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Volume XXVll, No. 7

October 2012

The Independent Medical Business Newspaper

A perspective on med ed Past and future trends By Macaran A. Baird, MD, MS

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graduated from residency in 1978, practiced family medicine and had leadership roles in medicine for much of the next 35 years, and have been head of the University of Minnesota Medical School’s Department of Family Medicine and Community Health since 2002. What follows is my perspective on what has—and hasn’t—changed over the years in medical education and the medical profession, and what this means for the students who will be our future physicians.

What’s the same?

In thinking over the many changes that have occurred in medical education and medical practice since I entered med school, I’m struck by one particular thing that hasn’t changed: It is still a tremendous privilege to be a physician. As long as we are still prepared to earn the patient’s trust, we can join in partnership to learn about patients’ lives and help

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PROFESSION to page 10

PRSRT STD U.S. POSTAGE

The changing face of medicine

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Detriot Lakes, MN Permit No. 2655

Evolution of a profession

n medicine, change is a constant. Changes in technology, payment methods, medical procedures and medications, health system organization and regulation, medical education—they are all part and parcel of practicing medicine. To get a sense of what it’s like to practice medicine today, we asked seven physicians, whose experience spans five decades of medical practice, to respond to a few questions about their experience in the medical profession. We also asked two current medical school students to comment on their education experience, professional and personal aspirations, and expectations of medical practice. Though the contributors’ backgrounds, perspectives, and experience vary substantially, their remarks call to mind William

MED ED to page 18

Presidential candidates Page 8


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CONTENTS

OCTOBER 2012 Volume XXVII, No. 7

FEATURES Evolution of a profession The changing face of medicine

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A perspective on med ed Past and future trends

1 T H I R T Y- E I G H T H

By Macaran A. Baird, MD, MS

Evolution of a profession: Physician commentaries

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DEPARTMENTS CAPSULES

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ADDICTION MEDICINE Prescription drug abuse 24

MEDICUS

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By Carol Falkowski

INTERVIEW Presidential matters

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MEDICAL FACILITIES Does scale matter?

President Barack Obama and Gov. Mitt Romney

By Lee H. Beecher, MD, FAPA, FASAM

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By Meredith Hayes Gordon, MArch, Associate AIA, LEED AP BD+C

PROFESSIONAL UPDATE: ADDICTION MEDICINE Treating drug and alcohol addictions 22

MINNESOTA HEALTH CARE ROUNDTABLE

PHYSICIAN PERSPECTIVE “How’s that working out for ya?” 32 By Wayne Liebhard, MD

The Independent Medical Business Newspaper

www.mppub.com PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com

Background and Focus: The recent Supreme Court ruling on the Affordable Care Act clears the way for implementation of health insurance exchanges. States have the option of creating their own exchange by January 2014 or joining one created by the federal government. A health insurance exchange would provide consumers a place to compare and shop for health insurance coverage. In Minnesota this idea was first proposed as part of the Pawlenty administration’s healthAssuring they are meaningful care reform task force, and Gov. Dayton is a strong supporter of Thursday, November 1, 2012 creating a state-run program. 1:00 – 4:00 PM • Duluth Room Though simple and compelling at Downtown Mpls. Hilton and Towers first brush, creating a consumeraccessible, “apples-to-apples” website for comparing health insurance costs is challenging and very complex.

Health Insurance Exchanges:

Objectives: We will define what a health care insurance exchange is and, considering the detailed and proprietary design of health insurance coverage, how it can be meaningful. Health insurance policies contain terms like “medically necessary,” “investigative,” “cosmetic,” “not medically necessary,” and “contract/benefit exclusion”—all terms that are defined differently by different insurers. This alone makes it virtually impossible for anyone to compare plans effectively. Further, networks of providers vary, depending on whether you choose the “bronze,” “silver,” “gold,” or “platinum” option within a given insurer, as will access to hospital-based facilities, DME providers, and ancillary services. Throw in features like “deductibles,” “co-insurance,” “maximum out-of-pocket expenses,” “formulary design,” and “covered preventive services,” and you have a bewildering mathematical matrix. We will offer suggestions as to how an insurance exchange can address these issues and provide a meaningful, consumer-friendly comparison service. Panelists:  Peter Dehnel, MD, President, Twin Cities Medical Society; Medical Director for Utilization Management, BC/BS MN  Dan Maynard, President, Connecture  Beth McMullen, Health Policy Director, Minnesota Business Partnership  Manny Munson-Regala, JD, Deputy Director of the Health Insurance Exchange, Department of Commerce  Charles Sawyer, DC, Senior Vice President, NHSU  Dan Schuyler, Director, Leavitt Partners; Former Director of Technology, Utah Health Insurance Exchange Sponsors: Connecture • Novartis • PhRMA Please send me tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601. Name

ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com

Company

ART DIRECTOR Elaine Sarkela esarkela@mppub.com

Address

OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com

City, State, Zip

ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com

Telephone/FAX Card #

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace legal, tax, business or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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Please mail, call in or fax your registration by 10/25/2012

OCTOBER 2012 MINNESOTA PHYSICIAN

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CAPSULES

U of M Signs With ResearchMatch Clinical Trial Registry The University of Minnesota has enlisted a national research registry to help find volunteers for clinical trials. The partnership between The University of Minnesota Clinical and Translational Science Institute (CTSI) and ResearchMatch, a national group funded by the National Institutes of Health, will help U of M researchers connect with volunteers who are interested in participating in research studies. ResearchMatch gives potential participants information about clinical trials and other research they might be interested in, officials say. “Registering with ResearchMatch is an easy way for individuals to make a difference through research that is happening here at the University of Minnesota and other academic institutions across the country,” says Bruce Blazar, MD, a blood and marrow transplant

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expert and director of the university’s CTSI. Minnesota ranks high among states in the amount of medical research being done. However, shortages of volunteers are an ongoing problem for researchers and clinical trials. Officials say ResearchMatch can be a useful resource for all kinds of research efforts.

HealthPartners, Park Nicollet Agree To Merge In one of the largest consolidations seen in the Twin Cities health industry in decades, HealthPartners and Park Nicollet Health Services have agreed to a merger. The move, announced August 30, will make the new organization one of the largest health delivery systems in the state. HealthPartners’ unique position as both a health insurer and a delivery system may result in added scrutiny from regulators, who must approve the new arrangement.

MINNESOTA PHYSICIAN OCTOBER 2012

Bringing together two large provider groups in the metro area is historic, but not totally surprising at a time when Minnesota is seeing many small health systems being consolidated into larger groups. The new agreement will create a 1,500-multispecialtygroup practice that is tied to HealthPartners’ insurance arm, although the clinics and hospitals involved will continue to work with other insurers as well. Officials say the two groups will have a combined, consumer-governed board of directors. “HealthPartners and Park Nicollet share the same mission: making people healthier, making health care more affordable, and creating the best possible experience for our patients and members,” says Mary Brainerd, president and CEO of Bloomingtonbased HealthPartners, who will be CEO of the combined organization. “Separately, and in partnership, we’ve worked toward these goals in the Twin Cities area for decades. Together, we’ll be better able to pursue this mission across our region for

the benefit of the people we serve.” David Abelson, MD, president and CEO of St. Louis Parkbased Park Nicollet, will lead the new organization’s care delivery system, which will be named the Park Nicollet HealthPartners Care Group. The combined operations will include Park Nicollet Methodist Hospital in St. Louis Park, four HealthPartners hospitals—Regions Hospital in St. Paul, Lakeview Hospital in Stillwater, Hudson Hospital in Hudson, Wis., and Westfields Hospital in New Richmond, Wis.—and a large system of medical and dental clinics across the Twin Cities and western Wisconsin. Officials say they do not predict any layoffs or closures of facilities as a result of combining the two groups. The new arrangement did not involve a financial transaction, they add. Pending routine closure procedures and regulatory review, the agreement will be effective Jan. 1, 2013.


Researchers Say Sports Drinks Not Good for Kids University of Minnesota researchers are warning that sports drinks such as Gatorade and Powerade are not a healthier choice for children than sodas. A research survey by Mary Story, PhD, RD, and Laura Klein, MPH, professors at the U of M School of Public Health, finds that as sports drink consumption increases, the drinks are being targeted to children and adolescents as a healthy alternative to sodas. However, the drinks actually are designed for individuals engaged in prolonged vigorous exercise, and the study says most children and adolescents in the US “do not engage in enough physical activity to warrant sports drinks.” The research shows that even though the American Academy of Pediatrics recommends that most children and adolescents shouldn’t consume sports drinks, more than 27 percent of parents believe such drinks are healthy. “Given the already elevated levels of added sugar in the American diet and its detrimental impact on health, the increased consumption of sports drinks in recent years is of growing concern for parents, health professionals, and public health advocates,” the study says. Story and Klein write that sports drinks contribute added sugar and unnecessary sodium to young people’s diets, which may affect nutrition and increase the risk of poor dental health.

Consumer Reports Rates Clinics in State A special edition of Consumer Reports (CR) magazine includes ratings of Minnesota clinics, based on cost and quality of care in two areas: diabetes and cardiovascular disease. The edition published in Minnesota will differ from the national version of the magazine, with a different cover, a

feature story entitled “How Does Your Doctor Compare?” and a 32-page insert with ratings of 552 physicians’ group practices. The ratings were compiled by a collaboration among CR, the Robert Wood Johnson Foundation, and Minnesota Community Measurement (MNCM). In addition, a separate report in the magazine will compare cost and quality at 18 primary-care physician groups in Minneapolis and St. Paul. The report will look at HealthPartners insurance data on care, patient satisfaction, and affordability. According to Jim Chase, president of MNCM, his quality measurement organization is well known among providers in the state, but less so by consumers. He notes that CR reaches approximately 80,000 people in Minnesota. “It’s an opportunity for a lot more people to see the information,” he says. “We thought it was a good opportunity to partner with someone like Consumer Reports, who has a lot of experience at crafting messages for the public on how they can use information to make choices to improve their care. And in the issue, there’s a lot of information about why it’s important and what patients can do to improve results.”

Health Plans Show Strong Finances in 2011 Minnesota health plans are in excellent financial health, according to a twice-yearly report on the health care industry. Allan Baumgarten’s “Minnesota Health Market Review 2012, Part One” finds that although HMOs in the state continue to lose enrollment to PPO plans, the HMO model remains profitable, especially with public plans that serve Medicare and Medicaid populations. Baumgarten begins his latest report by noting that the Supreme Court’s ruling affirming the Affordable Care Act’s constitutionality means that reforms such as Medicaid expansion, insurance exchanges, and accountable care organizaCAPSULES to page 6

The Minnesota Organization on Fetal Alcohol Syndrome (MOFAS) is pleased to announce the first annual statewide FASD conference

“Building brighter futures: Working together to create change in Minnesota” November 1-2, 2012 DoubleTree by Hilton, 7800 Normandale Blvd, Bloomington, MN

You wouldn’t give a 2-year old a drink, so why would you give one to an unborn child?

Each year, over 8,500 babies are born in Minnesota with prenatal alcohol exposure which can cause permanent brain damage. This conference for both parents and professionals from all around Minnesota will present information on best practices, exchange insights and experiences and learn about the latest research in the field of FASD. Breakout topics will include prevention, intervention, diagnosis, national research and family support. Keynote Speaker: Dr. Sterling Clarren Dr. Clarren is a Clinical Professor of Pediatrics at the University of British Columbia Child and Family Research Institute and an internationally renowned FASD expert with over 35 years experience in the field. He will speak on how we collectively envision and encourage a comprehensive and coordinated approach to FASD prevention and intervention. Registration is $100 per person, groups of five or more are $90 each and includes admission to all sessions, program materials, and continental breakfast and lunches.

To register or for more information please contact Angie Dyer at angie@mofas.org or call 651-917-2370 or go online to www.mofas.org/events.

OCTOBER 2012

MINNESOTA PHYSICIAN

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CAPSULES Capsules from page 5 tions will now move forward. “While new regulations complicate the business of being a health insurer in the state, the initiatives to expand coverage create significant business opportunities for them,” writes Baumgarten. Underscoring that point is the report’s finding that government insurance products such as Medicaid plans, which are administered by the state’s private insurers, now represent the largest segment of business for the state’s HMOs. “HMOs began in Minnesota as vehicles for employers to provide employee benefits,” Baumgarten writes. “By the end of 2011, though, employer groups were less than one-fourth of the 934,00 enrollees in HMOs and the county-based purchasing plans. Enrollment in state public programs now accounts for 60 percent of total membership.” Enrollment for employerbased plans, Baumgarten notes, has largely shifted to PPO plans, which offer enrollees more flexibility, and can also include

op-tions such as consumer-driven plans featuring health savings accounts. Overall, enrollment in HMOs and county-based purchasing plans fell by 5 percent in 2011. Among HMOs in the state, the report says those products reported a net income of $230 million in 2001. The income would have been higher, but private insurers agreed to cap their Medicaid program income at 1 percent of their profits, returning $103 million to the state. In 2011, the state’s insurers saw an 8.5 percent margin on Medicaid plans. HMOs also saw strong profits on employer-based plans. “HMOs made $85.7 million on their commercial plans in 2011 compared to $53.5 million in 2010,” the report says. The profits that plans are seeing are building their financial reserves, Baumgarten reports. Health insurers are required to maintain at least two months of reserves, or enough capital to pay all expenses for that period, but several years ago lawmakers removed the upper ceiling for reserves. Most

insurers in the state now have enough reserves for three months, and some have enough for four months, the report says.

Mayo Cardiologists Cut X-ray Exposure Mayo Clinic cardiology specialists have been able to cut the amount of radiation exposure from imaging approximately 40 percent during cardiovascular procedures, according to a new report. The research found that targeted modifications to the use of X-ray equipment, along with radiation safety training, resulted in substantial reductions of radiation exposure. Exposure to radiation has been a growing concern, as it can cause harm to skin and increase the risk of cancer because of damage to a patient’s DNA. Cardiologists use X-ray images to identify heart problems and to provide real-time guidance for common procedures. At Mayo, clinicians attempted to lessen the risk of

radiation by setting equipment to a low output level as well as setting up other systems for tracking the amount of radiation a patient receives. Training of clinicians features an increased emphasis on radiation safety. Mayo staff are taught to use higher-dose imaging only when such detail is needed, while accepting adequate image quality at less critical steps in procedures. For the study, a total of 18,115 procedures at Mayo were performed by 27 staff cardiologists and 65 fellows over three years. Considering all procedures, researchers found, on average, a 40 percent reduction in radiation exposure over three years. “Through our efforts, we were able to quickly cut the overall radiation exposure to patients by nearly half using simple but effective methods,” says Charanjit Rihal, MD, chair of Mayo’s Division of Cardiovascular Diseases. “We think this program could serve as a useful model for other cath labs in the U.S.”

In person

Inbox

When changes in the local health care landscape promised a major influx of new UCare members coming through metro-area clinics and hospitals, we made sure those providers were prepared. In a span of just two weeks, May Ly was among the UCare staff that personally visited 449 unique health care locations to offer a heads-up and explain the impacts. Because being responsive to our partners’ needs isn’t just talk—it’s what we mean by health care that starts with you.

| provider assistance: 1-888-531-1493 | ucare.org/providers |

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MINNESOTA PHYSICIAN

OCTOBER 2012

©2012, UCare.


