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Statistics on adolescent and young adult cancer survival may be surprising.

Dario Chavez was diagnosed with stage III rhabdomyosarcoma at age 19. After being successfully treated at Children’s, Dario is now a married, cancer free 24-year-old.

Today’s adolescents and young adults diagnosed with pediatric cancers have a poorer prognosis than preteens, young children, and even many adults with cancer. However, there is strong evidence that this adolescent group typically experiences significantly better outcomes when treated at pediatric facilities. At Children’s, our team strives for optimal clinical outcomes through high levels of adolescent enrollment in clinical trials, state-of-the-art technology, developmentally appropriate care, and aggressive management of pain and side effects. For an oncology-related referral or consultation, call Children’s Physician Access at 1-866-755-2121 or (612) 343-2121.

www.childrensmn.org


November/December Index to Advertisers

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

TCMS Officers

President Edward P. Ehlinger, M.D. Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. 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 Katie Snow at (612) 362-3704.

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November/December 2010

President-elect Thomas D. Siefferman, M.D. Secretary Anthony C. Orecchia, M.D. Treasurer Melody A. Mendiola, M.D. Past President Ronnell A. Hansen, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Assistant Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Kathy R. Dittmer, Executive Assistant (612) 623-2885 kdittmer@metrodoctors.com Katie R. Snow, Administrative Coordinator (612) 362-3704 ksnow@metrodoctors.com

Acute Care, Inc. .................................................30 Bethesda Hospital ........... Outside Back Cover Billing Buddies ...................................................27 Brainerd Lakes Health .....................................29 Children’s Hospitals and Clinics of MN...... 1 Classified Ads.........................................................2 Crutchfield Dermatology................................23 The Davis Group .............. Inside Front Cover Fairview Health Services .................................29 Phillip Finkelstein Attorney at Law .............12 Hamm Clinic......................................................26 Healthcare Billing Resources, Inc. ...............14 Lockridge Grindal Nauen P.L.L.P. ...............21 Medical Weight Management Centers .......16 Mpls. Society of Internal Medicine .............11 Minnesota Epilepsy Group, P.A....................23 Minnesota Physician Services, Inc. ..............18 The MMIC Group .............Inside Back Cover Pediatric Home Service .....Inside Back Cover U.S. Army ............................................................31 University of St. Thomas ................................24 Uptown Dermatology & SkinSpa, P.A.......19 Weber Law Office .............................................26 Winona Health ..................................................31

For a complete list of TCMS Board of Directors go to www.metrodoctors.com.

correction Letter to the Editor, September/October 2010, "The Dark Side of Shamanism." The author clarified that Kumbo, also known as Banso Hospital, in 2000 had on its staff ten M.D.’s – mostly nationals with a few expatriates. Around 100 traditional healers lived in the surrounding area. (The traditional healers were not on staff at the hospital.)

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MetroDoctors

The Journal of the Twin Cities Medical Society


contents VOLUME 12, NO. 6

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Index to Advertisers/Classified Ads/Correction

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President’s Message

NOVEMBER/DECEMBER 2010

You Don’t Have Anything if You Don’t Have the Stories By Edward P. Ehlinger, M.D., MSPH

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tcMs in action By Sue Schettle, CEO

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Your Voice

“Minnesota Connect” By Tom Pettus, M.D. and Peter R. Bartling Pages 5 and 8

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White Coat Ceremony

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Honoring Choices Minnesota Hosts Community Dinner

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colleague interView

Rahul Koranne, M.D., MBA, FACP

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fighting obesitY

• Healthy Eating Minnesota: A Project of TCMS By Jennifer Anderson

Page 7

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• Obesity and Tobacco Abuse—What’s the Clinical Role of a Community Problem By Courtney Jordan Baechler, M.D.

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• Obesity Management By J. Michael Gonzalez-Campoy, M.D., Ph.D., FACE, and Rebecca C. Gonzalez-Campoy

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• Obesity—A Treatment Overview By Frederick Johnson, M.D. and Mary Silberschmidt, BSN

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• Obesity—It’s Not That Simple By Allison Holt, M.D.

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• Reducing Obesity and Tobacco Use at the Community Level By Cara A. McNulty, M.S. and Michael Hawton, MPA

Page 9

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• Progress on Childhood Obesity Policy in Minnesota By Rachel Callanan

Page 25 MetroDoctors

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MMA Holds 2010 Annual Meeting

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In Memoriam/Twin Cities Medical Society Forum

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New Members/Career Opportunities

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luMinarY of twin cities Medicine

M. Elizabeth Craig, M.D.

The Journal of the Twin Cities Medical Society

On the cover: Is there a solution to the rising rate of obesity? Articles begin on page 12.

November/December 2010

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President’s Message

You Don’t Have Anything if You Don’t Have the Stories EDwaRD p. EhLiNgER, M.D., MSph

As I reflect on the experience of that evening, I realize that storytelling is one of the most effective ways to address many of the individual attitudes, beliefs and behaviors that ultimately affect health. Because of that, I have searched for ways to incorporate storytelling into the fabric of my mediYou don’t have anything member of the Storytelling Circle had cal practice. And I have been amazed at If you don’t have the stories.” just finished telling a classic story to how many ways and opportunities there are an exceptionally attentive audience. to do that — from using stories to inform from Ceremony by Leslie Marmon Silko The palpable emotion in the room attested to patients about the importance of taking the fact that the woman’s story had powerfully impacted every listener. medications or learning how to swim to using stories during conversaAs I looked around the room, I noticed that all of the women had tears tions with families about end-of-life choices and decisions. Using stories in their eyes or were quietly sobbing — obviously moved by the story. in lectures to health science students about what works and what doesn’t The men, while enthralled by the story, sat dry-eyed, bewildered, and with patients with specific diseases or conditions has also been a way to somewhat uncomfortable with what was unfolding around them. influence the other end of the patient/physician dyad. The story that had been told was the Greek myth of the abduction I have also discovered that stories can be an effective tool in nonand rape of Persephone by Pluto, the brother of Zeus. As we discussed clinical situations to influence public policy and public health. Sharing the story, each woman shared that the story vividly brought back all stories with legislators and other policy makers often has a greater impact of the memories and emotions of her first sexual encounter. Without than our research-based charts and graphs. Stories can help community exception, each woman revealed that, in retrospect, her loss of sexual groups identify with health and social justice issues in their neighbor“innocence” had affected her more than she had anticipated. All of the hoods and stimulate action to confront those issues. And stories can be women felt that they had been inadequately prepared for the psychohelpful in raising issues and advancing conversations among colleagues logical, emotional and spiritual consequences that would ensue from when used in newsletters, magazines and journals such as MetroDoctors. a single experience in some mundane place like the back seat of a car. Our technologies and medicines are extremely powerful in treating The initiation of sexual activity was a life-changing event and they all diseases and injuries but they are nearly useless in dealing with many of the wished that they had been better prepared. attitudes, beliefs and behaviors that play a major role in determining the “If only I had known years ago what I’ve learned tonight, I would status of our individual health and the health of our communities. These have approached that first experience differently” was the uniform and are influenced more by the everyday experiences with family, friends, apologetic response from each of the males in the group. community, the media, religious institutions, and schools. Ultimately, Much of my professional life has been spent trying to educate stories, in various forms, may be the only way to modify those influences. adolescents and young adults about how their lives would dramatically Only when we can effectively incorporate our medical expertise change once they became sexually active, even if pregnancy didn’t occur. with our human stories will we be able to optimally enhance the health Never had my didactic lectures or counseling sessions, and certainly not of our patients and the communities in which they live. I encourage you my distribution of condoms or prescriptions for oral contraceptives, had to become aware of the stories in your profession and in your life and the kind of impact that I was observing among this disparate group of honor the telling of those stories in your office, hospital, organizations people. As I listened to the story circle discussion and felt the impact and community because in the end “they are all we have…to fight off of the tale on the women and saw the insights gained by the men, I illness and death.” wished that every boy and girl who was approaching puberty and every In science and society (and in TCMS) “you don’t have anything if man and woman contemplating the initiation of sexual activity could you don’t have the stories.” be exposed to a similar educational experience. “I will tell you something about stories. They aren’t just entertainment. Don’t be fooled. They are all we have, you see, All we have to fight off Illness and death.

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November/December 2010

MetroDoctors

The Journal of the Twin Cities Medical Society


tcMs in action SUE a. SChETTLE, CEO

“It’s about the conversation…” is probably the easiest way of describing what’s behind the Honoring Choices Minnesota initiative. This project is multifaceted but essentially it is about encouraging family discussions of values and beliefs about end of life care so that when the time comes family members and loved ones can feel comfort in knowing what their loved ones wanted. Sure, it’s also about filling out a health care directive, but the value of what this initiative brings to families is having the conversation and expressing feelings and desires. What is a “good death” to one patient might be completely different to another. Some patients want to try every possible remedy for their ailment, others only want to try a few things. The conversation is aimed at finding out what the patient wants, and documenting it. It is a gift that you can give your family. I have heard story after story from physicians of TCMS who have been faced with really difficult challenges when life threatening situations arise in the course of a patient’s treatment. Physicians are faced with situations where family members haven’t had conversations with mom or dad about what they would have wanted if they couldn’t speak for themselves and yet, a decision has to be made. This makes for a dicey situation where the care team is caught in an emotional tsunami that might have been avoided had a conversation occurred. The Honoring

Choices Minnesota initiative is a first step in what we hope will be a longstanding societal change in our community. On September 13, 2010 the Twin Cities Medical Society hosted a community dinner at the Midland Hills Country Club. Over 130 people attended the event. Mary Brainerd, CEO of HealthPartners, Inc. served as the host. Kent Wilson, M.D. and Ed Ehlinger, M.D. from TCMS and others, proposed to the community the concept of a community-wide collaboration around this idea of having a conversation. The energy in the room was palpable and there is indeed support. Longterm fundraising to support the initiative has already started. Twin Cities Public Television (TPT/Channel 2) filmed the entire evening. To learn more, please contact me at (612) 362-3799. TCMS Votes to Combine Caucuses in 2011

The TCMS board of directors voted at its last meeting to merge the East Metro and West Metro caucuses into one in 2011. The board acted on the recommendation of the joint East Metro and West Metro caucus that met on Friday at the MMA annual meeting in September. The joint caucuses voted unanimously to recommend that the caucuses merge which will make for a more streamlined process and more robust discussion. There will be a joint TCMS caucus starting in May 2011. At the MMA annual meeting in September TCMS will caucus as one organization, rather than as two Trustee districts. What is a Caucus?

