MetroDoctors March/April 2020: Promoting Primary Care

March/April 2020

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Promoting

Primary Care

In This Issue: • • • •

The Challenges and Rewards of Primary Care An interview with AG Ellison on JUUL Lawsuit Steven Miles, MD Receives Shotwell Award Luminary of Twin Cities Medicine

“Your patients will thank you for referring them to Dr. Crutchfield.”

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves.

Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column.

Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring under-represented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters.

Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild

1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

Contents VOLUME 22, NO. 2 MARCH/APRIL 2020

3

The Faces of Primary Care By Thomas E. Kottke, MD

4 5 6

Page 6

President’s Message

The Renaissance Physician By Ryan Greiner, MD

In this issue

TCMS in Action By Ruth Parriott, MSW, MPH, CEO

The JUUL Lawsuit: A Conversation with Attorney General Keith Ellison

By Thomas E. Kottke, MD

8

promoting primary care

• Primary Care as a High Value Proposition

By Shailey Prasad, MD, MPH

10 • Colleague Interview: A Conversation with Renee Crichlow, MD 13 • Primary Care in Rural Minnesota

By Zora Radosevich, MPA 15 • Family Medicine Obstetrical Care: Partners in Providing Maternity Care and Improving Outcomes

By Andrea Westby, MD, FAAFP and Cora Walsh, MD, MSc 17 • Family Medicine and Primary Care: Challenges Mount, But Solutions Exist

By Jerry Potts, MD

Page 30

19

• Primary Care in the West 7th Community —Tradition and Evolution

By Sue Inoue, MD

21 • A Vocation, Not a Job: A Model for Primary Care from the Abbott Northwestern General Medical Associates

By Tod Worner, MD and Michael Cummings, MD 23 • Primary Care Saved My Life

By Carol C. White, MA, MPH 24

• Family Medicine Residency Program Expands Across the WI Border

26 Page 5

• SPONSORED CONTENT: The Vital Role Pharmacists Play Within Today’s Primary Care Team

By Taylor Hill, PharmD, BCACP, Mary Sauer, PharmD, BCACP, AE-C, CDE and Kyle Walburg, PharmD

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Page 32 MetroDoctors

March/April 2020

By Kelly Frisch, MD

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Promoting

Primary Care

Building a Tobacco-free Future for Minnesotans with Mental Health and Substance Use Disorders

By Annie Krapek, MPH Environmental Health — The US House Select Committee on the Climate Crisis

By Mike Menzel, MD and Kristi White, PhD

30 31 32

Luminary of twin cities medicine

Leif Ivar Solberg, MD

Steven Miles, MD Receives 2019 Shotwell Award In Memoriam/Career Opportunities

The Journal of the Twin Cities Medical Society

In This Issue: • The Challenges and Rewards of Primary Care • An interview with AG Ellison on JUUL Lawsuit • Steven Miles, MD Receives Shotwell Award • Luminary of Twin Cities Medicine

This issue of MetroDoctors acknowledges and celebrates the role of Primary Care Providers— from conception to end-of-life, and everything in between.

Articles begin on page 8.

March/April 2020

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Zineb Alfath Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer

TCMS Officers

President: Ryan Greiner, MD President-Elect: Sarah Traxler, MD Secretary: Andrea Hillerud, MD Treasurer: Rupa Polam Austria, MD Past President: Thomas E. Kottke, MD At-large: Matthew A. Hunt, MD

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

M Health Fairview.............................................31

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

March/April 2020

Crutchfield Dermatology......................................

Inside Front Cover Lakeview Clinic..................................................31

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com

COPIC..................................................................25

Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com

Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

Code Blue Event................................................... 9

TCMS Executive Staff

Kerry Hjelmgren, Executive Director, Honoring Choices Minnesota (612) 362-3704; khjelmgren@metrodoctors.com

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

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March/April Index to Advertisers

MagMutual........................ Outside Back Cover MedCraft................................................................ 7 Minnesota Community Care.........................22 North Memorial...................Inside Back Cover

Annie Krapek, MPH, Program Manager (612) 362-3715; akrapek@metrodoctors.com

PrairieCare............................................................30

Amber Kerrigan, Program Coordinator (612) 362-3706; akerrigan@metrodoctors.com

PrairieCare PAL..................................................20

Kate Feuling Porter, Program Manager (612) 362-3724; kfeuling@metrodoctors.com

PSP/LifeBridge....................................................25

TCMS Annual Celebration Monday May 11th, 6-8pm

Celebrating 10 Years Together RSVP at metrodoctors.com/celebrate

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

The Faces of Primary Care

T

he evidence is clear: Vaping kills; and vaping nicotine maims the adolescent brain. So, when Attorney General Keith Ellison announced that Minnesota was suing JUUL, I needed an interview. Not only did I learn that the AG is passionate about protecting Minnesota youth from vaping when the Federal Government is unwilling, I also learned that he has medical roots: AG Ellison’s father is a retired psychiatrist and his brother practices internal medicine in Detroit. Read the interview and then let me know if you agree that Minnesota physicians need to join the fight to protect our youth from the predatory practices of the individuals and companies that make vaping devices.

Primary care has many faces — OB/Gyn, Pediatrics, Family Medicine, General Internal Medicine, Geriatrics. Not only are their services a panoply, they tend to be high value. Dr. Shailey Prasad presents the evidence in our opening series on primary care.

This issue’s Colleague Interview, Dr. Renee Crichlow, is a community treasure. Dr. Crichlow will be known to many metro physicians either because she trained them in Family Medicine through the North Memorial residency program or through the Minnesota Academy of Family Physicians, where she serves as president. I was particularly inspired by The Ladder, an organization she founded to mentor individuals at all levels to help them achieve their professional and social goals.

Did you know that 62% of Minnesota counties qualify as primary care shortage areas? We asked Zora Radosevich, Director of the MDH Office of Rural Health and Primary Care to describe the epidemiology of care disparities and the agency’s programs that have been developed to address them. One, in particular, is the Rural Family Medicine Residency Grant Program that supports new and existing residency programs in rural Minnesota.

The approaches that primary care providers take to deliver services are as myriad as the problems their patients face. Drs. Cora Walsh and Andrea Westby describe how family physicians

By Thomas E. Kottke, MD Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

provide high quality obstetrical services. In three articles, Dr. Jerry Potts at Hennepin Health and Dr. Sue Inoue at the United Family Practice Residency program describe how they train physicians in urban settings; and, Dr. Kelly Frisch writes about a residency program at HealthPartners designed to prepare physicians for practice in rural settings.

While communication between primary care and hospitalists can be challenging for many physician groups, this is not the case for Abbott Northwestern General Medical Associates (ANGMA). As described by Drs. Tod Worner and Michael Cummings, ANGMA maintains communication by rotating their general internists through hospital duty.

To give us a patient’s perspective on the value of primary care, Carol White describes how her primary care physician saved her life by guiding her care over the decades.

Three North Memorial pharmacists — Taylor Hill, Mary Sauer, and Kyle Walburg — tell the readers how fostering strong, trusting, working relationships through Medication Therapy Management improves outcomes.

The penultimate articles are two updates to help our readers stay informed: Annie Krapek describes how the TCMS Physician Advocacy Network is helping mental health and substance use disorder patients end nicotine dependence, and we published the comments and recommendations of the Health Professionals for a Healthy Climate to The US House Select Committee on the Climate Crisis.

I am particularly pleased that this issue’s Luminary is Dr. Leif I. Solberg. I met Leif nearly 40 years ago when he came up to me during a blizzard and suggested that “we might collaborate on a bit of research.” Little did I know that I had just met a life-long inspiration and the energizer bunny of primary care practice and research. Among his other honors is election to the National Academy of Medicine.

We hope you enjoy reading this issue of MetroDoctors.

March/April 2020

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President’s Message

The Renaissance Physician Ryan Greiner, MD

D

onatello was an Italian sculptor whose work was highly influenced by the revival of interest in the sciences, mathematics and architecture that was taking place in Florence during the 15th century. He was a master of many mediums: stone, bronze, wood, stucco, clay and wax which were foundational in his discovery of new possibilities in materiality. He advanced the traditional artistic focus on the realm of religious expression into an exploration of the human’s place in the natural world. He was and remains a forefather of the Italian Renaissance and was considered to be the first to illustrate the art of sculpture among the moderns. But what of our age…

In our modern age of increasingly specialized and technologically-driven medical care, the traditional role of the physician is evolving and changing. As I have written previously, the advancement of artificial intelligence, quantum computing, and sophisticated software applications have the potential to replace many of the diagnostic and analytical components of medical care and perhaps may someday even encroach upon the manual application of our craft. In the meantime, increasing clinical specialization, artificially created care networks and the drift toward emotionally depersonalized medicine has created fragmented care which challenges our ability to address the fundamental basis of clinical practice — the human interaction. So I pose the question, “Who will guide us into this future?”

A renaissance individual is a well-educated and sophisticated person who has talents and knowledge that span many different areas of study, but also has the skill to recognize the interplay between these subjects to devise and create novel applications of their most interesting and applicable characteristics. Medicine is ripe for the emergence of the Renaissance Physician to become central to our future. The complexity of our healthcare systems, the increasing understanding of the primacy of “non-medical” determinants of health and well-being, the need to find balance between health care as a right but maintain it as a commodity, and to ensure the sustainability of the practitioners of our craft — all these things demand the Renaissance Physician to emerge as the thought leader and convener of vision and progress. But who is this person? They may have always been here…

How timely, this edition of MetroDoctors and its focus on primary care. The generalist as the craft of all things — the counselor, the researcher, the existentialist and the technical master. Birth to death — the generalist follows us on our path through life, attending to our emotions, our fears, our indecision and most importantly our health and well-being. They bring us into the world, manage the disruption of our adolescence, deliver our babies, prevent, delay, and treat the diseases of age and lifestyle and guide us on our passing and death. What could be more renaissance...

The primary care physician, the generalist, is and should be one of our most cherished assets within our profession. To be true, in many places they are appreciated for what they bring to their communities and organizations.

Yet, in too many places and in many ways, they are taken for granted, reduced to the idea of an RVU and placed in an artificially constructed productivity model that emphasizes numbers rather than people. Imagine if we embraced all they had to offer, all that is represented in this edition of MetroDoctors. Imagine if we consistently recognized and appreciated the renaissance of their specialty. It would change how we care for and guide the health and well-being of our communities and people.

So, I invite you to take a minute to offer your appreciation to all your generalist and primary care colleagues for all they do for your patients, organizations and communities. Offer them a place at the table of decision making and embrace their opinions, struggles and aspirations. Allow them to lead the Renaissance that will be the next 50 years of our craft. We, at the Twin Cities Medical Society, stand ready to support and convene the Renaissance of the primary care physician. Join us at that table and make your membership about the vision for the future — a shared experience of our love and concern for each other and the patients we serve each and every day.

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March/April 2020

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION Ruth Parriott, MSW, MPH, CEO

Ready or not, Legislative Session 2020

Minnesota’s state legislative session kicked off in February and our members are speaking out on several priority issues, beginning by addressing the disturbing upward trend in youth tobacco addiction. While the federal minimum purchase age has increased to 21, Minnesota law needs to conform its regulations to match the new age and restrict all flavored vape products, including menthol, that research clearly shows attract youth. In tobacco use cessation, a bill seeks to improve cessation services for Medicaid and MinnesotaCare enrollees.

TCMS also supports a healthy kids’ meal bill that would make water and milk the default beverage option for children’s menus at restaurants across Minnesota. This policy is an easy way to support families who want to make healthier choices for their children by reducing added sugars in their diet.

We continue to pursue state investment in advance care planning, particularly in underserved communities. We support a technical fix to the wording in the statute related to Minnesota’s breast and cervical cancer screening program that would eliminate an unintended barrier to treatment for indigenous women. Finally, there are some perennial uphill battles that must continue to be discussed and promoted by medical professionals: gun violence prevention and improving vaccination rates. To learn more about the current status of any of these issues contact Annie Krapek at akrapek@metrodoctors.com and follow us on twitter@TCMSMN. Good Things Take Time

When the medical student advocacy fellows gathered mid-year to share their experiences pursuing public health policy, MetroDoctors

two clear themes emerged: how slowly things can move in population health, and how willing busy professionals were to offer their time, advice and networks to help these burgeoning activists. After learning the basics of legislative policy advocacy, the students were both challenged and inspired by nurse-turned-legislator Erin Murphy. Crediting her clinical training for some of her skills as an elected official, Murphy stressed the importance of listening and observing before acting, and noted “power should be used to help those in need.”

The fellows are launching projects as diverse as addressing urban vs. rural rates of HPV vaccination, expanding syringe exchange programs, and promoting the use of psychiatric advance directives, but all are rooted in a desire to reduce current health inequities.

You will want to learn about all of the fascinating topics when the students showcase their work during an early evening reception on April 23 at Mill City.

Mark your calendar and find details at metrodoctors.com/fellowship.

attorneys and accountants. As PSP president Annie Burton, MD memorialized, “She was much more than an employee of PSP to so many of us; she was a friend, confidant, and fearless leader in addressing and supporting physicians and others with substance use disorders.”

