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Volume x x vii, N o. 7

Oc t ober 2013

Multicultural advance care planning Perspectives from the field By Miguel Ruiz, MD, and Barbara Greene, MPH

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ulture has an important impact on a patient’s decision whether or not to perform advance care planning. Culture includes the values, beliefs, and behaviors that people hold in common, transmit across generations, and use to interpret their experiences. Understanding cultural differences can help physicians open the gate to conversations concerning complex end-of-life care decision-making. By being sensitized to language, ethnicity, history, and other perspectives, physicians can reinforce patient and family trust when it matters most.

Managing polarities Getting from “either/or” to “and” By Val Ulstad, MD, MPA, MPH, and Kathy Ogle, MD

Sharing two case studies Case Study 1: A 74-year-old Latino man is admitted to the hospital with a several-week history of nausea, intermittent vomiting, and dysphagia. He reports a decreased appetite and a 30-pound weight loss over the last six months. Multicultural advance care planning to page 12

The single biggest problem with communication is the illusion that it has taken place. — George Bernard Shaw, playwright and critic (1856–1950)

Managing polarities to page 10

PRSRT STD U.S. Postage

it feel like the person you are seeing connects with you? Do you believe that person hears you? Are your questions and concerns answered in ways that

Detriot Lakes, MN Permit No. 2655

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s elders (>50) in the community who also happen to be docs, we are often asked (by friends and family) how to know if a particular clinician is “good.” We find ourselves asking them again and again: Does


NEW ICD-10 DEADLINE:

OCT 1, 2014

2014 COMPLIANCE DEADLINE FOR ICD-10 The ICD-10 transition is coming October 1, 2014. The ICD-10 transition will change every part of how you provide care, from software upgrades, to patient registration and referrals, to clinical documentation, and billing. Work with your software vendor, clearinghouse, and billing service now to ensure you are ready when the time comes. ICD-10 is closer than it seems. CMS can help. Visit the CMS website at www.cms.gov/ICD10 for resources to get your practice ready.

Official CMS Industry Resources for the ICD-10 Transition

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CONTE NTS

October 2013 • Volume XXVII, No. 7

Features Managing polarities

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MINNESOTA HEALTH CARE ROUNDTABLE

Getting from “either/or” to “and” By Val Ulstad, MD, MPA, MPH, and Kathy Ogle, MD

Multicultural advance care planning

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Perspectives from the field By Miguel Ruiz, MD, and Barbara Greene, MPH

Departments Capsules

4

Medicus

7

Interview

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Don W. Brady, MD Vanderbilt University Medical Center, Nashville

integrative clinical care 18 Hypnosis comes of age By Shepherd Myers, PhD

Psychiatry 28 Seasonal affective disorder By Barry Rittberg, MD, and S. Charles Schulz, MD

Professional update: Orthopedics Wrist injuries

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By L.T. Donovan, DO

Orthopedics Spine Outcomes Research Trial

32

Shared suffering

By Amy Lynn Conners, MD

“So, how was your vacation?”

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By Rachel Frazin, APRN

Physician shadow program 22

Advance care planning Thursday, October 24, 2013 1:00 – 4:00 PM • Symphony Ballroom Downtown Mpls. Hilton and Towers

Special focus: Physician-patient communication 20

SESSION

Addressing end-of-life issues

By David H. Strothman, MD

Keeping the lines open

FORTIETH

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By Art Wineman, MD

Background and focus: For the majority, end-of-life is the most medically managed part of life. With it come complex issues that involve economics, ethics, politics, medical science, and more. Advances in technology are extending life expectancies and require a redefinition of the term “end-of-life.” It now entails a longer time frame than one’s final weeks or hours, and provokes debate as to when life is really over. Mechanisms exist to facilitate personal direction around this topic, but there is a need for improved coordination among the entities that provide end-of-life support.

Objectives: We will discuss the significant infrastructure that supports end-of-life care. We will examine the roles of long-term care/assisted living, palliative care, gerontology, and hospice. We will review the elements that go into creating advanced directives, including societal issues that make having them necessary, and the difficulties encountered in bringing them to their current state. We will present a potential road map to optimal utilization of end-of-life support today and how it may best be improved in the future. Panelists include:

By Naomi Hertsgaard, MPH, William Nersesian, MD, MHA, and Craig Roth, MD, FACP

◆ Ed Ratner, MD, University of Minnesota Center for Bioethics ◆ Suzanne M. Scheller, Esq., Scheller Legal Solutions, LLC The Independant Medical Business Newspaper

◆ Cheryl Stephens, PhD, MBA, President, CEO, Community Health Information Collaborative ◆ Tomás Valdivia, MD, MS, CEO, Luminat ◆ Maggie O'Connor, M.D., Facilitator, Sacred Art of Living & Dying

Sponsors: Community Health Information Collaborative Luminat • Scheller Legal Solutions www.mppub.com

Publisher Mike Starnes mstarnes@mppub.com Senior Editor Donna Ahrens dahrens@mppub.com ASsociate Editor Janet Cass jcass@mppub.com Assistant Editor Jennifer Hollingsworth-Barry jhb@mppub.com Art Director Alice Savitski asavitski@mppub.com Office Administrator Amanda Marlow amarlow@mppub.com Account Executive Iain Kane ikane@mppub.com Account Executive Madge Johnson mjohnson@mppub.com 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 are opinions expressed by authors of published articles are solely those of the authors and do not neccessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publications. 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 within written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name Company Address City, State, Zip Telephone/FAX Card #

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2013 October Minnesota Physician

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C a psu les

Thyroid Cancer Overdiagnosed, Study Suggests A growing gap between rates of thyroid cancer diagnoses and deaths from the disease has led to the conclusion that some lowrisk cancers are being overdiagnosed, according to study results from the Mayo Clinic Center for the Science of Health Care Delivery. The findings are featured in the most recent issue of the British Medical Journal (BMJ). According to Mayo officials, surgical removal procedures in the U.S. have tripled over the last 30 years, from 3.6 in 100,000 people in 1973 to 11.6 in 100,000 people in 2009. “High-tech imaging technologies such as ultrasound, CT, and MRI can detect very small thyroid nodules, many of which are slow-growing papillary thyroid cancers,” says the study’s lead author, Juan Pablo Brito, MD, an endocrinologist at

Mayo Clinic. “This is exposing patients to unnecessary and harmful treatments that are inconsistent with their prognosis.” This information has prompted the recommendation for a new diagnostic term to help patients avoid unnecessary surgeries, medication, and radiation, as well as the associated costs for the treatment. Brito and his colleagues argue that patients with thyroid tumors smaller than 20 millimeters and no family history of the disease should be diagnosed as having microPapillary Lesions of Indolent Course (microPLIC). He also notes the need for additional research to determine appropriate care strategies for these patients. “Uncertainty about the benefits and harms of immediate treatment for low-risk papillary thyroid cancer should spur clinicians to engage patients in shared decision-making to ensure treatment is consistent with the research evidence and patient goals,” says Brito.

CHIC, Orion Health Partner Community Health Information Collaborative (CHIC), a Duluth-based nonprofit that promotes health information exchange across care settings, has announced a partnership with Orion Health, an international eHealth technology company. Orion Healths technology has been selected to power HIEBridge, the state-certified health information exchange (HIE). Enhancing care coordination between health care organizations and providers to improve outcomes, save time for patients and providers, and reduce health care costs is CHIC’s main objective with this move, officials with the company say. Organizations currently using HIE-Bridge services will be moved to Orion Health’s infrastructure in the coming months, and those seeking to join will be added in the fourth quarter of this year. The HIE services will

include access to clinical patient information, medication and immunization histories, and laboratory and diagnostic test results. Clinical data analytics will be added in the future. “CHIC engaged in a vigorous RFP [request for proposal] process as we researched HIE software vendors. We selected Orion Health due to its outstanding customer service and breadth of solutions from which we can build a much more mature HIEBridge-CONNECT offering for our clients in Minnesota,” says Cheryl Stephens, president and CEO of CHIC. “CHIC’s vision of notifications to providers of emergency room visits by patients and having a longitudinal patient record that could be accessed quickly, securely, and configured to a physician’s viewing preference, plus many more enhancements, is now possible with the Orion Health solution.”

Capsules to page 5

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Minnesota Physician October 2013


Study looks at EndHospital Observation of-Life Care for CanStatus Costly for cer Patients Medicare Patients An analysis released by the

Capsules from page 4

According to a recent report by the U.S. Department of Health and Human Services, hospitals are increasingly designating patients with multi-day stays as observation status (technically classified as outpatient status), instead of inpatient admissions. For those on Medicare, this can have major cost implications, as follow-up treatment in a nursing home is covered only if they have been classified as an inpatient for a minimum of three days. In 2012, more than 600,000 Medicare patients were hospitalized for at least three days but did not qualify for nursing home care coverage. The report also says that for the 2,000-plus outpatient and observation status hospital stays last year, patients were responsible for a total of $22 million in follow-up nursing home charges not covered by Medicare. During the same period, Medicare was found to have improperly paid out $255 million for follow-up care for patients who should not have been eligible for such coverage. The nonprofit Center for Medicare Advocacy has filed a class-action lawsuit against the Department of Health and Human Services challenging the observation status policy. Representatives from the center said the increased use of observation stays is fueled by hospitals’ financial concerns, at a time when federal overseers are cracking down on hospital readmissions and other Medicare spending. Toby Edelman, senior attorney for the center, says, “To deny people coverage in the nursing home because the hospital called them outpatients makes absolutely no sense.” Rep. Joe Courtney (D-Conn.) has proposed legislation aimed at resolving the issue. Under the bill, Medicare would be required to pay for follow-up care in a nursing home for any patient hospitalized for three days or longer, regardless of status.

Dartmouth Atlas Project, based at the Dartmouth Institute for Health Policy and Clinical Practice, has found that in Minnesota, late-stage cancer patients are less likely than their counterparts in other states to have lastchance treatment attempts or be sent to the intensive care unit, and more likely to receive hospice services or palliative care, which prioritize comfort over life-sustaining interventions. The report examined end-of-life care trends for advanced cancer patients across regions, academic medical centers, and National Cancer Institute-designated cancer centers. Nationally, one in four late-stage cancer patients died in a hospital in 2010. In Minnesota, the rate was one in five, though the rates varied significantly among hospitals across the state. In the U.S., fewer Medicare patients spent the end of their lives in a hospital in 2010 compared to data from 2003 to 2007. However, aggressive treatment was shown to continue in their last days; there was no change in the number of patients likely to receive treatments such as intubation or cardiopulmonary resuscitation in the final month of life, or to undergo chemotherapy during the last two weeks of life. “Our research continues to find that patients with advanced cancer are often receiving aggressive care until their final days, when we know that most patients would prefer care directed toward a better quality of life through hospice and palliative services. The increase in patients admitted to hospice care only days before death suggests that hospice services are often provided too late to provide much benefit,” says David C. Goodman, MD, MS, coprincipal investigator for the Dartmouth Atlas Project.

Capsules to page 6

Request for nomination Request for nomination

Request for nomination

2010 Community Caregivers 2014 2010 Community Community Caregivers Caregivers Nomination Closing: Friday, October 9, 2009 Publication Date: March 2010

Nomination Closing: Friday, December 6, 2013 Recognizing Minnesota physician volunteers Nomination Closing: Friday, October Publication Date: March 20149, 2009

Publication Date: March 2010 Community Minnesota Physician Publishing announces our annual Recognizing physician volunteers Caregivers feature. WeMinnesota are seeking nominations of Minnesota physicians who have volunteered medical services in communities in Minnesota, Recognizing physician volunteers Minnesota PhysicianMinnesota Publishing announces our annual Commuin the U.S.,Physician or abroad. nity Caregivers feature. We are seeking our nominations of Minnesota Minnesota Publishing announces annual Community physicians who have volunteered medical inthe communities The nominees selected for seeking recognition will be services featured in March Caregivers feature. We are nominations of Minnesota physicians in Minnesota, in U.S., or abroad. 2010have edition of the Minnesota Physician, most widely read who volunteered medical servicesthe in region’s communities in Minnesota, publication. medical in the U.S., or abroad. The nominees selected for recognition will be featured in the March To qualify, nominees should be physicians practicing ininmost Minnesota who 2014 edition of Minnesota Physician, region’s widely read The nominees selected for recognition willthe be featured the March medical publication. have performed medical services, either ormost abroad, during 2010 edition of Minnesota Physician, thelocally region’s widely read2009. Both teams and individual physicians may be nominated; theMinnesota nominapublication. medical To qualify, nominees should be physicians practicingifin tion is for a team, please designate one or two physicians who could be who have performed medical services, either locally or abroad, To qualify, nominees should be physicians practicing in Minnesota who interviewed if selected forservices, the feature. during 2013. Both teams and individual be2009. nomihave performed medical either locallyphysicians or abroad, may during

nominathenominaTo nominate a physician physicians, please fill out nated; if theand nomination isteam for aofteam, designate one or two Both teams individualorphysicians may please be nominated; if the physicians who could be interviewed selected forOctober the tion is form submit it by mail oriftwo fax by Friday, 9, 2009. tion for abelow team,and please designate one or physicians whofeature. could be interviewed if selected for the To nominate a physician orfeature. team of physicians, please out the Send to Minnesota Physician Publishing, 2812 East 26thfill Street, nomination below it by mail or fill faxout by the Friday, nominaTo nominate form a MN physician orand teamsubmit physicians, please Minneapolis, 55406. Fax toof612-728-8601. Dec. 6, 2013. tion form below and submit it by mail or fax by Friday, October 9, 2009. For more information, call (612) 728-8600. Send toMinnesota Minnesota Physician Publishing, East Street, 26th Street, Send to Physician Publishing, 28122812 East 26th 55406. Fax to 612.728.8601Form Minneapolis, MN 55406.MN Fax to 612-728-8601. 2010Minneapolis, Community Caregivers Nomination

For more information, call 612.728.8600. For more like information, call (612) 728-8600. I would to nominate the following physician(s): Name and location of physician’s practice:

2010Community Community Caregivers Caregivers Nomination 2014 NominationForm Form

I would like to nominate the following physician(s): Name and location of physician’s practice: Physician’s phone number and e-mail address:

Physician’s phone number and e-mail address: Brief description of the physician’s medical service:

Brief description of the physician’s medical service:

Nomination submitted by: Name: Address: Nomination submitted by: City/state/ZIP code: Name: Phone number: Address: E-mail: City/state/ZIP code: Phone number: E-mail:

2013 October Minnesota Physician

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Capsules from page 5

Technology Monitors Post-Surgery Recovery, Improves Outcomes Wireless monitoring of mobility may accelerate patients recovery after heart surgery and improve postoperative outcomes because of the opportunity for early identification and intervention, a study from the Mayo Clinic has found. Results of the study were published in the September 2013 issue of the Annals of Thoracic Surgery. Following elective heart surgery (coronary artery bypass grafting, valve repair or replacement, or both), patients wore off-the-shelf monitors on their ankles, so the researchers could track the total number of steps the patients took each day after they were moved from the intensive care unit to a regular hospital room. Patients were categorized by discharge destination—home, home with

health care support (HHC), or a skilled nursing facility (SNF)— and length of hospital stay (short, intermediate, or long). A major difference among the groups appeared on recovery day two. The median number of steps taken by patients who had been discharged to their homes was 675, compared to a median of 108 steps for the HHC and SNF groups. The study also found that patients with short hospital stays walked significantly more than those with long stays. The researchers concluded, “Wireless monitoring of mobility after major surgery was easy and practical. There was a significant relationship between the number of steps taken in the early recovery period, length of stay, and dismissal disposition in an older cardiac surgery population. This opens the door for changing recovery models and improving outcomes in surgical practice.” Claude Deschamps, MD,

senior author of the study, said, “The benefits this technology brings to most elderly hospitalized patients will be tremendous. The technology is already robust and reliable, and the next three years will bring the software integration to allow the data to easily populate electronic medical records or patient dashboards.”

