MetroDoctors May/June 2020: Celebrating 10 Years of Supporting Physicians

May/June 2020

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Celebrating

10 Years

of Supporting Physicians

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AES

THET I C

L OF APPROVA L SEA

CONTENTS V O L U M E 2 2 , N O . 3 M AY / J U N E 2 0 2 0

3

TCMS — 10 Years of Rock-Solid Support for Physicians

By Peter J. Dehnel, MD

4

PRESIDENT’S MESSAGE

“Live not for the battles won. Live not for the-end-of the-song. Live in the along.”

By Ryan Greiner, MD

5

Page 9

IN THIS ISSUE

TCMS IN ACTION

By Ruth Parriott, MSW, MPH, CEO

6

CELEBRATING 10 YEARS OF SUPPORTING PHYSICIANS

• Colleague Interview:

9

A Conversation with TCMS Presidents

• Celebrating 10 Years of Physician Advocacy

10

• The Resilience Bank Account — Skills for Optimal Performance

By Michael Maddaus, MD

12 • Burnout: Not Capturing the Entirety of the Problem?

By Timothy J. Usset, MDiv, MPH, LMFT Page 21

14 • Physicians Use and Misuse of Alcohol and Other Mood-Altering Drugs: How Physicians Serving Physicians Can Help and Improve Outcomes

By Mike Koopmeiners, MD 16 • Changing the Workplace Culture to Mitigate Burnout and Establish Well-being

By David A. Rothenberger, MD 18

• Evolving Support for the Mental Health of Medical Students

By Michael H. Kim, MD and W. Scott Slattery, PhD

21 Page 24

24

26

29

Page 26 MetroDoctors

Environmental Health — Why Reduce Your Carbon Footprint

By Mike Menzel, MD and Tom Kottke, MD Honoring Choices Minnesota: From the Grassroots to the Treetops

By Kerry Hjelmgren, Executive Director Lessons Learned from TCMS’s Tobacco Work

By Annie Krapek, MPH, Senior Project Manager Dr. Pete Dehnel Public Health Advocacy Fellowship —Meet Our Fellows

The Twin Cities Medical Society Foundation — Your Physician Foundation

31

In Memoriam/Career Opportunities

32

LUMINARY OF TWIN CITIES MEDICINE

Recognizing Our Society’s Leadership

The Journal of the Twin Cities Medical Society

May/June 2020

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Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Celebrating

10 Years

of Supporting Physicians

A collage of memories highlighting 10 years of dedicated work and rewards from our TCMS members.

May/June 2020

1

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 Medical Student Co-editor Zineb Alfath Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek 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.

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.

May/June Index to Advertisers 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

COPIC.................................................................... 8 Crutchfield Dermatology......................................

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

TCMS Executive Staff

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

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

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

MagMutual............................Inside Back Cover

Kerry Hjelmgren, Executive Director, Honoring Choices Minnesota (612) 362-3704; khjelmgren@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

MedCraft..............................................................11 Minnesota Community Care........................... 2 PNC Bank.......................... Outside Back Cover PrairieCare............................................................19

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

PrairieCare Ridgeview.......................................20

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

PSP/LifeBridge....................................................30

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

Schuster Clinic....................................................28

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

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.

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

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.

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.

Together, we are Minnesota Community Care.

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MetroDoctors

10:31 AM The Journal of the Twin Cities9/10/19 Medical Society

IN THIS ISSUE...

TCMS — 10 Years of Rock-Solid Support for Physicians

T

he 10th anniversary of the Twin Cities Medical Society (TCMS) comes at an unprecedented time of challenge and opportunity for medical communities locally, across the nation and around the world. As this edition goes to press the coronavirus pandemic is just beginning to unfold in Minnesota with over 1,300 confirmed cases of coronavirus in the state.

That said, this edition highlights the accomplishments of TCMS over these first 10 years. It also focuses on physician wellness — a very pertinent topic when our healthcare resources are being stressed to a previously untested level.

We begin with an outstanding message from our TCMS President Dr. Ryan Greiner, instilling hope for the days to come. I’m sure you will be humbled by his message. This is followed by the Colleague Interview which is a compilation of brief summaries by each of the presidents who served our medical society throughout the first 10 years.

The theme of Physician Wellness first includes a personal writing by Michael Maddaus, MD entitled “The Resilience Bank Account,” an article that focuses on the importance of a well-founded operating system which “gives us the best shot at being our best self, day after day.” Two articles from Physicians Serving Physicians (PSP) follow, Timothy J. Usset MDiv, MPH, Executive Director, steps us through the distinction between burnout, moral injury and moral distress and how each of these pertain to physicians. Michael Koopmeiners, MD, Medical Director of PSP, outlines the very challenging topic of substance use disorder among physicians, but also the impressive success that is possible with effective treatment solutions.

Two articles on the prevention and mitigation of physician stress and burnout follow. David A. Rothenberger, MD, Senior Advisor to the Medical School Dean for Physician Wellbeing, discusses efforts to reverse the epidemic of burnout that results in a myriad of adverse outcomes for

By Peter J. Dehnel, MD Member, MetroDoctors Editorial Board

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The Journal of the Twin Cities Medical Society

physicians, their families and the patients they serve while Michael H. Kim, MD and W. Scott Slattery, PhD, discuss efforts at the medical school level to enhance future physician well-being.

An article by the Environmental Health Task Force challenges us: “Why Reduce your Carbon Footprint.”

The work of TCMS over the past 10 years, as referenced in the summaries of our presidents, is brought to life in greater detail by our staff: the successes of Honoring Choices Minnesota leading the way on advance care planning; and the Physician Advocacy Network bringing physician advocates to the table to educate and move elected officials to support T21, ban flavored tobaccos and vaping products.

In addition, we hear from our second cohort of nine 20192020 TCMS Public Health Advocacy fellows as each reflects on their advocacy interests. They are representative of the promise of a bright future for our physician community.

The TCMS Foundation rounds out the work of our medical society. This philanthropic arm of TCMS provides grants to community programs, funds our recognition awards, provides a medical student scholarship and serves as a fiscal agent for great projects. Your donations to the TCMS Foundation help to support these efforts.

Dr. Marvin Segal once again completes the issue highlighting the four executive directors as our “Luminary Leaders” who provided the foundation of our current organization.

As was stated at the outset, this is an unprecedented time of challenge and opportunity for our medical community. TCMS will continue to support physicians as it has done since the founding of the organization. Please let us know how we can better serve you as you serve your patients and communities during these exceedingly stressful times.

May/June 2020

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President’s Message

“Live not for the battles won.

Live not for the-end-of the-song.

Live in the along.”

RYAN GREINER, MD

Hello friends and colleagues. I write this column while distracted by the need to prepare for the COVID-19 outbreak that is emerging in our communities. Please forgive any lack of brevity in the words that follow. We are truly in an unparalleled societal emergency that the American people are ill equipped to face. The lack of trust in government, the desire to continue living as they always have and the need to cope with fear and anxiety by emotionally distancing the reality of what is here, will leave us all in an unprecedented public health emergency. Americans are not going to look to their governments or their leaders to save them from this scourge — they are going to look to us.

The other day I met with my team of hospitalists and attempted to bring their attention and focus to the task at hand. For all of them, this will be the first pandemic they have experienced. Hopefully, it will be the last. I asked them to imagine a future when they inevitably remove their white coat and lay their stethoscope down for the last time. How do you want to remember this time? How do you want to remember your role in this crisis? How do you want to be remembered by your friends and colleagues?

Over the years and in many ways, the practice of medicine has begun to feel more like a job and the burdens of practice have weighed heavy on our minds and hearts. This will change over the coming months as we are asked to rise and fulfill the oath we took when our first white coat was placed upon our shoulders. That oath, given to us by the “Father of Medicine” — Hippocrates — and poetically transcribed for the ages, gave us the philosophical foundation of our practice and profession. Let us remember that oath and work each day to fulfill its foundational purpose — to care for the sick.

I have been so humbled by the efforts of healthcare providers across this state as they come together and support each other in preparing for what is here and coming. Nurses, doctors, physician assistants, nurse practitioners, administrators, leaders and allied health professionals are working together in fellowship and service. Let us not forget the families of these professionals as they carry the burden of our anxieties and fears while continuing to love and support us in the care we so passionately and selflessly wish to provide. How could they have imagined this time? How could they have anticipated the risk in our profession?

Fortunately, we live in a time of incredible medical and technological advancement. As I write this, there is hope that we will have treatments for the sickest of patients soon. As I write this, industry is working to make ventilators, masks and other personal protective equipment. As I write this, clinical trials are already underway for vaccines. It also appears that we live in a time of unanticipated altruism. Social media platforms are ripe with calls and postings asking people to donate and make masks for healthcare workers. Countries around the world are sharing resources and ideas. It truly is a remarkable time.

There is hope — real hope. We will get through this together. We will come out of this stronger and more unified. We will be better clinicians, stronger advocates and more passionate providers. Make this moment about being your best self. Let it transform you in ways you couldn’t have imagined. Finally, thank you for being here, for choosing this profession, and dedicating your life to the most transformative and fulfilling vocation that is the practice of medicine.

Footnote: Speech to the Young: Speech to the Progress-Toward — Poem by Gwendolyn Brooks; 1/1/2004 4

May/June 2020

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO

Flexible Measures for Changing Times

It is ironic to be preparing a column entitled “In Action” when under government orders to “hunker down,” but at Twin Cities Medical Society we are focused on acting as quickly as possible to clear the calendars of our member physicians so you can concentrate on medical practice in the midst of the expanding COVID-19 pandemic.

At the same time, we are adjusting our public health programming to meet the demands of physical distancing.

Advance care planning discussions are needed now more than ever, and Honoring Choices is launching pilot projects to offer virtual services. An on-line facilitator training is in development.

One-on-one advance care planning discussions are now offered by our skilled ambassadors via phone and Zoom, with centralized data collection to measure outcomes. The experience gained through these pilots will likely inform future Honoring Choices activities.

TCMS remains committed to addressing the harms of tobacco, particularly as we see early reports that people with a history of tobacco use may be MetroDoctors

more susceptible to severe COVID-19 infections. While vaping education within clinics and schools is suspended for now, educational materials are downloaded from our website daily, so we are exploring electronic vaping presentations that could be used by healthcare professionals, teachers and parents. The Physician Advocacy Network continues to weigh in on policy advocacy related to access to health care and to address food insecurity during this time of upheaval.

Physicians Serving Physicians held its first virtual support group meeting in March and it attracted the most participants in over two years! The need for confidential peer support remains, and a virtual option can expand PSP services into rural areas of the state and increase access for all physicians.

Luckily, the Twin Cities Medical Society team was ready to embrace digital tools in anticipation of the expiration of our office lease later this year.

To prepare for a “work from anywhere” culture, we are conducting business meetings via Zoom, and now use Zoom for lunch hour socializing, often joined by the other occupants of our homes!

Perhaps the wise public health responses to coronavirus are simply accelerating the inevitable march of the digital age. Necessity is the mother of invention, and we trust we will emerge from this time more nimble and responsive to the needs of our physician

The Journal of the Twin Cities Medical Society

members, medical organizations and our community.

A Future Physician Advocate

Shortly before the legislature suspended public gathering at the Capitol, a bill to reinstate state funding for advance care planning was heard in the Senate Committee on Family Care and Aging.

