9septemberoctober00

Sept/October 2000

Doctors MetroDoctors Pediatrics Marjorie Hogan, M.D.,

Karen Dickson, M.D., Psy chiatry

Laurel Krause, M.D., Pathology

Surgery M.D., General Judy Grisard,

icine Kathleen Ayaz, M.D., Internal Med

The Stories of Women Physicians

Gynecology Elisa Wright, M.D., Obstetrics/

Charlene McE voy, M.D., Pu lmonary Med icine

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.

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VOLUME 2, NO. 5

2

SEPTEMBER/OCTOBER 2000

PHYSICIAN’S SOAP BOX

Penny A. Wheeler, M.D.

4

FEATURE: WOMEN PHYSICIANS

History of Women Physicians in the United States and Minnesota

8

COLLEAGUE INTERVIEW

Balancing a Life of Medicine: Stories From HMS & RMS Women Physicians

13

Physicians and Their Families: Eight Secrets of the New Heroes

17

Blue Cross Relents on Plans to Force Providers into Contract Stacking

18

HealtheCare Aligns Incentives of Consumers, Physicians and Employers

20

Transition Update from Wisconsin Physician Services (WPS)

20

Winter CME Conference

21

Minnesota’s External Review Program: Will it Help Patients?

23

Expert Practice Launches New Benchmarking Tool for Physicians

23

Classified

RAMSEY MEDICAL SOCIETY

24 25 26 27

President’s Message RMS Update Applicants for Membership/In Memoriam RMS Alliance

HMS In Action HMS News/2000 Candidates

The Stories of Women Physicians y Elisa Wright, M.D., Obstetrics/Gynecolog

HMS Alliance

Laurel Krause, M.D., Pathology

Surgery M.D., General Judy Grisard,

Kathleen Ayaz, M.D., Internal Medicine

President’s Report

Charlene McEvoy, M.D., Pulmonary Medicine

29 30 31 32

Karen Dickson, M.D., Psychiatry

HENNEPIN MEDICAL SOCIETY

Doctors MetroDoctors

Pediatrics Marjorie Hogan, M.D.,

Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available.

CONTENTS

Sept/October 2000

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

On the cover: Women physicians are selecting a variety of specialties and are working to balance career and family. Articles begin on page 4.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2000

1

PHYSICIAN'S SOAP BOX

Confessions of an Optimist

I

I ADMIT IT. I’M WORRIED — and that’s not an easy thing for an optimist to admit. I’m concerned about the rapid changes in health care, the economic pressures, and the resulting organizational and personal depression. It is a song with which we’ve all become familiar — continuing to do more with less and its resulting fatigue. The pace of clinical practice seems to be increasingly frenetic and the age of consumerism pays no attention to declining funding and reimbursement. Our nurses are working harder than ever taking care of sicker patients and turnover is high. There seems to be a widening chasm between management and those caring for patients at the bedside, with managers having to increasingly focus on the bottom line. Last year, 70 percent of hospitals in the United States lost money from their bottom lines. While the most unprecedented economic boom of all times embraces those outside medicine, inside we have the dust bowl. Everyone is very tired. How can we resuscitate our hopes and transfuse those with whom we work most closely so that we can continue to deliver quality and compassionate care for our patients? What is a doctor to do?

We seem to be in need of our own “New Deal” which does not lose sight of our old ideals. I wish I was able to write a prescription which, if adhered to, would allow us to cure health care and all of its current ailments. Like many of you, I have many more questions than answers, but can still maintain my optimism enough to see daylight from the well.

Although these questions contribute to our angst, they can also provide a catalyst for the transformation of health care. I believe if we can collectively go back to the basics and focus on the health of all who provide care for patients, both directly and indirectly, we can still thrive and provide uncompromising care. Some changes will be local; others will require wholesale political, social and economic shifts in the way we provide medical care.

Revitalizing Care Providers Not surprisingly, there is a relationship between how one feels about one’s work and the care and satisfaction that patients feel. Morale seems to be at a nadir yet, so far, for the most part, we’ve pulled ourselves up by our bootstraps and tended appropriately to our patients. The increasing amount of time and energy needed for physicians and nurses and all those who support the care of patients to do their work can eventually sap even the most vigorous souls, however.

Some are walking away from health care because the risk/benefit ratio has swung away from their initial idealism. I am especially concerned about the nurses upon whom we rely so dearly. Their work, which was always difficult, seems increasingly so and the turnover rate is high. The average age of an Abbott Northwestern nurse is 42 (nationally, it is 46!) As one nurse wrote in a recent column, “Can you imagine what impression a

BY PENNY A. WHEELER, M.D.

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September/October 2000

teenage girl considering various careers would form from her mother, a nurse who talks about her job every day? How likely is that child to enter nursing?”

What strategies can we grasp to rid us of this doom and gloom? What hope can we offer physicians, nurses and all those others who are directly or indirectly involved to revitalize our medical souls?

Not unexpectedly, it turns out that monetary compensation does not top the list of what satisfies health care workers; rather, positive relationships, engaging people and measuring results of what is achieved, creating work-life balance, and having regular contact with leadership is far more important. We need to get away from the notions of who people work for and change it to who they work with. We must develop vertically integrated groups when there is a challenge at hand so that a cross-section of people — from administrators to physicians to managers to those at the bedside, as well as those who support that work — have an honest forum and can make a difference. At a time when we are weary, we have to be involved. Ironically, it is at the time we most need to be involved that we feel too tired to do so, but it is the only way to a more abundant future.

Lessons from Patients Whenever I feel that the weight is mounting, I always try to return to the basics. Usually our patients give us frequent reminders of those premises that make what we do worthwhile. Recently, I ran into my partner in the wee small hours of the morning. I was startled by her weariness and her edematous eyes, which had clearly spent much of the night crying. She had almost “lost” both a mother and her child to an amniotic fluid embolism — a rare obstetrical event that none of us like to read about, let alone experience. She had done all of the right things but was left wondering if any of her actions would make a difference and whether she wanted that much responsibility in her life. As the sun rose higher, the mother and child continued their fight to recovery, the patient’s husband cornered my partner, and expressed his gratitude for her care and expertise. He was grateful that his wife and infant were still alive. Even when we can’t control the course of events, our compassion can and does change lives. Unlike some other professions, each of us — from neurologist, to the nurse on Station 40, to the housekeeper, to the lead administrator, to the lab tech, and the cast of thousands who support patient care — can make a difference in someone’s life every day. This ability to make a difference still fuels my optimism. As Norman Cousins said, “Ultimately it is the physician’s respect for the human soul that determines the worth of his science.” ✦ Penny A. Wheeler, M.D., is Abbott Northwestern Hospital’s Medical Staff President. (This article is reprinted with permission from the June 2000 Abbott-Northwestern Hospital Medical Staff Newsletter.)

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September/October 2000

3

FEATURE STORY

“A Woman’s Sphere” and “Hen Medics:” Some History of

Women Physicians in the United States and Minnesota

“We have had an oddity in town— a female Doctor, Miss Elizabeth Blackwell, M.D. She graduated at Geneva NY and is going to Paris. She looks intelligent & homely & is remarkably self possessed. I prophesy she will make money.”

James H. Stuart (medical student), letter to his mother, Philadelphia, November 14, 1849

I

IN 1869, AFTER YEARS OF REQUESTS by their Dean, students from the Woman’s Medical College of Pennsylvania were invited to attend the all-male teaching clinics in general surgery of the Pennsylvania Hospital. But when 35 women medical students approached the clinics one Saturday morning, they had an unpleasant surprise: according to the Philadelphia Evening Bulletin, “The students of the male colleges, knowing that the ladies would be present, turned out several hundred strong… Ranging themselves in line, these gallant gentlemen assailed the young ladies, as they passed out, with insolent and offensive language, and then followed them into the street, where the whole gang, with the fluency of long practice joined in insulting them…During the last hour, missiles of paper, tinfoil, tobacco-quids, etc., were thrown upon the ladies, while some of the men defiled the dresses of the ladies near them with tobacco juice.”

The male students, reported Elizabeth Keller, later senior surgeon at the New England Hospital for Women and Children, were “determined to make it so unpleasant for us that from choice, we would not care to attend another [clinic].” Prejudice against women physicians was rarely expressed in so extreme a way — newspaper criticism of the male students was strong, and popular support for women physicians was considerable — but prejudice in subtler forms made obtaining medical training and credentials by women in the second half of the nineteenth century a challenge.

Elizabeth Blackwell, the first woman graduate of a United States medical school, was denied admission to 12 medical schools before entering the medical school at Geneva, New York, in 1847. Even then, she was admitted against the wishes of the faculty, who made her enrollment conditional on its unanimous approval by a vote of the male students. There, students startled their faculty, first by approving her admission, and then by resolving officially that “one of the radical principles of a Republican Government is the universal education of both sexes; that to every branch of scientific education the door should be open equally to all; that the application of Elizabeth Blackwell to become a member of our class meets our entire approbation; and…no conduct of ours shall cause her to regret her attendance at this institution.”

Though Elizabeth Blackwell gained the first medical degree by a woman in the United States, women had actively practiced medicine since colonial times, as nurses, midwives, rural “doctresses,” practitioners of herbal medicine, or even, in the later case of Harriet Hunt of Boston, as physicians without degrees. Few early male physicians in the United States had medical degrees; like them, Dr. Hunt received her training through relatively unregulated apprenticeship.

B Y L I S A B O U L T, M . D . , M . P. H .

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September/October 2000

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Even as a practicing physician, however, Harriet Hunt had difficulty gaining access to medical classes. She was refused admission to the Harvard Medical College in 1847 and again in 1850, over the objections of the faculty and Dean, Oliver Wendell Holmes, who feared a rebellion by her would-be classmates. Having already had their “cup of humiliation” filled by the prior admission of black men to Harvard, the students resolved “[t]hat no woman of true delicacy would be willing in the presence of men to listen to the discussions of the subjects that necessarily come under the consideration of the student of medicine…we object to having the company of any female forced on us, who is disposed to unsex herself, and to sacrifice her modesty, by appearing with men in the medical lecture room.”

In the late nineteenth century, most male physicians opposed women’s practicing medicine, but many supported it, and debate was heated. To some, women were, by virtue of their female anatomy and physiology, unsuited for the privations, rigors, and sights of medical training and practice — that medicine was not woman’s “proper sphere.”

Many practitioners feared economic competition — and particularly the enticing away of female patients — from women physicians when competition for livelihood among physicians was fierce. Others argued that women’s compassionate nature suited them to caring for others, and that their rectitude and modesty would morally elevate the practice of medicine, in an era when medicine was not always a highly respected pursuit. Even advocates of women physicians disagreed about their proper role. Some believed women especially suited for the nurturing care of women, children, and the poor — and women did disproportionately practice gynecology, pediatrics, and public health. Others believed in strict equality between the sexes, with no special considerations granted to women and no limitations on their practice: hospital medicine, medical school teaching, even surgery.

Many medical schools remained unwilling to admit women (like Harvard, until the 1940s); others did so freely, with several mid-western medical schools (the universities of Michigan, Minnesota, and Iowa, for example) admitting them from the start. But admission to medical school did not end a woman student’s exposure to prejudice. Bertha van Hoosen, later a gynecologist and surgeon, and the founder and first president of the American Women’s Medical Association, recounted to her students that at the University of Michigan in 1885, her classmates’ “antagonism against the ‘hen medics’ saturated the very air she breathed.”

Some women gained medical training through the slow penetration of previously male institutions, or by attending institutions that were coeducational from the start; others did so by attending, or working at, all-women’s institutions — medical schools, clinics, hospitals, dispensaries, and settlement houses that were founded and staffed by

Others argued that women’s compassionate nature suited them to caring for others, and that their rectitude and modesty would morally elevate the practice of medicine, in an era when medicine was not always a highly respected pursuit.

