INTERVIEW

Changing the Future of Health Care

Kevin J. Mullaney, MD

This month you graduate your 50th class from your fellowship program. Please tell us something about the first class.

The John H. Moe Spine Fellowship program is named for our founder and a true pioneer of spine care, Dr. John Moe. Over the past 50 years, the program has trained 189 spine surgeons from 16 countries. Our first John Moe Fellowship class started in 1971, and it focused primarily on the care and treatment of scoliosis. There were two fellows in that initial group that graduated in 1972: Dr. Claudio Pedras, from Brazil, and Dr. Edgar Dawson, who later became chief of staff at both UCLA and Shriner’s Hospital in Los Angeles. Dr. Dawson also served in 1995 as the President of the Scoliosis Research Society (SRS), which Dr. Moe had helped to establish and served as its first president in 1966.

Over the years, how has the program both changed and remained the same?

The program has grown in a number of ways. As our practice grew, we were able to expand the number of yearly fellows we desired to accept and train. We typically have four fellows a year now, who rotate among the 10 Board Certified and Fellowship Trained surgeons that make up Twin Cities Spine Center.

The emphasis of the training has also grown— from primarily scoliosis and spinal deformity care to all conditions of the spine, including degenerative, traumatic and tumors. Perhaps the most dramatic change to our program was the addition of cervical pathologies, which now make up roughly 30-40% of our patients.

What has remained constant in our program and our practice is our commitment to excellence, leadership, education, research and outstanding patient care.

What can you tell us about the kind of person that is drawn to your program?

Our fellowship program attracts orthopaedic and neurosurgical trained surgeons interested in

What has remained “...” constant… is our commitment to excellence, leadership, education, research and outstanding patient care. “...”

subspecializing in spine and seeking a training program that will provide a large and diverse number of spine patients. Twin Cities Spine is known for seeing some of the most complicated spine cases, as well as doing what would be considered more routine spine care and surgery of the lumbar, thoracic and cervical spine. Our teaching surgeons use a wide variety of surgical approaches, from traditional open surgery to minimally invasive techniques and robotic assisted procedures. Applicants choose our program because it is comprehensive in the sense that we emphasize conservative care, taught by a balance of clinical assessments, research and surgical exposure. Because our fellowship includes a research component, we also attract applicants with an interest in research and academics. We seek applicants who are ethical, moral and come with a strong training foundation. We look for self-motivated individuals with early positions of employment or responsibilities requiring the use of their hands. We realize our reputation is a key part of our identity, and this, thankfully, has allowed us to maintain a strong pipeline of outstanding applicants from all areas of our country and beyond our borders.

Looking at the last 50 years, what have been some of biggest advances in your specialty?

Over the past 50 years, we have seen a significant number of advances in regard to techniques applicable to spinal pathology. This ranges from minimally invasive techniques to roboticassisted procedures and high-tech CT-guided instrumentation, placement and confirmation. We have been able to care for patients with more spinal pathologies with less morbidity.

There have also been significant advances in perioperative pain management, which often allows us to perform surgeries with a shortened length of hospital stay or same-day discharges. Patients are able to return back home sooner to familiar surroundings and comfort. Imaging of spinal pathology has also been greatly enhanced with the onset of 3D images, robotic reconstruction, high-grade MRI and CT.

What kinds of research/clinical trials is your practice working on?

We study surgical and non-surgical treatments for adult neck and low back disorders and adolescent idiopathic scoliosis. We also investigate related topics like the effectiveness of osteobiological agents for bone healing and the prevention of postoperative surgical site infections. And we seek to evaluate new and developing technologies such as minimally invasive techniques and robotassisted spine surgery.

The fellows in our program are required to take on at least one research project during their year with us. They have the support (and extensive data) of the Twin Cities Spine Research Department as they set out to

answer a spine specific research question. The ultimate goal and expectation of this project is a completed and published article in a peerreviewed medical journal.

Please tell us about how Fellows interact with other health care professionals as part of the care team that serves your patients.

Our fellows play an integral role amidst the teams that care for and support our patients. These teams include the partner surgeon, physician assistants, nurse practitioner, social worker, RNs and ancillary support staff. In their role as fellows, they are under the supervision of a TC Spine surgeon. Fellows rotate quarterly with the various spine teams and take part in clinical exams, non-operative management, surgical decision making and planning, observing and assisting in the OR, consulting on cases in the ED, rounding on patients in the hospital and conducting follow up with patients. Fellows also work closely with our research department as they pursue their spine research projects.

