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Ophthalmology Sioux Falls

Contents Midwest Medical Edition

January / February 2013

Regular Features 2 | From Us to You 4 |  Meet a MED Advisor — Paul Amundson, MD 6 |  News & Notes News events and announcements from around the region

21 | Complementary Therapy: Acupuncture How this ancient art is helping modern patients in the Sioux Falls are fight problems from pain to insomnia.

24 | The Nurses Station 27 | Grape Expectations: Wine and Romance | By Heather Taylor Boysen

29 | Learning Opportunities: Upcoming Symposiums, Conferences, CME Courses

In This Issue 4 | Kaiser Foundation Forecasts SD’s Medicaid Eligibility Expansion Impact

| By Dave Hewett

5 | Pictures are Worth 1,000 Words

| By Tana Phelps If you are not using Pinterest to promote your practice, you could be missing out on a valuable new way to boost patient engagement.

12 | World’s Smallest Microscope Now in Use at Sanford 16 | Study to curb alcohol-exposed pregnancies receives funding

16 | South Dakota Project Receives NCI Grant for Cell Phone-Based Study $1.8 million will let Rapid City cancer doctors educate at-risk patients with high-tech help.

19 |

Mercy Dedicates New Robotic Operating Suite

20 | The Evolution of Health Insurance: The Case for a Defined Contribution Model |

by Bradley K. Arends

23 | South Dakota Vets and High-Tech Healthcare South Dakota VA’s are embracing the benefits of telehealth to bring long-distance expertise to the state’s veterans. | By Caroline Chenaul

28 | The Human Touch

| By Mark Graban Automation may save time and eliminate errors in the hospital but one author says nothing beats engaged employees for quality improvement.



cover feature

Once, I had this case . . . You can’t be in practice for long without gathering some good stories. Whether it’s an unusual case, an extraordinary clinical outcome, or an entertaining patient, certain memories just stick. For this issue’s Cover Feature, we asked, ‘What makes a memorable case?’. We highlight a few of the answers, as well as the stories themselves, from your colleagues around the region as we kick off a new MED column, Case By Case.

From Us to You

Staying in Touch with MED


anuary and February are a busy time of year for physicians. Just as other people may be calming down and getting re-centered after the rush of the holidays, physicians are gearing up for a host of infectious diseases and their associated complications. Even the incidence of diseases that one would not expect to be seasonal often pick up in the winter months. Hematologist Kelly McCaul, MD, cites leukemia as one example. In the midst of your winter rush, we hope you can find some time to unwind with this month’s issue of MED. In addition to some compelling (and sometimes entertaining!) practice stories from a few of your colleagues, you’ll also find plenty of “news you can use”: The experts at Cassling make the case for engaging more patients with Pinterest, a local family physician explains why she sought training in acupuncture, and our MED wine diva, Heather Boysen, has advice for choosing the perfect beverage to enjoy with your sweetheart. As always, we also have all of the latest medical community news plus a list of upcoming events and CME opportunities. A few minutes with MED and you’re up to date! We welcome Dr. Paul Amundson to the MED Advisory Board (page 2, Meet a MED Advisor) and we invite those of you with an interest in helping to guide the direction of this publication to let us know. We hope to meet some of you in person at the American Heart Association’s Go Red for Women event on February 22nd. Here’s to a healthy, happy and productive new year!


MED Magazine, LLC Sioux Falls, South Dakota

VP Sales & Marketing Editor in Chief Design/Art Direction Cover Design Photographer Web Design Contributing Editor Copy Editor

Steffanie Liston-Holtrop Alex Strauss Corbo Design Darrel Fickbohm Kristi Shanks 5j Design Darrel Fickbohm Hannah Weise

Contributing Writers

Bradley Arends Heather Boysen Mark Graban Dave Hewett Tana Phelps

Liz Boyd Caroline Chenault John Knies

Steffanie Liston-Holtrop

Staff Writers

Contact Information Alex Strauss

—Steff and Alex

Steffanie Liston-Holtrop, VP Sales & Marketing 605-366-1479 Alex Strauss, Editor in Chief 605-759-3295 Fax 605-271-5486 Mailing Address PO Box 90646 Sioux Falls, SD 57109 Website

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©2011 Midwest Medical Edition, LLC Midwest Medical Edition (MED Magazine) is committed to bringing our readership of 3500 South Dakota area physicians and healthcare professionals the very latest in regional medical news and information to enhance their lives and practices. MED is published 8 times a year by MED Magazine, LLC and strives to publish only accurate information, however Midwest Medical Edition, LLC cannot be held responsible for consequences resulting from errors or omissions. All material in this magazine is the property of MED Magazine, LLC and cannot be reproduced without permission of the publisher. We welcome article proposals, story suggestions and unsolicited articles and will consider all submissions for publication. Please send your thoughts, ideas and submissions to Magazine feedback and advertising and marketing inquiries, subscription requests and address changes can be sent to MED is produced eight times a year by MED Magazine, LLC which owns the rights to all content.


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A talk with MED Advisor

Kaiser Foundation Forecasts SD’s Medicaid Eligibility Expansion Impact

Paul Amundson, MD Medical Officer, Dakotacare Q: After 15 years in family medicine, you left a little over five years ago to join Dakotacare. What convinced you to make the leap into administration? A: I have always had interest in organized medicine and already knew a lot of the doctors around the state. But this was still a difficult decision for me. I loved taking care of patients. I just knew that this was probably a better use of my talents and gifts at this point in my life. Instead of taking care of patients at an individual or one-on-one level, I’m now trying to improve the health of an entire population.

By Dave Hewett


he Kaiser Commission

on Medicaid and the Uninsured recently released its report entitled, “The Cost and Coverage Implications of the ACA Medicaid Expansion: National and Stateby-State Analysis.” The report provides each state’s projected Medicaid expenditures between 2013 and 2022 (10 years) and estimates of their relative increases in Medicaid enrollment and reductions in their uninsured populations.

Q: What are you hoping that you can accomplish in this role? A: I am interested in helping doctors to look to the future so that they can plan their future practices accordingly. We are in a quickly evolving environment now, both in how care is provided and how it is reimbursed. The historic way (fee for service) is going away and compensation connected to quality and outcomes are going to be thrust upon healthcare providers. As physicians, we have to be able to provide outcome data to justify why we are as good or better than the competitor and this is not something many physicians are used to doing. Q: How can doctors deliver care more efficiently, given the looming shortage of providers, without compromising the quality of care? A: We have to be more efficient in how docs are going to see patients. Maybe it means that not every patient interaction is going to be face-to-face in the office. There may be more efficient uses of your time and theirs. Whether it’s through email, or telehealth, or in some sort of group situation, other options are available now. That being said, we have to find ways to compensate physicians for that time. If they spend 2 hours a day emailing we still have to find a compensation plan that will work for them.

Here are the Kaiser Foundation’s findings for South Dakota:


If South Dakota expanded Medicaid eligibility as allowed under the Affordable Care Act: • Federal Medicaid expenditures in South Dakota over that 10-year period would increase from $9.260 billion to $11.370 billion or 22.8%. So, over that 10-year period, Federal revenues coming into the State would increase by $2.110 billion. • State Medicaid expenditures in South Dakota over that 10-year period would increase from $5.451 billion to $5.608 billion or 2.9%. So, over that 10-year period South Dakota would be spending $157 million more with the expansion. • So for every additional dollar the State might spend on expanded Medicaid eligibility, it would generate $13.43 in Federal Matched Funds (FMAP).



 he number of people enrolled T in the State’s Medicaid program would increase from 116,000 annually to 160,000 – a 37.9% increase.


 he number of South Dakotans T without health insurance would fall from 84,000 to 58,000 – a 31.0% reduction. Currently, without the ACA, the report places the number of uninsured at 116,000.

