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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 

"T 

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 
maximizing  my  personal  time." 

Thomas  Knabel,  M.D.,  Fatnily  Practice 

"T 

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. 

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612  / 623-8444  collect 

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Where  a doctor  can  be  a doctor. 

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

Copyright  € 1940  Group  Health,  Inc. 


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. 

t 

31 

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 

35 

DEPARTMENTS 

Editor’s  Notebook 

5 

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

41- 

Instructions  for  Authors 

26 

CiME  in  Minnesota 

45*" 

President’s  Letter 

37  1 

i (Classified  Advertising 

49 

Book  Review 

39 

Index  to  Advertisers 

56 

In  Memoriam 

40 

January  1992/Volume  75 

34  35PT  XL  -inr  mII 

01/93  03-900-03 

1 

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 


3 


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 


5 


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. 


i 


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, 
PV  2093  AMP  (1015911 

Additional  information  available  to  the  profession  on  reguest 
Eli  Lilly  and  Company 
Indianapolis,  Indiana 
46285 


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We  at  Seabury  &.  Smith  are  pleased  to  be  the  new  administrator  for  the  MMA  Group  Insurance  Program. 
Our  goal  is  your  complete  satisfaction.  That  means  you  can  depend  on  us  for  your  Term  Life,  Extended  Care, 
Group  Disability  and  Medical  Plans.  And  you  can  expect  your  questions  or  claims  to  be  handled  quickly  and 
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SEABURY  & SMITH 


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 


9 


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 


10 


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 


11 


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12 


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 


13 


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. 


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14 


January  1992/Volume  75 


Minnesota  Medicine 


Join  Dr.  Hanley 


Join  The  AMA. 

“I  think  one  of  the  greatest  contributions 
of  the  AMA  is  its  activities  on  behalf  of  the 
most  vulnerable  in  our  society,  children. 

“The  AMA  adolescent  health  program  is 
a great  benefit  to  physicians  who  practice 
adolescent  medicine  and  to  policy-makers, 
i But  there  is  so  much  more  that  needs  to  be 
done.  The  AMA  deals  with  the  seemingly 


countless  number  of  issues  confronting 
medicine.  And  because  it  does,  it  gives  me 
a great  feeling  of  hope  about  the  future. 

“I  can’t  imagine  what  the  state  of 
medicine  would  be  without  the  AMA.” 

Join  Dr.  Kay  Hanley,  Pediatrician,  in  the 
American  Medical  Association.  Call  this 
toll-free  number  now. 


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COVER  STORY 


Than 


eQ 


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 


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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 


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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. 

i 

' 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 


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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. 


20 


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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 

AMERICA: 


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 


21 


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 


23 


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. 


24 


January  1992/Volume  75 


Minnesota  Medicine 


SPECIAL  REPORT 


f 


\ 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 


25 


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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. 

3.  Chaterjee  SN.  Use  of  GOR-TEX  grafts  as  vascular 
access  procedure  for  chronic  hemodialysis.  Abstract  of  a 
paper  submitted  to  the  European  Society  for  Artificial 
Organs  Eighth  Annual  Meeting,  Copenhagen,  August,  1981. 

4.  Thompson  NW.  Thyroid  and  parathyroid.  In:  Welch 
K j,  Randolph  JG,  Ravitch  MM,  et  ah,  eds.  Pediatric  Sur- 
gerv,  4th  ed.  Chicago:  Year  Book  Medical,  1986:  vol  1, 
522-33. 

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26 


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 


27 


CLINICAL  & HEALTH  AFFAIRS 


Table  1 

Preoperative  conditions  (cardiac) 


Number  Percent 


History  of  Ml 

20 

23 

Angina  or  CHF 

9 

10 

Rhythm  other  than 

1 1 

12.5 

sinus 

Total  cardiac  conditions 

35 

40 

Preoperative  conditions  (other) 

Number  Percent 


Hypertension 

49 

56 

Dialysis 

4 

4, 

Chronic  renal  insuff.* 

8 

9 

Kidney  transplant 

17 

19 

Diabetes 

69 

78 

Stroke/TIA 

16 

18 

Smoking,  20  pack/yr 

34 

39 

“■(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 

2.1 

Rest  pain 

1 1 

11.6 

Severe  claudication 

9 

9.5 

Ulcers 

70* 

7.37 

Unknown  or  others 

3 

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 


28 


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 

52 

14 

SAB 

PA,  art. 

1 4 days  sepsis, 
renal  failure 

86 

19 

GEN 

PA,  art. 

1 0 days,  sepsis.  Ml 
after  septic  episode 

84 

8 

GEN 

CVP,  art. 