Testimony was offered by legislative champion Sen. Mark Koran of North Branch, Honoring Choices medical director Ken Kephart, MD and St. Olaf graduate Christopher Prokosch. Christopher was part of a class team who researched and developed an advance care planning module for young adults.

Not only is Christopher an avid proponent of planning for serious illness and end-of-life decisions, he is also entering medical school at the University of Minnesota Twin Cities this fall! He spoke compellingly about both his responsibilities as a young adult and how he will apply his Honoring Choices education to his upcoming medical practice. We expect to hear much more from the future Dr. Prokosch!

May/June 2020

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Celebrating 10 Years of Supporting Physicians

Colleague Interview: A Conversation with TCMS Presidents Editor’s Note: Each TCMS President was invited to reflect on their term, their goals and accomplishments. I think you will agree, TCMS has been in good hands.

before several City Councils for Healthy Cities Acts to guide build outs of suburbs to create safe areas to walk and bike as part of the Twin Cities Obesity Prevention Coalition.

EDWARD P. EHLINGER, MSPH, MD — 2010 I took office as the first President of TCMS in 2010 marking a new beginning as physicians from “both sides of the river” agreed that forming a metro-wide medical society would enhance the physician voice on issues that affected our broader community. Today we celebrate the first 10 years. A new logo for the organization was developed — a blue river running through the circles representing the 7-county metro area, highlighting the bringing together of physicians who live and practice on both sides of the Mississippi River.

During my presidency, Honoring Choices was piloted and expanded to become a national model for initiating end-of-life conversations.

My main goal as President of the TCMS was to help re-integrate the fields of medical care and public health. Some of the greatest achievements of TCMS over this last decade have been in adding the physician voice and perspective to public health issues facing the Twin Cities and Minnesota.

PETER J. DEHNEL, MD — 2012 The privilege and honor to be a part of the Twin Cities Medical Society embodies many of the values of why I went into medicine — actively working to enhance the lives and health of the people we serve as physicians. Through TCMS we can do more as a coalition of physicians than any one of us can do individually.

In 2012 we focused on the expansion of Honoring Choices Minnesota by helping people across the community, even across the country, in end-of-life discussions. Support was provided for Healthy Eating Active Living resolutions in a number of communities throughout the metro and we explored the possible development of a TCMS physician network to address the changing managed care environment.

On a personal note, in November 2012, I was awarded the American Medical Association’s “Benjamin Rush Award for Citizenship and Community Service.” This was for work over a number of years on tobacco reduction and addressing pediatric obesity. Obviously, TCMS was an essential partner in securing successes in these areas.

THOMAS D. SIEFFERMAN, MD — 2011 I served as President during the tumultuous changes brought on by the Affordable Care Act and the pending formations of Accountable Care Organizations (ACOs). The TCMS Policy Committee held hearings and discussions and produced a White Paper on ACOs citing what doctors believed needed to be essential components to empower physicians to understand requirements and ramifications of joining an ACO. TCMS was also at the forefront on guiding Resolutions

EDWIN N. BOGONKO, MD — 2013 The highlights of my term as your TCMS President are noted in the signature achievements below.

A significant and important amount of time was spent shepherding the organization through contentious MMA governance changes and securing concessions that led to the Policy Council’s mandate as we know it today. We championed representation of physicians who have divergent views in our organized medicine discourse; and strengthened the foundation of Honoring

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May/June 2020

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Choices to be the signature program for the TCMS. Lastly, we continued to promote and support public health initiatives by our membership as an identified key strategy to empower members to impact the communities where they live.

LISA R. MATTSON, MD — 2014 Purely by chance, it was the first time that the President of TCMS and the President of MMA were women. Dr. Cindy Firkens-Smith and I both spent time at the University of Minnesota Medical School encouraging students to voice their opinions and be part of the solutions. I’d like to think that we inspired a new generation of women and young physicians to become involved in organized medicine as a result of having women in leadership roles.

As President, I was asked to testify on various medical issues that affected Twin Cities’ physicians including a ban on flavored cigarettes and cigarillos marketed to children and people of color, and also spoke in support of legislative funding for Honoring Choices MN. I’ve continued to testify when asked and am proud to have been part of making Plymouth the 5th city to endorse Tobacco 21. Those baby steps have now led to Tobacco 21 being endorsed by 71 counties and cities in Minnesota. I’ve learned that physicians are well respected by lawmakers and sharing our knowledge with them through testifying, e-mails, or personal visits to their offices can be a powerful means of affecting healthcare policy.

KENNETH N. KEPHART, MD — 2015 Highlights and memories from my term as President center on our community health activities. Honoring Choices Minnesota really expanded and thanks to our CEO, Sue Schettle and Lobbyist, Nancy Haas we were able to get a legislative appropriation of $250,000 over the biennium to expand our HCM work. I met more legislators and testified before more committees that year than any other time in my life. We also were on the leading edge of e-cigarette concern about the increased use among teens and its harmful effects. In addition, we received MetroDoctors

The Journal of the Twin Cities Medical Society

funding and started working with local communities to restrict sales. We had a successful strategic planning retreat that year, five years after the merger of East and West Metro Societies. We sponsored a successful “Healthiest State Summit” focused on reclaiming MN’s healthiest state status.

CAROLYN A. McCLAIN, MD — 2016 I am so proud to be a part of TCMS. The most impactful part of my tenure as President were the friendships I made with the amazingly talented physicians engaged in TCMS who volunteered their time to advocate for the health of their patients. The most fun part was when I was honored to be included in the sixpart series on KARE 11 featuring the work that Honoring Choices MN did, in collaboration with The Convenings (now End in Mind), to empower patients to lead their own journey at the end of their lives. It won an EMMY! I’m not gonna lie, that was pretty awesome.

MATTHEW A. HUNT, MD — 2017 During my tenure as President of the TCMS, we began initial discussions with Physicians Serving Physicians (PSP) about how we could better serve our physician community dealing with substance use disorders and maintain this valuable organizational resource. In addition, we engaged the MMA around leadership and the role of component medical societies. Work also began with many of our partners around Healthcare Legal Partnerships and their value to our patients. That work culminated in a full MetroDoctors edition (Nov-Dec 2019) devoted to the importance of legal aid in treating underlying barriers to health such as unsafe or unstable housing, food insecurity, and immigration uncertainty, and provided a tool to help physicians refer patients for legal services when these needs are recognized.

(Continued on page 8)

May/June 2020

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Celebrating 10 Years of Supporting Physicians Colleague Interview (Continued from page 7)

THOMAS E. KOTTKE, MD — 2018 2018 was a big year for transition in executive leadership at TCMS. We thanked Sue Schettle for 13 years of leadership that led to programs like Honoring Choices Minnesota, the Physicians Advocacy Network, Physicians Serving Physicians, and, the Environmental Health Task Force.

After saying goodbye to Sue, we said hello to Ruth Parriott and TCMS continued on a roll. We adopted a policy to reduce gun violence, supporting successful efforts in the Minnesota House of Representatives to pass universal background checks and extreme risk protection order (“Red Flag”) laws. In addition to focusing an issue of MetroDoctors on gun violence prevention, we published an issue on the first 1,000 days of childhood development, and an issue on ways that health care can reduce its carbon footprint. But the work that I outlined in my January 2018 President’s message is not finished: Assuring that everyone has access to sexual health services, assuring that all infants have the best early childhood experience possible; and, reducing homelessness and housing insecurity.

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May/June 2020

RYAN J. GREINER, MD — 2019 The challenge of physician well-being has been with us since the inauguration of our profession. I have been so honored to participate and lead with my colleagues in building and expanding resources for physicians in the mental health space.

Physicians Serving Physicians and LifeBridge will be the go-to space for resources to support physicians in their practice and personal lives. Nothing makes me prouder than to know that the Twin Cities Medical Society is focused on this important and essential need. As this continues to be a core initiative of the Society, I look forward to seeing our future leaders develop and expand its services, work to destigmatize mental health issues with physicians, and make our emotional well-being a priority from our first day in medical school to our last day in practice.

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The Journal of the Twin Cities Medical Society

Celebrating 10 years of physician advocacy The Twin Cities Medical Society has been supporting physicians and public health advocacy for 10 years.

We hope you can join us to celebrate this milestone together while enjoying delicious hors d’oeuvres and refreshments offered by Surly. Come to connect with your colleagues, find mutual encouragement and learn about the important and exciting work being done by TCMS members.

RSVP at metrodoctors.com/celebrate

OCT

5

2020 TCMS Annual Celebration Surly Brewery 520 Malcolm Ave SE, MPLS

6:00 PM

Celebrating 10 Years of Supporting Physicians

The Resilience Bank Account — Skills for Optimal Performance Have you ever wondered why humans have so little hair?

It’s so we can sweat.

Millions of years ago when climate changes shifted Africa to a more open savannah, the apes were forced to hunt for dinner in the open. To cope, they evolved a skeleton and exercise capacity that allowed them to walk and run, for hours, so they could chase their prey.

No hair allowed them to sweat and loose heat rapidly so they could keep moving.

The only weapons they had were sticks and stones. One lone Neanderthal couldn’t kill a beast on their own — they needed lots of help to capture and kill their next meal.

So, we also evolved the ability to cooperate to survive. As our skeletons and muscles changed, our brains grew as we developed the ability to plan, coordinate, track and communicate with each other as a prey killing team.

Working together we could chase an animal down until they overheated and collapsed, and then beat them to death with our sticks and stones. Then it was dinner time after a day of running and teamwork.

Because our survival depended on our ability to run and to be connected to each other, our muscles and brains grew up in the human household like conjoined twins. When we exercise, a flood of molecules called myokines are released into the blood that act directly

By Michael Maddaus, MD

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May/June 2020

on the brain to improve memory and increase neuroplasticity.

Our minds are literally connected to the use of our muscles.

Exercise and human connection are baked into our human operating system. It was a matter of survival then, and it’s a matter of survival now. It is why being sedentary and lonely are two of the biggest killers of our species.

We all have a Personal Operating System, but instead of being based on our biologic heritage it is often born of more modern habits we have acquired from our families and our careers.

I grew up in an alcoholic violent household, ended up on the streets and arrested 24 times. After dropping out of high school to avoid prison I got my GED and worked my way into medical school.

I remember showing up on the first day of my surgery internship all bright eyed with my Washington manual jammed tight in the pocket of my new white coat, thinking that residency was only about learning to take care of patients.

Little did I know that surgery residency had a hidden curriculum that

would install new habits into my Personal Operating System, like the: • Say yes to everything habit, no matter what; • And the discipline habit, to keep going, no matter what; • And the pretend you’re okay habit, even when you’re not, no matter what; • And the self-sufficiency habit, to handle everything on your own, no matter what.

Over the next 20 years, these four habits of my new Personal Operating System led to great “success.” I had a busy practice, I was a full professor with an endowed chair, I was making good money, I had a beautiful wife, six healthy kids…

I had it all.

But something wasn’t right.

Suddenly I was 55 years old and each

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morning, as I sat on the bed ready to start another day, this gnawing angst and low grade misery would jump on my back, and stay there all day, until I went to sleep.

So I kept pretending. And I kept feeling miserable.

The quality of my mind was not good, and it was going to get worse.

Exercise had been my stress reliever for 30 years until one day when, after a run, I found myself bent over in front of my house with severe back and radicular pain. I knew I would never run again. I stood up, wiped the tears from my face, and went inside.

