minnesota physician april 2014

Vo lum e x x V i i i , N o. 1A p r i l 2014

If you could have dinner with any physician, living or dead, who would it be and why?

This was the question we posed to some physicians who have contributed over the years to Minnesota Physician. Their answers yielded some very famil-iar names—William Osler, Sigmund Freud, Sir Arthur Conan Doyle—as well as some that are likely unknown to many of our readers—Cyril Wal-

wyn, Norman Bethune, Hans Kraus. Their eras of medical practice range from the 12th century to the present day.

The reasons for choosing dining companions were remarkably varied as well. Some doctors wanted to probe for detailed information about past medical techniques; others looked forward to sharing advances in their

Dinner with doctorsFood for thought, from centuries past to the present

By Donna Ahrens

Research on African American men’s health has focused on the individu-al-level risk factors in disease-spe-

cific areas. A more comprehensive approach, however, has been largely ignored. Recog-nizing this need, the National Institutes of Health has awarded a $13.5 million grant jointly to the University of Minnesota (UMN) and the University of Alabama at Birmingham (UAB)—creating a consortium national in scope—to develop and imple-ment a coordinated approach to address the health disparities of African American men across their life courses. A consortium of regional academic centers and community organizations has created a first-ever col-laborative center to develop, implement, and evaluate interventions to improve African American men’s health through research, outreach, and training.

Regional approach, national scope This consortium, called the National Transdisciplinary Collaborative Center

African American men’s healthConsortium addresses disparities nationally, locally

By Badrinath R. Konety, MD, MBA

Dinner with doctors to page 10

African American men’s health to page 16

Alcohol is more harmful to an unborn baby than cocaine, marijuana or heroin.Drinking during pregnancy can cause Fetal Alcohol Spectrum Disorders (FASD) which permanently harm the way your baby learns and behaves.

- ZERO ALCOHOL FOR NINE MONTHS.

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 protected]. 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 re-place medical, legal, tax, business or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

Features

DePartMeNts

PrOFessIONaL uPDate: aLLergy

sPecIaL FOcus: PractIce MaNageMeNt

April 2014 MINNESOTA PhySIcIAN 3

April 2014 • Volume XXVIII, No. 1

caPsuLes 4

MeDIcus 7

INTERVIEW 8

OrthOPeDIcs 26Advances in foot and ankle surgeryBy Benjamin Clair, DPM, FACFAS, and Aaron Benson, MS, ATC

NEuRology 28The frontotemporal degenerationsBy David Knopman, MD, and Bradley Boeve, MD

PuLMONOLOgy 32New lung cancer screening toolBy Cynthia Isaacson, Jill Heins Nesvold, MS, and Lee Kamman, MD

Measuring Total 20 Cost of Care By Gunnar Nelson

Group visits 22By Jennifer St. Peter, Edwin Anderson, MD, and Travis Luedke

Supporting medical 24 independenceBy Bruce Penner, RN

Mystery diagnosis for allergic reaction 18By Nancy L. Ott, MD

Pat Peschman, DNP, RN,GNP

Allina Health SeniorCare Transitions

Dinner with doctors 1Food for thought, from centuries past to the presentBy Donna Ahrens

African American men’s health 1Consortium addresses disparities nationally, locallyBy Badrinath R. Konety, MD, MBA

This August, Minnesota Physician will publish a feature recognizing physician-directed medical research projects. We invite nominations from our readers. If you or an associate is currently engaged in a medical research project, please contact us, either by phone or through the form below. The research may be from any field and conducted on any level—basic, clinical, community-based, epidemiological, health services-related, etc. The only criterion is that the principal investigator(s) is an MD.

Whether the research is conducted in an academic institution, a rural or urban clinic or hospital, a managed-care organization, health system foundation, corporation, or state agency, we welcome its nomination. In brief overview, we will feature as many projects as possible, representing a geographically and institutionally diverse sample.

Thank you for your participation. We welcome your assistance in recognizing Minnesota’s outstanding medical research community.

Send to: Minnesota Physician Publishing 2812 East 26th Street, Minneapolis, MN 55406 Tel: 612-728-8600 • Fax: 612-728-8601 • Email: [email protected]

Please note: All nominations must be received by June 15, 2014 and will be held in confidence. We will contact you and no information will be published without approval from the PI(s).

Name of project:

Research site:

Funder:

Principal investigator(s):

Contact data (Phone and/or email):

Comments:

PHY

SICIAN RESEARCH RECOGNITIONMinnesota Physician Publishing

2014

4 Minnesota Physician April 2014

New Bill Would Allow APRNs to Practice IndependentlyLegislation has been proposed that would remove physician supervision requirements for ad-vanced practice registered nurses (aPRns) in Minnesota.

sen. Kathy sheran (DFL-Mankato) and Rep. Dan schoen (DFL-st. Paul Park) are sponsoring the bill that would grant full practice authority to advanced practice registered nurses. aPRns are registered nurses who have completed a graduate-level education program and passed a national certifica-tion exam in order to practice in one of four areas: as nurse practitioners, nurse midwives, nurse anesthetists, or clinical nurse specialists. Proponents of the new legislation say the physi-cian supervision requirement is a significant barrier to practicing in areas that are experiencing a health care shortage.

“collaborative management puts us at the mercy of physi-

cians. if i didn’t have an agree-ment with a physician, i couldn’t practice at all,” said emily carroll, Rn, nurse practitioner at healthFinders collaborative, in an interview with Minnesota Pub-lic Radio. “i work in a free clinic, and often i’m the only provider in the building,” she added. “Peo-ple have to understand that this legislation isn’t going to expand what our licenses allow us to do. if i was with a patient and i believed i didn’t have the skills to treat them, i would send them to the appropriate physician. nurse practitioners are not going to act as cardiologists.”

the Minnesota advanced Practice Registered nurse coa-lition is lobbying for the change. according to its website, the new legislation would eliminate “unnecessary legislative and administrative barriers to aPRn practice, such as annual written agreements with a physician in order to prescribe, and legal requirements to have a collabora-tive management agreement with a physician in order to practice in Minnesota.” if the law passes, the Minnesota Board of nursing will

be responsible for aPRn regula-tion.

eighteen states and the Dis-trict of columbia currently allow aPRns to diagnose, treat, and prescribe medications to patients independently.

Regions Hospital Attains Stroke Center DesignationRegions hospital, st. Paul, has been certified as a comprehen-sive stroke center by the Joint commission and the american heart association/american stroke association. the hospital is the first in the state and one of 65 hospitals in the nation to receive this designation. Regions is one of only three certified com-prehensive stroke centers in the five-state area.

the Joint commission devel-oped this level of certification in 2012 to acknowledge hospitals that have specific abilities to receive and treat patients with complex stroke cases. Require-

ments include dedicated neuro-intensive care unit beds that pro-vide neurocritical care 24 hours a day, seven days a week, as well as advanced imaging capabilities, coordinating post-hospital care for patients, and participation in stroke research.

Waist Circumference Predicts Patient Risk For Diseasethe Mayo clinic has published results from an international collaborative study that found waist circumference has health consequences for patients, even those with a healthy body mass index (BMi).

Researchers from the U.s., europe, and australia shared data from 11 cohort studies that included information gathered from more than 600,000 people from around the world. they found that men and women with large waist circumferences were more likely to die at a younger age and were more likely to die

Capsules

High Pointe Health Campus Off I94 and Radio Drive

651.439.8807 or 800.423.1088 www.stcroixortho.com

URGENT C ARE

Radi

o D

rive

Hudson Blvd

High Pointe

7 DAYS A WEEK

Orthopaedic

Urgent CareProviding walk-in care for: • Fractures• Dislocations• Sprains and Strains• Muscle Pain

• Joint Pain• Sports Injuries• Concussions

Monday - Friday 1:00 p.m. to 8:00 p.m.Saturday & Sunday 8:00 a.m. to noon• No appointment is necessary• All patients are seen by a physician

April 2014 Minnesota Physician 5

of causes such as heart disease, respiratory issues, and cancer. Researchers examined BMi, tobacco and alcohol use, and physical activity levels.

specifically, men with a waist circumference of 43 inches or greater were found to have a 50-percent higher mortality risk than men with waist diameters less than 35 inches. Women with a waist 37 inches in diameter or greater were found to have about an 80-percent higher mortality risk than those with a waist circumference of 27 inches or less. according to the report, this information translates to an estimated three-year lower life expectancy for men, and about a five-year lower life expectancy for women, after age 40.

Researchers say a key find-ing from the study is that risk increased in a linear relationship to waist size, and that for every 2 inches of increased waist circum-ference, mortality risk increased by about 7 percent in men and 9 percent in women. these increased risks were observed regardless of participant BMi.

“BMi is not a perfect mea-sure,” said James cerhan, MD, PhD, Mayo clinic epidemiologist and lead author of the study. “it doesn’t discriminate lean mass from fat mass, and it also doesn’t say anything about where your weight is located. We worry about that because extra fat in your belly has a metabolic profile that is associated with diseases such as diabetes and heart disease.” cerhan suggested that physicians should consider BMi and waist circumference when assessing a patient’s risk for obesity-related premature mortality.

CentraCare Study Shows Health Care Home Impacthealth care homes are garnering attention in Minnesota, and the Minnesota Department of health recently reported that the service delivers higher quality of care at a lower cost.

centracare, an early adopter of the health-care home program, has released statistics illustrat-ing the program’s impact. as of Feb. 28, centracare had enrolled 1,736 patients in the health-care home program, served by 20 care coordinators at 11 clinic sites,

according to clinic officials. a 2012 study examined 192 cent-racare patients six months prior to enrollment in the program, and six months after enrollment. the results showed a decrease of 16 hospital readmissions, an increase of 213 outpatient visits, and a decrease of $255,000 in overall charges post-enrollment. additionally, a review of patient charges from February 2010 to March 2013 showed $2 million in cost savings based on the reduc-tion in charges for patients from one year before health care home enrollment to one year after enrollment.

“My passion for health care home stems from the power i see the process having in patients’ lives,” said Marilyn Peitso, MD, pediatrician with centracare clinic. “over and over again, i have seen dramatic reductions in hospitalizations, a decrease in need for urgent clinics, and an increase in autonomy for patients and their families. For example, i have a patient with multiple health care needs who now has been able to do more activities requiring travel away from home with his father or other relatives. Before having the security of a care plan, the mom was not comfortable allowing the child to travel without her, due to the complexity of the child’s care. i believe care coordination and care planning is one of the key features of effective health care in the future. it will be one of the foundational elements for reducing cost and improving outcomes.”

centracare will present its method and findings at the Min-nesota Department of health’s health care homes Learning Day this fall.

Senators Sponsor Bill To Change Medicare Payment Conditionsin late February, U.s. sen. Pat Roberts (R-Kan.) and sen. Jon tester (D-Mont.) introduced the critical access hospital Relief act of 2014 (s. 2037) to remove the 96-hour physician certifica-tion requirement as a condition of payment for critical access hospitals (cahs). Minnesota sen-ators amy Klobuchar (D) and al Franken (D) are cosponsors of the

News to page 6

Background and focus: As tools and techniques for treating chronic illness have expanded, so have methods and mechanisms of provider reim-bursement. More people now have access to care, and with this comes a heightened awareness of the impact of social determinants on health. The transition to rewarding physicians for maintaining a healthier population is slow but the promise is clear. Treating chronic illness remains an area of high-volume use and, improperly managed, quickly becomes an area of high cost.

Objectives: We will evaluate changes that health care re-form is bringing to chronic illness care. We will examine new community-based partnerships that are forming to address prevention, compliance, and better identification of risk. We will look at specific diseases and how workplace solutions, insurance companies, clinics, hospitals, long-term care facilities, and home care providers are working together to lower costs

MINNESOTA HEALTH CARE ROUNDTABLE

Please mail, call in, or fax your registration by 10/28 /2014

Please send me ____ tickets at $95.00 per ticket. Mail orders to Minnesota Physician Publishing, 2812 East 26th Street, Minneapolis, MN 55406. Tickets may also be ordered by phone 612.728.8600 or fax 612.728.8601.

Name

Company

Address

City, State, ZIP

Telephone/FAX

Card # Exp. Date Check enclosed Bill me Credit car (Visa, Mastercard, American Express or Discover)

Signature

Email


bill, along with 12 others.

according to current require-ments, at the time of admission, cah physicians are required to certify that a Medicare benefici- ary will be discharged or trans-ferred within 96 hours of admis-sion as a condition of payment. if the patient needs to stay longer than 96 hours for any reason, the physician must certify and docu-ment the circumstances in order to meet the condition of payment.

Recently, the centers for Medicare & Medicaid services published information implying it will enforce the condition of pay-ment moving forward, the Minne-sota hospital association (Mha) reports. historically, the rule has not been enforced. according to Mha, some of the services cahs offer entail lengths of stay that exceed 96 hours. Mha cites the example of a Medicare beneficia-ry with pneumonia who wishes to receive care from a local cah to remain close to home, rather than travel to another hospital system.

“Mha appreciates senators

Klobuchar and Franken’s lead-ership on this issue,” said Law-rence Massa, Mha president and ceo. “they recognize that if this condition of payment is enforced, it could create an access issue for rural beneficiaries. Mha strongly supports s. 2037 as a solution to this problem.”

HCMC Expands Cancer Center and Earns Certificationthe comprehensive cancer cen-ter at hennepin county Medical center (hcMc) recently received the staR Program certification from Massachusetts-based oncol-ogy Rehab Partners.

the certification qualifies facilities to offer premium cancer rehabilitation and survivorship services to patients who suffer from debilitating side effects caused by cancer treatments.

hcMc created a multidis-ciplinary group of 25 staff that will work together with each patient to determine a personal-

ized rehabilitation plan designed to increase strength and ener-gy, alleviate pain, and improve quality of life. the group includes the medical director of physical medicine and rehabilitation, ad-vanced practice providers, nurses, physical therapists, lymphedema specialists, occupational thera-pists, speech-language patholo-gists, a dietician, a social worker, and an exercise trainer.

in February, hcMc completed its $3.5 million renovation of its cancer care center, expanding it by more than 4,000 square feet. expansion created five additional exam rooms as well as counseling and procedure rooms.

Minneapolis VA Program Reduces Use of Opioidsthe Minneapolis Va health care system’s opioid safety initiative (osi) has decreased high-dose opioid use in veterans by 67 percent among its eight Min-nesota locations. the program

was launched in october 2013 to reduce opioid use by using non-prescription pain manage-ment methods.

“We started running num-bers on our patients and realized we did have a large number of patients on high dosages of opi-oids,” said Peter Marshall, MD, a primary care pain management physician at the Minneapolis Va Medical center.

osi emphasizes a team ap-proach to patient education, with close patient monitoring and fre-quent feedback, and alternative medicine practices such as acu-puncture and behavior therapy.

“We have developed and implemented joint pain manage-ment guidelines which encourage the use of other medications and therapies in lieu of habit-forming opiates,” said eric shinseki, U.s. secretary of Veterans affairs. “early results give us hope that we can reduce the use of opioids for veterans suffering chronic pain and share these best practic-es across our health care net-works.”

News from page 5

Rafael S. Andrade, MD

Kiran Lassi, MD

Ann Tienor, MD

Ben Mueller, MD, PhD

Lisa R. Mattson, MD


Rafael S. Andrade, MD, has been named chief of the section of thoracic and Foregut surgery in the Division of cardiothoracic surgery in the Univer-sity of Minnesota Medical school Department of surgery. he completed medical school at national autonomous University of Mexico; surgery residen-cy at the University of Minnesota; and fellowships at the University of Minnesota, indiana University (Bloomington), Memorial sloan-Kettering can-cer center (new york city), and the University of Pittsburgh. Board-certified in general surgery and

thoracic surgery, andrade previously served as interim chief of the same surgical section.

Robert Bösl, MD, has been named “2013 country Doctor of the year” by health-care staffing company staff care. the nationwide award is bestowed annually on a physician in a community of 30,000 or fewer residents. Bösl was chosen for the national award, in part, because he and his wife used their retirement savings to open a clinic after the sole hospital in their small, west-central Min-nesota town of starbuck closed. the clinic has since been acquired by stevens community Medical center of Morris, Minn. Board-cer-tified in family medicine, Bösl completed medical school and family medicine residency at the University of Minnesota. he is also a clinical assistant professor at the University of Minnesota–Morris.

Sarah A. Cooley, MD, director of oncology Medical informat-ics and services for the University of Minnesota Masonic cancer center, has received board certification in the newly created sub-specialty of clinical informatics. cooley is among the first group of physicians in the United states to become so certified. also board-certified in internal medicine, oncology, and hematology, she completed medical school at the University of Minnesota; internal medicine residency at the University of california, san Francisco; and a fellowship in hematology, oncology, and transplantation at the University of Minnesota.

Kiran Lassi, MD, has joined Minnesota oncology. Board-certified in medical oncology, hematology, and internal medicine, Lassi earned her medical degree from the University of nebraska school of Medicine, omaha. she completed an internal medicine residency at creighton University hospi-tal in omaha and a fellowship in medical oncology/hematology at Georgetown University hospital in Washington, D.c. Previously, she practiced at Fair-view southdale hospital.

