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MAURICE AND LAURA FALK LIBRARY

OF THE HEALTH SCIENCES
yNIVERSITY OF PITTSBURGH

FEB 11 1993

At Group Health,

You Can Be A Doctor
Without All
The Headaches

1 'M A MOTHER and a physician. Working at
Group Health means I have a choice about my
schedule — including part-time and four-day
week options. I love having time for my family
with the security of a competitive salary."

Karen Lucas, M.D., Fnmili/ Practice

1 ENJOY PRACTICING medicine because
Group Health takes care of the administrative
hassles — like billing patients and hiring staff.
They also provide an Answering Service and
Continuing Care Department which help me
provide better care for my patients while
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1 FEEL SECURE working at Group Health.

I receive paid malpractice insurance, strong
retirement plans with the option of 401k
participation, long-temi disability insurance,
continuing education incentives, and four weeks
of paid vacation."

Claire Neely, M.D., Pediatrics

Join our thriving multi-specialty group practice.

Call today for information on
primary care and sub-specialty openings.

Judy Meath, Director of Physician Services
612 / 623-8444 collect

■■GROUP

■■HEALTH

■■lINC:

Where a doctor can be a doctor.

2829 University Avenue S.E., Minneapolis, Minnesota 55414

Minnesota Medicine

A JOURNAL OF CLINICAL AND HEALTH AFFAIRS

COVER

The Less Than Equal Medical Treatment
women receive has been called the Yentl
syndrome. Not only do their health prob-
lems receive less research attention than
men’s, hut women also receive inequitable
care, even when their complaints are similar
to men’s, says this month’s feature story
(page 16). That story and our interview
with Doris Brooker, M.D., an ob/gyn pa-
thologist specializing in women’s health
(page 9), describe how women in Minne-
sota and elsewhere are confronting this bias.

Illustration by Linda Frichtel.

JANUARY 1992 VOLUME 75 NUMBER 1
FACE TO FACE
A Powerful Voice for Women’s Health

Minnesota Medicine intervieivs Doris C. Brooker, M.D. 9

MAURiei AND UURA FALK LIIRARY

Of the health SCleNCu

PERSPECTIVES UNIVEKilTY OF PITTSBURGH

Learning About Real Medicine and Real Life ^ ^ , /

BelhOke"

FEATURE

Less Than Equal Treatment: Women Battle Sex Bias. in, the
Health Care Arena

Beryl Bynian t 16

SPECIAL REPORT

MINNESOTA MEDICINE
Owner and Publisher
Minnesota Medical Association
Editor-in-Chief Edmund C. Burke, M.D.
Managing Editor Meredith McNab
Editorial Assistant Susan R. Rodsjo

Send manuscripts, subscriptions, and other
material for consideration to Minnesota
Medicine, 111 1 Universitv Avenue SE, Suite
400, Minneapolis, MN 55414, 612/378-
1 875. The editors reserve the right to reject
editorial, scientific, or advertising material
submitted for publication in Minnesota
Medicine. The views expressed in this jour-
nal do not necessarily represent those of the
Minnesota Medical Association, its editors,
or any of its constituents. Annual Subscrip-
tion - $27.00. Single copies - $2.25. Cana-
dian - $36.00. Foreign - $36.00.

To Advertise: Contact Michael Soucheray,
Minnesota Medicine, 2221 University
Avenue SE, Suite 400, Minneapolis, MN
554 1 4; 6 1 2/378- 1 875 or 800/999- 1875.

COPYRIGHT AND
POST OFFICE ENTRY
Minnesota Medicine (ISSN 0026-556X) is
published on the fifth of each month by the
.Minnesota .Vledical Association, 222 1 Uni-
versity Avenue SE, Suite 400, Minneapolis,
.MN 55414, copyright 1992. Permission to
reproduce editorial material in this maga-
zine must be obtained from Minnesota
Medicine. Second-class postage paid at
•Minneapolis, Minnesota. POST .MASTER,
send address changes to; Minnesota Medi-
cine, 111 I Universitv Avenue SE, Suite 400,
.Minneapolis, .MN ,554 1 4. (USPS 35 1 900.)

Minnesota Medicine

MMA Grapples with Health Care Reform

Minnnesota Medical Association Legislative Staff 23

CLINICAL & HEALTH AFFAIRS

Complications and Mortality of the In-Situ Saphenous Vein

Bypass for Lower Extremity Ischemia

David S. Beebe, M.D., Kumar G. Belani, M.B.B.S., M.S.,

Ji-Chia Lao, M.D., Ph.D., and David Knighton, M.D. 27

MEDICINE LAW & POLICY
Physician Malpractice and Managed Care Plans

James B. Platt, J.D.

ON THE BUSINESS

S 1

D E MAURICE AND LAURA FAU. LIDRAKY

Elexible-Benefit Plans Offer Savings for,,P^ health sciences
Employees, Employers

Hilary O’Donnell and Walter Jones

FEBu 1993

DEPARTMENTS

Editor’s Notebook

NWs Clips .. '' ,,b .. ' .

41-

Instructions for Authors

CiME in Minnesota

45*"

President’s Letter

37 1

i (Classified Advertising

Book Review

Index to Advertisers

In Memoriam

January 1992/Volume 75

34 35PT XL -inr mII

01/93 03-900-03

BECAUSEBUYING
INSURANCE
CAN BE

RISKY BUSINESS...

Whether you need insurance for yourself or your
practice, you can save time and money and minimize
your risk by enrolling in the insurance plans endorsed
by the Minnesota Medical Association.

Each program has been carefully evaluated by the
Minnesota Medical Services Corporation staff,
Insurance Committee, and Board of Directors to
provide convenience, reliability, personal service,
efficient claims processing, expert administration,
and special member rates.

IMMSC is

IprAT YOURi^

■ Service

GROUP TERM LIFE
PERMANENT LIFE
GROUP MAJOR MEDICAL
GROUP HOSPITAL INDEMNITY
GROUP LONG-TERM DISABILITY

INDIVIDUAL NON-CAN DISABILITY
AUTO/HOME/EXCESS LIABILITY
BUSINESSOWNERS LIABILITY
PROFESSIONAL LIABILITY
WORKERS’ COMPENSATION

LONG-TERM CARE

For information on any of these programs, please call us at (612) 378-0305.

The Minnesota Medical Services Corporation is the wholly-owned product and
services subsidiary of the Minnesota Medical Association.

MMA

Minnesota Medical Association

MINNESOTA
MEDICAL
SERVICES
CORPORATION

MINNESOTA MEDICAL ASSOCIATION

1990-91 Officers
President

Thomas A. Stolee, M.IT.

President-Elect
A. Stuart Hanson, M.D.

Chair, Board of Trustees
Andrew]. K. Smith, M.D.

Vice President
Barbara P. Yawn, .M.D.

Secretary

Thomas B. Dunkei, .M.D.
Treasurer

Joseph A. Celia, Jr., .VI. D.

Speaker of the House
J. Randolf Beahrs, .M.D.

Vice Speaker of the House
Richard D. .Mulder, .M.D.

Past President

Richard B. Tompkins, .M.D.

Chief Executive Officer
Paul S. Sanders, .VI. D.

Auxiliary

President
Phyllis H. Ellis

Editor-in-Chief
Edmund C. Burke, .M.D.

Advisory Committee
Edmund C. Burke, .VI. D.
Thomas W. Day, .VTD.
Alice G. Harris, .Vi.D.
Charles R. .Vleyer, .VI.D.
Paul S. Sanders, .M.D.
.Andrew]. K. Smith, .VI.D.
Anne B. Warwick, .VI.D.
.Meredith .VlcNab
.Mark Vukelich

Editors Emeritus
Richard L. Reece, .VI.D.
1975-1990

Reuben Berman, .VI.D.
1971-1974

Carl O. Rice, .VI.D.
1961-1970

Minnesota Medicine

Board of Trustees

N. W. District
Erick Reeber, .VI. D.

N.E. District
Thomas W. Day, .VI.D.

Jack B. Greene, .M.D.

N. Central District
James]. Dehen, .VI.D.

David .VI. Van Nostrand, .VI. E).

West Metro

Roger W. Becklund, M.D.
Andrew ]. K. Smith, .VI.D.,
Chr.

Richard E. Student, M.D.
George V. Tangen, .VI.D.
Ronald E. Villella, .VI.D.

East Metro

Joseph E. Rigatuso, .VI.D.

Kent S. Wilson, VI.D.

S. W. District

Theodore E. Eritsche, .M.D.
Anthony C. Jaspers, .VI.D.

S.E. District

Gail E. Gamble, M.D.

J. Paul .Vlarcoux, .VI.D.
Thomas E. Peyla, .VI.D.

Resident Member
Cherie J. Hayostek, .M.D.

Medical Student
Ty Dunn

Review Board
Chester A. Anderson, .VI.D.
Donald C. Bell, .VI.D.
Dorothy Bernstein, .VI.D.

E. Blanton Bessinger, .VI.D.
Jonathan H. Biebl, .VI.D.
Paul J. Bilka, M.D.

Clyde E. Blackard, .VI.D.

R. J. Campaigne, .VI.D.
Richard P. Carroll, .VI.D.
Roger S. Colton, .VI.D.
Gerald E. Cotton, .VI.D.
Peter Dorsen, .VI.D.

Peter Eehr, .VI.D.

Paul Gannon, .VI.D.

James B. Gaviser, .VI.D.

H. W. Heupel, .VI.D.

Neil Hoffman, .VI.D.

James Janecek, .M.D.

.Miles J. Jones, .VI.D.

Carl .M. Kjellstrand, .VI.D.
Arnold Kremen, .VI.D.
Warren L. Kump, .VI.D.

Van S. Eawrencc, .VI.D.

(,. Patrick Eilja, .VI.D.
.VIerle K. Eoken, .VI.D.
.VIerle S. .Mark, .M.D.

John K. .Vleinert, .VI.D.

AM A
T riistee

William E. Jacott, .VI.D.

AM A Delegates

Robert D. Christensen, .VI.D.

El. Duane Engstrom, .VI.D.

A. Stuart Hanson, .VI.D.
James E. Knapp, .VI.D.
Audrey .VI. Nelson, M.D.

Ben P. Owens, .VI.D.

Richard B. Tompkins, .M.D.,
Chr.

AM A Alternates
Carolyn J. .VIcKay, .M.D.
.Vlichael j. .Vlurrav, .M.D.

C:. Randall Nelms, Jr., .VI.D.
Eawrence .VI. Poston, .VI.D.
Thomas A. Stolee, .VI.D.
James]. Tiede, M.D.

E. Ashley Whitesell, .VI.D.

Senior Staff

Director of Exonomics &
Government Relations
Roger K. Johnson

Chief Einancial Officer
George C. Lohmer, Jr.

Director of Communications
.Mark S. Vukelich

General Legal Counsel
.Vlary E. Prentnieks, J.D.

James J. .Monge, .VI.D.

John S. Najarian, .VI.D.

Bruce C. Nydahl, .VI.D.

.Vlilton Orkin, .VI.D.

Richard R. Owen, .M.D.
.Vlichael .VI. Paparella, .VI.D.
James]. Pattee, .VI.D.

Willard Peterson, .VI.D.

John J. Regan, .M.D.

Krishna .VI. Saxena, .VI.D.
William E. Schoenwetter, .M.D.
Alvin E. Schultz, .VI.D.

Edward L. Seljeskog, .VI.D.
John E. Smith, .VI.D.

Earrell S. Stiegler, .M.D.

George T. Tani, .VI.D.

Robert ten Bensel, .VI.D.

John V. Thomas, .VI.D.

John Verby, .VI.D.

Anne B. Warwick, .VI.D.
Robert E. Woodburn, .VI.D.

Contributing

Organizations

.Minnesota Allergy Society
.Vlinnesota Society of
Anesthesiologists
Minnesota Dermatologic
Society

.Minnesota Association of
E.VIS Physicians
.Vlinnesota Chapter,

American College of
Emergency Physicians
.Minnesota Academy of
Eamily Physicians
.Minnesota Component,
American Society of
Internal .Medicine
.Minnesota Chapter, American
College of Physicians
.Minnesota Society of
Neurological Sciences
Association of Neurologists
of .Minnesota
.Minnesota Neurological
Society

.Minnesota Association of
Nursing Home .Medical
Directors

.Vlinnesota Obstetrical and
Gynecological Society
North Central Occupational
.Vledical Association
.Vlinnesota Academy of
Ophthalmology
.Vlinnesota Orthopaedic
Society

.Minnesota Academy of
Otolaryngology-Head dc
Neck Surgery
.Minnesota Society of
Clinical Pathologists
Northwestern Pediatric
Society

.Vlinnesota Chapter, American
Academy of Pediatrics
.Vlinnesota Physiatric Society
.Vlinnesota .Academy of
Plastic Surgeons
.Vlinnesota Psychiatric Society
.Vlinnesota Radiological
Society

.Minnesota Chapter, American
College of Surgeons
.Vlinnesota Surgical Society
Minnesota Thoracic Society
.Vlinnesota Urological Society

January 1992/Volume 75

Minnesota Medicine Advisers and Reviewers

HENNEPIN COUNTY MEDICAL CENTER / HENNEPIN FACULTY ASSOCIATES

1 992 Calendar of Medical Events

1 (Offered throughout the year)

CONTACT LASER LAPAROSCOPY CHOLECYSTECTOMY COURSE

Chairman: Richard Zera, MD

2 February 14, 1992

MINNESOTA DERMATOLOGICAL SOCIETY WINTER CONFERENCE

Chairman: Bruce Bart, MD

3 April 14, 1992

MINNESOTA REGIONAL SLEEP DISORDERS CENTER (MRSDC)
ANNUAL DINNER LECTURE-DAVID DINGES, PHD

Sleep research related topic
Chairman: Mark Mahowald, MD,

Minneapolis Athletic Club, Minneapolis

4 April 10, 1992

ANNUAL JOHN I. COE CONFERENCE
"CURRENT CONCEPTS IN DERMATOPATHOLOGY”

Held in conjunction with MSCP April 11, 1991 annual meeting
Chairman: Robert L. Strom, MD

5 April 24, 1992

ANNUAL PRACTICAL Gl CONFERENCE FOR PRIMARY CARE

Co-sponsored with St. Paul Ramsey Medical Center
Co-Chairmen: Martin Freeman, MD/Robert Olson, MD

6 May 14-16, 1992

ACUPUNCTURE FOR PAIN CONTROL

Chairman: Miles Belgrade, MD

7 May 21-22, 1992

PRIMARY CA^E TREATMENT FOR PRESSURE SORES

Special afternoon tracks for physicians and nurses
Chairman: George Peltier, MD

8 June 13, 1992

HCMC INTERN CLASS OF ‘61 MEDICAL REVIEW

Chairman: John Crosson, MD

9 June, 1992

CRISIS INTERVENTION PROGRAM

Chairman: Zigfrids Stelmachers, PhD

10 July 16-19, 1992

ADVANCES IN CLINICAL MANAGEMENT OF INFECTIOUS DISEASES

Co-Chairmen: Phillip Peterson, MD, HCMC/Dale Gerding, MD, VAMC
Brainerd, Minnesota

1 1 Fall, 1992

NEUROLOGY CME AND ANNUAL A. B. BAKER DINNER LECTURE

Chairman: Milton Ettinger, MD; Location/Topics to be announced

12 Fall, 1992

PEDIATRIC HEAD INJURIES CONFERENCE

Co-Chairmen: David Fisher, MD/Thomas Rolewicz, MD

13 September, October, November, 1992

HEALTH CARE OBJECTIVES FOR THE YEAR 2000

A three part lecture series

Co-Chairmen: Charles Oberg, MD/Pam Thul-lmmler, RN

1 4 September 10-11, 1 992

APPLIED CLINICAL RESEARCH METHODS

Co-Chairmen: Nicole Lurie, MD/Alfred Pheley, PhD

1 5 September 1 8, 1 992

PAIN MANAGEMENT FOR THE PRIMARY CARE PHYSICIAN

Chairman: Miles Belgrade, MD

16 Seotember 18-20, 1992

ANNUAL AMBULANCE MEDICAL DIRECTOR RETREAT

Chairman: David Larson, MD; Brainerd, Minnesota

17 September 24-26, 1992

4TH INTERNATIONAL VAGINAL SURGERY PROGRAM

Chairman: Stephen Cruikshank, MD; Ritz Carlson, St. Louis, MO

1 8 September 24-25, 1 992

TRAUMA AND CRITICAL CARE CONFERENCE

Co-Chairmen: Brian Mahoney, MD/Arthur Ney, MD

19 October 1992
TEACHING THE MEDICAL INTERVIEW

Chairman: Gregory Silvis,MD

20 October 8-9, 1992
ANNUAL FORENSIC SCIENCE SEMINAR

Chairman: Garry Peterson, MD

21 October 9, 1992

ANNUAL CONTEMPORARY ISSUES IN DIALYSIS THERAPY

Chairman: Robert Berkseth, MD; Sheraton Midway Flotel, St. Paul

22 October 16, 1992

ANNUAL ADVANCES IN GERIATRIC CARE

Chairman: Patrick Irvine, MD

23 October 22-24, 1992

2nH ANNUAL ORTHOPAEDIC AND TRAUMA SEMINAR

Chairman: Ramon Gustilo, MD

24 November 5-6, 1992

MEDICAL INTENSIVE CARE CONFERENCE

Chairman: James Leatherman, MD

25 November 13-14, 1992
HUNTINGTON'S DISEASE:

PRACTICAL APPROACHES TO PATIENT AND FAMILY CARE

Chairman: Martha Nance, MD; Minneapolis Athletic Club

26 November 20-21, 1992

PRIMARY CARE UPDATE/SPORTS MEDICINE

Chairman: Patricia Cole, MD

27 Courses offered on a regular basis throughout the 1992 year by
HCMC Emergency Medical Services. Call 612/347-5683 for more information

ACLS Provider Courses:

January 8, 9; April 8,10; July 8,10; October 7, 9
ATLS Provider Courses:

January 6,7; April 6,7; July 6,7; October 5, 6
Resuscitation Courses:

January 2-15; April 1-15; July 1-15; October 1-15

Courses are held at Hennepin County Medical Center unless otherwise noted

For more information regarding these courses contact

Hennepin County Medical Center

HCMC

Minnesota's Level X Trauma Center

HCMC/HFA Office of Academic Affairs
701 Park Avenue, Mail Code 867A
Minneapolis, Minnesota 55415-1829
612/347-2075
facsimile 612/347-6155

P OFFICE OF
ACADEMIC
AFFAIRS

EDITOR'S NOTEBOOK

Confronting Bias in Health Care

Edmund C . Burke, M . D .

Undeniably, women have re-
ceived inequitable medical
care as compared with men.
They have received inferior diagnoses
and treatments, in large part, be-
cause research on women’s health
has been inadequate. The U.S. Public
Health Service’s Task Force on Wom-
en’s Health Issues reported in 1985
that a lack of research limits the
understanding of women’s health
needs. Similar conclusions have been
appearing with increasing frequency
in leading medical journals and the
general media.

Still, in talking with some of my
colleagues, I discovered that they are
surprised by this bias. I believe their
surprise may prove a point — that we
have historically assumed what is
good for men is good for women. As
a result, research on men is often
mistakenly applied to women.

Researchers are reluctant to per-
form studies on women of childbear-
ing age for fear that the treatment or
procedure might adversely affect re-
productive capabilities — or damage
the fetus if the patient becomes preg-
nant. Women have also been exclud-
ed from research because of their
hormonal cycles, which can affect
therapeutic interventions. However,
it is precisely because of these unpre-
dictable hormonal effects that wom-
en should be included in research.

Although biological factors ac-
count for some differences in the
provision of care for men and wom-
en, studies indicate that nonbiologi-
cal factors may also affect clinical
decision making. In the July 25 Neiv
England Journal of Medicine, two
articles document evidence of sex
bias in the management of coronary
heart disease. In one study, women
were half as likely as men to undergo
cardiac catheterization. Is this bias
due to stereotypes of men’s greater

“We have historically
assumed what is
good for men is good
for women.”

societal value, as the AMA’s Council
on Ethical and Judicial Affairs spec-
ulates in the July 24 Journal of the
American Medical Association}
Whatever the factors, this health
care gender gap is cause for concern.
After studying the issue, the AMA
council recommended that physicians
examine their practices and attitudes
for biases that might affect medical
care; that research on women’s health
be pursued; and that we work to
increase the number of women phy-
sicians in leadership roles, which
would help to enhance the awareness
of socio-cultural factors that lead to
gender disparities.

In this month’s Face to Face in-
terview (page 9), Doris Brooker,
M.D., chair of the MMA’s Commit-
tee on Women Physicians, shares her
belief that organized medicine pro-
vides a voice for women’s health
issues. In fact, as our feature story
(page 16) discusses, within medicine
and without, women are becoming
more politically active in efforts to
ensure that their demand for equal
medical treatment is heard.

Bernadine Healy, M.D., director
of the National Institutes of Health,
is another who believes it is time for
a general awakening to the fact that
women have unique medical prob-
lems. In an editorial in the July 25
Neiu England Journal, she states that
women have greater morbidity than
men and are affected by more chron-
ic debilitating illness. Although wom-
en live longer, their quality of life
may be burdened by breast cancer,
lung and colon cancer, heart disease,
stroke, osteoporosis, depression, and
general frailty. She notes that the
NIH has mounted a multi-disciplin-
ary, multi-institute intervention study,
called the Women’s Health Initiative,
to address the major causes of death,
disability, and frailty among middle-
aged and older women. More than
140,000 women will participate in
the $500 million study.

On a smaller scale, Minnesota
has created a new task force to advise
the commissioner of health on wom-
en’s health issues. Dr. Brooker, who
was instrumental in establishing the
task force, describes its objectives
more fully in her interview.

Individually, we can all work to
improve health in our comiinunities.
Internists I recently spoke with
stressed the need for liealth care re-
sponsibility. We should be very con-
cerned, for example, that in spite of
campaigns to eliminate smoking, a
high percentage of young women still
smoke, and we must strive to educate
young people about the too-often
deadly consequences down the road.

We must continually counsel
against risk-taking activities. Drug
and alcohol abuse, sexually trans-
mitted diseases, and unwanted preg-
nancy demand our utmost effort in
teaching healthier lifestyles. mm

Minnesota Medicine

January 1992/Volume 75

ONiy ONE H, -ANTAGONIST HEALS REFLUX ESOPHAGITIS
AT OUOOENAL ULCER DOSAGE. ONIY ONE.

Of all the H2-receptor antagonists, only Axid heals and
relieves reflux esophagitis at its standard duodenal ulcer dosage
Axid, 150 mg b.i.d., relieves heartburn in 86% of patients
after one day and 93% after one week. ’

ACID lESlED. PATIENT PROVEN.

1. Data on file, Lilly Research Laboratories. See accompanying page for prescribing information. ei99i, ELI LILLY and company N2-2947-B-249304

Axm

nizatidine

150 mg b.i.d.

AXID’

nizatidine capsules

Brief Summary. Consult the package insert for
complete prescribing information.

Indications and Usage: 1. Active duodenal ulcer -
' for up to 8 weeks of treatment at a dosage of 300 mg
I h.s. or 150 mg b.i.d. Most patients heal within 4 weeks.

2. Maintenance therapy -tof healed duodenal ulcer
I patients at a dosage of 150 mg h.s. at bedtime. The
consequences of therapy with Axid for longer than 1

' year are not known.

3. Gastroesophageal reflux disease (GERD)-\oi up
to 12 weeks of treatment of endoscopically diagnosed

I esophagitis, including erosive and ulcerative esophagitis,
and associated heartburn at a dosage of 150 mg b.i.d.

Contraindication; Known hypersensitivity to the drug
B^use cross sensitivity in this class of compounds has
been observed. Hj-receptor antagonists, including Axid.
should not be administered to patients with a history
of hypersensitivity to other H^-receptor antagonists.

Precautions: General-^. Symptomatic response to nizatidine therapy does not preclude the presence
of gastric malignancy.

2. Dosage should be reduced in patients with moderate to severe renal insufficiency

3. In patients with normal renal function and uncomplicated hepatic dysfunction, the disposition of
nizatidine is similar to that in normal subjects.

Laboratory Tests-False-positive tests lor urobilinogen with Multistix' may occur during therapy

Drug Interactions-t^o Interactions have been observed with theophylline, chlordiazepoxide, lorazepam.
Iidocaine, phenytoin, and warfarin. Axid does not inhibit the cytochrome P-450 enzyme system; therefore,
drug interactions mediated by inhibition of hepatic metabolism are not expected to occur. In patients given
very high doses (3.900 mg) of aspirin daily, increased serum salicylate levels were seen when nizatidine.
150 mg b.i.d.. was administered concurrently

Carcinogenesis. Mutagenesis. Impairment of Ferhlity-A 2-year oral carcinogenicity study in rats with
doses as high as 500 mg/kg/day (about 80 times the recommended daily therapeutic dose) showed no evidence
of a carcinogenic effect. There was a dose-related increase in the density of enterochromaffin-like (ECL) cells
in the gastric oxyntic mucosa. In a 2-year study in mice, there was no evidence of a carcinogenic effect in male
mice, although hyperplastic nodules of the liver were increased in the high-dose males as compared with
placebo. Female mice given the high dose of Axid (2.000 mg/kg/day. about 330 times the human dose) showed
marginally statistically significant increases in hepatic carcinoma and hepatic nodular hyperplasia with no
numerical increase seen in any of the other dose groups.The rate of hepatic carcinoma in the high-dose
animals was within the historical control limits seen for the strain of mice used. The female mice were given
a dose larger than the maximum tolerated dose, as indicated by excessive (30%) weight decrement as compared
with concurrent controls and evidence of mild liver injury (transaminase elevations). The occurrence of a marginal
finding at high dose only in animats given an excessive and somewhat hepatotoxic dose, with no evidence of a
carcinogenic effect in rats, male mice, and female mice (given up to 360 mg/kg/day. about 60 limes the human
dose), and a negative mutagenicity battery are not considered evidence of a carcinogenic potential for Axid.

Axid was not mutagenic in a battery of tests performed to evaluate its potential genetic toxicity, including
bacterial mutation tests, unscheduled DNA synthesis, sister chromatid exchange, mouse lymphoma assay,
chromosome aberration tests, and a micronucleus test.

In a 2-generation. perinatal and postnatal fertility study in rats, doses of nizatidine up to 650 mg/kg/day
produced no adverse effects on the reproductive performance of parental animals or their progeny.

Pregnancy-Teratogenic Effects -Pregnancy Category C-Oral reproduction studies in rats at doses up
to 300 times the human dose and in Dutch Belted rabbits at doses up to 55 times the human dose revealed no
evidence of impaired fertility or teratogenic effect; but. at a dose equivalent to 300 times the human dose,
treated rabbits had abortions, decreased number of live fetuses, and depressed fetal weights. On intravenous
administration to pregnant New Zealand White rabbits, nizatidine at 20 mg/kg produced cardiac enlargement,
coarctation of the aortic arch, and cutaneous edema in 1 fetus, and at 50 mg/kg, it produced ventricular
anomaly, distended abdomen, spina bifida, hydrocephaly, and enlarged heart in 1 fetus. There are. however,
no adequate and well-controlled studies in pregnant women. It is also not known whether nizatidine can
cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Nizatidine
should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers -S\.u6\es in lactating women have shown that 0.1% of an oral dose Is secreted
in human milk in proportion to plasma concentrations. Because of growth depression in pups reared
by treated lactating rats, a decision should be made whether to discontinue nursing or the drug, taking
into account the importance of the drug to the mother.

Pediatric t/se-Safety and effectiveness in children have not been established.

Use in Elderly Patients -HeaUng rates in elderly patients were similar to those in younger age groups
as were the rates of adverse events and laboratory lest abnormalities. Age alone may not be an important
factor in the disposition of nizatidine. Elderly patients may have reduced renal function.

Adverse Reactions; Worldwide, controlled clinical trials included over 6.000 patients given nizatidine in
studies of varying durations. Placebo- controlled trials in the United States and Canada included over 2,600 patients
given nizatidine and over 1 ,700 given placebo. Among the adverse events in these placebo-controlled Inals, only
anemia (0.2% vs 0%) and urticaria (0.5% vs 0.1%) were significantly more common in the nizatidine group. Of
the adverse events that occurred at a frequency of 1% or more, there was no statistically significant difference
between Axid and placebo in the incidence of any of these events (see package insert for complete information)

A variety of less common events were also reported, it was not possible to determine whether these
were caused by nizatidine.

Wepaf/c-Hepatocellular injury (elevated liver enzyme tests or alkaline phosphatase) possibly or probably
related to nizatidine occurred in some patients. In some cases, there was marked elevation (>500 lU/L) in
SGOT or SGPT and. in a single instance, SGPT was >2.000 lU/L The incidence of elevated liver enzymes
overall and elevations of up to 3 times the upper limit of normal, however, did not significantly differ from that
in placebo patients. All abnormalities were reversible after discontinuation of Axid. Since market introduction,
hepatitis and jaundice have been reported. Rare cases of cholestatic or mixed hepatocellular and cholestatic
injury with jaundice have been reported with reversal of the abnormalities after discontinuation of Axid.

Cardiovascular-\n clinical pharmacology studies, short episodes of asymptomatic ventricular tachycardia
occurred in 2 individuals administered Axid and in 3 untreated subjects.

C/VS- Rare cases of reversible mental confusion have been reported.

Endocrine-C\in\c2\ pharmacology studies and controlled clinical trials showed no evidence of anti-
androgenic activity due to nizatidine. Impotence and decreased libido were reported with similar frequency
by patients on nizatidine and those on placebo. Gynecomastia has been reported rarely.

Hemafo/og/c- Anemia was reported significantly more frequently in nizatidine than in placebo-treated
patients. Fatal thrombocytopenia was reported in a patient treated with nizatidine and another H^-receptor
antagonisl This patient had previously experienced thrombocytopenia while taking other drugs. Rare cases
of thrombocytopenic purpura have been reported.

/nfegumenfa/- Urticaria was reported significantly more frequently in nizatidine- than in placebo-treated
patients. Rash and exfoliative dermatitis were also reported.

Hypersensitivity- As with other H2-receptor antagonists, rare cases of anaphylaxis following nizatidine
administration have been reported. Rare episodes of hypersensitivity reactions (eg, bronchospasm, laryngeal
edema, rash, and eosinophilia) have been reported.

O/her- Hyperuricemia unassociated with gout or nephrolithiasis was reported. Eosinophilia. fever, and
nausea related to nizatidine have been reported.

Overdosage: Overdoses of Axid have been reported rarely. If overdosage occurs, activated charcoal,
emesis, or lavage should be considered along with clinical monitoring and supportive therapy. The ability of
hemodialysis to remove nizatidine from the body has not been conclusively demonstrated: however, due to its
large volume of distribution, nizatidine is not expected to be efficiently removed from the body by this method,
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FACE TO FACE

A Powerful Voice for Women’s Health

Minnesota Medicine interviews Doris C . B r o o k e r , M . D .

Women are increasingly demanding equal treat-
ment in the doctor’s office. They are joining
physicians, researchers, and others in calling
attention to women ’s health issues and the need for more
research on such illnesses as breast
cancer and cardiovascular disease.

Recent studies document that not
only is research on women’s health
lagging behind that on men’s health,
but, in some instances, women’s
medical complaints are taken less
seriously than men ’s, even when their
symptoms are similar. Additionally,
women tend to receive less intensive
medical care than men do. For exam-
ple, women are also half as likely as
men to undergo cardiac catheteriza-
tion and less likely to undergo bypass
surgery or balloon angioplasty.

Doris Brooker, M.D., an obigyn
pathologist specializing in women’s
health at the University of Minneso-
ta, is working to improve women’s
health in the state. Dr. Brooker, the
governor’s staff, and Commissioner
of Health Marlene Marschall have
created a women’s health task force
to advise the health commissioner.

The goals of this bipartisan task force will be to consider
women ’s health problems, set priorities, and recoinmend
solutions for the state. Education and information dis-
semination are key components of the initiative.

Dr. Brooker, who is also chair of the Minnesota
Medical Association’s Committee on Women Physi-
cians, believes that participation in organized medicine
provides a powerful voice for women’s health issues. In
this month ’s interview, she says the MM A led the way for
the American Medical Association and other groups
when it formed the Committee on Women Physicians in
the early 1 980s. Women are now involved in organized
medicine in all areas of the state and in every specialty,
according to Dr. Brooker, who emphasizes the leader-
ship role Minnesota women physicians have played in
the AMA, as well as more locally.

Dr. Brooker believes we must strive for equality in
women’s health care hut says we should avoid getting
caught up in negative images of the past. Women ’s health
has come a long way in recent years, and it’s important
that we continue moving forward, she says.

Doris C. Brooker, M.D

‘Let’s move ahead
and make things
happen equally.”

Minnesota Medicine: Dr. Brooker, let’s start with your
background. Where did you go to medical school, where
did you do your residency training, and how did you end
up in your current position?

Brooker: I am from Milwaukee, Wis-
consin, and I went to the Marquette
University School of Medicine. I did
my residency training in pathology in
a Harvard program, and I did a post-
doctoral fellowship at Johns
Hopkins University in the ob/gyn
department. My last training was in
clinical pathology here at the Univer-
sity of Minnesota, where I accepted a
position in 1 975 and now have a joint
appointment in the Department of
Laboratory Medicine and Pathology
and the Department of Ob/Gyn. I am
a pathologist specializing in women’s
health. My research currently focuses
on quality assurance in obstetrics and
women’s cancer and on infectious
disease in ob/gyn.

Organized Medicine’s Voice

Minnesota Medicine: You are chair
of the Minnesota Medical Associa-
tion’s Committee on Women Physicians. Tell us a little
about the committee.

Brooker: I have been part of that committee intermit-
tently for the past 1 0 years. The MMA led the way for the
American Medical Association and other groups in
allowing those of us who are interested in women’s issues
to express ourselves through organized medicine. The
committee was formed in the early 1980s. The Minneso-
ta Medical Association is our voice on women’s issues in
all areas of medicine, including such issues as pregnancy
and maternity leave, violence and abuse, and research on
women’s health. We’ve been lucky in Minnesota that
we’ve had a voice and we’ve been listened to. I encourage
women physicians to get involved. 1 realize young men’s
and young women’s lives are very busy — many women
physicians have several different roles and a lot of time
constraints — but if they choose to get involved, there is
ample opportunity in this medical association. It is
critical that we all be involved, even in a limited role.

Minnesota Medicine: As a member of the American

Minnesota Medicine

January 1992/Volume 75

FACE TO FACE

Academy of Pediatrics, I know that half of all pediatric
residents are currently women. The AAP’s membership
is now about one-third women, and the last president
was a woman. How involved are women in Minnesota’s
medical societies.^

Brooker: We now have four women physicians who are
presidents of local medical societies in Minnesota and
three or four who are officers. There are about 2,200
women physicians in .Minnesota, including about 1,200
in Hennepin and Ramsey counties, 100 in Twin Cities
suburbs, 350 in Olmsted County, and 50 in St. Louis
County. The other appro.ximately 450 are in Greater
Minnesota, so women are represented in every area of
the state and in every specialty. About half the state’s
women physicians are involved in organized medicine.
Women physicians are increasingly branching off into
areas other than psychiatry, pediatrics, and oh/gyn — the
specialties that have traditionally attracted women phy-
sicians. We are particularly proud of the contributions of
Dr. Peggy Craig, the first woman president of the MMA
and now a University of Minnesota regent, and Dr.
Audrey Nelson, who is on the Mayo Clinic board and is
a long-time AMA delegate.

Minnesota Medicine: Do you think greater numbers of
women physicians will improve women’s health general-
ly and increase the attention paid to women’s health
issues?

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Brooker: I would like to believe that men and women
physicians complement each other in their care of wom-
en. Women’s health issues are nor exclusively the respon-
sibility of women physicians. In Minnesota, some of the
foremost women’s health advocates are men. A good
example of women’s health advocacy is Gov. Arne
Carlson’s public statement in August that violence against
women is an issue society as a whole must address in
attitude and dialogue.

New State Task Force on Women’s Health

Minnesota Medicine: You have been involved in a state
effort to draw attention to women’s health issues. What
can you tell us about this effort?

Brooker: As you know, health care reform has emerged
as an important issue in Minnesota and elsewhere. I have
joined many others in suggesting ways of making health
care more accessible and cost effective. Last summer, the
governor’s staff expressed a strong interest in forming a
women’s health advisory task force. This is now a
reality. An advisory task force to the commissioner of
health will be created to consider women’s health issues
and recommend solutions. The advisory group will be
composed of physicians and other health professionals
who daily listen to the problems of women. It will be a
unique voice for women in Minnesota. The core group
will be women in medicine, including physicians, nurses,
technologists, physical therapists, psychologists, mid-
wives, and nurse clinicians. Interest in, experience with,
and knowledge of the issues and how to solve them will
be the factors used to choose the task force members. We
don’t want to make the group e.xclusive to health care
providers; a great number of other women professionals
will be part of this task force — legislative, judicial,
managed care, and business representatives, for exam-
ple. In fact, the women’s health task force will include
men. The National Women’s Political Gaucus has been
successful, and it has many male advocates from Con-
gress. Women exclusively providing women’s health is
not the focus we want.

Improving access to health care and the quality of
care for women patients is the priority of this group.
Consumers — women patients — will have the most im-
portant voice in this task force. I know of no better way
to ensure success in this effort than to empower women
with knowledge about health issues important to them.
This is my bias as an educator and teacher.

An Assessment of Women’s Health — As
Compared with Men’s

Minnesota Medicine: Women’s health has been the fo-
cus of many medical articles lately in such journals as
I AMA and The Neti’ England Journal of Medicine. How
has women’s health changed in recent years?

Brooker: In the past few decades, women’s health has
changed dramatically. We’ve seen, for example, signifi-
cant improvements in cancer survival, fertility, and

January 1992/Volume 75

Minnesota Medicine

FACE TO FACE

survival rates of mothers and neonates since 1940.
Hormone therapy is one example of how women’s
health has changed in terms of medical treatment. Wom-
en were taught 20 years ago that estrogen and hormone
therapy might he dangerous and cancer producing, so
use was limited. Today, we have more data showing that,
in fact, cardiovascular disease is a much more likely
cause of death for women than breast cancer or endome-
trial cancer. We can now screen women’s risk status and
watch for complications from hormonal therapy, which
is absolutely necessary for preventing osteoporosis and
maintaining cardiovascular health. Women deserve the
physical and psychological benefits of hormone-
replacement therapy.

Minnesota Medicine: A number of other recent articles
have discussed gender disparities in health care. One in
particular talks about differences in procedures used for
women and men hospitalized for coronary artery dis-
ease. I think it comes as a shock to a lot of physicians that
they may not have taken care of women as well as they’ve
taken care of men. How do you feel about this?

Brooker: Awareness of gender dis-
parities in medicine started with the
National Women’s Political Caucus
about five or six years ago. That
group generated significant interest
in the issue. The National Cancer
Institute, the National Institutes of
Health, and the Institute of Medicine
followed with important informa-
tion about discrepancies in research
and funding of women’s health con-
cerns, such as breast cancer. It has
also become clear that we need to
include women in studies of cardio-
vascular disease. We need more re-
search on which hormonal medications and what
combinations will help prevent cardiac disease in women
while presenting the least risk of cancer. Men certainly
have a preponderance of morbidity and mortality from
this disease, but as women age and lose estrogen, they
lose protection and their risk becomes greater.

Medicine evolves as issues evolve. I think it’s helpful
to look at the past, but I don’t want to compromise our
future by criticizing the past. What’s important is to
develop a bank of information from credible research
evaluations. There has already been a lot of progress in
women’s health; however, I don’t want to de-emphasize
the fact that there have been inequities in women’s health
as compared with men’s. We must learn from the past,
but let’s move ahead and make things happen — and
happen equally.

Women, Children, and AIDS

Minnesota Medicine: AIDS is another illness more typ-
ically associated with men, but it’s becoming a signifi-
cant issue for women. By the year 2000, the number of
women with AIDS worldwide is expected to equal that

of men. Do you have any comments on this?

Brooker: By December 1, 1991, 1 63 women in Minneso-
ta had been recognized as HIV seropositive; 40 of them
actually had the disease. The university’s ob/gyn depart-
ment has just organized a task force to address some of
the problems faced by these women and develop a
strategy to assist Minnesota physicians who are treating
women with AIDS. These women have a greater risk for
cancer, for pregnancy loss, and for many other problems,
and it is our responsibility to provide quality care and
education about prevention of this disease.

Minnesota Medicine: AIDS among teenagers is also a
serious concern. What can physicians do about the
problem?

Brooker: I believe young men and women are very open
to information from physicians and other adults, as well
as their peers. It’s important that we provide correct
information about sexually transmitted diseases and
birth control and, especially, use of condoms. It’s a
serious and ongoing challenge for physicians to educate
young people, who are susceptible to
misinformation. 1 think we also need
more funding for adult education
about sexually transmitted diseases
and family planning. We all need to
be more aware of AIDS and the need
for protection. The public expects
medicine to take a leading role in
education and public protection.

Minnesota Medicine: Often the most
vulnerable populations tend to reject
advice.

Brooker: Peers and sports figures,
such as Magic Johnson, often have
the greatest influence on teens, but physicians and other
people they respect also have influence, and 1 believe we
have a responsibility to exert our influence. We must help
parents and our educators deal directly with this prob-
lem.

Minnesota Medicine: In closing, do individual physi-
cians also have a responsibility to improve women’s
health?

Brooker: I believe any successful effort must begin with
individual initiative. Each of us has our advocacy and our
priorities. Women’s health issues involve many aspects
of medicine and its specialties. Improvement will come
gradually as each physician practices with the new
knowledge he or she accepts as credible. Organized
medicine will play a role in changing medical practice for
the better by focusing on these issues. mm

“I would like to
believe that men and
women physicians
complement each
other in their care of
women.”

Minnesota Medicine

January 1992/Volume 75

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January 1992/Volume 75

Minnesota Medicine

PERSPECTIVES

Learning About Real Medicine
and Real Life

Beth Olsen

Editor’s Note: As a third-year medical student
participating in the University of Minnesota's
Rural Physician Associate Program, Beth Olsen
spent nine months in Willmar, Minnesota, living
in the community, studying, and working along-
side practicing rural family physicians. Following
is an essay she wrote at the conclusion of her
RPAP experience. When the program’s Interim
Director Walter Swentko, M.D., sent us the pa-
per, he wrote, “The essay captures some of the
magic and mystery, the joys and pains, of learning
about medicine. ”

While working as a rural physician in Willmar,
Minnesota, through the Rural Physician Asso-
ciate Program, I rediscovered the reason I
chose to study medicine. I had lost track of it as a medical
student studying chick wing bud experiments, anti-
microbials, glycolysis, and the treacherous twists and
turns of cranial nerve number 7. Even my first clinical
rotations lost their glamour after I discovered it was my
job to determine what every patient’s potassium was
doing, to locate Mrs. P’s misplaced CT scan, to find out
whether the nurses’ station had any caffeinated coffee,
and to hunt for the missing 30-gauge needles.

While on clinical rotations, I did connect more
personally with one man and his family from Virginia,
Minnesota. Alfred was a wonderful man whose body
was dying of metastatic lung cancer. Why, then, did I
shed only a few tears when I hugged him and turned to
his family to say goodbye? (Why not a whole Kleenex
full? Good grief, 1 sobbed when E.T. was going home!)
Apparently, I had already learned to become detached
after 10 weeks of clinical experience. I hope he didn’t see
it. Oh, I had concern and compassion (much more than
my resident), but I didn’t take the time to stop and think
of Alfred again — until 1 met Walter during my Rural
Physician Associate Program (RPAP) experience.

Like Alfred, Walter was experiencing shortness of
breath. We gave him a sack of inhaler samples to stop the
problem, which stemmed from a soon-to-be-detected
cauliflower growth in his right mainstem bronchus.

One evening when Walter was in the hospital, he and
his wife called me into his room and began asking me
questions about how to take prednisone. The conversa-
tion turned to other topics — what western Nebraska
wind was like in the winter, how many cows, how many

acres, why did 1 want to be a doctor, and had 1 ever seen
the sandhill cranes along the North Platte River? I sat
patiently on the corner of his bed, and we shared stories
about the loss of limbs. A grain auger had stolen my dad’s
arm, and a war had claimed Walter’s. We chuckled,
reminiscing about times when children had stared and
pointed to “Captain Hook.”

I made more time to spend with Walter than 1 had
with Alfred; 1 had the time to follow Walter’s course over
months, not days. I began to make sense of dignity — of
individuality. I began to understand what to fight for and
what to leave to God. 1 truly came to realize why Alfred
had wanted to escape the metropolitan hospital without
radiation treatment and return to Virginia, where the
leaves were already changing to gold.

Detachment is undoubtedly needed in medicine —
especially in emergency situations. At times it can be
more important to sort the stack of Advanced Cardiac
Life Support algorithms and plunge needles into col-
lapsed veins than to recognize confusion, panic, and fear.
Acknowledging the feelings that both you and the pa-
tient possess, however, is what RPAP is about.

Going back and forth between compassion and
detachment is tough. Physicians tend to feel more com-
fortable playing it safe. We inadvertently learn detach-
ment. We forget that a human being is in front of us, not
just a Great Cause or a Pathetic Case. It’s easy for most
physicians to talk about the broken hip in room 323 or
the melanoma in 456. It’s hard to talk about the evasive,
capricious areas of human life.

When I saw a young woman in the clinic with signs
of an impending spontaneous abortion, I had to tell her
what was happening inside her body. Yes, I gave a
somewhat technical explanation, but 1 also was able to
blend in sensitivity, true concern, and attentive listening.
I was mad that night, as I lay sleepless, wondering if she
was bleeding to death in a Chevy on the way to Eargo (she
had decided to go to her parent’s home and not stay close
to the hospital, as I had suggested). No other medical
student at the University of Minnesota was spending her
valued sleep contemplating what she would say to a jury.
Although I eventually realized I was being overdramatic
and unreasonable, I still couldn’t rest — mostly because 1
knew this wouldn’t be my last sleepless night. What
problems would some of my future patients have? Would
uncertainty and restless nights forever be part of my
work?

The phenomenon of disease brings disbelief and
horror to patient and physician. But where in medical

Minnesota Medicine

January 1992/Volume 75

PERSPECTIVES

school did my preceptors sit down with me and discuss
the sufFering, the loneliness, or my own inadec]uacy —
constant companions oF my chosen proFession? Chemo-
therapy, surgery, and large metropolitan hospitals can’t
Fix everything. My RPAP physician-teachers, Drs. Michael
Morris, Lyle Munneke, and Kevin Switzer, answered my
questions. They added to my armamentarium, which
now includes more than just procedures and therapeu-
tics. I Found Family care at its Finest. 1 also allowed myselF
to conFront my own Fear oF death, something that had
been so easy to ignore.

No, I wasn’t “pimped” as much as some oF my
colleagues, and no, I never got to those noon conFerences
on Sezary’s syndrome or the diFFerent types oF human
papilloma virus. Yet, 1 learned about these things be-
cause I had time and easy access to journal articles and
textbooks. I wasn’t always struggling over progress
notes or that damn potassium, or waiting my turn to
sneak a peek at the operating Field. The Rural Physician
Associate Program allowed me to learn real medicine
and real liFe. I couldn’t ask For more. MM

Beth Olsen is a fourth-year medical student at the
University of Minnesota and is from western Nebraska,
where, she tells us, her parents (her biggest supporters)
still reside.

Minnesota Medicine

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January 1992/Volume 75

Minnesota Medicine

Join Dr. Hanley

Join The AMA.

“I think one of the greatest contributions
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“The AMA adolescent health program is
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COVER STORY

Than

UAL

Treatment

Women Battle Sex Bias
in the Health Care Arena

Beryl By man

Chris Norton wasn’t worried
about breast cancer. The
45-year-old English teacher from
Cottage Grove, Minnesota, had no
family history of the disease and she
never skipped her regular mammo-
gram, so she was surprised a year
ago when she felt a lump in her
breast. Norton immediately had an-
other mammogram, but the test

failed to diagnose the lump as can-
cer. Her shock quickly turned to
anger when, six months after her
discovery of the lump, a biopsy re-
vealed that it was malignant and she
underwent a mastectomy. Today,
Norton has turned anger into action
by organizing the Minnesota Breast
Cancer Coalition’s letter-writing
campaign.

COVER STORY

Minnesota physi-
cians may find
that more of
their patients are becom-
ing politically active in
women’s health issues. The
goal of Chris Norton’s
letter-writing campaign,

“ Do the Write Thing,” was
to deliver 175,000 signa-
tures to Washington, D.C.,
requesting more research
on breast cancer. The

175,000 signatures repre-
sent the number of new
breast cancer cases antici-
pated for 1991. Although
Minnesota’s goal was

3,000 letters, 9,000 letters
were written. Nationwide,

600,000 were sent.

Kim Sundet attributes
this increased activism to
the fact that women with
breast cancer are now di-
agnosed earlier, at a younger age. Sundet is a program
manager for ENCOREA17omen’s Health Promotion,
which is part of the Minneapolis YWCA. The organiza-
tion serves primarily as a support group for breast cancer
patients. Women who grew up during the political
activism of the ’70s are likely to continue their campaign
ofactivism,but in other directions, says Sundet. “Younger
women are more likely to demand attention to these
issues. They want to see their children grow up.”

Physicians are also gathering political forces to bring
women’s health issues to the forefront. On a national
level, Nancy Dickey, M.D., trustee of the American
Medical Association, speaks across the country about
the need to allocate more money for research on wom-
en’s diseases.

Political activism is not limited to breast cancer.
Heart disease, osteoporosis, and Alzheimer’s, as well as
breast cancer, were all discussed at an April 19, 1991,
hearing of the Senate Subcommittee on Women and
Aging convened by Sen. Brock Adams, D-Wash. Speak-
ers testified that women across the country are disadvan-
taged in medical research, diagnosis, and treatment.

Research: Women Are Not
Equally Represented

The disparities begin with research, reported Dickey at
an October 25, 1991, conference on medicine, law, and
ethics at St. Olaf College in Northfield, Minnesota,
where she spoke of women’s historic underrepresenta-
tion in research trials.

Consider the U.S. Physicians Study. This pioneering
study of 22,000 male physicians showed that aspirin
reduces heart attack risk in men by 44 percent. Thus far,
she said, there has not been a comparable definitive study
that measures whether the prophylactic use of aspirin

also reduces the risk of
heart attack in women.
Correctly or incorrectly,
the Physicians Health
Study results are extrap-
olated to women.

Researchers often ex-
clude women from study
protocols because of
concern over medical
and legal risks. Should a
woman of childbearing
age become pregnant
while on an experimental
drug, the fetus might be
adversely affected. Scien-
tists also worry that
confounding, cyclic hor-
monal factors would not
permit a reliably con-
trolled study, so they sim-
ply leave women out.
Dickey argued that it is
precisely because of the
need to measure hormon-
al variables that women must be included in such studies.
As another example of unequal treatment, she cited an
antidepressant drug study conducted only on men, even
though women experience higher rates of clinical depres-
sion.

Einally, Dickey said, women have not received their
fair share of research dollars. Breast cancer, which
strikes 1 1 percent of El.S. women, is phenomenally
underfunded, she said. That wouldn’t be the case if the
tables were turned and the disease affected men; instead,
there would be an unending flow of research dollars,
testified one speaker at the Senate subcommittee hearing
chaired by Sen. Adams.

Treatment Inequities: The
Yentl Syndrome Exists in Medicine

Bernadine Healy, M.D., director of the National Insti-
tutes of Health, called such gender disparities the “Yentl
syndrome” in the June 25, 1991, New England Journal
of Medicine, borrowing the phrase from Isaac Bashevis
Singer’s story about a woman who pretends to be a man
in order to achieve equality. In the doctor’s office, the
Yentl syndrome means that women’s complaints are not
taken as seriously as men’s, even when their medical
symptoms are similar.

At first glance, it appears that because women under-
go more examinations and receive more tests and pre-
scriptions than men, they use more than their fair share
of medical resources, reports the AMA Council on
Ethical and Judicial Affairs in the July 24, \99\, Journal
of the American Medical Association. But women have
less access to high-tech medicine, as indicated by the
smaller percentage of women receiving kidney trans-
plants. Women with end-stage renal disease are far less
likely than men to receive a kidney transplant. In the

ll.l.USTRATIONS BY LIN'D A FRICHTLI

Minnesota Medicine

January 1992/Volume 75

COVER

STORY

group aged 46 to 60, women are half as likely as men to
receive a transplant.

The Ai\IA authors speculate that medical disparities
result from society's stereotype that men’s social worth
is greater than women’s. Doctors may assume that in
contrast to a woman, a working man — the breadwinner
— would be greatly inconvenienced by the cumbersome
process of dialysis and would benefit more from a kidney
transplant because it would allow him to return to work
quickly.

Heart disease: women receive unequal care
This “breadwinner” psychology may also account for
the gender differences in treatment of cardiovascular
disease, reported two articles in the July 25, 1991, New
England Journal of Medicine. These studies, which in-
volved thousands of patients, showed that women are
half as likely as men to undergo cardiac catheterization
and far less likely than men to undergo bypass surgery or
balloon angioplasty to unclog blocked arteries.

The treatment differ-
ences were evident despite
the fact that many of
the women patients had
more advanced heart
disease than the men.

“These findings demon-
strated that women who
are hospitalized for coro-
nary heart disease under-
go fewer major diagnostic
and therapeutic proce-
dures than men,” wrote
John Ayanian, M.D., and
Arnold Epstein, M.D., of
Harvard Medical School,
authors of one of the
studies.

Shortly following these
disclosures, the Novem-
ber 13, 1991, New York
Times revealed yet anoth-
er gender gap. A study
reported at a November
12 meeting of the Ameri-
can Heart Association
showed that out of 5,000 men and women treated for
heart attacks, men were twice as likely as women to
receive newer, life-saving treatments such as streptoki-
nase and tissue plasminogen activator. These reports
confirmed what many women have long suspected:
women are less likely than men to get equal consider-
ation of their health needs.

The breadwinner psychology has a historical and
medical basis. Thirty years ago, if a man in his late 30s
or early 40s died of heart disease, people assumed he left
a wife and children behind, says Mayo Clinic cardiolo-
gist Thomas Kottke, M.D. Clinical studies confirmed
that men were dying of heart disease at a much younger
age than women. For example, a 1950 to 1982 Mayo

Clinic study on heart disease rates for men and women
indicated that age-adjusted heart disease rates were
about twice as high for men as for women. If a doctor sees
both a 50-year-old man and a 50-year-old woman with
chest pain, the woman is half as likely to have heart
disease, says Kottke, adding, “The doctor is trained not
to chase after rare diseases.”

Younger women do have an advantage over men in
cardiovascular disease, but women’s disease risk begins
to rise after menopause, when estrogen levels fall. After
menopause, women’s risk of heart disease approaches
that of men. Still, it is viewed as a “man’s disease,” even
though it is the leading cause of death in women. Of the
more than 520,000 people who die from heart attacks
each year, approximately 247,000 are women.

Now demographics are shifting. Researchers are
facing an aging population. Women are living longer,
and age is a key risk factor for women. One in nine
women aged 45 to 64 has cardiovascular disease, but the
ratio narrows to one in three after age 65. In Rochester,

says Kottke, “four out of
five 80-year-olds are
women, and people in
their 80s die.”

The increased num-
bers of older American
women may invite anoth-
er subtle form of gen-
der discrimination, says
Nancy Jecker, Ph.D., in a
December 4, 1991,/AMA
article. The aging of
America, together with
the drive to control health
care costs, is pushing age-
based rationing, Jecker
argues. On the face of it,
these measures are not
expressly designed to dis-
criminate against women,
but given the larger num-
ber of women than men
over the age of 80, they
may indirectly affect
women more than men.
In the doctor’s office,
says Valerie Ulstad, M.D., a University of Minnesota
cardiologist, women who complain of chest pains are
evaluated differently than men. Physicians often under-
estimate the severity of heart disease in women, attribut-
ing chest pain to anxiety or boredom. Men with chest
pain are immediately assumed to have heart disease. This
sentiment, said the AMA’s Dickey, is consistent with
what was once taught in medical schools — that women’s
health care overwhelmingly involves issues of emotion
and overanxiety as opposed to physiology.

One problem, says Ulstad, is that without detailed
studies, no one knows for certain what the best medical
approach is for women with suspected or confirmed
heart disease. She pointed out a number of differences in

January 1992/Volume 75

Minnesota Medicine

COVER STORY

both test results and therapies for men
and women:

•Treadmill tests give different
j results in women. In the standard
treadmill tests, women have more false
positives.

• Thrombolytic therapy has been
worked out for men but not for wom-
en. Data from men have simply been
extrapolated for women’s smaller

; body size.

• For reasons unknown, coronary
! bypass surgery is associated with a
il higher mortality rate for women than

for men. Does the higher rate suggest
that this procedure is less effective
1 for women? Is it that women are
older and consequently have more
' advanced disease at the time of sur-
gery? Is it because women’s arteries
i are smaller, thus making surgery more
difficult?

f What we do know is that cardio-
1 vascular disease is the leading killer of
; both men and women older than 60.

' “The problem is to convince both

j the lay and medical sectors that coro-
' nary artery disease is also a woman’s
, disease, not a man’s disease in dis-

! guise,” said Healy.

' Breast cancer: women are
t confused

' Naturally, breast cancer is not viewed as a man’s disease
j in disguise. Breast cancer primarily affects women — and
in increasing numbers. The incidence rate reported by
i the National Cancer Institute increased by an average of
: 5 percent per year from 1984 to 1987.

I As with cardiovascular disease, demographic shifts

contribute to rising breast cancer rates, and two radical
; changes have increased women’s risk. One is delayed
childbearing, which increased significantly over the last
decade. Childbirth after age 30 approximately doubles a
i woman’s breast cancer risk over that of women who
have children when they are younger than 20, explains
James Ingle, M.D., an oncology consultant at Mayo
I Clinic. Another is our aging society. The longer women
' live, the greater their chance of acquiring breast cancer.
In 1 900, there were 4,890,000 women over the age of 50;
in 1990, there were 35,677,000.

Researchers and activists call attention to alarming
statistics:

• In 1 99 1 , there will be 1 75,000 new cases of breast
cancer in the United States, according to the American
Cancer Society.

• One in every nine women will develop breast
cancer during her lifetime, and one of every 13 women
will die of the disease. (Minnesota cancer rates reflect the
national average.)

Ironically, the growing numbers — 1.6 million new

cases of breast cancer predicted by the end of the de-
cade— are due, in part, to breast screening programs and
educational efforts of the American Cancer Society and
other organizations, says Ingle. Mammography screen-
ing is on the rise. A National Cancer Institute study
shows that in 1990, at least 64 percent of women had one
mammogram, up from 37 percent in 1987.

But despite the success of mammography screening
in detecting breast cancer early, the procedure is not
without problems, as Chris Norton discovered. Substan-
dard equipment, untrained technicians, and inexperi-
enced radiologists result in a 3 1 percent failure to image
the breast properly, according to findings presented at a
February 1991 hearing of the Senate Subcommittee on
Women and Aging called, “Improving the Quality of
Mammography: How Current Practice Fails.” During
the hearing. Sen. Adams expressed concern that the
potential profits from the millions of mammograms
covered by private insurance and Medicare will bring a
proliferation of low-cost, low-quality machines. Making
matters worse, there are no federal standards to guaran-
tee that mammography is safe and accurate. Although
the American College of Radiology established quality
standards for accreditation in 1987, today — four years
after the start of the program — only one in four facilities
is accredited. In 1991, only nine states passed legislation
to assure quality. Minnesota was not among them.

Again, there’s the problem of research. A lack of

Minnesota Medicine

January 1992/Volume 75

COVER

STORY

conclusive studies on heart disease and breast cancer
results in conflicting medical information that often pits
prevention of cardiovascular disease against breast
cancer prevention. Take, for example, the findings re-
ported in an April i7, i991. Wall Street Journal article
citing a Centers for Disease Control report that links
estrogen with breast cancer: “Women who took estrogen
for 15 years were 30 percent more likely to develop
breast cancer,” the article states.

Clearly, this information would discourage women
from taking estrogen; yet, hormone-replacement thera-
py is commonly prescribed to prevent osteoporosis,
heart disease, and other postmenopausal problems. Are
women being forced to cboose between preventive med-
icine for one disease at the risk of developing another?
Because of the paucity of research, no one appears to
know, and women are confused.

“Women are afraid of dying of breast cancer, but
they really should fear coronary artery disease,” says the
university’s Ulstad. In 1991 an estimated 44,500 women
were expected to die of breast cancer and 500,000 of
heart disease.

AIDS: women’s rislz grows

If women are now most concerned about cardiovascular
disease and breast cancer, they may soon shift their
attention to AIDS. In their race toward equality with
men, women are, unfortunately, reaching equal status in
HIV infection.

The number of women with
AIDS in 1990 increased 29 percent
from the previous year, said Surgeon
General Antonia Novello, M.D., in a
report to the American Public Health
Association. By the year 2000, she
said, the worldwide number of
women with AIDS will equal that of
men. The October 23, 199 [, Journal
of the American Medical Association
reports that an estimated 3 million
women worldwide will die of AIDS
in the 1 990s. Among women of color
in New York and New Jersey, AIDS is
already the leading cause of death.

In Minnesota, the number of women
with AIDS is still small-40 as of De-
cember 1, 1991. But a spokesperson
for the Minnesota AIDS Project said
that, like the national figures,
the number of HIV-infected women
is likely to grow, particularly among women of color.

Recognition of the risk AIDS poses to women has
been slow, and more work must be done on the manifes-
tation of HIV in women, according to an October 23,
1991, JAMA article. “Because of our failure to focus on
women earlier in the course of the epidemic, there are
significant gaps in our knowledge about HIV disease in
women,” wrote M. Roy Schwarz, M.D., in a letter to
CDC Director William Roper, M.D. Schwarz, AMA
senior vice president of medical education and science.

praised CDC’s call for further research on HIV in women
in the April 1991 issue of the CDC’s HIV/AIDS preven-
tion newsletter, adding that the AMA would “happily
support this progress in whatever way possible.”

Political Activism in the ’90s

In an effort to garner more government research funds,
women throughout the country are looking to AIDS
activists as political role models. “Women are angry,”
says encore’s Sundet. “Over and over again, I hear
how the health care system is not meeting tbeir needs.”
But will Minnesota women follow the AIDS activists and
chain themselves to fences as ACT-UP (AIDS Coalition
to Unleash Power) members have done in California?
No, predicts Shirley Williams, a clinical nurse specialist
at St. Paul-Ramsey Medical Center. “Scandinavian
women are more polite. In Minnesota, the approach to
breast cancer is more traditional — self-examination,
mammography, and regular visits to a physician.”

Nonetheless, Minnesota physicians can expect to see
more political activism. ENCORE and the newly orga-
nized Minnesota Breast Cancer Coalition are planning a
conference to be held October 16, 1992, at Minneapolis
Community College. Kim Sundet said the conference
will bring together policymakers, health care providers,
and women who have had cancer to consider how to
make the system work better. These groups are also
considering printing and distributing posters that talk
about stopping the “epidemic” of
breast cancer, investigating specific
research projects and supporting those
they believe look promising, and per-
haps conducting more fund-raising
for breast cancer research.

Meanwhile, Norton plans to con-
tinue her political activity, as well.
Having had breast cancer herself, she
is worried that her daughter has a
higher risk of contracting the disease.
One of Norton’s goals is to plan a
Minnesota rally to promote aware-
ness of breast cancer and to encour-
age politicians to allocate additional
research dollars for the disease. Breast
cancer activists point out that since
1980, breast cancer has taken four
times as many lives as AIDS; yet, the
National Cancer Institute estimates
that in 1 99 1 , $90.2 million was spent
on breast cancer research compared
with $160 million for AIDS.

Political activism in health care is not new. Although
political pressure focuses needed attention on medical
inequities, it can also lead to polarization of scarce
medical dollars, said Dickey at the St. Olaf conference.
While she supports women’s health initiatives, she said
distributing research dollars equitably is a problem.

“Money is directed to people who have used the
political process and brought their issue to the attention
of politicians and the public. It means that if you create

“Money is directed to
people who have
brought their issue to
the attention of
politicians and the
public. If you create
enough noise, your
disease may get
funding.”

-Nancy Dickey, M.D.

January 1992/Volume 75

Minnesota Medicine

COVER

STORY

enough noise, your disease may get funding,” she ex-
plained. “There may be equally large numbers of people
who don’t have a voice, who do not have as ‘sexy’ a
disease, and they remain unfunded.”

New Research Initiatives

Nationally, political pressure has begun to pay off for
women. In September 1992, 140,000 women will take
part in a $500 million NIH study of cancer, cardiovascu-
lar disease, and osteoporosis — common disorders in
older women. About 50 centers will be chosen for the
study’s first phase, which will follow postmenopausal
women for nine years. The second phase will examine
community-based health promotion programs in 40
communities. The goals are twofold: to evaluate the
effectiveness of unproven approaches such as hormone-
replacement therapy and low-fat diets to reduce the risk
of heart disease and cancer, and to find out why women
do not always take steps to live healthy lifestyles, even
when the information they need is available.

Other studies on the table address the gender gap.
Anticipating the need for more information about HIV-
infected women, the Centers for Disease Control recent-
ly called for expanded HIV research projects that focus
on women. One proposed CDC project will examine
how the human immunodeficiency virus in women dif-
fers from HIV in men and how social factors, such as
family structure, access to health care, and cultural
values, affect women already infected with the virus.

Closer to home, James Ingle reports that the Mayo
Clinic has begun a randomized study on the effectiveness
of autologous bone marrow transplantation in breast
cancer patients, an experimental procedure that costs
$150,000. Even though there has been considerable
publicity on bone marrow transplantation, the proce-
dure is still investigational, and patients must be aware
that its value is as yet undetermined, he cautioned.

The Physician’s Role in
Bridging the Gender Gap

These studies will have enormous importance for the
future of women’s health. The results of the new NIH
initiative will enable physicians to improve women’s
health dramatically in the next century, says William
Harlan, M.D., director of the study.

Meanwhile, until the research results are in, physi-
cians themselves can begin to narrow the medical gender
gap. First, the AMA recommends, physicians should
examine their own attitudes about gender bias and dis-
card any assumptions they might have about the relative
social value of women vs. men. The AMA also suggests
that physicians take steps to support women in leader-
ship roles in teaching, research, and medical practice.

With gender issues on the political forefront,
Healy says she hopes that “Yentl will survive, but her
syndrome will slip back into history as a curiosity of
times gone by.” MM

Beryl Byman is a free-lance writer and independent radio
producer living in Rochester, Minnesota.

STRONG

CHILDREN

FOR A

STRONG

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national choices,
community strategies

CHILDREN'S DEFENSE FUND

ANNUAL NATIONAL CONFERENCE

AAARCH 5-7, 1 992
ATLANTA AAARRIOH MARQUIS

ATLANTA, GEORGIA

The Children's Defense Fund's 1992 conference will be
an opportunity to share strategies, build on successes,
fortify skills, and learn more about communications,
fund raising, coalition-building, management, and
program implementation. For more information, write:
CDF Conference, 122 C Street, N.W., Washington, D C.
20001, (202) 628-8787.

Film: Prescribing
Controlled Substances

A new film on the prescribing of con-
trolled substances has been made avail-
able by the Minnesota Medical Associa-
tion. This videotape, which was the sub-
ject of a recent seminar series, examines
the appropriate use of benzodiazepines
and narcotic pain medications and em-
phasizes the elements of a proper medical
record. The film has been reviewed and is
acceptable for one hour of prescribed credit
by the American Academy of Family Phy-
sicians. For further information or to or-
der the film, please call Vicki Westling at
the MMA, 612/378-1875 or 800/999-
1 875. A $10 fee is charged per showing to
cover shipping and handling expenses.

Minnesota Medicine

January 1992/Volume 75

This 1$ A H^y Retiiement

It’s the peace of mind you get knowing you have saved for the future. It’s a U.S.
Savings Bond. With just a little from each paycheck, you can invest in Bonds through
the Payroll Savings Plan where you work. And they will keep earning interest for up to
30 years. Make an investment in your future with U.S. Savings Bonds today. Ask your
employer for details.

U.S. Savings Bonds

A public service of this publication.

SPECIAL REPORT

MMA Grapples with Health Care Reform

Minnesota Medical Association Legislative Staff

The growing number of uninsured in the United
States is a severe problem. Even though Minneso-
ta has a relatively small number of uninsured
citizens compared with the rest of the nation, the Minne-
sota Health Care Access Commission found that 370,000
Minnesotans go without insurance all or part of any
year. That means 8.6 percent of the state’s population
goes without access to needed health
care.

The Minnesota Medical Associa-
tion has worked closely with policy-
makers over the past two years to
formulate a program that would pro-
vide good, accessible care to all Min-
nesotans. Many MMA members have
devoted tremendous amounts of time
to the development of a program that
would offer all Minnesotans access to
health care that is compatible with
our current health care delivery sys-
tem. In 1990, the Minnesota Medical
Association House of Delegates is-
sued a resolution stating that access to basic health care
is a right of all Minnesotans.

In November 1991, the MMA Board of Trustees
adopted the “MMA Principles for Health Care Reform.”
This paper outlines the eight principles, which call for
necessary reforms in health care delivery, insurance
underwriting, public health education, rural health, and
state financing. It is the intent of the MMA that these
principles guide the development of comprehensive
health care access legislation in Minnesota.

History of the Problem in Minnesota

The problem of Minnesota’s uninsured emerged as a
predominant legislative issue after the Minnesota Health
Care Access Commission published its report in January
1991. The commission found that 370,000 Minnesotans
were without health insurance and that another 366,000
had purchased coverage with high deductibles and co-
pays that proved to be a barrier to receiving care.

The commission also found that of the 370,000
individuals without coverage, 28 percent delayed seek-
ing care even though they thought it was needed. For
those who delayed care, 70 percent said it was for a “very
serious or somewhat serious” problem, and 84 percent
said the delay was due to cost.

As a result of the Health Care Access Commission’s
report, Rep. Paul Ogren, DFL-Aitkin, and Sen. Finda

Berglin, DFF-Minneapolis, introduced House File 2/
Senate File 2 in 1991. This was referred to as the Health
Care Access bill.

This legislation proposed the Minnesotans’ Health
Plan, a state program that would have provided subsi-
dized coverage for individuals earning below 275 per-
cent of the federal poverty level. (At that time, 275
percent equaled $34,947 for a family
of four.) In addition, the bill called for
greater use of outcomes data to devel-
op practice parameters, changes in
other state health care programs, use
of managed care throughout the state,
creation of a state office of rural health,
and drastic reforms in private insur-
ance underwriting.

The Minnesota Medical Associa-
tion worked very closely with legisla-
tive leaders to ensure that the final
solution would truly provide access.
The legislation was passed at the end
of the 1991 Fegislative Session, only
to be vetoed by Gov. Arne Carlson because of concern
that the funding source was not adequate for future
growth and that the bill provided a false hope of “univer-
sal” coverage.

The 1992 Legislative Session begins January 6, 1992,
and health care access will again be a prominent issue.
There may be attempts to override the governor’s veto of
House File 2, and numerous other proposals are on the
table. The governor, the HMO Council of Minnesota,
and the Insurance Federation of Minnesota have each
proposed plans for health care access reform. Each
proposal addresses the problem somewhat differently by
putting varying emphasis on the public and private
sectors.

The MMAs Principles of Health Care Reform

The Minnesota Medical Association’s Legislative Com-
mittee, Executive Committee, and Board of Trustees
reviewed all these proposals in detail. The MMA sought
additional input through outreach meetings with county
medical societies throughout the state. The clear message
was that the MMA must be actively involved in finding
a legislative solution.

In response, the Board of Trustees adopted the MMA
Principles for Health Care Reform, which the organiza-
tion intends to use in its lobbying efforts to promote
health care access for all Minnesotans. The MMA be-

“As patient advocates,
physicians must be
committed to ensuring
that all citizens have
access to basic
health care.”

Minnesota Medicine

January 1992/Volunne 75

SPECIAL REPORT

lieves these principles should be included in any health
care access proposal. The principles stress universal
access; obligations for the individual, the state, and the
employer; cost containment; improved quality; mean-
ingful insurance reforms; and an equitable, broad-based,
dedicated funding source.

These principles, which follow, will require change
in today’s health care system. This may be hard for some
people to accept; however, as advocates, physicians must
be committed to ensuring that all citizens have access to
basic health care.

Al l, Minnesotans are entitled to a basic

LEVEL OE HEALTH CARE.

• The MMA’s Medical Benefits Task Force Report
(adopted February 1991) should be used as a model for
all health plans in both small and large markets.

• All health plans must emphasize preventive and
primary services as an integral part of a total health care
package.

Individuals, employers, and government all

HAVE AN OBLIGATION TO ENSURE ADEQUATE
COVERAGE FOR ALL CITIZENS.

• Every citizen must be required to have coverage for
basic health care.

• Appropriate mechanisms, such as copays, deduct-
ibles, and prior authorization, must be implemented to
encourage patient responsibility and proper utilization
of health care services.

• The state has an obligation to provide assistance on
a sliding scale to low-income individuals who cannot
afford coverage for basic health care.

• The state should provide tax incentives similar to
those available to employers (e.g., deductions or credits)
to individuals purchasing basic health care coverage.

• Employers should be encouraged through the use
of additional incentives to offer basic health care cover-
age to employees and their dependents.

• The problem of the uninsured must be addressed
through a societal solution.

Reforms must be implemented to improve the

EFFECTIVENESS AND QUALITY OF CARE.

• Physicians and health researchers must continue to
develop, analyze, and appropriately apply practice pa-
rameters and outcome data to enhance the quality of
health care in Minnesota.

• To truly enhance quality, all data initiatives must
be based on scientifically valid research and analysis, and
the data collected must be considered private for individ-
ual patients and physicians.

• Professional medical organizations have important
roles in coordinating and disseminating appropriate
practice parameters as they are developed. The interests
of the state and other public and private organizations
must be balanced with the MMA’s pivotal role in this
endeavor.

• Peer review is an essential way to enhance the
effectiveness of educational efforts and modify medical

practice. The MMA is committed to providing peer
review services for physicians to improve practice meth-
ods and outcomes.

Insurance must be portable for individuals

CHANGING JOBS OR MOVING TO OTHER PARTS
OF THE STATE.

• Flealth plans should establish premium rates for
individuals and small groups on a carrier-specific, state-
wide, community-rated basis. This allows risk to be
spread among all insured individuals.

• Health plans must be prohibited from using pre-
existing condition clauses or denying coverage based on
health status. This is often the major barrier to portabil-
ity and continuity in health care coverage.

• Health plans must be allowed to share risk through
a reinsurance mechanism for those who were previously
considered uninsurable.

Cost containment must be achieved

WHILE MAINTAINING HIGH-QUALITY DELIVERY.

• The health care system must reduce administrative
costs through a variety of mechanisms, including the
establishment of standardized claim forms, billing pro-
cedures, and utilization review criteria.

• The state must review the issues and costs related to
technology. Although increased technology has greatly
enhanced medical care throughout the state, the remain-
ing areas of duplication and excessive use of technology
must be addressed. A Minnesota technology review
committee must be established to review all issues related
to the use of medical technology and make recommenda-
tions. This committee should be composed of physicians,
hospital representatives, medical device manufacturers,
purchasers, consumers, and ethicists.

• A system must be developed to facilitate cost-
effective and appropriate utilization of prescription drugs.

• Managed-care techniques will continue to be used
to achieve cost containment. These techniques are not
limited to HMOs; they also can be implemented by
individual clinics, by the state, through preferred-
provider networks, or through indemnity plans.

• A multi-payer system must be maintained to pre-
serve patient choice.

• The state must begin addressing the cost of health
care associated with our tort system and defensive med-
icine. Any study of tort reform in Minnesota should
include, but not be limited to:

1. Reasonable periodic payment awards,

2. Reasonable caps on non-economic damages,

3. Mandatory offsets for collateral sources of pay-
ment,

4. Payment of punitive damage awards to states for
the improvement of health care,

5. Reasonable limits on attorney contingency fees,
and

6. Expedited settlement provisions.

• The state must address issues related to the sharing
of services and the antitrust implications for health care
facilities.

January 1992/Volume 75

Minnesota Medicine

SPECIAL REPORT

\ Geographic access must be assured

THROUGHOUT MINNESOTA.

• The establishment of an office of rural health

I within the Department of Health is essential to coordi-
! nating programs aimed at improving access, quality, and
affordability of health care in rural Minnesota. This
office should work in conjunction with the state’s med-

Iical schools, nursing schools, the Minnesota Center for
Rural Health, and other associations concerned with
rural health issues.

)• The state must develop programs to assist commu-
nities in need with the recruitment and retention of
health professionals.

• The stare must provide assistance to communities
I for local planning to assure continued geographic access.

* Public education and health promotion

EFFORTS MUST BE EXPANDED.

I* Additional funding should be given to the Depart-
ment of Health to increase efforts in its health promotion
and disease prevention division.

• We all must increase efforts to achieve a smoke-free
I society by the year 2000. A unified effort among the
medical profession, the school systems, the media, and
the Minnesota Department of Health is necessary to
. reduce the number of smokers.

I 'A massive educational campaign needs to be devel-

I oped within the state and implemented through physi-
cians’ offices, hospitals, public health nurses, and the
I school systems to educate people about the appropriate
use of the health care system and about available health
care resources.

• The MMA and other health care organizations
I must intensify public health education efforts to create
greater awareness and provide accurate information
about such issues as drunken driving and alcohol abuse,
sexually transmitted diseases, exercise, healthy diets,
and use of motorcycle and bicycle helmets.

An adequate, broad-based funding source
MUST be dedicated TO ENSURING
UNIVERSAL COVERAGE.

• Because the health care access problem demands a
societal solution, funding must come from a multitude of
sources. Funding should be raised from each of the
following sources:

1. Tobacco taxes should be greatly increased to
reflect more closely the true health costs attributed
to smoking.

2. Alcohol taxes should be increased to reflect more
closely the health costs related to chemical depen-
dency and alcohol-related injuries.

3. A payroll tax levied on all employers, with
increased tax credits for employers subsidizing
health coverage, should be promoted.

4. Income taxes should be used as a source of revenue
to fund health care access.

• It is essential that these taxes be dedicated to
assuring access to health care for all Minnesotans, mm

YOCON*

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine Is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its
action on peripheral blood vessels resembles that of reserpine. though it is
weaker and of short duration. Yohimbine's peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.

Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone.

Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.

Indications: Yocon^ is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac.

Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications.

Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history. Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug,T2 Also dizziness,
headache, skin flushing reported when used orally. T3
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence, ’ '3,4 i tablet (5,4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to Vz tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks. 3
How Supplied: Oral tablets of Yocon* 1/12 gr. 5.4 mg in

AVAILABLE AT PHARMACIES NATIONWIDE

bottles of 100's NDC 53159-001-01 and 1000's NDC
53159-001-10.

References:

1. A. Morales et al.. New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed,, p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4,

1983.

4. A. Morales etal,, The Journal of Urology 128:

45-47, 1982.

VOCQN*

Rev. 1/85

PALISADES

PHARMACEUTICALS, INC.

219 County Road
Tenafly, New Jersey 07670

(201) 569-8502
1-800-237-9083

Minnesota Medicine

January 1992/Volume 73

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paper submitted to the European Society for Artificial
Organs Eighth Annual Meeting, Copenhagen, August, 1981.

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522-33.

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January 1992/Volume 75

Minnesota Medicine

CLINICAL & HEALTH AFFAIRS

Complications and Mortality of the In-Situ Saphenous
Vein Bypass for Lower Extremity Ischemia

David S . Beebe, M . D . , Kumar G . B e I a n i , M . B . B . S . , M . S ,

J i - Ch i a Lao, M . D . , P h . D . , and David Knighton, M . D .

ABSTRACT

We retrospectively reviewed tfie records of
88 patients who underwent a total of 95 in-
situ bypass operations. Seventy-eight
percent were diabetics, 56% hypertensives,
23% had a history of a myocardial
infarction, 1 8% a previous stroke or
transient ischemic attack, and 19% a renal
transplant. Eighty-eight percent had
general anesthesia. Eighty-four percent of
the operations extended distal to the
popliteal trifurcation, with an average
operating time of 5. 1 2± 1 .25 hours and
blood loss of 354±239 ml. The overall
mortality was 4.2%, with two deaths due to
wound sepsis and two deaths due to
congestive heart failure. The perioperative
myocardial infarction rate was 6.3%. The
average age of the patients who died was
significantly greater than the age of those
who survived (78.2± 1 7.7 years vs.
59.9±14.8 years, p<0.05). The Goldman
risk index was not helpful in predicting
cardiac complications. The results show that
patients undergoing in-situ bypass
operations are at high risk for
cardiovascular complications. Aggressive
perioperative evaluation and management
similar to that shown to reduce such
complications in abdominal aortic
aneurysm surgery should be helpful.

In-situ saphenous bypass for arte-
rial reconstruction of the lower
extremity is a common operation
in many medical centers. Because
this technique offers improved graft
patency, much smaller vessels in the
lower extremity may be bypassed
than was previously possible, thus
offering a limb-salvage operation to
diabetics and others with severe small-
artery disease who would otherwise
require amputation.'

The risk involved in major aortic
reconstructive surgery has tradition-
ally been high,- and extensive preop-
erative cardiovascular evaluation,’’'^
as well as intraoperative invasive
monitoring, is the norm of practice.*’
Surgeons have typically considered
infra-inguinal bypass a lower-risk
procedure because it is not intra-
abdominal and has no major blood
loss. However, since the advent of
the in-situ bypass, the preoperative
condition of patients presenting
for infra-inguinal bypass has become
much more severe. We undertook
this retrospective study to quantify
these patients’ preoperative condi-
tions, determine the type and
incidence of their perioperative com-
plications, and recommend appro-
priate anesthetic and perioperative
management.

Methods

We retrospectively reviewed the
charts and anesthetic records of 88
patients who in total received 95 in-
situ bypass operations between 1 985
and 1986. We noted preoperative
conditions and quantified periopera-
tive cardiac risk using the method of
Goldman and Associates, which cal-
culates a number based on preopera-
tive data correlated with the risk of
perioperati veca rdiovascular com pli-
cations.^ We then classified the pa-
tients according to four risk groups:

January 1992/Volume 75

class I, zero to five points, low risk;
class II, six to 12 points; class III, 13
to 25 points; and class IV, greater
than 25 points, high risk.

We noted indications for opera-
tion and the levels of distal anasto-
mosis, and we reviewed the anesthet-
ic techniques and monitoring. By
protocol, all patients undergoing
in-situ bypass were admitted imme-
diately following operation to the
surgical intensive care unit, where 1 2
lead electrocardiograms and three
sets of cardiac enzymes, each eight
hours apart, were obtained. If there
were indications of a new myocardi-
al infarction, a cardiology consult
was obtained. Renal failure was de-
fined as a rise in serum creatinine of
0.5 mg/dl per day. For suspected
strokes, a computerized tomography
scan was obtained.

We summarized the data as mean
±standard deviation (SD) or as a per-
centage, and used Student’s t-test or
chi-square analysis to determine sig-
nificance, which was defined as
p<0.05.

Results

Eighty-eight patients, 58 male and
30 female, had 95 in-situ bypasses.
The mean age was 60.8±15.0 years
(range, 28 to 91). Table 1 lists their
pre-existing diseases. The average
Goldman risk index was 4.74±6. 12,
(range, 0 to 26). Seventy-four per-
cent were Goldman class 1, 12.5%
wereclassll, 12.5%classIIl,and 1%
class IV.

Non-healing ulcers were the chief
indication for this operation (Table
2). Eighty-four percent of the grafts
extended distal to the popliteal tri-
furcation. Only seven (7.4%) opera-
tions were reoperations and one
(1.1%) was due to a failed angioplas-
ty. The operating time was 5. 1 2± 1 .25
hours, with an average blood loss of

Minnesota Medicine

CLINICAL & HEALTH AFFAIRS

Table 1

Preoperative conditions (cardiac)

Number Percent

History of Ml

Angina or CHF

Rhythm other than

1 1

12.5

sinus

Total cardiac conditions

Preoperative conditions (other)

Number Percent

Hypertension

Dialysis

Chronic renal insuff.*

Kidney transplant

Diabetes

Stroke/TIA

Smoking, 20 pack/yr

“■(Cr. > 3.0 mg/dl, includes dialysis)
MI = myocardial infarction
CHF = congestive heart failure
Cr = serum creatinine
TIA = transient ischemic attack

354±239 ml. Twenty-six patients
were transfused an average of
483±244 ml of packed red blood
cells.

Nine patients had spinal anesthe-
sia and two had epidural anesthesia.
However, four of the 1 1 patients
who had regional anesthesia for the
operation eventually required gener-
al anesthesia. The majority (88%)
had general anesthesia.

Forty-two percent of the patients
had pulmonary artery catheters
placed prior to administration of
anesthesia, 13% had pulmonary ar-
tery catheters placed after induction,
and 14% had only a central venous
catheter placed after induction. Sev-
enty-six percent of patients had an
arterial line placed before adminis-
tration of anesthesia. Twenty-two
percent had no invasive monitoring
for the procedure. Only 27% of the
patients who received regional anes-
thesia had a pulmonary artery cath-
eter placed. However, one was placed
emergently two hours into the proce-
dure to aid in hemodynamic manage-
ment.

The overall 30-day mortality for
this operation was 4.2% (Table 3).
Two patients died of complications
of wound sepsis one to two weeks
postoperatively, and two others died

Table 2

Indications for operations

Number

Percent

Gangrene

2.1

Rest pain

1 1

11.6

Severe claudication

9.5

Ulcers

70*

7.37

Unknown or others

3.1

'Tour patients had severe claudication as
well as ulcers.

from complications of congestive
heart failure. The mean age was sig-
nificantly higher for the patients who
died than for those who survived the
operation (78.2±17.7 years vs.
59.9±14.8 years, p<0.05). However,
both cardiac deaths occurred in only
Goldman class I and II patients.

