Minnesota Physician January 2014 by Minnesota Physician Publishing

Vo l u m e x x v i i , N o . 10 J a n u a r y 2 014

The I nde p endent M e dical Business N ewsp ap er

Session or “unsession”? Anything can happen By H. Theodore Grindal, JD, and Nate Mussell, JD

he 2014 Minnesota legislative session gets underway on Feb. 25. Even-year sessions are traditionally shorter— often just a few months long—and most often center on the bonding bill for capital investment projects, although even-year sessions have often bucked this trend in recent years. The state’s biennial budget for FY2014–15 was passed in the 2013 session, but the Legislature is likely to pass a small supplemental budget to address any projected surplus or shortfall. The upcoming November elections, in which every member of the House of Representatives and the governor will be on the ballot, will prompt legislators to focus on a few key accomplishments and try to adjourn quickly so they can return to their districts and start campaigning. During his State of the State address last year, Gov. Mark Dayton deemed the upcoming session the “unsession,” and he is urging the Legislature to focus on repealing unnecessary laws. However, the November budget forecast, combined with the inevitable politicking during an election year, make the prospect of an “unsession” rather unlikely.

The evolution of concussion Mild traumatic brain injury in the 21st century By Ronald Tarrel, DO

ild traumatic brain injury (mTBI), or concussion, has been recognized and documented in every civilization throughout history. The physical effects of mTBI are documented on the walls of caves, in ancient scriptures, and in historical text. Mild traumatic brain injury to page 10

Session or “unsession”? to page 12

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Januar y 2014 • Volume XXVII, No. 10

Features The evolution of concussion 1

MINNESOTA HEALTH CARE ROUNDTABLE

Mild traumatic brain injury in the 21st century By Ronald Tarrel, DO

Session or “unsession”? 1

Anything can happen

By H. Theodore Grindal, JD, and Nate Mussell, JD

Minnesota Health Care Roundtable Advance care planning

DEPARTMENTS CAPSULES

MEDICUS

7 INTERVIEW 8 Cindy Firkins Smith, MD Minnesota Medical Association

PHYSICIAN-PATIENT COMMUNICATION

Caring for patients with hearing loss

By Scott Benson, MD

PATIENT PERSPECTIVE 30 Finding balance By Matt Hovila

DERMATOLOGY

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Post-acute care Fixing cracks in the system

Thursday, April 17, 2014 1:00–4:00 PM, Symphony Ballroom Downtown Minneapolis Hilton and Towers

By Joseph Shaffer, MD

PROFESSIONAL UPDATE: PULMONOLOGY 16 Reducing readmissions for COPD

By Sofia Ali, MD, MPH, and Jill Heins Nesvold, MS

www.mppub.com Publisher Mike Starnes mstarnes@mppub.com Senior Editor Donna Ahrens dahrens@mppub.com ASsociate Editor Janet Cass jcass@mppub.com ASsistant Editor Andrea Peterson apeterson@mppub.com Art Director Alice Savitski asavitski@mppub.com Office Administrator Amanda Marlow amarlow@mppub.com Account Executive Iain Kane ikane@mppub.com 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 neccessarily 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 within written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

Background and focus: Postacute care is becoming an increasingly important component of health care delivery. It is also becoming increasingly community-based. Medical advances are dramatically expanding the range of access to these services and, at the same time, creating a larger number of problems providing them. Choppy access to electronic medical records and ensuing medication management complications, as well as problems with care team coordination, can impede the goal of improving outcomes while lowering costs.

Objectives: We will discuss the evolution of post-acute care and illustrate the dynamic potential it holds. From the hospital to the physician to skilled nursing, rehab, and home care, we will present perspectives from across the care continuum. We will investigate communication problems between care team members and present potential solutions. We will examine how elements of health care reform like ACOs and insurance exchanges can drive both improvement in and higher utilization of post-acute care. We will discuss the tools that are necessary for post-acute care to reach its full potential.

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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Capsules

MNsure Executive Director Resigns April Todd-Malmlov resigned as executive director of MNsure, the state’s health exchange, at a closed-door meeting with the program’s executive committee on Dec. 17. The board has named Scott Leitz, Minnesota’s assistant commissioner of health care, as MNsure’s interim CEO while it launches a national search for a candidate to fill the position permanently. Todd-Malmlov’s resignation came amid ongoing problems with the state health exchange’s website and implementation, as well as increasing pressure from consumers, legislators, and Gov. Mark Dayton. “The recent problems some have experienced with MNsure are completely unacceptable,” said Dayton. “I am hopeful that this new leadership will lead to their swift resolution.” Leitz has been assistant commissioner of health care at the Minnesota Department of Health since 2011. In his 20 years of

health care and public health experience, Leitz has been responsible for overseeing the state’s Medicaid program and MinnesotaCare eligibility and benefits. “He’s got the skills that are needed at this point in time,” said Julie Brunner, executive director of the Minnesota Council of Health Plans. “And he understands that if you’re going to solve a problem, you need to understand all the stakeholders’ concerns around a particular issue.” Minnesota is one of 15 states that opted to build a state health insurance exchange program, along with the District of Columbia, and is not the only exchange to undergo major leadership changes. The director of Maryland’s health exchange stepped down recently; the head of Hawaii’s exchange announced her resignation in November; and the leader of Oregon’s exchange took a medical leave of absence in December as state officials reviewed his job performance due to delays in the enrollment system.

World’s Largest Imaging Magnet Arrives at U of M The University of Minnesota’s Center for Magnetic Resonance Research (CMRR) received the world’s largest magnetic resonance imaging (MRI) magnet on Dec. 6. The Agilent Technologies magnet is the first of its kind, rated at 10.5 Tesla (a unit of measurement for the strength of a magnetic field). Most medical MRIs use magnets rated 1.5 to 3 Tesla or lower. University officials say the new magnet will be used for brain research and whole-body human imaging. A magnet of this caliber has never been used to map the human brain and body, so the next 5 to 10 years will be spent developing technology to create images researchers can use. “The kind of information that we need to generate an accurate wiring diagram of the human brain simply doesn’t exist,” said

Kamil Ugurbil, PhD, director of CMRR and part of President Obama’s 10-year, $100 million BRAIN Initiative Working Group. “This will enable us to be unique in terms of human brain studies.” The 110-ton magnet was built at the Agilent Magnet Technology Center in Oxford, U.K., and delivered via a month-long boat trip across the Atlantic and through the Great Lakes. To ready the magnet, 40,000 liters of helium will be used in an energizing process that will take approximately 100 days. Once the magnet is in place, a custom-built iron box will be constructed around it in about 90 days. Officials expect it to be ready for system development and research in July 2014. “CMRR pioneered the use of very high magnetic fields to study brain function. The 10.5T magnet is the culmination of the approximately two-decade-old effort, since the introduction of high field functional imaging to study the activity of the human brain, to reach currently unavailable resolutions and detail, even with the most advanced high field instruments currently operational

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in CMRR,” said Ugurbil. “We expect to take the study of the human brain to a new level of sophistication with this system.” The university funded this project with an $8 million grant from the National Institutes of Health.

Mayo Clinic Endoxifen Results Encouraging A Phase I study of endoxifen, an active metabolite of the cancer drug tamoxifen, indicates that the experimental drug is safe and shows early evidence for antitumor activity, a Mayo Clinic study has found. Mayo Clinic Cancer Center and the National Cancer Institute (NCI) codeveloped the formulation of the drug known as Z-endoxifen hydrochloride. Researchers say study findings indicate potential for a new and better treatment for some women with estrogen positive breast cancer, particularly for those who do not respond to tamoxifen and aromatase inhibitors. “We achieved up to 60-fold higher levels of endoxifen compared to endoxifen levels achieved with the standard dose of tamoxifen,” said Matthew Goetz, MD, Mayo Clinic oncologist and lead author of the study. “We have seen evidence for tumor regression in patients who had failed standard hormonal therapies, including aromatase inhibitors, fulvestrant, and tamoxifen. This is an exciting first step in the development of this drug.” Tamoxifen has been used for more than 40 years as a hormonal therapy to prevent breast cancer and to reduce the risk of recurrence. Goetz and Matthew Ames, PhD, of Mayo Clinic Cancer Center, began their collaboration with the NCI to develop formulations of endoxifen in 2008. In the Phase I study, researchers gave the new formulation of endoxifen daily to 22 women with estrogen receptor-positive breast cancer that was resistant to standard treatments. The drug appeared to be safe up to the highest dosage of 160 milligrams per day. Goetz and his colleagues are currently determining the optimal dose of endoxifen and expect further studies of the drug.

Results from the study were presented at the 2013 San Antonio Breast Cancer Symposium in mid-December.

U of M President Agrees to External Review of Practices Eric Kaler, University of Minnesota president, says he will form an outside panel to review how human subjects are treated during clinical trials at the university. Kaler’s announcement on Dec. 5 followed the U of M Faculty Senate’s passage of a resolution that calls for outside experts to review how the school conducts research on human subjects. The panel will convene almost 10 years after the 2004 death of Dan Markingson, a patient who committed suicide while participating in a clinical drug study at the university. Markingson was mentally ill when he was asked to sign up for the study, and his psychiatrist, Steven Olson, MD, was the principal investigator. Markingson’s mother says she complained to the university repeatedly that her son’s condition was getting worse and that she feared he would kill himself. In October of this year, a group of bioethicists from around the world wrote to the Faculty Senate, which Kaler chairs, asking for an outside investigation of the case. They raised several concerns, including a Minnesota Board of Social Work investigation and a lawsuit filed against the university by Markingson’s mother. Then, on Dec. 5, a friend of the Markingson family delivered a petition with almost 3,500 signatures to Gov. Mark Dayton’s office, requesting “an external panel of experts to investigate ethical wrongdoing in psychiatric research at the University of Minnesota, including the circumstances surrounding Dan’s death.” Kaler says he welcomes the review and that it would put to rest doubts over how the U of M handles human subjects during clinical trials. “Let’s look at what we’re doing now, currently. I have a great deal of confidence in what we’re doing, and I think an external validation of that—which is Capsules to page 6

R e q u e s t f o R n o m i n at i o n s

2014 HealtH care arcHitecture & Design

Seeking Exceptionally Designed Health Facilities in Minnesota Nomination Closing: Friday, May 9, 2014 Publication Date: June 2014

Minnesota Physician announces our annual health Care architecture & Design honor roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. the nominees selected for the honor roll will be featured in the June 2014 edition of Minnesota Physician, the region’s most widely read medical publication. eligible facilities include any construction designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. interiors, exteriors, expansions, renovations and new structures are all eligible. in order to qualify for the nomination, the facility must have been designed, built or renovated since January 1, 2013. it also must be located within Minnesota (or near the state border within Wisconsin, north Dakota, south Dakota or iowa). color photographs are required. if you would like to nominate a facility, please fill out the nomination form below and submit the form, three to eight 300 DPi resolution color digital photographs, and a brief project description (150-250 words) by Friday, May 9, 2014. For more information, call (612) 728-8600. 2014 health caRe aRchitectuRe & design honoR Roll nomination foRm FaCility NaMe tyPe oF FaCility loCatioN owNershiP orgaNizatioN owNer CoNtaCt NaMe and PhoNe owNer aDDress City, state, ziP arChiteCt/iNterior DesigN FirM arChiteCt CoNtaCt NaMe and PhoNe arChiteCt aDDress City, state, ziP eNgiNeer CoNtraCtor CoMPletioN Date total Cost square Feet NuMber oF Color PhotograPhs eNCloseD (Note: please include a caption for each photo) NoMiNatioNs ProCeDure: submit the information on this form, along with a project description (150-250 words), and 300 dpi resolution color 8" x 10" digital photographs (no more than eight) to amarlow@mppub.com For further information, please phone (612) 728-8600, fax (612) 728-8601 or e-mail comments@mppub.com

January 2014 Minnesota Physician

Capsules from page 5 what I expect it to be—will close the chapters,” he said. Kaler will form the review panel in early 2014. “I’ll consult with experts on campus to identify external people who have the expertise necessary to make an evaluation,” he said. “We’ll invite them to come review what we do and we’ll report the result.”

Mayo Clinic Plans $72 Million Expansion And Renovation Mayo Clinic is finalizing plans for two major expansion and renovation projects that are set to begin in the second quarter of 2014. The health care system plans to add five floors to the Mary Brigh East Building and renovate the third floor of the Domitilla Building at St. Mary’s Hospital in Rochester. Currently, Mayo is finishing construction on the existing four floors of the Mary Brigh East Building as part of a surgery

expansion project. The five floors that will be added to the building include three floors of patient care units, with each floor containing 23 private rooms. Ceiling lifts and private bathrooms and showers will be installed in each room. The top two floors will be used for shell space and mechanical infrastructure. In total, the expansion will create an additional 131,800 square feet of finished space. The three floors of patient care units will replace the 73 inpatient beds currently in the Joseph Building, which officials say has become outdated. Once the Mary Brigh East Building expansion is complete, the Joseph Building will be used to provide clinical support space for hospital-based staff. The Domitilla Building currently houses one of the largest adult general care inpatient units at Mayo Clinic. Renovations to the building, including installing ceiling lifts and adding bathrooms to private patient rooms, are meant to increase patient comfort and safety. Mayo Clinic officials say they

expect the projects to be completed by early 2016. The total budget is $72.1 million.

Quello Clinic Gets New Name in 2014 Quello Clinic locations have changed their name to Allina Health as of Jan. 1. The reason for the name change is to more clearly link Quello Clinic with Allina Health. Quello has been a part of Allina since 2008. Officials say that clinic staff, providers, and phone numbers will remain the same. Clinics in Lakeville, Burnsville, Chanhassen, Edina, and Savage are implementing the name change.

Partnership for Patients Funding Awarded to Minnesota The Minnesota Hospital Association (MHA) Hospital Engagement Network (HEN) has been awarded a third year of funding for the Partnership for Patients

contract from the Centers for Medicare and Medicaid Services (CMS), allowing it to continue work on the project through December 2014. The Partnership is aimed at helping Minnesota hospitals reach health care goals of reducing hospital-acquired conditions by 40 percent and readmissions by 20 percent. Fifty-eight participating hospitals have met the benchmark on three or more hospital-acquired conditions. MHA said in a press release that it plans to specifically focus on addressing catheter-associated urinary tract infections (CAUTI) readmissions. CAUTIs are the most common kind of health-care associated infection, and rates in Minnesota are higher than the national average. MHA will also focus on increasing engagement with patients and families. It has formed a Patient and Family Advisory Committee to assist hospitals with this at a statewide level.

