Minnesota Physician April 2014 by Minnesota Physician Publishing

Vo l u m e x x v i i I , N o . 1 A p r i l 2 014

African American men’s health Consortium addresses disparities nationally, locally By Badrinath R. Konety, MD, MBA

Dinner with doctors Food for thought, from centuries past to the present By Donna Ahrens

f you could have dinner with any physician, living or dead, who would it be and why?

This was the question we posed to some physicians who have contributed over the years to Minnesota Physician. Their answers yielded some very familiar names—William Osler, Sigmund Freud, Sir Arthur Conan Doyle—as well as some that are likely unknown to many of our readers—Cyril Wal-

wyn, Norman Bethune, Hans Kraus. Their eras of medical practice range from the 12th century to the present day. The reasons for choosing dining companions were remarkably varied as well. Some doctors wanted to probe for detailed information about past medical techniques; others looked forward to sharing advances in their Dinner with doctors to page 10

esearch on African American men’s health has focused on the individual-level risk factors in disease-specific areas. A more comprehensive approach, however, has been largely ignored. Recognizing this need, the National Institutes of Health has awarded a $13.5 million grant jointly to the University of Minnesota (UMN) and the University of Alabama at Birmingham (UAB)—creating a consortium national in scope—to develop and implement a coordinated approach to address the health disparities of African American men across their life courses. A consortium of regional academic centers and community organizations has created a first-ever collaborative center to develop, implement, and evaluate interventions to improve African American men’s health through research, outreach, and training. Regional approach, national scope This consortium, called the National Transdisciplinary Collaborative Center African American men’s health to page 16

Alcohol is more harmful to an unborn baby than cocaine, marijuana or heroin. Drinking during pregnancy can cause Fetal Alcohol Spectrum Disorders (FASD) which permanently harm the way your baby learns and behaves.

- ZERO ALCOHOL FOR NINE MONTHS.

April 2014 • Volume XXVIII, No. 1

Dinner with doctors Food for thought, from centuries past to the present By Donna Ahrens

African American men’s health Consortium addresses disparities nationally, locally By Badrinath R. Konety, MD, MBA

CAPSULES 4 MEDICUS 7 INTERVIEW

Pat Peschman, DNP, RN,GNP

Advances in foot and ankle surgery By Benjamin Clair, DPM, FACFAS, and Aaron Benson, MS, ATC

The frontotemporal degenerations By David Knopman, MD, and Bradley Boeve, MD

This August, Minnesota Physician will publish a feature recognizing physician-directed medical research projects. We invite nominations from our readers. If you or an associate is currently engaged in a medical research project, please contact us, either by phone or through the form below. The research may be from any field and conducted on any level—basic, clinical, community-based, epidemiological, health servicesrelated, etc. The only criterion is that the principal investigator(s) is an MD.

New lung cancer screening tool By Cynthia Isaacson, Jill Heins Nesvold, MS, and Lee Kamman, MD

Whether the research is conducted in an academic institution, a rural or urban clinic or hospital, a managed-care organization, health system foundation, corporation, or state agency, we welcome its nomination. In brief overview, we will feature as many projects as possible, representing a geographically and institutionally diverse sample.

PROFESSIONAL UPDATE: Allergy Mystery diagnosis for allergic reaction By Nancy L. Ott, MD

Special Focus: Practice Management Measuring Total Cost of Care By Gunnar Nelson

Supporting medical independence By Bruce Penner, RN

2014

Minnesota Physician Publishing

Pulmonology 32

Allina Health SeniorCare Transitions

Orthopedics

Neurology

ESEARCH REC R N

ON ITI GN

DEPARTMENTS

PHY SIC

Features

Thank you for your participation. We welcome your assistance in recognizing Minnesota’s outstanding medical research community.

Group visits 22 By Jennifer St. Peter, Edwin Anderson, MD, and Travis Luedke

Name of project: Research site: Funder: Principal investigator(s): Contact data (Phone and/or email): Comments:

Send to: Minnesota Physician Publishing 2812 East 26th Street, Minneapolis, MN 55406 Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email mpp@ mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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Please note: All nominations must be received by June 15, 2014 and will be held in confidence. We will contact you and no information will be published without approval from the PI(s).

April 2014 Minnesota Physician

Capsules

New Bill Would Allow APRNs to Practice Independently Legislation has been proposed that would remove physician supervision requirements for advanced practice registered nurses (APRNs) in Minnesota. Sen. Kathy Sheran (DFL-Mankato) and Rep. Dan Schoen (DFL-St. Paul Park) are sponsoring the bill that would grant full practice authority to advanced practice registered nurses. APRNs are registered nurses who have completed a graduate-level education program and passed a national certification exam in order to practice in one of four areas: as nurse practitioners, nurse midwives, nurse anesthetists, or clinical nurse specialists. Proponents of the new legislation say the physician supervision requirement is a significant barrier to practicing in areas that are experiencing a health care shortage. “Collaborative management puts us at the mercy of physi-

cians. If I didn’t have an agreement with a physician, I couldn’t practice at all,” said Emily Carroll, RN, nurse practitioner at HealthFinders Collaborative, in an interview with Minnesota Public Radio. “I work in a free clinic, and often I’m the only provider in the building,” she added. “People have to understand that this legislation isn’t going to expand what our licenses allow us to do. If I was with a patient and I believed I didn’t have the skills to treat them, I would send them to the appropriate physician. Nurse practitioners are not going to act as cardiologists.” The Minnesota Advanced Practice Registered Nurse Coalition is lobbying for the change. According to its website, the new legislation would eliminate “unnecessary legislative and administrative barriers to APRN practice, such as annual written agreements with a physician in order to prescribe, and legal requirements to have a collaborative management agreement with a physician in order to practice in Minnesota.” If the law passes, the Minnesota Board of Nursing will

be responsible for APRN regulation. Eighteen states and the District of Columbia currently allow APRNs to diagnose, treat, and prescribe medications to patients independently.

ments include dedicated neurointensive care unit beds that provide neurocritical care 24 hours a day, seven days a week, as well as advanced imaging capabilities, coordinating post-hospital care for patients, and participation in stroke research.

Regions Hospital Waist Circumference Attains Stroke Center Predicts Patient Risk Designation For Disease

Regions Hospital, St. Paul, has been certified as a Comprehensive Stroke Center by The Joint Commission and the American Heart Association/American Stroke Association. The hospital is the first in the state and one of 65 hospitals in the nation to receive this designation. Regions is one of only three certified comprehensive stroke centers in the five-state area. The Joint Commission developed this level of certification in 2012 to acknowledge hospitals that have specific abilities to receive and treat patients with complex stroke cases. Require-

The Mayo Clinic has published results from an international collaborative study that found waist circumference has health consequences for patients, even those with a healthy body mass index (BMI). Researchers from the U.S., Europe, and Australia shared data from 11 cohort studies that included information gathered from more than 600,000 people from around the world. They found that men and women with large waist circumferences were more likely to die at a younger age and were more likely to die

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of causes such as heart disease, respiratory issues, and cancer. Researchers examined BMI, tobacco and alcohol use, and physical activity levels. Specifically, men with a waist circumference of 43 inches or greater were found to have a 50-percent higher mortality risk than men with waist diameters less than 35 inches. Women with a waist 37 inches in diameter or greater were found to have about an 80-percent higher mortality risk than those with a waist circumference of 27 inches or less. According to the report, this information translates to an estimated three-year lower life expectancy for men, and about a five-year lower life expectancy for women, after age 40. Researchers say a key finding from the study is that risk increased in a linear relationship to waist size, and that for every 2 inches of increased waist circumference, mortality risk increased by about 7 percent in men and 9 percent in women. These increased risks were observed regardless of participant BMI. “BMI is not a perfect measure,” said James Cerhan, MD, PhD, Mayo Clinic epidemiologist and lead author of the study. “It doesn’t discriminate lean mass from fat mass, and it also doesn’t say anything about where your weight is located. We worry about that because extra fat in your belly has a metabolic profile that is associated with diseases such as diabetes and heart disease.” Cerhan suggested that physicians should consider BMI and waist circumference when assessing a patient’s risk for obesity-related premature mortality.

CentraCare Study Shows Health Care Home Impact Health care homes are garnering attention in Minnesota, and the Minnesota Department of Health recently reported that the service delivers higher quality of care at a lower cost. CentraCare, an early adopter of the health-care home program, has released statistics illustrating the program’s impact. As of Feb. 28, CentraCare had enrolled 1,736 patients in the health-care home program, served by 20 care coordinators at 11 clinic sites,

according to clinic officials. A 2012 study examined 192 CentraCare patients six months prior to enrollment in the program, and six months after enrollment. The results showed a decrease of 16 hospital readmissions, an increase of 213 outpatient visits, and a decrease of $255,000 in overall charges post-enrollment. Additionally, a review of patient charges from February 2010 to March 2013 showed $2 million in cost savings based on the reduction in charges for patients from one year before health care home enrollment to one year after enrollment. “My passion for health care home stems from the power I see the process having in patients’ lives,” said Marilyn Peitso, MD, pediatrician with CentraCare Clinic. “Over and over again, I have seen dramatic reductions in hospitalizations, a decrease in need for urgent clinics, and an increase in autonomy for patients and their families. For example, I have a patient with multiple health care needs who now has been able to do more activities requiring travel away from home with his father or other relatives. Before having the security of a care plan, the mom was not comfortable allowing the child to travel without her, due to the complexity of the child’s care. I believe care coordination and care planning is one of the key features of effective health care in the future. It will be one of the foundational elements for reducing cost and improving outcomes.” CentraCare will present its method and findings at the Minnesota Department of Health’s Health Care Homes Learning Day this fall.

Senators Sponsor Bill To Change Medicare Payment Conditions In late February, U.S. Sen. Pat Roberts (R-Kan.) and Sen. Jon Tester (D-Mont.) introduced the Critical Access Hospital Relief Act of 2014 (S. 2037) to remove the 96-hour physician certification requirement as a condition of payment for critical access hospitals (CAHs). Minnesota Senators Amy Klobuchar (D) and Al Franken (D) are cosponsors of the News to page 6

MINNESOTA HEALTH CARE ROUNDTABLE

Background and focus: As tools and techniques for treating chronic illness have expanded, so have methods and mechanisms of provider reimbursement. More people now have access to care, and with this comes a heightened awareness of the impact of social determinants on health. The transition to rewarding physicians for maintaining a healthier population is slow but the promise is clear. Treating chronic illness remains an area of high-volume use and, improperly managed, quickly becomes an area of high cost. Objectives: We will evaluate changes that health care reform is bringing to chronic illness care. We will examine new community-based partnerships that are forming to address prevention, compliance, and better identification of risk. We will look at specific diseases and how workplace solutions, insurance companies, clinics, hospitals, long-term care facilities, and home care providers are working together to lower costs Please send me ____ tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone 612.728.8600 or fax 612.728.8601. Name Company Address City, State, ZIP Telephone/FAX Card #  Check enclosed

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News from page 5

bill, along with 12 others. According to current requirements, at the time of admission, CAH physicians are required to certify that a Medicare beneficiary will be discharged or transferred within 96 hours of admission as a condition of payment. If the patient needs to stay longer than 96 hours for any reason, the physician must certify and document the circumstances in order to meet the condition of payment. Recently, the Centers for Medicare & Medicaid Services published information implying it will enforce the condition of payment moving forward, the Minnesota Hospital Association (MHA) reports. Historically, the rule has not been enforced. According to MHA, some of the services CAHs offer entail lengths of stay that exceed 96 hours. MHA cites the example of a Medicare beneficiary with pneumonia who wishes to receive care from a local CAH to remain close to home, rather than travel to another hospital system. “MHA appreciates Senators

Klobuchar and Franken’s leadership on this issue,” said Lawrence Massa, MHA president and CEO. “They recognize that if this condition of payment is enforced, it could create an access issue for rural beneficiaries. MHA strongly supports S. 2037 as a solution to this problem.”

HCMC Expands Cancer Center and Earns Certification The Comprehensive Cancer Center at Hennepin County Medical Center (HCMC) recently received the STAR Program Certification from Massachusetts-based Oncology Rehab Partners. The certification qualifies facilities to offer premium cancer rehabilitation and survivorship services to patients who suffer from debilitating side effects caused by cancer treatments. HCMC created a multidisciplinary group of 25 staff that will work together with each patient to determine a personal-

Minnesota Physician April 2014

ized rehabilitation plan designed to increase strength and energy, alleviate pain, and improve quality of life. The group includes the medical director of physical medicine and rehabilitation, advanced practice providers, nurses, physical therapists, lymphedema specialists, occupational therapists, speech-language pathologists, a dietician, a social worker, and an exercise trainer.

was launched in October 2013 to reduce opioid use by using non-prescription pain management methods.

In February, HCMC completed its $3.5 million renovation of its cancer care center, expanding it by more than 4,000 square feet. Expansion created five additional exam rooms as well as counseling and procedure rooms.

OSI emphasizes a team approach to patient education, with close patient monitoring and frequent feedback, and alternative medicine practices such as acupuncture and behavior therapy.

Minneapolis VA Program Reduces Use of Opioids The Minneapolis VA Health Care System’s Opioid Safety Initiative (OSI) has decreased high-dose opioid use in veterans by 67 percent among its eight Minnesota locations. The program

“We started running numbers on our patients and realized we did have a large number of patients on high dosages of opioids,” said Peter Marshall, MD, a primary care pain management physician at the Minneapolis VA Medical Center.

“We have developed and implemented joint pain management guidelines which encourage the use of other medications and therapies in lieu of habit-forming opiates,” said Eric Shinseki, U.S. Secretary of Veterans Affairs. “Early results give us hope that we can reduce the use of opioids for veterans suffering chronic pain and share these best practices across our health care networks.”

