minnesota physician march 2012

iven only onechoice, whatwould you

choose:• A doctor/clinic with

better health carequality rankings OR

• A doctor/clinic withbetter medical care quality rankingsThese two ratings presently are lumped

together as “health care.” Health care is amajor contributor to any individual’s well-being, but it is not the only part. Medicalcare is also a major contributor to a longlife. This article examines the distinctionbetween “health care” and “medical care”and questions a measuring system thathighlights one over the other under one“quality” banner. Both types of care are

important to everyonein the community, sothe difference is impor-tant to appreciate.

The Merriam-Webster dictionarydefines “health” as thestate of

being free from illness orinjury. It defines “medicine” asthe science or practice of diag-nosis, treatment, and preven-tion of disease.” What’s espe-cially relevant is that, begin-ning in the mid-1980s, whatused to be known as “medicalcare” was supplanted by the

CARE to page 10

Volume XXV, No. 12

March 2012

Stepping uppatient safetyHealth care asa team sport

By Karyn D. Baum, MD, MSEd,and Albertine S. Beard, MD

As the operation draws to aclose, Nancy, a third-year med-ical student, is confused. She is

sure there is one more sponge yet to beaccounted for. But should she speakup? Her attending is well respectedand a good physician—surely he mustrealize? Nancy wants to become a sur-geon, and does not want to risk theanger of the chief surgeon by publiclypointing out a mistake. After all, sheneeds a letter from him if her dreamsof a urology residency are ever tobecome reality.

Many of us have been Nancyat some point in our careers. TheInstitute of Medicine’s 1999 publica-tion “To Err is Human” brought intothe public eye the gravity of thesafety issues in health care, with esti-mates of between 44,000 and 98,000deaths per year in the United States

SAFETY to page 12

The Independent Medical Business Newspaper

IN THIS ISSUE:Community CaregiversPage 20

“Medical care”and “health care”

An avoidable conflictBy E. John English, MD

G

(952) 925-9455 www.mapeterson.com

View your homein a new way.

CAPSULES 4

MEDICUS 7

INTERVIEW 8

PROFESSIONAL UPDATE:RADIOLOGYSpotlight on imaging 14By Scott R. Schultz, MD

SCREENING GUIDELINESThe prostate cancerdilemma 16By Thomas J. Stormont, MD

SCREENING GUIDELINESScreeningmammography 18By Joseph H. Tashjian, MD

PSYCHIATRYA breakthrough intreating depression 28By Abraham Verjovsky, MD

TRANSPLANTATIONFrom fiction to realityin half a century 30By William D. Payne, MD

ALLIED PROFESSIONSPhysician assistants 34By Pamela M. Dean, MBA

DEPARTMENTS

C O N T E N T S MARCH 2012 Volume XXV, No. 12

MARCH 2012 MINNESOTA PHYSICIAN 3

Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Ouraddress 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 pub-lication. All views and opinions expressed by authors of published articles are solely those of theauthors and do not necessarily represent or express the views of Minnesota PhysicianPublishing, Inc., or this publication. The contents herein are believed accurate but arenot intended to replace legal, tax, business or other professional advice and counsel. Nopart of this publication may be reprinted or reproduced without written permission ofthe publisher. Annual subscriptions (12 issues) are $48.00. Individual issues are $5.00.

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OFFICE ADMINISTRATOR Juline Birgersson [email protected]

ACCOUNT EXECUTIVE John Berg [email protected]

ACCOUNT EXECUTIVE Sharon Brauer [email protected]

ACCOUNT EXECUTIVE Iain Kane [email protected]

TheIndependentMedicalBusinessNewspaper

“Medical care” and “health care” 1An avoidable conflictBy E. John English, MD

Stepping up patient safety 1Health care as a team sportBy Karyn D. Baum, MD, MSEd, andAlbertine S. Beard, MD

Community Caregivers 2012 20Making a difference inMinnesota and the worldBy Scott Wooldridge

FEATURES

www.mppub.com

Larry ShellitoMinnesotaDepartment ofVeterans Affairs

Exp. Date

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Please mail, call in or fax your registration by 04/12/2012

MINNESOTA HEALTH CARE ROUNDTABLEMINNESOTA HEALTH CARE ROUNDTABLE

Background and focus:Medications treating chronicand/or life-threatening dis-eases are frequently newproducts, which are oftenmore expensive than genericor older, branded productsthat treat similar conditions.The term specialty pharma-cy has come to be associ-ated with these medications.Exponents claim the newtechnology improves qualityof life and lowers the costof care by reducing hospital-izations. Opponents claimthe higher per-dose costspread over larger popula-tions does not justify theexpense.

The cost of research, bothfailed and successful, is reflected in product pricing. Currentfederal guidelines allow generic equivalents marketplace accessbased on the patent date, not the release date, of a product. Thisconsiderably narrows the window in which costs of advances maybe recovered. A further complicating dynamic involves the payers.Physician reimbursement policies sometimes reward utilizinglower-cost “proven” products and cast those prescribing higher-cost products as “over-utilizers,” placing them in lower-tieredcategories of reimbursement and patient access.

Objectives: We will discuss the issues that guide the earlyadoption of new pharmaceutical therapies and how they relate tomedical devices. We will examine the role of pharmacy benefitmanagement in dealing with the costs of specialty pharmacy. Wewill explore whether it is penny-wise but pound-foolish to restrictaccess to new therapies and what level of communication withinthe industry is necessary to address these problems. With the babyboomers reaching retirement age, more people than ever will betaking prescription medications. As new products come down thedevelopment pipeline, costs and benefits will continue to esca-late. We will provide specific examples of how specialty phar-macy is at the forefront of the battle to control the cost of care.

T H I R T Y - S E V E N T H S E S S I O N

Please send me tickets at $95.00 per ticket. Mail orders to MinnesotaPhysician Publishing, 2812 East 26th Street, Minneapolis, MN 55406.Tickets may also be ordered by phone (612) 728-8600 or fax (612) 728-8601.

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Signature

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Thursday, April 19, 20121:00 – 4:00 PM • Duluth Room

Downtown Mpls. Hilton and Towers

Specialtypharmacy

Controlling the cost of care

4 MINNESOTA PHYSICIAN MARCH 2012

WestHealth to OpenStand-alone EDWestHealth, an outpatient med-ical center owned by AllinaHospitals and Clinics, will opena stand-alone emergency depart-ment by the end of this year,officials announced recently.The new facility will be

staffed by emergency medicinephysicians from AbbottNorthwestern and is part of anongoing expansion at the site inPlymouth. The emergencydepartment will be an 18,000-square-foot building adjacentand attached to the 180,000-square-foot campus.“This will be the outpatient

health care campus of the futureand another step toward Allina’scommitment to achieving theTriple Aim of lower costs, higherquality, and improved patientexperience,” says Ben Bache-Wiig, MD, president of AbbottNorthwestern Hospital.Officials say the WestHealth

campus is designed to meet awide spectrum of needs at alocation convenient to patents inthe west metro area. The facility

currently offers primary care,pharmacy, outpatient surgery,imaging, specialty care, andurgent care. Future plans forthe site include a transitionalcare unit to provide care in alower cost setting than a tradi-tional hospital.

Allina AnnouncesName ChangeAllina Hospitals and Clinics ischanging its name to AllinaHealth, officials with theMinneapolis-based health sys-tem said recently. The namechange is being phased inslowly, but new signage willstart making an appearancethis spring, officials say.According to David

Kanihan, spokesman for thehealth system, the change hasbeen under discussion for sometime and reflects changes goingon in health care delivery in gen-eral. “Our name has been AllinaHospitals and Clinics, and whilehospitals and clinics will con-tinue to be a core part of whatwe do, our focus needs to bebroader than that,” Kanihan

says. “If we’re going to be in aposition to be charged withoverall health of a community,we have to be involved with peo-ple beyond what happens in ahospital or clinic.”The move reflects new

approaches to health care deliv-ery that emphasize health man-agement, integrated approachesto care, and “upstream” preven-tive measures. Kanihan notesthat health care reform effortsput a great emphasis on preven-tion and community health, andsays the name change willunderscore those strategies.“Our measure of success has

been how many admissions tohospitals we’ve been able to gen-erate,” he notes. “Our measureof success in the future may bethe complete opposite.” He saysthe system will continue tosharpen its focus on wellness,prevention, chronic diseasemanagement, and end-of-lifecare.The name change got its

first public debut at a speech inFebruary at the University ofMinnesota by Ken Paulsen,Allina’s CEO. Paulsen was

quoted by the Minneapolis StarTribune as saying, “We’re nevergoing to build another hospital,”and Kanihan says the statementreflects the organization’s newfocus.“Hospitals are important,

but we need to think beyondhospitals,” Kanihan says. “Wehave 11 really good hospitals andthey will continue to be very im-portant to what we do, but theywon’t be the only thing we do.”

HealthPartners toOpen Southside ClinicHealthPartners has announcedplans to open a primary careclinic with urgent care servicesin South Minneapolis laterthis year.The 7,800-square-foot

clinic, called HealthPartnersClinic in South Minneapolis,will offer a range of services,including family practice, ob-gyn, chiropractic, laboratory,and imaging services. The clinicwill also feature an evening andweekend urgent care clinic. Itwill be located on ChicagoAvenue between 47th and 48th

C A P S U L E S

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

| provider assistance: 1-888-531-1493 | ucare.org/providers | ©2012, UCare.


Streets in an existing retailspace, with five physicians ex-pected to practice at the facility.“We’re looking forward to

partnering with the local com-munity, including neighborhoodgroups, schools, and busi-nesses,” says Mary Brainerd,HealthPartners president andCEO. “Their involvement,engagement, and support is vitalthroughout the planning anddesign process. We want theclinic to reflect the character ofthe neighborhood it serves.”

ACA ChangesPhysician ReportingOf Drug CompanyFederal regulators are creating asystem to publicly report pay-ments to physicians from drugcompanies and medical devicemanufacturers, as a way ofincreasing the transparency ofsuch arrangements. The Phy-sician Payment Sunshine Act,part of the Affordable Care Act(ACA), would create a nationalsystem that mirrors ground-breaking legislation passed byMinnesota lawmakers in 1993.This may lead to the currentMinnesota database of physicianpayments being discontinued.The Minnesota law requires

drug companies to report to astate database, compiled by theMinnesota Board of Pharmacy,every time they pay a physician$100 or more in speaking orconsulting fees. It also requiresdrug manufacturers to reportgifts given to physicians, such asmeals or entertainment outings.The new national regula-

tions would require companiesthat manufacture pharmaceuti-cals, medical devices, or biologi-cal or medical supply productsto track and report payments of$10 or more made to physiciansand teaching hospitals. The newrule also requires manufacturersand group purchasing organiza-tions to disclose any financialties to physicians or their familymembers.Proponents of the Sunshine

Act often cited the Minnesotareporting law, first implementedin 1997, as a model for provid-ing transparency in physicianpayments from drug companiesand device manufacturers.

According to Cody Wiberg,executive director of the Minne-sota Board of Pharmacy, hisgroup monitors both nonmone-tary gifts to practitioners as wellas payments for things such asconsulting, research, and med-ical education. The Minnesotadatabase on gifts will continue,Wiberg says, but the new federalregulations preempt state data-bases, so his organization willbe required to stop collectingdata on payments to physiciansfrom drug manufacturers.The Minnesota system,

though not the only state data-base, did encourage a change inthe way physicians and drugcompanies approach payments,Wiberg says. “I think they’re tak-ing reporting far more seriouslythan they used to,” he says.“Physicians and health institu-tions are more careful aboutaccepting research grants, andpharmaceutical manufacturersare a little more careful abouthow they give them.”

Accretive HealthLicense SuspendedBy CommerceA Chicago-based debt collectionagency is getting additionalscrutiny from the state ofMinnesota. Accretive Health,which was recently sued byMinnesota Attorney GeneralLori Swanson over lost patientmedical records, is under inves-tigation from the state Depart-ment of Commerce, officialsannounced on February 3rd.Swanson’s suit, filed in

January, called on Accretive tofully disclose what informationit gathers on patients in Minne-sota, where the company workswith Fairview Health Servicesand North Memorial HealthSystem. In July 2011, anAccretive employee lost sensi-tive information on 23,500patients when a laptop wasstolen from a car.In the new move by the

Commerce Department,Commissioner Mike Rothmanhas suspended Accretive’slicense to do collections inMinnesota until the company isin compliance with state law.Rothman says his agency is

CAPSULES to page 6

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investigating whether Accretivedeceived debtors, allowed unreg-istered employees to act as debtcollectors, and disguised its roleas a collection agency.“These allegations represent

a troubling disregard for ourdebt collection laws,” Rothmansays. “We are investigating thismatter thoroughly, which willrequire the company’s utmostcooperation.”

Gundersen LutheranTo Market HMOIn MinnesotaA new health plan was certifiedfor the Minnesota market inFebruary, as the MinnesotaDepartment of Health (MDH)announced Gundersen LutheranHealth Plan Minnesota wouldoperate an HMO in four coun-ties. The health plan, based inOnalaska, Wis., will do businessin Fillmore, Houston, Olmsted,and Winona counties in south-eastern Minnesota. TheGundersen Lutheran healthplan, which has 90,000 members

in Wisconsin and Iowa, is thefirst to be certified in Minnesotasince 1998.The state certified the plan

after a Minnesota Departmentof Commerce analysis ofGundersen’s financial fitness.As with all health plans market-ed in Minnesota, the new HMOwill operate as a nonprofit.According to Allan

Baumgarten, an analyst whoregularly issues reports on theMinnesota HMO market, thethree main areas of HMO enroll-ment in southeastern Minnesotaare senior plans, Medicaid plans,and employer-based plans—withthe last category seeing a signifi-cant decline in numbers duringthe past 10 years.Baumgarten notes that

Gundersen serves similar mar-kets in western Wisconsin. “Theycould probably position them-selves effectively in all threemarket segments, because theyhave a significant physician andhospital presence in the region,”he says. “I think they couldleverage that to offer competitiveprices, so the opportunities arepotentially good for them.”

There is also the possibilitythat the state will expand itscompetitive bidding process forMedicaid plans to cover areassuch as southeastern Minne-sota, Baumgarten says. “Thiscould be an opportune time fora new entrant like Gundersen tomake a proposal,” he says.

Stratis ExpandsPalliative CareStratis Health has announcedthat it has chosen seven ruralMinnesota communities towork with in improving pallia-tive care. The Rural PalliativeCare Community DevelopmentProject will involve more than40 organizations in an effortto establish or strengthenpalliative care in rural areas ofthe state.The announcement follows

earlier programs launched byStratis to promote palliativecare in Minnesota. To date, 23Minnesota communities havebeen part of Stratis’ palliativecare initiatives.Palliative care helps patients

manage chronic disease and

other serious and advanced ill-ness. The approach centers onrelieving suffering and improv-ing quality of life for patientsand their families.“With chronic diseases as a

leading cause of death and dis-ability in Minnesota, our healthcare services need to evolve toprovide appropriate care. Weneed treatment plans tailored toeach patient’s goals and newdelivery methods that cross mul-tiple health care settings,” saidJennifer Lundblad, PhD, MBA,president and CEO, StratisHealth. “By fostering palliativecare in rural communities wehope to decrease the number ofpatients having to leave theirhome community to receive thispatient-centered care.”The organizations chosen

for this initiative are Commun-ity Memorial Hospital Associa-tion in Cloquet; JohnsonMemorial Homecare in Dawson;Kenyon Senior Living; MadeliaCommunity Hospital; MadisonHospitals Home Care Agency;Mercy Hospital in Moose Lake;and Essentia Health East RangeHospice in Virginia.

Capsules from page 5

www.cmecourses.umn.edu2012 CME Courses(All courses in the Twin Cities unless noted)

Pediatric DermatologyProgress & PracticesMay 18, 2012

Bariatric Education DaysMay 23-24, 2012

Workshops in Clinical HypnosisMay 31-June 2, 2012

Trauma, Critical Care & AcuteCare SurgeryJune 7-8, 2012

Topics & Advances in PediatricsJune 7-8, 2012

FALL COURSESPediatric Hypnosis Training (NPHTI)September 20-22, 2012

Twin Cities Sports MedicineOctober 5-6, 2012

Practical Dermatology, Duluth, MNOctober 26-27, 2012

Internal Medicine ReviewOctober, 2012

Geriatric TraumaNovember 29-30, 2012

ONLINE COURSES (CME credit available)For more information:www.cme.umn.edu/online

Fetal Alcohol Spectrum Disorders (FASD)Global Health (7 Modules), to include:

- Intro to Health Care for Immigrant andRefugee Populations

- Parasitic Infections- Travel Medicine

Promoting a lifetime of outstanding professional practice

Office of Continuing Medical Education612-626-7600 or 1-800-776-8636

email: [email protected]

SPRING COURSESLillehei SymposiumApril 5-6, 2012

Cardiac ArrhythmiasApril 13, 2012

Integrating Behavioral Health into theHealth Care HomeApril 13, 2012

ICU Team TrainingApril 23-25, 2012

NCCIDSA Annual MeetingApril 28, 2012

Care Across the ContinuumMay 11, 2012

Global Health TrainingMay 14-27, 2012

Tim Zager, MD, began his new role as presidentof Essentia Health-Duluth Clinic in December.Zager has served in many leadership roles atEssentia Health, most recently as chief of theMedical Specialties Division, a position he hadheld since 2004. A board-certified pediatricianat Essentia Health–Duluth Clinic since 1982,Zager is also a clinical assistant professor at theUniversity of Minnesota,Duluth, School of Medi-

cine and has won several teaching awards fromthe Duluth Family Practice Residency.