(Continued on page 6)

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The Journal of the Hennepin and Ramsey Medical Societies

September/October 2000

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(Continued from page 5)

women, often separatists, for the benefit of women. The first such medical school was the Woman’s Medical College of Pennsylvania, founded in 1850, and schools in other cities soon followed. Their graduates founded and staffed the women’s hospitals and clinics that provided sites for women to obtain the post-graduate training that they were excluded from in other institutions. In these institutions, women were deans and department heads, surgeons and teachers. Women formed their own medical societies and founded, edited, and wrote such medical journals as the Journal of the American Women’s Medical Association and the Medical Women’s Journal. Such enterprises were suffused with explicit feminism; in some ways, women physicians in the late Victorian era were more autonomous than at any other time until the 1970s.

For all their gains, however, women still faced exclusion from many settings, including hospitals, medical faculties, and medical societies, in which participants determined policies about medical practice and discussed medical innovations. Members of some medical societies wrangled for years about whether to admit women who had applied for membership. In these controversies, even some advocates of women’s admission to the regular profession had ends other than gender equality in mind: while they feared the potential competition that women would represent, they also feared that to deny women admission to regular medical societies and medical schools would drive them into the hands of the “irregulars” — practitioners of nonstandard, mostly homeopathic, medicine — who were more welcoming to women than the “regulars.”

Post-graduate positions open to women were limited, especially in prestigious institutions. And the all-women facilities, though a great deal better than none, sometimes provided teaching that 6

September/October 2000

was second-rate; they were poorer, they had less available clinical material, and many of their instructors had had to settle for an inferior education themselves. Alice Hamilton, M.D., later the first woman professor at the Harvard Medical School, lamented what was available to her as a

“It irritates me to think that there is not a man medical graduate in the country who would accept so inferior a position as this; yet here we are, who know just as much as men students, obliged to accept places where we must divide among six the work that is only enough for two.”

Alice Hamilton, M.D., later the first woman professor hired by the Harvard Medical School

woman doctor at the New England Hospital for Women and Children: “It irritates me to think that there is not a man medical graduate in the country who would accept so inferior a position as this; yet here we are, who know just as much as men students, obliged to accept places where we MetroDoctors

must divide among six the work that is only enough for two.”

Minnesota’s Women The first female physician in Minnesota was Aurora Giddings, who came from Albany, New York, in 1854; by 1900, about 50 women physicians had come to Minnesota from other places.

The first woman to receive a degree from the University of Minnesota, in 1887, was Dr. Catharine A. Burnes, a member of the school’s fourth class. The second was Dr. Benedicta L. Carlson two years later.

Between 1887 and 1965, 388 women graduated from the University of Minnesota Medical School. A list of their names and dates of graduation shows that in several of these early years, no women graduated. In others, a lone woman graduated, or two women graduated, suggesting considerable determination in these women, and probably a measure of loneliness as well.

From the first, Minnesota’s women physicians were prominent and influential members of the community. As in other places, women physicians in Minnesota created establishments of their own, including the Maternity Hospital, founded in 1886, and Northwestern Hospital for Women and Children, founded in 1883, both in Minneapolis. Women physicians in Minnesota tended to treat women, children, and the poor: in rural areas, they had rigorous general and obstetrical practices.

Minnesota Medical Society was founded in 1853 and reorganized in 1869 as the Minnesota State Medical Society. The struggle over whether to admit women echoed those elsewhere. After debate on this issue that lasted 11 years, the first women were admitted to the Society in 1880; they were Drs. Harriet E. Preston and Edith M. Gould, both graduates of the Woman’s Medical College of Pennsylvania, and Clara E. Atkinson, a graduate of the University of Iowa, all of St. Paul; all three already belonged to the Ramsey County Medical Society.

The Journal of the Hennepin and Ramsey Medical Societies

Decreasing Numbers By the end of the nineteenth century, women made up between 4 percent and 5 percent of physicians, a number that remained stable until the 1960s. Only in 1970 did the percentage of women physicians exceed 7 percent (reaching 11.6 percent in 1980 and 16.9 percent in 1990).

But by World War I, women’s medical institutions were on the wane, either closing their doors or merging with other institutions that did not focus on women.

Women’s attendance at medical school declined, and ever fewer women were in positions of leadership as the twentieth century began.

Why did this happen? After the barriers had fallen and the bastions been stormed, why was it that in the early decades of this century — in some ways until the 1970s — women were not a visible part of the medical practice? Why did their numbers decrease, both in real and proportionate terms? This has often been blamed partly on stricter licensing examinations, but in fact, women generally did well on licensing examinations — even those attending women’s medical schools, for example, had less than one third the failure rate of the examinees in general between 1901 and 1903. The findings of the Flexner Report of 1910 are also often blamed for this decline, the implication being that these institutions were driven to close because they were sub-standard. But in fact, the number of women medical students had already decreased 19 percent in the six years preceding Flexner’s work, as he noted in his report.

The real reasons are complex, but they include both changes in the culture and the kind of role strain that is recognizable today. In the late nineteenth century, many professional women, fueled by feminist ideals, had dedicated themselves to careers and foregone marriage and child-rearing; only 12 percent of professional women in 1890 were married. But later the cultural meaning of marriage changed, with more MetroDoctors

emphasis on companionship, and fewer women wanted to forego this. Women combining marriage, medical practice, and child-rearing found the stress excessive; when things began to fall apart they blamed themselves. Other options appeared, and many women who might have been physicians instead went to graduate school or became social workers. As expensive technology became necessary for medical facilities, women could no longer afford to equip their separate institutions adequately.

The separatist feminism that characterized many of the early women’s institutions declined. It appeared to many younger women — prematurely, it turns out — that the barriers to women’s practicing medicine had fallen. The women’s institutions closed or merged with others, decreasing the opportunities for women who wanted to be leaders.

It would be nice to look back, more than 150 years after Elizabeth Blackwell’s graduation from medical school, and see that women are now involved in medicine in an equal way to men. But this is still not the case, though the numbers of female medical students have continued to grow in the last decades; in 1998-99, 43.2 percent of American medical students were women. Among women practicing and teaching medicine, there is still not parity in pay or position. Most women still practice in the four least lucrative specialties— pediatrics, internal medicine, psychiatry, and family practice. Women, after the same number of years in practice, are paid less per hour and per patient encounter than men in the same specialties. In 1997, while 19.5 percent of practicing internists, 15.4 percent of pediatricians, 7.5 percent of obstetrician-gynecologists, and 9.8 percent of family physicians were women, fewer than one tenth of one percent of practicing urologists and cardiothoracic surgeons, 0.1 percent of neurosurgeons, and 0.4 percent of orthopedic surgeons and otolaryngologists were women.

The situation is similar in academic

The Journal of the Hennepin and Ramsey Medical Societies

medicine. In 1998, six of 119 American medical school Deans were women; 174 of 249 Associate Deans were women.

Thirty-one percent of male and 10.5 percent of female full-time faculty members are full professors; while 35.6 percent of male and 49.6 percent of female full-time faculty members are assistant professors.

This last is not completely a function of age or number of years out of medical school.

It will, at the present rate of change, take 25 more years for the proportion of female full professors to reach half that of men.

In conclusion, the statistics show that the numbers of women in medical school continue to increase as do the numbers of women physicians in practice. With the concentration of women physicians in the specialties that are less lucrative such as family practice and pediatrics, and given the lower salaries of women physicians, it is fair to conclude that woman physicians are not realizing as large a piece of the health care pie as their numbers would indicate. The opportunities to develop leaders from among the corps of women physicians may also be compromised by the lack of numbers of women physicians on our medical school faculties and by the small numbers of women physicians in many of the specialties. Future women medical students may have to strive harder to eventually attain faculty positions or to claim a residency slot in specialties such as neurosurgery or orthopedic surgery if these statistics are to significantly improve. ✦ References are on file and are available upon request.

Lisa Boult, M.D., M.P.H., practices geriatrics in St. Paul. She is Clinical Assistant Professor of Family Practice and Community Health and a Ph.D. candidate in the History of Medicine at the University of Minnesota.

September/October 2000

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COLLEAGUE INTERVIEW

Balancing a Life of Medicine Linda Bohn, M.D., FACR Radiologist

I

I THOUGHT I COULD DO IT ALL. Sometime in my late forties, I found out I couldn’t. From the perspective of a female physician, I was asked to address working full-time vs. part-time, and being involved in organized medicine. At the age of almost 51, I think I finally know the answers for me. But remember, this is just one person’s viewpoint.

First — the full-time vs. part-time issue, which gets me back to the beginning, i.e., I thought I could do it all. In the sixties, the smart girls graduating from high school went to college to become a teacher or a nurse. So I became a teacher, teaching fourth grade for two years. By then it was the early seventies, and women were being told they could “do it all.” So I went back to college to complete pre-med requirements. In 1974 I started medical school, and my first child was 10 months of age. By 1985 I had three children, a husband with a very demanding career of his own, and three years out in radiology practice, working passionately for the cause of earlier detection of breast cancer. I was definitely in the midst of thinking I could do it all.

As time went on, I became more involved in my medical career, my husband’s job seemed to get more stressful, my children grew, I started volunteer work (teaching Sunday School, American Cancer Society, etc.), and I became active in organized medicine — both in radiology and Ramsey County Medical Society.

We also had a full-time nanny. In essence, my children had three adults raising them. I look back on those years and know that my children were well taken care of, but much of the time it was by someone other than their mother. Even when I was home, I was frequently not available emotionally for my husband or children, either because I was working on something (a lecture, an upcoming meeting agenda, etc.), or I was exhausted. I don’t know if my children would say they “suffered” — my teenage sons think that I’m sometimes around too much now — but I know that I feel sad that I missed too much of their childhood.

Part of the problem with cutting back on anything was that I felt so intensely about everything I was involved in, whether it was detecting breast cancer at a more curable stage, or getting the county medical society more relevant to practicing physicians.

But as I said in the beginning, in my late forties I found out that I couldn’t do it all. I felt completely and chronically fatigued, depleted.

Changes were urgently needed. I went from working more than full-time to working part-time; I cut down on my commitments to medicine out8

September/October 2000

Dr. Linda Bohn with her family. (From left) James, husband Jim, Andy, Dr. Bohn and Jesse.

side of my job (lectures, organized medicine, etc.), and I spent more time with my family. It was very difficult to do this — a part of me felt like a failure that I couldn’t do it all. I recently cut back even further — changing to a different job within my group, St. Paul Radiology; totally ceasing giving any lectures (just medical lectures — my kids wish I would extend this to them); getting out of organized medicine completely in any active sense; and cutting way back on my volunteer work.

I love spending more time with my family, and actually spending some time for myself. One of the first things I did after going part-time was to join a book club. I love to read, but I had done a negligible amount of pleasure reading since starting med school. Now I look forward each month to a new book and delightful discussion in my book club. I don’t feel chronically fatigued any more. I exercise more regularly. Our whole family feels more relaxed.

So, full-time vs. part-time? For me, at this stage of my life, part-time is a better fit. I think it’s a rare person — male or female —that can have a full-time+ career, a spouse with a full-time+ career, be involved in raising children, and active in organized medicine and volunteer work all at the same time. The reality, however, is that for many years of a person’s medical career, working part-time is simply not an option. Medical school, internship, residency, and probably the first several years of practice are MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

full-time. So there are probably at least ten years where full-time is a necessity. I believe that participation in organized medicine, and doing volunteer work in your community are very important. But perhaps it’s going to be done after your children are off to college, or for shorter periods of time.

When I was asked to write this, I was somewhat hesitant for several reasons. One is that to answer this honestly, it gets somewhat personal.

Another is that I feel that these issues are not unique to female physicians.

I think that many male physicians who have a spouse with a full-time demanding career and children would echo many of my thoughts. My last reason is that I didn’t want to sound pessimistic.

What advice would I give my children or young physicians? I would say “you can do it all, but not all at one time.” Perhaps before you have children you can work full-time. Or perhaps your volunteer work, including involvement in organized medicine, will be for a shorter period of time, or more extensive when you can work part-time. I’m always telling my children that hopefully their generation will have more availability of professional part-time work, for men and women.

I know she’s not a physician, but I like the following quote by Barbara Walters: “A career means long hours, frustration, and plain hard work, and finally perhaps a realization that you can’t have it all”…at least not all at the same time.

