Volume XXVll, No. 1
April 2013
The Independent Medical Business Newspaper
Collaborating with patients Shared decision-making in palliative care By Jan Schuerman, MBA, and Claire Neely, MD
S
P
arsing the distinctions between public health, population health, and community health is like analyzing the differences of narcissus, daffodils, and jonquils. It can be done, but who cares, other than a few academics and journal editors? But for those purists and the curious, public health and population health
PAID
By Edward P. Ehlinger, MD, MSPH
CULTIVATING to page 10
PRSRT STD U.S. POSTAGE
The intersection of public health and medical care
Detriot Lakes, MN Permit No. 2655
Cultivating health
(like narcissus and daffodils) are different names for the same thing. And just as jonquils are a species of narcissus, community health is a species of public health. Public health focuses on the overall physical, mental, and social well-being of a population whether or not that population is part of a geographic community. Using public health principles and approaches as its foundation, community health focuses on the health status of people within a defined geographical area. In reality, everyone is part of a larger community (country or state) that is made up of a mosaic of smaller communities. And everyone is a member of various communi-
hared decision-making, the collaboration between patients and providers to ensure optimum outcomes, is becoming more prevalent in today’s health care environment. Research shows that acknowledging a patient’s preferences improves patient outcomes, lowers costs, and improves a patient’s experience. A new Collaborative Conversation model developed by the Institute for Clinical Systems Improvement (ICSI) and piloted in a variety of settings is making integration of shared decision-making into everyday care easier and more effective for both providers and patients. Shared decision-making has been defined as “a process in which patients and providers collaborate to ensure that the patient is wellinformed, clarify all acceptable options and choose a SPECIAL FOCUS: course of care consistent with patient values COMMUNITY and preferences and CAREGIVERS the best available medPage 26 ical evidence.” PATIENTS to page 12
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CONTENTS
APRIL 2013 Volume XXVII, No. 1
FEATURES Cultivating health The intersection of public health and medical care
1
MINNESOTA HEALTH CARE ROUNDTABLE
By Edward P. Ehlinger, MD, MSPH
Collaborating with patients 1 Shared decision-making in palliative care
T H I R T Y- N I N T H
SESSION
By Jan Schuerman, MBA, and Claire Neely, MD
Community caregivers Making a difference in Minnesota and the world
26
By Scott Wooldridge
DEPARTMENTS CAPSULES
4
MEDICUS
7
INTERVIEW
8
PROFESSIONAL UPDATE: RHEUMATOLOGY Spondyloarthritis 14 By Paul Waytz, MD
HEMATOLOGY Preoperative anemia
William Begg, MD
16
By Kathrine Frey, MD
Danbury Hospital, Danbury, Conn.
PRACTICE MANAGEMENT Call-schedule creation and communication 18 By Justin Wampach and Patrick Zook, MD
SPECIAL FOCUS: PUBLIC HEALTH/ COMMUNITY HEALTH Converging Bringing health care health systems 20 to the community By John Finnegan Jr., PhD
Community-clinic partnerships
24
By Clarence Jones and Angela Gerlach
Patient engagement Creating measures that work Thursday, April 25, 2013
Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle choices into health care delivery is necessary, but how should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).
Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential. 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers
Panelists include: Vivi-Ann Fischer, DC, Chief Clinical Officer, Chiropractic Care of Minnesota, Inc.
22
Laura Gandrud, MD, Children's Hospitals and Clinics of MN, Diabetes and Endocrinology
By Lynne Ogawa, MD, and Lynn Balfour, MBA
Peter Mills, MD, CEO, nGage Health The Independent Medical Business Newspaper
William Nersesian, MD, MHA, Chief Medical Officer, Fairview Physician Associates Pam Van Zyl York, MPH, PhD, RD, LN, MDH Health Promotion and Chronic Disease Division Sponsors: ChiroCare • nGage Health • Sanofi
www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com
Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name
ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com
Company
ART DIRECTOR Elaine Sarkela esarkela@mppub.com
Address
OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com
City, State, Zip
ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com Telephone/FAX ACCOUNT EXECUTIVE Matt Nichols mnichols@mppub.com Card # 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 legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.
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APRIL 2013 MINNESOTA PHYSICIAN
3
CAPSULES
Mayo Financially Solid, Continues To Innovate The finances of Mayo Clinic in 2012 were “solid,” officials with the Rochester-based clinic say. The clinic, which has major facilities in Minnesota, Arizona, and Florida, along with a health system in this state and affiliations with a number of other systems, reported revenues of $8.8 billion for 2012. The company, which has more than 61,000 employees, treats more than 1 million patients each year from roughly 135 counties. Expenses for 2012 were $8.4 billion. Officials note that Mayo has taken several innovative steps over the past year, including expanding its Mayo Clinic Care Network, a partnership between Mayo Clinic and independent health systems around the country. The clinic is also developing applications for mobile devices for both physicians and patients. And it is engaged in clinical strategies to expand the number
FOR LEASE
of midlevel providers serving patients, implement best practices, and integrate care between the clinic and the Mayo Clinic Health System. “Mayo Clinic is redesigning its practice to create higher quality of care at lower costs,” says John Noseworthy, MD, Mayo Clinic president and CEO. The clinic is currently working with legislators on a “Destination Medical Center” bill that would bring more than $500 million in state funding to infrastructure projects in Rochester. Officials say the Rochester area needs improvements to help Mayo Clinic compete with large medical centers in cities like Cleveland and Baltimore.
Dayton Signs Bill Creating State Health Insurance Exchange Gov. Mark Dayton signed a bill on March 20 establishing a health insurance exchange in Minnesota. The measure had been put on a fast track for pas-
sage in order to meet federal deadlines for exchanges to be set up as part of the Affordable Care Act (ACA). The health insurance exchange will allow Minnesotans to shop for insurance online, with broader access for small businesses and individuals who currently can’t afford insurance. Under the ACA, exchanges will offer subsidies for people under certain income levels. Supporters of the exchange say the model will expand coverage while giving consumers the ability to shop and compare insurance products. When the Senate passed the bill on March 7, Sen. Tony Lourey (DFL–Kerrick) said the new exchange will benefit consumers, providers, and the business community. “After 12 hours of robust debate, the Minnesota Senate took a historic step today toward accomplishing honest health care reform by voting to create a Minnesota-based health insurance exchange,” Lourey said. “We all share the priority of building a Minnesota-based exchange that works for individ-
ual consumers, families, small businesses, and the health care industry as a whole. Tonight we made significant progress toward that goal.” Opponents of the exchange said it gives government too much control of the insurance marketplace. “We are going to have a system that picks the winners and losers within the insurance business,” said Sen. Bill Weber (R–Luverne) during floor debate. “It is unfair to our consumers; it is unfair to the insurance industry. In my opinion, it is the beginning of the end of one of the great health care systems in this country.”
ADHD Can Continue Into Adulthood, New Study Says The first large study to follow children with attention-deficit hyperactivity disorder (ADHD) finds that many continue to have the condition as adults, and that it is linked to other psychiatric disorders and suicide.
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MINNESOTA PHYSICIAN APRIL 2013
of health care experience
Officials say the study is unique because it followed a large group of ADHD patients from childhood to adulthood and looked at a cross-section of the ADHD population, rather than focusing on more severe cases. The study followed more than 5,000 children in Rochester, including 367 diagnosed with ADHD. It found that 29 percent of children with ADHD still had ADHD as adults. In addition, 57 percent of children with ADHD went on to have least one other psychiatric disorder as adults, compared with 35 percent of those studied who didn’t have childhood ADHD. The most common comorbidities were substance abuse/dependence, antisocial personality disorder, hypomanic episodes, generalized anxiety, and major depression. Of the children who still had ADHD as adults, 81 percent had at least one other psychiatric disorder, as compared with 47 percent of those who no longer had ADHD and 35 percent of those without childhood ADHD. Seven of the 367 children with ADHD (1.9 percent) had died by the time the study began, three of them from suicide. Of the 4,946 children without ADHD whose outcomes could be ascertained, 37 children had died, five by suicide. Ten adults who had childhood ADHD (2.7 percent) were incarcerated when the study started. “We suffer from the misconception that ADHD is just an annoying childhood disorder that’s overtreated. This couldn’t be further from the truth. We need to have a chronic disease approach to ADHD as we do for diabetes. The system of care has to be designed for the long haul,” says lead investigator William Barbaresi, MD, of Boston Children’s Hospital, who started the study when he was a Mayo Clinic physician.
SHIP Working to Improve Community Health, MDH Says Minnesota’s Statewide Health Improvement Program (SHIP) saw advances in community health efforts for 2012 despite recent budget cuts, officials reported in March. The SHIP initiative was passed by the Legislature in 2008 and put in place in 2009 as part of state health-care reform efforts. The program’s aim is to improve statewide health and reduce health care costs. The program includes community health goals such as reducing obesity and tobacco use, and increasing physical activities, as major strategies toward a healthier state. In its third annual report on the program, the Minnesota Department of Health (MDH) says that SHIP is continuing to make progress in reducing obesity rates and combating rising health care costs. “Communities across the state are recognizing the need to take a communitywide approach to combating obesity and tobacco—two of the biggest factors pushing up health care costs,” says MDH Commissioner Ed Ehlinger, MD. “Healthy living isn’t just an issue for the health department or local clinics, it is an issue that all parts of the community need to address.” MDH officials say they aim to expand the program after budget cuts reduced its scope in recent years. SHIP received a 70 percent cut for fiscal years 2012–13. It is now providing community grants to just over half the state. For fiscal years 2014–15, Gov. Mark Dayton has proposed a $40 million budget for SHIP that would again make the program statewide, officials say.
REQUEST FOR NOMINATIONS
2013 HEALTH CARE ARCHITECTURE & DESIGN
HONOR ROLL NOMINATION CLOSING: FRIDAY, MAY 10, 2013 PUBLICATION DATE: JUNE 2013
Seeking Exceptionally Designed Health Facilities Minnesota Physician announces our annual Health Care Architecture & Design Honor Roll. We are seeking nominations of exceptionally designed health care facilities in Minnesota. The nominees selected for the honor roll will be featured in the June 2013 edition of Minnesota Physician, the region’s most widely read medical publication. Eligible facilities include any structure designed for patient care: hospitals, individual physician offices, clinics, outpatient centers, etc. Interiors, exteriors, expansions, renovations, and new structures are all eligible.
In order to qualify for nomination, the facility must have been designed, built or renovated since January 1, 2012. It also must be located within Minnesota (or near the state border within Wisconsin, North Dakota, South Dakota or Iowa). Color photographs are required. If you would like to nominate a facility, please fill out the nomination form below and submit the form, three to eight 300-dpi-resolution color digital photographs, and a brief project description by Friday, May 10, 2013. For more information, call (612) 7288600.
2013 HEALTH CARE ARCHITECTURE & DESIGN HONOR ROLL NOMINATION FORM FACILITY NAME TYPE OF FACILITY LOCATION OWNERSHIP ORGANIZATION OWNER CONTACT NAME and PHONE OWNER ADDRESS CITY, STATE, ZIP ARCHITECT/INTERIOR DESIGN FIRM ARCHITECT CONTACT NAME and PHONE ARCHITECT ADDRESS CITY, STATE, ZIP ENGINEER CONTRACTOR COMPLETION DATE TOTAL COST SQUARE FEET NUMBER OF COLOR PHOTOS ENCLOSED [Note: Please include a caption for each photo]
Study Raises Concerns About High Cesarean Rates A study by the University of Minnesota’s School of Public Health raises concerns about the wide variation in rates of
NOMINATION PROCEDURE: Submit the information on this form, along with a project description (150–250 words) and 300-dpi-resolution color 8”x10” digital photographs (no more than eight) to mmacedo@mppub.com For further information, please phone (612) 728-8600, fax (612) 728-8601 or e-mail comments@mppub.com.
CAPSULES to page 6 APRIL 2013
MINNESOTA PHYSICIAN
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CAPSULES Capsules from page 5 cesarean delivery in the U.S. The study, which appeared in a recent edition of Health Affairs, notes that cesarean delivery is the most common surgery in this country, with 1.67 million cases performed annually. The researchers found that cesarean delivery rates varied tenfold across U.S. hospitals, from 7.1 percent to 69.9 percent. When the researchers look at statistics for lower-risk pregnancies they found an even greater rate of variation, from 2.4 percent to 36.5 percent. “We were surprised to find greater variation in hospital cesarean rates among lower-risk women. The variations we uncovered were striking in their magnitude, and were not explained by hospital size, geographic location, or teaching status,” says lead author Katy Kozhimannil, PhD, assistant professor in the University of Minnesota School of Public Health. “The scale of this variation signals potential quality issues that should be quite alarming to women, clinicians,
hospitals, and policymakers.” The U.S. has seen an increasing rate of cesarean deliveries, which are more expensive than vaginal deliveries. The report notes that cesarean rates have increased, from 20.7 percent in 1996 to 32.8 percent in 2011. The increase in cesareans also has meant an increase in public health costs, with nearly half of all U.S. births financed by state Medicaid programs. “Cesarean deliveries save lives, and every woman who needs one should have one,” says Kozhimannil. “The scope of variation in the use of this procedure, especially among low-risk women, is concerning, as its use also carries known risks compared to vaginal delivery such as higher rates of infection and rehospitalization, more painful recovery, breastfeeding challenges, and complications in future pregnancies.”
MMIC Expands Into Indiana and Four Western States Minneapolis-based medical liability insurance company MMIC has taken several steps to expand its business in the past few months. In February, MMIC acquired a medical liability insurance company doing business in four western states, and on March 7, MMIC announced it had entered the Indiana market, bringing the number of states in MMIC’s core territory to nine. “We are excited at the prospect of expanding our mutual company mission and business footprint to another state, and look forward to building a long-standing tradition of MMIC excellence in Indiana,” said president and CEO Bill McDonough when the expansion was announced. The company has hired several agents in the Indiana market, and will offer products in all of MMIC’s business segments, which include professional liability insurance, risk management consulting, and health
information technology services. The move follows the company’s Feb. 4 announcement of its acquisition of Utah Medical Insurance Association (UMIA), which provides liability insurance for physicians in Utah, Montana, Idaho, and Wyoming. The move will allow UMIA to retain its brand and leadership while becoming a whollyowned subsidiary of MMIC. Financial terms of the deal were not disclosed. “A partnership between UMIA and MMIC will provide benefits for both sides,” McDonough said in announcing the acquisition. “We will be better and stronger together. This partnership will extend MMIC’s geographic footprint and broaden UMIA’s access to products and services—and we are both interested in preserving the legacy of our respective companies.” MMIC officials say that the number of policyholders between the two companies will be nearly 20,000 across 14 states, including Indiana.