7 days,  CHF 

91 

5 

SAB/GEN 

PA,  art.  placed 

4 hours  into  case 

7 days,  CHF 

Cardiovascular 

morbidity 

Age 

Goldman  index 

Anesthesia 

Monitoring 

Type 

71 

16 

GEN 

Art. 

Subendocardial  Ml,  CHF 

58 

0 

GEN 

PA,  art. 

Inferior  Ml 

76 

5 

GEN 

PA,  art. 

Subendocardial  Ml 

67 

3 

GEN 

PA,  art. 

Anterior  Ml,  CHF 

66 

3 

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 


29 


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. 


30 


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. 

31 


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- 


32 


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 


33 


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College  of 
Radiology 


1891  Preston  White  Dr 
Reslon,  Virginia  22091 
(703)  698-8900 


HUTCHINSON,  MN 

BC  OR  BE  OB/GYN,  FAMILY 
PRACTICE  PHYSICIAN, 
INTERNAL  MEDICINE  PHY- 
SICLVN  AND  PEDIATRICIAN 

wanted  for  a progressive  14 
physicians’  group  located  in 
Hutchinson,  MN,  60  miles  west 
of  the  Twin  Cities  on  Highw^ay 
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 


34 


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 


35 


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 


Interested  in 

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Eleven  First  Ave.  S. 
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Phone:  1-800-876-7171 


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. 


36 


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 


37 


“ 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 


ii 


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 


39 


IN  MEMORIAM 


1: 


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 


40 


January  1992/Valume  75 


Minnesata  Medicine 


I 


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 

I 

1 

I 

I 


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. 


42 


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 


43 


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 


44 


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 


45 


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. 


46 


January  1992/Volume  75 


Minnesota  Medicine 


r 


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 


47 


9 


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Address 

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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 


49 


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. 


50 


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 


51 


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 


52 


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 

Gn 

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 


53 


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 


J 


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 


55 


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- 


56 


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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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 


55414;  612/378-1 875  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  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 
Medicine.  Second-class  postage  paid  at 
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send  address  changes  to:  Minnesota  Medi- 
cine, 111  1 University’  Avenue  SE,  Suite  400, 
Minneapolis,  MN  5.54 1 4.  (USPS  35 1 9000.) 


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 

5 

News  Clips 

43 

Letters  to  the  Editor 

7 

CME  in  Minnesota 

47 

Instructions  for  Authors 

24 

Classified  Advertising 

50 

President’s  Letter 

41 

Index  to  Advertisers 

56 

February  1992  /Valume 

75 

1 

We  know  kids 
inside. 


I 


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 


©1991.  Children's  Hospital  of  St.  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 


3 


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 

5 


“ 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 


7 


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 
by  the  victim/survivor,  legal  issues, 
and  an  effective  and  legally  compe- 
tent model  of  interviewing  chil- 
dren. 

To  register,  or  for  a complete 
brochure,  contact  Campbell 
Meeting  Management,  1437 
Marshall,  Suite  102,  St.  Paul, 
Minnesota  55 104;  612/646-5060. 

Diane  Campbell 
Seminar  Coordinator 
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 

Do  you  have  a concern?  Minne- 
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. 


SIXTH  ANNUAL 


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Egg  Harbor,  Wisconsin 
Sessions  run  9:00  a. m. 12:15  p.m.  daily 
CME  and  CECJ  credits  available. 

July  27-31,  1992 


Session  1 

Harry  Levinson,  Ph.D. 

Organizational  Diagnosis 

Session  II 

Russell  Barkley,  Ph.D. 

Attention  Deficit 

Disorders 

August  3-7,  1992 

Session  III 

Albert  Eis,  Ph.D. 

Rational  Emotive  Therapy 

Session  IV 

Diana  Kirschner,  Ph.D. 

Treating  Survivors  of 

S Sam  Kirschner,  Ph.D. 

Incest  and  Abuse 

Session  V 

James  Jefferson,  M.D. 

Psychopharmacology 

Update 

August  10-14,  1992 

Session  VI 

JetTold  Post,  MD. 

Political  Psychiatry 

Session  VII 

Stephen  Rao,  Ph.D. 

Thomas  Hammeke,  Ph.D. 

& Mariellen  Rscher,  Ph.D. 

neuropsychological 

Testing 

For  more  information: 

Carlyle  H.  Chan,  M.D.,  Summer  Institute  Director,  Psychiatry  Dept. 
Medical  College  of  Wisconsin,  8701  Watertown  Plank  Road, 
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Minnesota  Medicine 


February  1992/Volume  75 


9 


ONLY  ONE  HrANTAGONIST  HEALS  REFLUX  ESOPHAGITIS 
AT  DUODENAL  ULCER  DOSAGE.  ONLY  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  mo.  PATIENT  PROVEN. 