Back row from left: Sean Kershaw, Citizens League; and Ed Ehlinger, M.D., TCMS President. Front row from left: Bill Hanley, TPT; Mary Brainerd, HealthPartners; Sue Schettle, TCMS; and Kent Wilson, M.D., Honoring Choices Minnesota.

MetroDoctors

The Journal of the Twin Cities Medical Society

The caucus is actually a meeting of TCMS physicians that occurs usually in May and again in September at the MMA annual meeting. The meeting is chaired by a physician of TCMS and it serves as a place where physicians can bring forward ideas for the MMA to work on. When I meet with a new member of TCMS I generally tell them that if they wonder what we (TCMS and MMA) do, they should attend a caucus (and the MMA annual meeting). This is likely one of the few places where a multitude of issues are discussed by your colleagues, ranging from single payer to mandatory medical staff influenza policies. Photos by Blasing Shots Photography November/December 2010

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YOUR VOICE

“Minnesota Connect”

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recent best seller about the legendary investor Warren Buffet was entitled “The Snowball.” The book title came from an investment philosophy created by the “Oracle of Omaha,” that states, “Life is like a snowball. The important thing is finding wet snow and a really long hill.” We think that we have found both with the current health care crisis. Our wet snow is the multitude of problems and opportunities that constitute the current medical environment; and our long hill is the impact of caregivers, organized in a specific manner, providing the best care for the patient, which will result in significant cost savings for the system. If we were running for Governor of this great state of ours, we would focus our intellect and our energy on health care reformation, not only because it is our area of expertise, but also because it touches almost all other components of public policy — education, employment environment, and equity. There seems to be a general consensus on objectives with respect to health care, both here in Minnesota and across the country: (1) improve the health of our population and (2) management of costs, i.e. expense reductions. While there may be no serious disagreements on health care objectives, there is a vast range of opinion on solutions to providing affordable health care to all Americans. Since we want to be part of the solution, rather than part of the problem, we offer the following program, which might be called “Minnesota Connect.” 1) Accountable Care Organizations — The Patient Protection and Affordable Care Act will evoke a wide expansion of health care networks, to be called “Accountable Care Organizations” or ACOs. ACOs will have a significant impact on both health care delivery and reimbursement. An ACO is an integrated medical network that enables providers to come together and coordinate care, improve cost and quality and participate in the savings generated from their uniform and collective efforts. Think Allina or Fairview and their network of hospitals, owned clinics and independent physician groups. Think the Mayo Clinic and their system of employed physicians. ACO’s feature collective responsibility for patient care, which means coordinated decision making, even though there are multiple points of entry in an integrated system. An ACO is an investment in health care, not transactions. Payment is not tied to output, but rather to care results. We will be delivering better care, not more care, with the ACO model. 2) System Retention — It is imperative that patients stay in the ACO integrated network long enough to see definitive improvements in their health status. Measurement improves performance, and healing and wellness are generally evolving, not revolutionary. 3) Information Management — Accelerate the electronic 6

November/December 2010

transmission of health related information among medical organizations through the use of standardized Electronic Medical Records. EMRs will improve the health of all Minnesotans, while maintaining patient privacy through appropriate safeguards. 4) Prevention — Encourage prevention initiatives across the continuum of care: seat belt utilization, dietary measures, helmet use, cholesterol-lowering drugs, smoking cessation, health club memberships, etc. Whatever it takes to change behavior and alter lifestyles for the better should be enhanced, incentivized and supported. 5) System Productivity — According to Dr. Tor Dahl, from the School of Public Health at the University of Minnesota, productivity is… “A measure of output over input, results over resources consumed.” Productivity techniques, whether they are Six Sigma or the teachings of W. Edwards Deming, can increase life expectancy, lower infant mortality, reduce and/or control chronic diseases and preserve functional capacity. These methods and comparable others should be embraced and employed relentlessly throughout every health care organization. 6) Fraud and Abuse — It is estimated that Medicare fraud costs American taxpayers $60 to $90 billion each year. Every effort should be made to prevent and prosecute these crimes through the increased sharing of information across governmental bodies and the expansion of overpayment recovery efforts. 7) Increase Competition — Start here with allowing health insurance companies to compete on a national basis for customers, thereby minimizing state oligopolies and their market dominance. 8) Medical Tourism — Encourage health care utilization from the world-wide global community, along the lines of the Johns Hopkins Medicine International program. This project could be spearheaded by the Minnesota Department of Tourism; with assistance from all the major health care systems in the state. Minnesota’s clinical services are next to none and should be shared with the world! 9) Jobs-Jobs-Jobs — Minnesota is on the cusp of change as it relates to health care reform. Its Accountable Care Organizations could be replicated across America, thereby creating the next generation of a Mayo Clinic type entity. Medical Tourism could also expand, with a commensurate increase in the need for health care professionals and their support cadres. A journey of a thousands miles always begins with that first step. Minnesota health care is a vast and complicated industry, with no easy answers, only difficult solutions. We hope that we have suggested a few. Tom Pettus, M.D., Twin Cities Geriatrician, and Peter R. Bartling, Health Care Consultant. MetroDoctors

The Journal of the Twin Cities Medical Society


White Coat Ceremony The University of Minnesota Medical School held its White Coat Ceremony on August 9, 2010, recognizing the 170 first year medical students with their white coats, a symbol of the professional values and responsibilities of the patient-doctor relationship. TCMS is honored to be a supporter of this event. Edward P. Ehlinger, M.D., president, presented an ADC Buck Hammer to each student engraved with the TCMS name and logo.

Statement of Commitment University of Minnesota Medical School Class of 2014 As the University of Minnesota Medical School students and future physicians, we take this oath as we enter into a career of partnership with our patients, collaboration with our colleagues, and improvement of our health care system. We pledge to commit ourselves to excellence in the care of our patients. We will not simply treat illness, injury, or disease, but will always remember that we are treating individual human beings who have unique needs and concepts of health. We will be our patients’ allies, listening actively and serving as compassionate partners in healing. We will treat all patients with respect and dignity, regardless of race, ethnicity, gender, age, sexual orientation, lifestyle, or class. We will strive to practice medicine with courage, wisdom, and grace. We pledge to uphold the integrity of medicine and commit to maintain the highest standards of professionalism. We recognize the role we play in the lives of our patients and strive to conduct ourselves respectfully. In the spirit of collaborative care, we will seek knowledge from others when we do not know the answers. We humbly acknowledge that it is a privilege to be members of the medical community, and thus assume the responsibility of learning from our mistakes and holding ourselves accountable for our actions.

Each medical student was given an ADC Buck Hammer by Edward Ehlinger, M.D., TCMS President.

We pledge to be stewards of education. We dedicate ourselves to lifelong learning and intellectual growth. We strive to create a community of support, collaboration, and innovation among all health professionals. We will empower our patients to make informed decisions. We commit to sharing our knowledge with society as advocates of healthy living. We pledge to embrace our social responsibility to practice medicine justly. We recognize that as doctors, our society will require us to speak out about health care legislation, to advocate for patient rights, and to be in solidarity with the poor. We will collaborate with local and global communities to eliminate health care disparities, and we will be steadfast in our efforts to provide care to those who do not have access. We will invest ourselves in the institutions of medicine, so that together we may achieve what any one individual cannot. We pledge to lead a balanced and healthy lifestyle. We recognize that in caring for ourselves we will be better prepared to care for our patients. We will strive for an understanding of our own strengths and limitations. We dedicate ourselves to personal and professional development through our experiences in order to gain perspective, maintain a positive attitude and remain flexible as medicine and society continue to change.

Dr. Kathleen Watson, associate dean for students, addresses the class.

MetroDoctors

The Journal of the Twin Cities Medical Society

Let this white coat be a reminder of this pledge, of the privilege we hold as students of medicine, and of our commitment to service. November/December 2010

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Honoring Choices Minnesota Hosts Community Dinner Honoring Choices Minnesota held a dinner event in September at Midland Hills Country Club for 130 community leaders. Attendees represented hospitals, health care and senior services organizations, charitable foundations, various community groups and local businesses and many ethnic and religious organizations. Mary Brainerd, president and CEO of HealthPartners, served as the event host; Bud Hammes, Ph.D., director of Gundersen Lutheran Medical Foundation, spoke about the national opportunity to be had with this initiative; and Bill Hanley, VP of Twin Cities Public Television (TPT) and Sean Kershaw, executive director of the Citizens League discussed their partnership in a public engagement campaign. This effort is proving to be a truly remarkable example of how interested parties can collaborate to provide better care for Minnesotans. Honoring Choices Minnesota looks forward to obtaining full financial support and beginning a two year work plan with TPT and the Citizens League to develop tools for thinking and talking about end of life decisions, as well as continuing to advocate for From left: Thomas Von Sternberg, M.D.; Edward Ratner, advance care planning to be M.D.; and Victor Sandler, M.D. the health care community’s collaborative standard of care for adults.

Bill Hanley (left) and Sean Kershaw share plans to engage the wider community.

From Left: Loree Kalliainen, M.D.; Charles Haynor, JD; and Brian Rank, M.D.

Mary Brainerd served as host for the evening.

Photos by Blasing Shots Photography

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November/December 2010

MetroDoctors

The Journal of the Twin Cities Medical Society


COLLEAGUE INTERVIEW

A Conversation With

Rahul Koranne, M.D., MBA, FACP

R

ahul Koranne, M.D., MBA, FACP is medical director of Bethesda Hospital. He is board certified in internal medicine and geriatrics. Dr. Koranne attended medical school at the University of Delhi in India. He completed his internal medicine residency at the State University of New York in Brooklyn and his fellowship in geriatrics at the University of Minnesota. Dr. Koranne earned a master of business administration (MBA) degree at the Carlson School of Management at the University of Minnesota. Dr. Koranne serves as the physician lead for Care Navigation, which is a system-wide strategy of coordinating care for patients across all sites of care. He is also the physician strategist advising HealthEast Home Care division on enhancing partnerships across the care continuum, and has been very active at the Minnesota state level with various health care reform steering committees.