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6
MINNESOTA PHYSICIAN
APRIL 2013
MEDICUS
Jackie Kawiecki, MD, has joined the Physical Medicine and Rehabilitation Clinic at Hennepin County Medical Center. She is a diplomate of the American Board of Physical Medicine and Rehabilitation for both physical medicine and rehabilitation and spinal cord injury medicine. Kawiecki sees a variety of rehabilitation patients including those with spinal cord injury, stroke, brain injury, trauma, and cerebral palsy, as Jackie Kawiecki, MD well as amputees. Kawiecki is also an adjunct assistant professor at the University of Minnesota Medical School’s Department of Physical Medicine and Rehabilitation. The Mayo Clinic in Rochester has named Gregory Gores, MD, as executive dean for research. Gores, previously chair of Mayo’s Division of Gastroenterology and Hepatology, succeeds Robert Rizza, MD, and will oversee research across Mayo Clinics and Mayo Clinic Health System. Gores is the Reuben R. Eisenberg Endowed Professor of Medicine and Physiology at Mayo Clinic, and currently is principal investigator of three NIH research project grants. John Bollins, DO, has joined St. Luke’s Pavilion Surgical Associates in Duluth. Bollins received his doctor of osteopathy degree from Ohio University in Athens and completed his general surgery internship at Doctors Hospital and general surgery residency at Doctors Hospital/Grant Medical Center in Columbus, Ohio. He is board-certified in general surgery and surgical critical care. Bollins most recently was the Pediatric Trauma Program medical director for Essentia Health St. Mary’s Medical Center in Duluth. Ben Johnson, MD, has joined St. Luke’s Urgent Care in Duluth. Johnson received his medical degree from the University of Minnesota Medical School, Minneapolis, and served his family practice residency through the University of Wisconsin at the Appleton (Wis.) Family Health Center. Mounaf Alsamman, MD, has joined Allina Medical Clinic–Brooklyn Park. Alsamman, a family medicine physician, received his medical degree from the University of Damascus Medical School in Syria. He completed his family practice internship at the University of Texas in Houston and his residency at the UT Southwestern Medical Center in Dallas. Joseph Mounaf Alsamman, MD Graif, MD, has joined Allina Medical Clinic– Coon Rapids. Graif is an internal medicine physician with a subspecialty in pulmonary medicine. He received his medical degree from the University of Minnesota Medical School, Minneapolis; he completed internship and residency programs at Hennepin Country Medical Center, as well as a fellowship at the University of California in San Diego. Matthew Penning, MD, a board-certified family physician, has joined Lake Superior Joseph Graif, MD Community Health Center in Duluth. Penning attended medical school at the University of Minnesota–Duluth and completed his residency through the Duluth Family Medicine Residency Program. John Allen, MD, a partner at Minnesota Gastroenterology, has left the practice after 22 years to become the clinical chief of gastroenterology and hepatology at Yale New Haven John Allen, MD Health System and a professor of medicine at Yale University (effective April 2013). Allen was selected to chair the Quality Committee of Allina Health in September 2012 and will remain in that position, as well as continuing as one of two physician members of the Allina Health board of directors. Last May he was elected vice president of the American Gastroenterological Association and will become president in May 2014.
New Specialty Care Center
Fairview Ridges Campus Expansion Join us as we embark on the largest expansion in the history of the Fairview Ridges Hospital campus - positioning Fairview Ridges to address changing community demographics and an increased demand for health care in the Twin Cities south metro market.
Specialty Care Center As a physician dedicated to excellence, you deserve resources that grow and build your practice. To provide physicians with an opportunity to practice on campus and invest in the project, Fairview has selected Frauenshuh, a leading developer of health care real estate, to partner in the development of a new 133,000 square foot Specialty Care Center.
Ambulatory Surgery Center Participating physicians tenants have the opportunity to invest in the Ambulatory Surgery Center located in the Specialty Care Center.
www.TogetherAtFairviewRidges.com
For Physician Leasing & Ownership Information Contact: Jessica Anderson or Tom Immen 952-829-3480 Jessica.Anderson@Frauenshuh.com Tom.Immen@Frauenshuh.com
APRIL 2013
MINNESOTA PHYSICIAN
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INTERVIEW
Speaking out after Newtown ■ Why has gun violence become a public
health issue?
William Begg, MD Danbury Hospital, Danbury, Conn. William Begg, MD, is the emergency medical services director and president of the medical staff at Danbury Hospital in Danbury, Conn. He was in charge of the emergency room as his hospital received victims from the mass shooting at Sandy Hook Elementary School in Newtown, Conn., last December. Begg testified before the U.S. Senate Judiciary Committee on Feb. 27, as Congress began to look at expanded gun control laws in response to the Newtown mass shooting. He also is a founding member of United Physicians of Newtown, a group dedicated to stopping what it describes as a national epidemic of gun violence.
8
■ In your testimony, you talk about the impact
this has had on responders and the people who were involved.
Go back to the statistics in our country: A leading cause of death in our country is from gun-related It has had a profound impact. Many first responinjuries. The raw numbers are over 30,000 gun ders have not returned to work and those that have deaths a year in our country. You can break it are still undergoing counseling. Many families that down into suicide, homicide, or unintentional had children in the school still have not had their death. Gun-related deaths are the 12th-leading children return to school or if they have, they also cause of death in our country if you place that needed counseling. against all other disease processes, like heart ■ In February you testified before Congress on attack and stroke. the topic of gun violence. What can you tell us In my personal experience and the experience about what you said and how it was received? of my colleagues who are emergency physicians, gun death is a common disease process that we see My first testimony was before the Connecticut in the emergency department. When we see, on a State and Judiciary Committee in January, and my continual basis, people being murdered or people passionate plea for change was the impetus for me committing suicide with guns, I feel it is important being asked to speak before the U.S. Senate in that we advocate on behalf of patients to reduce February. the risk of people dying from these injuries. What I tried to talk about was my experience It’s similar to us advocating for a decrease in in the emergency room on December 14 during the the death rate relative to stroke, heart attacks, and time of this Sandy Hook massacre. It has spurred cancer. I see the same relationme on to take a closer look at ship. The difference is that, while how my colleagues and I can We believe that physicians have been educating effect change. I’m part of United gun violence is a their patients and doing research Physicians of Newtown, a group on the top causes of death in our major public issue. of over 100 doctors that practice country, for many reasons, we or live in Newtown, Conn. have not been doing research or We formed a core platform of doing educational spots relative to gun violence. I four basic tenets, which we try to promote in varifeel that should change. ous venues. My testimony related to our proposals but also was a plea to the legislators to revisit this ■ In your testimony before Congress you said that public health issue and to try to effect some one of the first things you saw as a resident was change. I think we, as medical providers, can be a gunshot wound. more proactive. There are many other groups lobMy first day as a medical student in New York City bying and promoting their viewpoint, but as those I saw a store owner who died at the hands of an in the frontline and those caring for families affectassault weapon. ed by gun violence, I feel strongly that physicians It is a common presentation—it is one of the and health care providers should be more proactive most common causes of immediate death in the going forward. ER. To clarify, many other disease processes pres■ Were you political or involved in political causes ent, like asthma, but those folks don’t die in the before this? ER. We see a disproportionate number of deaths related to guns. I and others are passionate in talking about this, having seen the emotional trauma it causes the families when we have to tell them that their loved ones have been killed. ■ What can you share with us about your
experiences on December 14 of last year? A lot of what I have discussed relative to my time as an emergency physician on December 14 is in the public record. Being in the medical field, privacy laws prevent me from discussing the specifics. I will tell you that my experience from being in the emergency room that day has spurred me on to try to be an advocate for change, because no town, no family, should experience what the families in the town of Newtown experienced on December 14.
MINNESOTA PHYSICIAN APRIL 2013
Before this, as a general answer, I would say no. I do come from a political family; my parents were both state representatives in Connecticut. After the Sandy Hill massacre, the viewpoints that I had kept personal, I felt the need to speak about. ■ What has been the response from lawmakers
in Washington, D.C.? Did you feel that people where listening? I felt that the lawmakers overall were respectful. I feel though, that despite lawmakers’ personal viewpoints, many lawmakers will vote based on their political background or based on the support they have received from lobbyists, not on what they may truly believe. I will say that I thought your senators [from Minnesota] who both were sitting on the panel had a balanced approach and seemed quite receptive to opportunities for change. Both felt strongly that maintaining our 2nd Amendment rights was impor-
tant. Both seemed to want to strike a balance with the rights of potential victims who may be in harm’s way from guns. ■ What is the mission of United Physicians
of Newtown? We believe that gun violence is a major public health issue, similar to other public health issues. We are trying to effect change in four basic categories—mental health, research, education, and gun legislation. Our goal going forward is to not only try to effect change by public testimony and the like, but to be a resource for others, whether it is locally within our town forums or on regional or national forums. ■ What could be gained from creating a
comprehensive national firearm injury database? The research relative to gun violence is significantly lacking. In 1996, essentially all funds to the CDC were cut. Since then the research has been quite limited. My viewpoint is that there should be research relative to gun violence and the number of gun deaths commensurate with research into other disease processes. With increased research, we would have the ability to educate the population on the risks associated with gun violence. We presently have a public service announcement, broadcast nationally, referencing the
2013 CME Activities
idea that if you text and drive you are 23 times as likely to die in a car accident. Yet, there aren’t public service announcements saying that if you own a gun in your home, you are at significantly increased risk of dying from homicide, suicide, or unintentional death. Having a comprehensive database would help the gun legislation debate and would help in educating the population.
health care providers, even if they don’t vote based on health-care provider recommendations. In 2013, I can say with confidence, they are listening. One of the things I didn’t realize, when I was asked to speak on some national networks like CNN and MSNBC, is that there are not a lot of health care providers willing to speak out, which was surprising to me.
■ This is something that we are hearing
■ Why do you think that is?
from physicians—that regardless of the politics, we need more data. That is true; in fact, some Republican senators on the judiciary committee when I testified said multiple times that we need more empiric data to reference. My frustration is that funding for research was cut over 15 years ago so there is not a lot of empiric data to refer to. ■ What role can physicians play in solving
these problems? Physicians could be more proactive by educating their patients, by doing research, by standing up for mental health rights of their patients, by voicing their opinion relative to gun legislation. We need to be more proactive, that’s the bottom line. ■ Do you feel policymakers are going to
listen to the medical community?
There are number of issues. When physicians speak out in national or a public forums, you are at risk for unfounded criticisms. You may feel at risk for your own personal safety. You may feel at risk from losing your job because of HIPAA issues. You may receive criticism from your own medical society for not representing their views exactly. I have had to deal with all those issues to varying degrees. ■ So why take the risk?
I personally have taken the risk because for me, it’s personal, but also because I feel strongly that allowing over 30,000 Americans to die unnecessarily every year is unconscionable. Physicians and health care providers went into the medical field to provide the best care they can. That means more than just seeing patients in their office.
The lawmakers respect the opinions of
For a full activity listing, go to www.cmecourses.umn.edu
(All courses in the Twin Cities unless noted)
APRIL - SEPTEMBER 2013 Chronic Pain: Challenges & Solutions for Primary Care April 19-20, 2013 Cardiac Arrhythmias: An Interactive Update for Internal Medicine, Family Medicine, & Pediatrics April 26, 2013 Psychiatry Update: Promoting Healthy Eating & Lifestyles May 3, 2013 Global Health Training (weekly modules) May 6-June 2, 2013 Dermatology 2013: Advances & Discoveries May 17, 2013
Topics & Advances in Pediatrics in cooperation with MN-AAP May 30-31, 2013 (NEW DATES!) Midwest Cardiovascular Forum: Controversies in CVD June 1-2, 2013 Bariatric Education Days (9th Annual) June 5-6, 2013 Update in GI Surgery (77th Annual) June 7-8, 2013 Workshops in Clinical Hypnosis June 6-8, 2013 Maintenance of Certification in Anesthesiology (MOCA) Training June 15, 2013
ONLINE COURSES (CME credit available) www.cme.umn.edu/online U Fetal Alcohol Spectrum Disorders (FASD) - Early Identification & Intervention U Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health
Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners September 5-6, 2013 (NEW DATES!) Care Across the Continuum: A Trauma & Critical Care Conference September 27, 2013
Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: cme@umn.edu
Promoting a lifetime of outstanding professional practice APRIL 2013
MINNESOTA PHYSICIAN
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Cultivating from cover ties that extend beyond geographic boundaries. This makes defining the distinction between public health and community health an exercise in futility. However, the concepts and principles behind public health and community health are worthy of examination because they embody an approach that has the potential to improve health for individuals and the communities in which they live. Historic success
For most of history, infectious diseases and injuries were the leading causes of death and disability. Most of these were beyond the ability of an individual to control. Community-wide efforts were essential to ensure the clean air and water, effective sanitation, safe food, safe worksites, and immunizations necessary to reduce these threats and improve the health of community members. These community efforts, in combination with clinical care, dramatically reduced deaths from acute diseases and injuries, which made
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room for chronic diseases like heart disease, cancer, and diabetes to rise and take their place. Surprisingly, the approach used so successfully for acute diseases has not been embraced to address modern-day killers. Instead, the focus has been on clinical care and individual education about personal behaviors, which has resulted in an underinvestment in community interventions. That individual behaviors are a major contributor to the development of most chronic conditions has been known for decades, but it’s only in the past few years that we’ve understood the role the community has in influencing those personal behavioral choices. Studies show that while health behaviors are the result of personal choices, most choices are made in a broader social context that can either support or undermine them. While the ultimate choice may be individual’s, the locus of intervention needs to be wide enough to incorporate the environment or social context in which those choices are made.
MINNESOTA PHYSICIAN APRIL 2013
In other words, to change individual behaviors, we may need to change some community factors first. Other social conditions within communities, such as housing, education, economic status, transportation, food distribution systems, and discrimination, among other factors, have also gained recognition as determinants of health. For
Improvement Program (SHIP). COPC springs from the clinical sector of our health system while SHIP has evolved from the public health sector. Both have gained attention as policymakers, health systems, clinicians, and communities look for ways to achieve the Triple Aim of health reform—improved population health, a reduction in health care costs, and greater
Clinical care determines only about 10 percent of our overall health. example, estimates are that the lack of a high school diploma is associated with 245,000 deaths per year and that poverty contributes to nearly 200,000 deaths per year. These are community issues affecting the health of individuals. Two models of community/public health
This intersection of community factors and individual health is where public health meets clinical care and where the community health approach offers the most promise. Recognizing that clinical care determines only about 10 percent of our overall health, it is attendant upon clinicians, whose task it is to maximize the health of their patients, to become engaged in finding effective ways to address the other 90 percent of health determinants. It is also attendant upon the public health community to find ways to get prevention and health promotion services (such as those outlined by the U.S. Preventive Services Task Force) integrated into clinical systems. Community health is where clinical care and public health can and should come together. Two models of community health stand out as approaches that effectively integrate clinical care and public health in ways that improve the health of both individuals and their communities. One is Community-Oriented Primary Care (COPC); the other is Minnesota’s Statewide Health
citizen satisfaction with our health system. The World Health Organization has defined communityoriented primary care as “… an approach to health care delivery that undertakes responsibility for the health of a defined population. Community-oriented primary care is practiced by combining epidemiologic study and social interventions with clinical care of individual patients, so that the clinical practice itself becomes a community medicine program. Both the individual patient and the community or population are the foci of diagnosis, treatment and ongoing surveillance.” The concept of COPC has been around since the 1950s when South African Sydney Kark, MD, coined the term community-oriented primary health care (COPHC, later changed to COPC) to describe his work of embedding public health principles in a clinical practice. Interest in this approach has recently increased as health plans have embraced a more population-based approach to health and as evolving accountable care organizations recognize that a COPC model offers the best hope for achieving the Triple Aim. Health care homes, community care teams, and accountable health communities using community clinics are recent iterations of the COPC concept. The Statewide Health Improvement Program is a
publicly supported effort to implement evidence-based and population-focused prevention strategies in communities throughout Minnesota. By engaging individuals from the health care, business, education, public health, and agriculture sectors, SHIP has coalesced community efforts around reducing the major contributors to poor health:tobacco use, poor
clinical prevention services. SHIP also has been able to leverage fiscal and manpower resources from multiple sources to sustain a community-wide approach to creating good health. Although the program has been in existence only since 2008, evidence is growing that it is one of the most powerful community health interventions of the last 50 years. Like the
The Institute of Medicine defines public health as what we, as a society, do collectively to assure the conditions in which people can be healthy. nutrition, and physical inactivity. By focusing on policy, systems, and environmental changes, SHIP has been able to stimulate changes in school lunch programs, establish worksite wellness programs, support farmers markets and community gardens, create safe routes to school and walkable communities, and enhance the delivery of
polio vaccine of the 1950s, the SHIP approach has the potential to be the 21st-century “inoculation” for obesity, diabetes, and heart disease. Over the past 60 years, it has become evident that treatment alone won’t create health. While it may repair some injuries, relieve some discomfort, cure some diseases, and prolong some
lives, treatment alone will not improve our overall health. The reason is that our lifestyles and environment are creating unhealthy conditions that are overwhelming the curative and rehabilitative capacity of our health care system. Although we have an excellent medical care system, it is being inundated by increasing rates of obesity and chronic disease among an aging population. What is needed to foster good health is an effective prevention strategy that incorporates the best of clinical care and public health. A community health model, exemplified by the chiastic approaches of COPC and SHIP, achieves that goal. COPC integrates the prevention aspects of clinical care with the community prevention aspects of public health, while SHIP aligns the community prevention services with the prevention activities of clinical care. Both are communi-
ty health initiatives, but evolving from different perspectives. Both are needed to create healthy communities. Assuring the health of individuals and communities
The Institute of Medicine defines public health as what we, as a society, do collectively to assure the conditions in which people can be healthy. Community health initiatives that integrate clinical care with community-focused prevention are some of the most effective ways to enhance that collective action. Whether it’s called public health, population health, or community health, these community-focused efforts with the active involvement of the medical community are what is needed to help create a healthy community in which all people can blossom. Paraphrasing Juliet: “What’s in a name? That which we call a narcissus by any other name would smell as sweet.” Edward P. Ehlinger, MD, MSPH, is commissioner of the Minnesota Department of Health.