Two physicians were recognized for theirservice to the community at the annual meetingof Lakeview Hospital medical staff in December.Thomas Stormont, MD, was recognized for hislong commitment to Lakeview Hospital, wherehe continues to serve as Surgery Departmentchair. He is a board-certified urologist who completed his residencyat Mayo Clinic. Andrew Dorwart, MD, was recognized for leadershipcommitment to Lakeview Health System. He has held many leader-

ship positions in the past and currently serves aspresident of Stillwater Medical Group. Dorwartis a board-certified internal medicine physicianwho completed his residency at HennepinCounty Medical Center. This is the 16th yearthat Lakeview Hospital has awarded physicianrecognition awards, which are given annually byphysician peers to recognize fellow physiciansfor their overall distinguished service to Lake-view Hospital, its patients, and the community.

Aspen Medical Group has recently added three physicians at itsclinics. Kang Xiaaj, MD, family medicine, will practice at the EastLake Street Clinic. Xiaaj earned her degree at the University ofMinnesota Medical School and completed her residency at RegionsHospital. Josaleen Davis, MD, internal medicine and geriatrics, willsee patients at the Hopkins clinic. Davis earned her degree at theUniversity of Minnesota Medical School and completed her residencyat Maine Medical Center. Heather Jensen, DPM, MHA, will seepatients at the Bloomington and Hopkins clinics and the SpecialtyCenter in St. Paul. Jensen earned her degree at Des Moines (Ia.)University’s College of Podiatric Medicine and Surgery.

Jennifer Johnson Martinelli, MD, has joined Essentia Health’sDuluth Clinic urgent care department. She most recently worked atSt. Luke’s hospital in Duluth. Martinelli received her medical diplomafrom St. George’s University School of Medicine in Big Shore, N.Y.,and completed her internship at St. Paul-Ramsey Medical Centerand her residency at HealthPartners Institute for Medical Educationin St. Paul.

Chad Pedersen, MD, an internal medicinephysician, has joined the Winona Health med-ical staff as a hospitalist. Pedersen receivedhis medical degree at the University of NorthDakota in Grand Forks and completed hisresidency at Gundersen Lutheran MedicalSystem in La Crosse, Wis., where he served aschief resident.

Craig Strauss, MD, MPH, has joined theMinneapolis Heart Institute and will see patients in Alexandria, Cam-bridge, Monticello, and Plymouth. Strauss has worked on researchprojects with the Minneapolis Heart Institute since 2005, includingparticipating in its acute aortic dissection program. Strauss receivedhis medical degree at Dartmouth Medical School and also earned amaster’s of public health degree at the Dartmouth Institute for HealthPolicy and Clinical Practice. He completed his residency at AbbottNorthwestern Hospital, where he was chief resident, and performeda fellowship at the University of Minnesota.

M E D I C U S

Tim Zager, MD

Thomas Stormont, MD

Andrew Dorwart, MD

Craig Strauss, MD, MPH


In our August 2012 edition, Minnesota Physician willprofile 100 of our state’s most influential health careleaders. In a format featuring photos, bios and quotes,we will highlight the men and women most respon-sible for making Minnesota a global model for health

care delivery.

These individuals willrepresent every aspect

of the industry —physi-cians, business execu-tives, political leaders,policy analysts, etc.

We invite you, ourreaders, to partici-pate in this recogni-tion process. If you

know anyone within your organization you feel shouldbe considered, please fill out the form below andreturn it by mail, fax or email prior to May 25, 2012.

We welcome your input and participation in makingthis list as comprehensive and meaningful as possible.

COMPLETE AND RETURN THE FORM BELOW

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� Please tell us about the size and scope of theVA in Minnesota.

The Veterans Administration (VA) is the federalside, and they are the ones that do a lot of themedical care. The two main facilities in Minnesotaare the Minneapolis VA Medical Center, here inMinneapolis, and the St. Cloud Medical Center.There’s also a medical center in Sioux Falls, S.D.,that covers part of our state’s southwest corner, andthe Fargo, N.D., medical center that catches someof our northwest veterans.

St. Cloud has a community-based outreachclinic (CBOC). There are CBOC locations inMontevideo, Brainerd, and Alexandria. There’s alsoone in Fergus Falls, but that’s part of Fargo. A lotof our veterans just need that checkup and some oftheir medications and so forth, so they can gothere without having to travel a great distance.That’s all on the federal side.

Now with the Minnesota Department of Veter-ans Affairs (MDVA), on the state side, we have fiveveterans’ homes. They’re like nursing homes, withresidential living. They are located in Minneapolis,which is our largest, and in Hastings, Luverne,Fergus Falls, and Silver Bay.

In addition, every county has County VeteranService Officers (CVSOs).They are paid for by thecounty but coordinated byour state office. Their job isto seek out veterans that livein their community and edu-cate them as to what benefitsare available. With older veterans, they would edu-cate them about our Veterans Homes. Or, if theyhave medical needs and medications, we will actu-ally transport them to the federal medical centersin St. Cloud or Minneapolis.

They’re the people that go out into the veterancommunity and say, “All right, here’s what youneed.” If it’s to get your medicines and check yourblood pressure, we’ll take you to the nearest com-munity-based outreach center. A veteran’s physi-cian might discover something that’s pretty serious,so the CVSO would help to get you to the nexthigher level, which would be the medical center.

The CVSO oversees a variety of benefits for ourveterans. But if veterans don’t ask for it, they’re notgoing to get it. Most veterans don’t know how toask for it.

� How do these different facilities interact?

Let’s pick Alexandria as an example. They have aCBOC. They might say, “This is a little bigger med-ical issue than we can care for. So we’re going totransport you now to St. Cloud.” St. Cloud mightdecide the patient should go to the next higherlevel. The highest level of care would then be at theMinneapolis medical center.

With that concept of triage, my personal goalis to have care delivered at the most appropriatelevel. That’s the most cost effective.

� What are your responsibilities as MDVACommissioner?

My responsibility is to make sure that those CVSOsare trained. I have two elements under my directsupervision. I have a deputy commissioner incharge of the five veterans’ homes and I haveanother deputy commissioner who is responsiblefor our programs and services. The program servic-es are programs for traumatic brain injury, coun-seling, financial assistance, those types of things.

� As Commissioner, what are your goals for theMDVA in Minnesota in the coming years?

There are 380,000 veterans in the state of Minne-sota. According to the VA, 72 percent of them don’treceive any benefits from the government. My goalis to do outreach, to find the veterans, make themaware of what opportunities they have available tothem, and then work with them to help them getthe services that they need.

We have been at war for over 10 years. Wehave created a lot of veterans. These veterans arecoming back with different issues. In the VietnamWar, there were over 53,000 killed in action. Thenumber with the new conflicts is around 5,000.What makes up that difference is the medical com-

munity. The medical respon-siveness in Afghanistan andIraq is absolutely phenome-nal. When these veteranscome back, we’re going tohave them for the next 40years.

Again, as with most wars, there’ll be a lot ofthem that will be sent home, and then all of a sud-den the memories, the flashbacks, the undiagnosedPTSD will be there, and that’s where our focus isgoing to be. Our goal, the mantra that we are usingis, “Bring them all the way home,” which meansnot only physically but also mentally and emotion-ally, and get them back into productive society.

� You mention that many veterans don’t utilize VAservices—what can be done about that?

One of the issues we have is that on hospital orclinic admissions forms, no one ever asks, “Are youa veteran?” Just add another question about beinga veteran. That could create additional opportuni-ties. Especially with the older veterans, I see this asbeing extremely important. There are a lot of peo-ple who don’t have health insurance. A physiciancould say, “Here’s another option you might wantto think about—call your CVSO.”

� With the economy the way it is, a lot of peoplefall off the employer-based insurance plans, sowhat you’re saying is that this would be anotherplace veterans could go.

Correct. I just had a carotid artery worked on.That’s about a $40,000 bill, and that would devas-tate most people in the state, especially if they’re on

Maj. Gen. Larry ShellitoMinnesota Department

of Veteran Affairs

Larry Shellito wasappointed by

Gov. Mark Dayton as theCommissioner of the

Minnesota Departmentof Veterans Affairs.

A retired major generalwith the Minnesota

National Guard, he ledthe fifth-largest stateGuard for seven years,

overseeing 14,000members in 63 facilities

across the state.As commissioner,

Shellito’s responsibilitiesinclude oversight of

Minnesota’s fiveVeterans Homes, as wellas the MDVA’s claims,outreach, benefits,higher education

program, and mentalhealth services.

Shellito had a 42-yearcareer in the military,

including servingin Vietnam. He hasbeen awarded the

Distinguished ServiceMedal, Legion of Merit,

Bronze Star, andCombat Infantryman’s

Badge.

Caring for the returning veteran


I N T E R V I E W

The mantra that weare using is, “Bring them

all the way home.”

a retirement income or they’re not fully em-ployed. A primary care physician could tellsomeone in that situation about their CVSO.We also have a website, MinnesotaVeteran.org, for information.

Our goal is to be continually educatingveterans on their benefits. There are somany things that are changing on the fed-eral level; it’s very dynamic. We’re talking topeople, we’ve got our website, we’ve gotCVSO training, all those things, but in away, the enemy is Minnesota pride: That 72percent basically say, “I’m okay, take care ofmy buddy, take care of my friend.”

� Women are playing a larger role in ourarmed forces; what kind of challenges dotheir health care needs present?

First of all, you are absolutely correct.Women are playing a larger and growingrole in the military. They have proven them-selves to be absolutely outstanding. One ofthe early complaints, on the federal level inparticular, is that all of the medical centerswere male-oriented—the exam rooms, thebathrooms, etc. That is continually beingaddressed because of the number of femaleveterans. With new construction, thosecommunity-based outreach centers, whichare relatively new, have facilities and doctorsthere to take care of women also.

� Traumatic brain injuries (TBI) have gottena lot of attention since the Iraq War. Howis the VA addressing this health issue?

On the federal side, there are specialists atthe Minneapolis VA Center. As I said, it isnoted nationwide. They are one of the fourpolytrauma centers in the United States.What we are doing as a state is to have amember of our MDVA staff working with theDepartment of Human Services to addressTBI here in Minnesota. We are working veryactively on the state level to identify peoplewith TBI and then direct them to the treat-ment that they need, whether it be local,state, or federal.

� What can you tell us about how theMDVA system is dealing with the mentalhealth needs of veterans?

In addition to the federal VA programs,MDVA partnered with Lutheran Social Ser-vice and created a program we call CORE,which stands for Case Management, Out-reach, Referral, and Education. Basically it’san outreach, where the state provides fund-ing to enable our veterans to seek profes-sional counseling close to or in their owncommunities When veterans have mentalhealth issues, their unit commander will getthem connected to a trained professionalcounselor with the CORE program. Thisprogram provides essential mental healthservices to active duty members, veterans,

and family members at no charge. It’s fund-ed by the state and through the Support OurTroops license plate fees.

� What would you like physicians inMinnesota to know about the resourcesthat the Minnesota VA provides?

I want physicians to know that there are anumber of safety net programs for patientswho are veterans. Ask patients to identify ifthey are or are not veterans. If they are vet-erans, then that makes some other optionsavailable. Obviously, first and foremost,physicians should just take good care of alltheir patients, do the diagnostic, and if theyget to the point where there are more thingsneeded, say, “As a veteran, you also have thisoption to check out.”

Physicians don’t need to know all theanswers. They just need to know that everycounty has a CVSO.

And if they have a moment during anoffice visit with a veteran: Just visit withhim or her and let that be part of the learn-ing process. We’ve taken a lot of 18-, 19-year-old kids and made them grow up prettydang fast, and they’re struggling. I go backto my same doctor, not just because he’sgood, but it’s the relationship, the bond oftrust. If the physician can establish a bondof trust with that veteran, that is absolutelyessential and critical.


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term “health care.” These termsare now used interchangeably;however, they are very differentapproaches to the same end

point: the patient’s maximumwell-being. Interchangeable usecauses confusion for doctors,patients, and policy makers—especially when measurementswith mandatory public rankingson quality of doctors/clinics areinvolved.

Differentiating between “healthcare” and “medical care”

First, let’s focus on the term“health care.” Health care is apopulation-based approachdesigned to improve everyone’swell-being. It’s prevention, pureand simple. It is a public

health–centered, top-downapproach that traditionally hasbeen the responsibility of thestate. It is focused on commu-nity attainment of proven,general preventive meas-ures; its aim is to preventall society from illnessor injury by institutingbroadly accepted guide-lines for improvement.Once a particular meas-ure is demonstrated tohave broad benefit,almost anyone can pro-mote and promulgate it.

Originally, state-directed public health programsaddressed such areas as requir-ing a community to maintain aclean water supply or achieveproper sewage treatment. Butas those public health goalshave been achieved, healthplans have intervened and the“health care” message hasbecome “stop everyone’s smok-ing, have everyone lose weight,control everyone’s blood pres-sure, lower everyone’s choles-terol, get everyone to exercisethree times a week.” The listgoes on … but not on forever.The neat part is that all thesepreventive recommendationscan be written down on just oneor two pieces of paper.

So it’s not that patientsdon’t know what they shoulddo; it’s the actual doing it that isthe problem. In other words, itis compliance or the lack of itthat determines the outcome.Success of the various healthcare programs is measured bypercentages of attainment. Themore people do the acceptedright thing, the less disease andinjury occur. And, importantly,

it’s patients themselves thatmainly determine the outcome.Unfortunately, patients—other-wise called people—can be a bitornery with compliance. Forwhatever reasons, sometimesthey simply don’t comply.

Preventive “health care”absolutely works, is absolutelyworthwhile, absolutely hasgreat benefit, is absolutely time-consuming, and, as an aside—absolutely costs a lot (andremember, cost is the issue inhealth care today).

Medical care is completelydifferent. It is an individual-based method to restore, main-tain, or improve an individual’swell-being. It is highly personaland is, in fact, usually attainedone person at a time. It is ahands-on, bottom-up approach.It is diagnosis- and treatment-centered. At some point ineveryone’s life, it is desired,demanded, and sought out,basically after the preventivemeasures have failed.

Traditionally, medical carehas centered on having a gooddoctor who is proficient in hisor her craft. One who has areal-time working knowledge of,say, 20,000 pages of text andcan constantly make real-timeadjustments to meet changingpatient needs. One who identi-fies medical problems early—and directs proper treatmentpromptly. One who knows whatsymptom complex is serious,and what is not. And, of course,one who additionally promotesvarious health-care preventivemeasures—but perhaps more inthe context of how they pertainto each specific individual’scapabilities. At a bare mini-mum, “medical care” successshould be measured by howwell an individual’s desiredneeds are met, as judged by thepatient.

Curative “medical care” isabsolutely worthwhile, absol-utely works, absolutely hasgreat benefit, is absolutely time-consuming, and, as an aside—absolutely costs a lot (andremember, cost is the issue inhealth care today).

Both “health care” and“medical care” approaches areeffective and have true value.Doctors should—and do—com-bine them to help each individ-

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We need to collectively address with ourpatients—the public—where we physicians

really fit into the well-being equation.

ual achieve the goal of maxi-mum well-being. This results insociety’s maximum well-being.

The quality measurementimbalance

In the past three decades, espe-cially in primary care, there hasbeen a continuedemphasis on measur-ing “health care”attainment, with littleemphasis on measur-ing “medical care” suc-cess or improvement.Patient satisfactionbegins to measuremedical care but doesnot address diagnostic accuracy,efficiency, or ideal treatment.That can be judged only by adoctor’s working peers—not bysome outside rating agency.This is the area that reallyneeds to be addressed in thetoday’s publicly reported ratingsreports. This is what the publicreally wants to glean from apublic rating system.

The Minnesota 2008 HealthReform Law mandated publicreporting of various health care“quality measures” attained by

doctors/clinics, beginning in2010. This legislation ups theante for physicians. The publicneeds to be aware of exactlywhat type of quality is beingmeasured and publicly re-ported. The answer right nowis, “It’s health care”—which is

largely under the control of thepatients themselves, not thephysician.

The doctor’s role

As physicians, we first musttruly appreciate the distinctionbetween medical care andhealth care. It then followsthat two different types of qual-ity measurements are nowneeded—one to measure eachtype of care. We must nowinsist on the proper labeling foreach of these measurements.

We must insist that present“quality care” be relabeled as“preventive services measure-ment” or some similar designa-tor, rather than simply beingcalled “quality care measure-ment.” This latter term is justtoo broad and confusing to the

public. Our various physicianorganizations can be instru-mental in this endeavor.

