Minnesota Physician September 2014 by Minnesota Physician Publishing

Vo l u m e x x v i i I , N o . 6 S e p t e m b e r 2 014

The coming physician shortage What are the issues? By Nate Mussell, JD

ealth care has been at the center of federal and state politics for decades. No matter which way the political winds are blowing, health care in Minnesota and the rest of the country has been in a state of change for several years. While much of the attention recently has focused on the Affordable Care Act and the ever-changing environment in which it continues to operate, there are a number of fundamental issues that Minnesota will face in the coming years. One issue that has garnered significant attention recently is whether the state will have the workforce in place to meet the growing health care demands.

Maintenance of certification Is MOC necessary for lifelong learning? By Jon Thomas, MD, MBA

aintenance of certification (MOC) means different things to different people. Currently much press has been given to the cynical and the skeptical. To the cynical it simply represents an opportunity for the American Board of Medical Specialties (ABMS), and its specialty member boards, to gouge physicians by mandating allegedly expensive and irrelevant educational programs. To

the skeptical it foists an unproven process with the overly optimistic claim of improved patient outcomes. Both positions are untenable. MOC is, first and foremost, a form of continuous professional development, which is a structured approach to education, learning, and practice improvement to ensure a phyMaintenance of certification to page 10

There seems to be a general consensus in Minnesota that the state will face a physician shortage in the very near future as more physicians reach the age of retirement and fewer new graduates and residents fill those gaps. Although the numbers vary based on who does the analysis, most people who have looked at the issue in recent years, including the Minnesota Medical Association and The coming physician shortage to page 12

Ahead of the Curve

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When you need to move a patient on to the next step, it’s good to know you can turn to a leader in managing complex cases. Turn to Bethesda Hospital – a Long Term Acute Care Hospital (LTACH). For more information, visit bethesdahospital.org.

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September 2014 • Volume XXVIII, No. 6

Features Maintenance of certification 1 Is MOC necessary for lifelong learning?

MINNESOTA HEALTH CARE ROUNDTABLE

By Jon Thomas, MD, MBA

The coming physician shortage What are the issues?

By Nate Mussell, JD

DEPARTMENTS CAPSULES

MEDICUS

INTERVIEW

Ruth Lynfield, MD

Oncology

First Person

MIBG therapy By Emily Greengard, MD

Autism spectrum disorder By Elizabeth Reeve, MD

42nd Session

Minnesota Department of Health (MDH)

medicine and the law

Medical marijuana in Minnesota By Kevin Riach, JD

Professional Update: Pain Medicine 14 Prescription drug abuse By Cody Wiberg, PharmD, MS, RPh

Special focus: Chronic Illness Caring for patients with multiple sclerosis By Amy Diede, MD Can you hear me now? By James Keane, MD, and John Olive, MHA

Sickle cell disease By Stephen C. Nelson, MD

Background and focus: As tools and techniques for treating chronic illness have expanded, so have methods and mechanisms of provider reimbursement. More people now have access to care, and with this comes a heightened awareness of the impact of social determinants on health. The transition to rewarding physicians for maintaining a healthier population is slow but the promise is clear. Treating chronic illness remains an area of high-volume use and, improperly managed, quickly becomes an area of high cost. Objectives: We will evaluate changes that health care reform is bringing to chronic illness care. We will examine new community-based partnerships that are forming to address prevention, compliance, and better identification of risk. We will look at specific diseases and how workplace solutions, insurance companies, clinics, hospitals, long-term care facilities, and home care providers are working together to lower costs and improve outcomes.

Panelists include: • L. Read Sulik, MD, PrairieCare • Durand Burns, MD, Minneapolis Heart Institute Foundation

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Account Executive Stacey Bush | sbush@mppub.com Account Executive Jan Ehrlich | jehrlich@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 necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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Record Number of Clinics Rewarded by Bridges to Excellence The Minnesota Health Action Group has announced that a record number of clinics will receive rewards for achieving specific clinical outcomes as part of the 2014 Bridges to Excellence program and the Minnesota Quality Incentive Payment System, a state program also administered by the group. The clinics receiving rewards reached goals related to diabetes, vascular disease, and depression. According to the Minnesota Health Action Group, these three conditions are the primary drivers of health care costs. This year, the highest number of clinics since the program’s inception qualified for “achievement,” the highest level of recognition in all three categories. Sixty-two clinics qualified for achievement goals for optimal diabetes care, 69 for optimal

vascular care, and 75 for optimal depression care. In addition, a record number of clinics qualified for improvement goals in optimal vascular care (132) and improvement in depression remission at six months (49). Sixty-four clinics are being recognized for reaching improvement goals in optimal diabetes care. “We’re thrilled to see an increase in the overall number of clinics being rewarded, but what’s even more important is the number of Minnesotans who are receiving better care and realizing better health outcomes because of the commitment these health care providers have made to improving the quality of care they deliver,” said Carolyn Pare, president and CEO of the Minnesota Health Action Group. Pare added that the results mean 5,600 more Minnesotans received optimal care for diabetes compared with the previous year. More than 2,700 more received optimal care for vascular disease,

and more than 850 patients received improved care for depression. In addition, 12 clinics were recognized this year for meeting the program’s optimal care achievement goals in all three of the disease categories: Allina Health in Centennial Lakes, Richfield, Shoreview, and Uptown; Entira Family Clinics in Maplewood/Battle Creek, Shoreview, Vadnais Heights, and White Bear-Bellaire Avenue; and Park Nicollet in Eagan, Maple Grove, Plymouth, and Prairie Center. Only three clinics qualified for this recognition last year.

Dayton Creates Panel to Enhance U of M Med School Gov. Mark Dayton has signed executive order 14-13 establishing a Blue Ribbon Committee for the University of Minnesota Medical School “to ensure the state’s

preeminent medical school is a national leader in medical training, research, and innovation.” The committee will make specific recommendations to Dayton and lawmakers for the 2015 legislative session. Recommendations will include specific strategies and investments to bolster the school’s reputation. These will focus on retaining and attracting prominent faculty, staff, students, and residents; sustaining national leadership in health research, care innovation, and health care delivery; expanding clinical services; and addressing Minnesota’s health workforce needs while taking into account a growing aging population and increasing chronic health needs. “The future health of Minnesotans depends on what we do now to train the next generation of medical professionals in our state,” Dayton said in a statement. “Today’s medical students will become the doctors who will care for our families, and the research professionals who will develop

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Minnesota Physician September 2014

life-saving innovations in medical technology in years to come.” According to the statement, Dayton hopes strategic leverage of the school’s strengths will help continue Minnesota’s tradition of excellence in health care. More than 70 percent of physicians in the state have earned their medical degrees or taken courses at the medical school. In addition, the school provides training to 1,200 primary care physicians and specialty residents, and offers continuing education courses to 10,000 physicians, annually. The committee members include 14 university officials, health care professionals and administrators, state agency leaders, and health association representatives. Four legislative leaders also will serve on the committee, including Rep. Tom Huntley (DFL–Duluth), Sen. Leroy Stumpf (DFL–Marshall), Sen. Jeremy Miller (R–Winona), and another GOP legislator to be named at a later date.

State Hospital Groups Partner to Study ACA Impact The Minnesota Hospital Organization, the Robert Wood Johnson Foundation (RWJF), and 23 other state hospital organizations have teamed up to study the Affordable Care Act’s (ACA’s) impact on hospital admissions and emergency department utilization. Researchers predict that more people having health care coverage will lead to an increased use of primary care and ambulatory services, while reducing reliance on hospital emergency departments. To determine if this is true, the state hospital organizations share summary-level data on a quarterly basis by payer category for conditions they believe to be sensitive to insurance status. Data from 2013 has been compiled and will be the study’s baseline. Data from the first quarter of 2014 will offer the first glimpse into the effects of the ACA. “The potential financial impact of health reform on hospitals is also unclear,” said Katherine

Hempstead, RWJF coverage team director and senior program officer. “While the reduction in uncompensated care is clearly a plus, there may be significant increases in utilization by patients who have payers that reimburse at relatively low rates.”

UCare Purchases Building, Plans to Consolidate Offices UCare has finalized its purchase of 600 Stinson Blvd. N.E. in Minneapolis. This is the nonprofit health care plan’s first property purchase in its 30-year history. Currently, UCare staff works out of three leased office spaces in northeast Minneapolis. The newly acquired 250,000-squarefoot, three-story space will consolidate UCare staff and operations into two neighboring buildings, the newly purchased building, and another site UCare currently leases, by 2018. “Purchasing this building gives us a long-term option for more space while also allowing us to stay in the northeast Minneapolis neighborhood we consider our ‘work home,’ ” said Hilary Marden-Resnik, UCare senior vice president and chief administrative officer. “By consolidating our workspace, we can achieve even greater operational efficiencies and better accommodate future growth. We also are proud to continue contributing to the city’s employment and economic stability by employing nearly 800 people at our offices in this well-established Minneapolis community.”

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Minnesota Best State For Health Care ROI, Report Says Minnesota has ranked first in the U.S. for health-related return on investments (ROI), according to a recent study by WalletHub, a financial social network. WalletHub calculated the ROI for health care services for 47 Capsules to page 6 September 2014 Minnesota Physician

Capsules from page 5

states using death rates, America’s Health Rankings, and average individual health insurance premiums. Maine, Rhode Island, and Vermont were not included in the study due to limited available data. The information was then compiled into a common score used to compare average ROI for health care in each state. “In 2013, the nationwide average annual health insurance premium for an individual had a

price tag of $5,884 while families paid an average of $16,351 for group coverage,” the report said. It also noted that since 2003, single coverage has increased by 74 percent and family coverage has increased by 80 percent. Minnesota had the lowest health care costs, with an average individual health insurance premium of $2,292, while Alaska had the highest, with an average of $5,424. California had the lowest death rate (adjusted by age

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group), and Mississippi had the highest. Utah, Kansas, Hawaii, and Iowa join Minnesota in the top five states for health care ROI. Mississippi ranked the worst, preceded by Louisiana, Arkansas, West Virginia, and Indiana. In general, states whose residents predominantly vote for the Democratic Party scored better than those whose residents predominantly vote for the Republican Party. Democratic states’ residents had an average rank of 20.35. Those in GOP states had an average rank of 27.42. “For a country that spends $2.9 trillion a year on health care—twice as much per capita as other industrialized nations— one would think the United States is home to the healthiest humans on the planet,” the report said. “And yet, the reverse is true: Americans have shorter lives, higher infant mortality rates, and more cases of chronic diseases than populations of other wealthy countries.”

Study Projects Physician Shortage in Minnesota

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Minnesota Physician September 2014

Results from a new study show that a shortage of primary care physicians will unfold over the next decade. The Minnesota Hospital Association (MHA) asked Towers Watson, a global professional services firm specializing in risk management and human resource consulting, to conduct an in-depth study of the status of primary care physician and registered nurse workforces in Minnesota. The company analyzed data from the national Bureau of Labor Statistics, the state of Minnesota, and workforce data that MHA compiled from Minnesota hospitals. “The current pipeline of graduates barely appears adequate to replace retirements as they occur,” the study reports. “That, coupled with projected increases in demand because of an aging population, will result in a signifi-

cant talent gap for physicians.” The study projects a cumulative shortfall of nearly 850 primary care physicians in Minnesota by 2024 due to a lack of annual growth in Minnesota’s graduate medical education programs, including residency or clinical training positions. “Many of our hospitals, especially those in Greater Minnesota, already have difficulty attracting physicians,” said Lawrence Massa, president and CEO of MHA. “I hope this new information will provide an impetus to policy makers to make the urgent decisions needed on both the state and federal levels to give our health professional students access to the clinical training and residency experience they need to become licensed to practice.” According to the study, there likely will not be a gap in the RN workforce, as long as RN education programs continue to grow at expected rates. Nationally, the study noted that an aging population, slow graduate growth, increasing rates of retirement, and a growing population are “driving an impending talent shortage in the health care industry on a national level.”

Minnesota Joins Prescription Drug Abuse Project Minnesota has joined the Prescription Drug Abuse Project to collaborate with other states to develop comprehensive statewide action plans to combat prescription drug abuse, using data, evidence-based strategies, and technical assistance from the National Governors Association (NGA). According to the NGA, prescription drug abuse is the fastestgrowing drug problem in the nation and the most common type of drug abuse among children age 12 to 17, after marijuana use. Participating states were chosen by the NGA and include Michigan, North Carolina, Wisconsin, Nevada, and Vermont, in addition to Minnesota.