Why did you decide to become a physician administrator? Over the last 11 years — after my internal medicine residency and geriatrics fellowship — I have had the opportunity to work in a variety of settings along the care continuum. Short- and long-term acute hospitals, skilled nursing facilities, transitional care units, home care, palliative care and hospice, emergency departments, clinics: all of these settings gave me a clearer understanding of what total patient care was and how to best deliver it across settings. I wanted to be a change agent for total patient care, impacting not only the course of one patient’s case, but making a difference within a broader population. I believe that being a physician executive for Bethesda Hospital, as well as HealthEast Home Care and Care Navigation, gives me the opportunity to generate ripple effects which impact the care of thousands of patients each and every year. Different milestones throughout my schooling and career have influenced my journey. I was one of the first students in my medical school to earn honors in the field of preventive and social medicine, which may have been the beginning of my love for community-based health care services. I came to Minnesota in 1999 to complete a geriatrics fellowship at the University of Minnesota and then moved to a small town where I became active in leadership positions at the local nursing home and home care agency. Since I moved back to the Twin Cities in 2005 and joined HealthEast, I have been given opportunities to be part MetroDoctors

The Journal of the Twin Cities Medical Society

of teams that were champions for innovating our care delivery model. All of these experiences have helped me as a physician administrator to make sustainable changes in the way care is delivered to patients.

How does your business background impact your perspective and work at HealthEast? I completed my MBA at the Carlson School of Management and this chapter of my life was transformational for me. I am a firm believer in a team-based approach to health care, but the “team” is not just made up of the traditional members of physician, nurse, social worker, pharmacists, etc. It also includes finance, operations, marketing, strategy and others. The MBA learnings gave me a glimpse into what each of these team members brings to the table and how to most effectively communicate with them to achieve the best outcomes for the organization. My finance professor hit the nail on the head when he said, “I do not want you to know every nuance of finance; I do want you to know enough to ask the right questions.” This MBA training has reaffirmed to me that health care needs to analyze and learn from other industries, especially in the new era of accountable care and value-based purchasing that is dawning in the United States. (Continued on page 10)

November/December 2010

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Colleague Interview (Continued from page 9)

What do you hope to achieve as the medical director of a hospital and what do you see for yourself in the future? As Bethesda’s medical director, I am privileged to be a member of a very energetic, high functioning, values-based executive team. We are the only not-for-profit long-term acute care hospital (LTACH) in Minnesota and one of the largest LTACHs in the nation. We have made great strides in the last few years around measuring and benchmarking our quality metrics and ensuring that they exceed national standards. As I walk on the units of the hospital and observe our multi-disciplinary rounds, I feel a deep appreciation for our team-based model of care. I believe it is the magic ingredient that helps us excel at providing world class, specialty care for patients with the highest Case Mix Indices in the state. Our current and future work will be to continue the expansion of a total patient care philosophy, not just in one site of delivery, but rather across the continuum and especially at transitions. No one can absolutely predict what the future holds, but I do know that I want to keep learning new skills. For example, I recently graduated from a development course called the “Art of Convening” and it gave me a new perspective on how to lead groups and meetings. It is important for physician leaders to explore unconventional knowledge, to read extensively and to try to tread off the beaten path.

What are the greatest challenges for a medical director at a hospital, interacting with three different groups of constituents: administration, physician staff, and patients? Health care organizations are very complex entities with multiple moving parts and stakeholders. I believe that our internal health care “community” consists not only of administration, physicians and patients, but also other important stakeholders such as social workers; pharmacists; physical, occupational, speech, nutritional and recreational therapists; wound care nurse practitioners; and case managers to name a few. Just as a physician on one of our units has to be part of this multi-disciplinary team in order to truly create a robust care plan for a given patient, I believe that I have to be part of a larger team with leaders from each of these specialty areas in order to create meaningful strategies for the future, deliver operational results and encourage buy-in and satisfaction within and between these various departments. Today, the challenges of a hospital medical director stem from the two worlds we are being forced to live in. We have to sustain in the current fee-for-service world while pioneering a future care delivery model where the Institute for Healthcare Improvement’s Triple Aims of quality metrics, cost control and customer satisfaction will be rigorously measured, reported and incentivized. The fact that some of the inaugural innovators may end up being penalized for taking risks is worrisome to me and may discourage other systems from truly thinking outside the box.

Can you explain the purpose of the new health care collaborative project that you are participating in at the U of M? What will that mean for Minnesota physicians? The University of Minnesota has embarked on a journey to engage in partnerships with the health care community. Its quest is to encourage mutual discovery of new knowledge to advance the health of our state. To that end, it has created an Office of Community Engagement for Health (OCEH) and has formed three collaboratives focusing on health disparities, health care systems and rural health issues. As chair of the health care systems collaborative, I am convinced that our community will benefit from the mutual generation of ideas and research with the assistance of University experts. A stated goal of this new partnership is to reduce the time lag between research and its application in the real world, and this possibility is very exciting to me. The fact that this partnership is happening in our own backyard offers many opportunities for Minnesota physicians to become involved. OCEH started providing pilot funding, which can spur innovation by community health care entities as well as give them an opportunity to closely partner with researchers from the U to create bi-directional learnings. I would strongly encourage interested physicians to check out OCEH’s website at http://www.ctsi.umn.edu/community/office.shtml to get more information.

Where do you see the relationship between hospitals and MDs going in the near term future? One of the results of health care reform discussions has been the clarification of the indicators of success or value in our industry. A model I personally like is the Institute for Healthcare Improvement’s Triple Aim (quality, cost control and patient satisfaction). As we better understand what health means for our communities and that we need to think of “systems of care” rather that “episodes and sites of care,” the various stakeholders will need to find new ways to come together around our consumers. It is important to be flexible and inventive in how we forge these relationships. At HealthEast, we have had great success in our system-physician relationships using “Guiding Principles” that were articulated by our Medical Executive Committee as a compact between our medical staff and organization. Through my involvement with the Department of Health and organizations such as the Minnesota Hospital Association etc., I have seen and felt a combination of trepidation over impending change and a commitment to rallying around the patients and communities we serve. Physicians are steadfast when it comes to building on the trust that the various stakeholders have, especially in a state such as Minnesota. Having unified targets and outcomes such as the Triple Aim will continue to align our destinies and unify our paths.

Do you think Minnesota is still at the forefront of health care quality? Absolutely! Value in health care is our rallying cry; from personal experience, I can see the state’s dedication to remaining a leader in quality/ value. I was honored to be a part of the payment methodology steering

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MetroDoctors

The Journal of the Twin Cities Medical Society


committee of the Health Care Home initiative from the Department of Human Services. With the help of multi-stakeholder input, we created a revolutionary care coordination payment method for work that practices were performing but not getting reimbursed for. As we conducted exhaustive literature search for other models that could inform our work, we realized that what we were building was completely new — a first in the nation. Another example was how the various stakeholders came together around the Baskets of Care concept last year. Although the particular model did not gain traction, it was most gratifying to watch the level of trust and the open conversation that happened between payers, government, providers, consumers and others. Other examples include the transformation that is occurring with “1Health” at the University’s Academic Health Center and the work of the Institute of Clinical Systems Improvement. We, in Minnesota, need to be grateful for this trust between various stakeholders, which we have fostered over the years, and leverage it as we enter health care’s next challenging era. I am convinced that Minnesota has the potential to create standards on how to create and deliver health for our community on a national stage.

How important do you think patient satisfaction is in the overall health care reform debate? How will systems address the patient satisfaction issues and quality issues when resources are at risk and being cut? As one of the three triple aims, I believe patient satisfaction is of crucial importance in the equation of health care value. Moving forward, patients

will be charged with taking more control in managing their own health and they will decide where they receive care based upon this key metric. A must-have for consumers before they can make educated decisions about their health is health care literacy. I believe we need to pay more attention to how we will convert consumers from passive receivers of care to active partners and members of our health care teams. In HealthEast we have had enormous success with our Transition Coach model, which is based upon Dr. Eric Coleman’s work from the University of Colorado. One of the key tenets of this model is using “coaching” instead of the historical and paternalistic “doing.” We have found that this model not only leads to improved health care literacy and partnering behavior, but also results in significantly increased consumer engagement and better experiences. As a physician, I always go back to thinking about how each and every patient feels and what they deserve as they receive care from our hospitals, our clinics, our home care agencies and other sites of care delivery. Patient experience is not just a triple aim or a metric, it is what we owe to our patients, consumers and communities. This is the reason we exist. At the end of the day, we are all health care consumers and we know what we expect and deserve from the health care industry. Economies and systems are always in flux and especially in 2010, change is the new constant in health care. I believe the way that systems will be able to address each of the triple aims is to think outside the box, create honest measurement, monitoring and benchmarking, leverage partnerships and make each of these drivers of value a core component of how they do business.

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Fighting Obesity

Healthy Eating Minnesota a project of TCMS

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t’s difficult to open a newspaper or magazine and not find an article about the rising rate of obesity in America. Everyone has an opinion on how to tackle this mammoth public health threat. Some think individual responsibility is the answer. Others feel environmental changes need to be made to help us make healthier choices. Whatever the answer, the issue of obesity is front and center and unless something is done soon, future generations are in for the fight of their lives. By Jennifer anderson

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The numbers associated with obesity are dire. According to the U.S. Centers for Disease Control and Prevention (CDC), the national adult obesity rate in 2009 was 27 percent. Minnesota currently stands at almost 25 percent. For a little perspective, in 1990 Minnesota’s obesity rate was less than 15 percent. There are now only two states in the nation with obesity rates under 20 percent. They are Colorado and the District of Columbia. Public Health Law & Policy stated, “Obesity costs the United States $147 billion dollars annually in direct health care costs. Local governments can help improve the health of residents by changing laws, implementing new policies and encouraging businesses and private entities to take action to reverse rising obesity rates.” “Weight is killing us. It’s making people sick and it’s costing us all,” said Dr. Marc Manley, Chief Prevention Officer at Blue Cross. “We can stop this epidemic and help Minnesotans manage their current weight and prevent future weight gain by approaching it from all angles — working with individuals, businesses and communities — to encourage moving more

and eating better. It’s clear the healthy choice must be the easy choice in our state.” In April 2010, the Twin Cities Medical Society (TCMS) refocused the Healthy Eating Minnesota project to work toward reducing the rising obesity rate. There are several ways to tackle this goal. At the local level, TCMS will be educating and mobilizing physicians and other constituents to advocate for local communities to pass obesity prevention resolutions. According to the National Policy & Legal Analysis Network (NPLAN), “Passing a local resolution is one way for communities to promote obesity prevention policies. Local governments can have a significant impact on the environmental factors that contribute to obesity. The advantage of a local obesity prevention resolution is that it gives local lawmakers an opportunity to demonstrate their support for obesity prevention policies.” Obesity prevention resolutions have been passed in various cities around the country and most widely in California. TCMS is currently in the community assessment phase of work, which includes creating a new local coalition of supportive individuals and organizations that can assist in bringing policy change to communities. The Healthy Eating Minnesota project will reach out to organizations and other local obesity focused efforts committed to creating policy change which will enforce the message that obesity prevention resolutions are a solid foundation for communities to begin the fight against obesity. For further information or to join the Healthy Eating Minnesota coalition, please contact Jennifer Anderson, Project Coordinator at janderson@metrodoctors.com or (612) 362-3752.