Best (Professional) Party of the Year!

Plan to join your colleagues on Monday evening May 11, 6:00 pm, at Surly Brewery for our Annual Celebration of physician activism. In addition to the usual socializing and noshing, you’ll be reminded of the many inspiring activities of TCMS over our 10-year history.

Save the Date!

TCMS Annual Celebration Monday, May 11th, 6-8 pm Dr. Pete Dehnel Public Health Advocacy Fellows with Erin Murphy (center front).

Remembering Diane Naas

Diane Naas, longtime executive director of Physicians Serving Physicians (PSP), passed on January 15, 2020. In addition to her dedication to physician wellness, Diane pioneered confidential peer support work with nurses, pharmacists,

The Journal of the Twin Cities Medical Society

Celebrating 10 Years Together

Plan now to join us for an evening to celebrate successes and promote visions for our future.

Hearty appetizers will be provided Surly Brewing Company RSVP at metrodoctors.com/celebrate

March/April 2020

5

The JUUL Lawsuit: A Conversation with Attorney General Keith Ellison

D

uring the second half of 2019, episodes of severe lung disease and even death from vaping were in the news. In response, Governor Tim Walz announced on December 4 that the State of Minnesota was suing JUUL. To give MetroDoctors readers a deeper understanding, TCMS Immediate Past President Thomas E. Kottke, MD interviewed Attorney General Keith Ellison on January 17, 2020. The transcript, edited for clarity and length, follows:

TEK: Why did you run for Attorney General?

TEK: I’d like to start with finding out about the Attorney General as a person.

Where are your roots?

TEK: When did you start thinking about suing JUUL?

AG Ellison: I was born and raised in Detroit. I’m the third son out of five, no sisters. My dad is from Burke County, Georgia, and my mother is from Natchitoches, Louisiana. My mother graduated from Xavier University in New Orleans, and after getting a degree in pharmacy, my father went to the University of Michigan Medical School. He trained to be a psychiatrist back in the fifties when they didn’t even let black students live on campus. My brother is an internist in the city of Detroit. I moved to Minnesota about the age of 22 to go to law school at the University of Minnesota and have been here ever since.

TEK: What led you to serve in Congress?

AG Ellison: The reason I ran for Congress is because I felt that, as a lawyer, I could only handle one case at a time, but in Congress I could help millions of people at one time by passing laws like the Affordable Care Act. 6

March/April 2020

AG Ellison: The seat opened up so I jumped into it because I thought that we can do stuff about vaping, and we can do stuff about health care, and we can do stuff about telecom, and consumer justice, and wages, and we can deal with the social determinants of health like housing and education. So, I jumped into it, and I’ve been doing it for a year.

I love it.

AG Ellison: I thought about a lawsuit when I started seeing a lot of junior high school kids vaping, and when I read about the pods containing a lot of nicotine, and I started to understand how addictive nicotine can be and how debilitating getting an addiction as a preteen or teenager can be to life as an adult.

Elijah Cummings, before he passed away, was conducting some hearings on JUUL and vaping and the deceptive practices that they were engaged in. So, I decided that the Attorney General’s Office would do something about JUUL. We filed a lawsuit that is primarily targeted at the deceptive trade practices related to young people. While we think JUUL has to tell the truth to adults, too, their advertising to young people is particularly bad; it creates a very serious health risk to our society. So, we decided to take them on.

If JUUL wants to market an inherently hazardous substance to adults, they need to tell the truth about the risk they’re running, and then adults can make their

Thomas E. Kottke, MD and Attorney General Keith Ellison.

own decisions. But if you are lying to kids, we’re going to sue you.

TEK: Was there a particular trigger for the lawsuit?

AG Ellison: The stories in the paper about people dying piqued my interest.

When I dug into it, I became convinced that we needed to sue. And, I’ll tell you quite frankly, a very good friend of mine called me one day and told me that they were working for JUUL. And this good friend of mine told me that JUUL was “harm reduction” and that it was going to be a good thing for adults because it’s less hazardous than combustible cigarettes. I just thought to myself, “if these guys are hiring people with real bona fides in the civil rights area to convince me about how wonderful they are, they must really be desperate.” So, it had the opposite effect, right? They wanted to get me to think, “This is my buddy, I can be happy with what they’re doing.”

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The Journal of the Twin Cities Medical Society

In fact, it made me suspicious and that actually accelerated my investigation.

TEK: In the last lawsuit the state sold off the assets. Do you have a plan to prevent this from happening again?

TEK: Why has the state engaged Robins Kaplan, LLP again?

AG Ellison: We want to make sure that the money goes to the people who are the victims, and that includes institutions that have to pay for mitigation. We learned from last time that we need to be very clear in the law this time.

AG Ellison: While the Attorney General’s Office is absolutely in the driver’s seat on this lawsuit, there’s a voluminous number of documents that we’re going to have to sort through and tasks we’re going to have to take on. Therefore, we put out a request for quotations from outside firms and hired both Robins Kaplan and Zimmerman & Reed, Pllp.

Robins Kaplan, in particular, knows about the tobacco litigation — where the tricks are, and they understand the deceptions. The CEO of JUUL made it very clear publicly that they research the tobacco files to figure out how to do the marketing.

TEK: What level damages are you looking for?

AG Ellison: The damages will be substantial, but the amount is dependent upon what we find in discovery. Damages will have to be enough to compensate for the losses. Because our system of addiction recovery for teenagers is not well developed, we’re going to have to build new medical models. I believe JUUL needs to be responsible for that.

We’ll also be looking for mitigation laws and compensation to help free young people of addiction. And now JUUL says, “Oh, we don’t really market to the kids anymore.” Well, maybe they do, maybe they don’t, but even if they don’t, they’ve already addicted them. They’ve locked in their consumer base through addiction. So, we’re going to have to unlock that, and they’re going to have to help us pay for it. We know that if you experience addiction as an adult the neural pathways may not be so deeply grooved that you can’t break free of it, but if you get addicted as a kid while your brain is actually being mapped, that addiction may be even tougher than if you started as an adult.

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TEK: Who do you think ought to be responsible for allocating the resources?

AG Ellison: Part of it will be driven by the negotiation. I think the Attorney General’s Office is going to have to have some responsibility. I think we would invite the legislature to be part of it because, of course, it is their job to be in touch with constituents. What we’re not going to do is stick the money into the general fund and then just cut taxes for rich people. The legislature has an important role to play, but this money is to compensate for real damage that people have suffered; it’s just not a slush-fund to cut taxes for wealthy people.

S M C Edina, MN

R M B Burnsville, MN

TEK: Do you think the Clearway model has been effective?

AG Ellison: I don’t have any complaints about Clearway, but I am very mindful of the fact that Clearway is based on a problem that happened 20 years ago.

We’ve got to be adaptive to the moment that we’re in. Because the lawsuit is focused on the targeting of young people, we want to engage more young people in whatever new institution that might emerge. We want to make sure that the voice of young people and of educators is there in a way that may not have been in the past. We’re going to learn based on what happened before, and we’re going to be very mindful of the past as we go forward.

2800/2828 M B Minneapolis, MN

Leased By: ®

MIKE FLEETHAM

(952) 7672842

MFleetham@MedCraft.com

JOLENE LUDVIGSEN

(952) 8387126

JLudvigsen@MedCraft.com

Owned By:

TEK: Thank you for your time. Good luck!

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Promoting Primary Care

Primary Care as a High Value Proposition

O

ver the past 10-15 years there has been increased emphasis placed on “value” in health care.1 Yet, the meaning of what constitutes value varies; patients, providers, payers and policy makers have different ideas of what aspect of health care has more value and how these needs are to be computed.2 Despite this inherent challenge, there is a consensus emerging that a value-based model, as opposed to a volume-based one, will provide normative guidelines for better patient care.

One of the essential questions then is: What value does primary care contribute to health care? This question should look at the essential tenets of primary care as a way to understand the value proposition — that of first contact with the patient, continuity with individual patients, comprehensiveness in care and coordination of care with other disciplines.3 The context and the community in which care is delivered are also pertinent in the delivery of primary care.

Let us then look at “value” from different lenses.

The main thrust of “Value Based Purchasing” is about holding providers, or health systems, accountable for both cost and quality of the health care delivered.

What about the value of primary care in this? Do the transactional metrics favor primary care?

Cost of Care — Low Value Care (LVC), is a metric that looks at unnecessary expenditure due to tests and other medical procedures performed that do not

By Shailey Prasad, MD, MPH

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March/April 2020

improve quality of care. A recent study showed that Family Medicine physicians have, on average, $1.03 lower LVC spending. This was higher in the Midwest at $2.80, possibly due to increased primary care attributes in the Midwest.4 This shows that Family Medicine physicians tend to use less “low-value” or wasteful tests and procedures.

Having a primary care physician increases preventive care and lowers hospitalization rates. This has shown to decrease total healthcare costs in areas with higher ratios of primary care physicians to population.3 This is also shown to be true among elderly living in metropolitan areas in the US.5 Medicare claims data analysis also shows a linear decrease in Medicare spending with an increase in the supply of primary care physicians, as well as better quality of care (concerning the treatment of six common medical conditions).6 Relationship with a primary care physician — In general, patients prefer relational value from interactions with the healthcare system rather than the transactional value that payers look at.7 The cornerstone of this is patient satisfaction.

Multiple studies have shown that continuity of care is the best predictor of this,8 and has strong correlation to improved chronic disease management, decreased emergency department use and improved quality of care.9 Adults in the US who reported having a primary care physician rather than a specialist, after controlling for differences in health status, smoking status, health insurance status, reported diagnosis and demographic characteristics, had lower five-year mortality rates. In other words, patients identifying with a primary care physician for their usual source of care are healthier, regardless of demographic characteristics and initial health status.10 Paul Batalden, healthcare quality thought leader, emphasizes the need to “co-produce” quality between the patient and the provider,11 and a requirement for this would be a trusted relationship between a patient and a primary care provider.

Health Equity — Primary care physicians, particularly Family Medicine physicians, provide a disproportionate share of medical care for medically underserved (poverty, disadvantaged minority, uninsured) populations in the US.12 In the US, income inequality significantly increases all-cause mortality, heart disease mortality and cancer mortality. However this effect is considerably decreased when the number of primary care physicians is high.13 The impact on decreasing all-cause mortality is four times greater in the African American population than in the white majority population when there is greater supply of primary care physicians, indicating that primary care presence has a direct impact in decreasing racial disparities.14

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Population level impact — Multiple studies have shown that the stronger the primary care orientation (measured by the comprehensiveness of services provided by, and multiple family members cared for, by a primary care provider) the lower the rates were of all-cause mortality, all-cause premature mortality, and cause-specific premature mortality from pulmonary diseases, and cardiovascular disease. This was seen in 18 developed countries, including the US.15 While the US is generally considered low in primary care orientation, increasing the primary care score by 25% in the US is projected to reduce premature deaths from respiratory illnesses by about 6.5% and reduction in premature cardiovascular mortality could be as high as 15%.12 The typical image of a primary care physician is that of a Marcus Welby. The tenets that made the fictional Dr. Welby successful: broad-spectrum practice, longitudinal continuity with the population that he served and inspiring confidence in the work that he did, is not a myth. Today’s primary care physician is all that and satisfies various aspects of “value” in the healthcare delivery. We need to continue to nurture and grow more to improve the efficacy of our healthcare system.

The US is far behind in the supply of primary care physicians. There is a projected shortage of around 35,000 primary care providers in the US by 2025.16 This is particularly important as the supply of primary care physicians, particularly Family Physicians, is shown to decrease all cause mortality.10 An increase of one primary care physician per 100,000 population has been projected to decrease as many as 127,617 deaths per year in the US.10 The University of Minnesota (UMN) consistently ranks among the top three in sending medical students to Family Medicine and other primary care fields. The Minnesota Medical School is the one of two medical schools in the country ranked in the top quartile of NIH research and overall social mission score (measured by the percentage of graduates practicing primary care, work in underserved areas, MetroDoctors

and are underrepresented minorities).17 The Department of Family Medicine and Community Health at the UMN has had 1,940 graduates since 1970 and serves 80% of Minnesota counties. While these numbers are laudatory, we need more primary care physicians trained to take care of the projected shortage of 35,000 by 2025.16

The Journal of the Twin Cities Medical Society

Shailey Prasad, MD, MPH is the Executive Director and Carlson Chair of Global Health, Center for Global Health and Social Responsibility. http://globalhealthcenter. umn.edu/, Professor & Vice Chair for Education, Dept. of Family Medicine and Community Health, University of Minnesota.

References available upon request.

April 4, 2020 McNamara Alumni Center University of Minnesota

Health Professionals for a healthy climate

for patient earth Come learn how climate change is impacting health, and how health professionals and health care institutions can take action to meet these challenges!