Medicus Christopher Alcala, MD, board-eligible in orthopedic surgery, has joined Twin Cities Spine Center (TCSC), Minneapolis. He completed medical school and a residency in orthopedic surgery at the University of Puerto Rico School of Medicine, San Juan, and a fellowship in spinal surgery at TCSC. Michael Belzer, MD, chief medical officer at Hennepin County Medical Center (HCMC), has been selected to receive the 2014 Charles Bolles Bolles-Rogers Award by the West Metro Medical Foundation and the Twin Cities Medical Society. The highest award given by the medical society, it is given to a physician who, in the opinion of the selection committee, has become the outstanding physician of this and other years by reason of professional contribution on the basis of medical research, achievement, or leadership. Michael Belzer, Belzer graduated from the University of MinneMD sota medical school; served an internal medicine residency at the University of North Carolina, Chapel Hill; and completed a fellowship in hematology/oncology at the University of California–Los Angeles. He is board-certified in medical oncology, hematology, and internal medicine. Christopher Alcala, MD

Rajshekhar Chakraborty, MD, board-certified in internal medicine, has joined Essentia Health–St. Joseph’s Medical Center, Brainerd, as a hospitalist. He earned a medical degree from the University College of Medical Sciences at the University of Delhi, India. He served a residency in internal medicine at Icahn School of Medicine at Mount Sinai/Queens Hospital Center in Jamaica, N.Y. Joining Essentia Health–St. Mary’s Children’s Hospital in Duluth is pediatric intensivist Karen Sethi, MD, board-certified in pediatrics. Sethi graduated from St. George’s University School of Medicine in Grenada, West Indies, and completed both a residency and a critical care fellowship in pediatrics at the University of Rochester School of Medicine, N.Y.

Rajshekhar Chakraborty, MD

Jessica Downes, MD, and Erik J. Peterson, Karen Sethi, MD MD, joined St. Croix Orthopaedics in August. Downes graduated from Creighton University School of Medicine, Omaha; served an orthopedic surgery residency at the University of Minnesota; and completed a foot and ankle fellowship at the University of Alabama, Birmingham. Peterson graduated from the Medical College of Wisconsin, Milwaukee, and served a residency in orthopedic surgery at the University of Minnesota. Both doctors are board-eligible in orthopedic surgery. William Gerardi, MD, MBA, has been named chief medical officer and senior vice president of health management at Blue Cross and Blue Shield of Minnesota. Most recently, Gerardi served as chief medical officer at Aetna Better Health of Illinois. He earned a medical degree from Georgetown University, Washington, DC, and an MBA from the Wharton School, University of Pennsylvania, Philadelphia.

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September 2014 Minnesota Physician

Interview

Keeping Minnesota healthy W hat do your duties as state epidemiologist include? My duties include advising the commissioner of health regarding the emergence, occurrence, prevalence, and preventability of infectious and noninfectious diseases and conditions of public health importance. Also, I provide medical and epidemiologic expertise for the development of strategic initiatives and policies to improve health. W e understand that you are increasingly involved in projects of a more national nature. What can you tell us about this? I serve on a number of federal advisory committees, including the National Vaccine Advisory Committee for the National Vaccine Program Office; the Vaccines and Related Biological Products Advisory Committee for the FDA; and the Board of Scientific Counselors for the Office of Infectious Diseases at CDC.

Ruth Lynfield, MD Minnesota Department of Health (MDH) Ruth Lynfield, MD, received her medical degree from Cornell University Medical College and did postgraduate training in pediatrics and in pediatric infectious diseases at Massachusetts General Hospital. She joined the Minnesota Department of Health as a medical epidemiologist, and was appointed medical director of infectious disease in 2003, state epidemiologist in 2007, and medical director of the Department in 2010. Dr. Lynfield is board-certified in pediatric infectious disease and is an adjunct professor of medicine at the University of Minnesota.

sure was in the Arabian Peninsula. Saudi Arabia has the most cases (as of July 10, the Ministry of Health in Saudi Arabia reported 721 cases and 295 deaths). The incubation period can be up to 14 days, the median age has been 47 (but ages have ranged from 9 months to 94 years), 64 percent have been male, and many cases have had medical comorbidities. Spread of MERS has occurred in the health care setting, so appropriate infection control precautions are important (standard, contact, and airborne precautions should be followed, including eye protection). There have been two confirmed cases in the U.S., and both had health care exposure in Saudi Arabia. Interestingly, genetically indistinguishable coronaviruses have been found in camels, and similar coronaviruses have been found in bats. For more information on MERS, please see the MDH website at www.health. state.mn.us/divs/idepc/diseases/mers/ or if you have questions, please call MDH at (651) 201-5414.

here may be some public and professional T misinformation surrounding HPV vaccinations. What should doctors know? Human papillomavirus (HPV) vaccine is safe and effective. Currently, there are two HPV vaccines available: Cervarix and Gardasil. Both vaccines prevent cervical cancer and Gardasil has activity against genital warts, and cancer of the vagina, vulva, anus, • Meningococcal vaccine and oropharynx. Gardasil and Tdap for grades is also approved for males. 7 to 12 The HPV vaccine is given Antibiotic resistance is an urgent as a three-shot series over • Hepatitis A and hepatiand rapidly increasing health six months, and is recomtis B vaccines for child mended at age 11 to 12 care and early childthreat everywhere. years, but can be given up hood programs to age 26. There are 150,000 • Kindergarten children HPV-related cancers in must have their final dose of DTaP and inacwomen and 7,000 HPV-related cancers in men each tivated polio vaccine on or after their fourth year in the U.S. that may be prevented by the HPV birthday vaccine. Even though it is very effective, this vaccine The changes were made to more closely align has not had the uptake of other vaccines, perhaps due with national recommendations. Minnesota’s immuin part to concerns about linking the vaccine with nization registry, called the Minnesota Immunizasexual activity. The vaccine is given in early adolestion Information Connection (MIIC), can be used to cence because vaccination at this age produces better identify and call in children who are behind schedule antibody levels than vaccination at older ages, and it on vaccinations. For more information on immuniis ideal to vaccinate years prior to sexual debut. The zations, please visit the MDH website at www.health. HPV vaccine is life saving. Parents and children more state.mn.us/immunize readily accept vaccination when the physician thinks the vaccine is important. You can see video clips of model conversations at www.wevaxteens.org W hat is Middle East Respiratory Syndrome (MERS)? MERS is caused by the MERS virus, a coronavirus, W hat can you tell us about antibiotic so named because of the presence of projections that resistance? are crown-like when it is visualized using electron Antibiotic resistance is an urgent and rapidly inmicroscopy. It is in the same virus family as the creasing health threat everywhere. The CDC issued a SARS-associated coronavirus, which caused infecreport on antibiotic resistance, which can be accessed tions worldwide in 2003. MERS was first reported in at: www.cdc.gov/drugresistance/threat-report-2013/ Saudi Arabia in 2012 and is associated with fever and index.html Unfortunately, in Minnesota we have had severe respiratory symptoms. As of July 11, there have infections due to bacteria such as carbapenem-resisbeen 851 cases reported and 324 deaths. Cases have tant Enterobacteriaceae that are resistant to almost been linked to exposure in the Arabian Peninsula, or all usable antibiotics. We have also had increasing in a few cases to a person with MERS whose expo-

T here have been recent changes to state school immunization laws. What should doctors know? The changes to Minnesota’s immunization law took effect on Sept. 1, 2014, and apply to children entering school, child care, and early childhood programs. New requirements include:

Minnesota Physician September 2014

numbers of infections due to Clostridium difficile, cases of vancomycin-intermediate Staphylococcus aureus, and of extremely drugresistant tuberculosis. The loss of effectiveness of antibiotics can impact almost all areas of medicine, including intensive care, transplant medicine, surgery, and oncology. Antibiotic resistance is driven by antibiotic use, so all of us need to be careful stewards of antibiotics. Antibiotic stewardship programs are recommended across the continuum of health care. For more information on antibiotic resistance and on antibiotic stewardship please see www. health.state.mn.us/divs/idepc/dtopics/ antibioticresistance/

tion can be found at www.health.state.mn.us/ divs/eh/indoorair/radon/mitigationsystem.html

 What are some of the biggest environmental health issues that physicians need to know about? Exposure to environmental hazards can affect health. It is important to have awareness of a patient’s housing, school or work environment, diet, and other lifestyle factors, in order to evaluate possible exposures. Here are some examples:

Ask your patients about fish consumption. Most fish are healthy to eat and an excellent source of low-fat protein. Eating fish also may reduce the risk of heart disease, diabetes, and other chronic illnesses. However, fish (store-bought or sport-caught) could contain contaminants such as mercury, that can harm health—especially child and fetal development. It is important to know which fish are safer than others to eat. More information can be found at www.health.state.mn.us/divs/eh/fish/ index.html

Radon is the second-leading cause of lung cancer in the U.S., and is responsible for more than 21,000 deaths each year. In Minnesota, two in five homes have elevated radon levels. Encourage your patients to test their homes. High levels can be mitigated. The MDH indoor air unit can partner with you to conduct patient and staff awareness programing. More informa-

such as air fresheners, cleaning products, and wood smoke also can be a problem. Ways to avoid allergens can include keeping dust levels down, keeping pets out of the bedroom, use of high-efficiency particulate air filtration and vacuum cleaners, use of allergen-impermeable mattress and pillow covers, extermination of pests, smoking cessation, and keeping the environment dry to control mold growth in the home. Additional information can be found at www.health.state.mn.us/asthma/

There is no safe level of lead exposure for children. The commissioner recently lowered the definition of an elevated blood level of lead to 5 micrograms per deciliter of blood. This allows actions to be taken earlier to find and stop the source of exposure. Because there are usually no signs or symptoms of lead poisoning in patients, you should pay special attention to indicators of exposure risk. The primary ones are living in a house built before 1978 and being on Medicaid. More information can be found at www.health.state.mn.us/ divs/eh/lead/index.html

Allergens and irritants in indoor and outdoor environments can adversely impact a person who has asthma. Asthma triggers commonly found in the home include indoor dampness, mold, pests, and pets. Irritants

Melanoma rates are increasing in Minnesota. The vast majority of melanomas are caused by exposure to ultraviolet light. Physicians should talk to parents, teens, and adults about reducing exposure to ultraviolet light through use of sunscreens, protective clothing, limiting time in the midday sun, and avoiding indoor tanning beds. Use of a tanning bed before the age of 35 increases the risk of skin cancer by 59 percent. Minnesota law now prohibits minors from indoor tanning; other age groups should also avoid this risky behavior.  Do you have other recommendations? I have steered you to some sites on the MDH website, but there is much more information there on other topics. Please feel free to contact MDH if you have public health questions or concerns, and thank you for all that you do to keep Minnesotans healthy!

University of Minnesota - Continuing Professional Development (formerly the Office of CME) Education is essential to achieving and sustaining quality healthcare. Through partnership with healthcare leaders, our educational activities provide quality improvement and patient care initiatives.

2014 -15 CPD Activities (All courses in the Twin Cities unless noted)

LIVE COURSES Psychiatry Review: Evolving Frontiers in Psychiatric Care September 29-30, 2014 Twin Cities Sports Medicine October 3-4, 2014 Practical Dermatology (Duluth, MN) October 17-18, 2014 North Central College Health Association (NCCHA) October 22-24, 2014 Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners October 23-24, 2014 Maintenance of Certification in Anesthesiology (MOCA) Training October 25, 2014 & January 10, 2015

Got Your Shots Immunization Conference (St. Cloud, MN) October 27-28, 2014 Internal Medicine Review November 12-14, 2014 Emerging Infections November 21, 2014 Bakken Symposium: Heart & Lung Transplant December 2, 2014

www.cmecourses.umn.edu ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Global Health - To include Travel Medicine & Refugee Health - Family Medicine Specialty - Pediatric Specialty • Adolescent Vaccination - COMING SOON! • Nitrous Oxide for Pediatric Procedural Sedation For a full activity listing, go to www.cmecourses.umn.edu

Geriatric Orthopaedic Fracture Conference December 5-6, 2014 Office of Continuing Professional Development 612-626-7600 or 1-800-776-8636 • email: cme@umn.edu

Promoting a lifetime of outstanding professional practice

September 2014 Minnesota Physician

Maintenance of certification from cover

sician’s continued excellence in the practice of a medical or surgical specialty. MOC is changing, and this is evolutionary, not revolutionary. It is an iterative and adaptive program whose changes are informed by new knowledge and information about what works. ABMS has attempted to make the program more relevant and user-friendly. The ideal would be a program that integrates seamlessly into medical practice. Board certification and licensure Specialty board certification signifies a physician’s knowledge and skills to practice medicine at a very high level in a particular medical specialty. Traditionally, board-certification occurred within several

years of completing residency and/or fellowship training and was good for the professional life of the physician. Unlike licensure, which is a minimum standard and mandatory for practice, board-certification is voluntary and considered a

recognized as insufficient. Given the rapidly changing body of knowledge and changes in a physician’s scope of practice, for certification to be accurate and relevant it needed to occur more than once in the lifetime of a physician. So the funda-

We don’t “self-teach” ourselves medicine.

higher standard. Some may argue that it isn’t voluntary because in a state like Minnesota it is difficult, if not impossible, to find employment or receive hospital privileges without board-certification. The traditional notion of a certification based on a one-time assessment at the start of a career and lasting the life of the physician was