Medicus Rafael S. Andrade, MD, has been named chief of the Section of Thoracic and Foregut Surgery in the Division of Cardiothoracic Surgery in the University of Minnesota Medical School Department of Surgery. He completed medical school at National Autonomous University of Mexico; surgery residency at the University of Minnesota; and fellowships at the University of Minnesota, Indiana University Rafael S. (Bloomington), Memorial Sloan-Kettering CanAndrade, MD cer Center (New York City), and the University of Pittsburgh. Board-certified in general surgery and thoracic surgery, Andrade previously served as interim chief of the same surgical section. Robert Bösl, MD, has been named “2013 Country Doctor of the Year” by health-care staffing company Staff Care. The nationwide award is bestowed annually on a physician in a community of 30,000 or fewer residents. Bösl was chosen for the national award, in part, because he and his wife used their retirement savings to open a clinic after the sole hospital in their small, west-central Minnesota town of Starbuck closed. The clinic has since been acquired by Stevens Community Medical Center of Morris, Minn. Board-certified in family medicine, Bösl completed medical school and family medicine residency at the University of Minnesota. He is also a clinical assistant professor at the University of Minnesota–Morris. Sarah A. Cooley, MD, director of Oncology Medical Informatics and Services for the University of Minnesota Masonic Cancer Center, has received board certification in the newly created subspecialty of clinical informatics. Cooley is among the first group of physicians in the United States to become so certified. Also board-certified in internal medicine, oncology, and hematology, she completed medical school at the University of Minnesota; internal medicine residency at the University of California, San Francisco; and a fellowship in hematology, oncology, and transplantation at the University of Minnesota.

Kiran Lassi, MD

Lisa R. Mattson, MD

Kiran Lassi, MD, has joined Minnesota Oncology. Board-certified in medical oncology, hematology, and internal medicine, Lassi earned her medical degree from the University of Nebraska School of Medicine, Omaha. She completed an internal medicine residency at Creighton University Hospital in Omaha and a fellowship in medical oncology/ hematology at Georgetown University Hospital in Washington, D.C. Previously, she practiced at Fairview Southdale Hospital. Lisa R. Mattson, MD, has been installed as president of the Twin Cities Medical Society for 2014. Board-certified in obstetrics and gynecology, Mattson earned a medical degree from Mayo Medical School, where she completed an obstetrics and gynecology residency. She is the director of Women’s Clinic at Boynton Health Service, University of Minnesota.

Ben Mueller, MD, PhD, boardeligible in orthopedic surgery, has joined The Spine Center at Regions Hospital, St. Paul. He completed medical school and an orthopedic surgery residency at the University of Minnesota and a fellowship in spine surgery at Norton Leatherman Spine Center, Louisville, Ky. Ann Tienor, MD, board-eligible in neurology, has joined Noran Neurological Clinic. Tienor earned her medical degree from the University of Minnesota Medical School; completed a neurology residency at the University of Iowa Hospitals and Clinics, Iowa City; and completed a headache medicine fellowship at Loyola University Medical Center, Maywood, Ill.

Ben Mueller, MD, PhD

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interview

A health system approach to providing care to seniors

H ow did Allina SeniorCare Transitions start?

Pat Peschman, DNP, RN, GNP Allina Health Pat Peschman is the director of Allina Health SeniorCare Transitions program. She has a doctorate of nursing practice from St. Catherine’s University and is certified as a gerontological nurse practitioner.

Aspen Medical Group—which joined Allina In the skilled nursing facility transitional care Health in 2008—had a geriatrics practice called units (TCU), we provide post-acute medical care AspenCare. The practice, composed of physicians to patients who are in the TCU for short-term and nurse practitioners, rehab. This includes mandelivered on-site priagement of the acute issues mary care to residents that were the primary We bring medical services of nursing homes who reasons for hospitalization, on site, so patients don’t were too frail to come and chronic conditions that have to go out to clinics. into the clinic for care, may affect their rehab. We and post-hospital care also participate in disto medical group pacharge planning, patient tients who required rehabilitation in designated education, and the management of care transiskilled nursing facilities. This practice was the tions. We selected TCU locations that are near foundation of SeniorCare Transitions. We have Abbott Northwestern, Mercy, Unity, United, and found that quality of care is increased by having Regina hospitals; Cambridge Medical Center; and a group of providers who are dedicated to taking St. Francis Regional Medical Center. In assisted care of patients in nursing homes, as opposed to living facilities, we deliver primary care services individual physicians, in the midst of their busy with a strong focus on chronic condition manageclinic practices, trying to manage a few of their ment, maintenance of function, and end-of-life aged patients in nursing homes. care.

 What is your role with the program?

 In what care settings do you work?

I am the program director. I am accountable for both the business and clinical outcomes of our program. I manage a team of two medical directors, three advance practice nurse managers, and an operations manager who supports our staff.

We have a large post-acute program. Our teams provide care in 24 TCUs in skilled nursing facilities. We also have a primary care program that we bring to assisted living settings. In addition, we are in a joint venture with Geriatric Services of Minnesota for care delivery to long-term care patients.

My job includes implementing our strategic vision for post-acute care for seniors, and developing collaborative relationships with other parts of our organization, to develop an integrated system of care for seniors. I also develop relationships with external partners—primarily skilled nursing and assisted living providers—to promote growth of our programs and improve processes of care for our shared patients. I have been involved in the design and fulfillment of creative payment mechanisms for seniors. Additionally, I am accountable for staff and leadership development.

W hat health care services does your program provide?

Minnesota Physician APRIL 2014

 How do you choose the TCU locations? The sites are selected based on several criteria. They include locations with a dedicated TCU unit with nursing, social services, and therapy staff competent in the delivery of post-acute care. There must be programming for post-acute care that includes admission seven days a week, therapy at least six days a week, interdisciplinary team rounds, and coordinated discharge plan-

ning. Additionally, the skilled nursing facility must meet federal, state, and local regulations and achieve a 4- or 5-star rating on “Nursing Home Compare.” The staffing ratios must be adequate to deliver high-quality care, and appropriate ancillary services need to be place, including lab and X-ray with rapid response capability and a pharmacy with stat delivery capability. The facility must be willing to partner to improve care integration and patient outcomes, and offer amenities that allow providers to work on site, such as work space, Wi-Fi, etc.

  W hat providers are part of your care team? Our primary team for TCU and assisted living are a physician and nurse practitioner in collaborative practice. In our larger locations, clinical assistants support the providers. We partner with Allina Home Health, Hospice, Allina Health Home Oxygen and Medical Equipment, and other specialty services such as palliative care and care management to deliver care to our patients.

H ow often do your providers see patients? In the TCU, most patients are seen twice

from the hospital to post-acute care in a skilled nursing facility, then back home—through process improvement, standardized workflows, use of electronic medical records, and continuous monitoring of results.

per week. We are able to see them more frequently, however, if needed. In assisted living facilities, we generally see our patients about every other month.

 How are these services paid for? Our services are billed to a patient’s health insurance, including Medicare.

• To improve patient experience scores for patients’ acute and post-acute episodes by preparing patients for the experience of a transitional care unit, engaging patients in goal-setting and development of self-care skills during their stays in transitional care units, delivering comprehensive geriatric care in the assisted living settings, and strong patient/family communication.

W hat are the benefits patients receive from your services? There are many. We specialize in the care of older adults. We bring medical services on site, so patients don’t have to go out to clinics. We improve care transitions, communication, and care coordination. As part of a large health system, we are able to access a comprehensive network of services to provide care in a coordinated manner. We also work in strong partnership with the staff in the skilled nursing and assisted living facilities where we deliver care, to improve systems of care.

• To improve the quality of our care in TCU by tailoring our visit schedules to the acuity and needs of the patients, creation of care pathways for common diagnoses, continuing education for staff in the skilled nursing facilities as well as in our provider group, case reviews, and delivery of evidence-based care in a more consistent manner.

W hat results do you hope to achieve with this model of care delivery? We have several goals: • To improve the quality of transitions—

We are in the process of developing improved metrics to measure our unique results.

University of Minnesota Continuing Professional Development 2014 CME/CPD Activities (All courses in the Twin Cities unless noted)

Annual Surgery Course: Vascular Surgery May 1-2, 2014

Pain Mechanisms: From Molecules to Treatment June 2-6, 2014

Maintenance of Certification in Anesthesiology (MOCA) Training Course May 3, 2014

Workshops in Clinical Hypnosis June 5-7, 2014

Live Global Health Training (weekly modules) May 5-30, 2014 Global Health - Honoring Choices Across Cultures May 7, 2014 Midwest Cardiovascular Forum May 17-18, 2014 Bariatric Education Days: Decade of Bariatric Education May 21-22, 2014 Topics & Advances in Pediatrics May 29-30, 2014

NPHTI Pediatric Clinical Hypnosis September 11-13, 2014 Psychiatry Review September 29-30, 2014 Twin Cities Sports Medicine October 3-4, 2014 Practical Dermatology (Duluth, MN) October 17-18, 2014 Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners October 23-24, 2014 Internal Medicine Review November 12-14, 2014 Emerging Infections November 21, 2014

ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health - NEW! Family Medicine Specialty • Nitrous Oxide for Pediatric Procedural Sedation

For a full activity listing, go to www.cmecourses.umn.edu

Geriatric Orthopaedic Fracture Conference December 5-6, 2014

Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 • email: cme@umn.edu

Promoting a lifetime of outstanding professional practice

APRIL 2014 Minnesota Physician

Dinner with doctors from cover

specialty with a pioneering physician from another century. Still others cited the inspiring deeds and principles of physicians who had a major influence on them. We hope the responses to our question will strike a chord with our readers, and we thank the contributors to this feature for their thoughtful replies.

itas” to all of the students and medical staff. It’s been so many years that I don’t remember why Robert Ganz, MD I was asked to present that essay Gastroenterologist; Minnesota (and I highly doubt that many Gastroenterology, PA house staff are asked to present Many years ago, during my classic essays in training today), internal medicine training at but it was a lucky break for me, the West as up to Side VA that point I in ChicaI have read Osler’s essay had had no go—a very idea who so many times challengOsler was. I’ve lost count. ing time of That sinmy life— gular essay the chief helped me immensely through of medicine, Clifford Pilz, asked my training, and since then I me to read and present Wilhave read it so many times I’ve liam Osler’s essay “Aequanimlost count.

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Minnesota Physician April 2014

No one in medicine has ever analyzed and explained people, doctors, training and the physician-patient relationship better than Osler, or communicated that understanding in such a forthright, caring, and professional manner. To say that Osler has had more influence on medicine and medical training than anyone else is true; but it is also true that no one understood better than he what patients and physicians go through on a daily and lifelong basis. No one person has helped me understand medical practice more than Osler. Which physician would I want to have dinner with? With a great deal of equanimity, my answer is Osler. Paul Waytz, MD Rheumatologist; Arthritis and Rheumatology Consultants PA

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I have also now read much a difference—after our first of Osler’s history and his comyear of medical school. Though pendium of writings. Whenever we barely knew anything, we I feel low or overwhelmed by thought otherwise and carried my practice or research; when out a research project with things aren’t going the way I more than 500 African-Amerwant; when I don’t understand ican children in the Holmes why patients or colleagues react County Head Start program. the way they do in certain situations; or if I’m just looking for wisdom in life, or how to be a better physician, husband, father or teacher, I pull out my Osler essays. Invariably, I find that he confronted the same situations—and wrote about them in a way that explains human nature and medicine so adroitly, and with such perfect During three insight, months there, His vision of the that I am and using some world made clear immeinventiveness, we diately how naïve mine was. met other kindred consoled spirits in our or helped quest to improve and can move on with better health care in the rural South. understanding. On August 15, we met Cyril

My dinner will require some time travel; my physician, some resurrection. If you’ve heard of him, I will pay you a dollar. It was the summer of 1970, and I traveled from Chicago to the still-segregated Mississippi Delta with a close friend—another white boy bent on making

Walwyn, MD, for the first time. Ten days later, we drove two hours to Yazoo City to spend the afternoon and evening with him. Born in the Caribbean and educated at Howard, he staffed the African-American Hospital and maintained a nearby office as well. We walked up a long, hot flight of stairs to encounter a 4-ft. by 20-ft. waiting room and an even smaller examination room, crowded with books, papers, and equipment. Later, at his beautifully decorated home, we sat in the garden, sharing several glasses of Jack Daniels. The setting, and maybe our presence, seemed to lay the kindling for an extraordinary conversation. (His wife later told us that she couldn’t remember when he last had a drink, adding, “You boys stirred something in him.”) We spoke about the life of an African-American GP, blackwhite relations, poverty and the South—and many other things. He spoke, gently but persistently. His words questioned and challenged. His vision of the world made clear how naive mine was: In Mississippi, it would take more than a threemonth effort by a couple of in-

spired med students; the times, as well, would have to change. I’d go back to have a long dinner at his home and revisit that conversation. I would tell him that we have an African-American president now. He would remind me that Holmes County is the poorest in the country. Lindsey C. Thomas, MD Forensic pathologist; Hennepin County Medical Examiner’s Office

If I could have dinner with any physician, living or dead, it would be Elizabeth Blackwell (1821–1910). In 1849, Dr. Blackwell became the first woman to receive a medical degree in the United States. The story is that

and England.

physician who is clinically superb using only a simple history and physical exam is, still, a clinician particularly worthy of admiration. For that reason, I would choose Arthur Conan Doyle and his mentor, Joseph Bell, for my imaginary dinner!

A physician who is clinically superb using only a simple history and physical exam is, still, a clinician particularly worthy of admiration.

I would be curious to know what role her theology played in her practice; she was raised Congregationalist but later explored other religious perspectives, including Unitarianism. She wrote about the importance of sanitation and hygiene, but also the “fundamental connection of mind and body” in her book, “Why Hygienic Congresses Fail: Lessons Taught by the International Congress of 1891.” It is intriguing to think of that in light of the interest today in holistic integrated medicine. I’d love to hear what Dr. Blackwell would think of medicine today!

William Nersesian, MD, MHA Pediatrician; Chief medical officer, Fairview Physician Associates A great hero of mine is Sherlock Holmes. While detective Holmes is fictional, his creator, (Sir) Dr. Arthur Conan Doyle (1859–1930), was very real. Doyle attended medical school at the University of she was admitted to Geneva Edinburgh, Scotland, and was Medical College in upstate New influenced by a particularly York only because, when the astute professor there, Joseph dean and faculty put her appliBell. Bell had a legendary abilcation for admission up for a ity to observe a patient’s attire, vote by the 150 male medical appearance, speech, accent, and students, all of them voted to ac- mannerisms and could make cept her, believing it was a joke. astounding deductions about the person’s occupation, history, Dr. Blackwell was the marital status, degree first woman to receive a of wealth, education, medical degree in the and many other aspects of the patient’s life and United States. background. A smudge of yellow-tinged mud on a boot might mean that the I think it would be fascipatient had traveled that mornnating to hear Dr. Blackwell ing through East London—the discuss why she was interested in medicine and what it was like only place for miles where that particular hue of mud could be for her as the only woman in her class. Even after graduating, found. A characteristic tattoo on a patient’s wrist meant that it was hard for her to find emthe man was a seaman and had ployment as a physician. Evensailed the Orient, where that tually she opened an infirmary in New York City with her sister, special design was commonplace. In the Victorian era, a who was the third woman phyworn-out felt hat and a dishevsician in the U.S. Dr. Blackwell eled hatband could only mean also founded four-year medical that the owner was a bachelor, colleges for women in the U.S.