And following this truth-in-ranking move, we need to col-lectively address with ourpatients—the public—where wephysicians really fit into thewell-being equation. Yes, wepromote preventive health care:always have, always will. Andwe should take a portion (butdefinitely not all) of the respon-sibility for its attainment.

But our real value in the

system is our understandingand application of a great bigbunch of knowledge calledmedical care. If you’re having ababy, your child gets meningi-tis, a heart attack begins, yourgall bladder gets infected, a badinjury occurs, or if you just

can’t find an answer toyour condition—you’refeeling punk, and youdon’t know why—youneed a good medicaldoctor. That’s what youwant a ranking systemfor. That’s the answer tothe lead-in question ofthis article. And that

means a doctor whose meas-ured patients may or may nothave chosen to opt out of theirchild’s immunizations, stopsmoking, exercise, take theirmedication—or whatever.

E. John English, MD, was a full-timefamily practitioner for over 40 years, 35of which were in Apple Valley, Minn. Heis presently semi-retired from practice butserves as chairman of the board of theMidwest Independent Practice Associ-ation, an organization of independentmedical clinics.


The public needs to be awareof exactly what type of

quality is being measuredand publicly reported.

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as a result of errors in the verysystem designed to improvehealth. The Joint Commissionhas consistently reported thatpoor communication is a majorfactor in almost two-thirds ofcases. These reports raised thequestion: If physicians, despitethe finest training and bestof intentions, could not keeppatients safe, what could bedone?

Other highly complex, high-stakes industries, such as avia-tion, offered some intriguingsolutions. These high-reliabilityorganizations minimized humanerror and became extraordinar-ily safe by having several quali-ties in common, including anobsession with avoiding mis-takes, and teams that are adap-tive, highly effective, anddemonstrate excellent commu-nication. Most importantly,these effective teams did notjust happen. They were carefullytrained and developed.

A group of researchers atBeth Israel Deaconess Hospitalin Boston applied many of

the team training principlesdeveloped for aviation safetyto their obstetrics departmentand saw their adverse event(and lawsuit) rate drop by half.Building on that work, theAgency for Healthcare Researchand Quality (AHRQ) and theDepartment of Defense (DOD)developed TeamSTEPPS.

Developing theTeamSTEPPS curriculum

TeamSTEPPS, which stands forTeam Strategies and Tools toEnhance Performance andPatient Safety, is based on morethan 25 years of the best avail-able scientific evidence foractively creating effective teamsable to deliver safe, consistentresults. Data were incorporatedfrom aviation, the military, andother high-stakes industries suchas nuclear power. Organizational

psychologists helped design acurriculum to teach these strate-gies and tools that was tailoredto health care providers workingin all clinical settings. In late2006, the curriculum wasreleased for use, free of charge,on the AHRQ website.

Through the use of didac-tics, discussion, exercises, andscenarios, the program teachesspecific concrete and usableteamwork skills in four keyareas: leadership, communica-tion, mutual support, and situa-tion monitoring. These skillstouch on all aspects of medicalteamwork, such as effectivecommunication during emergen-cies, concise and clear briefingsand feedback, appropriate asser-tion during conflict, and supportfor and awareness of other teammembers’ actions. They aredesigned to ensure that a poten-tial error by any individual teammember is caught and correctedby the team as a whole.

Skills are demonstratedusing written, case-based scenar-ios and videos from a variety ofhealth care specialties in bothclinic and hospital settings. Thevariety of materials allows thecourse to be customized to theneeds of the receiving audience.Clinical simulation is oftenpaired with the curriculum,allowing participants to practicethe skills they have learned priorto using them in real clinical sit-uations. In Nancy’s case, train-ing in TeamSTEPPS not onlywould have fostered a climatein the operating room wherespeaking up was both encour-aged and expected, but alsowould have taught Nancy howto do so firmly but respectfully,with the ultimate goals of main-taining her relationship with thesurgeon while protecting thepatient from harm.

Though the skills taughtduring TeamSTEPPS trainingare not complicated, overcomingold habits and incorporatingthese skills into daily practicecan be challenging. In a recent

The New Yorker article, surgeonAtul Gawande described theimportance of coaching for thecontinued improvement of hisprofessional performance.TeamSTEPPS recognizes thecrucial role of coaches in honingindividual skills and incorpo-rates sessions on coachingcoworkers to continually andeffectively use these skills. Thecurriculum also addressesimplementation planning andchange management, both ofwhich are crucial for implemen-tation of TeamSTEPPS at theinstitutional level.

The AHRQ website providesthe PowerPoint slides, handouts,and facilitator guides for eachlesson, as well as a host of sup-porting material, including theevidence used to develop eachsection, along with citations,more than 100 additional videosand scenarios, and even a lead-ership brief to help obtain sup-port from institution manage-ment for implementation.Curriculum materials can bereviewed and downloaded, withsupplemental materials availablefor purchase if desired, athttp://teamstepps.ahrq.gov/. Thewebsite also provides additionalinformation, including imple-mentation stories from instit-utions around the world, webi-nars (including transcripts), anda readiness assessment, toassure that the facility is readyto begin this journey.

After the release of theTeamSTEPPS program, theAHRQ and the DOD jointlysponsored the national imple-mentation of the TeamSTEPPSinitiative. This effort wasdesigned to aid in the dissemin-ation and implementation ofTeamSTEPPS nationally. Theimplementation program offered2.5-day “train-the-trainer” ses-sions free of charge at five train-ing resource centers throughoutthe country. The University ofMinnesota was one such center,along with Duke Medical Center,Carilion Clinic, CreightonUniversity, and the University ofWashington. Over the past fouryears, as a result of this pro-gram, more than 2,000 mastertrainers have completed trainingat the training resource centers,and more than 10,000 healthcare workers across the country


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TeamSTEPPS is based on more than25 years of the best available scientific

evidence for actively creating effective teamsable to deliver safe, consistent results.

have undergone TeamSTEPPStraining locally at their homeorganizations. The success ofthis training and support pro-gram has led to the continuationof this effort; information on thecurrent centers (which includesthe University of Minnesota) canbe found at http://teamstepps.ahrq.gov/.

Many organizations havedocumented improvementsresulting from this training.Carilion Clinic in Roanoke, Va.,which integrated this systeminto its pediatric intensive careunits, subsequently recordeddecreases in medical errors,improved patient satisfaction,and decreased staff turnover.Butler County Health CareCenter, a 25-bed critical accesshospital in Nebraska, docu-mented improved communica-tion and an improved culture ofsafety throughout the organiza-tion using TeamSTEPPS. Giventhe success of the initial trainingefforts, the AHRQ is continuingits support by hosting futureadditional train-the-trainerworkshops and continuing anational annual users meetingdesigned to allow organizationsto share their successes as wellas lessons learned.

TeamSTEPPS in Minnesota

Minnesota facilities are alsosuccessfully incorporatingTeamSTEPPS. The Universityof Minnesota Medical Center,Fairview integrated these princi-ples into its Safe Surgery Pro-cess, encouraging every personin the room to speak up whensafety or quality might be com-promised. Stratis Health, thestate’s Quality ImprovementOrganization, uses TeamSTEPPSto help improve communicationand patient safety in a variety ofsettings, from nursing homes tocritical access hospitals. Re-cently the Minneapolis VeteransAffairs (VA) Health Care Systemintroduced TeamSTEPPS on oneinpatient unit. VA staff, fromnurses to hospitalists, pharma-cists to social workers, and evenenvironmental services, under-went a 3.5-hour training sessionthat included simulated exer-cises to practice these new skills.Within days, staff membersnoticed a more supportive cul-ture on the unit.

The Minnesota HospitalAssociation and the MinnesotaAlliance for Patient Safety(MAPS) are collaborating todevelop an evidence-based“Roadmap to a Culture ofSafety.” This document isdesigned to be a detailed imple-mentation plan for fostering aculture of safety at any healthcare site, from small clinics tolarge health care organizations.One crucial domain for develop-ing and sustaining such a cul-ture is teamwork, and the pri-mary source of information usedto create this domain wasTeamSTEPPS. This roadmap isin the final stages of develop-ment; more information can befound at the MAPS website,www.mnpatientsafety.org/.

However, in order to fullydevelop cultures of safety andeffective teams, it is essential toequip not only our currenthealth care providers with theseskills but also those in training.Many medical schools across thecountry, including the Universityof Minnesota and the Universityof North Dakota, are developingcourses to educate their studentsin these essential teamworkskills. Increasingly, this is occur-ring in the interprofessional set-ting, and almost always byadapting TeamSTEPPS conceptsfor learners. TeamSTEPPS isalso being used successfully atthe graduate medical educationlevel. The Accreditation Councilon Graduate Medical Education,which accredits all residencytraining programs in the U.S.,now requires them to includecurricula on communication,professionalism, and systemimprovement. TeamSTEPPS hasbeen a natural fit for addressingthese essential skills.

Though extensive researchhas shown these teamworkskills to improve outcomes inindustries like aviation andnuclear power, the research isjust emerging in health care. Inlocations throughout the coun-try, TeamSTEPPS has beenfound to decrease adverseevents, improve communication,and even to improve patient,

staff, and provider satisfaction.The University of Minnesota,along with Fairview HealthSystems, is leading a nationaleffort to study the effects of insitu (on the ward) simulation ondecreasing adverse events inobstetrics using TeamSTEPPS.The Mineapolis VA is examiningthe effects of TeamSTEPPStraining on staff satisfaction,team behaviors, and patientoutcomes.

Simple in theory,challenging in practice

One of the challenges ofTeamSTEPPS implementationis that the skills appear decep-tively simple to health careproviders. We have come toexpect that improvements inpatients’ health require invest-ment in costly complex technol-ogy. But what can appear simplein theory can be quite challeng-ing in practice. Straightforwardindividual skills, when used con-

sistently and correctly, can trans-late into highly effective teamscomposed of people who areadaptive and communicate well.In other high-stakes industrieswith similar challenges—techni-cal complexity, a history of rigidhierarchy, life-threatening emer-gencies—this approach has beenshown to prevent error andimprove safety. We have onlyrecently started to understandand to harness the power ofthese skills in health care.

It’s time for Nancy to beable to speak up, and to bethanked for doing so. The safetyof our patients requires that webecome All-Pro in this mostimportant of team sports.

Karyn D. Baum, MD, MSEd, is anassociate professor of medicine and theassociate chair of clinical improvementin the Department of Medicine at theUniversity of Minnesota Medical School.She is also the director of the MinnesotaTeamSTEPPS Training Resource Center.Albertine S. Beard, MD, is an assis-tant professor of medicine at the Universityof Minnesota and practices internal medi-cine at the Minneapolis VA Medical Center.She is a TeamSTEPPS Master Trainer.


Within days, staff members noticed amore supportive culture on the unit.

P R O F E S S I O N A L U P D A T E : R A D I O L O G Y

Radiology remains one ofthe most technologicallyadvanced fields in medi-

cine, leading to exciting break-throughs in the diagnosis andtreatment of many different dis-eases. Along with these advanceshave come challenges. The mostformidable changes currentlyfacing radiology are:• Increased regulation alongwith decreased reimbursement

• Commoditization of radiology,in association with the emer-gence of “nighthawk” and “dayhawk” imaging companies

Regulation andreimbursement issues

Many areas of medicine arefacing increased regulation anddecreased reimbursement, butthese issues have hit radiologyparticularly hard in the lasttwo years.

Preauthorization require-ment. One of the more challeng-ing hurdles has been the require-ment of “preauthorization” priorto ordering a high-tech imagingexam, such as an MRI or CTscan. In the past, if a physician

wanted to order a CT scan for apatient, the order would begiven and the physician’s officewould call the imaging centerand schedule it. Within the pastfew years, however, several largethird-party payers have institu-ted the requirement of preautho-rization prior to scheduling ahigh-tech exam. There are twobasic forms of preauthorization:(1) by telephone and (2) comput-er-based.

Preauthorization by tele-phone involves the physician’soffice calling an 800 numberand describing the high-techexam the physician wants toorder and the clinical reason(s)for ordering it. In the past, if aphysician wanted to order ahead CT for headache, therewere no issues scheduling the

exam. With preauthorization,headache alone would be rejec-ted as an acceptable reason forgetting the head CT. The officewould be told over the phonethat the study was not author-ized for headache, and thereforewould not be covered by insur-ance. In order for the study tobe authorized, the patient wouldneed to have headache plusphotophobia, weakness, or anynumber of associated symptoms.

The computer-based modelof preauthorization involves thescheduler logging onto a websiteand then entering the patientdata and clinical reasons for theexam. If the study is authorizedby the online system, then it canbe scheduled. If the study isdenied in either model, theordering physician can chooseto simply not have the examdone, or can interact over thephone or online to jump throughenough hoops to get the studyapproved. Additionally, theordering physician can moveforward with the test even if theappeal is denied. In that case,the center performing the studywill not get reimbursed but theordering physician will receivethe clinical information neces-sary to care for the patient.

Obviously, the preauthoriza-tion requirement adds an extra“hassle factor” when ordering ahigh-tech exam. The end resultis that preauthorization leads tofewer high-tech exams beingperformed; whether they areappropriate or not remains anopen question. Looking aheadmost leaders in radiology feelthat some form of preauthoriza-tion is here to stay.

Reimbursement. Reim-bursement cuts are affectingall areas of medicine; however,imaging has been a specialfocus of cuts by the Centers forMedicare & Medicaid Services(CMS). A prime example of adrastic cut that affected imaging

last year was CMS’ “bundling”of CPT codes. Specifically, CMSdecided that because CTAbdomen and CT Pelvis wereoften ordered together, the twoexams would be bundled into asingle exam—resulting in a dra-matic decrease in reimburse-ment. This single move by CMSled to numerous imaging facili-ties across the country closingtheir doors. We can likely expectCMS to bundle more imagingcodes in the future.

Imaging accounts for a largepart of the health care dollar.This fact has attracted the atten-tion of many payers, but thegovernment in particular. TheDeficit Reduction Act of 2005(DRA) called for annual sched-uled cuts for all physicians.Fortunately, Congress has con-tinued to postpone many of thecuts, thanks in part to efforts bymedical societies, including theAmerican College of Radiology(ACR) and the Radiology Busi-ness Management Association(RBMA).

Additionally, the DRA resul-ted in a draconian cut in thetechnical component of imaginga few years ago. Outpatientimaging has two billing compo-nents: the professional compo-nent goes to the physician inter-preting the images, and the tech-nical component covers the costof the imaging equipment, tech-nical staff, and its associatedoverhead. There are two mainfee schedules for outpatientimaging. The MedicarePhysician Fee Schedule is linkedto the RBRVS (resource-basedrelative value scale) and appliesto imaging services provided ina freestanding physician officesetting. The OPPS (outpatientprospective payment system)applies to imaging services pro-vided in a hospital outpatientsetting. Both fee schedules arebased on the resources requiredto provide the particular serviceand the historical costs associ-ated with providing said service.CMS decrees that the technicalcomponent always be paid at thelesser of the two fee schedules.

The combination of legisla-tive cuts such as CT Abd/Pelvisbundling and the DRA were sosignificant that some imagingcenters closed, and manyremaining imaging centers are

Spotlight on imagingAdvances and challenges

are changing the face of radiology

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Technological advances

Over the past decade, technolog-ical advances in digital imagingand picture archiving and com-munication systems (PACS)have transformed the practiceof radiology.

Digital imaging has com-pletely changed the layout of animaging department. With digi-tal imaging, there are no moreX-ray films and, thus, no needfor darkrooms, film rooms/libraries, or film clerks. The digi-tal images can be read anywhereon a high-resolution monitorwith high-speed Internet connec-tivity and the proper software.This technology has been of par-ticular benefit to radiologistsserving rural and remote areasand/or multiple sites.

PACS allow for these digitalimages to be stored online, sothat physicians can view imagesonline without needing to go tothe radiology department. PACStechnology has transformed theculture of the radiology depart-ment. In the past, all specialistswould come through the radiol-ogy department on a daily basisto view the films of theirpatients and converse with theradiologists. This no longeroccurs, because both the imagesand the report can be viewed onany computer connected to thehealth system. The result is thatthe radiologist and the referringphysicians have more time andcan be more efficient; however,the loss of doctor-to-doctorinteraction has isolated theradiologist. The relationshipsthat radiologists traditionallyhad with their referring physi-cians have become harder tomaintain.

In the 2000s, as digitalimaging and PACS were chang-ing the nature and culture ofradiology departments,“nighthawk” radiology compa-nies sprang up around the globe.The term refers to radiologistsreading images remotely.Initially, nighthawk serviceswere provided by radiologistsliving in a different country anddifferent time zone. A CT scandone at 3 a.m. in Minnesota

could be interpreted by a radiol-ogist in India during the middleof the day there, due to the dif-ference in time zones. Again,this made life more efficient forthe U.S.-based radiologists, yetat the same time it isolated themfurther from emergency depart-ment and other physicians.