MetroDoctors

The Journal of the Twin Cities Medical Society


Obesity and Tobacco Abuse— what’s the Clinical Role of a Community problem

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t doesn’t take a medical degree to look around the community and see the overwhelming problem of obesity. As obesity statistics worsen, the subsequent chronic diseases impacted by obesity increase. We know that nearly 40 percent of all deaths worldwide can be accounted for by four risk factors (nutrition, physical activity, smoking, and alcohol abuse)1. Clearly, the answers to these problems are not straightforward, in fact they need to be addressed from an environmental perspective to be successful at decreasing the rate of risk factor development. Fortunately, in 2008, the legislature for the state of Minnesota agreed that this was a problem that needed to be addressed from the policy level and initiated SHIP (Statewide Health Improvement Program), which included $47 million to help decrease obesity and tobacco abuse for all Minnesotans. SHIP involves a variety of action plans throughout 87 counties and nine tribal governments in Minnesota addressing communities, schools, the workplace, and clinical implications to improve obesity and tobacco outcomes. Just what is the clinical role to help the problems of obesity and tobacco use? Many doctors complain there isn’t reimbursement for these services, there isn’t time to assess or counsel on these services given the overwhelming schedule of the average physician, and furthermore, where is the evidence that any of these interventions work, “we don’t have the answers to these problems, or we would be doing it.” Unfortunately, our medical system is not geared toward obesity and chronic disease prevention. Reimbursement, medical training, systems and our culture are largely designed for disease intervention and treatment.

By Courtney Jordan Baechler, M.D.

MetroDoctors

The Multi-grantee SHIP intervention, including the health departments of Bloomington, Hennepin County and Minneapolis, is trying to address these problems. This group has chosen a SHIP intervention that involves implementing the ICSI (Institute for Clinical Systems Improvement) guidelines for Primary Prevention of Chronic Disease (PPCD) and the Prevention and Management of Obesity into clinical practice. First, let’s talk about the evidence behind these interventions. Back in 2007, ICSI had a group of experts convene in order to truly understand what the evidence is for intervening on the four major risk factors for chronic disease (tobacco use, lack of physical activity, poor nutrition, and excessive alcohol intake) and summarize the evidence in a guideline that could be used by physicians, policy makers, communities and patients. As the guideline (PPCD) states, “Nearly all individuals would derive measurable benefits from healthier lifestyles; even small improvements across a large portion of the population would have a greater impact than focusing on a small portion of the population that is at the upper end of the

The Journal of the Twin Cities Medical Society

risk distribution.” Although this guideline was not intended solely for clinical encounters, we know that evidence shows that providers are one part of the puzzle in accomplishing good health practices, before disease sets in. In fact, research shows over and over the impact that the trusting relationship between providers and patients can be a powerful tool for behavior change. The Multi-grantee SHIP health care project started in the fall of 2009 and has an overarching goal of merging public health and clinical medicine as it relates to the prevention of tobacco abuse and obesity. The Multi-grantee project has partnered with nine individual clinics and one clinic system. They are also working specifically with four Minneapolis clinics to create a community resource system to help facilitate resources for providers to use after these risk factors are identified. Because so often the disease disproportionately affects the underserved, this group specifically sought out individual clinics with underserved and diverse patient populations, to identify challenges that may be missed in larger clinical settings with more resources. Since the project started we have developed a team of individuals made up of physicians and health system representatives, as well as health plan representatives to guide this process. We have baseline data from the clinics and system assessing how frequently these guidelines are currently being used and defining some of the barriers that exist in implementing these guidelines. ICSI has teamed up with

(Continued on page 14)

November/December 2010

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Fighting Obesity Obesity and Tobacco Abuse (Continued from page 13)

Multi-grantee Intervention Clinics • •

• • • • •

Bloomington Lake Clinics (Minneapolis and Bloomington) Hennepin Care East (Minneapolis) and Hennepin Care North (Brooklyn Center) Neighborhood HealthSource (Fremont, Central and Sheridan Clinics) Neighborhood Involvement Program Park Nicollet clinic system (initial pilot at Minneapolis site) Phillips Neighborhood Clinic The People’s Center Medical Clinic Community Resource System Intervention Clinics

• • • •

AXIS Medical Center Broadway Family Medicine NorthPoint Health and Wellness Center Phillips Neighborhood Clinic

SHIP Multi-grantee staff and has led three, day-long training sessions with teams of clinic staff to help facilitate sustainable change and provide resources for modifying clinic processes to effectively implement these guidelines. All of the clinics have set goals and plans to achieve these goals over the next 12 months. For example, assessing BMI in all individuals during preventive maintenance exams, educating the patient on the number, and providing counseling and resources to improve nutrition and physical activity. As this project continues we realize what an overwhelming problem chronic disease prevention is. Part of our goal is to develop sustainable clinic policies, systems and practices that maximize medical providers’ impact on the obesity epidemic. We have developed a group that is specifically looking at reimbursement for these services to further make these guidelines achievable. It has also become clear that providers need and patients desire easy and reliable community-based resources such

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as dieticians/nutritionists, tobacco cessation counseling services, and physical activity opportunities. With this in mind, a group has also convened to help make this more central and strategic, to help make prevention similar to a disease process where there are certain standards and procedures that all providers do. If you work in a primary care setting, I’m sure you frequently hear the buzz words of “medical home” and “accountable care organization” as clinics try to keep up with increasing regulations. Implementation of guidelines like ICSI’s PPCD and obesity prevention guidelines will likely be a part of these processes in the future with an effort to increase the well-being of patients, improve outcomes, and decrease cost. There is nothing easy about attacking problems that have taken over a century to develop (tobacco abuse and obesity), nevertheless tobacco use continues as the number one cause of preventable death and the obesity epidemic continues to spiral out of control. Everyone knows that primary care providers are the front line of the medical system that addresses these problems and they continue to be overworked with protocols and paperwork. However, it’s all the more reason to develop these strategic policies, clinical plans, and reimbursement that work to decrease the burden of obesity and tobacco for the future. For more information on the work of Multi-grantee SHIP Intervention, including a clinical toolkit for implementing the guidelines, go to http://www.ci.minneapolis.mn.us/ dhfs/ship-health-care-sites.asp. To register your clinic for the clinic fax referral system to connect patients with Minnesota tobacco cessation resources, go to http:// www.preventionminnesota.com/objects/pdfs/ Clinic_Fax/X16675R03_web.pdf. Courtney Jordan Baechler, M.D., cardiologist, University of Minnesota; physician consultant for the SHIP Multi-grantee Project. 1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. Mar 10 2004;291(10):1238-1245.

MetroDoctors

The Journal of the Twin Cities Medical Society


Obesity Management

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wo thirds of Americans are overweight or obese by body mass index (BMI) definitions. All health care professionals deal with the complications of excess weight and are aware of the strong relationship between increasing BMI and morbidity. Yet most physicians are not fluent in the treatment options for obesity. There are many reasons for this clinical inertia, and chief among them is the historical bias against obesity as a disease, and obesity medications in particular. The concept that it is a person’s fault that their BMI is high, and that they can simply modify their behavior to achieve a leaner weight, ignores two decades of discovery regarding the biological mechanisms that help animals regulate their energy balance and fat stores. Obesity is a biological, preventable and treatable disease. The model of chronic disease management which we readily apply to other common metabolic disorders such as hypertension, diabetes, and dyslipidemia, works for the management of patients with overweight or obesity. All patients should be counseled on lifestyle changes, including the implementation of a healthy meal plan, and the institution of regular physical activity. Payment for dietician services is excluded from most coverage packages. Most practices are unable to defray the cost of these educational services. The words “diet” and “exercise” are obstacles and are best avoided. Frequent small amounts of physical activity add up to significant caloric expenditure. A two minute walk every hour on the hour during the waking hours of the day, adds up to a 30 minute walk at the end of the day.