Phillip Kibort, MD, MBA Pediatric gastroenterologist; Chief medical officer, Children’s Hospitals and Clinics of Minnesota

I’ve chosen three physicians, based upon different areas of interest in my life.

as no respectable wife would let her husband be seen in public with such a hat! In our era, when clinicians make medical diagnoses using sophisticated blood tests and expensive imaging studies, a

One of my key responsibilities at Children’s is overseeing quality and safety. The names Berwick, Pronovost, and Osler come to mind quickly, but I would be most fascinated to talk to Ernest Amory Codman (1869–1940). This pioneering Boston surgeon had the courage to suggest to his peers that we ought to measure our outcomes; know about the quality of work we do; and make our results

Dinner with doctors to page 12

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From the Courtroom to the Capitol.® April 2014 Minnesota Physician

I would most like to talk to is John F. Kennedy’s secret physician, Hans Kraus. Kennedy had public. He stood up for what he many medical problems and believed. Unfortunately, he endwas taking a polypharmacy of ed up a pauper and was kicked drugs. I would ask Kraus what out of his hospital and surgical he thought he was doing and society because of his courahow he felt he was protecting the U.S. Maimonides reconciled living by covering up for this president, a fully spiritual life with prowhether in regard moting the scientific world. to his back issues, Addison’s, or use of amphetamines. geous vision and foresight. Like many great visionaries, he was Finally, in light of my ethnic rejected by his own and only and religious background, I later considered to be correct. I would love to talk to Moses Maiwould love to know his thought monides (1135–1204). Maimonprocess in the early 20th centuides, who lived in Spain, was ry—and to tell him we’ve only a brilliant rabbinical scholar, recently begun to do what he philosopher, and astronomer, dreamed of. as well as a revered physician. Dinner with doctors from page 11

My second choice of physician to dine with stems from my avocation of studying American presidential history. While it’s tempting to choose from the physicians who dealt with Garfield, Lincoln, Kennedy, or Reagan after they were shot,

He had great impact on the leaders of Spain, his influence on Jewish law resonates even today, and some medical schools still use his oath. I would ask how he reconciled living a fully spiritual life with promoting the scientific world.

Chris Leisz, DO Physical Medicine/Rehab Specialist; Courage Kenny Rehab Institute, St. Paul

I would love to dine with Frank Netter, MD, aka “Medicine’s Michelangelo.” As every physician knows, he is the author and illustrator of the “Atlas of Human Anatomy,” which most physicians know eponymously as “the Netter.” Has any other medical publication been utilized as extensively as this book? Netter was born in 1906 and attended art school in the 1920s, but his father did not

his illustrations have helped me understand the musculoskeletal system. He evidently collaborated with the medical giants of his time, so it would be fun to hear his stories about that part of his work. He died in 1991, having lived enough to see some miraculous advancements in medicine. It would truly be a privilege to get to know this man. Charles Bransford, MD Internist; Director of Hospice and Palliative Care Services, Lakeview Hospital, Stillwater

When I was asked to contribute to this feature, I was actually at a conference run by the person I would choose as a dinner companion: Jim Gordon, founder and director of the Center for Mind-Body Medicine (CMBM), based in Washington, D.C. He and his growing group of trained practitioners provide care to traumatized people across the world, using the CMBM model described in his book “Unstuck.” Their goal is to provide training for “people on the Has any other medical ground” who can conpublication been utilized as tinue care long after they leave.

extensively at “The Netter?”

At the conference, Jim and I were able to have a real discussion about his work. We sat close together on soft hotel chairs. He leaned in close, as he is hard of hearing. I asked Jim to think about his greatest patient care experience and the guiding principle of his remarkable career. I expected him to recount some incredible

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Minnesota Physician April 2014

approve of his chosen career. He graduated from NYU Medical School and completed a surgical residency, but he continued to draw and paint. Ciba-Geigy began featuring his illustrations in their publications in 1937. Most of us who trained in the last 20 years remember the Ciba “Clinical Symposia” series. The conditions he depicted in the series were His work transcends so vivid and memorable culture and language. that they provided a clear mental image for medical students learning about disease states. experience in Gaza, Haiti, the Through his work with Ciba, Syrian camps, New Orleans after Katrina, or his work with Netter was able to abandon returning vets or cancer pasurgical practice and become tients. But no; he told me about a full-time medical illustrator, a young, traumatized, adopted producing more than 4,000 immigrant boy he is working paintings during his career. with, using mind-body therapy As a physical medicine such as guided imagery and specialist, I continue to use meditation. The boy had man“the Netter” almost every day. I aged to keep the same job as a would like to tell him how much busboy for six months without

getting fired, and had made his first friend—pretty close to a miracle, given his history. Jim described his guiding principle as living as much as possible in the present moment. Sitting with

him, I could sense his wondrous curiosity about the human condition, accompanied by an overwhelming drive for justice in the world and for relief of suffering. There is a remarkable cando, entrepreneurial spirit surrounding Jim. He believes each of us has the power of healing within ourself. To watch him work with groups and see them gradually transform themselves into something greater than each individual is truly to appreciate Jim’s genius. His work transcends culture and language. It represents a lifetime of experience that he freely shares with the world. Look for the CMBM team at the next world crisis—they will be there. Lee Beecher, MD Psychiatrist; President, Minnesota Physician-Patient Alliance; Adjunct professor, University of Minnesota

Here’s what I’d say to Sigmund Freud if we had a conversation at dinner: Dr. Freud, the “intimate medical relationship” is under great threat in 2014. You anticipated the need to know how the brain works with your “Project for a Scientific Psychology” in 1895. But, within the limits of neuroscience in your time, you also showed how crucial human relationships shape our brains and personalities. And you demonstrated the clinical power of helping patients through

understanding and reshaping their words, language, stories

We still can’t say what it takes for a human being’s brain to be conscious. and relationships within an intimate, trusting doctor-patient relationship, which you termed psychoanalysis. Even though you focused on psychological issues primarily during your career, you never overlooked the fact that it is an organ composed of three pounds of flesh—the human brain—that creates and retains all thoughts and emotions. The good news: In 2014 neuroscientists are zooming in on the fine structure of indi-

And, given the current ecoClinic, St. Paul-Ramsey County nomics and politics of mediMy dinner would be with Francal practice, obtaining an cis Peabody, whose seminal adequate assessment of a article The Care of the Patient patient’s diagnosis and evalwas published in JAMA in 1927. uating an ongoing plan of I would tell Dr. Peabody that I treatment is daunting—givlove this quote from that article: en a 10-minute visit autho“… the secret of the care of the rized by the clinic manager patient is in the caring for the or insurance company, patient.” along with mandatory computer Then I would ask him about documentation and limitations another quote from that article: on future appointments. An “What is spoken of as a ‘clinical intimate medical encounter picture’ crucial to the is not just practice of a photo“… the secret of the care interpersongraph of a al medicine of the patient is in the man sick is severely caring for the patient.” in bed; limited now, it is an and this impresthreatens sionistic painting of the patient the ability of psychiatrists and surrounded by his home, his many other physicians to do work, his relations, his friends, their best work with patients. his joys, sorrows, hopes, and fears. Now, all of this backSanne Magnan, MD, PhD Internist; President and CEO, In- ground of sickness which bears stitute for Clinical Systems Improve- so strongly on the symptomatology is liable to be lost sight of in ment; Staff physician, Tuberculosis Dinner with doctors to page 14

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vidual neurons, each of which has 10,000 synapses. They are charting the biochemistry of the brain, surveying how more than 100 billion neurons produce and employ thousands of different proteins, creating representations of the brain’s 100,000 miles of white matter tracks, and starting to identify the differences between ordinary brains and those with disorders such as schizophrenia, autism, and Alzheimer’s disease. Yet, despite advances in psychopharmacology over the past 60 years, we face challenges in doing clinical medicine in 2014. First, scientifically, we still can’t say what it takes for a human being’s brain to be conscious or, biophysiologically, to think or to think specific thoughts. The vision of a scientific psychology as outlined in your “Project” in 1895 remains unfulfilled.

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Dinner with doctors from page 13

our facilities, but also in many other ways in their lives and communities.

instrument, and then I would bring him up to date with

Thomas J. Stormont, MD Urologist; Stillwater Medical Group

the hospital.” I would hope we could then discuss what “the care of the patient” would look like for our patients today. How do we go beyond the four walls of our clinic or hospital to care for patients and their families in their communities? How do we use our influence, credibility, and reputations to improve the communities where our patients live, learn, work, pray, and play?

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I believe that Dr. Peabody’s insights would re-inspire us to care for our patients not only in

I would like to have dinner with the German physician Philipp Bozzini in the early 1800s in his favorite restaurant in his hometown of Frankfurt, Germany. It would be of historic interest to hear of the lichtleiter (light conductor), which he invented in 1805. The lichtleiter was com- current flexible high-definition digital endoscopy and the posed of various rigid examinworking channels that allow ing tubes lasers and other using instruments a wax We would wash down to be used. He candle in likely be would our dinner with plenty a holder as impressed and a of German beer. with current mirror for state-of-the-art illuminaendoscopy as I would be with tion; its use eventually led to the his ability to inspect a man’s development of modern endosbladder by candlelight, using copy. primitive anesthesia and his I would want to hear about rigid lichtleiter. the development and use of his We would wash down our dinner with plenty of German beer, making sure the food was all thoroughly cooked and served with clean hands—some sources report that Dr. Bozzini died of typhoid fever at age 35, in 1809, long before the introduction of pasteurization.

Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability?

I would love to speak with Semmelweis about his deductive logic, and to explain to him the huge effect he had on the world by illuminating the association between fever/infection and hand washing/cleanliness. I would want him to know that more than 150 years later, we still focus on hand washing. One of the mysteries in Semmelweiss’s day was why women got sick during childbirth in the famous teaching hospital in Prague, but not in the small towns while being cared for by

Jon Nielsen, MD Obstetrician-gynecologist; Oakdale Ob-Gyn

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analysis led to the discovery of puerperal (childbed) fever, which at the time had up to 40 percent mortality. However, his suggestion that physicians wash their hands and clothes to help prevent such deaths was met with ridicule and anger. In 1865, Semmelweis was committed to an asylum, where he was beaten, and he died 14 days after admission.

Minnesota Physician April 2014

One day when I was 15 years midwives. He would be surold, I picked up a book in our prised to learn that despite all living room entitled “Cry and our progress in medicine, we the Covenant” and began readstill have to worry about paing it. I had decided by age His suggestion that physicians 9 that I wanted to be a doctor, wash their hands and clothes to and already help prevent such deaths was had a keen interest in met with ridicule and anger. European history, so I was delighted to discover this book tients getting sick in hospitals covered both interests. It made and acquiring infections that a lifelong impression on me. can be fatal. Written as an historical novel, the book described the life of Ignaz Semmelweis, a Hungarian/German obstetrician who lived and practiced medicine in Prague. Semmelweis’s common-sense deductive

As an obstetrician-gynecologist, I would want to ask Semmelweiss about other things he knew about delivering babies, long before the introduction of our current technology. And, having graduated one course

short of a minor in European history in college, I would be fascinated to hear about life in Prague in the mid-1800s.

a proclaimed atheist, he had a heart for service. During

I would like to thank him for being a hero of medicine and in some way apologize for his treatment by his fellow man. Ann Dillon, MD Internist; Dillon Sharpe Cockson & Associates, PA

My first thought was to dine with a famous doctor: Albert Schweitzer. After all, here was medical school he took a year a man with three pages of off to teach reading and writing quotes on the Internet. Howevto workers in remote lumber er, on further consideration, my and mining camps. He again thoughts turned to a less famous doctor who was Bethune started using mobile connected with blood transfusion services to my medical school (McGill take blood to wounded University in soldiers near the front lines. Montreal): Norman Bethune. Born in 1890, Bethune grew up in rural Canada. From the beginning, although he was

suspended his studies to be a stretcher-bearer in France during World War I. Later, as a

doctor in Montreal, he treated the poor and was a proponent of socialized medicine. On a trip to Russia in 1935 to observe their system of health care, Bethune decided to become a communist. The next year, he went to Spain to fight the fascists in the Spanish Civil War, during which he started using mobile blood transfusion services to take blood to wounded soldiers near the front lines. In 1938, Bethune traveled to China to help Mao Zedong organize medical services during the Chinese Civil War and the Second Sino-Japanese War. He performed many emergency battlefield surgeries and trained doctors, nurses, and orderlies. While there, he developed septicemia and died in 1939. Bethune was relatively unknown in Canada until Mao published an essay later that year documenting his devotion to the Chinese people and his selflessness. I would talk to him over

dinner about where politics and medicine overlap, and how to contribute beyond the dayto-day business of medicine. Though few of us are willing to go to a war zone or permanently uproot our lives to practice in a remote location, many of us went into this profession for altruistic reasons. And we have found ways to express our altruism, whether through mission work, hospital community outreach, or volunteering in free clinics. Even if we cannot dine with doctors such as Norman Bethune (and, yes, Albert Schweitzer), they inspire us to find more meaning in our life and our profession. Editorâ&#x20AC;&#x2122;s note: Donna Ahrens served as editor of Minnesota Physician from 1999-2014. She has recently retired and as her final project put together this feature. From all of us at Minnesota Physician Publishing we wish her the best in her next chapter and send our sincerest thanks for all of her enthusiasm, dedication and outstanding work.