Nighthawk radiology com-panies rapidly became moreprevalent in the U.S. and eventu-ally began offering “day hawk”services: board-certified special-ists available to read imagesnight and day, 24 hours a day,seven days a week. These com-panies began to compete witheach other on pricing, furthereroding radiologist incomes. Thelatest development is nighthawkcompanies purchasing wholeradiology practices across theU.S., truly making imaging acommodity—and devaluing it asa specialty—in the eyes of manykey players in health care.

Redefining our future

Radiologists clearly face anuncertain economic future.Some independent practices arefolding, being purchased bynighthawk companies, orbecoming employed by hospi-tals/health care organizations.However, other independentpractices are meeting the cur-rent challenges by providing:(1) unique services (e.g., on-siteminimally invasive image guidedprocedures), (2) high quality, up-to-date imaging technology, and(3) on-site leadership (medicaldirectors who ensure the appro-priateness, quality, and safety ofthe exams). These leading-edgeradiology practices are addingvalue to the care deliveryprocess by providing timelyand accurate subspecialty diag-nostic information to helppatients heal more quickly andavoid expensive unnecessaryinvasive procedures.

Radiology practices thatremain independent are alsodoing so by diversifying—forexample, having interventional

radiologists perform proceduressuch as epidural steroid injec-tions, venous ablation, and cos-metics in an office-based setting.Interventional radiologists arerecognized as experts in mini-mally invasive procedures, so formany it is a natural extension oftheir practice.

Radiology is fortunate tohave major support from theACR and RBMA organizations,as well as other radiology andmedical societies. The ACR andRBMA do an outstanding jobof keeping the membershipabreast of the sweeping currentand future changes they face.Additionally, these organizationsare working proactively onCapitol Hill, trying to assurethat every patient’s imagingstudy is of the highest quality,safe, and most appropriate.

I personally interpreted thetheme of the ACR meeting inspring 2011 as: “The future ofradiology is bright, just not nec-essarily for radiologists—unlessthey redefine their own futures.”At a November 2011 meeting ofthe Radiological Society ofNorth America, John Patti, MD,current chair of the ACR Boardof Chancellors, said this aboutthe challenges facing our spe-cialty: “We need to recast anintrospective spotlight on our-selves and determine who we are[and] what value we provide.”

Radiology remains the non-invasive window into the humanbody and the diseases that affectit. The future of radiology isbright indeed; it’s up to radiolo-gists to keep the spotlight shin-ing down the right path.

Scott R. Schultz, MD, is presidentof Minneapolis Radiology and currentpresident of the Minnesota RadiologicalSociety.


Radiology remains the noninvasivewindow into the human bodyand the diseases that affect it.

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S C R E E N I N G G U I D E L I N E S

Agovernment healthpanel—the United StatesPreventive Services Task

Force (USPSTF)—has decidedthat men should no longer bescreened for prostate cancerwith a PSA (prostate specificantigen) test. This position con-tradicts the recommendations ofother professional organizationsand leaves men and physiciansconfused and uncertain aboutPSA screening. To help clini-cians understand this dilemma,this article reviews the back-ground and recent research onPSA screening, summarizesscreening guidelines, and offersscreening recommendations tohelp primary care physiciansadvocate for their patients.

Background

Prostate cancer is common;in the U.S., there were an esti-mated 240,890 new cases and33,720 deaths in 2011. Withwidespread PSA testing in the1990s, prostate cancer diagnosishas nearly doubled, but in thepast two decades the incidencehas declined and mortality rateshave fallen about 33 percent.

For many years, the DRE (digi-tal rectal examination) was theprimary screening tool; however,the majority of cancers foundwere at an advanced or metasta-tic stage, when there was oftensymptomatic urinary tractobstruction or bony metastasis,in men 75 years old. In the post-PSA era, most cases are asymp-tomatic, 80 percent are confinedto the prostate, and only 4 per-cent have metastasized, with anaverage age at diagnosis of 67.

However, most prostate can-cer seems to be indolent, andautopsy studies commonly haveshown that 70 percent of menover age 70 have occult prostatecancer. The vast majority ofmen with prostate cancer die ofother causes. Unfortunately,PSA screening alone does not

accurately “risk-stratify” theinnocuous cancers from thepotentially life-threateningaggressive cancers.

There are other considera-tions that further confound PSAscreening. Certain clinical sce-narios can affect PSA levels: Forexample, PSA can increase dueto benign enlargement as well asinfection, and can decrease by50 percent in men being treatedfor an enlarged prostate withfinasteride or dutasteride. Aftera patient has had a catheteriza-tion, prostate biopsy, or urinarytract infection, PSA testingshould be postponed for at leasta month (however, ejaculationand digital exam have generallyshown negligible PSA effects).Lab variability can yield resultsthat differ by 25 percent, de-pending on the type of assayused, so it is important to try touse a single lab for longitudinalmonitoring.

Attempts to improve uponPSA diagnostic accuracy havebeen implemented. The arbitraryPSA cutoff of 4.0 ng/ml is nolonger considered a valid thresh-old because prostate cancer isfound in a significant number ofmen with PSA <4.0, especially ifthere is an abnormal DRE. Theuse of age-adjusted PSA levelsrecognizes this and has resultedin the increased number of can-cer diagnoses in younger menand a decline in diagnosis inolder men. Other modificationsto improve PSA testing includethe use of free PSA, PSA velocity(rate of change), and PSA dens-ity (PSA/gland volume). Also,there are continuing efforts todiscover and implement newbiomarkers for prostate cancer(i.e., the PCA3 urine test). Whileall these modifications andmarkers have shown promise,their impact on screening hasnot yet been validated or provenconsistent or useful.

Conflicting resultsof screening trials

More confusion about PSAscreening arises from the con-flicting published results of thethree most recent prospective,randomized, controlled screen-ing trials.

The PLCO (Prostate, Lung,Colon and Ovary) study involvedPSA screening in 76,693 men inthe U.S. The authors concludedthere was no improvement inprostate cancer mortality atseven years between thescreened and control groups(Andriole et al., N Engl J Med,March 2009). However, a recentsubgroup PLCO analysis(Crawford et al., Jrnl Clin Onc,Feb. 2011) found healthy menunder 65 who were screened hada significant decrease in prostatecancer death.

The ERSPC (EuropeanRandomized Study of Screeningfor Prostate Cancer) studyreported on the effects of PSAscreening of 181,160 men(Schröder et al., N Engl J Med,March 2009). As in the PLCOstudy, no difference in death ratewas found at seven years—but atnine years, a 20 percent reduc-tion in prostate cancer wasfound in men who had beenscreened. The authors estimatedthat 1,410 men would need to bescreened and 48 would need tobe treated to prevent one death.

The Göteborg (Sweden) ran-domized screening trial involved10,000 patients (Hugosson et al.,Lancet Oncology, August 2010).At 10 years, its findings weresimilar to those of the ERSPCstudy, but at 14 years theauthors found increasing sur-vival benefit in the screenedpatients—a 50 percent reductionin mortality in the screenedgroup. It was estimated in thisstudy that a total of 293 menneeded to be screened and only12 treated to prevent one death.

There are some significantdifferences and criticisms in themethodology among these threestudies, the most cited beingthe contaminated control groupand short study period in thePLCO study. However, it isapparent that with longerfollow-up, there is a significantand increasing survival benefitto PSA screening.

The prostate cancerdilemma

To screen or not to screen

By Thomas J. Stormont, MD


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Costs of PSA screening

Finally, the subject of cost andmorbidity from PSA screeningmust be addressed. An abnormalPSA often leads to a prostatebiopsy, a five-minute office pro-cedure that can cause stress,bleeding, pain, and, rarely, infec-tion. It is the prostate biopsy—not the PSA—that actually estab-lishes the diagnosis of prostatecancer. Overall, it is estimatedthat 32 percent of Medicarepatients who undergo prostatebiopsy are found to have cancer,and this rate increases withpatient age and PSA value.

In the February 2011 issueof the Journal of ClinicalOncology, prostate cancerresearcher Peter Carroll, MD,wrote that the main problemwith PSA screening is that“diagnosis is almost uniformlyfollowed by treatment and thusovertreatment.” FDA-approvedtreatment options include (aloneor in combination): active sur-veillance, radiation, cryoabla-tion, androgen ablation, andradical prostatectomy. The mainlong-term side effects of all thesetreatments, except for active sur-

veillance, can be long-term uri-nary incontinence, sexual dys-function, rectal problems, anddepression.

The yearly dollar cost ofprostate cancer screening, esti-mated to be in the billions ofdollars, can be difficult to quan-tify. And this cost accrues overtime—not just from screeningbut also from primary therapy,subsequent surveillance, andtreatments of side effects and/orsalvage therapies for failures.

To date, organizations thathave established guidelines forprostate cancer screening havenot yet considered economics intheir recommendations. How-ever, it appears inevitable thatthe financial burdens of screen-ing will become an increasingconsideration by policymakers,especially with the passage ofthe 2009 Accountable Care Act.

Screening guidelines

Summaries of some medicalgroups that have published

guidelines regarding PSA screen-ing are summarized below.Screening often includes bothPSA and DRE. High-risk refersto blacks and patients with first-degree relatives diagnosed withprostate cancer. Shared decision-making means an informed dis-cussion between the patient andphysician. The testing interval isusually annual.1. American Cancer Society

(ACS): Shared decision-mak-ing at age 50 (40–45 for high-risk men).

2. American College ofPreventive Medicine (ACPM):Shared decision-making atage 50 (at younger age forhigh-risk men). Screeningquestionable in older menwith chronic illnesses and lifeexpectancy less than 10 years.

3. American Urological Asso-ciation (AUA): Shared deci-sion-making at age 40 and lifeexpectancy of at least 10years.

4. European Association ofUrology (EAU): Shareddecision-making at age 40.Screening probably notneeded for patients olderthan 75 with PSA <3.0.

5. National ComprehensiveCancer Network (NCCN):Shared decision-making atage 40. For PSA >1.0 or if thepatient is black, screen yearlyPSA. For PSA <1.0, screenPSA yearly beginning at age45. If PSA remains <1.0,screen PSA yearly beginningat age 50.

6. United States PreventiveServices Task Force(USPSTF): Recommendsagainst PSA screening inhealthy asymptomatic menregardless of age, family|history, or ethnicity.

Discussion

It is important for physicians togive open-minded considerationto PSA screening and not dis-miss it uniformly as nonbenefi-cial, given that, of all medicalgroups with guidelines, only the


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S C R E E N I N G G U I D E L I N E S

It has been a little more thantwo years since the U.S.Preventive Services Task

Force (USPSTF) changed its rec-ommendations regarding screen-ing mammography for women(www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm).Controversial among the scien-tific community, the guidelinesclearly have had the intendedeffect of decreasing the numberof screening mammographyexams across the country. Inaddition, the Canadian TaskForce on Preventive Health(CTFOPH) recently made similarrecommendations (www.cmaj.ca/content/183/17/1991.full).

Briefly, the USPSTF recom-mended that women 50–74 yearsof age have a screening mammo-gram every two years, ratherthan every year; that women40–49 years of age not undergoroutine screening; and that forwomen age 75 and over, thereisn’t enough information todetermine whether screening isuseful.

Why are these recommenda-tions suspect?

Task force issues

First, the members of the U.S.and Canadian task forces werechosen specifically for their pre-sumed lack of a conflict of inter-est. In practical terms, however,if you don’t have a conflict ofinterest, you likely don’t haveany expertise in the field. Yet de-spite their lack of expertise, thetask force members have beenunwilling to debate the issueswith any screening experts.Rather, they have relied onadvice from epidemiologist PeterGøtzsche, MD, of Denmark’sNordic Cochrane Centre, whohas been opposed to breast can-cer screening for over a decadeand has stated there is no bene-fit from screening for women atany age. Numerous analystshave refuted his analysis, and a

recent letter to the editor of theLancet journal, signed by morethan 40 experts in breast healthcare from around the globe, saidthe Cochrane Centre promotedan “active anti-screening cam-paign based on erroneous inter-pretation of data from cancerregistries and peer reviewed arti-cles” (Lancet, Nov. 2011). Ironi-cally, the Canadian task forcechose Gøtzsche to write in sup-port of their recommendations.

In essence, Gøtzsche and theCochrane Centre have elimin-ated studies that have shown abenefit for screening, based onalleged “technical flaws,” andhave included only those studiesthat have not shown a benefit—and then have trumpeted the lat-ter studies as being the onlyvalid examination of screening.It is particularly disappointingthat the studies that did notshow a benefit had major flawsin design and performance,including poor mammographyand placement of women withpalpable lumps and advancedcancer in the screening arm.

In addition, the task forcebased its recommendations pri-marily on randomized controltrials without looking at othermeans of assessment. Whilesuch trials are helpful, they havea major drawback: Once you areassigned to the control side orthe study side, you stay there,whether or not you receive thetreatment or exam. If a womanis randomized to the screeningside but doesn’t get the screen-ing study, she still remains in thescreening group. Conversely, ifshe is included on the controlside but feels screening mam-mography is useful and gets iton her own, she still stays in thecontrol side.

This “contamination” is sig-nificant. The first major trial toevaluate screening mammogra-phy was the Health InsurancePlan (HIP) of Greater New Yorktrial, initiated in December

1963. Only 67 percent of thewomen assigned to screeningreceived any screening, and only40 percent received all fourscreening examinations. Despitethis contamination, the HIPstudy still found a 15 percentreduction in mortality. If youlook at the women in this groupwho were actually screened, thedeath rate was cut by 49 per-cent, far exceeding the 15 per-cent originally reported (and,now, quoted by the task forces intheir recommendations).

There are other means ofassessing the value of screeningmammography. In Sweden, thecounty nurse is responsible formaking sure that everyone fol-lows the guidelines set by thecounty. Women are stronglyencouraged to obtain a screen-ing mammogram, and participa-tion is higher than 95 percent.Each county can decide whetherto begin screening mammogra-phy at age 40 or age 50. Studieshave shown that women in their40s had a 48 percent lower riskof death from breast cancer thanthose not screened. In Canada,similar results are seen inwomen from British Columbia,where there was a 40 percentdecrease in deaths amongwomen screened between theages of 40 and 79, and a 39 per-cent reduction in women age40–49, during the period1988–2003 (Tabar L, et al.,Lancet, 2003). A recent Swedishstudy by Hellquist et al. demon-strated a 29 percent reduction inmortality in women 40–49 yearsof age (Hellquist, BN et al.,Cancer, 2010).

What about screening everytwo years, rather than everyyear, in women in the 50–75 agerange? There are good data toshow that screening every twoyears instead of every year willincrease mortality 20 percent.This is even more true in womenaged 40–49 with breast cancer,among whom the cancers tendto grow and spread more ra-pidly. In fact, if women in thisage group are screened everythree years, there is little benefitat all. It is annual screening thatprovides the most benefit.

In addition, for approxi-mately 85 percent of womenwith breast cancer, their onlyrisk factor is being a woman.

Screeningmammography

Task force guidelines underestimate the benefit

By Joseph H. Tashjian, MD


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Basing screening on having afamily history of breast cancer,as recommended by the taskforces, means we will miss near-ly all of the breast cancers untilthey are too large to ignore.

Other concerns

Other concerns expressed bythe task forces pertained to theaccuracy of mammography,potential breast cancers causedby radiation exposure over time,and presumptive “harms” suchas the pain and suffering associ-ated with mammography andbiopsies. The pain of mammog-raphy is nothing compared tothe preparation for colonoscopy;however, no one is recommend-ing not having screening colon-oscopy because of the pain andsuffering associated with thepreparation.

Mammography is not per-fect, and it does not detect everybreast cancer. It does detectmost of them, however, even inthe 40–49 age group. Among100,000 women in their 40s,there will be 200 naturally oc-curring breast cancers, morethan 150 of which will be diag-nosed by mammography; andthere will be fewer than six can-cers potentially induced bymammography over their entirelifetime, and those would beexpected to be detected by con-tinued screening.

With the advent of digitalmammography, detection hassignificantly improved inwomen with dense breasts, whotypically are in the 40–49 agerange. Digital mammographywas not available for any of theclinical trials cited by the taskforces. A large prospective trialby the American College ofRadiology demonstrated animproved detection rate inwomen with dense breasts froma film/screen mammogram of35–50 percent to up to 70 per-cent with digital mammography,and this was in the early experi-ence with digital mammogra-phy. A recent study demonstrat-ed a cancer detection rate 36percent higher utilizing digitalmammography over convention-al film/screen mammography(Glynn CG et al., Radiology,Sept. 2011).

What about related anxiety,pain, and suffering? Women are

concerned when they have apositive result from a mammo-gram, just as men and womenare concerned when their chestX-ray shows a nodule in thelungs. For every 100 screeningmammograms performed, 10patients will be called back foradditional examination, six ofwhich will be found to be nor-mal. Two may be asked to returnin six months for a follow-upexam, and two to three mayhave a biopsy. Only one in fourto five of those biopsies will becancer.