Axm 

nizatidine 

150  mg  b.i.d. 


1 . Data  on  file,  Lilly  Research  Laboratories.  See  accompanying  page  for  prescribing  information. 


€ 1991.  ELI  LILLY  AND  COMPANY 


NZ-2947-B-249304 


AXID 


nizatidine  capsules 


Brief  Summary.  Consult  the  package  insert  for 
complete  prescribing  information 
Indications  and  Usage:  l Active  duodenal  ulcer- 
fot  up  lo  8 weeks  ol  treatment  at  a dosage  ot  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  150  mg  h.s.  at  bedtime.  The 
consequences  ol  therapy  with  Axid  for  longer  than  1 
year  are  not  known. 

3.  Gastroesophageal  reflux  disease  (GERD)-toi  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.  Hj-receptor  antagonists,  including  Axid, 
should  not  be  administered  to  patients  with  a history 
ol  hypersensitivity  to  other  Hj-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  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, 

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 -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 

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  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 


13 


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 


14 


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 


15 


Kfeknow 

2.7  miUm  people 

wtUimpu^ 

lai^  hearts. 


And  we  hope  you’ll  meet  some  of  them,  too.  They  are  the  enthusiastic 
volunteers  of  the  AHA,  and  they  generously  donate  their  time  and  care, 
visiting  homes,  schools  and  workplaces  everywhere,  helping  millions  learn 
how  to  reduce  their  risk  of  heart  disease.  Without  them,  our  organization 
wouldn’t  be  the  success  that  it  is.  If  you’d  like  to  volunteer,  or  simply  learn 
more,  call  or  write  your  nearest  American  Heart  Association. 


American  Heart 
Association 


This  space  provided  as  a public  service.' 


I 


i 


I 


a 

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tr 

tr 


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 


17 


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 


19 


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. 


D 


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 


L 


20 


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 


21 


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 


22 


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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612-785-3338 


Minnesota  Medicine 


February  1992/Volume  75 


23 


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 

Submit  clinical  articles,  essays,  letters,  book  reviews,  and 
other  manuscripts  at  any  time  to:  Meredith  McNab,  Man- 
aging Editor,  Minnesota  Medicine,  111  1 University  Avenue 
SE,  Suite  400,  Minneapolis,  MN  55414.  Manuscripts  are 
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Please  submit  two  copies  and  keep  one  for  your  files. 
You  may  submit  a Macintosh  or  IBM-compatible  ASCII 
(text)  floppy  disk  with  your  manuscript.  Disks  and  copies  of 
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Only  submit  unpublished  articles  that  have  not  been  sub- 
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Receipt  of  manuscripts  is  acknowledged  within  10 
days,  and  authors  are  usually  notified  whether  their  manu- 
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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 
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The  second  page  of  the  manuscript  should  include  an 
abstract  no  longer  than  150  words  that  highlights  for  the 
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facts  rather  than  descriptions  and  should  emphasize  the 
importance  and  uniqueness  of  the  findings  and  briefly  list 
the  approach  used  for  gathering  data  and  the  conclusions 
drawn. 

Author  Responsibility 

All  authors  should  be  involved  in  the  drafting,  revision,  and 
intellectual  content  of  the  manuscript  and  be  sufficiently 
familiar  with  the  paper  to  defend  its  findings.  Authors  are 
responsible  for  all  statements  made  in  their  work,  including 
changes  made  by  copy  editors.  Manuscripts  are  edited  for 
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printer.  Once  it  is  set  in  galleys,  only  minor  changes  can  be 
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All  authors  sign  a copyright  form  that  conveys  all 
copyright  ownership  to  the  Minnesota  Medical  Associa- 
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is  submitted  to  Minnesota  Medicine,  and  must  be  completed 
and  returned  before  the  article  is  published.  If  the  manu- 
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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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tions in  the  title,  and  limit  their  use  in  the  text.  Avoid 
medical  jargon. 

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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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Submit  two  copies  of  illustrations,  keeping  one  for  your 
files.  Eigures  should  be  professionally  drawn  or  photo- 
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good.  Do  not  send  original  artwork. 

Each  figure  should  have  a label  pasted  on  the  back 
indicating  the  figure  number,  author  names,  and  the  top  of 
the  figure.  Legends  should  be  included  in  the  text  of  the 
manuscript  with  numbers  corresponding  to  the  figures.  Do 
not  mount  figures  on  cardboard,  write  on  the  back  of  the 
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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 
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. 

