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Volume XXXII, No. 06

Motivational interviewing Helping patients change behaviors BY MIA CROYLE, MA, AND JANE PEDERSON, MD, MS


ach of us working in health care believes we can have a positive impact on the health and well-being of our patients. Recognizing that clinical care accounts for only 20 percent of a patient’s well-being, we can add significantly to our impact by influencing patient behaviors, which account for another 30 percent of their health and well-being. One tool that physicians and other clinicians can use to support patient behavioral change is Motivational Interviewing (MI)—a collaborative, goal-oriented style of communication developed in part by clinical psychologists William R. Miller and Stephen Rollnick that focuses on the patient’s own reasons for making change.

A patient’s “why” for change

Prescription drug prices Competition can drive down costs BY SEN. AMY KLOBUCHAR


ast year I met two identical twin girls from Cambridge, Minnesota, who play on their school softball team. One is a pitcher and the other is a catcher. A few years ago, one of them found out that she has diabetes. The other twin is perfectly healthy. The family now must buy insulin, but the price has tripled over the last decade, making it very difficult for them to afford this essential medication. Does it matter if the pitcher or the catcher has diabetes? No. They both deserve to be able to afford the medications they need. Prescription drug prices to page 124

When working with patients faced with making difficult behavior changes, supplying education and medication options is rarely sufficient. Often Motivational interviewing to page 144

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Volume XXXII, Number 6

COVER FEATURES Prescription drug prices Competition can drive down costs

Motivational interviewing Helping patients change behaviors

By Sen. Amy Klobuchar

By Mia Croyle, MA, and Jane Pederson, MD, MS

Examining cost and quality issues Thursday, November 1, 2018, 1-4 pm The Gallery, Downtown Minneapolis Hilton and Towers 1101 Marquette Avenue South



By Kathleen A. Harder, PhD



HEALTH CARE WORKFORCE 24 Advanced practice providers



Entering the Minnesota market Philip Kaufman UnitedHealthcare of Minnesota, North Dakota and South Dakota

ADMINISTRATION Sexual harassment

Expanding expertise and scope of practice By Kenneth Pallas, MD


A “sepsis” in medicine By Susan Strauss, RN, EdD



Guiding principles and strategies By Melissa G. French, MS, and Terry C. Davis, PhD

HEALTH CARE ADMINISTRATION 22 The “Safe Surgery Process” A systems approach to improved outcomes

BACKGROUND AND FOCUS: Consolidation in health care threatens the viability of the system and is escalating at an alarming pace. Patients are left with fewer choices, both in terms of which doctor to see and in terms of treatment options, including medications, from the doctor they do see. Costs are often increased and quality often decreases when systems become too large. Demands to comply with increasing regulations leave many medical practices in a bind. How can they maintain independence without the infrastructure of a large system?

OBJECTIVES: We will examine the root causes of health care consolidation. We will illustrate what has worked and what has not. We will explore cases where FTC regulations are pushed to the limits and the threat to patients this poses. We will look at the larger continuum of care and how public health issues are impacted by consolidation. We will discuss state legislative initiatives that need to be in place and what must be done to keep patient well-being at the center of health care delivery.

Panelists include:

Sponsors include:

Bryan Dowd, PhD, Professor, Division of Health Policy and Management, PROFESSIONAL UPDATE: BEHAVIORAL HEALTH University of Minnesota School of Public Health Eating disorders 16 Cindy Firkins Smith, MD, Know the signs

Co-CEO, Carris Health

By Mary Bretzman, MD

Timothy Hernandez, MD, Medical Director for Quality, Entira Family Clinics Responses to the opioid epidemic 18 Clinical quality improvements

Carris Health Center for Diagnostic Imaging (CDI) Entira Family Clinics Minnesota Gastroenterology, PA University of Minnesota School of Public Health

Scott M. Jensen, MD, Senator, District 47, Minnesota Legislature

By Kate S. Erickson, MSW

Scott R. Ketover, MD, AGAF, President and CEO, Minnesota Gastroenterology, PA Liz Quam, Executive Director, CDI Quality Institute



Mike Starnes,

Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (, or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable.

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

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Research Shows it’s Possible to Reverse Damage Caused by Aging Cells New research from the University of Minnesota Medical School has shown that there are types of small molecules called senolytics that can reverse the impact of aged, senescent cells. “We’ve always thought of aging as a process, not a disease,” said Paul Robbins, PhD, associate director of the new Institute on the Biology of Aging and Metabolism at the University of Minnesota. “But what if we can influence the impacts of aging at a cellular level to promote healthy aging? That’s what senolytics seeks to achieve.” The research determined whether introducing senescent cells to human and animal tissue would impact the cellular health of surrounding cells— they found that the transplant of a relatively small number of senescent


cells caused persistent physical dysfunction as well as the spread of cellular senescence in previously healthy cells. In addition, they found that a high fat diet, which causes a type of metabolic stress, or simply being old, enhances the physical dysfunction that comes from senescent cells. “Previous research has shown that our immune system’s ability to eliminate or deal with senescent cells is based 30 percent on genetics and 70 percent on environment,” said Robbins, who also noted that what we eat and how often we exercise can affect aging of cells. The researchers also determined that treatment with senolytic drugs, which are able to eliminate senescent cells, can reverse physical dysfunction and extend the lifespan even when used in aged animal models. “We saw greater activity, more endurance, and greater strength following use of senolytics,” said Robbins.


The researchers note that the results provide proof-of-concept evidence that improved health and lifespan in animals is possible by targeting senescent cells. The hope is that senolytics will prove effective in alleviating physical dysfunction and resulting loss of independence in older adult people as well. “This area of research is promising, not just to address the physical decline that comes with aging, but also to enhance the health of cancer survivors treated with radiation or chemotherapy—two treatments that can induce cell senescence,” said Laura Niedernhofer, MD, PhD, director of the Institute on the Biology of Aging and Metabolism.

Redwood Area Hospital to Join Carris Health The Redwood Area Hospital’s commission and the Redwood Falls city council voted on July 17 to

approve a legally binding transfer agreement to join the regional health system Carris Health, a recently formed subsidiary of CentraCare Health. The vote was unanimous. Discussions about a potential partnership with Carris Health began in April through an affiliation steering committee with representatives from Redwood Area Hospital, hospital commission, local physicians, Redwood Falls City Council, Carris Health, and CentraCare Health. In addition to strategy meetings, two listening sessions were held for community members to learn more about the affiliation and provide their input. The agreement outlines the transfer of ownership of Redwood Area Hospital to Carris Health. It includes a commitment from Carris Health to invest $60 million into the hospital over the next 10 years, including building a new health campus that would bring the

Max likes motivating his employees so he loves health plans with innovative wellness programs that encourage healthy behavior — which, by the way, can help increase productivity. If you’re like Max, you’ll like UnitedHealthcare.




hospital and Redwood Falls clinic together in one building. The site for the new health campus has not yet been determined. Carris Health will take ownership of the hospital on Jan. 1. The health system will then make a total of $1.2 million in lease payments over two years to the City of Redwood Falls for the current hospital building, which will cease once the new campus is built. In addition, the Redwood Area Hospital Health Pavilion will be deeded to Carris Health, and the health system will lease the Seasons Hospice House for $1 per year where it will continue to provide end-of-life care at that residential location. The remaining houses along Veda Drive will remain property of the City of Redwood Falls. The transfer agreement also provides a payment in lieu of taxes of $450,000 per year for 10 years, as well as an opportunity for additional

payments to the City of Redwood Falls based on hospital performance up to $6 million.

Mayo Clinic to Build New Birth Center on Austin Campus Mayo Clinic Health System–Albert Lea and Austin plans to create a third-floor Family Birth Center and a two-story connecting link between the main clinic entrance and the hospital on its Austin campus. Construction on the $11.2 million project will take place throughout 2019 and 2020. The Family Birth Center will be built in the third-floor space that is currently occupied by the Women’s Special Care Unit and step-down/telemetry unit, and it will also include additional construction for a large family waiting area. It will have 10 large rooms with private bathrooms and space for triage, a C-section suite,

and newborn nursery. The rooms will serve as labor and delivery and postpartum rooms so patients won’t have to be moved from one room to another as they do in the current spaces at Albert Lea and Austin, which each have five labor and delivery rooms and four postpartum rooms. Other details will continue to be finalized during the planning and design phases. “The rooms in the Family Birth Center will be 58 percent larger than our current rooms, providing the space necessary to meet the needs of our patients, families, and staff,” said Sumit Bhagra, MD, medical director for Mayo Clinic Health System–Albert Lea and Austin. Plans are also moving forward for the modernization of the Medical/Surgical/Pediatrics unit on the second floor of the medical center. The unit will expand to encompass the space currently occupied by the inpatient Psychiatric Services Unit, which is relocating to newly

remodeled space on the Albert Lea campus later this year. More information about that expansion will be available in early 2019. The addition of an extended link will connect the main entrance of the medical center directly to the newly expanded units and add nearly 5,000 square feet of usable space. Construction of the new units will allow Mayo Clinic Health System to complete the transition of inpatient services by 2020 as planned.

New Direct Primary Care Clinic Health Joins Integrity Health Network St. Cloud-based Simplicity Health, PA, which opened in mid-July, has joined Integrity Health Network as a member clinic. Simplicity Health, specializing in family medicine and emphasizing price transparency and affordable care, is owned and operated


WE TREAT YOUR PATIENTS LIKE YOU TREAT YOUR PATIENTS. According to recent CAHPS survey data, 99% of MN Gastroenterology patients say they were treated with courtesy and respect, were made to feel comfortable during their procedure, and would recommend us to their family and friends. Don’t your patients deserve the best quality and experience when it comes to colon care? Refer your patients today by using our secure online Referral Site at or by calling 612-870-5400.



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by Julie Anderson, MD. The clinic offers direct primary care, in which people pay a set amount each month as a type of membership fee. At Simplicity Health, that cost is $75. It covers the basic medical services that account for a high percentage of why patients visit doctor’s offices, including blood pressure, cholesterol management, diabetes, colds and flus, physicals, pap smears, and basic labs. The logistics and fees are managed by PrimaCare Direct, a health membership for primary care comprised of a cooperative of clinics in Minnesota that want to lower the cost of health care in order to encourage patients to visit their physician regularly and build a working relationship with them to achieve good health outcomes. The clinic also uses Epic electronic medical records to be compatible with other health care providers. “We offer direct primary care in addition to the standard fee-for-service

model to allow patients better access to care,” said Anderson. She earned her medical degree at the University of Minnesota and previously practiced at St. Cloud Medical Group. Simplicity Health will have four providers on staff, including Anderson, a second physician, and two physician assistants. She is also planning to build a second, larger clinic within the next year or so that will offer medical, dental, and mental health care, as well as imaging services.

Methodist Hospital Honored for Leadership And Innovation The American Hospital Association (AHA) has named Park Nicollet Methodist Hospital a 2018 Citation of Merit award recipient as part of its annual Quest for Quality. The hospital, part of HealthPartners, was one of two hospitals across the U.S. to receive the award, which

recognizes health care leadership and innovation in improving quality and advancing health in communities. All recipients demonstrate a commitment to improving access; providing high quality, safe care; creating value; partnering with patients and families; focusing on well-being; and providing seamless, coordinated care. AHA notes several reasons why Methodist Hospital was chosen—it has patients and families sit in on internal committees and suggest improvements; the CEO regularly attends quality improvement meetings; and senior hospital leaders make visits to 250 departments to host hour-long interactive discussions. In addition, the hospital set up medical clinics at four area high schools, and hospital clinicians provide telehealth mental health services to local schools. It sends its mammography truck to churches and community centers to provide

2,000 imaging exams each year. And bereavement counseling and support is extended to children who lose a parent or sibling beyond the first year of loss and through their sophomore year of college. The AHA Quest for Quality Prize seeks to increase understanding of the value of organizational focus and commitment to achieving quality health care and advancing health in communities. Each year it awards the Quest for Quality Prize winner, finalists, and citations of merit. Methodist Hospital was the only Minnesota hospital to receive one of these awards. | 651.287.8888

HEALTHCARE REAL ESTATE Development, Property and Asset Management



Sayeed Ikramuddin, MD, MHA, has been appointed as the head of the department of surgery at the University of Minnesota Medical School by Jakub Tolar, MD, PhD, dean of the medical school. It is an initial appointment of two years, and Ikramuddin will also hold the Jay Phillips Chair in Surgery. Previously, Ikramuddin served as interim head of the department. He has also previously held the Robert and Katherine Goodale Chair in Minimally Invasive Surgery at the medical school. His research focus is now on the outcomes of type 2 diabetes following bariatric surgery and vagal nerve stimulation to produce weight loss. Ikramuddin completed his medical degree at Albany Medical College, New York.