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Patients from cover (Minnesota Shared DecisionMaking Collaborative). ICSI recently used a grant from the Robert Wood Johnson Foundation to study the concept of shared decision-making in palliative care. The sensitive nature of addressing patients with life-limiting conditions makes shared decision-making especially important. ICSI wanted to know whether using this concept could help medical professionals achieve the Triple Aim of improving the health of the population, the patient experience, and the affordability of care. The goals for the study were to: 1. Increase patient-centered care by listening to and honoring the preferences and values of patients and families 2. Increase the sharing of evidence-based medicine with patients and families, and engage them by using shared decision-making in care decisions 3. Collaborate with patients and families to create tools and methods to achieve these aims
Collaborative Conversation Map
Work on the ICSI study led to the creation of a Collaborative Conversation Map (see Fig. 1) to guide shared decision-making discussions. By using the map, health care teams have reported a more cohesive environment based on an increased understanding of the roles and responsibilities of team members. Many groups have built the process into electronic health record systems, care management meeting settings, and reporting structures. The Collaborative Conversation Map also
helps patients become comfortable with the shared decisionmaking process, making them better able to share critical information with family and clinicians. One of the greatest benefits of using a Collaborative Conversation Map is understanding how to partner with patients in health care discussions. The model makes it easy for care teams to watch for changes in a patient’s priorities or life goals, diagnosis or prognosis, health status or symptoms, support system, medical evidence or best practice, or clinician and caregiver contacts. In addition, patient and family needs might include requests for information or support, advanced care planning, consideration of values, trust, care coordination, and a responsive care system. Sometimes it is as simple as giving patients permission to participate in discussions about their care. The Collaborative Conversation Map was piloted in several different medical settings. In all cases, care was improved by enabling providers and clinical staff to implement a shared decision-making model. Some of the key insights gained in three of these pilot programs are described below. Marshfield Clinic
Clinicians at the Marshfield Clinic in western Wisconsin used shared decision-making to address palliative medicine and medical oncology, two disciplines that had not always worked well together, according to Sherry Wiedow, RN. A multidisciplinary team set four aggressive goals:
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• Integrate palliative medicine and medical oncology practices • Create cohesiveness between palliative medicine and medical oncology, improving interactions and decreasing variability in how well these two departments worked together • Increase physician and staff knowledge of shared decisionmaking • Improve patient and family understanding of how and why palliative medicine fits into the cancer care continuum Physicians and staff completed a Collaborative Conversation Map, which served as a script as they reviewed patient progress. To help prioritize a patient’s two most bothersome issues, the team initiated a PEACE-Tool that enabled patients and the team to rate and find options for dealing with: P = physical symptoms E = emotive and cognitive symptoms A = autonomy and agency issues (e.g., How do I maintain selfcontrol? How can I arrange for transportation?) C = communications, closure, and contribution (e.g., How do I talk about dying?) E = economic issues (e.g., How can I afford this care?) T = transcendent items (e.g., What will happen to my spirit when I die?) Surprisingly, issues that clinical staff identified as high priority were not necessarily the issues of most concern to patients. Pain might rate lower on a patient’s anxiety scale than his or her concern about transportation, for example. Using shared decision-making and the Collaborative Conversation Map enabled the team to build bridges between medical oncology and palliative medicine. Increased patient satisfaction was considered a successful outcome of the shared decision-making and collaborative process. The clinic plans to expand its model to additional providers and collaborate with its survivorship program on the patient symptom and distress assessment tool.
Key points North Memorial Hospital
North Memorial Hospital in Minneapolis introduced shared decision-making into a pilot program for end-of-life care under the leadership of John Degelau, MD. The goal was to make the patient’s life more predictable and sustainable. In a combined effort between clinicians and key patient advocates, including home care liaisons, social workers, case managers, and chaplains, the team created a Collaborative Conversation Map and clinical workflow process. This alone produced a better balance of influence between care team and patient when it came to decisions regarding patient care. Following a review of medical facts and decisions to be made, patients were asked to share their most important concern, which then guided future discussions about options. Once options had been addressed and decisions had been made, physicians were careful to check the patient’s understanding and answer questions. Any decisional conflicts were resolved with a form of negotiation. If necessary, issues were revisited. This sometimes happened when a condition-specific decision aid was offered or when the patient’s situation escalated. Minnesota Oncology
According to Michele O’Brien, RN, of Minnesota Oncology, patients who are diagnosed with cancer often have trouble absorbing information. Putting them in control of the conversation increases their satisfaction with care. In early 2012, Minnesota Oncology studied 75 patients using a Functional Assessment of Chronic Illness Therapy (FACIT) measurement system. Top patient concerns were: • Physical/functional – 60 percent • Fatigue – 52 percent • Emotional – 41 percent • Food/nutritional – 37 percent • Body image – 31 percent • Mind/body/spirit – 24 percent • Health care directive – 21 percent A pilot program was created to introduce survivorship and
• Research shows that acknowledging a patient’s preferences through shared decision-making can improve patient outcomes, lower costs, and improve a patient’s experience. • Shared decision-making is effective in palliative care, but can be equally effective throughout the care continuum, from preventive care to end-of-life discussions. • ICSI’s Collaborative Conversation Map is a tool that clinicians and their patients can use to more easily share in the decision-making process in selecting care treatments. • Shared decision-making increases the satisfaction of both clinicians and patients. palliative care concepts early in a patient’s treatment. It wove Shared Decision-Making and the Collaborative Conversation Map into several steps along the continuum of care, especially at diagnosis, change in status, and end of treatment. Each time, patient satisfaction was measured. Proactive, evidence-based care provided by a physiciannurse team has demonstrated improved results. In one trial involving 904 older patients with chronic conditions, patients who experienced such guided care had: • 24 percent fewer hospitalizations • 37 percent fewer skilled nursing facility stays • 15 percent fewer Emergency Department visits • 29 percent fewer home care episodes In addition to increasing patient satisfaction, the pilot program provided real cost benefits. The annual net savings was $75,000 per nurse or $1,364 per patient. Team members at Minnesota Oncology said they were pleased with the use of the Collaborative Conversation Map. They felt this tool helped their patients relate better to their physicians and improved a team’s ability to address physical, functional, emotional, and social needs. Conclusions and next steps
ICSI’s exploration of how best to enhance patient-centered care by engaging patients in shared decision-making revealed some pivotal insights, first and foremost that even the process of initiating conversations about health care decisions requires kick-starting. The Collaborative Conversation model developed
for this project accomplishes exactly that. The locations that fully embraced this model represent a broad range of care delivery models, and each location determined how best to integrate the model into its usual care. Increases in patient centeredness, care team cohesiveness, and patient and provider satisfaction were universal. One unexpected benefit of this project occurred precisely because of patient involvement. A version of the Collaborative Conversation Map presented to the ICSI Patient Advisory Council elicited edits that transformed it from a provider-facing tool into one that is equally valid
for patients. The use of the Collaborative Conversation Map by both patients and providers is a concrete manifestation of the “mirrored approach” inherent in the philosophical partnering of the patient and the provider. Despite its origins in palliative care, the Collaborative Conversation Map has been adopted by practices throughout the care continuum, from preventive care to end-of-life discussions. The model is flexible enough to work equally well in all of these settings, and therefore lends itself to becoming a normal component of usual care. Integrating the Collaborative Conversation Map into usual care has helped to improve patient centeredness, enhance the flow of information between patients and providers, and honor patients’ values and preferences in making choices among evidence-based options. Our work will continue. Jan Schuerman, MBA, is Shared Decision Making Project lead and Claire Neely, MD, is medical director of the Institute for Clinical Systems Improvement.
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PROFESSIONAL
T
he inflammatory spondyloarthropathies—now categorized as spondyloarthritis (SpA)—comprise a group of rheumatic diseases with a number of shared and overlapping features. Though not as common as rheumatoid arthritis, SpA has the potential to cause significant joint damage and loss of function. In a number of cases, extra-articular manifestations may either be associated or dominate, particularly when there is involvement of the skin, GI tract, or eye. Spondyloarthropathies are not new diseases, as signs of skeletal involvement have been found in ancient human remains (unlike rheumatoid arthritis, which was not observed until the 1600s). Yet, especially when there are only axial skeleton symptoms, clinicians may not consider SpA as a diagnosis, in deference to more common forms of back pain, including disc disease, facet joint disease, injury, or mechanical issues associated with secondary soft tissue involvement. SpA is unrelated to classic
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Spondyloarthritis An important group of related inflammatory diseases By Paul Waytz, MD autoimmune diseases and should be easily differentiated to maximize an overall approach to management. This article discusses the characteristics of SpA in hopes of further guiding clinicians toward making an early and appropriate diagnosis. Causes and symptoms of SpA
Under the umbrella of SpA, five diseases are recognized: ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, reactive arthritis, and undifferentiated SpA. Shared features include an inflammatory arthritis of the sacroiliac (SI) joints and spine, inflammation of ligaments and tendons at bony attachment sites (enthesopathy/enthesitis), familial involvement, and the absence of typical laboratory and imaging findings more typi-
MINNESOTA PHYSICIAN APRIL 2013
cal of rheumatoid arthritis. A cardinal feature of most of the SpA illnesses is low back pain, which is not usually found in more common rheumatic conditions such as rheumatoid arthritis and lupus. People with SpA generally begin having symptoms between the ages of 15 and 40 and often describe waxing and waning symptoms punctuated by flareups and extended periods of remission. Patients commonly attribute low back pain to overuse. However, with SpA, as with other types of inflammatory syndromes, morning stiffness and stiffness following inactivity, improved by activity and “loosening up,” are important and distinguishing characteristics. Aside from psoriatic arthritis, these conditions affect men more frequently than women. The cause of these illnesses is unknown. However, there is evidence that both genetic and environmental factors play a role, especially in reactive arthritis, which numerous reports link to bacterial and mycoplasma triggers from intestinal and urinary tract infections. More importantly, the HLA-B27 gene, located on the sixth chromosome, shows significant association with SpA, especially ankylosing spondylitis (AS), where this marker is present in more than 90 percent of affected patients. The precise role of the HLA-B27 gene in disease etiology remains to be completely elucidated, but ongoing studies offer exciting immunologic insights. A caution: The gene is present in approximately 8 percent of Caucasians, and less than 5 percent of positive individuals develop any SpA. Therefore, HLA-B27 should not be considered a screening test for patients with low back pain. The four differentiated types of SpA and diagnosis of SpA are discussed below.
Ankylosing spondylitis
Ankylosing spondylitis is the prototype SpA. Initial symptoms of low back pain are a result of sacroillitis and apophyseal joint inflammation, almost always in a symmetric presentation. Patients may describe “alternating sciatica”; however, symptoms do not radiate below the knee and are not associated with paresthesias. Mild episodes of pain may persist for years before a diagnosis is made, although some people have severe and relentless discomfort. Often, pain is confined to the buttocks. Findings on examination are often subtle, usually manifesting as SI joint tenderness and loss of the normal lumbar lordosis, eventually leading to complete straightening. As the disease progresses, there is further loss of vertebral column mobility and reduced chest expansion. Over time, large joint involvement can occur, especially affecting hips, shoulders, and knees; however, obvious swelling may be detected only in the knees. Thus, a diagnosis of AS is often based on essential historical features and a careful physical examination. A personal history of plantar fasciitis or iritis and a family history of lower back pain in young individuals, or of another SpA, are extremely helpful in making the diagnosis. Many patients present rather late in their course because they have adapted to discomfort over time. Physical findings at that time usually relate to the extreme loss of axial skeleton mobility, making it difficult to perform simple tasks such as parallel-parking a car. Because of vertebral column fusion, pain may not be an issue at this point, but simply the stiffness in trying to move en bloc. Patients may report dyspnea with mild exertion because of chest wall immobility and may demonstrate characteristic signs of accessory muscle and abdominal breathing. Even at later stages, patients may not show evidence of peripheral joint swelling, but end-stage hip disease may be a major source of morbidity. Psoriatic arthritis
Psoriasis occurs in 3 percent of the general population, and
Key points approximately one-quarter of these patients develop psoriatic arthritis (PsA). It is unusual for both skin and joint manifestations to occur simultaneously, and there may be a long lag time before the second aspect of the disease presents. Some patients with PsA never develop skin lesions, but the disease may be diagnosed by the clinical appearance and characteristic nail changes of pitting and nonfungal oncholysis. Five subsets of PsA are generally recognized: distal joint arthritis, asymmetric oligoarthritis, symmetric polyarthritis (resembling rheumatoid arthritis, but seronegative), spondylitis, and severe arthritis mutilans. Significant erosive joint damage can occur with any subtype. The spondylitis type may show atypical changes compared with AS, including unilateral sacroillitis and “skip” areas of vertebral column involvement. A positive HLA-B27 is most highly associated with this form of PsA. The appearance of tenosynovitis, enthesitis, and dactylitis (“sausage” finger or toe) can help fur-
• Spondyloarthritis comprises a group of five rheumatic diseases that are unrelated to classic autoimmune diseases. • Low back pain is a cardinal feature of most SpA and is rarely seen in rheumatoid arthritis or other connective diseases. • Screening autoimmune studies are not useful because of false positive rates with rheumatoid factor and ANA in particular. • Both genetic and environmental factors play a role in SpA. The HLA-B27 gene shows significant association with SpA, but its role in SpA is still being investigated. HLA-B27 is not recommended as a screening test for patients with low back pain. • A careful history and physical, along with conventional X-rays, are key to diagnosis of SpA. • Nonsteroidal anti-inflammatory drugs are the initial approach to symptom management. Disease-modifying medications, such as methotrexate, and biologics show promise in treating SpA. ther establish the diagnosis. Enteropathic arthritis
Enteropathic arthritis is the term applied to the inflammatory arthritis associated with either ulcerative colitis or Crohn’s disease. Arthritis occurs in 15 percent to 20 percent of patients who have these types of inflammatory bowel disease, with a somewhat higher prevalence in Crohn’s disease. Either the bowel disease or the arthritis may precede and, similarly to PsA, a lengthy period of time may elapse before both conditions are correlated.
Two forms of enteropathic arthritis are recognized: enteropathic spondyloarthritis and peripheral arthritis. The former usually becomes indistinguishable from typical AS in terms of clinical and radiologic features, as well as a higher incidence of HLA-B27 positivity. In the peripheral form, the arthritis is often oligoarticular and asymmetric, with a tendency for involvement of joints of the lower extremities. Dactylitis and enthesitis are seen with this subtype, and there is a much lower incidence of positive HLA-B27.