Other factors not included in these numbers are overall savings resulting from less uncompensated care being provided by hospitals, the practical elimination of County Poor Relief (as we know it), and economic growth generated from the additional federal dollars coming into the state. It also does not account for longer term savings that will be derived from a healthier population because they have health insurance coverage. SDAHO supports the expansion of Medicaid eligibility. But we also understand that there are other considerations that need to be accounted for as the State considers this most important issue. First and foremost is the trust that the Federal share will remain as is. (While nothing is for sure, we should have a better idea of that when the “Fiscal Cliff” negotiations conclude in DC.) We also need to better understand the population that would be benefitting from expanded Medicaid coverage. That said, it is difficult to ignore a 13:1 return on state dollars, especially when we know the result is a healthier South Dakota and a more effective health care delivery system. ■

Midwest Medical Edition

Pictures are Worth 1,000 Words

Improve Patient Engagement through Pinterest By Tana Phelps


or many hospitals and

health systems, communicating to patients via Facebook, YouTube, Twitter and LinkedIn is a fixed part of their social media strategy. However, a game changer—in the form of a picture-sharing social site called Pinterest—offers health-care organizations a new set of tools for engaging with patients. With more referral traffic than LinkedIn, Google+ and YouTube combined, Pinterest is one of the fastest-growing social services in the world. It acts as a virtual corkboard, allowing users to “pin” images of the people, places and things that interest them. And few things are of greater interest to us than our health. That makes Pinterest a perfect fit for health-care organizations. So do its demographics. Almost 70 percent of Pinterest users are females ages 25-54, and it’s these women who control 90 percent of all household health-care decisions. They say pictures are worth a thousand words. Since patients’ attention spans for marketing messages are shrinking, Pinterest might be the next best thing to engage them.

useful. Curate disease-specific boards (e.g., heart disease, diabetes, cancer) with resources and tips for patients coping with chronic conditions. Likewise, post exercise routines for rehabilitating athletes and parenting advice for expectant moms.

v Install the “Pin It” button. Photos on your

v Link pins to your site. If you’re seeking

v Measure, measure, measure. To maximize

referrals, Pinterest can extend a dialogue with existing patients who have already experienced your care. Create a “Healthy Eating” board linking back to recipes from your newsletters or patient programs.

your ROI, the time to join (and pin) is now, while interest is high and competition is low. Measure by followers, repins, and perhaps most importantly, by traffic back to your website. ■

your progress. Dive into your organization’s archives and post photos over the years to show your growth. This is a great way to engage hospital employees, too.

v Showcase

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v Focus on photos and graphics. Pinterest is Work with us! There is a difference!

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Stay at Work/Return to Work Program Assistance Customized Training Safe Patient Handling Programs Injury Assistance Center Local Claims and Case Management

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more than services. Your Pinterest boards should be inspiring and

January / February 2013

Tana Phelps is a marketing specialist at

Quarter Page Horizontal 3.875 x 5.275 JAN 2012B ISSUE_Layout 1 12/3/2012 4:39 PM Page 1

Use these tips to make the most of Pinterest:

not like Twitter or Facebook. It relies on visuals, not text. Use photos, infographics and other images, especially ones your competition doesn’t have. Don’t just grab them from Google, and be sure you comply with Pinterest’s guidelines for copyright.

website should be able to be pinned back to Pinterest by visitors. This will require you to implement a toolbar widget on your site. Pinterest offers free instructions for this on its website.



Happenings around the region

South Dakota Southwest Minnesota Northwest Iowa Northeast Nebraska

News & Notes Avera

Black Hills

Dr. Edward Zawada, vice president of Scientific Affairs and medical director of

Jim Simons, Physical Therapist (PT), Orthopedic Clinical Specialist (OCS), and Custer Regional Hospital (CRH) Director of Rehabilitation Services, was recently inducted into

the Intensivist Program and eICU at Avera McKennan Hospital & University Health Center, has been selected by peers to be included in the Best Doctors in America 2013 database. The selection is based on an extensive, impartial, peer-reviewed survey that involves thousands of doctors nationwide.

Joseph Fanciullo, MD, of Avera Medical Group Rheumatology Sioux Falls is the recipient of the 2011-12 Chair Award for outstanding service to the Department of Internal Medicine from the University of South Dakota Sanford School of Medicine. Dr. Fanciullo serves as division chief of Rheumatology for the Department of Internal Medicine, program director for the Transitional Residency Program and associate program director for Internal Medicine residency. He has been a faculty member for 14 years.

Kara Payer is the new Vice President of Mission at Avera Sacred Heart Hospital in Yankton. The Wagner native comes to the position from the Avera Central Office in Sioux Falls where she was a clinical intelligence analyst.


the South Dakota Physical Therapy Association (SDPTA) Hall of Fame. Simons was recognized for his years of service and commitment to the field of physical therapy by SDPTA.

Six Veterans in the VA Black Hills Health Care System (BHHCS) got a new lease on life last month when they entered into the Homeless Veterans Apprenticeship Program and became the newest full-time employees at Black Hills National Cemetery near Sturgis. Apprentices were referred from VA BHHCS’s Homeless Veteran Supported Employment Program which provides vocational assistance, job development and placement, and ongoing employment support to Veterans who are homeless, formerly homeless, or at-risk of homelessness. The new cemetery caretakers undergo a one-year probationary period and receive the same benefits that other Federal employees receive.

Sylvia R. Medley, MD, MPH. has joined the team of hospitalists at the physicianowned Black Hills Surgical Hospital (BHSH). Dr. Medley will be working with Raymond Pierce, MD and David Johnson, MD in providing inpatient hospital care and pre-operative consultations. After receiving her Medical Doctorate from the University of Nebraska, Dr. Medley completed her Residency in Preventive Medicine, a Fellowship in Occupational Medicine, and a Masters of Public Health and Management all from John Hopkins University, Baltimore, MD. Dr. Medley is also board certified by the American Board of Internal Medicine.

Athletic trainers with Regional Sports Medicine in Spearfish donated $6,680 to the Rapid City Regional Hospital Foundation to benefit the John T. Vucurevich Regional Cancer Care Institute on Friday, Nov. 9. Proceeds came from donations to the Pink Tape Against Cancer fundraiser, which took place at high school sporting events in Belle Fourche, Lead-Deadwood, and Spearfish as well as in Hulett, Sundance, and Upton, Wyoming, during the month of October. Donations were generated by providing athletes the opportunity to choose pink tape for their pregame wraps, and additional events conducted by the athletic trainers, student athletes, and student councils. In the past three years, the Pink Tape Against Cancer drive has generated nearly $20,000 for cancer research.

Regional Health has donated $4,500 to Starting Strong Rapid City. Launched in fall 2012, the three-year Starting Strong Rapid City pilot gives 3- and 4-year-old children from low-income families the opportunity to enter school ready to learn. Parents choose a quality preschool from among approved programs that provide transportation, nutrition, and highly qualified teachers. University researchers will evaluate program effectiveness.

Sanford The South Dakota High School Basketball Hall of Fame, a program to honor the state’s best prep basketball athletes, will move to the Pentagon at the Sanford Sports Complex when the facility opens in the fall of 2013. Established in 2009, the South Dakota High School Basketball Hall of Fame installed its first class in 2010. A total of 49 athletes have been inducted in the Hall of Fame’s history. Until it is relocated, the South Dakota High School Basketball Hall of Fame will stay at its current home at the Community Center in Madison.

Brett Baloun, MD, Sanford Gastroenterology Clinic – Sioux Falls, has received his board certification in Gastroenterology/Hepatology. Dr. Baloun, who recently joined Sanford, specializes in general gastroenterology & hepatology, inflammatory bowel diseases, celiac disease, colorectal cancer screening, upper endoscopy and capsule endoscopy. In addition, Dr. Baloun performs single-balloon enteroscopy, a service that previously had to be outsourced at another facility.

Midwest Medical Edition

Sanford USD Medical Center and the team at Sanford Heart Hospital have received the American College of Cardiology Foundation’s NCDR ACTION Registry – GWTG Platinum Performance Achievement Award for 2012 – one of only 164 hospitals nationwide to do so. The award recognizes Sanford USD Medical Center and Sanford Heart Hospital’s commitment and success in implementing a higher standard of care for heart attack patients. It also signifies that the hospitals have reached an aggressive goal of treating these patients to standard levels of care as outlined by the American College of Cardiology/American Heart Association clinical guidelines and recommendations

Researchers with the Sanford Eating Disorders and Weight Management Center in Fargo are part of a team that has developed a promising new therapy for bulimia. The team’s leader, Stephen Wonderlich, and colleague James Mitchell are also University of North Dakota Neuroscience Professors. The new bulimia treatment was a collaborative effort between UND, the Universities of Minnesota and Wisconsin, the Neuropsychiatric Research Institute and Sanford Health. The new treatment is psychological in nature and focuses on eating- and emotionrelated behavior through the arduous process of dealing with, and hopefully eliminating, their bulimic symptoms.

Heather McDougall, MD, Sanford Gastroenterology Clinic – Sioux Falls, has received her board certification in Gastroenterology/ Hepatology. Dr. McDougall, who joined Sanford in November 2011, specializes in general gastroenterology, inflammatory bowel diseases, celiac disease, colorectal cancer screening and upper endoscopy.

Brian LeylandJones, MB BS, PhD, director of Edith Sanford Breast Cancer Research, recently presented eight scientific abstracts highlighting emerging treatments for hard-totreat cancers, such as triple negative breast cancer, and new insights on biologic targets and prevention at the 2012 CTRC-AACR San Antonio Breast Cancer Symposium. LeylandJones was joined by Edith Sanford associate scientist Pradip De, PhD and Nandini Dey, PhD, as well as staff scientists Yuliang Sun, MD, PhD. Now in its 35th year, the annual symposium is the foremost gathering of scientists, physicians and health care professionals dedicated to eradicating breast cancer. The team’s research on triple negative breast cancer was also the highlighted cover article in a research issue of Current Drug Targets.