Registration is now open at... http://z.umn.edu/codeblue

Featured keynote “The Psychology of Climate Change” Christina Manning, PhD, Macalester College

March/April 2020

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Promoting Primary Care

Colleague Interview: A Conversation with Renee Crichlow, MD

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enee Crichlow, MD, FAAFP, is the Director of Advocacy and Policy and Assistant Professor, University of Minnesota School of Medicine, Department of Family Medicine and Community Health. She serves as faculty on the North Memorial Family Medicine Residency Program. Dr. Crichlow is board certified in Family Medicine and is currently the President of the Minnesota Academy of Family Practice.

This Interview has been edited for clarity and length.

When did you decide to train in Family Medicine?

Please tell me about yourself.

When I went to medical school, I remember being on campus the first day and someone asked me, what do you want to go into when you graduate? “I want to be a doctor; I want to take care of people.” Like, what specialty? “Doctor. A doctor who takes care of people.” Well, then you probably want to be a Family Medicine doctor. “OK, then I want to be a Family Medicine doc.” I really love taking care of people their whole life — a grandma and her grandchildren. I love babies and delivering babies. I love hospital work and sitting down in the outpatient clinic with my patients that I’ve known forever. I love the continuity and comprehensiveness and I love the opportunity to be involved in people’s life choices for their whole life. I really enjoyed my third year of medical school and every rotation told me that I should go into that specialty. I just nodded and said, thank you, I appreciate it, but I like taking care of all the people and not having to let them go. If I can’t treat what they need at that moment, I can take care of the rest of them. And, I love translating for my patients. When I refer them to a specialist that they need to see, they come back to me to convey what the specialist is trying to say to them. I love not letting them go. I love walking into a room and patients say: “you delivered my grandbaby.” I’ve seen their kids — I’ve been here for 10 years and I’m seeing kids that weren’t even walking.

I also love taking care of end-of-life issues. You get to be there

I grew up in Oklahoma, went to medical school in California and did a residency in Family Medicine at UC Davis and then was hired on as faculty with joint appointment in Family Medicine and OB/GYN. I was there for a few years but always wanted to live in Montana. Once I learned there was a residency training program in Montana I called them and we agreed that I should work there. I lived in a town called Red Lodge, Montana that had about 2,500 people. Our residency was in an FQHC (Federally Qualified Health Center) and we had several different sites around the county. I had my son there. But, for family reasons, we moved to Minneapolis. I had an opportunity to check out North Memorial’s Residency Program and found that it had all the aspects that I really loved about UC Davis — a really strong Family Medicine Department and also a really strong community-based hospital, which is what I really loved about Montana.

North Memorial has an amazing environment for teaching as we have a large availability of patients, a variety of acuity and we get to serve our community in the clinic, the hospital and out in the community. I think that is a really great way to train residents because so much of what causes people problems is outside of the exam room.

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The Journal of the Twin Cities Medical Society

to help them discuss care with their families. A lot of times you don’t get to cure things, but you can help them heal. It’s a sacred honor to be engaging with people at the times of challenge and being their doctor.

Has the practice of Family Medicine changed over the last 10-15 years?

There are many great medications that help patients be in control of their disease, e.g. Metformin for type 2 diabetes, Flonase for allergies, asthma medications, as well as new medications for treating depression and hypertension. What’s been bad is that I think we are living in the worst possible time for the EMR. It’s just good enough to make people crazy. When I dictated or hand wrote notes, my day was finished when I was done with clinic. We’ve trained an entire generation of people that spend two hours to every one hour they are in clinic to just finish their charts in a way that are appropriate for billing. EHRs were built for billing and not for taking care of patients. I think right now we are in a time where things are evolving; Artificial Intelligence (AI) is going to be very big in taking the WAC (work after clinic) burden down, or even remove it. I’m working on a pilot project with folks who have an AI device that is actually in the room with you that compiles your conversation with your patient and fills out your EMR. It engages with EPIC; you tell it to order something and it does it and then writes up a draft of your note; you approve it or change it. I think things like that are going to bring a lot of the joy back into practice. Physicians really need to get involved in the next stage of AI development because we weren’t integrally involved in the development of the EHR and we are paying the price for that. Technology needs to be something we (physicians) are on the ground floor in the development of. Our national academy, the American Academy of Family Physicians, has taken on a multi-year project working with AI companies developing the ground floor technology because we have seen what happens when we let other people design things that get between us and our patients. Any technology should facilitate the care between us and our patients — not obstruct our ability to engage with them.

How does primary care benefit the patient more than having multiple specialists?

If you look at the idea behind primary care, it is comprehensive and there is continuity. Those two things, especially for folks with chronic illness, folks trying to prevent chronic illness, and/ or people who are trying to engage in a healthy life, they have someone who knows them and has a relationship that engages trust. A healthy young person may not need to see me that often, a reproductive-aged woman may come in for her annual exam and if she doesn’t have blood pressure issues, diabetes, etc., she may just need to discuss preventive care every year or two. But, if she gets a cold, she knows she can trust me, and can trust MetroDoctors

The Journal of the Twin Cities Medical Society

me enough when I say, this is a cold and not pneumonia. That trusting, continuity of care relationship decreases unnecessary tests. I have a lot of patients with multiple chronic illnesses. In one visit I can take care of their diabetes, high blood pressure, reproductive issues and cold. Are you going to four different doctors that day? Or, are you going to talk to me, someone you know, and we’ll work through it? Data shows that primary care provides better health outcomes and lower costs. We can take care of undifferentiated conditions that are not life-threatening. If the patient doesn’t have that relationship with a physician they can trust who is watching for “red flag” issues, it can lead to so many unneeded tests, unneeded procedures. I’m watching for those red flags, so if they show up I can do what is appropriate and refer to the specialist to do their specialty stuff when needed.

Has the medical school’s curriculum prepared incoming residents sufficiently?

A big change is communication with patients. The University of Minnesota does a pretty good job in getting students engaged in communicating with patients, taking H&P’s and building relationships. I think that they are coming to us with a little more nuanced approach to patient communications, so I really like that.

I don’t know if they are getting as many procedural chances as I did when I was in medical school, but we can teach them that once they get to residency.

Have the expectations of the residents changed over the last 10-15 years?

Work hour rules have changed a lot. There is more shift work and I think that is just a part of the culture now. The EMR came out at about the same time as burnout was being first talked about.

Throughout the whole country everyone is stressed. Is there more burnout? We probably identify it more and our residency engages in proactively teaching resilience and building resilience into our program. We allow people to recognize it now.

How much OB, operative OB and Surgery is being taught in residency?

We have a very high-volume OB residency training for our residents. All our residents graduate with the ability to go into non-operative obstetrics if they want to, and, if I remember correctly, 40% of our grads continue OB in their practice in some manner, especially for those who go rural. Most of the doctors who go rural continue their OB practice. To do operative, c-sections, people get further training. We have an amazing prenatal and OB panel where we have a very high risk, high acuity panel of patients, but we also have one of the lowest c-section rates, even throughout the country, and even though we have a very high-risk (Continued on page 12)

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Promoting Primary Care Colleague Interview (Continued from page 11)

population. It is one of the things we can be most proud of is that we manage complicated cases and get the most successful vaginal deliveries — and then we take care of their kids. We have a very large pediatric population in our patient panel.

Do you use non-physician care providers? If so, how is this working?

I think team care is necessary now and will continue to be in the future. Non-physician clinicians, including Physician Assistants and Nurse Practitioners are a great asset to the primary care team.

Collaboration is very important and we respect everyone on the team as they practice to the level of their license. We are all part of the team and it is a good practice.

Please address patient safety and quality outcomes, especially in non-metro areas.

Having been someone who practiced rural, I would say that it is an interesting situation when you are a distance from high level acuity care. The number one thing we teach is how to stabilize and mobilize; knowing what you can care for and knowing when a higher level of care is required. It’s a complex set of issues and I don’t think there’s an easy answer. North Memorial Health is a Level 1 Trauma Center. You can’t have Level 1 trauma centers everywhere, therefore the best thing you can do is to match the patient condition with access and resources available. I think everyone is doing their best. Family physicians cover the majority of greater Minnesota and we have some of the best healthcare outcomes in the country. The system is not perfect here with a lot of opportunities for improvement, especially in our health inequities (both urban and rural) but, we have the best components to be the best healthcare systems in the country.

You are the founder of The Ladder. What are the objectives and what inspired you to start it?

The Ladder is a mentorship organization. We call it a “cascading mentorship” for kids in the low wealth communities interested in healthcare careers. It was started in 2012 for people ages 9-99.

The goal is to get kids engaged before they get into middle school and then we recruit high schoolers, undergraduates, medical students, practicing physicians, nurses and pharmacists who all come together the second Saturday of every month to build an organization of support, resiliency and encouragement, because at each of those levels you need support, resiliency and encouragement. One of my friends calls it “near peer mentoring.” One of the things that I found when I was younger is that you learn most about medicine, life and careers from the people 2-3 years ahead of you. So, our goal is to get this sort of ladder of folks in the pipeline of medical education and help each other get to the 12

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next level. The high schoolers are there as great examples for the middle school students and the college students are great examples for the high school students and they are able to tell them, you need to do this to get your applications in on time, do this test prep, etc. A large portion of attendees are people of color who are underrepresented in medicine. I have medical students who love coming to The Ladder as it is one of the places where they are not the only brown person in the room — it helps them to continue on in medicine. Every second Saturday we come together, we eat together, we tell stories. We always put up two quotes and you have to choose one of the quotes and tell a story about it, such as: Fall down 7 times, get up 8; or, you have two hands — one to help yourself, the other to help another. I like the Fall down 7, because I went to three different undergrad institutions before I graduated medical school and I now teach at one of the best medical schools in the country. So, younger students are seeing that failure is a part of growth and success. Our real goal is to just support each other at every single level and encourage each other to get to that next level. Some of these kids are at a place where it’s not easy being a smart kid; at The Ladder it’s great being the smart kid. We have tons of smart kids and kids who don’t know how smart they are yet. After we eat and tell stories we do rotating stations where they learn how to use AEDs, read chest x-rays, learn how to splint something. Last month it was learning how to do surgery, how to suture. Hands on learning keeps them excited and keeps them coming back. It’s really about support, building resilience and encouraging each other. Everyone volunteers their time and everyone gets something out of it. Today there are four active chapters throughout the country.

How has Broadway Clinic impacted North Minneapolis?

As an attending and preceptor, we say hi to all patients in the room and thank them for coming to Broadway Clinic. We hear from the patients that we are a part of their lives, a trusted part of their lives. There are a lot of good clinics in our community; our graduates come back to practice here and stay in North Minneapolis. It’s considered a trusted, safe place by the people who we care for and I think that’s important.

What’s your role in the Minnesota Academy of Family Practice?

I am the current MAFP President. MAFP is the largest single-specialty physician organization in the state of Minnesota. It’s awesome. We are membership-led and policy development is through membership engagement. Our vision is that all Minnesotans will have the best healthcare outcomes and Minnesota will be the best place to practice Family Medicine. Currently, we are working in collaboration with many stakeholders and other organizations on prior authorization issues, workforce development, and payment reform. I love teaching and practicing Family Medicine and so this has been an honor to serve.

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The Journal of the Twin Cities Medical Society

Primary Care in Rural Minnesota Health Care Economics Presents an Ever-Fluid Reality Rural or urban, young or old, when you need care, you want it to be there for you — affordable, high-quality, and centered around your needs and goals. But the healthcare delivery and payment system is incredibly complex. Hospitals, clinics and individual healthcare providers throughout Minnesota are constantly adapting to market changes on all sides — new organizational affiliations, consolidation, value-based budgeting, population health pressures and declining inpatient care. In rural areas, the challenges can sometimes be more complex and require solutions that are tailored to rural needs. Relatively higher use of government healthcare programs, declining payment rates, changing insurance mandates, and intense workforce issues in rural Minnesota require that we continuously assess and analyze trends to help ensure our healthcare systems are positioned to provide necessary, affordable and appropriate care in communities all across the state.

The Minnesota Department of Health’s (MDH) Office of Rural Health and Primary Care tracks Minnesota’s rural health systems and access to primary care for our rural residents, and uses that data to develop and implement programs to address rural healthcare needs.

The map of hospital affiliations shown below begins to reveal the complexities of current market trends.

In 2017, half of Minnesota’s rural hospitals were affiliated with a larger provider group. This trend yields mixed results. Hospitals that are part of larger systems may offer increased access to specialty services and may increase their financial viability. But, affiliation can also lead to consolidation of services, meaning some services may be less available in rural areas, and patients may face transportation and other barriers in accessing them. The Data Highlights report also shows how noncompetitive hospital markets are in Minnesota. Analysis shows that highly

concentrated healthcare markets can lead to higher prices.

We know that rural areas face a severe shortage of primary care physicians, including OB/GYNs, pediatricians and psychiatrists. Nine Minnesota counties lost hospital birth services between 2003 and 2018, with recent studies finding that increases in preterm births have been associated with the loss of these services in rural areas.

