Minnesota Physician August 2014 by Minnesota Physician Publishing

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Social determinants of health Potential contributors to illness By Kate S. Erickson, MSW, and Christopher Reif, MD, MPH

ur health is determined by social, economic, and environmental risks or opportunities. One person works at a desk; another works in a factory, where exposure to chemicals and risk of physical injury are routine. One person doesn’t think much about money; another budgets carefully for his five-person family, but comes up short and goes into debt to pay the food and electricity bills every month. One person lives in an updated 1960s style house; another rents an apartment with pest problems in a dilapidated building that is next to a contaminated field. Imagine the health outcomes of these different people. For each patient, there are numerous health determinants to consider, any one of which can impact patients’ ability to hear, understand, act on, and maintain health improvements.

Medical scribes A new job description By Alan J. Bank, MD

lectronic medical records (EMRs) are now used in the majority of medical practices in Minnesota and across the United States. The use of EMRs offers a number of potential benefits to physicians including better remote access to patient records, more complete and readily obtainable information on

their patients, and the potential for improved quality of care. However, despite these real and/or potential advantages of EMRs, many physicians feel that EMRs worsen professional job satisfaction. Common sources of physician dissatisfaction Medical scribes to page 10

There are five generally recognized determinants of health (see the figure on page 15). Three of the five are considered social determinants of health (SDH): socioeconomic environment, physical environment, and health care (U.S. Department of Health and Human Services, “Healthy People 2020”). It is impossible Social determinants of health to page 14

Ahead of the Curve

A national leader in wean rates When you’re faced with a particularly difficult respiratory patient who needs specialized ventilation care, consider a national leader. Consider Bethesda Hospital and our Respiratory Care program, established nearly 35 years ago and one of the first of its kind in our region. Since the founding of our program, we’ve been ahead of the curve in treating ventilation patients, thanks in part to a dedication to high acute care nursing ratios and therapy staffing. As a result our ventilator weaning rates are among the best in the nation, with 83 percent of our vent patients were fully weaned in 2013..

When you need to move a patient on to the next step, it’s good to know you can turn to a leader in managing complex cases. Turn to Bethesda Hospital – a Long Term Acute Care Hospital (LTACH). For more information, visit bethesdahospital.org.

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August 2014 • Volume XXVIII, No. 5

Features Medical scribes A new job description

MINNESOTA HEALTH CARE ROUNDTABLE

By Alan J. Bank, MD

Social determinants of health 1 Potential contributors to illness By Kate S. Erickson, MSW, and Christopher Reif, MD, MPH

DEPARTMENTS CAPSULES 4 MEDICUS

INTERVIEW

Jill Strykowski, MS, RPh, BCPS Past President of the Minnesota Pharmacists Association

Hospice Care

oncology

42nd Session

Why aren’t Minnesotans using hospice care? By Barry Baines, MD, and Janelle Shearer, RN, BSN, MA

Testicular cancer By Liangping Weng, MD

Professional Update: PSYchiatry A new approach to anxiety and panic By Mike Niehans, MD

Special focus: research The promise of regenerative medicine By Rep. Erin Murphy, RN, MA

2014 Physician research recognition By Janet Cass

Background and focus: As tools and techniques for treating chronic illness have expanded, so have methods and mechanisms of provider reimbursement. More people now have access to care, and with this comes a heightened awareness of the impact of social determinants on health. The transition to rewarding physicians for maintaining a healthier population is slow but the promise is clear. Treating chronic illness remains an area of high-volume use and, improperly managed, quickly becomes an area of high cost. Objectives: We will evaluate changes that health care reform is bringing to chronic illness care. We will examine new community-based partnerships that are forming to address prevention, compliance, and better identification of risk. We will look at specific diseases and how workplace solutions, insurance companies, clinics, hospitals, long-term care facilities, and home care providers are working together to lower costs and improve outcomes. Please send me ____ tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, Inc., 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone 612.728.8600 or fax 612.728.8601.

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email mpp@ mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

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Minneapolis Primary Care Costs Are Fourth-Highest An analysis conducted by San Francisco-based Castlight Health found that Minneapolis is the fourth-most expensive city in the U.S. for preventive primary care visits. The health-care cost-comparison company researched data from patients in the 30 most populous U.S. cities who have health insurance through their employers. The study focused on this group because almost 48 percent of Americans, or 149 million people, fall into this group. Costs were analyzed for four common outpatient services: a lipid panel, CT scan of the head/brain, MRI of the lower back, and an adult preventive primary care visit. Prices were defined as employee cost-sharing plus the amount paid by the employer. The average cost for a

primary care visit in Minneapolis is $209, with an individual cost ranging from $89 to $303. The three cities that are more expensive than Minneapolis in this category are San Francisco and Sacramento, Calif., and Portland, Ore., with average costs of $251, $219, and $216, respectively.

an ‘in-network’ doctor from their company’s health plan they are assured of paying less, or think that health care prices vary across the country but not in their backyard. This analysis dispels both those myths.”

DHS Begins New Background Checks For Care Workers

Minneapolis did significantly better in other categories. It ranked as the 21st-most expensive state for MRIs of the lower back, with an average cost of $1,243 and an individual cost ranging from $645 to $2,726, and 22nd-most expensive for head/brain CT scans, with an average cost of $702 and an individual cost ranging from $326 to $1,519.

On July 28, the Minnesota Department of Human Services (DHS) began a pilot for a new criminal background check system for new employees who provide care for children, individuals with disabilities, and the elderly.

“Understanding health care costs is a first step in enabling employers to fix what is broken in enterprise health care,” said Jennifer Schneider, MD, Castlight Health’s vice president of strategic analytics. “Many Americans believe if they select

“The new process means we can more thoroughly and accurately evaluate the criminal history of people who take care of our most vulnerable Minnesotans, while at the same time making the system easier for employers and workers,” said

Minnesota Physician August 2014

Human Services Commissioner Lucinda Jesson. New legislation passed this year requires DHS to compile fingerprints and photographs for each employee. It must also update software to increase accuracy and thoroughness of the background checks, as well as implement data privacy protections for fingerprint and photograph databases. The pilot is designed to help DHS transition to a new statewide system for using fingerprints to obtain state criminal information and photos for identity verification. Initially, five nursing facilities will participate in the new system: Park River Estates Care Center, Coon Rapids; Eldercare–Fitzgerald Rehabilitation, Eveleth; Eldercare of Minnesota–Little Falls; Good Shepherd Lutheran Home, Sauk Rapids; and Benedictine Health Systems–Cerenity Senior Care, White Bear Lake. Employees will no longer be required to undergo background checks when

changing jobs, and employers will be able to access this information more quickly. DHS will receive automated updates for criminal information from the Minnesota Court Information System, ensuring the records stay current. More providers will join the pilot this fall. Officials expect the new system to be implemented statewide in 2015.

Brain Injury Drug to Be Tested at Regions Regions Hospital is taking part in a national study to determine whether tranexamic acid (TXA) can lessen the damage caused by traumatic brain injury by reducing intracranial bleeding. TXA is FDA-approved and has already been used by the Department of Defense to treat combat injuries. “Over the past 30 years there have been few advancements in the treatment of traumatic brain injuries,” said R. J. Frascone, MD, medical director of Regions Hospital Emergency Medical Services department. “Smaller trials have suggested that TXA may provide these patients with better outcomes, and we hope that this larger study will help advance the treatment of these injuries.” The study will compare outcomes of almost 1,000 patients in the U.S., including 60 patients locally, between September 2014 and December 2015. Several Minnesota emergency medical service (EMS) providers are partnering with Regions for the study, as they are often the first to respond to trauma incidents. “Right now, the only way to stop bleeding in the brain is to take the patient in the operating room, remove part of the skull, and clamp the bleeder,” said Aaron Burnett, MD, assistant medical director at Regions Hospital EMS. “We’re hoping this medication will give our paramedics a chance to stop that bleeding without even having to go to the operating room.”

Because it is likely that potential patients will be unconscious due to the traumatic brain injury, they will be unable to give consent to participate in the study. HealthPartners’ Institutional Review Board has therefore made an exception to the consent requirement. In order to opt out of potentially being a patient in the study, people must contact Regions Hospital’s Critical Care Research Center to request an opt-out bracelet that they will wear in order to not receive TXA in the case of a traumatic brain injury.

State Health Care Spending Rate Reported Minnesota’s health care spending rose by 4 percent to $39.8 billion from 2011 to 2012, according to a report released by the Minnesota Department of Health (MDH). It is the third-lowest rate of increase since the state began tracking this information in the mid1990s. “By historic standards, Minnesota saw low growth in health care spending in 2012,” said Ed Ehlinger, MD, Minnesota commissioner of health. “However, projections of future spending highlight that we must continue to focus on disease prevention and creating health communities if we are going to ensure sustainability of health care costs over the long term.” Minnesota’s increased spending rate in 2012 was about the same as the national rate of almost 4 percent. However, its per-person spending was $7,403, compared to the national per person cost of $8,389. In addition, Minnesota’s health care spending made up a smaller portion of the economy, 13.5 percent, compared to 16.2 percent nationally. MDH cited several reasons for the slowed rate of increased spending, including a waning recession; continued shifting of costs to consumers; slower deCapsules to page 6

Conference in Pediatric Orthopedics 1.0 Free CME Credit

Pediatric Rehabilitation Pain Management

Presented by Tracy Harrison, MD, Mayo Clinic This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Minnesota Medical Association and Shriners Hospitals for Children – Twin Cities. The Minnesota Medical Association (MMA) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. AMA PRA Category 1 Credit Statement The Minnesota Medical Association designated this conference for a maximum of 1 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

September 25, 2014 7:30 – 8:30 am Location: Shriners Hospitals for Children – Twin Cities 2025 East River Parkway Minneapolis, MN 55414 Please RSVP to Sue Johnson at sjohnson@shrinenet.org or 612.596.6160. August 2014 Minnesota Physician

Capsules from page 5

velopment and implementation of new medical technologies; implementation of consumer protections; and initiatives aimed at improving care coordination. “It’s yet to be seen whether Minnesota will return to near double-digit rates of growth after the lagged effects of the recession have worn off,” said Stefan Gildemeister, MA, health economist with MDH. “What we are learning from Minnesota’s lower-than-national per-person spending suggests our role as a leader in delivering efficient health care services remains intact.” The report contains estimated projections of future health care spending in Minnesota, to include the impact of the Affordable Care Act and other state health reforms. MDH predicts that health care spending will reach $76.4 billion by 2022, accounting for an average yearly growth of 6.7 percent.

New Cancer Care Payment Model Reduces Costs

months. Oncologists were paid the same fee no matter which drugs were administered to the patient, while patient visits were reimbursed as usual.

UnitedHealthcare has released the results of a study demonstrating that a new cancer care payment model that rewards physicians based on best treatment practices and health outcomes, instead of the quantity of drugs prescribed, significantly reduced costs without affecting quality of care.

The study looked at 810 patients with breast, colon, or lung cancer, between October 2009 and December 2012 and used 60 quality and cost measures to compare performance between the pilot group and the control group. Researchers found that the new payment model resulted in a 34 percent decline in medical costs, or $33.36 million in savings. Although costs were reduced overall, there was a $13.46 million increase in chemotherapy medication costs.

Researchers conducted a three-year pilot project with five medical oncology groups across the U.S. Under the pilot, medical oncologists were reimbursed for a full cancer treatment program up-front, moving away from the fee-forservice model. The new “episode payment” model is based on expected standard treatment costs for the patient’s condition, predetermined by a doctor for a standard treatment period, which is usually six to 12

“The study, evaluating how physicians might be rewarded for improving clinical outcomes and reducing treatment costs rather than paying them based on the number of drugs administered to treat cancer, demonstrated a significant reduction in total costs for medical care without affecting the quality of

care,” said Lee Newcomer, MD, senior vice president of oncology at UnitedHealthcare and an author of the article reporting the results (Journal of Oncology Practice, July 8, 2014). The study was developed in response to an alarming rise in costs for cancer therapy. The National Cancer Institute estimates cancer care costs at $124.6 billion nationally in 2010; they are projected to reach $207 billion by 2020. “The episode payment project yielded significant savings for the treatment of cancer patients without any measurable effect on the health outcomes for patients,” said Bruce Gould, MD, medical director at Northwest Georgia Oncology Centers and co-author of the article. “The health care community needs to embrace new approaches to payment if we want to ensure the sustainability of our health care system for future generations.”

Many Faces oF coMMunity HealtH

2014 ConferenCe

community centered care and the People We serve Thursday, October 23 - Friday, October 24, 2014 • Marriott Minneapolis Southwest - Minnetonka, MN Join us for a two-day conference on improving care and reducing health disparities in underserved populations and among those living in poverty. We will examine new community care innovations and health care delivery models that promote health equity, prevent and manage chronic diseases, and assure access for those facing significant health disparities.

sPeakers include:

keynote: Jon Hallberg, Md Hippocrates cafe, edward ehlinger, Md, Phd, commissioner of Health, MdH nancy Garrett, Hennepin county Medical center lensa idossa, national Marrow donor Program dan Hawkins, senior Vice President for Public Policy and research, national association of community Health centers

For a complete list of speakers and times visit the conference web site

WWW.ManyFacesconFerence.orG For more information please call: 952-252-3573

Minnesota Physician August 2014

Medicus Fatima Alnaimat, MD, board-certified in internal medicine, has joined the rheumatology department at Essentia Health–Duluth Clinic. She graduated from the University of Jordan, Amman, and completed an internal medicine residency and a rheumatology fellowship at the University of Arizona, Tucson. Also joining Essentia is Ahmad Hazem, MD, a hospitalist at Essentia Health–St. Fatima Alnaimat, Mary’s Medical Center, DuluMD th. Board-eligible in internal medicine, he graduated from the University of Tishreen College of Medicine in Latakia, Syria; completed an internal medicine residency at the University of North Dakota School of Medicine, Ahmad Hazem, Fargo; and completed a preventive medicine MD research fellowship at Mayo Clinic. Susan A. Berry, MD, board-certified in medical genetics and pediatrics, has been named president of the state chapter of the American Academy of Pediatrics. Berry, division director for genetics and metabolism in the University of Minnesota Department of Pediatrics, graduated from the University of Kansas School of Medicine, Lawrence, and completed a pediatrics residency and a fellowship in medical genetics at the University of Minnesota. Vinay Gupta, MD, has joined Minnesota Oncology. Board-certified in hematology/oncology, Gupta graduated from the Mahatma Gandhi Medical College, University of Indore, India. He completed an internal medicine residency at Loma Linda University, Calif., and an oncology/ hematology fellowship at Mayo Clinic. Richard L. Lindstrom, MD, founder of and attending surgeon at Bloomington-based Vinay Gupta, MD Minnesota Eye Consultants, has been named fourth-most influential person in ophthalmology, internationally, and the first in the United States by industry publication, The Ophthalmologist, which cited Lindstrom’s leadership in corneal, cataract, refractive, and laser surgery.

