2001marchapril by Advocates for Better Health

March/April 2001

o N

y c n a c a V Is DEMAND outpacing dollars and manpower?

Design

Quality

Performance

Value

Selection

Ergonomic Assessments

For more details contact your US Office Products’ Account Executive: Gary Petro Phone: 651-639-4757 or Fax: 651-639-4747 Upper Midwest District, Inc. 2050 Old Highway 8 NW New Brighton, MN 55112 MetroDoctors The Journal of the Hennepin and Ramsey Medical Societies

Endorsed by Ramsey Medical Society

January/February 2001

Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. 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 HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. E-mail: nbauer@mnmed.org. For advertising rates and space reservations, contact Dustin J. Rossow, 4200 Parklawn Ave., #103, Edina, MN 55435; phone: (612) 2377363; fax: (612) 831-3260; e-mail: djrossow@aol.com. MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available.

CONTENTS VOLUME 3, NO. 2

MARCH/APRIL 2001

PHYSICIAN’S SOAP BOX

Managed Care System Beyond Repair

FEATURE: WORKER SHORTAGE

Where Have all the Doctors Gone?

No Room in the Inn

Twin Cities Area Hospitals Facing a Capacity Crunch

COLLEAGUE INTERVIEW

Paul F. Bowlin, M.D.

Blazing New Trails — Reclaiming Independence and Self-Reliance

Shortage of Health Professionals Challenges Health Care Delivery System

Medical School Applicants on the Decline

Fostering Medical Students

CME Conference: Abusive Behavior in the Medical Workplace

RAMSEY MEDICAL SOCIETY

24 25 26 27

President’s Message RMS Annual Meeting Applicants for Membership RMS Alliance

March/April 2001

Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Richard J. Morris, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Manager Dustin J. Rossow Cover Design by Susan Reed

HENNEPIN MEDICAL SOCIETY

29 30 31 32

Chair’s Report HMS In Action HMS News/Hoban Scholars/In Memoriam HMS Alliance

y anc c a No V Is DEMAND outpacing dollars and manpower?

On the cover: The Twin Cities are facing a shortage of medical workers. Articles begin on page 4. (Photo: © Pulschen/Custom Medical Stock Photo.)

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The Journal of the Hennepin and Ramsey Medical Societies

March/April 2001

PHYSICIAN'S SOAP BOX

Managed Care System Beyond Repair

Editor’s Note: An earlier version of this editorial was published in The Saint Paul Pioneer Press Tuesday, December 26, 2000:17A.

HEALTH CARE WAS A MAJOR ISSUE in the recent election.

Candidates leveled various degrees of criticism against the current Managed Care/Health Maintenance Organization system. Few defended it. Why? And what happens next? HMOs have failed in their promises to control costs and deliver quality care. Employers experience double-digit price increases to insure employee health benefits. Families complain about the lack of patient focused care. The HMO system was created in 1973 as it promised to control a rapid rise in medical cost-price inflation. What triggered this inflation? The first step toward inflation was taken in 1943. The Wage Controls Board found a way to raise worker pay despite the World War II wage freeze; tax-free dollars could be added to a paycheck if the money was used for health care insurance—fringe benefits were born. With the real price of quality medical goods and services hidden, inflation developed with the increased demand for more and better care. The inflation was funded in part by transfer of money into medicine from other vital segments of the economy. In 1965, demand inflation was further stimulated by Medicare and Medicaid legislation. Although this piecemeal approach to American style National Health Insurance meant that the majority of citizens had tax-subsidized coverage, the near poor must still fend for themselves. By 1973, policy makers and legislators thought it politically impossible to take away the popular tax subsidies driving inflation. Instead, they turned to HMO power for rationing the supplies of care available to the client populations of the ‘buyers of care’ in industry and government. All were led to believe that HMO corporations, driven by profit motives to keep people healthy, would more wisely spend insurance dollars than could Americans themselves. The impossible promise of the HMO Act of 1973 was to meet the conflicting goals of quality and open access to care on a fixed budget. It has not worked. Certain basic flaws have caused failure of the HMO system, a system which functions by means of corporate command and control networks. One flaw is that “health maintenance” was never more than a

B Y R O B E R T W. G E I S T, M . D .

March/April 2001

slogan since there are no medical means to keep a large population healthy comparable to public heath measures. But the chief flaw has been that managers must invoke their own wisdom for allocation of resources since they lack the accurate and prompt information available in any other industry where spending by thousands or millions of consumers is guided by prices. Yergin and Stanislaw (in The Commanding Heights, 1998) noted that the same lack of market information from consumer spending resulted in the collapse of the nationalized command and control industrial networks in Western Europe. By 1980, these planned industries suffered from inflation, poor quality products, erosion of infrastructure, and enlarging bureaucracies in futile attempts to solve their problems with even more planning. The inherent inefficiencies of these economically blind bureaucracies created a relentless need for subsidies despite the efforts of good and wellmeaning managers. There is no real remedy for these inept authoritarian command and control structures. It is curious that policy makers now routinely deplore authoritarian command and control structures for any industry but continue to support them for rationing medical care. Meanwhile, the practical response of HMO industry managers has been to protect their corporate treasuries. Many strategies are used. These include queuing (delay or denial of patient care), selling policies to only the healthy and wealthy, raising premium prices while they can to subsidize their weighty bureaucracies, and transferring financial risk of insuring care to clinics. A sign reported to hang in one Medicaid HMO on the West Coast reads, “Cost, access, quality — pick any two.” It is no wonder that the HMO system has generated public concern and caught the attention of political candidates. What’s next? One proposal would transfer power from HMOs to government using a single payer system, such as in Canada. This would ration care by fixing the supplies as well as prices for producing services based on the wisdom of planners and policy makers. Meanwhile, the current policy and practice of U.S. federal and state “single payers” is to entice the Medicare population and to force the less powerful Medicaid population into HMOs in order to ration their care. In contrast, private insurance proposals aim to return choice and financial power to people by having them retain their own money to insure health care. Advocates believe that all people, employed or not, should be eligible, and note that “job lock” from fear of losing health insurance would be eliminated. These proposals would make people price sensitive for ordinary medical expenses, fully cover major expenses, MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

and, theoretically, could be expanded into cost-effective health insurance for all Americans. Tax credit proposals would have the government return or give money, on an income related basis, directly to individuals for buying insurance. Support for this type of tax credit might prove politically difficult, since it would eliminate the current popular employer-based system of insuring health care. Medical Savings Accounts (MSAs) coupled with a major medical insurance policy would put about 40 percent of health care dollars into an individual’s own bank account for ordinary expenses such as office visits, laboratory tests, prescription drugs, and so forth. The other 60 percent would pay for the associated major medical policy. The average MSA family spends only 30 percent of the dollars from their savings account each year and can invest the rest for future health care needs.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

For this reason, MSAs are often called “medical IRAs.” Major medical/ MSA policies have the same tax advantage now enjoyed by HMOs, but severe congressional restrictions have made MSA policies almost unmarketable. Will our newly elected political leaders find a way to replace the failed HMO system of manager and policy-maker sovereigns rationing care? Will people, with the power of using their own money to purchase medical care, again be kings in the medical marketplace? It is not a sure thing. That’s why political leaders need a loud and clear message from the American people to find the best system—one for the benefit of patients. ✦ Robert W. Geist, M.D. is a retired urologist, residing in North Oaks, MN.

March/April 2001

FEATURE STORY

Where Have all

Worker Shortage the Doctors Gone?

Although the hospital staffing crisis has been well known, from nurses to pharmacists to social workers to therapists of all stripes (administrators, too?), little has been expressed about a physician shortage.

Introduction The SPIDA Experience Worker shortages are no surprise during a booming economy. Many physicians have experienced frustration when attempting to admit patients to a hospital, only to be told “There are no beds.” Actually, there are often physical beds, but no staff for those beds. Although the hospital staffing crisis has been well known, from nurses to pharmacists to social workers to therapists of all stripes (administrators, too?), little has been expressed about a physician shortage. At our practice, St. Paul Infectious Disease Associates, Ltd., (SPIDA) we have been looking for a new physician for over two years. Although we briefly had a new physician in the summer, this California import, with no ties to Minnesota, soon left to return to his wife in Orange County. Although we have interviewed many fine applicants, none had a Minnesota connection. The effect of our physician shortage has been a change in the nature of our practice. Gone is the in-office IV infusion business, a victim of low margins reimbursed to us by the few insurance companies that would pay for this service. Closed is the highly commended Travel Medicine service. Our low reimbursement from insurance companies, and time-intensive nature of high-quality pre-travel counseling meant little return for this business. Additionally, our appointments ballooned to a five to seven week waiting period for new referrals. Because we became so busy doing only what we could do, infectious disease consultations, we gave up most of our invasive procedures, such as lumbar punctures and central venous catheters to the radiologists and nurse-staffed PICC line services. We now only schedule patients sent from other physicians — no “walk-ins” or unreferred patients. As our services have become more proscribed, we are more dependent on reimbursement from patient services to pay our salary and that of any new hires. It should come as no surprise that it is difficult to offer a nationally competitive salary based on local reimbursement.

What is the Effect of the Problem? Longer Wait Times for Appointments As fewer physicians are available, waits for non-emergent appointments become longer. Physicians and surgeons will continue to triage important cases. For some hospitals, this has meant more “off-hour” surgeries and procedures, as overloaded surgeons push more cases to the end of the day. BY PETER BORNSTEIN, M.D.

March/April 2001

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The Journal of the Hennepin and Ramsey Medical Societies

More Physician Practices Closed to New Patients In St. Paul, as the number of retiring internists exceeds the number of new internists, it becomes more difficult to find an internist open to new patients. While many family practitioners are capable of handling complex and geriatric patients, this is an area in which internists have been especially trained. Fewer internists available means more patients being sent to medical sub-specialists for management of problems previously handled by the general internist. Some internists have closed their practice to new Medicare patients. This helps them bring the age of their patient panel downward, and perhaps increase their income and ease their workload. Hospitals Having Trouble Retaining Physicians for Staff As seen at the recent opening of Woodwinds Campus in Woodbury, there is increasing reluctance of already overextended physicians and surgeons to travel to a new hospital, even one as beautiful as Woodwinds. Few specialist physicians are hungry enough to add an hour of driving time to see a handful of patients, unless they already live in the Woodbury area. More Difficulty With Continuity of Care Much has been written about the rise of hospitalists, and their effect on continuity of care of the patients. Yet, for already overextended primary care specialists, the time spent caring for ever-sicker hospitalized patients draws them away from their busy clinics. Hospitalist services make it easier for these primary care physicians to stay at their clinics. For busy hospitals, this means physicians that are more facile at manipulating the hospital systems to get the patients out faster. The effect on specialty groups has been different. Busy specialists have also transformed their physicians into hospital-based physicians, in order to increase their efficiency in caring for their heavy loads. The most striking example I have observed is in cardiology services, where a patient may have separate cardiologists who manage their care on the wards, read their echocardiogram, do a transesophageal echocardiogram (if indicated), perform cardiac catheterization, and, if necessary, place a pacemaker or defibrillator. No wonder the patients and I donâ&#x20AC;&#x2122;t know who their cardiologist is!

Fewer internists available means more patients being sent to medical sub-specialists for management of problems previously handled by the general internist.