3.  Chaterjee  SN.  Use  of  GOR-TEX  grafts  as  vascular 
access  procedure  for  chronic  hemodialysis.  Abstract  of  a 
paper  submitted  to  the  European  Society  for  Artificial 
Organs  Eighth  Annual  Meeting,  Copenhagen,  August,  1981. 

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. 

Financial  Interest 

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that  may  have  a direct  interest  in  the  subject  matter  of  your 
manuscript.  This  information  will  be  held  in  strict  confidence 
until  publication,  and  then  will  be  printed  with  the  article  as 
is  deemed  appropriate  in  judging  the  validity  of  the  article. 

Reprints 

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forms  are  sent  to  authors  at  the  time  of  publication. 


Illustrations 


24 


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 


25 


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- 


26 


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 


27 


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 

10 

Thalidomide 

TF,  VSD,  ASD 

5-10 

Isotretinoin 

Complex,  VSD 

50 

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- 

28 


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 

50 

ECD,  VSD,  ASD 

Trisomy  1 8 

99 

VSD,  PDA,  PS 

Trisomy  1 3 

90-t 

VSD,  PDA 

4 p- 

40 

ASD,  VSD,  PDA 

5 p-  (cri-du-chat) 

20 

VSD,  PDA,  ASD 

45,  XO  (Turner) 

20 

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. 


Minnesota  Medicine 


February  1992/Volume  75 


29 


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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 


31 


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.'* 


32 


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 

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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. 

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Purchasers  are  looking  for  a rapid  acceleration  of  our  ability  to  tell  them 
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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 


33 


This  Is  AH^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. 


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- 

35 


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 


36 


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 

ft 


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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AMERICA: 


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ANNUAL  NATIONAL  CONFERENCE 

MARCH  5-7,  1992 
ATLANTA  AAARRIOH  AAARQUIS 

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. 


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Heart  attack  is  by  Far  the  bigge.st  killer  of  American  women,  claiming  nearly  250,000  lives  each  year. 

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American  Heart 
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This  space  provided  as  a public  service. 


38 


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 


39 


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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Phone:  1-800-876-7171 


40 


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? 


A 

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 


41 


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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Please  send  resume  to 
Brenda  M.  Maiers,  Administrator 
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3 Century  Ave. 

Hutchinson,  MN  55350 
Tel.  (612)  587-2020  Ext.  214 


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What  will 
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Many  of  your  patients  will  hear  about  screening  mammography  through  a 
program  launched  by  the  American  Cancer  Society  and  the  American  College  of 
Radiology,  and  they  may  come  to  you  with  questions.  What  will  you  tell  them’ 
We  hope  you'll  encourage  them  to  have  a screening  mammogram,  because 
that,  along  with  your  regular  breast  examinations  and  their  monthly  self 
examinations,ofTers  the  bestchance  of  early  detection  of  breast  cancer.a  disease 
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42 


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. 


44 


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 


45 


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 


46 


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. 

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  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.  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.  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 


47 


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  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  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 


48 


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 


49 


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. 

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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 
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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) 


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  Falls,  W1  54022;  715/425-6701. 

(=■•9/9 1-R) 

Urgent  Care/Primary  Care  physicians  for  over  90  group 
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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) 

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 15/425- 
6701.  (='-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-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) 


50 


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) 

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 1 0 Ninth  Street  SE,  Rochester,  MN  55904. 

(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) 


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;  414/727-4276.  (3/9 1-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 


51 


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) 


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.  (7/91-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 


52 


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) 


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 12/679- 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:  Jim  Schneckloth,  4 Sunset 
Place,  Charles  City,  I A 50616.  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.  'M-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  5200 1 ; or 
call  319/589-9981.  'M-2/92 


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 


53 


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 


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 


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 

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. 

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- 


54 


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. 


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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 


55 


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 


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-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 


56 


February  1992/Volume  75 


Minnesota  Medicine 


il 


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 

Designed  by  Members.  |! 
For  M^ers. 


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- 
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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. 

31 

ON  THE  BUSINESS 

S 1 

D E 

Financing  Reform:  Who  Will  Pay  the  Price  for 

America’s  Health  Care? 

The  Wyatt  Company 

35 

DEPARTMENTS 

Editor’s  Notebook 

5 

News  Clips 

42 

Letters  to  the  Editor 

7 

CME  in  Minnesota 

47 

Instructions  for  Authors 

30 

Classified  Advertising 

50 

President’s  Letter 

41 

Index  to  Advertisers 

56 

March  1992/Volume  75 


1 


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. 