When you need it.

Eleanor Orehek, MD, board-certified in neurology, has joined the Noran Neurological Clinic. Orehek graduated from the University of Minnesota Medical School, served a neurology residency at Boston University Medical Center, and completed a movement disorders fellowship at the University of Minnesota. Megan Shaughnessy, MD, has joined Hennepin County Medical Center’s infectious diseases department. Board-certified in internal medicine Eleanor Orehek, and pediatrics, she completed medical school at MD the University of Minnesota; an internal medicine and pediatrics residency at the University of Michigan, Ann Arbor; and a fellowship in infectious diseases at the University of Minnesota. Paul W. Sperduto, MD, MPP, board-certified in radiation oncology and co-director of the Gamma Knife Center at the University of Minnesota and director of radiation oncology at Ridgeview Medical Center in Waconia, has been named a Fellow of The American Society for Radiation Oncology. He graduated from Duke University School of Medicine, Durham, N.C., and served a residency in radiation oncology at the National Cancer Institute, National Institutes of Health, in Bethesda, Md.

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August 2014 Minnesota Physician

Interview

The changing face of pharmacy

Jill Strykowski, MS, RPh, BCPS Past president of the Minnesota Pharmacists Association Jill Strykowski, MS, RPh, BCPS, is director of pharmacy at Mercy and Unity Hospitals, part of Allina Health. She recently completed her term as president of the Minnesota Pharmacists Association.

 What are the most important things the Minoffered on pharmacy ownership, clinical and operanesota Pharmacists Association (MPhA) protional topics, and updates for pharmacists and technivides for its members? cians on drug diversion mitigation tactics. The issues MPhA is actively engaged in many initiatives to are contemporary for our membership and often in support the advancement of pharmacy practice for response to national or statewide events. Minnesota pharmacists. A current goal is to take advantage of, and expand, opportunities for pharmaT ell us about the MPhA’s work with the Pharcists and providers under the Medicaid program, and macy Practice Act Joint Task Force (PPAJTF). with other private payers, to receive compensation for The PPAJTF was formed during the 2014 legislative provision of patient care. MPhA works collaboratively session to draft and achieve legislative success in with partners on this goal including national legisladefining collaborative practice for Minnesota pharmative stakeholders, local pharmacy associations, and cists. Pharmacists can now practice with a group of interdisciplinary groups. On a national level, work providers under one collaborative practice agreement; is under way to partner with CMS for recognition of this logistical change has payment for pharmacist removed a bureaucratic imcognitive services. On a to providing medWe encourage physicians to get pediment statewide basis, MPhA is ication management. The actively engaged in several definition of collaborative to know the pharmacists that key strategies to back this practice was also expanded they work closely with. effort. beyond protocol; protocols A key tactic for MPhA has been to provide support for preparing Minnesota pharmacists to practice medication therapy management (MTM). Minnesota is a leader in design and concept of MTM through the University of Minnesota College of Pharmacy, and MPhA has been a key partner in this effort. MTM is broadly defined as a group of pharmacist-provided services that seek to optimize medication therapy outcomes. The services may include medication regimen reviews, anticoagulation management, immunizations, and or health and wellness coaching. MPhA is an association leader in providing MTM certificate programs for Minnesota pharmacists. Although newer graduates are already “MTM-ready,” many experienced pharmacists have benefited from the certificate program. MPhA also provides additional statewide structure for MTM through marketing strategies, outcomes-based research support, and payor relationships. Our tactic to advance pharmacy practice comes from MPhA’s long-standing strength as an organizational leader in government affairs. The MPhA Public Policy Committee proactively manages a variety of Minnesota pharmacy legislative issues through advocacy and member communications. MPhA partners on legislative activity with many groups: the Minnesota Board of Pharmacy, the University of Minnesota College of Pharmacy, nursing and physician groups, and other pharmacy associations. MPhA provides a broad array of educational offerings for pharmacists and pharmacy technicians in support of professional development. MPhA strives to leverage technology to reach out to members as well as offer “live” educational programs throughout the state. In response to member feedback, programs are

Minnesota Physician August 2014

generally are algorithmic and leave little room for sound clinical judgment. With a new, broader definition, the collaborative practice expands beyond a formulaic approach to a focus on optimizing medication outcomes. Executive leadership for both formation of the alliance and success of the 2014 legislation was largely under the direction of Liz Cinqueonce, MPhA executive vice president. The PPAJTF continues to prepare for future practice act changes in 2015. A monthly meeting of all stakeholders is held to develop strategies for the promotion of expanded legislation for immunization authority and investigating the scope of competent trained pharmacy technicians. Technicians are now legislated to practice in a given ratio with pharmacists; the role of both professions has changed and therefore an analysis of these changes will be done. MPhA is proud of this collaboration and ongoing legislative activity on behalf of MN pharmacists!  Please talk about the Pharmacy-Based Immunization Delivery Certificate Training Program. Pharmacists throughout the state are eligible to provide immunizations; current legislation does have restrictions on age and this is one of the key items for the PPAJTF to tackle in 2015. As of 2014, pharmacists can administer influenza vaccines to patients 10 years of age and older, and all other vaccines to patients 18 years of age and older when there is a written protocol with a physician or advanced practice nurse. With the ease of access to pharmacies for patients, the PPAJTF is proposing a loosening of the age restrictions for the benefit of public health. While this legislation is being developed with partners, experienced pharmacists with direct patient care

practice are eligible for certificate programs. The American Pharmacists Association (APhA) and the University of Minnesota College of Pharmacy both offer certification in immunizations. Topics in certification preparation include: vaccine basics, storage, handling, documentation and record keeping, and liability issues. MPhA recognizes the key role that pharmacists play in promoting immunizations as a public policy initiative. Pharmacists can prepare for this important role through several certificate programs that MPhA endorses.  Explain the appropriate utilization of Dispense as Written (DAW). When a provider writes a prescription for a brand-name drug, the pharmacist is allowed to substitute a generic drug in place of the branded product. If the provider marks “Dispense as Written” or “DAW” on the prescription, the pharmacist may not substitute the drug and the additional cost may be passed on to the patient in the form of a higher copay or cash price. The use of DAW has been shown to increase overall health care costs as patients are less likely to fill prescriptions that have a higher cost and adherence decreases. There may be very valid reasons for a DAW medication; these include clinical response, allergy or other reaction to a component of a generic product, or patient preference.

T ell us about the MPhA’s involvement with the Reducing Avoidable Readmissions Effectively (RARE) campaign. MPhA has endorsed RARE as a community partner. As a partner, participation in the campaign is promoted to members in an effort to reduce avoidable hospital readmissions. Partners agree to list their name publically in support of the campaign and provide input and support to the strategies that the campaign supports. Minnesota has exceeded goals for reducing avoidable hospital readmissions and the RARE campaign recently sent a letter of recognition to MPhA thanking the association for its support. At the end of 2013, Minnesota prevented 7,975 readmissions and MPhA is proud to have supported the work as a community partner. P lease update us on MPhA’s involvement with the Minnesota Prescription Monitoring Program (PMP). The MPhA has representatives on the Prescription Monitoring Program Advisory Committee, and works very closely with the Minnesota Board of Pharmacy on a regular basis. We were very pleased with the legislation passed in 2014 to enhance the Prescription Monitoring Program. It ensures that prescriber information is listed in the PMP to facilitate better communication between pharmacists and providers and allows pharmacists, with appropriate consent, to access the PMP for patient-care purposes.

H ow do pharmacists keep up with clinical updates on adverse medication interactions? Adverse medication reactions can occur either from one medication or when several medications interact. Pharmacists have a variety of ways to keep up to date on adverse medication reactions, which is, in part, dependent on practice setting. Pharmacy associations are very engaged in informing pharmacists of key interactions, in particular those that are in the lay press. Most pharmacists also have access to electronic databases either on their computer, iPhone, or tablet. Finally, at the point of prescription adjudication, databases will alert the pharmacist of interactions on a patient’s profile. Pharmacists encourage the support of one pharmacy provider to ensure that all medications are up to date and patient harm does not result from a missed drug interaction. W hat is the most important thing that physicians should know about pharmacists? We encourage physicians to get to know the pharmacists that they work closely with. Pharmacists embrace physician partnerships in caring for patients. We look forward to working together on advocacy efforts to collaborate on changing models of care so that we can practice at the top of both of our scopes. Pharmacists are a knowledgeable advocate and partner in the safe and effective medication management of patients!

University of Minnesota - Continuing Professional Development (formerly the Office of CME) Education is essential to achieving and sustaining quality healthcare. Through partnership with healthcare leaders, our educational activities provide quality improvement and patient care initiatives.

2014 CPD Activities

(All courses in the Twin Cities unless noted)

LIVE COURSES NPHTI Pediatric Clinical Hypnosis September 11-13, 2014 Care Across the Continuum: A Trauma and Critical Care Conference September 12, 2014 Psychiatry Review: Evolving Frontiers in Psychiatric Care September 29-30, 2014 Twin Cities Sports Medicine October 3-4, 2014 Practical Dermatology (Duluth, MN) October 17-18, 2014 Lillehei Symposium: Cardiovascular Care for Primary Care Practitioners October 23-24, 2014

Maintenance of Certification in Anesthesiology (MOCA) Training October 25, 2014 Got Your Shots Immunization Conference (St. Cloud, MN) October 27-28, 2014 Internal Medicine Review November 12-14, 2014 Emerging Infections November 21, 2014

www.cmecourses.umn.edu ONLINE COURSES (CME credit available) www.cme.umn.edu/online • Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health - Family Medicine Specialty - Global Pediatric Education Series • Adolescent Vaccination - COMING SOON! For a full activity listing, go to www.cmecourses.umn.edu

Geriatric Orthopaedic Fracture Conference December 5-6, 2014 Office of Continuing Professional Development 612-626-7600 or 1-800-776-8636 • email: cme@umn.edu

Promoting a lifetime of outstanding professional practice

August 2014 Minnesota Physician

Medical scribes from cover

with EMRs include wasted time performing data entry and other electronic tasks, inefficiency, difficulty exchanging information, worsening of clinical documentation, cost, poor design/user-friendliness, and disruption of direct face-to-face interaction with the patient. In most cases, EMRs do reduce physician productivity. One approach to address these and other problems of health care delivery in the EMR era is the use of medical scribes. Medical scribes are trained assistants who perform multiple tasks under physician supervision including: reviewing patient medical records; writing preliminary notes that summarize previous clinic visits and hospitalizations; finding and copying relevant test results; documenting physical examination

findings and treatment recommendations; typing patient instructions; entering billing codes; and scheduling future visits. Scribes are frequently college graduates planning to work in the medical profession

I began investigating the possible use of scribes in my cardiology clinic (United Heart and Vascular Clinic, Allina Health) over three years ago. I was unhappy with my outpa-

arm. Patients seen increased by 59 percent from 2.2 to 3.5 per hour and work relative value units (wRVU) generated increased by 57 percent from 3.5 to 5.5 per hour. Patient satisfaction was high and

Medical scribes are trained assistants who perform multiple tasks under physician supervision.

in the future. It is estimated that there are about 10,000 scribes currently working in the United States. The majority of scribes work in emergency rooms. However, scribes are being used in a small number of medical and surgical outpa-

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Minnesota Physician August 2014

tient clinical practice due to the inefficiencies of care (wasted time), disruptions in faceto-face interactions with my patients, and increased paperwork required when our clinic switched to an EMR. I spoke with some of my emergency room colleagues and they told me how the use of scribes had improved patient flow, clinical documentation, physician satisfaction, and financial performance. Studying the use of medical scribes We set up and published the first prospective, controlled research study assessing the value of medical scribes in a clinical setting (Bank A.J. et al., ClinicoEconomics and Outcomes Research 2013;5:399406). In this study, the same four physicians saw patients in a clinic for 65 hours with a scribe and for 65 hours without a scribe (standard care). Our standard practice is to see follow-up patients every 20 minutes and new patients every 40 minutes (with one open 20 minute slot every four hours to allow for physicians to “catchup” with their computerized documentation). For scribe visits we scheduled follow-up patients every 15 minutes and new patients every 30 minutes. A total of 81 additional patients were seen in the same 65 hours in the scribe arm of the study as compared to the control

similar under both conditions. Physician-patient interaction, as assessed by an experienced observer in the room, was significantly improved using scribes. Time spent in direct face-to-face interaction with the patient increased despite reduced overall time in the examination room. Direct and downstream revenue (generated to the health care system in the two months following each visit) increased markedly as a result of the increased productivity of the physicians. Since this study was completed, we now have 10 of 24 physicians using scribes routinely in our clinic. I am convinced that the use of scribes offers many advantages. Advantages to using scribes Physician productivity Productivity is defined as work performed per unit time. Physicians are constantly encouraged to be more productive, yet they are rarely given the tools or resources to accomplish this goal. One approach to improve productivity is to develop a system where physicians “only do, what only they can do.” So, any tasks that can be performed by a non-physician are delegated. In our study, we found that using scribes allowed each physician to see approximately one additional patient per hour.