Lisa R. Mattson, MD, has been installed as pres-ident of the twin cities Medical society for 2014. Board-certified in obstetrics and gynecology, Mattson earned a medical degree from Mayo Med-ical school, where she completed an obstetrics and gynecology residency. she is the director of Women’s clinic at Boynton health service, University of Minnesota.

Ben Mueller, MD, PhD, board- eligible in orthopedic surgery, has

joined the spine center at Regions hospital, st. Paul. he completed medical school and an ortho-pedic surgery residency at the University of Min-nesota and a fellowship in spine surgery at norton Leatherman spine center, Louisville, Ky.

Ann Tienor, MD, board-eligible in neurology, has joined noran neurological clinic. tienor earned her medical degree from the University of Min-nesota Medical school; completed a neurology residency at the University of iowa hospitals and clinics, iowa city; and completed a headache medi-cine fellowship at Loyola University Medical center, Maywood, ill.

Medicus

Physician Driven. Patient Inspired.

“The time they save me meetingreporting requirements allows me to spend

more time with patients.”— Christopher Wenner, MD, Clinic Owner

Integrity Health Network member, Cold Spring

• Referral network of 215 primary and specialtyphysicians

• QI/P4P Measurement development & reporting

• Competitive group purchasing contracts to controlyour costs

• Latest in EHR & Web Portal technology

• Partnering with health plans on new models of care

• Partnering with hospitals, clinics and employers towork on clinical integration and delivery

• Data Warehouse under development. Information iskey to competing and improving quality

• Marketing, risk management, clinic staff training

• Developing strategies to leverage exciting newopportunities: Accountable Care Organizations,Medical Home, Baskets of Care

Our independent physicians keephometown healthcare where it belongs.

Helping Independent Hospitals and Clinics compete:

Delivering a network of solutions

IntegrityHealthNetwork.com

Jeff Tucker, CEO([email protected])

Rachael Nyenhuis, COO([email protected])

888.722.8802Jeffrey L. Tucker, CEO

[email protected] 218.722.8802.112

Melissa Larson, [email protected]

218.722.8802.115

Helping Independent Hospitals and Clinics compete:

•Network of over 200 physicians and providers

•Q1/P4P Measurement development & reporting

•Competitive group purchasing contracts to control your costs

•AssistanceinfindinganEHRtomeetyourneeds

•Partnering with health plans on new models of care

•Partnering with hospitals, clinics and employers to work on clinical integration and delivery

•Data Warehouse under development. Information is key to competing and improving quality

•Marketing, risk management, clinic staff training

•Developing strategies to leverage exciting new opportunities: Accountable Care Organizations, MedicalHome,BasketsofCare

888.722.8802

IntegrityHealthNetwork.comDelivering a network of solutions

Our Independent physicians keep hometown healthcare where it belongs.

“The time they save me meeting reporting requirements allows me to spend

more time with patients.”– Christopher Wenner, MD, Clinic Owner

Integrity Health Network member, Cold Spring

interview

How did Allina SeniorCare Transitions start?

Aspen Medical Group—which joined Allina Health in 2008—had a geriatrics practice called AspenCare. The practice, composed of physicians and nurse practitioners, delivered on-site pri-mary care to residents of nursing homes who were too frail to come into the clinic for care, and post-hospital care to medical group pa-tients who required rehabilitation in designated skilled nursing facilities. This practice was the foundation of SeniorCare Transitions. We have found that quality of care is increased by having a group of providers who are dedicated to taking care of patients in nursing homes, as opposed to individual physicians, in the midst of their busy clinic practices, trying to manage a few of their aged patients in nursing homes.

What is your role with the program?I am the program director. I am accountable for both the business and clinical outcomes of our program. I manage a team of two medical direc-tors, three advance practice nurse managers, and an operations manager who supports our staff.

My job includes implementing our strategic vi-sion for post-acute care for seniors, and develop-ing collaborative relationships with other parts of our organization, to develop an integrated system of care for seniors. I also develop relationships with external partners—primarily skilled nursing and assisted living providers—to promote growth of our programs and improve processes of care for our shared patients. I have been involved in the design and fulfillment of creative payment mechanisms for seniors. Additionally, I am ac-countable for staff and leadership development.

What health care services does your pro-gram provide?

In the skilled nursing facility transitional care units (TCU), we provide post-acute medical care to patients who are in the TCU for short-term

rehab. This includes man-agement of the acute issues that were the primary reasons for hospitalization, and chronic conditions that may affect their rehab. We also participate in dis-charge planning, patient

education, and the management of care transi-tions. We selected TCU locations that are near Abbott Northwestern, Mercy, Unity, United, and Regina hospitals; Cambridge Medical Center; and St. Francis Regional Medical Center. In assisted living facilities, we deliver primary care services with a strong focus on chronic condition manage-ment, maintenance of function, and end-of-life care.

In what care settings do you work?We have a large post-acute program. Our teams provide care in 24 TCUs in skilled nursing facil-ities. We also have a primary care program that we bring to assisted living settings. In addition, we are in a joint venture with Geriatric Services of Minnesota for care delivery to long-term care patients.

How do you choose the TCU locations?The sites are selected based on several criteria. They include locations with a dedicated TCU unit with nursing, social services, and therapy staff competent in the delivery of post-acute care. There must be programming for post-acute care that includes admission seven days a week, therapy at least six days a week, interdisciplinary team rounds, and coordinated discharge plan-

A health system approach to providing care to seniors

Pat Peschman, DNP, RN, GNP

Allina Health

Pat Peschman is the director of Allina Health SeniorCare Transitions program. She has a doctorate of nursing

practice from St. Catherine’s University and is certified as a gerontological nurse

practitioner.

We bring medical services on site, so patients don’t have to go out to clinics.

8 MINNeSOTA PHySICIAN APRIL 2014

ning. Additionally, the skilled nursing facility must meet federal, state, and local regulations and achieve a 4- or 5-star rating on “Nursing Home Compare.” The staffing ratios must be adequate to deliver high-quality care, and appropriate ancil-lary services need to be place, including lab and X-ray with rapid response capability and a pharmacy with stat delivery capabil-ity. The facility must be willing to partner to improve care integration and patient outcomes, and offer amenities that allow providers to work on site, such as work space, Wi-Fi, etc.

What providers are part of your care team?

Our primary team for TCU and assisted liv-ing are a physician and nurse practitioner in collaborative practice. In our larger loca-tions, clinical assistants support the provid-ers. We partner with Allina Home Health, Hospice, Allina Health Home Oxygen and Medical equipment, and other specialty services such as palliative care and care management to deliver care to our patients.

How often do your providers see patients?

In the TCU, most patients are seen twice

per week. We are able to see them more frequently, however, if needed. In assisted living facilities, we generally see our pa-tients about every other month.

How are these services paid for?Our services are billed to a patient’s health insurance, including Medicare.

What are the benefits patients receive from your services?

There are many. We specialize in the care of older adults. We bring medical services on site, so patients don’t have to go out to clinics. We improve care transitions, communication, and care coordination. As part of a large health system, we are able to access a comprehensive network of services to provide care in a coordinated manner. We also work in strong partnership with the staff in the skilled nursing and assisted living facilities where we deliver care, to improve systems of care.

What results do you hope to achieve with this model of care delivery?

We have several goals:

• To improve the quality of transitions—

from the hospital to post-acute care in a skilled nursing facility, then back home—through process improvement, standardized workflows, use of elec-tronic medical records, and continu-ous monitoring of results.

• To improve patient experience scores for patients’ acute and post-acute episodes by preparing patients for the experience of a transitional care unit, engaging patients in goal-setting and development of self-care skills during their stays in transitional care units, delivering comprehensive geriatric care in the assisted living settings, and strong patient/family communication.

• To improve the quality of our care in TCU by tailoring our visit schedules to the acuity and needs of the patients, creation of care pathways for common diagnoses, continuing education for staff in the skilled nursing facilities as well as in our provider group, case re-views, and delivery of evidence-based care in a more consistent manner.

We are in the process of developing im-proved metrics to measure our unique results.

APRIL 2014 MINNeSOTA PHySICIAN 9

Office of Continuing Medical Education612-626-7600 or 1-800-776-8636 • email: [email protected]

Promoting a lifetime of outstanding professional practice

Annual Surgery Course: Vascular SurgeryMay 1-2, 2014Maintenance of Certification in Anesthesiology (MOCA) Training CourseMay 3, 2014Live Global Health Training (weekly modules)May 5-30, 2014Global Health - Honoring Choices Across CulturesMay 7, 2014Midwest Cardiovascular ForumMay 17-18, 2014Bariatric Education Days: Decade of Bariatric EducationMay 21-22, 2014Topics & Advances in PediatricsMay 29-30, 2014

ONLINE COURSES (CME credit available)www.cme.umn.edu/online

• Global Health - 7 Modules to include Travel Medicine, Refugee & Immigrant Health - NEW! Family Medicine Specialty• Nitrous Oxide for Pediatric Procedural

Sedation

For a full activity listing, go to www.cmecourses.umn.edu

Pain Mechanisms: From Molecules to TreatmentJune 2-6, 2014Workshops in Clinical HypnosisJune 5-7, 2014

NPHTI Pediatric Clinical HypnosisSeptember 11-13, 2014Psychiatry ReviewSeptember 29-30, 2014 Twin Cities Sports MedicineOctober 3-4, 2014Practical Dermatology (Duluth, MN)October 17-18, 2014Lillehei Symposium: Cardiovascular Care for Primary Care PractitionersOctober 23-24, 2014Internal Medicine ReviewNovember 12-14, 2014Emerging InfectionsNovember 21, 2014Geriatric Orthopaedic Fracture ConferenceDecember 5-6, 2014

University of Minnesota Continuing Professional Development

2014 CME/CPD Activities(All courses in the Twin Cities unless noted)

His vision of the world made clear

how naïve mine was.

I have read Osler’s essay so many times I’ve lost count.


specialty with a pioneering physician from another century. still others cited the inspiring deeds and principles of physi-cians who had a major influence on them.

We hope the responses to our question will strike a chord with our readers, and we thank the contributors to this feature for their thoughtful replies.

Robert Ganz, MDGastroenterologist; Minnesota Gastroenterology, PA

Many years ago, during my internal medicine training at the West side Va in chica-go—a very challeng-ing time of my life—the chief of medicine, clifford Pilz, asked me to read and present Wil-liam osler’s essay “aequanim-

itas” to all of the students and medical staff. it’s been so many years that i don’t remember why i was asked to present that essay (and i highly doubt that many house staff are asked to present classic essays in training today), but it was a lucky break for me,

as up to that point i had had no idea who osler was. that sin-gular essay

helped me immensely through my training, and since then i have read it so many times i’ve lost count.

i have also now read much of osler’s history and his com-pendium of writings. Whenever i feel low or overwhelmed by my practice or research; when things aren’t going the way i want; when i don’t understand why patients or colleagues react the way they do in certain situations; or if i’m just looking for wisdom in life, or how to be a better physician, husband, father or teacher, i pull out my osler essays. invariably, i find that he confronted the same situations—and wrote about them in a way that explains human nature and medicine so adroitly, and with such perfect insight, that i am imme-diately consoled or helped and can move on with better understanding.

no one in medicine has ever analyzed and explained peo-ple, doctors, training and the physician-patient relationship better than osler, or commu-nicated that understanding in such a forthright, caring, and professional manner. to say that osler has had more influ-ence on medicine and medical training than anyone else is true; but it is also true that no one understood better than he what patients and physicians go through on a daily and lifelong basis. no one person has helped me understand medical practice more than osler.

Which physician would i want to have dinner with? With a great deal of equanimity, my answer is osler.

Paul Waytz, MDRheumatologist; Arthritis and Rheumatology Consultants PA

My dinner will require some time travel; my physician, some resurrection. if you’ve heard of him, i will pay you a dollar. it was the summer of 1970, and i traveled from chicago to the still-segregated Mississippi Delta with a close friend—an-other white boy bent on making

a difference—after our first year of medical school. though we barely knew anything, we thought otherwise and carried out a research project with more than 500 african-amer-ican children in the holmes county head start program.

During three months there, and using some inventiveness, we met other kindred spirits in our quest to improve

health care in the rural south.

on august 15, we met cyril Walwyn, MD, for the first time. ten days later, we drove two hours to yazoo city to spend the afternoon and evening with him. Born in the caribbean and educated at howard, he staffed the african-american hospital and maintained a nearby office as well. We walked up a long, hot flight of stairs to encounter a 4-ft. by 20-ft. waiting room and an even smaller examina-tion room, crowded with books, papers, and equipment.

Later, at his beautifully decorated home, we sat in the garden, sharing several glasses of Jack Daniels. the setting, and maybe our presence, seemed to lay the kindling for an extraor-dinary conversation. (his wife later told us that she couldn’t remember when he last had a drink, adding, “you boys stirred something in him.”) We spoke about the life of an african-american GP, black-white relations, poverty and the south—and many other things. he spoke, gently but persisten- tly. his words questioned and challenged. his vision of the world made clear how naive mine was: in Mississippi, it would take more than a three-month effort by a couple of in-

Dinner with doctors from cover

SMARTDATASTREAMClearinghouse Services

Cleaner Claims. More Profit. Less Work.Smart Data Stream provides automated, real-time transaction capabilities supported by our vast and continually growing network. Smart Data Stream is able to provide automated integration of mailroom, data capture, data editing, and real-time reporting.

The Next Generation of ClearinghousesReduce costs and increase electronic volumes in the short-term while helping to create an effective and viable electronic network long-term. Smart Data Stream offers the most cost effective clearinghouse solutions with the highest quality of technical support, reporting, features and services.

Claims(837)

ERA(835)

Claim Status

Inquiries(276/277)

EligibilityInquiries(270/271)

BenefitsGet Paid Faster

Cleaner Claims, Fewer Rejections

Automatic Claim Forwarding

Easily Track and Monitor Claims

Reduce Time and Money Spent

Stop Manually Verifying Eligibility

Visit our Website Today!www.smartdatastream.us

or give us a call 651.690.0048

Leading Edge Reporting and Tracking | Lowest Transaction Fees | CORE Certified

Dr. Blackwell was the first woman to receive a

medical degree in the United States.

A physician who is clinically superb using only a simple

history and physical exam is, still, a clinician particularly

worthy of admiration.


spired med students; the times, as well, would have to change.

i’d go back to have a long dinner at his home and re- visit that conversation. i would tell him that we have an afri-can-american president now. he would remind me that holmes county is the poorest in the country.

Lindsey C. Thomas, MDForensic pathologist; Hennepin County Medical Examiner’s Office

if i could have dinner with any physician, living or dead, it would be elizabeth Blackwell (1821–1910). in 1849, Dr. Black-well became the first woman to receive a medical degree in the United states. the story is that

she was admitted to Geneva Medical college in upstate new york only because, when the dean and faculty put her appli-cation for admission up for a vote by the 150 male medical students, all of them voted to ac-cept her, believing it was a joke.

i think it would be fasci-nating to hear Dr. Blackwell discuss why she was interested in medicine and what it was like for her as the only woman in her class. even after graduating, it was hard for her to find em-ployment as a physician. even-tually she opened an infirmary in new york city with her sister, who was the third woman phy-sician in the U.s. Dr. Blackwell also founded four-year medical colleges for women in the U.s.

and england.

i would be curious to know what role her the-ology played in her practice; she was raised congrega-tionalist but later explored other religious perspectives, in-cluding Unitarianism. she wrote about the importance of sanitation and hygiene, but also the “fundamental connec-tion of mind and body” in her book, “Why hygienic con-gresses Fail: Lessons taught by the international congress of 1891.” it is intriguing to think of that in light of the interest today in holistic in-tegrated medicine. i’d love to hear what Dr. Blackwell would think of medicine today!

William Nersesian, MD, MHAPediatrician; Chief medical offi-cer, Fairview Physician Associates

a great hero of mine is sher-lock holmes. While detective holmes is fictional, his creator, (sir) Dr. arthur conan Doyle (1859–1930), was very real.

Doyle attended medical school at the University of edinburgh, scotland, and was influenced by a particularly astute professor there, Joseph Bell. Bell had a legendary abil-ity to observe a patient’s attire, appearance, speech, accent, and mannerisms and could make

astounding deductions about the person’s occupation, history, marital status, degree of wealth, education, and many other aspects of the patient’s life and background. a smudge of yellow-tinged mud

on a boot might mean that the patient had traveled that morn-ing through east London—the only place for miles where that particular hue of mud could be found. a characteristic tattoo on a patient’s wrist meant that the man was a seaman and had sailed the orient, where that special design was common-place. in the Victorian era, a worn-out felt hat and a dishev-eled hatband could only mean that the owner was a bachelor,

as no respectable wife would let her husband be seen in public with such a hat!

in our era, when clinicians make medical diagnoses using sophisticated blood tests and expensive imaging studies, a

physician who is clinically su-perb using only a simple history and physical exam is, still, a clinician particularly worthy of admiration. For that reason, i would choose arthur conan Doyle and his mentor, Joseph Bell, for my imaginary dinner!