24-Hour Blood Pressure Test may Increase Diagnosis Accuracy A new study by Allina Health tests the accuracy of 24-hour blood pressure monitoring devices versus that of conventional routine blood pressure tests, and says the new approach could give more reliable diagnoses to thousands of patients. Researchers are seeing increasing evidence that routine, point-in-time blood pressure

readings can lead to overdiagnosis of high blood pressure in up to 20 percent of patients whose numbers rise at their appointment due to nerves. Underdiagnosis is also occurring for those who have hidden hypertension that isn’t detected. The new method has been used to test the blood pressure of more than 1,000 patients in the Twin Cities over the past year. Patients are equipped with a wireless monitor that takes their blood pressure every 20 minutes, for 24 hours, and tracks the scores to be assessed by their doctors. For some patients, the new testing format has provided results that contradict those of their routine blood pressure checks at a health care facility, and either eliminate or confirm a need for medication. The U.S. Preventative Services Task Force is currently reviewing its stance on high blood pressure prevention and the role 24-hour monitoring could play.

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Minnesota Physician October 2013

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Nisha Jacobs, MD, has joined the Coon Rapids clinic of Minnesota Oncology. Board-certified in internal medicine and in medical oncology and hematology, Jacobs earned a medical degree from the University of Missouri, Kansas City, and completed a fellowship in medical oncology and hematology at the University of Minnesota. Christine Larsen, MD, a board-certified ophthalmologist specializing in glaucoma treatment, has joined Twin Cities-based Minnesota Eye Consultants. She completed medical school and residency at the University of Nebraska Medical Center, Omaha, and a fellowship in glaucoma at the University of Wisconsin, Madison. Nisha Jacobs, MD

Bradley Linden, MD, has joined Pediatric Surgical Associates, Minneapolis. Boardcertified in pediatric and general surgery, he earned a medical degree and completed his residency at the University of Minnesota and completed his fellowship at Boston Children’s Hospital. Linden previously served as director of minimally invasive pediatric surgery at Harvard Medical School and founded and directed the bariatric surgery program at Bradley Linden, MD Boston Children’s Hospital. James Peters, MD, board-certified in sports medicine and family medicine, has joined Sports & Orthopaedic Specialists, part of Allina Health. Peters earned a medical degree from Rush Medical College, Chicago, and completed residencies at the University of Minnesota. Most recently, he cared for patients at Fairview Sports and Orthopedic Care, which he founded. Aby Z. Philip, MD, board-certified in internal medicine, has joined the Cancer Center at Essentia Health-St. Joseph’s Medical Center, Brainerd, as an oncologist. Philip earned his medical degree from Government Medical College in Thiruvananthapuram, India. He served a residency in internal medicine and a fellowship in hematology and oncology at the University of Connecticut Health Care Center in Farmington, Conn.

Telephone Equipment Distribution (TED) Program

M e d i c us

Do you have patients with trouble using their telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services

Aby Z. Philip, MD

Steven Senica, MD, board-certified in obstetrics and gynecology, has joined the Essentia Health Baxter Specialty Clinic as an obstetrician-gynecologist and also will see patients at Good Beginnings OB Clinic at Essentia HealthSt. Joseph’s Medical Center, Brainerd. Senica earned a medical degree from Loyola University Stritch School of Medicine and completed a residency in obstetrics and gynecology at Loyola University Medical Center, both in Maywood, Ill. Ashok Saluja, PhD, received the George Palade Medal at September’s joint meeting of the International Association of Pancreatology and the Korean Pancreatobiliary Association in Seoul. The annually awarded medal was given for research into pancreatic and other cancers. Saluja is the Eugene C. and Gail V. Sit Chair in Pancreatic and Gastrointestinal Cancer and vice chair of research in the University of Minnesota Department of Surgery, where he is a professor. Daniel Weisdorf, MD, board-certified in hematology and medical oncology, has been appointed director of the Division of Hematology, Oncology and Transplantation in the University of Minnesota Department of Medicine. Weisdorf earned a medical degree from the University of Chicago Medical School, completed an internal medicine residency at Michael Reese Hospital, Chicago, and completed a hematology and medical oncology fellowship at the University of Minnesota.

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2013 October Minnesota Physician

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I nte rv i e w

Improving patient-physician communication

Don W. Brady, MD American Academy on Communication in Healthcare

A board-certified general internist, Don Brady currently serves as the president of the American Academy on Communication in Healthcare. Brady is chair of the faculty senate at Vanderbilt University, Nashville, Tenn., where he is a professor of medical education and administration. He is also a senior associate dean for graduate medical education and continuing professional development, and his deanships make him a designated institutional official professor of medicine.

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 lease tell us about the mission of the P American Academy on Communication in Healthcare.

 lease give us an example of how your P work has made positive change within the health-care delivery system.

The American Academy on Communication in Healthcare (AACH) is a nonprofit organization originally founded in 1978 as a task force of caring physicians, composed of clinicians and medical educators representing a variety of professions and specialties. AACH’s mission is to improve health care by enhancing communication skills among clinicians and across health care teams and systems. Inspired by a commitment to relationships as the fulcrum of health care delivery, AACH faculty devote time outside their regular positions to conduct onsite training for institutions, community health clinics, large medical centers, and private-practice groups.

Using time wisely. We live and work in an era when we only have a few minutes to see a patient. If you are a physician, you must understand the patient agenda and be able to explain to them what they must do. You must use the time wisely and balance the patient’s agenda with your agenda— and do all of this in only 10 minutes. Both must come to shared decisions that meet both agendas.  hat are the biggest obstacles that stand W in the way of improved communication within the health-care delivery system?

It’s a member-driven organization. Many members, like me, are communication educators, teaching in medical schools, medical centers, and hospitals. There are members who are researchers studying communication issues, such as decisionmaking, patient communication, or how to give better care. Others might teach communication skills, or deal with health care literacy or patient safety issues. Some individuals are addressing patient advocacy issues.

One barrier is the time factor. Even with improved skills, 10 minutes with one patient is a very short time. The second issue that stands in the way is the other pressures on physicians, such as billing issues. We must also learn to manage the expectations around how people want to communicate with their physician. I think that we’re going through a transition period involving the use of electronic devices, email communication, text communication, and how different generations use different modes of communication. We’re trying to figure out how we bridge those new technologies into patient care.

 hat kind of research does this W organization do to support its mission?

 hat do you see as the best outcomes for W the work the AACH is doing?

More than anything, we must understand that any medical encounter is a partnership between two people.

We primarily serve as a tool for researchers to collaborate. As an organization, we do not do the research ourselves, but serve as a community for researchers to come together. In fall 2014, AACH will host the biannual Research and Teaching Forum in Orlando, Fla. (For details, visit www. AACHonline.org.) The International Conference on Communication in Healthcare (ICCH) and AACH bring together over 400 health-care communication professionals from across North America and Europe to share the latest research and teaching methods related to communication and relationships in health care. The 2013 conference was held in Montreal, Sept. 29–Oct. 2.

Minnesota Physician October 2013

Helping systems to train physicians, particularly those who might have been struggling with communication issues. Our partnership with Mayo, for example, has helped identify physicians who could benefit from attending our classes, which have produced improved outcomes in the physicians’ ability to communicate with patients.  ow do you keep the communication H training going within an organization you’ve helped? Even when we’re training the trainer, the goal is to improve and create better communication in the end—the direct contact between the physician and the patient. Most of the trainers that we train are physicians, so they understand what needs to be known. If they are leaders within


their organizations, they can train other physicians to carry the message forward. Most recently we have been working with Mayo in this capacity.  hat are some changes in our W health-care delivery system that drive the need for better communication? The changes, in some ways, are giving mixed messages. Some of the reimbursements and incentives toward better communication are more focused on the patient experience and how they perceive their physician, but they are not necessarily changing the actual reimbursement or adding more time for the physician to see the patent. The difference between a 10-minute visit and 15 minutes is huge. You also have the issue of an aging population. It is very different to develop a relationship with a 35-year-old who is healthy, doesn’t have a lot of issues, and can be managed within a short time frame, than with a 75-year-old who may have cancer, COPD, heart disease, and arthritis. From a primary care physician’s perspective, we need to engage them both

and have meaningful conversations about how to manage the whole picture. These are two very different types of communications that we need to have in order to engage the patients around the conflicting nature of their illnesses. We also need to coordinate the physician, the nurse practitioner, and the PA with the patient as we help quarterback the care. We need to help the patient understand how all of the factors fit together to achieve the best outcomes and how all of the related care providers can work together.

there are cultural issues to deal with. That’s an area of training that we don’t do as well as we could or should at the medical school and residency levels. It’s a difficult issue. There is also the issue of communicating with the patient’s family members.  hat can you share with our readers W about ways they can improve their communication skills? What I would most like to share with them is to be open and to engage the patient from the moment they walk in the door. They need to understand what the patient is bringing, what their wishes are, and work from that point. To reach a common understanding of the patient’s values and then to use that information in combination with the physician’s own medical knowledge to create a partnership is ideal. The thing about health care is that if patients could make all their decisions alone, they would not need physicians. More than anything, we must understand that any medical encounter is a partnership between two people.

 ow do you address the issues in H physician/patient communication that arise from a growing number of cultural/ESL/health-care literacy concerns? Learning how to utilize translators is a definite issue that could also be listed as a goal barrier in terms of the number of bilingual, paralingual, and metalingual physicians serving as translators and helping to engage patients. In patient communications, sometimes we don’t convey information from person to person correctly. Even if the words are conveyed,

University of Minnesota Continuing Professional Development 2013 CME Activities

2014 CME Activities

Practical Dermatology October 25-26, 2013

Psychiatry Update: Promoting Healthy Eating & Lifestyles April 3-4, 2014

Pediatric Trauma Summit November 1-2, 2013 Donald Gleason Conference on Prostate & Urologic Cancers November 8, 2013

Cardiac Arrhythmias April 4, 2014 Integrated Behavioral Healthcare Conference April 25, 2014

Internal Medicine Review & Update November 13-15, 2013

Pediatric Dermatology April 25, 2014

Emerging Infections in Clinical Practice & Public Health: New Developments November 22, 2013

Annual Surgery Course: Vascular Surgery May 1-2, 2014 Global Health Training (weekly modules) May 5-30, 2014 Midwest Cardiovascular Forum May 17-18, 2014 Bariatric Education Days: Decade of Bariatric Education May 21-22, 2014 Workshops in Clinical Hypnosis June 5-7, 2014

ONLINE COURSES (CME credit available)

www.cme.umn.edu/online • Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health • Nitrous Oxide for Pediatric Procedural Sedation • Fetal Alcohol Spectrum Disorders (FASD) - Early Identification & Intervention For a full activity listing, go to www.cmecourses.umn.edu (All courses in the Twin Cities unless noted)

Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 • email: cme@umn.edu

Promoting a lifetime of outstanding professional practice

2013 october Minnesota Physician

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Managing polarities from cover

• Speaking and listening

you can understand? If the answer to all of these questions is yes, we say hang on to that person and let him or her guide you.

• Verbal communication and nonverbal communication

The creation of understanding between a clinician and a patient is much more than one mouth moving in the physical presence of another person. Nor is it a checklist that, once fulfilled, guarantees successful communication. And it certainly is not a relationship between a person at a computer (aka the doctor) and another person (aka the patient) who both happen to be in the same room. Rather, a meaningful interaction with and for a patient requires energy that we will call the productive tension of engagement, or engaging tension. Inherent in establishing a real connection between doctor and patient are attributes that may seem opposing, yet are interdependent. Some examples are:

• Awareness of self and awareness of other • Speaker’s intention and listener’s perception • Clinician’s imperative to inform and patient’s desire to tell his or her story • A set agenda in a timeconstrained visit and emergent priorities based on the patient’s history

able, the potential solutions are independent, and one does not need to include the alternatives in order for a solution to work. When you are right, those who disagree with you are wrong. Take the example of a nurse manager who is faced with deciding where to place containers of hand-cleansing foam to maximize staff compliance with hand sterilization. Several

Polarities— different from problems A polarity is different from a problem. A problem is solv-

potential independent solutions are correct, and the problem is solvable. In contrast, a polarity does not have a “correct” endpoint; it is not solvable through “either/or” problem-solving; and the alternatives cannot stand alone—both (or more) are needed to optimize the situation over time. For example, the work of reducing nosocomial infections requires managing polarities inherent in that work, such as efficiency and efficacy, or individual responsibility and system oversight. Managing polarities is an active process that requires energy and focus. A common mistake is to think in terms of “either/or” instead of “and” as we consider the polarities. Focusing on “either/or” turns the polarity into a problem that has just one potential solution. Focusing on “and” allows us to consider the upsides of both attributes. If this approach is not actively managed, the tendency will be to focus on one pole at the expense of the other. Since both aspects of a polarity are valid, taking either aspect to an extreme at the expense of the other results in oversimplification of complex issues. We all manage polarities intuitively every day, such as in managing the roles of physician and daughter when involved

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Minnesota Physician October 2013

Principles of polarities management The first steps in active manage-

Managing polarities is an active process that requires energy and focus.

• Helping a patient face reality and helping a patient remain hopeful These are polarities. Polarity expert Barry Johnson says these attributes “… identify a relationship that is ongoing and raise issues that won’t go away.”

in caring for an ill or aging parent. How can physicians use polarity management methods in routine practice to avoid pitfalls and understand what to do when things don’t go well, i.e., when our seemingly best attempts at communication fail?

ment of a polarity are to recognize what work we are trying to do, and to see the polarities within that work. If our work is to communicate effectively with patients, then one polarity inherent in that work is our intention as the speaker and our attention to the patient’s perception of the experience. Figure 1 maps out this polarity. Next, using Figure 1, we look at optimizing both sides of the polarity in reference to the work, as well as what happens when we overemphasize each pole to the extreme. Optimal focus on our intention as a speaker (upper left quadrant) includes being clear and concise; using language that the patient likely understands; offering enough but not too much information; pacing our speech at a rate that the patient can process it; and matching our verbal communication to our nonverbal communication. Optimal focus on our attention to the patient’s perception (upper right quadrant) involves listening carefully to the patient’s words and the meaning those words convey; being able to begin with a compassionate attitude toward a person who is probably afraid; observing and interpreting nonverbal communication, imagining we might be misunderstood, and being


Figure 1 - Polarity Map

Figure 2 - Constant Motion in a Constant Predictable Direction

Effective Communication Results of optimal focus on intention Being clear and concise.

Listening carefully to their words and the meaning those words convey.

Using language that the patient likely under stands.

Beginning with a compassionate attitude toward a person who is probably afraid.

Offering enough but not too much information. Pacing speech at a rate that patient can process it.

GAP or “the work”

Realizing that the last experience the patient had in the health care system is likely to initially be projected onto you.

Remembering the work is to be helpful.

and

Perception

Results of over-focusing on intention at the expense of perception

Results of over-focusing on perception at the expense of intention

Moving through an encounter like you are talking to a problem you have seen before, not a person.

Trying to be sure the patient likes you.

Trying to speak to every possible question or objection before they can bring it up.

Results of optimal focus on intention

Observing and interpreting their nonverbal communication. Imagining you might be misunderstood. Being ready to quickly correct misunderstanding that becomes evident.

Matching verbal communication to your nonverbal communication.

Intention

Effective Communication

Results of optimal focus on perception

Results of optimal focus on perception

GAP or “the work”

Intention

Perception

Results of overfocusing on intention at the expense of perception

Results of overfocusing on perception at the expense of intention

Doing whatever the patient asks, even if it is not indicated, so you get a good score on patient experience survey.

Getting angry when a patient interjects or questions your approach.