Physical activity for caloric expenditure does not have to happen all at once. And a “diet” is not sustainable regardless of which one is chosen. On the other hand, a meal plan that provides many options and focuses on portion control and foods with a low caloric index can be continued for life. Many complications of obesity create obstacles to weight loss. These vicious cycles must be identified and interrupted, including depression, sleep apnea, degenerative arthritis, insulin resistance, diabetes mellitus, male hypogonadism, and arteriosclerosis. Treatments for these complications which are associated with weight loss should be used. Conversely, treatments that promote weight gain should be avoided if possible. The team approach to obesity care, including dieticians, lifestyle coaches, psychologists, psychiatrists, physiatrists, orthopedists, sleep medicine specialists and bariatric medicine specialists is effective to treat obesity. Referral to bariatric centers should be considered if the expertise is not available in a primary care setting, the physician is uncomfortable writing prescriptions for weight loss agents,

By J. Michael gonzalez-Campoy, M.D., ph.D., FaCE and Rebecca C. gonzalez-Campoy

MetroDoctors

The Journal of the Twin Cities Medical Society

Photo by Jon Halvorsen

or a patient continues to gain weight despite repeated interventions. The most important change for individual physicians is to address the weight at every visit. Most health care professionals are comfortable referring for bariatric surgery if there is failure to achieve weight loss, or sustained weight gain. Yet, pharmacotherapy for overweight and obesity is underutilized. Obesity medications have been met with inordinate barriers to their implementation. The amphetamines, which are habit-forming, tolerance-building and addictive, resulted in effective weight loss. Needless to say, the benefit to risk ratio for these compounds is low, and it is not desirable to use them. When other centrally active compounds that caused weight loss came to market, the recommended length of use was restricted by the Food and Drug (Continued on page 16)

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Fighting Obesity Obesity Management (Continued from page 15)

Administration (FDA). However, the currently available obesity medications are not amphetamines. Rather, they are biochemically related compounds. Amphetamines are schedule II drugs, whereas obesity medications are schedule III or IV drugs. There are five medications that are centrally-acting and approved by the FDA for weight loss. Four were approved in the 1960s (benzphetamine and phendimetrazine), and 1970s (phentermine and diethylpropion). At the time of their approval obesity was not considered a disease, and given the recent experience with the amphetamines, the FDA approved them all for “short term use.” Sibutramine, approved in the 1990s, came at a time when obesity was considered a major health care problem for the nation, and therefore was approved for indefinite use. All five agents work by increasing norepinephrine levels in the hypothalamus. The result is early satiety with ensuing decreased caloric intake. The benefit to risk ratio for

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November/December 2010

these compounds is high. In the SCOUT trial sibutramine increased the risk of cardiovascular events but not mortality in patients with pre-existing vascular disease. The benefit to risk ratio is lower in patients with preexisting vascular disease, and other risk factors have to be aggressively co-managed. Orlistat, a pancreatic lipase inhibitor, is also approved for the treatment of obesity. It is approved for indefinite use, and is now available

for life. Many develop serious complications from chronic malabsorption. Surgical centers are not ideally suited to follow patients long term. Here again, referral to a bariatric medicine specialist may be appropriate if local expertise is not available. What can you do for your patients? • Every patient should have a height, weight, waist circumference and BMI calculation at every visit. It takes seconds to do, and

I

in Minnesota it is against the law for the state to pay for obesity medications, a statute that discriminates against patients with obesity.

over the counter. Fat malabsorption, the end result of lipase inhibition, causes steatorrhea, with all of its accompanying symptoms. The symptoms can be avoided with concomitant soluble fiber ingestion (i.e. psyllium seeds) and calcium carbonate dosed with every orlistat capsule (calcium saponifies the oily residue and makes it less irritating). The most commonly used obesity medication is phentermine. Phentermine is the cheapest, and most patients have to pay for obesity medications out of pocket. In Minnesota it is against the law for the state to pay for obesity medications, a statute that discriminates against patients with obesity. And obesity care is “carved out” of many health plan packages. The off-label use of phentermine and other older obesity medications for prolonged use is warranted if obesity is associated with significant morbidity. Bariatric surgery should be a treatment of last resort. It should be considered only when a medical program including pharmacotherapy has failed. Both restrictive and malabsorptive surgeries have benefits and risks. The precertification process leading to bariatric surgery is best handled by the surgical team. It is important to emphasize that these patients need follow-up

• •

• •

the information allows the patient to act. Trends are very important. Treat obesity, not just its complications. If you are not comfortable with obesity medication prescriptions, then refer the patient for treatment. Assess readiness for change at every visit, and facilitate incremental adjustments. Involve the patient’s support structure (family, friends, caregivers). This is especially important for children and teens — but it is important for adults as well. Become a role model — lead by example. Become an advocate. Work with legislators and health plan representatives to allow patients access to obesity care. Obesity is a treatable disease.

J. Michael Gonzalez-Campoy, M.D., Ph.D., FACE, medical director and CEO, Minnesota Center for Obesity, Metabolism and Endocrinology, PA. Rebecca C. Gonzalez-Campoy, executive director, Minnesota Center for Obesity, Metabolism and Endocrinology Foundation.

MetroDoctors

The Journal of the Twin Cities Medical Society


Obesity— A Treatment Overview Obesity is Epidemic and Life-Threatening

The National Institutes of Health (NIH) categorizes obesity by severity, using the body mass index (BMI). A BMI of 25 to 30 kg/m2 is categorized as overweight, 30 to 35 kg/m2 as obese, 35 to 40 kg/m2 as severely obese and 40 kg/m2 or greater as morbidly obese. In addition, some practitioners refer to a BMI of over 50 kg/m2 as super morbid obesity. It is not a surprise to anyone in the medical community that more than 33 percent of all U.S. adults are obese and roughly 6 percent are morbidly obese, according to the National Health and Nutrition Examination Survey (NHANES) 2003-2006 and 2007-2009. Obese people not only suffer social consequences and discrimination, but also are at a much higher risk of chronic medical conditions such as type 2 diabetes, atherosclerosis, hypertension and sleep apnea. The comorbidites not only degrade quality of life, but can cause premature death. Fontaine et al, estimated that a morbidly obese 20-year-old male can expect to live 13 years less than a 20-year-old male at a healthy weight (JAMA 2003, Jan 8; 289(2): 187-93). Chronic, sub acute inflammation often accompanies obesity and may lead to many comorbidities. (Obesity, inflammation on insulin resistance by Shoelson Gastroenterology. 2007 May;132(6):2169-80). Excess fat stored in some tissues may stimulate inflammation (i.e. non-alcoholic steatohepatitis). Obesity By Frederick Johnson, M.D., and Mary Silberschmidt, BSN

MetroDoctors

changes adipose tissue, modifying its protein production and secretion, which may also cause inflammation. (PPARS, Obesity and Inflammation, Stienstra) (PPAR Res. 2007;2007:95974). Obesity Is a Disease That Can Be Treated

The steep increase in obesity and all the associated comorbid conditions compel us to learn more about obesity and how to manage it. It is no longer reasonable to treat it as if it were merely a lack of will power or motivation. It is a chronic disease. Treatment options include behavior modification, medical management (medications) and weight loss surgery. Patients in all categories of excess weight need education and support to learn how to balance their intake of calories with their metabolism of those calories in order to lose excess pounds and maintain a healthy weight. All methods of treating obesity should be part of a comprehensive approach. No single treatment is effective by itself. It should be noted that even a small amount of weight loss can provide significant benefit to patients (Meta-analysis, Buchwald, H et al 2004). For those who have a BMI below 35 kg/m2

The Journal of the Twin Cities Medical Society

behavior modification leading to a change in diet and exercise patterns can be effective. Choosing foods low in sugar, fat and salt, measuring portions, using a food journal and participating in regular exercise will result in weight loss that can be sustained to some degree for these patients. However, for those in the morbidly obese category (BMI 40 kg/m2 or greater), diet and exercise alone are not an effective long-term treatment. These individuals are able to lose weight temporarily but most do not maintain the weight loss over time. Fewer than 2 percent are able to sustain even small losses over a five year period (Eliosoff, 1997, Sjostrom NEJM 2004; Obrien, J Laparoscopic Adv Surg Tech A 2003, Aug 13(4) 265-70). Medical management is limited. Three FDA approved medications recommended for short-term use are sibutramine (Meridia), orlistat (Xenical, alli) and phentermine. A healthy diet and exercise program must accompany prescription weight loss medicine. Morbidly obese patients who used medications for weight loss were not able to maintain that loss over time (See studies mentioned in paragraph above). Weight loss surgery is currently the only documented treatment method offering longterm success for managing morbid obesity. It is not a treatment option for those with a BMI less than 35 kg/m2, however. In general, surgical candidates must have a BMI of 40 kg/m2 or more or a BMI of 35 kg/m2 with at least one comorbid condition. In addition to being healthy enough to tolerate surgery, the patient must (Continued on page 18)

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Fighting Obesity Obesity—A Treatment Overview (Continued from page 17)

first have attempted other means of weight loss. Candidates for the surgery undergo a psychological exam to assure that they can adjust to the lifestyle changes that accompany bariatric surgery. Insurance companies each have their own specific criteria for coverage. Surgery is the Most Effective Treatment for Morbid Obesity

It is a misconception that obesity is simply the result of a lack of willpower or laziness and that surgery is an easy way out. Weight loss surgery is a tool that must be used correctly on a daily basis for the rest of a patient’s life. Getting and keeping weight off is still difficult but bariatric surgery provides a tool that significantly assists the individual in achieving long-term success. On the average, patients lose 45 to 80 percent of their excess weight, depending on the procedure they choose, and their commitment to a healthy lifestyle. (Brethauer, Chand, and Schauer, Risks and Benefits of Bariatric Surgery: Current Evidence, Cleveland Clinic Journal of Medicine, vol 73, 2006).

A well known study published in Annals of Surgery, 1995, vol. 222, No. 3, pp. 339352 showed that 89 percent of weight loss was maintained after 14 years. (Pories, WJ, Swanson, MS, MacDonald KG, et al. Who would have thought it? -An Operation Proves to be the Most Effective Therapy for Adult-Onset Diabetes Mellitus.) A meta-analysis (Buchwald, et al, 2004) of more than 22,000 bariatric surgery patients showed that many of the life-threatening conditions that accompany obesity are completely resolved or improved after the surgery. Diabetes was resolved in 76.8 percent of patients, and resolved or improved in 86 percent of patients. High blood pressure was resolved in 61.7 percent of patients, and resolved or improved in 78.5 percent. Sleep apnea was resolved in 85 percent of patients and more than 70 percent of patients improved or corrected their high cholesterol. Types of Surgery

Weight loss surgery works on two basic mechanisms: restriction and malabsorption. The most common surgical procedures utilize one or both

of these mechanisms. All procedures discussed are most commonly done laparoscopically. Average hospital stays tend to be just over two days with the majority of patients going home the day following surgery. Adjustable gastric banding restricts the amount of food that can be consumed at one time by placing an adjustable silastic band around the top of stomach. The band has an inner tube or balloon that can be injected with fluid so that the restriction can be increased or decreased. The small stomach pouch proximal to the band holds about ¾ cup to one cup of food. Because the pouch empties slowly, the small volume of food will control a patient’s appetite for about three to five hours. Patients lose weight slowly — about one to two pounds per week. They can expect to lose their excess weight over approximately 18-24 months. There are currently two bands in use in the U.S. today, the LapBand by Allergan and the Realize Band made by Ethicon. A sleeve gastrectomy is another restrictive procedure which reshapes the stomach into a long narrow tube. About 75 percent of the stomach is removed. This procedure has been