Clinic workflow We have not quantified the effect of using scribes on our clinic workflow. However, the medical assistants who room our patients have commented on several occasions that patients are moving through the clinic faster. In addition, several physicians who were typically 30 to 45 minutes behind their schedule are now seeing patients much closer to their scheduled time. Patients also have mentioned this improvement. Physician job satisfaction A recent publication by Shanafelt et al., in the Archives of Internal Medicine (2012) described a national survey of over 7,000 physicians. Just under half of the physicians in the survey reported at least one symptom of burnout. This rate was higher than that of other U.S. workers. Causes for physician burnout can include loss of autonomy, excessive

workload, inefficiency due to excessive administrative tasks, decline in job satisfaction, and problems with work-life balance. The use of scribes is one approach to improve physician job satisfaction and reduce burnout as it addresses some of these causes. The impact on physician satisfaction in our clinic has been dramatic since we started using scribes. Four physicians who were routinely staying after clinic for an additional three to four hours to complete paperwork are now finishing their work on time despite seeing about 10 percent more patients per hour than their colleagues who are not using scribes. I have been using scribes the longest, and am

important issues affecting my patients. I talk to patients in more detail and concentrate on making complex medical decisions. Clearly, studies are needed to try and quantify this effect.

Get doctors back to what they do best: Taking care of patients. now seeing approximately 30 percent more patients per hour and my enjoyment of clinic has increased markedly. Quality of care There are no studies assessing quality of care changes through using scribes. However, the quality of care I provide for my patients has improved for the simple reason that I have more time to focus on the

Patient access to care Access to care is a critically important issue for patients. Many clinics have significant patient wait times. Any change that results in improved physician productivity will necessarily improve patient access to care. With predictions of a future shortage of physicians, the use of scribes and many other strategies to improve access to care will need to be implemented.

Medical scribes to page 36

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August 2014 Minnesota Physician

HOSPICE CARE

he number of patients and families served by hospice nationally has steadily increased during the last several years. In 2008, more than 1.2 million Americans received hospice care. By 2012, that number increased to more than 1.5 million. That’s good news. Hospice care offers relief from pain and symptoms, along with specialized services for emotional and psychosocial issues associated with dying. Hospice caregivers ensure that patients have medications, medical supplies, and special equipment so that patients and their families have peace of mind during the time that a patient has left. Hospice also saves money. Hospice patients have lower rates of hospital and intensive care use, and fewer hospital readmissions. Interdisciplinary care in hospice helps to anticipate and head off problems that can lead to hospitalization.

Why aren’t Minnesotans using hospice care? A look at the reasons By Barry Baines, MD, and Janelle Shearer, RN, BSN, MA

Low hospice use in state Minnesotans don’t use hospice services as much as residents in other states. And when they

start of hospice services. In 2012, the National Hospice and Palliative Care Or-

Physicians tend to overestimate prognosis on average by 500 percent. do receive hospice care, many die within seven days of the

ganization reported that 73.5 percent of families rated hospice care as “excellent” for their loved ones. When the survey asked how well hospice services met the needs of the bereavement client, families responded “very well” 75.8 percent of the time. Health care professionals often hear the same comment about hospice from surviving family members: “We wish we would have used hospice care sooner.” With a service that is covered by Medicare and highly valued by families, why isn’t hospice used more often in Minnesota? Stratis Health recently embarked on a one-year special innovation project funded by the Centers for Medicare & Medicaid Services’ Quality Improvement Program to increase the use of hospice services in Minnesota. Called Targeting Resource Use Effectively (TRUE), this project sets out to help eligible patients get into hospice care sooner, and to increase hospice referrals and hospice use in Minnesota by identifying barriers to access.

Alexandria, Mora, and Waconia were chosen to participate in the project because Minnesota Physician August 2014

they had lower hospice-use rates as compared to other Minnesota cities, and they appeared to have opportunities to optimize the use of hospice. To identify hospice access barriers in these three communities, the project included conversations with laypersons, as well as patients and their families who were currently in hospice or had used hospice in the past. Meetings were also held with area physicians, and representatives from hospitals, clinics, and senior care facilities. Barriers to hospice access Across all three communities, patients and their families were nearly all in agreement that if they knew they had a life-limiting illness, they’d want to know about hospice. Yet, when Stratis Health interviewed health care providers, including physicians, they found that the biggest barrier to receiving hospice care for their patients was the fact that “patients are in denial about their illness” and that “they don’t accept that they have a serious illness.” This brings up even more questions. Are patients in denial or is it possible that patients and families don’t fully understand the nature of their serious illness? Do people not know enough to ask about hospice as an option? Is this a missed opportunity to discuss and educate people about hospice? Approximately 10 percent of deaths are unpredictable, e.g., those caused by accidents, such as a massive heart attack or a stroke. This means that 90 percent of deaths are predictable. For instance, we know that advanced cancer can’t be cured. However, research at Dana Farber Cancer Institute revealed that 70 percent of advanced lung cancer patients and 81 percent of advanced colon cancer patients believed the chemotherapy they were receiving would cure them. Congestive heart failure’s six-year survival rate is only 15 percent. A recent study reported that 60 percent of patients with heart failure did not understand that their illnesses were life limiting.

Previous research, along with anecdotal conversations, show that when physicians were asked if they were willing to talk to their patients about end-of-life care issues, the response was, “Yes, if the patient brings it up first.” As you might have guessed, when patients were asked if they were willing to talk about end-of-life care, they said, “Yes, if my physician broaches the subject first.”

discussions. This is especially true if physicians know that patients are going to question them about the seriousness of their illness and hospice as an option. Individuals who work in hospice or make referrals to hospice were asked to reach out to the lay community with brochures containing questions to ask physicians. Suggested questions included:

• What kind of care is available that focuses on making me comfortable? • I f my illness keeps getting worse, when is it a good time to think about getting supportive and comfort-focused care? • Will you be the one to tell me when to contact hospice?

If Minnesota physicians increased appropriate hospice referrals … they could achieve an incremental savings of more than $16 million.

Expand hospice use TRUE’s findings so far, point to several ways to increase the use of hospice. The recommendations that follow include actions for patients as well as for physicians since each have a part to play in assessing the need for hospice.

• Do I have a serious or life-limiting illness? • Can my illness be cured? • I f my illness can’t be cured, are there treatments that can slow down my illness?

Give patients questions to ask their physicians Each of the three participating communities agreed that giving patients questions to ask their physicians would be helpful in initiating hospice

• Will you stay involved with my care even when I am no longer looking for treatment for my disease? The brochures with these questions were placed in popular local gathering places: churches, restaurants, libraries, senior centers, clinics, and others. Opening the door to

hospice may start with questions from patients to their physicians. Give physicians the resources to begin the discussion about hospice Physicians don’t learn about end-of-life conversations in medical school or residency training. They need resources that help them start the hospice discussion. While physicians know the difference between curative treatments, remissive treatments (treatment that slows down the disease process), and palliative treatments (relieving symptoms, suffering, and improving quality of life) their patients often do not. New materials created for physicians’ offices give physicians easy-to-understand information so they can provide definitions, along with explanations to their patients. These Why aren’t Minnesotans using hospice care? to page 38

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August 2014 Minnesota Physician

Social determinants of health from cover

For more information on social determinants of health: • Visit Community–University Health Care Center: www.ahc.umn.edu/cuhcc/ • Read the Minnesota Department of Health Report, Advancing Health Equity: www.health.state.mn.us/divs/chs/healthequity/ahe_leg_report_020414.pdf • Read the World Health Organization Report, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health: www.who.int/social_determinants/thecommission/finalreport/en/

to include all of the factors that impact health in each of the categories. Moreover, factors can intersect with one another. A neighborhood impacts food choices. Social class impacts access to health care. Culture impacts gender identity. Researchers may never fully understand the precise contributions of each determinant of health. The negative or positive impact of social determinants of health can accumulate over a lifetime, alter a person’s life course, and be passed down to future generations. According to the World Health Organization, about 75 percent of health inequalities could be considered unfair and potentially avoid-

able, and as a result are labeled health inequities because they are avoidable, unfair, or unjust. The inequities are astounding Delving more deeply into any social determinant of health such as workplace safety, air quality, nutrition, education, neighborhood, or early childhood development there are staggering differences in each factor. • Where we live: Housing instability causes family distress in many ways. In a 2014 Harvard Magazine article entitled “Disrupted Lives,” it was reported that one in eight moves is a result of evic-

Minnesota Bridges to Excellence Recognizes Clinics for Delivering Optimal Care and Improved Patient Outcomes The Minnesota Health Action Group and the Champions of Change, the public and private sector purchasers who fund the recognition rewards, congratulate the 316 clinics across the state that qualified for rewards in 2014 for achieving or improving specific health outcomes for patients with diabetes, vascular disease, and depression. We extend our heartfelt thanks to the dedicated clinicians of the rewarded clinics for their commitment to excellence and continuous improvement. The Champions of Change are united in using common performance standards that support high-quality care and contribute to improving the health of all Minnesotans. A complete list of rewarded clinics can be found at our website – mnhealthactiongroup.org, along with the names of the Champions of Change.

Minnesota Physician August 2014

tion or involuntary displacement. Involuntary displacement is when landlords force tenants to move out by using aggressive tactics such as turning off utilities or removing doors. • What we eat: The actual cost of food in urban areas is 15 percent higher in supermarkets, 26 percent higher in medium-sized stores, and 38 percent higher in small stores than the market-basket-price (MBP). Folks with limited transportation use the corner store, paying an extra $2 for every $5 spent. The 1992 Morris study, “Food Security in America,” found that food in low-income communities is (1) inferior in quality, and, at times, inedible; (2) limited in quantity and variety, and; (3) most expensive in areas with the highest poverty concentration. • The words we speak: By first grade, children raised in middle-income households will have double the vocabulary compared to children raised in low-in-

nities of color are exposed to disproportionate amounts of diesel emissions, which causes health complications such as asthma exacerbation. The Sierra Club reports that children who live within 750 feet of a freeway are six times more likely to develop lung cancer. These inequities only compound over a person’s lifetime. The average life expectancy in the U.S. is now 77 years, according to the U.S. Census Bureau statistics. In her 2013 book, “How We Die Now,” Erickson discusses that, in the U.S., if you’re a white woman, your average lifespan is 81; if you’re a black man, your average lifespan is 72. Racial inequities take away almost a decade of life. People with serious and persistent mental illness live to be, on average, 52 years old according to the 2014 statistics from the Minnesota Department of Health.

In health care there has been a legacy of disrespect, and medically sanctioned racism, including atrocities such as the Tuskegee experiments and forced sterilization. Today, structural racism is cited as the Racial inequities take away main source of health inequities almost a decade of life. according to the Minnesota Department of Health report in March 2014. Struccome households, according to the U.S. Department tural racism is when decisions are made on a system-wide of Health and Human Serlevel that benefit whites and vices. Language skills are create chronic adverse outimpacted by the quantity comes for people of color and of reading time, access to Native Americans. Disparities reading materials, educain outcomes based on race are tional and literacy levels of found in Minnesota in infant caretakers, and the quality mortality rates, rates of obesiof child care. ty, intimate partner violence, • The air we breathe: The poverty, unemployment, high EPA reports that low-inschool graduation rates, and come people and commurates of incarceration.

Knowing patients in new ways When our grandparents were growing up, they had a family physician that knew the patient, the patient’s mother, and the patient’s grandmother. They understood the family’s living situation, neighborhood, health history basics, family drama, and, as a result, had a full picture of these peoples’ lives. Now, providers have to learn about patients in a constrained amount of time during a clinic visit.

Determinants of health

Factors that contribute to the social patterning of health, disease, and illness

Socioeconomic

Genetics and biology are generally unchangeable. Providers can try to motivate their patients’ health behaviors with evidence-based interventions, but these behaviors are ultimately the patient’s choice. Seventy-five percent of health inequities come from social determinants. While on the surface the amount of work that needs to be done may seem daunting, we should also be encouraged by the fact that these inequities are avoidable, alterable, and changeable. Given these challenges, how can providers learn about and address root causes of health inequities? • Patient-centered approach: Create an individualized care plan that takes into consideration a patient’s health vision, preferences, health-care literacy level, Social determinants of health to page 34

The Lawyers and Lobbyists that Doctors Trust Medicine is complicated. So are the laws that doctors, hospitals and insurance companies have to manage. Lockridge Grindal Nauen is one of Minnesota’s leading health care law firms. Our health care clients are so satisfied they’ll write us a referral.