Siouxland Mercy Medical Center physician Steven Joyce, MD, gave a presentation on the use and misuse of antibiotics in November as part of Mercy’s monthly public education program, Mercy 101. In addition to having the opportunity to listen and ask questions on the given topic, attendees receive a binder for their materials and are offered access to free health screenings and occasional giveaways.

During the month of December, Mercy Medical Center held a social media campaign designed to alert the community of the dangers of driving impaired. The initiative is part of Mercy’s Reality Education and Prevention Program (REAP). REAP is a diversion program designed to show OWI offenders the consequences of making the choice to drive impaired. Since 1981, every December has been proclaimed Drugged and Drunk Driving Prevention Month.

Other Brookings Health System has selected The Neighborhoods at Brookview as the name for the new skilled nursing facility, currently under construction and scheduled to open summer 2013. The

Melanie Barclay is the new regional director for Make-A-Wish® South Dakota in Rapid City. A native of Rapid City, Melanie is a University of South Dakota graduate and most recently worked in development at Youth and Family Services. Her main responsibilities are development, public relations and outreach. Her office is located on the second floor in the Great Western Bank building on St. Joseph Street. Make-A-Wish serves the entire state of South Dakota with the main office in Sioux Falls.

The Siouxland Surgery Center in Dakota Dunes has won a Bernard A. Kershner Innovations in Quality Improvement Award from the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC). The award was presented in November at a meeting in Las Vegas. The award is presented to healthcare organizations for their participation in quality improvement initiatives. Siouxland Surgery Center won the award in the Surgical/ Procedural Care category for their study entitled Surgical Site Infection Reduction Project.

Neighborhoods is a pod-style facility with three distinct neighborhood, all connected by a Town Center. The construction is phase two of Brookings Health System’s master campus plan. The 67,000 square foot structure will triple the existing space at the current facility, Brookview Manor.

January / February 2013


Once, I had g g g

g g g



Gastroenterologist, Sanford

stories that are memorable for physicians are often those stories where you’re fairly certainly that there was some form of divine intervention involved. I remember a young 45-year-old male patient last year with a typical bleeding ulcer. He had been taking an aspirin a day and had been having dark stools. I did an emergency endoscopy to determine the cause and to treat the ulcer. What we found was a very typical gastric ulcer that was bleeding, possibly related to the aspirin. So we cauterized it and treated it. Typically, we bring these patients back in 6 to 8 weeks just to make sure that everything is OK and to make certain that it wasn’t cancerous. This guy wasn’t having any more problems and actually cancelled his follow-up procedure because of scheduling issues. When we were finally able to bring him back in, his ulcer was almost completely healed. Even though this looked great, we decided to go ahead and do a biopsy anyway. I’m not really sure why we did, but it turned out to be malignant. And not just malignant, but a signet ring cell cancer, which is uniformly lethal. Here is a guy who just about didn’t come back. And even though it looked healed, we still took a biopsy. This patient had two thirds of his stomach removed and he’s doing great. Even he recognizes that this was a special situation. Some people wouldn’t have even biopsied it again. Clearly, this was life-saving. We all see these cases where there is a fine line between fortuitousness and miraculous. He knows it and I know it. Was it luck? Could have been. But you just know that there was more to it. Something intangible. They happen all the time. And, if he

Midwest Medical Edition

Photo courtesy Sanford Health

It is said that everyone has a story to tell and it may be even truer for those in the medical field. By its very nature, the unique role of physicians brings them into close and sometimes intense contact with a wide swath of humanity. We invited several area physicians to share some of their most memorable practice experiences and notable cases and we bring them to you here, in their own words. We hope their stories will inspire you to recall and share some of your own with your physician colleagues in MED as part of a new ongoing series.

Jeff Murray, MD

(The Stories We Could Tell)

this case • your eyes are open wide enough, you recognize that. And then you recognize that this is a pretty cool field to be in. Once I pulled a wedding ring out of a guy within a couple of hours of getting married. Their whole wedding was hanging on the tip of my endoscope. But that’s another story . . .


Beth Mikkelsen, MD General Internist, Yankton Medical Clinic

January / February 2013

for about a year and a half, but finally had to graduate him because he wasn’t getting any worse. He was never able to intellectually grasp his illness. He lived for five years. This is an example of a case that, on the surface seems very ordinary but, in many respects, was also extraordinary because of the patient and the situation and the family. As physicians, we are all caught up in the huge changes that are going on in our lives. We are being asked to do more things for less money. We are asked to deal with increasing piles of paperwork. We are being asked to communicate with patients electronically, which changes the dynamics of the relationship. But in the end, what we do, helping patients through the most intense periods of their lives, is really a privilege.


John Lee, MD Head & Neck Cancer Surgeon, Sanford



patients with head and neck cancer is not like a lot of things. If you have a cold and you don’t go in, 99 percent of the time you’re still going to get better. But that’s not the case with head and neck cancer. This has now become the 6th most common cancer, about 30 cases per 100,000 people. Patients come to me with real concern and it’s often a really interesting time in their lives. About half of my patients have gotten there because of poor decisions – smoking, or significant

Photo Courtesy Sanford Health

Photo Courtesy Yankton Medical Clinic


ou typically think of a memorable case as something that is out of the ordinary. But I have found that, sometimes, the most ordinary cases can really be wonderful, too. For me, as a long time practicing physician (I finished residency in 1986), what are memorable are the intimacies that my patients share with me on a daily basis. When one has the opportunity to develop a trusting relationship with them and their families, you may be told things that maybe no one else ever hears. People bare their souls. That is such a blessing and a burden. I am the medical director for hospice in Yankton and I run the palliative care program. I had a guy that some might think of as a miracle. He was a 60-year-old mentally disabled man. He was able to live semi-independently with lots of support and his brother and the brother’s wife were advocates for him and really treated him like another one of their children. This patient smoked for years, had underlying COPD and developed lung cancer. You would usually expect someone to die within a year of diagnosis with this type, because he was unable to tolerate chemotherapy. We followed him in hospice

• •


alcohol use. If you smoke, the risk is about 20-fold. If you are a drinker, it’s about 5-fold. But if you do both, the risk is about a hundred-fold. The cure rate is high but the treatments are difficult. Two different things might happen: The cancer is cured but the things that caused it don’t improve. Some of these patients continue to smoke through a hole in their neck. So the chance of recurrence is good. The other thing that can happen is someone who has been drinking a fifth a day finally quits and takes control of his life and becomes productive. I have had families say ‘You returned our dad to us.’ The patients who really do well are those who look at their lives and say ‘something has to change’. They’ve been told that it’s dangerous to smoke, but this makes them really look seriously at that. When patients really begin to look at ‘I could die’, they become vulnerable to allow themselves to change, often for the first time. People turn their lives around and they begin to see life differently and it is gratifying to be a part of that. One example is a guy I saw just last week who was working in a high-pressure job and was self-medicating. After cancer, he quit his job and went back to ranching, which he truly loves. His marriage has gotten better. He is feeling like he’s not under stress all the time. He realized things in his life that were causing these things. Cancer is a symptom of a larger problem, in this case. As a surgeon, if you take a few extra minutes to consider the whole person, you can be part of a real transformation. The double win is if you can not only cure their cancer, but can also help them change their lives. That is what makes me excited as a doctor.


“Cancer is a symptom of a larger problem, in this case. As a surgeon, if you take a few extraminutes to consider the whole person, you can be part of a real transformation.”

Tom Benzoni, DO


Emergency Medicine, Mercy Medical Center am


parochial. I think ER is the most fun and best place to work. It is constantly changing. What do you call an ER doc who takes his ADHS meds? Unemployable! (laughs) But seriously, as an emergency physician, I get to be there at some of the best and worst moments of peoples’ lives. We get all kinds of people. We had a little old lady come in for something – I don’t remember what – and the chart said her age was 99. Sometimes ‘99’ means we haven’t got the age entered yet, but in this case we confirmed that she really was 99. So we start talking about her 100th birthday, coming up in a month. I asked if she had anything special planned and she says, “I’m getting me some good whisky! I don’t have time for that cheap s**t!” Then, of course, you get people that have things in places where they don’t belong. Of all the things I’ve ever found up orifices where they don’t belong, I have never had anyone know how that glass tumbler or that light bulb got there. They always just ‘woke up’ with it or sat on it. Some cases are memorable for other reasons. We had a girl in her mid-20s. A dog yanked her while she was putting on her shoes and she lost her balance and broke her neck. She was paralyzed. I saw her later do the Spring Thaw Run in her wheelchair and she told me, ‘I really hated you that day. I wanted you to tell me that everyone would be OK and you wouldn’t.’ The great thing is that you never know what is going to come in. The next sore throat you see could be an ordinary sore throat or it could be a mass from a retropharyngeal abscess. It makes you realize how fragile life is. But it also makes you tough. You have to be able to cut a hole in somebody and put a hand in their side to make their heart beat if you have to. That kind of thing would be considered a felony in any other context, but I get paid for it!