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The Journal of the Twin Cities Medical Society


done for many years as part of a two stage operation. Recently, however, it has been used as a single stage procedure with good overall results. It has been an effective procedure for some patients with specific challenges such as an extremely high BMI or those that are on many medications. Patients can expect to lose weight more quickly than with an adjustable gastric band. A Roux en Y gastric bypass works using both restriction and malabsorption. The stomach is divided into two separate pieces. The smaller piece (referred to as the gastric pouch) receives the food and has approximately a one ounce capacity. The small capacity restricts the volume of food that can be consumed at one time. The pouch is then re-connected to a segment of small intestine. Food thus bypasses the remaining stomach, duodenum and some jejunum thereby altering absorption. The bypassed stomach, duodenum and proximal jejunum are anastomosed to the small intestine lower down the intestinal track. With both restriction and malabsorption working, patients lose weight rapidly. Most can expect to lose most of their weight in the first year.

also differ and may include some services and not others. Patients choosing to explore this option should be advised to work with the financial counselor or insurance specialist at their Bariatric Center. Cost of Not Doing Surgery

Surgery is costly, but so is untreated obesity. The cost of medications, medical supplies, office and emergency room visits, and hospitalizations for the treatment of chronic conditions is very high. Studies vary, but a 2009 study by the Centers for Disease Control and Prevention, with RTI International, estimated the direct and indirect costs of obesity could be as high as $147 billion annually. These numbers speak to the financial cost. There is in addition, however, the significant intangible cost to the individual patient suffering from the chronic disease of morbid obesity. This cost is difficult to quantify and consists of their reduced quality of life and shortened length of life. Summary

In summary, morbid obesity is a chronic disease associated with chronic inflammation. The Uptn. Quiz ad2B&W

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related comorbidities are many in number and create serious health risks for the individual who is overweight. Much needs to be done in terms of educating the public to understand that this is not due to poor motivation, laziness or lack of willpower but to a chronic condition that slowly takes the person’s life. The obese individuals themselves also need education about the disease of obesity and what they can do to help keep it at bay. Currently weight loss surgery for those that qualify is the only treatment leading to long-term weight control. Significant lifestyle changes must be made, however, to insure long term success. Frederick (Rick) Johnson, M.D., is a bariatric surgeon and co-medical director of the Unity Hospital Bariatric Center in Fridley, MN. He has been a general surgeon in the Twin Cities for more than 30 years. Since 2002, Dr. Johnson has dedicated his practice to improving the lives of morbidly obese patients, performing more than 1,700 weight surgeries in that time. Mary Silberschmidt, BSN, Unity Hospital Center program manager.

Page 1 Bariatric

Is Weight Loss Surgery Safe?

Costs of Surgery

The cost of surgery varies widely depending, in part, on insurance coverage. The American Journal of Managed Care (Sept 14, 2008) published a study (Cremieux et al) in which the mean cost for bariatric surgery ranged from $17,000 to $26,000. In their conclusion they estimated that all costs are recouped within two years for laparoscopic procedures and four years for open cases. Still, some insurance companies do not cover these procedures or cover them only partially. Self pay or out of pocket expenses MetroDoctors

The Journal of the Twin Cities Medical Society

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Weight loss surgery has become a very safe procedure since the establishment of international Bariatric Centers of Excellence. The New England Journal of Medicine (July 30, 2009) published a review of bariatric surgery safety which reported the national mortality rate for all weight loss procedures was 0.3 percent, approximately matching that of a gallbladder removal or hip replacement. More recent unpublished data from the American Society of Metabolic and Bariatric Surgery reports that mortality rates are even lower (0.1 percent) at Bariatric Surgery Centers of Excellence.

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November/December 2010

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Fighting Obesity

Obesity— It’s Not That Simple

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e’ve become used to conceptualizing obesity as an epidemic. Warnings of its health risks come from public health practitioners, politicians and others. But does this “epidemic” language help us reduce obesity? Obesity is a symptom or a state; until we address the underlying problems which produce it, obesity and its threats to health remain. In two multi-site studies the prevalence of Binge Eating Disorder (BED) among individuals seeking weight control treatment is between 28-30 percent, whereas the prevalence in community samples is 2-5 percent (Spitzer RL 1993). BED is characterized by eating large amounts of food without using compensatory behaviors, such as vomiting, fasting or compulsive exercise. Patients with BED eat until they are uncomfortably full, eat alone or secretively, eat when not hungry and feel guilty and depressed about their eating behaviors. Patients with BED regain lost weight more quickly after obesity treatments than those without BED (Marcus MD 1988). They also have more general psychopathology, have spent significant time dieting, are over-concerned with body shape and weight, and are more likely to have drug and alcohol abuse history (Spitzer RL 1993). Patients with BED are also more likely to be diagnosed with affective disorders, panic disorder, borderline and avoidant personality disorders (Yanovski SZ 1993). Thus, while treatments like bariatric surgery may help patients lose weight, it is crucial to treat their other psychological problems before and after weight loss. Researchers have attempted to elucidate the personality features of obese persons. Certain personality characteristics may predispose By allison holt, M.D.

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to overeating and weight gain, and conversely living with morbid obesity may influence personality, so there is bidirectional influence. It is important to note that a single obese personality type has not been found. Some researchers find evidence of difficulty modulating one’s emotions, thoughts and behaviors in those who are obese (Hutzler JC 1981). Some investigators describe people using obesity as a form of protection; persons with a fear of intimacy create an obesity “wall” to create distance between them and others. This could become a roadblock during efforts to lose weight because the obesity performs a psychological function (Glinski J 2001). Analysis of 2006’s Behavioral Risk Factor Surveillance System data suggests that men who were extremely obese, and women who were overweight or obese, were significantly more likely than normal weight subjects to have current or lifetime diagnosed depression and anxiety (Zhao G 2009). Many people who are obese have difficulty performing basic activities such as walking, climbing stairs, bathing and dressing. This causes distress and contributes to the increased risk for depression (Duval K, 2006).

In my practice I have two female patients who have each lost over 100 pounds with bariatric surgery and each patient’s current BMI is around 30. Both women see me for depression and the first patient is in partial remission from depression, while the second patient still has moderate depression. The first patient recently told me she likes her body, feels healthy and attractive, and enjoys regular, moderate exercise. Her compulsive overeating is in fairly good control. The second patient was 300 pounds before surgery and 150 pounds afterward. She regained about 30 pounds in the last year due to compulsive overeating and now feels very unattractive, refusing to wear shorts on hot days because she is so embarrassed by her legs. She describes both herself and the way she looks as “disgusting.” She reports that she was very happy with how she looked at 150 pounds, but at 180 pounds she feels as bad about herself as she did before surgery when she was 300 pounds. The difference in how these two patients view themselves is striking. It is as if the first post-bariatric surgery patient with a BMI of 30 enjoys her body and lives a body experience, or views her body as more than just a number on the scale, while the second patient is focused solely on her body image, even though her BMI is also 30. This suggests that while weight loss through diet or bariatric surgery alleviates morbid obesity, it may take psychotherapy and/or psychotropic medications to alleviate the poor self image and mental disorders that distress these patients. As a clinical psychiatrist I treat the depression, anxiety and poor body/self image that many obese people experience, with medications such as antidepressants as well as psychotherapy. At The Emily Program I work with psychotherapists and dieticians

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who are able to help my patients with their dysfunctional thoughts and behaviors around eating and food as well as their self-defeating cognitions about their body and their worth as humans, which often is connected to their weight. At times I also treat the urges to binge with medication, such as topiramate, naltrexone and acamprosate. If you are concerned that a patient may have an eating disorder, I recommend that you ask permission to discuss his/her eating habits: “I’m concerned about your eating. May we discuss how you typically eat and your relationship with food?” The following questions can help assess the situation (Morgan JF 1999): • Do you feel like you sometimes lose or have lost control over how you eat? • Do you ever make yourself sick because you feel uncomfortably full? • Have you gained or lost more than 14 pounds in the last 3 months? • Do you believe yourself to be fat, even when others say you are too thin? • Does food or thoughts about food dominate your life? • Do thoughts about changing your body or weight dominate your life? • Have others become worried about your weight and/or eating? In this informal survey, two or more “yes” answers indicate the presence of disordered eating. If you wish to consult on a patient’s difficulties with food, body image, weight, or eating, you may call The Emily Program at (651) 645-5323. It offers a wide array of services at multiple locations to treat all eating disorders — BED, compulsive overeating, anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified — and related issues. Additionally Park Nicollet has an eating disorder program called Melrose Institute which is also an excellent resource for consultation or treatment of eating disorders.

adults, 1999-2002. JAMA , 291, 2847-2850. Hutzler JC, K. J. (1981). Super-Obesity: A psychiatric profile of patients electing gastric stapling for the treatment of morbid obesity. J Clin Psychiatry , 42 (12), 458-462. Kuczmarski MF, K. R. (2001). Effects of age on validity of self-reported height, weight, and body mass index: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. J Am Diet Assoc , 101, 28-34. Maddi SR, R. F. (2001). Reduction in psychopathology following bariatric surgery for morbid obesity. Obes Surg , 11, 680-685. Marcus MD, W. R. (1988). Obese binge eaters: affect, cognitions, and response to behavioral weight control. J Consult Clin Psychol , 3, 433-439. Morgan JF, R. F. (1999). The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ , 319, 1467-1468. Spitzer RL, Y. S. (1993). Binge eating disorder: it’s further validation in a multisite study. Int J Eat Disorder, 12, 137-153. Yanovski SZ, N. J. (1993). Association of binge eating disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry , 150, 1472-1479. Zhao G, F. E. (2009). Depression and anxiety among U.S. adults: associations with body mass index. Internat J of Obesity , 33, 257-266.

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Allison Holt, M.D. is a psychiatrist who evaluates and treats child, adolescent and adult patients at The Emily Program, an eating disorder program in the Twin Cities and Duluth.

Works Cited: Duval K, M. P. (2006). Health-related quality of life in morbid obesity. Obes Surg , 104 (3), 574-579. Glinski J, W. S. (2001). The psychology of gastric bypass surgery. Obes Surg , 11, 581-588. Guisado Macias JA, V. L. (2003). Psychopathological differences between morbidly obese binge eaters and non-binge eaters after bariatric surgery. Eat Weight Disord., 8, 315-318. Hedley AA, O. C. (2004). Prevalence of overweight and obesity among U.S. children, adolescents and

MetroDoctors

She also performs electroconvulsive therapy at Abbott Northwestern Hospital. Dr. Holt strives to understand each of her patient’s unique life story and that is what she finds most fulfilling about her job as a psychiatrist. She earned a Bachelor Degree in psychology and her Doctor of Medicine from Ohio State University. She did her Psychiatry Residency and Child and Adolescent Psychiatry Fellowship at the University of Minnesota.