(Continued on page 6)

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March/April 2001

(Continued from page 5)

The Genesis of the Problem When trying to attract new physicians, the problems we have can be summarized as: no pay, no weather, and nobody in training. Relatively Lower Pay I won’t delve into this area too deeply. Much has been written elsewhere about all the reasons pay is lower for many physicians in the Twin Cities than in other comparably sized and expensive cities. The list of reasons is long: Medicare reimbursement rates, penetration of managed care, MinnesotaCare provider tax, etc. It is fair to note, however, that there are some areas of the country, such as California, where things may be even worse than here. Reduced Training Many specialists in St. Paul have expressed to me the deficit in trainees in their specialty at the University of Minnesota. Several different medical specialists tell me the retirement rate exceeds the training rate for their discipline. For example, the University has not graduated a trainee in infectious diseases in over three years. No doubt, some of this is due to a nationally orchestrated attempt to reduce the number of specialist physicians begun over 10 years ago. However, national strategies can have deleterious effects on local conditions. Most subspecialty trainees are at major academic metropolitan areas of New York, Chicago, San Francisco and Boston. If, by the time they are in their early thirties, they have already established roots in their communities, it is a high barrier to bring them to another community. Fewer FTE’s? Are there fewer physicians, physicians working less strenuously, or some just plain working less? The answer is all of the above. In addition to fewer specialists coming into 6

March/April 2001

training, many primary care physicians are looking at “total lifestyle” — time with the family, other avocations — as being as important as the practice of medicine. This is not necessarily a bad thing, but something to be worked into the equation. The entrance of women into medicine, and indeed all aspects of American professional life, has also changed practice patterns. It is too simplistic to look at only the fact that female physicians are more likely to take time away from practice to care for their families. Male physicians with professional wives also need to spend more time taking care of their families than when women stayed home alone. Some male physicians may also choose to relinquish the practice of medicine while their better-paid spouses provide more for their family unit than the male physician spouse could. Earlier Retirements Let’s face it. Despite the troubles with the stock market at the end of 2000, we have just finished the longest economic growth period in American history, and one of the longest Bull Runs on Wall Street as well. For many older physicians, these events have accelerated the growth of their retirement portfolios, and making feasible an earlier retirement. This phenomenon is not isolated to physicians, as many teachers and other professionals are faced with similar happy circumstances.

south of a line stretching from Boise to Denver to Chicago to Cincinnati to Philadelphia, surviving and enjoying a Minnesota winter is inconceivable. Even my mother, born and raised in Chicago, exclaimed to me when I told her I was moving to St. Paul said, “What do they do up there in the winter, sit around in their houses?” As much of the U.S. population grows up in the south, it is difficult to convince them to move north. What to Expect if Nothing Changes Continued Exacerbation of Problem Unless changes occur, I would expect to see continued slow progression of the problems we are already dealing with. The impending demographic tsunami of seniors means more people requiring cardiovascular, oncologic and orthopedic care. As physicians become more stressed, and unable to hire help, they will choose to limit the services they provide to those that are either most required to save lives or increase their income. Follow-up appointments will be curtailed. This will mean more delays of therapy, and perhaps lives lost, as patients wait to see physicians.

Practice Stress Again, this is an area of which much has been written, and I will not recapitulate it here. This is a popular essay topic in Medical Economics. Additional practice stress and uncertainty does all the more to press the older physicians to early retirement.

Physicians Dropping out of Managed Care Plans, Perhaps Medicare As physicians and surgeons find themselves with more work to do, it will be easier to drop the lowest paying plans. Currently, for most practices, the lowest payors are also those with the largest panels of patients—Medicare, Blue Cross, Medica and HealthPartners. While size matters, if some practices are 20 to 30 percent too busy, it will be easier to relinquish the lowest paying group, no matter how large. Even Medicare is not off the table.

Minnesota Weather The price of a perfect Minnesota summer is six months of winter. For most people

Referral of Non-Urgent Cases to Other Localities If physicians are too busy, and booked out

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

too far ahead, it may become necessary to send non-urgent cases out of town for care. No doubt this occurs already for some specialized care, especially cancer surgery. Perhaps it will also occur with other less specialized cares. Remedies for the Situation Increase Pay Of course, more money would certainly help, from a basic economic standpoint. But with a limited supply of healthcare dollars, physicians join other providers at the table. “Get it done in 2001” buttons are appearing on nurses around the Twin Cities, reflecting their determination for higher pay in their new contract negotiations. I suspect many physicians will be sympathetic to their position. A popular sentiment among physicians is to demonize managed care administrators, especially when reading published reports of munificent consulting fees for plans of dubious value. While there exists a natural adversarial tension between physicians and administrators, it is important for physicians to realize the entire healthcare system in Minnesota is relatively underfunded. Physicians may also have to get aggressive about seeking income from non-patient care sources, which are not under tight restriction by Stark II laws. Other income sources may include direct consulting with industry and healthcare entities, increased medicolegal work, and office-based research for pharmaceutical and device manufacturers. Repealing the MinnesotaCare tax would be helpful, but alone would not be enough to keep physicians in practice. Increase Training in Minnesota and the Twin Cities Key groups or hospitals may have to subsidize training to ensure an adequate supply of practitioners. Partnering with the MetroDoctors

University of Minnesota is important, but it may be important for hospitals or large practices to look at other potential teaching institutions as well. An example is Henry Ford Hospital, Detroit, where I did my residency, which has academic affiliations with several centers, such as the University of Michigan, Ann Arbor and Case Western Reserve University, Cleveland. Minnesota would be better off being a net exporter of well-trained practitioners, than a net importer. The University of Minnesota should be strengthened by the legislature and community to increase training for physicians, pharmacists and nurses, as well as other allied health professionals. Although I have noticed general antipathy toward the University from many physicians, we all need a strong University as the best source for future practitioners. Increase Grassroots Lobbying About the Nature of Healthcare Provider Shortage Grassroots lobbying needs to start where good healthcare starts: the patient-physician relationship. Physicians need not be shy about talking with their patients and families about the problems facing healthcare providers. Most seniors have no idea that Medicare benefits differ from state to state, and that Minnesota is on the low end of the reimbursement scale. This is especially galling considering we pay the same Medicare tax rates as the high reimbursement states. The United States Congress determines Medicare reimbursement rates. I tell seniors who are frustrated to tell the congressional representatives what is happening to them. Most people also have no idea that physicians pay an extra tax to support MinnesotaCare. And when your patients cannot be admitted to the hospital in a timely fashion, do not blame a non-existent “bed shortage.” The real problem is that hospitals are understaffed. Don’t expect hospi-

The Journal of the Hennepin and Ramsey Medical Societies

tals or health plans to publicize the crises facing health care. Their public relations departments will not allow them to express any information that may undermine the confidence of the public in their institutions. Working More Closely With Managed Care Organizations and Hospitals Tighter integration with managed care information systems may increase physicians’ ability to obtain important healthcare information about their patients. I would certainly appreciate having more timely and accurate information when seeing patients referred from other physicians. Hospitals are spending a lot of time and money to upgrade their information management systems. Learn them. Learn how to use the computer. Most of these systems are designed to increase the speed and accuracy of information management. If these systems do not help you, then let the hospitals and health care systems know this is occurring. Global Warming Hey, warmer winters may not be that bad. When Florida is flooded by rising global tides, people will need to go somewhere. Closing That Which Doesn’t Kill Us Makes Us Stronger When this crisis ends, chances are physicians may be in a stronger position than now. There is no substitute for what physicians and surgeons do. A system that does not support us will notice when we are not able to take care of them. Hopefully, this support will come before too many lives are lost, and not after. ✦ Peter Bornstein, M.D., an infectious disease specialist, practices at St. Paul Infectious Disease Associates.

March/April 2001

No Room in the Inn

(NO ROOM IN THE INN and now the stable is full, so the poor little donkey has no place to go.) Recently, TV news programs, national magazines and even the Minneapolis Star Tribune featured stories on “Packed ERs Turning Away Ambulances” (Star Tribune, January 7, 2001). These stories, however, have not focused on the underlying problem creating the ambulance diversions. The problem is not too many individuals coming to the emergency room; rather it is a lack of available inpatient hospital beds. Unfortunately, we continue to have those who believe that if only people with non-emergency problems wouldn’t use ERs then the emergency departments would not be overcrowded. In fact, the recent Minnesota Public Radio discussion of this issue resulted in several individuals calling in stressing the view that if only patients with sore throats would go to their doctor instead of the ER, the problem would go away. Even U.S. Surgeon General David Satcher, M.D., in an article published in the October 14, 2000 Boston Globe, reported to have said that the only thing that will help the problem is to educate people not to go to the emergency room unless they really need to. The current problem of ambulance diversions in the Twin Cities is NOT related to people filling our emergency rooms with minor medical problems. While the emergency department remains a safety net for people who otherwise would not have access to care, this is not the reason that ambulances are diverted. Minor medical problems may fill up the emergency department waiting rooms, but it is the seriously ill patients who are filling up all of our emergency department beds.

B Y G . PAT R I C K L I L J A , M . D . , FACEP

March/April 2001

Patients are being held in emergency departments for long periods of time because there is not enough available staffed beds in the hospitals to admit the acutely ill and injured in our community. This is particularly true for critical care beds. There are a number of reasons for this ongoing problem. One is certainly the lack of adequate health care professionals such as RNs, X-ray techs, lab techs and others. It may also be a lack of individuals to clean rooms once patients are discharged so they are quickly ready for the next admit. We may be unable to discharge patients because there is not a place in the community, such as nursing homes, with available beds to which they can be safely discharged. Lastly, we must realize that the patients coming to our emergency rooms are sicker and older than they were ten years ago. This means that a greater percentage of ER patient admissions are to a critical care bed. When our emergency room beds become filled with sick patients waiting for admission, the logical thing from the hospital’s perspective is to try and diMetroDoctors

vert ambulances to other facilities since we cannot close our doors to those who walk in. The Twin Cities ER Medical Directors began realizing three or four years ago that hospitals were diverting ambulances with increasing frequency. While this was a new phenomenon in the Twin City area, it actually started occurring in other parts of the country much earlier. Today almost all major metropolitan areas in the United States are facing the same problem. Over the last two years the Hennepin County EMS Council has attempted to address this issue and recently noted that the number of ambulance diversions in the Twin Cities has increased on a monthly basis. In one situation, an ambulance was turned away from three hospitals before they finally were allowed to go to a fourth hospital. It was almost like the ambulance was driving from motel to motel hoping to find a sign outside that said “vacancy” rather than “full.” The east metro system also had similar concerns during this period of time and adopted a policy that only two hospitals in the East Metro EMS System could be closed at any one time. The Hennepin County EMS Council (West Metro EMS System) adopted a similar policy. While this policy helped for a period of time, as the number of diversions increased and the time hospitals wished to remain closed became longer, the EMS system once again became stressed. On November 1, 2000, the Hennepin County EMS System, that includes hospitals in Hennepin, Anoka, Carver and Scott Counties, adopted a new ambulance diversion policy. If hospitals felt they had reached maximum capacity they could request to close for a maximum of four hours. This would hopefully allow them to bring in additional resources to deal with the patients waiting for admission in the

The Journal of the Hennepin and Ramsey Medical Societies

emergency rooms. At the end of this period they would have to reopen for a minimum of four hours. In addition, only two hospitals in the system could be closed at any one given time assuring that patients would always have a facility to which they could be transported. Also, if the other hospitals in the system felt they were being totally overwhelmed, they could request that all hospitals in the system reopen for a minimum of four hours. It was also clarified that ambulances that were already en route to a hospital would continue to that hospital if the hospital decided to close during the transport period. Ambulance crews who felt they had a critical patient needing immediate emergency care could, in all cases, bring that patient to the closest emergency room even if they were closed. Finally, an Internet connection was established between all hospitals and ambulance dispatch points in the Twin Cities. A system called EMSystem was funded by a grant from the Metro Regional EMS Board, Minnesota Department of Health, and Hennepin County Community Health. This system allows all ambulance dispatchers and emergency departments to have computer access to the open and closed status of all hospitals in the greater Twin Cities area. In addition, hospitals can change their status from open to closed on-line. The system also keeps track of how long hospitals have been closed and notifies them when they have to reopen. Hopefully the system will provide data on the frequency and length of all hospital closures enabling us to better plan for the future. While we currently have a system for ambulance diversions that is working fairly well, it obviously creates other problems for physicians. Ambulances deliver patients to hospitals where their physician does not have privileges. This obviously destroys the continuity of care as well as making it difficult to access the patient’s medical records. It also means that physicians at the receiving hospital will be asked to care for patients that they are not familiar with and whom they know will not remain their patients once discharged. Most importantly, it does nothing to correct the underlying problem, which is lack of in-hospital bed capacity. The current diversion policy does not provide a remedy if all of the hospitals in the Twin Cities area are over capacMetroDoctors

ity at the same time. The plan at this point calls for all hospitals to remain open to all ambulances and the hospitals will have to figure out a way to take care of the patients as they keep coming in. In the long term, we must readjust our system to assure that we have the in-hospital capacity to adequately care for the acutely ill and

injured. If we do not, we will continue to face the problem of how patients needing acute medical care can find “room in the inn.” ✦ G. Patrick Lilja, M.D., FACEP, is medical director Emergency and Trauma Services, North Memorial Health Care. He is also medical director of North Memorial Medical Transportation.

Hospital Closing Summary Monthly Closings by Hospital (4th Quarter 1999) West Hospitals Abbott Northwestern Children’s – Mpls. Fairview Riverside Fairview Southdale Fairview U of M Hennepin County Mercy Methodist North Memorial Ridgeview St. Francis Unity MONTHLY TOTAL *

Oct. 2 0 1 0 1 4 1 3 1 0 0 6 19

Nov. 2 0 9 0 1 3 2 3 3 0 0 6 29

Dec. 5 0 0 8 10 2 5 8 12 1 0 17 68

East Hospitals Children’s – St. Paul Fairview Ridges Regions St. John’s St. Joseph’s United Woodwinds

MONTHLY TOTAL

Oct. 0 2 0 0 0 2 0

Nov. 0 0 0 0 0 2 0

Dec. 0 0 1 1 0 8 0

Number of days in month when MRCC required all west metro hospitals to open

Month Total Required Openings October 1 November 5 December 16 Total 22 * Table does not include multiple openings in a single day, and no system alerts were issued for East Metro Hospitals indicating they were required to open.

