Jan/February 2015 - Whats on the Health Care Horizon for 2015 by Advocates for Better Health

Jan/February 2015

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

In This Issue: • • • •

Legislative Preview Mayors of Mpls and St. Paul Offer Health Agendas Interstate Licensure Compact Luminary of Twin Cities Medicine

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CONTENTS VOLUME 17, NO. 1

JANUARY/FEBRUARY 2015

IN THIS ISSUE

Welcome to 2015! By Peter J. Dehnel, M.D.

PRESIDENT’S MESSAGE:

Introducing the 2015 TCMS Leadership By Kenneth N. Kephart, M.D.

TCMS IN ACTION

By Sue Schettle, CEO

HEALTH CARE 2015

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What the 2015 Legislature Holds By Nancy A. Haas, J.D.

Page 8

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Colleague Interview: A Conversation with Maureen Reed, M.D.

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Leaders on Health By Mayor Chris Coleman, City of Saint Paul

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Moving the Dial on Equity Through Healthy Living By Mayor Betsy Hodges, City of Minneapolis

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Coming to a State Near You—New and Improved Medical Licensure By Jon V. Thomas, M.D., MBA

Page 32

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Electronic Cigarettes, Hookahs and Other Tobacco Products By Nancy Bauer

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The 5th Vital Sign, Visual Analogue Scale, and the “Patient Experience” By Chris Johnson, M.D.

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What to Expect from the 2014 Newborn Screening Law

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Physicians, Public Health and Climate Change By Bruce D. Snyder, M.D., FAAN

Page 25

2014 Charles Bolles Bolles-Rogers Award Recipient— Michael B. Belzer, M.D.

National Healthcare Decisions Day April 16

Honoring Choices Expands Nationwide By Barbara Greene and Karen Peterson

TCMS and MMA Host EBOLA Educational Forum

Senior Physicians Association News

New Members/In Memoriam Career Opportunities

Steven Miles, M.D.

Page 16 MetroDoctors

LUMINARY OF TWIN CITIES MEDICINE

The Journal of the Twin Cities Medical Society

On the Cover: Legislative and policy priorities for 2015 are outlined for medicine and our communities. Articles begin on page 6.

January/February 2015

January/February Index to Advertisers

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Andrea Farina MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

TCMS Officers

Allina Health.......................................................29

President: Kenneth N. Kephart, M.D. President-elect: Carolyn McClain, M.D. Secretary: Thomas Kottke, M.D. Treasurer: Matthew Hunt, M.D. Past President: Lisa R. Mattson, M.D.

Coldwell Banker Burnet.......................................

TCMS Executive Staff

Federal Bureau of Prisons .................................... Inside Back Cover

Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Karen Peterson, BSN Director of Program Operations, Honoring Choices Minnesota (612) 362-3704 kpeterson@metrodoctors.com

Inside Front Cover Crutchfield Dermatology.................................. 2 Fairview Health Services .................................31

HCMC ................................. Inside Front Cover Healthcare Billing Resources, Inc. ...............18 Lakeview Clinic .................................................31 Minnesota Epilepsy Group, PA ....................13 MMIC ................................ Outside Back Cover Saint Therese.......................................................21 Senior LinkAge Line.........................................10 St. Cloud VA Medical Center .......................30 Uptown Dermatology & SkinSpa................21 U.S. Navy Recruiting .......................................31

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For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.

January/February 2015

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The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Welcome to 2015!

or the first edition of this New Year, the Editorial Board of MetroDoctors is pleased to present a number of articles related to the topic of legislative influences on medicine, health and the delivery of health care services. The President’s Message by Ken Kephart, M.D., introduces you to the new physician leadership of the Twin Cities Medical Society. Know that they are working on your behalf and always available to hear from you. The first article is a great summary of the issues likely to be addressed in the 2015 Minnesota legislative session and the likely influences of the change in the House of Representative control from Democrat to Republican parties. Included in it is a listing of TCMS priorities for the upcoming session. As always, your participation with your own elected officials is encouraged — both during the session and outside of the session over the next several months. The “Colleague Interview” for this edition is by Dr. Maureen Reed. She has had a very extensive range of experience, from a practicing physician to leadership in a health plan to the University’s Board of Regents to Executive Director of the Nobel Peace Prize Forum. We trust that you will find her contribution very insightful as well as pertinent to the challenges we face in the practice of medicine today. Mayor Chris Coleman and Mayor Betsy Hodges very generously agreed to give their perspectives as mayors of the two largest cities in Minnesota. There is a good detailing of successes that they see as well as challenges that they — and we — continue to face to improve the overall level of health within our TCMS geographic footprint. The effect of recent legislative actions is detailed in two articles — electronic cigarettes and Minnesota’s newborn screening program. Physician engagement in both of these areas was critical, but also shows that additional engagement would likely end up with even better outcomes.

Legislated regulatory influences on the delivery of health care are highlighted in an article on pain assessment and control within medical settings. While many aspects of the regulatory pressure to improve pain control may have been well intended, the unintended consequences have presented a whole new set of challenges to practicing physicians. Two articles reflecting broader areas of legislation — climate change and progress on the interstate medical compact — round out the offering of articles for this edition. Dr. Marv Segal completes the edition with his “Luminary” series, highlighting the very notable career of Dr. Steven Miles. We thoroughly hope that you enjoy this edition of MetroDoctors. Your feedback is always welcome. Please email any comments to nbauer@metrodoctors.com.

By Peter J. Dehnel, M.D. Member, MetroDoctors Editorial Board MetroDoctors

The Journal of the Twin Cities Medical Society

January/February 2015

President’s Message Introducing the 2015 TCMS Leadership President — Ken Kephart, M.D. Hometown: Sigourney, Iowa Education: • Undergraduate: University of Minnesota (Social Work) • Medical School: University of Minnesota • Residency: St. Paul-Ramsey Medical Center Specialty: Family Medicine/Geriatrics/Palliative Care/Hospice Employer: Fairview Health Services Special Interests: Medical Director, Honoring Choices Minnesota, grandfather to 11 grandkids President-Elect — Carolyn McClain, M.D. Hometown: Sunfish Lake, Minnesota Education: • Undergraduate: Claremont McKenna College (Economics and Theater) • Medical School: Johns Hopkins University • Residency: HCMC Emergency Medicine Specialty: Emergency Medicine Employer: Emergency Physicians, P.A. Special Interests: Public Health Past-President — Lisa Mattson, M.D. Hometown: Plymouth, Minnesota Education: • Undergraduate: Macalester College (Biology, Chemistry, Secondary Education Teaching Certificate) • Medical School: Mayo School of CME • Residency: Mayo Graduate School Specialty: Obstetrics/Gynecology Employer: University of Minnesota Boynton Health Services Special Interests: Boating, travel, reading Secretary — Thomas Kottke, M.D., MSPH Hometown: Minneapolis, Minnesota Education: • Undergraduate: University of Minnesota (Anthropology with special interest in culture change and development) • Medical School: University of Minnesota • Residency: Royal Victoria Hospital, McGill University, Montreal and North Carolina Memorial Hospital, Chapel Hill, NC • Fellowship: MSPH (major in epidemiology) University of North Carolina at Chapel Hill; Cardiology Fellowship at University of Minnesota. Specialty: Cardiology, Public Health, General Preventive Medicine 4

January/February 2015

Employer: HealthPartners Special Interests: Social determinants of health; clinical preventive services; enablement and promotion of healthy lifestyles Treasurer — Matthew Hunt, M.D., F.R.C.S. Hometown: Louisville, Kentucky Education: • Undergraduate: Williams College, Williamstown, MA (Chemistry) • Medical School: University of Louisville School of Medicine • Residency: Oregon Health & Science University • Fellowship in Neurosurgical Oncology: Oregon Health & Science University, Blood Brain Barrier and Neuro-Oncology Program • Clinical Fellow in Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, UK Specialty: Neurosurgery Employer: University of Minnesota Physicians Special Interests: Downhill Ski, Golf At-Large — Nicholas Meyer, M.D. Hometown: White Bear Lake, Minnesota Education: • Undergraduate: U.S. Military Academy and University of Minnesota (Biochemistry and Chemistry) • Medical School: University of Minnesota • Residency: Medical College of Wisconsin • Fellowship: University of Minnesota Specialty: Orthopedics, Hand Surgery, Sports Medicine Employer: St. Croix Orthopaedics Special Interests: Fitness, exercise, outcomes tracking, weight management, author of The ProportionFit Diet At-Large — Stefan Pomrenke, M.D., MPH, MATS Hometown: Dayton, Ohio Education: • Undergraduate: University of Virginia College of Arts and Sciences (Biology, Biochemistry, Religious Studies) • Medical School: Medical College of Virginia/ Virginia Commonwealth University School of Medicine (MD/MPH Dual Degree) • Residency: St. Joseph’s Hospital Specialty: Family Medicine Employer: West Side Community Health Services, St. Paul, MN Special Interests: Family, cooking, community activism, church.

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

E-Cigarette Restriction Victories

Twin Cities Medical Society leaders testified before a Minneapolis City Council committee on Nov. 17 in an effort to place further restrictions on e-cigarettes. Lisa Mattson, M.D., TCMS president; Mike Tedford, M.D., co-chair of TCMS’ legislative and policy committee; and Stuart Hanson, M.D., former MMA president and longtime smokefree advocate testified in a packed chambers of the Minneapolis city council. After a public hearing, the committee voted unanimously to ban the use of e-cigarettes in indoor public places. The full Council voted to adopt the ordinance on Dec. 5. Dr. Hanson also testified on Nov. 17 before the Bloomington City Council, which voted unanimously to include e-cigarettes in its clean indoor air ordinance. The Council also set a minimum price for single cigars of $2.60 per cigar, which is intended to discourage youth from buying them. In recent weeks, TCMS also trained 15 physicians and medical students on what we know about e-cigarettes. The goal of the training session was to educate and equip TCMS members to become more actively involved in city, county and state e-cigarette advocacy.

This strategy proved to be helpful in Bloomington and Minneapolis as two of the three physicians testifying went through the training program. See related article on page 16. TCMS Expands Work on E-Cigarette Advocacy

TCMS will expand our metro-based work on e-cigarette advocacy to other parts of the state thanks to a grant that we will be receiving from a local funder. The details are still coming together at press time so you will hear more in future issues of MetroDoctors. The goal of the educational campaign is to provide physicians with the tools necessary to speak to their patients about e-cigs and to talk with local elected officials about what we know about e-cigs.

TCMS and MMA convened an educational event on Ebola on November 18 at the University of Minnesota’s St. Paul Campus. See related article on page 27.

TCMS to Introduce Legislation

At the time that I am writing this we are well on our way toward introducing legislation in the 2015 session to support advance care planning throughout Minnesota. Many communities are interested in expanding the work that was started through Honoring Choices and we are poised to assist as a technical advisor in the expansion of advance care planning to all parts of the state.