Midwest Medical Edition

Kelly McCaul, MD


Transplant Hematologist, Avera

ne patient

that stands out for me was about 58 years old when I first saw her about ten years ago. She had a high grade myelodysplastic syndrome (MDS). She had been seen by me and by other places, including Chicago, and no one really had a lot to offer at the time. So she developed acute myeloid leukemia (AML) and eventually was referred back to me. At the time, the median survival with what she had would have been 3 or 4 months. So I started to explore some different options for her and I found an NCI trial that I thought could offer her something. We really scrambled against time to get her into the NCI protocol. But after a really horrible two-and-a-half month hospital stay where she was very sick, we got her into remission and she became the first person in the state to get on this new drug, called

Vidaza. Now, ten years later, she has a perfectly normal blood count. She ended up going back to work, finishing her career and retiring and she is now travelling. She is an example of how important it can be to explore every option, including clinical trials. At some point, every drug is experimental. This drug has gone on to become the standard of care in the field. Another woman in her mid-50s with AML had a sibling match, so we did a transplant. She had a really, really tough course and barely survived. First she had complications like infections, then later developed graft-versus-host disease. But, after 7 years, that disappeared and now, 10.5 years post-transplant, she is totally cured, working full time, with a fabulous quality of life. We follow everybody forever, so I see these people all the time. At first I was seeing that patient two or three times a day. Now I only see her once or twice a year and she’s doing great. There’s not a lot of cookbook medicine in our area. Every case is unique and that keeps it interesting.

ggg If you have a memorable case or a story of your own to tell, tell us about it at and we may feature it in an upcoming column.

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January / February 2013

11/5/2012 3:12:27 PM


Clinical Spotlight

Dr. Muslim Atiq performs a procedure with the new Cellvizio microscope as resident Dr. Nishant Parmar observes.

World’s Smallest Microscope Now in Use at Sanford Physicians in Sioux Falls are using

the world’s smallest microscope during endoscopies to view internal tissues at the cellular level in real time. Sanford is the first in the region to offer this new advanced imaging, which is known as Cellvizio. Studies have shown that having this cellby-cell view of the lining of the gastrointestinal (GI) tract and lungs can lead to improved detection and faster treatment of abnormalities, such as cancer, in those areas. The technology is part of the GI and pulmonary programs at Sanford, where the first procedure using the technology recently took place. “Until now, if we found abnormal tissue during an endoscopy we sampled the area and sent it off to pathology for analysis,” said Lee Austin, MD. “Sometimes that biopsy sample does not reflect the changes seen on endoscopy. Patients then must come back at

a later date for additional procedures, either for more sampling of the area or a therapeutic procedure. With Cellvizio, we have the ability to visualize the tissues in real time and, therefore, better target our biopsy sites and make decisions about therapies in real time.” A growing body of published clinical data shows that by adding Cellvizio to colonoscopies, endoscopies and a standard pancreatic and bile duct exam, physicians have been able to more accurately differentiate cancerous and pre-cancerous changes in tissue. In some cases, because of the improved view and understanding of the tissue, physicians have been able to perform minimally invasive treatments for conditions that traditionally required major surgical operations. To use Cellvizio, the tiny microscope is threaded through a traditional endoscope like a catheter or biopsy forceps while the patient

is having an endoscopy. The microstructure of the digestive tract appears in real time on the screen under the administration of a contrast agent called fluorescein, allowing the physician to recognize typical features of healthy and diseased tissue. It adds only a few minutes to the standard endoscopic exam and has a proven safety record with no adverse events reported in thousands of cases. “With cellular-level views, we have more visual information about internal tissues at the patient’s bedside than ever before,” said Muslim Atiq, MD, who used Cellvizio last week at Sanford. “The technology allows us to be more purposeful in removing abnormalities we might see in the GI tract or lungs.” Sanford is one of about 50 centers in the United States using the Cellvizio confocal probe. Cellvizio is approved by the U.S. Food and Drug Administration for use in the GI tract and lungs. ■

The Cellvizio microscope from Mauna Kea Technologies is the world’s smallest microscope. It is FDA approved for procedures in the GI tract and lungs.


Midwest Medical Edition

• Nurse Call Systems • Synchronized Clock Systems • Low Voltage Specialists Brian Baxter, MD, Radiologist, left, talks to Sharon Lee, Chair of the Rapid City Regional Hospital (RCRH) Board of Directors, about the remodel of the RCRH Medical Imaging Department and newly installed technology.

Medical Imaging

Gets a Facelift at Regional The Medical Imaging Department at Rapid City

Regional Hospital has undergone a $2.8 million renovation of its treatment rooms, upgrading the technology and making them more patient-friendly. Treatment rooms and a waiting area have been remodeled with improved aesthetics including new flooring and tranquil colors to ease patient anxiety. The new technology will allow for improved visualization for the medical staff with the least possible radiation dose to the patient, and enhanced 3-D imaging for greater precision. The three renovated areas include a multipurpose room, fluoroscopy room, and radiography room. One of the three renovated areas, the multipurpose room, now features a Siemens floor mounted c-arm system which produces sharp detailed images and offers excellent performance for clinical workflow. In the fluoroscopy room, a new Siemens Lumino Agile Fluoroscopy Suite features versatile clinical applications for performing both angiography and fluoroscopy examinations. Finally, the radiography room has a ceiling mounted c-arm Siemens Interventional Suite allowing easy patient access, full-body coverage, and reduced procedure time. It also has a state-of-the-art injection delivery system. Its advanced imaging means less contrast and dosage is needed for the patient. The treatment rooms are utilized for angiograms, injections for pain relief, and more. ■

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MED Quotes “My mother had a fear of doctors - other than her daughter marrying one.”  —Shelley Berkley 

January / February 2013


It’s the medical equivalent It’s the medical equivalent to landing a man on the moon. to landing a man on the moon.

Now, it has Now, it has landed at Sanford. landed at Sanford.

Transcatheter Aortic Transcatheter Aortic Valve Replacement. Valve Replacement. Only at Sanford Health. Only at Sanford Health. It’s the kind of medical breakthrough thatthe comes once in a lifetime; It’s kind along of medical breakthrough a treatment someonce physicians have that comes along in a lifetime; to some the moon landing.have acompared treatment physicians compared to the moon landing.

Transcatheter Aortic Valve Replacement, or TAVR, treats aortic stenosis,Aortic a failure of the heart’s most Transcatheter Valve Replacement, or crucial TAVR,valve. treats It’s a crippling disease; patients with the most severe aortic stenosis, a failure of the heart’s most crucial valve. casesa have a mere 50% chance of surviving than It’s crippling disease; patients with the longer most severe two years. also leaves them toolonger fragilethan for cases have Tragically, a mere 50%itchance of surviving live-saving surgery. TAVR is a game changer, giving two years. Tragically, it also leaves them too fragile for these peoplesurgery. a new lease onislife. It waschanger, just approved live-saving TAVR a game giving for use in the United States...but only for of these people a new lease on life. It was the justhandful approved hospitals incredibly stringent criteria. Sanford for use in meeting the United States...but only for the handful of Health is one of the first. hospitals meeting incredibly stringent criteria. Sanford

Health is one of the first.

A Crucial 10 Seconds. A Crucial 10 Seconds.

Not only are the patients extremely ill, the treatment has a degree of difficulty like few others. The physician inserts Not only are the patients extremely ill, the treatment has a the Edwards SAPIEN valve into an artery in the patient’s degree of difficulty like few others. The physician inserts thigh, then navigates to the heart. Now comes the tricky the Edwards SAPIEN valve into an artery in the patient’s part. The physician has to place the device in the exact thigh, then navigates to the heart. Now comes the tricky right spot, within a window of just 10 seconds. part. The physician has to place the device in the exact right spot, within a window of just 10 seconds. The Edwards SAPIEN valve is expanded into placeEdwards with a balloon and The SAPIEN the delivery catheter is valve is expanded into readywith to bearemoved. place balloon and the delivery catheter is ready to be removed.