© Health  One  Corporation 


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 

i 

Fall  Schedule  For  Educational 
Telephone  Network 

September  8 & 22 
October  6 & 20 
November  3 & 17 
December  1 


i 


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I 

] 

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R 


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, 

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


March  1992/Valume  75 


Minnesota  Medicine  Advisers  and  Reviewers 


3 


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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 

5 


“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 


.1 


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 


7 


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. 


8 


March  1992/Volume  75 


Minnesota  Medicine 


FACE  TO  FACE 


f. 

} 

Health  Care  for  New  Americans 

Blending  Traditional  and  Western  Medicine 

\ Minnesota  Medicine  interviews  Patricia  F . Walker,  M . D . 


'l 

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» 


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 


9 


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.” 


10 


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.” 


UM 


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. 


OMMITTED  TO  EXCELLENCE 


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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.” 


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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 


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PERSPECTIVES 


A Job  Well  Done? 

Learning  to  Care  for  a Patient  with  AIDS 

J . Randall  Curtis,  M . D . 


i 


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I 

i 


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 

I 

I 

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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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Minneapolis,  Minnesota  55455 
(612)  624-2933 

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MinnesotaMedicine  Marchl992/Volume75  21 


ONiy  ONE  H, -ANTAGONIST  HEALS  REFLOX  ESOPHAGITIS 
AT  DOODENAL  OLCER  OOSAGE.  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  weekJ 

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. 


1 


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. 

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 -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 

Additional  information  available  to  the  profession  on  request 
Eli  Lilly  and  Company 
Indianapolis,  Indiana 
46285 


HENNEPIN  COUNTY 
MEDICAL  CENTER 

HENNEPIN  FACULTY  ASSOCIATES 
OFFICE  OF  ACADEMIC  AFFAIRS 

Spring  CME  Offerings 

A JOHN  I.  COE  CONFERENCE 

"Current  Concepts  in  Dermatopathology" 
April  10,  1992 

A course  covering  a variety  of  topics  relating  to 
dermatopathology  geared  to  pathologists  and 
dermatologists 


A MINNESOTA  REGIONAL  SLEEP 
DISORDERS  CENTER  (MRSDC) 

Dinner  Lecture  with  David  Dinges,  PhD 
April  14,  1992 

The  neuropsychology  of  sleepiness:  Experimental, 
clinical  and  occupational  challenges  (pilots,  apneics, 
sleep-deprived  young  adults) 


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 


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 


OFRCE  OF 

ACADEMIC 

AFFAIRS 


NZ-2947-B-249304 


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 


24 


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 


25 


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 


26 


March  1992/Volui 


75 


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 


27 


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. 


28 


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. 

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. 

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 


29 


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- 
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Receipt  of  manuscripts  is  acknowledged  within  10 
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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 

The  second  page  of  the  manuscript  should  include  an 
abstract  no  longer  than  150  words  that  highlights  for  the 
reader  the  essence  of  the  authors’  work.  It  should  focus  on 
facts  rather  than  descriptions  and  should  emphasize  the 
importance  and  uniqueness  of  the  findings  and  briefly  list 
the  approach  used  for  gathering  data  and  the  conclusions 
drawn. 

Author  Responsibility 

All  authors  should  be  involved  in  the  drafting,  revision,  and 
intellectual  content  of  the  manuscript  and  be  sufficiently 
familiar  with  the  paper  to  defend  its  findings.  Authors  are 
responsible  for  all  statements  made  in  their  work,  including 
changes  made  by  copy  editors.  Manuscripts  are  edited  for 
clarity  and  grammar  and  to  conform  to  Minnesota  Medi- 
cine style,  and  authors  receive  an  edited,  word-processed 
copy  of  their  paper  for  their  review  before  it  is  sent  to  the 
printer.  Once  it  is  set  in  galleys,  only  minor  changes  can  be 
made. 

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 


is  submitted  to  Minnesota  Medicine,  and  must  be  completed 
and  returned  before  the  article  is  published.  If  the  manu- 
script is  not  accepted  for  publication,  the  form  is  returned 
to  the  authors. 

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 
may  follow  generic  names  if  desired.  Do  not  use  abbrevia- 
tions in  the  title,  and  limit  their  use  in  the  text.  Avoid 
medical  jargon. 

Tables 

Tables  must  have  a title  and  be  on  separate  pages.  If  they 
occupy  more  than  one  page,  type  “title  (cont.).”  If  the  data 
in  the  tables  have  been  previously  published,  appropriate 
reference  should  be  given  in  the  text,  and  permission  should 
be  obtained  from  the  original  publisher  before  submission 
to  Minnesota  Medicine. 

