Volume XXVll, No. 7
The Independent Medical Business Newspaper
A perspective on med ed Past and future trends By Macaran A. Baird, MD, MS
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
PROFESSION to page 10
PRSRT STD U.S. POSTAGE
The changing face of medicine
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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OCTOBER 2012 Volume XXVII, No. 7
FEATURES Evolution of a profession The changing face of medicine
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
ADDICTION MEDICINE Prescription drug abuse 24
By Carol Falkowski
INTERVIEW Presidential matters
MEDICAL FACILITIES Does scale matter?
President Barack Obama and Gov. Mitt Romney
By Lee H. Beecher, MD, FAPA, FASAM
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 firstname.lastname@example.org EDITOR Donna Ahrens email@example.com ASSOCIATE EDITOR Janet Cass firstname.lastname@example.org
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
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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email email@example.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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OCTOBER 2012 MINNESOTA PHYSICIAN
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
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 firstname.lastname@example.org or call 651-917-2370 or go online to www.mofas.org/events.
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.”
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 |
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
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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.
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.”
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.”
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.
MINNESOTA PHYSICIAN OCTOBER 2012
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
Healthcare Planning and Design
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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How has the culture of medical practice changed since you began practicing? During my career, I’ve seen medicine change a
MINNESOTA PHYSICIAN OCTOBER 2012
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.
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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 â€œit is human nature not to be completely satisfied.â€? 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 patientâ€™s medical record, but also for billing and coding. Even within my four years of practice, I have
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MINNESOTA PHYSICIAN OCTOBER 2012
noticed the increase in the requirements for documentation, most recently with â€œmeaningful use.â€? 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 peopleâ€™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. Georgeâ€™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 â€œresidentâ€? to â€œphysicianâ€? (I completed my family medicine residency at St. Cloud Hospital through the University of Minnesota Medical School residency program). There is a lot more respectâ€”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 donâ€™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 â€œpersonalityâ€? 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 womenâ€™s health. As an undergraduate at Concordia College in Moorhead (Minn.), I took many courses in womenâ€™s studies and I directed â€œThe Vagina Monologuesâ€? 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 Schoolâ€”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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