TCMS physicians testify before Minneapolis and Bloomington City Councils in support of e-cigarette ordinances.

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TCMS and MMA Host Educational Forum on Ebola

The Journal of the Twin Cities Medical Society

KARE 11 reporter Dave Berggren interviews TCMS President Dr. Lisa Mattson at the educational event on Ebola.

TCMS Foundation

The East and West Metro Foundations have officially merged effective January 1, 2015. The new foundation will be called “Twin Cities Medical Society Foundation.” Board members include: Ken Britton, M.D., John Diehl, J.D., Thomas Dosland, M.D., Mark Engasser, M.D., Solveig Hagen, medical student, Elisabeth Hurlimann, M.D., Chris Jackson, M.D., Chris Johnson, M.D., James Jordan, M.D., Martin Lipschultz, M.D., Henri Minette, J.D., Robert Moravec, M.D., Chris Perdoni, medical student, Richard Schmidt, M.D., Peter Stiles, M.D., James Struve, M.D. and Andrew Thomas, M.D. We are looking forward to getting started on some really great philanthropic activities through the new Foundation. January/February 2015

Health Care 2015

What the 2015 Legislature Holds

he results of the 2014 election are now behind us and, as expected, they brought both excitement and change. Most notably, the Minnesota House of Representatives has moved to Republican control with 72 Republican seats and 62 Democratic seats. For the past two years, Democrats held the majority with 73 seats. Governor Mark Dayton has earned another four year term, along with his new Lieutenant Governor pick, Tina Smith. The Senate, which was not up for re-election this year, continues to have a Democratic majority of 39 members to the Republican’s 28. The focus now turns to the 2015 Legislative session, which begins on January 6. Minnesota operates on a biennial budget, passed every two years — in the odd numbered year. Therefore, the budget will be the top priority of the 2015 session. Given there is a Democratic Governor and Senate and a Republican House, cooperation and compromise will need to occur to move items forward. With the Republicans gaining control of the House of Representatives, committee chairs have changed over and committees as a whole have been restructured. The new Chair of the House Health and Human Services Finance Committee will be Representative Matt Dean. Representative Dean represents District 38B, which includes all or portions of Ramsey and Washington counties in the eastern Twin Cities metropolitan area. He was first elected in 2004 and has been active in health care issues, having previously served on the Health and Human Services Finance Committee. Representative Dean has worked on health care policy issues that

By Nancy A. Haas, J.D.

January/February 2015

aging population and has authored bills to improve long-term care.

focus on ways to improve the overall patient experience. The new Chair of the House Health and Human Services Reform Committee will be Representative Tara Mack. Representative Mack represents District 37A, which includes Burnsville and Apple Valley. She was first elected in 2008, and previously served on both the House Health and Human Services Finance Committee and the Policy Committee, where she was the minority lead. Representative Mack serves on the Minnesota Autism Task Force, and has been a proponent of health care choice and reform measures. Additionally, a new committee was created — the House Aging & Long-Term Care Policy Committee. This committee was created to specifically address emerging issues facing our aging population and ways to improve patient care. Representative Joe Schomacker will serve as Chair. Representative Schomacker represents District 22A, which includes portions of counties in the southwest corner of the state. He was first elected in 2010 and has previously served on both the House Health and Human Services Finance Committee and the Policy Committee. Previously, Representative Schomacker has shown dedication to the

Twin Cities Medical Society 2015 Legislative Priorities The TCMS Board has approved the 2015 Legislative Priorities. The following issues will be the focus of efforts at the capitol for the legislative session: • We support Honoring Choices Minnesota, whose mission is to ensure every person’s end-of-life health care choices are clearly defined and honored. • We support efforts of cities and counties to update their clean indoor air policies to include restricting the indoor use of e-cigarettes; efforts to require that e-cigs are sold behind the counter; prohibiting sampling of e-cigs in stores; efforts to educate health care professionals and others about e-cigs, the impact of nicotine, proven cessation resources; support efforts to restrict marketing of e-cigs to youth and efforts to ban advertising at the state and national levels; and we support state and national efforts to include e-cigs in comprehensive tobacco and nicotine control policies. • We support the continued phase out of the Provider Tax. • We support necessary statutory changes to require notification to physicians of any changes to their contract terms. • We support greater risk sharing between insurers who sell health savings account insurance products and the physicians and their clinics who are oftentimes left to collect payments from patients who have used their HSA account for other purposes. • We support the preservation of the doctor-patient relationship and oppose efforts to diminish that relationship.

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MNsure Expect significant discussion to center around MNsure and how to better implement it, if at all. Recently, the Office of the Legislative Auditor released an audit of the MNsure program. The key findings were as follows: • The Department of Human Services did not adequately verify that people who enrolled in public health care programs through MNsure were eligible for those programs. • The Department of Human Services lacked adequate controls to validate the completeness and accuracy of data transferred from MNsure to DHS’s medical payment system, and the department lacked monitoring controls to detect whether the Office of Minnesota Technology Agency (MN.IT) staff inappropriately accessed personal information. • Eligibility workers were unable to close cases when recipients had income and family relationship changes that made them ineligible for benefits or when recipients asked workers to close their cases. • The department did not verify critical criteria for eligibility — such as social security numbers, citizenship, income, and household sizes — which resulted in ineligible persons receiving public health care benefits. Medical Cannabis Last year the Minnesota Legislature passed the strictest medical cannabis law in the country. It allows the use of the medical cannabis, if delivered in the form of a liquid (oil), pill, or vaporized delivery method only if used with the liquid or oil. It does NOT allow use of the dried leaves, plant form, or smoking. A patient registry was set up for Minnesota residents who have been diagnosed by a health care practitioner with a qualifying medical condition. The patient registry will track who is allowed to access medical cannabis. Nine qualifying medical conditions were deemed eligible for the program, although the Commissioner can recommend adding medical conditions. A 23-member Task Force on medical cannabis therapeutic research was created to conduct an impact assessment of medical MetroDoctors

cannabis therapeutic research. The Task Force shall hold hearings to conduct an assessment that evaluates the impact of the use of medical cannabis, Minnesota’s activities, other states’ activities, and offer analysis. By law, they must provide their findings in a report to the legislature. It is possible, with the change in House leadership, that efforts to expand the program to include more qualifying conditions could be advanced. The Senate was open to a more expansive program. However, the Governor was intent on working with law enforcement to come to consensus on a bill, and his support for their opinion likely hasn’t changed. Health Care Workforce Reform The Legislative Health Care Workforce Commission has been hard at work throughout the interim on developing recommendations on how to achieve the goal of strengthening the workforce in health care. Once the Commission has finalized their report, it will be presented to the legislature for consideration, and policy discussions will follow on how to implement the suggestions. A few of the Commission’s preliminary recommendations are as follows: • The legislature should create a state health professions council that includes representatives from health professions schools, clinical training sites, students, employers and other relevant stakeholders. • The legislature should support continuation of program growth where warranted and where measurable benefit has been proven and discontinue programs that have served their purpose, in order to best utilize resources. • The legislature should explore public/ private partnership opportunities to develop, attract and retain a highly skilled health care workforce. • The legislature should target loan forgiveness and loan repayment programs specifically to primary care, and restore funding to levels equal to or greater than those of 2008. • The legislature should authorize funding to support the implementation of the Project Lead the Way science, technology, engineering, and math (STEM) program in the form of grants,

The Journal of the Twin Cities Medical Society

•

administered by the MN Department of Education to school districts. The legislature should support programs that expose K-12 students to health careers and programs that prepare and recruit rural students and nontraditional students into medical school and other health careers. MNSCU should create online Masters programs in health fields to provide rural residents with career ladder and advancement opportunities they may not find within a reasonable distance of their communities. The legislature should increase funding for Family Medicine residencies and similar programs, including both rural family medicine programs and those serving underserved urban communities.

Conclusion There are 26 new members in the House of Representatives. Both new and returning legislators want to hear your thoughts and opinions. It is important for individuals in the industry to share their experience as health care professionals and educate legislators on the issues critical to their profession. There are two sides to every story and it is important that both sides are heard. In bringing your experience to the table, you can ensure that the legislation being passed is fair and balanced. Legislators are receptive to the feedback they receive — reach out to them though a phone call, email, or a letter. Those opinions are often their guiding voice when it comes time to vote on important legislation. Nancy Haas, J.D. is a Shareholder and Chair of the Government Relations Division at Messerli & Kramer P.A. and previously served for four years as Deputy Chief of Staff and Intergovernmental Relations Director to the City of St. Paul and Mayor Randy Kelly. Ms. Haas graduated from St. Olaf College with a degree in Political Science and earned her law degree from William Mitchell College of Law in 2003. Nancy is also a licensed peace officer with the Minnesota State Fair. Her work with health care clients includes Twin Cities Medical Society, Minnesota Medical Group Management, Volunteers of America, Minnesota Oncology, and Life Science Alley. January/February 2015

Health Care 2015

Colleague Interview: A Conversation with Maureen Reed, M.D.

aureen Reed, M.D. has served in many leadership positions throughout her career, in medicine, politics, and the community. Initially with Aspen Medical Group, she served as its Chief of Staff and President, and then moved on to Executive Director of MedCenters Health Plan. For the next nearly 10 years she was Medical Director and Vice President, HealthPartners Health Plan. Taking a hiatus from medical administration, Dr. Reed served as the interim Executive Director of Parks & Trails Council of Minnesota and most recently, Executive Director of Nobel Peace Prize Forum. In addition, Dr. Reed was a candidate for two political offices — Lt. Governor (2006) and U.S. Congress (2009-2010). She also served on the University of Minnesota Board of Regents, including its chair (2001-2003). Dr. Reed received her medical degree from the University of Minnesota Medical School. She completed a residency in Internal Medicine and graduate cousework in Public Health at the University of Minnesota.

Do you continue to be engaged with your advocacy and influence on current legislative activities — state and national? If so, how? Except for informal discussion with friends or acquaintances, right now I am not engaged with health care policy at the state or national level. Frankly, I am enjoying the hiatus.

Now 30 years later, the medical establishment has moved in the direction of outcomes and total cost of care based on population risk. The lessons from the 1980s are still germane. First, care must be evidence-based and delivery systems must be able to show publicly that their care measures up. Second, attention to cost is essential. Third, the patient’s experience matters — a lot. Fourth, the care is only as good as the system through which it is delivered. Fifth, change occurs too slowly.

Describe the effect of the Aspen experience — early HMO and fee for service — on your vision and goals for our current medical systems, administration and delivery.

What are your views on a single payer health system?

When I joined the practice just out of internal medicine residency in 1982, our multispecialty group was almost completely pre-paid and the practitioners were all on salary. Also, in that era group practice and pre-payment were still viewed with some suspicion by physicians in small medical groups who largely practiced feefor-service medicine. Those circumstances compelled our group to be attentive to cost and attentive to measuring the quality of the care we provided. As a consequence, our group was held in high regard. For me personally, this formative experience at Aspen Medical Group (now part of the Allina Health System) revealed a profound reality: quality and cost are completely inseparable.