The Journal of the Twin Cities Medical Society

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November/December 2010

21


Fighting Obesity

Reducing Obesity and Tobacco Use at the Community Level

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he Statewide Health Improvement Program (SHIP) is the public health component of Minnesota’s Health Reform Initiative signed into law in 2008. Health reform’s intent is to improve the health of Minnesotans and redesign care (including chronic care management, payment reform and insurance coverage) to improve quality at lower costs. Without addressing prevention and the major risk factors for preventable death — obesity and tobacco use — the health of Minnesotans will likely not improve. Consequently, the SHIP component of health reform is intended to reduce obesity and tobacco use through changes in policy, the systems we interact with, and the environments in which we live, work, learn and play. These changes are implemented at the community level in four settings: communities, worksites, schools and health care. SHIP and Obesity Related Interventions

SHIP addresses obesity through healthy eating, improved nutrition, increased physical activity and active living to reduce the number of Minnesotans who are, or who may become, obese. The 41 grantees, covering all 87 counties and nine tribal governments, are implementing interventions selected from a menu of possible options provided at the beginning of SHIP. For example, active living interventions allow for the integration of physical activity into daily routines. Active schools, communities and worksites are created by: increasing opportunities for non-motorized transportation, such as walking or biking; increasing opportunities for individuals to access recreational facilities; and increasing the quality and time that children By Cara a. McNulty, M.S., and Michael hawton, Mpa

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spend in physical activity in schools and in child care settings. Similar to physical activity, lack of access to affordable, healthy foods is linked to a higher incidence of obesity, diabetes and other related health problems.1 SHIP interventions offer a variety of ways to improve access to nutritious foods in schools, communities and worksites. Examples include healthy lunch and snack policies in schools, increasing the number of and access to farmers markets, community and school gardens and providing information about the nutrition content of foods. These examples illustrate the commitment to improving the health of Minnesotans and reducing health care costs. A critical component of this commitment is partnering with Minnesota’s health care systems to make reducing obesity and tobacco use a top priority. Health care providers can promote the development and maintenance of healthy lifestyle behaviors by encouraging individuals to maintain healthy eating habits, and participate in physical activity on a regular basis. Health care professionals can also advocate for change in their communities and enhance government, media and industry efforts. This partnership with health systems and providers incorporates an array of SHIP interventions related to obesity in the health care setting. These interventions include: • implementing maternity care practices

encouraging breastfeeding through prenatal, birth and postpartum services; supporting implementation of the Institute for Clinical Systems Improvement (ICSI) Guidelines for “Prevention and Management of Obesity” and “Primary Prevention of Chronic Disease Risk Factors” for adults and children where applicable; building partnerships to facilitate active referral of patients to access local highquality nutritious foods and physical activity resources; and implementing support strategies to motivate and aid patients in making daily decisions to improve their behaviors relating to eating, physical activity and abstinence from tobacco use.

How can SHIP Impact Obesity in Minnesota Communities?

It is important to note, especially for communities, that systems and environmental changes have both impact and sustainability beyond the scope of traditional individual-based programs. Because health behaviors are affected by a wide variety of factors beyond individual motivation and knowledge, the environment in which people live, work, learn and play can either support or hinder their ability to adopt healthy behaviors. Health behavior changes in individuals

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The Journal of the Twin Cities Medical Society


and communities can occur through programs but they may not be far-reaching and sustainable unless they are formally or informally institutionalized. SHIP interventions are designed to be sustainable and affect a broad segment of the population. For example, programs that provide assistance to individuals who wish to eat more nutritious foods or become more physically active affect the individuals who are enrolled in the program; well-established and institutionalized referral systems to such programs affect a much larger segment of the population. Systems and environmental changes impact entire populations by targeting physical and organizational structures to support healthy lifestyles. Although these changes support healthy behaviors among all residents, strong efforts are needed to improve the outcomes of populations with the highest rates of obesity (i.e., at-risk/high-risk populations). Using a targeted approach to address the needs of these populations will result in the greatest reduction in risk factors with the available resources. SHIP systems and environmental change work is a long-term process that requires a significant commitment, with the equally significant benefits of more lasting change in schools, communities, worksites and health care settings. After receiving SHIP funding, grantees across the state have worked to engage their communities to assess their needs around obesity and tobacco. They are building support, forming and sustaining partnerships around these issues with local agencies, organizations and businesses. With these partnerships they are implementing strategies in schools, worksites, communities and health care settings. These activities and relationships, including those in health care, are expecting a long lasting impact on Minnesota communities as they meet objectives for implementing policy, systems and environmental changes leading to decreased obesity.

Minnesota Epilepsy Group is the largest and most comprehensive epilepsy program in the Midwest. As a regional referral facility, we are the recognized leader in treating epilepsy and other seizure-related conditions in patients of all ages, from infants to the elderly. We also offer comprehensive neuropsychological assessment for a broad range of acquired or developmental neurological conditions in both adult and pediatric patients. Adult Epileptologists Deanna L. Dickens, MD Julie Hanna, MD El-Hadi Mouderres, MD Patricia E. Penovich, MD Pediatric Epileptologists Jason S. Doescher, MD Michael D. Frost, MD Frank J. Ritter, MD Functional Neuro-Imaging Wenbo Zhang, MD, PhD

Appointments (651) 241-5290

225 Smith Avenue N St. Paul, MN 55102 www.mnepilepsy.org

Neuropsychologists Elizabeth Adams, PhD Robert Doss, PsyD Ann Hempel, PhD Donna Minter, PhD Gail Risse, PhD

Cara A. McNulty, M.S., Office of Statewide Health Improvement Initiatives Director. Michael Hawton, MPA, planning and strategy coordinator, Statewide Health Improvement Initiatives, Minnesota Department of Health. 1) U.S. Department of Health and Human Services. “The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity.” Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General 2001

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November/December 2010

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Fighting Obesity

Progress on Childhood Obesity Policy in Minnesota

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merican Heart Association has an impact goal of improving the cardiovascular health of Americans by 20 percent while reducing deaths from cardiovascular diseases and stroke by 20 percent by the year 2020. Legislation passed this year will help us achieve that goal by ensuring that our kids learn the lifelong skills to lead an active lifestyle through quality physical education programs. American Heart Association has partnered with a coalition of 25 organizations called the By Rachel Callanan

Minnesotans for Healthy Kids Coalition. Our goal is to promote public policy that helps our children live healthier lives to prevent chronic diseases. This year, the coalition promoted the Healthy Kids/Physical Education legislation. Working with a committed group of legislators who have organized to address childhood obesity, the Healthy Kids/PE Bill passed the House 121-7, the Senate unanimously supported the bill, and the governor signed the bill into law on May 25. The new law will strengthen physical education programs in our schools which has a two-fold positive impact by

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November/December 2010

boosting academic achievement and promoting more physical activity and physical fitness. The bill also promotes more physical activity and healthier food in our schools through the Healthy Kids Awards program, promoting best practices in recess, and giving parents more information about their schools’ wellness policies and quality of physical education classes offered by their schools. While this legislation represents important progress in state policy and indicates that this issue is a growing priority for legislators, there remains much to do. The Minnesotans for Healthy Kids Coalition and the legislative leaders participating in the Childhood Obesity Working Group, will join forces again this fall and winter to develop a policy agenda for the 2011 legislative session which begins January 4, 2010. For more information, please contact Rachel Callanan, Regional Vice President of Advocacy for American Heart Association at Rachel.callanan@heart.org, www.americanheart.org.

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The Journal of the Twin Cities Medical Society


MMA Holds 2010 Annual Meeting

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he tapping of the gavel brought to order the annual meeting of the MMA House of Delegates and the end of the presidential term of TCMS member, Benjamin Whitten, M.D. Fifty-nine TCMS members served as delegates throughout the two and a half-day event, testifying on proposed resolutions and voting for their colleagues to serve as 2011 officers, trustees and AMA delegates. A complete summary of actions taken by the House of Delegates is available at www.mnmed.org.

Election Results:

President — Patricia Lindholm, M.D. ��� Fergus Falls, MN President-elect — Lyle J. Swenson, M.D. – St. Paul, MN Secretary/Treasurer — David E. Westgard, M.D. – Rochester, MN Speaker of the House — Mark Liebow, M.D. – Rochester, MN Vice Speaker of the House — Robert Moravec, M.D. – St. Paul

Amy Gilbert, M.D. testifies before Reference Committee D.

TCMS Members Serving on the Board of Trustees:

Michale B. Ainslie, M.D. Beth A. Baker , M.D. Carl E. Burkland, M.D. Benjamin W. Chaska, M.D. V. Stuart Cox, III, M.D. Donald M. Jacobs, M.D. Fatima R. Jiwa, M.D., ChB – at large member Roger G. Kathol, M.D. Charles G. Terzian, M.D. David C.Thorson, M.D. – Chair

Louis Ling, M.D. served as chair of Reference Committee B.

Drs. David Hilden and Edward Spenny meet after reference committee concludes.

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(Continued on page 26)

First time delegates Drs. Carolyn A. McClain and Elizabeth E. Frost connect with Young Physician Section member Stuart E. Cameron, M.D.