MEDICUS

Jocelin Huang, MD, has joined Minnesota Oncology and began practicing at its clinics in Edina and Waconia in August. Huang received her medical degree from the University of Chicago Pritzker School of Medicine, and completed her fellowship in medical oncology and hematology at Mayo Clinic in Rochester. Huang’s areas of special interest include the treatment of colorectal, pancreatic, and hepatoJocelin Huang, MD biliary cancers; breast cancer; multiple myeloma; and lymphoma. Y. Ralph Chu, MD, has been honored with the Senior Achievement Award from the American Academy of Opthalmology. The award recognizes individuals for their contributions to the academy through instruction, participation, and other areas of service. Chu currently represents the Outpatient Ophthalmic Surgery Society on the AAO Council. He founded BloomingtonY. Ralph Chu, MD based Chu Vision Institute in 1999. Essentia Health has added several physicians to its clinics in Minnesota. Adam Swank, MD, has joined the Family Medicine Department at Essentia Health–West Duluth Clinic. Swank attended the Medical College of Wisconsin in Milwaukee and completed his residency through the Duluth Family Medicine Residency Program. Gastroenterologist Erin Thackeray, MD, has joined the Essentia Health–Duluth Clinic. Thackeray completed medical school at the University of Minnesota. She did her residency in internal medicine and completed a fellowship in gastroenterology at Mayo Graduate School of Medicine. Chad Filson, MD, has joined Essentia Health– Virginia (Minn.) Clinic. Filson received his medical degree from Medical University of the Americas in Devens, Mass., and completed a family medicine residency at MidMichigan Medical Center in Midland, Mich. Minto Porter, MD, an allergy and asthma specialist, has joined Essentia Health St. Joseph’s–Brainerd Clinic and began seeing patients in August. She graduated from the University of North Dakota Medical School; completed her residency at Michigan State University–Kalamazoo; and completed an allergy, asthma, and immunology fellowship at Henry Ford Hospital in Detroit. Lisa Young, MD, has been selected for this year’s Essentia Health Obstetrics Fellowship Program. The fellowship allows family medicine physicians who plan to practice in rural areas to train in obstetrics. Young attended Midwestern University in Glendale, Ariz., and completed a family medicine residency at Northern Colorado Family Medicine in Greeley, Colo. St. Croix Orthopaedics, PA, has added two physicians: Nicholas Holmes, MD, and Eric Kirksson, MD. Holmes, a primary-care sports medicine physician, will provide care for patients at the practice’s Nicholas Holmes, MD new urgent care clinic in Lake Elmo. He received his medical degree from St. George’s University, Grenada, West Indies; and completed an internship at St. Joseph’s Mercy-Oakland Hospital in Pontiac, Mich., and a residency at Seneca Lakes Family Medicine Program–Oconee Medical Center in Seneca, S.C. Holmes is board-eligible with the American Eric Kirksson, MD Board of Family Practice with a certificate of added qualification in sports medicine. Kirksson, a physical medicine and rehabilitation physician, will treat patients at the Lake Elmo, Fairview Lakes, and Stillwater clinics. He graduated from the University of Minnesota Medical School in 2006 and completed residency training at Mayo Clinic in Rochester, followed by a medical spine fellowship at Marshfield Clinic in Marshfield, Wis. He is certified by the American Board of Physical Medicine and Rehabilitation.

Serving independent physicians in Minnesota for over 30 years

Perkins+Will, along with our engineering partner M+NLB, was selected as the winning entry in Kaiser Permanente’s year long global “Small Hospital, Big Idea” competition.

Perkins+Will Perkins+W Wiill can be your partner in developing those ideas into reality. realityy. Givee us a call. Rick Hintz 612.851.507 70 rick.hintz@perkinswill.com www.perkinswill.com www w.perkin . nswill.com 612.851.5070 For more information on Kaiser Perman nente’’s “Small Hospital Big Idea Competi ition” visit: Permanente’s Competition” design. kpnfs.com design.kpnfs.com

OCTOBER 2012

MINNESOTA PHYSICIAN

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INTERVIEW

Presidential matters A discussion of health care with the two presidential campaigns PRESIDENT BARACK OBAMA Position on the ACA “The Affordable Care Act will make health care more affordable for families and small businesses and brings much-needed transparency to the insurance industry. “When fully implemented, the Affordable Care Act will keep insurance companies from taking advantage of consumers—including denying coverage to people with preexisting conditions and canceling coverage when someone gets sick. “Because of the new law, 34 million more Americans will gain coverage—many who will be able to afford insurance for the first time. Once the law is fully implemented, about 95 percent of Americans under age 65 will have insurance.”

With the Affordable Care Act’s (ACA) emergence as one of President Barack Obama’s signature accomplishments during his first term, health care was destined to be front and center in this year’s presidential race. Although the old axiom that the economy is always the first thing on voters’ minds remains true, in this election health care issues are also making an impact. And with the selection of Rep. Paul Ryan as Republican Mitt Romney’s running mate, the future of Medicare has become a major point of debate. With this in mind, Minnesota Health Care News has examined the two campaigns’ health-care policy positions. Here is a list of the candidates’ positions on top issues. All answers are taken from the official campaign websites unless otherwise noted.

How the ACA helps individuals and businesses “The ACA promotes better value through preventive and coordinated care, and eliminates waste and abuses. “The ACA also helps keep insurance premiums down. Insurance companies must publicly justify excessive rate hikes and provide rebates if they don’t spend at least 80 percent of premiums on care instead of overhead, marketing, and profits. As many as 9 million consumers are expected to get up to $1.4 billion in rebates because the President passed the ACA. “Millions of small businesses are now eligible for a tax credit to help pay for their health care premiums. The credit will increase to cover 50 percent of premium costs in 2014. “Under the ACA, help for small businesses—including the new insurance exchanges—will reduce small business health care spending by nearly 9 percent, according to independent estimates.”

Expanding coverage Starting in 2014, all Americans will have access to affordable health insurance no matter their circumstances—whether they change jobs, lose their job, decide to start a business, or retire early. Purchasing private insurance in the new state-based health insurance exchanges could save middle-class families who can’t get employer-provided insurance thousands of dollars. Young adults are now eligible to stay on their parents’ health insurance plans as they enter the workforce, until they turn 26. Since the health care law passed, 3.1 million young adults—traditionally the group least likely to be insured—gained insurance because of the ACA.

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MINNESOTA PHYSICIAN OCTOBER 2012

GOV. MITT ROMNEY

Position on the ACA “The transformation in American health care set in motion by Obamacare will take us in precisely the wrong direction. The bill, itself more than 2,400 pages long, relies on a dense web of regulations, fees, subsidies, excise taxes, exchanges, and rule-setting boards to give the federal government extraordinary control over every corner of the health care system. The costs are commensurate: Obamacare added a trillion dollars in new health care spending. To pay for it, the law raised taxes by $500 billion on everyone from middle-class families to innovative medical device makers, and then slashed $500 billion from Medicare. “Obamacare was unpopular when passed, and remains unpopular today, because the American people recognize that a government takeover is the wrong approach. While Obamacare may create a new health insurance entitlement, it will only worsen the system’s existing problems. Obamacare will violate that crucial first principle of medicine: ‘do no harm.’ It will make America a less attractive place to practice medicine, discourage innovators from investing in life-saving technology, and restrict consumer choice.” Repealing and replacing the ACA “On his first day in office, Mitt Romney will issue an executive order that paves the way for the federal government to issue Obamacare waivers to all 50 states. He will then work with Congress to repeal the full legislation as quickly as possible. “In place of Obamacare, Mitt will pursue policies that give each state the power to craft a health-care reform plan that is best for its own citizens. The federal government’s role will be to help markets work by creating a level playing field for competition. “Mitt will begin by returning states to their proper place in charge of regulating local insurance markets and caring for the poor, uninsured, and chronically ill. States will have both the incentive and the flexibility to experiment, learn from one another, and craft the approaches best suited to their own citizens.” The Romney campaign says it will ease regulations on private insurers, promote high-risk pools, enact tort reform, and enable small businesses to form purchasing pools for insurance coverage. The campaign also gives a nod to the consumer-driven care model that employs health savings accounts (HSAs) for group plans by saying that Romney will “end tax discrimination against the individual purchase of insurance; unshackle HSAs by allowing


Birth control and women’s health “As part of the ACA … many insurance plans will be required to fully cover birth control without copays or deductibles as part of women’s preventive care. This step will help more women make health care decisions based on what’s best for them—not their insurance company—and could save them hundreds of dollars every year. “Certain religious organizations, including churches, “Because of the will be exempt from the rules, and other religious organizanew law, 34 million tions will not have to pay for Americans will their insurers to cover birth gain [health care] control. “Thanks to unprecedentcoverage.” ed new guidelines in the ACA, women will have access to a wide range of preventive health services—mammograms, cervical cancer screenings, and birth control—without a copay or deductible. The Affordable Care Act will also prevent insurance companies from discriminating against women so that being a woman is no longer considered a pre-existing condition.” The future of Medicare [From the President’s weekly address, Aug. 25] “Thanks to the health care law we passed, nearly 5.4 million seniors with Medicare have saved over $4.1 billion on prescription drugs. That’s an average of more than $700 per person. And this year alone, 18 million seniors with Medicare have taken advantage of preventive care benefits like mammograms or other cancer screenings that now come at no extra cost. “Growing up as the son of a single mother, I was raised with the help of my grandparents. I saw how important things like Medicare and Social Security were in their lives. And I saw the peace of mind it gave them. That’s why, as President, my goal has been to strengthen these programs now, and preserve them for future generations. “That’s why, as part of the Affordable Care Act, we gave seniors deeper discounts on prescription drugs, and made sure preventive care like mammograms are free without a copay. We’ve extended the life of Medicare by almost a decade. And I’ve proposed reforms that will save Medicare money by getting rid of wasteful spending in the health care system and reining in insurance companies—reforms that won’t touch your guaranteed Medicare benefits. “Republicans in Congress have put forward a very different plan. They want to turn Medicare into a voucher program. That means that instead of being guaranteed Medicare, seniors would get a voucher to buy insurance, but it wouldn’t keep up with costs. As a result, one plan would force seniors to pay an extra $6,400 a year for the same benefits they get now. And it would effectively end Medicare as we know it.” “I’m willing to work with anyone to keep improving the current system, but I refuse to do anything that undermines the basic idea of Medicare as a guarantee for seniors who get sick.”

funds to be used for insurance premiums; and promote ‘co-insurance’ products.” Abortion and women’s health “Mitt believes that life begins at conception and wishes that the laws of our nation reflected that view. But while the nation remains so divided, he believes that the right next step is for the Supreme Court to overturn Roe v. Wade—a case of blatant judicial activism that took a decision that should be left to the people and placed it in the hands of unelected judges. “With Roe overturned, states will be empowered through the democratic process to determine their own abortion laws and not have them dictated by judicial mandate. “Mitt supports the Hyde Amendment, which broadly bars the use of federal funds for abortions. As president, he will end federal funding for abortion advocates like Planned Parenthood. He will protect the right of health care workers to follow their conscience in their work. And he will nominate judges who know the difference between personal opinion and the law.”

“Competition

Free market reforms drives improvements “Competition drives improvements in efficiency and effecin efficiency and tiveness, offering consumers effectiveness.” higher quality goods and services at lower cost. It can have the same effect in the health care system, if given the chance to work.” The Romney campaign says other steps to improve the free market for health care include: capping non-economic damages in medical malpractice lawsuits; empowering individuals and small businesses to form purchasing pools; preventing discrimination against individuals with preexisting conditions who maintain continuous coverage; and improving medical information technology systems. The future of Medicare “President Obama has had three years in office, during which time he has attacked every serious proposal to preserve and strengthen America’s entitlement programs while enacting cuts to Medicare and putting in place a bureaucratic board that one day may ration the care available through the program. “Mitt Romney … proposes that tomorrow’s Medicare should give beneficiaries a generous defined contribution, or ‘premium support,’ and allow them to choose between private plans and traditional Medicare. “Mitt’s plan honors commitments to current seniors while giving the next generation an improved program that offers the freedom to choose what their coverage under Medicare should look like. Instead of paying providers directly for medical services, the government’s role will be to help future seniors pay for an insurance option that provides coverage at least as good as today’s Medicare, and to offer traditional Medicare as one of the insurance options that seniors can choose. “With insurers competing against each other to provide the best value to customers, efficiency and quality will improve and costs will decline. Seniors will be allowed to keep the savings from less expensive options or choose to pay more for costlier plans.”

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Profession from cover Osler’s observation, more than a decade ago, about a life in medicine: “To have striven, to have made the effort, to have been true to certain ideals—this alone is worth the struggle.” We hope you enjoy reading these essays about medical education and practice, and we welcome your comments. Thanks to the contributing physicians and medical students for their thoughtful and candid responses to our questions.

Robert Gumnit, MD Founder and Physician, MINCEP Epilepsy Care, Minneapolis Years in practice: 48 Medical degree: 1957 (University of Pennsylvania) What aspects of medical practice have surprised you (in good and/or bad ways)? When I first went into practice, in 1964, physicians were relatively few and there wasn’t that much competition. I was surprised by how physicians sorted themselves out, good doctors wanting to practice with good doctors who challenged them, more laidback doctors just wanting camaraderie. The other thing that surprised me, although it shouldn’t have, was the amount of denial on the part of patients who often waited far too long to seek help. What were the most important factors for you in choosing a medical specialty? I had initially thought I would have a research

career in physiological and learning psychology. After entering medical school, it was logical for me to move into neurology. What was your debt upon graduating? As best I can recall, my debt was in the neighborhood of $4,800. At the time, a minimumwage job paid about $1,900 a year and a good blue-collar job paid about $3,800 a year. My debt was somewhere between one and two years’ total pre-tax income of the average blue-collar worker. How has the culture of medical practice changed since you began practicing? When I started practicing, most physicians were dedicated purely to doing the best they could for their patients and trying to find ways to help them. Most patients had no health insurance and paid out of pocket. An enormous amount of charity care was given without making much of a fuss about it. Here in the Midwest, many of my patients were uncomfortable with receiving charity. Often, quite literally, patients would offer to wash my windows, cut my lawn, bring me eggs, etc., because they didn’t want to be “freeloaders.” Today the culture of patients is different. There is more of a sense of entitlement and patients often expect the best without making an effort to pay for it. From the physician point of view, when I started, if you were able, available, and capable, you had a successful practice. With the advent of billing by CPT codes in 1966, we physicians have been turned into shopkeepers “working” the system to gain appropriate reimbursement for our services. Often I feel like I’m running a checkout counter in a supermarket, keeping track of all of the minutiae, rather than practicing medicine. Federal and insurance company regulation and the electronic medical record make it tougher to delegate than it was in the past. I am unable to work as efficiently as I could previously, nor am I able to provide charity care “up front.” Unnecessary complexity lends itself to waste. On the other hand, Medicare has been a blessing to tens of millions of people. I would never want to go back to 1964. Another striking change has been in the attitude of pharmaceutical companies. When I started, a number of companies attempted to educate physicians, and contact with the physicians occurred as much through the research and educational division as through marketing. Twenty years ago or so, we saw a rapid shift into physicians becoming “marks” and heavily manipulated by the marketing side of the drug companies. In my opinion, it is an ugly scene. What advice would you give to physicians entering medical practice? You are moving into an era in which you will be viewed as just another replaceable technician by a large health care organization. If you want to be seen as an individual and influence what you are doing, you should move to a small town where the health care organization will be smaller and the relationships more personal. No matter where you go, don’t expect to be given any special consideration except when the administrators (hospital, practice, insurers, government) want something from you. Be suspicious when they massage your ego. On the other hand, the satisfaction you will receive when you are alone with the patient in the examining room is enormous. It will make a career in medicine fully worthwhile. What, if anything, would you have done differently in your career? I would not have sacrificed so much of my personal and family life for my career. Most physicians did so when I started. In retrospect, it was a heavy price to pay. I should have struck a better balance. On the other hand, I don’t think I would ever have been satisfied working a standard shift and walking away without a sense of continuing responsibility to my patients. That, to me, is one of the essential parts of being a doctor. The relationship you build with your patient is one of the most satisfying aspects of practicing medicine.