Katie Klingberg, M.D. Resident

B

BALANCING THE DEMANDS OF RESIDENCY with family needs

basically boils down to three words: TEAMWORK, SACRIFICE, and PATIENCE. Whether married or single, with kids or without — the only way each resident appears to survive residency is by maintaining a supportive network of family and friends. These special few fully understand the real demands of residency and exhibit the patience necessary to help their loved ones through this stressful time. When I graduated medical school, the commencement speaker said that, on that momentous occasion, rather than solely celebrating our own personal achievement, we should also acknowledge and appreciate the collaborative effort of all who supported us to attain that goal. This same message holds true for residency.

A spouse or significant other of any resident deserves special recognition. Household duties are divided equally most days, except the days I must sleep overnight on call. The female residents who are also moms need husbands who know the children’s routines and are comfortable cooking, cleaning, giving baths and putting the kids to bed — all by themselves, and often multiple times each week. The concept of give and take between partners is significantly skewed during residency because of the demands placed on the resident, and their ever-changing and often grueling schedules. Even when couples have time together, pasta and pizza are oftentimes all either has energy to cook. The kids learn not to count on nightly bedtime stories or kisses. Watching a movie is no longer considered a fun date — rather it is merely another place to catch up on a nap for the sleep-deprived resident.

One’s immediate family and close friends also make sacrifices. During the time of residency, holidays and birthdays often cannot be celebrated as a family group, due to limited time off and weekend/holiday call. No one gets a birthday card on time, and it’s often difficult for many to understand what “being on call” truly entails.

The only way to balance the demands of residency and relationships MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Dr. Katie Klingberg and her husband, Rob.

is by being patient and flexible, and by making the most out of small moments together: when dad brings the kids to the hospital for a quick dinner to say hi to mom, or when canceled clinic appointments provide the unexpected opportunity to catch an afternoon matinee.

After residency is over, I am confident I will look back at this juggling act and thank not only my wonderful spouse, but each and every person who has helped shorten the journey through their love, patience, and understanding.

Medicine is a fabulous career full of opportunity and great reward.

Thanks to those who fought hard battles in the past (some of it not so distant), I haven’t felt inequality or had doors close because I am a female.

On the contrary, I have been told numerous times that being a female will better serve me in the current job market, as many patients now expressly request to see a female doctor! I feel welcomed and lucky to be a woman in medicine in the 21st century.

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Carol Featherstone, M.D. Family Physician

I

I HAVE FELT THAT IT IS IMPORTANT for physicians to take an ac-

tive role in the organizational end of medicine, as this influences the direction of medicine as a profession. If we don’t speak out, others will be glad to determine our fate without our input. As a woman, I feel that I have to be a part of that role, to help us move away from the “Old Boys Network” that was so predominant in the past. Women have changed the face of medicine (I think for the better!!), and while I would never minimize the impact of our clinical work, the voice and visibility of women in roles of leadership within medicine are crucial.

I have been a delegate at the House of the Minnesota Academy of Family Physicians for several years, and am currently President of the Hennepin Chapter; I am currently Vice Speaker of the House of Delegates.

I am also active in the Christian Medical and Dental Society. I serve as the president of the local chapter and am also on the Board of Trustees nationally for this organization.

I think that many of the medical organizations are realizing the importance of having diversity in their leadership, and this includes having more women in leadership positions. As organizations seek out women who have an interest and ability to work in these positions, giving opportunity for mentoring and training in leadership, we will see more women

moving into these positions. There are many day-to-day issues that women deal with in the clinical setting. Many married women physicians struggle with the pressures of clinic and call schedules and how that impacts family time. These women have a tremendous number of demands on them. I am not sure that organized medicine is able to help with this particularly, as there are so many permutations of the variables in each situation — age of children, supportiveness of spouse, the size and composition of the clinic and the type of practice, etc.

I find that opportunities for women in the field of medicine are very open right now. When I was in medical school we were excited that our class was the first to have 30 percent women in the class. The opportunities are opening up more and more as the numbers increase. Women are being sought out to work in primary care clinics — there is a great demand for women physicians. As the organizations are looking for more women in leadership, they are seeking out women who are interested.

Right now is a great time for women in medicine.

I have not experienced any significant barriers in my medical career.

When I talk to the women who were practicing 25-30 years ago I find out what barriers really are!! What most of us experience now days are really hardly more than irritating nuisances in comparison!

Ann Lowry, M.D. Colon and Rectal Surgeon

I

I CHOSE THE FIELD OF COLON AND RECTAL SURGERY because

I have always been interested in intestinal disorders. I chose surgery with some trepidation because most programs had not yet trained a woman. I applied to both OB-GYN and surgery programs but finally decided to try surgery at least for one year because I enjoyed it so much as a medical student. A woman who had finished training in one of the Boston hospitals told me it was a great field if I wanted to be a nun. A surgeon involved in my training said that he felt about my choosing surgery as he would feel if his daughter married a black man. Not too encouraging. However, once I started I had very supportive residents with me which helped immensely. The decision to do colon and rectal surgery came towards the end of my training because of my interest in intestinal diseases, compliments I’d received about my ability to do intestinal anastomoses and the balance of small and large procedures/problems included in the field.

I have trouble answering the question about unique opportunities.

It’s hard to know which opportunities come because I am a woman and which would have come anyway. I have been involved in organizing the women within the American Society of Colon and Rectal Surgery which has been fun and I hope helpful to younger surgeons. I was the first woman in a colon and rectal training program to be pregnant — certainly a unique opportunity. I now hear stories about the consternation it caused, but at

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the time I was treated very well.

I have encountered few barriers perhaps because I have excellent mentors who have supported and promoted me. I have at times felt at a disadvantage when arguing for an unpopular position. I was once told that while my ideas were good they were much more likely to be accepted if promoted by a man. All through surgical training one can hear crude jokes and ones at the expense of women. However, one learns to choose one’s battles.

I am not sure that I have managed to balance family and career. I do have two wonderful children and two great step-daughters. I make a great effort to be at the kids’ events and to volunteer in the schools which extracts a toll from my staff. I also live with feeling that I am not everything I should be as a mother or a surgeon. On the other hand, I have been able to serve as the program director for the colon and rectal surgery training program at the U and have held several positions nationally within the Society. Without the support of my husband and my extended family it would not be possible and it is, unfortunately, at the price of sleep.

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The Journal of the Hennepin and Ramsey Medical Societies

Mary Braun, Medical Student

I

I STARTED MY CAREER AS A COMPUTER programmer and was pretty good at it. However, I stopped working to take care of my daughter. I remember holding her in my arms nine years ago and thinking, “when this little girl grows up, if she feels about her job the way I feel about mine, I wouldn’t want her to go back to it.” I was fortunate enough to have a husband who was supportive of my desire to have a more fulfilling job and able to support us financially while I figured out what that might be.

When Emily was about two, I started thinking about what I might want to do professionally and came up with the idea of a “doula,” a type of birth attendant, pregnancy support, newborn support person for women.

I volunteered at a center for a summer to explore the idea. One day I overheard a group of doulas talking about a question on their board exams that revolved around whose blood was in the umbilical cord. As I listened, I realized that I knew whose blood it was and recalled I had really enjoyed the scientific and physiological reading I had done during my pregnancy. It hit me, literally, it was a physical experience: I could be a doctor.

I started down that path, taking some of the premed courses I hadn’t taken in college. I spent a day a week with a physician for a term so that I could explore being a physician more. I decided that this was, indeed, my calling. A few years went by and I was ready to apply to medical school.

Emily was ready to go to kindergarten and my husband was burnt out from being our sole financial support. We reconsidered our lives, where we were spending our time and money and where we were likely to be spending it in the future and decided we had to move away from the Bay Area, much as we loved it. We moved to Minnesota.

I applied to medical school at the U of M as an out-of-state student, got an interview and loved the school. I was put on the “hold” list and rejected in May. I reapplied and this time I was accepted and with great nervousness tried to imagine how I would set up my life to cope with a first grader and medical school classes.

I was fortunate enough to be chosen to take summer anatomy. I remember my first day so well. I came home around 6 p.m. after having listened to Dr. Robertson talk about the shoulder girdle for two or three hours and then had my first day of dissection of the same confusing area.

I walked into the house, still wearing my backpack and collapsed into a little heap in the doorway between the kitchen and dining room. I was exhausted. Too exhausted to even have any emotions. My wonderful husband made dinner and then fed it to me.

The family/school dilemma was easy that summer, probably because I had just one class. The time between when I came home and Emily went to bed was family time — I did no studying then. However, as soon as she went to bed, I studied my little brains out. The astute reader will notice that I mention nothing about spending time with my husband and the correct reader will predict problems from this eventually.

For the first year of medical school, I think we relied on our firm foundation of family time and made withdrawals from the family cohesiveness bank, so to speak, to provide balance.

Then, all too soon, the second year started. I think I felt like I had arrived. I had balanced things for a year. The class work was better than in the first year and I was happier for a while. But then…the ignored relationship with my husband, and the ignored issues of my past showed up MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

without an invitation, demanding attention. I am not sure what would have happened if I had not had a highly personal and extremely meaningful anniversary midway through second year: my daughter became the same age as I had been when my mother died. This event set off for me a huge internal process that involved reconsidering almost every aspect of my life and culminating in my search for my father who I had never met.

One afternoon, I was sitting in Dr. Paul Quie’s office, trying to sort out my life and he told me that whatever happened in my personal life, “medicine would always be a great comfort” which has been absolutely true. I spent the remainder of my second year wanting to take time off, take a break and attend solely to my personal life. Instead, I spent most of the year saying to myself every morning that I could decide tomorrow to take the next year off, but why didn’t I just go do today. Most days I doubted I would make it through to boards. Dr. Greg Vercellotti, who watched me twist and turn on the horns of my perpetual dilemma over and over said, “you can do it; go back out there and do tomorrow.” I did tomorrow over and over again and made it to the end of the year.

The day after our final exams, my family and I went to Holland on a vacation. We devoted ourselves to doing something that wasn’t medical school. We just did it — and had a great time. When I came back, I studied for and took step one, then we went and met my father’s family.

The rest of the summer I spent enjoying my husband and daughter.

Then began rotations. Med I went well, with no overnight call and a limited amount of late evening call. There was some conflict already as my husband changed to a job that required a lot of travel and I had to leave the hospital by 5 p.m. to pick up our daughter at school almost every non-call day. My resident evaluation stated that, “Mary will need to make changes in her outside responsibilities to allow more flexibility in her schedule: current limitations will not be feasible during many student rotations, nor during residency.”

The rotations with no or very limited call have been fine, but I have Med II coming up in September. Our plan is to get a family member to stay with us to take care of Emily when I have call and my husband is traveling. We’ll see.

Sometimes I think about what it must have been like for the first women with children who went through medical school and I can’t imagine how much determination and courage they must have had. At times it feels incredibly daunting to imagine how I am going to juggle everything.

It always helps me to remember that other women have done it before me, some with more kids or less support than I have and if they can do it, maybe I can try one more day and see how it goes.

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September/October 2000

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Kim Anderson, M.D. Internal Medicine

I

IN MOST WAYS, A WOMAN PHYSICIAN with children is the same as any working mother. However, there are plenty of women working long hours for corporations who do not have the job satisfaction that I do.

I could not change to part-time when I had children, so instead I hired nannies to come into my home when the children were young. I took advantage of all of my vacation time, and always took Mondays off after being on call for the group for the weekend.

I’ve occasionally made hospital rounds with young children in tow and I’ve even had an occasional sick child in a back exam room with videos, books and treats when my emergency resources didn’t work out. I think that any working mother, especially a physician, learns to be versatile and to cope.

When the children were young I volunteered at school on my days off. Not many working mothers can do that, and not all that do not work outside of the home take the time to volunteer at school. My children would just beam at seeing me there, and I really enjoyed the art lessons and school parties.

I did experience some unequal treatment because of my gender while in medical school and residency. I was surprised to find how quickly this

Dr. Kim Anderson (center), with her staff, is actively looking for partners to join her at Adult Medicine, P.A., (651) 644-7775.

reversed as a woman in primary care, and have the luxury of occasionally wondering if patients like me for being a good doctor or for the fact that I am a female.