Biopsies are now done withneedles on an outpatient basiswith localized numbing, usuallyperformed in less than an hourwith only minor discomfort.The vast majority of womencan resume normal activities,including work, immediatelyafter the biopsy. Biopsies arefrequently performed immedi-ately after a recommendation,so that all diagnostic evaluationcan be completed on the sameday. This significantly decreasesthe anxiety that comes withmammography.

Notably, the task forcedoesn’t talk about the pain andsuffering in women who havecancer detected at a later stage,whose cancer would have beeneasily diagnosed earlier withscreening mammography. Evenif we said there was no improve-ment in mortality from screen-ing (which there most definitelyis), the ability to treat with lessinvasive surgery is important.Also, not having to get chemo-therapy, lose your hair, becomenauseated and experience com-plications or memory loss, de-velop a peripheral neuropathy,etc., post-chemo treatment is ahuge plus for women.

Since the onset of routinescreening in 1990, the mortalityrate from breast cancer, whichhad been unchanged for the pre-ceding 50 years, has dropped by30 percent. Although there arefewer women in their 40s withbreast cancer, 40 percent of thelife years saved by screening arein that same group, because theywill live more years after theirdiagnosis and cure. In addition,screening mammography hascontinued to improve over thepast 20 years, where the dosehas been reduced and the detec-

tion rate improved. This hasbeen accomplished by improve-ments in equipment, perform-ance of the mammogram, andimprovement in interpretation.There are newer technical im-provements to digital mammog-raphy, such as digital tomosyn-thesis (3-D imaging), that willagain move the diagnosis for-ward. None of these advanceswere present at the time of anyof the screening trials cited bythe task forces.

Early detection,improved treatment

The goal of any screening studyis to find the disease earlier,when it is more likely to respondto treatment. For some cancers,like lung cancer, finding the can-cer earlier isn't helpful, becauseusually it has already spread bythe time it is detected. Earlydetection just means patients areaware of their cancer longer, notthat they have a longer life. Forother cancers, such as testicularcancer, the treatment is effectiveat almost any stage, and earlydetection is not useful.

In only a few cancers—such

as of the breast, colon orcervix—does screening find thedisease early enough that treat-ment is useful and prolongs thepatient’s life. The goal hasalways been to prevent cancer,rather than diagnose it earlierand treat it. Until we reach thatpoint, however, screening com-bined with advanced treatmentis the only method available toreduce the deaths from cancer.

In summary, there is ampledata to show at least 30 percent,and up to a 48 percent, improve-ment in mortality from breastcancer with screening. There hasbeen a concomitant drop inmortality of 30 percent duringthe performance of widespreadscreening in the U.S. Newertechniques continue to improvedetection while decreasing radi-ation dose, and better trainingand performance continue toevolve. To say otherwise is tomisinterpret, malign, or grosslyunderestimate the benefit ofscreening mammography.

Joseph H. Tashjian, MD, is a radiolo-gist with St. Paul Radiology and is chief ofstaff at Regions Hospital in St. Paul.


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When Rod Brown, MD, first traveled to PuertoLempira 14 years ago, he was struck by howundeveloped the port town was. No electric-ity. The only way into the town, located onHonduras’ isolated Atlantic coast region, wasby airplane or boat. Other than the localpriest’s dilapidated truck, the only things withwheels were wheelbarrows.

A lot has changed since that time, Brownsays. “Everybody has cell phones. There arecars and trucks and motorcycles, even taxis,”he says. “It’s just a dramatic transformationfrom this very remote, sleepy little village to akind of bustling small town.”

Still, the region, commonly called theMosquito Coast, has a ways to go. The hospi-tal that Brown works from on his yearly med-ical missions had running water for the firsttime last year. Electricity is supplied by gener-ators and is sometimes intermittent. Some ofthe X-ray equipment dates from the VietnamWar era. “It’s pretty primitive,” Brown says.“The facility is quite poor so anything youcan do to get patients in and out of the hos-pital is better. They have a nursing staff andbeds for patients, but linen and food andthose types of things have to be brought bythe patients’ families.

Brown has traveled every year for 14years to Puerto Lempira as part of missionswith International Health Service (IHS), a non-profit relief organization that is based in EdenPrairie. Brown is past president of the groupand has served as medical director. IHS sendslarge missions twice a year to the Hondurantown. The main medical mission takes placein February, and can consist of as many as120 medical, dental, and support staff.

Brown, an internist with GlacialRidge Medical Center in Glenwood,travels to Puerto Lempira as part ofthe February missions, and works

with a surgical team of eight to 12 people.He says his team will address a wide range ofissues on any given mission, including remov-ing tumors, fixing hernias, taking out tonsils,and repairing wounds from machetes or bul-lets. The hospital does have laparoscopic gear,so the visiting physicians also do some laparo-scopic work, he adds.

On a typical trip, Brown estimates, thesurgical team will do 50 to 70 proceduresover a 10-day period. “There’s no shortage ofpatients; we just try to get as much done aswe can while we’re there,” he says.

The missions also bring equipment andmedical supplies with them. “The hospitalhas some supplies, but we don’t want to usethem all up. We’re there to work with themand support them; what we don’t use weleave for their use,” Brown says. He notes thatStandard Fruit, which owns the Dole brand,works with IHS to bring two container loadsof supplies to the hospital every year.

Having made so many trips, Brown hasbecome good friends with some physiciansin Puerto Lempira and he says his familiaritywith the town has advantages. “You can stepright in and know what to expect,” he says.“You know the staff, and they know you, soyou don’t have to recreate the wheel eachtime. It makes for a smoother operation.”

The trips have also allowed him to showhis children what medical missions are like,Brown notes. “My son is now a physician intraining … and he got interested in medicineand surgery from going down there as a highschool student,” Brown says. “My daughterlikewise had an interest and she’s in herfourth year of dental school at the University

of Minnesota. That was a great oppor-tunity and motivator for her.”

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Making a difference in

C O M M U N I T Y C A R E G I V E R S 2 0 1 2

Providing care on the mosquito coast

“There’s no shortageof patients; we justtry to get as muchdone as we can whilewe’re there.”Rod Brown, MD


Loree Kalliainen, MD, recently made her thirdtrip to India to do medical mission work. Unlikeher first two trips, Kalliainen organized the lat-est mission herself, taking five other medicalprofessionals from Minnesota deep into one ofIndia’s poorest regions, to a hospital that hadnever seen an American physician before.

“It’s seven hours northwest of Calcutta in avery rural area called Jharkhand. No touristsever go up there,” says Kalliainen. “It’s veryimpoverished, even for India.”

Kalliainen, a plastic surgeon who is chiefof staff past at Regions Hospital in St. Paul,planned the trip after meeting an Indian physi-cian, Sister Victoria Aind, MD. Aind had askedKalliainen to come and do a plastic surgerymission at the hospital Aind runs, Holy CrossBelatanr. The small convent hospital has onefloor and 25 beds. It is located in a compoundthat holds the hospital and a leprosarium—Kalliainen notes that leprosy is still seen on aregular basis in the area.

After raising the money—Kalliainen esti-mates it cost each member approximately$5,000 for the entire trip—and doing planningand preparation, the team left for India inFebruary 2011.

Kalliainen describes the trip as a fascinat-ing experience. “Everything about India is amassive sensory assault,” she says. “It’s loudand noisy and smelly and colorful. It just took

me right out of my comfort zone.” ButKalliainen enjoyed the challenge, and she saysher team did as well. “I’ve been lucky becausethe people I’ve chosen to bring with me ontrips are of like mind. I don’t want anybodywhining about the food or making commentsabout having to bathe with a bucket of waterpoured over our head. It’s an amazing opportu-nity ... I try to never be the ugly American.”

Aind had asked Kalliainen to bring a teamfor a plastic surgery camp in part becauserural India has a high number of burn cases.People in the region use open fires to cookand commonly use kerosene lanterns, and

simple accidents often lead to serious buns.“There are still a few cases where people willset each other on fire, “ she adds. “Women willset each other on fire if one was looking atanother women’s husband.”

Burn treatments and cleft lip repair werethe vast majority of the mission’s work, andKalliainen says those treatments can make abig difference. “If their lips weren’t fixed, thesekids would be outcasts forever,” she notes. “IfI do a relatively simple hand surgery or scarrelease on an arm, now they can work.”

Despite the primitive conditions—“I don’tbring any electrical equipment because it willjust be blown apart by the Indian power grid;what little there is of it,” Kalliainen says—theteam was productive, doing more than 60operative procedures in one week. “We justhave some flashlights in the room, and whenthe power goes out … you just keep operatingunder flashlight,” she says.

Kalliainen speaks fondly of the local com-munity. “I think it’s wonderful to see that peopleare the same everywhere; you hear that all thetime and it really is true,” she says. “Even withthe immensity of the poverty, people are con-tent, happy, and very pleasant. It’s just reallyan amazing experience.”

Outside the comfort zone

Minnesota and the world

Caregivers to page 22

“Everything aboutIndia is a massivesensory assault.”Loree Kalliainen, MD


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It’s not a major commitment of time, Patrick Heller, MD, says; just a fewhours a month. The facilities are modest; a basement of a church, witha physician, a nurse, and a few volunteers. The service provides onlybasic screening and primary health care services.

Yet Project Health, Education, Access, Link (H.E.A.L.) serves a popu-lation that may not have any other regular access to health care. Theprogram was launched after local churches asked CentraCare HealthSystem to help provide basic health services for the homeless and unin-sured people in St. Cloud. Since then, the health system has partneredwith many groups, including Catholic Charities,the Boys & Girls Club, the Robert Wood JohnsonFoundation, and United Way St. Cloud, to fund andmaintain health care clinics in Cold Spring, LongPrairie, Melrose, St. Cloud, and Waite Park.

The program began in 1999, and now has morethan 70 volunteers. The CentraCare Health Foun-dation and Mid-Minnesota Family Medicine Centersupply equipment, and pharmaceutical companiesdonate medical supplies and sample medications.

“It’s a program to try to get care to people whodon’t have insurance,” Heller says. “There’s a popula-tion of people who don’t come in because they don’thave insurance and maybe aren’t in a position wherethey can go through all the paperwork. But being partof the community, you want to serve those people’sneeds too.”

Heller says that most of the people he sees areHispanic and he guesses that a good number of themare undocumented. He says that he doesn’t ask—hisemphasis is on giving care. “If I can use my profes-sional skills in that way, it makes sense,” he says. “Wedon’t restrict it in any way.”

The program has been recognized for its efforts to overcome barri-ers to care. In 2010, it was given the Governor’s Council on Faith andCommunity Service Initiatives Best Practices Award. The award is arecognition of faith and community organizations that create best prac-tice models for bringing together private and government resources toaddress community needs. Project H.E.A.L. has also received a FederalCommunity Access Program grant in recent years to assist with out-reach efforts in the St. Cloud metro area as well as the surroundingrural areas.

Heller says the scope of practice is limited but helpful. “Maybe a2-year-old has an ear infection, and we can see him, so they don’t have

to go the ER,” he says. “Even just a clinic visit or anurgent care visit is going to be pretty expensive forthem if they don’t have insurance.”

Other issues the clinic treats includes upper respira-tory infection, back pain, and minor injuries. Patientswith more serious conditions can be referred to otherfacilities. Heller notes in one case where a cancer wasdiagnosed, the clinic was able to send the patient on toa specialist. Other resources are available too—forexample, at Heller’s clinic a nutritionist is often avail-able to talk to patients about healthy eating.

Delivering health care can be as much about pro-viding moral support as administering medicine ortreatments, Heller notes. “There are some people thatcome frequently with fairly minor issues,” he says.“Some of what they need is reassurance, and they feelbetter just from the reassurance you give.”

The program is rewarding and also eye-opening,Heller says. “It just give you a little more insight intoother people who are out there; the people you don’tsee in the [regular] clinic. And it gives you a little moreinsight into what immigrants are dealing with.”

Overcoming barriers to care


“ Some of what theyneed is reassurance,

and they feel better justfrom the reassurance

you give.”Patrick Heller, MD


Boynton Health Service

Welcome to Boynton Health Service Physician

(612) 626-1184, [email protected]

and reference 175782

A Diverse and Vital Health Service

As medical director of Children’s Surgery International (CSI), PeterMelchert, MD, takes a big-picture approach to medical missions. Notonly does his Minneapolis-based group help needy children—with afocus on fixing cleft palates—but under Melchert’s leadership it worksto help the communities it visits improve their ability to provide theirown medical services.

“The question we ask ourselves is, are we fostering independenceby building local capacity?” Melchert says. “Are we going to a placewhere there's need and where our skills can be applied meaningfully,without taking away the job of a local physician?”

Melchert began working with CSI in 2003, and he became its med-ical director in 2004. In Minneapolis, Melchert is an internal medicineand pediatric hospitalist at Abbott Northwestern Hospital andChildren’s Hospitals and Clinics, but he describes hiswork with CSI as a second full-time job. He makes asmany as three trips a year for the group, oftenassessing sites for future missions.

That attention to detail and preparation is a keypart of his group’s philosophy, Melchert says. “Ourassessment is so comprehensive, I’m in the operat-ing room counting the number of outlets,” he says.“I meet all the people we’ll be working with side-by-side … That’s really the only way to be effective.”

Melchert, who also teaches as an assistant pro-fessor for the University of Minnesota’s GlobalHealth Course, says he has seen warehouses full ofdonated equipment that will never be used becausefacilities don’t have electricity or local physiciansaren’t trained on the equipment. His group believesin working closely with local physicians, trainingthem to do the work so that further missions fromU.S. doctors won’t be needed.

One new area for his group in building local capacity is the use ofinteractive training videos. With the help of a software developer, CSI isproducing a series of DVDs that feature real surgeries, with interactive“hot spots” placed over relevant areas of anatomy that users can clickon to choose the right instrument or procedure. The program willassess mistakes or confirm proper decisions.

“The trainees can do that at home or at the hospital before weever come, and they’re miles ahead in terms of preparation,” Melchertsays. “Even the most low-resource hospital in Africa without electricitywill have a computer for its physicians for continuing medical educationand communicating. It may be run by a little gas-powered generator,but everyone has a computer. We can make this tool that runs on asimple personal computer and broadly expand our trainee pool andtrain faster and at less cost.”

In addition to fixing cleft palates, many of the missions includepediatric surgeons or pediatric urologists. Melchertnotes that hernias are a big problem in the develop-ing world but that medical groups find it easier tofundraise for facial deformities than genital anom-alies. By including surgical teams that can handle arange of problems, the group greatly increases thegood it can do. “Very simple treatments can have agreat impact,” Melchert says.

According the Melchert, CSI is seeing anincrease in the number of physicians and medicalstaff who volunteer for the overseas work. He saysphysicians tell him the work revitalizes their practicesat home. “I find that when I’m working overseas,I’m doing the things I thought I would be doing,back when I was a medical student. All the doctorsand nurses that come on these trips tell me thesame thing: ‘This is why I went into medicine.’”

Healing patients, building capacity


“Very simple treatmentscan have a great impact.”

Peter Melchert, MD


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 itTo date, removing th

aid of a robot is happlica i

figure, given the rela-tively recent adoption

of the robot for use in

clinical applicationsThe rapid growth in

this field promisesto permanently alter

the way surgical proce-

dures—especially mini-

mally invasive surgeries—are perfor

and taughtThe currenT

Volume XXI, No.7October 2007


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

experienceShared decision-making involves

systematic interaction with

to arrive at an infobased on h

Talk it outShared decision-making improves

the patient experienceBy Marcus Thygeson, MD,

and Karen Kraemer, RN, CMC

Lending ahandRobotic surgerymakes inroads into the

OR and beyond

Volume XXI, No.8November 2007


Bringing a newmedical deviceto marketThe challengesof picking a winnerBy Curt Miller

in Minnesota Physician

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• Orthopedic Surgeon

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• Urologist

• Psychiatrist

Tina Slusher says medical mission work changes lives. She is an exampleherself—having gone from a general pediatric practice in easternKentucky to a career where she devotes three to four months a yearoverseas, treating children and doing research.

For the past 22 years, Slusher has gone to Africa or Thailand everyyear for extended medical missions, a devotion that has shaped thekind of practice she can do here in the United States. “It’s been a vari-ety of arrangements,” she says. “I refuse to take a job where [overseaswork] couldn’t be a significant part. The least I’ve negotiated is threemonths; that’s the bare minimum I will agree to.”

Slusher works with a number of organizations, sometimes as a vol-unteer and sometimes for varying amounts of pay.She says her devotion to mission work comes fromseeing the challenges that both patients and physi-cians face in developing nations. “I work with someabsolutely wonderful African doctors,” she adds.“They need U.S. colleagues, to be able to do whatthey do for their kids. They need our collaboration.”

Slusher’s main area of focus in Africa has beennewborn jaundice, an easily treated condition in theU.S. that is a major killer of newborn children incountries like Nigeria, where she has done much ofher work.

“Many of the places in Nigeria that are tryingto take care of newborn jaundice don’t have consis-tent electricity or don’t have electricity at all. Theydon’t have good phototherapy units even if theyhappen to have electricity,” she says. “That’s part ofthe reason that so many children are dying or dis-abled from jaundice.”