April 2014 Minnesota Physician

African American men’s health from cover

NTCC partners with national organizations The National Baptist Convention Foundation USA, Inc., (NBC) was established in Atlanta in 1895. It is the largest organization of African American Baptist congregations in the world, with more than 10 million parishioners. With the motto of “Building Health Communities—Congregation by Congregation,” the NBC Health Outreach Prevention Education Initiative works to dramatically improve the health of African Americans. 100 Black Men of America, Inc., (100 Black Men) is a national organization that seeks to improve the quality of life for all African Americans by enhancing educational and economic opportunities. In an outreach to improve health outcomes, 100 Black Men provides access and tools on prostate and colorectal cancer, cardiovascular disease, depression, and sickle cell anemia. The National Football League has a diverse portfolio of community outreach initiatives. They include prostate cancer screening and treatment initiatives in conjunction with the American Urological Association. The Minnesota Vikings will serve as the NTCC coordinating center. for African American Men’s Health (NTCC), has five distinct regional centers—UMN; UAB; MD Anderson Center, Houston; Johns Hopkins University

in Baltimore; and University of California, Davis. Research will focus on investigating the socioeconomic, behavioral, and biological factors that drive and

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Minnesota Physician April 2014

sustain the pronounced disparities in African American men in such areas as unintentional and violence-related injuries, cardiovascular disease, prostate and other cancers, diabetes, and stroke across the life course. The goal is to develop, implement and evaluate interventions that will improve African American men’s health. Why a new approach is needed Biomedical research traditionally focuses on how physiological processes impact health, while public health research has emphasized how the behavioral characteristics of individuals impacts health. The two are not mutually exclusive. The social contexts in which people are born and live, however, are often neglected in clinical research efforts to determine factors responsible for the differential health outcomes of African American men. The World Health Organization identifies the social determinants of health as circumstances in which people are born, live, work, and age. Social and economic policies, the distribution of power and resources, schooling and education, and other overarching fundamental factors each play a role in shaping these social determinants of health. By investigating the socioeconomic and environmental factors involved in African American men’s health, the NTCC takes a life-course approach, pinpointing critical periods in a person’s life, such as youth/adolescence, young adulthood, middle age, and old adulthood, when social context may be more salient in the way if affects physiology or shapes health behavior. The NTCC integrative approach accounts for multiple, simultaneous pathways that can lead to poor health outcomes in African American men. In particular, a complex interplay of socio-environmental, behavioral, and bio-physiological influences involved in the etiology, management, and melioration of chronic diseases, and the prevalence of unintentional

and violence-related injuries, cannot be underestimated. This integrative approach seeks to understand how risk of disease is differentially acquired and manifested over the life course and how it can be ameliorated. Health disparities in Minnesota While Minnesota has been recognized nationally as having some of the most positive health outcomes in the country, the same cannot be said for African Americans living here. Adverse health outcomes for African Americans are some of the highest in the nation. These health outcomes result in lower life expectancies for African Americans in Minnesota—75.4 years, compared with 81.1 years for whites. According to data from the Centers for Disease Control and Prevention/National Center for Health Statistics/ Health Data Interactive (www. cdc.gov/nchs/hdi.htm), the cancer death rate for males in Minnesota (per 100,000 population, 2007–2009) is 205.5 for whites and 295.0 for African Americans. The overall male cancer death rate in the U.S. is 217.8 for whites and 281.5 for African Americans. Socioeconomic factors, such as low education levels, widespread unemployment, unhealthy lifestyle behaviors, high poverty, lack of health insurance, and lack of health literacy—in combination with a number of biological factors—impact the prevalence and aggressiveness of cardiovascular disease, cancer, and stroke in African Americans. The Minnesota Department of Health’s “Eliminating Health Disparities Initiative” (EHDI) report (published in alternate years), stated in its January report that the death rate in Minnesota from diabetes for African Americans is almost twice the rate for whites, with kidney failure 40 to 50 percent greater in African Americans. Also in Minnesota, African American men die from stroke at a rate 22 percent higher than for white men. Many national health rankings place Minnesota high in

terms of general health status compared to other states, and the Agency for Healthcare Research and Quality—in its most recent ranking—places Minnesota No. 1 across quality measures. However, according to the EHDI report, some recent rankings find Minnesota has fallen to sixth. This drop is directly attributable to health differences between populations of color and white populations. According to the EHDI, economic instability, unsafe neighborhoods, and inadequate access to health care ultimately results in poor health outcomes and shorter life spans, as well as higher health care costs for those populations of color. For example, higher incidence of diabetes, heart disease, cancer, and generally poor health are found in people of color living in Minnesota. Recent immigrants from across the globe are contributing to Minnesota becoming an increasingly diverse state. In 1990, African Americans accounted for only 2 percent of the total population in Minnesota. From 1990 to 2010, growth in the African American population grew 189 percent, accounting for 5.2 percent of the total population.During this same period, the percent of African American foreign-born population accounted for 28 percent of the total African American population, compared to 5.2 percent in 1990. The EHDI projects that Minnesota’s non-white population by 2025 will be approximately 22 percent. While the report acknowledges that many issues contributing to health disparities are broad and complex, it also notes that to change the downward trajectory of Minnesota’s health status rankings, the approach needs to include community partnerships, both local and national. Developing community partnerships To implement proposed interventions and disseminate research activities, the NTCC has formed a partnership with three national community partners—

the National Baptist Convention Foundation USA, Inc., 100 Black Men of America, Inc., and the National Football League. These community partners will be instrumental in helping to develop collaborative strategies and interventions to change the current trajectory of African

Christopher Warlick, MD, PhD; Mary Kwaan, MD, MPH; Monica Colvin-Adams, MD; Sonia Brady, PhD; Chap Le, PhD; YenYi Ho, PhD: and Haitao Chu, PhD. Pilot project underway The NTCC is in the first phase

Community partner involvement will pay dividends for many years, both in Minnesota and across the nation. American men’s health on both a local and national level. Each of the national community partners has well-developed community engagement profiles and cultures, which eases the development of a unique academic-community partnership. Utilizing this infrastructure, the research landscape will be transformed dramatically, offering new opportunities to reach the African American community. Ultimately, community partner involvement will pay dividends for many years, both in Minnesota and across the nation.

of a five-year project. Locally, collaborative efforts between academic and community partners have begun, with a pilot project under the direction of Sonya Brady, PhD, project lead investigator, and Willie Winston, III, PhD, community coalition leader. “Communities Invested in Healthy Life Trajectories of African American Boys” is a community coalition that will select, refine, imple-

On the team with me are Jasjit Ahluwalia, MD, MPH; Kola Okuyemi, MD, MPH;

Badrinath R. Konety, MD, MBA,

is a professor at the University of Minnesota, where he holds the Dougherty Family Chair in Prostate Cancer and is director of the Institute for Prostate and Urologic Cancers. He is a fellow of the American College of Surgeons and the American Urologic Association.

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The NTCC community partners have respected, strong relationships with African American communities, which are essential in developing collaborative strategies to explore factors responsible for the differential outcomes of African American men involving unintentional and violence-related injuries, mental disorders, and chronic diseases. As part of the local community, UMN has assembled a multidisciplinary team of investigators and national experts, who have long track records of previous collaborations. This team has expertise in diverse fields from public health to cardiovascular disease, cancer control and prevention, surgical oncology, psychosocial motivations, adolescent risk-taking, to community-based participatory research.

ment, and evaluate a schoollinked intervention for socioeconomically disadvantaged African-American boys ages 8 to 14, and their caregivers at a St. Paul elementary school. The project’s goals are to prevent or reduce externalizing symptoms, risk behavior, schoolbased disciplinary action, and juvenile justice involvement, by promoting family, school, and community connectedness; academic investment; and social and emotional well-being. The final phase will include offering interventions to families and developing a communication campaign to promote family involvement.

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April 2014 Minnesota Physician

Professional Update: Allergy

naphylaxis is a medical emergency requiring immediate intramuscular epinephrine. It can be caused by food, drugs, stinging insects, radiocontrast dyes, or mastocytosis. Anaphylaxis can occur within minutes or up to two hours after exposure, which includes ingestion or injection. Many times the cause of anaphylaxis is unknown and labeled idiopathic. This is very frustrating for the patient as well as the provider. All cases of anaphylaxis should be referred to a board-certified allergist. The following case, which has had identifying information changed, was related to a newly identified trigger. Pieces of the puzzle Who? What? A 60-year-old man living in Minnesota had four episodes of anaphylaxis. During the first three episodes, the patient showed up at an emergency room with itchy red hives all over his skin, difficulty breathing, nausea, and vom-

Mystery diagnosis for allergic reaction New anaphylaxis trigger identified By Nancy L. Ott, MD

iting. Epinephrine was given immediately, which made his symptoms go away. The fourth episode occurred while he was on a hunting trip in a remote location; he self-injected epi-

This case illustrates the importance of taking a thorough medical history. nephrine with an EpiPen, which relieved the symptoms. An hour later he arrived at a hospital, where his symptoms did not recur.

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Introducing the newest member of our TCU team: Cristina Presbitero, BSN, RN, WCC

Cristina Presbitero is a Med-Surg and Wound Care Certified RN with over eight years of experience in complex wound care and enterostomal nursing and consulting. This means: • More wounds managed in house versus out patient, reducing total care cost and rehospitalization. • Wound vac management. • Track healing rates on hospital and house-acquired wounds, incident bases on diagnosis and risk factors, reducing hospitalization. Questions? Please contact our Admissions Coordinator Kelly Emerson at 651-632-8842

The first episode occurred while he was chopping wood during a vacation in Virginia, where he grew up. On two of the four occasions he experienced anaphylaxis, he had eaten fish

Minnesota Physician April 2014

one or two hours before symptoms appeared. But the other two allergic reactions occurred in the middle of the night, when he had not eaten for six to eight hours. Medical factors. The patient’s primary care provider tested the patient’s blood to see if the man was allergic to fish. The test was negative. The patient reported that he had not been stung by a bee, wasp, or hornet, which could have explained the anaphylaxis. Nor was he taking cancer medication, antibiotics, or blood pressure medication, which also could have caused his reaction. He had taken ibuprofen for knee pain two hours before one of the anaphylactic episodes but had tolerated ibuprofen after the reactions. He had exercised two hours before two of the episodes. His past medical history indicated that he had mild hayfever, which he self-treated with over-the-counter antihistamines as needed. He had no cancer, asthma, heart problems, or gastrointestinal problems. Geography, lifestyle. The patient’s lifestyle history revealed that he had recently retired from work as a park ranger. He was now spending more time visiting his relatives in Virginia; while there, he and they often visited a cabin where he had

spent a lot of time as a boy. This is where he was when his first anaphylactic episode occurred. Fitting the pieces together When it was revealed that he grew up in the middle states, a key question was asked that solved the puzzle. The New England Journal of Medicine reported in 2008 that a carbohydrate called galactose-alpha-1,3-galactose (alpha-gal) was causing anaphylaxis in patients who shared several things in common. One: These patients lived in the same part of the country, which included Virginia, Missouri, and Tennessee. Two: They were being treated with a cancer drug, (cetuximab) which contained alpha-gal. The third commonality among these patients? In addition to experiencing an allergic reaction shortly after their cancer drug was administered, these patients experienced a delayed allergic reaction hours after they ate red meat (i.e., beef, pork, or lamb). Red meat contains alpha-gal. The reason that these patients’ allergic reaction after eating meat was delayed compared with their faster onset of symptoms after administration of the cancer drug is that alpha-gal in meat is attached to protein. The delayed reaction occurred because the ingested alpha-gal had to go through the intestines in order for digestion to release the alpha-gal from the protein. At that point, the patients’ bodies recognized it as an allergen and responded with anaphylaxis. Furthermore, these patients also had allergic reactions to the lone star tick, which is endemic in their region of the United States. A blood test was developed to detect allergy to alpha-gal. The final puzzle piece The key question was whether or not the patient had any reaction to tick bites. In fact, he had large hives around the tick bites he received in Virginia—but

not tick bites in Minnesota. The middle states have the lone star tick, which is responsible for the alpha-gal allergy. The alpha-gal specific IgE test was performed on the patient’s blood and confirmed his allergy to alpha-gal. After further history-taking, he remembered having eaten steak or hamburger each day he experienced an anaphylactic reaction. The days his episodes occurred within two to four hours of eating beef were the days he was working vigorously (chopping wood, clearing brush) or had taken ibuprofen, both of which are known to enhance an allergic reaction such as anaphylaxis and may have hastened onset of the reaction. Although this patient lived in Minnesota where the lone star tick has not been found—yet— and although he was not taking the cancer drug that has been associated with this allergy, he did spend time in Virginia and

had a history of allergic reactions to tick bites. Lesson learned This case illustrates the importance of taking a thorough medical history. Although the patient had told his story to multiple providers during the course of two years, none of them had made the connection between his time spent in a state known to contain the lone star tick (Virginia), his long history of tick bite reactions, and his red meat consumption the day of the reactions. All factors pointed to alpha-gal. If your patients vacation or have lived in the region of the country known to contain the lone star tick and have had hives or reactions to tick bites, be aware of this unusual allergy. Check the CDC website for states that have the lone star tick (www.cdc.gov/ticks/maps/ lone_star_tick.html). Keep in mind that climate change may cause this tick to extend into

About the lone star tick The lone star tick (Amblyomma americanum) transmits Ehrlichia chaffeensis and Ehrlichia ewingii, causing human ehrlichiosis, tularemia, and STARI (southern tick-associated rash illness). It is primarily found in the southeastern and eastern United States. White-tailed deer are a major host of lone star ticks and appear to represent one natural reservoir for E. chaffeensis. The tick’s larvae and nymphs feed on birds and deer. Both nymphal and adult ticks may be associated with the transmission of pathogens to humans. STARI is specifically associated with the lone star tick. This is called the “lone star tick” because the female has a single silvery-white spot on its back, although the males have scattered spots or streaks around the body’s margins. The adult tick has eight legs, and is brown to tan. It’s about one-third inch long before feeding, growing up to one-half inch long after feeding. The bite is not initially felt by humans or other mammals. While lone star ticks are usually found in the U.S. South—from central Texas to Oklahoma—they also can be found along the Atlantic coast as far north as Maine. Sorce: Information from the Centers for Disease Control and Prevention (CDC) and Texas A&M University. For more information, visit (www.cdc.gov or https://insects.tamu.edu/fieldguide/cimg370. html). pediatric allergy and immunology. She is a senior associate consultant at the Mayo Clinic Children’s Center, Rochester.

more northern and western states over time. Nancy L. Ott, MD, is board-certified in pediatrics and in adult and

Are you satisfied with your claims processing? You will be with ClaimLynx! Every medical practice depends on cash flow. Very few people understand the required processes between when a doctor sees a patient and how/when insurance reimbursement is disbursed. We make these steps simple for you. Among the services we offer: • Direct, real time verification of eligibility • Secure online access to claims tracking • Secure online access to claims correction • Never miss a payment due to late filing • We handle every kind of insurance and every medical specialty • Less time on paperwork, more time with patients

ClaimLynx is used by many national clearinghouses. You may already be using our services and not know it. Shorten your submission route and remittance time—go straight to the payer using ClaimLynx. Every practice is unique and whether a solo practitioner or large multi-specialty group (and everything in between) we can tailor a solution to your claims processing needs that will maximize your benefits.