Sarah Hicks U.S. Naval Academy

Anthony Ross

Gianrico Farrugia, MD, current vice president of Mayo Clinic and CEO of Mayo Clinic in Florida, has been elected by the Mayo Clinic Board of Trustees to succeed John Noseworthy, MD, as president and CEO of Mayo Clinic. Noseworthy has led Mayo Clinic since 2009 and has been with the organization for 28 years. He will remain in the position until he retires at the end of the year. Farrugia has served as vice president of Mayo Clinic and CEO of Mayo Clinic in Florida since January 2005. Before that, he served as director of Mayo Clinic’s Center for Individualized Medicine and co-founded the Center for Innovation at Mayo Clinic. Farrugia has spent 30 years as a physician with Mayo Clinic and is jointly appointed in the Division of Gastroenterology and Hepatology, Department of Internal Medicine, and the Department of Physiology and Biomedical Engineering. He is a member of the board of trustees and the Mayo Clinic Board of Governors, and serves as a professor of medicine and physiology as well as a faculty member in biomedical engineering at Mayo Clinic Graduate School of Biomedical Sciences. Farrugia earned his medical degree from the University of Malta Medical School.

Osmo Vänskä

Tom Horejsi, MD, is the new medical director for the emergency department at Allina Health’s District One Hospital in Faribault, effective July 17. Horejsi has worked at Allina Health’s Abbott Northwestern Hospital in Minneapolis for the past eight years and is part of its Emergency Care Consultants. During his time there, he served as education director and advanced practice provider medical director. In his new role, Horejsi will be responsible for overseeing the operations and quality of care provided in the emergency department and providing leadership, medical direction, education, and oversight of emergency services at the hospital. He earned his medical degree at the University of Minnesota Medical School.

Gregory Porter


Vänskä Conducts Mahler’s Seventh Fri Nov 2 & Sat Nov 3

U.S. Naval Academy Glee Club with the Minnesota Orchestra

Sat Nov 10

Anthony Ross Plays Shostakovitch Thu Nov 15 11am Fri Nov 16 & Sat Nov 17

Nat “King” Cole and Me, starring Gregory Porter with the Minnesota Orchestra

Sat Dec 1

612-371-5656 / Orchestra Hall / #mnorch PHOTOS Vänskä, Ross & Hicks: Travis Anderson Photo. Other photo credits available online.




Helping people live healthier lives Philip Kaufman UnitedHealthcare of Minnesota, North Dakota and South Dakota UnitedHealthcare was started in Minnesota and now employs over 18,000 Minnesotans. However, until the new state law that went into effect this year allowing for-profit health insurance companies to operate in this state, few Minnesotans had UnitedHealthcare insurance. Please tell us about the goals and strategies that led to the formation of UnitedHealthcare of Minnesota.

How will this new product be different from existing employer choices?

UnitedHealthcare will offer a portfolio of fully insured and self-funded benefit products to employers of all sizes, including traditional

Everything starts with our mission: to help people live healthier lives and make the health system work better for everyone. After careful assessment of the Minnesota market, we felt strongly we could deliver on that mission in our home state. Beyond just providing additional options for affordable, quality health care, the expansion will bring UnitedHealthcare’s personal customer service experience, our state-of-theart technology, and our passion for serving communities where over 18,000 of our employees live and work.

We have many other initiatives in the pipeline. I think the amount of and the pace of innovation UnitedHealthcare is delivering to the market is unique in itself. A regulatory change that goes into effect in 2019 could open the market for Medicare Advantage Plans. What can you tell us about your plans in this area?

What were the challenges in creating your provider and hospital networks?

We recognized from the start that these were high-quality markets and our efforts needed to be beyond just signing a piece of paper—this was the start of building new relationships with physicians, hospitals, and their staff. In some areas, we will do things very differently from some of the other players in the market, and education with our physician partners will take time. I view our entry as a multi-year journey and one in which we acknowledge that mistakes will be made. Our team, from top to bottom, is committed to a great experience and we diligently collect feedback from providers through multiple forums each year.




We believe competition is a good thing.


The biggest challenge was definitely the scope of the effort. In just under a year, UnitedHealthcare needed to sign contracts with more than 30,000 providers and 250 hospitals across Minnesota, North Dakota, South Dakota, and western Wisconsin. In many cases, the contracts were complex, incorporating some of our best nationwide thinking on how to take the first steps toward value-based care.

to take a more active role in improving their overall health and health care decisions. They can set goals for things like eating better and getting more sleep, while also determining their “Rally Age,” which gives them an idea of their overall current health. We also recently launched a wellness program called UnitedHealthcare Motion. It’s our wearable device program (integrated with any device, including Apple Watch) that encourages people to be active and enables them to earn more than $1,000 per year for meeting certain daily goals.

medical plans and Health Savings Accounts, as well as plans that offer low out-of-pocket costs for things that are attractive to many consumers, such as primary care appointments, virtual visits, and urgent care needs. A differentiator is our ability to configure these plans in literally thousands of combinations to suit an employer’s needs. We have scale—more than 50 million members served across the U.S. and Brazil—and resources that allow us to invest in solutions not previously available in Minnesota. For example, we have a digital health resource called Rally, a digital platform that empowers people

We will offer individual Medicare Advantage plans to Minnesotans in the Minneapolis/ St. Paul metro area and in the Duluth area (St. Louis and Carlton counties). These plans will complement our existing Medicare Supplement plans, Medicare Prescription Drug plans, and the Medicare Advantage plans we offer Minnesota retirees who receive health insurance through their former employers. What kinds of tools and data-sharing initiatives do you have in place for working with physicians?

I have a strong belief that clinicians are by far the most trusted players in the health care system, and as such are absolutely critical to our mission of helping people live healthier lives. Multiple initiatives are under development that should advance the way we work with physicians, allowing them to spend more time on direct patient care. We’ve also begun working with Minnesota-based quality and measurement initiatives. PreCheck MyScript allows doctors to run a pharmacy trial claim before prescribing a medication for patients with UnitedHealthcare plans. Doctors can see how much a patient would have to pay for a medication if she went to her preferred

pharmacy at that very moment to pick it up. The system will also give lower-cost alternatives, when available, for higher cost medications in order to save patients money. When doctors look up a particular medication, they can see immediately whether the patient’s plan covers the medication and whether it requires a prior authorization. If it does, doctors can request approval right from the app with just a few clicks. While available on a stand-alone basis, we are working hard to integrate this functionality directly into the largest electronic medical record (EMR) programs in the country.

clinicians. As we work to provide access to data, we’re learning about some unique Minnesota challenges. For example, the Minnesota Health Records Act creates some challenges around care coordination and population health management. We look forward to working with the relevant stakeholders on ways to address the understandable need for privacy, while ensuring that our members get access to quality care.

We have an app called eligibilityLink that allows physicians to quickly check a UnitedHealthcare member’s eligibility and benefit information without picking up the phone. Physicians can also use the app to find out if referrals, notification, and prior authorization are needed for the member’s plan. Our claimsLink app is similar in that it allows physicians to get the most up-todate claims status for multiple UnitedHealthcare plans and payment information, and submit claim reconsiderations and appeal requests.

We have no current plans to enter the market for 2019, but will assess each market on a year-toyear basis and re-evaluate in 2020.

Overall, a huge focus for us is delivering timely, relevant information that could benefit patient health or course of treatment into the hands of

What plans do you have for working with MNsure?

What do you want physicians to know about UnitedHealthcare of Minnesota, and what benefits do you project for physicians as a result of the increase in competition that you are bringing to our marketplace?

We believe competition is a good thing. Competition amongst carriers can drive positive impacts in the system, not just for members and employers, but also for physicians. I will repeat what I said above because it is so critical: clinicians are by far the most trusted players in the health

care system, and as such, are absolutely critical to our mission of helping people live healthier lives. UnitedHealthcare is focused on engaging with providers in a patient-centered approach to health care. We are moving away from fee-for-service and focusing specifically on patient outcomes. With UnitedHealthcare, we constantly aspire to provide physicians with real-time analytics and useable data, so they can more quickly and easily manage their patients’ needs. As we enter this market we know we will make mistakes, but we are constantly gathering feedback and getting better. We aren’t perfect, but we are committed to improving every single day. It’s paramount to us that we get it right. Philip Kaufman is chief executive officer of UnitedHealthcare of Minnesota, North Dakota and South Dakota. Over the last 15 years, he has held several leadership positions within UnitedHealth Group, including president of UnitedHealthcare Specialty Benefits and chief executive officer of UnitedHealthcare Vision. He holds an MBA from Harvard Business School and a master of health care delivery science from Dartmouth.

Creating a Healthier Minnesota Juniper is helping rural and urban communities across Minnesota create a culture of health. Our evidence-based programs give your patients the tools they need to take manage their health in a way that works. Juniper programs offer group training to prevent escalation of disease, reduce hospital admissions, lower health care costs, and improve independence. Programs concentrate on: n

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To locate a Juniper program, or to start one through your clinic or in your community, please call us toll free at 1-855-215-2174 or email To find our more about the Juniper program please visit: Innovations for Aging, LLC, a nonprofit subsidiary of Metropolitan Area Agency on Aging, is the managing partner for Juniper, providing management information systems, coordination, member services and support to our partner organizations.



3Prescription drug prices from cover

Family Foundation, 92 percent of Americans agree on this solution—including Republicans, Democrats, and Independents. It’s time we get this done.

I’ve heard similar stories again and again—people getting sick and having to choose between paying the mortgage, turning on the heat in the winter, or refilling a critical prescription. In fact, one out of four Americans who take prescription drugs have cut pills in half or skipped doses instead of filling their prescriptions because of the cost. That’s just not right. No one should be forced into bankruptcy because they’re sick or have a chronic medical condition.

Escalating costs In the U.S., the prices of four out of the top 10 drugs have gone up by 100 percent in the last few years. The price of a multiple sclerosis drug went up 21 times in a decade. And another pharmaceutical company raised the price of a leukemia drug four times in one year alone—now it costs nearly $199,000 a year. It is unaffordable.

Competition in action

As the ranking member of the Subcommittee on Antitrust, Competition Policy and Consumer Rights, I know that competition is one of the best ways to make sure prescription drugs are affordable. Where there’s a lack of competition, price increases are sure to follow. The first step we can take is ending a true outrage called “pay-for-delay,” where big brandCompetition is one of the best name pharmaceutical companies pay off generic ways to make sure prescription manufacturers to keep less expensive products off drugs are affordable. the market. Sen. Chuck Grassley from Iowa and I have introduced the Preserve Access to Affordable Generics Act to limit this practice, which would generate approximately $2.9 billion in savings over ten years.

We need to take bold action to lower prescription drug costs for Americans. We can start by giving the 41 million seniors in Medicare Part D the power to negotiate for the best possible price of their medications. We all know our seniors are usually pretty good at finding a bargain —we should let them bargain for one of the most important and expensive things they buy. I have a bill, which already has the support of 34 other senators, to lift the ban that prohibits Medicare from negotiating prescription drug prices. According to the Kaiser

Find life worth living.