Of note, the activity of the arthritis often parallels the activity of the inflammatory bowel disease. In most cases of ulcerative colitis, total colectomy “cures” the arthritis. This is not the case with arthritis of Crohn’s disease, suggesting a similar but somewhat different etiology—or a lack of complete surgical resolution with Crohn’s. Reactive arthritis
Reactive arthritis occurs when a presumed infectious agent triggers an inflammatory arthritis that primarily involves the lower extremities and is oligoarticular in distribution. Enthesitis and dacytilitis are commonly seen, along with true arthritis; extraarticular manifestations, especially involving the skin, nails, and mucous membranes, are common. Mucous membrane lesions may be manifested as painless superficial oral and lingual ulcers. Cutaneous lesions include keratoderma blenorrhagicum involving the palms and soles, and shallow ulcers with heaped ridges on the penis. SPONDYLOARTHRITIS to page 38
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H E M AT O L O G Y
P
reoperative anemia is common, especially in patients undergoing nonemergent high-blood-loss surgical procedures such as joint replacement and cardiovascular (CV) surgeries, where loss of three or more grams of hemoglobin is not uncommon. Certain patients undergoing lowblood-loss surgeries, such as for endometrial abnormalities or colon cancer, often have severe anemia prior to the procedure due to disease-associated chronic bleeding. Anemia rates in presurgical patients range from 5 percent to 75 percent, depending on the procedure. Preoperative anemia is the strongest predictor of transfusion. A recent study of nearly 230,000 patients undergoing non-CV surgery found that even mild preoperative anemia is associated with increased morbidity and mortality, irrespective of transfusion (Musallam K. et al., Lancet, 2011). Studies with similar findings have been done in CV surgery patients (Karkouti K. et al, Circulation, 2008). Many studies in general sur-
Preoperative anemia Common, consequential, and correctable in non-emergent surgery By Kathrine Frey, MD
gery and CV surgery have found that transfusion is associated with increased complications in a dose-dependent manner. These adverse effects include pulmonary complications, infections, and increased length of hospital stay, among others (Vamvakis E.C. et al., Blood, 2009). From an infectious disease transmission standpoint, allogeneic blood is safer than ever. However, non-infectious risks remain, including volume overload, which is under-reported and currently estimated to occur in as many as 1 in 100 transfusions. In addition, up to 40 percent of transfusions administered currently may not meet medical indications, as described in a large meta-analysis by members of the International
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Consensus Conference on Transfusion Outcomes in 2011. To many transfusion and patient safety experts, transfusion is now considered an “undesirable event.” Risk factors for transfusion include female gender, age greater than 65 years, body weight less than 70 kg, creatinine greater than 1.2, multisite surgery, revision procedure, time to surgery of fewer than two weeks, and anemia. Unlike the other risk factors, anemia is generally correctable prior to surgery if it is identified with intent to treat and in a timely manner. Prevalence of preoperative anemia varies by surgical procedure, with rates of approximately 30 percent in joint replacement patients and in patients having coronary artery bypass grafting, and in 65 percent of patients undergoing valve replacement. Anemia is more common in the elderly and in patients with comorbid conditions. Iron deficiency, the most common type of anemia, is identified in 30 percent of anemic patients, followed by anemia of chronic disease (25 percent) and renal disease-associated anemia (15 percent to 20 percent). Medications can play a role in partially effective hematopoiesis, including iron deficiency due to antacid use and decreased erythropoietin in patients taking beta blockers and other cardiac medications. Multifactorial anemia is very common. Diagnosing preoperative anemia
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For patients undergoing highblood-loss surgeries, laboratory testing for “blood health” should include more than a solitary hemoglobin value; this may not be necessary for low-blood-loss surgeries unless the risk of preoperative anemia is very high (e.g., for some GI and GYN surgeries). Iron depletion and iron
deficiency precede anemia and, when present, impede the red cell regenerative response in the face of blood loss. For example, an initial laboratory evaluation panel for applicable non-emergent preoperative patients would include complete blood count; reticulocyte count; creatinine with GFR; and iron studies, including serum iron, percent saturation, iron binding capacity, and ferritin. Follow-on laboratory tests for patients with anemia or other hematologic abnormalities identified may include, but are not limited to, C-reactive protein, red cell folate, serum vitamin B12, soluble transferrin receptor, LDH, haptoglobin, direct antiglobulin test, leukocyte differential, and, sometimes, blood morphology (Goodenough LT et al., Anesth Analg, 2005). In addition to laboratory testing and knowing the patient’s medications, it is helpful to know the patient’s medical history, to correlate any blood health abnormalities with the known clinical situation. Consider the example of a diabetic female with chronic mild anemia and hemoglobin of 11.0 with low percent saturation, elevated ferritin, and elevated C-reactive protein inflammatory, who shows findings of anemia of inflammation. This clinical picture makes sense. In comparison, a middle-aged male with hemoglobin of 11.0 with iron deficiency as a new finding raises suspicion for gastrointestinal or other bleeding; the cause of these findings should be determined prior to elective surgery, and the surgery postponed. Transfusion for perioperative anemia
Blood transfusion prior to surgery is not a solution for preoperative anemia, and postoperative red cell transfusion is not advised in the absence of critical bleeding or symptoms of ischemia (increased heart rate not responsive to volume replacement or decreased oxygen saturation not responsive to oxygen therapy). There is ample medical evidence showing that a restrictive approach to transfusion (“permissive anemia”), such
Key points • Even mild preoperative anemia is associated with increased morbidity and mortality, irrespective of transfusion. • There is a need for a preoperative “blood health” check for non-emergent patients having high-blood-loss procedures well in advance of surgery (three or more weeks). • The blood health check should ensure that patient has maximized red cell mass and the ability to make red cells after blood is lost. • In general, IV iron, especially the newer forms, is a safer alternative to blood transfusion. treat anemia in several patient populations, but only epoetin alpha is approved by the FDA explicitly for use in patients undergoing major surgery with high anticipated blood loss. This agent is on label for joint replacement patients but currently is not used prior to cardiac surgery. Patients treated with ESAs must not be iron deficient prior to treatment, as the erythropoiesis-stimulating response requires the presence of iron for completion, and giving erythropoietin in the absence of iron will not produce red cells (some describe this as akin to stepping on the accelerator without any gas in the tank). Iron may be administered either orally or intravenously. It is important to note that ESAs are prothrombotic, so pharmacologic DVT prophylaxis should be considered. Preoperative anemia evaluation: Earlier is better
Several surgical societies, including the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons, as well as the Joint Commission, have weighed in in support of anemia evaluation 15–45 days prior to surgery. The Society of Thoracic Surgeons recommends preoperative hemoglobin of 13 g/dL for males and females prior to surgery. Some CV surgery programs now cancel cases the day of surgery if the patient is found to be anemic. Formal preoperative evaluation for anemia 30 days prior to elective surgery is not currently a common practice. Patients often visit their primary care physician in the two weeks prior to surgery; if anemia is identified, the physician can be in an uncomfortable position in regard to delaying surgery. Many
physicians are not aware of substantial hemoglobin loss in procedures like joint replacement, which averages four grams for knee and hip replacement. Similarly, they are not aware of transfusion variability for surgeons and other physicians, a phenomenon that is widely described in the medical literature. For example, a recent large study of transfusion in primary hip surgery at the University of Pittsburgh Medical Center showed that one surgeon who performed 350 cases transfused 5 percent of patients, while another surgeon who also performed 350 cases transfused 95 percent of patients. This underscores the importance of evaluation for and correction of ane-
Telephone Equipment Distribution (TED) Program
as holding transfusion until hemoglobin of 7.0 g/dL in noncritically bleeding, asymptomatic patients, is safer than transfusion unless the patient has active heart disease (Hebert Paul C. et al., NEJM, 1999). Pre- and postoperative anemia treatment strategies use the same therapeutic agents, namely, intravenous iron preparations and, sometimes, an erythrocyte stimulating agent (ESA). Oral iron is generally ineffective in treating anemia preoperatively unless there is a timeframe of several weeks to months to surgery, also noting that there is poor patient compliance with taking iron orally. Approximately 30 percent of patients will be intolerant to oral iron, and the response (or not) to the iron will likely be determined on the day of surgery. However, oral iron is a good option in patients found to be iron depleted or deficient but without anemia. Intravenous iron preparations are much safer now than they were years ago when anaphylactic reactions were a concern. Iron sucrose is commonly used in the perioperative setting. Unlike older IV preparations, iron sucrose and most other forms of IV iron cannot be given as a single dose, and divided doses totaling 1 g of iron are not uncommon. A rule of thumb is that 250 mg iron is needed to increase the Hgb by 1 gm, with addition of another 500 mg for iron-deficient patients to restore iron stores. Effect on hemoglobin level usually occurs starting at one week, with maximal effect achieved at two weeks. Hypotension, arthralgia, abdominal discomfort, and back pain are potential side effects of IV iron. In general, IV iron, especially the newer forms, is a safer alternative to blood transfusion. Death occurs at a much lower rate with iron than with blood transfusions (0.4/ million vs. 4/million, respectively); this is also true for life-threatening adverse events (4/million vs. 10/million, respectively), according to a systematic review by the Network for Advancement of Transfusion Alternatives. ESAs are FDA approved to
mia preoperatively. Assuring that patients presenting for surgery have maximized red cell mass and the ability to produce red cells after large amounts of blood are lost serves the patient, the hospital, and the community well, in a number of ways: • Patients avoid complications associated with preoperative anemia as well as transfusion. • Donor blood is used appropriately, assuring its availability for others in need. • Hospitals don’t use resources providing adverse event care and transfusion procedures that are avoidable. Presurgical anemia is common, clinically significant—and treatable. Physicians who see patients preoperatively can improve care and outcomes by recognizing patients at risk for anemia and treating them in a timely manner. Kathrine Frey, MD, is a pathologist and director of patient blood management services at Fairview Southdale Hospital.
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.
1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services APRIL 2013
MINNESOTA PHYSICIAN
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PRACTICE
Call-schedule creation and communication
C
reating, maintaining, and communicating the oncall schedule for a group of doctors can be one of administrative medicine’s nastiest jobs. A founding physician pioneer of a premier specialty medical practice recently confided that trying to get someone else to do the group’s call schedule was “like trying to give away a skunk.” His comment is understandable. After all, who would want to take on the thankless task of developing and applying rules, keeping track of a multitude of physician requests, setting up a schedule (whether on a software chart or in a three-ring binder)—and then having to listen to a litany of complaints once the schedule is distributed? And once the schedule is accepted by the group, how many times does the scheduler hear from a practice member who “didn’t have the call schedule in front of me,” creating a lastminute scramble to clue the physician in and/or find a replacement?
Turning a skunk into a rose By Justin Wampach and Patrick Zook, MD
The good news is that over the past decade, developments and improvements in call-scheduling software have taken some of the stink out of the call-scheduling process. In general, all of them will provide these basic elements: • Schedule creation • Schedule maintenance • Communication tools An effective call-scheduling program can help medical groups be more efficient, improve communication, and reduce “post-publication backlash.” However, many medical groups in the early stages of buying call-scheduling software
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MANAGEMENT
MINNESOTA PHYSICIAN APRIL 2013
focus on the wrong things and/or unknowingly create barriers that jeopardize their success in selecting the best program for their group’s particular needs. Some keys to evaluating which program is the best match for your medical group’s particular needs, and to avoiding common pitfalls in the selection process, are discussed below. Evaluating call-scheduling software
The evaluation team should consist of the person who creates the schedule, a lead physician, and the practice administrator. A single evaluator will have a much more difficult time convincing others of a need. If you are unable to assemble a team, you may want to reconsider whether you really have a problem. Here are five keys to evaluating on-call scheduling software programs. 1. Skip the sales pitch about how the software works. It’s common to get caught up in how the software works, especially when you are talking about rules and how the system interprets and applies them. But this can lead to endless “analysis paralysis.” Why? Because you have no idea what the results of scheduling software will be until you enter your data into the system and try to create a schedule. Software promotional materials and demos can paint a picture of perfection—but keep in mind that no program is the best fit for every medical group. Anyone can sit at a table, look at a software demo, and “talk smart” about how it will work. But how it works won’t matter if the product does not give you the results your practice needs.
2. Focus on results—not features. Features may look enticing, but if they do not help you achieve your goals, they can be almost worthless. For example, consider a feature that would automatically approve or deny a doctor’s day-off or vacation request based on a total number of doctors who can be off on a certain day. It sounds good—until you think of all the times you would not want it to automatically take action. A similar example is schedule change notification, which sounds good until you are making 10 changes in one day and you inundate the providers’ email accounts with change notifications. It’s important that you know your group’s desired results and drive toward them. Sit down with your stakeholders and create a list of items you want the new scheduling software to accomplish. One way to identify the top priorities is to give each member three colored dots to place by the goals that are most important to him or her. When they have finished and you have compiled the results, you should have a list of your top three needs. Most specialty groups identify these top needs: • Schedule automation • Tally automation • Ability to view the call schedule online 3. Be realistic about your needs. It’s easy to get carried away with the “what ifs” or “nice to haves.” Medical groups that are clear about their needs will more effectively identify the best software for them. There are three top areas where groups tend to be unrealistic: • How many rules we can have that limit or exclude. For example, Dr. X can never work on Monday. Or Dr. Y needs to be off the day before and day after call. These are not necessarily bad rules, but each rule limits who can be scheduled where. If the goal is to reduce the time to create a fair, balanced schedule, you can achieve this by reducing the number of rules that limit or exclude.
• How long to run the schedule out in order to achieve fair tallies. Often people want to create a schedule one month at a time, because that is the way it has always been done. The reason it is currently one month at a time is because that is all the scheduler’s brain can handle in one sitting. When choosing software, a good question is to ask is, how long should we “run itâ€? to get fair tallies?` • How many physicians can be unavailable for call at the same time. The larger the number, the harder it will be to create the schedule. The bottom line is that the fewer providers in your practice, the fewer rules you can have if you want to have someone available for call. The same is true regarding vacations. You need to have resources available from which to choose for on-call duties. If you are always working with the absolute minimum number of providers available, you will find it challenging when you need to make a change. When it comes to fair tallies— e.g., total days scheduled, total weekends scheduled, number of times scheduled on a certain day of the week—fairness in scheduling depends on stakeholders agreeing to “play niceâ€? by occasionally accommodating a less than perfectly equitable schedule. Very few practices will have enough providers to always have perfect tallies. 4. Limit your financial investment by trying the program without risk. How much risk are you willing to assume if this project bombs? Considering the high degree of uncertainty when it comes to the results of scheduling software, and considering that the results are subjective, it’s best to limit your risk as much as you can. How do you limit your risk? Start by selecting a vendor that uses a monthly, pay-as-you-go model. Until you know that what you are buying will meet your needs, results, and outcomes, play it safe: Go monthly. By paying as you go, you hold the control. Be aware that a trial is not the same as a money-back-guarantee. At the end of a trial, you decide what is best for you. With
a money-back guarantee, the company decides when—and if—it will return your money. Medical groups need 60–120 days to determine whether a particular call-scheduling program is a good fit. This allows enough time to set up, configure, create, publish, and modify the schedule and then evaluate its effectiveness. 5. People matter. The best businesses are the ones with the best people. When selecting a new call-scheduling software partner, choose one that offers great training and support. This will make all the difference in the world. There are several ways to achieve your desired results. Your biggest advocates will be the trainer and ongoing support, so leverage their expertise. They want to help you achieve your desired results; let them help you. Barriers to success
It is not always enough to know what we need to focus on; we also need to be aware of the red flags that signal we’re off track. Here are the top five things not to focus on, because they can derail medical groups from making the right decision regarding call-scheduling software. 1. Price. Few medical groups actually know what creating, maintaining, and publishing a schedule currently costs them, because they’ve never tracked it. In most cases, physicians find that on-call scheduling software significantly boosts the bottom line—both through time savings and through the increased productivity that allows the physicians to focus on caring for patients. 2. Company size. In today’s “flat,� technology-driven world, the number of employees at a company is less important in assessing the company’s success. In fact, the most nimble vendors may have the lowest overhead costs, which can translate into lower costs to you. 3. References. It really doesn’t matter if the software works for someone else. With your unique data, will it give you the results you need to satisfy your doctors? That is more important.