Are Your Patients Ready? Minnesota’s New Immunization Law Goes into Effect 9/1/14 There are important changes that apply to children entering school, child care, and early childhood programs. This means you likely have patients Are Your Kids Ready? who will need to get caught up on some of their immunizations between now AreMinnesota’s Your Kids Ready? Immunization Law Minnesota’s Immunization Law and the end of summer. vaccines that are required recommended, Usethe this chart as a guideFor to determine which vaccines are required to enrollor in child care, early childImmunization chart asand a guide to determine which vaccines are required to enroll in child care, early childhoodthis programs, school (public or private). Immunization Requirements Use please use thishood chart (legal exemptions are available). programs, and school (public or private). Requirements Find the child’s age/grade level and look to see if your child had the number of shots shown by the Find the child’s age/grade level and look tobirth see iftoyour number of shots shownLook by the checkmarks under each vaccine. Children age child 2 mayhad notthe have received all doses. at the checkmarks under iteach vaccine. Children birth to age 2 may not have received all doses. Look at the table on the back, shows the age when doses are due. table on the back, it shows the age when doses are due. Age: 5 through 6 years Age: 7 through 11 years Birth through 4 years Age: 12 years and older Age: 5 through 6 years Age: 7 through 11 years Birth through 4 years Age: 12thyears and older Early childhood programs For 1st through 6th For 7 through 12th For Kindergarten th Early childhood programs & Child care For 1stgrade through 6 For 7th grade through 12th For Kindergarten & Child care grade grade

 Check marks represent number of doses

Hepatitis A (Hep A) Hepatitis A (Hep A)  Hepatitis B (Hep B)  Hepatitis B (Hep B) 

DTaP/DT  DTaP/DT 

Polio  Polio  MMR  MMR  Hib  Hib  Pneumococcal  Pneumococcal  Varicella  Varicella

Hepatitis B  B Hepatitis 

DTaP

 DTaP 

Polio

Hepatitis B  B Hepatitis

diphtheria containing doses

atTdap 7th grade at 7th grade

 tetanus and anddoses tetanus diphtheria containing

 Polio  MMR  MMR 

Polio  Polio  MMR  MMR 

Varicella

Varicella  Varicella 

Immunizations recommended but not required:

Contact Eric Tostrud

612-339-6900 ectostrud@locklaw.com

Polio  Polio  MMR  MMR  Meningococcal  atMeningococcal 7th grade & at  age 16

 at 7th grade & at  age 16

 Varicella   Immunizations recommended but not required: Immunizations recommended but not required: Influenza

Rotavirus For infants Rotavirus



Tdap

Annually for all children age 6 months and older Influenza Annually for all children age 6 months and older

For infants

Varicella  Varicella 

Human papillomavirus At age 11 -12 years Human papillomavirus At age 11 -12 years

Call in patients who need vaccines. Use the Minnesota Immunization Information Connection (MIIC) to identify and call in children who still need to get their shots. For more information or technical assistance, contact your MIIC regional coordinator:

www.health.state.mn.us/divs/idepc/immunize/registry/map.html.

From the Courtroom to the Capitol.®

Exemptions Exemptions

Looking for Records?for Looking Records?

To enroll in child care, early childhood programs, and school in Minnesota, children must show To enrollhad in child early childhood and school in Minnesota, children must show they’ve thesecare, immunizations or fileprograms, a legal exemption. they’ve or file a legal Parentshad maythese file a immunizations medical exemption signed byexemption. a health care provider or a conscientious objection Parents may file a medical exemption signed by a health care provider or a conscientious objection signed by a parent/guardian and notarized. signed by a parent/guardian and notarized. For copies of your child’s vaccination records, talk to your doctor or call the Minnesota Immunization Information Connectionrecords, (MIIC) attalk 651-201-5503 or or 1-800-657-3970. For copies of your child’s vaccination to your doctor call the Minnesota Immunization Information Connection (MIIC) at 651-201-5503 or 1-800-657-3970.

Minnesota Department of Health, Immunization Program Minnesota Department of Health, Immunization Program

IC# 141-3830 (3/2014) IC# 141-3830 (3/2014)

August 2014 Minnesota Physician

Oncology

Testicular cancer

esticular cancer has one of the highest cure rates of all cancers: a five-year survival rate in excess of 90 percent overall, and almost 100 percent if it has not metastasized. Even for the relatively few cases in which malignant cancer has spread widely, modern chemotherapy offers a cure rate of at least 80 percent.

A major risk factor for the development of testis cancer is cryptorchidism (undescended testicles). It is generally believed that the presence of a tumor contributes to cryptorchidism; when cryptorchidism occurs in conjunction with a tumor, then the tumor tends to be large. Other risk factors include inguinal hernias, Klinefelter syndrome, and mumps orchitis. Physical activity is associated with decreased risk and sedentary lifestyle is associated with increased risk. Early onset of male characteristics is associated with increased risk. These may reflect endogenous or environmental hormones.

One of the success stories of modern medicine By Liangping Weng, MD

Symptoms may include one or more of the following: • A lump in one testis, which may or may not be painful • A sharp pain or a dull ache in the lower abdomen or scrotum • A feeling often described as “heaviness” in the scrotum • Breast enlargement (gynecomastia) from hormonal effects of ß-hCG

• L ow back pain (lumbago) tumor spread to the lymph nodes along the back It is not very common for testicular cancer to spread to other organs, apart from the lungs. If it has, the following symptoms may also be present: • Shortness of breath (dyspnea), cough, or coughing up blood (hemoptysis) from metastatic spread to the lungs • A lump in the neck due to metastases to the lymph nodes Diagnosis Primary initial diagnosis is via a lump or mass inside a testis. Generally, if a young adult or adolescent has a single enlarged testicle—which may or may not be painful—there can be reason to suspect testicular cancer. The nature of any palpated lump in the scrotum should be evaluated by scrotal ultrasound, which can determine the exact location, size, and some characteristics of the lump, such as cystic vs. solid, uniform vs. heterogeneous, sharply circumscribed or poorly defined. The extent of the disease is evaluated by CT scans, which are used to locate metastases. Blood tests are also used to identify and measure tumor markers.

The differential diagnosis of testicular cancer requires examining the histology of tissue obtained via an inguinal orchiectomy—surgical excision of the entire testis along with attached structures (epididymis and spermatic cord). A biopsy should not be performed, because it raises the risk of Minnesota Physician August 2014

spreading cancer cells into the scrotum. Inguinal orchiectomy is the preferred method because it lowers the risk of cancer cells escaping. Staging Testicular cancer is categorized as being in one of three stages (which have subclassifications). The size of the tumor in the testis is irrelevant to staging. In broad terms, testicular cancer is staged as follows: • Stage I: The cancer remains localized to the testis. • Stage II: The cancer involves the testis and metastasis to retroperitoneal and/or para-aortic lymph nodes (lymph nodes below the diaphragm). • Stage III: The cancer involves the testis and metastasis beyond the retroperitoneal and paraaortic lymph nodes. Stage III is further subdivided into non-bulky Stage III and bulky Stage III. Although testicular cancer can be derived from any cell type found in the testicles, more than 95 percent of testicular cancers are germ cell tumors. Seminoma is a tumor derived from only one germ cell type. Nonseminoma is a tumor that includes all other germ cell tumors, both pure and mixed. Treatment The three basic types of treatment are surgery, radiation therapy, and chemotherapy. Surgery is the initial treatment for testicular cancer, to remove the affected testicle (orchiectomy). While it may be possible, in some cases, to remove testicular cancer tumors from a testis while leaving the testis functional, this is almost never done, because the affected testicle usually contains precancerous cells spread throughout the entire testicle. Removing the tumor alone without additional treatment greatly increases the risk that another cancer will form in that testicle.

Facts about testicular cancer • Testicular cancer is most common among Caucasian men and is rare among men of African descent. Testicular cancer is uncommon in Asia and Africa. Worldwide, incidence has doubled since the 1960s, with the highest rates of prevalence in Scandinavia, Germany, and New Zealand. • Globally, as of 2010, testicular cancer resulted in about 8,000 deaths each year. • Higher rates of testicular cancer in Western nations have been linked to use of cannabis. A study conducted by the Fred Hutchinson Cancer Research Center and funded by the National Institutes of Health, published in the journal Cancer in 2009, linked long-term use of cannabis to an increased risk for testicular cancer, with the scientists concluding that cannabis is harmful to the human endocrine and reproductive system. In 2012, a study published in the journal Cancer became the third to link marijuana use to the development of testicular cancer. Since only one testis is typically required to maintain fertility, hormone production, and other male functions, the afflicted testis is almost always removed completely by inguinal orchiectomy. Radiation may be used to treat Stage II seminoma cancers, or as adjuvant therapy in the case of Stage I seminomas, to minimize the likelihood that tiny, nondetectable tumors exist and will spread (in the inguinal and para-aortic lymph nodes). However, radiation is ineffective against, and never

used as a primary therapy for, nonseminomas. Chemotherapy is the standard treatment for nonseminoma when the cancer has spread to other parts of the body (that is, Stage IIB or III). The standard chemotherapy protocol is three, or sometimes four, rounds of bleomycin-etoposide-cisplatin. An alternative, equally effective treatment, involves the use of four cycles of etoposide-cisplatin. Lymph node surgery also may be performed after chemotherapy to remove masses left behind

What YOU can do to

PREVENT DIABETES

(Stage IIB or more advanced), particularly in the cases of large nonseminomas. Since testicular cancer can recur decades after the primary tumor is removed, patients receiving adjuvant chemotherapy should remain vigilant and not assume they are cured even five years after treatment. Adjuvant treatment Since testicular cancers can spread, patients are usually offered adjuvant (preventive) treatment—chemotherapy or radiotherapy—to kill any

cancerous cells that may exist outside of the affected testicle. The type of adjuvant therapy depends largely on the histology of the tumor and the stage of progression at the time of surgery. If the cancer is not particularly advanced, patients may be offered careful surveillance by periodic CT scans and blood tests, in place of adjuvant treatment. As an adjuvant treatment, use of chemotherapy—as an alternative to radiation therapy Testicular cancer to page 32

1 in 3 adults has prediabetes. Most do not know it. 15-30% will go on to develop type 2 diabetes within 5 years. The good news is type 2 diabetes can be delayed or prevented in most people if they participate in the evidence-based National Diabetes Prevention Program (NDPP).

What you can do: • Screen every patient over age 45 or with multiple risk factors. • Refer those with prediabetes or history of GDM to a local NDPP site. IT WORKS! • Encourage everyone to be physically active, lose a little weight if overweight and to not smoke.

Learn more about prediabetes, the NDPP and sites in Minnesota at: www.icanpreventdiabetes.org

August 2014 Minnesota Physician

Special Focus: Research

The promise of regenerative medicine

am a registered nurse and, like many of my colleagues, my first professional experience was caring for people with chronic conditions such as diabetes, inflammatory bowel disease, and liver disease. Working at St Joseph’s Hospital in Marshfield, Wis., I observed firsthand how debilitating and costly chronic disease could be. Prevention was challenging and, unfortunately, cures were scarce.

On the unit in which I worked, we saw people admitted and readmitted as they struggled to manage their disease. I cared for those who, over time, lost limbs, vision, organ function, and their lives. As a professional nurse whose aim is patient self-determination, health promotion, and restoration, caring for those with unrelenting disease made a lifelong impression about the value of health, individually and for the population. I chose perioperative nurs-

How the Legislature is helping By Rep. Erin Murphy, RN, MA

ing as my specialty and Minnesota as my home, seeking to care for those undergoing transplantation to treat and cure their disease. I worked at the University of Minnesota

New scientific innovations that lower medical costs are the best option for improving Minnesota’s fiscal health in the coming decades. Hospital and Clinics, caring for people in surgery with cardiac

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Minnesota Physician August 2014

row donation. I witnessed the miracle of how a newly transplanted kidney pinks up and produces urine, a sign that a person suffering with end-stage renal disease was experiencing the gift of a healthier life. It was living proof of the ways in which scientific research and practice can bring hope and relief to countless families and their loved ones. Why fund regenerative medicine research? A year ago, I met Jakub Tolar, MD, PhD, who is the director of the Stem Cell Institute (SCI) at the University of Minnesota. I was curious about the work at the SCI and wanted to learn more. Unlike an organ transplant, regenerative medicine uses the science of stem cell biology to empower the body’s “natural self-healing properties,” according to Dr. Tolar. The science, if perfected, could empower regrowth treatment of debilitating diseases using practices and techniques that are far less invasive and risky than an organ transplant. I learned about similar work by Andre Terzic, MD, PhD, at the Mayo Clinic, who believes that regenerative medicine can

finally allow us to “evolve” the model of care delivery beyond treating just symptoms, to finally offer actual cures to complex diseases. After just an hour with Dr. Tolar, hearing accounts of the work underway to discover new avenues to treat and cure disease, I was inspired to act. How can regenerative medicine impact our state’s fiscal health? This work at the University of Minnesota and the Mayo Clinic, and our capacity to research and innovate are critical to our economy and the health of Minnesotans. However, this science also has profound implications for public policy and the future of our state budget. Since becoming a state legislator in 2006, I have experienced just two years when Minnesota was not struggling with some kind of a budget deficit (2007 and 2014). Those were also the only two years when we were able to avoid making cuts and cost reductions to the health and human services area of state government. Those cuts have had adverse consequences on Minnesotans throughout our state, and the stories of the impacted people are heartbreaking. The health-care budget pressures experienced by the state would be far easier to ameliorate through the development of new lower-cost technologies and treatments, rather than traditional, “Sophie’s Choice”-style budget cuts pitting hospitals against nursing homes. The state of Minnesota spends literally hundreds of millions of dollars treating chronic conditions like diabetes, rather than investing in pioneering ways to cure such illness altogether. With ever-growing health care needs of an aging population, new scientific innovations that lower medical costs are by far the best option for improving Minnesota’s fiscal health in the coming decades. With that goal in mind, I introduced legislation during the 2014 legislative session, to

add Minnesota to the list of more than a dozen states nationwide providing significant resources, funding, and effort to the development of regenerative medicine. Dr. Tolar and Dr. Terzic made a compelling case at the Capitol for the potential of their work, attracting broad support from unlikely allies among both Democrats and Republicans—an unusual feat in an election year. With the help of Sen. Katie Sieben, Sen. Richard Cohen, Sen. Terri Bonoff, Rep. Tony Albright, and Rep. Tim Mahoney, this proposal survived a difficult and lengthy budget conference committee and recently became law, with the signature of Gov. Dayton. What kind of regenerative medicine research is Minnesota funding? Minnesota’s new law provides over $4.3 million in permanent, annual state funding for the direct and indirect expenses of a new collaborative partner-

ship between the University of Minnesota and the Mayo Clinic for regenerative medicine research, clinical translation, and commercialization. The collaborative leaders are in the initial stages of forming an advisory group that will help guide decision-making in the coming months. The

as tangible, economic development opportunities. We expect the funding to provide sufficient resources for three to four research teams per year, whose work will be subject to oversight and ongoing audits for quality control and outcome evaluations. If the research collaborative at-

Our capacity to research and innovate are critical to our economy and the health of Minnesotans. collaborative is legally required to include representatives of private industry and others with expertise in regenerative medicine research, clinical translation, commercialization, and medical venture financing not affiliated with either the University of Minnesota or the Mayo Clinic. It was important to legislators that these funds support basic research, as well

tracts the interest of private or foundation funding, the results could be magnified far beyond the state’s initial investment. Can regenerative medicine change our health care system? The field of regenerative medicine has the potential to make new discoveries that transform the care and treatment of

chronic disease, just as those transplant surgeries at the University of Minnesota did a generation ago. Although I’m no longer working in surgery, I am just as excited and hopeful about playing a small role in a new initiative that can help Minnesota once again lead the nation and the world in an area of medical technology development. Now the burden of proof shifts to the medical research community—to take this opportunity and prove that regenerative medicine investment leads to real results for people suffering and in need of a cure. Rep. Erin Murphy, RN, MA, is the majority leader of the Minnesota House of Representatives and represents the citizens of District 64A in St. Paul. She was the former executive director of the Minnesota Nurses Association. Murphy is also a teacher in the Doctorate of Nursing Practice program at St. Catherine University, St. Paul.