10 years ago I underwent a 5 level lumbar fusion. After, I discovered both hips were bone on bone. I called a pain guy at work who injected them and then wrote a prescription for 360 tablets of hydrocodone, and for whatever else I wanted.

18 months later I was admitted to Hazelden for three months. There, I became convinced that the habits of my old Personal Operating System were, in some way, responsible for the mess I found myself in.

After Hazelden I began the slow and deliberate process of developing a new Personal Operating System, one of my own design.

First, I changed the first habit I learned as a surgeon — the say yes to everything habit — to saying no to everything, unless it served my short- and long-term goals.

Then I slowly incorporated these seven other scientifically backed habits into my Personal Operating System: 1. Sleep 7-8 hours every night — for neurologic housecleaning.

2. Exercise — for body and brain fitness.

3. Eat whole foods — for the right fuel.

4. Meditation — to untangle the knot with our thoughts and emotions.

5. Self-compassion — for the emotional resilience to recover from setbacks.

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6. Gratitude — to keep the right perspective.

7. Connection — for trusted, vulnerable and confidential connections with others to prevent emotional loneliness.

I have found, without question, that the daily practice of these habits is like making small daily deposits in what I call my personal Resilience Bank Account that have led to compound personal growth over time.

As physicians, the more we practice our craft, the better we get, until it becomes second nature. With the right intention, discipline and commitment, we reach a point where we become master clinicians.

Unlike medicine, where the path to mastery is clear, the path to mastery of living is anything but clear. There is no residency for how to live and be in the world!

If we end up “successful,” we think we have it figured out. Until we end up in the garage staring at our BMW, or lonely and isolated, or depressed, or addicted, or suicidal.

Intentionally designing our Personal Operating Systems with the habits of the Resilience Bank Account gives us the best shot at being our best self, day after day. It takes commitment, discipline, and the right intention, the same skills it takes to become a master clinician.

It is hard work, until it becomes second nature.

Michael Maddaus, MD, graduated from the University of Minnesota Medical School where he also trained in general surgery from 1982 to 1990. After two years of thoracic surgical training at the University of Toronto he returned to the University of Minnesota in 1992 where he remained until his retirement in 2012.

Since 2012 he has focused his efforts on the scientific study of personal resilience and the role of human connection in leadership.

He can be reached at: (612) 387-7297; email: michael@michaelmaddaus.com; or Website: www.michaelmaddaus.com.

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May/June 2020

11

Celebrating 10 Years of Supporting Physicians

Burnout: Not Capturing the Entirety of the Problem?

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urnout is a commonly studied construct among physicians that can manifest through depersonalization, loss of sense of professional efficacy and emotional exhaustion.1 Despite widespread study of burnout, significant variance exists in how to measure and address the issue. A 2018 systematic review on burnout found the prevalence ranged from 0-80.5% in physicians. The majority of studies used a version of the Maslach Burnout Inventory. Differences existed in study design, assessment methods, and definitions of burnout, which contributed to the variance in the results.2 Efforts to address burnout have had mixed results. Promoting individual well-being and resilience through mindfulness and self-care was necessary to help physicians cope with the competing demands of practicing medicine. Unfortunately, individual wellness practices can exacerbate problems by keeping physicians operating effectively enough to mask largescale institutional issues. Coping skills and behavioral changes are part of the solution, but ultimately healthcare systems need to find ways to work better for all involved. The 2019 National Academies of Sciences, Engineering, and Medicine report on physician well-being and burnout documents a need for the development of wide-scale, evidence-based, systemic interventions across the healthcare system.3 Dr. Mark Linzer’s research is a great local example of a team approaching burnout from a workplace and system improvement perspective.

Timothy J. Usset, MDiv, MPH, LMFT

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May/June 2020

Is Moral Injury an Alternative to Burnout?

Recently, attention in the physician community has shifted to the term moral injury as an alternative to burnout. What exactly is moral injury? Moral injury was first conceptually described by Johnathan Shay as “betrayal of what is right by someone who holds legitimate authority in a high stakes situation.”4 Shay’s definition was created through his work with Vietnam veterans. Brett Litz and his team expanded on the definition in their 2009 work to include “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”5 In military service members and veterans, exposure to potentially morally injurious events (PMIEs) has been associated with an increased risk for suicide, longer/more severe PTSD, and spiritual distress.6,7,8 Conceptually, moral injury, or more specifically, exposure to PMIEs, would explain many of the challenge’s physicians are experiencing in the workplace. Despite years of schooling, the Hippocratic Oath, and a passion to make a difference in the world, physicians face challenges from regulatory and administrative burdens at odds with what they know is best for their patients. Many physicians experience trauma and severe human suffering in their day-today care of patients. Moral injury captures the systemic challenges, moral ambiguity, and trauma of working in health care by acknowledging the complex moral environment physicians practice in a way that burnout does not.

The COVID-19 pandemic is a tragic example of what physicians and society are

forced to reckon with when healthcare and government institutions collectively fail to prepare and respond rapidly in an adequate manner to a public health crisis. Physicians and healthcare workers across the country responded to the pandemic without adequate PPE, having to put their own lives at risk to care for patients. Shortages in medications, ventilators and medical facilities brought about challenging, and sometimes overwhelming ethical dilemmas and situations (i.e. “bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations”9). The virus may not have been preventable, but the lack of preparation and response from the highest levels of healthcare organizations and government could be construed as a “betrayal of what is right by someone who holds legitimate authority in a high stakes situation.”4 As appealing as moral injury is, there are several problems that need to be addressed: 1) Moral injury has been predominantly studied in military service members and veterans; 2) There is no established “gold standard” for measuring moral injury. The measures that do exist do not have well established clinical

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The Journal of the Twin Cities Medical Society

cutoff scores; 3) Empirical studies in moral injury are only starting to study physicians and other healthcare professionals; and 4) Widespread disagreement exists in moral injury as a construct.

What About Moral Distress?

Though moral injury has not yet been studied significantly with physicians, another similar term has — moral distress.

Moral distress was first studied in nursing, but has expanded to physicians and other healthcare professionals. Moral distress was initially described as the “painful psychological disequilibrium” that follows knowing the appropriate ethical action, but being unable to take action due to constraints or limitation.10 More recent iterations have conceptualized moral distress becoming compromised as a moral agent in practicing with accepted professional values and standards.11 Common factors of moral distress identified in the development of the Measure of Moral Distress for Health Care Professionals were: complicity in wrongdoing; lack of voice; wrongdoing associated with professional values; repetitive experiences; and, three root causes inclusive of the patient, unit of work and system.12 Moral distress has been found to be associated with intention to leave a position and burnout.13,14 Moral distress is a more established construct in the healthcare literature than moral injury. One notable difference between the two is the way they treat personally held moral and/or spiritual beliefs.

Moral distress only accounts for distress caused by professional dilemmas and constraints (i.e. best care practice, code of ethics, regulatory constraints, etc). It does not account for distress brought about by an individual’s personal belief system.15 Moral injury has a broader definition that can include perceived violations of personal or professional moral/spiritual beliefs and accounts explicitly for betrayal by authority figures.16 Working Together for Systemic Solutions to Multi-faceted Problems

Moral injury may help us better understand challenges physicians experience; MetroDoctors

but, before broadly applying the term to physicians, more research needs to be done to create validated psychometric measures (yes; this means answering more surveys).

Moral distress is an existing concept with validated psychometric measures that may capture some of the systematic distress physicians face. Both moral distress and moral injury may be helpful in understanding the etiology and causal pathways of burnout. Moral injury may be especially helpful in better understanding and preventing physician suicide. Concurrent study of all three constructs will provide valuable insight into the development of organizational interventions that can move physician well-being farther upstream in our healthcare system. Through further research and program evaluation, we can move toward an evidence-based approach to measure distress in physicians and create system level solutions to the problems at hand.

About Physicians Serving Physicians (PSP)

PSP is currently expanding the support provided to physicians across the career lifecycle. In addition to our confidential peer support and counseling resources, we are looking to partner with other organizations to promote system level interventions to address stigma towards mental health treatment, burnout and moral distress in the physician community. More about Physicians Serving Physicians is discussed in the article written by our Medical Director, Dr. Michael Koopmeiners on page 14.

Timothy J. Usset MDiv, MPH is a licensed marriage and family therapist serving as the Executive Director for PSP. He has worked extensively with moral injury, spiritual distress and post-traumatic stress disorder on numerous clinical trials and clinical areas within the Veterans Health Administration. He is pursuing research on physician well-being, burnout and moral injury as a PhD student at the University of Minnesota’s School of Public Health. Tim is available for individual or organizational consultation through tusset@metrodoctors.com or (612) 362-3747.

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(Endnotes) 1. National Academies of Sciences, Engineering, and Medicine. (2019). Taking action against clinician burnout: a systems approach to professional well-being. National Academies Press.

2. Rotenstein, L. S., Torre, M., Ramos, M. A., Rosales, R. C., Guille, C., Sen, S., & Mata, D. A. (2018). Prevalence of burnout among physicians: a systematic review. Jama, 320(11), 1131-1150.

3. National Academies of Sciences, Engineering, and Medicine. (2019). Taking action against clinician burnout: a systems approach to professional well-being. National Academies Press.

4. Shay J: Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York (NY): Scribner; 1994.

5. Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009).

Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.

Clinical psychology review, 29(8), 695-706.

6. Currier, J.M., Holland, J.M., Drescher, K.C., 2015. Spirituality factors in the prediction of outcomes of PTSD for U.S. military veterans.

J. Trauma Stress 28, 57–64.

7. Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychological trauma: theory, research, practice, and policy, 10(1), 36.

8. Evans, W. R., Stanley, M. A., Barrera, T. L., Exline, J. J., Pargament, K. I., & Teng, E. J. (2018). Morally injurious events and psychological distress among veterans: Examining the mediating role of religious and spiritual struggles. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 360.

9. Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009).

Moral injury and moral repair in war veterans: A preliminary model and intervention strategy.

Clinical psychology review, 29(8), 695-706.

10. Jameton A. Nursing practice: The ethical issues.

Englewood Cliffs (NJ): Prentice Hall; 1984.

11. Varcoe, C., Pauly, B., Webster, G., & Storch, J. (2012). Moral distress: Tensions as springboards for action. In HEC forum (Vol. 24, No. 1, pp.

51-62). Springer Netherlands.

12. Epstein, E. G., Whitehead, P. B., Prompahakul, C., Thacker, L. R., & Hamric, A. B. (2019).

Enhancing understanding of moral distress: the measure of moral distress for healthcare professionals. AJOB empirical bioethics, 10(2), 113-124.

13. Allen, R., Judkins-Cohn, T., deVelasco, R., Forges, E., Lee, R., Clark, L., & Procunier, M. (2013).

Moral distress among healthcare professionals at a health system. JONA’S healthcare law, ethics and regulation, 15(3), 111-118.

14. Sajjadi, S., Norena, M., Wong, H., & Dodek, P. (2017). Moral distress and burnout in internal medicine residents. Canadian medical education journal, 8(1), e36.

15. Epstein, E. G., Whitehead, P. B., Prompahakul, C., Thacker, L. R., & Hamric, A. B. (2019).

Enhancing understanding of moral distress: the measure of moral distress for healthcare professionals. AJOB empirical bioethics, 10(2), 113-124.

16. Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182.

May/June 2020

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Celebrating 10 Years of Supporting Physicians

Physicians Use and Misuse of Alcohol and Other Mood-Altering Drugs How Physicians Serving Physicians Can Help and Improve Outcomes

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hysicians use and misuse of alcohol, opioids and other mood-altering drugs is a complex issue. With this article I will emphasize the following issues: 1. Substance Use Disorders (SUD) as a treatable chronic illness; 2. SUD as an illness does not equate to workplace impairment; 3. Workplace impairment is a result of untreated illness; 4. Early treatment of this chronic disease leads to: a) improved health for physicians and trainees;

b) abilities for providers to continue in active practice; and c) improved patient outcomes; and, lastly 5. Physicians Serving Physicians (PSP) a volunteer peer support organization that has 30 plus years of experience in providing confidential peer support services for physicians and their families struggling with SUD, and has recently expanded to provide assistance and resources for physician wellness and burnout.

“Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school or home.”1 Specific to the practice of medicine, the Federation of State Medical Boards defined

By Mike Koopmeiners, MD

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Impairment “as substance use that causes the inability to practice medicine with usual skill and safety.”2 Functional impairment is central to the definition of SUD. Physicians typically will exhibit significant functional impairment in their family, social and spiritual life before exhibiting workplace impairment. Therefore, early in the course of disease, family and social contacts, including physician colleagues, will observe concerning behaviors. As the untreated illness progresses, it will lead to workplace impairment. The time between onset of substance misuse and abuse and workplace impairment typically are years.3 This time lag, however, provides opportunities for the ill physician to receive treatment. Despite this opportunity physicians continue to access treatment late in their disease progression, frequently forced by workplace impairing behaviors.

Negative stigma around SUD continues to be prevalent in society. In addition,

there is even greater negative stigma around physicians with SUD, (as well as mental health issues). The “shame” around SUD coupled with fear of the loss of professional status and income make family and friends reluctant to intervene. Physician peers often are reluctant to “refer one’s self or a colleague due to a variety of reasons related to fear of repercussions, belief the problem has already been addressed, failure to recognize or ignorance.”3 The irony of these very real concerns is that delaying treatment for SUD may lead to the very outcomes that are feared.

The breath of SUD in physicians is significant. Dum et al., in a 2015 confidential self-reported study showed, “12.9% of male physicians and 21.4% of female physicians met the diagnostic criteria for alcohol abuse or dependence.”4 Physicians misuse drugs other than alcohol at rates similar to the general population though they are more likely to misuse prescription drugs. While some specialties have higher rates of SUD, the problems exist in all areas of medicine including students and trainees.5 Symptoms of early SUD are highly variable. Drinking alcohol more than intended at social gatherings, public inebriation, drinking alone, domestic distress, mood swings and social isolationism have been observed. Spending more time at work is common, since work is frequently the place of self-fulfillment. Peers who observe such behaviors usually do not express concerns, because the behavior is not impacting patient care. However, the individual is struggling, possibly due to

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SUD, mental illness, burnout, or other issues. Out of concern for their health and wellness, should you express your concern? If a colleague had an ulcerated black mole on the back of their neck, would you not bring this to their attention? Keep in mind, if you wait to express concerns until workplace impairment becomes overt, the physician most likely has been struggling with this untreated chronic disease for years.

Workplace behaviors indicating SUD, may include other impairing conditions such as a decreased responsiveness to calls, interpersonal conflicts with staff, peers and patients, missed work, arriving late for work and an increase in the number of patient complaints. Charting late and incomplete is a frequent early sign of health problems impacting work performance.

When a physician arrives at the worksite smelling of alcohol, slurred speech and other signs of intoxication, it would seem intuitively obvious that the physician is impaired; but occasionally, peers will send the colleague home to “sleep it off.” Denial is a powerful and at times destructive motivational force.

The good news is that treatment is available. Success rates for physicians treated for SUD exceed 80% five years after treatment.5 Like all chronic disease, early treatment improves outcomes and decreases secondary complications, which for SUD would be workplace impairment, and all of the potential negative ramifications on licensure and privileging.

If we, as a physician community, care for ourselves and our colleagues with the same degree of empathy we provide our patients, how would that change our approach to colleagues who appear to be struggling? Let’s acknowledge the stresses of healthcare delivery, especially during this current pandemic. We all can identify with the potential impact of these stresses on our health and the health of our colleagues. Talking about our stresses and encouraging others to engage in conversation is a powerful start of self-care and care for one another. Dr. Duran, a colleague at my former practice at the Minneapolis MetroDoctors

VAMC, demonstrated how “breaking the silence” around interpersonal struggles can be freeing.6 There are many resources available.

Physicians Serving Physicians (PSP) is one that has been in existence for 30 plus years.

PSP is a volunteer group of physicians who provide peer support for physicians, trainees and their family members. Historically PSP has worked with individuals with SUD, providing interventions, resources and a monthly physician-only peer support group. Recently we expanded our services to individuals with mental illness and other health stressors, such as divorce, financial concerns, elder care, work conflicts, etc.

In addition to calls from physicians, we have received calls from spouses, children, parents, and grandparents as well as peers and clinical leaders. Examples of calls have been for concerns about use and abuse of drugs, workplace stress, and the stress of being involved with a lawsuit. Recommendations range from short-term peer support, to evaluation by a professional resulting in day treatment, to intensive inpatient treatment. Self-limited conditions may not result in a recommendation to self-refer to the State of Minnesota Health Professions Support Program (HPSP).7 If self-referral to HPSP is appropriate, it would typically occur as part of a comprehensive treatment program resulting in improved clinical outcomes while also ensuring the physician and the community that they can safely care for patients.

Physicians struggle with substance use disorders (SUD) much like the patients they care for. SUD is a chronic treatable illness similar to the other common chronic diseases such as CAD, diabetes and depression. While left untreated, SUD may progress to significant impairment; early identification and treatment of an SUD can prevent or lessen the likelihood of such disease progression. Physicians who are engaged in their treatment, which may include an active monitoring program, maintain recovery including active practice of medicine 80% at five years.5 PSP and other resources are available to provide

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peer support and recommendations if called upon.

For more information visit the PSP website at psp-mn.com or call (866) 4405852. The local non-emergency phone number is (612) 362-3747. Please contact PSP with your early concerns — it leads to better outcomes!

Mike Koopmeiners, MD received his medical degree from the University of Minnesota and is board certified in Family Medicine as well as Addiction Medicine. After practicing full range family medicine including a faculty position at the U of MN, he moved to the Department of Veterans Affairs in Minneapolis MN in 2005. He held various posts, including Acting Senior Medical Consultant to the Department of Veterans Affairs for Disability Management Services. In 2012 he became the VISN 23 Medical Director for Primary and Specialty Medicine. His portfolio encompassed five midwestern states, including eight hospital systems with 67 outpatient clinics.

During his tenure, with strong collaboration with local leaders, VISN 23 quality measures were the best in the nation. He also led the development and implementation of a centralized call center for the VISN as well as a program to identify and treat all patients with Hepatitis C after the release of new drug treatments. He retired in 2018 and is currently the Medical Director for Physicians Serving Physicians. Dr. Koopmeiners is available for individual or organizational consultation through PSP@metrodoctors.com or (612) 362-3747.

References: 1. SAMHSA. 2. Federation of State Medical Boards (2011).

Policy on physicians Impairment.

3.

Substance Use Among Physicians and Medical Students, Dumitrascu et al., MSRJ # 2014 VOL: 03. Issue: Winter epub January 2014; www. msrj.org.

4.

Substance Use Among Physicians and Medical Students, Dumitrascu et al., MSRJ # 2014 VOL: 03. Issue: Winter epub January 2014; www. msrj.org.

5. The prevalence of substance use disorders in American physicians, Oreskovichk et al., The American Journal of Addictions, 2015;24:30-38 6. Duran A. Breaking the silence. JAMA. 2019;321:321-346.

7.

HPSP is the Minnesota state mandated healthcare monitoring program. PSP should not be confused with HPSP. For more information visit: https://mn.gov/boards/hpsp/.

May/June 2020

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Celebrating 10 Years of Supporting Physicians

Changing the Workplace Culture to Mitigate Burnout and Establish Well-being

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ast month, prior to the COVID-19 pandemic, one of my colleagues stopped me in the hallway and declared, “I am burned out reading about, hearing about and dealing with burnout!

You’re the senior advisor to the Dean for physician wellbeing. When are you going to fix this?” I was a bit taken aback…but the question prompted me to accept the invitation from the editors of MetroDoctors to contribute a short essay for its special edition on physician well-being.

Burnout Basics and Current Controversies

Healthcare professionals locally and nationally are in the midst of an unprecedented epidemic of burnout. Its prevalence among US physicians and medical students is now over 50% and rising. Three features characterize this syndrome: emotional exhaustion (“I can’t do this anymore”); cynicism (loss of idealism and dehumanization); and inefficacy (feeling incompetent and dissatisfied).1 We often deny and hide symptoms of burnout from ourselves, our loved ones and our colleagues. If burnout progresses, work performance inevitably deteriorates. Detachment, unpredictable and unacceptable behavior, substance abuse, broken relationships, near misses and medical errors that harm patients may result.2,3 Tragically, approximately 400 medical students or physicians commit suicide annually in the United States. Many of these occurred in the midst of a burnout crisis.4,5,6 Use of the term “burnout” has become controversial in recent years. Some

By David A. Rothenberger, MD

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believe it is inaccurate and harmful because it implies the involved clinician has somehow failed to be resilient or is not committed to their profession.7,8 Some suggest burnout be considered a new version of post-traumatic stress disorder.9 Others consider it part of a continuum from moral dilemma to moral distress, moral injury and burnout.8 Still others suggest this is a human rights violation. Asken8 urges caution before changing the term burnout.

Commonly offered explanations for the current burnout epidemic include: decreased caregiver autonomy to manage and prioritize workloads; burdensome electronic health record requirements and other administrative “busy work”; increased necessity to keep up with new discoveries but less time to do so; a chronic and growing imbalance of job expectations at a time of inadequate and shrinking job resources; and organizational mandates to increase profits and cut costs.10,11,12 Well-being and Workplace Culture

Jakub Tolar, MD, PhD, began his role as dean of the University of Minnesota Medical School on October 23, 2017.

Prolonged discussions to closely align or merge with Fairview had recently failed leaving many of the 3,300 medical school faculty members uncertain about their

Photo by Scott Streble

futures. Some showed classic signs of burnout. With characteristic energy, Dean Tolar tackled the challenge to engage and motivate faculty members. He solicited their ideas and sought advice from leaders inside and outside the University. After several discussions, I agreed to serve as the inaugural Senior Advisor to the Dean for Physician Wellbeing beginning January 1, 2018.

Dean Tolar and James Hereford, CEO of Fairview Health Services (FHS), initiated private discussions to understand the relationships of the University, UMPhysicians and FHS that owned and managed the University of Minnesota Medical Center. A six-month period of confidential negotiations followed. I used that interlude to observe, listen and ask questions of doctors, nurses, pharmacists, techs, clerks, residents and students. I heard about their frustrations and disappointments as well as the joy and satisfaction they got from their work. Many wanted more autonomy to control their schedules, prioritize their work and lessen their load of mundane

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tasks and other “stupid stuff.”13 “Allies” were recruited to join an informal, interdisciplinary “coalition of the willing” committed to work together to mitigate burnout and restore well-being in our workplace. We were gratified to learn that CEO Hereford was supporting a similar effort and had appointed Bryan Williams, MD, PhD, as the FHS System Director for Provider Wellbeing and Integrative Health.