I am more satisfied in my work now than I was when I started out 15 years ago in private practice. I am challenged by the science of medicine, love the reasoning and diagnoses, and find intense satisfaction in helping people. The older I get, the more important the helping is.

I would advise both men and women to do what you love, but your children grow up awfully fast. ✦

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MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Physicians and Their Families: Eight Secrets of the New Heroes A hero is someone who creates safe spaces for other people.

Wayne & Mary Sotile , co-authors of: The Medical Marriage: Sustaining Healthy Relationships for Physicians and Their Families (AMA, 2000)

F

FOR THE FIRST TIME in their long histories, the American Medical Association and the AMA Alliance have co-released a book (ours!) that describes the secrets of thriving medical couples. This event means something worth noting: Today’s medical families are the new pioneers; you are a generation of men and women charting your ways through as-yet uncharted territory. The “road maps” that prior generations of physicians and physician lovedones used to determine what they needed to do in order to be successful at home and at work simply do not apply anymore. Ours is a new day, and, creative institutions, hospitals, practices, and couples are recognizing that work/family balance issues are primary among the concerns of contemporary physicians and their loved ones.

In our 23 years of practice, we have had the privilege of treating more than 700 physicians. Thousands more have attended our medical marriage workshops and keynotes. These experiences have given us private glimpses into the inner workings of many “types” of medical marriages. We have found that, independent of the form — the doctor and his non-physician wife; the doctors; or the doctor and her husband — successful medical families distinguish themselves in clear ways from their less fortunate comrades. In a nutshell, these thriving medical couples are modern-day heroes; not just in terms of performing extraordinary feats, but, even more, in our definition of the term: Heroes create safe spaces for other people.

In this article, we present eight of the key lessons we have learned from these heroic medi-

B Y W AY N E M . S O T I L E , P h . D .

AND MARY O. SOTILE, M.A.

MetroDoctors

cal marriages, those folks who live busy lives and still manage to keep their love and passion alive.

Give up the myth of the balanced life.

Beware of the “Beaver Cleaver” family myth of the 1990s: the notion that healthy people live wonderfully balanced lives. Nothing could be further from the truth! No one lives in perfect balance between work, family, marriage, and self-focused pursuits. Furthermore, contrary to the popular “new-age guilt” rhetoric, it’s okay to love your work! In fact, the happiest and healthiest of people tend to have high levels of passion, both for their loved ones and for their work.

Don’t misconstrue the term. Balance does not refer to a static state. It is a dynamic process that involves regularly adjusting one’s stance.

Balance is more analogous to walking across a stream on rocks than standing still. Thriving medical couples do, indeed, go through periods over-focusing on one aspect of life or another (work, family, marriage, self). The key is that they do not lock-in the “wait-until” mentality and let any important aspect of their lives atrophy from chronic lack of attention.

Slow down, in spurts.

The antidote to the “wait-until” lifestyle is taking care to create at least moments of caring connection with loved ones, especially during the busy stretches. Given that three times as many physicians work 60 to 80 hours each week as any other professional group, it would be foolhearted to wait until the work schedule clears

The Journal of the Hennepin and Ramsey Medical Societies

before paying loving attention to your family.

The good news is that, when it comes to improving the quality of your relationships, little changes yield powerfully positive differences.

Thriving couples do, indeed, tend to live busy lives. But along the way, they follow a few guidelines that are worth emulating: • Never turn a monthly calendar without blocking out a 12-to-48 hour period of time that you designate as “marriage time.”

Protect that commitment just as you would your on-call schedule or your commitment to take your child to his orthodontist appointment. And show up with your teeth brushed and your hair combed! Most couples lose their romance out of neglect; not out of lack of love.

• Each day, find time to have multiple, brief, loving interactions with each other. Think for a moment about the many ways that take less than 20 seconds that you can say to each other “I love you” or “I appreciate you” or “I admire you” or “I miss you.”

Periodically throughout each day, take 20second breaks to make contact. Try doing this for a total of 10 minutes every day. It (Continued on page 14) September/October 2000

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can help you to stay connected, even during the difficult times.

Manage the relationship consequences of your high-powered coping styles.

It’s a two-part fact: (1) High-performing people tend to marry each other; and (2) High-performing couples tend to develop coping habits that serve them well in managing their BIG LIFE, but these same habits may hurt their relationships. We refer here to those wonderfully adaptive coping skills like multi-tasking (doing and thinking multiple things at once); being goal-directed and efficient; hyper-vigilance (scanning for flaws, and correcting them); delaying gratification; or staying focused on work and achievements. All of these are positive and necessary ways of coping…sometimes. But our relationships suffer when we over-use these tools.

Remember: what makes us successful at work does not necessarily make us successful at home.

Do your family a favor: Someplace between where you park your vehicle and enter your home, place a reminder — “No superpeople live here.”

Remember: No matter how noble your intentions, your loved ones only know you based on how you treat them during your day-to-day interactions.

Protect your communicationgenerating rituals.

Every couple starts out with a wonderful set of rituals that create time and space for them to give undivided attention to each other. What were yours? Healthy medical couples don’t do anything extraordinary here. After all, no one wants to spend hours each day, discussing their innermost insecurities and fears. (Most of us would rather have a root canal!) No, the “rituals” that thriving couples maintain are much smaller, much more gentle and realistic. Maybe it’s taking time to leisurely read the Sunday paper — not in parallel silence, but together, interacting about interesting points. Some develop the habit of setting aside 20 minutes each evening to sit and chat in a quiet room. Others make mealtime an opportunity to sit at the table for an extra 15 minutes, just to touch base. Still others protect their weekly walks together, their Tuesday night “recesses” (no working, nor wor-

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September/October 2000

morcon@isd.net

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rying, no discussing anything “heavy”). It doesn’t matter how you do it, just do it!

Celebrate your differences as man and woman.

When it comes to communication and intimacy, are men and women really that different? In our opinion, the popular rhetoric on this topic borders on normalizing stuff that just isn’t true. Sure, men do tend to be more action-oriented and more problem-solving in their communication tendencies. And women tend to more easily and more frequently talk about their feelings. But this doesn’t mean that we are doomed to suffer through marriages filled with mis-communication, justifying our misunderstandings with “that’s just the way men/women are” notions.

Healthy couples stretch to meet each other in the middle of this gender shuffle. They learn to appreciate and to participate in their partner’s styles of communicating and showing love. Put another way, healthy medical marriages orchestrate various dances of intimacy. A few examples: • Sometimes, he just listens, taking care not to offer advice. Instead, he simply offers empathy and compassion.

• Sometime she accepts that watching a ball game or a golf match together is a bona fide form of intimacy.

• Sometimes, he’s just physically affectionate, independent of any sexual agenda.

• Other times, she decides to bridge their distance by being sexual.

Be unpredictable. This might at first feel awkward. But putting new steps into your relationship dances will keep both of you interested and interesting. If you find yourself feeling bored, take a hard look at yourself. Ask: Am I bored, or boring?

Don’t expect your relationships to feel any better than you do.

Our clinical experiences suggest that both mates in a medical marriage tend to be scripted to be care-takers. If you are like most physicians and physician spouses we have known, you probably are great at ignoring your own needs in deference to taking care of others. This puts you at risk of developing a numbness that blunts your ability to stay connected with the very people you are so invested in taking care of.

Don’t forget to nurture your own mind/body/ spirit; rejuvenating yourself is the best way to preserve the energy you need to nurture others.

The Journal of the Hennepin and Ramsey Medical Societies

is for those who divorce. But loving families do something that safeguards their trust and friendship, even though they make mistakes: They treat each other with generosity and graciousness.

Be generous in what you offer to your loved ones. Offer them “gifts” that make them feel safe and special in your presence, even if offering their preferred forms of communication, affection, or attention feels awkward for you. And be gracious when responding to the “gifts” your loved ones offer to you, even if the

offering is not exactly what you wished for.

If we are to stay the course and remain stressresilient at work and at home, we must find ways to keep our marriage and family relationships healthy; doing so is the ultimate act of heroism.✦ Wayne and Mary Sotile serve as keynote speakers and as consultants to hospitals and medical practices.The Sotiles can be reached at: 1396 Old Mill Circle, Winston-Salem, NC 27103; Phone: 336-765-3032; E-mail: wsotile@attglobal.net.

Hennepin County Medical Center (HCMC) is one of the major teaching hospitals in Minnesota. Continuing Medical Education (CME), formerly known as the Office of Academic Affairs, was established at HCMC in 1983.

The mission of HCMC's CME Program is: "to provide organized, planned education activities to help physicians improve delivery of medical care."

FALL CONFERENCES:

September 15-16 Advanced Life Support in Obstetrics Location: HCMC, Minneapolis October 5-6 Annual Forensic Science Seminar Location: HCMC, Minneapolis October 6 Electrocardiography for Primary Care Physicians Location: Earle Brown Heritage Center, Brooklyn Center November 2-4 Annual Orthopaedic and Trauma Seminar Location: Minneapolis Convention Center November 3 A Global Affair: Caring for Immigrants and Refugees Location: HCMC, Minneapolis

Will be held in conjunction with the HCMC/MMRF (Minneapolis Medical Research Foundation) fundraising gala: A GLOBAL AFFAIR: CARING FOR A CHANGING WORLD on November 4, 2000 at the Minneapolis Marriott Hotel

November 10 Annual Minneapolis/St. Paul Diabetes Forum Location: Radisson Conference Center, Plymouth December 8 Ninth Annual Family Practice Update Location: Sheraton Inn Airport, Bloomington We would like to hear your comments and suggestions for future CME activities!

For More Information

Be Generous and Be Gracious.

There are no perfect people. There are no perfect marriages or families. Along the journey that is a lifetime marriage, we make many mistakes; we encounter many disappointments; and we regularly fail to please those we most love. This is just as true for thriving medical couples as it

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Hennepin County Medical Center Continuing Medical Education 701 Park Avenue, Mail Code 861-B Minneapolis, Minnesota 55415-1829 email robin.hoppenrath@co.hennepin.mn.us

The Journal of the Hennepin and Ramsey Medical Societies

612-347-2075 Fax: 612-904-4210 Toll Free: 888-263-4262

2000 CME @ HCMC

Remember: It’s never too early nor too late to make your marriage better.

When the American Medical Association asked us to revise our book, The Medical Marriage: Sustaining Healthy Relationships for Physicians and Their Families, we did so with glee. Not only were we excited about the compliment of the AMA’s endorsement; we were also anxious to add to our original manuscript a chapter on marriage in the second half. Responses to our “Dancing in the Empty Nest” chapter have, indeed, proven the point that it’s never to late to rejuvenate your marriage.

Once the kids are grown, medical couples face new opportunities and challenges. The second half of marriage is a time to look back with pride on what you have done and what you have endured; to forgive each other for mistakes you’ve made; to find new ways to spend time together; to dis-inhibit your sexual relationship; to renew your friendship; to establish new levels of nurturing companionship with your grown children; and to notice and express appreciation anew for all that your partner does and has done for you and your family.

But you don’t have to wait until retirement to enjoy variations of these relationship-boosters. Even during the busy, child-rearing, careerbuilding days of your journey, be sure to regularly carve-out islands of time to attend to each other. The emphasis here is on “regularly.” For example, we often advise busy medical families that, in terms of constructing a healthy marriage and family life, it is far better to take 20, two-day “vacations” each year than it is to take two, 10-day vacations. For a family to stay healthy, they must regularly take “recess” together. You need to frequently show each other your playful, joyful sides. Counterbalance your tendencies to work, worry, or teach your children with many, brief periods in which you simply be present, be playful, and be attentive. Remember: We fall in love with people who make us laugh; we stay in love with people who make us feel safe enough to come out and play.

September/October 2000

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Blue Cross Relents on Plans to Force Providers into Contract Stacking Editor’s Note: The following article was originally sent as a Payer Alert to HMS, RMS, MMA and MMGMA members. A follow-up alert sent in mid-August emphasized a September 6, 2000 deadline for action on this silent amendment.