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For more information please contact: Russel Campbell info@claimlynx.com 10700 Old County Road 15 Suite 200, Plymouth, MN 55441

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952-593-5969 April 2014 Minnesota Physician

Special Focus: Practice Management

ttempts to assess the “true” cost of health care in the U.S. are fraught with inconsistencies. Yet the goal is noble: to benchmark the per capita cost of care in order to control or even reduce it, making health care affordable for all. But deciding on a standard unit of measure for health care costs has been a challenge. For example, what should be used for comparison—the list price of a service or procedure, or only the patient’s portion of the cost? And how can we ever determine the true cost to society, encompassing direct and indirect aspects of care?

Measuring Total Cost of Care:

• Affordable (the calculation is within the reach of most payer databases)

The search for common ground

• Stable (reduces the impact of a single outlier)

By Gunnar Nelson

elusive:

While all math models have limitations, the key to a stable, consistent cost of care measure will be an agreed-on common methodology, with verifiable attribution and high enough sample size to lessen the impact of random variation. There are a variety of reasons that a universal Total Cost of Care measure has been so

1. Since medical records do not have cost information, especially for other providers involved in the patient care, the only central source is insurance claims. This means that one doctor does not know what other doctors are getting paid. 2. There is no perfect attribution system (i.e., the method to identify which provider will be allocated a patient’s costs).

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3. The actual amount paid varies by payer, network, and moment in time. 4. B ecause there have been different methods of measuring cost, providers have been known to get contradictory results, depending on who is doing the measuring, and how. 5. Finally, since cost is a continuous variable, risk adjustment and outlier rules need to be applied so a few patients don’t swamp the entire result. Costs can vary from $1 to $1,000,000 or more. The scope of service may also be reported in different ways, such as the unit price of a single procedure; the grouped price for an episode of care; or as the total cost of care for a patient over a set amount of time. Despite these challenges, one methodology for measuring cost of care is gaining ground. Developed in Minnesota and endorsed by the National Quality Forum in January 2012, the Total Cost Index (TCI) is a measure of a primary care provider’s risk-adjusted cost-effectiveness at managing the population they care for. TCI includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, and ancillary and behavioral health services. A total cost index is preferable to other methods because it is: • Complete (it measures all costs) • Standardized • Repeatable (can be deliv-

Minnesota Physician April 2014

ered across payer sources and across time)

Putting cost measurement into practice While arriving at a nationally endorsed, standardized measure of cost and resource use (TCI) was a monumental milestone, it was still only the first step in gathering the amount of data needed to establish benchmarks and make comparisons. MN Community Measurement (MNCM) undertook the following steps to ensure the practicality of implementing TCI as a community-wide measure for public reporting: • In 2011, assembled a “cost committee” to investigate the best way to measure costs. The multi-stakeholder group included representatives from health plans, provider groups, purchasers, and the State of Minnesota. • In 2012, developed the methodology specifications for a Total Cost of Care measure based on the TCI, with agreement from all participants on attribution (patient assignment), risk adjustment, and methods of calculation. • In 2013, developed a process to gather data from multiple health plans to calculate the TCI. Unlike most multi-payer cost measures, this process does not require an all-payer database, therefore, the administrative costs are lower, and there is no protected health information (PHI) risk. It also includes a system for providers to verify patient assignment. The process was tested with two payers, and the proof of concept was achieved for both the calculation and the patient verification. In 2014, MNCM will run a full pilot with all major com-

mercial health plans in Minnesota to further test the Total Cost of Care methodology. Then, MNCM and the cost committee will begin work on the Resource Use Measure—a total cost of care measure that uses a standardized pricing system to measure purely the utilization variation between providers. This will provide a complete measure of cost and utilization. Cost of care at the community level In addition, MNCM has joined forces with the Network for Regional Healthcare Improvement (NRHI) and four other regional health improvement collaboratives (RHICs) in a seminal study to: 1) identify drivers of regional health care costs, and 2) develop strategies to reduce health care spending and improve health care quality at the community level. MNCM hopes to learn from other regions doing similar work, and then to test the concept of measuring Total

Cost of Care across regions. The study, which is funded by the Robert Wood Johnson Foundation, will involve local physicians in each region.

A level playing field Most providers don’t really know where they stand compared to others, either locally or nationally. In addition, when providers refer their patients to other medical professionals, that cost and utilization is not always clear.

“We know the cost of care in Minnesota is lower than in many other states,” said Jim Chase, MNCM president. “We hope to better understand the

A universal Total Cost of Care measure has been elusive. The four other participating RHICs are Maine Health Management Coalition Foundation (MHMC-F); Center for Improving Value in Health Care (CIVHC) in Colorado; Oregon Health Care Quality Corporation; and the Midwest Health Initiative (MHI), located in the St. Louis region. The NRHI study, to be conducted over 18 months, represents the first time that standardized information will be available across several communities to compare the cost of care across multiple data sources.

differences in these costs, what drives these differences, and how to reduce costs while improving patient care.” Using the data from the study, the five partnering RHICs will create a process for benchmarking for health care costs; identify the best ways to share information with the public; and conduct focused efforts with physicians to help them adopt practices that will reduce costs while maintaining the quality of care.

It is our hope that all the efforts underway will give providers standardized tools and information to compare their cost and utilization patterns to others, and identify opportunities to get better value for their patients. Gunnar Nelson is a health economist at MN Community Measurement, where he leads initiatives, analytics, and development. Nelson has spent 26 years working in the areas of cost measurement and analysis, fee schedule development, and cost transparency. MN Community Measurement is a non-profit organization dedicated to improving the health of the community by driving change in cost, quality, and patient experience of care.

DON’T MISS THE SPCO THIS SPRING! Haydn, Stravinsky and Kernis

Thursday | Apr 24 | 7:30pm Friday | Apr 25 | 10:30am Saturday | Apr 26 | 8:00pm Ordway, Saint Paul

Roberto Abbado, conductor; Paul Neubauer, viola Stravinsky: Apollon Musagète Kernis: Viola Concerto (world premiere, SPCO co-commission) Haydn: Symphony No. 101, The Clock

The Turn of the Screw

Friday | May 23 | 8:00pm Saturday | May 24 | 8:00pm Ordway, Saint Paul

Thomas Zehetmair, conductor; Sara Jakubiak, soprano; Krista River, soprano; Thomas Cooley, tenor Britten: The Turn of the Screw

Britten, Mendelssohn and Shostakovich

Sunday | May 18 | 2:00pm Benson Great Hall

Thomas Zehetmair, conductor and violin; Maiya Papach, viola Mendelssohn: Overture to Son and Stranger Shostakovich: Prelude and Scherzo for String Octet Britten: Lachrymae Mendelssohn: Symphony No. 1 Subject to availability. All artists and programs subject to change.

MNPhysician_May.indd 1

9:09:32 AM April 2014 Minnesota4/10/2014 Physician 21

Special focus: Practice Management

n estimated 260,000 Minnesotans have diabetes, equaling approximately 6.2 percent of the population, according to the Centers for Disease Control and Prevention (CDC). Health care practitioners and clinic administrators are trying to find innovative ways during clinic visits to encourage patients with diabetes to improve their health status, while maintaining adequate revenue for those visits. Scenic Rivers Health Services (SRHS) in Bigfork, Minn., has begun diabetes group visits. Group visits are not a new concept, but they are becoming a more common practice. When facilitated correctly, group visits are a win-win-win situation. The patients have more face time with a provider than the typical 15-minute visit and benefit from peer discussion and education. The providers enjoy them, because they no longer have to repeat the same chronic disease information in separate

Group visits An increasingly common approach to diabetes care By Jennifer St. Peter, Edwin Anderson, MD, and Travis Luedke

diabetes visits throughout the day. Additionally, the provider is able to spend more time with patients in a casual setting. The final “win?” The clinic can bill for multiple visits at a single

Group visits are a win-win-win situation.

time. Because all the normal appointment services are provided, the clinic can bill for a routine visit by multiple clients.

Building Bridges to Quality Healthcare

HIE-Bridge™ is the state-wide health information exchange (HIE) service offered by Community Health Information Collaborative (CHIC). HIE-Bridge™ allows health care providers to have real-time access to clinical information from multiple sources. CHIC is the first and only MN state-certified Health Information Organization (HIO) offering full exchange capabilities.

With HIE-Bridge you will TM

• Greatly enhance clinical care coordination • Securely query, receive and exchange data in compliance with HIPAA and MN privacy laws • Access real-time information from multiple sources in a single, unified longitudinal view • Achieve Meaningful Use mandates

• Access the eHealth Exchange • Improve provider collaboration and workflow efficiency

To find out more… Call 218-625-5515 info@medinfosystems.org www.hiebridge.org

A group visit is essentially an individual medical appointment with an audience. Patients are provided all the services that they would have in a normal diabetes clinic visit, but they

Minnesota Physician April 2014

receive them in the presence of other patients. In addition to standard services, the group visits provide an opportunity for patient-to-patient discussion and diabetes education facilitated by a provider or other medical professional. Depending on the number of patients in the group and the services provided, these visits can last two to three hours. Scenic Rivers Health Services is a small rural clinic that is a federally qualified health center (FQHC) and is in the process of transitioning to a patient-centered medical home (PCMH). There is little published information about similar clinics implementing group visits. FQHCs and PCMHs require specific and more extensive documentation for billing purposes. In addition, FQHCs cannot bill for educational visits, as other clinics do. But even with these extra requirements, SRHS is able to successfully conduct (and bill for) group visits. Below are some of the strategies used to fulfill FQHC and PCMH requirements, as well as some advice on creating engaging group visits. Coordinating group visits Issue: Providers in FQHCs must meet with patients face-to-face

to bill for a visit. To fulfill this requirement, time is set aside within the group visit for each patient to meet one-on-one with the provider. SRHS’s group visits are done in a conference room, where patients can meet with the provider in one corner. This provides a semi-private setting in which the provider and patient can have uninterrupted conversation. During this time, the other patients in the group complete required visit documentation forms with nurses. Issue: PCMHs require extensive documentation in the electronic medical record (EMR). Patients need to answer several questions that normally would be asked by a nurse, who directly inputs information into the EMR. The questions include a general survey about diabetes health status. In addition, the nurse and patient need to complete an individualized goal setting care plan. SRHS recreated the EMR questions in layman’s terms and made paper copies. Instead of a nurse going through the information individually with patients during a clinic visit, he or she leads the entire group in filling out the paper questionnaires. A nurse then enters the answers into the EMR while the provider facilitates the discussion part of the visit. To complete all of the necessary documentation, the provider, registered nurse, and a licensed practical nurse work on different tasks simultaneously throughout the visit. The conference room has three stations. A room divider creates a private space to take weights. The corner desk provides a space for the individual face-toface visits mentioned above, and a conference table in the middle of the room creates the group space. We found the easiest way to coordinate tasks was to create a spreadsheet that explained what each member of the team was doing during each section of the visit.

Billing group visits Issue: FQHC’s cannot bill for group education. The Bigfork clinic cannot bill for group education due to its FQHC status. Regardless, at least a half hour of education with a provider or other medical specialist is scheduled during the group visit. Though the clinic cannot bill for that education portion, it still codes a 99078 for complete documentation of what was done. The professionals have found that the education portion is valuable for the patients, and the multiple patient aspect of the group visit allows more time to be spent on education. Revenue from the visit more than covers the time spent on group education. Tips for success Grouping patients. The most impactful visits occur when the participants vary in age and diabetic control status. Patients

who have been recently diagnosed with diabetes have the opportunity to learn from those who have decades of personal diabetes experience. People who are struggling to understand the long-term consequences of

patients. For example, patients are provided a nutritious buffet lunch when they come for a group visit. During one visit, a nutritionist reviewed the website MyPlate (www.choosemyplate.gov) before patients ate

Group diabetes visits are an educational, innovative, and satisfying way of providing high-quality care in a relaxed setting. poorly controlled diabetes can see and discuss these issues with patients who may have made poor lifestyle choices in the past. Patient-to-patient advice can be much more influential than suggestions given by the provider. Get creative. The Bigfork clinic staff has applied lessons learned from the initial group visits in 2012 to improve group visits. We use some of the revenue from these visits to increase hands-on learning and make the visits more enjoyable for

lunch. The patients were then encouraged to use their new knowledge to pick proper meal portions while they were serving themselves. During another group visit, the patient education portion focused on physical activity. To entice patients to exercise, SRHS partnered with the neighboring Bigfork Valley Hospital to offer a free onemonth exercise room membership for those participating the in the group visit. The catered lunch and engaging nature of the visits encourages patients to return.

Group diabetes visits are an educational, innovative, and satisfying way of providing high-quality care in a relaxed setting. As a FHQC and an aspiring PCMH, Scenic Rivers Health Services Clinic faced many obstacles to plan and implement group visits. Accordingly, the first group visit took extensive pre-planning and coordination. But the overwhelmingly positive postgroup visit feedback from patients at Scenic Rivers Health Services Clinic tells us that the effort was worth the time. The clinic is continuing to expand the number of diabetes group visits we offer, to make them more widely available to our patients. Jennifer St. Peter is a senior at Cornell University, Ithaca, N.Y.; Edwin Anderson, MD, is a physician, and Travis Luedke is clinic manager at Scenic Rivers Health Services in Bigfork, Minn.

Building a Healthy Medical Practice

How to Thrive, Not Just Survive AAPS National Spring Meeting

Friday, May 9, 2014: 12:30 to 6 PM: Dinner program follows Physicians, Surgeons, Nurses, Chiropractors, Medical Professionals, Employers, Individuals, Agents

Sponsored by the Association of American Physicians and Surgeons (AAPS) and the Minnesota Physician-Patient Alliance. Speakers from across the country assessing the future of your medical practice. • Empowering patients and MDs, innovations, legal issues, nuts and bolts on how to change your practice. • Presenting real-life stories of practicing physicians and surgeons who have transitioned from third-party paid practices to a direct-pay model. • $99 for Physicians and Health Care Professionals and $49 for Professional Staff. Scholarships for interns and residents.