EMSystem Summary *

Monthly Closings by Hospital (4th Quarter 2000)

West Hospitals Abbott Northwestern Children’s – Mpls. Fairview Riverside Fairview Southdale Fairview U of M Hennepin County Mercy Methodist North Memorial Ridgeview St. Francis Unity MONTHLY TOTAL **

Oct. 18 0 1 3 20 28 2 9 13 0 1 7 102

Nov. 9 0 2 4 7 9 0 6 1 1 0 1 40

Number of days in month when MRCC required all west metro hospitals to open

***

Month October November December Total

The Journal of the Hennepin and Ramsey Medical Societies

Total Required Openings 11 3 4 23

Dec. 27 0 4 6 6 13 2 21 10 1 0 3 93

East Hospitals Children’s – St. Paul Fairview Ridges Regions St. John’s St. Joseph’s United Woodwinds

MONTHLY TOTAL

Oct. 0 4 8 10 9 9 0

Nov. 0 6 11 8 2 8 3

Dec. 0 4 4 12 2 6 0

The report does not count times when only labor/delivery was closed

In reviewing reports created by EMSystem that was implemented September 2000, multiple entries related to single closing events were noted. These were reported previously as separate closing events. Repeated events are likely due to users editing previous entries. This report counts only closing events that were followed by a period of time being open. ** The Hennepin County EMS System ambulance diversion policy was changed November 1, 2000. The revised policy states no more than two hospitals in the west metro area can be closed at one time. When the third hospital attempts to close, all west metro hospitals are required to open. *** Table does not include multiple openings in a single day, and no system alerts were issued for East Metro Hospitals indicating they were required to open.

March/April 2001

Twin Cities Area Hospitals Facing a Capacity Crunch

IT’S CRUNCH TIME for Twin Cities area hospitals. Like most other hospitals in the U.S., they are facing significant capacity issues. This article addresses the reasons for the capacity issues and what hospitals can do/are doing about it. The reasons for the capacity crunch are manifold: the looming “boomer bulge,” the rapidly shrinking number of people entering health care (especially nursing) professions, recent upswings in acuity and complexity of care, the beginning stages of “baby boomer” demand, etc. The impacts of this tightening capacity situation are obvious: more ambulance diverts, increased demand on ERs, and chronic staffing challenges. Needless to say, the increase in transfers, diverts and delayed admissions has resulted in increasingly frustrated physicians, nurses and patients. It’s a truly sobering situation. At a not-toodistant point, if robust solutions aren’t developed and implemented, patients may experience delays in scheduling of treatment and the financial viability of hospitals will be threatened. These solutions cannot be attained by hospitals acting alone. This article addresses the elements of the capacity crunch, what hospitals/healthcare systems are doing to ameliorate the situation — and why hospitals can’t provide long-term solutions by themselves.

Financially Fettered The irony is that even though area hospitals are operating at or near capacity, they aren’t benefiting financially. There are many reasons for this, chief among them being poor reimbursement from Medicare and Medicaid. HMOs are paying their costs, but just barely. The reimbursement issue is glaringly illustrated by the

BY ANN SCHRADER

March/April 2001

fact that Medicare and Medicaid combined pay only 80 percent of their patients’ incurred costs for care, while constituting almost 50 percent of hospital volume. Reimbursement might be less of an issue if Minnesota hospitals were for-profit businesses with high margins. Instead, hospitals here are low-margin, nonprofit entities. HealthEast’s hospitals make their margin on just 8 percent of their business — and they are experiencing their thinnest margins ever, further limiting already narrow options for reinvesting and retooling. Yet another financial squeeze stems from increased lengths-of-stay (LOS). Hospitals are typically paid per stay, not by how many days a patient is under hospital care. Therefore, hospitals lose money on any patient who stays beyond the allotted dollars for their particular diagnosis. Increasing LOSs are occurring for a variety of reasons, key among them the aging population and increased acuity. Physicians face ever-increasing pressures, making them less available in the hospitals, at a time when patients are presenting with more complex medical needs and are requiring more care coordination. Hence, some patients end up staying a day or two longer in the hospital. LOS is the classic financial Catch-22 for hospitals — increased staffing demands that result in increased expenses, combined with fixed payments for such patients, which results in decreased net margin. Divert Dilemma According to a recent StarTribune article, headlined “Packed ERs saying no to ambulances,” Twin cities-area hospitals went on divert status about 1,000 times last year. The article stated that the nationwide hospital crunch “has increasingly left (ER) patients backed up like planes waiting for takeoff during a storm,” and gave the impression that the safety of patients is beMetroDoctors

ing routinely jeopardized because of the increasing number of diverts. While the number of diverts has gotten uncomfortably high, the actual number of impacted ER patients is smaller than the article would lead one to conclude, for a couple of reasons. First, it has to be kept in mind that most ER patients never encounter a divert situation, because they don’t arrive by ambulance. In fact, more than 80 percent of ER patients are not brought to the hospital by ambulance. Second, even in cases where ambulances are diverted, these vehicles and their crews are, in essence, mobile intensive care units. So, few diverts become life-or-death situations. But when they do, the ambulance crew has the authority to override the divert, and take their patient to the nearest hospital. But what about the capacity situation generally? Isn’t it true that hospitals occasionally get so full that they can’t accommodate any more inpatients? Yes, this is happening, and it is of course a troubling trend. Long-Term Care Complications Because of the capacity crunch, long-term care facilities are being asked to take more patients, the rationale being that such facilities have often served a transition role for recuperating patients who don’t need all of the services involved with hospital care, but still need monitoring and medical attention. But this is not a viable strategy, for a number of reasons. First, long-term care facilities are even more impacted by the industry’s staffing shortages. A state legislative task force noted that $90 million dollars would need to be spent in the next two years to attract and retain workers. It’s not expected that the legislature will pony up the suggested amount. And as a recent Star Tribune editorial (“Action on long-term care needed this session,” The Journal of the Hennepin and Ramsey Medical Societies

January 22) noted, the future of long-term care is a huge question mark for reasons other than staffing shortages, among them facilities that “are aging into obsolescence.” The editorial noted that as many as a dozen long-term care facilities in Minnesota might close this year — taking them totally and permanently out of any “recuperating” strategy, even if such a strategy were otherwise viable. It also noted another of the task force’s key recommendations: The state should immediately start shifting away from having long-term care facilities as the centerpiece of its senior care policies. The long and the short of the task force’s recommendations is that long-term care would not be in any position in the future to serve an enhanced “recuperating” role to relieve pressure on hospital beds — quite the opposite. In fact, the existence of fewer nursing homes will exacerbate hospitals’ capacity problems not just by making fewer “recuperating” beds available, but by putting some nursing home patients back in hospital beds. This will only exacerbate LOS rates and make fewer beds available for other patients. Unless viable alternatives to nursing homes are created that can take the pressure off of hospital capacity, the cycle will only worsen. Fewer Nurses, But Patients Aplenty Ironically, just as the nation’s boomers start turning into seniors, the number of young people entering the nursing profession — and the number of people who are staying in the profession — is slowing markedly. The practical and perturbing effect is that, just as the need for more beds to handle the boomers and their medical needs is increasing, hospitals are being forced to staff fewer beds. How serious is this staffing shortage? In terms of both people and time, very serious indeed. According to some industry experts, the nursing shortage is an enduring one, threatening to last for the next 20+ years. University of Minnesota Medical School Dean Al Michael was quoted in a recent newspaper article to the effect that nursing schools are already having trouble filling their rosters. And with the average age of nurses in the Twin Cities metro area standing at 47, it’s not hard to see what the implications are when these folks reach retirement age — let alone the issues of early retirement, job changes, etc. Area hospital administrators are addressMetroDoctors

ing the shortage situation in a variety of ways. One tactic that’s being implemented is changing assignments and responsibilities among care staff, so that nursing time is more fully spent on those activities that require nursing expertise. HealthEast and other healthcare systems are also looking to other countries, such as the Philippines, to develop a pipeline of high-quality nurses and techs. But these are, for the most part — and by necessity — “make-do” efforts, which do not change the fact that the staffing shortage is a long-term phenomenon, and one that is not easily mitigated.

The most critical element necessary for hospitals to gain some breathing room is adequate reimbursement rates. Long-term, strategic efforts are underway. Among them is an East Metro workforce development task force, which is moving to increase the supply of RNs and pharmacy, radiology and lab techs. Local hospitals are also pushing for a collaboration among themselves, state and local governments and colleges to attract and educate talent for RN and tech positions. Countering The Capacity Crunch East Metro hospital administrators have begun work on minimizing the operational effects of the capacity crunch. Among the solutions being put in place are better bed management/ utilization plans, which include such aspects as earlier-in-the-day discharges. Physicians are also doing advance education of patients and families regarding discharge, to assure that when the patient gets discharged, he or she has someone at the ready to take them out of the hospital. Also, changes are being instituted in the way elective surgeries are scheduled, and hospitals are revisiting whether certain types of patients, who in the past have been routinely hospitalized, can be effectively taken care of in other ways. Still at question is whether we have the “right place, right time” solutions that operate systematically for the community. The Minne-

The Journal of the Hennepin and Ramsey Medical Societies

sota Hospital and Healthcare Partnership also has a working group that is focused on meeting capacity challenges. One very vital factor in easing the East Metro area’s capacity crunch is the new 70-bed hospital at Woodwinds Health Campus in Woodbury. Opened last August, this full-service hospital has surgical and intensive care capabilities, with comprehensive adult and pediatric emergency room services. With its ability to handle 2,000 emergency room patients a month, the hospital promises to be a significant and timely element in keeping down the number of diverts in the East Metro area, and dealing with the increasing number of moreacute patients. It will also provide critical bed capacity for handling short-term patient increases caused by such seasonal phenomena as flus. Conclusion As noted above, hospitals are giving intense attention and energy to solving capacity issues. These efforts — including doing everything in their power to make it easier for physicians to manage patient care in an effective, expedient manner — must continue unabated. But hospitals can’t solve the problem alone. The most critical element necessary for hospitals to gain some breathing room is adequate reimbursement rates. Simply put, the legislature and Congress need to “up” the Medicare and Medicaid payment rates to hospitals, so that these programs are actually covering the cost of care. On these and other health care finance issues, the standard behavior of state and federal governments has been an unwillingness to recognize or to respond appropriately to the true costs. It remains to be seen whether policymakers can effectuate a “sea change” in their mentality and their attendant resource allocations that will help enable hospitals to get ahead — and stay ahead — of the financial curve. Beyond obtaining better reimbursement, easing the capacity crunch will require the Ramsey and Hennepin Medical Societies and others representing the medical profession to partner with hospitals, medical transportation providers and policymakers to design a longterm solution that truly addresses the “right place, right time” cycle in a community-based system of care. ✦ Ann Schrader is Chief Operating Officer, HealthEast Care System. March/April 2001

COLLEAGUE INTERVIEW

Paul F. Bowlin, M.D. Editor’s Note: “Colleague Interview” provides HMS and RMS members with an opportunity to ask questions of their colleagues who are in unique roles. In this issue, interview questions were asked by Drs.: Bruce Adams, E. Duane Engstrom, William E. Jacott, Dennis Lee, William E. Petersen, Jamie Santilli, Richard K. Simmons, and Kent Wilson.

As a member of the University of Minnesota Admissions Committee for 10 years, were there any characteristics of applicants that you predicted would make them outstanding physicians?

This question addresses one of the greatest frustrations I experienced as a member of the Admissions Committee. We had no method of routine follow-up on students selected by the committee. It would be very helpful if the selection process had some statistical measures addressing such student outcomes as: medical school GPA, performance on national boards, residency choice, and finally, the student’s ultimate practice location. These correlations would require data sets extending out six to 10 years. Such correlations are not kept by the medical school. They should be. That said, the committee did use certain selection criteria. In my opinion the most important criteria beyond academic parameters, are evidence of strong internal motivation for medicine and evidence of a “caring” personality or attitude. These qualities may be ascertained by the applicant’s attempts to investigate medicine as a career, to participate in patient contacts in some fashion as well as information gained from the personal interview and recommendation letters. In the end, you must realize that the selection process has considerable unavoidable subjectivity to it. Overall, the committee has done an outstanding job of selecting applicants considering the meager follow-up information available.