Minnesota Physician September 2014

mental questions become how rigorous and how often? If you survey the public about their expectations, they believe that it should be both very rigorous and often. Lifelong learning Two issues drive MOC: our growing knowledge in the learning sciences and the

quality improvement paradigm. This knowledge is starting to transform not just traditional education, but medical education as well. A concept that has been gaining traction in education is lifelong learning. In the past, completion of residency signaled the end of formal medical education with an implicit assumption that the physician would “keep up” with the literature for the remainder of his or her career. Today the completion of residency is no longer seen as an endpoint, but simply a point in time along the continuum of lifelong learning. While many physicians are quick to reassure their patients and the public that they already “keep up,” we know from research that physicians and human beings in general are not very good at self-assessment. Nor do they necessarily know how to choose and structure the appropriate educational ac-

tivities to actually improve their performance. The idea of structured learning is not new. This is the approach we take when learning new subject matter. We don’t “self-teach” ourselves medicine. We go to medical school. Yet we assume that we have the skill set to organize our lifelong learning, and that somehow it is intuitive. The science of learning has taught us that this is a fallacy. Humans suffer from a well-studied optimism bias. Low performers suffer from an optimism that leads them to believe they are actually performing much better than their true performance. The opposite holds for high performers who tend to underestimate their capabilities. The requirement that physicians engage in quality improvement through continuous professional development evinces the need for a structured, scientifically-based approach to learning. The MOC program MOC was formally adopted in 2000. In 2009, ABMS approved MOC standards and formalized program elements and timelines. The program was reassessed in 2012 and 2013, with those recommendations moving towards implementation in 2015. The new MOC standards are less prescriptive and focus less on process and more on outcome. This recognizes that member boards have varying resources and numbers of diplomates. This also encourages member boards to work with other stakeholders, including specialty societies, to develop educational content and tools for assessment. MOC is a structured process for continuous professional development that is based on six core competencies: • Practice-based learning and improvement • Patient care and procedural skills • Systems-based practice • Medical knowledge • Interpersonal and communication skills

• Professionalism As described in ABMS’ 2015 MOC Standards the program for MOC has an integrated fourpart framework that addresses: 1. P rofessional standing and professionalism 2. L ifelong learning and self-assessment 3. Assessment of knowledge, skills, and judgment 4. Improvement in medical practice The standards for ABMS programs for MOC are common across the ABMS member boards. However, there is flexibility in the standards that permit relevant differences and distinctions in programs among the specialties. To understand MOC, one has to also understand the ABMS, which is an umbrella organization made up of the 24 specialty boards. The ABMS “assist(s) its Member Boards in developing and implementing educational and professional standards to evaluate and certify physician specialists.” It does not receive any revenue directly related to the MOC activities of its member boards. Each specialty board has the ability to comply with MOC standards in its own way. Because each specialty board varies in the number of diplomates, some specialties with large numbers have greater resources and as a result the ability to continually produce more robust programs than the smaller specialties. This explains why the American Board of Internal Medicine (ABIM), the American Board of Family Medicine (ABFM), and the American Board of Pediatrics (ABP) have highly developed programs and earn a great deal more revenue than say pathology. This is why the larger specialties tend to receive more of the ire aimed at MOC. It is statistical.

clinical improvement. Given activities that are offered are the current state of electronic proprietary and specific to the health records this will have to member boards. A diplomate’s be evolutionary. choices are limited to The biggest the specialchallenge will ty. There is be the future of no effective the high-stakes competitive exam. A process market for of continuous educational professional activities, development which leads to uses approprithe conspirate and relevant acy theory of assessments to Maintenance MOC being a identify gaps in purely monof certification performance ey-making and educational means different scheme. opportunities

things to to improve outAnother comes. Using challenge is different people. assessments to integration identify gaps with the real makes sense. clinical data However, many physicians from electronic health records, registries, hospital data records, rightly question the role and purpose of a high-stakes exam. and other sources. For the system to be effective it must be informed by clinical data in order to drive effective appropriMaintenance of certification ate education and the desired to page 38

Challenges facing the new MOC standards One major challenge going forward is going to be in the area of integration and interoperability. Most of the MOC September 2014 Minnesota Physician

the Minnesota Hospital Association, predict that Minnesota will face a shortage of anywhere from 800 to a few thousand physicians in both primary and specialty care. On a national level, the Association of American Medical Colleges predicts a shortage of around 90,000 physicians in the coming years. Despite the number gap that exists going forward, there are people on all sides of this debate with concerns, but few concrete answers. How is graduate medical education paid for? The long-time system this country has had in place for educating and training physicians has contributed to the impending physician shortage. There is little question that it takes a considerable amount of time and money to become a physician. While there are certainly reforms taking place

at the medical schools around the country, most of the focus at the federal and state level has been on graduate medical education (GME). Currently, the federal Medicare program provides almost $11 billion dol-

Minnesota will face a shortage of anywhere from 800 to a few thousand physicians in both primary and specialty care. lars per year across the country to support graduate medical education. This money comes from both direct and indirect payments to teaching hospitals and other teaching facilities around the country. Minnesota receives just under $170 million dollars per year in federal GME funding. In Minnesota, on top of the federal Medicare dollars, the Medical Education and Research Costs (MERC) program, which is a program specific to the state, has provided around $57 million in additional state and federal Medicaid dollars

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for GME funding since 1998. Funding for the MERC program, however, has been in flux for a number of years, and is often the target of budget cuts and additional scrutiny by the Centers for Medicare & Medic-

Minnesota Physician September 2014

aid Services (CMS). In 2013, the Legislature took a step to specifically dedicate state dollars, through grants with the Department of Health, toward rural family medicine programs. While that grant program is still in its infancy, it will be interesting to see whether targeting dollars can help alleviate some of the challenges of enticing more physicians to practice in rural and underserved areas. In addition to the continuous budget challenges at both the federal and state level for

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The coming physician shortage from cover

GME funds, the Institute of Medicine released a report this past summer entitled, “Graduate Medical Education That Meets the Nation’s Health Needs,” which calls for a complete reform of the GME funding system and a phaseout of the current Medicare funds over the next 10 years, even calling into question whether a physician shortage exists at the front end. The new report raised a number of issues, including accountability in how GME dollars are spent, shifting training away from hospital settings to clinic-based settings, and shifting the focus away from training specialists to training more primary care physicians. The report certainly renews the debate about looking for alternative sources of funding to provide stability and a long-term solution to GME and training more physicians to meet the projected future demand for services.

Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

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Lots of challenges One of the central issues in the effort to help alleviate the physician shortage is that states are faced with many challenges in addition to the funding question. Some of the other challenges include federal restrictions on residency programs, limitations on clinical training sites, financial incentives, and geographic distribution. Each of these challenges play off each other and one would be hardpressed to find consensus in prioritizing them. Federal cap on residency slots. Apart from the ongoing challenge of budgets and overall funding, the most cited barrier to increasing the number of physicians in the workforce is the federal cap on residency slots. Since 1997, the federal government has maintained a restriction on the number of federally funded residency positions. Although more medical students are graduating every year, the cap on federally

funded residency slots limits the ability of a teaching institution from translating those additional graduates into an increased physician supply. These teaching institutions must bear the full extent of those train-

have argued that this is one of the most significant barriers to increasing the number of primary care physicians. It’s a problem because primary care practice is clinic-based rather than hospital-based and

The long-time system … in place for educating and training physicians has contributed to the impending physician shortage. ing costs themselves. Although there have been proposals in Congress to lift this cap in recent years, no formal action has been taken. This has prompted some states—including Wisconsin and North Dakota—to take a different approach and provide state-funded residency slots. Lack of training sites. Another significant challenge that hampers the training of physicians and other health care providers is the current lack of clinical training sites. Many

much of the graduate medical training takes place in clinics. On the surface, it may seem obvious to merely expand the number of primary care training sites, but it is not that simple. Medical clinics often do not have the space or the staff in place to meet training demands. Many clinics don’t have exam rooms that are large enough or any sufficient teaching space. They also don’t have the staff to train physician residents, and existing staff often ends up training without receiving compensation.

Debt burden. Finally, there is a significant economic challenge that affects the physician workforce—notably the increasing debt burden that new physicians incur. This economic burden may have an impact on the career path that new medical school graduates choose when deciding to pursue specialty training versus primary care training. Minnesota currently has a loan forgiveness program in place that targets primary care providers so they practice in rural areas, but the funds and opportunities remain limited. While loan forgiveness may be an effective tool for targeting a limited number of providers in rural and primary care, it remains to be seen whether it can make a significant impact on the current shortage of primary care and rural providers. How about non-physicians? While the debate continues about how to address the phyThe coming physician shortage to page 36

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September 2014 Minnesota Physician

Professional Update: Pain Medicine

rescription drug abuse is the use of such drugs for nontherapeutic purposes, most often to alter mood or state of consciousness. While prescription drug abuse is not a new problem, trends over the past decade are worrisome. According to the National Institute on Drug Abuse “prescription and overthe-counter … drugs are, after marijuana (and alcohol), the most commonly abused substances by Americans 14 and older.” Perhaps most alarming is the increasing abuse of opioid analgesics. The U.S. Centers for Disease Control and Prevention (CDC) has characterized deaths from opioid analgesic overdoses as an epidemic. A 2011 report from the CDC revealed that more than 40 people die every day from prescription narcotic overdoses. Overdoses involving prescription drugs now kill more Americans than heroin and cocaine combined.

Prescription drug abuse Policy initiatives designed to address an issue of epidemic proportion By Cody Wiberg, PharmD, MS, RPh

State Substance Abuse Strategy Several Minnesota state agencies have crafted the State Substance Abuse Strategy (SSAS), which is a collaborative and comprehensive multi-agency approach to the issue of substance abuse. The agencies that developed the SSAS concluded that “abuse of prescription opiates and heroin is a serious and rapidly escalating problem of significant proportion in Minnesota.” Consequently, abuse of those drugs was made the immediate policy priority

Minnesota Physician September 2014

when the SSAS was released in September 2012. The SSAS agencies have since worked on several policy initiatives designed to address prescription drug abuse, with a focus on the abuse of opioids. One initiative was support for the passage of certain provisions of Steve’s Law, which allow for easier distribution and use of naloxone, an opioid antagonist that can save lives when used to treat overdoses. Physicians, physician assistants, and advanced practice registered nurses can now authorize

emergency medical responders, law enforcement officers, and staff of community-based health disease prevention or social service programs to possess and administer naloxone, if certain requirements are met. Steve’s Law also has a “Good Samaritan” provision that provides some legal immunity for individuals who report overdoses, even though they also may have been abusing illegal drugs. The Prescription Monitoring Program The Board of Pharmacy, with the support of the other SSAS agencies, successfully worked to amend the section of statutes that requires the board to administer the Minnesota Prescription Monitoring Program (PMP). The PMP collects data on all Schedule II through V controlled substance prescriptions dispensed to residents of the state. (As of Aug. 18 of this year, tramadol became a federal Schedule IV controlled

substance and prescriptions for products containing tramadol now must be reported to the PMP.) Reporting is required from all instate pharmacies and other dispensers as well as from those out-of-state pharmacies that ship controlled substances to Minnesota residents. The PMP is primarily intended to be a source of information that prescribers and pharmacists can use when they are considering prescribing or dispensing controlled substances. In fact, prior to July 1, 2014, prescribers and pharmacists could use the PMP only when they were considering prescribing or dispensing controlled substances for current patients. Prescribers also now can use the PMP when providing emergency medical treatment for which access to the data may be necessary. Patient consent is not required when a prescriber uses the PMP for emergency treatment or when prescribing a controlled

substance. Prescribers can use the PMP when providing other, non-emergency, medical treatment, but only with the consent of the patient. Pharmacists are also allowed to use the PMP for purposes other than dispensing, with patient consent.

to this change. The board asked the Legislature to remove the reporting exemptions after learning that friends, family members, and even health care workers were using patient names to obtain controlled substances under false pretenses.

the release of prescriber names on the reports that are generated when prescribers and pharmacists query the PMP. Removal of that prohibition was the most frequent request the board received when it surveyed users of the PMP

Legislators, on a bipartisan basis, are very concerned with the epidemic of prescription drug abuse. Legislative changes to the PMP Some of the other changes related to the PMP that were made during the 2014 legislative session include: • A provision that allows the board to include the prescriber’s name on the reports that are generated when the PMP database is queried. Prior to this change, Minnesota was the only state to prohibit

• A provision that permits the board to engage in unsolicited reporting. After consulting with the PMP Advisory Task Force, the board will establish criteria that will be used to search the PMP database for individuals who might be engaged in inappropriate drug-seeking behavior. Letters then will be sent to the prescribers and pharmacies who appear to have provided care to those individuals. The letters will emphasize that the data alone is not enough to establish that drug-seeking behavior occurred.

about possible changes to the program. • A provision requiring that prescriptions be reported to the PMP when dispensed for individuals residing in certain long-term care facilities, receiving medication intravenously, receiving hospice care, or receiving home care services. Prescriptions for such patients were not reported to the PMP prior

Prescription drug abuse to page 34

Are Your Patients Ready? Minnesota’s New Immunization Law Goes into Effect 9/1/14