The mean age of patients who
sustained major cardiac complica-
tions or mortality (Table 3) was higher
than those who did not (73.2±11.2
years vs. 60.0±1.46 years, p<0.05),
but the Goldman risk index was not
significantly different (5.7±5.1 vs.
4.6±6.2, p>0.05). Five patients who
sustained major cardiac complica-
tions were Goldman class I.

Six patients sustained enzyme-
proven perioperative myocardial in-
farctions for a rate of 6.3%. Only
one of the six patients had a previous
MI, although three had known cardi-
ac disease. Two of the six Mis were
transmural, and four were subendo-
cardial. One patient who sustained
an MI (subendocardial) died postop-
eratively of congestive heart failure.

The mean age of the patients who
had enzyme-proven perioperative
Mis was higher than the mean age
of those who did not infarct
(71 .5± 11.7 years vs. 60.3114. 7 years,
0.05<p<0. 10), but did not reach sta-
tistical significance. Again, the mean
Goldman risk index was not signifi-
cantly different between those who
infarcted and those who did not.

Other complications included flu-

id overload requiring diuresis (8.4%),
wound infection (2.1%), pulmonary
atelectasis (3.2%), cardiac arryth-
mias (2.1%), cerebral vascular acci-
dents (2.1%), and worsening renal
insufficiency (4.2%).

Patients with renal transplants
constituted a large (19%) and poten-
tially high-risk group of patients in
this study. All of these patients were
diabetic, with a younger average age
(44.519.9 years vs. 63.4115.3 years,
p<0.05) and lower mean Goldman
risk index (2.213.9 vs. 5.316.3,
p<0.05) than the other patients. One
subendocardial MI was the only
major morbidity in this group of
patients, and there were no deaths.

Discussion

The in-situ saphenous vein bypass is
a limb-salvage operation for patients
with small-artery atherosclerosis.
Almost 80% of the patients in this
series were diabetic, and 40% had
some previous cardiac disease. Sev-
enty percent of the operations were
for tissue loss, a much higher per-
centage than that reported for other
series of infra-inguinal bypasses. 'The
surgery resulted in minimal blood
loss but involved a long operating
time (5. 1211.25 hours; range, 4 to 6
hours), particularly compared with
series using synthetic grafts (approx-
imately 2.5 hours).** The mortality
for this procedure was 4.2%, compa-
rable to reported rates of 0% to 6%
in series of synthetic or reversed
saphenous vein reconstruction.

There was, however, a high rate
of cardiovascular complications,
particularly in the older age group.
Six patients (6.3%) developed a peri-
operative myocardial infarction. Two
cardiac deaths occurred, both associ-
ated with congestive heart failure.
The rate of myocardial infarctions or
life-threatening cardiac complications
was as high as reported for patients
undergoing abdominal aortic aneu-
rysm repair.- Similar to other studies
on cardiovascular morbidity and
mortality after vascular reconstruc-
tion, the Goldman risk index was
not helpful in predicting cardiac
complications.'^

Preoperative angiographic stud-
ies on patients undergoing vascular
reconstruction show a 30% incidence

January 1992/Volume 75

Minnesota Medicine

CLINICAL & HEALTH AFFAIRS

Table 3

Mortality and cardiovascular morbidity

Mortality

Age

Goldman index

Anesthesia

Monitoring

Time and cause
of death post-op

SAB

PA, art.

1 4 days sepsis,
renal failure

GEN

PA, art.

1 0 days, sepsis. Ml
after septic episode

GEN

CVP, art.

7 days, CHF

SAB/GEN

PA, art. placed

4 hours into case

7 days, CHF

Cardiovascular

morbidity

Age

Goldman index

Anesthesia

Monitoring

Type

GEN

Art.

Subendocardial Ml, CHF

GEN

PA, art.

Inferior Ml

GEN

PA, art.

Subendocardial Ml

GEN

PA, art.

Anterior Ml, CHF

GEN

None

Subendocardial Ml

SAB=spinal anesthetic; GEN=general anesthetic; SAB/GEN=spinal anesthetic followed by general anesthesia; PA=pulmonary
artery catheter; art.=arterial line; CVP=central venous catheter; CHF=congestive heart failure; MI=myocardial infarction.

of severe coronary artery disease,
with a higher incidence in diabetics
and in patients more than 70 years of
age."’ In addition, the small-artery
atherosclerotic disease of many pa-
tients presenting for in-situ bypass
operations may increase the incidence
of severe coronary disease. Many
patients may also have diabetic or
uremic cardiomyopathy impairing
cardiac performance"-'^ and increas-
ing the risk for congestive heart fail-
ure.

Reul et al. showed that signifi-
cant reduction in the risk of cardio-
vascular complications occurs in vas-
cular surgery patients who have had
a previous coronary bypass opera-
tion. "Other authors have described
preoperative screening for coronary
artery disease by coronary angiogra-
phy, graded exercise testing, and,
most recently, thalliumdipyridamole

scanning. '’•'‘•"’Coronary artery bypass
or angioplasty may be indicated in
patients demonstrating severe coro-
nary artery disease before undergo-
ing the in-situ bypass.

Yeager et al. report a reduction in
cardiovascular morbidity and mor-
tality when epidural anesthesia is used
primarily or as a component of anes-
thetic management.'"* However, the
length of surgery makes regional an-
esthesia alone impractical for many
patients. The use of anticoagulants
intraoperatively, which may increase
the risk of an epidural hematoma
from a spinal or epidural anesthetic,
may also favor the use of general
anesthesia.''’

More extensive hemodynamic
evaluation and monitoring may help
reduce the rate of cardiovascularcom-
plications. Rao et al. found that the
incidence of perioperative myocardi-

al infarction in patients with a previ-
ous myocardial infarction, a known
high-risk group, can be reduced by
1) monitoring perioperative pulmo-
nary artery pressures and cardiac
outputs, 2) attempting to maintain
pulse and arterial and pulmonary
arterial pressures within 20% of pre-
induction values intraoperatively, 3)
keeping the patient in intensive care
postoperatively for at least 24 hours.

Operative mortality has been re-
duced in aortic aneurysm surgery by
preoperative pulmonary artery cath-
eterization and determination of the
ventricular response to volume load-
ing.^ Determination of the optimum
central venous pressure, pulmonary
capillary wedge pressure, and pul-
monary artery pressures for cardiac
performance is made. Currently, a
similar treatment protocol (figure) is
being used with University of Minne-

Minnesota Medicine

January 1992/Volume 7 5

CLINICAL & HEALTH AFFAIRS

if PCWP<15

Volume Challenge 250cc colloid

Repeat Cl, CVP, PAP, PCWP

if PCWP>15

FIGURE - Current evaluation and treatment plan for patients undergoing in-
situ saphenous vein bypass operations at the University of Minnesota.

sota patients undergoing in-situ by-
pass surgery.

Summary

In summary, patients undergoing in-
situ saphenous vein bypass surgery
are at high risk for cardiovascular
complications due to their extensive
vascular disease. Older patients, in
particular, seem prone to mortality
and cardiovascular complications.
The results suggest that patients un-
dergoing an in-situ bypass should
receive the same thorough perioper-
ative evaluation and management as
patients undergoing abdominal an-
eurysm surgery, where aggressive
perioperative evaluation, monitoring,
and anesthetic management have sig-
nificantly reduced cardiovascular
morbidity and mortality.’-*’ MM

The authors are from the depart-
ments of anesthesiology and surgery
at the University of Minnesota, Min-
neapolis.

REFERENCES

1. Leather RP, Shah D,M, Karmody AM.
Infrapopliteal arterial bypass for limb
salvage: increased patency and utilization
of the saphenous vein used in situ. Surgery
1981;9():IO()()-8.

2. Diehl JT, Cali RF, Hertzer NR, Bevcn
EG. Complications of abdominal aortic-
reconstruction: an analysis of perioperative
risk factors in 5,57 patients. Ann Surg
1983;197:49-56.

3. Cutler BS, Leppo jA. Dipyridamole
thallium 20 1 scintigraphy to detect coronary
artery disease before abdominal aortic-
surgery. Vase Surg 1987;5:91-100.

4. McPhail M, Calvin JE, Shariatmadar A,
Barber GG, Scohie TK. The use of
preoperative exercise testing to predict
cardiac complications after arterial
reconstruction. Vase Surg 1988;7:60-8.

5. Whittemore AD, Clowes AW, Elechtman
HB, Mannick JA. Aortic aneurysm repair:
reduced operative mortality associated with
maintenance of optimum cardiac per-
formance. Surgery I 980; I 92:4 1 4-2 I .

6. Goldman E, Caldera DE, Nussbaum SR,
et al. Multifactorial index of cardiac risk in
noncardiac surgical procedures. N Engl |
Med 1987;297:845-50.

January 1992/Volume 75

7. Veith EJ, Guptka SK, Ascer E, et al. Six-
\ear perspective multicenter randomized
comparison of autologous saphenous vein
and expanded polytetrafluoroethylene grafts
in infrainguinal arterial reconstructions.
Vase Surg 1986;3:104-14.

8. Quinones-Baldrich WJ, Martin-Paredero
V, Baker JD, Busuttil RW, Machleder HI,
Moore WS. Polytetrafluoroethylene grafts
as the first choice substitute in
femoropopliteal revascularization. Arch
Surgl984;l 19:1238-43.

9. Calvin JE, Kieser TM, Walley VM,
McPhail NV, Barber GG, Scohie TK.
Cardiac mortality and morbidity after
vascular surgery. Can J Surg 1 986;29:93-7.

1 0. Hertzer NR, Beven EG, YoungJR, et al.
Coronary artery disease in peripheral
vascular patients: a classification of 1000
coronary angiograms and results of surgical
management. Ann Surg 1984;199:223-33.
1 1. Sanderson JE, Brown Dj, Rivellese A,
Kohner E. Diabetic cardiomyopathy.^ An
echocardiographic study of voung diabetics.
Br Med 1 1987;1:404-7.

12. Hung j, Harris PJ, Uren Rj, Tiller DJ,
Kelly DT. Uremic cardiomyopathy: effect
of hemodialysis on left ventricular function
in endstage renal failure. N Engl [ ,Med
1980;301:547-51.

1 3. Reul GJ, Cooley DA, Duncan JM, et al.
The effect of coronary bypass on the
outcome of peripheral vascular operations
m 1093 patients. Vase Surg 1986;3:788-98.

1 4. Yeager MP, Glass DD, Neff RD, Brinck-
Johnsen T. Epidural anesthesia and analgesia
in high-risk surgical patients. Anesthesiologv
1987;66:729-36.

15. Varkey GP, Brindle GF. Peridural
anaesthesia and anti-coagulant therapy. Can
Anaesth Soc J 1 974;2 1 : 1 06-9.

16. Rao TEK, Jacobs KH, El-Etr AA.
Reinfarction following anesthesia in patient
with myocardial infarction. Anesthesiology
1983;,59:499-505.

Minnesota Medicine

MEDICINE LAW & POLICY

Physician Malpractice and
Managed Care Plans

James B . Platt, J ■ D .

Health care costs in the United
States have increased at a
tremendous rate during the
past decade. In 1990, we spent more
than $600 billion on healthcare — an
estimated 12.2 percent of the gross
national product. To contain these
runaway costs, many traditional in-
demnity plans have been replaced by
HMOs, PPOs, and other managed
care health plans.

Managed care plans employ a
variety of methods to lower costs.
These methods include:

• Reviewing utilization in order to
approve treatment plans prospectively
(i.e., precertification requirements),
concurrently (i.e., the length of a hos-
pital stay), and retrospectively;

• Identifying quality and cost-
efficient providers and rewarding
providers who meet the prescribed
standards;

• Monitoring quality and effec-
tive treatment;

• Designing benefit plans that
reduce the costs of care; and

• Encouraging and educating
patients regarding the costs of care.

Many physicians believe that cost
containment can interfere with the
traditional physician-patient relation-
ship. Because cost-control efforts may
influence the medical care provided,
they raise the potential for liability
for the physician as well as the man-
aged care organization.

If, for example, payment is de-
nied for a course of treatment, may
the physician abandon that treat-
ment plan? If there is doubt that the
patient and/or the HMO will pay for
the treatment, is the physician still
obligated to provide it? If the man-
aged care plan denies payment, should
the physician further pursue the issue
on the patient’s behalf?

Many physicians are asking these
questions in Minnesota, where

Minnesota Medicine

managed care plans are becoming
increasingly common. At the Sep-
tember 1991 meeting of the Minne-
sota Medical Association’s House of
Delegates, physicians raised questions
about the liability of third-party pay-

“ Cost-control efforts
raise the potential for
liability for the
physician as well as
the managed care
organization.”

ers who restrict treatment choices.
The issue was referred to the MMA
Board of Trustees for further study
and review.

Traditional Theories of
PlTysician Malpractice

In order to understand the tension
between cost containment and the
physician’s duty to the patient, it is
important to review the traditional
theories of physician malpractice.

Physicians must discharge their
duties with reasonable care. To do
otherwise constitutes negligence.
“Reasonable care” requires that the
doctor use the degree of skill and
learning that is normally possessed
by other members of the profession
practicing in similarcommunitiesand
under similar circumstances. In most
states, the courts have applied this
standard in several ways:

• A doctor is generally not negli-
gent simply because his or her efforts
prove unsuccessful or because the
doctor chooses between accepted

January 1992/Valume 75

methods of treatment.

• If a doctor knows or should
know that his or her expertise is not
sufficient to treat the patient, the
doctor has a duty to refer the patient
to a specialist.

• A doctor may not discharge a
patient from the hospital if doing so
is not consistent with the exercise of
reasonable care.

A physician has a duty to inform
patients of treatment risks and ob-
tain consent before proceeding. The
Minnesota Supreme Court has held
that a doctor may be liable for “neg-
ligent nondisclosure risk attendant
to proposed or alternative methods
of treatment.” ' The physician should,
therefore, inform the patient of the
significant risks of any proposed treat-
ment or alternatives.

A physician may not abandon a
course of treatment once it has be-
gun. Courts have recognized that a
physician may not discontinue need-
ed emergency care on the grounds
that previous services have not been
paid for. The existence of financial
incentives to limit care or other cost-
control mechanisms have generally
not been recognized as a defense.

Managed Care Plan
Liability: Recent Cases

Perhaps the most important case to
date involving liability under a
managed care plan was a California
decision. Wickline v. Stater The cir-
cumstances were as follows: Lois
Wickline was hospitalized for major
surgery involving poor circulation in
her legs. She suffered complications
after surgery and required still more
surgery. Her treating physician filled
out a medical form with Medi-Cal,
California’s Medicaid program, re-
questing an eight-day extension to
her scheduled hospital discharge date.

MEDICINE LAW & POLICY

Aher talking to a Medi-Cal physi-
cian adviser, the Medi-Cal on-site
nurse reviewer approved an exten-
sion oLonly Lour days. Lois Wickline
was discharged after the four-day
extension hut had to he readmitted
nine days later with severe pain and
discoloration in her leg. Eventually,
her leg was amputated above the
knee. She brought suit against Medi-
Cal, alleging that the payer had been
negligent in failing to approve the
full eight-day extension. The court
eventually held that Medi-Cal could
not he held liable for negligence in
this case because the actual decision
was made by Lois Wickline’s physi-
cians, not the payer. Medi-Cal was
not a party to that medical decision
and could not, the court stated, be
held liable if the decision was negli-
gent.

This case is significant not only
for managed care plans, which, the
court said, could be held liable for
“defects” in their managed care mech-
anisms that result in the denial of
medically necessary services, but also
for physicians who abide by HMOs’
decisions. Specifically, the court not-
ed the following:

• The physician has a duty to
care for the patient whether or not
the course of treatment will be paid
for by the HMO. By refusing to find
liability for Medi-Cal’s review deci-
sion, the court implicitly criticized
the physicians for failing to challenge
Medi-Cal’s decision.

• The physician has a duty to
inform the patient when he or she
disagrees with the HMO’s decision
regarding coverage of a treatment
plan.

Although Lois Wickline chose not
to sue her physician and the hospital,
the court’s commentary regarding
the physician’s duty is one of the first
instances where a court indicated
how the traditional theories of liabil-
ity may apply to a physician treating
a patient under a managed care plan.

In the 1990 case of Wilson v.
Bine Cross of Southern California^
the managed care plan refused to pay
for Howard Wilson Jr.’s hospitaliza-
tion after the 10th day of inpatient
treatment. His treating physician had
recommended three to four weeks of
inpatient care for depression, drug

dependency, and anorexia. Follow-
ing his discharge, Howard Wilson jr.
committed suicide. His parents then
sued Blue Cross and the treating phy-
sician, alleging that the refusal to
authorize additional days was a sub-
stantial factor in his suicide.

In this case, the court held that
the managed care plan could be held
liable because the insurance contract
terms stated that inpatient benefits
would be covered, up to a maximum
of 30 days, as long as the treating
physician deemed the care necessary.
Therefore, the plaintiffs contended,
the insurer had no right under the
contract to submit the physician’s

“The best means for
physicians to
minimize liability is
to continue
practicing good
medicine.”

decision to an outside utilization re-
view company.

In Bnsh v. Dakef the plaintiff, an
HMO enrollee, alleged that her man-
aged care plan was negligent because
it provided financial incentives that
led to her injury. After several months
of treatment by her physician for
vaginal bleeding, the plaintiff was
referred to a specialist. The specialist
performed some tests and advised
the patient to return if the symptoms
persisted. The symptoms did persist,
but the primary care physician re-
fused to authorize a second referral
to the specialist. Neither physician
performed a pap smear. Three months
later, the plaintiff was hospitalized
with cervical cancer. She claimed in
her suit that only the primary care
physician could perform pap smears
under the HMO’s compensation sys-
tem, and he did not receive any extra
compensation for performing the
procedures. That compensation sys-
tem, she alleged, provided disincen-
tives for physicians to treat, refer,
and diagnose patients, which con-

January 1992/Volume 75

tributed to her improper care.

Although this case was dismissed
without a court opinion, it stands as
one of the first cases reported where
a patient took the position that fi-
nancial cost incentives can lead to
negligence.

Reducing Physician Liability
Under Managed Care Plans

Based on these cases, some general
guidelines may help physicians min-
imize their potential for liability when
treating patients covered through
managed care plans.

• Continue providing good med-
ical care. Undoubtedly, the best over-
all means for physicians to minimize
liability is to continue practicing good
medicine. Physicians should not per-
mit their treatment decisions to be
based on financial incentives.

• Fully explain risks and alterna-
tives. Physicians should explain fully
to patients the recommended course
of treatn'tent. If, for example, a pa-
tient’s managed care plan will not
pay for additional hospital days, and
the physician believes the early dis-
charge creates a risk, he or she should
explain that to the patient.

• Document recommendations
and decisions. Physicians should doc-
ument in a patient’s medical record
the course of treatment recommend-
ed and the patient’s decision.

• Go to bat for the patient. Phy-
sicians may need to act on behalf of
the patient by questioning the man-
aged care plan’s decisions. The Wick-
line decision suggests that if a treat-
ing physician disagrees with the treat-
ment plan, he or she should investi-
gate. Was the review decision made
by qualified medical professionals?
Was a denial for surgery or extended
hospitalization reviewed by a licensed
physician? Was a specialist involved?

• Act as the patient’s advocate.
Some commentators have suggested
that physicians may need to help
patients take advantage of any rights
of appeal to an HMO’s decision,
particularly in situations where the
patient may be physically or mental-
ly unable to do so or may not have the
necessary resources or information
to do so.

• Be aware of HMO contract lan-

Minnesota Medicine

MEDICINE LAW & POLICY

guage. Physicians should carehilly
review their agreements with HMOs
and PPOs for language that makes
the physicians solely responsible for
treatment decisions. Are the referral
limitations acceptable? Will the spe-

cialists provide good care to the pa-
tient? How is “medical necessity”
determined? Physicians should also
be cognizant of the liability sections
of the contract. Often, these sections
require the physician to reimburse

the plan for any losses it may incur in
a lawsuit, including its attorney fees,
that arise out of the physician’s
services. Since most malpractice
insurers will add a rider to cover
indemnification clauses in HMO con-
tracts, the practical course of action
is to provide a copy of the contract to
the insurer and ask that coverage be
put in place.

Although there have been few
reported cases so far, the pressure to
control health care costs is likely to
increase, generating more cases in
the future. Physicians should careful-
ly review the language in the HMO
contract before signing and should
be familiar with how the HMO con-
trols costs and referral practices, mm

James Platt is an officer and share-
holder of Fredrikson & Byron and a
member of its Compensation Plan-
ning and Health Law departments.

REFERENCES

1. Cornfeldt v. Tongen. 261 N.W.ld 684,
699 (Minn. 1977).

2. Wickline v. State, 1 92 Cal. App.3d 1630,
239 Cal. Rptr. 810, (1986), cert, granted.
717 P.2d 753, 231 Cal. Rptr. 560 (1986),
rev. dismissed and remanded, 741 P.2d
613, 239 Cal. Rptr. 805 (1987).

3. Wilson V. Blue Cross of Southern
California, 111 Cal. App.3d 660, 27 1 Cal.
Rptr. 876 (1990).

4. Bushv. Dake.No. 86-25767-NM (Mich.
Cir. Ct., Apr. 27, 1989).

There are no small victories
in the fight against heart
disease.

American Heart
Association

K. James Ehlen, M.D.
Chairman, CEO Medica

MANAGED CARE ENHANCES
PHYSICIAN MANAGEMENT OF CARE

Last month I talked about the importance of physician participation in the
public health care reform debate and how managed care frames an
appropriate response to that challenge.

Let me tell you how physicians who participate in Medica are responding
to critics in the public and private sectors who want evidence that patients
receive appropriate, quality care.

One response is our Medical Policy Council. The medical policies
established by the Council, and shared with all Medica physicians, provide
essential support for all our medical management programs. Policies
include:

• Practice guidelines

• Guidelines for the medical necessity of important procedures and
therapies

• Criteria for appropriate utilization management

• Evaluation of experimental/investigational status for procedures

The Council’s four advisory committees — family practice, internal
medicine, pediatrics and obstetrics/gynecology — offer broad review of
issues within those specialties. Its 26 specialty subcommittees also address
an array of complex issues requiring medical policy positions.

MEDiCA

Minnesota Medicine

January 1992/Volume 75

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We hope you'll encourage them to have a screening mammogram, because
that, along with your regular breast examinations and their monthly self
examinations, offers thebestchance of early detection of breast cancer,a disease
which will strike one woman in 10

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Tel. (612) 587-2020 Ext. 214

January 1992/Volume 75

Minnesota Medicine

ON THE BUSINESS SIDE

Flexible-Benefit Plans Offer Savings for
Employees, Employers

Hilary O'Donnell and Walter Jones

As health care costs continue to
skyrocket at an average pace
of nearly 20 percent a year, a
growing number of companies are
limiting medical benefits while in-
creasing the financial contributions
that employees must pay toward their
health care plans. Many companies
are now incorporating a flexible-
benefit plan, often called a “cafeteria
plan,” into their insurance programs
to help confront this fiscal dilemma.
These plans offer an opportunity for
both the employees and the employer
to achieve substantial tax savings.

Flexible-benefit plans are autho-
rized under Section 125 of the Inter-
nal Revenue code. Employees have
the option of directing a portion of
their gross salary dollars into a spe-
cial account and then withdrawing
those pretax dollars to pay for “qual-
ifying” expenses. (See table fora list.)
This accounting procedure reduces
the employee’s taxable income, re-
sulting in more take-home pay. For
the employer, the lower base payroll
results in a reduction in the matching
FICA taxes the company must pay.

Three types of flexible-benefit
accounts allow for pretax savings in
the make-up of a flexible-benefit plan.
The first is often referred to as a
premium conversion account. This
account gives the employee the op-
tion of paying qualified group health
premiums with pretax dollars. Qual-
ified insurance premiums include
premiums paid for health care;
dental, disability and accident, and
cancer insurance; and premiums for
group-term life insurance of up to
$50,000. For example, an employee
in a 51 percent tax bracket and
contributing $100 per month for
the basic health plan would save an
average of $372 annually if the
monthly premium was paid with pre-
tax dollars.

The second type of pretax sav-
ings account in a flexihle-benefit plan
allows employees to he reimbursed
for eligible medical expenses that are
not covered by insurance plans. This
type of account is referred to as a

“Flexible-benefit
plans offer an
opportunity for both
the employees and
the employer to
achieve substantial
tax savings.”

medical-expense spending account.
Eligible expenses range from vision
care to wheelchairs and include costs
associated with chiropractor visits,
prescription drugs, and mental health
treatments. These pretax dollars can
also be used for paying plan deduct-
ibles or copayments.

The last type of pretax savings
account in a flexible-benefit plan
allows employees to he reimbursed
for dependent adult and/or child
care expenses. This type of account
is commonly referred to as a
dependent-care spending account.
An eligible dependent is a child under
13 years old who qualifies as a
dependent for federal income tax
purposes. Elderly parents can also
qualify as eligible dependents if they
are incapable of caring for them-
selves and qualify as dependents for
tax purposes. Dependent-careclaims
cannot exceed the lesser of either
$5, ()()() for one or more children, the
employee’s total yearly salary, or the

yearly salary of the employee’s spouse.
With today’s working families, this
option is one avenue that parents can
take to counteract rising child-care
costs. Under mostcircLimstances, it is
more advantageous for the employee
to pay for dependent care with pre-
tax dollars than to take the credit
available on his or her individual tax
return.

It is important to note that the
Internal Revenue Service has enacted
a few rules with regard to the
flexible-benefit program that all par-
ticipants should understand. The first
rule is the “use it or lose it” provi-
sion; participants must forfeit what-
ever money is left in the account after
all eligible expenses have been reim-
bursed at the end of the plan year.
Therefore, it is very important to
calculate carefully the money going
into each flexihle-benefit account so
that the amount will equal the year’s
expenses. The second rule requires
the employer or association to be
liable for what the employee directs
to the medical-expense spending ac-
count. This means that the employer
or association must make available
to the employee, at any time during
the year, the full amount that the
employee has directed to an account
by the end of the year. Also, if an
employee leaves the company and
has been reimbursed more money
than is actually in the account, the
employer or association is responsi-
ble for the difference. The last rule is
that money allocated for one account
cannot be used for another account.
These rules have been enacted to
ensure appropriate use of the plan
and to establish consistency in the
flexible-benefit program among var-
ious employers.

I'o illustrate the tax savings pos-
sible in a flexible-benefit plan, let’s
identify how a typical family with

Minnesota Medicine

January 1992/Volume 7 5

ON THE BUSINESS SIDE

Table

Eligible Section 12S Spending

Account expenses
Acupuncture
Alcoholism treatment
Ambulance hire
Artificial limbs and teeth
Birth-control pills
Braces

Braille books and magazines

Car controls for children with handicaps

Child care

Chiropractors

Christian Science practitioner fees

Co-insurance

Contact lenses

Crutches

Day care for dependents necessary for
employment

Deductible medical coverage

Dentures

Dentists

Diagnostic fees

Drug and medical supplies

Drug addiction treatment

Electrolysis

Eyeglasses, including exam
Hair transplants
Healing services

Health insurance (including some
Medicare)

Hearing aids and batteries
Home improvements based on medical
necessity
Hospital bills
Hospitalization insurance
Hypnosis for treatment of an illness
Insulin
Lab fees

Laetrile by prescription
Life fee to retirement home for medical
care

Medical information plan
Membership fees in association furnish-
ing medical, hospitalization, and
clinical care

Nurses (including board and social
security taxes paid by patient)

Obstetric care
Orthopedic shoes
Oxygen

Physicals and other diagnostic care
Physicians
Practical nurses
Psychiatric care
Seeing-eye dog and its upkeep
Smoking-cessation program if prescribed
Special education for the blind and
physically or mentally disabled people
Sterilization

Surgery and related treatment
Telephone and television audio display
for the deaf

Transportation related to medical
treatment

Vitamins by prescription
Weight-loss program if prescribed for
patient
Wheelchair
Wigs
X-rays

young children might participate. The
Smith’s dual income places them in
the 3 1 percent tax bracket. For 1 992,
their children will attend a Kinder-
Care Learning Center for $4,000,
and the Smiths estimate they will pay
$1,000 in out-of-pocket medical ex-
penses, including plan deductibles.
Under the flexible-benefit plan of-
fered by Mrs. Smith’s employer, the
Smiths can use pretax dollars from
the medical-expense and dependent-
care spending accounts to pay for
these expenses. Because the $4,000
for dependent care and the $1,000
for medical expenses are not taxed,
the Smiths will save $1,500. In this
example, the company will also real-
ize a savings of approximately $382
due to the $5,000 reduction in the
base payroll amount for matching
FICA taxes.

A flexible-benefit plan will not
replace the benefits already existing
in a company’s insurance program,
but it will enhance the program with
the opportunity for growth and tax-
free savings. There are no restrictions

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on the number of participants need-
ed to establish a program. Many
smaller employers use third-party
administrators to run their programs.
In doing so, they reap the benefits of
a flexible-benefit program while
avoiding the paperwork.

The most important ingredient
to any successful flexible-benefit pro-
gram is participation. The more
persons enrolled in a plan, the less
cost and liability incurred by the em-
ployer or association. Testing is also
needed to ensure that highly com-
pensated employees don’t receive a
disproportionate share of the bene-
fits. To ensure that plans are not
discriminatory, rules exist regarding
the percent of benefits that can ac-
crue to the highly compensated.

Flexible-benefit plans offer a win-
ning solution to the employee benefit
dilemma; however, careful consider-
ation and proper communication are
crucial to their success. Employees
must fully understand and partici-
pate for everyone involved to realize
the potential tax savings. MM

Hilary O'Donnell is an account ex-
ecutive u’itb Seabury & Smith in
Washington, D.C., the MMA’s group
insurance administrator, specializing
in association insurance program
management.

Walter Jones is an account executive
with Seabury & Smith specializing in
Section 125 programs and supple-
mental employee benefits for associ-
ations and corporations.

On the Business Side

Minnesota Medicine invites you
to submit informational articles
on such topics as clinic manage-
ment, personal and practice-
oriented financial management,
computer applications, taxes, and
human resources laws. We prefer
practical articles that include in-
formation Minnesota physicians
can put to immediate use. Submit
“On the Business Side” articles to
George Lohmer, chief financial
officer, Minnesota Medical Asso-
ciation, 2221 University Avenue
SE, Suite 400, Minneapolis, MN
55414.

January 1992/Volume 75

Minnesota Medicine

PRESIDENT'S LETTER

A Renewal of Purpose for 1992

Thomas A . S to I e e , M . D .

As we enter a new year, it is time
to ask ourselves these ques-
tions: What are we all about?
What is the purpose of the Minneso-
ta Medical Association?

To answer these questions, I will
quote our corporate purpose from
the MMA’s Articles of Incorpora-
tion, and then I will state my goals,
which are part of my effort to fulfill
these organizational objectives.

The corporate purpose states:
“The (MMA) is organized and shall
be operated exclusively to support
and improve the science and art of
medicine, and to advance communi-
ty welfare, community health, and
scientific education... and in further-
ance of such purposes the (MMA)
may:

1. Elevate the standards of med-
ical education and knowledge at both
the undergraduate and the graduate
levels;

2. Foster the presentation of pa-
pers, articles, findings, and studies by
its component medical societies in
the fields of medical research, diag-
nosis, therapy, operative procedure,
prevention of disease, and promo-
tion of the public health;

3. Promote high standards of
medical and health service in all pub-
lic programs established for the wel-
fare of the people of Minnesota;

4. Bring into one federation all
medical professionals in the state of
Minnesota and unite with similar
societies in other states to form the
American Medical Association;

5. Assist officials and agencies of
the state of Minnesota with advice
and service in the administration of
its medical, hospital, welfare, and
public health programs, and promote
through its component medical soci-
eties continuous advice and assis-
tance in county welfare and public
health programs; and

“We must continue
striving to satisfy our
objectives.”

6. Engage in any lawful programs
or activities that are supportive of
physicians’ professional growth and
development, that promote the sci-
ence and art of medicine, or that pro-
mote community welfare, community
health, and scientific education.”

There you have it. With these
objectives in mind, I have set goals
for my presidency. Although the paths
are sometimes convoluted and the
light occasionally dim, we will per-
sist. My goals are to:

• Bring about ready access to
health care for all Minnesotans, re-
gardless of where they live or what
their economic circumstance may be;

• Decrease the cost of health care
through wiser use of resources, greater
patient and physician accountability
for costs, greater support of preven-
tive medicine and primary care, sim-
plification of administrative red tape,
as well as insurance reform, malprac-
tice reform, and professional control
of technology use;

• Increase the availability of med-
ical care in rural and inner-city areas
through more equitable reimburse-
ment, enhanced physician incentives,
greater public awareness; and great-
er emphasis on primary care and

rural practice in medical schools and
residency programs;

• Increase the social and medical
wellness of our minority citizens
through fairness in educational,
health care, and employment oppor-
tunities;

• Continue to strive for equitable
Medicare reimbursement nationally
so that our patients do not continue
to subsidize those in other areas of
the country;

• Continue to strive for adequate
Medicaid reimbursement so that doc-
tors taking care of the poor do not
continue to suffer economic discrim-
ination;

• Continue the crusade against
tobacco use as a major public health
problem;

• Create a high level of public
awareness of the problems created
by addiction to alcohol, drugs, and
gambling;

• Educate the public about sexu-
ally transmitted diseases, including
AIDS and cervical carcinoma. Only
through public education can we hope
to control these menaces;

• Bring about more reasonable
mental health legislation to decrease
homelessness, increase community
mental health treatment capabilities,
and focus attention on people with
serious and persistent mental illness;

• Develop a fair peer-review ad-
vocacy system for Minnesota physi-
cians;

Obviously, we will not reach these
goals in one year, but we must con-
tinue striving to satisfy our profes-
sional and organizational objectives.
We have high ideals and high aspira-
tions for humanity. That’s why we
call ourselves physicians.

Please join me in renewing our
collective resolutions for 1992. My
family and I wish you and your loved
ones a happy New Year. mm

Minnesota Medicine

January 1992/Volume 75

“ Being a patient advocate is what being a physician is all about.”

Dr. Kevin Fullin, Cardiologist, Kenosha, Wisconsin, Member, American Medical Association

Why would a cardiologist get involved in the issue
of family violence? Perhaps, because what he saw
simply cried out for action.

“Fully a third of all women’s injuries coming into
our emergency rooms are no accident,” says Dr. Fullin.

While others were content to downplay the issue
of family violence. Dr. Fulltn would not. He petitioned
state officials, and through his efforts the first Domestic
Violence Advocate Program in his state was created.

“Organized medicine must serve as an advocate
for patients,” stressed Dr. Fullin.

The American Medical Association (AMA) couldn’t

agree more. We’re committed to focusing physician
attention on the issue of family violence.

You are invited to join Dr. Fullin and to join with
him in his efforts to bring quality health care to those in
need. Become a member of the American Medical
Association today.

Members of the AMA are encouraged to join their state, county and specialty societies.

American Medical Association

Physicians dedicated to the health of America

BOOK REVIEW

Ethics by the Bedside

By Charles M. Culver, M.D., Ph.D., Ed., University Press of New England, 1990

Reviewed by Spencer Reece

Because I could not stop for Death —

He kindly stopped for me —

The Carriage held hut just Ourselves —

And Immortality.

— Emily Dickinson

CCT ^ thics by the Bedside” is a collection of 12 essays

IH by physicians about moral dilemmas concern-
— d ing death in modern American hospitals. Death
was fairly simple in the past. A person would get ill,
descend into a hospital bed or bed at home, and expire
when the time was right. That was it. But we’ve now
taken mortality into our own hands. A person can die in
a few weeks, months, or years, depending on when the
ventilator and feeding tubes are removed. A very natural
process has become unnatural. The days of Death drop-
ping in on Emily Dickinson are not as reliable as they
once were. Death might come. But nowadays. Death
might also hang around for a while like a tiresome guest.

I found Dr. Culver’s book provoking for its multifar-
ious viewpoints. Each essay tells a different story about
death. Culver, a professor of psychiatry and adjunct
professor of philosophy at Dartmouth College, opens the
book with a reprint of a letter he wrote to ethicists when
he began requesting material for the book; “I want you
to tell a story, to emphasize the personal experience you
had, and extensive use of citations might tend to detract
from the sense of immediacy I hope will come through.”
The book holds true to Culver’s intent, offering tragic,
difficult, and engaging narratives with few citations.

As more machinery crowds the stage of life, ethics
committees are becoming commonplace in hospitals
around the country. They are often made up of ministers,
psychiatrists, Ph.D.s, and M.D.s. Where earlier there
was a doctor and a patient, there now is a whole jury to
carefully weigh issues. Ethics consultations are relatively
new to the world of medicine, and, thus, Culver’s collec-
tion of testimonies is somewhat a maverick.

In one essay, “A Philosophical Consultation” by
Bernard Gert, a family must decide when to withdraw
food and fluids from its permanently unconscious and
terminally ill father. Eistening to the family, Gert, a
philosophy professor at Dartmouth College, writes:
“It became quite clear to them that I was in no hurry,
that I was prepared to listen to them and talk to them
for as long as was necessary to resolve the problem. This
has a very beneficial effect. One of their main com-
plaints was that no one had been willing to sit down

and talk over the situation with them.”

With guidance from the hospital’s ethics committee,
the family members chose to remove the feeding tubes
and let their father die. Ironically, despite all the avail-
able high-tech instruments, the cure for this family was
talking and holding hands.

The stories range from families dealing with loved
ones coming to the end of their lives, to loved ones who
have just entered the world. Premature babies born with
multiple birth defects and with severe brain retarda-
tion— who not long ago would have died quietly and
naturally in a matter of seconds — can now be kept alive
for months and years. According to Alan Fleischman,
director of neonatology and professor of pediatrics at
Albert Einstein College of Medicine, “American perina-
tology has moved in the past decade to resuscitate
virtually all potentially viable infants, looking to con-
templative ethical analysis only when there is greater
certainty as to outcome after assessment of the patient’s
potential in the nursery.”

A mother in one of the stories questions the validity
of keeping her brain-damaged, ventilator-dependent,
premature baby alive. She wonders if it isn’t barbarism,
and some of what occurs does resemble a freak show. Eor
example, in one ghoulish story, a brain-dead infant is
kept alive for seven years, the parents hoping against
hope. The essayist tells us that after seven years, “Vivi-
an’s body had grown into a grotesque, contorted shape.
She showed no signs at all of higher mental function,
lacking even responsive eye movement. Whenever she
was taken off the ventilator, she was entirely unable to
breathe on her own.” The parents end up visiting the
hospital less and less. Only when the hospital forces the
parents to take Vivian home and care for her themselves
do the parents realize it is time for Vivian to die.

“Ethics by the Bedside” asks us to bring order and
dignity to death. The essays in Culver’s book stress that
Death is not the enemy. Quality of life is more important
than its quantity. The people whose stories are told in
these essays overwhelmingly want the natural: if the
brain is dead, let the body die. The more complicated the
exit from this world, the more simple the requests
become. MM

Spencer Reece is the managing editor of the Reece
Report, a medical newsletter published in Northfield,
Minnesota. He has published hook reviews in The Star
Tribune and The Northfield News, and is also the
recipient ofthisyear's I. oft Mentor Series Prize in Poetry.

Minnesota Medicine

January 1992/Valume 75

IN MEMORIAM

In Memoriam

Maurice J. Bany Jr., M.D.

University of Indiana, 1 944
Born: 1919, Died: Nov. 28, 1991

Alex G. Berger, M.D.

University of Minnesota, 1932
Born: 1904, Died: Sept. 4, 1991

Joseph G. Brennan, M.D.
University of Bologna, Italy, 1947
Born: 1916, Died: June 23, 1991

Morris L. Cable, M.D.

University of Minnesota, 1927
Born: 1902, Died: Sept. 22, 1991

Donald C. Campbell, M.D.

University of Nebraska, 1935
Born: 1910, Died: Oct. 30, 1991

t-*.-

Walter Coddon, M.D.

University of Minnesota, 1935
Born: 1911, Died: June 17, 1991

Robert W. Cranston, M.D.

University of Minnesota, 1928
Born: 1903, Died: Nov. 26, 1991

Bernhard J. Cronwell, M.D.

University of Illinois, 1927
Born: 1898,' Died: Nov. 20, 1991

i-A'

Richard M. Duff, M.D.

University of Minnesota, 1966
Born: 1940, Died: Sept. 16, 1991

Adolf F. Dysterheft, M.D.

University of Minnesota, 1930
Born: 1905, Died: Sept. 26, 1991

John J. Galligan, M.D.

University of Minnesota, 1946
Born: 1922, Died: Aug. 12, 1991

Elmer M. Hill, M.D.

University of Minnesota, 1 932
Born: 1905, Died: Nov. 14, 1991

Oscar Lipschultz, M.D.

University of Minnesota, 1929
Born: 1904, Died: Nov. 30, 1991

Theodore G. Martens, M.D.
University of Rochester, NY, 1943
Born: 1917, Died: Aug. 12, 1991

iA.

Harold Martin, M.D.

Indiana University, 1 944
Born: 1919, Died: June 6, 1991

Maty E. Morehouse, M.D.

University of Kansas, 1 982
Born: 1955, Died: June 6, 1991

Martin C. Peper, M.D.

Vanderbilt University, 1 955
Born: 1930, Died: Sept. 6, 1991

RobeH I. Roelofs, M.D.

University of Iowa, 1965
Born: 1939, Died: June 10,1991

>'*.

Cornelius A. Saffert, M.D.

University of Minnesota, 1926
Born: 1903, Died: Sept. 30, 1991

i-*'

Thomas H. Seldon, M.D.
Queens University, Ontario, 1929
Born: 1905, Died: Oct. 22, 1991

t*.

Sidney A. Whitson, M.D.

University of Minnesota, 1928
Born: 1902, Died: Aug. 15, 1991

t*.-

Eerdinand A. Zinter, M.D.

University of Minnesota, 1939
Born: 1907, Died: June 30, 1991

It keeps
more than
memories
aUve.

THE AMERICAN HEART
ASSOCIATION
MEMORIAL PROGRAM®

American Heart
Association

This space provided as a public service.

Now Open
For Business:
TteAMA
Member
Hotline.

Reserved exclusively for AMA
members, to get information fast
about membership status,
delivery of your JAMA, and
all your other AMA benefits,

1-800-AMA-3211

January 1992/Valume 75

Minnesata Medicine

NEWS CLIPS

People and Places Making Medical News

People

ACS Distinguished Service Award

The American Cancer Society
honored BJ. Kennedy, M.D.,
University of Minnesota regents
professor of medicine emeritus and
masonic professor of oncology
emeritus, at its annual meeting in
November. Kennedy received a
Distinguished Service Award for
his 45 years of distinctive and
compassionate care of cancer
patients and his vision in pioneer-
ing the field of oncology.

Kennedy has been an attending
: physician with the University of
Minnesota School of Medicine
since 1952 and has published
papers in more than 750 scientific
i publications. He has consulted and
edited 15 prominent medical
journals, most of which are specific
to cancer research and care.

Academy of Ophthalmology
Officers

j Richard P. Carroll, M.D., of
Minneapolis, has been elected
president of the Minnesota Acade-
my of Ophthalmology for 1991-92.
Other officers elected are Martin B.
Kaplan, M.D., Minneapolis,
president-elect; Rene W. Pelletier,
M.D., St. Paul, treasurer; and Jerry
L. Kobrin, M.D., St. Paul, secre-
tary. Raymond C. Croissant, M.D.,
Edina, continues as chair of the
external affairs committee, and
Paul T. Wicklund, M.D., St. Paul,
was appointed chair of the internal
affairs committee.

I AGFA Trustee

Audrey M. Nelson, M.D., Roches-
ter, was elected to the board of
j trustees of the American Group

1 1

' j

Minnesota Medicine

Practice Association at its 42nd
Annual Conference. She is the first
woman to hold the position.

Nelson is a consultant in internal
medicine, rheumatology, and
pediatrics at Mayo Clinic, an
associate professor in internal
medicine at Mayo Medical School,
and an MMA delegate to the AMA
House of Delegates.

Nursing Home Medical Directors
President

Thomas M. Altemeier, M.D.,
medical director of senior services
at HealthEast Bethesda Eutheran
Hospital, St. Paul, has been elected
to a two-year term as president of
the Minnesota Association of
Nursing Home Medical Directors.

Before becoming president of
the organization, Altemeier had
been serving as president-elect. He
is also medical director for nine
nursing homes in the Twin Cities
and is on the faculty of the Univer-
sity of Minnesota, where he teaches
a comprehensive course that he
helped develop for nursing home
medical directors.

Group Health Director

Henry Emmons, M.D., has been
named director of professional
services at Group Health’s Mental
Health Center. Emmons joined
Group Health, Inc., in 1989 as a
staff psychiatrist and has since
served as interim department head
at the Mental Health Center. He is
also on the hospital staff at River-
side Medical Center in Minneapolis.

Places

Phillips Teaching and Research
Center Opens

The Phillips Plye Institute inaugu-
rated the opening of its Center for
Teaching and Research in October.
The center, which cost $650, ()()() to

January 1992/Volume 75

build, is a multifaceted, ophthalmic
research and education facility. It is
located in an 1 1,800 square-foot
suite on the lower level of the Park
Avenue Medical Office Building
adjoining the Phillips Eye Institute.

The center is available to
industry, ophthalmologists, and
independent researchers to conduct
applied research or upgrade
surgical skills on a fee-for-use
basis. As a teaching facility, it
includes four operating room set-
ups with surgical equipment and a
viewing room connected via closed-
circuit television. The center also
includes conference rooms as well
as teaching and lecture support
services.

Mayo to Subsidize Tuition

Mayo Medical School is moving
toward a goal of full tuition
scholarships for its students by the
year 2005. During the current
school year, it is underwriting 14
percent of students’ tuition.

“Tuition support attempts to
lower student debt load and impact
tbe societal issues of health care
access and costs,” says Mayo
Medical School Dean Burton
Sandok, M.D. Some feel high debt
load influences the trend of medical
school graduates choosing higher-
paying specialties over lower-
paying positions in family medi-
cine, pediatrics, and internal
medicine.

Virginia Piper Institute Receives
Grant

Abbott Northwestern Hospital
officials announced in November
that The Kresge Eoundation of
Troy, Michigan, has approved a
$500,000 grant for the Virginia
Piper Cancer Institute. Douglas
Dayton, general chairman of the

NEWS CLIPS

insritute's Lund drive “Legacy and
Promise,” said the money will help
fund the renovation, expansion,
and equipping of the radiation
oncology unit.

The Kresge Foundation award-
ed more than 120 grants in 1991
for a total of more than $45
million. The foundation is an
independent, private foundation
created by the personal gifts of
Sebastian S. Kresge. The grant to
the Virginia Piper Cancer Institute
was made on a challenge basis,
contingent on raising the balance
of the Legacy and Promise $13
million goal. To date, $10.3
million has been raised.

Abbott Northwestern an-
nounced the creation of the Virgin-
ia Piper Cancer Institute in May of
this year. Piper was a long-time
hospital board member and former
board chair who died of cancer in
1988.

Fairview Milaca Converts Facilities

The boards of directors of the
Fairview Milaca Hospital and
Milaca Area Hospital District
voted to convert the hospital to a
full-scale ambulatory care center
and medical clinic effective Novem-
ber 22. The conversion was
originally planned to coincide with
the opening of Fairview’s new
regional medical center in Prince-
ton in 1993.

Until the new medical center in
Princeton opens, Milaca-area
residents requiring emergency
services and inpatient care will be
treated at Fairview Regional
Hospital, which is 14 miles from
Milaca.

Milaca’s need for more outpa-
tient services and declining use of
hospitalization services prompted
the decision, according to Glenn
Erickson, regional administrator.

Socioeconomics

Park Nicollet, Methodist Affiliation

Park Nicollet Medical Center and
Methodist HealthCare, parent
company of Methodist Hospital,

have announced approval of an
agreement to create a new affilia-
tion under common management
and governance. MHC Associates
and Methodist Hospital Founda-
tion will be subsidiaries of the new
parent organization.

Park Nicollet and Methodist
Healthcare’s leaders see the
affiliation as a step toward the
integration of inpatient and
outpatient services into a coordi-
nated system of care.

Methodist Hospital and Park
Nicollet Medical Center will
maintain their separate identifica-
tions and structures, and the
hospital’s medical staff will contin-
ue to be open to all physicians in
the community.

State Health Worker Layoffs

The Minnesota Department of
Health was forced to lay off 29
nursing home and hospital inspec-
tors and investigators because of a
shortfall of $3 million in federal
and state funds for inspections. As
Minnesota Medicine went to press,
the layoff was scheduled for
December 31.

The department hired 43 new
inspectors in August after federal
officials indicated that the depart-
ment’s list of expanded surveys
would be approved. Because of
seniority, most of those laid off
were new employees.

The cuts will reduce the
department’s ability to oversee the
quality of care in hospitals and
nursing homes, said Mike Tripple,
assistant director of the depart-
ment’s health resources division.
Among other things, the depart-
ment will lose its ability to provide
training to hospital and nursing
home staffs, he said.

Health Care Costs for Seniors

Three of Minnesota’s HMOs
announced increases in Medicare
premiums for 1992, while two
announced reductions for some
members. Group Health Seniors is
reducing premiums by about 15
percent, with monthly costs going
from $45.75 to $38.75 starting
February 1. Group Health was able

to reduce rates by dropping its
coverage of prescription drugs.

Blue Plus Medicare is reducing
its premiums for subscribers aged
65 to 69 starting January 1.
However, most subscribers over
age 69 will see rate increases. Blue
Plus joins PHP and MedCenters in
charging higher rates for older
Medicare enrollees.

Other HMOs announced sharp
increases in Medicare premiums,
saying Medicare reimbursements
haven’t increased enough to cover
rising health care costs.

$hare Senior Care increased its
premiums by 23 percent, with
monthly costs going from $39.95
to $48.95 effective January 1.

PHP Plus Medicare’s premiums,
which are based on age, ranged
from $47.50 to $69.50 per month
in 1991. On January 1, the range
increased to $59.75 to $87.

MedCenters charged $59.95 in
1991, but it began using an age-sex
rating system January 1. Its new
premiums range from $64.95 to
$69.75.

Soaring medical costs could
destroy the financial security of
future retirees, according to a
report by the Northwestern
National Life Insurance Company.
The Minneapolis-based insurer
warned that the nation must cut
rapidly increasing medical costs
and determine who will pay the
high retiree medical bills.

In a national survey of 500
workers over age 40, the company
found that most people surveyed
believe they will be well prepared
for retirement, failing to recognize
that medical bills could quickly
deplete their assets.

Child Mental Health Program
Failing in Ramsey

Ramsey County’s mental health
programs for children are failing,
according to an advisory council
created by the Legislature to
monitor county efforts. The
program is inaccessible because it
must struggle to control costs, said
council members.

January 1992/Volume 75

Minnesota Medicine

NEWS CLIPS

Some county officials blamed
the state for the problems because
it required counties to provide
mental health care but provided no
money. The county faces dimin-
ished funding from state and
federal sources, as well as limits on
property tax levies, and can,
therefore, only shift funding
between needy populations, said
Commissioner Diane Ahrens.

The advisory council recom-
mended that the County Board
identify services to children as a
top priority and start active
partnerships with schools and
other agencies; that the Community
Human Services Department
determine whether it is cost
effective to place children in foster
care if residential treatment offers
more effective intervention; that the
department develop training
standards for social workers,
especially on cross-cultural values;
and that the hoard appropriate
money for crisis services.

Innovations

M-Gus Treated by Replacing
Plasma

Mayo Clinic researchers have
confirmed that the crippling disease
M-Gus can he reversed by replac-
ing the patient’s plasma. M-Gus, a
form of polyneuropathy, severely
damages nerves in the arms and
legs.

In a double-blind study, Mayo
researchers replaced 19 M-Gus
patients’ plasma with artificial
plasma consisting of saline solution
and albumin, a protein common in
animal tissue. Twenty patients
received a sham treatment.

Some patients who were unable
to walk before the study were able
to walk again after the plasma
exchange, said Peter James Dyck,
director of Mayo’s Peripheral
Neuropathy Research Laborato-
ries. The researchers suspect the
treatment works because the
antibodies that attack the nerves
are discarded with the plasma.

Nerve function in the patients

who received the real treatment
improved six times as much as in
those who got the sham treatment,
and their muscle strength improved
10 times as much. The patients
who received the sham treatment
were offered the real treatment
after the study.

Heart Pumps Successful

Mechanical assist devices have had
spectacular success rates at the
Minneapolis Heart Institute,
according to a report the institute
presented at the American Heart
Association’s annual meeting in
November. The institute has one of
the best success rates in the nation:
All 13 patients with mechanical
assist devices lived to receive new
hearts. Three of 10 candidates for
heart transplants typically die
before they get a new heart.
Mechanical assist devices, which
the FDA still considers experimen-
tal, can potentially improve these
numbers.

Nine of the 13 Heart Institute
patients are still alive, one died
after 28 months, and three died
within a year after receiving donor
hearts.

TPA May Save Frostbitten Limbs

The clot-busting drug TPA has
saved four severely frostbitten
patients at Hennepin County
Medical Center from amputation,
said physicians. The drug, typically
used to stop heart attacks, restored
circulation to the patients’ thawed
hands and feet.

The FDA has authorized John
Twomey, M.D., a surgeon at the
hospital, to test the therapy on six
patients. Three of the first four
needed no amputation after
receiving TPA. The fourth patient
lost four fingers on one hand and
one on the other, but without
treatment, he would have lost both
legs below the knee and possibly
both hands, said Twomey.

Because it’s impractical to

administer TPA to all frozen areas
of patients, Twomey said physi-
cians gave priority to the most
important limb — such as the right
hand in right-handed people. But
the physicians were surprised to
find that the drug also reached
other limbs, said Twomey.

Other clot-dissolving drugs
such as urokinase and streptoki-
nase, which cost far less than TPA,
will probably be tested later if TPA
proves successful, said Twomey.

Medical Research

Emergency Care Futile for Cardiac
Arrest Victims

Virtually all people who suffer
cardiac arrest and cannot be
revived by rescue workers will die
and should not be taken to a
hospital, according to a study
published in the November 14
issue of The New England Journal
of Medicine. Even if the patient can
be revived in an emergency room,
there is almost no chance the
patient will live to leave the
hospital. Researchers recommend-
ed that rescuers declare such
patients dead at the scene rather
than subjecting them to dehuman-
izing and costly hospital treatment.

The researchers reviewed 185
cardiac arrest victims brought to
Rhode Island Hospital in Provi-
dence during a 19-month period.
Only 16 of the patients were
revived, only one regained con-
sciousness, and none lived to be
discharged from the hospital.

Heart Drug Poses Risk

Digitalis, one of the oldest and
most widely used heart drugs,
increased the risk of sudden cardiac
death in people who had survived a
heart attack, according to a study
reported at the American Heart
Association annual meeting in
November. Researchers also found
that beta blockers help prevent
sudden death. About 25 percent of
the 1 million Americans who
survive heart attacks each year are
treated with digitalis.

Minnesota Medicine

January 1992/Volume 7 5

NEWS CLIPS

Beta Carotene Reduces Women's
Health Risks

One serving per day ot foods rich
in beta carotene, such as carrots,
spinach, and apricots, cuts wom-
en's risk of stroke by 40 percent
and heart attack by 11 percent,
reported doctors at the American
Heart Association's annual meeting
in November. Women who rook
vitamin E supplements had a 36
percent lower risk of heart attack
and a slightly lower risk of stroke
than women w'ho took less than
the U.S. recommended daily
allowance of the vitamin. The
study monitored 87,245 nurses
starting in 1976.

AIDS Update

CDC Drops Plan

Because of strong opposition, the
Centers for Disease Control
decided not to draft a list of
e.xposure-prone procedures that
HIV-infected health care workers
should not perform. Critics argued
that there is no scientific reason to
ban infected health care workers
from performing such procedures.
The CDC's new draft guidelines
suggest instead that emphasis be
placed on identifying infected
health workers who do not meet
standards of infection control or
whose stamina or mental state
makes them unfit to practice. The
draft also suggests that local panels
decide on a case-by-case basis
whether health care workers
should perform particular proce-
dures. The guidelines continue to
oppose mandatory testing.

Louis Sullivan, M.D., secretary
of Health and Human Services,
must approve the change.

BMP Proposes HIV Testing Plan

The Minnesota Board of Medical
Practice has proposed voluntary
AIDS testing guidelines for physi-
cians who perform exposure-prone
procedures and has asked the

Minnesota Legislature to adopt the
plan.

The BMP proposal would give
the board broad power to regulate
the practice of health care workers
infected with HIV. The Minnesota
Medical Association Board of
Trustees voted to oppose the
BMP's plan and gave approval for
the MMA staff to develop a
legislative proposal for oversight of
infection-control practices in the
health care setting.

The BMP plan proposes that
physicians who do surgical and
other exposure-prone procedures
undergo voluntary testing; that
doctors with AIDS stop doing
exposure-prone procedures; and
that the board have legal authority
to make unannounced inspections
of physician offices.

Minnesota Study Calls For Caution

Authorities should be cautious
about notifying patients of HIV-
infected physicians, recommended
Minnesota officials in the Novem-
ber 14 Neiu England Journal of
Medicine. In a study conducted
primarily by experts from the
Minnesota Department of Health,
officials said that under most
circumstances, it is unnecessary to
notify and test patients who were
treated by infected physicians. Such
look-back investigations are too
costly and unproductive to conduct
routinely, the authors concluded.

According to the report,
notification should be considered
only in three cases: 1) It should be
mandatory when a health care
worker has spread the virus to a
patient; 2) it should be considered
when there is evidence that a health
care worker has violated standard
infection-control practices while
infected with HIV (this guideline
applied to the Philip Benson, M.D.,
case last summer); and 3) it may be
considered for some studies
designed to define more clearly the
risk of transmitting HIV from
health care worker to patient.

U Proposal Would Require Testing

Under a proposal released in
November, physicians at the

January 1992/Volume 75

University of Minnesota Hospital
and Clinic who perform exposure-
prone procedures would be re-
quired to sign a document every
two years certifying that they have
tested negative for HIV. Lrank
Rhame, M.D., the hospital's
infection control chief, recom-
mended the proposal, which must
pass through hospital committees
before it can become policy.

Some Docs Reluctant to Treat AIDS

In a survey of 2,004 internists and
general and family practitioners,
almost one-third said they do not
feel a responsibility to treat people
with AIDS. Half said they would
not work with AIDS patients if
they had a choice.

Authors of the article, which
appeared in the November 27
Journal of the American Medical
Association, traced the results
partially to a bias against homosex-
uals and intravenous drug users —
those affected most by AIDS. In the
survey, 35 percent agreed with the
statement that they ‘‘would feel
nervous among a group of homo-
sexuals," and 55 percent said they
would feel uncomfortable having
intravenous drug users as patients.

The physicians also had other
worries. Eighty-three percent said
they needed more information
about AIDS, and 84 percent agreed
that caring for people with AIDS
puts extra demands on their time.

The AMA believes physicians
have a responsibility during an
epidemic to treat the ill regardless
of the risk, and in 1988, the AMA
stated that it is unethical for a
physician to refuse treatment
because a patient is infected with
the AIDS virus. MM

Minnesota Medicine

CME IN MINNESOTA

A Calendar of Continuing Medical Education Courses

Provided through the MMA Medical Education Subcommit-
tee on CME Resources. For assistance with scheduling meet-
ings or for information on future medical meetings and CMF
courses, please contact the MMA office: 2221 University
Avenue SE, Suite 400, Minneapolis, Minnesota 55414; 612/
378-1875. Information for each entry is arranged by date;
name of program; primary sponsor; location; contact person.

JANUARY 1992

Jan. 6-10 Team Management of Diabetes Mellitus Interna-
tional Diabetes Center; International Diabetes Center, Min-
neapolis, MN. CONTACT: Cindy Poppitz, International
Diabetes Center, 5000 West 39th Street, Minneapolis, MN
55416; 612/927-3393.

Jan. 1 1 Teen Program Seminar (Pediatric and Mental Health
Topics) Group Health Inc.; Minneapolis Metrodome Hilton,
.Minneapolis, MN. CONTACT: Debbie Bladine, Group
Health Inc., 2829 University Avenue SE, Minneapolis, MN
55414; 612/623-8479.

Jan. 16 Promoting Fitness Group Health Inc.; Minneapolis
Metrodome Hilton, Minneapolis, MN. CONTACT:
Debbie Bladine, Group Health Inc., 2829 University Ave-
nue SE, Minneapolis, MN 554 14; 6 12/623-8479.

Jan. 16-31 South Pacific Medical Education Seminar IN-

TRAV, North Central Medical Conference; Fiji, New Zea-
land, Australia, Great Barrier Reef. CONTACT: North
Central Medical Conference, 1 845 Hampshire Avenue #200,
St. Paul, MN 55116.

Jan. 18 Rehabilitation Group Health Inc.; Minneapolis
Metrodome Hilton, Minneapolis, MN. GONTAGT:
Debbie Bladine, Group Health Inc., 2829 University Ave-
nue SE, Minneapolis, MN 55414; 6 12/623-8479.

Jan. 25-Feb. 4 Trans-Panama Canal Medical Education
Seminar INTRAV, North Central Medical Conference;
Acapulco, Costa Rica, Curacao, St. Croix, St. Thomas, and
San Juan. CONTACT: North Central Medical Conference,
1 845 Hampshire Avenue #200, St. Paul, MN 55 1 1 6.

Jan. 27-31 Team Management of Diabetes Mellitus Interna-
tional Diabetes Center; International Diabetes Center, Min-
neapolis, MN. CONTACT: Cindy Poppitz, International
Diabetes Center, 5000 West 39th Street, Minneapolis, MN
55416; 612/927-3393.

FEBRUARY 1992

Feb. 5-12 HealthEast Winter Medical Seminar HealthFiast;
Hawaii. CONTACT: Eisa Harrell, 1700 University Ave-
nue, St. Paul, MN 55104; 612/641-51 12.

Feb. 6 Kidney Stones — Treatment, Prevention Group Health
Inc.; Minneapolis Metrodome Hilton, Minneapolis, MN.
CONTACT: Debbie Bladine, Group Health Inc., 2829

University Avenue SFl, Minneapolis, MN 55414; 612/623-
8479.

Feb. 6-9 Prostatic Diseases: Current Concepts in Diagnosis
and Management Mayo Clinic/Mayo Foundation; The
Breakers, Palm Beach, FL. CONTACT: Rita Kunz or Jan
Fleck, Mayo Clinic, 200 1st Street SW, Rochester, MN
55905; 507/284-2509 or 800/323-2688.

Feb. 7 Domestic Violence: Assessment and Plan for Physi-
cian Action St. Paul-Ramsey Medical Center; Holiday Inn
East, St. Paul, MN. CONTACT: Bonnie Young, 640 Jack-
son Street, St. Paul, MN 55 10 1; 6 12/22 1-3992.

Feb. 8-9 Fourth Annual Issues in Pediatrics Children’s
Hospital and Fargo Clinic MeritCare; Arrowwood Resort,
Alexandria, MN. CONTACT: Sue Heinze, 720-Fourth
Street North, Fargo, ND 58102; 701/234-5737.

Feb. 10-14 Team Management of Diabetes Mellitus Interna-
tional Diabetes Center; International Diabetes Center, Min-
neapolis, MN. CONTACT: Cindy Poppitz, International
Diabetes Center, 5000 West 39th Street, Minneapolis, MN
55416; 612/927-3393.

Feb. 14 Burn Care Today St. Paul-Ramsey Medical Center;
Holiday Inn East, St. Paul, MN. CONTACT: Bonnie Young,
640 Jackson Street, St. Paul, MN 55101; 612/221-3992.

Feb. 1 4-23 Primary Care Update Office of CME, University
of Minnesota Medical School; Hotel Sanur Beach, Bali,
INDONESIA. CONTACT: Bart Galle, Office of CME,
Radisson Hotel Metrodome, Suite 107, 615 Washington
Avenue SE, Minneapolis, MN 55414; 612/626-7600.

Eeb. 15-22 HealthEastWinter Medical Seminar HealthEast;
Steamboat Springs, CO. CONTACT: Eisa Harrell, 1700
University Avenue, St. Paul, MN 55 1 04; 6 1 2/64 1-5112.

Feb. 20 Newer Antibiotics in Our Basic Armamentarium

Group Health Inc.; Minneapolis Metrodome Hilton, Min-
neapolis, MN. CONTACT: Debbie Bladine, Group Health
Inc., 2829 University Avenue SE, Minneapolis, MN 55414;
612/623-8479.

Feb. 21-22 Sexual Attitude Reassessment Seminars (SAR)

Program in Human Sexuality; Holiday Inn Metrodome,
Minneapolis, MN. CONTACT: SAR Coordinator or Secre-
tary, Program in Human Sexuality, FMC Building, 1300
South 2nd Street, Minneapolis, MN 55454.

Feb. 26-27 Geriatric Drug Therapy Symposium Office of
CMFi, University of Minnesota Medical School; Radisson
Hotel Metrodome, Minneapolis, MN. CONTACT: Becky
Noren, Office of CMFi, Radisson Hotel Metrodome, Suite
1 07, 6 1 5 Washington Avenue SFi, Minneapolis, MN 554 14;
612/626-7600.

Feb. 28 Prevention and Management of Atherosclerotic
Diseases Office of CMFi, University of Minnesota Medical

Minnesota Medicine

January 1992/Volume 75

CME IN MINNESOTA

School; Radisson Hotel Metrodome, Minneapolis, MN.
CXTNTACT; Becky Noren, Office of CMH, Radisson Hotel
Metrodome, Suite 107, 615 Washington Avenue SF, Min-
neapolis, MN 55414; 612/626-7600.

MARCH 1992

March 5 Medical Aspects of Drug Abuse — Cocaine Group
Health Inc.; Minneapolis Metrodome Hilton, Minneapolis,
.MN. CONTACT: Debbie Bladine, Group Health Inc.,
2829 University Avenue SE, .Minneapolis, MN 55414; 6 12/
623-8479.

.March 6-7 Cutaneous Laser Surgery Abbott Northwestern
Hospital; Abbott Northwestern Hospital, Minneapolis,
.MN. CONTACT: Cathy Kohn, CME Office 14202, Ab-
bott Northwestern Hospital, 800 East 28th Street, Minne-
apolis, .MN 55407; 612/863-5461.

.March 9- 1 3 Medical Update 1 992 Office of CME, Depart-
ment of Surgery, University of Minnesota Medical School;
Hughes Education and Conference Center, Holy Cross
Hospital, Eort Lauderdale, EL. CONTACT: Becky Noren,
Office of CME, Radisson Hotel .Vletrodome, Suite 1 07, 6 1 5
Washington Avenue SE, .Minneapolis, MN 55414; 612/
626-7600, or 800/888-8642.

.March 12-13 Family Practice Today St. Paul-Ramsev .Med-
ical Center; Holiday Inn East, St. Paul, .VIN. CONTACT:
Bonnie Young, 640 Jackson Street, St. Paul, MN 55101;
612/221-3992.

.M arch 13-18 Neurology in Clinical Practice Mayo Clinic/
.Mayo Eoundation; Capitva, EE. CONTACT: Rita Kunz or
Jan Eleck, Mayo Clinic, 200 1st Street SW, Rochester, MN
55905; 507/284-2509 or 800/323-2688.

.March 14 Ob/Gyn Seminar Group Health Inc.; Minneap-
olis Metrodome Hilton, Minneapolis, .VIN. CONTACT:
Debbie Bladine, Croup Health Inc., 2829 University Ave-
nue SE, Minneapolis, MN 55414; 612/623-8479.

.Vlarch 19 Common Skin Disorders Group Health Inc.;
Minneapolis Metrodome Hilton, Minneapolis, MN. CON-
TACT; Debbie Bladine, Group Health Inc., 2829 University
Avenue SE, .Vlinneapolis, VIN 55414; 612/623-8479.

March 20 Annual Occupational Medicine Update St. Paul-
Ramsey Medical Center; Vlinneapolis Metrodome Hilton,
.Vlinneapolis, .MN. CONTACT: Bonnie Young, 640 Jack-
son Street, St. Paul, MN 55 10 1; 6 12/22 1-3992.

March 20-2 1 Advanced Laparoscopic Abdominal Surgery
Seminar Abbott Northwestern Hospital; Abbott North-
western Hospital, Minneapolis, MN. CONTACT: Cathy
Kohn, CME Office 14202, Abbott Northwestern Hospital,
800 East 28th Street, Minneapolis, VIN 55407; 612/863-
546 1 .

Vlarch 2 1 -22 Sexual Attitude Reassessment Seminars (SAR)

Program in Human Sexuality; Holiday Inn Metrodome,
Vlinneapolis, VIN. CONTACT: SAR Coordinator or Secre-
tary, Program in Human Sexuality, EMC Building, 1300
South 2nd Street, Minneapolis, MN 55454; 6 1 2/625- 1 500.

Vlarch 26-27 Critical Care: Practical Approaches & Case

Discussion St. Paul-Ramsey Medical Center; Holiday Inn
East, St. Paul, MN. CONTACT: Bonnie Young, 640
Jackson Street, St. Paul, VIN 55101; 612/221-3992.

.March 28 Teen Program Seminar (Pediatric and Mental
Health Topics) Group Health Inc.; Minneapolis Metrodome
Hilton, Vlinneapolis, MN. CONTACT: Debbie Bladine,
Croup Health Inc., 2829 University Avenue SE, Minneap-
olis, .MN 55414; 612/623-8479.

APRIL 1992

April 2-3 Allergy and Clinical Immunology Office of CVIE,
University of Minnesota Medical School; Radisson Hotel
Metrodome, .Minneapolis, .MN. CONTACT: Becky Noren,
Office of C.VIE, Radisson Hotel Vletrodome, Suite 107, 615
Washington Avenue SE, .Vlinneapolis, VIN 55414; 612/
626-7600.

April 2-3 Annual Obstetrics and Gynecology Update St.

Paul-Ramsey .Vledical Center; Holiday Inn East, St. Paul,
.MN. CONTACT: Bonnie Young, 640 Jackson Street, St.
Paul, .MN 55101; 612/221-3992.

April 3 ENT Update St. Paul-Ramsey .Medical Center; St.
Joseph’s Hospital, St. Paul, .MN. CONTACT; Bonnie
Young, 640 Jackson Street, St. Paul, .MN 55 1 0 1; 6 1 2/22 1 -
3992.

April 6-7 Annual Ophthalmology Course Office of C.VIE,
University of .Minnesota Medical School; Radisson Hotel
.Metrodome, .Vlinneapolis, VIN. CONTACiT: Becky Noren,
Office of C.VIE, Radisson Hotel .Vletrodome, Suite 1 07, 615
Washington Avenue SPA .Vlinneapolis, .VIN 55414; 612/
626-7600.

April 10-11 Advanced Laparoscopic Abdominal Surgery
Seminar Abbott Northwestern Hospital; Abbott North-
western Hospital, .Vlinneapolis, .VIN. CONTACT: Cathy
Kohn, CVlPi Office 14202, Abbott Northwestern Hospital,
800 East 28th Street, .Vlinneapolis, MN 55407; 612/863-
546 1 .

April 16 Spondyloathropathies Croup Health Inc.; .Vlinne-
apolis .Vletrodome Hilton, .Vlinneapolis, .MN. CONTACT:
Debbie Bladine, Croup Health Inc., 2829 University Ave-
nue SE, Vlinneapolis, MN 55414; 612/623-8479.

April 24-25 Sexual Attitude Reassessment Seminars (SAR)

Program in Human Sexuality; Holiday Inn .Vletrodome,
Vlinneapolis, .VIN. CONTACT: SAR Coordinator or Secre-
tary, Program in Human Sexuality, E.MC Building, 1300
South 2nd Street, .Minneapolis, .VIN 55454; 6 12/625- 1 500.

April 27-29 Bone & Soft Tissue Tumors Mayo Clinic/.Mayo
Eoundation; Hilton Beach & Tennis Resort, San Diego, C.V.
CONTACT: Postgraduate Courses, .Vlayo Clinic/.Vlayo
Eoundation, 200 First Avenue SW, Rochester, .VIN 55905;
507/284-2509 or 800/323-2688.

January 1992/Volume 75

Minnesota Medicine

Vice President
Operations

Our prestigious national medical organization, which special-
izes in state-of-the-art treatment of venous disorders, is a
leader in its field. New growth opportunities have created a
unique need for a Physician Executive with extensive medical
and operational experience to join our management team.
Selected candidate, reporting to the President, would direct
the company’s operational activities and be responsible for
the profitability of all clinics. Additionally, the selected in-
dividual would have responsibility for quality assurance, op-
erational planning, development of new clinics and serving as
a liaison between the medical staff and corporate office on all
operational issues.

The selected candidate will be a senior level Physician Execu-
tive with extensive experience in medical affairs and opera-
tions for a medical service corporation or hospital. Addition-
ally, you will have exceptional people skills and the ability to
make things happen. The compensation and equity package
will be attractive to an aggressive, entrepreneurial business
builder. Send your resume and salary history in complete
confidence to: Lloyd R. Shapiro, Vein Clinics of America,
2 Trans Am Plaza Drive, Suite 450, Oakbrook Terrace, IL
60181. Equal Opportunity Employer.

Vein Clinics of America

PHYSICIAN REVIEWER

Part-Time

Health Risk Management, Inc. is a Twin Cities based
leader providing quality managed health care services
to Fortune 500 companies and government clientele
internationally.

We currently have a part-time opportunity (15-20
hours/week) for a physician to provide utilization
review services in internal medicine. This position
will also be an educational and support resource for
our nurse reviewers and review coordinators.

To qualify you must have:

• Experience in general Internal Medicine

• Good communication skills

• Knowledge of managed health care

We offer:

• Career enhancement

• Competitive pay

• Opportunity to impact the quality and cost of

health care

• Flexible part-time schedule

• Professional environment
Please send resume to:

HEALTH RISK MANAGEMENT, INC.
8000 West 78th Street
Mail Station 8-210
Minneapolis, MN 55439

Equal Opportunity Employer

CONTINUING MEDICAL EDUCATION

ST. PAUL-RAMSEY MEDICAL CENTER

Spring Conference Schedule

CfME

640 Jackson Street
St. Paul, MN 55101
(612)221-3992

1992

February 7
February 14
March 12-13
March 20
March 26-27
April 2-3
April 3

Domestic Violence, A Focus on Adult Women, St. Paul
Burn Care Today, St. Paul
Family Medicine Update, St. Paul
Occupational Medicine Update, St. Paul

Critical Care: Practical Approaches & Case Discussions, St. Paul
OB/Gyn Update, St. Paul

ENT Update for Primary Care Physicians, St. Paul

Information and Registration

Continuing Medical Education, St. Paul-Ramsey Medical Center,
640 Jackson Street, St. Paul, MN 55101; Phone 612/221-3992.

Minnesota Medicine

January 1992/Volume 75

7 7 Seconds Are j
^ ^Like Hours When
You Need to Access
Important Medical
Information

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the Gratefui Med software of the NLM

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the GRATEFUL MED software package assists the user in finding the most current
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Name

Title

Address

City

State

ZIP

Telephone No.

I saw this ad in

CLASSIFIED ADVERTISING

Physician Opportunities and Miscellaneous Listings

Classified rates are SO<t a word. Minimum monthly
charge is $ 1 0; with box number $2 additional. Ads will
not be accepted by phone.

• Placement of ads must be made six weeks before the date of
publication (e.g., January 15 for March ad). Please send ad
requests to Minnesota Medicine, 2221 University Avenue SE,
Suite 400, Minneapolis, Minnesota 55414.

• The publisher reserves the right to decline or withdraw
advertisements. The publisher is not responsible for clerical or
typographical errors and is not permitted to divulge the identity
of advertisers who have replies sent to box numbers.

• Cancellation of ads must be made by the first of the month
preceding month of issue.

Johnson & Falls Search Associates represents new practice
opportunities locally and nationally. Working exclusively
in the area of physician search, we are committed to
expanding your professional options while meeting our
clients’ needs. There are no fees to candidates. For a
thorough, confidential search, send CV or call: Liz Johnson
or Pat Falls, Johnson &: Falls Search Associates, 34 Forest
Dale Road, Minneapolis, MN 55410; 612/922-0237. (R)

Bemidji, Minnesota: Excellent opportunities for well-trained
physicians. We are seeking BC/BE physicians in family
practice and otolaryngology to join a young 33-physician
multispecialty group practice located in northern Minneso-
ta. Competitive salary guarantee plus incentive first year
and excellent benefits. An excellent opportunity for a phy-
sician to enjoy practice in the center of hunting, fishing, and
clear air. Please respond with CV to: C.C. Eowery, Admin-
istrator, Bemidji Clinic-MeritCare, 1233 34th Street NW,
Bemidji, MN 56601; 218/751-1280. (R)

Internist to join a progressive 13-physician group practice.
Rural college town 30 miles from St. Paul, Minnesota. New
clinic and constructing new hospital. Contact: Robert B.
Johnson, M.D., River Ealls, W1 54022; 715/425-6701.

(’'•9/91-R)

Urgent Care/Primary Care physicians for over 90 group
positions in metropolitan Phoenix/Tucson, Arizona. Excel-
lent compensation/partnership opportunities. Other quali-
ty positions nationwide. Send CV or call: Mitch Young
(MM), PO Box 1804, Scottsdale, AZ 85252; 602/990-
8080. (M/90-R)

Family Practitioner to join a progressive 1 3-physician group
practice. Rural college town 30 miles from St. Paul, Minne-
sota. New clinic and constructing new hospital. Contact:
Robert B. Johnson, M.D., River Falls, WI 54022; 7 1 5/425-
6701. (’^9/9 1 -R)

Mankato: FP partner to join four board-certified family
physicians, ages 34-43, in fast-growing, full-range practice.
Ob optional. Population 40,000-i-. Seventy miles to Twin
Cities. Fourcolleges nearby. Subspecialty consultation readi-
ly available on hospital staff. Academic appointment avail-
able. Call: Tony Giefer, M.D., 507/387-8231. (8/9 1-R)

Family Physicians: Well-established south suburban Min-
neapolis family practice group seeks associates part/full
time to staff day clinic. Excellent call schedule, salary, and
fringe benefits. Also seeking locum tenens to staff PT/ET
Urgent Care Centers and/or day clinic. Contact: Adminis-
tration, Eamily Physicians, P.A., 612/435-4125, or send
inquiries to Suite 100, 14050 Nicollet Avenue South, Burns-
ville, MN 55337. (’’•9/89-R)

Mankato Clinic, Ltd. is seeking BC/BE physicians in the
following specialties: dermatology, gastroenterology, inva-
sive cardiology, occupational medicine, oncology/hematol-
ogy, ophthalmology, pulmonary medicine, family practice,
and general internal medicine. The Mankato Clinic is a 50-
physician multispecialty group practice in south-central
Minnesota with a trade-area population of +250,000. Guar-
anteed salary first year, incentive thereafter with full range
of benefits and liberal time off. Eor more information call:
Roger Greenwald, Administrator, or Dr. B. C. McGregor,
507/625- 1 8 1 1 or 800/657-6944, or write: 501 Holly Lane,
Mankato, MN 5600 1 . (12/91-R)

BC/BE Family Practice and Ob/Gyn Physician: Excellent
opportunity to join well-established, progressive, 20-physi-
cian multispecialty group located in an economically sound
community of 20,000 (drawing area of 40,000), 65 miles
south of the Twin Cities. Eull membership after one year.
Competitive salary and fringe benefits package. Contact:
Ed Durst, M.D., or Terry Tone, Administrator, 1 34 South-
view, Owatonna, MN 55060; 507/451-1120. (8/91-R)

Forest Lake Doctor's Clinic is seeking a BC/BE family physi-
cian, pediatrician, ob/gyn, and internist to join 1 0-physician
multispecialty group. Located 25 miles north of Minneap-
olis-St. Paul in progressive community with excel lent schools,
many beautiful lakes, recreational activities, golf, fishing,
boating, skiing. Local hospital directly across street. Con-
tact: Dr. Harvey J. Erank or Dr. Doug Sill, 121 SE 1 1th
Avenue, Forest Lake, MN 55025; 612/464-7100.

(4/90-R)

Lake City, Minnesota: Family physician BC/BF^ needed to
join three other FPs in progressive, growing practice on
Lake Pepin/Mississippi River in southeastern Minnesota.
Excellent first-year salary/benefits in a scenic community
with multiple recreational opportunities. Contact: D.D.
Pflaum, M.D., 303 South Washington, Lake City, MN;
612/345-3318. (8/90-R)

Minnesota Medicine

January 1992/Volume 75

CLASSIFIED ADVERTISING

PHYSICIANS

Nights and/or Weekends

Veterans Affairs Medical Center, St. Cloud,
Minnesota, is a 600-bed Medical Center
providing acute psychiatric, intermediate
medicine, and long term care to veterans.

We have full or part-time opportunities for
several physicians to cover the off-shift hours.

Responsibilities include: unscheduled ad-
missions, medical rounds, and emergency
response.

Our focus is a flexible schedule to meet the
mutual needs of staff and Medical Center.

Call or Write to explore these unique
opportunities.

Steve Erickson, 612-255-6301
Veterans Affairs Medical Center
4801 N 8th Street
St. Cloud, MN 56303

Equal Opportunity Employer

Department of
Veterans Affairs

PRIVATE PRACTICE
OPPORTUNITIES

Available in Minnesota, Wisconsin, and Iowa

• Dermatology • Internal Medicine

• Emergency Medicine • Obstetrics /Gynecology

• ENT • Ophthalmology

• Eamily Practice • Pediatrics

LifeSpan is a network of affiliated hospitals,
clinics and related health care organizations in
Minnesota and Wisconsin.

Please contact Jerry Hess at (612) 863-4193 or
(800) 248-4921.

LifeSpan

HEALTH CARE SERVICES

800 East 28th Street
Minneapolis, MN 5.5407

Olmsted Medical Group is seeking BC/BE physicians in the
following specialties: orthopedics, radiology, family prac-
tice, emergency medicine, and ob/gyn. Great opportunity
for well-trained physicians to join a 55-i- physician multispe-
cialty group in a dynamic, progressive practice. In addition
to the main office in Rochester, the group operates eight
branch offices in southeastern Minnesota. Excellent salary/
benefits package includes malpractice insurance, flexible
benefits plan, 401(k) and profit sharing, and relocation
assistance. Send CV to: Olmsted Medical Group, Attn:
Susan Schuett, 2 10 Ninth Street SE, Rochester, MN 55904.

(1/92-R)

Downtown Office Space for Renf; Physician in the Medical
Arts Building, 825, wishes to sublet to another physician on
a part-time basis for the purpose of sharing overhead
expenses. Call: 612/370-0553. (6/90-R)

MDsearch assists medical groups and hospitals in their
recruiting efforts. For confidential information on opportu-
nities in the Upper Midwest, send CV and/or call collect:
Marv jo Cordes, MDsearch, PO Box 2 1 507, St. Paul, MN
55121; 612/454-7291. (12/91-R)

Wisconsin: 120-physician multispecialty clinic in the Fox
River Valley of northeastern Wisconsin desires two BC/BE
pediatricians to join department of 1 5 BC/BE pediatricians.
Excellent compensation and benefits package, leading to
shareholder status after two years. The community offers a
superb recreational, cultural, and family environment in
which to practice. For information please call or write:
Howard Kidd, M.D., La Salle Clinic, 41 1 Lincoln Street,
Neenah, WI 54956; 4 14/727-4276. (3/9 1-R)

Family Physician wanted to join three board-certified M.D.s
m well-established, expanding group practice. Weekend ER
coverage. No buy-in. Financial package hard to beat. Enjoy
a progressive, rural city within easy reach of St. Cloud and
Minneapolis. Contact: Dr. Jim Mohs, Melrose Clinic, 603
West Main Street, Melrose, MN 56352; office, 612/256-
4228; home, 612/256-3488. (4/9 1-R)

Physician: BC in emergency medicine, experienced in FP (no
ob), and licensed in Minnesota, South Dakota, Wisconsin,
available for locum tenens coverage. Reply to: Minnesota
Medicine (850), 2221 University Avenue SF/, Suite 400,
Minneapolis, MN 55414. (5/9 1-R)

Internal Medicine, Pediatrics, and Dermatology practice
opportunities available at the Faribault Clinic. The Faribault
Clinic is a multispecialty group practice of 19 physicians.
Faribault is located 50 miles south of Minneapolis on 1-35.
For more information contact: Ray W. Wood, M.D., or Ken
Smith, Administrator, 924 NE First Street, Faribault, .MN
55021; 507/334-3921. (4/90-R)

Stillwater: .Multispecialty group with emphasis on primary
care seeking BC/BFi family physician, pediatrician, and
internist. Scenic location with excellent school system.

January 1992/Volume 75

Minnesota Medicine

CLASSIFIED ADVERTISING

supportive medical community with strong local hospital,
competitive salary and benefits. Send CV to: jon Petersen,
St. Croix Valley Clinic, 92 1 Greeley, Stillwater, MN 55082;
612/439-2215. (12/92-R)

Family Physician wanted to join five-physician, two-P.A.,
two-site family practice group in St. Anthony and Shore-
view. Ob available. Competitive salary, benefits package,
and call schedule. Contact: Gerald Pitzl, M.D., Silver Lake
Clinic PA, 612/788-9251. (7/9 1 -R)

General Surgeon: Five-man family practice group seeks
surgeon. Only clinic in city of 8,000, one hour from Minne-
apolis. Position should generate adequate salary and lots of
family time. Write: Minnesota Medicine (853), 2221 Uni-
versity Avenue SE, Suite 400, Minneapolis, MN 55414.