Through the years, I have changed employers three times, obtained individual private insurance twice, and been (briefly) uninsured once. Without proficiency in English, access to the internet, a degree in medicine, experience in health care administration, and time to sort through the whole mess, I would have been tough out of luck. So let’s split this question into two parts: single financing system and single administrative system. Although I was not traditionally a fan of a single financing system, the disadvantages of employer-based health insurance have become painfully obvious. It is onerous for patients, it is expensive for all of us, and it diminishes potential by trapping people in jobs and circumstances

January/February 2015

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they don’t like. We should move toward a single financing system, divorced from employment, which evolves in a planned fashion over a number of years. The notion of a single administrative system is more problematic for me. Minnesota is light-years ahead of many states in our ability to understand, measure, coordinate, regulate and execute. Call it provincial, but the prospect of throwing in with states that have no notion about any of this is unpleasant.

What is your position on the balance of both public and personal responsibility for health care? For example, financial reward for good health, penalty for unhealthy behavior; higher premiums for patients who smoke, lost withhold for clinics whose patients don’t lose weight. The greater the alignment of incentives, the greater likelihood of success. People with unhealthy lifestyles have a much larger burden of illness which dramatically affects the cost of care. The big three are tobacco, alcohol, and obesity. Rewarding people who engage in healthy lifestyles (and/or penalizing those who don’t) makes all kinds of sense. Additionally, health systems have a proven ability to constructively intervene in both tobacco cessation and alcohol treatment. We should take the time to reward health systems that are effective in helping their patients adopt healthy lifestyles (and/or penalize those who don’t). But when it comes to health behaviors, let’s not forget about public policy. We are highly social creatures that are highly influenced by the world around us. Our future public policies should make it easier, less expensive, and more acceptable for people to make the right choices about the things that burden us all with debt and misery. Whether we’re talking about tobacco labeling, definitions of drunk driving, or availability of safe sidewalks, public policy must align with our interest in promoting population health and public safety.

You have had extensive experience in the role of governance and leadership while some of us feel that physicians are increasingly marginalized away from leadership roles. How can physicians regain a greater position of influence for the benefit of medicine and patient care outcomes? I’m not sure I agree with the premise that physicians are marginalized from leadership. When I look around Minnesota, I see physicians as CEOs, CMOs, State Commissioners, and much more. But if one does believe that physicians are marginalized, then the question becomes, “What kinds of characteristics are required of strong 21st Century leaders?” Regardless of sector or enterprise, effective leaders share similar qualities. They see things that do not yet exist, they articulate what they see, and they persuade others to assist in making the vision MetroDoctors

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better and making the vision happen. Additionally, they are very adaptable and richly creative. I have every reason to believe that physicians will continue to exhibit these traits and bring them to bear at all levels of the health care sector — and beyond.

Are there additional ways that we can celebrate the accomplishments and successes of medicine in the Twin Cities — Minnesota — the U.S.? We certainly celebrate sports stars, media celebrities, and even occasionally elect them to political office. Where, and how, can we better celebrate — or even acknowledge — the local and regional accomplishments in medicine? Unlike the sports or entertainment world, medicine is not about the stars on the field. It’s a team sport more dependent upon how well the team functions than how well the individual stars perform. In medicine, our best successes are the things that never happened: the kid who never started smoking, the mom whose colon cancer was found and treated early, the grandma who didn’t have a stroke because her hypertension was controlled for 30 years. Instead of looking for the dramatic, we must find compelling ways to put a face on these everyday stories that are the lifeblood of the profession.

You served on the U of M Board of Regents for eight years. In what areas do you see opportunities for the Regents to actively enhance medical education at the University of Minnesota? This includes medical school, residency and post-residency education. While there are many opportunities for improvement, Minnesota’s health status and health care is among the best in the country. It is quickly advancing, and the pace of change is accelerating. By comparison, the pace of change within academic institutions is slow. This is worrisome across all of American higher education. Fifty years ago, academic institutions were the epicenters of innovation. They are no longer. As an academic institution, the University of Minnesota Academic Health Center is caught in this same historic time warp and is slow to recognize or embrace change. It is not clear that the AHC has a complete enough understanding of today’s “in the field” realities. Whether we speak of the University’s education, research, or patient care (outreach) missions, each should be tightly linked with our needs and realities. The AHC must more thoroughly understand and more aggressively participate in today’s world of health care. My rather radical recommendation is that the University shred the 20th Century academic script and ask the most innovative Minnesota health and health care systems to re-write the script for the 21st Century.

(Continued on page 10)

January/February 2015

Health Care 2015 Colleague Interview (Continued from page 9)

You most recently served as the Executive Director of the Nobel Peace Prize Forum. What interested you in this position? What learnings did you gain from this leadership position? Imagine the thrill of watching His Holiness the Dali Lama explain the meaning of compassion, hearing President F.W. deKlerk discuss his difficult work with Nelson Mandela, or speaking with Prof. Mohammed Yunus about the concept of courage. The Nobel Peace Prize Forum is an annual conference designed to inspire peacemaking by studying the work of Peace Prize winners. It is the only entity outside of Norway authorized by the Norwegian Nobel Committee to use the name “Nobel Peace Prize.” Having been involved on the Executive Committee for several years, I couldn’t resist the opportunity to step forward when the Forum needed to re-structure itself to become an international event. Our task was fundamentally to construct an event that would draw a huge public and collegiate audience into discussions so serious and substantive that the lives of the participants would be changed. This experience proved to be one of the most exciting opportunities of my life. Nobel Peace Prize winners are luminaries of

January/February 2015

humanity, and they have much to teach us about tenacity, failure, conviction, and success. Most importantly, they taught me that each Nobel winner is flawed, but these human imperfections are the essence of their ability to inspire. The person who has achieved much despite the flaws is one who causes us to believe that we, too, can accomplish much despite our flaws. Second, I discovered something I should have already known: that people of all ages are thirsty for inspiration and eager for the chance to fulfill their lives in a more complete way. Third, I rediscovered a few things I had long known: international affairs are personally intriguing, working with 20 and 30-year-olds is deeply invigorating, wildly aggressive goals are crucial, and perfection is the enemy of good enough. Finally, I learned that when you’ve made the contribution you hoped to make, it’s time to move on.

What’s next on your career agenda? I can’t wait to find out. My mom is 104 years old and is mentally sharp as a tack. If genetics and statistics play out, I may be looking at more than 40 years of productive life. So retirement is not in the cards. For now, however, it is simply marvelous to be taking a little sabbatical with time to read, research, and write. If past experience is a predictor, in a few weeks or months a feeling of restlessness will emerge, and then a new idea will launch me into the next phase.

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The Journal of the Twin Cities Medical Society

Leaders on Health

s mayor of the most livable city in America, health is at the center of everything I do. To be “livable” means to promote vitality, and vitality encompasses every aspect of health — emotional, mental, social and physical. To support a healthy community, a city must have accessible services and resources, and a system that supports each person in a healthy way, no matter their age, gender, ethnicity, sexual orientation, ability, or economic background. This kind of community has been characterized and promoted across the globe by Gil Penalosa. His creation of the “8-80” city is what has inspired me and so much of the work that’s been done, and that’s on the horizon, for the City of Saint Paul. An 8-80 city is one that works for each resident — from a 2nd grader to an 80 year old. An 8-80 city has safe, connected bicycle and pedestrian paths, access to libraries, community centers and parks, and equitable, handicap-accessible public transportation. An 8-80 city supports a person’s need to be physically active by providing safe, easily reachable places to do so, and prioritizes social development and health through education, community involvement and opportunity. Here in Saint Paul, we’ve taken great steps toward being this kind of community — Saint Paul was one of the first cities to ban indoor smoking; our public libraries are offering educational resources such as Lynda.com for free to library card holders; Parks and Recreation spent the spring, summer and fall offering free fitness classes in parks across the city; the East Metro Mental Health Roundtable — a coalition of stakeholders and health care providers — launched the “Make It OK” campaign to help destigmatize mental health issues and connect the general public with tools and resources; and By Mayor Chris Coleman, City of Saint Paul MetroDoctors

of course the city recently completed the Green Line, which has seen record ridership in its first few months — proof that public transportation connects communities to jobs and resources, in turn providing opportunity, access and stability — all integral parts to a person’s ability to live a happy, healthy life. At the center of Gil Penalosa’s ideal city is the 8-80 Rule — a simple way to evaluate public spaces in a community. First, think of an older adult. Then, think of a young child. Finally, ask yourself, “Would I send them out together for a walk to the park?” If the answer is yes, then your public spaces are working as they should — as the foundation to a healthy city. Here in Saint Paul, a huge aspect of our residents’ healthy living is our amazing parks and recreation system. Across the city there are 179 parks that are walkable for 90 percent of Saint Paul’s residents. At those parks and other community spaces, more than 3,500 educational classes, sports and activities are offered each year. With roughly 4,000 acres of parkland throughout the city, it is a huge resource for bettering all aspects of health. Another key piece to an 8-80 city is access — in other words, its transportation system. No matter how great a city’s public spaces and services are, if residents cannot safely and easily get to them, they are not functioning for the community.