We have also called on the Federal Trade Commission to investigate whether drug makers are using similar tactics to delay cheaper alternatives to biologics—a fast-growing class of medicines derived from living material—from reaching patients as well. For example, AbbVie Inc.’s (AbbVie) Humira is a biologic medicine that treats multiple inflammatory diseases and is the world’s top-selling prescription drug with annual sales of $16 billion, including more than $10 billion in the U.S. alone. Yet, AbbVie has entered into settlement agreements over the past year


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with several companies that make biosimilars of Humira. Under the agreements, the less expensive biosimilar alternatives will not be available in the U.S. until 2023, but the companies will be able to launch their biosimilars into the European market in October 2018. This means that while European patients will benefit from biosimilar competition later this year, Americans may be without access to Humira biosimilars for almost five more years. “Pay-for-delay” is just one anticompetitive practice used by some brand-name pharmaceutical and biologic companies. Some also refuse to provide samples or share important information about how to distribute a drug safely in order to delay the approval of lower-cost alternatives. I worked with a bipartisan group of my colleagues on the Senate Judiciary Committee to introduce a bill, the Creating and Restoring Equal Access to Equivalent Samples Act (CREATES Act), to combat these tactics. This bipartisan bill is cosponsored by 14 Democrats and 14 Republicans and the nonpartisan Congressional Budget Office (CBO) estimates it would save taxpayers $3.8 billion over 10 years. Our legislation was passed by the committee in June of 2018 with a strong bipartisan vote, moving us one step closer to ending these unfair practices that drive up prescription drug costs.

A lesson from the north We should also look beyond our borders when it comes to increasing competition. In Minnesota, we know that our friends across the border in Canada often pay less—much less—for prescription drugs than we do. A recent study in the Journal of the American Medical Association found that Canada spent less than half as much on prescription drugs as the U.S. does. The difference can be even bigger for some very common medicines. Crestor (rosuvastatin), a cholesterol drug, costs more than three times less in Canada than in the U.S. That’s why I joined with Sen. John McCain to push for a common-sense, bipartisan fix that would allow Americans to safely import prescription drugs from Canada. We deserve to have the choices that are available in other countries with similar safety standards.

Act now The longer we wait to take action, the higher the prices will rise, and the higher the costs will be for patients, taxpayers, and the family of those twin girls in Cambridge. The time is now for Congress to finally pass these bills and provide real relief to families in Minnesota and across the country. Sen. Amy Klobuchar has earned a reputation as an effective, resultsdriven legislator willing to reach across the aisle to get things done. In the Senate, she has supported efforts to reduce the cost of health care


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3Motivational interviewing from cover patients already know what changes are needed, and they may even know how to make the change. Mary knows she needs to adhere more closely to her prescribed medication regimen to manage her chronic condition. She understands when she is supposed to take each of her medications (what), and even has a pillbox to help her keep track (how).

To evoke and reinforce the patient’s own arguments for change, MI practitioners use open questions, affirmations, reflective listening, and summarization. When used proficiently, these techniques have been shown to increase “change talk”—anything a patient says that favors movement toward change. In turn, increased frequency and strength of change talk has been demonstrated to positively predict outcomes.

Motivational interviewing process

The relational and technical components are used The challenge is how to connect with the throughout the four processes of an MI interaction: patient’s why, so they can effectively make the The challenge is how to connect engaging, focusing, evoking, and planning with the patient’s why. changes needed for better health. With MI, (Motivational Interviewing: Helping People the patient develops their personal reason for Change, Miller and Rollnick). First, and critical change, rather than being told what to do by to a successful intervention, is engaging, which the clinician. When Mary identifies that her aims to establish and maintain a collaborative medication will help her manage her condition working relationship with the patient. Ways to better so she can feel well enough to babysit her promote engagement include: grandkids again (why), she has tapped into a much stronger motivation • Ask for and listen to what the patient wants. for change. • Seek an understanding of how important the topic at hand may be Motivational interviewing approach to the patient. MI has both a relational component, in which a clinician embraces a spirit • Look for what you can genuinely appreciate and comment of empathy, and a technical component involving specific techniques that positively about. support patients to state their desire, ability, and need for change. The spirit • Provide the patient with some sense of what to expect. of MI relies on a partnership with the patient. It creates an atmosphere of acceptance and support for the patient’s autonomy and operates with compassion in the best interest of the patient.

• Offer hope—explain how what you do may help. By contrast, clinicians can disengage patients if we: • Rely on our expert role to persuade the person to change. • Move too quickly into an assessment process. • Prematurely focus on one specific problem.

Solutions through experience and collaboration

• Use language that indicates labeling or blaming. The second process is focusing, which is the collaborative, ongoing seeking and maintaining of progress toward a goal or direction for behavior change. This can be especially important for patients who struggle to make recommended changes. For example, during the appointment, a clinician might ask, “What would be most useful for us to spend our time on today regarding your concerns about alcohol?” If the patient doesn’t offer a suggestion that progresses the discussion about change, the clinician might follow up with options to discuss, then ask, “If it’s OK, can you tell me how alcohol is impacting your life?”

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Third is evoking, when a clinician tries to bring out the patient’s own ideas about motivations for change by asking questions like, “If you were to reduce how much alcohol you drink on a weekly basis, how do you think that might impact your overall health?” Throughout an encounter, the clinician listens for change talk. While change talk often occurs naturally, sometimes a clinician has to ask intentional questions and reflect back the patient’s statements, such as, “Besides just feeling better, what else in your life would be different if you felt healthier?” Simply asking patients how they would like things to be different can help them express if they have identified the need to make a change. The final process is planning to maintain your relationship with the patient and maintain the patient’s motivation. Planning might include asking how the patient will address barriers when they come up, such as,



“What might you do if you are going to be in a situation where you know it will be hard for you to limit your alcohol intake?” Physicians can close a visit with positive reinforcement and affirmation of the ongoing partnership with the patient: “It sounds like you have a plan. I’ll be eager to hear how it is working out at our next visit.”

Motivational interviewing in clinical practice Clinicians incorporate motivational interviewing techniques into patient encounters in a variety of ways. Some might start with a small shift, such as asking a few different questions—specifically ones that target change talk, such as, “How would you like things to be different?” or “Why do you think it might be time for a change?” In this instance, the MI technique may take as little as a minute or two. Some clinicians may choose to use a more comprehensive MI approach, which could take three to seven more minutes. And for patients who could benefit from a more intensive approach, a clinic may choose to have dedicated MI practitioners with advanced training to work with patients outside of the physician visit. This is likely the most effective delivery of MI, although physicians who draw on MI techniques as part of the visit can better engage patients. Borrowing individual techniques from MI might prove valuable to some clinicians and patients, and gradually weaving the components into patient interactions can build skill and confidence in using this complex communication style. It takes time and practice to learn MI to the level that it can be used with fidelity—which is the only way to fully realize the outcomes that the research indicates are possible. Receiving assessment and counseling has been associated with greater patient satisfaction. Boost that with improved clinician empathy through MI training, which patients feel and respond positively to. Value-based care and participation in accountable care models empower physicians to play a more active role with patients as partners in managing their health, making MI a perfect skill set to employ. MI also is synergistic with various care models, such as a health care home, that have a patientcentered focus. Training all care team members on MI skills can encourage a shared, supportive approach with patients. In one study where all clinic staff were training in MI, they reported the unforeseen benefit of improved team-building and cohesiveness for their care teams. Use of MI also has been associated with improved physician satisfaction and reduced feelings of burnout, perhaps due to patients making more and better changes.

Behavioral health and substance use A growing body of evidence shows MI is an effective technique, especially for patients who are facing difficult challenges such as substance misuse. For alcohol and substance misuse disorders, physicians can use MI techniques to gently open a dialog that can be continued on subsequent visits. Using an MI approach, a provider can share clinical education with a patient in a nonjudgmental way. Studies have shown that when adults screened for hazardous drinking patterns at their medical appointments were provided a brief intervention with a 15-minute MI counseling session, their subsequent alcohol consumption was lower than those who did not receive MI counseling. Motivational interviewing to page 384

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Eating disorders Know the signs BY MARY BRETZMAN, MD


ight years ago, when I left general family practice and started working at The Emily Program, I felt confident about my knowledge base and ability to function in this new setting. Then I met my first patients. Initially, I was overwhelmed by the severity of the illness, and the chronicity and rigid thinking in many of the patients who presented with the illness. However, I quickly realized that my patients were my greatest teachers. As is so often the case in medicine, we learn more from our relationships with our patients than we ever could from an article or conference. One of the most important things I’ve learned is that stereotypes are often a barrier to diagnosis and treatment of eating disorders. There is a perception that eating disorders only occur in white, affluent young women who present as severely underweight. In reality, eating disorders affect people of all shapes and sizes, and the illness is prevalent in every age group, gender, and socioeconomic situation. I would encourage medical professionals to be curious and look for signs of eating disorders in all of their patients. Eating disorders have the

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highest mortality rate of any mental illness due to medical complications or suicide. This statistic is all the more tragic given the fact that eating disorders are often highly treatable. Early detection is key for improving the chance of recovery from an eating disorder, and those of us in the health care profession play a significant role in recognizing signs and symptoms and ensuring that our patients receive appropriate specialty care. However, these serious illnesses can be difficult to detect, especially when patients hide their struggle with food or hesitate to speak up due to embarrassment, stigma, or reliance on their disorder. For medical professionals, including those in primary care, there are common physical symptoms and specific behaviors that can be recognized in the course of an office visit.

Physical symptoms of eating disorders Individuals with eating disorders often experience physical symptoms that can be recognized by physicians or those close to them. While certain physical symptoms may be the same across eating disorders, such as malnutrition, menstrual irregularities, hair thinning/loss, and brittle nails, there are also symptoms that are specific to each type of eating disorder. Patients with anorexia typically weigh themselves regularly, eat small quantities of food, and have a relentless desire to be thin. These patients will generally be unable to maintain a healthy weight and can experience dramatic weight loss. Those with anorexia may also experience impaired immune functioning, dizziness, fainting, sleep problems, and slow-healing wounds. Those suffering from bulimia engage in a cycle of binging and purging. These patients frequently eat large quantities of food, generally sweets, in a short amount of time. They may have uncontrollable eating where they are unable to stop eating even after they are full. Following these binges, individuals will compensate by purging. Vomiting as a method of purging can result in swollen cheeks, broken blood vessels in the eyes, dental issues (eroded enamel, cavities, decay, sensitivity, discoloration), and enlarged salivary glands. They may also develop calluses, marks, or cuts on the back of their hands from self-induced vomiting. Those who abuse laxatives may develop gastrointestinal consequences such as stomach pain and constipation. Patients who abuse diuretics may experience low potassium levels and dehydration. Like anorexia, bulimia can cause dizziness, fainting, and sleep problems. Aside from anorexia and bulimia, there is also binge eating disorder, Other Specified Feeding or Eating Disorders (OSFED), and Avoidant Restrictive Food Intake Disorder (ARFID). Individuals with binge eating disorder use food as a way to soothe negative feelings. This can result in insomnia, digestive problems, obesity, and high cholesterol. Those with OSFED have symptoms dependent on the type of disorder (atypical anorexia, less frequent bulimia, purging disorder, night eating syndrome) and the symptoms are often similar to the main disorder it most closely resembles (anorexia, bulimia, or binge eating). Patients with ARFID often experience dramatic weight loss, stunted growth, gastrointestinal issues, lack of appetite, anemia, muscle weakness, and feeling faint or unwell.

Specific behaviors in individuals with eating disorders

increases. These signs and symptoms may appear during an exam, be selfreported by the patients, or, in a pediatric setting, expressed by parents.