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topics include • Evaluation and Diagnosis of the Chronic Pain Patient • Lumbar Spine Examination & Assessment • Behavioral Health and Physical Therapy and Pain • ICSI Guidelines / Proper Prescribing • Controlled Substance and Drug Diversion • Advances in Implantable Treatment Options

August 2014 Minnesota Physician

2 014 P h ys i c i a n r e s e a r c h r e c o g n i t i o n

Different methods, a common goal: Physician researchers strive to improve health

Medical research in Minnesota has a long history of excellence, from firsts in open-heart surgery and bone marrow transplantation to reknowned physician researchers such as C. Walton Lillehei, Owen H. Wangensteen, and Robert A. Good. Today, innovative and dedicated researchers working in academic institutions, urban and rural clinics, managed-care companies, health system foundations, and medical professional societies continue to advance our knowledge of medical care. Minnesota Physician Publishing periodically presents this feature, which recognizes the hard work and quality outcomes of physician-led medical research in our state. We regret that we cannot highlight every entry, and thank everyone who participated in the nomination process and in compiling and writing the project descriptions.

ESEARCH REC R N

2014

O ON ITI GN

PHY SIC

Congratulations to the physician investigators listed here and to all of Minnesotaâ&#x20AC;&#x2122;s medical researchers for the distinctive standing their research holds in our community.

Minnesota Physician Publishing

Minnesota Physician August 2014

Hirohito Kita, MD

Enhanced innate type 2 immune response in peripheral blood from patients with asthma Research site: Mayo Clinic, Rochester

Principal investigator: Hirohito Kita, MD Co-investigators: K athleen Bartemes, Gail

Kephart, Stephanie J. Fox, MD

Funding: National Institutes of Health and the Mayo Foundation

urpose: Asthma is estimated to affect 14.9 million people in the United States, causing more than 1.5 million emergency room visits, 500,000 hospitalizations, and more than 5,500 deaths each year. Previous research in mice has shown that group 2 innate lymphoid cells (ILC2s) modulate inflammation associated with helminths, raising the possibility that ILC2s may play a potential role in the inflammation associated with asthma. Determining the role of group 2 innate lymphoid cells in asthmatic patients could provide novel therapeutic targets for the treatment of asthma. Peripheral blood analysis could be potentially useful in determining a specific classification of asthmatic inflammation in the lung. In addition, illuminating the pathogenesis of asthmatic inflammation and improving our ability to characterize and quantify asthmatic inflammation is important, as novel biological agents that inhibit inflammation such as

eosinophilic inflammation are undergoing clinical trials for asthma. This study demonstrated that innate type 2 immune responses that may be identified through peripheral blood are enhanced in asthmatic patients. Methods: Fifty-two patients (32 female, 20 male) were recruited for study. They included 18 healthy controls, 16 individuals with allergic rhinitis, and 18 with allergic asthma. This study is no longer enrolling new patients. Acquisition of peripheral blood from healthy controls and subjects with asthma or allergic rhinitis was followed by use of a fluorescent activated cell sorter, peripheral blood cell stimulation, and analysis of cytokines by immunochemical methods. Primary outcomes: Human peripheral blood mononuclear cells demonstrate innate type 2 immune responses to interleukin-33 and interleukin-25 in the presence of interleukin 2. Group 2 innate lymphoid cells isolated from peripheral blood mononuclear cells produce large quantities of interleukin-5 and interleukin-13, but not interleukin-4, when stimulated with interleukin-33. Secondary outcome: Peripheral blood was shown to be useful in evaluating innate type 2 immunity in humans. This study has been completed and accepted for publication by the Journal of Allergy and Clinical Immunology.

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P Nathan L. Hartin, MD

Fusion risk score Evaluating baseline risk in thoracic and lumbar fusion surgery Research site: Twin Cities Spine Center, Minneapolis

Principal investigator: Nathan L. Hartin, MD (while a fellow at Twin Cities Spine Center; now practicing in Australia) Co-investigators: Amir A. Mehbod, MD; S. B.

Joglekar, MD (while a fellow at Twin Cities Spine Center; now clinical instructor, UCSF Orthopedics, Fresno, Calif./orthopedic staff surgeon, VA Medical Center, Fresno); Ensor E. Transfeldt, MD; and John E. Lonstein, MD

Funding: Twin Cities Spine Center

urpose: Thoracolumbar fusion surgery for degenerative conditions is on the rise, and the patients are often elderly, with multiple comorbidities. The magnitude of fusion surgery can be tailored, taking the patient’s general health into consideration. An objective method of stratifying risk preoperatively allows the surgeon to both control risk through tailoring intervention and to explain differences in complication profile in high-complexity practice. For example, one would choose a smaller, less invasive surgery for a patient with multiple medical problems. The Fusion Risk Score (FRS) is introduced to objectively assess baseline risk of spine surgery. The score is the sum of two components: One arises from risks unique to the individual patient (Patient Score) and the other, from the planned surgery (Procedure Score). The patient score cannot be changed but the surgeon can change the procedure score to reduce the total score in order to minimize risk. We present the formulation and validation of this score. Methods: Retrospective review was made of 364 consecutive fusion surgical procedures performed during an 18-month period in patients older than 65 years of age. Logistic regression analysis was performed to identify factors predictive for the occurrence of perioperative events. The predictive variables were incorporated in a weighted fashion into

the FRS, scaled from 1 to 20. Patient demographics and comorbidities were incorporated into the FRS patient score (maximum 10) and surgical approach, levels, and osteotomies into the FRS procedure score (maximum 10). Multivariate analysis demonstrated chronic kidney disease (P = 0.008), chronic obstructive pulmonary disease (P < 0.001), ischemic heart disease (P < 0.001), an open anterior approach (P = 0.010), diabetes (P = 0.004), previous spinal surgery at the same site (P = 0.005), age (P = 0.019), and the number of motion segments fused (P = 0.049) to be predictive of perioperative events. When applied, the FRS was highly predictive of perioperative events, intensive care unit admission, operative time, blood loss, and length of stay (all P < 0.0001). A score over threshold 9 carries a greater than 50 percent risk of perioperative events. In a subsequent study, we validated the score to predict the 90-day perioperative morbidity for a different cohort of 131 patients. Conclusions: The FRS predicts the risk of complications after spine fusion surgery on the basis of patient and surgery characteristics. It also predicts the risk of intensive care unit admission and correlates with operative time, blood loss, and postoperative length of stay. By balancing the FRS procedure score to the individual FRS patient score, the surgeon can quantify and control perioperative risk.

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August 2014 Minnesota Physician

2 014 P h ys i c i a n r e s e a r c h r e c o g n i t i o n

P Patricia F. Walker, MD, DTM&H, FASTMH

Culturally competent cancer screening

Research sites: HealthPartners clinics in the

Twin Cities metro and HealthPartners Center for International Health, St. Paul

Principal investigator: Patricia F. Walker, MD,

DTM&H, FASTMH

Co-investigators: Mohamed Hassan, MD,

(University of Minnesota); Douglas Pryce, MD, (Hennepin County Medical Center); and HealthPartners Institute for Education and Research colleagues Emily Parker, Chris Enstad, Jerry Amundson, Shelley Russell, and Brita Hedblom

Funding: University of Minnesota Center for Clinical and Translational Science Institute, Program in Health Disparities Research

urpose: Centers for Disease Control and Prevention guidelines recommend that clinicians screen all patients born in countries that have a prevalence of hepatitis B virus (HBV) greater than 2 percent. This research project tested a point-of-care decision support tool called the “Global Health Wizard” to see if the Wizard would enhance detection of HBsAG-positive patients. This tool utilizes an algorithm based on language and country of origin to educate and prompt providers to: 1) screen for HBV and 2) order appropriate follow-up care. Methods: Nine HealthPartners clinics that each had more than 450 nonEnglish-speaking patients were selected and randomized to either active or passive intervention. In the active intervention arm, the Wizard had a smart set with orders for hepatitis B screening test appended. In the passive intervention, the alert appeared but had no smart set appended. Data was collected for nine months during the two-year study, which began in 2011 and ended in 2013. Preliminary results: Over the course of the nine-month data collection period,

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5,441 unique patients triggered the Wizard; 58 percent were non-English speaking. Hepatitis B screening tests were ordered in 12.7 percent of encounters in active intervention clinics and in 15.6 percent of encounters in passive intervention clinics. Twenty-eight carriers for hepatitis B were identified. These preliminary results confirm the hypothesis that the Global Health Wizard will increase screening rates and identify more carriers for hepatitis B. These results also suggest use of the Wizard as a best practice alert. Culturally competent cancer screening can be improved by utilization of best practice alerts triggered by use of granular demographic data, including a patient’s language and country of origin. HealthPartners Medical Group and Hennepin County Medical Center are planning to disseminate the Global Health Wizard as a best practice system-wide.

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Minnesota Physician August 2014

2 014 P h ys i c i a n r e s e a r c h r e c o g n i t i o n

Michael Mollerus, MD

SMDC CRM-MRI Prospective Case Series Monitoring patients with pacemakers or ICDs who undergo MRI scans Research site: St. Mary’s Medical Center, Duluth Principal investigator: Michael Mollerus, MD Funding: Essentia Health

urpose: The significance of this research is that MRI scanning is now the imaging modality of choice for a number of neurological, vascular, or musculoskeletal conditions. Data suggest that patients

with pacemakers or ICDs, when carefully monitored, can safely undergo MRI scanning. This study will allow for careful monitoring of the safety of MRI scanning in this population, and has the potential to improve practice models and protocols in the future. Methods: This study is a prospective, nonrandomized, unblinded case series of patients with permanent pacemakers and implantable cardioverter-defibrillators (ICDs) and who undergo medically required MRI scans. Patients will be enrolled over the course of a 60-month period and followed for 12 months. Data will be collected in order to evaluate the study’s primary endpoint, which is change in pacing thresholds over time. Data also will be collected to evaluate a series of secondary endpoints. These endpoints include adverse events, symptoms, the need to make pacemaker programming changes, and possible artifacts created by the pacemaker systems on the MRI scans. The population for this study includes males and females who are at least 18 years old and who are followed at St. Mary’s Medical Center, Duluth, and who have a permanent pacemaker or ICD that has been implanted for at least six weeks. In addition, subjects must be referred for a medically required MRI scan by a physician not participating in this trial.

Primary outcome: The primary outcomemeasure is pacing threshold increase: any change greater than 1V at a pulse width of 0.5 msec in a pacemaker or ICD lead at any time within 12 months of the MRI scan. This is designated as a safety issue. Secondary outcomes: There are two secondary outcome measures. One is increased cardiac ectopy at the time of the MRI scan. The timeframe for this measure, which is designated as a safety issue, is one hour. The other secondary outcome measure is pacemaker reprogramming: unanticipated pacemaker or ICD reprogramming because of alterations in device behavior that may be related to the MRI scan. The timeframe for this measure is 12 months and also is designated as a safety issue. This study began in October 2012 and has an estimated primary completion date of October 2017 (final data collection date for primary outcome measure). With an estimated ultimate enrollment of 500 individuals, this study is actively recruiting. Preliminary results: To date, 70 scans have been performed without complication of all body landmarks and without SAR restrictions. (SAR is Specific Absorption Rate, a measure of the absorption of electromagnetic energy in the body, typically expressed in watts per kilogram, or W/kg).

