying patients with prediabetes? The biggest consequence is that they will go on to develop type 2 diabetes, which is the single greatest cause of end stage renal disease and adult blindness in our country. Diabetes is the seventh leading cause of death in the United States in 2010. The direct medical costs associated with caring for people with diabetes in 2012 was $176 billion, which is 2.3 times higher than the costs associated with caring for people without diabetes. The indirect costs of the disease, which include disability, work loss, and premature death, were $69 billion in the same year. Prediabetes is also associated with an increased risk for cardiovascular disease. Risk factor modification such as treating hypertension and hyperlipidemia in people with prediabetes will improve their cardiovascular health.
with Lifestyle Intervention or Metformin N Engl J Med 2002; 346:393-403.
Elizabeth Seaquist, MD is President, Medicine & Science of the American Diabetes Association. She is also a Professor of Medicine at the University of Minnesota where she holds the Pennock Family Chair in Diabetes Research. Dr. Seaquist is a clinical investigator interested in the complications of diabetes. Her research focuses on the effect of diabetes on brain metabolism, structure and function. She directs the University of Minnesota site for the ACCORD (Action to Control Cardiovascular Risk in Diabetes) and GRADE (Glycemia Reduction Approaches for Diabetes: a Comparative Effectiveness Study) Trials, and has an active clinical practice. The American Diabetes Association awarded her the Distinguished Clinical Scientist Award in 2009. Dr. Seaquist holds a bachelor of arts degree from Vassar College in Poughkeepsie, N.Y., and a doctorate in medicine from the University of Minnesota in Minneapolis. She is board certified in Internal Medicine and Endocrinology, Diabetes, and Metabolism. Dr. Seaquist can be reached at: seaqu001@umn.edu; (612) 624-9176; https://www.facebook.com/umndiabetes; MMC 101, 420 Delaware St SE, Minneapolis, MN 55455. Delivery address: PWB 6-132, 516 Delaware St SE, Minneapolis, MN 55455.
Notes: 1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014. 2. Diabetes Prevention Program Research Group. Reduction in the Incidence of Type 2 Diabetes
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The Journal of the Twin Cities Medical Society
Senior Physicians Association Holds Summer Event
S
eventy members and guests of the Senior Physicians Association (SPA) met on Tuesday, July 22 at the American Swedish Institute for their Annual Event. The day started with a tour of the Turnblad Mansion followed by a three-course lunch in Paulson Hall. After lunch, attendees and their guests had the privilege of hearing a presentation by Stephan Osman on the role of Minnesota in the Dakota and Civil Wars. Stephan Osman is a retired senior historian of the Minnesota Historical Society and had managed Historic Fort Snelling for over three decades. The
Members socializing while lunch is served.
event received many positive reviews on how informative and fascinating the tour and presentation were. The next SPA event is scheduled for Tuesday, September 16 at Broadway Ridge featuring Peter Kernahan, MD, who will be presenting a talk on Was there a Golden Age of Medicine? The luncheon begins at 11:30 a.m. and is $25.00 per person. Additional details and registration can be found online at http://goo. gl/v09WjB.
Stephen Osman, guest speaker.
Members touring the Turnblad Mansion.
Honoring Choices 5th Annual Conference a Success Thursday, July 17 over 125 people gathered at the fifth annual Advance Care Planning (ACP) conference held by Honoring Choices Minnesota. Sharing the Experience has become a muchanticipated event for health care providers, community volunteers, and others interested in and working with ACP. This year’s event, which focused on the power of stories, included two keynote speakers, special topic break-out sessions, and several reports and
Howard Epstein, MD, of ICSI speaks with conference attendees.