(8/91-R)

Wadena, Minnesota: Beautiful central Minnesota is home
to the Wadena Medical Center, a five-physician group, and
Tri-County Hospital. A scenic three-hour drive from Min-
neapolis. Family physicians to do obstetrics. Contact Dr.
Matt Yelle, 2 1 8/63 1-1360, or Jim Lawson, Administrator,
218/631-3510. You’ll not want to pass up this attractive
place and offer. (8/91-R)

Ideal Internal Medicine Practice: Excellent opportunity for
BC/BE internist to establish a prosperous practice. Progres-
sive 107-bed community hospital with a medical staff of 45
physicians and a service-area population of over 45,000.
Vibrant Northern Michigan community with all summer
and winter recreational activities. Very competitive first-
year guarantee with benefits. Send CV or contact: John
Schon, Administrator, Dickinson County Hospitals, 400
Woodward Avenue, Iron Mountain, MI 49801; 800/323-
8856. ’M-1/92

Professional Resume Services: Successfully serving our phy-
sician clients since 1976. CV, cover letter development,
career planning. All specialties. Effective, creative, confi-
dential. Ongoing commitment to professionalism, excel-
lence, and product quality. 800/786-3037 (24 hrs.), Alan
Kirschen, M.A. "-8-4/92

Pediatrician wanted to join group of five board-certified
pediatricians in a well-established, progressive group prac-
tice. Eocated in Minneapolis, minutes away from Chil-
dren’s Medical Center. Small practice stressing patient care
and preventive medicine. Contact: Gregg Savitt, M.D.,
3145 Hennepin Avenue, Minneapolis, MN 55408.

(9/9 I -R)

I Family Practice: Physicians seeking a BC/BF) family practice
I physician for the Norway, Michigan, service area. The
' physician would have the option of joining one of the
j existing practices and/or setting up his/her own practice.
1 Anderson Memorial Hospital is a part of Dickinson County
I Hospitals and has a service-area population of over 45,000.
I (Contact: Dr. Paul Hayes’ office, 906/563-9255, or Dr.

Join a medical group rich in support
in an area rich in natural beauty.

When you join The Duluth Clinic, Ltd., you'll become port of o 1 70-
physician multi-specialty group located on the beautiful shores of Lake
Superior and close to the Boundary Waters Canoe Area Wilderness.
As a regional referral center, the Clinic serves over 500,000 people in
northern Minnesota, northern Wisconsin and upper Michigan through
its main clinic and a network of 1 0 neighborhood centers.

Rewarding opportunities are currently available for BC/BE physicians
in the following areas;

• Allergy

• Cardiology/Electrophyslology

• Cardiolhoracic Surgery

• Dermatology

• Emergency Medicine

• Family Practice

• Hematoiogy/Oncology

• Infectious Diseases

• Internai Medicine

• Interventional Cardiology
We offer competitive compensation, a flexible benefits package and
excellent continuing education opportunities. Please send you CV to:
Michael Griffin, Physician Recruitment, The Duluth Clinic, Ltd., Dept.
T-01, 400 East Third Street, Duluth, MN 55805. Or call TOLL-FREE 1-800-
342-1388. An equal opportunity employer.

• Neurology

• Ophthalmology

• Orthopedics (Pediatric)

• Pediatrics

• Pediatric Pulmonology
(Intensivist)

• Plastic Surgery

• Pulmonology

• Rheumatology

St. Cloud Medical Group, P.A.

St. Cloud Medical Group, a 23 physician
Multi-specialty Group, is now recruiting
BC/BE physicians in the following
specialities:

• Occupational Medicine

• Pediatrics

• Family Practice

• Surgery

• OB/GYN

Guaranteed first year salary. Production
program thereafter with a full fringe
Denefit package.

If interested in joining a progressive
Medical Group in Central Minnesota,
call or send C.V. to:

Daryl G. Mathews

Administrator

St. Cloud Medical Group

1301 W. St. Germain Street

St. Cloud, MN 56301

612-251-8181

Minnesota Medicine

January 1992/Volume 75

CLASSIFIED ADVERTISING

E.N.T., PEDIATRICS,
and

FAMILY PRACTICE
for

BRAINERD MEDICAL CENTER

• Immediate Opportunity

• 20 Physician Multi-
Specialty Clinic

• New Clinic Building

• No Capitation

• No Start-up Costs

• Progressive New 162
Bed Hospital

• Beautiful Lakes and
Trees

• Two Hours from
Minneapolis

• Ideal for Families

Call CollectAVrite: Administrator Curtis j. Nielsen,
(218) 828-7100 or (218) 829-4901, P.O. Box 524,
Brainerd, MN 56401.

William Gladstone’s home, 906/563-8743. Anderson Me-
morial Hospital, Main Street, Norway, MI 49870; 906/
563-9243. -0-1/92

Pediatrics: Marshfield Clinic, a 400-physician multispecial-
ty group practice, is seeking BC/BE pediatricians to join
expanding regional centers in Chippewa Falls and Rice
Lake, Wisconsin. These are beautiful, wooded Wisconsin
areas with an abundance of lakes, rivers, and streams. Both
communities offer a thriving economic environment, clean
air, low crime, excellent schools and exceptional four-
season recreation. Chippewa Falls is a community of 22,000
with 8,000 to 10,000 permanent residents living around
adjacent Lake Wissota. It borders Eau Claire, Wisconsin, a
city of nearly 80,000 that includes a major campus of the
University of Wisconsin. Rice Lake is a lakeside community
of 8,500 people. In addition to excellent primary and
secondary schools, both public and parochial, educational
opportunities include a UW Center and VTAE campus.
Both opportunities have beautiful new clinic buildings
situated adjacent to comparably modern and progressive
hospitals. In addition to their many local resources, the
nearby proximity of major metropolitan areas (i.e., 1 1/2
hours from Minneapolis/St. Paul) provides a catalog of
readily accessible cultural activities, shopping, fine dining,
and professional spectator sports. Each opportunity has its
own special qualities with more attractive features relative
to individual needs and preferences. Emphasis on lifestyle
and quality practice is combined with a guaranteed salary
and outstanding fringe benefits package. If this combina-

tion of professional excellence and lifestyle made possible
through the backup resources of a leading medical center in
conjunction with the uncommon, varied beauty of Wiscon-
sin’s land and lakes sounds interesting to you, please send
CV and references to: David L. Draves, Director, Regional
Development, 1000 North Oak Avenue, Marshfield, WI
54449; or call 800/826-2345, ext. 5376. =M-l/92

Office Space Available 5/1/9 1 for sublease. 1,220 square
feet, Southdale Medical Building. Two exam rooms, confer-
ence room, waiting/reception area. Inquiries: 6 1 2/333-6484.

6-3/92

Redwood Falls, Minnesota — Family Physician: Outstanding
practice site in rural southwestern Minnesota, 2 1/2 hours
from Twin Cities or Rochester. Currently have four family
physicians, one general surgeon; looking to expand by one
or two BC/BE family physicians. Eull range of family
practice with competitive salary. Superb benefits and retire-
ment package, very liberal vacation time. Please respond
with CV and three letters of reference to: Dr. S. D. Medrud,
Redwood Medical Center, 1 100 East Broadway, Redwood
Ealls, MN, 507/637-2985; or Mr. Jim Schulte, Hospital
Administrator, Redwood Ealls Hospital, 100 Fallwood
Road, Redwood Ealls, MN 56283; 507/637-2907.

3-1/92

Eugene, Oregon. BC/BE Internist to join well-established,
44-physician, primary-care group. Excellent schools. Abun-
dant cultural and recreational opportunities. Near Cascade
Mountains and coast. Home of University of Oregon.
Please send CV to David Strutin, M.D., Oregon Medical
Group, 495 Oakway Road, Eugene, Oregon, 97401; or call
503/342-2134. ‘ 3-1/92

For Rent — Ski Vail, Beaver Creek, Colorado: Beautiful two-
bedroom, two-bath condo, 1,100 square feet. Located at
the entrance of Beaver Creek. On bus route. Contact: Dr.
Herald A. Trimmell, 4 14/567-8386. -=-3-1/92

Emergency Physician: Are you looking for an occasional
extra shift, or perhaps more exposure to a busy, trauma-
receiving, emergency department? North Memorial Emer-
gency Physicians are seeking BC, EM residency-trained
individuals for part-time employment as the third or fourth
physician on duty. Elexible hours/competitive pay. Contact:
Bruce Adams, M.D., or Eord Erickson, M.D., North Me-
morial Medical Center, Robbinsdale, MN 55422; 6 1 2/520-
5536. (-=-ll/91-R)

Family Physician/Internist: Regional treatment center inter-
ested in two full-time, BC/BE family practitioners/inter-
nists. Forty hours/week. Competitive salary and benefits.
Live in the exciting Brainerd lakes area. Send CV to: Chief
of Medicine, Brainerd Regional Human Services Center,
1777 Highway 18 East, Brainerd, MN 56401. 6-4/92

Burdick Treadmill and EKG for lease/rentand used medical
equipment and supplies for sale. Excellent condition. Call

218/828-1358.

6-4/92

January 1992/Volume 75

Minnesota Medicine

CLASSIFIED ADVERTISING

Internist to join two internists in active practice in scenic
upper Michigan. Medical school affiliation. Contact; North
Shore Internal Medicine, 2420 First Avenue South, Es-
canaba, MI 49829; 906/786-1563. ('■- 1 1/9I-R)

Mora, Minnesota — Family Physician needed to join a seven-
member FP group. We are a well-established, expanding
practice and offer competitive salary and benefits package
with partnership available. We have JCAHCO-accredited
hospital, on-site consultations from numerous specialty
disciplines, satellite offices located in Pine City and Hinck-
ley. Mora is a progressive community located 65 miles
north of the Twin Cities with an excellent school system and
many cultural and recreational opportunities within easy
access. Contact: Larry J. Brettingen, M.D., 224 Seventh
Street, Mora, MN 5505 1 ; 6 1 2/679- 1 340. 6-5/92

General Surgeon: Join established lucrative practice serving
two excellent hospitals and two-county population of
35,000. Peaceful, scenic city of 8,500. Excellent housing,
school system, shopping, and progressive medical staff.
Send CV to: Jim Schneckloth, 4 Sunset Place, Charles City,
lA 50616. 3-2/92

Family Practice: Fine opportunity for growing and lucrative
group practice. Progressive medical staff serves 61 -bed
hospital and county population of 19,000. Peaceful, scenic
city of 8,500 with excellent housing, schools, shopping,
hunting, sports, and wide range of community and hospital/

health services. Send CV to: [im Schneckloth, 4 Sunset
Place, Charles City, lA 506 1 6.' 3-2/92

Improve Your Writing: Need help with your writing for
professional publications or popular magazines? Former
magazine editor and University of Minnesota School of
Journalism professor of magazine writing will analyze your
writing and tutor you. 612/426-7495. ' 4-3/92

BC/BE Pediatrician to join group of six within 70-physician
multispecialty clinic. This growing and diverse practice
offers a competitive salary plus incentive, insurance, bene-
fits, excellent hospitals, schools, colleges, and cultural and
recreational activities in town of 60,000. Practice serves a
tri-state area of 225,000 population. Send CV to: Denis P.
Albright, Director of Physician Recruiting, Medical Associ-
ates Clinic, P.C., 1 000 Langworthy, Dubuque, lA 52001; or
call 319/589-9981. =‘'3-2/92

Medical Equipment for Sale: Medical equipment, furniture,
and supplies to adequately furnish a one- or two-doctor
medical practice. All equipment is in excellent and well-
maintained condition. Equipment will furnish three com-
plete exam rooms, emergency room, laboratory. X-ray
room, business office, receptionist area, and waiting room.
Laboratory includes a ZF-5 Coulter analyzer and binocular
microscope. X-ray includes older model 300 ma Profexray
X-ray machine adequate for extremities and automatic
developer. Sorry, but items cannot be sold separately. Must

Primary Care Physicians

^MULTICARE » ASSOCIATES

• THE • TWIN • CITIES

Twin Cities

Positions available for board-certified
and board-eligible physicians.

FAMILY PRACTICE
OBSTETRICS/GYNECOLOGY
INTERNAL MEDICINE
PEDIATRICS

For more information contact:

Multicare Associates of the Twin Cities,
a multi-specialty/multi-location, pre-
dominately Fee for Service Group
located in the northern suburbs of the

Twin Cities is recruiting Board Certi-
fied/Board Eligible Physicians in the
following departments:

• Family Practice

Jennifer J. Mitchell

• OB/GYN

Fairview Physician & Clinic Services

• Occupational Health

600 West 98th Street, Suite 390

• Family Practice with interest

Bloomington, MN 55420

in Occupational Health

(612) 885-6225

• Internal Medicine

or toll free 1-800-842-6469

Excellent salary and benefit package

leading to shareholder status.

Contact: Jeannine Schlottman

Administrator

Fairview

7675 Madison ST. N.E.

Hospital and Heallhcan> Sen ices

Minneapolis, MN 55432

Ah cquu! (ifilHirtiinilv viHfilifver

612-785-3338

Minnesota Medicine

January 1992/Volume 75

The backbone of
American medicine.

The human brain.

It allows our nation’s doctors to determine the best course of care for their patients.
And weigh decisions about saving money and saving lives.

Free thought founded this country. And free thought keeps it ahead of all the
others. Some say we should stop leading the world, and follow, by replacing our current
medical system with one the government controls.

But The American Medical Association believes the power of conviction and
American ingenuity can still come through with solutions. Health Access America,
the AMA’s 16-point proposal for reform of our national health care system, is a good
example. Along with preseiwing the positive aspects of American medicine. Health
Access America would improve access to it.

You can lend your support to the backbone of American medicine by advanc-
ing this significant proposal. For more information on Health Access America, call
1-800-AMA-3211.

In America, standing up for what’s best isn’t just our right. It’s our responsibility.

Health

Access

America

The AMA proposal to improvt
to affordable, quality health (

American Medical Association

Physicians dedicated to the health of America

CLASSIFIED ADVERTISING

see to appreciate. Will sacrifice for $20,000. For a complete
list of equipment or an appointment to see equipment,
please send inquiries to: Minnesota Medicine (H54), 2221
University Avenue SE, Suite 400, Minneapolis, MN 554 14.

3-2/92

Family Practice: Northeastern Iowa. Become part of the
growing Family Care Network. Established practice, ob
optional, ample coverage. Small-town atmosphere, 40-bed
hospital, 260-bed regional referral center within one-hour
drive. Excellent income guarantee plus benefits. Wanda
Parker, E. G. Todd Physician Search, Inc., 915 Broadway,
Suite 1 101, New York, NY 10010; 800/221-4762; fax:
212/777-5701. ='■ 5-4/92

Family Practice Wiscansin: Physician needed for partner-
ship in broad-based primary care practice in exceptional
south-central community. Shared call, fully equipped and
staffed office, very competitive guaranteed salary, and
comprehensive benefits package. Eor information on this
and other opportunities in the Upper Midwest, contact and
send CV to: Mary Jo Cordes, President, MDsearch, PO Box
21507, St. Pauk'MN 55121; or call: 612/454-7291. Pax:
612/454-7277. M-3/92

Orthopedic Surgeon, Minneapolis: BC/BE orthopedic sur-
geon needed to join the Department of Orthopedic Surgery
of a 340-physician multispecialty medical clinic in desirable
Twin Cities area. Our medical clinic is a highly reputable,
well-established clinic that has been in existence for over 40
years. Teaching and clinical research are encouraged, and
salary and benefits are highly competitive. Send CV and
letters of inquiry to: Patrick Moylan, Park Nicollet Medical
Center, 5000 West 39th Street, Minneapolis, MN 55416.

2-2/92

Medical Ophthalmologist needed to join a 340-physician,
multispecialty medical clinic in the attractive Minneapolis-
St. Paul area. Pull or part time will be considered. Send CV
and letterof inquiry to: j. Timothy Diegel, M.D., Chairman,
Ophthalmology, Park Nicollet Medical Center, 5000 West
39th Street, Minneapolis, MN 55416; 6 12/569-4830.

2-2/92

Internal Medicine: Immediate opportunity available for BC/
BE internist to join a well-established, 85-physician, multi-
specialty group practice in the metro Twin Cities area.
Excellent compensation and benefits package. Contact:
Nancy Borgstrom, Aspen Medical Group, 1020 Bandana
Boulevard West, St. Paul, MN 55 1 08; 6 1 2/64 1 -7 1 70. EOE.

M-1/92

Occupational Medicine Physician needed to join rapidly
expanding practice within a multispecialty group. Although
BC/BFi preferred, will consider experienced physician with
strong interest in occupational medicine. Offering subur-
ban living with easy access to unlimited array of cultural,
educational, and recreational opportunities. We offer a
highly competitive first-year guaranteed salary, produc-
tion-based compensation, and an exceptional benefits pack-

()xl>oro Clinics, a large, progressive, multi-
specialty practice with offices in Bloomington
and Burnsville, offers outstanding physician
opportunities.

• Pediatrics

• Obstetrics/Gynecology

• Internal Medicine

For more information, contact:

Jennifer J. Mitchell
Fairview Physician & Clinic Services
600 West 98th Street, Suite 390
Bloomington, MN 55420
(612) 885-6225
or toll free 1-800-842-6469

age. For further information contact: John Bordwell, M.D.,
9055 Sprmgbrook Drive, Coon Rapids, MN 55433; 612/
780-9155. M-1/92

Family Practice: BC/BF family practitioner to join 21-
person family practice department that is part of a 45-
person multispecialty group located in the northern suburbs
of Minneapolis. Practice opportunities available in rural
and suburban locations. Highly competitive first-year guar-
anteed salary, production-based compensation, and excep-
tional benefits package. Respond with CV to: Penny Mag-
nuson, M.D., 9055 Springbook Drive, Coon Rapids, MN
55433; 612/780-9155. M-1/92

Oshkosh, Wisconsin: Single-specialty groups arc recruiting
in family practice, pediatrics, ob/gyn, and cardiology. Osh-
kosh is an attractive community of 55,000 people, located
on the shores of Eake Winnebago and in the heart of
Wisconsin’s beautiful Fox River Valley. Competitive finan-
cial packages. Contact: Christopher Kashnig, Physician
Recruiter, Mercy Medical Center, 63 1 Hazel Street,
Oshkosh, WI 54902; or call: 800/242-5650, Ext. 2430, or
414/236-2430. T3-,3/92

Exam Couches for sale. Three tan, upholstered exam couch-
es with stirrups and receptacles. In excellent condition and
priced right for quick sale. Suitable for new practitioner or
practice expansion. Please call 6 12/935-3962. 1-1/92

Minnesota Medicine

January 1992/Volume 75

CLASSIFIED ADVERTISING

Eleventh Annual Big Sky Pulmonaty/Ski Conference: March
25-29, 1 992. Contact: American L.nng Association of Mon-
tana, 825 Helena Avenue, Helena, MT 59601;406/442-
6556. M-1/92

Family Practice — Minnesota: Enjoy the benefits of country
living yet have the resources of a major metropolitan area
close at hand. Health One Buffalo Hospital is seeking a
family physician to join two FPs and a nurse practitioner in
its clinics in Annandale and Winsted. Share call with five
physicians. Competitive compensation with excellent ben-
efits including year-round outdoor recreation in “the heart
of the lakes.” Contact: Kim Isenberg, Health One Buffalo
Hospital, 303 Catlin Street, PO Box 609, Buffalo, MN
55313; 612/682-1212, Ext. 245. 6-6/92

The University of Minnesota School of Dentistry invites
applications for part-time and full-time non-regular faculty
for consultative diagnostic and treatment-planning services
in specialty clinics. M.D. required, with training and expe-
rience in otolaryngology, cleft palate patient care, and/or
physical medicine and rehabilitation with experience in
chronic pain. The University of Minnesota is an equal
opportunity educator. Send resume (indicating specialty or
area(s) of clinical expertise] by 6/30/92 to: Dean Richard P.
Elzay, University of Minnesota School of Dentistry, 515
Delaware Street SE, Minneapolis, MN 55455. 1-1/92

The University of Minnesota School of Dentistry invites
applications for research fellow (M.S., M.D., or D.D.S.
required), research associate (Ph.D. required), and postdoc-
toral associate (Ph.D. within three years required) posi-
tions. Applicants must have at least two years of research
training. Positions v/ill provide research expertise in plan-
ning and execution of research design and methodology.
The University of Minnesota is an equal opportunity educa-
tor and employer. Send resume [indicating specialty or
area(s) of clinical expertise] by 6/30/92 to: Dean Richard P.
Elzay, University of Minnesota School of Dentistry, 515
Delaware Street SE, Minneapolis, MN 55455. ‘^1-1/92

Quality Childcare in Your Home: Individual attention from
a nurturing nanny educated in child development. Person-
ally interviewed. Rebecca’s Nanny Agency, 6 1 2/763-46 1 0.

M-1/92

Wisconsin — Internist Wanted: Group Health Cooperative,
a progressive, growing, staff-model HMO in a city of
60,000 in west-central Wisconsin, is currently recruiting a
third internist. Very competitive salary with excellent fringe
benefits. Practice high-quality internal medicine in a most
desirable location. Please contact: Stuart R. Lancer, M.D.,
M.B.A., Medical Director, Group Health Cooperative, PO
Box 3217, Eau Claire, W1 54702-3217; 715/836-8552.

3-3/92

ational area. Competitive salary and fringe benefits. Con-
tact: Stuart R. Lancer, M.D., M.B.A., Medical Director,
Croup Health Cooperative, PO Box 3217, Eau Claire, W1
54702-3217; 715/836-8552. «-3-3/92

Wisconsin — Family Practitioner Needed by progressive and
growing group practice in west-central Wisconsin city of
60,000. Ninety miles from Minneapolis/St. Paul. Primarily
prepaid practice with large component FES. Highly compet-
itive salary with excellent fringe benefits. Practice high-
quality care in a good recreational area. Send CV to: Stuart
R. Lancer, M.D., M.B.A., PO Box 3217, Eau Claire, WI
54702-3217; 715/836-8552. =•-3-3/92

New '92 Cars, Minivans, and Trucks — Save $$: Pay only a
few hundred dollars over actual dealer cost! All makes and
models. Full factory warranty. Save money. Save time. Save
aggravation. Dealership delivery. Call Tom Rush at Auto
Direct, 612/342-2886. ='-l-l/92

JANUARY 199 2 INDEX TO ADVERTISERS

Benno L. Kristensen 12

Brainerd Medical Center 52

C. F. Anderson Company, Inc 7

Duluth Clinic 5 1

Eli Lilly N Company 6, 7

Fairview Physician & Clinic Services 53

G.D. Searle Cover 4

Group Health, Inc Cover 2

Health Risk Management 47

Hennepin Faculty Associates 4

Hutchinson Medical Center 34

Leonard, Street and Deinard 34

Lifespan Health Care Services 50

Medica 33

Medical Claims Processing, Inc 34

Minnesota Medical Services Corporation 2

Multicare Associates of the Twin Cities 53

Oxhoro Clinics 55

Palisades Pharmaceuticals, Inc 25

Quality Transcription, Inc 10

Runyan-Vogel Architects 12

St. Cloud Hospital 51

St. Paul-Ramsey Medical Center 47

Sea bury & Smith 8

University of Minnesota CME Cover 3

University of Minnesota Medical Outreach 12

Vein Clinics of America 47

Veterans Administration Medical Center, St. Cloud 50

Whitesell Medical Locums, Ltd 36

Wisconsin — Fourth BC/BE Obstetrician/Gynecologist need-
ed to join stable, progressive, primary-care-based HMO/
group practice in university town of 60,000 near Minneap-
olis/St. Paul. Excellent quality of life and outstanding recre-

January 1992/Volume 75

Minnesota Medicine

and i:^racticc intcmctT

Podin tries

Continuing Education and Extension, University of Minnesota

992

.ardiovascular Update
utsen Lodge
anuary 18-19

ifectious Disease Update
anuary 31

,/eekend Seminar Series:

(I Update
utsen Lodge
ebruary 29-March 1

I rimary Care Update
'''ali, Indonesia
ebruary 14-23

leriatric Drug Therapy
lymposium:

Psychotropic Medications
ebruary 26-27

■revention and Management of
'itherosclerotic Diseases
ebruary 28

Medical Update '92
Ft. Lauderdale, Florida
March 9-13

Geriatric Medicine Review
March 11-14

50th Annual
Allergy and Clinical
Immunology
April 2-3

Annual Ophthalmology Course
April 6-7

Seminar in Colorectal Diseases
for the Primary Care Physician
April 24

Weekend Seminar Series:
Current Developments in
Pediatrics and Obstetrics
April 25

Symposium of the International
Liver Transplantation Society
April 29-May 2

Family Practice Review and

Update

May 4-8

Symposium on Gynecology and
Gynecologic Oncology
May 12

Current Concepts in Radiation

Therapy

May 13-15

Clinical Hypnosis: Introductory
and Advanced Workshops
June 5-6

Topics and Advances in

Pediatrics

June 10-12

Progress in Vascular Surgery
June 17-20

Continuing Medical Education, Suite 107, Radisson Hotel Metrodome, 615 Washington Avenue SE, Minneapolis, Mh 55455, (612) 636-7600
j The University of Minnesota is an equal opportunity educator and employer.

CAPim

The recommended starting dose for Calan SR is 180 mg
once daiiy. Dose titration will be required in
some patients to achieve blood pressure control.

A lower initial starting dosage of 120 mg/day may be warranted in some patients
(eg, the elderly, patients of small stature).

Constipation, which is easily managed in most patients, is the most commonly
reported side effea of Calan SR.

BRIEF SUMMARY

Contraindications: Severe LV dysfunction (see Warnings), hypotension (systolic pressure
< 90 mm Hgl or cardiogenic shock, sick sinus syndrome (if no pacemaker is presenti, 2nd- or
3rd-degree AV block (if no pacemaker is present), atrial flutter/fibrillation with an accessory
bypass tract (eg, WPW or LGL syndromes), hypersensitivity to verapamil.

Warnings: Verapamil should be avoided in patients with severe LV dysfunction (eg, ejection
fraction < 30%) or moderate to severe symptoms of cardiac failure and in patients with any
degree of ventricular dysfunction it they are receiving a beta-blocker Control milder heart failure
with optimum digitalization and/or diuretics before Calan SR is used. Verapamil may occasionally
produce hypotension. Elevations of liver enzymes have been reported. Several cases have been
demonstrated to be produced by verapamil. Periodic monitoring of liver function in patients on
verapamil is prudent. Some patients with paroxysmal and/or chronic atrial flutter/fibrillation and
an accessory AV pathway (eg, WPW or LGL syndromes) have developed an increased antegrade
conduction across the accessory pathway bypassing the AV node, producing a very rapid
ventricular response or ventricular fibrillation after receiving I.V. verapamil (or digitalis). Because
of this risk, oral verapamil is contraindicated in such patients, AV block may occur (2nd- and
3rd-degree, 0,8%). Development of marked Ist-degree block or progression to 2nd- or 3rd-
degree block requires reduction in dosage or, rarely, discontinuation and institution of appropriate
therapy. Sinus bradycardia, 2nd-degree AV block, sinus arrest, pulmonary edema and/or severe
hypotension were seen in some critically ill patients with hypertrophic cardiomyopathy who were
treated with verapamil.

Precautions: Verapamil should be given cautiously to patients with impaired hepatic function
(in severe dysfunction use about 30% of the normal dose) or impaired renal function, and patients
should be monitored for abnormal prolongation of the PR interval or other signs of overdosage.
Verapamil may decrease neuromuscular transmission in patients with Duchenne's muscular
dystrophy and may prolong recovery from the neuromuscular blocking agent vecuronium. It may
be necessary to decrease verapamil dosage in patients with attenuated neuromuscular transmis-
sion. Combined therapy with beta-adrenergic blockers and verapamil may result in additive
negative effects on heart rate, atrioventricular conduction and/or cardiac contractility; there have
been reports of excessive bradycardia and AV block, including complete heart block. The risks
of such combined therapy may outweigh the benefits. The combination should be used only
with caution and close monitoring. Decreased metoprolol and propranolol clearance may occur
when either drug is administered concomitantly with verapamil. A variable effect has been seen
with combined use of atenolol. Chronic verapamil treatment can increase serum digoxin levels
by 50% to 75% during the first week of therapy, which can result in digitalis toxicity. In patients
with hepatic cirrhosis, verapamil may reduce total body clearance and extrarenal clearance of
digitoxin. The digoxin dose should be reduced when verapamil is given, and the patient carefully
monitored. Verapamil will usually have an additive effect in patients receiving blood-pressure-
lowering agents. Disopyramide should not be given within 48 hours before or 24 hours after
verapamil administration. Concomitant use of flecainide and verapamil may have additive effects
on myocardial contractility, AV conduction, and repolarization. Combined verapamil and quinidine
therapy in patients with hypertrophic cardiomyopathy should be avoided, since significant
hypotension may result. Concomitant use of lithium and verapamil may result in a lowering of
serum lithium levels or increased sensitivity to lithium. Patients receiving both drugs must be
monitored carefully. Verapamil may increase carbamazepine concentrations during combined use.
Rifampin may reduce verapamil bioavailability. Phenobarbital may increase verapamil clearance.
Verapamil may increase serum levels of cyclosporin. Verapamil may inhibit the clearance and
increase the plasma levels of theophylline. Concomitant use of inhalation anesthetics and calcium
antagonists needs careful titration to avoid excessive cardiovascular depression. Verapamil may
potentiate the activity of neuromuscular blocking agents (curare-like and depolarizing): dosage
reduction may be required. There was no evidence of a carcinogenic potential of verapamil
administered to rats for 2 years. A study in rats did not suggest a tumorigenic potential, and
verapamil was not mutagenic in the Ames test. Pregnancy Category C. There are no adequate
and well-controlled studies in pregnant women. This drug should be used during pregnancy,
labor, and delivery only if clearly needed. Verapamil is excreted in breast milk; therefore, nursing
should be discontinued during verapamil use.

Adverse Reactions: Constipation (7.3%), dizziness (3.3%), nausea (2.7%), hypotension (2.5%),
headache (2.2%), edema (1.9%), CHF, pulmonary edema (1.8%), fatigue (1.7%), dyspnea (1.4%),
bradycardia: HR < 50/min (1.4%), AV block: total r,2°,3° (1.2%), 2° and 3° (0.8%), rash
(1.2%), flushing (0.6%), elevated liver enzymes, reversible non-obstructive paralytic ileus. The
following reactions, reported in 1.0% or less of patients, occurred under conditions where a
causal relationship is uncertain: angina pectoris, atrioventricular dissociation, chest pain, claudi-
cation, myocardial infarction, palpitations, purpura (vasculitis), syncope, diarrhea, dry mouth,
gastrointestinal distress, gingival hyperplasia, ecchymosis or bruising, cerebrovascular accident,
confusion, equilibrium disorders, insomnia, muscle cramps, paresthesia, psychotic symptoms,
shakiness, somnolence, arthralgia and rash, exanthema, hair loss, hyperkeratosis, macules,
sweating, urticaria, Stevens-Johnson syndrome, erythema multiforme, blurred vision, gyneco-
mastia, galactorrhea/hyperprolactinemia, increased urination, spotty menstruation, impotence.

4/11/91 .P91CA6277V

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Box 5110. Chicago. IL 60680

Address medical inquiries to
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Minnesota Medicine

A JOURNAL OF CLINICAL AND .HEALTH AFFAIRS

COVER

Family Violence, long recognized as a soci-
etal problem, is clearly a medical problem as
well. Physicians treat thousands of battered
women each year, and, says this month’s
cover story (page 19), they can help arrest
the cycle of violence simply by asking com-
passionate questions and offering informa-
tion. Reporting abuse is not necessarily
straightforward, says the Medicine Law &
Policy article (page 35), which describes the
legal remedies available to battered women.

Cover illustration by Susan Nees, who
lives in Athens, Georgia.

MINNESOTA MEDICINE
Owner and Publisher
Minnesota Medical Association
Editor-in-Chief Edmund C. Burke, M.D.
Managing Editor Meredith McNab
Editorial Assistant Susan R. Rodsjo

Send manuscripts, subscriptions, and other
material for consideration to Minnesota
Medicine, 111 1 University Avenue SE, Suite
400, Minneapolis, MN 55414, 612/378-
1 875. The editors reserve the right to reject
editorial, scientific, or advertising material
submitted for publication in Minnesota
Medicine. The views expressed in this jour-
nal do not necessarily represent those of the
■Vlinnesota Medical Association, its editors,
or any of its constituents. Annual Subscrip-
tion - $27.00. Single copies - $2.25. Cana-
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To Advertise: Contact Michael Soucheray,
Minnesota Medicine, 2221 University
Avenue SE, Suite 400, Minneapolis, MN

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COPYRIGHT AND
POST OFFICE ENTRY
Minnesota Medicine (ISSN 0026-556X) is
published on the fifth of each month by the
Minnesota Medical Association, 222 1 Uni-
versity Avenue SE, Suite 400, Minneapolis,
MN 55414, copyright 1992. Permission to
reproduce editorial material in this maga-
zine must be obtained from Minnesota
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send address changes to: Minnesota Medi-
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Minnesota Medicine

FEBRUARY 1992 VOLUME 75 NUMBER 2
FACE TO FACE

The Shape of Things to Come: MMA Docs Have Their Say
at the Legislature

Minnesota Medicine interviews MMA Legislative Committee Chair
Roger W. Becklitnd, M.D. 13

PERSPECTIVES

Like Horatio, Physician Struggles to Make Sense of Tragedy

Clifton R. Cleaveland, M.D. 17

COVER STORY

Family Violence Intervention: Physicians Find It’s More
Than Treating Injuries

Miriam K. Feldman 1 9

CLINICAL & HEALTH AFFAIRS

The Child at Risk for Developing Heart Disease —

Third of Three Parts

Albert P. Rocchini, M.D., and Mary Ella Pierpont, M.D. 25

Lasers in Dermatology: A Review

Charles H. Dicken, M.D. 31

MEDICINE LAW & POLICY

The Physician’s Response to Domestic Violence:

Legal Issues

Loretta M. Frederick, J.D. 35

ON THE BUSINESS SIDE

Market Timing: Prime Investment Strategy or
Optimist’s Dream?

Dale L. Waltz 39

DEPARTMENTS

Editor’s Notebook

News Clips

Letters to the Editor

CME in Minnesota

Instructions for Authors

Classified Advertising

President’s Letter

Index to Advertisers

February 1992 /Valume

We know kids
inside.

And out.

It’s nice to have family nearby when
you’re faced with a medical problem. Es-
pecially if you’re a kid. So we see a lot of
families at Children’s Hospital of St. Paul.

In fact, we believe that you can’t care
for kids without caring for families, too.
We call it family- centered care, and it
means we have a lot more than a waiting
room. We have parent support groups. We
have a child life program that helps
parents understand behavior changes in
their child, and prepares sisters and
brothers to feel comfortable in a hospital
environment. We have unrestricted visit-
ing for parents, siblings and even pets.
And our rooms are private and designed
so a parent can stay overnight.

It’s not just our facilities but also our
attitude. Our staff knows how to commu-

nicate with children in language they
understand. We encourage as much
involvement as possible with parents.
Our staff explains and reassures every
step of the way Because we understand
that many times the parent is more
frightened than the child.

But mostly, we understand kids. At
Children’s Hospital of St. Paul, everything
from the playrooms to the emergency
room is planned for kids. We have one of
the finest pediatric staffs in the country
And the latest in pediatric advances.

So when your child
needs medical care,
come to the place that
really knows how to
care. For the family as
well as the child.

Children’s

Hospital

*Sf. Paul

MINNESOTA MEDICAL ASSOCIATION

1990-91 Officers
President

Thomas A. Stolee, M.D.

President-Elect
A. Stuart Hanson, M.D.

Chair, Board of Trustees
Andrew J. K. Smith, M.D.

Vice President
Barbara P. Yawn, M.D.

Secretary

Thomas B. Dunkel, M.D.
Treasurer

Joseph A. Celia, Jr., M.D.

Speaker of the House
J. Randolf Beahrs, M.D.

Vice Speaker of the House
Richard D. Mulder, M.D.

Past President

Richard B. Tompkins, M.D.

Chief Executive Officer
Paul S. Sanders, M.D.

Auxiliary

President
Phyllis H. Ellis

Editor-in-Chief
Edmund C. Burke, M.D.

Advisory Committee
Edmund C. Burke, M.D.
Thomas W. Day, M.D.
Alice G. Harris, M.D.
Charles R. Meyer, M.D.
Paul S. Sanders, M.D.
Andrew J. K. Smith, M.D.
Anne B. Warwick, M.D.
Meredith McNab
•Vlark Vukelich

Editors Emeritus
Richard E. Reece, M.D.
1975-1990

Reuben Berman, M.D.
1971-1974

Ciarl O. Rice, M.D.
1961-1970

Minnesota Medicine

Board of Trustees

N. W. District
Erick Reeber, M.D.

N.E. District
Thomas W. Day, M.D.

Jack B. Greene, M.D.

N. Central District
James J. Dehen, M.D.

David M. Van Nostrand, M.D.

West Metro

Roger W. Becklund, M.D.
Andrew J. K. Smith, M.D.,
Chr.

Richard E. Student, M.D.
George V. Tangen, M.D.
Ronald L. Villella, M.D.

East Metro

Joseph E. Rigatuso, M.D.

Kent S. Wilson, M.D.

S.W. District

Theodore L. Eritsche, M.D.
Anthony C. Jaspers, M.D.

S.E. District

Gail E. Gamble, M.D.

J. Paul Marcoux, M.LT.
Thomas L. Peyla, M.D.
Resident Member
Cherie J. Hayostek, M.D.

Medical Student
Ty Dunn

Review Board
Chester A. Anderson, M.D.
Donald C. Bell, M.D.
Dorothy Bernstein, M.D.

F. Blanton Bessinger, M.D.
Jonathan H. Biebl, M.IT.
Paul J. Bilka, M.D.

Clyde E. Blackard, M.D.

R. J. Campaigne, M.D.
Richard P. Carroll, M.D.
Roger S. Colton, M.D.
Gerald E. Cotton, M.D.
Peter Dorsen, M.D.

Peter Fehr, M.D.

Paul Gannon, M.D.

James B. Gaviser, M.D.

H. W. Heupel, M.D.

Neil Hoffman, M.D.

James Janecek, M.D.

Miles J. Jones, M.D.

Carl M. Kjellstrand, M.D.
Arnold Kremen, M.D.
Warren 1.. Kump, M.D.
Van S. Eawrence, M.D.

Cj. Patrick Eilja, M.D.
Merle K. Eoken, M.D.
Merle S. Mark, M.D.

John K. Meinert, M.D.

AM A
Trustee

William E. Jacott, M.D.
AMA Delegates
Robert D. Christensen, M.D.
E. Duane Engstrom, M.D.

A. Stuart Hanson, M.D.
James F. Knapp, M.D.
Audrey M. Nelson, M.D.

Ben P. Owens, M.D.

Richard B. Tompkins, M.D.,
Chr.

AMA Alternates
Carolyn J. McKay, M.D.
Michael J. Murray, M.I9.

C. Randall Nelms, Jr., M.D.
Lawrence M. Poston, M.D.
Thomas A. Stolee, M.D.
James J. Tiede, M.D.

L. Ashley Whitesell, M.D.

Senior Staff

Director of Economics &
Government Relations
Roger K. Johnson

Chief Financial Officer
George C. Lohmer, Jr.

Director of Communications
Mark S. Vukelich

General Legal Counsel
Mary E. Prentnieks, J.D.

James J. Monge, M.D.

John S. Najarian, M.D.

Bruce C. Nydahl, M.D.

Milton Orkin, M.D.

Richard R. Owen, M.D.
Michael M. Paparella, M.D.
James J. Pattee, M.D.

Willard Peterson, M.D.

John J. Regan, M.D.

Krishna M. Saxena, M.D.
William F. Schoenwetter, M.D.
Alvin L. Schultz, M.D.

Edward L. Seljeskog, M.D.
John E. Smith, M.D.

Farrell S. Stiegler, M.D.

George T. Tani, M.IT.

Robert ten Bensel, M.D.

John V. Thomas, M.D.

John Verby, M.D.

Anne B. Warwick, M.D.
Robert E. Woodburn, M.D.

Contributing

Organizations

Minnesota Allergy Society
Minnesota Society of
Anesthesiologists
Minnesota Dermatologic
Society

Minnesota Association of
EMS Physicians
Minnesota Chapter,

American College of
Emergency Physicians
Minnesota Academy of
Family Physicians
Minnesota Component,
American Society of
Internal Medicine
Minnesota Chapter, American
College of Physicians
Minnesota Society of
Neurological Sciences
Association of Neurologists
of Minnesota
Minnesota Neurological
Society

Minnesota Association of
Nursing Home Medical
Directors

Minnesota Obstetrical and
Gynecological Society
North Central Occupational
Medical Association
Minnesota Academy of
Ophthalmology
Minnesota Orthopaedic
Society

Minnesota Academy of
Otolaryngology-Head &:
Neck Surgery
Minnesota Society of
Clinical Pathologists
Northwestern Pediatric
Society

Minnesota Chapter, American
Academy of Pediatrics
Minnesota Physiatric Society
Minnesota Academy of
Plastic Surgeons
Minnesota Psychiatric Society
Minnesota Radiological
Society

Minnesota Cihapter, American
College of Surgeons
Minnesota Surgical Society
Minnesota Thoracic Society
Minnesota Urological Society

February 1992/Volume 75

Minnesota Medicine Advisers and Reviewers

TO BENEFIT
YOU AND YOUR
PRACTICE...

When you think about member benefits, insurance
programs often come to mind. However, as a
member of the Minnesota Medical Association, you
are entitled to much, much more. The Minnesota
Medical Services Corporation sponsors a variety of
other programs for you and your practice.

Each program has been carefully evaluated by the
Minnesota Medical Services Corporation, a
wholly-owned subsidiary of the MMA, to provide
convenience, reliability, personal service, expert
administration, and special member rates.

IMMSC is

I^AT YOURi=f

; Service

COMPUTER SYSTEMS TRAVEL PROGRAMS

EQUIPMENT LEASING

COLLECTION SERVICE CAR RENTAL DISCOUNTS MOBILE CELLULAR PHONES

MAGAZINE SUBSCRIPTIONS
MAILING LISTS

PERSONAL AND BUSINESS
CREDIT CARD PROGRAMS

CREDIT CARD PROFESSIONAL
SERVICES

MANAGEMENT CONSULTING
RESOURCE LIST

LEGAL SERVICES
RESOURCE LIST

For information on any of these programs, please call us at (612) 378-0305.

The Minnesota Medical Services Corporation is the wholly-owned product and
services subsidiary of the Minnesota Medical Association.

MMA

Minnesota MeOlcal Association

MINNESOTA
MEDICAL
SERVICES
CORPORATION

EDITOR'S NOTEBOOK

Physicians Fight Family Violence

Edmund C . Burke, M . D .

One hundred thousand days
of hospitalization, 30,000
emergency department visits,
and 40,000 physician visits consti-
tute the annual medical cost of
family violence. “The home is actual-
ly a more dangerous place for Amer-
ican women than city streets,” said
U.S. Surgeon General Antonia C.
Novello, M.D., at a news conference
to announce the American Medical
Association’s National Campaign
Against Family Violence, which is
intended to heighten physician
awareness of this major health
problem.

Novello challenged physicians to
take an active role in the “fight”
against family violence. Physicians
have traditionally had only minor
involvement in addressing sexual
abuse, spouse battering, and elder
abuse, she said. “While doctors are
often the first to see battered women,
children, and the elderly, they lack
the training and sensitivity to help
arrest the violence.”

According to this month’s cover
story (page 19), from 2 to 4 million
women nationwide and 63,000 in
Minnesota are physically abused each
year by the men in their lives. By
simply asking compassionate ques-
tions and offering information on
resources for battered women,
physicians can help women escape
the violence, says tbe article. Also in
this issue, the Medicine Law & Policy
article (page 35) describes the legal
remedies available to victims and
outlines physicians’ legal require-
ments for reporting, or not reporting,
domestic abuse.

At its interim meeting in Decem-
ber, the AMA adopted council
recommendations to recognize fami-
ly violence as a medical problem.
Physicians have an ethical obligation
to intervene, concluded the associa-

Minnesota Medicine

“We must put an end
to the tragic cycle of
family violence.”

tion, which advises physicians to
familiarize themselves with proto-
cols for diagnosing and treating
domestic abuse.

As part of its effort to educate
physicians about the problem, the
AMA is sending letters to all physi-
cians asking them to participate in a
National Coalition of Physicians
Against Violence. Coalition mem-
bers will establish violence preven-
tion committees to develop resource
directories, distribute protocols,
conduct educational programs, and
lobby for state and federal legisla-
tion related to domestic violence.

As part of the AMA campaign,
the association is establishing a
national resource center and
clearinghouse that will provide
clinical protocols to help physicians
diagnose, treat, and try to prevent
continuing family violence. The
center will also offer consultation
and training on issues of family
violence through conferences, work-
ing groups, and publications.

The protocols were distributed in
January and are available from the
AMA. Ciarole Warshaw, M.D., one
of the authors and a psychiatrist,

February 1992/Volume 75

internist, and former emergency phy-
sician at Cook County Hospital in
Chicago, said, “Inquiry about abuse,
even if specific indicators are not
present, should become a standard
part of medical care.” The protocols
give examples of how to ask women
about abuse in an open and support-
ive manner.

The AMA campaign coincides
with new standards set by the Joint
Commission on the Accreditation of
Healthcare Organizations to address
domestic and elder abuse. The new
standards, which took effect January
1 , require all emergency and ambula-
tory care services to develop criteria
to identify victims of abuse; collect,
retain, and safeguard specimens, pho-
tographs, and other evidence of abuse;
notify authorities when legally re-
quired; and refer victims to appropri-
ate community services.

Our own state has some excellent
programs for helping victims of
domestic abuse. Susan Hadley,
M.P.H., runs a program at Fairview
Southdale Hospital in Edina called
“WomanKind,” which trains staff
to identify battered women and
provides victims with support and
referrals. Since Hadley started the
program in 1 986, it has assisted more
than 4,000 clients.

The Duluth Abuse Intervention
Project has a coordinated system of
responses to domestic violence, in-
cluding court-mandated education
and counseling for batterers and
mandatory arrest if there is injury
and sufficient evidence of abuse. The
program follows abuse cases for
several years to ensure that the sys-
tem responds appropriately.

I urge you to do your part. It is
our duty as physicians to treat all
aspects of illness, and to do so we
must put an end to the tragic cycle of
family violence. mm

“ Being a patient advocate is what being a physician is all about!’

Dr. Kevin Fullin, Cardiologist, Kenosha, Wisconsin, Member, American Medical Association

Why would a cardiologist get involved in the issue
of fanruly violence? Perhaps, because what he saw
simply cried out for action.

“Fully a third of all women’s injuries coming into
our emergency rooms are no accident,” says Dr. Fullin.

While others were content to downplay the issue
of family violence. Dr. Fullin would not. He petitioned
state officials, and through his efforts the first Domestic
Violence Advocate Program in his state was created.

“Organized medicine must serve as an advocate
for patients,” stressed Dr. Fullin.

The American Medical Association (AMA) couldn’t

agree more. We’re committed to focusing physician
attention on the issue of family violence.

You are invited to join Dr. FuUin and to join with
him in his efforts to bring quality health care to those in
need. Become a member of the American Medical
Association today.

Members of the AMA are encouraged to join their state, county and specialty societies.

American Medical Association

Physicians dedicated to the health of America

LETTERS TO THE EDITOR

HCMC Shares Concern for Teenage
Medical Assistance Patients

In a December letter to the editor
(“Teenage Pregnancy and Infant
Mortality,” page 7), Dr. Alec L.
Janes expressed concern that
Hennepin and Ramsey county
hospitals are denying services to
teenage, indigent patients most at
risk for problem pregnancies.

We share Dr. Janes’ concern for
this population and wish to express
our own concern that while such
was not the case at Hennepin
County Medical Center when Dr.
Janes wrote his letter, it may, in
some instances, be the case now.
The reason is complex and starts
with the 1985 state mandate that
all Medical Assistance recipients,
including AFDC, select a managed
care health plan, thereby eliminat-
ing access to care through the
historical fee-for-service system.

MA recipients were given three
managed care plans from which to
choose: PHP (now Medica),

U-Care, and Metropolitan Health
Plan (MHP), Hennepin County’s
own certified HMO.

Unfortunately, since the
inception of the mandated pro-
gram, HCMC has not been al-
lowed to participate in the Medica
hospital network. This has not
meant that HCMC has denied care
to Medica patients when they’ve
presented at HCMC, but it has
meant that Medica has denied
reimbursement to HCMC for
services rendered to Medica
enrollees. Because many Medica
enrollees had historically been
HCMC patients, they continued to
come here for care totalling more
than $1 million between 1985 and

1988. In 1989-90, another $99,814
worth of patient services was
delivered gratis to Medica enroll-
ees.

Only recently, given the tough
economic realities of managing a
major tertiary teaching hospital
that serves a broad spectrum of the
community, was it decided to deny
access (except in emergencies) to
Medica MA enrollees, effective
January 1992. Since September, we
have implemented an aggressive
educational program for “our
patients” explaining that because
our hospital is not part of the
Medica network, they must select
MHP as their managed care
program if they wish to continue
coming to HCMC. To date, 521
Medica enrollees have taken notice
and changed their managed care
affiliation to MHP.

HCMC’s and Hennepin
County’s long-standing commit-
ment to the teenage at-risk popula-
tion is reflected in HCMC’s
preterm-birth prevention program,
which has shown outstanding
results for more than 250 clients
over the past four years, and Pilot
City Health Center’s school-based

“mini-clinic,” which has served
thousands of high-risk pregnant
teenagers during its 12-year
history.

It is understandable that the
general public, patients, and
physicians are confused about the
mandated managed care program
and HCMC’s role in it. Historical-
ly, HCMC’s mission has been to
serve the community at large,
including its less fortunate mem-
bers and at-risk populations. To
fulfill this mission, HCMC must
remain financially viable. We shall
continue our efforts to explain this
system to our patients so they can
continue to be served here and we
can be reimbursed for that service.
Like Dr. Janes, we hope that “a
concerted effort on the part of all
concerned can be successful” both
for the sake of the patients and the
providers that serve them.

John W. Blitford
Deputy Administrator
Hennepin County Medical Center
and Director
Metropolitan Health Plan
Minneapolis, Minnesota

County Hospital Staffs Not
Abandoning Patients

I would like to respond to the letter
to the editor from Alec L. Janes,
M.D., in the December 1991 issue
of Minnesota Medicine. It is true
that Hennepin County Medical
Center and St. Paul-Ramsey
Medical Center are no longer
providers for AFDC/PHP patients,
and this may, indeed, have an
adverse impact on availability and
continuity of care, especially for
young, pregnant patients. How-
ever, the medical staffs at these
institutions had nothing to do with
the decision, which was made by
PHP (Medica) for economic

Minnesota Medicine

February 1992/Volunne 75

LETTERS TO THE EDITOR

reasons. It upsets me to think that
some practitioners believe we are
willfully abandoning our tradition-
al clientele.

I am a dermatologist, not an
obstetrician/gynecologist, but one
of the reasons that I, and many of
my HCMC colleagues, work for
“the county” is because our
underserved patient populations
sorely need competent care. It feels
good to provide such care. I believe
most of us would prefer to provide
care under AFDC/PHP. I hope the
private sector will rise to the
occasion and fill some of the needs
this policy has created.

Cynthia L. Olson, M.D.

Staff dermatologist

Hennepin County Medical Center

Minneapolis, Minnesota

Show Up and Be Counted

The Minnesota Legislature and the
United States Congress are current-
ly in session. As the old adage goes,
“Life, limb and property are not
safe while either is in session.” This
year, the Minnesota Legislature
will consider several health care
issues that directly affect physicians
and their practices (see this
month’s Face to Face interview
with MMA Legislative Committee
Chair Roger Becklund, M.D., page
13).

The problem is, as one state
senator has said, “Those who show
up get listened to,” and physicians
as a group do not show up at the
Legislature. To “show up” means
that you get to know your legisla-
tor and let him or her know your
position on issues; you become
active in your legislator’s cam-
paign; and you team up with our
lobbyists from the Minnesota
Medical Association and make
rounds to important senators and
representatives who are involved in
particular legislation.

Most physicians feel removed
from and disinterested in the
legislative process. They are

frustrated by the slow-moving,
muddled nature of the process,
which is dominated by compro-
mise. However, getting involved in
the process is the best way to
influence health care legislation.

Many physicians think nothing
of spending an hour in the doctor’s
lounge moaning about “what the
legislature is doing to us now” but
will not join the MMA in its
lobbying efforts or spend time
talking to legislators. It is as simple
as writing a letter, making a phone
call, or showing up at the State
Capitol while the Legislature is in
session. It is simply not enough for
physicians to hire lobbyists. The
lobbyists do a remarkable job and
are very adept at their profession,
but hiring a lobbyist is similar to
hiring someone to attend your
child’s school play — you cannot get
parental credit for sending some-
one else. At the Legislature, there is
no equal substitute for the physi-
cian. It is far more effective for a
practicing physician who knows
the ins and outs of the problem to
tell the representative or senator
exactly how the law will affect his
or her practice and patients.

It is imperative that we, as
physicians, get involved. Write
letters, make phone calls, join and
support the MMA and its lobbying
efforts (even if you don’t agree
with 100 percent of its views),
become involved in MEDPAC, pay
attention to the elections in your
district, and give money to those
who support your views. Remem-
ber, none of us is too busy to pay
attention to the issues that affect
our ability to deliver quality
medical care to our patients. Stop
moaning in the doctor’s lounge and
show up and be counted.

John A. Dowdle, M.D., P.A.

Orthopedic surgeon

University Park Medical Bnilding

St. Paid, Minnesota

February 1992/Volume 75

Child Abuse Workshop

A new workshop for professionals
who work with victims of child
sexual abuse and perpetrators has
been developed by local experts
Ann Ahlquist, A.C.S.W., and Jane
G. Gilgun, Ph.D. The workshop
stresses both the theoretical
understanding and the practical
skills needed to be competent in
one’s role in a child sexual abuse
case as social worker, attorney,
guardian ad litem, or any profes-
sional who must make decisions
about the issue of sexual abuse of
children.

The seminar, called “The
Fragile Relationship Between
Victims and Perpetrators,” is open
to any professional concerned with
the sexual abuse of children. It will
be held from 8:30 a.m. to 4:30
p.m., February 7, 1992, at West
River Point Conference Center,
Minneapolis, and February 14,
1992, at Best Western Edgewater,
Duluth. The fee is $1 10 per person.

The seminar is designed for the
various professionals who work
together on child sexual abuse
cases. It covers a broad spectrum of
topics, including a look at the
continuum of victim/perpetrator
relationships, blocks to disclosure
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To register, or for a complete
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Campbell Meeting Management
St. Paid, Minnesota

AAOS Launches Campaign to
Prevent Injury

The American Academy of Ortho-
paedic Surgeons has launched a
national public education program
on injury prevention. The initial
phase concerns juvenile injuries
sustained in recreational activities.

Minnesota Medicine

LETTERS TO THE EDITOR

with an emphasis on playgrounds.

Last year, 237,000 children
under age 15 were treated in
hospital emergency rooms for
injuries related to playground
equipment, and many more were
treated in physicians’ offices. Focus
group interviews have disclosed
that the public is unaware of the
large number of injuries related to
playground equipment. The
participants said physicians’ caring
image would be enhanced if the
physicians presented information in
their offices about preventing
injury.

The academy is calling atten-
tion to the problem and to the
playground safety guidelines of the
U.S. Consumer Product Safety
Commission in a “Play It Safe”
poster and brochure.

Members of your medical
association may be interested in
distributing the information in
their practices or reaching out to
their local communities. For
posters or brochures, contact the
AAOS Department of Communica-
tions and Publications, 222 South
Prospect Avenue, Park Ridge, IL
60068; 708/823-7186.

Robert Herisinger, M.D.
first Vice President
American Academy of Orthopaedic

Surgeons
Park Ridge, Illinois

Send Letters

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sota Medicine'’s Letters to the
Editor department provides a
forum for discussing, rebutting,
or debating views presented in
Minnesota Medicine — or for
sharing any aspect of practicing
medicine in Minnesota. Your
letter will reach about 90
percent of the state’s physicians,
plus many other health profes-
sionals.

Please keep letters under 500
words and mail them to: Edmund
C. Burke, M.D., Editor-in-Chief,
Minnesota Medicine, 2221
University Avenue SE, Suite 400,
Minneapolis, Minnesota 55414.

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Minnesota Medicine

February 1992/Volume 75

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Precautions: General- 1 . Symptomatic response to nizatidine therapy does not preclude the presence
of gastric malignancy.

2. Dosage should be reduced in patients with moderate to severe renal insufficiency.

3. In patients with normal renal function and uncomplicated hepatic dysfunction, the disposition of
nizatidine is similar to that in normal subjects.

Laboratory Tesfs-False-positive tests ior urobilinogen with Multistix’ may occur during therapy.

Drug Interactions -No interactions have been observed with theophylline, chlordiazepoxide, lorazepam,
lidocaine, phenytoin, and warfarin. Axid does not inhibit the cytochrome P-450 enzyme system; therefore,
drug interactions mediated by inhibition ol hepatic metabolism are not expected to occur. In patients given
very high doses (3,900 mg) of aspirin daily, increased serum salicylate levels were seen when nizatidine,
150 mg b.i.d., was administered concurrently

Carcinogenesis. Mutagenesis. Impairment of Fertility- A 2-year oral carcinogenicity study in rats with
doses as high as 500 mg/kg/day (about 80 times the recommended daily therapeutic dose) showed no evidence
ot a carcinogenic effect. There was a dose-related increase in the density ol enterochromaffin-like (ECL) cells
m the gastric oxyntic mucosa. In a 2-year study in mice, there was no evidence ol a carcinogenic effect in male
mice, although hyperplastic nodules ol the liver were increased in the high-dose males as compared with
placebo. Female mice given the high dose of Axid (2,000 mg/kg/day. about 330 times the human dose) showed
marginally statistically significant increases In hepatic carcinoma and hepatic nodular hyperplasia with no
numerical increase seen in any of the other dose groups.The rate of hepatic carcinoma in the high-dose
animals was within the historical control limits seen lor Ihe strain ol mice used. The female mice were given
a dose larger than the maximum tolerated dose, as indicated by excessive (30%) weight decrement as compared
with concurrent controls and evidence of mild liver injury (transaminase elevations). The occurrence ot a marginal
finding at high dose only in animals given an excessive and somewhat hepatotoxic dose, with no evidence of a
carcinogenic effect in rats, male mice, and female mice (given up to 360 mg/kg/day, about 60 times the human
dose), and a negative mutagenicity battery are not considered evidence of a carcinogenic potential for Axid,

In a 2-generation, perinatal and postnatal fertility study in rats, doses of nizatidine up to 650 mg/kg/day
produced no adverse effects on the reproductive performance of parental animals or their progeny.

Pregnancy- Teratogenic Effects -Pregnancy Category C-Oral reproduction studies in rats at doses up
to 300 times the human dose and in Dutch Belted rabbits at doses up to 55 times the human dose revealed no
evidence of impaired fertility or teratogenic effect; but, at a dose equivalent to 300 times the human dose,
treated rabbits had abortions, decreased number of live fetuses, and depressed fetal weights. On intravenous
administration to pregnant New Zealand White rabbits, nizatidine at 20 mg/kg produced cardiac enlargement,
coarctation of the aortic arch, and cutaneous edema in 1 fetus, and at 50 mg/kg, it produced ventricular
anomaly, distended abdomen, spina bifida, hydrocephaly, and enlarged heart in 1 fetus. There are. however,
no adequate and well-controlled studies in pregnant women. It is also not known whether nizatidine can
cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Nizatidine
should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers -Studies in lactating women have shown that 0.1% ot an oral dose is secreted
in human milk in proportion to plasma concentrations. Because of growth depression in pups reared
by treated lactating rats, a decision should be made whether to discontinue nursing or the drug, taking
into account the importance of the drug to the mother.

Pediatric L/se-Safety and effectiveness in children have not been established.

Use in Elderly Patients -Heating rates in elderly patients were similar to those in younger age groups
as were the rates of adverse events and laboratory test abnormalities. Age alone may not be an important
factor in the disposition of nizatidine. Elderly patients may have reduced renal function.

Adverse Reactions: Worldwide, controlled clinical trials included over 6,000 patients given nizatidine in
studies of varying durations. Placebo- controlled trials in the United States and Canada included over 2,600 patients
given nizatidine and over 1 .700 given placebo. Among Ihe adverse events in these placebo-controlled trials, only
anemia (0.2% vs 0%) and urticaria (0.5% vs 0.1%) were significantly more common in the nizatidine group. Of
the adverse events that xcurred at a frequency of 1% or more, there was no statistically significant difference
between Axid and placebo in the incidence ot any of these events (see package insert lor complete information).

A variety ol less common events were also reported; it was not possible to determine whether these
were caused by nizatidine.

ffepafrc-Hepatocellular injury (elevated liver enzyme tests or alkaline phosphatase) possibly or probably
related to nizatidine occurred in some patients. In some cases, there was marked elevation (>500 lU/L) in
SCOT or SGPT and, in a single instance, SGPT was >2,000 lU/L. The incidence of elevated liver enzymes
overall and elevations of up to 3 times the upper limit of normal, however, did not significantly differ from that
in placebo patients. All abnormalities were reversible after discontinuation of Axid. Since market introduction,
hepatitis and jaundice have been reported. Rare cases of cholestatic or mixed hepatocellular and cholestatic
injury with jaundice have been reported with reversal of fhe abnormalities after discontinuation of Axid.

Cardiovascular-tn clinical pharmacology studies, short episodes of asymptomatic ventricular tachycardia
occurred in 2 individuals administered Axid and in 3 untreated subjects.

C/VS-Rare cases of reversible mental confusion have been reported.

Endocrine-Ctinieat pharmacology studies and controlled clinical trials showed no evidence of anti-
androgenic activity due to nizatidine. Impotence and decreased libido were reported with similar frequency
by patients on nizatidine and those on placebo. Gynecomastia has been reported rarely.

Hematologic -Anemia was reported significantly more frequently in nizatidine than in placebo-treated
patients. Fatal thrombocytopenia was reported in a patient treated with nizatidine and another Hj-receptor
antagonist. This patient had previously experienced thrombocytopenia while taking other drugs. Rare cases
ol thrombocytopenic purpura have been reported.

Inlegumenlal -Wicaiia was reported significantly more frequently in nizatidine- than in placebo-treated
patients. Rash and exfoliative dermatitis were also reported.

Hypersensitivity -As with other Hj-receptor antagonists, rare cases ol anaphylaxis following nizalidine
administration have been reported. Rare episodes ol hypersensitivity reactions (eg, bronchospasm, laryngeal
edema, rash, and eosinophilia) have been reported,

Of/ier-Hyperuncemia unassociated with gout or nephrolithiasis was reported Eosinophilia, lever, and
nausea related to nizatidine have been reported

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emesis, or lavage should be considered along with clinical monitoring and supportive therapy. The ability of
hemodialysis lo remove nizatidine from the body has not been conclusively demonstrated: however, due to its
large volume ol distribution, nizatidine is not expected to be efficiently removed from Ihe body by this method.
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FACE TO FACE

The Shape of Things to Come

MMA Docs Have Their Say at the Legislature

Minnesota Medicine interviews Roger W . B e c kl u n d , M . D .

Physicians have been major players in policy de-
bates in this state, thanks to the commitment of
physicians like Roger Becklund, M.D., who chairs
the MMA Legislative Committee. Physicians will again
have the opportunity to help shape
health care in Minnesota when the
state Legislature reconvenes Febru-
ary 17. In this month ’s interview. Dr.

Becklund explains the role of the
MMA's Legislative Committee and
urges physicians to get involved in
politics by contributing to campaigns
and getting to know their legislators.

State legislators often look to the
Minnesota Medical Association for
guidance on health care issues. In the
last few years alone, the MMA has
successfully promoted several health-
related initiatives, including a law
that gave legal weight to living wills,
a plan that established a loan-
forgiveness program for physicians
in rural areas, and legislation that
has increased cigarette taxes to the
highest level in the nation.

According to Dr. Becklund,
health care access and AIDS testing
will be the most important medical
issues on this year's legislative agen-
da. Others will likely include Medi-
caid reimbursement, workers' com-
pensation reform, and regulation of
utilization review firms. Medicaid reimbursements are
scheduled to increase July 1, and ensuring that the
increases actually take place is an MMA priority.

The Legislative Committee recommends MMA posi-
tions on such issues after discussing how they will affect
patients and the practice of medicine, says Dr. Becklund.
After positions are established by the House of Delegates
or the Board of Trustees, MMA lobbyists communicate
them to legislators. But in order for lobbying efforts to be
successful, physician members must be involved. Not
only should members call and write their legislators, but
they can also join tbe lobbing effort — go to the Capitol
and testify before committees or discuss issues with
legislators in person. Dr. Becklund believes legislators
truly listen to physicians' views on health care issues, but
first physicians must let their legislators know they have
something to say.

Minnesota Medicine: Dr. Becklund, please tell us a little
about your background. Where did you go to school,
where did you get your surgical training, and how did
you end up in Minneapolis.^

Becklund: I received my undergradu-
ate degree from St. Olaf College in
Northfield, Minnesota, in 1957. I
graduated from the University of
Chicago School of Medicine in 1961,
and I did my internship in surgical
residency at Blodgett Hospital in
Grand Rapids, Michigan. I then
came to Minneapolis and started my
own private practice.

Minnesota Medicine: You’re not
solo any longer, are you?

Becklund: No, I’m nor. After about
13 years, another physician joined
my practice, and about three years
later, we added two more physicians.
Our practice now consists of four
general surgeons.

MMAs Legislative Committee

Minnesota Medicine: How did you
become interested in the Minnesota
Medical Association, and how did
you eventually become chair of the
MMA’s Legislative Committee?

Becklund: Before I became involved with the MMA, I
was a trustee, president, and chairman of the board of the
Hennepin County Medical Society. In 1988,1 was asked
to serve as a trustee representing HCMS on the MMA
Board of Trustees, and 1 agreed to serve for a short time.
As it turns out. I’m still a board member.

1 became involved with the Legislative Committee in
1989, when Dr. Paul Sanders — then chairman of the
MMA board — asked me to chair the Legislative Com-
mittee.

Minnesota Medicine: What is the function of the MMA’s
Legislative Committee?

Becklund: The committee has several goals, but I think
the most important one is to assist the MMA Board of
Trustees in developing association policy for health-
related matters. The committee reviews all resolutions

Roger W. Becklund, M.D.

“If physicians want
to be major players
in policy debates,
they have to get
involved.”

Minnesota Medicine

February 1992/Volume 75

FACE TO FACE

from the House of Delegates that deal with legislation
and then makes recommendations to the board. It also
reviews health care legislation that other groups intro-
duce. The Legislative Committee is usually involved in
drafting proposed legislation, which we review again
after the staff finishes it. We also disseminate informa-
tion to the membership on various legislative issues.

Minnesota Medicine: How large is the Legislative Com-
mittee?

Becklund: We have about 15 members, which is typical
of the MMA's standing committees. We have represen-
tatives from all around the state, based on the number of
physicians in each district, and we have a broad represen-
tation of specialists.

The committee is made up of very dedicated mem-
bers who take their responsibility seriously. We meet five
to seven times per year with activities beginning in
November and intensifying from February through May.
We also have an outstanding staff that makes sure we
have access to all the information we need to make
appropriate decisions.

Taking a Stand

Minnesota Medicine: How does the MMA develop
positions on specific legislation?

Becklund: The MMA House of Delegates establishes
MMA policy, but the house is only in session two days
a year, at the MMA’s annual meeting. Because medical
issues change continuously, the Board of Trustees is
empowered to establish policy when the House of Dele-
gates isn’t in session.

Many people look at the Legislature and see a slow-
moving, inefficient body, but, in reality, things move
very quickly at times. That’s why we have full-time
lobbyists following activities very closely at the Capitol.
As issues arise, staff members present them to the com-
mittee and recommend appropriate MMA positions.
The committee thoroughly discusses the issue and con-
siders how it will affect our patients and the practice of
medicine. After discussion, the committee adopts a rec-
ommendation, which is sent to the board.

At times, particularly near the end of legislative
sessions, when things move very fast, the MMA Execu-
tive Committee makes final decisions based on Legisla-
tive Committee recommendations.

Reaching Legislators and MMA Members

Minnesota Medicine: Once the MMA Board of Trustees
adopts a position, how is it communicated to legislators?

Becklund: First, we disseminate the information to our
members, and we hope they will discuss it with their
legislators. Then our staff lobbyists meet regularly with
the legislators during the legislative session to communi-
cate our positions. Our staff also meets with legislators
throughout the year to discuss important issues.

Minnesota Medicine: How do you reach the members?

Becklund: We communicate through the MMA’s publi-
cations, Minnesota Medicine and The Monitor. We also
send out Legislative Alerts. These alerts are crucial to our
lobbying efforts. They usually are a “call to action’’
asking physicians to call or write their legislators about
a specific issue. We need a good response from the
membership for these alerts to be effective.

The MMA Auxiliary also has been extremely valu-
able. The auxiliary has set up an effective system for
calling on key contacts to write or call their legislators.
When we need a message to reach the Legislature, for
example, they are ready to respond and have done so
many times in the past.

Minnesota Medicine: What’s the best way for a physi-
cian to respond to a Legislative Alert}

Becklund: Letters are best for physicians who don’t
know the legislators well enough to call them. Even a
short note has real impact. Even better is to pick up the
phone and talk directly to the person. A call from a
physician the legislator knows is far more effective than
a call from a stranger. In spite of what we might think,
legislators listen to us when it comes to health care issues,
especially if the issues don't involve financing.

Minnesota Medicine: Do you testify before House and
Senate committees and lobby legislators?

Becklund: I, personally, have not testified. The commit-
tee and the MMA lobbyists make sure physicians are
available to testify, and we try to call on people who have
known expertise in the area of testimony. At times, our
lobbyists testify, but whenever possible, we get physi-
cians.

Minnesota Medicine: Do you consider federal, as well as
state, issues?

Becklund: Yes, we look at federal issues that involve
Minnesota physicians, and our participation in these
issues has increased during the last few years. We rely a
great deal on the American Medical Association for
direct lobbying on federal issues, but we have improved
our relations with the Minnesota Congressional Delega-
tion to the point where its members sometimes ask us to
take positions on specific federal legislation.

MMA’s 1992 Legislative Agenda

Minnesota Medicine: What are the top legislative issues
currently affecting health care and Minnesota Medical
Association members?

Becklund: The two main things on our agenda this year
are health care access and AIDS. A health care access bill
was passed and subsequently vetoed last year, and the
issue is certainly going to come up again. This was a
major piece of legislation that would have directly
affected every physician in Minnesota. Because the gov-
ernor vetoed the bill, the issue will be back in several
different forms this year. The governor, the HMO
Council, and the Insurance Federation all have their own
bills, and there may be an attempt to override the

February 1992/Volume 75

Minnesota Medicine

FACE TO FACE

governor’s veto from last year. The MMA plans to be a
major player in negotiations for a solution. This is a top
priority.

Of equal importance to physicians is the effort to
control the spread of AIDS in the health care setting. We
know this issue will be considered by the Legislature this
session, and we are attempting to develop a response to
the outcry for mandatory testing. We want to ensure that
any related legislation is responsible
to the public and is based on rational,
scientific findings.

Minnesota Medicine: Do you think
legislators will try to pass mandatory
testing laws? The Department of
Health and the MMA are urging
voluntary testing.

Becklund: I think the issue will be
brought up in the Legislature, but I
doubt the Legislature will agree to
mandatory testing. The thing that
worries us is that some politicians
might try to appease the public because it’s an election
year. We are trying to make sure this issue is not decided
based on hysteria.

Minnesota Medicine: With elections coming up, do you
think it’s accurate to assume that every politician run-
ning for office will have his or her own version of what
ought to be done to improve our health care system?

Becklund: Yes, I think that’s true. However, we hope our
legislators will do more than merely respond to public
pressure and, instead, will act as leaders and try to
educate the public. At times, it requires tough and
unpopular decisions by legislators. Historically, those
legislators willing to make sometimes unpopular deci-
sions have become the great leaders of our society.

MEDPAC’s Impact

Minnesota Medicine: Do candidates for office come to
you or the MMA to ask about our stance on particular
health care issues?

Becklund: In general, politicians are more likely to listen
to our views on issues that don’t involve the finances of
medicine. Candidates for office are usually more inter-
ested in MEDPAC, the MMA’s political action commit-
tee. It’s a separate organization that is supported by
voluntary contributions from MMA and auxiliary
members. As the political arm of the medical association,
MEDPAC endorses candidates and contributes money
to campaigns. The endorsements are based on each
candidate’s stance on important health care issues.

Minnesota Medicine: How effective is MEDPAC?

Becklund: It’s quite effective. At a minimum, it makes
physicians visible through its campaign contributions.
MEDPAC doesn’t do any actual lobbying. Its work is
limited to making campaign contributions to legislators
who represent, or at least consider, our viewpoints. It is

one of the largest PACs in the state. In the last election,
more than 90 percent of the candidates endorsed by
MEDPAC won their elections.

Minnesota Medicine: Would you urge MMA members
to join MEDPAC?

Becklund: Definitely. Although MEDPAC is fairly large,
less than 10 percent of MMA members join. Therefore,
a large number of MMA physicians
are benefiting from the financial
support of a small number of mem-
bers. Nobody likes writing checks
to political campaigns, but if physi-
cians want to be major players in
policy debates, they have to get in-
volved.

There are actually two ways to
contribute to campaigns. When you
join MEDPAC, your money is dis-
tributed to various campaigns, de-
pending on the candidates’ positions.
You can also make individual cam-
paign contributions to people running for office in
your area. Both types of contributions are very effective.
We can’t buy legislators’ votes, and I don’t want to
give the impression that we can, but by contributing
to the campaigns, we get access to the legislators. Giv-
ing contributions won’t sway legislators’ decisions,
but it gives us an opportunity to talk to them about the
issues.

Minnesota Medicine: How beneficial is MEDPAC to
physicians?

Becklund: It’s very beneficial, but I believe it’s even more
important for physicians to get to know their individual
legislators. Invite them out for breakfast and talk over
the issues, attend their fundraisers, contribute to their
campaigns, and volunteer to be on their campaign com-
mittees— that’s important.

The MMA staff and officers travel to medical
societies during the year to discuss legislative issues
with members and local legislators. Attending these
meetings is a good way to meet your local legislator.
This year, MMA President Tom Stolee has taken it
upon himself to visit every society in the state, and he’s
putting forth tremendous effort.

Minnesota Medicine: Many physicians become frustrat-
ed with the legislative process and don’t understand why
we need to be involved. What do you have to say to these
physicians?

Becklund: Medicine has undergone many changes over
the past 25 years, but can you imagine the chaos we
would have if physicians had no input into these
changes? In a loose paraphrase of Winston Churchill:
“Democracy is far from perfect, but it’s the best form
of government we have.” It’s our responsibility as phy-
sicians, like it or not, to be involved in the democratic
process in order to dedicate ourselves to protecting our
patients’ best interests. mm

“We hope our
legislators will do
more than merely
respond to public
pressure.”

Minnesota Medicine

February 1992/Volunne 75

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PERSPECTIVES

Like Horatio, Physician Struggles to
Make Sense of Tragedy

Clifton R. Cleave land, M.D.

The week had been tiring and discouraging — more
long-term patients than usual had come to my
office with illnesses for which I could do little but
empathize and palliate. Aged men and women with
declining intellects, emphysemic men slowly fading on
continuous oxygen, a young woman with rapidly pro-
gressive motor neuron disease — I felt
progressively stymied and ineffectual,
longing for some more acute situa-
tion in which I could work toward a
cure.

I sought respite at a weekend
showing of the new movie version of
“Hamlet.” The reviews had been
enthusiastic, and I was prepared for
a cinematic treat. Thirty minutes
passed, and 1 was really into the film,
marveling at the language, the scen-
ery, and the splendid diction of Close
and Gibson. Then a door at the rear of
the cinema opened, and an usherette
cried out that a doctor was needed.

Reflexively, I followed her out. As we
rushed to the auditorium next door, I asked what was
wrong. She said that a man had been shot. I ran down the
center aisle to the side of an old man stretched out supine,
apparently having had a cardiac arrest. The house lights
had not yet been turned up; “Dances With Wolves”
played on the screen. Apparently, the old man’s collapse
into the aisle had coincided with gunfire from the
soundtrack. Some of the audience clustered around;
others nearby seemed fixed in their seats. Most in the
full house were unaware of what had happened. An
elderly woman wept in an adjacent seat.

The man was not breathing. He had no pulse. My
reflexes took over as I began chest compressions and
directed a nurse who had just arrived to begin mouth-to-
nose respirations.

“Call 911.”

“We have.”

Kevin Costner continued on the wide screen behind
us, blurring our boundaries of reality. Another nurse
arrived and then a family physician acquaintance. The
elderly lady, apparently the victim’s wife, sobbed, “What
will 1 do, what will I do? We’ll have no place to live.” 1
tried to lend comfort as 1 elicited a fragmentary history
from her. Her husband had had a heart attack five
years earlier, he took digoxin, and he had been asymp-
tomatic and active.

“Where’s the rescue squad?”

“We’ve called again.”

Five compressions and a breath, five compressions
and a breath; the house lights slowly came up. His pupils
were reactive; the old man began to breathe; he moved
his lips.

Our impromptu team was gain-
ing. A firm carotid pulse at a rate of
30 to 40 was present and then faded.
I resumed chest compressions while
one of the nurses mopped my fore-
head and helped to remove my sweaty
jacket. The family physician spelled
me at the chest, and I checked pupil-
lary responses and femoral pulses,
now bounding from the closed chest
massage. The old man moved his
hands — the last spontaneous move-
ment we were to see.

After 20 minutes, a fireman ar-
rived with a bottle of oxygen, and I
took another turn at the chest — five
and one, five and one. The numbing
and pounding work of resuscitation continued. Helpful
strangers guided the tearful wife away from the circle and
tried to console her. From the back door, the theater
manager announced that everyone should leave and
obtain a ticket refund. Many patrons, however, re-
mained frozen in their seats, staring now at the film’s
buffalo stampede. Perhaps the movie freed them from
the horror that all now perceived in the center aisle.

Finally, the equipment-laden rescue squad arrived,
as did a third physician, who placed an IV in the man’s
left arm. One EMT inserted an endotracheal tube, while
another attached the leads of a cardiac monitor. Coarse
ventricular fibrillation. We shocked. No response. Bicar-
bonate and lidocaine were given, followed by a second
shock and another. A junctional rhythm appeared
briefly before deteriorating into fibrillation. The electri-
cal and chemical ritual of resuscitation continued
against a backdrop of increasing hopelessness. Three
doctors, three nurses, and a team of EMTs were power-
less to do any more in the theater aisle. We eased the
old man onto a board, board onto stretcher, and then
stretcher into ambulance. The rescue squad assumed
control for the several-mile ride to the nearest hospital.
I learned later that the death begun in the theater had
ended in the emergency room.

Who was the old man? What would become of

“Our job is to try to
restore order, to allay
somehow the grief and
hurt of others. But
what becomes of the
feelings engendered
in us?”

Minnesota Medicine

February 1992/Volume 75

PERSPECTIVES

the new widow? Who was the retarded adult sitting next
to her? A stranger? A kinsman? Why was she worried
about losing her home? I knew neither the man nor his
wife, yet in the curious way of clinical
medicine, a bond of sorts had been
struck.

I was weak, sweat-drenched, and
utterly wrung out. I wanted to cry. I
wanted to know the old man’s story.

For a brief few minutes our lives had
twisted together. I was sharply aware
of my own mortality because he lost
his life. I felt shaky, decidedly non-
professional, and vulnerable. I washed
up in the cinema’s restroom and com-
posed myself. As I rejoined my wife for
what remained of “Hamlet,” Mel Gib-
son delivered the Prince’s epiphany to
Yorick’s skull — words made all the more piercing by the
real life just concluded. We viewed the compounded
tragedy of the final scene: Gertrude, Claudius, Laetes,
Hamlet, all dead. Horatio was left to mourn and to
struggle to make sense of the calamities engulfing the
survivors.

As physicians we see much. Things go predictably for
us most of the time, and then chaos erupts. At such times

we are trained to shift to methodical, automatic counter- |
measures. Sometimes these prevail. Oftentimes death '
prevails. Grief erupts and swirls about us. Our job is to '
try to restore order, to allay somehow !
the grief and hurt of others. But what
becomes of the feelings engendered '

in us?

The immediate feelings — fatigue, |

frustration, a sense of aloneness —
will wane. Over a longer term we
may think that tragedy may broaden |
our sympathies, but tragedy may also
quietly add to our burden of grief,
building life charge in an emotional j
capacitor. Burn-out lurks always, or
worse, insensitivity. We try to dis-
tance ourselves from the hurt by
speaking to colleagues of a failed
code or some intervention gone awry. We retreat behind
jargon and understatement. Somehow we put the mask
of professionalism back in place. We are ready for
another day. mm

Clifton Cleaveland is with Associates in Internal Medi-
cine, Chattanooga, Tennessee. The essay is reproduced
with permission from: Cleaveland CR. "CPR," Ann
Intern Med 199 1 ;1 1 5:570-1 .

“For a brief few
minutes our lives had
twisted together. I was
sharply aware of my
own mortality because
he lost his life.”

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18 February 1992/Volume 75 Minnesota Medicine

COVER STORY

Kevin J. Fullin, M.D., a cardiologist in Kenosha, Wisconsin, recently helped
establish a hospital-based program for victims of domestic violence. Now
Dr. Fullin has earned a reputation as the doctor who treats battered women.
Fullin’s colleagues often say to him, “I hear you’re working with battered
women.” And Fullin replies, “So are you.” ♦ Fullin’s response, as

related by Amanda Cosgrove, coordinator of the Domestic
Violence Project at St. Catherine’s Hospital in Kenosha,
implies that physicians everywhere are treating battered
women; many just don’t realize it. Thousands of battered
women and other victims of domestic violence visit
doctors’ offices and emergency rooms each year. In most
cases, they are treated and sent back to violent homes.

Family Violence Intervention

Physicians Find Its More Than Treating Injuries

♦ Doctors don’t return patients to violent situations because they are callous
or indifferent. Physicians simply haven’t been taught to
recognize or deal with the signs of domestic violence.

“We spend hours and hours in medical school talking about
diseases that we probably will never see, and we spend no time
learning about [domestic violence], which is extremely pervasive,
and the morbidity and mortality is expensive,” says David Moen,

M.D., who works in the emergency room at Fairview Southdale Hospital and has
written about his own experiences treating battered women. “We’re not trained
to recognize [abuse] in our practices, and if you’re not trained to recognize
something, you tend not to look for it.”

By Miriam K . Feldman

Minnesota Medicine

February 1992/Volume 75

COVER

STORY

Physicians across the country are about to get a
crash course in domestic violence. With the AMA
leading the way, physicians will be hearing more
and more about the violence that occurs between people
who are intimate with one another. Last October, the
AMA launched its “Campaign Against Family Vio-
lence,” with Robert McAfee, M.D., proclaiming, “Do-
mestic violence is an epidemic
that threatens the public
health. Yet until now,
America’s physicians
have not been educated
about this epidemic in
any coordinated way.”
McAfee, who is vice
chair of the AMA’s
board of trustees, chal-
lenged every physician
in America to “be aware
of the role domestic violence may be playing in your
patients’ medical complaints.”

The AMA’s campaign grew out of its Council on
Scientific Affairs report on violence against women,
although the campaign also covers violence against
children and the elderly. (This article focuses on battered
women, a problem that until now has received little
attention from the medical profession.) The campaign
includes a letter to every physician in the country urging
each one to learn more about family violence; establish-
ment of the National Medical Resource Center and
Clearinghouse for the Prevention of Family Violence;
publication of a special issue oi JAMA devoted to family
violence; and creation of a set of guidelines to assist
doctors in diagnosing, treating, and, when possible,
preventing continuing domestic violence.

Family violence is a medical problem, the AMA
asserts, and physicians have an obligation to intervene.

“Health care providers
may be the first and only
professionals in a position to
recognize violence in their
patients’ lives.”

-Susan Hadley, M.P.H.

Although physicians can’t stop abuse, they can identify
and document it, provide victims with sensitive support,
make necessary referrals, and report the abuse when
appropriate (see “The Physician’s Response to Domestic
Violence: Legal Issues,” page 35).

The facts on domestic violence, cited by the AMA,
are overwhelming:

• From 22 percent to 35 percent of women who visit

emergency rooms have symptoms related to abuse, but
as few as 5 percent of the victims are identified as such.

• Between 2 million and 4 million women nation-
wide, and 63,000 in Minnesota, are physically battered
each year by the men in their lives.

• Domestic violence is the single largest cause of
injury to women in the United States, more frequent than
automobile accidents, muggings, and rapes combined.

• Each year, domestic violence leads to 1 00,000 days
of hospitalization, 30,000 emergency room visits, and
40,000 visits to the physician.

• More than one-third of women murdered in Amer-
ica are killed by husbands or boyfriends.

• At least half the time, if the wife (mother) is being
physically abused, so are the children.

• One in five battered women presenting to physi-
cians has sought medical attention for injuries from
abuse 1 1 times previously.

• Children who have been abused and returned home
without intervention face a 50 percent chance of further
abuse and a 10 percent chance of death resulting from
abuse.

• Child homicide is now among the five leading
causes of death in childhood, with the majority of infant
victims killed by parents, relatives, and other children.

• More than 1 million — 4 percent — of older Ameri-
cans are physically and emotionally abused by their
relatives.

espite the preva-
lence of domes-

tic violence
and the frequen-
cy with which
victims seek
medical care,
physicians rarely
acknowledge the role
violence plays in their pa-
tients’ complaints, according to a
study by Carole Warshaw, M.D., an
internist and psychiatrist at Cook County
ITospital in Chicago. Physicians probed into the
causes of injuries in less than one-third of the cases she
studied at Cook County Hospital, and in 92 percent of
the cases, the discharge diagnosis did not reflect the
presenting symptoms of abuse.

“Even when a woman had clearly been injured by
another person, often her spouse, she would rarely be
asked any questions that would indicate an awareness on
the part of the physician that he or she was interacting
with a woman at risk for abuse,” Warshaw writes in the
journal Gender & Society.

Warshaw, a member of the committee that is writing
guidelines for the AMA’s campaign on family violence,
isn’t indicting individual physicians, but rather is com-
menting on a medical system that reinforces detachment
and allows the physician to remain emotionally aloof.