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Minnesota Physician January 2014

Medicus Bjorn Engstrom, MD, has joined Consulting Radiologists, Ltd., Twin Cities, as a board-certified radiologist specializing in interventional radiology. Engstrom graduated from Dartmouth Medical School in Lebanon, N.H. He completed a residency and fellowship in vascular and interventional radiology at Duke University Medical Center in Durham, N.C. Anna Hatchett, MD, board-certified in surgery and surgical critical care, has joined Essentia Health—Duluth Clinic as a trauma surgeon. She earned her medical degree from Case Western Reserve University, Cleveland; completed a general surgery residency at University Hospitals Case Medical Center, Cleveland; and a fellowship in surgical critical care at East Carolina University in Greenville, N.C. Peter Kebbekus, MD, a Anna Hatchett, hematologist/oncologist board-certified in MD internal medicine, has joined the Essentia Health Cancer Center in Duluth. He earned a medical degree from the University of Minnesota and served a residency in internal medicine and a fellowship in hematology and oncology at Dartmouth Hitchcock Medical Center, Lebanon, N.H. Meysam Kebriaei, MD, board-eligible in neurosurgery and pediatric neurosurgery, has joined Children’s Hospitals and Clinics of Minnesota. He completed medical school and a neurosurgery residency at the University of Nebraska Medical Center, Omaha, and a fellowship in pediatric neurosurgery at Emory University, Atlanta. Chad Richardson, MD, has been named director Meysam Kebriaei, of trauma services at Hennepin County Medical Center (HCMC); MD he had served as assistant director since 2008. Richardson graduated from the University of Minnesota Medical School, completed a surgery residency and a fellowship in surgical critical care at HCMC, and a fellowship in renal transplant at the Karolinska Institute, Stockholm. Joining HCMC’s obstetrics and gynecology staff is Ericka Stone, Chad Richardson, MD MD, who earned a medical degree from Southern Illinois University School of Medicine, Springfield, and completed an obstetrics and gynecology residency at Louisiana State University, New Orleans. Joining HCMC’s nephrology department is Connie Wang, MD, who graduated from BeiEricka Stone, MD jing Medical University. Wang completed an internal medicine residency at Michigan State University, East Lansing, and fellowship training in nephrology at Johns Hopkins University Medical Connie Wang, MD Center, Baltimore. Previously, Wang was on the faculty at University of Kansas, Kansas City.

Richard Sharp, PhD

Richard Sharp, PhD, is the director of the newly formed Mayo Clinic Biomedical Ethics Program, intended to help researchers, physicians, and patients address ethical questions raised by advances in biology and medicine. The program includes bioethics research, institutional service and consultation, education, programming, and outreach. Sharp previously served as Cleveland Clinic’s director of bioethics research and co-director of the Center for Genetic Research Ethics and Law at Case Western Reserve University, Cleveland.

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Interview

Working to improve health care delivery

Cindy Firkins Smith, MD Minnesota Medical Association

Cindy Firkins Smith, MD, is the current president of the Minnesota Medical Association. She is a dermatologist at the Affiliated Community Medical Centers in Willmar and a clinical professor at the University of Minnesota, where she also graduated from medical school. Smith has written and testified on legislation to ensure the safety of patients undergoing laser procedures and to prevent minors from using tanning booths. She wears sunscreen every day and encourages everyone else to do the same.



What effect do you see health insurance exchanges having on medical practice?



How do you see accountable care organizations (ACOs) impacting health care delivery?

primary care physicians has failed to acknowledge many of their core strengths: their ability to support prevention, their expertise in coordinatExchanges will mean that thousands more Minne- ing the care for patients with complex problems, sotans will have access to health coverage through and their skill in helping patients understand their the private market and make it easier to shop for various treatment plans and care goals. The cona “healthier” set of insurance benefits. Physicians sequences of this failure in how care is paid for will benefit from having more patients covered are widely apparby private ent: confusion and insurance and frustration among seeking care. patients, lots of Collaborative care delivery ensures Physicians will fragmentation, and see improved that patients receive safe, high quality duplication of payment for serservices. New ways care from the practitioner who is best vices and have of paying for and less concern supporting the core educated and trained to provide it. about bad debt strengths of primaand collections. ry care are needed, But it will and models like the also be important to monitor the types of prodhealth care home begin to do just that by paying ucts and the associated networks of providers for care coordination services that are not otherthat are sold on the exchanges to ensure adequate wise recognized. access to care for Minnesota patients. We can When I talk to primary care physicians inexpect products with more narrow networks but volved in these models, they are generally thrilled. if that is the only cost-saving approach advanced This excitement and reinvigoration in how priby health plans then the exchanges will not have mary care can and should be practiced may help accomplished anything in terms of supporting im- encourage medical students to select careers in proved health care value. The Minnesota Medical primary care. The projected shortage of primary Association (MMA) is supportive—but cautious— care physicians here and across the country is about the role of MNsure to actively encourage the something that all physicians—all Minnesotans— development of products that support health and should be concerned about. Making primary care improve efficiencies. practice more attractive clinically and financially

ACOs are an attempt to change the model by giving health care providers more flexibility in how to deliver care by rewarding—and holding providers responsible for achieving—improvements in patients’ health. The jury, of course, is still out. Although ACOs are unlikely to be the silver bullet to all that ails our health care system, they should be tested and examined and we should all be open to continuously working to improve care delivery.



How are payment reforms and the shortage of primary care providers likely to intersect?

Historically, the payment for care provided by

Minnesota Physician January 2014

is essential to building a viable primary care physician supply in the future.



What do you see as the upside and downside of allowing allied providers such as nurses and PAs to open independent clinics, prescribe medication, and be eligible for insurance reimbursement?

The MMA supports physician-led collaborative care teams. High quality, patient-centered care is best advanced when physicians and other health care providers practice as part of a collaborative team. Collaborative care delivery—not independent APRN (advanced practice registered nurse) practice—ensures that patients receive safe, high quality care from the practitioner who is best educated and trained to provide it. While there is a projected shortage of physicians, substituting APRNs for physicians is not the answer. Patients’

access to care in rural and underserved areas is a serious concern. However, no data exist to show that if laws are changed to authorize APRN independent practice that more APRNs will go to rural areas.



What can you tell us about the efforts to repeal the Medicare Sustainable Growth Rate (SGR)?

The MMA worked closely with the AMA to petition Congress to repeal SGR in 2013. In November 2013, a group of our members who were in Washington, D.C., to attend an AMA meeting met with Sen. Al Franken, Rep. Erik Paulsen, Rep. Tim Walz, and staff from Sen. Amy Klobuchar’s, Rep. John Kline’s, and Rep. Betty McCollum’s offices to gain their support. This is the most optimistic we’ve been on SGR for years. The current proposal has bipartisan, bicameral support and the leaders we met with in Washington are very receptive. However, the big question on everyone’s minds is how we are going to pay for it.



What are some issues unique to practice in greater Minnesota that metro area doctors may not be aware of?

Rural practice is extraordinarily fulfilling. But practicing in a rural setting also creates

12th Annual

challenges. We often struggle to recruit physicians who have ties to urban centers and are concerned about geographical isolation or the demands of a very busy rural practice and often more arduous call schedule. Also in rural Minnesota, a greater percentage of our patients are covered by government programs—Medicare, MinnesotaCare and Medical Assistance—and we struggle financially with the lower reimbursement afforded by these insurers.



What should physicians know about the work being done on the issue of physician safety?

Many of our members have started to talk about what we can do to create safeguards against future incidents. We would alert physicians to list their clinic address and not their home address with the Board of Medical Practice. Also, clinics should have plans in place on how to deal with difficult patients and family members. For the past six months, MMA staff have been part of a new workgroup formed by the Minnesota Department of Health that is examining issues related to violence prevention in health care workplaces. Their task is to develop tools to help health care organizations assess risk of violence and prevent harm through education and preparedness.



What would you like to tell physicians about other work the MMA is doing?

We are working on a number of issues that directly affect each practice in Minnesota. For example, prior authorization of medications is one of the many administrative burdens that plague physicians. We have retained a physician to explore this issue in-depth and meet with other physicians and clinic administrators to explore solutions. We have also formed a task force to study prescription opioid abuse, addiction, and misuse. The task force is working with representatives from ICSI to develop standardized, evidence-based guidelines that doctors can use in prescribing opioids for acute care. We also formed a task force to address the primary care physician workforce shortage and recently held a summit with more than 50 physicians to explore strategies to fix this issue. We have a task force committed to the Choosing Wisely campaign. We also are busy preparing for the 2014 legislative session. An issue that we haven’t discussed that we will be keeping an eye on at the capitol is e-cigarettes. We will oppose their growth just like we’ve fought against tobacco.

PREPAREDNESS PRACTICUM 2014

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Mild traumatic brain injury from cover

Return-to-sport guidelines For individuals with symptoms of concussion, return to sport and physical activity must follow a step-wise approach:

difficulty with thinking and memory, and visual changes. But more unusual symptoms, such as personality changes, depression or other mood changes, incoordination, fatigue, and loss of simple abilities (e.g., adding or subtracting

direct relation to technology. With the rise of technology have come advances in our modes of travel, weapons of war, recreational activities, and sheer human abilities that put us at greater risk of concussion than at any other time in history.

In the military, more than half of all combat deaths include mTBI and approximately two-thirds of all combat injuries involve head injury.

1. Complete rest until asymptomatic 2. Light aerobic exercise 3. Sport-specific training 4. Non-contact training 5. Contact allowed 6. Return to competition Yet, throughout history and to the present, the various symptoms related to mild traumatic brain injury have remained somewhat mysterious and unpredictable. There are the most common symptoms, which include headache, dizziness or lightheadedness,

numbers), can be overlooked in an exam. The management of brain-injured patients is still based only loosely on scientific evidence, though it has evolved rapidly over the past 20 years. Mild traumatic brain injury is a potential consequence of simple physical mishaps but also occurs between individuals—for example, in sport or in warfare. The frequency and severity of head injury has a

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Minnesota Physician January 2014

Indeed, the Institute of Medicine conducted a study on this subject last year. [The report on its findings and recommendations, “Sports-Related Concussions in Youth: Improving the Science, Changing the Culture,” may be downloaded at www. iom.edu/concussion.] The prevalence of concussion is staggering. Though study results vary, an estimated 2 million to 3.8 million concussions occur annually in the United States. Each year, 50,000 people will die as a result of their injuries; more than 500,000 will require hospitalization; and nearly 100,000 will have permanent injuries. The cost of mTBIs has been estimated at nearly $17 billion per year in the U.S., where there are currently more than 5 million concussion survivors. This article reviews our current understanding of the mechanism of head injury, associated symptoms, examination, and management of mild traumatic brain injury. Mechanism of injury Concussion is not always a result of blunt trauma to the head. Concussive forces can be indirect and related to acceleration-deceleration injury, distant explosive forces, and even chemical injury. Any insult to the brain that affects biomechanical functioning can be classified as mild traumatic brain injury. There can be evidence of superficial contusion or skull fracture, but far more commonly there is little or no evidence of external injury.

Examination and immediate imaging with CT or MRI can reveal intracranial changes, including contusion, sometimes with coup contrecoup injury (i.e., evidence of brain injury in the exact opposite region from the site of the trauma), intracranial hemorrhage, or diffuse axonal injury, likely from acceleration-deceleration forces. These changes lead to parenchymal (brain tissue) damage with resulting impairment of cerebral blood flow in metabolism. Ensuing changes in brain chemistry lead to a cascade of events that affect cell membrane permeability, free radical formation, and inflammation. Fluid leaking out of the cells causes edema. Individuals who have a history of previous mTBI or neck injury are more likely to suffer concussion and to have more severe symptoms with a second mTBI. The “second impact syndrome” is a well-documented phenomenon, describing the more severe compounding and lasting symptoms of a second mTBI before a first has healed. Conditions in which certain groups are more prone to mTBI have not been defined, but certain trends have been noted, especially in sports-related concussion. For example, high school athletes are 30 percent to 50 percent less likely than college students to sustain a concussion in their sport of choice. However, younger children and teenagers are more likely to have prolonged symptoms. High school girls who play soccer or basketball are more prone to concussion than boys in the same sports and to have more prolonged symptoms than their male counterparts. Though participants in American football and Australian rugby are considered at greatest risk of concussion compared to other sports, boxing, martial arts, skiing, or snowboarding all carry significant risk. In the military, more than half of all combat deaths include mTBI and approximately two-thirds of all combat injuries involve head injury.

Table 1. Comparison of grading systems developed to determine the severity of concussion. Grading Systems Cantu Grade 1 concussion

Grade 2

Grade 3

• No loss of consciousness

• Loss of consciousness

• Amnesia < 30 minutes

• Amnesia > 30 minutes

• Amnesia > 24 hours

Colorado Grade 1 concussion

Grade 2

Grade 3

• No loss of consciousness

• No amnesia

• Amnesia

• Confusion

• Loss of consciousness

American Academy of Neurology Grade 1 concussion

Grade 2

Grade 3

• No loss of consciousness

• Concussive symptoms < 15 minutes

• Concussive symptoms > 15 minutes

Evaluating/diagnosing concussion Recognition of concussion has improved dramatically over the past two decades, with increased awareness across the community, athletes and their coaches, and, of course, the military.

provided us with a variety of functional tests to aid in diagnosing concussion. These include, but are not limited to, electroencephalography (EEG), CT scanning, and MRI; and more advanced tests, such as functional MRI (fMRI) and diffusion tensor MRI.

Immediate evaluation in the field includes a quick visual assessment of the injured person, including the individual’s alertness and responsiveness and presence of external head injury, followed by measures of performance on a set of physical and cognitive tasks, often compared to previously established baseline functioning or established normative values.

The severity of concussion has been determined by various methods. Three popular tools include those developed by the American Academy of Neurology, the Cantu Grading System, and the Colorado Grading System, among others (see Table 1). There is agreement across the board that loss of consciousness for any period of time leads to the classification of a most severe (Grade 3) event and is associated with prolonged symptomatology and less favorable outcome overall. According to the American Academy of Neurology guidelines, permanent brain injury can occur with either a Grade 2 or Grade 3 concussion, such as when a person has extended loss of consciousness or undue persistence of symptoms.

Common tests utilized include ImPACT (Immediate Post Concussion Assessment and Cognitive Testing), SCAT2 (Sport Concussion Assessment Tool 2), and C3 Application (an iPad-adapted program incorporating information from ImPACT and SCAT2). In addition, physical assessment testing compiles information from any other testing and incorporates simple and surprisingly telling measures, such as the drop test (in which the patient attempts to catch a dollar bill immediately after the examiner lets it go, before it falls through the patient’s fingers) and the BESS (Balance Error Scoring System), which measures balance with different foot positions. Current technology has

• Loss of consciousness

For the more severely injured person (i.e., Grade 3 concussion), respiratory and circulatory stability must first be achieved. If the patient remains severely affected or unconscious and hospitalization is required, various therapeutic

options can be considered to stabilize the injured person. Hypothermia or normothermia can be employed as protective measures. Such therapy is still controversial to some degree, but patients with elevated intracranial pressure as a result

Mild traumatic brain injury to page 38

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January 2014 Minnesota Physician

Session or “unsession”? from cover

A budget surplus The November 2013 economic forecast showed a $1.08 billion surplus, which was largely unexpected by many political observers. That number may increase or decrease slightly when the next economic forecast is released in late February. Dayton has stated that if the forecast stays at a similar level, he would most assuredly look at repealing some of the business-to-business taxes passed in the 2013 legislative session. According to state law, part of the projected budget surplus will be spent first on repaying obligations from previous sessions. The $1.08 billion surplus will be reduced by $246 million to pay back the remaining portion of the K-12 education shift (used in the 2012 session to balance the state budget); and an additional $15 million will be repaid to the state airports fund. If the upcoming Febru-

ary forecast is similar to the November forecast, the state would still have a surplus of $820 million. Several legislators have suggested repealing part of the taxes passed during the 2013 Legislative session, including

Given the very small window of time for committee hearings, physicians need to keep a very close eye on the dealings at the capitol for any and every possible scenario that could arise at the Legislature. the three business-to-business taxes ($314 million), and implementing some gift tax and federal conformity reforms (likely $241 million). If these reforms are adopted, more than $250 million still remains for the Legislature to potentially put toward budget reserves or spend elsewhere.