Phillip Kibort, MD, MBAPediatric gastroenterologist; Chief medical officer, Children’s Hospitals and Clinics of Minnesota

i’ve chosen three physicians, based upon different areas of interest in my life.

one of my key responsibili-ties at children’s is overseeing quality and safety. the names Berwick, Pronovost, and osler come to mind quickly, but i would be most fascinated to talk to ernest amory codman (1869–1940). this pioneering Boston surgeon had the courage to suggest to his peers that we ought to measure our outcomes; know about the quality of work we do; and make our results


Medicine is complicated. So are

the laws that doctors, hospitals

and insurance companies have to

manage. Lockridge Grindal

Nauen is one of Minnesota’s

leading health care law firms. Our

health care clients are so satisfied

they’ll write us a referral.

Contact Eric Tostrud

[email protected]

The Lawyers

and Lobbyists

that Doctors

Trust

From the Courtroom to the Capitol.®

Has any other medical publication been utilized as extensively at “The Netter?”

Maimonides reconciled living a fully spiritual life with pro-moting the scientific world.

His work transcends culture and language.


public. he stood up for what he believed. Unfortunately, he end-ed up a pauper and was kicked out of his hospital and surgical society because of his coura-

geous vision and foresight. Like many great visionaries, he was rejected by his own and only later considered to be correct. i would love to know his thought process in the early 20th centu-ry—and to tell him we’ve only recently begun to do what he dreamed of.

My second choice of physi-cian to dine with stems from my avocation of studying amer-ican presidential history. While it’s tempting to choose from the physicians who dealt with Garfield, Lincoln, Kennedy, or Reagan after they were shot,

i would most like to talk to is John F. Kennedy’s secret physi-cian, hans Kraus. Kennedy had many medical problems and was taking a polypharmacy of drugs. i would ask Kraus what he thought he was doing and

how he felt he was protecting the U.s. by covering up for this president, whether in regard to his back issues, addison’s, or use

of amphetamines.

Finally, in light of my ethnic and religious background, i would love to talk to Moses Mai-monides (1135–1204). Maimon-ides, who lived in spain, was a brilliant rabbinical scholar, philosopher, and astronomer, as well as a revered physician. he had great impact on the leaders of spain, his influence on Jewish law resonates even to-day, and some medical schools still use his oath. i would ask how he reconciled living a fully spiritual life with promoting the scientific world.

Chris Leisz, DOPhysical Medicine/Rehab Specialist; Courage Kenny Rehab Institute, St. Paul

i would love to dine with Frank netter, MD, aka “Medicine’s Michelangelo.” as every phy-sician knows, he is the author and illustrator of the “atlas of human anatomy,” which most physicians know eponymously as “the netter.” has any oth-er medical publication been utilized as extensively as this book?

netter was born in 1906 and attended art school in the 1920s, but his father did not

approve of his chosen career. he graduated from nyU Medical school and completed a surgi-cal residency, but he continued to draw and paint. ciba-Geigy began featuring his illustra-tions in their publications in 1937. Most of us who trained in the last 20 years remember the ciba “clinical symposia” series. the conditions he depicted in the series were so vivid and memorable that they provided a clear mental image for medical students learning about disease states.

through his work with ciba, netter was able to abandon surgical practice and become a full-time medical illustrator, producing more than 4,000 paintings during his career.

as a physical medicine specialist, i continue to use “the netter” almost every day. i would like to tell him how much

his illustrations have helped me understand the musculo-skeletal system. he evidently collaborated with the medical giants of his time, so it would be fun to hear his stories about that part of his work. he died in 1991, having lived enough to see some miraculous advancements in medicine. it would truly be a privilege to get to know this man.

Charles Bransford, MDInternist; Director of Hospice and Palliative Care Services, Lakeview Hospital, Stillwater

When i was asked to contribute to this feature, i was actual-ly at a conference run by the person i would choose as a dinner companion: Jim Gordon, founder and director of the center for Mind-Body Medicine (cMBM), based in Washing-ton, D.c. he and his growing group of trained practitioners provide care to traumatized people across the world, using the cMBM model described in his book “Unstuck.” their goal

is to provide training for “people on the ground” who can con-tinue care long after they leave.

at the conference, Jim and i were able to

have a real discussion about his work. We sat close together on soft hotel chairs. he leaned in close, as he is hard of hearing. i asked Jim to think about his greatest patient care experience and the guiding principle of his remarkable career. i expected him to recount some incredible

experience in Gaza, haiti, the syrian camps, new orleans after Katrina, or his work with returning vets or cancer pa-tients. But no; he told me about a young, traumatized, adopted immigrant boy he is working with, using mind-body therapy such as guided imagery and meditation. the boy had man-aged to keep the same job as a busboy for six months without

Dinner with doctors from page 11

Lakeside Historic Lodge • Log Homes • condos • townHomes

8 8 8 . 7 4 8 . 5 1 7 0 • l u t s e n l o d g e . c o m

Spectacular Fall Getaways. Relaxing, romantic vacations on Lake

Superior’s shore. Enjoy fabulous lakeside dining, a great wine list,

fall color hikes and guided sea-kayak tours. A great couples getaway.

The perfect place to unwind.

We still can’t say what it takes for a human being’s

brain to be conscious.

“… the secret of the care of the patient is in the caring for the patient.”

getting fired, and had made his first friend—pretty close to a miracle, given his history.

Jim described his guid-ing principle as living as much as possible in the pres-ent moment. sitting with

him, i could sense his wondrous curiosity about the human condition, accompanied by an overwhelming drive for justice in the world and for relief of suffering.

there is a remarkable can-do, entrepreneurial spirit sur-rounding Jim. he believes each of us has the power of healing within ourself. to watch him work with groups and see them gradually transform themselves into something greater than each individual is truly to ap-preciate Jim’s genius. his work transcends culture and lan-guage. it represents a lifetime of experience that he freely shares with the world. Look for the cMBM team at the next world crisis—they will be there.

Lee Beecher, MDPsychiatrist; President, Minne-sota Physician-Patient Alliance; Adjunct professor, University of Minnesota

here’s what i’d say to sigmund Freud if we had a conversation at dinner:

Dr. Freud, the “intimate medical relationship” is under great threat in 2014. you antici-pated the need to know how the brain works with your “Project for a scientific Psychology” in 1895. But, within the limits of neuroscience in your time, you also showed how crucial human relationships shape our brains and personalities. and you demonstrated the clinical power of helping patients through

understanding and reshaping their words, language, stories

and relationships within an intimate, trusting doctor-patient relationship, which you termed psychoanalysis. even though you focused on psychological issues primarily during your career, you never overlooked the fact that it is an organ composed of three pounds of flesh—the human brain—that creates and retains all thoughts and emotions.

the good news: in 2014 neuroscientists are zooming in on the fine structure of indi-

vidual neurons, each of which has 10,000 synapses. they are charting the biochemistry of the brain, surveying how more than 100 billion neurons produce and employ thousands of dif-ferent proteins, creating repre-sentations of the brain’s 100,000 miles of white matter tracks, and starting to identify the differences between ordinary brains and those with disorders such as schizophrenia, autism, and alzheimer’s disease.

yet, despite advances in psy-chopharmacology over the past 60 years, we face challenges in doing clinical medicine in 2014. First, scientifically, we still can’t say what it takes for a human being’s brain to be conscious or, biophysiologically, to think or to think specific thoughts. the vision of a scientific psychology as outlined in your “Project” in 1895 remains unfulfilled.

and, given the current eco-nomics and politics of medi-

cal practice, obtaining an adequate assessment of a patient’s diagnosis and eval-uating an ongoing plan of treatment is daunting—giv-en a 10-minute visit autho-rized by the clinic manager or insurance company,

along with mandatory computer documentation and limitations on future appointments. an intimate medical encounter crucial to the practice of interperson-al medicine is severely limited now, and this threatens the ability of psychiatrists and many other physicians to do their best work with patients.

Sanne Magnan, MD, PhDInternist; President and CEO, In-stitute for Clinical Systems Improve-ment; Staff physician, Tuberculosis

Clinic, St. Paul-Ramsey County

My dinner would be with Fran-cis Peabody, whose seminal article the care of the Patient was published in JaMa in 1927. i would tell Dr. Peabody that i love this quote from that article: “… the secret of the care of the patient is in the caring for the patient.”

then i would ask him about another quote from that article: “What is spoken of as a ‘clinical

picture’ is not just a photo-graph of a man sick in bed; it is an impres-

sionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes, and fears. now, all of this back-ground of sickness which bears so strongly on the symptomatol-ogy is liable to be lost sight of in



For more information or to receive a no-cost insurance assessment please call

Tom Stender218-625-2120 • [email protected]

Providing SoluTionS To The unique inSurance needS of rural PhySicianS

for over 125 yearSIndependently owned with offices in Duluth, Hibbing,

and Ashland. We understand the challenges of being a health care provider in outstate Minnesota.

We provide customized policies and highly personalized service in the fields of:

• Medical Malpractice/ Tail Coverage• Property/ Liability/ Workers’ Comp• Personal insurance with umbrellas up to $20 Million

• Financial Planning• Group Benifits

www.otismagie.com332 W Superior Street Suite 700 • Duluth, MN 55802

We would wash down our dinner with plenty

of German beer.

His suggestion that physicians wash their hands and clothes to

help prevent such deaths was met with ridicule and anger.

the hospital.”

i would hope we could then discuss what “the care of the patient” would look like for our patients today. how do we go beyond the four walls of our clinic or hospital to care for patients and their families in their communities? how do we use our influence, credibility, and reputations to improve the communities where our patients live, learn, work, pray, and play?

i believe that Dr. Peabody’s insights would re-inspire us to care for our patients not only in

our facilities, but also in many other ways in their lives and communities.

Thomas J. Stormont, MDUrologist; Stillwater Medical Group

i would like to have dinner with the German physician Philipp Bozzini in the early 1800s in his favorite restaurant in his home-town of Frankfurt, Germany. it would be of historic interest to hear of the lichtleiter (light conductor), which he invented in 1805. the lichtleiter was com-posed of various rigid examin-ing tubes using a wax candle in a holder and a mirror for illumina-tion; its use eventually led to the development of modern endos-copy.

i would want to hear about the development and use of his

instrument, and then i would bring him up to date with

current flexible high-defini-tion digital endoscopy and the working channels that allow

lasers and other instruments to be used. he would likely be as impressed with current state-of-the-art

endoscopy as i would be with his ability to inspect a man’s bladder by candlelight, using primitive anesthesia and his rigid lichtleiter.

We would wash down our dinner with plenty of German beer, making sure the food was all thoroughly cooked and served with clean hands—some sources report that Dr. Bozzini died of typhoid fever at age 35, in 1809, long before the intro-duction of pasteurization.

Jon Nielsen, MDObstetrician-gynecologist; Oakdale Ob-Gyn

one day when i was 15 years old, i picked up a book in our living room entitled “cry and the covenant” and began read-ing it. i had decided by age 9 that i wanted to be a doctor, and already had a keen interest in european his-tory, so i was delighted to discover this book covered both interests. it made a lifelong impression on me.

Written as an historical novel, the book described the life of ignaz semmelweis, a hungarian/German obstetri-cian who lived and practiced medicine in Prague. semmel-weis’s common-sense deductive

analysis led to the discovery of puerperal (childbed) fever, which at the time had up to 40 percent mortality. however, his suggestion that physicians wash their hands and clothes to help prevent such deaths was met with ridicule and anger. in 1865, semmelweis was committed to an asylum, where he was beat-en, and he died 14 days after admission.

i would love to speak with semmelweis about his deduc-tive logic, and to explain to him the huge effect he had on the world by illuminating the asso-ciation between fever/infection and hand washing/cleanliness. i would want him to know that more than 150 years later, we still focus on hand washing.

one of the mysteries in sem-melweiss’s day was why women got sick during childbirth in the famous teaching hospital in Prague, but not in the small towns while being cared for by

midwives. he would be sur-prised to learn that despite all our progress in medicine, we still have to worry about pa-

tients getting sick in hospitals and acquiring infections that can be fatal.

as an obstetrician-gynecolo-gist, i would want to ask sem-melweiss about other things he knew about delivering babies, long before the introduction of our current technology. and, having graduated one course 14 Minnesota Physician April 2014

Dinner with doctors from page 13

Do you have patients with trouble usingtheir telephone due to hearing loss, speechor physical disability?

If so…the TED Programprovides assistive telephoneequipment at NO COSTto those who qualify.

Please contact us,or have your patientscall directly, for moreinformation.

1-800-657-3663www.tedprogram.org

The Telephone Equipment Distribution Program is funded through theDepartment of Commerce Telecommunications Access Minnesota (TAM)and administered by the Minnesota Department of Human Services

Duluth • Mankato • MetroMoorhead • St. CloudTe

lepho

neEq

uipm

ent

Dis

trib

utio

n(T

ED)

Prog

ram

Bethune started using mobile blood transfusion services to

take blood to wounded soldiers near the front lines.


short of a minor in european history in college, i would be fascinated to hear about life in Prague in the mid-1800s.

i would like to thank him for being a hero of medicine and in some way apologize for his treatment by his fellow man.

Ann Dillon, MDInternist; Dillon Sharpe Cockson & Associates, PA

My first thought was to dine with a famous doctor: albert schweitzer. after all, here was a man with three pages of quotes on the internet. howev-er, on further consideration, my thoughts turned to a less famous doctor who was connected with my medical school (McGill University in Montreal): norman Bethune.

Born in 1890, Bethune grew up in rural canada. From the beginning, although he was

a proclaimed atheist, he had a heart for service. During

medical school he took a year off to teach reading and writing to workers in remote lumber and mining camps. he again

suspended his studies to be a stretcher-bearer in France during World War i. Later, as a

doctor in Montreal, he treated the poor and was a proponent of socialized medicine.

on a trip to Russia in 1935 to observe their system of health care, Bethune decided to become a communist. the next year, he went to spain to fight the fascists in the spanish civil War, during which he started using mobile blood transfusion services to take blood to wound-ed soldiers near the front lines.

in 1938, Bethune traveled to china to help Mao Zedong organize medical services during the chinese civil War and the second sino-Japanese War. he performed many emergency battlefield surgeries and trained doctors, nurses, and orderlies. While there, he developed septicemia and died in 1939. Bethune was relatively unknown in canada until Mao published an essay later that year documenting his devotion to the chinese people and his selflessness.

i would talk to him over

dinner about where politics and medicine overlap, and how to contribute beyond the day-to-day business of medicine. though few of us are willing to go to a war zone or permanent-ly uproot our lives to practice in a remote location, many of us went into this profession for altruistic reasons. and we have found ways to express our altruism, whether through mis-sion work, hospital community outreach, or volunteering in free clinics. even if we cannot dine with doctors such as nor-man Bethune (and, yes, albert schweitzer), they inspire us to find more meaning in our life and our profession.

Editor’s note: Donna Ahrens served as editor of Minnesota Physician from 1999-2014. She has recently retired and as her final project put together this feature. From all of us at Minnesota Physician Publishing we wish her the best in her next chapter and send our sincerest thanks for all of her enthusiasm, dedication and outstanding work.


sustain the pronounced dispar-ities in african american men in such areas as unintentional and violence-related injuries, cardiovascular disease, prostate and other cancers, diabetes, and stroke across the life course. the goal is to develop, imple-ment and evaluate interventions that will improve african amer-ican men’s health.

Why a new approach is neededBiomedical research tradition-ally focuses on how physiolog-ical processes impact health, while public health research has emphasized how the behavioral characteristics of individuals impacts health. the two are not mutually exclusive. the social contexts in which peo-ple are born and live, however, are often neglected in clinical research efforts to determine factors responsible for the differential health outcomes of african american men.

the World health orga-nization identifies the social determinants of health as circumstances in which people are born, live, work, and age. social and economic policies, the distribution of power and resources, schooling and edu-cation, and other overarching fundamental factors each play a role in shaping these social determinants of health. By investigating the socioeconom-ic and environmental factors involved in african american men’s health, the ntcc takes a life-course approach, pinpoint-ing critical periods in a person’s life, such as youth/adolescence, young adulthood, middle age, and old adulthood, when social context may be more salient in the way if affects physiology or shapes health behavior.

the ntcc integrative ap-proach accounts for multiple, simultaneous pathways that can lead to poor health outcomes in african american men. in particular, a complex interplay of socio-environmental, behav-ioral, and bio-physiological in-fluences involved in the etiology, management, and melioration of chronic diseases, and the prevalence of unintentional

and violence-related injuries, cannot be underestimated. this integrative approach seeks to understand how risk of disease is differentially acquired and manifested over the life course and how it can be ameliorated.