We have a Thursday Lecture component to our program which brings guest lecturers in to present and dialogue with our fellows. These guests are leading providers in a variety of subspecialties including radiology, neurology, pain medicine, orthotics, chiropractic and others. We emphasize collaborative and coordinated care. On Monday mornings, the fellows present cases and research to our staff surgeons and others at a 60-90 minute spine conference. These conferences (excepting the first Monday of the month) are open to all providers interested in learning and dialoguing about optimal spine care.

Is there a key emphasis or learning that your program seeks to teach fellows?

Perhaps the thing we work hardest to impart to our fellows is best summed up in a phrase used by my mentor and our past fellowship director, Dr. Ensor Transfeldt, who always taught that “the decision is more important than the incision.” The decision occurs between the surgeon and patient—listening to the patient’s concerns, priorities, goals and expectations and truly understanding the unique factors and needs of the individual patient in order to determine if surgery should even be an option. That decision process is more important than the type of incision (the technique of surgery) that might be performed.

We train spine surgeons. But we first want to train them to be excellent spine clinicians. Getting an accurate patient history, conducting a thorough exam and knowing when to seek additional diagnostics is key. Arriving at an accurate diagnosis is paramount for treatment planning. We emphasize conservative management.

How does having the role of teacher/ trainer impact the spine surgeons at Twin Cities Spine Center?

We see the fellowship as an integral part of our fabric at the Twin Cities Spine Center. We view our fellows as colleagues that have come to us from all parts of the country and the world. They bring new ideas and techniques, and they are inherently inquisitive. Frankly, this keeps us, as the trainers, current. When your practice is training the next generation of spine surgeons, you need to be at the

Changing the Future of Health Care

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dominance of government- and corporate-run medicine, are physicians still in a position to honor their ethical duty when it comes to the appropriate use of telemedicine? Or have their employers now taken over control of what the patient is offered when it comes to options for care? Is telemedicine yet another great promise by some to “save” heath care in the United States? Another panacea? Or is it yet another quagmire?

While studies still seem to suggest that patients rank interpersonal interactions with their caregivers at the top of their medical care list, the rest of that list has changed dramatically in recent years, most notably in relation to the notion of “convenience.” Consumers of medical care, henceforth referred to as “patients,” still desire competent, empathetic, affordable medical care. Just as important, they now want the provision of that care to fit their lifestyles. In other words, they want it fast and easy, as well as inexpensive. Like everything else in America, though, “fast and easy” is never supposed to imply “risky and unpredictable.” Kind of like that hamburger from McDonald’s. Why? Because there is always someone in America looking out for the welfare of the consumer of everything commercially branded, right?

Buyer beware

Anyone with half a functioning brain understands the potential risk in buying five pounds of shrimp on a 90-degree day from some guy selling it off the back of his rusty pickup truck. The sign for “Jim and Bob’s Bungee Jumping/ Go-Cart Track/Hog Roast” establishment should likewise get one to think critically about whether exiting I-95 to check it out. For most anything else in America, we have a vast array of consumer protection agencies, oversight bureaus and government commissions to ensure that anything we touch, consume or breathe should always be free from harm. Exactly why “fast and easy” is never supposed to imply “risky and unpredictable” here in America.

There is, of course, a pecking order of trust that further aids Americans in making choices when it comes to their actions. A January 2020 article published in “MarketWatch” (“Americans trust Amazon and Google more than the police or the government”) takes note of a study regarding the most trusted brands, public figures and institutions in the U.S. In that study, subjects were asked to consider entities such as teachers, law enforcement officers, doctors, public figures and celebrities. The study included the question of whether the subjects trusted information from health and weather advisories or scientific studies.

Score one for the family doc. Based on the study’s results, 50% of subjects–the greatest share–trusted their family doctor to do the right thing. The military was listed next at 44%. Hollywood scored only a 4% share, with Wall Street at 5%, the U.S. government at 7%, capitalism at 14% and religious leaders at 15%. In between 50% and 14%, Amazon took 39% and Google 38%, followed by extreme weather warnings, teachers, the police, scientific studies and health warnings or advisories. Tom Hanks and Oprah also beat out the president and Warren Buffett.

So, what does this have to do with optimum medical care? On the surface, perhaps it means that people trust their family doctor more than Tom Hanks or Wall Street to provide their medical care. That’s a good thing, as trust is an extremely important part of the doctor-patient relationship. Given that good medical care can mean the difference between life and death, it’s indispensable to have formed relationships with trusted clinicians in the event those situations should ever present.