People with eating disorders often have specific behaviors that can set off an alarm to those around them. They frequently have an unhealthy If you believe one of your patients is struggling with an eating disorder, it preoccupation with food, dieting, and/or exercise. They may spend a large is important to ask specific questions and to listen. Providers can applaud their amount of time obsessing about food, calories, patient’s bravery in speaking about their illness and or their body image. They may avoid eating in validate their experience. Providers should start public, escape to the bathroom immediately a dialogue and open the lines of communication after a meal, or refuse to attend social activities about their patient’s eating disorder while expressing that revolve around food and eating. There is concern. It is important to let your patient know often a compensatory behavior present. For that eating disorders don’t have to be forever and My patients were my example, individuals may engage in exercise to greatest teachers. that, with the proper treatment, they can experience justify eating. Individuals may misuse laxatives a full recovery. From there, it is essential to provide or diuretics to engage in purging behaviors and your patient with treatment options and make the may steal or hide food in strange places to engage appropriate referral to a program that specializes in in binging behaviors. Often those suffering with eating disorder care. eating disorders will have trouble concentrating If you know someone who is struggling from and will withdraw from friends, social situations, or activities. They often an eating disorder, it is essential that they receive professional treatment as have low self-esteem and experience isolation due to their inability to cope soon as possible. The longer an eating disorder is left untreated, the more with their eating disorder. Guilt, shame, and disgust around eating are severe it will become and the longer the recovery process will be. It is advised common feelings experienced by those struggling with food issues. that medical professionals refer their patients to a program that specializes in eating disorder treatment. What providers can do For medical providers who wish to become an ally to those struggling A comprehensive approach to treatment with eating disorders, the most important step is to educate themselves. If A holistic approach to treating eating disorders is essential for lasting professionals know the signs and symptoms of eating disorders and what to do when they are spotted, an individual’s likelihood of treatment and recovery Eating disorders to page 364

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Responses to the opioid epidemic Clinical quality improvements BY KATE S. ERICKSON, MSW


ubstance use disorder (SUD) is a preventable and treatable illness that impacts the lives of individuals, families, and communities. Health care providers play an important role in preventing, identifying, and treating opioid use disorder. This article presents specific quality improvements that providers and clinic systems could employ to address substance use disorder and prevent overdose.

Preventing deaths from opioid overdose Query the Prescription Monitoring Program (PMP). To provide the most comprehensive and informed care, query the PMP to learn about the patient’s prescribing history. Identifiable risk factors include multiple provider or multiple pharmacy episodes, overlapping opioid prescriptions, or concomitant prescribing of benzodiazepines and opioids. Providers can assign delegates who are authorized to query the PMP on their behalf. As of July 1, 2017, enrollment in the PMP is mandatory. Within the next year, enhancements may include additional proactive reports or patient safety alerts, more data visualization, and risk calculations.

Co-prescribe naloxone. Naloxone (sold under the brand names of Narcan and Evzio) temporarily blocks the effects of opioids during an overdose. Assess the risk of the prescribed medication(s), instead of assessing the risk of the patient. Long-acting opioids, high-dose opioids, and overlapping prescriptions are not recommended, however, if these risks are present, co-prescribe naloxone. Other circumstances where it is especially important to prescribe and provide patient education about naloxone include if a patient is taking opioids with other substances, has a previous nonfatal overdose, has a current substance use disorder, or has a positive urine toxicology for illicit substances. When possible, engage the patient’s support system—family, friends, caregivers, and others—to respond in the event of an opioid overdose emergency by administering naloxone and calling 911. For additional information, see

Addressing chronic opioid use and identifying opioid use disorder Identify the signs and symptoms of an opioid use disorder. SUDs are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). A patient would meet criteria for a mild substance use disorder if they were: 1) taking the opioid in larger amounts and for longer than intended, and 2) having cravings or a strong desire to use opioids. Other criteria include wanting to cut down or quit but not being able to do so, or spending considerable time obtaining the opioid. These symptoms are more regularly observed than they are diagnosed. Early detection provides an opportunity for early intervention. See www. Address the perception of pain. Pain is more than tissue damage. Perception of pain is impacted by previous experiences of pain and trauma, the current state of the central nervous system, and the conditions of recovery. Rather than a reduction in pain, goals can be an increase in functioning, selfreliance, and self-compassion, all of which may include: returning to loved activities and hobbies, engaging in family life, independence in activities of daily living, increased capacity for employment, or dedication to self-care. When setting functional goals related to pain, consider including one of each of the following: active interventions such as exercise, yoga, physical therapy, walking, or swimming; passive interventions such as acupuncture, injections, or medications; and mind-body interventions such as therapy, mindfulness, prayer, or meditation. Learn more at Taper when possible. Use talking points with patients. Consider telling patients that: • Opioids are far more addictive and potentially harmful than we previously knew. Long-term opioid use decreases your function and increases your pain sensitivity. • Opioids are not the only solution for chronic pain. We can explore options together. • When we are ready to look at a taper together, we will go slowly, carefully, and have frequent visits.



• If your body is not tolerating a taper, this is an indication that your body is already dependent. If it comes to that point, there are other medications we can explore to help your body adjust to the change.

collapsed veins, and abscesses. Assist your patient in identifying the nearest syringe access (via pharmacies) or syringe service programs (SSPs). Inquire about sexual health, provide infectious disease testing, and discuss safer sex practices and family planning services as needed. Explore the conditions • We have to dig deeper to get to the root cause of your pain. of each drug use circumstance, including the drug The CDC recommends a decrease of no more (drug type, manner of use, adulterates), the setting than 10 percent of the original dose per week as (using alone or with others, how others feel about a reasonable starting point when developing a their use, anticipated outcomes), and their body taper strategy. Additional guidance on tapering (tolerance and emotional well-being). Discuss is available in the Opioid Prescribing Guidelines, Statistically speaking, you benefits of practical and lifesaving harm reduction Section V: already have patients with strategies, such as: Access SUD treatment. Minnesotans seeking an opioid use disorder. • Do not use opioids alone. If using alone, substance use disorder treatment must first get a communicate with someone before and after use. Rule 25 chemical use assessment. This assessment • Use slowly and take one drug at a time includes factors such as acute intoxication/ (understanding that drugs are often withdrawal potential, medical conditions, unknowingly laced with multiple products). behavioral health, readiness to change, relapse potential, recovery environment, and interviews with support people. Over the next two years, the Minnesota Department of Human Services (DHS) is leading substance use disorder reform. One of its main goals is to reduce the wait time from expressed interest to treatment entry. Minnesota will have “direct access” for patients to go directly to their treatment of choice. DHS launched a statewide searchable database for mental health and substance use disorder treatment openings, called the Fast-Tracker ( Become a MAT-waivered provider. Statistically speaking, you already have patients with an opioid use disorder. Primary care providers can get a medication-assisted treatment (MAT) waiver by completing an 8-hour training to provide clinic-based buprenorphine, which is primarily used to treat opioid use disorder. There is a large emphasis on increasing access to office-based opioid treatment (OBOT) because of the overwhelming evidence of the efficacy of buprenorphine. Most programs include some form of psychosocial support, such as care coordination, therapy, and/or peer support. See

• When possible, do not stack doses; wait for the effect. • Use extreme caution if using when tired, sick, dehydrated, or after a break from using. • Designate someone who is equipped with naloxone to observe for signs of an opioid overdose. The Harm Reduction Coalition offers additional background and strategies at Responses to the opioid epidemic to page 324

Perform Case Consultation. Form an interdisciplinary care team (e.g., medical provider, mental health provider, pharmacist, care coordinator/ social worker/peer support specialist) to: • Provide oversight to a list of patients with chronic pain and/or a substance use disorder. • Review each patient using “SBAR”: situation, background, assessment, and recommendations or requests. To learn more, visit • Consider complicating risk factors. For example, elderly patients are more likely to fall while on opioids than on nonsteroidal antiinflammatory drugs (NSAIDs), and overdose risk is increased for patients with a sleep disorder or who are obese. • Explore options for each patient, including non-opioid treatments and mental and chemical health referrals. Practice harm reduction. Licit and illicit drug use exists, and treatment is available for patients who are ready. In the meantime, there are effective strategies to reduce the harms of drug use. For people who inject drugs (PWID), consider harm reduction strategies to reduce the risk of infectious disease, skin infections, and related health conditions. Perform a thorough skin assessment for scarring, inflammation, skin infections, damaged or MINNESOTA PHYSICIAN SEPTEMBER 2018



Sexual harassment A “sepsis” in medicine BY SUSAN STRAUSS, RN, EDD


orkplace sexual harassment dates back to the 19th century, when women first appeared in the marketplace in large numbers. During this Victorian era, Florence Nightingale believed that male hospital administrators failed to intervene on her nurses’ behalf when harassed by physicians, and that the nurses needed protection. Her only “protection” at the time was to require female nurses to live in nursing homes and to observe strict codes of conduct. A 2018 nationwide study by Medscape, a clinician-focused website, demonstrates that both female and male physicians continue to experience sexual harassment. Women physicians were significantly more likely to experience sexual abuse, harassment, or misconduct (12 percent) than their male peers (4 percent). The numbers are even higher for health care professionals who witness such acts: 13 percent of female physicians, and 14 percent of male physicians. Female and male physicians both reported egregious instances of harassment and, in some cases, forceful physical encounters. Others reported sexual innuendo directed at the individual or shared with colleagues or

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superiors, as well as disparaging remarks about other sexes or genders. Sexual harassment runs the gamut from blatant assaults to offensive remarks and comments, all falling under the categories of verbal, nonverbal, visual, and physical misconduct.

What is sexual harassment? Unlike other industries and the public sector, medicine has not yet had a #MeToo movement on social media. While public awareness may have been raised, some still question what constitutes sexual harassment. Definitions abound. One may be found in your health care organization’s policy. Or you could review legal definitions. Sexual harassment is a form of sex discrimination and a violation of Title VII of the 1964 Civil Rights Act (though the U.S. Supreme Court did not recognize workplace sexual harassment as a form of sex discrimination until 1986). The law describes sexual harassment as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature. This is a confusing and ambiguous definition at best, but one that is redefined with each new court case. Sexual harassment stems not from sexual attraction, but from an abuse of power. The misconduct does not need to be “sexual,” but may include derogatory comments about a person’s sex or gender. For example, if offensive comments are made about women to other women (or men who find it offensive), it may constitute illegal harassment. And if one sex is targeted by “bullying” because of the target’s sex, it can also be sexual harassment even in the absence of overt sexual comments. Sexual harassment is illegal when it is severe and/or pervasive enough to create a hostile or offensive environment and interferes with the ability of a “reasonable person” (as defined by the courts) to do their job. This is referred to as a hostile environment. Offhanded comments and isolated incidents that are not severe are not illegal. The reasonable person/woman standard recognizes that, even if the offensive conduct is the norm and is expected as part of the job (as many female physicians and nurses believe), the behavior may still constitute a hostile work environment. “Quid pro quo” is a more severe type of harassment in which an individual’s job is threatened with termination or demotion for refusing an employer’s sexual demands. Quid pro quo carries absolute liability—a single instance is illegal. Sexual harassment falls into three dimensions—sexual coercion (bribery for sexual activity), unwanted sexual attention (leering and touching), and gender harassment (sexist or misogynist comments). Gender harassment, the most common form of sexual harassment, can be psychologically injurious to all health care workers. Sexual harassment research typically focuses on the target of the behavior, ignoring the witnesses who are indirectly exposed to ambient sexual harassment—indirect exposure to sexual harassment in the workplace. Ambient sexual harassment can also produce negative psychological, health, and job outcomes, and may provide a legal remedy for victims. Sexual harassers do not have to be employees of the institution. The misconduct may also come from physicians, patients, their families and visitors, medical device representatives, and service providers. The

organization is responsible to protect their employees from sexual harassment even if the perpetrator is not an employee.

taken. Thirty-one percent were retaliated against for complaining. Is it any wonder physicians do not report their victimization?