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There are important changes that apply to children entering school, child care, and early childhood programs. This Ready? means you likely have patients Are Your Kids Your Ready? Minnesota’s Immunization Law immunizations between who will need to get Are caught up onKids some of their Minnesota’s Immunization Law this chart as a guide to determine which vaccines are that requiredare to enroll in child care,or earlyrecomchildImmunization now and theUse end of the summer. For vaccines required chart asand a guide to determine which vaccines are required to enroll in child care, early childhoodthis programs, school (public or private). Immunization Requirements Use hood programs, and school (public private). Requirements mended, please use this chart (legal available). Find the child’s age/grade level andorlook toexemptions see if your child hadare the number of shots shown by the Find the child’s age/grade level and look tobirth see iftoyour number of shots shownLook by the checkmarks under each vaccine. Children age child 2 mayhad notthe have received all doses. at the checkmarks under iteach vaccine. Children birth to age 2 may not have received all doses. Look at the table on the back, shows the age when doses are due. table on the back, it shows the age when doses are due. Age: 5 through 6 years Age: 7 through 11 years Birth through 4 years Age: 12 years and older Age: 5 through 6 years Age: 7 through 11 years Birth through 4 years Age: 12thyears and older Early childhood programs For 1st through 6th For 7 through 12th For Kindergarten Early childhood programs & Child care For 1stgrade through 6th For 7th grade through 12th For Kindergarten & Child care grade grade

 Check marks represent number of doses

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DTaP/DT  DTaP/DT 

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

Polio  Polio  MMR  MMR  Hib  Hib  Pneumococcal  Pneumococcal  Varicella  Varicella

Hepatitis B  B Hepatitis 

DTaP

 DTaP 

Polio

Hepatitis B

 B Hepatitis  tetanus and anddoses tetanus diphtheria containing

diphtheria containing doses

 Polio  MMR  MMR 

Polio  Polio  MMR  MMR 



Tdap

atTdap 7th grade at 7th grade

Polio  Polio  MMR  MMR  Meningococcal  atMeningococcal 7th grade & at  age 16

 at 7th grade & at  age 16

Varicella

 Varicella   Immunizations recommended but not required: Immunizations recommended but not required: Influenza

Varicella  Varicella 

Immunizations recommended but not required: Rotavirus For infants Rotavirus

Hepatitis B  B Hepatitis

Annually for all children age 6 months and older Influenza Annually for all children age 6 months and older

For infants

Varicella  Varicella 

Human papillomavirus At age 11 -12 years Human papillomavirus At age 11 -12 years

Call in patients who need vaccines. Use the Minnesota Immunization Information Connection (MIIC) to identify and call in children who still need to get their shots. For more information or technical assistance, contact your MIIC regional coordinator:

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To enroll in child care, early childhood programs, and school in Minnesota, children must show To enrollhad in child early childhood and school in Minnesota, children must show they’ve thesecare, immunizations or fileprograms, a legal exemption. they’ve or file a legal Parentshad maythese file a immunizations medical exemption signed byexemption. a health care provider or a conscientious objection Parents may file a medical exemption signed by a health care provider or a conscientious objection signed by a parent/guardian and notarized. signed by a parent/guardian and notarized. For copies of your child’s vaccination records, talk to your doctor or call the Minnesota Immunization Information Connectionrecords, (MIIC) attalk 651-201-5503 or or 1-800-657-3970. For copies of your child’s vaccination to your doctor call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 1-800-657-3970.

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September 2014 Minnesota Physician

medicine and the law

innesota was the 22nd state to legalize medical marijuana. The road to legalization in Minnesota was long and winding, and the law will no doubt change in the coming years. This article addresses what health care practitioners need to know about the new law, its opportunities and pitfalls, and the likely direction of future action on this issue in Minnesota.

The basics Under federal law, marijuana cannot be prescribed. Minnesota’s law does not change that prohibition. Instead, the law provides that “health care practitioners” will “certify” that patients have a “qualifying condition.” (The law defines “health care practitioners” to include Minnesota licensed doctors of medicine, physician assistants acting within the scope of practice, and licensed advanced practice registered nurses who have primary responsibility for the care and

Medical marijuana in Minnesota Information that health care practitioners need to know By Kevin Riach, JD treatment of the qualifying medical condition of a person diagnosed with that condition.) Patients will use this written certification to obtain a license to purchase medical cannabis from the Minnesota Department of Health (MDH). Qualifying conditions include cancer accompanied by severe or chronic pain or nausea, glaucoma, AIDS, Tourette syndrome, amyotrophic lateral sclerosis (ALS), epilepsy, severe and persistent muscle spasms (including those characteristic of multiple sclerosis), and Crohn’s disease. In addition,

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Minnesota Physician September 2014

terminally ill patients with a life expectancy under one year who are experiencing severe or chronic pain or nausea qualify to obtain medical marijuana. The commissioner of health has the authority to add qualifying conditions to this list, but the legislature may veto any addition. Physicians may also certify that a patient is physically or developmentally disabled in such a way that prevents self-administration of their medical cannabis. These patients may designate a caregiver to acquire and administer

the medicine for that individual patient. For example, a minor child with severe epilepsy may not be able to self-administer medical cannabis. The “caregiver” certification will allow the child’s parent or guardian to both obtain and administer the medical cannabis without violating Minnesota’s controlled substance laws. The commissioner of health will license two manufacturers to produce medical cannabis in Minnesota. Marijuana cannot be imported from manufacturers in other states because of federal drug trafficking laws, so all medical cannabis used in Minnesota must be produced in the state. The licensed manufacturers must each operate four distribution sites, one of which may double as a manufacturing site. Distribution sites must be located in such a way that ensures reasonable patient access throughout the state. Manufacturers must employ licensed pharmacists to distribute the medical marijuana. The

commissioner will set a range of recommended doses for each qualifying condition. The pharmacist who distributes marijuana to a patient will consult with the patient to determine the appropriate dose, relying in part on the commissioner’s recommended dosage. Health care practitioners will not prescribe medical cannabis or recommend a dosage to a patient— again, the practitioner’s role is limited to certifying that a patient has a certain condition. The law authorizes several delivery methods for medical cannabis: (1) vaporizing (essentially smoking via an e-cigarette); (2) pills; and (3) oil. The law authorizes the commissioner to approve other delivery methods, subject to veto by the legislature. Smoking medical cannabis in any form, and consumption of the raw/dried marijuana plant, are notably absent from the list of approved delivery methods.

Provider responsibilities The law creates several “healthcare practitioner duties” beyond simply providing the appropriate certifications of qualifying condition or disability.

ed to the practitioner may be disclosed in aggregate form in connection with research to be performed by MDH regarding the efficacy of medical cannabis treatment.

We can expect broader access and more widespread use of medical cannabis in the coming years. First, prior to a patient’s enrollment in the medical cannabis program, a practitioner must provide the patient with certain “explanatory information” that will be developed by the commissioner of health and provided to health care practitioners prior to the commencement of the program. This “explanatory information” will include a disclosure about the experimental nature of the therapeutic use of medical cannabis, the possible risks, benefits, and side effects of medical cannabis, and a Tennessen warning that indicates any patient information provid-

Once a patient is registered and participating in the program, the law requires that health care practitioners report the health records of the patient to the commissioner and annually recertify the patient’s qualifying condition. The law does not speak to a health care practitioner’s duty to rescind certification if, between yearly recertifications, the practitioner’s diagnosis changes, or if the use of medical cannabis abates the qualifying condition. For example, one qualifying condition is cancer accompanied by chronic nausea. If

the nausea abates for several weeks, a month, or a year after treatment with medical cannabis, does the health care practitioner need to recertify at any of these points? The law is silent. Unfortunately, practitioners will likely need to wait for implementation of the law to resolve such questions. Task force The law establishes a task force to evaluate medical evidence about the efficacy of medical cannabis, as well as the social impact of the new law. The task force members include law enforcement, legislators, patients, health care providers, substance abuse treatment providers, and commissioners of several state agencies. The task force will report to the legislature in February 2015 and every two years thereafter. Task force reports will include suggested revisions to the law. Medical marijuana in Minnesota to page 30

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September 2014 Minnesota Physician

oncology

euroblastoma is a rare childhood cancer that can be difficult to treat. According to the American Cancer Institute, an estimated 700 people in the United States are diagnosed with this form of cancer each year. It accounts for only 7 percent of all childhood cancers, but 15 percent of childhood cancer deaths. Approximately half of all children with neuroblastoma are considered to have high-risk disease at diagnosis, making their treatment journey more precarious. Neuroblastoma typically presents in children less than 10 years of age and the symptoms at diagnosis differ depending on the location of the cancer. Children presenting with abdominal tumors may have pain, swelling of the legs, or changes in bowel habits. Those with mediastinal disease may present with chest pain, difficulty breathing, and/or Horner’s syndrome. Children with high-risk disease that have

MIBG therapy New hope for neuroblastoma patients By Emily Greengard, MD

metastases at diagnosis may present with bone pain. When the level of suspicion is high for neuroblastoma, imaging studies that include CT or MRI should be obtained, as well as urine studies for HVA and VMA.

Traditionally, patients with

MIBG therapy has been shown to be effective and has led to disease response or stabilization in 55 percent of cases. The diagnosis is confirmed by biopsy, and staging includes a nuclear medicine scan called Metaiodobenzylguanidine (MIBG) as well as bone marrow studies. The prognosis is quite variable depending on

American Diabetes Association EXPO Healthcare Professional Breakfast Saturday, October 11, 2014 at 7:00am Minneapolis Convention Center Meeting Room 103 DEF What are the Most Effective Weight Loss Interventions for Diabetes and Prediabetes Presentation by Dr. Charles Billington, MD Losing a few pounds can dramatically improve health and quality of life especially for people with diabetes and prediabetes. Effective weight loss can involve multiple techniques and strategies including lifestyle changes, medication and surgical options. Please join us for an informative discussion on the most effective weight loss interventions for those with diabetes and prediabetes as well as how to guide your patient through the weight loss process. Objectives: Compare the range of approaches for weight loss Describe the body’s physiologic mechanisms to protect against weight loss Identify ways to support a patient working to lose weight 7:00 am - 8:15am Breakfast, Networking, Presentation and Discussion RSVP on-line at http://diabetesmn.wufoo.com/forms/hcp-breakfast-rsvp/ Space is limited. Please RSVP by Friday, October 3, 2014 Event is free of charge and open to all healthcare professionals to attend

the age of the patient, stage of the disease, and biology of the tumor. Only about 50 percent of children classified as having high-risk disease will survive.

Minnesota Physician September 2014

high-risk neuroblastoma receive multimodal treatment with chemotherapy, surgery, autologous stem cell transplant, radiation, and immunotherapy. When these treatments are unsuccessful in reducing or eliminating the cancer, patients and their health care providers are left with very few options. However, a more novel treatment option now available at the University of Minnesota has shown some promise: This treatment is called MIBG therapy. MIBG therapy for the treatment of relapsed neuroblastoma has been used for more than 20 years at hospitals across the country including Philadelphia, San Francisco, and Michigan. Now, MIBG therapy is available in Minnesota at the University of Minnesota Children’s Hospital (formerly Amplatz Children’s Hospital). We began treating patients with MIBG therapy in January 2014 and have had positive results so far. Prior to this, the closest institutions using MIBG therapy were the University of Wisconsin–Madison and the University of Colorado in Denver. The University of Minnesota Children’s Hospital is able to offer MIBG therapy because of the research that takes place here. The treatment is not FDA-approved, so in order for patients to access MIBG therapy, they must enroll in a

clinical trial. Due to the radioactivity associated with the therapy, institutions offering this treatment need a strong nuclear medicine and radiation safety program. The university Children’s Hospital offers all of these components. Targeted therapy MIBG is a targeted therapy used in conjunction with radioactive isotopes of iodine for children with relapsed or refractory neuroblastoma who have not responded well to other therapies. MIBG therapy has been shown to be effective and has led to disease response or stabilization in 55 percent of cases. When MIBG is radiolabeled with radioactive iodine and injected into a patient’s vein, it travels to anywhere in the body where the neuroblastoma is. The radioactive iodine is absorbed by the neuroblastoma cells and the cells are killed as a result. Thus far, MIBG has only been used in patients with refractory and relapsed disease, however, new studies are in development to assess its effectiveness as an up-front treatment. In order to be eligible for treatment, patients must be over 1 year of age and have disease that is MIBG avid. As the treatment involves a radioactive material, patients are housed in a lead-lined room during their treatment and are released once they are no longer radioactive. Currently, there are three common scenarios in which MIBG therapy is used: 1. The patient has gone through standard of care for high-risk neuroblastoma and has a disease recurrence. 2. The patient has disease progression during standard of care therapy for neuroblastoma. 3. The patient has had a reasonable response to chemotherapy, but still has residual disease prior to proceeding to myeloablative chemotherapy and autologous stem cell rescue.

Previous studies have shown that MIBG therapy is very well tolerated. In fact, patients have commented that it may be the easiest therapy they have received. Not only is MIBG therapy “easier,” 30 percent to 40 percent of patients will see a partial response and another 30 percent will have disease stabilization. Patients have reported that the hardest part of the treatment is being isolated in a lead room for up to a week due to the radioactivity of the treatment. Patients are discharged from the hospital and allowed to leave the room, once the levels of radiation they emit are at a safe level. This typically takes three to seven days. For younger children, parents are able to stay in the room with the patient; however, their radiation exposure is monitored very closely. During the week in isolation, patients are kept quite comfortable and have access to music, games, movies, and television. Anything they bring in from home must be screened

initial patients have had positive results. Our first patient to be treated, a 20-year-old man from North Dakota, had significant improvement in both his pain Previous studies have and respiratory status shown that MIBG therapy following his first treatment. He returned is very well tolerated. for a second treatment and continues to have stable disease and be free MIBG therapy is, however, of symptoms. From previous not free of side effects. The patients across the U.S., the most common side effect is that average patient will receive one MIBG therapy suppresses the to two MIBG treatments for bone marrow and patients may neuroblastoma. As long as the need an autologous stem cell inpatient has stable disease or a fusion following treatment with response to the therapy after MIBG if they have prolonged the first treatment, he or she cytopenias. Nausea at the time is eligible to receive a second of infusion and significant dry treatment. mouth also have been reported. for contamination at the time of discharge and if contaminated, cannot be taken home.