Read us online Wherever you are!

www.mppub.com August 2014 Minnesota Physician

2 014 P h ys i c i a n r e s e a r c h r e c o g n i t i o n ees found its educational materials helpful in changing their eating habits, physical activity, or screen time, and to determine if any changes are needed to improve BWT. Methods: Patients ages 4 to 20 are enrolled in BWT during a regular orthopedic visit based on results of an assessment and recommendation by Nutrition Services. Assessment includes BMI measurement and metabolic labs such as serum blood glucose. BMI above the 85th percentile and abnormal metabolic lab values indicate risks for pediatric obesity and trigger a nutritional consultation. Enrollees’ families Deborah Smith-Wright, MD receive a monthly mailed follow-up for six months, consisting of wellness topics designed Be Well Together to encourage healthy eating habits, increase Analysis of current strategies physical activity, and decrease screen time. Research site: Shriners Hospitals for This study is currently enrolling subjects, Children–Twin Cities with final enrollment of approximately 40 parPrincipal investigator: Deborah Smith-Wright, MD ent-child dyads anticipated by September 2014. Eight dyads have enrolled to date. Co-investigator: Amy Cantor This qualitative and descriptive study Funding: Unfunded except for Shriners’ “Straight reflects patient and parent response to a to the Heart Scholarship” awarded to Ms. Cantor phone survey using open-ended questions. All patients who participated in BWT will be urpose: Because obesity can hinder asked to participate in the study. If parents recovery after orthopedic surgery, and and patients agree, a phone survey is conductbecause pediatric obesity has tripled in ed during evening hours. One parent of each the past 40 years, Shriners’ Be Well Togethpatient 10 years old or older, plus the patient, er (BWT) program aims to help overweight are interviewed about their experience in BWT, patients make healthy nutritional choices and using a survey developed by nutrition and set weight-loss goals. The purpose of this study research staff at Shriners–Twin Cities. Particiis to evaluate BWT and determine if enroll-

pants are asked if BWT’s nutritional consultation and follow-up mailings helped them make healthy nutritional decisions and contributed to changes in physical activity. BWT was initiated in the fall of 2013. Evaluation began in May 2014 and is expected to last six to eight months. Primary outcome: Obtain information about BWT and perform a descriptive analysis based on answers to survey questions. Secondary outcome: Improve our current nutritional support program as informed by study results. Preliminary results: Parents’ responses to phone survey indicate that, due to the typical volume of mail received at home, it is difficult to pay attention to BWT mailings. Both parents and children suggest incorporating more interactive participation into the program, such as having support groups at Shriners. Parents suggest offering budget-shopping ideas and providing telephone follow-up in addition to mailings. Children’s responses indicate that time after school is usually spent watching TV and playing computer games but that they are interested in the program and want to meet again with our nutritionist. The investigators gratefully acknowledge the help of clinical research coordinator Gabriela Ferski, RN, MPH, MS, and clinical dietitian Alicia Rodriguez, RD, LD.

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2014

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Minnesota Physician August 2014

2 014 P h ys i c i a n r e s e a r c h r e c o g n i t i o n Funding: Pine Tree Apple Tennis Classic, St.

Baldrick’s Foundation, Foundation of Children’s Hospitals and Clinics of Minnesota, Randy Shaver Cancer Research and Community Fund, and Hyundai Hope on Wheels

P Kris Ann P. Schultz, MD

Clinical and genetic aspects of ovarian and testicular stromal tumors

Research site: Children’s Hospitals and Clinics of Minnesota Collaborating sites: Children’s National Medical Center (Washington, DC), Washington University Medical Center (St. Louis, Mo.), and Boston Children’s Hospital/Dana-Farber Cancer Institute (Boston) Principal investigator: Kris Ann P. Schultz, MD, Children’s Hospitals and Clinics of Minnesota Co-investigators: Anne Harris, MPH, CCRP, Children’s Hospitals and Clinics of Minnesota; Yoav H. Messinger, MD, Children’s Hospitals and Clinics of Minnesota; D. Ashley Hill, MD, Children’s National Medical Center, Washington, DC; A. Lindsay Frazier, MD, Dana-Farber Cancer Institute, Boston; Louis P. Dehner, MD, Washington University, St. Louis, Mo.; Leslie Ann Doros, MD, Children’s National Medical Center, Washington, DC; Robin H. Young, MD, Massachusetts General Hospital, Boston

urpose: Ovarian sex cord-stromal tumors are rare tumors that typically occur in children, adolescents, and young adults. In 2009, investigators from the International Pleuropulmonary Blastoma (PPB) Registry, based at Children’s Hospitals and Clinics of Minnesota, discovered an association between mutations in the gene DICER1 and the development of PPB, a rare and aggressive lung cancer in young children. Data from family members of children with PPB showed ovarian tumors in several closely related individuals. Based on those findings, Children’s established the International Ovarian and Testicular Stromal Tumor (OTST) Registry to study causes of these rare tumors and how best to treat them. We hypothesized that many girls and women with ovarian stromal tumors would have underlying germline mutations in DICER1, a critical gene in human development that functions as a “dimmer switch” for cell proliferation. Our research confirms this. DICER1 mutations also were found in a small number of girls and women with juvenile granulosa cell tumor and gynandroblastoma. We are working to further un-

derstand this connection, and are collecting clinical and treatment data on all ovarian and testicular stromal tumors to understand the best treatment regimens. Methods: For each registry participant, clinical data and biologic specimens, such as germline DNA and tumor tissue, are collected and studied to understand tumor development and to look for potential chemotherapy targets. This study began in December 2011. With an ending date yet to be determined, this study is actively recruiting. Primary outcome: Earlier detection of tumors. Secondary outcome: DICER1 affects the expression of mRNA and miRNA. Preliminary findings: Germline mutations in DICER1 have been found in 59 percent of girls and women with Sertoli-Leydig cell tumors. (Research presented at the annual American Society of Clinical Oncology meeting, June 2014.) We are currently studying whether these tumors behave differently than those without the DICER1 mutation. DICER1 mutations also were found in a small number of girls and women with juvenile granulosa cell tumor and gynandroblastoma. Because DICER1 affects the expression of mRNA and miRNA, we are studying the levels of these in tumor tissue to best understand how to target these tumors.

August 2014 Minnesota Physician

2 014 P h ys i c i a n r e s e a r c h r e c o g n i t i o n

P Anne Murray, MD, MSc

BRain IN Kidney (BRINK) memory study

Research sites: Primary: Hennepin County

Medical Center1 Medical Research Foundation, Berman Center for Outcomes & Clinical Research

Secondary: V.A. Medical Center2, Minneapolis; University of Minnesota, Minneapolis3; HealthPartners Institute for Education and Research4; Mayo Clinic, Rochester5 Principal investigator: Anne Murray, MD, MSc Co-investigators: Robert Foley, MB, MSc1, David Tupper, MD1, Kamakshi Lakshminarayan MD, PhD2, Yelena Slinin, MD, MPH2,3, Paul Drawz, MD, MPH3, Rebecca Rossom, MD, MPH4, Dave Knopman, MD5, Clifford Jack, MD5

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Funding: National Institute on Aging, an institute of the NIH

urpose: We want to know how often memory loss, confusion, and difficulty with daily activities occur in patients with chronic kidney disease (CKD). We also want to know how stroke affects memory, thinking, and physical activities in people with CKD. We hope to identify risk factors for, or causes of, memory loss that may occur in these people compared with people without CKD, and at what point in the disease process memory loss and confusion begin. Outcomes: The BRain IN Kidney Disease (BRINK) study aims to (1) measure the prevalence of cognitive impairment (CI) and its risk factors in patients with moderate chronic kidney disease (CKD, defined as estimated glomerular filtration rate <45 mL/min/1.73 m², but not on dialysis). We also aim to (2) identify potential risk factors (e.g., stroke, white matter disease, inflammation, kidney function, microalbuminuria, dialysis initiation) for cognitive decline over a 3-year period and to (3) compare the rates of decline in ‘global’ cognition and specific cognitive domains, including memory and executive function, in patients with and without CKD. Methods: A medical history interview, cognitive assessment, and laboratory measurements are completed for all participants

at baseline. Follow-up assessments are conducted at six, 12, 18, 24, 30, and 36 months. Additionally, participants receive follow-up phone calls at three, nine, 15, 21, 27, and 33 months. Brain MRIs are obtained in about half of patients at baseline and three years. Serum and urinary biomarkers are measured at baseline and three years. This research began Sept. 1, 2011, and will end May 31, 2016. However, we hope to be awarded a continuation of grant funding. To date, we have recruited 266 of 325 eventual CKD patients and 85 of 130 eventual non-CKD patients. Preliminary findings: Higher cholesterol is associated with a lower risk of cognitive impairment in CKD patients, whereas higher phosphorous is associated with higher risk. Having African American background is also a strong risk factor for cognitive impairment, an observation that has been made in other studies of nonCKD patients. We also found significantly higher volumes of white matter disease and micro-hemorrhages in CKD than non-CKD patients, as well as a trend toward higher incidence of all stroke types combined (both cortical and subcortical) in patients with CKD.

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Minnesota Physician August 2014

2 014 P h ys i c i a n r e s e a r c h r e c o g n i t i o n

Outpatient management of acute kidney stone disease Iterative quality improvement Research site: HealthEast Kidney Stone Institute, St. Paul

Primary investigator: Andrew Portis, MD Co-investigator: Sue Neises, RN, MA, CPHQ Funding: HealthEast

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Andrew Portis, MD

urpose: Patients with kidney stone symptoms commonly present to the emergency department (ED) for initial management of symptoms. While these symptoms generally can be controlled rapidly with parenteral medications, the stone, which is the underlying cause, will not be resolved during the ED encounter. Initial management of acute kidney stone disease is a severe test of integration of patient care delivery. After symptom control in the ED, most patients require further urologic care, which generally occurs at a future time, off-site, and out of system. Nationally, approximately 10 percent of patients initially presenting to an ED with acute stone disease return to the ED for further care within seven days. We consider this to be a failure of outpatient management. The HealthEast Kidney Stone Institute delivers subspecialty care for acute and chronic stone issues. While it is a “destination” for patients with stone issues, it cannot be an “island,” and to provide effective care it must be integrated with the rest of the care process. We seek to improve patient experience and cost and quality indices by improving integration of the process of care delivery from initial diagnosis to conclusion of the acute stone episode.

Methods: Subjects are patients with acute stone disease presenting to HealthEast emergency departments (approximately 1,400 visits annually). We perform ongoing tracking of key metrics representing access to care, efficiency, and efficacy of outpatient management. Improvement is measured over time relative to previous experience and relative to program participation. Specific quality improvement projects have included providing prompt nurse triage and outpatient coaching, early access to subspecialty care, systematic care protocols, and patient education. Primary outcome: Decreased repeat ED encounters Secondary outcome: Improved resource utilization Preliminary observations: The strongest predictor of success appears to be early contact with subspecialty care. Within the HealthEast system, patients achieving contact with the Kidney Stone Institute have a repeat ED rate within seven days of initial presentation of approximately 4 percent compared with a local rate of approximately 9 percent for patients that do not achieve contact. Further efforts are underway to consolidate improvements and create a generalizable model of care for these patients.

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August 2014 Minnesota Physician

professional Update: Psychiatry

“A

re you OK?” my partner inquired, matter-of-factly. I was crying uncontrollably in the hallway outside a conference room in the Airport Hilton. She and I were practicing our skills in our first Eye Movement Desensitization and Reprocessing (EMDR) training session. The assignment was to pick an innocuous, slightly upsetting memory; she would encourage me to “notice what comes up” in my mind while she moved a finger back and forth across my field of vision for my eyes to follow. I had chosen the shame and guilt I felt about a thoughtless remark I had made at the grocery store about brain cancer, forgetting that the bagger’s mother was being treated for a brain tumor. Thoughts follow their own logic. Mine went to the moment when as a young child I’d carelessly slammed the car door on my little brother’s finger. From there they went straight to his

A new approach to anxiety and panic Eye movement desensitization and reprocessing By Mike Niehans, MD

suicide some 20 years later. Hence, the intense emotion. Evidently, all three events were joined in the culpability file somewhere in the nether reaches of my brain. My partner waited for me to compose myself, and then I noticed a remarkable thing. I still remembered, as clearly as ever, the early-morning phone call in which my father informed me of my brother’s violent death, but now the pain linked with

American Diabetes Association EXPO Healthcare Professional Breakfast Saturday, October 11, 2014 at 7:00am Minneapolis Convention Center Meeting Room 103 DEF What are the Most Effective Weight Loss Interventions for Diabetes and Prediabetes Presentation by Dr. Charles Billington, MD Losing a few pounds can dramatically improve health and quality of life especially for people with diabetes and prediabetes. Effective weight loss can involve multiple techniques and strategies including lifestyle changes, medication and surgical options. Please join us for an informative discussion on the most effective weight loss interventions for those with diabetes and prediabetes as well as how to guide your patient through the weight loss process. Objectives: Compare the range of approaches for weight loss Describe the body’s physiologic mechanisms to protect against weight loss Identify ways to support a patient working to lose weight 7:00 am - 8:15am Breakfast, Networking, Presentation and Discussion RSVP on-line at http://diabetesmn.wufoo.com/forms/hcp-breakfast-rsvp/ Space is limited. Please RSVP by Friday, October 3, 2014 Event is free of charge and open to all healthcare professionals to attend