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Blaine | Edina | Lake Elmo/Woodbury | Lakeville | Minneapolis | Plymouth What is optimum care?

What about medical care for less emergent, but still urgent situations? Everyone knows that it’s time to go straight to the emergency room if the bungee cord at Jim and Bob’s broke and someone dropped thirty feet directly onto cement. What about a cough? What if the patient’s eye is red with lashes stuck shut upon waking up in the morning? What if there is abdominal pain–off and on? Not severe, yet not going away? In an ideal world, everyone would own their own hospital and have instant access to an ophthalmologist for an eye problem, a pulmonologist for a cough and a surgeon to evaluate abdominal pain. There is a sweet spot somewhere between having no access to care and owning one’s own hospital. For economists, we’ll call it the “affordability spot” on the Laffer Curve of medicine–the place where people get care—care we all would like to believe is optimum. At its heart, optimum care means care in which the diagnosis is correct, the treatment is correct and both are done in a timely manner–with the care being accessible and affordable. Care provided in a timely, accessible and affordable manner is useless, and potentially dangerous, if the diagnosis and/or treatment are incorrect.

This, of course, begs the following question: How does a patient know that the diagnosis and/or the treatment is correct once the medical system has been engaged? Answer: the patients don’t, at least not until they get better, or until the medicine they are taking makes their eyelashes fall out. Why, then, would anyone engage the medical system at all, given that lack of certainty? There are two reasons, and they both relate to a risk/benefit ratio.

First, no one would engage the medical system if they felt there was more risk than potential benefit in doing so. On a more subconscious basis, the same type of reasoning is behind the choice to get up each morning and take the risk of driving to work. Indeed, many individuals take their chances and choose to not engage Western medicine at all. They are not convinced that the risk is worth the potential benefit.

Second, the patient had developed enough trust in Western medicine or in their “provider” of choice. Physicians, in general, take exception to the word “provider.” Provider is a term that has the effect of devaluing clinicians and making them all appear interchangeable. In any case, the level of trust allows engagement with a system having more risks than eating the roadside shrimp and risks as serious as the bungee cord rupturing.

Who wouldn’t trust a large medical conglomerate which owns hospitals and all sorts of shiny new multiple-story buildings when it advertises its telemedicine services with the following: “Get the same great care as an office visit”? Certainly, those large medical conglomerate physicians buy in completely to the provision of urgent care by telemedicine for just about any condition imaginable, right? Certainly, those physicians were consulted as to how the telemedicine process would be set up, how it would work, and–most important—what conditions as presented by patients would be routed through for a telemedicine visit, right? Certainly, those physicians were trained in the intricacies of providing care by telemedicine, more so than just the nuts and bolts of getting connected with their patients and figuring out how to have them stick their iPhones down their throats to try to get a peek at their tonsils, right? Certainly, in a rush to capitalize on the new age of telemedicine, a large medical conglomerate would not attempt to direct as many patients as possible toward video visits, even if they already had presented at a clinic for a face-to-face visit right? Certainly…Certainly.

Likewise, who wouldn’t trust a slick online medical “provider” (here the term is more appropriate) with a picture of a handsome young clinician on the first page? This “provider” notes how easy it is to book an online appointment and that “we can treat almost anything” simply through a visit on your phone. The subsequent list is almost endless: “prescriptions, antibiotics, diabetes, refills, birth control, gout, hypertension, PrEP, pneumonia, hypothyroidism, lipid regulators, IBS, asthma, depression, ear infection, acne, anxiety, STDs, sinus infection, erectile dysfunction, cough, flu, UTI… and almost anything else!” Why stop there? Surely, the home appendix removal kit is right around the corner. Just because telemedicine is now being offered to evaluate and treat almost anything doesn’t mean that telemedicine is safe to evaluate and treat almost anything.

Optimum care means care in which the diagnosis is correct, the treatment is correct and both are done in a timely manner. Optimum Medical Care to page 124

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How about this bit of telemedicine advertising: “The last thing you want to do is trek across town to see a doctor”? Perhaps, then, we should add a line to Jim and Bob’s sign that would read: “The last thing you want to do is drive another two miles up the road to where the bungee jumping is safety monitored.” The implication seems to be that no one ever really needed to be examined in person by a doctor. It just took until now, when technology would allow, for us to admit that an interaction on a screen is, in fact, superior to an interaction in person.