On June 18, 2018, an expanded, multi-year collaboration between the University, UMPhysicians and Fairview Health Services (FHS) was announced publicly. The University and FHS wellbeing teams combined. Together, we conducted an informal inventory to identify and assess the effectiveness of current well-being initiatives, tools, seminars and other projects begun by well-intentioned people in our workforce. Several sections and units seemed to have achieved at least limited success to mitigate burnout; but, we found little objective evidence of meaningful progress to improve well-being across our system. We concluded we did not have a model we could replicate across the system. On January 1, 2019, the MHealth Fairview Joint Clinical Enterprise combining academic and community medicine across 10 hospitals and 60 clinics was officially launched. Service line leaders were named, and many other related organizational changes were instituted. This reorganization provided further impetus to extend and formalize the well-being work across the entire enterprise. We accepted the challenge to design, implement and sustain an action plan to restore professional well-being in our system. It was up to us to create an expectation that organizational conditions will change in ways that promote the well-being of the people doing the work. To accomplish that, we needed to change our workplace culture.

That is not to say individual healthcare professionals and workers are off the hook until someone from the dean’s office or corporate suite solves the problem. Nor MetroDoctors

does it mean there is no need for national organizations to be involved. The National Academy of Medicine recently published its consensus study report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Using lessons learned by experts in human factors and systems engineering, the authors propose a methodological approach to design, implement and sustain professional well-being in healthcare organizations.12 Highlights of our Work-in-Progress

Goal: We will monitor and change our organization’s culture to mitigate burnout, restore joy and establish well-being across our interdisciplinary healthcare workforce.

Wellbeing Alliance (WBA): The WBA is an informal, interdisciplinary coalition of healthcare professionals working across our system to achieve our goal. The WBA includes clinicians, educators, researchers, trainees, students, and other professionals as well as health care administrators and workers from across our entire system.

Executive Leadership Team (ELT): The ELT is an interdisciplinary advisory group of leaders including several deans and faculty members, corporate officers, administrators, advisors and other experts.

Collectively, we serve as the lens through which major organizational decisions are scrutinized to assess their potential impact, intended or unintended, on well-being.

We provide advice to implement, monitor and optimize the impact of institutional decisions on the culture of our workplace.

The ELT develops its recommendations by consensus and communicates any concerns or advice directly to the decision-makers.

The ELT solicits advice from local and national experts to guide our culture change initiatives.

Organizational Structure: To avoid creating a new, large and expensive bureaucracy, the ELT is committed to using a decentralized, matrix organization model for its work. Decentralization offers a framework

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that promotes equal access to useful information, builds strong connections to others in our system, enables participants to self-organize in workable units and allows teams to become more than the sum of their parts.14 Well-being Initiatives: Whenever possible, well-being initiatives will be inter-professional, longitudinal (from student to trainee to early-mid-late career and into retirement) and evidence-based. The ELT will encourage research to objectively determine how organizational decisions impact the culture in our workplace environments.

Next Steps

Calls to diagnose and mitigate burnout in medicine come from many sources.

Despite numerous, well-intended interventions, verifiable, nationally impactful and sustainable progress to achieve wellbeing remains an elusive goal. We believe healthcare professionals working together in interdisciplinary teams are best suited to develop and champion well-being specific to their local environment. Our focus is now moving from understanding and measuring the problem to making changes in our workplace to solve the problem.15 The COVID-19 pandemic makes this work more essential than ever.

Dr. David Rothenberger, the immediate past Jay Phillips Professor and Chairman of the Department of Surgery at the University of Minnesota, currently serves as the inaugural Senior Advisor to the Medical School Dean for Physician Wellbeing. He is dedicated to improving patient care by increasing collaborations in the healthcare system to enhance quality, safety and delivery of services to all people and to mentoring future physician leaders, fostering scientific discovery and innovation, and enhancing our profession’s culture. His current focus is on physician burnout and well-being.

References available upon request.

May/June 2020

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Celebrating 10 Years of Supporting Physicians

Evolving Support for the Mental Health of Medical Students

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he World Health Organization (WHO) defines health as, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”1 In this regard, health is an asset for well-being. It is dynamic with environmental, personal, social, economic and physical factors that have the capacity to promote or diminish it. From an intervention perspective, promoting health is similarly achieved through active efforts that both enhance this asset and mitigate threats to it.

In assessing this balance, the resources students bring to medical school are often inadequate for the corresponding demands they encounter. Medical training is highly demanding and results in higher levels of distress compared to the general population.2 Data from the Medical School’s Graduation Questionnaire and internal surveys support this reality by indicating consistently high levels of burnout, depression and moral distress.

When we began leadership roles in the Medical School Office of Student Affairs five years ago, we focused principally on the health “enhancement” side of the wellness equation by bringing an employee wellness program approach to students and invested in a well-being program created and managed by students with Medical School funding and administrative support. Engagement in wellness activities was incentivized through prizes, and though the program grew annually, it was embraced by a limited sample of students overall.

Seeking a more inclusive approach addressing student mental health needs, we adopted prevention modeling to guide strategic

By Michael H. Kim, MD and W. Scott Slattery, PhD

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interventions. Specifically, efforts were developed along primary (education), secondary (coaching) and tertiary (remediation) prevention levels. These enabled broad-based, proactive, and flexible responses with involvement by constituencies on multiple Medical School and University levels.

W. Scott Slattery, PhD Michael H. Kim, MD While the resulting support system proved effective in growing support newly created Senior Advisor for Physician for students experiencing adversity (academWellbeing). ically, professionally, personally), levels of Over the following year, community burnout and depression remained largely forums and small groups were provided to unaffected. A subsequent survey assessing process and better understand student needs. prospective barriers suggested that learnConsistent with emerging data on the liming environment factors such as schedules itations of employee well-being programs, and cognitive demands, stigma-based issues and input that responsibility for well-being (e.g., fear of consequences to progression for should not be placed disproportionately on revealing mental illness) and accessibility individuals (the “don’t just tell me to do more (e.g., extended waitlist periods for counseling yoga” effect), these outreach efforts resulted services) were preventing students from seekin a renewed Medical School commitment ing help. These data and feedback clarified to supporting mental health, and the develthe need to better understand barriers and opment of the Wellbeing Alliance, led by develop effective responses.

Dr. Rothenberger, to consider well-being Prior to deriving solutions, our Medilongitudinally from learners to practicing cal School community received devastating physicians. news on May 17th, 2018 that a student From student responses, perspectives starting third year clinical rotations had died shared at national meetings and reports from by suicide. This tragedy was compounded the literature,3 greater focus on threat mitigatwo months later when a recent graduate tion efforts and cultivating community conalso took his life. The loss of these two nections emerged as focal needs. As a result, students rocked the Medical School and we further expanded our existing theoretical catalyzed us to redouble focus and energy conceptualization of well-being in terms of toward supporting student mental health three interdependent dimensions: 1. Impact and well-being. of the learning and working environment; Immediate support came from the in2. Access to supportive relationships and valuable leadership of Dr. Kaz Nelson in community; and 3. Ability to engage in an Graduate Medical Education, Dr. Mandy effective self-care plan. Efforts in each diTermuhlen in Faculty Affairs and Dean Tolar mension are informed by the prevention (through his financial support and commodel noted previously and intersections of missioning Dr. David Rothenberger to the the dimensions permit an understanding of MetroDoctors

The Journal of the Twin Cities Medical Society

how to foster a sense of belonging, emotional capacity and self-efficacy for students.

Safe and Effective Learning Environment Student success depends upon a welcoming and supportive learning experience that takes a developmental approach and provides critical feedback for improvement. Regrettably, high content volume and increased emphasis on USMLE Step 1 (United States Medical Licensing Exam — a full-day testing exam divided into seven 60 min. blocks) have raised the cognitive load; and with increased productivity demands for their clinical teams, burnout levels in attending and resident physicians have residual impacts on learners.

In response we have recently decreased content by over 15%, moved to a pass-fail grading system, and developed a more active learning curriculum in the pre-clerkship years. For clinical clerkships, extra time is given for rest and recuperation as well as independent learning time for exam preparation and career discernment. We have also put more effort in responding to concerns about mistreatment and harassment.

Supportive Relationships and Community Students encountering personal and academic challenges tend to lack a sense of community that reinforces experiences of isolation. Having a sense of belonging and access to social infrastructure are protective during these challenges.4 We have encouraged greater connection to resources through increased administrative access opportunities such as informal (coffee) conversations, informational and feedback forums and the creation of an academic advising program.

To foster community we have developed an academic houses structure (think Hogwarts) that divides Twin Cities Campus students into three learning communities and allows for a more readily available group of students for Duluth Campus students to connect with as they transfer into their clerkship years. We have also created a robust peer mentorship program with every incoming student assigned a second year mentor.

Self-Care Plan Students know what works for them to manage stress. We have focused on providing MetroDoctors

time (through the reduction of content and contact hours) and space (with new wellbeing spaces) to facilitate effective self-care practices. Additional efforts include continued support of the student well-being program; expansion of consultation options and providing new mental health resources.

Conclusion Through this emerging well-being model, the Medical School has a truly comprehensive system that provides both enhancement and threat mitigation. It moves away from putting the focus on student behavior and moves to a model of shared responsibility for well-being. In each of the areas a collaborative approach with students and other stakeholders results in better learning experiences and improved student satisfaction. History suggests that it will continue to evolve; however, for now, it stands as a platform with capacity to meet a range of student needs.

Michael H. Kim, MD joined the faculty of the Department of Pediatrics in the Division of Academic General Pediatrics as a hospitalist in 2006 after completing his bachelor’s degree, Medical School, and residency training at the University of Minnesota. Additionally, Dr. Kim did his residency at the University of Minnesota in the Department of Internal Medicine and Pediatrics.

W. Scott Slattery, PhD joined the Office of Medical Education as Director of Learner Development in 2014 after previously serving as a Sr. Psychologist at the University of Minnesota’s Student Counseling Services. Dr. Slattery earned his bachelor’s degree from the College of William and Mary, and doctorate at the University of Pittsburgh.

References 1. World Health Organization. Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946.

Link: https://www.who.int/about/who-we-are/ constitution.

2.

Rotenstein LS, Ramos MA, Torre M. Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students. JAMA 2016;316(21):2214-223.

3. Slavin SJ, Schindler DL, Chibnall JT. Medical student mental health 3.0: improving student wellness through curricular changes. Acad Med. 2014 Apr;89(4):573-7.

4.

Klinenberg, Eric. Heat Wave: A Social Autopsy of Disaster in Chicago. University of Chicago Press. 2003.

The Journal of the Twin Cities Medical Society

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hysicians are facing several climate change effects on the health of their patients, including heat stress, vector-borne diseases, decreased air and water quality and increased allergen exposure. As we treat our patients, we can lead by example what we can do to help the environment.

For example, Dr. Tom Kottke (past TCMS President) installed roof solar panels to provide energy for his highly-efficient induction cooking range, thereby allowing him to avoid using a polluting natural gas range. He rides his bike and takes public transportation to work and meetings. Over a lifetime, he will decrease his contribution of CO2 to the atmosphere by 190,000 pounds as well as helping maintain good health (https://bit.ly/CommutingMap).