Do you think there is, or will be, a physician shortage in Minnesota? What factors have contributed to a shortage and what may be done as a remedy? I have no current data to answer this question factually. My impression is that there may be physician shortages developing in certain specialties and sub specialties. However, I have no facts to back up this impression. As for potential future remedies vis-à-vis physician shortages, the answers are complex and multiple. 12

March/April 2001

Medicare and Medicaid payment schedules for Minnesota are so low that physician incomes are seriously impacted when compared with other parts of the country. We can train good physicians in Minnesota, but we cannot force them to practice in Minnesota when they can earn substantially more elsewhere. Our congressional delegation should insist on Medicare payment adjustments. It has been shown in published studies that applicants to medical school who come from rural communities have the greatest potential for returning to rural communities to practice medicine. Therefore, special consideration in the selection process might be given to rural applicants interested in family practice. Nominal increases in incoming class size might be considered. However, this would require cooperation from the state legislature in increasing the funding to the medical school. Is this a realistic expectation? On a more philosophic and futuristic note, I have recently read an interesting book by a Harvard Business School professor named Christiansen. It is entitled The Entrepreneurs Dilemma. In it he describes the rise and fall of certain well-run companies that have become victims of what Christiansen calls “disruptive technology.” He implies that the best candidate for disruptive technology in medicine would be the computerized medical record. The further implication of this being that such technology could open the door to wider use of lesser trained medical personnel, i.e., physician assistants, nurse practitioners and Pharm D’s; thereby decreasing the need for primary care physicians (read lower cost personnel). It is only a short leap from that construct to the assumption MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

that fewer physicians may be needed in the future! An interesting thought! The Christiansen book should be required reading for all physician leaders.

How can the University of Minnesota Medical School Admissions Committee increase the number of students who would have an interest in a rural primary care practice? A partial response to this question was posited in the previous answer, i.e., select more applicants from rural origins and you will probably have more trained primary care physicians returning to their rural roots to practice medicine. An additional aspect of the answer would be to emphasize and expand the RPAP (Rural Physician Associate Program) at the medical schools. This has been an effective recruitment tool for rural practice. A potential third answer to this question might be the newly developed foreign medical opportunities now being offered by the medical school. Third world medicine experiences have the potential of increasing student interest in primary care and secondarily in rural medicine.

Do you believe it necessary for a Vice President of Medical Affairs to continue practicing medicine in order to maintain credibility? The question refers to my six year stint as director of medical affairs at Fairview Southdale Hospital from 1986-1992. I have only my personal experience to relate to this question. In my case, it made no difference. But then I had been in practice in the community for almost 30 years, was well known by the staff of the hospital, and was asked by the staff leaders to take the position. A younger person with less time in practice or with no ready made medical staff relationships might find some continuing patient contacts necessary to maintain credibility with his/her peers. In other words it is dangerous to generalize in this area. Each situation must be judged on the multiple elements brought to the decision table.

What was the most rewarding experience as Vice President of Medical Affairs? My whole experience as director of Medical Affairs was rewarding for me. I have very warm feelings for the hospital, administration and its medical staff for the six years of working together. Two things stand out in my memory. The 1987-1990 period was a time when measurement of clinical quality of care rose to prominence. We began with a development of a quality department allied with a quality committee of the medical staff. It was a learning experience for all. The cooperation of the medical staff leaders and the hard work of the quality staff resulted in the gradual increase in number and accuracy of measurements and a demonstrable reduction in adverse clinical events in the hospital. The cooperation of the medical staff was remarkable. Interestingly, my closest mentor in this process was Harvey Golub, a member of the Southdale Hospital Board of Trustees and later the CEO of American Express. His insight into the MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

quality of care process was absolutely brilliant. The second memory I have is the remarkable cooperation from the medical staff leaders I received on the occasional need to mete out medical staff discipline. Discipline is a task to be avoided if at all possible. It may bring long term consequences for both parties yet, on the rare occasion when tough discipline was called for, the medical staff leaders performed admirably and the recipients of the discipline were better for it. A very rewarding record and memory.

How did you manage the tension inherent in a medical staff/hospital administrative relationship? This question recognizes the potential difficulties at the border of clinical practice and administrative necessities. As the complexities of hospital care increase, the potential for conflict at the edges increases. In truth, I experienced little difficulty with this. In administrative meetings I always represented the concerns of the medical staff. In medical staff meetings I tried to explain the hospital’s position. Two ploys helped: humor always lightens up a difficult or tense presentation. I used it liberally. Secondly, you always should be well prepared. Physicians respond to documentation, literature references, etc. So do hospital administrators. The only time the resolution of issues was not satisfactory was when I approached the subject matter in a too cavalier fashion. In other words, there are no simple issues only less complex ones.

You served on the Metropolitan Health Board—what was its charge? This question requires that I dredge up ancient history. It refers to my seven year stint on the Metropolitan Health Board from 1977-1984. There were only two physicians on this appointed body most of that time. This volunteer service was my first experience in health care politics. The Board was quite political. It had a monitoring and planning function vis-à-vis health care facilities in our seven county metro area. However, the Board’s major function was to implement the Certificate of Need (CON) legislation passed by the state legislature in the early seventies. This was a major public attempt via legislation to control the content, location, and mix of health care facilities in the name of cost control. All capital expenditures by health care entities over $250,000 were required to go through the CON process. The hearings were very contentious. The physicians and hospital members argued for market forces to control capital spending decisions while most board members opted for bureaucratic central planning. In 1980 and 1981 the board embarked on a four phased approach to close hospital beds and limit expenditures for the rapidly advancing technology such as CT scanners and MRI machines. This outraged the provider members of the Board and ultimately resulted in my submitting a carefully referenced minority report to the Board’s final hospital closing document. Almost incidentally, the state legislature came to the realization that the CON efforts were counter-productive in the health care (Continued on page 14)

March/April 2001

(Continued from page 13)

community. By 1985 and 1986 the Certificate of Need law was repealed. That was the end of attempts to control health care costs by centralized planning of capital expenditures. It just will not work.

Recently many hospitals in the metro area have required ambulances to drive to other facilities due to bed/staffing issues. Do you feel we are on the verge of a hospital health care crisis? What strategies should be used to prevent the continued diversion of patients to other facilities? Would these issues have been a role for the Metropolitan Health Board? Diversion of ambulances due to lack of available beds has been a periodic problem in our community for many years. The current economic realities dictate that we run a “lean” hospital system vis-à-vis beds. Insurers are loath to pay for “empty beds” or “moth balled beds.” This system courts disaster under a public health emergency scenario, i.e., bioterrorism, large chemical or radiation spills, etc. Our public health policy is relatively silent on this issue and public interest or money is not available to address the implications of such a bed shortage. If the ambulance diversions now occurring are due to hospital staff

shortages rather than bed unavailability this is a problem of considerable concern to me. I worry about the health and welfare of our colleagues in the nursing profession. Increased job stress, demand for longer hours, sicker patients to care for, and a general lack of respect for their efforts, all add up to lower recruitment, early retirements, and more competition from other industries for bright young people. This truly could be the beginning of a real crisis in hospital care. Prevention strategies will vary depending upon the cause. Medical staff triage policies, emergency room observation units, and rapid discharge plans have all been tried with varying success. On the staffing side of the issue, longer term efforts are needed to attract bright young people into nursing. A tough assignment in the face of competition from medicine, law, and high tech industries. We cannot escape the reality that healthcare is labor intensive, stressful, and requires highly trained, dedicated, altruistic individuals. Health care professions must be restructured to attract such people against the competition posed by other attractive vocations. My seven year experience on the Metropolitan Health Board leads me to opine that the Health Board would not be up to the task of solving the questions posed. The Metropolitan Health Board was a prime mover in reducing the number of hospital beds under the assumption that empty beds were non-productive and cost the system money. On the other hand, the Metropolitan Health Board could be a player in public health disaster planning in areas such as recruitment of nursing home beds, use of military facilities, and out of area evacuations etc.

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March/April 2001

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Can you give us your thoughts on the basic Hippocratic Oath and how this relates to the new economic forces physicians are subjected to in practice? This is a fascinating question — one I have thought about at some length. The Hippocratic Oath requires physicians to do what they feel is best for their patient and above all else not to harm the patient. The managed care environment asks the physician to interpose cost in his/her decision vis-àvis care of the patient. The tension inherent in this change of philosophy is obvious. In my opinion, cost considerations per se, in a physician’s decision making are not wrong or unethical. However, the process used to consider the cost implications of a specific decision may have anti-Hippocratic consequences. Examples that come to mind are: 1. Physician risk contracts that reduce physicians income if patient care costs exceed a predetermined level; 2. The threat of annual contract non-renewal solely on the determination that the physician’s practice is not cost-effective; 3. Denial and/or substitution of requested diagnostic tests based solely on computerized standard practice parameters with no exceptions; 4. Denial and/or substitution of prescribed drugs based on an established formulary with no exceptions; and 5. I’m sure the reader can name other egregious inroad on the Oath better than I. As the managed care systems have become more sophisticated and sensitive to patient and physician’s concerns, certain modifying processes have been developed that blur the anti-Hippocratic tenor of the relationship, i.e.: 1. Allowable exceptions in diagnostic testing and prescribing; 2. Appeal procedures; 3. “Opt out” clauses that allow individual patients to share in costs of non-formulary drugs or non-protocol tests; and 4. Attempts to measure overall patient’s severity or burden of illness in individual practices as a way of modifying financial penalties. The end result of all these machinations has been an overall decline in the quality of a physician’s practice environment due to: 1. The “hassle factor;” 2. Challenges to physician autonomy; 3. Increased non-productive time spent dealing with insurance matters; 4. Increased office overhead secondary to staff additions necessary to deal with managed care entities; 5. Decline in the quality of the doctor-patient relationship due to outside interference; and 6. Etc.

What are one or two conclusions you have reached after your career as a practicing physician, a public volunteer, and as a hospital Vice President of Medical Affairs? 1.

Physicians continue to be the most honest, ethical, caring, well-intentioned professionals in the world.

Please feel free to add any other thoughts or concerns you have about the profession of medicine. I have enjoyed answering these very well thought out questions. My thanks to my colleagues that posed them to me. This opportunity to make a few additional comments must be seized. To those colleagues who are discouraged about the current state of medicine and the practice environment I say, “Take Heart.” Medicine is still a wonderful profession filled with many satisfactions at the doctor-patient level. Yes medical practice is changing, but the essence of the doctor-patient relationship endures. The public needs us to work with and advise them as medicine evolves into a better system for both patients and those who provide care. Finally, I believe that the dysfunction in our health care system at its core is one of an abnormal funding/economic factors. Employment based health insurance has outlived its usefulness. Our society has the ability to insure all citizens at affordable base cost while preserving strong elements of user choice, tax deductibility, and public support of low income citizens. At this time our society lacks the political will to embark on the various experiments necessary to test the proposed changes. We should encourage those efforts as much as possible. Thank you for the opportunity to express myself on these very difficult issues. ✦

The one-on-one doctor-patient relationship still rules in medicine. It is the most effective means of improving health of individuals.

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The Journal of the Hennepin and Ramsey Medical Societies

March/April 2001

Blazing New Trails – Reclaiming Independence and Self-Reliance Editor’s Note: The following five physicians agreed to participate in this article exploring the reasons for leaving a group practice environment and the challenges/rewards of independent practice. The next issue of MetroDoctors will interview physicians making the move from independent to group practice. • David Gilbertson, D.O., family physician, St. Anthony Park Clinic, St. Paul, MN • Richard Morris, M.D., allergy, asthma and immunology, Allergy and Asthma Care, P.A., Maple Grove, MN (opening February 19) • T. Michael Tedford, M.D., otolaryngology, Ear, Nose & Throat Clinic and Hearing Center, Edina, MN • James Zavoral, M.D., preventive cardiology, Preventive Cardiology Institute, Edina, MN • Kimberly Anderson, M.D., internal medicine, Adult Medicine, St. Paul, MN

IT MAY NOT EQUATE TO THE settling of

the West but the unfolding story of metro doctors seeking independence and personal fulfillment is part of a great American tradition. I recently talked with five of them — some are well down the trail toward independence and others are just starting out. It was great to hear excitement and anticipation again in the voices of doctors — tempered of course with a healthy dose of apprehension.

Making the Decision to Choose Independence Doctors are choosing to go back to independent practices because they want to be responsible for their decisions again. They want to pracBY BOB THOMPSON

March/April 2001

tice styles of medicine that match their values and their patients’ expectations. I heard variations on this common story: I merged my practice into a big system. They told me I could continue to practice as I had. Later they said I was costing them too much money. I wasn’t meeting goals. Then they said they were going to close the office. That’s when I decided I had to get out.

“You have to get out when you believe your patients are not getting the kind of care you want to give them.” T. Michael Tedford, M.D.

I asked them why they felt a loss of enthusiasm and dedication after joining a systemowned group. “Our work turned into an eight to five routine,” lamented David Gilbertson, D.O. “The culture of large organizations is the product of compromise,” said Michael Tedford, M.D., adding: “They resist change, they miss opportunities.” Richard Morris, M.D. observed, “There may be some economies of scale but mostly their bigness just feels cumbersome, inefficient.”