In 2017, retaliation claims—filed by employees for asserting their Only 5 percent of physicians reported that the incident was not rights to be free from harassment—comprised 49 percent of all U.S. Equal upsetting, but 36 percent found it very upsetting, according to Medscape. Employment Opportunity Commission (EEOC) Sexual harassment interfered with physicians’ retaliation complaints. Health care organizations ability to do their job, with 18 percent indicating that it was a significant interference. sometimes accept retaliation and harassment if the perpetrator is a highly specialized surgeon, Etiology of sexual harassment in medicine a physician who admits a high percentage of Concerned about a hostile health care work patients, or was responsible for obtaining research Sexual harassers do not have to environment, the Joint Commission in 2008 be employees of the institution. grants or philanthropic gifts. issued a Sentinel Event Alert titled “Behaviors Sexual harassment in health care That Undermine a Culture of Safety.” While A 1995 University of Michigan study found the alert extends beyond sexual harassment to that 52 percent of women in academic medicine include intimidating and “disruptive” behavior, it reported being sexually harassed. The university’s recognizes that hospital cultures are hierarchical more recent study showed a decrease in that number, with 30 percent of and have been a traditionally male field, despite the fact that the majority of women and 4 percent of men experiencing sexual harassment. entering medical students are female since 2016. The 2018 Medscape study found that physicians were most likely to experience: deliberate infringement on body space; sexual comments about their body; leering; and unwanted groping, patting, hugging, or other physical contact. Physicians had been targeted by one to seven harassers. Most targets were female physicians and most perpetrators were male physicians. Among the male physicians who were harassed, about one-fourth were harassed by other men. Texts, emails, sexual comments, and leering were the behaviors most often repeated. By far the most likely harasser was a physician (47 percent), followed by nurses (16 percent). Twenty-eight percent of targeted physicians were harassed by primary care physicians, and 72 percent were harassed by specialists. The most frequent locations for the harassment were the hallways, perpetrator’s office, operating room, patient rooms, and patient care units.

Many women believe that physicians and hospital administrators see other health care professionals as “beneath” them, and therefore feel free to engage in misconduct. Some believe that the sexual advances are so frequent that they have become the norm, to the point where women just accept it as part of the culture. Sexual harassment to page 314

In 2012, the most significant U.S. sexual harassment lawsuit awarded $168 million to a physician’s assistant for repeated sexual harassment by cardiovascular surgeons in the OR. A 2007 Minnesota study examining physician abuse to RNs documented harassment in the OR, and a recent NBC Investigative News report labeled sexual misconduct as ingrained in the culture of the health care system.

Broad and deep impacts Health care professionals report feelings of anger, frustration, disgust, depression, suicide ideation, and increased anxiety. This often results in increased absenteeism and turnover, lowered employee engagement, and negative relationships with physicians. Abuse can also negatively impact the quality of patient care, interfering with efficiency, accuracy, safety, and patient outcomes. Nurses report a decline in empathy with patients, and physicians and others find they are more distracted with impaired decisionmaking. Unfortunately, the Medscape study demonstrated that 77 percent of the organizations failed to investigate a sexual harassment complaint. The Medscape study also found that female physicians were most impacted by leering and groping. Over half of the physicians, and 78 percent of the residents, did not report or confront the harasser—an alltoo-common response by victims. While about 25 to 60 percent of women are sexually harassed, 94 percent do not file a complaint or confront the offender, according to the EEOC. Those who did report found that the perpetrator’s misconduct was trivialized, and 37 percent said no action was

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The “Safe Surgery Process” A systems approach to improved outcomes BY KATHLEEN A. HARDER, PHD


ystemic diversions in health care delivery can often consume valuable time and thwart physician attention to direct patient care. Process barriers and inefficient information flow can detract from focused medical reasoning, and can frustrate efforts to stay on top of patient information and patient care. Distractions produced by fragmented workflows can contribute to a vacuum of assumptions and incomplete understanding—all of which can prevent physicians from dedicating the time needed to fully engage with patients. In some instances, these pressures can even lead to preoperative and surgical errors. Strategically designed systems built around processes, information, and health technology to promote effective and efficient cognitive engagement— capturing and sustaining physician attention—are needed now more than ever. Using deep human-centered systems thinking to create “cognitively digestible” processes affords clinicians the time to engage more fully in direct patient care. These systems can also channel attention in a way that provides clinicians with the information needed, in the format needed, at the time needed.

In the operating room, this streamlined information flow is particularly essential. Skilled surgeons and surgical teams may have performed a given procedure multiple times, but will still benefit from processes designed to capture and sustain provider attention at relevant care delivery points, with systematic restatements of patient information and stages in the surgical process—all with the goal of ensuring safe, effective, and efficient patient care. It is also instrumental in creating a less stressful, more satisfying work experience for providers. The Safe Surgery Process (SSP), approved by the Joint Commission, is a comprehensive process intended to do just that, with action steps beginning in the preoperative period and extending throughout the surgery itself.

Facilitating clinician and team performance The Safe Surgery Process is designed to ensure “correct patient, correct procedure, correct site” by capturing and sustaining each team member’s attention at relevant points. It addresses human information processing biases involving, for example, risk perception, overconfidence, and confirmation bias, and it considers potential pitfalls of “automated” behavior as well as fallible memory and attention issues to which we all succumb at times. By removing unwieldy barriers, the SSP is designed to help the team provide the care they want to deliver. The SSP closes gaps that can allow wrong-patient, wrong-procedure, and wrong-site events to occur. It cognitively engages team members through clear role delineation and clear performance expectations from beginning to end, and provides a final safety check, or Time Out, just prior to incision or procedure start.

OB & GYN CARE FOR ALL STAGES OF LIFE Low- and high-risk obstetrics,

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management of peri-menopause

Certified nurse midwifery.

Center for Urinary and Pelvic Health, including urodynamics.

Gynecologic care, including well-woman screenings and in-office procedures

Gynecologic surgeries,

including minimally invasive surgeries and robotics for conditions such as endometriosis and pelvic organ prolapse

Preoperative area


While the patient is in the preoperative holding area, the SSP calls for these steps:

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M A P L E G R O V E • B L A I N E • P LY M O U T H • C R Y S T A L


Elements of the SSP are summarized below. Many of these steps may already be in place within your practice. The SSP routinizes elements that may be seen as intuitive, and codifies them into best practice.

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Early, late, and Saturday appointments


The SSP is designed to level hierarchy and foster effective teamwork. Even the most experienced surgeons and anesthesiologists benefit from a process that addresses the malleability and fallibility of human memory throughout the perioperative process. In preop, it includes behavioral elements for the anesthesia care provider, circulating nurse, preop RN, and surgeon. In the operating room, it details elements for the anesthesia care provider, circulating nurse, scrub, and surgeon. All team members must participate.


Caregivers identify the patient. Physicians and staff ask patients to state their name and date of birth (DOB) while silently verifying that the information matches that on the patient’s ID band. Preop RN matches documents to patient. After reconfirming patient information, the preop RN reviews documents and confirms the procedure and surgical site. Surgeon marks surgical site. First, the surgeon reconfirms the procedure and surgical site accuracy from source documents and with the patient.

These documents include: the procedure order (or if an organization does not have an order, the patient’s history and physical/progress notes/consult); informed consent form; image(s) or radiologist’s report, as appropriate; and pathologist’s report, if applicable. The surgeon also asks the patient or patient’s representative to restate the procedure site and level or levels (if there are levels). After this comprehensive review, the surgeon resolves any discrepancies in the above information sources. Next, the physician performing the procedure marks the procedure site with his/her initials, using a marker that will remain visible after completing skin prep and sterile draping. The site is marked so it will be visible after the patient is in his/her final position for the procedure and sterile draping is completed.

Pre-anesthesia. Team briefing occurs before the patient undergoes anesthesia to verify that the team shares the correct plan for the procedure, and to confirm with team members what will be needed during the procedure and when it will be needed. Performing this step before anesthesia induction eliminates the risk the patient will experience anesthesia unnecessarily if the team briefing reveals an unanticipated barrier The entire process adds little time to the entire surgical procedure. that will delay procedure onset. Surgical site marking. Site marking (if required) is located during patient prep.

Anesthesia care provider or circulating RN reconfirms information. Before moving the patient to the OR, the person transporting the patient rechecks the informed consent form for the procedure and site, and visualizes the physical site marking to verify the surgical site marking (if site marking is required for the procedure).

Operating room SSP continues at several stages in the operating room: Entry into the OR. Immediately upon patient entry, the person transporting the patient introduces the patient to the scrub. Next, the circulating nurse and anesthesia care provider match the patient’s name,

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DOB, and medical record number on patient documents to the information on the patient ID band.

Surgical Time Out. This occurs after the surgeon scrubs and gowns, just prior to the incision/ procedure start. To facilitate the cognitive engagement of each team member, the focus is on the correct patient, correct procedure, and correct site only. The prescribed order of the role sequence decreases variability and clearly assigns role responsibility for participation to the entire team. The Time Out is standardized for each team member: • The surgeon initiates Time Out. The rest of the team ceases all other activity and focuses on the Time Out. (Anesthesia care providers continue to monitor the patient as appropriate.) The “Safe Surgery Process” to page 304

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Advanced practice providers Expanding expertise and scope of practice BY KENNETH PALLAS, MD


ncreasingly, medical practices are using a combination of physicians and advanced practice providers, primarily physician assistants and nurse practitioners, to provide timely, comprehensive, and costeffective care to patients. The Apple Valley Medical Clinic, the family medicine clinic arm of Apple Valley Medical Center, has worked with nurse practitioners and physician assistants for many years. Currently, we employ eight advanced practice providers, a significant increase from a few years ago and a highly effective model for providing quality health care. Nurse practitioners and physician assistants often work side by side, but they come to the profession by different routes and fulfill different roles in health care organizations.

Nurse practitioners


Nurse practitioners enter the practice of medicine with approximately six years of academic and clinical preparation, according to the American Association of Nurse Practitioners (AANP). In Minnesota, nurse practitioners must practice for at least 2,080 hours within the context

of a collaborative agreement with a physician before they are granted fully independent practice authority. Today, the AANP estimates there are more than 248,000 nurse practitioners licensed in the U.S., and the Star Tribune reports approximately 5,600 in Minnesota. Nurse practitioners can write prescriptions, including for controlled substances, in all 50 states. Nearly 90 percent choose to practice in primary care, with more than 60 percent in family medicine, according to the AANP. Unlike physician assistants, who are educated in general medicine, most nurse practitioners choose a population focus, such as pediatrics or women’s health. They provide care in many types of settings, including clinics, hospitals, emergency departments, urgent care clinics, private practices, long-term care facilities, schools, colleges, and public health departments. Our clinic’s nurse practitioners work autonomously but are assigned to a physician for oversight. They are able to: • Order, perform, and interpret diagnostic tests, such as lab work and X-rays. • Diagnose and treat patients with acute and chronic conditions, including diabetes, high blood pressure, infections, and injuries. • Prescribe medications and other treatments.

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Nurse practitioners often manage a patient’s overall care, but more than other advanced practice providers, they place a unique emphasis on health promotion, disease prevention, health education, counseling, and positive lifestyle choices. In many cases, they play the role of mentor and educator.

Adult geriatric nurse practitioners Multidisciplinary Spine Care Team Active Care Plan Cognitive Behavioral Coaching Program Patient Education Series Outcome Measurement & Reporting

PDR Outcomes

• 67% of patients rate their pain reduction between 50-100%

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We also have an adult geriatric nurse practitioner at the Apple Valley Medical Clinic. She sees patients from the age of 13 upward and has replaced a physician as the primary caregiver for a nearby senior apartment complex. She focuses on medical issues that impact her patients’ quality of life, including balance issues, memory decline, incontinence, or medication-related side effects, as well as difficulty with activities of daily living. The combination of chronic disorders often makes medical care more complex for older patients.

Physician assistants We also use physician assistants in our practice to diagnose illness, develop and manage treatment plans, and prescribe medicine. According to the American Academy of Physician Assistants (AAPA), there currently are 123,000 physician assistants practicing in the U.S. today. The Minnesota Academy of Physician Assistants (MAPA) estimates that 2,150 physician assistants practice in Minnesota. The profession itself was established in 1967 with the first physician assistant trained at Duke University School of Medicine. Today, the profession requires a candidate to have 2,000 hours of clinical rotation and graduate from one of the more than 250 accredited physician assistant programs in the U.S.