Finally, we cannot underscore enough the impact closure of a healthcare facility has on its community. In many rural areas, the clinic or hospital is one of the largest employers in the area, as well as being an important part of a community’s identity. The loss of readily accessible health care causes great hardship to any local community, and then creates a domino effect that makes it harder for other parts of the community to grow. Young families may find it difficult to move to a community that does not offer healthcare services.

We are still digging into how consolidation affects rural populations, particularly (Continued on page 14)

Rural Health Care in Minnesota: Data Highlights On National Rural Health Day 2019, MDH published Rural Health Care in Minnesota: Data Highlights (https://www.health. state.mn.us/facilities/ruralhealth/docs/ruralhealthcb2019.pdf ), a chartbook of data from across the department that “paints a picture” of rural health care in Minnesota.

By Zora Radosevich, MPA MetroDoctors

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Promoting Primary Care Primary Care in Rural Minnesota (Continued from page 13)

when it comes to primary care. We do know that there are fewer primary care physicians in independent practices across the state.

We’re gathering economic data from a variety of sources to better visualize and understand the rural healthcare map to help rural communities anticipate changes in healthcare delivery.

Primary Care Improving access to health for rural and underserved Minnesotans is the core purpose of Minnesota’s Office of Rural Health and Primary Care (ORHPC). Ensuring access to primary care plays a large role in what we do. Studies show that focusing on primary care can lead to better health outcomes and lower costs. We also know that the presence of even a single primary care provider has a significant effect on the economic vitality of a rural community.

Workforce Shortage In addition to healthcare workforce shortages across rural Minnesota, we have a serious mal-distribution of primary care providers.

The majority of providers work in urban areas. As a result, rural areas face a more severe shortage, especially when it comes to primary care and mental health. In fact, 80% of Minnesota counties qualify as mental health professional shortage areas and 62% of Minnesota counties qualify as primary care shortage areas. In addition, we know that rural physicians are older and closer to retirement than their urban counterparts, underscoring the need to increase efforts to recruit providers to rural Minnesota and build a more effective pipeline of rural providers.

Improving the Pipeline Currently, we are addressing this in a number of ways. Minnesota has a robust healthcare loan forgiveness program (https://www. health.state.mn.us/facilities/ruralhealth/ funding/loans/index.html) for healthcare professionals that has demonstrated a 72% retention rate for rural physicians over the last 25 years. Physicians and other health professionals who choose to practice in rural areas or among the urban underserved can have significant portions of their school loans

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forgiven in exchange for practicing in these areas. Expanding this program to recruit additional physicians for the hardest hit areas of the state is a promising concept. We welcome input on identifying providers motivated by the opportunity afforded in rural practice to deliver the full scope of services.

One of the surest ways to promote practice in rural areas is to provide more training in rural areas. It is well-known that people tend to practice where they train, and Minnesota could do a better job of providing these opportunities. To this end, we are working on several fronts to learn what it takes to build more rural tracks for physicians and other primary care providers. Minnesota has had great success with the Rural Physician Associate Program (https://med.umn. edu/md-students/individualized-pathways/ rural-physician-associate-program-rpap), a nine-month, community-based educational experience for University of Minnesota third-year medical students who live and train in rural communities across Minnesota and western Wisconsin. We are interested in exploring whether some of those sites could add residency programs.

In addition, ORHPC administers several grant programs to encourage the development of more rural and primary care residency programs, including: • The Primary Care Residency Expansion Grant to help with planning and the initial funding; • The Rural Family Medicine Residency Grant to support new and existing residency programs in rural Minnesota; • The International Medical Graduates Primary Care Residency Grant for Minnesota IMGs who agree to practice in rural and underserved areas of the state; and • The Health Professional Clinical Training Expansion Grant to expand clinical training for other primary care providers.

In order for these programs to have real impact in expanding the number of residencies in rural Minnesota, we are working to understand the longer-term needs in creating new residency slots.

Scope of Practice ORHPC is also interested in promoting practices that allow primary care professionals to work at the top of their license,

especially in underserved areas where the alternative can mean no access to service.

Physicians can’t do it all on their own, especially when the population-to-provider ratio for primary care physicians is so much higher in small towns and isolated rural areas compared to metropolitan areas of the state.

In all areas of rural health care, it seems clear that more can be done when clinical education, training and on-site practices like care coordination, which MDH’s Health Care Homes program actively promotes, continue to encourage team approaches where everyone makes the highest and best use of their skills and abilities.

Conclusion Ensuring that Minnesota’s rural health and healthcare system remains strong, financially stable, and able to meet the needs of all rural residents through all stages of life is critical.

While the needs of rural communities are unique, so are the opportunities, energy and partnerships that exist in rural areas.

In Minnesota and across the nation, exciting new models are being developed and tested — e.g., primary care and community collaboration models, global budgets for rural hospitals, and population-based or value-based payment systems centered around rural needs and challenges. These all hold promise for ensuring that our rural health systems thrive. ORHPC continues to work with community members, healthcare providers, legislators, members of the Governor-appointed Blue Ribbon Commission on Health and Human Services, and experts from around the nation to learn more about these strategies and how they could be used successfully in Minnesota.

The issues of rural health are complex, and we’ll continue to work with communities and providers to build multi-faceted responses that adapt to changing times while valuing the economic and social networks that drive rural life.

Zora Radosevich, MPA brings a passion for rural health and the viability of rural communities to her role as director of the Minnesota Office of Rural Health & Primary Care.

Zora has an MPA from the Harvard Kennedy School, and has served as an adjunct faculty member at the University of Minnesota. She can be reached at Zora.Radosevich@state. mn.us, (651) 201-3859.

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Family Medicine Obstetrical Care: Partners in Providing Maternity Care and Improving Outcomes

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n the state of Minnesota, Family Medicine physicians are an integral part of the primary care workforce, and the role of family physicians varies significantly in communities and practices across the state. Family physicians are ubiquitous within a variety of healthcare settings throughout the state, from urgent cares and emergency rooms to long-term care facilities, tertiary care centers to critical access hospitals. We are in rural, suburban and urban community clinics, large hospital system-based clinics, FQHCs, direct primary care practices including mobile clinics and tribal clinics.1 We have addiction medicine and gender affirming hormone practices, we teach in our state’s medical schools and we serve in local and state government. We are also a strong presence in labor and delivery rooms and nurseries.1 The philosophy of Family Medicine is wide-reaching and yet very specific: we care for individuals, families and communities from birth to death and everything in between. Our guiding principles include listening deeply to our patients, families and communities, balancing their needs and preferences with evidence-based medicine. Comprehensive care for the whole person is our area of expertise. The American Academy of Family Physicians (AAFP) states on their website, “Unlike other specialties that are limited to a particular organ or disease, Family Medicine integrates care for patients of all genders and every age, and advocates for the patient in a

By Andrea Westby, MD, FAAFP and Cora Walsh, MD, MSc

MetroDoctors

complex health care system.�1 As we work together as a medical community to address complex issues such as maternal morbidity and mortality and the racial disparities within these outcomes, Family Medicine physicians remain an important partner in the Twin Cities medical community.

For many family physicians, obstetrical and prenatal services Cora Walsh, MD, MSc are an essential component of Andrea Westby, MD, FAAFP the care they provide, contributing to significant joy in practice, stavdelivery. Family physicians often see paing off burnout, and preserving a wider tients who are among the most vulneraspectrum of practice. Nationally, 18% of ble during the pregnancy and postpartum family physician members of the AAFP period such as women of color, Medicaid report providing obstetrical care, and 32% recipients, people with unstable housing 2 provide newborn care in their practices. or living in poverty, and people with a In the United States, approximately onenumber of significant chronic diseases such third of pregnant women report having as substance use disorders, hypertension, received care from a family physician in diabetes and other mental health condithe previous year.3 tions.4,5 In situations where patients have While more often thought to be very high obstetrical or medical risk, family associated with rural settings, family physicians are an important touchpoint for physicians are currently providing comspecialist, obstetrician and maternal-feprehensive obstetrical care across the tal-medicine referrals and overall coordiTwin Cities metro area through North nation of care.

Memorial Health, Allina Health, Health In a 2019 editorial in American Family East/Fairview/MHealth, HealthPartners/ Physician, Katy Kozhimannil, PhD and Park Nicollet, Hennepin County Medical Andrea Westby, MD outlined how famCenter, Northpoint Health and Wellness, ily physicians are part of the solution to Northwest Family Physicians, Entira Famreducing maternal mortality.6 They highily Clinics, United Family Medicine, and lighted the unique role of family physicians MN Community Care (formerly East Side in addressing health risks in the postparCommunity Health). In the majority of tum period such as breastfeeding issues, cases, family physicians continue to remain postpartum depression, and intimate parton-call for their individual obstetrical paner violence during newborn visits, as a tients in order to preserve continuity in the physician-patient relationship through (Continued on page 16)

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Promoting Primary Care Family Medicine Obstetrical Care (Continued from page 15)

“one-stop-shop” for parents and children alike. Family physicians often see siblings and parents in concurrent or consecutive office visits, and this continuity is highly valued by providers and the patients who choose family medicine physicians for their maternity care. Further, as recognition grows of the importance of continued care through the 4th trimester in improving maternal outcomes, combining maternal and child access to care with the same physician may support efforts to improve these outcomes.

Despite the plethora of specialty medical services available in the Twin Cities, for many urban underserved patients barriers to care may still exist in the form of transportation difficulties, financial and insurance barriers, or historically rooted mistrust of the medical system. For such patients, community clinics, continuity of care with a single physician and the capacity to address multiple medical issues within a single visit may take on even greater importance in facilitating access to care.

“For me, the opportunity to provide a family with a continuity of care — starting before pregnancy, through prenatal to birth, and then including infancy and childhood — allows me to have a deep impact on their long-term health and wellbeing.

The moment of childbirth is so central to that journey. Being in the delivery room and helping them bring their child into the world creates such a powerful, trusting bond between me and the family. I feel that it enables me to be an even more effective guide and advocate for them down the road.” — Nancy Struthers, MD; Physician Lead for Family Medicine Obstetrics at Allina Health, East Metro Region.

In addition to clinical risks, family physicians have a role in addressing social determinants of health. Family Medicine clinics often have robust care coordination and referral systems for addressing social needs such as food insecurity, housing 16

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instability, financial difficulties, insurance lapses and community support. Family physicians are also known in the medical and public spheres for their dedicated activism and advocacy on behalf of patients and communities.

Family Medicine residency training incorporates routine prenatal care and births as a standard, although some family physicians also choose to do an Obstetrics Fellowship to gain further experience in interventional obstetric care such as surgical training in Cesarean section. There are 46 Board of Certification in Family Medicine Obstetrics (BCFMO)-recognized Family Medicine-Obstetrics fellowships in the United States, including two in Minnesota.7 Additionally, the AAFP annually hosts a high quality and highly popular CME course called Family Centered Maternity Care,® and it developed the Advanced Life Support in Obstetrics (ALSO®) course and certification, which focuses on preparing participants for obstetrical and medical emergencies in a team-based approach.

As the field of obstetrical care continues to evolve, challenges have emerged that have resulted in fewer numbers of family physicians continuing obstetrical care as a component of their practice, perhaps most notably in rural areas where the need for obstetrical providers is often greatest.4 The AAFP Obstetrics Member Interest Group identified the following challenges to Family Medicine OB care and target areas of advocacy:8 • Improving access to job and proctorship opportunities for AAFP members practicing maternity care and rural medicine • Removing barriers to physician credentialing in rural and physician shortage areas • Supporting fair reimbursement for maternity care services in rural areas • Ensuring hospital operative and non-operative obstetric privileges for family physicians In both urban and rural settings, Family Medicine physicians providing obstetrical care continue to fill an important clinical role whether due to patient barriers

to accessing other models of obstetrical care or patient preference for a Family Medicine model of care. It is critical that we continue to address challenges to Family Medicine physicians incorporating obstetrics into their practice, to maintain Family Medicine physicians as partners with OB/GYN, midwifery, maternal fetal medicine, nursing and community health in improving maternal health outcomes in the Twin Cities and across the state.

The cross disciplinary care we offer within the Twin Cities and as partners working together makes us a stronger medical community for our patients.

Andrea Westby, MD, FAAFP, Assistant Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, and full spectrum Family Medicine faculty at North Memorial Family Medicine Residency program. She can be reached at: westby@umn.edu.

Cora Walsh, MD, MSc, Family Physician with Obstetrics, Allina Health, West St. Paul Clinic. She can be reached at: cora.walsh@ allina.com.

References 1. American Academy of Family Physicians, Get to Know the Academy, “Family Medicine Specialty”. https://www.aafp.org/about/the-aafp/ family-medicine-specialty.html. Accessed Jan 24, 2020.

2.

American Academy of Family Physicians, Get to Know the Academy, “Family Medicine Facts”, statistics from 2018 member survey, Accessed Jan 24, 2020. https://www.aafp.org/about/ the-aafp/family-medicine-specialty/facts/table-11(rev).html.

3. Kozhimannil KB, Fontaine P. Care from family physicians reported by pregnant women in the United States. Ann Fam Med. 2013;11(4):350– 354.