MetroDoctors

Reporting to non-doctors bred dissatisfaction and damaged collegiality. As Gilbertson put it, “We stopped caring about each other under regimented business models and processes.” System executives “were not seen as accountable to doctors, their involvement felt more like interference than leadership” Morris asserted. How Practices Change After the Break When I asked about their return to independence, without hesitation they said: • I’m much happier and my patients can tell it. • I set my own pace and focus of my activities. • I decide how much time to spend with each patient. Operating at a human scale matters to these doctors. In smaller settings patients don’t have to navigate layers of bureaucracy to get to them. In independent groups, doctors have intimate knowledge of the business side of the practice and they bear the consequences of decisions. As Morris quipped, “I can make on-the-spot decisions — I don’t need a committee to make mistakes for me.” They learned they can survive after walking away from corporate medicine. “There was not nearly the competition for patients that I expected,” said Kim Anderson, M.D. “There are so many people out there looking for a more personal style and higher standard of care.” Anderson talked about an older patient willing to bear a much higher co-pay if he could stay with her. I asked her why conventional (HMO) wisdom maintains that patients aren’t loyal and they’ll switch plans and groups to save a few dollars. We wondered what happens to

The Journal of the Hennepin and Ramsey Medical Societies

the doctor-patient relationship when too many aspects of medicine are viewed through the lens of marketing and finance. Among the five I spoke to, none were sure how their incomes would fare over the next few years. Some said lower incomes are more a part of larger medical trends than any personal decisions about practice settings. While nobody expected to make big financial strides by going independent, being in control gave them a new sense of security. “At least I feel I can continue to practice medicine the way I want to and I didn’t feel that way before,” emphasized James Zavoral, M.D. Reasons to Consider Independence The right time to consider a change is when you feel it in your gut. The depth of emotion that drove these doctors out of systems and into independent practice was palpable. Tedford put it bluntly; “You have to get out when you believe your patients are not getting the kind of care you want to give them.” He continued, “When the culture is not consistent with your values and the compromises you’re making are not honestly acceptable, make a change.” “You have to practice a style of medicine that fits your values and your beliefs,” echoed Gilbertson.

Freedom and independence don’t mean going it alone. Morris felt that joining a network, in his case Minnesota Specialty Physicians, strengthened his resolve and eased the change. Tedford urged “Choose a knowledgeable, experienced consultant to help. Give yourself twice the lead time that you expect — and stay flexible.” The Future of Medical Practices After telling me their experiences and hopes, I asked them about future prospects for American medicine. Anderson recounted how one system medical director told her “doctors are at the bottom of the power chain now.” Gilbertson saw more of the older generation of doctors leaving medicine as soon as they could financially swing it. Morris’ pessimistic side saw “applicants to medical schools declining, an increasingly regimented health care system, and continued control by insurance companies and financiers.” His optimistic side saw “creativity coming back as more doctors are engaging in strategies to im-

Advice to Colleagues Considering Independence Almost uniformly everyone said, “go for it” while adding a few cautions. “Be clear about the type of practice you want,” Morris advised and then, “sleep on it a while, don’t act out of emotion, and talk to your family about how it will affect them.” Returning to independence is easier, Zavoral pointed out, “When you have loyal patients who appreciate a high quality and personal style of medicine.” You can’t take loyalty to the bank so “financial literacy about the business side of a practice is essential,” Gilbertson cautioned. He reminds colleagues that “having enough capital to make independent decisions is a great advantage.” Anderson added a warning born of experience, “Don’t take on a lot of overhead early on.”

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The Journal of the Hennepin and Ramsey Medical Societies

prove care and to make medicine a more rewarding profession.” Zavoral predicted new variations on feefor-service medicine would make a comeback. Gilbertson anticipated “Medical savings accounts will give patients the flexibility to buy the kind of care they want from whom they want, although HMOs and insurers will fight MSAs right to the end.” Tedford believes “Greater personal responsibility for the costs of care will stimulate patients to hold physicians directly accountable for services they provide.” For this group of doctors and all those others striking out on the trail to independence, they’ll be ready to satisfy the demand for medicine on a human scale. ✦ Bob Thompson is an independent hospital and physician consultant. Bob has worked across the U.S. enabling doctors, hospitals and hospital systems to improve their performance and regain a sense of purpose. He once worked for a large health care system in the Twin Cities. He can be reached at www.rthompson111@earthlink.net, or 952/ 929-7270.

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March/April 2001

Shortage of Health Professionals Challenges Health Care Delivery System

nesota to the national average of 3.1 pharmacy graduates per 100,000 people. It will ensure that Minnesota has sufficient pharmacists to play a larger role in patient care, managing drug therapies, and reducing medication errors.

OUR NATION IS EXPERIENCING a short-

age of health professionals, which is reflected here in Minnesota. What is at risk for Minnesotans is continued access to the quality of health care that we have come to expect and rely upon. The shortage is already challenging our health care delivery system. As our population ages, this shortage will become more acute, primarily because the increased demand will come at a time when a large number of health professionals are approaching retirement age. Currently, not enough younger workers are being trained to fill the projected gap. The workforce shortages are felt most dramatically in the areas of nursing, dentistry, pharmacy, and medical technology, but there’s also a shortage of rural physicians and specialty physicians, particularly in the areas of internal medicine, general surgery, pediatrics, obstetrics/gynecology, geriatrics, and cardiology. The University of Minnesota Academic Health Center is supporting a statewide effort involving MnSCU and Minnesota’s private colleges to solve the workforce problem. During the last year, the AHC has developed a vision with an overarching goal to prepare the new health professionals who improve the health of our communities, discover and deliver new treatments and cures, and strengthen the economic vitality of our health industries. Our vision is supported by our strategic plan, which includes a detailed approach to addressing the health care workforce shortages. That plan, however, is dependent on receiving funding from the Minnesota Legislature. Overall, the University of Minnesota is requesting $221.5 million from the Legislature over the next biennium, which includes $33.7 million for the AHC. The AHC request includes three primary components: BY FRANK B. CERRA, M.D.

March/April 2001

Core funding to close the gap between revenues and expenses in the Medical School. 2. An investment to rebuild the Medical School’s faculty. 3. An investment to address shortages in Minnesota’s health care workforce. Regarding the third item, we’re asking the state to provide $7.1 million to address workforce shortages in nursing, pharmacy, dentistry, and medical technology. That funding would be used for the following purposes: • The College of Pharmacy proposes to expand its enrollment by 50 percent beginning in fall 2002. This includes creating a site in Duluth for 50 students, who will complete three years of the program there. The fourth-year experiential clerkships for students will be provided at locations outside of the Twin Cities, including Duluth, St. Cloud, and Rochester. Today, there is already a critical shortage of pharmacists, with over 200 unfilled openings in Minnesota. That shortage is projected to grow as the population ages, and we increasingly rely on drugs for chronic health problems related to aging. An enrollment increase will bring Min-

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• The School of Nursing proposes to establish a satellite of its Bachelor of Science Nursing (BSN) program in Rochester by fall 2002. That program will be part of the University of Minnesota campus in Rochester, and a collaborative effort with Mayo Foundation and MnSCU. The joint effort will enroll a total of 60 students — 30 in the University’s BSN program, and 30 students in MnSCU programs at Winona and Mankato. This is a first step toward addressing statewide nursing shortages. Today in Minnesota, there are more than 1,700 openings for registered nurses, and 180 positions for nurses with specialty preparation, which reflects the national shortage of nurses. As health care shifts from hospital settings to the community and home, and as the state’s population ages, the demand for nursing care will continue to increase. • The Academic Health Center proposes establishing a satellite of its highly ranked medical technology program in Rochester, in collaboration with the MnSCU system and the Mayo Foundation as part of the development of the University of Minnesota campus in Rochester. The program would enroll 20 students each year. Currently, there are nearly 100 unfilled openings for medical technologists statewide, and Minnesota continues to have a shortage of these health care professionals despite the fact that there are three accredited medical technology programs in the state. Demand for medical technologists is accelerating with medical advances and the increasing complexity of diagnostic procedures.

The Journal of the Hennepin and Ramsey Medical Societies

• The School of Dentistry proposes establishing a new program designed to recruit and train dental professionals in rural communities, where the need is greatest. The request will fund a full-service, low-cost dental clinic in partnership with MnSCU and Hibbing Community College, and a second clinic in conjunction with the Otter Tail County Public Health Department. Under the plan, 20 percent of the school’s undergraduate dental and dental hygiene students and 12 of its graduate dental residents will serve clinical training rotations in one of the clinics. These students will provide services for 8,000 to 10,000 patients. School officials say that about 50 percent of students of such rural programs join existing rural practices upon graduation and that about 10 percent open new practices. Rural communities are already experiencing a shortage of dentists and dental hygienists. The shortage will become critical statewide as more than 21 percent of the state’s dentists are expected to retire in the next 10 years. Medical School Currently, there is a shortage of about 300 physicians in Minnesota. Included in the University of Minnesota legislative request is $16 million to stabilize our Medical School’s core funding. Since 1992, the cost of education in the Medical School has exceeded revenues because of reduced patient care fees. Many measures have been taken to offset the deficit, including selling the University’s hospital, streamlining operations, and raising tuition by 28 percent. In addition, the school lost 84 faculty positions and 86 staff positions because of market forces. The Medical School has used $67 million in cash reserves and endowments to cover shortfalls. Today, despite these efforts, a gap remains between revenues and expenses. In order to maintain current enrollments and provide primary care physicians and specialists for Minnesota, the Medical School is requesting this funding to stabilize its budget. Without these funds, the Medical School will be forced to cut core programs and enrollments. This will mean fewer doctors for Minnesota at a time when we need more doctors to care for our aging population. The Medical School is also seeking funds to hire additional clinician-scientists and re-establish its leadership in education, research, and patient care. Throughout our history, the Academic Health Center has prepared the health profes-

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sionals who care for Minnesotans when they are sick. Now our future — and the future health of Minnesotans — is at risk. Through our strategic planning process, we’ve realigned resources and reduced costs within our schools and colleges. We are now well positioned to prepare the health professionals of the future. However, we need a new covenant with Minnesota and its communities to ensure a healthy future. We need your help in this effort. Please contact your legislators and let them know that you support

the University of Minnesota Academic Health Center legislative request. Please join the AHC Community Network by contacting the AHC Office of Communications at 612-624-5100 or sign up on-line at www.ahc.umn.edu/legislative/ 2001/postcard.html. Thank you. ✦ Frank B. Cerra, M.D. is Senior Vice President for Health Sciences, University of Minnesota Academic Health Center.

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The Journal of the Hennepin and Ramsey Medical Societies

March/April 2001

Medical School Applicants on the Decline

WHY ARE THERE FEWER NUMBERS of medical school applicants? This is a question that has attracted the attention of all of us â&#x20AC;&#x201D; both professionals and the public at large. The local press, as well as publications from the Association of American Medical Colleges, have reported on the steady decline in the number of medical school applicants over recent years. For the national applicant pool this trend began in 1997 and it has continued through to the present time. The highest number of medical school applicants ever was reached in 1996 with 46,968 applicants. This decreased to a national applicant pool of 37,136 for the 2000 entering class. Historically, ebbs and flows have been observed in the size of the national pool of medical school applicants. In 1988, a declining applicant pool reached its nadir and a less competitive applicant pool, as evidenced by declines in Medical College Admissions Test (MCAT) scores and undergraduate grade point averages, emerged. In contrast, the more recent decrease in the number of medical school applicants has not been associated with decreasing qualifications. In fact, there has been an upward trend in applicantsâ&#x20AC;&#x2122; academic qualifications (e.g., mean undergraduate GPA has risen, MCAT scores have increased) despite the reduced applicant pool. Also, recent applicant levels are still considerably higher than in 1988 when there were fewer than 27,000 medical school applicants. While the number of applicants has varied considerably, the number of students that medical schools have enrolled and graduated (approximately 16,000 students a year) has re-

B Y M A R I LY N J. B E C K E R , P h D . , L P

March/April 2001

mained stable over the past two decades. Hence, the ratio of accepted applicants has ranged from 1.7 to 2.9. In 2000 the ratio was 2.3 (16,301 accepted applicants and 20,835 non-accepted applicants). Many applicants are not accepted because of the competitiveness of the medical school applicant pool, rather than due to poor qualifications.