All physician assistants rotate through the major specialties and must pass a national certification exam and become licensed in the state in which they choose to practice. While nurse practitioners are trained in the advanced practice of nursing, physician assistants are trained to practice medicine based on a medical school curriculum.

registered professional nurse, one year or more of full-time work experience as a registered nurse in a critical care setting, a master’s degree from a nurse anesthesia educational program, and national certification. In many states, including Minnesota, they are no longer required to be under the supervision of physicians.

Unlike nurse practitioners, who are drawn to family medicine, only about 25 percent of physician assistants practice in primary care, according to the AAPA. A similar number choose to practice in surgical subspecialties, with the remaining split between internal medicine subspecialties, emergency medicine, pediatric subspecialties, and other areas.

Certified nurse midwives

Guided by the American College of NurseMidwives, these providers have been recognized since 1929. Today, there are nearly 12,000 Patient levels of satisfaction certified nurse midwives in the U.S., attending with nurse practitioners and more than 330,000 births and caring for physician assistants are very high. women’s reproductive concerns and primary care issues. They can write prescriptions, conduct According to MAPA, 47 percent of physician annual exams, offer nutrition counseling, and assistants practice in a physician’s office or clinic, provide parenting education. A graduate degree while 37 percent opt for a hospital setting. The is required to become a certified nurse midwife, and nearly 5 percent have rest are in urgent care, retail clinics, or elsewhere. doctoral degrees. The AAPA approved a new policy in 2017 to authorize physician Our urgent care center is a good entry point for advanced practice assistants to practice without an agreement with a specific physician. State providers. Here, they see a wide range of health care issues and have an chapters will now decide whether or not to change state laws to agree opportunity to build relationships with new patients or those without a with the national recommendation. Currently, Minnesota still requires a primary care provider. One of our physician assistants has been building written delegation agreement between a physician and a physician assistant quite a practice through patients she saw originally in the clinic’s urgent care. outlining duties and responsibilities of the physician assistant. If so noted by the supervising physician, a physician assistant in Minnesota can prescribe drugs, devices, and controlled substances. Advanced practice providers to page 294

• Diagnose, develop treatment plans, and coordinate care for patients with acute and chronic conditions. • Order and interpret lab, radiological, and other diagnostic testing. • Prescribe medication within the guidelines of the law. • Perform minor in-office procedures. • Assist in surgery. • Counsel patients on preventive medicine, wellness, medications, and therapies. • Make rounds in hospitals and nursing homes. • Perform clinical research.

Certified registered nurse anesthetists While our clinic does not employ certified registered nurse anesthetists or certified nurse midwives, a discussion of advanced practice providers would not be complete without some mention of their role in today’s health care environment. Certified registered nurse anesthetists have been credentialed since 1956. They are the primary providers of anesthesia in rural America and practice in a wide range of settings, including hospital surgical suites, delivery rooms, critical access hospitals, ambulatory surgical centers, and offices of dentists, ophthalmologists, and others. They are used heavily by the U.S. military, especially on the front lines. According to the American Association of Nurse Anesthetists, certified registered nurse anesthetists need a bachelor’s degree, a license as a

Telephone Equipment Distribution (TED) Program

At the Apple Valley Medical Clinic, each physician assistant has a physician assigned to him or her to review patient charts and consult on individual cases. Typically, physician assistants:

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 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 MINNESOTA PHYSICIAN SEPTEMBER 2018



Health literacy Guiding principles and strategies BY MELISSA G. FRENCH, MS, AND TERRY C. DAVIS, PHD

Resources for health care providers include:

t is no secret that many people struggle to understand health information. The consequences of this misunderstanding can be devastating. For example, patients who don’t understand their diagnosis and prognosis cannot participate fully in their care, those who don’t understand their risk factors can fail to get necessary screenings and preventive care, and inadequately comprehending medication instructions can limit a drug’s effectiveness or, worse, lead to errors and injury. One way to help people with the challenge of understanding and acting upon health information is to recognize the importance of health literacy. Health literacy offers a number of guiding principles and strategies that can help increase understanding and lead to higher quality care and better patient outcomes.

• Health Literacy Universal Precautions Toolkit: mp-precautions.


What is health literacy? Health literacy was originally defined as an individual’s ability to understand and act on health and medical information. Over time the meaning of health literacy has expanded to include the ability of providers and organizations to communicate effectively. The expanded definition represents an important shift from focusing on individual skills to system responsibilities.

Helping physicians communicate with physicians for over 30 years. MINNESOTA




Volume XXXII, No. 05

CAR T-cell therapy Modifying cells to fight cancer BY VERONIKA BACHANOVA, MD, PHD


niversity of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

Physician/employer direct contracting

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia. CAR T-cell therapy to page 144

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Exploring new potential BY MICK HANNAFIN


ith the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk, Physician/employer direct contracting to page 124

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• Health Literacy as an Essential Component to Achieving Excellent Patient Outcomes: • “What Did the Doctor Say?”: Improving Health Literacy to Protect Patient Safety: • HHS Health Literacy Action Plan: mp-action-plan.

Why does it matter? According to the only national health literacy survey to date, more than one-third of U.S. adults have only basic or below basic health literacy skills and over half have limited health numeracy skills, defined by the Centers for Disease Control and Prevention (CDC) as “the ability to access, use, interpret, and communicate mathematical information and ideas, to engage in and manage mathematical demands of a range of situations in adult life.” Numerous studies have documented that limited health literacy and numeracy significantly impacts an individual’s health and health care. People with lower health literacy have less health knowledge, poorer selfmanagement of chronic disease, poorer medication adherence, and lower use of preventive care. They tend to have poorer health outcomes as well as higher emergency room and hospitalization rates. The U.S. Department of Health and Human Services (HHS) reports that nearly nine out of 10 adults have difficulty using health information that is routinely available in doctors’ offices and the media. Providers often aren’t aware of this lack of understanding and function as if their patients have adequate health literacy skills and can easily access, understand, and act on health information and services. Clinicians may fail to grasp the gap between what they are trying to communicate and what patients understand. This communication problem is compounded because patients with limited health literacy ask fewer questions in the office visit, and are less likely to seek heath information from printed resources or understand medical terminology and jargon. Studies have shown that patients often leave a physician visit with a very different understanding of what they are supposed to do than their clinician intended. They are often not clear about all they need to do to adhere to medical instructions and therefore they are more likely to make mistakes, especially with their medications. They are also less likely to adequately navigate our complex health system or understand informed consent documents for procedures and research studies.

What can providers do? The HHS National Action Plan on Health Literacy calls for health information to be accurate, accessible, understandable, and actionable. Every patient, no matter how well educated, is at risk for misunderstanding health information if the issue is complex or emotionally charged. Providers sometimes forget what it is like not knowing basic health information. Some assume their well-educated patients fully understand critical information. Numerous studies have shown,

however, that an individual’s education level is not an accurate indicator of their health literacy. For this reason, the Agency for Healthcare Research and Quality recommends taking a universal precautions approach to health literacy. There are some things that providers can do to prioritize health literacy and increase effective communication: • Slow down. • Use plain language. • Limit content—prioritize what needs to be discussed and limit information to three to five key points (the more information the doctor gives, the more that is forgotten).

• Be positive and motivating—they are the ones who must manage their health at home. Doctors need to take special care when giving medication instructions. When explaining medication, the physician or nurse needs to “break it down” for the patient and go step-by-step, essentially performing a dress rehearsal for taking the medication at home. Providers should then check for understanding:

Nearly nine out of 10 adults have difficulty using health information that is routinely available in doctors’ offices.

• Use pictures or illustrations as teaching tools (pamphlets or brown bag medication reviews). Write brief take-home information: What’s the health problem (diagnosis)? What does the patient need to do (treatment)? Why is it important that they do this (benefit)? • Engage the patient in the treatment plan as much as they want to be involved. • Repeat and summarize information. • Teach back or show back to confirm understanding—you do not know if they have adequately understood unless you ask them to “teach back,” repeating key points in their own words.

• What the medication is for (indication). • When to take it—what time of day. • How many pills at a time. • Duration—how long to take it. • Why (benefit). • What to expect (side effects). • How much it costs and who will pay (Medicare/insurance coverage, other options for payment).

Written material can also be helpful to patients. However, when there are too many materials in a doctor’s office, it can be overwhelming. It is best to limit the number of materials and use them as teaching tools. Almost all patients prefer materials that are easy to read—that get to the point quickly Health literacy to page 284


Thursday–Friday, October 25-26, 2018 • Hyatt Regency Bloomington, MN Join us for a two-day conference that explores ways to improve care and health equity in under-served populations and among those living in poverty. It brings information and resources on chronic disease prevention and care, public policy and health innovations to Minnesota’s health care community, with a focus on safety net providers. Keynote Speakers: Dr. Michael Westerhaus and Dr. Roli Dwivedi of the Social Medicine Consortium The Consortium is a collective of committed healthcare professionals, universities, and organizations fighting for health equity through education, training, service, and advocacy, with social medicine at its core. This session will address the ways that structural and societal barriers faced by patients can often cause healthcare professionals to feel overwhelmed and isolated. Members of the Consortium will share tools that help us to rediscover agency, purpose, and collective impact in our work. Continuing Education Stratis Health designates the 2018 Many Faces Conference for 10 hours (6 hours on Thursday and 4 hours on Friday) of AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Attendees are responsible for determining if this program meets the criteria for licensure or recertification for their discipline.

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

For more information: contact Shelby Maidl / / 612-253-4715 ext 10 MINNESOTA PHYSICIAN SEPTEMBER 2018


3Health literacy from page 27

The responsibility for communicating the results of the tests and engaging in shared decision-making will fall to the system’s primary care physicians.

and allow them to get the information they need easily. Forms can also be challenging for some patients. In a health-literate system, forms are clear and easy to read and patients are offered help in filling them out.

The hope is that, armed with this knowledge, patients can work with their primary care doctors to develop plans to change risky behaviors or increase screenings in response to an individual’s test results. The question is, will patients be able to understand and act on this information? Given what we know about most people’s baseline literacy and health literacy and adding in the stress of hearing from one’s doctor about a genetic predisposition to a feared illness, will providers be able to communicate with patients in a productive way? In this scenario, the alignment of system demands with individual skills is vital.

For suggestions on drafting effective written health information, see: • CDC Clear Communication Index: mp-cdc-index. • CMS Toolkit for Making Written Materials Clear and effective: • CDC Plain Language Checklist: mp-cdc-plain-language.

Looking ahead One tremendous benefit of family practice is the opportunity to develop trusting relationships with patients and their families. Numerous studies have shown how important that is to patients. They trust their family doctor and believe they know them and truly care for them and their situation. This trust can form a strong foundation for better communication and increasing health literacy. Health literacy will be even more salient to delivering high quality health care as we move into the future. The rise of genetic testing and precision medicine is promising for patients but offers communication challenges for primary care providers. A Washington Post article from May 2018 reported that the Pennsylvania-based Geisinger Health System will begin rolling out a program that will eventually offer DNA sequencing to all of its three million patients.



Achieving health literacy in a health care encounter, finding that place where the information given to a patient is understood and the patient feels as though he or she can act on it, is necessary to providing high quality, patient-centered care. By recognizing health literacy as a factor in patient outcomes and taking steps to improve understanding, doctors can provide better care and do more to help their patients. Melissa G. French, MS, is the director of the Roundtable on Health Literacy of the National Academies of Sciences, Engineering, and Medicine.

Terry C. Davis, PhD, is professor of medicine and pediatrics, Louisiana State University Health Sciences Center–Shreveport.

The views expressed in this article are their own.

3Advanced practice providers from page 25 Coordinating with advanced practice providers

holistic in their care of patients, and patients develop strong relationships with them, sharing details of their lives that perhaps they wouldn’t share with a physician.