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updates on different aspects of ACP throughout the Twin Cities metro area and in the state. Speakers shared how stories can impact choices and facilitate better understanding. Attendees shared that this was one of the most interesting and informative conferences they had attended. “All the speakers were relevant and I learned from each one.” “I really appreciated learning about different cultures, and information regarding their views on death and ACP.” “Networking with other ACP providers and idea-sharing was great.” “Good diversity of perspectives — that is very much appreciated!” The sixth conference will be held July 16, 2015. Mark your calen- Keynote speaker Gregory Plotnikoff, MD dars now to attend! presents Courageous Conversations. September/October 2014
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New Members
Class of 2018 Medical School Orientation
Christopher Alcala-Marquez, MD Twin Cities Spine Center Orthopedic Surgery Felix K. Ankel, MD Regions Hospital Emergency Medicine John M. Chandler, MD Hennepin Healthcare System, Inc. Internal Medicine Jane E. Korn, MD, MPH Minnesota Department of Health Internal Medicine, Public Health & General Preventive Medicine Victor M. Sandler, MD Fairview Home Care and Hospice Internal Medicine, Geriatric Medicine, Palliative Medicine Maria V. Svetaz, MD Hennepin Healthcare System, Inc. Family Medicine, Adolescent Medicine
In Memoriam JAMES R. BERGQUIST, MD, age 94, passed away on May 16, 2014. Dr. Bergquist graduated from the University of Minnesota Medical School in 1950 and was the founder of OB/GYN West, P.A. He retired from practice in 1988. Dr. Bergquist became a member in 1955. FREDERIC J. KOTTKE, MD, passed away on May 23, 2014 at the age of 96. Dr. Kottke attended the University of Minnesota Medical School, graduating in 1945. He was a professor at the University of Minnesota and head of the Department of Physical Medicine and Rehabilitation until his retirement in 1982. Dr. Kottke became a member in 1947. JAMES L. MCKENNA, MD, passed away on May 17, 2014. Dr. McKenna graduated from Marquette University School of Medicine. He joined Abbott Hospital in 1960 and practiced at Minneapolis Internal Medicine and Minnesota Oncology Hematology, P.A. Dr. McKenna became a member in 1962. 30
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170 incoming medical students were introduced to organized medicine by: Alex Feng, MS2, Eric McDaniel, MS3 and Katherine Holten, MS3.
CAREER OPPORTUNITIES
See Additional Career Opportunities on page 31.
Fairview Health Services Opportunities to fit your life
Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team. We currently have opportunities in the following areas: Dermatology Emergency Medicine Family Medicine General Surgery Geriatric Medicine •
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Hospice Hospitalist Internal Medicine Med/Peds OB/GYN • • • • •
Orthopedic Surgery Palliative Care Psychiatry Rheumatology Urgent Care
Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800-842-6469 or e-mail recruit1@fairview.org
Sorry, no J1 opportunities. fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer
MetroDoctors
The Journal of the Twin Cities Medical Society
Please also visit www.metrodoctors.com
Here to care Join a primary care team where you can build your practice, grow in your profession and partner with those who share your passion. At Allina Health, our care model focuses on the relationship between physicians and patients, so you can focus on what really matters.
Make a difference. Join our primary care team. 1-800-248-4921 (toll-free) Madalyn.Dosch@allina.com
allinahealth.org/careers
Recruit
18821 0614 ©2014 ALLINA HEALTH SYSTEM. TM - A TRADEMARK OF ALLINA HEALTH SYSTEM. EOE/AA/Vet/Disabled Employer
CAREER OPPORTUNITIES
A Journey of Opportunity Medical Director, Palliative Care and Hospice St. Paul, MN
With
MetroDoctors!