Establishing a physician workforce to practice the medicine of tomorrow and to meet the healthcare needs of people from a greater variety of cultures requires vision and focused effort. Except for two specific areas, the data for the University of Minnesota Medical School Minneapolis has mirrored that of the national pool. In the first area, declines in the applicant pool have been observed earlier here than nationally. With 786 applicants, the University of Minnesota Medical School - Minneapolis ap-

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plicant pool was at its lowest level in 1987. Also, the most recent decline in the number of applicants began in 1995 (vs. 1997 nationally). The applicant trends at the University of Minnesota Duluth School of Medicine have been similar to those at the University of Minnesota Medical School - Minneapolis. Mayo Medical School did not begin experiencing the most recent downward trend in number of applicants until 1999. The second area of discrepancy is related to the number of entered students. While the national figures for entering students have remained fairly constant at approximately 16,000, the University of Minnesota Medical School Minneapolis has had a decrease in entering class size from 238 in 1983 to the current class size of 165. Entering class size at University of Minnesota Duluth School of Medicine has shown a slight variation over the same time period (4853 students/year) and Mayo Medical Schoolâ&#x20AC;&#x2122;s entering class size has increased from 40 to 42 in that same time frame. Although, the number of rejected applicants continues to exceed the number of applicants accepted into medical school each year, and the competitiveness of the applicant pool is not being compromised by the decreasing applicant pool, there is mounting concern over the possible factors contributing to the fewer number of medical school applicants. Further, there is an underlying fear that the future physician workforce may suffer from lack of qualified graduates. Though no precise cause for the decline has been identified, it is theorized that factors in two domains may be contributing to the applicant decline. Namely, those related specifically to medicine and those related to the broader social context. The individual factors have been cited as the following:

The Journal of the Hennepin and Ramsey Medical Societies

• • • • • •

Decrease in physician compensation; Perceived loss of physician autonomy; Heightened fears of malpractice litigation; Growth of managed care; Strong economy; Increasing variety of challenging, high-paying professions/careers; • Natural highs and lows of interest in professional schools; and • Rise in educational debt. Simply stated, there are concerns about the decrease in the attractiveness of medicine as a career due to “negative images of contemporary medical practice,” the increased appeal of other career options for high ability individuals, and the costs associated with pursuing a medical career. The challenges of contemporary medical practice are apparent and recognized by physicians and applicants alike. The current decline in medical school applicants has led many to think broadly about the future of medicine, the

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“whole” of being a physician (in terms of both the positive and negative aspects), medical practice and services in Minnesota, and the potential for upcoming physician shortages within our state. Without a doubt, there continues to be a pool of highly qualified individuals seeking to enter the medical profession. However, there is no guarantee that this situation will continue, or that the diversity of Minnesota’s physician workforce will automatically increase with the increasing diversity of the population of Minnesota. Establishing a physician workforce to practice the medicine of tomorrow and to meet the healthcare needs of people from a greater variety of cultures requires vision and focused effort. The Medical School has evolved to meet the needs of medical students and future healthcare needs of Minnesota through extensive recruitment efforts, an enriched curriculum, establishing an increasingly diverse student body, and providing new options in dual degree pro-

The Journal of the Hennepin and Ramsey Medical Societies

grams (MD/MPH, MD/MBA). There also exist many challenges and opportunities for physicians. It is through direct contact with physicians that students learn of the “possibilities” of a career in medicine, of what it is like to be a physician, of the new frontiers in medicine, of how to pursue a medical career. The Hennepin and Ramsey Medical Societies, in conjunction with the Medical School, have begun to strategize on ways to collaborate to promote careers in medicine and establish meaningful connections between our present and future physicians. The myriad of opportunities for physicians in the 21st century makes this healing profession an attractive career. The Medical School is anxious to partner with the community to attract the brightest and most compassionate students into medicine. ✦ Marilyn J. Becker, Ph.D., LP, is Director of Admissions for the University of Minnesota Medical School.

March/April 2001

Fostering Medical Students

HMS AND RMS have been very visible at a number of recent medical student activities.

• Lunch ’n Learn — On January 9, nearly 200 first and second year medical students gathered to learn about the pros and cons of the Patient Bill of Rights, presented by Ann Kinsella, J.D., Assistant Attorney General, and Michael Scandrett, J.D., Executive Director, Council of Health Plans. Janis Amatuzio, M.D., forensic pathologist, will be the featured speaker at the February 15 session.

Ben Baechler, Ann Kinsella, J.D., Michael Scandrett, J.D., Kelley du Ford, and Adam Kim following the January Lunch ‘n Learn program.

“Professional Projects for the Professional” • Clinics • Professional Buildings • Hospitals •

• Mentoring Program — First year medical students and their physician mentors met for breakfast to kick-off the “Connections” program on Friday, January 12. Eugene Ollila, M.D., president of the University of Minnesota Medical Alumni Society and former HMS Chair, spoke about the unlimited opportunities for mutual growth and nurturing in this physician/ medical student mentoring program. HMS, RMS, the U of M Medical School, and Medical Alumni Society are the co-sponsors of this program. Numerous HMS and RMS members are participating in this mentoring program.

Craig Eckfeldt, Greg Vercellotti, M.D., Heather Stefanski and Eugene Ollila, M.D. at the mentoring program breakfast.

Morcon Construction, Inc. 5905 Golden Valley Road Golden Valley, MN 55442 763-546-6066 Phone: 612-546-6066 Bill Jundt Medical Construction Specialist Member MMGMA/Gold Sponsor Eugene Ollila, M.D., President of the Medical School Alumni Society addresses the students.

March/April 2001

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The Journal of the Hennepin and Ramsey Medical Societies

• White Coat Ceremony — Blanton Bessinger, M.D., Virginia Lupo, M.D., Reuben Berman, M.D., Eugene Ollila, M.D., and Roger Johnson, RMS CEO, joined the U of M medical school faculty members at the podium to address first year medical students at the “white coat” presentation ceremony on January 13. In addition, Drs. David Swanson (HMS President) and Robert Moravec (RMS President-elect), distributed Cross Pens to the students.✦

Medical students recite “The Minnesota Oath of New Physicians.”

Greg Vercellotti, M.D., Senior Associate Dean for Education, addresses the medical students.

Caitlin Anderson receives her Cross Pen from Drs. David Swanson and Robert Moravec.

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The Journal of the Hennepin and Ramsey Medical Societies

Reuben Berman, M.D., provides a historical perspective of caring for patients.

First-year medical students receive their white coats.

March/April 2001

PRESIDENT’S MESSAGE ROBERT C. MORAVEC, M.D.

From Where I Sit RMS-Officers

President Robert C. Moravec, M.D. President-Elect Peter H. Kelly, M.D. Past President John R. Gates, M.D. Secretary Jamie D. Santilli, M.D. Treasurer Peter J. Daly, M.D. RMS-Board Members

Kimberly A. Anderson, M.D., Specialty Director Victor S. Cox, M.D., Specialty Director Charles E. Crutchfield, III, M.D., At-Large Director Kelley C. du Ford, Medical Student Thomas B. Dunkel, M.D., MMA Trustee Michael Gonzalez-Campoy, M.D., At-Large Director James J. Jordan, M.D., Specialty Director F. Donald Kapps, M.D., Specialty Director Kathryn M. Klingberg, M.D., Resident Physician Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Kenneth E. Nollet, M.D., Ph.D., At-Large Director Thomas F. Rolewicz, M.D., Specialty Director Paul M. Spilseth, M.D., At-Large Director Lyle J. Swenson, M.D., MMA Trustee Jon V. Thomas, M.D., At-Large Director David C. Thorson, M.D., Specialty Director Russell C. Welch, M.D., At-Large Director RMS-Ex-Officio Board Members & Council Chairs

Blanton Bessinger, M.D., MMA President Paul J. Dyrdal, M.D., Sr. Physicians Assoc. President Kenneth W. Crabb, M.D., AMA Alternate Delegate Stephen P. England, M.D., Community Health Council Chair *Michael Gonzalez-Campoy, M.D., Education Resource Council Chair Eleanor Goodall, Alliance President Frank J. Indihar, M.D., AMA Delegate William E. Jacott, M.D., U of MN Representative *F. Donald Kapps, M.D., Council on Professionalsim & Ethics Chair Melanie Sullivan, Clinic Administrator *Lyle J. Swenson, M.D., Public Policy Council Chair *Russell C. Welch, M.D., Communications Council Chair *Also elected RMS Board Member RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Doreen M. Hines, Assistant Director

I AM HOPEFUL that this will be an eventful year in the history of the Ramsey Medical Society. I thank you all for the privilege of being your president and the confidence you have shown in leading this organization. This current issue of MetroDoctors describes a shortage of health care specialists, nursing staff, technical and therapy staff, all of which lead to a staffed bed shortage, increased burnout and increased attrition. Recently, both Ramsey and Hennepin Medical Society staffs have organized regular hospital leadership meetings to discuss these issues, as well as others, that affect health care in our community. In January, the shortage of long-term care beds was discussed. The impact of recent closures of long-term care facilities and shortage of long-term care beds has resulted in increased lengths of stay for hospitals. Hospitals and their medical staff are finding themselves unable to provide adequate continuity of care and appropriate transitions of care for the acutely ill patients. These issues are of immediate concern to every physician in the state, whether you practice urgent or emergency care, pediatrics or geriatrics, primary care or a specialty care. The inability to hire qualified staff to help reduce the growing burden on existing practitioners is acutely felt across the continuum of care. The health care system is finding itself assaulted for its rate of accidents, medical errors, and patient safety problems. The 1999 Institute of Medicine report entitled To Error is Human, described patient errors and medical mistakes in terms of possible deaths per year. Whether or not you subscribe to the numbers generated from the report, it did launch a national effort on safety and it will continue to be a focus for discussions on quality improvement for years to come. We should very soon have available to us the next Institute of Medicine report (due out now) focusing on the overuse/underuse of medical care and problems with delivery, efficiency, and other measures of quality and performance

improvement. I understand that there will be six themes to the next report: • Safety — patients should not suffer harm from care that is intended to help them; • Effectiveness — patients should receive care that is proven on scientific grounds to be helpful and that avoids care that is known to be harmful; • Patient Centeredness — delivery of respectful treatment with a focus on individual value-driven treatment; • Timeliness — health care should not waste the time of patients or health care professionals, rather it should be responsive to the needs of patients; • Efficiency — health care should avoid waste of supplies, energy, and resources, while striving to reduce the re-work necessary in our current system; • Equity — health care should reach all Americans regardless of race, gender, age, or ability to pay. On a national level, a leading group of Fortune 500 companies and other large health care purchasers have founded “The Leapfrog Group” by creating and committing to a common set of purchasing principles to drive “leaps” in patient safety. Their goal is to mobilize employer purchasing power to initiate breakthrough improvements in the safety and overall value of health care to American consumers. If you haven’t already done so, you should become more familiar with this group by logging onto their website at www.leapfroggroup.org. The initial selection of three safety standards shows us the most important issues upon which to focus (from the point of view of business and benefit and human resource leaders.) These initiatives are based on scientific evidence, feasibility of implementation in the near future, and (Continued on page 26)

March/April 2001

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The Journal of the Hennepin and Ramsey Medical Societies

130th RMS Annual Meeting Robert C. Moravec, M.D. Installed as President

Ramsey Medical Society attracted over 100 physicians, spouses, and guests to the North Oaks Golf Club on Friday, January 26, 2001. Dr. Robert Moravec was installed as president by outgoing president, Dr. John Gates. Dr. Moravec presented his agenda for RMS that includes: continuing the role of RMS as an advocate for the patient/doctor relationship and assist where possible other groups that advocate for the same thing; becoming an accredited provider of CME because continuing medical education is a key element of good medical care; working for the continuation of credentialing

services of physicians and recognizing the role RMS and HMS have played in providing the credentialing service to physicians; involving RMS in working on the issue of patient safety. Dr. Wayne Thalhuber was presented with the RMS Community Service Award for 2000. Dr. Thalhuber was recognized for the work he has done to educate physicians in end of life care issues, in working with patients who are experiencing the end of life, and for his work in advocating hospices. Dr. Joseph Rigatuso was recognized for his long service representing the East Metro on the MMA Board of Trustees and for his service to

Dr. Robert Moravec is installed as the new president by Dr. John R. Gates. Dr. Wayne Thalhuber received the RMS Community Service Award for 2000.

Dr. Tony Giefer and his wife, Mary Ann.

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Drs. Peter J. Daly and Peter H. Kelly with their wives, Nancy Kelly and Lulu Daly.

The Journal of the Hennepin and Ramsey Medical Societies

Dr. Robert Moravec, President, resides in Stillwater with his wife, Mari, and their two young sons.

RMS as an MMA Delegate and Board member. He was presented with a framed calligraphy of the Commendation Resolution adopted by the MMA House of Delegates. The evening concluded with the viewing of a thought-provoking video titled “Escape Fire” by Dr. Donald Berwick, the founder, president, and CEO of the Institute for Healthcare Improvement. If you are interested in borrowing the video to view, call the RMS office at (612) 362-3706. ✦

Dr. Robert Moravec honors Dr. Joseph Rigatuso for his years of service representing the East Metro on the MMA Board of Trustees.

Dr. Gretchen Crary and her husband, David.