Dr. Michael Menzel (TCMS Environmental Health Task Force (EHTF) member) is unable to use roof solar panels because of surrounding trees on his property, but he subscribes to a community solar garden that provides electricity for his home and electric car (https:// bit.ly/HomeSolarTips). Another option is to join Xcel Energy’s Windsource or Energy Connect for an additional $2-5 a month to your electricity bill. Xcel will use electricity from its renewable projects for your energy needs. More information is available at https://bit. ly/XcelResidentRebate.

Dr. Mark Nissen (EHTF member) uses solar panels and low flow toilets at his cabin to provide electricity for his home and electric car and to decrease water usage. Note that the price of electric vehicles is coming down.1 If physicians can demonstrate by their actions that climate change is real and affecting the health of the population, patients will become more aware of the steps needed to mitigate the consequences of global warming. These personal and individual actions may seem small but think of the collective action if many of us take these actions.

Our successful steps can help spawn conversations with our colleagues and inspire healthier and more sustainable lifestyles.

References: 1. The Bottom Line on Electric Cars: They are Cheaper to Own, Forbes, Oct 24, 2017.

Search for Twin Cities Medical Society on Facebook and follow us on Twitter @TCMSMN

By Mike Menzel, MD and Tom Kottke, MD MetroDoctors

The Journal of the Twin Cities Medical Society

Honoring Choices Minnesota: From the Grassroots to the Treetops

I

t has been more than 10 years since Honoring Choices Minnesota (HCM) took root, thanks to an extraordinary agreement of the leaders of Minnesota’s major healthcare systems and health plans to collaborate and fund an initiative to promote and provide Advance Care Planning (ACP) resources in Minnesota. Since our founding in 2008, HCM has embraced the vision of making ACP the community’s collaborative standard of care for adults to ensure every person’s informed healthcare choices are clearly defined and honored.

To achieve this vision, HCM: • promotes the benefits of ACP through public awareness, education and involvement • provides ACP education and training for future and current healthcare providers and professionals • collaborates with community partners/members of culturally diverse populations to develop ACP materials and methods that are culturally accommodating (i.e., that honor cultural beliefs, values and practices) • engages groups routinely overlooked by our healthcare system in ACP • guides healthcare organizations in adopting and implementing methods and processes of ACP In our work with the public, we partner with a wide variety of organizations, educating civic, faith and community groups, as well as in worksites, professional associations and academic settings. HCM has expanded its educational outreach to

By Kerry Hjelmgren, Executive Director MetroDoctors

include future healthcare providers and professionals, with an ACP curriculum for medical students, and regular presentations to nursing students and long-term care administration students. We are continuing to expand our ACP Kerry Hjelmgren, Executive Director, HCM (left) with Volunteer Ambascollaborations sador Richard Shank, MD and Lynn Betzold, HCM Program Coordinator. with vulnerable populations: persons with dementia and hospital in the state was invited to colmental health diagnoses; people experienclaborate in developing a local ACP proing homelessness; incarcerated individuals; gram (with guidance and support from and survivors of domestic abuse. We rely HCM). Of the initial respondents, nine upon our team of committed and trained communities comprised the first Greater volunteer Ambassadors and Facilitators Minnesota seven-member cohort: Aitkin/ to help us educate our community and Crosby, Duluth, Ely, Faribault/Owatonorganizations in ACP. Through in-person na, Luverne, Northfield and Staples. The presentations, social and print media, rafollowing year, a second cohort of commudio and television appearances, together nities took action: Hastings, International we are planting seeds of awareness and Falls, Park Rapids, Walker and Surroundproviding encouraging messaging to help ing communities. Communities displayed all Minnesotans engage in the process of different strengths which were celebrated ACP. and different challenges which were tackled together. Each community-based ACP Stretching State-Wide program was uniquely tailored to the needs Thanks to legislatively appropriated addiof its system and/or community. HCM tional funding in recent years, HCM has worked with community leaders to design broadened our reach both programmatthe right approach and strategies for sucically and geographically. A 2015-2017 cessful implementation. These two Greater grant from the Minnesota Department of Minnesota ACP cohorts continue to raise Health enabled us to stretch beyond the community awareness of ACP, help local Twin Cities metro area to engage greater healthcare professionals enhance their ACP Minnesota communities in ACP. Each

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Honoring Choices Minnesota (Continued from page 21)

Honoring Choices Minnesota By the Numbers

facilitation skills, share best practices and resources, and measure their impact within their communities. HCM has grown ACP into a movement extending throughout Minnesota — a truly remarkable example of how both healthcare and non-healthcare organizations can work together to provide patient-centered public health initiatives for the benefit of all Minnesotans.

Promoting Health Equity Through ACP

A second legislative health equity funding appropriation for 2017-2019 allowed HCM to collaborate with organizations and institutions that represent and serve diverse populations. Such groups are often underserved by ACP efforts and are a crucial health equity goal. HCM has formed working partnerships with the African American community with Volunteers of America Caregiver and Dementia Services, and the Native American community with the Center of American Indian and Minority Health at the University of Minnesota Duluth. Relationship and trust-building have been the cornerstones upon which the work of these partnerships is being done. Once that foundation was formed, our respective roles could be defined and our mutual desire to teach and learn from each other resulted in the creation of: • culturally responsive ACP materials and resources for community awareness • ACP community outreach opportunities consistent with culturally meaningful interaction, and • ACP training for and with the healthcare providers serving these communities.

In 2020, HCM is actively seeking Honoring Choices Minnesota’s Health Care Directive is available in these languages: • Arabic • Chinese • English • Hmong

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• Russian • Somali • Spanish

• • • •

•

86,750 Health Care Directives downloaded from our website 6 Patient education handouts in 5 languages 7 Languages in which families can download Health Care Directives 3 Step-by-Step instructional videos in Somali, Hmong and Spanish are accessible to Minnesota clinics, hospital systems and patient education settings 12 state/region-based Honoring Choices programs are in the US

funding to continue to promote health equity through ACP with our established partners, and to expand our reach to other major cultural communities in Minnesota to engage with us in developing ACP materials and communication that accommodate cultural beliefs and practices.

At the same time HCM has been working with our culturally diverse partners, we have also collaborated with St. Olaf College to improve ACP engagement among young adults ages 18-25, a commonly underserved population in the ACP realm. Students who took the course Living and Dying: Explorations with Young Adults: • developed an ACP community event evaluation tool for statewide use • engaged their peers in conversations and activities focused on end-of-life topics, and • produced a video about their positive experiences as young adults discussing death and dying to encourage young adult participation in ACP. View video at: https://bit.ly/YoungAdultsTalk.

We are hopeful that this course will be offered annually at St. Olaf to generate new waves of young adults who will make ripples of ACP engagement among their peers and families.

HCM’s Reach Beyond Minnesota

The reputation and integrity of Honoring Choices Minnesota’s program is recognized nationwide. Our program is a national leader in ACP and serves as the convener of a network of 12 other state and region-based programs around the country licensing the HCM brand and logo and emulating our program’s structure and resources. The network has grown from just three states in 2013 to 12 in 2020. Over

the last decade, HCM has had the honor of sharing our work at state, national and international ACP conferences.

Looking ahead, HCM will continue its outreach and education while also exploring new opportunities, partnerships, methods and resources. We are currently exploring ways to efficiently and effectively connect with both urban and rural Minnesotans, and to better use technology to enhance our efforts. Over the next decade, we are committed to continuing our collaboration with the community at large, diverse and underserved populations, healthcare organizations and professionals, and other organizations to ensure that ACP and decision-making related to individual preferences for how we want to live as we approach the end-of-life remains front and center for all adults in Minnesota.

It is with great appreciation that I extend my thanks to our current medical director, Ken Kephart, MD, and former, Kent Wilson, MD, for their inspiration and leadership of Honoring Choices MN. Honoring Choices National Network Partners • Delaware • Florida • Idaho • Indiana • Massachusetts • Minnesota • North Dakota • Pacific Northwest (Washington & Oregon) • Tennessee • Virginia • Wisconsin • Napa, California

MetroDoctors

The Journal of the Twin Cities Medical Society

MetroDoctors

The Journal of the Twin Cities Medical Society

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Lessons Learned from TCMS’s Tobacco Work

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n 2015, Twin Cities Medical Society received funding from the Center for Prevention at Blue Cross Blue Shield of Minnesota to address the emerging trend of e-cigarettes and engage Minnesota physicians in tobacco prevention and control efforts. As we look forward to the next decade of physician advocacy, I wanted to share four key lessons I’ve learned from our work together on this program.

Physicians Can and Do Save Lives Beyond Their Clinic Walls

The first lesson is one I’m reminded of every day — physician advocacy makes a difference. Physicians are uniquely positioned to act as advocates for population health issues. Not only do physicians have a deep understanding of the medical issues involved in population health topics, but they are highly trusted sources of information for both elected officials and the public. TCMS’s former CEO, Sue Schettle, has shared that during the early days of the smoke-free movement, city council members would ask “if this issue is so important, where are the physicians?”

As many of you know, our local medical societies and the physician community showed up in force to help pass smoke-free laws in Hennepin County in 2005 and continued to support the policy at a statewide level in 2007. As e-cigarettes began to gain popularity around 2015, physicians renewed their advocacy in this area and advocated for policies that would include e-cigarettes in Minnesota’s clean indoor air

By Annie Krapek, MPH Senior Project Manager

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policies. Physicians played a critical role in countering vape industry propaganda and providing elected officials with evidenced-based information on harms of vaping and unknowns about the health impact of second-hand aerosol exposure. After the passage of several local policies, Min- TCMS Staff, Annie Krapek, Kate Feuling Porter and Amber Kerrigan nesota passed leg- attend Minnesotans for a Smoke-free Generation’s Day at the Capitol islation to include in 2019. e-cigarettes in the state’s clean indoor air adult-only tobacco shops. St. Paul and policy in 2019. Physician’s involvement Duluth soon followed suit. Emboldened in the smoke-free movement illustrates by these policies, other Minnesota cities that physicians can save lives not just in began passing policies to ban the sale of their medical practice, but beyond clinic all flavored tobacco, including menthol walls as well. tobacco, in their communities. Now, in 2020, a bill to ban the sale of all flavored We Must Dream Big if tobacco products, including menthol, in We Want Big Changes Minnesota passed the Minnesota House Over the past five years, we’ve seen the Health and Human Services Committee. power of setting courageous goals. When TCMS first began educating our membership about the harms and health inequities caused by menthol flavored tobacco in 2016, the idea of taking any policy action to restrict the sale of menthol tobacco was completely audacious. Just a handful of municipalities in the United States had taken any action on menthol tobacco. But in 2017, thanks to tireless advocacy from residents, including over 50 physicians and medical students, the city of MinDr. Alex Feng testifies in favor of a bill to neapolis passed a groundbreaking policy ban the sale of all flavored tobacco products at the Minnesota House of Representato restrict the sale of flavored tobacco to tives in 2020.

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The Journal of the Twin Cities Medical Society

We’ve faced significant, and at times underhanded, opposition from the tobacco industry over the years, but through courageous goals and hard work we are making real progress on addressing the harms of menthol tobacco.