Health disparities in MinnesotaWhile Minnesota has been recognized nationally as having some of the most positive health outcomes in the country, the same cannot be said for af-rican americans living here. adverse health outcomes for african americans are some of the highest in the nation. these health outcomes result in lower life expectancies for african americans in Minnesota—75.4 years, compared with 81.1 years for whites. according to data from the centers for Disease control and Prevention/nation-al center for health statistics/ health Data interactive (www.cdc.gov/nchs/hdi.htm), the cancer death rate for males in Minnesota (per 100,000 popu-lation, 2007–2009) is 205.5 for whites and 295.0 for african americans. the overall male cancer death rate in the U.s. is 217.8 for whites and 281.5 for african americans. socio-economic factors, such as low education levels, widespread un-employment, unhealthy lifestyle behaviors, high poverty, lack of health insurance, and lack of health literacy—in combination with a number of biological factors—impact the prevalence and aggressiveness of cardio-vascular disease, cancer, and stroke in african americans.

the Minnesota Department of health’s “eliminating health Disparities initiative” (ehDi)report (published in alternate years), stated in its January report that the death rate in Minnesota from diabetes for af-rican americans is almost twice the rate for whites, with kidney failure 40 to 50 percent greater in african americans. also in Minnesota, african american men die from stroke at a rate 22 percent higher than for white men.

Many national health rank-ings place Minnesota high in

African American men’s health from cover

NTCC partners with national organizations

The National Baptist Convention Foundation USA, Inc., (NBC) was established in Atlanta in 1895. It is the largest organization of African American Baptist congregations in the world, with more than 10 million parishioners.

With the motto of “Building Health Communities—Congregation by Congregation,” the NBC Health Outreach Prevention Educa-tion Initiative works to dramatically improve the health of African Americans.

100 Black Men of America, Inc., (100 Black Men) is a national organization that seeks to improve the quality of life for all African Americans by enhancing educational and economic opportunities. In an outreach to improve health outcomes, 100 Black Men pro-vides access and tools on prostate and colorectal cancer, cardio-vascular disease, depression, and sickle cell anemia.

The National Football League has a diverse portfolio of communi-ty outreach initiatives. They include prostate cancer screening and treatment initiatives in conjunction with the American Urological Association. The Minnesota Vikings will serve as the NTCC coordi-nating center.

for african american Men’s health (ntcc), has five distinct regional centers—UMn; UaB; MD anderson center, hous-ton; Johns hopkins University

in Baltimore; and University of california, Davis. Research will focus on investigating the socioeconomic, behavioral, and biological factors that drive and

Quality Transcription, Inc.

Settingthe

standardsfor

excellence

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

Our equipment is state of the art with 24 hourdictation lines and nationwide accessibility.

We are experts in our field. We deliver ontime. We have experienced staff. We monitorthe quality of our work.

We provide services tailored to your needs andwill do whatever it takes to get the job done.

Quality Transcription, Inc.8960 Springbrook Drive, Suite 110Coon Rapids, MN 55433Telephone 763-785-1115Toll Free 800-785-1387Fax 763-785-1179e-mail [email protected] www.qualitytranscription.com


terms of general health status compared to other states, and the agency for healthcare Research and Quality—in its most recent ranking—places Minnesota no. 1 across quality measures.

however, according to the ehDi report, some recent rank-ings find Minnesota has fallen to sixth. this drop is directly attributable to health differenc-es between populations of color and white populations. accord-ing to the ehDi, economic in-stability, unsafe neighborhoods, and inadequate access to health care ultimately results in poor health outcomes and shorter life spans, as well as higher health care costs for those populations of color. For example, higher incidence of diabetes, heart disease, cancer, and generally poor health are found in people of color living in Minnesota.

Recent immigrants from across the globe are contrib-uting to Minnesota becoming an increasingly diverse state. in 1990, african americans accounted for only 2 percent of the total population in Min-nesota. From 1990 to 2010, growth in the african american population grew 189 percent, accounting for 5.2 percent of the total population.During this same period, the percent of african american foreign-born population accounted for 28 percent of the total african american population, com-pared to 5.2 percent in 1990. the ehDi projects that Min-nesota’s non-white population by 2025 will be approximately 22 percent. While the report acknowledges that many issues contributing to health dispar-ities are broad and complex, it also notes that to change the downward trajectory of Min-nesota’s health status rankings, the approach needs to include community partnerships, both local and national.

Developing community partnershipsto implement proposed inter-ventions and disseminate re-search activities, the ntcc has formed a partnership with three national community partners—

the national Baptist conven-tion Foundation Usa, inc., 100 Black Men of america, inc., and the national Football League. these community partners will be instrumental in helping to develop collaborative strategies and interventions to change the current trajectory of african

american men’s health on both a local and national level.

each of the national com-munity partners has well-devel-oped community engagement profiles and cultures, which eas-es the development of a unique academic-community partner-ship. Utilizing this infrastruc-ture, the research landscape will be transformed dramatical-ly, offering new opportunities to reach the african american community. Ultimately, commu-nity partner involvement will pay dividends for many years, both in Minnesota and across the nation.

the ntcc community partners have respected, strong relationships with african american communities, which are essential in developing col-laborative strategies to explore factors responsible for the differential outcomes of african american men involving unin-tentional and violence-related injuries, mental disorders, and chronic diseases.

as part of the local com-munity, UMn has assembled a multidisciplinary team of inves-tigators and national experts, who have long track records of previous collaborations. this team has expertise in diverse fields from public health to cardiovascular disease, cancer control and prevention, surgical oncology, psychosocial motiva-tions, adolescent risk-taking, to community-based participatory research.

on the team with me are Jasjit ahluwalia, MD, MPh; Kola okuyemi, MD, MPh;

christopher Warlick, MD, PhD; Mary Kwaan, MD, MPh; Mon-ica colvin-adams, MD; sonia Brady, PhD; chap Le, PhD; yen-yi ho, PhD: and haitao chu, PhD.

Pilot project underwaythe ntcc is in the first phase

of a five-year project. Locally, collaborative efforts between academic and community partners have begun, with a pilot project under the direction of sonya Brady, PhD, project lead investigator, and Willie Winston, iii, PhD, community coalition leader. “communities invested in healthy Life tra-jectories of african american Boys” is a community coalition that will select, refine, imple-

ment, and evaluate a school-linked intervention for socio-economically disadvantaged african-american boys ages 8 to 14, and their caregivers at a st. Paul elementary school. the project’s goals are to prevent or reduce externalizing symp-toms, risk behavior, school-based disciplinary action, and juvenile justice involvement, by promoting family, school, and community connectedness; academic investment; and social and emotional well-being. the final phase will include offering interventions to families and developing a communication campaign to promote family involvement.

Badrinath r. Konety, MD, MBA, is a professor at the University of Minnesota, where he holds the Dougherty Family Chair in Pros-tate Cancer and is director of the Institute for Prostate and Urologic Cancers. He is a fellow of the Amer-ican College of Surgeons and the American Urologic Association.

Community partner involvement will pay dividends for many years, both in

Minnesota and across the nation.

Order

Jetted tubs are full of dangerous biofilm, body waste, mold and bacteria if not cleaned properly. It takes specialized cleaners like Oh Yuk Jetted Tub Cleaner to effectively and safely clean contaminants from the tubs plumbing system. Improperly cleaned tubs may put users at risk of infections and/or respiratory problems.

• for your home Jetted tub or hot tub

• for your clinics’ rehab therapy whirlpools

• tellyourpatients!

Is your jetted tub making you sick?

For product information visit:www.scientificbiofilmsolutions.com

Anaphylaxis is a medical emergency requiring immediate intramus-

cular epinephrine. It can be caused by food, drugs, stinging insects, radiocontrast dyes, or mastocytosis. Anaphylaxis can occur within minutes or up to two hours after exposure, which includes ingestion or injection. Many times the cause of anaphylaxis is unknown and labeled idiopathic. This is very frustrating for the patient as well as the provider. All cases of anaphylaxis should be referred to a board-certified allergist.

The following case, which has had identifying information changed, was related to a newly identified trigger.

Pieces of the puzzleWho? What? A 60-year-old man living in Minnesota had four episodes of anaphylaxis. During the first three episodes, the patient showed up at an emergency room with itchy red hives all over his skin, difficulty breathing, nausea, and vom-

iting. Epinephrine was given immediately, which made his symptoms go away. The fourth episode occurred while he was on a hunting trip in a remote location; he self-injected epi-

nephrine with an EpiPen, which relieved the symptoms. An hour later he arrived at a hospital, where his symptoms did not recur.

The first episode occurred while he was chopping wood during a vacation in Virginia, where he grew up. On two of the four occasions he experienced anaphylaxis, he had eaten fish

one or two hours before symp-toms appeared. But the other two allergic reactions occurred in the middle of the night, when he had not eaten for six to eight hours.

Medical factors. The patient’s primary care provider tested the patient’s blood to see if the man was allergic to fish. The test was negative. The patient reported that he had not been stung by a bee, wasp, or hornet, which could have explained the anaphylaxis. Nor was he taking cancer medication, antibiotics, or blood pressure medication, which also could have caused his reaction. He had taken ibu-profen for knee pain two hours before one of the anaphylactic episodes but had tolerated ibu-profen after the reactions. He had exercised two hours before two of the episodes. His past medical history indicated that he had mild hayfever, which he self-treated with over-the-coun- ter antihistamines as needed. He had no cancer, asthma, heart problems, or gastrointes- tinal problems.

Geography, lifestyle. The pa-tient’s lifestyle history revealed that he had recently retired from work as a park ranger. He was now spending more time visiting his relatives in Virginia; while there, he and they often visited a cabin where he had

spent a lot of time as a boy. This is where he was when his first anaphylactic episode occurred.

Fitting the pieces togetherWhen it was revealed that he grew up in the middle states, a key question was asked that solved the puzzle.

The New England Journal of Medicine reported in 2008 that a carbohydrate called galactose-alpha-1,3-galactose (alpha-gal) was causing ana-phylaxis in patients who shared several things in common.

One: These patients lived in the same part of the country, which included Virginia, Mis-souri, and Tennessee.

Two: They were being treated with a cancer drug, (cetuximab) which contained alpha-gal.

The third commonality among these patients? In addi-tion to experiencing an allergic reaction shortly after their cancer drug was administered, these patients experienced a delayed allergic reaction hours after they ate red meat (i.e., beef, pork, or lamb).

Red meat contains alpha-gal.

The reason that these pa-tients’ allergic reaction after eating meat was delayed com-pared with their faster onset of symptoms after administra-tion of the cancer drug is that alpha-gal in meat is attached to protein. The delayed reaction occurred because the ingested alpha-gal had to go through the intestines in order for digestion to release the alpha-gal from the protein. At that point, the patients’ bodies recognized it as an allergen and responded with anaphylaxis. Furthermore, these patients also had allergic reactions to the lone star tick, which is endemic in their region of the United States. A blood test was developed to detect allergy to alpha-gal.

The final puzzle pieceThe key question was whether or not the patient had any reac-tion to tick bites. In fact, he had large hives around the tick bites he received in Virginia—but

18 MINNESOTA PHySIcIAN April 2014

Professional UPdate: allergy

Mystery diagnosis for allergic reaction

New anaphylaxis trigger identified

By Nancy L. Ott, MD

This case illustrates the importance of taking a thorough medical history.

Cutting edge expertisemakes Episcopal Church Home your TCU of choice

for patients requiring

Complex Wound Care

Introducing the newest member of our TCU team: Cristina Presbitero, BSN, RN, WCC

Cristina Presbitero is a Med-Surg and Wound Care Certified RN with over eight years of experience in complex wound care and enterostomal nursing and consulting. This means:

• More wounds managed in house versus out patient, reducing total care cost and rehospitalization.

• Wound vac management.

• Track healing rates on hospital and house-acquired wounds, incident bases on diagnosis and risk factors, reducing hospitalization.Questions? Please contact our Admissions Coordinator

Kelly Emerson at 651-632-8842

April 2014 MINNESOTA PHySIcIAN 19

not tick bites in Minnesota. The middle states have the lone star tick, which is responsible for the alpha-gal allergy.

The alpha-gal specific IgE test was performed on the pa-tient’s blood and confirmed his allergy to alpha-gal.

After further history-taking, he remembered having eaten steak or hamburger each day he experienced an anaphylactic reaction. The days his episodes occurred within two to four hours of eating beef were the days he was working vigorously (chopping wood, clearing brush) or had taken ibuprofen, both of which are known to enhance an allergic reaction such as ana-phylaxis and may have hastened onset of the reaction.

Although this patient lived in Minnesota where the lone star tick has not been found—yet—and although he was not taking the cancer drug that has been associated with this allergy, he did spend time in Virginia and

had a history of allergic reac-tions to tick bites.

Lesson learnedThis case illustrates the im-portance of taking a thorough medical history. Although the patient had told his story to multiple providers during the course of two years, none of them had made the connection between his time spent in a state known to contain the lone star tick (Virginia), his long his-tory of tick bite reactions, and his red meat consumption the day of the reactions. All factors pointed to alpha-gal.

If your patients vacation or have lived in the region of the country known to contain the lone star tick and have had hives or reactions to tick bites, be aware of this unusual allergy. check the cDc website for states that have the lone star tick (www.cdc.gov/ticks/maps/lone_star_tick.html). Keep in mind that climate change may cause this tick to extend into

more northern and western states over time.

Nancy l. Ott, MD, is board-cer-tified in pediatrics and in adult and

pediatric allergy and immunology. She is a senior associate consultant at the Mayo Clinic Children’s Center, Rochester.

The lone star tick (Amblyomma americanum) transmits Ehrlichia chaffeensis and Ehrlichia ewingii, causing human ehrlichiosis, tularemia, and STARI (southern tick-associated rash illness). It is primarily found in the southeastern and eastern United States.

White-tailed deer are a major host of lone star ticks and appear to represent one natural reservoir for E. chaffeensis. The tick’s larvae and nymphs feed on birds and deer. Both nymphal and adult ticks may be associated with the transmission of pathogens to humans.

STARI is specifically associated with the lone star tick.

This is called the “lone star tick” because the female has a single silvery-white spot on its back, although the males have scattered spots or streaks around the body’s margins. The adult tick has eight legs, and is brown to tan. It’s about one-third inch long before feeding, growing up to one-half inch long after feeding. The bite is not initially felt by humans or other mammals.

While lone star ticks are usually found in the U.S. South—from central Texas to Oklahoma—they also can be found along the Atlantic coast as far north as Maine.

Sorce: Information from the Centers for Disease Control and Prevention (CDC) and Texas A&M University. For more information, visit (www.cdc.gov or https://insects.tamu.edu/fieldguide/cimg370.html).

About the lone star tick

Are you satisfied with your claims processing?

You will be with ClaimLynx!Every medical practice depends on cash flow. Very few people understand the

required processes between when a doctor sees a patient and how/when insurance reimbursement is disbursed. We make these steps simple for you.

Among the services we offer:• Direct, real time verification of

eligibility• Secure online access to claims

tracking• Secure online access to claims

correction• Never miss a payment due to late filing• We handle every kind of insurance and

every medical specialty• Less time on paperwork, more time

with patients

ClaimLynx is used by many nationalclearinghouses. You may already beusing our services and not know it.Shorten your submission route and remittance time—go straight to the payer using ClaimLynx.

Every practice is unique and whether a solo practitioner or large multi-specialtygroup (and everything in between) we can tailor a solution to your claimsprocessing needs that will maximize your benefits.

www.claimlynx.com

For more information please contact:Russel Campbell [email protected]

10700 Old County Road 15 Suite 200, Plymouth, MN 55441

952-593-5969

Claims processing is an art. Let us showyou the difference we can make


attempts to assess the “true” cost of health care in the U.s. are fraught

with inconsistencies. yet the goal is noble: to benchmark the per capita cost of care in order to control or even reduce it, making health care affordable for all. But deciding on a stan-dard unit of measure for health care costs has been a challenge. For example, what should be used for comparison—the list price of a service or procedure, or only the patient’s portion of the cost? and how can we ever determine the true cost to so-ciety, encompassing direct and indirect aspects of care?

While all math models have limitations, the key to a stable, consistent cost of care measure will be an agreed-on common methodology, with verifiable attribution and high enough sample size to lessen the impact of random variation.

there are a variety of rea-sons that a universal total cost of care measure has been so

elusive:

1. since medical records do not have cost informa-tion, especially for other providers involved in the patient care, the only cen-tral source is insurance claims. this means that one doctor does not know what other doctors are getting paid.

2. there is no perfect attri-bution system (i.e., the method to identify which provider will be allocated a patient’s costs).

3. the actual amount paid varies by payer, network, and moment in time.

4. Because there have been different methods of measuring cost, providers have been known to get contradictory results, de-pending on who is doing the measuring, and how.

5. Finally, since cost is a con-tinuous variable, risk ad-justment and outlier rules need to be applied so a few patients don’t swamp the entire result. costs can vary from $1 to $1,000,000 or more. the scope of ser-vice may also be reported in different ways, such as the unit price of a single procedure; the grouped price for an episode of care; or as the total cost of care for a patient over a set amount of time.