4. Printing capability. The health care industry is going electronic. Few doctors request printed versions of call schedules now, and that number will continue to decline with time. 5. The rules and scheduling engine. It is almost impossible for someone to tell you whether and how well something will work for you without using your specific data. Don’t get bogged down in understanding exactly how the software is configured; focus on whether it can deliver what you need when you need it. Are you ready to make the switch?
Switching from doing call scheduling manually to an online electronic system takes time and commitment, and shouldn’t be approached lightly. As a rule of thumb, your medical group may be ready to consider a different method of on-call scheduling when: 1. You’re willing to make modifications to the current process. 2. You’re willing to make some changes to the current rules.
3. You’re willing to make some changes to the schedule length. 4. You have identified your group’s top three needs. 5. You have established a budget or have funds available. 6. You have time set aside to configure and learn a new program. By concentrating on evaluating the relevant aspects of the software options and avoiding getting sidetracked by incorrect assumptions or expectations, you’ll be able to pick a callscheduling program that’s a good fit for your practice. You may even come out smelling like a rose—or, at least, not like a skunk. Justin Wampach is president of Adjuvant, LLC, which provides online scheduling tools and technology to providers. Patrick Zook, MD, has practiced family medicine at the St. Cloud Medical Group for 32 years.
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SPECIAL
FOCUS:
Health Ed Ehlinger, MD, points out in this month’s cover story, where clinical care and
H E A LT H / C O M M U N I T Y
Converging health systems
As Commissioner of
“Community health is
PUBLIC
Reform-in-progress and educating the next generations of health professionals
public health can and
By John Finnegan Jr., PhD
should come together.� The articles in our special focus illustrate ways that health organizations and leaders in Minnesota are putting collabora-
I
t has taken a century for the United States to provide its citizens nearly universal access to health care for the first time in its history. However, if this historic achievement of the
changes in the complex systems that shape our health. We have only to read a January 2013 Institute of Medicine report (“U.S. Health in International Perspective�) to remind us of
tive public healthcommunity health models into practice to improve the health of individuals and communities and to educate health workers for the future.
The U.S. public health system has been chronically underdeveloped and underfunded compared to its counterparts among the richest nations. Affordable Care Act (ACA) actually meets its promise, it could well be unsustainable should we fail to make equally historic
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the challenge: We spend more per capita on health care than any other nation, yet U.S. residents have shorter lifespans and worse health outcomes among the richest nations. Two major challenges are the connections among systems—public health and health care providers—and the system by which we educate the next generations of health professionals. The cascade of change triggered by ACA is engaging us in some serious thinking about where and how we channel the forces of reform. In many ways, Minnesota is a leader in these areas, but key players acknowledge there is a long way to go. To begin with, reform needs purpose. Health as asset— the purpose of reform
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MINNESOTA PHYSICIAN APRIL 2013
Among its many provisions, the ACA created the National Prevention, Health Promotion and Public Health Council, composed of leaders of 17 federal agencies that shape U.S. health policy. Chaired by Surgeon General Regina Benjamin, the council published the National Prevention Strategy in June 2011. The vision is practical yet compelling:
H E A LT H
“The strength and ingenuity of America’s people and communities have driven America’s success. A healthy and fit nation is vital to that strength and is the bedrock of the productivity, innovation, and entrepreneurship essential for our future. Healthy people can enjoy their lives, go to work, contribute to their communities, learn, and support their families and friends. A healthy nation is able to educate its people, create and sustain a thriving economy, defend itself, and remain prepared for emergencies.� The purpose of health reform framed in this vision is the preservation and growth of an asset that determines the future of nations and individuals alike. Health as an individual AND a collective asset is composed of all those conditions and factors that lead to physical, psychological, social, and spiritual well-being. How do we create systems that support and build health for each individual at every age, but also shape the “big picture� factors that condition our health as individuals? The federal government has never been the only actor addressing these challenges. States play a decisive role based on their own culture, history, and policy. Minnesota in particular is prominent among bellwether states for progressive health policy and experimentation that long preceded ACA. Much of what happens here provides guidance and leadership for the nation. It’s about health and systems
The path to better health is easily lost if we aren’t equipped to embrace and engage the complexity of the challenges related to system reforms. A seminal 2008 Health Affairs article by former CMS interim director Don Berwick and colleagues explained these as the “Triple Aim� of improving community and population health, improving health care quality and outcomes, and reducing per capita costs that now top $8,400 a year. Understanding how we as a nation slipped so badly into high health costs and poor outcomes is important in clarifying the path to the better future we need
Key points and want. It is axiomatic that for decades we over-invested in a fragmented system, wrongly incentivized and inefficiently competitive, to treat primarily sickness rather than health. Intentionally or not, we crafted incentives to provide excessive treatment irrespective of the evidence for effectiveness or improved outcomes, and to have third parties (government or private insurance) pay for it. At the same time, we starved the “upstream” approaches of public health that address the conditions shaping the “big picture” of health in the first place. As the Institute of Medicine (IOM) recently reported, the U.S. public health system has been chronically underdeveloped and underfunded compared to its counterparts among the richest nations (“For the Public’s Health: Investing in a Healthier Future,” 2012). In today’s health reform era, IOM recommended doubling national and state investment in public health just to catch up with developed nations that have far more balanced “investment portfolios” in medical services and public health. ACA has loosed forces that are changing the U.S. picture rapidly. In health care, the dynamics of meeting the goals of the Triple Aim are leading toward new, integrated community health systems, according to University of Minnesota professors Dan Zismer, PhD, and Frank Cerra, MD. Writing in a Governance Institute White Paper (“High-functioning Integrated Health Systems: Governing a ‘Learning Organization’”) last year, the two observed that ACA is influencing corporate consolidation and integrating physicians and other licensed care professionals: “The IHS [integrated health system] model of community health services delivery is fundamentally different from the historic and conventional models composed of single or multihospital systems with “affiliated, ”independent physicians making up the medical staff … With the integrated model everything changes: organizational design, legal structures, operating mod-
• Health systems must support both the health of individuals and population/community health. • The ACA will change the economic focus from hospital-based inpatient to outpatient and home care. • Minnesota has a history of integrating public health into health initiatives, but must continue working to address disparities in health outcomes. • The University of Minnesota Academic Health Center has received funding to create a national center for coordination and leadership in interprofessional professional education of health professionals. • Connecting students across health professions’ curricula will help them create effective and coordinated care teams in integrated health systems. els, leadership models, methods of organizing and aligning operating and financial incentives, as well as, for some, visions and missions.” Zismer and Cerra note a key impact of this change: IHS models will transform from primarily hospital-based to outpatient care-based economics; from a focus on sickness to a focus on health; and from a focus on treatment to a focus on value and outcomes. Another important force is the ACA’s allocation of accountability for population and community health outcomes as a shared responsibility of integrated health systems. For many health care organizations, this will entail a huge cultural shift— from waiting for sick people to come through the doors to active engagement of community organizations and partnerships in collaborative efforts promoting health and preventing disease. This sets the stage for a closer relationship between health care systems and public health. For many in public health, such a partnership is long overdue. Writing in the Journal of Law, Medicine and Ethics in 2011, Georgetown University fellow Lorian Hardcastle and her colleagues noted the necessity for health care and public health systems to improve their coordination, noting that both should collaborate “… as two parts of a single integrated health system.” Minnesota has an advantage in leadership in this area, rooted in its culture of collaboration and cross-sector partnerships. Not only does Minnesota have a robust neighborhood and community health movement, but
many of the state’s major health care organizations have created community health promotion initiatives already—long before ACA. They have gained experience in forming relationships across private, public, and government sectors, as has the public health community. Allina’s Backyard Initiative and New Ulm Heart Health Program are examples; another is Hibbing’s engaging the University of Minnesota, the city’s three health systems, pharmacists, and other health professionals in a campaign to improve aspirin use as a heart attack preventive. The many
other such initiatives are too numerous to list here. Part of Minnesota’s advantage goes back to 1998, when the state settled its lawsuit against Big Tobacco. It provided resources for a sustained statewide initiative across sectors, helping smokers to quit and preventing young people from starting. Unfortunately, raiding these resources in tough budget times was just too tempting for the Legislature. Nevertheless, the initiative provided a model for Minnesota’s Statewide Health Improvement Program (SHIP) through the Minnesota Department of Health, that emerged out of the state’s 2008 health reform act. SHIP has continued to provide “… sustainable, systemic changes in schools, worksites, communities and health care organizations …” as one kind of partnership model focused on the big picture, according to the MDH website’s SHIP overview. While the state has an advantage borne of leadership, HEALTH SYSTEMS to page 36
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APRIL 2013
MINNESOTA PHYSICIAN
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SPECIAL
S
o important is the development of health care homes in Minnesota that Gov. Mark Dayton listed it as one of his administration’s accomplishments over the past two years to improve the health of Minnesotans. As of January 2013, the Minnesota Department of Health (MDH) had certified 220 clinics as health care homes, and many more applications for certification are in the pipeline. Among the key components of this model of care are being patient- and family-centered, providing care coordination services, and connecting patients with community resources. MDH is emphasizing the third component—helping patients connect with help available in their own communities— as part of the second year of health-care home certification for clinics. This article highlights some opportunities for health care homes to partner with community-based resources that can provide services to patients.
FOCUS:
H E A LT H / C O M M U N I T Y
Community-clinic partnerships A key component of health care home recertification By Lynne Ogawa, MD, and Lynn Balfour, MBA
Community-clinic partnerships
MDH requires that one year after certification, health care homes must apply for recertification. That is where community resource organizations come into the picture. To be recertified, health care homes must establish a partnership with at least one community resource organization and demonstrate an ongoing connection and work plan with that organization. Partnerships with community and patient advocacy groups help to extend the continuum of care for patients. As an example, the Creando Puentes program at West Side Community Health Services in St. Paul delivers
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MINNESOTA PHYSICIAN APRIL 2013
bilingual/bicultural services (mainly case management at West Side) to patients diagnosed with mental illness. Creando Puentes is a collaboration of La Clinica (West Side), Comunidades Latinas Unidas en Servicio (CLUES), and Ramsey County. This is just one way that clinics are pursuing ties and partnership with community organizations to improve the care of their patients. “There is a real eagerness by clinics to work with community organizations,” says Marie MaesVoreis, RN, MA, program manager of health care homes at MDH. “Through the recertification process, clinics establish a community partnership by meeting and planning together to provide seamless resources to patients and families. While there are many examples, a few include working with school nursing, community mental health programs, home visiting, health and wellness programs, programs for developmental readiness, seniors programs, and local public health.” Hundreds of community resource organizations in Minnesota provide nonmedical services, patient support and education, and clinician continuing education. Health care homes seeking recertification should first consider what type of partnership they need to help their practice extend the continuum of care for patients enrolled in their health care home. Using a patient registry or quality assurance goals, clinic staff can identify specific patient populations that need extra attention—such as those with diabetes, asthma, or cognitive impairment—and then find a local resource that offers assistance to those populations.
H E A LT H To expedite that process, and with funding from UCare, the Minnesota Academy of Family Physicians Foundation is working on a project to connect health care homes with nonmedical provider organizations, such as community resource organizations, so they can begin a dialogue and explore partnership opportunities. The foundation can help health care homes identify nonmedical providers, make introductions, schedule a brief information meeting, and determine next steps. A sampling of community resources
Here are a few programs and organizations poised to partner with Minnesota’s health care homes, as well as other clinics: Chronic Disease SelfManagement Program. This evidence-based program, developed by Stanford University, is available in Minnesota through a number of licensed organizations, including the MDH. During the six-week course, patients learn and practice selfmanagement techniques to better manage their disease and live a healthier, more satisfying life. Led by two trained peer leaders, the course may be implemented through a partnership between a clinic and community organization such as a senior center, assisted living facility, or community center. As an example, the Northwest Family Physicians clinic in Rogers worked with a senior living center to offer the course. Most of the participants came from nearby senior apartments, and the clinic provided the course leaders. To receive a free DVD about the program, contact Lynn Balfour at (952) 542-0130 or foundation@mafp.org. Minigrants are available to clinics that pilot a session before June 30, 2013.
American Diabetes Association of Minnesota. Many clinics are working to improve diabetes and pre-diabetes care. The American Diabetes Association (ADA) educates and supports
people with diabetes and prediabetes, providing information about standards of diabetes care, materials and resources for patients with specific needs, position statements, access to advisory committee members, and programs such as these: • Living with Type 2 Diabetes, a free 12-month program, offered in English and Spanish, that provides information and support to people newly diagnosed with type 2 diabetes. Patients can participate online or through the mail. • Camp Needlepoint, for children with diabetes ages 8–16 years. It includes 24-hour medical supervision, meals/snacks, housing, supervised program activities, most diabetes supplies, and more. Camp Daypoint is a day camp for children ages 5–9 years. Both camps are held in August at YMCA Camp St. Croix. • Diabetes EXPO, to be held Oct. 12, 2013, at the Minneapolis Convention Center. The free event will feature health screenings, expert presentations, cooking demonstrations, and diabetes product and service exhibitors. To learn more about ADA’s resources for patients and physicians, visit www.diabetes.org or contact Chris Schaefer at cschaefer@diabetes.org, (763) 593-5333.
American Lung Association in Minnesota (ALA). Working to improve quality measures for asthma and COPD? Numerous national guidelines require the use of spirometry for patients with a diagnosis of asthma or COPD. A knowledge of spirometry techniques and effective coaching in administering the exam are critical to achieving reproducible and valid test results. Proper interpretation of the results leads to good diagnoses that align with treatment criteria. The ALA’s Implementation and Interpretation of Spirometry, a course for health care professionals who administer spirome-
www.guidelineadvantage.org or contact jeanne.rash@heart.org for additional information.
Partnerships with community and patient advocacy groups help to extend the continuum of care for patients.
Not ready to decide on a community resource partner?
try tests and providers who interpret the results, will be offered April 25 at the ALA in St. Paul. The morning session will focus on how to teach proper spirometry technique and coaching for reproducibility. The afternoon session will review how to interpret test results for proper diagnosis. The cost is $90 for just one session or $160 for the entire day; CEUs provided. To register for the course, visit www.lungmn.org or call the ALA at (651) 268-7612.
Alzheimer’s Association Minnesota–North Dakota Chapter. Working with patients who have memory complaints? For clinics that want to improve post-diagnostic care for patients with Alzheimer’s disease or a related dementia, these Alzheimer’s Association programs can help: • Tools for Providers on cognitive assessment, diagnosis, and post-diagnostic care are available at www.alz.org/mnnd/ in_my_community_20775.asp. • 24/7 Helpline, at (800) 2723900. Trained professionals are available 24/7 to answer questions and provide information. • Care Consultation, offering assistance in developing a plan post-diagnosis, is available through consultation in person, over the phone, and online. The Alzheimer’s Association also offers education classes (in person and online), interactive workbooks, and support groups for families. Call them at (800) 272-3900 or visit www.alz.org/mnnd. American Heart Association in Minnesota. The Guideline Advantage program combines the expertise of the American Cancer Society, American Diabetes Association, and American Heart Association to advance prevention and dis-
ease management in the outpatient setting. Available at no charge to practices, the program promotes the use of evidence-
based treatment guidelines, performance measurement tools, and quality improvement strategies with the goal of helping clinics offer their patients every advantage for a healthy life. The program aligns with key national initiatives, including Meaningful Use, PatientCentered Medical Home, and Million Hearts. To learn more about this program and how to participate, visit
Perhaps your clinic is unsure which community resource organization would be most helpful to you and your patients. You can order a free resource packet to review with your colleagues and then decide. To order a packet and a discussion guide, contact Lynn Balfour at the Minnesota Academy of Family Physicians Foundation, (952) 542-0130 or (800) 999-8198, or at foundation@mafp.org. Lynne Ogawa, MD, is a family physician who practices at West Side Community Health Services and is vice president of the Minnesota Academy of Family Physicians Foundation. Lynn Balfour, MBA, is executive director of the Minnesota Academy of Family Physicians Foundation, the philanthropic arm of the Minnesota Academy of Family Physicians (a membership organization for specialists in family medicine).