I am fortunate to have both a nurse practitioner and a physician assistant The bottom line is that advanced practice providers are an integral working directly with me. I can help them with part of today’s health care environment. Working patients who have complex needs, perhaps offering to maximize their potential and their contributions guidance on how closely to follow up with the achieves all three tenets of the Institute for patient or which specialist is most appropriate Healthcare Improvement’s Triple Aim: improving for a referral. These providers are carving out the patient experience of care, improving the health Advanced practice providers niches for themselves with women’s health, sports of populations, and reducing the per capita cost of are an integral part of today’s medicine, and endocrinology. They are attracting health care. health care environment. patients of their own and continue to grow their individual practices. Kenneth Pallas, MD, is a board-certified family Most physicians don’t want to develop a clone medicine physician with the Apple Valley Medical of themselves, but they do want to work with Center. He received his medical degree from Wayne advanced practice providers who follow their State University and has more than 40 years of experience in family medicine. style of medicine and agree with their basic philosophies. Because of our extended hours, my schedule often doesn’t match with the staff under my supervision. They know they are free to consult with other physicians on our staff at any time. When we first hire an advanced practice provider, we spend a lot of time reviewing patient information with them. They become more independent as time goes on—and as our comfort level increases. Our advanced practice providers are more likely to see patients who need chronic care management for conditions such as diabetes or congestive heart failure. Well-child or well-adult visits also are suited for care by nurse practitioners or physician assistants. We don’t let our advanced practice providers care for patients with chronic pain, however, as there are just too many nuances for this kind of complex care management. This is a challenging area that we believe needs a physician oversight. If a patient being seen by an advanced practice provider turns into a patient with chronic pain, a physician will take the lead in that patient’s care. In addition to providing patient care supervision, we also guide these providers in administrative issues, including billing. There is a learning curve when it comes to documenting a patient’s treatment, and we don’t want to overbill or underbill any cases.

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We also make sure our advanced practice providers are up to date when it comes to business issues affecting our clinic. They are part of our team, and we treat them accordingly, filling them in on board meeting information, for example.

Patient advantages of advanced practice providers Our experience has shown that patient levels of satisfaction with nurse practitioners and physician assistants are very high. This is despite inequities in reimbursement. Some insurance companies reimburse advanced practice providers at less than 100 percent of physician rates. We offer all of our patients the option of seeing a nurse practitioner or a physician assistant instead of a physician. When patients find out they generally can get an appointment sooner, they agree, and many of them stay with that provider for future treatment. Our advanced practice providers see patients every 20 minutes versus the 15 minutes for family medicine physicians. Advanced practice providers also often can be more

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3The “Safe Surgery Process” from page 23 • The circulating RN audibly reads the following from the patient’s informed consent form: patient name, procedure, and laterality of procedure (and level) as appropriate. • The anesthesia care provider states a shorthand version of the procedure. • The scrub states a shorthand version of the procedure for which he/ she has set up, and verbally confirms that he/she sees the site marking (if there is a site marking). • The surgeon states the complete procedure and site from memory. Any discrepant information is resolved with all appropriate team members before proceeding with the procedure. “I agree” or “yes” in isolation are not acceptable statements during the Time Out, because each of these statements fails to convey meaningful, case-specific information. With a statement such as “I agree,” there is no indication that a team member is cognitively present in the patient’s case. (With “I agree,” for example, a team member may be agreeing that the sky is blue outside.) For this reason, during the Time Out, each team member verbally states case-relevant information, which cannot by design become rote. Stating relevant, case-specific information helps to ensure that each team member is cognitively present and engaged in the patient’s case. The cognitively engaging Time Out phase of the SSP takes about 20 seconds, on average—not much time to ensure correct patient, correct procedure, correct site. Many providers appreciate its value in helping the team to engage with focused attention prior to incision/procedure start.



Team debriefing. This occurs following the procedure, before the surgeon leaves the operating room.

The process in action The Safe Surgery Process has been in place for nearly 10 years in various facilities in Minnesota. Since that time it has been implemented in facilities across the United States. Across the nation, some providers expressed initial resistance, in part because the process appeared to be time consuming. When implemented, however, the entire process adds little time to the entire surgical procedure. The process has reduced errors, sometimes soon after implementation; for example, during the first week of implementing the SSP in another state, the cognitively engaging Time Out revealed a misunderstanding that could have led to a surgical error. In this era of health care consolidation, as practices are acquired by larger groups, one of the inherent threats is the loss of institutional memory. As new leadership replaces old, a shared understanding of the benefits provided by processes designed specifically to foster improved cognitive engagement in direct patient care can be lost in the transition to new leadership. The Safe Surgery Process to ensure correct patient, correct procedure, and correct site cognitively engages providers and other team members, effectively and efficiently, to produce excellent patient outcomes. Kathleen A. Harder, PhD, is director of the Center for Design in Health and director of Graduate Studies, Human Factors Program, at the University of Minnesota.

3Sexual harassment from page 21 Other risk factors include the 24/7 nature of the job, dealing with body parts and nudity, and stress. Pervasive sexism and gender bias in medicine have been listed as an even bigger problem than sexual harassment by some female physicians, and may serve as the antecedent to sexual harassment.

Prevention and intervention Leaders must take a strong, active role, implement strategic plans with measurable goals and objectives, and communicate their policies and procedures to all health care staff. The Joint Commission now requires all accredited hospitals and health care organizations to have such a policy as a condition of continued accreditation. The policy should require yearly review and revisions to comply with current case law. Confidential reporting mechanisms must be implemented and followed, with timely and thorough investigations by a trained and competent investigator. As an expert witness for lawsuits, however, I can state that those tasked with conducting investigations often have not been trained, and therefore do an inadequate job, leading to ongoing harassment and increased liability. Preventive training is a must, but it is not sufficient. It must go beyond “check the box” training, and must be repeated every few years. Those in leadership positions, including the board of directors, require specific training regarding their legal and ethical roles. Physicians require training tailored to their unique roles within the system. Training should be conducted by an expert, focus on civility, and teach “speaking up” skills to physicians and nurses. And it should involve live, customized presentations with question-and-answer periods.

Training should also include dealing with patients and visitors who sexually harass physicians and nurses. Design a patient information flyer that spells out expectations for patient and visitor behavior. Physicians may still deal with aggressive patients responding to their diagnosis, but the focus must be on reasonable measures to make the workplace as safe as possible. Assess the organization’s climate related to sexual and other forms of harassment. Use those assessment results to establish goals and objectives to enhance the culture. Instigate prevention strategies and, three years after implementation, reassess the organization to determine if the prevention strategies have been effective.

Conclusion Sexual harassment must be tackled from a systems ecological perspective that recognizes health care’s rich hegemonic history. Sexual harassment is rooted in this hegemony and is difficult to change. In medicine, a system with a strong, often male-dominated power structure, dealing with the culture will be the only effective way to minimize sexual misconduct. It is a paradox that the relationship among health care professionals is sometimes the antithesis of the healing and caring philosophy interwoven throughout patient care. Susan Strauss, RN, EdD, works with private and public sector organizations, including health care institutions, to address discrimination, harassment, and bullying. She is also an expert witness for harassment, discrimination, and bullying lawsuits in the workplace and schools, and conducts training on those topics.


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Quality Transcription (located in Minnesota) maintains a professional office environment, thus the confidentiality of your work is strictly maintained. We provide medical transcription services on a contract or overload basis.

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3Responses to the opioid epidemic from page 19

pills, set a follow-up appointment to assess progress and discuss healing and recovery. Avoid refills following an injury or surgery in the postEngage in continuing education. Look for continuing medical education acute period. This period, up to 45 days following an acute injury or opportunities. Two such opportunities are Project ECHO (Extension for surgery, is a critical timeframe when people can become dependent on, or Community Healthcare Outcomes), a weekly addicted to, opioids. During acute pain, patients teleconference hosted by DHS, and the Opioid are told to “stay on top of it” with medications. Lecture Series, hosted by the Minnesota Medical This messaging needs to shift dramatically during Association ( the post-acute period. Educate patients about the function of pain in the body, and how they can use Preventing the development of new chronthis biofeedback as a way to slow down, rest, and Query the PMP to learn about the ic opioid users recover fully. patient’s prescribing history. Implement universal screening. Train staff to Educate patients about safe disposal of unused administer simple screening tools such as the medications. Educate patients to safely dispose of any PHQ-2 (for depression) and the AUDIT-DAST unused or expired medications. Let patients know (for substance use disorder) at all medical visits. that keeping medications “just in case” presents a Identify a clinic flow for positive screens that match risk of accidental poisoning and diversion. The your clinic’s capacity and resources. See additional Minnesota Pollution Control Agency hosts a statewide searchable database information at called “Earth 911” ( to look up the Follow the Opioid Prescribing Guidelines ( site for safe disposal of medications. guidelines) developed by the DHS Opioid Prescribing Workgroup. Use non-opioid treatment modalities whenever possible. Discuss the benefits, Clinic system improvements for addressing the opioid epidemic risks, and alternatives for pain management approaches. Many studies Ask your providers what additional skills, training, or resources they need to manage chronic pain and/or substance use disorder. Some provider training show that over-the-counter pain medications have comparable benefits has focused on: without the substantial risk of physical and psychological dependence. If opioids are used, prescribe the lowest dose and duration that is clinically indicated. Instead of sending patients home with “more-than-enough” Responses to the opioid epidemic to page 344

Change Lives Boynton Health is a national leader in college student health. We serve the University of Minnesota, delivering comprehensive health care services with a public health approach to campus well-being. Our patients are motivated and diverse undergraduate, graduate and international students, faculty and staff. On campus, you will have access to cultural and athletic events and a rich academic environment. Boynton is readily accessible by transit, biking and walking. With no evening, weekend or on-call hours, our physicians find exceptional work/life balance.

PHYSICIAN Boynton Health is seeking a Full-Time Physician with a Sports Medicine background to work in our Primary Care and Urgent Care Clinics. We have in-house mental health, pharmacy, physical therapy, lab, x-ray and other services to provide holistic care of your patients. This position offers a competitive salary, comprehensive benefits, CME opportunities and a generous retiremetnt plan. Professional liability coverage is provided.

To learn more, contact Michele Senenfelder, Human Resources at 612-301-2166, Apply online at and search Keyword 324537. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer.

410 Church Street SE, Minneapolis, MN 55455 612-625-8400



For more information, contact TSgt James Simpkins 402-292-1815 x102 or visit ©2013 Paid for by the U.S. Air Force. All rights reserved.



3Responses to the opioid epidemic from page 32 • Academic detailing (provider-to-provider mentoring) for opioid tapering. • Analyzing and documenting urine toxicology results.

exercise, and massage), and medication reconciliation; or 2) decreasing the total number of opioid prescriptions, multiple provider/pharmacy episodes, high-dose prescriptions, long-acting prescriptions, harmful interactions, and unnecessary emergency room costs.

• Maximizing the use of delegates for querying the PMP. • Using the restricted recipient program for patients with multiple provider/pharmacy episodes. • Medication reconciliation following any hospital stay or transition between health systems.

Use non-opioid treatment modalities whenever possible.

There are tangible actions that health care providers and clinic systems can take to save lives, address the harms that have already happened, and prevent harms from happening. For more information, please visit the MDH Opioid Dashboard, a one-stop shop for opioid-related data and information: www. Kate S. Erickson, MSW, is the opioid overdose

• Reducing the harms associated with injection drug use.

prevention director for the Minnesota Department of Health (MDH).