Ineffective Communication ready to quickly correct misunderstanding when it becomes evident; and realizing that the patient is likely to project his or her last experience in the health care system onto us. Overfocus on our intention as the speaker at the expense of attending to the patient’s perception (bottom left quadrant) can result in moving through an encounter “on autopilot”; speaking to the patient using an unvarying script; trying to cover every possible question or objection before the patient can bring it up; or even getting angry when a patient interrupts or asks a question. Overfocus on attention to the patient’s perception at the expense of our intention as the speaker (bottom right quadrant) can result in trying to be sure that the patient likes us; doing whatever the patient asks, even if not indicated, so we get “a good patient experience survey score”; or avoiding giving difficult news so as to not upset the patient. Polarity management in practice When we find ourselves acting out behaviors that represent overfocus on one pole at the expense of the other, polarity management suggests that the best solution is to be found in optimizing the opposite pole. Situation 1: Let’s say we find ourselves angry with a patient who constantly interjects comments or asks questions and, thus, have overfocused on our

intention as the speaker (bottom left quadrant in Fig. 1). To counter this overfocus on our intention, we can refocus on the patient’s perception (top right quadrant). We might recall, for example, that this patient may well be projecting her last experience in the health care system onto us. This type of adjustment can help balance intent with perception, leading to improved communication. It’s important to keep in mind, however, that while awareness of the patient’s perceptions is desirable, focusing on that aspect of the office visit at the expense of the opposite pole (intention) can lead to incomplete communication. Situation 2: All of us have at times felt uncomfortable giving patients difficult news for fear of upsetting them. To avoid the inclination to overfocus on the patient’s perception (lower right quadrant in Fig. 1), we would optimize our intention as a speaker by focusing on clarity, judicious information transfer, and appropriate speech pacing (top left quadrant). Similar to the situation above, simply pushing our intention harder at the expense of paying attention to the perception of the patient will likely lead to incomplete and ineffective communication. Managing the tension in polarities The above scenarios reflect what we do constantly in managing the tension between polarities in our lives and work: We shift between the polarities as we

Ineffective Communication sense the need to adjust the tension. These back-and-forth adjustments are predictable and occur in a predictable direction, as shown in Figure 2. Think of the loops in the figures as eyeglasses trained on the polarities of intention and perception. The key is our awareness of the relationship between the poles of a polarity in order to optimally manage it, and

our ability to use the power of “and” to maximize the upside of both poles. This is an ongoing, dynamic dance we all do every day in our lives. If we manage polarities mindlessly or unconsciously, the interaction will look more like Figure 3, where the eyeglasses are focused on the downsides of both poles. In Managing polarities to page 38

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2013 October Minnesota Physician

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Multicultural advance care planning from cover

Differences in advance care planning and health care decision-making for majority cultures versus minority cultures Majority culture influences

Minority/multicultural influences

Emphasis on individualism

Emphasis on collectivism

Nuclear-focused definition of family

Extended and non-blood kinship definition of family

Direct communication patterns

Indirect, often nonverbal communications

Autonomy in ACP

Beneficence

Physician and medical technology intervention

Divine plan, trust in a higher power, other consideration

Belief that discussion may be useful

Belief that discussion of end-of-life care may be self-fulfilling

Autonomy in decision-making

Paternalistic decision-making (“My doctor knows what is best for me. “)

“I don’t want to be a burden to my family.”

“My family will help care for me in the best way possible. We’ll do what is best for our family.”

A CT of the chest, abdomen, and pelvis reveals upper abdominal lymphadenopathy and several lesions in the liver suspicious for metastatic disease. An

esophageal mass was identified on upper endoscopy and biopsy of the mass now shows evidence of adenocarcinoma. The patient is from Mex-

ico and has been in the U.S. for the past two years. He has mentioned that he wants to go back to Mexico in the next few months. He lives with his daughter and does not speak English. His daughter is his closest relative. He does not have an advance care directive (ACD) and does not know what an ACD actually is.

Understanding cultural differences can help physicians open the gate to conversations concerning complex end-of-life care decision-making. When her father was admitted, the patient’s daughter asked the medical team not to let her father know if the biopsy showed cancer. She believes that if her father is told of a cancer diagnosis, he will be so depressed that “he will quit fighting and will die.” • What should the medical team do? Should they inform the patient of the biopsy results or follow the request from the family?

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Minnesota Physician October 2013

The patient’s family wants “everything” done. When the critical care team starts to discuss his extremely poor prognosis and mentions a possible transition toward comfort care, the family members are upset; they know “he is strong and he will make it.” They already have declined a palliative care consultation offered the day after admission. The family

• The patient has the right to know the diagnosis and his prognosis, but does he want to know? Case Study 2: A 52-year-old African American man has a history of advanced liver disease secondary to chronic hepatitis C. He presented five days ago to the emergency department with respiratory failure and septic shock secondary to pneumonia. He had persistent hypotension and was not responding to aggressive IV fluid administration. The patient was intubated at presentation and was started on vasopressors several hours after admission to the ICU. Over the following two days, his condition remained critical. He now has developed ARDS (acute respiratory distress syndrome) and progressive multi-organ failure. His condition continues to decline in spite of maximal support. The patient does not have an advance care directive.

wants to maintain the patient’s “full code” despite having been informed by the medical team that CPR and other aggressive resuscitation attempts most likely will be futile. During the course of the conversation, they mention that they believe God will “make a miracle” and save him. • How can the medical team best help this struggling family accept the fact that the patient seems to be dying? • Are there any cultural beliefs that may help explain why the family does not seem to accept the unavoidable? • How can the physician help the family understand that transitioning toward comfort in this situation is not “giving up” or providing second-class treatment? • When is it time to call for an ethics consult or to invoke the hospital’s futility policy? • How can the family be counseled regarding faith, end of life, their conviction that a miracle will happen, etc.? Cultural issues in advance care planning Beliefs about protecting family members from bad news, preferences about returning to one’s Managing polarities to page 38


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*Victoza® 1.2 mg and 1.8 mg when used alone or in combination with OADs. † Victoza® is not indicated for the management of obesity, and weight change was a secondary end point in clinical trials.

Liraglutide causes dose-dependent and treatment-durationdependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate Victoza® is a registered trademark of Novo Nordisk A/S. © 2013 Novo Nordisk All rights reserved.

human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors. Do not use in patients with a prior serious hypersensitivity reaction to Victoza® (liraglutide [rDNA origin] injection) or to any of the product components. Postmarketing reports, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis. Discontinue promptly if pancreatitis is suspected. Do not restart if pancreatitis is confirmed. Consider other antidiabetic therapies in patients with a history of pancreatitis. When Victoza® is used with an insulin secretagogue (e.g. a sulfonylurea) or insulin serious hypoglycemia can occur. Consider lowering the dose of the insulin secretagogue or insulin to reduce the risk of hypoglycemia. Renal impairment has been reported postmarketing, usually in association with nausea, vomiting, diarrhea, or dehydration which may sometimes require hemodialysis. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Serious hypersensitivity reactions (e.g. anaphylaxis and angioedema) have been reported during postmarketing use of Victoza®. If symptoms of hypersensitivity reactions occur, patients must stop taking Victoza® and seek medical advice promptly. There have been no studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. The most common adverse reactions, reported in ≥5% of patients treated with Victoza® and more commonly than in patients treated with placebo, are headache, nausea, diarrhea, dyspepsia, constipation and antiliraglutide antibody formation. Immunogenicity-related events, including urticaria, were more common among Victoza®-treated patients (0.8%) than among comparator-treated patients (0.4%) in clinical trials. Victoza® has not been studied in type 2 diabetes patients below 18 years of age and is not recommended for use in pediatric patients. There is limited data in patients with renal or hepatic impairment. Please see brief summary of Prescribing Information on adjacent page.

0513-00015590-1

June 2013

5/31/13 12:47 PM

2013 OctOber Minnesota Physician

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B:11.125”

Important Safety Information

S:10”

Victoza® (liraglutide [rDNA origin] injection) is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. Based on spontaneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis has been observed in patients treated with Victoza®. Victoza® has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at increased risk for pancreatitis while using Victoza®. Other antidiabetic therapies should be considered in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. Victoza® has not been studied in combination with prandial insulin.

T:10.5”

Indications and Usage


Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatmentduration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. Based on spontaneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis has been observed in patients treated with Victoza®. Victoza® has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at increased risk for pancreatitis while using Victoza®. Other antidiabetic therapies should be considered in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and prandial insulin has not been studied. CONTRAINDICATIONS: Do not use in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Do not use in patients with a prior serious hypersensitivity reaction to Victoza® or to any of the product components. WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies. In the clinical trials, there have been 6 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 2 cases in comparator-treated patients (1.3 vs. 1.0 cases per 1000 patient-years). One comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Five of the six Victoza®-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One Victoza® and one non-Victoza®-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with on-treatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebo-treated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: Based on spontaneous postmarketing reports, acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis, has been observed in patients treated with Victoza®. After initiation of Victoza®, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® should promptly be discontinued and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Consider antidiabetic therapies other than Victoza® in patients with a history of pancreatitis. In clinical trials of Victoza®, there have been 13 cases of pancreatitis among Victoza®-treated patients and 1 case in a comparator (glimepiride) treated patient (2.7 vs. 0.5 cases per 1000 patient-years). Nine of the 13 cases with Victoza® were reported as acute pancreatitis and four were reported as chronic pancreatitis. In one case in a Victoza®-treated patient, pancreatitis, with necrosis, was observed and led to death; however clinical causal-

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Minnesota Physician OctOber 2013

VICU3X1334_ISI_Update_A_Size_Ad_BS_r6.indd 1

ity could not be established. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) or insulin may have an increased risk of hypoglycemia. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea (or other concomitantly administered insulin secretagogues) or insulin Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Hypersensitivity Reactions: There have been postmarketing reports of serious hypersensitivity reactions (e.g., anaphylactic reactions and angioedema) in patients treated with Victoza®. If a hypersensitivity reaction occurs, the patient should discontinue Victoza® and other suspect medications and promptly seek medical advice. Angioedema has also been reported with other GLP-1 receptor agonists. Use caution in a patient with a history of angioedema with another GLP-1 receptor agonist because it is unknown whether such patients will be predisposed to angioedema with Victoza®. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® has been evaluated in 8 clinical trials: A double-blind 52-week monotherapy trial compared Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, and glimepiride 8 mg daily; A double-blind 26 week add-on to metformin trial compared Victoza® 0.6 mg once-daily, Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, placebo, and glimepiride 4 mg once-daily; A double-blind 26 week add-on to glimepiride trial compared Victoza® 0.6 mg daily, Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, placebo, and rosiglitazone 4 mg once-daily; A 26 week add-on to metformin + glimepiride trial, compared double-blind Victoza® 1.8 mg once-daily, double-blind placebo, and open-label insulin glargine once-daily; A doubleblind 26-week add-on to metformin + rosiglitazone trial compared Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily and placebo; An open-label 26-week add-on to metformin and/or sulfonylurea trial compared Victoza® 1.8 mg once-daily and exenatide 10 mcg twice-daily; An open-label 26-week add-on to metformin trial compared Victoza® 1.2 mg once-daily, Victoza® 1.8 mg once-daily, and sitagliptin 100 mg once-daily; An open-label 26-week trial compared insulin detemir as add-on to Victoza® 1.8 mg + metformin to continued treatment with Victoza® + metformin alone. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparator-treated patients in the five double-blind controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. In these five trials, the most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Common adverse reactions: Tables 1, 2, 3 and 4 summarize common adverse reactions (hypoglycemia is discussed separately) reported in seven of the eight controlled trials of 26 weeks duration or longer. Most of these adverse reactions were gastrointestinal in nature. In the five double-blind clinical trials of 26 weeks duration or longer, gastrointestinal adverse reactions were reported in 41% of Victoza®-treated patients and were dose-related. Gastrointestinal adverse reactions occurred in 17% of comparator-treated patients. Common adverse reactions that occurred at a higher incidence among Victoza®-treated patients included nausea, vomiting, diarrhea, dyspepsia and constipation. In the five double-blind and three open-label clinical trials of 26 weeks duration or longer, the percentage of patients who reported nausea declined over time. In the five double-blind trials approximately 13% of Victoza®-treated patients and 2% of comparator-treated patients reported nausea during the first 2 weeks of treatment. In the 26-week open-label trial comparing Victoza® to exenatide, both in combination with metformin and/or sulfonylurea, gastrointestinal adverse reactions were reported at a similar incidence in the Victoza® and exenatide treatment groups (Table 3). In the 26-week open-label trial comparing Victoza® 1.2 mg, Victoza® 1.8 mg and sitagliptin 100 mg, all in combination with metformin, gastrointestinal adverse reactions were reported at a higher incidence with Victoza® than sitagliptin (Table 4). In the remaining 26-week trial, all patients received Victoza® 1.8 mg + metformin during a 12-week run-in period. During the run-in period, 167 patients (17% of enrolled total) withdrew from the trial: 76 (46% of withdrawals) of these patients doing so because of gastrointestinal adverse reactions and 15 (9% of withdrawals) doing so due to other adverse events. Only those patients who completed the run-in period with inadequate glycemic control were randomized to 26 weeks of add-on therapy with insulin detemir or continued, unchanged treatment with Victoza® 1.8 mg + metformin. During this randomized 26-week period, diarrhea was the only adverse reaction reported in ≥5% of patients treated with Victoza® 1.8 mg + metformin + insulin detemir (11.7%) and greater than in patients treated with Victoza® 1.8 mg and metformin alone (6.9%). Table 1: Adverse reactions reported in ≥5% of Victoza®-treated patients in a 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Reaction Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Headache 9.1 9.3 Table 2: Adverse reactions reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Metformin Placebo + Metformin Glimepiride + Metformin N = 724 N = 121 N = 242 (%) (%) (%) Adverse Reaction Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial Placebo + Glimepiride Rosiglitazone + All Victoza® + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Reaction Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2


Constipation Dyspepsia

5.3 0.9 1.7 5.2 0.9 2.6 Add-on to Metformin + Glimepiride Victoza® 1.8 + Metformin Placebo + Metformin + Glargine + Metformin + + Glimepiride N = 230 Glimepiride N = 114 Glimepiride N = 232 (%) (%) (%) Adverse Reaction Nausea 13.9 3.5 1.3 Diarrhea 10.0 5.3 1.3 Headache 9.6 7.9 5.6 Dyspepsia 6.5 0.9 1.7 Vomiting 6.5 3.5 0.4 Add-on to Metformin + Rosiglitazone Placebo + Metformin + Rosiglitazone All Victoza® + Metformin + Rosiglitazone N = 355 N = 175 (%) (%) Adverse Reaction Nausea 34.6 8.6 Diarrhea 14.1 6.3 Vomiting 12.4 2.9 Headache 8.2 4.6 Constipation 5.1 1.1 Table 3: Adverse Reactions reported in ≥5% of Victoza®-treated patients in a 26-Week Open-Label Trial versus Exenatide Victoza® 1.8 mg once daily + Exenatide 10 mcg twice daily + metformin and/or sulfonylurea metformin and/or sulfonylurea N = 235 N = 232 (%) (%) Adverse Reaction Nausea 25.5 28.0 Diarrhea 12.3 12.1 Headache 8.9 10.3 Dyspepsia 8.9 4.7 Vomiting 6.0 9.9 Constipation 5.1 2.6 Table 4: Adverse Reactions in ≥5% of Victoza®-treated patients in a 26-Week Open-Label Trial versus Sitagliptin All Victoza® + metformin Sitagliptin 100 mg/day + N = 439 metformin N = 219 (%) (%) Adverse Reaction Nausea 23.9 4.6 Headache 10.3 10.0 Diarrhea 9.3 4.6 Vomiting 8.7 4.1 Immunogenicity: Consistent with the potentially immunogenic properties of protein and peptide pharmaceuticals, patients treated with Victoza® may develop anti-liraglutide antibodies. Approximately 50-70% of Victoza®-treated patients in the five double-blind clinical trials of 26 weeks duration or longer were tested for the presence of anti-liraglutide antibodies at the end of treatment. Low titers (concentrations not requiring dilution of serum) of anti-liraglutide antibodies were detected in 8.6% of these Victoza®-treated patients. Sampling was not performed uniformly across all patients in the clinical trials, and this may have resulted in an underestimate of the actual percentage of patients who developed antibodies. Cross-reacting antiliraglutide antibodies to native glucagon-like peptide-1 (GLP-1) occurred in 6.9% of the Victoza®-treated patients in the double-blind 52-week monotherapy trial and in 4.8% of the Victoza®-treated patients in the double-blind 26-week add-on combination therapy trials. These cross-reacting antibodies were not tested for neutralizing effect against native GLP-1, and thus the potential for clinically significant neutralization of native GLP-1 was not assessed. Antibodies that had a neutralizing effect on liraglutide in an in vitro assay occurred in 2.3% of the Victoza®-treated patients in the double-blind 52-week monotherapy trial and in 1.0% of the Victoza®-treated patients in the double-blind 26-week add-on combination therapy trials. Among Victoza®-treated patients who developed anti-liraglutide antibodies, the most common category of adverse events was that of infections, which occurred among 40% of these patients compared to 36%, 34% and 35% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. The specific infections which occurred with greater frequency among Victoza®-treated antibody-positive patients were primarily nonserious upper respiratory tract infections, which occurred among 11% of Victoza®-treated antibody-positive patients; and among 7%, 7% and 5% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. Among Victoza®-treated antibody-negative patients, the most common category of adverse events was that of gastrointestinal events, which occurred in 43%, 18% and 19% of antibody-negative Victoza®-treated, placebo-treated and active-control-treated patients, respectively. Antibody formation was not associated with reduced efficacy of Victoza® when comparing mean HbA1c of all antibody-positive and all antibody-negative patients. However, the 3 patients with the highest titers of anti-liraglutide antibodies had no reduction in HbA1c with Victoza® treatment. In the five double-blind clinical trials of Victoza®, events from a composite of adverse events potentially related to immunogenicity (e.g. urticaria, angioedema) occurred among 0.8% of Victoza®-treated patients and among 0.4% of comparator-treated patients. Urticaria accounted for approximately one-half of the events in this composite for Victoza®-treated patients. Patients who developed anti-liraglutide antibodies were not more likely to develop events from the immunogenicity events composite than were patients who did not develop anti-liraglutide antibodies. Injection site reactions: Injection site reactions (e.g., injection site rash, erythema) were reported in approximately 2% of Victoza®-treated patients in the five double-blind clinical trials of at least 26 weeks duration. Less than 0.2% of Victoza®-treated patients discontinued due to injection site reactions. Papillary thyroid carcinoma: In clinical trials of Victoza®, there were 7 reported cases of papillary thyroid carcinoma in patients treated with Victoza® and 1 case in a comparator-treated patient (1.5 vs. 0.5 cases per 1000 patient-years). Most of these papillary thyroid carcinomas were <1 cm in greatest diameter and were diagnosed in surgical pathology specimens after thyroidectomy prompted by findings on protocol-specified screening with serum calcitonin or thyroid ultrasound. Hypoglycemia: In the eight clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 11 Victoza®-treated patients (2.3 cases per 1000 patient-years) and in two exenatidetreated patients. Of these 11 Victoza®-treated patients, six patients were concomitantly using metformin and a sulfonylurea, one was concomitantly using a sulfonylurea, two were concomitantly using metformin (blood glucose values were 65 and 94 mg/dL) and two were using Victoza® as monotherapy (one of these patients was undergoing an intravenous glucose tolerance test and the other was receiving insulin as treatment during a hospital stay). For these two patients on Victoza® monotherapy, the insulin treatment was the likely explanation for the hypoglycemia. In the 26-week open-label trial comparing Victoza® to sitagliptin,