Being a good doctor means “fixing and solving
problems, coming up with a diagnosis, and then doing

February 1992/Volume 75

Minnesota Medicine

COVER STORY

something about it,” Warshaw said in a
recent interview. But to treat victims of
violence, the physician must delve deeper
and look beyond the presenting symptoms.

“It really challenges the role of the physi-
cian,” she said. “The physician needs to
help facilitate change, not control it.”

Health care workers are in a key posi-
tion to treat domestic violence, even though
the traditional medical model discourages in-
volvement and medical training ignores the sub-
ject altogether. “Health care providers may be the
first and only professionals in a position to recog-
nize violence in their patients’ lives,” says Susan Hadley,
M.P.H., the founder and director of WomanKind, which
provides advocacy for battered women and education
for health care professionals at Fairview Southdale Hos-
pital in Edina and Fairview Ridges Hospital in Burns-
ville. “They are in a position to recognize and provide
early intervention, before the violence gets worse. If a
woman comes in today and is not recognized, I can
almost promise that she will come back in six months and
be more severely battered.”

Physicians may wonder how they can find time to

deal with domestic violence, particularly if
they already feel overworked or believe the
issue belongs with the courts, police, or
social workers. But experts say it doesn’t
take much time to address the issue. What’s
more, acknowledging the problem could
help break the cycle of violence that repeat-
edly sends the victim back for medical care.
‘The medical profession is ready,” says Had-
ley. “They just don’t know what to do. What
if they ask a woman if she’s been battered and
she says yes, then what do they do?”

Warshaw agrees. “It’s not very hard if they’re
prepared to do it. They’re afraid if they open it up, it will
take forever. ‘Uh, oh, now what do I do?’ As opposed to,
‘I know what to do, and I can take care of it.’ ”

There are a number of things physicians can do,
starting with learning to recognize the signs of
abuse. According to Moen, the signs are not
much different from the red flags for child abuse: a
delay between injury and presentation and injuries to the
head, neck, breast, trunk, abdomen, or pelvic areas.
“Those things are a tip-off for violent injuries as

Physician, Heal Thyself

Physician, heal thyself. That’s the premise of a
program developed by the Hennepin County
Medical Society in which physicians and nurses
at a number of hospitals around the metro area are
examining the abuse in their own lives and their
attitudes toward domestic violence.

“Physicians and nurses are saying that it is critical
to recognize abuse that is present in their training,
clinics, hospitals, families, and childhoods as the
means of recognizing abuse in patients,” according to
the medical society.

This is a ground-breaking project, according to
Deborah Anderson, president of Respond 2, Inc., and
a consultant who is facilitating the projects at North
Memorial Medical Center, the nursing department
at the University of Minnesota Hospital and Clinic,
Riverside Medical Center, Fairview Southdale Hos-
pital, Unity and Mercy Hospitals, Park Nicollet
Medical Center, and the Hennepin County Medical
Society Auxiliary.

“It’s very hard for physicians to identify abuse
unless they can see it in themselves. If they can
recognize it in each other, they will immediately know
what to do with patients,” says Anderson, who calls
this “a major new role for physician leadership.”
Physicians, she says, are acknowledging abuse as a
“we” problem and asking, “How would we want to
be treated?” They are asking how to recognize abuse,
what barriers keep them from identifying it, and what

their role is in defining new kinds of interventions.

Research has shown that abuse, particularly ver-
bal abuse, is common in hospitals and affects patient
care, staff productivity, morale, and turnover. Merle
S. Mark, M.D., of North Memorial Medical Center,
said in the March/April 1991 HCMS Bulletin, that
there is also a need to address conflict, abuse, and
neglect in health care families. “Medical marriages are
fraught with stresses and strains on spouses and
children above and beyond the norm in many profes-
sional families,” he says.

Allen Kuperman, M.D., chairs a committee at
North Memorial Medical Center that is examining
conflict, abuse, and neglect in health care families.
“Most of us are familiar with signs and symptoms of
more overt family violence, child abuse, and so on,”
says Kuperman, a pediatrician. “Hopefully, as 1 phy-
sicians | come to grips with some of the developmental
antecedents — the experiences that put a person at
risk — they will begin to recognize signs in patients at
much earlier stages,” he says. “1 think certainly a
physician who fails to recognize this in himself puts a
blind eye to it and may do the same to his patients.”

The medical society project is important, says
Susan Hadley, founder and director of WomanKind,
Inc., a hospital-based advocacy program for battered
women. “We can’t identify in someone else what we
haven’t begun to look at in ourselves.”

MKF

Minnesota Medicine

February 1992/Volume 75

COVER STORY

For more information . . .

The AMA’s message is loud and clear: Physicians
everywhere should consider the role domestic
violence plays in their patients’ medical com-
plaints. This is new territory for most physicians, and
dealing appropriately with victims of violence is going
to take some education.

Physicians should keep an open mind and try to
learn as much about the problem as they can, says
David Moen, M.D., an emergency physician at Fair-
view Southdale Hospital in Edina. “There’s going to
be a lot published, and I would encourage physicians
to educate themselves as much as they can about the
problem.’’

There are numerous resources available to help
physicians learn more about the problem of domestic
violence. Here are just a few:

• Minnesota Coalition for Battered Women. This
organization can provide a directory of ail the shelters
and intervention projects in the state. For more infor-
mation, call 6 12/646-6177. The coalition also has a

24-hour crisis number, 612/646-0994.

• “Empowering Battered Women: Suggestions for
Health Care Providers,” discusses the cycle of vio-
lence, indicators of battering, and what to do when a
victim is identified. This 50-page booklet costs $12,
plus $2.50 for postage. Write: Massachusetts Coali-
tion of Battered Women Service Groups, 107 South
Street, Fifth Floor, Boston, MA 02111. Or call
617/426-8492.

• Susan M. Hadley, M.P.H., the founder and
director of WomanKind, Inc., gives one- to three-hour
seminars and presentations on domestic violence, the
role of the nurse and allied health care professional in
treating abuse, and how to work with battered wom-
en in the health care system. For more information,
call 612/924-5775.

• The AMA is establishing a National Medical
Resource Center and Clearinghouse for the Preven-
tion of Family Violence. For more information, call
312/464-5000.

MKF

opposed to accidental injuries,” he said.

Often, however, victims of domestic violence present
with symptoms that aren’t obvious. “They tend to come
in with vague complaints — headaches, anxiety, depres-
sion,” says Moen. Injuries often are dismissed by expla-
nations likes, “I hit my head on the door,” or “I fell down
the stairs.”

Even if a patient tries to conceal the cause of injury,
she really wants the truth to be known, Hadley says.
“When a woman reaches out to the medical system,
she wants to be asked. If it’s not brought up, she feels
more shame because she thinks it’s not important to talk
about it.”

As Warshaw puts it: “If you ask the right question,
women will tell you.” But what is the right question?
What do you say to a patient you suspect has been
abused? There are certain rules that always apply, the
experts say. First, never ask the woman about her
situation unless she is alone. She is not free to talk if her
abuser is present, and he frequently is. Second, be
nonjudgmental; never blame the woman for what hap-
pened to her.

Amazing as it sounds, victims frequently are blamed
for their injuries. Hadley tells about one physician
whose response to a woman’s nasal fracture was: “What
did she do that made him hit her? What caused him to
do that?”

Whatever happened, it wasn’t her fault, says Hadley.
And that’s exactly what she says to battered women:
“No one deserves to be hit. Not for any reason. You
don’t deserve to be abused.”

If a physician suspects that a woman has been beaten,
Hadley says it is appropriate to say something like, “I
notice you have a number of bruises. Did someone hit
you? Could you tell me how it happened?”

Moen takes a similar approach and tells patients,
“This injury looks like it may have been caused by
someone hitting you, and that concerns me. I just want
you to know that this is a safe place to come if you feel
threatened and in danger again.”

In cases where the abuse isn’t obvious, where the
woman presents with psychosomatic symptoms, anxi-
ety, or depression, it’s appropriate, says Hadley, for the
physician to say: “What is going on in your life that seems
overwhelming right now?”

Learning to say the right thing is just part of what
physicians can do to help victims of violence. They
also should carefully document what they have
observed, says Denise Eng, a legal advocate for the
Harriet Tubman Women’s Shelter in Minneapolis.
Physicians should photograph visible injuries, if possi-
ble, or else indicate on the patient’s record the precise
nature and location of the injury and any information
about how the injury was received. This is very impor-
tant, especially if the woman decides to press charges,
says Eng.

Even when physicians acknowledge the violence and
ask the “right” questions, the woman is likely to return
to the abusive situation. Y et the AMA reports that simply
identifying the abuse is the most important intervention
a physician can make because that alone can empower

February 1992/Volume 75

Minnesota Medicine

COVER

STORY

rhe victim to begin the process to free herself. If she does
go hack, it’s only testimony to how difficult it is to break
away, says Eng. “If you see a woman several times, it’s
not testimony to her weakness, it’s how badly |her
abuser] is trying to hang onto her and how much control
he’s exercising over her.”

It took Moen a long time to learn that lesson, as he
explained in an article for Mpls. St. Paul magazine about
his own experiences treating battered women. Moen
wrote about his inability to empathize with battered
women, particularly those who made repeated visits to
the emergency room, and how he blamed them for not
dealing with their problems. “In this, I believe, I was like
most doctors. Untrained to recognize the signs of domes-
tic violence and to deal with the emotions it generates, we
become impatient with its victims,” he wrote.

In a recent interview, Moen said he became more
compassionate once he learned more about the cycle that
traps women and the reasons why they hide the problem.
Moen also knows that he can’t really solve his patients’
problems. “We’ll all be very frustrated if we think we’ll
solve the problem for the victim. You can’t solve the
problem, but you can let the victim know that people
have gotten out of these situations and that people don’t
deserve to be treated violently in their homes.”

Programs like WomanKind and Dr. Fullin’s pro-
gram in Kenosha make it easier for physicians to
treat victims of violence. Hadley founded Woman-
Kind in 1986 after realizing that the medical system was
doing almost nothing for battered women, even
though it was often the first place they turned for help.
Since then, the program has assisted more than 4,000
clients.

WomanKind, a model program that has recently-
received national recognition through both JAMA and
the “Today Show,” provides advocates to work with
battered women and teaches health care workers about
the dynamics and myths of domestic violence and
about ways to identify battered women. WomanKind
provides the kind of back-up that makes a physician’s
job a lot easier. “1 think of a team approach,” Hadley
says. “I don’t think any one person can do all that
patient care. It may take a physician, nurse, social
service, or an advocacy program. They {physicians] have
to provide a supportive environment, and they have
to ask the right questions. But once ]the victim] is
identified, you call in other members of the team.”

Unfortunately, most physicians don’t have a pro-
gram like WomanKind to call on. If a program doesn’t
exist at your hospital, organize one, Warshaw suggests.
Even without a formal back-up system, physicians still
can make a difference, she says. “Even a little bit does
help. Letting the patient know that you’re concerned,
that she doesn’t deserve to be beaten, does make a
difference.” MM

Miriam Feldman is a free-lance writer living in Minneap-
olis and is a frequent contributor to Minnesota Medi-
cine.

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Minnesota Medicine

February 1992/Volume 75

INSTRUCTIONS FOR AUTHORS

Mimiesota Medicine is the official journal of the Minnesota
Medical Association, and its purpose is to provide Minne-
sota physicians with timely information regarding all as-
pects of medicine so they can more capably serve their
patients and more readily achieve their professional goals.
Therefore, the editors are pleased to consider for publica-
tion clinical and health papers (clinical studies, reviews, case
reports) and essays, letters, poems, and opinion pieces
related to medical practice in Minnesota.

Manuscripts

Receipt of manuscripts is acknowledged within 10
days, and authors are usually notified whether their manu-
script is accepted within one to three months, but longer
delays are sometimes unavoidable.

Title and Authors’ Names

The first page of the manuscript should include: 1 ) a title —
make it short, specific, and direct, 2) the full names of all
authors, with their academic degrees, 3) authors’ positions
in hospitals or other institutions — include current position
and tbe position held when the work reported in your
manuscript was done, as well as academic appointments
and other information pertinent to the paper’s topic.

Abstract

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All authors sign a copyright form that conveys all
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is submitted to Minnesota Medicine, and must be completed
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Style

Use JAMA style or consult the AMA’s Manual for Authors
& Editors. Use generic drug names, unless citing a brand
name relevant to your findings; brand names in parentheses
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Tables must have a title and be on separate pages. If they
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References

All references must be cited in the text and should be
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Mediciis.

Examples:

1. Benson RC Jr. Laser photodynamic therapy for
bladder cancer. Mayo Clinic Proc 1986;61:859-64.

2. Guttormson NL, Bubrick MP. Mortality from is-
chemic colitis. Dis Colon & Rectum, to be published.

4. Thompson NW. Thyroid and parathyroid. In: Welch
KJ, Randolph JG, Ravitch MM, et ak, eds. Pediatric Sur-
gery, 4th ed. Chicago: Year Book Medical, 1986: vol 1,
522-33.

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February 1992/Volume 75

Minnesota Medicine

CLINICAL & HEALTH AFFAIRS

The Child at Risk for Developing Heart Disease

Third of Three Parts

Albert P . Ro c ch i n i , M.D., and Mary Ella Pierpont, M . D .

ABSTRACT

We discuss how to identify the child at risk
for developing or having heart disease. We
describe both the child at risk for
developing adult-onset heart disease and
the child or fetus at risk for having
congenital heart disease. With respect to
the child at risk for developing adult-onset
heart disease, we concentrate on how four
risk factors (cigarette smoking, hyper-
lipidemia, reduced physical activity, and
obesity) affect the development of
cardiovascular disease, and we review the
types of therapy currently being used to
modify them. We also discuss the
etiological factors related to the risk of
developing congenital heart disease, such
as single-gene conditions, known cardiac
teratogens, chromosomal anomalies, and
multifactorial inheritance.

This is the final article in a
three-part series on cardio-
vascular disease in children.
The first two articles in the series
focused on the management of chil-
dren with congenital heart disease.
This article describes how to identify
both the child at risk for developing
adult-onset-type heart disease (i.e.,
atherosclerotic heart disease) and the
child or fetus at risk for having con-
genital heart disease.

Atherosclerotic Heart
Disease Risk

Coronary artery disease has its ori-
gin in childhood. Epidemiological and
clinical studies in adults with coro-
nary heart disease have made it pos-
sible to develop a list of risk factors
that help identify individuals suscep-
tible to coronary heart disease. Those
factors are increased cholesterol lev-
els in the blood, elevated blood pres-
sure, cigarette smoking, obesity, and
poor physical fitness. This article
concentrates on the types of therapy
currently being used to treat coro-
nary heart disease and describes how
four risk factors (cigarette smoking,
hyperlipidemia, reduced physical ac-
tivity, and obesity) promote the de-
velopment of cardiovascular disease.

Smoking

Cigarette smoking is an avoidable
cardiovascular risk factor. Since
1964, more than 30 million Ameri-
cans have stopped cigarette smok-
ing, yet its prevalence has not
decreased among adolescents, who
represent the largest group of indi-
viduals at risk for starting to smoke.
Smoking directly increases cardio-
vascular risk by altering blood pres-
sure regulation, increasing total
serum cholesterol, and decreasing
HDL-cholesterol levels.

February 1992/Volume 75

The most effective way to treat
smoking is through prevention. Since
smoking rates are highest among
adolescents, prevention is most crit-
ical in this group. School-based pre-
vention programs, beginning in grade
six and with booster sessions through
secondary school, can significantly
reduce adolescent smoking.

Hyperlipidemia

Hyperlipidemia is a significant risk
factor for the development of adult-
onset heart disease. To understand
abnormalities of lipid metabolism and
their treatment, it is important to
understand how the body handles
cholesterol.

Cholesterol from dietary fat is
digested, absorbed, and reprocessed
in the liver. The liver secretes the
reprocessed cholesterol into either
the intestines as bile or into the blood
stream in combination with triglyc-
erides as very-low-density lipopro-
tein (VLDL) particles. In plasma, the
VLDL particles are converted to low-
density lipoproteins (LDL), which
can then be taken by the cells and
reconverted back into cholesterol.
The LDL particles are guided by ap-
oproteins (lipoprotein surface pro-
teins) to the LDL receptor sites on the
cell. The number of LDL receptors
and their affinity for apoproteins
determines the level of cholesterol in
the blood.

Intracellular cholesterol that the
cells do not use or store is passed
out of the cell and combined with
recycled LDL particles to form HDL
particles. The liver eventually re-
moves these HDL particles from
circulation. Excess cholesterol is pri-
marily removed from cells through
the formation of HDL-cholesterol.

Abnormalities in the way cells
handle LDL-receptor formation
causes familial hypercholesterolemia.

Minnesota Medicine

CLINICAL & HEALTH AFFAIRS

Table 1

Genetic fonns of hyperlipidemia

Disorder

Phenotypes

Mode of inheritance

Exogenous hypertriglyceridemia

Type 1

Autosomal recessive

Familial hypercholesterolemia

Type IIAJIB

Autosomal dominant

Familial hypertriglyceridemia

Type IV, V

Autosomal dominant

Familial combined hyperlipidemia

Types IIA,IIB,IV,V

Autosomal dominant

Polygenic hypercholesterolemia

Types I1A,I1B

Polygenic

Sporadic hypertriglyceridemia

Types IV, V

Non-genetic

Broad B disease
(dysbetalipoproteinemia)

Types lll,IV

Autosomal dominant

Phenotypes: Type l=Inc chylomicrons. Type IIA=Inc l.DL, Type IIB=Inc LITL and VLDL,
Type III=ahnormal lipoprotein, Type IV=Inc VLDL, Type V=Inc chylomicrons and VLDl,.

a common genetic form of hyperlip-
idemia. In this disease, either the
number or function of LDL receptors
is altered, leading to a reduced bind-
ing of LDL-cholesterol to the recep-
tors, a higher serum LDL-cholesterol
concentration, a higher plasma cho-
lesterol, and atherogenesis. Table 1
summarizes the various known ge-
netic forms of hyperlipidemia.

Historical information is of prime
importance for determining which
children should be screened for hy-
perlipidemia. Children with a family
(parent or grandparent) history of
premature atherosclerotic disease,
defined as the appearance of clinical
manifestations of atherosclerosis be-
fore age 50 for men and age 60 for
women, are at clear risk and should
be screened. Several other historical
features also suggest hyperlipidemia,
such as recurrent, unexplained pan-
creatitis or abdominal pain; a history
of abnormal glucose tolerance,
hyperuricemia, or xanthoma; disease
of the thyroid, liver, or kidneys; or
diabetes. Lipid screening is recom-
mended only if a child has a history
compatible with hyperlipidemia.

Hyperlipidemia is diagnosed by
measuring the plasma levels of
lipoproteins. Ideally, a blood sample
should be drawn after a 12- to 14-

hour fast. To be interpreted, the plas-
ma values must be compared with
normal values. As with most clinical
laboratory tests, normals are based
on a statistical distribution of values
in the general population. Tradition-
ally, values greater than the 90th
percentile cutoff have been employed
for defining abnormal cholesterol and
triglycerides.

The cornerstone of lipid manage-
ment is diet. Both the saturated fat
content and the cholesterol content
of the diet must be reduced to main-
tain maximum dietary benefit. Satu-
rated fat appears to increase the
synthesis of LDL-cholesterol and de-
crease LDL-cholesterol disposal.
Polyunsaturated fat decreases VLDL-
triglyceride, cholesterol, and apopro-
tein-B synthesis. Monounsaturated
fat, such as olive oil and peanut oil,
are especially beneficial because they
not only reduce LDL-cholesterol but
also reduce the LDL-cholesterol/
HDL cholesterol ratio. High-fiber
foods, such as oar bran, beans, and
other water-soluble fibers, can also
lower cholesterol.

Dietary management alone can
recTice cholesterol levels by 5% to
20%. The American Heart Associa-
tion phase-I diet recommends the
intake of 30% of calories as fat, 55%

as carbohydrates, and 15% as
protein. The fat should be approxi-
mately equally divided between poly-
unsaturated, monounsaturated, and
saturated fats. The major source of
carbohydrates should be complex
carbohydrates, and cholesterol in-
take should be below 300 mg/day.

Other than diet, the non-
pharmacological forms of therapy
for hyperlipidemia are weight reduc-
tion and exercise. The goal of diet
therapy should be to reduce total
cholesterol below 200 mg% and
LDL-cholesterol below 120 mg%,
while maintaining HDL-cholesterol
greater than 40 mg%. Most pediatric
lipid specialists do not recommend
lipid-lowering drugs unless dietary
means are unable to reduce total cho-
lesterol to a level below 250 mg% and
LDL-cholesterol below 175 mg%.

It is important to remember that
although there is growing evidence
that treating hyperlipidemia in adults
can reduce coronary mortality and
lead to a regression of atherosclerotic
lesions, little or no data are available
on the efficacy of managing chil-
dren’s cholesterol levels to prevent
atherosclerosis in adulthood.

Physical exercise
Exercise levels directly correlate with
HDL-cholesterol levels and inversely
with cholesterol and triglyceride lev-
els and obesity.

For children, 30 to 60 minutes of
e.xercise four times per week is suffi-
cient to maintain cardiovascular
fitness. The exercise must be individ-
ualized— it must consider the type of
exercise the child most enjoys and
the facilities and equipment avail-
able. Not all types of exercise benefit
cardiovascular fitness equally. Activ-
ities requiring effort against heavy
resistance, such as weightlifting, can
increase the efficiency of certain
muscle groups, but do little to im-
prove cardiovascular fitness. Aero-
bic exercise is necessary to achieve
sufficient cardiovascular condition-
ing. Any activity that can be main-
tained continuously, is rhythmical,
and uses large groups of muscles is
aerobic. Activities such as vigorous
walking, jogging, skating, skiing,
aerobic dance, and bicycling are rec-
ommended. Despite the reported ben-

February 1992/Volume 75

Minnesota Medicine

CLINICAL & HEALTH AFFAIRS

FIGURE — Outline of a pediatric weight-loss program.

efits of regular aerobic exercise, the
drop-out rate among those begin-
ning regular exercise is high, and
support from family and friends is
critical to maintain compliance.

Obesity

We have documented that 97% of
obese adolescents have four or more
of the following risk factors: elevated
serum triglyceride levels, decreased
HDL-cholesterol levels, increased
total cholesterol levels, elevated sys-
tolic and/or diastolic blood pressures,
diminished maximum work capaci-
ties, and strong family histories of
coronary heart disease. Obesity is
defined as an accumulation of body
fat greater than 22% of total body
weight for men and greater than 30%
of total body weight for women.
Weight-for-height standards are also
useful in defining obesity. A com-
monly accepted definition for child-
hood obesity is the combination of
triceps and subscapular skinfolds
greater than the 80th percentile and
weight for height greater than the
75th percentile for age and sex. By
these criteria, 1 5% to 20% of all U.S.
school-age children are obese.

Appropriate treatment for obese
children and adolescents can be cat-
egorized into one of a combination
of six basic approaches: caloric re-
striction, anorectic drugs, increased
physical activity, therapeutic starva-
tion, bypass surgery, and habit-
pattern changes based on social-
learning therapy.

A practical weight-loss program
is outlined in the figure. In order to
assess a child’s ability to comply with
a weight-loss program, we believe
the child should be placed on a trial
diet for two to three weeks. Only if
the child is successful with the trial
diet — loses at least one to two pounds
in two to three weeks — is he or she
likely to benefit from the program.

The weight-loss program should
consist of diet, behavior change, and
exercise. For a child to lose one to
two pounds per week, his or her
caloric intake must be reduced by
500 to 1,000 calories per day. Ado-
lescent weight-reduction diets should
not go below 1,200 calories per day
to ensure the child is getting ade-
quate vitamins and nutrients for nor-
mal growth and development. We
recommend an exchanged-type diet
because it teaches the essentials of
good nutrition and actively involves
the child in determining his or her
own diet. The behavior-change com-
ponent of our program includes a
one-hour weekly class for 20 weeks,
then classes every other week until
the child has maintained his or her
goal weight for at least one month.
The classes should emphasize I ) nu-
trition education, 2) record keeping,
3) stimulus control for restricting the
external cues that set the occasion for
eating, and 4) reinforcement of alter-
native behavior. T he weight-loss pro-
gram should have a built-in re-
inforcement system to help the child
establish and maintain new habits.

In addition to the child’s structured
portion of the program, family sup-
port is critical. The child’s family
needs to be taught how to give the
child positive support without
nagging or taking over the child’s
weight-loss program. It is important
to remember that if the child does not
want to lose weight, no weight-loss
program, regardless of its approach
or cost, will be successful.

Congenital Heart Disease Risk

Congenital heart malformations oc-
cur at a rate of eight per 1,000 live
births. In Minnesota, since there are
approximately 60,000 births per year,
the expected incidence of congenital
heart disease is about 500 children
per year. An identifiable cause can be
established in only 15% to 18% of
these children. Some of the etiologic
factors relating to congenital heart
malformations are listed in Table 2.

Single-gene conditions

A large number of identifiable syn-
dromes or conditions are associated
with congenital heart malformations.

In the Holt-Oram syndrome, skel-
etal anomalies of the upper limbs
(radius and thumb) are associated
with cardiac malformations, includ-
ing secundum atrial septal defect and
ventricular septal defect.

The Ellis-Van Creveld syndrome,
a rare autosomal-recessive condition
also called chondroectodermal dys-
plasia, is most commonly found
among inbred populations, such as
the Amish. Individuals with this syn-
drome have short-limbed dwarfism.

Table 2

Etiologic factors & congenital
heart malformations

Cause %

Single Mendelian
gene conditions

3-5

Known cardiac teratogens

1-3

Chromosome anomalies

8-10

Multifactorial inheritance

82-88

Minnesota Medicine

February 1992/Volume 75

CLINICAL & HEALTH AFFAIRS

Table 3

Known cardiac teratogens

Cardiac malformations* Estimate of frequency (%)

Infection

Rubella

PDA, PS, ASD

25-35

Drugs

Alcohol

VSD, ASD, PDA

20-40

Lithium

Ebstein anomaly, ASD

2-5

Amphetamines

VSD, PDA, TGA

Thalidomide

TF, VSD, ASD

5-10

Isotretinoin

Complex, VSD

Maternal Disease

Diabetes

VSD, TGA, AS

3-5

Phenylketonuria

TF, VSD, ASD

15-20

’■■AS=aortic stenosis, ASD=atrial septal defect, PDA=patent ductus arteriosus, PS=pulmonary
stenosis, TF=tetralogy of Fallot, TGA=transportation of great vessels, VSD=ventricular
septal defect.

malformed teeth, accessory frenula,
hypotrichosis, and fine-textured hair.
Heart abnormalities include defects
of the atrial septum, ventricular sep-
tum, AV canal, and single atrium.

In the autosomal-dominant
Noonan syndrome (also known as
the male Turner syndrome or Turner
phenotype with normal karyotype),
short stature, ocular hypertelorism,
triangular facies, ptosis, and web-
bing of the neck can be associated
with congenital heart malformations.
Nearly half of all individuals with
Noonan syndrome have some type of
cardiac anomaly, most commonly
pulmonary valvular stenosis.

LEOPARD syndrome is an auto-
somal-dominant condition that
resembles Noonan syndrome.
LEOPARD is an acronym for the
syndrome’s common features: len-
tigines, electrocardiographic abnor-
malities, ocular hypertelorism,
pulmonary stenosis, abnormal geni-
talia, retardation of growth, and deaf-
ness. Lentigines, small dark brown
spots distributed primarily over the
trunk, can be present at birth or can
develop as the child gets older. Car-
diovascular abnormalities, including
pulmonary valvular stenosis and hy-
pertrophic cardiomyopathy, are quite
common in LEOPARD syndrome.

Supravalvular aortic stenosis oc-
curs in two distinct forms. In one, it
is inherited in families as an autoso-

mal-dominant condition. These indi-
viduals have cardiovascular malfor-
mations, including narrowing of the
supravalvular aortic region, that can
be associated with peripheral pulmo-
nary artery stenosis. The second form
of supravalvular aortic stenosis oc-
curs in individuals with Williams
elfin facies syndrome, for which the
inheritance pattern is unknown.

Thrombocytopenia absent ra-
dius syndrome is associated with
bilateral abnormalities of the radius.
Cardiac malformations, most
commonly tetralogy of Fallot, ven-
tricular septal defect, and atrial
septal defect, occur in 20% to 25%
of individuals with the syndrome.
This autosomal-recessive condition
has a 25% risk of recurrence in sub-
sequent children.

Known cardiac teratogens

Table 3 lists some of the environmen-
tal agents that can contribute to ab-
normal cardiovascular development.
The influence of a cardiac teratogen
on cardiac development is dependent
on the genetic predisposition of each
individual and the timing of the ex-
posure during a vulnerable period of
cardiac development. Thus, many
environmental agents that have no
importance to the population in
general have a profound effect on
individual families or groups with a
specific genetic predisposition. Em-

February 1992/Volume 75

bryologic studies suggest that forma-
tion of the heart and major blood
vessels is complete by 60 days after
conception; therefore, the vulnerable
period for cardiac teratogenesis is
from 1 8 to 60 days after conception.

Prenatal rubella infection is re-
sponsible for a number of fetal
abnormalities, including micro-
cephaly, psychomotor retardation, cat-
aracts, deafness, and congenital heart
malformations. The most common
congenital heart malformations in-
clude patent ductus arteriosus and pe-
ripheral pulmonary artery stenosis.

Alcohol is the the most widely
used drug known to be a teratogen.
Infants with full fetal alcohol syn-
drome may have the following symp-
toms: microcephaly, growth and
developmental retardation, hyperac-
tivity, facial anomalies, and cardiac
anomalies. In fact, cardiac anomalies
are present in up to 40% of infants
who have full fetal alcohol syndrome.
They include ventricular septal de-
fect, patent ductus arteriosus, and
atrial septal defect. The risk of dam-
age in the children of a chronic alco-
holic mother is as high as 50%, and
subtle signs of fetal alcohol syndrome
also may be present in the offspring
of women who are social drinkers.
The incidence of full fetal alcohol
syndrome is estimated to be one or
two per 1,000 births.

A high incidence of the rare car-
diac malformation Ebstein anomaly
has been reported in the offspring of
mothers taking lithium, and amphet-
amines also have been implicated in
the etiology of some congenital heart
anomalies. Recent data suggest as
much as a 10.9% risk of cardiac
malformation following maternal
amphetamine exposure. The drug
thalidomide, which is no longer avail-
able for use, is also a potent terato-
gen. Studies indicate that fetal abnor-
malities, including central nervous
system, thymus, craniofacial, and
cardiac anomalies, occur in a high
proportion of infants with prenatal
exposure to isotretinoin (Accutane),
which has been used in recent years
to treat severe cystic acne. Conotrun-
cal cardiac abnormalities, as well as
ventricular septal defect and pulmo-
nary stenosis, are common.

Finally, maternal diseases such as

Minnesota Medicine

CLINICAL & HEALTH AFFAIRS

Table 4

Cardiac malfonnations in chromosome disorders

Condition

Occurrence

(Percent)

Usual cardiac
malformations*

Trisomy 21

ECD, VSD, ASD

Trisomy 1 8

VSD, PDA, PS

Trisomy 1 3

90-t

VSD, PDA

4 p-

ASD, VSD, PDA

5 p- (cri-du-chat)

VSD, PDA, ASD

45, XO (Turner)

CA, AS, VSD

AS=aortic stenosis, ASD=atrial septal defect, CA=coarctation of the aorta, ECD=endocardial
cushion defect, PDA=patent ductus arteriosus, PS=pulmonary stenosis, VSD=ventricular
septal defect.

diabetes and phenylketonuria are
associated with an increased inci-
dence of congenital heart malforma-
tions.

Chromosome anomalies

Approximately 8% to 10% of new-
borns with cardiac malformations
have chromosome abnormalities. In
the more commonly occurring chro-
mosome anomalies (Table 4), the
type and occurrence of cardiac mal-
formations are well established.

The most common chromosome
abnormality is Trisomy 21 (Down’s
syndrome), which occurs at a rate of
one in 660 births. Cardiac malfor-
mations occur in nearly 50% of these
children, the most common being
endocardial cushion defect, ventric-
ular septal defect, or atrial septal
defect. All children with Down’s syn-
drome should undergo cardiac eval-
uation as young infants to assess
their medical condition and provide
for timely cardiovascular follow-up.

Trisomy 1 8 occurs in one of 3,500
births and can lead to early death.
Cardiac anomalies occur in more than
99% of infants with trisomy 1 8, with
the most common malformations
being ventricular septal defect, patent
ductus arteriosus, and pulmonary
stenosis.

Trisomy 13 occurs in one of
7,000 births. Cardiac malformations
are present in 90% of infants with
trisomy 13, the most common
anomalies being ventricular septal
defect and patent ductus arteriosus.

Monosomy X (Turner) syndrome
occurs in one of 2,500 females. Car-
diac abnormalities occur in one-third
of girls with Turner’s syndrome, with
coarctation of the aorta being the
most common cardiac malformation.

The rare cytogenetic abnormali-
ties 4p- and 5p- occur in fewer than
one of 50,000 births. Infants with 4p-
are profoundly retarded and have
microcephaly, wide nose, and cleft lip
and palate. Survival varies. Cardiac
malformations, including atrial septal
defect, ventricular septal defect, and
patent ductus arteriosus, are present
in 40% of these infants. In 5p-, or
cri-du-chat syndrome, survival is typ-
ically longer than 30 years. A cat cry
is characteristic in infancy, and the
child has microcephaly, moon facies.

and, occasionally, renal abnormali-
ties. Cardiac malformations are present
in 20% of these infants and include
ventricular septal defect, patent duc-
tus arteriosus, and atrial septal defect.

Many less common chromosome
abnormalities are associated with
congenital cardiac malformations.
Therefore, evaluation of children
with chromosomal abnormalities
should routinely include cardiovas-
cular assessment. Other chromo-
some abnormalities that are known
to have significant incidences of con-
genital heart malformations include
trisomy 8, trisomy 9, 13q-, trisomy
22, and partial trisomy 22.

Multifactorial inheritance
By far, however, most congenital
cardiac malformations in children
have no known etiology. It was sug-
gested in the 1 960s that multifactori-
al inheritance would best explain the
genetic basis for most cardiac mal-
formations with unknown etiology.
In this type of inheritance, which
may account for 82% to 88% of
cardiac malformations, the individu-
al’s genetic predisposition interacts
with the environment or an environ-
mental agent to produce the cardiac
anomaly. With multifactorial inher-
itance, the risk of recurrence is higher
for more closely related individuals.
The risk of recurrence decreases as

the relationship becomes more re-
mote. The offspring of mothers and
fathers with congenital heart malfor-
mations are also at increased risk for
cardiac malformation. These risks
range from 12.3% in the offspring of
a mother with atrial septal defect to
2% in the offspring of a father with
pulmonary stenosis. The recurrence
risks justify careful search for cardiac
anomalies in the brothers and sisters
of affected children as well as in the
offspring of affected parents. When
parents have cardiac malformations
or have children with cardiac malfor-
mations, fetal echocardiography
should be employed when the moth-
er is pregnant. MM

Albert Rocchini is a professor of
pediatrics and director of pediatric
cardiology at the University of
Minnesota Medical School, Minne-
apolis, Minnesota.

Mary Ella Pierpont is an associate
professor of pediatrics at the Univer-
sity of Minnesota.

REFERENCES

1. Moller JH, Kaplan EL. Forty years of
cardiac disease in children: progress and
problems — first of three parts. Minn Med
l99l;74(9);27-33.

2. Dunnigan A, Bass J, Braunlin E, Krahill K,
Rocchini AP. Diagnostic and therapeutic
advances in pediatric cardiology — second of
three parts. Minn Med 1 99 1 ;74( l2);27-32.

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February 1992/Volume 75

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CLINICAL & HEALTH AFFAIRS

Lasers in Dermatology

A Review

Charles H . D i ck e it , M . D .

ABSTRACT

The use of lasers in dermatology has
become widespread over the past decade.
This article reviews the types of lasers in
current use and the skin problems that
could benefit from their use.

Lasers (light amplification by
stimulated emission of radia-
tion) have proved extremely
useful for treating a wide range of
skin problems. Dermatologist Leon
Goldman, M.D., established one of
the first laser laboratories at the Uni-
versity of Cincinnati in 1961, and he
used the skin as a model for laser-
tissue interaction in many clinical
and experimental studies.

The laser is a very bright light
with three primary characteristics. It
is monochromatic, meaning one col-
or; collimated, meaning the light
does not diverge as does a flashlight
beam; and coherent, meaning that
the wave forms are spatially and tem-
porally coherent — the peaks and
troughs occur in parallel.

The ability to produce a spatially
coherent, single-wavelength, intense
beam of laser light has made it
possible to produce tissue effects that
were previously impossible. Several
lasers with different wavelengths
are currently used in dermatology' **
(Table 1).

Argon Laser

The argon laser is blue-green light at
476 to 5 14 wavelengths. Its relative-
ly select destruction of hemoglobin
and melanin chromophores has made
the argon laser useful in treating
vascular lesions, especially port-
wine stains and telangiectasias and
some lesions that contain melanin
(Table 2).

The argon laser was the treat-
ment of choice for port-wine stains
until the more recent development of
yellow-dye lasers. The argon laser is
still useful, especially for telangiecta-
sias and for dark purple port-wine
stains with nodules. However, the
risk of scar and pigment loss in young-
er patients is higher with the argon
laser than the yellow-dye laser.''

Yellow-Dye Lasers

The yellow-dye laser is also referred
to as tunable because the wavelength
can be varied. The wavelengths cho-
sen to treat cutaneous blood vessels
are in the 580 nm range. These wave-
lengths coincide with the absorption
band of oxyhemoglobin that is far-
thest from the melanin absorption
range. This decreases the risk of pig-
mentation loss and also increases
cutaneous penetration. It is impor-
tant to limit the laser emission of each
pulse so that only the blood vessels
will be damaged. The flashlamp-
pumped laser has the shortest pulse
duration of the yellow-dye lasers. It
is capable of delivering a 500-MS
range pulse duration and, thus, limits
damage to blood vessels. This pro-
cess is referred to as selective photo-
thermolysis— the selective conversion
of light to heat.

The flashlamp-pumped yellow-
dye laser with short-pulse duration
has made treatment of vascular le-
sions possible — especially port-wine
stains — in young children with a very
low occurrence of skin texture chang-
es or undesired pigmentary chang-
es'"'"’ (Table 2). The mild pain that
occurs when the laser hits skin makes
anesthesia necessary in children, but
adults usually tolerate the pain
without anesthesia. Postoperative
care is minimal, but purpura is present
and takes several days to resolve.

Two other types of yellow-dye
lasers are available: the copper vapor'’
and the argon laser-pumped yellow-
dye laser.' These two lasers have the
advantage of variable spot size and
can be used to treat various vascular
lesions. They also can be used for
photodynamic therapy, which is the
use of laser light irradiation and pho-
tosensitizers to treat disease processes
such as cutaneous malignancies.

Minnesota Medicine

February 1992/Volume 75

CLINICAL & HEALTH AFFAIRS

Table 1

Types of lasers used in

dermatology

Wavelength (nm)

Use

Ruby

694

Tattoos

Pigmented lesions

Argon

476-514

Vascular

Pigmented lesions

Argon-pumped yellow dye

577-638

Vascular

Photodynamic

therapy

Pigmented lesions

Copper vapor

510 (green)

578 (yellow)

Pigmented lesions
Vascular

Flashlamp-pumped

577

Vasculor

Pulsed dye

585

Carbon dioxide

1 0,600

Superficial
vaporization
Bloodless incisions

Nd:YAG

1064

Photocoagulation
Bloodless incisions

Excimer

1 93, 248, 308, 500

Cutting

Helium-neon

632

Aiming beam
V7ound healing

Carbon Dioxide Laser

The carbon dioxide laser is the most
frequently used laser. It can be
used to destroy tissue in two distinct
ways by changing the focus, which
allows for tremendous clinical versa-
tility. While the beam is defocused, it
vaporizes superficial lesions; while
focused, it can bloodlessly excise most
tissue (Table 3).

Energy is emitted from the CO,
laser in the infrared invisible range
of 10,600 nm. Its principal tissue
chromophore is water. Skin is 80%
water, and the laser beam can be ab-
sorbed with minimal thermal scatter-
ing, limiting the thermal damage to
600 nm or less in the cutting mode.

Advances in technology have de-
creased the cost and size of the CO,
laser, and before too long, fiber-
optics delivery should become

practical. Table 3 indicates the wide
potential use for CO, lasers, but, as
Dr. Leon Goldman said many years
ago, “If you don’t need the laser,
don’t use it.”

Nd:YAG Laser

The Neodymium: Yttrium-Alumi-
num-Garnet (Nd:YAG) laser is in the
infrared 1,064 nm range and has
been of limited use for cutaneous
lesions, but new changes that couple
different synthetic sapphire tips
with fiberoptic delivery permit this
laser to be used similarly to the car-
bon dioxide laser to provide blood-
less incisions.**

Ruby Laser

The ruby laser was the first one
Goldman used on the skin, but it has
only recently been approved for treat-

Table 2

Vascular lesions treated with the
argon or yellow-dye lasers

Port-wine hemangioma

Telangiectasia

Red nose

Venous lakes

Spider angiomas

Cherry angiomas

Angiofibromas

Other lesions with vascular component

Table 3

Skin lesions treated with carbon
dioxide laser vaporization and
laser excision

Carbon dioxide loser Laser excision

Rh inophyma Keloids

Actinic cheilitis Skin cancer

Recalcitrant warts Tumor

excisions

Tattoos

Various skin tumors

ment of tattoos. The technique,
known as Q-switching, uses red light
with a wavelength of 694 nm emitted
as extremely high-energy pulses of
40 to 80 nanoseconds in duration.
Pigmented tissues, including melanin
and foreign materials commonly
found in tattoos, absorb this wave-
length of light. Reports indicate the
procedure’s success in fading or re-
moving tattoos without injury to the
skin surface or significant scarring.**

Other Lasers

The excimer laser at 193 nm or
248 nm can produce precise ablation
or clean incisions. Other excimer
lasers may be useful for selective
photothermolysis of melanocytes. ■*
The low-energy laser, or helium-neon
laser, at 632 nm, is used as a pointer
for lectures and as a directing device
for the invisible beam of the CO,
laser but may also be effective in
enhancing the healing of such wounds
as chronic skin ulcers.'*

February 1992/Volume 75

Minnesota Medicine

CLINICAL & HEALTH AFFAIRS

Laser Safety

Appropriate safety measures are a
must for laser use. Patients and health
care personnel must wear eye protec-
tion that is appropriate for the type
of laser used. Eyeshields must be
inserted before performing laser sur-
gery on the eyelids.

The carbon dioxide laser can ig-
nite dry surgical drapes or other com-
bustible materials. Cloth and paper
surgical drapes that surround the
operative field should be saturated
with water or saline.

The laser plume should not be
inhaled and should be evacuated
immediately from the operative field
using a high-capacity smoke evacua-
tor. A “laser in use” sign should be
on the door during laser use.

Future

The future of laser use in dermatolo-
gy appears promising. New technol-
ogies will create more effective forms
of laser therapy, but physicians will
need to be knowledgeable about
the use of lasers in order to inform
patients of realistic expectations and
treatment risks. mm

Charles Dicken is a dermatologist in
the Dermatology Department at the
Mayo Clinic, Rochester, Minnesota.

REFERENCES

L. McDaniel DH. Cutaneous vascular
disorders: advances in laser treatment. Cutis
1990;45:346-9, 354-60.

2. Bailin PL, Ratz JL, Wheeland RG. Laser
therapy of the skin. A review of principles and
applications. Otolaryngol Clin North Am
1990;23:123-64.

3. Gregory RO. Applications of lasers in plastic
surgery. J Fla Med Assoc 1989; 76:59,5-8.

4. McBurney EL Dermatologic laser surgery.
Otolaryngol Clin North Am 1990;23:77-97.

5. Hanke CW. Lasers in dermatology. Indiana
.Med 1990;83:394-402.

6. Garden JM, Geronemus RG. Dermatologic
laser surgery. | Dermatol Surg Oncol
1990;16:156-68.

7. Goldherg D). Laser surgery of the skin. Am
Fam Physician 1989;40:109-16.

8. Wheeland RG. Cutaneous laser surgery.
Otolaryngol Clin North Am 1990;23:165-9.

9. Brauner G, Schliftman A, Cosman B.
Evaluation of argon laser surgery in children
under 13 years of age. Plast Reconstr Surg
1991;87:37-43.

10. Tan OT, Sherwood K, Ciilchrest BA.
Treatment of children with port-wine stains
using the flashlamp-pulsed tunable dye laser.
N Engl I Med I 989;,320:4 1 6-2 I .

11. C.arden j.M, Polla I.L, Tan OT. The

treatment of port-wine stains by the pulsed
dye laser. Arch Dermatol 1988; 124:889-96.

12. Cieronemus RG, Ashinoff R. The medical
necessity of evaluation and treatment of port-
wine stains. Dermatol Surg Oncol 1 99 1 ; 1 7:76-
9.

13. Reyes BA, Geronemus R. Treatment of
port-wine stains during childhood with the
flashlamp-puinped pulsed dye laser. J Am

Acad Dermatol I990;23:l 142-8.

14. Ashinoff R, Geronemus RCj. Capillary
hemangiomas and treatment with the flash
lamp-pumped pulsed dye laser. Arch Dermatol
1991;127:202-5.

15. Pickering |W, Walker EP, Butler PH, van
Halewyn CN. Copper vapour laser treatment
of port-wine stains and other vascular malfor-
mations. Br J Plast Surg 1990;43:273-82.

K. James Ehlen, M.D.
Chairman, CEO Medica

MANAGED CARE, CLINICAL AUTONOMY
AND MARKET PRESSURES

I was quoted recently in a Twin Cities newspaper saying that the push by
health care purchasers for greater accountability for what their dollars buy
could lead to changes in the way HMOs charge for services and how
physicians practice medicine.

It’s true.

Purchasers are looking for a rapid acceleration of our ability to tell them
how well Medica providers are doing. It’s not enough for us to say that
physicians who participate with Medica are “good.” We’ve got to show
them.

“Showing them” requires both performance data and processes to assure
quality. But those requirements are often seen as unnecessary interference
by physicians who are practicing quality medicine.

It isn’t that we lack credibility; we lack communication.

We need to answer questions raised by a society under increasing pressure
from rising health care costs. These answers lay in our daily work and in
the records of our achievements. They can be communicated by
practitioners and Medica through managed care activities.

We must respond to the marketplace in a way that combines the clinical
strengths of medical practice and the administrative strengths of managed
care. Neither interest should submerge or subvert the other.

Medica is forming a response with the help of physicians on the Medical
Policy Council. They are helping to guide unique research that will support
credible performance guidelines and standards for credentialing of
physicians participating in Medica.

Next month, I’ll tell you the details of our ground-breaking work.

MEDiCA.

Minnesota Medicine

February 1992/Volume 75

This Is AH^y Retiiement

U.S. Savings Bonds

A public service of this publication.

MEDICINE LAW & POLICY

The Physician’s Response to Domestic Violence

Legal Issues

Loretta M. Frederick, J . D .

Physicians who wish to respond
fully and appropriately to vic-
tims of domestic abuse must be
aware of the legal remedies available
to protect the victims from future
abuse and the legal implications of
treating them.

Minnesota is a national leader in
the movement to provide legal pro-
tection for victims of domestic abuse.
The state’s ground-breaking laws
have often been copied in other states,
and Minnesota’s battered women’s
movement is considered a leader in
the effort to enact and implement
effective legal responses to domestic
abuse.

The use, enforcement, and ad-
ministration of these model civil and
criminal laws depend, however, on
the effort of Minnesota citizens. Phy-
sicians, like police officers, are often
the first persons approached by vic-
tims seeking assistance. They are,
therefore, in a unique position to
offer information about legal reme-
dies and protections. Physicians can
best respond if they are familiar with
the legal measures available to pro-
tect victims and with the domestic
abuse reporting laws.

Order for Protection

An Order for Protection is the most
commonly used and most important
remedy available to battered wom-
en"' in Minnesota. The Order for

'■ Because assaults on women by their
intimate partners constitute approxi-
mately 95 percent of all domestic assaults
and because such assaults are usually only
part of an overall pattern of controlling
and threatening behavior, the author uses
the term “battered women” in this article.
The remedies described are also available
to protect children and other individuals
who suffer domestic abuse.

Minnesota Medicine

Protection is a court order that tells
the abuser to stop abusing or threat-
ening the victim and can ban the
abuser from entering the victim’s
home.

An Order for Protection is avail-

“Physicians are
in a unique position
to offer information
about legal remedies
and protections.”

able to any person who is a victim of
“domestic abuse,” which is defined
by law as “physical harm, bodily
injury, assault, or the infliction of
fear of imminent physical harm.”
The domestic abuse must have oc-
curred between “family or house-
hold members,” defined as spouses,
former spouses, parents and their
children (an adult household mem-
ber must file on behalf of a minor
child), persons related by blood, per-
sons who either live together now or
have done so in the past, and persons
who have a child in common, includ-
ing situations where the woman is
pregnant and the abusive man is al-
leged to be the father.

The Order for Protection is avail-
able to women or men battered in
heterosexual or homosexual relation-
ships, as well as to roommates and
family members. Couples who have
dated but have never lived together
are not covered by this law.

The procedure for obtaining an
Order for Protection is relatively sim-
ple. The victim goes to the court
administrator’s office at the local

February 1992/Volume 75

county courthouse for forms and as-
sistance, which the office must pro-
vide to anyone who asks. The victim
does not need an attorney to assist
her in either the application or the
court hearing. The customary court
filing fee and cost of service are waived
in these proceedings.

After applying for the Order for
Protection, the victim presents the
petition to a judge for consideration.
If the petition alleges an immediate
and present danger of domestic abuse,
the court may issue an immediate
order to restrain the abusing party
from committing acts of abuse, ban
the abuser from the petitioner’s resi-
dence (even if it is a shared dwelling),
and ban the abuser from the petition-
er’s place of employment. The court
must, at this point, order a hearing to
be held within 14 days. The alleged
abuser (the respondent) is personally
notified, usually by the local sheriff’s
deputies, who will also ensure that
the abuser leaves the residence if so
ordered.

At the court hearing, the judge or
referee may expect the parties, at
least the petitioner, to testify about
the abuse. After hearing the testimo-
ny and reading the documents, the
court will decide if abuse has oc-
curred. If it has, the judge will issue
an order, which will usually be in
effect for one year. The order can
restrain the abusing party from com-
mitting acts of domestic abuse, ban
the abusing party from the victim’s
residence and place of employment,
award temporary child custody and
visitation, establish temporary child
and/or spousal support, order treat-
ment for the abuser or counseling for
both parties if they havechildren and
the victim requests it, and award
temporary use of personal property,
such as cars.

Violation of the Order for Pro-

MEDICINE LAW & POLICY

tecrion is a misdemeaiKM'. IL the po-
lice have reason to believe the abuser
has committed another act of abuse
or has gone to the victim’s place of
employment or residence in viola-
tion of the order, they must, by law,
arrest the abuser.

Physicians should be aware of
the types of provisions patients can
request from the court. If the victim
has this information, she is in the
best position to decide whether she
should apply for protection. Every
health care facility should make
brochures from local legal-aid or
battered women’s programs readily
available. The materials often de-
scribe the Order for Protection pro-
cess and give details about local
advocacy and safe-shelter programs.
The physician may be tempted to
instruct a battered woman to get an
Order for Protection, but it is better
to provide information about its
availability and encourage the wom-
an to seek support from battered
women’s programs in the area. Sep-
aration from an abuser is the most
dangerous, sometimes lethal, point
in a violent relationship, and the
adult victim herself can best evaluate
when and how to escape the abuse.

In addition to offering support
and information about the Order for
Protection, the physician could offer
to provide a statement about the
nature, extent, and probable cause of
the woman’s abuse-related injuries.
The physician also should help the
woman acquire copies of relevant
medical records to use as evidence in
any subsequent legal proceeding.

Dissolution of Marriage

Divorce, called “dissolution of mar-
riage” in Minnesota, is another legal
remedy available to women who are
abused by their husbands. In a di-
vorce proceeding, the court can issue
restraining orders as in an Order for
Protection. However, there is no le-
gal requirement that police arrest an
abuser who violates a divorce re-
straining order, so the battered
woman might want to obtain an
Order for Protection in addition to
the regular divorce court orders.

The dissolution of marriage can
only be used if at least one spouse has
been a resident of the state for at least

180 days. The dissolution court can
make permanent property distribu-
tion orders, as well as child or
spousal support, child custody, and
visitation orders.

Threats to hurt, kill, kidnap, or
win custody of children are among
the most common and effective means
batterers use to keep their partners
from leaving them. Because parents’
mental and physical health is one
factor in courts’ child-custody deci-
sions, and because battered women
often suffer from situational but
severe anxiety and/or depression as
a result of abuse, it is imperative that
physicians avoid making diagnoses,
particularly of mental health prob-
lems, that do not clearly reflect
the impact of abuse on the victim’s
condition. Many battered women
have lost custody of their children to
violent fathers, in part because the
fathers used inaccurate diagnoses of
mental illness to assert that the
mother was too mentally unstable to
be given custody.

An attorney must be retained to
file for a divorce. Many battered
women have difficulty obtaining le-
gal counsel because they don’t have
the money or they don’t know
which local attorneys are sensitive to
domestic abuse issues. Physicians
should be prepared to provide infor-
mation about local legal-aid programs
and bar association referral services.
Local battered women’s advocacy
programs are often a good source
for information about attorneys
who are e.xperienced at representing
battered women.

Reporting vs. Confidentiality

Battenng as a criminal behavior

Nearly all domestic abuse victims
that physicians treat are victims of
crime — most commonly assault,
which can range in severity from
felony assault (which might involve
use of a weapon or serious injury) to
the misdemeanor of fifth degree, or
simple assault. In Minnesota, police
may arrest a person if they have
probable cause to believe the person
has assaulted a family or household
member. If the arrest is for fifth-
degree assault, it must occur within
four hours of the assault. The victim

February 1992/Volume 75

need not make the arrest decision nor
support the arrest. As with many
laws, enforcement is sometimes lack-
ing, and in some communities, police
do not make arrests even when there
is substantial evidence.

Many battered women are vic-
tims of additional crimes, as well.

“Physicians are often
the first persons
approached by
victims seeking
assistance.”

For example, most battered women
are also raped by their abusers. In
Minnesota, rape is a crime, regard-
less of whether the perpetrator and
victim are married. There are four
degrees of felony-level criminal
sexual conduct, ranging from
fourth degree, which involves sexual
contact accomplished by force or
coercion, to first degree, which can
involve sexual penetration accom-
plished with force, coercion, use of
an accomplice, use of a weapon, or
infliction of fear or imminent great
bodily harm. A physician treating a
patient for rape-related injuries
should be sure to inform the victim
that rape is a crime even if the perpe-
trator is her husband.

Children can be affected by do-
mestic violence as primary or sec-
ondary victims. Studies indicate
that children who witness domestic
abuse may experience depression,
anxiety, behavior problems, sleep
pattern disturbances, and various psy-
chosomatic illnesses. Children can
also be direct victims of abuse in
battering cases. Several studies rely-
ing on adult victims’ self-reports in-
dicate that 53 percent to 70 percent
of the men who batter their spouses
also abuse their children. Other stud-
ies based on child abuse hospital
records and mothers’ medical records
show that 45 percent to 5 1 percent of
the mothers of abused children are
battered.

It is a crime in Minnesota to use
unreasonable force or cruelty on a

Minnesota Medicine

MEDICINE LAW & POLICY

child when the act causes substan-
tial emotional harm. It is also a crime
to willfully neglect a child when
it causes substantial harm to the
child’s physical or emotional health.
It is a gross misdemeanor to confine
or restrain a child (by tying, locking,
chaining, or caging, for example) for
prolonged periods of time and in a
cruel and excessive manner when it
results in substantial harm to the
child.

Reporting criminal or other
abuse

The criminality of domestic abuse
raises questions about the extent of a
physician’s right or responsibility to
report the crime to authorities or to
provide information to the court.
The answers to such questions vary
with the patient’s age, health, and
other characteristics. Most battered
women are legally competent adults
who have the right to confidential-
ity in the physician-patient relation-
ship. Generally, only the patient can
waive this right, which can prevent
the physician from breaking confi-
dence even to report criminal acts.

State law requires health profes-
sionals to report all bullet wounds
and other injuries from the discharge
of a firearm. A similar statute re-
quires health care professionals to
report severe burn injuries.

A physician who is confronted
with evidence that a legally compe-
tent adult patient is a victim of abuse
that did not involve a firearm may
feel compelled to report the crime to
law enforcement, a human services
agency, or a battered women’s pro-
gram. Legal and ethical provisions,
however, prevent such a report. The
physician’s alternative is to express
concern to the patient, without
placing blame, and to offer informa-
tion, resources, and referrals.

Confidentiality rules are some-
what different in the case of a do-
mestic abuse victim who is also a
vulnerable adult. A vulnerable adult
is a person who 1 ) lives in or receives
services from a facility licensed by
the Minnesota Department of Health
(e.g., nursing homes, hospitals) or
Department of Human Services (e.g.,
chemical dependency) or 2) regard-
less of place of residence, is unable or

Minnesota Medicine

unlikely to report abuse or neglect
without assistance because of physi-
cal or mental function or emotional
status.

By law, physicians must report
abuse and neglect of such vulnerable
adults, and failure to do so can result
in civil damage actions or criminal
charges against the physician. Physi-
cians who consider filing a report
must decide whether the victim is, in
fact, a vulnerable adult. Usually, the
answer depends on whether the pa-
tient is unable to report the abuse or
neglect because of “impairment of a

“Most battered
women are legally
competent adults
who have the right to
confidentiality in the
physician-patient
relationship.”

physical or mental function or emo-
tional status.” When it is not clear
whether the patient is a vulnerable
adult, the physician is best advised
to offer the patient information and
referrals in a supportive manner. It
is important to note that reporting
abuse will not necessarily increase
the victim’s safety. In fact, after being
reported, the abuser may discourage
the victim from seeking medical
treatment, and fear of the abuser
might prevent the victim from seek-
ing it.

When the victim is a child, appli-
cable confidentiality provisions are
more clear. Physicians must report
suspected physical abuse, sexual
abuse, or neglect of a child under the
child abuse reporting law. The oral
report must be immediate, followed
by a written report made within 72
hours, exclusive of weekends and
holidays.

The patient’s right to confidenti-
ality extends to situations where the
physician or medical records are
subpoenaed. Minnesota law estab-

February 1992/Volume 75

lished a testimonial privilege in the
physician-patient relationship. This
prevents the physician, or other
personnel, from divulging without
the patient’s permission any infor-
mation or opinion that he or she
acquired while attending the patient
in a professional capacity or that
was necessary to enable the physi-
cian to act in that capacity. Although
there are some exceptions to this
rule, such as medical malpractice
litigation, child abuse, and vulnera-
ble adult cases, the testimonial
privilege is an unqualified one. How-
ever, in Minnesota, if a third person,
other than medical personnel cov-
ered by the privilege, is present in the
exam room with the acquiescence of
the patient, the privilege does not
exist and the patient cannot prevent
the physician from disclosing infor-
mation to a court.

In addition, the physician-patient
privilege is inapplicable to child abuse
or neglect. This permits physicians to
testify in court about alleged neglect
or physical or sexual abuse of a child.

Regardless of whether the law
permits or requires a physician to
report a domestic abuse incident or
injury, the physician should be aware
that reporting the abuse may not
improve the victim’s safety. Experi-
ence shows that it is very important
to provide the patient with clear,
supportive messages, information
about legal remedies, and referrals to
battered women’s advocacy or shel-
ter programs. MM

Loretta Frederick is the managing
attorney of the statewide Battered
Women's Legal Advocacy Project, a
joint effort of the Minnesota Coali-
tion for Battered Women and South-
ern Minnesota Regional Legal
Services, Inc. She currently lives in
Winona, Minnesota.

UNIVERSITY OF MINNESOTA
DEPARTMENT OF OPHTHALMOLOGY
RAMSEY CLINIC

ST. PAUL RAMSEY MEDICAL CENTER

The University of Minnesota Department of Ophthalmology and Ramsey Clinic
are seeking a full or part-time assistant professor to |Oin the current staff of 3,5
ophthalmologists. This is an annually renewed, non-tenured position located in
the Department of Ophthalmology at St, Paul-Ramsey Medical Center,

Minimum requirements are completion of an ophthalmology residency, board eligi-
bility and teaching experience. Teaching will include residents, fellows, medical
and technician students. The opportunity to conduct research exists and is sup-
ported, but IS not a requirement. Patient care responsibilities will be in the area
of general ophthalmology.

Ramsey Clinic is a multi-specialty group practice based in St, Paul, Minnesota.
More than 250 physicians are members of the clinic, with specialists in virtually
every medical field. The clinic has a unique partnership with St. Paul-Ramsey
Medical Center, a 435-bed primary and tertiary hospital. Cur mission: to provide
high quality medical care to all patients, regardless of their ability to pay. This mis-
sion, combined with an emphasis on teaching, support for research and an excep-
tional partnership between the clinic and medical center, makes this an ideal group
practice for physicians interested in making a difference. You can practice medi-
cine just about anywhere. So how do you choose the practice setting that's right
for you? If you wantthesatisfaction that comes from direct patient care, the ener-
gizing effect of training new physicians, the challenges and discoveries inherent
in research, and the satisfaction of working with colleagues considered experts
in their field, then the choice is clear — Ramsey.

A letter of interest and curriculum vitae should be forwarded by March 30, 1992

to Mark Sneed, M.D., c/o Loriese A. Stoll, Director of Professional Services,
Ramsey Clinic, 640 Jackson Street, St. Paul. MN 55101-2595, (612) 221-3067.

RAMSEY

Equal Opportunity Employer

STRONG

CHILDREN

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MARCH 5-7, 1992
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Nearly liaJf of aH heart attack victims
are horinjiider this sign.

Heart attack is by Far the bigge.st killer of American women, claiming nearly 250,000 lives each year.

But there is hope. Thanks to AHA-supported research and educational efforts, millions of women have learned
how to reduce their risk. And you can, too, by calling or writing your nearest American Heart As.sociation.

American Heart
Association

This space provided as a public service.

February 1992/Volume 75

Minnesota Medicine

ON THE BUSINESS SIDE

Market Timing

Prime Investment Strategy or Optimisfs Dream f

Dale L. Waltz

In the midst of the turhtilent in-
vestment markets of the early
1 980s, I found myself in a crowd-
ed conference room listening atten-
tively to a marketing representative
from the Lowry Market Timing Fund
explain (rather loudly) the over-
whelming benefits of his fund. As a
retail broker with five years’ experi-
ence at the time, I was leery; my
skeptical side took over as he told my
peers and me that the fund invested
in rising stock markets and sold its
positions before the markets soured.
After all, why would anyone want
their capital invested in markets that
were going down?!

At that point, it was time for a
reality check. Did I feel insulted and
offended by just another high-
pressure sales presentation that
couldn’t possibly hold water in the
real world, or was I the victim of an
Upper-Midwest upbringing, leading
me to believe that anything worth-
while had to be either earned the
hard way or chalked up to blind
luck? I owed it to myself and my
clients to find out. This article is the
culmination of extensive reading,
research, and reflection in the decade
since.

Asset Allocation vs. Market
Timing

Traditional asset allocation, or ob-
jective setting, entails deciding on a
base mix of the various asset classes
(e.g., stocks, bonds, cash instruments)
for an investment portfolio. Each
asset class has relatively well-defined
characteristics over the long term.
Since the overwhelming majority of
investment performance can be ex-
plained by asset class selection and
weightings, successful investing re-
quires matching the overall goals of
the investor (e.g., cash flow needs,

growth, risk tolerance, and time
frame) to the appropriate investment
vehicle. This approach leads to ma-
jor portfolio shifts only if a material
change occurs in the investor’s objec-
tives.

“Market timers
must be correct a
superhuman amount
of the time to
outperform the
market.”

Market timing, on the other hand,
is the active switching of assets with-
in an investment portfolio among
stocks, bonds, and cash equivalents
in the hopes of being fully invested in
the best performing market(s) and
avoiding the worst. Devotees of mar-
ket timing believe they can deliver
substantially higher returns, reduce
risk, or both. But can they?

The Evidence

Although the concept is intuitively
appealing, let us examine the facts to
see if market timing really works.
Over the years, a growing number of
studies have been done on the sub-
ject. In 1974, William F. Sharpe, a
Stanford University finance profes-
sor, conducted one of the earliest
academic studies of market timing.
After examining market data from
1934 to 1972, he concluded that a
market timer choosing between
stocks and cash would have to be
accurate 82 percent of the time to
fare as well as an investor using a
buy-and-hold strategy in stocks.'

Professor Sharpe’s work assumed 2
percent trading costs — a figure much
higher than many of today’s large
institutional investors pay but that is
very reasonable for most retail
investors.

One unpublished study followed
100 large pension funds over a
five-year period. Every one of the
funds had engaged in some market
timing during the five years, but not
one had improved its rate of return as
a result of timing! In fact, 89 of the
pension funds actually lost an
average of 4.5 percent during that
five-year period due to their unsuc-
cessful timing efforts.’

Robert Jeffrey, president of
Jeffrey Co., an investment firm
headquartered in Columbus, Ohio,
conducted a study on the effects of
market timing from 1975 to 1982.
He found that the maximum quar-
terly losses due to market timing
were twice as large as the potential
gains, that overall positive stock
market returns depend primarily on
being present during a few brief peri-
ods, and that those periods often
followed sizable declines in cash —
leaving investors captive to conven-
tional consensus and their own
emotions. His research showed that
only 9 percent of the quarters ac-
counted for the entire positive real
(after inflation) return of the stock
market. Investors intimidated by the
market collapses of 1973-74 and
1981-82 who missed out on the
ensuing bull-market quarters of ear-
ly 1975 and late 1982 would have
done just as well in Treasury bills
over the entire eight-year period.’ To
see if his conclusions were valid over
a longer rime frame, Jeffrey tested
the entire 57-year period from 1926
through 1982. In virtually every

(lontintiecl

Minnesota Medicine

February 1992/Volume 75

ON THE BUSINESS SIDE

respect, the analysis supported his
earlier conclusions.

Similar findings were reported by
Bernstein Research in a study of stock
market timing from 1945 through
1984. Bernstein found that each
dollar invested in stocks, using the
Standard and Poor’s 500 Index as a
proxy, grew to $72 over that 40-year
period. A dollar invested in Treasury
bills grew to $5.60 over the same
rime frame. A market timer who
didn’t invest in stocks during the six
largest up-years would have had
only $4.40 to show for his or her
efforts — well under the returns from
Treasury hills. ^

Finally, Jess Chua and Richard
Woodward, associate professors at
the University of Calgary, Alberta,
concluded that a marker timer must
be accurate 72 percent of the time to
beat a buy-and-hold stock portfolio.
They determined that even if a timer
were 1 00 percent accurate in predict-
ing bear markets and 50 percent ac-
curate on bull markets, the timer
would still be a net loser.'

Wrap-Up

Additional studies questioning the
validity of market timing can be cited
ad nauseam. However, an equally
credible body of evidence supporting
market timing cannot be found. To
be sure, a number of studies have
been undertaken, but they seem to
cluster around very short time peri-
ods during which one or a few great
calls made a large impact, or they
focus on computer simulations
showing how much greater inves-
tors’ returns could have been had
they predicted a number of consecu-
tive bull and bear markets. If market
timing is ever to become an accepted
and viable investment strategy,
back-dated historical studies will not
suffice. Market timing will need to be
proven in a real-world setting.

It is worth noting that not one of
the best-known long-term investors —
John Templeton, Warren Buffett, or
Peter Lynch — follows a market-
timing strategy. In fact, all condemn
it. Why is it that market timing has
been unable to produce champions
of this ilk?

Don Phillips, editor of Mutual
Fund Values, a publication devoted

to the evaluation and analysis of
hundreds of mutual funds, says,
“Despite the overwhelming evidence
against timing, it — like alchemy be-
fore it and astrology to this day — still
boasts devoted followers.”'’

$tock market returns are neither
consistent nor predictable — but over
the long term they have in the past

“Not one of the best-
known long-term
investors follows a
market-timing
strategy. ”

and likely will in the future exceed
those of fixed income and cash
equivalents. Market timers must not
only be correct a superhuman amount
of the time to outperform the mar-
ket, but they must also overcome
commissions, as well as taxes, for
taxable clients.

Market timing remains an opti-
mist’s dream. A rational investor can
only judge an investment strategy’s
merits by its demonstrated real-world
record, and market timing has not
come close to producing a record
investors would wish to emulate.
There will always be another hot
hand appearing on the horizon, but
we can best chalk that up to statisti-
cal “noise” given the number of
investors seeking immediate gratifi-
cation. If and when timers put to-
gether a proven track record instead
of simulated wishes, it will then be
time to revisit the issue.

By the way, last summer the
Lowry Market Timing Fund was mer-
cifully put to rest — along with its
performance record — as it was
merged into another mutual fund
with entirely different objectives.
There is order in the universe, after
all! MM

Dale Waltz, now a principal and
portfolio manager with Compass
Capital Management in Minneapo-
lis, has over 15 years' investment

experience. Formerly, he was vice
president and senior portfolio
manager at Norwest Investment
Management and a registered repre-
sentative with Piper, Jaffray and
Hop wood. He is a member of the
Twin Cities Society of Security Ana-
lysts.

REFERENCES

I. Sharpe WF. Likely gains from market
timing. Financial Analysts Journal 1975;
March/April.

1. Ellis D. Investment policy: how to win
the loser’s game. Homeville, IL: Dowjones-
Irwin, 1985.

3. Jeffrey RH. The folly of market timing.
Harvard Business Review 1984;Jul\7
August: 102- 10.

4. Bernstein Research. Investment strategy:
stock market timing may be hazardous to
your wealth. New York: Sanford C.
Bernstein & Co., 1986.

5. Donnelly B. Market timing in new form
gains adherents. Wall Street Journal 1988
July 7.

6. Phillips P. Another one bites the dust.
.Mutual Fund Values 1991 July 12.

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February 1992/Volume 75

Minnesota Medicine

PRESIDENT'S LETTER

HMSS Tackles the Tough Questions

Thomas A . S t o I e e , M.D.

Let’s play a game of 20 ques-
tions. As you think about the
answers, ask yourself how im-
portant this particular item is to you,
your practice, your hospital medical
staff, and your patients.

1. Are you concerned about the
certification and precertification for-
mats that health care insurers use? If
you want them changed, what type
of improvements would you suggest?

2. Do you feel that there is a “due
process” problem in the awarding of
severity points and sanctions by the
PROs? Do you feel there should be
an arbitration process? How would
you suggest this be done?

3. Do you feel that medical utili-
zation review is the practice of
medicine? Do you think that the de-
cisions payers make to allow or dis-
allow hospitalization should be made
by physicians? Should physicians
making such decisions in our state be
licensed in Minnesota?

4. Do you feel that parameters of
care should be developed by federal
agencies or by physicians? Do you
feel that federally developed param-
eters of care should be used in ambu-
latory surgery?

5. Do you feel changes should be
made in the new Medicare payment
system (RBRVS)? What changes
should be made? Why?

6. We spend close to $700 billion
per year on health care in the United
States. Much of this cost is adminis-
trative. Do you think the cost of
medicine should be studied so that
changes can be made? What changes
would you suggest to control costs?

7. In Maryland, hospitals have
suffered Medicare decertification
based on a single incident without
due process. This situation is starting
to occur elsewhere around the coun-
try. Does this concern you? What do
you want to do about it?

“Reaching a
consensus with
federal agencies and
legislative bodies is a
difficult process but
one that must take
place.”

8. In Ohio, legislation has been
introduced to mandate assignment
for all private and public carriers,
pay hospitals for services of all
hospital-based physicians, and set
uniform fees for all private and pub-
lic services. Do you think this could
happen in Minnesota?

9. Hospital medical staff bylaws
exist for your legal protection. Who
writes them in your hospital? The
administration? The medical staff?
What’s in them? Are you concerned?
Would you like to see organized
medicine develop model bylaws?

10. Who should elect medical
staff officers? The medical staff? The
administration? The hospital board?

1 1. Is the joint Commission on
the Accreditation of Healthcare
Organizations fulfilling its function?
What are its strengths and weakness-
es? How should it be improved?

12. Should physician reviewers

be of the same specialty? Should they
be licensed in the same state? Should
physician review be a function of
organized medicine or private review
companies?

13. Should physicians and hospi-
tals be allowed to enter into joint
ventures? Are there any problems
such as anti-trust considerations?
What are the advantages?

14. How much do you know
about the National Practitioner Data
Bank? What problems does the data
bank pose for physicians?

15. Do practice parameters ben-
efit medical practice? Do they pose
potential medical-legal problems?
How do you think they should be
used?

16. Physicians in this country have
been vilified by apparently inaccurate
infant mortality statistics. How do you
think this should be corrected?

17. Should HIV testing be man-
datory for health care workers?
Should reporting to licensing bodies
be required? Should HIV-positive
doctors do invasive procedures? What
are these “invasive procedures”?

18. Should doctors be allowed to
order HIV testing for their patients
without special written permission?
Should they be allowed to order HIV
testing just like CBCs, glucoses, etc.?

19. If an HIV-positive doctor is
not allowed to practice, should the
doctor be declared disabled so he or
she can collect disability insurance?
How do we convince the insurance
companies?

20. Do all the doctors on your
medical staff understand the Patient
Self-Determination Act? What are
physicians’ obligations, if any? What
are the medical staff’s responsibilities?

Don’t write to tell me your opin-
ions on these matters. These issues
were thoroughly discussed and posi-
tions were decided at the recent AM A

MInnesoto Medicine

February 1992/Volume 75

PRESIDENT'S LETTER

Hospital Medical Staff Section meet-
ing in Las Vegas. After consensus is
reached on various questions, the
AM A works with the proper agen-
cies or organizations to bring about
changes. These changes, albeit slow
in the making, are usually accom-
plished. Reaching a consensus with
federal administrative agencies and
legislative bodies is a lengthy, diffi-
cult process, hut one that must take
place in a democratic society.

Each hospital in Minnesota is
entitled to an HMSS delegate, wheth-
er the hospital has 12 or 500 beds. To
qualify, you must be an AMA mem-
ber and you must be duly elected by
your medical staff or appointed by
your elected chief of staff.

I’m amazed that despite the fact
that each hospital medical staff can
have direct input into national poli-
cies, only six people (four from the
Twin Cities, one from Hibbing, and
one from Duluth) represented Min-
nesota at the recent assembly. I’ve
come up with possible reasons for
doctors’ lack of interest in their own
professional future:

1. Doctors are apathetic. Being a
doctor means taking an active role in
treatment. So, how can a physician
be apathetic about the world and still
practice medicine?

2. Doctors and hospitals cannot
afford the cost of airfare and three
days’ lodging. No comment.

3. Doctors are not informed. Let-
ters and information go to every chief
of staff and administrator before the
June and December meetings. I would
hope that these people do not abro-
gate their leadership responsibilities.
The June 1992 meeting will be an-
nounced by April. If it’s not brought
up at your staffer executive commit-
tee meeting, ask why not.

4. Doctors are reluctant to take
the time. Many regulators count on
this.

As MMA president, I am request-
ing that every hospital medical staff
in Minnesota appoint or elect a
representative to attend the 1992
annual AMA-HMSS conference June
19-20 in Chicago. If you have any
questions, contact Dr. Homer
Venters, chair of the Minnesota
Delegation, at St. Paul-Ramsey
Medical Center. MM

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February 1992/Volume 75

Minnesota Medicine

NEWS CLIPS

People and Places Making Medical News

People

Minneapolis Healfh Commissioner

Carolyn McKay, M.D., former
director of Maternal and Child
Health at the Minnesota Depart-
ment of Health, is the new Minne-
apolis Commissioner of Health.
Mayor Don Fraser and other
members of the city executive
committee nominated her to the
position in December. McKay said
she hopes to focus attention on
combatting premature births,

I sudden infant death syndrome, and
I death by violence.

McKay succeeds David Lurie,
who resigned in June to head the
Seattle-King County (Washington)
Health Department.

Ramsey County Medical Society
President

j. Randolf Beahrs, M.D., a urolo-
, gist and MMA speaker of the
^ house, has been elected president of
the Ramsey County Medical
Society for a one-year term. He
succeeds internist Frank T. Indihar,
M.D.

Family practice physician
Donald S. Asp, M.D., was voted
president-elect.

HeolthEost Medical Director

William Hosfield, M.D., has been
named medical director of the
' adolescent intervention unit at
HealthEast Divine Redeemer
I Memorial Hospital in South St.
t Paul. Hosfield is certified by the
American Board of Psychiatry and
I Neurology and has a subspecialty
in the treatment of children and
I adolescents. The intervention unit
i serves young people aged 13 to 18.

Minnesota Medicine

MDH Assistant Commissioner

Barbara Colombo Nerness has
been named an assistant commis-
sioner of health at the Minnesota
Department of Health. In her new
position, she will head the agency’s
Bureau of Health Delivery Systems,
which includes programs in
maternal and child health, health
promotion, and local public health.
Nerness, a registered nurse and
lawyer, joined the Department of
Health earlier this year as director
of legal and policy affairs.

Medico Director of Public Policy
Development

Lois B. Wattman, formerly legisla-
tive counsel for Blue Cross and
Blue Shield of Minnesota, has been
named director of public policy
development for Medica. Before
joining Blue Cross and Blue Shield
in 1986, Wattman was director of
the Minnesota Medical Associa-
tion’s division of health policy and
initiatives.

Hungarian Family Practice

Five Minnesota family physicians
led a delegation to Hungary in
January to help the country
establish its first training program
in family medicine. The delegation
held a four-day meeting with about
30 Hungarian physicians to
establish a nationwide postgradu-
ate educational curriculum.

The relationship between
family physicians in Minnesota and
Hungary was established through
the efforts of native Hungarian
Zoltan Varga, M.D., who left his
homeland in 1987. He is now in
the second year of his family
practice residency training at St.
John’s Hospital in St. Paul.

When Varga heard in mid- 1991
that his native country wanted to
start training family physicians, he
and David Ciurrent, M.D., director

February 1992/Valume 75

of the St. John’s residency pro-
gram, arranged the visit to Hunga-
ry. In addition to Varga and
Current, the delegation included
Edward Ciriacy, M.D., chief of
family practice at the University of
Minnesota; Robert Bosl, M.D.,
president of the Minnesota Acade-
my of Family Physicians; Robert
Beck, M.D., vice president of
medical affairs at the HealthEast
hospital group; and Sonia Patten,
Ph.D., assistant professor at the
University of Minnesota.

Bokken Professorship

Frederick B. Silver, a faculty
member at Rutgers University and
the Robert Wood Johnson Medical
School (RWJMS) in New Jersey,
has been named the first Earl E.
Bakken Professor in Biomedical
Engineering at the University of
Minnesota. An MIT graduate.

Silver is chief of the division of
biomaterials pathology, which he
founded, and director of graduate
studies in biomedical engineering at
Rutgers and RWJMS. At the
University of Minnesota, he will be
senior associate director of the
Biomedical Engineering Center,
where he will direct the graduate
studies and industrial relations
programs. He will assume his new
position July 1.

Places

St. Poul-Romsey Selected for
Notional Heart Study

The National Institutes of Health
recently designated St. Paul-
Ramsey Medical Center as one of
25 principal investigation sites for
a major research project on sudden
cardiac death. The national study,
called MUSTT (Multi-center

NEWS CLIPS

Unsustained Tachycardia Trial),
will take Live years to complete,
involve 4,500 patients, and cost
$10 million. Pablo Denes, M.D., is
the principal investigator at
Ramsey.

Ramsey is working with other
local hospitals to recruit patients
for the study, which began in
January. An ideal candidate is one
who has had a previous heart
attack and has ventricular arrhyth-
mias. For more information, call
Kathy Vittum, R.N., at 612/221-
3660 or 221-3462.

Mayo, 'U', and BCBSM Join
Breast Cancer Study

The University of Minnesota and
Mayo Clinic are two of 37 centers
designated by the National Cancer
Institute to participate in a national
study of autologous hone marrow
transplants to fight breast cancer.
Such transplants are used to treat
leukemias and ITodgkin’s disease,
but no definitive study has been
conducted on bone marrow
transplants to treat breast cancer.

A pilot study of such transplants at
Duke University showed optimistic
results, with cancer relapse rates
dropping by about one-half, but no
women were assigned to control
groups and given conventional
therapy.

The study will include 340
women whose cancer has spread to
10 or more lymph nodes in the
armpit but has not spread to the
rest of their bodies. The women
will be randomly assigned to
transplants or conventional
therapy.

As part of the study, Blue Cross
and Blue Shield of Minnesota will
spend up to $1.5 million during the
next three years to help cover the
experimental treatment in 20 to 25
of its patients. Nationwide, 16
BCBS plans will help pay for the
cost of treating more than 1,200
women.

Methodist Opens Oncology ICU

The new George and Mary Lee
Hess Oncology Intensive Care Unit
opened at Methodist Hospital in
St. Louis Park with a ribbon-
cutting ceremony January 15. The
10-bed unit, which was recently
completed as an addition to the
hospital’s southeast tower, features
a controlled environment for
cancer patients requiring isolated
conditions.

The unit is named after George
and Mary Lee Hess, both former
Methodist patients who died of
cancer. Through a planned estate
gift, they donated $1.2 million —
the largest gift ever received by the
Methodist Hospital Foundation.

Ramsey County Board Rejects
Abortion Ban

The Ramsey County Board rejected
a proposal by Commissioner
Duane McCarty that would have
added abortion restrictions to the
lease agreement between the board
and St. Paul-Ramsey Medical
Center. The county owns the
hospital and land, and the lease is
necessary for the hospital to obtain
bond financing for new construc-
tion. The board voted 4-3 against
McCarty’s proposed provision,
which would have banned the
hospital from performing abortions
unless the woman’s life was in
danger or she was a victim of rape
or incest.

St. Paul Red Cross to Expand

As part of a national effort to
standardize and consolidate the
American Red Cross Blood Bank
system, the St. Paul laboratory will
be upgraded and changed to a
regional center next summer.
arc’s 52 blood-testing laborato-
ries will be consolidated into 14
regional centers, which will
perform about 95 percent of all
tests on blood samples, including
tests for infectious diseases. The 38
remaining labs will continue to
provide routine services and blood
tests, such as matching bone
marrow recipients with the proper
unit of blood.

February 1992/Volume 75

The St. Paul center will add
about 50 employees, and its lab
will eventually process about

500.000 samples of blood annual-
ly. It currently handles about

190.000 samples.

Health Risk Management
Accredited

Health Risk Management, Inc., a
Minneapolis-based international
provider of health care information
and management services, an-
nounced in December that it is the
first managed care company in
Minnesota to receive national
accreditation by the Utilization
Review Accreditation Commission.

Gillette Arches to be Saved

The St. Paul City Council voted
December 31 to preserve the
central arches of the former west
wing of Gillette State Children’s
Hospital in Phalen Park but to
demolish the rest of the building.
The hospital moved to downtown
St. Paul in 1978.

Socioeconomics

Emergency Room Visits Up

Minnesota’s emergency rooms have
experienced large increases in
visits, often from patients with
minor illnesses such as sore throats,
fevers, and strained muscles. Many
doctors and hospital administrators
believe the increase in visits is a
result of state Medicaid policies,
which do not require a copay to
visit emergency rooms. Most
HMOs and insurance companies
create a financial disincentive by
requiring patients to pay part of
the bill when they visit the emer-
gency room. Patients in rural areas
and small towns, where there is a
shortage of physicians, may also
find it faster to visit emergency
rooms than their doctors’ over-
crowded offices.

The largest increases were at
rural and small-town hospitals,
where emergency department visits

Minnesota Medicine

NEWS CLIPS

rose from 358,027 in 1981 to
653,828 in 1990, an increase of 83
percent, according to the Depart-
ment of Health. In Minneapolis,
the increase was 58 percent, up
from about 140,500 visits to nearly
200,500. St. Paul’s emergency
room visits went from 141,435 in
1981 to 162,698 in 1984, hut
several hospitals closed during the
decade, and the number of visits
leveled off after 1984. Visits to
suburban Twin Cities hospital ERs
increased from just under 200,000
in 1981 to 311,000 in 1990.

Twin Cities Hospitals Under
Financial Stress

Financial stress remains a problem
for Twin Cities hospitals, accord-
ing to a report from the Council of
Hospital Corporations released in
December.

After increasing in 1989, three
important factors declined in 1990:
the number of patients treated
declined 0.3 percent, total inpatient
days fell 2.6 percent, and the
average length of stay dropped 2.3
percent. In addition, the number of
outstate Minnesotans treated in
Twin Cities hospitals decreased for
the first time in five years.

One positive finding was that
the number of outpatient visits has
been increasing since 1984. It’s
more cost efficient to treat patients
on an outpatient basis than to
hospitalize them, said Vic Ellison,
spokesperson for the council.

Only one-third of Twin Cities
hospitals are earning the 4 percent
return on investment that experts
say they need to survive.

MedCenters Adds Aspen fo
Network

MedCenters Health Plan has added
the Aspen Medical Group, includ-
ing seven new clinics and 84 new
physicians, to its provider network.

Aspen Medical Group is a
multispecialty practice offering a
broad range of patient services.
MedCenters is the third largest
HMO in Minnesota, with more
than 265,000 members.

Minnesota Medicine

Fairview Acquires Interest in
Riverside Medical Center

Fairview health system purchased
Carondelet LifeCare Corporation’s
50 percent interest in Riverside
Medical Center in December.

Riverside was incorporated in
1 987 as a joint venture of Fairview
Riverside and St. Mary’s hospitals.
The operating agreement consoli-
dated services, management, and
personnel, but the respective
parent companies — Fairview and
Carondelet — retained ownership of
their own assets. Under the terms
of the acquisition. Riverside will be
fully integrated into the Fairview
system. According to Richard A.
Norling, Fairview president and
chief executive officer, there are no
immediate plans to change the
medical center’s operation or
management structure.