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or more than 40 years, Southside Community Health Services, Inc. (SCHS) has provided medical, dental, and vision services to those who are uninsured and underinsured in south Minneapolis and the Stillwater area. SCHS, a Federally Qualified Health Center established in 1971, strongly believes in reaching out to the community to improve access to primary health care and reduce health disparities. Our three clinics in south Minneapolis are located in areas where there is a high incidence of health issues that affect our community and the metropolitan community as a whole, such as hypertension, diabetes, periodontal disease, glaucoma, and lack of access to medical care. In 2012, SCHS saw 11,796 patients, for a total of 33,022 visits; 31.3 percent of them were uninsured, and 57.8 percent of the uninsured were at 100 percent of poverty level or below. Southside offers sliding fee discounts to those who qualify so that we can provide health care
FOCUS:
PUBLIC
H E A LT H / C O M M U N I T Y
Bringing health care to the community Helping bridge the gap between underserved communities and primary care By Clarence Jones and Angela Gerlach
to the underserved population. Slightly more than 32 percent of our patients were covered by some form of public assistance for health care. The race/ethnicity breakdown for patients who self-reported this data was: • African American—18.2 percent • White Non-Hispanic—28.9 percent • Hispanic/Latino—32.46 percent To provide a full range of health services to our patients, the clinic staff includes physicians, dentists, nurse practitioners, a dental hygienist and assistants, medical assistants, patient advocates, psychiatrists, opto-
metrists, and support staff. In addition to clinics, SCHS offers a broad range of outreach activities, known as Q Health Connections. In 2012, these services reached 10,264 community members through local health fairs, a variety of programs, and other community events. Q Health Connections provides much-needed health education and health awareness, especially to our minority populations. This article describes several recent innovative programs at Southside that bring together research, government, and community components to improve the health of our patients and reduce health disparities. Fathering and men’s health programs
Most of the research regarding men and their role in the family has focused on their earning capabilities. In contrast, very little has been written on the role of fathers in helping to ensure a healthy family—and much of that research has focused on the importance of their involvement during the pregnancy. Q Health Connections works with fathers from preconception through pregnancy and in the lives of their children, to engage them in their role as nurturer. This is especially important for nonresidential fathers. In our Fathers Program sessions, topics covered include (but are not limited to): • STIs and HIV/AIDS • Birth control methods • Car seat safety • Depression and anxiety • Nutrition • Sudden infant death syndrome • Domestic and child abuse • Addictions • Child development • Fetal alcohol syndrome
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H E A LT H
• Anatomy (male and female) • Violence education and prevention Communication and relationship components are woven into all sessions, so participants can learn how to deal with these issues and address them in a healthy manner with their partners and their children. Participants are encouraged to interact with the educators and each other, as well as ask questions and present real-world situations in which this information will be useful. Participant postsession surveys have been very favorable. The men we work with are also encouraged to meet with Southside staff to apply for medical assistance or prescription assistance programs. Fathers and foods. Historically, men have been seen as economic providers. We are using that paradigm to teach them how to keep themselves and their children healthy, whatever their economic situation. Several SCHS projects have focused on fathers and foods. SCHS has worked with the City of Minneapolis on a VOICES (Valuing Our Individual Cultures through Engagement) project, in which community members from various cultural backgrounds share insights, through storytelling and storybased dialogues, about how culture is connected to food, healthy weight, and body size. The resulting series of videorecorded dialogues provides a deep understanding of cultural impacts on eating preferences. We have also collaborated with University of Minnesota Extension on Good Food Good Fathering, for fathers between the ages of 17 and 37. The program teaches fathers about the importance of providing healthy foods to their children. It involves hands-on learning opportunities for fathers and their children, including visits to farmers markets and community gardens, shopping trips, menu planning, and healthy food preparation. Computer health screening program (men’s health assessment). A new component of the Fathers Program is a Web-based
screening tool developed by the Minneapolis Department of Health and Family Support to assess psychosocial risks among expectant and new fathers. Called BRO (Brief Risk Overview), the survey tool screens men for psychosocial risk factors that affect their health and the health of their children, covering 16 health domains: telephone access, transportation access, food insecurity, housing instability, lack of social support, unsafe sex, partner violence, anger management, drug use, alcohol use, cigarette smoking, depression, post-traumatic stress, anxiety, legal problems, and involvement in child protection services. Interviewers can use the BRO to quickly and systematically address risk factors among new and expectant fathers and refer them to appropriate resources. The BRO not only screens men in the self-reported behavioral health areas, but also is used to determine the pregnancy status of their partners. Men are usually the first to know when their partner is pregnant, and many times they are unaware of their role in helping her to have a healthy baby. This innovative approach provides the SCHS staff with the opportunity to share information relevant to having a healthy child with the expectant fathers. Our goal is to identify the pregnancy earlier, provide accurate and do-able information, encourage the father in assisting the mother throughout the pregnancy, and help him develop parenting skills and resources. An ultimate aim of this program is to help reduce the incidence of infant mortality and low-birth-weight infants. In order to effectively connect fathers with resources to improve the health situations of themselves and their children, Q Health Connections is continuing to develop the MENgaging spreadsheet tool used in conjunction with health screening tools such as the BRO. The spreadsheet is used as a resource in connecting community members with organizations in 12 areas of concentration (e.g., food insecurity, hous-
Programs at Southside bring together research, government, and community components to improve the health of our patients and reduce health disparities. ing, transportation, physical health, mental health, education, and parenting). Each organization included as a resource has undergone a four-step process to validate its openness to the community and its effectiveness in addressing certain issues. Our vision is to use this resource tool as a base for connecting individuals with specific contacts at organizations that will provide them with the respect and care they deserve. Prenatal and child health programs
In addition to using the BRO and MENgaging tools to help reduce infant mortality and low birth weight, the SCHS Outreach Department works closely with partners in the Twin Cities Healthy Start Program, in particular the city of Minneapolis. In collaboration with the city, this program uses community-driven strategies to provide women with high-risk pregnancies supportive resources to improve their own health, their baby’s health, and their family’s health. Twin Cities Healthy Start. Through this program, Minneapolis is the 103rd stop on the “Birthing Project USA: Railroad to New Life,” the only national African American maternal and child health program in the United States. The program is a simple yet innovative approach to increasing infant and maternal child health through social and emotional support. The program connects community members of various professional backgrounds, called “Sister Friends,” with high-risk expectant mothers, called “Little Sisters.” In addition, SCHS and collaborating partners with Twin Cities Healthy Start are the first organizations in the U.S. to pilot the Birthing Project for expectant fathers. The program began in March 2013 with fathers
whose babies are due around September, and will continue for a year. Each man will have monthly meetings with their “Brother Friend” and with the other expectant fathers in the Birthing Project Twin Cities. Topics of these sessions include how to support the mother, coparenting, baby’s growth before and after birth, and various health topics. Minnesota Birth Center. Steve Calvin, MD, is a specialist in maternal/fetal medicine and the medical director of Southside Community Health Services and the Minnesota Birth Center, a midwife-directed, freestanding birth center in Minneapolis. A focus of the clinic and the birthing center is to support mothers of all ethnicities and in the full range
of socioeconomic circumstances in having a healthy and positive prenatal, birthing, and postnatal experience. National Children’s Study. SCHS also supports the National Children’s Study, an initiative that is tracking the health of 100,000 children from before birth through their 21st birthdays. The ultimate goal of the study is to raise healthier babies by determining how environmental, social, genetic, behavioral, and cultural influences may interact and ultimately affect the health of children and adults. As one of nine national representatives to the study, SCHS Community Outreach Director Clarence Jones has been active in bringing more clarity to the community voice in discussing the environmental affects on children’s health. “Q”mmunity Mobile Medical Unit
In May 2011, Southside’s Community Outreach Department was chosen to receive COMMUNITY to page 34
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COMMUNITY CAREGIVERS 2013
Making a difference in Recognizing Minnesota’s volunteer physicians Each year, Minnesota Physician Publishing honors physicians who have volunteered medical services in recent years. Through volunteer medical activities that span the globe, Minnesota’s volunteer physicians have provided medical care and medical education while expanding crosscultural skills and understanding. Their compassion, commitment, and generosity reflect deeply held values of Minnesota’s medical community. By Scott Wooldridge Assistant editor, Minnesota Physician Publishing
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MINNESOTA PHYSICIAN APRIL 2013
Blogging from the epicenter considered a large hospital, with approximately 70 beds. Yoon notes that the hospital has a number of issues that would give U.S. physicians pause but which are not unusual for a Haitian facility. These include power shortages, sanitation issues, and a staff that is overworked and underpaid. Since his first trip in July 2010, Yoon has collaborated with Tom Slater, a surgical technician from HCMC who also participated in the Haiti mission trips, to blog about the team’s experience of providing health care in Haiti after the earthquake. The blog provides remarkable insights into the experiences of the American health care workers. Providers write about looking out over tent cities of injured Haitians and their families, choking on air thick with smoke from trash fires, or hunkering down to weather out hurricanes that further complicate their efforts to deliver health care. The topics can be relatively lighthearted as well, such as when the bloggers note the temporary loss of Internet service because the hospital didn’t pay its bill, or compare notes on local food, or write of enjoying their trips to local orphanages. (“Every Haitian kid I see is the absolute cutest kid ever ... until I see the next one,” one provider writes.) “It’s a way to process what we’ve been through,” Yoon says of the blog. “A lot of Our team resting at night after a long day in the OR. times you have very strong emotions that can country’s severe poverty have combined to cre- occur with all the stress of working 17-, 18hour days under what can be sometimes very ate ongoing demand for volunteer health care hectic conditions. It’s a way to digest it and I experts such as the HCMC providers. guess vent in a way so that you don’t keep it “There’s absolutely a need,” Yoon says. all bottled up inside. There are oftentimes “There’s been a shift from taking care of the emotional moments where there are patients acute injuries from the quake to taking care of you can’t save or who’ll never walk again. It’s a some of the long-term sequelae and complicaway to process all that and deal tions of injuries, for example, with it in our own way.” nonhealing bones and chronic Yoon says the blog, which infections.” often features photographs of HCMC providers have been providers and patients alike, has traveling to Haiti about twice a drawn a following back home in year, Yoon says, working primarMinnesota, including followers ily out of Hospital Adventiste on Facebook. “It’s somewhat d’Haiti, in the town of Carrefour. educational to let them know On his trip in March 2012, Yoon how bad people have it down says his team saw a mix of condithere in a country that’s really tions, including chronic infections not very far away at all,” he says. due to injuries from the quake, “There are congenital deformities in chilpatients you can’t “We try to not just treat patients as numbers, but [also show] dren, and acute broken bones, save or who’ll faces to put with the names and which he notes is a common problem in a city with many never walk again.” show that these are human beings, no better than you or roads that are still in bad shape. Patrick Yoon, MD me, just the same as us, that The Adventist hospital is have had horrible things happen located 20 miles outside Haiti’s to them and need help.” capital of Port-au-Prince, and is “On Wednesday night there was a magnitude 4.5 earthquake. We only felt it as a slight vibration where we were, but it very understandably caused a lot of concern.” So goes an entry in the blog “Project Ortho: From Hennepin to Haiti,” which chronicles the work of Patrick Yoon, MD, and other providers from Hennepin County Medical Center (HCMC) as they provide health care services in Haiti. Orthopedists from HCMC have been traveling to Haiti on a regular basis since a January 2010 earthquake devastated that country. The severity of that earthquake, its effect on Haiti’s infrastructure and economy, and the
n Minnesota and the world Giving back For the past seven years, S. Jafar Hasan, MD, an ophthalmologist with Edina Eye Physicians and Surgeons, has offered free eye-care clinics on a bimonthly basis. He says he was motivated to launch the clinics primarily by seeing the number of people without access to good health care. Hasan notes that doing something as simple as providing glasses can make a tremendous difference to people with poor vision. “Getting a pair of glasses can really change someone’s life, so it’s a really easy thing to do, with a big reward,” he says. The free clinics screen for basic eye conditions and provide eye exams. Hasan says Edina Eye provides eyeglass prescriptions at a significant discount for patients of the free clinic. Hasan has also been involved with Big Brothers, Big Sisters organization, and has worked with local schools to provide preventive eye care to children. He says he’s always had an interest in helping others. “My father is a social worker, so he just kind of ingrained that in me.” Hasan, who is Muslim, says his religion influences his community work. “We’re taught
to give back, and that’s what I’m trying to do,” he says. Hasan and some colleagues started Muslim Physicians of Minnesota a few years ago. “Basically our goal is to provide access to health care and education for all people, not just Muslims; our goal is to incorporate everybody,” he says. The group provides health care services at health fairs and educational seminars, and at
“ We’re taught to give back, and that’s what I’m trying to do.” Jafar Hasan, MD
Day of Dignity, an annual community event sponsored by the Masjid An-Nur mosque and Islamic Relief USA. Day of Dignity has been held on Minneapolis’ north side in October the past two years. Hasan says the annual event allows groups like his to reach out to the community. “It’s kind of an open house for people who don’t
have access to many social services,” he says. “They’ll have financial people there, nurses giving out flu shots. We had a booth there, not just for eye care; we had a cardiologist, blood pressure screenings, cholesterol screenings, and other things.” According to Hasan, Muslim Physicians of Minnesota has a membership of approximately 200 people, which includes health care workers other than physicians. He says the group has been trying to raise its visibility and the response has been good so far. In addition to the eye clinics he provides, the group also sponsors primary care and pediatric clinics at different locations around the Twin Cities. “The other thing we’re working on now is outreach to try and get mentors for students, particularly Somali students,” he says. “Many of them don’t have [mentors] in the community if they’re interested in the medical field.” Hasan hopes to begin offering his eye clinic on a monthly basis, in response to increasing demand. “There’s definitely a need,” he says. “There are more and more people without access to good health care. There’s been a pretty significant backlog of people needing eye care.” Caregivers to page 28
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COMMUNITY CAREGIVERS 2013 and provide training at the medical school in Gondar, in an effort to leave a self-sustaining medical legacy behind, Kobrin notes. Many physician volunteers go on medical missions that involve traveling Northern Ethiopia is beautiful, Kobrin says, not the desert that one from developed nations to relatively impoverished regions. Jerry Kobrin, might expect. “The northern region is mountainous and quite green, MD, along with his wife Hilary Stecklein, MD, have worked to prepare actually. It has a fascinating history and very warm and friendly people.” thousands of people from a poor region of Africa to travel to new, However, he adds, the people of northern Ethiopia are often quite healthier lives in Israel. impoverished, with most working as subsistence farmers. “It’s very hard Kobrin and Stecklein are both physicians with HealthPartners; for them to scratch out a living there,” Kobrin says. Emigrating to Israel Kobrin is an ophthalmologist and Stecklein, a pediatrician. They have gives them a future of new opportunities, he says, but the transition is recently been working with Jewish Healthcare International (JHI) on an not easy. He says the Ethiopian emigrants are “terrified and excited. It’s ongoing project that has relocated thousands of Ethiopian Jews. The a whole new life for them. It’s like going to another planet.” Ethiopians have been working with the Israeli government since the To help with that, JHI and the Israeli government have instituted a 1980s to relocate members of this ethnic minority to Israel, a process number of programs to educate emigrants and help them with language called aliyah. According to JHI officials, the Israeli training and other acclimation issues. JHI’s program government is planning to relocate the approximately to identify health conditions and create medical 8,000 Jews remaining in Ethiopia to Israel by 2015. records is part of those transition efforts, Kobrin says. As part of that effort, Kobrin and Stecklein travThe JHI program, he says, “… tries to identify eled last June to Gondar, Ethiopia, a region where medical problems early and pay attention to the many Ethiopian Jews are located. The two doctors types of medical conditions these people are bringing provided physicals and medical screenings for indiwith them. It’s like going back 2,000 years on the viduals who were scheduled for aliyah. Health issues clock. In developed countries, you don’t see rampant such as tuberculosis and malnutrition are not uncommalnutrition, malaria, tuberculosis. With the help of mon, and the Israeli government, along with JHI, is the medical university there, when we identify someworking to make sure that the emigrants are relaone who is really sick, we can provide them with care tively healthy and have up-to-date medical records. to get them on their feet again so they can be healthy Kobrin says the program identifies those with the enough for the journey.” “It’s like going back most pressing medical needs and treats them, usuKobrin, who worked with JHI on earlier medical 2,000 years on the clock.” ally at a local hospital. “It all depends on the urgmissions to Eastern Europe, says the work with Jews Jerry Kobrin, MD, and ency,” he says. “It could be a minor thing like dental preparing for aliyah was very fulfilling. “It was wonHilary Stecklein, MD care. We can alert the authorities so the proper apderful to get back to the basics. It was very heartpointments are made. If it’s an urgent situation, we warming working side-by-side with my spouse,” he can make sure they’re taken care of and healthy says. “These are gentle people, very appreciative, enough to go.” Physicians with JHI also give lectures and it was wonderful to help them start a new life.”