the incidence of hypoglycemic events defined as symptoms accompanied by a fingerstick glucose <56 mg/ dL was comparable among the treatment groups (approximately 5%). Table 5: Incidence (%) and Rate (episodes/patient year) of Hypoglycemia in the 52-Week Monotherapy Trial and in the 26-Week Combination Therapy Trials Victoza® Treatment Active Comparator Placebo Comparator None Monotherapy Victoza® (N = 497) Glimepiride (N = 248) Patient not able to 0 0 — self−treat Patient able to self−treat 9.7 (0.24) 25.0 (1.66) — Not classified 1.2 (0.03) 2.4 (0.04) — ® Glimepiride + Placebo + Metformin Add-on to Metformin Victoza + Metformin (N = 724) Metformin (N = 121) (N = 242) Patient not able to 0.1 (0.001) 0 0 self−treat Patient able to self−treat 3.6 (0.05) 22.3 (0.87) 2.5 (0.06) Continued Victoza® None Add-on to Victoza® + Insulin detemir + ® Metformin Victoza + Metformin + Metformin alone (N = 163) (N = 158*) 0 0 — Patient not able to self−treat Patient able to self−treat 9.2 (0.29) 1.3 (0.03) — Add-on to Victoza® + Glimepiride Rosiglitazone + Placebo + Glimepiride (N = 695) Glimepiride (N = 231) (N = 114) Glimepiride Patient not able to 0.1 (0.003) 0 0 self−treat Patient able to self−treat 7.5 (0.38) 4.3 (0.12) 2.6 (0.17) Not classified 0.9 (0.05) 0.9 (0.02) 0 Placebo + Metformin Add-on to Metformin Victoza® + Metformin + Rosiglitazone None + Rosiglitazone + Rosiglitazone (N = 355) (N = 175) 0 — 0 Patient not able to self−treat Patient able to self−treat 7.9 (0.49) — 4.6 (0.15) Not classified 0.6 (0.01) — 1.1 (0.03) Add-on to Metformin Victoza® + Metformin Insulin glargine Placebo + Metformin + Glimepiride + Metformin + + Glimepiride + Glimepiride (N = 230) Glimepiride (N = 232) (N = 114) Patient not able to 2.2 (0.06) 0 0 self−treat Patient able to self−treat 27.4 (1.16) 28.9 (1.29) 16.7 (0.95) Not classified 0 1.7 (0.04) 0 *One patient is an outlier and was excluded due to 25 hypoglycemic episodes that the patient was able to self-treat. This patient had a history of frequent hypoglycemia prior to the study. In a pooled analysis of clinical trials, the incidence rate (per 1,000 patient-years) for malignant neoplasms (based on investigator-reported events, medical history, pathology reports, and surgical reports from both blinded and open-label study periods) was 10.9 for Victoza®, 6.3 for placebo, and 7.2 for active comparator. After excluding papillary thyroid carcinoma events [see Adverse Reactions], no particular cancer cell type predominated. Seven malignant neoplasm events were reported beyond 1 year of exposure to study medication, six events among Victoza®-treated patients (4 colon, 1 prostate and 1 nasopharyngeal), no events with placebo and one event with active comparator (colon). Causality has not been established. Laboratory Tests: In the five clinical trials of at least 26 weeks duration, mildly elevated serum bilirubin concentrations (elevations to no more than twice the upper limit of the reference range) occurred in 4.0% of Victoza®treated patients, 2.1% of placebo-treated patients and 3.5% of active-comparator-treated patients. This finding was not accompanied by abnormalities in other liver tests. The significance of this isolated finding is unknown. Vital signs: Victoza® did not have adverse effects on blood pressure. Mean increases from baseline in heart rate of 2 to 3 beats per minute have been observed with Victoza® compared to placebo. The long-term clinical effects of the increase in pulse rate have not been established. Post-Marketing Experience: The following additional adverse reactions have been reported during post-approval use of Victoza®. Because these events are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure: Dehydration resulting from nausea, vomiting and diarrhea; Increased serum creatinine, acute renal failure or worsening of chronic renal failure, sometimes requiring hemodialysis; Angioedema and anaphylactic reactions; Allergic reactions: rash and pruritus; Acute pancreatitis, hemorrhagic and necrotizing pancreatitis sometimes resulting in death. OVERDOSAGE: Overdoses have been reported in clinical trials and post-marketing use of Victoza®. Effects have included severe nausea and severe vomiting. In the event of overdosage, appropriate supportive treatment should be initiated according to the patient’s clinical signs and symptoms. More detailed information is available upon request. For information about Victoza® contact: Novo Nordisk Inc., 800 Scudders Mill Road, Plainsboro, NJ 08536, 1−877-484-2869 Date of Issue: April 16, 2013 Version: 6 Manufactured by: Novo Nordisk A/S, DK-2880 Bagsvaerd, Denmark Victoza® is covered by US Patent Nos. 6,268,343, 6,458,924, 7,235,627, 8,114,833 and other patents pending. Victoza® Pen is covered by US Patent Nos. 6,004,297, RE 43,834, RE 41,956 and other patents pending. © 2010-2013 Novo Nordisk 0513-00015681-1 5/2013

2013 OctOber Minnesota Physician 5/31/13 12:48 PM

15


Professional update: Orthopedics

W

rist injuries are common conditions seen by hand and orthopedic surgeons. They can vary from a simple non-displaced torus fracture of the distal radius in a skeletally immature patient to a complex dislocation of the wrist. The mechanism of injury can be helpful in diagnosing patients who have sustained a wrist injury. It is important to examine above and below the so-called “zone of injury.” In a complex system such as the forearm and wrist, it is common to see an associated bone or joint injury. In addition, a thorough neurovascular examination should be performed, especially in a high-energy trauma situation, so as not to miss an associated nerve or vascular injury. Obtaining radiographs After performing a standard physical examination, it is critical for the physician to

Wrist injuries Considerations in treating both common and complex injuries By L.T. Donovan, DO

obtain adequate radiographs to evaluate the injury pattern. When a patient is first examined, a “shotgun” approach is often used to evaluate the extent of the injury. When a patient complains of wrist and forearm pain following an injury, it might be tempting to obtain a forearm radiograph so that the entire forearm can be evaluated rather than obtaining separate joint-specific radiographs. By taking this approach, however, one loses the ability to visualize the specific area in question. One problematic area we see on a regular basis is difficulty in obtaining a true lateral radiograph of the wrist. In those

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Minnesota Physician October 2013

situations, a cross-table lateral radiograph usually is sufficient. After obtaining the appropriate radiographs, we take a systematic approach to interpreting them. My recommendation is to look away from the area of the suspected injury first. If one looks directly at the area of injury and focuses on the “obvious” fracture, then one often tends to overlook other subtleties, such as a ligament injury resulting in a diastasis on the X-ray. In a distal radius fracture, we look for certain characteristics, not only to identify a fracture, but also to analyze how well the fracture is aligned and what the tendency is for that fracture to stay reduced. I often refer to this as the “gestalt” of the fracture. Sometimes, just looking at the fracture pattern can provide a sense of whether or not the fracture will be stable. On the PA (posteroanterior) view, we look at the height of the articular surface of the radius in relation to the ulna. In most cases, the radius and the ulna are at the same level. In cases of significant displacement, the radius will be shortened. On the lateral projection, the articular surface of the distal radius should be in a neutral alignment. With an increasing amount of angulation (usually apex volar), one can see a corresponding decrease in wrist flexion. The degree of dorsal displacement is also significant, not only in regard to the fracture pattern but also because of the possibility of developing post-traumatic carpal tunnel syndrome. Determining treatment When deciding what type of treatment to recommend, a

physician must consider several factors, including the patient’s age, health, physical demands, and overall expectations. Older patients are usually more wary of surgical intervention, as are those from certain cultural groups. Younger, more physically demanding patients are usually not very tolerant of a wrist deformity and are anxious about trying to get back as much normal function as possible. Fortunately, a relatively new technology for the operative treatment of wrist fractures is available. Around 2000, a new internal fixation plate was released for general use in treating wrist fractures. The low-profile plate is of a special anatomic design that hugs the volar surface of the distal radius. We often refer to this as a volar locking plate. It enables the operating surgeon either to insert the screws in a standard fashion where the tip of the screw engages the opposite (dorsal) cortex, or to use a special locking mechanism in which the head of the screw has separate threads that allow it to be “locked” into the plate, preventing the screw from backing out. These locking screws are placed below the subchondral surface of the dorsal radius and, in essence, function as a scaffold to hold the radius out to length. This allows the patient to start moving the wrist in about one week. With the ever-expanding goal of improving patient care and incorporating the need for a less invasive technique that can combine locking technology with standard fixation techniques, a new design has recently been approved by the FDA for fixation of wrist fractures. The Conventus DRS system allows for a similar degree of stability of fixation for a wrist fracture while requiring less soft tissue exposure to implant the device and simultaneously allowing early range of motion of the wrist. When comparing the results of nonoperative and operative treatments, as long as the same parameters are followed con-


lized for an extended period of time.

cerning the adequacy of the reduction, the overall results one year from the time of the fracture are about the same. In cases of a distal radius fracture, the radiographs need to be evaluated carefully so as not to miss any associated injuries, such as a scaphoid fracture or a tear of the scapholunate ligament. In scrutinizing the radiograph, we look for a widening of the scapholunate interval beyond 3 mm. In addition, on the lateral projection, the lunate should be well visualized to determine whether there is any rotation (a volar or dorsal tilt of the lunate). There is no uniform consensus on how an acute scapholunate injury should be treated. This ligament is extremely small but very strong. Most often, it is repaired either directly (open technique) or by a closed reduction and placement of several pins across the scapholunate joint (temporarily) and immobi-

The long-term problem with a scapholunate ligament injury is the development of posttraumatic arthritis of the wrist. This leads to a scapholunate advanced collapse (SLAC) wrist. The treatment of SLAC wrist varies, and these operations are considered to be salvage-type procedures that involve some degree of a fusion, resulting in a significant loss of motion of the wrist. Healing scaphoid fractures A fracture of the scaphoid remains a frustrating condition for a hand surgeon. The scaphoid is one of the most difficult bones in the body to heal due to its poor vascular supply. This is because it is essentially covered by articular cartilage. In the past, almost all scaphoid fractures were treated with cast immobilization. We are moving more and more toward oper-

ative stabilization today, due to the fact that the operative procedure has become more reproducible, requires less time of immobilization, and results in better healing rates overall. The problematic area of scaphoid injuries involves nonunion, where the scaphoid has not healed due to a limited blood supply. The treatment can vary from a bone graft only (Russe graft), without any internal fixation but with prolonged cast immobilization, to a super-sophisticated free-graft transfer from the knee, which requires a vascular anastomosis to a local vessel. The primary problem with an untreated scaphoid nonunion is that there is an extremely high rate of developing post-traumatic arthritis, a scaphoid nonunion advanced collapse (SNAC) wrist. A dislocation of the wrist usually includes a dislocation of the lunate. Typically, the lunate is “extruded” volarly, with a

significant degree of trauma. The treatment involves an open reduction of the perilunate dislocation and repair of the ligaments, often requiring a volar and dorsal approach. The carpal bones are usually held in a reduced position with multiple pins, and the overall result is a significant loss of wrist motion with a limited outcome. Injuries can affect function, earning power Injuries that involve the wrist require an understanding of the anatomy and the complexities of the joint itself. One must recognize not only the more common injuries but also the less common, but potentially devastating, associated injuries. These can result in a significant loss of function and impairment of the wrist, affecting not only the patient’s lifestyle but also his or her economic ability. L.T. Donovan, DO, of Summit Orthopedics, practices at several locations, including the Apple Valley Medical Center.

Help prevent or delay diabetes in patients with a history of gestational diabetes (GDM) Screen for diabetes • First, 6-12 weeks postpartum (follow postpartum screening guidelines) Immediately after pregnancy, up to 10% of women with GDM will have diabetes * • Then, at least every 3 years thereafter 35-60% will develop diabetes 10-20 years after pregnancy* Encourage Healthy Behaviors • Be physically active most days • Make healthy food choices • Maintain a healthy weight

• Do not smoke • Get regular doctor visits

Refer overweight patients with prior GDM to a nearby National Diabetes Prevention Program group

For more information visit: www.icanpreventdiabetes.org *percentages estimated before the introduction of recent (IADPSG) gestational diabetes screening guidelines

2013 october Minnesota Physician

17


Integrative clinical care

A

Hypnosis comes of age

fidgeting, anxious patient is able to set aside her fears and lie still while undergoing an MRI. In the hospital, a recovering surgical patient listens to a personalized CD designed to speed recovery and reduce complications. A woman with chronic insomnia learns to fall asleep without the need for hypnotic medication. The common denominator that improved these patients’ experiences and outcomes? Integrating clinical hypnosis as part of their care. Yet medical professionals have often been skeptical of hypnosis, in part because of its negative connotations: Think of a movie villain swinging a watch like a pendulum. In reality, hypnosis has developed into a well-researched clinical method that can be utilized as a primary treatment, or to complement medication and surgical interventions.