The Journal of the Twin Cities Medical Society

Along with increasing access to bikes and safe, connected bikeways, Saint Paul’s Bike Plan has set a goal to increase the percentage of bicycling commuters from 0.6 percent to 2.5 percent by 2025. It’s a modest goal, but one that will greatly increase the health of our community — physically, mentally and emotionally. According to the U.S. Census American Community Survey data, roughly 15 percent of Saint Paul residents do not have vehicles for daily use. Along with the access created by the Green Line, investing in bicycle facilities, particularly in low-income areas with high levels of dependency on transit, will provide healthy, inexpensive transportation options, allowing those residents access to jobs, services and amenities that allow them to lead healthy, happy lives. With more safe, equitable access to alternative forms of transportation, Saint Paul will be opening the doors to all of its amazing public spaces, community resources and opportunities that the great employees of this city are already working night and day to provide. Our vision for the future will bring us closer to earning the title of an 8-80 city as we continue to strengthen the mental, physical, social and emotional health of each person who calls Saint Paul home. Chris Coleman took office as Saint Paul’s Mayor in 2005 after several years as a city councilmember, community and neighborhood leader. He was the most recent President of the National League of Cities, a national organization of city leaders across the United States. In 2012, Mayor Coleman was elected as the Second Vice President of the National League of Cities, and became the League’s Vice President in 2013. Mayor Coleman completed his undergraduate degree and Juris Doctor at the University of Minnesota. He can be reached at: Email: mayor@ci.stpaul.mn.us Phone: (651) 266-8510. January/February 2015

Health Care 2015

Moving the Dial on Equity Through Healthy Living

s mayor of Minneapolis, I have been focused on three main goals: running the city well, continuing to grow the city, and reducing the disparities between white people and people of color. I know that improving the health of my community helps me move the dial on all three of these goals — particularly my goal to move the dial on equity. There are major disparities in health across our country when the zip code you live in has the ability to predict your life span. The social determinants of health, as laid out by the Minnesota Department of Health include such things as poverty, poor housing conditions, and institutional racism. One of the recommendations for changing this condition is to identify and advocate for public policies that encourage healthy living. Because these disparities start early in life, one of my priorities has been my Cradle to K Initiative, which is focused on developing a plan to eliminate disparities for children in the City of Minneapolis prenatally to three years old. Research shows that racial disparities can be closed, even prevented, by focused, results-driven interventions in early childhood; and increasingly, cities are making critical investments in early childhood that yield great returns over time. My Cradle to K Cabinet is a new collaborative of multi-sector experts, leaders, and parents who are working to By Mayor Betsy Hodges, City of Minneapolis

January/February 2015

prevent disparities by aligning policies, closing gaps, and increasing resources where needed to ensure that all Minneapolis children have a healthy start, are stably housed, and have continuous access to high-quality, child-developmentcentered child care and early education, regardless of their race, neighborhood, income or family structure. The cabinet is preparing a report which will guide our work in 2015 and beyond. One of the clear areas that has surfaced is issues surrounding the health and development of children prenatal to three. Gaps in the system in regards to making sure every child receives a developmental screen at age three has garnered a great deal of attention. An early childhood screen is required by law for a child to enter Kindergarten. However, it is recommended to have this screen at age three to catch any developmental concerns early and to be able to provide interventions and resources, when needed, to a family with the goal of preparing the child for Kindergarten. Many recent efforts have increased the numbers of children screened at this age in Minneapolis but we are still only reaching around 40 percent of children. A comprehensive developmental screen happens by qualified staff at Minneapolis Public Schools (MPS) and Head Start, but a doctor’s screen is also acceptable and many families choose to have their child screened at the doctor’s office when they go for annual check-ups. However, many medical and community experts

agree the screen that a child receives at the doctor’s office is not as comprehensive, thereby, leaving many children without the benefit of a comprehensive screen that could identify developmental delays such as speech and language problems, emotional behavioral issues, and delays with small and large motor skills. There are efforts mobilizing to work on this issue such as the Close the Loop Project of Hennepin County which is a project focused on improving the referral and feedback process and the Generation Next K Readiness Network. It’s clear we need to better coordinate what the screening should include, so that whether a child goes to a clinic or the school, they are getting a comprehensive screening which is standard across the board. We also need to ensure those children with identified delays are getting referrals for services. One of the reasons this is so important to the issue of equity is that many of the children desperately needing developmental services are those with multiple barriers such as homelessness, deep

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poverty, a parent with a chemical dependency, or mental health issues. These children often are the ones that show up not ready to learn in Kindergarten. If screened early there are interventions and services available for these children that can successfully prepare them for Kindergarten. I believe we also need to address the behavioral health of our youth. Many young people, even as early as zero to three are experiencing high levels of trauma due to domestic and community violence, high mobility and homelessness, and behavioral health and substance abuse issues. Currently, there are very few professionals trained in identifying trauma in very young children; when we do, there are few places to refer them to for service. This is an area where our community needs to come together to develop a plan for how to build our service system. In addition, continuing support of the Healthy Start program, with the purpose of eliminating disparities in infant mortality, is also a priority for me. In my proposed 2015 budget, I included support to continue working with pregnant women and babies to make sure children and families are getting what they need to thrive. I know that health also depends on our physical spaces. In Minneapolis today, 87 percent of lead-poisoned children are children of color. While lead is toxic to everyone, babies and young children are at the greatest risk for health problems from lead poisoning. This exposure can have deep, lasting impacts for life outcomes. We need to ensure residential homes are safe from lead hazards by conducting inspections for children with diagnosed lead poisoning. Because of new federal and state directives on childhood lead poisoning, the city has a backlog of inspections. To address this backlog, I have proposed investing new funding to ensure all children have a healthy place to call home. I have also been focused on sustainability and creating a Zero Waste MetroDoctors

Minneapolis. Air pollutant concentrations are higher for the neighborhoods northwest and southeast of the Hennepin Energy Recovery Center (HERC), which are predominantly non-white population areas. We can create healthier environments, cutting down on asthma and other health problems surfacing in low-income communities by reducing the waste stream that is sent to the incinerator. As a city, I also believe we should be actively encouraging recreation and a healthy lifestyle. We do this in part by making sure there are bike paths, recreational activities, and parks that are accessible year-round to all parts of the city. These efforts can improve the health of all residents, while also working to combat childhood obesity. The health and development of our residents is of upmost importance to me. Creating policies and making alignments that improve the health of

The Journal of the Twin Cities Medical Society

the community is a big priority in Minneapolis. I know this work will make our city a stronger one, and I look forward to continued partnerships with stakeholders who can help us drive this work. Betsy Hodges is the 47th mayor of Minneapolis. Prior to becoming mayor, she served on the Minneapolis City Council for eight years as the representative of Ward 13. Before running for public office, Mayor Hodges was an organizer. She worked for TakeAction Minnesota and the Minnesota Justice Foundation. She also helped found a program in Albuquerque, New Mexico to get HIV-positive women the help and resources they needed. Mayor Hodges did her undergraduate work at Bryn Mawr College and her graduate work at the University of Wisconsin-Madison. Mayor Hodges can be reached at: (612) 673-2100, or: Betsy.Hodges@minneapolismn.gov.

January/February 2015

Health Care 2015

Coming to a State Near You â&#x20AC;&#x201D; New and Improved Medical Licensure

ny physician actively practicing acknowledges that everything seems to be changing. A cataclysmic change that has yet to be felt is the mobile health or mHealth revolution. Telecommunications technology and the handheld computer means the physician delivering care can be in one state and the patient receiving care can be located in another state. We have the ability to deliver care to the most remote corners of the country. There is one small hitch. You will need a medical license to do that. The care of the patient occurs where the patient is located and the physician will need a license in that state to treat the patient. This is very frustrating for the entrepreneurial telemedicine physicians that see the entire U.S. as their oyster. They want unfettered access to every patient in the U.S. and view state-based licensure as an anathema of some antiquated bygone era. They would prefer what they believe to be a far simpler system of national licensure, fantastical as that may sound. Fortunately given the current state of affairs in Washington, DC, very few congressional leaders have the stomach for creating a new bureaucracy and infrastructure to deal with national licensure. Where we all agree is there needs to be a better solution to licensure. The concept of state licensure is based on constitutional principles going back to the Articles of Confederation and the Constitution. A brief refresher is helpful

By Jon V. Thomas, M.D., MBA

January/February 2015

to understand the debate that has been fought from the very beginning between Alexander Hamilton and Thomas Jefferson and continues to this day. The Articles of Confederation under which the colonies were united initially provided for a weak Federal government. This proved very frustrating for some of the founding fathers, especially Alexander Hamilton who wanted a strong Federal government with a standing army, the power to tax and the ability to engage in international diplomacy. Thomas Jefferson wanted the opposite, a weak Federal government with strong states. The state vs. federal debate is still being waged today, albeit in what many readers of history would consider a somewhat more civilized fashion. The 10th Amendment to the Constitution states simply: The power not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved

to the States respectively, or to the people. In constitutional law, the 10th Amendment grants the states power to establish and enforce laws protecting the welfare, safety, and health of the public. So if you ever wondered why a physician needs a license to practice medicine in a particular state, it is constitutionally based on the policing power of the state to protect the public. It is that simple. This state of affairs is frustrating for practices with physicians active in numerous states. For example tele-radiology practices will license their physicians in many, if not all, states. Locum tenems physicians have to manage multiple licenses. In addition to the hurdle of the application process, relicensing is not any easier. States have varying requirements for CME. In addition, the renewal cycles are not standardized. Managing licensing in these practices can be complex and costly â&#x20AC;&#x201D; typically requiring dedicated staff. In speaking with tele-radiology and locum tenems administrators who are used to managing this complexity and have done it for years, they view it as the cost of doing business. Frustration with licensing is not new. Over 100 years ago there was an effort to push the concept of license reciprocity. If a physician obtained a license in one state and was in good standing, other states should also recognize the license and grant that physician the ability to practice in their state. Unfortunately there were few if any standards for licensure about which states could agree. There was considerable variation in the training and licensure

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requirements from state to state. In addition physicians in some states didn’t want the competition from physicians coming from other states. The licensure reciprocity never gained any significant traction. The Federation of States Medical Boards has taken up the mantle for several decades with efforts around the idea of license portability, reducing or minimizing regulatory barriers for practicing in multiple jurisdictions. One of the efforts, the Uniform Application, was a push for states to adopt a standardized application form. Another effort was FCVS, the Federation Credential Verification Service. This effort resulted in a portfolio of primary source verification of educational training. Once completed it can be used by 49 states for their licensure process. Another effort by the Federation was to help states develop IT systems to improve efficiency and productivity of state’s boards in processing a license. While significant, none of these efforts significantly reduces barriers to licensure, nor changes how a physician is licensed. An interstate compact has the ability to solve the licensure issue and preserve state’s rights. An interstate compact is a constitutionally protected agreement between states that solve problems between the states obviating the need for federal intervention. As is often stated, once you have seen one compact you have seen one compact. The similarity between interstate compacts is their constitutional protection and the fact that they are acts of state legislatures that are signed by Governors. Beyond that they can address myriad issues. Compacts address water rights and use involving lakes and rivers. The Driver License Compact allows us to drive anywhere in the nation without having to apply for a license to drive in each state. The Interstate Medical Licensure Compact provides for a streamlined process to licensure in multiple states for a qualified physician. To be eligible a physician must: 1. Have successfully passed USMLE or COMLEX-USA MetroDoctors

2. Have successful completion of a GME program 3. Have specialty certification or timeunlimited certificate 4. Have no discipline on any state medical license 5. Have no discipline related to controlled substances, and 6. Not be under investigation by any agency A qualified physician who has a medical license from a compact state will be able to obtain medical licenses in any or all of the other compact states through simple notification and payment of a state’s licensing fee. The license obtained through the compact process is the same as a license obtained the traditional way. It comes with the same benefits and responsibilities on the part of the physician without changing a state’s existing Medical Practice Act. A state medical board in a compact state would retain jurisdiction and be able to impose an adverse action against a license to practice medicine within that compact state. The Interstate Medical Licensure Compact also affirms that the practice of medicine occurs where the patient is located at the time of the physician-patient encounter. This would require that a physician be under the jurisdiction of the state medical board where the patient is located. Initially state medical boards were concerned that there would be a loss of autonomy or control. In a compact the states remain firmly in control. In addition, information sharing in the compact is facilitated so if there are concerns about patient safety, compact states would be able to share appropriate information with other states — something that has been very difficult given many state’s statutes concerning data privacy and information sharing. The ability of an incompetent physician to escape scrutiny would be limited. While the framework and language of the compact was completed in September of 2014, we have not yet seen adoption. The Federation of State Medical Boards

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that helped to develop the compact is done with its work. Now it is up to the state legislatures to pass it in the upcoming legislative sessions. Once seven states pass the legislation the compact will then become active and a Compact Commission will be developed by the participating states. The Compact Commission will administer the compact. For those states signing on first there will be an opportunity to significantly influence how the compact will work through rule writing. Many more than seven states have already expressed interest in being in on the ground floor. Given the interest of telemedicine physicians, multi-state managed care organizations and states where there are physician shortages we expect that the compact will be activated in 2015. While this has been very positive for physicians, in the end it will benefit patients because they will have unfettered access to the care that they desire. Jon V. Thomas, M.D., MBA is Immediate Past Chair of the Board of Directors of the Federation of State Medical Boards, representing state medical boards in their protection of the public. He has served on Minnesota’s Board of Medical Practice since 2001 and was recently reappointed by Governor Mark Dayton. During his service on the Minnesota Board he has held several leadership roles including Secretary, Vice President, President. In addition to his regulatory experience Dr. Thomas has held leadership positions serving as President of his group, Ear, Nose & Throat SpecialtyCare of Minnesota, PA and Chief of Staff of United Hospital. Dr. Thomas is board certified in Otolaryngology-Head and Neck Surgery with a subspecialty interest in head and neck tumors. He continues to practice full time in St. Paul, MN. Dr. Thomas can be reached at: (651) 227-0821; or jonthomasmd@gmail.com.