Illustrations 

Submit  two  copies  of  illustrations,  keeping  one  for  your 
files.  Eigures  should  be  professionally  drawn  or  photo- 
graphed, if  possible.  We  prefer  glossy,  clear  black-and- 
white  photographs,  but  color  is  acceptable  if  the  contrast  is 
good.  Do  not  send  original  artwork. 

Each  figure  should  have  a label  pasted  on  the  back 
indicating  the  figure  number,  author  names,  and  the  top  of 
the  figure.  Legends  should  be  included  in  the  text  of  the 
manuscript  with  numbers  corresponding  to  the  figures.  Do 
not  mount  figures  on  cardboard,  write  on  the  back  of  the 
figures,  or  attach  paper  clips  to  them.  If  a patient  in  a photo 
is  identifiable,  a written  release  form  from  the  subject  must 
accompany  the  photo. 

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. 

3.  Chaterjee  SN.  Use  of  GOR-TEX  grafts  as  vascular 
access  procedure  for  chronic  hemodialysis.  Abstract  of  a 
paper  submitted  to  the  European  Society  for  Artificial 
Organs  Eighth  Annual  Meeting,  Copenhagen,  August,  1981. 

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 

List  all  affiliations  with  or  financial  interest  in  organizations 
that  may  have  a direct  interest  in  the  subject  matter  of  your 
manuscript.  This  information  will  be  held  in  strict  confidence 
until  publication,  and  then  will  be  printed  with  the  article  as 
is  deemed  appropriate  in  judging  the  validity  of  the  article. 

Reprints 

Authors  may  order  article  reprints  for  a fee.  Reprint  request 
forms  are  sent  to  authors  at  the  time  of  publication. 


30 


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 


31 


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- 


32 


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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• Architecture 

• Interior  Design 

• Space  Planning 

• Land  Planning 

The  Runyan /Vocel  Group 

Arci  iitects/Pi,anners 

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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 


33 


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. 

35 


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 


( 

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March  1992/Volume  75 


Minnesota  Medicine 


36 


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. 

37 


I 


i. 


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 

38 


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 


39 


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 

Repritrted  with  pertnission  from 
Wyatt  \m\dtr,  January  1 992.  ©1 992 
The  Wyatt  Company. 

The  Wyatt  Company  is  an  mterna- 
tional  consulting  firm  specializing  in 
the  areas  of  human  resources,  finan- 
cial management,  and  administra- 
tive systems. 


Share  Your  Expertise  with 
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to  submit  informational  articles 
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ment, personal  and  practice- 
oriented  financial  management, 
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can  put  to  immediate  use.  Submit 
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SE,  Suite  400,  Minneapolis,  MN 
55414. 


©1992  Faimcw 

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I I 

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I I 


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40 


March  1992/Volume  75 


Minnesota  Medicine 


T 


PRESIDENT'S  LETTER 


A Tale  of  Two  Cities 

Thomas  A . S t o I e e , M . D . 


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« 


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 


I 


Minnesota  Medicine 


March  )992/Volume  75 


41 


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 


42 


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 


43 


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 


44 


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 


45 


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 


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46 


March  1992  /Volume  75 


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. 

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  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;  612/626-7600. 

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  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  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.  CON- 
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  20-21  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  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  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 


47 


i 


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  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  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. 


48 


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. 

m 

• 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 


49 


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. 

• 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.  Lowery,  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  Falls,  WI  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;  715/425- 
6701.  (’‘•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) 

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 
55121;  612/454-7291.  (12/91-R) 


50 


March  1992  /Volume  75 


Minnesota  Medicine 


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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) 

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) 

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/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 


51 


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 

©1992  HealthEast 


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 


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.  (7/91-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,  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) 

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 


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/ rent  and  used  medical 
equipment  and  supplies  for  sale.  Excellent  condition.  Call 
218/828-1358.  6-4/92 


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 1/91-R) 

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.  *4-5191 

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 


52 


March  1 9 9 2 / V o I u m e 75 


Minnesota  Medicine 


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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 


53 


1 


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 

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-3/92 


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: 

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.  *1-5191 

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  ■ 


54 


March  1992/Volume  75 


Minnesota 


M e d i 


I 

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 


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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 


55 


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 

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.  ’H-3/92 

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 


56 


March  1992/Volume  75 


Minnesota  Medicine 


r 


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 

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,  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 


I 


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 
teaching  of  residents  and  students  in  both  outpatient  and  inpatient  settings.  Competitive 
salary  and  benefits.  Protected  time  is  available  for  research  and  teaching. 

• Internal  Medicine/Emergency  Medicine  Immediate  opening  for  a BC/BE  internist 
with  emergency  medicine  experience.  Join  a rapidly  growing  group  of  internists  who  cover 
the  Emergency  Room  and  in-house  patients  at  United  Memorial  Hospital  in  Greenville, 

Michigan  (1  hour  from  Lake  Michigan  and  35  miles  from  Butterworth  Hospital).  Flexible 
hours,  no  call,  excellent  reimbursement  and  benefit  package. 