Clinical uses can improve care By Shepherd Myers, PhD, LP

Hypnosis and other complementary methods can make an important contribution in decreasing the emphasis on medical interventions and empowering patients to use their own resources to heal and manage their medical conditions. Given recent initiatives aimed at reducing the use of narcotics and sleep medication and lowering medical costs, the time is ripe to fulfill the potential of clinical hypnosis. Clinical applications Some of the more common

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Minnesota Physician October 2013

clinical uses of hypnosis are described below. Pain reduction. There is mounting evidence that hypnosis has neurological and physiological impact, not merely a placebo effect. Research on the use of hypnosis in reducing pain has demonstrated that it affects spinal and supraspinal pain pathways. Functional MRI findings demonstrate impact in midbrain (ACC) and cortical structures. One study demonstrated the ability to use hypnosis to condition the impact of benzodiazepines, producing EEG changes and self-reported reduction of anxiety that occurred with the medication when it was withdrawn. Chronic pain. Hypnosis has many applications as part of comprehensive treatment of chronic pain. Patients are taught to produce a deep state of relaxation, use imagery to block or lower pain signals, explore methods of lowering arousal, and develop a constructive emotional and cognitive response to their pain. These methods help lower muscular tension and central sensitization, which are strong contributing factors to persistent pain. Hypnosis also can be used effectively to uncover and resolve resistance and obstacles to healing and recovery, which are often related to unresolved trauma. The importance of hypnosis and other complementary methods with chronic pain patients is to encourage self-management and empowerment, and to reduce the emphasis on narcotic pain medication. Irritable bowel syndrome. The literature has shown hypnosis to have strong efficacy in the treatment of irritable bowel syndrome (IBS). Treatment

protocols of seven to 12 sessions of hypnosis have shown efficacy greater than most medications, and effectiveness in 80 percent of patients. In these studies, the key ingredient appears to be imagery, administered while the patient is in a deep trance state, that replicates desired physiological processes. While hypnotized, IBS patients are instructed to produce feelings of comfort and calm in their GI tract, or imagine a flowing river (with the constipated subtype) or controlling the flow of the river (with the diarrhea subtype). This research provides an intriguing gateway to facilitating mind-body healing. Non-pharmaceutical sedation. Elvira Lang, MD, an interventional radiologist, has developed Comfort Talk, a method of non-pharmaceutical patient sedation designed to be administered by radiology technicians and other trained health care professionals to reduce patients’ pain and anxiety during procedures such as MRIs. Comfort Talk has been shown to lower anxiety, reduce no-show rates, improve patient satisfaction, and lower cost. These methods of hypnosis have promise to produce similar outcomes in other procedures, such as angioplasty and pain interventions. Hypnosis also has been utilized with minor surgery (e.g., laparoscopic and minor orthopedic procedures) and childbirth as an alternative when anesthesia is contraindicated or undesired and as a method to improve surgical outcomes. In my work with a multidisciplinary transplant team, individuals with psychological distress and arousal are targeted for treatment, since they may be at risk for negative outcomes—such as persistent pain, medical complications, and poor postsurgical adjustment. Hypnosis in combination with psychological interventions has proven useful in shortening hospital stays and reducing the use of narcotic pain medication. Insomnia. Hypnosis has the potential to be a primary treatment for insomnia, by


helping patients prevent cognitive arousal, which is often the cause of delayed sleep onsets; maintain sleep; and return to sleep if they awaken during the night. When used in conjunction with cognitive behavioral therapy for insomnia, hypnosis can be especially important in reducing the use of sleep medication. It also has shown promise in treatment of parasomnia, such as nightmare disorder and sleepwalking. Mental health. Hypnosis has wide applications in mental health, especially to lower anxiety, address resistance to progress, and increase selfworth in depression. For example, hypnosis has been used for in-session exposure therapy, an essential component in the treatment of trauma and other anxiety disorders. The benefit of hypnosis is that it is experiential—guiding a patient to a desired state or experience in the session—and, thus, is an important addition to traditional talk therapies such as cognitive behavior therapy. Improving communication When employed as a formal method, hypnosis includes an induction, deepening, intervention, and post-hypnotic suggestions. However, informal and brief methods of hypnosis have been developed that are more applicable to the time limitations typical of most clinic office visits. Hypnosis can be administered in as little as three to 10 minutes, so it can easily be incorporated into an office visit, to assist in a medical procedure or to augment a treatment goal in addition to medication, such as lowering hypertension and managing stress. Awareness and application of the concepts of hypnosis also may be used to improve patient communication. Most of a physician’s comments to a patient are, in fact, suggestions, which are a key element of hypnosis. Thus, a physician’s statements can have surprising impact on virtually all patients, who (like hypnosis subjects in general) are naturally in a vulnerable position in their doctor’s office.

Learning to use the power of metaphors and suggestions can improve the doctor-patient relationship and patients’ compliance. A prominent example is the chronic pain patient. When these patients are asked what they were told by their

nurse practitioners, physical and occupational therapists, dentists, chiropractors, and acupuncturists. Each June, MSCH offers an introductory workshop providing basic training on clinical hypnosis, in additional to an advanced workshop for expe-

Given recent initiatives, the time is ripe to fulfill the potential of clinical hypnosis. physicians about their pain, comments such as, “I have to learn to live with my pain” are common. For these patients, the take-away message is that “My physician believes the pain is all in my head,” or “My doctor does not believe that the pain is real,” and that the prognosis for improvement is hopeless. Unfortunately, such unintended messages result in patients being less open to self-management, lowering their pain medications, and addressing their mental health issues. To avoid these types of misinterpretations, physicians can strive to be sensitive to suggestions and language, communicating that they believe that their patients are experiencing real pain (i.e., remember that even psychogenic pain has a physiological basis); that although medical treatments have not resulted in the desired improvement, there are many other methods to explore; and that they have seen many patients improve the quality of their lives. The “hypnosis state” Minnesota has emerged as one of the best areas in the nation for training in clinical hypnosis. The Minnesota Society of Clinical Hypnosis (MSCH, www. msch.us/), founded in 1971, held its 42nd annual convention this summer. The membership of MSCH represents a wide range of disciplines and includes psychologists, clinical social workers, marriage and family therapists, mental health counselors, medical doctors, nurses,

rienced practitioners. Both workshops are administered by the University of Minnesota Medical School’s Office of Continuing Medical Education. MSCH also offers daylong and half-day workshops throughout the year. The training is multidisciplinary and open to licensed health care providers. In addition, the National Pediatric Hypnosis Training Insti-

tute (www.nphti.net/) holds its annual workshop every fall in the Twin Cities. The workshop features training by national and international faculty on the use of hypnosis with children and adolescents, who tend to be particularly responsive to hypnosis methods. Clinical hypnosis has stepped out of the shadow of misconceptions and stereotypes to become a well-respected clinical method. A growing body of evidence supports its use as a primary treatment and adjunct to medical care; with a particular benefit of lowering costs, improving patient self-care and satisfaction, and reducing reliance on pharmaceutical and surgical methods. Shepherd Myers, PhD, LP, is president of the Minnesota Society of Clinical Hypnosis. He is a health psychologist with Fairview Pain Clinic and the Total Pancreatectomy and Islet Autotransplantation Program at the University of Minnesota Medical Center.

Do you have patients that could benefit from Hypnosis? At ABHC Bill Ronan, LICSW, brings over 39 years of professional experience as a State Licensed Psychotherapist, LICSW and practitioner of Medical Hypnoanalysis. He has worked successfully with many physician groups across many specialties. He provides non-invasive, non habit forming support and can enhance the outcomes of many medical procedures. Here are some examples: • Childbirth • Smolking cessation • Anxiety & depression • Addictions • ADHD

• Sexual Dysfuctions • IBS • Weight Loss • Surgical procedures • Pain management

For more information about how you can integrate hypnosis into your care coordination please call:

Bill Ronan, LICSW

Author: The Psychological Autopsy

Bill@MNHypnosis.com | 952-933-3460 527 2nd St NE | Hopkins, MN 55343

2013 october Minnesota Physician

19


Special focus: Physician-patient communication

I

t’s a typical day; you are in the middle of a busy patient schedule and dictations pile up on your desk as you try to answer emails and phone messages. Your assistant walks into your office and brings your day to a grinding halt: “Sorry to interrupt, but Mrs. Smith is here and she is upset. She wants to talk to you …” We all face challenging patient interactions from time to time. Though most patient interactions go smoothly, even an occasional upset patient can consume a significant amount of our time and energy. Even though our first instinct might be to shy away (I know mine is), taking the opportunity to connect and communicate with an upset patient can turn a tense situation into a positive one for both the patient and the physician. Good patient-physician communication has been demonstrated to significantly

Keeping the lines open Dealing with challenging patient encounters By Amy Lynn Conners, MD

improve patient experience (key in this age of satisfaction surveys). In addition, providers who feel confident about

their communication skills experience improved job satisfaction. According to

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Fortunately, like so much

According to JCAHO, poor communication is at the root of 70 percent of sentinel events studied.

Quality Transcription, Inc. Setting the standards for excellence

JCAHO, poor communication is at the root of 70 percent of sentinel events studied.

Minnesota Physician October 2013

Acknowledge your own feelings. Before going to talk to Mrs. Smith (sometimes even while walking to the consultation room), it may help to take a moment to notice and acknowledge your own feelings and reactions. In parallel with Mrs. Smith, you are bringing into the room with you your past experiences with other patients, the stories of colleagues and friends, and the stress and worries you have been living with. We providers are also human beings—we need to recognize our experiences and feelings so they do not interfere with our ability to respond to and help our patients.

Communication and the office visit So, what to do with Mrs. Smith? Below are a few tips I try to employ in challenging situations with patients.

Ask an open-ended question and listen attentively. Often our first instinct is to anticipate what Mrs. Smith might be upset about and begin the conversation with our defense. Perhaps we will argue for the treatment we recommended or will present our reasons why she could not have more pain medication. At this point, it is helpful to remember that the patient’s perceptions and priorities might be vastly different from our own. Even if someone has relayed to us the patient’s stated reasons why she is upset, there may be nuance or a backstory that we do not yet have. Because of this, a great way to start the conversation is to ask an open-ended question, and then listen attentively to the answer. This allows us to avoid making assumptions that might further upset the patient, and helps us to be sure we are dealing with the actual problem at hand.

Acknowledge the patient’s feelings. I find it helpful to remember that when Mrs. Smith arrives in my department, she brings with her not just her experiences with me, but her past experiences with other providers, the stories of her family and friends, the pain or worry she has been living with, the fight with her significant other that morning. It is not uncommon that the concern being presented to you is not really about you at all!

I once saw a patient who was upset because her screening mammogram had shown a possible mass, and she had been asked to return for additional mammographic views. One of our technologists told me that she was refusing any extra views until I came and explained the need. I was prepared to explain how extra views worked and give my mini-lesson on radiation dose and risk. Thankfully, I followed the advice of a senior colleague

of what we do, communication is a skill that can be taught, practiced, and improved. I’ve worked with the faculty of the Communication in Healthcare group at my institution and am grateful to them for the skills they have taught me that inform this article. Many other resources are available through the American Academy on Communication in Healthcare (www.aachonline.org), a professional organization that focuses on communication and relationships with patients, families, and health care teams.


and started by asking, “I heard that you have some questions or concerns. How can I help?” To my surprise, the patient replied, “I can’t believe that you’re recommending more mammogram pictures after everything I’ve researched and read online. …. Don’t you know that when you compress the breast it causes cancer?!” Her actual concern was very different from what I had assumed. The open-ended question gave us a chance to focus right away on her real concern. I suspect that if I had started with my radiation defense, we would have built our care relationship on shaky ground, even if we eventually worked our way to her actual concern. Sometimes, providers are concerned that asking an openended question and letting the patient speak freely will take an unacceptable amount of time. According to a 1999 article in JAMA by Marvel et. al., physicians interrupt their patients’ initial description of their complaint after just 23 seconds, while patients who were allowed to complete their statements took just 6 seconds longer. However, patients who were interrupted were more likely to bring up additional new concerns later in the interview—and, according to a study by Rhoades et al., have less favorable impressions of their visit (Rhoades, DR et al., 2001, Fam Med 33(7)). The very act of listening attentively can decrease patient anxiety and improve satisfaction. Form a partnership. Getting back to Mrs. Smith: You have acknowledged your own feelings, asked an open-ended question, and listened to her concerns without interruption. For many patients, being able to describe their pain, anxiety, or dissatisfaction and having someone else listen and show compassion is essentially all they need. You might find that Mrs. Smith’s negative emotions dissipate when you get to this point. Or they might not. The range of possible causes for

her concern is endless at this point, but there are a few tools that you can use in almost any case. One of my favorites is forming a partnership. Often when a patient is upset or angry, the tension can cause an adversarial, “me-versusyou” dynamic. Forming a partnership with the patient helps remove that dynamic and can be very effective at de-escalating a tense situation. And, it can be used whether you agree with the patient’s assessment or not. For example, say Mrs. Smith wants antibiotics for her son’s runny nose, but they are not indicated. A good partnership phrase might be, “We both want your son to feel better and to give him the best we can to make him healthy.” This statement reframes the situation so that it is you and Mrs. Smith fighting together against disease, rather than you and Mrs. Smith fighting against each other. Offer support. Another powerful tool is to offer support whenever appropriate. A tense patient interaction may cause the patient to worry that he or she will be abandoned or may not get the best care possible. Offering support may be a general statement of encouragement like, “I am here for you and will do my best to help you.” It may take the form of making a specific plan for the next visit or set of tests so the patient knows exactly what the next step will be. (This is especially helpful if the patient has just received bad news.) In some cases it may not be possible or appropriate for you to continue to see the patient, and offering support may mean connecting the patient with a new provider. Physicians are often taught to avoid apologizing, but, when appropriate, offering an apology can be the best way to defuse a tense situation. “I’m so sorry you had to wait; you now have my full attention,” can be a powerful statement when the patient has had to endure a long wait in the clinic office. Especially in cases where you are not at fault, a

good alternative to “I’m sorry” is “I wish.” For example, “I wish there was a more effective treatment” is a great way to convey empathy. Improved satisfaction for patients and physicians As patient satisfaction gains emphasis and time for appointments gets shorter, communication skills take on greater importance. Techniques such as these can significantly improve the patient’s experience while saving time. Though difficult patient encounters like the one with Mrs. Smith are no one’s favorite part of the day, they can also be opportunities to connect with patients and improve satisfaction—both theirs and yours!

Tips for Effective Patient Communication • Acknowledge the patient’s feelings. • Acknowledge your own feelings. • Ask an open-ended question. • Listen attentively. • Form a partnership. • Offer support.

Amy Lynn Conners, MD, is a board-certified radiologist at Mayo Clinic, Rochester, and is an assistant professor of radiology at Mayo Clinic College of Medicine.