Sister Mary Madonna Ashton,
president and chief executive
officer of Carondelet FifeCare, said
the proceeds of the sale will allow
the Sisters of St. Joseph to continue
a number of its programs and to
broaden efforts in serving the needs
of the poor, homeless, abused,
chemically dependent, and elderly.

Innovations

Coronary Laser Procedure

Cardiologists at St. Paul-Ramsey
Medical Center in St. Paul are
using laser energy to vaporize
plaques in coronary arteries.
Ramsey is one of 20 hospitals
nationwide conducting clinical
trials of the Eclipse laser, a cold
laser angioplasty device.

Two patients at St. Paul-
Ramsey were the third and fourth
people in the world to have heart
attacks instantly stopped with the
laser. Both were doing well after
the surgery. As of January 1, St.
Paul-Ramsey had unclogged
coronary arteries in 20 patients
using the device.

“The data from more than 400
patients who underwent the
Holmium Faser angioplasty
nationwide reveal excellent results.

February 1992/Volume 75

very low rate of complications, and
possibly significantly lower rate of
recurring blockage,” said On
Topaz, M.D., an interventional
cardiologist at Ramsey who has
performed the laser procedure.

The laser has been used in
conjunction with balloon angio-
plasty in the cases performed at
Ramsey. The laser procedure is
much the same as balloon angio-
plasty, in which the catheter is
threaded through the femoral
artery to the area of blockage.

Once the laser catheter reaches the
blockage, the physician uses several
small pulses of laser energy to
vaporize the blockage. Tbe laser
uses holmium and thulium, both
non-toxic, environmentally safe
gases.

The laser’s apparent success
could lead to improved treatment
and reduced cost for heart attack
victims. The laser catheter, which is
used only once, costs about $900
compared with $2,000 for the clot-
destroying drug TPA.

New Equipment Diagnoses
Heart Attacks

New equipment to diagnose heart
attacks in patients coming to the
hospital with chest pain has shown
significant improvement over
traditional methods in a study
conducted recently at Fairview
Southdale Hospital. Results of the
study were published in the
January Annals of Emergency
Medicine in an article by David
Justis, M.D., emergency physician,
and William Hession, M.D.,
cardiologist and medical director of
the Heart Center, both of Fairview
Southdale.

The equipment tested was a 22-
lead electrocardiogram (EGG)
developed by Cherne Medical, Inc.,
of Minneapolis. During the study,
163 patients were tested on both
22- and 12-lead ECGs. Use of the
22-lead EGG showed a significant
improvement over the traditional
12-lead EGG in identifying those

NEWS CLIPS

patients with chest pain who were
actually having a heart attack.

In the article, Justis concludes
that the 22-lead ECG is accurate in
diagnosing more than 97 percent of
heart attacks and reduces by 69
percent unnecessary hospital
admissions to determine if the
patient has suffered a heart attack.

Medical Research

Herpes Drug Fights Chickenpox

The antiherpes drug acyclovir
effectively fights chickenpox, said
University of Minnesota virus
specialist Henry Balfour, M.D., in
the November 28 New England
Journal of Medicine. Balfour
reported that a trial involving 815
healthy children aged 2 through 12
showed that the drug relieves
symptoms, reduces the number of
sores, and shortens the illness by
about 25 percent. Balfour reported
similar results in a smaller study
published in the April \990 Journal
of Pediatrics.

In his new report, Balfour and
his 1 1 coauthors said the treatment
cost for acyclovir, ranging from
$25 to $70, is made up by allowing
the child’s parent to return to work
a day earlier than otherwise.

Mayo Study Finds Family Link for
Heart Disorder

A Mayo Clinic study offers new
evidence that the often life-
threatening heart disorder idio-
pathic dilated cardiomyopathy may
have a previously undocumented
familial link, according to a report
in the January 9 New England
Journal of Medicine. In a study of
59 patients diagnosed with cardio-
myopathy and 315 of their rela-
tives, Mayo researchers determined
that up to 20.3 percent (about one
in five) of the families had addi-
tional family members who showed
signs of the disease.

Previous research conducted at
Mayo and elsewhere identified
familial cardiomyopathy in only 6
percent to 8 percent of cases

Studied, but these studies used
family medical histories as the basis
for comparison. In contrast, family
members participating in the Mayo
study provided medical histories
and underwent detailed physical
examinations and laboratory tests.

“By performing derailed cardiac
evaluations on 315 family mem-
bers, we were able to detect a
familial pattern, even in cases
where symptoms had not yet
surfaced,” explained Mayo geneti-
cist Virginia Michels, M.D., the
study’s primary investigator.

Idiopathic dilated cardiomyop-
athy is one of the major indications
for cardiac transplantation, with
associated costs of $177 million
per year. Little is known about the
cause of the disease.

AIDS Update

State Hits Record 220 AIDS Cases

Minnesota saw a record 220 new
AIDS cases in 1991, up from 194
in 1990 and 175 in 1989. The
year-to-year increase in new cases
has slowed but has not leveled off.
State Epidemiologist Michael
Osterholm predicted that 224 to
240 Minnesotans will develop
AIDS in 1992. Last year, 186
people in the state died from AIDS,
up from 160 in 1990.

Most of Minnesota’s AIDS
cases continue to be in gay or
bisexual men, but experts are
concerned about the spread of
AIDS from heterosexual sex and
sharing of needles during intrave-
nous drug use. Spread of the AIDS
virus from intravenous drug abuse
is growing in Minnesota, according
to a report from the state Human
Services Department. The good
news is that Minnesota has a
relatively low rate of AIDS cases
among drug abusers; intravenous
drug use accounted for only 4
percent of Minnesota’s cases in
1991 compared with 22 percent
nationwide (excluding those who
are gay or bisexual men and may
have acquired the virus through
sex). Spread of the AIDS virus by
needles has caused the AIDS
epidemic to soar in New York.

February 1992/Volume 75

Citizens League Opposes
Mandatory Testing

The Citizens League in December
called for more limited voluntary
testing than CDC officials had
suggested and stated that manda-
tory testing could backfire if tried.
CDC guidelines issued last summer
called for voluntary testing for all
health care workers performing
“exposure-prone” procedures. The
Citizens League said the risk of
spreading the virus is so small
during these procedures that only
health care workers at reasonable
risk of carrying the virus should be
tested.

The league, a nonpartisan
group that studies Minnesota
public policy, said mandatory
testing could “make the situation
worse” by frightening away those
who should be tested (they might
find ways to avoid testing) and by
giving false security to those who
have been tested but later acquired
the virus.

U of M Drops Plan for HIV Policy

The University of Minnesota has
tabled a proposed policy that
would have required surgeons
performing invasive procedures to
sign a declaration every two years
stating that they are HIV negative.
Hospital policy has prohibited
HIV-infected surgeons from
performing such procedures since
1987, but the university might
change its policy if the CDC
guidelines say there are no restric-
tions on what procedures HIV-
infected physicians can perform.

Lrank Rhame, M.D., the
hospital’s chief infection control
officer, had drafted the proposal.

Minnesota Medicine

CME IN MINNESOTA

A Calendar of Continuing Medical Education Courses

Provided through the MMA Medical Education Subcommit-
tee on CME Resources. For assistance with scheduling meet-
ings or for information on future medical meetings and CME
courses, please contact the MMA office: 2221 University
Avenue SE, Suite 400, Minneapolis, Minnesota 55414; 612/
378-1875. Information for each entry is arranged by date;
name of program; primary sponsor; location; contact person.

FEBRUARY 1992

Feb. 5-12 HealthEast Winter Medical Seminar HealthEast;
Hawaii. CONTACT: Lisa Harrell, 1700 University Ave-
nue, St. Paul, MN 55104; 612/641-5112.

Feb. 6 Kidney Stones — Treatment, Prevention Group Health
Inc.; Minneapolis Metrodome Hilton, Minneapolis, MN.
CONTACT: Debbie Bladine, Group Health Inc., 2829
University Avenue SE, Minneapolis, MN 55414; 61 2/623-
8479.

Feb. 6-9 Prostatic Diseases; Current Concepts in Diagnosis
and Management Mayo Clinic/Mayo Foundation; The
Breakers, Palm Beach, FL. CONTACT: Rita Kunz or Jan
Fleck, Mayo Clinic, 200 1st Street SW, Rochester, MN
55905; 507/284-2509 or 800/323-2688.

Feb. 7 Domestic Violence: Assessment and Plan for Physi-
cian Action St. Paul-Ramsey Medical Center; Holiday Inn
East, St. Paul, MN. CONTACT: Bonnie Young, 640 jack-
son Street, St. Paul, MN 55101; 612/221-3992.

Feb. 8 Winter CME Lake Superior Chapter MAFP Lake
Superior Chapter MAFP, Holiday Inn, Duluth, MN. CON-
TACT: D. R. Weslander, 330 North Eighth Avenue East,
Duluth, MN 55805; 218/723-1 1 12.

Feb. 10-14 Obstetrical and Gynecologic Update for the
Primary Care Physician Mayo Clinic/Mayo Foundation;
Hyatt Orlando, Orlando, EL. CONTACT: Postgraduate
Courses, Mayo Clinic/Mayo Foundation, 200 First Street
SW, Rochester, MN 55905; 507/284-2509 or 800/323-
2688.

Feb. 14 Burn Care Today St. Paul-Ramsey Medical Center;
Holiday Inn East, St. Paul, MN. CONTACT: Bonnie Young,
640 Jackson .Street, .St. Paul, MN 55 10 1 ; 6 1 2/221-3992.

Feb. 14-23 Primary Care Update Office of CME, University

of Minnesota Medical School; Hotel Sanur Beach, Bali,
INDONESIA. CONTACT: Bart Galle, Office of CME,
Radisson Hotel Metrodome, Suite 107, 615 Washington
Avenue SE, Minneapolis, MN 554 1 4; 6 1 2/626-7600.

Feb. 15 Family-Centered Approach to Management of
Chronic Illness Naeve Hospital; Albert Lea Technical Col-
lege, Albert Lea, MN. CONTACT: Dr. Jon Wogensen,
Naeve Hospital, 404 Fountain Street, Albert Lea, MN
56007; 507/377-6221.

Feb. 15-22 HealthEast Winter Medical Seminar HealthF/ast;
Steamboat Springs, CO. CONTACT: Lisa Harrell, 1700
University Avenue, St. Paul, MN 55104; 612/641-51 12.

Feb. 20 Newer Antibiotics in Our Basic Armamentarium

Group Health Inc.; Minneapolis Metrodome Hilton, Min-
neapolis, MN. CONTACT: Debbie Bladine, Group Health
Inc., 2829 University Avenue SE, Minneapolis, MN 55414;
612/623-8479.

Feb. 2 1 Prostate Seed Implantation: A Practical Course

Abbott Northwestern Hospital; Abbott Northwestern Hos-
pital, Minneapolis, MN. CONTACT: Gathy Kohn, CME
Office, 800 East 28th Street, Minneapolis, MN 55407; 6 1 2/
863-5461.

Feb. 21-22 Sexual Attitude Reassessment Seminars (SAR)

Program in Human Sexuality; Holiday Inn Metrodome,
Minneapolis, MN. CONTACT: SAR Coordinator or Secre-
tary, Program in Human Sexuality, FMC Building, 1300
South 2nd Street, Minneapolis, MN 55454.

Feb. 21-22 Hyperlipidemia: New Therapeutic Strategies

Abbott Northwestern Hospital; Radisson Plaza Hotel,
Minneapolis, MN. CONTACT: Minneapolis Heart Insti-
tute Foundation, 920 East 28th Street, Minneapolis, MN
55407; 612/863-3979.

Feb. 26-27 Geriatric Drug Therapy Symposium Office of
CME, University of Minnesota Medical School; Radisson
Hotel Metrodome, Minneapolis, MN. CONTACT: Becky
Noren, Office of CME, Radisson Hotel Metrodome, Suite
1 07, 6 1 5 Washington Avenue SE, Minneapolis, MN 55414;
612/626-7600.

Feb. 28 Prevention and Management of Atherosclerotic
Diseases Office of CMF/, University of Minnesota Medical
School; Radisson Hotel Metrodome, Minneapolis, MN.
CONTACT: Becky Noren, Office of CME, Radisson Hotel
Metrodome, Suite 107, 615 Washington Avenue SFi,, Min-
neapolis, MN 55414; 612/626-7600.

MARCH 1992

March 2-6 Team Management of Diabetes Mellitus Interna-
tional Diabetes Center; International Diabetes Center, Min-
neapolis, MN. CONTACT: Cindy Poppitz, International
Diabetes Center, 5000 West 39th Street, Minneapolis, MN
55416; 612/927-3393.

Minnesota Medicine

February 1992/Volume 75

CME IN MINNESOTA

March 3-7 First Annual Minnesotan-Costa Rican Medical
Week; Diagnostic and Therapeutic Frontiers in Medicine

Llnivcrsity of Minnesota and Autonomous School of Med-
ical Sciences of Central America; San jose, Costa Rica.
CiONTACT; Dr. Hugh D. Westgate, Fairview Ridges Hos-
pital, 201 F'ast Nicollet Blvd., Burnsville, MN 55337; 612/
892-2042 or 612/892-2080.

.March 5 Medical Aspects of Drug Abuse — Cocaine Group
Health Inc.; Minneapolis Metrodome Hilton, Minneapolis,
.MN. CONTACT: Debbie Bladine, Group Health Inc.,
2829 University Avenue SF', Minneapolis, MN 55414; 6 12/
623-8479.

March 6 The Duluth Clinic 1 992 Family Practice Conference

The Duluth Clinic; Fitger’s Spirit of the North Theatre,
Duluth, MN. CONTACT: Rockie Odberg, CME Office,
400 East Third Street, Duluth, MN 55802; 2 1 8/725-3838.

.March 9-13 Medical Update 1992 Office of CME, Depart-
ment of Surgery, University of Minnesota Medical School;
Hughes Education and Conference Center, Holy Cross
Hospital, Fort Eauderdale, EL. CONTACT: Becky Noren,
Office of CME, Radisson Hotel Metrodome, Suite 1 07, 6 1 5
Washington Avenue SE, Minneapolis, MN 55414; 612/
626-7600, or 800/888-8642.

March 11-14 Geriatric Medicine Review Office of CME,
University of Minnesota Medical School; Park Inn Interna-
tional, Minneapolis, MN. CONTACT: Registrar, Office of
CME, 615 Washington Avenue SE, Minneapolis, MN
55414; 626-7600.

March 12-13 Family Practice Today St. Paul-Ramsey Med-
ical Center; Holiday Inn East, St. Paul, MN. CONTACT:
Bonnie Young, 640 Jackson Street, St. Paul, MN 55101;
612/221-3992.

March 13-18 Neurology in Clinical Practice Mayo Clinic/
Mayo Eoundation; Capitva, PL. CONTACT: Rita Kunz or
Jan Fleck, Mavo Clinic, 200 1st Street SW, Rochester, MN
55905; 507/284-2509 or 800/323-2688.

March 14 Ob/Gyn Seminar Group Health Inc.; Minneap-
olis Metrodome Hilton, Minneapolis, MN. CONTACT:
Debbie Bladine, Group Health Inc., 2829 University Ave-
nue SE, Minneapolis, MN 55414; 612/623-8479.

March 16-20 Team Management of Diabetes Mellitus Inter-
national Diabetes Center; International Diabetes Center,
Minneapolis, MN. CONTACT: Cindy Poppitz, Interna-
tional Diabetes Center, 5000 West 39th Street, Minneapo-
lis, MN 55416; 612/927-3393.

March 19 Common Skin Disorders Group Health Inc.;
Minneapolis Metrodome Hilton, Minneapolis, MN. GON-
TACT: Debbie Bladine, Group Health Inc., 2829 University
Avenue SE, Minneapolis, MN 55414; 612/623-8479.

March 20 Annual Occupational Medicine Update St. Paul-
Ramsey Medical Center; Minneapolis Metrodome Hilton,
Minneapolis, MN. CONTACT: Bonnie Young, 640 Jack-
son Street, St. Paul, MN 55101; 612/221-3992.

March 20-2! Advanced Laparoscopic Abdominal Surgery
Seminar Abbott Northwestern Hospital; Abbott North-
western Hospital, Minneapolis, MN. CONTACT: Cathy
Kohn, CME Office 1 4202, Abbott Northwestern Hospital,
800 East 28th Street, Minneapolis, MN 55407; 612/863-
5461.

March 2 1 -22 Sexual Attitude Reassessment Seminars (SAR)

Program in Human Sexuality; Holiday Inn Metrodome,
Minneapolis, MN. CONTACT: SAR Coordinator or Secre-
tary, Program in Human Sexuality, PMC Building, 1300
South 2nd Street, Minneapolis, MN 55454; 612/625-1500.

March 26-27 Critical Care: Practical Approaches & Case
Discussion St. Paul-Ramsey Medical Center; Holiday Inn
East, St. Paul, MN. CONTACT: Bonnie Young, 640
Jackson Street, St. Paul, MN 55 10 1; 6 12/22 1-3992.

March 27-28 Lasers in Orthopedic Surgery Laser Center of
Abbott Northwestern Hospital; Abbott Northwestern Hos-
pital, Minneapolis, MN. CONTACT: Laser Center 39102,
Abbott Northwestern Hospital, 800 East 28th Street, Min-
neapolis, MN 55407; 612/863-3000.

March 28 Teen Program Seminar (Pediatric and Mental
Health Topics) Group Health Inc.; Minneapolis Metrodome
Hilton, Minneapolis, MN. CONTACT: Debbie Bladine,
Group Health Inc., 2829 University Avenue SE, Minneap-
olis, MN 55414; 612/623-8479.

March 29-April 1 Management Strategies in Complex
Congenital Heart Disease Mayo Clinic/Mayo Eoundation;
Phoenix, AZ. CONTACT: Postgraduate Courses, Mayo
Clinic/Mayo Eoundation, Section of Continuing Educa-
tion, 200 Pirst Street SW, Rochester, MN 55905; 507/284-
2509 or 800/323-2688.

APRIL 1992

April 2-3 Allergy and Clinical Immunology Office of CME,
University of Minnesota Medical School; Radisson Hotel
Metrodome, Minneapolis, MN. CONTACT: Becky Noren,
Office of CME, Radisson Hotel Metrodome, Suite 107, 615
Washington Avenue SE, Minneapolis, MN 55414; 612/
626-7600.

April 2-3 Annual Obstetrics and Gynecology Update St.

Paul-Ramsey Medical Center; Holiday Inn East, St. Paul,
MN. CONTACT: Bonnie Young, 640 Jackson Street, St.
Paul, MN 55101; 612/221-3992.

April 3 ENT Update St. Paul-Ramsey Medical Center; St.
Joseph’s Hospital, St. Paul, MN. CONTACT: Bonnie
Young, 640 Jackson Street, St. Paul, MN 55101; 612/221-
3992.

April 6-7 Annual Ophthalmology Course Office of CME,
University of Minnesota Medical School; Radisson Hotel
Metrodome, Minneapolis, MN. CONTACT: Becky Noren,
Office of CME, Radisson Hotel Metrodome, Suite 1 07, 6 1 5

February 1992/Volume 75

Minnesota Medicine

CME IN MINNESOTA

Washington Avenue SE, Minneapolis, MN 55414; 612/
626-7600.

April 8-10 Annual Spring Refresher — Minnesota Academy
of Family Physicians Minnesota Academy of Family Physi-
cians; Hyatt Regency Hotel, Minneapolis, MN. CON-
TACT: Virginia Barzan, Minnesota Academy of Family
Physicians, 2221 University Avenue SE, Minneapolis, MN
55414; 612/331-2506.

April 10-11 Advanced Laparoscopic Abdominal Surgery
Seminar Abbott Northwestern Hospital; Abbott North-
western Hospital, Minneapolis, MN. CONTACT: Cathy
Kohn, CME Office 14202, Abbott Northwestern Hospital,
800 East 28th Street, Minneapolis, MN 55407; 612/863-
5461.

April 1 -11 Pelviscopic Surgery Including Laparoscopic
Hysterectomy Abbott Northwestern Hospital; Abbott North-
western Hospital, Minneapolis, MN. CONTACT: Easer
Center 39102, Abbott Northwestern Hospital, 800 East
28th Street, Minneapolis, MN 55407; 6 12/863-3000.

April 1 1 Treatment of Renal and Ureteral Stones in the '90s

Minnesota Urological Society; St. Paul Hotel, St. Paul, MN.
CONTACT: Jennifer Syltie, Minnesota Medical Associa-
tion, 2221 University Avenue SE, Suite 400, Minneapolis,
IMN 55414; 612/378-1875 or 800/999-1875.

■April 16 Spondyloathropathies Group Health Inc.; Minne-
japolis Metrodome Hilton, Minneapolis, MN. CONTACT:
iDebbie Bladine, Group Health Inc., 2829 University Ave-
,nue SE, Minneapolis, MN 55414; 6 12/623-8479.

April 24-25 Lasers in Orthopedic Surgery Easer Center of
Abbott Northwestern Hospital; Abbott Northwestern Hos-
pital, Minneapolis, MN. CONTACT: Laser Center 39102,
lAbbott Northwestern Hospital, 800 East 28th Street, Min-
neapolis, MN 55407; 612/863-3000.

[April 24-25 15th Annual Update in Clinical Cardiology

Abbott Northwestern Hospital; To Be Determined. CON-
TACT: Minneapolis Heart Institute Foundation, 920 East
28th Street, Minneapolis, MN 55407; 612/863-3979.

April 24-25 Sexual Attitude Reassessment Seminars (SAR)

Program in Human Sexuality; Holiday Inn Metrodome,
Minneapolis, MN. CONTACT: SAR Coordinator or Secre-
!ary. Program in Human Sexuality, EMC Building, 1300
!>outh 2nd Street, Minneapolis, MN 55454; 612/625-1500.

April 24-26 First Annual Mayo Clinic Conference on Ad-
vances in Clinical Anesthesiology Mayo Clinic/Mayo Foun-
lation; Amelia Island Plantation, Amelia Island, EE. CON-
TACT: Postgraduate Courses, Mayo Clinic/Mayo Eounda-
ion, 200 First Street SW, Rochester, MN 55905; 507/284-
!i509 or 800/323-2688.

\pril 27-29 Bone & Soft Tissue Tumors Mayo Clinic/Mayo
■oLindation; Hilton Beach &c Tennis Resort, San Diego, CA.
30NTACT: Postgraduate Courses, Mayo Clinic/Mayo
4)undation, 200 First Avenue SW, Rochester, MN 55905;
:07/284-2509 or 800/323-2688.

Vpril 29 Orthopedic Challenges in Rheumatology Abbott
4orthwestern Hospital; Abbott Northwestern Hospital,

\innesota Medicine

Minneapolis, MN. CONTACT: Cathy Kohn, CMF' Office
14202, Abbott Northwestern Hospital, 800 East 28th
Street, Minneapolis, MN 55407; 6 1 2/863-546 1 .

MAY 1992

May I -2 Advanced Laparoscopic Abdominal Surgery Sem-
inar Abbott Northwestern Hospital; Abbott Northwestern
Hospital, Minneapolis, MN. CONTACT: Cathy Kohn,
CME Office 14202, Abbott Northwestern Hospital, 800
East 28th Street, Minneapolis, MN 55407; 6 1 2/863-546 1 .

May 2 Interventional Radiology Abbott Northwestern Hos-
pital; Abbott Northwestern Hospital, Minneapolis, MN.
CONTACT: Cathy Kohn, CME Office 14202, Abbott
Northwestern Hospital, 800 East 28th Street, Minneapolis,
MN 55407; 612/863-5461.

May 4-8 Family Practice Review and Update Office of
CME, University of Minnesota Medical School; Radisson
Hotel Metrodome, Minneapolis, MN. CONTACT: Becky
Noren, Office of CME, Radisson Hotel Metrodome, Suite
107, 6 1 5 Washington Avenue SF2 Minneapolis, MN 55414;
612/626-7600.

May 12 Gynecology and Gynecologic Oncology Office of
CME, University of Minnesota Medical School; Radisson
Hotel Metrodome, Minneapolis, MN. CONTACT: Becky
Noren, Office of CME, Radisson Hotel Metrodome, Suite
107, 615 Washington Avenue SE, Minneapolis, MN 55414;
612/626-7600.

May 13-15 Current Concepts in Radiation Therapy Off ice of

CME, University of Minnesota Medical School; Mayo
Memorial Auditorum, U of M, Minneapolis, MN. CON-
TACT: Becky Noren, Office of CME, Radisson Hotel
Metrodome, Suite 107, 615 Washington Avenue SE, Min-
neapolis, MN 55414; 612/626-7600.

May 21 Adult Survivors of Sexual Abuse in Childhood

Group Health Inc.; Minneapolis Metrodome Hilton, Min-
neapolis, MN. CONTACT: Debbie Bladine, Group Health
Inc., 2829 University Avenue SE, Minneapolis, MN 55414;
612/623-8479.

May 29-30 Lasers in Orthopedic Surgery Laser Center of
Abbott Northwestern Hospital; Abbott Northwestern Hos-
pital, Minneapolis, MN. CONTACT: Laser Center 39 1 02,
Abbott Northwestern Hospital, 800 East 28th Street, Min-
neapolis, MN 55407; 612/863-3000.

JUNE 1992

June 5-6 Clinical Hypnosis Workshops: Advanced and
Introductory Office of CME, University of Minnesota Med-
ical School; Sheraton Midway Hotel, St. Paul, MN. CON-
TACT: Becky Noren, Office of CME, Radisson Hotel
Metrodome, Suite 107, 615 Washington Avenue SE, Min-
neapolis, MN 55414; 612/626-7600.

June 1 1-25 Scandinavia/Russia Air/Sea Cruise INTRAV;
Denmark, Russia, Finland, Sweden, Poland, Norway, Hol-
land. CONTACT: North Central Medical Conference,
1 845 Hampshire Avenue, #200, St. Paul, MN 55 1 1 6; 6 12/
698-1888.

February 1992/Volume 75

CLASSIFIED ADVERTISING

Physician Opportunities and Miscellaneous Listings

Classified rates are 50^ a word. Minimum monthly
charge is S 1 0; with box number $2 additional. Ads ti’ill
not be accepted by phone.

• Placement of ads must be made six weeks before the date of
publication (e.g., February 15 for April ad). Please send ad
requests to Minnesota Medicine, 2221 University Avenue SE,
Suite 400, Minneapolis, Minnesota 55414.

• The publisher reserves the right to decline or withdraw
advertisements. The publisher is not responsible for clerical or
t\ pographical errors and is not permitted to divulge the identity
of advertisers who have replies sent to box numbers.

• Cancellation of ads must be made by the first of the month
preceding month of issue.

Johnson & Falls Search Associates represents new practice
opportunities locally and nationally. Working exclusively
in the area of physician search, we are committed to
expanding your professional options while meeting our
clients’ needs. There are no fees to candidates. For a
thorough, confidential search, send CV or call: Liz Johnson
or Pat Falls, Johnson & Falls Search Associates, 34 Forest
Dale Road, Minneapolis, MN 55410; 612/922-0237. (R)

Bemidji, Minnesota: Excellent opportunities for well-trained
physicians. We are seeking BC/BE physicians in family
practice and otolaryngology to join a young 33-physician
multispecialty group practice located in northern Minneso-
ta. Competitive salary guarantee plus incentive first year
and excellent benefits. An excellent opportunity for a phy-
sician to enjoy practice in the center of hunting, fishing, and
clear air. Please respond with CV to: C.C. Lowery, Admin-
istrator, Bemidji Clinic-MeritCare, 1233 34th Street NW,
Bemidji, MN 56601; 2 1 8/75 1- 1280. (R)

(=■•9/9 1-R)

Urgent Care/Primary Care physicians for over 90 group
positions in metropolitan Phoeni.x/Tucson, Arizona. Excel-
lent compensation/partnership opportunities. Other quali-
tv positions nationwide. Send CV or call: Mitch Young
(MM), PO Box 1804, Scottsdale, AZ 85252; 602/990-
8080. (“-1/90-R)

Mankato: FP partner to join four board-certified family
physicians, ages 34-43, in fast-growing, full-range practice.
Ob optional. Population 40,000-r. Seventy miles to Twin
Cities. Fourcolleges nearby. Subspecialty consultation readi-
ly available on hospital staff. Academic appointment avail-
able. Call: Tony defer, M.D., 507/387-8231. (8/91-R)

Family Physicians: Well-established south suburban Min-
neapolis family practice group seeks associates part/full
time to staff day clinic. Excellent call schedule, salary, and
fringe benefits. Also seeking locum tenens to staff PT/FT
Urgent Care Centers and/or day clinic. Contact: Adminis-
tration, Family Physicians, P.A., 612/435-4125, or send
inquiries to Suite 100, 14050 Nicollet Avenue South, Burns-
ville, MN 55337. (=^9/89-R)

Mankato Clinic, Ltd. is seeking BC/BE physicians in the
following specialties: dermatology, gastroenterology, inva-
sive cardiology, occupational medicine, oncology/hematol-
ogy, ophthalmology, pulmonary medicine, family practice,
and general internal medicine. The Mankato Clinic is a 50-
physician multispecialty group practice in south-central
Minnesota with a trade-area population of -1-250,000. Guar-
anteed salary first year, incentive thereafter with full range
of benefits and liberal time off. Eor more information call:
Roger Greenwald, Administrator, or Dr. B. C. McGregor,
507/625- 1 8 1 1 or 800/657-6944, or write: 50 1 Holly Lane,
Mankato, MN 56001. (12/91-R)

BC/BE Family Practice, Internal Medicine, and Ob/Gyn
Physician: Excellent opportunity to join well-established,
progressive, 20-physician multispecialty group located in
an economically sound community of 20,000 (drawing area
of 40,000), 65 miles south of the Twin Cities. Full member-
ship after one year. Competitive salary and fringe benefits
package. Contact: Ed Durst, M.D., or Terry Tone, Admin-
istrator, 134 Southview, Owatonna, MN 55060; 507/451-
1120. (2/92-R)

Forest Lake Doctor's Clinic is seeking a BC/BE family physi-
cian, pediatrician, ob/gyn, and internist to join 1 0-physician
multispecialty group. Located 25 miles north of Minneap-
olis-St. Paul in progressive community with excellent schools,
many beautiful lakes, recreational activities, golf, fishing,
boating, skiing. Local hospital directly across street. Con-
tact: Dr. Harvey J. Frank or Dr. Doug Sill, 121 SE 11th
Avenue, Forest Lake, MN 55025; 612/464-7100.

(4/90-R)

MDsearch assists medical groups and hospitals in their
recruiting efforts. For confidential information on opportu-
nities in the Upper Midwest, send CV and/or call collect:
Mary Jo Cordes, MDsearch, PO Box 21507, St. Paul, MN
55 1 2 1 ; 6 1 2/454-7291 . (12/91-R)

February 1992/Volume 75

Minnesota Medicine

CLASSIFIED ADVERTISING

Lake City, Minnesota: Family physician BC/BFi needed to
join three other FPs in progressive, growing practice on
Lake Pepin/Mississippi River in southeastern Minnesota.
Excellent first-year salary/benefits in a scenic community
with multiple recreational opportunities. Contact: D.D.
Pfiaum, M.D., 303 South Washington, Lake City, MN;
612/345-3318. (8/90-R)

(1/92-R)

Primary Care Physicians

Twin Cities

Positions available for board-certified
and board-eligible physicians.

FAMILY PRACTICE
OBSTETRICS/GYNECOLOGY
INTERNAL MEDICINE
PEDIATRICS

For more information contact:

Jennifer J. Mitchell
Fairview Physician & Clinic Services
600 West 98th Street, Suite 390
Bloomington, MN 55420
(612) 885-6225
or toll free 1-800-842-6469

Downtawn Office Space for Rent: Physician in the Medical
Arts Building, 825, wishes to sublet to another physician on
a part-time basis for the purpose of sharing overhead
expenses. Call: 612/370-0553. (6/90-R)

Family Physician wanted to join three board-certified M.D.s
in well-established, expanding group practice. Weekend ER
coverage. No buy-in. Financial package hard to beat. Enjoy
a progressive, rural city within easy reach of St. Cloud and
Minneapolis. Contact: Dr. Jim Mohs, Melrose Clinic, 603
West Main Street, Melrose, MN 56352; office, 612/256-
4228; home, 612/256-3488. (4/91-R)

Physician: BC in emergency medicine, experienced in FP ( no
ob), and licensed in Minnesota, South Dakota, Wisconsin,
available for locum tenens coverage. Reply to: Minnesota
Medicine (850), 2221 University Avenue SE, Suite 400,
Minneapolis, MN 554 14. (5/91-R)

Internal Medicine, Pediatrics, and Dermatology practice
opportunities available at the Faribault Clinic. The Faribault
Clinic is a multispecialty group practice of 19 physicians.
Faribault is located 50 miles south of Minneapolis on 1-35.
For more information contact: Ray W. Wood, M.D., or Ken
Smith, Administrator, 924 NFi First Street, Faribault, MN
55021; 507/334-3921. (4/90-R)

Stillwater: Multispecialty group with emphasis on primary
care seeking BC/BF/ family physician, pediatrician, and

Fairview

Hospital and Healthcare Services

.■\n equal (ifiiiorlunily emfiloYcr

E.N.T. and PEDIATRICS

for

BRAINERD MEDICAL CENTER

• Immediate Opportunity

• 20 Physician Multi-
Specialty Clinic

• New Clinic Building

• No Capitation

• No Start-up Costs

• Progressive New 162
Bed Hospital

• Beautiful Lakes and
Trees

• Two Hours from
Minneapolis

• Ideal for Families

Call CollectAA/rite: Administrator Curtis J. Nielsen,
(218) 828-7100 or (218) 829-4901, P.O. Box 524,
Brainerd, MN 56401.

Minnesota Medicine

February 1992/Volume 75

CLASSIFIED ADVERTISING

Mankato Clinic, Ltd.

501 Holly Lane
Mankato, MN 56001

48-doctor multi-specialty group practice
in southcentral MN with trade area
pop. of 200,000 + . Guaranteed salary
1st year with incentive pay plan. Full
range of benefits. Liberal time off.
Community ranked ninth best “micro-
politan” city in America.

Seeking BE/BC physicians:

• Dermatology

• Pulmonology

• Pediatrics

• Internal
Medicine

• Orthopaedic
Surgery

For more

• Oncology/
Hematology

• Invasive Cardiology

• Family Practice

• Gastroenterology

• Ophthalmology

information call:

Roger R. Greenwald, Administrator, or
Byron C. McGregor, M.D., President

(507) 625-181 1 (800) 657-6944

()xJ>oro CUnics, a large, progressive, multi-
specialty practice with offices in Bloomington
and Burnsville, offers outstanding physician
opportunities.

• Pediatrics

• Obstetrics/Gynecology

• Internal Medicine

For more information, contact:

Jennifer J. Mitchell
Fairview Physician & Clinic Services
600 West 98th Street, Suite 390
Bloomington, MN 55420
(612) 885-6225
or toll free 1-800-842-6469

XBORO

CLINICS

internist. Scenic location with excellent school system,
supportive medical community with strong local hospital,
competitive salary and benefits. Send CV to: Jon Petersen,
St. Croix Valley Clinic, 92 1 Greeley, Stillwater, MN 55082;
612/439-2215. (12/92-R)

General Surgeon: Five-man family practice group seeks
surgeon. Only clinic in city of 8,000, one hour from Minne-
apolis. Position should generate adequate salary and lots of
family rime. Write: Minnesota Medicine (853), 2221 Uni-
versity Avenue SE, Suite 400, Minneapolis, MN 55414.

(8/91-R)

Wadena, Minnesota: Beautiful central Minnesota is home
to the Wadena Medical Center, a five-physician group, and
Tri-County Hospital. A scenic three-hour drive from Min-
neapolis. Family physicians to do obstetrics. Contact Dr.
Matt Yelle, 218/63 1-1360, or Jim Lawson, Administrator,
218/631-3510. You’ll not want to pass up this attractive
place and offer. (8/91-R)

Pediatrician wanted to join group of five board-certified
pediatricians in a well-established, progressive group prac-
tice. Located in Minneapolis, minutes away from Chil-
dren’s Medical Center. Small practice stressing patient care
and preventive medicine. Contact: Gregg Savitt, M.D.,
3145 Hennepin Avenue, Minneapolis, MN 55408.

(9/91-R)

Office Space Available 5/1/91 for sublease. 1,220 square
feet, Southdale Medical Building. Two exam rooms, confer-
ence room, waiting/reception area. Inquiries: 612/333-6484.

6-3/92

Emergency Physician: Are you looking for an occasional
extra shift, or perhaps more exposure to a busy, trauma-
receiving, emergency department.^ North Memorial Emer-
gency Physicians are seeking BC, EM residency-trained
individuals for part-time employment as the third or fourth
physician on duty. Elexible hours/competitive pay. Contact:
Bruce Adams, M.D., or Lord Erickson, M.D., North Me-
morial Medical Center, Robbinsdale, MN 55422; 6 1 2/520-
5536. (M1/91-R)

Family Physician/Internist: Regional treatment center inter-
ested in two full-time, BC/BE family practitioners/inter-
nists. Eorty hours/week. Competitive salary and benefits.
Live in the exciting Brainerd lakes area. Send CV to: Chief
of Medicine, Brainerd Regional Human Services Center,
1777 Highway 18 East, Brainerd, MN 56401. 6-4/92

Burdick Treadmill and EKG for lease/ rent and used medical
equipment and supplies for sale. FNcellent condition. Call

218/828-1358.

6-4/92

February 1992/Volume 75

Minnesota Medicine

CLASSIFIED ADVERTISING

Internist to join two internists in active practice in scenic
upper Michigan. Medical school affiliation. Contact: North
Shore Internal Medicine, 2420 First Avenue South, Es-
canaba, MI 49829; 906/786-1563. (M I/91-R)

Family Practice: Northeastern Iowa. Become part of the
growing Family Care Network. FAtablished practice, ob
optional, ample coverage. Small-town atmosphere, 40-bed
hospital, 260-bed regional referral center within one-hour
drive. Fixcellent income guarantee plus benefits. Wanda
Parker, Fk G. Todd Physician Search, Inc., 915 Broadway,
Suite 1101, New York, NY 10010; 800/221-4762; fax:
212/777-5701. T5-4/92

Family Practice Wisconsin: Physician needed for partner-
ship in broad-based primary care practice in exceptional
south-central community. Shared call, fully equipped and

CHISAGO HEALTH SERVICES

Our integrated, multispecialty, 19-member med-
ical practice has positions available for BE/BC
physicians in the areas of;

•Family Practice
•Obstetrics/Gynecology
•Internal Medicine
•Urgent Care

This is your opportunity to join a progressive,
growing medical team located in a land of lakes
only 35 minutes from Minneapolis and St. Paul.

Contact: Scott Wordelman, President
Chisago Health Services
11685 Lake Blvd., N.

Chisago City, MN 55013

“Care by ‘People Who Care”

612/257-8485

St. Cloud Medical Group, P.A.

St. Cloud Medical Group, a 23 physician
Multi-specialty Group, is now recruiting
BC/BE physicians in the following
specialities:

• Occupational Medicine

• Pediatrics

• Family Practice

• Surgery

• OB/GYN

Guaranteed first year salary. Production
program thereafter with a full fringe
benefit package.

If interested in joining a progressive
Medical Group in Central Minnesota,
call or send C.V. to:

Daryl G. Mathews

Administrator

St. Cloud Medical Group

1301 W. St. Germain Street

St. Cloud, MN 56301

612-251-8181

Minnesota Medicine

February 1992/Volume 75

CLASSIFIED ADVERTISING

ALEXANDRIA CLINIC, P . A.

The Alexandria Clinic, P.A., is a 16 physician
multi-specialty Group currently recruiting
physicians In the following specialties:

• INTERNAL MEDICINE

• OBSTETRICS & GYNECOLOGY

• FAMILY PRACTICE

• GENERAL SURGERY

• PEDIATRICS

staffed office, very competitive guaranteed salary, and
comprehensive benefits package. For information on this
and other opportunities in the Upper Midwest, contact and
send CV to: Mary Jo Cordes, President, MDsearch, PO Box
21507, St. Paul, MN 55121; or call: 612/454-7291. Fax:
612/454-7277. M-3/92

2-2/92

First year salary guarantee with production bonus,
second year partnership. Excellent contract benefits.

If Interested In Joining a young, growing organization
located in beautiful lakes area community, please
contact:

Timothy A. Hunt, Administrator
Alexandria Clinic, P.A.

610 Fillmore Street
Alexandria, MN 56308
612 . 763 •5123

Family Medicine, ENT,
Orthopedic Surgeon

ALBERT LEA REGIONAL MEDICAL GROUP, PA.
1602 Fountain Street, Albert Lea, MN 56007

• Rewarding Opportunities Now Available.

• 35 Physician Multi-Specialty Clinic

• Competitive Salary/Incentive Package

• Comprehensive Benefit Package

• Modern 1 1 5 Bed Hospital Within Blocks

• Beautiful Lakes and Park Areas

• Ideal for Families

CONTACT: Bill Brouwer, Administrator
Telephone: 507/373-8251

Medical Ophthalmologist needed to join a 340-physician,
multispecialty medical clinic in the attractive Minneapolis-
St. Paul area. Full or part time will be considered. Send CV
and letter of inquiry to: J. Timothy Diegel, M.D., Chairman,
Ophthalmology, Park Nicollet Medical Center, 5000 West
39th Street, Minneapolis, MN 55416; 612/569-4830.

2-2/92

Oshkosh, Wisconsin: Single-specialty groups are recruiting
in family practice, pediatrics, ob/gyn, and cardiology. Osh-
kosh is an attractive community of 55,000 people, located
on the shores of Lake Winnebago and in the heart of
Wisconsin’s beautiful Fox River Valley. Competitive finan-
cial packages. Contact: Christopher Kashnig, Physician
Recruiter, Mercy Medical Center, 631 Flazel Street,
Oshkosh, WI 54902; or call: 800/242-5650, Ext. 2430, or
414/236-2430. T3-3/92

Family Practice — Minnesota: Finjoy the benefits of country
living yet have the resources of a major metropolitan area
close at hand. Health One Buffalo Hospital is seeking a
family physician to join two FPs and a nurse practitioner in
its clinics in Annandale and Winsted. Share call with five
physicians. Competitive compensation with excellent ben-
efits including year-round outdoor recreation in “the heart
of the lakes.” Contact: Kim Isenberg, Health One Buffalo
Hospital, 303 Catlin Street, PO Box 609, Buffalo, MN
55313; 612/682-1212, Ext. 245. 6-6/92

CT3/92

Wisconsin — Fourth BC/BE Obstetrician/Gynecologist need-
ed to join stable, progressive, primary-care-based HMO/
group practice in university town of 60,000 near .Minneap-

February 1992/Volume 75

Minnesota Medicine

CLASSIFIED ADVERTISING

olis/St. Paul. Excellent quality of life and outstanding recre-
ational area. Competitive salary and fringe benefits. Con-
tact: Stuart R. Lancer, M.D., M.B.A., Medical Director,
(iroLip Health Cooperative, PO Box 3217, Eiau Claire, WI
54702-3217; 715/836-8552. "-3-3/92

Wisconsin — Family Practitioner Needed by progressive and
growing group practice in west-central Wisconsin city of

60.000. Ninety miles from Minneapolis/St. Paul. Primarily

prepaid practice with large component FES. Highly compet-
itive salary with excellent fringe benefits. Practice high-
quality care in a good recreational area. Send CV to: Stuart
R. Lancer, M.D., M.B.A., PO Box 3217, Eau Claire, WI
54702-3217; 715/836-8552. =M-3/92

One or Two Family Practice Physicians to join five family
practitioners. Population 8,000. One hour south of Burns-
ville Center. Lakes, industry, negotiable salary. Clinic adja-
cent to hospital. Ample free time to enjoy family life.
Contact James W. Dey, M.D., or Ruth Hawker, Clinic
Manager, 50 1 North State Street, Waseca, MN 56093; 507/
835-3110. (2/92-R)

Orthopedic Surgeons needed for several Midwest practices.
Choose from solo with shared call and medical draw of

60.000, two-way call in family community with medical

draw of 160,000, partnership in waterfront community
with outstanding potential, or group with four-way call just
45 minutes from metro area. Interest in sports medicine a
plus for several of these opportunities. For more informa-
tion, mail CV or call Bill Sherriff at 800/533-0525; Sherriff
& Associates, 10983 Granada, Suite 202, Overland Park,
Kansas 662 11. "1 -2/92

Pediatrician: BC/BE pediatrician needed for hospital-
sponsored clinic in Midwest metro location with medical
draw of I million. Opportunity offers practice manage-
ment, six-way call, negotiable guarantee, and optional
academics in a community with top-rated public schools,
colleges, museums, symphony, water recreation, and first-
class affordable housing. Potential first-year income of
$150,000-r. For more information, mail CV or call Barb
Inselman at 800/533-0525; Sherriff & Associates, 10983
Granada, Suite 202, Overland Park, Kansas 66211.

M-2/92

The Monticello Clinic: Well-established multispecialty clinic
adjacent to 39-hed acute-care/91 -bed long-term care facil-
ity in a rural setting seeking a BG/BE family practitioner.
Ideal location to raise a family. Thirty miles from large
metropolitan area. Year-round cultural and recreational
activities. Excellent salary guarantee, production incentive.

)

■e,

)SI

ed-

101

FLIGHT SURGEONS
WANTED.

Discover the thrill of flying, the end of
paperwork and the enjoyment of a gener-
al practice as an Air Force flight surgeon.
Take flight with today’s Air Force and dis-
cover quality benefits, 30 days of vaca-
tion with pay each year and the support
of a dedicated staff of professionals.

Enjoy a true general practice on the
ground, with the kind of stimulating chal-
lenge that will get your medical skills air-
borne. Talk to an Air Force medical pro-
gram manager about becoming an Air
Force flight surgeon. Call

USAF HEALTH PROFESSIONS
COLLECT
(612) 854-2535

ap-

n n e s o t a

Medicine

February 1992/Volunne 75

CLASSIFIED ADVERTISING

and benctirs package. For more information, contact: Fen-
ny .\1. Vail, Director, Clinic Services, North Memorial
Medical Center, 3300 Oakdale North — 3E Perinatal, Min-
neapolis, MN 55422; 612/520-4839. 3-4/92

Northbrook Clinic: Special opportunity for BC/BE family
practitioner to join a well-established, three-physician clin-
ic. This practice will be moving in 1992 to a new facility.
This northern suburb offers a safe family enrivonment and
outstanding educational, cultural, and recreational ameni-
ties. E.xcellent salary guarantee, production incentive, and
benefits package. For more information, contact: Penny M.
Vail, Director, Clinic Services, North Memorial Medical
Center, 3300 Oakdale North — 3E Perinatal, Minneapolis,
MN 55422; 612/520-4839. 3-4/92

Wayzata Family Physicians: Special opportunity for BC/BE
family practitioner to join a well-established, five-physician
practice located in a prime suburb community near beauti-
ful Eake Minnetonka. The area is surrounded by top-
quality schools, shopping centers, and an abundance of
recreational, family, and social activities. Excellent salary
guarantee, production incentive, and benefits package. Eor
more information, contact: Penny M. Vail, Director, Clinic
Services, North Memorial Medical Center, 3300 Oakdale
North — 3E Perinatal, Minneapolis, MN 55422; 612/520-
4839. 3-4/92

Southeast Wisconsin Pediatrics: Join busy pediatric group in
prospering community close to Milwaukee, Madison, and
Chicago. Rewarding lifestyle, capable colleagues, shared
call, first-class hospital with special-care nursery. Please
contact: Kathryn lorio, M.D., Waukesha Pediatric Associ-
ates, Etd., 1111 Delafield Street, #115, Waukesha, WI
53188; 414/542-6999. 3-4/92

Delinquent Accounts Receivable: We buy them without
recourse. Also have financing plan to cover patients’ pri-
vate-pay bills up front — improves cash flow dramatically.
Give your patients a break — get out of the collection busi-
ness and practice health care instead. Call Phil Berglund,
612/721-3054. M-2/92

Ideal Internal Medicine Practice: Excellent opportunity for
BC/BE internist to establish a prosperous practice. Progres-
sive 1 07-bed community hospital with a medical staff of 45
physicians and a service-area population of over 45,000.
Vibrant Northern Michigan community with all summer
and winter recreational activities. Very competitive first-
year guarantee with benefits. Send CV or contact: John
Schon, Administrator, Dickinson County Hospitals, 400
Woodward Avenue, Iron Mountain, MI 49801; 800/323-
8856. M-2/92

Contact: Dr. Paul Hayes’ office, 906/563-9255, or Dr.
William Gladstone’s home, 906/563-8743. Anderson Me-
morial Hospital, Main Street, Norway, MI 49870; 906/
563-9243. M-2/92

Family Practice: BC/BE family practitioner to join 21-
person family practice department that is part of a 45-
person multispecialty group located in the northern suburbs
of Minneapolis. Practice opportunities available in rural
and suburban locations. Highly competitive first-year guar-
anteed salary, production-based compensation, e.xception-
al benefits package. Respond with CV to: Penny Magnuson,
M.D., 9055 Springbrook Drive, Coon Rapids, MN 55433;
612/780-9155. M-2/92

Administrative Services: Medical wordprocessing and ad-
ministrative work. Minimum one-year contract — $10,000.
Call Janice S., 6 12/776-2699. M-2/92

For Sale: 3'/i- year-old disc computer system. Contact Wan-
da DuCharme, M.D., 507/433-7351. ’■1-2/92

Position Available for Family Physician in Suburban St. Paul:

Exceptional opportunity exists to join our clinic of three
family physicians, three internists, and one pediatrician.
The practice combines the satisfaction and independence of
a small practice with the many benefits of an affiliation with
a larger multispecialty group. Comfortable and pleasant
working conditions and an excellent benefits package. Part-
or full-time positions are available. Please contact Karen
Steiner, M.D., Ramsey Clinic Maplewood, 1774 Cope
Avenue, Maplewood, MN 55109; 612/770-1497. Equal
Opportunity Employer. ''2-3192

FEBRUARY 19 9 2 INDEX TO ADVERTISERS

Albert Lea Regional Medical Group, P.A 54

Alexandria Clinic, P.A 54

Benno L. Kristensen 9

Blue Cross and Blue Shield of Minnesota Cover 3

Brainerd Medical Center 51

Chisago Health Services 53

Columbia Hospital 9

Compass Capital Management 42

C.F. Anderson Company, Inc 1 1

Eli Lilly & Company 10, 1 1

Fairview Physician & Clinic Services 51

Feldmann Imports, Inc Cover 2

G.D. Searle Cover 4

Group Health, Inc 18

Hutchinson Medical Center 42

Mankato Clinic, Ltd 52

Medica 33

Minnesota Medical Services Corporation 4

Multicare Associates of the Twin Cities 23

Oxboro Clinics 52

Quality Transcription, Inc 23

Ramsey 38

Runyan/Vogel Group 9

St. Cloud Medical Group, P.A 53

St. Paul Children’s Hospital 2

U.S. Air Force 55

Whitesell Medical Locums, Ltd 40

February 1992/Volume 75

Minnesota Medicine

Working Together, We^re Making It
Throu^ Some Difficult Waters.

As medical costs continue to
increase, so do our efforts to contain
them. Programs like BLUE PRINTS
FOR HEALTH, a statewide campaign,
encourage healthy lifestyles, and
responsible use of the medical
system. And, by using our technology

to track statewide health trends, we
can work with communities to attack
health problems on a local level.

But the key to these programs,
and all our cost containment efforts,
is you. For without the help and
support of our participating providers.

our race against rising medical costs
would have been lost long ago.

BlueOoss
Blue ^iekj

ol MinneioU)

TheRisLlheRituie

u-iTAiN€0-ReiFASfC*PVETS

The recommended starting dose for Calan SR is 180 mg
once daiiy. Dose titration wiii be required in
some patients to achieve biood pressure controi.

A lower initial starting dosage of 120 mg/dav may be warranted in some patients
(eg, the elderly, patients of small stature).

Constipation, which is easily managed in most patients, is the most commonly
reported side effect of Calan SR

BRIEF SUMMARY

Contraindications: Seyere LV dysfunction (see Warnings], hypotension (systolic pressure
< 90 mm Hg) or cardiogenic shock, sick sinus syndrome (if no pacemaker is present), 2nd- or
3rd-degree AV block (if no pacemaker is present), atrial flutter/fibrillation with an accessory
bypass tract (eg, WPW or L(jL syndromes), hypersensitiyity to yerapamil.

Warnings: Verapamil should be avoided in patients with severe LV dysfunction (eg, ejection
fraction < 30%) or moderate to severe symptoms of cardiac failure and in patients with any
degree of ventricular dysfunction if they are receiving a beta-blocker. Control milder heart failure
with optimum digitalization and/or diuretics before Calan SR is used. Verapamil may occasionally
produce hypotension. Elevations of liver enzymes have been reported. Several cases have been
demonstrated to be produced by verapamil. Periodic monitoring of liver function in patients on
verapamil is prudent. Some patients with paroxysmal and/or chronic atrial flutter/fibrillation and
an accessory AV pathway (eg, WPV\/ or LGL syndromes) have developed an increased antegrade
conduction across the accessory pathway bypassing the AV node, producing a very rapid
ventricular response or ventricular fibrillation after receiving I.V, verapamil (or digitalis). Because
of this risk, oral verapamil is contraindicated in such patients. AV block may occur |2nd- and
3rd-degree, 0,8%). Development of marked Ist-degree block or progression to 2nd- or 3rd-
degree block requires reduction in dosage or, rarely, discontinuation and institution of appropriate
therapy. Sinus bradycardia, 2nd-degree AV block, sinus arrest, pulmonary edema and/or severe
hypotension were seen in some critically ill patients with hypertrophic cardiomyopathy who were
treated with verapamil.

Precautions: Verapamil should be given cautiously to patients with impaired hepatic function
(in severe dysfunction use about 30% of the normal dose) or impaired renal function, and patients
should be monitored for abnormal prolongation of the PR interval or other signs of overdosage.
Verapamil may decrease neuromuscular transmission in patients with Duchenne's muscular
dystrophy and may prolong recovery from the neuromuscular blocking agent vecuronium. It may
be necessary to decrease verapamil dosage in patients with attenuated neuromuscular transmis-
sion. Combined therapy with beta-adrenergic blockers and verapamil may result in additive
negative effects on heart rate, atrioventricular conduction and/or cardiac contractility; there have
been reports of excessive bradycardia and AV block, including complete heart block. The risks
of such combined therapy may outweigh the benefits. The combination should be used only
with caution and close monitoring. Decreased metoprolol and propranolol clearance may occur
when either drug is administered concomitantly with verapamil. A variable effect has been seen
with combined use of atenolol. Chronic verapamil treatment can increase serum digoxin levels
bv 50% to 75% during the first week of therapy, which can result in digitalis toxicity. In patients
with hepatic cirrhosis, verapamil may reduce total body clearance and extrarenal clearance of
digitoxin. The digoxin dose should be reduced when verapamil is given, and the patient carefully
monitored. Verapamil will usually have an additive effect in patients receiving blood-pressure-
lowering agents. Disopyramide should not be given within 48 hours before or 24 hours after
verapamil administration. Concomitant use of flecainide and verapamil may have additive effects
on myocardial contractility, AV conduction, and repolarization. Combined verapamil and quinidine
therapy in patients with hypertrophic cardiomyopathy should be avoided, since significant
hypotension may result. Concomitant use of lithium and verapamil may result in a lowering of
serum lithium levels or increased sensitivity to lithium. Patients receiving both drugs must be
monitored carefully. Verapamil may increase carbamazepine concentrations during combined use.
Rifampin may reduce verapamil bioavailability. Phenobarbital may increase verapamil clearance.
Verapamil may increase serum levels of cyclosporin. Verapamil may inhibit the clearance and
increase the plasma levels of theophylline. Concomitant use of inhalation anesthetics and calcium
antagonists needs careful titration to avoid excessive cardiovascular depression. Verapamil may
potentiate the activity of neuromuscular blocking agents (curare-like and depolarizing); dosage
reduction may be required. There was no evidence of a carcinogenic potential of verapamil
administered to rats for 2 years, A study in rats did not suggest a tumorigenic potential, and
verapamil was not mutagenic in the Ames test. Pregnancy Category C. There are no adequate
and well-controlled studies in pregnant women. This drug should be used during pregnancy,
labor, and delivery only if clearly needed. Verapamil is excreted in breast milk; therefore, nursing
should be discontinued during verapamil use.

Adverse Reactions: Constipation (7.3%), dizziness (3.3%), nausea (2.7%), hypotension (2.5%),
headache (2.2%), edema (1,9%), CHF, pulmonary edema (1.8%), fatigue (1,7%), dyspnea (1.4%),
bradycardia: HR < 50/min (1,4%), AV block: total r,2°,3° (1,2%), 2° and 3° (0.8%), rash
(1.2%), flushing (0.6%), elevated liver enzymes, reversible non-obstructive paralytic ileus. The
following reactions, reported in 1.0% or less of patients, occurred under conditions where a
causal relationship is uncertain: angina pectoris, atrioventricular dissociation, chest pain, claudi-
cation, myocardial infarction, palpitations, purpura (vasculitis), syncope, diarrhea, dry mouth,
gastrointestinal distress, gingival hyperplasia, ecchymosis or bruising, cerebrovascular accident,
confusion, equilibrium disorders, insomnia, muscle cramps, paresthesia, psychotic symptoms,
shakiness, somnolence, arthralgia and rash, exanthema, hair loss, hyperkeratosis, macules,
sweating, urticaria, Stevens- Johnson syndrome, erythema multiforme, blurred vision, gyneco-
mastia, galactorrhea/hyperprolactinemia, increased urination, spotty menstruation, impotence.

4/11/91 •P91CA6277V

SEARLE

G D Searle & Co

Box 5110. Chicago. IL 60680

Address medical inquiries to
G D Searle & Co
Medical & Scientific
Information Department
4901 Searle Parkway
Skokie. IL 60077

A91CA6148T

MAURIM and UURA paw MIRAIIY
OP THI HBALTH SClINCtt
UNIVERSITY OF PITTSBUROH

, MAR 1 8 ^qq9

Is as Indi?Mual as You Are.

Our Term Life Insurance Plan is custom-
designed for members of our profession. What’s
more, each policy can then be tailored to suit your
individual needs. As these needs change, so can
the policy — and it can stay with you no matter
how often you change jobs, provided you maintain
your membership in MMA.

Our group purchasing power helped us to
n^otiate top quality insurance, at a very low price.

To take advantage of this benefit of
membership, call 1 800 424-9883 for further
details (in Washington, D.C. call (202) 457-6820).

pt;

rtr

MMA INSURANCE t

COVER

Refugee health care has challenged Minne-
sota physicians since the first large wave of
Southeast Asian immigrants entered the
state in the mid-1970s. As this month’s
interview and cover story describe, refugees
in need of medical care face many ob-
stacles, but physicians are learning to meet
their needs — expanding their own under-
standing of medicine at the same time.

Photo of Mao Vang and daughter Pa
Nhia Xiong at a visit to the Family Medical
Center in Minneapolis by Douglas Clement.

MINNESOTA MEDICINE
Owner and Publisher
Minnesota Medical Association
Editor-in-Chief Edmund C. Burke, M.D.
Managing Editor Meredith McNab
Editorial Assistant Susan R. Rodsjo
Send manuscripts, subscriptions, and other
material for consideration to Minnesota
Medicine, ITl 1 University Avenue SE, Suite
400, Minneapolis, MN 55414, 612/378-
1 875. The editors reserve the right to reject
editorial, scientific, or advertising material
submitted for publication in Minnesota
Medicine. The views expressed in this jour-
nal do not necessarily represent those of the
Minnesota Medical Association, its editors,
or any of its constituents. Annual Subscrip-
tion - $27.00. Single copies - $2.25. Cana-
dian - $36.00. Foreign - $36.00.

To Advertise: Contact Michael Soucheray,
Minnesota Medicine, 2221 University
Avenue SE, Suite 400, Minneapolis, MN
55414; 612/378-1875 or 800/999-1875.

COPYRIGHT AND
POST OFFICE ENTRY
Minnesota Medicine (ISSN 0026-556X) is
! published on the fifth of each month by the
Minnesota Medical Association, 222 1 Uni-
versity Avenue SE, Suite 400, Minneapolis,
llj MN 554 14, copyright 1992. Permission to
j reproduce editorial material in this maga-
' zine must be obtained from Minnesota
I ^ Medicine. Second-class postage paid at
Minneapolis, Minnesota, and at additional
mailing offices. POSTMASTER, send ad-
dress changes to: Minnesota Medicine, 112 1
University Avenue SE, Suite 400, Minnea-
j I polis, MN 5.5414. (USPS 3519000.)

I J Minnesota Medicine

MARCH 1992 VOLUME 75 NUMBER 3
FACE TO FACE

Health Care for New Americans: Blending Traditional and
Western Medicine

Minnesota Medicine interviews Patricia P. Walker, M.D., director of

St. Paul-Ramsey’s International Clinic 9

PERSPECTIVES

Cross-Cultural Medicine at Home

Thomas W. Day, M.D. 15

A Job Well Done? Learning to Care for a Patient
with AIDS

J. Randall Curtis, M.D. 19

COVER STORY

Border Crossings: Refugees Travel Difficult Route
to Health Care

Douglas Clement 24

MEDICINE LAW & POLICY

Hospital-Physician Joint Ventures Revisited: New
Tax Ruling May Restrict Hospitals’ Options

Steven N. Beck, J.D.

ON THE BUSINESS

S 1

D E

Financing Reform: Who Will Pay the Price for

America’s Health Care?

The Wyatt Company

DEPARTMENTS

Editor’s Notebook

News Clips

Letters to the Editor

CME in Minnesota

Instructions for Authors

Classified Advertising

President’s Letter

Index to Advertisers

March 1992/Volume 75

Selected 1992 Seminars

Educational Telephone Network
1992 Scheduled Events

Health One
Office of
Medical
Education
and Research

For further information, contact the
Office of Medical Education and
Research, Health One. (612) 574-7895
or call toll-free 1-800-343-3627.

February

10 & 11 Advanced trauma Life Support
(ATLS) - 7:30 a.m. - 5:00 p.m. -
United/Children’s Conference
Center - Lab at St. Paul Ramsey
Medical Center.

March

10 & 11 Trauma Nursing Core Course

(TNCC) - 7:30 a.m. - 5:00 p.m. -
Health One Unity Hospital.

April

27 & 28 Advanced trauma Life Support
(ATLS) - 7:30 a.m. - 5:00 p.m. -
United/Children’s Conference
Center - Lab at St. Paul Ramsey
Medical Center.

May

11 Emergency Medicine Seminar
for Nurses/Paramedics - 8:00
a m. - 400 p.m. Earle Brown
Heritage Center, Brooklyn
Center.

22 & 23 Advanced Life Support

Obstetrics (ALSO) - Earle Brown
Heritage Center, Brooklyn
Center 7:30 a.m. - 5:30 p.m.

September

10 & 11 Second Annual Children’s

Hospital of St. Paul CME Course

- 8:00 a.m. - 5:00 p.m. - United/
Children’s Hospital Conference
Center.

October

2 & 3 Neurological Seminar - Epilepsy

- 8:00 a.m. - 4:30 p.m. United/
Children’s Conference Center.

9 Current Clinical Cardiology For
Physicians and the Eleventh
Annual Jesse E. Edwards, M.D.
Lecture - 8:00 a.m. - 6:00 p.m. -
United/Children’s Conference
Center.

19 & 20 Advanced trauma Life Support
(ATLS) - 7:30 a.m. - 5:00 p.m. -
United/Children’s Conference
Center - Lab at St. Paul Ramsey
Medical Center.

23 & 24 Fifth Annual New Ulm Fall

Seminar, Holiday Inn New Ulm.

November

7 Fourth Annual Oncology

Conference Radisson Ridgedale
8:00 a.m. - 4:30 p.m.

February

18 “Diagnosis and Management

of Anemias in Children” -
Christopher Moertel, MD,

Health One Unity Hospital.

March

3 “Antibiotic Associated Colitis” -

Robert Raszkowski, MD,
University of South Dakota.

(

17 “Biology and Therapy of j

Childhood Asthma” - Paul Kubic, J
MD, Children’s Hospital St. Paul '

31 “Prostatic Specific Antigen:

Diagnostic Value” - Robert Geist, '
MD, Leslie Rainwater, MD,

United Hospital St. Paul.

April

7 “Newer Antibiotic Trends” -

A1 Heaton, Pharm.D., United
Hospital St. Paul.

21 “New Proposals for Health Care <

Reform” - Steven Miles, MD, :

HCMC. 1

Fall Schedule For Educational
Telephone Network

September 8 & 22
October 6 & 20
November 3 & 17
December 1

(

]

(

Health One.

Medical Affairs Division

MINNESOTA MEDICAL ASSOCIATION

1990-9 1 Officers
President

Thomas A. Stolee, M.D.

President-Elect

A. Stuart Hanson, M.D.

Chair, Board of Trustees
Andrew J. K. Smith, M.D.

Vice President
Barbara P. Yawn, M.D.

Secretary

Thomas B. Dunkel, M.D.
Treasurer

Joseph A. Celia, Jr., M.D.

Speaker of the House
J. Randolf Beahrs, M.D.

Vice Speaker of the House
Richard D. Mulder, M.D.
Past President
Richard B. Tompkins, M.D.

Chief Executive Officer
Paul S. Sanders, M.D.

Auxiliary

President
Phyllis H. Ellis

Editor-in-Chief
Edmund C. Burke, M.D.

Advisory Committee
Edmund C. Burke, M.D.
Quentin N. Anderson, M.D.
Frank A. Bures, M.D.
Thomas W. Day, M.D.
Charles R. Meyer, M.D.

Paul S. Sanders, M.D.
Andrew J. K. Smith, M.D.
Anne B. Warwick, M.D.
Barbara P. Yawn, M.D
Meredith McNab
Mark Vukelich

Editors Emeritus
Richard L. Reece, M.D.
1975-1990

Reuben Berman, M.D.
1971-1974

Carl O. Rice, M.D.
1961-1970

Minnesota Medicine

Board of Trustees

N.W. District
Erick Reeber, M.D.

N.E. District
Thomas W. Day, M.D.

Jack B. Greene, M.D.

N. Central District
James J. Dehen, M.D.

David M. Van Nostrand, M.D.
West Metro

Roger W. Becklund, M.D.
Andrew J. K. Smith, M.D.,
Chr.

Richard E. Student, M.D.
George V. Tangen, M.D.
Ronald L. Villella, M.D.

East Metro

Joseph L. Rigatuso, M.D.

Kent S. Wilson, M.D.

S.W. District

Theodore L. Fritsche, M.D.
Anthony C. Jaspers, M.D.

S.E. District

Gail L. Gamble, M.D.

J. Paul Marcoux, M.D.
Thomas L. Peyla, M.D.
Resident Member
Cherie J. Hayostek, M.D.
Medical Student
Ty Dunn

Review Board
Chester A. Anderson, M.D.
Donald C. Bell, M.D.
Dorothy Bernstein, M.D.

F. Blanton Bessinger, M.D.
Jonathan H. Biebl, M.D.
Paul J. Bilka, M.D.

Clyde E. Blackard, M.D.

R. J. Campaigne, M.D.
Richard P. Carroll, M.D.
Roger S. Colton, M.D.
Gerald E. Cotton, M.D.
Peter Dorsen, M.D.

Peter Fehr, M.D.

Paul Gannon, M.D.

James B. Gaviser, M.D.

H. W. Heupel, M.D.

Neil Hoffman, M.D.

James Janecek, M.D.

Miles J. Jones, M.D.

Carl M. Kjellstrand, M.D.
Arnold Kremen, M.D.
Warren L. Kump, M.D.

Van S. Lawrence, M.D.

G. Patrick Lilja, M.D.

Merle K. token, M.D.
Merle S. Mark, M.D.

John K. Meinert, M.D.

AM A
Trustee

William E. Jacott, M.D.

AM A Delegates

Robert D. Christensen, M.D.

E. Duane Engstrom, M.D.

A. Stuart Hanson, M.D.
James F. Knapp, M.D.
Audrey M. Nelson, M.D.

Ben P. Owens, M.D.

Richard B. Tompkins, M.D.,
Chr.

AMA Alternates
Carolyn J. McKay, M.D.
Michael J. Murray, M.D.

C. Randall Nelms, Jr., M.D.
Lawrence M. Poston, M.D.
Thomas A. Stolee, M.D.
James J. Tiede, M.D.

L. Ashley Whitesell, M.D.

Senior Staff

Director of Economics &
Government Relations
Roger K. Johnson

Chief Financial Officer
George C. Lohmer, Jr.

Director of Communications
Mark S. Vukelich

General Legal Counsel
Mary E. Prentnieks, J.D.

James J. Monge, M.D.

John S. Najarian, M.D.

Bruce C. Nydahl, M.D.

Milton Orkin, M.D.

Richard R. Owen, M.D.
Michael M. Paparella, M.D.
James J. Pattee, M.D.

Willard Peterson, M.D.

John J. Regan, M.D.

Krishna M. Saxena, M.D.
William F. Schoenwetter, M.D.
Alvin L. Schultz, M.D.

Edward L. Seljeskog, M.D.
John E. Smith, M.D.

Farrell S. Stiegler, M.D.

George T. Tani, M.D.

Robert ten Bensel, M.D.

John V. Thomas, M.D.

John Verby, M.D.

Anne B. Warwick, M.D.
Robert L. Woodburn, M.D.

Contributing

Organizations

Minnesota Allergy Society
Minnesota Society of
Anesthesiologists
Minnesota Dermatologic
Society

Minnesota Association of
EMS Physicians
Minnesota Chapter,

Minnesota Association of
Nursing Home Medical
Directors

Minnesota Obstetrical and
Gynecological Society
North Central Occupational
Medical Association
Minnesota Academy of
Ophthalmology
Minnesota Orthopaedic
Society

Minnesota Academy of
Otolaryngology-Head &
Neck Surgery
Minnesota Society of
Clinical Pathologists
Northwestern Pediatric
Society

Minnesota Chapter, American
Academy of Pediatrics
Minnesota Physiatric Society
Minnesota Academy of
Plastic Surgeons
Minnesota Psychiatric Society
Minnesota Radiological
Society

Minnesota Chapter, American
College of Surgeons
Minnesota Surgical Society
Minnesota Thoracic Society
Minnesota Urological Society

March 1992/Valume 75

Minnesota Medicine Advisers and Reviewers

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EDITOR'S NOTEBOOK

Professional Perfidy, or Whatever Happened

to Conscience?

Edmund C. Burke, M.D.

Doctors involved in Medicaid
fraud. Young physicians re-
fusing to honor contractual
commitments. Whatever happened
to conscience? Perhaps I am over-
sensitive, but these abuses raise my
professional anger to the boiling
point.

Some young physicians are refus-
ing to honor commitments to serve in
rural areas in exchange for the fi-
nancing of their medical education.
How shocking that some medical
students accept financial assistance
and then refuse to serve the terms of
their contracts.

Neither the MMA nor the AMA
has taken a stand on this perfidy. I
believe it is time we consider estab-
lishing penalties, such as withhold-
ing licensure or denying hospital
privileges, to ensure that these
fledgling professionals honor their
responsibilities. By not doing so, we
condone these actions. I suggest that
the AMA Medical Student Section,
as well as resident and other young
physicians, deal with this matter at
the AMA House of Delegates meet-
ing in June.

This problem could possibly be
eliminated, or at least diminished, if
Congress extended the deferment time
on medical student loans. However,
a bill in the U.S. Senate (S.1150)
proposes that resident physician de-
ferments be eliminated as of 1993.
The AMA is urging Congress at least
to continue the currently allowed
deferment time of three years during
residency, or, preferably, to expand
deferment until completion of resi-
dency, which can last anywhere from
three to six years. The AMA is also
calling on Congress to support the
continuation of the forbearance of
resident physician loans for a full
10-year period without regard to
resident income. I encourage you to

Minnesota Medicine

“Medicaid fraud
and contractual
abuses tarnish our
professional
image.”

support these measures.

Physicians must also confront
Medicaid fraud. Although their
numbers are believed to be small,
more seasoned members of our pro-
fession have been convicted of such
fraud, which is not only a breach of
professional ethics, but is also crim-
inal behavior. In the December 18
Journal of the American Medical
Association, Paul Jesilow, Ph.D., and
co-authors report on physician
violations of Medicaid laws and
regulations. They located background
information on 138 of the 147 phy-
sicians sanctioned for Medicaid fraud
from 1977 to 1982, and they inter-
viewed 42 of these physicians. Per-
haps the most disturbing aspect of
their findings is that these crooked
docs would not acknowledge they
had done anything wrong. They
blamed the bureaucratic and bur-
densome Medicaid system as a justi-
fication for their actions. Do some
physicians believe it is justifiable to
use any means to improve their lot?

In an accompanying editorial,

March 1992/Valume 75

AMA Executive Vice President James
Todd, M.D., commented pointedly,
“Whatever their mentality, whatever
their justification, it is wrong.” Al-
though he emphasizes that these
physicians do not represent the main-
stream of American medicine, he
states, “The sort of behavior detailed
by Jesilow et al. is a blot on the entire
profession.” Like Todd, I find it
frightening to think that the public
might ascribe such behaviors to the
entire medical profession.

No one knows just how many
physicians partake in such illegal
action, but, of course, we’d like to
assume the numbers are small.
Nonetheless, the costs of Medicaid
fraud are estimated to be high.
Jesilow says estimates usually fall
around 10 percent to 25 percent of
the total program cost, which was
expected to exceed $66 billion for
1991. Apparently, it is time to em-
phasize the importance of profes-
sional values.

In his editorial, Todd writes, “The
American Medical Association and its
members are rededicating themselves
to the principles of professionalism —
principles that stress honesty, compe-
tence, and self-regulation.”

Medicaid fraud and contractual
abuses place physicians under scruti-
ny and tarnish our professional im-
age. As physicians, we have been
accorded special privileges in society,
and those privileges involve certain
responsibilities and duties that we
must uphold. As Todd writes, “More
than most, the medical profession,
because of its unique role and the
consequences of base behavior, has
traditionally striven to instill in its
practitioners a strong sense of duty
and professionalism.” Now, more
than ever, physicians must rise to the
professional status society has ac-
corded them. MM

“I have never gotten used to people dying. And I don’t
want to get used to it.”

Dr. Aliza Lifshitz, Internist, Los Angeles, California, Member, American Medical Association

Patients come to physicians for many reasons.
Beyond relief from pain, they seek compassion,
empathy and support. AIDS patients receive all of
these and more from Dr. Aliza Lifshitz.

Bom and raised in Mexico and educated at one of
Mexico City’s finest medical schools, Dr. Lifshitz now
serves the Hispanic community in Southern California.
Over a third of her patients have tested HIV positive.
Most live below the poverty level. Many are illegal aliens.

“I never forget what it means to be a doctor, and
what it means is embodied in the Principles of Medical

Ethics of the American Medical Association (AMA),” '
states Dr. Lifshitz.

You are invited to join Dr. Lifshitz and to join witl
her in her efforts to bring quality health care to those
in need. Become a member of the American Medical
Association today.

Members of the AMA are encouraged to join their state, county and specialty societies.

American Medical Association

l%sicians dedicated to the health of America

LETTERS TO THE EDITOR

Healing Spirit Finds New Home

I thought your readers would be
interested in the sculpture entitled
“Healing Spirit” by Georgette
Sosin as a follow-up to your
December cover story about the
closing of Metropolitan-Mount
Sinai Medical Center. The sculp-
ture, which was mentioned in your
article, was originally commis-
sioned by the Mount Sinai Auxilia-
ry and graced the western wall of
Mount Sinai Hospital from 1980
to 1990. After the merger with
Metropolitan Medical Center, the
sculpture was moved to the com-
bined Metropolitan-Mount Sinai
Medical Center. When M-MSMC
closed in 1991, the sculpture was
moved again to Abbott Northwest-
ern, where, it is hoped, the sculp-
ture has found a permanent home.

Sosin was inspired by the
passage in Jeremiah 13:17, “ ‘For I
will restore health to you, and your
wounds I will heal,’ says the Lord.”
She was also inspired by the
Hebrew expression, “Refua
Schlema,” which means perfect
healing of mind, body, and spirit.
The figure at the lower end of the
sculpture is the Hebrew letter Shin,
which symbolizes the presence of
God. The intertwining elements
rising from the letter represent the
interactions of mind, body, and
spirit. Sosin expressed the wish that
the sculpture should be “a blessing
to all who enter here.”

The symbolism of this statue
and its migrations is meaningful,
particularly to the members of the
former Mount Sinai medical staff
who have now found a pleasant,
and, it is hoped, permanent, home
at Abbott Northwestern.

David A. Berman, M.D.

Cardiovascular Diseases
Doctors Diagnostic Center, Ltd.

Minneapolis, Minnesota

-JHW llW " '

“Healing Spirit" at Abbott Nortb-
western. Photo by David Berman.

The Effects of a Walking Program
on a Nursing Home Population

We at the Parkview Care Center, a
long-term care facility in Buffalo,
Minnesota, evaluated the effects of
a vigorous walk program on
certain musculoskeletal and
cardiovascular parameters. Despite
growing emphasis on rehabilitation
in the nursing home, it is still very
apparent that nursing home
residents as a group are an ill
population. The Parkview Care
Center has always had a resident
walk program, and, as at many
facilities, many of our residents
refuse to participate.

From February 1, 1990, until
November 30, 1990, we studied
the effects of a vigorous walk
program on pulse, blood pressure,
and lower-extremity range of
motion. The program resulted in
an increase in total resident walks
per month, enhanced self-esteem
with improved ability to perform
activities of daily living, and
increased motivation for both
residents and staff. Unfortunately,
no statistical benefit was apparent
in either range of motion or

cardiovascular measurements. A
few individuals showed improve-
ment in hip flexor and/or heel cord
(ankle) range of motion. We
attributed these improvements to
an increase in these patients’
motivation and an increase in the
attention given these people, who
were at a stage in their rehabilita-
tion where they responded to
therapy.

Despite the impetus to ensure
appropriate rehabilitation in the
nursing home population, it is
important for all of us to realize
that many of these people are,
indeed, ill. A good portion of the
nursing home population is not
amenable to rehabilitation. Our
study supports the concept that the
importance of nursing home care is
to provide a homey, supportive
environment where socialization is
possible and people are able to
reach their fullest potential. We
should do what we can to improve
or maintain their quality of life, but
we should not have unrealistic
expectations.

Robert G. Milligan, M.D.,
F.A.A.F.P.

Medical Director
Parkview Care Center
and Clinical Instructor
Department of Family Practice
University of Minnesota

HCMC Stymied in Efforts to Treat
Medical Assistance Patients

After reading Dr. Alec Janes’ letter
in the December Minnesota
Medicine, which voiced alarm that
Hennepin and Ramsey county
hospitals in the last six to eight
months have been refusing to take
AFDC/PHP patients, I realize there
is a large misunderstanding, even

Minnesota Medicine

March 1992/Volume 75

LETTERS TO THE EDITOR

among physicians, about the total
revamping of health care for the
poor in Hennepin County as of
July 1990. Beginning then and
continuing monthly for the ensuing
year, all AFDC recipients in
Hennepin County either chose or
were arbitrarily assigned to receive
all their health care in one of three
managed care settings: physicians
and hospitals recognized by PHP
(now Medica); the physicians and
facilities of Hennepin County
Medical Center, known as Metro-
politan Health Plan (MHP); or
physicians and facilities served by
the family practice residencies of
the University of Minnesota,
known as U-Care. Each of these
managed care settings is exclusive
of the others unless an emergency
exists. As a result of the final
assignment of AFDC recipients in
Hennepin County, only 30 percent
of welfare patients may be admit-
ted to Hennepin County Medical
Center. Sixty percent of AFDC
recipients may be admitted only to
Medica hospitals. Although
Medica authorizes admission of its
non-welfare patients to HCMC, it
does not allow its welfare patients
to utilize our facility. Several times
a week, a patient is taken by
ambulance from our emergency
room and dropped at another
private hospital that is a Medica-
approved provider because the
patient did not realize that his or
her AFDC benefits do not allow
access to Hennepin County Medi-
cal Center.

As the director of high-risk
obstetrics and an active participant
in HCMC’s resident and medical
student teaching programs, I have
serious concerns about the implica-
tions of managed care on the
health care provided to pregnant
women in Hennepin County. Social
services, language interpretive
services, and centralized, coordi-
nated care are available to poor
patients at our county facility that
simply are not present in private
practice settings. We now offer

same-day access to prenatal care
for women who call in because
they think they may be pregnant
and want to start seeing a physi-
cian. No longer do they face the
three- or six-week wait for a new
ob appointment; no longer must
they wait until a particular welfare
card or documentation is received.
We offer the Ob Express Clinic,
with the aim of seeing patients
within 15 minutes for routine
obstetric care. We have full-time
Hmong, Fao, Cambodian, Viet-
namese, Spanish, and other inter-
preters, as well as a WIC office on
site, and a full-time chemical
dependency social worker whose
sole responsibility is to assist
patients using obstetrics services.
Yet, we can only offer these
services to the 30 percent of
indigent women in Hennepin
County who are assigned to the
MHP managed care option. We
would welcome many more
pregnant women, but until and
unless the Department of Human
Services allows patients to be
admitted to our hospital for
obstetric care, this is not possible.

Many physicians in the private
sector resent being inundated with
AFDC/Medica patients for whom
they do not have adequate social
services and office time; mean-
while, our teaching programs are
seeing a fall-off in patients who are
best served in our tertiary and
centralized center. Dr. Janes, I
would welcome any and all of
these mothers in a moment, but
they are currently in ambulances
on the way to your hospital since
they are not allowed to be admitted
to mine.

Virginia R. Lnpo, M.D.

Director, Maternal-Fetal Medicine

Hennepin Coimty Medical Center

Mmneapolis, Minnesota

Bylaws Analysis Service Available
at Lower Cost

As you may know, California
Medical Association (CMA)
attorneys review medical staff
bylaws both for California medical
staffs and medical staffs in other

states. This service has been
extremely popular both in Califor-
nia and other states. The cost for
the analysis to California dues-
paying medical staffs is $2,000; for
out-of-state medical staffs, we have
been charging $5,000.

While some medical staffs have
been able to pay the out-of-state
fee, others have stated that, al-
though they desperately need a
review of their medical staff bylaws
from a medical staff attorney (as
opposed to a hospital-oriented
attorney), they simply cannot pay
$5,000. Because of the number of
complaints of this nature and the
increasing efficiency of our review
service, we have decided to reduce
this fee to $3,000. As you know,
for a complete review of a set of
medical staff bylaws, this fee is a
bargain.

Out-of-state bylaws analyses
include review for compliance with
the Health Care Quality Improve-
ment Act, the Joint Commission
Manual, and general principles of
medical staff self-governance. 5tate
law will not be discussed. More-
over, CMA does not negotiate
bylaws. The service is an adjunct to
a medical staff attorney, not a
replacement for one.

We would appreciate it if you
would inform interested medical
staffs that they may send their
bylaws for review to Bylaws
Analysis, California Medical
Association, P.O. Box 7690, $an
Francisco, CA 94120-7690.

Aynah Askanas
Legal Counsel
California Medical Association
San Francisco, California

Correction

Our February cover story,
“Family Violence Intervention:
Physicians Find It’s More Than
Treating Injuries” (page 19),
quoted David Moen, M.D., who
is a physician at Riverside
Medical Center in Minneapolis,
not Fairview 5outhdale Hospi-
tal, as stated in the story.

March 1992/Volume 75

Minnesota Medicine

FACE TO FACE

}

Health Care for New Americans

Blending Traditional and Western Medicine

\ Minnesota Medicine interviews Patricia F . Walker, M . D .

ISfl

ion

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ine

Patricia Walker, M.D., first learned of cultural
diversity while growing up in Southeast Asia.
Today, diversity is part of her everyday life as
medical director of St. Paul- Ramsey’s International Clinic,
where she cares for patients from varied cultures, often
in their own language. Fluent in Thai
and able to speak Lao and Cambodi-
an, Dr. Walker is knoivn in the South-
east Asian community as “the doctor
who speaks. ’’

Dr. Walker first began treating
Southeast Asian refugees during her
third year of medical school at Mayo,
when she traveled to the Thai-
Cambodian border to work with the
American Refugee Committee. From
the start. Dr. Walker was amazed at
the refugees’ ability to remain hope-
ful and optimistic through unimag-
inable suffering. “They have made
me feel how incredibly resilient the
human spirit is and helped me . . . put
my own struggles into perspective, ”
she said in a recent news article.

Dr. Walker’s care for refugees
has extended beyond medical care;
she has sponsored five refugees and
has helped hundreds get out ofcarnps
or settle in the United States. Three
Cambodian siblings now live with
her, including 25-year-old Monorom
Hang, whom Dr. Walker first met
while working on the Thai-Cambo-
dian border. At age 1 0, Hang lost his mother in a frantic
crowd while fleeing Cambodia, and he later learned that
both his parents died. Recently, he and his brother were
reunited with their 1 6-year-old sister, whom they hadn’t
seen since she was two days old.

Dr. Walker, regarded as an expert on medical care
and politics in Southeast Asia, is also a respected lecturer
and consultant and frequently discusses Western health
care with Southeast Asian groups. She stresses, and
continually demonstrates, that international patients
can successfully blend traditional health care methods
with Western medicine. She believes that before patients
from other cultures will begin to accept Western health
care practices, their physicians must learn to understand
their diverse beliefs and medical practices and encourage
them to continue using traditional healing methods.

Minnesota Medicine: Dr. Walker, please tell us a little
about your background and how you became interested
in refugee health care.

Walker: 1 was born and raised in Southeast Asia. I was
born in Taipei, Taiwan, and lived
there until I was five, when my family
moved to Bangkok, Thailand. At the
time, my father was the chief pilot for
Air America during the Vietnam War
and was working primarily in Laos
with the Hmong people. The Hmong
acted as the CIA’s secret army in Laos
during the Vietnam War, and Air
America was their support airline.
My father was based in Bangkok but
worked all over Southeast Asia. My
siblings and I grew up in Bangkok
and Vientiane, Laos.