MIBG therapy also can be toxic to the thyroid, but potassium iodide drops will help to mitigate those side effects. Promising results Consistent with the results that other institutions have had, our

Our patient from North Dakota had multiple treatments for recurrent neuroblastoma prior to receiving MIBG therapy and is a great example of the need for new treatment options and clinical research studies for neuroblastoma. The

data being collected is invaluable in our goal to obtain FDA approval by increasing data on safety and efficacy. We are also developing other early phase clinical trials for patients with relapsed and refractory neuroblastoma. As our neuroblastoma program continues to grow, we hope to develop more innovative clinical trials to help and improve the lives of our patients and future patients. We are optimistic that MIBG therapy will become a more routine treatment option for children with neuroblastoma. Emily Greengard, MD, is board-certified in pediatrics and pediatric hematology/oncology. She is an assistant professor in the Division of Pediatric HematologyOncology and the program director for the pediatric hematology/ oncology fellowship program at the University of Minnesota. She is the institutional PI for the Children’s Oncology Group Phase I Consortium and established the MIBG therapy program at the University of Minnesota Children’s Hospital.

Many Faces oF coMMunity HealtH

2014 ConferenCe

community centered care and the People We serve Thursday, October 23 - Friday, October 24, 2014 • Marriott Minneapolis Southwest - Minnetonka, MN Join us for a two-day conference on improving care and reducing health disparities in underserved populations and among those living in poverty. We will examine new community care innovations and health care delivery models that promote health equity, prevent and manage chronic diseases, and assure access for those facing significant health disparities.

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September 2014 Minnesota Physician

SPECIAL FOCUS: CHRONIC ILLNESS

ultiple sclerosis (MS), a chronic, degenerative neurological disease of the central nervous system, affects 400,000 patients in the United States every year, according to the National Multiple Sclerosis Society. The cause is unknown. Current theories suggest a variety of causes, including viral, genetic, and environmental.

Caring for patients with multiple sclerosis

The average age at diagnosis is 32 years. Most people diagnosed with MS have grown up or currently live in the northern latitudes. Some believe that vitamin D plays a part in MS because of its positive effect on immunity. People living closer to the equator are exposed to more sunlight and, therefore, have higher levels of vitamin D.

By Amy Diede, MD more manageable. As a result, patients are living longer and are more functional. Just like the rest of the population, they experience medical problems that have nothing to do with their MS—yet, the MS may change the way a physician treats the accompanying problem.

For most patients, a primary care physician will be the first to recognize symptoms of MS and will continue to treat the patient’s overall health in the years ahead. While MS is not yet curable, today’s health care environment makes the disease

Diagnosis and follow-up Primary care physicians are often the first to recognize motor difficulties, sensory deficits, and cognitive decline that often suggest MS. A patient may present with numbness, tingling, or burning

The role of the primary care physician

What YOU can do to

PREVENT DIABETES

pain; visual disturbances; weakness or fatigue; bowel or bladder incontinence; spasticity; vertigo; or short-term memory loss. Early recognition of these symptoms can lead to a timely formal diagnosis by a neurologist. It is the primary care physician, however, who often coordinates ongoing care and disease management. This might include treating and managing any MS relapses, or return of the symptoms noted above, on an outpatient basis, as well as monitoring the patient’s overall health to ensure that he or she receives the

proper screening for common problems such as high blood pressure, diabetes, reduced kidney function, and emotional distress. If the exacerbation is more severe, a short course of high-dose steroids may be helpful, either in oral or infusion form. A more serious case would likely involve coordinating a team of providers, including a neurologist, urologist, rehabilitation specialists, mental health providers, nutritionists, and nurses. In some cases, the presence of MS may require a more complex health-care decision-making process. Sometimes the symptoms of MS can overshadow or block symptoms of other illnesses, making it critical for primary care physicians to engage their patients in an open and honest dialogue about their medical condition. While the physician plays an important role in guiding these conversations, today’s patients often come armed with information they have found on the Internet and a desire to play a

1 in 3 adults has prediabetes. Most do not know it. 15-30% will go on to develop type 2 diabetes within 5 years. The good news is type 2 diabetes can be delayed or prevented in most people if they participate in the evidence-based National Diabetes Prevention Program (NDPP).

What you can do: • Screen every patient over age 45 or with multiple risk factors. • Refer those with prediabetes or history of GDM to a local NDPP site. IT WORKS! • Encourage everyone to be physically active, lose a little weight if overweight and to not smoke.

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Minnesota Physician September 2014

larger role in decisions affecting their health. Physicians need to allow enough time for these conversations to take place. Common health issues for patients with MS Patients with MS are first and foremost individuals who are susceptible to the same aches and pains as everyone else. In addition, however, they often present with unique health concerns as a result of their MS. Some of the more common health issues affecting patients with MS include: • Infections. Infections can trigger an MS relapse and require a physician to treat the infection simultaneously with the increased MS symptoms. Some of the newer MS therapies also may suppress the immune system, increasing the risk for infections or malignancies. Patients with MS should receive a flu shot (not the mist) and Pneumovax vaccine if they are at risk. They also need regular blood tests, such as complete blood cell counts, blood chemistry, and liver profiles to monitor any signs of infection. • Skin breakdown. Since patients with advanced MS often use a wheelchair or spend significant time in bed, they are susceptible to skin breakdown or pressure sores. These sores typically occur at the tailbone, buttocks, heel, shoulder blade, elbow, or back of the head. When sores develop from sliding across a bed or wheelchair seat, they are called shear. Skin is more likely to break down if it is wet or infected, so incontinence can complicate the healing process. Sometimes a referral to a wound care specialist is in order. • Cognitive impairment. Short-term memory loss is often the first sign of cognitive impairment, but a patient with MS also may experience decreased executive function, trouble concentrating, and difficulty with spatial relations. Interventions might include referrals to physical and occupa-

tional therapy, medications to slow the progression, and exercises to enhance cognitive function. • Diminished bladder and bowel function. Bladder issues are present in about half of all MS patients. They may manifest themselves as urinary tract infections or various forms of incontinence, including a failure to store urine or empty the bladder efficiently. Bowel problems can include constipation, diarrhea, or fecal incontinence. Diminished bladder and bowel functions can lead to increased social isolation and may be handled best with a referral to a specialist.

High-dose steroids may help to shorten the duration of the disease, but have not shown any improvement in the long-term prognosis for vision. Many times, ophthalmology becomes involved in the treatment at this point. Treatment In addition to addressing these health care concerns, physicians also may need to monitor medication levels more closely for MS patients and schedule screenings that a non-MS patient may not

need. Disease-modifying agents can slow the progression of relapsing forms of MS. Some of the more common medications used today include the following: • Beta interferons (Avonex, Betaseron, Extavia, Rebif) are injected. They may cause flu-like side effects, and patients need blood tests to monitor their liver enzymes. • Dimethyl fumarate (Tecfidera) is administered twice a day. Side effects might inCaring for patients with multiple sclerosis to page 32

• Osteoporosis. Because patients with advanced MS often use a wheelchair and, thus, are non-weight bearing, they have a greater risk for osteoporosis. In addition, the use of corticosteroids can increase the loss of bone density. Frequent monitoring, along with calcium, vitamin D, and medications designed to slow the progression of osteoporosis, are sometimes necessary. • Decreased motor skills. Patients with MS can develop decreased motor skills, making them more susceptible to falls and difficulty swallowing. For patients with spasticity or tremor, there are products on the market today to lessen the impact of these symptoms, including drug pumps and deep brain stimulation devices. • Decreased vision. Optic neuritis, an inflammation of the optic nerve, can be a symptom of an MS flare-up. It presents with rapid, painful loss of vision, usually only in one eye. Optic neuritis is present in 25 percent of MS patients, according to the National Multiple Sclerosis Society, often accompanied by pain and a blind spot in the center of vision. Not only is this frightening and uncomfortable, but it also can lead to a greater loss of independence, such as driving restrictions.

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September 2014 Minnesota Physician

Special Focus: Chronic Illness

arely do we have an option to add a new service that immediately affects a big percentage of patients in a positive way with minimal investment, minimal change to the practitioner/staff workload, and significant contribution to the revenue base of the practice. Several months ago, a consulting firm with a novel idea approached the CEO at Multicare Associates: Add hearing care as a fully-integrated new service. To be honest, we had never considered the idea. The learning process that ensued was profound, and our hearing care department is now six months old. Building the case for a hearing program The facts and statistics that support the addition of a hearing care program are impressive. They are compiled from the Better Hearing Institute in Washington, D.C., a clearinghouse for data, literature, and

Can you hear me now? Another way to help your patients By James Keane, MD, and John Olive, MHA

direct consumer research about hearing loss and hearing aids. • Arthritis, hypertension, and hearing loss are the three most common chronic medical conditions in the world. • Hearing loss (35dB+ in both ears) is heavily concentrated in the senior adult population. It affects from 30 percent (at age 55) to over 80 percent (at age 75+) of all older patients.

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• Johns Hopkins now cites 48 million patients with hearing loss >35dB (up from 34 million a decade ago). • Eighty percent of patients with hearing loss of 35dB+ (the point at which communication and speech comprehension are significantly impaired) have never been tested or treated. The aggregate services of ENT, audiology clinics, and retail hearing aid stores in the U.S. have reached only 20 percent of patients with the problem. • Ninety percent of all cases of hearing loss are not correctable or reversible. Hearing aids are the only effective treatment option. • Patients cite “the recommendation of my physician” as the single-most powerful influence on decisions to have their hearing tested or get hearing aids. • The absence of hearing testing and physician guidance in the primary care setting is a major contributor to the low capture and treatment of clinically significant hearing loss. • The baby boomer generation is experiencing much higher incidence of hearing loss, caused primarily by lifelong exposure to loud music and the use of headphones and other electronic devices. All generations that follow will reflect the same loss. • Digital technology, features, sound performance, and miniaturization have

Minnesota Physician September 2014

significantly improved patient interest in and acceptance of hearing instruments; however, many patients distrust the conventional retail setting. They want their doctors’ input. Is it just a “quality of life” issue or is there more? To be sure, difficulty hearing and understanding has a negative impact on virtually every aspect of daily life. However the National Council on Aging (NCOA) goes further to link untreated hearing loss to clinical depression, acceleration of dementia and Alzheimer’s, anger management issues, an increase of fears and phobias, and social withdrawal and isolation. In its 1999 study, “The Consequences of Untreated Hearing Loss in Older Persons,” the NCOA concludes that untreated hearing loss “has a profoundly negative effect on virtually every aspect of physical, cognitive, behavioral and social functioning.” Summary translation of the facts and figures Our practices are full of patients who have hearing loss and don’t know what to do about it. They want our direction and guidance. Hearing loss, when ignored, often goes untreated for up to 10 years or more and has negative effects on everything from personality to the ability to remain engaged and functional in the world. With a basic program of screening, testing, and hearing aid fitting (along with referral to an ENT for more serious problems), we can help up to 90 percent of the patients we identify on-site at our offices. This is the care that patients want. Why didn’t we do this sooner? If hearing care is such a good idea today, why didn’t we incorporate it years ago? Most likely, the answer is simple, but with multiple parts: • For decades, hearing aids simply weren’t believed to be much help with hearing

loss. Digital technology now has revolutionized how these devices work, but that wasn’t the case for a long time. • The clinical impact of untreated hearing loss has been largely unknown or minimized. • The power of physician influence was unknown. • We abhor the idea of high-pressure, gimmicky retail sales that we associate with hearing aids, and we have never wanted that type of service housed in our clinics. • We never had access to a “service provider” that could provide a turnkey operation that is clinically sound, technologically superior, and would conform to the character of our respected medical practices. The decision to go forward We looked at our large number

of patients over age 55 and the statistics about the occurrence of significant hearing loss in this population. We saw a compelling opportunity to help our patients and establish a robust new clinical service. We wanted a low-key program with no selling required from our staff, and no pressure on our patients.