B

BLUE CROSS AND BLUE SHIELD OF MINNESOTA (BCBSM) announced in Provider Bulletin (P6-00) on May 25, 2000 that they were unilaterally stacking providers into a new auto medical product and a non-certified work comp product based on your current BCBSM agreement retroactively to May 1, 2000. After the Metropolitan Medical Practice Forum (MMPF) with the Minnesota Medical Association (MMA) expressed concern regarding this significant unilateral contract action, BCBSM responded. We are pleased to notify you regarding BCBSM’s acknowledgment of new contract rights of great interest to providers. These rights, described in a July 18, 2000 BCBSM memo, were included in a contract amendment sent out on August 4, 2000.

To understand these changes a review of the May 25 announcement and related events is helpful.

(1) We believe the May 25 BCBS action is in violation of the spirit of the newly enacted state law statute 62Q.74 which prohibits health plans from forcing providers into new categories of health care service without first negotiating the terms and acceptance of such obligations with providers. The new statute gives this protection to physicians as of August 1, 2000.

(2) Limits on consumer choice are implicit in this expansion of managed care control over auto medical and workers compensation markets. The medical infrastructure to provide care will be underresourced by lower BCBS payments with these products. Consumers may not be aware of the loss of choice.

(3) We believe the contract stacking action as described on May 25, 2000 by BCBSM would shift more economic risk to providers without the provider having the chance to analyze the risk or negotiate their concerns.

(4) Forced participation in these new products removes a whole category of business from providers and substitutes it with an entirely different economic package. The additional unknown managed care service obligations of these products may jeopardize the fiscal stability of many providers already coping with declining reimbursements, rising patient expectations for service, regulatory compliance obligations and accountability expenses.

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The Journal of the Hennepin and Ramsey Medical Societies

Several conversations have taken place with representatives of BCBSM. The MMPF, MMA and several provider associations met with the Minnesota Department of Commerce, which regulates BCBSM, and the Attorney General of Minnesota to discuss our concern. The MMPF contacted Rep. Jim Abeler and Sen. Sheila Kiscaden, the authors of 62Q.74, who have expressed concern regarding this violation of the spirit of the newly enacted public policy protecting providers from the business practice of contract stacking. As a result we believe the changes announced July 23 by BCBSM signal a significant step forward to improved contractual relations with all payers.

We applaud BCBSM for acknowledging, in the July 18 memo to providers, your right to examine new contractual categories of insurance service before being obligated to perform. This memo also acknowledges the important right of providers to continue participation in other BCBSM products even if they decline participation in these new product categories.

You should have received the July 18th BCBSM memo, which describes these changes and the opportunity to amend your agreement with BCBSM. The promised amendment will document your right to decline participation in this new category of insurance. You have only 30 days (until September 6, 2000) to respond to avoid automatic inclusion in the auto medical and non-certified worker compensation programs.

Be aware that if you, as a provider, elect not to participate in this program, that your future participation, according to the agreement, will be “at the discretion of BCBSM.” If you would like to express your reaction to these events, listed below are the addresses for some of the interested parties to this discussion.We encourage you to express your opinions or concerns.

• Mark Banks M.D. CEO, Blue Cross Blue Shield, 3535 Blue Cross Road, Eagan, MN 55122 • Gary LaVasseur, Assistant Commissioner of Commerce, 133 E. 7th Street, St. Paul, MN 55101 • Jodie Root, VP Contracting and Payment, Blue Cross Blue Shield, 3535 Blue Cross Road, Eagan, MN 55122 • Mike Hatch, Attorney General, Office of the Attorney General, St. Paul, MN 55155 ✦

September/October 2000

17

Healthe Care Aligns Incentives of Consumers, Physicians and Employers

W

WHAT IF EVERY CONSUMER service only

required a $10 copayment? Need some landscaping done? It’s only $10. A consultation with your attorney or accountant? Again, it’s $10.

How about a bottle of wine at your favorite restaurant? Still $10. What effect would this have on your patterns of consumption of these discretionary services? Interestingly, this is the predominant model for the utilization of health care services today. This is in spite of the fact that, to a large extent, consumption is determined by the price of the service.

Misguided pricing models notwithstanding, several other facts speak to a broader disillusionment with our current health care system.

Consumers and physicians express marked dissatisfaction with managed care, employers continue to see large increases in premiums for covering their employees, and regulators continue to propose legislation that will place further controls on all parties.

Consumer dissatisfaction is commonly expressed in terms of lack of choice. Consumers want to have the ability to choose which physician they see and which services they receive — without intervention by a third party.

Moreover, choice is frequently cited as the most important factor for consumers; service closely follows choice in consumer surveys. Forty-two percent of consumers surveyed last year gave HMOs a negative rating for service (Deloitte & Touch, VHA Inc., 1999). Clearly the promise of open access and more choice by health plans has not been met.

Dissatisfaction among consumers is not limited to health plans. Consumers are also unhappy with the level of service they receive from their physicians. Eighty percent of con-

B Y T O M Á S V A L D I V I A , M.D., M.S.

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September/October 2000

sumers surveyed perceived that their time with doctors was less than it was 10 to 15 years ago (Yankelovich Monitor). Issues related to scheduling, claims submission, waiting room time, and follow-up all make an impression on the consumer’s service experience. While patient satisfaction surveys have attempted to measure these factors and have become incorporated as a proxy for quality, unfortunately, they seem to have done little to influence the way services are provided.

Physicians continue to attempt to provide patient care within the context of increasing external constraints. These well-known constraints include pre-certification and pre-authorization of procedures and hospital admissions, referral requirements to send patients to certain specialists and drug formularies. In addition, physicians must familiarize themselves with the differences among all the plans in which they participate. These restrictions increase administrative expenses for the physicians and decrease time devoted to the actual delivery of care.

Administrative constraints also contribute to the overall feeling of diminished autonomy MetroDoctors

in the practice of medicine. Physicians lose the ability to make recommendations on the best course of treatment for their patients because they are required to verify that the treatment will meet the stipulations set forth by the health plan. The loss of autonomy and encroachment of a third party into the physician-patient relationship significantly contribute to dissatisfaction among physicians.

Employer dissatisfaction is being driven largely by double-digit premium increases. A host of recent studies by the top benefit consulting firms show year 2000 increases ranging between 10 percent and 16 percent, while 2001 plan renewals for many employers are forecast at increases of 20 percent to 35 percent. Even beyond, the upward trend is projected to continue: One Hewitt Associates’ estimate suggests costs will rise as much as 50 percent by 2005.

In sum, the result of misaligned financial incentives and invasive third-party payors is increased costs, disaffected patients and demoralized providers across the health care industry.

The HealtheCare Model A new health plan from Minneapolis-based HealtheCare works to bring the incentives of consumers, physicians and employers into alignment. At the heart of the HealtheCare plan is consumer choice, coupled with personal responsibility for spending employer-funded health benefit dollars. Under the plan, employees receive a defined amount of pre-tax money annually from their employers. This money is placed into a Personal Care Account — an account not unlike a checking account, from which employees pay for health services. The employee is free to choose the healthcare products and services they want to consume and who will deliver them. For example, there is not a requirement to stay within a network of physicians

The Journal of the Hennepin and Ramsey Medical Societies

nor are referrals required for seeing specialists.

If employees encounter unexpected medical expenses and deplete the funds in their Personal Care Accounts, high-deductible medical insurance is activated as provided by the employer through the plan.

The incentive for consumers, aimed at encouraging healthy behaviors and efficient use of health services, is the opportunity to continually roll over unused dollars at the end of each year. Herein lies the motivation for wise use.

The balance of the Personal Care Account can be rolled from one year to the next to fund future health and wellness services, many of which are rarely covered, or covered only in part, by most managed care plans, including prescription glasses, vision correction surgery, gaps in dental coverage and many forms of alternative and complementary care.

In a model such as this, access to information is paramount. To help consumers make informed decisions, HealtheCare provides its members with easy access to pre-screened medical content and the cost of services. Members will have the ability to identify providers who meet their needs and weigh the options presented by their physician.

When consumers are able to make choices by spending their own health care dollars, traditional market forces come into play. Consumers will begin by gathering information on quality, access, service and price. Decisions will be made by the consumer to optimize the value they receive for the money they spend. For example, a physician recommending an allergy prescription may be asked to explain the difference between Allegra and Claritin, and if there is a discernible difference in efficacy given the price difference. The drugs are no longer the typical $10 copayment. The full price of the prescription is deducted from the employee’s Personal Care Account.

As the consumer becomes a shopper for health care services, it provides a new opportunity for physicians to eliminate many of the administrative constraints typical under managed care. The physician no longer needs to check with the employee’s health plan to make a referral to a specialist. The formulary does not need to be consulted prior to writing a prescription. The health plan no longer pre-authorizes services. The physician becomes an autonomous decision maker who is able to concentrate on MetroDoctors

the needs of the patient rather than the needs of the health plan.

Implications for Providers A consumer-driven health care marketplace will enable physicians to differentiate themselves on the basis of the quality, service and price of their product. The physician, group or care system under the HealtheCare model will soon be able to set their own prices for services as well as package services to reflect consumer demand. For example, a physician or group will be able to distinguish themselves by offering extraordinary customer service, such as extended hours or guaranteed phone response time. Such services would be priced based on the availability (supply) of such services and the demand by consumers. In much the same way LASIK surgery is priced today, physicians will also be able to package their services (e.g., an allergy testing package), so that assessment, procedures, supplies and facility fees are wrapped together into one package with a single price. Under the HealtheCare model, informed consumers, in control of their own health care dollars, will place a premium on good service and will be able to pay for those services directly.

Conclusion It is clear that managed care, despite its past achievements, is not satisfying consumers, physicians or employers. It is time for our health care models to evolve to provide appropriate incentives to those participating in the delivery of care. Under a system of consumer choice, the incentives become realigned so that physicians and well-informed patients can make health care decisions without the restrictions imposed by a third party. HealtheCare’s health plan model fosters opportunities for physicians to develop their practices to meet the needs of their patients and will emerge as a distinct alternative to today’s offerings. ✦ Dr. Valdivia serves as chief medical officer and chief medical information officer for HealtheCare. A board-certified internist, he previously served as the assistant department head of general internal medicine for HealthPartners, Inc., Minneapolis, and associate residency program director for the University of Minnesota.He holds a master’s degree in health informatics from the University of Minnesota, where he is assistant professor of medicine.

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2000

19

Transition Update from Wisconsin Physician Services (WPS)

H

HCFA ANNOUNCED a new transition date of September 15, 2000 for the cutover of Medicare Part B administrative responsibilities in Minnesota. On that date, Wisconsin Physician Services (WPS) is scheduled to become the new Medicare carrier in Minnesota, taking over the duties currently performed by UHC. The Health Care Financing Administration (HCFA) originally announced a mid-summer transition date for the administration of Medicare Part B from United HealthCare (UHC) to the replacement carriers. Due to the processing system transfer being delayed 30 days, the overall transition date was moved back to the September date. The new date allows for comprehensive system testing and preparations.

Mark Your Calendar The Annual HMS/RMS

Winter Medical Conference is scheduled for Saturday, Feb. 17, 2001 to Saturday, Feb. 24, 2001, at the Moon Palace Resort near Cancun, Mexico.

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September/October 2000

Transition Activities WPS’ transition plans have progressed well.

Meetings and conference calls with their counterparts at UHC continue to provide information allowing educated decision-making and achievement of transition goals. To ensure consistency during and after the transition, WPS will continue to publish the Medicare Provider News, with November planned for the first edition. Most importantly, WPS anticipates that the majority of current Medicare Part B employees in the UHC Bloomington office will join them. Finally, the current address and telephone numbers for Medicare Part B will remain the same: WPS-Medicare Part B, 8120 Penn Avenue South #200, Bloomington, MN 554311394. Beneficiary Telephone Numbers: • Toll free (800) 352-2762; • Local (952) 884-7171.

Provider Telephone Numbers: • Provider Services (952) 884-3030; • Provider Appeals (952) 885-2953; and • Provider Maintenance (952) 884-3030 (The provider services counselors will refer the provider to a specific Provider Maintenance Counselor.)