Minnesota Medicine: Did you learn
to speak Thai.^

Walker: Actually, my first language
was Chinese, but when I subsequent-
ly moved to Thailand, I forgot most
of my Chinese and picked up Thai. I
now speak Thai and some Lao and
Cambodian. I learned Cambodian in
1987 and 1988 when I was working
on the Thai-Cambodian border.

Minnesota Medicine: When did you
move to the United States.^

Walker: My parents divorced when I was 1 1 years old,
and my mother’s family is from Minnesota — she’s a
Minnesota Swede — so my brother and sisters and I
moved back to the United States with her. I continued my
education in the United States and went to Gustavus
Adolphus College and then to Mayo Medical School and
Mayo Graduate School of Medicine. I oftentimes won-
der whether I would have pursued medicine as a career
if 1 had continued my education in Thailand.

After our parents divorced, my siblings and I would
spend each school year in the United States with our
mother and then travel back to Laos and Thailand for
three months to live with our father, who was still flying
for the war effort at the rime. I continued my internation-
al travel through college, until just before I began medical
school.

Patricia F. Walker, M.D.

“If I encourage
patients to continue
seeing a traditional
healer, they also
come back to me for
health care.”

Minnesota Medicine

March 1992/Volume 75

FACE TO FACE

Shaping a Cross-Cultural Medical Career

Minnesota Medicine: Neither of your parents is a physi-
cian. Why do you think medicine appealed to you?

Walker: Actually, two of my grandparents were physi-
cians, but they both passed away before I was born. In
terms of choosing a career, I don’t remember ever
considering any career other than medicine. I really
wanted the challenge of medicine and the service options
I would have as a physician. Medi-
cine was a natural fit with my
international interests. I tell medical
students and residents who are inter-
ested in international work that, as
a physician, you’re really a tremen-
dous resource for people in less de-
veloped countries, where public
health and other medical problems
can be overwhelming.

Interestingly, four of the five chil-
dren in my family have at one time or
another done full-time refugee work
in Southeast Asia — three of us for 1 0
years or more. Even though my other siblings aren’t in
medicine, they are very committed to Southeast Asians
and helping them through refugee agencies. My older
sister is the director for Handicap International in South-
east Asia, which is an agency that makes prosthetic limbs
for amputees. My younger sister worked 10 years for the
Joint Voluntary Agency, which interviews refugees for
resettlement in the United States.

Minnesota Medicine: After you finished medical school,
you completed your residency through the Mayo Clinic.
Tell us how your career progressed from there.

Walker: One of the wonderful things about Mayo was
its support of my involvement in international health. I
first worked overseas during my third year of medical
school at Mayo. The school allowed me to leave the
program for two months to work with the American
Refugee Committee on the Thai-Cambodian border,
and I subsequently continued my involvement in South-
east Asian health care issues while still in medical school.
My plan was to return to Southeast Asia to work with
refugees after my internal medicine residency, but be-
cause I had put myself through college and medical
school, I wasn’t in a financial position to go back
immediately. Instead, I chose to do emergency room
work for several years to pay off my school loans and
later return to Thailand. That’s just what I did. I was the
medical director of the emergency department at Mount
Sinai Hospital in Minneapolis for several years. That
was a wonderful training ground for international work,
which requires the physician to be more than an inter-
nist— to be a good primary care provider. In 1987, I
arranged my current position at Ramsey before traveling
to Thailand to work as medical director for International
Rescue Committee at a refugee camp on the Thai-
Cambodian border.

Minnesota Medicine: What are your responsibilities at
Ramsey and how long have you been with the clinic?

Walker: I’ve been at Ramsey since 1988, and I’m cur-
rently medical director of Ramsey’s International Clinic
and its International Travel Clinic. I also attend on the
medicine wards, teaching medical students and house
staff three or four months per year, and I work at
Ramsey’s Health Center for Women. It’s a wonderful
mix of outpatient medicine, teaching, and supervising.

With the International Clinic and
International Travel Clinic, we’re one
of the largest specialty clinics at Ram-
sey. We have an interpretive staff of
eight — two Cambodian, two Hmong,
two Vietnamese, and two Spanish —
and we’re hiring a half-time Soviet
interpreter. Our basic criteria for ac-
cepting patients is that their primary
language is something other than
English. We see a wonderful mix of
patients from all over the world. We
see Southeast Asians, Ethiopians,
West Africans, Hispanics, Soviets, and

Poles, for example.

Minnesota Medicine: How often do you go to Asia or
Thailand?

Walker: I have gone at least once a year since 1 988. Eor
several years, I have gone twice. I still have family
members living in Thailand, so I sometimes go home
simply to see my family and friends. I also am actively
involved in refugee issues in Southeast Asia. I’ve been
working with one program out of Case Western Reserve
University in Cleveland, Ohio. The university’s Center
for International Health is revising the medical school
curriculum in Vientiane, Laos. I’ve also been working on
a program through the U.N. that helps identify medically
at-risk refugees, such as adults with rheumatic valvular
disease or children with congenital heart defects who will
soon die if they aren’t removed from refugee camps.
After identifying those at risk, the program finds medical
institutions to sponsor and care for the refugees in the
United States and other countries.

Minnesota Medicine: Y ou’ve personally sponsored some
refugees. Please tell us a little about that.

Walker: Sometimes I feel overwhelmed by the problem
of Cambodian refugees on the Thai-Cambodian border.
Providing primary care in a refugee camp is important,
but I sometimes feel as though I can’t do enough to help
individual people, so in the last few years I’ve sponsored
a few individual refugees or refugee families. Currently,
two young men — brothers who are orphans — are living
with me. One of them worked with me as a medic in a
refugee camp on the Thai-Cambodian border and is now
one of our interpreters at the International Clinic. Their
younger sister, whom they hadn’t seen since she was two
days old, just arrived a few weeks ago. She’s 16 and is
now living with us as well.

“The point is our
[health care] systems
do not have
to be mutually
exclusive.”

March 1992/Volume 75

Minnesota Medicine

FACE

TO FACE

The Merging of Health Care Practices

Minnesota Medicine: What are some of the medical
problems Asians face when they immigrate to the United
States?

Walker: For one, Asians face problems accepting West-
ern medicine because of tremendous cultural differences
in their health care beliefs and practices. Asians have
difficulty trusting and understanding Western medicine,
but Western health care providers have also had a
tremendous problem understanding and respecting Asian
health care beliefs and practices. For example, they
haven’t encouraged Asian patients to continue their
traditional health care practices, particularly the ones we
know are not harmful and may even be helpful in solving
medical problems.

Some infectious diseases from Southeast Asia can
have a long latency period, and health care providers
need to be aware of such diseases as melioidosis, chronic
parasitemia, tuberculosis, and the hepatitis B carrier
state, with its relationship to hepatoma, which is the
leading cause of cancer-related deaths in many Asian
countries. Physicians need to be aware of hepatitis B
immunization protocols, as well as protocols for screen-
ing for primary cancer of the liver. However, with
refugees in Minnesota for more than 15 years, infectious
diseases are less of a primary concern. Instead, refugee
and immigrant health care providers are dealing with the
long-term psychological consequences of the Vietnam
War and of Pol Pot’s Cambodia: post-traumatic stress
disorder, depression, and severe anxiety disorders. We
also continue to struggle with care of chronic illnesses,
such as diabetes and hypertension, and lack of familiar-
ity with Western preventive health care practices.

Minnesota Medicine: What are some examples of tradi-
tional health care practices?

Walker: Herbal medicine that doesn’t have lead or ar-
senic may be helpful for some patients physiologically
and is certainly helpful for its placebo effect. Health care
providers are realizing that before patients from other
cultures will accept Western health care practices, we
must learn about their health care beliefs and practices
and use the two systems together to provide effective
health care. Western practitioners need to reach out to
patients by providing health educational materials in
different languages. If we don’t do that, we’re not going
to be effective, especially for chronic problems and
preventive care.

Minnesota Medicine: We American physicians are some-
times so enthusiastic about our system that we forget it
may not be the only valid care system in the world.

Walker: Exactly. The most important point is that our
systems do not have to be mutually exclusive. Certainly,
as a Mayo-trained practitioner, I believe in the biomed-
ical model and the practice of Western medicine, but I
find that if I encourage patients to continue seeing a
traditional healer, for example, a Hmong shaman or a

Cambodian Kru Khmer, the patients also come back to
me for health care.

Refugee Health Care in Minnesota

Minnesota Medicine: Lack of immunizations led to a
measles epidemic in St. Paul’s Asian community last
year. How can we prevent another epidemic?

Walker: Immunization is a significant problem for mi-
norities because they lack access to health care. Some of
the Hmong children who contracted measles were under
1 5 months old — under the age at which immunization is
recommended — so in those cases, the outbreak was not
a result of Hmong families avoiding immunization.
During the measles epidemic, the media portrayal of
Hmong families was sometimes quite racist. People
assumed that Hmong families were not willing to immu-
nize their children, when, in fact, many families did not
know that immunizations were needed at a certain time
or didn’t know where to get immunizations.

How do we reach minority communities? We need to
get the message out in the Hmong language, as well as in
Spanish, Cambodian, and Vietnamese, so that family
members know about immunizations and where they
can get them. Language is a primary barrier to health
care access.

Minnesota Medicine: How well did the state health
department respond to the measles epidemic?

Walker: They were the movers and shakers in respond-
ing to the epidemic. The Acute Diseases Program did an
absolutely superb job. Ramsey County has a wonderful
group of public health nurses that we affectionately call
the “I” team. They are an “international” team of nurses
specifically focused on reaching Southeast Asian and
other minority communities. The nurses have had years
of experience reaching out to those communities either in
refugee camps or in the United States. The group was
actively mobilized during the measles epidemic. The St.
Paul Division of Public Health, the Minnesota Health
Department, and the Ramsey County “I” team were all
crucial in halting the measles epidemic.

Minnesota Medicine: Minnesota appears to be very com-
mitted to refugee health care.

Walker: That’s one of my reasons for continuing to live
in Minnesota. It’s a wonderful place to be if one wants to
do refugee health care. We have the fourth largest refugee
population in the United States. We have more than
40,000 refugees from Southeast Asia in Minnesota. Lor
example, one of every 18 people in St. Paul is Asian. In
Minneapolis, one of every 22 people is Asian. And 23
percent of the kindergartners in the St. Paul school
system are Asian.

There are a lot of reasons for the large number of
Asians in our state. Several agencies in Minnesota have
sent medical volunteers to places around the world to do
refugee health care — Minnesota International Health
Volunteers and the American Refugee Committee, for
example. One reason refugees come to Minnesota is

Minnesota Medicine

March 1992/Volume 75

because of the very large number of Minnesota physi-
cians, nurses, and other health care providers who have
done international work. Those individuals speak highly
of our state and the refugee services that are available,
and many of them sponsor refugees
as well. Minnesota also has many
church-affiliated and other agencies
that sponsor refugees. The refugee
pipeline to Minnesota has been active
since 1975 or earlier.

In addition, many services are
available to refugees in Minnesota.

More than 70 refugee service provid-
ers in the Twin Cities offer refugee
health, English as a second language
classes, and job training programs. Forty-four mutual
assistance associations, refugee self-help agencies, are
listed in the Twin Cities area.

Looking to the Future

Minnesota Medicine: What do you think the future
holds for Cambodia, now that there seems to be an
established peace? Do you think that any of the Cambo-
dian refugees will consider returning to Cambodia?

Walker: I believe most of the 300,000-plus Cambodians
on the Thai-Cambodian border would want to go home
if they knew true peace existed and knew they could
make a living for themselves. They would go back to

farming or to their lives in the cities. One major concern
is the land mines in Cambodia, which is one of the most
heavily mined countries in the world, probably aside
from Kuwait at present. Today, 600 to 1,000 people are
killed or maimed per month in Cam-
bodia from land mines. I have a lot of
hope for the future of Cambodia
during the next decade or so. The
country will need a tremendous
amount of international financial
support to rebuild after 30 years of
war. The American Refugee Com-
mittee already has one health
program in Cambodia, and I hope
Minnesota physicians, nurses, and
other health care providers will return to Cambodia to
help rebuild the country. I hope to be involved myself.

Minnesota Medicine: What other plans do you have?

Walker: I would like to get my master’s degree in tropical
medicine and hygiene, because, as Minnesota and the
United States become more multicultural, the need for
experts in tropical medicine will continue to rise. One
interesting study I recently read said that by the year
2000, one-third of the population growth in the United
States will be from immigration. I also plan to continue
working to expand Minnesota’s role in the provision of
high-quality primary care to people from other cultures
both overseas and in Minnesota. MM

“The refugee pipeline
to Minnesota has
been active since
1975 or earlier.”

University of Minnesota
Medical School

RURAL PHYSICIAN ASSOCIATE PROGRAM (RPAP)

Rural Physicians Associate Program is an academic program that enables selected third-year University of Minnesota medical students to live, learn
and work for 9-12 months in a rural community and encourages them to enter rural medical practice after completion of their residency training.
Applications are invited for the position of Program Director (with appropriate faculty rank dependent upon individual qualifications). The Program
Director, will provide leadership in administration, liaison with community physicians and state-wide community leaders, program coordination
with University-based physicians, advocacy for primary health care in rural communities, curriculum development, and conduct relevant research.

The candidate will be expected to be board certified in family practice. He/she should have experience in rural health care and/or involvement in
rural health care initiatives and credentials in clinical research and curriculum development. Qualifications for Assistant Professor include demonstrated
involvement in research and educational activities; qualifications for Tenured Associate Professor include professional distinction in research and
demonstrated effectiveness in teaching and advising; and qualifications for Tenured Professor include a national reputation in research and evidence
of leadership in candidate’s professional field.

Submit inquiries and curriculum vitae by March 31, 1992 to:

U ]D A Paul Quie, M.D.

Chair, RPAP Search Committee
University of Minnesota Medical School
Box 483 UMHC
420 Delaware Street S.E.

Minneapolis, MN 55455

The University of Minnesota is an equal opportunity educator and employer.

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PERSPECTIVES

Cross-Cultural Medicine at Home

Thomas W. Day, M.D.

“Look at me when I speak to you. ..so I know
you’re listening.” — white mother

“Why do you watch my mouth. ..do you see the
words come out?” — Ojibwe mother

These statements reveal the marked variation be-
tween the norms guiding social interaction in
Ojibwe and white American cultures. Making eye
contact when talking to a doctor is the norm in white
American culture, but among Ojibwe, direct eye contact
with a health practitioner may be a sign of disrespect or
outright defiance. Many culturally based practices result
in misunderstanding, which, in turn, can lead to stereo-
1 typing. Most Minnesota physicians have likely heard
some stereotyping of Ojibwe patients — that they are
disinterested, present a flat affect, avoid eye contact, say
very little, and offer only tangential or indirect responses.
Those same physicians, however, may not be aware that
their Ojibwe patients hold stereotypic views of physician
behavior as well. Generally, the Ojibwe see the white
American doctor as distrustful, defiant, distant, fast-
1 talking, and ignorant about the realities of life as an
I Indian person. Like many stereotypes, these contain
! elements of truth, and, taken together, they suggest that
conflicting expectations of Ojibwe people and white
I doctors could jeopardize collaboration, create alien-
ation, and disrupt continuity of care. The physician who
' treats Ojibwe patients should be well aware of the
potential for misunderstanding.

Similarly, the physician who steps into an examina-
tion room to be greeted by an Ethiopian refugee with
limited English skills immediately recognizes that she is
entering a cross-cultural interaction. She would be aware
of the importance of clear communication and would
likely supplement verbal statements with drawings and
written instructions. An enlightened physician would
watch for subtle messages from the patient and be careful
to avoid making unintended, non-verbal statements.

I Most important, the physician would prepare herself to
recognize and tolerate values and goals different from
her own.

I Most physicians realize that treating a patient who
I speaks a foreign language is a cross-cultural encounter,
. but, in fact, any communication involving a patient with
a set of values different from one’s own is cross-cultural.

' The skills needed to treat an adolescent or street person,
for example, are qualitatively the same as those required
for treating a patient of a different nationality.

The term culture refers to patterns of learned behav-
iors, customary beliefs, social norms, and values shared
by members of a group. Patients from other cultures may
understand health, illness, and medical care in ways that
differ greatly from a white American doctor’s under-
standing. In many cultures, traditional health practitio-
ners, such as the Hmong shaman or Indian medicine
man, may appear to compete directly with “modern” or
Western medical care. For example, many traditional
Hmong families continue to rely on a shaman to diag-
nose and cure illness using herbal medicine or ritual
ceremonies. The American physician’s empirical scien-
tific training may prejudice him against such cultural
health practices, and the patient may interpret such
prejudice as racism. More than one Southeast Asian
family has been investigated for child abuse after health
professionals noted the skin lesions caused by traditional
coin rubbing treatment.

Structured physician-patient interactions beginning
in medical school prepare physicians to care for people
in the traditional Western medical setting. These experi-
ences teach us certain assumptions and expectations; for
example, we are trained to believe that most disease
derives from a physiological ailment that a “good”
doctor will identify, and we expect that a “good” patient
will answer all questions with declarative sentences and
will follow directions precisely. Yet, patients who have
exclusively experienced non-Western medical models
have no reason to act according to our expectations, and
they may frustrate and confuse us when they don’t.
Eikewise, the methods of the Western-model physician
may bewilder the patient.

Cross-Cultural Methods

“It is more important to know what sort of a patient
has a disease than what sort of disease a patient
has. ” — Sir William Osier

Sir William Osier had a good point. Teaming to care for
people from other cultures, or even people from the same
culture who use non-traditional treatment methods,
such as Christian Science practices or chiropractic treat-
ments, can be demanding and takes preparation. When
such preparation is inadequate, the doctor and patient
may be unable to collaborate: Illnesses may be misdiag-
nosed. The patient may have difficulty complying or may
refuse to cooperate. Resources may be misused and
alienation may develop between doctor and patient early

1 5

Minnesota Medicine

March 1992/Volume 75

PERSPECTIVES

in the relationship. Later on, the physician will likely
become frustrated and angry, feel disoriented and, even-
tually, helpless. Preparation can help the physician avoid
such culture shock.

Martin has outlined several suggestions for physi-
cians who treat patients with health beliefs different
from their own.' According to Martin, the physician
should 1) listen in an unhurried manner; 2) use open-
ended questions that will encourage
discussion about the patient’s expec-
tations and beliefs; 3) try to identify
the patient’s beliefs about the cause of
symptoms, about the expected out-
come of the illness, and about the
benefits and risks of treatments; and
4) acknowledge and respond to the
patient’s beliefs when interpreting
symptoms and determining the ap-
propriate treatment. This last step is
probably the greatest challenge —
selecting a medically appropriate treat-
ment that does not conflict with the
patient’s beliefs. Can the physician
accept the patient’s use of traditional
methods and visits to traditional heal-
ers and at the same time prescribe
Western methods without offending
the patient? To do so, the physician must be cognizant
of her own behaviors, goals, biases, ethics, spirituality,
and beliefs about health and illness.

Traditional Ojibwe Practices

Outside the Minneapolis/St. Paul metropolitan area, the
Ojibwe people are Minnesota’s largest minority group.
Examination of their traditional health beliefs and prac-
tices exemplifies important aspects of cross-cultural
medical interaction.

Before Europeans arrived in North America, groups
of Ojibwe people functioned very effectively in the
northern environment. Their success resulted from
well-coordinated mutual effort and through promotion
of the group. Individuals’ needs were subordinated to
tbe needs of the family and the band. Three important
values typify traditional Ojibwe culture: wholism, bal-
ance, and harmony. Together, these cultural traits deter-
mine many other aspects of traditional life and influence
each person’s beliefs and behaviors.

Wholism

The practice of wholistic medicine in the dominant
culture has received increasing public attention recently,
but few non-Indian health care professionals compre-
hend the degree to which many American Indian cultures
have developed the concept of wholism. In traditional
Ojibwe culture, the individual is viewed as the dynamic
interaction of three components: body, mind, and spirit.’
The inner core (heart, conscience) and the immortal part
of the person make up the Spirit Eorce, which is strength-
ened through meditation and requires self-esteem, a
sense of belonging, faith, and fun. The mind is nurtured

1 6

by learning. To function well, it needs discipline, knowl-
edge, security, and freedom. The body (the least impor-
tant of the three) needs oxygen, water, food, and shelter
and is refreshed by sleep. The traditional Ojibwe healer
treats all three components of the whole person. This
differs considerably from the Western medical model,
which requires separate healers: a psychiatrist, an inter-
nist, and a member of the clergy. Under traditional
Ojibwe beliefs, the natural world is
also viewed wholistically. Humans
are but one component of the natural
order. The other components — plants,
rocks, animals, birds, etc. — are hon-
ored through traditional practices.

Balance

The traditional Ojibwe acknowl-
edges dynamic interaction among
the constituent parts of the individual
and those of the natural world, while
emphasizing the importance of bal-
ance among the parts. Indeed, over-
development of one component at
the expense of the others is akin to
illness. Disease is the consequence of
imbalance within the individual. In
the view of the traditional Ojibwe,
white society’s efforts to control nature disrupt the
natural balance, with negative consequences; for exam-
ple, dams cause pollution and floods, which kill fish and
animals by destroying their natural habitats.

Harmony

The third traditional Ojibwe value is harmony. People
succeed in their environment through knowledge and
respect of the coexisting beings and by achieving a state
of harmony with them. The person who recognizes an
interdependence with a tree would be unlikely to cut it
down just to watch it fall. Harmony within the social
group is also valued. An American Indian band depen-
dent on complementary interaction of all members
cannot tolerate major discord. Although individual ex-
pression is greatly valued and defended, such expression
cannot threaten the group’s cohesion, which is achieved
through interconnections of the family and group as well
as ties to the natural world. Indeed, disease results from
conflict among the individual and the family, tribe,
environment, or universe.

When Traditional Ojibwe and Western
Medical Care Come Together

Wholism, harmony, and balance helped the Ojibwe
survive in a frequently hostile environment. Traditional
Ojibwe still hold these values, and the physician must
consider this when treating Ojibwe patients. The physi-
cian should recognize that use of the culture’s teachings
may help to achieve his and the patient’s common goal —
improved health. People of Ojibwe ancestry may follow
the traditional culture closely, not at all, or to any degree

Minnesota Medicine

“The more disparate a
patient’s and doctor’s
world views and
lifestyles, the greater
the effort required on
both sides to
communicate and
collaborate.”

SB]

aji

ist

la-

if!:

|P,r

March 1992/Volume 75

PERSPECTIVES

in between. Harmony can be achieved in circumstances
that appear contradictory to the Western view. A woman
who participates in every pow-wow may be a devout
Lutheran. A university scholar may carefully follow
traditional teachings — including meditating every day at
sunrise and visiting the medicine man before important
events. The physician who sees Indian patients will have
few clues to indicate the form of spirituality they prac-
tice. Simply determining whether a patient has gone to a
traditional healer or attends church can greatly improve
the physician’s understanding of the patient.

A very traditional Ojibwe who has bodily disease
beyond the medicine man’s expertise may be referred to
a physician for care. The medicine man recognizes that
physicians have more drugs and procedures to treat
physiologic ills. If the patient needs to be hospitalized,
the physician should recall the Ojibwe values of wholism,
balance, and harmony and realize that healing the pa-
tient will require more than an operation and drugs. Just
as some patients require a Catholic priest, the traditional
Ojibwe may need to be seen by a medicine man and, if
severely ill, may require a healing ceremony. The cere-
mony assures treatment of the whole person by strength-
ening the spirit and by promoting mental health and,
therefore, helps the patient return to balance and harmo-
ny. Because the ceremony may involve the burning of
sage or cedar, chanting, or the use of a drum or flute, the
physician and nurses should help determine the best time
and place for the ceremony in order to minimize possible
interruptions by curious patients and staff. The doctor
practicing cross-cultural medicine can facilitate such a
visit by intervening with the hospital hierarchy. In Du-
luth, medicine men are accorded “community clergy”
status and their visits are coordinated through the chap-
lain’s office.

White medical professionals must be aware of other
aspects of Ojibwe culture and how they can affect a
patient’s use of the health care system. The physician
should realize, for instance, that a sudden illness or
family emergency may supersede an Ojibwe individual’s
own needs — even if it means missing a doctor’s appoint-
ment. The physician who recognizes that his patient is
following cultural dictates will more easily tolerate what
appears to be unusual or noncompliant behavior.

Summary

The cross-cultural approach allows the white physician
to see the Ojibwe patient as a person with goals both
similar and different from her own. Both the physician
and the patient understand that the purpose of the visit
is to retain or acquire good health. However, the expec-
tations, communication, and the style of interaction may
mask that concordance. Even the definitions of health
differ between physician and patient. The Western med-
ical model emphasizes normal physiologic health. The
Ojibwe view incorporates spiritual health to a greater
degree and emphasizes a wholistic approach encompass-
ing a harmonious balance among the individual, com-
munity, and nature, as well as among body, mind, and
spirit.

The methods and attitudes so apparent in cross-
cultural medical interactions are really no different from
those needed for the delivery of good medical care
generally. The more disparate a patient’s and doctor’s
world views and lifestyles, the greater the effort required
on both sides to communicate and collaborate. Nearly
every patient encounter will be improved by a cross-
cultural perspective. Acknowledgment and tolerance of
health practices different from our own can lead to
greater flexibility and understanding within the medical
care system, thereby allowing for care with less confron-
tation and conflict. Physicians who incorporate such
methods will likely gain better understanding of their
own values and practices, which will enhance their care
of all patients. mm

Thomas Day is director of the Duluth Family Practice
Residency Program and an assistant professor in the
Department of Family Practice and Community Flealth
at the University of Minnesota. He is also a member of
the Minnesota Medicine Advisory Committee.

REFERENCES

1. Martin AR. Exploring patient beliefs: steps to enhancing
physician-patient interaction. Arch Intern Med 1983; 143:1773-5.

2. Clark F. Interfacing traditional and Western medicine. Sixth
annual Native American emphasis science research symposium,
University of Minnesota-Duluth School of Medicine, August 1986.

ADDITIONAL READING

1 . Coulehan, JL. Navajo Indian medicine: implications for healing.
Earn Pract 1980;10(1):55-61.

2. Hall ET. The Silent Language. Garden City, New York:
Doubleday, Anchor Books, 1973.

3. Leiniger M. Transcultural heath care: issues apd conditions.
Philadelphia: FA Davis Co., 1976.

4. Lewis TH. A Sioux man describes his own illness and approaching
death. Ann Intern Med 1980;92:417-8.

5. Martin M. Native American medicine — thoughts for post-
traditional healers. JAMA 1981; 245(2):141-3.

6. Nidorf JF, Morgan MC. Cross-cultural issues in adolescent
medicine. Prim Care 1987;245(2):69-82.

7. Snow LF. Traditional health beliefs and practices among lower
class black Americans. West J Med 1983;139(6):820-8.

8. Thao X. Southeast Asian refugees of Rhode Island: the Hmong
perception of illness. R1 Med J 1984; 67:323-30.

Minnesota Medicine

March 1992/Volume 75

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March 1992/Volume 75

.ta JU

PERSPECTIVES

A Job Well Done?

Learning to Care for a Patient with AIDS

J . Randall Curtis, M . D .

Sitting here in the intensive care unit, waiting quietly
while friends and family gather around the bedside
to say their final good-byes to Paul, I find myself
staring blankly out the window. The mechanical whir of
the ventilator and the cold December rain on the window
help me to drift peacefully back over the last two and
one-half years.

Paul was 23 years old when he
and I first met. It was a warm July day
in Seattle. I was in the first month of
my internship, and it was Paul’s first
visit to my clinic. He had been healthy
all his life, until the previous month,
when he landed in the hospital with
bacterial pneumonia. He did well,
spending only 36 hours in the hospi-
tal, and was referred to my clinic for
follow-up care. As I rounded the cor-
ner to the examination room, the first
I saw of him was his black, pointed-
toe, suede boots propped up on my desk. When 1
introduced myself, standing formally with right hand
outstretched, he slipped his feet slowly off the desk, put
his Rolling Stone magazine in his canvas shoulder bag,
and offered his hand, but didn’t stand. I felt the contrast
between his floppy blond curls hanging down around his
round gold-rimmed wire glasses and my close-cut care-
fully combed brown hair: his oversized gray sweatshirt
and my shirt and tie. Yet I remember feeling put at ease
by his warm smile and attentive blue eyes. Because his
medical history was short, we had plenty of time to cover
nonmedical issues. He worked as a chef at a local
restaurant but wanted to open a restaurant of his own in
a few years. His restaurant was going to be such a success
that he would be able to open a new one every time he felt
ready to move to a new city. His last restaurant was going
to be on one of the San Juan Islands where he and his
lover would retire.

He seemed very comfortable telling me he was gay
but added quickly that he had practiced safe sex since
1 982 and had been in a monogamous relationship for the
last five years. He had never had an HIV test, mostly
because he didn’t think he was at high risk. I talked him
into having HIV serologic testing. Much can be done
these days — even before any symptoms appear, I remem-
ber saying. I expected the result to be negative but
wanted to be reassured because of his recent pneumonia.

He returned a week later. 1 greeted him cheerfully in
the hall and went off to find his chart while a nurse put

him in an examination room. When I found his chart and
his HIV results, I had to sit down alone for a few minutes
to collect my thoughts. I hadn’t received any training on
how to tell a 23-year-old that his dreams and hopes may
have to take on an entirely new time frame — that he
would probably never own a restaurant or retire in the
islands. I remember hoping that he
wouldn’t break down and cry in my
office — more for my sake than his. I
also remember wanting to let him
place his hope on the possibility that
the test was wrong, but that didn’t
seem fair. Somehow we both got
through the next half hour.

Over the next two years, Paul and
I saw a lot of each other. There were
spells when we saw each other once a
week. Often he would come to the
clinic just to express his fears and
anxieties; his friends and family some-
times found it difficult to listen to his anguish. Most of
all, he feared the loss of freedom that he’d seen bedridden
friends experience. At first, I would try to hide my
discomfort when he talked about being afraid or when he
cried. With time, I learned to listen without withdrawing
or trying to talk him out of his pain. Eventually, I gave
him my home phone number and he would sometimes
call me there with urgent questions or simple worries.

He called me at home about a year ago; a close friend
had died several days earlier and Paul had just returned
from the memorial service. Paul called, he said, to ask me
about some sores in his mouth. The pauses in his conver-
sation made me suspect that the mouth sores were not his
main concern. When I asked about his friend, he told me
the story of a carefree young artist with progressive
dementia, many of whose friends had pulled away in the
last weeks. Paul resented those friends, his friends, who
had stopped going to the hospital. Yet each time Paul
went to the hospital to meet the unrecognizing eyes and
to hear the incoherent ramblings, his anguish and sense
of futility grew. He would dread each visit and then
would chastise himself for his feelings. At first I tried to
ease his guilt, but when my words met with a cool
reception, 1 realized that wasn’t what he wanted. Instead,
I listened. The next time I saw him, the crisis had passed
and the mouth sores had healed. Paul thanked me more
for the mouth rinse than for the time we had spent
talking, but it wasn’t the mouth rinse prescription that
made me feel most like Paul’s doctor.

“With time, I learned
to listen without
withdrawing or trying
to talk him out of
his pain.”

iciiitl MinnesotaMedicine Marchl992/Volume75 19

PERSPECTIVES

Paul called me at home three weeks ago to tell me that
his usual low-grade fevers were now up to 102 degrees
and that he was having trouble catch-
ing his breath. I admitted him that
night, and he hasn’t been home since.

Once in the hospital, he seemed to get
worse quickly. It wasn’t long before
Paul and I had to talk about intuba-
tion. Even then, Paul had a sharp
mind and a knack for asking ques-
tions for which there were no an-
swers. I talked in percentages and
survival rates; Paul talked in time left
to be with friends. Finally, we decided
we would intubate him if we had to,
but he made me promise that if the outlook became
dismal, we would make him comfortable and turn off the
machines. Two days after his decision, he was intubated.

There was a flurry of activity about Paul’s bed for his
first few days in the ICU; consulting residents, fellows,
and attendings came and went. Their experience and
their technology were called into action, but, in Paul’s
story, it was the disease that was most persistent. The
consultants have since drifted away — in part because
they had little left to offer.

The outlook is dismal. He has been intubated for
almost two weeks. I can’t talk with him anymore, but he
writes some and still has those crystal-clear blue eyes.

Sitting here in the ICU, staring out blankly at the

drizzling gray sky, I realize that I feel content. I’m sad,
although perhaps not as sad as I was that day when I saw
Paul’s HIV results and felt an iron
door slam shut on his future. Sad, but
also proud of my role in Paul’s life. I
couldn’t save his life, but I worked
hard to give him as much time as
possible. Not time spent exhausted
and unable to get out of bed, but time
to be with friends, to enjoy a breeze,
or to cook a meal. When his last
infection came, I acted quickly and
aggressively in hope of giving him
more time. But now it is clear that this
is not the type of time we were fight-
ing for, and I am prepared to stop. Not to stop giving my
support and comfort. Not to stop spending time with
Paul. But to stop trying to prolong his life. To some, this
would be a failure. To me, for better or worse, this was
a job well done. mm

/. Randall Curtis is a physician at the Seattle Veterans
Affairs Medical Center.

Acknowledgments

The author thanks Drs. Erika Goldstein and Bruce Psaty
for their support and manuscript review.

Reprinted with permission, Curtis JR. A job well done?
Ann Intern Med 1991;115:823-4.

“I couldn’t save his
life, but I worked hard
to give him as
much time as
possible.”

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MinnesotaMedicine Marchl992/Volume75 21

ONiy ONE H, -ANTAGONIST HEALS REFLOX ESOPHAGITIS
AT DOODENAL OLCER OOSAGE. ONIY ONE.

ACID TESTED. PATIENT PROVEN.

1 Data on file, Lilly Research Laboratories See accompanying page tor prescribing information. e 1991. ELI Lilly and company NZ-2947-B-249304

Axm

nizatidine

150 mg b.i.d.

AXID*

nizatidine capsules

Brief Summary. Consult the package insert tor
complete prescribing information.

Indications and Usage: Active duodenal ulcer-
tot up to 8 weeks of treatment at a dosage of 300 mg
h.s. or 150 mg b.i.d. Most patients heal within 4 weeks.

2. Maintenance therapy - for healed duodenal ulcer
patients at a dosage of 1 50 mg h.s. at bedtime. The
consequences of therapy with Axid for longer than 1
year are not known.

3. Gastroesophageal reflux disease (GERD)-tot up
to 12 weeks of treatment of endoscopically diagnosed
esophagitis, including erosive and ulcerative esophagitis,
and associated heartburn at a dosage of 150 mg b.i.d.

Contraindication: Known hypersensitivity to the drug.

Because cross sensitivity in this class of compounds has
been observed, H;-receptor antagonists, including Axid,
should not be administered to patients with a history
ot hypersensitivity to other H^receptor antagonists.

Precautions: General- 1. Symptomatic response to nizatidine therapy does not preclude the presence
of gastric malignancy.

2. Dosage should be reduced in patients with moderate to severe renal insufficiency.

3. In patients with normal renal function and uncomplicated hepatic dysfunction, the disposition of
nizatidine is similar to that in normal subjects.

Laboratory Tests -False-positive tests ior urobilinogen with Multistix' may occur during therapy.

Drug Interactions -No interactions have been observed with theophylline, chlordiazepoxide, lorazepam,
lidocaine, phenytoin, and warfarin. Axid does not inhibit the cytochrome P-450 enzyme system; therefore,
drug interactions mediated by inhibition of hepatic metabolism are not expected to occur. In patients given
very high doses (3,900 mg) of aspirin daily, increased serum salicylate levels were seen when nizatidine,
150 mg b.i.d., was administered concurrently.

Carcinogenesis. Mutagenesis. Impairment of Fertility- A 2-year oral carcinogenicity study in rats with
doses as high as 500 mg/kg/day (about 80 times the recommended daily therapeutic dose) showed no evidence
ot a carcinogenic effect. There was a dose-related increase in the density of enterochromaffin-like (ECL) cells
in the gastric oxyntic mucosa. In a 2-year study in mice, there was no evidence of a carcinogenic effect in male
mice, although hyperplastic nodules of the liver were increased in the high-dose males as compared with
placebo. Female mice given the high dose of Axid (2,000 mg/kg/day, about 330 times the human dose) showed
marginally statistically significant increases in hepatic carcinoma and hepatic nodular hyperplasia with no
numerical increase seen in any of the other dose groups.The rate of hepatic carcinoma in the high-dose
animals was within the historical control limits seen lor the strain of mice used. The female mice were given
a dose larger than the maximum tolerated dose, as indicated by excessive (30%) weight decrement as compared
with concurrent controls and evidence of mild liver injury (transaminase elevations). The occurrence of a marginal
finding at high dose only in animals given an excessive and somewhat hepatotoxic dose, with no evidence of a
carcinogenic effect in rats, male mice, and female mice (given up to 360 mg/kg/day, about 60 times the human
dose), and a negative mutagenicity battery are not considered evidence of a carcinogenic potential for Axid.

Pregnancy -Teratogenic Effects -Pregnancy Category C-Oral reproduction studies in rats at doses up
to 300 times the human dose and in Dutch Belted rabbits at doses up to 55 times the human dose revealed no
evidence of impaired fertility or teratogenic effect; but, at a dose equivalent to 300 times the human dose,
treated rabbits had abortions, decreased number of live fetuses, and depressed fetal weights. On intravenous
administration to pregnant New Zealand White rabbits, nizatidine at 20 mg/kg produced cardiac enlargement,
coarctation of the aortic arch, and cutaneous edema in 1 fetus, and at 50 mg/kg, it produced ventricular
anomaly, distended abdomen, spina bifida, hydrocephaly, and enlarged heart in 1 fetus. There are, however,
no adequate and well-controlled studies in pregnant women. It is also not known whether nizatidine can
cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Nizatidine
should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers -Studies in lactating women have shown that 0.1% of an oral dose is secreted
in human milk in proportion to plasma concentrations. Because of growth depression in pups reared
by treated lactating rats, a decision should be made whether to discontinue nursing or the drug, taking
into account the importance of the drug to the mother.

Pediatric Use-Safety and effectiveness in children have not been established.

Use in Elderly Palients-Healmg rates in elderly patients were similar to those in younger age groups
as were the rates of adverse events and laboratory test abnormalities. Age alone may not be an important
factor in the disposition of nizatidine. Elderly patients may have reduced renal function.

Adverse Reactions: Worldwide, controlled clinical trials included over 6,000 patients given nizatidine in
studies of varying durations. Placebo-controlled trials in the United States and Canada included over 2,600 patients
given nizatidine and over 1,700 given placebo. Among the adverse events in these placebo-controlled trials, only
anemia (0.2% vs 0%) and urticaria (0.5% vs 0.1%) were significanfly more common in the nizatidine group. Of
the adverse events that occurred at a frequency of 1% or more, there was no statistically significant difference
between Axid and placebo in the incidence of any of these events (see package insert for complefe information).

A variety of less common events were also reported; it was not possible to determine whether these
were caus^ by nizatidine.

Hepa/rc- Hepatocellular injury (elevated liver enzyme tests or alkaline phosphatase) possibly or probably
related to nizatidine occurred in some patients. In some cases, there was marked elevation (>500 lU/L) in
SGOT or SOFT and, in a single instance, SGPT was >2,000 lU/L. The incidence of elevated liver enzymes
overall and elevations of up to 3 times the upper limit of normal, however, did not significantly differ from that
in placebo patients. All abnormalities were reversible after discontinuation of Axid. Since market introduction,
hepatitis and jaundice have been reported. Rare cases of cholestatic or mixed hepatocellular and cholestatic
injury with jaundice have been reported with reversal of the abnormalities after discontinuation of Axid.

Cardiovascular -\t\ clinical pharmacology studies, short episodes of asymptomatic ventricular tachycardia
occurred in 2 individuals administered Axid and in 3 untreated subjects.

CNS-Rare cases of reversible mental confusion have been reported.

Endocrine-Clinical pharmacology studies and controlled clinical trials showed no evidence of anti-
androgenic activity due to nizatidine. Impotence and decreased libido were reported with similar frequency
by patients on nizatidine and those on placebo. Gynecomastia has been reported rarely.

Hematologic -Anemia was reported significanby more frequently rn nizatidine than in placebo-treated
pahents. Fatal thrombocytopenia was reported in a patient treated with nizatidine and another H,-receptor
antagonist. This patient had previously experienced thrombocytopenia while taking other drugs. Rare cases
of thrombocytopenic purpura have been reported.

Inlegumenlal -UiXicana was reported significantly more frequently in nizatidine- than in placebo-treated
patients. Rash and exfoliative dermatitis were also reported.

Hypersensitivity -As with other Hj-receptor antagonists, rare cases of anaphylaxis following nizatidine
administration have been reported. Rare episodes of hypersensitivify reactions (eg, bronchospasm, laryngeal
edema, rash, and eosinophilia) have been reported.

Offier-Hyperuricemia unassociated with gout or nephrolithiasis was reported. Eosinophilia, fever, and
nausea related to nizatidine have been reported.

Overdosage: Overdoses of Axid have been reported rarely. If overdosage occurs, activated charcoal,
emesis, or lavage should be considered along with clinical monitoring and supportive ttierapy. The ability of
hemodialysis to remove nizatidine from the body has not been conclusively demonstrated; however, due to its
toge volume of distribution, nizatidine is not expected to be efficiently removed from the body by this method
PV 2093 AMP (1015911

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Dinner Lecture with David Dinges, PhD
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A PRIMARY CARE TREATMENT FOR
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1991 , ELI LILLY AND COMPANY

COVER STORY

Border

Crossings

Refugees Travel Difficult Route to Health Care

Dr. Charles Oberg examines 2-year-old Ames Yang, a Hmong patient at the
Family Medical Center, an FiCMC satellite clinic in south Minneapolis.

CC ' I ’his pain is with me always. But
X it’s no problem. I have the war
in my mind all the time. No problem.
And I remember my children who died
in the war. No problem.”

The tiny woman with rounded
face and long, dark hair punctuates
each sorrow with a phrase of denial.

But soon tears well up in her eyes and
words begin to flow. “We escaped be-
cause the war is very hard. It killed my
two oldest children. And my two broth-
ers. And 20 cousins, they are dead. All
the family. That’s why we left. We feel
good because we escaped. We are alive.
But I remember my children.”

Story and photos by
Douglas Clement

March 1992/Volume 75

Minnesota Medicine

COVER STORY

Laotian interpreter Khamtu Mnnsisoumang translates for Saeng Phetsamone,
a pregnant patient at the Family Medical Center.

Just over a year ago, Maria
Lopez (not her real name)
arrived in Minnesota from El
Salvador with her husband and
their four surviving children. She
now complains of persistent head-
aches and back pain. Her youngest
son is deaf in one ear and constant-
ly has colds — a consequence, she
says, of having been raised in a war
zone. “My child is very sick now,
but I don’t have Medicaid. 1 don’t
have any assistance to cover for his
bills. So I don’t bring him to the
doctors.”

Maria is an alien, a refugee, an
immigrant. She is a new American.

And she presents our health care
system with difficult challenges.

Before Maria and her family get
the care they need, they will likely encounter barriers to
health care access, personal communication, and cultur-
al respect. For refugees in Minnesota and the doctors
who treat them, these obstacles to good health care have
often seemed borders never to be crossed. But time,
tolerance, and cultural sensitivity are clearing the way.

America, of course, is a nation of immigrants. In a
sense, all of us who are not Native Americans are boat
people. The largest recent wave of immigration began in
1975, as Hmong from the mountains of Laos, Vietnam-
ese from their shattered country, and Cambodians flee-
ing Pol Pot’s violence began to enter the United States. By
1980, more than 10,000 Southeast Asian refugees had
come to Minnesota; 6,500 more arrived the next year. By
October 1 99 1 , we had an official total of 40, 136 refugees
living within Minnesota’s borders, 92 percent of whom
were Southeast Asian.'

These numbers significantly understate reality. Inter-
nal migration (e.g., Hmong moving from Wisconsin to
Minnesota) and illegal immigrants swell the numbers far
past statisticians’ ability to keep track. The state’s official
refugee count includes, for example, only nine refugees
from Latin America.

The numbers alone also obscure significant differ-
ences within each population. The Southeast Asian
grouping comprises Cambodians, Vietnamese, Laotian,
and Hmong, including white and blue Hmong, urban
and rural Hmong, upper- and lower-status Hmong, and
animist and Christian Hmong. Three phases of Vietnam-
ese immigration have brought city dwellers, then farm-
ers, and now Amerasian children and “re-education
camp” detainees.

These differences have strong implications for health
care providers, but many remain ignorant that distinc-
tions exist. “I still, to this day, occasionally will get a call
saying, ‘I need a Southeast Asian interpreter,’ ” says Ellen
Rau, Hennepin County Medical Center’s interpreter
supervisor. “ ‘OK, what language?’ I ask. ‘How should
I know?’ they reply.”

Confusion is likely to grow. Recent refugee influxes

to Minnesota include Soviet, Ethiopian, Polish, and
Romanian natives, each population with its own reli-
gious, linguistic, and cultural distinctions. The result is
waiting rooms that sound like Towers of Babel, clinics
that look like U.N. lobbies, and doctors who don’t know
where to begin.

“The situation |in the late 1970sJ was health care
providers being overwhelmed by a group of people with
very different medical problems and very different cul-
tural beliefs about how one interacts with a health care
provider,” says Patricia Walker, M.D., medical director
of St. Paul-Ramsey’s International Clinic. Diseases rare-
ly encountered in Minnesota were commonplace among
the refugees: malaria, tuberculosis, hepatitis B, intestinal
parasites, malnutrition, anemia, chronic ear infections,
and serious dental problems.

Faced with an overwhelming situation, Minnesota
responded as it traditionally does — with generosity and
“can-do” optimism. In Minneapolis, the Health Depart-
ment screened new Minnesotans for TB and sent the
women and children down the hall to Maternal and
Child Health. The men, it was hoped, would be helped
by their sponsors to get medical care outside public
health programs. Similar screening was done in St. Paul.

In 1 980, Neal Holtan, M.D., now medical director of
the St. Paul Public Health Department, helped start St.
Paul-Ramsey’s International Clinic. “The plan was to do
this for five years and then the need would cease to exist.
That’s how naive we were,” recalls Holtan. “We thought
once I the refugees] got settled, learned English, and got
jobs and insurance, we wouldn’t need the clinic any-
more. Well, it’s grown every year since 1980, and it’s
busier now than it’s ever been.”

Busier. And more complex. Initially, health care
providers were confronted with the acute medical prob-
lems of immigrants from tropical countries, and while
the problems were unusual for Minnesota, treatment
was fairly basic. But over time, refugee health care needs
changed significantly and posed more serious challenges.
Illness patterns evolved from the acute to the chronic.

Minnesota Medicine

March 1992/Volunne 75

COVER STORY

from physical to mental, and from
bacterial origins to those that are so-
cial.

“A shift has occurred,” says
Walker. “The major problems used to
be infectious diseases of a public health
significance. The major problems now
are primarily personal issues: post-
traumatic stress disorder, depression,
anxiety, and people who’ve been vic-
tims of torture. They’re more chronic,
more difficult to treat.”

Surmounting Barriers to
Access

Every patient must cross several bor-
ders to receive health care. The first
passage — learning about, getting to,
and paying the doctor — sounds sim-
ple enough. But for an immigrant, those steps can seem
impossible. Without practical access to health care infor-
mation and facilities, refugees may never seek help.
Maria Lopez from El Salvador, for example, knows little
about the health care available in Minnesota and hasn’t
the transportation or funds to access it.

“My concern is that refugees don’t have basic health
information,” says Deborah Wexler, M.D., a family
physician with West Side Health Center in St. Paul.
“There’s been no public health effort to really teach
people in their own language about why immunizations
important.” After the measles outbreak of 1990,

“Most [refugees]
are finding jobs
that do not provide
health care
coverage; they’re in
that category of the
American working
poor.”

— Carol Berg

are

Wexler worked with St. Paul Public Health to provide
health care to Hmong families where they live, rather
than hoping they’d go to area hospitals.

Wexler now runs a weekly clinic in McDonough
Homes, a predominantly Hmong community in North
St. Paul. Without such efforts, says Wexler, “we’ll have

Monica Overkamp, a nurse practitioner at St. Paul-
Ramsey's International Clinic, questions 68-year-old
Russian Lev Abromovich about his hack pain.

more epidemics, more measles outbreaks, more hepatitis
B.” (One in seven Southeast Asians is a chronic carrier of
hepatitis B. The virus is also disproportionately common

in Africans and some South Ameri-
cans, according to the Centers for
Disease Control, which recently add-
ed hepatitis B inoculation to the list of
standard vaccinations for all infants.)

Pear, as well as distance and igno-
rance, can keep refugees away. “Most
of the people we see are illegal
[aliens],” observes Linda Gonzales, a
medical assistant at West Side Health
Center, which serves many Latin
American immigrants. “They’re
afraid to ask for any kind of help
because they think that as soon as we
ask them, ‘Are you legal?’ we’re go-
ing to turn them over [to authori-
ties].”

Even legal immigrants who pur-
sue the American dream are likely to
find health care financially inaccessible. “Most are find-
ing jobs that do not provide health care coverage; they’re
in that category of the American working poor,” notes
Carol Berg, Refugee Health Program coordinator for the
Minnesota Department of Health.

Mastering the Art of Cross-Cultural
Communication

Lor those who gain physical and financial access to
Minnesota’s health care providers, the next barrier is
communication. “Without a well-trained interpreter,”
says Holtan, “it’s practically impossible to provide qual-
ity care.”

Amos Deinard, M.D., of Community University
Health Care Center (CUHCC), concurs: “The use of
professional interpreters really is a key to providing
health care to any group. You cannot say, ‘Well, Ell bring
my sister along, or my cousin.’ There is an art to being an
interpreter.”

Those who’ve neglected the art have caused more
than a little confusion. Win Terrell, a St. Paul health
educator, recalls the time a doctor needed a blood sample
from a Hmong patient. “The interpreter was not much
more skillful than the client,” says Terrell. “And the
words “test” and “taste” sound very much alike. Lor a
long time, we had to fight the myth that our doctor
wanted to drink the blood. And when we asked for urine
and stool specimens, they just laughed.”

But the art of interpretation goes well beyond accu-
rate word choice. When refugees first came to our state,
the major problems of miscommunication were due not
to poor translation, but to conflicting expectations and
inadequate training of interpreters. Doctors often enlist-
ed interpreters as assistants, expecting them to persuade
patients to accept medical advice. Patients, in turn,
wanted interpreters to be their advocates. During serious
disagreements, both doctor and patient blamed the mes-
senger.

Today, more Minnesota interpreters have been trained
both in medical terminology and in the professional
ethicsof neutrality, objectivity, and confidentiality. What

March 1992/Volui

Minnesota Medicine

COVER STORY

Dr. Mary Nesvig gives Linda Thao a check-up at the McDonough Homes
Community Center while the baby’s mother, Shoa Xiong, watches.

still is needed is training for health care professionals in
how to work with interpreters. “A kind of tradition has
evolved, even in the agencies that are very good at dealing
with immigrants, of asking the interpreter to assume
different roles,” says Bruce Downing, professor of lin-
guistics at the University of Minnesota. “It just makes
too many demands on them. ... People tend to be satis-
fied with it, but when you push them on it, they have
horror stories about terrible misunderstandings.”

Horror stories aren’t hard to come by — of nine-year-
olds asked to translate “sedated CT scan” into Laotian,
of patients whose ear infections per-
sisted because they thought ear drops
! were to be taken orally, not aurally —
i and they’ll continue as long as health
I care providers can’t communicate well
with their patients.

At present, Hennepin County
; Medical Center and St. Paul-Ramsey
I are the only two Twin Cities hospitals
with full-time interpreters. CUHCC,

I Model Cities Health Center, and the
West Side clinic have nursing assis-
I tants, social workers, and other staff
t who are bilingual and so serve double-
duty. When available, the casework-
ers at Jewish Family Services provide
! telephone interpretation for Soviet
[ jews, and a few Russian interpreters
? work free-lance. The efforts are noble, but they’re often
j not enough.

I Recent Medical Assistance changes that shift some
MA patients away from county hospitals to other health
! plans may further impede communication. The idea is to
■ improve access to quality care, but some state officials

are concerned that the new system may
present barriers to those who don’t speak
English because the county hospitals are
typically better prepared than the private
health plans to help foreign patients.

“Some [health plans] are already do-
ing very well,” says MDH’s Berg. “Oth-
ers ... have a long way to go as far as
learning how to accommodate special
needs of newer Minnesotans. The HMOs
will tell you the system is in place, but in
reality, it doesn’t work for the clients. ...
A lot of people are falling through the
cracks.”

Overcoming Culture Clash

“Suppose you were dropped in the mid-
dle of a Hmong village in the highlands of
Laos and you felt ill,” suggests David
Loveridge, director of the Wilder Refu-
gee Program. “And you were told that the
reason you felt ill was that you’d offended
some ancestor and, therefore, you needed
to buy a pig and make a sacrifice. Well,
you wouldn’t want to spend the money
on a pig, for a start. And probably, you wouldn’t do it.
Now, suppose you also happened to have a bottle of
Tylenol handy...”

By making us refugees, Loveridge’s hypothetical
situation illustrates the third barrier to refugee health
care: culture clash. And his story includes all the key
elements: different theories of disease causation, non-
compliance with a prescribed health care regimen, use of
traditional remedies by the noncompliant patient.

Even among Western cultures, healers view illness in
very different ways. Erench doctors, for instance, at-
tribute much disease to “crise de foie”
(liver crisis), Germans to “Herzinsuf-
fizienz” (heart insufficiency.) Accord-
ingly, the Erench prefer suppositories
because of proximity to the liver, and
Germans use six times the amount of
heart drugs per capita as either the
Erench or English. ’

It shouldn’t be surprising, then, to
find that Hmong, Soviet Jews, and
Hispanics view illness and its reme-
dies differently than Americans. An
animist Hmong, for example, may
believe that illness is caused by soul
loss, or by the spirit of a dead ancestor
visiting his body. Western medicine
might treat the symptoms success-
fully, but the illness will be gone only
if the proper healing ceremony is done to show respect
to the ancestors. Because antibiotics were scarce in
their homeland, Soviet refugees may expect to keep a
child with strep throat out of school for weeks. An
Hispanic immigrant may consider “mal de ojo” (evil eye)
to be the cause of a serious ailment, or believe that

“There are many
ways of being in
the world, either
culturally or
medically, without
compromising our
standards of care.”
— Patricia Walker, M.D.

Minnesota Medicine

March 1992/Volume 75

COVER STORY

excessive air can cause back pain.

“I had a woman in my office the other day who said
she wasn’t going to pay her hill because she didn’t get
better with the doctor’s recommen-
dation,” says West Side’s Gonzales.

The woman, who complained of
constantly swollen glands and fever,
returned to Mexico to consult a
traditional healer. “The curandero
gave her some kind of tea to drink,”
says Gonzales. “She said the doctor
here didn’t do anything for her, but in
Mexico she became 100 percent
better. In fact, she wanted us to pay
her for the blood that we took for
testing.”

Such stories sound “quaint” to
us, but only cultural arrogance could
pronounce other healing theories less appropriate than
ours. After all, it is not oitr illness that is being treated.
Nevertheless, serious conflicts over medical treatment
have occurred in Minnesota. Especially in the early
1980s, doctors who were convinced that surgery was
necessary sometimes used verbal intimidation and legal
force to ensure that it took place.

Such conflicts have had long-lasting negative effects,
observes Walker. “Some people in the Asian community
believe that Western health care providers perhaps can’t
be trusted to be respectful.”

“The trust is not there,” agrees Gher Vang, Hmong
parent representative at St. Paul Ghildren’s Hospital. But
he’s optimistic that Hmong trust will grow if doctors
show greater understanding of
Hmong concerns and more patience
with their decision-making process.

“What the Hmong people want
to tell the Western doctors is that
they need to be patient,” says Vang.

“If they spend a little more time and
build the trust, in the long run I think
we can get things done easier. If the
Hmong people trust you, then they
will allow you to do whatever you
want to do, because they know you
aren’t going to do any harm.”

Appreciation of a patient’s world
view is a necessity for good cross-
cultural health care, but sincere re-
spect can be difficult for physicians
who view the biomedical model as
the only “right” way of providing health care. “But the
reality is that unless you’re culturally sensitive, the pa-
tient may leave your practice,” says Walker. “I think we
can acknowledge that there are many other ways of being
in the world, either culturally or medically, without
compromising our standards of care.”

Yet even Walker faces dilemmas. Recently, a young
Hmong man under her care suffered his second ventric-
ular fibrillation and died in St. Paul-Ramsey’s emergency
department. When the ED nurse called Walker at home

to notify her of the death, the doctor decided not to sign
the death certificate, hoping that an autopsy might reveal
some clue to Sudden Unexpected Death Syndrome.

As soon as Walker hung up the
phone she drove down to the ED.
“There, a huge extended family of
Hmong elders, about 25 people, sat
with this young man, stroking his
body, grieving his loss,” she recalls.
“And an older Hmong man gave me
a 15-minute lecture about Hmong
health care beliefs and religious be-
liefs. ‘You know, I came to America
because this is a country where you
have freedom,’ he said. ‘And you are
not allowing me to have freedom of
religion if you do an autopsy of my
nephew. If you do an autopsy, all of
his souls will escape. They won’t be able to go with him
to the next life. And those souls will wreak havoc on the
rest of the family for eternity.’ ”

Walker signed the death certificate. “I think that was
the culturally appropriate thing to do,” she now reflects.
“But I still remain torn as a physician about whether or
not we would have found out some clue to a problem that
plagues the Hmong community.”

Walker is not the only Minnesota physician to en-
counter such dualities. Usually, however, different ways
of healing can run parallel paths. Gharles Oberg, M.D.,
an HCMG pediatrician, recently examined a IVz-year-
old Gambodian boy recovering from pneumonia and
found long, red bruises on his back. The marks were the
result of “coining,” a Cambodian
treatment for fever that involves
rubbing warm oil and coins across
the skin. Oberg, who works exten-
sively with refugees, encouraged
the parent’s use of the traditional
cure while also giving a standard
course of antibiotics.

Respecting other cultural be-
liefs does not mean that physicians
should start practicing Hmong
healing rituals, of course. And try-
ing to include traditional healers
within the mainstream health care
system is unlikely to succeed. But
formal recognition and support of
those traditional healers (e.g., the
Hmong txiv neeb, Cambodian Kru
Khmer, and Hispanic curanderos) would undoubtedly
improve understanding between health professionals
who currently view one another with little more than
skepticism.

“I encourage health professionals to be very respect-
ful of those folk practices because for years they have
worked,” says Dr. Blanca Rosa Egas, an Ecuadoran
psychiatrist and former director of Community
Mental/Chemical Health for Hennepin County. “If tra-
ditional healers are doing those practices safely, we

“The Hmong
people want to tell
the Western
doctors that they
need to be patient.”
— Cher Vang

Neng Vue and her 2-year-old son,
Ames Yang.

March 1992/Volume 75

Minnesota Medicine

COVER STORY

Two-year-old Rodanal Heng suffered from pneumo-
nia and was given a common Cambodian treatment
known as coining. His mother, Chhavy Kim Heng,
shows the resulting marks during a visit to the
Family Medical Center.

should endorse them.”

Ultimately, then, for refugees to cross the final health
care border will require that doctors come half-way.
“Providing health care to the Hmong and other unique
populations must be viewed as a cooperative undertak-
ing,” write Deinard and Dunnigan.^ “(It is] a bi-direc-
tional process.” And in that process, Minnesota’s med-
ical community, as much as its newest citizens, will be the
beneficiary.

“We talk about our health care system, but what we
really have in this country is a sick care system,” observes
Oberg. “I think [Southeast Asians] have a better under-
standing of wellness than we do. And just as there’s a
great deal they can learn from us in regard to the
diagnosis and treatment of disease, they have much to
teach us about the concept of wellness.” MM

Douglas Clement is a free-lance writer and photographer
living in Minneapolis.

REFERENCES

YOCON'

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.

Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower It; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage,
indications: Yocon< is indicated as a sympathicolytic and mydriatric. it may
have activity as an aphrodisiac.

Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and Inadequate information at hand, no precise tabulation
can be offered of additional contraindications.

Warniiqi: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history. Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.T? Also dizziness,
headache, skin flushing reported when used orally.T3
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. ' ^ ^ tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to '/a tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Applied: Oral tablets of Yocon^ 1/12 gr. 5.4 mg in
bottles of 100's NDC 53159-001-01 and 1000's NDC „
53159-001-10.

References:

1. A. Morales et al.. New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed., p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4.

1983.

4. A. Morales etal.,TheJoumalof Urology 128:

45-47, 1982.

Rev. 1/85

AVAILABLE AT PHARMACIES NATIONWIDE

1. Refugee and Immigrant Assistance Division, Minnesota
Department of Human Services.

- 2. Payer L. Medicine and Culture. New York: Henry Holt and Co.,

1988.

3. Deinard AS, Dunnigan T. Hmong health care: reflections on a
six-year experience. Int Migr Rev 1 987;21(3):8.S7-6.5

PALISADES

PHARMACEUTICALS, INC.

219 County Road
Tenafly, New Jersey 07670

(201) 569-8502
1-800-237-9083

Minnesota Medicine

March 1992/Volume 75

INSTRUCTIONS

FOR AUTHORS

Mmtiesota Medicine is the official journal of the Minnesota
Medical Association, and its purpose is to provide Minne-
sota physicians with timely information regarding all as-
pects of medicine so they can more capably serve their
patients and more readily achieve their professional goals.
Therefore, the editors are pleased to consider for publica-
tion clinical and health papers (clinical studies, reviews, case
reports) and essays, letters, poems, and opinion pieces
related to medical practice in Minnesota.

Manuscripts

Submit clinical articles, essays, letters, book reviews, and
other manuscripts at any time to: Meredith McNab, Man-
aging Editor, Mmtiesota Medicine, 222 1 University Avenue
SE, Suite 400, Minneapolis, MN 55414. Manuscripts are
reviewed by the editors and peer reviewed by the Advisory
Committee, the Review Board, and other experts in particu-
lar specialties.

Receipt of manuscripts is acknowledged within 10
days, and authors are usually notified whether their manu-
script is accepted within one to three months, but longer
delays are sometimes unavoidable.

Title and Authors’ Names

The first page of the manuscript should include: 1) a title —
make it short, specific, and direct, 2) the full names of all
authors, with their academic degrees, 3) authors’ positions
in hospitals or other institutions — include current position
and the position held when the work reported in your
manuscript was done, as well as academic appointments
and other information pertinent to the paper’s topic.

Abstract

Author Responsibility

All authors sign a copyright form that conveys all
copyright ownership to the Minnesota Medical Associa-
tion. This form is mailed to the authors after a manuscript

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Style

Tables

Tables must have a title and be on separate pages. If they
occupy more than one page, type “title (cont.).” If the data
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be obtained from the original publisher before submission
to Minnesota Medicine.

Illustrations

References

All references must be cited in the text and should be
arranged in the order in which they are cited in the text — not
alphabetically. Journals should be abbreviated as in Index
Medicus.

Examples:

1. Benson RC Jr. Laser photodynamic therapy for
bladder cancer. Mayo Clinic Proc 1986;61:859-64.

2. Guttormson NL, Bubrick MP. Mortality from is-
chemic colitis. Dis Colon & Rectum, to be published.

4. Thompson NW. Thyroid and parathyroid. In: Welch
KJ, Randolph JG, Ravitch MM, et ah, eds. Pediatric Sur-
gery, 4th ed. Chicago: Year Book Medical, 1986: vol 1,
522-33.

Financial Interest

Reprints

Authors may order article reprints for a fee. Reprint request
forms are sent to authors at the time of publication.

March 1992/Volume 75

Minnesota Medicine

MEDICINE LAW & POLICY

Hospital-Physician Joint Ventures Revisited

New Tax Ruling May Restrict Hospitals' Options

Steven N . Beck, J . D .

Congress and the Internal Rev-
enue Service have for some
time been reconsidering
whether and in what circumstances
health care organizations should be
accorded the benefit of tax-exempt
status. Various legislative proposals
have emerged, including many that
would require hospitals to demon-
strate that the public benefits engen-
dered by hospital operations equal or
outweigh the value of tax benefits
conferred on hospitals through tax-
exempt status. In effect, this approach
would require hospitals to identify
tangible, public benefits and to quan-
tify those charitable benefits to justi-
fy their status.

On December 4, 1991, the IRS
issued a general counsel memoran-
dum (GCM) that overturned three
private letter rulings relating to hos-
pitals’ tax-exempt status. The factual
focus of the private rulings was on
hospitals that sold revenue streams
from current and existing operations
to limited partnerships involving
physician staff members. Each of the
three private letter rulings held that
the sale of revenue streams did not
result in private inurement or other-
wise endanger the hospitals’ tax-
exempt status. The new GCM revises
that conclusion and indicates that
sale of a hospital’s revenue stream in
certain circumstances may endanger
a hospital’s tax-exempt status.

The GCM’s underlying philo-
sophical premise is similar to that
being heralded by hospital tax-
exemption reformers. Essentially, the
GCM seems to reject the premise that
anything good for the hospital’s fi-
nancial health is good for the public
and, thus, supports the hospital’s
charitable mission. The GCM would
instead require a hospital to identify
specific effects of a joint venture that
support its charitable purposes.

Factual Setting of the New
Ruling

The factual setting in which the IRS
examined these issues was quite nar-
row. The three overturned letter rul-

“A venture will no
longer be justifiable
solely because it will
increase hospital
admissions or
utilization.”

ings involved three similar ventures.

The first letter ruling involved a
limited partnership’s purchase of a
hospital’s outpatient surgical pro-
gram and gastroenterology labora-
tory. The hospital or an affiliated
organization was the sole general
partner in the partnership. Physicians
invested in the venture as limited
partners, and the limited partnership
interests created an investment re-
turn for the physicians that arguably
could be maximized through physi-
cian referrals. The hospital, as gener-
al partner, continued to manage and
operate the facilities.

The second letter ruling involved
a hospital’s outpatient surgery de-
partment and day surgery unit, which
were competing for business with an
ambulatory surgery center that was
less than five miles away and in-
volved physician investors. To level
the competitive playing field, the
hospital created a limited partner-
ship with an affiliated entity as the
general partner and physicians as

March 1992/Volume 75

limited partners. The limited part-
nership entered into an agreement to
use the outpatient surgery facilities in
exchange for payment equaling the
present value of related income
stream. As general partner, the hos-
pital continued to operate the sur-
gery facilities.

The third letter ruling involved
establishment of four limited part-
nerships with a corporate general
partner owned jointly by the hospital
and a group of physicians. The limit-
ed partnerships governed four
hospital outpatient departments:
outpatient surgery, outpatient diag-
nostics, ophthalmology, and cardiac
nuclear medicine. The effect of the
arrangement was to “lease” the de-
partments for a period of time to the
limited partnerships. Again, the hos-
pital retained actual control of the
facilities through a management
agreement.

The IRS Analysis:
Re-examining Public Purposes

In substance, the GCM held that the
arrangements jeopardized the tax-
exempt status of the hospitals for
three reasons. Eirst, the sale of the
income streams produced “private
inurement” — payments resembling
dividends — to the medical staff phy-
sicians who purchased the income
streams. Second, the sale of the in-
come streams resulted in greater than
incidental benefits being accorded to
private parties and, therefore, con-
flicted with the hospital’s stated pub-
lic missions. Third, the sale of the
income streams may have been ille-
gal under the Medicare fraud and
abuse law and, as illegal activity, was
not in accordance with the hospitals’
tax-exempt purposes.

Each of the three lines of analysis
applied in the GCM has separate

Minnesota Medicine

MEDICINE LAW & POLICY

significance. The private inurement
and “private benefit” tests are really
alternative approaches to the same
basic issue. “Private inurement”
means providing an insider or con-
trolling person with an interest in the
net profits of the tax-exempt entity.
There is no exception to the private
inurement prohibition for small in-
terests in the net profits; however,
private inurement must involve a di-
vision of net profits or other payment
resembling distribution of a dividend.
The private-benefit prohibition, on
the other hand, involves an activity
that, although undertaken for public
charitable purposes, benefits private
interests. For purposes of determin-
ing whether there is an impermissible
private benefit, the benefit need not
flow to insiders or controlling per-
sons. Because all charitable activities
arguably benefit private persons in
some way, private benefit is permis-
sible if it is “qualitatively and quan-
titatively incidental” to the public
purpose of the activity. This means
that the private benefit must be nec-
essary when providing an important
public benefit, and the private bene-
fit must be insubstantial as compared
with the public benefit resulting from
the activity. The IRS has formulated
a practical test to decide whether a
joint venture between a hospital and
physicians creates an impermissible
private benefit. A joint venture is
problematic if 1 ) it does not further a
charitable purpose, 2) the hospital is
inadequately protected against finan-
cial loss, or 3) physician investors
have improper financial gain.

The Medicare fraud and abuse
analysis included in the GCM reveals
a new approach by the IRS to deter-
mining whether an activity endan-
gers a hospital’s tax-exempt status.
This approach again focuses on
whether the activity furthers the in-
stitution’s charitable purpose. The
IRS concludes from a policy perspec-
tive that an activity that would vio-
late a criminal law does not benefit
the public. Thus, the IRS says that an
activity amounting to Medicare fraud
and abuse endangers a hospital’s ex-
emption because it controverts the
organization’s public charitable pur-
pose.

The GCM analyzed the three fact

situations under the three tests de-
scribed above. Under each test, the
analysis suggested that the arrange-
ment would endanger the facility’s
tax-exempt status. In discussing the
ventures, the GCM characterized the
relationship between physicians and
hospitals generally as one in which
hospitals, driven by the prospective
payment system, are using any means
available to increase admissions while
controlling utilization of ancillary

“Hospitals should
take stock of their
joint ventures and be
careful to document
the charitable
purposes of those
ventures.”

hospital services and discharging
Medicare beneficiaries as quickly as
medically appropriate. According to
the GCM, the medical staff holds the
key to maintaining the hospital’s
bottom line. Implicitly, the GCM
says that these relationships were
entered into solely to maintain or
improve that bottom line.

The GCM concludes that the
arrangements amounted to private
inurement because medical staff
physicians are insiders or controlling
persons and because the structure of
these transactions “creates a result
that is indistinguishable from paying
dividends on stock.”

The GCM further indicated that
the private benefits conferred on phy-
sician investors in the ventures were
direct and substantial, not inciden-
tal. Moreover, the public benefit
achieved by hospitals in entering into
these arrangements seemed tenuous
to the IRS. As a result, the GCM
concluded that the activities endan-
gered the tax-exempt status of the
hospitals under the private benefit
test.

Finally, the IRS said that hospital

activities that may be intended to
induce or reward referrals must be
analyzed in accordance with the prin-
ciples set forth in the memorandum.
The GCM indicated that it had “good
reasons” for believing that the ven-
tures violated the anti-kickback stat-
ute, but it did not actually conclude
that they were Medicare violations.
It commented that entering into a
joint venture simply as a means to
attract, retain, or reward physicians
in order to gain the patients they will
refer should not be viewed as further-
ing a hospital’s tax-exempt purpose.

The impact of the GCM will be
hard to gauge. On its terms,
the GCM is limited to the fact
situations in the three private letter
rulings. Moreover, the GCM empha-
sizes that these ventures involved his-
torical hospital operations that were
sold, and did not involve the expan-
sion of new health care resources, the
introduction of a new technology or
provider, or the improvement of treat-
ment modalities. One might easily
conclude that in a different factual
setting, the result might be much
different. For instance, if, instead of
selling a revenue stream from exist-
ing surgery facilities, the ventures
had involved the development of new
ambulatory surgery centers, the pri-
vate letter rulings arguably would
not have been overturned.

Also worth noting is the extent to
which the GCM seems to have been
prepared in concert with authorities
from the Office of Inspector General
of the Health Care Financing Admin-
istration (HCFA). The memorandum
makes it more clear that these two
regulators are combining their ex-
pertise in an effort to better under-
stand and attack medical enterprises.
It seems likely that hospital ventures
will endure greater Medicare fraud
and abuse scrutiny than other joint
ventures, if only because tax auditors
focusing on these issues will supple-
ment the HCFA’s own investigative
resources.

In response to the memorandum,
hospitals should take stock of their
joint ventures and be careful to
document the charitable purposes
of those ventures. Most hospital-
physician ventures will either be un-

March 1992/Volume 75

Minnesota Medicine

MEDICINE LAW & POLICY

affected by the ruling because they
are outside its scope or will be able to
point to an expansion of health care
resources that furthers the hospital’s
charitable purposes. However, a ven-
ture will no longer be justifiable sole-
ly because it will increase hospital
admissions or utilization. Ironically,
it is also possible that rulings of this
kind may push hospitals and physi-
cians into closer relationships than
ever before.

Roughly contemporaneously
with the GCM’s issuance. House
Health Committee Chairman Fort-
ney “Pete” Stark introduced a bill
designed to provide for specific sanc-
tions, including certain excise taxes,
against tax-exempt hospitals enter-
ing into specified relationships with
physicians that might be described as
promoting self-referral. This effort
represents another avenue of attack
on joint ventures between hospitals
and physicians. Evidently, the trend
toward greater scrutiny of medical
joint ventures is continuing on many
fronts. Entering into joint ventures is
not impermissible. Nevertheless, the

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thicket of regulations governing these
ventures continues to grow. MM

Steven Beck is an attorney in the
Health Law Group at Vredrikson &
Byron, P.A., in Minneapolis. He rep-

resents physicians, hospitals, and
other health care providers on such
issues as risk management, reimburse-
ment, contracting, and joint venture
arrangements.

K. James Ehlen, M.D.
Chairman, CEO Medica

GIVING FULL MEASURE
TO PATIENTS AND PURCHASERS

Last month I promised to share details on our work to respond to mar-
ketplace demands for accountability.

Medica has launched a new and unique project to measure the quality of
patient care delivered by physicians participating with the plan. We call
it Ambulatory Care Evaluation (ACE).

ACE is a PC-based system for tracking quality of care through medical
record review. It’s the first of its kind in the Twin Cities. It was inspired
by the pioneering work of J. Michael McCoy, M.D., assistant professor
and assistant dean for instructional computing at the UCLA School of
Medicine.

Our Medical Policy Council, working with Dr. McCoy and Medica’s
quality assurance staff, has developed guidelines for the care of several
common pediatric and adult conditions. These guidelines identify impor-
tant elements of care in dimensions such as history, physical examination,
diagnostic testing and treatment.

Now we can review ambulatory care in a way that is fair, credible and
objective. We can show physicians just how they stack up against their
specialty peers. We can identify opportunities for improvement.

We expect this effort to be good news for physicians and purchasers of
health care. Physicians will receive feedback and education designed to
promote continuous improvement. Purchasers will realize that demon-
strable quality improvement can be achieved in a large network of in-
dependent practitioners.

We think the ACE program is a good example of Medica’s ability to
bridge the interests of physicians and purchasers, helping add value to the
health of its members and the citizens of Minnesota.

MEDiCA.

Minnesota Medicine

March 1992/Volume 75

This isn’t the
only support system
available to seniors.

Sometimes seniors living on
their own have no one to turn to
for support - for help with their health
or their housework. Often, they be-
come lonely, ill, or confused.

senior who needs help. We’ll con-
nect them with the services they
need, from Meals on Wheels to home
health care and more.

We give older people a support

But you can call us if you know a system they can rely on.

Minnesota Adult Protection Coalition

In East Metro, call 291-4666 (TDD 291-4630)
In West Metro, call 824-9999 (V/TDD)

ON THE BUSINESS SIDE

Financing Reform

Who Will Pay the Price for America’s Health Caref

The Wyatt Company

As health care reform heats up,
the business community may
be headed for a showdown
with federal lawmakers over the fi-
nancing of a new health care bill, say
many observers. U.S. businesses claim
they pay more than their fair share of
the American health care burden,
and given today’s business environ-
ment, they expect relief from the
onerous cost of providing health ben-
efits. To fulfill this expectation, any
new national legislation must ad-
dress the costs of providing access to
those individuals now lacking cover-
age. But American business is not
getting its message across, despite
urgency felt by business leaders; pol-
icymakers seemingly fail to grasp the
economics of the situation.

A number of pending reform bills
and proposals would expand health
benefit coverage without attempting
to control costs. The funding mecha-
nisms attached to many proposals
would require employers overall to
increase their financial commitment
to health care benefits. While the
business community is concerned
about access and quality, it believes
those dimensions must be balanced
against cost.

Private Markets

Consider that in 1940, fewer than 1 0
percent of Americans had health in-
surance, while in 1980, more than 80
percent of Americans had some type
of health coverage. This growth in
health care coverage underscores the
tremendous change that has occurred
in the financing of health care in the
nation’s recent history. Americans
now seem to accept the notion that
quality health care should be avail-
able to all, regardless of one’s ability
to pay. But unlike other nations that
nationalized their health care sys-
tems to distribute health care “rights”

Minnesota Medicine

to citizens, the United States has large-
ly maintained the private-market-
based system in health care. More
specifically, America has maintained
private-market financing of health
care.

“Businesses claim
they pay more than
their fair share of
the American health
care burden.”

Problems with the nation’s health
care system are obvious to all. There
is general agreement that it is not
working. The health care system is so
complex that it is impossible to esti-
mate with any certainty who pays
what or what any level of payment
buys. Taxpayers, consumers, stock-
holders, and employees can be sure
that their own health care bills, tax
payments, or daily purchases con-
tain some component of other peo-
ples’ health costs. Confusion arises
because the answer to the question
“Who actually pays for health care?”
is different from the answer to “Who
writes the checks?” Because of the
stakes involved, business leaders are
focusing on who is paying for what,
in hopes of demonstrating to policy-
makers that business pays more than
is widely acknowledged. That way,
they say, America can balance to-
day’s social interests with its long-
term economic interests.

Shouldering the Load

Whether or not the current financing
system should be maintained is open

March 1992/Volume 75

to debate. Why? Because consider-
able confusion exists over who is
paying the nation’s health care tab.
This may seem an odd proposition
because there are ample statistics in-
dicating who is writing the checks for
the care being provided. America’s
national health care expenditures
totaled $540 billion in 1988. The
federal government’s expenditures
equaled 29.17 percent of the total
and were related largely to Medicare
and the federal portion of Medicaid,
but they also included expenditures
for other federal health benefit
programs that provide care for
military personnel, veterans, and oth-
ers. State and local government ex-
penditures, at 12.89 percent of the
total, were largely for Medicaid.
Out-of-pocket expenditures, which
are direct payments that consumers
make for services, prescriptions, etc.,
accounted for 20.98 percent of total
U.S. health care spending. Private
insurance, at 32.37 percent of the
total, was the biggest financier of
health care in the United States, and
of the amount financed through in-
surance programs, slightly more than
80 percent was provided through
employer-sponsored benefit pro-
grams. Other private expenditures,
the largest element of which is phil-
anthropic contributions, accounted
for the remaining 4.6 percent of all
health care spending.

The confusion over who is pay-
ing America’s health care bill is re-
lated to the fact that only about
one-fifth of all expenditures are di-
rect out-of-pocket payments for ser-
vices provided. The rest is financed
through other arrangements affect-
ing different segments of society. Fed-
eral payments are largely composed
of Medicare and Medicaid. The Hos-
pital Insurance portion of Medicare
is financed through a payroll tax.

ON THE BUSINESS SIDE

The Supplementary Medical Insur-
ance (SMI) portion of Medicare is
financed through participant premi-
ums and general revenue infusions,
the largest source of which is from
personal and corporate income tax
collections. General revenues fund
the federal share of Medicaid. The
state’s share is funded in a variety of
ways depending on each state’s ap-
proach.

In the case of employer-provided
health insurance benefits, some ar-
gument exists over who pays the
cost. Given the concerns that em-
ployers have been voicing about
health cost increases and the liabili-
ties they face for retiree benefits, it is
clear that employers believe they are
absorbing some of the health cost
burden. Alternatively, Princeton Uni-
versity health economist Professor
Uwe Reinhardt argues in the Winter
1989 issue of Health Affairs that this
is not so. He contends that employers
are not that adversely affected by
health benefits cost increases because
the costs are part of the wage bill. As
health benefits costs have increased,
he argues, escalation in other ele-
ments of the wage bill have been
retarded. He also says that investors
in capital markets already have
looked through the veil of account-
ing rules and considered retiree health
liabilities in assessing the value of
companies.

Resolving the question of who
pays for health benefits cost increas-
es is of more than academic interest
because it implies different strategies
for responding to the problem. Busi-
ness leaders have argued that one
result of high health care costs is that
many American industries are at a
competitive disadvantage when com-
pared with their international com-
petitors. Competing nations finance
national health care through general
tax revenues, whereas the United
States funds much of its health care
through business. The incidence of
health benefits cost increases have to
fall on the employer in the form of
reduced profits, the worker in the
form of reduced compensation of
other sorts, the buyer of the good or
service in the form of higher prices,
or some combination of these. Con-
trolling benefits cost increases is less

Table 1

Methods of covering cost increases in employer-sponsored health
benefits programs

Percent

Benefits cost increases are passed along to consumers as price increases

14.8

Benefits cost increases reduce profits alone

9.8

Benefits cost increases hold down other forms of compensation to workers

11.2

A combination of lower profits and price increases

26.3

A combination of lower profits and reduced wages

6.0

A combination of price increases and reduced wages

2.7

A combination of all three

29.1

Source; The Wyatt Company, Management USA: Leading a Changing Work Force, 1990.

a concern to a plan sponsor who can
pass the cost back to the worker or
on to the buyer than to a plan spon-
sor who must absorb the cost in the
form of lower profits.

While perception is not always
consonant with reality, it may be a
great motivator even when it is wrong.
To learn executives’ perceptions, and
perhaps their motivations, when deal-
ing with health benefits programs.
The Wyatt Company asked execu-
tives in the Management USA sur-
vey, “How does your company try to
cover increases in the costs of em-
ployer-sponsored health benefit
plans? ” Their responses are shown in
Table 1. A substantial majority, 64
percent, believe the burden of health
benefits cost increases is shared.
Among the respondents, 73 percent
believe that at least some cost in-
creases are passed on in the form of
lower wages; 71 percent believe that
they reduce profits; 49 percent be-
lieve they reduce other forms of com-
pensation; but only 1 1 percent think
that the full burden falls on workers
through reductions in other elements
of the compensation package. Clear-
ly, employers believe they have a
vested interest in America’s national
health care problems. In that light,
they are particularly concerned about

the inflation of health care costs and
its effects on profitability.

Shouldering An Ever-heavier
Burden

Recent estimates suggest that the
United States is converting 1 percent
of its gross national product to the
delivery of health care services every
30 months. The magnitude of the
increases in health benefits plan costs
has been staggering. The cost of health
benefits per employee has tripled over
the last 10 years, averaging about
$3,000 per worker in 1990. U.S.
businesses are now laying out the
equivalent of about one-quarter of
their net earnings for these benefits.
In The Wyatt Company’s Manage-
ment USA survey, business execu-
tives identified health care benefits as
the most important human resource
issue they expect to face this decade.
Problems with their medical benefits
programs ranked well ahead of other
concerns, including foreign competi-
tion, lack of qualified workers,
environmental concerns, worker pro-
ductivity, and government regulation.

In recent years, employers have
tried various techniques to manage
costs. These include using managed
care programs and utilization review

(

•ij

iuc

per

iui

March 1992/Volume 75

Minnesota Medicine

ON THE BUSINESS SIDE

Table 2

Total health expenditures as a percent of gross domestic product for
selected Organization for Economic Cooperation and Development

countries

Annual

Growth

Country

1975

1989

Rote

Australia

5.7

7.0

1.5

Canada

7.3

8.7

1.3

France

6.8

8.7

1.8

Germany

7.8

8.2

0.4

Italy

5.8

7.6

1.9

Japan

5.5

6.7

1.4

Netherlands

7.7

8.3

0.5

Spain

5.1

6.3

1.5

United Kingdom

5.5

5.8

0.4

United States

8.4

11.8

2.5

Mean, all OECD countries

6.5

7.6

1.1

Data from 1975 and 1989 taken from Economic Cooperation and Development, Health
OECD, Facts and Trends (forthcoming) as presented by George J. Schieber and Jean Pierre
Poullier, “International Health Spending: Issues and Trends,” in Health Affairs, Spring
1991, p. 109. The growth rates shown in the table were calculated by the author.

and implementing various forms of
cost shifting. While some of these
changes have reduced costs to em-
ployers, the reductions have continu-
ally been buffeted by the systemic
inflation in our national health deliv-
ery system.

Some executives fear that the
burden of health care costs places
U.S. companies at a competitive dis-
advantage. A widely cited New York
Times article in 1989 quoted Chrys-
ler Chairman Lee lacocca as saying
that the price of every Chrysler car
included $700 of medical benefits
costs, while major European com-
petitors had only half that amount,
and the Japanese only a third. This
means that if the rest of the compet-
itive playing field were level, U.S.
carmakers would be at a substantial
cost disadvantage compared with the
major international competitors be-
cause of health benefits costs.

In the long run, economic theory
says that for many goods, the higher
cost of health care as a business ex-
pense cannot be passed along through
higher prices. America’s main eco-
nomic competitors — ^Japan, Germa-
ny, France, England, etc. — have all
organized their mechanisms for pur-
chasing health care differently than
we have. Comparing U.S. health care
expenditures with those of its major
economic peers puts the American
experience in a broader context.
Table 2 shows the share of gross
domestic product (GDP) dedicated
to health care expenditures by the 10
largest Organization for Economic
Cooperation and Development
(OECD) countries in 1975 and 1989,
and the compounded annual growth
in GDP spent on health care in be-
tween those two years. During 1975,
the United States spent 8.4 percent of
its GDP on health care, more than
any of the largest OECD countries
j on the list, and 29 percent more than
i the average level of spending by all
the OECD countries. By 1989, the
United States was spending 11.8 per-
cent of its GDP on health care, 55
percent more than the average OECD
expenditure. Even though the United
States started with the highest level
of health care expenditures, it also
realized the highest growth rate dur-
ing the period. The growth rate in the

Minnesota Medicine

share of GDP spent on health care in
the United States over the 14-year
period was twice the average for all
OECD countries.