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2013 october Minnesota Physician

21


Special Focus: Physician-patient communication

R

obert Brown is 66 years old and has had diabetes since age 46. He presents for an annual visit carrying a list of questions ranging from his recent weight gain to annoying sinus symptoms. In addition to answering Robert’s questions, his internist, Sue Jenkins, brings her own “to do” list to cover—items often dictated by appropriate preventive and disease-specific care. During a 15- to 30-minute office visit, Mr. Brown and Dr. Jenkins do not have enough time to cover both agendas. Something’s got to give. Dr. Jenkins is accountable to see many patients like Robert in a short amount of time, in addition to her responsibilities for increasingly vigorous documentation standards and management of complex disease. Visit length is unlikely to change, and her agenda may even continue to grow. Instead of becoming discouraged, Dr. Jenkins must use her time

“So, how was your vacation?” Connecting with patients to provide better care By Naomi Hertsgaard, MPH, William Nersesian, MD, MHA, and Craig Roth, MD, FACP

more efficiently while genuinely connecting with and listening to Robert. It turns out that one significant way to do this is to improve her communication and relationship skills. Research shows that good communication between provider and patient can improve providers’ quality scores, increase patient adherence to recommended treatments, improve patient and provider experience, and decrease malpractice suits, among other benefits. Effective communication becomes even

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Minnesota Physician October 2013

more imperative when providers help patients with behavior or lifestyle changes, an increasingly essential component of medical care. Providers at Fairview Physician Associates, a network of independent and employed providers, recently participated in a workshop designed to improve provider-patient communication. Just as actors rehearse tirelessly for important roles or athletes strategize before games, so too can providers perfect their communication with patients through practice and coaching. Throughout the workshop, young providers and seasoned veterans alike shared their communication challenges, participating in role-play exercises incorporating evidence-based communication strategies, such as Dr. Jenkins learned to practice with Robert. Set the right tone, from the first minute The first minute of a visit can make or break how the rest of the visit goes. Patients often feel that their providers do not listen to them, and research shows that even confident, well-educated people frequently feel intimidated at the doctor’s office. The need to see many patients in a short amount of time can cause even the most well-intentioned provider to rush patients, leaving them feeling unheard or unimportant. A sense of urgency can also cause providers to interrupt patients before they complete their thoughts or symptom descriptions. Dr. Jenkins begins by using Robert’s name and connecting with him, perhaps by asking him about his recent vacation

or how his day is going. She faces Robert, keeping her legs and arms relaxed and uncrossed, and does not glance at the computer, the door, or her watch. These brief, simple acts help to establish warmth and can even neurochemically raise oxytocin levels, which enhance trust and correlate positively with health outcomes. After setting the tone for positive communication, Dr. Jenkins asks Robert to share his concerns. Before getting into any of them in depth, she lets him know what she needs to discuss at the visit. If she believes that there is not enough time to cover everything, she might ask Robert, “Which of your items is most important to you today?” and then use his response to guide which issues she can cover in the visit. Alternatively, she may use her medical expertise to choose problems that cause her the greatest concern and address them, with Robert’s approval. Studies show that patients often do not mention their chief complaint first, but on average may bring it up as the third item on their list. Patients may not immediately identify their main concern for reasons such as shyness, shame, worry about getting bad news, denial, or lack of complete trust in the provider. Seek the patient’s perspective Having laid the groundwork for a positive relationship, Dr. Jenkins gathers relevant data for the visit, including Robert’s feelings, ideas, symptom concerns, and expectations for the visit. Instead of just acquiring “only the facts,” she explores and clarifies Robert’s viewpoints. She avoids rattling off weight loss advice, writing a prescription for Robert’s sinus infection, or offering quick solutions before she finishes gathering data. Dr. Jenkins is respectfully curious about how Robert is experiencing his situation: “How has your weight gain affected your daily life? What would you like about losing


weight? What would be some challenges for you personally if you had to change your eating habits?” Robert’s answers may reveal that he is struggling with depression as a result of his health issues, and could benefit from talking to a mental health professional. His answers also reveal strong ambivalence related to his enjoyment of preparing and sharing food with friends and family on the one hand, and wanting the health benefits of losing weight on the other. So Dr. Jenkins demonstrates her skillful listening by using a response that captures Robert’s feelings and their source: “I can see this has really been a challenge for you. Food, family, and cooking are important in your life, and so is your health.” Overlooking Robert’s own perspectives on his health issues may be as erroneous as ignoring a weeping wound. Dr. Jenkins’s brief acknowledgement of his feelings takes but a few seconds, yet establishes a genuine connection by making him feel he has been heard. Check for understanding After listening to Robert’s perspective and asking clarifying questions, Dr. Jenkins offers a diagnosis or treatment plan that addresses Robert’s original concerns. If she responds only to Robert’s sinus symptoms and ignores his possible depression and recent weight gain, Robert likely will leave the appointment no better off than when he arrived. Dr. Jenkins confirms Robert’s understanding of the treatment plan by asking him to explain it back to her (“teachback”). She realizes that sometimes patients nod their heads as if they understand, yet leave without a clear “what now?” plan. In fact, studies show that patients often forget the majority of medical information from a visit or remember it incorrectly. To combat this, Dr. Jenkins asks Robert another question: “Did you receive what you needed most from the visit?” This gives Robert one more opportunity to clear up any misunder-

standings, if necessary, and to ask clarifying questions. Now he is more satisfied with the visit and more likely to adhere to his medications and treatment regimen. It also must be recognized that occasionally a subsequent visit will be needed to address all the patient’s concerns and expectations. Draw on the medical team Even after working on her own communication skills, Dr. Jenkins may realize that there simply is no way she alone can provide all the education and intervention Robert requires. The good news is that she doesn’t have to. Dr. Jenkins knows she is one member of a team of professionals, each with a role to play. Perhaps the best person to explain Robert’s new medication to him is a pharmacist. Or, Robert might receive more comprehensive information to manage his diabetes from a certified diabetes educator. If Robert does have depression, he would benefit more from comprehensive counseling from a mental health professional than from a busy clinician attempting to sum everything up in a couple of minutes. As an example, providers in the Fairview Physician Associates network can refer patients struggling to develop healthy lifestyle habits to CAN DO program health coaches who provide in-depth information and personalized guidance. These coaches/health educators are specifically trained to assess motivation and work within a patient’s framework, culture, and capabilities. Referring providers may ask patients at subsequent appointments how the program is going, yet they are not responsible for the time-consuming aspects of lifestyle coaching. When Dr. Jenkins releases some activities to her teammates, she has more time to discuss topics such as Robert’s elevated HbA1c and blood pressure.

satisfied—perhaps even connected! Robert has several new resources in hand, including the phone number of the mental health professional Dr. Jenkins recommended. Dr. Jenkins was able to discuss her agenda items because she set expectations early, and she enjoyed connecting with Robert about his recent vacation, as she also loves to travel. There is time to connect with patients, listen to them, and address their concerns, as well as to offer medical information and education (even if it means using teammates). Many providers’ biggest fear is that if they connect with a patient personally and offer the thorough education they were taught in their training, they will consume too much time and will fall “way behind” in their schedules. Paradoxically, time-based studies show that when a provider gains a patient’s trust early in the visit,

does a quick assessment of all the patient’s questions, and sets priorities, visits are actually slightly shorter and are more manageable. Some people are born communicators and inherently know how to connect with patients, satisfy their needs, and still stay on schedule. The great news for the rest of us is that we can all learn communication skills. Every provider can improve through continuous training and practice to offer the kind of care we envisioned when we entered medicine. Naomi Hertsgaard, MPH, is a quality data analyst at Fairview Physician Associates. William Nersesian, MD, MHA, is a pediatrician with a background in public health. He is currently chief medical officer at Fairview Physician Associates. Craig Roth, MD, FACP, is an internist at the Minneapolis VA Health Care System, and an associate professor of medicine at the University of Minnesota. He has been trained and certified by the American Academy on Communication in Healthcare in advanced clinical communication and group facilitation.

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A satisfying connection Dr. Jenkins and Robert both leave the appointment feeling 2013 october Minnesota Physician

23


S pec i a l fo c us: Ph ys i c i a n - pati e nt com m u n i c ati o n

“T

o live is to suffer.” Joseph Campbell, the 20th-century popularizer of comparative mythology, said it most succinctly, although he had likely paraphrased the Buddha.

Shared suffering Common humanity connects the wounded and the healer

And yet, our mission as medical providers is to discover the cause of suffering and alleviate it.

By Rachel Frazin, APRN

What an arduous, impossible task we are given. For once we have apprehended the causes of suffering, we must snuff them out, tame them, or, even better, prevent them in the first place— all within the limits of a 10-minute office visit.

A chasm breached Until a few years ago, I was a healthy, contented, middle-class white woman, advising patients who were often poor and immigrants to exercise in moderation, remember their pills, and “take heart: things will get better.”

The notion that we might consciously engage our own suffering in our encounters with patients goes against our professional training, with its emphasis on dispassionate analysis. Yet, I have been doing just that in my work as a family nurse practitioner.

Implicitly, though, I felt a sense of personal immunity to the problems that I witnessed daily. A whiff of superiority infused my relationships with patients. I extended myself to them with an air of noblesse oblige, as though they resided in a land of the ill-fated beyond a gulf that

would protect me and mine. That chasm was breached on Aug. 18, 2009, when my 24-yearold daughter Daniele committed suicide. From that day forward, I was forced to face ineluctable impermanence, an undertaking no parent readily embraces. When Daniele had begun struggling with debilitating anxiety and depression during childhood, I was confident in the power of problem-solving and loving parents to turn her around. I spent my days helping people mend themselves and, in time, most did. Why would my daughter be an exception? Yet despite a hiatus during high school, Daniele spiraled downward in her twenties. Helplessly, I watched her negotiate the treacherous narrows of young adulthood—impeded by failed love, lost jobs, and the struggle to find authenticity in an often unforgiving world. I thought I had ratcheted back my expectations for her, but nothing could have prepared me for the end of hope that came with her death. With her loss came an anxious emptiness born of a sense of lost purpose. I dropped 20 pounds to a size 2, my resting heart rate climbed by 10 beats a minute, and my brain sped up, compressing my speech and disturbing my sleep. Bouts of soul-clobbering sobbing came as unexpectedly as seizures.

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Perhaps intuiting that my patients held the key to my sanity, I returned to work a week after Daniele’s death. Immediately, I noticed that something had changed. I experienced a mysterious opening up and surrender, as though I had stepped into their circle of suffering. Unexpectedly, I found that connecting my patients’ suffering to

my own deepened their motivation to care for themselves and provided me solace in my encounters throughout the day. Just recognizing how we share this most human dilemma had created the conditions for an exchange that transcended our roles as patient and provider. A compassionate agenda On a recent summer day as I arrived for my afternoon clinic at West Side Health Center in St. Paul, the medical assistant informed me that the first of 10 scheduled patients, a 29-yearold diabetic Mexican man complaining of a recent onset of weakness, was ready to be seen. Then she delivered the blows: “His most recent hemoglobin A1C was over 14, and he says he does not want any blood tests or insulin.” Although I would need to evaluate him for ketoacidosis, other metabolic disturbances, and underlying infection, I knew that the biggest challenge to treating him effectively would not be diagnostic in nature. Instead, I would need to contend with his refusals, which he had employed like bludgeons in order to maintain his autonomy. Given the time limitations, I knew I’d be lucky to help him find a way to divert his defensive energy toward something positive, like achieving glycemic control. If I could find a way to use my own suffering to connect with his, maybe I would not need to know the reasons behind his resistance. Before I entered the exam room, I consciously imagined how frustrating it would be to have a body that could not perform an essential metabolic dance that normal bodies do without a thought. Then I considered the web of shame that so often entangles a patient who defies medical advice. I understood the fearsome anger that comes with betrayal, although, unlike my patient, it was not my body that was duplicitous. Instead, Daniele’s self-destruction was akin to a terrorist’s work, imploding our family’s edifice and wreaking havoc on our wholeness.


I greeted my patient in Spanish, pausing to scrutinize his facial expression. I thought I saw a timid appreciation in his fleeting glance, perhaps at my addressing him in his native language. Or it might have been in response to my Duchenne’s eye-crinkling smile, which releases the bonding neurohormone oxytocin. His normal vital signs, alert gaze, and the erect posture of his diminutive 99-pound, 65inch frame reassured me that he was not gravely ill. Even before eliciting the specifics from his history and physical exam, I had “thin-sliced” this patient; that is, I had unconsciously interpreted patterns in his presentation that enabled me to make a rapid, intuitive assessment, which would leave me time to focus on cultivating our relationship. I sat down to face him instead of the computer, knowing that the visual connection between us would help kindle the trust that would be needed if I were to help him help himself. I spent time asking him questions related to infection, life-threatening DKA, and other possible causes of weakness— not only because the answers were important diagnostically, but also to reassure him that I was considering all the possible causes for his weakness, instead of jumping directly to the issue of hyperglycemia from his failure to take insulin. Having completed the history, I began the physical exam. As I stepped close to begin examining his eyes, his fruity breath confirmed ketonemia.  After finishing his exam, I explained that I could arrive at a more accurate assessment of his problem if I could run a few blood tests. He asked, “Can you give me fluid in my veins? That would make me feel better.” Since he did not appear significantly dehydrated, intravenous fluid might not have been necessary, but giving him a bag of saline would signal that I honored his need. I replied, “As long as the blood tests are normal, we can

give you salt water through your veins. If not, it would be safer for you to go to Regions Emergency Department.” “I can’t go there. I have no money.” Although I didn’t ask, he probably didn’t have a green card either, and the threat of deportation added to his sense of powerlessness.

of life. The very act of teaching him suggested that ours was an egalitarian relationship in which I am simply a knowledgeable guide. When we tried to set up another appointment, he demurred: “I can’t miss work.” I agreed to call him to adjust his insulin by phone so long

The notion that we might consciously engage our own suffering in our encounters with patients goes against our professional training, with its emphasis on dispassionate analysis. I resonated with his frustration and anxiety over having little control over something so essential to peace of mind. After Daniele had attempted to overdose five years before her death, my husband and I had asked how we could prevent her from trying again. Our friend, a psychologist, told us we could do nothing because we couldn’t babysit her 24/7 to keep her from killing herself, which left us feeling helpless in the face of an overwhelming threat. Intimidating the patient with my medical authority by demanding he go to the ED would have compromised our relationship and his motivation to heed my recommendations about how best to care for himself. He did agree to the lab tests, which confirmed my clinical suspicion: glucose level too high to read, 4+ urinary ketones, and a normal CBC and basic metabolic panel. After the nurse gave him seven units of regular insulin and a liter of saline, I directed my attention to his need for understanding his disease. I could have threatened him with loss of life and limb from poorly controlled diabetes, but that would have increased his level of threat detection to a code red, further inflaming his aggression and alienation.

as he checked his blood glucose twice a day. Because he was not yet ready to make the necessary concessions demanded by his disease, I would need to remain patient, setting humble goals with him on future visits. I had been setting myself a similarly compas-

sionate agenda in my grief. The need for patience in my own journey of loss had nourished my empathy for the unique path that others take through their suffering. I did not fool myself into thinking that the patient was fixed, but I was confident that he had thin-sliced me in return, and would “know” unconsciously that I had recognized his suffering. I could only hope that this deep recognition of our shared humanity might help him to accept his disease and to take better care of himself. When I returned home, I felt the way I have so many days since Daniele’s death: There is no meaningful difference between wounded and healer. Rachel Frazin, APRN, is a family nurse practitioner who practices as a locum tenens at West Side Health Center in St. Paul, Neighborhood Health Services in Minneapolis, and at Maniilaq Health Center in Kotzebue, Alaska. She is writing a memoir about her daughter’s life and death and her own journey of discovery.

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Instead, I explained what had gone wrong in his body and how insulin made it right, leading to better energy and quality 2013 october Minnesota Physician

25


S pec i a l Fo c us: Ph ys i c i a n - Pati e nt Com m u n i c ati o n

Y

ears ago, as a young physician, I took part in a program designed to help doctors improve their interactions with patients. Part of it involved the doctor and patient being videotaped in the exam room. At the time, it was my practice to give a good solid knock on the door before I entered. It turned out my entrance was a little too robust. The videotape revealed that my patients, who were already a little tense, would jump when they heard the knock, startled at the sudden noise. The patient’s heart would be pounding before we even started the exam.

From then on I toned down my knock, thankful for the constructive feedback revealed by the program. Flash forward to today, and I am involved in another program to help physicians improve their patients’ experience. As head of family medicine at HealthPartners, I know our

Physician shadow program

That gives the doctor a chance to incorporate a couple of things that have come up so far. At the end of the day, the coach offers a few more comments.

Improving the patient experience

Benefiting from feedback The coach’s second day is spent collating all the notes and impressions that came up the previous day. Some of it is directed with a checklist the coaches follow, and some of it is just their own free-flowing thoughts of what they observed. They then write up a report, which is sent to the physician they shadowed. That report is sent only to the doctor—it’s not seen by administrators, medical directors, or anyone else.

By Art Wineman, MD reputation for providing quality care. But what we haven’t always been good at was providing the highest quality

Frequently the feedback will point out things we are doing unconsciously. of experience for patients. So in 2010, we started the Physician Shadow Program to help doctors and other providers improve the patient experience.

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Setting up the shadow The main idea behind the shadowing program is to have someone who knows what it’s

Minnesota Physician October 2013

Sorry, no J1 opportunities.

like to be a patient sit in and observe physicians, watch their interactions with their patients throughout the day, and give them feedback on ways they can improve. We had heard of versions of this program at other facilities, so we talked to some of those groups and decided to see if it would work for us. Unfortunately, we did not have anyone on staff who could teach us how to do the shadowing, so we brought in a coach who helped us set up the program and train some of our employees to be shadow coaches. We wanted shadow coaches who were not medically trained, and we received volunteers from all parts of the organization: finance, marketing, supplies— you name it. They were asked to volunteer their time 12 days over a 14-month period, so they could build trust and really get to know the physician’s style and how they work. Here’s how the program works. The shadow coach introduces himself to the physician and says he’ll be in the corner of the exam room, not saying anything, except for perhaps a brief greeting to the patient. The coach may make a few notes, then partway through the day, will sit down and say, “This is what I’ve found so far and this is what you might want to try.”