Recently, Slusher has been doing research on phototherapy usingnatural sunlight, and she notes her work has become a mix of research,training, and patient care. “There are a lot of blurred lines there. There’sa lot of teaching with the research, and there’s a lot of patient care inthe teaching and in the research. It’s not a clear delineation.”

In addition to her work in Africa, Slusher has done teaching inThailand, which she says has significant cultural differences comparedto Africa. “Generally speaking, Asia is more resourced and more high-tech than Africa, of course excluding South Africa. Sub-Saharan Africa isgenerally struggling a lot more with resources and basics like electrici-ty,” she says. “It’s a very different world. Asian culture moves a lotfaster. African culture is much slower; relationships are important, timeis not important.”

The lack of resources and high mortality among children can bediscouraging, Slusher says. But she says she findsinspiration in the passion and hard work of herAfrican colleagues, who carry on despite huge chal-lenges. She adds that her faith also plays a role. “Isee my faith as part of what I do every day. I reallythink God expects us to do what we do and do itvery well.”

Slusher is on staff at Hennepin County MedicalCenter and a faculty member of the GlobalPediatrics program at the University of Minnesota.She says her teaching position gives her an excel-lent opportunity to promote overseas medical workto medical students. “I encourage every medicalstudent or resident to go at least once because itcompletely changes how you practice medicine inthe United States, even if you never go back,”Slusher says. “It makes you more conscious and lesswasteful. I believe that you’re a better physician [ifyou take part in a medical mission].”

A lifelong devotion tomedical missions

“It completely changeshow you practice medicine

in the United States.”Tina Slusher, MD



Live in the relaxed lake country of Mille Lacs and practice medicine where you will make a difference.

We’re looking for a Family Physician to join us atMille Lacs Health System in Onamia, Minnesota.

Loan forgiveness options may be available.

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Urgent Care

We have part-time and on-call positions available at a variety of Twin Cities’ metro areaHealthPartners Clinics. Evening and weekend shifts are currently available. We are seeking BC/BE full-range family medicineand internal medicine pediatric (Med-Peds) physicians. We offer a competitive salary and paid malpractice.

For consideration, apply online at healthpartners.jobs and follow the Search Physician Careers link toview our Urgent Care opportunities.For more information, pleasecontact [email protected] or call Diane at: 952-883-5453; toll-free:1-800-472-4695 x3. EOE

©

h e a l t h p a r t n e r s . c o m

Many medical missions involve large organizations and impressiveamounts of logistics, but medical volunteer work in developing coun-tries can exist on a smaller scale as well. Kevin Treacy, MD, an ophthal-mologist from Duluth, has proved that with his Project SCENE.

The project’s name reveals its roots: Sister Congregations EnjoyingNew Eyesight (SCENE) was born when Treacy traveled to his church’ssister diocese in Kingstown, the capital of St. Vincent and the Grena-dines. The Caribbean nation consists of 32 islandsnorth of Venezuela and near Grenada.

St. Vincent, with a population of 125,000, ispoor and has traditionally had a high rate of diabetesand related conditions such as diabetic retinopathy.That condition is a leading cause of blindnessthroughout the world for people aged 25 through65, Treacy notes.

Treacy first visited Kingstown in 1999, and beganlaying the groundwork for regular ophthalmologymissions to treat diabetic retinopathy and other eyeconditions. With the help of groups such as theRotary Club and the Lions Club in Minnesota, heraised enough money to purchase two lasers fortreating eye conditions. Before Treacy’s efforts, nosuch technology was available in St. Vincent.

“There was no real funding available for thatcare,” Treacy says. “Either a family could come upwith money [to fly to another country for treatment],or they would basically lose their vision.”

Since his first trip in August 2000, Treacy hasvisited the island nation 18 times. In addition, he hasspent many hours working in Minnesota to raise

funds for equipment and travel expenses.A typical trip, Treacy says, includes approximately 10 volunteers,

including two physicians. In addition to providing laser treatments atMilton Cato Memorial Hospital in Kingstown, they often travel to med-ical sites around the islands, visiting clinics with primitive facilities. Eachtrip lasts a week and the medical team typically treats 400 to 600patients in that time period. The staff works long hours, Treacy notes.“I’ve never brought sunscreen because I’ve been inside pretty muchsunup to sundown,” he says. “There’s that much work to do.”

The SCENE program is also training local physicians to do eye pro-cedures so patients can continue to be treated on a regular basis. Treacy

says he has cut back on cataract surgery becausesome patients told local surgeons they wanted to waitfor the American doctors. “You can become counter-productive in terms of our goal of trying to supportlocal doctors and their practices,” he says. “That cancause a threat to their livelihood and a threat to thepermanent care that we want to see in place.”

To support the local health care system in St.Vincent, Treacy donated a cash award he received in2004 from the Minnesota Academy of Ophthalmol-ogy toward training a physician from St. Vincent. Thephysician has since begun offering cataract surgery inhis clinic, Treacy notes. “That’s our goal, to give themthe tools they need, the education to do the work.Basically, I’d love to put myself out of business.”

Treacy says he’s found the work very rewardingand has enjoyed taking his family along to help withthe medical missions. “It’s been very fulfilling effort,”he says. “Eye care is universally appreciated, so evenwhen there are political or cultural differences, it’ssomething that we can all enjoy.”

“That’s our goal, to givethem the tools they need.”

Kevin Treacy, MD

Project SCENE brings eye care toCaribbean island



Two BC/BE Orthopaedic Surgeonswanted to join four orthopaedic sur-geons at Sanford Bemidji OrthopaedicsClinic in Bemidji, Minnesota. Part ofan 85-physician, multi-specialty grouppractice and 118 bed acute care hospi-tal. 1:6 call anticipated. Competitivecompensation/benefits package, paidmalpractice, relocation assistance andmore. Sanford Health of NorthernMinnesota has 1,450+employees andis part of Sanford Health system basedin Fargo, ND and Sioux Falls, SD.

Bemidji, Minnesota, located in north-western Minnesota, is a beautifulresort community offering exceptionalschools, a state university, and year-round cultural activity as well as greataccess to the outdoors for year-roundrecreation activity. To learn moreabout this excellent practiceopportunity contact:

Kathie Lee,Director Physician PlacementPhone: 701-280-4887Fax: 701-280-4136Email: [email protected]

AA/EOE

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OpportunityLive in Beautiful

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fairview.org/physiciansTTY 612-672-7300 EEO/AA Employer

Fairview Health Services

Leading the way in innovationFairview is seeking compassionate and adventurous caregivers—four full-time physicians and eight full-time nurse practitioners/physician assistants—to join us in developing a unique new outpatient care model. Highlights of this opportunity include:

• Care for adult patients with complex medical and behavioral needs—those not well-served in the traditional outpatient clinic—through development of a primarily home-based practice

• Partner with a Fairview Medical Group team who has demonstrated the capacity to provide compassionate, high-quality and efficient care for a similarly complex patient population

• Provide outpatient care only; inpatient care provided by our team of hospitalists and our community and academic medical centers

Candidates must have 7+ years experience as a practicing clinician. Emphasis in hospital-based medicine, cardiac, pulmonary or end-of-life care preferred.

Visit fairview.org/physicians to explore this and other opportunities and apply online, call 612-672-2277 or email [email protected].

Sorry, no J1 opportunities.

Patrick Ebeling, MD, a surgeon with Twin Cities Orthopedics, is rela-tively new to medical missions. His first, to Haiti, came just months afterthe devastating earthquake that destroyed much of the nation’s capitol,Port-au-Prince. His second was to Port Harcourt in Nigeria, a city soplagued by kidnappings of westerners that the group sponsoring themission, Doctors Without Borders, required Ebeling to sign a proof-of-life document in case he was abducted.

“Filling out that form was definitely a moment where I thought,‘What am I doing here?’” Ebeling says.

But despite the eye-opening circumstances of his first two medicalmissions, Ebeling admits that he has “caught the bug”and is looking forward to doing more. And he says eventhe discomfort of working in a very different culture canbe seen in a positive light.

“You definitely feel unsettled,” he says. “That unset-tled feeling is one of the benefits. I think being able torecall that feeling of being so unsettled and being somuch the outsider makes you a more empathetic person,not just in your job but in your daily life.”

Ebeling first traveled to Port-au-Prince with ProjectMedishare in May 2010, where he worked in a tempo-rary hospital offering follow-up care for people who hadbeen in injured in the January earthquake. He traveledthere again in September 2011 for a week, again seeingearthquake victims but also treating congenital condi-tions and common, day-to-day injuries.

In May of 2011 Ebeling went on a longer, one-month mission to Port Harcourt with Doctors WithoutBorders. The city, with a metro population of approxi-mately 1.5 million people, is the center of Nigeria’s oilindustry, and kidnappings of westerners for ransom is

something that Doctors Without Borders took very seriously.“We would get into our Land Rovers behind a locked gate, and

they would open the gate and we’d drive to the hospital, then wewould get out behind another locked gate,” he says. “They wanted usto be careful to wear our Doctors Without Borders shirt at all times, sothey know you’re a doctor and not an oil worker, because that’s whothey are usually looking to kidnap.”

As part of an international team sponsored by the Paris-basedgroup, Ebeling provided surgical care at a free trauma center at a hospi-tal in Port Harcourt. The port town was a rough place, and Ebelingnotes that the lack of traffic controls leads to many auto accidents andinjuries. “There’s an unbelievable number of cars hitting pedestrians,

and that was a lot of what we saw,” he says. “In a placewhere everybody’s scraping for what they can get, thereare a lot gunshot wounds and machete injuries. A lot ofinterpersonal violence.”

Although physicians with the program were re-stricted in where they could travel because of safetyconcerns, Ebeling said he never felt he was in any dan-ger. “I felt safe the whole time, and I think that’s a testa-ment to how they run the program.”

Ebeling said the African trip was a little stressful onhis family, but he was surprised at how quickly thingsgot back to normal when he returned. “Even after amonth away, after two or three days of being backyou’re kind of back into your routine. You definitelyhave a different perspective on how much you can getdone with different equipment and how much you cando in a rough situation,” he notes. “But it is possible tobe gone for a month and experience something like thisand help some people, and then get back to normal lifewhen you come back.”

“That unsettledfeeling is one ofthe benefits.”

Patrick Ebeling, MD


The outsider experience


In the heart of the Cuyuna Lakes region of Minnesota, the medical campus in Crosby includes Cuyuna Regional Medical Center,a critical access hospital and clinic offering superb new facilities with the latest medicaltechnologies. Outdoor activities abound,and with the Twin Cities metropolitan area just a short drive away, you can experience the perfect balance of recreational and cultural activities.

Enhance your professional life in an environment that provides exciting practice opportunities in a beautiful Northwoods setting.The Cuyuna Lakes region welcomes you.

Contact: Todd Bymark, [email protected](866) 270-0043 / (218) 546-4322 | www.cuyunamed.org

We invite you to explore our opportunities in:

• Family Medicine

• Internal Medicine

• Hospitalist

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Rice Memorial Hospital has an out-standing opportunity for the rightperson to serve as its Chief MedicalOfficer (CMO).Reporting directly to the CEO, thissenior executive will be responsible forleading the medical staff in the plan-ning, facilitating and implementing ofprograms to enhance physician effec-tiveness, quality of practice, clinicalintegration and patient satisfaction.The CMO will be line administrator forphysician services within the Emergency Department and is expectedto provide direct patient care at least four shifts per month in theEmergency Room.The position requires an MD or DO with a license to practice medicinein the State of Minnesota; as well as a minimum of seven years ofclinical experience and at least two years of physician leadershipexperience. An MBA or Masters degree in public health is desirable.Located in the lakes region two hours west of the Twin Cities, RiceMemorial Hospital is the state’s largest municipal hospital, providinga vast array of services to the residents of west central Minnesota,including high-tech diagnostics, rehabilitation, long-term care, DME,mental health, dialysis, radiation oncology and hospice. Rice recentlycompleted a $52 million building and renovation project.

Chief Medical OfficerCandidates submit a coverletter and resume to:Michael Schramm, CEORice Memorial Hospital301 SW Becker AvenueWillmar, MN 56201

Rice provides a competi-tive salary and generousbenefit package. To learnmore see our website atwww.ricehospital.com


The Federal Medical Center, Rochester,MN, is an accredited Joint Commissionmedical and behavioral health referralcenter for the Federal Bureau of Prisons.

Psychiatrists work closely with a multi-disci-plinary team consisting of health care, mental

health care, social work, rehabilitation services,and correctional professionals to provide diagnosticand treatment services to federal inmates.

The Federal Bureau of Prisons, Health ServicesDivision, is committed to providing evidence-basedmedical and psychiatric treatment and has a nationalimpact through the development of comprehensivemedical and psychiatric clinical guidelines.

The Federal Bureau of Prisons offers a competitivesalary and benefits package. The Federal Bureau ofPrisons is an Equal Opportunity Employer.

Contact: Lynn Platte,Assistant Human Resource Manager

[email protected] or call (507) 424-7521

Psychiatrist40 Hour Work Week

Lake Region Healthcare is located in a magnificent, rural, andfamily-friendly setting in Minnesota lakes country where we aimto be the state’s preeminent regional health care partner.

Our award winning patient care and uncommon medical special-ties set us apart from other regional health care groups. LakeRegion’s physicians and their families also enjoy an unmatchedquality of professional and personal life.

Current opportunities including competitive salary and benefitpackages available for BE/BC physicians are:

Practice Well.Live Well.

Lake Region Healthcare is an Equal Opportunity Employer. EOE

712 Cascade St. S., Fergus Falls, MN736-8000 • (800) 439-6424

For more information contactBarb Miller, Physician [email protected] • (218) 736-8227

www.lrhc.org

• Dermatologist• Family Medicine• General Surgery• Hospitalist

• Internal Medicine• Pediatrics• Emergency Medicine

Family Medicine

St. Cloud/Sartell, MN

We are actively recruiting exceptional part-time or full-time BC/BE

family medicine physicians to join our primary care team in Sartell,

MN. This is an out-patient only opportunity and does not include

labor and delivery or hospital call and rounding. Our current primary

care team includes family medicine, adult medicine, OB/GYN and

pediatrics. Previous electronic medical record experience is preferred

but not required. We use the Epic electronic medical record system

at all of our clinics and admitting hospitals.

Our HealthPartners Central Minnesota Clinics – Sartell moved

into a new primary care clinic in the summer 2010. We offer a

competitive salary, an excellent benefit package, a rewarding practice

and a commitment to providing exceptional patient-centered care.

St Cloud/Sartell, MN is located just one hour north of the Twin

Cities and offers a dynamic lifestyle in a growing community with a

traditional appeal.

For more information, please contact [email protected] or call Diane at 800-472-4695 x3. EOE

©

h e a l t h p a r t n e r s . c o m

www.altru.org

• Country Lifestyle....Urban Technology

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Idylic Practice Opportunitieslocated in family friendly

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Crookston, MNand Roseau, MN

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Altru Health SystemPO Box 6003

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1-800-437-5373 Fax: [email protected]

P S Y C H I A T R Y

Atage 45, Suzanne had suf-fered from anxiety anddepression her entire life,

although she was not clinicallydiagnosed until early adulthood.She had been on and off antide-pressant therapy for nearly 20years, but recently had foundher depression so disabling thatshe could barely interact withfamily and friends or continueher work as a dental hygienist.Caroline described her life

as a “pernicious hell” of voicesin her head, unshakable despon-dency, and daily thoughts ofsuicide. Decades of talk therapy,meditation, and antidepressantdrugs—Zoloft, Lexapro,Wellbutrin—all had failed tolift her black cloud of depres-sion. At age 50, the marriedmother of two teenaged daugh-ters was actively fantasizingabout taking her own life.Suzanne and Caroline are

typical of patients suffering fromtreatment-resistant depression,or TRD. Their depression is life-long and overpowering, and theyhave found antidepressants par-tially or completely ineffective.

And over the years, they had losthope of ever finding relief ortruly enjoying their lives.The downsides of antide-

pressants are well known. Asidefrom their slow and often incon-sistent effectiveness, they comewith an army of side effects—insomnia, anxiety, weight gain,fatigue, bowel complications,sexual dysfunction, and more.The primary alternative hasbeen electroconvulsive therapy(ECT), the modern version ofthe old electroshock treatmentsso grimly depicted in movies like“One Flew Over the Cuckoo’sNest.” ECT has been dramati-cally refined over the years andit is highly effective and safe forTRD patients, but it carries sig-nificant baggage as well; it

requires general anesthesia andcauses significant confusion andmemory loss in many patients.Other options, such as vagusnerve stimulation and deepbrain stimulation, involve thesignificantly more invasivemeasure of brain surgery, andunfortunately are often lesseffective in treating depression.The sad fact is that many

people with major depressionnever seek treatment, in partbecause the treatment optionsare scary.Over the past two years,

however, Suzanne and Carolineand thousands like them havefound release from their lifelongemotional imprisonment witha newly available technologycalled transcranial magneticstimulation (TMS). I first begantracking the research into thistechnology a decade ago, fol-lowed its FDA clearance process,and began treating patients withit in 2010, shortly before theAmerican Psychiatric Associa-tion added TMS to its treatmentguidelines for major depression.