How Business Pays Extra for
Health Care

In addition to coping with general
inflation in health costs, employers
also believe they are paying a hidden
tax that is causing the cost of benefits
to soar. This “tax” is “cost shifting”
from public to private health plans.
An implicit social policy for some
time, government-initiated “cost
shifting” has been growing as a source
of irritation to businesses over the
last few years, but it is only now
beginning to gain widespread atten-
tion outside the employer communi-
ty. For instance, last month, the

March 1992/Volunne 75

Prospective Payment Assessment
Commission, a congressionally ap-
pointed commission charged with
monitoring Medicare’s Prospective
Payment System, released a report
detailing the impact of cost shifting.
Among its findings:

• cost shifting, defined as cross
subsidization, clearly exists;

• on average, private payers pay
128 percent of costs, while Medicare
pays 91 percent and Medicaid only
74 percent;

• the average hospital generates
a $3.3 million yearly profit from
private payers, and nearly $2 million
in losses from Medicare and Medic-
aid; overall, the average hospital will
make $800,000 in profits;

• the burden of uncompensated
care is spreading.

ON THE BUSINESS SIDE

Pay or Play Bills

Rep. Dan Rostenkowski (D-Illi-
nois). H.R. 3205 would require
employers to provide employees
with a minimum package of health
insurance benefits or pay an excise
tax. The tax would fund a public
plan similar to Medicare, which
would cover employees whose firms
choose to pay the tax, as well as
individuals not covered through the
work force. Whatever portion of
the public plan that is not paid for
by the excise tax would be financed
through a combination of a health
surtax imposed on the income of
corporations and individuals, plus
hikes in Medicare’s wage-based tax.
The legislation includes a process
for setting provider fee caps.

Sen. Jay Rockefeller (D-West
Virginia)/Rep. Henry Waxman (D-
California). Based on recommen-
dations from the Pepper Commis-
sion, S. 1 1 77 and H.R. 2435 would
require businesses with 1 00 or more
employees to provide health insur-
ance coverage for their workers or
contribute to a public plan. Em-
ployers would have to provide the
coverage by either purchasing cov-
erage from a reformed private in-
surance market or by paying a pre-
mium set as a percentage of payroll.

Sen. George Mitchell (D-
Maine). S. 1227 would require em-
ployers either to provide employees

with a minimum level of health care
benefits or to contribute a percentage
of payroll to “AmeriCare,” a public
insurance system that, except for long-
term care expenses, would replace
Medicaid. Provider payments would
be capped if a panel of negotiators
can agree.

Single-payer Legislation

Rep. Peter Stark (D-California).
H.R. 650 would create MediPlan, a
billion-dollar national health care
program that would be funded by a 2
percent tax on gross income, plus
contributions from employers and
employees. Benefits would be similar
to those that the elderly receive under
Medicare.

Rep. Mary Rose Oakar (D-Ohio).
H.R. 8 would create a federal pro-
gram administered by the states. This
program would allow all residents
and U.S. citizens to enroll and would
replace Medicaid. Each state would
be responsible for financing and im-
plementing the comprehensive health
care plan.

Rep. Marty Russo (D-Illinois).
H.R. 1300 would provide all Ameri-
cans with a package of basic health
benefits. No copayments or deduct-
ibles would be required, and partici-
pants could select their physicians.
Einancing would occur through a 6
percent payroll tax on employers and
an increase, from 34 percent to 38
percent, in the corporate income tax

for businesses with more than
$75,000 in profits.

Sen. Bob Kerrey (D-Nebraska).
S.1446 would replace Medicare,
Medicaid, and health programs for
military personnel and civil servants.
Eamilies and individuals would pay a
$ 1 00 deductible, a copayment for each
office visit, and up to 20 percent of the
cost of each procedure. Out-of-pocket
costs would not exceed $2,000 per
family.

Small Group Health
Insurance Market Reform

Sen. Lloyd Bentsen (D-Texas)/Rep.
Dan Rostenkowski (D-Illinois).
S. 1 872 and H.R. 3626 would extend
permanently the current tax deduc-
tion for health insurance costs of self-
employed individuals and increase
the deduction from the current level
of 25 percent to 100 percent. Mini-
mum standards would be imposed
for health insurance sold to small
employers with between two and 50
employees. Insurers could not cancel
policies because of claims experience
or worker health status. Annual pre-
mium increase amounts would equal
the increase in the lowest premium
charges to small businesses, plus 5
percent.

Sen. Dave Durenberger (R-Min-
nesota). S.700 would aid small em-
ployers in providing coverage for their
workers by guaranteeing the issu-

What is Cost Shifting^

Hospitals provide a substantial
amount of service that is either not
paid for at all — “uncompensated
care” — or only partially paid for —
“undercompensated care.” It is gen-
erally agreed that cost shifting occurs
when one group of patients pays less
than the provider-estimated cost of
treatment, and the revenue shortfall
is recouped by charging another
group of patients an amount greater
than the cost of treatment.

Since the early 1 980s, only about
30 papers and articles have been pub-
lished about health care cost shifting,
with no widespread agreement on

what constitutes cost shifting and
how it occurs. What divides research-
ers on the issue is not that different
groups pay different prices for the
same service: they do. What divides
researchers is the reason why some
groups pay more for a given service
than do others. Some researchers ar-
gue that if one group pays more than
another, it may not necessarily be a
shifting of costs, but rather perfectly
rational price-discrimination behav-
ior by hospitals that have enough
market power to dictate different
prices to different buyers. Although
hospitals vary widely in their market
power, hospitals of all different sizes
and geographic areas have demon-

March 1992/Volume 75

strated their market power as evi-
denced by their ability to shift costs
between groups of payers.

Looking at the existence of price
differentials another way, it could be
that some purchasers of health care
are “better” consumers than others:
they are wiser or stronger, so they
strike better bargains. However, the
semantics that economists use to de-
scribe “cost shifting” are unimpor-
tant to the businesses that bear cost
shifting; business executives believe
they are paying more than their fair
share.

Eor several reasons in times past,
the provision of uncompensated care
did not affect any one group particu-

Minnesota Medicine

ON THE BUSINESS SIDE

ance of policies, limiting an insur-
ers’ ability to restrict coverage be-
cause of preexisting conditions, and
restricting experience rating and
limits on annual increases in premi-
ums. Insurers also would be re-
quired to make “Medplans,” two
tailored benefit packages, available
to small employers. Both plans
would be exempt from state benefit
mandates.

Rep. Nancy Johnson (R-Con-
necticut). H.R.1565 would create
an affordable package of basic ben-
efits (hospital, medical, surgical, and
some preventive benefits) for em-
ployers with between three and 25
employees. Companies that sell
small employer health insurance
programs would have to offer the
package to all small companies that
apply, and no individual within that
group could be rejected.

Sen. John Chafee (R-Rhode Is-
land). In addition to limiting health
care costs for small businesses by
reforming the small insurance mar-
ket, S.1936 also would aid in the
purchase of health insurance by pro-
viding a $1,200 tax credit to fami-
lies earning less than $32,000 a
year, or a $600 credit for individu-
als earning less than $16,000 a year.
The legislation also would create
four new business tax credits so
that employers would be more in-
clined to provide health insurance.

larly adversely. First, medical care
was much less costly than it is today.
Costs have risen for many reasons
(two frequently cited reasons are
advances in technology and increased
demand for, and utilization of, health
care services). Second, the number of
uninsured and underinsured has ris-
en steadily during the past decade.
Currently, about 35 million Ameri-
cans have no health insurance, and
perhaps another 35 million are un-
derinsured. Because this same group
of Americans may find it difficult to
pay for routine and preventive ser-
vices, they are likely to enter the
health care system with advanced-
stage illnesses requiring greater

medical resources for treatment. A
self-perpetuating cycle is at work in
the system.

Finally, the number of groups
able or willing to absorb the financial
impact of uncompensated care has
declined. Those who continue to
shoulder the burden are left with a
disproportionate share. Because
Medicaid and Medicare are now part
of the problem of cost shifting —
no longer paying their own way —
private-sector groups are the payers
of last resort. And even within the
private sector, there are far fewer
businesses on which to spread the
burden. Increasing numbers of com-
panies now participate in managed
care networks, whose rate-setting
structures minimize the financial
burden imposed by uncompensated
care. As managed care becomes more
widespread, this will leave only the
remaining segment of employers and
individual self-payers to shoulder the
entire burden of uncompensated care.

As a consequence, many business
executives believe they are justified
in arguing that they pay more than
their fair share and that their eco-
nomic position is likely to get worse
before getting better.

Financing Health Care
Reform

Given the current political climate, it
is not surprising that many reform
proposals avoid financing from
broad-based personal income tax.
Instead, combinations of the follow-
ing tax mechanisms are proposed to
pay for reform: increasing payroll
tax, increasing the marginal corpo-
rate tax rate, eliminating tax-free
status of employee health benefits,
capping the deductibility of health
benefits for employers, including a
value-added tax, and increasing tax-
es of the most profitable firms and
high-income individuals. Also, many
proposals call for financing “through
the tax system,” implying that some
income tax would be involved. Other
funding mechanisms involve cost-
sharing between firms and individu-
als and employer funding with tax
relief attached.

A number of policy analysts are
eager to eliminate the tax-free status

of health benefits. First, it is a rela-
tively painless source of money, and
second, they believe this “tax subsi-
dy” is largely responsible for the
inflation in today’s health care sys-
tem. For instance, in June, North-
western Economics Professor Burton
Weisbrod wrote: “Throughout the
postwar period the expansion of pri-
vate health care insurance has been
spurred by federal tax policy. By
making employer-financed health
insurance nontaxable income to em-
ployees, federal policy distorted
worker choice between health insur-
ance and cash wages, encouraging
excessive health insurance.”

And in December, Nobel Laure-
ate Milton Friedman agreed in his
briefing paper, “Input and Output
in Medical Care,” that employer-
provided health benefits should
be treated as taxable income for
employees — but deductible for em-
ployers— for two reasons. First, echo-
ing Weisbrod, he argues that tax
policy has encouraged Americans to
take a larger fraction of their total
remuneration in the form of health
care than they would have if health
benefits had the same tax status as
other compensation. $econd, Fried-
man believes that people would pur-
chase health care services more
efficiently if the current employer-
based financing scheme were elimi-
nated. He argues, “The employee is
likely to do a far better job of moni-
toring health care providers in his
own interest than is the employer.”

According to the Official Budget
for Fiscal Year 1992, the tax expen-
diture for “Exclusion of Employer
Contributions for Medical Insurance
Premiums and Medical Care” is esti-
mated to be $41 billion next year.
Presumably, if the deductibility of
health benefits for employers were
eliminated, and employer-paid bene-
fits were to be taxable to employees,
then the Treasury would recover the
full $41 billion. Among current pro-
posals, the Senate Republican Task
Eorce on Health Care Reform’s draft
proposal would come closest to com-
pletely eliminating health benefits’
tax-exempt status. It would cap de-
ductibility of health benefits for
employers and would make health
benefits taxable for all except those

Minnesota Medicine

March 1992/Volume 75

ON THE BUSINESS SIDE

in the k)\v- to middle-income range.

Other proposals that would
change the tax status of health care
benefits include: the Treasury De-
partment Report (issued in March
1990); the American Medical Asso-
ciation’s “Health Access America”
plan (introduced in February 1990);
the Heritage Foundation Proposal
(released in 1989); and the Depart-
ment of Health and Human Services
Task Force (no formal proposal is-
sued yet).

Employers believe that a closer
look at who actually pays for health
care is in order. If the expansion of
the nation’s health care system is
funded through a tax on employer-
provided health benefits, it may
compound a burden that employers
are already struggling to pay. A del-
icate balance exists between access,
quality, and cost, and too little atten-
tion to any one of these dimensions
could prove costly for not only the
business community but society as a
whole. MM

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March 1992/Volume 75

Minnesota Medicine

PRESIDENT'S LETTER

A Tale of Two Cities

Thomas A . S t o I e e , M . D .

)

Beverley Hawkins had a dream.
Ray Christensen had a dream.
With the help of others who
shared their visions, they have real-
ized their dreams and improved the
lives of Minnesotans both urban and
rural.

Having lived and practiced in St.
Paul for five years, I have a strong
personal attachment to our beautiful
capital city, which, along with Min-
neapolis, has become a renowned
cultural and business center. But not
all of St. Paul’s residents have been
fortunate enough to benefit from ed-
ucation, wealth, or luck of the draw.
Some are poor, some are home-
less, some suffer from discrimina-
tion, some are sick, some feel
hopelessness, some are chronically
mentally ill.

In 1967, a Summit-University
neighborhood initiative for the de-
velopment of an area health clinic
crystallized; a grant from the city
brought about a van-based outreach
program to provide medical care to
those in need. Federal money was
procured in 1969, and the program
was named the Model Cities Health
Center. Then, in 1977, Kansas City
native Beverley Hawkins came
along with a Ph.D. in educational
psychology from the University of
Minnesota. She had dream — to com-
bat urban poverty.

The success of the Model Cities
Health Center has grown with Dr.
Hawkins’ involvement in the project.
In 1987, the center moved from the
Dr. Martin Luther King Center into
its highly functional, attractive
home at 430 North Dale Street. Now,
with four full-time-equivalent dedi-
cated physicians, a knowledgeable
staff, and volunteer support, the cen-
ter provides health care to 14,000
people and runs a marvelous child-
development facility.

“Minnesota
physicians are taking
the lead in battling
problems of health
care access.”

Cromwell, Minnesota, is home
to 227 people. The city was
settled 1 1 0 years ago and over
the years has been the center of a
small agricultural area in Carlton
County, populated by hard-working
people mainly of Finnish descent.

The folks in Cromwell are right-
fully proud of their school, which
will be expanded in May; of their
EMT-certified ambulance personnel;
and of their nursing home with at-
tached low-rent housing. However,
the nearest physicians are 23 miles to
the south in Moose Lake, 23 miles to
the east in Cloquet, 44 miles to the
west in Aitkin, and 18 miles to the
north in Floodwood, where physi-
cians are provided by an area medi-
cal clinic one day a week. Some
people in and around Cromwell are
too sick, old, and poor to travel for
routine health care. The health care
we take for granted is just not avail-
able to them.

Then Ray Christensen, M.D.,
came along. Dr. Christensen grew up

on a farm near Milltown and Centu-
ria, Wisconsin. He understood the
lack of ready access to health care for
people in rural areas. He understood
the hard life and uncertainties of
agriculture. Ray Christensen also had
a dream — to combat rural poverty.
He found willing help in the Lake
Superior Medical Society.

On January 29, the Rural Access
Clinic opened in Cromwell. One
evening a month, the clinic provides
free health screening for the poor and
uninsured from the area. Physicians
from Moose Lake, Cloquet, Duluth,
and Two Harbors work with nurses
and technicians to provide exams,
immunizations, and pediatric check-
ups at no charge. The clinic is the
brainchild of Dr. Christensen, who
organized the resources of the Lake
Superior Medical Society and its
auxiliary, the Carlton County Health
Services, the College of St. Scholas-
tica, the University of Minnesota-
Duluth School of Medicine, the
Minnesota Center for Rural Health,
the Duluth Family Practice Residen-
cy Program, and the Minnesota
Medical Association.

Drs. Hawkins and Christensen
are not just dreamers. They are lead-
ers. They see a problem, understand
its genesis, and marshal the support,
talent, work, and enthusiasm needed
to create a solution. Thankfully, there
are other similar projects in Minne-
sota. Thankfully, Minnesotans care.
Thankfully, Minnesota physicians are
taking the lead in battling the prob-
lems related to health care access,
health care costs, and rural health
care, as well as problems of the poor.
Let us continue to press forward in
our concern and care for our less
fortunate fellow humans. Let us con-
tinue to work together to make
dreams come true. mm

Minnesota Medicine

March )992/Volume 75

NEWS CLIPS

People and Places Making Medical News

People

Riverside Staff Officers

Psychiatrist Ronald Groat, M.D.,
has been elected 1992 chief of staff
at Riverside Medical Center. He is
in practice with Clinical Psycho-
pharmacology Consultants, P.A.,
of Minneapolis.

Kent Molde, M.D., is chief of
staff elect; Gregory Amer, M.D., is
secretary/treasurer; and Sandra
Engwall, M.D., is past chief.
Members at large are James
Breitenbucher, M.D., Randall
Schapiro, M.D., Kevin Kelly, M.D.,
and Daniel Zydowicz.

FHCE Officers

The Foundation for Health Care
Evaluation elected Raymond
Christensen, M.D., board chair
at its annual board meeting.
Christensen is a family practitioner
from Moose Lake, Minnesota.

Burton Haugen, M.D., a family
practitioner from Walker, Minne-
sota, is FHCE’s new chair of the
Medical Standards and Practice
Committee.

FHCE is a peer review organi-
zation under contract with the
federal government to review the
health care services rendered to
Medicare beneficiaries in Minne-
sota.

Modern Healthcare's Trustee of the
Year

Modern Healthcare magazine, a
health industry business news
weekly, named Roger P. Foussard
“Trustee of the Year.” Foussard
chairs HealthEast’s board and
Foussard Associates, a St. Paul
management consulting firm.

According to Modern Health-
care Editor Clark W. Bell, the
award is in “honor of the diligence
and determination of hospital
governing boards.” Candidates for
the trustee award must have helped
improve the quality of care in their
communities, as well as the finan-
cial stability of their institutions.
Foussard was central in Health-
East’s recent financial turnaround.
The hospital system lost $35
million in 1988 and $21 million in
1989. Foussard led the organiza-
tion through a major turnaround
that left HealthEast with surpluses
of $3.9 million in 1990 and $8
million in 1991.

National Diabetes Committee Chair

Donnell D. Etzwiler, M.D., presi-
dent and founder of the Interna-
tional Diabetes Center in St. Louis
Park, recently became chair of an
ad hoc committee on diabetes
mellitus for the American Academy
of Pediatrics. The committee will
address the postgraduate education
of practicing general pediatricians
in the field of diabetes.

Etzwiler is a clinical professor
at the University of Minnesota
Medical School, co-director of an
international diabetes program
with the countries of the former
Soviet Union, and a pediatric
diabetes specialist at Park Nicollet
Medical Center. He is also past
president of the American Diabetes
Association and former commis-
sioner of the National Commission
on Diabetes.

New Goodwill/Easter Seal Board
Member

Linda Krach, M.D., medical
director of Rehabilitation at
Gillette Children’s Hospital in St.
Paul, has been named to the board
of directors of the St. Paul-based
Goodwill Industries, Inc./Easter
Seal Society of Minnesota, which

serves as a dual local affiliate of
both Goodwill Industries of
America and the National Easter
Seal Society.

Nurse Executives' President-elect

Christine Milbrath, R.N., of St.
Paul, was recently named presi-
dent-elect of the Twin Cities
Organization of Nurse Executives.
Milbrath is the vice president of
patient services at Gillette Chil-
dren’s Hospital in St. Paul.

Healy to Speak at Symposium

Bernadine Healy, M.D., director of
the National Institutes of Health,
will be the keynote speaker at an
all-day breast cancer symposium
sponsored by Abbott Northwestern
Hospital’s Virginia Piper Cancer
Institute. Healy will discuss wom-
en’s rights regarding effective
screening and care for breast
cancer. The symposium, called
“Breast Cancer: Issues in Preven-
tion and Cure,” will be held April
24 from 8:30 a.m. to 4:30 p.m. at
the Minneapolis Convention
Center. The public is invited to
attend Healy’s 1 p.m. address at no
charge.

Cosponsors for the program are
WomenCare and the Office of
Continuing Medical Education of
Abbott Northwestern Hospital, the
University of Minnesota School of
Public Health, and the Minnesota
Department of Health. For infor-
mation, call 612/863-5461.

Places

Cromwell Clinic Offers Free Care

A free health care clinic in Crom-
well, Minnesota, attracted 33
patients its opening evening,
January 29. The Rural Access

March 1992/Volume 75

Minnesota Medicine

NEWS CLIPS

Clinic, which will be offered at
Cromwell High School the last
Wednesday of each month for at
least a year, is intended to help
address rural barriers to health care
access, including lack of insurance,
distance from medical facilities,
and a need for extended hours.

A team of more than two dozen
volunteer health care professionals,
including seven physicians, saw
patients with a variety of com-
plaints that ranged from an earache
to chronic stomach problems.

The Lake Superior Medical
Society initiated the clinic and has
enlisted the help of a number of
organizations, including the
Minnesota Medical Association,
the College of St. Scholastica, the
University of Minnesota-Duluth
School of Medicine, the Minnesota
Center for Rural Health, and
Carlton County Health Services
(see this month’s President’s Letter,
page 41).

Sisters of Carondelet Establish
Clinics for Poor

The Sisters of St. Joseph of Caron-
delet opened a health care clinic for
the poor on January 30. It’s the
first of what they hope will be 20
clinics in Twin Cities neighbor-
hoods. St. Mary’s Health Clinic,
located in the Northside Child
Development Center at 1011 14th
Avenue North in Minneapolis, will
focus on immunizing children and
treating children with chronic ear
infections, asthma, and nutritional
problems, said Mary Madonna
Ashton, former state health com-
missioner and president and chief
executive officer of Carondelet
LifeCare. As Minnesota Medicine
went to press, the sisters were
planning to open a second clinic in
late February or early March at a
center for women and children
located in the old Crosby home at
2104 Stevens Avenue South in
Minneapolis.

Almost 70 physicians and
nurses have volunteered to staff the

clinics, and hospitals have agreed
to provide lab services and supplies
at cost. Initially, patients will not
be charged for services, but later
the clinics will begin charging
patients according to their ability
to pay.

New Indian Clinic Opens in St. Paul

An American Indian Health Clinic
recently opened in a former post
office building on St. Paul’s East
Side. The clinic, which is not
related to the former Urban Indian
Health Clinic that closed in
December 1990, will receive
$213,431 from the city, county,
state, and St. Paul Foundation this
year. The clinic charges patients
who are above the poverty level on
a sliding fee scale.

St. Paul Health Department Offers
Free Screenings

The St. Paul Health Department is
now offering free breast exams,
mammograms, and Pap smears to
women who cannot afford them.
The program, called the Women’s
Health Screening Clinic, is being
administered by the Minnesota
Health Department and funded by
the Centers for Disease Control in
Atlanta. Minnesota is one of eight
states to receive CDC funding for
the screenings.

The St. Paul Health Depart-
ment, which was selected to
conduct the project because it has
trained personnel and has a history
of providing family planning
services, is offering the clinics on
the third Thursdays and last
Tuesdays of every month at the
Public Health Center, 555 Cedar
Street, in St. Paul. The clinic is
open to all eligible women regard-
less of where they live. The pro-
gram will eventually be expanded
to the rest of the state.

Abbott Opens Parkinson's Center

Abbott Northwestern Hospital has
opened a Parkinson’s Disease
Center at its Minneapolis Neuro-
science Institute. The center is
operated by neurologists Paul
Silverstein, M.D., and Felix
Zwiebel, M.D.

The center includes physicians,
nurses, and experts from physical
therapy, speech, occupational
therapy, nutrition services, and
social services. Patients receive a
thorough evaluation to assist them
and their families plan further care
and treatment. The patient’s family
physician receives a taped account
and written summary of the
meeting.

Fairview Southdale Expands

James H. Zavoral, M.D., has
joined Fairview Southdale Hospital
to create the Preventive Cardiology
Institute. Zavoral is known inter-
nationally for his heart disease
prevention research and treatment.

The purpose of the institute is
to prevent or halt the progression
of heart disease and, in some cases,
to reverse it. It will focus on two
groups of patients: 1) those who do
not have the disease but have its
risk factors and 2) those who have
the disease and who may have had
a heart attack or other symptoms
or who have had treatments such
as bypass surgery or angioplasty.

Fairview Southdale has recently
completed a major expansion of its
Emergency Department and
adjacent areas. The $4.5 million
project responds to increasing
numbers of people seeking emer-
gency care and to changing tech-
nology. The hospital added 6,300
square feet to the emergency area
and remodeled 13,200 square feet
of space for an enlarged surgery
admissions and urgent care center
area.

Clinic Starts Lacal Stroke Chapter

Stroke victims and their families
will soon have access to services
including a stroke information line,
research updates, and support
groups through the newly formed
Minnesota chapter of the National
Stroke Association, sponsored by

Minnesota Medicine

March 1992/Volume 75

NEWS CLIPS

Noran Neurological Clinic with
offices in Minneapolis, Fridley,
Burnsville, and Edina.

The group will also offer
stroke-prevention education
programs to high-risk groups and
will offer health care providers
information about developments in
stroke prevention and treatment.

Noran Clinic is providing
staffing, medical counsel, and
facilities to start the local chapter,
which will operate as an indepen-
dent, nonprofit organization.

Socioeconomics

LifeSpan and Health One to
Consolidate

LifeSpan Inc. and Fiealth One
Corp. announced in January that
they will merge, creating the area’s
largest hospital organization. The
consolidation will combine the
assets of Health One, including
United Hospital in St. Paul, Mercy
Hospital in Coon Rapids, and
Unity Medical Center in Fridley,
with LifeSpan and several of its
controlled organizations, including
Abbott Northwestern Hospital and
LifeSpan’s outstate affiliates. The
consolidation is subject to federal
approval.

LifeSpan’s Minneapolis Chil-
dren’s Medical Center and Health
One’s Children’s Hospital of St.
Paul will not be included in the
merger but will pursue a possible
relationship of their own. Chil-
dren’s in St. Paul shares a building
and services with United and will
remain associated with the hospital
in a wide variety of joint clinical
programs. Methodist Hospital, a
member of LifeSpan, is expected to
pursue an affiliation with Park
Nicollet Medical Center and will
not participate in the consolida-
tion.

Conley Brooks, chair of the
LifeSpan board of directors, said,
“Our vision is to create an integrat-
ed, regional health care system that
can more efficiently act on a

commitment to deliver high-quality
services at the lowest possible cost.
And that will benefit not only
patients, but employers, payers,
physicians, and the entire commu-
nity, as well.”

The new organization will
include 13 hospitals in Minnesota
and western Wisconsin, will consist
of 2,600 beds, and will employ
approximately 15,000 people. The
combined organizations will have
assets in excess of $825 million and
a net worth (general fund balance)
of more than $275 million.

Mayo Establishes Practice in Iowa

Mayo announced in February the
establishment of a regional practice
in Decorah, Iowa, affiliating with
Decorah Medical Associates, P.C.
The facility will remain a family
practice clinic, providing general
health care to patients in and
around Decorah. Under the
agreement. Decorah Medical
Associates’ physicians will become
employees of Mayo Regional
Practices, P.C., an affiliate of Mayo
Foundation for Medical Education
and Research. The practice will be
renamed Decorah Clinic, P.C. — A
Mayo Regional Practice.

Medical Associates has had a
long-term working relationship
with Mayo, which currently offers
cardiovascular and ear, nose, and
throat care to Medical Associates’
patients. Mayo Medical School
students also complete a portion of
their training at the clinic.

HMO Council Spearheads
Immunization Project

The Minnesota Council of HMOs
announced in February that it will
spearhead a childhood immuniza-
tion project designed to raise the
immunization rates of Minnesota’s
2-year-old children to 90 percent
or more by the year 2000. Recent
Department of Health statistics
indicate that less than 60 percent of
Minnesota children receive the
complete series of immunizations
by age 2.

To reach this goal, the council
has created a task force to work
with public and private health

organizations throughout the state
to educate consumers and health
care professionals about the
importance of childhood immuni-
zation. The HMO task force will
also study current immunization
rates throughout the state, identify
specific reasons why Minnesotans
don’t immunize their children, and
then develop strategies to help
consumers and health care profes-
sionals overcome these barriers.

Numerous organizations
throughout the state have commit-
ted to working with the HMO
Council in these efforts, including
the Minnesota Medical Associa-
tion, the Minnesota Department of
Health, the Minnesota Hospital
Association, the Minnesota Nurses
Association, Children’s Hospital of
St. Paul, and Minneapolis Chil-
dren’s Medical Center.

Twin Cities Employers Pay Less for
Medical Plans

Twin Cities employers pay less
than the national average for
employee medical plans, but their
costs increased more than the
national average in 1991, reports
Foster Higgins, an international
employee-benefits consulting firm.
Twin Cities companies paid $3,141
per employee in 1991 compared
with the national average of
$3,605. The percentage increase
from 1990 to 1991 was 16 percent
in the Twin Cities compared with
12 percent for the nation. Ann
Robinow, a spokesperson in the
firm’s Twin Cities office, said the
difference might be due to changes
in sampling; the company surveyed
128 Twin Cities employers in 1991
compared with 38 in 1990. The
figures include indemnity plans,
HMOs, dental plans, and vision
and hearing plans.

Sf. Paul Acts to Cut Infant Mortality

Roy Garza, former head of the St.
Paul Community Services Depart-
ment, has been hired by the St.

Paul Public Health Division to
improve the city’s infant mortality

March 1992/Volume 75

Minnesota Medicine

NEWS CLIPS

rate. In his temporary position, he
will find ways to improve existing
city programs aimed at pregnant
women at high risk of having
babies that might die during their
first year of life.

In 1989, St. Paul had an infant
mortality rate of 11.2 deaths per
thousand births. Blacks in the city
had a rate of 21.2. Statewide, the
rate was 7.1 overall and 18.1 for
blacks. Garza said his goal is to
reduce the city’s total rate to 8.9 by
1995.

Fifth Ward Council Member
Janice Rettman, chair of the
council’s finance committee,
questioned whether Garza’s
appointment is the best use of city
money. “Infant mortality is a very
serious concern, but if they’re
moving money from people directly
helping parents of these kids. I’m
going to be very concerned about
whether this allocation is proper,”
she said in a January 7 St. Paul
Pioneer Press article.

Innovations

Mayo Uses Laparoscopy in Place of
Chest Surgery

Mayo Clinic physicians have
adopted laparoscopic techniques to
chest surgery and, as a result, have
avoided opening the chests of
about 120 patients since they
started using the procedure last
June. They have used laparoscopic
surgery for patients who need small
nodules removed from their lungs
or fluid drained from their chest
cavities.

Mark Allen, M.D., one of four
thoracic surgeons using the tech-
nique at Mayo Clinic, said patients
undergoing the procedure experi-
ence little postoperative pain and
recover more quickly than with
traditional chest surgery. For
example, traditional surgery
requires a week of hospitalization
and six weeks of recovery at home.
With the new procedure, patients
leave the hospital after two or three
days and can resume normal
activity within two weeks. Patients

undergoing the new procedure
experience about 1 percent of the
pain associated with traditional
surgery, according to Allen.

FDA Panel Tentatively Approves
Condom for Women

An expert panel of the Food and
Drug Administration tentatively
recommended approval February 1
of the first condom designed for
women. The panel approved the
condom for use in disease preven-
tion, noting that approval of
contraceptives is a longer process.

The new condom, called a
vaginal pouch, is a polyurethane
sheath that lines the vagina. It is
held in place by two flexible plastic
rings, one at the cervix and one
outside the body.

The panel asked the manufac-
turer, Wisconsin Pharmacal Co., to
complete several studies on the
female condom before the FDA
begins its formal approval process.
The panel members questioned
some of the manufacturer’s claims
about the condom’s effectiveness in
preventing the spread of sexually
transmitted diseases and in pre-
venting pregnancy.

Preliminary results show that if
1,000 American women used the
female condom for six months, 104
would get pregnant, a rate compa-
rable with diaphragms and other
barrier contraceptives, said Mary
Ann keeper, senior vice president
of Wisconsin Pharmacal. keeper
anticipates that the condom will be
approved by the end of the year.

Ortho to Develop Birth-control
Vaccine

Ortho Pharmaceutical Corp., a
Johnson & Johnson subsidiary,
plans to develop a contraceptive
vaccine that causes women to
become immune to sperm. The
vaccine, which is currently being
tested on baboons, makes the
immune system produce antibodies

to a protein molecule found on the
head of sperm. The antibodies bind
with sperm, making them unable to
fertilize an egg.

The vaccine would come in the
form of an injection or pill and
would last from two to five years.

It won’t be tested on humans for at
least two years, said John Herr, the
University of Virginia researcher
who created the vaccine and is
directing its testing.

Medical Research

Mayo Frees Patients from Ventilator

Mayo Clinic researchers report a
nearly 90 percent success rate with
a new program that frees hospital-
ized patients from their dependence
on artificial ventilators.

The study, published in the
February issue of Mayo Clinic
Proceedings, reports on the first 18
months’ experience with the
program, set up to rehabilitate
patients who have become depen-
dent on ventilators while being
cared for in an intensive care unit.
Eighty-seven percent of the 61
patients treated were weaned of
their dependence and were able to
return to their homes or a local
care facility. The cost of caring for
these patients was significantly
reduced; the daily cost per patient
averaged $600 less than for
treatment in the ICU.

Key to the success of the Mayo
program, according to Douglas
Gracey, M.D., a pulmonary
specialist at Mayo Clinic and the
main author of the report, is
removing patients from the inten-
sive care unit to a unit where they
can get more specialized attention.
The six-bed specialized unit uses a
team approach involving nursing,
physical therapy, respiratory
therapy, dietetics, and a variety of
medical specialists. A critical factor
is having nurses experienced in
treating patients with ventilator
dependence, Gracey said.

The program focuses on
removing tubes from patients as
soon as possible, cutting down on
multiple medications, building

Minnesota Medicine

March 1992/Volume 75

NEWS CLIPS

patients’ strength, and restoring
good nutrition, sleep habits, and
family support.

Mayo’s Ventilator Dependence
Unit, located at Saint Marys
Hospital, is one of four such units
in the United States being funded
by the Health Care Financing
Administration as a demonstration
project.

Deaths from Ectopic Pregnancy Fall

Fewer women are dying from
ectopic pregnancy even though the
number of such pregnancies has
increased dramatically since 1970,
reports a Mayo physician in the
January 22 Journal of the Ameri-
can Medical Association. While the
number of ectopic pregnancies
increased from about 17,800 in
1970 to about 88,000 in 1987,
only 30 women died from it in
1987. At one time, ectopic preg-
nancy claimed up to 70 percent of
its victims, said Steven Ory, M.D.,
author of the report and chair of
the reproductive endocrinology and
infertility section of Mayo Clinic’s
ob/gyn department.

The decreased mortality is a
result of better treatment and
earlier diagnosis, said Ory. Using a
new pregnancy test that is 99
percent accurate, physicians are
able to detect such pregnancies in
women at high risk before serious
complications develop.

Physicians are uncertain why
the number of ectopic pregnancies
has increased every year but one
since 1970, but they believe the rise
is related to the increase in sexually
transmitted diseases, more conser-
vative surgical procedures that
allow women who have had an
ectopic pregnancy to conceive
again, and greater use of fertility
treatments, said Ory.

'U' Researchers Conduct AIDS
Survey

In a survey involving more than
300 house calls. University of
Minnesota researchers found that
people are willing to fill out
sexually explicit questionnaires on
AIDS risks, although they are
reluctant to give blood samples.

The results suggest that a broader,
national survey could be successful-
ly completed, said the researchers
in the Journal of the Public Health
Service.

The 1989 survey, which
researchers stress does not include
a representative sampling of Twin
Cities residents, involved visits to
homes in a middle-class area of a
St. Paul suburb and a working-
class area in south Minneapolis
without regard for the residents’
lifestyles. Researchers asked one
adult at each home to fill out the
confidential survey; only 10
percent of the men and 6 percent of
the women refused. Half of the
respondents were asked to give a
blood sample for AIDS testing but
only 72 percent agreed; none was
found to have the AIDS virus.
Twenty-five percent of the men and
1 9 percent of the women said that
as a result of the AIDS epidemic,
they have made changes in their
sexual practices, including having
fewer sex partners, using more care
in selecting partners, and using
condoms more often.

'U' Studying Osteoporosis

The University of Minnesota is
participating in the largest study
ever of osteoporosis and is recruit-
ing 600 women to participate.
Researchers at the university and
10 other medical centers nation-
wide plan to study the effective-
ness of the experimental drug
alendronate on 6,600 women over
four years. Alendronate, which has
not received FDA approval for
general use, slows bone loss by
creating a protective layer over
bone-absorbing cells, said Kristine
Ensrud, M.D., co-principal investi-
gator with Richard Grimm, M.D.,
at the university. The drug’s only
side effect is an occasional upset
stomach associated with high
dosages.

Women who wish to partici-
pate must be between 55 and 80
years old and must have low bone
density, said Ensrud. Eor informa-
tion, women should call 612/336-
5512. MM

Interested in

HASSLE FREE
PRACTICE?

Write your ov
schedule.

Malpractice
insurance
belongs to us
no tail JT

problems.

Medical Locums, Ltd.

Whitesell Medical Locums, Ltd.
Eleven First Ave. S.
Buffalo, MN 55313

Phone: 1-800-876-7171

HUTCHINSON, MN

BC OR BE INTERNAL
MEDICINE PHYSICIAN

wanted for a progressive 16
physicians’ group located in
Hutchinson, MN, 60 miles west
of the Twin Cities on Highway
7. State of the art hospital facili-
ties attached to the Medical
Center, competitive salary,
professional growth opportuni-
ties and a dynamic community
with an excellent economic
base are the variables offered
to the successful physician
applicants.

Please send resume to
Brenda M. Maiers, Administrator
Hutchinson Medical Center, P.A.

3 Century Ave.

Hutchinson, MN 55350
Tel. (612) 587-2020 Ext. 214

March 1992 /Volume 75

Minnesota Medicine

CME IN MINNESOTA

A Calendar of Continuing Medical Education Courses

MARCH 1992

March 6 The Duluth Clinic 1 992 Family Practice Conference

The Duluth Clinic; Fitger’s Spirit of the North Theatre,
Duluth, MN. CONTACT: Rockie Odberg, CME Office,
400 East Third Street, Duluth, MN 55802; 218/725-3838.

March 6-7 Cutaneous Laser Surgery Abbott Northwestern
Hospital; Abbott Northwestern Hospital, Minneapolis,
MN. CONTACT: Cathy Kohn, CME Office 14202, Ab-
bott Northwestern Hospital, 800 East 28th Street, Minne-
apolis, MN 55407; 612/863-5461.

March 9-13 Medical Update 1992 Office of CME, Depart-
ment of Surgery, University of Minnesota Medical School;
Hughes Education and Conference Center, Holy Cross
Hospital, Fort Lauderdale, EL. CONTACT: Becky Noren,
Office of CME, Radisson Hotel Metrodome, Suite 107, 615
Washington Avenue SE, Minneapolis, MN 55414; 612/
626-7600, or 800/888-8642.

March 12-13 Family Practice Today St. Paul-Ramsey Med-
ical Center; Holiday Inn East, St. Paul, MN. CONTACT:
Bonnie Young, 640 Jackson Street, St. Paul, MN 55101;
612/221-3992.

March 13-18 Neurology in Clinical Practice Mayo Clinic/
Mayo Foundation; Capitva, EL. CONTACT: Rita Kunz or
Jan Fleck, Mayo Clinic, 200 1st Street SW, Rochester, MN
55905; 507/284-2509 or 800/323-2688.

March 19 Common Skin Disorders Group Health Inc.;
Minneapolis Metrodome Hilton, Minneapolis, MN. CON-
TACT: Debbie Bladine, Group Health Inc., 2829 University

Avenue SE, Minneapolis, MN 55414; 612/623-8479.

March 20-21 Advanced Laparoscopic Abdominal Surgery
Seminar Abbott Northwestern Hospital; Abbott North-
western Hospital, Minneapolis, MN. CONTACT: Cathy
Kohn, CME Office 14202, Abbott Northwestern Hospital,
800 East 28th Street, Minneapolis, MN 55407; 612/863-
5461.

March 21-22 Sexual Attitude Reassessment Seminars (SAR)

Program in Human Sexuality; Holiday Inn Metrodome,
Minneapolis, MN. CONTACT: SAR Coordinator or Secre-
tary, Program in Human Sexuality, EMC Building, 1300
South 2nd Street, Minneapolis, MN 55454; 612/625-1500.

March 26-27 Critical Care: Practical Approaches & Case
Discussion St. Paul-Ramsey Medical Center; Holiday Inn
East, St. Paul, MN. CONTACT: Bonnie Young, 640 Jack-
son Street, St. Paul, MN 55101; 612/221-3992.

March 29-April 1 Management Strategies in Complex
Congenital Heart Disease Mayo Clinic/Mayo Foundation;
Phoenix, AZ. CONTACT: Postgraduate Courses, Mayo
Clinic/Mayo Foundation, Section of Continuing Educa-
tion, 200 1st Street SW, Rochester, MN 55905; 507/284-
2509 or 800/323-2688.

APRIL 1992

April 2-3 Allergy and Clinical Immunology Office of CME,
University of Minnesota Medical School; Radisson Hotel
Metrodome, Minneapolis, MN. CONTACT : Becky Noren,
Office of CME, Radisson Hotel Metrodome, Suite 107,615
Washington Avenue SE, Minneapolis, MN 55414; 612/
626-7600.

April 2-3 Annual Obstetrics and Gynecology Update St.

Paul-Ramsey Medical Center; Holiday Inn East, St. Paul,
MN. CONTACT: Bonnie Young, 640 Jackson Street, St.
Paul, MN 55101; 612/221-3992.

April 3 ENT Update St. Paul-Ramsey Medical Center; St.
Joseph’s Hospital, St. Paul, MN. CONTACT: Bonnie

Minnesota Medicine

March 1992/Volume 75

CME IN MINNESOTA

Young, 640 Jackson Street, St. Paul, MN 55101; 612/221-
3992."

April 3 Eighth Annual Duluth Heart Conference The Duluth
Clinic, Ltd.; Fitger’s Spirit of the North Theatre, Duluth,
MN. CONTACT: Thomas E. Elliott, M.D., 400 East Third
Street, Duluth, MN 55802; 2 1 8/725-3755.

April 6-7 Annual Ophthalmology Course Office of CME,
University of Minnesota Medical School; Radisson Hotel
Metrodome, Minneapolis, MN. CONTACT: Becky Noren,
Of fice of CME, Radisson Hotel Metrodome, Suite 107, 615
Washington Avenue SE, Minneapolis, MN 55414; 612/
626-7600.

April 6- 10 Team Management of Diabetes Mellitus Interna-
tional Diabetes Center; International Diabetes Center, Min-
neapolis, MN. CONTACT: Cindy Poppitz, International
Diabetes Center, 5000 West 39th Street, Minneapolis, MN
55416; 612/927-3393.

April 8-10 Annual Spring Refresher — Minnesota Academy
of Family Physicians Minnesota Academy of Eamily Physi-
cians; Hyatt Regency Hotel, Minneapolis, MN. CON-
TACT: Virginia Barzan, Minnesota Academy of Eamily
Physicians, 2221 University Avenue SE, Minneapolis, MN
55414; 612/331-2506.

April 10-11 Pelviscopic Surgery Including Laparoscopic
Hysterectomy Abbott Northwestern Hospital; Abbott North-
western Hospital, Minneapolis, MN. CONTACT: Easer
Center 39102, Abbott Northwestern Hospital, 800 East
28th Street, Minneapolis, MN 55407; 6 12/863-3000.

April 1 1 Treatment of Renal and Ureteral Stones in the '90s

Minnesota Urological Society; St. Paul Hotel, St. Paul, MN.
CONTACT: Jennifer Syltie, Minnesota Medical Associa-
tion, 2221 University Avenue SE, Suite 400, Minneapolis,
MN 55414; 612/378-1875 or 800/999-1875.

April 16 Spondyloathropathies Group Health Inc.; Minne-
apolis Metrodome Hilton, Minneapolis, MN. CONTACT:
Debbie Bladine, Group Health Inc., 2829 University Ave-
nue SE, Minneapolis, MN 554 14; 6 12/623-8479.

April 20-24 Team Management of Diabetes Mellitus Inter-
national Diabetes Center; International Diabetes Center,
Minneapolis, MN. CONTACT: Cindy Poppitz, Interna-
tional Diabetes Center, 5000 West 39th Street, Minneapo-
lis, MN 55416; 612/927-3393.

April 24-25 Lasers in Orthopedic Surgery Laser Center of
Abbott Northwestern Hospital; Abbott Northwestern Hos-
pital, Minneapolis, MN. CONTACT: Laser Center 39102,
Abbott Northwestern Hospital, 800 East 28th Street, Min-
neapolis, MN 55407; 612/863-3000.

April 24-25 15th Annual Update in Clinical Cardiology

Abbott Northwestern Hospital; Location to be determined.

CONTACT: Minneapolis Heart Institute Eoundation, 920
East 28th Street, Minneapolis, MN 55407; 612/863-3979. j

April 24-25 Sexual Attitude Reassessment Seminars (SAR) !

Program in Human Sexuality; Holiday Inn Metrodome, '
Minneapolis, MN. CONTACT: SAR Coordinator or Secre- j
tary. Program in Human Sexuality, PMC Building, 1300 j
South 2nd Street, Minneapolis, MN 55454; 612/625- 1 500.

April 24-26 First Annual Mayo Clinic Conference on Ad-
vances in Clinical Anesthesiology Mayo Clinic/Mayo Poun-
dation; Amelia Island Plantation, Amelia Island, PE. CON-
TACT: Postgraduate Courses, Mayo Clinic/Mayo Pounda-
tion, 200 1st Street SW, Rochester, MN 55905; 507/284-
2509 or 800/323-2688.

April 27-29 Bone & Soft Tissue Tumors Mayo Clinic/Mayo
Eoundation; Hilton Beach & Tennis Resort, San Diego, CA.
CONTACT: Postgraduate Courses, Mayo Clinic/Mayo
Eoundation, 200 1st Street SW, Rochester, MN 55905;
507/284-2509 or 800/323-2688.

April 29 Orthopedic Challenges in Rheumatology Abbott
Northwestern Hospital; Abbott Northwestern Hospital,
Minneapolis, MN. CONTACT: Cathy Kohn, CME Office
14202, Abbott Northwestern Hospital, 800 East 28th
Street, Minneapolis, MN 55407; 612/863-5461.

MAY 1992

May 1-2 Advanced Laparoscopic Abdominal Surgery Sem-
inar Abbott Northwestern Hospital; Abbott Northwestern
Hospital, Minneapolis, MN. CONTACT: Cathy Kohn,
CME Office 14202, Abbott Northwestern Hospital, 800 ^

East 28th Street, Minneapolis, MN 55407; 612/863-546 1 . !

May 2 Interventional Radiology Abbott Northwestern Hos- I
pital; Abbott Northwestern Hospital, Minneapolis, MN.
CONTACT: Cathy Kohn, CME Office 14202, Abbott I
Northwestern Hospital, 800 East 28th Street, Minneapolis,
MN 55407; 612/863-5461. ,

May 2 1992 Perinatal/Neonatal Update Abbott North-
western Hospital and Minneapolis Children’s Medical Cen-
ter; Madden’s on Gull Eake, Brainerd, MN. CONTACT:
Cathy Kohn, CME Office 14202, Abbott Northwestern
Hospital, 800 East 28th Street, Minneapolis, MN 55407;
612/863-5461.

May 4-8 Family Practice Review and Update Office of
CME, University of Minnesota Medical School; Radisson
Hotel Metrodome, Minneapolis, MN. CONTACT: Becky
Noren, Office of CME, Radisson Hotel Metrodome, Suite
107, 6 15 Washington Avenue SE, Minneapolis, MN 55414;
612/626-7600.

May 12 Gynecology and Gynecologic Oncology Office of
CME, University of Minnesota Medical School; Radisson
Hotel Metrodome, Minneapolis, MN. CONTACT: Becky
Noren, Office of CME, Radisson Hotel Metrodome, Suite
1 07, 6 1 5 Washington Avenue SE, Minneapolis, MN 55414;
612/626-7600.

March 1992/Volume 75

Minnesota Medicine

CHISAGO HEALTH SERVICES

Our integrated, multispecialty, 21 -member med-
ical practice has positions available for BE/BC
physicians in the areas of:

(^Bl 11 ALEXANDRIA CLINIC, P . A.

• Obstetrics/Gynecology

• General Surgery

The Alexandria Clinic, P. A., Is a 16 physician
multl-sp>eclalty Group currently recruiting
physicians In the following specialties:

This is your opportunity to join a progressive,
growing medical team located in a land of lakes
only 35 minutes from Minneapolis and St. Paul.

Contact: Scott Wordelman, President
Chisago Health Services

11685 Lake Blvd., N.

Chisago City, MN 55013

• INTERNAL MEDICINE

• OBSTETRICS & GYNECOLOGY

• FAMILY PRACTICE

• GENERAL SURGERY

• PEDIATRICS

First year salary guarantee wtth production bonus,
second year partnership. Excellent contract benefits.

If Interested In Joining a young, growing organization
located in beautiful lakes area community, please
contact:

Timothy A. Hunt, Administrator

Alexandria Clinic. P.A.

610 Fillmore Street

Alexandria, MN 56308

612.763.5123

“Care by 'People Who Care"

612/257-8485

CONTINUING MEDICAL EDUCATION

ST. PAUL-RAMSEY MEDICAL CENTER

CfME

Spring Conference Schedule

640 Jackson Street

St. Paul, MN 55101
(612)221-3992

1992

March 12-13 Family Medicine Today, St. Paul

March 20 Occupational Medicine Update, Minneapolis

March 26-27 Critical Care: Practical Approaches &

Case Discussions, St. Paul

April 2-3 Ob/Gyn Update, St. Paul

April 3 ENT Update for Family Physicians, St. Paul

Mark your calendar for these fall programs:

October 29-30 Practical Approaches to Managing Trauma, St. Paul
November 12-14 Strategies in Primary Care, St. Paul

December 3-5 Cardiopulmonary Medicine, St. Paul

Information and Registration

Continuing Medical Education, St. Paul-Ramsey Medical Center,

640 Jackson Street, St. Paul, MN 55101; Phone 612/221-3992

RAMSEY

Minnesota Medicine

March 1992/Volume 75

CLASSIFIED ADVERTISING

Physician Opportunities and Miscellaneous Listings

Classified rates are 50^ a word. Minimum monthly
charge is $10; with box number $2 additional. Ads will
not be accepted by phone.

• Placement of ads must be made six weeks before the date of
publication (e.g., March 15 for May ad). Please send ad
requests to Minnesota Medicine, 2221 University Avenue SE,
Suite 400, Minneapolis, Minnesota 55414.

• Cancellation of ads must be made by the first of the month
preceding month of issue.

Johnson & Falls Search Associates represents new practice
opportunities locally and nationally. Working exclusively
in the area of physician search, we are committed to
expanding your professional options while meeting our
clients’ needs. There are no fees to candidates. For a
thorough, confidential search, send CV or call: Liz Johnson
or Pat Falls, Johnson & Falls Search Associates, 34 Forest
Dale Road, Minneapolis, MN 55410; 612/922-0237. (R)

Bemidji, Minnesota: Excellent opportunities for well-trained
physicians. We are seeking BC/BE physicians in family
practice and otolaryngology to join a young 33-physician
multispecialty group practice located in northern Minneso-
ta. Competitive salary guarantee plus incentive first year
and excellent benefits. An excellent opportunity for a phy-
sician to enjoy practice in the center of hunting, fishing, and
clear air. Please respond with CV to: C.C. Lowery, Admin-
istrator, Bemidji Clinic-MeritCare, 1233 34th Street NW,
Bemidji, MN 56601; 218/751-1280. (R)

(’^9/91-R)

Mankato; FP partner to join four board-certified family
physicians, ages 34-43, in fast-growing, full-range practice.
Ob optional. Population 40,000+. Seventy miles to Twin
Cities. Four colleges nearby. Subspecialty consultation readi-
ly available on hospital staff. Academic appointment avail-
able. Call: Tony Giefer, M.D., 507/387-8231. (8/91-R)

Family Physicians: Well-established south suburban Min-
neapolis family practice group seeks associates part/full
time to staff day clinic. Excellent call schedule, salary, and
fringe benefits. Also seeking locum tenens to staff PT/FT
Urgent Care Centers and/or day clinic. Contact: Adminis-
tration, Family Physicians, P.A., 612/435-4125, or send
inquiries to Suite 100, 14050 Nicollet Avenue South, Burns-
ville, MN 55337. ('•9/89-R)

Mankato Clinic, Ltd. is seeking BC/BE physicians in the
following specialties: invasive cardiology, oncology/hema-
tology, pulmonary medicine, general surgery, gastroenter-
ology, family practice, and general internal medicine. The
Mankato Clinic is a 53-physician multispecialty group
practice in south-central Minnesota with a trade-area pop-
ulation of +250,000. Guaranteed salary first year, incentive
thereafter with full range of benefits and liberal time off. For
more information call: Dr. B. C. McGregor, President, or
Roger Greenwald, Executive Vice President, 507/625-18 1 1
or write: 501 Holly Lane, Mankato, MN 56001.

(12/91-R)

Forest Lake Doctor's Clinic is seeking a BC/BE family physi-
cian, pediatrician, ob/gyn, and internist to join 1 0-physician
multispecialty group. Located 25 miles north of Minneap-
olis-St. Paul in progressive community with excellent schools,
many beautiful lakes, recreational activities, golf, fishing,
boating, skiing. Local hospital directly across street. Con-
tact: Dr. Harvey J. Frank or Dr. Doug Sill, 121 SE 11th
Avenue, Forest Lake, MN 55025; 612/464-7100.

(4/90-R)

MDsearch assists medical groups and hospitals in their
recruiting efforts. For confidential information on opportu-
nities in the Upper Midwest, send CV and/or call collect:
Mary Jo Cordes, MDsearch, PO Box 21507, St. Paul, MN
55121; 612/454-7291. (12/91-R)

March 1992 /Volume 75

Minnesota Medicine

)

■2

I'l

1?.[

'H-

ill

eii

til-

fl:

CLASSIFIED

Lake City, Minnesota: Family physician BC/BE needed to
join three other FPs in progressive, growing practice on
Lake Pepin/Mississippi River in southeastern Minnesota.
Excellent first-year salary/benefits in a scenic community
with multiple recreational opportunities. Contact: D.D.
Pflaum, M.D., 303 South Washington, Lake City, MN;
612/345-3318. (8/90-R)

Olmsted Medical Group is seeking BC/BE physicians in the
following specialties: orthopedics, radiology, family prac-
tice, emergency medicine, and ob/gyn. Great opportunity
forwell-trainedphysiciansto joina 55+ physician multispe-
cialty group in a dynamic, progressive practice. In addition
to the main office in Rochester, the group operates eight
branch offices in southeastern Minnesota. Excellent salary/
benefits package includes malpractice insurance, flexible
benefits plan, 401 (k) and profit sharing, and relocation
assistance. Send CV to: Olmsted Medical Group, Attn:
Susan Schuett, 210 Ninth Street SE, Rochester, MN 55904.

(1/92-R)

Downtown Office Space for Rent: Physician in the Medical
Arts Building, 825, wishes to sublet to another physician on
a part-time basis for the purpose of sharing overhead
expenses. Call: 612/370-0553. (6/90-R)

Wisconsin: 120-physician multispecialty clinic in the Fox
River Valley of northeastern Wisconsin desires two BC/BE
pediatricians to join department of 1 5 BC/BE pediatricians.
Excellent compensation and benefits package, leading to
shareholder status after two years. The community offers a
superb recreational, cultural, and family environment in
which to practice. For information please call or write:
Howard Kidd, M.D., La Salle Clinic, 411 Lincoln Street,
Neenah, WI 54956; 414/727-4276. (3/91-R)

Stillwater: Multispecialty group with emphasis on primary
care seeking BC/BE family physician, pediatrician, and
internist. Scenic location with excellent school system,
supportive medical community with strong local hospital,
competitive salary and benefits. Send CV to: Jon Petersen,
St. Croix Valley Clinic, 921 Greeley, Stillwater, MN 55082;
612/439-2215. (12/92-R)

ADVERTISING

PHYSICIANS

Nights and/or Weekends

Veterans Affairs Medical Center, St. Cloud,
Minnesota, is a 600-bed Medical Center
providing acute psychiatric, intermediate
medicine, and long term care to veterans.

We have full or part-time opportunities for
several physicians to cover the off-shift hours.

Responsibilities include: unscheduled ad-
missions, medical rounds, and emergency
response.

Our focus is a flexible schedule to meet the
mutual needs of staff and Medical Center.

Call or Write to explore these unique
opportunities.

Steve Erickson, 612-255-6301
Veterans Affairs Medical Center
4801 N 8th Street
St. Cloud, MN 56303

Equal Opportunity Employer

Department of
Veterans Affairs

UNIVERSITY OF MINNESOTA
DEPARTMENT OF OPHTHALMOLOGY
RAMSEY CLINIC

ST. PAUL-RAMSEY MEDICAL CENTER

The University of Minnesota Department of Ophthalmology and Ramsey Clinic
are seeking a full or part-time assistant professor to join the current staff of 3.5
ophthalmologists. This is an annually renewed, non-tenured position located in
the Department of Ophthalmology at St. Paul-Ramsey Medical Center.

Minimum requirements are completion of an ophthalmology residency, board eligi-
bility and teaching experience. Teaching will include residents, fellows, medical
and technician students. The opportunity to conduct research exists and is sup-
ported, but is not a requirement. Patient care responsibilities will be in the area
of general ophthalmology.

Ramsey Clinic is a multi-specialty group practice based in St. Paul, Minnesota.
More than 250 physicians are members of the clinic, with specialists in virtually
every medical field. The clinic has a unique partnership with St. Paul-Ramsey
Medical Center, a 435-bed primary and tertiary hospital. Our mission: to provide
high quality medical care to all patients, regardless of their ability to pay. This mis-
sion, combined with an emphasis on teaching, support for research and an excep-
tional partnership between the clinic and medical center, makes this an ideal group
practice for physicians interested in making a difference. You can practice medi-
cine just about anywhere. So how do you choose the practice setting that's right
for you? If you want the satisfaction that comes from direct patient care, the ener-
gizing effect of training new physicians, the challenges and discoveries inherent
in research, and the satisfaction of working with colleagues considered experts
in their field, then the choice is clear — Ramsey,

A letter of interest and curriculum vitae should be forwarded by March 30, 1992

to: Mark Sneed, M.D., c/o Loriese A. Stoll, Director of Professional Services,
Ramsey Clinic, 640 Jackson Street, St. Paul, MN 55101-2595, (612) 221-3067.

RAMSEY

Equal Opportunity Employer

ini

Minnesota Medicine

March 1992/Volume 75

CLASSIFIED ADVERTISING

Is This Your
Only Solution To
Chronic Pain?

The Pilling Pain Clinic at
HealthEast Midway Hospital, the
only comprehensive pain clinic in
St. Paul, can help patients with
chronic pain reduce their
dependency on medication while
teaching them to manage their
pain and become productive
again. Call 641-5610 to learn how.

HealthEast ^ Midway Hospital
Pilling Pain Clinic

1700 University Ave., St. Paul, MN 55104

Family

Practice

Lake Region Clinic in Brainerd, Minnesota is cur-
rently recruiting 2 Family Practice physicians to join
4 family practice physicians. Able to do the full scope
of family practice including ICU (OB optional). Good
cooperative working relationship with specialists in
orthopedic surgery, urology, ENT, OBG, general sur-
gery, internal medicine, ophthalmology, and psy-
chiatry.

Modern well-equipped 160 bed hospital within two
blocks.

We offer first year guarantee plus incentive, vacation
time, CME study time, insurance, and more.

Send CV or contact:

Darral Mischke, Administrator,
or David Boran, M.D., at

218-829-3568

(8/91-R)

Wadena, Minnesota: Beautiful central Minnesota is home
to the Wadena Medical Center, a five-physician group, and
Tri-County Hospital. A scenic three-hour drive from Min-
neapolis. Family physicians to do obstetrics. Contact Dr.
Matt Yelle, 218/631-1360, or Jim Lawson, Administrator,
218/631-3510. You’ll not want to pass up this attractive
place and offer. (8/91-R)

(9/91-R)

Office Space Available 5/1/91 for sublease. 1,220 square
feet, Southdale Medical Building. Two exam rooms, confer-
ence room, waiting/reception area. Inquiries: 612/333-6484.

6-3/92

Burdick Treadmill and EKG for lease/ rent and used medical
equipment and supplies for sale. Excellent condition. Call
218/828-1358. 6-4/92

March 1 9 9 2 / V o I u m e 75

Minnesota Medicine

I-

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for

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iieJ

CLASSIFIED

hospital, on-site consultations from numerous specialty
disciplines, satellite offices located in Pine City and Hinck-
ley. Mora is a progressive community located 65 miles
north of the Twin Cities with an excellent school system and
many cultural and recreational opportunities within easy
access. Contact: Larry J. Brettingen, M.D., 224 Seventh
Street, Mora, MN 55051; 612/679-1340. 6-5/92

Family Practice: Northeastern Iowa. Become part of the
growing Family Care Network. Established practice, ob
optional, ample coverage. Small-town atmosphere, 40-bed
hospital, 260-bed regional referral center within one-hour
drive. Excellent income guarantee plus benefits. Wanda
Parker, E. G. Todd Physician Search, Inc., 915 Broadway,
Suite 1101, New York, NY 10010; 800/221-4762; fax:
212/777-5701. ’^5-4/92

Family Practice Wisconsin: Physician needed for partner-
ship in broad-based primary care practice in exceptional
south-central community. Shared call, fully equipped and
staffed office, very competitive guaranteed salary, and
comprehensive benefits package. Eor information on this
and other opportunities in the Upper Midwest, contact and
send CV to: Mary Jo Cordes, President, MDsearch, PO Box
21507, St. Paul, MN 55121; or call: 612/454-7291. Pax:
612/454-7277. M-3/92

Oshkosh, Wisconsin: Single-specialty groups are recruiting
in pediatrics, ob/gyn, cardiology, pathology, and orthope-
dic surgery. Oshkosh is an attractive community of 55,000
people, located on the shores of Lake Winnebago and in the
heart of Wisconsin’s beautiful Pox River Valley. Competi-
tive financial packages. Contact: Christopher Kashnig, Phy-
sician Recruiter, Mercy Medical Center, 631 Hazel Street,
Oshkosh, WI 54902; or call: 800/242-5650, Ext. 2430, or
414/236-2430. =^3-3/92

Family PracHce — Minnesota: Enjoy the benefits of country
living yet have the resources of a major metropolitan area
close at hand. Health One Buffalo Hospital is seeking a
family physician to join two PPs and a nurse practitioner in
its clinics in Annandale and Winsted. Share call with five
physicians. Competitive compensation with excellent ben-
efits including year-round outdoor recreation in “the heart
of the lakes.” Contact: Kim Isenberg, Health One Buffalo
Hospital, 303 Catlin Street, PO Box 609, Buffalo, MN
55313; 612/682-1212, Ext. 245. 6-6/92

Wisconsin — internist Wanted: Group Health Cooperative,
a progressive, growing, staff-model HMO in a city of
60,000 in west-central Wisconsin, is currently recruiting a
third internist. Very competitive salary with excellent fringe
benefits. Practice high-quality internal medicine in a most
desirable location. Please contact: Stuart R. Lancer, M.D.,
M.B.A., Medical Director, Group Health Cooperative, PO
Box 3217, Eau Claire, WI 54702-3217; 715/836-8552.

*3-3/92

Wisconsin — Fourth BC/BE Obstetrician/Gynecologist need-
ed to join stable, progressive, primary-care-based HMO/

ADVERTISING

PRIVATE PRACTICE
OPPORTUNITIES

for Family Physicians in;

• Arlington

• Cannon Falls

• Crosby

• Eden Prairie

• Hopkins

• Minneapolis

• Monticello

• Morris

• Mound

• New Prague

• Wayzata

• Grantsburg, WI

LifeSpan is a network of affiliated hospitals,
clinics and related health care organizations.

Please contact; Jerry Hess at (612) 863-4193
or (800) 248-4921

LifeSpan

HEALTH CARE SERVICES

800 East 28th Street

Minneapolis, MN 55407

group practice in university town of 60,000 near Minneap-
olis/St. Paul. Excellent quality of life and outstanding recre-
ational area. Competitive salary and fringe benefits. Con-
tact: Stuart R. Lancer, M.D., M.B.A., Medical Director,
Group Health Cooperative, PO Box 3217, Eau Claire, WI
54702-3217; 715/836-8552. M-6/92

Wisconsin — Family Practitioner Needed by progressive and
growing group practice in west-central Wisconsin city of
60,000. Ninety miles from Minneapolis/St. Paul. Primarily
prepaid practice with large component PPS. Highly compet-
itive salary with excellent fringe benefits. Practice high-
quality care in a good recreational area. Send CV to: Stuart
R. Lancer, M.D., M.B.A., PO Box 3217, Eau Claire, WI
54702-3217; 715/836-8552. M-6/92

One or Two Family Practice Physicians to join five family
practitioners. Population 8,000. One hour south of Burns-
ville Center. Lakes, industry, negotiable salary. Clinic adja-
cent to hospital. Ample free time to enjoy family life.
Contact James W. Dey, M.D., or Ruth Hawker, Clinic
Manager, 501 North State Street, Waseca, MN 56093; 507/
835-3110. (2/92-R)

The Monticello Clinic: Well-established multispecialty clinic
adjacent to 39-bed acute-care/9 1-bed long-term care facil-
ity in a rural setting seeking a BC/BE family practitioner.
Ideal location to raise a family. Thirty miles from large
metropolitan area. Year-round cultural and recreational

;ia!

Minnesota Medicine

March 1992/Volume 75

CLASSIFIED ADVERTISING

E.N.T. and PEDIATRICS

for

BRAINERD MEDICAL CENTER

• Immediate Opportunity

• 21 Physician Multi-
Specialty Clinic

• New Clinic Building

• No Capitation

• No Start-up Costs

• Progressive New 162
Bed Hospital

• Beautiful Lakes and
Trees

• Two Hours from
Minneapolis

• Ideal for Families

Call CollectA/Vrite: Administrator Curtis j. Nielsen,
(218) 828-7100 or (218) 829-4901, P.O. Box 524,
Brainerd, MN 56401.

activities. Excellent salary guarantee, production incentive,
and benefits package. For more information, contact: Pen-
ny M. Vail, Director, Clinic Services, North Memorial
Medical Center, 3300 Oakdale North — 3E Perinatal, Min-
neapolis, MN 55422; 612/520-4839. 3-4/92

Northbrook Clinic: Special opportunity for BC/BE family
practitioner to join a well-established, three-physician clin-
ic. This practice will be moving in 1992 to a new facility.
This northern suburb offers a safe family environment and
outstanding educational, cultural, and recreational ameni-
ties. Excellent salary guarantee, production incentive, and
benefits package. For more information, contact: Penny M.
Vail, Director, Clinic Services, North Memorial Medical
Center, 3300 Oakdale North — 3E Perinatal, Minneapolis,
MN 55422; 612/520-4839. 3-4/92

Wayzafa Family Physicians: Special opportunity for BC/BE
family practitioner to join a well-established, five-physician
practice located in a prime suburb community near beauti-
ful Lake Minnetonka. The area is surrounded by top-
quality schools, shopping centers, and an abundance of
recreational, family, and social activities. Excellent salary
guarantee, production incentive, and benefits package. For
more information, contact: Penny M. Vail, Director, Clinic
Services, North Memorial Medical Center, 3300 Oakdale
North — 3E Perinatal, Minneapolis, MN 55422; 612/520-
4839. 3-4/92

Southeast Wisconsin Pediatrics; Join busy pediatriegroup in
prospering community close to Milwaukee, Madison, and
Chicago. Rewarding lifestyle, capable colleagues, shared
call, first-class hospital with special-care nursery. Please
contact: Kathryn lorio, M.D., Waukesha Pediatric Associ-
ates, Ltd., nil Delafield Street, #115, Waukesha, WI
53188; 414/542-6999. 3-4/92

Family Practice: Physicians seeking a BC/BE family practice
physician for the Norway, Michigan, service area. The
physician would have the option of joining one of the
existing practices and/or setting up his/her own practice.
Anderson Memorial Hospital is a part of Dickinson County
Hospitals and has a service-area population of over 45,000.
Contact: Dr. Paul Hayes’ office, 906/563-9255, or Dr.
William Gladstone’s home, 906/563-8743. Anderson Me-
morial Hospital, Main Street, Norway, MI 49870; 906/
563-9243. M-3/92

Position Available for Family Physician in Suburban St. Paul:

Are You Seeking a Position in Neonatology, Orthopedics,
Dermatology, Allergy, Radiology, Oncology, Neurosur-
gery, or Rheumatology? We have positions available in
Ohio, Missouri, Wisconsin, and Nebraska. Attractive guar-
antees and benefit packages. Single or multispecialty groups.
To discuss your practice preferences and these opportuni-
ties, please call our toll-free number, 800/243-4353, or send
your CV to Strelcheck & Associates, Inc., 1 0624 North Port
Washington Road, Mequon, WI 53092. *2-4/92

Internal Medicine: Excellent opportunity available for BC/
BE internist in picturesque southwestern Wisconsin. Solo
practice or partnership. Benefits include competitive in- ;
come guarantee, malpractice insurance, paid vacation, and
more. Confidential inquiries welcome: 800/969-7715, Dan i
Jones, Gielow/Laske Associates, 306 North Milwaukee
Street, Milwaukee, WI 53202. *1-3/92 ■

March 1992/Volume 75

Minnesota

M e d i

CLASSIFIED ADVERTISING

Family Practice, Ob/Gyn, Internal Medicine, and Urgent
* Care positions are available in a variety of settings from

(Central Michigan, through Illinois, Wisconsin, and Nebras-
ka, to the rolling plains of Kansas. Single or multispecialty
groups, faculty, or solo with generous call coverage. Attrac-
l tive guarantees and benefits. For more information, please
contact our toll-free number, 800/243-4353, or send your
CV to Strelcheck & Associates, Inc., 10624 North Port
Washington Road, Mequon, WI 53092. ”'2-4/92

3t I

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BC/BE Internist with or without subspecialty training to join
six other internists in 16-member multispecialty clinic in
Worthington, Minnesota. Liberal vacation and meeting
time including stipend. Contact R. D. Sudmeier, M.D., or
John J. Sieve, Administrator, Worthington Medical Center,
P.A., Worthington, Minnesota 56187; 507/372-2921.

3-5/92

Sixth Annual Door County Summer Institute: Egg Harbor,
Wisconsin. Sessions run from 9 a.m. to 12:15 p.m. daily.
CME and CEU credits available. July 27-31, 1992: Session
I — Harry Levinson, Ph.D., Organizational Diagnosis. Ses-
sion II — Russell Barkley, Ph.D., Attention Deficit Disor-
ders. August 3-7, 1992: Session III — Albert Ellis, Ph.D.,
Rational Emotive Therapy. Session IV — Diana Kirschner,
Ph.D., and Sam Kirschner, Ph.D., Treating Survivors of
Incest and Abuse. Session V — ^James Jefferson, M.D., Psy-
chopharmacology Update. August 10-14, 1992: Session
VI — ^Jerrold Post, M.D., Political Psychiatry. Session VII —
Stephen Rao, Ph.D., Thomas Hammeke, Ph.D., and Mari-
ellen Eischer, Ph.D., Neuropsychological Testing. Spon-
sored by the Psychotherapy Center at Columbia Hospital
and the Department of Psychiatry at the Medical College of
Wisconsin. Eor more information, contact Carlyle H. Chan,
M.D., Summer Institute Director, Psychiatry Department,
Medical College of Wisconsin, 8701 Watertown Plank
Road, Milwaukee, WI 53226; 414/257-5995. M-3/92

Diagnostic Radiologist: Excellent opportunity to join a
three-man group in a flourishing general radiology practice
that includes all modalities (angio and interv. limited at this
point but could be expanded). Generous salary leading to
early partnership in professional corporation. Great com-
munity where recreational and cultural activities abound.
Relatively free from metro competitive hassles. Send CV to:
James P. Zachman, M.D., Radiology Department, Rice
Memorial Hospital, Willmar, MN 56201; 612/231-4530.

3-5/92

General Internist — St. Cloud, Minnesota: Opportunity avail-
able in a growing physician clinic of specialists and subspe-
cialists of internal medicine. Community has three colleges,
excellent school system, and abundant recreational activi-
ties. Eamily living conditions are excellent! The St. Cloud
Clinic is located in a new facility with access to the latest
medical technological developments. Eor more information
about this position, please contact: Scott Davis, M.D., or
Mark Murphy, Administrator, 1200 Sixth Avenue North,
St. Cloud, MN 56303; 6 1 2/252-5 131. 2-4/92

Rheumatologist — St. Cloud, Minnesota: Opportunity avail-
able in a growing physician clinic of specialists and subspe-
cialists of internal medicine. Community has three colleges,
excellent school system, and abundant recreational activi-
ties. Eamily living conditions are excellent! The St. Cloud
Clinic is located in a new facility with access to the latest
medical technological developments. Eor more information
about this position, please contact: Scott Davis, M.D., or
Mark Murphy, Administrator, 1200 Sixth Avenue North,
St. Cloud, MN 56303; 612/252-5131. 2-4/92

Internal Medicine: Opportunities available for BC/BE inter-
nists to join a well-established, 85-physician, multispecialty
group practice in the metro Twin Cities area. Excellent
compensation and benefit package. Contact: Nancy
Borgstrom, Aspen Medical Group, 1020 Bandana Boule-
vard West, St. Paul, MN 55108; 612/641-7170. EOE.

1-3/92

Overwhelmed by the Possibilities? You need a good head-
hunter! Someone to decipher the pros and cons of practice
opportunities, salaries, contracts, buy-ins. We’ll network
and negotiate for you. Judi White, R.N., B.S.N., Dunhill of
South Lenexa, 9718 Rosehill Road, Lenexa, KS 66215;
913/599-6270. Eax: 913/599-6542. 1-3/92

Introducing Preferred Search for Your Physician Needs: Eull
retained services for one small retainer. Personal service
dedicated to your specific position. Accountability! Eor

Oxboro Climes, a large, progressive, multi-
specialty practice with offices in Bloomington
and Burnsville, offers outstanding physician
opportunities.

• Pediatrics

• Obstetrics/Gynecology

• Internal Medicine

For more information, contact:

Jennifer J. Mitchell
Fairview Physician & Clinic Services
600 West 98th Street, Suite 390
Bloomington, MN 55420
(612) 885-6225
or toll free 1-800-842-6469

(Id!

Minnesota Medicine

March 1992/Valume 75

CLASSIFIED ADVERTISING

inLormation, call: Judi White, R.N., B.S.N., Dunhill of
South Lenexa, 9718 Rosehill Road, Lenexa, KS 66215;
913/599-6270. M-3/92

New Beginnings at Waverly — Medical Director: Immediate
opportunity for a physician licensed in the state of Minne-
sota to serve as medical director for 40-bed, JCAHO adult
chemical dependency treatment center. Duties include H&Ps,
patient education, UR/case management, involvement and
participation in a multidisciplinary treatment approach to
therapy. Position involves approximately 20 hours per
week and call. Malpractice insurance provided, excellent
benefits including 401k and pension. New Beginnings is
located 35 miles west of Minneapolis on lakeshore proper-
ty. Contact: Jane Hausladen, Human Resources, or Gil
Gilchrist, Administrator, at 800/487-8758. ’■''2-4/92

Continuing Medical Education: Third Annual Specialty Up-
date hosted by the Division of General Internal Medicine,
Medical College of Wisconsin, June 24-26, 1992. Location:
The American Club resort and Blackwolf Run golf course,
Kohler, Wisconsin. Course fee of $360 includes two days of
golf. Approved for seven category 1 CME credits. For
registration and information contact: Amy Barnickel, 414/
257-6040. =’•2-4/92

BC/BEOb/Gyn needed to join active solo ob/gyn practice in
surburban Minneapolis. Purchase of practice with favor-
able terms available if desired. Call 612/377-7373 evenings.

3-5/92

Door County, Wisconsin. Emergency Medicine. BC/BE fam-
ily practice, internal medicine, pediatrics, or emergency
medicine. General emergency medicine experience required.
ACES/ATES required, PAES preferred. Eull-time position
with eight to ten 24-hour shifts monthly with flexibility.
Competitive salary and benefits package. Modern 89-bed
hospital with a new emergency department and outpatient
services addition. Approximately 10,000 visits per year.
Exceptional four seasons’ recreation along Lake Michigan
shores. Proximity to Milwaukee/Chicago. Top-rated schools.
Quality community life. Send CV to: Priscilla Khoury,
Physician Recruitment Coordinator, 330 South 16th Place,
Sturgeon Bay, WI 54235. =’'3-5/92

Pain Fellowship: Position for PGY4 or PGY5 to participate
in a one- or two-year program of clinical pain management
and clinical or basic research beginning July 1, 1992,
sponsored by the Department of Neurology, Hennepin
County Medical Center in Minneapolis. The program main-
tains an active outpatient practice and sees hospitalized
patients on a referral basis from all departments. Opportu-
nities to learn pharmacological management, acupuncture,
peripheral nerve blockade, biofeedback techniques, and

other areas related to pain are available. Hennepin County
Medical Center is an equal opportunity educator and em-
ployer and specifically invites and encourages applications
from women and minorities. Application and CV should be
sent to: Miles J. Belgrade, M.D., Director, Hennepin Pain
Clinic, Department of Neurology, Hennepin County Med-
ical Center, 701 Park Avenue South, Minneapolis, MN

55415. 3-5/92

MARCH 19 9 2 INDEX TO ADVERTISERS

Alexandria Clinic, P.A 49

Boynton Health Services 21

Brainerd Medical Center 54

C.F. Anderson Company, Inc 18

Chisago Health Services 49

Duluth Clinic 4

Early Detection Health Services, Inc 20

Eli Lilly & Company 22, 23

Eairview Physician & Clinic Services 4

Eairview Southdale Hospital 40

G.D. Searle Cover 4

Group Health, Inc 21

HealthEast Midway Hospital 52

Health One 2

Hennepin Faculty Associates 23

Hutchinson Medical Genter 46

Lake Region Glinic 52

Leonard, Street and Deinard 40

Lifespan Health Care Services 53

Medica 33

Minnesota Medical Services Corporation Cover 3

Multicare Associates of the Twin Cities 18

Oxboro Clinics 55

Palisades Pharmaceuticals, Inc 29

Postgraduate Medicine 4

Quality Transcription, Inc 18

Ramsey Clinic 51

Roche Laboratories 13, 14

Runyan/Vogel Group 33

St. Paul-Ramsey Medical Genter 49

Seabury & Smith Cover 2

University of Minnesota Medical School 12

Veterans Administration Medical Center, St. Cloud 51

Whitesell Medical Locums, Ltd 46

March 1992/Volume 75

Minnesota Medicine

WHEN TIME
IS NOT ON
YOUR SIDE...

I MMSC is

* Service

With so much to do and so little time, how can you
choose from the numerous insurance and other
programs on the market? Help is available.

The Minnesota Medical Services Corporation is at
your service with a variety of products and services
for members of the Minnesota Medical Association
and their clinics. Each program has been carefully
evaluated to assure you of good, reliable service at
a reasonable price.

INSURANCE PROGRAMS

• Group Term Life

• Permanent Life

• Group Major Medical

• Group Hospital Indemnity

• Long-Term Disability

• Individual Non-Can Disability

• Auto/Home/Excess Liability

• Businessowners Liability

• Professional Liability

• Workers’ Compensation

• Long-Term Care

COMPUTER SYSTEMS
COLLECTION SERVICE
MAGAZINE SUBSCRIPTIONS
MAILING LISTS
TRAVEL PROGRAMS
CAR RENTAL DISCOUNTS
EQUIPMENT LEASING

MOBILE CELLULAR PHONES

PERSONAL AND BUSINESS
CREDIT CARD PROGRAMS

CREDIT CARD PROFESSIONAL
SERVICES

MANAGEMENT CONSULTING
RESOURCE LIST

LEGAL SERVICES
RESOURCE LIST

For information on any of these programs, please call us at (612) 378-0305.

The Minnesota Medical Services Corporation is the wholly-owned product and
services subsidiary of the Minnesota Medical Association.

IMMA

Minnesota Medical Association

MINNESOTA

MEDICAL

SERVICES

CORPORATION

O «l£AS€ CAPIETS

The recommended starting dose for Calan SR is 180 mg
once daiiy. Dose titration wiii be required in
some patients to achieve blood pressure control.

A lower initial starting dosage of 120 mg/day may be warranted in some patients
(eg, the elderly, patients of small stature).

Constipation, which is easily managed in most patients, is the most commonly
reported side effect of Calan SR.

BRIEF SUMMARY

Warnings: Verapamil should be avoided in patients with severe LV dysfunction (eg, ejection
fraction < 30%) or moderate to severe symptoms of cardiac failure and in patients with any
degree of ventricular dysfunction if they are receiving a beta-blocker Control milder heart failure
with optimum digitalization and/or diuretics before Calan SR is used. Verapamil may occasionally
produce hypotension. Elevations of liver enzymes have been reported. Several cases have been
demonstrated to be produced by verapamil. Periodic monitoring of liver function in patients on
verapamil is prudent. Some patients with paroxysmal and/or chronic atrial flutter/fibrillation and
an accessory AV pathway (eg, WPW or LGL syndromes) have developed an increased antegrade
conduction across the accessory pathway bypassing the AV node, producing a very rapid
ventricular response or ventricular fibrillation after receiving I.V verapamil (or digitalis). Because
of this risk, oral verapamil is contraindicated in such patients. AV block may occur (2nd- and
3rd-degree, 0 8%). Development of marked Ist-degree block or progression to 2nd- or 3rd-
degree block requires reduction in dosage or, rarely, discontinuation and institution of appropriate
therapy Sinus bradycardia, 2nd-degree AV block, sinus arrest, pulmonary edema and/or severe
hypotension were seen in some critically ill patients with hypertrophic cardiomyopathy who were
treated with verapamil.

Precautions: Verapamil should be given cautiously to patients with impaired hepatic function
(in severe dysfunction use about 30% of the normal dose) or impaired renal function, and patients
should be monitored for abnormal prolongation of the PR interval or other signs of overdosage.
Verapamil may decrease neuromuscular transmission in patients with Duchenne's muscular
dystrophy and may prolong recovery from the neuromuscular blocking agent vecuronium. It may
be necessary to decrease verapamil dosage in patients with attenuated neuromuscular transmis-
sion. Combined therapy with beta-adrenergic blockers and verapamil may result in additive
negative effects on heart rate, atrioventricular conduction and/or cardiac contractility; there have
been reports of excessive bradycardia and AV block, including complete heart block. The risks
of such combined therapy may outweigh the benefits. The combination should be used only
with caution and close monitoring. Decreased metoprolol and propranolol clearance may occur
when either drug is administered concomitantly with verapamil. A variable effect has been seen
with combined use of atenolol. Chronic verapamil treatment can increase serum digoxin levels
by 50% to 75% during the first week of therapy, which can result in digitalis toxicity. In patients
with hepatic cirrhosis, verapamil may reduce total body clearance and extrarenal clearance of
digitoxin. The digoxin dose should be reduced when verapamil is given, and the patient carefully
monitored. Verapamil will usually have an additive effect in patients receiving blood-pressure-
lowering agents. Disopyramide should not be given within 48 hours before or 24 hours after
verapamil administration. Concomitant use of flecainide and verapamil may have additive effects
on myocardial contractility, AV conduction, and repolarization. Combined verapamil and quinidine
therapy in patients with hypertrophic cardiomyopathy should be avoided, since significant
hypotension may result. Concomitant use of lithium and verapamil may result in a lowering of
serum lithium levels or increased sensitivity to lithium. Patients receiving both drugs must be
monitored carefully. Verapamil may increase carbamazepine concentrations during combined use.
Rifampin may reduce verapamil bioavailability. Phenobarbital may increase verapamil clearance.
Verapamil may increase serum levels of cyclosporin. Verapamil may inhibit the clearance and
increase the plasma levels of theophylline. Concomitant use of inhalation anesthetics and calcium
antagonists needs careful titration to avoid excessive cardiovascular depression. Verapamil may
potentiate the activity of neuromuscular blocking agents (curare-like and depolarizing); dosage
reduction may be required. There was no evidence of a carcinogenic potential of verapamil
administered to rats for 2 years. A study in rats did not suggest a tumorigenic potential, and
verapamil was not mutagenic in the Ames test. Pregnancy Category C. There are no adequate
and well-controlled studies in pregnant women. This drug should be used during pregnancy,
labor, and delivery only if clearly needed. Verapamil is excreted in breast milk; therefore, nursing
should be discontinued during verapamil use.

Adverse Reactions: Constipation (7.3%), dizziness (3.3%), nausea (2.7%), hypotension (2.5%),
headache (2.2%), edema (1,9%), CHF, pulmonary edema (1.8%), fatigue (1.7%), dyspnea (1.4%),
bradycardia; HR < 50/min (1.4%), AV block: total r,2°,3° (1.2%), 2° and 3° (0.8%), rash
(1.2%), flushing (0.6%), elevated liver enzymes, reversible non-obstructive paralytic ileus. The
following reactions, reported in 1.0% or less of patients, occurred under conditions where a
causal relationship is uncertain: angina pectoris, atrioventricular dissociation, chest pain, claudi-
cation, myocardial infarction, palpitations, purpura (vasculitis), syncope, diarrhea, dry mouth,
gastrointestinal distress, gingival hyperplasia, ecchymosis or bruising, cerebrovascular accident,
confusion, equilibrium disorders, insomnia, muscle cramps, paresthesia, psychotic symptoms,
shakiness, somnolence, arthralgia and rash, exanthema, hair loss, hyperkeratosis, macules,
sweating, urticaria, Stevens-Johnson syndrome, erythema multiforme, blurred vision, gyneco-
mastia, galactorrhea/hyperprolactinemia, increased urination, spotty menstruation, impotence,

4/11/91 •P91CA6277V

SEARLE

G D Searle & Co

Box 5110. Chicago. IL 60660

Address medical inquiries to
G D Searle & Co
Medical & Scientific
Information Department
4901 Searle Parkway
Skokie. IL 60077

A91CA6148T

Minnesota Medicine

RNAL OF CLINICAL AND HEALTH AFFAIRS

Medicine Makes News

Buttei?woi?th

HEALTH SYSTEM

The Science of Healing... The Art of Caring

Exceptional professional and recreational choices are yours in West
Michigan. Due to rapid growth, the Butterworth Health System offers
attractive professional positions in its 530 bed tertiary care teaching
hospital, 4 affiliate hospitals, and 7 Med+Centers. Positions are
available in pediatrics, medicine/pediatrics, internal medicine, surgery,
orthopedic surgery, otolaryngology, radiology, and OB/GYN.