On September 15 and 18, the claims system will not be available so certain final cutover tasks may be completed. All claims processing functions and customer service telephone inquiries will be suspended for these two days.

Beginning Tuesday September 19 WPS will resume regular business activities and customer service telephone service from 8:00-4:00. Your patience is appreciated during this time.

Electronic Data Interchange (EDI) Transition Significant progress also has been made in the EDI transition. Many EDI processes will remain unchanged. For example, there will be no change MetroDoctors

in the availability of the Bulletin Board System (BBS) in Bloomington for claim submission, and no change in the EDI pre-system edit reports. WPS will accept and return the same EDI formats and versions currently used in Minnesota. There is one important change, however, to ensure successful claim submission. HCFA has assigned WPS a new Carrier Identification (ID) number: 00954.

• This ID must be placed in the AAO record, field 17, positions 227-242 of the National Standard Format (NSF) for all EDI claim files.

• Submitters who use the American National Standards Institute’s (ANSI) X12 837 format must place the new Carrier ID in the ISA segment, element 08, the GS segment, element 03, and NM1 segment, element 09.

You must begin using the new WPS ID for all claim files submitted after 11:30 a.m. Central Standard Time on September 14, 2000. Claim files submitted after September 14 without the new WPS Carrier ID 00954 will be rejected in the WPS pre-system edit process.

• Accelerate Software Users—If you have not received your software upgrade from UHC, please contact the EDI team.

WPS encourages your office staff to coordinate the planning process now with your vendor or clearinghouse to accommodate the new ID within your claim and remittance files. If you have any questions regarding submission of EDI claims to WPS or the change in Carrier ID, contact the EDI team at (952) 885-2882, (952) 885-2889, and (952) 885-2811.

Submitters who are still working toward converting from bisynchronous telecommunications to BBS would want to contact the EDI team to finalize their plans to complete conversion. ✦ The Journal of the Hennepin and Ramsey Medical Societies

Minnesota’s External Review Program: Will it Help Patients?

T

TOUTED AS AN APPEAL OPTION of last

resort, the Minnesota Legislature passed Minn.

Stat. Section 62Q.68-73 (1999) and 62M.06 which were implemented April, 1, 2000. This new law administered by the Minnesota Department of Health (MDH) permits patients to obtain an “external review” of a denied health plan complaint second step appeal, a UR decision which was not reversed on appeal to the health plan, or any denial finding by an insurer based on a lack of health plan medical necessity. According to Kent Peterson at the MDH, at the end of July, three appeals had been sent to the contractor selected by MDH, The Center for Health Dispute Resolution (CHDR) in Pittsford, New York; two decisions are pending and one was decided in favor of the health plan.

No wins for patients yet.

Kent Peterson, Manager of the MDH Managed Care Systems Section told members of the Minnesota Physician Patient Alliance on June 14 that an external review may be initiated by a patient, physician, or family member with the patient’s permission. The dispute/appeal can be about either clinical medical necessity denials or contract coverage issues, and the result of the review by CHDR is binding on the health plan. The patient in any case may choose to sue for recovery of treatment costs, but not damages related to the health plan’s actions. The MDH selected CHDR because of its extensive experience doing Medicare HMO appeals across the country. Thirty-three states now have an external review law of some sort, and there is great variation on their scopes and costs. For example, the Minnesota law requires a patient to pay $25 to initiate the process, which then involves a flat $325 state-paid fee to CHDR, after the patient (and sometimes the

physician) submit a Request for External Appeal Form available from MDH at kent.peterson@health.state.mn.us. The physician can request an expedited appeal if the attending M.D. cosigns the form. There is also a hardship waiver for the $25 fee if a patient discloses his low income or financial burdens.

According to Thomas Naughton, Esq., CHDR External Appeals Director, Minnesota’s law is more comprehensive and patient-friendly than most, compared say to Oklahoma’s which has a $500 patient fee threshold to start the process. Mr. Naughton also said in a phone interview that CHDR has resolved over 35,000 cases drawn from over 500 U.S. managed care plans since 1998, and that their primary experience

has been with Medicare HMO dispute resolution. The organization claims to have a profile of every case it has resolved. You can find out more at www.healthappeal.com and/or e-mail CHDR President David Richardson at drichardson@maximus.com.

Will this new law resolve patient grievances and spur Minnesota health plans to greater accountability to patients and physicians here?

• First, the program does not cover most Minnesotans because Medicare and medical assistance patients are not eligible, nor are those covered with self-insured ERISA, which include most private insurance plans in Minnesota, particularly in the metropolitan area. So, the new law (Continued on page 22)

The Hennepin Medical Society and the Hennepin Medical Society Alliance Invite you to join us for

Stepping Stones Gala A Celebration of the Alliance’s 90th Anniversary Saturday, September 23 6:30 p.m.

Gateway Center — U of M Featuring dinner, dancing, and an auction to benefit the Annex Teen Clinic, TAMS, and West Suburban Teen Clinic.

For more information, call (612) 623-3030

BY LEE BEECHER, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

September/October 2000

21

(Continued from page 21)

may be more relevant to privately insured patients in rural Minnesota than those in the Twin Cities and large metro areas, since there are proportionately fewer ERISA plans in greater Minnesota.

• Second, the program does not require peer review by Minnesota physicians of the same or similar specialty who are licensed in Minnesota. Although CHDR uses a national network of qualified physician reviewers, there is no accountability to a Minnesota medical community standard as would be the case if the physician reviewer was, based on Minnesota licensure, under the jurisdiction of the Minnesota Board of Medical Practice.

• Third, the CHDR process depends wholly on consideration of paper medical records and the complaints on the forms. Health plans are initially asked to provide their medical necessity review results, criteria, and comments. This might make them think more about patient care denials, particularly if the MDH does an ongoing, detailed, audit of this program

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September/October 2000

and each case. But as we physicians know, there is considerable variation among Minnesota health medical necessity plan criteria and often little if any reason given to the treating physician or patient for the medical director or other reviewer denial. Unfortunately, there is presently no provision for a direct physician to physician contact with the contracted reviewers at CHDR, and no expedited review of any sort unless the patient’s physician is actively involved in submitting the form. The attending physician ought to have an opportunity to discuss a clinical case with the reviewing physician. We see this as a weakness in the review process.

• Fourth, there is no provision for damages due the patient as a result of the plan’s denials or coverage interpretations, even when the patient “wins.”

Another important question is the willingness of physicians to sign on to and support these external reviews, be they routine or expedited.

Will physician employees of HMOs or clinics, which themselves function as health plans, challenge their own company UR decisions on behalf of patients through this program? How

MetroDoctors

much do physicians, either employed or contracted by health plans, fear retaliation from the plans for challenging corporate medical necessity (being patient advocates)?

Clearly, the program as it stands can’t hurt the cause of patient protection unless it is used by health plans or corporate supporters as an excuse to oppose substantive health care reforms such as the AMA-sponsored federal NorwoodDingall and Campbell bills.

Here in Minnesota during the 2000 legislative session, we urged passage of HF 3211(1999) which was not heard in the House or Senate but supported last year by MPPA and MMA; this bill requires Minnesota licensure for M.D. reviewers and accountability to the Minnesota Board of Medical Practice for physician review decisions.

Meanwhile, let’s keep our eye on the MDH/CHDR external review program and support our patients by filing an appeal when they need our help in standing up to unfair health plan denials. ✦ Lee Beecher, M.D. is President of the Minnesota Physician-Patient Alliance (MPPA) and is a West Metro MMA Trustee.

The Journal of the Hennepin and Ramsey Medical Societies

Expert Practice Launches New Benchmarking Tool for Physicians Free Trial to RMS/HMS Members

E

EXPERT PRACTICE, an on-line application

service provider for small- to medium-size medical practices, recently announced that it has launched a new product that enables physicians to track, trend, compare and improve medical practice performance. This new product, called ManageYourPractice™, delivers customized, on-line reports that compare the user’s individual or practice performance to peer and national standards and provides detailed recommendations on how to increase revenue and productivity.

ManageYourPractice™ is easy to use, even for those new to the Web. All the health care professional or practice administrator has to do

is complete a short, on-line questionnaire each month that collects a variety of operational and financial data. This information is submitted through a highly secure server to Expert Practice and the user immediately receives a dashboard showing how his or her practice performance compares to peer and national standards in six different areas, including: revenue, accounts receivable, productivity, compensation, staffing and expenses. In addition, this product offers customized recommendations, or “recipes for success” that help the user leverage opportunities for increased income and operational efficiency. This tool provides a similar level of

measurement, feedback and guidance that one might get from a consultant, for a fraction of the cost.

To kick off the launch of this new product, Expert Practice is giving away to Ramsey and Hennepin Medical Society members, three free months of ManageYourPractice™ — a retail value of nearly $150. Physicians or health care professionals interested in trying the product should call (800) 646-5615 or send an email to service@expertpractice.com. In addition to the three-month trial period, users also will have access to free web site development services and an on-line publication called, Physician’s Weekly.✦

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MetroDoctors

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The Journal of the Hennepin and Ramsey Medical Societies

NAS REPLY SERVICE Dept. 7mp755 8009 34th Avenue South Minneapolis, MN 55425

September/October 2000

23

PRESIDENT’S MESSAGE J O H N R . G AT E S , M . D .

The Influence of Women in Medicine RMS-Officers

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

Kimberly A. Anderson, M.D. Charles E. Crutchfield, III, M.D. Peter J. Daly, M.D. Kelley C. du Ford, Medical Student Thomas B. Dunkel, M.D. Michael Gonzalez-Campoy, M.D. James J. Jordan, M.D. F. Donald Kapps, M.D. Kathryn M. Klingberg, M.D., Resident Physician Charlene E. McEvoy, M.D. Ragnvald Mjanger, M.D. Joseph L. Rigatuso, M.D. Thomas F. Rolewicz, M.D. Paul M. Spilseth, M.D. Jon V. Thomas, M.D. David C. Thorson, M.D. Randy S. Twito, M.D. Russell C. Welch, M.D. RMS-Ex-Officio Board Members

Blanton Bessinger, M.D., MMA President-Elect Raymond Bonnabeau, M.D., Sr. Physicians Association 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 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 RMS-Executive Staff

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

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September/October 2000

I

IN THE 20+ YEARS I have been in medical

practice in Minnesota, I have been delighted to see the increasing influence of women in medicine. In my graduating class from the University of Minnesota Medical School in 1976, the vast majority of graduates were male. It is my understanding that in the graduating class of 2000, the majority of graduates were female.

This influx of women (finally) in the most rewarding of all professions (medicine) is welcomed.

I have especially enjoyed the bold pioneers who have eschewed the more traditional female dominated medical specialties for the almost exclusive realm of male physicians, in particular the surgical specialties. For the last ten years, it has been my pleasure to work with Dr. Mary Dunn at United and St. Paul Children’s Hospital, a neurosurgeon with superb skills, who has also clearly demonstrated her unique contribution as a woman and neurosurgeon. For example, some years ago, as we did more and more temporal lobectomies, realizing the extraordinary response we could achieve in terms of seizure freedom for patients with the syndrome of mesial temporal sclerosis (scarring on the hippocampus of the temporal lobe), we observed in the young women on whom we operated, the significant trauma of having their heads shaved in order to perform the surgery. Dr. Dunn carefully reviewed this experience and the necessity of shaving the whole head, and developed a marvelous technique, which allowed us to shave a very limited part of the temporal area in order to perform the temporal lobectomy, so the hair can be combed to cover the area. As a male physician, I was concerned by the emotional discomfort of my young female patients who had to have their heads shaved, but it took Mary Dunn to recognize the “whys and wherefores” of sensitivity of this apparently innocuous procedure that produced such significant trauma.

MetroDoctors

Her awareness and sensitivity combined with exceptional surgical skills, allowed her to develop a less invasive, less traumatic procedure in a very simple way.

This is simply one small but important example of the “female influence” I have witnessed taking place in medicine over the years.