Development of TMS

Since the days of Mesmer, mag-netic forces have been thoughtto hold special power overhuman behavior. The earliestscientific attempts to use mag-netic energy to alter brain activ-ity were conducted by Frenchphysician and physicist J.-A.d’Arsonval in 1898 and byEnglish electrical engineer S.P.Thompson in 1910. They builtmagnetic stimulators powerfulenough to activate retinal cells,causing subjects to perceive lightflashes, but the fields generatedwere too weak to stimulate braintissue. Magnetic stimulation wasused as a brain-mapping tech-nique, but the observation thatneuromodulation caused moodchanges encouraged furtherresearch. It was not until 1985that Anthony Barker at the

University of Sheffield, England,designed an instrument withsufficient power to activatecortical neurons and performedthe first study of TMS.TMS therapy was approved

by the FDA in 2008, based onstudies proving its efficacy inthe treatment for depression.Prior to receiving FDA approval,TMS already was in use in othercountries, including Canada,New Zealand, and Israel, as atreatment for depression forpatients who had not respondedto medications and who mightotherwise be considered forECT.TMS uses highly focused

electromagnetic pulses todirectly stimulate the neurons inthe location of the left prefrontalcortex that controls mood. TMSis an outpatient, noninvasiveprocedure that requires no anes-thesia—the pulses are deliveredby a coil that is positioned onthe scalp, and the magnetic fieldpasses through the skull andpenetrates 2 to 3 centimetersinto the targeted area. Thepatient experiences a tappingsensation on the skull (manyhave described it as a “wood-pecker”), which can be irritatinguntil the patient habituates to itbut is rarely painful. A typicalcourse of TMS treatmentrequires 20 to 30 daily sessions,five days a week for four to sixweeks. Each treatment delivers atotal of 3,000 pulses over thecourse of 37 minutes.These magnetic pulses cause

neurons to fire and release neu-rotransmitters such as sero-tonin. The impact on the patientis often immediately evident—some patients have described itas a “light switch” clicking on.Two days prior to beginningTMS therapy, Caroline wrote inher journal that she was vividlyimagining “a glass or two ofwine, a very sharp razor, andlots of blood.” After her first twoTMS treatments, her journalentry began, “Feel great!!!! …HAVE ENERGY!”Research on TMS has

shown that half of the patientsexperience significant improve-ment in their symptoms, andone in three achieve actualremission. The success rate inmy own clinical experience hassurpassed the research num-

A breakthrough intreating depression

Transcranial magnetic stimulation

By Abraham Verjovsky, MD


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bers—I have seen dramaticimprovement in 85 to 90 percentof my patients. This may bebecause most of them sufferfrom refractory depression.Anecdotal reports from TMSproviders around the countryshow similar rates of success.

Limitations/contraindications

There are some precautions inthe use of TMS. Patients withimplanted metal devices in oraround the head should not betreated, but dental implants arenot generally a problem. TMSshould be used with caution inpatients with implanted pace-makers or cardioverter/defibril-lators (ICDs).

Comparison with other brainstimulation therapies

There are other innovativeoptions to antidepressants,namely vagus nerve stimulation(VNS) and deep brain stimula-tion (DBS). Unfortunately, bothoptions are quite invasive andtherefore significantly riskier, asthey both require surgery.With VNS, there are two

implants. First, an electricalwire is coiled around the vagus,or 10th cranial nerve, as it exitsthe skull and passes through theleft side of the neck. This con-nects to a pacemaker-like devicethat is implanted in the chest.After the patient heals from theprocedure, typically two weekslater, the pulse generator isturned on for the first time. Thephysician in the office programsit, and it can be accessedthrough software in subsequentoffice visits. Though this treat-ment modality was FDA-approved for the treatment ofTRD in 2005, it remains contro-versial because of its invasivenature, complications such astriggering sleep apnea, and lowefficacy rates.As the name implies, deep

brain stimulation involves surg-ically implanting electrodesunder stereotactic guidance inan area of the brain known asBrodmann area 25, or the sub-genual cingulate. As with VNS,the electrodes are connected to apulse generator/power sourceimplanted in the patient’s chest.Though DBS appears to havesome promise, it remains an

experimental procedure and isnot FDA-approved for treatmentof depression. Most patientsreceiving DBS are involved inclinical trials.

Further potential

TMS is proving to be a valuablebreakthrough, not just for psy-chiatrists but for family physi-cians whose patients’ lives arebeing affected, or even endan-gered, by intractable depression.Many TMS providers are spe-cialists to whom family doctorsrefer TRD patients in the sameway they would refer a patientto an orthopedist for knee sur-gery. After a course of treatment,the patients return to the refer-ring physician—ideally, in farbetter shape to handle whateverother medical challenges theymay face.TMS is also an exciting new

resource for ob-gyns with preg-nant patients suffering fromdepression. Women of reproduc-tive age make up a significantpercentage of psychiatricpatients, outnumbering menabout two to one, and the hor-monal changes of pregnancy cansignificantly exacerbate depres-sion symptoms. Pregnantpatients on depression medica-tion—and their obstetricians—often face a potentially agoniz-ing choice, because late-termantidepressant use has beenshown to increase the risk ofbirth defects to the fetus. Inorder to protect their babies,women must often stop takingtheir medications just when theyneed them the most, and theirdoctors must constantly weighthe risk of unchecked depressionto the mother versus the drugrisk to the baby.With TMS, pregnant women

and their doctors don’t have tomake that difficult choice. TMSis completely noninvasive andsafe for both the mother and theunborn child.

Fewer than 400 physiciansnationwide currently are regu-larly using TMS. The barrierto faster and more widespreadadoption of the technology iscost—health insurance doesn’tcover TMS (at least, not withouta fight …), and most patientsmust pay out-of-pocket at a costof $8,000 or more for a fullcourse of treatment. As a result,doctors have been slow to makethe considerable initial invest-ment in the equipment. As TMStechnology advances and moreresearch on its use becomesavailable, insurers and physi-cians will become better versedin it. I expect this treatmentmodality to become a majorinfluence on how we treat

depression in the future.It has already had that

impact on my patients. Thevoices tormenting Carolinefaded after a few treatmentsand have not returned. Heroccasional depressive episodesare milder and of much shorterduration. She is medication-freeand no longer has thoughts ofsuicide. “TMS pulled me fromthe abyss,” she wrote recently,“and I believe the change ispermanent.”Suzanne believes, quite sim-

ply, that TMS saved her life. Sheremains on a daily antidepres-sant but is dramatically morefunctional—and happy. “I havenever felt better in my life,” shewrites.

Abraham Verjovsky, MD, is certifiedby the American Board of Psychiatry andNeurology, and has been in private prac-tice in Edina for more than 20 years.


TMS is proving to be a valuablebreakthrough, not just for psychiatrists

but for family physicians whose patients’lives are being affected, or even endangered,

by intractable depression.

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T R A N S P L A N T A T I O N

The transplantation of vitalvascularized organs hasgone from the stuff of fic-

tion to mainstream reality in thepast 50 years. During that time,some of the most significantcontributions have come fromvenerable regional institutions inthe Upper Midwest, such as theUniversity of Minnesota and theMayo Clinic, where innovativeand bold teams continue to havean impact on the field of organtransplantation.

Organ donation

Transplantation is unique inmedicine because of the inevi-table involvement of multiplesurgical teams in the perform-ance of any transplant proce-dure. Because these teams areseparate in time and even space,a highly complex system oforgan donation and distributionhas evolved to serve ourpatients. While highly regulated,this system is also highly trans-parent, with readily accessibledata on the performance oftransplant centers and organprocurement organizations pro-vided by the Scientific Registry

of Transplant Recipients (SRTR).The SRTR is a database of trans-plantation statistics, which isadministered by the ChronicDisease Research Group of the

Minneapolis Medical ResearchFoundation, the research arm ofHennepin County MedicalCenter. These data are availableto the public by accessing theSRTR website at www.srtr.org.

Organ donation services inMinnesota, South Dakota, and

North Dakota are provided byLifeSource, one of 58 regionallydistributed, nonprofit organ pro-curement organizations in theUnited States. LifeSource man-

ages the authorization andorgan recovery processes inpartnership with the hospitals inour region. In 2011, 526 trans-plants were performed withorgans recovered from 160organ donors in the LifeSourceregion. In addition, LifeSourcefacilitates the transportation oforgans imported from otherregions of the country to thetransplant centers in NorthDakota, South Dakota, andMinnesota.

LifeSource also has a vitalrole in informing the publicabout the need for donatedorgans. More than 3 million peo-ple in the three-state region areregistered as organ and tissuedonors, nearly all of themthrough the donor check-off ontheir driver’s licenses or state IDcards. The Department ofTransportation in North Dakotaand the departments of publicsafety in South Dakota andMinnesota have partnered withLifeSource to allow residents ofthe Upper Midwest to have theinformation they need to makean informed decision aboutdonation when they are in thelicense office. In our region, 60percent of licensed drivers havedesignated a desire to donateon their licenses, compared to42 percent nationally. This is anadmirable accomplishment, butone that can be improved upon.

As of January 2012, Minne-sotans can contribute $2 to sup-

port public education aboutorgan, tissue, and eye donationwith a check-off on their driver’slicenses or state ID applications.The money raised by the “Youand $2” program will supportpublic education about donationas part of the state’s commit-ment to ensure that Minne-sotans have access to the neces-sary information that allowsthem to make a positive,informed decision about regis-tering as an organ, tissue, andeye donor.

Kidney transplantation

Kidney transplantation contin-ues to thrive as a therapyfor end-stage renal disease.Currently, there are four kidneytransplant programs inMinnesota, all with fully matureteams providing excellent out-comes to the patients of thestate. However, many patientsremain on wait lists becausethey have formed antibodiesagainst cell surface antigens.Exposure to these antigens inthe form of pregnancies, transfu-sions, or prior transplants canstimulate the formation of anti-bodies which can lead to early,potent rejection and graft loss. Ifpotential recipients develop mul-tiple antibodies, their serummay react with the cell surfacesof available donors with the cor-responding antigens, and thismay preclude safe transplanta-tion from those donors.

To circumvent this occur-rence, the antibody profile of therecipient is tested and character-ized and a search is made for apotential donor with compatibleantigens. If the only potentialliving donors available aredeemed to be unsuitable becauseof incompatibility, the availabledonors of other recipients arescreened, if they have agreed toparticipate. In its simplest form,the incompatibilities of twodonor recipient pairs are solvedby switching or exchangingdonors. This strategy, known as“domino-transplants,” has beenextended to form complexexchanges and chains of trans-plants involving multiple donor-recipient pairs at different cen-ters. The kidney transplant cen-ters in Minnesota are all activeparticipants in nationwidepaired-donation coalitions.

From fiction to realityin half a century

Organ transplantationin the Upper Midwest

By William D. Payne, MD


For more information, please contact: Kaitlin Osborn, Allina Physician Recruitment Toll-free: 1-800-248-4921 | Fax: 612-262-4163Email: [email protected]: allina.com/jobsEOE

10127 1211 ©2011 ALLINA HEALTH SYSTEM. ®A REGISTERED TRADEMARK OF ALLINA HEALTH SYSTEM

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We make a di�erence in the lives of our patients,our sta�, and our communities. Physicians can focuson patient care and can professionally thrive in Allina,and the result is the quality of care for which we areknown. We are based in Minneapolis, and havecomprehensive services throughout Minnesotaand in western Wisconsin. Become a part of theAllina team, joined together with a commonpurpose and uncommon caring.

In 2011, 526 transplants were performedwith organs recovered from 160 organ

donors in the LifeSource region.

Heart transplantation

The three heart transplant cen-ters in Minnesota are active intreating patients with end-stageheart failure with transplanta-tion, as a first-line replacementtherapy, and as a final therapyafter bridging to transplant withartificial devices, both totalheart replacement devices andleft ventricular-assist devices.The results of these transplantsare among the most successful,with patient survivals exceeding90 percent one year after graft.

Liver transplantation

Our regional liver transplantcenters continue to deliver state-of-the-art care to patients at theMayo Clinic and the Universityof Minnesota, Fairview, andAmplatz Children’s Hospital.Since the development of thenational transplant database in1988, more than 100,000 livertransplants have been reportedto the United Network for OrganSharing. In 2010, 6,291 livertransplants were performed inthe U.S., 124 in Minnesota.

The most common indica-tion for liver transplantation iscirrhosis caused by hepatitis C,which accounts forabout 30 percent ofcases. Cirrhosis dueto fatty disease ofthe liver is rapidlyincreasing and hasincreased as an eti-ology of liver fail-ure, with transplan-tation rates risingsixfold over the past10 years. Anti-viraltreatment of hepatitisC is still being developed, andrecurrence after transplantationis almost universal at present.While it remains an indolentdisease in most recipients aftertransplant, these recurrences areone of the thorniest problemsfacing the transplant team in thecare of their patients. Hope isbuoyed by the excellent successtreating patients with hepatitis Bwho receive transplants. In thesecases, antiviral prophylaxis inthe peritransplant period canprevent reinfection in the vastmajority of cases. New andemerging antiviral therapies pro-vide the prospect of more effec-tive treatment of hepatitis C inthe near future.

Lung transplantation

Lung transplant programs haveseen steadily improving resultsover the past decade but con-tinue to face the challenge of aprofound shortage of suitableorgans for transplant. The lungsare particularly susceptible todamage during the dyingprocess in trauma patients andin the intensive care unit envi-ronment. Care from intensive

care specialists andadvanced practicecritical care nurses,as well as expertcare by skillednurses in the hospi-tal intensive careunits has improvedthe prospects forlung retrieval inmany moreinstances over thepast several years.

Nonetheless, the lungs remainthe vital organ that is least likelyto be used in the organ donor,even in cases where the prospec-tive donor previously was inexcellent health.

Pancreas and pancreatic islettransplantation

Transplantation for the treat-ment of insulin-dependent dia-betes continues to be a gratify-ing yet challenging part of solidorgan transplantation. Suitabledonor organs either are trans-planted as whole vascularizedorgans or are processed toextract the islets of Langerhansand transplanted in an injectableform as clusters of cells. These

islet-alone transplants are com-pelling because they eliminatethe necessity of transplantingthe exocrine pancreas, thesource of much of the morbidityof whole-organ pancreas trans-plant. Islet transplants are doneas a part of investigational pro-tocols and have afforded selectpatients freedom from insulintherapy, but they are not yetrefined to a point that they can

be broadly delivered to largenumbers of patients. Whole-organ pancreas transplants donealone or in combination withkidney transplants were per-formed in 1,200 patients in theU.S. last year and can renderpatients free of the need forinsulin therapy in 80 percent ormore of cases.

This brief overview hastouched upon only a few topicsin the field of transplantation.Our regional transplant centersand LifeSource continue tomake meaningful contributionsto this discipline, supported inno small measure by the effortsof our regional hospitals thatprovide the care to our donorsand their families. Throughorgan donation, transplantationis truly the delivery of care tosuffering patients by the entirecommunity.

William D. Payne, MD, is medicaldirector of LifeSource and a professor inthe Department of Surgery at theUniversity of Minnesota Medical School,Minneapolis.


Regional transplant centers

Institution/location Type of organ transplant

Abbott Northwestern HospitalMinneapolis, Minn. Heart, kidneyAvera McKennan Hospital andUniversity Health CenterSioux Falls, S.D. Kidney, pancreasHennepin County Medical CenterMinneapolis, Minn. KidneyMayo Clinic Heart, kidney, liver, lung,Rochester, Minn. pancreas, pancreatic isletsMedcenter One Health SystemsBismarck, N.D. KidneySanford Medical CenterFargo, N.D. Kidney, pancreasSanford USD Medical CenterSioux Falls, S.D. Kidney, pancreasUniversity of Minnesota Heart, intestine, kidney, liver, lung,Medical Center, Fairview pancreas, pancreatic isletsMinneapolis, Minn.

Regional organand tissuerecovery servicesLifeSource2550 UniversityAvenue West,Suite 315 SouthSt. Paul, Minnesota55114-1904www.life-source.org/

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2012 physician opinion survey 1of 4We are pleased to present the results fromthe last of four physician opinion surveyswe will publish in 2012.Through a numberof sampling methods,we received 148responses to Phase 1. If you would like tobe included in future surveys, please contact

us via e-mail at [email protected] call 612-728-8600.The surveys are online,are quick to complete, and are completelyanonymous and confidential.We welcomeyour suggestions for this and future surveys.Our thanks to those who participated.

Per

cen

tag

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fto

tal

resp

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ses

Agree No opinionStrongly

agree

Strongly

disagree

Disagree0

5

10

15

20

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30

35

40

6.1%

39.2%

14.2%

36.5%

4.1%

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No Don’t know/

does not apply

Yes0

20

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100

83.8%

2.7%

13.5%

Pe

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No Don’t know/

does not apply

Yes0

10

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50 48.6%

25.0% 26.4%

1. I understand what is meant by the termspecialty pharmacy.

4. Patients for whom I have prescribedspecialty pharmacy products havereported difficulty finding pharmaciesthat carry them.