Despite these challenges, one methodology for measuring cost of care is gaining ground. Developed in Minnesota and endorsed by the national Quality Forum in January 2012, the total cost index (tci) is a measure of a primary care provider’s risk-adjusted cost-ef-fectiveness at managing the population they care for. tci includes all costs associated with treating members includ-ing professional, facility inpa-tient and outpatient, pharmacy, lab, radiology, and ancillary and behavioral health services.

a total cost index is prefer-able to other methods because it is:

• complete (it measures all costs)

• standardized

• Repeatable (can be deliv-

ered across payer sources and across time)

• affordable (the calculation is within the reach of most payer databases)

• stable (reduces the impact of a single outlier)

Putting cost measurement into practiceWhile arriving at a nationally endorsed, standardized mea-sure of cost and resource use (tci) was a monumental mile-stone, it was still only the first step in gathering the amount of data needed to establish bench-marks and make comparisons. Mn community Measurement (MncM) undertook the follow-ing steps to ensure the practi-cality of implementing tci as a community-wide measure for public reporting:

• in 2011, assembled a “cost committee” to investigate the best way to measure costs. the multi-stakehol- der group included rep-resentatives from health plans, provider groups, purchasers, and the state of Minnesota.

• in 2012, developed the methodology specifications for a total cost of care measure based on the tci, with agreement from all participants on attribution (patient assignment), risk adjustment, and methods of calculation.

• in 2013, developed a pro-cess to gather data from multiple health plans to calculate the tci. Unlike most multi-payer cost mea-sures, this process does not require an all-payer database, therefore, the administrative costs are lower, and there is no pro-tected health information (Phi) risk. it also includes a system for providers to verify patient assign-ment. the process was tested with two payers, and the proof of concept was achieved for both the calculation and the patient verification.

in 2014, MncM will run a full pilot with all major com-

Special FocuS: practice ManageMent

Measuring Total Cost of Care:

The search for common ground

By Gunnar Nelson

We are specialists in Apple devices (including iPads and iPhones) and software. We also support Windows and Windows to Apple integration. We are certified through the Apple Consultants Network serving individ-uals and businesses inquiring about moving to Apple, or how to improve existing systems.

Services include:

612-643-0643www.perfecteden.com

Rapid service and reasonable ratesProviding service throughout the metro area and remote service connection throughout Minnesota

Computer Problems?

•On-sitetraining–inyourclinic,hospitalorathome

•GroupWorkshops

•ExpeditedComputerRepairs

•DataRecovery

•Systemupgrades

•Networkconnectivityissues


mercial health plans in Min-nesota to further test the total cost of care methodology. then, MncM and the cost com-mittee will begin work on the Resource Use Measure—a total cost of care measure that uses a standardized pricing system to measure purely the utilization variation between providers. this will provide a complete measure of cost and utilization.

Cost of care at the community levelin addition, MncM has joined forces with the network for Re-gional healthcare improvement (nRhi) and four other regional health improvement collabora-tives (Rhics) in a seminal study to: 1) identify drivers of regional health care costs, and 2) develop strategies to reduce health care spending and improve health care quality at the commu-nity level. MncM hopes to learn from other regions doing similar work, and then to test the concept of measuring total

cost of care across regions. the study, which is funded by the Robert Wood Johnson Founda-tion, will involve local physi-cians in each region.

the four other participat-ing Rhics are Maine health Management coalition Foun-dation (MhMc-F); center for improving Value in health care (ciVhc) in colorado; oregon health care Quality corpora-tion; and the Midwest health initiative (Mhi), located in the st. Louis region.

the nRhi study, to be conducted over 18 months, represents the first time that standardized information will be available across several communities to compare the cost of care across multiple data sources.

“We know the cost of care in Minnesota is lower than in many other states,” said Jim chase, MncM president. “We hope to better understand the

differences in these costs, what drives these differences, and how to reduce costs while im-proving patient care.”

Using the data from the study, the five partnering Rhics will create a process for bench-marking for health care costs; identify the best ways to share information with the public; and conduct focused efforts with physicians to help them adopt practices that will reduce costs while maintaining the quality of care.

A level playing field Most providers don’t really know where they stand com-pared to others, either locally or nationally. in addition, when providers refer their patients to other medical professionals, that cost and utilization is not always clear.

it is our hope that all the efforts underway will give pro-viders standardized tools and information to compare their cost and utilization patterns to others, and identify opportuni-ties to get better value for their patients.

Gunnar Nelson is a health econ-omist at MN Community Measure-ment, where he leads initiatives, an-alytics, and development. Nelson has spent 26 years working in the areas of cost measurement and analysis, fee schedule development, and cost transparency. MN Community Mea-surement is a non-profit organization dedicated to improving the health of the community by driving change in cost, quality, and patient experience of care.

A universal Total Cost of Care measure has been elusive.

DON’T MISS THE SPCO THIS SPRING!

Subject to availability. All artists and programs subject to change.

Photography © 2013 Ash & James Photography

Haydn, Stravinsky and KernisThursday | Apr 24 | 7:30pmFriday | Apr 25 | 10:30amSaturday | Apr 26 | 8:00pmOrdway, Saint PaulRoberto Abbado, conductor; Paul Neubauer, violaStravinsky: Apollon MusagèteKernis: Viola Concerto (world premiere, SPCO co-commission)Haydn: Symphony No. 101, The Clock

Britten, Mendelssohn and ShostakovichSunday | May 18 | 2:00pmBenson Great HallThomas Zehetmair, conductor and violin; Maiya Papach, violaMendelssohn: Overture to Son and StrangerShostakovich: Prelude and Scherzo for String OctetBritten: Lachrymae Mendelssohn: Symphony No. 1

The Turn of the Screw Friday | May 23 | 8:00pmSaturday | May 24 | 8:00pmOrdway, Saint PaulThomas Zehetmair, conductor; Sara Jakubiak, soprano;Krista River, soprano; Thomas Cooley, tenorBritten: The Turn of the Screw

MNPhysician_May.indd 1 4/10/2014 9:09:32 AM


an estimated 260,000 Min-nesotans have diabetes, equaling approximately

6.2 percent of the population, according to the centers for Disease control and Prevention (cDc). health care practitioners and clinic administrators are trying to find innovative ways during clinic visits to encourage patients with diabetes to im-prove their health status, while maintaining adequate revenue for those visits.

scenic Rivers health ser-vices (sRhs) in Bigfork, Minn., has begun diabetes group visits. Group visits are not a new concept, but they are becoming a more common practice. When facilitated correctly, group visits are a win-win-win situation. the patients have more face time with a provider than the typical 15-minute visit and ben-efit from peer discussion and education. the providers enjoy them, because they no longer have to repeat the same chronic disease information in separate

diabetes visits throughout the day. additionally, the provider is able to spend more time with patients in a casual setting. the final “win?” the clinic can bill for multiple visits at a single

time. Because all the normal appointment services are pro-vided, the clinic can bill for a routine visit by multiple clients.

a group visit is essentially an individual medical appointment with an audience. Patients are provided all the services that they would have in a normal diabetes clinic visit, but they

receive them in the presence of other patients. in addition to standard services, the group visits provide an opportunity for patient-to-patient discussion and diabetes education facilitated by a provider or other medical professional. Depend-ing on the number of patients in the group and the services provided, these visits can last two to three hours.

scenic Rivers health ser-vices is a small rural clinic that is a federally qualified health center (FQhc) and is in the process of transitioning to a patient-centered medical home (PcMh). there is little pub-lished information about simi-lar clinics implementing group visits. FQhcs and PcMhs require specific and more exten-sive documentation for billing purposes. in addition, FQhcs cannot bill for educational vis-its, as other clinics do. But even with these extra requirements, sRhs is able to successfully conduct (and bill for) group visits. Below are some of the strategies used to fulfill FQhc and PcMh requirements, as well as some advice on creating engaging group visits.

Coordinating group visits Issue: Providers in FQHCs must meet with patients face-to-face

to bill for a visit.

to fulfill this requirement, time is set aside within the group visit for each patient to meet one-on-one with the provider. sRhs’s group visits are done in a conference room, where patients can meet with the provider in one corner. this provides a semi-private set-ting in which the provider and patient can have uninterrupted conversation. During this time, the other patients in the group complete required visit docu-mentation forms with nurses.

Issue: PCMHs require exten-sive documentation in the elec-tronic medical record (EMR).

Patients need to answer several questions that normally would be asked by a nurse, who directly inputs information into the eMR. the questions include a general survey about diabe-tes health status. in addition, the nurse and patient need to complete an individualized goal setting care plan. sRhs recreated the eMR questions in layman’s terms and made paper copies. instead of a nurse going through the informa-tion individually with patients during a clinic visit, he or she leads the entire group in filling out the paper questionnaires. a nurse then enters the answers into the eMR while the provider facilitates the discussion part of the visit.

to complete all of the necessary documentation, the provider, registered nurse, and a licensed practical nurse work on different tasks simultane-ously throughout the visit. the conference room has three stations. a room divider creates a private space to take weights. the corner desk provides a space for the individual face-to-face visits mentioned above, and a conference table in the middle of the room creates the group space. We found the easiest way to coordinate tasks was to cre-ate a spreadsheet that explained what each member of the team was doing during each section of the visit.

Special focuS: practice ManageMent

Group visitsAn increasingly common approach to diabetes care

By Jennifer St. Peter, Edwin Anderson, MD, and Travis Luedke

Group visits are a win-win-win situation.

With HIE-BridgeTM you will• Greatlyenhanceclinicalcarecoordination

• Securelyquery,receiveandexchangedataincompliancewithHIPAAandMNprivacylaws

• Accessreal-timeinformationfrommultiplesourcesinasingle,unifiedlongitudinalview

• AchieveMeaningfulUsemandates

• AccesstheeHealthExchange

• Improveprovidercollaborationandworkflowefficiency

Call [email protected]

www.hiebridge.org

To find out more…

Building Bridges to Quality Healthcare

HIE-Bridge™isthestate-widehealthinformationexchange(HIE)serviceofferedbyCommunityHealthInformationCollaborative

(CHIC).HIE-Bridge™allowshealthcareproviderstohavereal-timeaccesstoclinicalinformationfrommultiplesources.

CHICisthefirstandonlyMNstate-certifiedHealthInformationOrganization(HIO)offeringfullexchangecapabilities.


Billing group visits Issue: FQHC’s cannot bill for group education.

the Bigfork clinic cannot bill for group education due to its FQhc status. Regardless, at least a half hour of educa-tion with a provider or other medical specialist is scheduled during the group visit. though the clinic cannot bill for that education portion, it still codes a 99078 for complete docu-mentation of what was done. the professionals have found that the education portion is valuable for the patients, and the multiple patient aspect of the group visit allows more time to be spent on education. Rev-enue from the visit more than covers the time spent on group education.

Tips for successGrouping patients. the most impactful visits occur when the participants vary in age and diabetic control status. Patients

who have been recently diag-nosed with diabetes have the opportunity to learn from those who have decades of personal diabetes experience. People who are struggling to understand the long-term consequences of

poorly controlled diabetes can see and discuss these issues with patients who may have made poor lifestyle choices in the past. Patient-to-patient advice can be much more influ-ential than suggestions given by the provider.

Get creative. the Bigfork clinic staff has applied lessons learned from the initial group visits in 2012 to improve group visits. We use some of the reve-nue from these visits to increase hands-on learning and make the visits more enjoyable for

patients. For example, patients are provided a nutritious buffet lunch when they come for a group visit. During one vis-it, a nutritionist reviewed the website MyPlate (www.choose-myplate.gov) before patients ate

lunch. the patients were then encouraged to use their new knowledge to pick proper meal portions while they were serv-ing themselves. During another group visit, the patient educa-tion portion focused on physical activity. to entice patients to exercise, sRhs partnered with the neighboring Bigfork Valley hospital to offer a free one-month exercise room member-ship for those participating the in the group visit. the catered lunch and engaging nature of the visits encourages patients to return.

Group diabetes visits are an educational, innovative, and satisfying way of providing high-quality care in a relaxed setting. as a FhQc and an aspiring PcMh, scenic Rivers health services clinic faced

many obstacles to plan and implement group visits. ac-cordingly, the first group visit took extensive pre-planning and coordination. But the overwhelmingly positive post-group visit feedback from pa-tients at scenic Rivers health

services clinic tells us that the effort was worth the time. the clinic is continuing to expand the number of diabetes group visits we offer, to make them more widely available to our patients.

Jennifer St. peter is a senior at Cornell University, Ithaca, N.Y.; Edwin Anderson, MD, is a physician, and Travis luedke is clinic manager at Scenic Rivers Health Services in Bigfork, Minn.

Group diabetes visits are an educational, innovative, and satisfying way of providing

high-quality care in a relaxed setting.

Building a HealthyMedical Practice

How to Thrive, Not Just SurviveAAPS National Spring Meeting

Friday, May 9, 2014: 12:30 to 6 PM: Dinner program followsPhysicians, Surgeons, Nurses, Chiropractors, Medical Professionals, Employers, Individuals, Agents

Marriott, Minneapolis Airport2020 American Boulevard E - Bloomington MN 55425

Details at http://tinyurl.com/aapsmtg or call 651.705.8583

Up to 6.75 CME Credits Available

This activity has been planned and implementedin accordance with the Essential Areas andPolicies of the New Mexico Medical Society(NMMS) through the joint sponsorship ofRehoboth McKinley Christian Health Care Services(RMCHCS) and the Association of American Physi-cians and Surgeons (AAPS). Rehoboth McKinleyChristian Health Care Services is accredited by theNew Mexico Medical Society to provide continuingmedical education for physicians. RMCHCS desig-nates this live activity for a maximum of6.75 AMA PRA Category 1 Credits™. Physiciansshould only claim credit commensurate with theextent of their participation in the activity.

Keynote Speakers:Richard L. Reece, MDMerrill Matthews, PhD

Session Speakers:Robert Sewall, MD - TXSusan Wasson, MD - MNDonald Gehrig, MD - MNDoug Nunamaker, MD - KSKathy Brown, MD - ORMitchell Brooks, MD - TXLee Beecher, MD - MNJane Orient, MD - AZLawrence Huntoon, MD - NYAndrew Schlafly, JDTwila Brase, RN - MNPeter Nelson, JD - MNDave Racer, MLitt - MNSean Parnell - VA

Sponsored by the Association of AmericanPhysicians and Surgeons (AAPS) and theMinnesota Physician-Patient Alliance.

Speakers from across the country assessing the future ofyour medical practice.• Empowering patients and MDs, innovations, legalissues, nuts and bolts on how to change your practice.• Presenting real-life stories of practicing physicians andsurgeons who have transitioned from third-party paidpractices to a direct-pay model.• $99 for Physicians and Health Care Professionals and$49 for Professional Staff. Scholarships for interns andresidents.


integrity health network (ihn) is more than a great name—it’s a descriptive

statement of how we operate and provide care. the success of the network of independent medical practices is inherently dependent on the success of our individual clinics, so the work done at the network level must address the needs of the clinics.

ihn is founded on physician leadership and the belief in the value of independent medicine. a board of governors—made up of our president/ceo and physi-cians representing both primary and specialty care—over-sees the network’s operations. the board’s monthly meetings are attended by ihn quality and operational staff and our med-ical directors of primary and specialty care who give recom-mendations regarding clinical and quality issues.

Building on a strong founda-tion of physician leadership and clinical expertise, we support our members by addressing cost

and quality in several areas. ihn provides quality improve-ment initiatives and support for each clinic, understanding

that cost and quality must encompass all aspects of health care delivery. We work closely with clinic administrative staff, keeping them informed of the latest advancements in cost

and quality control, and, where feasible, supporting the needs of their clinics from an operational perspective.

Physician leadershipihn’s Quality improvement Medical Directors (QiMD) committee is the clinical voice that addresses issues of cost and quality across the network. Led by the medical directors for primary and specialty care, this committee meets every other month. each clinic has a physician representative in this group. originally this group developed, implemented, and internally reported quality mea-sures and quality data. now, with the onset of external forces such as state and federal quality mandates, this group responds to and develops plans to comply with these measures.

the QiMD committee is a strong voice on behalf of inde-pendent physicians, both in and out of our network, as it offers comments to health plans, gov-ernment agencies, and others on the measures and mandates that are handed down. the committee shares a conviction in the value of, and the need for, high-quality and low-cost care. But that conviction includes a belief that sustained improve-ment occurs best when built from the ground up, not when mandated from the top down.

the collegiality of the committee allows peer-driven change that establishes and maintains improvement. Physi-cians hear and respond to other

physicians, who are often the best source of influence for each other. While the approach to is-sues may differ from a specialty vs. a primary care practice, the consensus drawn at these meetings has proven to be of tremendous value.

one significant result of this group’s work is a set of simple guidelines instituted by ihn called the care continuum initiative guidelines. these are short, bullet-point-formatted guides for the pre-referral care of various conditions. the intent of these guidelines is to maxi-mize the clinical and resource efficiency of primary care as an effective way of improving quality and reducing cost. they address the things that should and should not be done in pre-referral care. and, to the credit of the specialists involved in developing these guides, they also define criteria for when a referral is not warranted.