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Minnesota Physician January 2014

minimum wage and the size and scope of the capital investment (bonding) bill. It will be very interesting politically to see what budget proposals emerge during the short session and the ultimate decision of how the remainder of the funds are spent or not spent—particularly in the DFL House caucus, where members face a difficult reelection challenge to maintain their majority status in 2014. ACA implementation The health care focus over the last six months has been almost entirely on health insurance exchanges—both the federal exchange based in Washington, D.C., and Minnesota’s statebased health insurance exchange, MNsure. In the first few months of 2014, as insurance exchange coverage and the individual mandate for health insurance coverage take effect, attention will shift from the cost of these new plans to the new coverage options and the reimbursement structures. An important upcoming issue with MNsure is whether its board decides to adopt an “active purchaser” model versus the current “clearinghouse” model. MNsure was originally set up to allow all plans that met the baseline requirements in statute to be offered by MNsure to consumers during the first year. After the first year, the board would be given authority to impose more stringent requirements for plans

to be offered on the exchange. However, one of the concerns that came into prominence during the exchange roll-out, particularly in southeast Minnesota, was the very limited number of plans offered that met even the initial minimum requirements. The question of access, particularly in light of the national debate over people being able to keep their health plans, will be center stage during 2014. Another ACA issue to watch at the federal level is the potential for further delays in some of the major portions of the bill. The employer mandate has already been delayed until 2015, though a delay in the individual mandate is unlikely. In addition, the U.S. Supreme Court has agreed to rule on a case challenging the mandate for most employers to cover contraception (the ACA grants an exemption to certain nonprofit religious organizations, but not to private companies). Although the Supreme Court upheld major portions of the ACA on a close vote two years ago, any opportunity for the court to take a closer look at the law creates the potential for a far-reaching decision. Scope of practice Back at the state level, the list of health care issues on the legislative agenda for 2014 is not nearly as long as it was coming into the 2013 session. However, there may be plenty of opportunities for debate should the Legislature put forward a supplemental Health and Human Services budget. Scope-of-practice issues, which were not addressed in last year’s session, will likely arise in 2014. Every year sees the introduction of a litany of licensing or scope of practice bills involving some form of new licensure or expanded practice for health care or alternative care professionals. One of the major bills involves advanced practice registered nurses (APRNs) and a push for independent practice. Debate between advanced practice nurses and physicians on these

issues goes back many years, but the passage of the Affordable Care Act has renewed the expanded scope-of-practice legislative effort nationally. In Minnesota, APRNs are defined by statute to include nurse practitioners (NPs), clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists (CRNAs). Currently, APRNs are required to practice within a collaborative management relationship with a physician and to have a written prescribing agreement in order to maintain prescriptive authority. Legislation introduced in Minnesota’s 2013 session, modeled after the APRN Consensus Model, would have eliminated both the requirement for collaborative practice between an APRN and a physician and the requirement for a written prescribing agreement between the two groups for all scheduled drugs. Nationally, only 16 of the 50 states allow for nurse practi-

tioners to practice completely independent of a physician; the other 34 states require some

to advance legislation in 2014 on expanded scope of practice. Some of these groups have been

The Affordable Care Act has renewed the expanded scope-of-practice legislative effort nationally. form of physician involvement, ranging from collaboration with a physician to direct supervision by a physician. Only Nevada has passed legislation allowing for independent practice by nurse practitioners, but that state’s law requires NPs to have at least two years of experience before setting up their own practice. Other bills in Connecticut, Kentucky, and California were all defeated in the past year. The Pennsylvania legislature even went so far as to strengthen the supervision requirements specifically for CRNAs. In addition, chiropractors, surgical technicians, and laboratory technicians are looking

lobbying for expanded licensure for several years, while others will be launching new efforts in the upcoming year. Stay tuned As in every legislative session, there are sure to be plenty of surprises in 2014. In an election year, anything can happen, especially as some legislators view this as their last chance to potentially advance a cause or issue that matters personally to them (or to a constituent). Given the very small window of time for committee hearings, physicians need to keep a very close eye on the dealings at the capitol for any and every possi-

ble scenario that could arise at the Legislature. The best way to ensure that your practice or clinic’s opinion is heard is to contact your state senator or state representative. The state’s website at www. leg.state.mn.us lists contact information for all members of the Minnesota House and Senate and provides up-to-date information on legislation, as well as descriptions of all bills introduced during the legislative session. You can call Senate Information at (651) 296-0504 or House Information at (651) 296-2146 for more information. Contact information for the governor’s office can be found at mn.gov/governor. H. Theodore Grindal, JD, and Nate Mussell, JD, are with the Minneapolis law firm of Lockridge Grindal Nauen PLLP. They provide government relations and legal services for health care providers.

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January 2014 Minnesota Physician

Dermatology

Mohs surgery

he incidence of nonmelanoma skin cancer (NMSC) has been rising dramatically, and more than 3.5 million basal cell carcinomas and squamous cell carcinomas are now diagnosed in the United States every year. Basal cell carcinomas can occur almost anyplace on the body, including areas with no sun exposure such as the axilla, genitals, deep in the ear canal, and under a good head of hair. The most common presentation is a lesion that bleeds and then seems to heal, only to break down and bleed again. Any lesions where bleeding has been reported should be biopsied.

Squamous cell carcinomas, with the exception of genital squamous cell carcinoma, are always found on areas that have had sun exposure. They range from in situ lesions that can be slow growing and asymptomatic, to fast-growing, painful lesions that can double in size within a week. Immunosupressed patients, especially

A treatment option for common skin cancers By Joseph Shaffer, MD

those who have had an organ transplant and people with chronic lymphocytic leukemia, are especially at risk for aggressive tumors.

dure should not be attempted again, as the chance of curing the tumor with a second try is extremely low. Excision with repair is a viable option for many tumors, especially on A variety of treatment opthe trunk and extremities, but tions exist for these tumors, all a larger margin has to be takwith different risk, benefit, and en around the Mohs surgery is extremely safe, tumor to try to make sure it is with a published infection rate of removed in one operation. When less than 1 percent. positive margins occur, further attempts cost profiles. Simple curette should be made to remove and cautery (CC) can treat many thin tumors, but the heal- the tumor. Radiation therapy is an option for inoperable ing may be prolonged and scartumors. It is time consuming, ring unacceptable. If a lesion has significant cost, can cause recurs following CC, the proceside effects, and may have a poor cosmetic outcome, but it is still a good option when others are not feasible.

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Minnesota Physician January 2014

This article discusses Mohs surgery, a method of treatment for skin cancer that offers a very high cure rate (rates of 98 percent to 99 percent are reported), is extremely safe, and maximizes the functional and cosmetic outcomes. What is Mohs surgery? Mohs surgery is named after Frederick Mohs, a general surgeon at the University of Wisconsin who pioneered the procedure in the 1930s. The tissue was prepared in a different way then, by applying a zinc chloride paste; fresh-tissue techniques were developed in the 1950s and have been refined since then. Mohs surgery in its modern format has been performed since the 1970s. In performing surgery to remove a tumor, we are most concerned about the margins and whether the entire tumor has been removed. Tissue excised in the traditional way is cut into sections vertically, much the way a loaf of bread is cut. The tissue slices are then

Who performs Mohs surgery? In Mohs surgery, the physician identifies and removes the tumor, examines the tumor pathology, and repairs/reconstructs the wound area. Many, but not all, of the physicians who perform Mohs surgery have received extensive training in the procedure. Physicians and patients may be unaware of the significant differences in training that Mohs surgeons may have had. The vast majority of Mohs surgeons are trained initially as dermatologists. After residency, they can apply to a one- to twoyear fellowship training program though a competitive matching process. Fellowship-trained surgeons work under close supervision by an experienced Mohs surgeon and undergo extensive supervised training in reconstructive surgery and pathology. Fellows must perform 500 cases during the training and submit research into Mohs surgery for publication. After completing the fellowship, they are eligible to be voted into the American College of Mohs Surgery (www.mohscollege.org). However, many doctors perform Mohs surgery without having undergone this training. They can become members of the American Society for Mohs Surgery (www.mohssurgery. org). To join this society at the highest level, a physician must be a board-certified dermatologist and submit two cases performed for review. At other membership levels in this society, the only requirement is that the physician be board-certified in a medical specialty.

laid on their slide, stained, and examined. In the bread loaf analogy, the margins are the outer crust of the bread. Traditional processing examines only the outer layer at several points, where the tissue was cut. This amounts to less than 5 percent of the true margin. The aim of the Mohs surgeon is to examine and evaluate 100 percent of the tumor margin as the surgery progresses. This is achieved in the way the tumor is removed and prepared in the lab. The tissue is processed in a way that allows the

Figure 1. Reconstruction example: large squamous cell carcinoma in situ removed with Mohs surgery. Left: Defect affects cheek, lower eyelid and approaches the nasal sidewall. Middle: Repair using a cheek rotation flap with a skin graft. Right: Appearance one month after surgery. The patient has a squamous cell carcinoma on the nasal dorsum that needs Mohs.

surgeon to examine the entire outer edge and underneath it. A series of colored inks and surface cuts are used to orient the tissue so that if more tumor is seen, the surgeon can identify where it needs to be removed. The process is repeated until the entire tumor is clear. Once the tumor has been fully removed, the wound can be repaired. Because the Mohs procedure is tissue sparing, the surgeon does not need to start with the larger margins of normal-appearing tissue that a standard excision requires. If the margins are positive, that will be seen during the procedure, and more of the tumor can be excised from that specific area. The examination of fresh tissue in Mohs surgery differs from frozen section histology, which does not examine the entire margin for residual tumor. Importantly, in the Mohs procedure the surgeon is also the pathologist. There are enormous benefits to having seen the clinical lesion and then examining its pathology. When should Mohs surgery be used? Mohs surgery is not the answer for every tumor. The dramatic increase in non-melanoma skin cancer from 1995 to 2009 has been accompanied by a 400 percent increase in use of the Mohs surgery codes, leading to concern about overutilization. Previously, 1 in 10 skin cancers were treated with Mohs; now the ratio is 1 in 4. In response to these concerns, the American Academy of Dermatology (AAD) developed appropriate

use criteria for Mohs surgery and published the criteria in the academy’s journal in October 2012. (The AAD guidelines may be downloaded at www. aad.org/education/appropri ate-use-criteria/mohs-surg ery-auc) The guidelines comprise a decision support tool that selects out characteristics related to the tumor (e.g., type, tumor size, location) and the patient. Based on these factors, the criteria determine whether published evidence indicates that Mohs surgery is appropriate, unproven, or inappropriate. The table on page 19 summarizes the criteria for appropriate use of Mohs. Given that the goals of Mohs surgery are to have a very high cure rate and to conserve tissue, there are some general guidelines for its use: • High-risk areas such as the central face, ears, temples, genitals, hands, shin, feet, and ankles (where there is not much available tissue) are often referred for Mohs. • Tumors with pathologic features that are more aggressive should be treated with Mohs, as subclinical extension is common and can be tracked out using the tissue-mapping process.

noma with Mohs; however, most Mohs surgeons feel there is no advantage to this practice and do not support it. Some Mohs surgeons treat in situ melanoma with Mohs surgery, usually in combination with immunostains, but many Mohs surgeons do not, and instead use traditional excisional surgery to remove these tumors. Reconstruction After the tumor is removed,

the patient has a wound that most often needs repair (see Fig. 1). Mohs surgeons deal daily with complicated nasal and facial reconstruction. In some circumstances, wounds can be left to “heal in.” Although this may be costeffective from the payer point of view, it may create a lot of work for the patient in terms of weeks of daily wound care. Second intention healing is not advisable in people who are immunosuppressed, on blood thinners, diabetic, or unable to comprehend or perform regular wound care. In addition, certain body sites can be very slow to heal and may result in unacceptable scarring or lead to ectropion or eclabium. Trained Mohs surgeons are reconstructive surgeons. Many advanced repairs that have been developed or refined by Mohs surgeons have been adopted by other specialties that also deal with facial wounds.