The future of telemedicine

Undeniably, telemedicine now has a definite place in the delivery of medical care. In fact, in some instances and some circumstances, it is the best available modality through which to access certain kinds of care. There is no doubt that, in remote areas or in small hospitals without immediate access to specialty care, telemedicine can be a godsend as a conduit to that specialty care. There are also certain services (such as diabetic consults or mental health visits) that, while still best delivered by face-to-face visits, can be reasonably delivered through telemedicine consults when circumstances demand. In early 2020, as we all know, circumstances regarding medical care changed drastically. In an effort to continue to support the provision of medical care during the COVID-19 pandemic, CMS substantially amended the rules previously governing the delivery of and remuneration for telemedicine services.

Large health care systems took notice–immediately. Access to the same reimbursement for telemedicine consults as for live visits was a financial win for health care conglomerates. In some sectors, there appeared to be promotion of urgent care by telemedicine for just about any condition imaginable. Unfortunately, the level of practicing physician involvement in this rush to telemedicine was nominal. How much were doctors consulted about how the telemedicine process would be set up, how it would work, and what conditions as presented by patients would be routed through for a telemedicine visit? How much physician training was given regarding the intricacies of providing care by telemedicine? In order to provide optimum medical care, physician engagement is critical. The control of the delivery of medical care in the U.S. must never be taken out of the hands of clinicians.

To sum up, the expanded use of telemedicine is here to stay and does offer some benefits in its use. Optimum care, however, means care that is always safe and appropriate. Patients need to be fully aware of their care options and of the limitations inherent in the use of telemedicine so they may be guided in using that knowledge to obtain optimum medical care. For telemedicine to be used safely and appropriately, practicing physicians— along with their patients—need to decide if, how, and when it is used.

Wayne Liebhard, MD, is a family practice physician now practicing in an emergency medicine clinic. He is also the author of the recently published book, “Walking The Tightrope—Trusting Your Life To Telemedicine.”.

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Prior to the pandemic, the demand for mental health care far exceeded the supply, and now that equation has been made worse with one in every four job openings in the field unfilled. This situation is even worse in outstate areas where patients face unique barriers to seeking care. In small towns, not only is it more likely for everyone to know everyone else’s business, and such things to travel quickly, but the stigma—internal or external—of dealing with mental health concerns can be higher. Farmers, for example, have an ingrained can-do attitude of pulling themselves up by their boot straps, an admirable attitude but one that does not translate well, for example, to dealing with depression or anxiety disorder. As of mid 2022, nearly 30 farmers in America are dying by suicide every day, meaning they have one of the highest suicide rates of any occupational group. Though it may not help with climate change related drought or poor government policies, better access to mental health services would certainly help address this.

The Zero Suicide Initiative, a national program with the goal of reducing suicides to zero through use of a set of tools—one of those being screening and assessment in clinics and emergency departments—is a program we have been using since 2016. The majority of suicides—75%—take place within 60 to 90 days after a medical encounter. This doesn’t assess any blame; it’s just a reality check for all of us, and it points to an opportunity for prevention. We won’t always catch it—in fact, research tells us that the decision to take one’s own life is usually made only a couple of hours earlier. But if we can spot a downward trend and encourage that person to take action, we might save a life.

Another element for concern relates to substance use disorder (SUD). Many people assume that large cities are havens for mind-altering drug use and alcohol abuse, however smaller communities have seen dramatic increases in opioid misuse and overdoses, and meth may be even more available there than in urban and suburban areas. What is not available are inpatient treatment beds, after care programs and certified counselors to help people understand and deal with these problems. While there are tools available to help start these kinds of programs, the infrastructure and staffing to accomplish this is rarely present. Some estimates suggest that as many as 50% of patients have SUD issues, no matter whatever other primary medical problem there might be. A basic mental heath patient in-take screening tool could help identify these concerns.

Increasing access to care

One recent positive development is the new 988 Lifeline. Going live on July, 16, 2022, this nationwide service follows NAMI’s standard of care and is billed as “a direct connection to compassionate accessible care.” Designed to strengthen and expand the National Suicide Prevention Hotline, this 24/7 service will serve and support anyone experiencing mental healthrelated distress. Funding for the program comes through the Substance Abuse and Mental Health Services Administration (SAMHSA). They envision a robust crisis care response system that will link callers across the country to community-based providers and resources that can deliver a full range of crisis care service. There are expected growing pains, as there were rolling out 911, but the hope is to help address the growing mental health crisis; this action is an example of the scope and serious nature of the challenges this presents.