For the full story, visit SANFORDHEALTH.ORG For the full story, Keyword: TAVR visit SANFORDHEALTH.ORG Keyword: TAVR

Edwards SAPIEN transcatheter heart valve Edwards SAPIEN transcatheter heart valve

A Difficult Prognosis. A Difficult Prognosis. For patients like Jeanenne Hatletvedt, it’s more than a once-in-a-lifetime discovery.Hatletvedt, It gave Jeanenne herthan life a For patients like Jeanenne it’s more back. She came to Sanford withIta history of pneumonia. once-in-a-lifetime discovery. gave Jeanenne her life Non-Hodgkins lymphoma. Chemo treatments. Reliance back. She came to Sanford with a history of pneumonia. on oxygen. Arthritis. And Chemo finally, treatments. aortic stenosis, or Non-Hodgkins lymphoma. Reliance hardening of the aortic valve. Sanford Cardiologist Dr. Tomor on oxygen. Arthritis. And finally, aortic stenosis, Stys knew traditional methods of treatment, such as hardening of the aortic valve. Sanford Cardiologist surgery, Dr. Tom were out of the question due to Jeanenne’s frailty. the Stys knew traditional methods of treatment, such asSo, surgery, decision was made to try this bold new procedure. were out of the question due to Jeanenne’s frailty. So, the

decision was made to try this bold new procedure. Dr. Tom Stys is part of a team of specialists at Sanford Health that provide patients the first Dr.only Tomtranscatheter Stys is part ofheart a team of specialists and valve replace- at Sanford Health that provide patients the first ment (TAVR) approved by the U. S. Food andDrug only Administration transcatheter heart valveThis replaceand (FDA). new ment (TAVR) approved U. S. who Food procedure is typically usedbyinthe patients and Drug Administration (FDA). This new don’t have other treatment options. procedure is typically used in patients who don’t have other treatment options.

A Life-Saving Result. A Life-Saving Result.

Today, Jeanenne is back home in Minnesota, with family, friends and one important difference. After Today, Jeanenne is back home in Minnesota, with months of dizziness, weakness and reliance on family, friends and one important difference. After oxygen, “the day after surgery, the first thing I noticed months of dizziness, weakness and reliance on was that I could breath again.” oxygen, “the day after surgery, the first thing I noticed was that I could breath again.”

Choose innovation. Choose Sanford Health.

Choose innovation. Choose Sanford Health.

Photo Courtesy RCRH Daniel Petereit, MD, consults with a patient about her smart phone for the Walking Forward grant received from the National Cancer Institute

Mark Dignan, MPH, PhD, from University of Kentucky; and Stevens Smith, PhD., from the University of Wisconsin in Madison. Dr. Smith is a tobacco cessation expert and will serve as the consultant with the project. “Dr. Petereit, his research team, and, in particular, the American Indians and members of the community served by the Walking Forward Program, have made and continue to make important steps in bringing improved cancer care to all Americans,” said Norm Coleman, MD, Associate Director at the NCI. “Success in grant funding is a challenge, particularly so in the current tight budget climate, so this award demonstrates the superb quality of this team and community. It is a privilege for us at the NCI to be part of this effort.” ■

South Dakota Project Receives NCI Grant for Cell Phone-Based Study The John T. Vucurevich Regional Cancer Care Institute’s (CCI) Walking

Forward program has received a grant from the National Cancer Institute (NCI) to fund a first-of-its-kind research project among Northern Plains American Indians. The “American Indian mHealth Smoking Dependence Study” is one the first projects in the state to utilize mobile technology to analyze risky behaviors and promote smoking cessation. The NCI grant is $1.85 million over four years and is one of 57 granted from among 700 applicants. The grant was awarded as part of NCI’s new “Provocative Questions Project”, a research effort designed to address “important but not obvious” questions in cancer research and treatment. “This is a great opportunity for us to use innovative technologies that are currently in use – such as cell phones–in order to address research questions that may positively impact the lives of many in this region,” said Daniel Petereit, MD, CCI Radiation Oncologist, Medical Director of Research at Rapid City Regional Hospital, and Principal Investigator of the study. “It was a great honor to have been awarded this grant as we were competing against major academic centers throughout the country.” mHealth (mobile health) is the use of wireless devices such as cell phones to provide health-related information. The wireless devices will utilize the Theory for Planned Behavior (link between attitudes and behaviors) to provide health-related information, keep project costs down, and increase efficiency. “American Indians cell phone usage is increasing and I am very excited to be the first in the region to conduct this type of research,” said Dr. Petereit. “We anticipate using the results from this study to help all populations that live in this part of the country.” Dr. Petereit will collaborate in the study with Shalini Kanekar, PhD., Consultant, CCI; Linda Burhansstipanov, MSPH, DrPH; Linda Krebs, Native American Cancer Initiatives in Denver, CO.; Sheikh Iqbal Ahamed, PhD., from Marquette University in, Milwaukee, WI.;


Study to curb alcohol-exposed pregnancies receives funding A Sanford Research initiative to prevent alcohol-exposed pregnancies (AEP) and fetal alcohol spectrum disorders (FASD) in American Indian communities has been granted funding of more than $800,000 by the National Institutes of Health. Titled “Tribal collaborations in the prevention of alcohol-exposed pregnancies”, the three-year project will focus on nonpregnant American Indian women and

Midwest Medical Edition

will be led by Jessica D. Hanson, PhD, an assistant scientist for the Center for Health Outcomes and Prevention Research at Sanford Research. Hanson and her team plan to use a community-based participatory research (CBPR) model. That model is currently in use with the Oglala Sioux Tribe in South Dakota as part of Project CHOICES, which—through the use of motivational interviewing and encouragement of contraception use—is focused on the prevention of AEP in nonpregnant American Indian women seen at tribal clinics. The study aims to implement and sustain the already successful CHOICES program, or a similar initiative, at other tribal health facilities in South Dakota. “We have already experienced great success with the CHOICES program in decreasing binge drinking and minimizing

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unintended pregnancies,” said David Pearce, PhD, vice president of Sanford Research. “Our goal now is to expand the footprint of this effective program—or something that closely mirrors it.” The Pine Ridge Tribal Health Administration and the Rosebud Tribal Health Administration will be partners, assisting in program design, participant recruitment and

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data collection and analysis. Those organizations will also help develop an AEP community needs assessment to appropriately implement prevention efforts. “This project is innovative because it focuses on pre-conceptual women rather than pregnant women,” said Hanson. “We will be able to utilize existing experiences from CHOICES to develop and expand on programs with other tribes.” The program will be piloted and implemented at three tribal sites in South Dakota.

MED Quotes “The great secret of doctors, known only to their wives, but still hidden from the public, is that most things get better by themselves; most things, in fact, are better in the morning.”   —Lewis Thomos

January / February 2013


The new DaVinci Robotic Surgery System at Mercy Medical Center

Mercy Dedicates New Robotic Operating Suite Mercy Medical Center, the first hospital in Siouxland to offer robotic surgery, has officially dedicated its new state-ofthe-art operating room designed to accommodate the growing demand for robotic procedures. The new 625 square foot surgery suite is nearly four times the size of the previous surgical suite. Dr. Andrew Bourne of Siouxland Urology Associates says the new Mercy OR is unlike any other in this region. “This new space was designed specifically for the surgical robot,” said Dr. Bourne. “I commend Mercy for making this investment with patients and surgeons in mind.” The robotic suite features a fully integrated monitoring system, touch screen physician-friendly technology, new equipment and anesthesia booms and an innovative lighting system that is the first of its kind in the area. Mercy introduced robotic surgery to Siouxland (identified as Sioux City and the surrounding metro area) in 2009 and has since seen a dramatic increase in the number of patients and physicians interested in robotic surgery. In response to that growing interest, Mercy President and CEO Bob Peebles says the medical center plans to continue to make significant investments into robotic technology. “Our sole intent is giving patients and our physician partners the safest environment possible and the opening of this new robotic operating room is a huge step in that direction,” says Peebles. ■


Midwest Medical Edition

The Evolution of Health Insurance The Case for a Defined Contribution Model By Bradley K. Arends, J.D.


n the wake of President Obama’s

reelection, Washington will continue to hammer out the details of implementing the PPACA. We can expect changes at the company level as well based on one unassailable truth: healthcare costs are rising so precipitously that many employers can no longer afford to provide employee healthcare coverage according to the current group insurance model. The situation is analogous to the pension landscape in the 1980s. Back then, employers were sinking under the weight of the cost of providing pensions for their retiring employees. The pension model, known as a defined benefit, simply became unsustainable. As a result, companies began to migrate to the defined contribution model, which now takes the form of the ubiquitous system of 401k plans. In the healthcare realm, a similar shift from the current defined benefit model to a defined contribution model is also likely to occur. Although some employers are skittish about switching to a different healthcare model, just as they were about switching from pensions to 401k plans, a defined contribution model can have significant upsides, both in terms of a company’s financial wellbeing and employee health and well-being. My own experience is a case in point. For a number of years, my 100 employees comprised an extremely healthy group, which kept insurance costs in check. But as the workforce started to age and a handful of employees continued to maintain

January / February 2013

Bradley Arends, JD, is President and CEO of Alliance Benefit Group in Albert Lea, Minnesota.