Mohs to page 19

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• Immunosupressed patients at high risk for aggressive tumors that can grow quickly are good candidates for Mohs. • Mohs is indicated in young patients where tissue conservation is paramount. A small number of Mohs surgeons treat invasive mela-

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Professional update: Pulmonology

Reducing readmissions for COPD

he rate of hospital readmissions for COPD continues to be high; in Minnesota, the aggregate rate in 2009 and 2010 was 12.5 percent for COPD as any cause of readmission. Many patients receive their initial diagnosis of COPD when they are hospitalized with an exacerbation for the first time. They are discharged from the hospital with limited education and self-management skills, so it is not surprising when they are readmitted with a continued exacerbation. Currently, COPD readmission rates are as high as 28 percent at some hospitals in Minnesota. Reducing these rates will require a coordinated, comprehensive approach. There has been little discussion of the critical role of the primary care provider in ensuring a smooth post-hospital course. The patient’s follow-up visit, which should occur within three to seven days after discharge, provides an opportuni-

Primary care follow-up after a hospitalization By Sofia Ali, MD, MPH, and Jill Heins Nesvold, MS

ty to reassess and improve the patient’s COPD management. This article discusses key components of the follow-up visit: • Obtaining the patient’s self-assessment • Obtaining the patient’s pre-exacerbation history • Determining the patient’s current COPD status and providing appropriate

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Minnesota Physician January 2014

treatment • P roviding patient education • Addressing logistical needs and assuring patient safety • Scheduling follow-up appointment/services/referral • Identifying additional opportunities to improve COPD care This article is based on a consensus statement developed by the Minnesota COPD Coalition, administered by the American Lung Association in Minnesota. Since July 2013, nearly 30 health care professionals from various disciplines have contributed their thoughts, experience, and expertise to this consensus statement. It may be downloaded at www. lung.org/associations/states/ minnesota/events-programs/ mn-copd-coalition/tools--re sources/primary-care-followup-after.pdf. Pre-exacerbation history A detailed history of the patient’s condition prior to the exacerbation provides valuable information regarding the triggers and patient’s adherence to and understanding of his or her COPD management plan. In obtaining the history, providers should: Confirm the COPD diagnosis with a pre- and post-bronchodilator spirometry test. Though there is no consensus on the length of time to wait

between an exacerbation and a follow-up spirometry test, four weeks is the minimum recommendation. If symptoms such as persistent cough, elevated temperature, elevated white blood cell count, or severe dyspnea remain, spirometry might be altered by the continued underlying condition. Ask about and address factors that may have precipitated the exacerbation. Medication non-adherence is a preventable cause of exacerbations resulting in hospitalizations. Other common issues include contracted virus, smoking, or poorly controlled comorbidities. Determine the patient’s level of COPD severity and control and the patient’s symptom history prior to the exacerbation. The Global Initiative on Lung Disease (GOLD) released new guidelines in 2011 stressing the importance of assessing the patient’s severity, control, and risk. One of the cornerstones of appropriate COPD care is to have an up-to-date COPD Action Plan for every patient with COPD. Similar to an asthma action plan, a COPD Action Plan is drafted with a health care provider and advises the patient and caregivers on which medications to use daily and what steps to take during an exacerbation. If the patient had a COPD Action Plan, review it and determine whether it was followed during the exacerbation. In addition, assess the patient’s ability to monitor COPD symptoms appropriately and his or her understanding of how to use the COPD Action Plan. Ask whether prednisone or antibiotic therapy started prior to the hospital/ED visit and, if so, whether the primary care provider was contacted prior to the hospitalization. Assess patient-reported albuterol use, ED visits, or hospitalizations prior to this exacerbation. Patient self-assessment One excellent opportunity to gain additional information from a patient quickly is to have the patient complete one or

more assessments while in the waiting room or exam room. Three suggested patient selfassessment tools are the mMRC dyspnea scale; the Adherence Estimator, a three-item tool used to determine the likelihood of medication adherence; and a symptom self-assessment, such as the COPD Assessment Test (CAT). Current status and appropriate treatment In addition to conducting a physical exam, the provider must determine the patient’s current level of COPD severity and disease stage and decide whether that information needs to be changed on the medical record, based on the patient’s recent hospitalization. This is especially important because the COPD severity rating guides appropriate medication therapies. The physician should review the patient’s inpatient medication regimen and initiate new medications that are consistent with the COPD guidelines and reflect the patient’s current disease state, symptoms, and stage. In addition, the physician should provide discontinuation orders, treat comorbid conditions (e.g., ensure that controller/maintenance medication is prescribed and that the patient is taking it); review the patient’s use of prednisone and antibiotics; and assess the patient’s medication adherence and inhaler technique. Finally, influenza and pneumococcal vaccinations should be administered, if needed. Patient education The Chronic Care Model developed by Ed Wagner, MD, director of the MacColl Institute for Healthcare Innovation, and colleagues. It identifies the patient’s understanding of his or her condition and treatment plan as an integral factor in successful control of chronic conditions such as COPD. Providers are encouraged to review the best practices education components listed in the sidebar and to then tailor education to the patient at hand. Ideally, all topics are addressed with patients; however, prioritizing one or two that will help the

patient prevent further exacerbations is recommended. Physicians often have time constraints and can take the opportunity to use other professionals within the clinic to provide patient education. Practices that have a staff person designated to provide COPD education can benefit from a coordinated effort at the time of the follow-up visit. Ideally, the visit would be automatically scheduled as a provider appointment followed by an educator/nurse appointment on the same day. Upon reviewing the patient history, the provider and educator can identify the most important education topics for the visit. Address logistical needs/ Assure patient safety Following a hospitalization for COPD, patients have numerous logistical needs. Taking care of these needs at the post-hospitalization visit reduces the need for time-consuming communications later. Here are a few items that can be addressed during the visit:

Key components of COPD education COPD education should ensure that patients understand the following: 1. Disease progression and symptoms—in terms the patient can understand 2. When and how to take medications (names and purpose, maintenance and reliever medications, correct inhaler technique, possible side effects, cost, and prescription assistance options) 3. How to recognize worsening symptoms, including information on infection prevention and vaccinations 4. What to do if symptoms are worsening—know when follow-up and/or emergency help is needed Numbers 2, 3, and 4 above can be done efficiently while completing or reviewing the COPD Action Plan. 5. How to prevent and manage shortness of breath 6. How smoking affects COPD. The COPD educator should also assess the patient’s readiness to quit smoking

Reducing readmissions for COPD to page 18

• P rescribe/refill medications. • P rescribe a spacer, if needed. • Review the hospital discharge plan. For example, is the patient able to manage at home? What other services does he or she need? Does the patient need assistance with mobility and ADLs? Is in-home health care or a personal care attendant needed? Would the patient benefit from home physical therapy? Does the patient/family know whom to contact with questions or concerns? • Determine who else needs to know of changes (e.g., assisted living, skilled nursing home, etc.). • Refer uninsured and underinsured families to a social worker. • Order home oxygen, oxygen education, and a home oxygen evaluation, if appropriate. Discontinue home oxygen when no longer meeting criteria.

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January 2014 Minnesota Physician

Reducing readmissions for COPD from page 17

• Ensure COPD is added to the patient’s problem list and/or add the patient to the COPD registry. Follow-up At the post-hospitalization visit, schedule an appointment to see the patient again in four to six weeks to address COPD and comorbid conditions and, if necessary, to provide COPD education. If COPD is a new diagnosis for the patient, an appointment should be scheduled to conduct spirometry (after exacerbation resolves) to confirm the diagnosis. Follow-up should also include referrals, as appropriate, to: • A merican Lung Association Better Breathers Club support groups • A merican Lung Association HelpLine at (800) LUNG-USA or (800) 548-8252

• Advance care planning services • COPD educator (e.g., if there is not one at the clinic) • Home health care services

patient care. In reviewing hospital readmissions of COPD patients, please consider the following questions, as part of an effort to identify opportunities for improving COPD care in our

The patient’s understanding of his or her condition and treatment plan is an integral factor in successful control of chronic conditions such as COPD. • Home oxygen services • Pulmonologist • Tobacco cessation program Identify opportunities for improving care Despite providers’ good intentions, sometimes they miss opportunities to provide appropriate COPD care for patients. Improving clinic systems may facilitate better access and

community: • Why did the patient choose the hospital/emergency department? • Was this an appropriate choice? • Did this patient contact your clinic prior to returning to the hospital/emergency department? • What advice did clinic staff give the patient?

• Was a timely appointment offered to the patient? • Did the patient have a COPD Action Plan? • Did this patient/family have the COPD education necessary to help recognize an exacerbation or worsening symptoms in its earlier stages? Resources The American Lung Association in Minnesota and the Minnesota COPD Coalition have developed a variety of trainings, resources, and tools related to COPD for health care professionals. To access these resources, go to http://bit.ly/Ngr qNR. Sofia Ali, MD, MPH, practices family medicine in St. Paul. Jill Heins Nesvold, MS, is director of respiratory health for the American Lung Association in Minnesota, North Dakota, and South Dakota.

Chemical dependency in older adults is hard to recognize We help your patients live healthier lives Alcohol and drug abuse by seniors often goes unnoticed because of isolation and loneliness. As a result, the older adult continues to suffer in silence. Senior Helping Hands is a program of St. Cloud Hospital Recovery Plus and a recognized national leader providing support and services to stop the suffering. Senior Helping Hands serves individuals age 55 and older. Services • Outreach service and consultation with family or concerned persons • Evaluation and assessment for chemical dependency and/or mental health issues completed by qualified professionals • Volunteer support for older adults who are chemically dependent • Support from peer volunteer counselors for older adults with mental health issues Programs Older Adult Chemical Dependency Primary Treatment Program A comprehensive program that involves physical/psychosocial/chemical use assessments performed by professionals trained in chemical dependency and mental health, including a full time Medical Director who is an addictionist. The program provides a slow pace, holistic approach to recovery. Transportation and temporary housing are available if needed.

Contact Us 713 Anderson Ave., St. Cloud, MN 56303 (320) 229-3762 • (800) 742-HELP toll-free www.centracare.com (Search: Senior Helping Hands)

Minnesota Physician January 2014

Mohs from page 15

Safety Mohs surgery is extremely safe, with a published infection rate of less than 1 percent. Mohs is performed on an outpatient basis under local anesthetic, even for extremely large or complicated repairs. A good surgeon can put patients at ease during the procedure. Having the patient awake allows the surgeon to explain what is going on and to educate the patient about other aspects of skin cancer, follow-up, and prevention. One area that has changed in recent years is the management of anticoagulants. In the past, patients were asked to stop these, but now all anticoagulants are continued through the surgery. The risk of intraoperative bleeding, postoperative bruising, or a hematoma is considered less of a concern than the real risk of a thrombotic event such as a stroke, pulmonary embolus, or cardiac event that might result from stopping these medications.

VErDi

Mohs surgery follow-up About half of all patients who have developed a skin cancer will develop another skin cancer within three years. Therefore, an episode of skin cancer cannot be treated simply as an isolated incident. If the patient has not seen a dermatologist since the surgery was performed, it is a good idea to have a dermatologist perform a baseline head-to-toe examination. The dermatologist not only will look for new lesions but also will actively help manage the patient’s sun damage (actinic damage). Depending on the severity of the damage, a variety of procedures, prescriptions, and daily over-the-counter products can help protect the skin going forward and undo past damage. Given the locations where skin cancer can occur, simply evaluating sun-exposed skin will miss many lesions. Having patients fully undress is essential to evaluating their skin and

MAC BE TH

When to use Mohs Tumor factors • Recurrent tumors • Incompletely excised tumors • Poorly demarcated tumors • Large tumors • Tumors on the head or neck • Tumors on the genitals • Tumors on the hand or feet • Tumors on the nail or shins

Patient factors

Aggressive pathology

• Immunosuppressed

• Poorly differentiated SCC

• CLL

• Undifferentiated SCC

• Age <40

• Fibrosing BCC

• High cosmetic requirements

• Infiltrative BCC

• Prior radiation or deep X-ray treatment in the area

• Micronodular BCC

• Basal cell nevus syndrome • Xeroderma pigmentosum

should be a routine part of the annual examination. It is often helpful to frame the discussion of sun damage in terms used to talk about diabetes or hypertension; that is, the disease is not cured but managed. With effective management, we can decrease the number of cancers that the patient will develop in the future.

• Morpheaform BCC • Basosquamous carcinoma • Perineural tumor growth • Keratoacanthoma

We may not eliminate them all, but we can significantly reduce their occurrence with proper management. Joseph Shaffer, MD, is a fellowship-trained Mohs surgeon and president of Dermatology Consultants, St. Paul.

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January 2014 Minnesota Physician

Minnesota health care roundtable

MR. STARNES: What do we mean when we say advance care planning?

DR. RATNER: It’s the process of considering what your options are, learning about your disease, the scenarios that might face a person at an advanced stage of illness or at some point in the future if they developed an illness, and then communicating your preferences and attitudes to someone else. Communication could include a health care directive, living will, or a durable power of attorney for health care: something that names somebody else to make decisions. Or, it could be verbal communication. You’re communicating what you would want if you couldn’t speak for yourself anymore.

About the Roundtable Minnesota Physician Publishing’s 40th Minnesota Health Care Roundtable examined the topic of advance care planning. Five panelists and our moderator met on October 24, 2013, to discuss this topic. The next roundtable, on April 17, 2014, will address post-acute care.

MS. SCHELLER: Advance care planning represents choices a person makes about health care before a health crisis or end of life. It includes appointing an agent and predetermining care options through a health care directive but also encompasses finances, insurance, and other concepts. It is generally best completed when the person’s health is stable. Advance care planning may occur when a person creates a will or similar document and may be discussed with a medical professional, social worker, or attorney. DR. VALDIVIA: There has been evolution from advance directives to advance care planning, which is broader than an advance directive and includes Physician Orders for Life Sustaining Treatment, or POLST. These are specific orders that a physician writes with the patient, and which go with the patient wherever they move. A person’s advance care directive needs to interact with their POLST. DR. STEPHENS: I hope that when this information is needed, it will be available to whatever provider you have or whatever setting you may be in. We’re looking at the possibility of having a registry or a database for information that you want your family and provider to know and your long-term care setting to understand. What is important is that, because this information changes depending on what kind of conversations you’ve had with your provider or your family, we need to be able to reflect those changes any time they occur. MR. STARNES: Another term that we need to define is “end of life.” When is end of life? Do we limit this term to lack of respiration? How should we approach it?

Minnesota Physician January 2014

MS. SCHELLER: End-of-life is a term primarily used in connection with treatment and care decisions made by the patient (or his or her agent) prior to or near the end of life, when faced with a terminal condition or advanced age. It may include a physician’s order related to life-saving measures and is most synonymous with care in the final months and years of life in order to maintain the person’s health, quality of life, and wishes. It inherently carries with it the concept of choice: how a person will live when faced with a health crisis, and, to some extent, how they will die. DR. RATNER: End-of-life care occurs before that last breath, that last heartbeat. Advance care planning is most useful when people are at a point in life when either they have an illness with a trajectory toward dying from that condition or they are in a position where something tragic and unexpected might happen. As soon as you’re an adult you

should have some sort of advance care plan, because you could end up suddenly unable to express your preferences. Then it’s unclear, at least in Minnesota, who gets to make decisions for you. The POLST is intended for decision-making in perhaps the last year of life, but advance care planning should start when you send your kid off to college.

MS. MAGNUSON: There are three different phases of planning. The first one starts at age 18, as Dr. Ratner said. The second one we usually start around age 55. And of course, people should revisit their advance health care directives at least once a decade or after there is a big change in their lives like divorce. The third phase would be when someone has a diagnosis like ALS, diabetes or chronic congestive heart failure. That person needs to consider how that diagnosis is going to change what their health care directive looks like. They need to explore the risks, the benefits, and the burdens of life-sustaining treatment. DR. VALDIVIA: “End of life” is extremely hard to define, in part because different constituents have different views of what it means. If you’re a caregiver caring for a loved one that is debilitated, that might be your definition of the beginning of end of life. A cancer specialist might have a totally different perspective. We’ll probably adopt the view that end of life begins when a patient faces a trajectory that leads to debilitation where they need support and other people to speak for them. DR. O’CONNOR: For some young people, there may be a point where they no longer want their parents or immediate family to speak for them. They may be in a relationship that they view as primary, even if they’re not married. The default will be that their immediate biological family will be sought out for decisions. Young people need to be explicit about what their wishes are in terms of somebody else speaking for them. DR. RATNER: In addition to discussing chronic progressive illnesses in terms of advance care planning, also think of asymptomatic, high-risk illnesses. Let’s say somebody has a large abdominal aortic aneurysm that at any point could rupture and cause a catastrophic event. That person isn’t debilitated but knows they have a ticking time bomb. In scenarios like that, people need to have a clear plan in advance, because when they have that event

Minnesota health care roundtable that may or may not happen, it will be too late for them to express their preferences.