It’s simply feedback for that physician. Often the doctors will choose to share the report with their chiefs with the hope that the feedback will change certain behaviors among the staff. And sometimes they had no clue they were doing those behaviors (like me with my heavy knock). The feedback can help them be more effective in connecting with patients. As we physicians are well aware, patients are more likely to follow through and have better outcomes if they’ve built a strong relationship with their doctor. We want our patients trusting us and knowing we care. The shadow program is a way to help us build up some of those attributes and improve results. Frequently the feedback will point out things we are doing unconsciously. For example, we all wash our hands when we walk out of the room. Many of us do it before we walk into the room too—but the patients don’t see that. So by washing our hands while we’re in the room, even if we don’t feel it’s absolutely necessary, we can reassure the patient. That’s one of the things the shadow coaches may pick up that the doctors may not necessarily think about. Keeping the connection One of the things the shadow coaches are very good at is helping the physicians learn how to


use the new technology, while maintaining a strong connection with the patient. A good example is how much more efficient we’ve become at providing better care while using the electronic medical record. While I pull up a record to find out about a patient’s previous history or visit, my eyes leave the patient and go to the computer screen. It’s very important to keep the connection with the patient and the technology. Being shadowed When the shadow coach goes in for the first couple of patients, it feels a bit artificial and the doctors are on their best behavior. They might do and say things they wouldn’t normally do or say, because they have someone watching them. But by the fourth or fifth patient of the day, the shadow is just part of the background. You forget he or she is there and just start acting the way you normally would with patients.

That’s the value of having someone there the entire day. It’s not just that the shadowed physicians get to see a lot of interactions with different types of patients; the physicians also become more used to their presence and can ultimately give more of an example of how they truly behave with those patients—which results in more honest feedback. Physicians say it’s a more pleasant and less intrusive process than they expected. And almost all of them find at least one or two new things they’re going to try to change, based on the shadowing experience. Positive results; positive response So far the results and the response to the program have been very good. Seventy-one percent of the providers who have been shadowed have improved their individual patient experience scores. Generally an individual’s improvement falls

in the 3.5 percent to 4 percent range. But overall, HealthPartners individual physician scores have seen improvement ranging from .5 percent to 59 percent, based on the NCR Picker, a national database of patient satisfaction. Five years ago, our group was average in patient experience and satisfaction, and we are now in the upper tier. Because this is only one of many steps we’ve taken to improve patient experience, we can’t attribute all score increases to the shadow program, but it is definitely a key factor. A word of caution to anyone thinking about starting a similar program: Make sure doctors know if there are plans to have someone follow them. Early on, our leaders were so enthusiastic, they signed up their entire staffs for the program. Shadow coaches would show up to the surprise of the doctor. Needless to say, a surprised doctor was not usually enthusiastic about having a shadow that day.

So we’ve made sure doctors know when they’re going to be shadowed and have made it clear that this is something they need to want to do for themselves. It’s strictly on a volunteer basis, although it is now an expectation for our new doctors. Since starting the program as a pilot, we’ve expanded the program to make it available to all our advance practice providers. In all, we’ve sent coaches to shadow 348 providers and counting. Even the best physicians in the business have room for improvement, and our physician shadow program helps them make those little tweaks. Maybe their handshake could be a little firmer. Maybe their greeting could be a little warmer. Whatever it is, we might not notice it—but the patient certainly does.   Art Wineman, MD, is the department head of HealthPartners Family Medicine.

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Ps yc h i atry

T

his time of the year brings crisp weather, apple-picking, leaf piles— and shortened daylight hours. The latter brings with it the increased prevalence of seasonal depression, which is called seasonal affective disorder (SAD) or recurrent depression with seasonal onset. The human brain has an internal clock that adjusts itself based on duration of light that enters the retina. The suprachiasmatic nucleus is the brain system that controls the internal clock. Some people with recurrent depression are very sensitive to the yearly reduction in daylight hours. They show what is termed a phase delay

Seasonal affective disorder (SAD) Diagnosing and treating the “winter blues” By Barry Rittberg, MD, and S. Charles Schulz, MD in their circadian rhythm. This can trigger an episode of major depression at the same time each year. In general, the farther from the equator one lives, the higher the likelihood of experiencing SAD. The incidence of this mood disorder is about

2.4 percent in higher latitudes (including Minnesota). Women in their childbearing years are the group at highest risk for SAD. Patients with bulimia also have high rates of SAD.

As with nonseasonal depression, there are abnormalities in CNS serotonin, norepinephrine, and dopamine in people with SAD. Resources for patients with SAD There is also a genetic link involved “Winter Blues,” by Norman E. Rosenthal, MD (Guilford Press, 4th ed., 2012) in SAD, and seawww.ncbi.nlm.nih.gov/pubmedhealth/PMH0002499/ sonal depression is often seen in the sibwww.webmd.com/depression/tc/seasonal-affective-disorder-sad-topic-overview lings or offspring of www.nami.org/Template.cfm?Section=By_Illness (click on “Seasonal Affective Disorder”) those affected. Some researchers have speculated that the very low rate of SAD in native Icelanders and their descendants, despite Iceland’s high latitude, may be due to their genetic adaptation to winter darkness.

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Minnesota Physician OCTOBER 2013

Symptoms and diagnosis of SAD The core symptoms of SAD are low energy, increased eating, and increased sleep. Other symptoms of depression must also be present, including impaired concentration, low mood, and loss of interest in normally enjoyed activities. Suicidal thoughts may also be present, and these patients should be referred to a psychiatrist or psychologist for further evaluation. Ten percent to 12 percent of people will develop a seasonal energy drop unrelated to depression. Therefore, in order for a clinician to make a diagnosis of SAD, a patient must have a complete remission of depression during summer. Some patients have recurrent depression that may worsen in winter, but also have episodes at other

times of the year. Therefore, when screening for depression during the summer, it is wise to ask patients whether they have experienced winter depression. SAD will not be captured by a PHQ-9 or similar depression screens unless the screening tests are administered during the fall or winter. Treatments for SAD Light-box therapy. SAD can be treated with light-box therapy, which is also called bright-light therapy. (Bright-light therapy is less effective for people who have depressive episodes at other times of the year.) This therapy extends the patient’s daylight hours through the use of a high-intensity light box that produces 10,000 lux of illumination. Harmful ultraviolet rays are filtered out by a plastic screen on the light box or by a special coating in the fluorescent tubes. The “Tips” sidebar on page 29 provides additional information about evaluating light boxes for effectiveness. When patients use the light box for about 20 to 30 minutes in the morning before the sun has fully risen, the therapy essentially tricks the patient’s brain into believing the daylight hours are longer. Many seasonally depressed people have a hard time getting up before sunrise and cannot fit in the use of the light box in the morning. For them, evening use of the lights can be helpful, but not as much as using the lights in the morning. Additionally, a common side effect can be insomnia if the lights are used too late in the evening. The benefits of light-box therapy—improved mood and energy—are felt fairly rapidly, within a few days. If people stop using the lights, the benefit of the therapy rapidly diminishes. As spring arrives, most people will be able to stop the light therapy without problems. A subset of people will develop excess energy, decreased need for sleep, and increased social interaction in spring. These symptoms may become prob-


Tips for choosing the most effective light boxes

Clinical pearls of seasonal depression

Light boxes are not federally regulated, so consumers need to be aware of what parameters of light are the most helpful in treating SAD.

• The further from the equator you live, the higher the incidence of SAD.

Lux is a measurement of light intensity. This takes into account the sensitivity of the eye to different frequencies of light. Lux is inversely related to the distance of the eye from the light source. Clinicians are looking for light boxes that will produce 10,000 lux at a reasonable distance; 10,000 lux at a distance of 10 inches would mean the user would need to have the light box 10 inches from the eyes. In this case, we are looking for a light source that that will allow a person to read or do other relaxing activities a reasonable distance from the light box. Ideally, this would be 18 to 24 inches.

•C  ore symptoms include excess sleep and appetite and low energy. •B  right-light therapy (light-box therapy) is the most common treatment. •T  he intensity of the light is the most important factor when choosing a light box.

Another measurement of light is its color or frequency. Though a light source that involves the full spectrum of light was once thought to be necessary for benefit, more recent research shows that intensity of light is more important. Several recent studies have shown that a specific frequency of blue light is the most important color, even at lower light intensity. Adequate light-therapy boxes can be purchased for $200 to $300 over the Internet or from durable medical suppliers. Modern boxes use compact fluorescent bulbs, which are smaller, run cooler, and use less electricity. Many insurance companies will cover the cost or rental of light boxes if the seasonal pattern is well documented and there are no nonseasonal episodes. Patients need to obtain prior authorization for such coverage. Note that replacing the fluorescent lights in the workplace with full-spectrum bulbs is ineffective in treating SAD, because the bulbs are too far away from the people. However, one pleasant effect of full-spectrum bulbs is that the light does look more natural; regular fluorescent lights can have a yellow cast.

lematic and need to be treated with a mood stabilizer. This would be a bipolar variant of SAD and should be referred for further evaluation. Light-box therapy is never as good as real sunlight. The intensity of light at noon on a summer day can reach almost 70,000 lux. If they can afford it, some SAD patients will plan a two-week vacation to a southern destination during January or February. We have had patients move to southern states to minimize the effects of the shortening of daylight. In addition to light therapy, outdoor exercise, especially on sunny days, has been found to be useful. Compliance with bright-light therapy can be spotty, even more so than compliance with taking medications. If patients stop the light therapy, the SAD symptoms return quickly. We recommend that SAD patients be monitored regularly (monthly during the period of depression). This enhances

compliance while also allowing the clinician to assess residual symptoms that may be helped by antidepressant medications. Antidepressants. Not all seasonal depressions should be treated with bright-light therapy alone. If a patient has more than just fleeting wishes of death, a referral to a psychiatrist or psychologist should be made. For patients who have significant suicidal thoughts, we also treat with antidepressant medications. There is no one preferred antidepressant, but those that worsen the hyperphagia and hypersomnia associated with SAD should be avoided. These would include mirtazapine and tricyclic antidepressants. Electronic negative air ion generators have been shown to be helpful, but not as much as light-box therapy. Negative air ions have a calming effect on animals, whereas positive ions are agitating. Waterfalls generate negative ions. Positive air ions are in preponderance just

prior to thunderstorms and negative ions, afterward. This may relate to the edginess we feel prior to storms and the calmness we feel afterward. People who develop agitation as a side effect of light box therapy may consider an ion generator as an alternative.

Additional resources Many patients have heard of seasonal depression and the treatment with bright-light therapy and may already be self-treating with light therapy. The sidebar on page 28 lists several useful resources for the general readership about SAD and its treatment. Barry Rittberg, MD, is an assistant professor in the Department of Psychiatry at the University of Minnesota. S. Charles Schulz, MD, is a professor in and head of the same department.

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Table 1. Common issues and communication recommendations regarding advance care planning (ACP)

Issues

Recommendations

It is not unusual for many families of minority populations to request that the medical team not disclose bad news. This “conspiracy of silence” impacts how to best counsel the patient and family.

Ask the patient how much he/she wants to know. While some patients are much more comfortable leaving decisions up to their loved ones, others want to be included in the discussion.

While mainstream culture has a strong bias toward self-autonomy, other traditions prefer that a larger extended family makes final care decisions.

Clarifying who the decision-makers are eases mutual understanding of who is making the decision and what will be shared.

Health care statistics show that minorities have a lower rate of health-care directive completion than do majority populations. Many factors account for this, including beliefs that minorities do not receive the same opportunities for care.

Clarify with all patients that ACP is a standard preventive procedure for all patients 18 years of age and older. This primary health intervention helps persons of all ages identify who would make decisions if they were unable to communicate for themselves.

Many individuals believe that an ACP discussion means they have a lifethreatening illness.

Educate all people on the preventive importance of advance care planning. Explain that we know that many individuals do not get the care they want and value during an illness. By beginning an ACP dialogue and completing a health care directive, families reveal their misconceptions and replace mistrust with family-centered preparedness in the event of an emergency or health care crisis.

Multicultural advance care planning from cover

homeland, belief in the power of miracles, and other practices have a huge impact on patients’ decision-making. For individuals affected by health care

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Minnesota Physician October 2013

health care directive. While only a fraction of the mainstream public has had this conversation, introducing this topic to people of other backgrounds can result in significant pitfalls.

toms, and making it possible for them to lead as fulfilling a life as possible.”

Cases like the two described above are seen frequently by physicians who care for multicultural patients and families, and these situations share common themes. Identifying these themes before a crisis occurs increases opportunities for better care. By following the practical recommendations shown in Table 1, care providers can increase family trust and open the door to more productive dialogue concerning advance care planning.

In case study 2, the physician can explain what palliative care provides, and how it will improve the loved one’s life by providing support and care for the “entire person”—i.e., assisting with physical, emotional, and spiritual needs for complete care. The physician can also explain and introduce the role of the multidisciplinary team and how the team can offer support to the patient and his family.

Suggestions from the field Physicians can share bad news by explaining the diagnosis and disease process in terms that can be more easily understood and using practical examples and analogies. Checking for understanding by asking the patient/family to repeat back what they understand is the best way to confirm that communication has been successful. Physicians can navigate the “conspiracy of silence” by showing an open attitude toward the family’s requests, and, at the same time, respectfully explaining that it is the patient who ultimately decides how much he or she wants to know or get involved in these conversations. Care providers can sustain family hope through statements such as, “I will continue to provide excellent care for your loved one by reducing their pain, managing their symp-

Returning to case study 1, a suggested physician response would be, “I will tactfully and gently ask your father how much he wants to know regarding the results of the different tests. I’ll ask him whether he wants me to explain the results to him directly, or if he prefers that I review these with you. If he chooses the latter, I will ask him if he wants to be present or if he prefers that we meet outside of his room.”

A gift to families Offering “the best care possible” means different things to different people. As physicians and other medical providers become more familiar with the impact of language and culture in ACP, significant end-of-life care patient/family conversations will begin to emerge. As patients see that their physician has a greater understanding of their own lives and values, slow, significant changes will take place in ACP acceptance. And as patients gain a deeper understanding of the breadth of care possible, completion of health care directives that identify key decision-makers will become a new norm. For physicians and health care providers, these are among the greatest gifts we can give the families we serve—the opportunity to receive the care they prefer. Miguel Ruiz, MD, is a palliative care and internal medicine physician with HealthPartners. Barbara Greene, MPH, is director of community engagement with Honoring Choices Minnesota, an initiative of the Twin Cities Medical Society. For additional multicultural patient perspectives, stories, and resources visit www. honoringchoices.org.