Per

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eo

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agree

Strongly

disagree

Disagree0

10

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3.4%

22.3%

60.8%

12.8%

0.7%

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agree

Strongly

disagree

Disagree0

10

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4.1%8.8%

73.6%

10.8%

2.7%

Per

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agree

Strongly

disagree

Disagree0

10

20

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2.0%

6.8%

14.3%

43.5%

33.3%

2. How often do you prescribe medicationsdescribed as specialty pharmacy?

Pe

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Daily WeeklyMany times

daily

NeverRarely0

10

20

30

40

50

4.1%2.7%

12.2%

39.9% 41.2%

To participate in future surveys or offer suggestions,please contact us at [email protected].

5. I have seen dramatic improvement inpatients taking specialty pharmacy products.

7. I advise patients about matters ofpublic health such as smoking,domestic violence, depression, drink-ing during pregnancy, drug use, etc.,even if I am not seeing them for thosespecific reasons.

8. I feel that patients often do notprovide accurate responses to myquestions about their health status.

9. My practice screens patients aboutmatters of public health such assmoking, domestic violence, drinkingduring pregnancy, drug use, etc.

10. I have encountered patients I canidentify as having fetal alcoholspectrum disorders.

Per

cen

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eo

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agree

Strongly

disagree

Disagree0

10

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25.7%

9.5%5.4%

3.4%

58.8%

Per

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agree

Strongly

disagree

Disagree0

5

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16.2%

33.1%

12.2%

31.1%

7.4%

Per

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agree

Strongly

disagree

Disagree0

5

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12.2%

29.7%

18.2%

4.1%

35.8%

3. There are unnecessary barriers to pre-scribing certain medications where I work.


6. I feel it interferes with the physician-patientrelationship when clinics screen for dataabout public health such as smoking,domestic violence, depression, drinkingduring pregnancy, drug use, etc.

A L L I E D P R O F E S S I O N S

Since 1990, Minnesota hasbeen ranked among thetop six healthiest states in

America’s Health Rankings (anannual report by the UnitedHealth Foundation), and forseven of those years it held theNo. 1 spot. However, as pres-sures on the health-care deliverysystem increase with the agingof baby boomers and increasedpatient access to health careinsurance through theAffordable Healthcare Act, allstates will be challenged to keeptheir citizens healthy. And pro-viding them with access to high-quality medical care will be akey component in this effort.

As a result of these popula-tion and health-care systemchanges, physician-led, team-based care is taking center stageand becoming an important partof the health care model. Thegood news is that members ofone group of non-physician cli-nicians—certified physicianassistants (PA-Cs)—are alreadymaking an impact as membersof physician-led teams in healthcare practices in every specialtyand every state.

The National Commissionon Certification of PhysicianAssistants (NCCPA) reports thatin January 2012, more than1,500 certified PAs were licensedto practice in Minnesota.

According to a 2000 studyconducted by the NCCPA, physi-cians who are already workingwith certified PAs have experi-enced the positive impact they

make on medical and surgicalpractices:• 94.2 percent of physician assis-tant employers say that certi-fied PAs have helped increasethe number of patients seen.

• 92.5 percent agree that certi-fied PAs have enabled them toshorten the time patients mustwait for appointments.

• 91.2 percent say that certifiedPAs enable them to allowpatients more time to askquestions during their officevisits.

Employers also give highmarks on the quality of care,with more than 99 percentreporting that certified PAs pro-vide high-quality health care, arecompassionate clinicians, andare valuable members of thehealth-care delivery system.

There are other benefits aswell. According to a study by theAmerican Medical Association,physicians in a solo practicewho employed a physician assis-tant were able to work one weekless per year on average, whileproviding greater access to carefor their patients.

All that said, bringing anyclinician into a practice requiresa foundation of mutual trust andrespect, so it’s important thatphysicians considering introduc-ing a certified PA to their teamsunderstand the profession’s gen-esis, regulation, training, abili-ties, and credentials.

Emergence of thePA profession

The PA profession emerged inthe mid-1960s in response to theshortage of doctors in theUnited States created by thepost-World War II baby boom.The first PAs were Army, AirForce, and Navy medics return-ing from military service havingreceived a tremendous amountof medical and surgical trainingand experience in the field.However, there was no place forthem within the civilian healthcare system until the PA profes-sion was created.

The PA profession still hasclose ties to its roots, with certi-fied PAs caring for the sick andinjured in the Army, Navy, AirForce, and Coast Guard. Certi-fied PAs are also widely de-ployed by the Department ofVeterans Affairs (the nation’slargest employer of PAs). TodayPAs work just about anywhereelse you find physicians—fromsolo physician practices to largemultispecialty clinics, hospitals,surgical centers, long-term carefacilities, prison systems, andwell beyond.

While the first PAs wereinformally trained in the mili-tary, today’s PAs are formallyeducated in accredited pro-grams, most of which awardgraduate degrees. Those pro-grams include didactic trainingin medical and behavioralsciences and clinical rotationsin internal medicine, familymedicine, surgery, pediatrics,obstetrics and gynecology,emergency medicine, andgeriatric medicine.

Like physicians, PAs arelicensed in every state. InMinnesota, PA practice is gov-erned by the Minnesota Boardof Medical Practice.

To obtain NCCPA certifica-tion (a prerequisite for PA licen-sure in all states), graduatesmust pass a comprehensivenational exam. To maintain cer-tification, PAs must log 100CME hours every two years andpass the Physician AssistantNational Recertifying Examin-ation every six years.

In practice, certified PAsperform a wide variety of activi-

Physician assistantsA critical and evolving role

in team-based care

By Pamela M. Dean, MBA


The perfect matchof career and lifestyle.

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

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The Rochester communityprovides numerous cultural,educational, and recreational

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Olmsted Medical Centeroffers a competitive salary

and comprehensivebenefit package.

Send CV to:

OlmstedMedical Center

Administration/Clinician Recruitment

1650 4th Street SE

Rochester, MN 55904

email: [email protected]

Phone: 507.529.6610

Fax: 507.529.6622

EOE

Opportunities availablein the following specialty:

Family MedicineRochester Northwest ClinicRochester Southeast Clinic

St.Charles Clinic

Internal MedicineSoutheast Clinic

Occupational MedicineSoutheast Clinic

DermatologySoutheast Clinic

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.

Boynton Health Service

Welcome to Boynton Health ServiceGynecologist/Clinical Supervisor

176093

A Diverse and Vital Health Service

ties: obtain medical histories,examine and treat patients,order and interpret diagnosticstudies, articulate differentialdiagnoses, and recommend/-implement treatment plans forthe range of human illnesses andinjuries, both acute and chronic.They can perform minor surgeryand assist in major surgery,instruct and counsel patients,order or carry out therapy, andprescribe medications. PAs per-form those roles within a scopeof practice that is established bythe supervising physician inaccordance with state regula-tions; generally speaking, PAscan perform any tasks delegatedby the physician.

“The role of physicianassistants is to become the righthand of the physicians theywork with,” says Katherine J.Adamson, MA, PA-C, a certifiedPA for more than 30 years whonow serves as a medical consult-ant to the NCCPA. “The relation-ship is very collegial, and it isfrom a team perspective that thephysicians are comfortable

entrusting their patients’ well-being to their PA colleagues.”

A growing need

The growing need for PAs andother physician extenders isclear. The Association ofAmerican Medical Collegesreports that the nation couldface a shortage of up to 150,000physicians in the next 15 years.In addition, America’s seniorpopulation is growing at anunprecedented rate, and healthcare reform could bring millionsof additional patients into thesystem. More and more prac-tices will begin to rely on thebreadth of knowledge and skillsthat certified PAs provide tomeet this growing demand.

“With the growing strain onthe health care system, thedemand for physician assistantshas never been higher, and it

will continue to grow,” saysRandy D. Danielsen, PhD, PA-C,senior vice president of theNCCPA Foundation and emeri-tus professor and former deanof the Arizona School of HealthSciences at A.T. Still University.“In my 38 years as a certified PAand a longtime educator, I haveyet to see the demand for theprofession met. It’s incredible towatch the profession try to keepup.” According to the Accredi-tation Review Commission onPhysician Assistant Education(ARC-PA), the profession’saccreditation authority, thenumber of accredited PA pro-grams increased from 54 in 1991to 159 in 2011. ARC-PA’s execu-tive director, John McCarty,reports that there are more than50 new programs in the processof seeking accreditation thatcould potentially be accreditedby the end of 2015.

Over the past decade, PApractice has steadily trendedtoward specialization, with to-day’s PAs practicing in virtu-allyevery medical and surgical spe-cialty. According to an annualcensus report by the AmericanAcademy of Physician Assis-tants, in 2000, approximately51 percent of PAs worked in pri-mary care, with the remainderpracticing in a range of special-ties. By 2010, only 31 percentremained in primary care.

“PAs are going to go wherethe doctors go, just given thenature of our profession,” saysAdamson. “We pride ourselvesas a profession on our solidgrounding in primary care,which we demonstrate everytime we take and pass ournational recertification exam.”

Danielsen notes that“because PAs are trained as gen-eralists and have to maintain ageneralist fund of knowledge tomaintain certification, we oftenare able to bring a broaderrange of care even within spe-cialty practice.”

In recognition of this trendtoward specialization, theNCCPA launched the Certificateof Added Qualifications (CAQ)program in 2011 as a comple-ment to the existing certificationprocess. The CAQ program pro-vides a way for certified PAs todocument specialty experience,skills, and knowledge. The pro-gram includes licensure, CME,and experience requirements aswell as a specialty exam. Todayit is available to certified physi-cian assistants practicing in car-diovascular and thoracic sur-gery, emergency medicine,nephrology, orthopedic surgery,and psychiatry. According to asurvey conducted by the BantamGroup in 2011, 66 percent ofphysicians agree that a CAQ isa valuable credential for certi-fied PAs.

An expanding role inpatient care

With health care reform andthe inevitable changes in theAmerican health care system,certified PAs will undoubtedlyplay a larger role in providingcare for current patients, as wellas for the millions of newpatients expected to enter thesystem. Most physician organi-zations, including the AmericanMedical Association, supportphysician-led health care teamsthat include physician assistants.In fact, the American Academyof Family Physicians issued ajoint policy statement with theAmerican Academy of PhysicianAssistants in February 2011,calling for health policies thatrecognize physician assistantsas primary care clinicians inmultidisciplinary, physician-directed teams.

For additional informationon certified physician assistantsand the CAQ program, visitwww.nccpa.net.

Pamela M. Dean, MBA, is vice presi-dent of operations with the NationalCommission on Certification of PhysicianAssistants.


PAs from page 34

National Commission onCertification of Physician Assistants

The National Commission on Certification of Physician Assistants(NCCPA) is the only certification organization for physician assistantsin the United States. Since its inception as a not-for-profit organiza-tion in 1975, more than 97,000 physician assistants have beencertified by NCCPA.

Read usonlinewherever you are!

www.mppub.com


Family PracticeUrgent Care

NEW POSITIONS:

Dynamic, independent 3 location, single-specialtypractice in northwest Minneapolis suburbs is seekingadditional associates for its Rogers site and has Full Time/Part Time shifts in the Crystal and Rogers Urgent Care.

• Partnership opportunity after 2 years

• Competitive salary with incentives

• Excellent benefits, 401k/employer paid pension

• Practice at one site/one hospital

• Physician-owned

Please contact or fax CV to:Joel Sagedahl, M.D.

1495 Highway 101 North, Plymouth, MN 55447763-504-6600 • Fax 763-504-6622

Visit our website at www.NWFPC.com

Delivering care thatmakes patients feelknown and understoodAt Essentia Health, we have a supportive group of 750physicians across 55 medical specialties. Located in largeand small communities across Minnesota, Wisconsin, NorthDakota and Idaho, Essentia Health is emerging as a leader inhigh-quality, cost-e�ective, patient-centered care. EOE/AA

LEARN MORE

EssentiaHealth.org/Careers800.342.1388 ext 63165

The Northwest Wisconsin Region of Mayo Clinic HealthSystem has more than 300 physicians representing a widerange of medical specialties in a community healthcaresetting. We are a respected and financially secure organiza-tion with strong emphasis on high quality care and patientsatisfaction. A Mayo One emergency medical helicopter isbased in Eau Claire, offering surrounding communitiesaccess to the area’s only verified Level II trauma center.Our current opportunities include:Dermatology OncologyEmergency Medicine Orthopedic Surgery –

General, Sports, & TraumaEndocrinology Palliative CareFamily Medicine PathologyGeneral Surgery PM & RHospitalist Psychiatry – AdultInternal Medicine RheumatologyNeurology UrologyNeurosurgery

If you wish to learn more or to express interest in thisposition, please contact:

Cyndi Edwards/Christie Blink by phone (800-573-2580);email [email protected] [email protected]

USPSTF is averse to any screen-ing whatsoever. PSA screeningdoes detect prostate cancer atearlier stages, when men havemore options and success withtreatment. The prostate cancermortality rate has dropped inthe post-PSA era; and whilethere are disparate conclusionson the death rate benefits fromscreening, studies appear toshow some survival benefit,which accrues over time. How-ever, it is also clear that screen-ing can lead to significant over-diagnosis and subsequent over-treatment, with side effects andcosts being important factors.

Given these complexities,how can primary care physi-cians in their everyday practicebest serve their patients regard-ing PSA screening?

As noted, virtually all guide-lines recommend a shared deci-sion-making model for PSA test-ing—discussing the harms andbenefits and individualizing thediscussion by considering thepatient’s anticipated lifespan,preferences, and values while

acknowledging the variability inPSA results and in the guide-lines. Achieving this withoutsome guidance during a routineclinic appointment wouldappear to be a stupendous task.It may help primary care doc-tors advocate for their patientsto use a prostate cancer decisionaid (available from the Centersfor Disease Control andPrevention at www.cdc.gov/cancer/prostate/pdf/prosguide.pdf) and to focus on the follow-ing key points culled from theguidelines:• Shared decision-makingregarding PSA testing is inthe patient’s best interest.Potential benefits and over-diagnosis need to be part ofthe discussion.

• Prostate cancer screeningshould include history (voidingsymptoms, bone pain), DRE,

and PSA. Symptomatic menshould be screened.

• Informed asymptomatic menshould be offered the yearlytest at age 40 or 50. Considerearly testing for blacks, andthose with a close family mem-ber who has been diagnosedwith prostate cancer.

• Interpretation of the PSA bythe screening physician is criti-cal, as there is a continuum ofrisk. The PSA threshold of4.0 ng/dl by itself is no longervalid. The decision for urologyreferral and possible biopsymay now account for manyrisk factors (DRE, age, familyhistory, ethnicity, symptoms,PSA velocity, etc.).

• Asymptomatic men with alifespan of less than 10 yearsprobably will not benefit fromscreening.

• While there are new prostatecancer biomarkers, they areunproven. PSA remains thebest test available.

As of the end of January2012, the USPSTF's statementwas still in draft form, and itmay yet be modified. Whateverthe outcome, primary carephysicians are encouraged toremain educated and open-minded about PSA screeningdata and guidelines, advocatingfor men to help them makeinformed prostate cancer screen-ing decisions. Decision aids canhelp make this discussion moreefficient. We urologists, who arein the unique position of diag-nosing and treating prostatecancer, need to take a strongleadership role as the paradigmshift “unlinking” diagnosis andimmediate aggressive treatmentevolves.

Thomas J. Stormont, MD, is aurologist with Stillwater Medical Group.


Prostate from page 17 PSA screening does detect prostate cancerat earlier stages, when men have moreoptions and success with treatment.

education that measurably improves patient care healthpartnersIME.com

30th Annual OB/GYN Update April 12-13, 2012

Psychiatry Update for Primary Care April 19-20, 2012• Child and Adolescent Mental Health April 19, 2012• Adult Mental Health April 20, 2012

Pediatric Fundamental Critical Care Support May 3-4 and November 8-9, 2012

Fundamental Critical Care Support July 19-20, 2012

30th Annual Strategies in Primary Care Medicine September 20-21, 2012

Midwestern Region Burn Conference October 11-12, 2012• Pre-Conference Workshops October 10, 2012

– Burn Rehabilitation: The Bridge to Recovery – The Pathway to Improving Outcomes for Pediatric Burn Injuries (includes simulation-based learning) • Post-Conference ABLS Provider Course October 13, 2012

Optimizing Mechanical Ventilation October 26-28, 2012

13th Annual Women’s Health Conference November 2, 2012

continuing medical education

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

As a physician, it’s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy.

Share 049: Zero Alcohol For Nine Months.

www.mofas.org

We protect your peace of mind. And we do it in

lots of ways for physicians, facilities and hospitals.

Whatever your situation, we’ve been there, and will be

there. We’ve gotten good at it. Excellent, actually, with

a proven success rate. It’s a peace of mind movement.

And we’d love to have you along.

Join the Peace of Mind Movement at

PeaceofMindMovement.com,or contact

your independent agent or broker.

minnesota physician march 2012

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