MS. MAGNUSON: Yes, we’re trying to avoid crisis decision-making by using advance care planning. DR. O’CONNOR: High school and college students often have a fascination with death and can hold it at enough distance that it’s a ripe time to begin to talk with them about ethics and the scope of decisions, even if they aren’t going to necessarily make an advanced care plan, so that it’s familiar and comfortable language for them. MR. STARNES: End of life and advance care planning touch several societal flash points that could impede progress in establishing meaningful best practices. What are challenges to getting advance care planning part of mainstream discussion without creating unwanted controversy? MS. SCHELLER: Not all controversy is bad because it can raise awareness, which needs to happen in order to create mainstream discussion. Challenges include not wanting to talk about death; not wanting family discord around who will care for Mom and how to pay for her care; and not understanding the complexity of options and ramifications. DR. VALDIVIA: “Without creating controversy” would be very difficult. I know from talking with health plans that they’re afraid of working with organizations that deal with end of life. Health plans already have a trust factor that’s just below tobacco companies, and once they address end of life they’ll immediately be called on the carpet by policy makers and labeled “death panels.” It’s going to require a gradual, slow shift in society to eliminate stigma around this issue and allow us to have open and honest discussion. DR. RATNER: Something that probably wouldn’t be controversial would be a semi-mandatory proxy designation. When people come into the hospital, sometimes they are asked to name next of kin. Often that information isn’t updated. Perhaps on admission to a health care institution, whether a nursing home or hospital, we should ask, “Do you have a proxy?” We run into a problem when the patient hasn’t appointed anybody to make decisions. MS. MAGNUSON: Families don’t want to talk about it; residents typically do want to talk about it. They want their physi-

cians to bring it up.

MR. STARNES: There’s been comparison of the cost of life in America to that in other countries. What does this data management perspective mean to our discussion? DR. STEPHENS: If we look at the fear people have because of discussions around “How much money is the insurance company going to spend on me in the last 24 hours of my life?” or “What kind of a bill am I going to leave my family at this time when there is truly no purpose to lasting another 24 hours?” The data management part of that for me is that I know there will be a certain percentage of people that will want to have this information available. Another one-third of people won’t want to talk about it. Then there are people who frankly don’t even interact with the concept of death. They’re just floating along and life happens to them. We have to help people understand that if you care about how you are treated at any point in your life, doing advance care planning is something that you should do for yourself. If you care about your family having to make decisions that are hard for them, this is the time to make those decisions and have that information available so that it can be accessed by people who are responsible for your care, and not, as Laura said, as crisis decision-making.

MS. MAGNUSON: Sometimes people change their minds. A family friend with diabetes complications went on dialysis and eventually said, “I can’t do it anymore. It’s too hard on me.” He decided to forgo treatment and died shortly afterward. Even though you want to try treatments, you may change your mind and that’s okay. The point is that he had his wishes carried out. MS. SCHELLER: More and more, discussions regarding end of life relate to costs of care rather than simply patient choice. Medicare rationing, insurance billing practices, physician beliefs as to futility and quality of life, and a perceived finite availability of financial resources are moving the discussion. Data cannot help but be part of the landscape. But we must be careful not to communicate a system defined by patient choice on one hand and reject the choice of reasonable life-sustaining treatment due to costs or management factors on the other. DR. RATNER: Challenges in talking about

Laura Magnuson, MEd, is a learning and devel-

opment specialist with Presbyterian Homes and Services, a nonprofit older-adult services organization. She has more than 13 years’ experience teaching and eight years of experience working with both residents and staff in long-term care, assisted living, and memory care environments. She is a guest lecturer on advance care planning in the nursing and social work programs at Bethel University and mentors new hospice volunteers through Fairview Hospice.

Maggie O’Connor, MD, is a palliative care physi-

cian at Abbott Northwestern Hospital, Minneapolis, and has a particular interest in spirituality as part of the clinician’s role. She also serves as a facilitator with the Sacred Art of Living and Dying Center in Bend, Ore., which presents workshops nationwide that teach caregivers best practices for end of life. These workshops are attended by medical professionals, spiritual directors, and others working with end-of-life concerns, and explore interrelationships among all dimensions of human health and suffering.

Edward Ratner, MD, an internist, geriatrician, and

specialist in hospice and palliative care, has led or co-led multiple research studies related to advance care planning. He serves as graduate school faculty in gerontology and bioethics at the University of Minnesota, where he is responsible for geriatrics and end-of-life care curriculum for the medical school. Ratner sees patients at the Minneapolis Veterans Medical Center and chairs the Minnesota steering committee developing a statewide POLST form (Provider Orders for Life-Sustaining Treatment).

Suzanne M. Scheller, Esq., is a solo practitioner

with Scheller Legal Solutions, LLC, in Champlin, Minn. She practices in the areas of nursing home litigation; elder abuse, neglect, and financial exploitation; Medicare liens; elder law; estate planning; school law; and compliance/risk management. She is a member of working groups designed to improve laws affecting vulnerable adults and is a past chair of the Minnesota State Bar Association Elder Law Section, on which she continues to serve as a member of the governing council.

Cheryl Stephens, PhD, MBA, is the president and CEO of Community Health Information Collaborative (CHIC), Duluth. CHIC’s mission is to provide regional access and utilization of health care information, in part by facilitating collaboration between all regional health-care related entities. Stephens has more than 27 years of experience in senior-level health care administration, with an emphasis on expanding rural capacity. Stephens is a member of the Minnesota eHealth Advisory Committee and the Nationwide Health Information Network Exchange Coordinating Committee. Tomás Valdivia, MD, MS, an internist and medical informaticist with 20-plus years’ executive experience in health care, is co-founder and CEO of Minnesota-based Luminat and Valquist, LLC. Luminat is a preference management system enhancing provider organizations’ end-of-life services. Valquist, LLC, helps provider organizations improve health care delivery. Previously, Valdivia founded Advanced Informatics, a company providing evaluation technology used by health care organizations. As chief medical officer for Definity Health, he led development of consumer activation strategies and services.

A bo ut th e Mo d e r ato r Mike Starnes has been the publisher at Minnesota Physician Publishing since 1986. His duties include the production of MedFax, Minnesota Physician, Employee Benefits Planner, and Minnesota Health Care News; directing the Minnesota Health Care Consumer Association; and hosting the Minnesota Health Care Roundtable.

Editor’s note: Personal issues prevented Suzanne M. Scheller, Esq., from participating on this panel. Her comments were added after the initial edit of the conference transcript. Panelists participate in a three-phase curriculum development survey for every session of the Roundtable, and Ms. Scheller’s active involvement in this process was an important part of this conference. January 2014 Minnesota Physician

Minnesota health care roundtable end of life are presumptions in evaluating quality and certain levels of disability. If you say death represents zero quality of life, while being perfectly healthy, active in your life, and enjoying your family is 100 percent quality of life, what’s the numerical value of being on a ventilator at home and not being able to speak but being with your family and enjoying their company? Is that 1 or 50? You’re still doing the things you enjoy. The point of advance care planning is to think about and communicate your wishes at this point in your life or in the future, based on your experience with others who are sick, at end of life or at various stages of disability. What would you want done when you can’t speak anymore? That scenario isn’t necessarily permanent, but could arise when a person is acutely ill and in the hospital. At that point the doctor asks, should we start dialysis—which might be permanent—or should we not. Saying, “Yes, I would want things done to see how my health changes or to see if I regain the ability to express my preferences” is very different from saying, “I definitely don’t want anything.”

that arises from death. It might be denial on a personal level or it may be supporting your culture and community so that you know that it is going to live beyond you. Should health care providers talk to their patients about POLSTs? Absolutely. Providers should talk about POLSTs with their patients because it’s a medical decision. Until we begin to talk about it, there’s going to be a struggle in our society to do anything about the cost of health care.

MR. STARNES: Let’s talk about what should be included in an advance care directive. Cheryl, do you have some thoughts on that? DR. STEPHENS: A proxy has to be identified, plus having some way for me to write a paragraph that describes the quality of life that I want instead of only having boxes to check for specifics like, “Do you want resuscitation? Do you want no resuscitation?”

The challenge of looking at advance care planning is to improve our return on investment in quality-adjusted life. My current practice is heavily involved with ALS patients, some of whom make choices to not pursue lifelong treatment and others who want everything that can be done. Quality of life is very subjective. Trying to avoid things that people don’t want is the purpose of drafting an advance care plan. We have technology to keep people alive against their will. In the absence of being told not to, we will do everything. You have to opt out of it.

MR. STARNES: Is a fundamental fear of death one challenge to having this become a bigger part of mainstream discussion? MS. SCHELLER: Yes, but the irony is that it is more likely a fundamental fear of living when death is imminent that people don’t want to discuss. That’s exactly where advance care planning and end-of-life planning, particularly through open discussions with family members, may help calm that fear. DR. O’CONNOR: Research found that awareness of death changed people’s decisionmaking. We create a buffer for the anxiety

and legal, then it needs to be followed.

DR. RATNER: To build on the idea of naming the proxy based on trusting that person to carry out your preferences: You have to communicate those preferences in some way, whether it’s additionally in the document, in conversations, or other ways. You also need to tell whoever isn’t named proxy that you want them to defer to the person who is named proxy. Research shows that a fair percentage of the time, an advance care directive isn’t followed as intended, or it’s unclear, or you can’t find it to act on it. Everyone involved understands that there is going to be some ambiguity, unless the scenario that occurs is anticipated—a ruptured aneurysm or ALS-associated respiratory failure—and you can say this is what we’re going to do when this happens. You need to get all the people around the table and openly discuss why they think what they’re thinking, what their motivations are. You can use an ethics committee or people who are interested in facilitating those conflicts, because we’re not going to do away with conflict. We just need good processes when it occurs.

DR. VALDIVIA: Just a couple things I’d add. One is to divide this up into two big chunks. One is the concept of how we help people create their advance care plan or advance directive. Two, how do we enact the plan

As soon as you’re an adult, you should have some sort of advance care plan. Edward Ratner, MD

MS. MAGNUSON: Cheryl’s correct. At the very least, have a proxy who you know will carry out your wishes. A friend’s mom suddenly became critically ill. My friend was her mom’s health care proxy and agreed with her mom’s decisions, but her sister did not. If the mom had named her sister proxy, I’m not confident her sister would have done what her mom wanted. Be sure that you name someone who will actually be able to carry out those decisions. That’s hard for families sometimes, but if it’s written, documented,

that person has created or expressed? Each of those two components is necessary but neither is sufficient by itself. For example, for the high schooler maybe the only thing you really need to know is the proxy. As you move to something more specific and practical, such as if you have ALS, you might not know the time frame, but you know the arc of that disease. It adds layers of complexity to this, but it also recognizes reality. What it means for an 18-year-old going off to college and what it means for somebody that’s 50 and diagnosed with ALS is different.

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Minnesota Physician January 2014

Minnesota health care roundtable MS. SCHELLER: The primary function of an advance care directive is to appoint an agent to make health care decisions should the patient not be able to do so. Inclusion of more specific instructions about cardiopulmonary resuscitation, intubation, antibiotic use, and other treatments should be used with caution, even when faced with a terminal condition. That’s because a patient often cannot predict the circumstances that may cause him or her to need treatment, nor future breakthroughs in treatment. Appointing an agent who can filter the specific circumstances along with the patient’s wishes is the best option for the patient rather than having specific instructions that cannot account for various factors accompanying a health event. Of course, if a patient feels strongly that certain treatments be given or not, the directive should include those wishes.

MR. STARNES: Any thoughts about what conflicts of interest there might be in putting together an advance care plan?

Have a proxy who you know will carry out your wishes.

MS. SCHELLER: Medical providers who proactively and systematically prepare advance care plans represent a conflict of interest. In addition, people appointed as health care agents or who stand to gain financially from a person’s health choices should not draft health care directives.

doesn’t have a conflict of interest? If I’m a physician thinking of fee for service, that means I want to do more; if I’m thinking of total cost of care, I want to do less. Or an attorney that wants to revise an advance care directive 15 times and get paid each time. The only way to avoid conflict of interest is to make those conflicts obvious. From a legal standpoint there are guides in place in some states; a family member can’t be a legal witness for an advance care directive. In many states a witness can’t be a health care provider.

DR. O’CONNOR: One piece that’s critical in all professions, particularly medicine, is that of recognizing the professional responsibility and the covenant with patients to put their needs first. This began in the ’80s when health care insurance companies began to have more of a say in what could or could not be done in health care, and physicians were, in a sense, spokespersons for the insurance companies. This needs to be clear to patients. The other piece is that many people are very vulnerable when they are completing an advance care plan. Having the proxy family present in those conversations is very important. MR. STARNES: What factors should determine when a medical professional begins having end-of-life discussions with a patient?

DR. RATNER: An example would be a health insurance program that is financially at risk for your care and helps you fill out your health care directive. You can see how, as an insurance company, they want you to live as short a time as possible after you’re sick and costly. On the other hand, a life insurance company that pays out when you die would have the opposite incentive. Conflicts of interest need to be public and transparent.

DR. O’CONNOR: When a doctor is with a patient who has a serious chronic illness, this topic should begin to come up. It needs to be normalized into interactions, but there are particular red flag moments. You have to have conversation in the hospital, but that’s not the ideal time. If people are at risk of hospitalization, there needs to be conversation ahead of time.

DR. VALDIVIA: I completely agree. Who

If people live in a nontraditional family, there needs to be conversation. If they hold

views that are not typical of their community and they want something that’s different from what would be “normal,” they need to have conversation to begin to make this a document and have this conversation with those who are going to be affected by it.

DR. RATNER: Another kind of marker is when people have an actuarial life expectancy of less than 10 years, and certainly when anyone’s in their mid-80s. The way I approach a brand-new patient is to introduce myself, ask them about themselves, then ask, “How old are you?” Then I ask, “How old do you expect to be, or are you shooting for 100?” Just the answer to that, in an informal, almost joking way, gives me an opening to go into advance care planning later. The reason I use 10 years is that so many of our interventions that we think are important, like diabetes control, have windows of 10-plus years— do something now to get a benefit more than 10 years later. If the person isn’t planning on living that long, that’s actually fairly predictive of how long they will live. You can change the whole care plan. It’s not just about end-of-life care. It can be about routine care now based on their expectations of how long they want to live.

MS. SCHELLER: Ideally, medical professionals should not be the ones beginning end-oflife discussions. It should be discussed by families and nonmedical professionals when not in a crisis mode. Age should not be a mandatory factor but health status should be. End-of-life discussions should also occur when enrolling in Medicare or other health insurance, or when creating an estate plan. MR. STARNES: Thinking of problems with advance care plans, what happens when they exist but they can’t be accessed when they’re needed? Laura, have you seen examples of this? MS. MAGNUSON: If a resident suddenly goes down, staff knows where to find those documents. We require all of our nursing home residents to have a POLST. DR. O’CONNOR: One thing about a POLST is that if the wish is not to be resuscitated, not to be hospitalized, a clear plan needs to be made, just like with an ALS patient who’s inevitably going to run into difficulty with breathing. If staff doesn’t know what to do, they’re going to send the person to the hospital, so a POLST needs to trigger further

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Minnesota health care roundtable planning if the patient’s decision is, “I’m 96. I’ve lived a good life. I don’t want to go back to the hospital.” The difficulty is that someone won’t necessarily qualify for hospice, but there’s got to be a plan.