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Physician, Raiter Clinic, Cloquet Years in practice: 52 Medical degree: 1959 (University of Minnesota) What aspects of medical practice have surprised you (in good and/or bad ways)? (a) The rapidity with which the insurance industry took over the practice of medicine, beginning in the late 1960s. It is now virtually impossible to survive on fee-for-service. (b) The advances in technology, diagnostic and therapeutic. In 1957, the bubble oxygenator was being used for the first time; now it is routine. Radiation therapy was administered using vacuum tubes. Digitalis leaf was still being used. Penicillin was being augmented with more and better antibiotics. Since then, through basic science, ongoing increases in knowledge of physiology, down to the molecular level, have improved therapeutics. (c) The technological advances have come at a price. One unexpected and disturbing consequence of the advancement in knowledge and technology has been the rise of subspecialties, to the detriment of general medicine practice. About 40 years ago I saw a cartoon depicting an office door with the legend, “Dr. John Smith, Specialty: Side effects.” Then it was a joke; now it’s for real. (d) We have become so technically oriented that Mrs. Jones has become “the gall bladder in room 3.” We are struggling to retain our sense of empathy with our patients, largely for economic reasons. It costs to have the machines and the special drugs, and we can’t afford them without seeing more patients and shortening appointment times. What were the most important factors for you in choosing a medical specialty? Both of my parents were practicing physicians. I grew up getting dinner-table M&Ms, so it was only natural to step right in. I did preceptoring in the St. Luke’s (Duluth) Pathology Department during summer breaks in college and got grounded in basic anatomy and pathology. I joined my parents’ general medical practice, Puumala Clinic, in Cloquet in 1960, and worked there until the practice closed in 2005. Since then I’ve practiced part-time at Raiter Clinic, also in Cloquet. What was your debt upon graduating? Thanks to my parents, I emerged from medical school debt-free. How has the culture of medical practice changed since you began practicing? (a) The increased acceptance of women into the medical profession has been great. In 1930, my mother was among six women in her class at the University of Illinois College of Medicine. In 1956, there were six women in my class (including my wife, Barbara) at the University of Minnesota. Our three-doctor clinic employed two women physicians—my mother and, later, an RPAP [the U of M’s Rural Physician Associate Program] student who had trained at the clinic. Four of the 13 family physicians at the Raiter Clinic are women, and this number will certainly increase. (b) With the technical advances, the cost of examinations, and the ancillary staff needed to run a large medical group, the physician’s ability to sit down with a patient and find out what is really bothering the patient has been reduced to a waiting-room checklist. The 15-minute office visit is not satisfying. I fear that we are losing the art of medicine; instead of a profession, it has become a job. (c) The shift away from general medicine toward subspecialties reflects a major cultural shift in medicine from 50 years ago. In part, this has occurred in response to the increasing use of midlevel practitioners in place of family doctors; in addition, the six-

digit debt that medical students now typically incur sends them to advanced, more lucrative training. This cultural shift bodes ill for the medical generalist. A light at the end of the tunnel is the advance care directive. It will help protect our resources, enabling us to provide them to those who will benefit the most. What advice would you give to physicians entering medical practice? Get a full, rounded basic medical education and general internship before you enter specialty training. I think you’ll have a better understanding of the humans you are dealing with. What, if anything, would you have done differently in your career? I would have done nothing different in my career. I wanted to be a general doctor and, more than 50 years later, I am still doing that.

Paul Waytz, MD Physician and Partner, Arthritis & Rheumatology Consultants, Edina Years in practice: 32 Medical degree: 1974 (University of Illinois–Chicago) What aspects of medical practice have surprised you (in good and/or bad ways)? I have been in private practice for 32 years and have been amazed by the quantum leap in technology and availability of advanced diagnostic tools. Is what I have witnessed in the past three decades any different than the replacement of horsehair with synthetic suture material? Perhaps these observations answer both the “good” and the “bad” aspect of the question. PROFESSION to page 12

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Profession from page 11 Tempered by the very hands-on and contemplative nature of my subspecialty, is it any easier for me to diagnosis rheumatoid arthritis? I am not so sure. On the other hand, I can probably assess prognosis better and choose medications more intelligently, even though there are still no 100 percent guarantees of effectiveness. Diagnostic tools, primarily serologic testing, now allow us to separate subsets of diseases or rename and identify “new” diseases. Sophisticated laboratory investigations now give us detailed insights into the behavior of the immune system in both normal and abnormal situations. In addition to a better understanding of fundamental processes, this knowledge has led to the development of biologic treatments that have the potential to dramatically change the treatment of the severe diseases affecting younger people. I am concerned that the reliance on new technology has replaced a more straightforward initial approach where history, physical examination, and basic testing can provide substantial information as well as the diagnosis. Sophisticated testing is clearly more expensive and may be confusing as well. False laboratory positives and nonspecific imaging changes may lead to delays and costlier testing and not influence management whatsoever. And why does the diagnosis and management of gout still befuddle so many physicians? What were the most important factors for you in choosing a medical specialty? I chose my specialty while interning as a result of being turned on by my mentor. What was your debt upon graduating? An eon ago, as a resident of Illinois, I paid tuition of $250 per quarter at the university. I could also walk into the bursar’s office and receive an interest-free loan for up to $100 with months to repay. I had no debt—aside from my debt to society.

How has the culture of medical practice changed since you began practicing? I feel things too large and grandiose have overly subserved the culture of medicine, especially the large systems of caregiving wherein a patient may become more of an app entry and the physician loses a certain autonomy. Yet, the physician can be part of this problem by relying too much on evaluation (see above) and less on management. It is abundantly clear that patients perceive distance; this is not good at all. Do grandiose treatment plans and expectations realistically prolong life and improve quality and at the same time overwhelm? Have too many of us ignored the care of the impoverished in favor of some easier decision? Can the culture of “bigness” be downshifted to something smaller and more inward, so that everyone’s culture is improved? We have lost something along the way—admittedly, I am part of this—but we can certainly work to rediscover, can’t we? What advice would you give to physicians entering medical practice? Remember always, even though it will be difficult at times, that you are lucky and you have a special gift. Working hard isn’t life-threatening, as you need to be both responsive and responsible. Treat every person—at all levels—with the respect that you would want from him or her. Don’t gloat about accomplishments—because something will soon come along and teach humility. Not every day or week or month will necessarily be happy, but you can still find the way to be happy with yourself and have fewer regrets. What, if anything, would you have done differently in your career? (a) Insisted that my partners purchase Apple stock for the Pension and Profit-Sharing plan when it was selling for $9 a share. (b) Stood a little closer to that nurse on B6 at MMC when doing CPR. (c) Took a two-month vacation in Italy rather than one. In fact: nothing.

Loie Lenarz, MD

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Medical director, St. Mary’s Health Clinics, Fairview Health Services, Minneapolis Years in practice: 27 Medical degree: 1981 (University of Minnesota) What aspects of medical practice have surprised you (in good and/or bad ways)? In my nearly 30 years of medical practice and work as a physician leader, perhaps my biggest surprise is how much I love what I do, in ways I hadn’t expected. I have cherished the gift of helping to bring new life into the world, and I expected to feel honored to be a part of doing so. I didn’t anticipate the blessings I discovered in helping someone navigate a chronic illness, or leave this world with as much dignity and grace as possible.

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What were the most important factors for you in choosing a medical specialty? Most people enter medical school brimming with idealism, and I was no exception. I began medical school in 1976 believing I wanted to provide broad-spectrum care to patients of all ages. Though other specialties intrigued me, especially obstetrics, family medicine fed my interest in a wide range of medical areas and in relationship-based care. What was your debt, if any, upon graduating? During medical school I met and married a fellow medical student. Both of us come from large families, so we needed to cover the cost of medical school ourselves. At the time of graduation we had a combined debt of approximately $60,000 that we finally paid off when we were about 45.

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great deal. We know more about how to prevent and treat illness. At the same time, physicians must perform vastly more paperwork, much of it electronically. And administrative and government leaders now expect physicians—reasonably—to balance the often competing priorities of clinical outcomes, patient experience, and cost of care. My physician colleagues and I are moving through an enormous cultural shift. Where once we received payment based exclusively on our volume of work, our reimbursement now is tied to clinical quality of care, and the patient’s experience of care. Further changes in the care model now drive a more team-based approach to practice. Physicians, nurses, medical assistants, receptionists, pharmacists, care coordinators, social workers, and others now share responsibility for a domain I alone once claimed. We have weathered extensive cultural change, and I believe the rate of change in health care will continue to be steep. I also believe the intensity of change has exhausted many of my colleagues. I am grateful for those in whom I can still see a commitment to their calling. I am surprised and saddened by those whose passion appears to stop with their own self-interest.

During medical school, I enjoyed the basic sciences much more than the clinical, so I had been considering specialties like endocrinology. But wanting to keep my options open, I decided to apply for a combined internal medicine-pediatrics residency program. After my intern year, I started to really enjoy myself. And while I love children, I found that I did not really enjoy pediatrics and that my real passion was for the acutely ill adult. Because I didn’t carry with me a medical school debt, I never worried about a large loan impacting my career decision. I have felt guilty about this for years, watching my friends and colleagues stress about their finances, moonlighting whenever they could.

What, if anything, would you have done differently in your career? Knowing what I know now, I would still choose medicine as a career.

How has the culture of medical practice changed since you began practicing? When I started practicing, evidence-based medicine was all the rage—and it still is. What is different is how we’ve added technology to enhance and support our practice of evidencebased medicine. Software abounds, on computers and on mobile devices, including cell phones. Coupled with that, technology has helped us broaden our agenda to enhance patient care outside of diagnosis and treatment. It now helps us improve quality, safety, experience, and affordability. But to be clear, it wasn’t technology that brought those objectives to light. I think those objectives are also “new” to the forefront of medicine.

What advice would you give to physicians entering medical practice? I talk regularly with premed and medical students about choosing medicine as a career. While I am always reluctant to give advice, I do tell them the following: If, once you have a sense of the complexity of the health care industry and the degree to which is it changing, you find yourself saying, “Wow, really complex. Lots of challenge and work to be done. Cool!,” then medicine is a great place to be. If on the other hand, you find yourself saying, “Wow, really complex. Lots of challenge and work to be done. Scary!,” perhaps another career would be a better choice. Most important, I tell students to find a place they like, with people they respect and enjoy. Much of the rest will be outside their control. And maybe that’s okay. Perhaps, as has been true for me, they will discover unexpected blessings.

What was your debt upon graduating? I was fortunate to graduate without any debt. I went to Mayo Medical School, where every student received some amount of scholarship, thanks to an endowment created especially for medical students. In fact, the tuition I paid there was less than at my state school, the University of Wisconsin. That was an important factor in choosing to go there, as my parents were supporting me during my four years in medical school. I was definitely in the minority and probably one in only a handful to have been that fortunate.

PROFESSION to page 14

Jerome Siy, MD, SFHM, CHIE Department head, Hospital Medicine, HealthPartners Medical Group, Regions Hospital, St. Paul Years in practice: 12 Medical degree: 1997 (Mayo Medical School) What aspects of medical practice have surprised you (in good and/or bad ways)? During my first few years of practice, I was most surprised by the intricacies of the health care system and how little medical school and residency prepared us for that. What first came to light were more direct processes, like billing and coding; but later, it became quite clear that the health care system was even more complex than I had imagined, going well beyond the act of seeing a patient and prescribing a treatment. Suddenly, there was talk of integrated health systems, population health, core measures, medication reconciliation, lean processes, peer review, and so much more, in diverse areas of medicine. At first it was frustrating, but then it became a welcome challenge. What were the most important factors for you in choosing a medical specialty? Was your med school debt a factor? Choosing a specialty was at first quite difficult. I think I was one of the only students who didn’t find anything he really had a passion for.

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Profession from page 13 What advice would you give to physicians entering medical practice? My advice would be to welcome the coming challenges to improve patient care and the health care system. Only if you are a part of it can you affect change. It is our responsibility as leaders in care delivery to own our profession and advocate for our patients and the health of the country. We should remember that this responsibility is not only to the individual who sits before us, but also to the population as a whole. What, if anything, would you have done differently in your career? I have no regrets about my career. A colleague of mine once commented that “it is human nature not to be completely satisfied.� So of course, there are things I would have liked to have done more of, learned more of, or experienced more of. But there is no sense worrying about what I could have done differently; instead, I need to think about what I need to do differently in the future.

Annie Tan, MD, PhD Gynecologic oncologist, Minnesota Oncology, Coon Rapids clinic Number of years in practice: 4 Medical degree: 2000 (University of Minnesota) What aspects of medical practice have surprised you (in good and/or bad ways)? My medical training did not prepare me for the administrative aspect of medicine. There is so much documentation, not only the patient’s medical record, but also for billing and coding. Even within my four years of practice, I have

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noticed the increase in the requirements for documentation, most recently with “meaningful use.� These requirements have increased the time needed for administrative work and detracted from the time for actual patient care. I was surprised to learn about the politics in medicine at the local and national level, and how it affects my daily practice. This is not in reference to office politics, but rather how policies and laws can influence how we want to run our practice and care for patients. What were the most important factors for you in choosing a medical specialty? Early on, I had an interest in oncology at the basic science level, which was the topic of my graduate dissertation. In medical school, I found that I enjoyed doing surgical procedures. I wanted to be in a field of medicine where I could combine these interests and also feel like I was making a difference in people’s lives. I found that to be true in gynecologic oncology. Fortunately, because I had no medical school debt, I was able to pick the specialty that truly interested me the most. What was your debt, if any, upon graduating? I was in a combined MD/PhD program and had full financial support with a tuition scholarship and stipend. How has the culture of medical practice changed since you began practicing? I have noticed that there is much more acceptance for physicians to find a work-life balance, with resources available to assist with overall physician well-being. Even within our practice, there is a committee working actively to achieve this for the whole group. The paradigm for how we care for patients is also changing. There has also been a shift to a patient-centered care model. I see more collaborative efforts and better communication among the different specialties, resulting in better coordinated care for patients. There is more practice of evidenced-based medicine, applying this to many more aspects of patient care. Along with this, there is the expanded effort to be cost conscious in how we care for patients. This has affected the types of procedures we do, length of stay in the hospital, medicines we prescribe, and clinical tests we order. What, if anything, would you have done differently in your career? I am very fortunate to be very happy with my career, my practice, and my colleagues, and would not change a thing. What advice would you give to physicians entering medical practice? I would recommend finding a practice where you like and respect your colleagues. These are the people you will be working with daily and who will cover the care of your patients on call or when you are out of the office. They can influence patient perceptions of you, as well as the growth of your practice. If you are at a new facility, find key physicians that you can ask for help if needed. For instance, when I started, I did not have any of my gynecologic oncology colleagues at the same hospital or clinic site. So I introduced myself to a colorectal surgeon, general surgeon, and urologist that I could comfortably discuss patient cases with and also operate with when necessary. I also made myself readily available for consults and questions. This helped to build my presence not only at the hospital but also in the community. Lastly, it is also important to find a good work-life balance. This has been ignored throughout medical training but is necessary if you plan to work for at least 30 years without burnout.


Camille Lang, MD Family medicine physician, Cuyuna Regional Medical Center, Crosby Years in practice: 1 Medical degree: 2003 (St. George’s University, Grenada, West Indies) What aspects of medical practice have surprised you (in good and/or bad ways)? Although the practice has been about as expected, I am surprised by the change in attitude from patients, and sometimes even staff, when one changes from “resident� to “physician� (I completed my family medicine residency at St. Cloud Hospital through the University of Minnesota Medical School residency program). There is a lot more respect—and that feels strange initially because we are not that different in the first year of practice than we were in the last year of residency. What have been the most challenging aspects for you in beginning to practice medicine? The most challenging aspect is making the transition from an academic center where you can always call for back-up to a rural practice where we face challenging and sometimes critical illnesses without having the same availability of specialists. This is especially true in obstetrics, where there is not always time to transport patients to a more appropriate facility. The on-call weekends are also difficult, as they are 48 hours followed by full clinic, compared to the 36-hour limit in residency. I see this becoming an even greater challenge as residency shift restrictions tighten and physician shortages continue to require practicing physicians to work long hours. Although less challenging, an important part of the stress of being in practice is the amount of time spent with data entry (progress notes, orders, documentation of Minnesota measures, etc.). The amount of paperwork continues to increase and gives physicians less time to spend with their patients. What are you most looking forward to in practicing medicine? I look forward to getting to know more families and seeing babies I deliver grow into adults. What were the most important factors for you in choosing a medical specialty? I wanted a field where I would have variety and would not be limited to one type of patient. I also wanted to live in a rural area, which does limit the number of options available. What was your debt, if any, upon graduating? Over $250,000 (sorry, I don’t remember the exact numbers). What advice would you give to physicians entering medical practice? (a) Never decide what you want to do based on income. (b) Family should be a priority and it is important to keep them involved in the decision-making process. (c) Try to set up rotations at places you are considering working so you can get a better feel for the work environment, since each place has its own “personality� and the people you work with can make your job awful or wonderful. (d) Make sure to find a good nurse.

practice because I believe this would offer the right blend of autonomy and balance. I would like to stay in the Twin Cities because my family is here. I would also like to be involved in teaching medical students in some capacity. What medical specialties are you considering, and why? At this point, I am undecided. My top two interests are pathology and obstetrics-gynecology. Pathology attracts me because it is incredibly intellectually challenging. I enjoy the visual nature of this field, and I appreciate how pathologists connect the most basic aspects of cellular function to the phenotype and prognosis of a disease. Ob-gyn interests me because it is a unique combination of primary and specialized care with many procedures. I would enjoy developing long-term relationships with women and focusing on their sexual and reproductive health. When and why did you first seriously consider pursuing a medical school degree? I came to medicine through the perspective of women’s health. As an undergraduate at Concordia College in Moorhead (Minn.), I took many courses in women’s studies and I directed “The Vagina Monologues� by Eve Ensler as my senior thesis in theatre. These activities solidified for me the connection between the health of the body and the empowerment of the individual. After graduating, I volunteered for Planned Parenthood and thought for the first time about going into medicine. However, I had not taken the requisite classes to apply to medical school. I decided that before going back to complete those courses, I needed to test my motivation to enter a service profession, so I spent two years in Bulgaria teaching English as a Peace Corps volunteer. That experience strengthened my appreciation for health care and health education, and it tempered my commitment to a career of service. PROFESSION to page 16

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Annie Jacobsen University of Minnesota Medical School—Twin Cities Medical student, Year 3 How do you see yourself practicing (e.g., independent vs. health organization, small or large practice, rural/urban/suburban, parttime/full-time)? I see myself working full-time in a small

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Profession from page 15

Charles Vang

What are a few of your strongest memories (good and bad) of medical school? My strongest memory is of gross anatomy, my first substantial experience with death and the human body. Developing a tactile knowledge of the various anatomical structures and discovering their relationships to one another was both an intellectual challenge and a rite of passage. I loved that this course was so physically demanding, and I will never forget the sense of accomplishment I felt when I found my first fascial plane.