4. ACOG Committee opinion no. 586: Health disparities in rural women. Obstet Gynecol.

2014;123(2 pt 1):384–388.

5. Gregory DS, Wu V, Tuladhar P. The pregnant patient: managing common acute medical problems. Am Fam Physician. 2018;98(9):595– 602.

6. Kozhimannil KB, Westby A. What Family Physicians Can Do to Reduce Maternal Mortality.

Am Fam Physician. 2019 Oct 15;100(8):460-461.

7.

American Board of Medical Specialties, “Board of Certification in Family Medicine Obstetrics (BCFMO)-recognized Family Medicine-Obstetrics fellowships”. https://www.abpsus.org/family-medicine-obstetrics-fellowship-programs.

Accessed Jan 24, 2020.

8.

American Academy of Family Physicians, Member Interest Groups, Obstetrics MIG. Accessed Jan 24, 2020.

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Family Medicine and Primary Care: Challenges Mount, But Solutions Exist

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n the 1969 feature film Butch Cassidy and the Sundance Kid, our heroes face an impossible choice: to either be captured by the pursuing posse, or jump off a cliff into a raging river. An embarrassed Sundance at first declined to jump, confessing he couldn’t swim. Butch chuckled and assured him it didn’t matter; the fall would most likely kill them both.

Similarly, difficult choices face today’s primary care providers. They must either: spend long hours navigating the myriad of escalating requirements of the healthcare industry (payers, regulators, EHR) to fulfill a myriad of escalating requirements, or work tirelessly to maintain a delicate balance of professional and home life. And for most, neither is likely to happen.

Primary care systems nationwide are in crisis. As systems rapidly adopt changes to their care models, providers are put at risk. They are expected to respond to rapid and often haphazard implementations of electronic health record systems, worsening reimbursement, and an increasing demand for quality measure reporting.

These, and many other factors, contribute to provider burnout that has becoming increasingly common.1 As even more time is needed to keep up with the demands of the EHR and other administrative tasks, less time is available to attend to the needs of patients.

Frustrated Providers

Providers spend increasing amounts of their time outside of clinic hours corresponding with patients via email, Epic

MyChart, and text messages. This time is usually non-reimbursable but takes its toll on providers available time. They are also expected to increase productivity as reimbursement lags, and commonly see their professional life infringing on home life as “pajama time” — a term used to describe EHR and other work done at home — an average of 86 minutes of additional time per day — that could not be fit into the clinic day.2 Current practices such as limited clinic visit lengths and productivity needs force a lessening of connections between providers and their patients, connections that providers often cite as the most enjoyable part of their practice. While attempting to balance work and home and lessen the effects of burnout seen in the majority of primary care providers, many choose to work other than full-time as a career choice.

their specialty focus based on their own unique passion and interest. They were often influenced by faculty mentors or those practicing in specialties that the student might have an interest in pursuing.

Students might come to family medicine and other primary care specialties with an altruistic view of the world or as a way to serve their communities. In our residency program, we look to acquaint medical students with Family Medicine as a specialty that provides continuing and comprehensive care for individuals and families, seeing the relations with patients as a special and trusted bond.

But it is increasingly difficult to teach learners the joy of practice while at the same time acknowledging the difficulty parsing time among numerous priorities.

As new providers become familiar with the workload required to care for their patients, their enthusiasm wanes. They are more often seeing primary care specialties as less desirable as they recognize the increasing level of work expectations (both in hours and in intensity) that will be placed upon both them and their families as they start out their careers.

Debt as New Focus

Specialty decisions are also often based on future compensation rather than personal passion. As the level of debt (medical school tuition and living costs) that medical students incur rises, loan repayment becomes a significant influence on specialty choices.

The increasing debt load that many residents carry further dampens their

Future Career Choices Affected

By Jerry Potts, MD

MetroDoctors

Traditionally, medical students chose

The Journal of the Twin Cities Medical Society

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Promoting Primary Care Family Medicine and Primary Care (Continued from page 17)

passion for Family Medicine and other primary care specialties. Medical students regularly speak of their specialty choice as driven by the need to repay their student loans, rather than a choice based on a passion for the specialty itself. Many come to residency training with significant debt (often more than $350,000). They are increasingly resigned to paying off their debt throughout their career or choosing to live an austere lifestyle for many years to repay their debt more rapidly.

Solutions

But solutions to these worrisome issues, e.g. increased administrative workload, lack of home/work balance, student debt, do exist, if we can muster the courage to act.

Restructured financing of medical education could make a significant difference in the number of students choosing primary care specialties. The elimination of medical school tuition (as NYU has done) or a wider use of forgivable loan programs (based on specialty choice) are two innovative ways to reduce or eliminate medical student debt. Such plans would both promote freedom in specialty choice and enhance career satisfaction.

Such programs, properly focused, could also address the critical shortage of primary care providers.

Those who are in charge of federal healthcare budgets (such as CMS) acknowledged that the coding expectations placed on systems is convoluted and excessive. Counting elements in a physical exam or the number of problems addressed in a visit is a tedious and inaccurate process to measure care. Within the next year, new E&M coding regulations will be deployed that will hopefully lessen some of this coding burden. It is a modest step at best, but at least acknowledges the administrative burden placed on systems to simply ensure they are properly reimbursed.

Team-Based Care Approach

To reverse the concerns of overwhelming administrative work and provider burnout, 18

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the clinic care model needs to change.

It is evident that the model that places the provider at the center of all patient care activity is flawed. Such a model is not built for current and future patient or system needs. To embrace a truly patient-centered focus, systems must align with patients and providers. Meeting the patient where they are comfortable (home, clinic), communicating with them in ways that work best for the patient (clinic visit, email, text), and encouraging the team to be the source of care are all ways that the present model can improve. Developing a sophisticated practice infrastructure for form completion (a significant clinic and provider burden), chart updating (meds, problem lists, allergies, results), healthcare staff trained to review patient registries to encourage needed care in a timely way, shared in-box responsibilities, and quality measure reporting are important ways to meet the needs of patients and payers, and reduce the overhead burden placed on providers.

To bring about this transformation from provider to team, from individual to group care, regulations must be examined to allow others (besides the provider) to initiate, complete and be reimbursed for the care provided to the patient. Systems must demonstrate a willingness to move beyond viewing the clinic visit as the anchor point for where and how all care is provided, and move to a multi-dimensional view of care provided by a variety of resources, in a multitude of ways, dictated by the needs of the patient, not the requirements of a system.

Care Model Change Roadmap

Care model solutions will vary based on the type of practice and the needs of the patient. Some ideas that have been shown to be successful in practice include: • Proactive planned care between visits • Team-based care that includes expanded rooming and discharge protocols, standing orders and panel management • Shared clerical tasks including documentation, order entry, and prescription management

•

Protocols that allow nursing and support staff wider latitude for handling traditional provider work (inbox messages, initiating orders, results communication)2

Patients See Change Coming

Patients can sense opportunities other than clinic visits to obtain care. Smart phone apps assist patients to collect data for their own use and share with their providers.

“Dr. Google” is often the first place patients turn to with a health concern. Enhanced EHR access (such as Epic Open Notes), group visits, telemedicine (Virtuwell and online “clinic visits”), all let patients access care in convenient and timely ways. When patients have the opportunity, they show interest in more varied ways to access care. Telehealth, especially in more sparsely populated areas, can allow patient access to primary care providers and other healthcare professionals that might not otherwise be available.

As healthcare systems fail to embrace the changes that patients clamor for, they face an overtaxed system where ED visits are often the default care site available. But if primary care practices can embrace, and regulatory agencies can support, improving care models and systems can reverse their role in the growing career dissatisfaction among providers, and primary care can remain the most effective and comprehensive care model for patients into the future.

Jerry Potts, MD is the Chair, Department of Family Medicine, Hennepin County Medical Center. He can be reached at jerome.potts@ hcmed.org; (612) 873-8077.

References 1. 10 Bold Steps to Prevent Burnout in General, Internal Medicine J Gen Intern Med, Jan 2014; vol. 29 no. 11: 18–20.

2. Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations, Ann Fam Med, Sep/Oct 2017; vol. 15 no. 5: 419-426.

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The Journal of the Twin Cities Medical Society

Primary Care in the West 7th Community — Tradition and Evolution

T

he Twin Cities is fortunate to have many strong Family Medicine residencies, and United Family Practice Residency (UFPR) is no exception. This 27-year-old residency program is steeped in rich St. Paul history, staffed by a faculty, about half of whom have been with the program for over 20 years, inspired by residents who are drawn to the program from all over the country, and housed in a Federally Qualified Health Center (FQHC).

The unique local nature of UFPR is evident from the moment residency applicants set foot into the clinic. They are taken on a tour of the West 7th neighborhood and given a history lesson, because both the community we serve and the roots of our clinic define us. We descended from the Wilder Infirmary, which began providing free and low cost care in the 1930s at Miller Hospital. When Miller Hospital merged with St. Luke’s Hospital, the Wilder Infirmary became the Miller Outpatient (MOD) Clinic. United Family Practice Health Center evolved from MOD Clinic and Helping Hand Health Center, which was started by St. Luke’s Hospital and West 7th residents. Four of the physicians from the time of this merger continue to practice medicine at United Family Practice Health Center. Dr. Tim Rumsey could boast (but does not — we do) that he has in his panel patients he has seen for 40 years and he has also provided continuity of care to some of the most transient of patients — our homeless population. The clinic operated under United Hospital,

By Sue Inoue, MD MetroDoctors

within the Allina Health System, but has since become a FQHC, maintaining the 90-year commitment to promote access to comprehensive patient-centered primary health care for low income and medically underserved St. Paul residents.

In keeping with the theme of continuity and longevity, the residency is led by its original director, Dr. Kathleen Macken.

It is not unusual for a resident to attend a delivery with Dr. Macken and discover that she had been at the delivery of the laboring mother, as well as the father, multiple aunts, uncles and cousins.

The strength of the relationships she has developed with her patients was illustrated when the residents asked her to see one of her patients in the ICU at United Hospital. She found a very tense situation as she approached the room. A couple of security guards and the chaplain were standing outside a patient room. Dr. Macken had been the patient’s physician through her pregnancies, attended her deliveries and provided primary care up until this admission. The patient’s children were now large men in their thirties and staff

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felt threatened by them as discussions of their mother’s poor prognosis were not well received. There was visible relief on the faces of these men, when they saw her approach and they asked her if there was truly nothing more that could be done for their mother. She gently told them she agreed with the ICU staff. The patient’s sons were immediately satisfied and agreed to transition their mother to comfort cares.

Due in large part to the strength of family practice physicians in providing prenatal care, Dr. Macken was asked to take over the directorship of a prenatal clinic, which had been started by a perinatologist, at Face to Face Clinic on the East Side in 1992. Faculty and residents care for pregnant and postpartum women here between the ages of 12 and 25 years of age. For many of the young mothers seen there, relationships forged with residents and staff are the first profound experiences with primary care.

UFPR’s commitment to the community extends beyond providers providing excellent care. From its inception in 1992, UFPR has been committed to Community Oriented Primary Care (COPC) and each resident participates in a longitudinal project that partners with community members to assess and respond to the community’s needs. Projects have included community gardens, project coordination in local homeless running groups, establishment of a multi-disciplinary geriatric assessment clinic, engagement with Reach Out and Read, a national early literacy program, and electronic mapping of neighborhood assets.

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Promoting Primary Care Primary Care in the West 7th Community (Continued from page 19)

American Psychiatric Association

2019 Community Gold Award!

Your Link to Mental Health Resources

855.431.6468 mnpsychconsult.com Available Monday-Friday from 8am-6pm 20

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As a result of one of these resident COPC projects, the clinic began to provide CenteringPregnancy, a group prenatal care program, which has been shown to decrease the rate of preterm births, low birth rate babies, and increase breastfeeding rates by combining risk assessment, prenatal education and support into one entity. One teenage mother told me that her Centering group gave her the courage to face labor.

Point of care ultrasound made its way into the curriculum thanks to the efforts of a recent graduate of the program who joined the faculty. Hand held ultrasounds are now well utilized by residents, as well as senior faculty. The clinic has implemented a medication-assisted treatment program for opioid addiction, partnering clinicians with behavioral health staff. Residents have been quick to adopt the Integrative Behavioral Health into their continuity clinic flow, pulling in dedicated behavioral health staff to see patients in real time, who may be interested in behavioral change to adopt healthier habits, who may be actively experiencing grief, or whose anxiety creates barriers to improving their health. I am grateful to be able to drop into our dental clinic for curbside consults and to refer more urgent patients quickly. We have also forged a medical legal partnership with the Mitchell Hamline School of Law, which has been instrumental in relieving the stress of many of our patients.