Future Progress Will Require Equitable, Innovative Solutions

We’ve made tremendous progress in reducing tobacco use in Minnesota. Thanks to sustained policy and community efforts, the smoking prevalence among Minnesota adults fell from 22% in 1999 to 14% in 2018. Despite this progress, staggering inequities in tobacco use remain. 19% of African American adults, 28% of adult Medicaid enrollees and a staggering 38% of American Indian adults in Minnesota smoke. These inequities are unacceptable, and it’s clear that in order to reduce these inequities we must support policies and programs that are specifically designed to serve these populations. One example of this kind of work is Clearway Minnesota’s American Indian Quitline. This program

features American Indian cessation coaches, longer periods of free nicotine replacement therapy and integrates respect for sacred tobacco into counseling. Policies to restrict or ban the sale of menthol tobacco and zoning policies that prevent the concentration of tobacco stores in neighborhoods with primarily poor residents or people of color are other targeted policy solutions. Some organizations are also looking even further upstream to the impact of Adverse Childhood Experiences (ACEs) on future tobacco use. Programs that identify and support children who have experienced ACEs or even work to prevent ACEs in the Chris Reif joins TCMS staff to celebrate the passage first place could play an important Dr. of a policy to restrict the sale of menthol tobacco to role in addressing tobacco-related adult-only stores in Minneapolis in 2017. inequities. Understanding the interconnected nature of public health issues Minnesota Physicians is a lesson that can be extended beyond Go Above and Beyond tobacco control to many other issues facing Above all else, I am struck by the dedicaour community. tion and generosity of TCMS’s members and physicians throughout Minnesota.

Since TCMS launched our program to address commercial tobacco use five years ago, physicians have supported the passage of over 55 local policies throughout the state, as well as several important statewide policies. From contacting elected officials to publishing letters in local papers to testifying at city and statewide hearings, the physician community has been a dedicated and powerful force for policy, systems and environment change in tobacco control.

I am particularly grateful for our Medical Director, Dr. Pete Dehnel, and members of our advisory committee for the countless hours they have volunteered on this issue (and in many cases, years of advocacy in tobacco control preceding this project).

Myself and the rest of the TCMS staff are incredibly grateful for your passion and willingness to use your voice to improve public health in Minnesota. We can’t wait to see what changes the next 10 years of physician advocacy brings!

Dr. Caleb Schultz (far right) celebrates with community advocates as Edina becomes the first city in Minnesota to raise the tobacco sales age to 21 in 2017.

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Dr. Pete Dehnel Public Health Advocacy Fellowship — Meet Our Fellows

T

he Dr. Pete Dehnel Public Health Advocacy Fellowship creates a connection between medicine and public health for medical students by offering opportunities for students to connect with a physician mentor and engage in local public health advocacy activities.

In the second year of our program, Twin Cities Medical Society staff supported nine exceptional medical students from both the Twin Cities and Duluth campuses to build their advocacy skills as they engaged in their public health area of interest while being mentored by a seasoned physician advocate. We hope you will enjoy learning about this year’s cohorts in their own words.

Learn more about our students and their mentors at metrodoctors.com/fellowship.

If you are a physician interested in mentoring a future fellow or if you are a student interested in learning how physicians can create change beyond their clinic walls, please email TCMS Program Coordinator Amber Kerrigan at akerrigan@ metrodoctors.com.

Thaius Boyd, MS1, Duluth Campus; Mentor: Laalitha Surapaneni, MD Sengithamu, (greetings), the impacts Line 3 will have on manoomin (wild rice) and its effects on tribal communities is frightening. Four wild rice fields reside directly in the pipeline pathway, and a total of 17 wild rice fields reside within 0.5 miles of the pathway.

Manoomin is central to the Anishinaabe’s Creation-Migration story, and is a sacred, traditional and healthy food used for sustenance. Ricing activities also provide physical activity, a strong sense of community and spiritual well-being, contributing to an average of 90,000 dollars per year of prevented healthcare costs 26

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for Native Americans in Minnesota.

Governor Walz stated he would continue legal actions to challenge construction of Line 3. This step is in the right direction; however, we must be adamant in making our voice heard and demand a transition to a renewable and sustainable future. Green energy will safeguard manoomin, tribal health and future generations.

Megan Crow, MS4, Twin Cities Campus; Mentor: Matt Kruse, MD Psychiatric Advance Directives (PADs) are an important tool for mental health treatment. These documents give patients the power to have input in their health care during times when they are in crisis and unable to speak for themselves. PADs are completed by patients in collaboration with their mental health providers to communicate their wishes during times of crisis. Patients can name a healthcare agent (typically a friend or family member who knows them well) to speak on their behalf during these times. These directives can also give their healthcare team guidance on which medications and other interventions work best for them. Despite the many advantages of PADs, they are not used very widely. We are undertaking an initiative to increase the use of PADs in Minnesota.

Maggie Flint, MS4, Twin Cities Campus; Mentor: Sarah Traxler, MD One of my favorite things about the TCMS advocacy fellowship has been the opportunity to see physicians doing advocacy in their daily lives. It gives me a clearer vision of what my future career could look like in OB/GYN, having the opportunity to advocate for my patients daily in the clinic or hospital as well as

at the legislature. I recently attended the MMA Day at the Capitol where I spoke to my representative with a group of OB/ GYN residents and a physician. I was able to practice the elevator pitch I crafted in the fellowship about maternal morbidity and mortality and could see how it was even more impactful when I shared my expertise and patient stories. My experience in this fellowship has given me a new lens through which to think about advocacy work, and I can better appreciate how physicians I have worked with are able to translate daily experiences with patients into policy changes statewide.

Sami Gibson, MS2, Twin Cities Campus; Mentor: Ed Ehlinger, MD Over 70% of all cancers caused by human papillomavirus (HPV) are vaccine preventable — not only cervical cancers, but also anal, penile and oropharyngeal cancers, whose rates are increasing in Minnesota.

Yet only 56.8% of adolescents in our state had received their first dose of the HPV vaccine in 2017, according to the Minnesota Department of Health. Compare this to the >77% first-dose coverage for both Meningococcal and Tdap vaccines recommended at the same age and it’s evident where we can improve. Our efforts could spare more than 650 Minnesota families each year from cancer diagnoses. The proven solution couldn’t be simpler: strong recommendation during adolescent clinic visits. This means recommending HPV, Meningococcal, and Tdap vaccinations in the same way on the same day. Strong HPV vaccine recommendation is clarified and repeated in response to any questions or concerns. Persistence with recommendation can and will protect Minnesota youth from preventable cancers.

MetroDoctors

The Journal of the Twin Cities Medical Society

Megan Robinson-Lucas, MS2, Twin Cities Campus; Mentor: Courtney Baechler, MD Racial disparities are recognized in nearly every measure of health. Disparities in infant and maternal mortality have been most salient recently, and I began the Dr. Pete Dehnel Public Health Advocacy Fellowship focused on this issue. However, with the opportunity to delve further into this and meet people working to address disparities in Minnesota, I found myself continually returning to question why the medical community has not taken a more active role toward this issue. Our medical system has a history marred by injustices against people of color, many of which persist today. Race-based medicine, or the use of race as a factor in clinical decision-making, is one such example. This practice is problematic for many reasons; one is the implication that biological differences drive racial health disparities, rather than racism and other structural factors. I believe it is the responsibility of the medical profession to more actively address the causes of these disparities and the role our system has in perpetuating them. It is part of a physician’s job to advocate for patients and communities, and in this case, I think that means increased education and action within the medical profession.

Aaron Rosenblum, MS2, Twin Cities Campus; Mentor; Eva Pesch, MD Between 1995-2019 the United States spent $396.9 billion in farm subsidies,

L to R: Alex Kuehen, Riley Shearer, Sami Gibson, Tom Schmidt, Sruthi Shankar, Megan Crow, Maggie Flint, Thaius Boyd and Aaron Rosenblum.

with 52% funding corn, soybeans, and wheat;1 crops often destined for climate warming animal agriculture. We subsidise feedstocks for unhealthy processed foods then pay again when these foods make us sick.

A 2019 JAMA meta analysis found a 30% risk reduction in type 2 diabetes by eating a healthy plant-based diet.2 Such diets could significantly reduce our nation’s chronic disease burden. Moreover, reorienting food systems to center human and environmental health comes with additional benefits such as empowering communities through local production and reducing greenhouse gas emissions.

The US farm bill is reauthorized every

Our closing celebration was moved to a virtual gathering where fellows reflected on lessons learned and connections forged during their program year. Physician mentors Laalitha Surapaneni, MD and Ed Ehlinger, MD joined us and shared how their passion for public health has helped bring meaning to their practices and helped prevent burnout.

MetroDoctors

The Journal of the Twin Cities Medical Society

five years and presents the greatest opportunity to influence food policy on a large scale. Health professionals should speak up and advocate for smarter agricultural policies that center local food systems, sustainable production, and an abundance of affordable healthy foods.

Tom Schmidt, MS4, Twin Cities Campus; Mentor: Frank Rhame, MD Injecting Passion into Harm Reduction. If we wish to continue reducing the impact of the opioid crisis in Minnesota, we need to work aggressively to reduce the harm of injecting drugs. Reducing harm for people who inject drugs means increasing access to health care, clean injection supplies, and naloxone.

In Minnesota, according to the DHS, there has been a 33% decrease in new opioid prescriptions since 2016 through education campaigns. While prescriptions have been declining, we continue to see overdoses and infectious disease transmission in our communities of people who inject drugs. Public health organizations are working hard to provide clean injection supplies to prevent the transmission of HIV and HCV. We need to be innovative and aggressive in our harm reduction efforts if we truly hope to see an end to the impact of the opioid crisis on our fellow Minnesotans.

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Public Health Advocacy Fellowship (Continued from page 27)

Sruthi Shankar, MS2, Twin Cities Campus; Mentor: Lisa Saul, MD New research shows that weight and BMI are poor predictors of health, disease and longevity in the general population, except for those at statistical extremes.

Restrictive dieting and calorie-counting have proven to be poorly-sustainable long-term prescriptions for weight loss

and health maintenance. These behaviors, which inevitably lead to weight cycling, can contribute to inappropriate food/ body associations that may have serious physical and psychological implications.

Adopting a weight-neutral provider lens that favors the development of long-term healthy behaviors, without an inherent focus on the scale, may be beneficial for those patients for whom their adiposity is not the inherent cause of their disease.

THE SCHUSTER CLINIC FOR ENDOCRINE AND METABOLIC DISORDERS −and−

THE THYROID CENTER

www.schusterclinic.com 50th and France, Edina/Minneapolis MN

In pregnancy, however, due to (1) the current limitations of medical technology (like ultrasound) and (2) the current data about medical complications in mothers with certain risk factors (like gestational diabetes, sleep apnea), addressing weight/ adiposity may still be an important aspect of care. One major challenge currently facing all physicians in general, but particularly obstetrics providers, is the lack of guidance by professional medical societies regarding respectful discussions of weight-related topics with patients. My project, under collaboration with Dr. Lisa Saul and the Mother Baby Center at Abbott Northwesern Hospital, aims to identify areas of discomfort from both the clinician and patient perspective and seeks to eventually outline patient-centered language guidance for medical providers when addressing weight-related topics.