• Multi-Specialty  Outpatient  Group:  Family  Practitioner,  Med/Peds, 

Internai  Medicine,  Pediatrician 

Dynamic  7 physician  multi-specialty  group  providing  outpatient  care  at  United  Memorial 
Hospital  seeks  additional  physicians.  Full-time  position,  4 1/2  days  Monday  through  Friday 
with  additional  hours  available  in  the  urgent  care  center  or  Emergency  Room.  Located  in 
Greenville,  Michigan  (1  hour  from  Lake  Michigan  and  35  miles  from  Buttenworth  Hospital). 

Call  and  inpatient  care  is  optional  with  opportunities  available  to  do  procedures  in  the 
hospital  or  office.  Competitive  salary  and  full  benefit  package  including  malpractice 


For  information  about  the  above  positions,  please  call  or  write  to 
Nancy  Martens,  Manager  Medical  Staff  Placement  1-800-788-8410. 

Butterworth  Health  System,  MC  73,  Nancy  Martens,  100  Michigan  NE, 
Grand  Rapids,  Michigan  49503 


1 


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 
material  for  consideration  to  Minnesota 
Medicine,  111  1 University  Avenue  SE,  Suite 
400,  .Minneapolis,  .MX  55414,  612/378- 
1875.  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  .Vledical  Association,  its  editors, 
or  any  of  its  constituents.  Annual  Subscrip- 
tion - S27.00.  Single  copies  - $2.25.  Cana- 
dian - S36.00.  Foreign  - S36.00. 

To  Advertise:  Contact  Michael  Soucheray, 
Minnesota  Medicine,  2221  University 
Asenue  SE,  Suite  400,  .Minneapolis,  .MX 
55414;  612/378-1875  or  800/999-1875. 


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 
reproduce  editorial  material  in  this  maga- 
zine must  be  obtained  from  Minnesota 
Medicine.  Second-class  postage  paid  at 
•Minneapolis,  .Minnesota,  and  at  additional 
mailing  offices.  POST.MASTER,  send  ad- 
dress changes  to:  Minnesota  Medicine,  111  1 
University  Avenue  SE,  Suite  400,  .Minnea- 
polis, .MX  55414.  'USPS  3519000., 


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 


DEPARTMENTS 


Editor’s  Notebook 

5 

C.\1E  in  .Minnesota 

54 

Instructions  for  Authors 

36 

Classified  Advertising 

58 

President’s  Letter 

47 

Index  to  Advertisers 

66 

News  Clips 

49 

April  1992/Volume  75 


1 


BECAUSEBUYING 
INSURANCE 
CAN  BE 

RISKY  BUSINESS... 


IMMSC  is 

I AT  YOUR 

Service 


L 


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. 

• GROUP  TERM  LIFE 

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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. 


IMMA 

Minnesota  Medical  Association 


MINNESOTA 
MEDICAL 
SERVICES 
CORPORATION 


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 

Director  of  Member  Relations 
Roger  K.  Johnson 

Chief  Financial  Officer 
George  C.  Lohmer,  Jr. 

Director  of  Communications 
Mark  S.  Vukelich 

Coordinator  of  Government 
Affairs  & Public  Policy 
Kristine  D.  Hanson 

General  Legal  Counsel 
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, 

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


Advisers  and  Reviewers 


April  1992/Volume  75 


3 


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 


5 


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 


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 


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 


7 


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.” 


8 


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.” 


LONDON 


North  Central  Medical  Conference 


August  21  -29, 1992 

«995  per  person,  double  occupancy 


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Two  Exciting  Fall  Tours  to  Europe 


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For  additional  information  call: 


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Minnesota  Medicine 


April  1992/Volume  75 


9 


1 


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. 

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  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. 

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  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  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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Lommen,  Nelson,  Cole  & 
Stageberg,  P.A. 

Attorneys  Servicing  the  Needs  of  Medical 
Professionals  in  Minnesota  and  Wisconsin 

Unique  Legal  Services: 

Lommen  Nelson  has  particular  expertise  in  pro- 
viding legal  services  to  medical  professionals  and  other 
health  care  providers.  Among  the  firm's  current  clientele 
are  physicians,  nurses,  professional  associations,  clinics, 
hospitals,  medical  device  manufacturers,  clinical  labora- 
tories, and  insurers. 