University of Minnesota Medical School—Twin Cities Medical student, Year 3

What advice would you give to students entering medical school? There are many mixed messages about well-being in medical school. Enormous demands are placed on your time, but then everyone is telling you to sleep more, exercise enough, eat the right things, and “take time out for you.� I have often heard doctors say, “Don’t give up who you are,� after telling a regretful story about how they gave up their favorite instrument or pastime to go to medical school. It is very easy for them to say these things in hindsight, but it does nothing to alleviate the stress you are feeling in the moment. In fact, it may make things worse, and you may think, “If I’m not exercising every day for 60 minutes, getting honors, leading five different student groups, and continuing my (fill in the blank with your favorite hobby), I’m failing at this.� My advice is to not fall into this way of thinking. Medical school is stressful. The healthiest way to deal with that is to simplify your expectations about what you can accomplish. There is value in setting something aside and rediscovering it later. Do extracurricular or nonmedical activities because you enjoy them, not for fear of missing an opportunity or losing “who you are.� If you learn how to get your work done and learn how to turn it off so you can rest, everything else will work out. Do your best and give yourself a break.

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How do you see yourself practicing (e.g., independent vs. health organization, small or large practice, rural/urban/suburban, part-time/ full-time)? When I graduate, I see myself working with a health organization in the Twin Cities in order to gain more experiences and increase my knowledge base. I also aspire to play a role in policymaking that would allow greater accessibility to medical services from all groups of people. Having grown up in St. Paul and Minneapolis, I cannot picture a better place to practice medicine. What were the most important factors for you in deciding on a medical specialty? Was your med school debt a factor? I want to practice medicine in the way that I view the world: The individual and community are intricately connected and the changes in one will affect the other. The health of the individual impacts those around them, such as their family and community. Primary care provides the approach and continuity that I value. My medical school debt was a consideration, but I felt that practicing medicine the way I view the world was more important. What will your debt be upon graduating from medical school? My medical school debt will be a little over $200,000 when I graduate. What are a few of your strongest memories (good and/or bad) of medical school? I remember walking into anatomy lab with my scrubs and three-year-old tennis shoes with soles that had become

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get through, but this is also an amazing loose, exposing the structural material point in your life. Few have the experiences underneath that gnawed away at my heel. you will have and the knowledge you will The preservative and a heightened sense of gain. If that doesn’t work, then you can anticipation made the room heavy. The floor always bring on a smile when you think was neatly kept. The whiteboards had that about how water is also known as “wa wa,” day’s anatomical structures drawn on them, and how learning protein synthesis was with a sidebar of medical history trivia, and made better by YouTube videos (if you have the stainless steel boxes were waiting to be not seen it and have 13:23 minutes to opened. That was when it hit me: Medical spare, check out the “protein synthesis school was starting. dance” on YouTube). I am part of the Student National Medical Association, the oldest and largest If you were the medical school dean, how student-run organization focused on the would you change the medical school needs and concerns of medical students of experience? The University of Minnesota color. As it turns out, the University of Medical School experience has been great. Minnesota chapter is one of the most active The staff and professors are always present in terms of its members and community to answer questions and provide support in “Perhaps my biggest service and outreach opportunities. One of both the academic and personal aspects of the most memorable events was the middlesurprise is how much life. Something I thought was a great idea school portion of the premedical forum. I and would like to see more of is to have I love what I do, in was at one of the pathology stations and more clinical experiences incorporated into had 15 minutes with each group. I was terthe first two years of medical school. My ways I hadn’t expected.” rified. Everything I had learned, which was class is the first to go through the new curnot much at this point, had conveniently riculum, which includes clinical experience —Loie Lenarz, MD found its way out of my brain. My sympaearlier in medical school. I think that the U thetic nervous system kicked in—and in that of M is on the right track. It seems that seeexact moment, the kids came over. But it ing patients earlier and incorporating classturned out to be a blast. The kids were amazing, asking lots of room learning helps better solidify the knowledge base that is questions and showing real interest. needed in real practice. What advice would you give to students entering medical school? Don’t forget to enjoy medical school. There is an overwhelming amount of knowledge to be gained and many exams to

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MINNESOTA PHYSICIAN

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Med ed from cover them manage or overcome their medical problems. Sometimes we provide insight into why our jointly created prevention and treatment plan is important; at other times we diagnose and treat medical and mental conditions. The overall experience is still rewarding and a reason to be thankful to practice medicine. In my role as a teacher and administrator, I continue to see class after class of bright, energetic, idealistic medical students, residents, and fellows. My teaching colleagues and I remain excited about our daily job of helping them expand their knowledge and build new skills as they grow to their full potential in their medical careers. That challenge and responsibility are still before us every day. Also still with us are the challenges and frustrations of providing medical, dental, and mental health care services for underserved, undereducated, and disadvantaged citizens. These patients who have had poor access to education and

routine health services, those who have never experienced longitudinal family and community support, and those with chronic overlapping medical and behavioral health conditions are still often unable to find well-coordinated, accessible care. And those of us providing that care are usually struggling with underfunded systems of support. What’s different?

Student diversity: Our students, residents, and fellows are more diverse in ethnicity, and more women are joining the ranks of medicine. For the fifth year since 2001, women have outnumbered men in University of Minnesota Medical School, Twin Cities campus, entering class. Compared to medical students of the past, our current students have more international experience and are more willing to spend an added one or two years in medical school to gain research experience or earn a master’s degree in public health or business. Some spend a full additional year working for organizations serving the under-

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MINNESOTA PHYSICIAN OCTOBER 2012

served in Africa, India, Asia, or Latin America. They enter residencies with new skills, which stimulate their residencies to expand learning options for these talented residents. Teaching methods: Our teaching practices are better than in the past. We insist on more active supervision of all trainees, are more concrete about learning objectives in clinical settings, and use more simulations in teaching surgical and interviewing skills. Increasingly, we work more collaboratively with other disciplines, such as pharmacy, nursing, and a variety of mental health disciplines that help create interprofessional educational and clinical teams. In Minnesota, most family medicine residencies work from a base practice which is now a certified health-care home. Residents almost always work side by side with mental health clinicians, pharmacists, care managers, and social work staff. Therefore, current training is more often interdisciplinary, and the learning is more often in the direct line of patient care, providing information health professionals need when they need it, so they can deliver more effective and efficient care. Practice methods: I am encouraged that new patientcentered health care homes, complex care assessments, and interdisciplinary clinics are being created to meet the needs of the underserved; and that we are learning more about the important role of more efficient and effective interdisciplinary teams in doing so. New funding models are being tested, though balancing the need for highquality, accessible, coordinated care with available resources remains a formidable challenge. Electronic medical records (EMRs) were new to most of us a decade ago and only a distant fantasy 30 years ago. Now we can almost always find our past care notes, lab results, and consultants’ reports if we share access to the same record or can find compatible electronic methods of communication. In our digital age, we can also see images immediately and share them across distances. Unfortunately, one dimension of our

new electronic charts is that physicians and other providers often spend significant additional hours every week documenting all sorts of details, not just care plans, in the EMR. I am confident that this added task will become simplified and streamlined as we become more proficient. But after five or more years dealing with this challenge, I am among the most eager for improved documentation methods. I am eager to see more of the efficiency that is so often heralded in discussions of EMRs. At this point, the efficiency gain still comes at the expense of a longer workday for most physicians. In addition to changes in student diversity, teaching methods, practice models, and technology, I feel a new level of economic uncertainty about almost everything in health care and higher education. The tension over how to fund both health care and higher education in Minnesota and the nation has nearly always been present. But now these questions of how to achieve our educational and clinical missions with fewer resources seem to be coming to an inflection point where things we have often taken for granted must change. For example, can medical students at the University of Minnesota Medical School continue to carry an average debt of $170,000+ as a personal burden? Will we lose the middle-class students who have carried most of the weighty challenge of entering primary care and other less remunerative medical careers? For that matter, what will happen if other bright, dedicated college students cannot find entry-level jobs after earning their baccalaureate degrees? Past generations of premed students sometimes spent a year or two in graduate school earning more degrees and improving their probability of further advancement. Those options may become less viable as the added student debt passes a risky threshold equivalent to a home loan so early in a young professional’s life. Among the positive changes are new enthusiasm and graduMED ED to page 38


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Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied. CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dosedependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a comparator-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have subsequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with ontreatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebotreated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

20

MINNESOTA PHYSICIAN OCTOBER 2012

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other potentially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparatortreated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer. Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Event Term Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Upper Respiratory Tract Infection 9.5 5.6 Headache 9.1 9.3 Influenza 7.4 3.6 Urinary Tract Infection 6.0 4.0 Dizziness 5.8 5.2 Sinusitis 5.6 6.0 Nasopharyngitis 5.2 5.2 Back Pain 5.0 4.4 Hypertension 3.0 6.0 Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Placebo + Glimepiride + Metformin N = 724 Metformin N = 121 Metformin N = 242 (%) (%) (%) Adverse Event Term Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial All Victoza® + Placebo + Glimepiride Rosiglitazone + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Event Term Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2


Victoza® (liraglutide [rDNA origin] injection) Rx Only BRIEF SUMMARY. Please consult package insert for full prescribing information. WARNING: RISK OF THYROID C-CELL TUMORS: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Victoza® causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as human relevance could not be ruled out by clinical or nonclinical studies. Victoza® is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Based on the findings in rodents, monitoring with serum calcitonin or thyroid ultrasound was performed during clinical trials, but this may have increased the number of unnecessary thyroid surgeries. It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate human risk of thyroid C-cell tumors. Patients should be counseled regarding the risk and symptoms of thyroid tumors [see Contraindications and Warnings and Precautions]. INDICATIONS AND USAGE: Victoza® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Important Limitations of Use: Because of the uncertain relevance of the rodent thyroid C-cell tumor findings to humans, prescribe Victoza® only to patients for whom the potential benefits are considered to outweigh the potential risk. Victoza® is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise. In clinical trials of Victoza®, there were more cases of pancreatitis with Victoza® than with comparators. Victoza® has not been studied sufficiently in patients with a history of pancreatitis to determine whether these patients are at increased risk for pancreatitis while using Victoza®. Use with caution in patients with a history of pancreatitis. Victoza® is not a substitute for insulin. Victoza® should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of Victoza® and insulin has not been studied. CONTRAINDICATIONS: Victoza® is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). WARNINGS AND PRECAUTIONS: Risk of Thyroid C-cell Tumors: Liraglutide causes dosedependent and treatment-duration-dependent thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Victoza® will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors could not be determined by clinical or nonclinical studies [see Boxed Warning, Contraindications]. In the clinical trials, there have been 4 reported cases of thyroid C-cell hyperplasia among Victoza®-treated patients and 1 case in a comparator-treated patient (1.3 vs. 0.6 cases per 1000 patient-years). One additional case of thyroid C-cell hyperplasia in a Victoza®-treated patient and 1 case of MTC in a comparator-treated patient have subsequently been reported. This comparator-treated patient with MTC had pre-treatment serum calcitonin concentrations >1000 ng/L suggesting pre-existing disease. All of these cases were diagnosed after thyroidectomy, which was prompted by abnormal results on routine, protocol-specified measurements of serum calcitonin. Four of the five liraglutide-treated patients had elevated calcitonin concentrations at baseline and throughout the trial. One liraglutide and one non-liraglutide-treated patient developed elevated calcitonin concentrations while on treatment. Calcitonin, a biological marker of MTC, was measured throughout the clinical development program. The serum calcitonin assay used in the Victoza® clinical trials had a lower limit of quantification (LLOQ) of 0.7 ng/L and the upper limit of the reference range was 5.0 ng/L for women and 8.4 ng/L for men. At Weeks 26 and 52 in the clinical trials, adjusted mean serum calcitonin concentrations were higher in Victoza®-treated patients compared to placebo-treated patients but not compared to patients receiving active comparator. At these timepoints, the adjusted mean serum calcitonin values (~ 1.0 ng/L) were just above the LLOQ with between-group differences in adjusted mean serum calcitonin values of approximately 0.1 ng/L or less. Among patients with pre-treatment serum calcitonin below the upper limit of the reference range, shifts to above the upper limit of the reference range which persisted in subsequent measurements occurred most frequently among patients treated with Victoza® 1.8 mg/day. In trials with on-treatment serum calcitonin measurements out to 5-6 months, 1.9% of patients treated with Victoza® 1.8 mg/day developed new and persistent calcitonin elevations above the upper limit of the reference range compared to 0.8-1.1% of patients treated with control medication or the 0.6 and 1.2 mg doses of Victoza®. In trials with ontreatment serum calcitonin measurements out to 12 months, 1.3% of patients treated with Victoza® 1.8 mg/day had new and persistent elevations of calcitonin from below or within the reference range to above the upper limit of the reference range, compared to 0.6%, 0% and 1.0% of patients treated with Victoza® 1.2 mg, placebo and active control, respectively. Otherwise, Victoza® did not produce consistent dose-dependent or time-dependent increases in serum calcitonin. Patients with MTC usually have calcitonin values >50 ng/L. In Victoza® clinical trials, among patients with pre-treatment serum calcitonin <50 ng/L, one Victoza®-treated patient and no comparator-treated patients developed serum calcitonin >50 ng/L. The Victoza®-treated patient who developed serum calcitonin >50 ng/L had an elevated pre-treatment serum calcitonin of 10.7 ng/L that increased to 30.7 ng/L at Week 12 and 53.5 ng/L at the end of the 6-month trial. Follow-up serum calcitonin was 22.3 ng/L more than 2.5 years after the last dose of Victoza®. The largest increase in serum calcitonin in a comparator-treated patient was seen with glimepiride in a patient whose serum calcitonin increased from 19.3 ng/L at baseline to 44.8 ng/L at Week 65 and 38.1 ng/L at Week 104. Among patients who began with serum calcitonin <20 ng/L, calcitonin elevations to >20 ng/L occurred in 0.7% of Victoza®-treated patients, 0.3% of placebotreated patients, and 0.5% of active-comparator-treated patients, with an incidence of 1.1% among patients treated with 1.8 mg/day of Victoza®. The clinical significance of these findings is unknown. Counsel patients regarding the risk for MTC and the symptoms of thyroid tumors (e.g. a mass in the neck, dysphagia, dyspnea or persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with Victoza®, if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation. Pancreatitis: In clinical trials of Victoza®, there were 7 cases of pancreatitis among Victoza®-treated patients and 1 case among comparator-treated patients (2.2 vs. 0.6 cases per 1000 patient-years). Five cases with Victoza® were reported as acute pancreatitis and two cases with Victoza® were reported as chronic pancreatitis. In one case in a Victoza®-treated patient,