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MINNESOTA PHYSICIAN APRIL 2013
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Outside the comfort zone
ering from surgery. Bretzke says the surgical team does five to six cases a day, with restrictions due to lack of supplies and medical supMargit Bretzke, MD, has been part of a small, Minneapolis-based medport. “We have to do the kind of surgeries that keep people in the hospiical mission to Guatemala for the past eight years. The organization, tal maybe one or two nights, that aren’t going to need an intensive care Medical Teams Serving Guatemala, sends teams of surgeons and other unit, that are unlikely to need a blood transfusion.” providers for a total of three weeks (one week for every team) each fall Even within those limits, there are many serious conditions to treat. to the city of Antigua, west of Guatemala’s capital, Guatemala City. “They can be like the biggest hernias you’ve ever seen; the gallbladder’s There, the teams provide treatment for Guatemalans who otherwise always hard, but people have had these issues for years and years and would have little hope of being seen by a surgeon. haven’t had access to health care,” she says. “The other thing that is Bretzke says the trips have been something that she has enjoyed always so remarkable to us is that they don’t require much for pain. I sharing with her family. Her husband, Jeff Hanson, MD, has an extenthink these people live with a lot of pain in their lives, and they’re just so sive history of working in community clinics in Minneapolis as a family happy to have things taken care of. You’ll send them home with ibupropractice physician, and her son, Peter, has been on sevfen and that’s it. They never complain, and they may have eral trips, starting when he was 10 years old. She notes to walk 10 miles. It’s just remarkable.” that Peter has always helped out with jobs associated Despite having to operate in less than ideal condiwith the Catholic church where the mission is based. tions, Bretzke says the surgeons who participate in the “One year he helped inoculate chickens; he helped mission enjoy the trip and often will chip in extra money to build prefab houses that they would send into the mounhelp fund the mission. “You can have a lot of fun, and you tains for people. He and Jeff would do language school,” learn,” she says. “Most surgeons, I think, are thrill seekers she says. “Peter actually had the opportunity to come into in one way or another. You’re doing things really out of the operating room a couple times just to see what that your comfort zone. You’re not sure about your equipment, was like.” When asked if the experience had left an always; you’re not sure what you’re going to find.” impression on Peter, Bretzke laughs. “Yes, he’s real clear Bretzke says that another program that has become that he doesn’t want to go into medicine.” She adds that important to her is the Common Hope initiative, which “Most surgeons, while visits to the operating room were rare, children of gives providers on the mission the opportunity to help I think, are thrill providers have often come on the missions and have sponsor a Guatemalan child’s education. “The deal is that always gotten a lot out of the trips. seekers in one way Common Hope will continue to support this child as long “It’s a really good experience,” she says. “They realas they stay in school. A lot of people who have gone or another.” ize how lucky they are in the United States. We’ve down there ended up doing this,” she says. “Every year always wanted our son to think globally, and this helps, Margit Bretzke, MD we visit the family. That last day you’re not operating; most to do things like this and understand what people are up people go visit the child they’re helping support. That is against.” unbelievably powerful, to get to know that family.” The patients served by the mission come from all Caregivers to page 30 around the region, and stay at a local facility while recov-
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COMMUNITY CAREGIVERS 2013 “People were already lined up outside of the building, which was kind of their community center, but it was really kind of the equivalent Aaron Johnson, MD, has seen firsthand how important building trust is of a barn. There were three incandescent light bulbs down the length when U.S. providers undertake medical missions in impoverished areas of this room, which was probably 35 feet,” Johnson says. “So we just of Mexico and Guatemala. Johnson, who has been traveling to commu- kind of set up makeshift partitions, and each provider had one light nities in those countries for four years with Minnesota Doctors for bulb above us. We went until about midnight. There were just so many People (MDP), knows the troubled history of the region, which has people there that had walked to this little town, which was a big town seen political corruption, crime, and civil war. for them, but still a pretty small place. So we just kept seeing people.” “There’s always been that trust piece; they have a hard time knowJohnson says the providers see a wide range of conditions, from ing who to trust,” says Johnson, a family practice physician from United diabetes, to infections, to muscle strains. In some cases, they perform Hospital District in Blue Earth. “In Chiapas, I noticed when we were minor surgeries. With chronic conditions, such as diabetes, they can down there last year, people came back to us and said, offer only limited help. Other conditions are easier to ‘Yeah, we remember your group.’ That’s huge, because deal with. “We see a lot of parasite-type stuff, which is the indigenous Indians there have a fair amount of disone of the things we can actually treat, so it’s fairly trust and they’re not sure they should even talk to you, rewarding,” he says. “We can give them a three-day let alone let you look in their mouth or at their back. Just course of anti-worm medicine and know it’s going to be breaking down those barriers is progress. But it’s slow.” taken care of. Doesn’t mean that they’re not going to Johnson says it helps that his group works closely get it again; but at least you can treat it.” with local providers and hospitals, especially in The missions can be eye-opening, Johnson notes, as Guatemala where MDP has a longer history, to provide the MDP teams regularly encounter conditions very supplies and support. “We try to do as much teaching as rarely seen in the U.S. “There’s lots of really bizarre we can,” he says. “It’s more than just going down and pathology that you’d see in a textbook in a medical throwing Band-Aids on; we’re actually trying to help the school—rheumatic heart disease, for example. Most “We see a lot of local parishes and communities, and local individual parasite-type stuff, people go through medical school and their practice [caregivers]. Some of them are the equivalent of an RN, and [never see it], unless it’s in a 90-year old, a true which is one of and for a lot of stuff, they would be very qualified to rheumatic heart murmur. You’ll hear it in 20-, 30-, 40manage things like high blood pressure.” year-olds all the time down there.” the things we A typical trip for Johnson and the other MDP Johnson adds that the experience is both emotioncan actually treat.” providers lasts from seven to 10 days. Physicians and ally draining and, at the same time, invigorating. “It Aaron Johnson, MD medical staff see up to 60 patients a day, usually at kind of takes you back to why most individuals want to makeshift clinics set up in remote villages. He recalls one be a nurse or a doctor,” he says. “It takes you back to visit from last year’s trip, when they arrived in a small the basic level of just being able to help somebody.” town and started seeing patients in the early afternoon.
A mission of trust
Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership. Currently we are seeking to add the following specialists: General Surgery
Pediatrics
Orthopedic Surgery
Obstetrics/Gynecology
Radiology/Oncology
Family Practice
Internal Medicine
Emergency Medicine
Psychiatry
Ophthalmology Optometry
For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691. Dave.Dertien@avera.org Avera Marshall Regional Medical Center 300 S. Bruce St. Marshall, MN 56258
www.averamarshall.org
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MINNESOTA PHYSICIAN APRIL 2013
Practice Well. Live Well. Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner. Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • Emergency Medicine
• Medical Oncologist • Pediatrics • Urology NP/PA
For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227
712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424 Lake Region Healthcare is an Equal Opportunity Employer. EOE
www.lrhc.org
very good successes, and we had some that didn’t work so well.” More recently, Hart has been working with the March of Dimes on projects such as “Healthy Babies Are Worth the Wait,” a program Richard Hart, MD, has a long history of medical missions and commuencouraging expectant mothers to carry babies to 39 weeks. March of nity work to his credit. The St. Cloud pediatrician’s latest recognition Dimes officials note that some births are being scheduled earlier than was being named the recipient of the 2012 Caduceus Award from 39 weeks for nonmedical reasons, and they warn of health problems St. Cloud’s CentraCare Health Foundation. The Caduceus award recognizes physicians who have made a com- that can come from early deliveries. Hart says that he and his wife, Patricia, a neonatal nurse practitionmitment of $10,000 or more to support the mission of improving er who serves on the March of Dimes state board, strongly support the health and health care in central Minnesota. Winners are selected by Healthy Babies program. “A lot of maturation of the fetus occurs in the their peers in the medical community. Officials with CentraCare note last few weeks [before birth],” he says. “Before 37 weeks, there can be that Hart was instrumental in forming a program developed by a significant number of problems, and before 39 weeks, they don’t St. Cloud State University that created care plans for severely disabled have their full nutrition. They’re still prone to jaundice children. and other problems that can show up a little bit later.” The award also highlighted Hart’s long history of With his history of community service and volunteer medical missions, such as work with HELPS International, work for medical missions, Hart says he appreciates the an Addison, Texas–based charitable foundation that volunteering spirit of health care providers in the works with nongovernmental organizations to provide St. Cloud area. “There’s a lot of local interest in volunhealth care, education, economic development, and teering for a variety of programs,” he says. “We’re not other services to impoverished areas. on as big a scale as the bigger programs in the Twin Hart recalls working with HELPS in the ‘90s, when he Cities, but we’re finding more and more people [who participated in medical missions to rural communities in volunteer].” Guatemala. “It was about a 10-hour or 12-hour bus ride Hart also says his experience suggests that physithrough the tropical forest,” he says. “We had to take cians and health care groups should pay attention to the two buses, because if one would get stuck, the second “There’s a lot of feedback they receive from communities they serve. one would be able to pull the first bus out.” local interest in “From a volunteer standpoint, that becomes the most Closer to home, Hart’s work with St. Cloud State University brought together school specialists, psycholovolunteering for a important thing,” he says. “Rather than us deciding we’re going to do, see where the patients or famigists, public health officials, and pediatricians to address variety of programs.” what lies demonstrate a need—then you can help them out the needs of disabled children in local schools. “We took Richard Hart, MD with that specific need.” children who were having a great deal of difficulty in the school system,” he says. “We spent half a day evaluating Caregivers to page 32 each student and tried to come up with a care plan that would work. We did get some feedback. We had some
Committed to community service
Family Medicine St. Cloud/Sartell, MN
Spine Surgeons, join our team and set the standards for patient care. Orthopaedic Associates of Duluth is seeking a highly motivated passionate and experienced SPINE SURGEON to provide outstanding orthopaedic care to its patients. The successful candidate will be part of our expanding and growing, well-respected team that serves patients from Duluth to northern Minnesota. Orthopaedic Associates of Duluth is a group of nine orthopaedic surgeons that provide comprehensive orthopaedic services ranging from specialty specific exams and diagnosis to state-of-the-art inoffice MRI and imaging and surgery at their physician-owned surgery center.
Email CV to jwaller@slhduluth.com or call 800-461-8843 (Sue) or 218-625-2731 (June)
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 out-patient 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.jobs or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE
healthpartners.com APRIL 2013
MINNESOTA PHYSICIAN
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COMMUNITY CAREGIVERS 2013
Mogadishu Spring
In addition to treating patients, Ahmed, an internal medicine resident at HCMC, worked to educate some of the hospital staff that Last spring, Hani Ahmed, MD, returned to Somalia, a country she had lacked medical training. She taught staff to take vital signs and doculeft 23 years earlier as a child. Ahmed volunteered in 2012 with the ment medication for patients. She set up an isolation ward for tubercuAmerican Refugee Committee (ARC) to work for a month at a hospital losis patients. “I had to learn to do as much as I could with as little in the capital of Mogadishu. The timing was not perfect: Somalia was possible,” she says. “Those kinds of experiences make you realize what suffering from a famine and some of the worst factional fighting in is a priority.” recent years. Despite the lack of resources and the dangerous state of the city, Ahmed’s coworkers at Hennepin County Medical Center (HCMC) Ahmed describes the experience as tremendously rewarding. “I can’t were not eager to see her travel into a war zone. “My program director think of any better feeling,” she says. “It was overwhelming when I was concerned; I remember her saying, ‘We want you to be safe,’” went there, but when I left I felt very happy.” She said Ahmed says. “I really pushed for it. I felt I had to do it.” the knowledge that she could make a real difference was It’s not hard to understand her director’s concern. one reason why she pushed to go to Mogadishu. “Being Ahmed described having trouble sleeping at night due to Somali myself, I knew the biggest impact I was going to mortar shells overhead. She heard gunshots on a daily make was going to be in a place like Somalia,” she says. basis. Minneapolis-based ARC provided her with an armed “I speak the language. The people are my people. I felt escort and evacuation insurance. like I could just do so much more.” “There was a lot of violence when I was there,” Ahmed says she plans to return to Somalia, probably Ahmed recalls. “Driving through the city, we had to in 2014. She notes that the security situation is improving wear bulletproof vests every day and a helmet because and that the country is now more politically stable. of possible stray bullets. You couldn’t go anywhere at In the meantime, Ahmed is raising funds for ARC and night. You had this constant sense of agitation; you just sharing her story with other health care providers and the couldn’t really relax.” “We had to wear community. She is talking with Somali physicians about The hospital where she worked, Benadi Children’s bulletproof vests the possibility of regular trips to the country and of sendHospital, had also been marked by war. She describes a equipment and money to hospitals like Benadi every day and a ing facility lacking in supplies and run by a handful of young Children’s Hospital. To help with fundraising, she has doctors just out of medical school. “Probably some of my helmet because of developed a slideshow of pictures she took during her earliest reactions were shock and despair,” she says. mission. “The concern of donors is always whether stray bullets.” “Especially the first two weeks; it was really overwhelming money is going to reach the people in need,” she says. “I Hani Ahmed, MD to take in how bare it was. There was no monitoring think seeing pictures from the ground, they see firsthand equipment of any kind. There were times when there what ARC is doing. They see exactly what the sort of were no physicians. All the medications were locked in a need is and how much need there is.” cabinet because they could be sold in the market. We just had the absolute minimum of everything we needed.”
Minneapolis VA Health Care System The Minneapolis VA Health Care System is a 341-bed tertiary-care facility affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel. The Twin Cities offers excellent living and cultural opportunities. License in any state required. Malpractice provided. Applicants must be BE/BC. Opportunities for full-time and part-time staff are available in the following positions: • Chief, Radiation Oncology • Chief, Surgery/Specialty Care Director • Chief, Emergency Medicine • Chief, Ophthalmology • Compensation & Pension Examiner • Emergency Medicine • Admitting physician, ED (off tour shifts) • Gastroenterology • Imaging o Resident Coordinator o Interventional Radiology o Neuro Radiologist
• Internal Medicine or Family Practice • Interventional Cardiologist • Hematology/Oncology • Hospitalist • Outpatient Clinics: Internal Medicine or Family Practice o Maplewood, MN o Ramsey, MN o Chippewa Falls, WI o Rice Lake, WI • Medical Director, Rochester Outpatient Clinic
• Psychiatry: Inpatient • Psychiatry: Outpatient Clinics o Superior, WI o Ramsey, MN o Rice/Hayward, WI–V-tel and on-site o Maplewood, MN –V-tel and on-site • Radiation Oncology • Rheumatology
Competitive salary and benefits with recruitment/relocation incentive and performance pay possible.