Historically, neurology has been a predominantly male dominated specialty, however, increasingly women are choosing it as their career. Another example of the “female influence,” comes from my associate at the Minnesota Epilepsy Group, Dr. Patricia Penovich, who adds a rich dimension to our practice as a person who clearly reflects her compassion, skills, confidence and attitudes in the excellent care she provides to her patients. Her skills complement mine and offer a much richer resource to our patients.

Both of these women are sterling examples and are representative of the finest of the now many women physicians with whom I am acquainted. These physicians embody change for the better. They bring challenge to the “old” ways of thinking and doing, and offer observations and solutions for “new” ways to practice medicine.

Each of us, as all physicians do, bring an “extra value” to the care and treatment of our patients. The extra value we each contribute enriches the medical profession as a whole, as well as in the physician’s individual expression of patient care. In my experience, women in medicine do, in fact, bring a new, refreshing, welcome spirit to medicine that does enhance the whole. Just think of it…the title “doctor” is gender-free! ✦

The Journal of the Hennepin and Ramsey Medical Societies

R M S U P DAT E ROGER K. JOHNSON, RMS CEO

RMS Board River Cruise Over fifty RMS Board members, spouses, and guests enjoyed a beautiful cruise aboard the Magnolia Blossom on the Mississippi River on Thursday evening, June 22. George Halvorson, CEO and President of HealthPartners, addressed the health care issues facing physicians and health plans. The

guests included Mary Brainerd of HealthPartners, Elmer Schindel and Brett Oslund of Paine Webber, and Pat Powers of Olsen Thielen CPAs. RMS Medical Student RESCUE RMS medical student members enjoyed an evening at Billy’s on Grand on July 17. The planning committee tabbed the evening event as the RMS RESCUE. Drs. Kent Wilson, Peter Daly, and Lyle Swenson talked to the medical students about organized medicine and the benefits of being involved. RMS Medical Student Board Member Kelley du Ford explained the meaning of RESCUE, Ramsey Encouraging Student’s Commitment to Universal Excellence.

RMS Board members and guests relax on a boat cruise on the Mississippi River.

Enjoying the boat cruise are: RMS President John R. Gates, M.D., Mary Brainerd, Blanton Bessinger, M.D., George Halvorson, and Thomas B. Dunkel, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

RMS Sponsoring 19 Resolutions for MMA House of Delegates When the MMA House of Delegates meets on September 14 and 15 in Duluth, members of the House will consider 19 resolutions sponsored by RMS among the reports and resolutions that the House will consider. Dr. Lyle Swenson, chair of the RMS delegation, reports that, “the topics of the resolutions range from supporting the funding base of the University of Minnesota to osteoporosis and densitometry.” RMS has 27 delegates representing the East Metropolitan Trustee District of the MMA. Dr. Blanton Bessinger will be inaugurated as president of the MMA on Thursday evening, September 14. ✦

Matt Pollema, Mandi Beman, Peter Daly, M.D., Tara Karan, Kelley du Ford, and Kent Wilson, M.D. participate in the RMS RESCUE.

RMS medical student members gather for an evening at Billy’s on Grand.

September/October 2000

25

Ramsey Medical Society

Special Thank You Thank you to the family of Donald P. Smiley, M.D., for the memorial gifts to the Ramsey Medical Society Foundation. Memorial gifts recognize the departed loved one and they are appreciated as they enhance the ability of the RMS Foundation to serve the RMS community.

Resident Naomi Duke, M.D. Harvard Medical School Pediatrics Model Cities Health Center, Inc. Stephen B. Eigles, M.D. Georgetown University Radiology University of Minnesota

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

Active Dominic F. Frecentese, M.D. University of Iowa Radiology St. Joseph’s Hospital Mohammed Miradi, M.D. Tehran University, Iran Internal Medicine/Infectious Diseases St. Paul Infectious Disease Assoc., Ltd.

Gary B. Schwochau, M.D. University of Minnesota Internal Medicine/Nephrology Associated Nephrology Consultants, P.A.

Kathryn M. Klingberg, M.D. Loyola University Family Practice Bethesda Family Practice Clinic

Active-1st Year in Practice Jane B. Moore, M.D. Medical College of Wisconsin Dermatology Dermatology Consultants, P.A.

Student

Kamalesh M. Pillai, M.D. University of Michigan Internal Medicine/Cardiovascular Disease St. Paul Heart Clinic, P.A.

(from the University of Minnesota)

Lisa G. Remedios Transfer into RMS — Active Eleanor-Irene B. Bucu, M.D. University of the Philippines Pediatrics HealthPartners, St. Paul Clinic Transfer into RMS — Student (from the University of Minnesota)

Steven Jacobson Carolyn A. Kampa Lori A.N. Nidersson Christine L. Swanson ✦

In Memoriam CHARLES H. MANLOVE III, M.D., 78, died

on June 30 from complications of leukemia. He was born in the Philippine Islands on an army base where his father was a Pathologist. He graduated from the University of Oregon Medical School and served his internship and surgical residency at Anker Hospital in St. Paul.

Dr. Manlove retired in 1991 after 36 years of surgical practice. After retiring, he volunteered at St. Mary’s Carondelet Clinic in West St. Paul.

Dr. Manlove joined RMS in 1957.

WALLACE JAMES PAULSON, M.D., an anesthesiologist, died May 21 at the age of 81. He graduated from New York Medical College, completed an internship at Sacred Heart Hospital in Spokane Washington, and post graduate work at the University of Minnesota Hospital.

Dr. Paulson joined RMS in 1953. ✦ 26

September/October 2000

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

RMS ALLIANCE NEWS ELEANOR M. GOODALL

A Message to Spouses of Ramsey Medical Society Physicians

B

Perhaps you should come!

To show our intent to have something for everyone’s interests, the RMS Alliance’s second program of the year, on Saturday evening, September 16, is scheduled to be a “Style Show” at the Town and Country Club. In addition to the latest designs in haute couture in the Twin Cities, the plan is to have several gorgeous male models (who also just happen to be physicians) gracing the fashion runway. Both events will feature hors d’oeuvres, desserts, wine and coffee. Come! Bring your spouse and come!

October 25 finds us sponsoring a joint event with the Hennepin Medical Society Alliance at The Science Museum in downtown St. Paul. We’re planning a luncheon, a tour of the exhibits and the Omni Theater show, all about dolphins. Part educational, part fun and a wonderful new experience. We’ve built this program just for you. Bring a friend and come!

December heralds the incredible, almost world famous, Holiday Auction. This is one you don’t want to miss. Mark your calendars for the evening of December 5. Potluck hors d’oeuvres make for a sumptuous feast, imbibe in a little wine and enjoy the live auction — an event in and of itself. (Perhaps we’ll have a repeat performance on the various ways a prospective buyer could enjoy a fluffy white sheepskin rug!) Not only is this a fun-filled evening, but it also serves as an important fund-raiser for our community service projects. So, we need you to come!

The winter schedule has a February pro-

“Stress and the Medical Marriage” Based on the book by Wayne Sotile, Ph.D. and Mary Sotile, M.A. with Patti Herlihy (Nationally recognized speaker)

Tuesday, September 12 ts es e u G com el W

5:30-7:30 p.m.

Hors d’oeuvres, wine and dessert $8 per person

Home of Andrea and Stephen McCue; 6 Sunfish Lane, Sunfish Lake, MN 55118; (651) 451-9964 For more information, call RMS at (612) 362-3705

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

gram on “Live and then Give,” organ and tissue donation. We hope to have a panel of donors and recipients to tell their stories and answer questions. Find out more about how the organ and tissue donation program works and, if it interests you, what you have to do to be part of it. Come and learn!

Spring brings the Annual Health Fair, “Body Language.” When the call goes out for volunteers, please plan to respond. This vital program of community service has achieved accolades from students, teachers and parents who have been in attendance. As children face more and more choices in their young lives, it becomes increasingly more important to make sure they have information about those choices.

Such information, given in a great learning setting like the Health Fair, helps them understand how their bodies work and how to keep themselves physically and mentally healthy.

This week-long event is possible only because of a large group of dedicated volunteers who care about the children in our communities. I think you are one of those who cares. Even a couple of hours of your time is a boon. Together, we can make the Health Fair a success.

But we need you to come!

Besides scintillating programming, the Ramsey Medical Society Alliance has several outstanding volunteer opportunities. The feel good kinds of things that give that added dimension of meaning to our lives. More on this later.

For now, back to the baseball metaphor, the message is that we’ve built an outstanding year of learning, fun, friendship and significance.

We believe in the work of the Alliance. The last part is up to you. Won’t you come to the game!

(For further information on any of the RMS Alliance programs or events, please call Eleanor Goodall, 763/441-8308.) ✦

September/October 2000

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Ramsey Medical Society

BUILD IT AND THEY WILL COME. Remember the movie, “Field of Dreams”? And the cornfield in Iowa that was turned into a baseball field in just about the middle of nowhere?

Against all odds, the farmer built a baseball field, instead of planting a crop of corn, and indeed “they came.” I think the message was one of if you believe in something strongly enough it will happen. A little simplistic? A little childish?

Maybe. But there is some truth in it as well.

Because, when you believe strongly in something you tend to work harder to make it happen.

That’s how I feel about the Ramsey Medical Society Alliance. We’re building it, we believe strongly in the volunteer work we do for our communities — and I know you will come!

Who is this you? You are the spouse of every physician. We’re building this dream, called the Alliance, so that you can come to the game.

Obviously, we’re not building a baseball diamond in a cornfield. So, just what are we building for you to come to?

We’re building a year of fabulous programs with absolutely something for everyone. I know we’ve got your interests covered. Just come! We’re kicking off this year on the evening of September 12 with a national speaker addressing the topic, “Stress and the Medical Marriage,” based on the book with the same title by Dr. Wayne and Mary Sotile. Is this topic of relevance to you? Do you think it might be some time in the future? This could be an important message and we’ve built the occasion for your benefit.

PRESIDENT’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. Herbert K. Cantrill, M.D. William Conroy, M.D. Dianne Fenyk, Alliance Co-President James P. LaRoy, M.D. Barbara C. LeTourneau, 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. T. Michael Tedford, M.D. D. Clark Tungseth, M.D. Trish Vaurio, Alliance Co-President Joan M. Williams, M.D. HMS-Ex-Officio Board Members

E. Duane Engstrom, 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 Robert Finke, MMGMA Rep. HMS-Executive Staff

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

MetroDoctors

W

WOMEN ARE IN MEDICINE today more than ever before and work as providers in all the subspecialties that exist in medicine. But more than just the obvious change in the gender demographics of our profession in the last 30 years, is the change in the patient population we care for in Minnesota, with women speaking up to voice their preference for the gender of their medical provider. This has certainly been accelerated, though not led, by our immigrant populations in Minnesota. Female surgeons have known for a long time how quickly they become the breast cancer specialists within their general surgery groups, and the first new female member of an internal medicine group often has to quickly instruct the front desk to limit the number of annual gynecologic exams that are scheduled with her.

At present, the Twin Cities are home to the largest Somali community in the United States, second in North America only to the Toronto population. A subset of Somali women is adamant about only allowing female providers to attend to the care of their bodies when dealing with the delicate issues of reproduction, pregnancy and delivery.

Many of the Somali women we see in the Twin Cities were professionals in their country.

They are observant Muslims who speak Somali, not Arabic. Thanks to the Italian invasion of Africa during World War II, spaghetti is a familiar food staple for them. Systemic tuberculosis, sometimes presenting with supraclavicular masses or brain lesions, is present, and the rates of hepatitis B carriage and positive PPD’s approaches 50 percent. Only a subset of the population appears to have emigrated, with the majority of Somali immigrants being young men and women with their children; the elderly appear much less often to leave their homes and come to America. Alcohol, tobacco and drug use are thus far non-existent within the female population and the main problem that western providers face is the different cultural value placed on medical intervention by Somali women. The convenience of scheduled inductions of labor which has swept U.S. metropolitan areas, resulting in 25 percent rates of labor

The Journal of the Hennepin and Ramsey Medical Societies

induction in some hospitals, has not caught hold in the Somali population, with some very difficult discussions being held at the end of a pregnancy that has already gone two weeks past its due date, and with signs of fetal compromise present. There is sometimes a great reluctance on the part of the mother-to-be to have her labor induced and a much greater faith that things will work out fine on their own. Our defensive, litigious practice of medicine, to say nothing of our genuine desire to prevent obstetric disasters, makes it difficult to acquiesce to equally strong desires to decline our interventions.