pancreatitis, with necrosis, was observed and led to death; however clinical causality could not be established. One additional case of pancreatitis has subsequently been reported in a Victoza®-treated patient. Some patients had other risk factors for pancreatitis, such as a history of cholelithiasis or alcohol abuse. There are no conclusive data establishing a risk of pancreatitis with Victoza® treatment. After initiation of Victoza®, and after dose increases, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting). If pancreatitis is suspected, Victoza® and other potentially suspect medications should be discontinued promptly, confirmatory tests should be performed and appropriate management should be initiated. If pancreatitis is confirmed, Victoza® should not be restarted. Use with caution in patients with a history of pancreatitis. Use with Medications Known to Cause Hypoglycemia: Patients receiving Victoza® in combination with an insulin secretagogue (e.g., sulfonylurea) may have an increased risk of hypoglycemia. In the clinical trials of at least 26 weeks duration, hypoglycemia requiring the assistance of another person for treatment occurred in 7 Victoza®-treated patients and in two comparator-treated patients. Six of these 7 patients treated with Victoza® were also taking a sulfonylurea. The risk of hypoglycemia may be lowered by a reduction in the dose of sulfonylurea or other insulin secretagogues [see Adverse Reactions]. Renal Impairment: Victoza® has not been found to be directly nephrotoxic in animal studies or clinical trials. There have been postmarketing reports of acute renal failure and worsening of chronic renal failure, which may sometimes require hemodialysis in Victoza®-treated patients [see Adverse Reactions]. Some of these events were reported in patients without known underlying renal disease. A majority of the reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration [see Adverse Reactions]. Some of the reported events occurred in patients receiving one or more medications known to affect renal function or hydration status. Altered renal function has been reversed in many of the reported cases with supportive treatment and discontinuation of potentially causative agents, including Victoza®. Use caution when initiating or escalating doses of Victoza® in patients with renal impairment. Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Victoza® or any other antidiabetic drug. ADVERSE REACTIONS: Clinical Trials Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of Victoza® was evaluated in a 52-week monotherapy trial and in five 26-week, add-on combination therapy trials. In the monotherapy trial, patients were treated with Victoza® 1.2 mg daily, Victoza® 1.8 mg daily, or glimepiride 8 mg daily. In the add-on to metformin trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or glimepiride 4 mg. In the add-on to glimepiride trial, patients were treated with Victoza® 0.6 mg, Victoza® 1.2 mg, Victoza® 1.8 mg, placebo, or rosiglitazone 4 mg. In the add-on to metformin + glimepiride trial, patients were treated with Victoza® 1.8 mg, placebo, or insulin glargine. In the add-on to metformin + rosiglitazone trial, patients were treated with Victoza® 1.2 mg, Victoza® 1.8 mg or placebo. Withdrawals: The incidence of withdrawal due to adverse events was 7.8% for Victoza®-treated patients and 3.4% for comparatortreated patients in the five controlled trials of 26 weeks duration or longer. This difference was driven by withdrawals due to gastrointestinal adverse reactions, which occurred in 5.0% of Victoza®-treated patients and 0.5% of comparator-treated patients. The most common adverse reactions leading to withdrawal for Victoza®-treated patients were nausea (2.8% versus 0% for comparator) and vomiting (1.5% versus 0.1% for comparator). Withdrawal due to gastrointestinal adverse events mainly occurred during the first 2-3 months of the trials. Tables 1, 2 and 3 summarize the adverse events reported in ≥5% of Victoza®-treated patients in the six controlled trials of 26 weeks duration or longer. Table 1: Adverse events reported in ≥5% of Victoza®-treated patients or ≥5% of glimepiride-treated patients: 52-week monotherapy trial All Victoza® N = 497 Glimepiride N = 248 (%) (%) Adverse Event Term Nausea 28.4 8.5 Diarrhea 17.1 8.9 Vomiting 10.9 3.6 Constipation 9.9 4.8 Upper Respiratory Tract Infection 9.5 5.6 Headache 9.1 9.3 Influenza 7.4 3.6 Urinary Tract Infection 6.0 4.0 Dizziness 5.8 5.2 Sinusitis 5.6 6.0 Nasopharyngitis 5.2 5.2 Back Pain 5.0 4.4 Hypertension 3.0 6.0 Table 2: Adverse events reported in ≥5% of Victoza®-treated patients and occurring more frequently with Victoza® compared to placebo: 26-week combination therapy trials Add-on to Metformin Trial All Victoza® + Placebo + Glimepiride + Metformin N = 724 Metformin N = 121 Metformin N = 242 (%) (%) (%) Adverse Event Term Nausea 15.2 4.1 3.3 Diarrhea 10.9 4.1 3.7 Headache 9.0 6.6 9.5 Vomiting 6.5 0.8 0.4 Add-on to Glimepiride Trial All Victoza® + Placebo + Glimepiride Rosiglitazone + Glimepiride N = 695 N = 114 Glimepiride N = 231 (%) (%) (%) Adverse Event Term Nausea 7.5 1.8 2.6 Diarrhea 7.2 1.8 2.2

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MINNESOTA PHYSICIAN

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PROFESSIONAL

T

here is broad consensus that abuse of alcohol and drugs is responsible, to a significant degree, for traffic accidents, street crimes, transmissions of infectious diseases, instances of child abuse and neglect, danger in the workplace, and the excessive use of medical services. Indeed, probably every physician, whether knowingly or not, has treated many patients who are addicted to drugs or alcohol. Yet, despite recent calls for screening and better management of these patients, drug addiction often goes undetected and untreated in most medical settings. We know that drug addiction, cigarette smoking, and alcohol in particular are associated with medical comorbidity and premature death. In recent years we have seen a rise in addiction to physician-prescribed opioids and respiratory suppression deaths from opiate overdoses. There are effective medications that physicians can prescribe to reduce or stop a patient’s consumption of addict-

U P D AT E :

ADDICTION

MEDICINE

Treating drug and alcohol addictions Diagnosis, medications— and the physician’s role By Lee H. Beecher, MD, FAPA, FASAM

ing drugs/alcohol. This article highlights some of these medications, reviews issues in diagnosing and treating these addictions, and notes ways that physicians can become better trained in addiction medicine. The causes of drug addiction

What causes drug addiction? The addiction behavior pattern is caused by an alteration in brain chemistry, which, in turn, is caused by exposure to addictive drugs. Current scientific thinking postulates a common neuronal pathway involving brain reward centers in the ventral tegmentum involving the neurotransmitter dopamine. Most symptoms and signs of

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drug intoxication and withdrawal vary greatly depending on the particular drugs involved. Evaluation and treatment

Best practices for treatment of patients with drug and alcohol addictions are patient-centered, bio-psycho-social approaches. The first task is to identify an addiction pattern and gain the patient’s trust. Then, one needs to motivate and support the patient in a plan to abstain from the drug(s) of addiction and avoid drug acquisition. Treatment usually means breaking the pattern of seeking out the addictive substance(s) and abstaining from their use. To thwart continuing addiction, patients must accept responsibility for implementing what strategies work for them and avoiding what doesn’t. The doctor provides ongoing expertise and support in this effort. Evidence-based treatments

Most physicians are familiar with abstinence-based treatments that parallel the 12 Steps of Alcoholics Anonymous or Narcotics Anonymous (AA or NA) and are featured by most Minnesota chemical dependency treatment centers and programs. Although there is evidence that some student binge drinkers can learn how to modify their drinking patterns and thus avoid the addiction pattern, in general, abstinence from drugs of abuse is necessary in order for patients to control and stop addiction. Diagnosing addiction

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MINNESOTA PHYSICIAN OCTOBER 2012

The diagnosis of an alcohol or drug addiction pattern follows the mnemonic CCC, R+D, which is based on criteria for drug dependency listed in the Diagnostic and Statistical

Manual of Mental Disorders (DSM IV) of the American Psychiatric Association, and the American Medical Association’s definition of alcoholism. CCC, R+D translates as:

• Inability to Control or stop use of the drug or drugs. • Compulsive use of the drug. • Bad Consequences, which significantly impair physical and mental health, social relationships, and result in work and legal problems. Very often the three C’s are accompanied by Rationalization (“I can stop anytime ... I’ll quit tomorrow”) and Denial (“I don’t have a problem ... I am not an addict”). The chief complaint

There is almost always distress and expressed concern about the patient’s behavior and safety from the patient, family members, workmates, and/or others who are close to and familiar with the situation. Increasingly, patients come to evaluation or treatment from law enforcement, an employer, or another source. Since addiction is always to one degree or another a problem for those close to the patient, concerned others should be brought into the clinical evaluation. They are a potential support network for ongoing care and a vital resource of information for accurate diagnoses. Physicians should strongly recommend that the patient’s significant other(s) be asked to participate, not only to make an accurate diagnosis, but also so that the doctor (and patient) can understand the patient’s real world. A hallmark of drug dependency (which also occurs in most addicts) is a physiological withdrawal reaction, the symptoms and physical signs of which appear when the drug is removed. Patients should be advised on how to step down doses of prescribed medications to avoid withdrawal from benzodiazepines, sleeping pills, corticosteroids, opioids, and antidepressants. Common drugs of addiction

After tobacco, the most common drug of addiction is alco-


hol. Marijuana, cocaine, methamphetamine, opioid pain medications (e.g., Vicodin, OxyContin, Percocet, and morphine), and heroin are also common drugs of addiction. Hallucinogenic drugs such as LSD, Ecstasy, and synthetic â&#x20AC;&#x153;bath saltsâ&#x20AC;?are less addicting, but they may cause profound distortions in mental functioning, which require psychiatric consultation and hospitalization. Treatment goals: harm reduction and abstinence

Most people with serious addiction problems benefit most from work geared toward staged, individualized, behavioral goals. Substantial research shows that brain changes associated with addiction may persist for years following cessation of drug use. Abstinence from drugs of abuse does generally improve brain functioning. So, in fact, harm reduction and abstinence from the drugs of concern are dual and compatible treatment goals. There are usually behavioral deficits in life skills for the addict to overcome and work on. Treatment of addiction, like the treatment of many other illnesses, is geared to helping patients develop effective and rewarding self-management strategies over the long term. Celebration of life achievements is key to recovery. Many patients benefit from active participation in 12-step recovery or other selfhelp programs augmented by physician encouragement. Medications used in drug addiction treatment

Except for emergency acute care, I advise that medications for addictions be prescribed only when a doctor and patient have an ongoing relationship and they both agree that the patient should abstain from certain drugs. There are a number of medications that may reduce a patientâ&#x20AC;&#x2122;s craving to use alcohol and/or drugs. Most patients will report the urge or thought to use previous drugs of addiction. Decreasing reported cravings or fantasies to use are important monitors of medication effectiveness. Urine drug

screening should be employed as clinically appropriate. As a general rule, physicians need to be available and accessible to the patient and his or her support network so as to collaboratively monitor and adjust the plan of care. Familiarity with psychotherapy techniques is a real plus for prescribers. Medication cost and formulary availability are always a consideration for gauging patient medication adherence. We should ask the patient: How much do you pay for medication at the pharmacy? Medications to treat alcohol addiction

There are at least three evidence-based medications that decrease alcohol drinking: Disulfiram (Antabuse). Patients taking disulfiram (125â&#x20AC;&#x201C;250 mg) on a daily basis will get sick if they drink alcoholâ&#x20AC;&#x201D;with vomiting, facial flushing, and headache rapidly ensuing. Disulfiram works by interfering with the catabolism of alcohol with acetaldehyde causing the toxic reaction. Three decades of clinical experience and numerous field studies show that disulfiram taken daily is very effective for selected individuals over extended periods of time. Daily compliance (adherence) in taking disulfiram is greatly enhanced when a spouse, significant other, or clinicianmonitor visually and personally supports the patientâ&#x20AC;&#x2122;s daily decision to take disulfiram (Antabuse). Relapse to alcohol drinking ensues in most disulfiram cases in the absence of monitoring and psychosocial support, such as AA and/or ongoing psychotherapy geared to promoting abstinence. I would advise physicians not to prescribe disulfiram for alcoholic patients with current active problem drinking or those who are new to addiction treatment or recovery. Naltrexone (Revia, Trexan) is an orally administered opioid antagonist that blocks endogenous opioid brain receptors, which are stimulated by alcohol consumption. Revia was approved by the FDA in 1994, and more than 20 field studies

show a modest but statistically significant effect on reducing alcohol cravings. Compliance in taking the medication has been a problem. An injectable form of naltrexone (Vivatrol), approved by the FDA in 2006, provides clinically effective blood levels of naltrexone for 30 days. Acamprosate (Campral) was approved by the FDA in 2004 for the purpose of curbing cravings and return to alcohol abuse. Acamprosate works on brain neuronal receptors differently than does naltrexone. Clinical trials have shown, for most patients, only a modest benefit in reducing alcohol cravings. Neither acamprosate nor naltrexone has proved to be a potent strategy to thwart alcoholism. A recent comprehensive clinical trial (Anton RF et al., JAMA 295(17), 2006) showed that orally administered naltrexone barely beat placebo, and acamprosate was little more effective than placebo.

Medications for opioid addiction

The following three medications have robust evidence supporting their medical use in combating opioid (opiate) addiction. Methadone. This synthetic opioid is a replacement therapy for heroin, morphine, Vicodin, OxyContin, and other opioid drugs that can cause opioid addiction. Methadone has a long half-life, slow onset of action, and can be administered orally. Over 30 years of studies support its effectiveness in reducing opioid addiction, crime, and the spread of infections associated with heroin dependence. Methadone administration is regulated by the federal government, and patients must attend a methadone clinic. For locations of clinics in Minnesota, go to www.methadonecliniclocator. com/methadone_clinics_in_ minnesota.html. Buprenorphine (Suboxone).

In 2002, the FDA approved the use of buprenorphine for treating opioid dependence in genADDICTIONS to page 27

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OCTOBER 2012

MINNESOTA PHYSICIAN

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ADDICTION

Prescription drug abuse

P

ills. It seems everywhere we go, we’re surrounded by people selling them, buying them, or consuming them. Modern America is awash in pills. Schoolchildren line up outside the nurses office at lunchtime to get their “meds.” At parties and in libraries, people nonchalantly share pills to help them party hearty or study longer. In homes, children watch their parents, siblings, or grandparents take their daily pills with their morning orange juice. Mothers at shopping malls rummage through their purses until they find the prescription bottle. In restaurants over lunch, harried businesspeople casually pop a prescription medication, barely missing a beat in the conversation. Advances in medical science seek to improve the quality of life, prevent and arrest disease, and reduce suffering, which precipitates more medications, supplements, and vitamins than ever. In pursuit of a healthier, pain-free life, more and more people are using prescription

What health care professionals need to know By Carol Falkowski medications not as medically directed, but recreationally, for their psychoactive effects. This is now a problem of epidemic proportion, nationally and in Minnesota. Those of us in the addiction field have long known that drug abusers and addicts will use whatever substances they can get their hands on. Today prescription medications are part of that mix. In 2010, roughly 7 million people age 12 and older—2.7 percent of the U.S. population— were current users (past 30-day use) of psychotherapeutic drugs taken nonmedically (National Survey on Drug Use and Health, 2010). The medications most commonly abused were:

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MEDICINE

MINNESOTA PHYSICIAN OCTOBER 2012

• pain relievers—5.1 million users • tranquilizers—2.2 million users • stimulants—1.1 million users • sedatives—0.4 million users According to the same survey, abuse of prescription drugs was highest among young adults 18 to 25 years of age, with 5.9 percent reporting use in the past month. Each year since 2002 has seen another 2 million or more users of new nonmedical pain relievers, including over 500,000 who initiated use without ever having used an illicit drug. Eight percent of high school seniors reported nonmedical use of Vicodin in the past year; 6.5 percent reported Adderall abuse; and 4.9 percent reported OxyContin abuse. Of note, 70 percent of the high school seniors who used prescription medications reported acquiring them from friends or relatives for free. Contrary to popular belief, online purchases were negligible (2011 Monitoring the Future Survey). Risks and consequences

Prescription opiates have high abuse potential, high addictive potential, and high overdose potential. Depressants used for anxiety and sleep disorders can produce seizure-inducing withdrawal if tapered too rapidly. Both opiates and depressants can cause severe, sometimes fatal, respiratory depression, especially when used in combination with other medications or alcohol. Effects of stimulant abuse include psychosis, seizures, addiction, and cardiovascular complications. Many people who initially abuse prescription narcotics eventually cross over and start using heroin. Why? Because heroin produces the same effects and is cheaper. In the Twin

Cities, heroin has never been so cheap, pure, and readily available. Diverted prescription narcotics typically sell for $1 per milligram, whereas heroin sells for less—in Minneapolis, for as little as 25 cents per pure milligram. According to the Heroin Domestic Monitor Program of the U.S. Drug Enforcement Administration, in 2007, 2008, and 2009, Minneapolis had the highest purity heroin sold at the lowest cost of all 19 U.S. cities with Mexican heroin. From 2001 to 2010, prescription opiate dependence rose from 936,000 to 1.4 million people. In 2010, most of these people were 26 or older (56.6 percent), but about one-third (463,000) were between 18 and 25 years of age (2010 National Survey on Drug Use and Health). From 2002 to 2010, the number of people receiving addiction treatment services for prescription opiate dependence more than doubled, from 199,000 to 406,000. In 2010, 65.7 percent were 26 or older, and 25.9 percent were 18 to 25 years old. Prescription opiate overdoses resulted in nearly 15,000 deaths in the U.S. in 2008. This is more than three times the number of deaths in 1999, and more than the number of deaths from heroin and cocaine combined. In 2011, the U.S. Centers for Disease Prevention and Control (CDC) reported that nonmedical use of prescription opiates costs health insurers up to $72.5 billion annually in direct health care costs. Local snapshot of opiate addiction

In Hennepin County and Ramsey County combined, opiate-related deaths rose from 92 in 2010 to 120 in 2011, a 30.4 percent increase. And in 2011, in an unprecedented development, heroin and other opiates accounted for just over 20 percent of admissions to addiction treatment programs in the Twin Cities, second only to treatment admissions for alcohol. Heroin users, in particular, were quite young. In 2011, 41.6 percent of the 2,223 heroin admissions to addiction treat-


Identifying “doctor-shoppers” ment programs in the Twin Cities were for people 18 to 26 years of age. Of the 1,987 treatment admissions for “other opiates,” mostly prescription narcotics, 27 percent were in that age group. The most common route of administration was oral (65.8 percent), followed by snorting (15.3 percent) and injection (12.1 percent). What’s behind this trend?