MS. SCHELLER: Most medical providers should have a system to retrieve the directive or physician’s order. The primary care physician or long-term care provider should proactively ask for such documents to have on file. Sometimes the patient has not provided the document and at times does not remember that they drafted a directive. Prompting by the provider is helpful. I have seen patients handed new directives to fill out without the provider asking if they already have one. DR. VALDIVIA: Statistics show that about half the time an advance care plan exists, the health system isn’t aware of it. And even when there is awareness, the patient’s wishes are followed about half the time. A large trial researched how much an advance care plan influenced care. If I remember right, of roughly 4,000 patients there were about nine cases where researchers felt that someone’s plan significantly influenced care. There is still a huge disconnect on the enactment side. Long-term care may be a setting that’s better prepared for this, but I think, in general, we’re not doing a very good job of (a) being aware that advance care plans exist, and (b) even when we are, changing the way we deliver care to be consistent with people’s wishes.

branching points so that you can create a document specific for a person’s needs.

DR. VALDIVIA: I obviously have a conflict of interest because that’s what Luminat does. One big issue, as Ed articulated beautifully, is that we use paper and pencil to document wishes. Sometimes we do that with a facilitator, and what organizations are finding is that the result of that process is extremely variable in terms of its utility for the actual care team when it comes time to enact someone’s wishes. This is an example of where technology can help us. I don’t believe technology is a silver bullet for this problem. But there are ways to leverage technology that aren’t being utilized. For one thing, can we hire enough people to be facilitators for these conversations? Can we find more efficient ways to facilitate these conversations? Then, how can we make information available when it’s needed rapidly? Can we leverage technology to do that in a way that’s sensitive to the people using the technology?

We need to move away from paper-based systems that can’t be located when they’re needed. The other advantage of an electronic-based form is that it can allow

MS. MAGNUSON: One way to impact how society’s cared for would be to improve coordinating end-of-life care, home care, long-term care providers, hospitals, and physicians. The biggest improvement that can be made in coordinating end-of-life care is the transfer of wishes between settings. One of the biggest complaints in long-term care is, “I filled out this form in the hospital and now I got transferred to the nursing home and they’re having me do it again. ” DR. STEPHENS: One of the most commonly funded studies in the last 12 to 16 months has been on transitions of care. How can we improve flow of information from the hospital to a long-term post-acute care setting and back to that hospital if that patient is readmitted? Many readmissions occur because meds that are prescribed in the hospital are not effectively communicated to the long-term care facility. Flow of information between settings can have immeasurable impact on patient outcomes. DR. RATNER: As we’ve said, the hospital isn’t the right time or place to think about longterm things. The question is, are accountable care organizations going to continue to hire nurses and social workers to add more peo-

Many people do want very aggressive end-of-life care. Maggie O’Connor, MD

DR. RATNER: Here’s a concrete example: I was my mother-in-law’s proxy and we had to make end-of-life decisions. Where’s her health care directive? Her health care system didn’t have it. We had to rush around and find it so that I had authority to enroll her in hospice. The historic model of having a multi-page document that contains a variety of information and is filed somewhere doesn’t work anymore. Patients are mobile; they go from one institution to another. Or, as people increasingly complete their health care directives early, the time lag increases between when the directive is filed and when it might be needed.

the way they’re caring for their patients.

On average, older folks may not have the same predilection for using technology as younger people. How can we use technology in a way that’s easy to use and facilitates conversation?

DR. STEPHENS: I’ve had many conversations with clinical practices and clinicians about whether the electronic medical record (EMR) improves care. Will having an advance directive in a registry assist in final decision-making and assure that your wishes are followed? We have to start someplace. Physicians need to see how the EMR affects

ple as transition coaches? If we had somebody who took care of the patient long term it would make more sense. Evidence for that comes from a study last year that showed that using hospitalists has been very effective at achieving intended outcomes and shortening length of stay, but not at saving money. What the study found was that everything we saved in terms of getting somebody out of the hospital, we lost in terms of rehospitalizations, often from nursing homes. Abbott Northwestern Hospital has a

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Minnesota Physician January 2014

Minnesota health care roundtable project that hires coaches solely to help people manage chronic illness. They weren’t trained as nurses or health professionals; they were trained to help people manage their issues long term. The study showed that having somebody who cares for you over time made a big difference. Thinking how we’re going to develop that one-to-one relationship across care settings might be part of the solution.

MS. MAGNUSON: That’s because, as Dr. Ratner says, people in that care provider role tend to focus on nonmedical issues: what’s important to that patient right now, and patients like that. DR. STEPHENS: A project that’s coming is the State Innovation Model. The state is going to be developing accountable communities for health. The concept is that the patient’s care is not just medical—it also contains social determinants. Can they get to an appointment? Can they feed themselves or afford to buy food? We’re looking at all of the aspects of the patient rather than just their disease state. It will be interesting to see if this patient-centered, longitudinal view helps. MR. STARNES: Maggie, what positives and negatives does hospice care bring to this discussion? DR. O’CONNOR: Hospice care is a wonderful idea. The challenge is when you can access it. You have to be at that point where you don’t want to come back into the hospital, you don’t want IV antibiotics for pneumonia, you don’t want aggressive treatment. Part of that hurdle is, are you ready to die? First of all, most people who are of sound mind don’t want to die. They may know and accept that they’re dying; they’re not saying they want to do it faster. Secondly, there are existential and spiritual issues. People need to make that whole psychospiritual transition to embrace that the best way to live is to accept that they are dying and back off from any treatment beyond comfort. Hospice is a very good model of care for people with terminal illness but it is under incredible financial pressure. Access to hospice has become limited. Hospice has to be very careful about who to accept because the per diem has been flat or reduced, and good hospice care costs a lot.

MS. SCHELLER: The positive thing about hospice is that people are facing the reality of death and are more apt to engage in

discussion about planning. They have better clarity about what heroic measures they may or may not want to sustain life. A negative aspect is that medical diagnosis, a person’s will to live, and other factors make the determination of hospice an inexact science. The person may plan for one eventuality that never happens.

that might enable people to get hospice care.

don’t have the ability to do hospice for a person who has a year and a half to live, or for a child with the progressive neurological disease who may live to age 5 or 10. They’re not eligible for hospice in that 6-month window.

Some care management team members have to be from the patient’s background. That seems like it would add expense. But if our family’s involved in our care, they’ll know our culture and how we expect things to be done. From the technology point of view, patient records need to include more than just clinical information. Otherwise, we lose our psychological sensitivity to the patient.

MR. STARNES: How does the fact that people have a wide range of different cultural values affect end of life?

DR. VALDIVIA: We have to recognize biases we have as a system and as individuals. Having cared for folks from cultural backPerhaps the biggest negative is the inability grounds different from mine, I know how to provide curative treatment by definition widely the care that they want for their loved of being on hospice. ones at end This is one reason of life varies. People who stand to gain palliative care needs Some don’t to grow. My mothfinancially from a person’s want you in the er passed away in room. Some health choices should not hospice and would don’t want draft health care directives. likely have chosen certain things palliative care and done; others Suzanne M. Scheller, Esq. continued treatment want everyafter a short break thing done, had supports for and it stems palliative care been at all similar to hospice. from their beliefs and culture. Language barriers are something where technology DR. RATNER: I referred a patient with ALS can help. Some examples of technology read to hospice, and the hospice said, “We don’t an advance directive to you and give you an think he’s eligible.” Medicare guidelines, opportunity to speak what your wishes are, which other insurance companies follow, rather than you typing your wishes. say that you can only enroll in hospice if you meet certain criteria. Medicare says that DR. STEPHENS: How these considerations can every hospice program must meet a very be built into electronic health records comes detailed set of specifications. It’s one-sizefrom what Tom said about biases. Within fits-all, but patients vary. a care management team, you have to have culturally competent people. When I lived We have neither an insurance model nor a program model, outside of the hospital, where in Arizona I got to know quite a few Navajo individuals who had a completely different we have palliative care programs that vary concept of what life was at the end than I had. across settings. But in the community, we

We have an access issue because we set out an insurance program model that is exactly like this, and then we can’t offer it to everybody because it’s either too complex or too expensive or we just decided that we needed to limit it inappropriately. If you’re a hospice program paid a certain amount per day and you have a patient who’s costing two to three times that, a small program can’t accept not just the risk but the known losses on individual patients. In terms of improving, there is talk about some sort of case-mix adjustment or less money in the middle months of hospice so that we can enroll more people eventually. Those are some of the programmatic models

MS. SCHELLER: We need to better understand cultural differences in order to address barriers to end-of-life care. One example is that many older residents who are native English speakers simply cannot hear well enough to comprehend staff that aren’t native English speakers. Both parties suffer. DR. RATNER: Each person has their own microculture. Cross-generational issues can sometimes be greater than issues of religion, gender, race, or country of origin. When I

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January 2014 Minnesota Physician

Minnesota health care roundtable teach medical students about the elderly, I say a person who’s 70 years older than you represents a different culture, so don’t make assumptions about them. The VA, as essentially a single-payer system, has done many things for a number of years that other kinds of health care organizations are starting to do. For example, the VA has had inpatient palliative care units so that we don’t have to send people out of the hospital for the last days of life. And if you’re seriously ill and a vet, you can get care. If, as a society, we say, “Gee, should we be doing so much better for vets than we are for other people?” that might move us toward trying to replicate those same policies for other populations.

DR. VALDIVIA: If you honor people’s wishes for less intervention, for being at home, for not dying in the hospital, you substantially reduce the cost of care that gets delivered. In this case, there is a strong argument to be made where costs and the individual’s wishes align. If we don’t address the cost of end of life, we won’t have money to do anything else because of the coming baby boomer generation that is going to face end-of-life. About 30 percent of Medicare dollars are spent during the last year of life. DR. O’CONNOR: A book by Amanda Bennett proposes that we need to support the person who says, for whatever reason, “I know I could do chemotherapy, but I’m going to step away from it.” There needs to be a very broad conversation about that issue. DR. VALDIVIA: We have a culture that’s always focused on intervention. We have to address that culture, probably going all the way to whom we select for nursing and medical school, and then how we train. The extent of my training was a resident telling me, “Here’s how you have a conversation about DNR/DNI: ‘Do you want a breathing tube? Do you want someone to push on your chest if your heart stops?’” That was it. MS. MAGNUSON: From a long-term care perspective, when death becomes hidden rather than understood as natural and inevitable, tension results between policies that focus on increasing independence and policies that emphasize providing supportive comfort care for residents. There’s such a focus on rehab and staying well, even in long-term care; the conversation really isn’t about how we can provide comfort care.

MR. STARNES: Perhaps some of the change will come from a grassroots level and from patients themselves. If we’re going to expand public education and engagement around end of life what are the best ways that can happen? MS. SCHELLER: More stories are needed from patients and their families so others can learn the impact of care decisions and possible pitfalls that could be avoided with planning. DR. RATNER: It comes down to having recognizable people talk about these things, the same way we changed cancer and adoption from being taboo to something that people could talk about. Health care providers need to depend on tools that we’re not used to working with, like television and other media, to try to get the word out. DR. O’CONNOR: Faith communities could be powerful, especially for cultures other than mainstream American culture. MS. MAGNUSON: A lot of faith communities are hosting Honoring Choices and advance care planning sessions. DR. RATNER: There is the Death Cafe. I haven’t visited one, but it’s an informal dis-

don’t want this to happen to me,” it’s going to become more apparent that it’s a part of what you do for health care. The other difference that we have now is the level of openness. It’s amazing when I think of my younger friends putting information on Facebook. My word! They’ll be able to talk about anything by the time they’re my age.

DR. STEPHENS: It’s imperative that, since we are living in this world where everybody knows everything about everybody because it’s all over the Internet anyway, why not use it to our advantage and make sure that our care at our end of life is what we want it to be. That’s what data should be for. MR. STARNES: What are the most important things that can be done to improve end-of-life care? Do we need a new kind of professional to be part of the health-care delivery system? MS. MAGNUSON: A lot of other organizations have advance care planning facilitators who are trained to have these conversations. That may be a really good start. DR. VALDIVIA: Absolutely. Some of it is going to be how we improve connectedness through technology. My generation doesn’t think of technology as facilitating connectedness, but for my kids and the generation in between, it’s almost the de facto way of connecting around these issues. The other thing I was thinking is that we’ve talked

Statistics show that about half the time an advance care plan exists, the health system isn’t aware of it. Tomás Valdivia, MD, MS

cussion among people who are not dying but who get together to talk about death in a mutual support model. It’s like a book club.

DR. VALDIVIA: Stories are the way we’ll instruct and engage broader swaths of the community: compelling stories that make you recognize this is an important issue. MS. MAGNUSON: As more and more people say, “I had to do this for my mom and I don’t want to have to do it for anybody else or I

about laypeople: We cannot keep adding people to the care team. Allina has been working on a layperson model called LifeCourse. This involves a layperson interacting with patients over a longer period of time near end of life, maybe for years. Something that struck me is that our solutions and approaches are embryonic. We’ve tried a few things in advance care planning but there isn’t a gold standard. That means there are opportunities to try things.

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Minnesota health care roundtable DR. RATNER: It’s not about health care professionals; it’s the question of, “How are we going to change society to make this work better?” A big challenge is to make this easier for families. Maybe that means improving school curriculum so that a basic competency is how to care for somebody at the end of life. Maybe it’s practical skills, like how to transfer somebody from a bed to a wheelchair. We need to create a broader pool of people who can care within their families, not just highly trained professionals. Training nonprofessionals to be coaches, but also training family to do bedside care, will be a major shift that is inevitable due to demographics.

trade-offs that we may have to face as a country. In Sweden they make decisions about when you can get dialysis and how, if you want it after a certain age, you’re going to pay for it yourself. I suspect that at the societal level, we’ll have to have those conversations, as difficult as they will be. At the health system level, how we pay for care drives some of the status quo in health care; paying for piecemeal care reinforces delivering piecemeal care. Then, at the level of the family, supporting the family

I got to know quite a few Navajo individuals who had a completely different concept of what life was at the end than I had. Cheryl Stephens, PhD, MBA

MS. MAGNUSON: When need be, families will step up and take care of their loved ones. In the assisted-living setting, services are à la carte. You pay for what you need. Families are saying, “We can’t afford that. You toilet Mom once a day, we’ll take care of the rest.” So you might see more of that happening. DR. STEPHENS: Are we going to learn from the way it used to be, when Grandma lived with Mom and Dad and the kids? We need to become more loving and caring and understanding, rather than expecting somebody out there to have the funds to cover care. DR. O’CONNOR: Sometimes we have a myth that if everybody wrote a clear advance care plan, we’d change the economics of endof-life care because people would not want aggressive care. That’s not true. Many people do want very aggressive end-of-life care. That’s not going to be the panacea that saves us enough money. Secondly, I think there will be a revolution, as both Ed and Laura have mentioned, of re-looking at family. What does “family” mean and how are we going to live together and make decisions? DR. VALDIVIA: Other countries are making

in providing care is going to be an important change.