Clinic and administrative involvementachieving a higher standard of care has to involve more than physician input. each clinic has a Quality improvement coor-dinator (Qic) who participates in informational meetings and trainings organized by the net-work at least quarterly. in these meetings the details of new initiatives, both cost- and qual-ity-related, are broken down to the “boots-on-the-ground” level.

Qics are people who usually work directly with physicians and are responsible for the overall quality improvement processes, including data collec-tion and reporting. ihn’s role is to provide them with tools and support to carry out their work. ihn also provides opportunities and venues for the exchange of ideas. it is not uncommon to see meetings end with informal networking, where problems and solutions are shared.

ihn also recognizes the value and importance of ad-ministrators and managers in the management of cost and quality. We keep administrators informed of important develop-ments regarding clinical, quality and operational issues. they

special focus: practice ManageMent

Supporting medical independence

A health network’s model founded on cooperation

By Bruce Penner, RN

We see independent medicine not only surviving, but thriving.

Read usonlineWherever you are!

www.mppub.com


are also encouraged to share stories of success and challenge with each other and they often gain insights and solutions from each other.

several years ago, the board implemented an attendance pol-icy that requires 65 percent at-tendance by the clinic represen-tatives to the QiMD, Qic, and administrator meetings. this resulted in vastly increasing the value of the meetings. since the policy was implemented, we have seen a steady improvement in our quality outcomes data.

ihn also provides sup-port with regular visits to our clinics. each year, every primary care clinic is visited at least once—with a formal presentation—by our medical director for primary care. these meetings are designed for all medical, clinical, and support staff in each clinic. the topics covered included quality mea-surement definitions, coding training, quality improvement process training, and more.

our medical directors for primary care and specialty care are available to respond to ques-tions and concerns from their peers across the network, and they routinely communicate with them on issues of interest and importance. additionally, ihn administrative staff is al-ways available and often on-site providing support to our clinics.

Thriving on independenceLooking ahead, we see indepen-dent medicine not only surviv-ing, but thriving, in this rapidly changing world of health care reform. improving quality and appropriately managing costs are not contrary philosophies; historically, independent phy-sicians have been successful at achieving both. But to sustain this success, we see a need for more sharing of resources and cross-pollination of clinic cul-tures. independent physicians should be able to remain inde-pendent. By collaborating with others of similar spirit when and where it makes sense, they

will be able to do so.

everyone’s hard work paid off in 2013, when ihn received a silver award for Generic Utilization Rates (with clinics ranking fifth and seventh in the state) as well as a gold award for total cost of care in Primary care (with clinics ranking first and ninth in the state). Both awards were given by health-Partners’ “Partners in excel-lence” program.

although the network’s name is on the plaques, the real

work was done in the offices and exam rooms of the indi-vidual clinics that make up our network. the success of ihn is inherently dependent on their success. a message we often share internally is, “you need some degree of interdependence to maintain independence.”

Bruce penner, rN, is IHN’s director of quality. A large part of his work involves supporting clinics in quality programming and the collection, re-porting, and analysis of quality data.

IHN was formed in 2010 as the result of the merger of two longstand-ing independent practice associations, Northstar Physicians Network and Northland Medical Associates.

Today, IHN includes 200 physicians, and 47 clinics and facilities, located in 23 communities in northern and central Minnesota, and northern Wisconsin. IHN doesn’t own clinics; the network is owned by a group of independent and autonomous clinics, with the goal of improving the patient care experience and enhancing health care outcomes.

In Minnesota, IHN clinics and facilities are located in Albertville-St. Michael, Baxter, Buffalo, Clearwater, Cloquet, Cold Spring, Cromwell, Duluth, Eveleth, Grand Marais, Grand Rapids, Hermantown, Monticello, Moose Lake, Sartell, St. Cloud, Virginia, and Two Harbors.

About integrity Health Network

2014-2015See 3 or more

operas and save up to 25%

Ticket Office: M – F, 9am – 6pmmnopera.org 612-333-6669

LA FANCIULLA DEL WESTSept. 20 – 28, 2014

HANSEL AND GRETELNov. 1 – 8, 2014

THE ELIXIR OF LOVE Jan. 24 – 31, 2015

THE MANCHURIAN CANDIDATE Mar. 7 – 14, 2015

CARMEN Apr. 25 – May 3, 2015


the human foot and ankle is composed of 31 bones, 34 joints, 117 ligaments,

and numerous muscles and tendons. Many foot and ankle ailments get in the way of work, limit activity, and prohibit athletic competition. Recent ad-vances in foot and ankle treat-ment and surgery, however, are helping people recover rapidly and get back to their activity, work, and sport.

Heel painPatients’ heel pain is commonly encountered by the foot and ankle specialist. Most commonly, plantar fasciitis is the culprit. this is a condition affecting the plantar fascial band—a ligamentous structure connecting the heel to the front of the foot through the arch. Plantar fasciitis often comes from abnormal mechanical influences and induced inflam-matory factors, which lead to pain. it is usually experienced upon a person’s first step after

sitting or resting. Plantar fascial pain is also common in those who stand for long hours while at work.

treatment mainstays are stretching programs, orthotic (shoe insert) management, and anti-inflammatory treatment in oral and steroid injection forms.

new developments include treating diseased fascial tissue, surgery to release the fascia and promote natural tissue healing,

and treatments utilizing growth factors and radio frequency to stimulate healing.

Great toe joint deformity, arthritisthe most common foot defor-mity is termed “hallux val-gus”—commonly known as a bunion (see Figures 1 and 2). this deformity results from imbalance around the great toe joint, which causes a deformity. it is hereditary, but improper-ly fitting shoes can hasten its progression.

there are many methods of managing this condition, but surgical treatment is the only way to correct it. Recent devel-opments in surgical correction for hallux valgus revolve around a procedure that corrects the deformity definitively, pre-venting recurrence, as well as implanting hardware tech-nology that allows for earlier weight-bearing post-operatively. other surgical techniques are available for correction that utilize joint fusion procedures, osteotomies (precise bone cuts), and capsular and tendon trans-fer procedures for rebalancing.

Great toe joint arthritis is termed “hallux rigidus” (see Figures 3a and 3b). it pre-maturely wears out the first metatarsal phalangeal joint because of mechanical imbal-

ance factors. Patients present all along the spectrum with this condition.

Procedures to surgically correct this problem range from decompressive osteotomies (precise bone cut procedures) that improve joint motion, to interpositional biologic joint repairs, to definitive joint fusion for relief of arthritic pain. De-velopments in this area include advanced plating and screw technology, which allow for im-proved mechanical support and improved recovery time after the procedure. current research can be utilized to determine the most appropriate interventions, as treatment varies according to the specific degree of osteoar-thritis of the great toe joint.

Toe contracturesDigital contractures of the toes, commonly referred to as hammertoes, are the result of imbalance of the flexor and ex-tensor tendons to the toe. these contractures can exist alone or in combination with other fore-foot deformities.

correction of these digital deformities is possible—recent improvement has been made to the intramedullary bone devices that hold the toe in position as it heals, without the need for wires sticking out the end of the toes during healing. this has resulted in earlier activity and return to regular shoes after surgery.

Foot, ankle arthritic conditionsthese can result from old injuries and fractures, or from acquired structural conditions that lead to early wearing out of the joints (osteoarthritis). treatments range from orthotic management and injections, to surgery.

implant technology has rap-idly evolved, providing surgeons new ways of applying plates and screws to correct deformities, fuse painful arthritic joints, and return people to work and the activities they enjoy. ankle arthritis usually results from old fractures, and can also de-velop primarily. surgical ankle arthroplasty/replacement aims

OrthOpedics

Advances in foot and ankle surgery

New treatments help patients recover quickly

By Benjamin Clair, DPM, FACFAS and Aaron Benson, MS, ATC

A custom-made treatment plan will get a patient back to a full range of activity.

Connecting your business to your market

Connecting your business to your market

By Robert Sweet, MD“I have prostate cancer

… and I want a robotic

prostatectomy.” This is

a common presenting“chief complaint” heard

nowadays in urologists’

offices across the state

and across the country.

If you perform robotic prostatectomy, it

can be a plus in marketing your practice.

If you don’t, you either try to convince your

patient that robotic prostatectomy isn’t all

it’s cracked up to be, or you refer him to

someone who does it. To date, removing the prostate with the

aid of a robot is the most common current

application of robotic surgery. Approx-

imately 90,000 radical prostatectomies

are done annually in the United States—

and, according to Intuitive Surgical,

of Sunnyvale, Calif., the company that

manufactures and sells the gold-standard

da Vinci robot, this year over half of them

will be done robotically. This is an amazing

figure, given the rela-tively recent adoption

of the robot for use in

clinical applications.The rapid growth in

this field promises to permanently alter

the way surgical proce-

dures—especially mini-

mally invasive surgeries—are performed

and taught. The current state-of-the-art

The da Vinci robot and its

progeny, the da Vinci S HD

surgical system, were released

in 1999 and 2006, respectively.

Essentially, the robot has

expanded the benefits of

laparoscopic surgery to the

“masses” of classically trained

open-surgeons. The current

state of technology represents

clinical advances in laparo-

LENDING A HAND to page 10

PRSRT STDU.S. POSTAGEPAIDMpls. MNPermit No. 2655

Volume XXI, No.7October 2007

The Independent Medical Business Newspaper

B edside manner may be

viewed as a “soft” skill these

days, and advances in medi-

cine continue to heighten the

emphasis on clinical and technical

expertise. But as medicine shifts its

focus to become more patient cen-

tered, patient experience is fast gain-

ing ground as a key measure of qual-

ity. In 2004, for example, the U.S.

Medical Licensing Examination

added a national skills test on per-

sonal interaction and communica-

tion that medical students must pass

to be eligible for licensure. And this

year, the National Committee for

Quality Assurance (NCQA) added

“shared decision-making” as one of

seven measures to assess patient

experience. Shared decision-making involves

systematic interaction with patients

to arrive at an informed decision,

based on their values and prefer-

DECISION-MAKING to page 12

Talk it out Shared decision-making improves

the patient experienceBy Marcus Thygeson, MD,

and Karen Kraemer, RN, CMC

Lending ahandRobotic surgery makes inroads into the

OR and beyond

Special Focus: Rural HealthPage 20

ES:MPAug06 Cover 3P-ES 10/2/07 10:54 AM Page 1

HDHPs, P4P incentives, and the patient-physician relationshipBy Mary Sue Beran, MD, MPHThe cost of health care is rising, particularly

for consumers (patients). High-deductiblehealth plans (HDHPs) are gaining in popu-

larity as health care costs continue toincrease and employers look for ways to shift

more of the responsibility to the consumer.

This added expense may be a problem forpatients with chronic disease who need fre-

quent care that is often complex and costly. At the same time, health care is also

changing for physicians. One key messagefrom the 2001 Institute of Medicine (IOM)

report, “Crossing the Quality Chasm,” is that

the quality of medical care in the American

health system needs improvement. A more

recent study of adults in the United Statesdocumented that among a range of preven-

tive, acute, and chronic care, adults received

only about half of recomend-ed medical care processes(McGlynn EA, N Engl J Med,2003;348(26): 2635–2645). Pay-for-performance(P4P) programs have becomea popular way to attempt tomeasure quality of care inhopes of improving healthcare in the U.S. Physiciansare now being evaluated and,

in some circumstances, paidCOLLISION COURSE to page 10

PRSRT STDU.S. POSTAGEPAID

Mpls. MNPermit No. 2655

Volume XXI, No.8November 2007

The Independent Medical Business Newspaper

Bringing a new medical deviceto market was a lot easier in the good old days. It was

essentially a two-step process. Step one: Develop a product that im proved patient care. Step two:Show it to a doctor. If the doctorliked it, you had a winner. Over the past 15 years, payment

issues and increased regulatoryrequirements have made things a lot more complicated. Today a newdevice must fit a considerably morecomplex model in order to be suc-cessful in the marketplace. Thewoods are still full of good (and bad)ideas for new devices;the challenge is pick-ing a likely winnerfrom among the possibilities. Here, in approximate orderof importance, are thefactors that we con-sider most critical inevaluating ideas for anew device.

Special Focus:Home CarePage 20MARKET to page 12

Bringing a newmedical deviceto marketThe challenges of picking a winnerBy Curt Miller

Collision course?

ES 10/29/07 10:56 AM Page 1

in Minnesota Physician

612-728-8600

Advertise

Advances in foot and ankle surgery to page 38


to restore natural ankle motion and replacement methods can be excellent alternatives to an-kle joint fusion. Under certain conditions, however, an ankle fusion may be the most defini-tive operative intervention.

Repairing cartilage injury and damagecartilage damage and focal cartilage defects (osteochondral defects) are commonly encoun-tered by the foot and ankle spe-cialist, typically around the big toe joint and ankle joint. these result from acute injury or from advancing arthritis problems.

Many new developments have been made in cartilage repair methods. some involve transplanting healthy, active cartilage cells to a cartilage de-fect; they grow in, repairing the defect. Biocartilage products have been developed that can be combined with a patient’s own growth factors to improve outcomes and promote healing. the arena of cartilage repair and regrowth continues to grow in exciting ways.

Diabetes and amputation preventionDiabetes causes foot problems through a pathological process of the nerves, called neuropathy. this condition is a consequence of poorly managed glucose control. it can result in lower

extremity numbness, tingling and pain, usually affecting the digits of the foot first. Without feeling, diabetic patients can sustain ulcerations.

education about and pre-vention of these problems is the best treatment. Diagnosis through peripheral nerve fiber testing is the most significant advancement in this area. additionally, tremendous advancement has been made in making certain that blood flow is adequate to the lower leg and foot, to cure wounds and prevent amputation. new intra-vascular procedures are being performed by vascular surgeons and interventional physicians that improve perfusion. the key to preventing amputation is early identification of nerve and vascular flow abnormalities.

Fractures of the foot and anklethese fractures—from twists, falls, car accidents, and crush injuries—often are displaced or involve a joint structure, which requires surgical treatment. Recent improvements include anatomic, locked-plating technology, allowing anatomic correction and early return to weight bearing and motion.

Sports injuriesUsually the consequence of overuse or repetitive use activi-

ties, sports injuries include ten-donitis, sprains, and muscle and mechanical mediated pain. new topical products and treatments show favorable results. tendon

treatments have been developed, including ultrasound, radio frequency, and bone marrow aspirate and growth factor injections. additional tendon

Figure 3a. First metatarsopha-langeal joint status post ar-throdesis to treat hallux rigidus

Figure 3b. intraoperative photo illustrating changes in articular cartilage associated with hallux rigidus

Figure 1. radiographic depiction of hallux valgus

Figure 2. Status post surgical hallux valgus correction

THE STRENGTH TO HEAL

Learn the latest treatments and play an important role in the care of Soldiers and their Families. As a physician on the U.S. Army Reserve Health Care Team, you’ll continue to practice in your community and serve when needed. You’ll work with the most advanced technology and distinguish yourself while working with dedicated professionals. You’ll make a difference.

© 2010. Paid for by the United States Army. All rights reserved.

and stand by those who stand up for me.

To learn more, call 1-855-276-9579 or visitwww.healthcare.goarmy.com/q955.


Neurology

When the first author was a third-year medical student at

the University of Minnesota, he recalls a teaching session with the famed Dr. a.B. Baker, in which Baker said something like: “there are two forms of presenile dementia, alzheimer’s and Pick’s. there is not much to say about them and you can’t tell them apart [in life], so let’s go on and talk about dizziness.” Dr. Baker was correct in 1973, but in 2014, that view couldn’t be farther from the truth. the frontotemporal degenerations, including Pick’s disease, are now at center stage in neurosci-ence research, and their clinical characterization has advanced with breath-taking speed.

the frontotemporal degener-ations—the accepted name for the group—are much less com-mon than alzheimer’s disease, in terms of total number of affected individuals. the fronto-temporal degenerations include about 50,000 to 100,000 cases

in the U.s., whereas alzheimer’s affects close to 5 million amer-icans. however, in people under the age of 65, the prevalence of the two disorders is probably nearly equal.

Diagnosis the frontotemporal degenera-tions can indeed be diagnosed in life. there are a number of

distinctive syndromes that are almost always due to one of the frontotemporal degenera-tions. these clinical presenta-tions (syndromes) are primary progressive aphasia, behavioral

variant frontotemporal demen-tia, progressive supranuclear palsy, corticobasal syndrome, and amyotrophic lateral scle-rosis. to be sure, a solid know-ledge of clinical neurology is required for optimal diagnosis of these syndromes. Many phy-sicians, including neurologists, don’t encounter them often enough to develop familiarity with them. Brain imaging with MR and FDG Pet have proved to be excellent, though not infal-lible, adjuncts to the clinical diagnosis for distinguishing frontotemporal degeneration from the syndromes of alzhei-mer’s disease and Lewy Body disease.

Why diagnose these disor-ders? ask any family member and you will get an answer, loud and clear: these disorders are distressing, they clearly fall outside of the common pattern of dementia due to alzheimer’s, and the patients and their fami-lies need help in coping with the illness. Frontotemporal degen-erative disorders are extremely disruptive to families. While as yet there are no treatments for any of the frontotemporal degenerations, their molecular biology is beginning to yield strong candidates for pharma-cological interventions.