unhealthy lifestyles, healthcare costs skyrocketed. The deteriorating health of a handful of workers, combined with rising healthcare costs across the board, forced my firm’s renewal rates up more than 25 percent for three straight years. In order to control costs, we decided that we needed to do two things: change the model for providing healthcare insurance and help employees take responsibility for their behaviors. We replaced our group health plan with an allowance, or defined contribution, that employees could use to purchase their own individual health insurance. In addition, we instituted aggressive wellness and disease-management programs to encourage employees to take care of themselves, which could help them to lower their insurance premiums and healthcare costs. The shift to a defined contribution model helped my company bring healthcare costs to a manageable and sustainable level, both for the firm and our employees. But the more profound change came thanks to the wellness program, which monitors and grades employee health. Employees who maintain high scores or significantly improve their scores receive more money that they can apply to their insurance payments. This incentive-based model has yielded tremendous results. For example, it encouraged our employees to band together to lose weight. Through an on-site Weight Watchers program that the employees established, some 23 of our workers dropped over 900 pounds in less than six months. The program

also effectively created a separate, lower rate for employees who quit smoking. Instituting a defined contribution program raises a number of issues. On the practical side, applying for individual insurance takes work. Employees need to learn how to shop for and evaluate insurance plans, a task that should become easier as online “shopping malls,” a.k.a. private exchanges, spring up. While a defined contribution healthcare program may sound too complicated and harsh to some who believe that employers are responsible for providing healthcare at any cost, the fact is, Americans’ poor lifestyle choices are simply driving employer healthcare costs up to unsustainable levels. Just look at diabetes. Since 1984, the number of Americans suffering from diabetes has risen nearly four-fold to 20 million people. Medical expenses for people with diabetes are estimated to be more than 2 times higher than for people without diabetes. In the current defined benefit system, employers must cover the rising costs of this disease, which is affecting more and more people. Right now, employers have an alternative for providing health insurance to employees, and it’s a good one. A defined contribution system based on consumer choice and wellness programming can both cap employer healthcare costs while encouraging employees to take responsibility for their lifestyle choices. This is a model whose time has certainly come. ■


Complementary Therapy Supporting a Holistic Approach Dawn Flickema, MD, administers the modern version of an ancient practice at the Avera Cancer Center in Sioux Falls.


Dawn Flickema MD Title

Family Practice Physician And Acupuncture Pr actitioner Business

Aver a McGreev y Clinic


he concept of complementary or alternative therapies is gaining momentum as patients search for new ways to maintain or regain health in the face of rising healthcare costs.

As a result, the number of alternative medicine practitio-

ners and programs in the South Dakota region has also grown dramatically. Some are offered within a traditional healthcare setting, while others are free-standing businesses. In this new column, we take a closer look at some of the therapies being offered in our region and meet the

DF: Acupuncture is a form of neuromodulation. Acupuncture points are a dense collection of peripheral nerves. When you place needles into these points, you are stimulating the peripheral nervous system, which sends a message to the central nervous system. A drug like Neurontin for pain also stimulates the central nervous system, but does it through chemical means. MED: We know that acupuncture has been used in Eastern medicine for centuries, but is there any science behind it?

DF: There is, but many of the studies have been done outside the U.S. and do not meet our standards for methods and control groups. There are more studies now being done in the U.S. and the WHO in 1997 did a review of the literature on acupuncture from across the world. The science we do have suggests that about 75 percent of patients will see a response with acupuncture. In the two years that I have been offering it, I have found that my own results with patients are pretty close to that.

people who practice them.

MED: What kinds of conditions can be treated with acu-

MED: You are trained in modern allopathic medicine.

DF: Acupunctures melds very well with family practice

What attracted you to the ancient Eastern practice of acupuncture?

DF: More and more, we are beginning to recognize that traditional Western medicine does not have all the answers. And a growing number of patients are looking for things other than drugs to treat their problems. They come in and ask their doctor about them, and it forces you to look at the legitimacy. It is easy to tell them that you don’t know anything about it, but that is not the answer they are looking for. They are looking for someone to counsel them on these things, someone whose opinion they trust. Also, I had some issues with a cervical disc myself and acupuncture helped me deal with it.

MED: How do you explain what acupuncture is?

puncture? And how do you decide who is a good candidate? because of the variety of problems I treat. Acupuncture is often associated with treatment of chronic pain, but I also use it to relieve menopausal hot flashes, anxiety and depression, chronic abdominal pain, constipation and diarrhea, dysmenorrhea, fertility issues and seasonal allergies. Most of my patients have already had the appropriate medical workup for their complaint and have either tried a few treatments and not gotten relief, or were bothered by the side effects. Some of these are my own patients, some are patients of my partners in the clinic, and some are referred by outside physicians. Some patients have read about acupuncture and are self-referred. In these cases, we always make sure that they have had a full medical workup first and I do a consultation with every patient to determine if I think acupuncture could help them.

For this issue, MED Editor Alex Strauss spoke with Dr. Dawn Flickema 20

Midwest Medical Edition

MED: How many treatments – and how many needles – are needed before a patient could expect to see results?

DF: New patients need to come in at least once a week, because the effects of acupuncture are cumulative. I tell patients not to expect much change from the first three treatments, but by the sixth treatment, we usually know if we are going to see results and may decide at that point if we should stop or we should go ahead and do another six treatments. If a patient has had their condition for a long time, it is going to take longer to treat them. Patients with acute conditions usually see faster results. Depending on what you’re treating, you may use as few as 4 acupuncture points or as many as 10. We’re treating them bilaterally, so you could have as few as 8 needles or as many as 20. At each appointment, needles are left in place for 20 minutes, or 30 minutes if you are doing ear acupuncture, which I also offer. Some people may need to come back for more treatments after a few months, and others with more acute problems may not need to come back at all.

“As physicians, we have so many unknowns coming our way...

One thing I am certain about is my malpractice protection.”

MED: What has been the reaction of your physician colleagues to acupuncture?

DF: When I first started doing this, I expected that younger physicians would be the most open-minded and accepting of it, but I have found the opposite to be true. Many long-time doctors are very open about it. I think, the longer you practice, the more you realize that you don’t have all the answers. I have found the same thing with patients. Many seniors have chronic problems that they just haven’t been able to find relief for, or they may be on multiple medications and want to avoid another drug.

Medicine is feeling the effects of regulatory and legislative changes, increasing risk, and profitability demands—all contributing to an atmosphere of uncertainty and lack of control. What we do control as physicians: our choice of a liability partner.

impact on your acupuncture practice?

I selected ProAssurance because they stand behind my good medicine. In spite of the maelstrom of change, I am protected, respected, and heard.

DF: I think there is a comfort level for patients in

I believe in fair treatment—and I get it.

MED: Does the fact that you have an MD have any

having a physician offer them the treatment. And because of my medical knowledge I can always refer them back if they need another kind of treatment. My goal is to take the best from Eastern and Western medicine and combine them to offer the best possible treatment for each individual patient and condition. ■

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January / February 2013


South Dakota Vets and High-Tech Healthcare Veterans in our region are taking advantage of improved access to healthcare thanks to the VA’s growing use of telemedicine technology.

The telehealth carts now in use by the VA BHHCS have monitors for two-way viewing and peripheral attachments for examining the ears, eyes, nose and throat. Veterans can use them to avoid long drives for follow-up primary care appointments.


eleheatlh offers a digital link between

patients in one location and a medical provider in another. It’s especially valuable in a state like South Dakota, where many patients live in rural areas, sometimes hours away from the nearest healthcare provider. As difficult as access may be for many patients, it is even moreso for the region’s veterans who get their healthcare through one of a limited number of VA facilities. The VA Black Hills Health Care System (BHHCS) is addressing the issue by offering returning vets the opportunity to take advantage of Skype-like telehealth services. This video technology makes it possible for Veterans to come to one of VA BHHCS’s community-based outpatient clinics or VA Medical Centers and connect with their medical provider, who may be in a hospital more than a hundred miles away. Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn veterans can now utilize telehealth for their follow-up, primary care appointments. “We wanted to expand and see patients where it’s more convenient for them,” explains Primary Care PA, David Cohen, the first primary care provider to begin utilizing telehealth for follow up appointments at VA BHHCS.


By Alex Strauss

The Technology In addition to high quality video chat capabilities, the mobile telehealth carts have peripheral attachments for examining ears, eyes, nose and throat and contain a total exam camera extension for taking close-up photos of a patient’s skin. In the near future, providers will be able to transmit and receive heart and lung sounds clearly with a secure broadband or internet connection and the use of a stethoscope that is part of every cart. A telehealth clinical technician assists with the exam from the Veteran’s location. Cohen says that the telehealth option is especially appealing to younger veterans who are more likely to embrace new technology. “They love the idea that they can use their time more wisely,” says Cohen. “I have patients in North Dakota, Wyoming, Nebraska and the Pierre area. Why should my Pierre patient have to drive two hours to the VA Medical Center for a follow up appointment that will take 15 minutes?”

Telehealth for Pain While telehealth services have been available to veterans in the Eastern part of the state for some time, the Sioux Falls VA is taking its telehealth services to the next level, connecting certain veteran patients with VA pain specialists outside the region.

Midwest Medical Edition

VA Clinical Psychologist Vanessa Ferguson, PhD, consults with pain patient Rob Dickerson, one of the first patients to utilize the VA’s new TeleBehavioral Pain Program.