Minnesota Physician August 2014

memory was gone—and it hasn’t troubled me since. Now it was my turn. My partner fought back tears as she recalled the shame she felt about needing someone else’s help to deal with a phobia. I practiced my newly-learned skill on her. The next day I asked her about it. “That was so insignificant,” she said, “it wasn’t worth talking about.” The EMDR treatment invites a person to revisit the scene of the trauma and re-experience the emotions, but this time in the presence of someone who is safe, empathic, and attuned. Why the eye movements? The precise mechanism has yet to be determined, but sensory stimulation alternating from side to side evidently makes it easier for the brain to retrieve and refile emotionally loaded memories. What is going on here, and how is it relevant to anxiety and panic? When I was attending medical school—at the dawn of the Golden Age of Psychopharmacology—who could have imagined that in the 21st century we would deal with psychic pain by moving fingers back and forth across a person’s field of vision? This seems like a dramatic departure from the axiom that “for every twisted thought there is a twisted molecule.” As an eager student, I was proud to grind up rat brains in the lab in the hope of mapping drug receptors in the central nervous system. We were sure that, by understanding neurotransmitters, we would

be able to use medications to correct brain malfunctions. Surely the research would lead to better ways to combat anxiety than benzodiazepines like Ativan and Klonopin, whose limitations were all too apparent. The pharmaceutical industry spotted the opportunity; it lavishly financed research while successfully promoting the notion that emotional disturbances are signs of a “chemical imbalance.” If that was true, then what better way to remedy the problem than a prescription for one of the many products available to restore chemical equilibrium? Meds are not always the answer Great were the expectations. But it’s with the resigned air of a fisherman heading back to shore with an empty hold that we contemplate the accumulating studies highlighting the limitations of prescriptions in combating anxiety. What practitioner hasn’t seen patients who bring in lengthy lists of medications that may have worked for their anxiety for a while, only to lose their benefit over time? It’s easy to feel defeated when patients are convinced that they have a “chemical imbalance” and the right medication combination just hasn’t been found yet. What’s more, recent research suggests that the newer antidepressants are no better than those venerable benzodiazepines. Perhaps the brain is too complicated and adaptable to be changed by the administration of a chemical that modifies one of the ways that messages are transmitted between neurons. Even when a medication has the desired benefit at first, over time the brain often has a way of reasserting itself, becoming refractory to the medication. What is to be done? No one has done more to propel the field in a radically new direction than Bessel van der Kolk, the founder and medical director of the Trauma Center at Justice Resource Institute, in Brookline, Mass. His lifelong

commitment to helping people who are suffering the painful effects of traumatic life events has led him in unexpected directions. Noting that many of his patients were getting little relief from established approaches, he looked beyond the familiar psychiatric methods for anything that would help. He took a particular interest in the way that traumatic events can be reflected in “body memories.” It had been observed that, after an overwhelming experience, the body is left in an eternal state of readiness to react to a recurrence. For example, after a bee sting, a person’s brain and body end up being hyperalert to any sign of a bee. When a buzz is heard, the resulting fight-or-flight response can resemble a panic attack. This is the primitive, “reptilian” part of our brain, starting with the amygdala, doing one of its main jobs—protecting us from danger. The self-preser-

vation network is much more closely connected to the body than to the conscious mind. In fact, if danger is perceived, the blood supply to the prefrontal cortex, where we formulate plans and make decisions, is

vince people that they’re having a heart attack. Why do some people have such strong reactions to life events, while others are so unflappable that they have to resort to thrill seeking to achieve

EMDR is taking the treatment of trauma, anxiety, and panic in a radically different direction. reduced. That will surprise no one who’s struggled to think clearly in a crisis. By the time we’re consciously aware of the trouble, our hearts are pounding, our breathing is faster, our guts are churning, and our muscles are tensed; our bodies are primed for action. The problem is that, much like an overanxious parent, the brain can sometimes try too hard to keep us safe. Once the sympathetic nervous system is revved up in response to a perceived danger, the resulting palpitations and chest pain can con-

the same rush? Genetics play a part, accounting for roughly a third of the variance. In rare cases, medical disorders—notably pheochromocytoma— can cause bouts of panic. The brain’s trauma memory seems to resemble the immune memory in its readiness to be triggered by perceptions that are somehow reminiscent of a past traumatic event. And then there’s the grind of daily life. “Most men lead lives of quiet desperation,” Thoreau observed. The stress of a demanding and unappreciative

employer, an unkind partner, a child at risk of going astray, or of poverty or ill health is enough to evoke anxiety in most people. Therapy or medication? What works? There is good evidence for the role of exercise, fish oil, and of mindfulness, meditation, and relaxation. Numerous studies support the effectiveness of cognitive and behavioral treatments. The debate rages on whether therapy plus medication is superior to therapy alone. The effect of medication has a quicker onset, but it is lost once the medication is stopped. There is evidence that the benefits of therapy continue to accrue even after the therapy ends. On brain imaging, the changes in response to medications and therapy are similar in some areas, but different in others. At last count there were A new approach to anxiety and panic to page 30

Are you satisfied with your claims processing? You will be with ClaimLynx! Every medical practice depends on cash flow. Very few people understand the required processes between when a doctor sees a patient and how/when insurance reimbursement is disbursed. We make these steps simple for you. Among the services we offer: • Direct, real time verification of eligibility • Secure online access to claims tracking • Secure online access to claims correction • Never miss a payment due to late filing • We handle every kind of insurance and every medical specialty • Less time on paperwork, more time with patients

ClaimLynx is used by many national clearinghouses. You may already be using our services and not know it. Shorten your submission route and remittance time—go straight to the payer using ClaimLynx. Every practice is unique and whether a solo practitioner or large multi-specialty group (and everything in between) we can tailor a solution to your claims processing needs that will maximize your benefits.

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For more information please contact: Russel Campbell info@claimlynx.com 10700 Old County Road 15 Suite 200, Plymouth, MN 55441

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952-593-5969

August 2014 Minnesota Physician

A new approach to anxiety and panic from page 29

fective treatment?

more than 200 different schools of psychotherapy. How does one compare different therapeutic approaches? By conducting comparative trials, the empirically minded will respond. But there’s a monkey wrench that’s jamming up those efforts: Investigations of what makes therapy work are finding that the crucial ingredient of effective treatment is the therapeutic relationship—so much so that, in one review, a well-liked doctor with an ineffective drug had better results than a disliked doctor with an effective drug. If it’s the relationship that matters, then how can one conduct comparative studies? What distinguishes cognitive and behavioral treatments is that following a manual can reproduce them. But a manual can’t teach empathy, attunement, respect, and thoughtfulness. What if those are, in fact, the essence of ef-

The explanation may lie in our growing understanding of attachment and its importance in the way we handle stress. In the face of a threat, the child will seek parental comfort and

respectful can help to restore a sense of security. EMDR is taking the treatment of trauma, anxiety, and panic in a radically different direction. What accounts for the dramatic benefits that are

I’ve been struck by the number of people who consult me in the hope of getting a doctor’s blessing to stop taking medications that they don’t find helpful. protection. The inability to find this comfort and protection is profoundly traumatic, leaving the child with a sense of being alone in a hostile world. As it strives to protect the child from danger, her brain will become hypervigilant for threats. The experience of abandonment in childhood will leave the person more vulnerable to anxiety and panic in the face of adversity as an adult. A relationship with a person who is attentive and

so often seen? There is evidence that it is a uniquely powerful method, which will be effective in the hands of most welltrained practitioners. But at the same time it offers a framework for a healing relationship between two people, which is based on intangible qualities that are crucial but cannot be quantified. It offers two equally important benefits, by relieving the psychological burden of distressing past events and by

providing an emotional safety net that can cushion future blows. In the end it comes down to what people want. No one can match the financial clout of the pharmaceutical industry, but I’ve been struck by the number of people who consult me in the hope of getting a doctor’s blessing to stop taking medications that they don’t find helpful. Now there is much exciting research about the brain and its preoccupation with human relationships. What if these cutting-edge neuroimaging studies taught us that what is most healing of all are a listening ear, an attentive eye, and (from the right person) a caring touch?

Mike Niehans, MD, is boardcertified in general psychiatry and in child and adolescent psychiatry. He practices with Arbor Therapy Center, LLC, in St. Louis Park.

WE CHOSE MERCY FOR THE PRACTICE; BC/BE Family Practice Physician Immediate opening at dynamic urban clinic serving the Native American community. We are passionate about our work and about providing exceptional care. We are looking for a physician who will be a good fit for our clinic and for the community we serve. This is a full-time position (80 hours per pay period), with health and dental benefits. We are a NHSC and IHS loan repayment site. Must be licensed to practice in Minnesota and have current board certification or eligibility. Clinic hours are Monday thru Friday 9am-5pm and Saturdays 10am-2pm.

No phone calls please. Submit Cover Letter and Resume to hr@nacc-healthcare.org. CLOSING DATE: Open until filled. 1213 E. Franklin Avenue, Minneapolis, MN 55404

WE’RE STAYING FOR THE

COMMUNITY! Mercy and North Iowa offer: • Premier rural health care network in northern Iowa and southern Minnesota; • Centers of Excellence: Bariatric, Breast Imaging; • Family-friendly communities with plenty of parks, great schools and activities; • Culture: museums, nature centers, The Legendary Surf Ballroom; • Half-way between Des Moines and Minneapolis/St. Paul, MN Family Medicine (with and without OB) Opportunities in the following North Iowa communities: • Algona • Britt • Clear Lake • Cresco • Emmetsburg • Hampton • Iowa Falls • Mason City • Osage For more information: Cindy Scott: 641-428-5551, scottcl@mercyhealth.com www.mercynorthiowa.com

Mercy MED IC A L C ENTER N O RT H I OWA A member of Mercy Health Network

Minnesota Physician August 2014

Jonna Quinn, D.O., OB/GYN, joined Mercy 2013 Mark Lloyd, D.O., Family Medicine, joined Mercy 2014

Psychiatrist Unique Practice – Unique Psychiatrist Needed! HealthPartners Medical Group is a top Upper Midwest multispecialty group practice based in Minneapolis/St. Paul, Minnesota. We have a unique metropolitan-based outpatient position available for a talented, bilingual BC/BE psychiatrist interested in a non-conventional practice. This full-time position combines cross-cultural psychiatric medicine with community mental health. Receiving practice support from both HealthPartners Center for International Health and from the Ramsey County Mental Health Center, 0.5 FTE of the position will provide psychiatric care to an international refugee patient population utilizing an integrated holistic/ primary care model. The other 0.5 FTE of the position will work as part of a multidisciplinary team to provide care to individuals with serious mental illness, chemical health difficulties and/or co-occurring medical problems. This exciting practice is full-time, but qualified candidates interested in part-time outpatient opportunities in Cross-Cultural Psychiatric Medicine or Community Mental Health are encouraged to apply. In addition to a competitive salary and benefits package, there are opportunities for an academic faculty appointment at the University of Minnesota, teaching involvement in the Global Health Pathway (globalhealth.umn.edu) and further development of best practice programming at Ramsey County Mental Health Center. For consideration, please forward your CV and cover letter to lori.m.fake@healthpartners.com, apply online at healthpartners.com/careers, or call Lori at (800) 472-4695 x1. EOE

Opportunities for full-time and part-time staff are available in the following positions: • Dermatologist

• Medical DirectorExtended Care & Rehab • Geriatrician/ Hospice/ (Geriatrics) Palliative Care • Ophthalmologist • Internal Medicine/ Family Practice

• Psychiatrist

Applicants must be BE/BC.

Minnesota Physician 4" x 5.25" B&W

Emergency Room Physicians Looking for leisure work hours? • Set your own hours • No contract • No obligations

Attention Physicians • Immediate openings • Casual weekend or evening shift coverage

• Choose from 12 or 24 hour shifts • Competitive rates • Paid malpractice

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information: Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV

Great Emergency Department in Southern Minnesota

Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

763-682-5906 • 1-800-876-7171 F-763-684-0243 michelle@whitesellmedstaff.com

(320) 255-6301 August 2014 Minnesota Physician

Testicular cancer from page 17

in the treatment of seminoma—is increasing, because radiation therapy appears to have more significant long-term side effects. Two doses of carboplatin, typically delivered three weeks apart, or occasionally a single dose, is proving to be a successful adjuvant treatment, with recurrence rates in the same ranges as those of radiotherapy. However, verylong-term data on the efficacy of adjuvant carboplatin in this setting do not exist. Before 1970, survival rates from testicular cancer were low. Since the introduction of adjuvant chemotherapy— chiefly platinum-based drugs like cisplatin and carboplatin—the outlook has improved substantially. Although 7,000 to 8,000 new cases of testicular cancer occur in the United States yearly, only 400 men are expected to die of the disease.

Surveillance For many patients with Stage I testicular cancer, adjuvant therapy following surgery may not be appropriate, and patients will undergo surveillance. The form it takes will vary. The aim is to avoid unnecessary treatments in the

Surveillance tests generally include physical examination, blood tests for tumor markers, chest X-rays, and CT scanning. However, the requirements of a surveillance program differ according to the type of disease since, for seminoma patients, relapses can occur later and

Although 7,000 to 8,000 new cases of testicular cancer occur in the United States yearly, only 400 men are expected to die of the disease. many patients who are cured by their surgery, and ensure that any relapses with metastases are detected early and cured. This approach ensures that chemotherapy and/ or radiotherapy are only given to the patients that need it. The number of patients ultimately cured is the same using surveillance as postoperative adjuvant treatments, but the patients have to be prepared to follow a prolonged series of visits and tests.

blood tests are not as good at indicating relapse. For more advanced stages of testicular cancer, and for those cases in which radiation therapy or chemotherapy was administered, the extent of monitoring after treatment will vary on the basis of the circumstances. Normally it should be done for five years in uncomplicated cases, and longer in those with higher risks of relapse.

Fertility A man with one remaining testis can lead a normal life, because the remaining testis takes up the burden of testosterone production and will generally have adequate fertility. It is, however, worth the (minor) expense of measuring hormone levels before removal of a testicle. Sperm banking may be appropriate for younger men who still plan to have children, since fertility may be lessened by removal of one testicle, and can be severely affected if extensive chemotherapy and/or radiotherapy is done. Fewer than 5 percent of men who have testicular cancer will have it again in the remaining testis. A man who loses both testicles will normally have to take hormone supplements (in particular, testosterone), and will be infertile, but can lead an otherwise normal life. Liangping Weng, MD, is a board-certified oncologist who practices with Sanford Worthington Cancer Clinic.

Fairview Health Services Opportunities to fit your life Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team. We currently have opportunities in the following areas: • Dermatology • Dermatology

•• Hospitalist Hospitalist

•• Pain Medicine Pediatrics

• Emergency • Emergency

•• Hospice Hospice

•• Psychiatry Psychiatry

Medicine Medicine

• Endocrinology • Family Medicine • Family Medicine • General Surgery • General Surgery

• Geriatric • Medicine Geriatric Medicine

•• Internal Medicine Internal Medicine •• Rheumatology Rheumatology •• Med/Peds Med/Peds

•• Urgent Care Sports Medicine

•• Ob/Gyn Ob/Gyn

• Urgent Care

•• Orthopedic Orthopedic

• Vascular Surgery

Surgery Surgery

Visit fairview.org/physicians to explore our current opportunities, then apply online, call 800‑842‑6469 or e-mail recruit1@fairview.org

Sorry, no J1 opportunities.