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MMA Annual Meeting (Continued from page 25)

Are you considering a mental health assessment for your patient? Hamm Clinic in St. Paul is a leader in psychiatric consultation and psychotherapy treatment. Our services include: x x x x x

Psychiatric Consultations Individual and group psychotherapy Couples therapy Services in English and Spanish Evening hours

Please call our intake coordinator at 651-224-0614 with any questions you may have or visit us at www.hammclinic.org

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AMA Delegates (TCMS members) Kenneth W. Crabb, M.D. Blanton Bessinger, M.D. (Alternate Delegate) Benjamin H. Whitten, M.D. (Alternate Delegate) David L. Estrin, M.D. (Alternate Delegate) Awards:

The following TCMS members were recognized at the Award Luncheon: Medical School Student Award — Honors an MMA/MMS student who has an outstanding commitment to the medical profession. Elizabeth R. Vogel

Physician Leadership in Quality — Presented to a Minnesota physician who exhibits a commitment to improvement methods, demonstrates leadership in advancing health care quality and safety, fosters a culture of quality in his or her work environment and inspires other physicians and colleagues. William S. Nersesian, M.D., MHA Decade Awards — Physicians who have practiced medicine and maintained their MMA membership for 50+ years. Maland C. Hurr, M.D. Physician Communicator Award — Honors a physician who demonstrates exemplary skill in communicating with the public through radio, television, or the newspapers and whose work contributes to a better understanding of medicine and health in Minnesota. David R. Hilden, M.D., FACP

Thank you to the following TCMS members who served as delegates: Michael B. Ainslie, M.D. Donald P. Asp, M.D. Beth A. Baker, M.D. Macaran A. Baird, M.D. Richard L. Baron, M.D. Lee H. Beecher, M.D. Blanton Bessinger, M.D. Carl E. Burkland, M.D. Stuart E. Cameron, M.D. Benjamin W. Chaska, M.D. Kenneth W. Crabb, M.D. Roger J. Day, M.D. Peter J. Dehnel, M.D. Karen K. Dickson, M.D. Arkadius Z. Dudek, M.D. (Reference Committee) Edward P. Ehlinger, M.D. David L. Estrin, M.D. Patricia L. Fontaine, M.D. Elizabeth E. Frost, M.D. Robert W. Geist, M.D. Amy L. Gilbert, M.D. J. Michael Gonzalez-Campoy, M.D. Carol M. Grabowski, M.D. Elisa M. Hansen, D.O. Ronnell A. Hansen, M.D. A. Stuart Hanson, M.D. Lucas S. Henry, M.D. David R. Hilden, M.D. Donald K. Jacobs, M.D. William E. Jacott, M.D. James J. Jordan, M.D.

Mary H. Kathol, M.D. (Reference Committee) Roger G. Kathol, M.D. Kenneth N. Kephart, M.D. Renee C. Koronkowski, M.D. Louis J. Ling, M.D. (Reference Committee) Harry J. Marshall, M.D. Lisa R. Mattson, M.D. Carolyn A. McClain, M.D. (Reference Committee) Nicholas J. Meyer, M.D. Robert C. Moravec, M.D. Richard J. Morris, M.D. Stefan H. Pomrenke, M.D. Douglas J. Pryce, M.D. Thomas D. Siefferman, M.D. (Reference Committee) Edward A. L. Spenny, M.D. Stephanie D. Stanton, M.D. Lynne P. Steiner, M.D. (Credentials Committee) Lyle J. Swenson, M.D. Karin M. Tansek, M.D. T. Michael Tedford, M.D. Charles G. Terzian, M.D. David C. Thorson, M.D. Elizabeth R. Vogel, medical student (Reference Committee) Jessica M. Voight, medical student Ann H. Wendling, M.D. Hynatu L. Williamson, M.D. Kent S. Wilson, M.D. Peter B. Wilton, M.D. (Reference Committee) Benjamin H. Whitten, M.D.

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The Journal of the Twin Cities Medical Society


In Memoriam MAXWELL M. BARR, M.D., age 91, died on July 29, 2010. He graduated from the University of Minnesota Medical School. Dr. Barr was an Obstetrician/Gynecologist delivering over 4,000 babies during his career. He was medical director of Hennepin County Cancer Society, chief of staff at Mt. Sinai Hospital, and a captain in the U.S. Army Medical Corps during WWII. Dr. Barr joined WMMS in 1945.

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GARY R. BLACKMORE, M.D. died September 9, 2010 at the age of 66. He was a psychiatrist in private practice, and affiliated with the Fairview University Hospital system. He graduated from the University of Minnesota Medical School. Dr. Blackmore joined WMMS in 1985. WILLIAM H. HOULTON, M.D. died on July 28, 2010, at the age of 87. Dr. Houlton attended the University of Minnesota Medical School, specializing in anesthesiology. He spent more than 35 years practicing in St. Paul and was known for his personal, compassionate care and willingness to volunteer his services. Dr. Houlton joined EMMS in 1959. CHRISTIAN J. WAGNER, M.D. died from cancer on July 26, 2010. He was 85. He was born in Bischoff, East Saxony, Germany, and was drafted into the German People’s Army at the tender age of 16. He graduated from Medizinische Fakultaet der Freien Universitaet Berlin. Dr Wagner moved to the United States in the early 1950s. He specialized in anesthesiology and completed his residency at the Mayo Clinic in Rochester. Dr. Wagner spent the majority of his career working at North Memorial Medical Center in Robbinsdale. He joined WMMS in 1963.

Twin Cities Medical Society Presents

Twin Cities Medical Society Forum Towards Real Health Reform Speaker: Stephen T. Parente, Ph.D., Carlson School of Management

Friday, November 19, 2010 7:30 a.m. – 8:30 a.m.

United Hospital John Nasseff Medical Center, 333 North Smith Ave. St. Paul, MN – Miller/St. Luke’s Conference Rooms

Watch TCMS website for additional information, www.metrodoctors.com

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New Members

CAREER OPPORTUNITIES

see additional career opportunities on page 30.

Joseph P. Amberg, M.D. HealthEast Midway Clinic Internal Medicine/Palliative Medicine David W. Brown, M.D. Park Nicollet Clinic Obstetrics/Gynecology Elizabeth E. Doty, M.D. Hennepin Faculty Associates Obstetrics/Gynecology Joseph M. Dundee, M.D. Emergency Physicians & Consultants, PA Emergency Medicine Sarah E. Dundee, M.D. Emergency Physicians & Consultants, PA Emergency Medicine John A. Hitt, M.D. Hennepin County Medical Center Internal Medicine/Infectious Diseases Mark J. Hudson, M.D. Children’s Hospital and Clinics – St. Paul Pediatrics/Child Abuse Mohamed A. Ibrahim, M.D. Allina Medical Clinic-Midwest Surgery General Surgery Valerie E. Johnson, M.D. Emergency Physicians & Consultants, PA Emergency Medicine Timothy J. Krueger, M.D. Metropolitan Anesthesia Network, LLP Anesthesiology Joseph W. Leach, M.D. Minnesota Oncology Hematology, PA Internal Medicine/Hematology/Oncology Kyle Onan, D.O. Kidney Specialists of Minnesota, PA Internal Medicine/Nephrology Shou-Ching Tang, M.D. Minnesota Oncology/Hematology, PA Internal Medicine/Oncology Resident Physician Lucas S. Henry, M.D. Hennepin County Medical Center Psychiatry

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fairview.org/physicians TTY 612-672-7300 EEO/AA Employer

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Career Opportunities

CAREER OPPORTUNITIES

Please also visit www.metrodoctors.com for career opportunities.

Introducing the “Career Opportunities” section of MetroDoctors!

A great avenue for professionals to learn about job opportunities AND a perfect place for recruiters to promote openings! Recruiters, call for our special recruitment rate. Betsy Pierre, ad sales 763-295-5420

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on the latest TCMS news, events and legislative issues; Board and committee actions; past issues of MetroDoctors;

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• Hospitalist

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

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

THERE’S A CONFERENCE ROOM IN THE OFFICES OF THE MMA/TCMS. Upon entering that empty room, one is struck with a feeling of calm serenity and warmth. It’s a tidy looking place; no frills, comfortable, yet capable of conducting important business using up-to-date technological aids. Whimsical art on its walls represents the West Metro, the East Metro and an elegant structure bridging the gently flowing Mississippi. The room honors the memory of M. Elizabeth Craig, M.D., the first woman President of the MMA, and exemplifies many of her characteristics: composed, unruffled, kind, resourceful, welcoming and proficient. Her lengthy career span in our profession allowed her to experience first hand some mighty powerful transformations, among them the bridging movement from male dominated medicine toward more gender equality. Peggy Craig was born in Minneapolis, educated at the University of Minnesota (U of M), completed hospital residency training at Milwaukee County and the old Minneapolis St. Barnabus. She practiced pediatrics in the western suburbs for nearly 40 years and held medical staff memberships at Asbury, Methodist and Minneapolis Children’s Hospital. In addition to her general pediatrics practice, her clinical interests were varied and included adolescent chemical dependency and child abuse prevention. She was the founding medical director of the Institute for Eating Disorders at Methodist and served a five year stint as the Pediatric Training Coordinator for the University/Methodist Residency Program. Peg proudly contributed to her profession and her community by serving in leadership capacities for Asbury Hospital, Methodist Hospital (first woman president of the medical staff), the Minnesota Coalition for a Smoke Free Society, Hennepin County Medical Society (HCMS), MMA (first woman President), and the U of M Alumni Association (first woman National President). Some of her numerous Board positions were at the Foundation for Health Care Evaluation, 32

November/December 2010

West Hennepin Independent Physician Associates, Blue Cross and Blue Shield of Minnesota, the Minneapolis Foundation, and she was a six year Regent of the U of M. Notable among Dr. Craig’s many honors were the Outstanding Achievement Award from the U of M, the Gold Headed Cane Award from the Department of Pediatrics, the Charles Bolles Bolles-Rogers Award from HCMS and the Shotwell Award from Metropolitan-Mount Sinai Hospital. With all of the above competing activities, did she have time for a family life? You bet she did! Peg’s long marriage to Howard L. Lincoln was blessed with two children, Craig and Libby Lincoln, both of whom achieved extraordinary successes in athletics and their chosen professions. For them, she was an energetic spectator at innumerable diving and gymnastics meets, and regularly spent her “doctor’s Wednesday afternoon off” as a dedicated Girl Scout Leader. She was always there for her family — to gently nurture, to wisely advise and to share a hug or a soft shoulder on which to lean. Those same initiatives were also applied in the patient care activities she provided for her young patients. Interestingly, that same approach even carried over into her medical management pursuits. Peggy was once asked, “Dr. Craig, as a leader of all those big important doctors, how did you — a modest, diminutive and reserved woman get those chaps to comply with your wishes?” She quietly replied, “I spoke to them as a mother would … and they just followed along.” Peggy passed away just two years ago and unfortunately did not have a chance to see the conference room named in her honor. We are pleased to be just another in a long line of admirers of Dr. Peg Craig as we honor her as a Luminary of Twin Cities Medicine. MetroDoctors

The Journal of the Twin Cities Medical Society


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2010 November/December