January/February 2015

Health Care 2015

Electronic Cigarettes, Hookahs and Other Tobacco Products What is an E-Cigarette?

An e-cigarette is a battery-powered electronic device that simulates smoking and contains a cartridge filled with liquid nicotine, flavoring and other chemicals, often referred to as e-liquid. Developed by a pharmacist from Beijing, China, in 2003, it was introduced to the European market in 2006, and the U.S. in 2007. While ecigarettes do not contain tobacco, they do contain various levels of tobacco-derived nicotine.(1) There is no government oversight of electronic cigarettes or e-liquid(2) and early studies have found detectable levels of cancer-causing chemicals in two leading brands of e-cigarettes.(1) Over 250 e-cigarette brands are currently on the market, with the three largest tobacco companies (R.J. Reynolds, Phillip Morris and Lorillard) investing significant time and money developing and promoting these new products. Public Health Concerns

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E-cigarettes are untested, unregulated products. Without FDA oversight, there is no way to know what chemicals are in e-cigarettes or how much nicotine is being inhaled.(1, 2) Lack of regulation makes studying the short- and long-term health effects challenging. There is no evidence that using ecigarettes or inhaling the second hand emissions is safe. Studies have shown heavy metals, carcinogens, fine particles, and nicotine in e-cigarette emissions.(1) E-cigarettes are not proven to help quit smoking.(1)

By Nancy Bauer

January/February 2015

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E-liquid is usually flavored to smell and taste like candy or fruit and research shows flavored tobacco products appeal to youth.(3) E-juice also contains highly concentrated nicotine; contact with skin can be harmful to users and just a small amount can poison a child.(1,4) • A CDC study found e-cigarette use among middle and high school students more than doubled between 2011 and 2012.(5) • E-cigarettes can complicate smokefree indoor air laws because it can be difficult to distinguish e–cigarettes from traditional cigarettes. E-cigarettes and e-liquid are often sold at e-cigarette lounges where customers may taste-test and use products in a social environment, complete with

couches, televisions and refreshments, for an unlimited amount of time. The FDA has the ability to regulate these products, but has not yet taken action. In Minnesota, e-cigarettes are taxed as a tobacco product and cannot be sold to minors. However, as they are not covered under Minnesota’s Clean Indoor Air Act, smoking them indoors and in public places is not against state law. As a result, many Minnesota communities have decided to regulate e-cigarettes at the local level. Sampling: Hookah Bars and Vaping Lounges

Hookahs and e-cigarettes are novel tobacco products that are growing in popularity, especially among youth and young adults. Hookah is a water pipe that is used to smoke tobacco, also known as shisha,

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The Journal of the Twin Cities Medical Society

which is heated using coals or wood burning embers. Shisha is a sticky mixture of tobacco, honey or molasses, and other flavorings such as bubble gum, peanut butter, grape and mint.(6, 7) Hookah bars often sell coffee or alcohol and are becoming increasingly common around colleges and universities.(2) Other Tobacco Products

Other tobacco products (OTP) include non-cigarette tobacco products like cigars, little cigars and cigarillos, smokeless tobacco (chew tobacco or snus) and dissolvable tobacco. Often these products resemble candy and can come in many flavors such as strawberry, grape and chocolate. OTPs are regulated differently than cigarettes, but are no less harmful or addictive.(8,9) TCMS Response

Twin Cities Medical Society has had a long-standing history of supporting efforts to reduce exposure to tobacco and related products. Early involvement in city and county efforts to restrict smoking indoors led to the statewide Freedom to Breathe law restricting smoking in bars, restaurants and other indoor locations. The preponderance of evidence that substantiated the claim that tobacco use and secondhand smoke exposure was harmful to your health was key to this success. There is still much to learn about e-cigarettes, and it is with that in mind that TCMS has an opportunity to take a public health stance early on in this debate and become a leader locally, similar to our

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approach with tobacco and secondhand smoke prevention efforts. TCMS E-Cigarette Policy Position

TCMS agrees with the American Medical Association’s policy that calls for a greater oversight role of e-cigarettes by the FDA. In addition, TCMS acknowledges that ecigarettes remain a public health concern and therefore supports: • Efforts of cities and counties to update their clean indoor air policies to include restricting the indoor use of e-cigarettes. • Efforts to require that e-cigarettes are sold behind the counter. • Prohibiting sampling of e-cigarettes in stores. • Efforts to educate health care professionals and others about e-cigarettes, the impact of nicotine, proven cessation resources. • Supports efforts to restrict marketing of e-cigarettes to youth and efforts to ban advertising at the state and national levels.

The Journal of the Twin Cities Medical Society

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Supports state and national efforts to include e-cigarettes in comprehensive tobacco and nicotine control policies.

Education and Resources

On October 22, 2014 TCMS held an educational event and training for physicians and medical students on e-cigarettes and other tobacco products. Peter Dehnel, M.D., chair of the Policy and Legislative Committee, served as the moderator with presentations by Pete Rode, Ph.D. research scientist, Minnesota Department of Health, Betsy Brock, MPH, Association for Non-Smokers-MN, and Pat McKone, American Lung Association Minnesota. Throughout the discussion on emerging tobacco products, actual samples of e-cigarette devices and flavorings, Hookahs and flavored cigars where displayed, noting their appeal to youth. Data on use rates (both youth and adults) was presented; 2.8 percent of students reported e-cigarette use within the previous 30 days in a 2012 CDC study(5) of high school (Continued on page 18)

January/February 2015

Health Care 2015 Electronic Cigarettes (Continued from page 17)

students, doubling the 2011 numbers. The Minnesota Youth Tobacco Survey, released on November 10, 2014 by the Minnesota Department of Health,(10) revealed that 28.4 percent of our own high school students have tried e-cigarettes and 12.9 percent have tried or used an e-cigarette at least once in the past 30 days. The good news is that from 2011-2014, traditional cigarette use has markedly decreased (25.8 percent to 19.3 percent); however, dual use of cigarettes and e-cigarettes is now a major concern. Several cities and counties around the state have begun implementing strategies to strengthen e-cigarette regulations by adopting policies to include e-cigarettes in their Clean Indoor Air ordinances. Sales regulations require that all vendors be licensed to sell electronic delivery devices and by January 1, 2015 any liquid sold for use in e-cigarettes (“juice” or “e-juice”) must be sold in child resistant packaging.

January/February 2015

Participants at TCMS sponsored e-cigarette educational event and training.

TCMS members have the opportunity to serve as a resource to their patients and spokespersons at local community gatherings and city/county hearings. A second physician and medical student education/ training session is being planned for early 2015. Please contact the TCMS office at (612) 623-2885 if you are interested in participating. Nancy Bauer, associate director, TCMS.

Sources: 1) German Cancer Research Center (Ed.) Electronic Cigarettes — An Overview. Heidelberg. 2013. 2) U.S. Food and Drug Administration. FDA and Public Health Experts Warn About Electronic Cigarettes. July 2009. 3) U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. 4) National Capitol Poison Center. (2013). Electronic Cigarettes (e-Cigs): E-Liquid and Smoke Juice Are Dangerous for Kids. Accessed 15 Jan 2014, http://www.poison.org/poisonpost/ sep2013/ecigarettes.htm. 5) Tobacco Product Use Among Middle and High School Students — United States, 2011-2012. Morbidity and Mortality Weekly Report, 62(45), 893-897. 6) WHO Study Group on Tobacco Product Regulation; Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Geneva, Switzerland; 2006. Available from, http://www.who.int/ tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final,pdf. 7) American Lung Association. Hookah Smoking: A Growing Threat to Public Health Issue Brief. Smokefree Communities Project, 2011. Available from, http://www.lung.org/stop-smoking/ tobacco-control-advocacy/reports-resources/ cessation-economic-benefits/reports/hookahpolicy-brief.pdf. 8) National Cancer Institute. Cigars: Health Effects and Trends, Smoking and Tobacco Control Monograph No. 9. Smoking and Tobacco Control Monograph No. 9. Bethesda (MD): National Institutes of Health, National Cancer Institute, 1998. Accessed 2014 Jan 13. 9) American Legacy Foundation, Cigars, Cigarillos & Little Cigars Fact Sheet (2009), available at http://www.legacyforhealth.org/PDF/CigarsCigarillos-and-Little-Cigars_FactSheet.pdf. 10) Minnesota Department of Health. Teens and Tobacco in Minnesota, 2014 Update, Executive Summary. November 10, 2014. www.health. state.mn.us.