• Clinical configuration: The hearing care program is designed to blend with our existing workflow for complete annual physicals and non-acute visits. Patients are screened as part of the routine workup. The screening takes less than one minute. Our doctors

Our practices are full of patients who have hearing loss and don’t know what to do about it. And we wanted it to be easy. We found a program model that met these criteria. How does it work? We partnered with Hearing Health, Inc. because they know how to build and run a hearing care program, so we do our thing, and they do theirs. Here is how the hearing program has worked for us:

comment on the screening result (pass or fail) during their patient interview. Patients who have trouble on the hearing screening are referred for a more complete test, which is scheduled at our office and is conducted by our licensed hearing specialist. All subsequent clinical decisions (including referral to ENT as needed) and

discussions about hearing aids (when appropriate) are handled by the hearing professional. • A turnkey operation: Our partner provides a complete hearing department, including clinical staff and equipment and the forms and procedures we need. They manage the clinical person onsite, though this person has fully integrated with our daily operation and has become a member of our team. Training and regular consultation with our CEO is part of the package. Our job is to screen and refer patients. They do the rest. • Time sensitive: The program is designed to minimize the time required from our doctors, techs, and front desk staff. We’re still working out the kinks, but the intent is that each Can you hear me now? to page 29

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September 2014 Minnesota Physician

Special Focus: Chronic Illness

or the past 21 years, I have had the honor of caring for the majority of children with sickle cell disease (SCD) in Minnesota. Since I last wrote about SCD for Minnesota Physician 14 years ago there have been many changes. Since then, the number of babies diagnosed by newborn screening in Minnesota has more than doubled. We now care for just over 200 children with SCD, and that number has almost tripled. In my last update, I talked about stroke prevention, hydroxyurea, and bone marrow transplantation. Letâ&#x20AC;&#x2122;s take a fresh look at these issues, along with some exciting new developments. Stroke Stroke is perhaps the most dreaded complication of sickle cell disease. Historically, 10 percent of children with Hb SS disease (sickle cell anemia) suffered a stroke before the age of 16. We now have a way to predict who will have a

Sickle cell disease Steady progress toward a cure By Stephen C. Nelson, MD

stroke so we can prevent it. The 1998 STOP (stroke prevention) trial used transcranial doppler ultrasonography (TCD) to measure intracranial arterial blood flow velocities. Increased velocity correlates with vascular stenosis and increased risk of stroke. This randomized trial in children with abnormal TCD showed that monthly red cell transfusion decreased stroke incidence by 90 percent. The follow-up STOP II trial published in 2005 recommended that transfusions be continued indefinitely for children with abnormal TCDs. As you can imagine, this is a huge burden on patients, families, and the health care system. We are one of 25 centers

participating in the NIH-sponsored TWiTCH study (ClinicalTrials.gov Identifier: NCT01425307) that compares hydroxyurea therapy to transfusions for stroke prevention. This is a non-inferiority trial to see if hydroxyurea is not worse than transfusions in preventing strokes. This study will be completed in 2015, and will hopefully make stroke prevention less burdensome. Hydroxyurea Increased levels of fetal hemoglobin (Hb F) interfere with red blood cell sickling and can help prevent certain complications of sickle cell disease. Infants with sickle cell disease are protected from vaso-

occlusive problems until their Hb F percentage falls to adult levels by 6 months of age. Fetal hemoglobin levels of 10 percent may prevent silent end-organ damage, and levels of 20 percent or more may prevent acute vaso-occlusive phenomena such as pain and acute chest syndrome. Hydroxyurea is an oral chemotherapeutic agent that can increase Hb F levels by an unclear mechanism. The use of hydroxyurea in children continues to increase and it appears to be even more effective than in adults. The recent BABY HUG study proved efficacy and safety in children as young as 9 months of age. We now have over 20 years of experience with hydroxyurea in children. The initial fears are decreasing and most feel (including the new NIH guidelines) that all patients with SCD should be offered hydroxyurea. At Childrenâ&#x20AC;&#x2122;s, our goal is to get as many infants on hydroxyurea as we can by 12

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Minnesota Physician September 2014

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months of age. At the National Sickle Cell Conference in April, we presented our initial experience with six patients where we started therapy by 6 months of age. The responses in our patients have far surpassed the results from the BABY HUG study where the mean age was 14 months. However, hydroxyurea is still underutilized and more work is needed to increase the use of the only disease-modifying medication we have.

plants as well as reduced-intensity preparative regimens that have significantly reduced transplant-related morbidity and mortality. Most recently, the group at Johns Hopkins (headed by Robert Brodsky, MD) has tried the new approach of using haploidentical donors (half-matched, such as a par-

Bone marrow transplantation The only current available cure for SCD is stem cell transplantation. The first successful transplant for SCD was done in 1984 in a child that also had leukemia (the reason for the transplant). Since then, hundreds of transplants have been performed. But, this curative therapy is still limited by its toxicity and by a lack of suitable donors. Things are much better now because of improvements with unrelated donor trans-

ent). If successful, this would greatly increase the access to this treatment, as over 95 percent of the population will have at least one potential haploidentical donor.

echocardiography, and that this is associated with early mortality. Since that time it has become clear that pulmonary hypertension (PHT) is the leading cause of death for those with SCD. In 2007, we published our study in the Journal of Pediatric Hematology/Oncology showing that one-third of children also

Among the many complications of sickle cell disease, the hallmark is pain.

New developments Pulmonary hypertension In 2004, Mark Gladwin, MD, and colleagues reported in the New England Journal of Medicine that 32 percent of adults with SCD have elevated pulmonary pressures as measured by

show evidence for PHT. Since then we have been screening all of our patients for PHT starting at age 10. For those who have elevated pressures, we start hydroxyurea therapy. This is effective in correcting the PHT in over 90 percent of children. Gene therapy I believe a cure for SCD will be found in gene therapy. Early results of the ongoing French trial using autologous stem cells transduced with a lentiviral vector encoding the human

beta-globin gene are quite promising (ClinicalTrials.gov Identifier: NCT02151526). As the genetic defects for thalassemia and SCD are found in the same part of chromosome 11, it makes sense to try this technology in people with SCD. In fact, there is an open gene therapy trial at St. Jude’s (ClincalTrials.gov Identifier: NCT00669305) and one soon to be open at Cincinnati Children’s. Both sites are using retroviral vectors containing γ-globin coding sequences to increase Hb F production. If successful, this will allow patients to stop taking hydroxyurea. Greg Vercellotti, MD, and colleagues at the University of Minnesota are planning to test whether a TALEN-mediated in situ site-specific correction of human beta-hemoglobin gene in human stem cell progenitors from sickle cell patients will translate normal hemoglobin A in vitro.

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September 2014 Minnesota Physician

FIRST PERSON

y clinical practice as a psychiatrist focuses on the needs of children, adolescents, and adults with developmental disabilities. In this role I often hit roadblocks for my patients when they need services and treatments other then traditional medical care. This is especially true for people with autism, a condition that now is estimated to occur in one out of every 88 children. After nearly 25 years in practice my clinical experiences are extensive, but they don’t have quite the same impact as my personal experiences do. My 26-year-old son has autism, and seeing the system through the perspective of a mother really brings home the need for improving the quality of life for people his age who are approaching adulthood. My son does a lot on his own; he is relatively self-sufficient on a day-to-day basis and graduated this spring from a technical school program. He does not drive, but is able to take public transportation

Autism spectrum disorder Improving the quality of life for adolescents and young adults By Elizabeth Reeve, MD and enjoys many independent activities such as biking and walking the dog. He has a wonderful sense of humor, works hard, perseveres at everything he does, and enjoys being with others. Despite all of these skills there is also a lot he cannot do. Right now this means he is unable to live on his own. As my son, and other high-functioning adolescents and young adults with autism move into the early stages of adult life, their difficulties do not go away. As a physician, you should be aware of the issues that families and patients with autism may face

Read us online Wherever you are!

www.mppub.com 26

Minnesota Physician September 2014

during the transition to adulthood. The challenges of approaching adulthood Finding meaningful employment is a serious challenge for young adults on the autism spectrum. Statistics suggest that this group is at a very high risk for not completing school and failing to find employment or success in secondary education. While there are a growing number of agencies that specifically target job placement for people with autism, the unique job needs of these young adults still makes job placement difficult. Often, a young adult with autism may have sensory needs that impair the ability to work in certain environments. Decision-making skills may be slowed and therefore fast-paced jobs may cause increased stress or anxiety. There is a growing need for committed individual employers who can see the rewards of hiring an individual who may have unique needs, but who also can bring exceptional value to an organization. Housing is another area of need, and our current social service model of working toward independent living may not always be the best for someone with autism. A typical young adult may find the thrill of a first apartment exciting and motivating. They may explore the neighborhood and join the local gym in order to meet new people. A person with autism may be overwhelmed by all of the change and isolate him or herself. They may turn on the computer and get so lost in the Internet that they forget to buy groceries or shower. The perceived benefits of integrating a person with autism into the community may quickly disap-

pear. Many agencies are now working on a variety of living options. Apartment buildings with individual units and a fulltime staff will triage, assist, and check in on autistic residents. Shared space with a part-time staff is an option to consider. Families also could join together and purchase a separate home for several young adults. Creativity is the key to housing success and individual needs must always be the priority. Learning to drive, a rite of passage for most teens, may be a challenge if you have autism. Many adults with autism can drive, but many cannot. Although the physical aspects of driving may not be difficult, the multitasking required to drive safely may be. Not driving may limit job seeking and socialization, and people with autism in rural areas of the state have a greater risk for being isolated if they can’t drive. Physicians with questions about the ability of their patients to manage driving can refer their patient with autism to a rehabilitation organization that conducts independent driving assessments. Social vulnerability Consideration needs to be given to the social vulnerability of this unique group. Young adulthood is a time when there are many complex new experiences such as signing contracts, buying a car, taking out a credit card, and learning to manage money. People with autism may be vulnerable to being taken advantage of in predatory interactions. You will likely ignore the phone message left on your answering machine guaranteeing a “free” vacation in the Bahamas as a possible scam. Less sophisticated young adults with autism may fall prey to such schemes and quickly find themselves in over their heads without knowing what happened! I know of a young man with autism working as a cashier who was convinced by his friends to give them a 10 percent discount every time they came through his checkout line. His line became popular and he perceived this to mean that he was making more

friends when he really was being misled and taken advantage of. Because of these social vulnerabilities, families may want to consider pursuing legal guardianship for their young adult. The physician’s role As a physician, you can contribute a great deal to helping people with autism and their families make a successful transition to adulthood. For starters, doctors can initiate a discussion with families about transition issues and plans. This should start at the age of 14 or 15, long before most families may be thinking about future jobs and issues like guardianship. It may take a family several years to process the complexities of the system issues and to grieve about the losses they may experience related to raising their child. Physicians should become familiar with community services specifically related to autism and encourage families to make connections

with these organizations. Every local autism society maintains a detailed list of service organizations. Societies often hold educational sessions that explain issues such as guardianship, future financial arrangements, medical insurance, and housing options. Physicians can and should play an active role in encouraging caregivers to take care of themselves. Often families are dealing with great stress when they are living with an older adolescent or an adult who has a disability. Encouraging selfcare, exercise, and time away is imperative for the long-term well-being of the caregiver. It is important as the medical provider to recognize that the young adult may not seem that difficult to manage in your office, but may present many challenges that the family has dealt with for years. Long-term cumulative stress is emotionally exhausting and may exacerbate medical conditions. Caregivers have increased rates

of chronic medical problems such as hypertension, obesity, and cardiovascular disease as well as increased mental health concerns. Remember to take care of the caregivers in your practice! Learn to talk about the possible financial stresses your patients’ families may be having because of their child’s disability. Often parents have accrued financial debt supplying ser-

Physicians can help by recognizing that autism is a permanent disability. vices and treatments as their child has grown. Retirement plans may be disrupted due to the need for parents to stay nearby the disabled adult. Partially or underemployed adults with autism may make enough of an income to decrease their dependence on social services,

but not enough to live comfortably. This financial discrepancy may be mitigated by the family, causing further financial strain. Finally, physicians can help by recognizing that autism is a permanent disability. Growth and change will occur over time, but the range of development between people is huge and outcomes are variable depending on many factors. Take the time to talk to your patients and families who have children with autism about work, school, housing, and finances. My son is doing well now but I will not always be here to care for him. It is my greatest fear in life that he will not be able to manage his future. You can be part of the support for the families dealing with autism in your practice. I should know—I need all the help I can get! Elizabeth Reeve MD, is a board-certified child and adolescent psychiatrist practicing with HealthPartners Medical Group.