MS. SCHELLER: Without a family member involved, a resident of an elder care facility is vulnerable to the support of the system. Often, residents tell me that no one made a needed appointment or that they cannot arrange transportation. Currently, the system operates so that different entities involved in care pass a baton rather than coordinate. Some families afford geriatric care managers but most cannot, or don’t know about that option. Increased coordination of long-term care is one of the most important things to be done. MR. STARNES: Final question: As policy around the issue of end of life moves forward, how will we be able to tell that end-of-life care has improved? What metric should be considered to ensure that best practices around end-of-life care have been established and are being met consistently? MS. SCHELLER: Factors in assessing improvement could include the number of persons with health care directives, the number of people on hospice and for what length

of time, patient surveys, medical provider surveys, hospital readmissions, and home care options for end of life. Any marker of improvement needs to include that patients’ choices are clear and honored.

DR. VALDIVIA: One of the most important metrics is measuring how families fare through that death. Research shows that people with advance care plans have families with one-third less anxiety and depression after that person dies. For a dying person, part of quality of care is the degree to which we understand and honor that person’s wishes, but it includes the family experience as much as it’s about that dying individual. DR. STEPHENS: For me, the metric would be what percent of people felt their end-of-life care wishes were followed. There is a statistic that says 5 percent of them felt that their wishes were followed. When we know we’ve reached a much higher percentage than 5 percent, we’ll know that we are having better outcomes. MS. MAGNUSON: The metric would be looking at someone’s POLST and their health care directive, and matching them against what was actually done. If they match, that person’s end-of-life care was successful. DR. RATNER: Measuring quality of end-oflife care is a challenge; each person has a different goal. We need to move away from disease- or treatment-specific measurements and measure satisfaction when people come out of the hospital. We need to figure out how to give each person their own goal and aggregate those goals across people. That’s a complexity of measurement we haven’t addressed anywhere else in health care. We need to ask patients, “What are you afraid of?” or, “Where do you want to be at the end of life?” Then, maybe use a nay or yea or a 1-to-10 scale to see how closely the patient’s wishes were met. DR. O’CONNOR: Burnout among health care professionals isn’t the only measure I’d like to see as a way to assess quality of end-of-life care. But it’s one measure. Everything we’ve talked about concerns trying to match health care that’s delivered with people’s goals. If staff knew they were promoting a closer match it could lessen the sense of futility. If all these conversations could lead to that endpoint of less sense of futility, it would be very valuable for our health care system.

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Physician-patient communication

ommunication between physician and patient is essential to achieving excellent medical care. We know that effective communication between physician and patient results in better compliance, better follow-up, fewer unnecessary diagnostic tests, better health care outcomes, and better overall patient health care satisfaction. Sometimes, however, a patient’s hearing loss presents a challenge to effective communication, making it necessary for a physician to change his or her style and take a little more time with an appointment.

have a deaf or hearing-impaired patient coming to the clinic. Remind your nurse to get the patient in person. Calling his or her name from the door will not be sufficient.

Ways to improve the office visit

Get the patient’s attention. Before speaking, get the patient’s attention, perhaps by gently tapping him or her on the arm or shoulder and then making eye contact. Say the patient’s name first, so he or she does not miss words at the beginning of the discussion. Acquaint the patient with the topic of the conversation and avoid changing the subject without first telling the patient.

By Scott Benson, MD

Physicians need to be alert to signals that a patient is having trouble hearing and identify this condition in the patient’s medical record for others to see. For example, does a patient: • Repeat questions?

Identifying the hearing loss While some patients with complete hearing loss are very open about their condition, others with perhaps new or worsening hearing loss may try to hide their condition. It can take up to seven years for a person with a hearing loss to decide to seek help for this condition, and often it is the spouse who raises the issue.

driven by your

Caring for patients with hearing loss

• Turn his or her head to listen? • Have a history of noise exposure?

Make sure the room is well-lit with light shining on your face so the patient can see your expression clearly. • Have a confused look? • Refrain from asking questions?

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• Complain of ringing in an ear?

Speak clearly. Speak loudly, but not so loudly that your voice is distorted. Speak slowly and avoid using sentences that are too complex. Position yourself toward a patient’s “good” ear, if this is an issue. Pause between sentences and wait to make sure the patient has understood what you’ve said.

There may be medical reasons for hearing loss that can be addressed and corrected. Check for ear infections, especially in children who may tug or pull at an ear. Obesity, smoking, and some medications can also lead to hearing loss. In women under 50, taking ibuprofen or acetaminophen two or more days a week has been associated with an increased risk of self-reported hearing loss. Other drugs associated with hearing loss include antibiotics and chemotherapy medications, as well as aspirin in large doses and certain diuretics. If medical conditions for hearing loss have been ruled out, refer the patient to an otolaryngologist or audiologist for a complete hearing evaluation.

Keep your face visible. Part of the hearing process is watching the speaker’s facial expression and lip movements. Keep your hands away from your face while you are talking, and refrain from chewing gum. Even a mustache or beard can interfere with this visualization. If a patient needs a procedure, make sure he or she understands everything before you move to the procedure room; it is difficult to have a conversation behind a mask. Many exam rooms today are equipped with computers for physicians to enter medical information as they work with a patient. Often, this puts the physician’s back to the patient. Make sure to talk directly to the patient before turning to the computer.

Communicating tips Treating patients with hearing loss, whether partial or complete, requires extra communication on the part of physicians and other health care professionals. Here are some lessons I’ve learned that work well.

Write it down. Physicians may have to write down more information than usual, including information about the patient’s illness, course of treatment, and medications. Using an erasable whiteboard may be helpful. Encourage the patient to bring a family member or friend to the appointment to capture some of the information. If you are sending

Establish effective office policies. Document hearing loss on a patient’s chart and make sure frontline staff know when you

a prescription to a pharmacy electronically, give the patient a written note so he or she knows what medication to pick up. Ask questions and repeat comments. Ask the patient questions to ensure that he or she has heard and understood your words. Be patient and repeat your comments, if necessary. A patient’s puzzled look might indicate misunderstanding. If a patient appears to have trouble understanding a particular word, find a new way of conveying the same thing without repeating the word. Use visual aids. Don’t be afraid to use an anatomy chart or even material on the Internet during an exam. Pointing to something on paper or a screen can be clearer than trying to make a complicated medical term understandable to the patient. Minimize noise; maximize light. For patients with partial hearing, turn off any other

noise that may interfere with the ability to hear you. It helps if the exam room has curtains and carpets to soften noise levels. Also, make sure the room is well lit with light shining on your face so the patient can see your expression clearly.

psychological issues, especially depression and anxiety, are associated with hearing loss. Be sure to address these issues with the patient whenever you suspect they may be a concern. Involve the family. Living

Physicians need to be alert to signals that a patient is having trouble hearing and identify this condition in the patient’s medical record. Use outside services. There are teletypewriter (TTY) options available on your computer; search Google for free TTY services. You might also engage a sign language interpreter, but they can be expensive. Even so, avoid using family or children of the patient to fill this role, particularly when discussing highly sensitive topics or when the patient is under stress.. Don’t ignore the psychological aspect. Emotional and

with someone with hearing loss can be stressful. Probe for family sensitivities. Removing barriers Many people, particularly those with hearing impairments, have more difficulty comprehending when they are tired or ill. Patients who cannot hear well or who are deaf need help with communication during their medical appointments in order to obtain complete, accurate information and avoid misun-

Fast Facts about Hearing Loss The American SpeechLanguage Hearing Association reports that: • Approximately 28 million people in the U.S. have a hearing impairment. • The number of Americans with hearing loss has doubled during the past 30 years. • Approximately 314 in 1,000 people over age 65 have hearing loss.

derstandings. As physicians, we are called upon to provide the best medical care to all of our patients. Removing any barriers to access and communication for our patients with hearing loss is essential. Scott Benson, MD, practices family medicine at Apple Valley Medical Center.

January 2014 Minnesota Physician

Patient perspective

Finding balance

o begin with, there is nothing “mild” about what a mild traumatic brain injury does to your life. My brain injury from sports-related concussions has affected nearly every aspect of my life for more than a decade. Grade school: Injuries and diagnosis My first concussion occurred in 2002 when I was in fourth grade playing football. My doctor had me sit out for two weeks, at which time I was cleared to return to play. My first weekend back in action, I suffered a subsequent whiplash injury that started my concussion symptoms all over again. I had some problems at school the rest of that year, but no one connected my behavior to my concussion. Knowing what I know now, I suspect that my concussion was the cause for my behavior-based school troubles that year. My real love was basketball, which I had started playing

Living with post-concussion syndrome By Matt Hovila

before kindergarten. In 2005, when I was in sixth grade, we played a very competitive team in a fast-paced game. A player from the opposing team and I were chasing each other to their

We headed to the emergency room. Though a CT scan showed “normal” results, for two solid weeks I couldn’t walk without holding a wall, and my head felt like it was cracking in

There is nothing “mild” about what a mild traumatic brain injury does to your life. basket. I beat him to the basket, took a charge, and fell straight back. My head hit the hardwood floor and the player landed on my head, bashing my head into the floor a second time. I sat out the rest of this game with my head spinning—I was dizzy, could not focus my eyes, and felt extremely “out of it.”

half. My symptoms from this injury lasted for months. My neurologist had a name for it—post-concussion syndrome (PCS)—but no tips on how to manage my life, school, and everything else, all of which were falling apart. The same

doctor suggested that I should “try harder” at school. Even now, those two words make me angry. Before my concussion, I was a straight-A student, with a strong work ethic and tremendous time management and organization skills. By insinuating that I was a “slacker,” this doctor became the first of many people to assign that same label to me through my school years. Here’s the truth: My brain injury didn’t wipe out my memories of who I was and what I could accomplish before my injury. I wanted to be that person again; I worked hard at trying to be that person. The last thing I wanted to be was a slacker; that went against my values. Even though the brain injury has changed how my brain works, it has not changed my values or the expectations I have of myself. The effort I now have to put forth to accomplish my schoolwork is something most people will never understand. Finding balance to page 32

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Finding balance from page 30

Academically, I struggled through the rest of sixth grade. That summer my behavior worsened. No one knew what was going on. My parents assumed I was “acting like a teen,” but I felt out of control. I took more risks and started hanging out with different kids. One day, I ran away from home. Maybe I was running away from the person I had become due to my brain injury. In the first few months of seventh grade, nothing was going right at school. I couldn’t concentrate; I couldn’t read. My world literally wavered. Nobody understood the drastic change in my personality or my academic ability. I was anxious and depressed. My parents and I spent much time at doctor appointments trying to find the reason for all these changes. I was placed on a variety of medications for headaches and anxiety, without relief. After be-

ing on Zoloft awhile for depression, I became suicidal from the medication. After this, my mom took me to a new neurologist. We had changed doctors many times over the years trying to find one that understood traumatic brain injury. At this new clinic a doctor determined that I was severely sleep deprived from the disruption caused by my brain injury. I was placed on a medication that decreased my anxiety and helped me sleep. High school: improvement, and a setback By the end of eighth grade, I was finally able to start concentrating at school. That summer I saw a pediatric neuro-ophthalmologist (after seeing three ophthalmologists) who determined that I had vision changes caused by my brain injury. My glasses and contacts were corrected to allow me to read. Now, when studying or reading for prolonged

periods of time, I use additional reading glasses and/or increase the font size on my computer.

Connections4Concussions: A teen/young adult PCS support group Connections4Concussions offers a supportive environment for youth and young adults dealing with concussions and post-concussion syndrome (PCS) to connect with their peers. Participants learn from each other and find encouragement and support. The group also provides support and resources for caregivers, family members and friends.

Due to these two simple changes— medication to The first peer-to-peer support group of its kind improve sleep in the Twin Cities, Connections4Concussions was and vision formed by Kayla Meyer of New Prague and Matt correction—my Hovila of Bloomington, both of whom live with freshman year the aftermath of concussions. of high school For more information, visit the website at was calm and Connections4Concussions.org. productive. The IEP (Individuest I can remember, my parents alized Educawere much more concerned tion Plan) developed for me in about my health than they were middle school was kept in place about sports. As I pleaded the throughout high school becase for playing one last high cause of the many health issues school season, they continued surrounding brain injury that to help me realize how I still affect academics. had my whole life ahead of me. After being injury-free and Thanks to them and to one symptom-free for a few years, doctor who voiced concern, we I entered my senior year as all came to an agreement: One co-captain of my high school basketball team. From the earli- Finding balancey to page 34

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

• Radiology/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 32

Minnesota Physician January 2014

Urgent Care 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.jobs 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

Opportunities for full-time and part-time staff are available in the following positions:

• Dermatologist

• Pain Specialist

• Geriatrician/ Hospice/ Palliative Care

• Psychiatrist • Urgent Care Physician (IM/ FP/ ER)

• Internal Medicine/ Family Practice • Medical DirectorExtended Care & Rehab (Geriatrics)

Applicants must be BE/BC.

MN Physician 4" x 5.25" 4-color

Opportunities available in the following specialties: Dermatology

Rochester Southeast Clinic

Olmsted Medical Center, a 160-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Family Medicine

Pine Island Clinic Rochester Southeast Clinic Plainview Clinic

Internal Medicine

Rochester Southeast Clinic Women’s Health Pavilion (Hospital)

Hospitalist

Rochester Hospital

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.

Plastic Surgeon

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

Send CV to:

For more information: Visit www.USAJobs.gov or contact

Rochester Hospital

Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: dcardille@olmmed.org Phone: 507.529.6748 Fax: 507.529.6622

Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

EOE

www.olmstedmedicalcenter.org January 2014 Minnesota Physician

What My Physicians Need to Know... Advice from a Patient with Post-Concussion Syndrome (PCS) 1. Know that my goal is to live the best life I can. This requires addressing, balancing, re-addressing, and re-balancing the symptoms I live with. Balancing these symptoms often requires dedicated professional care and various medications. 2. Have a team of specialists who are educated about brain injury that includes a physical therapist, speech therapist, ocular-vestibular therapist— whomever I may need. Implement a plan coordinating my various therapies since I will require them for some time. 3. Create a Medication Plan A, Plan B, and Plan C for me. During the school year, I may need a more aggressive medication plan due to the increased cognitive and physical demands. With my lighter schedule in summer, we might want to implement a less aggressive medication plan. Recognizing these patterns and having a plan allows some semblance of normalcy in my life. 4. Understand that pain management is a top priority for me in order to be able to manage my life responsibilities. Pain has become a part of my life. Many of us with PCS live with pain levels of “5 out of 10” on a daily basis. 5. Have connections in the field of brain injury with whom to discuss symptoms and treatment options. Continuously learn and keep up with current research findings. 6. Be stubborn, relentless, and creative. Be optimistic. Provide hope. 7. Hang in there with me. Changing doctors only creates another setback for me; I become discouraged when I have to start this process all over again. I need someone for the long haul who can help me manage my day-to-day needs as I gradually heal. Finding balance from page 32

more season and I’m done. A month later, I stepped on the court for the last time. During the last minute of our first conference game, an opposing player’s elbow came down on the base of my skull. There were no immediate symptoms, but about an hour later that sickening feeling returned. I knew I had a concussion; an ER doctor confirmed it.