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The Journal of the Twin Cities Medical Society

The 5th Vital Sign, Visual Analogue Scale, and the “Patient Experience” Why the Medical Community Still Has No Response to the Opiate Public Health Crisis

he faces stare at you. There are six of them and you know them well. You have been assured that they, and the numbers they are associated with, have meaning for you and your patients. Starting in 2001, they have even told you whether you were doing your job or not. The face on the far left smiles at you as if to say “thank you so much, I feel great, job well done!” The face on the far right frowns at you as if to say “I am miserable! How could you abandon me in this pain!? How could you !?” The face on the far right’s next conversation may well be with the hospital’s patient representative — to talk about you. I am speaking of the Visual Analogue Scale (VAS) for pain assessment and the Wong Baker Faces® Pain Rating Scale. The Joint Commission in 2001 released a statement informing all of us involved in direct patient care that part of our professional duty was to aggressively manage a patient’s pain and that some tool for assessment needed to be used and pain repeatedly re-assessed. This VAS became the choice for most hospitals and has been present in every patient room I have worked in since that time. Alongside this scoring system came another mantra — that pain was the “5th Vital Sign.” A creation of the American Pain Society in 1995, we were instructed as health care professionals that the number generated on this scale was to be treated as meaningfully as blood pressure and heart rate. A patient with “10 out of 10” pain thus would be considered as unstable and in as dire a condition as a By Chris Johnson, M.D. MetroDoctors

patient with a persistent blood pressure of 70/40. I had my doubts, though. Unlike the other vital signs, the number generated for pain was a reported number, not a measured one. Essentially it was an opinion that had a numeric value attached to it. That confused the nature of the data, however, because now it was in a form that could be added, divided and standard deviated. Among all the statistical analysis, you would forget that, in the end, it was still just an opinion. During my residency years at HCMC (2000 – 03), the 5th Vital Sign campaign was in full swing and we were reassured that opiates were perfectly safe. In fact, among the studies used by the American Pain Society (who worked with the Joint Commission in 2001) was an article in the New England Journal of Medicine, stating the risks of developing

The Journal of the Twin Cities Medical Society

addiction to narcotics was less than 1 percent. What I was not aware of at the time, however, was a report by the Government Accountability Office which clarified that the “pain management education program” organized by the Joint Commission in 2001 was funded substantially by Purdue Pharma, the makers of OxyContin. And that study in the New England Journal with the “less than 1 percent become addicted” conclusion? It was not a study. It was a five sentence paragraph by two doctors (Porter and Jick, 1980) in a letter to the editor, barely 100 words long. It was not a study. It was a “tweet.” It has been 13 years since the Joint Commission statement and almost 20 since the 5th “Vital Sign,” and we are in the midst of a public health disaster. The number of prescriptions has skyrocketed — in 1991, there were 76 million prescriptions for opiates, in 2011 there were 219 million. The United States now contains approximately 5 percent of the world’s population, yet we consume 80 percent of the world’s opiates. And paralleling the rise in prescriptions has been the rise in overdose deaths. In 1999, there were 4,030 fatal overdoses, in 2010 there were 16,651. The data also show that deaths are just the “tip of the iceberg.” A recent study looked at data for the year 2010 and found that over 92,000 ER visits were due to overdose of prescription opiates. This resulted in $1.4 billion in costs even though less than 2 percent of the overdoses were fatal. (Continued on page 20)

January/February 2015

Health Care 2015 The 5th Vital Sign (Continued from page 19)

The closer we look back at the “data” from the 90s about opiate safety that started this trend, the more we are finding it simply does not exist. Dr. Russell Portenoy was the President of the American Pain Society in 1995 and sought to “rehabilitate” the medical community of their “opiophobia.” He was the subject of the December 2012 Wall Street Journal article “A Pain Drug Champion Has Second Thoughts” in which he offered as much of a retraction as one can see in academic medicine. In a taped interview in 2010 he said, “I gave innumerable lectures in the late 1980s and 90s about addiction that weren’t true.” The truth is, there are no studies that demonstrate long-term efficacy and safety of opiates for chronic pain conditions other than cancer pain. Dr. Erin Krebs, of the University of Minnesota, was recently part of a federal task force commissioned to look at the literature on opiate use and the results of that investigation revealed that the FDA approved the use of opiates for chronic, non-cancer pain on the basis of studies that lasted no longer than 12 weeks. That’s right. 12 weeks. Now we are in 2015 and we are faced with the question “So what do we do about it?” The answer to this question is multifaceted. I will not attempt to list or comment on all parts of the answer such as monitoring programs for prescribers, medical “homes” for chronic pain patients, Narcan for first responders, etc. These are all important but I want to focus on a few key elements that I see as the most crucial to solving this crisis. The first part of the answer has to be honesty — we have to acknowledge these prescription drugs for what they are: oral versions of heroin (aka, diacetylmorphine). We have allowed academic sounding language to obscure the fact that all opiates are fundamentally the same and carry risk. The dramatic 20

January/February 2015

increase in the number of prescription overdose deaths and the boom in heroin use should disabuse us of the notion that these chemicals are so different. Another key component is education. We need to train our physicians, both current and future, about the nature of pain and help them distinguish acute vs. chronic and how treatment for those conditions is different. And we need to teach physicians that there was never any sound, scientific reason to put patients with chronic, non-cancer pain on opiates. However, education alone will not solve this. The ugly truth is that there are very powerful economic forces in the delivery of health care in this country that are doing quite well and have no incentive to change things. The most obvious are the pharmaceutical companies themselves. At no time has a CEO of any of these companies released a statement about the unproven benefits of opiates for use in chronic non-cancer pain, nor discouraged primary care providers from prescribing opiate pain relievers until long-term studies are done. We should not expect any such statement. In fact, to make such a statement would likely get the CEO fired by the Board for failing fiduciary responsibility. Another obstacle we face is the current culture of pain management. The collective result of initiatives such as the “Pain is the 5th Vital Sign” is the view that pain much above “0” is a truly abnormal condition of life or even negligent care. And this is just absurd. Pain can and should be treated in so far as one would want relief from an acute injury

so one can function. But the drive to achieve a “0 or 1” puts extraordinary pressure on doctors and nurses to achieve a meaningless metric and is worsening the excessive use of opiates. But perhaps more implacable and challenging is the nature of the health care economy itself. Here I am referring to the imperative felt in all hospitals and clinics to make the patient happy. The “buzz” word used for this is the “patient experience.” The problem is what will provide an opiate dependent patient with a pain “flare up” a satisfying “experience” is precisely what they do not need — another dose of opiates. The doctor who simply writes for 20 Percocet to make the patient satisfied bears no liability for long-term adverse outcome. And no administrator would even notice. But the doctor who decides NOT to write for more pills bears real risk of complaint and reduced patient satisfaction scores. Now that the hospital definitely notices. Clinicians are incentivized to “get their satisfaction scores up” and keep complaints down, because complaints are costly. Beyond the time it takes for the patient representative to read and respond, complaints are costly because an unhappy patient is likely to demand the bill be reduced or eliminated. Reimbursement advisors have explained to me that the cost of a complaint in terms of revenue the company would have had is between $1,000-$2,000. Now, complaints from chronic pain patients may be quite infrequent, but multiply that in a clinic system that sees hundreds of thousands of patients per year and it

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becomes clear that there is real financial incentive to just make the customer happy. I would like to think that as part of our Hippocratic Oath, we would accept this cost as “part of doing business,” where our first allegiance must be to the long-term health of the patient. However, it is delusional to expect those of us providing care to continue incurring costs for doing the right thing when doing the wrong thing is invisible, more profitable and carries no liability. We doctors are human and respond to incentives. And the incentives now place very little value on collectively turning this prescription problem around. This is not a call to abandon the patient in pain. We need to use all of the resources we can to provide compassionate relief. When appropriate we should help patients with chronic pain find a pain clinic that can help them using all modalities available such as physical and behavior therapy. But I do want to urge abandonment of opiates for treatment of non-malignant chronic pain. If longterm cohort studies get done which provide real numbers on efficacy and safety, we can reconsider. I remain an optimist. I believe that when incentive structures for the business of medicine allow such vast numbers of patients to be harmed, that those ultimately responsible for public safety will act to find solutions and change the incentive structures. This will require engaging multiple partners — political leaders, law enforcement, families, payers, etc. — and a concerted will to change. But it can be done. Because the patients deserve better. In fact, we all do. Chris Johnson, M.D. is a staff physician at Methodist Hospital Emergency Center in St. Louis Park. He has served on the Minnesota Medical Association’s Opiate Task Force and the Institute for Clinical Systems Improvement’s Opiate Work Group and was recently elected to the MMA’s Board of Trustees. He can be reached by email at chrisj442@gmail.com. MetroDoctors

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January/February 2015

Health Care 2015

What to Expect from the 2014 Newborn Screening Law

n May 6, Governor Mark Dayton signed the newborn screening restoration bill into law with the full support of the Minnesota Chapter of the American Academy of Pediatrics (MNAAP) and other medical organizations. The new law, effective August 1, 2014, positions Minnesota to save as many lives as possible while upholding parents’ rights to refuse testing, request destruction of test results, or both. Q&A with Mark McCann, Program Manager, Newborn Screening, Minnesota Department of Health (MDH) What changes went into effect on August 1? The new legislation passed earlier this year authorizes MDH to store blood spots and test results. Under this new law, MDH can keep blood spots and test results indefinitely unless parents request the destruction of the blood spot and/or test results. Additionally, the new legislation explicitly states that MDH should promote materials describing the newborn screening program and encourage medical providers and medical education programs to thoroughly discuss newborn screening with expectant parents and parents of newborns. What about babies born before August 1? Blood spots collected before August 1 are subject to the old practice of retaining blood spots for 71 days and test results for two years. Blood spots collected on or after August 1 will be retained by MDH 22

January/February 2015

indefinitely unless parents request destruction of the blood spot and/or test results. How is MDH educating expectant parents about newborn screening? The legislation makes it clear that MDH is to provide information to health care providers, including pediatricians, about benefits associated with blood spot storage and test results. We’ve been educating expectant parents for a number of years. But because of the new legislation, we’re taking additional steps to educate both parents and medical providers about newborn screening. We are planning to survey 8,000 parents of babies born over a 6-week period to understand what they learned prenatally about newborn screening and what they wish they would’ve known. We also have a mailing going out to over 1,600 prenatal providers and clinics that includes new and improved prenatal education materials. Additionally, we’ll be conducting a survey of prenatal care providers to better understand how they can be more successful in having a discussion with parents on newborn screening. MDH continues to make education materials and forms available to childbirth education programs. If parents do not want their spots saved, what is the process for destruction? Parents should fill out the proper forms on the MDH website. Within 30 days of receiving their request, MDH will destroy the blood spots. MDH is required by CLIA to maintain test results for two years.

If parents are interested in having their child’s blood spot specimens returned to them, they should contact the Minnesota Department of Health Newborn Screening Program at (651) 201-3548. The new legislation clearly sets out the parameters of what things MDH can do as part of program operations. Parents may revoke approval for storage and use of samples and results at any time. Under this new law, MDH can keep all indefinitely unless a parent fills out a request form to order their destruction. Anything else pediatricians should know about? With new legislation, our ability to operate as a nationally recognized program has clearly been strengthened. The program now has more clarity about how and when blood spots can be used. We really look forward to continuing our work with Minnesota physicians toward giving all Minnesota babies a healthy start. I would encourage all pediatricians to make sure they ask for newborn screening reports from the patient’s birth hospital and review them with parents at the first well child visit. For more information, including parental option forms, visit www.health.state. mn.us/divs/phl/newborn/index.html. For more information, including parental option forms, please visit www. health.state.mn.us/divs/phl/newborn/index.html. Reprinted with permission from the Minnesota Chapter of the American Academy of Pediatrics.