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Thursday, October 2, 7:30pm – BEST AVAILABILITY Friday, October 3, 8:00pm Saturday, October 4, 8:00pm St. Andrew’s Lutheran Church, Mahtomedi John Storgårds, conductor Baiba Skride, violin Sibelius: Pelléas and Mélisande Martin: Violin Concerto Beethoven: Symphony No. 5

TICKETS: $12-$50

Beethoven’s First Symphony Thursday, October 9, 7:30pm Trinity Lutheran Church, Stillwater Friday, October 10, 10:30am – BEST AVAILABILITY Saturday, October 11, 8:00pm Ordway Music Theater, Saint Paul Sunday, October 12, 2:00pm Ted Mann Concert Hall, Minneapolis Martin Fröst, director and clarinet Grieg: Holberg Suite Mozart: Clarinet Concerto Beethoven: Symphony No. 1

TICKETS: $10-$40

To order:

MNPhysician_Sep2014.indd 1

9:08:42 AM27 September 2014 Minnesota9/10/2014 Physician

Sickle cell disease from page 25

All of this work is incredibly exciting. Gene therapy likely will be much safer than stem cell transplantation and it does not require a donor. This means that this potentially curative technology would be available to every patient with SCD. GMI-1070 Until a routine cure with gene therapy is readily available, we need to still focus on ameliorating the complications of SCD. Previous treatments often focused on the abnormal hemoglobin as the main factor in vaso-occlusion and resultant disease. However, over the years we have recognized the myriad pathways that lead to vascular obstruction. Inflammation is a huge issue and much work is being done in this area. Perhaps one of the most exciting treatments is a pan-selectin inhibitor called GMI-1070. Among the many complications of SCD, the hallmark is pain. Unfortunately, this is the area

of management where we’ve made the least headway. For decades, the management of pain has consisted of fluids, analgesics, and non-pharmacologic comfort measures such as heat, massage, and guided imagery. To date, there has been no intervention directed at the acute vaso-occlusive vascular obstruction that causes pain in people with SCD. Hopefully, this is about to change. We have been invited to participate in a Phase III multicenter study to evaluate the efficacy and safety of GMI-1070 in the treatment of vasoocclusive crisis in hospitalized children with SCD. GMI-1070 is an investigational, intravenous, novel pan-selectin inhibitor. It acts to block adhesion of red blood cells to the blood vessel wall. In a randomized, placebocontrolled study in adults with SCD, those receiving GMI-1070 were discharged home an average of 60 hours earlier than patients receiving placebo. If approved, this could improve

the lives of many people with SCD. Final thoughts Progress is slow and uneven. Sickle cell disease was first described in 1910 by James Herrick, MD, in the Archives of Internal Medicine. In the ensuing 104 years, there has been only one FDA-approved therapy for sickle cell disease. The drug, hydroxyurea, was actually not developed for sickle cell disease but to treat malignancies. There are, however, 37 FDA-approved medications to treat HIV. This can be partially explained by marked discrepancies in funding directed at certain diseases. In July 2011, I wrote about health equity in Minnesota Physician. I reported on the funding discrepancies between SCD (a disease that predominantly affects black patients) and cystic fibrosis (CF), a disease that predominantly affects white patients. Unfortunately, the gap has widened. As presented at the National Sickle Cell Confer-

ence in April, per-patient funding for CF is 11 times greater than that for SCD. The number of NIH Career Development Awards is the same for CF and SCD research. However, there are three times as many Americans with SCD when compared with those with CF. Furthermore, since 2009, there have been five new FDA-approved medications for CF and none for SCD. As I look back over the past decade, I am excited about how far we’ve come. I am hopeful for a cure, but, after 104 years, progress sometimes feels just a little too slow. Stephen C. Nelson, MD, is board-certified in pediatric hematology/oncology and is the director of the hemoglobinopathy program and co-director of the Vascular Anomalies Clinic at Children’s Hospitals and Clinics of Minnesota. He is also an adjunct assistant professor of pediatrics at the University of Minnesota and is a member of the Newborn Screening Advisory committee at the Minnesota Department of Health.

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Minnesota Physician September 2014

URGENT CARE

Can you hear me now? from page 23

patient only requires about 30 additional seconds from each of us. All of the complex questions about hearing loss and hearing aids, including all those unsavory things like price, satisfaction, and care of the devices, are handled by the licensed clinician. She functions as our director of hearing care. • Focus on quality: Our program features world-class hearing instruments. We use state-of-the-art testing equipment. The whole operation is designed to rival the best providers in the area. Obviously, the thing we leverage the most is that our hearing care program is an on-site part of our practice, and our patients love the added sense of “quality assurance” that comes with it being part of our practice.

• Custom-tailored for any practice of any size: We have three large clinic locations, so the hearing care program is full-time for us. This same level of service is available to practices of virtually any size or patient volume (one to five days per week). • It does require a routine: Incorporating hearing care into our practice

loss is legitimately affecting a huge percentage of our patients, and having this service on-site as a built-in part of our routine patient exam is an unbelievable plus. We just have to get into the permanent groove of thinking “hearing” for every older patient. We know that’s how we will build this program to the major department we think it can be.

With a basic program of screening, testing, and hearing aid fitting … we can help up to 90 percent of the patients we identify. is our biggest “learning curve” issue. The screening is an easy step, and so is the follow-up comment we need to make to each patient. But as with anything new, we have to get used to “what to say” and “when to say it.” Hearing

The financial piece Any practice interested in developing a hearing care program should develop a pro forma using your actual data for unique patients (age 55+) and non-acute visits in the current or prior year. Our partner was

able to help us develop revenue projections, based on a decade of experience with conversion of hearing loss patients into hearing aid buyers in physician practice settings. Suffice it to say that this program has exceptional potential. It is worth a serious look from any progressively minded practice, large or small. The patient response Across the board, our patient sentiments can be summed up this way: “I am so grateful that you have this service. I knew I had a problem. I just didn’t know what to do about it. Thank you.” James Keane, MD, is a board-certified family medicine physician and has practiced at Multicare Associates for the past 33 years. He currently serves on the board of directors at Multicare and is the medical director for the practice. John Olive, MHA, is executive vice president at Hearing Health, Inc.

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

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*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

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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 September 2014 Minnesota Physician

Medical marijuana in Minnesota from page 17

New liabilities under the law The law establishes several new criminal offenses related specifically to the provision of medical cannabis. A health care practitioner commits a misdemeanor if he or she knowingly: (1) refers patients to a medical cannabis manufacturer or to a designated medical cannabis caregiver; (2) advertises as a medical cannabis manufacturer; or (3) issues certifications while holding a financial interest in a medical cannabis manufacturer. However, the law also provides that health care practitioners cannot be subject to Board of Medical Practice discipline for participating in registry programs or certifying patients with qualifying conditions where appropriate. Patients who divert their medical marijuana face significant penalties. Diversion of any amount is a felony punishable by up to two years in prison.

The law also criminalizes false statements related to medical marijuana, including statements about an individual’s eligibility for medical marijuana or participation in the medical marijuana program. Next steps The most immediate next steps involve selecting and licensing Minnesota’s medical cannabis manufacturers. By Aug. 1, 2014, the commissioner of health must determine whether or not the state will be able to obtain medical cannabis from the federal government. It is unlikely that the state will be able to procure medical cannabis from the federal government— no state has yet been able to obtain medical cannabis in this manner—so it will likely turn to private entrepreneurs to establish the manufacturing and distribution facilities required under the law. The commissioner must evaluate and select potential manufacturers by Nov. 1, 2014.

By Jan. 1, 2015, the commissioner will publish the proposed rules for the registry program. Manufacturers will begin distribution of medical cannabis by July 1, 2015 and will be fully operational by July 1, 2016.

Medical cannabis is now a part of life in Minnesota. The law will likely have undergone significant changes by that time. The most likely changes involve expansion of the list of qualifying conditions and delivery methods. In other states with legal medical marijuana, the trend has been for laws to continue to expand access to the drug. There is every reason to believe such expansion will occur here. Medical cannabis is now a part of life in Minnesota. No state that has legalized medical cannabis or medical marijuana

has repealed that legislation— so medical cannabis is most likely here to stay. Further, the trend is for expansion of access to marijuana or cannabis in states that have legalized it. We can expect broader access and more widespread use of medical cannabis in the coming years. Finally, given the large number of states that have legalized marijuana in some form or another, and the tension between those state laws and the federal prohibition on marijuana manufacture and use, Congress has begun to explore decriminalization or rescheduling of marijuana to resolve that tension. Any such Congressional action will only increase momentum to broaden access nationwide and here in Minnesota. Kevin Riach, JD, is a senior associate within the White Collar and Regulatory Defense Group at the law firm of Fredrikson & Byron, PA. He advises clients facing government investigations and defends clients in a wide range of white-collar criminal, civil, and regulatory matters.

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

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 • General Surgery • Geriatrician • Outpatient Internal Medicine

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

• Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Urgent Care

F O R M O R E I N F O R M AT I O N :

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

30 Minnesota Physician September 2014 MN Physician 4" x 5.25" 4-color

www.acmc.com |

WE CHOSE MERCY FOR THE PRACTICE; WE’RE STAYING FOR THE

COMMUNITY! Mercy and North Iowa offer: • Premier rural health care network in northern Iowa and southern Minnesota; • Centers of Excellence: Bariatric, Breast Imaging; • Family-friendly communities with plenty of parks, great schools and activities; • Culture: museums, nature centers, The Legendary Surf Ballroom; • Half-way between Des Moines and Minneapolis/ St. Paul, MN Family Medicine (with and without OB) Opportunities in the following North Iowa communities: • Ackley/Iowa Falls • Algona • Britt • Clear Lake • Cresco • Emmetsburg • Hampton • Lake Mills • Mason City • Osage

Fairview Health Services Opportunities to fit your life Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team.

For more information: Cindy Scott: 641-428-5551, scottcl@mercyhealth.com www.mercynorthiowa.com

We currently have opportunities in the following areas: • Dermatology • Dermatology

•• Hospitalist Hospitalist

•• Pain Medicine Pediatrics

• Emergency • Emergency

•• Hospice Hospice

•• Psychiatry Psychiatry

Medicine Medicine

• Endocrinology • Family Medicine • Family Medicine • General Surgery • General Surgery

• Geriatric • Medicine Geriatric Medicine

•• Internal Medicine Internal Medicine •• Rheumatology Rheumatology •• Med/Peds Med/Peds

•• Urgent Care Sports Medicine

•• Ob/Gyn Ob/Gyn

• Urgent Care

•• Orthopedic Orthopedic

• Vascular Surgery

Surgery

Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail recruit1@fairview.org

Sorry, no J1 opportunities.

fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer

MercyCE NT E R

Jonna Quinn, D.O., OB/GYN, joined Mercy 2013 Mark Lloyd, D.O., Family Medicine, joined Mercy 2014

ME DICA L N O RT H I OWA

A member of Mercy Health Network

September 2014 Minnesota Physician

Caring for patients with multiple sclerosis from page 21

clude gastrointestinal upsets and lower white cell counts. • Fingolimod (Gilenya) is taken once a day. It may slow the heart rate and raise the blood pressure, so patients should be monitored for the first few hours after the first dose. • Glatiramer acetate (Copaxone) is an injectable medication. It can block the immune system’s attack on myelin. There are few side effects. • Teriflunomide (Aubagio) is taken once a day. It can cause liver damage and hair loss, and can be harmful to unborn children. • Natalizumab (Tysabri) is given to patients with severe cases of MS who do not tolerate other medications. It blocks immune cells going from a patient’s blood to the brain and spinal cord. Risks

include viral infections of the brain. • Mitoxantrone (Novantrone) is an immunosuppressant and is used only for severe, advanced cases of MS because of its potential harm to the heart and its implications in blood cancers. The cost of these medications can be substantial, and not all insurance companies cover all medications. Some pharmaceutical companies offer patient assistance programs to help financially. Primary care physicians also should be aware of clinical trials that may benefit their patients with MS. Currently, the National Multiple Sclerosis Society lists several open trials, including some that focus on new medications, bone marrow transplant, and memory training. Providing emotional support It is common for patients with MS to suffer depression or anxiety. They are learning to cope

with a chronic disease and may be anxious about how that disease might progress. They worry about the loss of independence and changes to their lifestyle, perhaps including loss of a job or loss of intimacy with a loved one. The patient’s family also is affected by concerns about the disease and how it will affect them. Managing one’s life with any chronic illness can be difficult.

or other illness. In some cases, fatigue can be the reason behind cognitive dysfunction or depression.

Physicians need to be alert to signs of emotional distress, including depression and anxiety, and be proactive about asking patients about their emotional health. Then, offer options for help, including counseling, support groups, and anti-anxiety or antidepression medications.

Primary care physicians can be the best providers to manage the multiple, complex needs of patients with MS, which often include referrals to social workers, mental health professionals, and physical therapists. This requires good communication with other providers and constant vigilance to ward off any complications and help the patient maintain optimum functionality.

Final thoughts MS symptoms can fluctuate, giving patients good days and bad days. Bad days do not necessarily mean that the disease is progressing. They may be caused by a patient’s increased body temperature due to stress, exercise,

Current wisdom is to treat symptoms with non-pharmacological agents first before trying medications. But since MS is a progressive disease, it is important that patients take any medications prescribed and have regular physical exams.

Amy Diede, MD, is board-certified in family medicine and practices at the Apple Valley Medical Center.

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.

Avera Marshall Regional Medical Center

Currently we are seeking to add the following specialists:

300 S. Bruce St. Marshall, MN 56258

• General Surgery

• Internal Medicine

• Radiation Oncology

• Family Practice

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

www.averamarshall.org 32

Minnesota Physician September 2014

September 2014 Minnesota Physician

Prescription drug abuse from page 15

Another provision passed during the session requires the board to submit a report to the Legislature by December 2014, with recommendations on: “(1) requiring the use of the prescription monitoring by prescribers when prescribing or considering prescribing, and pharmacists when dispensing or considering dispensing, a controlled substance … ; (2) allowing for the use of the prescription monitoring program database to identify potentially inappropriate prescribing of controlled substances; and (3) encouraging access to appropriate treatment for prescription drug abuse through the prescription monitoring program.” The board’s PMP Advisory Task Force will hold a series of meetings over the next several months so that the board can receive input from members of the task force. Those members represent professional associations, state agencies, and the public.