Professional  Liability  Expertise: 

The  firm's  reputation  for  handling  professional 
liability  issues  is  enhanced  by  the  proven  abilities  of 
Phillip  A.  Cole  and  by  the  experience  and  knowledge  of 
its  medical  malpractice  department,  chaired  by  John  R. 
McBride.  The  attorneys  within  Lommen  Nelson  can  pro- 
vide medical  malpractice  defense,  consultation  on  risk 
management  systems,  development  of  compliance  proto- 
cols for  various  legal  requirements  unique  to  health  care 
professionals,  representation  on  licensing  issues  and  other 
assistance  relating  to  problems  which  may  occur  in  the 
course  of  a health  care  practice.  Members  of  this  depart- 
ment have  been  frequent  lecturers  and  seminar  leaders  on 
topics  related  to  medical  malpractice  and  practice  man- 
agement. 

Business  Expertise: 

The  firm's  services  to  the  health  care  industry 
are  not  limited  to  practice  management  issues.  The 
corporate  department,  chaired  by  Roger  V.  Stageberg,  of- 
fers diverse  experience  in  areas  of  particular  application  to 
medical  professionals,  including  business  organization; 
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 
planning;  and  general  legal  services  tailored  for  the  medical 
professional  clientele.  Thomas  E.  Dougherty  specializes  in 
tax  considerations  relating  to  business  activities  in  which 
health  care  professionals  are  involved. 

An  Invitation  to  You: 

The  law  firm  of  Lommen,  Nelson,  Cole  & 
Stageberg,  P.A.  has  established  a tradition  of  excel- 
lence in  providing  services  to  the  medical  professional.  The 
breadth  of  services  offered  by  Lommen,  Nelson,  Cole  & 
Stageberg,  P.A.  results  in  a better  understanding  and  a 
more  sophisticated  response  to  the  legal  issues  facing  health 
care  entities  than  can  be  obtained  from  a firm  that  only 
provides  malpractice  defense  or  business  advice.  Lommen 
Nelson  invites  you  to  contact  John  R.  McBride  or  Thomas 
F.  Dougherty  at  339-8131  for  further  information. 


1800  IDS  Center 
80  South  Eighth  Street 
Minneapolis,  Minnesota  55402 
(612)339-8131 


Southside  Office  Plaza, 
Suite  2A 

1810  Crestview  Drive 
Hudson,  Wisconsin  54016 
(715)386-8217 


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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 


13 


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 

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.'  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 

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219  County  Road 
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14 


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 


15 


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 

“Setting  the  standards  for 
documentation  in 
health  care" 

Need 

we 

say 

more 

Quality  Transcription,  Inc. 
612-785-1115 


Partners  Medical  Management,  Ltd. 

Is  Pleased  To  Announce  That: 


HARRY  M.  SHALLCROSS,  Ph.D 


I 


HAS  BECOME  A PRINCIPAL  IN  THE  FIRM 


Dr.  Shallcross  provides  consulting  in  die  design,  development  and  management  of  Mental 
Healtli  and  Substance  Abuse  Service  Delivery'  Systems.  Specific  areas  of  consultation  include; 

• Strategic  Planning  • Clinical  Service  Evaluation  and  Design 

• Service  System  Design  and  Development  • Quality  Management 

• Managed  Care  Positioning 


Dr.  Shallcross  is  a clinical  psychologist  with  over  10  years  experience  in  Managed  Mental 
Health  and  Substance  Abuse  Services.  His  expertise  includes  VP  of  Medical  Serv'ices  with  a 
national  insurance  company;  VP  Operations  with  a national  Mental  Health  Sendee  delivery’ 
system;  and  a variety  of  administrative  and  direct  service  positions  in  clinical  operations. 
He  has  been  an  independent  consultant  to  purchasers  and  providers  of  behavioral  health 
care  services  for  the  past  year. 


Partners  Medical  Management,  Ltd. 
Parkdale  Plaza,  Suite  250 
1660  South  Highway  100 
Minneapolis,  MN  55416 
Phone:  (612)  591-1414 
Fax:  (612)  591-9930 


16 


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. 


© 1991  Warner-Lambert  Company 


PARKE-DAVIS 


ACCUpriliS  (Quinapril  Hydrochloride  Tablets) 


Accupril®  (Quirrapril  Hydrochloride  Tablets) 


1 


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 


11 


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. 


k 


PARKE-DAVIS 


Division  of  Warner-Lambert  Company 
Morris  Plains,  New  Jersey  07950 


PD-I03-JA-7164-A2(022)i 


k. 


1 


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 


1 


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.” 


20 


April  1992/Volunne  75 


Minnesota  Medicine 


i, 


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 


21 


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. 


22 


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 


23 


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.” 


24 


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 


25 


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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