“We have a number of chronic pain patients that need additional, specialized help,” says Vanessa Ferguson, PhD, Clinical Psychologist in Primary Care Mental. “Pain affects so many areas of a person’s life... Their sleep, their social life, their levels of anger and irritability. It can completely take over a person’s life.” Established at the Sioux Falls VA this summer, the TeleBehavioral Pain Program gives local area pain patients access to a proven highly-specialized cognitive behavioral therapy program based in Connecticut that they would not otherwise be able to use. The program, which has been in operation since 2010, falls under the National Tele Mental Health Center which is a combination of the Office of TeleHealth and the Office of Mental Health. The National TeleMental Health Center offers consultation for a variety of issues such as pain, Hep C, and diabetes to VA sites that may not have experts in these fields available to them for various reasons, such as small size or remote location.

Patient Selection To take advantage of the program, the local area veteran must have had chronic non cancer-related pain for 3 to 6 months. Referrals can come from any source and potential patients are reviewed by licensed psychologists in Connecticut. Once a patient has been chosen, a comprehensive psychosocial and pain history is completed, looking at the impact the pain has had on their functioning, the status of their pain, mood etc. If the patient has a primary mental health provider,

January / February 2013

the pain psychologists work with that person for continuity of care. Appointments take place either at the Sioux Falls VA or Community-based outpatient clinics in Spirit Lake, Sioux City, Aberdeen, Watertown or Wagner. A nurse sets up the telehealth computer where the patient sits with it in a private room, just as if he or she were meeting with the psychologist in person.

Open Floodgates “Every patient’s reaction to the technology is different, but most are just happy to be getting services that they wouldn’t be getting otherwise,” says Dr. Ferguson, who says the VA’s first 7 local TeleBehavioral Pain Program

patients have “opened the floodgates”. There are now more than 20 veterans enrolled in the program, which has two full days of 45-60 minute appointments booked every week. But with a pain population in the hundreds, there is still plenty of room for growth. “One of the things this does is it gives us the option to explore alternatives for pain, beyond just medication,” says Ferguson. “Stress and how a person thinks can impact their level of pain. Some of these patients may have to deal with pain for the rest of their lives and they have to find a way to cope and go on with their lives. We are trying to offer them every option for the best possible quality of life.” ■



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The Nurses’ Station Nursing News from Around the Region

Avera McKennan Reports Successful Quality Results of CUSP Collaboration The Nursing Department at Avera McKennan Hospital & University Health Center reports significant success in reducing central-line associated bloodstream infections (CLABSI) through participating in CUSP, Comprehensive Unit-Based Safety Program. Established in 2001 in partnership with the family of a pediatric patient who was a victim of medical error, CUSP has been expanded nationwide.

Trowbridge Promoted

to Nursing Director at Brookview Manor / Hayti, South Dakota-native Amanda Trowbridge was recently promoted to nursing director at Brookview Manor nursing home in Brookings. Trowbridge has worked at Brookview Manor for the past six years. She started as a charge nurse and then became a case manager. Trowbridge’s previous work experience includes ten years in nursing at Parkview Care Center in Bryant, SD, and nine years at the Golden Living Center in Lake Norden, SD. She holds an associate’s degree in nursing from the University of South Dakota. As nursing director, Trowbridge is responsible for nursing staff performance at the long-term care facility and providing leadership to the nursing, activities, social services and restorative teams. ■

In South Dakota, CUSP is a collaboration between the South Dakota Association of Healthcare Organizations and Johns Hopkins. CUSP is designed to change a unit’s workplace culture to bring about significant safety improvements by empowering staff to assume responsibility for safety. Nationwide, CUSP has been used to target patient falls, hospital-acquired infections and medication administration errors, to name a few. Avera McKennan CUSP projects in the Intensive Care Unit and the 3East Transplant/Oncology Unit have focused on preventing central-line associated bloodstream infections. At Avera McKennan, ICU and the Transplant/ Oncology Unit on 3East not only utilize the largest volume of central venous catheters, but also care for the most acutely ill and vulnerable patients. These units put several initiatives in place, for example,

Garner, CNP, Receives AANP State Award Jacqueline Garner, CNP, a nurse practitioner in

weekly dressing changes, regular RN assessment of central line sites, “scrubbing the hub,” and patient education and empowerment, to name a few.

Nephrology at Regional Medical Clinic – Aspen Centre

Since February 2011, the Avera McKennan ICU

in Rapid City, recently received the 2013 American Academy

has had zero central line infections. On 3East, there

of Nurse Practitioners (AANP) State Award for Excellence.

have been zero CLABSI since February 2012, and

The award is given annually to a dedicated nurse practitioner

several “zero” months before that date as well. The

in each state who demonstrates excellence in their area of

3East Transplant/Oncology Unit has seen a 94 per-

practice. Ms. Garner will be recognized for her achievement

cent reduction in central-line bloodstream infections

during the AANP 28th National Conference, which will take

over the past 18 months.

place in June 2013 in Las Vegas, Nev. ■

Hospital-wide, Avera McKennan is well below its goal of 1.57 CLABSI per month. In light of its

MED Quotes “Don't you know this, that words are doctors to a diseased temperament? ”   —Aeschylus


Midwest Medical Edition

success statewide, South Dakota’s CUSP CLABSI program was recognized by the Johns Hopkins University Armstrong Institute for Patient Safety and Quality. Avera McKennan staff are being asked to present nationally on CUSP results. Each year approximately 99,000 patients in the United States die due to hospital-acquired

Nurses Lead the Way in Flu Shots

Persinger Honored with RCRH DAISY Award

infections. The average cost to treat one CLABSI

Data from the Centers for Disease Con-

at Avera McKennan is estimated to be $64,000.

trol and Prevention indicates that the

Amy Persinger received the November

In addition to saving much difficulty for patients

nation’s nurses are leading the way

DAISY Award for Extraordinary Nurses

and families, Avera McKennan estimates a cost

among healthcare professionals when it comes to

at Rapid City Regional Hospital (RCRH).

savings of $1.4 million for the organization as a

getting their seasonal flu shots. An internet panel

Persinger is a Registered Nurse in the

result of infections prevented through CUSP.

survey found that, as of November 2012, nurses

Emergency Department and has worked at

“More important than cost savings is the

had a vaccination rate of 81.5 percent – 6 percent

the hospital for 19 years.

benefit we’re able to pass along to patients

higher than the immunization rate for nurses at

nominated for the award by a patient’s

Persinger was

and their families,” said Judy Blauwet, senior

the same time last year and 12 percent higher than

family. The nomination stated Persinger was

vice president of Hospital Operations and chief

the rate the year before.

able to calm the patient and their family

nursing officer at Avera McKennan. “We’re

The same survey found that healthcare pro-

during a stressful injury and made them feel

driven by the philosophy that it’s the right

fessionals had an overall immunization rate of

like their loved one was the only patient in

thing to do, and CUSP has given us a strong

62.9 percent. The American Nurses Association

the Emergency Department.

framework for implementing quality improve-

says the survey is an “encouraging sign that

The DAISY Award is a recognition program

ment initiatives. We’re proud of the ownership

nurses are heeding the call to be vaccinated to

in partnership with health care organizations,

our caregivers have taken in this project, and

protect themselves and those they care for”. The

now in seven countries, that celebrates the

hope to expand it to other units of the hos-

CDC’s national goal for immunization among

extraordinary skill and compassion nurses

pital,” Blauwet added. ■

healthcare professionals is 90 percent. ■

bring to patients and families every day. ■

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January / February 2013


Did You Know?