Session Speakers: Robert Sewall, MD - TX Susan Wasson, MD - MN Donald Gehrig, MD - MN Doug Nunamaker, MD - KS Kathy Brown, MD - OR Mitchell Brooks, MD - TX Lee Beecher, MD - MN Jane Orient, MD - AZ Lawrence Huntoon, MD - NY Andrew Schlafly, JD Twila Brase, RN - MN Peter Nelson, JD - MN Dave Racer, MLitt - MN Sean Parnell - VA

Marriott, Minneapolis Airport 2020 American Boulevard E - Bloomington MN 55425 Details at http://tinyurl.com/aapsmtg or call 651.705.8583

Keynote Speakers: Richard L. Reece, MD Merrill Matthews, PhD

Up to 6.75 CME Credits Available This activity has been planned and implemented in accordance with the Essential Areas and Policies of the New Mexico Medical Society (NMMS) through the joint sponsorship of Rehoboth McKinley Christian Health Care Services (RMCHCS) and the Association of American Physicians and Surgeons (AAPS). Rehoboth McKinley Christian Health Care Services is accredited by the New Mexico Medical Society to provide continuing medical education for physicians. RMCHCS designates this live activity for a maximum of 6.75 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

April 2014 Minnesota Physician

special focus: Practice Management

Supporting medical independence

ntegrity Health Network (IHN) is more than a great name—it’s a descriptive statement of how we operate and provide care. The success of the network of independent medical practices is inherently dependent on the success of our individual clinics, so the work done at the network level must address the needs of the clinics.

IHN is founded on physician leadership and the belief in the value of independent medicine. A board of governors—made up of our president/CEO and physicians representing both primary and specialty care—oversees the network’s operations. The board’s monthly meetings are attended by IHN quality and operational staff and our medical directors of primary and specialty care who give recommendations regarding clinical and quality issues. Building on a strong foundation of physician leadership and clinical expertise, we support our members by addressing cost

A health network’s model founded on cooperation By Bruce Penner, RN

and quality in several areas. IHN provides quality improvement initiatives and support for each clinic, understanding

We see independent medicine not only surviving, but thriving. that cost and quality must encompass all aspects of health care delivery. We work closely with clinic administrative staff, keeping them informed of the latest advancements in cost

Read us online Wherever you are!

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and quality control, and, where feasible, supporting the needs of their clinics from an operational perspective.

Minnesota Physician April 2014

Physician leadership IHN’s Quality Improvement Medical Directors (QIMD) committee is the clinical voice that addresses issues of cost and quality across the network. Led by the medical directors for primary and specialty care, this committee meets every other month. Each clinic has a physician representative in this group. Originally this group developed, implemented, and internally reported quality measures and quality data. Now, with the onset of external forces such as state and federal quality mandates, this group responds to and develops plans to comply with these measures. The QIMD committee is a strong voice on behalf of independent physicians, both in and out of our network, as it offers comments to health plans, government agencies, and others on the measures and mandates that are handed down. The committee shares a conviction in the value of, and the need for, high-quality and low-cost care. But that conviction includes a belief that sustained improvement occurs best when built from the ground up, not when mandated from the top down. The collegiality of the committee allows peer-driven change that establishes and maintains improvement. Physicians hear and respond to other

physicians, who are often the best source of influence for each other. While the approach to issues may differ from a specialty vs. a primary care practice, the consensus drawn at these meetings has proven to be of tremendous value. One significant result of this group’s work is a set of simple guidelines instituted by IHN called the Care Continuum Initiative guidelines. These are short, bullet-point-formatted guides for the pre-referral care of various conditions. The intent of these guidelines is to maximize the clinical and resource efficiency of primary care as an effective way of improving quality and reducing cost. They address the things that should and should not be done in pre-referral care. And, to the credit of the specialists involved in developing these guides, they also define criteria for when a referral is not warranted. Clinic and administrative involvement Achieving a higher standard of care has to involve more than physician input. Each clinic has a Quality Improvement Coordinator (QIC) who participates in informational meetings and trainings organized by the network at least quarterly. In these meetings the details of new initiatives, both cost- and quality-related, are broken down to the “boots-on-the-ground” level. QICs are people who usually work directly with physicians and are responsible for the overall quality improvement processes, including data collection and reporting. IHN’s role is to provide them with tools and support to carry out their work. IHN also provides opportunities and venues for the exchange of ideas. It is not uncommon to see meetings end with informal networking, where problems and solutions are shared. IHN also recognizes the value and importance of administrators and managers in the management of cost and quality. We keep administrators informed of important developments regarding clinical, quality and operational issues. They

Several years ago, the board implemented an attendance policy that requires 65 percent attendance by the clinic representatives to the QIMD, QIC, and administrator meetings. This resulted in vastly increasing the value of the meetings. Since the policy was implemented, we have seen a steady improvement in our quality outcomes data. IHN also provides support with regular visits to our clinics. Each year, every primary care clinic is visited at least once—with a formal presentation—by our medical director for primary care. These meetings are designed for all medical, clinical, and support staff in each clinic. The topics covered included quality measurement definitions, coding training, quality improvement process training, and more.

Our medical directors for primary care and specialty care are available to respond to questions and concerns from their peers across the network, and they routinely communicate with them on issues of interest and importance. Additionally, IHN administrative staff is always available and often on-site providing support to our clinics. Thriving on independence Looking ahead, we see independent medicine not only surviving, but thriving, in this rapidly changing world of health care reform. Improving quality and appropriately managing costs are not contrary philosophies; historically, independent physicians have been successful at achieving both. But to sustain this success, we see a need for more sharing of resources and cross-pollination of clinic cultures. Independent physicians should be able to remain independent. By collaborating with others of similar spirit when and where it makes sense, they

About Integrity Health Network IHN was formed in 2010 as the result of the merger of two longstanding independent practice associations, Northstar Physicians Network and Northland Medical Associates. Today, IHN includes 200 physicians, and 47 clinics and facilities, located in 23 communities in northern and central Minnesota, and northern Wisconsin. IHN doesn’t own clinics; the network is owned by a group of independent and autonomous clinics, with the goal of improving the patient care experience and enhancing health care outcomes. In Minnesota, IHN clinics and facilities are located in Albertville-St. Michael, Baxter, Buffalo, Clearwater, Cloquet, Cold Spring, Cromwell, Duluth, Eveleth, Grand Marais, Grand Rapids, Hermantown, Monticello, Moose Lake, Sartell, St. Cloud, Virginia, and Two Harbors.

will be able to do so. Everyone’s hard work paid off in 2013, when IHN received a silver award for Generic Utilization Rates (with clinics ranking fifth and seventh in the state) as well as a gold award for Total Cost of Care in Primary Care (with clinics ranking first and ninth in the state). Both awards were given by HealthPartners’ “Partners in Excellence” program. Although the network’s name is on the plaques, the real

See 3 or more operas and save up to 25%

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2014-2015

are also encouraged to share stories of success and challenge with each other and they often gain insights and solutions from each other.

work was done in the offices and exam rooms of the individual clinics that make up our network. The success of IHN is inherently dependent on their success. A message we often share internally is, “You need some degree of interdependence to maintain independence.” Bruce Penner, RN, is IHN’s director of quality. A large part of his work involves supporting clinics in quality programming and the collection, reporting, and analysis of quality data.

LA FANCIULLA DEL WEST Sept. 20 – 28, 2014

HANSEL AND GRETEL Nov. 1 – 8, 2014

THE ELIXIR OF LOVE Jan. 24 – 31, 2015

THE MANCHURIAN CANDIDATE Mar. 7 – 14, 2015

CARMEN Apr. 25 – May 3, 2015

April 2014 Minnesota Physician

Orthopedics

Advances in foot and ankle surgery

he human foot and ankle is composed of 31 bones, 34 joints, 117 ligaments, and numerous muscles and tendons. Many foot and ankle ailments get in the way of work, limit activity, and prohibit athletic competition. Recent advances in foot and ankle treatment and surgery, however, are helping people recover rapidly and get back to their activity, work, and sport.

New treatments help patients recover quickly By Benjamin Clair, DPM, FACFAS and Aaron Benson, MS, ATC

Heel pain Patients’ heel pain is commonly encountered by the foot and ankle specialist. Most commonly, plantar fasciitis is the culprit. This is a condition affecting the plantar fascial band—a ligamentous structure connecting the heel to the front of the foot through the arch. Plantar fasciitis often comes from abnormal mechanical influences and induced inflammatory factors, which lead to pain. It is usually experienced upon a person’s first step after

sitting or resting. Plantar fascial pain is also common in those who stand for long hours while at work.

A custom-made treatment plan will get a patient back to a full range of activity. Treatment mainstays are stretching programs, orthotic (shoe insert) management, and anti-inflammatory treatment in oral and steroid injection forms.

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No .7

2007

and treatments utilizing growth factors and radio frequency to stimulate healing. Great toe joint deformity, arthritis The most common foot deformity is termed “hallux valgus”—commonly known as a bunion (See Figures 1 and 2). This deformity results from imbalance around the great toe joint, which causes a deformity. It is hereditary, but improperly fitting shoes can hasten its progression. There are many methods of managing this condition, but surgical treatment is the only way to correct it. Recent developments in surgical correction for hallux valgus revolve around a procedure that corrects the deformity definitively, preventing recurrence, as well as implanting hardware technology that allows for earlier weight-bearing post-operatively. Other surgical techniques are available for correction that utilize joint fusion procedures, osteotomies (precise bone cuts), and capsular and tendon transfer procedures for rebalancing.

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d Ka s Thyg ren eso Kraem n, MD er, RN , , CM C edside viewe manner day d as a “so may be cine con s, and adv ft” ski empha tinue ances ll these to in expert sis on clin height The Indep en the mediendent Med ical focus ise. But By Ro and ical Busin as tered, to becom medic technica ess New “I hav bert Sw ine shi l spaper eet, ing gropatient e more fts its … and e prosta MD pat experi te can ity. In und as ence ient cen prosta I want cer a a Medic 2004, for key me is fast gaia com tectomy.” robotic asu added al Licens example, re of quan“chief mon pre This is lsentin sonal a nation ing Exam the U.S now compla g . al ada int tion interactio skills ination figure, office ys in uro ” heard tes that s acr medic n and com t on per to be tively given the Ro and oss the logists’ acr year, eligible al studen munic mak botic su of the recent ado relastate If you oss the the Na for lice ts mu aes rg robot cou pti per Qu er clin in nsu on st tio ntr can form alit y pass ro for use ical nal Co re. y. be app “share y Assura The OR an ads into mm And thi If you a plus robotic nce rapid licatio in prosta in (NC ittee for s seven d decisio d be the this fiel growth ns. patien don’t, you marke tectom QA ting yond experi measures n-making” ) added in y, it to per d promi you it’s cra t that rob either ence. to ass ma try to r practic as mally the wa nently ses som cked up otic pro ess pat one of e. Sh eone statec convin to be, alter y sur system ared dec ient and invasive dur who or you tomy ce your taught surger es—esp gical pro To doe to arr atic int ision-maki aid of date, rem s it. refer isn’t all . ceecially ies—a By eractio ng inv him The re per Curt based ive at an oving Mille mi n applicaa robot to curre forme ni- r the on the inform with pat olves is the nt sta The d imate tion of ients ed dec ir val DEC most prostate da Vin teISIO rob ly ues isio wit com pro ofotic ci rob N-M are don 90,000 and n, gen the-ar ringing surger mon cur h the AK ING prefer a new medic surgic y, the da ot and e ann radica t and, to pag its l pro y. Appro rent to mark al device accord ually e 12 in 199 al system Vinci S et was a Speci xin the statec of Su al Foc ing lot easier HD in the good tom nn Essent 9 and 200 , were rel us: ies manu yvale, to Intuit United old essentially Rural Calif. ive Su States a two-step days. It wasPage expand ially, the 6, respec eased Step Healt da Vinfactures , the — 20 rgical process. h com ci rob and sel laparo ed the robot has tively. im one: Develop a , will product ben proved patien ls the pany tha be don ot, thi “mass scopic sur efits of gol t t care. Step that Show it e rob s year to a docto ove d-standar two: otical open-s es” of cla gery to r. If the liked it, d the ly. Th r half of doctor you had state urgeon ssically is is the a winne traine s. Th of tec an am m Over r. PRS the past e cur clinica d hn azing 15 years issues and U.S. RT STD l adv ology rep rent , payment POS increased ances TAG res requiremen LEN regula PAID E in lap ents DIN ts have made tory G A aroMpls lot more HA ND things a . MN comp Perm it No. to pag device must licated. Today 2655 e 10 a new fit a consi complex derably model in more order to cessful in be sucthe mark etplace. woods are The still full of good (and bad) ideas for new devic HDHPs, P4P the challe es; nge is pickincentive ing a likely and the s, patient-p the qualit from amon winner hysician y of relations g health system medical care possibilities the hip in the . Here, By Mary recent study needs improveme American in appro Sue Beran ximate order nt. A more , MD, MPH The cost documented of adults in the of impo rtanc of United States for consu health care is rising tive, acute that among a factors that e, are the range of mers , and chron prevenhealth plans (patients). High- , particularly only about sider most we conSpecial ic care, Focus: adults deduc critic half (HDH of al tible receiv Ps) larity as recom in ed medic evaluating Home Care ed health care are gaining in al care proce endideas for popuincrease costs contin (McGlynn new devic Page 20 a sses and emplo e. EA, N Engl ue to yers look more of 2003;348(2 J Med, the MARK ET for ways 6): 2635– to page to This added responsibility to 2645). 12 Pay-for-perf the consu shift expense ormance mer. patients may be (P4P) progr a problem with chron ams have for ic diseas quent care a popular become PRSRT e who need STD that is often way to attem U.S. POSTAG fremeasur com pt t At t

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New developments include treating diseased fascial tissue, surgery to release the fascia and promote natural tissue healing,

Great toe joint arthritis is termed “hallux rigidus” (See Figures 3a and 3b). It prematurely wears out the first metatarsal phalangeal joint because of mechanical imbal-

ance factors. Patients present all along the spectrum with this condition. Procedures to surgically correct this problem range from decompressive osteotomies (precise bone cut procedures) that improve joint motion, to interpositional biologic joint repairs, to definitive joint fusion for relief of arthritic pain. Developments in this area include advanced plating and screw technology, which allow for improved mechanical support and improved recovery time after the procedure. Current research can be utilized to determine the most appropriate interventions, as treatment varies according to the specific degree of osteoarthritis of the great toe joint. Toe contractures Digital contractures of the toes, commonly referred to as hammertoes, are the result of imbalance of the flexor and extensor tendons to the toe. These contractures can exist alone or in combination with other forefoot deformities. Correction of these digital deformities is possible—recent improvement has been made to the intramedullary bone devices that hold the toe in position as it heals, without the need for wires sticking out the end of the toes during healing. This has resulted in earlier activity and return to regular shoes after surgery. Foot, ankle arthritic conditions These can result from old injuries and fractures, or from acquired structural conditions that lead to early wearing out of the joints (osteoarthritis). Treatments range from orthotic management and injections, to surgery. Implant technology has rapidly evolved, providing surgeons new ways of applying plates and screws to correct deformities, fuse painful arthritic joints, and return people to work and the activities they enjoy. Ankle arthritis usually results from old fractures, and can also develop primarily. Surgical ankle arthroplasty/replacement aims