For more information: Visit www.usajobs.gov or email Brittany.Sierakowski@va.gov EEO employer
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MINNESOTA PHYSICIAN APRIL 2013
Urgent Care FAMILY PRACTICE w/OB
We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We will be opening a new Urgent Care clinic in Hugo, MN in the spring of 2013! Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE
Warroad, MN Roseau, MN Crookston, MN • Dedicated Team Approach • Competitive Salary & Benefits • EPIC Healthcare Information System Idylic Practice Opportunities located in family friendly communities with close access to some of Minnesota’s most beautiful lakes. Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003 1-800-437-5373 Fax: 701-780-6641 khjelmstad@altru.org
www.altru.org
healthpartners.com
Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community
An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000. Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact: Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org AA/EOE - Not subject to H1B Caps
Opportunities available in the following specialties: Adult Psychiatry
Olmsted Medical Center, a 150-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
Southeast Clinic
Dermatology Southeast Clinic
Family Medicine Byron Clinic, Cannon Falls Clinic, and Pine Island Clinic
Hospitalist Rochester Hospital
Internal Medicine Southeast Clinic
Sports Medicine Orthopedic Surgeon Southeast Clinic
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
EOE
www.olmstedmedicalcenter.org
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Community from page 25 UCare’s newly retired mobile dental vehicle. The vehicle, a 38-foot-long Winnebago, was still in great condition and UCare believed that, in the hands of the right organization, it could continue to be of use to the community. SCHS was honored to receive this donated vehicle. Because we already had a mobile dental unit, our Outreach Department decided to transform UCare’s vehicle into one that would provide mobile medical services and health education to people in the community, some of whom did not receive regular—or any—medical care. Today, the “Q”mmunity Mobile Medical Unit—so-named because of its community focus and commitment to “quick” and “quality” service—has a fully functional private exam room and space in which staff and volunteer health personnel provide a variety of free preventive health services. Medical services include checking blood pressure, BMI,
The “Q”mmunity Mobile Medical Unit has a fully functional private exam room and space in which staff and volunteer health personnel provide a variety of free preventive health services. cholesterol, and glucose. These screenings can alert the person being tested to the need to modify diet and exercise in order to reduce the risk of developing diabetes, hypertension, and other chronic diseases. In addition, in collaboration with other organizations, “Q”mmunity provides HIV/STD testing, vaccines, child/teen checkups, clinical breast exams, referrals for mammograms, and patient education. The “Q”mmunity Mobile Medical Unit is staffed by Southside staff, volunteer and paid public health nurses from the Minnesota Visiting Nurse Agency, Minnesota Black Nurses Association, University of Minnesota medical students,
and staff from other Federally Qualified Health Centers, including NorthPoint Health and Wellness Center, Neighborhood Health Source, and Open Cities. Last summer, the “Q”mmunity Mobile Medical Unit provided health screenings to more than 2,500 individuals in the Twin Cities metro area and provided resources and educational materials to more than 7,500 individuals in the same areas. Public and community health go hand in hand
The Q Health Connections’ integral involvement in Good Food Good Fathering, BRO, MENgaging, Twin Cities Healthy Start/Birthing Project, the Birth-
ing Center, National Children’s Study, and “Q”mmunity Mobile Medical Unit expresses Southside Community Health Services’ vision of helping to bridge the gap that often exists between underserved communities and primary care. Our goal is to connect patients to a medical home, inform uninsured patients about health care programs available to them, help keep people out of emergency rooms, and emphasize the importance of having a primary care doctor. The public health of our community goes hand in hand with outreach initiatives that connect patients with programs that help them take responsibility for their health. Clarence Jones is community outreach director for Southside Community Health Service, Inc. (SCHS), a Federally Qualified Health Center established in 1971. Angela Gerlach is the outreach administrator for Q Health Connections, a division of SCHS.
Trinity Health One of the region’s premier healthcare providers.
Currently Seeking BC/BE s Ambulatory Internal Medicine s Emergency Medicine s General Surgery
s Psychiatry s Urology Contact us for a complete list of openings.
Based in Minot, the trade center for Northern and Western North Dakota, Trinity Health offers the opportunity to work within a dramatically growing community that offers more than just a high quality of life. Comprised of a network of nearly 200 physicians in hospitals, clinics and nursing homes, Trinity Health hosts a Level II Trauma Center, Critical Care Helicopter Ambulance, Rehab Center, Open Heart and Lung Program, Joint Replacement Center and Cancer Care Center.
For immediate confidential consideration, or to learn more, please contact
Physicians are offered a generous guaranteed base salary. Benefits also include a health and dental plan, life and disability insurance, 401(k), 401(a), paid vacation, continuing medical education allowance and relocation assistance.
www.trinityhealth.org
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MINNESOTA PHYSICIAN APRIL 2013
Shar Grigsby Health Center - East 20 Burdick Expressway Minot ND 58702 Ph: (800) 598-1205, Ext 7860 Pager #0318 Email: shar.grigsby@trinityhealth.org
Emergency Medicine Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:
Hibbing Little Falls Park Rapids Alexandria Austin For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:
recruiting@epamidwest.com or visit our website at
www.epamidwest.com
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 Urologist Psychiatrist Chief of Primary & Specialty Medicine Family Practice
Cardiologist Internal Medicine Neurologist Endocrinology
Sioux Falls VA HCS (605) 333-6858 www.siouxfalls.va.gov
Applicants can apply online at www.USAJOBS.gov
Your Emergency Practice Partner
Family Med/ER Physicians Small Town, Big Impact! We’re recruiting Family Med physicians with Emergency Room experience for our full-time practice in the western Wisconsin community of Amery. Utilizing a team of five dedicated FM/ER physicians, Amery Regional Medical Center’s ER has an annual volume of 6,000 and provides backup to ARMC’s 12,000 visits/year Urgent Care unit. Our FM/ER physicians work 32 hours per week in a block schedule of 12-hour (weekday) and 24-hour (weekend) shifts. BC/BE Family Med physicians with ER experience and an interest in pursuing alternative EM board certification are preferred; ABEMcertified EM physicians are also welcome to apply. You must have or be eligible for WI medical licensure. Nestled near the WI/MN border, Amery offers abundant outdoor recreation, affordable housing and excellent schools — all just 60 minutes east of Minneapolis/St. Paul, MN. As part of the HealthPartners Medical Group,our Amery FM/ER physicians receive a competitive comp and benefits package, paid malpractice coverage and the security of being part of a successful multi-specialty medical group. Apply online at healthpartners.jobs or email your CV and cover letter to sandy.j.lachman@ healthpartners.com. EO Employer
© Paid for by the U.S. Air Force. All rights reserved.
AIRFORCE.COM/HEALTHCARE
healthpartners.com
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Health systems from page 21 experience, and commitment to investing in population health, Commissioner of Health Ed Ehlinger, MD, recently issued two cautionary notes. Speaking on a panel at the University of Minnesota in January, he noted that while public health and health care have overlapping interests and should collaborate even more, public health must not become “medicalized,” losing its focus on communities, prevention, and health promotion. Moreover, he noted that Minnesota has yet to succeed fully in bridging gaps in health outcomes across socioeconomically disadvantaged groups based in race and ethnicity. These remain some of the worst disparities in the nation. No silos: Educating the new health professionals
Minnesota is a national leader in a related important dimension of health reform: educating the next generation of health professionals across professional boundaries. Because of its experience in interprofessional
Minnesota has pioneered an effort to reduce the “silos” by educating and connecting students across the health professions early in their training. education (IPE) and the breadth and depth of its health professional units, the University of Minnesota Academic Health Center (AHC) was recently awarded a five-year, multimillion-dollar contract by the federal Health Research and Services Administration (HRSA) to establish a national center for coordination and leadership. Headed by AHC assistant vice president for education Barbara Brandt, the National Center for Interprofessional Practice and Education (NCIPE) will create a “national nexus” of pilot projects, guidelines, and a network of professional engagement guiding training and curricular development. This initiative occurs in the context of considerable national and international rethinking of health professions training.
Minnesota has pioneered an effort to reduce the “silos” by educating and connecting students across the health professions early in their training. Building these connections will enable students in each profession to appreciate the training and leadership of the others when it comes to building effective and coordinated care teams in integrated health systems. Although IPE has focused strongly on team-based care training across the licensed health professions, it is just beginning to address the training and curricular issues raised by the ACA in addressing population and community health. Frank Cerra, MD, former senior vice president of the university’s AHC, dean of the medical school, and a key player in the new IPE center, recently joined a
national initiative led by the Association of Schools of Public Health to do just that. The public health profession nationally is engaged in a major discussion about the training framework and curricula for the 21st century. As part of the discussion, the profession also seeks to develop recommendations for competencies and curricula that could guide IPE in the areas of community and population heath. This discussion will be important to integrated health systems in meeting community and population health goals, but also for the public health system in assuring broad training in these areas across the health professions. The challenge is about systems converging and harmonizing goals and strategies while continuing to improve their special tools to get us where we need to be. John Finnegan Jr., PhD, is dean and professor, University of Minnesota School of Public Health, and is board chair (2012–14) of the Association of Schools of Public Health.
Sanford Health is the largest not for profit rural integrated health care system with over 1200 primary and specialty care physicians in over 140 clinic locations. The following communities are looking for BE/BC Family Medicine Physicians: Aberdeen, SD: • Large newer clinic attached to brand new 48-bed hospital • Current call 1:7 • OB is optional • Numerous onsite hospital services • Specialty physicians include Anesthesiologists, General Surgeons, and Interventional Cardiologists • Population over 25,000 • SD has no state income tax Windom, MN: • Current call is 1:7 for admits only and shared with community physicians • OB is a must
• Population over 4,300 • MN Medical school loan repayment available • J1 physicians may apply Worthington, MN: • Medical staff of primary care and some specialists • Current call 1:4 • Population over 10,000, service area 35,000 • City is 200 miles Southwest of Minneapolis/St. Paul • MN Medical school loan repayment available
Excellent benefits package including Paid Malpractice and Tail Coverage Competitive compensation and generous incentive
Dedicated to the work of health and healing
For more information, contact: Mary Jo Burkman, Physician Placement Associate Sanford Health (605)328-6996 or (866)-312-3907 Mary.Jo.Burkman@sanfordhealth.org Visit: www.practice.sanfordhealth.org
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A landscape of opportunities
Physicians Gundersen Lutheran Health System, based in LaCrosse, Wis., offers you the opportunity to practice cuttingedge medicine. But we also believe that medicine is about people and that’s why our medical outcomes are among the nation’s best (gundluth.org/accomplishments). Currently seeking physicians for the following: • Family Medicine • Neurology • General Surgery • Emergency Physician • Dermatology • Endocrinology • Psychiatry • Otolaryngology We are a physician-led health system, where teaching and research are possible with competitive salary, benefits, CME and loan forgiveness.
Cathy Mooney (608)775-3637 camooney@gundluth.org gundluth.org/MedCareers
EOE/AA/LEP
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Spondyloarthritis from page 15 Half of these cases will have a known infectious etiology, with Salmonella, Shigella, Yersinia, Campylobacter, and Chlamydia species predominating. The estimated frequency of reactive arthritis following exposure to potential agents may be close to 10 percent. Diagnosing spondyloarthritis
As with most rheumatic conditions, a careful history and physical are key to diagnosing SpA. Acute, painful iritis occurs in one-third of patients with AS but much less commonly in PsA. Typically, the picture is one of unilateral and alternating involvement and is characterized by photophobia, blurred vision, and redness. Inadequately treated iritis may lead to scarring and visual loss. Iritis may precede the development of AS or may be associated with asymptomatic “disease,” with classic radiologic findings when looked for. Patients with reactive arthritis may demonstrate relatively asymptomatic conjunctivitis, compared to the painful iritis
occurring in other SpA. Laboratory evaluation of SpA is often unhelpful; indeed, misinterpretation of an abnormal test may generate many erroneous decisions regarding further work-up, diagnosis, and management. When elevated, markers of inflammation (ESR and CRP) can help with the diagnosis but may well be normal in spite of active disease. Anemia of chronic disease may occur in any of the diseases, as well as iron deficiency anemia in patients with inflammatory bowel disease. Clinicians should avoid ordering screening autoimmune studies, given the high false positive rates of both rheumatoid factor (5 percent) and ANA (20 percent) and the absence of clinical features suggesting this type of disease. Appropriate cultures of urine, stool, and blood are essential when considering a diagnosis of reactive arthritis. Conventional imaging studies often show typical changes of sacroillitis at the time of diagnosis with AS and the spondylitis form of inflammatory bowel disease. Early changes include
sclerosis involving both sides of the joint, erosions, and pseudowidening, with later findings showing complete ankylosis. Axial skeleton findings include squaring of the anterior aspect of the vertebrae, apophyseal joint erosions, and typical syndesmophytes bridging one level to the next. Calcification and ossification of soft tissue structures lead to the classic “bamboo spine” appearance. Conventional X-rays are the mainstay of diagnosis although MRI of the SI joints is quite helpful when plain films are negative and there is a high degree of suspicion. Radiologic changes in peripheral forms of PsA are similar to those of rheumatoid arthritis, with early juxta-articular osteopenia and the potential evolution of severe erosive and destructive disease. “Pencil-incup” deformities are seen with the severe arthritis mutilans subtype. A notable feature distinguishing psoriatic arthritis from rheumatoid arthritis is the periosteal new bone formation (often termed “fluffiness”) seen at sites of enthesitis or associ-
ated with dactylitis. Pharmaceutical treatment
An in-depth discussion of medication is beyond the scope of this article, but a few words are necessary given ongoing advances in treatment. Nonsteroidal anti-inflammatory drugs are a mainstay and still the initial approach in attempting to quickly bring symptoms under control. However, rheumatologists are turning to disease-modifying medications such as methotrexate much earlier in hopes of better managing the clinical picture and slowing down the disease process. Biologic agents are also becoming key players in the treatment plan, especially when there is potential for severe joint damage, such as in PsA. Because these agents are also quite effective with inflammatory bowel diseases, the treatment of two illnesses with one medication is becoming ever more common— and successful. Paul Waytz, MD, practices at Arthritis and Rheumatology Consultants, PA, in Edina.
continuing education Managing Life Limiting Illness and End of Life Care (two day event) Simulation Facilitator Course
May 8-10, August 20-22 or November 6-8, 2013
Pediatric Fundamental Critical Care Support
May 16-17, 2013
Fundamental Critical Care Support
July 18-19, 2013
Trauma Education: The Next Generation* * Formerly Emergency Medicine and Trauma Update: Beyond the Golden Hour Managing Life Limiting Illness and End of Life Care (two day event) Primary Care Update Fundamental Critical Care Support 35th Annual Cardiovascular Conference: Current Concepts and Advancements in Cardiovascular Disease
Education and research to improve the health of our community
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May 7 and May 9, 2013
MINNESOTA PHYSICIAN APRIL 2013
September 5, 2013 October 1 and October 3, 2013 October 10-11, 2013 October 24-25, 2013 December 12-13, 2013
HealthPartnersInstitute.org
It’s time to see beneath the surface. September 8–10, 2013 http://www.mayo.edu/transform/
Looking for a better way to manage risk?
Get on board.
At MMIC, we believe patients get the best care when their doctors feel conďŹ dent and supported. So we put our energy into creating risk solutions that everyone in your organization can get into. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care. To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.