New Study Finds Eating Lean Beef Every Day as Part of a Heart-Healthy Diet Can Improve Cholesterol Levels Although many people may think

there’s little place in cholesterol-lowering diets for beef, surprising research suggests just the opposite. According to a clinical study, Beef in an Optimal Lean Diet (BOLD), published in the January 2012 edition of the American Journal of Clinical Nutrition, including 4.0 to 5.4 oz of lean beef daily in the gold standard heart-healthy diet (DASH – Dietary Approaches to Stop Hypertension) lowered participants’ LDL “bad” cholesterol by 10 percent. Researchers tested two levels of lean beef in heart-healthy diets: the BOLD diet, which included 4 ounces of lean beef every day, and the BOLD-PLUS diet, which contained 5.4 ounces of daily lean beef. Subjects


consuming both the BOLD and BOLD-PLUS diets experienced a 10% decrease in their LDL cholesterol levels from the start of the study. After 5 weeks, significant reductions in total cholesterol and LDL cholesterol were evident in the BOLD, BOLD-PLUS and DASH diets compared to a “Healthy” American control diet that contained an average of 0.7 oz (20 g) of beef per day. The improvements in heart health realized by the BOLD diets are similar to those found in the gold-standard DASH diet and other highly referenced heart-healthy diets. Previous nutrition studies have found evidence that lean beef can be as effective as lean chicken in a cholesterol-lowering diet, and the BOLD results strengthen the science

providing evidence that beef is also as good as plant protein-rich diets for heart health. These new insights about beef’s benefits in a heart-healthy diet, demonstrating that lean beef, in addition to being satisfying and great-tasting, can be part of a solution to building a heart-healthy diet. To access the study, go to: BOLDAJCN. To learn more about lean beef’s nutrition and heart-health benefits, please visit or Beef ■

Midwest Medical Edition

Grape Expectations

Wine and Romance By Heather Taylor Boysen


ebruary is a wonderful month

for wine. I never have a problem coming up with an occasion to open a bottle of wine myself, but there are two really great reasons for cracking open a bottle of wine in February including Valentine’s Day and Open That Bottle Night. Wine is all about passion, desire, romance, and beauty. The language of wine itself seems to be very suggestive. Wine can be soft, velvety and smooth or regal, bold and sophisticated with a long finish. How about lean and racy or lush and full-bodied? I think you get my point. Romance and wine go together! Perhaps thinking about what kind of mood you want to create on Valentine’s Day may also help you decide which wine you want to have on hand. Fun and flirty feels like a bottle of sparkling wine such as Gruet Demi Sec. Hot and heavy might be a luscious Cabernet Sauvignon such as Beau Vigne Romeo or Beau Vigne Juliet. Jarvis Estate Chardonnay is certainly smooth and sophisticated while Alexana Pinot Noir is deep and mysterious. As an old French proverb states “In water one sees one’s own face; but in wine one

January / February 2013

beholds the heart of another. Let Cupid’s arrow fly and if nothing else, fall in love with a great bottle of wine! If you are not one to celebrate Valentine’s Day then Open That Bottle Night (OTBN) is for you. It is celebrated the last Saturday in February and gives us all an excuse to open any bottle of wine we have without attaching an occasion to it. This special Saturday was invented in 2000 by Dorothy J. Gaiter and John Brecher, wine columnists for the Wall Street Journal. As they stated in their column, “Whether it’s the only bottle in the house or one bottle among thousands, just about all wine lovers have that very special wine that they always mean to open, but never do.” Since its inception, OTBN has become the world-wide celebration of friends, family and memories. Do you remember when you shared a really special moment in your life with the perfect bottle of wine? Are you saving a special bottle of wine for the perfect occasion but just haven’t figured out what that occasion might be? The wine doesn’t have to be expensive and it doesn’t have to be on a Top 100 list somewhere. It only has to remind you of an event whether it was a really great day, a job promotion, the birth of a child, the death of a loved one or a wine you had on your first date with your spouse. My favorite OTBN night happened to be with friends in Minneapolis almost 12 years ago. We were all in the Cities for a wine weekend and had dinner reservations on OTBN. I brought a 1979 Louis Martini Pinot Noir for the occasion. I had received this bottle as part of a wine trade I had done with a friend. The Pinot had been part of his Dad’s cellar. His Dad was a dear

“In water one sees one’s own face; but in wine one beholds the heart of another.” – French Proverb friend of our family and had given me some wonderful bottles of wine over the years. It was a way to remember him on that day. The wine shouldn’t have been good at all, but it was very good to everyone’s surprise! I was so thrilled about how my little bottle of wine had survived all those years that I wrote to the Wall Street Journal about my OTBN experience and they printed it! Not only did they print it but John Brecher actually called me to let me know that when he and his wife had first married, the Louis Martini Pinot Noir was one of their favorite wines. He also let me know that the going rate back then for my bottle of wine was around $6! So, on Valentine’s Day or Open That Bottle Night, open that bottle! Don’t let your special bottle of wine go untasted. ■


By Mark Graban

The Human Touch Engage Every Employee in Improvement and You Won’t Think Of Replacing Them with Robots


recent story in The Wall Street Journal promises (or threatens) that robots are taking over our hospitals, replacing minimum wage “blue collar” positions. The Journal paints a picture of robots rolling through hospital hallways, efficiently delivering medications and supplies without needing to take breaks or stopping to chat about their tournament brackets. Even if robots deliver their promised cost savings, there’s one critical thing even the smartest robots can’t do – generate and implement ideas for making the hospital better. There is a certain “gee whiz” factor with robotics and technology that often captivates the executives who control the purse strings. Some patients might be impressed and associate robotic supply delivery with a cutting-edge health system that delivers the best care. However, many patients will see robots as something that dehumanizes what can already be a scary, stressful place. Robots are an expensive upfront cost and they require ongoing spending for maintenance and reprogramming. In a hospital setting, a robotic “tugger” might be able to pull boxes to an inpatient unit’s supply room, but a human is still required to actually place individual boxes and linens onto shelves. The robots arguably automate a


relatively small piece of the delivery process. Companies that sell robots see healthcare as a new market opportunity, but hospital leaders need to first ask what problem is being solved with this technology. Is the hospital unable to fill relatively low-skilled positions? That seems unlikely, given high unemployment rates. Are there safety or ergonomic risks involved in rolling a cart of linens from central supply to inpatient units? Robots might reduce that risk of employee injury, but there might be other ways to address that problem, such as carts with better handles and wheels that roll more smoothly. In the video that accompanied the Journal story, the reporter commented that “the robots have highly sophisticated brains,” referring to the sensors that prevent them from running into people. But there are so many things that robots can’t do. Human workers actually have the more impressive brains, because all people, even those making the minimum wage, have the ability to make improvements in the workplace. A human delivering linens can offer a friendly smile to patients who are rehabilitating in the hallway. Humans can notice a visitor who looks lost, pointing them in the right direction and then initiating improvements to hospital signage that prevents others from getting lost in the future.

The “kaizen” improvement methodology is being used increasingly by hospitals around the world. Kaizen, which was brought from Japan to the West by author Masaaki Imai in his 1986 book of that same name, was originally portrayed as a system to be used by factory workers. The idea that everybody “from the janitor to the CEO” can make improvements (without the fear of layoffs) is one of the best ideas that hospitals can adopt from manufacturing. Traditional organizations (in manufacturing or healthcare) view employees as a cost to be reduced, while organizations that embrace kaizen realize that the brain of each employee is their greatest asset. One of the ways healthcare can address the crisis of high costs and poor quality is to ask all employees and clinicians to share and implement their ideas. Leaders then need to help provide a structured process and the right management support to allow changes to happen. The front-line staff members are in the best position to understand and solve many of the problems that hospitals face. ■ Mark Graban is a consultant, author, speaker, and blogger in the world of “lean” healthcare. He is the author of the book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement.

Midwest Medical Edition

Learning Opportunities January – April 2013 January 10 5:30 pm – 6:30 pm

Sanford PROMISE Community Lecture Series Finding the Cheese: Using Mouse Models to Identify Genetic Causes of Rare Pediatric Diseases Presenter: Lance Lee, PhD, Associate Scientist, Sanford Research/USD Location: Sanford Center, 2301 E. 60th Street North, Sioux Falls RSVP to or call 605-312-6590

January 26 Juvenile Diabetes Research Federation Walk for a Cure 2013 9:00 am Registration starts at 7:30 am Location: Sanford Center, 2301 E. 60th Street North, Sioux Falls February 14 The Sanford PROMISE Community Lecture Series - How the Internet Works 5:30 pm – 6:30 pm Presenter: Vernon Brown, Marketing and Community Relations Director, SDN Communications Location: Sanford Center, Sioux Falls RSVP to or call 605-312-6590. February 28 5:30 pm – 7:00 pm March 1 8:00 am – 5:00 pm

Third Annual Sanford Rare Disease Symposium Location: Sanford Center, Sioux Falls Registration:

March 2 Avera Nuclear Medicine Conference 8:00 am – 4:00 pm Location: Avera Education Center Information: Registration: March 8 8:00 am – 4:00 pm

Avera Neuroscience Institute Conference Location: Avera Education Center Information:, 322-8950 Registration:

April 17 7:30 am – 4:00 pm

21st Annual Trauma Symposium: Excellence in Trauma & Surgical Care Location: Sioux Falls Convention Center Information:, 322-8950 Registration:

MED reaches more than 5000 doctors and other healthcare professionals across our region 8 times a year. If you know of an upcoming class, seminar, webinar, or other educational event in the region in which these clinicians may want to participate, help us share it in MED. Send your submissions for the Learning Opportunities calendar to the editor at

Groundbreaking Technology The region’s first and only robotic catheterization system Sanford Heart announces robotic-assisted cardiac catheterization coming soon to Sanford Heart Hospital and Sanford Aberdeen Medical Center. Progressive and talented cardiologists install stents and balloons with skilled hands and robotic precision. Sanford Heart Hospital (605) 312-2200 Sanford Health Aberdeen Clinic (605) 725-1700

Your heart. Our hands. Connected.

500-54120-0133 12/12

MED-Midwest Medical Edition-January/February 2013  

Jan-Feb Issue