The rising tide of prescription drug abuse is, in part, a logical outgrowth of the larger culture in which we live. Again: We are awash in pills. Watching television, we hear about all sorts of prescription drugs and why we need them. Direct-to-consumer advertising of prescription medications implies that there may be a pill for whatever ails you: Just ask your doctor. Well, apparently people have asked—and the doctors have answered. From 1997 to 2011, the number of prescriptions for opioid analgesics increased from 100 million to 210 million annually, and for stimulants, from 16 million to

Physicians and their office staffs need to better identify drug addicts and drug dealers in order to help reverse the growth in prescription drug abuse. As a first step, enroll in the Minnesota Prescription Monitoring Program. Then, become familiar with the behaviors and modus operandi of drug seekers that are summarized below. • Exhibits unusual behavior in the waiting room • Must be seen right away: overly assertive, demanding immediate attention • Shows up or requests an appointment at end of, or after office hours • Is reluctant to provide reference information • Often has no regular doctor or health insurance, or states primary doctor is unavailable • Claims to be passing through town, not a permanent resident. • Claims a prescription has been lost or stolen • Gives medical history with textbook symptoms or is overly vague about medical history • Has no general interest in the diagnosis; fails to follow through on future diagnostic tests or consult another practitioner. • Feigns physical pain (migraines, back pain, kidney stones) in an

• •

effort to obtain narcotics Feigns psychological problems (anxiety, insomnia, depression) to obtain CNS stimulants or depressants May utilize a child when seeking methylphenidate or an elderly person when seeking pain medication Pressures practitioner by eliciting sympathy or guilt, or by direct threats May possess unusual knowledge of controlled substance or specific drugs and drug effects Requests refills too soon after original prescription Often requests a specific drug by name and will accept no substitutes May exhibit cutaneous signs of drug abuse: skin tracks or scars on neck, forearm, foot, wrist, or ankle, or inflamed lesions or “pop” scars from subcutaneous injections

[Source: Falkowski, Carol L., “Prescribe with caution: The rising tide of prescription drug abuse,” Minnesota Physician 16(5), August 2002.]

45 million (SDI Vector One®: National [VONA]). In our pill-saturated culture, most people are quite familiar and comfortable with various medications because they are already part of their everyday life. As a consequence, few people perceive the actual risks. Medications that come from a doctor, they reason, must be safe—whether the pills are used “as directed” or not. Reminders to physicians

How do we navigate our way out of this problem? While law enforcement, prescription monitoring programs, drug take-back (disposal) programs, and public education play major roles, physicians—the prescribers—are at the core of this issue. More than 80 percent of Americans saw a health care professional last year. Clearly, physicians are uniquely positioned to help reverse this dangerous drug abuse trend. They can make an enormous difference. Below are some reminders for physicians vis-à-vis their role DRUG ABUSE to page 26

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Drug abuse from page 25 as prescribers. Learn to better identify “doctor-shoppers” (see sidebar). Because people addicted to prescription narcotics require greater and greater amounts to achieve the same effects and because there is a great deal of money to be made from the diversion of opiates into street markets, more people are going to extreme lengths to obtain scheduled narcotics. Therefore, physicians need to learn to identify patients who may be seeking prescriptions because they are addicted themselves or are acquiring them to sell to others. Start using Minnesota’s Prescription Monitoring Program. This program (www. pmp.pharmacy.state.mn.us/), operated by the Minnesota Board of Pharmacy, is a handy and effective tool that identifies individuals engaged in doctorshopping. Sign up now if you haven’t already. Take extra care in prescribing. As always, physicians need to prescribe only the quantity of painkillers required for the

expected duration of the pain. For patients on pain medications long-term, consider using patient-provider agreements combined with ongoing urine drug tests. Learn how to talk with patients about medications of their own and those for their family members. And if possible, try to spend some solo time with adolescent patients to hear their particular concerns without parents hovering about. Screen for substance abuse. Another vital element is to incorporate screening for substance abuse and mental health problems into primary practice. Primary care practices routinely screen for other chronic diseases with behavioral components such as hypertension, asthma, and diabetes, but not for addiction. Few physicians confidently identify, much less discuss, high-risk drinking and drugging behavior, because they lack formal training and because they know that some people achieve recovery without the help of medical professionals at all. As a result, substance-use disorders are typically addressed

only when the disease is well advanced and, even then, often by a referral to an external, specialty clinic. There are science-based screening tools and other valuable resources to assist physicians in addressing a broad range of substance-abuse and addiction-related issues. Developed by the National Institutes of Health, these tools can be found online at the following websites: • http://pubs.niaaa.nih.gov /publications/clinicianGuide /guide/intro/index.htm This state-of-the-art educational course, which offers CME credits, is a clinician’s guide to addressing drinking behaviors as part of clinical practice; it was developed by Mark Willenbring, MD, and the National Institute on Alcohol Abuse and Alcoholism. • http://www.drugabuse.gov/ medical-health-professionals Sponsored by the National Institute on Drug Abuse, this website is the gateway to tools and resources that assist health care providers in identifying

drug use early and referring patients to treatment. Offer opiate addiction treatment. Finally, consider expanding your practice to include treatment of opiate addiction. The Drug Addiction Treatment Act of 2000 allowed qualified physicians, for the first time, to prescribe narcotic medications (Schedules III to V) for the treatment of opioid addiction. In 2002 the FDA approved Subutex (buprenorphine) and Suboxone tablets (buprenorphine/naloxone), making them the first medications to be eligible for prescribing under that act. Since then, nearly 10,000 physicians have taken the training needed to prescribe these two medications. Consider becoming one of them. In Minnesota, the need has never been greater. Carol Falkowski is author of the reference book “Dangerous Drugs: An Easy-toUse Reference for Parents and Professionals.” She has participated in a 20-member, nationwide drug abuse epidemiological surveillance network of the National Institute on Drug Abuse since 1986.

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Addictions from page 23 eral medical practice outpatient settings, when administered by physicians who have completed a brief educational course for certification by the FDA. Buprenorphine is both an agonist and antagonist at the mu opioid receptor and has a different mode of action than methadone, with little danger of overdose. In inpatient detoxification settings, buprenorpine is used to stabilize patients who have withdrawn from heroin and other opioids of addiction, but unlike methadone, buprenorphine can be administered in a physician’s office. I have been prescribing buprenophine for seven years. Many patients tell me it does not impair their mental functioning and they are able to regain employment and social functioning without frequently attending a methadone clinic. Urine drug screens to rule out concomitant drug use are a necessary component of care for these patients. A combination product (Suboxone) combines buprenorphine with the opioid antagonist naloxone as a sublin-

gual tablet or filmstrip to obviate IV use and diversion. Patients genuinely appreciate the opportunity to use buprenorphine or Suboxone to suppress their cravings for heroin and opioid pain medications. They are seen as “regular” patients in the office setting, report few if any mental impairments from the medication, and do not experience a “high” as some patients do with methadone. Most Minnesota third-party payers will cover buprenorphine or Suboxone. Some abstinencebased chemical dependency programs view buprenorphine and methadone as substituting a drug of dependency for a drug of addiction. Some programs will prescribe small amounts of Suboxone at discharge from detoxification units or rehabilitation for patients placed on buprenorphine during their detox or inpatient stays; but. unfortunately, when patients run out of medication, they often relapse to opioid drug addiction. For online information and access to the national registry of buprenorphine

providers, go to www. buprenorphine.samhsa.gov/ bwns_locator (the SAMHSA Buprenorphine Physician & Treatment Program Locator). Naltrexone (see above). Naltrexone is an orally administered opioid antagonist that blocks opioid effects for 48 to 72 hours. When given to a patient who has opioid in his or her system, naltrexone will produce immediate opioid withdrawal. Symptoms of opioid withdrawal include nausea, sweating, diarrhea, and restlessness. Most addicts will go to great lengths to avoid the unpleasant withdrawal symptoms and signs, although opioid withdrawal is not life threatening. Naltrexone shuts down pain mitigation and euphoria in opioid drug users. Therefore, compliance with naltrexone is generally poor in addicts, unless there are significant additional requirements for them to maintain complete abstinence, such as a directive from a professional licensure board. Long-acting injectable naltrexone is available for selected populations.

Needed: Physician expertise

Substance-related disorders are very common. Patients will clearly benefit from increased physician familiarity and expertise in diagnosing and treating these disorders. Physicians, we need more of you! Get training in addiction medicine. The American Society of Addiction Medicine (ASAM) offers excellent courses and a pathway via written examination to be certified by ASAM; more information is available at the ASAM website, www.ASAM.org. Minnesota also has a local chapter of ASAM called MNASAM. Transcripts of monthly MNASAM journal club sessions since 2007 are available at www.mnasam.org/. Lee H. Beecher, MD, FAPA, FASAM, is an adjunct professor of psychiatry at the University of Minnesota, practices psychiatry and addiction psychiatry in St. Louis Park, and is president of the Minnesota Physician-Patient Alliance (www.physician-patient.org). He is secretary-treasurer of the Minnesota chapter of the American Society of Addiction Medicine.

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MEDICAL

D

FACILITIES

Does scale matter?

oes the physical size and scale of a hospital contribute to or compromise the quality of patient expeCompetition spurs rience and the effectiveness of “smaller is better” hospital design patient care? Many modern health-care By Meredith Hayes Gordon, MArch, Associate AIA, LEED AP BD+C environments utilize an industrialized model to focus on effidence that the next handoff will several stories tall, and disconciencies and throughputs. provide the necessary informanected entries make it difficult Endemic to that model is the tion and background. The to find your way on these large concept of “economies of scale,” patient is a number rather than health-care campuses. Parking the assumption that increasing a familiar face. often is scarce and a long way volume leads to better outcomes from the destination. Any social from specialization, leveraged Challenging the connection to the surrounding costs, increased revenue, and a bigger-is-better assumption community has long since been better bottom line. The health lost as the scale of these faciliThis large-scaled, high-volume, care industry, like many other ties has overtaken the original industrially modeled assemblyindustries, has swung in favor of neighborhood. line approach to hospital care is large-scale operations that proBigger hospitals, by their finally being challenged. Small, vide the benefits of efficiencies nature, specialize and subdivide appropriately scaled health care and consolidation of resources. into numerous departments and that integrates into the commuFor patients, there may indeed specialty centers out of the need nity it serves is growing in popube some advantages to finding to make the hospital more manlarity. Economic and demoan endless array of specialty ageable. Caregiving teams pass graphic factors, among others, care in a single location, but patients off from department to have renewed interest in conoften the disadvantages far outdepartment, from shift change structing smaller health care weigh the convenience. to shift change, from one unionfacilities. The economic recesBigger may not always be defined work category to an sion has forced systems and better in the delivery of care for other. Patients experience feelinstitutions to think on a limited the average patient. Large hospiings of anonymity and disconscale with limited resources. tals are confusing and scary to nected care, and a lack of confiAnother growing concern in many of us. Multiple buildings,

Psychiatrist 40 Hour Work Week The Federal Medical Center, Rochester, MN, is an accredited Joint Commission medical and behavioral health referral center for the Federal Bureau of Prisons. Psychiatrists work closely with a multi-disciplinary team consisting of health care, mental health care, social work, rehabilitation services, and correctional professionals to provide diagnostic and treatment services to federal inmates. The Federal Bureau of Prisons, Health Services Division, is committed to providing evidence-based medical and psychiatric treatment and has a national impact through the development of comprehensive medical and psychiatric clinical guidelines. The Federal Bureau of Prisons offers a competitive salary and benefits package. The Federal Bureau of Prisons is an Equal Opportunity Employer.

Contact: Lynn Platte, Assistant Human Resource Manager lplatte@bop.gov or call (507) 424-7521

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MINNESOTA PHYSICIAN OCTOBER 2012

health care delivery is the aging population; older patients require easily accessible care in an easy-to-comprehend setting, something a large complex specialty care institution has difficulty providing. In addition, the highly uncertain future of health care reform and how it could change the delivery and motivations of care are pushing health systems to consider flexible spaces that can easily morph to accommodate such changes. There are many other benefits to smaller scale that a growing number of health systems are recognizing. One such health system is the large nonprofit health plan and care provider Kaiser Permanente, headquartered in California. A year and a half ago, Kaiser launched the “Small Hospital, Big Idea” competition to design a small hospital. Kaiser had mastered the art of providing care on a large scale with a number of 300-bed hospitals around the country, but their attempts at shrinking that model for a smaller community had been far less successful.

Medical Director Minnesota Veterans Home – Minneapolis Salary Range: $ 146,536 - $ 219,344 annually JOIN OUR TEAM – PROUDLY SERVING THOSE WHO HAVE SERVED The Minnesota Veterans Home - Minneapolis recognizes the great courage of the individuals who fought for our freedom. Our facility has been providing care to Veterans since 1887. Our beautiful and historic campus is located on 51 wooded acres overlooking the Mississippi River. We provide skilled care and boarding for veterans. Free parking is available and we’re easily accessible by bus, car or light rail transit. The Medical Director is responsible for the planning, development, direction and management of all direct resident services and for the overall quality of care and treatment throughout the facility; assures that medical and clinical services are provided and administered according to federal and state requirements and professional standards and regulations, through the supervision of the staff physicians in carrying out their position responsibilities; provides medical leadership for research and training and innovative program development and activities in long-term care. This is a permanent, full-time vacancy, working Monday through Friday, daytime business hours. Qualifications: Board certified by a National Medical Specialty Board; Two years of medical practice in a nursing home; Managerial, technical and interpersonal skills; Knowledge of all contemporary modes of treatment likely to be used, as well as informed and up to date regarding administrative policies and practices; State of MN medical license; MN Board Certified; Must be able to pass MN Background study. GREAT BENEFITS PACKAGE! The State of Minnesota offers a comprehensive benefits package including low cost medical and dental insurance, employer paid life insurance, short and long term disability, pre-tax flexible spending accounts, retirement plan, tax-deferred compensation, generous vacation and sick leave, and 11 paid holidays each year. Please submit your resume online at the state careers website www.state.careers.mn.us and refer to job posting 12MDVA000189.

at

For more information, please contact Kay Pearson in Human Resources by email at: kay.pearson@state.mn.us, or by phone at: 612-548-5907. An Equal Opportunity Employer


Illustrations from the Perkins+Will /M+NLB entry in the Kaiser competition. Left: aerial view. Right: main desk.