As for the media hype surrounding the subject of ritual female genital surgery, it is demeaning to stigmatize an entire female population by that one practice and to focus on that as an issue that must be addressed by every provider at every visit. The procedure may not be legally performed in the United States. As Pat Schroder, former Colorado representative said in the New England Journal of Medicine, “some things are not legal in America. Just because slavery may be legal in a country from which an immigrant comes, doesn’t mean it has to be legal in America.”

Thus far we have no reason to suspect that genital surgery is being performed on young girls or teens in our area. If a provider is at a loss as to how to perform a pelvic exam or a urethral catheterization or delivery on a patient with such surgery, there is a growing body of experience in dealing with these problems within our area that can be quickly accessed by providers by making a few phone calls and finding someone with helpful suggestions on how to proceed.

Who would have ever thought 30 years ago that Minnesota would be such a hotbed of international medicine? Geography, sociology, international politics and religious traditions are impacting our daily practice of medicine more than we could have ever imagined. The practice of medicine continues to be very interesting and ever-changing. ✦ September/October 2000

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Hennepin Medical Society

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

The Metropolitan Medical Practice Forum, along with the Minnesota Medical Association, has produced another “payer alert.” This one references the recent BCBSM intent to unilaterally stack providers into a new auto medical product and a non-certified work comp product based on current agreements. A copy of the payer alert is reprinted in this issue of MetroDoctors on page 17.

The Veterans Administration Medical Center was the host for the recent Metropolitan Hospital Physician Leadership meeting. Chiefs of Staff and Vice Presi-

dents for Medical Affairs have agreed to meet on a quarterly basis to discuss issues of common interest and concern. William Jacott, M.D. presented an update of the status of the University of Minnesota Academic Health Center and some of the future directions of the JCAHO. Mark your calendar and plan to attend the “Stepping Stones Gala” on Saturday,

September 23, 2000 at the University of Minnesota Gateway Center. Proceeds from this event, celebrating the 90th anniversary of the Hennepin Medical Society Alliance, will be donated to the Annex Teen Clinic, Teen Age Medical Services, and West Suburban Teen Clinic. In addition, Elizabeth Jerome, M.D. will be recognized for her pioneering work in adolescent medicine in the community. Minnesota Health Commissioner, Jan Malcolm, will serve as the emcee.

The Senior Physicians Association co-hosted their annual summer outing with the Ramsey Medical Society Senior Physicians Association at the new Science Museum of Minnesota. One hundred retired physicians and their spouses attended this event.

Many HMS members and the HMS staff attended the 40th anniversary of Karen Tourdot’s employment with the MMA. Karen’s continued efforts and skills will be evident by those attending this year’s MMA Annual Meeting scheduled for September 13-15, in Duluth.

In collaboration with the MMA, HMS and RMS leadership met on July 17 with Medica leadership to discuss issues critical to the practicing physicians. These meetings are scheduled on a quarterly basis.

MMA, RMS and HMS, along with representatives of several other Minnesota professional associations, met with the Attorney General’s Staff and in a separate meeting with the interim Commerce Commissioner to discuss a contract stacking issue with BCBSM. A. Stuart Hanson, M.D. continues to chair the Healthy, Abuse-Free Workplace Project. Future plans include the development of an AMA Guidebook on workplace abuse, designing a breakout session for the AMA leadership conference scheduled for March 2001, and the creation of a poster with an anti-abuse message suitable for mounting in a clinic setting. ✦

Women physicians attending the joint HMS/RMS Senior Physician Association Summer Outing at the Science Museum of Minnesota included: (from left) Florence Bouthilet, M.D.; Maxine Nelson, M.D.; Elaine McKenzie, M.D.; Wendla Leinonen, M.D.; Barbara Subak, M.D.; and Elizabeth Jerome, M.D. (Back row): Maria Ha˚rdstedt, visiting medical student, Karolska Institute, Stockholm, Sweden.

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September/October 2000

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

HMS NEWS

HMS 2000 Candidates

T. MICHAEL TEDFORD, M.D. Dr. Tedford is board certified in otolaryngology and works at Southdale Otolaryngology in Edina. He was appointed to the HMS Board in 1999 as a representative for Abbott-Northwestern Hospital. Dr. Tedford has served as a Delegate to the MMA Annual Meeting the past two years. In addition to HMS and MMA, he is also a member of AMA, American Academy of Otolaryngology/Head & Neck Surgery, Minnesota Academy of Otolaryngology, Minnesota Specialty Physicians, and MPPA. “I would like to serve as president-elect of the Hennepin Medical Society because physicians in the Twin Cities are working in complicated systems responding to many forces peripheral to the delivery of quality care and the doctor/patient relationship. In these times, any significant change results from the work of large organizations, rather than the actions of any one person. HMS, working with the Ramsey Medical Society, represents us in the continuing evolution of the health care system. I am standing for election to serve our professional interests in that process.”

Re-election as Secretary RICHARD M. GEBHART, M.D. Dr. Gebhart is a board certified family physician. He has been with Camden Physicians since 1984 and currently serves as its Medical Director. He is a Clinical Professor for the University of Minnesota’s Department of Family Practice and Community Health and teaches at Creekside Family Physicians and North Memorial Health Care.

Dr. Gebhart will be completing his first 3-year term as Secretary on September 30.

“The Hennepin Medical Society has worked hard to become an organization of value to physician members.

I have enjoyed participating in this process. Many issues are important across specialties and this organization has good representation to be able to comment and address the issues brought forth. Efforts to increase participation of members must continue to be a priority.”

Hennepin Medical Foundation Board of Directors S. CHARLES SCHULZ, II, M.D. Dr. Schulz is board certified in psychiatry and neurology. In 1999 he became Professor and Head of the Department of Psychiatry at the U of M Medical School. He moved from Cleveland, Ohio where he was Professor and Chair of the Department of Psychiatry at Case Western Reserve University. Dr. Schulz graduated in 1973 from UCLA Medical School, Los Angeles, CA. “I feel I can make a contribution related to behavioral initiatives. I appreciate the invitation to participate.”✦

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The Journal of the Hennepin and Ramsey Medical Societies

September/October 2000

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Hennepin Medical Society

President-Elect

HMS ALLIANCE NEWS

W

WE, AT THE HENNEPIN Medical Society

Alliance, have a wonderful event planned for this fall, and hope that you have set aside Saturday, September 23 for the first Stepping Stones Gala. The evening will be a fun combination of dinner, silent auction, music, and dancing. Jan Malcolm, Commissioner of Health, has agreed to serve as our emcee for the evening and Michael Resnick, Ph.D., will offer us some words of advice on the uniqueness of adolescents. In addition, for those of you who attended the University of Minnesota, this is an opportunity to explore the fabulous new Gateway Center on the campus. This is the smashing space that includes the Gateway to the old Memorial Stadium. We will also be able to walk through the History Center with its wall of books produced by University of Minnesota authors.

The Gala is a benefit for three of our local teen clinics, all of which are running on a shoestring and can really use some assistance. They are the Annex Teen Clinic in Robbinsdale, the West Suburban Teen Clinic in Excelsior, and TAMS, or the Teen Age Medical Service, in South Minneapolis. We hope you can join us for a great kickoff to the fall of 2000!

I would like to introduce myself as the in-

coming co-president with Dianne Fenyk. I may look somewhat familiar to some of you since I worked eight years as a medical technologist at Hennepin County Medical Center long enough ago that it was still a hospital, not a medical center! My husband, Ed, and I both graduated from the University of Minnesota, although Ed’s undergraduate degree was from Hamline University. While I was working at HCMC, Ed was finishing medical school, and then internship and residency at HCMC. After a year in Korea and a year in Washington state, we returned to Minnesota where Ed has practiced internal medicine at the former Metropolitan Medical Center and Abbott-Northwestern Hospital.

My interest and commitment to HMSA began with Body Works, our annual health fair for Minneapolis third grade students. It is a wonderful opportunity to inform the children about health issues and give them some life skills to make healthy choices for themselves. This year Body Works will be held January 29 to February 2 at Lutheran Brotherhood. We invite anyone interested to come visit us—HMS has been very supportive of our project!

HMSA has an eventful year ahead. We want to combine community service, some fun,

The annual picnic for medical students, residents and spouses, sponsored by HMSA, was held at Penny and Cecil Chally’s cabin in Wisconsin.

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September/October 2000

MetroDoctors

Dianne Fenyk Co-President

Trish Vaurio Co-President

and some informational activities to keep us connected to one another and our community.

• October 25 will be a joint meeting with the Ramsey Medical Society Alliance at the Science Museum of Minnesota.

• November 25 we have planned a lighter program with a holiday floral class at Koehler and Dramm, perhaps to get our creative sides ready for the coming holidays.

• December 8 is our annual Holiday Tea and Silent Auction where we have a great time as a holiday kick off, while making money for Body Works.

We have also set a goal to continue distributing the HIV/AIDS Educational Folders to senior high and middle school students. We plan to lend our support to medical student and resident partners, and continue anti-violence efforts especially for younger children, in conjunction with our Body Works health fair.

Watch your mail for an invitation to the Stepping Stones Gala and please join us for a wonderful evening. We selected the name “Stepping Stones” as a foundation for health choices, a goal our Alliance feels is important as spouses of physicians. Consider purchasing a table and ask your friends to join us and HSMA to celebrate our 90th Anniversary. We are the oldest medical alliance in the country with a history of which we feel very proud. We would also like to invite any physician spouses (male and female) to join us, keeping in mind we have goals and commitments to our community, but also just enjoy getting together to meet new and old friends.

For more information please feel free to call Trish Vaurio (952) 929-7360 or Dianne Fenyk (763) 377-9707. ✦ Trish Vaurio, Co-President The Journal of the Hennepin and Ramsey Medical Societies

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Health and Human Rights Symposium Friday, December 8, 2000 Radisson Hotel Metrodome • Minneapolis, Minnesota

M A R K

Y O U R

C A L E N D A R

The "Health and Human Rights Symposium" is designed for physicians, attorneys, nurses, and other professionals interested in health and human rights. Continuing education credit will be provided for physicians, attorneys and nurses.

The program has been planned by representatives of the sponsoring organizations. It features a faculty that draws upon state, national, and international experts in the field. The symposium begins with an introduction, then an overview of major issues in health and human rights by Stephen Marks, followed by an examination of health and human rights issues particularly affecting women. A cluster of presentations on prison health, torture, and forensic medicine will be followed by a panel discussion on "Refugees and Torture: Health Issues." Issues in the distribution of health resources will be represented by presentations on "Pathologies of Power" and "Child Survival" and a panel discussion on "Inequality and the Human Right to Health." Following a presentation on child labor, the symposium will conclude with a panel presenting options for professional involvement in the field of health and human rights. On the panel will be representatives from organizations active in health and human rights.

Venue

The symposium will take place at the Radisson Hotel Metrodome, 615 Washington Avenue SE, on the east bank of the University of Minnesota campus in Minneapolis, Minnesota. To call for hotel reservations, please call 612.379.8888 and refer to "Health and Human Rights Conference".

Registration

A complete brochure will be mailed early in the fall which will include a registration form and all pertinent details about this educational symposium. If you would like to get on the waiting list for the brochure, please call the University of Minnesota Continuing Medical Education office at 612.626.7600.

Support for this conference has been provided through an unrestricted educational grant from Pfizer, Inc. Jointly Sponsored By: International Medical Education and Research Program Continuing Medical Education University of Minnesota Medical School Human Rights Center University of Minnesota Law School Center For Victims of Torture

In Cooperation With: American Refugee Committee Center for Bioethics Institute for Global Studies Minnesota Advocates for Human Rights Minnesota International Health Volunteers Physicians for Human Rights Physicians for Social Responsibility Student International Health Committee

Artwork from Light from the Yellow Star: A Lesson of Love from the Holocaust, paintings and prose by Robert O. Fisch, MD. Used with permission of the author.