March/April 2001

Ramsey Medical Society

THE 130TH ANNUAL MEETING of the

R M S U P DAT E President’s Message (Continued from page 24)

ability to measure their presence or absence in the health care system.

Applicants for Membership We welcome these new applicants for Ramsey Medical Society membership.

Active Rene P. du Cret, M.D. University of Texas Radiology St. Paul Radiology, P.A. Timothy C. Goertzen, M.D. University of Manitoba Diagnostic Radiology/Vascular and Interventional Radiology St. Paul Radiology, P.A. Christopher A. Jackson, M.D. University of Minnesota Diagnostic Radiology/Neuroradiology St. Paul Radiology, P.A. Thomas E. Jones, M.D. Duke University Family Practice Quello Clinic, Ltd.

Suzanne S. Teragawa, M.D. University of Minnesota Family Practice Aspen Medical Group - Bandana Garrett R. Trobec, M.D. University of Minnesota Family Practice North Suburban Family Physicians Shoreview Anne M. Weisensee, M.D. University of Minnesota Diagnostic Radiology St. Paul Radiology, P.A. 1st Year Practice Ronnell A. Hansen, M.D. University of Minnesota Diagnostic Radiology St. Paul Radiology, P.A. Jyothi B. Kesha, M.D. Kasturba Medical College, India Urology Metropolitan Urologic Specialists, P.A. Student (University of Minnesota)

Jennifer J. Mehmel, M.D. University of Minnesota Pediatrics Aspen Medical Group - Bandana John P. Miller, M.D., Ph.D. University of Connecticut Clinical Pathology/Blood Banking/ Transfusion Medicine American Red Cross Jane C. Pederson, M.D., M.S. University of Minnesota Geriatric Medicine/Internal Medicine Stratis Health

March/April 2001

Cheri N. Hauger Transfer into RMS — Active Daniel E. Larkin, M.D. Medical College of Wisconsin - Milwaukee Family Practice HealthEast Rice Street Clinic Transfer into RMS — 1st Year Practice Jeffrey S. Phelan, M.D. Creighton University Diagnostic Radiology St. Paul Radiology, P.A. Transfer into RMS — Student Graham S. Clark ✦

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The initial selections are: • Prescriptions in hospitals should be computerized. Computerized physician order entry systems should be implemented to reduce serious prescribing and transcription errors; • Certain elective procedures and treatments should be guided to hospital and clinical teams that are more likely to produce better results. Evidence-based hospital referral would be used to reduce the chances of complications and improve survival for several key procedures and surgeries; and • Hospital ICU care should be managed by a physician certified (or eligible for certification) in critical care medicine. When “intensivists” are quickly available for all ICU patients, the risk of dying in the ICU has been shown to be reduced by more that 10 percent. Right now, our collective ability to respond to these purchasing challenges is limited at best. We are a fractured and intensely protective profession that will have a difficult time adapting to these challenges under the old paradigm (and I don’t mean just physicians — I include hospitals, “integrated” health care systems, nurses, therapists and all other health care professionals). I see one of the roles for organized medicine as working collaboratively with organizations such as The Leapfrog Group and our other interested professional associations, so that their interests in improving patient outcomes and patient safety are met head on with our best ideas, strategies and abilities. I believe that the Ramsey Medical Society, Hennepin Medical Society, and Minnesota Medical Association can play a role in these quality improvement initiatives. I challenge each and every one of you to look for ways to be involved either at your hospital, clinic, medical society, or through coalition groups. I would also challenge each of you to have a dialogue with your patients on patient safety and hear directly from them what issues scare our patients the most and how we can best address their needs. ✦ The Journal of the Hennepin and Ramsey Medical Societies

RMS ALLIANCE NEWS ELEANOR M. GOODALL

A Message for Spouses of Physicians

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Nutrition: Teaches children to identify the major food groups in the Food Guide Pyramid so that they can select a healthy diet, with a focus on aiming for a healthy weight. Physical Fitness: Teaches children the importance of exercise for life and inspires them to exercise. Hospital Room: Teaches children about a hospital setting to minimize their anxiety about hospitals, familiarize them with commonly used equipment and introduce them to infection control procedures. Skeletal: Teaches children about bones, their

functions and how to take good care of their bones. Demonstrates sports safety equipment and motivates them to follow safe procedures when at play. Mental Health: Teaches children to develop good mental health by increasing self esteem and promoting respect for oneself and others. Deals with emotions, actions and consequences. HiTECH Heart: Teaches children about heart

health and promotes healthy lifestyles. Gives them an understanding of how the heart works and how to take care of it, through the use of a large heart model with a functioning pump.

The overall goals of the Health Fair are: 1) to enrich and expand the third grade health curriculum; and, 2) to reach children at an early age to teach them positive attitudes and habits that lead to lifelong physical and mental health. This is an important endeavor. The school district, the teachers, the children all say so. It’s a chance for us, as Alliance members, to give back, to participate in our community life and to make a difference, potentially a lifelong, healthy difference, for hundreds of children every year. Be a part of this. It is exciting, it feels good to be doing good. And, it’s fun! Body Language Health Fair will be held April 23-26, at the United Hospital Heart & Lung Building. Plan to help out. Check your calendar for a little free time on these days and call us. YOU ARE NEEDED! ✦ For further general information about the RMS Alliance or to find out about volunteer opportunities at the Health Fair, please call Eleanor Goodall, H: (763) 441-8308 or W: (651) 268-6107.

BODY LANGUAGE HEALTH FAIR April 23-26, 2001 Volunteer now for an exceptional, worthwhile, fun experience.

Sandi Butler demonstrates the use of a stethoscope in the Hospital Room booth.

The Journal of the Hennepin and Ramsey Medical Societies

Add value to your community.

March/April 2001

Ramsey Medical Society

Make a Difference We are all citizens of our communities. And, you know what? Citizenship is not a spectator sport! It’s important that we participate, that we add value to our community and, in this way, we make a difference. That’s what membership in the Ramsey Medical Society Alliance is all about — making a difference. Improving the health and well being of our community. And, when we work together on this goal, we make things happen. “Together” is the operative word here. We can’t do it alone. It is a little easier with a group. And, when we all pull together, with as many RMS Alliance members and friends as possible, we can do it! In this case, the “it” we are doing is the Body Language Health Fair. The year 2001 marks the 15th Annual Health Fair for third grade children in the St. Paul Schools. We are a huge success in this endeavor. School officials, who assist the Alliance in making arrangements, tell us that it is one of the most popular outings the children go on. Teachers tell us that it is rewarding and that it meets much of their health education curriculum needs. The kids tell us that they learn lots and that it is fun. So, how many Alliance members and friends do you figure it takes to teach 1,500 plus kids about their bodies and the importance of keeping them healthy? Whatever number you guessed, it is probably an understatement. We need lots and lots and lots of volunteers to “staff” the various booths. WE NEED YOU to be one of these volunteers. Each booth covers a different topic of health education. Pick one that interests you, say to yourself, “I can do this for one morning in April to help out, and give us a call to volunteer. The booths each have written goals and objectives and volunteers follow a short script — so you don’t have to be a health care “expert” in any field. Also, each booth has a Chairperson who will mentor you through the process. What are these booths? And, what do they teach?

Swing to the music of

The Jaztronauts Performing at the Spare Key Butterfly Ball Saturday, March 10, 2001 The Saint Paul Hotel

Dine and dance at this gala benefit for Spare Key Foundation Fun begins at 6 p.m.

350 Market Street

For more information, contact Ramsey Medical Society/

Ramsey Medical Society Alliance at

612-362-3705.

For more information about the band, call (612) 926-6202 or (651) 665-9098 Visit their Web Site at http://www.jaztronauts.com

SAVE THE DATE!!

Abusive Behavior in the Medical Workplace: Its Effect on Employee Satisfaction, Retention, and Patient Safety Thursday, May 3, 2001 8:00 a.m. – 12:15 p.m. Holiday Inn — Minneapolis West 9970 Wayzata Boulevard, Minneapolis, MN 55426 Jointly Sponsored by: Healthcare Human Resources Association of Minnesota Hennepin Medical Society Minnesota Medical Association Ramsey Medical Society

Audience: Physician Leaders, Medical Staff Officers, Vice Presidents for Medical Affairs, Nursing Home Medical Directors, Chief Executive Officers, Chief Nursing Officers, Human Resource Executives, and others involved in promoting healthy, abuse-free medical environments.

Local and national experts will discuss abusive behavior in the medical workplace, its impact on employees and patients, how to address it, and how to create healthy, abuse-free workplaces. Cost: $45.00, which includes continental breakfast, registration, and syllabus.

This activity has been approved for AMA PRA credit.

March/April 2001

Contact Nancy Bauer, Hennepin Medical Society, (612) 623-2893 for further information.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT VIRGINIA R. LUPO, M.D.

HMS-Officers

HMS-Board Members

Ben Baechler, Medical Student Michael Belzer, M.D. Carl E. Burkland, M.D. Jeffrey Christensen, M.D. William Conroy, M.D. Dianne Fenyk, Alliance Co-President Paul A. Kettler, M.D. James P. LaRoy, M.D. Monica Mykelbust, M.D. Ronald D. Osborn, D.O. Joseph F. Rinowski, M.D. Richard D. Schmidt, M.D. Marc F. Swiontkowski M.D. D. Clark Tungseth, M.D. Trish Vaurio, Alliance Co-President Joan M. Williams, M.D. HMS-Ex-Officio Board Members

Barbara H. Subak M.D., Senior Physicians Association Lee H. Beecher, M.D., MMA-Trustee Karen K. Dickson, M.D., MMA-Trustee John W. Larsen, M.D., MMA-Trustee Robert K. Meiches, M.D., MMA-Trustee Henry T. Smith, M.D., MMA-Trustee David W. Allen, Jr., MMGMA Rep. HMS-Executive Staff

Jack G. Davis, Chief Executive Officer Nancy K. Bauer, Associate Director

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Editor’s Note: This letter was sent to Frank Cerra, M.D., Senior Vice President for Health Sciences, University of Minnesota’s Academic Health Center, on behalf of HMS members in support of the AHC’s legislative budget request. It is being reprinted here for information.

THE HENNEPIN MEDICAL SOCIETY un-

derstands the importance of the state’s role in supporting health education and research, and therefore, endorses the University of Minnesota’s Academic Health Center legislative request of $33 million. Minnesotans have come to expect first class health care, delivered from first class institutions. A top tier health care education infrastructure to support those expectations is needed. Current funding streams are no longer able to meet the core needs of the medical school and as a result the future of health education is in jeopardy. For that reason, we support the legislative request of $16 million to secure the core funding for medical school programs at the University of Minnesota Medical School. We also understand that the future of our health care infrastructure, including our health care industries, relies on the highest quality research done in public institutions with the support of public and private dollars. As the state support of medical education decreases, so too has the University’s ability to attract and retain a full load of quality research faculty. While top tier medical schools receive over 95 percent of funds available through the National Institutes of Health, the University’s Medical School has dropped from that top tier. We also understand that for every one million research dollars brought into the state by University faculty, 38 jobs are generated for the Minnesota economy. For that reason, we support the biennial legislative request and long-term investment of just over $10 million to replenish the nearly 20 percent drop in teaching and research faculty of the Academic Health Center. Finally, the Academic Health Center’s

The Journal of the Hennepin and Ramsey Medical Societies

schools of nursing, dentistry, pharmacy and medicine are working creatively to expand its ability to meet the workforce demands of our health care system. For that reason, we support the biennial legislative request and long-term investment of $7.4 million to educate health professionals. On behalf of Hennepin Medical Society, we urge the 2001 Legislature to support the core funding and long-term investment plans of the Academic Health Center by fully funding their legislative request. ✦

A Call for Delegates If you are interested in serving as a Delegate, please contact us at your earliest convenience

A Call for Resolutions Resolutions are due at the Hennepin Medical Society no later than Friday, May 11.

HMS Caucus Wednesday, May 23, 2001 7:00-8:30 a.m. at Park Nicollet Clinic — Naegele Auditorium, St. Louis Park

MMA Annual Meeting Wed.-Fri., September 19-21, 2001 St. Cloud, MN If you have any questions contact Kathy Dittmer, executive assistant, at (612) 623-2885.

March/April 2001

Hennepin Medical Society

Chair Virginia R. Lupo, M.D. President David L. Swanson, M.D. President-Elect T. Michael Tedford, M.D. Secretary Richard M. Gebhart, M.D. Treasurer Michael B. Ainslie, M.D. Immediate Past Chair David L. Estrin, M.D.