Behavioral variant fron-totemporal dementia. the prototype frontotemporal degeneration clinical syndrome is the one now referred to as behavioral variant frontotem-poral dementia (bvFtD). it has a distinctive and unmistakable clinical presentation. affected individuals undergo a personal-ity change, exhibit a coarsening of their interpersonal behavior and demonstrate various exam-ples of flamboyant disregard of social norms and the feelings of others. While these phenomena may occur in other demen-tias, their early and dramatic appearance is unique to bvFtD. often, though not always, the dissolution of personality and interpersonal relationships oc-curs despite preserved memory, language, and spatial abilities.

a diagnosis of bvFtD can most effectively be made from the history provided by a close family member; brief cognitive exams and even more detailed neuropsychological testing may be equivocal in early cases. in the majority of instances, obvi-ous prefrontal and/or anterior temporal lobe atrophy is visible on either brain ct or MR. in some bvFtD cases with normal brain MR, FDG Pet scans will demonstrate hypometabolism in the frontal and/or temporal lobes (Figure 1).

Primary progressive apha-sia. the other prototypical clinical presentation of fronto-temporal degeneration is that of a disturbance of language, pri-mary progressive aphasia (PPa). the diagnosis of PPa can be suspected as soon as the physi-cian engages the patient in con-versation, because the language problems are the illness. there are many clinical subtypes of PPa, and their characterization has proved challenging. however, certain consistent patterns have been identified.

there is a form of PPa in which expressive speech is labored, nearly dysarthric, telegraphic, and agrammatic, now referred to as the non-fluent/agrammatic variant of PPa. often these individuals have preserved personalities, memory, and other non-lin-

The frontotemporal degenerationsMuch more than Pick’s disease

By David Knopman, MD, and Bradley Boeve, MD

The affected individuals have normal- sounding speech, but they experience an

erosion of their vocabulary.

Sioux Falls VA Health Care System

Sioux Falls VA HCS, SD

Applicants can apply online at www.USAJOBS.gov

Sioux Falls VA HCS(605) 333-6852

www.siouxfalls.va.gov

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

Primary Care (Family Practice or Internal Medicine)PsychiatristEndocrinology

PulmonologistOncologistCardiologist (part time)Gastroenterologist (part time)


guistic abilities. interestingly, these individuals often respond to questions in a manner that is opposite of their intention, typically saying “yes” when they mean “no” and vice versa. their brain imaging shows asymmet-ric frontal or insular atrophy, although the degree of atrophy can be quite subtle early in the course. the nonfluent/agram-matic variant of PPa is almost always due to one of the fronto-temporal degenerations.

the other distinctive PPa that is invariably due to a frontotemporal degeneration is the semantic variant of PPa. in this disorder, the affected individuals have normal-sound-ing speech but they experience an erosion of their vocabulary and their understanding of the meaning of words and objects. the most common and dra-matic illustration of this loss is when an examiner asks the patient to say what an object, such as a watch, is used for. the patient with semantic variant PPa will reply, “a watch? What’s a watch?”

there are other patterns of progressive aphasia where word selection in spontaneous speech is impoverished, called logopenic PPa. interestingly, this form of PPa can be due to alzheimer’s or to frontotempo-ral degeneration.

Progressive supranuclear palsy, corticobasal syndrome, and amyotrophic lateral scle-rosis. the frontotemporal degenerations also include progressive supranuclear palsy syndrome and corticobasal syn-drome. although these condi-tions were originally described as movement disorders, many or most individuals with one of these syndromes also have some form of dementia. the patholo-gy of both of these disorders is that of frontotemporal degener-ation.

While it might seem over-reaching to call amyo-trophic lateral sclerosis (aLs) one of the frontotemporal degenerations, the fact is that many patients with typical aLs have changes in behavior and cognition if those symptoms are

actually sought. and, impor-tantly, the most common cause of familial aLs is the same mu-tation that is the most common cause of familial frontotempo-ral degeneration. the pathology in motor neurons in aLs is identical to that of one of the frontotemporal degeneration subtypes. Motor neuron disease has long been recognized in people with rapidly progressive forms of frontotemporal degen-eration.

A transformation in understandinga half-dozen pivotal discoveries in the past 15 years have trans-formed our understanding of the neuropathology of fronto-temporal degeneration from the 19th-century discovery of the Pick body to a 21st-century mul-tidimensional molecular model.

the first protein to be implicated in frontotemporal degeneration was the micro-tubule-associated protein tau (MAPT). Mutations in the MAPT gene were shown to cause many cases of frontotemporal degen-eration. two species of the tau protein, one with 3 repeating (3-R) units and another with 4 repeating (4-R) units, were shown to make up the patho-logical intra- and extra-cellu-lar protein deposits in Pick’s disease (a 3-R tauopathy), progressive supranuclear palsy and corticobasal degeneration (both 4-R tauopathies) and cas-es with mutations in the MAPT gene (also 4-R tauopathies). it so happened that Pick’s disease, the “grand-daddy” of frontotem-poral degeneration, developed silver-staining positive round intraneuronal inclusions, that enabled arnold Pick and alois alzheimer to recognize the dis-order using classical histopatho-logical techniques, more than 100 years ago. about half of cases of frontotemporal degen-eration tauopathies are genetic, while the others are apparently sporadic.

another major discovery was that many cases of fronto-temporal degeneration showed tau-negative intracellular protein inclusions containing a protein called transactive

response DNA binding protein of 43 kilodalton molecular weight (tDP-43). about two-thirds of all frontotemporal degeneration involves abnormal intracellu-lar cytoplasmic aggregates of tDP-43. two genetic discoveries

subsequently linked abnormal accumulation of cytoplasmic tDP-43 with mutations in the gene granulin (GRN) (also termed progranulin and abbre-viated as PGRN) and the gene chromosome 9 open reading

Figure 1. Mr scan showing frontal atrophy typical of what occurs in patients with behavior variant frontotemporal dementia

The frontotemporal degenerations to page 30

PsychiatristCross-Cultural MedicineHealthPartners Medical Group in St. Paul, Minnesota, seeks a BC/BE licensed psychiatrist to practice cross-cultural medicine with our experienced Behavioral Health team at the Center for International Health (CIH), an internationally recognized refugee/immigrant medicine clinic which has helped defi ne best practices in refugee and immigrant healthcare for 30+ years. U.S. and international experience providing psychiatric care to refugees and globally mobile populations is strongly preferred. Qualifi ed bilingual psychiatrists (especially those fl uent in Somali, Khmer, Oromo, Karen, Vietnamese, Hmong, Nepali or Russian) are encouraged to apply.

This part-time (0.5 FTE) position will provide outpatient psychiatric care closely integrated with primary care in a holistic care model, while partnering with community organizations and the MN Department of Health’s Refugee Health Program. There is also opportunity for an academic faculty appointment at the University of MN and teaching involvement in the Global Health Pathway (www.globalhealth.umn.edu).

HealthPartners offers a rewarding practice with a competitive salary and benefi ts package. Forward your CV and cover letter, specifying your language fl uency and global health/refugee medicine experience, to [email protected] or apply online at healthpartners.com/careers. For more details, call 800-472-4695 x1. EOE

© 2013 NAS(Media: delete copyright notice)

Minnesota Physician4" x 5.25"B&W

healthpartners.com

frame 72 (C9ORF72). [The MAPT gene was initially discovered by our colleagues at Mayo Clinic Jacksonville, led by Mike Hut-ton; both GRN and C9ORF72 were initially co-discovered by another of our colleagues at Mayo Clinic Jacksonville, Rosa Rademakers.] Mutations in these genes invariably lead to

either bvFTD or a PPA syn-drome, and invariably the neu-ropathology includes abnormal protein accumulation within neurons and/or glia. The story

with the C9ORF72 gene muta-tion, a hexanucleotide repeat expansion, is even more inter-esting and informative because it is the one that also is the most common cause of familial ALS.

Where are we now? What’s next?In contrast to the complexity of Alzheimer’s disease, the clini-cal-genetic-neuropathological relationships in the individual frontotemporal degenerations seem ripe for discovery of ways to interrupt the process, and to delay the appearance or wors-ening of the symptoms and the pathological changes. However,

in addition to finding drugs that are safe and effective, further improvements in diagnosis are needed.

While virtually all of the

semantic variant of PPA is due to sporadic TDP43 proteinop-athy, and virtually all of pro-gressive supranuclear palsy is due to sporadic 4-R tauopathy, the most common syndromes of the frontotemporal degen-erations—namely, bvFTD and non-fluent agrammatic variant PPA—can be caused by any of the neuropathological and genetic subtypes. Thus, for the majority of patients with fron-totemporal degeneration, the clinical syndromes do not allow determination of the molecular and neuropathological subtype. Imaging and fluid biomarkers are desperately needed to allow

antemortem molecular diagno-ses. The soon-to-be-available PET ligand for tau protein may be a breakthrough imaging marker for the frontotemporal degenerations as well as for Alzheimer’s.

Treatment of the frontotem-poral degenerations is now just beginning. At Mayo Clinic, we are participating in a clinical trial for bvFTD of leuco-meth-ylthioninium, a derivative of methylene blue, a therapy that putatively prevents the aggre-gation of both tau and TDP43 proteins.

Hopefully, this trial will be successful; but unless the world is incredibly fortunate, many more therapies will have to be explored before we can make a dent in this devastating set of illnesses.

David Knopman, MD, and Brad-ley Boeve, MD, are professors in the Behavioral Neurology Section, Department of Neurology, at the Mayo Clinic, Rochester.

Mayo Clinic provides educational seminars for patients and particularly for families with loved ones with the frontotemporal degener-ations. More information on these seminars can be gained by calling (507) 284-1324.

Additional information on the frontotemporal degener-ations can be accessed at the Association for Frontotemporal Degeneration website (www.theaftd.org).

Additional resources

The frontotemporal degenerations from page 29

In addition to finding safe and effective drugs, improvements in diagnosis are needed.

30 MInnESoTA PHySICIAn April 2014

Physician Recruiters Meghan Anderson & April Knapp Email: [email protected] 1.800.321.3790 ext. 5721 & ext. 5027

St. Luke’s Hospital 915 E 1st Street Duluth, MN 55805 www.SLHDuluth.com

THE PATIENT ABOVE ALL ELSE. ® Current Duluth Opportunities: St. Luke’s Family Practice, Duluth, MN (OB optional) Internal Medicine, Duluth, MN OB/GYN: Duluth, MN Practice Specifics: Salary: MGMA Market Competitive & Generous Signing Bonus St. Luke’s-employed position Clinic Hours: M-F 8:00-5:00 40 patient care hours/26 as scheduled clinic hours Benefits for .6 FTE or higher

-Minimum 6 weeks Paid Time Off -Flexible Benefits Plan -Medical, Dental & Life -Relocation -Pension & 401(k) -Physician’s Supplemental Retirement Plan -Sick Leave & Personal Days -Short & Long Term Disability -Flexible Spending Account -Malpractice & Tail Coverage

Family Practice/Internal MedicineIndian Health Service (IHS), the Cass Lake Hospital (Federal) is seeking 2 Family Practice BE/BC Physician Providers and 1 BE/BC Internal Medicine Physician Provider.

The CL Hospital offers inpatient/outpatient, ambulatory care, dental, optometry, pharmacy, audiology, laboratory, X-Ray, physical therapy and a diabetes clinic. We work within various teams, each team consisting of a physician provider, PA-C/NP, RNs and LPNs.

We are located on the Leech Lake Indian Reservation in Cass Lake, MN. Most of the providers and staff reside in Bemidji which is a short 15-20 minutes commute. We offer competitive salary, excellent Federal benefits including health and life insurance along with Thrift Sav-ings Plan (401K), Annual Leave, Sick Leave, 10 Paid Federal Holi-days, student loan repayment eligible.

Come practice where others vacation. Please contact Tony Buckanaga at

218-444-0486 for further details and how


Urgent Care

We have part-time and on-call

positions available at a variety of Twin

Cities’ metro area HealthPartners

Clinics. We are seeking BC/BE 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.com/careers and

follow the Search Physician Careers link

to view our Urgent Care opportunities.

For more information, please contact

[email protected]

or call Diane at: 952-883-5453;

toll-free: 1-800-472-4695 x3. EOE

healthpar tners .com© 2014 NAS(Media: delete copyright notice)

MN Physician4" x 5.25"4-color

The perfect matchof career and lifestyle.

www.acmc.com |

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

• ENT• Family Medicine• General Surgery• Geriatrician• Outpatient

Internal Medicine

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

• Psychiatry• Pediatrics• Pulmonary/

Critical Care• Rheumatology

For more inFormaTion:

Kari Bredberg, Physician Recruitment | [email protected] | (320) 231-6366

Here to care

At Allina Health, we’re here to care, guide, inspire and comfort the millions of patients we see each year at our 90+ clinics, 12 hospitals and through a wide variety of specialty care services throughout Minnesota and western Wisconsin. We care for our employees by providing rewarding work, flexible schedules and competitive benefits in an environment where passionate people thrive and excel.

Make a difference. Join our award-winning team.

Madalyn Dosch, Physician Recruitment ServicesToll-free: 1-800-248-4921 Fax: 612-262-4163 [email protected]

allinahealth.org/careers

13273 0414 ©2014 ALLINA HEALTH SYSTEM ® A TRADEMARK OF ALLINA HEALTH SYSTEM

EOE/AA

3.5x4.75_AD_MN_Medicine.indd 1

Lung cancer is one the deadliest types of cancer, killing 2,174 Minnesotans

in 2011, according to the Min-nesota Department of Health’s Vital Statistics. Unlike mam-mography for breast cancer or colonoscopy for colon cancer, however, the federal government has had no recommendations on lung cancer screening—until now.

Screening for some types of cancer has reduced deaths by early detection and treatment, including surgery, medications and radiation. Because the dis-ease often shows no symptoms until it is in an advanced stage, however, finding a way to detect lung cancer early has long been sought, especially for people at higher risk of developing the disease.

Now there is a test that can reduce death from lung can-cer through early detection. Lung cancer screenings test for cancer before there are any symptoms. By screening at-risk individuals, the medical community believes it could

prevent as many as 3,000 to 4,000 deaths nationwide a year, according to the National Lung Screening Trial study. The first step is determining who should receive the screening.

The National Lung Cancer

Screening Trial (NLST) consist-ed of 53,454 current or former heavy smokers from across the United States. It compared low-dose helical computed tomog-

raphy (CT) and standard chest X-ray in the detection of lung cancer. Both methods had been studied in finding lung cancer early, but the effects of these methods used in lung cancer screening to reduce mortality hadn’t been studied.

The findings reveal that par-ticipants who received low-dose CT scans had a 20 percent lower risk of dying from lung cancer than participants who received

standard chest X-rays because the low-dose CT screen provides a clearer image, allowing earlier detection. The initial findings were released in November 2010. The primary results were published online on June 29, 2011 in the New England Jour-nal of Medicine and appeared in the print issue on August 4, 2011.

Should my patient be screened?On Dec. 31, 2013, the United States Preventive Services Task Force recommended annual low-dose CT screening for individuals at high risk for lung cancer, now an estimated nine million Americans. This screen-ing is recommended for indi-viduals who meet the following critiera:

• A current or former smo- ker (former smokers hav-ing quit within the past 15 years)

• And in the age group of 55

New lung cancer screening tool

Low-dose CT scan can find disease earlier

By Cynthia Isaacson, Jill Heins Nesvold, MS, and Lee Kamman, MD

Pulmonology

Advise current smokers to quit smoking, offering to help them with appropriate options.

32 MINNESOTA PHySICIAN April 2014

New lung cancer screening tool to page 34

If you are looking for an alternative to practicing in a big system and want to help lead innovation, change and quality, consider North Memorial Health Care. We are a physician-lead organization with opportunities in primary and specialty care.

Practice options include positions with North Memorial, as well as our closely aligned, physician owned practices. We work closely with our physicians to individually tailor practice models that work for our patients and physicians.

ExpEriEncE tHe north MEMorial DiffErEncE

For more information contact Mark Peterson at (763) 581-2986, [email protected] visit northmemorial.com.

Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional full-time BE/BC Family Medicine physicians to join our primary care team at the HealthPartners Central Minnesota Clinics - Sartell. This is an outpatient clinical position. Previous electronic medical record experience is helpful, but not required. We use the Epic medical record system in all of our clinics and admitting hospitals.

Our current primary care team includes family medicine, adult medicine, OB/GYN and pediatrics. Several of our specialty services are also available onsite. Our Sartell clinic is located just one hour north of the Twin Cities and offers a dynamic lifestyle in a growing community with traditional appeal.

HealthPartners Medical Group continues to receive nationally recognized clinical performance and quality awards. We offer a competitive compensation and benefi t package, paid malpractice and a commitment to providing exceptional patient-centered care.