Rates starting as low as $175—call today! Options for website listings available as well. www.metrodoctors.com
Betsy Pierre, ad sales (763) 295-5420 betsy@pierreproductions.com
MetroDoctors
The Journal of the Twin Cities Medical Society
Discover HealthEast® Care System, the largest integrated healthcare delivery system in the east metro of Saint Paul, MN. Our Palliative Care and Hospice programs focus on the best possible quality of life care for individuals that are experiencing or living with a serious or life-limiting illness. Palliative Care at HealthEast is a rapidly growing discipline with a thriving and well-integrated practice in the ICUs, hospital units and in outpatient oncology clinics. We are seeking a dynamic individual who exhibits passion for clinical excellence and end of life care. Key responsibilities will include: Strategic Direction, Business Development, Clinical Integration, Best Practices and Quality Assurance. Board certification in Palliative Care and Hospice required; previous experience practicing Palliative Care and Hospice required; previous leadership experience preferred. For more information visit our website or contact Melissa Coulson at 651-232-2459 or mlcoulson@healtheast.org. EOE
www.healtheast.org/careers
September/October 2014
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, MD
VIRGINIA R. LUPO, MD Dr. Virginia Lupo has done so much for so many! Her professional life has been marked with a staggering array of involvements that have benefitted countless patients, medical colleagues and our community in general. Though born in New York’s Nassau County, she obtained her high school and medical degrees in Minnesota. Early surgical residency years were spent at our U of M and Boston’s Beth Israel Hospital. Following a reflective period of professional broadening as a Twin Cities’ emergency physician and Medical Director of a community clinic, her sights became focused on a career in Ob/Gyn. After five years in the prominent University of Cincinnati program as a resident and Maternal-Fetal fellow, Virginia returned to Minnesota to become a full-time faculty member at HCMC — a position that she has continued for nearly 30 years. Those years have not been ordinary in any sense, rather were packed chock-full of activities that displayed the good doctor’s talents and beliefs. Notable among them were her energetic efforts in 1989, when she and others convinced our legislators to implement an approach to the reporting of substance abuse in pregnancy to Child Protective Services instead of primarily to law enforcement authorities. Though modified several times through the years, it has continued to better assure the safety of children in a more stable and nurturing home environment. Dr. Lupo has been the recipient of many distinguished teaching awards from varied groups including the Association of Professors of Gynecology and Obstetrics, the Minnesota Medical Foundation and the American College of Ob-Gyn while mentoring students, residents and practicing physicians. The topics of her instructional endeavors haven’t been purely the more objective aspects of her field — such as pelvic dimensions, cervical effacement and gynecological technicalities — but have been marvelously woven with an element of respect and understanding in the care of diverse nationalities and the economically disadvantaged. Virginia states, “Anyone can be nice to a lady lawyer or doctor who is pregnant. It says a lot more about my residents and students if they can 32
September/October 2014
be understanding of someone who may be poor and overweight and isn’t interested in following all of their recommendations.” Dr. Lupo instills a pride in her students to provide the very best care possible despite existing conditions. For example, caring for a pregnant diabetic who is not comfortably conversant in English and fasts during Ramadan requires some very special fact finding and delicate management skills — elements that she diligently incorporates into her teaching approach. She has been the Ob/Gyn Chair at HCMC since 2000, just after her Bush Foundation Mid-Career Sabbatical Award when she completed graduate studies in clinical research at her alma mater. Dr. Lupo’s thirst for knowledge has been both stimulated and satisfied by her recent service on the prestigious Editorial Board of Obstetrics and Gynecology. Her presented abstracts, lectures and published articles cover a veritable panorama of meaningful subjects in her field of interest — from gestational diabetes to neonatal morbidity, eclampsia, and more — and among her most intriguing of titles are, “What An Obstetrician Wishes Every Internist Knew” and “A Day in the Life of a Low-Income Pregnant Woman in Minneapolis.” Virginia exclaims about her teaching experiences, “It’s a blast; it never gets old!” To that, her students and colleagues thankfully agree — as they utilize and spread her wisdom near and far. Yes, our Luminary has indeed done so much for so many! 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
Sometimes saving lives requires 19 operations and over 120 units of blood.
Mike
Lester
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RLD CLA
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Megan
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Watch their stories of survival at hcmc.org/trauma25
A A C
Hennepin County Medical Center is proud to have served the region for 25 years as Minnesota’s first Level I Trauma Center.
Client:
Hennepin County Medical Center
Color:
4C
Job#
HCMC-0314-8
Publication:
Metro Doctors
Size:
7.375” x 4.625”
Run Date:
May/June Issue
Montrell
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Birkeland & Burnet
01 1929 Knox Ave S $1,999,999; 02 6400 Parkwood Road Edina $3.995M; 03 1205 Oakview Road Medina $850,000; 04 4913 Rolling Green Parkway $2.995M; 05 4600 Arden Ave Edina $729,900; 06 6175 Ridge Road Shorewood $1.25M
Bruce Birkeland / 612.925.8405 / BirkelandBurnet.com
BURNET
The more we get together, the happier and healthier we’ll be.
At MMIC, we believe patients get the best care when doctors, staff and administrators are humming the same tune. So we put our energy into creating risk solutions that help everyone feel confident and supported. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care. To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.