The faculty are extremely well-rounded. We are all practicing physicians with busy patient panels and work in both the inpatient and outpatient settings. Fewer opportunities exist that allow physicians to practice in both settings. The continuity of care has been rewarding for the faculty, whose patients appreciate seeing a familiar face when their health deteriorates or when they are experiencing labor. Residents witness the entire spectrum of disease processes and learn from core faculty the role primary care plays in managing much of what walks in the clinic or the emergency

room. The opportunity to speak directly with consultants at the hospital has been invaluable, particularly when many of our patients are uninsured or under insured and we can coordinate care in creative ways.

One essential component to the UFPR is the quality of care provided to every patient, regardless of income or background. One room can find a homeless man and the next room could be occupied by a local TV celebrity. Sixty percent of the patients are covered by medical assistance, 20% are uninsured, and 20% have commercial insurance. Residents have a panel of patients that range from fetal to geriatric, from mentally resilient to psychotic, from pleasant to combative.

A major sustaining force for the providers at our clinic model is the engagement and opportunity to work alongside highly motivated residents; the newest generation of physicians maintains the curiosity and optimism to provide exemplary primary care to the culturally rich and diverse population of the West 7th neighborhood and beyond. It is truly a privilege “To Serve and To Teach” in a clinic that began 90 years ago with the Wilder Infirmary and provide compassionate, respectful health care for the urban underserved here in the West 7th neighborhood of St. Paul.

Sue Inoue, MD has been a faculty member in the United Family Medicine Residency for 19 years. She attended the University of MN Medical School after graduating from the University of Chicago, followed by a Residency at St. Paul Ramsey Medical Center and Maternal Child Health Fellowship from West Suburban Hospital in Oak Park, IL. She is a member of the Board of Directors of the MAFP Foundation. Dr. Inoue is a soccer mom with a minivan, insisting all children sharing her residence study music.

Favorite decompression activity — knitting.

Least favorite, running, but can’t give it up.

MetroDoctors

The Journal of the Twin Cities Medical Society

A Vocation, Not a Job A Model for Primary Care from the Abbott Northwestern General Medical Associates What, exactly, is primary care?

And what does it have the potential to be?

In an age that is increasingly decentralized, specialized and efficient, how can primary care be relevant anymore? Surely, the notion of the general practitioner broadly-versed in medicine and familiar with the entire family is something out of heartwarming Norman Rockwell paintings. It is a role rooted in nostalgia: Endearing, quaint and impractical.

Or is it?

How many times have we, in primary care (Internal Medicine, Pediatrics, Family Medicine, or Obstetrics/Gynecology), been told by our front desk that a patient called to see if we could add them to our schedule for a conversation? Why? Because they have seen a specialist or have a galling, unresolved problem or are trying to navigate their care, and they want us to help them understand, help them decide, or simply help them to be confident that the chosen course is the right one.

While we may glory in the amazing tools and therapies at a physician’s disposal in the twenty-first century — whether PET/ CTs, angiograms, LVADs, targeted chemotherapies, antibiotics, or monoclonal antibody therapy — we can never forget what we all want for our parents, our children and ourselves: a physician who knows us, a physician we can trust.

Notwithstanding the virtues found in specialization, there is something utterly refreshing and indispensable in someone who looks at the whole picture. The danger

By Tod Worner, MD and Michael Cummings, MD MetroDoctors

in a specialization devoid of general considerations is an imbalanced reductionism. A patient is greater than the sum of their component parts.

The tools of the primary care physician transcend their familiarity with the pathophysiology of each organ system, the selection of diagnostic modalities, or the choice of therapeutic options. As Sir William Osler would remind, “The good physician Michael Cummings, MD Tod Worner, MD treats the disease; the great physician treats the patient who has the disease.”

Our primary care practice is built The primary care physician, especially, around this fundamental truth: We want has to cultivate and rely on common sense, to be the physician for others that we would intuition and finesse that informs (and want for ourselves and our loved ones. chastens) clunky technique, algorithm and Abbott Northwestern General Medical efficiency. A primary care physician is not Associates (ANGMA) is a burgeoning west valuable simply because of his/her familiarity metro internal medicine clinic operating in with the manifestations and management of Edina (Center for Outpatient Care), Plymmultiple ongoing disease processes in their outh (West Health), and Minneapolis (Medcomplex patient population. Even more, it icine Clinic). The three pillars upon which is the primary care physician’s wise judgment ANGMA is built are: service, education and that comes from knowing the patient — truly innovation. comprehending the patient’s many probService: ANGMA’s first calling is to lems, level of understanding, and general serve the patient. Our clinic follows a traphilosophy of health — and integrating these ditional model where the majority of hours variables into a sensible approach to care. To are spent in outpatient clinical care. A subset a primary care physician, context matters. of our physicians rotate weekly on hospital And, we only understand context if we truly call caring for any and all patients admitted take time to understand the complicated from the clinic’s population. Both in and patient who finds himself in a given medical outside the hospital, we have cultivated a circumstance. warm collegiality with our specialist partners.

Here is an interesting fact: If we were In building and enjoying these partnerships, to ask our patients why their primary care we have crafted a more thoughtful and nudoctor matters, the answers would vary but anced approach to each patient’s needs. From follow a common theme: My primary knows front desk staff, medical assistants, and lime; is smart; listens; cares; goes the extra mile censed practical nurses to registered nurses, and takes care of my whole family. I trust my primary care physician.

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Promoting Primary Care A Vocation, Not a Job (Continued from page 21)

physicians, and administration, a rich culture of respect and interdependence helps our efforts to be a collective calling. Our work is a vocation, not a job. Physicians know their patients and enjoy them. Whether it is scheduling or triaging, streamlining phone calls or medical messaging, administration and support staff do all in their power to ensure that the fundamental face-to-face meeting between physician and patient is available, amiable and efficacious. Our calling is to serve our patient’s healthcare needs.

Education: ANGMA is passionate about forming future physicians. Our clinic offers a respected and award-winning preceptor experience for University of Minnesota medical students (part of the Primary Care and Beyond rotation) as well as a robust clinical mentorship for Abbott Northwestern Hospital Internal Medicine residents. In addition to clinical education, ANGMA has crafted a unique curriculum around critical reasoning and vocational understanding.

Seeking to fill the widening void where

common sense and deep purpose used to be, we offer lessons in heuristics and intuition, literature and philosophy. In sum, we seek to better answer practical (but philosophical) questions in an age of hyper-efficiency and burnout, namely “How do you think?” and “Why are you here?” Our Minneapolis branch (Medicine Clinic) especially works passionately on behalf of the underserved.

Residents learn the vicissitudes of navigating the pressing social needs of patients that directly impact their health. Finally, ANGMA has a vigorous inpatient bedside, didactic and procedure-based curriculum that prepares internal medicine residents for the challenges of caring for a very ill patient population. Our whole approach to educating future physicians is formation.

By moving beyond simple facts, we aim to cultivate a lens through which residents can truly see. We strive to be mentors in the art of medicine.

Innovation: Beyond their experience in residency, many physicians are interested in research and quality initiatives. As such, ANGMA has encouraged interested physicians to explore innovations in care.

At Minnesota Community Care, we believe in health for all.

Tod Worner, MD is the Clinical Director of Outpatient Resident & Medical Student Education at ANGMA–Center for Outpatient Care/West Health for the Abbott Northwestern Hospital Internal Medicine Residency Program.

In addition, he serves as Adjunct Clinical Assistant Professor of Medicine for the University of Minnesota Medical School and as Adjunct Assistant Professor, College of St. Benedict/St. John’s University where he teaches “The Art of Healing” to pre-professional students.

That’s why we provide comprehensive primary health services to everyone regardless of age, financial situation, access to insurance, language or immigration status. While our name has evolved, our purpose has remained the same over the past 50 years - to serve the health needs of our community.

Together, we are Minnesota Community Care.

Michael Cummings, M.D. is the Co-Director of Abbott Northwestern General Medical Associates and has particular interests in clinical decision support tools, preoperative assessments, and twenty-four hour automated blood pressure monitoring. He further serves as Adjunct Clinical Assistant Professor of Medicine for the University of Minnesota Medical School.

mncare.org | 651.602.7500 Ad_English_5x5_r4.indd 22MCC_6.10.19 March/April 2020

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The Automated Blood Pressure Monitor, twenty-four hour blood pressure cuff, program has brought better care to patients in discerning who truly has hypertension and the adequacy of their control. The Pre-Op Tool has streamlined pre-operative assessments by providing a thoughtful guide to evidence-based care. This tool has helped decrease needless testing, while leaving a physician’s decision-making autonomy intact. The Vascular Care Guide has provided evidence-based guidance to physicians (and patients) on the most pervasive maladies (diabetes, hypertension, coronary disease, obesity) to afford better care and less waste.

Attending staff and residents conduct high-quality research which is presented frequently at local and national venues. ANGMA has also crafted a world-class bedside ultrasound program helping patients and training residents to bring this marvelous tool to their future corner of the world.

It is time for us to remember an oft-forgotten truth about primary care: It is a vocation, not a job. It is a deeply human calling to treat an ailing brother or sister. It involves thinking, explaining, advocating, treating and caring. At ANGMA, we want to be the type of physician that we would like for ourselves and our loved ones. It is time for a renaissance in primary care. Along with our partners from different systems, we are proud to play our small part.

9/10/19 10:31 AM

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The Journal of the Twin Cities Medical Society

Primary Care Saved My Life

M

y father was a surgeon in Illinois. When he died in 2009, several people came up to me at his funeral and said, “Your father saved my life.” That was nice to hear, but at the same time I couldn’t help but think, Of course you saved peoples’ lives, Dad — they were at Death’s door and you did something dramatic that kept them alive.

Well, I want to make the case that one doesn’t have to be a surgeon or oncologist or other specialist to save lives. In fact, I would argue that generalist physicians may save more lives than specialists by recognizing a range of problems earlier, encouraging more preventive care, making educated referrals and, when done well, serving as the case manager when an accurate diagnosis necessitates gathering data from a number of specialists. I am a case in point.

For almost all of my life here in Minneapolis (45 years) I have chosen “Group Health” (now HealthPartners) as my healthcare provider network. They encouraged me to choose a primary care provider (PCP) and stick with that person.

The idea was that my PCP would get to know me and my healthcare needs. With that knowledge he/she could provide more continuity of care than the ala carte system for choosing providers. I followed their advice and have had several PCPs over that time period.

For the past 20 years or more I have had the same PCP. Previously, I was seeing a nurse practitioner, but sadly she died too young. All this to say that I am not

By Carol C. White, MA, MPH MetroDoctors

fickle about who I trust with my general care needs. When I reached 50 that NP reminded me that it was time for my first colonoscopy. I dutifully signed up and had the procedure done at the network hospital. It wasn’t very pleasant, but the results were good. When I turned 60 with a new PCP, I must admit that I didn’t schedule that second colonoscopy. For the next five years my PCP badgered me about getting it done. When that wasn’t working, he began to prescribe the FIT test, a noninvasive fecal DNA test that requires the patient to collect a stool sample and send it in. Ick! By the time I reached 67 I finally did the FIT test and sent it in.

Shortly after, I received a letter saying that my test was positive, and I should schedule a colonoscopy ASAP. Frightened, I scheduled one for right after Christmas.

I was relieved to discover that in the 17 years since my last test, the pain control methods had improved greatly. Conscious, but VERY mellow, I and the gastroenterologist watched the screen while he visited my colon. Suddenly, he said “Look here, I see a cancer,” and pointed to a small alien attached to the outside of my upper colon. Thanks to the new pain meds, my first thought was, “that’s interesting.”

My non-drugged husband was not so sanguine. Six weeks later, after blood tests had been done and shown a low-level cancer, I had colon surgery. The surgeon took lots of lymph nodes along with the alien to see if it had spread. No lymph node involvement and no need for radiation or chemo. Six weeks later I was back to my old self and five years later I feel great — skiing, backpacking and traveling.

I have had several colonoscopies in that

The Journal of the Twin Cities Medical Society

time, and I checked my own blood work via “My Chart” once a year, along with my oncologist. We agreed that nothing was changing. After three years of follow-up with the oncologist, I asked him if I could go back to being monitored by my PCP. He said it was OK by him if it was OK with my PCP. And, at any time, if I had any symptoms or wanted to see him, I only needed to call and schedule an appointment. Now I have colonoscopies every three years and blood work every year.

I am 74 years old. Cancer in remission is not the only thing I need to pay attention to. My PCP worries about my glucose level, whether I have had my mammograms, whether I am exercising enough, and he hears about my latest travel adventure (the one where I got taken down off the too steep mountain hike by horseback in the Andes). God forbid, should he die before I do, I plan to go to his funeral and tell his child or wife, “Your father/husband saved my life!”

Carol C. White, MA, MPH, is a retired public health professional. Her last 20 years of work were spent with small public health/primary care hybrid organizations serving a range of underserved communities with special cultural needs. Through these experiences, along with experiences as a patient, she developed a strong interest in using quality improvement methodologies, systems analysis, consumer advocacy and multi-disciplinary approaches to refresh and reorient American health care for better and more affordable healthcare outcomes.