Figure 1. Radiographic depiction of hallux valgus

to restore natural ankle motion and replacement methods can be excellent alternatives to ankle joint fusion. Under certain conditions, however, an ankle fusion may be the most definitive operative intervention. Repairing cartilage injury and damage Cartilage damage and focal cartilage defects (osteochondral defects) are commonly encountered by the foot and ankle specialist, typically around the big toe joint and ankle joint. These result from acute injury or from advancing arthritis problems. Many new developments have been made in cartilage repair methods. Some involve transplanting healthy, active cartilage cells to a cartilage defect; they grow in, repairing the defect. Biocartilage products have been developed that can be combined with a patient’s own growth factors to improve outcomes and promote healing. The arena of cartilage repair and regrowth continues to grow in exciting ways. Diabetes and amputation prevention Diabetes causes foot problems through a pathological process of the nerves, called neuropathy. This condition is a consequence of poorly managed glucose control. It can result in lower

Figure 2. Status post surgical hallux valgus correction

Figure 3a. First metatarsophalangeal joint status post arthrodesis to treat hallux rigidus

Figure 3b. Intraoperative photo illustrating changes in articular cartilage associated with hallux rigidus

extremity numbness, tingling and pain, usually affecting the digits of the foot first. Without feeling, diabetic patients can sustain ulcerations.

ties, sports injuries include tendonitis, sprains, and muscle and mechanical mediated pain. New topical products and treatments show favorable results. Tendon

treatments have been developed, including ultrasound, radio frequency, and bone marrow aspirate and growth factor injections. Additional tendon

Education about and prevention of these problems is the best treatment. Diagnosis through peripheral nerve fiber testing is the most significant advancement in this area. Additionally, tremendous advancement has been made in making certain that blood flow is adequate to the lower leg and foot, to cure wounds and prevent amputation. New intravascular procedures are being performed by vascular surgeons and interventional physicians that improve perfusion. The key to preventing amputation is early identification of nerve and vascular flow abnormalities. Fractures of the foot and ankle These fractures—from twists, falls, car accidents, and crush injuries—often are displaced or involve a joint structure, which requires surgical treatment. Recent improvements include anatomic, locked-plating technology, allowing anatomic correction and early return to weight bearing and motion. Sports injuries Usually the consequence of overuse or repetitive use activi-

Advances in foot and ankle surgery to page 38

THE STRENGTH TO HEAL

and stand by those who stand up for me. Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference. To learn more, call 1-855-276-9579 or visit www.healthcare.goarmy.com/q955. © 2010. Paid for by the United States Army. All rights reserved.

April 2014 Minnesota Physician

Neurology

hen the first author was a third-year medical student at the University of Minnesota, he recalls a teaching session with the famed Dr. A.B. Baker, in which Baker said something like: “There are two forms of presenile dementia, Alzheimer’s and Pick’s. There is not much to say about them and you can’t tell them apart [in life], so let’s go on and talk about dizziness.” Dr. Baker was correct in 1973, but in 2014, that view couldn’t be farther from the truth. The frontotemporal degenerations, including Pick’s disease, are now at center stage in neuroscience research, and their clinical characterization has advanced with breath-taking speed.

The frontotemporal degenerations—the accepted name for the group—are much less common than Alzheimer’s disease, in terms of total number of affected individuals. The frontotemporal degenerations include about 50,000 to 100,000 cases

The frontotemporal degenerations Much more than Pick’s disease By David Knopman, MD, and Bradley Boeve, MD

in the U.S., whereas Alzheimer’s affects close to 5 million Americans. However, in people under the age of 65, the prevalence of the two disorders is probably nearly equal.

The affected individuals have normalsounding speech, but they experience an erosion of their vocabulary. Diagnosis The frontotemporal degenerations can indeed be diagnosed in life. There are a number of

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distinctive syndromes that are almost always due to one of the frontotemporal degenerations. These clinical presentations (syndromes) are primary progressive aphasia, behavioral

Minnesota Physician April 2014

variant frontotemporal dementia, progressive supranuclear palsy, corticobasal syndrome, and amyotrophic lateral sclerosis. To be sure, a solid knowledge of clinical neurology is required for optimal diagnosis of these syndromes. Many physicians, including neurologists, don’t encounter them often enough to develop familiarity with them. Brain imaging with MR and FDG PET have proved to be excellent, though not infallible, adjuncts to the clinical diagnosis for distinguishing frontotemporal degeneration from the syndromes of Alzheimer’s disease and Lewy Body disease. Why diagnose these disorders? Ask any family member and you will get an answer, loud and clear: These disorders are distressing, they clearly fall outside of the common pattern of dementia due to Alzheimer’s, and the patients and their families need help in coping with the illness. Frontotemporal degenerative disorders are extremely disruptive to families. While as yet there are no treatments for any of the frontotemporal degenerations, their molecular biology is beginning to yield strong candidates for pharmacological interventions.

Behavioral variant frontotemporal dementia. The prototype frontotemporal degeneration clinical syndrome is the one now referred to as behavioral variant frontotemporal dementia (bvFTD). It has a distinctive and unmistakable clinical presentation. Affected individuals undergo a personality change, exhibit a coarsening of their interpersonal behavior and demonstrate various examples of flamboyant disregard of social norms and the feelings of others. While these phenomena may occur in other dementias, their early and dramatic appearance is unique to bvFTD. Often, though not always, the dissolution of personality and interpersonal relationships occurs despite preserved memory, language, and spatial abilities. A diagnosis of bvFTD can most effectively be made from the history provided by a close family member; brief cognitive exams and even more detailed neuropsychological testing may be equivocal in early cases. In the majority of instances, obvious prefrontal and/or anterior temporal lobe atrophy is visible on either brain CT or MR. In some bvFTD cases with normal brain MR, FDG PET scans will demonstrate hypometabolism in the frontal and/or temporal lobes (Figure 1). Primary progressive aphasia. The other prototypical clinical presentation of frontotemporal degeneration is that of a disturbance of language, primary progressive aphasia (PPA). The diagnosis of PPA can be suspected as soon as the physician engages the patient in conversation, because the language problems are the illness. There are many clinical subtypes of PPA, and their characterization has proved challenging. However, certain consistent patterns have been identified. There is a form of PPA in which expressive speech is labored, nearly dysarthric, telegraphic, and agrammatic, now referred to as the nonfluent/agrammatic variant of PPA. Often these individuals have preserved personalities, memory, and other non-lin-

guistic abilities. Interestingly, these individuals often respond to questions in a manner that is opposite of their intention, typically saying “yes” when they mean “no” and vice versa. Their brain imaging shows asymmetric frontal or insular atrophy, although the degree of atrophy can be quite subtle early in the course. The nonfluent/agrammatic variant of PPA is almost always due to one of the frontotemporal degenerations. The other distinctive PPA that is invariably due to a frontotemporal degeneration is the semantic variant of PPA. In this disorder, the affected individuals have normal-sounding speech but they experience an erosion of their vocabulary and their understanding of the meaning of words and objects. The most common and dramatic illustration of this loss is when an examiner asks the patient to say what an object, such as a watch, is used for. The patient with semantic variant PPA will reply, “A watch? What’s a watch?” There are other patterns of progressive aphasia where word selection in spontaneous speech is impoverished, called logopenic PPA. Interestingly, this form of PPA can be due to Alzheimer’s or to frontotemporal degeneration. Progressive supranuclear palsy, corticobasal syndrome, and amyotrophic lateral sclerosis. The frontotemporal degenerations also include progressive supranuclear palsy syndrome and corticobasal syndrome. Although these conditions were originally described as movement disorders, many or most individuals with one of these syndromes also have some form of dementia. The pathology of both of these disorders is that of frontotemporal degeneration. While it might seem over-reaching to call amyotrophic lateral sclerosis (ALS) one of the frontotemporal degenerations, the fact is that many patients with typical ALS have changes in behavior and cognition if those symptoms are

actually sought. And, importantly, the most common cause of familial ALS is the same mutation that is the most common cause of familial frontotemporal degeneration. The pathology in motor neurons in ALS is identical to that of one of the frontotemporal degeneration subtypes. Motor neuron disease has long been recognized in people with rapidly progressive forms of frontotemporal degeneration. A transformation in understanding A half-dozen pivotal discoveries in the past 15 years have transformed our understanding of the neuropathology of frontotemporal degeneration from the 19th-century discovery of the Pick body to a 21st-century multidimensional molecular model. The first protein to be implicated in frontotemporal degeneration was the microtubule-associated protein tau (MAPT). Mutations in the MAPT gene were shown to cause many cases of frontotemporal degeneration. Two species of the tau protein, one with 3 repeating (3-R) units and another with 4 repeating (4-R) units, were shown to make up the pathological intra- and extra-cellular protein deposits in Pick’s disease (a 3-R tauopathy), progressive supranuclear palsy and corticobasal degeneration (both 4-R tauopathies) and cases with mutations in the MAPT gene (also 4-R tauopathies). It so happened that Pick’s disease, the “grand-daddy” of frontotemporal degeneration, developed silver-staining positive round intraneuronal inclusions, that enabled Arnold Pick and Alois Alzheimer to recognize the disorder using classical histopathological techniques, more than 100 years ago. About half of cases of frontotemporal degeneration tauopathies are genetic, while the others are apparently sporadic. Another major discovery was that many cases of frontotemporal degeneration showed tau-negative intracellular protein inclusions containing a protein called transactive

Figure 1. MR scan showing frontal atrophy typical of what occurs in patients with behavior variant frontotemporal dementia

response DNA binding protein of 43 kilodalton molecular weight (TDP-43). About two-thirds of all frontotemporal degeneration involves abnormal intracellular cytoplasmic aggregates of TDP-43. Two genetic discoveries

subsequently linked abnormal accumulation of cytoplasmic TDP-43 with mutations in the gene granulin (GRN) (also termed progranulin and abbreviated as PGRN) and the gene chromosome 9 open reading

The frontotemporal degenerations to page 30

Psychiatrist Cross-Cultural Medicine HealthPartners Medical Group in St. Paul, Minnesota, seeks a BC/BE licensed psychiatrist to practice cross-cultural medicine with our experienced Behavioral Health team at the Center for International Health (CIH), an internationally recognized refugee/immigrant medicine clinic which has helped define best practices in refugee and immigrant healthcare for 30+ years. U.S. and international experience providing psychiatric care to refugees and globally mobile populations is strongly preferred. Qualified bilingual psychiatrists (especially those fluent in Somali, Khmer, Oromo, Karen, Vietnamese, Hmong, Nepali or Russian) are encouraged to apply. This part-time (0.5 FTE) position will provide outpatient psychiatric care closely integrated with primary care in a holistic care model, while partnering with community organizations and the MN Department of Health’s Refugee Health Program. There is also opportunity for an academic faculty appointment at the University of MN and teaching involvement in the Global Health Pathway (www.globalhealth.umn.edu). HealthPartners offers a rewarding practice with a competitive salary and benefits package. Forward your CV and cover letter, specifying your language fluency and global health/refugee medicine experience, to lori.m.fake@healthpartners.com or apply online at healthpartners.com/ careers. For more details, call 800-472-4695 x1. EOE

Minnesota Physician 4" x 5.25" B&W

April 2014 Minnesota Physician

The frontotemporal degenerations from page 29

Additional resources Mayo Clinic provides educational seminars for patients and particularly for families with loved ones with the frontotemporal degenerations. More information on these seminars can be gained by calling (507) 284-1324. Additional information on the frontotemporal degenerations can be accessed at the Association for Frontotemporal Degeneration website (www.theaftd.org).

frame 72 (C9ORF72). [The MAPT gene was initially discovered by our colleagues at Mayo Clinic Jacksonville, led by Mike Hutton; both GRN and C9ORF72 were initially co-discovered by another of our colleagues at Mayo Clinic Jacksonville, Rosa Rademakers.] Mutations in these genes invariably lead to

either bvFTD or a PPA syndrome, and invariably the neuropathology includes abnormal protein accumulation within neurons and/or glia. The story

in addition to finding drugs that are safe and effective, further improvements in diagnosis are needed. While virtually all of the

In addition to finding safe and effective drugs, improvements in diagnosis are needed. with the C9ORF72 gene mutation, a hexanucleotide repeat expansion, is even more interesting and informative because it is the one that also is the most common cause of familial ALS. Where are we now? What’s next? In contrast to the complexity of Alzheimer’s disease, the clinical-genetic-neuropathological relationships in the individual frontotemporal degenerations seem ripe for discovery of ways to interrupt the process, and to delay the appearance or worsening of the symptoms and the pathological changes. However,

semantic variant of PPA is due to sporadic TDP43 proteinopathy, and virtually all of progressive supranuclear palsy is due to sporadic 4-R tauopathy, the most common syndromes of the frontotemporal degenerations—namely, bvFTD and non-fluent agrammatic variant PPA—can be caused by any of the neuropathological and genetic subtypes. Thus, for the majority of patients with frontotemporal degeneration, the clinical syndromes do not allow determination of the molecular and neuropathological subtype. Imaging and fluid biomarkers are desperately needed to allow

antemortem molecular diagnoses. The soon-to-be-available PET ligand for tau protein may be a breakthrough imaging marker for the frontotemporal degenerations as well as for Alzheimer’s. Treatment of the frontotemporal degenerations is now just beginning. At Mayo Clinic, we are participating in a clinical trial for bvFTD of leuco-methylthioninium, a derivative of methylene blue, a therapy that putatively prevents the aggregation of both tau and TDP43 proteins. Hopefully, this trial will be successful; but unless the world is incredibly fortunate, many more therapies will have to be explored before we can make a dent in this devastating set of illnesses. David Knopman, MD, and Bradley Boeve, MD, are professors in the Behavioral Neurology Section, Department of Neurology, at the Mayo Clinic, Rochester.