• Recognizing the signs and symptoms of an overdose and administering naloxone. Select process and outcome measurements for your opioid prescribing and chronic pain management. For tips on identifying and testing achievable results, see Determine a measurable goal for each quality metric, such as 1) increasing PMP enrollment or queries, co-prescribing of naloxone, making referrals to mental and chemical health services (e.g., therapy, psychiatry, Rule 25 or chemical dependency assessment, and MAT program waivers), employing non-opioid treatment modalities (e.g., PT, OT, swim therapy, acupuncture, chiropractic, yoga,

This publication was supported by the Data Driven Prevention Initiative Grant or Cooperative Agreement Number, NU17CE924861-02-01, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

Practice Opportunities throughout Greater Minnesota: Our nation faces an unprecedented number of individuals who having served their country now receive health care benefits through the VA system. We offer an opportunity for you to serve those who have served their country providing community based health care in modern facilities with access to world-leading research and research opportunities. We provide outstanding benefits with less stress and burnout than many large system policies create. We allow you to do what you do, best – care for patients.

Minneapolis VA Health Care System Metro based opportunities include: • Chief of General Internal Medicine • Chief of Nephrology • Cardiologist • Internal Medicine/Family Practice • Urologist • Psychiatrist • Tele-ICU (Las Vegas, NV)

Ely VA Clinic

Hibbing VA Clinic

Current opportunities include:

Current opportunities include:

Internal Medicine/Family Practice

Internal Medicine/Family Practice

US citizenship or proper work authorization required. Candidates should be BE/BC. Must have a valid medical license anywhere in US. Background check required. EEO Employer.

Possible Education Loan Repayment • Competitive Salary • Excellent Benefits • Professional Liability Insurance with Tail Coverage

For more information on current opportunities, contact: Yolanda Young: • 612-467-4964 One Veterans Drive, Minneapolis, MN 55417



A Place To Be Your Best. Dr. Julie Benson, MN Academy Family Physician of the Year

Family Medicine Northfield Hospital & Clinics is seeking a Family Medicine Physician (no OB) to join our growing practice in our Lakeville Clinic, conveniently located just off Hwy 35. Joining our independent healthcare organization allows you to advocate for patient choice while providing the best care for the individual. We use a team approach to provide seamless, integrated care with easy access to a variety of services and specialties. Learn more at or submit your resume to For more information contact our Recruiter, Erin, at 507-646-8170.


OB GYN & FAMILY MEDICINE – Full-scope practice available (ER, OB, C-Section, Hospitalist, Clinic) • Independent/growing system • Located in the heart of lakes country, Staples, MN • Critical access hospital with 5 primary clinics and a senior living facility • 15 family medicine physicians and 16 advanced practice clinicians • Competitive salary, benefits, and sign-on bonus available Contact Michael Paul at 218.894.8633, or

Join the Best. Join Entira Family Clinics. Entira Family Clinics is an award-winning, physician owned and operated group of primary care, after hours care, and express care clinics serving the East Metro for over 50 years. If you want the opportunity to influence how your practice is run, then look no further. Where Generations Thrive®: Our community-based clinics offer high-quality care specializing in family medicine and serve families at all stages of life.

Join our team today!

For more information, contact: Len Kaiser: 651-772-1572 or

| |

| MN Physician ½ page 0918



3Eating disorders from page 17 recovery. It is important that providers understand that eating disorders are not just about food and they aren’t a phase, a fad, or a choice. Eating disorders are severe illnesses caused by genetic, biological, psychological, social, and cultural factors. Providers should understand this and work to treat the patient as a whole person, instead of just treating the eating disorder. Multidisciplinary care teams, like ours at The Emily Program, consist of therapists, registered dietitians, psychiatrists, and primary care providers who have a detailed knowledge base and experience in treating eating disorders. Therapies offered during eating disorder treatment can include: dialectical behavior therapy, cognitive behavioral therapy, yoga, art, meditation, meal therapy, co-occurring substance use disorder services, trauma recovery support, and/or LGBTQIA+ support services. The benefit of receiving treatment at a specialized program is that clients more often experience lasting recovery. By engaging and understanding clients as a whole, these programs are able to treat the underlying causes of an individual’s eating disorder and create lifelong change and healing. It is also essential that providers understand that patients often have co-occurring disorders. By referring patients to programs that can also address other disorders such as substance abuse, individuals don’t have to seek care at multiple facilities and may be more likely to work to overcome multiple issues affecting them. By having treatment localized into one program, individuals receive more succinct treatment and superior levels of care.

At The Emily Program, for example, we offer a range of services tailored to the needs of all age groups. Options include outpatient therapy, intensive outpatient programs, intensive day programs/partial hospitalization programs, and 24/7 residential programs. Integrated eating disorder/ substance use disorder programming is also available, and individual programs address nutrition and recovery skills development. If one of your patients presents with symptoms of an eating disorder or expresses concerns, assure them that they will be able to find a program that meets their needs, and consider offering to make a referral.

Directing patients to help and treatment Encourage patients to seek a treatment program tailored to their individual needs. Many patients will benefit most from the multidisciplinary, holistic approach detailed in this article. Urge patients with co-occurring disorders to look for programs that can address their specific needs. The Emily Program is available to discuss referrals or to answer questions about a specific case. Not all communities offer eating disorder services, so The Emily Program strives to provide consultative care in coordination with community providers. Mary Bretzman, MD, is a family physician who has specialized in eating disorder care at The Emily Program for over eight years. She believes in engaging patients to help them find their own motivation to make the lifestyle changes necessary to improve their health.

Carris Health is the perfect match “I found the perfect match with Carris Health.” Dr. Cindy Smith, Co-CEO & President of Carris Health

Carris Health is a multi-specialty health network located in west central and southwest Minnesota. Carris Health is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/ BC physicians in the following specialties: • Dermatology • ENT • Family Medicine • Gastroenterology • Geriatrician • Hospitalist

• Internal Medicine • Nephrology • Neurology • OB/GYN • Oncology • Orthopedic Surgery

• Pediatrics • Psychiatry • Pulmonary/ Critical Care • Rheumatology • Urology

Loan repayment assistance available.

FOR MORE INFORMATION: Shana Zahrbock, Physician Recruitment | | (320) 231-6353 | Carris Health is an innovative health care system committed to reinventing rural health care in West Central and Southwest Minnesota. Carris Health was formed in January 2018 and is part of CentraCare Health. Visit for more information.



Family Medicine & Emergency Medicine Physicians • • • • •

Great Opportunities

Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice

St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria

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

• Physician (Care In the Community/ Integrative Whole Health) • Physician (Hospice & Palliative Care)

• Physician Psychiatrist (Mental Health)

• Physician (Hematology/Oncology) Part-Time • Physician (Pulmonologist) Part-Time • Physician (IM/FP) St. Cloud MN

763-682-5906 | 763-684-0243


Family Practice Physician Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.

WORK-LIFE BALANCE: •  Competitive salary •  Significant starting & residency bonuses •  4-day work weeks •  51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 218-361-3190

• Physician (IM/FP) Brainerd MN

• Physician (IM/FP) Montevideo MN

• Associate Chief of Staff/ Education (Office of the Director)

• Associate Chief of Staff Primary & Specialty Ambulatory Medicine

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BC/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer. Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information:

Visit or contact Jane Blommel, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301



3Motivational interviewing from page 15 The Substance Abuse and Mental Health Services Administration (SAMHSA) promotes the use of MI. The Centers for Medicare & Medicaid Services (CMS) identified alcohol and substance use as issues to be addressed through its Quality Improvement Organization (QIO) program to support better outcomes for Medicare consumers. As a QIO, Lake Superior Quality Innovation Network (QIN) trained more than 250 participants around Minnesota on the fundamentals of MI to build capacity within primary care clinics for behavioral health and substance abuse assessment. “In my work with primary care physicians, and in my practice as a behavioral health clinician, we need information from the patients in order to help them,” said Laura Maxwell, MSW, LICSW, a behavioral health clinician at Fairview Mesaba Clinic in Hibbing who attended one recent MI training session. “MI techniques provide a mechanism to get that needed information, in an inviting manner that provides the opportunity for a deeper engagement and more pleasurable appointment for everyone. Using motivational interviewing skills helps the patient feel listened to and want to continue to work.”

Reimbursement Motivational interviewing can be eligible for reimbursement when included in the provision of brief advice and counseling services for patients with commercial, Medicare, or Medicaid coverage. Two types of counseling lend themselves particularly well for including an MI approach. For patients with a positive screen for alcohol and/or substance abuse, Screening &

Brief Intervention (SBI) services delivered by a physician or mental health provider may be eligible for reimbursement (Medicare codes G0396, G0397, G0443; commercial and Medicaid CPT codes 99408 or 99409). Smoking and tobacco use cessation also may be eligible (Medicare codes G0436 and G0437; commercial and Medicaid CPT codes 99406 and 99407). Mia Croyle, MA, is a behavioral health project specialist at MetaStar. She is a member of the Motivational Interviewing Network of Trainers (MINT) and has been training and coaching professionals for the past 10 years.

Jane Pederson, MD, MS, chief medical quality officer at Stratis Health, provides leadership and clinical guidance to health care quality and safety initiatives. Board-certified in geriatrics, she is a geriatrician with Allina Health Senior Health, providing primary care for individuals residing in assisted living settings. Dr. Pederson is an adjunct assistant professor in the Division of Health Policy and Management at the School of Public Health at the University of Minnesota.

MetaStar and Stratis Health are partners in Lake Superior QIN, which brings together Medicare beneficiaries, providers, and communities in Michigan, Minnesota, and Wisconsin through data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality.

Urgent Care Physicians HEAL. TEACH. LEAD.

At HealthPartners, we are focused on health as it could be, affordability as it must be, and relationships built on trust. Recognized once again in Minnesota Physician Publishing’s 100 Influential Health Care Leaders, we are proud of our extraordinary physicians and their contribution to the care and service of the people of the Minneapolis/St. Paul area and beyond. As an Urgent Care Physician with HealthPartners, you’ll enjoy: • Being part of a large, integrated organization that includes many specialties; if you have a question, simply pick up the phone and speak directly with a specialty physician • Flexibility to suit your lifestyle that includes expanded day and evening hours, full day options providing more hours for FTE and less days on service • An updated competitive salary and benefits package, including paid malpractice HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. Find an exciting, rewarding practice to complement all the passions in your life. Apply online at or contact Diane at 952-883-5453 or EOE


Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package.

The VAHCS is currently recruiting for the following positions:

Cardiologist Endocrinologist Neurologist PACT Physiatrist

Psychiatrist Psychologist Pulmonologist Women Health Director

apply online at

(605) 333-6852 · 38


Emergency Medicine (part-time) ENT (part-time) Gastroenterologist (part-time) Urologist (part-time)


Minimize the things that get in the way of why you’re in healthcare to begin with. A focus on reducing lawsuits is just one way we do this. For more information or your nearest agent, contact us at 800.225.6168 or through M E D I C A L P R O F E S S I O N A L L I A B I L I T Y I N S U R A N C E  A N A LY T I C S  R I S K M A N A G E M E N T  E D U C A T I O N

Insurance products issued by ProSelect® Insurance Company and Preferred Professional Insurance Company® MINNESOTA PHYSICIAN SEPTEMBER 2018


Succeeding when kidneys fail When a child is sick, you’d do anything to help. At University of Minnesota Masonic Children’s Hospital, we became the largest and most experienced pediatric kidney transplant program in the world by doing so. Through advanced treatments — including innovative kidney transplants for complex disorders such as VATER syndrome, congenital nephrotic syndrome and hyperoxaluria — and a highly regarded dialysis center, we’ve successfully helped over 1,000 children get back to living healthier lives. Honored as one of the top pediatric nephrology programs in the nation by U.S. News & World Report

University of Minnesota Health Transplant Care for Pediatrics Physician Referrals: 612-625-5115 ext. 6

University of Minnesota Health is a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. ©2018 University of Minnesota Physicians and University of Minnesota Medical Center

Minnesota Physician September 2018  

Prescription drug prices Competition can drive down costs By Sen. Amy Klobuchar Motivational interviewing Helping patients change behaviors...

Minnesota Physician September 2018  

Prescription drug prices Competition can drive down costs By Sen. Amy Klobuchar Motivational interviewing Helping patients change behaviors...