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Promoting Primary Care

Family Medicine Residency Program Expands Across the WI Border

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atients in rural settings have less access to health care and are more likely to die from the five leading causes of death than people who live in urban settings. According to a report published by the Wisconsin State Legislature in 2016, 26% of Wisconsin’s population lives in rural areas, but only 14% of all physicians practice in these communities.

The HealthPartners Western Wisconsin Rural Family Medicine Residency Program was launched in 2017 in response to the shortage of primary care physicians, especially in rural areas.

HealthPartners Hospitals and Clinics are located across Minnesota and western Wisconsin and the healthcare organization is committed to providing quality care close to home. This new residency program provides training to Family Medicine residents in rural Wisconsin with the goal to increase the number of primary care physicians who practice in these communities. This demonstrates our commitment to the training and development of future medical professionals to meet the needs of our members and patients.

The HealthPartners Western Wisconsin Rural Family Medicine Residency Program, led by Dr. Jeremy Springer and Dr. David DeGear, is a “1-2 rural training track” in which the first year is spent in a traditional high-acuity urban hospital and the second and third years are embedded in well-established rural clinics with critical-access hospitals. There are approximately 30 Family Medicine rural training track programs across the United States and these programs provide an opportunity for urban and rural hospitals and nonhospital

By Kelly Frisch, MD

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clinical settings to promote rural training by forming residency programs in partnership.

Residents in the HealthPartners’ program spend their first year training in St. Louis Park alongside the residents in the Methodist Hospital Family Medicine Residency Program. In years two and three, the residents move to western Wisconsin to split their time between Amery Hospital & Clinic and Westfields Hospital & Clinic in New Richmond, which are both critical access hospitals. They learn the full spectrum of primary care from four family medicine preceptors at each location and experience rural practice embedded in the community. In addition to primary care training, HealthPartners consultants across the range of medical and surgical subspecialists provide specialty education. This program offers unique training in Geriatric Psychiatry in the dedicated inpatient facility as well as wound management. The curriculum also includes topics such as rural health policy and practice management.

In June 2019, the first resident, Dr. Catherine Kress, started training in western Wisconsin and next summer two more residents will join her to train at Amery and Westfields Hospitals and Clinics. By 2021, four residents will train each year in these communities as a way to increase the

number of primary care physicians who practice in rural and underserved areas of Wisconsin.

Many Family Medicine residency programs are based in urban settings and offer 4-8 week rural rotations, but this may not provide the education and experiences to prepare for rural practice. Studies show that residents practice where they train. There is good evidence that the more time spent training in a rural setting, the greater the likelihood of graduate placement in a rural community practice. According to a study published in American Family Physician in 2013, 56% of Family Medicine residency graduates practice within 100 miles of where they completed their residency training, 39% locate within 25 miles, and 19% stay within five miles of their training program.

Recruitment for this program is focused on those medical students who want to live and practice in rural communities.

This includes students who grew up in rural communities and/or want to practice in a rural setting.

The HealthPartners Western Wisconsin Rural Family Medicine Residency Program is the first primary care GME program sponsored by the HealthPartners Institute which also sponsors GME training programs in Emergency Medicine, Occupational Medicine, Dermatology, Emergency Medicine Services, Hand Surgery, Pediatric Emergency Medicine, Medical Toxicology, Foot and Ankle Surgery as well as Advanced Practice Clinicians Fellowships in Emergency Medicine, Psychiatry, Hospital Medicine and Primary Care. The startup of the HealthPartners Western Wisconsin Rural Family Medicine Residency Program was supported by a generous grant from the Wisconsin Department of Health Services

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which has focused on ways to train physicians in rural areas and encourage them to stay in these communities as they begin their practice.

We are excited for the family medicine residency as this starts a new era for Amery and Westfields Hospitals and Clinics as training environments for residents and program faculty. By increasing the number of primary care physicians in western Wisconsin, we are improving the care of our patients.

Kelly Frisch, MD was born and raised in Minnesota and completed her training in Internal Medicine at the University of Minnesota. She truly enjoys being a primary care physician and caring for the needs of a diverse patient population. She has a special interest in medical education and feels a commitment to teach our future clinicians. She also serves as the Executive Director of Health Professional Education at the HealthPartners Institute and supports undergraduate and graduate medical education, advanced practice clinician education and clinical simulation across HealthPartners. She can be reached at: Kelly.K.Frisch@HealthPartners.com.

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The Journal of the Twin Cities Medical Society

Confidential Peer Support and Wellness Resources for Minnesota Physicians and Their Families www.psp-mn.com

Physicians Serving Physicians

Physicians Serving Physicians (PSP) is a discrete program that provides free peer support, mentoring, and referral to physicians, their families and colleagues who are affected by substance use disorders. For 35 years, PSP has supported physicians through recovery and successful return to practice. Find help at www.psp-mn.com or by calling 612-362-3747.

PSP has recently expanded its offerings to include wellness resources and four free, confidential counseling sessions through LifeBridge for all Minnesota physicians, residents, medical students, and their family members.

Learn more at www.psp-mn.com/wellnesss or by calling 866-440-5825.

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The Vital Role Pharmacists Play Within Today’s Primary Care Team Contributed by Taylor Hill, PharmD, BCACP, Mary Sauer, PharmD, BCACP, AE-C, CDE and Kyle Walburg, PharmD The CDC1 says 74% of Integrated Into the physician visits involve Clinic Experience drug therapy while 80% of Pharmacists physically loall treatment plans include cated and embedded within medications.2 In 2018, $344 the primary care clinic are billion were spent on 5.8 integral to MTM and fosbillion prescriptions in the ter strong, trusting working United States and that’s prorelationships. Consults over jected to grow by 18 to 26% the phone or via home visits over the next five years.3 are also available and teleTaylor Hill, PharmD, Mary Sauer, PharmD, Kyle Walburg, PharmD Medications only work health is currently under BCACP BCACP, AE-C, CDE if you take them, but two consideration. While proout of every three prescriptions are actually viders can easily refer customers via Epic MTM pharmacists meet with customers filled the first time4 and only half of those get to a MTM pharmacist, they frequently to glean personal lifestyle preferences, forrefilled six months later. Compliance rates seek curbside consults to discuss a specific mulary restrictions and a complete list of decline even further as time passes and barcustomer’s challenge. MTM pharmacists supplements. With an eye toward evaluating riers like affordability and lifestyle multiply. can review physician schedules to identify medication effectiveness, safety and conThe reasons range from not understanding customers with long medication lists and venience, the MTM pharmacist considers why the medication is needed to affordability request time with customers already on the each customer’s health condition, history, and convenience. schedule. The pharmacist can join an existproblem list and clinical notes to identify Medication adherence can impact outing customer appointment or see them after medication regimens that are understandable comes more than the treatment itself aca provider has identified that they would and affordable. cording to the World Health Organization. benefit from MTM. Customers truly valMTM pharmacists are well-versed in Nonadherence accounts for up to 50% of ue MTM pharmacists and say things like, evidence-based guidelines and the clinical treatment failures, 125,000 deaths, and a “That’s the person I see at my doctor’s office nuances of medication selection. By creatquarter of hospitalizations annually in the who saved me $1,500/year on my meds,” or ing care plans collaboratively, pharmacists US. Customers working with their care team “She brought down my A1C from 11 to 7 work in lockstep with primary care providers are key to changing this pattern and saving and helped me reach my goal.”

(PCP), specialists and other clinicians un$100 to $300 billion in healthcare costs der a collaborative practice agreement that MTM Impacts Quadruple Aim annually.5 defines where they can start, stop or adjust A recent study published in the Journal of the medications without physician approval.

Personalized Med Management American Board of Family Medicine 6 explored North Memorial Health experienced Medication Therapy Management (MTM) the impact of MTM in the primary care quality score improvements following at North Memorial Health takes a personsetting and found that adding a pharmacist’s MTM pharmacist visits (diabetes outcomes alized, holistic view of pharmaceutical care deep knowledge of pharmacotherapy freed increased 14%) and received positive cusby bridging the knowledge gap and making up PCPs to focus on medical issues. PCPs felt tomer feedback about the enhanced clinic each customer an expert in their medicine. better supported, “less burned out” and had experience and ease in managing their mediEquipped with a deep understanding of meda higher quality of work life. They described cations. Providers also felt less overwhelmed ications and treatments along with allergens, seven outcomes including: and burned out after a MTM pharmacist drug interactions and contraindications, • decreased workload joined the care team.

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March/April 2020

MetroDoctors

The Journal of the Twin Cities Medical Society

• • • • • •

increased customer satisfaction about receiving better care reassurance decreased mental exhaustion enhanced professional learning increased provider access achievement of quality measures

Save Time and Money With MTM, it’s common to save customers thousands of dollars annually by taking a closer look at what’s on their formulary or realizing they qualify for drug manufacturer assistance. If a customer needs an expensive drug, test claims can determine which medication is covered at the best rate before the provider even sees the customer.

While Medicaid and Medicare cover MTM services, commercial insurance coverage varies; value and risk-based contracts often incentivize comprehensive MTM visits.

Best Use of Expertise Doctors only have 20 minutes to discuss all health concerns with each customer. They don’t have time to focus on the nuances of each medication or delve into what may be a barrier for the customer to take a medication.

By changing the care team landscape and viewing the pharmacist as a key component to the team, doctors and staff save time and are able to work at the top of their expertise.

And, there is more access to care with customers following-up with their pharmacist on things like hypertension, asthma and diabetes.

After working with MTMs and experiencing their impact first-hand, clinicians said, “You’re the best resource I never knew I

Medication Therapy Management pharmacists embedded in the clinical care team positively influence all quadruple aim goals with improved outcomes and decreased drug expenditures, readmissions, hospitalizations and provider burnout. needed,” and “You make me a better doctor every day I work with you.”

Doctorate-trained Pharmacists MTM pharmacists are doctorate-trained with a minimum of six-years of education.

Most have a bachelor’s degree followed by a four-year doctor of pharmacy program.

They are all board-certified pharmacological specialists and many also complete residency training and board-certification in specialties like ambulatory care, asthma, diabetes, oncology, pediatrics or geriatrics.

The North Memorial Health Difference MTM pharmacists at North Memorial Health are embedded in the primary care team and trained in motivational interviewing and setting SMART goals. They practice shared decision making with customers and are empowered to do what’s right for each customer. Recently, a customer called their MTM pharmacist saying, “I’m running out of insulin and I’m due for my shot. I can’t draw it up. I just can’t do it!” The pharmacist immediately closed his schedule, drove to the customer’s home and drew up enough insulin for the remainder of the month.

Who is Medication Therapy Management Best Suited For?

Complex customers often have many medication-related problems. A Medication Therapy Management (MTM) pharmacist’s assessment can simplify, organize and resolve many medication-related problems leaving providers more accessible.

MTM is beneficial for customers who are: • polypharmacy, taking six-plus medications • not meeting their health goals including diabetes care, hypertension, asthma, COPD, depression, anxiety, insomnia, or cholesterol • having adherence issues due to affordability or lack of insurance • having trouble understanding why they’re taking various meds • recently diagnosed with diabetes, osteoporosis, COPD or need smoking cessation • transgender on HRT • on multiple supplements • in need of a step-up with additional medication(s) that may cost a lot • in need of an infusion or self-administering an injection

MetroDoctors

The Journal of the Twin Cities Medical Society

The customer is always at the forefront, particularly when confronted by time sensitive, critical issues. Customer satisfaction data bears this out with 99% of North Memorial Health customers feeling more confident managing their medications after seeing a MTM pharmacist and 100% saying they would recommend their MTM pharmacist.

To learn more or get a curbside consult with a North Memorial Health MTM pharmacist, call (763) 581-2153.

Taylor Hill, PharmD, BCACP, Medication Therapy Management. Dr. Hill also focuses on caring for customers with diabetes, asthma and high cholesterol. Dr. Hill received his Doctorate Degree from the University of Minnesota College of Pharmacy and completed his Ambulatory Care Pharmacy Residency at Essentia Health, Duluth.

Mary Sauer, PharmD, BCACP, AE-C, CDE, Medication Therapy Management, Asthma Educator, Certified Diabetes Educator. Dr. Sauer focuses on caring for customers through shared decision making. Dr. Sauer received her Doctorate Degree from the University of Minnesota College of Pharmacy and completed her Family Medicine Residency at Park Nicollet.

Kyle Walburg, PharmD, Medication Therapy Management. Dr. Walburg’s main passion is diabetes management, but she also focuses on caring for individuals with asthma, COPD, hypertension and more. Dr. Walburg received her doctorate degree from the University of Minnesota College of Pharmacy and is in progress of completing her Pharmaceutical Care Leadership Residency at the University of Minnesota Twin Cities.

(Endnotes) 1. CDC Therapeutic Drug Use. 2. American College of Clinical Pharmacy Comprehensive Medication Management in Team-Based Care.