HMS IN ACTION JACK G. DAVIS, CEO

HMS in Action highlights activities that your leadership and executive office staff have participated in, or responded to, between MetroDoctors issues. We solicit your input on these activities and encourage your calls regarding issues in which you would like our involvement.

distributed the revised draft to the board and will have a full discussion and hopefully adoption at our March board meeting. Nancy Bauer met with Paul Bowlin, M.D. and Neal Holtan, M.D. to develop a plan

A mini-Community Internship Program was offered for three Hoban

to involve the Senior Physicians Association in the issue of bioterrorism. The idea is to have retired

Scholars, each of whom is working toward a Masters degree in Health Care Administration. (See related photos on the next page.)

physicians available in the event of a terrorist attack. A presentation to the Senior Physicians Association is planned for this summer.

Jack Davis and Nancy Bauer, along with Sister Mary Madonna Ashton, Mick Johnson and Dr. Chris Johnson (Park Nicollet Foundation) and Barbara Dickey (St. Mary’s Clinics) met with Assistant Health Commissioners and senior staff at the Minnesota Department of Health to explore opportunities for leadership on expanding statewide the “Caring Clinics” model of mainstreaming uninsured patients into existing primary

care clinics and help with the pharmacy cost issue. HMS and RMS continue to operate MCSM (central credentialing) on an interim basis. The Minnesota Joint Purchasing Coalition (MJPC) seems to be on track to

select a final vendor, with final interviews scheduled. MCSM may continue its interim operation past the February 28 deadline, if the MJPC requires more time. HMS is part of a loosely organized “contract coalition,” which has drafted

HMS and RMS held another medical student “Lunch ‘n Learn.” More than 200

medical students attended to hear about patient protection legislation. Nancy Bauer attended the kick-off breakfast for the “Connections” mentoring program. Jointly sponsored with RMS, AHC and the Medical Alumni Society at the University, 275 member physicians volunteered for 165 mentoring spots. The purpose of the breakfast was to introduce the student and their mentor. Eugene Ollila, M.D. is the President of the Alumni Society. HMS played an active role. David Swanson, M.D. and Nancy Bauer represented the medical society at the medical student White Coat Ceremony. Virginia Lupo, M.D. and Reuben Berman, M.D. were featured speakers. Our participa-

tion, along with RMS’s, was referred to a number of times from the podium.

legislation that focuses on three issues: (1) full disclosure to patients; (2) full disclosure to physicians; and (3) prohibition of silent amendments. Senate staff has agreed to draft the legislation.

tan Hospital Physician Leadership Committee.” The Committee is made up

The HMS ad hoc Ethics Committee has authored Ethical Principles and an attestation document for physicians to sign and frame for their clinics. We have

of VPMA’s and Chiefs of Staff. These meetings have been held over the last year or so on a quarterly basis. The agenda has included JCAHO issues, U of M AHC update, credentialing concerns, disruptive

March/April 2001

HMS and RMS, at the request of several physicians in hospital leadership positions, convened a group called the “Metropoli-

MetroDoctors

physician policy, medical manpower shortages, emergency room diversion problems and nursing home capacity issue. A meeting with Senator John Hottinger has been scheduled for February 27, at noon, to discuss: (1) nursing home funding, staffing, and capacity issues; (2) the ER diversion and hospital bed capacity problems; and (3) planning for possible service interruption due to 2001 metropolitan hospital nursing contract renewal. Nancy Bauer and Jack Davis, along with spouses, attended the annual meeting of the Ramsey Medical Society at North Oaks Country Club. Robert Moravec, M.D. was installed as their new President. Leaders of the Hennepin and Ramsey Medical Societies have been combining efforts with the Employers Association and Hennepin County to offer a new health care product to small employers in the Twin Cities through an Accountable Provider Network. The model is envisioned to be inclusive of local providers and seeks to restructure the system to allow for more direct accountability by the patient, the physician, and the employer. January 24, 2001 marked the date of the last “official” meeting of the Success By 6® Phillips and Powderhorn Healthy Babies Collaborative. However,

members are encouraged to continue to meet the needs of the communities through continued networking and sharing of resources at quarterly “brown bag” lunches to be held at Abbott Northwestern Hospital and by becoming involved in the Way To Grow initiatives in both the Phillips and Powderhorn neighborhoods.✦

The Journal of the Hennepin and Ramsey Medical Societies

HMS NEWS

In Memoriam

Hoban Scholars Participate in Community Internship Program school. All three are enrolled in Masters Degree programs in Health Care Administration. Eric Nielsen provided this evaluation of the program: “To summarize my experience, the results were nothing but positive and well worth my time. Besides experiencing the delivery of care, I was able to have intriguing discussions with all the doctors. I learned a great deal!” ✦ Thanks again to the following HMS physicians who agreed to serve as faculty: Raul Cifuentes, M.D. William Conroy, M.D. Paul Crowe, M.D. Peter Dyrud, M.D. David Estrin, M.D. David Joesting, M.D. Eric Johnson, M.D. Phillip Murray, M.D. Bruce Norback, M.D. Eugene Ollila, M.D. Chris Roland, M.D. Jeff Vespa, M.D. Intern Eric Nielsen with Dr. David Estrin.

Dr. Phil Murray with intern Brian Cooper.

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The Journal of the Hennepin and Ramsey Medical Societies

HOWARD L. HORNS, M.D., died on January 10. He was 88. He graduated from the University of Minnesota Medical School. Dr. Horns was a former associate dean of the University of Minnesota Medical School and retired from the old Nicollet Clinic. In 1989 the University honored him with the Harold S. Diehl award for long and distinguished service. Dr. Horns joined HMS in 1950. KATHERINE C. GOODMAN M.D., MPH, died December 14 at the age of 83. She graduated from the University of Alberta, Faculty of Medicine, Edmonton. She completed a fellowship in pediatric cardiology at Children’s Memorial Hospital in Chicago, where her research helped establish the link between Rubella and birth defects. She was an assistant professor of anatomy at the University of Minnesota. Dr. Goodman joined HMS in 1980. ALVIN L. SCHULTZ, M.D., died January 19 at the age of 79. He graduated from the University of Minnesota. Dr. Schultz was a professor emeritus of medicine at the University of Minnesota. He served as Chief of Medicine of Hennepin County Medical Center from 1965 to 1988 where he helped to establish a program to train residents in internal medicine. In 1992, he received the Charles Bolles Bolles-Rogers and Shotwell awards for his outstanding contributions and achievements in the medical field. Dr. Schultz joined HMS in 1955. LEO A. ZAWORSKI, M.D., died January 11. He was 81. He graduated from the Medical College of Wisconsin, Milwaukee. He practiced in Northeast Minneapolis at the Northeast Medical Clinic and at St. Mary’s Hospital. Dr. Zaworski joined HMS in 1985. ✦ March/April 2001

Hennepin Medical Society

Brian Cooper, John Jendro, and Eric Nielsen, all recipients of the Thomas W. and Mary Kay Hoban Scholarship, recently participated in a HMS sponsored Community Internship Program. Following their observation of orthopedic, cardiovascular and general surgery; neurology, neonatology, and radiology; pediatrics and emergency medicine, the interns returned to their daily routines of work and

RICHARD P. DOE, M.D., Ph.D. died December 11 in Carmel, CA, his home since 1988. He was 74. He was a graduate of the University of Minnesota Medical School and received his Ph.D. in biochemistry. He did a rotating internship at Permanente Foundation Hospital in Oakland, CA, and an internal medicine residency as well as an endocrinology fellowship at the VA Hospital in Minneapolis. He was a professor emeritus at the University of Minnesota Medical School. Dr. Doe joined HMS in 1978.

HMS ALLIANCE NEWS

THE HENNEPIN MEDICAL Society Alliance

has been a dedicated partner to the Medical Society for 90 years. We have changed with the times to meet the needs of both society and our members, but we have not wavered from our mission of promoting health and well-being through education, advocacy, and service. In January and February, we educated 2,800 inner city third graders about their bodies and making healthy choices at Body Works. As all others before it, our 18th Body Works kept the traditional design of a health education fair, but was updated to reflect changes in society — students signed an anti-violence pledge and one thousand “I Can Stop Violence” puzzles were distributed to Minneapolis teachers to use in their classrooms. As part of our partnering responsibilities to the Medical Society, Body Works includes a session on preventing dog bites and we distribute the dog-bite brochure HMS has purchased from the Animal Humane Association. Another example of how we address current educational needs is our HIV/AIDS education folder. To date, more than 200,000 of these folders have been distributed in Minnesota. Several copies of the folder were translated into Russian and delivered to educators in that

country by Hennepin Medical Society Alliance member Penny Chally. As a result, some physicians and teachers in Russia are using the folders as a teaching tool. Additionally, the folders have been taken to Kenya and Tanzania; distributed to students in Texas and Wisconsin; and used as a resource by the Hopkins School District’s HIV/AIDS Task Force. Teachers throughout Minnesota have stated that they use the folder as a resource in their health education classes. One out-state teacher said that our folder is her only HIV/AIDS resource. We will soon be sending out HIV/AIDS folder order forms to principals and superintendents for next year’s classes. To make things easier for the schools, the order form has been added to our website (another example of how we change with the times). For the past eight years, HMS and the Hennepin Medical Foundation have been extremely supportive of Body Works and the HIV/ AIDS folder. We are grateful for both the financial and the moral support that you give to these two programs. By working together, our two organizations educate more people, promote better health for our community and strengthen the bonds of the family of medicine. It’s a good partnership!

Dianne Fenyk Co-President

Trish Vaurio Co-President

In our 90 year history, our organization has changed in many ways, but one thing remains the same — we are always proud of the physicians of the Hennepin Medical Society — after all, we ARE married to you! We especially look forward to honoring you on Doctor’s Day, March 30. It was on this date in 1842, that Dr. Crawford W. Long of Jefferson, Georgia, administered the first ether anesthetic for surgery. His history-making achievement and the continuous efforts by doctors to alleviate human suffering form the basis for celebrating Doctors’ Day. Each year on March 30, HMSA places recognition certificates, flowers and candy in the doctors’ lounges of several local hospitals as a token of our respect and gratitude. This year when you stop in the Doctors’ lounge on Doctors’ Day — you’ll know who is sending the hugs, the pats-on-theback, and the handshakes — your partners, the members of the Hennepin Medical Society Alliance! ✦ Dianne Fenyk, HMSA Co-President

Thank You Doctors

National Doctors’ Day Cheryl Steffen, a health educator from the Minneapolis Heart Institute Foundation, teaches the students using their HiTECH Heart.

March/April 2001

MetroDoctors

March 30 The Journal of the Hennepin and Ramsey Medical Societies

C O N T I N U I N G

M E D I C A L

E D U C A T I O N

Continuing Education and Extension, University of Minnesota 2001 CME Calendar 2nd Annual Upper Midwest Brain Tumor Symposium March 23 • Radisson South • Bloomington 13th Annual Course on Cardiac Arrhythmias April 20 • Earle Brown Heritage Center • Brooklyn Center Allergy and Clinical Immunology April 27 • Weisman Art Museum • Minneapolis Aging Skin: Implications for Wound Healing, Skin Cancer and Skin Care May 4 • Gateway Center on the U of MN Campus • Minneapolis Family Practice Review: Update 2001 May 7-11 • Radisson Hotel Metrodome • Minneapolis

Lillehei Symposium: Cardiovascular Care for Primary Practitioners May 21-22 • Radisson Riverfront Hotel • St. Paul Clinical Hypnosis Workshops May 31-June 2 • Earle Brown CE Center • St. Paul North Central Neonatology Issues Conference June 8-10 • The Grand Geneva Resort and Spa • Lake Geneva WI Annual Surgery Course: Gastointestinal June 13-16 • Hyatt • Mpls. Pan American Society of Pigment Cell Research June 14-17 • Regal Minneapolis

Topics and Advances in Pediatrics June 21-22 • Radisson Hotel Metrodome • Minneapolis GI Topics for the Primary Care Physician June 25 • Radisson Plymouth Remodeling and Progression of Heart Failure (ISHR) July 12-14 • Minneapolis Convention Center Endorectal Ultrasonography September 4 • Minneapolis Pelvic Floor Workshop September 5 • Minneapolis Principles of Colon and Rectal Surgery September 6-8 • Minneapolis Hilton and Tower

Heart Failure Society of America: 5th Annual Meeting September 9-12 • Washington DC Internal Medicine Review October 10-12 • Radisson Hotel Metrodome • Minneapolis Evaluation and Management of Peripheral Vascular and Cerebrovascular Diseases October 15-16 • Radisson Hotel Metrodome • Minneapolis 32nd Annual Seminar Obstetrics and Gynecology October 22-23 • Radisson Hotel Metrodome • Minneapolis

Continuing Medical Education, Medical School, Academic Health Center Radisson Hotel Metrodome, Suite 107, 615 Washington Avenue S.E., Minneapolis, MN 55414 (612) 626-7600 • 1-800-776-8636 • www.med.umn.edu/cme The University of Minnesota is an equal opportunity educator and employer