Monitoring prescribing practices The inclusion of the language that requires the board to prepare the above-mentioned report did not come at the board’s request. During discussions at the Capitol, it became clear that legislators, on a bipartisan basis, are very concerned with the epidemic of prescription drug abuse. Many key legislators expressed the belief that use of the PMP should be required and that the PMP should be used to try to identify inappropriate prescribing of controlled substances. The board encouraged legislators to delay action on such changes until additional information can be gathered. If not implemented correctly, either a mandatory use requirement or the use of the PMP to monitor prescribing practices might have deleterious unintended consequences, such as a “chilling effect” on legitimate prescribing or an increase in workloads for health care professionals already hard-

Sioux Falls VA Health Care System

Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Primary Care (Family Practice or Internal Medicine) Psychiatrist

Pulmonologist Oncologist Cardiologist (part time)

Endocrinology

Sioux Falls VA HCS (605) 333-6852 www.siouxfalls.va.gov

Applicants can apply online at www.USAJOBS.gov

pressed for the time needed to care for patients appropriately. On the other hand, if properly implemented, these changes might help reduce prescription drug abuse without significant adverse consequences. A number of other states do, in some way, “require” prescribers and pharmacists to use their PMP. However, most of those states have established exemptions from this requirement. Those exemptions can help focus the use of the PMP in situations where drug-seeking behavior is more likely to occur. Depending on how it is done, using the PMP to monitor prescribing practices might be viewed by prescribers as threatening. One approach that the board will be exploring is coupling efforts to educate certain prescribers on the appropriate prescribing of opioid analgesics, with the provision of information about the reported prescribing patterns of those prescribers. Prescribers would

Minnesota Physician September 2014

The meetings of the Board of Pharmacy’s PMP Advisory Task Force will be public and anyone interested in attending or providing input is encouraged to check the PMP website for updates (www.pmp. pharmacy.state.mn.us). It will be critical for the board to receive feedback from prescribers, pharmacists, and patients as it develops the report that it must submit to the Legislature later this year. Cody Wiberg, PharmD, MS, RPh, is the executive director of the Minnesota Board of Pharmacy. He is also a clinical assistant professor at the University of Minnesota College of Pharmacy, and an instructor and course director at the University of Florida.

Psychiatrist Unique Practice – Unique Psychiatrist Needed! HealthPartners Medical Group is a top Upper Midwest multispecialty group practice based in Minneapolis/St. Paul, Minnesota. We have a unique metropolitan-based outpatient position available for a talented, bilingual BC/BE psychiatrist interested in a non-conventional practice. This full-time position combines cross-cultural psychiatric medicine with community mental health. Receiving practice support from both HealthPartners Center for International Health and from the Ramsey County Mental Health Center, 0.5 FTE of the position will provide psychiatric care to an international refugee patient population utilizing an integrated holistic/ primary care model. The other 0.5 FTE of the position will work as part of a multidisciplinary team to provide care to individuals with serious mental illness, chemical health difficulties and/or co-occurring medical problems. This exciting practice is full-time, but qualified candidates interested in part-time outpatient opportunities in Cross-Cultural Psychiatric Medicine or Community Mental Health are encouraged to apply. In addition to a competitive salary and benefits package, there are opportunities for an academic faculty appointment at the University of Minnesota, teaching involvement in the Global Health Pathway (globalhealth.umn.edu) and further development of best practice programming at Ramsey County Mental Health Center. For consideration, please forward your CV and cover letter to lori.m.fake@healthpartners.com, apply online at healthpartners.com/careers, or call Lori at (800) 472-4695 x1. EOE

healthpartners.com

be encouraged to follow the guidelines when making decisions about prescribing these drugs. The approach would be educational and nonpunitive.

Minnesota Physician 4" x 5.25" B&W

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

Make a difference. Join our award-winning team. 1-800-248-4921 (toll-free) Crystal.Lester@allina.com

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Take your leadership career in a new direction

Olmsted Medical Center, a 160-clincian multispecialty 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.

Opportunities available in the following specialties: Cardiologist Rochester Southeast Clinic Child Psychiatrist Rochester Southeast Clinic Dermatology Rochester Southeast Clinic Family Medicine Byron Clinic Pine Island Clinic General Surgery Call Only – Rochester Hospital Hospitalist Hospital Send CV to: 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

www.olmstedmedicalcenter.org

HEALTH Fairview-Southdale Hospital ICU Medical Director University of Minnesota Physicians is seeking a Medical Director for the Fairview-Southdale ICU (FS-ICU). This position will provide and direct outstanding care of critically ill patients in a multidisciplinary ICU at Fairview-Southdale Hospital. This position will also serve as Chair of the multidisciplinary critical care committee. The majority of efforts will be onsite at Fairview-Southdale Hospital. Requirements for this position include: • Have or be eligible for MN State Medical License • Board certified in Critical Care (Anesthesia, Medicine, Surgery or Pulmonary; Pulmonary physicians will have opportunity to develop additional practice if desired) • Four years of experience post fellowship is preferred • Experience in a community setting strongly desired

FOR MORE INFORMATION AND A COMPLETE JOB DESCRIPTION, CONTACT: Greg J. Beilman, M.D. Medical Director, Fairview System Critical Care Program Deputy Chair, Department of Surgery University of Minnesota 420 Delaware Street S.E., Mayo Mail Code 195 Minneapolis, MN 55455 EMAIL: beilm001@umn.edu

Family Medicine

Stevens Community Medical Center’s Starbuck Clinic is looking for a family medicine physician. Enjoy the beautiful area lakes, quiet atmosphere and all that West Central Minnesota has to offer. Starbuck Clinic is home to Staff Care’s 2013 Country Doctor of the Year. Dr. Bösl and Greg Rapp, PA provide full clinic services in the picturesque town of Starbuck, MN on Lake Minnewaska. Dr. Bösl would like to transition into retirement. If you would enjoy the serenity of a rural lake community plus the comfort of an independent practice, this is your opportunity!

For more information, contact John Rau, CEO or Dr. Robert Bösl. Morris location

Starbuck location

320.589.7655 jrau@scmcinc.org

320.239.3939 rbosl@hcinet.net

John Rau, CEO

Dr. Robert Bösl

www.scmcinc.org

Visit us on Facebook and Twitter.

EOE

September 2014 Minnesota Physician

The coming physician shortage from page 13

sician shortage, many feel that other health care professionals can help address the increase in demand for health care services by an aging population. One topic that is debated in states around the country is whether more non-physician providers should be able to administer certain types of routine care. Proponents who want to increase the use of non-physician providers often argue that this could help offset the need for more primary care physicians. During the 2014 legislative session, Gov. Dayton signed into law an expansion of the practice authority for nurse practitioners and other advanced practice registered nurses. Whether this newly granted authority will have an impact on increasing the number of providers in primary care and in rural areas remains to be seen. However, there is no question that non-physician provid-

ers will play an important role in meeting the greater health care workforce needs facing the state and our country. What is Minnesota doing? In recent years, Minnesota has tried to address health-

The most cited barrier to increasing the number of physicians in the workforce is the federal cap on residency slots. care workforce issues through various taskforces and commissions. This past legislative session, a health-care workforce commission began work on addressing some of the health care challenges facing the state. Gov. Dayton recently launched the formation of a Blue Ribbon Committee to enhance the national prominence of the University of Minnesota Medical School. The committee is tasked with providing recom-

Join the top ranked clinic in the Twin Cities

The eventual solution to Minnesota’s and the rest of the country’s health-care workforce

Nate Mussell, JD, is with the Minneapolis law firm of Lockridge Grindal Nauen PLLP. The firm provides legal and government relations services to a variety of health care providers.

An ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage available, but not required. GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites.

• Family Practice • Urgent Care

For more information Call Kirk Stensrud, CEO 320.634.4521

Please contact or fax CV to:

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

763-504-6600 Fax 763-504-6622

Mail CV to: Kirk Stensrud, CEO 10 Fourth Ave SE Glenwood, MN 56334 Email CV to: kirk.stensrud@glacialridge.org

www.glacialridge.org www.NWFPC.com

ciation Health Workforce Policy Academy on graduate medical education and the health care workforce. Although each of these commissions taken singularly is not likely to come up with a solution to a long-term problem, collectively they hope to continue moving the state in a direction of sustainability.

issues is not going to come from a magic bullet. Nor is it going to be easy to get all of the interested parties to agree on one solution. It will require a lot of creativity and commitment. Many of the traditional sources that have historically paid for medical training are going to continue to come under yearly budget pressures, so states and local communities that value the importance of medical providers are going to have to get creative and find new and innovative ways to attract and train physicians and other providers. Minnesota has long been a national leader in health care, so don’t be surprised when Minnesota ends up leading the efforts by providing innovative and creative ways to address the health-care workforce crisis.

Family or Internal Medicine Physician

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:

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.

mendations to the legislature in 2015, including how the medical school can help to meet the needs of the state’s workforce and health-care delivery issues. Finally, Minnesota is one of a handful of states participating in the National Governors Asso-

Minnesota Physician September 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.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

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

• Medical DirectorExtended Care & Rehab • Geriatrician/ Hospice/ (Geriatrics) Palliative Care • Ophthalmologist • Internal Medicine/ Family Practice

• Psychiatrist

Applicants must be BE/BC.

MN Physician 4" x 5.25" 4-color

Emergency Room Physicians Looking for leisure work hours? • Set your own hours • No contract • No obligations

Attention Physicians • Immediate openings • Casual weekend or evening shift coverage

• Choose from 12 or 24 hour shifts • Competitive rates • Paid malpractice

Great Emergency Department in Southern Minnesota

763-682-5906 • 1-800-876-7171 F-763-684-0243 michelle@whitesellmedstaff.com

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

For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301 September 2014 Minnesota Physician

Maintenance of certification from page 11

The future of MOC MOC is here to stay. Whether it is called MOC or something entirely different in the future, a physician will ultimately not be able to run from the public’s requirement for reassurance and accountability. Specialty certification means that a physician has met certain standards at a specific point in time. As MOC becomes integrated into actual practice using data from electronic health records, registries, outcomes, and other data sources, it will move from point-in-time to real-time assessments. One can easily imagine getting real-time information about gaps in performance and a recommendation for an effective educational activity that will help close that gap. Unlike MOC, which is voluntary, medical licensure is not voluntary. Currently most state medical boards require a simple attestation of completion of

a prescribed number of credit hours of Continuous Medical Education to renew a license. In the future, it is expected that states will gradually adopt Maintenance of Licensure (MOL), a process to ensure the ongoing competence of physicians seeking renewal of licensure. Physicians will be expected to be engaged in continuous professional development. Both MOC and Osteopathic Continuous Certification (OCC) should substantially qualify and count towards MOL. If a physician was never specialty certified or doesn’t wish to participate in MOC or OCC, there are other activities that would qualify. Therefore, in the future, as MOL is adopted, all physicians would have to be involved in a process of continuous professional development. The lawsuit Since the inception of the MOC program, ABMS has weathered significant resistance from

Minnesota Physician September 2014

physician advocacy groups. ABMS is currently embroiled in a lawsuit with the Association of American Physicians and Surgeons (AAPS), which has alleged restraint of trade among other allegations. Other groups point to the revenues of several of the larger specialty boards and the salaries of their executive directors as proof that MOC’s sole purpose is to enhance the wealth of the member boards and ABMS. While these types of allegations raise suspicion and doubt because of these organizations’ non-profit status, all of this information is already publicly available on websites (e.g., guidestar.com). Unfortunately, meaningful educational and assessment tools for physicians don’t come cheap. It may make sense to have educational content and activities that are compliant with MOC, yet not proprietary. There are managed care organizations that are working with ABMS and its member boards

to develop activities within their organizations that would, in effect, achieve compliance with MOC standards. In the future it might be possible to comply with MOC through such an organization. That is really a peek at the future: a physician’s ability to demonstrate continued clinical competence through MOL, and continued professional excellence through MOC or OCC. This would be achieved by participating in clinically integrated activities developed and supported by a variety of organizations helping to seamlessly support physicians and, ultimately, better protect the public. Jon Thomas, MD, MBA, is a member and past chair of the board of directors of the Federation of State Medical Boards and member and past president of the Minnesota Board of Medical Practice.

oSMo VänSkä

anthony RoSS

edo de waaRt

Celebrating Richard Strauss’ 150th Birthday Join us in honoring this musical giant with three sets of extraordinary concerts surrounded by pre- and post-show events including Alpine-inspired treats, special music and craft beer tastings.

Immortal Stories

Shadows and Light

Musical Mountains

Thu Oct 9 11am Fri Oct 10 & Sat Oct 11 8pm

Thu Oct 16 11am Fri Oct 17 8pm

Fri Oct 24 & Sat Oct 25 8pm

Andrew Litton, conductor Anthony Ross, cello

Osmo Vänskä, conductor and clarinet Andrew Staupe, piano

We jump from the radiant strings of Capriccio, our composer’s last opera, to the serenade written when he was just 17. For our grand finale, we perform the majestic An Alpine Symphony.

Principal Cello Anthony Ross takes the title role in Don Quixote, based on Cervantes’ immortal novel. Then Salome offers one of the most sensual (and shocking) scenes in all of opera.

Works illuminate Strauss’ incredible creative range—and our Music Director’s! Osmo Vänskä shines on the clarinet in the Suite for Winds.

Edo de Waart, conductor

For a complete list of entertainment, vendors and special activities visit mnorchestra.org/oktoberfest

612.371.5656 / minnesotaorchestra.org / Orchestra Hall PHOTOS Vänskä: Ann Marsden, Ross: Greg Helgeson

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