They understood that in order to develop a new model for this different scale, they would need new thinking. Kaiser opened up a global competition to find just that. Participants in the competition were challenged to imagine a small-scale, forward-thinking health care facility that would combine the best of facility design, sustainability, and modern technology. After reviewing more than 100 design concepts from architects, design firms, students, health care companies, and engineering and construction firms, Kaiser narrowed the field down to three finalists. Each of the finalists was given resources and several months’ time to develop the concepts

further. When the winners were announced, the team of Perkins+Will/M+NLB came out on top with a design that went far beyond the health system’s expectations of what a small hospital could be. “As leaders in sustainable health-care design, we are thrilled to play a role in designing and bringing to fruition a medical facility that will serve as a benchmark for the future of health care,” said Rick Hintz, principal in the Minneapolis office of Perkins+Will, which worked closely with the firm’s New York office on the winning design. “We are incredibly proud just to be among the three finalist firms out of a global array of entries, topped only by then

being chosen as the winning concept by Kaiser Permanente to reshape the way health care is designed and delivered.” Components of the design

Multiple, flexible parts. Kaiser chose a design that offers a wide range of flexibility in how the hospital size could change over time. While Kaiser initially requested a prototype design for this facility, allowing them to build, refine, and duplicate the model time and time again, the design process revealed a strong need for flexibility. A one-sizefits-all solution would not be financially viable given the fluctuating market conditions. The answer would be a flexible infrastructure built around a basic

framework that allowed for the various pieces to be included or excluded from each individual location. The design provides a variety of parts that can be assembled in multiple ways to accommodate market conditions. Any given site could begin with as little as a small clinic, freestanding emergency center, or wellness and patient services pavilion. As a community grows and requires additional services, the infrastructure allows other parts from the toolkit to be incorporated in a well-considered and coherent way. An additional component of flexibility is the notion of incremental growth. Any building project or major renovation is a SCALE to page 30

NEW POSITIONS: Opportunities available in the following specialties:

Olmsted Medical Center, a 150-clinician multi-specialty clinic with 9 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.

Family Medicine Rochester Northwest Clinic Wanamingo Clinic Chatfield Clinic Dermatology Southeast Clinic Child Psychiatry Southeast Clinic Hospitalist OMC Rochester Hospital Emergency Medicine OMC Rochester Hospital

Family Practice Urgent Care Dynamic, independent 3 location, single-specialty practice in northwest Minneapolis suburbs is seeking additional associates for its Rogers site and has Full Time/ Part Time shifts in the Crystal and Rogers Urgent Care. • • • • •

Partnership opportunity after 2 years Competitive salary with incentives Excellent benefits, 401k/employer paid pension Practice at one site/one hospital Physician-owned

Please contact or fax CV to:

Send CV to: Olmsted Medical Center Administration/Clinician Recruitment

Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429 763-504-6600 • Fax 763-504-6622

1650 4th Street SE Rochester, MN 55904 email: egarcia@olmmed.org Phone: 507.529.6610 Fax: 507.529.6622

www.olmstedmedicalcenter.org

EOE

Visit our website at www.NWFPC.com OCTOBER 2012

MINNESOTA PHYSICIAN

29


Scale from page 29 serious capital investment for an organization. Often there is a focus on reduced square footage for such a project to keep capital investment low, which, in turn, limits flexibility of the infrastructure. Kaiser saw that focusing on a solution with the lowest square footage was placing undue importance on upfront costs and not considering the full lifecycle of the facility. By spending a small percentage more on the initial infrastructure of the facility, Kaiser was able to build in the ability to adapt within a very short time frame, constructing one or two additional patient rooms at a time rather than being required to invest in an entire floor of patient rooms. By analyzing the lifecycle of such an investment, the organization can virtually eliminate the high expense of contracted care. Integrated patient experience. The experience of the patient is key to the design of this small hospital. Large hospitals are often surrounded by a sea of parking that does not

allow the institution to be seen as an integrated member of the community. The Kaiser design focuses on reducing the scale in order to integrate more holistically with its surroundings. The design also connects with the community through a new Kaiser wellness business line. Since Kaiser provides not only care but also health insurance, the organization has an incentive to keep members healthy and out of the high-cost hospital setting. The total health environment is a unique place where members interact much more frequently than they would with a traditional hospital setting. By integrating the wellness business line, members become more invested in caring for their own health and more connected with the institution that catalyzes that investment. Rather than thinking of the hospital as a place to go only when one is ill, it is designed as a community hub that draws the members in through wellness coaching, fitness facilities, healthy cooking classes, and other health-related programs.

North Memorial is seeking driven providers to be part of our 2012-2013 growth initiatives. Opportunities exist in Family Medicine Internal Medicine Obstetrics Gynecology

and in multiple

Over 700 physicians in more than 40 specialties. An award-winning hospital and network of primary/urgent and specialty clinics.

Kaiser Permanente’s small hospital competition exemplifies how progressive-thinking providers are beginning to let go of many long-held and possibly erroneous assumptions about what really is a cost-effective health-care delivery solution. Smaller scaled facilities allow an individual patient to be just that: an individual, and not a number. Could it be that smaller scaled, more approachable facilities foster more personalized patient care? With less of a fixation on volume, throughput, and reactive treatment, the business model can turn the focus to education, wellness, and prevention. In this case, smaller really is better. Meredith Hayes Gordon, MArch, Associate AIA, LEED AP BD+C, is a sustainable health-care strategist for the Minneapolis office of Perkins+Will. She has more than eight years of design and architecture experience and, during her six years with Perkins+Will, has completed a number of projects of multiple scale around the world.

Minneapolis/St. Paul, Minnesota

For

of Your Career

Fostering personalized care

BREAST/GENERAL SURGEON

Growth and Opportunity

Every Stage

Environmentally responsible. Kaiser required the small hospital to be designed as a netzero facility, that is, a building that produces as much energy as it uses over the course of a year. This was a challenging proposition since hospitals are among the world’s leading energy consumers. The winning design went beyond net-zero and become a regenerative facility, one that not only did no harm to the environment it inhabited but also aimed to restore that environment. The small hospital utilizes three primary streams—energy, water, and waste—to provide for the built and natural environments. Within each stream, a menu of options is provided and analyzed based on lifecycle costs and site-specific conditions with the intent of using waste from one stream as an input to another stream. The resulting outcome for the example site in southern California eliminated cooling towers and boilers saving a very significant portion of operational costs.

surgical or medical specialties

HealthPartners Medical Group is a large, successful multi-specialty physician group based in Minneapolis/St. Paul, central Minnesota and western Wisconsin. Our busy surgical team at Level 1 trauma center Regions Hospital in St. Paul has an excellent opportunity for a full-time, BC/BE Breast/ General Surgeon. This well-established, mature practice is based at Regions Breast Center, and provides best care in general and breast surgery. No night call is involved. We offer a great group of colleagues, generous benefits and comp, opportunity for teaching and research, and the excitement of a metropolitan practice. Apply online at healthpartners.jobs or forward your CV and cover letter to sandy.j.lachman@ healthpartners.com. EO Employer

Optimize your education and leadership potential. To learn more, contact Mark A. Peterson, Physician Recruiter 763-520-1336 mark.peterson@northmemorial.com northmemorial.com

30

MINNESOTA PHYSICIAN OCTOBER 2012

healthpartners.com


St. Cloud VA Health Care System is accepting applications for the following full or part-time positions: • Associate Chief, Primary & Specialty Medicine (Internist-St. Cloud) • Dermatologist (St. Cloud) • Director, Primary and Specialty Medicine (Internal Medicine) (St. Cloud) • ENT (St. Cloud)

• Internal Medicine/ Family Practice (Alexandria, Brainerd, St. Cloud, Montevideo) • Medical DirectorExtended Care & Rehab (IM or Geriatrics) (St. Cloud) • Psychiatrist (Brainerd, St. Cloud) • Radiologist (St. Cloud)

• Geriatrician (Nursing Home-St. Cloud) • Hospice/Palliative Care (St. Cloud)

• Urgent Care Provider (MD: IM/FP/ER) (St. Cloud)

US Citizenship required or candidates must have proper authorization to work in the US. J-1 candidates are now being accepted for the Hematology/Oncology positions.

Look for the friendly doctor in a MN based physician staffing service ...

Physician applicants should be BC/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum limitation under the provision of the Education Debt Reduction Program. Possible relocation bonus. EEO Employer.

Excellent benefit package including: Favorable lifestyle

13 days sick leave

26 days vacation

Liability insurance

CME days Competitive salary

Physicians: • Let us do your scheduling & credentialing • Paid Malpractice • Physician Friendly • Choose where and when you want to work • Competitve Rates • Courteous Staff

Clients: • Prevent loss of revenue • BC/BE physicians • Competitive rates • Quality coverage • Malpractice coverage paid by us

P-763-682-5906/F-763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com

Interested applicants can mail or email your CV to VAHCS

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

Sharon Schmitz (Sharon.schmitz@va.gov) 4801 Veterans Drive, St. Cloud, MN 56303 Or fax: 320-654-7650 or Telephone: 320-252-1670, extension 6618

OCTOBER 2012

MINNESOTA PHYSICIAN

31


PHYSICIAN

â&#x20AC;&#x153;Howâ&#x20AC;&#x2122;s that workinâ&#x20AC;&#x2122; out for ya?â&#x20AC;?

I

recently read the article â&#x20AC;&#x153;The Heartbeat of Health Reformâ&#x20AC;? (Minnesota Physician, April 2012), which described the accountable care organization (ACO) model of care being adopted by health plans in Minnesota. It was an interesting article and made a number of good points. In reading it, however, it occurred to meâ&#x20AC;&#x201D;againâ&#x20AC;&#x201D; how isolated, powerless, and open to manipulation physicians have become. After being driven out of our private practices and into large organized health care conglomerates by insurance industry dominance and state initiatives like the ISNs (integrated service networks) of the 1990s, the majority of Minnesota physicians are now employees of larger organizations. Trying to take in stride the massive changes we have seen in the last three decades, and being first and foremost doctors whose primary goal is to care for our patients, we trudge onâ&#x20AC;&#x201D;though we may attempt to look at the bright side of now being employees: decreased risk, a

PERSPECTIVE

Primary-care physicians and ACOs By Wayne Liebhard, MD stable (though less opportunistic) income, etc. However, times continue to change. In America, you can start your own business, assume the risks, be your own boss, and reap the potential rewardsâ&#x20AC;&#x201D; unless you are a Minnesota primary care physician. Or you can sign up as an employee and opt for more stability and less riskâ&#x20AC;&#x201D; again, unless you are a Minnesota primary care physician. This is where isolated, powerless, and manipulated enter the picture. Today, even in the employee role, primary-care physicians employed under the ACO model will be expected to assume not less, but ever increasing financial risk. In pondering this situation, I wonder if my employed friends

and neighbors, including those who work factory jobs, would be happy to go to work each day knowing that they were assuming risk that could suddenly change the wages they have been promised. Fortunately for many of these people, they can do something that I, as a physician, canâ&#x20AC;&#x2122;t do: join a union. Topping off this scenario are the actual drivers for the high cost of health care in the U.S. that we physicians are now supposed to assume, including massive health-plan administrative overhead, and largely obese and largely noncompliant segments of our population. These are factors, of course, over which we have little control. But alas, we have been herded into the Stepford Clinic, where we are

supposed to dress up, smile, and perform our duties admirably and without question, protest, tort reform, or freedom from yet another government initiative. Where is the patient in the equation?

The biggest fallacy here is the conceit, often voiced by health care â&#x20AC;&#x153;reformers,â&#x20AC;? that somehow our current system is â&#x20AC;&#x153;provider focused.â&#x20AC;&#x153; Itâ&#x20AC;&#x2122;s been a long time since our system has been anything but government- and insurance industry-focused. If accountable care organizations are a â&#x20AC;&#x153;patient-centeredâ&#x20AC;? system, as the aforementioned article notes, why did the article not include a single mention about patient responsibility within this system? The answer is that ACOs arenâ&#x20AC;&#x2122;t really anything new. Remember the HMO revolution of the 1980s? The idea was to create savings by limiting the utilization of services. Todayâ&#x20AC;&#x2122;s ACOs are to be composed of providers who will be held jointly accountable for reducPRIMARY CARE to page 34

Family Medicine St. Cloud/Sartell, MN

)NTHEHEARTOFTHE#UYUNA,AKESREGION OF-INNESOTA THEMEDICALCAMPUSIN#ROSBY INCLUDES #UYUNA 2EGIONAL -EDICAL #ENTER ACRITICALACCESSHOSPITALANDCLINICOFFERING SUPERBNEWFACILITIESWITHTHELATESTMEDICAL TECHNOLOGIES/UTDOORACTIVITIESABOUND AND WITHTHE4WIN#ITIESAND$ULUTHAREAJUSTA SHORTTWOHOURDRIVEAWAY YOUCANEXPERIENCE THE PERFECT BALANCE OF RECREATIONAL AND CULTURALACTIVITIES CULTURAL ACTIVITIES %%NHANCE NHANCE YYOUR OUR PROFESSIONAL PROFESSIONAL LIFE LIFE IN IN AN AN EENVIRONMENT NVIRONMENT THAT THAT PROVIDES PROVIDES EEXCITING XCITING PRACTICE PRACTICE OOPPORTUNITIESINABEAUTIFUL.ORTHWOODSSETTING PPORTUNITIESINABEAUTIFUL.ORTHWOODSSETTING 44HE#UYUNA,AKESREGIONWELCOMESYOU HE#UYUNA,AKESREGIONWELCOMESYOU

We invite you to explore our opportunities in: s&AMILY-EDICINE s%MERGENCY-EDICINE s)NTERNAL-EDICINE s(OSPITALIST s/RTHOPAEDIC0!

We are actively recruiting exceptional part-time or full-time BC/ BE family medicine physicians to join our primary care team in Sartell, MN. This is an out-patient only opportunity and does not include labor and delivery or hospital call and rounding. Our current primary care team includes family medicine, adult medicine, OB/ GYN and pediatrics. Previous electronic medical record experience is preferred, but not required. We use the Epic electronic medical record system at all of our clinics and admitting hospitals. Our HealthPartners Central Minnesota Clinics â&#x20AC;&#x201C; Sartell moved into a new primary care clinic in the summer 2010. We offer a competitive salary, an excellent beneďŹ t package, a rewarding practice and a commitment to providing exceptional patientcentered care. St. Cloud/Sartell, MN is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with a traditional appeal. Apply on-line at healthpartners.jobs or contact diane.m.collins@ healthpartners.com or call Diane at 800-472-4695 x3. EOE

Contact: Todd Bym Bymark, mark, tbymark@cuyunamed.org (866) 270-0043 / (218) 546-4322 | www.cuyunamed.o org www.cuyunamed.org

healthpartners.com

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MINNESOTA PHYSICIAN OCTOBER 2012


Orthopaedic Surgery Opportunity Live in Beautiful Minnesota Resort Community

An immediate opportunity is available for a BC/BE orthopedic surgeon in Bemidji, MN. Join three board certified orthopedic surgeons in this beautiful lakes community. Enjoy practicing in a new Orthopedic & Sport Medicine Center, opening spring 2013 and serving a region of 100,000. Live and work in a community that offers exceptional schools, a state university with NCAA Division I hockey and community symphony and orchestra. With over 500 miles of trails and 400 surrounding lakes, this active community was ranked a “Top Town” by Outdoor Life Magazine. Enjoy a fulfilling lifestyle and rewarding career. To learn more about this excellent practice opportunity contact: Celia Beck, Physician Recruiter Phone: (218) 333-5056 Fax: (218) 333-5360 Email: Celia.Beck@sanfordhealth.org AA/EOE - Not subject to H1B Caps

With Essentia Essentia He H Health, alth, yyou’ll ou’ll find group more a supportive supportive gr o of mor oup e than 750 medical 7 50 physicians physicians across across 55 55 me dical specialties. large spe cialties. Located Located in lar ge and

Think ““Outside” Think Outside” the C linic Clinic If yyou’re If ou’re ready ready to to expand impact exp and yyour our im pact beyond office b eyond o ffice vvisits, isits, ts ccall all us. us. You You can can make make a rreal eal difference diff ffeerence in rrural ural health medical h ealth ccare are as as a m edical leader le ader for for our our small, small, yet yet innovative health inn ovaative h ealth plan. plan.