Apply online at healthpartners.com/careers orcontact [email protected]. Call Diane at 952-883-5453; toll-free:800-472-4695 x3. EOE

healthpartners.com© 2014 NAS(Media: delete copyright notice)

MN Physician4" x 5.25"4-color


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

Sorry, no J1 opportunities.

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

• Dermatology

• Emergency Medicine

• Endocrinology

• Family Medicine

• General Surgery

• Geriatric Medicine

• Hospitalist

• Hospice

• Internal Medicine

• Med/Peds

• Ob/Gyn

• Orthopedic Surgery

• Pediatrics

• Psychiatry

• Rheumatology

• Sports Medicine

• Urgent Care

• Vascular Surgery

Fairview Health Services seeks physicians to improve the health of the communities we serve. We have a variety of opportunities that allow you to focus on innovative and quality care. Be part of our nationally recognized, patient‑centered, evidence‑based care team.

We currently have opportunities in the following areas:

Opportunities to fit your lifeFairview Health Services

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

US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Applicant(s) selected for a position may be eligible for an award up to the maximum

limitation under the provision of the Education Debt Reduction Program. Possible recruitment bonus. EEO Employer.

Competitive salary and benefits with recruitment/ relocation incentive and performance pay possible.

For more information:Visit www.USAJobs.gov or contact

Nola Mattson, [email protected] Resources

4801 Veterans Drive, St. Cloud, MN 56303

(320) 255-6301

• Dermatologist

• Geriatrician/ Hospice/ Palliative Care

• Internal Medicine/ Family Practice

• Medical Director- Extended Care & Rehab (Geriatrics)

• Psychiatrist

• Urgent Care Physician (IM/ FP/ ER)

Applicants must be BE/BC.

CDC AND THE U.S. PREVENTIVE

SERVICES TASK FORCE RECOMMEND

ANYONE BORN FROM 1945-1965

GET TESTED FOR HEPATITIS C

more than 75% of adults infected with hepatitis c

are baby boomers

Liver disease, liver cancer, and deaths from Hepatitis C are on the rise. Testing can lead to lifesaving care and

treatment for your patients.

For more information, go to: www.health.state.mn.us/hepatitis

to 74

• And with a smoking histo-ry of at least 30 pack-years (1 pack per day for 30 years, 2 packs per day for 15 years, etc.)

• And no history of lung cancer

There is no evidence at this time that other high-risk groups should be screened. Patients with lung disease, particularly COPD, should be evaluated by pulmonologists regarding the advisability of CT screening de-pending on the severity of their disease.

If you have patients who are wondering if they should get screened, the American Lung Association has launched an online tool to help easily identify potential candidates. www.LungCancerScreening-SavesLives.org takes visitors through a series of questions that helps determine whether they meet the guidelines for a

low-dose CT screening for lung cancer.

CostBecause the NLST results are recent, health insurance com-panies and Medicare may not cover the cost for a CT scan to screen for lung cancer at this time. That means that your patients may have to pay for the procedure out of their own pockets. Be sure to advise your patients to check with their in-surance plans for the screening scan to see what is covered, if the results of the CT scan show that they should have addition-al procedures. Ask the referral facility doing the CT scan to carefully and clearly explain to your patients all the costs that they may possibly incur and not just the cost of the CT scan alone.

If approved, the screenings would be covered by Medi-care. The Affordable Care Act may also require many health insurance companies to pro-vide the test for free. Currently in Minnesota, Blue Cross Blue

34 MINNeSOTA PhySICIAN April 2014

New lung cancer screening tool to page 36

Shield of Minnesota is the only private insurance company that will cover the low-dose CT as a screening tool for lung cancer. For patients not covered by their insurance companies, the aver-age cost of a low-dose CT screen in the state is $150.

Why low-dose CT scan?Lung cancer may have spread by the time a person has symp-toms, which is why screening is a great option to find lung cancer in early stages. One reason lung cancer is so seri-ous is because it usually is not found until it has spread and is more difficult to treat. Scien-tists study screening tests to find those with the fewest risks and most benefits. They look at results over time to see if find-ing the cancer early decreases a person’s chance of dying from the disease. Three screening tests have been studied to see if they decrease the risk of dying from lung cancer.

Of these tests, studies showed that only low-dose spiral CT scan reduced the risk

of dying from lung cancer in high-risk populations. A chest x-ray does not detect lung can-cer early enough and sputum cytology is often done after a patient is already experiencing symptom and therefore are not recommended as screening methods.

What should physicians do before the screening?Considering screening for lung cancer can bring up a variety of questions. The American Lung Association has released new guidelines to help physicians, their patients and the public in their discussions about lung cancer screening. The test is not recommended for everyone and it has risks as well as benefits. CT scan screening is a compli-cated process that requires you first:

• Take a complete health history

• Determine possible comor-bidities (conduct spirome-

New lung cancer screening tool from page 32

Shar GrigsbyHealth Center - East

20 Burdick Expressway Minot ND 58702

Ph: (800) 598-1205, Ext 7860 Pager #0318

Email: [email protected]

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

www.trinityhealth.org

Physicians are offered a generous guaranteed base salary. Benefits also include a health and dental plan, life and disability insurance, 401(k), 401(a), paid vacation, continuing medical education allowance and relocation assistance.

•Ambulatory Internal Medicine•Emergency Medicine•General Surgery

•Psychiatry•Urology

Trinity Health One of the region’s premier healthcare providers.

Based in Minot, the trade center for Northern and Western North Dakota, Trinity Health offers the opportunity to work within a dramatically growing community that offers more than just a high quality of life.

Comprised of a network of nearly 200 physicians in hospitals, clinics and nursing homes, Trinity Health hosts a Level II Trauma Center, Critical Care Helicopter Ambulance, Rehab Center, Open Heart and Lung Program, Joint Replacement Center and Cancer Care Center.

Currently Seeking BC/BE

Contact us for a complete list of openings.


Physician Practice Opportunities

www.averamarshall.org

Avera Marshall Regional Medical Center is part of the Avera system of care. Avera encompasses 300 locations in 97 communities in a five-state region. The Avera brand represents system strength and local presence, compassion-ate care and a Christian mission, clinical excellence, technological sophistication, an array of specialty care and industry leadership.Currently we are seeking to add the following specialists:

For details on these practice opportunities go to http://www.avera.org/marshall/physicians/For more information, contact Dave Dertien,

Physician Recruiter, at 605-322-7691 • [email protected]

• GeneralSurgery• RadiationOncology• InternalMedicine• Pediatrics

• Obstetrics/Gynecology• FamilyPractice• Ophthalmology

Avera Marshall Regional • Medical Center300 S. Bruce St. • Marshall, MN 56258

Olmsted Medical Center, a 160-clincian multi-specialty

clinic with 10 outlying branch clinics and a 61 bed hospital,

continues to experience significant growth.

Olmsted Medical Center provides an excellent

opportunity to practice quality medicine in a family

oriented atmosphere.

The Rochester community provides numerous cultural,

educational, and recreational opportunities.

Olmsted Medical Center offers a competitive salary

and comprehensive benefit package.

Opportunities available in the following specialties:

Dermatology Rochester Southeast Clinic

Family Medicine Byron Clinic

Pine Island Clinic Rochester Southeast Clinic

Internal Medicine Women’s Health Pavilion (Hospital)

Urologist Rochester Hospital

Send CV to:Olmsted Medical Center Administration/Clinician

Recruitment102 Elton Hills Drive NW

Rochester, MN 55901 email: [email protected]

Phone: 507.529.6748

Fax: 507.529.6622

www.olmstedmedicalcenter.org

EOE www.glacialridge.org

Family Medicine Physician

with C-sectionAn ideal balance between your professional and personal life. Provide comprehensive care in a clinical and hospital practice. ER coverage and obstetrics available, but not required.

GRHS is a progressive 19 bed Critical Access Hospital with two clinics. Glenwood is a family oriented community with an excellent school system. Recreational opportunities include boating, hiking, excellent fishing and hunting. We are halfway between Fargo and the Twin Cites.

For more informationCall Kirk Stensrud, CEO320.634.4521

Mail CV to:Kirk Stensrud, CEO10 Fourth Ave SEGlenwood, MN 56334

Email CV to:[email protected]

try if indicated)

• Educate about symptoms of lung disease and lung cancer

• Discuss the benefits, risks and possible procedures associated with the screen-ing process

• Discuss the costs of screen-ing, including financial, personal and time costs

• Advise current smokers to quit smoking, offering to help them with appropriate pharmacologic and behav-ioral options.

• Explain that a “positive” or “suspicious” result means that the CT scan shows something abnor-mal, but many of these nodes are “false positive.” Nodes found could mean lung cancer or some other serious condition and ad-ditional procedures could be needed to confirm, and

those procedures may car-ry additional risks.

• Explain that if there is an “indeterminate” result, it will be monitored for a year or two; this can cause the emotional stress of possibly having cancer.

Where should I refer a pa-tient for a CT scan to screen for lung cancer? Refer your patient to institu-tions that have experience in conducting low dose CT scans, and use the latest CT technolo-gy. There should be a link to an expert multidisciplinary team that can provide follow-up for evaluation of nodules. If the fa-cility does not have that exper-tise on site, they should be able to make referrals to appropriate institutions. The team should also discuss the results and how they will follow up with you and your patient after the screen-ing. In Minnesota there are 11 clinics that have a lung cancer screening program, including:

• Consulting Radiologists– Edina & Plymouth

• Suburban Imaging–Coon Rapids & Maple Grove

• St. Paul Radiology–United Campus St. Paul, Eagan, Maplewood, Woodbury/Lake Elmo, and Gallery Towers/St. Joseph’s Cam-pus St. Paul

• Mayo Clinic–Rochester

• The University of Minneso-ta Fairview–Minneapolis

• Hennepin County Medical Center–Minneapolis

Cynthia Isaacson is manager of respiratory health for the American Lung Association in Minnesota. Jill Heins Nesvold, MS, is director of respiratory health for the American Lung Association in Minnesota, North Dakota, and South Dakota. Lee Kamman, MD, is board-certified in pulmonary medicine, internal med-icine, and critical care; he practices with AllinaHealth.

36 MINNESoTA PHySICIAN AprIL 2014

New lung cancer screening tool from page 34

The American Lung Association has tracked the incidence and mortality attributed to lung cancer. Below are some of the organi-zation’s findings.

• Lungcanceristhesingle-leadingcauseofcancerdeathintheUnitedStates.

• Thediseaseaccountsformoredeathsthanbreast,prostate,colon,liver,andkidneycancerscombined.

• Lungcanceristheleadingcancerkillerinbothmenandwomen.

• In1987,itsurpassedbreastcancertobecometheleadingcauseofcancerdeathsinwomen.

• Non-smokersandformersmokersarealsoatriskforlungcancer.

• Thefive-yearsurvivalrateisonly15percent.

Trends in lung cancer morbidity and mortality

Think about what you really want in a career.

We’ve got you covered from both sides...

The Left Side Your Analytical, Pragmatic Side

*Company Paid Malpractice Insurance *Comprehensive Healthcare Benefits + 401(k) Plan

*Consistent & Predictable Work Schedule *Freedom from the Hassles of Managed Care;

No Insurance or Billing Issues

The Right Side Your Creative, Spontaneous Side

*Generous Paid Time Off & Holidays *Professional Satisfaction Treating Diverse & Clinically Interesting Cases

*Collaborate with an Experienced Treatment Team of Healthcare Professionals and Security Staff

*CME Paid Days Off & Reimbursement

We are also seeking a Primary Care Physician to serve as our STATEWIDE MEDICAL DIRECTOR based out of our Regional Office in St. Paul.

MHM Services, in conjuction with Centurion of Minnesota is proud to be the provider of healthcare services to the Minnesota Department of Corrections. We currently have excellent Full Time, Part Time & Per Diem

PRIMARY CARE and PSYCHIATRIST opportunities available throughout Minnesota, including the following locations:

Lino Lakes * Shakopee * Oak Park Heights * Stillwater Faribault * Moose Lake * Red Wing * Rush City * St. Cloud

For more information, please contact: Tracy Glynn· 877.616.9675· [email protected]

www.mhm-services.com | Equal Opportunity Employer


Emergency Room Physicians

Looking for leisure work hours?

• Immediate openings

• Casual weekend or eveningshift coverage

• Choose from 12 or 24 hourshifts

• Competitive rates• Paid malpractice

Attention Physicians

763-682-5906 • 1-800-876-7171

F-763-684-0243

[email protected]

• Set your own hours

• No contract

• No obligations

Great Emergency Department in Southern Minnesota

AIRFORCE.COM/HEALTHCARE

© Paid for by the U.S. Air Force. All rights reserved.

Please contact or fax CV to:

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

763-504-6600 Fax 763-504-6622

www.NWFPC.com

Join the top ranked clinic

in the Twin CitiesA leading national consumermagazine recently recognizedour clinic for providing the bestcare in the Twin Cities based on quality and cost. We are currently seeking new physicianassociates in the areas of:

• Family Practice

• Urgent Care

We are independent physician-owned and operated primaryclinic with three locations in theNW Minneapolis suburbs. Work-ing here you will be part of anaward winning team with partner-ship opportunities in just 2 years. We offer competitive salary andbenefits. Please call to learn howyou can contribute to our innova-tive new approaches to improvinghealth care delivery.

treatments include advanced tendon repair methods, tendon transfer options, and methods of tendon augmentation.

Ankle instability This is a relatively common condition that results either after a severe ankle sprain or after multiple, repeated ankle injuries. Ankle ligaments are no longer supportive of the ankle. Symptoms include repeated ep-isodes of the ankle “giving way,” a person’s apprehension on uneven ground, and looseness around the ankle joint. This condition can sometimes be associated with ankle cartilage disorders, which may also need to be addressed.

Many new ankle instability procedures have been pio-neered. They utilize new anchor and ligament repair methods, some of which are performed with minimum invasion, uti-lizing an arthroscope. These

surgical procedures allow early active range-of-motion and earlier return to weight bearing and activity.

Achilles tendon disordersAchilles tendon ruptures occur when too much torque is placed upon the Achilles tendon and

it fails. This usually happens during active athletic partic-ipation. Under some circum-stances, an MRI can finalize the diagnosis. Surgical repair of the ruptured tendon, aimed at early return to motion and activity, has advanced in both the type of suture technique utilized and the type of suture material utilized.

Some of the strongest syn-thetic surgical material created are utilized to surgically repair

these tendon ruptures. This ma-terial, in the proper suture tech-nique, allows for earlier return to activity and weight-bearing than previously possible. New techniques utilize minimally invasive methods that allow a quicker recovery.

The other form of Achil-

les tendon disorder is termed Achilles tendinopathy. It usually occurs after multiple episodes of Achilles tendinitis, often affecting active individuals. Treatments range from focused stretching programs to tendon surgical procedures, including microtenotomy procedures, tendon debridements, growth factor injections, and tendon transfer techniques.

Achilles tendon disorders can be disabling. It is important

to have them evaluated by a foot and ankle specialist.

New treatments for common disordersFoot and ankle disorders are common. Significant advance-ments have been made in the diagnosis and management of these conditions. Treatment is aimed at rapid restoration and recovery. Foot and ankle spe-cialty care will include a phys-ical exam and imaging (X-ray, MRI, or CT scans) to determine a diagnosis and to create a custom-tailored treatment plan that gets a patient back to full range of activity and a desired lifestyle.

Benjamin Clair, DPM, FACFAS, is a foot and ankle specialist at St. Croix Orthopaedics, with a focus on trauma, arthroscopy, cartilage repair, tendon repair, and orthopedic surgical conditions of the foot and ankle. Aaron Benson, MS, ATC, is an athletic trainer who works with Dr. Clair.

Significant advancements have been made in the diagnosis and

management of these conditions.

Advances in foot and ankle surgery from page 27

38 MINNeSoTA PhySICIAN APril 2014

REGISTER TODAYSept. 7-9, 2014

www.mayo.edu/transform

Mayo Clinic’s Transform Symposium addresses tough questions, focuses on results and engages attendees to catalyze practical innovation for health and health care. Join this growing community of thought leaders, innovators and disruptors all focused on transforming the experience and delivery of health care as only as Mayo Clinic can by attending the annual Transform Symposium on Sept. 7-9, 2014.

Five Reasons to Attend Transform:• Learn from thought leaders from around the world• Ask tough questions and understand patient perspectives• Build a network of collaborators across multiple industries• Springboard and promote your own innovation efforts• Positively impact the health care delivery system

REGISTER TODAY

YOU SHOULD BE HERE

CMYK_FullPageAd_Transform2014NEW.indd 1 2/14/14 12:58 PM

At MMIC, we believe patients get the best care when their doctors feel calm and confi dent. So we put our energy into creating risk solutions designed to eliminate worry. Solutions such as medical liability insurance, physician well-being, health IT support and patient safety consulting. It’s our own quiet way of revolutionizing health care.

To join the Peace of Mind Movement, give us a call at 1.800.328.5532 or visit MMICgroup.com.

Relax.Discover solutions thatput you at ease.

minnesota physician april 2014

Documents

consortium national

national institutes

university of minnesota

national scope

regional approach

past medical techniques

coordinated approach

comprehensive approach