Not being able to play the sport I fell in love with, ever again, was just part of the aftermath of that concussion. I missed more than 100 days during the second half of my senior year. Fatigue, headaches, and a sense of overwhelming loss filled my days. I grieved over losing the most important activity in my life and the huge hole it left. I had become depressed and, again, risk-taking behaviors

appeared. My medical team placed me on an antidepressant, even though my mom raised the red flag of my earlier response to Zoloft. Again, I had suicidal thoughts and was weaned off the antidepressant. A major achievement: PCS support group for teens In February 2012, just one year and one month out from my last injury, I was able to turn this nightmare into something I will

be proud of forever. I co-founded a youth-led support group for young people with mild traumatic brain injury, called Connections4Concussions (see sidebar on page 32). The idea to create this group originated after an event hosted by the Minnesota Brain Injury Alliance. My family met the family of Kayla Meyer, a hockey player from New Prague, who also had to give up her sport Finding balance to page 36

What if every one of your patients was a learner, an explorer, a writer, a researcher . . . a University of Minnesota student? These are the people you would serve as a Psychiatrist for the University of Minnesota’s Boynton Health Service.

100

400

This is a full-time position with a competitive salary and excellent benefits including CME and professional liability coverage. There are no evening, holiday or on-call commitments. To learn more please contact Steve Hermann, MD, Mental Health Clinic Director (612) 624-1444 or shermann@bhs.umn.edu. Apply on-line at https://employment.umn.edu and reference requisition number 188412.

Minnesota Physician January 2014

Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community

An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000. Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact: Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org AA/EOE - Not subject to H1B Caps

Minneapolis VA Health Care System Physician/Physiatrist

The MVAHCS, affiliated with the University of Minnesota, is seeking a Spinal Cord Injury and Disorders BE/BC physician/physiatrist. Duties include providing interdisciplinary care for acute and chronic SCI/D Veterans in the inpatient and outpatient setting. Staff has on-site access to medical and surgical specialties, advanced imaging techniques, and state of the art electronic medical record. Opportunities exist for interacting with medical students, residents, and other health professions trainees. SCI/D Fellows strongly encouraged to apply. Be a part of this dynamic and rapidly growing SCI/D Center in a great location. Must have a valid medical license anywhere in the US. Must be US citizen. VA physicians enjoy an excellent benefits package, paid malpractice insurance, and competitive salary and benefits. Recruitment incentive and student loan repayment may be authorized.

For more information: Visit www.usajobs.gov or email your CV to Robyn.Owings@va.gov Telephone 612-467-4337 EEO employer

Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

Please contact or fax CV to:

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

www.NWFPC.com January 2014 Minnesota Physician

Finding balance from page 34

due to a brain injury. While our families got acquainted, Kayla and I jokingly said to each other, “Wouldn’t it be great if there were a support group for kids with brain injury?” Our dream of a support group came to life on Feb. 28, 2012, as Kayla and I co-led our first meeting for youth with brain injuries. There was an immediate, emotional connection as we all shared our experiences and journeys. I am grateful to the Minnesota Brain Injury Alliance for their support in helping us start this group, and for the resources they make available to families struggling with brain injury. Continuing the battle This January, three years will have passed since my last injury. I still have headaches, migraines, and fatigue, making for a roller coaster of good days and bad days. The perfect blend

of medications to ease my headaches and address my other lingering symptoms still eludes me. I’ve spent many nights in the ER receiving IV medications when my migraines and headaches have escalated to a point where the daily medications don’t help. I still don’t have the physical endurance or stamina to be as physically active as I would like to be. Yet, despite these symptoms, I am finding success at the University of Minnesota as a junior studying applied economics with an emphasis in finance. My experiences have led me to the following conclusions: • One very important symptom that physicians and parents miss is the behavioral aspect of brain injury. If a young person who has had a concussion is irritable, short-fused, or anxious; can’t concentrate, focus or organize; or isn’t involved in his or her usual activities, these are indicators that this

student is still having brain injury symptoms and should not participate in activities that put him or her at risk for re-injury. • Brain injury is complex, often affecting social, academic, physical, and emotional aspects of life. Due to this complexity, treatment for brain injury requires a team of specialists. • Though my injuries happened at a time when less was known about concussions, mild traumatic brain injuries, and post-concussion syndrome, I am encouraged that more research, education, and information are available today to those who have suffered a concussion. My treatment plan is more aggressive now than it was a few years ago. My brain injury has changed my life in many ways, but those changes have also helped me grow in many ways. My outlook

on life is positive. I have learned how to be flexible and creative, how to explain my injury, and how to self-advocate to my professors and others. I have learned to “read” my headaches and figure out what I need and how to manage my health the best I can. I have discovered that I have to push myself to complete a lot of my homework on my good days, because tomorrow I might start a headache cycle that takes me “out of life” for two weeks at a time. As much as a young adult can, I try to find the right balance in my life to minimize my symptoms and create an environment for success. The changes in my life have not been “mild” and neither was my brain injury, but I am strong and will continue to battle everything my injury throws in my path. Matt Hovila, co-founder of Connections4Concussion, has mild traumatic brain injury. He is a junior at the University of Minnesota.

Minneapolis VA Health Care System Great place to work, great place to live.

You are invited to be part of the Department of Veterans Affairs that has been leading change in the health care sector. The Minneapolis VA is a 341-bed tertiary care medical center affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel. The Twin Cities area offers excellent living and cultural opportunities. Opportunities for full-time and part-time staff Physicians are available in the following positions: • Gastroenterologist • Emergency Department • Hematology/Oncology • Internist, w/Women’s Health Experience • Compensation and Pension • General Internal Medicine (Minneapolis) • General Internal Medicine (Rice Lake/Hayward, WI Outpatient Clinic) • General Internal Medicine (Rochester, MN Outpatient Clinic) Physician applicants should be BC/BE. Possible recruitment bonus. Interested applicants should email CV to Joan L. Potter, HRMS, Joan.potter@va.gov

Fax 612-725-2287 Telephone 612-629-7306 EEO Employer.

Minnesota Physician January 2014

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

FAMILY PRACTICE w/OB Warroad, MN Roseau, MN Crookston, MN • Dedicated Team Approach • Competitive Salary & Benefits • EPIC Healthcare Information System Idylic Practice Opportunities located in family friendly communities with close access to some of Minnesota’s most beautiful lakes. Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003 1-800-437-5373 Fax: 701-780-6641 khjelmstad@altru.org

www.altru.org

Minnesota Physician 4" x 5.25" B&W

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: • ENT • Family Medicine • Geriatrician/Outpatient Internal Medicine • Hospitalist • Infectious Disease

• Internal Medicine • Med/Peds Hospitalist • OB/GYN • Oncology • Orthopedic Surgery • Psychiatry

• Psychology • Pediatrics • Pulmonary/ Critical Care • Radiation Oncology • Rheumatology

For additional information, please contact:

Kari Bredberg, Physician Recruitment karib@acmc.com, (320) 231-6366

Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052

www.acmc.com January 2014 Minnesota Physician

Mild traumatic brain injury from page 11

of the chemical changes in the brain are most likely to have deterioration in cerebral blood flow and tissue oxygenation. Prevention of elevated temperature will affect cerebral metabolism and improve tissue oxygenation. Intracranial monitoring can be employed if necessary to maintain temperature, pressure, tissue oxygenation and cerebral blood flow. Patients who have a witnessed seizure or are thought to be at highest risk can empirically be placed on antiepileptic medication, at least over the short term (one week to three months). Treatment recommendations for all grades of mTBI are uncertain at best. Beyond any hospitalization, there are no certain treatments with proven benefit, though many anecdotal approaches are utilized. Safe and seemingly helpful in regard to long-term improvement and return to premorbid activity are

the notion of rest and the belief that persistent post-concussive symptoms should not be challenged, but rather, should be avoided and minimized. Almost every other aspect

Improving safety in sport Several methods of stepwise progression of activity have been developed and various timelines have been developed. Most of these have centered on athletes returning to their sport

Persistent post-concussive symptoms should not be challenged, but rather should be avoided and minimized. of medical treatment across all medical specialties involves initiation of therapies as early as possible. The same is not true of concussion. Any level of activity that will increase post-concussive symptoms is to be avoided. Whether it be headache, lightheadedness or dizziness, vertigo, nausea, disorientation, or fatigue, the activities that worsen or elicit such symptoms should be prohibited.

without restriction. Professional, college, and high school athletic programs are all following strict guidelines, hoping to ensure individual safety in their sport following concussion (see sidebar on page 10). Coaches, trainers, and physician experts are working together to promote safety for their athletes. Improvement in equipment has helped in some cases but has failed to make an impact in others. For example:

• Headgear in various sports seems to be beneficial in minimizing the risk of and extent of mTBI. • Good conditioning and specific strengthening of the neck are also helpful. • Mouth guards have failed to demonstrate benefit for athletes. Education is most beneficial for everyone involved. Detection of injury, knowledge of symptoms of mTBI, assessment, and initiation of appropriate workup and treatment are all essential to the injured person. Then, following the guidelines for rehabilitation and return to activity will keep that person safe. With greater knowledge and awareness, we can all help to minimize the occurrence of head injury. Ronald Tarrel, DO, practices at Noran Neurological Clinic, specializing in vascular neurology and neurocritical care.

Think about what you really want in a career. We’ve got you covered from both sides...

The Left Side

The Right Side

Your Analytical, Pragmatic Side

Your Creative, Spontaneous Side

*Company Paid Malpractice Insurance *Comprehensive Healthcare Benefits + 401(k) Plan *Consistent & Predictable Work Schedule *Freedom from the Hassles of Managed Care; No Insurance or Billing Issues

*Generous Paid Time Off & Holidays *Professional Satisfaction Treating Diverse & Clinically Interesting Cases *Collaborate with an Experienced Treatment Team of Healthcare Professionals and Security Staff *CME Paid Days Off & Reimbursement

MHM Services, in conjuction with Centurion of Minnesota is proud to be the provider of healthcare services to the Minnesota Department of Corrections. We currently have excellent Full Time, Part Time & Per Diem PRIMARY CARE and PSYCHIATRIST opportunities available throughout Minnesota, including the following locations: Lino Lakes * Shakopee * Oak Park Heights * Stillwater Faribault * Moose Lake * Red Wing * Rush City * St. Cloud We are also seeking a Primary Care Physician to serve as our STATEWIDE MEDICAL DIRECTOR based out of our Regional Office in St. Paul. For more information, please contact: Tracy Glynn· 877.616.9675· tracy@mhmcareers.com

www.mhm-services.com | Equal Opportunity Employer

Minnesota Physician January 2014

EDUCATION TRAINING PROGRAM EDUCATION TRAININGTRAINING PROGRAM EDUCATION PROGRAM

LGBTQ Health Professional Development Training Datesan for this training willHealth be held on 2/15,LGBTQ 3/8, 3/22 andissues. 4/5 The first half of the LGBTQ Health Professional Development Training This 4 hour training offers in-depth understanding of specific health LGBTQ Professional Development Training training This is an4 hour LGBTQ it covers general terms and LGBTQ patient For second training offers an in-depth ofguidelines specific LGBTQ health issues. Thecare. first half ofthe the This101; 4 hour training offers understanding an in-depth understanding offor specific LGBTQ health issues. The first half of the halftraining of theistraining, choose one of theguidelines topics below, or they work theFor RHI. antraining LGBTQclients it may covers general terms and forguidelines LGBTQ patient care. Forwith thecare. second is101; an LGBTQ 101; it covers general terms and for may LGBTQ patient the second half of the training, clients may choose the topics below, or they may work with thework RHI.with the RHI. half of the training, clients one may of choose one of the topics below, or they may

Education Manager to develop a custom training:

Education Manager to develop custom training: Education Managerato develop a custom training: 



Caring for transgender patients Caring for transgender patients 

 

GBTQ use GBTQ tobacco tobacco use  GBTQ tobacco use

 

Caring for transgender patients

GBTQ recovery  GBTQ recovery GBTQ recovery

 Creating a competent clinic: Environment, policy & administration  culturally Creating a culturallyclinic: competent clinic: Environment, & administration Creating a culturally competent Environment, policy & policy administration

Length: 4 hours long 4 hours long Length:

Length: 4 hours long

PRA Category 1 Credit s™ 1 Credits™ Earn 4 AMA Earn 4 AMA PRA Category

Earn 4 AMA PRA Category 1 Credits™

This training This is well suitedisfor health and service providers, students pursuing degrees in social training well suited forsocial health and social service providers, students pursuing degrees in social nursing, dentistry, health, and medicine; administrative staff; and health providers. work, is nursing, dentistry, health, and medicine; administrative staff;care anddegrees health care This training wellwork, suited forpublic health andpublic social service providers, students pursuing in providers. social

public health, and medicine; administrative staff; and health care providers. work, nursing, dentistry, The cost of this training is $75 dollars for CEU (to be determined) The cost of this training is $75 dollars for CEU (to be determined)

The cost of this training is $75 dollars for CEU (to be determined)

ACCME Accreditation ACCMEStatement: Accreditation Statement: This activity hasThis been planned implemented accordance with the Essential Areas and Policies of the activity hasand been planned andinimplemented in accordance with the Essential Areas andAccreditation Policies of the Accreditation Council for Continuing Education through the joint sponsorship of sponsorship the Minnesota Medical Association andAssociation Rainbow and Rainbow Council Medical for Continuing Medical Education through the joint of the Minnesota Medical Health Initiative. The Minnesota Medical Association (MMA) is accredited by the Accreditation Council for Continuing Initiative. The Minnesota Medical Association (MMA) is accredited by the Accreditation Council for Continuing ACCME Accreditation Health Statement: Medical Education to provide continuing medical education for physicians. Medical Education to provide continuing medical education for physicians.

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation AMA PRA Category Credit Statement: AMA 1PRA Category 1 Credit Statement: Council for Continuing Medical Education through the joint sponsorship of the Minnesota Medical Association and Rainbow The Minnesota The Medical Association designates this designates training for this a maximum of 4a AMA PRA Category Credit s™. Physicians Minnesota Medical Association training for of 4 AMA 1PRA Category 1 Credits™. Physicians Health Initiative. The Minnesota Medical Association (MMA) is accredited by maximum the Accreditation Council for Continuing should claim only the credit commensurate with the extent of their participation in the activity. should claim only the credit commensurate with the extent of their participation in the activity. Medical Education to provide continuing medical education for physicians. AMA PRAContact Category 1Brianna.McMichael@rainbowhealth.org Credit Statement:

for hours (612-206-3180)

The Minnesota Medical Association designates this training for a maximum of 4 AMA PRA Category 1 Credits™. Physicians

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