Another area of emerging awareness, and crisis, involves pediatric mental health. It is now estimated that one in seven children aged 10-19 has some kind of mental illness with depression, anxiety or behavioral disorders leading the way. Almost 20% of U.S. high school students have given serious thought to suicide and almost 10% have actually tried to kill themselves. Evidence clearly shows a sharp increase in pediatric behavioral issues over the past 15 years, despite some calling it a hoax. Many factors for the increase can be cited, but there have also been many outstanding responses. Children require a different approach to treating behavioral health issues, and many medications for adults are not appropriate for developing brains.

One recent response that is proving beneficial is the development of the school-based health center and incorporating behavioral health services into these centers. It is an expansion on school nurses who may have to visit several schools each week and can work with a variety of community resources. As an example of this, our organization has been working for the past five years with school teachers in Brookings to help them understand ways they can assist students who may be facing behavioral health issues. We have recently expanded this outreach to include a middle school in Sioux Falls.

The growing creation of dedicated adolescent behavioral health inpatient treatment facilities, and dedicating sections of hospitals to this use, further illustrates the scope and importance of the issue. Children whose issues can be identified and treated early in life can minimize the development of chronic conditions later in life that can have serious adverse effects on their overall health.

Dedicated facilities

Additionally, and importantly, the creation of new modern facilities addresses several issues. On a very basic level, these facilities build awareness around the

serious nature of behavioral health treatment and foster acceptance replacing stigma. Depression is no different than high blood pressure or diabetes and should not be viewed as a weakness. Psychiatry was often confined to a broom closet at the back of the top floor of a hospital, a mistake leading to many downstream complications that are slowly being corrected. Our hospital, Avera Behavioral Health Hospital, was originally constructed in 2006 to serve all behavioral health care needs in our area; recently we added 60,000 square feet, which includes 24/7 behavioral health urgent care and youth addiction care services. We now have almost 150 inpatient beds and the facility is truly a world-class destination for mental health services. People come from all over the country to study our model, and we hope it will lead to similar advances in other markets.

Perhaps we have proven the Field of Dreams maxim of “if you build it, they will come,” but that does not address the lack of behavioral health providers, especially in the outstate areas. There it becomes the de facto proxy of primary care providers to prescribe medications around whose benefits and uses they may have received minimal training. PAs, nurse practitioners, masters level social workers, psychologists and others are also called into service and must all work together with as much coordination as possible to address the workforce shortage crisis. There are phone counseling services available that can be accessed during a patient visit that can be very helpful.

Telemedicine applications to behavioral health have existed at Avera for 25 years, but that use was significantly increased during the pandemic. From the difficulties of the pandemic, it is important we use this as an opportunity to revolutionize the care of behavioral health patients. Developing the trust to make therapeutic progress can take time, but it is a pathway to care that is now more widely available. It should be explored and offered as an option, as it offers the flexibility to be incorporated into any clinical setting in a variety of ways. Most insurance continues to cover it, and while some patients simply do not have access to the internet or have limited literacy around computers and related technology, almost everyone can use a smart phone. The convenience of seeing a professional from their own home, or in the case of a farmer from their tractor, can have a significant appeal. In fact, research over the years has shown that some patients feel it is easier to build rapport with a therapist and to talk about difficult subjects via televideo instead of in person. Simple mental health baseline data should be a part of every patient’s medical record.

Thomas Otten, MA, is the behavioral health service line administrator for Avera Health, where for the past 22 years he has held positions relating to managing, improving and expanding behavioral health care within the hospital, university health center and the region.

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Addressing the future

Another challenge facing the delivery of behavioral health care is an increasingly diversified patient base. Different cultures perceive and respond to common diagnoses in different ways. In our practice, we see this most clearly in serving the Native American population. We provide specialized training to providers and support staff around how to best communicate around sensitive and complex issues. Oftentimes, when dealing with behavioral health concerns, listening is as important, or even more important, than offering a care plan. Part of diversity training is learning what to listen for. It is also important to understand that diversity goes beyond race and must also include age, economic status, people with disabilities and more. People from all of these groups may have behavioral health concerns and must be treated with equity and awareness of the unique challenges they may face.

As we move forward, solving the many challenges facing the delivery of behavioral health care will require building new partnerships. As an industry, this will mean new ways of involving and working with employers, communities, payers and state government. Each of these entities has a vested interest in everyone’s individual health and, as we have discussed, behavioral health is a big part of overall health. Each of these entities must be encouraged to continue their work in removing the stigma a person may feel around seeking help for behavioral health care concerns. Public and private partnerships are an incredibly effective way to help meet this challenge. We must all work together to raise awareness of what these concerns are and how

they may be treated.

Contact Mark L. Hansen, AIA, to discuss your next healthcare project: 952.426.7400

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