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Pro fess i o n a l u pdate: O rth o pe d i cs

U

ntil recently, there has been a relative paucity of data to support clinician decision-making for common disorders of the lumbar spine. In 2006, results from the first of several multicenter, randomized, prospective studies—the Spine Outcomes Research Trial, or SPORT—were published. The studies critically compared surgical treatment to nonsurgical treatment for common spine conditions. Data were collected from 13 centers across 11 states. The researchers compared surgical and nonsurgical treatment outcomes in patients with herniated discs, spinal stenosis, and degenerative spondylolisthesis. SPORT unquestionably proves the benefit of surgical management in these selected patients. This article summarizes the findings of the SPORT studies. Intention-to-treat analysis Before examining the data from the individual studies, it is im-

Spine Outcomes Research Trial Results guide decision-making for common spine disorders By David H. Strothman, MD

portant to first understand “intention-to-treat” analysis, which was used in the randomized portions of SPORT research. Intention-to-treat analysis compares outcomes by the group that a patient is randomized to, not by what treatment the patient actually receives. Though this type of analysis is statistically very powerful, it pushes the outcomes toward the null hypothesis, i.e., that there is no difference between two measured phenomena (in this case,

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 out-patient 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.jobs or contact diane.m.collins@healthpartners.com. Call Diane at 952-883-5453; toll-free: 800-472-4695 x3. EOE

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MN Physician 32x Minnesota Physician 4" 5.25" 4-color

October 2013

surgical versus nonsurgical treatment). For example, a patient who is randomized to have surgery but then is feeling better prior to his surgery date obviously would want to cancel surgery and continue with conservative care—and, thus, would cross over to nonsurgical care. And a patient who is randomized to conservative care but develops worsening pain would naturally cross over and have surgery. The more such “crossover” patients in the study, the more similar the two groups become—and the closer the outcomes will get to the null hypothesis. In all three SPORT studies, the crossover rates were high enough to invalidate the intention-to-treat analysis. Consequently, the as-treated analysis offers the more important guidance in making clinical decisions. Herniated discs Two separate studies of treatment for herniated disc were published in JAMA in 2006: one observational (Weinstein et al., 2006, JAMA 22;296(20):2451– 2459) and one randomized (Weinstein et al., 2006, JAMA 296(20):2441–2450). The randomized trial was limited by the high crossover rate; the researchers wrote that “because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.” Consequently, the discussion below focuses on the observational study. The study included patients age 18 and older who were felt to

have a herniated disc, with clinical findings and exam findings that correlated to the level and location of the herniation; had failed at least six weeks of conservative management; and were felt to be surgical candidates. Conservative management included education/counseling (71 percent), physical therapy (67 percent), epidural injections (42 percent), chiropractic therapy (32 percent), anti-inflammatory medications (61 percent), and opioid analgesics (40 percent). A total of 1,244 patients were enrolled, with 500 patients agreeing to participate in the randomized intention-to-treat trial and 743 patients declining the randomized trial but agreeing to enroll in the observational trial. Of the 743 patients in the observational trial, 521 chose surgery and 222 chose nonoperative care. There is some potential bias here because all of these patients chose not to be randomized, making it highly likely that this group of patients felt more strongly about their choice than did the patients in the randomized group. Overall, 95 percent of patients who chose surgery had a discectomy procedure within six months. Over time, an increasing percentage of patients in the nonoperative group crossed over to surgery. In the first six weeks, only 2 percent of these patients underwent surgery; by six months 16 percent had undergone surgery; and by two years, 22 percent of the nonoperative patients had undergone surgery. Findings. Patients who had surgery did significantly better in the primary outcome measures than patients who did not have surgery, despite patients choosing their treatment course. At three months, the average Oswestry Disability Index (ODI) improved by 36 points for patients who had surgery and by 21 points for those who did not have surgery. Similarly, on the bodily pain and physical function components of the SF-36 health survey, patients who had surgery improved by 41 percent and 41 percent, respectively, as Spine Outcomes Research Trial to page 34


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Spine Outcomes Research Trial from page 32

compared to improvement of 26 percent and 25 percent, respectively, for patients treated with conservative care. Over the course of two years the treatment effects narrowed, but surgery was statistically significantly better at all treatment time points. Not only was surgery better than conservative care, but this difference was maintained out to four years in follow-up studies (Weinstein et al., 2008, Spine 33(25): 2789– 2800). Spinal stenosis To be included in the spinal stenosis trial, patients had to have had at least 12 weeks of symptoms; imaging showing spinal stenosis without spondylolisthesis at one or more segments; and been judged to be surgical candidates (Weinstein et al., 2008, N Engl J Med

358:794–810). Nonsurgical care prior to study enrollment included physical therapy, epidural injections, chiropractic care, anti-inflammatories, and opioid analgesics. The study was organized into both a randomized and an observational cohort; 289 patients were enrolled in the randomized study, and 365 patients were enrolled in the observational cohort. In the randomized cohort, there was considerable crossover. In the surgery group, only 63 percent of patients had undergone surgery at one year and 67 percent at two years. In the nonsurgical group, 42 percent had undergone surgery at one year and 43 percent at two years. A full one-third of patients who were felt eligible for surgery did not proceed with it. Patients who crossed over from surgery to nonsurgical care had less

Key messages Patients with a herniated disc and at least six weeks of symptoms have a better outcome with surgical treatment at two years than patients treated only with conservative care, and that difference is maintained through four years. Patients with spinal stenosis who have had at least three months of symptoms have a better outcome with surgical treatment at two years than patients treated with conservative care, and that difference is maintained through four years. Patients with spondylolisthesis and stenosis who have had at least three months of symptoms have a better outcome with surgical treatment at two years than patients treated with conservative care, and that difference is maintained through four years.

bothersome symptoms and were less likely to rate their symptoms as worsening than patients who remained in the surgery group. This does not represent a failure of surgical care, but rather patient choice. The 43 percent of patients who crossed over from nonsurgical care to surgery likely represents a failure of conservative care for these patients. However, in the intention-to-treat analysis, they were treated as if they did not have surgery, even though they did. Despite the neutralization effect of the crossover in this study, there was a significant treatment effect favoring surgery at two years, even with the intention-to-treat analysis. However, ODI and SF-36 changes were not statistically significant. Findings. Both the observational cohort and the as-treated analysis showed statistically significantly better improvements in all outcome measures at all time points in surgery patients as compared to patients who received usual conservative care. At two years, 72 percent of surgery patients reported a major improvement in symptoms, as compared to 20 percent of nonsurgical patients. ODI scores improved by 21 points in surgery patients and by 7.6 points in nonsurgical patients. Similar trends were seen for SF36 scores, stenosis bothersome index, leg pain bothersomeness scale, and low-back-pain bothersomeness scale.

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Minnesota Physician October 2013

The data conclusively demonstrate superiority of surgery as compared to nonsurgical care for patients with spinal stenosis without spondylolisthesis who have failed three months of conservative care and are judged to

be surgical candidates (Weinstein et al., 2008, N Engl J Med, op cit.). Four-year follow-up data demonstrate that the advantage of surgical treatment is maintained (Weinstein et al., 2010, op cit.). Degenerative spondylolisthesis To be included in the degenerative spondylolisthesis trial, patients had to have neuroclaudication symptoms or radicular leg pain; spinal stenosis on imaging; degenerative spondylolisthesis on a standing lateral X-ray; had symptoms for 12 weeks; and been judged to be a surgical candidate (Weinstein et al., 2007, N Engl J Med 356:2257–70). Conservative treatments prior to surgery included physical therapy (68 percent), lumbar epidural injections (55 percent), chiropractic care (25 percent), anti-inflammatories (63 percent), and opioid analgesics (30 percent). Interventions included either surgical care with a decompressive laminectomy (with or without a fusion, with or without instrumentation) versus usual care, including at least physical therapy and anti-inflammatory medications. As in the stenosis trial, patients were divided into a randomized “intent to treat” trial, and those who did not wish to be randomized were placed into an observational cohort. In the randomized cohort, 159 patients were assigned to surgery and 145 patients were assigned to nonsurgical care. Sixty-four percent of patients assigned to surgery underwent surgery within two years, meaning that 36 percent of patients crossed Spine Outcomes Research Trial to page 36


Physician Practice Opportunities Opportunities available in the following specialties: Olmsted Medical Center, a 150-clincian multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Dermatology Southeast Clinic

Family Medicine Pine Island Clinic

Hospitalist

Rochester Hospital

Internal Medicine

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. Currently we are seeking to add the following specialists: General Surgery

Pediatrics

Orthopedic Surgery

Obstetrics/Gynecology

Radiology/Oncology

Family Practice

Internal Medicine

Emergency Medicine

Psychiatry

Ophthalmology Optometry

Southeast Clinic

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment 102 Elton Hills Drive NW Rochester, MN 55901 email: dcardille@olmmed.org

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

Phone: 507.529.6748 Fax: 507.529.6622

www.averamarshall.org

Minneapolis VA Health Care System Great place to work, great place to live.

You are invited to be part of the Department of Veterans Affairs that has been leading change in the health care sector. The Minneapolis VA is a 341-bed tertiary care medical center affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel. The Twin Cities area offers excellent living and cultural opportunities. Opportunities for full-time and part-time staff Physicians are available in the following positions: • Gastroenterologist • Emergency Department • Hematology/Oncology • Compensation and Pension • General Internal Medicine (Minneapolis) • General Internal Medicine (Rice Lake/Hayward, WI Outpatient Clinic) • General Internal Medicine (Chippewa Falls, WI Outpatient Clinic) Physician applicants should be BC/BE. Possible recruitment bonus. Interested applicants should email CV to Joan L. Potter, HRMS, Joan.potter@va.gov

Fax 612-725-2287 Telephone 612-629-7306 EEO Employer.

2013 october Minnesota Physician

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Spine Outcomes Research Trial from page 34

over to nonsurgical care. In the nonsurgical care group, 49 percent of patients crossed over and had surgery within two years. The high degree of crossover again pushes the results toward the null hypothesis. As in the stenosis trial, the patients who underwent surgery (regardless of the group to which they were originally assigned) were more likely to rate their symptoms as worsening, and to have greater pain and disability. In the observational arm, 97 percent of patients who initially chose surgery underwent a surgical procedure and 25 percent of patients who chose nonsurgical care underwent a surgery at two years. Findings. Not surprisingly, the randomized intention-to-treat analysis showed no significant differences between the two groups. Given that roughly 40 percent of patients

from each group crossed over, the groups were close to a 50:50 mix of surgery and nonsurgery patients. In the as-treated analysis of the combined cohorts, surgery was statistically significantly better then nonsurgical care in all primary measures. ODI scores improved by an average of 24 points in patients receiving surgery vs. 7.5 percent in patients undergoing nonsurgical care. Almost 69 percent of surgery patients reported they were satisfied or somewhat satisfied, as compared to only 32 percent of nonsurgical patients; and 74 percent of surgical patients reported major improvements in their symptoms, as compared to 24 percent of nonsurgically treated patients. Again, fouryear data demonstrate the improvements seen with surgery are maintained through the latest four-year follow-up (Weinstein et al., 2009, J Bone Joint Surg Am 91:1295–304).

Limitations One of the criticisms of the SPORT studies has been the inclusion of usual care rather than an aggressive standardized conservative treatment plan. Although inclusion of such a plan would have helped limit criticism, it would have been difficult to implement such a plan over multiple different centers in different states. In addition, there is little agreement about what treatments such a plan would have included. All study locations were instructed to provide at least physical therapy and anti-inflammatories, but most did this and more. Conservative care often included injections, rehab, and other modalities. The inclusion of an intention-to-treat analysis is probably the most confusing part of each section of SPORT. Although it is a powerful statistical tool, the amount of crossover present in this surgical study rendered this type of analysis useless and

potentially could lead clinicians to overlook the powerful data collected from these trials. Conclusion The results of SPORT represent the best data available to help guide decision-making for three of the most common lumbar spine conditions: herniated discs, spinal stenosis, and spondylolisthesis. The considerable crossover between surgery and conservative care groups and vice versa underscores the importance of patient education and choice. In the as-treated analysis in all three studies, surgery outperformed usual conservative care at all time points, and the advantage of surgical care continued through four-year follow-up. David H. Strothman, MD, is boardcertified in orthopedic surgery and fellowship-trained in spine surgery. He practices with the Institute for Low Back and Neck Care, PA.

Trinity Health

One of the region’s premier healthcare providers.

Currently Seeking BC/BE • Ambulatory Internal Medicine • General Surgery • Psychiatry

• Urology • Neurology • Otolaryngology

Contact us for a complete list of openings.

Based in Minot, the trade center for Northern and Western North Dakota, Trinity Health offers the opportunity to work within a dramatically growing community that offers more than just a high quality of life. Comprised of a network of nearly 200 physicians in hospitals, clinics and nursing homes, Trinity Health hosts a Level II Trauma Center, Critical Care Helicopter Ambulance, Rehab Center, Open Heart and Lung Program, Joint Replacement Center and Cancer Care Center. Physicians are offered a generous guaranteed base salary. Benefits also include a health and dental plan, life and disability insurance, 401(k), paid vacation, continuing medical education allowance and relocation assistance.

www.trinityhealth.org

36

Minnesota Physician October 2013

For immediate confidential consideration, or to learn more, please contact

Shar Grigsby Health Center - East 20 Burdick Expressway Minot ND 58702 Ph: (800) 598-1205, Ext 7860 Pager #0318 Email: shar.grigsby@trinityhealth.org


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.jobs 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

Opportunities for full-time and part-time staff are available in the following positions: • Associate Director, Primary & Specialty Medicine (IM)

• Medical DirectorExtended Care & Rehab (Gariatrics)

• Dermatologist

• Pain Specialist

• Geriatrician/ Hospice/ Palliative Care

• Psychiatrist

• Internal Medicine/ Family Practice

healthpar tners .com

• Radiologist • Urgent Care Physician (IM/ FP/ ER) Applicants must be BE/BC.

© 2013 NAS (Media: delete copyright notice)

MN Physician 4" x 5.25" 4-color

Emergency Medicine

Emergency Practice Associates has immediate full-time, part-time and locums opportunities at our sites in:

Hibbing Little Falls Park Rapids Alexandria Austin

For more information contact Tina Dalton or Mike Coulter at 800-458-5003, email:

recruiting@epamidwest.com or visit our website at

www.epamidwest.com

US Citzenship requited or candidates must have proper authorization to work in the US. Physician applicants should be BE/BE. Applicant(s) selected for a postion may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reducion Program. Possible recruitment bonus. EEO Employer.

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

Your Emergency Practice Partner

(320) 255-6301

2013 october Minnesota Physician

37


Figure 3 - Mindless Pull of Gravity

Figure 4 - Mindful Continual Readjustment

Effective Communication

Results of optimal focus on intention

Effective Communication

Results of optimal focus on perception

GAP or “the work”

Results of optimal focus on intention

Results of optimal focus on perception

GAP or “the work”

Intention Results of overfocusing on intention at the expense of perception

Perception Results of overfocusing on perception at the expense of intention

Ineffective Communication Managing polarities from page 11

this situation, we end up alternating ineffectually between the suboptimal states and spend more of our time in ways of acting that do not serve our work optimally. Using the principles of polarities management in our lives and our work gives us

the opportunity to deal with issues that seem daunting or unsolvable. By understanding the dynamic tension of “and” and concentrating on making thoughtful, prompt corrections when we focus on one pole at the expense of another, we get more time in the optimal situation of both poles while minimizing their downsides, as illustrated in Figure 4. Successfully

Bach’s Brandenburg Concertos

DEC 12 Temple Israel, Minneapolis 7:00pm DEC 13 St. Philip the Deacon, Plymouth 7:00pm DEC 14 Saint Paul’s UCC, Saint Paul 7:00pm DEC 15 Trinity Lutheran Church, Stillwater 3:00pm Continuing our annual holiday tradition, the SPCO presents Bach’s most cherished set of orchestral works, the Brandenburg Concertos. These cornerstones of the Baroque literature have been praised by generations of music lovers for their profound inventiveness and dazzling instrumental virtuosity.

Intention Results of overfocusing on intention at the expense of perception

Perception Results of overfocusing on perception at the expense of intention

Ineffective Communication engaging the tension inherent in the physician-patient communication can mean the difference between a frustrating visit and a satisfying one. Val Ulstad, MD, MPA, MPH, and Kathy Ogle, MD, are co-founders and partners in the Minnesota health-care leadership development consulting firm Partners at Cascade Bluff. Ulstad is board-certified in internal medicine and

cardiology and practiced in academic, private, and safety-net hospital settings for more than 25 years. Ogle is board-certified in internal medicine, medical oncology, and palliative and hospice medicine and practiced in academic, private, and safety-net hospital settings for more than 25 years. The authors reference Barry Johnson’s “Polarity Management: Identifying and Managing Unsolvable Problems” (1996, Human Resource Development Press) as a resource for this article.

Handel’s Messiah

DEC 20 Basilica of Saint Mary, Minneapolis 8:00pm DEC 21 Basilica of Saint Mary, Minneapolis 1:00pm Celebrate the holidays with one of classical music’s most beloved traditions as rising young British maestro Jonathan Cohen conducts Handel’s Messiah. A cherished holiday custom since its premiere in 1742, this is sure to be a wonderful musical experience for the whole family and a highlight of the Twin Cities holiday season.

order online thespco.org phone 651.291.1144

1 38MNPhysician_Oct.indd Minnesota Physician

October 2013

10/10/2013 12:31:15 PM


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Minnesota Physician October 2013  

Health care infomation for Minnesota doctors Cover: Managing polarities by Val Ulstad, MD, MPA, MPH Multicultural advace care planning by M...

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