Riley Shearer, MS2, Twin Cities Campus; Mentor: Emily Brunner, MD Walking into my City Council member’s office, I could tell they were confused by why I had an appointment on their calendar. I sensed this was not the moment to lead with my prepared “elevator pitch” on rising rates of methamphetamine and polysubstance use and the needed public health response. Instead, I drew on lessons we learned in the first two years of medical school and asked him what his concerns were. And then I listened. An engaging conversation followed, and it wasn’t until we talked about the issues, he found important that I brought up the need for harm reduction strategies. Although advocacy, by definition, involves making a case to support a policy, I found it was much easier to do this after empathetically listening to understand the concerns of my elected official. Similar to working with patients, you must listen first to later be heard in health advocacy.

(Endnotes) 1. Ewg. “EWG’s Farm Subsidy Database.” EWG Farm Subsidy Database || the United States Conservation Database, farm.ewg.org/region. php?fips=00000&progcode=total.

2. Qian F, Liu G, Hu FB, Bhupathiraju SN, Sun Q. Association Between Plant-Based Dietary Patterns and Risk of Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA Intern Med. 2019;179(10):1335–1344. doi:10.1001/jamainternmed.2019.2195.

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MetroDoctors

The Journal of the Twin Cities Medical Society

The Twin Cities Medical Society Foundation — Your Physician Foundation Who We Are The Twin Cities Medical Society Foundation is a physician-led philanthropic organization that strives to improve the health and well-being of the community through strategic initiatives.

Twin Cities Medical Society Foundation (TCMSF) is the philanthropic arm of the Twin Cities Medical Society and was launched on January 1, 2015 following the merger of the East Metro Medical Society Foundation and the West Metro Medical Foundation. Chris Johnson, MD has served as the chair since inception, with Dr. James Jordan and now Dr. Mark Engasser serving as Vice Chair; Robert Moravec, MD, Treasurer and Elisabeth Hurliman, MD, PhD, Secretary, complete the Executive Committee.

TCMSF has a rich history of responding to the needs of the community with a focus on providing funding to organizations that offer healthcare services and resource connections to our underserved residents.

We also celebrate “Physicians of Excellence” and medical student scholars with award recognitions.

Impact Honoring Choices Minnesota® is the stalwart public health initiative of the Twin Cities Medical Society Foundation, working in collaboration with organizations throughout Minnesota and the nation to promote advance care planning.

In addition, the Foundation is honored to serve as the fiscal agent for the Dr. Pete Dehnel Public Health Advocacy Fellowship, where medical students are given the opportunity to join TCMS members by engaging their voices and skills in public health advocacy work.

Since 2015, TCMSF has provided over $170,000 in grant dollars to our community.

Recent beneficiaries include: MetroDoctors

•

• • • • •

• •

Greater Minneapolis Crisis Nursery: Pediatric Assessment and Medical Management Program Hope Dental Clinic: Providing free oral health care MN Mental Health Community Foundation: Fast-Tracker Program North Metro Pediatrics: Healthy Beginnings Program Phillips Neighborhood Clinic: Clinic Operations: lab tests and medications Physicians Serving Physicians: A peer program that provides support to physicians, families and colleagues with substance use disorders Steve Rummler HOPE Network: Opioid Prescriber Education Lecture Series Roosevelt High School: Health Careers Mentorship Program

Awards Twin Cities Medical Society Foundation is honored to provide awards to our physicians of excellence and outstanding medical students: • Charles Bolles Bolles-Rogers Award — First awarded in 1952, candidates for the award are nominated by their colleagues at Twin Cities area hospitals and clinics for contributions to medical research, achievement or leadership in medicine.

• Shotwell Award — For the past 48 years, this award has been presented to a person within the state of Minnesota for a noteworthy effort in the field of health care. The award was sunset in 2019.

• Twin Cities Medical Society Foundation Scholarship — Over the past 30 years, TCMSF has awarded $90,000 in scholarships to Medical Students for excellence in leadership, service and healthcare advocacy.That’s $90,000 supporting our future physicians!

The Journal of the Twin Cities Medical Society

Funding Funding for the Twin Cities Medical Society Foundation has come through various donations including, most notably, the legacy of Dr. Eduard Boeckmann, a man remembered for his charitable contributions to medicine and unimpeachable character to practice, and for the development of surgical catgut treated with pyoktanin. The manufacturing and proceeds from this suture were donated to the Ramsey County Medical Society to support and cover the expense of a medical library. Following the closing of the library, these funds were transferred to the Boeckmann Fund maintained today by the TCMS Foundation.

Other legacy gifts, donations in honor of or in memory of a colleague, friend or family member, and an annual appeal to the Twin Cities Medical Society members continue to provide the basis for grant dollar allocations.

Your Contributions are Welcomed!

Donations to the Twin Cities Medical Society Foundation can be made at any time throughout the year, and particularly in honor or memory of a colleague, friend and/ or family member. Please make your check payable to TCMSF and mail to Twin Cities Medical Society Foundation, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Online donations can be made at www.metrodoctors.com; click on the Foundation tab. If you wish to designate your gift, please include a brief note. Gifts are used to support the mission to improve the health and well-being of the community.

Questions about the Foundation? Contact Nancy Bauer at nbauer@metrodoctors.com; (612) 623-2893.

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Physicians Serving Physicians

Confidential Peer Support for Physicians with Substance Use Disorders 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 through one-on-one counseling, serving as a liaison between clients and treatment centers, and offering a monthly support group to participants.

We welcome you to join us at our confidential monthly meetings which are held by a community of physicians (only) to offer mutual support, education, and discussion of issues that are unique to physicians in recovery.

Confidential Peer Support and Consultation for Individuals & Organizations: 612-362-3747 • www.psp-mn.com

Free Confidential Wellness Resources for Minnesota Physicians & Their Families LifeBridge provides a safe harbor to empower and equip you with the tools you need to take care of yourself as well as your patients.

Minnesota physicians, residents, medical students, and their immediate family members qualify for four free, confidential counseling sessions to address stressors like: • Depression and anxiety • Relationship issues • Loss and grief • Financial concerns In addition to counseling services, LifeBridge offers a comprehensive, web-based resource with a rich library of interactive tools and information about wellness and other everyday life issues.

Physician Wellness Resources: 866-440-5825 and mention PSP • www.psp-mn.com/wellness PSP MetroDocs Ad Full Page.indd 1

4/1/2020 2:49:44 PM

In Memoriam MARK BANKS, MD, passed away on March 17, 2020. After practicing in Internal Medicine for 10 years, Dr. Banks transitioned into administrative medicine retiring in 2008 as the CEO of Blue Cross Blue Shield. Dr. Banks joined the medical society in 1979.

JAMES KRAMER, MD, passed away on March 31, 2020. He was an orthopedic surgeon practicing for over 30 years primarily in St. Paul and served as Chief of Staff at St. Joseph’s Hospital.

Dr. Kramer joined the medical society in 1963.

MARK MAHOWALD, MD passed away on March 18, 2020. Dr. Mahowald was trained in Neurology, epilepsy, and sleep medicine and worked at HCMC for more than 30 years. He served as the Director of the Minnesota Regional Sleep Disorder Center. Dr. Mahowald joined the medical society in 1985.

HENRY (HAL) MEEKER, MD, passed away on February 26, 2020. Dr. Meeker practiced Obstetrics and Gynecology at John Haugan and Associates in Edina from 1963 until his retirement in 2000.

He was a Chief of Staff at Abbott Northwestern Hospital and served as President of the Continental Gynecologic Society.

Dr. Meeker joined the medical society in 1964.

TIMOTHY NEALY, MD, passed away on March 26, 2020. Dr. Nealy was a family physician practicing primarily throughout southern Minnesota. Dr. Nealy joined the medical society in 1967.

TERRELL YEAGER, MD, passed away on February 20, 2020. An Obstetrician/ Gynecologist, Dr. Yaeger practiced at the Mork Clinic in Anoka for over 35 years. He was a charter member of the Mercy Hospital medical staff. Dr. Yaeger joined the medical society in 1988.

MetroDoctors

The Journal of the Twin Cities Medical Society

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May/June 2020

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, MD

Recognizing Our Society’s Leadership This year marks the anniversary of the merger of two former medical societies — Ramsey/East Metro and Hennepin/West Metro. The resulting creation of our Twin Cities Medical Society (TCMS) 10 years ago is being celebrated, and as part of commemorating its creation, the editors of MetroDoctors have decided to depart from the usual format of the Luminary feature. For this current issue, instead of honoring one notable physician, we will compliment four outstanding former administrative leaders of our predecessor organizations.

THOMAS HOBAN — Hennepin 1969-1995 This genially gregarious, no-nonsense leader had a “tough act to follow” — taking over from the efficacious and long-standing Executive Director, Thomas Cook. And follow it he did — with 26 sterling years of successful leadership. Notable during that span was the contribution of our society in the formation of the Physicians Health Plan — an organization preceding the present United Health Care — an activity strategized and implemented by Mr. Hoban. He also played a major role in forming the medical liability company, MMIC, which became a successful competitor to our physicians’ then-favorite malpractice insurance company. Tom now modestly gives most of the credit for those achievements to “my doctor colleagues,” but — truth-betold — he had wise visions of what was required and he just made them happen.

ROGER JOHNSON — Ramsey 1994-2007 This quietly efficient 13-year executive came to his society with a strong background of organizational medicine experience. He effectively utilized the tools he learned in his prior staff activities with the MMA and his national lobbying tasks on behalf of his physician membership.

Roger now very unpretentiously speaks of his role in aiding the creation of the “Smoke-Free Coalition,” a remarkable public health initiative whose impact has had far-reaching positive population results. Additionally, in collaborative work with his Hennepin “colleagues across the river,” the economies of scale benefits that he instituted undoubtedly sowed the seeds for the future actual merger of the two societies.

32

May/June 2020

JACK DAVIS — West Metro 1994-2010 This pacesetting skipper with a pleasantly wry sense of humor spent 16 years at the helm of his society, leading it through changes while keeping our multiple missions on target. Early on, he recognized that the pre-existing geographic loyalty of our two societies was waning and that we are one large medical community with co-existing complementary talents and capabilities. He methodically and deftly “aimed us away from organizational duplication of valuable resources” of both a fiscal and clinical nature, resulting in the formation of our current strong TCMS. Jack’s early life included a stint as a hospital orderly, and there he gained an appreciation for the health and well-being of a community. It’s probable that experiences there aided his impactful contribution to the creation of our state’s landmark legislation regarding second-hand smoke.

SUE SCHETTLE — Twin Cities 2007-2017 This energetic community-minded CEO presided over the newly formed TCMS, having come from the leadership position at East Metro. Her tactical abilities shepherded the merger transition in a smooth and stress-free fashion. The results of those efforts continue to be recognized and appreciated by our society’s membership and staff each day. She has left an indelible mark on the health and well-being of our community via programs such as the Environmental Task Force. Her potent activities resulted in millions of dollars of grant awards used in a variety of excellent public health initiatives which extended far beyond the walls of doctors’ offices. Behaviors were enhanced as she modified the roles of our society and helped “make the most of physicians’ existing considerable credibility” — championing their partnership in the creation of the advance care initiative program, Honoring Choices.

The above accomplishments are but a fraction of the meaningful impact these assertive leaders developed. They admirably led and wisely conveyed our thoughts and they were our voices — for that, and much more, we are eternally grateful as we honor them as true Luminaries.

MetroDoctors

The Journal of the Twin Cities Medical Society

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