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Physicians, Public Health and Climate Change

limate Change is altering our world in a number of ways and there are important implications for public health and specific concerns for Minnesota Physicians and our patients. Polar ice caps are melting, sea levels rising, summers are longer and hotter. Extreme weather events â&#x20AC;&#x201D; storms, droughts, floods and major wildfires â&#x20AC;&#x201D; are increasingly common. Such organizations as the World Bank, the World Meteorological Association, and the National Academy of Sciences acknowledge the reality of Climate Change and endorse the scientific bases for this conclusion. Climate Change is a non-partisan issue because all of us are in this together. In this context there are significant health related challenges to consider and prepare for.(1, 2, 3) 1. Infectious Disease: Extreme precipitation events and flooding threaten fresh water supplies and sanitation systems as just seen with Minnesotaâ&#x20AC;&#x2122;s Spring floods. This was the fourth 500 year flood we have suffered in a decade. Storm runoff and flood waters contaminate wells, overwhelm septic systems and wash sewage and pollutants into reservoirs.(4) Outbreaks of water borne illness such as Cryptosporidiosis are more likely to occur in relation to severe storms. Damp moldy indoor environments increase the prevalence of asthma and respiratory infections. Heavy rains and floods expand insect breeding sites, and drive rodents from burrows and sewers. Warmer average temperatures effect disease transmission by broadening By Bruce D. Snyder, M.D., FAAN

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the geographic range of disease vectors; lengthening their active season; and increasing breeding sites. A global temperature increase of 2-3o C can increase the population at risk for Malaria by 3-5 percent.(5) In Minnesota there has been a much higher incidence of Lyme cases and near historic high numbers of Anaplasmosis and Babesiosis infections reported in recent years.(6) Dust storms associated with drought conditions are associated with increased exposure to Coccidioidomycosis and other soil pathogens. 2. Cardiovascular, Respiratory and Allergic Disease: Increases in global temperatures are associated with increases in morbidity and mortality related to ozone and particulate pollution.(7) Factors that promote ozone formation include heat, high concentrations of precursor chemicals, and methane emissions. Particulates pollution results primarily from wildfires, dust storms and air stagnation episodes.(8) Peak elevations of ozone and air pollutants correlate with an increased frequency of ER visits and admissions for cardiac and respiratory disease particularly in patients over 65. Increased atmospheric CO2 content increases the production of

The Journal of the Twin Cities Medical Society

plant-based allergens. More frost-free days and warmer seasonal air temperatures prolong flowering time and pollen release from allergenic plant species increasing allergic sensitizations and asthma episodes. In Minnesota the ragweed season added 21 days between 1995 and 2011. Asthma is a leading cause of morbidity and school absence. Between 2004 and 2011 the U.S. asthma prevalence increased over 20 percent.(9) 3. Heat-Related Illness: Extreme heat events are becoming more frequent and prolonged. Projections indicate that heat-related deaths will continue to rise.(10) Heat-related illnesses disproportionately affect the poor, very young, elderly and chronically ill. In 2000 there were 330 ER visits for (Continued on page 24)

January/February 2015

Health Care 2015 Physicians, Public Health and Climate Change (Continued from page 23)

heat-related illness in Minnesota. By 2010 that number climbed to 740.(11) Similar increases have been noted in other states.(12) Although some of this can be related to aging and growth of the population, increases of 50 to over 100 percent likely reflect longer and more intense heat events. 4. Trauma: Major weather events cause traumatic injuries and deaths. Hurricane Katrina struck New Orleans on 8/29/05. There were 971 Louisiana deaths: 387 drownings; 246 severe traumas; the rest unspecified. 70 were hospital inpatients; 57 other victims were recovered from hospital buildings. 78 deaths happened in nursing facilities. 49 percent of victims were elderly. Multiple large hospitals flooded and lost power and sanitation. Extreme heat after such storms also contributes to morbidity and mortality.(13) 5. Mental Health and Stress-related Disorders: Weather extremes affect mental health. Mental illness rates rise after disasters. Researchers have documented high levels of anxiety and post-traumatic stress disorder symptoms among people affected by Hurricane Sandy.(14) Similar observations have followed floods and heat waves. Suicide rates increase during extreme heat events. 6. Collapse of Infrastructure and Critical Support Systems During Extreme Climate Events: Extreme storms and flooding can disable hospitals, pharmacies and clinics. If multiple area facilities go off-line it may be difficult to find beds to accept inpatients in transfer. Transportation systems, electric power, communications, sanitation, safe water supplies as well as critical response and public safety services may be disrupted for extended periods. Medical records may be unavailable. People with chronic illnesses may not be able to access their medications or medical equipment.(15) This will particularly 24

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impact patients with chronic illness like epilepsy; patients on anticoagulants; patients requiring extensive physical and/or respiratory support; and the critically ill. Disaster plans will have to be updated to accommodate anticipated changes in climate and weather.(13, 15,16) The causes and consequences of Climate Change have been intensively studied.(1, 2) Many national, state and local governments, as well as industries and businesses are developing programs and new technologies to reduce carbon emissions; improve energy efficiency; and reduce pollution. However much more has to be done to reduce greenhouse gas emissions and develop plans to manage the effects of Climate Change. Physicians are respected opinion leaders and decision makers in our institutions and communities. Throughout the modern era of scientific medicine physicians have acted forthrightly and decisively to end major threats to the public health. Whether from contaminated water or uncontrolled insect vectors; from improved surgical hygiene to vaccination and immunization the medical profession has been a safeguard for communities throughout the world. In this context we have a role to play in a public health challenge of unprecedented magnitude. Major medical organizations such as the World Health Organization, the American Medical Association, the American Academy of Pediatrics and the American Academy of Family Practice have adopted policy positions declaring Climate Change to be a major health threat and urging action to reduce its impact. This is all to the good, however policy statements must be wedded to action. Information and education are key. We need Climate education for ourselves, our colleagues and students. We can assist in the effort to educate our patients, communities and political leaders about this complex issue. We can support organizations working to preserve the planetâ&#x20AC;&#x2122;s environmental integrity and consider how best to assist and participate in their efforts. There is still time to gain control of Climate Change and Global

Warming and prevent ever more severe consequences, if we act together, now. Bruce D. Snyder, M.D., FAAN, Clinical Professor of Neurology, University of Minnesota Medical School. HealthPartners Dept. of Neurology. He can be reached at: bdsnyd@ gmail.com. References: 1) 5th Assessment Report-Intergovernmental Panel on Climate Change. http:// www.ipcc.ch/report/ar5/. 2) National Climate Assessment. http:// nca2014.globalchange.gov/highlights/ overview/overview. 3) Climate Change the Health Impacts. Physicians for Social Responsibility. www. psr.org. Accessed 10/2014. 4) Climate changes, environment and infection: Facts, scenarios and growing awareness from the public health community within Europe. Bezirtzoglou et al. Anaerobe 17 (2011) 337-340. 5) Climate Change and Infectious Disease. Shuman, E. NEJM 362:1062-3, 2010). 6) Minnesota Dept. of Health. http://www. health.state.mn.us/macros/topics/diseasestats.html. Accessed 10/2014. 7) Global premature mortality due to anthropogenic outdoor air pollution and the contribution of past climate change. Silva A et al. Environ. Res. Lett. 8 (2013) 034005 R. 8) Human health effects of air pollution. Kampa, M. and E. Castanas. Environmental Pollution, 151, 362-367, 2007. 9) Trends in Asthma Morbidity and Mortality. American Lung Association Epidemiology and Statistics Unit Research and Health Education Division. September 2012. 10) Heat related deaths could rise from 2,000 to 12,000 a year by the 2080s, health agency says. Torjesen, I. (2012). Bmj, 345, e6138. doi:10.1136. 11) Minnesota Dept. of Health. https://apps. health.state.mn.us/mndata/heat_ed. Accessed 8/2014. 12) Centers for Disease Control. http://www. cdc.gov/climateandhealth/default.htm). Accessed 8/2014. 13) Hurricane Katrina deaths, Louisiana, 2005. Brunkard, J., Namulanda, G., & Ratard, R. (2008). Disaster Medic Public Health Prep, 2(4), 215. doi:10.1097/ DMP.0b013e3181aaf55. 14) The association of disaster-related experiences and self-reported recollections of national trauma with posttraumatic stress disorder symptoms following Hurricane Sandy. Ben-Ezra, M., Palgi, Y., Hamama-Raz, Y., Rubin, J., & Goodwin, R. (2013). Journal of Clinical Psychiatry, 74(12), 1265-1266. doi:10.4088/ JCP.12/08535. 15) Lessons from Sandy-Preparing Health Systems for Future Disasters. Redlener, I and Reilly, M. NEJM 367:2269-71, 2012. 16) Electronic health records access during a disaster. Horahan, K., Morchel, H., Raheem, M., & Stevens, L. (2014). Online Journal of Public Health Informatics, 5(3), 232. doi:10.5210/oiphi.v5i3.4826.

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2014 Charles Bolles Bolles-Rogers Award Recipient—Michael B. Belzer, M.D.

ichael B. Belzer, M.D. has had a 35 year distinguished history of senior leadership at Hennepin County Medical Center and is only the third ever medical director in the history of HCMC. He has served as HCMC’s Medical Director and Chief Medical Officer since 1990. In addition, he has demonstrated over 24 years of commitment to bringing a voice and services to the underserved, vulnerable, and disadvantaged in our community at the Hennepin County Board, Minnesota State Legislature, and Federal level. He also serves as Medical Director for Hennepin County’s Community Health Department and Associate Dean for the University of Minnesota Medical School. Dr. Belzer has been an active participant in the Twin Cities Medical Society (formerly West Metro Medical Society), serving as its President-Elect, President and Board Chair (2002-2004) where he was instrumental in advocating for the state smoking ban in restaurants and bars. He has held numerous other committee appointments at TCMS and at the Minnesota Medical Association, including serving on the MMA Health Reform Task Force. Other significant leadership positions include: National Association of Public Hospitals, chairman of the Board of Directors of Hospice of the Twin Cities, founder and multiple-time chair of the Metro Minnesota Council of Graduate Medical Education, representing the major University of Minnesota teaching hospitals, and he served for nine years on MetroDoctors

the Board of Minnesota Visiting Nurse Agency. Dr. Belzer is a recognized physician leader, a mentor with a dedicated commitment to medical education and an

The Journal of the Twin Cities Medical Society

advocate for the vulnerable and underserved. The West Metro Medical Foundation is honored to award him the Charles Bolles Bolles-Rogers Award.

Edwin Bogonko, M.D., TCMS past president, (right) presents Michael Belzer, M.D. with the Charles Bolles Bolles-Rogers Award.