small communities communities across across Minnesota, Minnesota, Wisconsin, North Dakota Idaho, Wis consin, Nort th D akota and Idah o, Essentia Health emerging E ssentia He alth h is emer ging as a leader cost-effective, le ader in high-quality, high-q quality, c ost-effectivve, patient-centered care. p atient-centered c are. EEOE/AA OE//A AA

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33


Primary care from page 32 tions in the rate of spending growth (read: limiting the utilization of services). This is supposed to make me, as a physician, suddenly get excited that I get to be a member of the ACO “team”? I completely agree that there is a need to limit utilization of health care services, because we overspend mightily, with no end in sight. The seminal question is: Why do we overutilize? The answer is pretty straightforward, and largely related to personal responsibility. As those in control keep trying to tweak the system, the reality we can’t seem to accept is that physicians simply cannot force patients to take better care of themselves. So, we continue to carve out a massive amount of our GDP to spend on what we erroneously call “health care.” Health care used to be—and still should be—setting your fracture, sewing up your laceration, treating your pneumonia, etc. Instead, we’ve added a burgeoning budget for “preventive medicine” and “health mainte-

nance”(joint replacements, gastric bypass surgery, high-end cholesterol management, etc). In a perfect, non-financially limited (and, therefore, nonexistent) world, we could do everything for everyone, including making sure that people who have carried an extra 150 pounds around for 30 years never have joint pain. Yet, even in our imperfect, financially limited world, we keep trying to do the impossible and spend our way out of reality. My favorite example of this is the twisted logic that says “we need to spend more now [gastric bypass] to avoid spending more later [joint replacement].” Neither of these procedures is inherently a bad thing. They should, however, be a personal—not a societal— responsibility. A medical cartoon I recently ran across sums it up nicely, depicting a patient on an exam table saying to his doctor (paraphrased): “Of course I don’t take care of myself—that’s what you’re for.” Why can’t we say no? Why can’t we stop the attempts at social engineering and let reality

force people to take better care of themselves or face the consequences? The answer is that the parties now in control of our health care system have little or no reason to promote reality. Neither your congressman nor your health plan will tell you that you are too fat, nor will they truly promote any policy that forces personal responsibility. Instead, we get oppressive, expensive state mandates for health care coverage, and ACOs —where your doctor is supposed to take the hit for your not being able to keep your face out of the refrigerator. Similarly, the insurance industry remains more than happy with a system that puts the blame on doctors while it micromanages the edges of a failing system that, at least for now, continues to guarantee insurers high profits. As long as those profits continue, so will the smokescreen micromanaging that deflects attention from the real issues while we motor on toward the abyss. So at present the question of patient responsibility is,

sadly, rhetorical. Health plans and patients rarely take the hit. Bad patient behaviors and subsequent “poor outcomes” are deemed “poor quality of care,” and the insurance industry is again let off the hook. The article states that “… health plans are entering into provider contracts with accountability and incentives for improving total costs along with improved health outcomes and experience.” Really? The in-thetrenches translation might read as follows: “… health plans are entering into provider contracts where they are allowed to set the rules that continue to generate their profits, keep physicians subservient to them, and keep plan premiums high.” We all know that the insurance industry and government hold all the cards, so can we just tell it like it is? Despite everything we have seen over the past 30 years, a huge portion of the health care “reform” crowd continues to look at the insurance industry as the savior of cost control rather than (at least at PRIMARY CARE to page 36

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

Black Hills VA HCS, SD

Fargo VA HCS, ND

Urologist Psychiatrist ENT Hospitalist Endocrinology

Psychiatrist Neuropsychologist General Surgeon Physician (Primary Care) Hospitalist (Internal Medicine) Urologist

Psychiatrist Hospitalist Family Practice Internal Medicine

Orthopedic Surgeon Radiologist Cardiologist Pulmonologist Physiatrist

Sioux Falls VA HCS (605) 333-6858 www.siouxfalls.va.gov

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

Fargo VA HCS (701) 239-3700 x2353 www.fargo.va.gov

Applicants can apply online at www.USAJOBS.gov

34

MINNESOTA PHYSICIAN OCTOBER 2012


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

Hibbing Little Falls Park Rapids Alexandria Austin

FAMILY PRACTICE w/OB Warroad, MN Roseau, MN Crookston, MN • Dedicated Team Approach • Competitive Salary & Benefits • EPIC Healthcare Information System Idylic Practice Opportunities located in family friendly communities with close access to some of Minnesota’s most beautiful lakes.

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

recruiting@epamidwest.com or visit our website at

Contact: Kerri Hjelmstad, Physician Recruiter Altru Health System PO Box 6003 Grand Forks, ND 58201-6003

www.epamidwest.com

1-800-437-5373 Fax: 701-780-6641 khjelmstad@altru.org

Your Emergency Practice Partner

Internal Medicine?

Yup.

Family Medicine?

NEW clinic in Mahtomedi, MN?

Internal and Family Medicine Opportunities Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services in the St. Croix Valley, just east of the Twin Cities metro area. Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education. For further information please contact: Lori Martin, Executive Assistant 1500 Curve Crest Blvd, Stillwater MN (651) 275-3305, lmartin@lakeview.org stillwatermedicalgroup.com

www.altru.org

Practice Well. Live Well. Lake Region Healthcare is located in a magnificent, rural, and family-friendly setting in Minnesota lakes country where we aim to be the state’s preeminent regional health care partner. Our award winning patient care and uncommon medical specialties set us apart from other regional health care groups. Lake Region’s physicians and their families also enjoy an unmatched quality of professional and personal life. Current opportunities including competitive salary and benefit packages available for BE/BC physicians are: • Dermatologist • Family Medicine • Emergency Medicine • Internal Medicine

• Orthopedic Surgeon • Pediatrics • Psychiatrist • Psychiatric NP or PA

For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424 Lake Region Healthcare is an Equal Opportunity Employer. EOE

We’ll make it all better.

www.lrhc.org OCTOBER 2012

MINNESOTA PHYSICIAN

35


Primary care from page 34 times) the fox guarding the henhouse. The rest of the crowd seems to feel that we should turn health care over to the federal government, which already controls half of health care and has obviously done a less than stellar job of that up to this point. We do need the insurance industry, because we do need insurance—if nothing else, as a hedge against a complete federal takeover by a government quickly running out of money. What we don’t need are expensive “prepaid health care” plans that have replaced the traditional concept of insurance—you know, the stuff you used to buy that insured you against catastrophe instead of claiming to cover all of your medications. Alas, huge portions of our total health care dollars keep getting funneled into such plans, ensuring that the insurer gets its cut and that the risk pool still supports the spending of 30 percent of our health care dollars on 1 percent of our population. Bad health behaviors, expensive patient demands, and increased

profits continue their onward march, while physicians are told that we must be the stewards of the health care dollar and, now, simultaneously (even as employees) assume ever-increasing financial risk under the ACO model as well as under “pay for performance.” On top of that, add the coming onslaught of the Affordable Care Act, which is long on new patients but short on any real reforms. What’s the answer?

Essentially, for Minnesota’s primary-care physicians, it’s already game over. The other day, a colleague of mine remarked, “These days, when people ask me what I do, I don’t even bother to use the word ‘doctor.’ I tell them I do customer service and data entry.” This is where doctors have ended up in the pecking order of importance in our health care system. Somehow, though, even at that lowly perch, we apparently can still be billed for the ills of the system and its high costs, while we watch certain health care administrators collect huge

Heart of Minnesota Lakes Country Practice Opportunities Sanford Clinic North – Excellent practice opportunities in communities located in the ‘Heart of Minnesota Lakes Country.’ Good call arrangements and modern well-managed community-owned hospitals. Alexandria • Dermatology • ENT • Family Medicine • Hospitalist/IM • Internal Medicine • Ob/Gyn Detroit Lakes • Dermatology • Family Medicine • Internal Medicine • General Surgery • Pediatrics

East Grand Forks • Family Medicine • IM/Peds Moorhead • Family Medicine New York Mills/ Perham • Family Medicine • Orthopedic Surgery

Thief River Falls • Dermatology • Family Medicine • Hospitalist/IM • Internal Medicine • Ob/Gyn • Optometry Wheaton • Family Medicine

drive personal responsibility and personal cost control. Generic and life-saving drugs would be covered, and the price of others would drop to a reasonable level in a true free market. If we still want to try to insure health maintenance, we could make it a separate plan (or at least an 80/20 proposition) that puts its financial onus on its user group, and makes real health care more affordable to those who really need it. Demanding something of everyone at every point of health care access—on a sliding scale, starting even at a dollar—will also help remind even those with “full coverage” that health care is not free. Looking back at the last 30 years of failed experience and government/insurance industry control, I feel inclined to invoke the question often posed by Dr. Phil: “So, how’s that workin’ out for ya?” Wayne Liebhard, MD, is a primary care physician and the author of “Elephants in the Exam Room: The BigPicture Solution to Today’s Health Care ‘Crisis.’“

Minneapolis VA Health Care System Great place to work, great place to live. You are invited to be part of the Department of Veterans Affairs that has been leading change in the health care sector.The Minneapolis VA is a 341-bed tertiary care medical center affiliated with the University of Minnesota. Our patient population and case mix is challenging and exciting, providing care to veterans and active-duty personnel.The Twin Cities area offers excellent living and cultural opportunities. Opportunities for full-time and part-time physicians are available in the following positions: • Cardiac Anesthesiologist • Chief of Surgery/Director of Specialty Care Service Line • Compensation & Pension (Occupational Medicine) • Gastroenterologist • General Internal Medicine

Sanford Health, serving western Minnesota, eastern North Dakota and South Dakota, is redefining health care. Sanford offers innovative technology, support of a multi-specialty organization and dependable colleagues. Our employment model includes: market competitive salary, comprehensive benefits, paid malpractice insurance and a generous relocation allowance. To learn more contact: Shannon Ellering, Physician Recruiter Email: Shannon.Ellering@sanfordhealth.org

Phone: (701) 280-4817 EOE/AA

36

salaries and accolades for “transforming health care.” Don’t get me wrong; we need good, caring administrators. We also need good, caring doctors, and we won’t get or keep them by blaming them, philosophically or financially, for the ills of our system. The reason why many of my former private-practice patients can’t seem to find a primary care doctor, and why many primary-care practices can no longer find doctors who want to carry a decent workload, is blatantly obvious—and it’s not just a generational thing. It’s time to admit that practicing physicians have been taken out of the reform equation. The only entity that has any chance of regaining control of health care and effecting real reform is made up of responsible health-care consumers, who first need to demand a separation between health care and health maintenance. They then need to demand of their legislators and employers a highdeductible health plan/HSA model that will do away with prepaid health care and instead

MINNESOTA PHYSICIAN OCTOBER 2012

• Internal Medicine/Family Practice – Rice Lake, Chippewa Falls and Superior, WI • Psychiatrist – Ramsey, MN and Superior, WI Physician applicants should be BC/BE. Possible recruitment bonus. Interested applicants should email CV to: Brittany Sierakowski, HRMS • brittany.sierakowski@va.gov Fax 612-725-2287 • Telephone 612-629-7873 EEO Employer


Practice Well. Live Well. Lake Region Medical Group is seeking a full-time Certified Physician Assistant to join our Lake Region Healthcare team of 2 orthopedic surgeons; providing care in a multi-specialty clinic with 50+ providers. We are looking for a hardworking, conscientious individual committed to providing quality care to our patients as we develop our Orthopedic Center of Excellence. Duties will include new and follow-up patient visits, assisting with surgery, post-op visits and hospital rounds in our 108 –bed community based hospital. The ideal candidate will have 2-5 years experience in orthopedics. We offer a competitive salary with a healthy benefit package. For more information contact Barb Miller, Physician Recruiter bjmiller@lrhc.org • (218) 736-8227

712 Cascade St. S., Fergus Falls, MN 736-8000 • (800) 439-6424

The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties: • ENT • Internal Medicine • Psychology • Family Medicine • Med/Peds Hospitalist • Pediatrics • General Surgery • OB/GYN • Pulmonary/ Critical Care • Geriatrician/Outpatient • Oncology Internal Medicine • Radiation Oncology • Orthopedic Surgery • Hospitalist • Rheumatology • Psychiatry • Infectious Disease For additional information, please contact:

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

Julayne Mayer, Physician Recruitment mayerj@acmc.com, (320) 231-5052

Lake Region Healthcare is an Equal Opportunity Employer. EOE

www.lrhc.org

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Urgent Care

Spine Surgeons, join our team and set the standards for patient care. Orthopaedic Associates of Duluth is seeking a highly motivated passionate and experienced SPINE SURGEON to provide outstanding orthopaedic care to its patients. The successful candidate will be part of our expanding and growing, well-respected team that serves patients from Duluth to northern Minnesota. Orthopaedic Associates of Duluth is a group of nine orthopaedic surgeons that provide comprehensive orthopaedic services ranging from specialty specific exams and diagnosis to state-of-the-art inoffice MRI and imaging and surgery at their physician-owned surgery center.

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

Email CV to jwaller@slhduluth.com or call 800-461-8843 (Sue) or 218-625-2731 (June)

healthpartners.com OCTOBER 2012

MINNESOTA PHYSICIAN

37


Med ed from page 18 ally increased support for primary care in the U.S. We thought we were going to see the flowering of primary care in the mid-1990s, but that vision collapsed along with the other aspects of â&#x20AC;&#x153;managed care.â&#x20AC;? So we will see if the new emphasis on primary care remains in the coming years, given current pledges of improved public support, moderately better reimbursement, and, potentially, a huge increase in demand for primary care delivered with greater emphasis on teams. Whatâ&#x20AC;&#x2122;s coming?

Itâ&#x20AC;&#x2122;s become clear that the U.S. population can no longer afford more of our fragmented, expensive, non-patient-centered care. In general, a new cycle of demands for improved quality, improved patient experience, and lower overall costs is afoot. I believe the larger market forces have already shifted toward supporting accountable primary care clinicians and systems of care. With the 2012 Supreme Courtâ&#x20AC;&#x2122;s recent decision on the

Patient Protection and Accountable Care Act (ACA), I expect these trends to continue. We already have plans to support improved payment for improved patient outcomes and improved patient satisfaction, and we will continue to seek ways to reduce overall costs of care. Bundled payments and risk-sharing contracts will continue to be part of this effort. The ACA will shift 15 million or more citizens into Medicaid and use care management payments and other incentives to support an expanded primary care physician workforce. Looking at the broader health care industry in Minnesota, I think we will see provider groups consolidate and the number of truly independent practices continue to shrink. Consolidation among insurance systems may also occur, with a small number of large insurers continuing to dominate the market in Minnesota. Minnesota has a chance to continue as a national leader in populationbased health improvement, innovations in cost-effective

care, and excellence in primary care education. I believe new medical devices will face a greater demand to demonstrate safety before they are released to the general market. Drug manufacturers will need to not only demonstrate the safety of new drugs but also prove that new drugs are at least equivalent in benefit to comparable existing drugs. The biggest opportunity for new medications will continue to shift toward new drugs to treat cancer and other more immediately life-threatening conditions, as the patents run out on current, very effective medications that treat more common chronic conditions. Self-care and patientdirected care will move to the forefront of care plans as our technology expands the treatments and biologic assessment that can be done directly by the patient at home. We can already measure many body fluids and vital signs at home, and those options will continue to expand. In primary care, we will have more team visits and spend

more time helping patients with complex blends of medical, social, and behavioral health problems. Home visits by some health care professionals will increase and office visits will be more complex, as those visits will be used to manage what cannot be done at home, by phone, or over the Internet. The â&#x20AC;&#x153;therapeutic densityâ&#x20AC;? of office visits will increase as teams work very closely with patients and families to improve outcomes. The value of primary care physicians and other members of the primary care team will depend more on improving the outcomes of care rather than on just the volume of services. As an incurable optimist, I see this as an exciting time in medicine and just the right time to be fully involved in medicine and medical education. I look forward to whatever comes next. Macaran A. Baird, MD, MS, is professor and head of the Department of Family Medicine and Community Health at the University of Minnesota Medical School, Minneapolis, and is chairman of the board of directors of UCare.

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You wouldnâ&#x20AC;&#x2122;t give a 3-year-old a drink, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.

www.mofas.org



Minnesota Physician October 2012