Opportunities include group practice, partnership, and solo or salaried
urgent care and outpatient practices.

Choose Butterworth Hospital in Grand Rapids, which serves a
population of 700,000, plus a 13 county referral area, or a small
community or rural environment at one of the affiliate hospitals. Grand
Rapids is West Michigan’s cultural, educational, and economic center.

With Lake Michigan only 30 miles away and numerous forests and parks
nearby, there are ample opportunities for recreation and entertainment.

Listed below are a few of the many opportunities available.

• Family Practitioner/Outpatient Practice BC/BE family practitioner full-time, 4 1/2
days, Monday through Friday. Established satellite outpatient practice, offering continuity
of care, no call and regularly scheduled hours. OB, call, and hospital practice optional.

Full benefit package, competitive salary with quarterly and year-end bonus. Opportunity
to work additional hours in Med-i-Center, if desired.

• Family Practitioner/Private Practice Three well established and thriving group
practices at Butterworth Hospital desire to expand by adding an additional BC/BE family
practitioner. Join existing groups consisting of 2 - 5 physicians, OB optional. Desirable
call schedules, competitive salaries and benefit packages.

• Famiiy Practitioner/Urgent Care Center Join the growing field of ambulatory
care, Med-i-Center BC/BE family practitioner needed to provide medical services to
patients on a regularly scheduled basis. No call schedule, flexible hours, excellent
compensation and benefits.

• Family Practitioner/Primary Care Clinic BC/BE family practitioner or internist
needed for a large, primary care medical and dental clinic in Grand Rapids. The clinic is
managed by Butterworth Ventures, the largest health care system in West Michigan and
funded by private donations and a federal grant. Staffing includes 2 family practitioners, a
pediatrician, nurse practitioner, medical director and support personnel. This is a salaried
position with a competitive compensation and benefit package and 1 in 5 call schedule.

•Internal Medicine/Faculty Position Board certified general internist with teaching
and clinical skills needed to join dynamic full-time academic faculty for internal medicine
residency. Responsibilities include direct patient care in faculty practice, supervision and
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For information about the above positions, please call or write to
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jUNIVERSiTV Of PlMifcyK^

if R,? ^ 10V

A JOURNAL OF CLINICAL AND HEALTH AFFAIRS

COVER

Medicine Makes News. The public’s appe-
tite for medical news has brought success to
physician reporters like WCCO-TV’s
•Michael Breen, .\L.D., profiled in our cover
stors- 'page 20). In that story and this
month’s intersiew with Thomas Shives,
.M.D., host of the popular Rochester radio
show “Healthline” 'page 7), we look at
how M.D. journalists reach patients
through a variety' of media.

Photo by Rob Levine of .VIinneap)olis.

MINNESOTA MEDICINE
Owner and Publisher
•Minnesota Medical Association
Editor-in-Chief Edmund C. Burke, M.D.
Sianaging Editor .Meredith \IcNab
Editorial Assistant Susan R. Rodsjo

Send manuscripts, subscriptions, and other
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APRIL 1992 VOLUME 75 NUMBER 4

FACE TO FACE

Physician Broadcaster Gets Good Reception

Minnesota Medicine interviews Thomas C. Shives, M.D. 7

PERSPECTIVES

.Medicine in the Trenches: The Agony and the Ecstasy of the
Rural Practitioner

Walter W. Benjamin, Ph.D. 13

COVER STORY

TV Doctor, Michael Breen

Ralph C. Heussner, Jr. 20

SPECIAL REPORTS

Clinician Responsibilities Under the National Childhood
Vaccine Injury Act

Diane C. Peterscm 29

.Minnesota HIV/HBV Joint Task Force Recommendations:
Executive Summary 32

CLINICAL & HEALTH AFFAIRS

The Result of an Educational Intervention for Physicians

Providing HIV-Antibody Testing and Counseling

Paul Terry, Ph.D., Alfred Pheley, Ph.D., David Williams, M.D., and

Scott Strickland, M.D. 37

MEDICINE LAW & POLICY

New OSHA Rule Governs Employees’ Exposure to
Bloodborne Pathogens

Mary Anne Colovic, J.D. 40

COPYRIGHT AND
POST OFFICE ENTRY
Minnesota .Medicine (ISSX 0026-556X) is
published on the fifth of each month by the
.Minnesota .Medical Association, 2221 Uni-
versity Avenue SE, Suite 400, .Minneapolis,
.MX 55414, copyright 1992. Permission to
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Minnesoto Medicine

ON THE BUSINESS SIDE

Rural Health Care Delivery: Survival May Require an
Integrated Model

Daniel K. Zismer, Ph.D., and Davis D. Pansier 43

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April 1992/Volume 75

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MINNESOTA MEDICAL ASSOCIATION

1991-92 Officers
President

Thomas A. Stolee, M.D.

President-Elect
A. Stuart Hanson, M.D.

Chair, Board of Trustees
Andrew]. K. Smith, M.D.

Vice President
Barbara P. Yawn, M.D.

Secretary

Thomas B. Dunkel, M.D.
Treasurer

Joseph A. Celia, Jr., M.D.

Speaker of the House
J. Randolf Beahrs, M.D.

Vice Speaker of the House
Richard D. Mulder, M.D.

Past President

Richard B. Tompkins, M.D.

Chief Executive Officer
Paul S. Sanders, M.D.

Auxiliary

President
Phyllis H. Ellis

Minnesota Medicine

Editor-in-Chief
Edmund C. Burke, M.D.

Advisory Committee
Edmund C. Burke, M.D.
Quentin N. Anderson, M.D.
Erank A. Bures, M.D.
Thomas W. Day, M.D.
Charles R. Meyer, M.D.

Paul S. Sanders, M.D.
Andrew]. K. Smith, M.D.
Anne B. Warwick, M.D.
Barbara P. Yawn, M.D.
Meredith McNab
Mark Vukelich

Editors Emeritus
Richard E. Reece, M.D.
1975-1990

Reuben Berman, M.D.
1971-1974

Carl O. Rice, M.D.
1961-1970

Minnesota Medicine

Board of Trustees

N.W. District
Erick Reeber, M.D.

N.E. District
Thomas W. Day, M.D.

Jack B. Greene, M.D.

N. Central District
James J. Dehen, M.D.

David M. Van Nostrand, M.D.
West Metro

Roger W. Becklund, M.D.
Andrew]. K. Smith, M.D.,
Chr.

Richard E. Student, M.D.
George V. Tangen, M.D.
Ronald L. Villella, M.D.

East Metro

Joseph L. Rigatuso, M.D.

Kent S. Wilson, M.D.

S.W. District

Theodore L. Fritsche, M.D.
Anthony C. Jaspers, M.D.

S.E. District

Gail L. Gamble, M.D.

J. Paul Marcoux, M.D.
Thomas L. Peyla, M.D.

Resident Member
Cherie J. Hayostek, M.D.
Medical Student
Ty Dunn

Review Board
Chester A. Anderson, M.D.
Donald C. Bell, M.D.
Dorothy Bernstein, M.D.

F. Blanton Bessinger, M.D.
Jonathan H. Biebl, M.D.
Paul]. Bilka, M.D.

Clyde E. Blackard, M.D.

R. J. Campaigne, M.D.
Richard P. Carroll, M.D.
Roger S. Colton, M.D.
Gerald E. Cotton, M.D.
Peter Dorsen, M.D.

Peter Fehr, M.D.

Paul Gannon, M.D.

James B. Gaviser, M.D.

H. W. Heupel, M.D.

Neil Hoffman, M.D.

James Janecek, M.D.

Miles J. Jones, M.D.

Carl M. Kjellstrand, M.D.
Arnold Kremen, M.D.
Warren L. Kump, M.D.
Van S. Lawrence, M.D.

G. Patrick Lilja, M.D.
Merle K. Loken, M.D.
Merle S. Mark, M.D.

John K. Meinert, M.D.

AM A
Trustee

William E. Jacott, M.D.

AM A Delegates

Robert D. Christensen, M.D.

E. Duane Engstrom, M.D.

A. Stuart Hanson, M.D.

James F. Knapp, M.D.

Audrey M. Nelson, M.D.

Ben P. Owens, M.D.

Richard B. Tompkins, M.D.,
Chr.

AMA Alternates
Carolyn J. McKay, M.D.
Michael J. Murray, M.D.

C. Randall Nelms, Jr., M.D.
Lawrence M. Poston, M.D.
Thomas A. Stolee, M.D.

James J. Tiede, M.D.

L. Ashley Whitesell, M.D.

Senior Staff

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Director of Communications
Mark S. Vukelich

Coordinator of Government
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Kristine D. Hanson

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Mary E. Prentnieks, J.D.

James]. Monge, M.D.

John S. Najarian, M.D.

Bruce C. Nydahl, M.D.

Milton Orkin, M.D.

Richard R. Owen, M.D.
Michael M. Paparella, M.D.
James J. Pattee, M.D.

Willard Peterson, M.D.

John J. Regan, M.D.

Krishna M. Saxena, M.D.
William F. Schoenwetter, M.D.
Alvin L. Schultz, M.D.

Edward L. Seljeskog, M.D.
John E. Smith, M.D.

Farrell S. Stiegler, M.D.

George T. Tani, M.D.

Robert ten Bensel, M.D.

John V. Thomas, M.D.

John Verby, M.D.

Anne B. Warwick, M.D.
Robert L. Woodburn, M.D.

Contributing

Organizations

Minnesota Allergy Society
Minnesota Society of
Anesthesiologists
Minnesota Dermatologic
Society

Minnesota Association of
EMS Physicians
Minnesota Chapter,

Minnesota Association of
Nursing Home Medical
Directors

Minnesota Obstetrical and
Gynecological Society
North Central Occupational
Medical Association
Minnesota Academy of
Ophthalmology
Minnesota Orthopaedic
Society

Minnesota Academy of
Otolaryngology-Head &
Neck Surgery
Minnesota Society of
Clinical Pathologists
Northwestern Pediatric
Society

Minnesota Chapter, American
Academy of Pediatrics
Minnesota Physiatric Society
Minnesota Academy of
Plastic Surgeons
Minnesota Psychiatric Society
Minnesota Radiological
Society

Minnesota Chapter, American
College of Surgeons
Minnesota Surgical Society
Minnesota Thoracic Society
Minnesota Urological Society

Advisers and Reviewers

April 1992/Volume 75

and prcuftice intcnX^

coriTiriuiNQ medical EDUCAxioni

Continuing Education and Extension, University of Minnesota

The Spectmm of Colon and
Rectal Disease in Primary Care
April 24

Pain, bleeding, infection,
hemorrhoids, fissures, warts,
incontinence, cancer, diet

Pediatric-Obstetrics Update
(with Group Health, Inc.)

April 25

Preventing prematurity,
perinatal distress, genetics,
circumcision, immunizations,
chronic abdominal pain,
adolescent sexuality,
contraception, STDs

2nd Symposium of the
International Liver
Transplantation Society
April 29-May 2
Hepatorenal syndrome,
circulation in liver disease,
immunosuppression and
rejection, hepatopulmonary
syndrome, other topics

Family Practice Review and

Daily Management of HIV-

Update

Positive Patients

May 4-8

May 15

Comprehensive review of

Initial responses, assessment.

family medicine designed

education, treatment.

especially for family

resources, legal issues, future

physicians taking the
recertification examination

trends

Smoking Cessation: Update

Gynecology and Gynecologic

and Intervention Strategies

Oncology

May 29

May 12

nicotine addiction, physical
deprendency, phamiacologic

Current Concepts in Radiation

interventions, relapse.

Therapy

May 13-15

physician strategies

Gynecologic, genitourinary.

Laparoscopic Urologic

post-riiodern brachytherapy.

Surgery

stereotactic radiosurgery,
lymphoma, pediatric oncology

May 29-30

Clinical Hypnosis Workshops
June 4-6

Introductory and advanced
workshops with lectures and
small-group practice sessions

Topics and Advances in

Pediatrics

June 10-12

Hematology and oncology,
infectious disease,
gasteroenterology and
nutrition, screening issues,
community piediatrics,
adolescent health,
controversies

56th Annual Course Progress
in Vascular Surgery
June 17-19

Comprehensive review of
new developments in
vascular surgery by local and
national faculty

Continuing Medical Education, Box 202 UMHC, 420 Delaware Street SE, Minneapolis MM 55455, (612) 626-5525

The University of Minnesota is an equai opportunity educator and empioyer. I

EDITOR'S NOTEBOOK

Public Tunes in to Medical Communicators

Edmund C . Burke, M . D .

The public seems to have an
insatiable appetite for medi-
cal news as evidenced by the
number of successful medical jour-
nalists in the state and country to-
day— including an estimated 250
physicians nationwide who appear
on radio and television, some on
national programs. This month, I’d
like you to meet some local media
doctors. Our cover story (page 20)
features the Twin Cities’ “TV Doc-
tor” Michael Breen, M.D., with a
sidebar about Paul Quie, M.D., and
his University of Minnesota-
sponsored medical TV show “Health
Talk and You.” We also talk with
Thomas Shives, M.D., host of the
medical talk show “Healthline” on
KROC-AM in Rochester, in this
month’s interview (page 7).

Unlike the other medical com-
municators featured in this month’s
issue. Dr. Michael Breen is not a
practicing physician. He graduated
from Albert Einstein College of Med-
icine and did a residency in internal
medicine, but because of what he
calls disillusionment, he left his med-
ical training for journalism school.

Comments Dr. Breen makes in
our cover story regarding his disillu-
sionment concern me and might
bother other physicians who have
spent years caring for patients. I
hope Dr. Breen’s empathy tank was
not on “E” when he made his deci-
sion to leave clinical practice; per-
haps he just wasn’t cut out to deal
with patients and their day-to-day
problems and wisely chose another
path. Yet, despite his rather critical
view of the medical profession, I hope
Dr. Breen is able to secure the coop-
eration and warm reception of those
of us in medicine, the ultimate goal
being to serve the public better.

Audience surveys indicate that
medical stories receive high ratings

“Medical

communication is a
superb way to serve
our patients.”

on news shows, just below news up-
dates and weather, according to Jack
Reilly, executive producer of “Good
Morning America.” As a result, phy-
sician reporters have become a hot
commodity. Take Dr. Timothy
Johnson, for example. After 13 years
as an emergency physician in Massa-
chusetts, he is now medical editor for
“Good Morning America” and “ABC
News.” In addition, he prepares re-
ports for “World News Tonight,”
“20/20,” and “Nightline.” Dr. Bob
Arnot, medical correspondent for
CBS’s “This Morning,” is another
example. He is regarded as the most
colorful and aggressive of the morn-
ing news doctors. This fall. Dr. Holly
Atkinson, a former internist, joined
NBC’s “Today” show as medical
correspondent, replacing Dr. Art
Ulene, who moved to ABC’s “Home”
show.

Medical information makes its
way into the news in a variety of
ways — TV, radio, newsletters, mag-
azine stories, and newspaper arti-
cles, for example. Each medium
offers physicians unique opportuni-

ties to educate patients in innovative
ways. While I encourage every med-
ical society to designate and train a
physician to handle media questions
and assist with public relations, I also
believe interested physicians should
personally get involved in medical
communication. There are many
ways to do so:

1. Look for opportunities to tie
media interviews in with a broad
message on health care.

2. Write a letter to the editor.

3. Submit an op/ed article to your
local newspaper.

4. Get to know local reporters
who cover health care reform and
initiate contact.

5. Pass along any new research or
statistics to your media contacts with
a personal note.

6. Inform your media contacts
about local events.

7. Arrange a meeting with your
newspaper’s editorial board to dis-
cuss your society’s or your own opin-
ions on various health matters of
legislative concern.

Some physicians, such as Dr.
Shives, have the talent and energy to
start their own medical programs. If
you’re interested in radio, take note
of Dr. Shives’ message that prepara-
tion is the most important element in
any successful radio program.

Minnesota has many physicians
who are on TV, who write columns
or editorials, or who have radio talk
shows. I extend an invitation to those
of you involved in medical com-
munication to write me about your
activity. Please share any advice you
might have for other physicians
wanting to enter this exciting arena.
1 commend those of you who have
gotten involved; medical communi-
cation is a superb way to serve our
patients. mm

Minnesota Medicine

April 1992/Volume 75

Working Together, We're Making It
Throng Some Difficult Waters.

to track statewide health trends, we our race against rising medical costs
can work with communities to attack would have been lost long ago.
health problems on a local level.

But the key to these programs,
and all our cost containment efforts,
is you. For without the help and
support of our participating providers.

TheRisLTheRiture

FACE TO FACE

Physician Broadcaster Gets Good Reception

Minnesota Medicine interviews Thomas C . Sh iv e s , M . D .

Thomas Shives, M.D., an orthopedic surgeon at
Mayo Clinic, has found a new vocation — radio.
Each Saturday from 9:15 to 10 a.m., he hosts a
medical talk show called “Healthline” on KROC-AM in
Rochester, a show he created with
the Zumbro Valley Medical Society.

When the show started last June, it
hit the ground running and has taken
off faster than any of the station ’s top
programs, according to KROC Pro-
gram Director Joe O’Brien.

Each week Dr. Shives interviews
guests about a hot medical topic and
then opens the phone lines for listen-
er questions. The phone banks are
full nearly every week. “Feedback
from listeners has been quite out-
standing, ” says O’Brien. “There are
weeks when we could take the show
an additional hour and still not get
through all the phone calls. People
are that interested. ”

O’Brien credits the program’s
success to Dr. Shives. “Not only is he
a knowledgeable physician, but he
also has a great on-air presence,”
says O’Brien. “His preparation is
phenomenal, and he is very particu-
lar about the guests he brings on the
show. Not only are they expert phy-
sicians, but they are able to commu-
nicate with the layman. And the topics he chooses
interest the listener — they’re real consumer topics. ”

Dr. Shives chooses topics in conjunction with mem-
bers of the Public Liaison Committee of the Zumbro
Valley Medical Society. Together, they come up with
issues that generate public interest, such as cancer,
cardiovascular health, nutrition, and AIDS. The com-
mittee then approaches expert physicians — usually
members of the Zumbro Valley Medical Society — to
participate as guests.

Dr. Shives and O’Brien have been overwhelmed by
the program ’s success. “ We ’re thrilled to have the show, ”
says O’Brien. “We’re thrilled to have some of the top
medical experts not only in our state, but in the country
and world, come into our humble radio station every
week to be on the show. ” In the following Face to Face
interview. Dr. Shives discusses the program and its
success.

Minnesota Medicine: To be begin with, Dr. Shives, please
tell us about your background — where you grew up,
went to school, completed your residency, and started
practicing orthopedic surgery.

Shives: I grew up in the small town of
Newton, Iowa, and attended Cornell
College in Mount Vernon, Iowa. I
completed my medical school train-
ing in 1 974 at the University of Iowa.
I then came to Rochester for my
orthopedic surgery residency and an
orthopedic oncology fellowship. I
joined the Mayo Clinic staff in 1979.

Minnesota Medicine: I understand
that you have some background in
broadcasting. How did your interest
in broadcasting get started and how
has it progressed?

Shives: Actually, my experience in
high school speech and debate has
helped me most in broadcasting. I
never did radio work until a few years
ago, after I had an operation to repair
a cervical disc. Because I was unable
to perform surgery for three months,
I needed something to occupy my
time, so I went to KROC radio and
told them that I wanted to give the
news. They were a bit dumfounded at
my request, but it didn’t hurt that I was willing to do it
for free. I auditioned, and Program Director Joe O’Brien
and News Director Kim David tutored me — I practiced.
For two months of my recovery I gave the afternoon
news under an assumed name. That’s how I really got my
initial experience in the technical aspects of radio — how
to run “the board” and what it’s all about. I really
haven’t had any other broadcasting experience.

Getting ‘Healthline’ Started

Minnesota Medicine: How did “Healthline,” the new
radio program you host on KROC-AM in Rochester, get
started?

Shives: About a year ago. Dr. Ed Henderson asked me to
chair the Public Liaison Committee of the Zumbro
Valley Medical Society, and I agreed. He told me that the
society had been thinking about starting a radio program

t ' I

Thomas C. Shives, M.D.

“The public has an
almost insatiable
desire for medical
news and
information.”

Minnesota Medicine

April 1992/Volume 75

FACE TO FACE

to help inform the public about medical issues. Since I
knew the people at KROC radio, I approached them
about it. I told them my idea for a show, and they were
enthusiastic about having us. They decided Saturday
morning would be an excellent time for the show.

On June 1, 1991, we aired our first show, and since
then we have been gradually building our audience. We
don’t do a great deal of marketing, but I think our
audience grows by word of mouth. We mail flyers to
hospitals, pharmacies, and nursing homes, and we place
an ad once a week in the local newspaper announcing the
week’s topic and listing the program’s guests.

The Format, Audience, Topics, and Guests

Minnesota Medicine: Please describe the show’s format.

Shives: When I designed the format, I tried to figure out
what the public wanted and what we
could do, as a medical profession, to
help. I believe the public has an al-
most insatiable desire for medical
news and information, but it’s also
sophisticated enough to want it from
experts. The first thing we incorpo-
rated into the show was a review of
the week’s medical news. I glean
medical stories from the newspaper,
the Prodigy news service, and various
journals, and then I try to edit them
into lay language. I present the sto-
ries in a five-minute medical news-
cast to start the show. Then, to satisfy
the public’s desire for expert medical
information, we have a different guest
each week — physicians who are experts in their fields. I
interview them for 1 0 or 15 minutes, which allows them
to gain credibility with the audience. We then open the
program to call-in questions from our audience. The
format seems to work quite well. We get phone calls for
virtually every show, and sometimes we get many more
than we can handle. However, because we have a
relatively small audience, some topics don’t generate as
many phone calls as others. I think people are listening
to those shows, but some topics are sensitive, like
psychiatric issues and impotence. People are more hesi-
tant to call about these problems because someone might
recognize their voice.

Minnesota Medicine: Joe O’Brien, program director,
mentioned that the shows with fewer calls generate more
requests for taped copies. It sounds as though people are
listening, whether they call or not.

Shives: Actually, we probably get more information out
when people don’t call because I can ask questions
without being interrupted. However, it’s a better show
when we have phone calls. I think our listeners want to
hear what other people want to know.

Minnesota Medicine: Do you have problems with crank
calls?

Shives: No, we don’t. The thing that worried me most
when I proposed the format is that we would get inap-
propriate questions, such as inquiries about sports med-
icine when we’re talking about gallbladder attacks. But
that hasn’t happened; the audience is quite sophisticated.
As far as true crank calls, we have had none.

Minnesota Medicine: How do you select your topics?

Shives: I do that in conjunction with the Public Liaison
Committee. At each of our meetings, we try to come up
with topics that would be of interest to the public. I also
use newsworthy topics that seem to be most popular in
the Mayo Clinic Health Letter. Most people think the
biggest issues with regard to their health are cancer,
cardiovascular health, nutrition, and AIDS. We start
from there, select the most popular topics, and then think
about all the different specialties and subspecialties we
have at the clinic and how we could
incorporate those into the program.
Virtually all medically oriented top-
ics have interest. Physicians have
participated in all but one show, a
program on living wills. We had two
attorneys on that program. It was
one of the early shows, and we didn’t
get many phone calls. Otherwise, all
the programs have been medical.

Minnesota Medicine: Where do you
find your experts, and are they typi-
cally willing to go on the radio?

Shives: All our guests, with the ex-
ception of the two attorneys, have
been members of the Zumbro Valley
Medical Society, and most of them practice either at the
Olmsted Medical Group or at Mayo Clinic. The physi-
cians we contact are almost always willing to be on the
show. The only people who have refused to participate,
and we’ve only had one or two, have been frightened of
being on the radio; otherwise, everyone has been most
cooperative. In fact, with the program’s increased pop-
ularity, we have begun to receive requests from individ-
uals, sections, and subspecialties to be on the program,
so it’s become easier to attract guests. Never has anyone
refused because they were unwilling to take the time to
help with the show.

One of the complaints we get as physicians is that we
sometimes don’t spend enough time with our patients; I
think this show demonstrates that physicians are willing
to spend the time to educate the public, even on a
weekend.

Can Anybody Start a Radio Program f

Minnesota Medicine: What advice do you have for coun-
ty, state, or specialty societies, or even local physicians,
who are interested in starting similar radio programs?

Shives: Preparation is the key. I probably spend 10 to 12
hours a week getting ready for each show. Anyone

“This show
demonstrates that
physicians are willing
to spend the time
to educate the
public, even on a
weekend.”

April 1992/Volume 75

Minnesota Medicine

FACE TO FACE

\ interested in doing a program like this has to be willing
to spend the time. I believe a poor performance would be
worse than no performance at all.

I suppose the best start is to approach a local radio
station. Most are receptive to having some kind of local
medical programming. However, I think it’s becoming
more difficult because there are so many sources of
medical information available now, most of which are
relatively good. Still, I think a local
radio station is always receptive to
local talent. Ask whether the station
would be willing to help you learn
the mechanics of being on the radio.

Again, it takes time to learn about
radio and to become comfortable with
the format.

Minnesota Medicine: Are there any
training programs for physicians in-
terested in broadcasting?

Shives: The American Medical Asso-
ciation has an annual Health Reporting Conference,
which was held April 2-5 this year. The conference offers
seminars on broadcast writing, production, speech, and

editing. I recommend that physicians interested in broad-
casting attend the program next year. (Call Jill Stewart at
312/464-5414 for more information.)

Communication as Patient Care

Minnesota Medicine: What is the value of “Healthline”
to the public? Does the program actually improve your
listeners’ health?

Dr. Shives: The public is, understand-
ably, confused about a number of
health issues. For example, people
are perplexed about good and bad
cholesterol, the difference between
low fat and “lite,” the risks of sili-
cone-gel breast implants, and how
much exercise is enough. Determin-
ing what is and isn’t good for you is
no easy task in the ’90s.

Frequently, before our callers
hang up, they’ll say: “You’ve helped
me a lot,” or “I really appreciate your
time.” To me, that says it all. I think that if our listeners
heed the advice they get on “Healthline,” they’ll definite-
ly benefit from it. mm

“The public is,
understandably,
confused about a
number of health
issues.”

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Minnesota Medicine

April 1992/Volume 75

ONLY ONE HrANTAGONIST HEALS REFLUX ESOPHAGI1IS
AT DUODENAL ULCER DOSAGE. ONLY ONE.

Axm

nizatidine

Of all the H2-receptor antagonists, only Axid heals and
relieves reflux esophagitis at its standard duodenal ulcer dosage.
Axid, 150 mg b.i.d., relieves heartburn in 86% of patients
after one day and 93% after one week.^

150 mg b.i.d.

ACID mo. PATIENT PROVEN.

1 . Data on file. Lilly Research Laboratories See accompanying page for prescribing information. c 1991 . EU LILLY and company

NZ-2947-8-249304

AXID'

nizatidine capsules

- Briel Summary. Consult the package insert tor
complete prescribing information
Indications and Usage: Active duodenal ulcer -

lor up to 8 weeks ol treatment at a dosage of 300 mg
h.s. or 150 mg b.i.d. Most patients heal within 4 weeks.

2. Maintenance therapy - for healed duodenal ulcer
patients at a dosage ol 1 50 mg h.s. at bedtime. The
conseguences of therapy with Axid lor longer than 1
year are not known

3. Gastroesophageal reflux disease (GfflDJ-tor up
to 12 weeks of treatment of endoscopically diagnosed
esophagitis, including erosive and ulcerative esophagitis,
and associated heartburn at a dosage ol 150 mg b.i.d.

Contraindication: Known hypersensitivity to the drug
Because cross sensitivity in this class ol compounds has
been observed. H;-receptor antagonists, including Axid.
should not be administered to patients with a history
of hypersensitivity to other Hj-receptor antagonists.

Precautions: General- Symptomatic response to nizatidine therapy does not preclude the presence
of gastric malignancy.

2. Dosage should be reduced in patients with moderate to severe renal insufficiency.

3. In patients with normal renal function and uncomplicated hepatic dysfunction, the disposition of
nizatidine is similar to that in normal subjects.

Laboratory Tes/s-False-positive tests ior urobilinogen with Multistix' may occur during therapy.

Drug Interactions -tio interactions have been observed with theophylline, chlordiazepoxide. lorazepam.
Iidocaine. phenytoin. and warfarin. Axid does not inhibit the cytochrome P-450 enzyme system; therefore,
drug interactions mediated by inhibition of hepatic metabolism are not expected to occur. In patients given
very high doses (3.900 mg) of aspirin daily, increased serum salicylate levels were seen when nizatidine.
150 mg b.i.d., was administered concurrently.

Carcinogenesis. Mutagenesis. Impairment of fertility- A 2-year oral carcinogenicity study in rats with
doses as high as 500 mg/kg/day (about 80 times the recommended daily therapeutic dose) showed no evidence
ol a carcinogenic etfecl. There was a dose-related increase in the density of enlerochromatfin-like (ECL) cells
in the gastric oxyntic mucosa. In a 2-year study in mice, there was no evidence ot a carcinogenic effect in male
mice, although hyperplastic nodules of the liver were increased in the high-dose males as compared with
placebo. Female mice given the high dose ol Axid (2,000 mg/kg/day, about 330 times the human dose) showed
marginally statistically significant increases in hepatic carcinoma and hepatic nodular hyperplasia with no
numerical increase seen in any ol the other dose groups.The rate ol hepatic carcinoma in the high-dose
animals was within the historical control limits seen (or the strain ol mice used. The female mice were given
a dose larger than the maximum tolerated dose, as indicated by excessive (30%) weight decrement as compared
with concurrent controls and evidence of mild liver injury (transaminase elevations). The occurrence ol a marginal
finding at high dose only in animals given an excessive and somewhat hepatotoxic dose, with no evidence of a
carcinogenic effect in rats, male mice, and female mice (given up to 360 mg/kg/day, about 60 times the human
dose), and a negative mutagenicity battery are not considered evidence of a carcinogenic potential (or Axid

Axid was not mutagenic in a battery ol tests performed to evaluate Its potential genetic toxicity, including
bacterial mutation tests, unscheduled DNA synthesis, sister chromatid exchange, mouse lymphoma assay,
chromosome aberration tests, and a micronucleus test.

Pregnancy -Teratogenic Effects -Pregnancy Category C-Oral reproduction studies in rats at doses up
to 300 times the human dose and in Dutch Belted rabbits at doses up to 55 times the human dose revealed no
evidence ol impaired fertility or teratogenic effect; but, at a dose equivalent to 300 times the human dose,
treated rabbits had abortions, decreased number of live fetuses, and depressed letal weights. On intravenous
administration to pregnant New Zealand White rabbits, nizatidine at 20 mg/kg produced cardiac enlargement,
coarctation of the aortic arch, and cutaneous edema In t (etus, and at 50 mg/kg. It produced ventricular
anomaly, distended abdomen, spina bifida, hydrocephaly, and enlarged heart in 1 fetus. There are, however,
no adeguate and well-controlled studies in pregnant women. It is also not known whether nizatidine can
cause letal harm when administered to a pregnant woman or can affect reproduction capacity. Nizatidine
should be used during pregnancy only If the potential benefit justifies the potential risk to the (etus.

Nursing Mothers-SMies in lactating women have shown that 0.1% of an oral dose is secreted
in human milk in proportion to plasma concentrations. Because ol growth depression in pups reared
by treated lactating rats, a decision should be made whether to discontinue nursing or the drug, taking
into account the importance ot the drug to the mother.

Pediatric Dse-Safety and effectiveness in children have not been established.

Use in Elderly Patients -Heating rates in elderly patients were similar to those in younger age groups
as were the rates of adverse events and laboratory test abnormalities. Age alone may not be an Important
factor in the disposition of nizatidine. Elderly patients may have reduced renal (unction.

' the adverse events that occurred at a frequency of 1% or more, there was no statistically significant difference

between Axid and placebo in the incidence ot any ot these events (see package insert for complete information).

A variety of less common events were also reported, it was not possible to determine whether these
were caused by nizatidine.

/Tepaf/c-Hepatocellular injury (elevated liver enzyme tests or alkaline phosphatase) possibly or probably
related to nizatidine occurred in some patients. In some cases, there was marked elevation (>500 lU/L) in
SCOT or SGPT and. in a single instance, SGPT was >2,000 lU/L. The incidence of elevated liver enzymes
overall and elevations ot up to 3 times the upper limit of normal, however, did not significantly differ from that
in placebo patients. All abnormalities were reversible after discontinuation of Axid. Since market introduction,
hepatitis and jaundice have been reported. Rare cases of cholestatic or mixed hepatocellular and cholestatic
injury with jaundice have been reported with reversal ot the abnormalities after discontinuation of Axid.

Cardiovascular -\n clinical pharmacology studies, short episodes ol asymptomatic ventricular tachycardia
occurred in 2 Individuals administered /kxid and in 3 untreated subjects.

C/VS-Rare cases ol reversible mental confusion have been reported.

• Endocrine-Omica\ pharmacology studies and controlled clinical trials showed no evidence ol anli-
androgenic activity due to nizatidine. Impotence and decreased libido were reported with similar frequency
by patients on nizatidine and those on placebo. Gynecomastia has been reported rarely.

Hematologic -Anemia was reported significantly more frequently in nizatidine than in placebo-treated
patients. Fatal thrombocytopenia was reported in a patient treated with nizatidine and another Hj-receptor
I antagonist. This patient had previously experienced thrombocytopenia while taking other drugs. Rare cases
I of thrombocytopenic purpura have been reported.

Integumental-Urticana was reported significantly more (requently in nizatidine- than in placebo-treated
I patients. Rash and exfoliative dermatitis were also reported.

1 Hypersensitivity -As with other Hrreceptor antagonists, rare cases of anaphylaxis following nizatidine

I administration have been reported. Rare episodes of hypersensitivity reactions (eg, bronchospasm, laryngeal
1 edema, rash, and eosinophilia) have been reported,

I Of/ier-Hyperuncemia unassoclaled with gout or nephrolithiasis was reported, Eosinophilia. (ever, and
I nausea related to nizatidine have been reported.

Overdosage: Dverdoses of Axid have been reported rarely. If overdosage occurs, activated charcoal,
[ emesis, or lavage should be considered along with clinical monitoring and supportive therapy The ability ol
I hemodialysis to remove nizatidine from the body has not been conclusively demonstrated; however, due to its
' large volume of distribution, nizatidine is not expected to be efficiently removed from the body by this method
PV 2093 AMP 1101591)

I Additional information available to the profession on reguest
Eli Lilly and Company
Indianapolis, Indiana
46285

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Stageberg, P.A.

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Professionals in Minnesota and Wisconsin

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Lommen Nelson has particular expertise in pro-
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Professional Liability Expertise:

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agement.

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The firm's services to the health care industry
are not limited to practice management issues. The
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business sales and combinations; employment law; pen-
sion and profit sharing plans; tax law, including specific
issues relating to tax exempt entities; real estate; estate
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PERSPECTIVES

Medicine in the Trenches

The Agony and the Ecstasy of the Rural Practitioner

Walter W . Benjamin, P h . D .

Recent studies warn that primary health care deliv-
ery in rural areas is, to use a medical term, in
extremis. Greater Minnesota is short 200 physi-
cians, and the need is growing. As the son of a solo
practitioner whose career
spanned the middle of this
century in a southwestern
Minnesota town of 5,000,

I wanted to uncover the
personal and medical bi-
ographies of those who fol-
lowed in his footsteps. Why
is his profession — rural, in-
timate, and viewed almost
as a religious vocation —
being repudiated by later
generations.’ I hoped to
uncover positive stories
that, if brought to light,
might encourage more
young physicians to give
up the urban vanity fairs
for rural practice.

During the summer of
1990, I sent a 57-question
survey to 40 randomly se-
lected family physicians in
rural Minnesota and Wis-
consin. Twenty-nine of the physicians, all board certi-
fied, returned the survey. Later, I traveled 2,500 miles to
conduct open-ended interviews with 18 of the respon-
dents. They were eager to tell their stories. What follows
are my observations and discoveries.

Driving across the rural heartland can be a depress-
ing experience. It seems that every fourth or fifth farm-
stead is abandoned and gradually sinking into the soil
upon which it once solidly stood. Rusted machinery,
boarded-up windows, barn roofs open to the sky, over-
grown groves, and chest-high Canadian thistles bear
silent witness to broken dreams. About one of every four
shops along the four-block main street of a typical town
is closed, boarded-up, and for sale. Where there used to
he three grocery stores or gasoline stations, there now is
one.

Northern forests hide the poverty so visibly concen-
trated in urban areas. Mobile homes no longer mobile
are scattered within the jack pine forests. In some coun-
ties, 70 to 80 percent of the land is controlled by the
government, and use of forests and minerals is often

restricted, limiting jobs and preventing families from
getting off welfare. Against a national average of 1 1
percent, 35 percent of the citizens of many rural com-
munities are more than 65 years old. Fifty to 60 percent

of a typical rural medical
practice may consist of
Medicare, Medicaid, and
Medical Assistance pa-
tients. Communities with-
out industry are often
precariously supported by
a three-legged stool —
school, clinic, hospital/
nursing home. The demise
of any one of the three can
be devastating.

Physician Profile

The rural physicians I
met are delightful and en-
gaging men and women.
They are egalitarian, not
patronizing. They eschew
medical mystification
and believe in educating
and empowering their
patients. They rarely in-
troduce themselves as
“doctor” or write M.D. after their names. They wear
ties, white coats, and other symbols of status only if
their patients prefer it that way. Limited specialty
back-up requires that they be able to perform a wide
range of procedures. The income of the rural physicians
I surveyed, from those just beginning practice to those
about to retire, averaged $90,000.

The physicians I talked with said they attended an
average of two medical conferences a year at tertiary
teaching centers. They listed 29 different medical period-
icals among their professional readings, with /AMA and
The New Englatid Journal of Medicine heading the list.
Some mentioned such specialty journals as Drug Thera-
py, Annals of Internal Medicine, and Clinical Ohstetri-
cian and Gynecologist. Non-medical reading included
authors such as Stephen jay Ciould, John Steinbeck,
Barbara Tuchman, Stephen Hawking, Robert Hughes,
Nikos Kazantzakis, and FTic Hanson.

Despite numerous frustrations, most physicians told
me they love their practices and lifestyles, which allow
them to enjoy nature, spend more time with their fami-

Minnesota Medicine

April 1992/Volume 75

HENNEPIN COUNTY
MEDICAL CENTER

HENNEPIN FACULTY ASSOCIATES
OFFICE OF ACADEMIC AFFAIRS

Spring CME Offerings

A ADVANCES IN GASTROENTEROLOGY
"New Developments for Primary Care"
May 1, 1992

Course topics include new developments in
Hepatitis C; an update on AIDS and the gut and
approaches to the Cl hemorrhage

A ACUPUNCTURE FOR PAIN CONTROL
May 14-16, 1992

An intensive study of acupuncture for physicians
involving history and basic concepts as well as
clinical training

A PRIMARY CARE TREATMENT FOR
PRESSURE SORES
May 21-22, 1992

A practical course in prevention and management
of the pressure sore for both nurses and physicians

A HCMC INTERN CLASS OF '61
MEDICAL REVIEW
June 13, 1992

Full program and topics to be announced

A CRISIS INTERVENTION PROGRAM
June 19, 1992

An examination of the many faces of suicide from
medical, philosophical, ethical and survivalist
perspectives

A ADVANCES IN CLINICAL

MANAGEMENT OF INFECTIOUS

DISEASES

July 16-19, 1992

An infectious disease update covering all

important developments related to the diagnosis

and treatment of bacterial, viral, fungal and

parasitic infections of importance to practicing

physicians

for additional information call
HCMC/HFA Office of Academic Affairs
701 Park Avenue, MC 867A
Minneapolis, Minnesota 55415-1829
phone 347-2075 facsimile 347-6155

OFFICE OF

ACADEMIC

AFFAIRS

YOCON*

YOHIMBINE HCI

Descriptiofl: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indoialkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its
action on peripheral blood vessels resembles that of reserpine, though it Is
weaker and of short duration. Yohimbine's peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity. It is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.

Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug . Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone

Indications: Yocon ^ is Indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac.

Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications

Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither Is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history. Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.T2 Also dizziness,
headache, skin flushing reported when used orally.' 3
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence, ’ ^ 1 tablet (5.4 mg) 3 times a day. to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness . In the event of side effects dosage to be reduced to 'k tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks. 3
How Applied: Oral tablets of Yocon* 1/12 gr. 5.4 mg in
bottles of 100's NDC 53159-001-01 and 1000's NDC
53159-001-10.

References:

1. A. Morales et al,, New England Journal of Medi-
cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis
of Therapeutics 6th ed., p. 176-188.

McMillan December Rev. 1/85,

3. Weekly Urological Clinical letter, 27:2, July 4.

1983.

4. A. Moralesetal., The Journal of Urology 128:

45-47, 1982.

Rev. 1/85

AVAILABLE AT PHARMACIES NATIONWIDE

PALISADES

PHARMACEUTICALS, INC.

219 County Road
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1-800-237-9083

April 1992 /Volume 75

AAinnesoto Medicine

PERSPECTIVES

lies, live in egalitarian communities with low crime rates
and little drug use, and perform a wide range of medical
procedures. One mining-town physician found his pa-
tients’ concern for his welfare particularly rewarding.
Another physician described “the privileged participa-
tion in my patients’ drama for life and dignity” as a
benefit of rural practice.

Naturally, physicians reported drawbacks of rural
practice as well, namely, incessant call demands, limited
cultural activities, social isolation, government and third-
party interference, and limited peer contact. Many also
complained that they are treated as second-class citizens
by their urban colleagues.

Rural Physician Opinions

The social contract

Rural physicians have two families — one biological, one
social. Practicing on one’s extended social family can be
psychologically destructive. The inviolate covenant link-
ing healer and community during medicine’s Golden Age
has become increasingly fragile. Before World War II, it
was inconceivable for a patient to sue the family physi-
cian. Today, it’s commonplace; three-fourths of the sur-
vey respondents said they had been sued by a patient.

“Without some armor, [litigious patients] will chew
you up and spit you out,” said one physician. In fact, the
wounds sometimes become so deep that physicians find
it hard to continue practicing. A number of physicians
indicated they had become increasingly withdrawn, de-
fensive, and guarded in their relationships with patients.

Medicare: a malevolent system?

Before the recent implementation of the resource-based
relative value scale (RBRVS) and Minnesota’s shift to a
single Medicare payment district, northern and southern
Minnesota were fourth and second, respectively, from
the bottom of 247 Medicare reimbursement localities
nationwide. Rural physicians said they support RBRVS
but feel its five-year phase-in will be too slow to prevent
physician exodus and the closure of many hospitals and
clinics.

Middle-aged physicians, especially, seem to feel
trapped. With their older colleagues retiring, some said
they wonder how long they can continue to maintain
their own practices under an increased patient load.

Medical education

With the exception of a few older physicians, the men
and women interviewed tended to report feeling some
animus toward medical education. Most felt “the sys-
tem” denigrates the L.M.D. (local medical doctor) and
discourages medical students from returning to their
communities. Respondents said residents are socialized
into believing rural docs are “hicks in the boonies”
practicing by “flashlights and candles.” A discouraging,
“Why would you want to go out there}'' might be an
attending physician’s response to someone interested in
rural practice. Those surveyed believe the system under-
mines students’ confidence and makes them passive and

fearful of caring for patients without subspecialty back-
up. Several said they believe members of the medical/
research/education establishment have lost their ability
to empathize with students and patients.

Older physicians said they are astonished at the “me-
ism” of residency graduates, most of whom they say
want $70,000 and benefits for 35 hours a week and one
night of call in four. The average search for a new
physician takes two years, costs $75,000, and may
necessitate a new car or a $10,000 bonus. Some physi-
cians said that too many demands by new physicians can
lead to animosity and slower integration into the group.

Possible Prescriptions for Rural Medicine

The future of rural health care delivery seems discourag-
ing, but it’s not bleak. While it may be unrealistic to
expect physicians to stay in counties where the popula-
tion and economic base are eroding, the following sug-
gestions might retard physician flight.

Emphasize the positive: In spite of frustration, rural
physicians are happy with their practices and lifestyles.
Few regret their decision to locate in a small town, and
they want to stay. They receive far more prestige within
their communities than their urban peers, and they find
the wider scope of practice appealing. Financial relief,
while not perfect, is here in the form of RBRVS.

Clearly, the medical establishment must find ways to
emphasize these positive aspects of rural practice. For
example, medical schools could make personal narra-
tives about both the joys and challenges of rural practice,
such as David Hilfiker’s “Healing the Wounds: A Physi-
cian Looks at His Work,” part of medical education.

Nurture future rural physicians: Today’s physicians
need to work with educators, businesses, farm organiza-
tions, and other groups to encourage students to consid-
er rural medicine as a career. Some physicians find ways
to support pre-med students in college, send them notes
of encouragement, and invite them to go on rounds.

Enhance student/practitioner contacts: Experience
shows that a weekend or month-long contact with rural
clinics is too short to overcome a physician’s possible
bias toward small towns. Working with a physician for
nine to 12 months after the sophomore year in medical
school often successfully counteracts this negative bias.
The University of Minnesota’s Rural Physician Associate
Program is nationally renowned in this regard and
returns about 57 percent of its participants to rural
practice. The University of Minnesota-Duluth School of
Medicine is also successful, with 60 percent of its grad-
uates practicing in non-metropolitan areas — 40 percent
of those in towns of 20,000 or less. Such programs
deserve widespread support.

Regionalize: Rural practitioners will survive only
through financial and administrative cooperative ar-
rangements with regional clinics and hospitals (see also
“Rural Health Care Delivery: Survival May Require an
Integrated Model,” page 43). This can provide relief
from the major burden of rural practice — unremitting
pressure from evening and weekend call — and stabilize
income levels. The price of such security may mean

Minnesota Medicine

April 1992/Volume 75

PERSPECTIVES

increased bureaucracy, but a shift to larger administra-
tive units is the trend in most organizations today.

Challenge the subspecialty dominance in medical
education: Rural physicians believe medical schools are
poorly serving the areas where they practice. They ask
that public institutions serve public needs — that there be
greater equity between primary physicians and proce-
duralists. The doctors interviewed tend to believe med-
ical schools are elitist, isolated, and overly concerned
about issues that enhance their own status. Medical
educators should address these problems.

The Few — The Proud

No geographical site meets all the criteria for the idyllic
life, whether personal or professional. Because of
troublesome economics and demographics, rural medi-
cine faces a problematic future. Nevertheless, just as
the elite United States Marine Corps has always appealed
to “the few — the proud,” the challenge of bringing
healing to an isolated community will continue to attract
many of noble character. Although these doctors should
know that authentic motivation must come from with-
in themselves, the evidence is clear that their rewards —
personal, familial, and professional — are a kind not
shared by their urban colleagues. MM

Walter Benjamin is a professor of ethics at Hamline
University m St. Paul, Minnesota. He specializes in
biomedical and business ethics and is a member of Park
Nicollet Medical Center's Medical Ethics Committee.

Quality

Medical

Transcription

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April 1992/Volume 75

Minnesota Medicine

The ACCUPRIL
Single-Agent Commitment

Parke-Davis is confident that for many of your hypertensive
patients ACCUPRIL will achieve the decrease in blood pressure
you expect.

If, in your medical judgment, your patient requires a diuretic in
addition to ACCUPRIL at any time during ACCUPRIL therapy,
Parke-Davis will refund your patient’s cost of the diuretic.

ONCE-A-DAY^

® TM

quinapril HCI tablets 10, 20, 40 mg

I * See DOSAGE AND ADMINISTRATION section of prescribing information.

I If. after an adequate trial of ACCUPRIL alone. ba.sed on your medical judgment as tbe prescribing physician, you determine that your patient requires the addition of a diuretic.

) Parke-Davis will refund to the patient his/her cost for the diuretic prescription less any amount reimbursed or paid for by an HMO. insurance company, or any other plan or program.

; For more details, ask your Parke-Davis Representative or call l-8(X)-955-.^077.

t' In some patients, the antihypertensive effect may diminish toward the end of the once-daily dosing interval. In such patients, an increa.se in dosage or twice-daily administration may
be warranted.

I ACCUPRIL is available in 10. 20. and 40 mg tablets. Usual initial starting dosage is 10 mg once daily.

■ ACCUPRIL is contraindicated in patients who are hypersensitive to this product and in patients with a history of angioedema related to previous treatment with an ACE inhibitor.
^ Plea.se see brief summary of prescribing information on following page.

PARKE-DAVIS

ACCUpriliS (Quinapril Hydrochloride Tablets)

Accupril® (Quirrapril Hydrochloride Tablets)

Before prescribing, please see full prescribing information. A bnef summary follows.

INDICATIONS AND USAGE

ACCUPRIL IS indicated lor the treatment of hypertension. It may be used alone or In combination with thiazide diuretics.

In using ACCUPRIL. consideration should be given to the tact that another angiotensin-converting enzyme (ACE) inhibitor, cap-
topni. has caused agranulocytosis, particularly in patients with renal impairment or collagen vascular disease. Available data
are insufficient to show that ACCUPRIL does not have a similar risk (see WARNINGS).

CONTRAINDICATIONS

ACCUPRIL is contraindicated in patients who are hypersensitive to this product and in patients with a history of angioedema
related to previous treatment with an ACE inhibitor.

WARNINGS

Neutropenia: Patients should be told to report promptly any indication of Infection (eg. sore throat, fever) which could be a
sign of neutropenia.

NOTE; As with many other drugs, certain advice to patients being treated with ACCUPRIL is warranted. This information is
intended to aid in the safe and effective use of this medication. It is not a disclosure of all possible adverse or intended effects.

Drug Interactions

Angioedema: Angioedema of the face, extremities, lips, tongue, glottis, and larynx has been reported in patients treated with
ACE inhibitors and has been seen in 0.1% of patients receiving ACCUPRIL. Angioedema associated with laryngeal edema can
be fatal. If laryngeal stridor or angioedema of the face, fongue. or glottis occurs, treatment with ACCUPRIL should be discon-
tinued immeiliately. the patient treated in accordance with accepted medical care, and carefully observed until the swelling
disappears. In instances where swelling is confined lo the face and lips, the condition generally resolves without treatment:
antihistamines may be useful in relieving symptoms.

Where there is involvement of the tongue, glottis, or larynx likely to cause airway obstruction, emergency therapy including,
but not limited to. subcutaneous epinephrine solution t:t000 (D.3 to 0.5 mL) should be promptly administered (see ADVERSE
REACTIONS).

Concomitant diuretic therapy; As with other ACE inhibitors, patients on diuretics, especially those on recently instituted
diuretic therapy, may occasionally experience an excessive reduction of blood pressure after initiation of therapy with
ACCUPRIL. The possibility of hypotensive effects with ACCUPRIL may be minimized by either discontinuing the diuretic or
cautiously increasing salt intake prior to initiation of treatment with ACCUPRIL. If it is not possible to discontinue the diuretic,
the starting dose of quinapril should be reduced (see DOSAGE AND ADMINISTRATION).

Agents Increasing serum potassium: Quinapril can attenuate potassium loss caused by thiazide diuretics and increase serum
potassium when used alone. If concomitant therapy of ACCUPRIL with potassium-sparing diuretics (eg. spironolactone,
triamterene, or amiloride). potassium supplements, or potassium-containing salt substitutes is indicated, they should be used
with caution along with appropriate monitoring of serum potassium (see PRECAUTIONS)

Hypotension: ^mptomatic hypotension was rarely seen in uncomplicated hypertensive patients treated with ACCUPRIL but.
s with other ACE inhibitors. It is a possibi

Tetracycline and other drugs that Interact with magnesium: Simultaneous administration of tetracycline with ACCUPRIL
reduced the absorption of tetrar^ycline by approximately 28% to 37% . possibly due to the high magnesium content in
ACCUPRIL tablets. This interaction should be considered if coprescribing ACCUPRIL and tetracycline or other drugs that
interact with magnesium.

as with other ACE inhibitors, it Is a possible consequence of therapy in salt/volume depleted patients, such as those previously
treated with diuretics or dietary salt restriction or who are on dialysis (see PRECAUTIONS. DRUG INTERACTIONS, and
ADVERSE REACTIONS). In controlled studies, syncope was observed in 0.4% of patients (N = 3203): this incidence was
similar to that observed for captopril (1%) and enalapril (0.6%).

In patients with concomitant congestive heart failure, with or without associated renal insufficiency. ACE inhibitor therapy may
cause excessive hypotension, which may be associated with oliguria or azotemia and. rarely, with acute renal failure and death.
In such patients. ACCUPRIL therapy should be started at the recommended dose under close medical supervision. These

Lithium: Increased serum lithium levels and sj
tani lithium and ACE inhibitor therapy. These

_ concomi-
frequent monitoring of serum

patients should be followed closely for the first 2 weeks of treatment and whenever the dosage of antihypertensive medication
- '■■''■ADMINISTRATION).

IS increased (see DOSAGE AND
If symptomatic hypotension occurs, the patient should be placed in the supine position and. if necessary, normal saline may
be administered intravenously. A transient hypotensive response is not a contraindication to further doses: however, lower
doses of ACCUPRIL or reduced concomitant diuretic therapy should be considered

symptoms of lithium toxicity have been reported in patients receiving
rfrugs should be co-administered with caution, and frequent monitorii
lithium levels is recommended. If a diuretic is also used, it may increase the risk of lithium toxicity

Other agents: Drug interaction studies of ACCUPRIL with other agents showed:

• Multiple dose therapy with propranolol or cimetidine has no effect on the pharmacokinetics of single doses of ACCUPRIL,

• The anticoagulant effect of a single dose of warfarin (measured by prothrombin time) was not significantly changed by
quinapril coadministration twice-daily.

• ACCUPRIL treatment did not affect the pharmacokinetics of digoxin.

■ No pharmacokinetic interaction was observed when single doses of ACCUPRIL and hydrochlorothiazide were administered
concomitantly.

Neutropenia/Agranulocytosis: Another ACE inhibitor, captopril. has been shown lo cause agranulocytosis and bone marrow
depression rarely in patients with

depression rarely in patients with uncomplicated hypertension, but more frequently in patients with renal impairment, espe-
cially if they also have a collagen vascular disease such as systemic lupus erythematosus or scleroderma. Agranulocytosis did
occur during ACCUPRIL treatment in one patient with a history of neutropenia during previous captopril therapy. Available data
from clinical trials of ACCUPRIL are insufficient to show that, in patients without prior reactions to other ACE inhibitors.
ACCUPRIL does not cause agranulocytosis at similar rates. As with other ACE inhibitors, periodic monitoring of white blood
cell counts in patients with collagen vascular disease and/or renal disease should be considered.

Fetal/Neonatal morhidity and mortality: ACE inhibitors, including ACCUPRIL. can cause fetal and neonatal morbidity and
mortality when administered to pregnant women.

When ACE inhibitors have been used during the second and third
trimesters of pregnancy there have been reports of hypotension,
renal failure, skull hypoplasia, and death. Oligohydramnios has

also been reported, presumably resulting from decreased fetal
renal function: oligohydramnios has been associated with fetal
limb contractures, craniofacial deformities, hypoplastic lung
development, and intrauterine growth retardation.

Prematurity and patent ductus arteriosus have been reported,
although it is not clear whether these occurrences were due to
the ACE-inhibitor exposure or to the mother's underlying dis-
ease. It is not known whether exposure limited to the first
trimester can adversely affect fetal outcome.

ONCE-A-DAY

ACCUPRIL

quinapril HCI tablets

A patient who becomes pregnant while taking ACE inhibitors, or who takes ACE Inhibitors when already pregnant, should be
:ial hazard to her fetus. If she continues to receive ACE inhibitors during the second or third trimester of

apprised of the potential

pregnancy, frequent ultrasound examinations should be performed to look for oligohydramnios. When oligohydramnios is
lound. ACE inhibitors should generally be discontinued

Infants with histories of in utero exposure lo ACE inhibitors should be closely observed for hypotension, oliguria, and hyper-

d support of bloo '

kalemia. If oliguria occurs, attention should be directed toward support of blood pressure and renal perfusion. Hemodialysis
and peritoneal dialysis have little effect on the elimination of quinapril and quinaprilat.

No fetotoxic or teratogenic effects were observed In rats at quinapril doses as high as 300 mg/kg/day (180 and 30 times the
maximum daily human dose when based on mg/kg and mg/m', respectively), despite maternal toxicity at 150 mg/kg/day
Tested later in gestation and during lactation, reduced offspring body weight was seen at >25 mg/kg/day and changes in
renal histology (juxtaglomerular cell hypertrophy, tubular/pelvic dilation, glomerulosclerosis) were observed both in dams and
offspring treated with 150 mg/kg/day. Quinapril was not teratogenic in the rabbit: however, as noted with other ACE inhibitors,
maternal toxicity and embryotoxicity were seen in some rabbits at quinapril doses as low as 0.5 mg/kg/day (one time the
recommended human dose) and t .0 mg/kg/day, respectively.

PRECAUTIONS

General

Impaired renal function: As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function
mi^ be anticipated in susceptible individuals. In patients with severe heart failure whose renal function may depend on the
activity of the renin-angiotensin-aldosterone system, treatment with ACE inhibitors, including ACCUPRIL, may be associated
with oliguria and/or progressive azotemia and rarely acute renal failure and/or death.

In clinical studies in hypertensive patients with unilateral or bilateral renal artery stenosis, increases in blood urea nitrogen and

Carcinogenesis, Mutagenesis. Impairment of Fertility

Quinapril hydrochloride was not carcinogenic in mice or rats when given in doses up to 75 or 100 mg/kg/day (50 to 60 times
the maximum human daily dose, respectively, on a mg/kg basis and 3.8 to tO times the maximum human daily dose when
based on a mg/m’ basis) for 104 weeks. Female rats given the highest dose level had an increased incidence of mesenteric
lymph node hemangiomas and skin/subcutaneous lipomas. Neither quinapril nor quinaprilat were mutagenic in the Ames bac-
terial assay with or without metabolic activation. Quinapril was also negative in the following genetic toxicology studies: in
vitro mammalian cell point mutation, sister chromatid exchange in cultured mammalian cells, micronucleus test with mice, in
vitro chromosome aberration with V79 cultured lung cells, and in an in vivo cytogenetic study with rat bone marrow. There
were no adverse effects on fertility or reproduction in rats at doses up to 100 mg/kg/day (60 and 10 times the maximum daily
human dose when based on mg/kg and mg/m', respectively)

Pregnancy

Pregnancy Category D: See WARNINGS. Fetal/Neonalal
morbidity and mortality.

Nursing Mothers

It is not known if quinapril or its metabolites are secreted in
human milk. Quinapril is secreted to a limited extent, however, in
milk of lactating rats (5% or less of the plasma drug concentra-
tion was found in rat milk). Because many drugs are secreted in
human milk, caution should be exercised when ACCUPRIL is
given to a nursing mother.

Geriatric Use

Elderly patients exhibited increased area under the plasma con-
centration time curve (AUC) and peak levels for quinaprilat compared to values observed in younger patients: this appeared to
relate to decreased renal function rather than to age itself. In controlled and uncontrolled studies of ACCUPRIL where 918
(21%) patients were 65 years and older, no overal differences in effectiveness or safety were observeil between older and
younger patients. However, greater sensitivity of some older individual patients cannot be ruled out.

Pediatric Use

The safety and effectiveness of ACCUPRIL in children have not been established,

ADVERSE REACTIONS

ACCUPRIL has been evaluated for safety in 4960 subjects and patients. Of these. 3203 patients, including 655 elderly patients, i
participated in controlled clinical trials. ACCUPRIL has been evaluated for long-term safety in over 1400 patients treated for
1 year or more.

Adverse experiences were usually mild and transient.

Discontinuation of therapy because of adverse events was required in 4.7% of patients treated with ACCUPRIL in placebo-
controlled hypertension trials.

Adverse experiences probably or possibly related to therapy or of unknown relationship to therapy occurring in 1% or more of
the 1563 patients in placebo-controlled hypertension trials who were treated with ACCUPRIL are shown below.

Adverse Events in Placebo-Controlled Trials

serum creatinine have been observed in some patients following ACE inhibitor therapy. These increases were almost always
reversible upon discontinuation of the ACE Inhibitor and/or diuretic therapy. In such patii

patients, renal function should be mon-
itored during the first few weeks of therapy.

Some hypertensive patients with no apparent preexisting renal vascular disease have developed increases in blood urea and
serum creatinine, usually minor and transient, especially when ACCUPRIL has been given concomitantly with a diuretic. This
is more likely to occur in patients with preexisting renal impairment. Dosage reduction and/or discontinuation of any diuretic
and/or ACCUPRIL may be required

Evaluation of h

ACCUPRIL
(N = 1563)

Incidence

(Discontinuance)

Placebo ,|

(N = 579) l|

Incidence 1

(Discontinuance) |

Headache

5.6 (0.7)

10.9 (0,7)

Dizziness

3.9 0.8

2.6 (0.2)

Fatigue

2.6 0.3

1.0

Coughing

2.0 0.5

0,0

Nausea/Vomiting

1.4 0.3

1.9 (0.2)

Abdominal Pain

1.0 (0.2)

0,7

if hyportonsivo patlonts should always include assessment of renal function (see DQSAGE AND
ADMINISTRATION)

Clinical adverse experiences probably or possibly related, or of uncertain relationship to therapy, occurring in 0.5% to t .0%
ACCUPRIL (with 0

Hyperkalemia and potassium-sparing diuretics: In clinical trials, hyperkalemia (serum potassium >5.6 mmol/L) occurred in
approximately 2% o( patients receiving ACCUPRIL, In most cases, elevated serum potassium levels were isolated values which
resolved despite continued therapy. Less than 0.1% of patients discontinued therapy due to hyperkalemia. Risk factors for the
development of hyperkalemia include renal insufficiency, diabetes mellitus. and the concomitant use of potassium-sparing
diuretics, potassium supplements, and/or potassium-containing salt substitutes, which should be used cautiously, if at all.
with ACCUPRIL (see PRECAUTIONS, Drug Interactions).

Surgery/anesthesia: In patients undergoing major surgery or during anesthesia with agents that produce hypotension,
ACCUPRIL will block angiotensin II formation secondary to compensatory renin release. If hypotension occurs and is consid-
ered to be due to this mechanism, it can be corrected by volume expansion.

Information tor Patients

Angioedema: Angioedema. including laryngeal edema, can occur with treatment with ACE inhibitors, especially following the
lust dose. Patients should be so advised and told to report immediately any signs or symptoms suggesting angioedema
(swelling of face, extremities, eyes. lips, tonpe. difficulty in swallowing or breathing) and to stop taking the drug until they
have consulted with their physician (see WARNINGS).

(except as noted) of the patients treated with ACCUPRIL (with or without concomitant diuretic) in controlled or uncontrolled
trials (N = 4397) and less frequent, clinically significant events seen in clinical trials or post-marketing experience (the rarer
events are in italics) include (listed by body system);

General: back pain, malaise

Cardiovascular: palpitation, vasodilation, tachycardia, heart tailure, hyperkalemia, myocardial inlarction, cerebrovascular
accident, hypertensive crisis, angina pectoris, orthostatic hypotension, cardiac rhythm disturbances
Gastrointestinal: dry mouth or throat, constipation, gastrointestinal hemorrhage, pancreatitis, abnormal liver function tests
Nervous/Psychiatric: somnolence, vertigo, syncope, nervousness, depression
Integumentary: increased sweating, pruritus, exloiialive dermatihs, photosensitivity reaction
Urogenital: acute renal tailure

Other: amblyopia, pharyngitis, sinusitis, bronchitis, agranulocytosis, thrombocytopenia

Angioedema: angioedema has been reported in patients receiving ACCUPRIL (0. 1%). Angioedema associated with laryngeal a

' id/o '

edema may be fatal. If angioedema of the face, extremities, lips, tongue, glottis, and/or larynx occurs, treatment with ACCU-

' lid

Symptomatic hypotension: Patients should be cautioned that lightheadedness can occur, especially during the first few days
of ACCUPRIL therapy, and that it should be reported to a physician. If actual syncope occurs, patients should be told to not tak!
the drug until they nave consulteil with their physician (see WARNINGS).

bnottake

the drug until they have consulted with their physician (seetAIARNINGS).

All patients should be cautioned that inadequate fluid intake or excessive perspiration, diarrhea, or vomiting can lead to an
excessive fall In blood pressure because of reduction in fluid volume, with the same consequences ol lightheadedness and
possible syncope.

Patients planning to undergo any surgery and/or anesthesia should be told to inform their physician that they are taking an
ACE inhibitor.

Hyperkalemia: Patients should be told not to use potassium supplements or salt substitutes containing potassium without
consulting their physician (see PRECAUTIONS).

PRIL should be discontinued and appropriate therapy instituted immediately (See WARNINGS.)

Clinical Lahoratory Test Findings
Hematology; (See WARNINGS)

Hyperkalemia: (See PRECAUTIONS)

Creatinine and blood urea nitrogen: Increases (>t. 25 times the upper limit of normal) in serum creatinine and blood urea
nitrogen were observed in 2% and 2%, respectively, of patients treated with ACCUPRIL alone. Increases are more likely to
occur in patients receiving concomitant diuretic therapy than in those on ACCUPRIL alone. These increases often remit on
continued therapy.

♦ In some patients, tlie antihypertensive effect may diminish toward the
end of the once-daily dosing interval. In such patients, an increase in
dosage or twice-daily administration may be warranted.

PARKE-DAVIS

Division of Warner-Lambert Company
Morris Plains, New Jersey 07950

PD-I03-JA-7164-A2(022)i

1 “I have never gotten used to people dying. And I don’t
iwant to get used to it.”

. Dr. Aliza Lifshitz, Internist, Los Angeles, California, Member, American Medical Association

Patients come to physicians for many reasons,
f Beyond relief from pain, they seek compassion,

I empathy and support. AIDS patients receive all of
e these and more from Dr. Aliza Lifshitz.

Bom and raised in Mexico and educated at one of
1 Mexico City’s finest medical schools, Dr. Lifshitz now
»! serves the Hispanic community in Southern California.
pOver a third of her patients have tested HIV positive,
i Most live below the poverty level. Many are illegal aliens.

“I never forget what it means to be a doctor, and
V'what it means is embodied in the Principles of Medical

Ethics of the American Medical Association (AMA),”
states Dr. Lifshitz.

You are invited to join Dr. Lifshitz and to join with
her in her efforts to bring quality health care to those
in need. Become a member of the American Medical
Association today.

Members of the AMA are encouraged to join their state, county and specialty societies.

American Medical Association

Physicians dedicated to the health of America

COVER STORY

TV Doctor, Michael Breen

By Ralph C. Heussner, Jr.

Photos by Rob Levine

Michael Breen, M.D., has the largest practice in the state of Minnesota, but he actually
sees only a few patients each week — and he has no clinic of his own! Although licensed
in Minnesota as a general practitioner, he specializes in preventive medicine. He is
disillusioned by a health care system that he claims is motivated by profit, yet he interacts daily
with leaders of the medical establishment.

Some doctors grimace when they hear his voice; others welcome his phone calls.

Despite the contradictions. Dr. Michael Breen is probably one of the most influential
physicians in Minnesota. He decides what the public knows about the latest medical
developments.

In case you don’t recognize his name, you certainly know him by his moniker, “TV doctor.”

April 1992/Volunne 75

Minnesota Medicine

COVER

STORY

It’s 9:30 a.m., and Dr.
Breen has just left a
brief meeting of news
editors and reporters at
WCCO-TV. He’s obvi-
ously excited because a
story he pitched has been
selected for the 10 p.m.
news — the most watched
TV newscast in the Twin
Cities market. The story is
about condoms for wom-
en, and Breen believes he
will be the first and only
reporter with the story.
It’s certainly going to raise
the eyebrows of some
viewers, and probably bolster the ratings.

Breen has already arranged to interview several
women at the Meadowbrook Clinic in the early after-
noon, so he will spend the morning developing future
stories, reading medical journals, checking the mail — as
many as 30 to 50 letters and news releases a day — and
responding to dozens of phone calls.

“I’m on every health and medical mailing list in the
world — the American Red Cross, Arthritis Association,
Sjogren’s Syndrome Foundation. You name it. Everyone
wants publicity,” he says.

Since 1979, Breen has followed the daily schedule
of a full-time reporter — first at Channel 1 1, then Chan-
nel 5, and, most recently, at Channel 4. He has turned
down job offers in Philadelphia and New York. He is
one of an estimated 250 physicians nationwide who
appear on radio or
television, at least on
a part-time basis. And
that number seems to
be growing.

“Medical journal-
ists with an M.D. are
hot commodities,”

Breen acknowledges.

“But I’ve chosen to
stay in the Twin Cities
largely due to person-
al reasons, as well as
professional ones. It’s
not uncommon for
someone who is pop-
ular in one market to
go to another city and
literally become a
laughing stock.”

Breen, 39, and his
wife, Kimberly, a
former television re-
porter in Atlanta, have
made roots in the
Twin Cities. They
have a 1 -year-old son.

Michael Jr., and a second child on the way. Breen has
another son, Matthew, age 7, from a previous marriage.

In the Beginning: The Disillusionment

Like most young physicians, Breen was an idealist when
he entered medicine. He received his M.D. from Albert
Einstein College of Medicine in New York in 1977 and
went on to Duke University for an internship in internal
medicine.

“I became a physician because I thought medicine
was magic,” he says. “I believed that if a patient was
sick and wanted to get better, all you had to do was
perform a few tests, prescribe the pills, and the patient
shook your hand and went on to live a wonderful life.
That was my image of medicine. But then, when I was an
intern at Duke working with a VA population, I found
that two-thirds of my patients had self-induced disease
created by alcohol, cigarettes, or obesity. I also found
that many patients were unwilling to take responsibility
for their own health. They were more interested in being
handed some kind of magic bullet. I found this very
disillusioning.

“I was also disillusioned by another aspect of medi-
cine. In my mind, the medical system was purposely not
treating people until they became ill, because that’s
where the money is. There’s no money in prevention; all
the money is waiting for somebody to develop heart
disease and then jneed] the bypass.”

There was a third element to the disillusionment of
young Dr. Breen. It had to do with the attitudes of some
physicians toward their patients. He said: “Many doc-
tors purposely maintain a mystique that medicine is

Michael Breen had his face made ttp before a live appearance on
WCCO-TV’s 10 p.m. newscast.

Minnesota Medicine

April 1992/Volume 75

COVER STORY

Breen ansivers questions from anchor Don Shelby during a live broadcast
of the 10 pan. news.

beyond the capacity of patients to understand. They act
like members of an ancient guild where people protect
their store of knowledge.”

So Breen took a leave of absence from the Duke
residency program to pursue a graduate degree at
the Columbia School of Journalism. His father a novelist
and playwright and his mother a widely published mag-
azine writer, Breen initially put his sights on medical
writing. But an academic adviser, who was also a CBS-
TV producer, encouraged him to consider television
because of the potential to reach a larger audience. The
adviser, unbeknownst to Breen, had given his name to a
“head-hunter” for Metro-Media, which owned tele-
vision stations around the country, including Channel
1 1 in Minneapolis.

“The headhunter called me and said he heard that I
was a good writer but wanted to know how I looked in
front of the camera. I told him, ‘My friends tell me I’m
terrific on camera,’ although I had never been in front of
a TV camera in my life,” Breen recalls.

That evening, Breen went to the local NBC affiliate
to tape a five-minute video that would decide his future.
He was asked to read a weather report! Only a few
months shy of completing his journalism degree, Breen
accepted a job with Channel 1 1 in the Twin Cities. His
starting salary was approximately one-third of that of a
young physician; today he says he earns nearly as much
as he could in clinical practice.

Gaining Acceptance, Building Trust

Despite his medical background, Breen does not have an
automatic entree to physicians as news sources. “I some-
times have to convince the physician that I’m not trying
to deceive him and talk about a malpractice case from 1 0

years ago,” he says. “Physicians who
don’t know me worry about the skel-
eton in the closet, worry about look-
ing stupid on the air, or worry about
whether they can trust me.”

Many physicians who meet Breen
for the first time question his creden-
tials as an M.D. “I run into that
problem a lot,” he says. “Very often,
I have to prove that I’m a physician.
They look at me and say, ‘Is he a real
doctor.^ How smart is he? He’s in
television.’ ”

Breen builds a bridge of confi-
dence by using the knowledge he
gained in medical school.

“If I’m interviewing a kidney ex-
pert, I’ll start talking about glomeru-
lonephritis while the camera is setting
up. I’ll be paying my dues by using the
big terms and showing [the physician]
that I understand a lot more about
kidney disease than he or she thought,”
Breen says.

But when the camera starts roll-
ing, and the physician is conversing doctor-to-doctor in
technical language, Breen faces another obstacle. Al-
though the physician now feels comfortable in the inter-
view, the technical language is unusable on the air. Breen
must now encourage the doctor to talk to the camera as
though she’s talking to patients.

“If I were a naive reporter, the physician might be a
little more elementary, talking layman’s language, and it
would be easier to get a sound bite,” Breen says.

“I became a physician because I
thought medicine was magic. But
I found that many patients were
unwilling to take responsibility
for their own health.”

Some physicians are reluctant to grant Breen an
interview simply because he is a doctor. “They don’t
have the same superiority that they are used to in the
normal patient-physician relationship,” Breen surmises.
“Therefore, some physicians are more likely to be a little
tense. And what do physicians do when they’re tense and
uncomfortable? They resort to jargon, and all I end up
with is a lot of jargon on camera.”

The first 10 minutes of the interview are crucial to
the success of the story. “On one hand, I have to show
them that I can discuss medical issues on their level, but
on the other hand, I have to not threaten them,” he says.

April 1992/Volume 75

Minnesota Medicine

COVER

STORY

“And, of course, I have to make sure that when the
camera starts rolling, they are talking to a layman.”

Hot Buttons:

Patient Privacy, News Embargoes

The two subjects most likely to strike a sensitive chord
with medical reporters are patient privacy and news
embargoes. Breen is no exception.

“Patient privacy is a legitimate concern,” he agrees,
“but my consistent experience has been it is most often
used by hospital public relations as a smoke screen to
control the story. They tell you, ‘Don’t be aggressive in
trying to contact the patient or interfering, because the
patient wants privacy.’ It’s a matter of turf fighting and
an attempt by hospitals to set the agenda so nobody gets

a break. If I’m the first at John Thompson |the North
Dakota teenager who recently underwent surgical re-
attachment of both arms after a farm accident |... then
the hospital has alienated some other media. So they try
to discourage you by saying this patient really wants
privacy. And it can occur in the most egregious circum-
stances. In some cases, I will have a patient calling me
upset with hospital treatment and then PR will say, ‘No,
you can’t interview that patient because you are violating
their privacy.’ Patients almost invariably are willing to
share their story, and many find it therapeutic to share
their story.”

Breen acknowledges a self-interest in his desire to
gain access to patients. Without patients, a story will not
sell. Breen explains: “Let’s say I do a story about the risk
factors for heart disease. I can get in front of a camera and

More TV Health Talk

Paul G. Quie, M.D., is probably
one of the most unlikely physi-
cians to be talking about medicine
on television. By his own admission, he
rarely watches the tube, and when he
does, it’s usually an athletic event.

But when the University of Minne-
sota went looking for a host for “Health
Talk and You” back in 1987, there
really was no question that Quie, pro-
fessor of pediatrics with a specialty in
infectious diseases, was the man for
the job.

“We wanted a person who had credibility with
both the medical staff and the community, and a
person whose name has immediate recognition among
the doctors,” says Sally Howard, head of the Univer-
sity’s Health Sciences Public Relations Office, who
helped organize the program. “We knew that Dr.
Quie would be perfect for the job.”

Since its debut in February 1988 on KTCI-TV in
Minneapolis, the weekly half-hour program has
aired 140 segments live, discussing topics ranging
from arthritis to atherosclerosis, from glaucoma to
gout.

“The purpose of the program is basically to
educate the public. We are providing a service by
giving them accurate information from some of the
leading specialists in a particular disease,” says Quie.

The show consists of Quie and three guests
drawn from the university faculty and community
physicians. After a brief introduction of the subject
by Quie, the phone lines are opened to viewers. And
the phones never stop ringing!

In contrast to commercial television, the format

is bland — no video clips of surgery or
modern medical technology in opera-
tion and no testimonials from patients.
Nonetheless, the show appears to be
hitting its mark. An average of 120 view-
ers call after each show requesting a
brochure with details about the disease
in question, and from 30 to 60 persons
call every Tuesday night with questions.
The station estimates the show has 7,000
to 10,000 viewers.

“I like to think that our program
allows enough time so we can thorough-
ly discuss an issue — from diagnosis to treatment
and, of course, prevention,” Quie says. “But some
subjects are so complicated that we need two shows
to really examine them in detail. We recently took
two weeks for arthritis.”

Although Quie is reluctant to criticize commer-
cial TV’s coverage of medical topics, he did observe
that the prime-time news often raises viewers’ expec-
tations whenever it airs a story about new treat-
ments, thus creating false hopes. He also emphasizes
that a medical news program can’t replace a trip to
the doctor.

“I know from our questions that people are often
looking for a second opinion or more information
about their particular treatment. What we try and do
is encourage the caller to see a physician,” Quie says.

Funding for “Health Talk and You” is provided
by the University of Minnesota Hospital & Clinic,
the Medical School, and Minnesota Medical Foun-
dation. Quie, the guest physicians, and health sci-
ence students, who answer the phones, all volunteer
their time.

Minnesota Medicine

April 1992/Volume 75

COVER

STORY

After a 2 p.m. interview, Breen went home to rest and
spend time with his family. He was hack before the
1 0 p.m. newscast so he could review the editing of
his tapes.

say ‘watch your cholesterol, watch for high blood pres-
sure, don’t smoke, and exercise regularly.’ If I do that,
everybody will turn the channel. Who cares.^ But if I
present you with a 35-year-old man with two young
children who’s now waiting for a heart transplant, and
he admits that he ignored his lifestyle his whole life and
now wishes that he could do it all again — because he’s
worried he won’t be a father for his children — everybody
watching is going to go, ‘Oh, my goodness.’ Then, you
sneak in the message: here are the lifestyle factors you
need to control.”

Breen views news embargoes as another example of
institutions trying to exercise control over the news
media. The New England Journal of Medicine and the
Journal of the American Medical Association both im-
pose arbitrary news release dates with their weekly
publications. A reporter who violates the embargo runs
the risk of having his journal subscription canceled.

“The argument that physicians should have time to
assimilate information before it is presented to the press
is a red herring,” Breen contends. “Like so many issues,
it gets back to control. The journal wants to control
when information is released. But I believe that if the
information is out there, it should be presented and
nobody should be sitting on it. We will, in some cases,
break embargoes if we feel they are arbitrary and there’s
no public service gained by keeping an embargo.”

Breen argues that the slowness of the editorial
process does more harm to patients than news
organizations do when they break embargoes, and he
points to the delays in publishing results of studies
of new AIDS treatments and a recent treatment for spinal
cord injuries. “Information that could have prevented
paralysis in thousands of cases was delayed in the

editorial process,” he says.

There is a professional reason that reporters dislike
embargoes; it means all media will have the story at the
same time. “I admit that I like to be first with the story,”
Breen says. “But an embargo ensures I will do the story
the same time everyone else does. So who is going to
remember Dr. Michael Breen if I do the same story that
Channel 5 and Channel 1 1 do on the same day?”

Handling Criticism

Television medical news is most frequently criticized for
simplifying and, in the process, distorting, complex
medical information.

“The fundamental question is do you do more harm
than good by taking a complex medical topic and de-
scribing it in 90 seconds? There are good and bad aspects
to what I do,” says Breen. “We will oversimplify and we
will miss the nuances. On the other hand, I view my job
as one of raising questions, and not providing definitive
answers. I also ask myself, do people know more after my
two-minute story? They usually do because they have
learned two or three facts that extend their knowledge of
kidney disease, heart disease, migraines, or whatever. I
think the bottom line is people are better off with
information. But we do miss shades of gray, and we do
oversimplify.”

Another criticism of TV news is that it is entertain-
ment in disguise.

“I’ll make no bones about that,” Breen agrees. “Peo-
ple don’t watch to be educated; they watch TV news for
the same value they get in prime time. They want to
connect with other people. They want to feel emotion.
And the only way I can deliver my medical message and
educate people is if I play that game. I have to hook you
with someone’s personal medical story, then I have to
slide the medical message in through the back door.

“People don’t watch
to be educated; they
watch TV news for the same
value they get in
prime time. They want
to feel emotion.”

because I would be off the air in two weeks if I simply sat
in front of the camera and lectured: ‘This is what you
need to know about glaucoma, cancer, heart disease.’ ”
Breen pauses to reflect: “I admit that I once was
working under the delusion that people would watch
medical news to save their lives. They don’t. They watch
medical news for the same reason they watch everything
else — to feel something.”

April 1992/Volume 75

Minnesota Medicine

COVER

STORY

Covering AIDS

Covering the AIDS epidemic has been the most challeng-
ing story of Breen’s journalistic career. And the particu-
lar story that caused him the most agony was the
revelation last summer that a Minnesota physician with
AIDS was continuing to practice despite open sores on
his arms.

Breen defends WCCO-TV’s coverage of the contro-
versy. Although he was not on the air during the past year
because of a contract stipulation at his previous employ-
er, KSTP-TV, he directed the Channel 4 news team and
wrote most of the stories about Dr. Philip Benson. Breen
contends that WCCO-TV was the first to know about
the case but delayed airing the story until confirming all
the facts. A competing station broke the story “with less
than 1 0 percent of the information that we had, and a lot
of theirs was inaccurate,” Breen says. “Yet we were
criticized for going with the story when we actually sat
on it for several days, scurrying like crazy, following false
leads that the Department of Health gave us to keep us
out of their hair. We finally put it on the air and did our
best to be balanced.”

But objectivity and balance are sometimes difficult to
attain. The Benson case illustrates the difficulty of telling
emotion-packed and controversial medical stories on
television.

On a news team, everyone must pitch in. Breen carries
the tripod on the way to an interview.

“Television is an emotional medium,” Breen says.
“You can deliver all the facts, but if one side has emotion
and the other side does not, you are presenting a biased
report. There were a lot of experts saying your odds |of
getting AIDS from a physician] are minuscule, but they
had very little chance against Kimberly Bergalis dying of
AIDS and stating her case before the U.S. Senate. That’s
one of the fallacies of television. You can present nothing
but truthful facts and still be biased — biased by over-

loading one side with emotion, or biased by choosing not
to present other facts. The truth by itself is not an
adequate defense when it comes to presenting a balanced
point of view.”

“I view my job as one of raising
questions, and not providing
definitive answers.”

Breen believes that his medical training has helped
him appreciate the actual risk of transmitting AIDS. This
background also gave him a perspective on the Benson
case that non-physician journalists don’t have.

“What concerned me most about the case was the
breakdown in the physician-patient relationship,” Breen
says. “Having experienced that trust and knowing how
important it is in what you can do for patients, I felt a
strong need to do all that we could to be balanced and
objective. The long-term casualty of the whole AIDS
scare is the breakdown of trust between patients and
physicians. I know that as a practicing physician, 60 to
70 percent of what you do for patients is to look them in
the eye and reassure them, or tell them that they’re not in
it alone. Creating antagonism between patient and phy-
sician undermines a critical part of what a physician
does, and I think that’s the unfortunate legacy of this
whole issue.”

Returning to Medical Practice?

When Breen first began his medical-journalism career in
Minneapolis, he had hoped to continue working part
time as a physician. In fact, he had been hired to work in
the emergency room of a local community hospital. But
the pressures of television have prevented him from
pursuing this interest.

Any chance Michael Breen will return to his clinical
calling?

“It does cross my mind,” he admits. “But it’s been so
long since I’ve cared for patients that I’ve lost the reflexes
for many common illnesses. I’ve gained a lot of skills; I
have the reflexes to put together a story, but my reflexes
for patient care are pretty rusty.

“Yet there is part of me that would like to do
everything. And, let’s be honest, television is not a
lifelong career. Part of me says that, maybe, someday. I’ll
go back into medicine — back to reality!” mm

Ralph Heussner is a medical writer and editor in the
Department of Laboratory Medicine and Pathology at
the University of Minnesota. He is the author of four
hooks, including ‘"Earning! The Media May Be Harm-
ful to Your Health: A Consumer's Guide to Medical
News and Advertising” (Andrews McMed, 1988).

Minnesota Medicine

April 1992/Volume 75

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SPECIAL REPORTS

Clinician Responsibilities Under the National
Childhood Vaccine Injury Act

Diane C . Peterson

The National Childhood Vaccine Injury Act of
1986 was enacted in response to vaccine liability
concerns that significantly threatened vaccine
programs during the 1980s. The act established a no-
fault compensation system for per-
sons injured by vaccines and has
become known as the National Vac-
cine Injury Compensation Program
(NVICP).=^

The vaccines and toxoids covered
I by this program include those to pre-
I vent diphtheria, tetanus, and pertus-
sis (i.e., DTP, DT, Td, T); measles,
mumps, and rubella (single antigen
I and combination vaccines such as
MMR and MR); and polio (i.e., OPV
I or IPV). The events for which com-

tpensation is provided are detailed in

the table;* other events not listed are considered case by
i case.

I Various components of the NVICP have become
operational since the law was enacted, including require-
ments for recording certain information in the patient’s
permanent medical record and reporting selected reac-
tions. In addition, clinicians are now required to provide
written statements about each vaccine to the vaccinee or
to the parent or guardian. (Vaccines to prevent Hae-
mophilus influenzae type B and hepatitis B are not
currently governed by this act.)

Recording Information on Immunizations

One component of the act, which took effect March 22,
1988, requires all health care providers who administer
' one or more of the specified vaccines to record the
following information in each patient’s permanent med-
ical record (or in a permanent office log or file): the date
the vaccine was administered, the manufacturer and lot
number of the vaccine, and the