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

Olmsted Medical Center, a 160-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth.

Opportunities available in the following specialties:

Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere.

Family Medicine

The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Child Psychiatrist Rochester SE Clinic

Dermatology

Rochester Southeast Clinic Byron Clinic Pine Island Clinic

General Surgery

Call Only – Rochester Hospital

Hospitalist Hospital

Send CV to: Olmsted Medical Center

Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: dcardille@olmmed.org Phone: 507.529.6748 Fax: 507.529.6622

www.olmstedmedicalcenter.org

Minnesota Physician August 2014

Family Medicine St. Cloud/Sartell, MN We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals. Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal. HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and beneﬁt package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Family Medicine • General Surgery • Geriatrician • Outpatient Internal Medicine

• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery

• Psychiatry • Pulmonary/ Critical Care • Rheumatology • Urgent Care

F o r m o r e i n F o r m aT i o n :

Kari Lenz, Physician Recruitment | karib@acmc.com | (320) 231-6366

healthpartners.com

www.acmc.com |

MN Physician 4" x 5.25" 4-color

We’re looking for you - Family Physician - Flight Surgeon - Internist - Pediatrician - Psychiatrist - General Surgeon - Neurological Surgeon - Trauma Surgeon

In the U.S. Air Force, the power of being a physician reaches new heights. Work on the most time-sensitive cases. See medical advances as they happen. Be a hero to heroes. And do it all at 30,000 feet.

1-800-588-5260

Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:

• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.

Please contact or fax CV to:

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429

763-504-6600 Fax 763-504-6622

www.NWFPC.com August 2014 Minnesota Physician

Social determinants of health from page 15

with unisex bathrooms, multicultural art, a prayer room, a lactation room, and play areas for children. Hire staff that reflect the diversity of the patient population. Create culturally specific interventions. For example, offer a pre-Ramadan visit to talk about a patient’s plans, adjust medications if needed, and create a health plan

family dynamics, and other social determinants of health. • Family-centered approach: If one child has an elevated blood lead level, then test all the children. If a parent has diabetes, invite the family in for an A1c. If a teenage mom is homeless, help her parents get housing too. • Community-centered approach: Look for unique partnerships with community groups like community centers, faith-based groups, and non-profit organizations. For example, team with local transitional housing facilities to integrate health needs into plans for jail-to-community transitions. • Culturally-centered approach: Adapt the clinic’s physical environment

incomplete if the root cause of asthma is mold in a patient’s apartment. Improvements in diet, exercise, and insulin adherence are incomplete if the root cause of diabetes is not being able to afford healthy food. Therapy, antidepressants, and physical activity are incomplete if the root cause of depression is social isolation.

Which determinants of health appear particularly significant in relation to health issues your patients face. to address unique needs while fasting over the next month. • Transformational approach: Address the root causes of illnesses and seek policy-level changes. An asthma action plan, inhaler demonstration, and triage coaching is

Consider transformational approaches to allocating resources for patients. Providers can be affordable housing advocates, food activists, and community builders. Think about which determinants of health appear particularly significant in relation

to health issues your patients face and their complex intersections. In what ways have your patients attained their full health potential? What about a patient’s social position affects their health, either positively or negatively? Are patients meaningfully engaged in some kind of work or community involvement? Ask questions about the patient’s social determinants of health, gather resources to address needs, engage in community efforts for health equity, and share lessons to create policy-level changes.

Kate S. Erickson, MSW, is the integrated care manager at Community–University Health Care Center. Christopher Reif, MD, MPH, is board-certified in family medicine and is a member of the Family Medicine and Community Health Department at the University of Minnesota. He is currently the director of clinical services at Community–University Health Care Center.

Physician Practice Opportunities Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassionate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.

Avera Marshall Regional Medical Center 300 S. Bruce St. Marshall, MN 56258

Currently we are seeking to add the following specialists:

• General Surgery

• Internal Medicine

• Radiation Oncology

• Family Practice

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/ For more information, contact Dave Dertien, Physician Recruiter, at 605-322-7691 • Dave.Dertien@avera.org

www.averamarshall.org 34

Minnesota Physician August 2014

August 2014 Minnesota Physician

Medical scribes from page 11

Patient satisfaction Some physicians have expressed reservations about having another person in the examination room during a patient visit and how this might adversely affect the doctor-patient relationship. Koshy et al. (Journal of Urology, 2010) studied the effect of scribes in a urology clinic and found patient satisfaction high both with a scribe (93 percent) and without (87 percent). In our study, we found that patient satisfaction was very high and unchanged with a scribe in the room, and that physician-patient interaction was significantly better. My patients like the fact that I can focus on them and not on the computer. I have had only one patient out of over 1,500 request that a scribe leave the room. Training for scribes as future medical professionals Most of the scribes who work

with us proceed to train in the health care profession (many as physicians) within one to two years of starting as scribes. The experience they obtain is invaluable. They learn medical terminology, understand the medical thought processes, and observe how physicians analyze problems and interact with patients. Economics of health care The economist Paul Krugman wrote, “Productivity isn’t everything, but in the long run it is almost everything. A country’s ability to improve its standard of living over time depends almost entirely on its ability to raise its output per worker.” The cost of health care in the U.S. continues to rise and exceed inflation. One of many approaches to reduce the cost of health care in the U.S. is to improve physician efficiency and productivity. If this is successfully accomplished by any means, a number of beneficial

financial results occur. In a fee for service environment, physician salary and health care system revenue increases. This increase is not due to performing more tests or using more resources, but rather by providing necessary care to more people in a more efficient manner. In an accountable care environment, the cost of care goes down because a given physician can provide greater care for a larger number of patients in a fixed amount of time. Conclusions Although changing physician workflow by incorporating scribes into routine clinical practice takes some time and effort, the payback is large for all concerned. In medicine we have been slow to adopt, and adapt to, change. There is no other business I am aware of that has many of its highest paid individuals typing, scheduling, searching for information, or performing

other tasks that can be done more effectively and efficiently by others. As physicians, the core tasks we should (and must) perform are actually very limited: evaluating and examining patients, making complex medical decisions, interpreting and performing diagnostic and therapeutic tests, and performing procedures. Unfortunately, many of us spend less than 50 percent of our time performing these core functions. Perhaps it is time we consider the use of scribes, and other creative solutions, to get doctors back to what they do best: Taking care of patients, and enjoying it!

Alan J. Bank, MD, is a board-certified cardiologist and the medical director of research at United Heart and Vascular Clinic, Allina Health, St. Paul. He is also an associate professor of cardiology at the University of Minnesota.

VA Health Care System In South Dakota Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions in the following location.

Sioux Falls VA HCS, SD Primary Care (Family Practice or Internal Medicine) Psychiatrist Endocrinology

Pulmonologist Oncologist Cardiologist (part time) Physician Assistant (Mental Health)

Sioux Falls VA HCS (605) 333-6852 www.siouxfalls.va.gov

Black Hills VA HCS Primary Care (Family Practice or Internal Medicine)

Psychiatrist Hospitalist

Black Hills VA HCS (605) 720-7487 www.blackhills.va.gov

Applicants can apply online at www.USAJOBS.gov 36

Minnesota Physician August 2014

Urgent Care We have part-time and on-call positions available at a variety of Twin Cities’ metro area HealthPartners Clinics. We are seeking BC/BE fullrange family medicine and internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice. For consideration, apply online at healthpartners.com/careers and follow the Search Physician Careers link to view our Urgent Care opportunities. For more information, please contact diane.m.collins@healthpartners.com or call Diane at: 952-883-5453; toll-free: 1-800-472-4695 x3. EOE

HEALTH

MN Physician 4" x 5.25" 4-color

Fairview-Southdale Hospital ICU Medical Director University of Minnesota Physicians is seeking a Medical Director for the Fairview-Southdale ICU (FS-ICU). This position will provide and direct outstanding care of critically ill patients in a multidisciplinary ICU at Fairview-Southdale Hospital. This position will also serve as Chair of the multidisciplinary critical care committee. The majority of efforts will be onsite at Fairview-Southdale Hospital. Requirements for this position include: • Have or be eligible for MN State Medical License • Board certified in Critical Care (Anesthesia, Medicine, Surgery or Pulmonary; Pulmonary physicians will have opportunity to develop additional practice if desired) • Four years of experience post fellowship is preferred • Experience in a community setting strongly desired

FOR MORE INFORMATION AND A COMPLETE JOB DESCRIPTION, CONTACT: Greg J. Beilman, M.D. Medical Director, Fairview System Critical Care Program Deputy Chair, Department of Surgery University of Minnesota 420 Delaware Street S.E., Mayo Mail Code 195 Minneapolis, MN 55455 EMAIL: beilm001@umn.edu

Family Medicine

Stevens Community Medical Center’s Starbuck Clinic is looking for a family medicine physician. Enjoy the beautiful area lakes, quiet atmosphere and all that West Central Minnesota has to offer. Starbuck Clinic is home to Staff Care’s 2013 Country Doctor of the Year. Dr. Bösl and Greg Rapp, PA provide full clinic services in the picturesque town of Starbuck, MN on Lake Minnewaska. Dr. Bösl would like to transition into retirement. If you would enjoy the serenity of a rural lake community plus the comfort of an independent practice, this is your opportunity!

For more information, contact John Rau, CEO or Dr. Robert Bösl. Morris location

Starbuck location

320.589.7655 jrau@scmcinc.org

320.239.3939 rbosl@hcinet.net

John Rau, CEO

Dr. Robert Bösl

www.scmcinc.org

Visit us on Facebook and Twitter.

EOE

August 2014 Minnesota Physician

Why aren’t Minnesotans using hospice care? from page 13

materials also educate patients and their families, so they don’t have to admit ignorance, and provide an opportunity to discuss the information with their physician. Many physicians believe that three to six months in hospice care is appropriate. Yet, according to published studies (Medical College of Wisconsin), physicians tend to overestimate prognosis on average by 500 percent. A patient they believe will live for five months may actually die in just one month. Since the median length of stay in hospice now stands at 18.7 days, it’s obvious that patients don’t receive hospice care early enough. It’s hard to predict a patient’s prognosis. Instead of trying to predict a six-month prognosis, doctors should ask a different question: Would I be surprised if I saw my patient’s name in the obituary column of my local newspaper in the next

year? These are the patients who would benefit from earlier conversations about end-of-life care and hospice. Provide a script for physicians What do you say to start the discussion on distinguishing curative-, remissive-, and com-

to slow it down, we have found that hospice care is a good option because it offers patients the opportunity to stay at home and to make personal decisions about how to spend the time that remains. We work with local hospices that offer these services.

Since the median length of stay in hospice now stands at 18.7 days, it’s obvious that patients don’t receive hospice care early enough. fort-focused treatments early on in the course of a serious illness? For talking with patients, we recommend something like this: In our practice, we believe that patient comfort and quality of life are as important as curing a disease or prolonging life. When curative treatments no longer have the desired effect, and when a disease continues to worsen in spite of treatments

Refer patients earlier According to a Duke University study, hospice use has been shown to reduce Medicare program expenditures during the last year of life by an average of $2,309 per patient. If Minnesota physicians increased appropriate hospice referrals so they were comparable to other states and served an additional 7,000 patients, they could

achieve an incremental savings of more than $16 million. With still-low hospice utilization and average length of stay across the country, the effort to increase referrals to hospice and to refer earlier is important. Physicians who dread having to tell patients “there’s nothing more that can be done” can replace that phrase with “Let’s talk about hospice and how I can help make you comfortable, while giving you a better quality of life.” Join us in this important work to increase referrals to hospice in Minnesota—and to refer earlier. The materials created for the TRUE project are available for your practice at: (www. stratishealth.org/providers/hospice.html). Barry Baines, MD, is medical director at Sholom Johnson Hospice and consultant at Stratis Health. Janelle Shearer, RN, BSN, MA, is program manager at Stratis Health.

alz.org/mnnd

24/7 Helpline 800.272.3900

Memory loss that disrupts daily life

New problems with words in speaking or writing

Challenges in planning or solving problems

Misplacing things and losing the ability to retrace steps

Difficulty completing familiar tasks

Decreased or poor judgment

Confusion with time or place

Withdrawal from work or social activities

Trouble understanding visual images and spatial relationships

Difficulty completing familiar tasks

Recognizing the symptoms is the first step toward doing something about it. Early detection matters. The Alzheimer’s Association can help your patients develop a plan for the future. 38

Minnesota Physician August 2014

GET READY FOR

ICD-10

STAY ON THE ROAD TO 10 STEPS TO HELP YOU TRANSITION The ICD-10 transition will affect every part of your practice, from software upgrades, to patient registration and referrals, to clinical documentation and billing. CMS can help you prepare. Visit the CMS website at www.cms.gov/ICD10 and find out how to: •

Make a Plan—Look at the codes you use, develop a budget, and prepare your staff

•

Train Your Staff—Find options and resources to help your staff get ready for the transition

•

Update Your Processes—Review your policies, procedures, forms, and templates

•

Talk to Your Vendors and Payers—Talk to your software vendors, clearinghouses, and billing services

•

Test Your Systems and Processes—Test within your practice and with your vendors and payers

Now is the time to get ready. www.cms.gov/ICD10

Official CMS Industry Resources for the ICD-10 Transition

www.cms.gov/ICD10

Minnesota_Physician_052814.indd 1

5/28/14 1:52 PM

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