3. IQVIA Market Prognosis, Mar 2019; IQVIA Institute, April 2019.

4. Ann Intern Med 2014;160(7):441-450.

5. US Pharmacist January 19, 2018, 018;43(1)3034.

6. The Journal of the American Board of Family Medicine July 2019, 32 (4) 462-473.

March/April 2020

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Building a Tobacco-free Future for Minnesotans with Mental Health and Substance Use Disorders Despite years of success in lowering the rate of adult tobacco use and its diminishing health consequences among the general population, this benefit has not been realized among persons with mental illness or substance use disorders. The disproportionate impact of tobacco use on these individuals’ lives is striking.

Recent studies show that people with mental illness or substance use disorders (SUD) are more than twice as likely to smoke cigarettes as adults without these conditions, are more dependent on tobacco, smoke more heavily and are actually more likely to die from tobacco-related illness than from the result of their mental health or substance use conditions.

75% of adults with serious mental illness and/or substance use disorders want to quit smoking, but only 40% of Minnesota’s mental health treatment facilities and 31% of substance use disorder treatment programs offer tobacco treatment.

Tobacco Treatment Improves Mental Health and SUD Outcomes

Contrary to long-held beliefs, treating tobacco dependence not only helps improve overall health but mental health as well. People with SUDs who are treated for tobacco in addition to other addictive substances have a 25% greater chance of long-term abstinence than those who do not receive tobacco cessation services.

Evidence suggests the beneficial effect of stopping smoking on symptoms of anxiety and depression can equal that of taking antidepressants.

By Annie Krapek, MPH Program Manager, Twin Cities Medical Society

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March/April 2020

Working Together to Reduce Tobacco Use Among People with Behavioral Health Conditions

Twin Cities Medical Society is proud to be an active part of The Lung Mind Alliance, a statewide coalition that is working to reduce disparities related to the impact of commercial tobacco on people with mental illness and/or substance use disorders.

At least 13 states require mental health and substance abuse disorders treatment facilities to provide tobacco treatment services to their clients.

The coalition is working to close this gap by increasing the number of mental health and substance use disorder programs that offer tobacco treatment and that have tobacco-free grounds using the following tactics: • changing social norms around tobacco use by those with mental illness or SUDs, • creating free educational resources for health facilities serving this population, • working to increase reimbursement for facilities that provide tobacco treatment, • and building a coalition to integrate tobacco treatment and tobacco-free environments in all Minnesota mental

health and substance use treatment settings.

The Lung Mind Alliance includes partners from mental health, substance use treatment, and public health organizations, as well as the Minnesota Department of Health and the Department of Human Services.

What Can You Do?

Successfully reducing tobacco-related disparities for people with mental illness or SUD will take a team effort.

• Challenge myths

Many people believe that people with mental illness and SUD do not want to or cannot stop smoking. These beliefs are not true, and you can help by educating your peers about the importance of tobacco treatment for people with mental illness and SUD. • Provide tobacco treatment People with mental illness and SUD may need more intensive support and a longer period of treatment in order to successfully quit tobacco. Providing individual or group counseling along with smoking cessation medications greatly improves the chances that a person will be successful in their quit attempt.

• Engage your colleagues Talk with your colleagues about how your workplace can better provide tobacco treatment services and create tobacco-free environments across all settings.

By working together, we can help individuals reach their recovery and wellness goals and add years to their lives.

MetroDoctors

The Journal of the Twin Cities Medical Society

Environmental Health —

The US House Select Committee on the Climate Crisis

T

he US House Select Committee on the Climate Crisis is charged with delivering climate policy recommendations to achieve substantial and permanent reductions in carbon emissions and related pollution that are worsening the climate crisis.

In September the Select Committee on the Climate Crisis called for public comment and input. Health Professionals for a Healthy Climate (www.hpforhc.org/) responded by submitting the following comments and recommendations: Adaptation and Resilience: Healthcare facilities are critical community and regional resources that are vulnerable to climate extremes. Policies are needed to ensure resilient healthcare systems.

We recommend the following steps: A. Enhance CDC/Public Health/FEMA capacities to manage climate/pollution-related health crises and multiple simultaneous climate/pollution-related disasters.

B. Increase support for research on infectious diseases entering or spreading within the US due to climate change.

C. Increase support for public health departments to develop and implement planning and programs addressing climate change-related vulnerabilities in their jurisdictions.

D. Provide support for the evaluation, regulation, and compliance monitoring of health facilities related to: 1. adequate emergency power with a focus on on-site, clean and renewable generation to reduce dependence on vulnerable power grids.

2. supplies, staffing and staff training for prolonged climate/pollution emergencies.

By Mike Menzel, MD and Kristi White, PhD MetroDoctors

3. facility hardening to withstand weather/climate-related damages.

E. Develop and regulate programs to maintain the availability of electronic health records (including insurance coverage information) and on-line communications connecting care providers, laboratories, radiology facilities, pharmacies and other healthcare resources during climate crises.

F. In recognition of the heightened vulnerabilities of communities of color and low income communities we recommend: 1. Directives and support for state/ regional health departments to develop transportation/evacuation capabilities and shelter planning and implementation for vulnerable communities. This should include special provision for welfare checks on the disabled, the isolated elderly, and families with small children.

2. Enhanced support for hospitals/ clinics that serve communities of color, indigenous communities, impoverished communities, and communities with higher rates of chronic medical and mental health disorders.

3. Planning and support for the special needs of rural communities to manage climate/pollution-related crises.

4. Planning and support to protect indigenous peoples from climate/ pollution related crises. This should include increased support for Indian Health Services, particularly in the areas of mental health and preventive services.

G. Consult with behavioral health professionals to develop interventions that are grounded in psychological and behavioral science to increase engagement, behavior change, and stress resilience.

The Journal of the Twin Cities Medical Society

Mitigation: Urgent reduction of carbon emissions, pollution and waste generation from health facilities. We recommend the following: A. Support carbon reduction programs and policies: 1. Implement policies for rapid reduction of carbon emissions throughout the healthcare sector including facilities, transportation services, and medical supply infrastructure.

2. Implement policies that move toward adapted infrastructure.

B. Reduce waste and pollution: 1. Institute organics recycling and food donation programs to reduce waste that contributes to methane emissions.

2. Institute waste and pollution prevention/reduction programs including the elimination of single-use materials.

C. Institute Sustainability Benefits Programs: 1. Incentivize healthcare sustainability practices, e.g.: hospitals must implement plan to go carbon free.

Estimates are that hospitals will save $15 billion by 2050 with basic energy efficiency investments.

2. Incentivize insurers to reduce premiums for healthy behaviors that have a climate co-benefit (e.g., bike commuting, local produce, low meat diets).

3. Institute “green benefits” for patients/staff who use telehealth services, green commuting, etc.

4. Institute incentives for staff/employee pension plans to divest from fossil fuel investments.

You can follow their recommendations at https://climatecrisis.house.gov.

Mike Menzel, MD and Kristi White, PhD, members of Health Professionals for a Healthy Climate.

March/April 2020

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March/April 2020

Steven Miles, MD Receives 2019 Shotwell Award On January 7, 2020, in partnership with Abbott Northwestern Hospital and its Medical Staff, the 2019 Shotwell Award was presented to Steven Miles, MD by Chris Johnson, MD, Chair, Twin Cities Medical Dr. Steven Miles (center) receives the Shotwell Award from TCMS Society Foundation. Foundation Chair Chris Johnson, MD (Left) and Daniel O’Laughlin, Dr. Miles, Professor MD, Medical Staff President, Abbott Northwestern Hospital.

Emeritus of Medicine and Bioethics at the Center for Medical Staff. The Shotwell Award has Bioethics, University of Minnesota, is recognized outstanding leaders throughknown for tackling controversial issues. out the State of Minnesota since 1971.

He participated in the development of This was the final granting of the award. the Do Not Resuscitate order and the A permanent plaque is located in the treatment of tuberculosis in refugee Courage Kenny Lobby on the Abbott camps. He worked with the failed ClinNorthwestern Hospital campus. ton healthcare reform and the successful MNsure legislation. He conducted research that largely ended the dangerous use of restraints in nursing homes. He candidly spoke about his mental illness and its prevalence among healthcare providers; his successful lawsuit advanced physicians’ rights to get confidential care of this disability without Board intervention. He exposed medical complicity with torture and has testified in the United States and Africa.

For the past 28 years, Twin Cities Medical Society Foundation has held the privilege of serving as the executor and fiscal agent of the Shotwell Award with the award funded through the generosity of Abbott Northwestern Hospital and its MetroDoctors

The Journal of the Twin Cities Medical Society

In Memoriam BERTON BARRINGTON, MD, passed away on January 7, 2020. An Ophthalmologist, Dr. Barrington practiced for 50 years primarily throughout southern Minnesota and ended his career at the VA Hospital in Minneapolis. Dr. Barrington joined the medical society in 2006.

EDWARD DONATELLE, MD, passed away on January 1, 2020. Dr. Donatelle practiced Family Medicine in Minneapolis. He joined the medical society in 1952.

MATTHEW GALL, MD, passed away on November 28, 2019. Dr. Gall was an oncologist practicing at Minnesota Oncology. He joined the medical society in 2005.

GERALD MULLIN, MD, passed away on December 13, 2019. Dr. Mullin was affiliated with Downtown Internal Medicine (Minneapolis) where he practiced Internal Medicine and Rheumatology.

He joined the medical society in 1961.

RICHARD OLSON, MD, passed away on January 19, 2020. Dr. Olson was a family physician in Chaska, MN, practicing for nearly 50 years. He joined the medical society in 1986.

POPATLAL SHAH, MD, passed away on December 31, 2019. Dr. Shah practiced Internal Medicine at North Memorial Hospital and the Osseo Clinic, and later at HealthPartners. Dr. Shah joined the medical society in 1972.

IRVING SHAPIRO, MD, passed away on December 31, 2019. Dr. Shapiro practiced Ophthalmology in Minneapolis and was the founding medical director of the Phillips Eye Institute.

He joined the medical society in 1957.

DONALD WOODLEY, MD, passed away on December 12, 2019. Dr. Woodley was an internist and worked as the medical director for several insurance companies. He joined the medical society in 1961.

MetroDoctors

The Journal of the Twin Cities Medical Society

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March/April 2020

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, MD

LEIF IVAR SOLBERG, MD Modesty is a quality that attempts to diminish one’s significant abilities and accomplishments. Our unassuming Luminary demonstrates this attractive attribute in both word and manner.

Dr. Leif Solberg was born 81 years ago in a downtown Minneapolis hospital, geographically in proximity to both the site of his current home and the setting of his long-standing career. He earned his BA and MD degrees at our U of M distinguishing himself academically with Summa Cum Laude, Phi Beta Kappa and AOA honors. After completing a medicine residency at the University of Maryland and a G.I. fellowship at the University of Pennsylvania, he entered the Army, serving at the Walter Reed Institute of Research and later directing the Automated Military Operating System (AMOS) experiences, he states, “influenced the future direction of my career.”

After Washington D.C. stints in private practice and academia, he, his wife and young children succumbed to the “gravitational pull” of family and the Twin Cities — they returned “home” for good. With that move, his future life in medicine unfolded.

Though sub-specialty trained, he realized that for him the early principles created while he was leading AMOS seemed most applicable to their development in primary care settings. Thus began his long tenure and faculty assent to Clinical Professorship in his alma mater’s Department of Family Practice and Community Health. Those military operating system formulas adapted particularly well in an ambulatory care framework, and he was able to refine and enhance them through the years while serving as Quality and Care Improvement Director at Blue Cross and more currently, as Senior Advisor of HealthPartners Care Group.

Concepts of quality/care improvement are diverse and far-reaching. They encompass the need to balance advances in medical care treatment capabilities with ever-changing economic factors. Resource utilization, electronic medical record institution and accepted evidence-based guidelines are among the most important of variables that Dr. Solberg has studied and implemented via comprehensive population research analyses. He played prominent roles in numerous studies conducted to help determine which approaches work, and which don’t in caring for patients.

His tireless efforts, very well documented in over 270 published articles, have encompassed topics including suicide prevention, 32

March/April 2020

breast and uterine cancer, diabetes, approaches to mental illness, geriatric care, emergency management, medication errors and lung cancer screening. His efforts in smoking cessation are among his most gratifying of pursuits — undoubtedly resulting in remarkably successful morbidity and mortality outcomes. His ability to share the integration of research with pragmatic practice care delivery has been gratefully appreciated by legions of colleagues.

Leif has served on US Preventive Service panels, lectured widely and held multiple peer review journal editorial positions.

He has been rightly recognized with honors including the Army Commendation Medal, numerous Researcher of the Year awards, the Maurice Wood Lifetime Contribution to Primary Care Research Award, the U of M Distinguished Medical Alumni Award, and membership in the National Academy of Medicine.

When the good doctor is asked about the highlight of his career, he responds, “It’s right now, when I am able to still contribute a bit in both the realms of research and administration and meet, work with and learn from a wonderful group of colleagues.

I have no intention of retirement!” Dr. Solberg opines, “The future of medicine is bright as it encourages the applications of the principles of consistency while still allowing individuality to play a prominent role.”

We are proud to add the honor of Luminary to this reserved, unpretentious and brilliant physician who has long shared his extraordinary abilities and accomplishments with us.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

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