Medical Staff: Hennepin County Medical Center Medical School: University of Minnesota, Minneapolis, MN 1974 Residency: University of North Carolina Memorial Hospital, Chapel Hill, NC Fellowship: University of California School of Medicine, Los Angeles, CA Board Certification: Internal Medicine, Hematology, Medical Oncology

January/February 2015

April 16 is National Healthcare Decisions Day. Now in its 8th year, this national observance promotes awareness of Advance Care Planning in a variety of ways, and in Minnesota we are expanding the day into an entire week!

April 11-18, 2015 will be Minnesota Healthcare Decisions Week Planned events include: • First Annual Honoring Choices Run/Walk for the Talk 5K race Saturday, April 18 • Free information nights at libraries and other public venues throughout the Twin Cities • Lunch-n-Learn sessions at local businesses and nonprofits • Radio and Television features • Media coverage and Social Media campaigns • Promotional kits shared with clinics, hospitals and other healthcare centers for individualized use

Get in on the action! 2015 NHDD events are sponsored by Twin Cities Medical Society and Honoring Choices Minnesota. You can explore ways to be involved on the Twin Cities Medical Society website (www.metrodoctors.com) — follow links to download posters to display in your lobby and patient rooms, flyers to share with your staff and patients, cards to distribute or mail to your contact lists, and registration information about the 5K race. We’ll happily personalize the information with your logo or site information. You can also request a guest speaker to come to your site to talk about Advance Care Planning at no charge.

NHDD provides an easy way to introduce Advance Care Planning to your practice during a time when national attention will be focused on the topic. Contact us at info@honoringchoices.org or by calling 612-362-3704 for more information.

January/February 2015

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Honoring Choices Expands Nationwide The concept of thinking small is a foreign one for Honoring Choices and the Twin Cities Medical Society. Nine states/regions have now joined our large-scale Advance Care Planning (ACP) framework — we’ve reached 20 percent of the United States! Wisconsin Massachusetts Florida Napa Valley Virginia

Pacific Northwest (Washington and Oregon) North Dakota Hawaii As members of the Honoring Choices National Network, each of these regions have chosen to partner with Honoring Choices Minnesota. The Minnesota office offers technical assistance, shared materials, educational resources and design/implementation strategies so no one has to “recreate the wheel.” New quarterly Honoring Choices national conference calls now connect ACP leaders of these partner states, plus there is an emerging HCM LinkedIn National Network. State/regional ACP directors and staff can now talk together, share together, and learn together. Isn’t that what collaboration’s all about? Barbara Greene, Director of Community Engagement Karen Peterson, Director of Program Operations

TCMS and MMA Host EBOLA Educational Forum

CMS and MMA convened an educational event on Ebola on November 18 at the University of Minnesota’s St. Paul Campus with roughly 100 people participating from all over the state. Speakers included: Aaron DeVries, M.D., MPH, medical director of disease epidemiology for MDH; Wendy Slattery, M.D., medical director of infection control for Allina Health; and John Hick, M.D., medical director for emergency preparedness at Hennepin County Medical Center. The event was moderated by Peter Bornstein, M.D., epidemiologist from HealthEast. The evening was kicked off by TCMS President, Lisa Mattson, M.D. Additional sponsors included: Allina Health, HealthEast Care System, Fairview, HealthPartners, Hennepin County Medical Center, Maple Grove Hospital, Minnesota Department of Health, Minnesota Hospital Association, North Memorial Health Care and University of Minnesota Health. MetroDoctors

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Ebola speaker panelists: from L: Wendolyn Slattery, M.D.; Peter Bornstein, M.D., moderator; Aaron DeVries, M.D., MPH; John Hick, M.D.; and Lisa Mattson, M.D., TCMS President.

January/February 2015

Senior Physicians Association News

hirty-five senior physicians gathered for a presentation on October 28, 2014 by David J. Satin, M.D., Compliance Officer and Risk Management Leader, Department of Family Medicine and Community Health, Faculty Advisory and ECM Co-Director, University of Minnesota Medical School. His enlightening comments were focused on “Postmodern Medicine—2000+.”

Outgoing and Incoming Members of the Senior Physicians Association Executive Committee: Left: Hugh Edmonson, M.D., At-Large Member 2012-14; Richard Woellner, M.D., At-Large Member 2013-2015; Flora MacCafferty, M.D., 2013 President; A. Stuart Hanson, M.D., 2015 President; Miriam McCreary, M.D., At-Large Member 2015-2017; and Robert Geist, M.D., 2014 President. Missing from photo: Marilyn Joseph, M.D., 2015 President-Elect, and At-Large Members: Peter Boardman, M.D., 2013-15; Irv Lerner, M.D., 2015-2017 and Martin Lipschultz, M.D., 2015-2017.

Upcoming 2015 events:

May Luncheon event with a presentation by David Willoughby from Clearway Minnesota on tobacco control in Minnesota. Annual event in July with a presentation by Susan Leaf on her book about Dr. Thomas Roberts, The Man Who Loved Birds.

Visit TCMS at www.metrodoctors.com

Watch for email updates! 28

January/February 2015

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In Memoriam

New Members

Mark J. Fallen, M.D. Urology Associates, Ltd. Urology Jamie K. Flohr, M.D. Midwest Ear, Nose & Throat Specialists Otolaryngology Karla J. Hansen, M.D. South Lake Pediatrics Pediatrics Patrick B. Herson, M.D. Fairview Health Services Family Medicine

RICHARD MATUS, M.D., passed away on November 15, 2014. Dr. Matus attended the University of Minnesota Medical School and was a pediatrician at St. Paul Children’s Hospital. Dr. Matus became a member in 1966. THEODORE PAPERMASTER, M.D., passed away at the age of 100 on November 10, 2014. Dr. Papermaster graduated from the University of Minnesota Medical School and was a pediatrician in Minneapolis for many years. Dr. Papermaster became a member in 1994. WILLIAM J. PAULE, M.D., passed away on November 4, 2014. Dr. Paule attended Yale Medical School, and completed his residency at Minneapolis General Hospital in internal medicine. Dr. Paule practiced at Abbott Northwestern for 40 years. Dr. Paule became a member in 1960. GLEN C. PFISTER, M.D., age 57, passed away on October 19, 2014. Dr. Pfister graduated from the University of Minnesota Medical School specializing in pediatrics. Dr. Pfister became a member in 1998. MARY KAY TUOHY, M.D., passed away on September 24, 2014 at the age of 61. Dr. Tuohy graduated from the University of Minnesota Medical School and practiced family medicine. Dr. Tuohy became a member in 1997.

Brian H. Johns, M.D. North Memorial Medical Center Psychiatry

CAREER OPPORTUNITIES

Nathalie L. Lechault, M.D. South Lake Pediatrics Pediatrics Janet Rasmussen Vraa, M.D. South Lake Pediatrics Pediatrics Bruce D. Snyder, M.D. HealthPartners – Riverside Neurology

See Additional Career Opportunities on page 30.

Here to care Join a primary care team where you can build your practice, grow in your profession and partner with those who share your passion.

Peter A. Stiles, M.D. TRIA Orthopedics Center Anesthesiology

At Allina Health, our care model focuses on the relationship between physicians and patients, so you can focus on what really matters.

Karin M. Tansek, M.D. Oakdale Ear, Nose and Throat Clinic, P.A. Otolaryngology

Make a difference. Join our primary care team.

Jason G. Young, M.D. South Lake Pediatrics Pediatrics

1-800-248-4921 (toll-free) recruit@allina.com

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allinahealth.org/careers

January/February 2015

Christy M. Boraas, M.D., MPH Planned Parenthood Obstetrics and Gynecology

DAVID J. BURAN, M.D., passed away on October 10, 2014. Dr. Buran graduated from George Washington School of Medicine. He specialized in otolaryngology and was an earnose-throat surgeon at Park Nicollet for 34 years. Dr. Buran became a member in 1967.

CAREER OPPORTUNITIES

Please also visit www.metrodoctors.com

Fairview Health Services Opportunities to fit your life

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

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January/February 2015

LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.

STEVEN MILES, M.D.

WHEN STEVEN MILES GRADUATED from medical school

in the mid-70s, as with all such young physicians, many future professional options were available. His choices made then and later were varied and distinct, and the reasons of how he came to choose them were even more unique. Dr. Miles grew up in the Twin Cities, earning B.A. and M.D. degrees from St. Olaf College and our U of M Medical School. His post-graduate internal medicine training was at HCMC where he served as Chief Medical Resident. As a youth, largely because of his father’s technical, political and international occupational activities, he was exposed to an amazing array of accomplished and well known individuals including Vice Presidents Humphrey and Mondale, Representative Don Fraser, rocket scientist Wernher Von Braun, and Mayor Arthur Naftalin. Steve describes those early experiences as providing him with a “window to the world,” and through it he developed a profound appreciation of diverse human conditions related to geography, gender and age. As a new physician, he shouldered responsibilities inherent in caring for his dying grandfather — further stimulating his acquisition of knowledge in the practical care of the aged and their accompanying end-of-life issues. Steve’s early professional travels through S.E. Asia developed his interest in many aspects of tropical medicine, nutrition and societal matters related to human suffering in oppressed societies. All of the above experiences, and more, led Dr. Miles to his current station in life as the Endowed Chair at his alma mater’s Center for Bioethics and a Professorship in the Department of Medicine. Along the way, various stops and pathways for this internist, hospitalist, geriatrician and bioethicist have included staff, board and faculty positions with the Centers on Aging, Advanced Feminist Studies, and Victims of Torture; the U of M Law School; the University of Chicago and the American Refugee Committee — for whom he served as its Chief Medical Officer and Medical Director for 25 years. One of his first medical articles was published in the 1982 Annals of Internal Medicine with colleagues, Drs. Ron Cranford and Al Schultz — “The Do-Not-Resuscitate Order in a Teaching Hospital.” There followed his authoring of some 200 other articles, over 20 chapters and four books on topics 32

January/February 2015

ranging from the conception and utilization of an effective short course of tuberculosis therapy to human rights, torture and a modern vernacular version of the Hippocratic Oath. Dr. Miles Photo by Tom Roster served as President of the American Society of Bioethics and Humanities, from whom he was presented with their prestigious Distinguished Service Award. Many additional honors, too numerous to relate, have been bestowed on this modest, soft spoken and highly productive physician. Steve’s interest in health care reform contributed to his candidacy for the office of U.S. Senator in the year 2000. He described that run for office as “a great experience” despite it being a losing effort. His work on a national health care proposal in the 90s probably contributed to later development of the current Affordable Care Act. Family activity has played a central role in his life, and the adoption to his nuclear family of two additional young members with special needs speaks to that important commitment. Dr. Miles’ legacy should reach beyond the many specific contributions of his professional and personal life. Rather, that legacy will surely encompass an overarching commitment to make a difference by simply going about the business of using his talents and experiences for the benefit of others. We have a suspicion that there will be much more to come from our energetic and dedicated Luminary of Twin Cities Medicine.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

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