Family Practice/Internal Medicine Indian Health Service (IHS), the Cass Lake Hospital (Federal) is seeking 2 Family Practice BE/BC Physician Providers and 1 BE/BC Internal Medicine Physician Provider. The CL Hospital offers inpatient/outpatient, ambulatory care, dental, optometry, pharmacy, audiology, laboratory, X-Ray, physical therapy and a diabetes clinic. We work within various teams, each team consisting of a physician provider, PA-C/NP, RNs and LPNs. We are located on the Leech Lake Indian Reservation in Cass Lake, MN. Most of the providers and staff reside in Bemidji which is a short 15-20 minutes commute. We offer competitive salary, excellent Federal benefits including health and life insurance along with Thrift Savings Plan (401K), Annual Leave, Sick Leave, 10 Paid Federal Holidays, student loan repayment eligible.

THE PATIENT ABOVE ALL ELSE. ®

Current Duluth Opportunities: St. Luke’s Family Practice, Duluth, MN (OB optional) Internal Medicine, Duluth, MN OB/GYN: Duluth, MN Practice Specifics:

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Salary: MGMA Market Competitive & Generous Signing Bonus St. Luke’s-employed position Clinic Hours: M-F 8:00-5:00 40 patient care hours/26 as scheduled clinic hours Benefits for .6 FTE or higher -Minimum 6 weeks Paid Time Off -Flexible Benefits Plan -Medical, Dental & Life -Relocation -Pension & 401(k) -Physician’s Supplemental Retirement Plan -Sick Leave & Personal Days -Short & Long Term Disability -Flexible Spending Account -Malpractice & Tail Coverage

Physician Recruiters

Come practice where others vacation.

Please contact Tony Buckanaga at 218-444-0486 for further details and how

Minnesota Physician April 2014

Meghan Anderson & April Knapp Email: mdrecruit@slhduluth.com 1.800.321.3790 ext. 5721 & ext. 5027

St. Luke’s Hospital 915 E 1st Street Duluth, MN 55805 www.SLHDuluth.com

Here to care At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 12 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel.

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties:

Make a difference. Join our award-winning team. Madalyn Dosch, Physician Recruitment Services Toll-free: 1-800-248-4921 Fax: 612-262-4163 Madalyn.Dosch@allina.com

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• ENT • Family Medicine • General Surgery • Geriatrician • Outpatient Internal Medicine

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

• Psychiatry • Pediatrics • Pulmonary/ Critical Care • Rheumatology

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Urgent Care

3.5x4.75_AD_MN_Medicine.indd 1

We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

MN Physician 4" x 5.25" 4-color

April 2014 Minnesota Physician

Pulmonology

New lung cancer screening tool

ung cancer is one the deadliest types of cancer, killing 2,174 Minnesotans in 2011, according to the Minnesota Department of Health’s Vital Statistics. Unlike mammography for breast cancer or colonoscopy for colon cancer, however, the federal government has had no recommendations on lung cancer screening—until now. Screening for some types of cancer has reduced deaths by early detection and treatment, including surgery, medications and radiation. Because the disease often shows no symptoms until it is in an advanced stage, however, finding a way to detect lung cancer early has long been sought, especially for people at higher risk of developing the disease. Now there is a test that can reduce death from lung cancer through early detection. Lung cancer screenings test for cancer before there are any symptoms. By screening at-risk individuals, the medical community believes it could

Low-dose CT scan can find disease earlier By Cynthia Isaacson, Jill Heins Nesvold, MS, and Lee Kamman, MD

prevent as many as 3,000 to 4,000 deaths nationwide a year, according to the National Lung Screening Trial study. The first step is determining who should receive the screening. The National Lung Cancer

raphy (CT) and standard chest X-ray in the detection of lung cancer. Both methods had been studied in finding lung cancer early, but the effects of these methods used in lung cancer screening to reduce mortality hadn’t been studied.

Advise current smokers to quit smoking, offering to help them with appropriate options. Screening Trial (NLST) consisted of 53,454 current or former heavy smokers from across the United States. It compared lowdose helical computed tomog-

The findings reveal that participants who received low-dose CT scans had a 20 percent lower risk of dying from lung cancer than participants who received

standard chest X-rays because the low-dose CT screen provides a clearer image, allowing earlier detection. The initial findings were released in November 2010. The primary results were published online on June 29, 2011 in the New England Journal of Medicine and appeared in the print issue on August 4, 2011. Should my patient be screened? On Dec. 31, 2013, the United States Preventive Services Task Force recommended annual low-dose CT screening for individuals at high risk for lung cancer, now an estimated nine million Americans. This screening is recommended for individuals who meet the following critiera: • A current or former smoker (former smokers having quit within the past 15 years) • A nd in the age group of 55 New lung cancer screening tool to page 34

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

32 MN Minnesota PhysicianPhysician 4" x 5.25" 4-color

April 2014

ExpEriEncE tHe

north MEMorial

DiffErEncE If you are looking for an alternative to practicing in a big system and want to help lead innovation, change and quality, consider North Memorial Health Care. We are a physician-lead organization with opportunities in primary and specialty care. Practice options include positions with North Memorial, as well as our closely aligned, physician owned practices. We work closely with our physicians to individually tailor practice models that work for our patients and physicians. For more information contact Mark Peterson at (763) 581-2986, mark.peterson@northmemorial.com or visit northmemorial.com.

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

• Hospitalist

• Pediatrics

• Emergency

• Hospice

• Psychiatry

• Internal Medicine

• Rheumatology

• Med/Peds

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• Ob/Gyn

• Urgent Care

• Orthopedic

• Vascular Surgery

Medicine

• Endocrinology • Family Medicine • General Surgery

Surgery

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Medicine

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

more than

Opportunities for full-time and part-time staff are available in the following positions: • Dermatologist • Geriatrician/ Hospice/ Palliative Care • Internal Medicine/ Family Practice

• Medical DirectorExtended Care & Rehab (Geriatrics) • Psychiatrist • Urgent Care Physician (IM/ FP/ ER)

Applicants must be BE/BC.

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US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer.

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible. For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

Liver disease, liver cancer, and deaths from Hepatitis C are on the rise. Testing can lead to lifesaving care and treatment for your patients.

(320) 255-6301

For more information, go to: www.health.state.mn.us/hepatitis April 2014 Minnesota Physician

New lung cancer screening tool from page 32

low-dose CT screening for lung cancer.

to 74 • A nd with a smoking history of at least 30 pack-years (1 pack per day for 30 years, 2 packs per day for 15 years, etc.) • A nd no history of lung cancer There is no evidence at this time that other high-risk groups should be screened. Patients with lung disease, particularly COPD, should be evaluated by pulmonologists regarding the advisability of CT screening depending on the severity of their disease. If you have patients who are wondering if they should get screened, the American Lung Association has launched an online tool to help easily identify potential candidates. www.LungCancerScreeningSavesLives.org takes visitors through a series of questions that helps determine whether they meet the guidelines for a

Cost Because the NLST results are recent, health insurance companies and Medicare may not cover the cost for a CT scan to screen for lung cancer at this time. That means that your patients may have to pay for the procedure out of their own pockets. Be sure to advise your patients to check with their insurance plans for the screening scan to see what is covered, if the results of the CT scan show that they should have additional procedures. Ask the referral facility doing the CT scan to carefully and clearly explain to your patients all the costs that they may possibly incur and not just the cost of the CT scan alone. If approved, the screenings would be covered by Medicare. The Affordable Care Act may also require many health insurance companies to provide the test for free. Currently in Minnesota, Blue Cross Blue

Shield of Minnesota is the only private insurance company that will cover the low-dose CT as a screening tool for lung cancer. For patients not covered by their insurance companies, the average cost of a low-dose CT screen in the state is $150. Why low-dose CT scan? Lung cancer may have spread by the time a person has symptoms, which is why screening is a great option to find lung cancer in early stages. One reason lung cancer is so serious is because it usually is not found until it has spread and is more difficult to treat. Scientists study screening tests to find those with the fewest risks and most benefits. They look at results over time to see if finding the cancer early decreases a person’s chance of dying from the disease. Three screening tests have been studied to see if they decrease the risk of dying from lung cancer. Of these tests, studies showed that only low-dose spiral CT scan reduced the risk

of dying from lung cancer in high-risk populations. A chest x-ray does not detect lung cancer early enough and sputum cytology is often done after a patient is already experiencing symptom and therefore are not recommended as screening methods. What should physicians do before the screening? Considering screening for lung cancer can bring up a variety of questions. The American Lung Association has released new guidelines to help physicians, their patients and the public in their discussions about lung cancer screening. The test is not recommended for everyone and it has risks as well as benefits. CT scan screening is a complicated process that requires you first: • Take a complete health history • Determine possible comorbidities (conduct spiromeNew lung cancer screening tool to page 36

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Minnesota Physician April 2014

For immediate confidential consideration, or to learn more, please contact

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Family Medicine Physician with C-section An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage and obstetrics available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites. For more information Call Kirk Stensrud, CEO 320.634.4521

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Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership. Currently we are seeking to add the following specialists: • General Surgery

• Obstetrics/Gynecology

• Radiation Oncology

• Family Practice

• Internal Medicine

• Ophthalmology

• Pediatrics For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • Dave.Dertien@avera.org

Avera Marshall Regional • Medical Center 300 S. Bruce St. • Marshall, MN 56258

www.averamarshall.org April 2014 Minnesota Physician

New lung cancer screening tool from page 34

those procedures may carry additional risks.

try if indicated)

• Explain that if there is an “indeterminate” result, it will be monitored for a year or two; this can cause the emotional stress of possibly having cancer.

• Educate about symptoms of lung disease and lung cancer • Discuss the benefits, risks and possible procedures associated with the screening process • Discuss the costs of screening, including financial, personal and time costs • Advise current smokers to quit smoking, offering to help them with appropriate pharmacologic and behavioral options. • Explain that a “positive” or “suspicious” result means that the CT scan shows something abnormal, but many of these nodes are “false positive.” Nodes found could mean lung cancer or some other serious condition and additional procedures could be needed to confirm, and

Where should I refer a patient for a CT scan to screen for lung cancer? Refer your patient to institutions that have experience in conducting low dose CT scans, and use the latest CT technology. There should be a link to an expert multidisciplinary team that can provide follow-up for evaluation of nodules. If the facility does not have that expertise on site, they should be able to make referrals to appropriate institutions. The team should also discuss the results and how they will follow up with you and your patient after the screening. In Minnesota there are 11 clinics that have a lung cancer screening program, including:

Trends in lung cancer morbidity and mortality The American Lung Association has tracked the incidence and mortality attributed to lung cancer. Below are some of the organization’s findings. • Lung cancer is the single-leading cause of cancer death in the United States. • The disease accounts for more deaths than breast, prostate, colon, liver, and kidney cancers combined. • Lung cancer is the leading cancer killer in both men and women. • In 1987, it surpassed breast cancer to become the leading cause of cancer deaths in women. • Non-smokers and former smokers are also at risk for lung cancer. • The five-year survival rate is only 15 percent.

• Consulting Radiologists– Edina & Plymouth • Suburban Imaging–Coon Rapids & Maple Grove • St. Paul Radiology–United Campus St. Paul, Eagan, Maplewood, Woodbury/ Lake Elmo, and Gallery Towers/St. Joseph’s Campus St. Paul • Mayo Clinic–Rochester • The University of Minnesota Fairview–Minneapolis

• Hennepin County Medical Center–Minneapolis Cynthia Isaacson is manager of respiratory health for the American Lung Association in Minnesota. Jill Heins Nesvold, MS, is director of respiratory health for the American Lung Association in Minnesota, North Dakota, and South Dakota. Lee Kamman, MD, is board-certified in pulmonary medicine, internal medicine, and critical care; he practices with AllinaHealth.

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Minnesota Physician April 2014

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www.NWFPC.com April 2014 Minnesota Physician

Advances in foot and ankle surgery from page 27

treatments include advanced tendon repair methods, tendon transfer options, and methods of tendon augmentation. Ankle instability This is a relatively common condition that results either after a severe ankle sprain or after multiple, repeated ankle injuries. Ankle ligaments are no longer supportive of the ankle. Symptoms include repeated episodes of the ankle â&#x20AC;&#x153;giving way,â&#x20AC;? a personâ&#x20AC;&#x2122;s apprehension on uneven ground, and looseness around the ankle joint. This condition can sometimes be associated with ankle cartilage disorders, which may also need to be addressed. Many new ankle instability procedures have been pioneered. They utilize new anchor and ligament repair methods, some of which are performed with minimum invasion, utilizing an arthroscope. These

surgical procedures allow early active range-of-motion and earlier return to weight bearing and activity. Achilles tendon disorders Achilles tendon ruptures occur when too much torque is placed upon the Achilles tendon and

these tendon ruptures. This material, in the proper suture technique, allows for earlier return to activity and weight-bearing than previously possible. New techniques utilize minimally invasive methods that allow a quicker recovery. The other form of Achil-

Significant advancements have been made in the diagnosis and management of these conditions. it fails. This usually happens during active athletic participation. Under some circumstances, an MRI can finalize the diagnosis. Surgical repair of the ruptured tendon, aimed at early return to motion and activity, has advanced in both the type of suture technique utilized and the type of suture material utilized. Some of the strongest synthetic surgical material created are utilized to surgically repair

Minnesota Physician April 2014

les tendon disorder is termed Achilles tendinopathy. It usually occurs after multiple episodes of Achilles tendinitis, often affecting active individuals. Treatments range from focused stretching programs to tendon surgical procedures, including microtenotomy procedures, tendon debridements, growth factor injections, and tendon transfer techniques. Achilles tendon disorders can be disabling. It is important

to have them evaluated by a foot and ankle specialist. New treatments for common disorders Foot and ankle disorders are common. Significant advancements have been made in the diagnosis and management of these conditions. Treatment is aimed at rapid restoration and recovery. Foot and ankle specialty care will include a physical exam and imaging (X-ray, MRI, or CT scans) to determine a diagnosis and to create a custom-tailored treatment plan that gets a patient back to full range of activity and a desired lifestyle. Benjamin Clair, DPM, FACFAS, is a foot and ankle specialist at St. Croix Orthopaedics, with a focus on trauma, arthroscopy, cartilage repair, tendon repair, and orthopedic surgical conditions of the foot and ankle. Aaron Benson, MS, ATC, is an athletic trainer who works with Dr. Clair.

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